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Li S, Poelmans G, van Boekel RLM, Coenen MJH. Genome-wide association study on pharmacological outcomes of musculoskeletal pain in UK Biobank. THE PHARMACOGENOMICS JOURNAL 2023; 23:161-168. [PMID: 37587271 DOI: 10.1038/s41397-023-00314-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 08/03/2023] [Accepted: 08/07/2023] [Indexed: 08/18/2023]
Abstract
The pharmacological management of musculoskeletal pain starts with NSAIDs, followed by weak or strong opioids until the pain is under control. However, the treatment outcome is usually unsatisfying due to inter-individual differences. To investigate the genetic component of treatment outcome differences, we performed a genome-wide association study (GWAS) in ~23,000 participants with musculoskeletal pain from the UK Biobank. NSAID vs. opioid users were compared as a reflection of the treatment outcome of NSAIDs. We identified one genome-wide significant hit in chromosome 4 (rs549224715, P = 3.88 × 10-8). Suggestive significant (P < 1 × 10-6) loci were functionally annotated to 18 target genes, including four genes linked to neuropathic pain processes or musculoskeletal development. Pathway and network analyses identified immunity-related processes and a (putative) central role of EGFR. However, this study should be viewed as a first step to elucidate the genetic background of musculoskeletal pain treatment.
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Affiliation(s)
- Song Li
- Department of Human Genetics, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Geert Poelmans
- Department of Human Genetics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Regina L M van Boekel
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Marieke J H Coenen
- Department of Human Genetics, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands.
- Department of Clinical Chemistry, Erasmus Medical Center, Rotterdam, The Netherlands.
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Lambert DG. Opioids and opioid receptors; understanding pharmacological mechanisms as a key to therapeutic advances and mitigation of the misuse crisis. BJA OPEN 2023; 6:100141. [PMID: 37588171 PMCID: PMC10430815 DOI: 10.1016/j.bjao.2023.100141] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/05/2023] [Accepted: 04/12/2023] [Indexed: 08/18/2023]
Abstract
Opioids are a mainstay in acute pain management and produce their effects and side effects (e.g., tolerance, opioid-use disorder and immune suppression) by interaction with opioid receptors. I will discuss opioid pharmacology in some controversial areas of enquiry of anaesthetic relevance. The main opioid target is the µ (mu,MOP) receptor but other members of the opioid receptor family, δ (delta; DOP) and κ (kappa; KOP) opioid receptors also produce analgesic actions. These are naloxone-sensitive. There is important clinical development relating to the Nociceptin/Orphanin FQ (NOP) receptor, an opioid receptor that is not naloxone-sensitive. Better understanding of the drivers for opioid effects and side effects may facilitate separation of side effects and production of safer drugs. Opioids bind to the receptor orthosteric site to produce their effects and can engage monomer or homo-, heterodimer receptors. Some ligands can drive one intracellular pathway over another. This is the basis of biased agonism (or functional selectivity). Opioid actions at the orthosteric site can be modulated allosterically and positive allosteric modulators that enhance opioid action are in development. As well as targeting ligand-receptor interaction and transduction, modulating receptor expression and hence function is also tractable. There is evidence for epigenetic associations with different types of pain and also substance misuse. As long as the opioid narrative is defined by the 'opioid crisis' the drive to remove them could gather pace. This will deny use where they are effective, and access to morphine for pain relief in low income countries.
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Castro I, Carvalho P, Vale N, Monjardino T, Mourão J. Systemic Anti-Inflammatory Effects of Intravenous Lidocaine in Surgical Patients: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:jcm12113772. [PMID: 37297968 DOI: 10.3390/jcm12113772] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 05/28/2023] [Accepted: 05/29/2023] [Indexed: 06/12/2023] Open
Abstract
There has recently been increasing evidence that the use of perioperative intravenous lidocaine infusion possesses analgesic, opioid-sparing and anti-inflammatory effects in surgical patients. Although opioid-sparing and analgesic properties have been strongly supported, the anti-inflammatory features are not well established in elective surgery. Therefore, the aim of this systematic review is to examine the effect of perioperative intravenous lidocaine infusion on postoperative anti-inflammatory status in patients undergoing elective surgery. A search strategy was created to identify suitable randomised clinical trials (RCTs) in PubMed, Scopus, Web of Science and Clinicaltrials.gov databases until January 2023. RCTs that evaluated the effect of intravenous lidocaine infusion, compared with placebo, on adult patients who underwent elective surgery, in inflammatory markers response were included. Exclusion criteria consisted of paediatric patients, animal studies, non-RCT methodology, intervention without intravenous lidocaine, inadequate control group, duplicated samples, ongoing studies and lack of any relevant clinical outcome measures. The following inflammatory markers-interleukin (IL)-6, tumour necrosis factor (TNF)-α, IL-1RA, IL-8, IL-10, C-reactive protein (CRP), IL-1, IL-1β, interferon (IFN)-γ, cortisol, IL-4, IL-17, high-mobility group protein B1 (HMGB1) and transforming growth factor (TGF)-β-were evaluated as outcomes in this review. A total of 21 studies, including 1254 patients, were identified. Intravenous lidocaine infusion significantly reduced the change from IL-6 baseline levels at the end of surgery compared to a placebo (standardised mean difference [SMD]: -0.647, 95% confidence interval [CI]: -1.034 to -0.260). Usage of lidocaine was associated with a significant reduction in other postoperative pro-inflammatory markers, such as TNF-α, IL-1RA, IL-8, IL-17, HMGB-1 and CRP. There was no significant difference in other markers, such as IL-10, IL-1β, IL-1, IFN-γ, IL-4, TGF-β and cortisol. This systematic review and meta-analysis provide support for the administration of perioperative intravenous lidocaine infusion as an anti-inflammatory strategy in elective surgery.
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Affiliation(s)
- Irene Castro
- Department of Anesthesiology and Intensive Care Medicine, Instituto Português de Oncologia do Porto (IPO-Porto), 4200-072 Porto , Portugal
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
- Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Pedro Carvalho
- Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
| | - Nuno Vale
- OncoPharma Research Group, Center for Health Technology and Services Research (CINTESIS), Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Community Medicine, Health Information and Decision (MEDCIDS), Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
| | - Teresa Monjardino
- Cancer Epidemiology Group, Centro de Investigação do Instituto Português de Oncologia do Porto (CI-IPOP), 4200-072 Porto, Portugal
| | - Joana Mourão
- CINTESIS@RISE, Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Department of Anesthesiology, Centro Hospitalar Universitário de São João, Alameda Professor Hernâni Monteiro, 4200-319 Porto, Portugal
- Surgery and Physiology Department, Faculty of Medicine, University of Porto, Rua Doutor Plácido da Costa, 4200-450 Porto, Portugal
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Bezu L, Kepp O, Kroemer G. Impact of local anesthetics on epigenetics in cancer. Front Oncol 2022; 12:849895. [PMID: 36110954 PMCID: PMC9468863 DOI: 10.3389/fonc.2022.849895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 08/01/2022] [Indexed: 11/13/2022] Open
Abstract
Defective silencing of tumor suppressor genes through epigenetic alterations contributes to oncogenesis by perturbing cell cycle regulation, DNA repair or cell death mechanisms. Reversal of such epigenetic changes including DNA hypermethylation provides a promising anticancer strategy. Until now, the nucleoside derivatives 5-azacytidine and decitabine are the sole DNA methyltransferase (DNMT) inhibitors approved by the FDA for the treatment of specific hematological cancers. Nevertheless, due to their nucleoside structure, these inhibitors directly incorporate into DNA, which leads to severe side effects and compromises genomic stability. Much emphasis has been placed on the development of less toxic epigenetic modifiers. Recently, several preclinical studies demonstrated the potent epigenetic effects of local anesthetics, which are routinely used during primary tumor resection to relief surgical pain. These non-nucleoside molecules inhibit DNMT activity, affect the expression of micro-RNAs and repress histone acetylation, thus exerting cytotoxic effects on malignant cells. The in-depth mechanistic comprehension of these epigenetic effects might promote the use of local anesthetics as anticancer drugs.
