Eugenia gracillima essential oil has pharmaceutical applications in pain and inflammation without toxic effects in mice

ETHNOPHARMACOLOGICAL RELEVANCE

Eugenia gracillima is widely used by the population in the manufacture of pulps and jellies, with popular reports of its use in the treatment of infections in the urinary system, respiratory and dermatological problems. A previous study reports that EO from E. gracillima leaves proved to be a promising antioxidant agent in combating the promastigote forms of protozoa. Despite this, this species has been little studied due to its pharmacological properties.

STUDY OBJECTIVE

In this study, an essential oil extracted (EO) from Eugenia gracillima leaves was evaluated for its acute toxicity and anti-inflammatory, antinociceptive and behavioral effects in mice.

METHODS

The EO was obtained by hydrodistillation, and the composition analysis was performed by gas chromatography coupled to mass spectrometry. Acute toxicity assessment was performed with observation of hematological parameters and histopathological evaluation, as well as tests to investigate antinociceptive, anti-inflammatory activities and behavioral effects.

RESULTS

Chromatographic analysis showed D-germacrene (16.10%), γ-muurolene-g (15.60%) and bicyclogermacrene (8.53%) as the majority of compounds. In the toxicity evaluation, no death or physiological changes were observed in mice treated with a single oral dose of up to 5000 mg/kg, and it did not lyse erythrocytes in vitro. The hematological parameters evaluated were not changed after treatment; however, 5,000 mg/kg promoted an increase in transaminase levels. In the histopathological evaluation, only the animals that received the dose of 5000 mg/kg showed discrete leukocyte infiltration around the centrilobular vein in the liver. Antinociceptive activity was detected through tests of acetic acid-induced writhing, formalin, and tail flick, promoted in part by the opioid receptor pathway. In the evaluation of anti-inflammatory activity, a reduction in inflammation was observed in the paw edema test and a decrease in the migration of leukocytes and neutrophils in the peritonitis test. The open field and elevated plus maze tests showed that EO did not affect the animals' motor functions or exploratory activity.

CONCLUSION

It was concluded that the essential oil of E. gracillima has potential for the development of pharmaceutical formulations with analgesic and anti-inflammatory actions in non-toxic concentrations.

Antioxidant, anti-inflammatory and analgesic activity of Mimosa acutistipula (Mart.) Benth

ETHNOPHARMACOLOGICAL RELEVANCE

Medicinal plants belonging to the genus Mimosa, such as Mimosa tenuiflora, M. caesalpinifolia, and M. verrucosa are known for their popular use for asthma, bronchitis and fever. Ethnopharmacological studies report that Mimosa acutistipula is used to treat alopecia and pharyngitis, conditions that can be related to oxidative stress, inflammatory processes and painful limitations. However, there is no studies on its efficacy and mechanism of action.

AIM OF THE STUDY

To elucidate the antioxidant, anti-inflammatory, analgesic and antipyretic activity of M. acutistipula leaves.

MATERIALS AND METHODS

Phytochemical profile of M. acutistipula extracts was evaluated by several reaction-specific methods. Secondary metabolites such as tannins, phenols and flavonoids were quantified with colorimetric assays. In vitro antioxidant potential was evaluated using DPPH and ABTS + as free radical scavenging tests, FRAP and phosphomolybdenum as oxide-reduction assays, and anti-hemolytic for lipid peroxidation evaluation. In vivo anti-inflammatory evaluation was performed by paw edema, and peritonitis induced by carrageenan. Analgesic effect and its possible mechanisms were determined by acetic acid-induced abdominal writhing and the formalin test. Antipyretic activity was evaluated by yeast-induced fever.

RESULTS

Cyclohexane, chloroform, ethyl acetate and methanol extracts of leaves had presence of tannins, flavonoids, phenol, alkaloids, terpenes (except methanolic extract), and saponins (only for methanolic and chloroformic extracts). In phenols, flavonoids and tannins quantification, methanolic and ethyl acetate extract had higher amounts of this phytocompounds. Ethyl acetate extract, due to its more expressive quantity of phenols and flavonoids, was chosen for carrying out the in vivo tests. Due to the relationship between oxidative stress and inflammation, antioxidant tests were performed, showing that ethyl acetate extract had a high total antioxidant activity (70.18%), moderate activity in DPPH radical scavenging, and a moderate ABTS + radical inhibition (33.61%), and FRAP assay (112.32 μg Fe²⁺/g). M. acutistipula showed anti-inflammatory activity, with 54.43% of reduction in paw edema (50 mg/kg) when compared to the vehicle. In peritonitis test, a reduction in the concentration of NO could be seen, which is highly involved in the anti-inflammatory activity and is responsible for the increase in permeability. In the analgesic evaluation, most significant results in writhing test were seen at 100 mg/kg, with a 34.7% reduction of writhing. A dual mechanism of action was confirmed with the formalin test, both neurogenic and inflammatory pain were reduced, with a mechanism via opioid route. In the antipyretic test, results were significantly decreased at all concentrations tested.

CONCLUSION

M. acutistipula leaves ethyl acetate extract showed expressive concentrations of phenolic compounds and antioxidant activity. It also exhibited anti-inflammatory and analgesic activity, besides its antipyretic effect. Thus, these results provide information regarding its popular use and might help future therapeutics involving this specimen.

Safety and preliminary outcomes of short-acting opioid agonist treatment (sOAT) for hospitalized patients with opioid use disorder

BACKGROUND

Patients with opioid use disorder (OUD) frequently leave the hospital as patient directed discharges (PDDs) because of untreated withdrawal and pain. Short-acting opioids can complement methadone, buprenorphine, and non-opioid adjuvants for withdrawal and pain, however little evidence exists for this approach. We described the safety and preliminary outcomes of short-acting opioid agonist treatment (sOAT) for hospitalized patients with OUD at an academic hospital in Philadelphia, PA.

