Painful Dysesthesia Research Articles

N-Check: nerve check to document chemotherapy-induced peripheral neuropathy (CIPN) in incurable cancer

Chemotherapy-induced polyneuropathy (CIPN) encompasses aspectrum of symptoms ranging from hypoesthesia with impaired gait, stance and fine motor skills to painful dysesthesia and allodynia and significantly impairs the quality of life of those affected. In the present pilot study, quantitative sensory testing (QST) was used to investigate CIPN as acommon adverse effect of cytostatic drugs in patients with incurable cancer. The QST is astandardized examination procedure that is not yet routinely used in cancer patients. It is used to examine thermal and mechanical perception and pain thresholds to record the subjectively experienced pain phenotype. In the N‑Check pilot project, the QST was used before and after tumor-specific, potentially CIPN-inducing treatment and the data collected was compared in apre-post analysis. In addition, the specific effects of CIPN on the health-related quality of life of patients treated primarily with apalliative intention were recorded using the Functional Assessment for Cancer Therapy-General (FACT-G) questionnaire. Overall, the patients showed significant heat hypoalgesia after chemotherapy as asign of damage to small nerve fibers. In addition, there were signs of deterioration of the quality of life. The feasibility of QST in patients with incurable cancer and palliative, neurotoxic chemotherapy was demonstrated in this pilot study.

(098) LOW INTENSITY SHOCKWAVE THERAPY FOR WOMEN WITH SEXUAL DYSFUNCTION

Abstract Introduction Low intensity shockwave therapy (LiSWT) has been used to treat sexual dysfunction by inducing genital tissue mechanotransduction. Mechanotransduction is the ability of a cell to actively convert contraction/expansion mechanical stimuli induced by exposure to the shockwave energy into biochemical signals with physiological effects including synthesis of nitic oxide, upregulation of vascular endothelial growth factors, recruitment of endothelial progenitor cells, vasodilation, and expression of tumor necrosis factor alpha mRNA with anti-inflammatory activity. The greater the shockwave energy absorbed in genital tissues, the greater the opportunity for mechanotransduction physiologic effects to occur and improve sexual function. Therefore, effectiveness of LiSWT depends, in part, on applied energy (mJ/mm2) and number of applications (total shocks). In 2019, our sexual medicine clinic began utilizing the SoftWave (Urogold 100™) LiSWT device, FDA cleared for pain amelioration, connective tissue activation, wound healing, and improved blood flow, to treat individuals with vulvas with sexual dysfunction. Objective To review the various sexual health concerns in individuals with vulvas effectively treated by LiSWT. Methods A chart review was performed of individuals with vulvas with various sexual dysfunctions, including genital pain and genito-pelvic dysesthesia (GPD), who received LiSWT between April 2019 and June 2023. In general, 2400 shocks were applied at energy flux density 0.05-0.08 mJ/mm2, Hz = 3, membrane pressure = 1. The Patient Global Impression of Improvement (PGI-I) was used to assess post-LiSWT outcome; improvement was positive if the post-LiSWT PGI-I ranged from 1-3. Results 189 women, mean age 32 (range 18–67) years, with sexual dysfunction underwent LiSWT treatments in the 38 months. 18 women with neuroproliferative vestibulodynia (NPV) who underwent vestibulectomy received 3-6 post-operative vestibular LiSWT to reduce post-operative pain and improve wound healing; 83% reported improved PGI-I. 24 patients with hormone-mediated vestibulodynia who elected not to use hormone treatment, underwent vestibular LiSWT; 54% reported improved PGI-I. 25 menopausal patients with persistent symptoms of Genito-Urinary Syndrome of Menopause (GSM) received multiple vestibular LiSWT treatments; 64% improved PGI-I, including reduction of urinary incontinence. 36 women with PGAD/GPD from lumbosacral annular tear-and/or Tarlov cyst-induced sacral radiculopathy who were not candidates for minimally invasive spine surgery or continued to have symptoms after recovering from spine surgery, underwent multiple treatments of lumbosacral spine LiSWT; 58% reported improved PGI-I. 86 patients with neuroproliferative vestibulodynia (NPV) underwent 2-3 pre-operative sessions of vestibular LiSWT immediately prior to complete subepithelial vestibulectomy surgery; they used significantly fewer opioids post-op than those without pre-operative LiSWT based on historical data prior to 2019. All patients received multiple LiSWT sessions to maximize mechanotransduction effects on genital tissues. There were no significant adverse events noted with LiSWT use. Conclusions Multiple LiSWT sessions are utilized in individuals with vulvas with sexual dysfunction to maximize mechanotransduction. LiSWT is associated with improved sexual health symptoms ranging from 54% - 75%, not associated with any side effects. More research is needed regarding the role of LiSWT for management of various sexual dysfunctions. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Softwave TRT.

