KR101444235B1 - A Diagnosis Method of Complex Regional Pain Syndrome Type 1 Using Correlation of Hypothalamic pituitary adrenal axis function - Google Patents

Abstract

The present invention relates to the diagnosis of CRPS-1 disease, and more particularly, to a method of using the correlation of function of chronic pain-depression-adrenal endocrine axis to provide information necessary for diagnosis of CRPS-1 disease accompanying depression To a method of evaluating cortisol levels from saliva as an indicator of HPA axis function.

Description

A method for diagnosing CRPS-1 disease using correlation of pituitary contractile function {A Diagnosis Method of Complex Regional Pain Syndrome Type 1 Using Correlation of Hypothalamic pituitary adrenal axis function}

The present invention relates to the diagnosis of CRPS-1 disease, and more specifically, to provide information necessary for diagnosis of CRPS-1 disease by using a correlation between functions of the spontaneously-adrenal endocrine axis, axis as an indicator of the function of the cortisol.

Complex Regional Pain Syndrome (CRPS) dms is a type of chronic refractory pain disorder classified as the most severe chronic pain classified by pain intensity classification.

Since there is no useful objective laboratory test for the accurate diagnosis and progression of Complex Regional Pain Syndrome (CRPS), the clinic depends entirely on the patient 's symptoms and signs for diagnosis. Therefore, there are cases that are diagnosed or abused for reimbursement. If you strengthen the standard to prevent it, or if you mainly trust the test results, it may affect the progress of the treatment. Can be deprived.

Because of these problems, several diagnostic criteria have been suggested for accurate diagnosis. Currently, modified diagnostic criteria of the International Association for the Study of Pain (IASP) are used for clinical and research purposes. . However, the development of more advanced diagnostic criteria and objective laboratory tests is required.

CRPS has a spectrum of extremely diverse symptoms. In other words, not all CRPS patients suffer from the same symptoms, and even if they have the same symptoms, they differ in magnitude. There is only one momentary state for the overall condition of CRPS patients, It is generally accepted that the symptoms described by the patient are more likely to be evaluated overall than the objective signs that are reflected. Therefore, the symptoms described by the patient play an important role in the diagnosis of CRPS patients. However, on the other hand, it is important to clearly distinguish between cases involving lawsuits and compensation, as they may mimic symptoms or appeal excessively.

In particular, there are many such CRPS patients in the army because there is a real benefit of military service exemption to soldiers, and a combination of mental and physical discomfort as a passive object of conscription. Psychiatric treatment is always linked to the field of chronic pain patients because depression and suicide in the home are also related.

Therefore, there is a need for objective and scientific predictors that can be easily accessed and interpreted in clinical medicine and clinical practice.

The present inventors have found that the frequency of the spontaneous lesion can be diagnosed and predicted by evaluating the cortisol level as an index of the HPA axis function based on the correlation between the CRPS and the adrenal endocrine axis, We have devised a new diagnostic method for CRPS disease that exploits the interaction of the function of the endocrine axis (HPA axis).

It is an object of the present invention to identify the correlation between Complex Regional Pain Syndrome (CRPS) and HPA axis function.

Another object of the present invention is to provide information necessary for diagnosis of Complex Regional Pain Syndrome (CRPS) disease.

In order to achieve the above object,

Methods for assessing cortisol levels from saliva as an indicator of HPA axis function are provided to provide information needed to diagnose Complex Regional Pain Syndrome (CRPS) disease.

Particularly, the complex site pain syndrome disease includes depression which is affected by the HPA axis function and does not involve the first type or the second type.

In the method of the present invention, the cortisol level evaluation is characterized by analyzing the concentration of cortisol measured from the saliva collected within 1 hour after the gas phase, continuously or discontinuously for a part or all of the period of 1 to 7 days, The cortisol concentration is preferably measured from the saliva collected immediately after the gas phase, 30 minutes after the gas phase and 1 hour after the gas phase, and most preferably measured from the saliva collected 30 minutes after the gas phase.

On the other hand, the information required for diagnosis of the complex site pain syndrome diseases which can be obtained by the method of the present invention is most typically related to the frequency of spontaneous pain attacks.

Particularly, the inventors of the present invention have for the first time established that the level of cortisol and the frequency of spontaneous vomiting are inversely proportional to the complex site pain syndrome disease,

The lower cortisol level was judged to be due to a decrease in the function of the pituitary gland (HPA axis) and an increase in the frequency of spontaneous palsy in CRPS-1 disease,

The higher cortisol levels can be attributed to increased pituitary contractile function and reduced frequency of spontaneous palsy in CRPS-1 disease.

As described above, the present invention is capable of evaluating the HPA axis function and the frequency of spontaneous pituitary palsy in the CRPS disease based on the change in post-gas phase concentration of cortisol over a certain period of time, Information can be provided.

BRIEF DESCRIPTION OF THE DRAWINGS Figure 1 is a simplified diagram illustrating the protocol for the experiment of the present invention.
Figure 2 shows the cortisol profile of the pain medication (On med), 72 hours after off-dosing (Off-Med), and 8 hours after dosing with dexamethasone (off-med / Dex).
FIG. 3 shows the results of a daily cortisol profile for each group by dividing the patients into two groups (0 to 4 times / day and 5 times / day for the number of spontaneous vasoconstriction) using a K-mean clustering mothod based on the number of spontaneous pain.
FIG. 4 is a graph showing differences in CARauc (A), CARi (B) and slope beta (C) for each patient group.