METHODS

From August 2021 to March 2022, a pharmacist guided implementation of a pilot sOAT protocol consisting of escalating doses of oxycodone or oral hydromorphone scheduled every four hours, intravenous hydromorphone as needed, and non-opioid adjuvants for withdrawal and pain. All patients were encouraged to start methadone or buprenorphine treatment for OUD. We abstracted data from the electronic health record into a secure platform. The primary outcome was safety: administration of naloxone, over-sedation, or a fall. Secondary outcomes were PDDs and respective length of stay (LOS), discharges on methadone or buprenorphine, and discharges with naloxone. We compared secondary outcomes to hospitalizations in the 12 months prior to the index hospitalization among the same cohort.

RESULTS

Of the 23 cases, 13 (56.5%) were female, 19 (82.6%) were 40 years or younger, and 22 (95.7%) identified as White. Twenty-one (91.3%) regularly injected opioids and four (17.3%) were enrolled in methadone or buprenorphine prior to hospitalization. sOAT was administered at median doses of 200-320 morphine milligram equivalents per 24-h period. Naloxone administration was documented once in the operating room, over-sedation was documented once after unsanctioned opioid use, and there were no falls. The PDD rate was 44% with median LOS 5 days (compared to PDD rate 69% with median LOS 3 days for prior admissions), 65% of sOAT cases were discharged on buprenorphine or methadone (compared to 33% for prior admissions), and 65% of sOAT cases were discharged with naloxone (compared to 19% for prior admissions).

CONCLUSIONS

Pilot implementation of sOAT was safe. Compared to prior admissions in the same cohort, the PDD rate was lower, LOS for PDDs was longer, and more patients were discharged on buprenorphine or methadone and with naloxone, however efficacy for these secondary outcomes remains to be established.

Anti-inflammatory and antinociceptive effects of a pectinolide-enriched fraction from Mesosphaerum pectinatum (L.) Kuntze

ETHNOPHARMACOLOGICAL RELEVANCE

Mesosphaerum pectinatum (L.) Kuntze (Lamiaceae), also known as sambacaitá, is a medicinal plant widely used in northeastern Brazil for the treatment of inflammatory and painful conditions, bacterial infections and cancer. Hence, the medicinal use of this species is quite meaningful to the search for bioactive compounds.

AIM OF THE STUDY

To evaluate the antinociceptive and anti-inflammatory activities of the pectinolide-enriched fraction of Mesosphaerum pectinatum (PEF) in animal models.

MATERIALS AND METHODS

The PEF was analyzed with HPLC-DAD and ¹H and ¹³C NMR. After the analysis, compounds of the pectinolide class were detected as major constituents in this fraction. The PEF (50, 100 and 200 mg/kg, p.o.) and the reference drugs - morphine (3.0 mg/kg, p.o.) and dexamethasone (2.0 mg/kg, p.o.) - were evaluated using models for nociception (hot plate, formalin-induced licking response) or inflammation (carrageenan-induced peritonitis and ear edema model).

RESULTS

The PEF significantly decreased the licking time of the animals treated when compared to the control group (second phase). In the carrageenan-induced peritonitis model, PEF (100 and 200 mg/kg) significantly decreased total and differential leukocyte counts. The PEF (0.3, 1.0 and 3.0 mg/ear) significantly reduced mice ear edema at the same extent and like the results obtained with the standard drug (dexamethasone). The MPO activity was reduced in mice ear at doses of 1 and 3 mg/ear. Antinociceptive effect on the hot plate test was not observed, demonstrating that there is no analgesic activity.

CONCLUSION

Our results suggest that the pectinolide-enriched fraction exhibits anti-inflammatory effects and that it is involved with inhibiting the release of the inflammatory mediators.

Schinus terebinthifolia leaf lectin has central and peripheral antinociceptive action mediated by its carbohydrate-recognition domain and delta-opioid receptors

ETHNOPHARMACOLOGICAL RELEVANCE

Preparations from the bark and leaves of Schinus terebinthifolia Raddi are commonly used to treat toothaches and sore throats. The use of medications based on leaves of this plant has also been reported for pain of arthritis, toothache, and sore throat. Some evidence indicated that the lectin SteLL is an antinociceptive agent from leaves.

AIM OF THE STUDY

This study evaluated the antinociceptive activity of S. terebinthifolia leaf lectin (SteLL) using mouse models of peripheral and central nociception.

MATERIALS AND METHODS

Animals were treated intraperitoneally with SteLL at 1, 5, and 10 mg/kg. An acetic acid-induced abdominal writhing test was performed to screen for the antinociceptive effect of the lectin. Next, the formalin test was used to assess the effects of SteLL on neurogenic (first phase) and inflammatory (second phase) pain, as well as to investigate the involvement of the carbohydrate-recognition domain (CRD) of SteLL and opioid receptors in the antinociceptive effect. The tail immersion test was performed to assess the central antinociception. Additionally, a rotarod test was performed to evaluate the effects of lectin on motor coordination in mice.

RESULTS

SteLL reduced the number of acetic acid-induced writhes by 83.5-100.0%. In the first phase of the formalin test, SteLL reduced paw licking time by 49.4-50.5%, while in the second phase, SteLL reduced paw licking time by 80.5-82.6%. This antinociceptive effect was reversed by the previous incubation of the lectin with ovalbumin (indicating the possible involvement of the CRD) and by the administration of naloxone, a nonselective opioid receptor antagonist. When testing selective antagonists of opioid receptors (μ, δ, and κ), only naltrindole, a selective δ receptor antagonist, blocked the antinociceptive action of SteLL during the second phase of the formalin test. In the tail immersion test, SteLL (1, 5, and 10 mg/kg) administration reduced sensitivity to thermal stimulus, which was observed even after 2 h. SteLL (10 mg/kg) did not affect animal motor coordination in rotarod test when compared to the control group.

