Safety and efficacy of the combination acetaminophen-codeine in the treatment of pain of different origin.

BACKGROUND: Pain is the most common reason people see doctors in developed Countries and a very common cause of access in Emergency Department (ED). The combination acetaminophen/codeine represents the standard medication in the second step of the WHO analgesic scale and codeine is one of the most commonly used opioid analgesic for a variety of pain conditions. However, many aspects related to safety and efficacy are still undefined. AIM: To summarize and review the results of the most relevant studies on the efficacy and safety profile of acetaminophen/codeine combination in the treatment of pain of different origin. MATERIALS AND METHODS: We performed a literature search to identify and evaluate all relevant english-language randomized controlled trials (RCTs), meta-analyses and reviews about the codeine plus paracetamol combination in the treatment of pain from any source. RESULTS: Acetaminophen/codeine combination is effective in the treatment of moderate to severe pain in all setting analyzed in this study, which include headache, postoperative, osteoarticular and post-traumatic. The best results in terms of safety and efficacy have been obtained in postoperative pain. Efficacy of acetaminophen/codeine combination is not inferior to NSAIDs. CONCLUSIONS: Acetaminophen/codeine combination is effective in the treatment of pain, through a synergistic action of the two molecules, and is not inferior to NSAIDs. Side effects of acetaminophen/codeine are usually minor, differently from NSAIDs, which may induce some potentially life threatening conditions.

The WNT receptor ROR2 drives the interaction of multiple myeloma cells with the microenvironment through AKT activation.

Multiple myeloma is the second most frequent hematological cancer after lymphoma and remains an incurable disease. The pervasive support provided by the bone marrow microenvironment to myeloma cells is crucial for their survival. Here, an unbiased assessment of receptor tyrosine kinases overexpressed in myeloma identified ROR2, a receptor for the WNT noncanonical pathway, as highly expressed in myeloma cells. Its ligand, WNT5A is the most abundant growth factor in the bone marrow of myeloma patients. ROR2 mediates myeloma cells interactions with the surrounding bone marrow and its depletion resulted in detachment of myeloma cells from their niche in an in vivo model, triggering apoptosis and thus markedly delaying disease progression. Using in vitro and ex vivo 3D-culture systems, ROR2 was shown to exert a pivotal role in the adhesion of cancer cells to the microenvironment. Genomic studies revealed that the pathways mostly deregulated by ROR2 overexpression were PI3K/AKT and mTOR. Treatment of cells with specific PI3K inhibitors already used in the clinic reduced myeloma cell adhesion to the bone marrow. Together, our findings support the view that ROR2 and its downstream targets represent a novel therapeutic strategy for the large subgroup of MM patients whose cancer cells show ROR2 overexpression.

Natural and synthetic avenanthramides activate caspases 2, 8, 3 and downregulate hTERT, MDR1 and COX-2 genes in CaCo-2 and Hep3B cancer cells.

Avenanthramides (AVNs) are natural polyphenols obtained from oat sprouts and can also be chemically synthetized. The aim of the present study was to assess the anticancer, anti-inflammatory and antioxidant effects of individual synthetized AVNs (s-2c, s-2p, s-2f) and a natural AVN mixture (n-MIX) on CaCo-2 and Hep3B cancer cells. In CaCo-2, the AVN s-2c was found to be the most cytotoxic followed by the n-MIX. In Hep3B cells, a marked cytotoxic effect was found but no significant difference was observed between the synthesized AVNs and the n-MIX. In both CaCo-2 and Hep3B cells, natural and synthetic AVNs activated caspases 8 and 3, and the n-MIX and the AVN s-2c were also able to activate caspase 2. Both synthetic and natural AVNs downregulated pro-survival genes hTERT, COX-2 and MDR1, inhibited the activity of pro-inflammatory COX-2 enzyme and reduced prostaglandin E2 levels, showing the potent chemopreventive effects of these oat-derived phytochemicals. Synthetic AVN s-2c was found to have the highest chemical antioxidant capacity, as indicated by ORAC, DPPH and ABTS values, whereas all AVNs and n-MIX were shown to have similar intracellular antioxidant activity, evaluated by means of the DCFH-DA assay. As AVNs have high bioavailability in humans, results of this study suggest that oat-based foods, fortified with AVNs, could be an alternative to produce functional foods with anticancer, anti-inflammatory and antioxidant effects for health benefits.