The terms used in the present invention are defined as follows.

"Diagnosis" means identifying the presence or characteristic of a pathological condition. For the purpose of the present invention, the diagnosis is to confirm the onset of acute myocardial infarction. Especially, it is useful for the occurrence of acute ST segment elevation myocardial infarction.

"Subject" or "patient" means any single entity that requires treatment, including human, cow, dog, guinea pig, rabbit, chicken, In addition, any subject who participates in a clinical study test that does not show any disease clinical findings, or who participates in epidemiological studies or used as a control group is included. In the present invention, the present invention was applied to humans.

"Sample" or "sample" refers to a collection of similar cells obtained from a subject or tissue of a patient. The source of the tissue or cell sample may be a solid tissue from fresh, frozen and / or preserved organ or tissue sample or biopsy or aspirate; Blood or any liquid type tissue. In the present invention, saliva is used.

"Label" or "label " means a compound or composition that facilitates the detection of a reagent, such as a reagent conjugated, conjugated, conjugated, or fused to a nucleic acid probe or antibody. The label may itself be detected (e. G., A radioactive isotope label or a fluorescent label), in the case of an enzyme label, to catalyze the chemical modification of the detectable substrate compound or composition.

An "effective amount" is an appropriate amount that affects a beneficial or desired clinical or biochemical outcome. An effective amount may be administered one or more times. For purposes of the present invention, an effective amount of an inhibitor compound is an amount sufficient to temporarily alleviate, ameliorate, stabilize, reverse, slow down, or delay the progression of a disease state. If the recipient animal is capable of enduring the administration of the composition, or the administration of the composition to the animal is suitable, the composition will be "pharmaceutically or physiologically acceptable ". If the dose administered is physiologically significant, it can be said that the formulation is administered in a "therapeutically effective amount ". The formulation is physiologically relevant if the presence of the formulation results in a physiologically detectable change in the recipient.

"Treatment" means an approach to obtaining beneficial or desired clinical results. For purposes of the present invention, beneficial or desired clinical results include, but are not limited to, alleviation of symptoms, reduction in the extent of disease, stabilization of the disease state (i. E., Not worsening), slowing or slowing the progression of the disease, (Either partially or totally), detectable or undetected, whether or not an improvement or temporary relief or reduction Also, "treatment" may mean increasing the survival rate compared to the expected survival rate when not receiving treatment. Treatment refers to both therapeutic treatment and prophylactic or preventative measures. Such treatments include treatments required for disorders that have already occurred as well as disorders to be prevented. &Quot; Palliating " a disease may reduce the extent of the disease state and / or undesirable clinical symptoms and / or delay or slow the time course of the progression, It means to lose.

"About" means that the reference quantity, level, value, number, frequency, percentage, dimension, size, quantity, weight or length is 30, 25, 20, 25, 10, 9, 8, 7, , Level, value, number, frequency, percent, dimension, size, quantity, weight, or length that varies from one to three, two, or one percent.

Throughout this specification, the words " comprising "and" comprising ", unless the context requires otherwise, include the stated step or element, or group of steps or elements, but not to any other step or element, And that they are not excluded.

Hereinafter, the present invention will be described in detail.

The present invention relates to providing information on the diagnosis of CRPS-1 disease.

Complex Regional Pain Syndrome (CRPS) is divided into Type 1 and Type 2, and Type 2 complex site pain syndrome is caused by nerve injury, Respectively.

The most common types of pain that patients are exposed to are burning, deep, sharp, and sensitive. Like other chronic pain disorders, mechanical stimuli, changes in ambient temperature, emotional stress The physical examination includes brushing, pushing, pin prick, cold stimulation, heat stimulation, etc., to confirm the trigeminal and sensory abnormalities. It can range from mild edema to painful pitting edema. It is not uncommon to have swelling or swelling even in the absence of actual edema. The degree of edema may vary with the progression and is often improved by treatment with a spinal cord stimulator.

CRPS causes disability of physical function caused by pain and reduces normal daily life ability as well as accompanying psychological diseases such as sleep disorder, emotional unrest, and depression. In particular, depression occurs in more than half of the CRPS patients and also negatively affects CRPS chronicity and after treatment. Depression is seen repeatedly after chronic pain treatment, and depressed patients show considerable deficiencies in societal and interpersonal relationships and are accompanied by a high frequency of suicide attempts.

Neuropsychiatric tests are often used in patients with CRPS because they can be accompanied by depression, anxiety, sleep disturbances, and other disabilities as well as other chronic pain patients, .