CONCLUSION

SteLL has peripheral and central analgesic action involving opioid receptor modulation without affecting the motor coordination of animals. These results provide new perspectives for developing analgesic agents using lectins.

Bio-guided study of the antinociceptive, anti-inflammatory, and free-radical scavenging capacity of the leaves of Rhus virens Lindh. ex A. Gray and its possible mechanism of antinociception

ETHNOPHARMACOLOGICAL RELEVANCE

Rhus genus is commonly known as sumac and widely used in the folk medicine. Rhus virens is a plant commonly used to treat diabetes or pain in the northern territory of Mexico. Even though R. virens is used in the folk medicine there is still a lack of evidence about the pharmacological effect of this species.

AIM OF THE STUDY

The aim of this study was to determine the antinociceptive, anti-inflammatory and antioxidant effect of R. virens through a bio-guided chemical separation.

MATERIALS AND METHODS

The aqueous, methanolic, and hexane extract of R. virens were obtained and tested in the formalin test, TPA-induced ear edema, and DPPH, ABTS, and FRAP assay. Also, possible interaction of pain pathways was studied using naloxone, bicuculline, L-NAME, ODQ, and glibenclamide in the formalin test in mice.

RESULTS

Rhus virens methanolic extract (30 mg/kg, p.o.) produced higher antinociceptive activity in both the early and late phases of the formalin test (35.0 and 52.9%, respectively). Also, pre-administration with naloxone, bicuculline, L-NAME, ODQ and glibenclamide prevented the antinociceptive effect of R. virens in the early phase of the formalin test. Meanwhile, only naloxone and bicuculline prevented the antinociceptive effect on the late phase of the formalin test. Chemical separation of methanolic extract allowed to isolate 1,2,3,4,6-penta-O-galloyl-glucopyranose (PGG), it was tested in the formalin test, producing an antinociceptive effect on the late phase of the formalin test. On the other hand, topical application of the derivatives of R. virens methanolic extract produced an anti-inflammatory effect in the TPA-induced ear edema, being PGG an anti-inflammatory molecule. Lastly, radical scavenging activity was higher in the extracts of higher polarity, comparable to the standard used Camellia sinensis.

CONCLUSIONS

In conclusion, R. virens produce an antinociceptive, anti-inflammatory and free-radical scavenging activity. The antinociceptive effect could be related to the opioidergic, GABAergic, and NO-GMPc-K + ATP channels pathways. These effects could be partially produced by the presence of PGG.

Analgesic, anti-inflammatory activity and metabolite profiling of the methanolic extract of Callicarpa arborea Roxb. leaves

ETHNOPHARMACOLOGICAL RELEVANCE

Callicarpa arborea Roxb. is widely used as traditional medicine especially by the tribal people of Bangladesh in the management of wide range of ailments. In addition to Bangladesh, the leaves of this plant is utilized as a remedy to various painful and inflammatory conditions including rheumatism, toothache and stomachache in other countries of Indian subcontinent.

AIM OF THE STUDY

Depending on the ethnomedicinal uses, we undertook this study to investigate the in-vivo analgesic and anti-inflammatory activities of the methanolic extract of C. arborea Roxb. leaves in Swiss albino mice as well as its chemical composition.

MATERIALS AND METHODS

We evaluated the analgesic activity of Callicarpa arborea Roxb. leaves by the acetic acid induced writhing test, the hot plate test, and the formalin test. We undertook the egg albumin induced paw edema test to determine the anti-inflammatory activity of the plant. Furthermore, we conducted the phytochemical profiling by gas chromatography-mass spectrometry (GC-MS).

RESULTS

In acute toxicity test, no mortality was observed at the highest dose of 2000 mg/kg b.w. Significant (p < 0.005) inhibition of acetic acid induced writhing was observed at both doses of the extract. A dose dependent increase in the response time was seen in the hot-plate test. In the formalin test, the extract significantly inhibited pain response in both early and late phase. We observed marked anti-inflammatory activity manifested by a significant (p < 0.005) reduction in egg albumin induced paw edema. We identified a total of twenty one compounds in the extract of by GC-MS analysis.

CONCLUSION

Taken all into consideration we conclude that the leaves of C. arborea Roxb. possesses potent analgesic and anti-inflammatory activity, thus justifying its's ethnomedicinal use against painful and inflammatory pathological conditions.

Safety and efficacy of etomidate in combination with oxycodone in painless gastroscopic procedures in the elderly: A prospective randomized controlled trial study

OBJECTIVE

Etomidate is often combined in rapid succession during induction of anesthesia. However, the effect of pretreatment with oxycodone on recovery of cognitive function and adverse effects has rarely been studied. We conducted a prospective randomized controlled trial to compare etomidate alone with etomidate combined with oxycodone in elderly patients undergoing painless gastroscopy.

METHODS

Hundred elderly patients undergoing painless gastroscopy were divided into a control and an observation group, with 50 cases in each group. The age, gender, height, weight, body mass index and American Society of Anesthesiologists physical status (I/II) of patients in both groups were recorded. The recovery of cognitive function was compared in both groups using the Neurobehavioral Cognitive Status Examination. Adverse events, including somatic motor reactions, hypotension, bradycardia, myocardial tremor, nausea and vomiting, and injection pain, were also recorded in both groups. Moreover, heart rate, peripheral capillary oxygen saturation, systolic blood pressure, and diastolic blood pressure were evaluated in the 2 groups at different time points.