Sun pain and solar dysesthesia: A new challenge in clinical practice.

A few patients report intense pain and other unpleasant sensations, such as burning, dysesthesia and hyperalgesia, after even brief exposure to the sun and in the absence of any skin lesion. Sometimes they also develop systemic symptoms, such as mild fever, fatigue, faintness and fainting. As a result, these patients carefully avoid even short-term sun exposure with a consequent severe negative impact on their lives. We have reviewed the clinical findings and the results of photobiological investigations of 10 patients who presented this clinical picture. Six of these patients were previously described by our group with the diagnosis of sun pain. We have reviewed the similarities with other previously described disorders such as solar dysesthesia and PUVA pain and have evaluated possible pathogenetic mechanisms. During phototesting our patients experienced intense pain in the exposed area and in the surrounding skin, without any visible lesion, even with very low sub-erythemal doses. At follow-up, five patients were diagnosed with fibromyalgia, three with a major depressive disorder, one with bipolar syndrome and one with a conversion disorder. The pathogenesis remains unclear, but the use of a psychopharmacological treatment with antidepressants improved both the neuropsychiatric symptoms and sensitivity to the sun in most subjects. For patients with pain and other severe symptoms in the absence of skin lesions and clinical and laboratory manifestations of known photodermatoses, a neuropsychiatric evaluation should be suggested.

Treatment of pediatric spasticity, including children with cerebral palsy, with Botox (onabotulinumtoxinA): Development, insights, and impact.

Spasticity is a velocity-dependent increase in muscle tone that has a negative effect on quality of life and hinders the ability of others to provide care. In children, most cases are caused by cerebral palsy. Traditionally, many children are treated with surgery, sometimes performed before their limbs had grown sufficiently to permit long-term success. Nonsurgical treatment comprises oral pharmacological options, but their efficacy is limited and side effects such as drowsiness and decreased short-term memory are common; nerve block procedures can cause painful dysesthesias and muscle scarring. OnabotulinumtoxinA was first approved for the treatment of pediatric lower limb spasticity in Europe in the 1990s and is now licensed for use in pediatric patients in over 80 countries worldwide, based on a large body of clinical evidence demonstrating its efficacy and safety. In 2019 the U.S. Food and Drug Administration approved onabotulinumtoxinA for the treatment of pediatric patients with upper or lower limb spasticity. This approval represents 3 decades of work to refine the dose, measurements, patient selection, and muscle selection. The availability of onabotulinumtoxinA as a treatment for pediatric spasticity can have a substantial impact on a patient's quality of life. The use of onabotulinumtoxinA in combination with orthoses and occupational/physical therapy can postpone corrective surgery until growth is nearly complete and minimize the number of corrective surgeries.

(004) Using Genital Anesthesia Testing (GAT) in the Management of Bothersome Genital Dysesthesia