Therefore, clinical symptoms or signs are crucial for the diagnosis of CRPS, but additional tests should be conducted to objectively demonstrate this. As a secondary diagnostic test, there are simple radiological examinations, three - phase bone scan, thermography, and QSART. However, in 50% of the patients with CRPS, only 50% of the patients are diagnosed with secondary diagnosis. Therefore, they should be regarded as reference level for diagnosis, and it is not always accurate to judge the appropriateness of treatment or to predict the prognosis . In other words, there are no single tests that can be diagnosed, and the symptoms and signs that appear to the patient are examined, and clinical examination and other detailed tests are integrated and diagnosed

The present invention relates to a novel method of exploiting the correlation of the function of the CRPS-adrenal endocrine axis (HPA axis) in order to provide more accurate and effective information in the diagnosis of such CRPS disease.

In particular, it provides information for the diagnosis of CRPS disease based on the new finding of the correlation between frequency of spontaneous pain and dysfunction of adrenal endocrine axis (HPA axis). In addition, by using an easy method for measuring the level and the change in the cortisol level from the saliva in comparison with the conventional complicated and complex diagnosis method, it is possible to more simply and conveniently use the information necessary for diagnosis of CRPS-1 disease .

CRPS-interrelationship of functional abnormalities of adrenal endocrine axis (HAP axis)

(1) Relationship between HPA axis and CRPS

Patients with CRPS complain of severe pain, and these extreme pain can result in unbearable physical and mental stress on the patient. Theoretically, these extreme stresses are transmitted to the brain's limbic system through the autonomic nervous system, which acts on the hypothalamus-pituitary-adrenal axis (HPA), which is the central axis of the endocrine system, And changes in hormone production, bovine circadian rhythm and hormone production. Pain is recognized by pain receptors, converted into electrical and chemical signals, transmitted to the cerebrum through chuck receptors, activated through the cerebral limbic system and activated by the adrenal endocrine axis (HAP axis) The secretion of cortisol is increased. In addition, the pain activates the LC / NE locus ceruleus-norepinephrine-autonomic nervous system and ultimately the concentration of epinephrine and the concentration of IL-6, C-reactive protein, IL-1-beta and TNF-alpha It is known to induce a rise. Continuous pain and inflammation factors maintain a high cortisol level by interfering with hormonal control by the feedback of the HAP axis. High cortisol levels are responsible for memory and emotional stability, as well as brain tissue that inhibits excessive activation of the adrenal endocrine axis , Hippocampus and amygdala.

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The present invention is based on the correlation of the CRPS and the adrenal endocrine axis, and is characterized by evaluating the cortisol level as an index of the HPA axis function.

Thus, the present invention, in one aspect, relates to a method for assessing cortisol levels from saliva as an indicator of HPA axis function to provide information necessary for the diagnosis of CRPS disease.

The "cortisol", known as the stress hormone, is a steroid hormone secreted by the adrenal cortex.

Adrenal rhythm is known to be regulated by cranial nerves, hypothalamus, and pituitary, and is fundamentally determined by the individual's sleep cycle. After sleeping normally at night, it wakes up in the morning when it wakes up in the morning. This signal reaches the suprachiasmatic nucleus (SCN) of the hypothalamus, and bioclock gene is activated, and this signal is transmitted to the paraventricular nucleus PVN. In the nucleus of the ventricle, the adrenocorticotrophic hormone (ACTH) is produced and secreted in response to this stimulus. The concentration of adrenocorticotropic hormone produced and secreted by the pituitary gland reaches its peak at 15 minutes after the meteoric rise. Adrenocorticotropic hormone secreted into the blood acts on the adrenal gland to increase the production of corticosteroid cortisol.

Therefore, the peak cortisol concentration is about 30 minutes after the gas phase, and the cortisol concentration at that time is the highest in the day. The cortisol response (cortisol awakening response below CAR) is the phenomenon that cortisol reaches its normal level in about 30 minutes after waking up in the morning. It is known that CAR is not affected by general sleeping environment, light, sleeping time, and health condition.

In the present invention, the level of this cortisol is evaluated, specifically, cortisol reaction (CAR) according to the gas phase; Evaluating the function of the adrenal endocrine axis (HPA axis) by evaluating the cortisol intracavitary rhythm, preferably the diurnal cortisol decline rhythm, and further evaluating the frequency of the vital pain of the CRPS.

The cortisol circadian rhythm evaluation is an indicator for determining whether cortisol diurnal rhythm is normal or not, and at the same time, it is an indicator for determining whether the endocrine endocrine function is normal. CAR index, which is the concentration of cortisol in the saliva of the cortisol reactor depending on the vapor phase; Sleep index, which is the concentration of cortisol in saliva immediately before bedtime, and the like.

In particular, the cortisol measured in the method of the present invention is characterized in that it is present in "saliva".

Meanwhile, the concentration of hormones was measured mainly in the blood. From an endocrinology standpoint, blood is not the target organ of the hormone but a mere hormonal transport medium. Most blood protein-based hormones (growth hormones, insulin, etc.) are well soluble in water and are present in an active form in the blood, but steroids produced in the adrenal cortex and gonads are not well soluble in water, And is present in the blood. When steroids are combined with the carrier medium, they are inactive and can not induce a physiological mechanism because they do not act on the hormone receptor of the target organ. Most of the steroids in the blood (95-99%) are present in this inactive state, and only a few (1-4%) are known to be in an unbound state (active state) with the carrier medium. Therefore, the concentration of steroid in the blood can be said to be the most inactive state rather than the active hormone concentration.

