Int J Clin Exp Pathol 2016;9(3):2831-2840

www.ijcep.com /ISSN:1936-2625/IJCEP0021902

Original Article
Adhesion of leukocytes is involved in increased
-endorphin and elevated pain threshold
in obstructive jaundice
Yong Tao1*, Jinmin Zhang1*, Erliang Kong1, Shujun Pei2, Yuming Sun1, Huiting Di1, Weifeng Yu1, Feixiang Wu1
1
Department of Anesthesiology, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai,
China; 2Department of Anesthesiology, 251 Hospital of PLA, Zhang Jiang Kou, China. *Equal contributors.
Received December 14, 2015; Accepted February 25, 2016; Epub March 1, 2016; Published March 15, 2016

Abstract: The elevated pain threshold is a special change in obstructive jaundice (OJ). It does not attract enough at-
tention, which leads to over-use of opioid drugs and causes many peri-operative complications. In the present study,
-endorphin in the plasma of OJ patients was measured by ELISA. Leukocytes were isolated from peripheral blood
of the OJ and non-jaundice (Non-J) patients. The mRNA of -endorphin precursor proopiomelanocortin (POMC) and
-opioid receptor (MOR) in the leukocytes of OJ patients were measured by Real-time PCR. After treated with biliru-
bin, the leukocytes from Non-J patients were used to measure the expression of -opioid receptor and -endorphin.
Opioid-containing leukocytes were also measured by Flow Cytometry after bilirubin incubation. After the obstructive
jaundice model of rats was established by bile duct ligation (BDL), the rats were injected with ICAM-1 antibody. The
pain threshold of rats was detected and -endorphin in the plasma was measured by ELISA method. The results
showed that -endorphin was higher in the OJ patients than that in the Non-J patients. The mRNA of POMC and
MOR in the leukocytes were significantly higher in the OJ patients than that in the Non-J patients. After leukocytes
from Non-J patients were treated with bilirubin, -endorphin in the supernatant was up-regulated. The POMC mRNA
of leukocytes was also increased. Meanwhile, the number of opioid-containing leukocytes was significantly raised
after bilirubin incubation. In the rat model of OJ, elevated pain threshold was reversed after treated with ICAM-1
antibody (0.5 mg/kg, 1 mg/kg). Meanwhile, the -endorphin in the plasma was down-regulated by ICAM-1 antibody.
The results demonstrated that the up-regulation of -endorphin is probably related to the elevated pain threshold
in OJ patients. The results further suggested that the adhesion of leukocytes was involved in the up-regulation of
-endorphin and MOR as well as elevated pain threshold among OJ patients. The changes in opioid-containing leu-
kocytes are probably an alternative explanation to this special pain change in OJ patients.

Keywords: Leukocyte, -endorphin, obstructive jaundice, pain threshold, bilirubin

Introduction compared with that in controls without jaundice

[2]. The electrical basal pain threshold was sig-
Obstructive jaundice (OJ), a common clinical nificantly higher and postoperative morphine
manifestation, is frequently caused by gall- consumption was lower in patients with jaun-
stones and malignant tumors. Patients with OJ, dice [3]. The underlying mechanism needs fur-
especially for the painless jaundice, have a ther study.
markedly reduced pain perception [1]. During
perioperative period, the relative lower opioid -endorphin is an endogenous analgesic neuro-
consumption caused by the elevated pain peptide, produced from processing of the pre-
threshold leads to relative over-dosage of opi- cursor proopiomelanocortin (POMC). The incre-
oid drugs, which increases complications and ase of plasma -endorphin in OJ patients has
mortality in OJ patients, such as delayed recov- been proved and the plasma -endorphin also
ery and respiratory depression. However, this tends to increase along with the rising of biliru-
problem has not been given enough attention. bin. It is suggested that -endorphin could
In our previous studies, we have shown that the be involved in the elevated pain threshold in
intraoperative requirement of remifentanil in jaundice patients. Liver dysfunction caused by
patients with OJ was significantly decreased jaundice may lead to the decrease of the
 Leukocytes and pain threshold in obstructive jaundice

