Consensus statement on the anticipation and prevention of acute postoperative pain: multidisciplinary RADAR approach.

BACKGROUND: There has been considerable investment in efforts to improve postoperative pain management, including the introduction of acute pain teams. There have also been a number of guidelines published on postoperative pain management and there is widespread agreement on how pain should be practically managed. Despite these advances, there is no apparent improvement in the number of patients experiencing moderately severe or extreme pain after surgery. This highlights significant scope for improvement in acute postoperative pain management. SCOPE: In January 2009, a multidisciplinary UK expert panel met to define and agree a practical framework to encourage implementation of the numerous guidelines and fundamentals of pain management at a local level. The panel recognised that to do this, there was a need to organise the information and guidelines into a simplified, accessible and easy-to-implement system based on their practical clinical experience. Given the volume of literature in this area, the Chair recommended that key international guidelines from professional bodies should be distributed and then reviewed during the meeting to form the basis of the framework. Consensus was reached by unanimous agreement of all ten participants. FINDINGS: This report provides a framework for the key themes, including consensus recommendations based upon practical experience agreed during the meeting, with the aim of consolidating the key guidelines to provide a fundamental framework which is simple to teach and implement in all areas. Key priorities that emerged were: Responsibility, Anticipation, Discussion, Assessment and Response. This formed the basis of RADAR, a novel framework to help pain specialists educate the wider care team on understanding and prioritising the management of acute pain. CONCLUSION: Acute postoperative pain can be more effectively managed if it is prioritised and anticipated by a well-informed care team who are educated with regard to appropriate analgesic options and understand what the long-term benefits of pain relief are. The principles of RADAR provide structure to help with training and implementation of good practice, to achieve effective postoperative pain management.

A review of sharps injuries and preventative strategies.

Exposure to bloodborne pathogens from sharps injuries continues to pose a significant risk to healthcare workers (HCW). The number of sharps injuries sustained by HCW is still unclear, primarily due to under-reporting. In this review a mean rate of 4.0% (range 1.0-6.2%) sharps injuries per 10000 HCW was calculated from eight studies involving more than 7000 HCW. Nurses and doctors were most at risk of sharps injuries, frequently from hollow-bore needles. Approaches to reduce this risk have included education and training on the safe handling and disposal of sharp devices, awareness campaigns and legislative action. More recently, preventative strategies have focused on needle protective devices, which may reduce the rate of sharps injuries. Introducing needle protective devices should be considered particularly in high-risk areas, after training, education, evaluation and cost-benefit analysis.

Regulation of E-box DNA binding during in vivo and in vitro activation of rat and human hepatic stellate cells.

BACKGROUND: Activation of hepatic stellate cells (HSCs) to a myofibroblastic phenotype is a key event in liver fibrosis. Identification of transcription factors with activities that are modulated during HSC activation will improve our understanding of the molecular events controlling HSC activation. AIMS: To determine if changes in E-box DNA binding activity occur during in vitro and in vivo activation of rat and human HSCs and to investigate mechanisms underlying any observed changes. METHODS: Nuclear extracts were prepared from rat HSCs isolated and cultured from normal and carbon tetrachloride injured rat livers and from HSCs isolated from human liver. EMSA analysis of E-box DNA binding activity was performed on nuclear extracts to determine changes during HSC activation. Western and northern blot analysis of MyoD and Id1 basic helix-loop-helix (bHLH) proteins was performed to confirm expression in HSC. RESULTS: HSC activation was associated with inducible expression of two low mobility E-box binding complexes that were immunoreactive with an anti-MyoD antibody. MyoD mRNA expression was found at similar levels in freshly isolated and activated HSCs; in contrast, MyoD protein expression was elevated in activated HSCs. Activation of rat HSCs was accompanied by reduced expression of the inhibitory bHLH protein Id1. CONCLUSIONS: In vitro and in vivo activation of rat and human HSCs is accompanied by induction of MyoD binding to E-box DNA sequences which appears to be mechanistically associated with elevated MyoD protein expression and reduced expression of the inhibitory Id1 protein. Clarification of the role of MyoD and Id1 proteins in HSC activation and liver fibrogenesis is now required.

Characterization of 5-HT receptors in the parasitic nematode, Ascaris suum.

