Analgesia enhancement and prevention of tolerance to morphine: beneficial effects of combined therapy with omega-3 fatty acids

Exploring the Place of Fish Skin Grafts with Omega-3 in Pediatric Wound Management

Wound healing in the pediatric population is known to be a challenge and poorly studied. Split-thickness skin grafts, full-thickness skin grafts, and flaps overlap their applications with the growing field of cellular and tissue-based therapies. However, their role in pediatric reconstruction has yet to be defined. The Kerecis® Omega-3 wound patch, derived from decellularized codfish skin, has garnered attention due to its preserved microscopic architecture resembling the human extracellular matrix. This acellular dermal matrix acts as a scaffold, fostering dermal cell and capillary adhesion while harnessing omega-3 polyunsaturated fatty acids for granulation acceleration and antimicrobial effects. This study presents a comprehensive review and surgical protocol for utilizing Kerecis® fish skin in pediatric wound care. The research embraces a case series involving five patients with diverse wound locations. The Kerecis® Omega-3 wound patch underwent meticulous application and careful monitoring. The results highlight an average time of 48.6 days for complete epithelialization, yielding favorable outcomes with no hypertrophic scarring and mild retraction. Kerecis® fish skin grafting stands as a tool that not only accelerates healing but also addresses the multifaceted challenges associated with wound management in the pediatric population: the avoidance of donor site morbidity and improved postoperative pain control.

Herbal Medicine for Pain Management: Efficacy and Drug Interactions

Complementary and alternative medicines such as herbal medicines are not currently part of the conventional medical system. As the popularity of and global market for herbal medicine grows among all age groups, with supporting scientific data and clinical trials, specific alternative treatments such as herbal medicine can be reclassified as a practice of conventional medicine. One of the most common conditions for which adults use herbal medicine is pain. However, herbal medicines carry safety concerns and may impact the efficacy of conventional therapies. Unfortunately, mechanisms of action are poorly understood, and their use is unregulated and often underreported to medical professionals. This review aims to compile common and available herbal medicines which can be used as an alternative to or in combination with conventional pain management approaches. Efficacy and safety are assessed through clinical studies on pain relief. Ensuing herb–drug interactions such as cytochrome modulation, additive and synergistic effects, and contraindications are discussed. While self-management has been recognized as part of the overall treatment strategy for patients suffering from chronic pain, it is important for practitioners to be able to also optimize and integrate herbal medicine and, if warranted, other complementary and alternative medicines into their care.

Acellular fish skin matrix on thin-skin graft donor sites: a preliminary study

OBJECTIVE

Surgery for head and neck cancer often requires free flap reconstructions, whose harvesting site often requires a thin-skin graft. Wounds from the thin-skin donor site are comparable to an intermediate or deep second-degree burn. This is uncomfortable and can lead to complications such as a long healing time, local infections and pain. Since they are reproducible, these wounds may serve as a model for an objective assessment of new healing medical devices. The acellular fish skin matrix is a new medical device designed to improve healing quality and time.

METHODS

We compared the outcomes between standard procedure and the use of this matrix placed on the split-thickness skin graft (STSG) donor site, in patients operated on in our centre for radial forearm free flap reconstruction for head and neck wounds.

RESULTS

There were 21 patients included. The healing time was halved when using the acellular fish skin matrix, from 68 to 32 days on average. Acellular fish skin matrix reduced pain levels and local infection. The visual analogue pain scale (VAS) was ≥3 at five days (p=0.0034) and infection rate reduced from 60% to 0% (p=0.0039).

CONCLUSION

These results are extremely encouraging. However, it is important to take into account the relatively high cost of this matrix for its future indications. A larger study including an overall cost estimation and an assessment on different wound types would be interesting, to better target the indications of the acellular fish skin matrix.

