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Neil Singla,1 Timothy Rogier,2 Diana S Meske3 1Lotus Clinical Research, New Providence, NJ, USA; 2Independent Consultant, Los Angeles, CA, USA; 3Chariton Pharmaceuticals, Cambridge, MA, USACorrespondence: Neil Singla, Email nsingla@lotuscro.comAbstract: To obtain broad regulatory approval for a new analgesic agent in acute postoperative pain, US and European regulatory authorities require pivotal studies in both hard (bony) tissue pain and soft tissue pain. Bunionectomy is by far the most common hard tissue pivotal trial model, in spite of the fact that the model has limited relevance to clinicians prescribing pain drugs (pain from bunionectomy is not extreme or long-lasting, and is adequately treated by existing drugs). The authors outline the experimental characteristics that make bunionectomy an appealing study model for researchers despite its lack of clinical relevance compared to larger surgeries. These include bunionectomy’s high signal-to-noise ratio (secondary to the ability to standardize surgical procedures, anesthesia and perioperative care) and relative operational simplicity (including relatively easy subject enrollment). They present an overview of the surgical and anesthetic protocols typical to modern bunionectomy studies, as well as common design paradigms, common endpoints, and other key design features of bunionectomy trials. They also provide an informal qualitative review of bunionectomy acute pain studies performed in the past 15 years, and a master table of acute pain bunionectomy trials performed from 2006– 2023. Drawing from their informal review of past studies, the authors discuss trends in rescue medication, study enrollment rates, subject demographics, and the advantages and disadvantages of bunionectomy compared with another common acute pain model, dental impaction pain (third molar extraction).Keywords: bunionectomy, acute pain clinical trials, acute postoperative pain

This first comprehensive report from Punjab province of India relates to patho-physiological alterations alongwith morpho-molecular characterisation and risk assessment of natural infections of Hymenolepis diminuta and Hymenolepis nana in 291commensal rodents including house rat, Rattus rattus (n=201) and lesser bandicoot rat, Bandicota bangalensis (n=90). Small intestine of 53.61 and 64.95 % rats was found infected with H. diminuta and H. nana, respectively with a concurrent infection rate of 50.86 %. There was no association between male and female rats and H. diminuta and H. nana infections (ᵡ2 = 0.016 and 0.08, respectively, d.f.= 1, P>0.05), while the host age had significant effect on prevalence of H. diminuta and H. nana (ᵡ2 = 28.12 and 7.18, respectively, d.f.= 1, P≤0.05) infection. Examination of faecal samples and intestinal contents revealed globular shaped eggs of H. diminuta without polar filaments (76.50 ± 3.01μm x 67.62 ± 2.42 μm), while smaller sized oval eggs of H. nana were with 4 – 8 polar filaments (47.87 ± 1.95 μm x 36.12 ± 3.05 μm). Cestode infection caused enteritis, sloughing of intestinal mucosa, necrosis of villi and inflammatory reaction with infiltration of mononuclear cells in the mucosa and submucosa. Morphometric identification of the adult cestodes recovered from the intestinal lumen was confirmed by molecular characterisation based on nuclear ITS-2 loci which showed a single band of 269 bp and 242 bp for H. diminuta and H. nana, respectively. Pairwise alignment of the ITS-2 regions showed 99.46 % similarity with sequences of H. diminuta from USA and 100 % similarity with sequences of H. nana from Slovakia, Kosice.