metabolism of the endogenous -endorphin, American Society of Anesthesiologists physical

which results in the increase of -endorphin. (ASA) and were aged between 20 and 70 yr.
Evidence has suggested that endogenous opi- Exclusion criteria were 1) age older than 70 yr
oid mediated antinociception in cholestatic or younger than 20 yr; 2) signicant obesity
mice due to the local effects of endogenous (body mass index >30 kg/m2); 3) a history of
opioids at sensory nerve endings [4]. The diabetes mellitus, cardiovascular, respiratory,
causes of the increase of -endorphin need fur- or renal disease; 4) hepatic encephalopathy,
ther researches. psychiatric illness, or neuropathy; 5) a history
Patients with OJ show high level of peripheral of acute or chronic pain; 6) a history of either
leukocytes. Many researches have revealed alcohol or drug abuse; 7) a history of opioids
that some leukocytes in peripheral blood could application within a week. Peripheral blood was
secrete opioid peptide, mainly -endorphin and obtained before elective surgery for peripheral
parts of dynorphin and encephalin under cer- blood leukocytes.
tain pathophysiological conditions, such as
jaundice [5, 6]. Various studies have shown Measurement of - endorphin in plasma
that cyclophosphamide, cyclosporine A and
-endorphin level was measured using a Elisa
other antineoplastic drugs compromised the
analgesic effects in the elevated pain threshold -endorphin Kit (Sigma, St. Louis, MO, USA)
models caused by stress due to the inhibition and resultant optical density was determined
of the activation and adhesion of opioid-con- using a microplate reader of hermo Multiskan
taining leukocytes [7-9]. Whether the opioid- MK3 (Thermo Fisher Scientific, MA, USA) at
containing leukocytes are involved in the 450 nm. It was performed according to the
increase of -endorphin and the elevated pain manufacturers instructions [11]. Results were
threshold in OJ patients requires further expressed as ng/mL.
studies.
Measurement of MOR mRNA and POMC
In the present study, -opioid receptor and mRNA expression in leukocytes
-endorphin expression in the leukocytes of OJ
patients were measured. The leukocytes from After low-speed centrifugation of peripheral
Non-J patients were treated with bilirubin and blood for 15 min, blood cells were collected
then the expression of -opioid receptor and and red blood cells were damaged. Then cells
-endorphin were detected to investigate in the leukocytes layer were collected and puri-
whether opioids in leukocytes were involved in fied. The MOR mRNA and POMC mRNA in leuko-
the change of pain threshold in OJ patients. cytes were detected by Real time-PCR meth-
Meanwhile, ICAM-1 antibody were used in the ods. The PCR primers of -receptor were as
rat model of obstructive jaundice to further follows: 5-GCCCTTCCAGAGTGTGAATTAC-3 (for-
investigate whether the adhesion of leukocytes ward); 5-GTGCAGAGGGTGAATATGCTG-3 (re-
was related to the up-regulation of -endorphin verse). The PCR primers of POMC were as
and elevated pain threshold in OJ.
follows: 5-CCCCTACAGGATGGAGCACTT-3 (for-
Patients and methods ward); 5-GATGGCGTTTTTGAACAGCGT-3 (re-
verse).
Patients
The Real-Time PCR Detection System (Roche,
The study was approved by the Institutional Switzerland) continually monitors the increase
Ethics Committee (Eastern Hepatobiliary Sur- in fluorescence, which is directly proportional
gery Hospital, Shanghai, China), and informed to the PCR product [12].
consent was obtained from each patient under-
going elective surgery for hepatobiliary diseas- Opioid-containing leukocytes counted by flow
es. Eighteen patients with obstructive jaundice cytometry
(serum total bilirubin >20 M) caused by neo-
plasm of the bile duct or the head of the pan- The leukocytes from non-J patients (n=6) were
creas were included in the study (OJ patients) collected and incubated on 12-well plates.
[10]. Sixteen men with pancreas tumor and no After the numbers of the cells were counted,
jaundice (serum total bilirubin <20 M) were bilirubin of 102 M was added into each plate.
included as control (non-J patients). All patients The same volumes of PBS were added as con-
were rated status I or II according to the trol. After incubated with bilirubin for 24 h, the