The pharmacological profiles of the 5-hydroxytryptamine (5-HT) receptors on Ascaris suum pharyngeal and somatic body wall muscles were investigated. The mechanisms involved following activation of these receptors were also studied. 5-HT activated and maintained pumping in isolated pharynxes with an EC-50 value of 44+/-1.7 microM. The 5-HT agonists, tryptamine, sumatriptan 8-OH-DPAT and 5-carboxyamidotryptamine all failed to stimulate pumping. The 5-HT2 antagonist, ketanserin, initially excited and then inhibited pumping while the 5-HT3 antagonist, ondansetron, had no effect. 5-HT and 5-HT agonists, 8-OH-DPAT, 5-carboxyamidotryptamine, alpha-methyl-5-HT and tryptamine all inhibited ACh-induced contractions of a somatic body wall muscle strip. Ketanserin partially blocked the inhibitory effect of alpha-methyl-5-HT and ACh-induced contractions while the 5-HT uptake blocker, fluoxetine, potentiated the effect of 5-HT on ACh-induced contractions. Basal levels of cAMP, 1540+/-232 pmol/mg, in pharyngeal muscle and 1721+/-134 pmol/mg, somatic body wall muscle, were both increased by forskolin. 5-HT had no effect on pharyngeal muscle cAMP levels but raised cAMP levels in somatic body wall muscle, e.g. 100 micron 5-HT, raised the level to 2851+/-212 pmol/mg and 1000 microM raised levels to 4578+/-1234 pmol/mg. 5-HT, 1000 microM, increased inositol phosphate levels in pharyngeal muscle. These results provide some evidence for a 5-HT2-like receptor on pharyngeal muscle. In contrast, the situation on somatic body wall muscle is more confusing since the pharmacological profile partly indicates a 5-HT2-like receptor but this receptor is linked to a rise in cAMP levels. Further studies are required to resolve the position but they must be based on the rational design of ligands specifically for nematode 5-HT receptors and not simply using ligands developed for the classification of mammalian 5-HT receptors. Such a design must take into account data from molecular biology studies of nematode 5-HT receptors.

Upstream tissue inhibitor of metalloproteinases-1 (TIMP-1) element-1, a novel and essential regulatory DNA motif in the human TIMP-1 gene promoter, directly interacts with a 30-kDa nuclear protein.

Elevated expression of the tissue inhibitor of metalloproteinases-1 (TIMP-1) protein and mRNA has been reported in human diseases including cancers and tissue fibrosis. Regulation of TIMP-1 gene expression is mainly mediated at the level of gene transcription and involves the activation of several well known transcription factors including those belonging to the AP-1, STAT, and Pea3/Ets families. In the current study, we have used DNase-1 footprinting to identify a new regulatory element (5'-TGTGGTTTCCG-3') present in the human TIMP-1 gene promoter. Mutagenesis and transfection studies in culture-activated rat hepatic stellate cells and the human Jurkat T cell line demonstrated that the new element named upstream TIMP-1 element-1 (UTE-1) is essential for transcriptional activity of the human TIMP-1 promoter. Electrophoretic mobility shift assay studies revealed that UTE-1 can form protein-DNA complexes of distinct mobilities with nuclear extracts from a variety of mammalian cell types and showed that induction of a high mobility UTE-1 complex is associated with culture activation of freshly isolated rat hepatic stellate cells. A combination of UV-cross-linking and Southwestern blotting techniques demonstrated that UTE-1 directly interacts with a 30-kDa nuclear protein that appears to be present in all cell types tested. We conclude that UTE-1 is a novel regulatory element that in combination with its cellular binding proteins may be an important component of the mechanisms controlling TIMP-1 expression in normal and pathological states.

The influence of a wide range of absorbed cholesterol on plasma cholesterol levels in man.

The influence of absorbed dietary cholesterol on plasma cholesterol concentration was studied in two populations, one Seventh Day Adventist (SDA) vegetarian and one nonvegetarian, representing a broad range of plasma cholesterol values and dietary cholesterol intakes. As a group, the SDA vegetarians had significantly lower levels of plasma cholesterol and triglycerides than did the nonvegetarians. This hypolipidemic pattern in the SDA vegetarians was apparently closely related to dietary habits, sinceanother group of SDA who were nonvegetarian had significantly higher plasma cholesterol and triglyceride levels than their vegetarian counterparts. Both the dietary intake of cholesterol and the percentage absorption of cholesterol were lower in vegetarians than in nonvegetarians. The mass of cholesterol absorbed increased linearly with the mass of cholesterol ingested in all groups, but no relationship could be demonstrated between absorbed cholesterol and plasma cholesterol concentration.