Caring for patients with pain during the COVID-19 pandemic: consensus recommendations from an international expert panel.

Chronic pain causes significant suffering, limitation of daily activities and reduced quality of life. Infection from COVID-19 is responsible for an ongoing pandemic that causes severe acute respiratory syndrome, leading to systemic complications and death. Led by the World Health Organization, healthcare systems across the world are engaged in limiting the spread of infection. As a result, all elective surgical procedures, outpatient procedures and patient visits, including pain management services, have been postponed or cancelled. This has affected the care of chronic pain patients. Most are elderly with multiple comorbidities, which puts them at risk of COVID-19 infection. Important considerations that need to be recognised during this pandemic for chronic pain patients include: ensuring continuity of care and pain medications, especially opioids; use of telemedicine; maintaining biopsychosocial management; use of anti-inflammatory drugs; use of steroids; and prioritising necessary procedural visits. There are no guidelines to inform physicians and healthcare providers engaged in caring for patients with pain during this period of crisis. We assembled an expert panel of pain physicians, psychologists and researchers from North America and Europe to formulate recommendations to guide practice. As the COVID-19 situation continues to evolve rapidly, these recommendations are based on the best available evidence and expert opinion at this present time and may need adapting to local workplace policies.

Ultrasound-guided approach to nerves (direct vs. tangential) and the incidence of intraneural injection: a cadaveric study.

This study evaluated the incidence of nerve puncture and intraneural injection based on the needle approach to the nerve (direct vs. tangential). Two expert operators in regional anaesthesia performed in-plane ultrasound-guided nerve blocks (n = 158) at different levels of the brachial plexus in cadavers, aiming either directly for the nerve (n = 77) or tangentially inferior to the nerve (n = 81). After reaching the outer limit of the nerve, the needle was intentionally advanced approximately 1 mm in both approaches, and 0.2-0.5 ml of saline was injected. Each operator classified (in real time) the needle tip and injectate as intraneural or not. Video clips showing the final position of the needle and the injection were evaluated in the same manner by seven independent expert observers who were blinded to the aims of this study. In addition, 20 injections were performed with ink for histological evaluation. Intraneural injections of saline were observed by the operator in 58% (45/77) of cases using the direct approach and 12% (10/81) of cases using the tangential approach (p < 0.001). The independent observers agreed with the operator in a substantial number of cases (Cohen's kappa index 0.65). Histological studies showed intraneural spread in 83% (5/6) of cases using the direct approach and in 14% (2/14) of cases using the tangential approach (p = 0.007). No intrafascicular injections were observed. There was good agreement between the operators' assessment and subsequent histological evaluation (Cohen's kappa = 0.89). Simulation of an unintentional/accidental advancement of the needle 'beyond the edge' of the nerve suggests significantly increased risk of epineural perforation and intraneural injection when a direct approach to the nerve is used, compared with a tangential approach.

Babesia divergens apical membrane antigen-1 (BdAMA-1): A poorly polymorphic protein that induces a weak and late immune response.

Babesiosis is an important veterinary and zoonotic tick borne disease caused by the hemoprotozoan Babesia spp. which infects red blood cell of its vertebrate host. In order to control the infection, vaccination that targets molecules involved in the invasion process of red blood cells could provide a good alternative to chemotherapy. Among these molecules, Apical Membrane Antigen-1 (AMA-1) has been described as an excellent vaccine candidate in Plasmodium spp. In this paper, we have investigated AMA-1 of Babesia divergens (BdAMA-1) as vaccine candidate by evaluating its polymorphism and by studying the humoral response against BdAMA-1 of sheep experimentally infected with B. divergens. Polymorphism of BdAMA-1 was investigated by sequencing the corresponding gene of 9 B. divergens isolates from different geographical areas in France. Two Bdama-1 haplotypes (A and B) could be defined based on 2 non-synonymous point mutations. In silico prediction of linear epitopes revealed that the antigenicity of the 2 haplotypes is very similar. Antibody production against the extracellular domain of BdAMA-1 is weak and late, between 1 and 5 months after the inoculation of parasites. Both IgG1 and IgG2 are components of the anti-BdAMA-1 response. These results indicate that while BdAMA-1 may not be an immuno-dominant antigen, it could induce a mixed type 1 and type 2 immune response. In light of these results, the potential of BdAMA-1 as vaccine candidate is discussed.