2832 Int J Clin Exp Pathol 2016;9(3):2831-2840

 Leukocytes and pain threshold in obstructive jaundice

Table 1. Demographic data of the patients tion, 0.5 mg/kg and 1 mg/kg ICAM-1 anti-
Non-J OJ P Value bodies were injected intravenously in the
ICAM-1 0.5 mg/kg group and ICAM-1 1 mg/
N 16 18
kg group respectively after the measure-
Age (y) 53.69.0 55.29.6 0.620
ment of pain threshold. The same volumes
Weight (Kg) 63.24.7 64.110.3 0.734
of PBS were injected in the PBS and Sham
Total bilirubin (mol/l) 10.53.4 183.6117.8 <0.01 group as well. After 0.5, 1, 2 hours of injec-
Bile acids (mol/l) 9.46.3 70.349.8 <0.01 tion, mechanical pain thresholds were
Albumin (g/l) 42.42.5 36.63.9 <0.01 detected using von Frey. The -endorphin
ALT (U/l) 26.814.5 143.085.3 <0.01 concentrations in the plasma were also
There was no difference in age, weight, and body mass index be- measure by ELISA method.
tween two groups (P>0.05). Total bilirubin, bile acids, and alanine
aminotransferase in plasma were significantly higher in OJ group Establishment of obstructive jaundice mod-
compared to those in Non-J group (P<0.01). Obstructive jaundice
els
was indicated as OJ; patients without jaundice were indicated as
Non-J patients.
The obstructive jaundice model was estab-
lished by bile duct ligation (BDL). After rats
leukocytes were harvested and incubated with were anesthesia by the injection of chloral
anti- receptor antibodies (1:20; Sigma, St. hydrate (300 mg/kg, i.p.), the main bile duct
Louis, MO, USA) at room temperature for 30 was ligated using two ligatures approximately
minutes. The FITC-labeled secondary antibod- 0.5 cm apart and then transected at the mid-
ies (1:300; Sigma, St. Louis, MO, USA) were point between the two ligatures. The bile duct
then added and incubated for 1 h at room tem- was isolated without ligation in the sham rats
perature. After supernatant and suspending after opening the abdomen. Cholestasis was
cells were removed, 500 L of 1% paraformal- confirmed by increased serum level of bilirubin
dehyde was added and then measured by Flow as well as intact bile duct ligature and proximal
Cytometry (Beckman Coulter Inc, BREA, CA, dilation of the bile duct at the time of sacrifice
USA). -endorphin in supernate was also mea-
[3].
sured by ELISA.
Mechanical pain threshold testing
Animals

This study was approved by the Animal Care Mechanical pain threshold testing was per-
Committee of the Second Military Medical formed using Electronic von Frey hair (IITC Life
University and performed in accordance with Science, Woodland Hills, CA, USA). Rats were
the Guide for the Care and Use of Laboratory acclimated daily for 10 min/day to the test envi-
Animals. Adult male Sprague-Dawley rats ronment (a Plexiglass box on a metal grid sur-
(weighing 200-250 g) were obtained from the face) for 3 days. On test days, rats were allowed
Shanghai Slac Experimental Animal Centre to acclimate for 5-10 min. The nociceptive stim-
(Shanghai, China). The rats were housed in indi- ulus, a single rigid filament attached to a hand-
vidual cages in a temperature-controlled room held transducer, was applied perpendicularly to
with alternating 12 h light/dark cycles. Food the medial surface of the hind paw with increas-
was withheld 8 h before the starting of the ing force. The endpoint was taken as nocifen-
experiments, but all animals had free access to sive paw withdrawal accompanied by head
water. Monitoring for health problems was per-
turning, biting and/or licking. As soon as this
formed three times a day and no death was
reaction occurred, the required pressure was
found during the experiments. The rats were
euthanized by CO2 after the whole experiments indicated in grams, and this value was consid-
were finished. ered to be the individual paw withdrawal thresh-
old (PWT) value [13]. Each rat was tested in
Grouping triplicate per time point and the average for the
three measurements was then calculated. Set
SD rats were randomly divided into 4 groups: a 80 g as the maximum.
sham group, a PBS group (n=8), an ICAM-1 0.5
mg/kg (n=8, intravenous injection of 0.5 mg/ Statistical analysis
kg of ICAM-1 antibody) and an ICAM 1 mg/kg
group (n=8, intravenous injection of 0.5 mg/kg All the data were expressed as mean stan-
of ICAM-1 antibody). On the 7th day after liga- dard deviation and analyzed by SPSS 17.0 sta-
2833 Int J Clin Exp Pathol 2016;9(3):2831-2840
 Leukocytes and pain threshold in obstructive jaundice