Abstract Introduction For women experiencing bothersome genital arousal, pain, or other dysesthesia symptoms (e.g. feelings of itching, burning, pulsating, tearing), it is important to ascertain whether symptoms are secondary to pathology in the genital area, or are referred from upstream pathology in the pelvis or perineum, cauda equina, spine, and/or brain regions. Specific understanding of the location of the trigger associated with the genital dysesthesia is critical to directing treatments for disease modification management. Objectives The aim of this study is to review the methodology of minimally-invasive genital anesthesia testing including the clitoral anesthesia test (CAT – Figures 1a, 1b), vestibular anesthesia test (VAT – Figure 2), urethral anesthesia test (UAT) and/or Bartholin cyst anesthesia test (BAT). Methods Prior to genital anesthesia testing the patient documents the symptom score intensity on a scale of 0 to 10 where 10 is most severe. It is critical that the patient have significant symptoms in the specific genital region(s) (clitoris, vestibule, urethral meatus and/or Bartholin’s cyst); the patient may need to perform some maneuvers to trigger the dysesthesia symptoms and/or reduce or discontinue medications that offer relief from the dysesthesia. The area to be tested is demarcated under vulvoscopic examination with a marking pen. Using a cotton swab as an applicator, benzocaine (20%), lidocaine (8%), tetracaine (8%), (BLT) is first applied to the inner arm to assess for allergies. Assuming there is no allergic reaction, the BLT is applied generously to the specific genital region. If needed, local subcutaneous administration of 1% lidocaine using a 30-gauge needle can supplement the anesthesia. After 10 minutes, provocative maneuvers are performed to determine whether or not there is clinically significant symptom reduction from the pre-genital anesthesia test symptom score. Results A positive genital anesthesia test is consistent with clinically significant symptom reduction from the pre-genital anesthesia test symptom score intensity. A positive genital anesthesia test implies that the local genital region (clitoris, vestibule, urethral meatus and/or Bartholin’s cyst) is the trigger of the genital dysesthesia so appropriate treatment strategies may be offered. For example, a positive CAT may require lysis of adhesions. A positive VAT may require hormone management for hormone mediated vestibulodynia, or vestibulectomy for neuro-proliferative vestibulodynia. A positive UAT may require surgical reconstruction of the urethral meatus. A positive BAT may require marsupialization. A negative genital anesthesia test is consistent with upstream pathology leading to testing of the integrity of the pudendal nerve or assessment of the cauda equina with neuro-genital testing and lumbar/sacral MRI. Conclusions Genital anesthesia testing is an excellent minimally invasive, in office diagnostic test to help localize the trigger of the genital arousal, pain, or dysesthesia in the genital region. Recognizing the location of the trigger associated with the genital dysesthesia as emanating from the genital region rather than the pelvis or perineum, cauda equina, spine, and/or brain region, will allow for disease modification and specific management strategies of the clitoris, vestibule, urethral meatus and/or Bartholin cyst. Disclosure No.

Robotic-Assisted Totally Extraperitoneal (eTEP) Hernia Repair with a Suprapubic Approach for Umbilical and Epigastric Hernias: A Retrospective Study

Abstract Background In the treatment of umbilical and epigastric hernias, during the last years were developed robotic-assisted techniques to avoid intraperitoneal mesh placement. Robotic-assisted transabdominal preperitoneal (eTAPP) and totally extraperitoneal (eTEP) were described and studies reported that both techniques were safe and achieved optimal results. However, no evidence is reported regarding the best technique. Aims The aim of our study was to assess the safety and effectiveness of the robotic-assisted eTEP compared to eTAPP with suprapubic trocar insertion to treat umbilical and epigastric hernias. Methods We selected from a prospectively maintained database patients who underwent robotic-assisted umbilical and epigastric hernia repair with a suprapubic approach, either eTEP or eTAPP. We retrieved clinical and follow-up data and a statistical analysis was carried out. Results During the study period, 53 patients were included. The mean age was 59.0 ± 13.9 years, 45 patients (84.9%) were male and the mean BMI was 28.0 ± 5.9 kg/m2. Most hernias were umbilical (81.1%) and primary (83.0%). Operative time was slightly shorter for eTEP than eTAPP (106 ± 43 min vs. 126 ± 74 min, p=0.232). No intraoperative complications occurred. Postoperatively, only a case of bleeding and a seroma were recorded. The length of follow-up was 11.3 ± 6.4 months in the eTEP group vs. 20.5 ± 9.7 months in the eTAPP group and no case of recurrence, chronic pain, or significant dysesthesia was recorded. Conclusions In our study, we found that the eTEP approach to treat epigastric and umbilical hernias was safe and feasible and achieved excellent perioperative and follow-up results. The outcomes were similar to patients undergoing the eTAPP approach, but with the advantages of a shorter operative time and not entering the peritoneum.

Phlegmasia cerulea dolens with lower leg compartment syndrome.