Betalains increase vitexin-2-O-xyloside cytotoxicity in CaCo-2 cancer cells.

Vitexin-2-O-xyloside (XVX) from Beta vulgaris var. cicla L. (BVc) seeds, betaxanthin (R1) and betacyanin (R2) fractions from Beta vulgaris var. rubra L. (BVr) roots were combined and tested for cytotoxicity in CaCo-2 colon cancer cells. XVX was the most cytotoxic molecule, but the combination of XVX with R1 and R2 significantly prolonged its cytotoxicity. Cytotoxicity was mediated by the intrinsic apoptotic pathway, as shown by an increase in Bcl2-like protein 4, cleaved Poly ADP-Ribosyl Polymerase 1 and cleaved Caspase 3 levels with a parallel decrease in anti-apoptotic protein B-cell leukemia/lymphoma 2 levels. R1 and R2, used alone or in combination, reduced oxidative stress triggered by H2O2 in CaCo-2 cells. Betalains dampened cyclooxygenase-2 and interleukin-8 mRNA expression after lipopolysaccharide induction in CaCo-2, showing an anti-inflammatory action. Our results support the use of a cocktail of R1, R2 and XVX as a chemopreventive tool against colon cancer.

Betacyanins enhance vitexin-2-O-xyloside mediated inhibition of proliferation of T24 bladder cancer cells.

Betacyanins (BC) were purified from beetroot (Beta vulgaris var. rubra L.) and tested, alone or in combination with vitexin-2-O-xyloside (XVX) from Beta vulgaris var. cicla L., for their ability to reduce the proliferation rate in T24 bladder cancer cells. Combination of BC and XVX exhibited a synergistic effect concerning the inhibition of proliferation in T24 cancer cells at 24 and 48 h but not after 72 h of incubation. The induction of apoptosis was evidenced by means of fluorescence activated cell sorting (FACS) analysis, as well as through the increase in caspase 3 and 8 activities. Using RTqPCR experiments, it was shown that the combination of XVX + BC was able to enhance the expression levels of pro-apoptotic BAX and downregulate anti-apoptotic BIRC5 (survivin), as well as pro-survival CTNNB1 (ß-catenin). The most evident effect of BC was the increase of the activity of caspase 8, leading to induction of extrinsic apoptosis. Moreover, XVX, BC and their combination showed no cytotoxic effect on normal human skin NCTC 2544 keratinocytes. These results demonstrated the efficacy and the mechanisms of the action of BC and XVX, extracted from edible plants, and suggested that a diet or a nutrition supplement, enriched with these bioactive molecules, could be used in the prevention of human bladder cancer.

Kinetics of iron reduction of ferritin cores and of a low molecular weight hydroxy-iron polymer.

The kinetics of reduction by dithionite of iron cores in ferritin and of iron cores after removal of the protein shell (isolated cores) has been analysed along with that of a low molecular weight hydroxy-iron polymer. Spectrophotometric measurements have shown that the time course of the reaction approximates a pseudo first-order behaviour. In the case of ferritin cores the pseudo first-order rate constant reaches an asymptotic value which markedly increases when the cores are isolated. In contrast, in the low molecular weight hydroxy-iron polymer, no clear asymptotic value is reached. Thus, the rate of reduction appears to be determined both by the presence of the protein shell and by the crystallite surface area. Kinetic light scattering experiments show that in ferritin and in the isolated cores a rapid drop in molecular weight occurs during the first stages of reduction, suggesting a fragmentation of the iron crystallite.

Redox potentials of normal and SH(beta 93)-modified human hemoglobin. Effect of pH and D-glycerate 2,3-bisphosphate.

