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.

Cryotherapy after Total Knee Arthroplasty provides faster recovery and better ranges of motion in short term follow up. Results of a prospective comparative study.

Cryotherapy is applied in Total Knee Arthroplasty (TKA) to improve functional outcome. The aim of this study is to investigate whether an advanced cryotherapy device does not increase the risk of complications and improves knee function or decreases swelling. A prospective cohort of TKA patients was formed by a cryotherapy group and a control group. The primary outcome was complication ratio. Our secondary outcomes were functional results and swelling. No significant differences were found in complication ratio between 31 patients in the cryotherapy group and 31 patients in the control group. The cryotherapy group showed a significant better knee flexion and less swelling in the early rehabilitation phase. No differences were found at the other follow-up moments or in the other outcomes. This advanced cryotherapy device is safe in respect of postoperative complications, improves knee function and decreases swelling in the early rehabilitation phase. However, it is questionable if an advanced cryotherapy device with its additional costs is necessary to provide the desired effects of cryotherapy.

Increasing the throughput of label-free cell assays to study the activation of G-protein-coupled receptors by using a serial agonist exposure protocol.

Label-free, holistic assays, monitoring, for example, the impedance of cells on electrodes, are gaining increasing popularity in the evaluation of G-protein-coupled receptor (GPCR) ligands. It is the strength of these approaches to provide the integrated cellular response non-invasively, highly automated and with a device-dependent time resolution down to several milliseconds. With an increasing number of samples to be studied in parallel, the available time resolution is, however, reduced and the cost for the disposable sensor arrays may become limiting. Inspired by protocols from organ pharmacology, we investigated a simple serial agonist addition assay that circumvents these limitations in impedance-based cellular assays. Using a serial addition of increasing concentrations of a GPCR agonist while continuously monitoring the sample's impedance, we were able to establish a full concentration-response curve for the endogenous agonist histamine on a single layer of U-373 MG cells endogenously expressing the histamine 1 receptor (H1R). This approach is validated with respect to conventional, parallel agonist addition protocols and studies using H1R antagonists such as mepyramine. Applicability of the serial agonist addition assay was shown for other GPCRs known for their signaling via one of the canonical G-protein pathways, Gq, Gi/0 or Gs as well. The serial agonist addition protocol has the potential to further strengthen the output of label-free analysis of GPCR activation.

Label-free versus conventional cellular assays: Functional investigations on the human histamine H1 receptor.

A set of histamine H1 receptor (H1R) agonists and antagonists was characterized in functional assays, using dynamic mass redistribution (DMR), electric cell-substrate impedance sensing (ECIS) and various signaling pathway specific readouts (Fura-2 and aequorin calcium assays, arrestin recruitment (luciferase fragment complementation) assay, luciferase gene reporter assay). Data were gained from genetically engineered HEK293T cells and compared with reference data from GTPase assays and radioligand binding. Histamine and the other H1R agonists gave different assay-related pEC50 values, however, the order of potency was maintained. In the luciferase fragment complementation assay, the H1R preferred ß-arrestin2 over ß-arrestin1. The calcium and the impedimetric assay depended on Gq coupling of the H1R, as demonstrated by complete inhibition of the histamine-induced signals in the presence of the Gq inhibitor FR900359 (UBO-QIC). Whereas partial inhibition by FR900359 was observed in DMR and the gene reporter assay, pertussis toxin substantially decreased the response in DMR, but increased the luciferase signal, reflecting the contribution of both, Gq and Gi, to signaling in these assays. For antagonists, the results from DMR were essentially compatible with those from conventional readouts, whereas the impedance-based data revealed a trend towards higher pKb values. ECIS and calcium assays apparently only reflect Gq signaling, whereas DMR and gene reporter assays appear to integrate both, Gq and Gi mediated signaling. The results confirm the value of the label-free methods, DMR and ECIS, for the characterization of H1R ligands. Both noninvasive techniques are complementary to each other, but cannot fully replace reductionist signaling pathway focused assays.

Pathogenesis of varroosis at the level of the honey bee (Apis mellifera) colony.