Elevation of -endorphin in
plasma among OJ patients

The blood samples of OJ and

Non-J patients were collected
and -endorphin in plasma
was measured by ELISA. The
results in Figure 1 showed
that plasma -endorphin was
markedly higher in the OJ
group compared to the Non-J
group (P<0.05). The results
suggested that the elevated
pain threshold in OJ patients
Figure 1. -endorphin expression in plasma of patients. The plasma might be caused by the eleva-
-endorphin increased in the OJ patients compared to Non-J patients de- tion of -endorphin.
tected by ELISA assay (*P<0.05). Obstructive jaundice was indicated as OJ;
patients without jaundice were indicated as Non-J patients. Up-regulation of MOR and
POMC mRNA in leukocytes of
OJ patients

The MOR and POMC mRNA

in leukocytes of OJ and Non-J
patients were detected with
real-time PCR method. As
shown in Figure 2, MOR mRNA
increased significantly in the
OJ patients compared to the
Non-J patients (P<0.05). Simi-
larly, the mRNA of POMC
was also higher in the OJ
patients compared to the
Non-J patients (Figure 3,
P<0.05). The results suggest-
Figure 2. POMC mRNA of leukocytes from OJ patients. The results of real- ed that the elevation of
time PCR showed that MOR mRNA in leukocytes increased significantly in the -endorphin in the plasma
OJ patients compared to the Non-J patients (*P<0.05). Obstructive jaundice could result from the high
was indicated as OJ; patients without jaundice were indicated as Non-J pa- expression of POMC in the
tients; -opioid receptor was indicated as MOR.
leukocytes. It also indicated
that the elevated pain thresh-
tistical software. Statistical analyses were old in OJ patients could relate to the up-regula-
performed using one-way or two-way ANOVA. It tion of MOR in leukocytes.
was considered statistically significant when
P<0.05. Changing of opioid system in leukocytes after
bilirubin stimulation
Results
To observe the changing of MORs and
Demographic data -endorphin expression during jaundice, leuko-
cytes from Non-J patients were incubated with
As shown in Table 1, there was no difference in bilirubin in vitro. The -endorphin in the super-
age, weight, and body mass index between two natants were increased after incubation with
groups (P>0.05). Serum concentrations of total bilirubin for 24 h (Figure 4, P<0.05). Meanwhile,
bilirubin, bile acids, and alanine aminotransfer- the POMC mRNA of leukocytes increased mark-
ase were significantly higher in the OJ group edly (Figure 5, P<0.05). The results in Figure 6
compared to the Non-OJ group (P<0.01). showed that the numbers of opioid-containing

2834 Int J Clin Exp Pathol 2016;9(3):2831-2840

 Leukocytes and pain threshold in obstructive jaundice

BDL (Figure 7, P<0.05). There

was no difference in mechani-
cal pain thresholds in three
BDL groups (P>0.05) at 0.5 h.
After 1 h and 2 h of treatment,
mechanical pain thresholds
significantly decreased in the
ICAM-1 0.5 mg/kg group and
ICAM 1 mg/kg group com-
pared to those of the PBS
group (P<0.05). The results
indicated that the leukocytes
adhesion could be involved in
the elevation of pain thre-
sholds.
Figure 3. POMC mRNA of leukocytes from OJ patients. The POMC mRNA in
leukocytes increased markedly in the OJ patients compared to the Non-J
Down-regulation of
patients as detected by real-time PCR (*P<0.05). Obstructive jaundice was
indicated as OJ; patients without jaundice were indicated as Non-J patients; -endorphin after ICAM-1 an-
proopiomelanocortin was indicated as POMC. tibody treatment

