Evidence for unmyelinated C fibres and inflammatory cells in human varicose saphenous vein

Ligustrazine mitigates chronic venous disease-induced pain hyperalgesia through desensitization of inflammation-associated TRPA1 activity in DRG

ETHNOPHARMACOLOGICAL RELEVANCE

Ligustrazine, an important active ingredient extracted from Ligusticum chuanxiong hort, has been widely used to cure cardiovascular diseases and exerts an analgesic effect.

AIMS OF THIS STUDY

The aim of this study is to investigate whether ligustrazine mitigates chronic venous disease (CVeD)-induced pain and to explore its underlying mechanisms.

MATERIALS AND METHODS

A mouse model of CVeD was established by vein ligature. Ligustrazine was administered intraperitoneally to CVeD mice for a single injection (20 mg/kg, 100 mg/kg, and 200 mg/kg) or once a day for three weeks (100 mg/kg and 200 mg/kg), and TRPA1 overexpressed HEK 293 cells were treated with ligustrazine (600 μM) in the presence of mustard oil (100 μM) for 2 min. Patch clamp and calcium imaging were used to measure the inhibitory response of ligustrazine on DRG neurons and TRPA1 transfected HEK293 cells.

RESULTS

The present results showed that mice receiving vein ligature surgery exhibited obvious pain hypersensitivity to mechanical, cold and thermal stimuli, whereas ligustrazine significantly reversed the pain hyperalgesia in CVeD mice. Furthermore, ligustrazine desensitized transient receptor potential ankyrin 1 (TRPA1) activity in the dorsal root ganglion (DRG) neurons, resulting in suppressing the DRG neuronal excitability in the CVeD mice. However, ligustrazine could not directly inhibit the response of TRPA1 transfected HEK293 cells to mustard oil. Strikingly, ligustrazine restricted the macrophage infiltration and decreased the mRNA levels of Interleukin-1β (IL-1β) and NOD-like receptor protein 3 (NLRP3) in the DRG neurons of the CVeD mice.

CONCLUSIONS

The present study provided evidence that ligustrazine alleviated pain hypersensitivity to mechanical, cold and thermal stimuli in CVeD mice. Ligustrazine could weaken the activity of TRPA1 in the DRG to mitigate CVeD-induced pain hyperalgesia mainly through inhibition of inflammation. Our findings identify that ligustrazine may be a new therapeutic agent for the treatment of CVeD-induced pain.

Impaired Lymphatic Drainage and Interstitial Inflammatory Stasis in Chronic Musculoskeletal and Idiopathic Pain Syndromes: Exploring a Novel Mechanism

A normal functioning lymphatic pump mechanism and unimpaired venous drainage are required for the body to remove inflammatory mediators from the extracellular compartment. Impaired vascular perfusion and/or lymphatic drainage may result in the accumulation of inflammatory substances in the interstitium, creating continuous nociceptor activation and related pathophysiological states including central sensitization and neuroinflammation. We hypothesize that following trauma and/or immune responses, inflammatory mediators may become entrapped in the recently discovered interstitial, pre-lymphatic pathways and/or initial lymphatic vessels. The ensuing interstitial inflammatory stasis is a pathophysiological state, created by specific pro-inflammatory cytokine secretion including tumor necrosis factor alpha, interleukin 6, and interleukin 1b. These cytokines can disable the local lymphatic pump mechanism, impair vascular perfusion via sympathetic activation and, following transforming growth factor beta 1 expression, may lead to additional stasis through direct fascial compression of pre-lymphatic pathways. These mechanisms, when combined with other known pathophysiological processes, enable us to describe a persistent feed-forward loop capable of creating and maintaining chronic pain syndromes. The potential for concomitant visceral and/or vascular dysfunction, initiated and maintained by the same feed-forward inflammatory mechanism, is also described.

Venous leg symptoms, ecchymosis, and coldness in patients with peripheral varicose vein: A multicenter assessment and validation study (VEIN-VIOLET study)

OBJECTIVES

We aimed to evaluate peripheral varicose vein symptoms including ecchymosis and coldness by using the Venous Insufficiency Epidemiological and Economic Study-Quality of Life/Symptoms (VEINES-QoL/Sym) questionnaire.