RESULTS

A total of 100 patients were enrolled in this study. The demographic characteristics in the 2 groups were not significantly different (P > .05). Regarding the recovery of cognitive functions, more subjects in the observation group passed the memory, arithmetic and orientation test than in the control group (P < .05). Fewer adverse events such as dynamic body reactions, cardiac tremor, nausea and vomiting, and injection pain occurred in the observation group than in the control group (P < .05). During anesthesia and after awakening, the results of peripheral capillary oxygen saturation, systolic blood pressure and diastolic blood pressure were better in the observation group than in the control group (P < .05).

CONCLUSION

Etomidate in combination with oxycodone for painless gastroscopic operation in the elderly is a safe and effective anesthetic strategy.

CATHETER DIRECTED THROMBOLYSIS IN ACUTE LIMB ISCHEMIA PATIENTS. A SINGLE CENTER'S EXPERIENCE

OBJECTIVE

The aim: This study evaluates catheter-directed thrombolysis (CDT) outcomes in patients with acute lower limb arterial thrombosis and acute limb ischemia.

PATIENTS AND METHODS

Materials and methods: 53 patients (17 females, 36 males, aged 53-76) were studied. 57% had femoropopliteal and below-the-knee (BTK) thromboocclusion, 43% had BTK thromboocclusion. Symptoms included pain, pallor, edema, and cyanosis. Exclusions criteria: contracture, recent surgeries, bleeding.

RESULTS

Results: In 29 (97%) patients regression of lower-limb ischemia rate by 1-2 stages according to the Rutherford classification were observed. One patient (3%) did not exhibit any regression in the degree of lower-limb ischemia, experiencing increasing pain and decreased sensitivity in the lower limb, leading to the development of contracture in the ankle joint and subsequent lower limb amputation over 7 days. Among 12 (40%) patients, after performing follow-up arteriography of the lower limb, angioplasty was performed on the diagnosed steno-occlusive lesions in the revascularized segment with secondary angioplasty. Within a year, one (3%) patient experienced recurrent thrombosis of the lower limb arteries with subsequent revascularization.

CONCLUSION

Conclusions: CDT is recommended for ALI Patients with arterial thrombooclusion.

Comparison of chemical-induced temporomandibular osteoarthritis rat models (monosodium iodoacetate versus collagenase type II) for the study of prolonged drug delivery systems

OBJECTIVE

To compare two agents that can induce a rat model of temporomandibular joint osteoarthritis (TMJOA) by chemical induction: monosodium iodoacetate (MIA) and collagenase type 2 (Col-2). We wished to ascertain the best agent for assessing drug-delivery systems (DDSs).

METHOD

Male Wistar rats underwent intra-articular injection with MIA or Col-2. They were manipulated for 30 days. The head withdrawal threshold (HWT), immunohistological assessment, and positron emission tomography (PET) were used to evaluate the relevance of our models.

RESULTS

For both the MIA and Col-2 groups, pain persisted for 30 days after injection. Change in the HWT showed that Col-2 elicited a strong action initially that decreased progressively. MIA had a constant action upon pain behavior. Histology of TMJ tissue from both groups showed progressive degradation of TMJ components.

CONCLUSIONS

MIA and Col-2 induced orofacial pain by their local chemical action on TMJs. However, based on a prolonged and greater sustained effect on the pain threshold, persistent histological changes, and imaging results, MIA appeared to be more suitable for creation of a rat model of TMJOA for the study of DDSs.

The Efficacy and Safety of Using Opioids in Acute Pancreatitis: an Update on Systematic Review and Meta-Analysis

Background

Most patients with acute pancreatitis (AP) suffer from abdominal pain that requires immediate pain relief, and there are various medication choices available, with opioids being the most prescribed analgesics.

Objective

Our objective is to compare the use of opioids with other medications in emergency settings for managing pain in patients with AP.

Methods

A systemic search was conducted in electronic databases (PubMed/Medline, Cochrane Library, Embase and Google Scholar) from inception to Feb 2023. All statistical analyses were conducted in Review Manager 5.4.1. The study's inclusion criteria was then selected. Only those Randomized Controlled Trials were involved that included patients having AP in an emergency setting. A random-effect model was used when heterogeneity was seen to pool the studies, and the result was reported in the Odds Ratio (OR) and Mean Difference (MD) along with the corresponding 95% confidence interval (CI). Narrative analysis was conducted for those variables which did not have sufficient data be included in the quantitative analysis.

Results

We include eight Randomized Controlled Trials in our study. The Pooled result showed non-significant differences in adverse effects between the two interventions (OR 1.42 [95% CI 0.62, 3.23]; p value= 0.40; I2= 20%). While overall, significantly additional drugs were used in the control group (OR 0.22 [95% CI 0.06, 0.85]; p value= 0.03; I2= 72%). Pain score and severity levels were also analyzed. We used a narrative approach to analyze the length of stay, mean time to reach significant decrease in pain, and mortality, which were all non-conclusive. We also narratively assessed the Pediatric population.

Conclusion

Opioids do not provide significant superiority over other medications and should be avoided due to their addictive nature.

Botulinum Toxin in the Oily Skin: Advantage of a Multi-Needle Device for a Controlled Release

BACKGROUND

Oily skin is one of the most common dermatological complaints. With the obligation to use masks to protect themselves from the Covid-19 virus, the problem has become even more evident. One of the treatments proposed is the use of onabotulinumtoxin-A injected sub-dermally. For an optimal result, the injections must be done on the whole area with numerous micro-injections located only in the sub-dermis. The procedure is often poorly tolerated by patients and sometimes accompanied by hematomas and bruises. This research aimed to test a disposable device to inject botulin toxin at 1.5 mm under the skin with a painless procedure and homogeneous distribution of the toxin.

METHODS

We treated patients with oily skin with the injection of 100 IU of Onabotulinumtoxin-A (diluted in 5 ml of a saline solution). All the patients were evaluated after 2 weeks, one month, and three months.

