Preoperative anxiety management: acupuncture vs. pharmacological treatment - A prospective study

OBJECTIVE

Acupuncture, both auricular and somatic, is a widely adopted and well-tolerated treatment for preoperative anxiety. The aim of our study was to compare the effectiveness of acupuncture with pharmacological treatment in reducing preoperative anxiety in patients undergoing cholecystectomy or TEP.

MATERIALS AND METHODS

We randomized 120 patients in a control group PT (where patients underwent pharmacological treatment with Midazolam) and in an acupuncture group (here patients received somatic acupuncture SA and auricular acupuncture AA). Anxiety reduction was measured by intraoperative consumption of Propofol and Fentanyl and preoperatively by the Italian Version of the State-Trait Anxiety Inventory questionnaire (STAI).

RESULTS

Propofol consumption in the somatic (SA) and auricular (AA) acupuncture groups was found to be lower compared to patients that did not receive any treatment. SA and AA patients required less Propofol than the PT group (p=0.0019 and p=0.0016 respectively) and patients that underwent SA treatment used less Fentanyl than the PT group (p=0.002). No difference was measured when comparing SA to AA (p=0.15) and AA to PT (p=0.16).

CONCLUSIONS

Acupuncture is a safe and well-tolerated procedure that reduces preoperative anxiety. Both somatic and auricular acupuncture are more effective than pharmacological treatment in the intraoperative period. AA is easier to implement than SA.

Transnasal sphenopalatine ganglion blockade for acute facial pain: a prospective randomized case-control study

OBJECTIVE

Long-term physical inactivity can cause the atrophy of skeletal muscle. The aim of this study is to explore the underlying mechanisms of physical inactivity-induced atrophy of skeletal muscle.

MATERIALS AND METHODS

14 Sprague- Dawley (SD) male rats were divided into 2 groups including normal control (NC) and hindlimb suspension (HS) groups. After two weeks of HS stimulation, the ratio between skeletal muscle weight and body weight, and cross-sectional area (CSA) of skeletal muscle fibers, were measured. Western blot was applied to evaluate the expression of proteins associated with atrophy and autophagy. The transmission electron microscope was used to observe the ultra-microstructure and the mitochondrial quality of skeletal muscle.

RESULTS

The rats subjected to 2-week HS treatment presented an evident atrophy of the skeletal muscle with a significantly reduced ratio between skeletal muscle weight and body weight, and smaller cross-sectional area (CSA) of skeletal muscle fibers when compared with control rats. Meanwhile, HS stimulation resulted in the damage of mitochondria, the increased expression of MuRF1 and Atrogin-1/MAFbx, and enhanced apoptosis, as well as dysfunctional autophagy in skeletal muscle.

CONCLUSIONS

HS-induced skeletal muscle atrophy involves the activation of AMPK/FoxO3 signal pathway, evidenced as AMPK phosphorylation, FoxO3 activation, and Atrogin-1 and MuRF1 up-regulation. FoxO3-mediated autophagy plays an important regulatory role in HS-induced skeletal muscle atrophy.

A critical assessment of force field accuracy against NMR data for cyclic peptides containing β-amino acids

Hybrid cyclic α/β-peptides, in which one or more β-amino acids are incorporated into the backbone, are gaining increasing interest as potential therapeutics, thanks to their ability to achieve enhanced binding affinities for a biological target through pre-organization in solution. The in silico prediction of their three dimensional structure through strategies such as MD simulations would substantially advance the rational design process. However, whether the molecular mechanics force fields are accurate in sampling highly constrained cyclopeptides containing β-amino acids remains to be verified. Here, we present a systematic assessment of the ability of 8 widely used force fields to reproduce 79 NMR observables (including chemical shifts and 3J scalar couplings) on five cyclic α/β-peptides that contain the integrin recognition motif isoDGR. Most of the investigated force fields, which include force fields from AMBER, OPLS, CHARMM and GROMOS families, display very good agreement with experimental 3J(HN,Hα), suggesting that MD simulations could be an appropriate tool in the rational design of therapeutic cyclic α-peptides. However, for NMR observables directly related to β-amino acids, we observed a poor agreement with experiments and a remarkable dependence of our evaluation on the choice of Karplus parameters. The force field weaknesses herein unveiled might constitute a source of inspiration for further force field optimization.

