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Ershad A, Shafiee Dolat Abadi S, Ebrahimian M, Hadeiy SK, Zamani N, Kolahi AA, Movafagh A, Hassanian-Moghaddam H. Association of the OPRM1 variant rs1799971 (A118G) and clinical manifestations in tramadol poisoned patients: a cross-sectional study. Clin Toxicol (Phila) 2024; 62:357-363. [PMID: 38946467 DOI: 10.1080/15563650.2024.2366921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 06/06/2024] [Indexed: 07/02/2024]
Abstract
INTRODUCTION The opioid receptor mu1 is a protein coding gene that can have different codes for a protein and may have variations (polymorphisms) affecting how opioids work. The aim of this study was to investigate the prevalence of the most common opioid receptor mu1 polymorphism (A118G) and any relationship between this polymorphism and features following tramadol overdose. MATERIALS AND METHODS This was a cross-sectional study of patients admitted with tramadol poisoning to an Iranian hospital. These patients were not taking any other drugs or medications and had no history of seizures. RESULTS The results showed that among the 83 patients included in the study, 57 (69 per cent) had the AA genotype, 25 (30 per cent) had the AG genotype, and one (1 per cent) had the GG genotype for the opioid receptor mu1 A118G polymorphism. Nausea and/or vomiting occurred in nine (11 per cent) patients and dizziness in 38 (46 per cent) patients. Serious adverse events included seizures in 51 (60 per cent) patients and respiratory failure requiring mechanical ventilation in 21 (25 per cent) patients. However, there was no significant association between the opioid receptor mu1 A118G polymorphism and these adverse events. DISCUSSION In our study, the frequency of the A allele was greater than the G allele, and the AA genotype was more prevalent than AG. The GG genotype was the least common among the polymorphisms of opioid receptor mu1 rs1799971. There was no significant association between the opioid receptor mu1 A118G polymorphism and symptoms in tramadol-poisoned patients. Although these allele proportions are similar to the results reported in other Caucasian populations, they are dissimilar to the findings in Chinese and Singaporean populations. In these Asian studies, the predominant allele was the G allele. It has been suggested that a mutated G allele will decrease the production of opioid receptor mu1-related messenger ribonucleic acid and related proteins, leading to fewer mu-opioid receptors in the brain. CONCLUSIONS This study found no significant association between the opioid receptor mu1 A118G polymorphism and adverse outcomes in tramadol-poisoned patients. However, more research is needed to draw more definitive conclusions due to the limited evidence and variability of opioid receptor mu1 polymorphisms in different populations.
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Affiliation(s)
- Ali Ershad
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | | | - Seyed Kaveh Hadeiy
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Ali-Asghar Kolahi
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Abolfazl Movafagh
- Department of Medical Genetics, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hossein Hassanian-Moghaddam
- Social Determinants of Health Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Next Step Drug and Alcohol Services, Mental Health Commission, Perth, Australia
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Lewandrowski KU, Sharafshah A, Elfar J, Schmidt SL, Blum K, Wetzel FT. A Pharmacogenomics-Based In Silico Investigation of Opioid Prescribing in Post-operative Spine Pain Management and Personalized Therapy. Cell Mol Neurobiol 2024; 44:47. [PMID: 38801645 PMCID: PMC11129978 DOI: 10.1007/s10571-024-01466-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/26/2024] [Indexed: 05/29/2024]
Abstract
Considering the variability in individual responses to opioids and the growing concerns about opioid addiction, prescribing opioids for postoperative pain management after spine surgery presents significant challenges. Therefore, this study undertook a novel pharmacogenomics-based in silico investigation of FDA-approved opioid medications. The DrugBank database was employed to identify all FDA-approved opioids. Subsequently, the PharmGKB database was utilized to filter through all variant annotations associated with the relevant genes. In addition, the dpSNP ( https://www.ncbi.nlm.nih.gov/snp/ ), a publicly accessible repository, was used. Additional analyses were conducted using STRING-MODEL (version 12), Cytoscape (version 3.10.1), miRTargetLink.2, and NetworkAnalyst (version 3). The study identified 125 target genes of FDA-approved opioids, encompassing 7019 variant annotations. Of these, 3088 annotations were significant and pertained to 78 genes. During variant annotation assessments (VAA), 672 variants remained after filtration. Further in-depth filtration based on variant functions yielded 302 final filtered variants across 56 genes. The Monoamine GPCRs pathway emerged as the most significant signaling pathway. Protein-protein interaction (PPI) analysis revealed a fully connected network comprising 55 genes. Gene-miRNA Interaction (GMI) analysis of these 55 candidate genes identified miR-16-5p as a pivotal miRNA in this network. Protein-Drug Interaction (PDI) assessment showed that multiple drugs, including Ibuprofen, Nicotine, Tramadol, Haloperidol, Ketamine, L-Glutamic Acid, Caffeine, Citalopram, and Naloxone, had more than one interaction. Furthermore, Protein-Chemical Interaction (PCI) analysis highlighted that ABCB1, BCL2, CYP1A2, KCNH2, PTGS2, and DRD2 were key targets of the proposed chemicals. Notably, 10 chemicals, including carbamylhydrazine, tetrahydropalmatine, Terazosin, beta-methylcholine, rubimaillin, and quinelorane, demonstrated dual interactions with the aforementioned target genes. This comprehensive review offers multiple strong, evidence-based in silico findings regarding opioid prescribing in spine pain management, introducing 55 potential genes. The insights from this report can be applied in exome analysis as a pharmacogenomics (PGx) panel for pain susceptibility, facilitating individualized opioid prescribing through genotyping of related variants. The article also points out that African Americans represent an important group that displays a high catabolism of opioids and suggest the need for a personalized therapeutic approach based on genetic information.
