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Headaches in Pregnancy and Postpartum: ACOG Clinical Practice Guideline No. 3.

To provide updated evidence-based recommendations for the evaluation and treatment of primary and secondary headaches in pregnancy and postpartum.

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Strategically Substituted Agmatine Analogs Reduce Neuropathic Pain and Show Improved Pharmacokinetics Compared to Agmatine.

Chronic pain remains a serious issue, affecting millions in the United States. Opioids serve as the most powerful therapeutic option but show limited efficacy in neuropathic pain and consequential side-effects, such as tolerance, addiction, and respiratory depression. Development of novel drugs to treat pain, though, continues to stagnate. Additionally, in conditions in which opioids are required, adjuvants to reduce opioid-induced neuroplasticity is critical. Agmatine has been shown to reduce neuropathic pain behavior and opioid tolerance, but use remains limited due to potentially reduced CNS penetration due to its hydrophilicity. Therefore, we have developed a series of agmatine-based compounds that exhibit greater lipophilicity while exhibiting equivalent pharmacological responses (Figure 1). The goal of this study was to assess differences in pharmacokinetics and dynamics of 4 of these strategically substituted agmatines (SSAs). Our hypothesis is that these compounds will have an increased plasma half-life and CNS distribution compared to agmatine, with equivalent reductions in neuropathic pain and opioid tolerance. Analysis of the pharmacokinetics in rat plasma was done using serial sampling via jugular catheter. All in vivo experiments were reviewed and approved by the University of Minnesota IACUC and the ACURO of the Department of Defense. After intravenous administration, the SSAs exhibit 2-phase distribution and elimination and have an increased elimination half-life over agmatine (9 minutes), with SSA3 and SSA4 showing the longest (Table 1). This increased half-life aligns with the increased lipophilicity of these compounds. Additionally, SSA2 and SSA4 show large volumes of distribution, suggesting increased CNS distribution. To test the impact of these compounds in vivo, we induced neuropathic pain by performing spared nerve injury (SNI). SNI drives robust tactile hypersensitivity measured using the von Frey assay in the ipsilateral hind-paw, with the contralateral paw serving as a non-injured control. Following intravenous administration, SSA2-4 reduced SNI-induced hypersensitivity at similar doses to agmatine, showing equivalent pharmacological activity. Additionally, after chronic morphine treatment alongside co-treatment with SSA1 and SSA2, opioid reduction in the warm water (52.5°C) tail flick response was preserved, representing a prevention of opioid tolerance. In conclusion, these chemical alterations to agmatine are able to improve pharmacokinetic parameters while maintaining the pharmacological reduction in neuropathic pain and opioid tolerance, suggesting potential as novel therapeutics to replace opioids in pain treatment.

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Sexually Dimorphic Effects of Nociceptor LKB1 on Mitochondrial Metabolism and Mechanical Allodynia After Fasting.

Pain induces metabolic stress in pain sensing neurons (nociceptors); alleviating this stress represents an avenue for treating pain. Liver kinase B1 (LKB1) is involved in maintaining energy homeostasis and is a key mediator of the cellular response to metabolic stress. If cellular energy modulation and pain relief is LKB1-dependent, then its removal could lead to metabolic imbalance and innocuous stimuli becoming painful (allodynia).

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Intrathecal Pumps.

Intrathecal drug delivery systems are a well-established intervention for chronic pain. The localized delivery of analgesics allows for reduced side effect profiles and pain scores in patients with chronic pain. Given their proven benefits and the development of novel intrathecal medications, intrathecal drug delivery systems are being used earlier in chronic pain management treatment pathways. Success is reliant on proper patient selection and mitigating the risks of various adverse events stemming from the implantation procedure, medications, and the device itself. This article discusses patient selection criteria, medication selection, risks, complications, supporting data, and future directions of intrathecal drug delivery systems.

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Update on Idiopathic Intracranial Hypertension Management.

Idiopathic Intracranial Hypertension (IIH) is a secondary headache with a steadily growing incidence. Currently, there is little evidence to guide the treatment of IIH.

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Soluble Epoxide Hydrolase Inhibitors: Design, Synthesis, in vitro Profiling and in vivo Evaluation in Murine Models of Pain.

Epoxyeicosatrienoic acids (EETs) are endogenous chemical mediators that show anti-inflammatory, antihypertensive, and analgesic effects. Soluble epoxide hydrolase (sEH) converts EETs to their corresponding dihydroxyeicosatrienoic acids, whereby the biological effects of EETs are modified. Therefore, inhibition of sEH has been suggested as a novel pharmacological approach for the treatment of inflammatory and pain-related disorders. Recently, we have discovered a new family of sEH inhibitors (sEHI) featuring a unique benzohomoadamantane scaffold. In a murine model of cerulein-induced acute pancreatitis, the administration of a selected candidate significantly reduced pancreatic damage and improved the health status of the animals. Herein we report further structure-activity relationships within this series of benzohomoadamantane-derived sEHI. Most of the novel derivatives were endowed with low nanomolar or even subnanomolar IC values at the human, murine and rat sEH. Further in vitro profiling (solubility, cytotoxicity, metabolic stability, selectivity, permeability, etc.) and pharmacokinetic studies permitted us to select a candidate for in vivo efficacy studies. This candidate reduced pain in the capsaicin-induced model of allodynia in a dose-dependent manner and outperformed other sEHI tested. In summary, these novel results and the previously reported studies using other families of sEHI, strongly suggest that sEH may be a target of clinical interest for managing pain. References: 1-Sun, C.-P.; Zhang, X.-Y.; Morisseau, C.; Hwang, S. H.; Zhang, Z.-J.; Hammock, B. D.; Ma, X.-C. J. Med. Chem. 2021, 64, 184-215. 2-Codony, S.; Calvó-Tusell, C.; Valverde, E.; Osuna, S.; Morisseau, C.; Loza, M.I.; Brea, J.; Pérez, C.; Rodríguez-Franco, M.I.; Pizarro-Delgado, J.; Corpas, R.; Griñán-Ferré, C.; Pallàs, M.; Sanfeliu, C.; Vázquez-Carrera, M.; Hammock, B. D.; Feixas, F.; Vázquez, S. J. Med. Chem., 2021, 64, 5429-5446. 3-McReynolds, C.; Morisseau, C.; Wagner, K.; Hammock, B. D. Adv. Exp. Med. Biol. 2020, 1274, 71-99.

