Background and aims
This living and systematic review aimed to provide an updated summary of the available evidence on pain undertreatment prevalence in patients with cancer; correlations with some ...potential determinants and confounders were also carried out.
Materials and methods
We updated a systematic review published on 2014, including observational and experimental studies reporting the use of the pain management index (PMI) in adults with cancer and pain, from 2014 to 2020. We conducted searches in PubMed/MEDLINE, Embase, and Google Scholar. We performed univariate and multivariable regression analyses to describe the relationship between PMI and a list of potential explanatory variables.
Results
Twenty new papers were identified, yielding a total sample size of 66 studies. The proportion of patients classified as undertreated according to the year of study publication shows a higher decrease from 1994 to 2013 (−13% as relative change) than the most recent years 2014–2020 (−11%). The quality of the included studies has increased over the years (from 80% to 93%). At the multivariable analysis, a statistically significant relationship was confirmed between undertreatment and the year of the publication of the study and with a low–medium economic level of the countries, where the studies were conducted.
Discussion
Despite the improvement when compared to the period 1994–2000, still about 40% of the cases identified received an analgesic treatment inadequate to the intensity of pain, according to the PMI. Despite its intrinsic limitations, PMI continues to be widely used, and it could allow a continuous monitoring of pain management across a different mix of studies and patients.
Abstract Background Worsening in clinical and cardiac status has been noted after chronic right ventricular pacing, but it is uncertain whether atriobiventricular (BiVP) is preferable to atrio-right ...ventricular pacing (RVP). Conventional versus Multisite Pacing for BradyArrhythmia Therapy study (COMBAT) sought to compare BiVP versus RVP in patients with symptomatic heart failure (HF) and atrioventricular (AV) block. Methods and Results COMBAT is a prospective multicenter randomized double blind crossover study. Patients with New York Heart Association functional class (FC) II-IV, left ventricular ejection fraction (LVEF) <40%, and AV block as an indication for pacing were enrolled. All patients underwent biventricular system implantation and then were randomized to receive successively (group A) RVP-BiVP-RVP, or (group B) BiVP-RVP-BiVP. At the end of each 3-month crossover period, patients were evaluated according to Quality of Life (QoL), FC, echocardiographic parameters, 6-Minute Walk Test (6MWT), and peak oxygen consumption (VO2max ). Sixty patients were enrolled, and the mean follow-up period was 17.5 ± 10.7 months. There were significant improvements in QoL, FC, LVEF, and left ventricular end-systolic volume with BiVP compared with RVP. The effects of pacing mode on 6MWT and VO2max were not significantly different. Death occurred more frequently with RVP. Conclusion In patients with systolic HF and AV block requiring permanent ventricular pacing, BiVP is superior to RVP and should be considered the preferred pacing mode.
Infection during mechanical circulatory support is a frequent adverse complication. We analyzed infections occurring in this population in a national tertiary care center, and assessed the ...differences existing between the setting of extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VADs).
An observational study was made of patients treated with ECMO or VAD in the San Raffaele Scientific Institute (Italy) between 2009 and 2011.
None.
Thirty-nine percent of the 46 patients with ECMO and 69% of the 15 patients with VAD developed infection. We observed a mortality rate of 36.1% during mechanical circulatory support and of 55.7% during the global hospitalization period. Although Gram-negative infections were predominant overall, patients with ECMO were more prone to develop Candida infection (29%), and patients with VAD tended to suffer Staphylococcus infection (18%). Patients with infection had longer ECMO support (p=0.03), VAD support (p=0.01), stay in the intensive care unit (p=0.002), and hospital admission (p=0.03) than patients without infection. Infection (regression coefficient=3.99, 95% CI 0.93-7.05, p=0.02), body mass index (regression coefficient=0.46, 95% CI 0.09-0.83, p=0.02), fungal infection (regression coefficient=4.96, 95% CI 1.42-8.44, p=0.009) and obesity (regression coefficient=10.47, 95% CI 1.77-19.17, p=0.02) were predictors of the duration of ECMO support. Stepwise logistic regression analysis showed the SOFA score at the time of implant (OR=12.33, 95% CI 1.15-132.36, p=0.04) and VAD (OR=1.27, 95% CI 1.04-1.56, p=0.02) to be associated with infection.
Infection is a major challenge during ECMO and VAD support. Each mechanical circulatory support configuration is associated with specific pathogens; fungal infections play a major role.