After 2 h of treatment with

ICAM-1 antibody, -endorphin
concentrations in the plasma
were markedly decreased in
the ICAM-1 0.5 mg/kg group
and ICAM 1 mg/kg group as
compared to those in the PBS
group (Figure 8, P<0.05). It
revealed that the leukocytes
adhesion could lead to the
up-regulation of -endorphin
in OJ state.

Discussion

The elevated pain threshold is

a special change in obstruc-
Figure 4. -endorphin expression in the supernatant of leukocytes from OJ tive jaundice with unknown
patients after bilirubin incubation. The levels of -endorphin in the super- mechanism. In the current
natant of the isolated leukocytes from Non-J patients were significantly in- study, -endorphin in the
creased after incubation with bilirubin for 24 h as detected by ELISA method. plasma as well as the mRNA
(*P<0.05) Patients without jaundice were indicated as Non-J patients.
of POMC and MOR in the leu-
kocytes were found increased
leukocytes were significantly increased after in the OJ patients. After leukocytes from Non-J
incubation with bilirubin (Ratio of opioid-con- patients were treated with bilirubin, -endorphin
taining leukocytes: control group 0.220.07%, level in the supernatant was up-regulated. The
bilirubin group 3.340.92%). The results sug- POMC mRNA of leukocytes was also increased.
gested that bilirubin be related to the increase Meanwhile, the numbers of opioid-containing
of opioid receptors and -endorphin in leuko- leukocytes were significantly increased after
cytes of OJ patients. bilirubin incubation. In the OJ rats treated with
ICAM-1 antibodies, the elevated pain thresh-
Decrease of pain thresholds after ICAM-1 anti- olds were reversed along with the down-regula-
body treatment tion of -endorphin in the plasma. The results
demonstrated that the up-regulation of
Compared to the sham group, mechanical pain -endorphin and MOR in the leukocytes could
thresholds increased in three groups receiving be involved in the elevated pain threshold in OJ.

2835 Int J Clin Exp Pathol 2016;9(3):2831-2840

 Leukocytes and pain threshold in obstructive jaundice

The adhesion of leukocytes

could be probably related
to the up-regulation of -
endorphin and MOR as well
as the elevated pain thresh-
old in OJ.

The increase of endogenous

opioids has been proved in
OJ, which induces pruritus,
hyporesponsiveness, hepatic
encephalopathy and other
symptoms [14, 15]. The up-
regulation of enkephalin in
keratinocytes of patients with
OJ has been confirmed in
our previous study and could
Figure 5. POMC mRNA of leukocytes from Non-J patients after bilirubin in- be relevant to increased
cubation. The POMC mRNA of leukocytes from Non-J patients increased pain thresholds [3]. The
markedly after bilirubin incubation as detected by real-time PCR (*P<0.05).
Obstructive jaundice was indicated as OJ; patients without jaundice were indi-
increase of -endorphin in
cated as Non-J patients; proopiomelanocortin was indicated as POMC. the plasma of OJ patients
and rats was also found in
the present study, which was
in agreement with the study
that the state of antinocicep-
tion was selectively reversed
by opioid antagonist nalox-
one in rats with cholestasis
[16]. We further demonstrat-
ed that POMC mRNA in the
peripheral leukocytes were
increased, which suggested
that the increased -endor-
phin could originate from leu-
kocytes. Patients with OJ
were mostly accompanied
with systemic inflammatory
response, which increased
the numbers of leukocytes
in jaundice patients. The opi-
oid-rich leukocytes are the
source of endogenous opioid
and play a key role in periph-
eral antinociception [17]. The
leukocyte-derived -endorp-
Figure 6. Detection of opioid-containing leukocytes from Non-J patients after hin as well as enkephalin,
bilirubin incubation. After incubation with different concentrations of bilirub dynorphin and endomorphin
in (102 M) for 24 h, the results of FCM showed that the numbers of opioid- are important in periph-
containing leukocytes from Non-J patients in the bilirubin group were signifi- eral antinociception [18-20].
cantly increased compared to that in the control group (*P<0.05). The ratio of
opioid-containing leukocytes/total leukocytes was increased significantly (Ra-
Thus, -endorphin from the
tio of opioid-containing leukocytes: control group 0.220.07%, bilirubin group peripheral leukocytes seems
3.340.92%). Patients without jaundice were indicated as Non-J patients. to be involved in the elevated