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On the Flame: The Fab Fragment of Rheumatoid Arthritis.

With more than 200,000 cases per year, Rheumatoid Arthritis (RA) is one of the most common autoimmune disorders in the United States. Across the globe, up to 14 million people are affected by its symptoms of joint pain, stiffness, swelling, fatigue, and even physical deformity. Rheumatoid factors (RF) are autoantibodies that correlate with RA severity and recognize epitopes in the Fc region of its antigen immunoglobulin (Ig) G, yet it is paradoxically found circulating in the blood alongside the antigen without binding to it. According to Thomsen, et. al, a 2018 study that contested the idea of IgG aggravation as the prerequisite to RF binding, the native state of IgG is present in a closed form, where the Fab fragment shields the Fc region, only exposing the Fc effector sites when a conformational change is induced. This closed form is a result of a missing galactose between the C□2 domains of the heavy chains, thus causing the IgG to self associate, forming immune complexes to fix the complement system. The subsequent heightened inflammatory response exacerbates the progression of joint damage in RA and other severe symptoms. In this study, we examined RF in relation to IgG forming immune complexes to achieve a better understanding of the immunological progression or pathogenesis of RA. The Mahtomedi MSOE Center for BioMolecular Modeling MAPS Team used 3-D modeling and printing technology to examine structure-function relationships of Fab and Fc fragments in IgG. The visual model will be a valuable tool in developing our story.

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Analgesic and Antinociceptive Effects of (2R,6R)-hydroxynorketamine (HNK) in Mice.

Chronic pain can be challenging to treat and increases the risk of developing psychological disorders such as depression. Identifying novel treatment modalities that effectively alleviate pain is essential to improve clinical treatment and rehabilitation for patients with pain conditions. Ketamine is an effective analgesic for many types of pain. However, its widespread use is limited by its side effect profile and requirement for intranasal/intravenous administration under medical supervision. (2R,6R)-hydroxynorketamine (HNK) is a ketamine metabolite that lacks the psychotomimetic effects of its parent drug but retains ketamine's anti-stress effects. Therefore, it is natural to question whether (2R,6R)-HNK may also possess analgesic activity. Administration of (2R,6R)-HNK produced antinociception in healthy mice exposed to a noxious, painful stimulus 24 hours after injection. The dose response for the delayed-yet-persistent antinociception revealed an inverted U shape with significant antinociception at doses of 10-18 mg/kg for both sexes and 30 mg/kg in female mice. Mice pretreated with different receptor antagonists to examine the potential mechanism for (2R,6R)-HNK mediated antinociception revealed a mechanism dependent on AMPA receptors and not opioid receptors. In contrast, ketamine antinociception was not dependent on AMPA receptors and partially dependent on opioid receptors. These results demonstrate that both (2R,6R)-HNK and the parent drug ketamine produce antinociception but work via different neural mechanisms. In separate studies, (2R,6R)-HNK administration reversed mechanical allodynia associated with localized inflammatory pain induced in mice by injecting λ-carrageenan into the hind paw. The onset for this analgesia-like activity was less than 1 hour with a duration greater than 24 hours following a single administration. (2R,6R)-HNK was effective at reversing mechanical allodynia at doses of 10 & 30 mg/kg in both male and female animals. These results demonstrate (2R,6R)-HNK exhibits great promise for treating inflammatory pain in addition to other pain types. Overall, these data suggest that (2R,6R)-HNK may be a safe alternative therapy for pain that could be made widely available to patients and support the need for continued investigation and development of (2R,6R)-HNK as a novel non-opioid pain treatment.

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Peripheral Nerve Stimulation for Chronic Pain and Migraine: A Review.

Interventional pain procedures offer treatments for chronic pain conditions refractory to conservative measures. Neuromodulation, including peripheral nerve stimulation (PNS), applies electrical stimuli to neural structures to treat pain. Here we review the literature on PNS for various chronic pain conditions including neuropathic pain, postamputation pain, musculoskeletal pain, migraine, and pelvic pain.

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Global trends in anesthetic research over the past decade: a bibliometric analysis.

Anesthesia is the reversible inhibition of function of the central and/or peripheral nervous system using drugs or other means to ensure a successful operation. This inhibition is mainly manifested as a loss of sensation, especially pain.

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