Chronic Intermittent Hypoxia Alters Local Respiratory Circuit Function at the Level of the preBötzinger Complex

Chronic intermittent hypoxia (CIH) is a common state experienced in several breathing disorders, including obstructive sleep apnea (OSA) and apneas of prematurity. Unraveling how CIH affects the CNS, and in turn how the CNS contributes to apneas is perhaps the most challenging task. The preBötzinger complex (preBötC) is a pre-motor respiratory network critical for inspiratory rhythm generation. Here, we test the hypothesis that CIH increases irregular output from the isolated preBötC, which can be mitigated by antioxidant treatment. Electrophysiological recordings from brainstem slices revealed that CIH enhanced burst-to-burst irregularity in period and/or amplitude. Irregularities represented a change in individual fidelity among preBötC neurons, and changed transmission from preBötC to the hypoglossal motor nucleus (XIIn), which resulted in increased transmission failure to XIIn. CIH increased the degree of lipid peroxidation in the preBötC and treatment with the antioxidant, 5,10,15,20-Tetrakis (1-methylpyridinium-4-yl)-21H,23H-porphyrin manganese(III) pentachloride (MnTMPyP), reduced CIH-mediated irregularities on the network rhythm and improved transmission of preBötC to the XIIn. These findings suggest that CIH promotes a pro-oxidant state that destabilizes rhythmogenesis originating from the preBötC and changes the local rhythm generating circuit which in turn, can lead to intermittent transmission failure to the XIIn. We propose that these CIH-mediated effects represent a part of the central mechanism that may perpetuate apneas and respiratory instability, which are hallmark traits in several dysautonomic conditions.

Prostaglandin E2 differentially modulates the central control of eupnoea, sighs and gasping in mice

Prostaglandin E2 (PGE2) augments distinct inspiratory motor patterns, generated within the preBötzinger complex (preBötC), in a dose-dependent way. The frequency of sighs and gasping are stimulated at low concentrations, while the frequency of eupnoea increases only at high concentrations. We used in vivo microinjections into the preBötC and in vitro isolated brainstem slice preparations to investigate the dose-dependent effects of PGE2 on the preBötC activity. Synaptic measurements in whole cell voltage clamp recordings of inspiratory neurons revealed no changes in inhibitory or excitatory synaptic transmission in response to PGE2 exposure. In current clamp recordings obtained from inspiratory neurons of the preBötC, we found an increase in the frequency and amplitude of bursting activity in neurons with intrinsic bursting properties after exposure to PGE2. Riluzole, a blocker of the persistent sodium current, abolished the effect of PGE2 on sigh activity, while flufenamic acid, a blocker of the calcium-activated non-selective cation conductance, abolished the effect on eupnoeic activity caused by PGE2. Prostaglandins are important regulators of autonomic functions in the mammalian organism. Here we demonstrate in vivo that prostaglandin E2 (PGE2) can differentially increase the frequency of eupnoea (normal breathing) and sighs (augmented breaths) when injected into the preBötzinger complex (preBötC), a medullary area that is critical for breathing. Low concentrations of PGE2 (100-300 nm) increased the sigh frequency, while higher concentrations (1-2 μm) were required to increase the eupnoeic frequency. The concentration-dependent effects were similarly observed in the isolated preBötC. This in vitro preparation also revealed that riluzole, a blocker of the persistent sodium current (INap), abolished the modulatory effect on sighs, while flufenamic acid, an antagonist for the calcium-activated non-selective cation conductance (ICAN ) abolished the effect of PGE2 on fictive eupnoea at higher concentrations. At the cellular level PGE2 significantly increased the amplitude and frequency of intrinsic bursting in inspiratory neurons. By contrast PGE2 affected neither excitatory nor inhibitory synaptic transmission. We conclude that PGE2 differentially modulates sigh, gasping and eupnoeic activity by differentially increasing INap and ICAN currents in preBötC neurons.