RESULTS

In 10 patients, after 15 days we observed a real improvement of the quality of the skin; for two, the results were present at the 1 month follow up. In all cases, the treatment appeared homogeneous in the entire face. All the patients considered the procedure virtually painless or with minimal discomfort.

CONCLUSION

In accordance with other authors, we confirm the real advantages of micro-botulinum toxin for oily skin. Moreover, the use of this simple and innovative device allows a homogeneous distribution of the drug in the correct plane, without pain, and reduces the risks of common complications. J Drugs Dermatol. 2023;21(1): doi:10.36849/JDD.6900.

Impact of fentanyl analgesia on the accuracy of HVPG measurements in patients with cirrhosis: a prospective, multicenter study

BACKGROUND

HVPG measurement is the gold standard for assessing portal hypertension. Many patients decline HVPG measurements due to associated pain. According to previous studies, propofol sedation during HVPG measurements potentially alters HVPG readings. However, opioid analgesics' effects on HVPG await full elucidation. This study aimed to evaluate fentanyl analgesia's effects on HVPG measurement accuracy in patients with cirrhosis.

METHODS

This prospective, multicenter study included patients with cirrhosis undergoing HVPG measurements, which were performed preanalgesia and under analgesia with fentanyl injection (1.0 or 1.5 μg/kg).

RESULTS

Of the 48 enrolled patients with cirrhosis, 23 were administered 1.0 μg/kg fentanyl analgesia during HVPG measurement. The HVPG was 13.4±4.9 mm Hg in preanalgesia and 13.5±5.2 mm Hg under analgesia. HVPG measurement accuracy was not altered after fentanyl analgesia (p = 0.801). The following measures also did not change: heart rate (p = 0.132), mean arterial pressure (p = 0.348), and blood oxygen saturation (p = 0.748); however, respiratory rate (p = 0.001) changes occurred. The Verbal Numerical Rating Score for comfort under analgesia was higher than that in preanalgesia (p = 0.001). Twenty-five patients were administered 1.5 μg/kg fentanyl analgesia during HVPG measurement. The HVPG was 19.5±5.7 mm Hg in preanalgesia and 19.6±5.6 mm Hg under analgesia. HVPG measurement accuracy did not alter after fentanyl analgesia (p = 0.469). Similarly, the following measures did not change: mean arterial pressure (p = 0.871) and oxygen saturation (p = 0.327); nevertheless, respiratory rate (p = 0.015) and heart rate (p = 0.019) changes occurred. The Verbal Numerical Rating Score for comfort under analgesia was higher than that in preanalgesia (p < 0.001).

CONCLUSION

Fentanyl analgesia did not alter HVPG measurement accuracy, and fentanyl improved comfort in patients with cirrhosis during HVPG measurements.

[Sacral fragility fractures: risk factors and outcomes after cement sacroplasty]

BACKGROUND

The objective of the present study on patients with fragility fractures of the sacrum (FFS) was to assess existing risk factors and clinical outcomes after cement sacroplasty (CSP).

PATIENTS AND METHODS

68 patients (64 women, 4 men) with previous FFS were followed up retrospectively. CT and MRI images were used to classify fractures according to Denis et al. and Rommens and Hofmann. Bone mineral content was determined by QCT in all patients. Concomitant diseases as well as central and peripheral fractures were recorded, considering the patient's medical history and X‑ray images. Vitamin D levels were also determined. If conservative therapy was unsuccessful, CSP was performed. The results were documented on the basis of pain development, physical independence, patient satisfaction, complication rate and mortality.

RESULTS

The age of the women in the study was Ø 83.2 (72-99) and that of the men Ø 77.8 (76-85) years. 42.4% had a Denis type 1, 4.2% a Denis type 2, 0% a Denis type 3, 43.3% a Denis type 1-2 and 10.1% a Denis type 1-2-3 fracture zone. FFP type II a to II c fractures were found in 88.2%, FFP type III c in 7.4% and FFP type IV b in 4.4%. Bilateral FFS were found in 68.8%. The average bone mineral content (BMC) was 35.4 (2-74) mg/ml, and the average vitamin D value was 8.8 (0-28) nmol/l. Other osteoporosis-associated fractures were found in around 50% of the patients. After CSP, patients showed a rapid and significant (p < 0.001) reduction in pain and sustained clinical improvement.

CONCLUSION

FFS fracture risk factors were found to be female gender, advanced age, existing osteoporosis and severe vitamin‑D deficiency. Patients with non-displaced FFS who could not be mobilised due to pain experienced sustained benefit from CSP.

Remimazolam Tosylate Combined with Low-Dose Propofol Improves Sedation and Safety in Hysteroscopy

BACKGROUND

Propofol is widely used for sedation of hysteroscopy. It can cause injection pain, respiratory depression, and hypotension. Remimazolam is a novel ultra-short-acting benzodiazepine. Clinical practice has found that the use of remimazolam alone often leads to body movement during hysteroscopy, which decreases the safety and comfort. Here this study is to investigate whether remimazolam combined with low-dose propofol can improve the sedation effect and safety of hysteroscopy.

PATIENTS AND METHODS

In this prospective, randomized, parallel-controlled trial, women (18 to 60 years) undergoing hysteroscopy were randomly assigned to receive propofol (Group P), remimazolam tosylate (Group R), or remimazolam tosylate plus propofol (Group RP). Intraoperative sedation depth was kept at the bispectral index (BIS) value of 40-60. 6 μg/kg alfentanil was used for analgesic before sedation. Intraoperative low pulse oxygen saturation (SpO2), body movement, injection pain, mean arterial pressure (MAP), heart rate (HR), and postoperative recovery time, dizziness, nausea and vomiting were recorded and compared.

