Search

Background: The purpose of this study was to examine how frequently invasive intensive care unit (ICU) treatments are delivered to critically ill patients despite clinicians’ impressions that ICU care may be nonbeneficial. Methods: Patients admitted to the medical ICU of an academic public hospital were prospectively categorized according to guidelines from the Society of Critical Care Medicine which classifies patients based on severity of illness and likelihood of recovery (categories 1-4). Clinical data and use of ICU treatments in patients with high (category 1) and low (category 3) likelihoods of benefit were collected by chart review. Multivariable regression analyses examined associations between use of invasive treatments and patient categories, and clinical factors associated with receiving invasive ICU treatments despite low likelihood of benefit. Results: There were 533 patients (369 in category 1 and 164 in category 3) in the study. A total of 19.8%, 29.9%, and 28.9% of patient-days on mechanical ventilation, vasopressors, and renal replacement therapy, respectively, were delivered to patients who were considered unlikely to benefit from ICU treatments (category 3) and ultimately did not survive hospitalization. These patients also received 35.2% of cardiopulmonary resuscitation attempts and 22.6% of central venous catheter placements. Clinicians’ impressions of likelihood of benefit (category 1 vs 3) were not associated with odds of receiving invasive ICU treatments. Clinical characteristics associated with greater odds of receiving potentially nonbeneficial treatments included older age, presence of dementia or malignancy, and higher Acute Physiologic Assessment and Chronic Health Evaluation score. Conclusions: Invasive ICU treatments are frequently delivered to patients who are not expected to benefit from ICU care and die during hospitalization. These findings highlight the need to improve utilization of ICU services among patients with advanced medical illnesses.

A multitude of therapies is available to treat disc herniation, ranging from conservative methods (medication and physical therapy) to minimally invasive (percutaneous) treatments and surgery. O2-O3 chemonucleolysis (O2-O3 therapy) is one of the minimally invasive treatments with the best cost/benefit ratio and lowest complication rate. Another substance recently made available exploiting the chemical properties of pure ethanol is DiscoGel®, a radiopaque gelified ethanol more viscous than absolute alcohol 8,9. The present study aimed to assess the therapeutic outcome of DiscoGel® chemonucleolysis in patients with lumbar disc herniation unresponsive to O2-O3 therapy. Thirty-two patients aged between 20 and 79 years were treated by DiscoGel® chemonucleolysis between December 2008 and January 2010. The treatment was successful (improvement in pain) in 24 out of 32 patients. DiscoGel® is safe and easy to handle and there were no complications related to product diffusivity outside the treatment site. The therapeutic success rate of DiscoGel® chemonucleolysis in patients unresponsive to O2-O3 therapy was satisfactory. Among other methods used to treat lumbar disc herniation, DiscoGel® chemonucleolysis can be deemed an intermediate procedure bridging conservative medical treatments and surgery.

Category: Hindfoot Introduction/Purpose: Plantar fasciitis is the most common cause of heel pain, resulting in an estimated 1 million visits to medical professionals annually. Conservative treatments for plantar fasciitis include rest, orthotics, night splint, stretching and non- steroidal anti-inflammatory drugs. Such treatments are successful in nearly 90% of patients, however, more invasive treatments are required for patients whose heel pain symptoms persist greater than six months. Fetal tissues, including the umbilical cord (UC) and amniotic membrane (AM) have been increasingly used to modulate healing in different parts of the body over the last two decades. These tissues have been demonstrated to possess anti-inflammatory and anti-scarring properties in addition to containing growth factors, cytokines, and matrix components to promote healing, and offer a potential therapy for plantar fasciitis. Methods: In this clinical series, we sought to evaluate the efficacy of cryopreserved, particulate UC/AM tissues as a treatment for plantar fasciitis as well as to determine if multiple injections provide an even greater benefit compared to a single injection. A multicenter prospective study was performed where patients were randomized to receive 25, 50, or 100 mg UC/AM tissue and either a single injection or two injections (at baseline and six weeks). All injections were administered under ultrasound guidance into the plantar fascia. At six, 12, and 18 weeks, patients returned and data on foot pain as well as the FAAM questionnaire were collected. Results: Last year, we presented interim data on 18 patients who had completed 18 weeks of follow-up. This year, we present the completed results of the study. Overall, patient foot pain was found to be significantly reduced in all treatment groups from baseline. FAAM scores for both activities of daily living and sports subscales also improved in all treatment groups, with overall improvement ranging from 60 – 150% compared to baseline. All patients showed variable degrees of improvement with no patients showing any deterioration. Conclusion: The results of this case series are similar to the results of an earlier study which found that injection of a particulate human amniotic membrane product for plantar fasciitis was safe and comparable to corticosteroids. While all treatments demonstrated improvement in both foot pain and FAAM scores, there was both a dose dependent as well as injection dependent effect of particulate UC/AM tissue on foot pain reduction (100 mg > 50 mg >25 mg; 2 injections > 1injection) suggesting a possible additive effect. Overall, these results are promising and highlight the potential effectiveness of UC/AM tissues as a treatment for plantar fasciitis.