In contrast, the steroids contained in saliva are in an active state that is not bound to the carrier medium, unlike blood, and active steroids contained in the extracellular fluid of the saliva are activated by passive diffusion, . Therefore, the concentration of steroid in saliva is recognized as the active steroid in the tissue.

In addition, unlike blood, saliva has the advantage of being able to easily study the daily rhythm of the hormone of the individual because it can be easily collected by the general public in accordance with the sleep cycle of the individual without the help of the medical staff. In other words, the use of saliva has the advantage of easy access to the concentration of active steroids, which was difficult to access to blood, and to the individual's daily rhythm of hormones.

The present invention measures the concentration of cortisol present in the saliva, and the above advantages can be effectively exhibited.

However, since the concentration of steroid contained in the saliva is as low as 1 / 100-1 / 1000 of the blood, it is preferable to use a saliva purification method such as the following method for measuring the concentration of a small amount of cortisol contained in the saliva Can be used.

(a) treating the collected saliva with a strong base of pH 12-14;

(b) heating and cooling; And

(c) a neutralization step; And

(d) Mucoadhesive protein (mucosal) removal step.

In this case, it is preferable to further include a step of removing the digestive enzymes and bacteria denatured by the pH and heat from the saliva by centrifugation after the step (b), and the step (d) Is further preferably performed. For a more detailed method, refer to Korean Patent Publication No. 10-2012-0066598.

Cortisol level measurement

In the present invention, it is preferable that the cortisol concentration is measured from saliva after the gas phase, preferably within 1 hour after the gas phase. More preferably, it can be carried out immediately after the gas phase, 30 minutes after the gas phase, and 1 hour after the gas phase.

During a period of time, the concentration change of salivothiazol, which occurs continuously or discontinuously during the first hour after the meteorological phase, is measured for some or all of the periods of 1 to 7 days, without limitation.

For example, in one embodiment of the present invention, the cortisol concentration for 6 days is measured, and on-med, 5-off-med, 6-day (om-med) The concentration of cortisol (level) in the saliva was measured by collecting saliva samples immediately after the meteorological phase, 30 minutes after the meteorological phenomenon and 1 hour after the meteorological day.

It is well known to those skilled in the art to best obtain the accuracy in cortisol concentration determinations. The sample may then be sent to the test facility, and the results may be obtained, for example, via the Internet. In addition, measurements can be made at the original location and supplied as a Palm Pilot. Saliva samples do not have to be handled in any particular way and are stable at room temperature for a long period of time, so there is a way to plot and place cortisol levels over time within 1 hour after meteorological.

It also provides objective measures to individuals, allowing individuals to make decisions based on changes in cortisol concentrations without having to consult a health care professional who manages the test and interprets the results.

In the present invention, various methods available in the art can be used to measure the cortisol concentration. That is, although there is no limitation, preferably, a radioimmunoassay method can be used.

For example, enzyme immunoassay (EIA) using enzymes as markers, chemiluminescence immunoassay (CIA) with increased sensitivity to luminol or its derivatives or aminobutyl-ethylisoluminol (ABEI), or fluorescent label Fluorescence immunoassay (FIA) using fluorescence immunoassay (FIA) may be used. In particular, it is preferable to use radioimmunoassay.

The radioimmunoassay has many advantages such as high sensitivity, precision, and accuracy and allows clear and clear detection after the reaction. Most preferably, the radioimmunoassay can be used For this, a liquid-phased-double antibody method can be used. More detailed measurement procedures are described in the literature on the measurement of hormones using the liquid-double antibody method (Salivary cortisol and DHEA levels in the Korean population, age-related differences, diurnal, and correlations with serum levels. Yonsei Med J. 2007; 48: 379 -88). ≪ / RTI >

Most of the hormone analyzes mainly use immunoassay using an antigen-antibody reaction. Since various foreign substances act as a factor of disturbance in the antigen-antibody reaction process and often show different results from actual hormone levels, Immunoassays allow more accurate concentration measurements.

judgment

In one embodiment, CRPS disease-related information can be obtained from the cortisol data measured.

In particular, the present inventors have for the first time confirmed that the frequency of spontaneous vaulting is correlated with a reduction in total cortisol levels in CRPS-1 patients. In other words, it was the first time that the cortisol level, an index of function of the HPA axis, was inversely proportional to the frequency of pain.

Therefore, based on the above finding that the abnormality of the pituitary gland contraction (HPA axis) in CRPS disease is closely related to the frequency of spontaneous vomiting, in the method of the present invention,

The lower cortisol level was judged to be due to decreased HPA axis function and increased frequency of spontaneous palsy in CRPS-1 disease. The higher cortisol level was associated with increased pituitary contractile function and the frequency of spontaneous pneumothorax As shown in Fig. More specific criteria will be described in the following examples.

Preferably, the frequency of the spontaneous vocal cords is determined using a cortisol concentration change of 30 minutes (AC 30 min) after the gas phase.

As described above, the present invention is capable of evaluating the HPA axis function and the frequency of spontaneous pituitary palsy in the CRPS disease based on changes in post-gas phase concentration of cortisol over a certain period of time, It can provide the key information needed for the diagnosis of CRPS.