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Affiliation(s)
- Kai-Uwe Lewandrowski
- Division of Personalized Pain Therapy Research & Education, Center for Advanced Spine Care of Southern Arizona, Arizona, USA.
- Department of Orthopaedics, Fundación Universitaria Sanitas and Member of Colombian National Academy of Medicine, Bogotá, DC, Colombia.
- Department of Orthopedics, Doctor honoris causa Hospital Universitário Gaffree Guinle Universidade Federal do Estado do Rio de Janeiro, and Member of the Brazilian National Academy of Medicine, Rio de Janeiro, Brazil.
- Center for Advanced Spine Care of Southern Arizona, 4787 E Camp Lowell Drive, Tucson, USA.
| | - Alireza Sharafshah
- Cellular and Molecular Research Center, School of Medicine, Guilan University of Medical Sciences, Rasht, Iran
| | - John Elfar
- Department of Orthopaedics and Sports Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Sergio Luis Schmidt
- Department of Neurology, Federal University of Rio de Janeiro (UNIRIO), University Hospital, Rua Mariz e Barros 750, Tijuca, Rio de Janeiro, RJ, Brazil
| | - Kenneth Blum
- Division of Nutrigenomics, SpliceGen, Therapeutics, Inc., Austin, TX, 78701, USA
- Department of Psychiatry, Wright State University Boonshoft School of Medicine, Dayton, OH, 45435, USA
- Division of Addiction Research & Education, Center for Sports, Exercise, & Mental Health, Western University Health Sciences, Pomona, CA, 91766, USA
- The Kenneth Blum Behavioral & Neurogenetic Institute, LLC., Austin, TX, 78701, USA
| | - Franklin Todd Wetzel
- Department of Orthopaedic Surgery & Sports Medicine, Director of Musculoskeletal Services Bassett Healthcare Network 1 Atwell Road, Cooperstown, NY, 13326, USA
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Ferreira do Couto ML, Fonseca S, Pozza DH. Pharmacogenetic Approaches in Personalized Medicine for Postoperative Pain Management. Biomedicines 2024; 12:729. [PMID: 38672085 PMCID: PMC11048650 DOI: 10.3390/biomedicines12040729] [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: 01/31/2024] [Revised: 03/08/2024] [Accepted: 03/19/2024] [Indexed: 04/28/2024] Open
Abstract
Despite technical and pharmacological advancements in recent years, including optimized therapies and personalized medicine, postoperative pain management remains challenging and sometimes undertreated. This review aims to summarize and update how genotype-guided therapeutics within personalized medicine can enhance postoperative pain management. Several studies in the area have demonstrated that genotype-guided therapy has the ability to lower opioid consumption and improve postoperative pain. Gene mutations, primarily OPRM1, CYP2D6, CYP2C9, COMT and ABCB1, have been shown to exert nuanced influences on analgesic response and related pharmacological outcomes. This review underscores the integration of pharmacogenetic-guided personalized medicine into perioperative care, particularly when there is uncertainty regarding opioid prescriptions. This approach leads to superior outcomes in terms of postoperative pain relief and reduced morbidity for numerous patients.
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Affiliation(s)
- Maria Leonor Ferreira do Couto
- Experimental Biology Unit, Department of Biomedicine, Faculty of Medicine of Porto, University of Porto, 4200-319 Porto, Portugal;
| | - Sara Fonseca
- Anesthesiology Department, São João University Hospital Centre, 4200-135 Porto, Portugal;
| | - Daniel Humberto Pozza
- Experimental Biology Unit, Department of Biomedicine, Faculty of Medicine of Porto, University of Porto, 4200-319 Porto, Portugal;
- Institute for Research and Innovation in Health and IBMC (i3S), University of Porto, 4200-135 Porto, Portugal
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Zhang B, Cai C, Pan Z, Zhuang L, Qi Y. Effect of Remifentanil on Acute and Chronic Postsurgical Pain in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-analysis. Clin J Pain 2024; 40:187-195. [PMID: 38053431 DOI: 10.1097/ajp.0000000000001183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 11/27/2023] [Indexed: 12/07/2023]
Abstract
OBJECTIVES Our purpose was to explore the effect of remifentanil on acute and chronic postsurgical pain after cardiac surgery. MATERIALS AND METHODS Randomized controlled trials were retrieved from electronic databases, such as PubMed, Cochrane Library, China National Knowledge Internet databases, Scopus, and Web of Science. A systematic review, meta-analysis, and trial sequential analysis (TSA) were performed. Basic information and outcomes were extracted from the included studies. The primary outcome was chronic postsurgical pain. Secondary outcomes were scores of postsurgical pain and morphine consumption within 24 hours after cardiac surgery. Risk of bias (ROB) assessment was based on the Cochrane ROB tool version 2. The overall quality of the evidence was rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. RESULTS Seven studies consisting of 658 patients were enrolled in the meta-analysis. A single study had a high ROB and 2 studies had a moderate ROB. The incidence of chronic postsurgical pain (4 studies [415 patients]; risk ratio: 1.02 [95% CI: 0.53 to 1.95]; P = 0.95; I2 = 59%; TSA-adjusted CI: 0.78 to 1.20) and the postsurgical pain score (2 studies [196 patients]; mean difference: 0.09 [95% CI: -0.36 to 0.55]; P = 0.69; I2 = 0%; TSA-adjusted CI: -0.36 to 0.55) were not statistically different between the 2 groups. However, morphine consumption (6 studies [569 patients]; mean difference: 6.94 [95% CI: 3.65 to 10.22]; P < 0.01; I2 = 0%; TSA-adjusted CI: 0.00 to 0.49) was higher in the remifentanil group than in the control group. CONCLUSION There was not enough evidence to prove that remifentanil can increase the incidence of chronic postsurgical pain after cardiac surgery, but interestingly, the results tended to support a trend toward increased complications in the intervention group. However, there was moderate certainty evidence that the use of remifentanil increases the consumption of morphine for analgesia, and more direct comparison trials are needed to inform clinical decision-making with greater confidence.
