The neuroimmunology of social-stress-induced sensitization.

Myriad clinical findings provide links between chronic stressors, inflammation, and mood disorders. Furthermore, traumatic or chronic exposure to psychological stressors may promote stress sensitization, in which individuals have long-term complications, including increased vulnerability to subsequent stressors. Post-traumatic stress disorder (PTSD) is a clinically relevant example of stress sensitization. PTSD alters neuronal circuitry and mood; however, the mechanisms underlying long-term stress sensitization within this disorder are unclear. Rodent models of chronic social defeat recapitulate several key physiological, immunological, and behavioral responses associated with psychological stress in humans. Repeated social defeat (RSD) uniquely promotes the convergence of neuronal, central inflammatory (microglial), and peripheral immune (monocyte) pathways, leading to prolonged anxiety, social withdrawal, and cognitive impairment. Moreover, RSD promotes stress sensitization, in which mice are highly sensitive to subthreshold stress exposure and recurrence of anxiety weeks after the cessation of stress. Therefore, the purpose of this Review is to discuss the influence of social-defeat stress on the immune system that may underlie stress sensitization within three key cellular compartments: neurons, microglia, and monocytes. Delineating the mechanisms of stress sensitization is critical in understanding and treating conditions such as PTSD.

Oral cancer patients experience mechanical and chemical sensitivity at the site of the cancer.

INTRODUCTION: Oral cancer patients suffer severe chronic and mechanically-induced pain at the site of the cancer. Our clinical experience is that oral cancer patients report new sensitivity to spicy foods. We hypothesized that in cancer patients, mechanical and chemical sensitivity would be greater when measured at the cancer site compared to a contralateral matched normal site. METHODS: We determined mechanical pain thresholds (MPT) on the right and left sides of the tongue of 11 healthy subjects, and at the cancer and contralateral matched normal site in 11 oral cancer patients in response to von Frey filaments in the range of 0.008 to 300 g (normally not reported as painful). We evaluated chemical sensitivity in 13 healthy subjects and seven cancer patients, who rated spiciness/pain on a visual analog scale in response to exposure to six paper strips impregnated with capsaicin (0-10 mM). RESULTS: Mechanical detection thresholds (MDT) were recorded for healthy subjects, but not MPTs. By contrast, MPTs were measured at the site of the cancer in oral cancer patients (7/11 patients). No MPTs were measured at the cancer patients' contralateral matched normal sites. Measured MPTs were correlated with patients' responses to the University of California Oral Cancer Pain Questionnaire. Capsaicin sensitivity at the site of the cancer was evident in cancer patients by a leftward shift of the cancer site capsaicin dose-response curve compared to that of the patient's contralateral matched normal site. We detected no difference in capsaicin sensitivity on the right and left sides of tongues of healthy subjects. CONCLUSIONS: Mechanical and chemical sensitivity testing was well tolerated by the majority of oral cancer patients. Sensitivity is greater at the site of the cancer than at a contralateral matched normal site.

Microglia Promote Increased Pain Behavior through Enhanced Inflammation in the Spinal Cord during Repeated Social Defeat Stress.