The parasitic mite Varroa destructor, in interaction with different viruses, is the main cause of honey bee colony mortality in most parts of the world. Here we studied how effects of individual-level parasitization are reflected by the bee colony as a whole. We measured disease progression in an apiary of 24 hives with differing degree of mite infestation, and investigated its relationship to 28 biometrical, physiological and biochemical indicators. In early summer, when the most heavily infested colonies already showed reduced growth, an elevated ratio of brood to bees, as well as a strong presence of phenoloxidase/prophenoloxidase in hive bees were found to be predictors of the time of colony collapse. One month later, the learning performance of worker bees as well as the activity of glucose oxidase measured from head extracts were significantly linked to the timing of colony collapse. Colonies at the brink of collapse were characterized by reduced weight of winter bees and a strong increase in their relative body water content. Our data confirm the importance of the immune system, known from studies of individually-infested bees, for the pathogenesis of varroosis at colony level. However, they also show that single-bee effects cannot always be extrapolated to the colony as a whole. This fact, together with the prominent role of colony-level factors like the ratio between brood and bees for disease progression, stress the importance of the superorganismal dimension of Varroa research.

Label-free analysis of GPCR-stimulation: The critical impact of cell adhesion.

Label-free cell-based assays have been attracting growing attention in drug research. Optical approaches based on evanescent electric fields (e.g. EPIC, RWG/DMR, SPR) and electrochemical impedance analysis (ECIS, xCELLigence) are by far the most widespread techniques for such purposes. We compared three label-free approaches (ECIS, RWG/DMR and SPR) with respect to the activation of the human histamine H1 receptor (H1R) expressed by U-373 MG glioblastoma and genetically engineered HEK 293T cells. HEK 293T cells were either expressing the hH1R alone or in combination with the adhesion protein hMSR1. The ß2-adrenergic receptor (ß2-AR) expressed by bovine aortic endothelial cells (BAEC) served as a second cell model. Reduced cell adhesion to the surface of the sensing devices affected both, the optical and the impedance-based readout, but became much more obvious in case of RWG- or SPR-based assays. By contrast, the co-expression of hH1R and hMSR1 in HEK 293T cells strongly enhanced the signal compared to hH1R expression alone. As the sensitivity of the optical readouts is confined to a distance of 100-200nm from the surface, depending on the wavelength of the incident light, this observation is in accordance with tighter adhesion of the co-transfectants, inducing a shorter distance between the cell membrane and the substrate. Combining ECIS and SPR, allowing for simultaneous registration of both signals for a single cell population, provided a direct correlation of both readouts, when H1R or ß2-AR stimulation was investigated for the same cell populations. Cell adhesion was found to have a critical impact on the results of label-free cell monitoring, in particular when techniques based on evanescent electric fields are applied.

Changes of murine sperm phospholipid composition during epididymal maturation determined by MALDI-TOF mass spectrometry.

After leaving the testis, spermatozoa undergo several important steps of biochemical maturation during the passage through the epididymis, increasing their motility and fertilizing ability. These changes comprise (among others) the modification of the phospholipid composition of the sperm membrane. This process is thought to be important for the achievement of motility and fertilizing capacity. The lipids of the sperm membrane are characterized by a significant content of unsaturated fatty acyl residues, resulting in a high sensitivity against oxidative stress. This is evidenced by the appearance of lysolipids, for example, lysophosphatidylcholine, which acts like a detergent and is normally present in only very small amounts in biological membranes. The epididymis represents a tubular system comprising three main parts (caput, corpus, and cauda), through which the spermatozoa are consecutively transported undergoing distinct maturation stages. Using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry, we established three striking differences in the lipid composition of murine spermatozoa from the different epididymal regions: in comparison to the caput sperm, sperm from the cauda are characterized by (1) a higher degree of unsaturation (PC 18:0/22:5 and 18:0/22:6 vs. 18:0/20:4 and 18:0/18:1), (2) an enhanced plasmalogen content, and (3) an enhanced content of lysolipids. These changes are likely to be of physiological relevance and potentially useful as diagnostic markers of sperm maturation and acquisition of motility.

Label-free monitoring of cell-based assays: combining impedance analysis with SPR for multiparametric cell profiling.

Label-free approaches to monitor cell-based assays provide an unprecedented, time-resolved and non-invasive view on the response of mammalian cells to chemical, biological or physical stimuli. The most widespread techniques are impedance analysis and optical sensing using evanescent waves like SPR. This study describes the combination of both in one experimental setup so that a given cell population can be monitored simultaneously for electrical and optical changes. The device is based on commercial SPR chips that are processed by photolithography to provide electrodes for impedance analysis and gold spots for surface plasmon excitation on the same substrate. Simultaneous recordings do not interfere with each other but provide independent, time-resolved information on cell shape changes (impedance) and dynamic mass redistribution (SPR) as they occur during exposure of the cells to drugs or toxins or along their normal life cycle. This study provides proof-of-concept experiments of the dual biosensor platform in two experimental settings: signals are recorded and analyzed (i) during cell attachment, spreading and differentiation of initially suspended cells and (ii) during the exposure of the mature cells to an actin cytoskeleton disrupting drug. Impedance and SPR recordings provide complementary information that can be used to trace and assign intracellular mechanisms of action.