The effect of pH and D-glycerate 2,3-bisphosphate on the oxidation-reduction equilibria of human hemoglobin, normal and modified at the SH(beta 93) groups by reaction with cystine dimethylester has been studied with the aim of comparing the redox equilibria with the oxygen equilibria previously studied under the same experimental conditions. Analysis of data has shown that: (i) the same groups are involved in the oxygenation and oxidation alkaline Bohr effect; (ii) the pK values of these groups are lower in met-hemoglobin than in oxyhemoglobin; (iii) the difference in the affinity for D-glycerate 2,3-bisphosphate of ferric and deoxyhemoglobin is pH-independent in the normal protein, while significantly decreasing with a decrease in pH in the modified protein; (iv) the high cooperativity of the redox process (also occurring at acid pH) and the reduced oxidation Bohr effect observed in the modified protein are consistent with the destabilization of the T structure induced by the bulky reagent bound to the SH(beta 93) groups of the protein.

Subunit interactions in the dimeric and tetrameric hemoglobins from the mollusc Scapharca inaequivalvis.

The dissociation behaviour of oxygenated Scapharea inaequivalvis HbII, the tetrameric hemoglobin component contained in the erythrocytes of this bivalve mollusc, has been compared with that of oxygenated human hemoglobin, HbA. At neutral pH the molluscan protein dissociates reversibly into dimers as does HbA, although dissociation is less marked; moreover the dimer-tetramer association constant is not sensitive to the presence of inorganic phosphates and high salt concentrations. HbII dimers hybridize with HbA dimers in solution, pointing to an overall similarity of the dimer interfaces in these hemoglobins from distantly related species. The gel filtration behaviour of the dimeric hemoglobin component of the erythrocytes. HbI, indicates that at neutral pH the protein has very little tendency to dissociate into monomers even at micromolar concentrations. Hb I was found to contain small amounts (2-4%) of bound carbohydrates.

Renaturation and urea-induced denaturation of 20 beta-hydroxysteroid dehydrogenase studied in solution and in the immobilized state.

Tetrameric 20 beta-hydroxysteroid dehydrogenase (17,20 beta,21-trihydroxysteroid:NAD+ oxidoreductase, EC 1.1.1.53) from Streptomyces hydrogenans was reactivated after inactivation, dissociation and denaturation with urea. The effect of several factors such as NAD+, NADH, substrate, sulphydryl reducing agents, extraneous proteins, pH and enzyme concentration on reactivation was investigated. The coenzymes were found to be essential for obtaining a high reactivation yield (about 90%), since in their absence the reactivation was less than 10%. NADH was effective at lower concentrations than NAD+. The reactivated enzyme, after the removal of inactive aggregates, showed physical and catalytic properties coincident with those of the native enzyme. The mechanism by which NADH affects the reconstitution of 20 beta-hydroxysteroid dehydrogenase was investigated using both soluble enzyme and enzyme immobilized on Sepharose 4B. The immobilization demonstrates that isolated subunits are inactive and incapable of binding NADH and suggests that subunit association to the tetramer is essential for enzymatic activity. NADH appears to act, after subunit assembly has taken place, by stabilizing tetramers and preventing their aggregation with monomers that would give rise to inactive polymers.

Functional properties of normal and sickle cell hemoglobins in polyethylene glycol 6000.

The functional properties of human hemoglobin A and S were studied in concentrated solutions of polyethylene glycol. Polyethylene glycol solutions are frequently used as media for protein crystallization. In particular, sickle cell hemoglobin, which does not make X-ray quality crystals in high salt solutions, will form high-quality crystals in polyethylene glycol. Comparison of the functional properties of normal and sickle cell hemoglobin in polyethylene glycol show that pH, anion effects and cooperativity of ligand binding are largely unaffected by polyethylene glycol. This suggests that the crystals grown in this medium are representative of the native structure.

Properties of hemoglobin G. Ferrara (beta57(E1) Asn replaced by Lys).