The role of testosterone in mu-opioid receptor expression in the trigeminal ganglia of opioid-tolerant rats

Although tolerance serves as a major limitation in the long-term clinical use of opioids in patients with chronic severe pain, mechanisms of opioid tolerance are poorly understood. In this study, a morphine tolerance model was established by subcutaneously injecting male rats with morphine (10 mg/kg) twice a day for 10 consecutive days. In addition, a subset of morphine-tolerant rats underwent testosterone replacement therapy. The levels of mu-opioid receptor (MOR) mRNA and protein in the trigeminal ganglia (TGs) of morphine-tolerant versus control rats and of morphine-tolerant rats with vs. without testosterone replacement therapy were measured. We found that testosterone levels were significantly lower in morphine-tolerant rats than in the controls (1.248 ± 0.231 ng/ml vs. 2.223 ± 0.153 ng/ ml, respectively; p = 0.008). Furthermore, chronic morphine exposure led to a downregulation in the levels of MOR mRNA to 79.3%, and of MOR protein to 68.9%. Testosterone replacement therapy restored MOR mRNA and protein levels specifically in rats who had developed a tolerance to morphine, thereby suggesting a potential role of testosterone in the opioid-receptor response to chronic morphine exposure. In summary, our study provides evidence for the involvement of testosterone in the proper regulation of the peripheral MOR system in rats following prolonged morphine exposure. We also suggest that analgesic therapeutic measures should take into account the testosterone levels of patients who have built up a tolerance to morphine.

Beneficial effects of fish oil enriched in omega-3 fatty acids on the development and maintenance of neuropathic pain

OBJECTIVE

The aim of this work was to assess the preventive effect of an eicosapentaenoic acid/docosahexaenoic acid-concentrate fish oil on neuropathic pain development and regenerative features of sciatic nerve in rats.

METHODS

In the present study, rats with chronic constriction injury (CCI) of the sciatic nerve and sham-operated ones received fish oil enriched in omega-3 fatty acids (0.36 or 0.72 g/kg per day, oral) or saline solution for 21 days, with thermal hyperalgesia and mechanical allodynia being assessed before and 3, 7, 14 and 21 days after injury.

KEY FINDINGS

Fish oil enriched in omega-3 fatty acids (0.72 g/kg) reversed thermal hyperalgesia and significantly reduced mechanical allodynia. In addition, ω-3 treatment (0.72 g/kg) promoted the recovery of the Sciatic Functional Index as well as restored axonal density and morphology, without the formation of neuroma in the injured sciatic nerves after 21 days.

CONCLUSION

We conclude that the fish oil enriched in omega-3 fatty acids administration relieves thermal hyperalgesia and mechanical allodynia effectively and also enhances the recovery process in rats with CCI of the sciatic nerve. These findings might contribute to new therapeutic approaches including omega-3 fatty acids in neuropathic pain treatment.

Hyperlocomotion and anxiety- like behavior induced by binge ethanol exposure in rat neonates. Possible ameliorative effects of Omega 3

Maternal alcohol consumption during pregnancy may cause neurocognitive and behavioral disorders that can persist until adulthood. Epidemiological data has revealed an alarming increase in the frequency of alcohol intake in pregnant women. Nutritional variables may also have an impact on the behavioral alterations occasioned by alcohol during development. Moreover, omega-3, a polyunsaturated fatty acid necessary for normal brain development, is deficient in ethanol-treated animals. Although studies have shown that omega-3 supplementation after prenatal ethanol (EtOH) treatment improves some disorders, there are no reports about acute treatment with omega-3 in binge alcohol neurotoxic models during postnatal development. The goal of this study was to determine whether an administration of omega-3, after an acute ethanol dose in neonates, would be able to attenuate alcohol effects in offspring. Male/ female rats were administered ethanol (2.5 g/kg s.c. at 0 and 2 h) or saline on postnatal day (PND) 7, with a single dose of omega-3 (720 mg/kg) 15 min after the last alcohol injection. It was have found that EtOH-treated animals showed hyperlocomotion on PND 14 (pre-juvenile), and anxiety-like behavior was observed at all the three ages studied. Administration of omega-3 after EtOH treatment reduced hyperlocomotion and the anxiety-like behaviors on PND 14, but did not diminish the anxiety on either PND 20 or 30 (juvenile). In conclusion, acute ethanol exposure produced neurobehavioral alterations that persisted in the offspring, with omega-3 able to ameliorate these effects on PND 14. These data are relevant considering that omega-3 administration may have therapeutic effects through mitigating some of ethanol´s damaging consequences.