Clinical studies indicate that psychosocial stress contributes to adverse chronic pain outcomes in patients, but it is unclear how this is initiated or amplified by stress. Repeated social defeat (RSD) is a mouse model of psychosocial stress that activates microglia, increases neuroinflammatory signaling, and augments pain and anxiety-like behaviors. We hypothesized that activated microglia within the spinal cord facilitate increased pain sensitivity following RSD. Here we show that mechanical allodynia in male mice was increased with exposure to RSD. This stress-induced behavior corresponded with increased mRNA expression of several inflammatory genes, including IL-1ß, TNF-α, CCL2, and TLR4 in the lumbar spinal cord. While there were several adhesion and chemokine-related genes increased in the lumbar spinal cord after RSD, there was no accumulation of monocytes or neutrophils. Notably, there was evidence of microglial activation selectively within the nociceptive neurocircuitry of the dorsal horn of the lumbar cord. Elimination of microglia using the colony stimulating factor 1 receptor antagonist PLX5622 from the brain and spinal cord prevented the development of mechanical allodynia in RSD-exposed mice. Microglial elimination also attenuated RSD-induced IL-1ß, CCR2, and TLR4 mRNA expression in the lumbar spinal cord. Together, RSD-induced allodynia was associated with microglia-mediated inflammation within the dorsal horn of the lumbar spinal cord.SIGNIFICANCE STATEMENT Mounting evidence indicates that psychological stress contributes to the onset and progression of adverse nociceptive conditions. We show here that repeated social defeat stress causes increased pain sensitivity due to inflammatory signaling within the nociceptive circuits of the spinal cord. Studies here mechanistically tested the role of microglia in the development of pain by stress. Pharmacological ablation of microglia prevented stress-induced pain sensitivity. These findings demonstrate that microglia are critical mediators in the induction of pain conditions by stress. Moreover, these studies provide a proof of principle that microglia can be targeted as a therapeutic strategy to mitigate adverse pain conditions.

Repeated social defeat in female mice induces anxiety-like behavior associated with enhanced myelopoiesis and increased monocyte accumulation in the brain.

Anxiety and mood disorders affect both men and women. The majority of experimental models of stress, however, are completed using only male animals. For repeated social defeat (RSD), a rodent model, this is due to the inherent difficulty in eliciting male aggression toward female mice. To address this limitation, a recent study showed that a DREADD-based activation of the ventrolateral subdivision of the ventromedial hypothalamus (VMHvl) was effective in inducing aggressive behavior in male mice towards females in a social defeat paradigm. Therefore, the goal of this study was to determine if this modified version of RSD in females elicited behavioral, physiological, and immune responses similar to those reported in males. Here, we show that female mice subjected to RSD with the male DREADD aggressor developed anxiety-like behavior and social avoidance. These behavioral alterations coincided with enhanced neuronal and microglial activation in threat-appraisal regions of the brain. Moreover, stressed female mice had an enhanced peripheral immune response characterized by increased myelopoiesis, release of myeloid cells into circulation, and monocyte accumulation in the spleen and brain. These results are consistent with previously reported findings that male mice exposed to RSD exhibited increased fear and threat appraisal responses, enhanced myelopoiesis, myeloid cell release and trafficking, and anxiety-like behavior. These findings validate that RSD is a relevant model to study stress responses in female mice.

Ropivacaine and Bupivacaine prevent increased pain sensitivity without altering neuroimmune activation following repeated social defeat stress.

OBJECTIVE: Mounting evidence indicates that stress influences the experience of pain. Exposure to psychosocial stress disrupts bi-directional communication pathways between the central nervous system and peripheral immune system, and can exacerbate the frequency and severity of pain experienced by stressed subjects. Repeated social defeat (RSD) is a murine model of psychosocial stress that recapitulates the immune and behavioral responses to stress observed in humans, including activation of stress-reactive neurocircuitry and increased pro-inflammatory cytokine production. It is unclear, however, how these stress-induced neuroimmune responses contribute to increased pain sensitivity in mice exposed to RSD. Here we used a technique of regional analgesia with local anesthetics in mice to block the development of mechanical allodynia during RSD. We next investigated the degree to which pain blockade altered stress-induced neuroimmune activation and depressive-like behavior. METHODS: Following development of a mouse model of regional analgesia with discrete sensory blockade over the dorsal-caudal aspect of the spine, C57BL/6 mice were divided into experimental groups and treated with Ropivacaine (0.08%), Liposomal Bupivacaine (0.08%), or Vehicle (0.9% NaCl) prior to exposure to stress. This specific region was selected for analgesia because it is the most frequent location for aggression-associated pain due to biting during RSD. Mechanical allodynia was assessed 12 h after the first, third, and sixth day of RSD after resolution of the sensory blockade. In a separate experiment, social avoidance behavior was determined after the sixth day of RSD. Blood, bone marrow, brain, and spinal cord were collected for immunological analyses after the last day of RSD in both experiments following behavioral assessments. RESULTS: RSD increased mechanical allodynia in an exposure-dependent manner that persisted for at least one week following cessation of the stressor. Mice treated with either Ropivacaine or Liposomal Bupivacaine did not develop mechanical allodynia following exposure to stress, but did develop social avoidance behavior. Neither drug affected stress-induced activation of monocytes in the bone marrow, blood, or brain. Neuroinflammatory responses developed in all treatment groups, as evidenced by elevated IL-1ß mRNA levels in the brain and spinal cord after RSD. CONCLUSIONS: In this study, psychosocial stress was associated with increased pain sensitivity in mice. Development of mechanical allodynia with RSD was blocked by regional analgesia with local anesthetics, Ropivacaine or Liposomal Bupivacaine. Despite blocking mechanical allodynia, these anesthetic interventions did not prevent neuroimmune activation or social avoidance associated with RSD. These data suggest that stress-induced neuroinflammatory changes are not associated with increased sensitivity to pain following RSD. Thus, blocking peripheral nociception was effective in inhibiting enhanced pain signaling without altering stress-induced immune or behavioral responses.