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Affiliation(s)
- Bi Zhang
- Department of Anesthesia, Ningbo Medical Center, Li Huili Hospital, Ningbo, Zhejiang, China
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Mokhtari L, Hosseinzadeh F, Nourazarian A. Biochemical implications of robotic surgery: a new frontier in the operating room. J Robot Surg 2024; 18:91. [PMID: 38401027 DOI: 10.1007/s11701-024-01861-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 02/01/2024] [Indexed: 02/26/2024]
Abstract
Robotic surgery represents a milestone in surgical procedures, offering advantages such as less invasive methods, elimination of tremors, scaled motion, and 3D visualization. This in-depth analysis explores the complex biochemical effects of robotic methods. The use of pneumoperitoneum and steep Trendelenburg positioning can decrease pulmonary compliance and splanchnic perfusion while increasing hypercarbia. However, robotic surgery reduces surgical stress and inflammation by minimizing tissue trauma. This contributes to faster recovery but may limit immune function. Robotic procedures also limit ischemia-reperfusion injury and oxidative damage compared to open surgery. They also help preserve native antioxidant defenses and coagulation. In a clinical setting, robotic procedures reduce blood loss, pain, complications, and length of stay compared to traditional procedures. However, risks remain, including device failure, the need for conversion to open surgery and increased costs. On the oncology side, there is still debate about margins, recurrence, and long-term survival. The advent of advanced technologies, such as intraoperative biosensors, localized drug delivery systems, and the incorporation of artificial intelligence, may further improve the efficiency of robotic surgery. However, ethical dilemmas regarding patient consent, privacy, access, and regulation of this disruptive innovation need to be addressed. Overall, this review sheds light on the complex biochemical implications of robotic surgery and highlights areas that require additional mechanistic investigation. It presents a comprehensive approach to responsibly maximize the potential of robotic surgery to improve patient outcomes, integrating technical skill with careful consideration of physiological and ethical issues.
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Affiliation(s)
- Leila Mokhtari
- Department of Nursing, Khoy University of Medical Sciences, Khoy, Iran
| | | | - Alireza Nourazarian
- Department of Basic Medical Sciences, Khoy University of Medical Sciences, Khoy, Iran.
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Frangakis SG, MacEachern M, Akbar TA, Bolton C, Lin V, Smith AV, Brummett CM, Bicket MC. Association of Genetic Variants with Postsurgical Pain: A Systematic Review and Meta-analyses. Anesthesiology 2023; 139:827-839. [PMID: 37774411 PMCID: PMC10859728 DOI: 10.1097/aln.0000000000004677] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
BACKGROUND Postsurgical pain is a key component of surgical recovery. However, the genetic drivers of postsurgical pain remain unclear. A broad review and meta-analyses of variants of interest will help investigators understand the potential effects of genetic variation. METHODS This article is a systematic review of genetic variants associated with postsurgical pain in humans, assessing association with postsurgical pain scores and opioid use in both acute (0 to 48 h postoperatively) and chronic (at least 3 months postoperatively) settings. PubMed, Embase, and the Cochrane Central Register of Controlled Trials were searched from 2000 to 2022 for studies using search terms related to genetic variants and postsurgical pain in humans. English-language studies in adult patients examining associations of one or more genetic variants with postsurgical pain were included. The primary outcome was association of genetic variants with either acute or chronic postsurgical pain. Pain was measured by patient-reported pain score or analgesic or opioid consumption. RESULTS A total of 163 studies were included, evaluating 129 unique genes and 594 unique genetic variants. Many of the reported significant associations fail to be replicated in other studies. Meta-analyses were performed for seven variants for which there was sufficient data (OPRM1 rs1799971; COMT rs4680, rs4818, rs4633, and rs6269; and ABCB1 rs1045642 and rs2032582). Only two variants were associated with small differences in postsurgical pain: OPRM1 rs1799971 (for acute postsurgical opioid use standard mean difference = 0.25; 95% CI, 0.16 to 0.35; cohort size, 8,227; acute postsurgical pain score standard mean difference = 0.20; 95% CI, 0.09 to 0.31; cohort size, 4,619) and COMT rs4680 (chronic postsurgical pain score standard mean difference = 0.26; 95% CI, 0.08 to 0.44; cohort size, 1,726). CONCLUSIONS Despite much published data, only two alleles have a small association with postsurgical pain. Small sample sizes, potential confounding variables, and inconsistent findings underscore the need to examine larger cohorts with consistent outcome measures. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Stephan G Frangakis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Mark MacEachern
- Taubman Health Sciences Library, University of Michigan, Ann Arbor, Michigan
| | - T Adam Akbar
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan. Current Position: Department of Anesthesiology, Northwestern Medicine, Chicago, Illinois
| | - Christian Bolton
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Victor Lin
- Victor Lin, D.O., Ph.D.; Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Albert V Smith
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Chad M Brummett
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan; Opioid Prescribing and Engagement Network, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor, Michigan
| | - Mark C Bicket
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan; Opioid Prescribing and Engagement Network, Institute for Healthcare Innovation and Policy, University of Michigan, Ann Arbor, Michigan