METHODS

A total of 1120 patients were enrolled to the analysis after the exclusion of 199 patients who did not match the inclusion criteria. Patients were asked to answer the VEINES-Sym questionnaire and questions about ecchymosis and coldness. Scores of ecchymosis and coldness were calculated similar to VEINES-Sym questionnaire. Classifications of peripheral varicose vein were made according to the clinical part of clinical, etiological, anatomical, and pathophysiological classification system and patients with grade 2 or higher were considered as positive for peripheral varicose vein.

RESULTS

Frequency of symptoms present in the VEINES-Sym instrument, ecchymosis and coldness were significantly higher in patients with peripheral varicose vein. Mean score of each symptom was significantly lower in peripheral varicose vein patients including scores of ecchymosis and coldness. Logistic regression analysis revealed that presence of hemorrhoids and all symptoms in VEINES-Sym questionnaire except restless leg were significantly and independently associated with peripheral varicose vein. Besides, ecchymosis (odds ratio: 2.04, 95% confidence interval: 1.34-3.08, p = 0.008) but not coldness was significantly and independently associated with peripheral varicose vein. There was also significant correlation of VEINES-Sym score with ecchymosis (r = 0.43, p < 0.001) and coldness (r = 0.47, p < 0.001).

CONCLUSIONS

Venous leg symptoms present in VEINES-Sym questionnaire except restless legs, presence of hemorrhoids and ecchymosis are significantly and independently associated with peripheral varicose vein. Not only ecchymosis but also coldness has shown an independent association with total VEINES-Sym score.

CEAP clinical classes C0S-C4: differences, similarities and role of Ruscus + HMC + vitamin C in patients with chronic venous disease

Since the publication of the CEAP classification, new research has enriched our knowledge; notably on the heritability of CVD and the genetic and environmental factors involved in this condition, as well as the symptoms apparent within the spectrum of the CEAP clinical classes and the benefits of medical treatment. Using the CEAP classification as a special theme, a symposium with the same title as the present paper was held at the annual meeting of the 2019 European Venous Forum. The lectures presented much valuable information, from which some key points can be extracted. The influence of environmental factors was demonstrated, and the fact that a large amount of information can be obtained from comprehensive history taking. There is robust evidence for heritability. Many candidate genes/loci have been identified, potentially offering new targets for treatment. More research is needed, notably using genome-wide association studies and also on microbiota, which may play a role in CVD through the inflammation pathway. Ruscus + HMC + vitamin C acts by increasing venous and lymphatic tone, protecting microcirculation, and reducing inflammation. It improves quality of life in C0S to C3 CVD patients, while a review of clinical studies and a meta-analysis have confirmed its clinical efficacy across a wide spectrum of CVD clinical classes: C0S, C1S, C2, C3 and C4. It has been awarded a Grade 1A recommendation by the international guidelines.

Symptoms in Dilating Venous Disease

Lower extremity venous diseases or insufficiency include clinically deteriorating conditions with morphological and functional alterations of the venous system, including venous hypertension, vascular wall structural abnormality, and venous valvar incompetency in association with an inflammatory process. In fact, the same pathophysiological processes are the main underlying mechanisms of other venous insufficiencies in different vascular territories such as Peripheral Varicose Vein (PVV), varicocele, Pelvic Varicosities or Congestion Syndrome (PCS) and Hemorrhoidal Disease (HD). Regarding the anatomical continuity of lower extremity venous system, urogenital system (pampiniform plexus in male and broad ligament and ovarian veins in female) and anorectal venous system, it is reasonable to expect common symptoms such as pain, burning sensation, pruritis, swelling, which arise directly from the involved tissue itself. High coexistence rate of PVV, varicocele/PCS and HD between each other underlines not only the same vascular wall abnormality as an underlying etiology but also the existence of common symptoms originating from the involved tissue in dilating venous disease. Accordingly, it might be reasonable to query the common symptoms of venous dilating disease in other venous vascular regions in patients with complaints of any particular venous territory.

Effect of Diosmin Administration in Patients with Chronic Venous Disorders on Selected Factors Affecting Angiogenesis