Preoperative Multisensory Room Use in Pediatric Patients With Autism: A Randomized Clinical Trial.

Purpose: To evaluate the impact of multisensory room (MSR) use on preoperative anxiety and postoperative outcomes in children with autism spectrum disorder (ASD) undergoing dental treatment with general anesthesia. Methods: Forty children, ages six to 17 years, with ASD re- quiring general anesthesia for dental treatment, participated in this study. Participants were randomized to either the control group (standard pre- operative waiting room) or intervention group (MSR) for 20 minutes prior to general anesthesia induction. Pre- and post-intervention preoperative anxiety were measured. Following surgery, postoperative emergence delirium was assessed. Short- and long-term postoperative pain and adverse behavioral effects were evaluated six hours, 24 hours, one week, and one month post-surgery. Data analysis employed repeated measures analysis of variance with two groups and either two or four time periods. Results: The sample was predominantly male (62.5 percent) and identified as either White or Black (53 percent) and non-Hispanic (60 percent). Preoperative behavioral anxiety levels increased post-intervention in the control group (P<0.05) and decreased in the MSR group (P<0.001). Following surgery, pain intensity was greater in the control group compared to the MSR group at six hours (P<0.05) and 24 hours (P<0.01), and similar at one and four weeks. Pre- and post-intervention measures of preoperative heart rate, postoperative emergence delirium, and behavioral effects were similar between groups and over time. Conclusion: These findings suggest a novel, nonpharmacologic technique that can be utilized by various health care specialties to reduce preoperative anxiety and improve post- operative outcomes in children with autism spectrum disorder.

Measurement of the Association of Pain with Clinical Characteristics in Oral Cancer Patients at Diagnosis and Prior to Cancer Treatment.

Aim: Oral cancer patients suffer pain at the site of the cancer, which degrades quality of life (QoL). The University of California San Francisco Oral Cancer Pain Questionnaire (UCSFOCPQ), the only validated instrument specifically designed for measuring oral cancer pain, measures the intensity and nature of pain and the level of functional restriction due to pain. Purpose: The aim of this study was to compare pain reported by untreated oral cancer patients on the UCSFOCPQ with pain they reported on the Brief Pain Inventory (BPI), an instrument widely used to evaluate cancer and non-cancer pain. Patients and Methods: The correlation between pain measured by the two instruments and clinical characteristics were analyzed. Thirty newly diagnosed oral cancer patients completed the UCSFOCPQ and the BPI. Results: Pain severity measurements made by the UCSFOCPQ and BPI were concordant; however, the widely used BPI average pain over 24 hours score appeared less sensitive to detect association of oral cancer pain with clinical characteristics of patients prior to treatment (nodal status, depth of invasion, DOI). A BPI average score that includes responses to questions that measure both pain severity and interference with function performs similarly to the UCSFOCPQ in detection of associations with nodal status, pathologic T stage (pT stage), stage and depth of invasion (DOI). Conclusion: Pain assessment instruments that measure sensory and interference dimensions of oral cancer pain correlate with biologic features and clinical behavior.