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May GB, de Souza BR, Gueuvoghlanian-Silva BY, Dos Reis EC, Mostardeiro SR, Boabaid May PP, Mateo EC, Vietta GG, Hoss GW. Distribution of pharmacogene allele and phenotype frequencies in Brazilian psychiatric patients. Pharmacogenomics 2023; 24:747-760. [PMID: 37846556 DOI: 10.2217/pgs-2023-0075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023] Open
Abstract
Purpose: This work was designed to identify the pharmacogenetic profile of Brazilian psychiatric patients receiving psychoactive drug treatment according to ethnicity. Methods: Based on the GnTech® database, this cross-sectional study analyzed data from self-reported sociodemographic and genetic results from the next-generation sequencing panel composed of 26 pharmacogenes from 359 psychotropic drug users. Results: Variant frequencies of multiple pharmacogenes presented differences between ethnicities (CYP3A5, CYP2D6, CYP1A2, CYP2B6, CYP3A4, UGT1A4, UGT2B15, ABCB1 rs1045642, ADRA2A rs1800544, COMT rs4680, GRIK4 rs1954787, GSK3B rs334558, GSK3B rs6438552, HTR1A rs6295, HTR2A rs7997012, HTR2C rs1414334, MTHFR rs1801131, OPRM1 rs1799971 and 5-HTTLPR), endorsing the necessity of individual-level analyses in drug treatment. Conclusion: A discussion of pharmacogenomic test implementation in psychiatric clinical practice is needed to improve treatment choices, especially in Brazil, a multiethnic country.
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Affiliation(s)
| | | | | | | | - Sofia Rech Mostardeiro
- Universidade do Sul de Santa Catarina (UNISUL)-Campus Pedra Branca, Palhoça, SC, 88137-270, Brazil
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Chiang DLC, Rice DA, Helsby NA, Somogyi AA, Kluger MT. The incidence, impact, and risk factors for moderate to severe persistent pain after breast cancer surgery: a prospective cohort study. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:1023-1034. [PMID: 37184910 PMCID: PMC10655209 DOI: 10.1093/pm/pnad065] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 04/18/2023] [Accepted: 05/04/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Few Australasian studies have evaluated persistent pain after breast cancer surgery. OBJECTIVE To evaluate the incidence, impact, and risk factors of moderate to severe persistent pain after breast cancer surgery in a New Zealand cohort. DESIGN Prospective cohort study. METHODS Consented patients were reviewed at 3 timepoints (preoperative, 2 weeks and 6 months postoperative). Pain incidence and interference, psychological distress and upper limb disability were assessed perioperatively. Clinical, demographic, psychological, cancer treatment-related variables, quantitative sensory testing, and patient genotype (COMT, OPRM1, GCH1, ESR1, and KCNJ6) were assessed as risk factors using multiple logistic regression. RESULTS Of the 173 patients recruited, 140 completed the 6-month follow-up. Overall, 15.0% (n = 21, 95% CI: 9.5%-22.0%) of patients reported moderate to severe persistent pain after breast cancer surgery with 42.9% (n = 9, 95% CI: 21.9%-66.0%) reporting likely neuropathic pain. Pain interference, upper limb dysfunction and psychological distress were significantly higher in patients with moderate to severe pain (P < .004). Moderate to severe preoperative pain (OR= 3.60, 95% CI: 1.13-11.44, P = .03), COMT rs6269 GA genotype (OR = 5.03, 95% CI: 1.49-17.04, P = .009) and psychological distress at postoperative day 14 (OR= 1.08, 95% CI: 1.02-1.16, P = .02) were identified as risk factors. Total intravenous anesthesia (OR= 0.31, 95% CI: 0.10 - 0.99, P = .048) was identified as protective. CONCLUSION The incidence of moderate to severe persistent pain after breast cancer surgery is high with associated pain interference, physical disability, and psychological distress. Important modifiable risk factors were identified to reduce this important condition.
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Affiliation(s)
- Daniel L C Chiang
- Department of Anaesthesiology, Perioperative & Pain Medicine, Waitemata District Health Board, Auckland, New Zealand
- Department of Pharmacology and Clinical Pharmacology, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
- Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - David A Rice
- Department of Anaesthesiology, Perioperative & Pain Medicine, Waitemata District Health Board, Auckland, New Zealand
- Health and Rehabilitation Research Institute, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Nuala A Helsby
- Department of Molecular Medicine and Pathology, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
| | - Andrew A Somogyi
- Discipline of Pharmacology, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Michal T Kluger
- Department of Anaesthesiology, Perioperative & Pain Medicine, Waitemata District Health Board, Auckland, New Zealand
- Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Auckland, New Zealand
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Cortade DL, Markovits J, Spiegel D, Wang SX. Point-of-Care Testing of Enzyme Polymorphisms for Predicting Hypnotizability and Postoperative Pain. J Mol Diagn 2023; 25:197-210. [PMID: 36702396 DOI: 10.1016/j.jmoldx.2023.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/16/2022] [Accepted: 01/05/2023] [Indexed: 01/24/2023] Open
Abstract
Hypnotizability is a stable trait that moderates the benefit of hypnosis for treating pain, but limited availability of hypnotizability testing deters widespread use of hypnosis. Inexpensive genotyping of four single-nucleotide polymorphisms in the catechol-o-methyltransferase (COMT) gene was performed using giant magnetoresistive biosensors to determine if hypnotizable individuals can be identified for targeted hypnosis referrals. For individuals with the proposed optimal COMT diplotypes, 89.5% score highly on the Hypnotic Induction Profile (odds ratio, 6.12; 95% CI, 1.26-28.75), which identified 40.5% of the treatable population. Mean hypnotizability scores of the optimal group were significantly higher than the total population (P = 0.015; effect size = 0.60), an effect that was present in women (P = 0.0015; effect size = 0.83), but not in men (P = 0.28). In an exploratory cohort, optimal individuals also reported significantly higher postoperative pain scores (P = 0.00030; effect size = 1.93), indicating a greater need for treatment.