Example

Hereinafter, the present invention will be described in more detail with reference to Examples. It is to be understood by those skilled in the art that these examples are for illustrative purposes only and that the scope of the present invention is not construed as being limited by these examples.

Preparation for experiment

1. Patients

Patients diagnosed with CRPS-1 (Complex Regional Pain Syndrome Type 1) were admitted with permission from the Armed Forces Capital Hospital (AFCH) anesthesiology department. All patients met the current diagnostic criteria for CRPS-1 being used in the art [Huygen FJ et al., Eur J Appl Physiol 2004; 91: 516-24.]. Patients (n = 12) who are currently undergoing interventional therapy (eg, sympathetic blockade) or who have received glucocorticoid therapy or systemic glucocorticoid therapy within 30 days have not shown any signs of hypertension, diabetes or other systemic disorders I excluded.

CRPS-1 patients followed the instructions for the inventive process shown in FIG. A total of 22 patients (mean age 21.9 ± 2.6 years) participated in the process of the present invention after 80 hours of medication. The data obtained from the above 22 patients were analyzed. The experiments were carried out according to the Helsinki Declaration, with the consent of the patients, and the protocol was approved by the Clinical Study Deliberation Committee of the Military Hospital.

2. Severity of disease ( disease severity )

In some CRPS-1-related measurements, such as the VAS (visual analog scale), the temperature difference and the number of spontaneous burning pain outbreaks (ie, spontaneous vestibular frequency) in 22 patients were confirmed on the first day. (Ie, minimal pain level) and stimulus-independent spontaneous vocalizations (ie, pain) on their VAS score, eg, a 10-cm unlabeled VAS (0, no pain; , Maximum pain level). The VAS scores of the patients were recorded each day (the day before the experiment and the first day of the experiment) and the average VAS scores were summarized in Table 1

Patients complained of difficulty in distinguishing their pain from deep pain and spontaneous vomiting. Therefore, it was difficult to determine this VAS score without taking medication.

The basal skin temperature including limbs and the basal skin temperature corresponding to the area not including limbs were measured on the day before the experiment.

Each patient stayed in the waiting room (25 ° C) for at least 20 minutes before measuring the basal skin temperature with a computer-assisted infrared thermograph (Model IRIS 5000, Medicore Co., Seoul, Korea) at room temperature (25 ° C). Before recording the temperature measurement, the camera was calibrated using the scale inside the software system.

The temperature sensitivity of the thermometer was 0.08 ~ 30 ℃ and the built-in digital video was 320 · 240 pixels (total 76,800 pixels). The average temperature of each limb was calculated from the video temperature recorder record. The absolute difference was determined by subtracting the mean temperature from the mean temperature including limbs.

Health status, stress, and other factors. Because psychological feelings and stressful events may also be related to late-on cortisol levels and CAR, patients were instructed to record the frequency of spontaneous vomiting on the day prior to saliva sample collection. The type of CRPS-1 spread from the initial site was determined according to the previous study method [Maleki J, et al., Pain 2000; 88: 259-66].

Pain-related measurements are summarized in Table 1 above, and drug dosing to the patient at primary saliva collection is as described below.

3. saliva collection Saliva collection )

Three different sets of saliva samples were successively collected from each of the 22 CRPS-I patients (Fig. 1).

One set of samples was collected during on-medication (on-Med, step 1) and the second batch was collected 72 hours after discontinuation of the drug (off-Med, step 2). Patients were dosed with 1 mg dexamethasone at 2230 hours after saliva sample collection at night time in step 2. A third set of saliva samples were collected the following morning (off-Med / Dex, step 3)

In the first and second steps, saliva samples were collected immediately (0 min), 30 and 60 minutes after the wake, and 4, 10 and 16 hours after the wake (i.e. 10:00, 16:00 and 22:00 h). In step 3, saliva was collected at 0, 30 and 60 min after the meteorological phase.

Age-matched medical assistants at AFCH were enrolled as healthy controls (n = 28, age = 21.3 ± 1.8 years) and exclusion criteria were accepted from previous studies.

Saliva samples were collected as instructed by healthy subjects and all participants were allowed to smoke, drink no water, or brush their teeth within 30 minutes prior to saliva collection. As with the other residents of the military barracks, patients and normal controls were allowed to wake up at 06:00.

The first saliva samples were collected within 5 minutes after the meteorological phase in stages 1, 2 and 3, and the saliva samples at night were collected within 5 minutes after the one-month mark (22: 00h)

After debridisation, the collected samples were stored at -70 ° C and the samples were dissolved and centrifuged (10,000 xg for 15 min at 4 ° C) to extract mucin. The supernatant was collected and stored at -70 [deg.] C for analysis.

4. Measurement of saliva cortisol

Cortisol concentrations in saliva were measured by radioimmunoassay (RIA).

The inter-assay coefficients of variation (CVs) were 8.5% and 10.2%, respectively, to assess quality control of cortisol concentrations from 2.8 to 13.4 nmol / L (n = 21). The coefficient of variation (CVs) of the inter-assay for the same case was less than 10% (n = 15). The analytical sensitivity for cortisol was 0.3 nmol / L.

