The complex regional pain syndrome (CRPS) is a painful disorder that can occur in an extremity after any type of injury, or even spontaneously. Data on the incidence of CRPS are scarce and mostly hospital based. Therefore the size of the problem and its burden on health care and society are unknown. The objective of the present study was to estimate the incidence of CRPS in the general population. A retrospective cohort study was conducted during 1996–2005 in the Integrated Primary Care Information (IPCI) project, a general practice research database with electronic patient record data from 600,000 patients throughout the Netherlands. Potential CRPS cases were identified by a sensitive search algorithm including synonyms and abbreviations for CRPS. Subsequently, cases were validated by electronic record review, supplemented with original specialist letters and information from an enquiry of general practitioners. The estimated overall incidence rate of CRPS was 26.2 per 100,000 person years (95% CI: 23.0–29.7). Females were affected at least three times more often than males (ratio: 3.4). The highest incidence occurred in females in the age category of 61–70 years. The upper extremity was affected more frequently than the lower extremity and a fracture was the most common precipitating event (44%). The observed incidence rate of CRPS is more as four times higher than the incidence rate observed in the only other population-based study, performed in Olmsted County, USA. Postmenopausal woman appeared to be at the highest risk for the development of CRPS. 2006 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

http://rsds.org/wp-content/uploads/2015/02/deMos_incidence_crps_pain_2006.pdf

The incidence of complex regional pain syndrome: a population-based study.

The purpose of this evidence summary is to provide the best available information on the effect of anti-oxidants on mortality in patients with various diseases.

/pdf/antioxidant-supplements-for-prevention-of-mortality-in-4y5qa95qy1.pdf

Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases

Since the early musings in the mid-1800s of Claude Bernard and his French neurological colleagues on the association of pain with the sympathetic nervous system, complex regional pain syndrome (CRPS) has both fascinated and perplexed practitioners. Some of the clearest and most interesting descriptions of ‘causalgia’ come from the American Civil War by one of Bernard’s students, Silas Weir-Mitchell. The low-velocity, high-mass missiles used in this confrontation (the ‘Minnie ball’) seemed to be particularly effective in inducing neuropathic pain associated with intense autonomic dysregulation. Weir-Mitchell’s depictions are clear and elegant, and as good as any clinical description that can be found in this century. 64 Many great minds have struggled with the pathophysiology of what came to be called ‘reflex sympathetic dystrophy’ in the later part of the 1900s and what has, since the Orlando consensus-based workshop of 1999, come to be called complex regional pain syndrome (CRPS) (Table 1). 37 63 85 From Leriche 46 and his vicious circles we have progressed through Livingston 47 and Sunderland 88 with the turbulence theory, and finally to the solid physiological information generated by the various animal models of causalgia, especially the chronic constriction injury model of Bennett and Xie. 5 Recently, the effort to understand the syndrome has turned towards consensus symposia. The first of these concerned taxonomy, as above. 37 85 A second Dahlem-type conference was conducted in regard to the guidelines for therapy, 84 and recently the International Association for the Study of Pain (IASP) sponsored a symposium in Cardiff, Wales in 2000 to discuss issues of pathophysiology and to amend the diagnostic considerations. 83 The epidemiology of the syndrome is very unclear. Although the syndrome has traditionally been considered rare, its ‘discovery’ by personal injury lawyers in the United States has caused a radical increase in the reporting of the syndrome (at least in the USA). The current diagnostic criteria, as set forth by the Committee of Classification of Chronic Pain of the IASP, have contributed to the liberalization of the diagnosis (Table 1). 63 This effort was extremely important in providing standardized diagnostic criteria, and caused a vast improvement in clinical communication and research homogeneity. It provided the hope that results could be generalized across studies, and in fact widespread use of these standardized criteria has helped all these things considerably. These criteria, while being very sensitive, greatly lack specificity. 92 1 31 The intent of the Orlando conference in 1994 was that these criteria should evolve on the basis of experience and empirical testing, and that they should be subject to systematic validation research over time. 37 62 85 This has been accomplished to some extent, and through a process of internal and external validation the opportunity to improve the specificity of the bedside diagnostic criteria is available. 92 1 31 Although the original IASP criteria required only subjective and potentially only historical signs and symptoms, the suggestions for improving these criteria are that some objectification and observed evidence be included. It is recommended that the diagnostic criteria be modified to include at least one symptom in each of the four diagnostic categories derived by factor analysis: sensory