The marine Omega3 wound matrix for treatment of complicated wounds: A multicenter experience report

Introduction

The Kerecis™ Omega3 Wound matrix is a decellularized skin matrix derived from fish skin and represents an innovative concept to achieve wound healing. The aim of this study was to report the cumulative experience of three centers for vascular surgery regarding use of the Omega3 Wound matrix in selected patients with complicated wounds.

Material and methods

In this study 23 patients with 25 vascular and/or diabetes mellitus-associated complicated wounds and partially exposed bony segments were treated with the Omega3 Wound matrix in three vascular centers. In several patients, conventional wound treatment with vacuum therapy had previously been carried out sometimes over several weeks without durable success. Following initial debridement in the operating room, the matrix was applied and covered with a silicone mesh. In the further course, wound treatment was conducted on an outpatient setting if possible.

Results

In total 25 wounds were treated with localization at the level of the thigh (n = 2), the distal calf (n = 7), the forefoot (n = 14) and the hand (n = 2). The time to heal varied between 9 and 41 weeks and between 3 and 26 wound matrices were applied per wound. Interestingly, a reduction of analgesics intake was noted when the treatment with the Omega3 Wound matrix was initiated.

Conclusion

The novel Omega3 Wound matrix in this study represented an effective treatment option in 25 complicated wounds. Further studies are necessary to evaluate the impact of the wound matrix on stimulation of granulation tissue and re-epithelialization as well as the potential antinociceptive and analgetic effects.

Food pyramid for subjects with chronic pain: foods and dietary constituents as anti-inflammatory and antioxidant agents

Emerging literature suggests that diet constituents may play a modulatory role in chronic pain (CP) through management of inflammation/oxidative stress, resulting in attenuation of pain. We performed a narrative review to evaluate the existing evidence regarding the optimum diet for the management of CP, and we built a food pyramid on this topic. The present review also describes the activities of various natural compounds contained in foods (i.e. phenolic compounds in extra-virgin olive oil (EVO)) listed on our pyramid, which have comparable effects to drug management therapy. This review included 172 eligible studies. The pyramid shows that carbohydrates with low glycaemic index should be consumed every day (three portions), together with fruits and vegetables (five portions), yogurt (125 ml), red wine (125 ml) and EVO; weekly: legumes and fish (four portions); white meat, eggs and fresh cheese (two portions); red or processed meats (once per week); sweets can be consumed occasionally. The food amounts are estimates based on nutritional and practical considerations. At the top of the pyramid there is a pennant: it means that CP subjects may need a specific customised supplementation (vitamin B12, vitamin D, n-3 fatty acids, fibre). The food pyramid proposal will serve to guide dietary intake with to the intent of alleviating pain in CP patients. Moreover, a targeted diet can also help to solve problems related to the drugs used to combat CP, i.e. constipation. However, this paper would be an early hypothetical proposal due to the limitations of the studies.

Endogenous Opiates and Behavior: 2016

This paper is the thirty-ninth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2016 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia, stress and social status, tolerance and dependence, learning and memory, eating and drinking, drug abuse and alcohol, sexual activity and hormones, pregnancy, development and endocrinology, mental illness and mood, seizures and neurologic disorders, electrical-related activity and neurophysiology, general activity and locomotion, gastrointestinal, renal and hepatic functions, cardiovascular responses, respiration and thermoregulation, and immunological responses.

Lokale Wundtherapie eines chronischen therapierefraktären Ulcus cruris venosum mit Omega3-Wundmatrix

Moderne Zusatzbehandlungen zur herkömmlichen Wundtherapie werden häufig notwendig, da ein großer Anteil chronischer Wunden unter der Standardbehandlung nicht vollständig abheilen bzw. auch häufig rezidivieren. Die Omega3-Wundmatrix (Kerecis®) stellt eine alternative Wundauflage dar, die aus der Haut des Kabeljaus durch entsprechende Verfahren wie z.B. die Dezellularisierung gewonnen wird.

