Pain Prevalence in two Italian Hospitals. An observational study.

Introduction: Pain is the most common and distressing medical symptom in hospitalized patients in all wards. Pain prevalence among hospitalized patients is an indicator of the quality of health care. Objective: The aim of this study is to describe pain prevalence in two Italian hospitals. Material and method: This is an observational study. It involved hospitalized patients of both sexes, able and unable to self-report. Descriptive analysis and multivariate analysis were applied. Results: A sample of 754 inpatients were included. In Terni Ho-spital (n = 255), pain prevalence was 80.8%. The mean pain severity was 5.2 (sd ± 3.33). At Rome's San Camillo Hospital (n=499), pain prevalence was 46.9%. Acute pain is more prevalent in women (OR= 0.65; CI 95% 0.43-0.99) and increases with age (OR= 0.97; CI 95% 0.96-0.99). Chronic pain is more prevalent in men (OR= 2.34; CI 95% 1.41-3.97) and increases with age (OR= 1.04; CI 95% 1.03-1.06). Discussion and conclusion.: San Camillo Hospital presents data showing reduced pain prevalence, and describing pain even in patients unable to self-report. It is reasonable to believe that pain control by the staff at San Camillo is better, even though both hospitals are equally important regional institutions.

The potential impact of acute coronary syndromes on automatic sensing system in Subcutaneous-ICDs.

BACKGROUND: The Subcutaneous-ICD (S-ICD) is emerging as a suitable option for most ICD candidates, however some open issues regarding the sensing algorithm still remain. OBJECTIVES: We aimed to examine the performance of the S-ICD sensing algorithm in patients hospitalized for ST elevation myocardial infarction (STEMI), non ST elevation acute coronary syndrome (NSTE-ACS) or chronic coronary syndrome (CCS), before and after revascularization. METHODS: We performed a S-ICD automated screening on 75 patients, 21 hospitalized for STEMI, 23 for NSTE-ACS and 31 for CCS, before and after percutaneous revascularization, regardless their eligibility to ICD implantation. RESULTS: Patients did not differ in clinical, electrocardiographic and echocardiographic parameters. Rates of screening pass were significantly lower in STEMI patients compared to NSTE-ACS and CCS (5% vs 56.7% vs 81% respectively, p < .0001). The viability of the primary vector was lower in STEMI patients compared to NSTE-ACS and CCS (33% vs 56% vs 71%, p .027 respectively). After revascularization, there were no more significant differences between groups. Pairing subjects at baseline and after revascularization, STEMI subjects percentages of screening success were respectively 5% and 81% (p < .001) and the rates of primary vector viability were 33% and 81% (p .002). STEMI was the only independent predictor of screening failure at multivariate logistic regression analysis (odds ratio 10.68 confidence interval 2.77-41.38, p = .001). CONCLUSION: The performance of the S-ICD and possible malfunction detections in the context of an acute ischemic event deserve further evaluation. Adequate patient selection and the development of dynamic device programming are warranted.

Ticagrelor and preconditioning in patients with stable coronary artery disease (TAPER-S): a randomized pilot clinical trial.

BACKGROUND: Ticagrelor is a reversibly binding, direct-acting, oral, P2Y12 antagonist used for the prevention of atherothrombotic events in patients with coronary artery disease (CAD). Ticagrelor blocks adenosine reuptake through the inhibition of equilibrative nucleoside transporter 1 (ENT-1) on erythrocytes and platelets, thereby facilitating adenosine-induced physiological responses such as an increase in coronary blood flow velocity. Meanwhile, adenosine plays an important role in triggering ischemic preconditioning through the activation of the A1 receptor. Therefore, an increase in ticagrelor-enhanced adenosine bioavailability may confer beneficial effects through mechanisms related to preconditioning activation and improvement of coronary microvascular dysfunction. METHODS: To determine whether ticagrelor can trigger ischemic preconditioning and influence microvascular function, we designed this prospective, open-label, pilot study that enrolled patients with stable multivessel CAD requiring staged, fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI). Participants will be randomized in 1:1 ratios either to ticagrelor (loading dose (LD) 180 mg, maintenance dose (MD) 90 mg bid) or to clopidogrel (LD 600 mg, MD 75 mg) from 3 to 1 days before the scheduled PCI. The PCI operators will be blinded to the randomization arm. The primary endpoint is the delta (difference) between ST segment elevations (in millimeters, mm) as assessed by intracoronary electrocardiogram (ECG) during the two-step sequential coronary balloon inflation in the culprit vessel. Secondary endpoints are 1) changes in coronary flow reserve (CFR), index of microvascular resistance (IMR), and FFR measured in the culprit vessel and reference vessel at the end of PCI, and 2) angina score during inflations. This study started in 2018 with the aim of enrolling 100 patients. Based on the rate of negative FFR up to 30% and a drop-out rate up to 10%, we expect to detect an absolute difference of 4 mm among the study arms in the mean change of ST elevation following repeated balloon inflations. All study procedures were reviewed and approved by the Ethical Committee of the Catholic University of Sacred Heart. DISCUSSION: Ticagrelor might improve ischemia tolerance and microvascular function compared to clopidogrel, and these effects might translate to better long-term clinical outcomes. TRIAL REGISTRATION: EudraCT No. 2016-004746-28. No. NCT02701140.  TRIAL STATUS: Information provided in this manuscript refers to the definitive version (n. 3.0) of the study protocol, dated 31 October 2017, and includes all protocol amendments. Recruitment started on 18 September 2018 and is currently ongoing. The enrollment is expected to be completed by the end of 2019. TRIAL SPONSOR: Fondazione Policlinico Universitario A. Gemelli - Roma, Polo di Scienze Cardiovascolari e Toraciche, Largo Agostino Gemelli 8, 00168 Rome, Italy.