Diosmin is a natural compound with a wide range of biological activity, e.g., it improves lymphatic drainage, supports microcirculation, and increases venous tone, and venous elasticity, hence, it is applied in the pharmacotherapy of chronic venous disorders (CVD). The aim of this study was to assess the correlation between diosmin administration (2 × 600 mg daily) in patients suffering from CVD and the levels of selected factors influencing angiogenesis, which are involved in CVD pathophysiology. Thirty-five CVD patients were examined. Levels of plasma tumor necrosis factor alpha (TNF alpha), vascular endothelial growth factor (VEGF-A and VEGF-C); angiostatin, interleukin 6 (IL-6), fibroblast growth factor 2 (FGF2); and plasminogen (PLG) were measured with an Elisa assay before and after three months of diosmin administration. The clinical symptoms of CVD were monitored using ultrasound images, echo Doppler assay, visual analogue scale (VAS), and measurement of the leg circumference. The average content of TNF alpha, VEGF-C, VEGF-A IL-6, and FGF2 decreased after the therapy with diosmin in a significant manner; with p < 0.001, p < 0.05, p < 0.05, p < 0.01, and p < 0.01, respectively, and a significant (p < 0.05) increase in the plasma angiostatin level after the three-month treatment was found. A significant (p < 0.05) decrease in edema and the average leg circumference of the patients was observed after the therapy. Diosmin influences the angiogenic and inflammatory mechanisms involved in the pathophysiology of edema presented in patients with a different class of CVD.

Functional chronic venous disease: A systematic review

Objectives

Functional chronic venous disease is an underestimated syndrome quite present in the general population. It affects up to 20% of the general population and is based on the presence of venous symptoms without instrumental evidence of anatomic and morphologic damage. The aim of this review article is to provide the reader with the most updated information on this phenomenon.

Methods

Medline and Scopus databases were searched without time limit using the key-word: ‘Functional chronic venous disease of legs’, C0s patients. We decided to include all the studies conducted about functional chronic venous disease. Randomised trials, cohort studies and reviews were contemplated in order to give a breadth of clinical data. Only publications in English were considered. We excluded all the studies with insufficient statistical analysis, possible biases and contradictions, not clear end-points, inconsistent or arbitrary conclusions.

Results

Of the 326 records found, after removal of 68 duplicates, 143 matched our inclusion criteria. After reading the full-text articles, 133 manuscripts were excluded. Ten full text articles were assessed for eligibility and four studies were excluded because of the following reasons: (a) no specific or important content and (b) insufficient data; the final set included six articles.

Conclusions

Functional chronic venous disease is a complex syndrome and further evidences are needed in order to assess the pathophysiology, the morbidity and the correct treatment of this venous dysfunction.

Psychosomatic disorder in phlebology

According to population-based studies, the prevalence of feelings of heaviness, swelling and pain in the legs is around 50 %. These feelings are often not accompanied by clinically detectable changes, but are the inevitable and generally unrecognised consequences of the increase in leg volume caused by standing still. We assume that the physiological change is detected as part of the constant information about the internal milieu that is sent to the corresponding centres in the brain. This information is modified by many factors, including emotion and – depending on the situation – is either appropriately perceived as an unpleasant sensation of swelling or not even noticed. These feelings can result in an impairment of vitality and depression. In some cases, a thorough phlebological work-up can reveal an occult organic venous disease, so that the feelings can be traced to a somatic cause. Feelings have a psychological and a somatic component; they are not imaginary. It is up to the doctor to discern the individual importance of the two components and to draw the appropriate conclusions regarding treatment.

Loss of nerve fibers in the oviduct isthmus in women with hydrosalpinx

Apart from the abnormalities of tubal anatomy, the main concern linked to infertility is impaired tubal motility associated with hydrosalpinx, which is thought to be controlled by hormones and nerves. The objective of this study was to determine the distribution of nerve fibers in the oviduct isthmus in women with and without hydrosalpinx. Histological sections of the oviduct isthmus tissue were obtained from 18 women undergoing salpingectomy for hydrosalpinx, and from 15 women undergoing hysterectomy and salpingectomy for benign gynecologic diseases. The tissues were immunohistochemically stained for protein gene product (PGP) 9.5, protein S100, neuropeptide tyrosine (NPY), and vasoactive intestinal peptide (VIP) to reveal all nerve fibers, as well as sympathetic and parasympathetic nerve fibers, in the oviduct isthmus. We detected the presence of PGP9.5, S100, VIP, and NPY-immunoreactive nerve fibers in the oviduct isthmus in all study subjects. However, the densities of PGP9.5, S100, VIP, and NPY-immunoreactive nerve fibers in the oviduct isthmus were all significantly decreased in women with hydrosalpinx compared with those in women without hydrosalpinx (P<0.01). Our results suggest that reduced nerve fibers in the oviduct isthmus in women with hydrosalpinx compared with women without hydrosalpinx may have an important function in the mechanism of hydrosalpinx-associated infertility.