Perioperative Management of Painful Phantom Limb Syndrome: A Narrative Review and Clinical Management Proposal.

OBJECTIVE: Painful Phantom Limb Syndrome (PPLS) occurs in 50 to 80% of patients undergoing amputation, having a great impact on quality of life, productivity and psychosocial sphere. The objective of this review is to summarize the pharmacological and non-pharmacological strategies, surgical optimization, and provide a multidisciplinary approach aimed at reducing the incidence of chronic pain associated with PPLS in patients undergoing limb amputation. METHODS: A narrative review was carried out using Medline, Pubmed, Proquest, LILACS and Cochrane, searching for articles between 2000 and 2021. Articles describing the epidemiology, pathophysiological considerations, and current treatments were selected after a screening process. RESULTS: A multidisciplinary and multimodal approach is required in PPLS, and should include the use of regional techniques, and adjuvants such as NSAIDs, ketamine, lidocaine and gabapentinoids. In addition, an evaluation and continuous management of risk factors for chronic pain in conjunction with the surgical team is necessary. CONCLUSION: The current literature does not support that a single technique is effective inthe prevention of PPLS. However, adequate acute pain control, rehabilitation and early restoration of the body scheme under a multidisciplinary and multimodal approach have shown benefit in the acute setting.

In vitro production of two chitinolytic proteins with an inhibiting effect on the insect coffee berry borer, Hypothenemus hampei (Ferrari) (Coleoptera: Curculionidae) and the fungus Hemileia vastatrix the most limiting pests of coffee crops.

Two genes from Streptomyces albidoflavus, one exochitinase (905-bp) and an endochitinase (1100-bp) were functionally expressed in Escherichia coli in form of a fusion protein with a maltose binding protein (MBP). The goal was to produce and test proteins that inhibit both the coffee berry borer insect Hypothenemus hampei and the coffee rust fungus Hemileia vastatrix. Both recombinant proteins MBP/exochitinase and MBP/endochitinase showed chitinolytic activity. When recombinant purified proteins were added to an artificial coffee-based diet for the coffee berry borer, MBP/exochitinase at a concentration of 0.5% W/W caused delayed growth of larvae and 100% mortality between days 8 and 15, while MBP/endochitinase caused 100% mortality at day 35. H. vastatrix urediniospores presented total cell wall degradation in their germinative tubes within 18 h of exposure to the proteins at enzyme concentrations of 5 and 6 mg ml-1, with exochitinase having the greatest effect. The dual deleterious effect of S. albidoflavus chitinases on two of the most limiting coffee pests worldwide, the coffee borer and the coffee rust, make them potential elements to be incorporated in integrated control strategies.