Complex Regional Pain Syndrome

Venous thromboembolism (VTE) is defined as the obstruction, partial or complete, of one or more veins of deep circulation. It is a condition that can lead to a deterioration in his state of health until death, manifesting as deep vein thrombosis (DVT) or pulmonary embolism (PE). The major orthopedic surgery and the surgical oncology are frequently associated with thromboembolic complications, because of conditions that are often critical in these patients. It is estimated that in Italy DVT has an incidence that varies between 50 and 150 new cases per 100,000 population, while the prevalence would be between 2.5 and 5%. In the absence of thromboprophylaxis, the orthopedic surgery lead to a high increased risk of VTE. In elective hip replacement, in the absence of prophylaxis, the incidence of DVT and of fatal PE is about 50% and 2% respectively. In elective knee arthroplasty the risk of venous thromboembolic complications is even higher. It is estimated that 56.2% of the costs of prophylaxis with Low Molecular Weight Heparin (LMWH) in patients undergoing major orthopedic surgery are attributable to the cost of drugs (about € 200), followed (with 44.8%) by the cost of administration (approximately € 159). The average total cost/day was estimated at € 8 per patient. In Italy, it has been estimated an annual cost for new cases between 215 and 260 million €. The clinical advantages of the New Oral Anticoagulants (NOA) appear to be substantially clear, the major concern with regard to their reimbursement is therefore linked to the financial impact, due to the higher cost per day of the NOA compared with LMWH. To this end, it was built a model of budget impact, in the perspective of the Italian NHS, from the data related to cases of major surgical orthopedic procedures and a meta-analysis on the pivotal RCT, which aims to measure the differential effects in terms of prevention of VTE. The results show that the financial impact of the NOA in the prophylaxis of major orthopedic surgery is not particularly relevant. In fact, the major pharmaceutical costs that, at national level, amount to € 10.8 mil. (€ 15.2 mil. in the case of prolonged prophylaxis in knee operations) would be more than offset by savings in terms of fewer treatments of VTE, which is based on the assumption of more than 4,000 cases, up to about 6,600 in hypothesis best efficacy.

/pdf/prevention-of-vte-in-orthopedic-surgery-patients-bofd0hdftp.pdf

Prevention of VTE in orthopedic surgery patients

https://www.anesthesiology.theclinics.com/article/S0889-8537(04)00127-0/pdf

Consequences of inadequate postoperative pain relief and chronic persistent postoperative pain.

https://rsds.org/wp-content/uploads/2015/02/Zollinger_VitC.pdf

Effect of vitamin C on frequency of reflex sympathetic dystrophy in wrist fractures: a randomised trial

Background: Complex regional pain syndrome type I is treated symptomatically. A protective effect of vitamin C (ascorbic acid) has been reported previously. A dose-response study was designed to evaluate its effect in patients with wrist fractures. Methods: In a double-blind, prospective, multicenter trial, 416 patients with 427 wrist fractures were randomly allocated to treatment with placebo or treatment with 200, 500, or 1500 mg of vitamin C daily for fifty days. The effect of gender, age, fracture type, and cast-related complaints on the occurrence of complex regional pain syndrome was analyzed. Results: Three hundred and seventeen patients with 328 fractures were randomized to receive vitamin C, and ninetynine patients with ninety-nine fractures were randomized to receive a placebo. The prevalence of complex regional pain syndrome was 2.4% (eight of 328) in the vitamin C group and 10.1% (ten of ninety-nine) in the placebo group (p = 0.002); all of the affected patients were elderly women. Analysis of the different doses of vitamin C showed that the prevalence of complex regional pain syndrome was 4.2% (four of ninety-six) in the 200-mg group (relative risk, 0.41; 95% confidence interval, 0.13 to 1.27), 1.8% (two of 114) in the 500-mg group (relative risk, 0.17; 95% confidence interval, 0.04 to 0.77), and 1.7% (two of 118) in the 1500-mg group (relative risk, 0.17; 95% confidence interval, 0.04 to 0.75). Early cast-related complaints predicted the development of complex regional pain syndrome (relative risk, 5.35; 95% confidence interval, 2.13 to 13.42). Conclusions: Vitamin C reduces the prevalence of complex regional pain syndrome after wrist fractures. A daily dose of 500 mg for fifty days is recommended. Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study.

Epidemiology and trends in severe burns in the Netherlands

https://repub.eur.nl/pub/69588/2_Strang-et-al_Burns-2014_40-1-_9-16_AAM.pdf

A systematic review on intra-abdominal pressure in severely burned patients.

Platelet-rich plasma (PRP) is a fraction of blood plasma with a platelet concentration above baseline. After activation of the platelets, growth factors are released, which are involved in wound-healing processes. Application of a multitude of growth factors seems to boost the healing process. In this review the authors provide a comprehensive overview of the many different aspects of PRP; this is followed by a short outline of the evidence for a wide range of applications and finally narrowing down to a more in-depth analysis of the literature on the potential use of PRP in burn treatment. The authors performed an extensive search on PRP and the different biological, as well as practical aspects for the different applications. Furthermore, we performed a systematic search on PRP in the treatment of burn wounds. A high variety exists in PRP products, procedures, and content. This makes interpretation and comparison of the evidence difficult. PRP has been reported to have beneficial effects on wound healing in different fields of surgery and in the treatment of acute, chronic, and diabetic wounds. Literature on the use of PRP in burns is scarce. Separate growth factors have shown beneficial results in the treatment of burns. Furthermore, an animal study and several case reports showed improved burn wound-healing time after the application of PRP. A deep dermal burn could benefit from PRP through its hemostatic antimicrobial abilities and the positive effects seen in wound healing. However, burn patients have an altered physiological state and it is unknown how this may affect platelet function and quality. Furthermore, the effect of PRP on scarring has not been evaluated properly. Future research is needed to elucidate the role of PRP in the treatment of burns.

Roelf S. Breederveld

Papers

Effect of vitamin C on frequency of reflex sympathetic dystrophy in wrist fractures: a randomised trial

Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study.

Epidemiology and trends in severe burns in the Netherlands

A systematic review on intra-abdominal pressure in severely burned patients.

Considerations on the Use of Platelet-Rich Plasma, Specifically for Burn Treatment