2836 Int J Clin Exp Pathol 2016;9(3):2831-2840

 Leukocytes and pain threshold in obstructive jaundice

way, opioids directly acted

on opioid receptors to ex-
ert peripheral antinociception
effect [25, 26]. ICAM-1 medi-
ates the combination of the
opioid-containing leukocytes
and endothelial cells, which
accelerates leukocytes accu-
mulation and -endorphin
production. Previous studies
revealed that inhibition of
ICAM-1 by ICAM-1 antibody
eliminated the analgesic
effect of endogenous opioids
Figure 7. Mechanical pain thresholds after ICAM-1 antibody treatment. Me-
chanical pain thresholds of rats were measured by VonFrey. Compared to through reducing the num-
the sham group, mechanical pain thresholds increased in the three groups bers of opioid-rich leukocytes
receiving BDL (*P<0.05). No difference was found in the ICAM-1 0.5 mg/ and/or inhibiting the adhe-
kg group and ICAM 1 mg/kg group as compared to that in the PBS group sion of the leukocytes with
0.5 h after ICAM-1 antibody treatment (P>0.05). After 1 h and 2 h of treat- sensory nerves [27-29]. The
ment, mechanical pain thresholds significantly decreased in the ICAM-1 0.5
mg/kg group and ICAM 1 mg/kg group compared to those in the PBS group current study demonstrated
(#P<0.05). Intercellular Adhesion Molecule 1 was indicated as ICAM-1. that the elevated pain thresh-
olds in the OJ rats were
reversed by ICAM-1 antibod-
ies, which indicated that leu-
kocytes adhesion to sensory
nerve could be important in
pain thresholds change in OJ.
In inflammatory state, the
up-regulation of endogenous
opioids, such as -endor-
phin, could increase the
expression of inflammatory
factors and then activate
inflammatory cells [5, 30],
which played a role of posi-
tive feedback. In this re-
search, the decrease of -
Figure 8. -endorphin in plasma after ICAM-1 antibody treatment. After 2 h of endorphin in the plasma
treatment with ICAM-1 antibodies, -endorphin in rats plasma were markedly by ICAM-1 antibodies could
decreased in the ICAM-1 0.5 mg/kg group and ICAM 1 mg/kg group as com-
pared to that in the PBS group (*P<0.05). Intercellular Adhesion Molecule 1
also reduce the inflammatory
was indicated as ICAM-1. response and reduce pain
thresholds.

pain in OJ, which was also supported by Lisa The pathogenesis of elevated pain in OJ is
Nelson [4] that endogenous opioid-mediated still unknown. It has been suggested that the
antinociception in cholestatic mice was periph- symptom could arise as a result of an interac-
erally mediated. tion between nerve endings and substances
retained in the plasma [31]. In this context, bile
The peripheral antinociception effect of opioid- acids have been considered as candidates
rich leukocytes does not depend on the release [32]. Previous studies have revealed that bile
of opioids into the plasma [21]. The opioid-rich acid induced analgesia through the activation
leukocytes were recruited surrounding the of TGR5 receptors, a G protein-coupled plasma
sensory nerve and adhered to the endings of membrane receptor for bile acids [1]. In the
sensory nerve through adhesion molecules current study, bilirubin was considered to be a
such as ICAM-1, integrin [22-24]. Through this candidate, since cholestatic patients showed