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Affiliation(s)
- Dana L Cortade
- Materials Science and Engineering, School of Engineering, Stanford University, Stanford, California.
| | - Jessie Markovits
- Department of Internal Medicine, School of Medicine, Stanford University, Stanford, California
| | - David Spiegel
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Stanford University, Stanford, California
| | - Shan X Wang
- Materials Science and Engineering, School of Engineering, Stanford University, Stanford, California; Electrical Engineering, School of Engineering, Stanford University, Stanford, California
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Vidic Z, Goricar K, Strazisar B, Besic N, Dolzan V. Association of OPRM1, MIR23B, and MIR107 genetic variability with acute pain, chronic pain and adverse effects after postoperative tramadol and paracetamol treatment in breast cancer. Radiol Oncol 2023; 57:111-120. [PMID: 36942908 PMCID: PMC10039478 DOI: 10.2478/raon-2023-0003] [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: 09/14/2022] [Accepted: 09/28/2022] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Tramadol is an opioid analgesic often used for pain management after breast cancer surgery. Its analgesic activity is due to the activation of the μ-opioid receptor, encoded by the OPRM1 gene. This study investigated the association of genetic variability in OPRM1 and its regulatory miRNA genes with outcomes of tramadol/paracetamol treatment after breast cancer surgery with axillary lymphadenectomy. PATIENTS AND METHODS The study included 113 breast cancer patients after breast cancer surgery with axillary lymphadenectomy treated with either 75/650 mg or 37.5/325 mg of tramadol with paracetamol for pain relief within the randomized clinical trial KCT 04/2015-DORETAonko/si at the Institute of Oncology Ljubljana. All patients were genotyped for OPRM1 rs1799971 and rs677830, MIR23B rs1011784, and MIR107 rs2296616 using competitive allele-specific PCR. The association of genetic factors with acute and chronic pain as well as adverse effects of tramadol treatment was evaluated using logistic regression, Fisher's exact test, and Mann-Whitney test. RESULTS The investigated OPRM1 related polymorphisms were not associated with acute pain assessed with the VAS scale within four weeks after surgery (all P > 0.05). Carriers of at least one polymorphic OPRM1 rs1799971 allele had a higher risk of constipation in the first four weeks after surgery compared to non-carriers (OR = 4.5, 95% CI = 1.6-12.64, P = 0.004). Carriers of at least one polymorphic OPRM1 rs677830 allele had a higher risk of constipation after third week of tramadol treatment (OR = 3.11, 95% CI = 1.08-8.89, P = 0.035). Furthermore, carriers of two polymorphic MIR23B rs1011784 alleles had a higher risk of nausea after 28 days of tramadol treatment (OR = 7.35, 95% CI = 1.27-42.6, P = 0.026), while heterozygotes for MIR107 rs2296616 allele had a lower risk of nausea after 21 days of tramadol treatment (OR = 0.21, 95% CI = 0.05-0.87, P = 0.031). In carriers of two polymorphic MIR107 rs2296616 alleles, chronic pain was significantly more common than in carriers of two wild-type alleles (P = 0.004). Carriers of at least one polymorphic MIR23B rs1011784 allele experienced more neuropathic pain after adjustment for tramadol dose (OR = 2.85, 95% CI = 1.07-7.59, P = 0.036), while carriers of at least one polymorphic OPRM1 rs677830 allele experienced less neuropathic pain compared to carriers of two wild-type alleles (OR = 0.38, 95% CI = 0.15-0.99, P = 0.047). CONCLUSIONS Genetic variability of OPRM1 and genes coding for miRNAs that could affect OPRM1 expression may be associated with adverse effects of tramadol/paracetamol treatment as well as with chronic and neuropathic pain after breast cancer surgery with axillary lymphadenectomy.