5. Data Analysis

A typical CAR is defined as an increase in cortisol level after at least 2.5 nmol / L on a baseline for individuals on each saliva sample collected at a given time. This value was used as an index for the normal cortisol reaction in this experiment.

For further analysis of CAR, the net increase in cortisol level within 30 minutes after the weather was calculated (CARi). The total cortisol secretion was also calculated in the first 60 minutes after the weather using the GraphPad Prism version 5.01 for Windows (GraphPad Software Inc., Sandi ago, CA, USA) (CARauc). Daily cortisol secretion was calculated as the area under the cortisol curve (DCauc) according to the interval from the time immediately after the wake up to the night time.

In addition, the daily cortisol slope < RTI ID = 0.0 > (beta) < / RTI > was calculated using linear regression between the cortisol values at the peak after the gas phase and at night.

A smaller β value indicates a steeper slope, which means that cortisol decreases more rapidly. A more gentle slope (large β value) means a slow decrease.

The difference in CARauc, CARi and slope beta between the medication-taking state (on-Med) and the interrupted state (off-Med) in the patient group was calculated by subtracting the value of the medication-taking state from each value of the drug- , ΔCARi and Δslope β.

The Shapiro-Wilk normality test showed that cortisol values and additional parameters (ie, CARauc, CARi and slope β) were normal.

The effects of taking drugs on the cortisol profile or the frequency of spontaneous vomiting were analyzed using repeated measures ANOVA.

Group differences in mean cortisol levels, CARauc, CARi, and slope β were measured by one-way ANOVA test, paired t test or two-tailed t test at 5% significance level test). When the ANOVA showed a significant difference (p <0.05), Tukey's post hoc test was performed to identify specific group differences. Statistical calculations were performed using SAS version 9.1 (SAS Institute Inc., Cary, NC, USA). p <0.05 was regarded as a significant value.

Example  One : Daytime  Cortisol profile ( Diurnal cortisol profiles ) analysis

1-1. drug When taking  And 72 hours after drug withdrawal Daytime  Cortisol profile ( Diurnal cortisol profiles )

Median doses of CRPS-1 (on-Med), 72 hours after drug withdrawal (off-Med), 8 hours after dexamethasone administration (off-Med / Dex) 2.

One-way repeated measures of CRPS-1 patient's cortisol profile in on-Med and off-Med status were analyzed using ANOVA [group (on-Med, off-Med) x time (6 different time points) And analyzed.

As a result, there was a significant group effect (F1, 249 = 57.0, p <0.001), reflecting higher cortisol levels in the off-Med state. Moreover, the prominent interaction effect (F5, 249 = 6.2, p < 0.001) meant a different pattern of cortisol secretion between the on-Med and off-Med states. It was also observed that the effect of time (F5, 249 = 29.7, p < 0.001) reflects the change in daytime at the cortisol level (Figure 2)

These results showed that there was a difference in the pattern of daily cortisol secretion between cortisol level and on-Med and off-Med status in CRPS-1 patients.

Furthermore, the daily cortisol profiles were compared with healthy controls using the one-time repeated measures ANOVA in the on-Med state.

There was a significant group effect (F1, 288 = 59.2, p <0.001) and a significant interaction effect (F5, 288 = 7.5, p <0.001) in the healthy control group with higher cortisol levels than the patient group (Fig.

In the off-Med state there was a significant group effect (F1, 288 = 11.9, p <0.001) with a high cortisol level in the patient group compared to the healthy control (F5, 288 = 1.4 , p = 0.24) (Figure 2).

These results indicate that the daily cortisol secretion pattern and cortisol level of the patient group in the on-Med state are significantly different from the healthy control group, but the cortisol secretion pattern of the patient group in the off-Med state is similar to that of the healthy control.

We also found that cortisol concentration was significantly higher in the off-Med state compared to the corresponding time in the on-Med state with paired t test (df = 21): 0 min (t = 3.65, p < 0.001), 30 min (t = 6.32, p <0.001) and 60 min (t = 4.58, p <0.001) In the on-Med state, cortisol concentrations after 4 h (t = 0.80, p = 0.43) and 16 h (t = 2.07, p = 0.051) .

These results suggest that treatment with opioids in combination with tri-cyclic antidepressants and anti-epileptic drugs (Appendix A) in CRPS-1 patients would result in an increase in cortisol levels at post-meteorological time rather than at night .

In the off-Med / Dex state, the cortisol concentration measured at each time point after the gas phase was negligible (that is, the cortisol concentration range was 1.0 to 1.2 nmol / L) (FIG. 2). This means that post-metathorotic cortisol secretion (CAR) in CRPS-1 patients is inhibited by dexamethasone.

Example  2 : CRPS -One In patients  Relationship between pain-related measures and cortisol secretory activity

Pain-related numeric measurements (ie, duration of onset of CRPS, VAS score, temperature difference, and spontaneous pain frequency) varied widely among patients (Table 1)

To determine whether pain-related measures in CRPS-1 patients are associated with cortisol secretory activity, these parameters and cortisol secretion activity index, peak cortisol concentration in the on-Med state, CARauc, CARi, DCauc And slope β (Table 2).