Wir berichten über eine 86-jährige Patientin, die über schmerzhafte, chronische und rezidivierende Ulzeration im Bereich des rechten Unterschenkels klagte. Vorausgegangen war eine operative Behandlung der venösen Insuffizienz mit Debridement, Vakuumtherapie und Spalthauttransplantation, wonach es im Verlauf zur deutlichen Vergrößerung und Schmerzhaftigkeit der Wunde kam. Nach anschließender lokaler Wundtherapie mit Omega3- Wundmatrix (Kerecis®) kam es zu einer rasch progredienten Wundheilung mit vollständiger Abheilung der Ulzerationen innerhalb von 14 Wochen.

Marine Omega3 wound matrix for the treatment of complicated wounds

Introduction Complicated wounds in the lower extremity can arise as a consequence of insufficient soft-tissue coverage after amputations in diabetic patients. The Kerecis® Omega3 wound matrix is a decellularized skin matrix derived from codfish and represents an alternative treatment option to achieve wound healing.

Methods 5 patients with diabetes mellitus and complicated wounds in the lower limb with exposed bony segments were treated with the Omega3 wound matrix between November 2014 and November 2015. Following initial debridement in the operating room, the wound matrix was applied and covered with a silicone mesh. In the further course, wound treatment was conducted on outpatient setting.

Results In total, 7 wounds were treated with localization at the level of the thigh (n=2) and the forefoot (n=5). For the wounds at the thigh, it took 26 weeks to achieve wound closure, whereas the wounds at the level of the forefoot showed healing times between 13 and 41 weeks. In all patients, a reduction of analgetics intake was noted when the treatment with the Omega3 wound matrix was initiated.

Conclusion The Kerecis® Omega3 wound matrix represents a viable treatment option in complicated wounds in the lower limb of diabetic patients to circumvent an otherwise necessary proximalization of amputation level. Further studies comparing the Omega3 wound matrix with appropriate control groups of standard therapies for soft-tissue conditioning/coverage like negative pressure therapy, biosurgery and other acellular dermal matrices are warranted.

Evidence of promising biological-pharmacological activities of the sertraline-based copper complex: (SerH2)2[CuCl4]

In the current study the ability of copper complex to exert multiple biological activities is combined with the pharmacological action of sertraline (SerH₂Cl, antidepressant drug). The hydrated and anhydrous forms of the tetrachlorocuprate(II) salts, namely (SerH₂)₂[CuCl₄]·½H₂O and (SerH₂)₂[CuCl₄], were synthesized and characterized by physicochemical methods. The crystal structures were determined by X-ray diffraction methods. The hydrate complex crystallizes in the monoclinic P2₁ space group with a=8.0807(2) Å, b=36.2781(8) Å, c=12.6576(3) Å, β=95.665(2)°, and Z=4 molecules per unit cell and the un-hydrate in P2₁ with a=13.8727(6) Å, b=7.5090(3) Å, c=18.618(1) Å, β=104.563(6)°, and Z=2. It has been suggested that Cu(II) ions might be critical in the development of mood disorders, showed potent biocidal activity, and also acted as analgesic adjuvant. To improve sertraline efficiency, the antidepressant and analgesic activities of the complex have been assessed in rats denoting a marked synergistic effect. Antithyroid and antimicrobial activities were also evaluated. Because depressive disorders and hyperthyroidism diseases led to an oxidative stress state, antioxidant capability has also been tested. The complex behaved as a good superoxide radical scavenger (IC₅₀=6.3×10^-6M). The ability of the complex to act as bromoperoxidase mimic was assessed. A pseudo-first order constant of k=0.157±0.007min^-1 has been determined. The complex evidences promising biological-pharmacological activities and the albumin binding studies showed a K_b of 2.90×10³M^-1 showing an improvement in the uptake of sertraline by albumin at 8h incubation (time required for effective interaction of sertraline with the protein).

Innovations in Pain Management: Morphine Combined with Omega-3 Fatty Acids

The treatment of acute and chronic severe pain remains a common major challenge faced by clinicians working with the general population, and even after the application of recent advances to treatments, there may still continue to be manifestations of adverse effects.

Chronic pain affects the personal and social life of the patient, and often also their families. In some cases, after an acute pain the patient continues to experience chronic pain, which can be a result of diseases such as cancer.