A 57-year-old man with a history of human immunodeficiency virus infection presented with sudden pain and swelling of the right leg that had developed over the preceding thirty minutes (Panel A). He reported having been taking antiretroviral drugs. Computed tomography (CT) demonstrates partial pulmonary artery embolism and massive deep vein thrombosis extending from the right external iliac to the popliteal veins. Despite commencing anticoagulation, he had severe pain and intense dysesthesia of the right leg. The intramuscular pressure in his right leg was 98 mmHg (reference: <10 mmHg), and his right dorsalis pedis pulse was not palpable. A clinical diagnosis of compartment syndrome secondary to phlegmasia cerulea dolens was made, and he underwent immediate fasciotomy (Panel B). As the dysesthesias did not improve by fasciotomy, catheter-directed venous thrombectomy was performed on day 5 of hospitalization using a 10-French Heartrail ST01 catheter (Terumo, Tokyo, Japan) via a cross-over 12-French DrySeal (WL Gore, Flagstaff, Arizona, USA) from the contralateral femoral vein after placing an inferior vena cava (IVC) filter. Although the final venography revealed restored venous flow, the filter could not be retrieved because of trapped thrombi (Panel C-E, see supplementary data online, Videos S1–S3). Postprocedural CT demonstrated complete thrombosis of the right external iliac vein, and swelling in the right thigh was persistent despite anticoagulation and intermittent pneumatic compression. After the second venous thrombectomy on day 15, the venous flow was completely restored, and the filter was retrieved (see supplementary data online, Videos S4 and S5). He was discharged on apixaban without symptoms of post-thrombotic syndrome (Panel F).

Hand Allodynia, Lack of Finger Flexion, and the Need for Carpal Tunnel Release

The clinical features of classic carpal tunnel syndrome are well known. However, some patients who may respond equally well to carpal tunnel release (CTR) display atypical signs and symptoms. The chief differential features are allodynia (painful dysesthesias), lack of finger flexion, and, on examination, pain on passive finger flexion. The goal of the study was to present the clinical features, increase awareness, facilitate accurate diagnosis, and report the outcomes after surgery. Thirty-five hands, from 22 patients with the main features of allodynia and lack of full finger flexion, were gathered in the period 2014-2021. The other common complaints included sleeping disturbances (20 patients), hand swelling (31 hands), and shoulder pain on the same side as the hand problem with limited range of motion (30 sides). The Tinel or Phalen signs were obscured by the pain. However, pain with passive flexion of the fingers was universally present. All the patients were treated with carpal tunnel release through a mini-incision approach: four patients had a trigger finger, which was treated concomitantly in six hands, and one patient underwent contralateral CTR for carpal tunnel syndrome with a more standard presentation. At a minimum of 6 months of follow-up (mean, 22 months; range, 6-60 months), the pain decreased by 7.5 ± 1.9 points on the Numerical Rating Scale, which ranges from 0 to 10. The pulp-to-palm distance improved from 3.7 to 0.3 cm. The mean Disabilities of the Arm, Shoulder, and Hand score decreased from 67 to 20. The mean Single-Assessment Numeric Evaluation score for the whole group was 9.7 ± 0.6. Hand allodynia and lack of finger flexion may be indications of median neuropathy in the carpal canal, which responds to CTR. Awareness of this condition is important because the uncharacteristic clinical presentation may not be considered an indication for surgery that can be beneficial. Therapeutic IV.

Postoperative dysesthesia after PVCR without anterior support applied in Yang's type A severe spinal kyphoscoliosis.