Glucocorticoid receptor mRNA expression in peripheral blood mononuclear cells in high trained compared to low trained athletes and untrained subjects.

BACKGROUND: Physiological needs during prolonged exercise are a potent stimulus for the hypothalamic-pituitary-adrenal (HPA) axis. Hence, athletes undergoing daily endurance training sessions may have frequent and prolonged phases of endogenous hypercortisolism. Since chronic glucocorticoids treatment leads to down-regulation of glucocorticoid receptor alpha (GR-alpha) mRNA expression, endurance training could lead to modulation of GR expression. AIM: The aim of the study was to evaluate GR-alpha and GR-beta mRNA expressions in peripheral blood mononuclear cells and plasma cortisol, ACTH and cortisol binding globulin (CBG) concentrations at rest in subjects undergoing different training regimes. SUBJECTS AND METHODS: Nine high trained (HT) swimmers (training volume: 21.6+/-1.7 hours/week in 10-12 sessions) were compared with two age-matched control groups represented by 8 low trained (LT) runners (training volume: 6.4+/-2.6 h/week in 3-5 sessions) and 9 untrained subjects. Expression of GR was determined by RT-PCR of total RNA. Hormone levels were determined by radioimmunoassay methods. RESULTS: HT athletes showed 10 times less GR-alpha mRNA expression than the untrained subjects, while LT athletes exhibited values about twofold less than the untrained subjects. GR-beta mRNA expression was undetectable in all subjects. No differences were observed among the three groups in hormone levels. CONCLUSIONS: GR- alpha mRNA expression is repressed in proportion to the amount and frequency of the stressful stimuli due to training. Hence, this down-regulation may be a consequence of the frequent and prolonged exposure to cortisol acute elevations induced by training. GR-beta did not play an important role in inducing the down-regulation of GR-alpha mRNA expression observed.

Single opioid administration modifies gonadal steroids in both the CNS and plasma of male rats.

While morphine remains one of the most widely used opioids for the treatment of painful conditions, other opioids are also commonly employed. Because of the interactions between opioids and gonadal hormones, in particular opioid-induced hypogonadism, this study investigated the effects of widely used opioids on plasma testosterone and estradiol levels and brain testosterone levels in male rats. Animals were s.c. injected with two concentrations of morphine (5 or 10 mg/kg), fentanyl (0.05 or 0.1 mg/kg), tramadol (10 or 40 mg/kg), buprenorphine (0.05 or 0.1 mg/kg) or saline (0.7 ml/kg). Four or 24 h after treatment, the rats were deeply anesthetized to collect blood samples from the abdominal aorta and to perfuse the brains with saline. Plasma and brain hormone levels were measured by radioimmunoassay. In rats studied 4 h after treatment, all the opioids except tramadol 10 mg/kg decreased plasma testosterone in comparison with saline administration. At the same time, plasma estradiol levels were lower than control in the groups treated with the low doses of morphine, tramadol and buprenorphine, while estradiol remained at control levels in the other groups. Twenty-four hours after treatment, plasma testosterone levels were different (higher) than control in the animals treated with the low doses of morphine, fentanyl and buprenorphine. Estradiol was lower than control in the low dose groups, while the high doses did not produce any changes with respect to control. Four hours after treatment, brain testosterone was drastically decreased in all groups except buprenorphine, in which it remained at control levels. All groups returned to control levels at 24 h after treatment. In conclusion, opioids exert important effects on plasma and CNS sex hormone levels. The different magnitude and time-course of the effects of the different opiates on testosterone and estradiol levels are likely due to their different mechanism of action.