Morphine is recommended as the first choice opioid in the treatment of moderate to severe acute and chronic pain. However, the development of adverse effects and tolerance to the analgesic effects of morphine often leads to treatment discontinuation.

The present work reviews the different pharmaceutical innovations reported concerning the use of morphine. First, its utilization as the first medication for the treatment of moderate to severe cancer pain and non-cancer pain in patients is evaluated, taking into account the most common complications and adverse effects. Next, strategies utilized to manage these side effects are considered, and we also summarize results using omega-3 fatty acids (eicosapentaenoic acid and docosahexaenoic acid) as a monotherapy or as an adjunct to morphine in the treatment of pain.

siRNA capsulated brain-targeted nanoparticles specifically knock down OATP2B1 in mice: a mechanism for acute morphine tolerance suppression

Regulating main brain-uptake transporter of morphine may restrict its tolerance generation, then modify its antinociception. In this study, more than 2 fold higher intracellular uptake concentrations for morphine and morphine-6-glucuronide (M6G) were observed in stable expression cells, HEK293-hOATP2B1 than HEK293-MOCK. Specifically, the K_m value of morphine to OATP2B1 (57.58 ± 8.90 μM) is 1.4-time more than that of M6G (80.31 ± 21.75 μM); Cyclosporine A (CsA), an inhibitor of OATP2B1, can inhibit their intracellular accumulations with IC₅₀ = 3.90 ± 0.50 μM for morphine and IC₅₀ = 6.04 ± 0.86 μM for M6G, respectively. To further investigate the role of OATP2B1 in morphine brain transport and tolerance, the novel nanoparticles of DGL-PEG/dermorphin capsulated siRNA (OATP2B1) were applied to deliver siRNA into mouse brain. Along with OATP2B1 depressed, a main reduction was found for each of morphine or M6G in cerebrums or epencephalons of acute morphine tolerance mice. Furthermore, calcium/calmodulin-dependent protein kinase IIα (CaMKIIα) in mouse prefrontal cortex (mPFC) underwent dephosphorylation at Thr286. In conclusion, OATP2B1 downregulation in mouse brain can suppress tolerance via blocking morphine and M6G brain transport. These findings might help to improve the pharmacological effects of morphine.

Incorporating Natural Products, Pharmaceutical Drugs, Self-Care and Digital/Mobile Health Technologies into Molecular-Behavioral Combination Therapies for Chronic Diseases

Merging pharmaceutical and digital (mobile health, mHealth) ingredients to create new therapies for chronic diseases offers unique opportunities for natural products such as omega-3 polyunsaturated fatty acids (n-3 PUFA), curcumin, resveratrol, theanine, or α-lipoic acid. These compounds, when combined with pharmaceutical drugs, show improved efficacy and safety in preclinical and clinical studies of epilepsy, neuropathic pain, osteoarthritis, depression, schizophrenia, diabetes and cancer. Their additional clinical benefits include reducing levels of TNFα and other inflammatory cytokines. We describe how pleiotropic natural products can be developed as bioactive incentives within the network pharmacology together with pharmaceutical drugs and self-care interventions. Since approximately 50% of chronically-ill patients do not take pharmaceutical drugs as prescribed, psychobehavioral incentives may appeal to patients at risk for medication non-adherence. For epilepsy, the incentive-based network therapy comprises anticonvulsant drugs, antiseizure natural products (n-3 PUFA, curcumin or/and resveratrol) coupled with disease-specific behavioral interventions delivered by mobile medical apps. The add-on combination of antiseizure natural products and mHealth supports patient empowerment and intrinsic motivation by having a choice in self-care behaviors. The incentivized therapies offer opportunities: (1) to improve clinical efficacy and safety of existing drugs, (2) to catalyze patient-centered, disease self-management and behavior-changing habits, also improving health-related quality-of-life after reaching remission, and (3) merging copyrighted mHealth software with natural products, thus establishing an intellectual property protection of medical treatments comprising the natural products existing in public domain and currently promoted as dietary supplements. Taken together, clinical research on synergies between existing drugs and pleiotropic natural products, and their integration with self-care, music and mHealth, expands precision/personalized medicine strategies for chronic diseases via pharmacological-behavioral combination therapies.