2837 Int J Clin Exp Pathol 2016;9(3):2831-2840

 Leukocytes and pain threshold in obstructive jaundice

increased bilirubin concentrations in the D, Bassat Q, Mandjate S, Macete E, Alonso P,

Abdulla S, Salim N, Juma O, Shomari M, Shubis
plasma [33]. The hypothesis was supported
K, Machera F, Hamad AS, Minja R, Mtoro A,
by the results that intrathecal injection of biliru-
Sykes A, Ahmed S, Urassa AM, Ali AM,
bin induced an anti-nociception effect in rats Mwangoka G, Tanner M, Tinto H, DAlessandro
(unpublished data) and that bilirubin modulat- U, Sorgho H, Valea I, Tahita MC, Kabor W,
ed the currents of neurons in a concentration- Oudraogo S, Sandrine Y, Guiguemd RT,
dependent manner [34]. The vitro study Oudraogo JB, Hamel MJ, Kariuki S, Odero C,
showed that POMC mRNA of leukocytes Oneko M, Otieno K, Awino N, Omoto J,
and opioid-containing leukocytes increased Williamson J, Muturi-Kioi V, Laserson KF,
after bilirubin incubation, which suggested Slutsker L, Otieno W, Otieno L, Nekoye O, Gondi
bilirubin as an alternative potential mediator. S, Otieno A, Ogutu B, Wasuna R, Owira V, Jones
D, Onyango AA, Njuguna P, Chilengi R, Akoo P,
Conclusion Kerubo C, Gitaka J, Maingi C, Lang T, Olotu A,
Tsofa B, Bejon P, Peshu N, Marsh K, Owusu-
In conclusion, this study demonstrated -end- Agyei S, Asante KP, Osei-Kwakye K, Boahen O,
orphin and MOR were up-regulated in OJ Ayamba S, Kayan K, Owusu-Ofori R, Dosoo D,
patients. Inhibition of adhesion of leukocytes Asante I, Adjei G, Adjei G, Chandramohan D,
reversed the elevated pain threshold along with Greenwood B, Lusingu J, Gesase S, Malabeja
the down-regulation of -endorphin and MOR A, Abdul O, Kilavo H, Mahende C, Liheluka E,
caused by OJ. Leukocytes adhesion could prob- Lemnge M, Theander T, Drakeley C, Ansong D,
Agbenyega T, Adjei S, Boateng HO, Rettig T,
ably be related to the up-regulation of
Bawa J, Sylverken J, Sambian D, Agyekum A,
-endorphin and MOR, and further resulted in
Owusu L, Martinson F, Hoffman I, Mvalo T,
elevation of pain threshold in OJ patients. Kamthunzi P, Nkomo R, Msika A, Jumbe A,
Chome N, Nyakuipa D, Chintedza J, Ballou WR,
Acknowledgements
Bruls M, Cohen J, Guerra Y, Jongert E, Lapierre
D, Leach A, Lievens M, Ofori-Anyinam O,
This study was supported by the National Vekemans J, Carter T, Leboulleux D, Loucq C,
Natural Science Foundation of China (No. Radford A, Savarese B, Schellenberg D,
81000155). Sillman M, Vansadia P; RTS, SClinical Trials
Partnership. First results of phase 3 trial of
Disclosure of conflict of interest RTS, S/AS01 malaria vaccine in African chil-
dren. N Engl J Med 2011; 365: 1863-75.
None. [3] Tao KM, Tao Y, Chen CY, Yang LQ, Lu ZJ, Sun
YM, Huang SD, Yu WF. Proteinase-activated re-
Address correspondence to: Dr. Weifeng Yu and
ceptor 1 contributed to up-regulation of en-
Dr. Feixiang Wu, Department of Anesthesia &
kephalin in keratinocytes of patients with ob-
Intensive Care, Eastern Hepatobiliary Surgical structive jaundice. Anesthesiology 2014; 121:
Hospital, The Second Military Medical University, 127-39.
Shanghai 200438, China. Tel: 021-81875232; [4] Nelson L, Vergnolle N, DMello C, Chapman K,
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