A systematic review of four injection therapies for lateral epicondylosis: prolotherapy, polidocanol, whole blood and platelet-rich plasma

OBJECTIVE

To appraise existing evidence for prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injection therapies for lateral epicondylosis (LE).

DESIGN

Systematic review.

DATA SOURCES

Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine.

SEARCH STRATEGY

names and descriptors of the therapies and LE.

STUDY SELECTION

All human studies assessing the four therapies for LE.

MAIN RESULTS

Results of five prospective case series and four controlled trials (three prolotherapy, two polidocanol, three autologous whole blood and one platelet-rich plasma) suggest each of the four therapies is effective for LE. In follow-up periods ranging from 9 to 108 weeks, studies reported sustained, statistically significant (p<0.05) improvement in visual analogue scale primary outcome pain score measures and disease-specific questionnaires; relative effect sizes ranged from 51% to 94%; Cohen's d ranged from 0.68 to 6.68. Secondary outcomes also improved, including biomechanical elbow function assessment (polidocanol and prolotherapy), presence of abnormalities and increased vascularity on ultrasound (autologous whole blood and polidocanol). Subjects reported satisfaction with therapies on single-item assessments. All studies were limited by small sample size.

CONCLUSIONS

There is strong pilot-level evidence supporting the use of prolotherapy, polidocanol, autologous whole blood and platelet-rich plasma injections in the treatment of LE. Rigorous studies of sufficient sample size, assessing these injection therapies using validated clinical, radiological and biomechanical measures, and tissue injury/healing-responsive biomarkers, are needed to determine long-term effectiveness and safety, and whether these techniques can play a definitive role in the management of LE and other tendinopathies.

Injection sclerotherapy of bleeding oesophageal and gastric varices using a flexible endoscope

Thirteen patients with acute or recent bleeding from gastro-oesophageal varices were treated by sclerotherapy using flexible fiberoptic endoscope. Primary haemostasis was obtained in 10 of 11 admissions with active bleeding. Three patients have been treated for gastric varices with the same method. Such treatment has not been reported before. During the follow-up period, three patients died, two of variceal haemorrhage and one of pneumonia. Ten patients are still alive 2-53 months after the first admission. A total of 117 treatment courses were given, on an average 9 per patient. Complications included superficial mucosal necrosis without clinical consequences in several cases, 3 patients developed oesophageal and gastric ulcers and one moderate oesophageal stenosis. Rebleeding occurred in 4 patients, in 2 of them because of ulcers at the sites of injections.

Comparison of the different types of surfactants for the effect on activity and structure of soybean peroxidase

In the pH 2.6 and 5.2 systems, soybean peroxidase (SBP) (isoelectric point, pI 3.9) has positive and negative charge, respectively. In order to acquire detailed knowledge on the role played by electrostatics in the denaturation of proteins, a comparison of anionic surfactant sodium dodecyl sulfate (SDS), nonionic surfactant nonaethylene glycol monododecyl ether [C12H25O(CH2CH2O)9H] (AEO9), and cationic surfactant cetyltrimethylammonium bromide (CTAB) for the influences on the activity and structure of soybean peroxidase (SBP) was carried out by measuring the activity, far-UV circular dichrosm, fluorescence, and electronic absorption spectra of SBP in the pH 2.6 and 5.2 systems at 30 degrees C. In the pH 2.6 systems, the interaction of SDS with SBP results in an increase in the fluorescence intensity with a red shift of the emission maximum of the tryptophan fluorescence and a blue shift of the Soret band. In the meantime, the alpha-helix of SBP is unfolded and the activity of SBP is lost irreversibly. In pH 5.2 systems, the fluorescence spectra features of SBP are similar to those in pH 2.6 systems with increasing SDS concentration, but a red shift of Soret band as well as an alteration of the tertiary structure of SBP occurs, and the lost activity is recoverable. The electrostatic interactions between SBP and SDS play an important role in the denaturation of SBP. The effects of AEO9 and CTAB in pH 2.6 and 5.2 systems on the activity and spectral features of SBP are similar to that of SDS in pH 5.2 systems, but AEO9 is prone to unfold the beta-sheet of SBP in pH 2.6 systems. The electrostatic interactions of CTAB with SBP are not the primary elements for denaturation of SBP, which distinctly differ from those of SDS. These results can be useful with respect to wide applications of the surfactants in the separation and purification of proteins.

