Feasibility Study Comparing Oral Paracetamol and Oral Non-Steroidal Anti-Inflammatory Drugs for Treating Pain after Musculoskeletal Injury: a Randomised, Double Blind, Controlled Trial

Objectives

To investigate the efficacy and safety of oral paracetamol compared with oral non-steroidal anti-inflammatory drugs (NSAIDs) or combination therapy in relieving pain after limb injury in an emergency department.

Design

Double blind, randomised, controlled study.

Setting

Emergency department of a university hospital in the New Territories of Hong Kong.

Subjects

50 adult patients with painful isolated limb injuries.

Main outcome measures

Primary outcome measures were pain relief at rest and with limb movement, and adverse events.

Results

There was no statistical difference in the mean reduction in pain score between oral paracetamol and oral NSAIDs in the first two hours of treatment or over three days. Patients' pain reduced significantly over three days but it was unclear whether this was due to natural healing rather than analgesic medication. There was no significant difference in pain relief between paracetamol and NSAIDs over three days treatment. All combinations appeared to be safe with no major adverse effects reported in the study.

Conclusion

Oral paracetamol may be as effective and as safe as moderate dose of NSAIDs in the management of musculoskeletal pain. A larger study is required to confirm this hypothesis.

Differential regulation of adrenomedullin gene expression in the fundic and pyloric regions of the rat stomach during acute and chronic starvation

Adrenomedullin (AM) has been shown to be present in the stomach but the role of gastric AM is obscure. To investigate the effects of starvation on AM in the stomach, we studied the changes in gene expression of preproadrenomedullin (preproAM) and AM receptors by reverse transcription-polymerase chain reaction (RT-PCR), and tissue AM concentrations by radioimmunoassay (RIA) in the fundus and pylorus of the stomach of rats subjected to either acute (1-day) or chronic (4-day) starvation. An up-regulation of preproAM gene expression was observed in the fundus after acute starvation, and in the pylorus after chronic starvation. Immunoreactive AM (ir-AM) levels were increased in both fundus and pylorus after chronic starvation. In addition, marked reductions in the gene expression of fundic calcitonin receptor-like receptor (CRLR) and receptor activity-modifying protein (RAMP) 3 as well as the pyloric CRLR and RAMP2 were observed in the chronically starved rats. The present study suggests that the gene expression of preproadrenomedullin mRNA is differentially regulated by starvation in the different parts of the stomach.

A novel, high stringency selection system allows screening of few clones for high protein expression

To obtain highly productive mammalian cell lines, often large numbers of clones need to be screened. This is largely due to low selection stringencies, creating many, but low protein producing clones. To remedy this problem, a novel, very stringent selection system was designed, to create few, but high protein producing clones. In essence, a selection marker with a startcodon that confers attenuated translation initiation frequency was placed upstream of the gene of interest with a startcodon that confers optimal translation initiation. From the transcribed bicistronic mRNA, the selection marker is translated at a low frequency, and the protein of interest at a high frequency. This selection system is so stringent that clones form only rarely. However, application of anti-repressor elements, which increase promoter activity, did induce the formation of clones that expressed proteins at high levels. When combined with anti-repressor elements, this novel selection system can be a valuable tool to rapidly create few, but highly productive mammalian cell lines.

Signal transduction in the ductuli efferentes testis of the rat: inhibition of fluid reabsorption by cyclic adenosine 3', 5'-monophosphate

It is important to identify the signal transduction pathway involved in the regulation of fluid reabsorption by the ductuli efferentes of the testis because they reabsorb most of the fluid leaving the testis and are essential for male fertility. Microperfusion studies of the ducts in vivo showed that 0.1 or 1.0 mM dibutyryl (db)-cGMP in the perfusate had no effect on fluid reabsorption, but 0.1 mM db-cAMP significantly reduced fluid reabsorption, 0.25 mM abolished reabsorption, and 0.5-1.0 mM caused secretion. The inhibitory effect of db-cAMP was reversible. Although the presence of db-cAMP in the perfusate did not affect the concentration of Na+ in the collectate, the concentrations of K(+) and Cl(-) increased, indicating that their transport is at least partly regulated by cAMP. Including the phosphodiesterase inhibitor pentoxifylline in the perfusate decreased fluid reabsorption by the ducts in a dose-dependent manner, and it also increased the concentration of cAMP (5.5-fold) in collectate. Pentoxifylline also increased the production of cAMP (4-fold) by ducts incubated in vitro. It is concluded that cAMP, but probably not cGMP, is an intracellular messenger regulating fluid reabsorption in the efferent ducts.