The incidence and characteristics of postoperative dysesthesia (POD) have not been reported for posterior vertebral column resection (PVCR) in the treatment of severe spinal kyphoscoliosis. The objective of the study is to investigate the incidence and characteristics of POD in PVCR without anterior support applied in Yang's type A severe spinal kyphoscoliosis. From August 2010 to December 2019, 167 patients diagnosed with Yang's type A severe spinal kyphoscoliosis who underwent PVCR without anterior support applied were retrospectively reviewed. All the patients were monitored using five modes of intraoperative multimodal neurophysiological monitoring. Neuromonitoring data, radiographic parameters, and neurological complications were reviewed and analyzed. The incidence and characteristics of POD were further summarized. POD was defined as dysesthetic pain or burning dysesthesia which could be caused by spinal cord kinking or dorsal root ganglion (DRG) injury but with no motor deficits. PVCR without anterior support was successfully conducted in all 167 patients. Intraoperative monitoring events occurred in five patients. One out of these five patients showed postoperative spinal cord injury (Frankel level C) but completely recovered within 9 months postoperation (Frankel level E). The number of levels and osteotomy space for vertebra resection were 1.28 and 3.6 cm, respectively. POD was confirmed in three patients (3/167, 1.8%), characterized as kyphosis with the apex vertebrae in T12 with the kyphotic Cobb angles of 100°, 115°, and 122°, respectively. The osteotomy space of vertebra resection in these three patients were 3.9, 3.8, and 4.2 cm, respectively. After the treatment by drug administration, they reported pain relief for 12-36 days. The pain gradually moved to the distal end of a proper DRG innervated region near the end. In this study, the incidence rate of POD in Yang's type A severe spinal kyphoscoliosis patients who underwent PVCR without anterior support applied was 1.8% (3/167). Evoked potential monitoring could not detect the occurrence of POD. POD in Yang's type A severe spinal kyphoscoliosis after PVCR could be ascribed to spinal cord kinking and DRG injury.

Posterior lumbar interbody fusion for dysplastic lumbar spondylolisthesis with high-grade slippage in two adolescent siblings: two case reports

BackgroundLumbar spondylolisthesis is reported to present with a familiar pattern, with the dysplastic type of spondylolysis being minor but more hereditary than the isthmic type. Siblings presenting during adolescence with neurological symptoms owing to high-grade dysplastic-type spondylolisthesis are rare.Case presentationThe older brother suffered from left leg pain and numbness and dysesthesia of the right posterior thigh and calf and could not walk without a crutch at the age of 15 years. He had canal stenosis with disc bulging and dysplastic bilateral facet joint at L5/S1. The L5 vertebral body was slipped anterior downward to S1, with a round-shaped S1 cranial endplate. We diagnosed dysplastic-type spondylolisthesis and performed posterior lumbar interbody fusion at L5/S with mild reduction and sublaminar wiring at L4/5. The younger brother had no neurological symptoms at age 14 years but suffered from bilateral lower leg numbness at age 18 years. He had canal stenosis with disc bulging at L4/5 and L5/S1 and dysplastic bilateral facet joint at L5/S1 with right pars defect. The L5 vertebral body was vertically displaced anterior to the S1 vertebral body, with an S1 round-shaped cranial endplate. We diagnosed dysplastic-type spondylolisthesis, and posterior lumbar interbody fusion at L4/5 and L5/S with reduction was performed. Their neurological symptoms of the lower legs disappeared, and interbody bone fusion was obtained.ConclusionsThe surgical technique for high-grade dysplastic spondylolisthesis remains controversial in terms of in situ fusion versus reduction. We recommend that surgery be performed promptly at the end of bone maturation because neurological symptoms often appear at the end of bone maturation. Because high-grade slips are rare but siblings may be present, the sibling should also be screened when dysplastic spondylolisthesis is detected.

Surgical Treatment of Painful Nerve Injury after Knee Arthroscopy.

Background; Pain at the surgical site is an important concern, especially in locations of main joints which may resolve important limitations of movement.&#x0D; Materials and Methods; We present the case of painful dysesthesia after knee surgery for traumatic meniscal rupture in a young lady. She presented with painful dysesthesia, limitation of knee flexion, and severe pain in light touch and pressure on the mid-patellar area of the left knee. &#x0D; Tinel’s sign at the site of surgical scar, dysesthetic area (abnormal sensation) corresponded with the medial reticular nerve at surgical exploration under a microscope.&#x0D; Results; Microsurgical exploration of the three nerves of medial subcutaneous nerves revealed the branch stack in the scar. The distal end was internalized subfascial inside the muscle fibers of the medial vastus of quadriceps femoris muscle according to Dellon. The other two were released from adherences and found to be in anatomical continuity were left in place. Immediate resolution of dysesthesia was referred by the patient and the amplitude of motion was complete at one-month postoperative control. She remains pain-free 4 months from surgery and the area of dysesthesia remains anesthetic at the center.&#x0D; Conclusions; Surgical identification and rerouting of the distal end of sensitive nerves is an efficient treatment after peripheral nerve injury.