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Affiliation(s)
- Zala Vidic
- Pharmacogenetics Laboratory, Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Katja Goricar
- Pharmacogenetics Laboratory, Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | | | - Vita Dolzan
- Pharmacogenetics Laboratory, Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Vetterlein A, Monzel M, Reuter M. Are catechol-O-methyltransferase gene polymorphisms genetic markers for pain sensitivity after all? - A review and meta-analysis. Neurosci Biobehav Rev 2023; 148:105112. [PMID: 36842714 DOI: 10.1016/j.neubiorev.2023.105112] [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: 07/30/2022] [Revised: 12/08/2022] [Accepted: 02/22/2023] [Indexed: 02/28/2023]
Abstract
The catechol-O-methyltransferase (COMT) gene has arguably been the designated pain sensitivity gene for nearly two decades. However, the literature provides inconsistent evidence. We performed several meta-analyses including k = 31 samples and n = 4631 participants thereby revealing small effects of rs4680 on pain thresholds in fibromyalgia, headache and across chronic pain conditions. Moreover, rs4680 effects were found across pain patients when affected, but not unaffected, body sites were assessed. No effect was detected for any other SNP investigated. Importantly, our results corroborate earlier findings in that we found a small effect of COMT haplotypes on pain sensitivity. Our review and meta-analysis contribute to the understanding of COMT-dependent effects on pain perception, provide insights into research issues and offer future directions. The results support the theory that rs4680 might only impact behavioural measures of pain when descending pain modulatory pathways are sufficiently challenged. After all, COMT polymorphisms are genetic markers of pain sensitivity, albeit with some limitations which are discussed with respect to their implications for research and clinical significance.
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Affiliation(s)
| | - Merlin Monzel
- Department of Psychology, University of Bonn, Germany
| | - Martin Reuter
- Department of Psychology, University of Bonn, Germany; Center for Economics and Neuroscience (CENs), Laboratory of Neurogenetics, University of Bonn, Germany
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12
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Korczeniewska OA, Kuo F, Huang CY, Nasri-Heir C, Khan J, Benoliel R, Hirschberg C, Eliav E, Diehl SR. Genetic variation in catechol-O-methyltransferase is associated with individual differences in conditioned pain modulation in healthy subjects. J Gene Med 2021; 23:e3374. [PMID: 34156736 PMCID: PMC9926975 DOI: 10.1002/jgm.3374] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/10/2021] [Accepted: 06/20/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Genetic variation in the catechol-O-methyltransferase (COMT) gene is associated with sensitivity to both acute experimental pain and chronic pain conditions. Four single nucleotide polymorphisms (SNPs) have traditionally been used to infer three common haplotypes designated as low, average and high pain sensitivity and are reported to affect both COMT enzymatic activity and pain sensitivity. One mechanism that may partly explain individual differences in sensitivity to pain is conditioned pain modulation (CPM). We hypothesized that variation in CPM may have a genetic basis. METHODS We evaluated CPM in 77 healthy pain-free Caucasian subjects by applying repeated mechanical stimuli to the dominant forearm using 26-g von Frey filament as the test stimulus with immersion of the non-dominant hand in hot water as the conditioning stimulus. We assayed COMT SNP genotypes by the TaqMan method using DNA extracted from saliva. RESULTS SNP rs4680 (val158 met) was not associated with individual differences in CPM. However, CPM was associated with COMT low pain sensitivity haplotypes under an additive model (p = 0.004) and the effect was independent of gender. CONCLUSIONS We show that, although four SNPs are used to infer COMT haplotypes, the low pain sensitivity haplotype is determined by SNP rs6269 (located in the 5' regulatory region of COMT), suggesting that inherited variation in gene expression may underlie individual differences in pain modulation. Analysis of 13 global populations revealed that the COMT low pain sensitivity haplotype varies in frequency from 13% to 44% and showed that two SNPs are sufficient to distinguish all COMT haplotypes in most populations.
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Affiliation(s)
- Olga A. Korczeniewska
- Center for Orofacial Pain and Temporomandibular Disorders, Department of Diagnostic Sciences, Rutgers School of Dental Medicine, Newark, NJ, USA
| | - Fengshen Kuo
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ching-Yu Huang
- School of Computer Science and Technology, Kean University, Union, NJ, USA
| | - Cibele Nasri-Heir
- Center for Orofacial Pain and Temporomandibular Disorders, Department of Diagnostic Sciences, Rutgers School of Dental Medicine, Newark, NJ, USA
| | - Junad Khan
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA
| | - Rafael Benoliel
- Center for Orofacial Pain and Temporomandibular Disorders, Department of Diagnostic Sciences, Rutgers School of Dental Medicine, Newark, NJ, USA
| | - Craig Hirschberg
- Department of Endodontics, Rutgers School of Dental Medicine, Newark, NJ, USA
| | - Eli Eliav
- Eastman Institute for Oral Health, University of Rochester Medical Center, Rochester, NY, USA
| | - Scott R. Diehl
- Department of Oral Biology, Rutgers School of Dental Medicine, Newark, NJ, USA
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13
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Cuitavi J, Hipólito L, Canals M. The Life Cycle of the Mu-Opioid Receptor. Trends Biochem Sci 2021; 46:315-328. [PMID: 33127216 DOI: 10.1016/j.tibs.2020.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/30/2020] [Accepted: 10/01/2020] [Indexed: 12/12/2022]
Abstract
Opioid receptors (ORs) are undisputed targets for the treatment of pain. Unfortunately, targeting these receptors therapeutically poses significant challenges including addiction, dependence, tolerance, and the appearance of side effects, such as respiratory depression and constipation. Moreover, misuse of prescription and illicit narcotics has resulted in the current opioid crisis. The mu-opioid receptor (MOR) is the cellular mediator of the effects of most commonly used opioids, and is a prototypical G protein-coupled receptor (GPCR) where new pharmacological, signalling and cell biology concepts have been coined. This review summarises the knowledge of the life cycle of this therapeutic target, including its biogenesis, trafficking to and from the plasma membrane, and how the regulation of these processes impacts its function and is related to pathophysiological conditions.