Fatal breathing dysfunction in a mouse model of Leigh syndrome

Leigh syndrome (LS) is a subacute necrotizing encephalomyelopathy with gliosis in several brain regions that usually results in infantile death. Loss of murine Ndufs4, which encodes NADH dehydrogenase (ubiquinone) iron-sulfur protein 4, results in compromised activity of mitochondrial complex I as well as progressive neurodegenerative and behavioral changes that resemble LS. Here, we report the development of breathing abnormalities in a murine model of LS. Magnetic resonance imaging revealed hyperintense bilateral lesions in the dorsal brain stem vestibular nucleus (VN) and cerebellum of severely affected mice. The mutant mice manifested a progressive increase in apnea and had aberrant responses to hypoxia. Electrophysiological recordings within the ventral brain stem pre-Bötzinger respiratory complex were also abnormal. Selective inactivation of Ndufs4 in the VN, one of the principle sites of gliosis, also led to breathing abnormalities and premature death. Conversely, Ndufs4 restoration in the VN corrected breathing deficits and prolonged the life span of knockout mice. These data demonstrate that mitochondrial dysfunction within the VN results in aberrant regulation of respiration and contributes to the lethality of Ndufs4-knockout mice.

Stapled haemorrhoidopexy: extent of tissue excision and clinical implications in the early postoperative period

AIM

This study quantified prospectively the amount of rectal wall removed during stapled haemorrhoidopexy and assessed its effect on ano-rectal function and health-related quality of life.

METHOD

Thirty-three consecutive patients who underwent stapled haemorrhoidopexy for second- or third- degree haemorrhoids, or for failed medical treatment, in the Department of Surgery and Gastroenterological Sciences at the University of Padova were included. All patients were assessed preoperatively and postoperatively using a structured questionnaire to determine the number of defecations per week, incomplete defecations, time taken to defecate any difficulty in defecating, soiling, the use of drugs and continence. All patients were reassessed at 1 and 2 weeks and at 30 days after the procedure using the Cleveland Global Quality of Life (CGQL) questionnaire. All patients underwent preoperative and postoperative ano-rectal manometry at least 30 days after stapled haemorrhoidopexy.

RESULTS

The median surface area of the resected rectal wall was 10.5 (range, 9-15) mm(2) and the median thickness was 3 (range, 2-4) mm. Muscle tissue was included in all specimens. The median thickness of the resected rectal wall correlated inversely with the rectal volume when the recto-anal inhibitory reflex (RAIR) was initiated during postoperative manometry (ρ = -0.50, P = 0.07). A significant, direct correlation was found between the surface area of the resected rectal wall and the rectal volume during postoperative manometry (ρ = 0.53, P = 0.08) and the use of analgesic drugs after 2 weeks (ρ = 0.63, P = 0.04). Significant correlations were found between being female and postoperative resting pressure (ρ = -0.74, P < 0.01), squeeze pressure (ρ = -0.64, P = 0.01) and maximum tolerated volume (ρ = -0.78, P < 0.01).

CONCLUSION

Stapled haemorrhoidopexy is safe and effective. The thicker the resected rectal wall, the lower the volume of initiation of the RAIR.

Chapter 3--networks within networks: the neuronal control of breathing

Breathing emerges through complex network interactions involving neurons distributed throughout the nervous system. The respiratory rhythm generating network is composed of micro networks functioning within larger networks to generate distinct rhythms and patterns that characterize breathing. The pre-Bötzinger complex, a rhythm generating network located within the ventrolateral medulla assumes a core function without which respiratory rhythm generation and breathing cease altogether. It contains subnetworks with distinct synaptic and intrinsic membrane properties that give rise to different types of respiratory rhythmic activities including eupneic, sigh, and gasping activities. While critical aspects of these rhythmic activities are preserved when isolated in in vitro preparations, the pre-Bötzinger complex functions in the behaving animal as part of a larger network that receives important inputs from areas such as the pons and parafacial nucleus. The respiratory network is also an integrator of modulatory and sensory inputs that imbue the network with the important ability to adapt to changes in the behavioral, metabolic, and developmental conditions of the organism. This review summarizes our current understanding of these interactions and relates the emerging concepts to insights gained in other rhythm generating networks.

Graded reductions in oxygenation evoke graded reconfiguration of the isolated respiratory network

Neurons depend on aerobic metabolism, yet are very sensitive to oxidative stress and, as a consequence, typically operate in a low O(2) environment. The balance between blood flow and metabolic activity, both of which can vary spatially and dynamically, suggests that local O(2) availability markedly influences network output. Yet the understanding of the underlying O(2)-sensing mechanisms is limited. Are network responses regulated by discrete O(2)-sensing mechanisms or, rather, are they the consequence of inherent O(2) sensitivities of mechanisms that generate the network activity? We hypothesized that a broad range of O(2) tensions progressively modulates network activity of the pre-Bötzinger complex (preBötC), a neuronal network critical to the central control of breathing. Rhythmogenesis was measured from the preBötC in transverse neonatal mouse brain stem slices that were exposed to graded reductions in O(2) between 0 and 95% O(2), producing tissue oxygenation values ranging from 20 ± 18 (mean ± SE) to 440 ± 56 Torr at the slice surface, respectively. The response of the preBötC to graded changes in O(2) is progressive for some metrics and abrupt for others, suggesting that different aspects of the respiratory network have different sensitivities to O(2).