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Affiliation(s)
- Lucillia Bezu
- Equipe Labellisée Par La Ligue Contre Le Cancer, Université de Paris, Sorbonne Université, INSERM UMR1138, Centre de Recherche des Cordeliers, Institut Universitaire de France, Paris, France
- Metabolomics and Cell Biology Platforms, Gustave Roussy Cancer Campus, Université Paris Saclay, Villejuif, France
- Service d’Anesthésie Gustave Roussy Cancer Campus, Villejuif, France
- *Correspondence: Lucillia Bezu, ; Guido Kroemer,
| | - Oliver Kepp
- Equipe Labellisée Par La Ligue Contre Le Cancer, Université de Paris, Sorbonne Université, INSERM UMR1138, Centre de Recherche des Cordeliers, Institut Universitaire de France, Paris, France
- Metabolomics and Cell Biology Platforms, Gustave Roussy Cancer Campus, Université Paris Saclay, Villejuif, France
| | - Guido Kroemer
- Equipe Labellisée Par La Ligue Contre Le Cancer, Université de Paris, Sorbonne Université, INSERM UMR1138, Centre de Recherche des Cordeliers, Institut Universitaire de France, Paris, France
- Metabolomics and Cell Biology Platforms, Gustave Roussy Cancer Campus, Université Paris Saclay, Villejuif, France
- Pôle de Biologie, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
- *Correspondence: Lucillia Bezu, ; Guido Kroemer,
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Mokini Z, Cama A, Forget P. Anesthetics and Long Term Cancer Outcomes: May Epigenetics Be the Key for Pancreatic Cancer? MEDICINA (KAUNAS, LITHUANIA) 2022; 58:1102. [PMID: 36013569 PMCID: PMC9414834 DOI: 10.3390/medicina58081102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/03/2022] [Accepted: 08/06/2022] [Indexed: 06/15/2023]
Abstract
Knowledge shows a divergence of results between preclinical and clinical studies regarding anesthesia and postoperative progression of cancer. While laboratory and animal data from then 2000s onwards raised much enthusiasm in this field of research leading to several clinical investigations worldwide, data from randomized trials seem to have killed off hope for many scientists. However several aspects of the actual knowledge should be reevaluated and there is space for new strategies of investigation. In this paper, we perform a critical review of actual knowledge and propose new research strategies with a special focus on anesthetic management and repurposed anesthetic adjuvants for pancreatic cancer.
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Affiliation(s)
- Zhirajr Mokini
- ESAIC Mentorship Program, BE-1000 Brussels, Belgium
- The European Platform for Research Outcomes after PerIoperative Interventions in Surgery for Cancer Research Group (Euro-Periscope): The Onco-Anaesthesiology Research Group (RG), BE-1000 Brussels, Belgium
| | - Alessandro Cama
- The European Platform for Research Outcomes after PerIoperative Interventions in Surgery for Cancer Research Group (Euro-Periscope): The Onco-Anaesthesiology Research Group (RG), BE-1000 Brussels, Belgium
- Department of Pharmacy, G. d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy
| | - Patrice Forget
- The European Platform for Research Outcomes after PerIoperative Interventions in Surgery for Cancer Research Group (Euro-Periscope): The Onco-Anaesthesiology Research Group (RG), BE-1000 Brussels, Belgium
- Epidemiology Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen AB25 2ZD, UK
- Department of Anaesthesia, National Health Service (NHS) Grampian, Aberdeen AB25 2ZD, UK
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Brogi E, Forfori F. Anesthesia and cancer recurrence: an overview. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:33. [PMID: 37386584 DOI: 10.1186/s44158-022-00060-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/05/2022] [Indexed: 07/01/2023]
Abstract
Several perioperative factors are responsible for the dysregulation or suppression of the immune system with a possible impact on cancer cell growth and the development of new metastasis. These factors have the potential to directly suppress the immune system and activate hypothalamic-pituitary-adrenal axis and the sympathetic nervous system with a consequent further immunosuppressive effect.Anesthetics and analgesics used during the perioperative period may modulate the innate and adaptive immune system, inflammatory system, and angiogenesis, with a possible impact on cancer recurrence and long-term outcome. Even if the current data are controversial and contrasting, it is crucial to increase awareness about this topic among healthcare professionals for a future better and conscious choice of anesthetic techniques.In this article, we aimed to provide an overview regarding the relationship between anesthesia and cancer recurrence. We reviewed the effects of surgery, perioperative factors, and anesthetic agents on tumor cell survival and tumor recurrence.
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Affiliation(s)
- Etrusca Brogi
- Department of Anesthesia and Intensive Care, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
| | - Francesco Forfori
- Department of Anesthesia and Intensive Care, University of Pisa, Via Paradisa 2, 56124, Pisa, Italy
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Zhou Y, Liu S. Threshold heterogeneity of perioperative hemoglobin drop for acute kidney injury after noncardiac surgery: a propensity score weighting analysis. BMC Nephrol 2022; 23:206. [PMID: 35690725 PMCID: PMC9188693 DOI: 10.1186/s12882-022-02834-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background Perioperative hemoglobin drop after noncardiac surgery is associated with acute kidney injury (AKI). However, opinion on the tolerable difference in postoperative hemoglobin drop in patients with different preoperative hemoglobin levels does not reach a consensus. This study aimed to identify hemoglobin drop thresholds for AKI after noncardiac surgery stratified by preoperative hemoglobin levels. Method This was a single-center retrospective cohort study for elective noncardiac surgery from January 1, 2012, to December 31, 2018. The endpoint was the occurrence of AKI 7 days postoperatively in the hospital. The generalized additive model described the non-linear relationship between hemoglobin drop and AKI occurrence. The minimum P-value approach identified cut-off points of hemoglobin drop within postoperative 7 days for patients with or without preoperative anemia. Stratified by preoperative anemia, hemoglobin drop’s odds ratio as continuous, quintile and dichotomous variables by various cut-off points for postoperative AKI were calculated in multivariate logistic regression models before and after propensity score weighting (PSW). Results Of the 35,631 surgery, 5.9% (2105 cases) suffered postoperative AKI. Non-linearity was found between hemoglobin drop and postoperative AKI occurrence. The thresholds and corresponding odds ratio of perioperative hemoglobin drop for patients with and without preoperative anemia were 18 g/L (1.38 (95%CI 1.14 -1.62), P < .001; after PSW: 1.42 (95%CI 1.17 -1.74), P < .001) and 43 g/L (1.81 (95%CI 1.35—2.27), P < .001; after PSW: 2.88 (95%CI 1.85—4.50), P < .001) respectively. Overall thresholds and corresponding odds ratio were 43 g/L (1.82 (95%CI 1.42—2.21)), P < .001; after PSW: 3.29 (95%CI 2.00—5.40), P < .001). Sensitivity analysis showed similar results. Heterogeneity subgroup analysis showed that intraoperatively female patients undergoing intraperitoneal surgery without colloid infusion seemed to be more vulnerable to higher hemoglobin drop. Further analysis showed a possible linear relationship between preoperative hemoglobin and perioperative hemoglobin drop thresholds. Additionally, this study found that the creatinine level changed simultaneously with hemoglobin level within five postoperative days. Conclusions Heterogeneity of hemoglobin drop endurability exists after noncardiac non-kidney surgery. More care and earlier intervention should be put on patients with preoperative anemia. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02834-3.