Real-time label-free monitoring of the cellular response to osmotic stress using conventional and long-range surface plasmons.

Cell volume and its regulation are key factors for cellular integrity and also serve as indicators of various cell pathologies. SPR sensors represent an efficient tool for real-time and label-free observations of changes in cell volume and shape. Here, we extend this concept by employing the use of long-range surface plasmons (LRSP). Due to the enhanced penetration depth of LRSP (~1µm, compared to ~0.4µm of a conventional surface plasmon), the observation of refractive index changes occurring deeper inside the cells is possible. In this work, the responses of a confluent normal rat kidney (NRK) epithelial cell layer to osmotic stress are studied by both conventional and long-range surface plasmons. Experiments are conducted in parallel using cell layers grown and stimulated under the same conditions to enable direct comparison of the results and discrimination of the osmotic stress-induced effects in different parts of the cell.

Toxicity of cryoprotectants to honey bee semen and queens.

Given the threats to the intraspecific biodiversity of Apis mellifera and the pressure on bee breeding to come up with disease-tolerant lines, techniques to cryopreserve drone semen are of great interest. Freeze-thawed drone semen of high viability and/or motility has repeatedly been obtained, but fertility of such semen, when it was measured, was always low. The cryoprotective agent (CPA) most frequently used with drone semen is dimethyl sulfoxide (DMSO), although this substance has been suspected of causing genetic damage in sperm. No form of sperm washing is currently performed. Using a membrane permeability assay, we measured the short-term toxicity of four possible replacements for DMSO, 1,3-propane diol, 2,3-butane diol, ethylene glycol, and dimethyl formamide. We also tested whether the practice of inseminating queens with CPA-containing semen affects sperm numbers in the storage organs of queens, or sperm fertility. Finally, we tested whether CPA-toxicity in vivo can be reduced by using mixtures of two CPAs, DMSO, and ethylene glycol. Our results show that, although short-term toxicity of all CPAs tested was low, the presence of single CPAs in insemination mixtures at concentrations required for slow freezing greatly reduced the number of sperm reaching the spermatheca. Contrary to earlier reports, this was also true for DMSO. Ethylene glycol was additionally shown to reduce the viability of spermatozoa reaching the storage organ. Mixtures of DMSO and EthGly performed better than either substance used singly at the same concentration. We conclude that the toxicity of CPAs, including DMSO, on honey bee semen and/or queens has been underestimated in the past. This could partly explain the discrepancy between in vitro and in vivo quality of cryopreserved drone semen, described by others. Combinations of several CPAs and techniques to partly remove CPAs after thawing could help to solve this problem.

Comparison of percutaneous electrical nerve stimulation and ultrasound imaging for nerve localization.

BACKGROUND: Percutaneous nerve stimulation (PNS) is a non-invasive technique to localize superficial nerves before performing peripheral nerve blocks, but its precision has never been evaluated by high-resolution ultrasound. This study compared stimulating points at the skin with the position of nerve structures determined by ultrasound. Correlations between distances and percutaneous stimulation thresholds were determined. METHODS: PNS was performed in 20 healthy volunteers systematically with a stimulating pen at the neck after attaching a transparent film with 49 (7×7) perforations. Stimulation thresholds were measured and impedance was controlled. Thereafter, an independent observer measured the depth (D) of the most superficial nerve structure with ultrasound. Distances between stimulating points and the most superficial nerve structure (S) were measured. Correlations between associated stimulating thresholds and distances D and S were calculated. RESULTS: The stimulating point with the lowest current was identical to the point closest to the nerve in only 10% of measurements. Median S was 12.6 (3.4-32.0) mm and D 7.6 (0.3-28.6) mm. Distances did not correlate with percutaneous stimulation thresholds. CONCLUSION: PNS with a stimulating pen is not a reliable technique for nerve localization in the brachial plexus as verified by high-resolution ultrasound.

Label-free and time-resolved measurements of cell volume changes by surface plasmon resonance (SPR) spectroscopy.