Sex Differences in the Mediating Effect of Kinesiophobia on Chronic Pain, Dysesthesia, and Health-Related Quality of Life in Japanese Individuals Aged 65 Years Old and Older Treated with Surgery for Lumbar Spinal Stenosis.

PurposeThis study aimed to determine whether kinesiophobia mediates the relationship between low back pain (LBP), leg pain (LP), and leg dysesthesia (LD) and health-related quality of life (HRQOL) among Japanese individuals aged 65 years old and older treated with surgery for lumbar spinal stenosis (LSS).Patients and MethodsData collection for this study took place between October 2019 and August 2020 at two Japanese medical facilities. Eligibility criteria for participants in this study were individuals aged 65 years or older and those who had undergone surgery for LSS at least more than one year ago. A self-administered questionnaire assessed the intensity of LBP, LP, and LD (numerical rating scale: NRS), HRQOL (EuroQol-5 Dimension-5 Levels: EQ-5D-5L), and kinesiophobia (Tampa Scale for Kinesiophobia-17 items: TSK-17). Mediation analysis using sex as a control variable was conducted.ResultsComplete responses were obtained from 238 of 431 individuals (73.1 ± 5.1 years; 135 males and 103 females). The mediating effect of NRS scores for LBP, LP, and LD to EQ-5D-5L index on TSK-17 score was significant, respectively (LBP: −0.007 [95% confidence interval −0.012, −0.004], p = 0.000; LP and LD: −0.007 [−0.011, −0.004], p = 0.000). The strength of the association between NRS scores and EQ-5D-5L index decreased when the mediating effect of TSK-17 score (LBP: β = −0.698 [−0.792, −0.603], p = 0.000 to β = −0.616 [−0.707, −0.524], p = 0.000; LP: β = −0.629 [−0.729, −0.529], p = 0.000 to β = −0.539 [−0.638, −0.440], p = 0.000; LD: β = −0.568 [−0.675, −0.460], p = 0.000 to β = −0.482 [−0.586, −0.378], p = 0.000). The mediating effect of TSK score was greater in females than males.ConclusionKinophobia partially mediated the relationship between LBP, LP and LD, and HRQOL in Japanese aged 65 years and older after lumbar surgery. The mediating effect differed by sex.

Decompression of the lateral femoral cutaneous nerve of the thigh : Treatment of meralgia paresthetica

Treatment of non-responding pain to conservative treatment located at the anterolateral thigh with surgical decompression of the lateral femoral cutaneous nerve of the thigh (LFCN). Compression syndrome of the LFCN; patients suffering from the following symptoms: pain (dysesthesia), numbness (paresthesia), hypersensibility to temperature (or temperature changes) along the course of the LFCN located at the anterolateral thigh. Anew or recrudescent hernia with additional pain or recent laparoscopic hernia repair as asupposed iatrogenically induced compression of the LFCN. Dissection and release of the LFCN of connective tissue, scar tissue, bone rims, and retraction located along the passage underneath the inguinal ligament and distally. Suture removal after 10-14days, no sports for 2weeks. Physiotherapy if necessary. Neurography 4months after surgery (obligatory if symptoms are persistent). The patient should be followed up for about 24months. Of the patients, 69% had a history of trauma or surgery, which were designated as the onset of pain. Of these patients, 78% had hip prostheses and 22% had previous falls. Postoperatively, asignificant reduction of pain of 6.6points on the numeric rating scale was observed. All other evaluated parameters also improved postoperatively. Patient satisfaction was high, with 86% reporting complete satisfaction, and 14% reporting partial satisfaction.