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Affiliation(s)
- Yan Zhou
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, 100034, China.
| | - Si Liu
- Department of Database Center, Peking University First Hospital, Beijing, 100034, China
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Dourson AJ, Willits A, Raut NG, Kader L, Young E, Jankowski MP, Chidambaran V. Genetic and epigenetic mechanisms influencing acute to chronic postsurgical pain transitions in pediatrics: Preclinical to clinical evidence. Can J Pain 2022; 6:85-107. [PMID: 35572362 PMCID: PMC9103644 DOI: 10.1080/24740527.2021.2021799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 11/30/2021] [Accepted: 12/20/2021] [Indexed: 12/02/2022]
Abstract
Background Chronic postsurgical pain (CPSP) in children remains an important problem with no effective preventive or therapeutic strategies. Recently, genomic underpinnings explaining additional interindividual risk beyond psychological factors have been proposed. Aims We present a comprehensive review of current preclinical and clinical evidence for genetic and epigenetic mechanisms relevant to pediatric CPSP. Methods Narrative review. Results Animal models are relevant to translational research for unraveling genomic mechanisms. For example, Cacng2, p2rx7, and bdnf mutant mice show altered mechanical hypersensitivity to injury, and variants of the same genes have been associated with CPSP susceptibility in humans; similarly, differential DNA methylation (H1SP) and miRNAs (miR-96/7a) have shown translational implications. Animal studies also suggest that crosstalk between neurons and immune cells may be involved in nociceptive priming observed in neonates. In children, differential DNA methylation in regulatory genomic regions enriching GABAergic, dopaminergic, and immune pathways, as well as polygenic risk scores for enhanced prediction of CPSP, have been described. Genome-wide studies in pediatric CPSP are scarce, but pathways identified by adult gene association studies point to potential common mechanisms. Conclusions Bench-to-bedside genomics research in pediatric CPSP is currently limited. Reverse translational approaches, use of other -omics, and inclusion of pediatric/CPSP endophenotypes in large-scale biobanks may be potential solutions. Time of developmental vulnerability and longitudinal genomic changes after surgery warrant further investigation. Emergence of promising precision pain management strategies based on gene editing and epigenetic programing emphasize need for further research in pediatric CPSP-related genomics.
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Affiliation(s)
- Adam J. Dourson
- Department of Anesthesia, Division of Pain Management, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,USA
| | - Adam Willits
- Neuroscience Graduate Program, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Anatomy and Cell Biology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Namrata G.R. Raut
- Department of Anesthesia, Division of Pain Management, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,USA
| | - Leena Kader
- Neuroscience Graduate Program, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Anatomy and Cell Biology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Erin Young
- Neuroscience Graduate Program, University of Kansas Medical Center, Kansas City, Kansas, USA
- Department of Anesthesiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Michael P. Jankowski
- Department of Anesthesia, Division of Pain Management, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,USA
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Vidya Chidambaran
- Department of Anesthesia, Division of Pain Management, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio,USA
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Aghagoli G, Del Re A, Yano N, Zhang Z, Gheit AA, Phillips RK, Sellke FW, Fedulov AV. Methylome of skeletal muscle tissue in patients with hypertension and diabetes undergoing cardiopulmonary bypass. Epigenomics 2021; 13:1853-1866. [PMID: 34802257 PMCID: PMC8619827 DOI: 10.2217/epi-2021-0388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 11/08/2021] [Indexed: 11/21/2022] Open
Abstract
Background: Epigenomic changes occurring during surgery have been neglected in research; diabetes and hypertension can affect the epigenome but little is known about the epigenetics of skeletal muscle (SKM). Methods: DNA methylation was profiled via Illumina MethylationEPIC arrays in SKM samples obtained at the beginning and end of heart surgery with cardiopulmonary bypass. Results: Methylation in patients with hypertension and diabetes was significantly different, more so for uncontrolled diabetes; hypertension alone produced minimal effect. The affected pathways involved IL-1, IL-12, IL-18, TNF-α, IFN-γ, VEGF, NF-κB and Wnt signaling, apoptosis and DNA damage response. Significant changes occurred during surgery and included loci in the Hippo-YAP/TAZ pathway. Conclusion: Cardiopulmonary bypass surgery affects the SKM methylome, and the combination of hypertension and diabetes induces changes in the SKM epigenome in contrast to hypertension alone.
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Affiliation(s)
- Ghazal Aghagoli
- Alpert Medical School of Brown University, Department of Surgery, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA
| | - Andrew Del Re
- Alpert Medical School of Brown University, Department of Surgery, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA
| | - Naohiro Yano
- Alpert Medical School of Brown University, Department of Surgery, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA
| | - Zhiqi Zhang
- Alpert Medical School of Brown University, Department of Surgery, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA
| | - Ahmad Aboul Gheit
- Alpert Medical School of Brown University, Department of Surgery, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA
| | - Ronald K Phillips
- Alpert Medical School of Brown University, Department of Surgery, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA
| | - Frank W Sellke
- Alpert Medical School of Brown University, Department of Surgery, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA
| | - Alexey V Fedulov
- Alpert Medical School of Brown University, Department of Surgery, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA
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Thomas M. Advances in Oncoanaesthesia and Cancer Pain. Cancer Treat Res Commun 2021; 29:100491. [PMID: 34837798 DOI: 10.1016/j.ctarc.2021.100491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The growing interest on how peri-‑operative interventions, especially regional anesthesia, during cancer surgery can alter oncological outcome increasing disease free survival is probably responsible for the birth of the new subspecialty called onco-anesthesia. A paradigm shift in the concept of anesthetic management has occurred recently owing to the innumerable diverse revelations from the ongoing research in this field. DISCUSSION Long lasting but reversible epigenetic changes can occur due to surgical stress and perioperative anesthetic medications. The exact relationship between these factors and tumor biology is being studied further. A popular topic under research now is the influence of regional anesthesia on cancer recurrence. Combining nerve blocks with total intravenous anesthesia (TIVA) brings down the requirement of opioids and volatile anesthetic agents implicated in cancer recurrence. The study of mechanism of pain at the molecular level has led to the discovery of novel modes of prevention of chronic post-surgical pain. Newer combination aggressive treatment therapies -intraoperative chemotherapy and radiotherapy, isolated limb perfusion, photodynamic therapy and robotic surgery require specialized anesthetic management. The COVID pandemic introduced new guidelines for safe management of oncosurgical patients .Use of genomic mapping to personalize pain management will be the breakthrough of the decade. CONCLUSION The discovery that anesthetic strategy could have significant oncological sequel is a quantum leap forward. Avoiding some anesthetic medications may decrease cancer recurrence. Comprehensive cancer care and translational research will pave the way to uncover safe anesthetic practices.
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Affiliation(s)
- Mary Thomas
- Regional Cancer Centre ,Thiruvananthapuram, India..