The incorporation of anionic excipients into polyplexes is a promising strategy for modulating siRNA binding versus release and integrating diagnostic capabilities; however, specific design criteria ...and structure–function relationships are needed to facilitate the development of nanocarrier-based theranostics. Herein, we incorporated poly(acrylic acid) (PAA) and quantum dot (QD) excipients into photolabile siRNA polyplexes to increase gene silencing efficiencies by up to 100% and enable self-reporting of nanocarrier disassembly. Our systematic approach identified the functional relationships between gene silencing and key parameters such as excipient loading fractions and molecular weights that facilitated the establishment of design rules for optimization of nanocarrier efficacy. For example, we found that PAA molecular weights ∼10–20× greater than that of the coencapsulated siRNA exhibited the most efficient release and silencing. Furthermore, siRNA release assays and RNAi modeling allowed us to generate a PAA “heat map” that predicted gene silencing a priori as a function of PAA molecular weight and loading fraction. QDs further promoted selective siRNA release and provided visual as well as Förster resonance energy transfer (FRET)-based monitoring of the dynamic changes in nanostructure in situ. Moreover, even with the addition of anionic components, our formulations exhibited substantially improved stability and shelf life relative to typical formulations, with complete stability after a week of storage and full activity in the presence of serum. Taken together, this study enabled synergistic improvements in siRNA release and diagnostic capabilities, along with the development of mechanistic insights that are critical for advancing the translation of nucleic acid theranostics into the clinic.
It is well known that fetal androgens are required for male sexual differentiation, and it is thought that fetal ovaries are not steroidogenically active. However, molecular details, such as which ...steroidogenic enzymes are present in fetal testes and which enzymes are absent in fetal ovaries, have not been established. The pattern of expression of the genes that encode four of the steroidogenic enzymes necessary for androgen and estrogen production was examined during fetal development in mouse gonads. Messenger RNA (mRNA) expression for cholesterol side-chain cleavage (P450scc), 3 beta-hydroxysteroid dehydrogenase/delta 5-delta 4-isomerase (3 beta HSD), P450 17 alpha-hydroxylase/C17-20 lyase (P450c17), and P450 aromatase (P450arom) was determined before ovaries and testes were distinguishable (13 days postconception) and during sexual differentiation (15, 17, and 20 days postconception) using reverse transcriptase-polymerase chain reactions (RT-PCR). A PCR assay for Sry was used to determine gender on day 13. P450scc, 3 beta HSD, and P450c17 transcripts were detected at all ages in fetal testes, indicating that mRNAs for the steroidogenic enzymes that are required to convert cholesterol to androgens are present in the male gonad even before sexual differentiation. P450arom mRNA was detected in several fetal testes on day 17, but consistently observed on day 20. The expression of P450arom suggests the potential of fetal and neonatal testes to convert androgens to estrogens. In contrast, although 3 beta HSD mRNA was detected in several of the ovaries examined, the detection of P450scc, P450c17, and P450arom transcripts was rare. These data suggest that the absence of fetal ovarian steroid hormone production is the result of lack of expression of at least three of the steroidogenic enzymes, P450scc, P450c17, and P450arom.
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Two of the most prominent challenges that limit the clinical success of siRNA therapies are a lack of control over cargo release from the delivery vehicle and an incomplete ...understanding of the link between gene silencing dynamics and siRNA dosing. Herein, we address these challenges through the formulation of siRNA polyplexes containing light-responsive polymer mixtures, whose varied compositions and triggered release behavior provide enhanced gene silencing and controlled dose responses that can be predicted by simple kinetic models. Through the straightforward mixing of two block copolymers, the level of gene knockdown was easily optimized to achieve the maximum level of GAPDH protein silencing in NIH/3T3 cells (~70%) using a single siRNA dose. The kinetic model was used to describe the dynamic changes in mRNA and protein concentrations in response to siRNA treatment. These predictions enabled the application of a second dose of siRNA to maximally suppress gene expression over multiple days, leading to a further 50% reduction in protein levels relative to those measured following a single dose. Furthermore, polyplexes remained dormant in cells until exposed to the photo-stimulus, demonstrating the complete control over siRNA activity as well as the stability of the nanocarriers. Thus, this work demonstrates that pairing advances in biomaterials design with simple kinetic modeling provides new insight into gene silencing dynamics and presents a powerful strategy to control gene expression through siRNA delivery.
Our manuscript describes two noteworthy impacts: (1) we designed mixed polymer formulations to enhance gene silencing, and (2) we simultaneously developed a simple kinetic model for determining optimal siRNA dose responses to maintain silencing over several days. These advances address critical challenges in siRNA delivery and provide new opportunities in therapeutics development. The structure-function relationships prevalent in these formulations were established to enable tuning and forecasting of nanocarrier efficiency a priori, leading to siRNA dosing regimens able to maximally suppress gene expression. Our advances are significant because the mixed polymer formulations provide a straightforward and scalable approach to tailor siRNA delivery regimens. Moreover, the implementation of accurate dosing frameworks addresses a major knowledge gap that has hindered clinical implementation of siRNA.