Unusual concomitant small‐ and large‐fiber neuropathy related to hypereosinophilic syndrome

AbstractBackgroundSmall‐fiber neuropathy is a disorder clinically dominated by neuropathic pain and autonomic symptoms. In &gt;50% of patients, no etiology can be identified. and some evidence suggests a possible role of the immune system. Among the most common manifestations of hypereosinophilic syndrome, neurological lesions have been described in the central and peripheral nervous systems. No correlation between idiopathic hypereosinophilia with systemic involvement and small‐fiber neuropathy has been described before.Case presentationWe present the case of a 21‐year‐old woman with large‐ and small‐fiber neuropathy associated with systemic idiopathic hypereosinophilic syndrome. The patient manifested a subacute itchy rash to the limbs and trunk with painless lymphadenopathy of the neck and groin, persistent lack of appetite, vomiting, and subsequent painful dysesthesia on the feet. At blood test, eosinophilic leukocytosis was detected, electrophysiological studies showed axonal sensory neuropathy on the sural nerve bilaterally, cerebrospinal fluid analysis showed a cytological–albumin dissociation, and skin biopsy was decisive in confirming a severe picture of the small fibers pathology and lymphocytic infiltrates with eosinophils in the dermis. The in‐depth diagnostic investigations excluded other significant alterations and pathologies. After steroid and immunoglobulin therapies, the patient progressively improved with resolution of the rash and vomiting episodes, resuming regular nutrition and obtaining important reduction of painful dysesthesia.ConclusionsIn the present case, we hypothesized that idiopathic hypereosinophilic syndrome was the likely cause of the atopic dermatitis and small‐fiber neuropathy, consistent with pain and dysautonomic symptoms.

Roles of TRPA1 in Painful Dysesthesia

Dysesthesia is an unpleasant abnormal sensation, often accompanied by pain, paresthesia (abnormal sensation), and numbness (decrease or loss of sensation). Dysesthesia has been associated with various conditions, although its underlying mechanisms are largely unknown. This study assessed the roles of transient receptor potential ankyrin 1 (TRPA1) in dysesthesia by utilizing three animal models of dysesthesia characterized by reductions in blood flow to the skin: a transient hindlimb ischemia/reperfusion model, characterized by spontaneous licking and tactile hypoesthesia of the ischemic hindpaw; a streptozotocin-induced diabetic neuropathy model in mice, characterized by cold hypersensitivity, which is likely parallel to the reduced skin blood flow of the hindpaw; and a hindlimb ischemia model. TRPA1 inhibition or deficiency blocked spontaneous licking in the transient hindlimb ischemia/reperfusion model and cold hypersensitivity in the diabetic mouse model mice. Consistent with these results, the nocifensive behaviors induced by intraplantar injection of a TRPA1 agonist were enhanced in the diabetic neuropathy and hindlimb ischemia models. Hypoxia enhanced H2O2-induced TRPA1 responses in human TRPA1-expressing cells and cultured mouse dorsal root ganglion neurons, with this hypoxia-induced TRPA1 sensitization to H2O2 being associated with hypoxia-induced inhibition of the hydroxylation of prolyl hydroxylases. These results suggest that dysesthesia following blood flow reduction is caused by the activation of TRPA1 sensitized by hypoxia and that hypoxia-induced TRPA1 sensitization plays a pivotal role in painful dysesthesia induced by peripheral blood flow reduction.

Neuropathic Pain Prevalence of Older Adults in an Urban Area of Iran: A Population-Based Study.

Background Pain prevalence would increase as the population grows older, but the exact prevalence rate is not apparent in Iran. Objectives This study, therefore, set out to reveal the prevalence of pain, especially neuropathic type and explore its associated comorbidities among Iranian older adults in a large urban population-based survey. Methods 5326 older people, aged ≥ 60 years, were randomly chosen by a multistage, cluster sampling method. The selected people then were interviewed by using the following instruments: a standard questionnaire about pain, questions of interview part of Douleur Neuropathique 4 Questions (DN4) and its comorbidities, GHQ-28, and a sociodemographic checklist. Descriptive statistics and multiple regression analysis were conducted to analyze the gathered data. Results The average of the participants' age was 68.92 ± 7.02 years. Of 5326 participants, 2529 (47.5%) of participants were male. About one-third of this population had chronic pain. Chronic neuropathic pain prevalence was 13.7% and nociceptive in 30%. Knee pain (20.6%) and feet dysesthesia (7.8%) were the most common sites of nociceptive and neuropathic pain, respectively. Results of multiple regression analysis revealed that the major comorbidities of chronic pain were osteoporosis, disability, diabetes mellitus, and stroke. Neuropathic pain experiences were significantly associated with GHQ-28 scores (t=-11.42, P<0.001). Conclusions In addition to neuropathic pain, other subtypes of pain prevalence and the comorbidities are determined in the community-dwelling elder adults. This study highlights the importance of neuropathic pain and its adverse consequences and can be used to manage this populations' needs in Iran effectively.