Provider perspectives on pain management practices and needs in pediatric dentistry.

BACKGROUND: Dental pain is common yet understudied and often undertreated in youth. To improve pain management in pediatric dentistry, it is necessary to understand practices and perceptions among providers. The authors assessed pediatric dentists' use of and attitudes toward evidence-based pain management (EBPM) strategies. METHODS: The authors used a 27-item online survey to assess attitudes about EBPM, pain management and assessment practices, tools for disseminating knowledge about EBPM, and opinions regarding priority areas for improving pain management. Descriptive statistics were used to summarize findings; open-ended items were analyzed thematically. RESULTS: Participants (N = 625) were pediatric dentists (89.2%) and pediatric dentistry residents (10.8%). Most respondents agreed that pain management is an important aspect of clinical care and thought that improvements in pain management practices are needed. Providers reported spending the most time facilitating pain management during the procedure (compared with before or after), and 73.2% said they feel this is an adequate amount of time. Distraction, tell-show-do techniques, and supportive language were the most used nonpharmacologic pain management strategies, and providers' observational approaches were used most frequently for pain assessment. Top priority areas for improving pain management were reported as developing tools for caregivers and provider resources on nonpharmacologic pain management (ie, continuing education courses). CONCLUSIONS: Providers reported high use of EBPM strategies, low use of validated pain assessment tools, and a particular interest for professional development opportunities and patient resources focused on nonpharmacologic pain management. PRACTICAL IMPLICATIONS: Findings from this survey can inform dissemination and implementation of science efforts to improve pain management in pediatric dentistry.

Practice Patterns Among Dentist Anesthesiologists for Pediatric Patients with Autism Spectrum Disorders.

PURPOSE: The purpose of this study was to evaluate practice patterns among dentist anesthesiologists for pediatric patients with autism spectrum disorders (ASD) undergoing sedation for dental procedures. METHODS: An electronic nationwide survey was delivered to all members of the American Society of Dentist Anesthesiologists. The survey assessed provider training and comfort in treating pediatric patients with ASD, perioperative procedures for children with and without ASD, and preferred educational resources for the perioperative management of pediatric patients with ASD. RESULTS: Respondents were 114 dentist anesthesiologists and residents (33.3 percent response rate). Respondents indicated a high comfort level for managing pediatric patients with ASD for sedation (mean equals 91.9±14.74 [SD] percent). The average number of patients with ASD who respondents treat per week was 3.48±2.44). Providers reported making scheduling and staffing accommodations for patients with ASD. More than half of respondents reported no difference between patient groups in medication dosing for sedation and medication regimens used intraoperatively; however, only 43.9 percent of providers indicated using equivalent preoperative medication regimens for both patient groups, and providers reported increased usage of preoperative anxiolytic techniques with patients with ASD. Importantly, 87.7 percent of respondents reported the same incidence of adverse events during the perioperative period between groups. CONCLUSIONS: Findings from this survey suggest there are both similarities and differences in how dentist anesthesiologists practice with pediatric patients with and without autism spectrum disorders. Additional research is warranted to measure the clinical benefits of modified practices for patients with ASD and identify best practices for this vulnerable population.

Auto-Brewery Syndrome and General Anesthesia: A Case Report.

Auto-brewery syndrome (ABS) is a rare condition in which ethanol is endogenously fermented by fungi in the gut following a carbohydrate-rich meal, resulting in intoxication. We present a case of a patient with ABS successfully undergoing general anesthesia for symptomatic wisdom tooth extraction. During previous anesthetics, the patient had experienced postoperative nausea and vomiting (PONV) and awareness under anesthesia. Patients with ABS can be optimized for anesthesia by assessing hepatic function, avoiding perioperative oral carbohydrates, increasing anesthetic depth, multimodal PONV prophylaxis, and avoidance of broad-spectrum antibiotics.