RESULTS

From February to July 2022, 193 patients were recruited and randomly assigned to group P (n=64), group R (n=64), or group RP (n=65). There was no significant inter-group difference of the intraoperative BIS values. The incidence of low SpO2, injection pain, hypotension, and postoperative dizziness in group RP were less than that in group P, and had no significant difference from group R. The incidence of body movement in group RP was less than that in group R, and had no significant difference from group P. Postoperative recovery time of group RP was shorter than that of the other two groups. No significant inter-group difference in bradycardia, nausea and vomiting was observed.

CONCLUSION

Remimazolam tosylate combined with low dose of propofol improved sedation and safety in hysteroscopy, and may be a more ideal sedative method for hysteroscopy.

A neuron-to-astrocyte Wnt5a signal governs astrogliosis during HIV-associated pain pathogenesis

Chronic pain is the most common neurological disorder of HIV patients. Multiple neuropathologies were identified in the pain pathway. Among them is the prominent astrocytic reaction (also know an astrogliosis). However, the pathogenic role and mechanism of the astrogliosis are unclear. Here, we show that the astrogliosis is crucial for the pain development induced by a key neurotoxic HIV protein gp120 and that a neuron-to-astrocyte Wnt5a signal controls the astrogliosis. Ablation of astrogliosis blocked the development of gp120-induced mechanical hyperalgesia, and concomitantly the expression of neural circuit polarization in the spinal dorsal horn. We demonstrated that conditional knockout of either Wnt5a in neurons or its receptor ROR2 in astrocytes abolished not only gp120-induced astrogliosis but also hyperalgesia and neural circuit polarization. Furthermore, we found that the astrogliosis promoted expression of hyperalgesia and NCP via IL-1β regulated by a Wnt5a-ROR2-MMP2 axis. Our results shed light on the role and mechanism of astrogliosis in the pathogenesis of HIV-associated pain.

Understanding pain related to adjuvant endocrine therapy after breast cancer: A qualitative report

OBJECTIVES

Most patients report pain while taking adjuvant endocrine therapy (AET) for the treatment of breast cancer. While studies have examined patients' experiences with side effects, none solely capture patients' experiences with AET-related pain, a troubling symptom that reduces quality of life and impairs treatment adherence. This study explored themes of AET-related pain to inform future intervention development.

METHODS

Between November 2017 and November 2018, female patients (n = 30) with early-stage breast cancer enrolled between 3 and 36 months post-initiation of AET. Purposeful sampling was stratified by adherence level, age, distress level and time taking AET. Study staff conducted, transcribed and coded semi-structured interviews via inductive thematic coding to identify pain-related themes and achieved high inter-coded reliability (Kappa = 0.96).

RESULTS

Several pain-related themes were observed. Attitudes around pain are generally negative, and management needs are largely unmet. Patients reported preferences for non-pharmacological management strategies and cited AET pain as a reason for medication breaks but not discontinuation. Patients within 19 months of starting AET and low adherers reported more intense and disruptive pain.

CONCLUSIONS

Patients' experiences varied by patient attributes and revealed modifiable factors that may be targeted through behavioural interventions. AET-related pain is a complex side effect for which psychosocial support may be beneficial.

Anti-inflammatory, antinociceptive effects and involvement of opioid receptors in the antinociceptive activity of Eugenia uniflora leaves obtained with water, ethanol, and propylene glycol mixture

ETHNOPHARMACOLOGICAL RELEVANCE

Eugenia uniflora (Myrtaceae) is a species native to Brazil and has a traditional use in the treatment of inflammation.

AIM OF THE STUDY

To evaluate the anti-inflammatory and antinociceptive effects, and the involvement of opioid receptors in the antinociceptive activity of extract and fractions from Eugenia uniflora leaves.

MATERIALS AND METHODS

TLC and HPLC were used to characterize the spray-dried extract (SDE) and fractions. In the in vivo assays, Swiss (Mus musculus) mice were used. Carrageenan-induced hind-paw edema and carrageenan-induced peritonitis models were used to determine the anti-inflammatory effect of the extract (50, 100, or 200 mg/kg). Acetic acid-induced writhing, tail-flick, and formalin tests were used to determine the antinociceptive effect of the extract (50, 100, or 200 mg/kg). The aqueous (AqF) and ethyl acetate (EAF) fractions (6.25, 12.5, and 25 mg/kg) were then combined with naloxone to evaluate the involvement of opioid receptors in the antinociceptive activity.

RESULTS

In this work, the TLC and HPLC analysis evidenced the enrichment of EAF, which higher concentration of gallic acid (5.29 ± 0.0004 %w/w), and ellagic acid (1.28 ± 0.0002 %w/w) and mainly myricitrin (8.64 ± 0.0002 %w/w). The extract decreased the number of total leukocytes and neutrophils in the peritoneal cavity (p < 0.05), at doses of 100 and 200 mg/kg and showed significant inhibition in the increase of paw edema volume (p < 0.05). The treatment per oral route (doses of 50, 100, and 200 mg/kg) significantly reduced the nociceptive response in acetic acid-induced abdominal writhing (p < 0.05). The effect of the extract on the tail-flick test showed a significant increase in latency time of animals treated at doses of 200 and 100 mg/kg (p < 0.05). The extract and ethyl acetate fraction reduced the nociceptive effect in both phases of formalin at all tested doses. The naloxone reversed the antinociceptive effect of EAF, suggesting that opioid receptors are involved in mediating the antinociceptive activity of EAF of E. uniflora in the formalin test.

CONCLUSION

The current study demonstrates the anti-inflammatory and analgesic activities of water: ethanol: propylene glycol spray-dried extract from E. uniflora leaves using in vivo pharmacological models in mice. Our findings suggest that spray-dried extract and ethyl acetate fraction exhibit peripheral and central antinociceptive activity with the involvement of opioid receptors that may be related to the presence of flavonoids, mainly myricitrin.