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Affiliation(s)
- Javier Cuitavi
- Department of Pharmacy and Pharmaceutical Technology and Parasitology, University of València, Burjassot, Spain
| | - Lucía Hipólito
- Department of Pharmacy and Pharmaceutical Technology and Parasitology, University of València, Burjassot, Spain
| | - Meritxell Canals
- Division of Physiology, Pharmacology and Neuroscience, School of Life Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, UK; Centre of Membrane Proteins and Receptors (COMPARE), Universities of Birmingham and Nottingham, the Midlands, UK.
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14
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Verscheijden LFM, Litjens CHC, Koenderink JB, Mathijssen RHJ, Verbeek MM, de Wildt SN, Russel FGM. Physiologically based pharmacokinetic/pharmacodynamic model for the prediction of morphine brain disposition and analgesia in adults and children. PLoS Comput Biol 2021; 17:e1008786. [PMID: 33661919 PMCID: PMC7963108 DOI: 10.1371/journal.pcbi.1008786] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 03/16/2021] [Accepted: 02/12/2021] [Indexed: 12/20/2022] Open
Abstract
Morphine is a widely used opioid analgesic, which shows large differences in clinical response in children, even when aiming for equivalent plasma drug concentrations. Age-dependent brain disposition of morphine could contribute to this variability, as developmental increase in blood-brain barrier (BBB) P-glycoprotein (Pgp) expression has been reported. In addition, age-related pharmacodynamics might also explain the variability in effect. To assess the influence of these processes on morphine effectiveness, a multi-compartment brain physiologically based pharmacokinetic/pharmacodynamic (PB-PK/PD) model was developed in R (Version 3.6.2). Active Pgp-mediated morphine transport was measured in MDCKII-Pgp cells grown on transwell filters and translated by an in vitro-in vivo extrapolation approach, which included developmental Pgp expression. Passive BBB permeability of morphine and its active metabolite morphine-6-glucuronide (M6G) and their pharmacodynamic parameters were derived from experiments reported in literature. Model simulations after single dose morphine were compared with measured and published concentrations of morphine and M6G in plasma, brain extracellular fluid (ECF) and cerebrospinal fluid (CSF), as well as published drug responses in children (1 day– 16 years) and adults. Visual predictive checks indicated acceptable overlays between simulated and measured morphine and M6G concentration-time profiles and prediction errors were between 1 and -1. Incorporation of active Pgp-mediated BBB transport into the PB-PK/PD model resulted in a 1.3-fold reduced brain exposure in adults, indicating only a modest contribution on brain disposition. Analgesic effect-time profiles could be described reasonably well for older children and adults, but were largely underpredicted for neonates. In summary, an age-appropriate morphine PB-PK/PD model was developed for the prediction of brain pharmacokinetics and analgesic effects. In the neonatal population, pharmacodynamic characteristics, but not brain drug disposition, appear to be altered compared to adults and older children, which may explain the reported differences in analgesic effect. Developmental processes in children can affect pharmacokinetics: “what the body does to the drug” as well as pharmacodynamics: “what the drug does to the body”. A typical example is morphine, of which the analgesic response is variable and particularly neonates suffer more often from respiratory depression, even when receiving doses corrected for differences in elimination. One way to mathematically incorporate developmental processes is by employing physiologically based pharmacokinetic/pharmacodynamic (PB-PK/PD) models, where physiological differences between individuals are incorporated. In this study, we developed a morphine PB-PK/PD model to predict brain drug disposition as well as analgesic response in adults and children, as both processes could potentially contribute to developmental variability in the effect of morphine. We found that age-related variation in BBB expression of the main morphine efflux transporter P-glycoprotein was not responsible for differences in brain exposure. In contrast, pharmacodynamic modelling suggested an increased sensitivity to morphine in neonates.
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Affiliation(s)
- Laurens F. M. Verscheijden
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Carlijn H. C. Litjens
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Department of Pharmacy, Radboud Institute for Health Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Jan B. Koenderink
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud university medical center, Nijmegen, The Netherlands
| | - Ron H. J. Mathijssen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Marcel M. Verbeek
- Departments of Neurology and Laboratory Medicine, Donders Institute for Brain, Cognition and Behaviour, Radboud university medical center, Nijmegen, The Netherlands
| | - Saskia N. de Wildt
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud university medical center, Nijmegen, The Netherlands
- Intensive Care and Department of Paediatric Surgery, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Frans G. M. Russel
- Department of Pharmacology and Toxicology, Radboud Institute for Molecular Life Sciences, Radboud university medical center, Nijmegen, The Netherlands
- * E-mail:
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15
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Slade GD, Fillingim RB, Ohrbach R, Hadgraft H, Willis J, Arbes SJ, Tchivileva IE. COMT Genotype and Efficacy of Propranolol for TMD Pain: A Randomized Trial. J Dent Res 2020; 100:163-170. [PMID: 33030089 PMCID: PMC8163522 DOI: 10.1177/0022034520962733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Propranolol is a nonselective β-adrenergic receptor antagonist that is
efficacious in reducing facial pain. There is evidence that its analgesic
efficacy might be modified by variants of the catechol-O-methyltransferase
(COMT) gene. We tested the hypothesis in a subset of 143
non-Hispanic Whites from a randomized controlled trial of patients with painful
temporomandibular disorder (TMD). Patients were genotyped for rs4680, a single
nucleotide polymorphism of COMT, and randomly allocated to
either propranolol 60 mg twice daily or placebo. During the 9-wk follow-up
period, patients recorded daily ratings of facial pain intensity and duration;
the product was computed as an index of facial pain. Postbaseline change in the
index at week 9 (the primary endpoint) was analyzed as a continuous variable and
dichotomized at thresholds of ≥30% and ≥50% reduction. Mixed models for repeated
measures tested for the genotype × treatment group interaction and estimated
means, odds ratios (ORs), and 95% confidence limits (95% CLs) of efficacy within
COMT genotypes assuming an additive genetic model. In
secondary analysis, the cumulative response curves were plotted for dichotomized
reductions ranging from ≥20% to ≥70%, and genotype differences in area under the
curve percentages (%AUC) were calculated to signify efficacy. Mean index
reduction did not differ significantly (P = 0.277) according to
genotype, whereas the dichotomized ≥30% reduction revealed greater efficacy
among G:G homozygotes (OR = 10.9, 95%CL = 2.4, 50.7) than among A:A homozygotes
(OR = 0.8, 95%CL = 0.2, 3.2) with statistically significant interaction
(P = 0.035). Cumulative response curves confirmed greater
(P = 0.003) efficacy for G:G homozygotes (%AUC difference =
43.7, 95%CL = 15.4, 72.1) than for A:A homozygotes (%AUC difference = 6.5, 95%CL
= -30.2, 43.2). The observed antagonistic effect of the A allele on
propranolol’s efficacy was opposite the synergistic effect hypothesized a
priori. This unexpected result highlights the need for better knowledge of
COMT’s role in pain pathogenesis if the gene is to be used
for precision-medicine treatment of TMD (ClinicalTrials.gov NCT02437383).