Rescuing the obese or burned airway: are conventional training manikins adequate? A simulation study.

BACKGROUND: Percutaneous tracheal access is required in more than 40% of major airway emergencies, and rates of failure are high among anaesthetists. Supraglottic airway management is more likely to fail in patients with obesity or neck pathology. Commercially available manikins may aid training. In this study, we modified a standard 'front of neck' manikin and evaluated anaesthetists' performance of percutaneous tracheal access. METHODS: Two cricothyroidotomy training manikins were modified using sections of belly pork to simulate a morbidly obese patient and an obese patient with neck burns. An unmodified manikin was used to simulate a slim patient. Twenty consultant anaesthetists were asked to manage a 'can't intubate, can't ventilate' scenario involving each of the three manikins. Outcome measures were success using their chosen technique and time to first effective breath. RESULTS: Success rates using first-choice equipment were: 'slim' manikin 100%, 'morbidly obese' manikin 60%, and 'burned obese' manikin 77%. All attempts on the 'slim' manikin succeeded within 240 s, the majority within 120 s. In attempts on the 'morbidly obese' manikin, 60% succeeded within 240 s and 20% required more than 720 s. All attempts on the 'burned obese' manikin succeeded within 180 s. CONCLUSIONS: Significantly greater technical difficulty was experienced with our 'morbidly obese' manikin compared with the unmodified manikin. Failure rates and times to completion were considerably more consistent with real-life reports. Modifying a standard manikin to simulate an obese patient is likely to better prepare anaesthetists for this challenging situation. Development of a commercial manikin with such properties would be of value.

Cloning and characterization of a new asparagine-rich protein in Plasmodium falciparum.

A cDNA clone that encodes a Plasmodium falciparum asparagine (N)-rich protein (PfARP) was isolated through immunoscreening of an expression library. A 9.4 kb PfARP transcript was identified by Northern blot hybridization and the gene was localized on chromosome 1. The complete coding sequence (6666 bp) revealed a protein that contains clustered as well as randomly distributed N residues (24.3%), seven copies of a repeat sequence [DNT(D/N)(K/N)(V/L/M)] and multiple copies of tripeptide repeats within a 101 amino acid region containing 89 D/E residues. The PfARP was immunogenic in inbred and outbred mice and endemic sera revealed the presence of low-titer antibodies against PfARP. Anti-PfARP sera showed cytoplasmic and surface localization of apparently cross-reactive malarial antigens in different life-cycle stages (ring, trophozoite, schizont, and gametocytes). Although the biological function(s) of PfARP are not known, the observation that it is present in multiple parasite stages and that it is a target of natural immune response warrants further study of PfARP as an immune target.

Differential transcription of histone genes in asexual and sexual stages of Plasmodium falciparum.

Molecular mechanisms of cell-cycle control in Plasmodium falciparum remain poorly understood. We have traced transcription of histones H2A, H2B and H3 as the parasite progresses through different developmental stages--rings, trophozoites, schizonts and gametocytes. Our results show that the ring stage parasites do not appear to synthesise any of the three histones. We also found a markedly elevated level of H3 transcript in the schizont stage parasite, while H2A and H2B were made in approximately equivalent amounts (in trophozoites, schizonts and garnetocytes). Further study might lead to a better understanding of the control elements involved in the regulation of histone levels in Plasmodium as it develops in the erythrocyte.

Disruption of the Pfg27 locus by homologous recombination leads to loss of the sexual phenotype in P. falciparum.