OZONE THERAPY IN DIABETES AND ITS COMPLICATIONS

OZONE THERAPY IN DIABETES AND ITS COMPLICATIONS

Role of TRPA1 in ischemia/reperfusion-induced painful dysesthesia and oxaliplatin-induced cold hypersensitivity

Role of TRPA1 in ischemia/reperfusion-induced painful dysesthesia and oxaliplatin-induced cold hypersensitivity

Spinal Cord Stimulator Explantation: Motives for Removal of Surgically Placed Paddle Systems.

Despite requiring successful trials prior to implantation, spinal cord stimulation (SCS) systems for pain are often later removed. Removing surgically implanted hardware subjects patients to the risks and discomfort of a second surgery, threatens the cost-effectiveness of SCS, and limits the perceived durability of SCS technology for pain problems. To investigate patterns of reasons given among patients who underwent SCS explant surgery (SCSES). Retrospective review of SCSES cases over 17 years at Allegheny General Hospital, Pittsburgh, PA. 165 patients underwent SCSES between 1997 and 2014. The top 3 reasons for explantation were inadequate pain control (IPC; 73%), hardware discomfort (22%), and need for magnetic resonance imaging (MRI) (10%). Other less frequent reasons were infection (9%), painful dysesthesias (9%), electrical arcing (4%), resolution of inciting symptoms (4%), weakness (2%), pseudomeningocele (1%) and muscle spasms (1%). Inadequate pain control is the most common reason for SCSES. Advances in technology are needed to improve the quality and duration of pain control, as well as to design improvements to make the hardware more comfortable. A significant number of implants are removed due to need for MRI, a fact obviating the need for MRI-compatible systems. Patients considering SCS paddle lead placement should be counseled on the most common reasons for later explantation.

The Effect of Gabapentin Enacarbil on Pain Associated with Moderate-to-Severe Primary Restless Legs Syndrome in Adults: Pooled Analyses from Three Randomized Controlled Trials.

Adults with moderate-to-severe primary restless legs syndrome (RLS) often experience painful dysesthesias, which may lead to impaired quality of life. The aim of this study was to assess the effects of gabapentin enacarbil (GEn) on pain associated with moderate-to-severe primary RLS in adults. Data were pooled from three double-blind, randomized, placebo-controlled, 12-week trials (NCT00298623, NCT00365352, NCT01332305) for adults receiving GEn or placebo once daily. Change in average daily RLS pain score and a combined International Restless Legs Scale (IRLS)-pain response were examined. The modified intention-to-treat population included 671 adults (placebo, n=244; GEn 600mg, n=161; GEn 1200mg, n=266). Both GEn doses significantly improved average daily RLS pain score at week 12 (p<0.001 for GEn 600mg vs. placebo and GEn 1200mg vs. placebo). The combined IRLS-pain response subanalysis included 366 patients with a baseline IRLS total score ≥15 and pain score ≥4 (placebo, n = 133; GEn 600mg, n = 86; GEn 1200mg, n=147). Most patients were both IRLS and pain responders (placebo, 40%; GEn 600mg, 70%; GEn 1200mg, 67%). Spearman rank correlations between IRLS total and pain score (change from baseline to week 12) were moderate or strong. The most frequent treatment-emergent adverse events were somnolence (placebo, 5%; GEn 600mg, 20%; GEn 1200mg, 23%) and dizziness (placebo, 4%; GEn 600mg, 13%; GEn 1200mg, 22%). This post hoc pooled analysis suggests that GEn (600 and 1200mg) once daily significantly improved pain associated with moderate-to-severe primary RLS in adults; however, the analysis was not powered to detect statistical differences between the two GEn doses. Numerically, more GEn-treated patients had a combined IRLS-pain response than placebo-treated patients.