[Radiofrequency ablation of the great saphenous vein in lower-limb varicose disease]

The authors herein share their experience gained in comprehensive treatment of patients diagnosed with lower-limb varicose disease treated by means of one the most state-of-the-art technologies, i. e., radiofrequency ablation. The work deals with the outcomes of managing a total of seventy-eight patients suffering from lower-limb varicose diseases with valvular insufficiency of the great saphenous vein. All the patients were subjected to radiofrequency ablation of the compromised great saphenous vein by means of the portable radiofrequency device "Surgitron" manufactured by the Company "Ellman International" (USA). Examination included ultrasonographic duplex and triplex scanning of the veins of the lower extremities. Intraoperative radiofrequency ablation of the great saphenous vein was performed by means of an original appliance consisting of a metallic probe whose length corresponded to that of the lower extremity concerned, with a figure-of-eight olive at the distal end and external plastic tube catheter. The construction of the probe made it possible to maximally free the great saphenous vein from blood through the lateral ports of the catheter, to reduce the risk of complications, to diminish the duration of the intervention, and to increase its effectiveness. Efficacy of radiofrequency ablation of the great saphenous vein amounted to 93.6%, with recanalization of the greater saphenous vein being established in five (6.4%) patients. Good functional and cosmetically pleasing therapeutic outcomes were observed in the majority of the patients (87.2%).

Sclerosing injections to treat midportion Achilles tendinosis: a randomised controlled study evaluating two different concentrations of Polidocanol

Two to three ultrasound (US) and colour Doppler (CD)-guided injections of the sclerosing substance Polidocanol (5 mg/ml) have been demonstrated to give good clinical results in patients with chronic midportion Achilles tendinopathy. This study aimed to investigate if a higher concentration of Polidocanol (10 mg/ml) would lead to a less number of treatments, and lower volumes, needed for good clinical results. Fifty-two consecutive Achilles tendons (48 patients, mean age 49.6 years) with chronic painful midportion Achilles tendinopathy, were randomised to treatment with Polidocanol 5 mg/ml (group A) or 10 mg/ml (group B). The patients and treating physician were blinded to the concentration of Polidocanol injected. All patients had structural tendon changes and neovascularisation in the Achilles midportion. Treatment was US + CD-guided injections targeting the region with neovascularisation (outside ventral tendon). A maximum of three treatments (6-8 weeks in between) were given before evaluation. Patients not satisfied after three treatments were given additional treatment with Polidocanol 10 mg/ml, up to five treatments. For evaluation, the patients recorded the severity of Achilles tendon pain during activity on a visual analogue scale (VAS), before and after treatment. Patient satisfaction with treatment was also assessed. At follow-up (mean 14 months) after three treatments, 18/26 patients in group A and 19/26 patients in group B were satisfied with the treatment and had a significantly reduced level of tendon pain (P < 0.05). After completion of the study, additional treatments with Polidocanol 10 mg/ml in the not satisfied patients resulted in 26/26 satisfied patients in both groups A and B. In summary, we found no significant differences in the number of satisfied patients, number of injections or volumes given, between patients treated with 5 or 10 mg/ml Polidocanol.

Soil washing using various nonionic surfactants and their recovery by selective adsorption with activated carbon

The performance of activated carbon in soil washing and subsequent selective adsorption for surfactant recovery from the washed solution was investigated. Sandy loam soil contaminated with phenanthrene at 200 mg kg(-1) was washed with four different nonionic surfactants: Tween 40, Tween 80, Brij 30 and Brij 35. The efficiency of soil washing was highest when using Brij 30 with the highest solubilizing ability for phenanthrene and low adsorption onto soil. In the selective adsorption step, surfactant recovery was quite effective for all surfactants ranging from 85.0 to 89.0% at 1 g L(-1) of activated carbon (Darco 20-40 mesh). Phenanthrene removal from the solution washed with Brij 30 was only 33.9%, even though it was 54.1-56.4% with other surfactants. The selectivity was larger than 7.02 except for Brij 30 (3.60). The overall performance considering both the washing and surfactant recovery step was effective when using Tween 80 and Brij 35. The results suggest that higher solubilizing ability of surfactants is a requirement for soil washing but causes negative effects on phenanthrene removal in the selective adsorption. Therefore, if a surfactant recovery process by selective adsorption is included in soil remediation by washing, the overall performance including the two steps should be considered for properly choosing the surfactant.