Can intravenous lidocaine definitely attenuate propofol requirement and improve outcomes among colonoscopic patients under intravenous sedation?: A double-blinded, randomized controlled trial

BACKGROUND

Propofol-sparing effect of lidocaine has not been fully elucidated because propofol is usually mixed with many medications in anesthetic practice. Therefore, the study aimed to verify the additive effect of intravenous lidocaine to propofol without other sedative medications and control the depth of anesthesia using the bispectral index (BIS) during colonoscopy in a prospective, randomized, double-blinded controlled trial.

METHODS

Sixty-eight patients scheduled and undergoing colonoscopy were randomly allocated to receive intravenous lidocaine (1.5 mg/kg then 4 mg/kg/h) (Group L) or a similar volume of normal saline (Group C) with propofol administration guided by BIS monitoring. The primary outcome was total propofol requirements between group comparisons. The secondary outcomes included the number of hypoxemic periods, hemodynamic changes, duration in returning of BIS > 85, sedation scores, pain scores, postoperative opioid requirement, and patient satisfaction between group comparisons.

RESULTS

Intravenous lidocaine showed significantly reduced total propofol use (151.76 ± 50.78 mg vs 242.06 ± 50.86 mg, Group L vs Group C, respectively, P < .001). Duration in returning to BIS > 85, sedation scores, and patient satisfaction scores were significantly superior in Group L (P < .05). The number of hypoxemic episodes, changes of hemodynamic response, pain scores, and postoperative opioid requirement were similar in both groups. No adverse effects were detected in both groups.

CONCLUSION

Intravenous lidocaine produced a definitely effective reduced propofol requirement without other sedative agents and improved outcomes including patient satisfaction, duration in returning to BIS > 85, and sedation score during colonoscopy without adverse effects.

Effective anesthetic management with remimazolam and ketamine without muscle relaxants for parotidectomy in a patient with myotonic dystrophy: A case report

RATIONALE

Patients with myotonic dystrophy (DM) are highly sensitive to anesthetics, muscle relaxants, and opioids, necessitating appropriate anesthetic management. Recently, remimazolam, an ultra-short-acting benzodiazepine, has been approved for use as a general anesthetic in Japan, and patients with DM have reportedly been treated with remimazolam. However, to the best of our knowledge, no study has reported on endotracheal intubation without the use of muscle relaxants under anesthetic management with remimazolam, nor on the combination of remimazolam and ketamine.

PATIENT CONCERNS

A 23-year-old man was referred to our hospital for right parotidectomy and diagnosed with DM just before surgery. At the surgeon's discretion, he was scheduled to undergo nerve monitoring to preserve the facial nerve.

DIAGNOSIS

Myotonic dystrophy.

INTERVENTIONS

We planned total intravenous anesthesia without muscle relaxants and selected remimazolam for anesthesia. Our aim was to prevent the intraoperative or postoperative complications associated with propofol and inhalational anesthetics. Additionally, we selected multimodal analgesia, including ketamine, to avoid opioid use. General anesthesia was induced with ketamine 30 mg, remifentanil 0.72 μg/kg/min, and remimazolam 12 + 6 mg. Endotracheal intubation was performed under videolaryngoscopy without the use of muscle relaxants. For postoperative analgesia, we administered additional doses of ketamine 20 mg and acetaminophen 1000 mg, and the surgeons infiltrated 8 mL of xylocaine 0.5% with epinephrine into the skin incision before starting the surgery. Intraoperative anesthesia was maintained with remimazolam 0.9 to 1.0 mg/kg/h and remifentanil 0.26 to 0.50 μg/kg/min. Flumazenil was administered for rapid awakening and safe extubation. All vitals, including the bispectral index, were stable during surgery.

OUTCOMES

The patient did not develop facial nerve paralysis, sore throat, or hoarseness, nor did he have any memory of the surgery. Good postoperative analgesia was achieved.

LESSONS

We achieved effective anesthetic management using remimazolam without muscle relaxants in a patient with DM. Furthermore, the combination of remimazolam and ketamine provided good sedation and postoperative analgesia.

Pain Severity and Interference and Substance Use Among Community Pharmacy Patients Prescribed Opioids: A Secondary Analysis of the PHARMSCREEN Study

This secondary analysis examined relationships between pain severity and interference and substance use among patients filling opioid prescriptions in Indiana and Ohio community pharmacies (n = 1,461). We likewise sought to explore the moderating role of gender in pain-substance use relations. We used patient-reported data from a cross-sectional health survey linked with controlled substance dispensing data from statewide prescription drug monitoring programs. Multivariable logistic regression estimated associations between pain severity and interference and various indices of risky prescription opioid use and non-opioid substance use. Exploratory analyses examined whether gender moderated associations. Increased pain severity was associated with increased odds of moderate- to high-risk opioid use (OR: 1.23; 95% CI: 1.16-1.31) and opioid-benzodiazepine co-use (OR: 1.20; 95% CI: 1.03-1.40). Increased pain interference was associated with greater odds of receiving opioids from multiple pharmacies or providers (OR: 1.15; 95% CI: 1.01-1.31). Increased pain severity and interference were associated with higher odds of any tobacco use (severity: OR: 1.13; 95% CI: 1.06-1.21; interference: OR: 1.07; 95% CI: 1.01-1.12) and weekly to daily sedative use (severity: OR: 1.13; 95% CI: 1.03-1.25; interference: OR: 1.13; 95% CI: 1.04-1.22). Increased pain severity was associated with decreased odds of any alcohol use (OR: 0.93; 95% CI: 0.88-0.99). Gender was a significant effect modifier in associations between pain and alcohol, tobacco, and cannabis use. The study was registered in the database of clinicaltrials.gov (register number NCT03936985). Perspective: This study suggests that pain severity and interference are associated with increased use of non-medical prescription opioids, sedatives, and tobacco and decreased use of alcohol, in ways that are different between women and men. Findings may guide the development of gender-sensitive evidence-based strategies to ameliorate or prevent substance misuse among patients living with pain.