Bisphenol-A differently affects estrogen receptors-alpha in estrous-cycling and lactating female rats.

The effect of long-term exposure to bisphenol-A (BPA) on estrogen receptor-alpha (ER) immunoreactivity was studied in the medial preoptic area, arcuate nucleus and the ventromedial nucleus of the hypothalamus of estrous cycling and lactating female rats. Pregnant/lactating or estrous cycling rats were exposed to BPA (40 mg/Kg/day) or peanut oil. Lactating females showed fewer ER-immunoreactive cells than non-lactating females in the medial preoptic area and ventromedial nucleus of the hypothalamus. BPA induced an increase in ER-immunoreactive cells in the medial preoptic nucleus irrespective of lactation. BPA only induced a decrease in ER-immunoreactive cells in the arcuate nucleus of the lactating group; oil induced an increase in ER-immunoreactive cells in the lactating with respect to non-lactating group. The results demonstrate that exposure of adult females to BPA modifies the number of ERs.

Effects of gonadal hormones and persistent pain on non-spatial working memory in male and female rats.

There are indications of a modulatory role carried out by gonadal hormones and pain in cognitive functions. We have examined this issue in male and female rats by assessing the impact of gonadectomy and persistent pain on the object recognition test. Intact and gonadectomized male and female rats were exposed to an open field (15 min) in which three objects were placed (Trial 1); the same test was repeated 2 h later (Trial 2), after the replacement of a "familiar" object with a novel one. Three days later (Day 2), the same procedure was repeated (Trial 3 and 4 with 2 h in between) but half of the animals were exposed to formalin-injection immediately before Trial 3. The latency, frequency and duration of approaching the three objects were recorded in each trial and compared by sex, gonadectomy and formalin treatment. The results showed that gonadectomized males and females had lower levels of approach to all objects and less locomotor/exploratory activity than intact animals in all experimental trials; their behaviour was not affected by repetition of the test or by pain. On Day 1, intact males showed a higher level of approach to the novel object than females. In intact males, the 2 h delay between the first and second trial failed to induce any significant modification of exploration of the novel object with respect to the familiar one, while in intact females the novel object was approached much less than the familiar one. Similarly on Day 2, the novel object was approached for a longer time by intact males than by all the other groups. In conclusion, our data show that physiological levels of circulating gonadal hormones significantly affected the performance of male but not female rats when exposed to the object recognition test.

Role of gonadal hormones in formalin-induced pain responses of male rats: modulation by estradiol and naloxone administration.

The aim of this study was to assess the possible mediation of endogenous opioids in the effects of gonadal hormones on the responses to formalin pain. We studied the effects of intracerebroventricular injection of estradiol and/or naloxone on the magnitude and time-course of the formalin-evoked behavioural and hormonal responses of intact and gonadectomized male rats. Animals were gonadectomized or left intact; on days 20 and 21 after surgery, they were intracerebroventricularly injected with 17beta-estradiol (1 microg/5 microl) or saline. On day 22, the animals received naloxone (2.5 microg/5 microl) or saline intracerebroventricularly and then, 15 min later, were subcutaneously injected with formalin (50 microl, 5%) or only pricked with a syringe needle in the dorsal hindpaw. The rats were then introduced to a testing apparatus where the formalin-induced licking, flexing and jerking of the injected limb and the other spontaneous behaviours were recorded for 60 min. At the end of the test, the animals were killed and blood was collected from the trunk. Gonadectomy and naloxone increased flexing duration independently of the other treatments. In gonadectomized rats, estrogen increased licking duration and decreased paw-jerk frequency during the first phase (0-15 min) of the formalin test. During the second phase (16-60 min), licking was increased by estrogen only in intact animals. Treatment with naloxone completely abolished all these modifications. The three measures of activity (rearing, inner and outer crossing) showed that while in sham-treated animals the gonadectomy-induced decrease in activity was completely counteracted by estrogen administration, in formalin-treated animals the gonadectomy-induced decrease was not affected by estrogen. In fact, estrogen appeared to further depress the motor activities in the formalin groups. Naloxone reversed these modifications only for outer crossing frequency, blocking the gonadectomy-induced decrease in sham-treated animals. Corticosterone plasma levels were increased by formalin only in estrogen-treated animals, independently of naloxone. In conclusion, these data indicate an important role of both male gonadal hormones and estrogen in formalin-pain responses, acting through opiate and non-opiate mechanisms.