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Caputi FF, Carboni L, Rullo L, Alessandrini I, Balzani E, Melotti RM, Romualdi P, Candeletti S, Fanelli A. An Exploratory Pilot Study of Changes in Global DNA Methylation in Patients Undergoing Major Breast Surgery Under Opioid-Based General Anesthesia. Front Pharmacol 2021; 12:733577. [PMID: 34621169 PMCID: PMC8491974 DOI: 10.3389/fphar.2021.733577] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/06/2021] [Indexed: 12/30/2022] Open
Abstract
This study aimed to investigate DNA methylation levels in patients undergoing major breast surgery under opioid-based general anesthesia. Blood samples were collected from eleven enrolled patients, before, during and after anesthesia. PBMC were isolated and global DNA methylation levels as well as DNA methyltransferase (DNMT) and cytokine gene expression were assessed. DNA methylation levels significantly declined by 26%, reversing the direction after the end of surgery. Likewise, DNMT1a mRNA expression was significantly reduced at all time points, with lowest level of −68%. DNMT3a and DNMT3b decreased by 65 and 71%, respectively. Inflammatory cytokines IL6 and TNFα mRNA levels showed a trend for increased expression at early time-points to end with a significant decrease at 48 h after surgery. This exploratory study revealed for the first time intraoperative global DNA hypomethylation in patients undergoing major breast surgery under general anesthesia with fentanyl. The alterations of global DNA methylation here observed seem to be in agreement with DNMTs gene expression changes. Furthermore, based on perioperative variations of IL6 and TNFα gene expression, we hypothesize that DNA hypomethylation may occur as a response to surgical stress rather than to opiate exposure.
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Affiliation(s)
- Francesca Felicia Caputi
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Lucia Carboni
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Laura Rullo
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Irene Alessandrini
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Eleonora Balzani
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Rita Maria Melotti
- Department of Surgical and Medical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Patrizia Romualdi
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Sanzio Candeletti
- Department of Pharmacy and Biotechnology, Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Andrea Fanelli
- Anesthesiology and Pain Therapy Unit, AOSP S.Orsola Hospital, Bologna, Italy
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Brenner D, Shorten GD, O'Mahony SM. Postoperative pain and the gut microbiome. NEUROBIOLOGY OF PAIN 2021; 10:100070. [PMID: 34409198 PMCID: PMC8361255 DOI: 10.1016/j.ynpai.2021.100070] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 06/24/2021] [Accepted: 07/26/2021] [Indexed: 12/12/2022]
Abstract
Poorly controlled postoperative pain remains a major unresolved challenge globally. The gut microbiome impacts on inflammatory pain and neuropathic pain. Microbiota metabolites can regulate peripheral and central sensitisation. Stress is linked to both postoperative pain and an altered gut microbiome.
In excess of 300 million surgical procedures are undertaken worldwide each year. Despite recognition of the prevalence of postoperative pain, and improvements in pain management techniques, poorly controlled postoperative pain remains a major unresolved challenge globally. An estimated 71% and 51% of patients experience moderate to severe pain after surgery in in-patient and outpatient settings, respectively. Inadequately controlled pain after surgery is associated with significant perioperative morbidity including myocardial infarction and pulmonary complications. As many as 20–56% of patients develop chronic pain after commonly performed procedures such as hernia repair, hysterectomy, and thoracotomy. Traditional analgesics and interventions are often ineffective or partially effective in the treatment of postoperative pain, resulting in a chronic pain condition with related socio-economic impacts and reduced quality of life for the patient. Such chronic pain which occurs after surgery is referred to as Persistent Post-Surgical Pain (PPSP). The complex ecosystem that is the gastrointestinal microbiota (including bacteria, fungi, viruses, phage) plays essential roles in the maintenance of the healthy state of the host. A disruption to the balance of this microbiome has been implicated not only in gastrointestinal disease but also neurological disorders including chronic pain. The influence of the gut microbiome is well documented in the context of visceral pain from the gastrointestinal tract while a greater understanding is emerging of the impact on inflammatory pain and neuropathic pain (both of which can occur during the perioperative period). The gut microbiome is an essential source for driving immune maturation and maintaining appropriate immune response. Given that inflammatory processes have been implicated in postoperative pain, aberrant microbiome profiles may play a role in the development of this type of pain. Furthermore, the microorganisms in our gut produce metabolites, neurotransmitters, and neuromodulators which interact with their receptors to regulate peripheral and central sensitisation associated with chronic pain. Microbiota-derived mediators can also regulate neuroinflammation, which is associated with activation of microglia as well as infiltration by immune cells, known to modulate the development and maintenance of central sensitisation. Moreover, risk factors for developing postoperative pain include anxiety, depression, and increased stress response. These central nervous system-related disorders have been associated with an altered gut microbiome and microbiome targeted intervention studies indicate improvements. Females are more likely to suffer from postoperative pain. As gonadal hormones are associated with a differential microbiome and pre-clinical studies show that male microbiome confers protection from inflammatory pain, it is possible that the composition of the microbiome and its by-products contribute to the increased risk for the development of postoperative pain. Very little evidence exists relating the microbiome to somatic pain. Here we discuss the potential role of the gut microbiome in the aetiology and pathophysiology of postoperative pain in the context of other somatic pain syndromes and what is known about microbe-neuron interactions. Investigations are needed to determine the specific role of the gut microbiome in this type of pain which may help inform the development of preventative interventions as well as management strategies to improve patient outcome.
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Affiliation(s)
- David Brenner
- Department of Anesthesia and Intensive Care Medicine, Cork University Hospital and University College Cork, Ireland
| | - George D Shorten
- Department of Anesthesia and Intensive Care Medicine, Cork University Hospital and University College Cork, Ireland
| | - Siobhain M O'Mahony
- APC Microbiome Ireland, University College Cork, Cork, Ireland.,Department of Anatomy and Neuroscience, University College Cork, Cork, Ireland
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López-Muñoz E, Mejía-Terrazas GE. Epigenetics and postsurgical pain: A scoping review. PAIN MEDICINE 2021; 23:246-262. [PMID: 34314508 DOI: 10.1093/pm/pnab234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Multiple factors are involved in the physiology and variability of postsurgical pain, a great part of which can be explained by genetic and environmental factors and their interaction. Epigenetics refers to the mechanism by which the environment alters the stability and expression of genes. We conducted a scoping review to examine the available evidence in both animal models and clinical studies on epigenetic mechanisms involved in regulation of postsurgical and chronic postsurgical pain. METHODS The Arksey & ÓMalley framework and the PRISMA-ScR (Preferred Reporting Items for Systematic Review and Meta-Analysis, scoping reviews extension) guidelines were used. The PubMed, Web of Science and Google Scholar databases were searched, and the original articles cited in reviews located through the search were also reviewed. English-language articles without time limits were retrieved. Articles were selected if the abstract addressed information on the epigenetic or epigenomic mechanisms, histone, or DNA methylation and microribonucleic acids involved in postsurgical and chronic postsurgical pain in animal models and clinical studies. RESULTS The initial search provided 174 articles, and 81 were used. The available studies to date, mostly in animal models, have shown that epigenetics contributes to regulation of gene expression in the pathways involved in postsurgical pain and in maintaining long-term pain. CONCLUSION Research on possible epigenetic mechanisms involved in postsurgical pain and chronic postsurgical pain in humans is scarce. In view of the evidence available in animal models, there is a need to evaluate epigenetic pain mechanisms in the context of human and clinical studies.