Cell volume and its regulation is one of the key players for cellular integrity and a strong indicator for several cell pathologies. But time-resolved volume measurements of adherently grown mammalian cells using established methods, such as extracellular impedance analysis or light microscopy, are complex and time-consuming. In this study, we demonstrate that surface plasmon resonance spectroscopy (SPR) is a powerful transducer device capable of reporting volume changes of cells that are directly grown on the SPR sensor surface. The approach is label-free, non-invasive and provides an outstanding time resolution. In proof-of-principle studies we recorded the volume change of confluent MDCK II cells induced by hypo- or hypertonic stimulation in a time-resolved manner. Comparison of the SPR-based experiments reported here with more recent studies using different approaches suggests a direct correlation between SPR signal shift and cell volume changes.

Functional rehabilitation of mandibular continuity defects using autologous bone and dental implants - prognostic value of bone origin, radiation therapy and implant dimensions.

AIM: The aim of this retrospective study was to investigate prognostic parameters for the rehabilitation of mandibular continuity defects with free autologous bone and dental implants for patients after intraoral squamous cell carcinoma. METHODS: Following potential prognostic factors for implant survival were analyzed: bony bed (local bone versus augmented iliac crest bone), radiation dose (no radiation, <50 Gy, >or=50 Gy) and implant dimensions. Kaplan-Meier survival estimates of the inserted implants were performed. RESULTS: After 5 years, the cumulative survival rate of all investigated implants was 82.6%. Dental implantation into augmented bone resulted in a significantly lower survival rate (78.4%), compared to original local bone (92.8%). Modifications of implant dimensions as well as radiation therapy showed no significant impact on implant survival. CONCLUSION: For the investigated compromised collective, our results reveal a satisfactory long-term survival rate of dental implants even in augmented bone and underline the value of dental implantation for the functional rehabilitation of cancer patients.

United Nations Environment Programme Capacity Building Pilot Project--training and interlaboratory study on persistent organic pollutant analysis under the Stockholm Convention.

Within the framework of a United Nations Environment Programme (UNEP) Capacity Building Project for training of laboratory staff in developing countries on persistent organic pollutant (POP) analysis, an interlaboratory study was organised following an initial evaluation of the performance of laboratories (reality check) and a series of training sessions. The target compounds were polychlorinated biphenyls (PCB) and organochlorine pesticides (OCP). Seven laboratories from five countries (Ecuador, Uruguay, Kenya, Moldova, and Fiji) participated. Most of the laboratories had no experience in determining PCBs. Although chromatograms improved considerably after the training and installation of new gas chromatographic (GC) columns at participating laboratories, the level of performance in the interlaboratory study was essentially on par with the moderate performance level achieved by European POP laboratories in the 1980s. Only some individual results were within +/-20% of the target values. The relative standard deviations (R.S.D.s) in POP concentrations determined by laboratories in a sediment sample were >200% in a number of cases. The results for a certified herring sample were better with at least some R.S.D. values below 50% and most below 100%. Clean up was as one of the main sources of error. After inspection it was ascertained that training of laboratory staff and investments in simple consumables such as glassware and GC columns would help to improve the quality of the analysis more than major investments in expensive instrumentation. Creating an effective network of POP laboratories at different continents together with a series of interlaboratory studies and workshops is suggested to improve the measurements of POPs in these countries.

Analysis of calcium channels by conditional mutagenesis.

Ca2+ influx through various ion channels is an important determinant of the cytosolic Ca2+ concentration, which plays a pivotal role in countless cellular processes. The cardiac L-type Ca2+ channel, Ca(v)1.2, represents a major pathway for Ca2+ entry and is in many cells expressed together with other high- and low-voltage-activated Ca2+ channels. This article will focus on the use of conditional transgenic mouse models to clarify the roles of Ca2+ channels in several biological systems. The phenotypes of conditional Ca2+ channel transgenic mice have provided novel, and often unexpected, insights into the in vivo function of L-type and T-type Ca2+ channels as mediators of signaling between cell membrane and intracellular processes in blood pressure regulation, smooth muscle contractility, insulin secretion, cardiac function, sleep, learning, and memory.

Distribution of organotin compounds in the bivalves of the Aegean Sea, Greece.

Five bivalve species--Mytilus galloprovinciallis (Mediterranean mussels), Venus gallina (stripped venus), Modiola barbatus L. (bearded horse mussels), Pecten jacobeus (scallops) and Callista chione (hard clams)--were collected from seven areas in Aegean Sea, Greece, between August 2001 and January 2003 and analyzed for organotins (OTs). The concentrations (as geometric means) found were 17.1 ng g-1 for tributyltin (TBT), 18.8 ng g-1 for dibutytltin (DBT), 7.8 ng g-1 for monobutyltin (MBT) and 13.0 ng g-1 for triphenyltin (TPhT) (wet weight), which are at similar or lower levels than those reported worldwide. Studying OTs distribution between different bivalve species, lower concentrations were observed in mediterranean mussels, possibly due to their growth in water column (grown on sea net pens in mussel farms), in contrast to the free-ranging species, collected from fishing grounds. Concentrations of the OTs in the examined bivalves varied seasonally.