Dong Fang,1,* Nirmish Singla,2,* Zhengqing Bao,1,3,* Syed M Jafri,4 Xiaohong Su,1 Zhenpeng Cao,1 Gengyan Xiong,1 Lei Zhang,1 Solomon Woldu,2 Ryan Hutchinson,2 Arthur Sagalowsky,2 Yair Lotan,2 Xuesong Li,1 Jay D Raman,4 Vitaly Margulis,2 Liqun Zhou1 1Department of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, Beijing, People’s Republic of China; 2Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA; 3Department of Urology, Beijing Jishuitan Hospital, The Fourth Medical College of Peking University, Beijing, People’s Republic of China; 4Division of Urology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA*These authors contributed equally to this workCorrespondence: Liqun ZhouDepartment of Urology, Peking University First Hospital, Institute of Urology, Peking University, National Urological Cancer Center, No. 8 Xishiku Street, Xicheng District, Beijing 100034, People’s Republic of ChinaTel +86-10-83575006Fax +86-10-66551726Email zhoulqmail@sina.comPurpose: To analyze the effect of preoperative serum sodium and hemoglobin on oncologic outcomes in upper tract urothelial carcinoma (UTUC) based on a multi-center cohort from China and the United States (U.S.).Methods: We retrospectively reviewed the records of 775 patients with UTUC treated surgically at tertiary care medical facilities in China or the US from 1998 to 2015. We analyzed associations of preoperative serum sodium and hemoglobin with clinicopathological characteristics, overall survival (OS), cancer-specific survival (CSS) and intravesical recurrence free survival (IVRFS).Results: The US patients had comparatively lower serum sodium and similar hemoglobin at baseline. Preoperative low serum sodium value was associated with tumor multifocality, lymph node metastasis (LNM) and lymphovascular invasion (LVI); preoperative anemia was associated with advanced age, tumor multifocality, high tumor grade and LVI. Preoperative low serum sodium was an independent predictor of worse OS in the entire cohort; preoperative anemia was an independent predictor of worse OS and CSS in the US cohort alone, Chinese cohort alone and the combined cohort. We developed a predictive nomogram for OS which exhibited better prognostic value when it included the values of sodium and anemia, and successfully validated it in different cohorts.Conclusion: Preoperative low serum sodium and anemia could be informative in predicting worse pathologic and survival outcomes in different UTUC patient ethnic groups.Keywords: upper tract urothelial carcinoma, serum sodium, anemia, survival, China, the United States

Harold Minkowitz,1 David Leiman,1 Lucy Lu,2 Scott Reines,2 Michael Ryan,2 Mark Harnett,2 Neil Singla3 1Clinical Research, HD Research, Bellaire, TX, USA; 2Clinical Operations, Avenue Therapeutics, New York, NY, USA; 3Clinical Research, Lotus Clinical Research, Pasadena, CA, USACorrespondence: Lucy Lu Email llu@avenuetx.comPurpose: There is a need to reduce exposure to Schedule II opioids in the United States (US) due to the ongoing opioid epidemic. Schedule II opioids have higher potential for abuse and misuse than Schedule IV opioids. This Phase 3, multicenter, single-arm, open-label, multiple-dose US trial evaluated the safety and tolerability of intravenous tramadol 50 mg, a Schedule IV opioid, in the management of postoperative pain in a real-world setting, where intravenous tramadol is not yet approved for use.Patients and Methods: Patients undergoing a range of soft-tissue and orthopedic surgeries were enrolled. Intravenous tramadol 50 mg was given at hours 0, 2, 4, and every 4 h thereafter through up to 7 days of treatment. Non-opioid medications per treating physicians’ discretion were allowed if additional pain relief was needed. Endpoints included treatment-emergent adverse events (TEAEs), laboratories, vital signs, electrocardiograms (ECGs), and patient global assessment (PGA) of effectiveness.Results: A total of 251 patients were enrolled, with 4% discontinuing due to TEAE; no patient discontinued due to a lack of efficacy. Patients averaged 13 doses, resulting in average 48 h of exposure. Intravenous tramadol was well tolerated, with TEAEs consistent with known tramadol pharmacology. No unexpected findings were observed, with 95% of patients reporting study medication was good, very good, or excellent for controlling pain.Conclusion: Outcomes from this real world use study demonstrated intravenous tramadol 50 mg was safe and well tolerated in the management of postoperative pain where intravenous conventional opioids are often used. Intravenous tramadol alone or coadministered with non-opioid medication (when needed) as a multimodal combination analgesia approach resulted in high patient satisfaction with their pain relief. In light of the US opioid epidemic, reducing the exposure to conventional opioids in these patients via use of IV tramadol may be possible.Keywords: multimodal analgesia, abuse risk, Schedule II opioid, real-world study