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Affiliation(s)
- Eunice López-Muñoz
- Medical Research Unit in Reproductive Medicine, Unidad Médica de Alta Especialidad, Hospital de Gineco Obstetricia No. 4, "Luis Castelazo Ayala", Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Gabriel Enrique Mejía-Terrazas
- Medical Research Unit in Reproductive Medicine, Unidad Médica de Alta Especialidad, Hospital de Gineco Obstetricia No. 4, "Luis Castelazo Ayala", Instituto Mexicano del Seguro Social, Mexico City, Mexico.,Anaesthesiology Service and Pain Clinic, Hospital Angeles México, Mexico City, Mexico
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14
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Tang F, Tie Y, Hong W, Wei Y, Tu C, Wei X. Targeting Myeloid-Derived Suppressor Cells for Premetastatic Niche Disruption After Tumor Resection. Ann Surg Oncol 2021; 28:4030-4048. [PMID: 33258011 PMCID: PMC7703739 DOI: 10.1245/s10434-020-09371-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/29/2020] [Indexed: 02/05/2023]
Abstract
Surgical resection is a common therapeutic option for primary solid tumors. However, high cancer recurrence and metastatic rates after resection are the main cause of cancer related mortalities. This implies the existence of a "fertile soil" following surgery that facilitates colonization by circulating cancer cells. Myeloid-derived suppressor cells (MDSCs) are essential for premetastatic niche formation, and may persist in distant organs for up to 2 weeks after surgery. These postsurgical persistent lung MDSCs exhibit stronger immunosuppression compared with presurgical MDSCs, suggesting that surgery enhances MDSC function. Surgical stress and trauma trigger the secretion of systemic inflammatory cytokines, which enhance MDSC mobilization and proliferation. Additionally, damage associated molecular patterns (DAMPs) directly activate MDSCs through pattern recognition receptor-mediated signals. Surgery also increases vascular permeability, induces an increase in lysyl oxidase and extracellular matrix remodeling in lungs, that enhances MDSC mobilization. Postsurgical therapies that inhibit the induction of premetastatic niches by MDSCs promote the long-term survival of patients. Cyclooxygenase-2 inhibitors and β-blockade, or their combination, may minimize the impact of surgical stress on MDSCs. Anti-DAMPs and associated inflammatory signaling inhibitors also are potential therapies. Existing therapies under tumor-bearing conditions, such as MDSCs depletion with low-dose chemotherapy or tyrosine kinase inhibitors, MDSCs differentiation using all-trans retinoic acid, and STAT3 inhibition merit clinical evaluation during the perioperative period. In addition, combining low-dose epigenetic drugs with chemokine receptors, reversing immunosuppression through the Enhanced Recovery After Surgery protocol, repairing vascular leakage, or inhibiting extracellular matrix remodeling also may enhance the long-term survival of curative resection patients.
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Affiliation(s)
- Fan Tang
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
- Department of Orthopeadics, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Yan Tie
- Department of Oncology, Sichuan Cancer Hospital and Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, People's Republic of China
| | - Weiqi Hong
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Yuquan Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China
| | - Chongqi Tu
- Department of Orthopeadics, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
| | - Xiawei Wei
- Laboratory of Aging Research and Cancer Drug Target, State Key Laboratory of Biotherapy, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, People's Republic of China.
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Schenning KJ, Holden S, Davis BA, Mulford A, Nevonen KA, Quinn JF, Raber J, Carbone L, Alkayed NJ. Gene-Specific DNA Methylation Linked to Postoperative Cognitive Dysfunction in Apolipoprotein E3 and E4 Mice. J Alzheimers Dis 2021; 83:1251-1268. [PMID: 34420963 PMCID: PMC8801332 DOI: 10.3233/jad-210499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Geriatric surgical patients are at higher risk of developing postoperative neurocognitive disorders (NCD) than younger patients. The specific mechanisms underlying postoperative NCD remain unknown, but they have been linked to genetic risk factors, such as the presence of APOE4, compared to APOE3, and epigenetic modifications caused by exposure to anesthesia and surgery. OBJECTIVE To test the hypothesis that compared to E3 mice, E4 mice exhibit a more pronounced postoperative cognitive impairment associated with differential DNA methylation in brain regions linked to learning and memory. METHODS 16-month-old humanized apolipoprotein-E targeted replacement mice bearing E3 or E4 were subjected to surgery (laparotomy) under general isoflurane anesthesia or sham. Postoperative behavioral testing and genome-wide DNA methylation were performed. RESULTS Exposure to surgery and anesthesia impaired cognition in aged E3, but not E4 mice, likely due to the already lower cognitive performance of E4 prior to surgery. Cognitive impairment in E3 mice was associated with hypermethylation of specific genes, including genes in the Ephrin pathway implicated in synaptic plasticity and learning in adults and has been linked to Alzheimer's disease. Other genes, such as the Scratch Family Transcriptional Repressor 2, were altered after surgery and anesthesia in both the E3 and E4 mice. CONCLUSION Our findings suggest that the neurocognitive and behavioral effects of surgery and anesthesia depend on baseline neurocognitive status and are associated with APOE isoform-dependent epigenetic modifications of specific genes and pathways involved in memory and learning.
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Affiliation(s)
- Katie J. Schenning
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Sarah Holden
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR, USA
| | - Brett A. Davis
- Department of Medicine, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Amelia Mulford
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR, USA
| | - Kimberly A. Nevonen
- Department of Medicine, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Joseph F. Quinn
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - Jacob Raber
- Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR, USA
- Department of Neurology, Oregon Health & Science University, Portland, OR, USA
- Department of Radiation Medicine, Division of Neuroscience, ONPRC, Portland, OR, USA
| | - Lucia Carbone
- Department of Medicine, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
- Division of Genetics, Oregon National Primate Research Center, Portland, OR, USA
- Department of Molecular & Medical Genetics, Oregon Health & Science University, Portland, OR, USA
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, USA
| | - Nabil J. Alkayed
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
- Department of Medicine, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
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Abstract
OBJECTIVE The majority of patients with colorectal cancer are diagnosed with locally advanced and/or disseminated disease, and treatment options include surgery in combination with cytotoxic chemotherapy regimens, biologics, and/or radiotherapy. Thus, colorectal cancer remains a heavy burden on society and health care systems.Mounting evidence show that driver gene mutations play only part of the role in carcinogenesis. Epigenetics are strongly implicated in initiation and progression of colorectal cancer along with major players such as intestinal microbiotic dysbiosis and chronic mucosal inflammation.To assess phenotypic changes in proteins and gene expression, multigene expression signatures based on sequencing techniques have been developed to hopefully improve predictors of the tumor profile, immune response, and therapeutic outcomes. Our objective was to review current advances in the field and to update surgeons and academics on driver gene mutations and epigenetics in colorectal cancer. BACKGROUND AND METHODS This is a narrative review studying relevant research published in the PUBMED database from 2012-2018. RESULTS AND CONCLUSION Increased understanding of the molecular biology will improve options to characterize colorectal cancer with regard to mutations and molecular pathways, including microsatellite instability, epigenetics, microbiota, and microenvironment. Research will inevitably improve risk group stratification and targeted treatment approaches.Epigenetic profiling and epigenetic modulating drugs will increase risk stratification, increase accessibility for DNA targeting chemotherapeutics and reduce cytotoxic drug resistance.New generation antibiotics such as biofilm inhibitors and quorum sensing inhibitors are being developed to target the carcinogenetic impact of colonic dysbiosis and inflammation.
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Sadahiro R, Knight B, James F, Hannon E, Charity J, Daniels IR, Burrage J, Knox O, Crawford B, Smart NJ, Mill J. Major surgery induces acute changes in measured DNA methylation associated with immune response pathways. Sci Rep 2020; 10:5743. [PMID: 32238836 PMCID: PMC7113299 DOI: 10.1038/s41598-020-62262-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 03/09/2020] [Indexed: 12/19/2022] Open
Abstract
Surgery is an invasive procedure evoking acute inflammatory and immune responses that can influence risk for postoperative complications including cognitive dysfunction and delirium. Although the specific mechanisms driving these responses have not been well-characterized, they are hypothesized to involve the epigenetic regulation of gene expression. We quantified genome-wide levels of DNA methylation in peripheral blood mononuclear cells (PBMCs) longitudinally collected from a cohort of elderly patients undergoing major surgery, comparing samples collected at baseline to those collected immediately post-operatively and at discharge from hospital. We identified acute changes in measured DNA methylation at sites annotated to immune system genes, paralleling changes in serum-levels of markers including C-reactive protein (CRP) and Interleukin 6 (IL-6) measured in the same individuals. Many of the observed changes in measured DNA methylation were consistent across different types of major surgery, although there was notable heterogeneity between surgery types at certain loci. The acute changes in measured DNA methylation induced by surgery are relatively stable in the post-operative period, generally persisting until discharge from hospital. Our results highlight the dramatic alterations in gene regulation induced by invasive surgery, primarily reflecting upregulation of the immune system in response to trauma, wound healing and anaesthesia.