Degenerated human intervertebral discs (IVDs) are commonly associated with low back pain conditions including stenosis, herniation, and axial back pain. There are few minimally invasive treatments available to treat painful IVD degeneration and axial back pain. Painful IVD degeneration is associated with structural disruption, chronic inflammation, and neurovascular ingrowth deep into the IVD and all of these conditions must be addressed to promote function and inhibit painful conditions in the spine. During development of the spine, the notochord produces factors including chondroitin sulfate that are important for creating the IVD structure as well as for patterning the spine to inhibit ingrowth of dorsal root ganglia (DRGs) axons into the IVD. Our overall concept is that we can use concepts and factors important in the developing spine to develop therapeutic candidates for painful IVD degeneration. In this study, we focus on improved understanding of notochordal cells, their maturation, and the secreted factors they produce that can be used for therapeutic effect. We focus on three studies. Study 1 describes the effects of loading on the notochordal cell phenotype. Study 2 identifies cell culture models to screen therapies for discogenic pain and to investigate which factors in notochordal cell conditioned medium are capable of inhibiting neurite growth. Study 3 investigates the capacity of notochordal cell conditioned medium to inhibit the neovascularization that may be a predecessor to neurite growth into the IVD. We use a variety of cell culture models using nucleus pulposus tissue from porcine IVDs and neural and vascular endothelial cells from human and rodent sources. Study 1 indicated that hydrostatic loading can induce maturation of notochordal cells from large vacuolated to small chondrocytic cells. This maturation was accompanied by some shifts in the quantity and quality of secreted factors. Study 2 determined that notochordal cell conditioned medium is capable of inhibiting neurite growth in two neural cell types: human neuroblastoma cells (SH-SY5Ys) and rat DRGs. Results indicated that the effect was dose-specific, and that CS is a necessary protein causing this inhibition. Study 3 determined that notochordal cell conditioned medium can inhibit neovascularization using cell human umbilical vascular endothelial cells. Importantly, notochordal cell conditioned medium was not cytotoxic to neural or endothelial cells, suggesting this could be used safely for back pain even if leakage occurred in the area around the IVD. However, future in vivo testing is required for further characterization of safety and efficacy profiles. Together, we present a novel paradigm for designing therapeutic interventions derived from trophic agents from notochordal cells and for screening the efficacy of those therapies. We conclude that notochordal cells secrete factors with structure and symptom modifying potential, and these may be useful for developing therapeutic agents with the capacity to restore IVD function and preventing discogenic pain. Acknowledgments This work was funded by NIAMS/NIH Grants (R01 AR064157 R01, R01 AR057397) and Grant S-13-50P of the AO Research Fund of the AO Foundation (D.P.) and Orthopaedic Research and Education Foundation (S.K.C.). Disclosure of Interest None declared

Objectives:Conservative treatments for anterior cruciate ligament (ACL) tears may have just as good an outcome as invasive treatments. These include muscle strengthening and neuromuscular proprioceptive exercises to improve joint stability and restore motion to the knee. The Purpose of the current work presents was to examine the feasibility of a novel non-invasive biomechanical treatment to improve the rehabilitation process following an ACL tear. This is a single case report that presents the effect of this therapy in a patient with a complete ACL rupture who chose not to undergo reconstructive surgery.Methods:A 29-year old female athlete with an acute indirect injury to the knee who chose not to undergo surgery was monitored. Two days after injury the patient began AposTherapy. A unique biomechanical device was specially calibrated to the patient’s feet. The therapy program was initiated, which included carrying out her daily routine while wearing the device. The subject underwent a gait analysis at baseline and follow-up gait analyses at weeks 1, 2, 4, 8, 12 and 26.Results:A severe abnormal gait was seen immediately after injury, including a substantial decrease in gait velocity, step length and single limb support. In addition, limb symmetry was substantially compromised following the injury. After 4 weeks of treatment, patient had returned to normal gait values and limbs asymmetry reached the normal range.Conclusions:The results of this case report suggest that this conservative biomechanical therapy may have helped this patient in her rehabilitation process. Further research is needed in order to determine the effect of this therapy for patients post ACL injuries.

Over the past two decades Britain, like many other countries, has developed a system of special care units for sick and preterm babies. These, together with the intensive care units which some of them incorporate, now admit between 15 and 20% of all newborn babies. Admission to these units and the employment there of a growing range of invasive treatments has led to a profound change in the neonatal environment for these babies and their parents. Some of these changes have provoked anxiety about their possible consequences for the development of these children. This, article describes some of the aspects of the environment of the preterm baby that have given rise to concern and some of the ways in which we may reduce the potential risks.