As a result, VAS score, CRPS symptom onset period, and temperature difference were not associated with any index of cortisol secretion activity (p> 0.05, Spearman's correlation test)

However, the frequency of spontaneous vomiting was significantly correlated with the cortisol concentration at 30 min (AC30min) after waking: AC30min-related index, CARauc, CARi and slope β (p <0.05, Spearman's correlation test).

Unsupervised partitional clustering algorithms (k-means) were used to group groups of patients into subgroups based on AC30min and spontaneous frequency.

By clustering analysis, the patient group was divided into two subgroups. The median cortisol level (mean) in one group was 5.2 nmol / L, and the frequency of spontaneous flow was 0-4 (subgroup 0-4, n = 14). The median cortisol value in the other group was 12.7 nmol / L, and the frequency range of spontaneous flow was at least 5 (subgroup ≥ 5, n = 8). The two patient subgroups differed significantly from the AC30min viewpoint (p < 0.001).

Example  3: Daytime  Cortisol profile Spontaneous  Frequency impact

To determine the effect of frequency of spontaneous vomiting in the daytime cortisol profile in CRPS-1 patients, the daily cortisol profile of each patient subgroup in the on-Med and off-Med status was compared to healthy controls (Figure 3).

The intradermal cortisol profiles in the patient subgroup (0-4 and ≥ 5) and in the healthy controls in the on-Med state were analyzed using the repeated-measures ANOVA test [group (subgroup 0-4, subgroup ≥ 5, controls) x time time points) were used to compare cortisol concentrations as independent variables.

We also found significant group effects (F2, 282 = 45.7, p <0.001) and significant interaction effects (F10,282 = 5.4, p <0.001).

In addition, the repeated-measures ANOVA of the intrathecal cortisol profile in the patient subgroup in the on-med state showed a significant group effect (F1, 120 = 14.8, p <0.001), which appeared at a higher cortisol level than in the subgroup 0-4, Respectively. No significant interaction effect was observed (F5, 120 = 1.8, p = 0.12) (Figure 3A).

The cortisol profile was used as an independent variable in the off-med state using the daily cortisol profile in the patient subgroup and the repeated-measures ANOVA [group (subgroup 0-4, subgroup ≥ 5, controls) x time (6 different time points) And compared with healthy controls.

As a result, significant group effect (F2,282 = 13.1, p <0.001) was confirmed, but interaction effect (F10, 282 = 1.9, p> 0.05) did not appear.

Repeated measures of the intrathecal cortisol profile in the patient subgroup in the off-Med state showed a significant group effect (F1, 120 = 9.9, p <0.001) in subgroup 0-4 at higher cortisol levels than in subgroup ≥ 5, Mean time effect (F1, 120 = 19.3, p <0.001) was also observed, but no significant interaction effect was observed (F5, 120 = 1.4, p = 0.22)

These comparative results indicate that patients with subgroup ≥ 5 in on-Med and off-Med status have lower total cortisol levels than subgroup 0-4 patients, suggesting that the frequency of spontan- Of the total number of patients.

Example  4 : CARauc , CARi  And slope  beta phase Jabbit  Influence of frequency

The differences between the patient subgroups, each subgroup, and the healthy controls were examined to determine the frequency effect of spontaneous pain in CARauc, CARi and slope beta.

The results are shown in Fig.

Figure 4A shows that CARauc (df = 20) of subgroup 0-4 patients in subgroup ≥ 5 in both on-Med (t = 2.62, p <0.05) and off- Respectively. One-way ANOVA analysis showed subgroup 0-4 patients and subgroup ≥ 5 patients in both on-Med (F2, 47 = 20.12, p <0.001) and off-Med (F2, 47 = 9.51, p < CARauc showed a remarkable difference.

 Tukey's post hoc test showed that CARauc was significantly lower in the two subgroups of patients in the on-Med state compared to the control (p <0.05 for all the analyzes). However, in the off-Med state, CARauc was significantly higher in the 0-4 subgroup of patients compared to healthy controls (p <0.05). Interestingly, CARauc was similar to healthy controls in off-med subgroup ≥ 5 patients (p> 0.05).

In the off-Med state, the CARi (df = 20) value was significantly higher in the subgroup 0-4 patients than in the subgroup ≥ 5 patients (t = 2.55, p <0.05). However, the CARi values in the two subgroups of on-Med status were similar (t = 1.71, p> 0.05) (Fig. 4B)

 Three patients with subgroup 0-4 (21.4%) and four patients with subgroup ≥ 5 (50%) did not show typical CARi (CARi ≥ 2.5 nmol / L) during the on-Med state. However, in the off-Med state, all patients in subgroup 0-4 showed typical CARi. Two patients with subgroup ≥ 5 (25%) did not show typical CARi in the off-Med state, and these patients also did not show typical CARi even in the on-Med state.

The one-way ANOVA analysis was significant in subgroup 0-4, subgroup ≥ 5, and between control group on-med status (F2, 47 = 12.72, p <0.001) and off-Med status (F2, 47 = 8.44, p <0.001) Respectively.

Tukey's post hoc test showed that patients with subgroup 0-4 and subgroup ≥ 5 had very low CARi values in the on-Med state (p <0.05 for all the analyzes). However, in the off-med state, CARi values in subgroup 0-4 patients were significantly higher than in the control group (p <0.05), whereas CARi values in the subgroup ≥ 5 patients were similar to those of the control group (p> 0.05).