Neuroimmune Interactions in Pain and Stress: An Interdisciplinary Approach.

Mounting evidence indicates that disruptions in bidirectional communication pathways between the central nervous system (CNS) and peripheral immune system underlie the etiology of pathologic pain conditions. The purpose of this review is to focus on the cross-talk between these two systems in mediating nociceptive circuitry under various conditions, including nervous system disorders. Elevated and prolonged proinflammatory signaling in the CNS is argued to play a role in psychiatric illnesses and chronic pain states. Here we review current research on the dynamic interplay between altered nociceptive mechanisms, both peripheral and central, and physiological and behavioral changes associated with CNS disorders.

Cathepsin S Evokes PAR2-Dependent Pain in Oral Squamous Cell Carcinoma Patients and Preclinical Mouse Models.

Oral squamous cell carcinoma (SCC) pain is more prevalent and severe than pain generated by any other form of cancer. We previously showed that protease-activated receptor-2 (PAR2) contributes to oral SCC pain. Cathepsin S is a lysosomal cysteine protease released during injury and disease that can activate PAR2. We report here a role for cathepsin S in PAR2-dependent cancer pain. We report that cathepsin S was more active in human oral SCC than matched normal tissue, and in an orthotopic xenograft tongue cancer model than normal tongue. The multiplex immunolocalization of cathepsin S in human oral cancers suggests that carcinoma and macrophages generate cathepsin S in the oral cancer microenvironment. After cheek or paw injection, cathepsin S evoked nociception in wild-type mice but not in mice lacking PAR2 in Nav1.8-positive neurons (Par2Nav1.8), nor in mice treated with LY3000328 or an endogenous cathepsin S inhibitor (cystatin C). The human oral SCC cell line (HSC-3) with homozygous deletion of the gene for cathepsin S (CTSS) with CRISPR/Cas9 provoked significantly less mechanical allodynia and thermal hyperalgesia, as did those treated with LY3000328, compared to the control cancer mice. Our results indicate that cathepsin S is activated in oral SCC, and that cathepsin S contributes to cancer pain through PAR2 on neurons.

The Influence of Microglial Elimination and Repopulation on Stress Sensitization Induced by Repeated Social Defeat.

BACKGROUND: Stress is associated with an increased prevalence of anxiety and depression. Repeated social defeat (RSD) stress in mice increases the release of monocytes from the bone marrow that are recruited to the brain by microglia. These monocytes enhance inflammatory signaling and augment anxiety. Moreover, RSD promotes stress sensitization, in which exposure to acute stress 24 days after cessation of RSD causes anxiety recurrence. The purpose of this study was to determine whether microglia were critical to stress sensitization and exhibited increased reactivity to subsequent acute stress or immune challenge. METHODS: Mice were exposed to RSD, microglia were eliminated by colony-stimulating factor 1 receptor antagonism (PLX5622) and allowed to repopulate, and responses to acute stress or immune challenge (lipopolysaccharide) were determined 24 days after RSD sensitization. RESULTS: Microglia maintained a unique messenger RNA signature 24 days after RSD. Moreover, elimination of RSD-sensitized microglia prevented monocyte accumulation in the brain and blocked anxiety recurrence following acute stress (24 days). When microglia were eliminated prior to RSD and repopulated and mice were subjected to acute stress, there was monocyte accumulation in the brain and anxiety in RSD-sensitized mice. These responses were unaffected by microglial elimination/repopulation. This may be related to neuronal sensitization that persisted 24 days after RSD. Following immune challenge, there was robust microglial reactivity in RSD-sensitized mice associated with prolonged sickness behavior. Here, microglial elimination/repopulation prevented the amplified immune reactivity ex vivo and in vivo in RSD-sensitized mice. CONCLUSIONS: Microglia and neurons remain sensitized weeks after RSD, and only the immune reactivity component of RSD-sensitized microglia was prevented by elimination/repopulation.