Hemoglobin G. Ferrara is an abnormal human hemoglobin in which an asparagine residue is replaced by a lysyl residue at position beta57 (beta57 Asn replaced by Lys). Oxygen equilibria show that cooperativity and alkaline Bohr effect are maintained to normal levels while the acid Bohr effect appears increased; in addition, a smaller effect of diphosphoglycerate is also observed. Flash photolysis experiments performed as a function of protein concentration show that the fraction of quickly reacting form is always higher than that of human hemoglobin A. This fact, together with the increase of the oxygen affinity observed at acid pH values, may be related to an enhanced dissociation of the molecule into dimers. Several attempts to isolate the native chains by treatment of the protein with p-chloromercuribenzoate were unsuccessful due to the great instability of the isolated variant beta-chains, which precipitated completely during incubation with p-chloromercuribenzoate. Therefore, although the substitution is on the surface of the molecule, there are several properties of hemoglobin G. beta Ferrara which are clearly different from hemoglobin A.

Steady-state and pre-steady-state kinetics of the trypsin-catalysed hydrolysis of alpha-CBZ-L-lysine-p-nitrophenyl ester.

The catalytic properties of bovine tyrpsin (EC 3.4.21.4) have been investigated using a synthetic chromogenic substrate: alpha-CBZ-L-lysine-p-nitrophenyl ester (ZLNPE). The use of ZLNPE allows the determination of trypsin down to a concentration of 2 . 10(-9) M. Steady-state and pre-steady-state data have been in the framework of the minimum three-step mechanism: (Formula: see text). The pH-dependence of the kinetic parameters shows that at acid pH values (congruent to 2.6) the k+3 step is rate limiting in catalysis, whereas for pH values higher than 4.8 k+2 becomes rate limiting. This change in rate-limiting step with pH illustrates the danger in the assumption that kcat vs. pH profiles for protease action on substrates with good leaving groups are equivalent to k+3 vs. pH profiles.

Studies on erythrocruorin. VII. Reconstitution of earthworm erythrocruorin from the apoprotein.

Apoerythrocruorin prepared from the giant respiratory hemoprotein of the earthworm (60 S, Mr = 3 X 10(-6)) is an electrophoretically homogeneous molecule which sediments as a single peak of low molecular weight (3.5 S) and has a lower alpha-helical content (approx. 30%) than the native protein. Titration of globin with ferric heme indicates the presence of different binding sites; however, after purification by ion exchange chromatography, the reconstitution product contains 1 haem/23 000 g of protein as the native molecule. Reconstituted ferric erythrocruorin is a low molecular weight hemichrome with the same optical and physicochemical properties of the hemichrome formed by natural ferric erythrocruorin. Reconstituted ferrous erythrocruorin reacquires the alpha-helical content and the quaternary structure of the native molecule. Reassociation into 10-S speices (1/12 of the whole molecules) is fast and easy, while that into whole molecules is slow and somewhat erratic. The functional properties of reconstituted ferrous erythrocruorin (oxygen affinity, cooperativity in oxygen binding, magnitude of Bohr effect) are very similar to those of the "stable" low cooperativity form of the undissociated protein.

The pH dependence of pre-steady-state and steady-state kinetics for the porcine pancreatic beta-kallikrein-B-catalyzed hydrolysis of N-alpha-carbobenzoxy-L-arginine p-nitrophenyl ester.