Eugene R Viscusi,1 Franck Skobieranda,2 David G Soergel,2 Emily Cook,2 David A Burt,2 Neil Singla3 1Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA; 2Trevena Inc., Chesterbrook, PA, USA; 3Lotus Clinical Research, LLC, Pasadena, CA, USA Purpose: Oliceridine is a novel G protein-biased µ-opioid receptor agonist designed to provide intravenous (IV) analgesia with a lower risk of opioid-related adverse events (ORAEs) than conventional opioids. Patients and methods: APOLLO-1 (NCT02815709) was a phase III, double-blind, randomized trial in patients with moderate-to-severe pain following bunionectomy. Patients received a loading dose of either placebo, oliceridine (1.5 mg), or morphine (4 mg), followed by demand doses via patient-controlled analgesia (0.1, 0.35, or 0.5 mg oliceridine, 1 mg morphine, or placebo). The primary endpoint compared the proportion of treatment responders through 48 hours for oliceridine regimens and placebo. Secondary outcomes included a composite measure of respiratory safety burden (RSB, representing the cumulative duration of respiratory safety events) and the proportion of treatment responders vs morphine. Results: Effective analgesia was observed for all oliceridine regimens, with responder rates of 50%, 62%, and 65.8% in the 0.1 mg, 0.35 mg, and 0.5 mg regimens, respectively (all P

Neil Singla,1 Harold S Minkowitz,2 David G Soergel,3 David A Burt,3 Ruth Ann Subach,3 Monica Y Salamea,3 Michael J Fossler,3 Franck Skobieranda3 1Lotus Clinical Research, Pasadena, CA, 2Memorial Hermann Memorial City Medical Center, Houston, TX, 3Trevena, Inc, King of Prussia, PA, USA Background: Oliceridine (TRV130), a novel µ-receptor G-protein pathway selective (µ-GPS) modulator, was designed to improve the therapeutic window of conventional opioids by activating G-protein signaling while causing low β-arrestin recruitment to the µ receptor. This randomized, double-blind, patient-controlled analgesia Phase IIb study was conducted to investigate the efficacy, safety, and tolerability of oliceridine compared with morphine and placebo in patients with moderate to severe pain following abdominoplasty (NCT02335294; oliceridine is an investigational agent not yet approved by the US Food and Drug Administration). Methods: Patients were randomized to receive postoperative regimens of intravenous oliceridine (loading/patient-controlled demand doses [mg/mg]: 1.5/0.10 [regimen A]; 1.5/0.35 [regimen B]), morphine (4.0/1.0), or placebo with treatment initiated within 4 hours of surgery and continued as needed for 24 hours. Results: Two hundred patients were treated (n=39, n=39, n=83, and n=39 in the oliceridine regimen A, oliceridine regimen B, morphine, and placebo groups, respectively). Patients were predominantly female (n=198 [99%]) and had a mean age of 38.2 years, weight of 71.2 kg, and baseline pain score of 7.7 (on 11-point numeric pain rating scale). Patients receiving the oliceridine regimens had reductions in average pain scores (model-based change in time-weighted average versus placebo over 24 hours) of 2.3 and 2.1 points, respectively (P=0.0001 and P=0.0005 versus placebo); patients receiving morphine had a similar reduction (2.1 points; P

Neil Singla,1 Stewart W McCallum,2 Randall J Mack,2 Alex Freyer,2 Sue Hobson,2 Wei Du3 1Lotus Clinical Research, Pasadena, CA, USA; 2Research and Development, Recro Pharma, Inc., Malvern, PA, USA; 3Clinical Statistics Consulting, Blue Bell, PA, USAPostoperative pain after laparoscopic surgery is one of the major concerns of patients. Improper pain management can be associated with varied respiratory, cardiovascular, gastrointestinal, and psychological complications. Pain after laparoscopic surgery may be transient or persistent2 and opioids have traditionally been the mainstay treatment for postoperative pain.3 Increasing evidence exists to support a multimodal treatment approach for postoperative pain that reduces opioid side effects and decreases pain intensity (PI) scores.3 A proprietary nanocrystal intravenous (NIV) formulation of the non-steroidal anti-inflammatory meloxicam, a long-acting preferential cyclooxygenase-2 inhibitor, is being evaluated with the aim of providing rapid and sustained analgesia.