pH and bicarbonate in the ductuli efferentes testis of the rat

The pH and bicarbonate concentrations of luminal fluids in the efferent ducts of the rat were estimated from pH measurements of samples in vitro under conditions of controlled temperature and carbon dioxide tension. The pH of scrotal blood was estimated to be more acidic than systemic blood (mean pH=7.44) at either of the putative scrotal carbon dioxide tensions (5% and 7%, pH, respectively,=7.42 and 7.28). For PCO2 tensions of 5% and 7%, respectively, the data indicated that the pH in the efferent ducts was significantly higher (distal initial zone pH=7.55 or 7.41; coni vasculosi pH=7.66 or 7.51; p < 0.01) than in fluid entering (rete testis fluid, pH=7.34 or 7.20) or leaving the ducts (zone 1a of the epididymal duct 7.26 or 7.11). Bicarbonate concentrations were also significantly higher (p < 0.01) in the efferent ducts (35.4 +/- 4.7 mM, distal initial zone; 45.2 +/- 7.6 mM, coni vasculosi) than in fluids entering (22.9 +/- 3.6 mM) or leaving (20.4 +/- 4.9 mM) the ducts. Estimates of the reabsorption of bicarbonate and fluid indicated that 96% of the testicular output of bicarbonate was reabsorbed in the efferent ducts, but there was also some secretion of bicarbonate into the ducts. It is concluded that luminal pH and bicarbonate levels in the efferent ducts of the rat are high relative to those found in the epididymis where low pH and bicarbonate contributes to sperm quiescence during storage. Nevertheless, the high rate of bicarbonate reabsorption in the efferent ducts is a major contributor to the establishment of the low pH and bicarbonate milieu of the epididymis.

Fluid and electrolyte reabsorption in the ductuli efferentes testis

The efferent ducts of mammals are a series of ducts that are arranged in parallel and reabsorb most of the fluid released with spermatozoa from the testis. This function is essential for spermatogenesis, and for sperm maturation and storage in the epididymis. There is evidence for the involvement of three major transport processes in the bulk reabsorption of water and low molecular weight solutes from the ducts: active solute transport, passive (presumably paracellular) diffusion and fluid phase endocytosis. A small back-flux into the ducts via anion secretion also appears to occur. Control of fluid reabsorption by the efferent ducts is emerging as a complex process with multiple components. Reabsorption is flow dependent which provides local control of reabsorption with a rapid response to changes in luminal conditions. Sex steroids (oestrogen as well as androgen), but not mineralocorticosteroids, are involved in the chronic control of reabsorption in the ducts. Control of epithelial transport in the efferent ducts appears to be mediated by cAMP and probably other signal transduction systems.

Chronic exposure to hypergravity affects thyrotropin-releasing hormone levels in rat brainstem and cerebellum

In studies to determine the neurochemical mechanisms underlying adaptation to altered gravity we have investigated changes in neuropeptide levels in brainstem, cerebellum, hypothalamus, striatum, hippocampus, and cerebral cortex by radioimmunoassay. Fourteen days of hypergravity (hyperG) exposure resulted in significant increases in thyrotropin-releasing hormone (TRH) content of brainstem and cerebellum, but no changes in levels of other neuropeptides (beta-endorphin, cholecystokinin, met-enkephalin, somatostatin, and substance P) examined in these areas were found, nor were TRH levels significantly changed in any other brain regions investigated. The increase in TRH in brainstem and cerebellum was not seen in animals exposed only to the rotational component of centrifugation, suggesting that this increase was elicited by the alteration in the gravitational environment. The only other neuropeptide affected by chronic hyperG exposure was met-enkephalin, which was significantly decreased in the cerebral cortex. However, this alteration in met-enkephalin was found in both hyperG and rotation control animals and thus may be due to the rotational rather than the hyperG component of centrifugation. Thus it does not appear as if there is a generalized neuropeptide response to chronic hyperG following 2 weeks of exposure. Rather, there is an increase only of TRH and that occurs only in areas of the brain known to be heavily involved with vestibular inputs and motor control (both voluntary and autonomic). These results suggest that TRH may play a role in adaptation to altered gravity as it does in adaptation to altered vestibular input following labyrinthectomy, and in cerebellar and vestibular control of locomotion, as seen in studies of ataxia.