Pre-steady-state and steady-state kinetics of the porcine pancreatic beta-kallikrein-B (EC 3.4.21.35) catalyzed hydrolysis of ZArgONp have been determined between pH 2.4 and 8. The results are consistent with a minimum three-step mechanism involving an acyl-enzyme intermediate: (see formula). The formation of the E X S complex may be regarded as a pseudoequilibrium process; the minimum values for k+1 are 5.9 X 10(6) M-1 X s-1 (pH 5.5) and 9.4 X 10(5) M-1 X s-1 (pH 2.4) and that for k-1 is 600 s-1. The value of k-1/k+1 (= Ks) changes from 102 microM at pH greater than or equal to 5.5 to 638 microM at pH less than 2.4. The pH dependence of k+2 conforms to two ionizing groups, in the E X S complex, with pKa values of 3.4 +/- 0.1 and 7.05 +/- 0.10. The pH profile of k+2/Ks (= kcat/Km) reflects the ionization of two groups, in the free enzyme, with pKa values of 4.2 +/- 0.1 and 7.05 +/- 0.10. The pH dependence of k+3 implicates two ionizing groups in the deacylation step with pKa values of 4.6 +/- 0.1 and 7.0 +/- 0.1. At acid pH values (pH 2.4-4.4), k+3 is rate-limiting in catalysis, whereas for pH values higher than 4.4, k+2 becomes rate-limiting. The observed neutral and acid ionizations probably reflect the acid-base equilibrium of His-57 and Asp-189 involved in the central site of beta-kallikrein-B. The structural basis for the specificity and catalytic behaviour of this proteinase are discussed and a role for Ser-226 is pinpointed.

Functional consequences of ligand-linked dissociation in hemoglobin from the sea cucumber Molpadia arenicola.

It has been established that Molpadia hemoglobin tends to dissociate into subunits as oxygen is bound. The kinetics and equilibria of carbon monoxide and ethylisocyanide binding reported here show a dependence on protein concentration that supports the conclusion that the aggregated hemoglobin has a lower ligand affinity than the dissociated subunits. This is true for the isolated D-chain as well as for the unfractionated hemolysate that contains four distinct polypeptide chains (A-D). This indicates that even homopolymers of Molpadia hemoglobin have lower ligand affinity than the dissociated subunits. At high protein concentration hemolysates of Molpadia hemoglobin show slight cooperativity. The time course of ligand binding to the deoxy D-chain also suggests cooperative interactions. The low affinity of the aggregated state may have a different molecular explanation than in human hemoglobin where tetramers of identical subunits (as in Hb H) show high oxygen affinity. The absence of tyrosine and histidine at the C-terminal of the Molpadia D-chains also suggests a different stabilization of the low affinity deoxy state. An additional functional difference between Molpadia hemoglobin and human hemoglobin is that organic phosphates do not alter the ligand affinity of the sea cucumber hemoglobin.

Properties of trout hemoglobin covalently bound to a solid matrix.

This paper reports the ligand binding properties of the major hemoglobin component from trout (Salmo irideus) covalently bound to a solid matrix (Sepharose or Sephadex). A comparison between the functional properties of this protein in solution and of the protein-matrix complex shows significant changes although the basic properties of the molecule are maintained on covalent binding to Sepharose (or Sephadex). Thus the Root effect, characteristic of Hb trout IV, is still present while the heme-heme interactions are, on the average, smaller in the matrix bound protein as compared to the soluble form. No differences in the O2 binding properties were observed when the protein was coupled to the resin, as the ligand bound or as the ligand free derivative. Although an unequivocal interpretation of the data is made difficult by the lack of information on the number and identity of the groups involved in the coupling, the main changes in the protein functional properties may be related to the chemical modifications "per se" more than to the immobilization imposed to the macromolecule by coupling to the matrix. Structural changes which mainly involve perturbation of the tertiary structure of the molecule may qualitatively rationalize the data.

Studies on Scapharca hemoglobins. Properties of the dimeric protein reconstituted with Fe- or Co-porphyrin.

A native globin from the dimeric hemoglobin, hemoglobin I, of the mollusc Scapharca inaequivalvis has been obtained with the acid-acetone method. The globin has a lower sedimentation coefficient than the native protein at neutral pH; its reconstitution product with natural heme has the same physicochemical and functional properties as the native protein. proto- and meso-cobalt hemoglobin I have been prepared and characterized. proto-Cobalt hemoglobin I binds oxygen reversibly with a lower affinity and a lower cooperativity than native hemoglobin I; thus, the changes in the functional properties brought about by substitution of iron with cobalt are similar to those observed in human hemoglobin A. The EPR spectra of deoxy-proto-cobalt hemoglobin I and of the photolysis product of oxy-meso-cobalt hemoglobin I indicate that two histidine residues are the apical heme ligands. The broad signal at g = 2.38 in deoxy-proto-cobalt hemoglobin I points to a constrained structure of the heme site in this derivative which results from a distorted coordination of the hindered proximal histidine. A similar structure has been proposed previously for the alpha chains in deoxy-cobalt hemoglobin A.