Gonadectomy and persistent pain differently affect hippocampal c-Fos expression in male and female rats.

Hippocampal c-Fos expression was studied in male and female rats after gonadectomy and persistent pain. Three weeks after surgery, animals were sham- or formalin-injected (50 microl, 10%) and placed in a familiar testing apparatus. The formalin-evoked licking, flexing and jerking of the injected paw were recorded for 60 min, c-Fos was determined in the dorsal and ventral hippocampus: dentate gyrus (DG), CA1 and CA3. Gonadectomy induced higher c-Fos in the dorsal DG of both sexes, in all ventral subfields of males and in the ventral CA3 of females. In normal males and females, formalin increased c-Fos in the dorsal DG and in the male ventral subfields. In gonadectomized ones formalin decreased or did not change c-Fos. Gonadectomy induced longer flexing in males and females. These data indicate an important and sex-dependent interaction between gonadal hormones, nociceptive input and neuronal activity in the hippocampus.

Effects of formalin pain on hippocampal c-Fos expression in male and female rats.

Immediate early genes are crucial intermediates in a cascade linking membrane stimulation to long-term alterations of neuronal activity. In the present experiment, we performed immunohistochemistry for c-Fos to determine the effects of persistent pain on cells of the hippocampus of male and female rats. Animals were subcutaneously injected with formalin (50 microl, 10%) and perfused: 2 h later, time 2; 24 h later, time 24; 24 h later after 20 min of the open-field test, time 24/OF. Controls were left undisturbed. In control, c-Fos was higher in females than in males in all hippocampal fields. In males at time 2, formalin increased c-Fos in the dentate gyrus (DG) and CA3 fields; at time 24, c-Fos returned to the control level; at time 24/OF, c-Fos was higher than in control in the DG, but not in the other fields. In the formalin-treated females at time 2 and at time 24, c-Fos levels were lower, or tended to be lower, than in control in all hippocampal fields; at time 24/OF, c-Fos levels in the DG were higher than in control and in males. In conclusion, persistent pain had different effects on c-Fos in the hippocampal subfields, depending on the time after treatment and the sex of the subject.

Disruption and phenotypic analysis of six novel genes from chromosome IV of Saccharomyces cerevisiae reveal YDL060w as an essential gene for vegetative growth.

The disruption of six novel genes (YDL059c, YDL060w, YDL063c, YDL065c, YDL070w and YDL110c), localized on the left arm of chromosome IV in Saccharomyces cerevisiae, is reported. A PCR-based strategy was used to construct disruption cassettes in which the kanMX4 dominant marker was introduced between two long flanking homology regions, homologous to the promoter and terminator sequences of the target gene (Wach et al., 1994). The disruption cassettes were used to generate homologous recombinants in two diploid strains with different genetic backgrounds (FY1679 and CEN. PK2), selecting for geneticin (G418) resistance conferred by the presence of the dominant marker kanMX4. The correctness of the cassette integration was tested by PCR. After sporulation and tetrad analysis of the heterozygous deletant diploids, geneticin-resistant haploids carrying the disrupted allele were isolated. YDL060w was shown to be an essential gene for vegetative growth. A more detailed phenotypic analysis of the non-lethal haploid deletant strains was performed, looking at cell and colony morphology, growth capability on different media at different temperatures, and ability to conjugate. Homozygous deletant diploids were also constructed and tested for sporulation. Only minor differences between parental and mutant strains were found for some deletant haploids.

Functional analysis of the evolutionarily conserved proline 53 residue in Proteus mirabilis glutathione transferase B1-1.

The role of the evolutionarily conserved residue Pro-53 in Proteus mirabilis glutathione transferase B1-1 has been examined by replacing it with a serine residue using site-directed mutagenesis. The effect of the replacement on the activity, thermal stability and antibiotic binding capacity of the enzyme was examined. The results presented support the view that Pro-53 participates in the maintenance of the proper conformation of the enzyme fold rather than playing a direct role in the catalytic reaction. Furthermore, this residue appears to be an important determinant of the antibiotic binding to the enzyme. Experiments with wild type and mutated enzymes provide evidence that glutathione transferases may play an important role in antibiotic resistance exhibited by bacteria.