Common bacterial metabolite indole directly activates nociceptive neuron through transient receptor potential ankyrin 1 channel

ABSTRACT

Nociceptors are known to directly recognize bacterial cell wall components or secreted toxins, thereby leading to pain induced by bacterial infection. However, direct activation of nociceptors by bacterial metabolites remains unclear although bacteria produce numerous metabolites related to health and disease. In this study, we investigated whether and how a common bacterial metabolite, indole, which is produced by normal microflora of the gastrointestinal tract and oral cavity, can directly activate nociceptive sensory neurons. We found that indole elicits calcium response and evokes inward currents in subsets of dorsal root ganglia (DRG) neurons. Intraplantar (i.pl.) injection of indole produced nocifensive behaviors in adult mice, which were enhanced in complete Freund's adjuvant-induced chronic inflammatory condition. Indole increased calcitonin gene-related peptide release in DRG neurons, and i.pl. injection of indole increased hind paw thickness, suggesting its role in generation of neurogenic inflammation. These in vitro and in vivo indole-induced responses were pharmacologically blocked by transient receptor potential ankyrin 1 (TRPA1) antagonist, HC-030031, and significantly abolished in TRPA1 knockout (KO) mice, indicating that indole targets TRPA1 for its action in DRG neurons. Nocifensive licking behavior induced by the injection of live Escherichia coli was significantly decreased in tryptophanase mutant (TnaA KO) E. coli- injected mice that lack indole production, further supporting the idea that bacteria-derived indole can induce pain during infection. Identifying the mechanism of action of indole through TRPA1 provides insights into bacteria-neuron interactions and the role of bacterial metabolites in pain signaling, especially in inflammation-accompanied bacterial infection.

Impact of a prescriber and patient educational intervention on discharge analgesia prescribing and hospital readmission rates following elective unilateral total hip and knee arthroplasty

Introduction

Pain management after elective, unilateral total hip and knee arthroplasty (THA and TKA) should use a multimodal approach. At discharge, challenges include ensuring correct prescribing practices to optimise analgesia and rationalise opioid use as well as ensuring patients are adequately educated to take these medications safely and effectively in the community. This audit cycle reports on a prescriber and patient education intervention using printed guidelines, educational outreach and prescription standardisation along with a patient information sheet to address the high unplanned readmission rate following THA and TKA at our institution.

Methods

Two cohorts of patients were identified before (2016) and after (2019) the introduction of the educational package. The primary outcome was the unplanned hospital readmission rate in the 42 days following discharge. Secondary outcomes were the compliance with the set prescribing standards and the prescription of strong opioid medications (morphine or oxycodone) on discharge.

Results

There was a reduction in the readmission rate from 20.4% to 10.0% (p=0.004). Readmission rates for pain and constipation were also reduced. The prescribing of tramadol (p<0.001) and non-steroidal anti-inflammatory drugs (p<0.001) both increased while the number of patients who received a strong opioid at discharge decreased (p<0.001) as did the number of patients who received a sustained release strong opioid (p<0.001).

Conclusion

We have observed significant improvement in discharge prescribing which coincided with a reduction in unplanned readmissions after elective TKA and THA. Our approach used prescriber guidelines, education and standardisation with printed information for patients to enhance understanding and recall.

Automated detection of squint as a sensitive assay of sex-dependent calcitonin gene-related peptide and amylin-induced pain in mice

ABSTRACT

We developed an automated squint assay using both black C57BL/6J and white CD1 mice to measure the interpalpebral fissure area between the upper and lower eyelids as an objective quantification of pain. The automated software detected a squint response to the commonly used nociceptive stimulus formalin in C57BL/6J mice. After this validation, we used the automated assay to detect a dose-dependent squint response to a migraine trigger, the neuropeptide calcitonin gene-related peptide, including a response in female mice at a dose below detection by the manual grimace scale. Finally, we found that the calcitonin gene-related peptide amylin induced squinting behavior in female mice, but not males. These data demonstrate that an automated squint assay can be used as an objective, real-time, continuous-scale measure of pain that provides higher precision and real-time analysis compared with manual grimace assessments.

Usefulness of Vaccine Adverse Event Reporting System for Machine-Learning Based Vaccine Research: A Case Study for COVID-19 Vaccines

Usefulness of Vaccine-Adverse Event-Reporting System (VAERS) data and protocols required for statistical analyses were pinpointed with a set of recommendations for the application of machine learning modeling or exploratory analyses on VAERS data with a case study of COVID-19 vaccines (Pfizer-BioNTech, Moderna, Janssen). A total of 262,454 duplicate reports (29%) from 905,976 reports were identified, which were merged into a total of 643,522 distinct reports. A customized online survey was also conducted providing 211 reports. A total of 20 highest reported adverse events were first identified. Differences in results after applying various machine learning algorithms (association rule mining, self-organizing maps, hierarchical clustering, bipartite graphs) on VAERS data were noticed. Moderna reports showed injection-site-related AEs of higher frequencies by 15.2%, consistent with the online survey (12% higher reporting rate for pain in the muscle for Moderna compared to Pfizer-BioNTech). AEs {headache, pyrexia, fatigue, chills, pain, dizziness} constituted >50% of the total reports. Chest pain in male children reports was 295% higher than in female children reports. Penicillin and sulfa were of the highest frequencies (22%, and 19%, respectively). Analysis of uncleaned VAERS data demonstrated major differences from the above (7% variations). Spelling/grammatical mistakes in allergies were discovered (e.g., ~14% reports with incorrect spellings for penicillin).