Physicochemical and functional properties of Perinereis cultrifera (Grübe) erythrocruorin.

Perinereis erythrocruorin has the following physicochemical properties: So20,w = 55S, corresponding to a molecular weight around 2.7-10(6); minimum molecular weight (on the basis of the heme content) 23 700 +/- 500; isoelectric point 5.1; alpha-helix content approximately 40%. At alkaline pH values in the oxygenated form the 55-S molecules dissociate into subunits with a weight average sedimentation coefficient of 3S, corresponding to a molecular weight approximately 35 000. Deoxygenation of partially dissociated samples promotes association of the 3-S subunits into a 9S component. The functional properties of Perinereis erythrocruorin are characterized by a low cooperativity in oxygen binding (n 1/2 = 1.5) at neutral pH. Cooperativity increases reversibly towards both the acid and alkaline pH range, irrespective of changes in molecular weight. This finding, taken together with the ultracentrifuge results, suggests that a subunit may represent the functional unit of the protein. The pH dependence of the oxygen affinity can be accounted for in terms of a single oxygen linked group with a pK of 8.

Dimeric and tetrameric hemoglobins from the mollusc Scapharca inaequivalvis. The oxidation reaction.

The oxidation by ferricyanide of the dimeric (HbI) and tetrameric (HbII) hemoglobins from the bivalve mollusc Scapharca inaequivalvis has been studied in static and kinetic experiments. Both hemoglobins give rise to hemichromes as stable oxidation products. Oxidation of deoxyHbI yields a hemichrome by a simple bimolecular process. No intermediate Met form can be detected during the reaction even in rapid mixing experiments. The HbI hemichrome undergoes a reversible pH-dependent dissociation into monomers. A simple model has been proposed to account for the linkage between proton binding and subunit dissociation. In the case of tetrameric HbII, oxidation yields an intermediate Met form. Thus, the kinetics of the oxidation reaction are always biphasic; the fast reaction is a bimolecular process and yields the Met derivative. The slow reaction is a monomolecular process and corresponds to the conversion of the Met form into the hemichrome; its rate is independent of the state of ligation of the ferrous protein and decreases with increase of pH. The HbII hemichrome is tetrameric when newly formed; it tends to dissociate into lower molecular weight species with the same optical properties. The rate of dissociation is relatively fast at neutral pH (t 1/2 approximately equal to 12 min) and markedly less at alkaline pH values. The HbI and HbII hemichromes are reduced by dithionite yielding the spectra of the native deoxygenated proteins; in the case of HbII, the tetrameric structure of the native protein is re-acquired.

Thermodynamic properties of oxygen equilibria of dimeric and tetrameric hemoglobins from Scapharca inaequivalvis.

Oxygen equilibrium curves of the dimeric and tetrameric hemoglobin components of Scapharca inaequivalvis were determined at several temperatures. The oxygen equilibrium curves were analyzed by the two-step and four-step oxygen equilibrium schemes of Adair for the dimeric and tetrameric hemoglobins, respectively. The enthalpy and entropy changes for each oxygenation step were determined by the temperature dependences of the Adair constants using van't Hoff equations. Neither dimeric nor tetrameric hemoglobins release protons or anions upon oxygenation under the experimental conditions of the present study. The enthalpy and entropy changes are non-uniform with respect to the oxygenation step and do not need to be corrected for the oxygenation-linked release of protons and anions. For the tetrameric hemoglobin, enthalpy-entropy compensation was observed between the first, second and third steps of oxygenation. The present results suggest that the origin of the co-operative oxygenation is primarily entropic for both hemoglobin components of S. inaequivalvis. Comparison of these data with those obtained on other hemoglobins shows that no simple generalization can be made as to the thermodynamic nature of co-operativity in oxygen binding.