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Affiliation(s)
- G D Slade
- Center for Pain Research and Innovation, Adams School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Division of Pediatric and Public Health, Adams School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - R B Fillingim
- Department of Community Dentistry and Behavioral Science, University of Florida, Gainesville, FL, USA
| | - R Ohrbach
- Department of Oral and Maxillofacial Surgery, University at Buffalo, State University of New York, Buffalo, NY, USA
| | | | | | | | - I E Tchivileva
- Center for Pain Research and Innovation, Adams School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Division of Oral and Craniofacial Health Sciences, Adams School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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16
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Silva EMVM, Lacerda RHW, Farias IL, Cavalcante BGN, Assis IO, Bezamat M, Modesto A, Vieira AR. COMT rs4818, pain sensitivity and duration, and alveolar bone grafting of oral clefts. Oral Maxillofac Surg 2020; 25:253-256. [PMID: 32989615 DOI: 10.1007/s10006-020-00912-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/22/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Verifying whether the mutation in COMT rs4818 could be involved in pain modulation. METHODS Thirty-two individuals born with cleft lip and palate that underwent bone graft from the iliac crest bone were assessed at 12, 24, 48, 72 h, and 7 days regarding their pain experience using a visual analogic scale. DNA from each participant was collected from saliva samples, and genotyping of rs4818 was performed using TaqMan chemistry. Overrepresentation of rs4818 alleles was tested using chi-square or Fisher's exact tests with an alpha of 0.05. RESULTS Of the 32 individuals, eighteen reported long pain duration, nine reported high pain intensity, and fourteen low pain intensity up to 48 h. No differences were found in the distribution of individuals depending on the reported pain by sex (p = 0.12), age (p = 0.42), or cleft type (p = 0.5). The distribution of COMT r4818 alleles was different depending on the intensity and duration of pain. Carriers of the C wild-type allele were four times more likely to show high pain intensity and duration (odds ratio = 4.29, 95% confidence interval 1.13-16.18), meaning that the G variant allele is protective. CONCLUSION COMT rs4818 is associated with postoperative pain after alveolar bone grafting.
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Affiliation(s)
- E M V M Silva
- Post-graduate Program in Dentistry and Center for Treatment of Cleft Lip and Palate, University Hospital Lauro Wanderley, Universidade Federal da Paraíba, João Pessoa, PB, Brazil
| | - R H W Lacerda
- Post-graduate Program in Dentistry and Center for Treatment of Cleft Lip and Palate, University Hospital Lauro Wanderley, Universidade Federal da Paraíba, João Pessoa, PB, Brazil
| | - I L Farias
- Post-graduate Program in Dentistry and Center for Treatment of Cleft Lip and Palate, University Hospital Lauro Wanderley, Universidade Federal da Paraíba, João Pessoa, PB, Brazil
| | - B G N Cavalcante
- Post-graduate Program in Dentistry and Center for Treatment of Cleft Lip and Palate, University Hospital Lauro Wanderley, Universidade Federal da Paraíba, João Pessoa, PB, Brazil
| | - I O Assis
- Post-graduate Program in Dentistry and Center for Treatment of Cleft Lip and Palate, University Hospital Lauro Wanderley, Universidade Federal da Paraíba, João Pessoa, PB, Brazil
| | - M Bezamat
- Department of Oral Biology, School of Dental Medicine, University of Pittsburgh, 412 Salk Pavilion, 335 Sutherland Street, Pittsburgh, PA, 15261, USA
| | - A Modesto
- Department of Pediatric Dentistry, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alexandre Rezende Vieira
- Post-graduate Program in Dentistry and Center for Treatment of Cleft Lip and Palate, University Hospital Lauro Wanderley, Universidade Federal da Paraíba, João Pessoa, PB, Brazil. .,Department of Oral Biology, School of Dental Medicine, University of Pittsburgh, 412 Salk Pavilion, 335 Sutherland Street, Pittsburgh, PA, 15261, USA.
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