Bradykinin shifts endothelial fluid passage from para- to transcellular routes.

The signalling peptide bradykinin (BK) is implicated in inflammation and angiogenesis. It promotes fluid transport from blood vessels to interstitial space, and thus facilitates oedema formation. To clarify whether paracellular or transcellular pathways mediate this effect, we investigated the BK-stimulated fluid transport across endothelial monolayers in vitro by comparison of electrical and fluorescence methods. Electrical cell impedance sensing monitored a biphasic response of cell layers to BK with high time resolution: a short decrease (18%, 1 min) was followed by a more sustained increase in paracellular resistance (30%, 10 min). The two phases can be assigned to second messengers of the BK-signalling pathway: Ca(2+) for the decrease and cyclic adenosine monophosphate for the rise of resistance, respectively. Despite tightening of the intercellular clefts, BK increased the fluid permeability by 39%, indicating transcellular fluid transport. Additionally, BK stimulated both in- and outwardly directed membrane trafficking as assessed by vesicular fluid uptake (by 49%) and secretion of von Willebrandt factor (by 85%). In conclusion, the combination of electrical and fluorescence data suggests that BK induces a shift from para- to transcellular fluid transport across endothelium.

Improved glucuronide hydrolysis in the determination of urinary 1-hydroxypyrene.

The efficiency of the glucuronide hydrolysis in the determination of urinary 1-hydroxypyrene was investigated as a function of the reaction conditions. A significant improvement could be obtained by increasing the enzyme concentration described in the literature.

Neuropathological findings after continuous intrathecal administration of S(+)-ketamine for the management of neuropathic cancer pain.

Questions have been raised about the potential neurotoxicity of the neuraxial use of ketamine although ketamine and its active enantiomer S(+)-ketamine have been used intrathecally and epidurally (caudally) for the management of perioperative pain and in a variety of chronic pain syndromes. Clinical experience following neuraxial administration of S(+)-ketamine has been documented without reference to local central nervous system toxicity following this approach. In addition, there are no preclinical safety data regarding stability, compatibility, and neurotoxicity on intrathecal use of single S(+)-ketamine or combinations of S(+)-ketamine, morphine, bupivacaine, and clonidine. In the present case, the continuous intrathecal administration of S(+)-ketamine, in combination with morphine, bupivacaine, and clonidine resulted in adequate pain relief in a patient suffering from intractable neuropathic cancer pain. However, postmortem observation of the spinal cord and nerve roots revealed severe histological abnormalities including central chromatolysis, nerve cell shrinkage, neuronophagia, microglial upregulation, and gliosis. Based on our results, neuraxial administration of S (+)-ketamine cannot be recommended for clinical practise before a systematic study of toxicology of neuraxial S(+)-ketamine in animals or humans has been performed.

Inhibition of L-type Cav1.2 Ca2+ channels by 2,(4-morpholinyl)-8-phenyl-4H-1-benzopyran-4-one (LY294002) and 2-[1-(3-dimethyl-aminopropyl)-5-methoxyindol-3-yl]-3-(1H-indol-3-yl) maleimide (Go6983).

Phosphatidylinositol 3-kinase (PI3-K) is involved in physiological processes of cellular proliferation and inflammation and, as postulated recently, in the regulation of L-type Ca(2+) channels. The latter conclusion arose in part from the inhibitory action of the compound 2,(4-morpholinyl)-8-phenyl-4H-1-benzopyran-4-one (LY294002), which has been established as a selective PI3-K inhibitor (IC(50) = 1.4 microM). Herein we show, however, that LY294002 and an inhibitor of protein kinase C (PKC), 2-[1-(3-dimethylaminopropyl)-5-methoxyindol-3-yl]-3-(1H-indol-3-yl) maleimide (Go6983), act as direct Ca(2+)-channel inhibitors, with IC(50) values of approximately 20 and 10 microM, respectively. Because both drugs are commonly used at concentrations of approximately 10 microM or higher, the interpretation of such experiments is questionable with respect to a regulatory action of PI3-K or PKC on L-type Ca(2+) channels.