Early abnormalities of post-sigh breathing in a mouse model of Rett syndrome

Rett syndrome is a neurodevelopmental disease accompanied by complex, disabling symptoms, including breathing symptoms. Because Rett syndrome is caused by mutations in the transcriptional repressor methyl-CpG-binding protein 2 (MeCP2), Mecp2-deficient mice have been generated as experimental model. Males of Mecp2-deficient mice (Mecp2(-/y)) breathe normally at birth but show abnormal respiratory responses to hypoxia and hypercapnia from postnatal day 25 (P25). After P30, Mecp2(-/y) mice develop breathing symptoms reminiscent of Rett syndrome, aggravating until premature death at around P60. Using plethysmography, we analyzed the sighs and the post-sigh breathing pattern of unrestrained wild type male mice (WT) and Mecp2(-/y) mice from P15 to P60. Sighs are spontaneous large inspirations known to prevent lung atelectasis and to improve alveolar oxygenation. However, Mecp2(-/y) mice show early abnormalities of post-sigh breathing, with long-lasting post-sigh apnoeas, reduced tidal volume when eupnoea resumes and lack of post-sigh bradypnoea which develop from P15, aggravate with age and possibly contribute to breathing symptoms to come.

Management of invasive and advanced thyroid cancer

The majority of thyroid cancers are slow growing and have an excellent prognosis after surgical and medical therapy. However, a subset of thyroid cancers do not follow an indolent course, and exhibit aggressive behaviour. Advanced thyroid malignancies can cause distressing and life-threatening symptoms by local invasion, growth of distant metastases. Extensive surgery may have curative or palliative effects, although morbidity should be considered before planning debulking operations. Novel therapies using molecular targets and redifferentiation agents promise to expand our ability to treat patients with advanced thyroid malignancies in the future.

Possible modulation of the mouse respiratory rhythm generator by A1/C1 neurones

Although compelling evidence exist that the respiratory rhythm generator is modulated by endogenous noradrenaline released from pontine A5 and A6 neurones, we examined whether medullary catecholaminergic neurones also participated in respiratory rhythm modulation. Experiments were performed in neonatal (postnatal days 0-6, P0-P6) and young mice (P14-P18) using "en bloc" medullary preparations (pons resected) and transverse medullary slices. In "en bloc" preparations, blockade of medullary alpha2 adrenoceptors with yohimbine and activation of catecholamine biosynthesis with L-tyrosine significantly depresses and facilitates the respiratory rhythm, respectively. In slices from neonatal and young mice, blockade of medullary alpha2 adrenoceptors also depressed the respiratory rhythm. Yohimbine local applications and lesion-ablation experiments of the dorsal medulla revealed implication of A1/C1 neurones in the yohimbine depressing effect. Although the mechanisms responsible for the yohimbine-depressing effect remain to be elucidated, our in vitro results in neonatal and young mice suggest that endogenous catecholamines released from A1/C1 neurones participate in respiratory rhythm modulation via medullary alpha2 adrenoceptors.