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Affiliation(s)
- Ryoichi Sadahiro
- Department of Immune Medicine, National Cancer Center Research Institute, National Cancer Center Japan, Tokyo, Japan. .,University of Exeter Medical School, University of Exeter, Exeter, United Kingdom.
| | - Bridget Knight
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom.,Royal Devon & Exeter Hospital, Exeter, United Kingdom
| | - Ffion James
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Eilis Hannon
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - John Charity
- Royal Devon & Exeter Hospital, Exeter, United Kingdom
| | - Ian R Daniels
- Royal Devon & Exeter Hospital, Exeter, United Kingdom
| | - Joe Burrage
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Olivia Knox
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Bethany Crawford
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Neil J Smart
- Royal Devon & Exeter Hospital, Exeter, United Kingdom
| | - Jonathan Mill
- University of Exeter Medical School, University of Exeter, Exeter, United Kingdom.
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18
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Agrimi J, Baroni C, Anakor E, Lionetti V. Perioperative Heart-Brain Axis Protection in Obese Surgical Patients: The Nutrigenomic Approach. Curr Med Chem 2020; 27:258-281. [PMID: 30324875 DOI: 10.2174/0929867325666181015145225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 08/01/2018] [Accepted: 09/25/2018] [Indexed: 02/06/2023]
Abstract
The number of obese patients undergoing cardiac and noncardiac surgery is rapidly increasing because they are more prone to concomitant diseases, such as diabetes, thrombosis, sleep-disordered breathing, cardiovascular and cerebrovascular disorders. Even if guidelines are already available to manage anesthesia and surgery of obese patients, the assessment of the perioperative morbidity and mortality from heart and brain disorders in morbidly obese surgical patients will be challenging in the next years. The present review will recapitulate the new mechanisms underlying the Heart-brain Axis (HBA) vulnerability during the perioperative period in healthy and morbidly obese patients. Finally, we will describe the nutrigenomics approach, an emerging noninvasive dietary tool, to maintain a healthy body weight and to minimize the HBA propensity to injury in obese individuals undergoing all types of surgery by personalized intake of plant compounds that may regulate the switch from health to disease in an epigenetic manner. Our review provides current insights into the mechanisms underlying HBA response in obese surgical patients and how they are modulated by epigenetically active food constituents.
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Affiliation(s)
- Jacopo Agrimi
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Carlotta Baroni
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
| | - Ekene Anakor
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Vincenzo Lionetti
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,UOS Anesthesiology, Fondazione Toscana G. Monasterio, Pisa, Italy
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Bach-Rojecky L, Vađunec D, Lozić M, Žunić K, Špoljar GG, Čutura T, Erceg D, Primorac D. Challenges in anesthesia personalization: resolving the pharmacogenomic puzzle. Per Med 2019; 16:511-525. [DOI: 10.2217/pme-2019-0056] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Clinicians are witnessing differences in the doses required for induction and maintenance of anesthesia, as well as prolonged recovery in some patients. Predictable factors like patient characteristics, factors related to the procedure, pharmacological characteristics of anesthetics and adjunctive drugs, might explain some of the observed differences. However, the role of various polymorphisms of genes encoding for drugs’ molecular targets, transporters and metabolic enzymes can have a significant impact on anesthesia outcome, too. In the present paper, we critically discuss pharmacological characteristics of the most common drugs used in anesthesia, with a focus on the possible genetic background of unpredictable diversities in anesthesia outcomes.
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Affiliation(s)
- Lidija Bach-Rojecky
- Department of Pharmacology, University of Zagreb Faculty of Pharmacy & Biochemistry, Zagreb 10000, Croatia
| | - Dalia Vađunec
- Department of Pharmacology, University of Zagreb Faculty of Pharmacy & Biochemistry, Zagreb 10000, Croatia
| | - Marin Lozić
- Department of Anesthesia & ICU Care of Neurosurgical Patients, Clinic for Anesthesia & Intensive Care, University Clinical Hospital Zagreb, Zagreb 10000, Croatia
| | | | | | - Tomislav Čutura
- St. Catherine Specialty Hospital, Zagreb 10000 & Zabok 49210, Croatia
| | - Damir Erceg
- St. Catherine Specialty Hospital, Zagreb 10000 & Zabok 49210, Croatia
- Croatian Catholic University, Zagreb 10000, Croatia
- Srebrnjak Children's Hospital, Zagreb 10000, Croatia
- University Josip Juraj Strossmayer Faculty of Dental Medicine & Health, School of Medicine, Osijek 31000, Croatia
- University Josip Juraj Strossmayer School of Medicine, Osijek 31000, Croatia
| | - Dragan Primorac
- St. Catherine Specialty Hospital, Zagreb 10000 & Zabok 49210, Croatia
- University Josip Juraj Strossmayer Faculty of Dental Medicine & Health, School of Medicine, Osijek 31000, Croatia
- University Josip Juraj Strossmayer School of Medicine, Osijek 31000, Croatia
- Eberly College of Science, State College, Penn State University, PA 16802, USA
- The Henry C. Lee College of Criminal Justice & Forensic Sciences, University of New Haven, West Haven, CT 06516, USA
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Linking Lifestyle Factors to Complex Pain States: 3 Reasons Why Understanding Epigenetics May Improve the Delivery of Patient-Centered Care. J Orthop Sports Phys Ther 2019; 49:683-687. [PMID: 31570075 DOI: 10.2519/jospt.2019.0612] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Persistent pain is determined by a diverse and ever-changing combination of biology, psychology, and society. Research suggests a need to embrace a patient-centered, biopsychosocial approach to improve outcomes. Only through in-depth understanding of complex mechanisms and by using mechanism-based reasoning can the clinician tailor interventions-the basic tenet of patient-centered care. Epigenetics is helping to unravel complex underlying mechanisms and might have at least 3 major clinical implications for orthopaedic and sports physical therapists. First, it promotes mechanism-based clinical reasoning by improved understanding of the pathophysiology of many health conditions and the underlying mechanisms of action of commonly used interventions. Second, it might help patient subgrouping, allowing more targeted interventions. Finally, it might be used as a biomarker to monitor the effects of environmental factors and lifestyle interventions on health. For these reasons, the authors urge clinicians and clinical researchers to follow this rapidly growing area of research, as it might be soon contributing to patient assessment. J Orthop Sports Phys Ther 2019;49(10):683-687. doi:10.2519/jospt.2019.0612.