Transmission of malaria depends upon the differentiation and development of the sexual stages of the parasite. In Plasmodium falciparum, it is a complex, multistage process, involving the expression of a large number of sexual stage-specific proteins. Pfg27 is one such protein, abundantly expressed at the onset of gametocytogenesis. We report successful disruption of the Pfg27 locus using homologous recombination and show that it is essential for the maintenance of the sexual phenotype. Transfectants lacking Pfg27 abort early in sexual development, resulting in vacuolated, highly disarranged, and disintegrating parasites. This suggests a critical role for Pfg27 in the sexual development of the parasite.

Immunization of mice with DNA-based Pfs25 elicits potent malaria transmission-blocking antibodies.

Immunological intervention, in addition to vector control and malaria chemotherapy, will be needed to stop the resurgence of malaria, a disease with a devastating impact on the health of 300 to 500 million people annually. We have pursued a vaccination strategy, based on DNA immunization in mice with genes encoding two antigens present on the sexual stages of Plasmodium falciparum, Pfs25 and Pfg27, to induce biologically important antibodies that can block development of the parasite in the Anopheles mosquito and thus transmission of the disease. DNA encoding Pfs25 when administered by the intramuscular route, either alone or with DNA encoding Pfg27, had the most potent transmission-blocking effects, resulting in up to a 97% decrease in oocyst numbers in mosquito midguts and a 75% decrease in rate of infection. Immunization with DNA encoding a Pfg27-Pfs25 fusion protein was less effective and DNA encoding Pfg27 elicited antibodies in sera that had only modest effects on the infectivity of the parasite. These results show for the first time that DNA vaccination can result in potent transmission-blocking antibodies in mice and suggest that the Pfs25 gene should be included as part of a multicomponent DNA vaccine.

Sexual differentiation and development in the malaria parasite.

The protozoan parasites belonging to the genus Plasmodium have a complex life cycle in which the asexual multiplication of parasites in the vertebrate host alternates with an obligate sexual reproduction in the mosquito. Gametocytes (male and female) produced in the vertebrate host are responsible for transmitting parasites to mosquitoes. Although our understanding of the biology and genetics of sexual differentiation in Plasmodium is expanding, the most basic questions concerning molecular mechanisms of sexual differentiation and sex determination still remain unanswered. Recently, insight into the control of this complex process in P. falciparum and P. berghei has come from studying parasite mutants with aberrant capacities for gametocyte production. Here, Cheryl-Ann Lobo and Nirbhay Kumar review these analyses in P. falciparum.

Novel proteins of Plasmodium falciparum identified by differential immunoscreening using immune and patient sera.

A differential serological screen of a lambda gt11 cDNA expression library of Plasmodium falciparum was performed in an attempt to identify novel and putative host-protective antigens of the parasite. The screening was done with two categories of sera: (i) acute-phase sera obtained from smear-positive acutely infected P. falciparum patients from various regions in India and (ii) immune sera taken from healthy, permanent adult residents of P. falciparum-endemic rural districts of Orissa in eastern India. These adults had not suffered from any clinical malarial symptoms for at least the previous 3 years at the time of serum collection. Sixty-five clones obtained by screening the lambda gt11 library with two immune serum samples were analyzed extensively with a total of 70 acutely infected patient serum samples. Eight of these clones failed to react with any of the patient sera. Each of these eight clones, when tested individually with 92 serum samples from the immune group, reacted with a minimum of 43% of the samples from this category of sera. Thus, these eight epitopes may encode host-protective elements since they are not recognized by antibodies in the patient sera but react exclusively and extensively with the clinically immune set. Sequence analysis of two of these clones reveals that they are novel Plasmodium genes.

Complement-fixation analysis of four subtypes of foot-and-mouth disease virus type A.

Complement-fixation patterns were established for four subtypes of foot-and-mouth disease virus by block assays against homologous and heterologous antiserum. Inhibition of fixation by excess antigen was observed in most homologous systems but rarely in the heterologous systems. The heterologous antibody titers were, in all instances, considerably lower than those for the homologous systems. Although relatively high dilutions of antiserum may be desirable for subtyping, higher concentrations of antibody should be used for determining serological types.