Biochemical markers of endothelial activation in primary hyperparathyroidism

Patients with primary hyperparathyroidism (PHPT) have impaired vasodilation both dependent and independent of endothelium. The aims of our study were to measure three different biochemical markers of endothelial activation, i. e., plasma thrombomodulin, soluble(s) E-selectin, and von Willebrand factor, in PHPT patients before and one year after successful parathyroidectomy, and to distinguish the potential effect of hypercalcemia and/or high parathyroid hormone from that of major cardiovascular risk factors (diabetes mellitus, hyperlipidemia, hypertension, obesity, smoking habit) on endothelial function. Twenty consecutive patients with PHPT subdivided into two groups according to the absence (n = 8) or presence (n = 12) of one or more risk factors, and fifteen healthy normocalcemic subjects were studied. Baseline thrombomodulin levels were similar in the groups with and without risk factors, and in controls. In contrast, sE-selectin and von Willebrand factor were higher in PHPT patients with risk factors than in those without risk factors (p < 0.05 and p < 0.01, respectively) and controls (p < 0.01). Neither thrombomodulin nor sE-selectin changed after parathyroidectomy in either PHPT group. Plasma von Willebrand factor decreased (p < 0.01) in patients without risk factors, while persisting at high levels in patients with risk factors. In conclusion, in spite of a limitation due to the small number of patients, our study suggests that classic cardiovascular risk factors seem to be the main determinants for the high plasma levels of sE-selectin and vWF in PHPT. Together with unaltered thrombomodulin and sE-selectin levels, a plasma vWF decrease after parathyroidectomy might reflect a specific mechanism of its endothelial calcium- and/or PTH-stimulated secretion in some PHPT patients without risk factors. Whether a vWF reduction after parathyroidectomy may be used as a biochemical index for improved endothelial function in PHPT patients without risk factors has yet to be demonstrated in larger studies.

Possible modulation of the mouse respiratory rhythm generator by A1/C1 neurones

Although compelling evidence exist that the respiratory rhythm generator is modulated by endogenous noradrenaline released from pontine A5 and A6 neurones, we examined whether medullary catecholaminergic neurones also participated in respiratory rhythm modulation. Experiments were performed in neonatal (postnatal days 0-6, P0-P6) and young mice (P14-P18) using "en bloc" medullary preparations (pons resected) and transverse medullary slices. In "en bloc" preparations, blockade of medullary alpha2 adrenoceptors with yohimbine and activation of catecholamine biosynthesis with L-tyrosine significantly depresses and facilitates the respiratory rhythm, respectively. In slices from neonatal and young mice, blockade of medullary alpha2 adrenoceptors also depressed the respiratory rhythm. Yohimbine local applications and lesion-ablation experiments of the dorsal medulla revealed implication of A1/C1 neurones in the yohimbine depressing effect. Although the mechanisms responsible for the yohimbine-depressing effect remain to be elucidated, our in vitro results in neonatal and young mice suggest that endogenous catecholamines released from A1/C1 neurones participate in respiratory rhythm modulation via medullary alpha2 adrenoceptors.

Synthesis and binding properties of conjugates between oligodeoxynucleotides and daunorubicin derivatives

Conjugation of an anthracycline to a triplex-forming oligonucleotide (TFO) allows delivery of this drug to a specific DNA site, preserving the intercalation geometry of this class of anticancer agents. Conjugate 11, in which the TFO is linked via a hexamethylene bridge to the O-4 on the D ring of the anthraquinone moiety, affords the most stable triple helix, through intercalation of the planar chromophore between DNA bases and binding of both the TFO and the amino sugar to the major and the minor groove respectively.

Native oligodeoxynucleotides specifically active against human immunodeficiency virus type 1 in vitro: a G-quartet-driven effect?

Among a series of unmodified phosphodiester (PO)-oligodeoxynucleotides (PO-ODNs) complementary to some of the human immunodeficiency virus type 1 (HIV-1) regulatory genes, several PO-ODN sequences complementary to the vpr gene (PO-ODNs-a-vpr, where a-vpr is the antisense vpr sequence) emerged as potent inhibitors (at concentrations of 0.8 to 3.3 microM) of HIV-1 multiplication in de novo infected MT-4 cells, while they showed no cytotoxicity for uninfected cells at concentrations up to 100 microM. Unlike phosphorothioate counterparts, PO-ODN-a-vpr sequences were not inhibitory to HIV-2 multiplication in de novo infected C8166 cells and neither prevented the fusion between chronically infected and bystander CD4+ cells nor inhibited the activity of the HIV-1 reverse transcriptase in enzyme assays. Moreover, they were not inhibitory to HIV-1 multiplication in chronically infected cells. Delayed addition experiments showed that PO-ODNs-a-vpr inhibit an event in the HIV-1 replication cycle following adsorption to the host cell, but preceding reverse transcription. Structure-activity relationship studies indicated that the antiviral activity of the test PO-ODN-a-vpr sequences is not related to an antisense mechanism but to the presence, within the active sequences, of contiguous guanine residues. Physical characterization of the test PO-ODNs suggested that the active structure is a tetramer stabilized by G quartets (i.e., four G residues connected by eight hydrogen bonds).