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Chen D, Pan J, Chen Y, Xing W, Yan Y, Yuan Y, Zeng W. The mu-opioid receptor is a molecular marker for poor prognosis in hepatocellular carcinoma and represents a potential therapeutic target. Br J Anaesth 2019; 122:e157-e167. [DOI: 10.1016/j.bja.2018.09.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 09/07/2018] [Accepted: 09/17/2018] [Indexed: 01/17/2023] Open
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Kim HJ, Park HS, Go YJ, Koh WU, Kim H, Song JG, Ro YJ. Effect of Anesthetic Technique on the Occurrence of Acute Kidney Injury after Total Knee Arthroplasty. J Clin Med 2019; 8:jcm8060778. [PMID: 31159309 PMCID: PMC6616515 DOI: 10.3390/jcm8060778] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 05/29/2019] [Accepted: 05/30/2019] [Indexed: 12/21/2022] Open
Abstract
Recent studies have reported the advantages of spinal anesthesia over general anesthesia in orthopedic patients. However, little is known about the relationship between acute kidney injury (AKI) after total knee arthroplasty (TKA) and anesthetic technique. This study aimed to identify the influence of anesthetic technique on AKI in TKA patients. We also evaluated whether the choice of anesthetic technique affected other clinical outcomes. We retrospectively reviewed medical records of patients who underwent TKA between January 2008 and August 2016. Perioperative data were obtained and analyzed. To reduce the influence of potential confounding factors, propensity score (PS) analysis was performed. A total of 2809 patients and 2987 cases of TKA were included in this study. A crude analysis of the total set demonstrated a significantly lower risk of AKI in the spinal anesthesia group. After PS matching, the spinal anesthesia group showed a tendency for reduced AKI, without statistical significance. Furthermore, the spinal anesthesia group showed a lower risk of pulmonary and vascular complications, and shortened hospital stay after PS matching. In TKA patients, spinal anesthesia had a tendency to reduce AKI. Moreover, spinal anesthesia not only reduced vascular and pulmonary complications, but also shortened hospital stay.
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Affiliation(s)
- Ha-Jung Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, College of Medicine, Seoul 05505, Korea.
| | - Hee-Sun Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, College of Medicine, Seoul 05505, Korea.
| | - Yon-Ji Go
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, College of Medicine, Seoul 05505, Korea.
| | - Won Uk Koh
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, College of Medicine, Seoul 05505, Korea.
| | - Hyungtae Kim
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, College of Medicine, Seoul 05505, Korea.
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, College of Medicine, Seoul 05505, Korea.
| | - Young-Jin Ro
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan, College of Medicine, Seoul 05505, Korea.
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Abstract
Surgery and other invasive procedures, which are routinely performed during general anesthesia, may induce an inflammatory response in the patient. This inflammatory response is an inherent answer of the body to the intervention and can be both beneficial and potentially harmful. The immune system represents a unique evolutionary achievement equipping higher organisms with an effective defense mechanism against exogenous pathogens. However, not only bacteria might evoke an immune response but also other noninfectious stimuli like the surgical trauma or mechanical ventilation may induce an inflammatory response of varying degree. In these cases, the immune system activation is not always beneficial for the patients and might carry the risk of concomitant, harmful effects on host cells, tissues, or even whole organ systems. Research over the past decades has contributed substantial information in which ways surgical patients may be affected by inflammatory reactions. Modulations of the patient's immune system may be evoked by the use of anesthetic agents, the nature of surgical trauma and the use of any supportive therapy during the perioperative period. The effects on the patient may be manifold, including various proinflammatory effects. This review focuses on the causes and effects of inflammation in the perioperative period. In addition, we also highlight possible approaches by which inflammation in the perioperative may be modulated in the future.
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Affiliation(s)
- Jan Rossaint
- From the Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
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24
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Evans MT, Wigmore T, Kelliher LJS. The impact of anaesthetic technique upon outcome in oncological surgery. BJA Educ 2018; 19:14-20. [PMID: 33456849 DOI: 10.1016/j.bjae.2018.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2018] [Indexed: 11/17/2022] Open
Affiliation(s)
- M T Evans
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
| | - T Wigmore
- The Royal Marsden Hospital NHS Foundation Trust, London, UK
| | - L J S Kelliher
- Royal Surrey County Hospital NHS Foundation Trust, Guildford, UK
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25
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Yamaguchi T, Hosomichi K, Takahashi M, Haga S, Nakawaki T, Hikita Y, Maki K, Tajima A. Orthognathic surgery induces genomewide changes longitudinally in DNA methylation in saliva. Oral Dis 2018; 25:508-514. [PMID: 30362655 DOI: 10.1111/odi.12998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Revised: 07/27/2018] [Accepted: 10/05/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Orthognathic surgery dramatically changes morphology of the maxillofacial deformity and improves the malocclusion morphologically and functionally. We investigated the influence of orthognathic surgery on genomewide DNA methylation in saliva. METHODS Saliva was obtained from nine patients undergoing orthognathic surgery and two healthy reference individuals before and 3 months after orthognathic surgery. Genomewide DNA methylation profiling of saliva (341,482 CpG dinucleotides) was conducted using Infinium HumanMethylation450 BeadChips. RESULTS Comparison between pre- and postsurgery saliva samples revealed significant changes in DNA methylation patterns at 2,381 CpG sites (p < 0.01) with suggestive significance. The differentially methylated probe sets were significantly associated with the cancer pathway (p = 2.8 × 10-7 ; a false discovery rate q-value = 3.7 × 10-4 ) and PI3K-Akt signalling pathway (p = 2.4 × 10-5 ; a false discovery rate q-value = 3.1 × 10-2 ). CONCLUSION Pathway enrichment analysis of genes with suggestive significance demonstrated that altered DNA methylation in saliva of patients undergoing orthognathic surgery, possibly as a response to surgical stress or bone injury. Further studies with a large sample size and long-term observation are needed to validate the phenomena identified in this study.
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Affiliation(s)
| | - Kazuyoshi Hosomichi
- Department of Bioinformatics and Genomics, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Ishikawa, Japan
| | | | - Shugo Haga
- Department of Orthodontics, Showa University, Tokyo, Japan
| | | | - Yu Hikita
- Department of Orthodontics, Showa University, Tokyo, Japan
| | - Koutaro Maki
- Department of Orthodontics, Showa University, Tokyo, Japan
| | - Atsushi Tajima
- Department of Bioinformatics and Genomics, Graduate School of Advanced Preventive Medical Sciences, Kanazawa University, Ishikawa, Japan
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Abstract
Abstract
The development of chronic pain is considered a major complication after surgery. Basic science research in animal models helps us understand the transition from acute to chronic pain by identifying the numerous molecular and cellular changes that occur in the peripheral and central nervous systems. It is now well recognized that inflammation and nerve injury lead to long-term synaptic plasticity that amplifies and also maintains pain signaling, a phenomenon referred to as pain sensitization. In the context of surgery in humans, pain sensitization is both responsible for an increase in postoperative pain via the expression of wound hyperalgesia and considered a critical factor for the development of persistent postsurgical pain. Using specific drugs that block the processes of pain sensitization reduces postoperative pain and prevents the development of persistent postoperative pain. This narrative review of the literature describes clinical investigations evaluating different preventative pharmacologic strategies that are routinely used by anesthesiologists in their daily clinical practices for preventing persistent postoperative pain. Nevertheless, further efforts are needed in both basic and clinical science research to identify preclinical models and novel therapeutics targets. There remains a need for more patient numbers in clinical research, for more reliable data, and for the development of the safest and the most effective strategies to limit the incidence of persistent postoperative pain.