Adrenal independence of fluid and electrolyte reabsorption in the ductuli efferentes testis of the rat

The ductuli efferentes testis (efferent ducts) of the rat were studied to determine whether fluid and electrolyte reabsorption by the ducts is under the control of adrenal mineralocorticoids. Testicular fluid output and the rate of fluid reabsorption by the ducts were determined in sham-operated controls and in rats which had been adrenalectomized 10 days previously, adrenalectomized 10 days previously and given aldosterone therapy (75 micrograms kg-1 day-1 S.C.) from day 3 to day 10 post adrenalectomy, and in rats given injections of the aldosterone antagonist, spironolactone, for 10 days (10 mg kg-1 day-1 S.C.). The values for testicular fluid output and fluid flow from the efferent ducts (means +/- S.E.M.) in the sham-operated rats were 36.0 +/- 7.8 and 1.23 +/- 0.12 microliters h-1, respectively, resulting in an estimate of fluid reabsorption by the efferent ducts of 94.8 +/- 1.6% of the testicular fluid output. None of the treatments resulted in a significant change in testicular fluid output or in fluid reabsorption from the efferent ducts. Similarly, the treatments did not significantly alter the osmolality or electrolyte concentrations in fluid samples from the rete testis or the distal end of the efferent ducts (sham-operated values for rete testis and efferent duct fluid, respectively, were: osmolality, 311.2 +/- 1.7 and 302.7 +/- 5.7 mosmol kg-1; [Na+], 151.2 +/- 5.6 and 150.8 +/- 8.1 mmol l-1; [Cl-], 147.9 +/- 6.6 and 126.7 +/- 2.2 mmol l-1; [K+], 15.2 +/- 0.7 and 13.5 +/- 2.4 mmol l-1). It is concluded that, like the homologous proximal tubule of the metanephric kidney, fluid reabsorption from the efferent ducts is independent of adrenal mineralocorticoid control.

Age-related changes in the contents of neuropeptides in the rat brain and pituitary

beta-Endorphin, Leu-enkephalin, Met-enkephalin, substance P, somatostatin, and cholecystokinin were measured in the brain and the pituitary of male Sprague-Dawley rats aged 3 months, 12 months, and 22 months. beta-Endorphin, Met-enkephalin and Leu-enkephalin contents in the neurointermediate lobe, and the enkephalin levels in the anterior lobe of the pituitary increased with age. The increases in contents were both in the day and at night for beta-endorphin and Met-enkephalin. However, the increase for Leu-enkephalin content was in the day only. Hypothalamic beta-endorphin content decreased with age only in the day. beta-Endorphin and Leu-enkephalin contents in the brain stem, and Leu-enkephalin levels contents in the cortex decreased with age at night. Leu-enkephalin in the striatum decreased with age in the day. There was also an age-related decrease for somatostatin and substance P contents in the striatum and the hypothalamus in the day, and in cholecystokinin levels in the hippocampus, and the hypothalamus at night. It is concluded that there are age differences in neuropeptide levels, and that these changes may differ according to diurnal rhythms.

T3 reverses the changes in met-enkephalin and beta-endorphin contents in the anterior lobe, but not the neuro-intermediate lobe of the pituitary of rats rendered hypothyroid by PTU-treatment

The changes in met-enkephalin and beta-endorphin contents in the pituitary in PTU-induced hypothyroidism were studied in the rat. After 2 weeks of PTU-treatment, both IR-met-enkephalin and IR-beta-endorphin contents in the pituitary were significantly reduced. Gel filtration chromatography followed by radioimmunoassay showed that the immunoactivities in the peaks of precursors, met-enkephalin, beta-lipotropin and beta-endorphin were all lower in the pituitaries from the PTU-treated rats. In another experiment, some of the PTU-treated rats were injected daily with 500 micrograms T3/kg b.w. In the hypothyroid rats, IR-met-enkephalin and IR-beta-endorphin contents were decreased in both the anterior and neurointermediate lobes. Only the changes in the anterior lobe were reversed by T3 treatment. In conclusion, while the effects on the anterior lobe are probably due to a deficiency in thyroid hormones, the mechanism for the decrease of opioid peptide contents in the neurointermediate lobe is still unclear.

Hypothyroidism and pituitary contents of immunoactive met-enkephalin and beta-endorphin in male rats of different ages

A comparison of the effect of PTU-induced hypothyroidism on the contents of immunoactive met-enkephalin and beta-endorphin in the pituitaries from rats aged 2 1/2, 12, and 18 months was made. In all ages, there was significant reduction of IR-met-enkephalin content in the anterior lobe and IR-beta-endorphin content in the neuro-intermediate lobe after PTU treatment. There was a significant age-related decrease in IR-beta-endorphin content in the anterior lobe. Rats of all three ages responded to PTU treatment with an increase in serum TSH level and a drastic reduction in serum T3 and T4 levels. The results indicate that there was no age-related difference in the change of pituitary opioid peptide contents in response to hypothyroidism.