Lactic acid bacteria (LAB) and yeasts were selected on the basis of in vitro proteolytic activity against wheat gluten protein and then assayed as leavening agents for pizza dough. Trials were ...carried out to compare a proteolytic starter (Prt
+), consisting of
Lactobacillus sakei T56,
Weissella paramesenteroides A51 and
Candida krusei G271, and a non-proteolytic starter (Prt
−), consisting of
Lb. sakei T58,
W. paramesenteroides A58 and
Saccharomyces cerevisiae T22. The proteolytic activity of the starter cultures was monitored immediately after mixing of the dough and throughout the fermentation process. The proteolytic activity was assessed by analysing the salt-soluble protein (SSP) and the dioxane-soluble protein (DSP) fractions of the pizza dough by discontinuous SDS-PAGE. Only the Prt
+ starter exhibited considerable qualitative and quantitative changes in the electrophoretic patterns of the protein fractions extracted. After the fermentation, the Prt
+ and Prt
− doughs were tested to evaluate the influence of the proteolytic activity on the mechanical properties of the dough before and after baking. Indications emerged suggesting an influence of the proteolytic activity on the viscoelasticity of pizza dough. The pizza dough with Prt
+ strains showed an increase in viscous properties during the fermentation as compared with the Prt
− dough. Moreover, an increase in the firmness of the crumb was observed in Prt
+ baked pizza dough.
Traumatic brain injury (TBI) is defined as an impact, penetration or rapid movement of the brain within the skull that results in altered mental state. TBI occurs more than any other disease, ...including breast cancer, AIDS, Parkinson's disease and multiple sclerosis, and affects all age groups and both genders. In the US and Europe, the magnitude of this epidemic has drawn national attention owing to the publicity received by injured athletes and military personnel. This increased public awareness has uncovered a number of unanswered questions concerning TBI, and we are increasingly aware of the lack of treatment options for a crisis that affects millions. Although each case of TBI is unique and affected individuals display different degrees of injury, different regional patterns of injury and different recovery profiles, this review and accompanying poster aim to illustrate some of the common underlying neurochemical and metabolic responses to TBI. Recognition of these recurrent features could allow elucidation of potential therapeutic targets for early intervention.
A total of 46 consecutive Chagas' disease patients had an automatic cardioverter defibrillator implanted at our institution from October 1998 to January 2004. A retrospective longitudinal study was ...carried out to identity type of life‐threatening ventricular arrhythmias as well as type of therapy delivered. Of these, 41 (91%) had been recovered from cardiac arrest. Five (15%) of 33 patients in whom echocardiography was done had no left ventricular function. Antiarrhythmic therapy was delivered to 37 (80%) patients during postimplant follow‐up. Thirty‐one of 37 (84%) patients received both shock and antitachycardia pacing, five (13%) only antitachycardia pacing, and one (3%) patient only shock. Median time to first shock was 16 days, varying from 1 to 576 days. Ventricular fibrillation was the cause of first shock in 12 patients (32%), ventricular tachycardia in 11 (29%), and ventricular tachycardia not responding to antitachycardia pacing degenerating into ventricular fibrillation in nine (24%). Five patients with ventricular tachycardia were treated with antitachycardia pacing. Probability of freedom from device discharged was 47% at 90 days, 34% at 180 days, and 9% at 360 days in the postimplant follow‐up. Thus, patients with chronic Chagas' heart disease recovered from cardiac arrest have a peculiar arrhythmogenic profile characterized by a high frequency of ventricular fibrillation and no left ventricular systolic dysfunction and a short period of time for first shock.
Guidelines tend to consider morphine and morphine-like opioids comparable and interchangeable in the treatment of chronic cancer pain, but individual responses can vary. This study compared the ...analgesic efficacy, changes of therapy and safety profile over time of four strong opioids given for cancer pain.
In this four-arm multicenter, randomized, comparative, of superiority, phase IV trial, oncological patients with moderate to severe pain requiring WHO step III opioids were randomly assigned to receive oral morphine or oxycodone or transdermal fentanyl or buprenorphine for 28 days. At each visit, pain intensity, modifications of therapy and adverse drug reactions (ADRs) were recorded. The primary efficacy end point was the proportion of nonresponders, meaning patients with worse or unchanged average pain intensity (API) between the first and last visit, measured on a 0–10 numerical rating scale. (NCT01809106).
Forty-four centers participated in the trial and recruited 520 patients. Worst pain intensity and API decreased over 4 weeks with no significant differences between drugs. Nonresponders ranged from 11.5% (morphine) to 14.4% (buprenorphine). Appreciable changes were made in the treatment schedules over time. Each group required increases in the daily dose, from 32.7% (morphine) to 121.2% (transdermal fentanyl). Patients requiring adjuvant analgesics ranged from 68.9% (morphine) to 81.6% (oxycodone), switches varied from 22.1% (morphine) to 12% (oxycodone), discontinuation of treatment from 27% ( morphine) to 14.5% (fentanyl). ADRs were similar except for effects on the nervous system, which significantly prevailed with morphine.
The main findings were the similarity in pain control, response rates and main adverse reactions among opioids. Changes in therapy schedules were notable over time. A considerable proportion of patients were nonresponders or poor responders.
NCT01809106 (https://clinicaltrials.gov/ct2/show/NCT01809106?term=cerp&rank=2).
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