Figure 4C shows that in two cases of slope beta (df = 20) on-Med status (t = 2.16, p <0.05) and off-Med status (t = 2.70, p <0.05) The slope β (df = 20) values are very small compared with patients.

One-way ANOVA analysis showed that the subgroup 0-4, subgroup 5, and on-Med status (F2, 47 = 16.53, p <0.001) and off-Med status (F2,47 = 7.31, p &Lt; 0.05).

Tukey's post hoc test showed that patients with subgroup 0-4 and subgroup ≥ 5 had significantly greater slope β values than healthy controls (p <0.05 for all the analyzes). In the off-med state, the slope β value of the subgroup 0-4 patients was significantly larger than that of the control group (p <0.05), while the slope β value of the subgroup ≥ 5 patients was similar to that of the control group (p> 0.05).

The difference in CARauc and CARi values between the subgroups of patients implies down-regulation of the frequency of HPA axis functional spontaneous vestibular function in CRPS-1 patients. In the off-Med subgroup ≥ 5 patients and controls, there was no difference in CARauc, CARi or slope β values, indicating that the HPA axis of subgroup ≥ 5 patients did not function normally.

In both subgroups, CARauc and CARi values increased and slope β values decreased after discontinuation of drug administration.

The CARauc and CARi values (ΔCARauc and ΔCARi), and the decreased slope β value (Δslope β), which are increased in each patient subgroup, are summarized in Table 3.

 Overall, ΔCARi was negatively correlated with the frequency of spontaneous pain (Spearman's r = -0.53, p = 0.01), ΔCARauc (r = -0.11, p = 0.63) or Δslope β It is not relevant.

ΔCARi in patients with subgroup ≥ 5 patients was significantly lower than patients in subgroup 0-4 (t = 2.23, df = 20, p <0.01 by two-tailed t test).

Although there was a difference between patients subgroups ΔCARauc and Δslope β, the difference was not statistically significant (p> 0.05 for all the analyzes by two-tailed t test) (Table 3).

The negative correlation between ΔCARi and the frequency of spontaneous lesion and the significant difference in ΔCARi between subgroups suggests that the frequency of spontaneous vocalization also includes a decrease in the HPA axis in the post-metaphyseal response.

Claims (9)

A method for evaluating the cortisol concentration 30 minutes after the morning air phase from saliva as an index of the HPA axis function to provide information necessary for diagnosis of Complex Regional Pain Syndrome (CRPS) disease,
In the absence of any drug administration,
An average of 16 nmol / L of cortisol concentration 30 minutes after the morning wake was determined by an increase in frequency of spontaneous pain attacks five times or more and a decrease in the HPA axis function of the pituitary gland,
When the concentration of cortisol 30 minutes after the morning wake has an average value of 25 nmol / L, it is determined by decreasing frequency of 0 to 4 times of spontaneous vomiting and increase of pituitary contraction function.
A method for evaluating the cortisol concentration 30 minutes after the morning air phase from saliva as an index of the HPA axis function to provide information necessary for diagnosis of Complex Regional Pain Syndrome (CRPS) disease,
With one or more drugs selected from the group consisting of analgesics pregabalin, tridol and acetaminophen administered,
The mean cortisol concentration was 5.2 nmol / L at 30 min after the morning wake, and the frequency of spontaneous pain attacks was 5 or more and the decrease of HPA axis function was determined.
When the cortisol concentration 30 minutes after the morning wake has an average value of 12.7 nmol / L, it is determined by decreasing the frequency of 0 to 4 times of spontaneous vomiting and increasing the pituitary contraction function.
A method for evaluating cortisol concentration from saliva as an index of HPA axis function to provide information necessary for diagnosis of Complex Regional Pain Syndrome (CRPS) disease,
Wherein at least one drug selected from the group consisting of analgesics pregabalin, tridol and acetaminophen is administered and in the absence of the drug,
When the difference in the total secretion amount (CARauc) of cortisol secreted during the first hour after the morning wake was 635.9 +/- 82.5 nmol / L, which was measured in the above two conditions, the decrease in the frequency of spontan- It is decided by the increase of the stretching function,
When CARauc has a mean value of 482.3 +/- 164.9 nmol / L, it is determined by increasing the frequency of spontaneous pain attacks 5 times or more and by decreasing the HPA axis function; or
When the difference in the net increase of cortisol (CARi) from 10 to +/- 30 nm after the morning wake was 10.1 +/- 2.0 nmol / L, the frequency of 0 ~ It is determined by the increase of function,
And the difference in CARi is 3.4 +/- 2.1 nmol / L, which is determined by increasing the frequency of spontaneous pain attacks more than 5 times and decreasing the function of the HPA axis in the pituitary gland.
4. The method according to any one of claims 1 to 3,
The cortisol concentration is evaluated by analyzing the concentration of cortisol measured from the saliva collected within 1 hour after the gas phase, continuously or discontinuously for a part or all of the period of 1 to 7 days.
4. The method according to any one of claims 1 to 3,
Wherein said complex site pain syndrome disease is Type I complex site pain syndrome. delete delete delete delete

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