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Xavier-Elsas P, Ferreira RN, Gaspar-Elsas MIC. Surgical and immune reconstitution murine models in bone marrow research: Potential for exploring mechanisms in sepsis, trauma and allergy. World J Exp Med 2017; 7:58-77. [PMID: 28890868 PMCID: PMC5571450 DOI: 10.5493/wjem.v7.i3.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 06/11/2017] [Accepted: 06/30/2017] [Indexed: 02/06/2023] Open
Abstract
Bone marrow, the vital organ which maintains lifelong hemopoiesis, currently receives considerable attention, as a source of multiple cell types which may play important roles in repair at distant sites. This emerging function, distinct from, but closely related to, bone marrow roles in innate immunity and inflammation, has been characterized through a number of strategies. However, the use of surgical models in this endeavour has hitherto been limited. Surgical strategies allow the experimenter to predetermine the site, timing, severity and invasiveness of injury; to add or remove aggravating factors (such as infection and defects in immunity) in controlled ways; and to manipulate the context of repair, including reconstitution with selected immune cell subpopulations. This endows surgical models overall with great potential for exploring bone marrow responses to injury, inflammation and infection, and its roles in repair and regeneration. We review three different murine surgical models, which variously combine trauma with infection, antigenic stimulation, or immune reconstitution, thereby illuminating different aspects of the bone marrow response to systemic injury in sepsis, trauma and allergy. They are: (1) cecal ligation and puncture, a versatile model of polymicrobial sepsis; (2) egg white implant, an intriguing model of eosinophilia induced by a combination of trauma and sensitization to insoluble allergen; and (3) ectopic lung tissue transplantation, which allows us to dissect afferent and efferent mechanisms leading to accumulation of hemopoietic cells in the lungs. These models highlight the gain in analytical power provided by the association of surgical and immunological strategies.
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Abstract
Persistent or chronic postsurgical pain (CPSP) has been defined as 'pain persisting beyond 2 months'. The cut-off limit of 2 months has been controversial, and some researchers argue for a 3-month period for the definition of CPSP. Multiple mechanisms, including both patient and surgical, have been shown to influence this transition. Patient factors include age, gender, anxiety, depression, somatisation, catastrophising, pre-existing pain anywhere and pain at the site of surgery. The various surgical factors include site and nature of surgery, infection, inflammation and repeat surgery. There is evidence that pre- or post-op chemotherapy and radiotherapy can also contribute towards the chronification of pain after surgery. The question of why pain following surgery or trauma persists long after the normal healing time is not yet fully explained by current evidence. This is frustrating to healthcare providers and intensely disappointing to the patients, many of whom suffer in silence for years. Genetics is now being shown to influence both the onset and the perpetuation of chronic pain in the susceptible patient. The main mechanisms are believed to be 'single nucleotide polymorphisms' (SNPs) and 'epigenetics', both of which will be discussed, with current and ongoing research and evidence, in this review. The influence of SNPs has not been replicated in recent studies and researchers advise caution in interpreting past studies. More research is needed to demonstrate the involvement of epigenetics as well as linking SNPs to the susceptible patient's journey.
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Epigenetic divergence in the TRPA1 promoter correlates with pressure pain thresholds in healthy individuals. Pain 2016; 158:698-704. [DOI: 10.1097/j.pain.0000000000000815] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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James S. The Genetics of Pain. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0185-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Pujol Lopez Y, Kenis G, Stettinger W, Neumeier K, de Jonge S, Steinbusch HWM, Zill P, van den Hove DLA, Myint AM. Effects of prenatal Poly I:C exposure on global histone deacetylase (HDAC) and DNA methyltransferase (DNMT) activity in the mouse brain. Mol Biol Rep 2016; 43:711-7. [PMID: 27216537 PMCID: PMC4906067 DOI: 10.1007/s11033-016-4006-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 05/10/2016] [Indexed: 01/17/2023]
Abstract
The aim of our study was to investigate the brain-specific epigenetic effects on global enzymatic histone deacetylase (HDAC) and DNA methyltransferase (DNMT) activity after prenatal exposure to maternal immune challenge by polyinosinic:polycytidylic acid (Poly I:C) at gestational day (GD) 17 in C57BL/6JRccHsd mouse offspring. Pregnant mice were randomly divided into 2 groups, receiving either 5 mg/kg Poly I:C or phosphate buffered saline (PBS) intravenously at GD 17. Subsequently, the effects on whole brain enzymatic HDAC and DNMT activity and the protein levels of various HDAC isoforms were assessed in the offspring. Overall, a significant sex × treatment interaction effect was observed after prenatal exposure to maternal immune challenge by Poly I:C, indicative of increased global HDAC activity particularly in female offspring from mothers injected with Poly I:C when compared to controls. Results on the levels of specific HDAC isoforms suggested that neither differences in the levels of HDAC1, HDAC2, HDAC3, HDAC4 or HDAC6 could explain the increased global HDAC activity observed in female Poly I:C offspring. In conclusion, we show that Poly I:C administration to pregnant mice alters global brain HDAC, but not DNMT activity in adult offspring, whereas it is still unclear which specific HDAC(s) mediate(s) this effect. These results indicate the necessity for further research on the epigenetic effects of Poly I:C.
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Affiliation(s)
- Yara Pujol Lopez
- School for Mental Health and Neuroscience (MHeNS), Department of Psychiatry and Neuropsychology, Maastricht University Medical Centre+, Universiteitssingel 50, Room 1.148, 6229 ER, Maastricht, The Netherlands.
| | - Gunter Kenis
- School for Mental Health and Neuroscience (MHeNS), Department of Psychiatry and Neuropsychology, Maastricht University Medical Centre+, Universiteitssingel 50, Room 1.148, 6229 ER, Maastricht, The Netherlands
| | | | - Karin Neumeier
- Psychiatric Hospital, Ludwig-Maximilian University, Munich, Germany
| | - Sylvia de Jonge
- Psychiatric Hospital, Ludwig-Maximilian University, Munich, Germany
| | - Harry W M Steinbusch
- School for Mental Health and Neuroscience (MHeNS), Department of Psychiatry and Neuropsychology, Maastricht University Medical Centre+, Universiteitssingel 50, Room 1.148, 6229 ER, Maastricht, The Netherlands
| | - Peter Zill
- Psychiatric Hospital, Ludwig-Maximilian University, Munich, Germany
| | - Daniel L A van den Hove
- School for Mental Health and Neuroscience (MHeNS), Department of Psychiatry and Neuropsychology, Maastricht University Medical Centre+, Universiteitssingel 50, Room 1.148, 6229 ER, Maastricht, The Netherlands.,Laboratory of Translational Neuroscience, Department of Psychiatry, Psychosomatics and Psychotherapy, University of Würzburg, Würzburg, Germany
| | - Aye M Myint
- School for Mental Health and Neuroscience (MHeNS), Department of Psychiatry and Neuropsychology, Maastricht University Medical Centre+, Universiteitssingel 50, Room 1.148, 6229 ER, Maastricht, The Netherlands.,Psychiatric Hospital, Ludwig-Maximilian University, Munich, Germany
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Abstract
Recent advances in the understanding of gene regulation have shown there to be much more regulation of the genome than first thought, through epigenetic mechanisms. These epigenetic mechanisms are systems that have evolved to either switch off gene activity altogether, or fine-tune any existing genetic activation. Such systems are present in all genes and include chromatin modifications and remodelling, DNA methylation (such as CpG island methylation rates) and histone covalent modifications (e.g. acetylation, methylation), RNA interference by short interfering RNAs (siRNAs) and long non-coding RNAs (ncRNAs). These systems regulate genomic activity 'beyond' simple transcriptional factor inducer or repressor function of genes to generate mRNA. Epigenetic regulation of gene activity has been shown to be important in maintaining normal phenotypic activity of cells, as well as having a role in development and diseases such as cancer and neurodegenerative disorders such as Alzheimer's. Newer classes of drugs regulate epigenetic mechanisms to counteract disease states in humans. The reports in this issue describe some advances in epigenetic understanding that relate to human disease, and our ability to control these mechanisms by pharmacological means. Increasingly the importance of epigenetics is being uncovered - it is pharmacology that will have to keep pace.
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Affiliation(s)
- Barbara Stefanska
- Department of Nutrition Science, Purdue University Center for Cancer Research, Purdue University, West Lafayette, IN, USA
| | - David J MacEwan
- Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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