Tong J Gan,1 Neil Singla,2 Stephen E Daniels,3 Douglas A Hamilton,4,5 Peter G Lacouture,6,7 Christian RD Reyes,8 Daniel B Carr4,9 1Department of Anesthesiology, Stony Brook University, NY, 2Lotus Clinical Research, LLC, Pasadena, CA, 3Premier Research, Austin, TX, 4Javelin Pharmaceuticals, Inc., Cambridge, MA, 5New Biology Ventures, LLC, San Mateo, CA, 6Magidom Discovery, LLC, St Augustine, FL, 7Department of Emergency Medicine, Brown University School of Medicine, Providence, RI, 8Hospira Inc., Lake Forest, IL, 9Department of Anesthesiology, Tufts Medical Center, Boston, MA, USA Purpose: Use of nonopioid analgesics (including nonsteroidal anti-inflammatory drugs) for postoperative pain management can reduce opioid consumption and potentially prevent opioid-related adverse events. This study examined the postoperative opioid-sparing effect of repeated-dose injectable diclofenac formulated with hydroxypropyl-β-cyclodextrin (HPβCD)-diclofenac. Patients and methods: Pooled data from two double-blind, randomized, placebo- and active comparator-controlled Phase III trials were analyzed. Patients received HPβCD-diclofenac, placebo, or ketorolac by intravenous injection every 6 hours for up to 5 days following abdominal/pelvic or orthopedic surgery. Rescue opioid use was evaluated from the time of first study drug administration to up to 120 hours following the first dose in the overall study population and in subgroups defined by baseline pain severity, age, and HPβCD-diclofenac dose. Results: Overall, 608 patients received ≥1 dose of study medication and were included in the analysis. While 93.2% of patients receiving placebo required opioids, the proportion of patients requiring opioids was significantly lower for patients receiving HPβCD-diclofenac (18.75, 37.5, or 50 mg) or ketorolac (P

Billy H Cordon,1 Nirmish Singla,1 Ajay K Singla2 1Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, 2Department of Urology, University of Toledo College of Medicine, Toledo, OH, USA Abstract: The artificial urinary sphincter (AUS), which has evolved over many years, has become a safe and reliable treatment for stress urinary incontinence and is currently the gold standard. After 4 decades of existence, there is substantial experience with the AUS. Today AUS is most commonly placed for postprostatectomy stress urinary incontinence. Only a small proportion of urologists routinely place AUS. In a survey in 2005, only 4% of urologists were considered high-volume AUS implanters, performing >20 per year. Globally, ~11,500 AUSs are placed annually. Over 400 articles have been published regarding the outcomes of AUS, with a wide variance in success rates ranging from 61% to 100%. Generally speaking, the AUS has good long-term outcomes, with social continence rates of ~79% and high patient satisfaction usually between 80% and 90%. Despite good outcomes, a substantial proportion of patients, generally ~25%, will require revision surgery, with the rate of revision increasing with time. Complications requiring revision include infection, urethral atrophy, erosion, and mechanical failure. Most infections are gram-positive skin flora. Urethral atrophy and erosion lie on a spectrum resulting from the same problem, constant urethral compression. However, these two complications are managed differently. Mechanical failure is usually a late complication occurring on average later than infection, atrophy, or erosions. Various techniques may be used during revisions, including cuff relocation, downsizing, transcorporal cuff placement, or tandem cuff placement. Patient satisfaction does not appear to be affected by the need for revision as long as continence is restored. Additionally, AUS following prior sling surgery has comparable outcomes to primary AUS placement. Several new inventions are on the horizon, although none have been approved for use in the US at this point. Keywords: artificial urinary sphincter, stress urinary incontinence, post prostatectomy incontinence, prostheses and implants, review

Microstomia is a clinical condition of reduced mouth opening that can be acquired or congenital in origin. Problems associated with microstomia can be related to function, esthetics, or both. Management of microstomia due to facial burns is complex due to the presence of hypertrophic and contracture scars. Available treatment options can be broadly classified as surgical, nonsurgical, or both. Splints can be used to prevent the contraction of perioral musculature or to recuperate lost mouth opening. Various intraoral or extraoral, tooth-borne or tissue-borne, and static or dynamic appliances are in clinical use, but their designs are case specific. This case report explains the management of microstomia secondary to facial burns by using a dynamic splint in combination with intralesional injections of triamcinolone acetonide and hyaluronidase. [ABSTRACT FROM AUTHOR]