Effects of novelty and pain on behavior and hippocampal extracellular ACh levels in male and female rats.

In vivo microdialysis was used to assess the effects of novelty and pain on hippocampal ACh release in male and female rats. Experiments were carried out during the dark phase and consisted of 2 days of tests: on Day 1, after Baseline 1, animals were exposed to a new cage (Novelty) to which, 30 min later, a plastic cylinder (Object) was introduced. On Day 2, after Baseline 2, the Formalin test (50 microl of formalin 10%, s.c. injected in the dorsal hindpaw) was carried out in the animal's home cage. All behaviors were recorded. The extracellular levels of ACh in the dorsal hippocampus were estimated, in 10-min samples, by assay of ACh in the dialysates by HPLC. On Day 1 the raw values of ACh were higher in females than in males, but no sex difference was present when the percentage of change was considered. In both sexes the Novelty and Object tests induced an increase in ACh levels with respect to Baseline. Higher levels of exploration were present in females than males during the first 10 min of Novelty. On Day 2, ACh release increased in both sexes during the Formalin test. No sex difference in either ACh raw values or the percentages of change were found. Females showed higher levels of licking and lower levels of activity than males. The present study shows that novelty and pain induce similar hippocampal cholinergic activation in male and female rats but different behaviors. The results are discussed in light of the several anatomical and functional sex differences present in the hippocampus.

Behavioural and hormonal effects of restraint stress and formalin test in male and female rats.

The formalin test was used to measure the analgesia induced by restraint in male and female rats. Animals were restrained for 30 min or left undisturbed in their cage and then (1) killed immediately to collect blood for hormonal determinations; or (2) subcutaneously injected with formalin in the hind paw (or sham-injected), introduced to an open field for recording of behaviour, and killed at the end of this procedure. In both experiments, corticosterone was found to be higher in females. In Experiment 1, the ability of restraint to be stressful was confirmed by the increase in corticosterone in both sexes and by the decrease of testosterone in males. In Experiment 2, restraint-treatment induced a reduction in licking and flexing that was limited to the second phase. The reduction occurred in different periods and to a different degree in the two sexes; it was greater in females. Spontaneous behaviours showed sex differences in restraint-treated but not in formalin-treated animals. The results show that the hormonal effects observed after restraint are not present after the formalin test and that the marked analgesia observed with phasic painful stimuli does not occur with a longer-lasting one such as that induced by formalin, after which only partial and short-lasting effects were observed.

Serotonergic modulation of acetylcholine release from cortex of freely moving rats.

The modulation of acetylcholine (ACh) release by 5-HT3 receptor activation was studied using in vivo microdialysis. Spontaneous and K+-stimulated ACh release were measured in frontoparietal cortex and hippocampus of freely moving rats. Two consecutive exposures to high K+ produced ACh release of similar magnitude. In the cortex, serotonin (5-HT) failed to alter spontaneous ACh release, but caused a concentration-dependent decrease of K+-evoked ACh release. Phenylbiguanide (PBG) and m-chlorophenylbiguanide, two selective 5-HT3 agonists, mimicked the 5-HT responses, but 8-hydroxy-2-(di-n-propylamino)tetralin, a selective 5-HT1A agonist, was without effect. However, PBG failed to modify K+-evoked ACh release from the hippocampus. Systemic and local administration of a highly selective 5-HT3 antagonist, tropisetron ((3-alpha-tropanyl)1H-indole-carboxylic acid ester) blocked the effect of both 5-HT and PBG. The inhibition of ACh release by PBG was sensitive to tetrodotoxin. These observations provide direct evidence that, in rat cortex, 5-HT modulates in-vivo release of ACh through activation of 5-HT3 receptors.

Site-directed mutagenesis of the Proteus mirabilis glutathione transferase B1-1 G-site.

In order to investigate the roles of near N-terminus Tyr, Cys, and Ser residues in the activity of bacterial glutathione transferase (GSTB1-1) site-directed mutagenesis was used to replace the following residues: Tyr-4, Tyr-5, Ser-9, Cys-10, Ser-11, and Ser-13. The results presented here show that, unlike all other alpha, mu, pi, theta and sigma classes of glutathione transferases so far investigated, GSTB1-1 does not utilise any Tyr, Ser or Cys residue to activate glutathione. These results also suggest that the bacterial glutathione transferases may require classification into their own class.