Effects of linear alkylbenzene sulfonate on the sorption of Brij 30 and Brij 35 onto aquifer sand

Surfactant sorption is of considerable importance to environmental applications, including surfactant flushing to mobilize hydrophobic contaminants; effects of surfactants on the transport of dissolved contaminants, microorganisms, and colloids through porous media; and bioremediation of hydrophobic organic compounds, as well as understanding the fate and transport of surfactants as environmental contaminants themselves. Although most sorption studies consider pure surfactants, commercial detergent formulations typically consist of mixtures of nonionic and anionic surfactants. In this study, the effects of varying concentrations of the anionic surfactant linear alkylbenzene sulfonate (LAS) on micelle formation and sorption behavior of the two commonly used nonionic surfactants Brij 30 and Brij 35 onto aquifer sand were examined. A strong linear relationship was observed between the critical micelle concentration (CMC) of the Brij surfactants and the concentration of LAS in the mixture, with the CMC decreasing with increasing concentration of LAS. The relative change in CMC as a function of the LAS concentration was identical forthe two Brij surfactants, indicating that LAS interacted with their common alkyl chains. Sorption isotherms were developed for Brij 30 and Brij 35 present as single surfactants in an aqueous solution as well as when present with LAS. Although LAS had minor effects on the maximum sorption plateaus of the Brij surfactants, Brij sorption at was significantly enhanced as a function of the LAS concentration for Brij aqueous concentrations below the CMC. Application of a multi-interaction isotherm model indicated that the formation of surface aggregates (e.g., hemimicelles) decreased with increasing LAS concentration. Overall, these results provide insight into the complex sorption behavior of surfactant mixtures.

Chemotherapy using hybrid liposomes along with induction of apoptosis

We have produced hybrid liposomes (HL) which can be prepared by ultrasonicating a mixture of dimyristoylphosphatidylcholine (DMPC) and polyoxyethylene(23)dodecyl ether in a buffer solution. The fifty-percent inhibitory concentration (IC50) of HL on the growth of human B lymphoma (RAJI) cells in vitro was determined. The IC50 of HL on the growth of RAJI cells was one half of that of DMPC liposomes. Induction of apoptosis by HL in RAJI cells was verified on the basis of flow cytometric analysis, agarose gel electrophoresis and fluorescence microscopy. Apoptotic DNA was observed in RAJI cells treated with HL. Fluorescence micrographs of RAJI cells after adding HL indicated the induction of apoptosis. The therapeutic effects of HL in vivo were examined using SCID mice inoculated with RAJI cells. Markedly prolonged survival of mice was obtained after treatment with HL. No adverse effects were observed in normal rats in toxicity tests carried out with HL. Clinical applications of HL for patients were examined after the approval of the Bioethics Committee. Remarkable reduction of a solid tumor and prolonged survival for one patient with advanced lymphoma were attained after treatment using HL. Chemotherapy with drug-free HL was established without any side effects for the first time.

Treatment of midportion Achilles tendinosis: similar clinical results with US and CD-guided surgery outside the tendon and sclerosing polidocanol injections

Sclerosing polidocanol injections targeting the area with vasculo/neural ingrowth on the ventral side of the tendon have previously been demonstrated to give good clinical results in patients with chronic painful midportion Achilles tendinosis. In this study, 20 consecutive patients (9 men and 11 women, mean age 46 years) with chronic painful midportion Achilles tendinosis were treated with either sclerosing polidocanol injections (Group A) or open surgical revision of the area with vasculo/neural ingrowth on the ventral side of the Achilles tendon (Group B). Before treatment, all patients had structural tendon changes and increased blood flow-neovascularisation demonstrated with US and colour Doppler. Under US and colour Doppler-guidance, both the injections and the surgical revision targeted the area with neovessels just outside the ventral part of the tendon. A maximum of two sclerosing injection treatments, with 6-8 weeks in-between, were given. For evaluation, the patients recorded the severity of Achilles tendon pain during tendon loading activity (their recreational or sport activity), before and after treatment, on a VAS. Patient global satisfaction with treatment was also assessed. At the 3 months follow-up 6/9 (one patient was excluded) patients in Group A, and 8/10 patients in Group B, were satisfied with the treatment and had a significantly reduced level of tendon pain (Group A VAS from 76 to 24, P < 0.05, Group B VAS from 75 to 21, P < 0.05). There was one deep infection in Group B. At the 6 months follow-up, 6/9 patients in Group A, and 10/10 patients in Group B were satisfied. In summary, both treatment with sclerosing polidocanol injections and open surgical revision outside the ventral Achilles midportion show promising short-term clinical results.

Comparison of 1% and 3% Polidocanol Foam in Ultrasound Guided Sclerotherapy of the Great Saphenous Vein: A Randomised, Double-Blind Trial with 2 Year-Follow-up. “The 3/1 Study”

OBJECTIVES

To compare 1% and 3% POL foam in treating the great saphenous vein (GSV) by ultrasound guided sclerotherapy.

DESIGN

Multicentre, prospective, randomised, double-blind trial with 2 year-follow-up.

PATIENTS AND METHODS

148 patients with GSV reflux (saphenous trunk diameter 4-8 mm) were randomised to undergo ultrasound guided foam sclerotherapy using either 1% or 3% POL foam in a single session. Foam production was standardised using a sterile disposable syringe kit including sterile air and the Turbofoam machine. Duplex ultrasonography was used to assess the outcome at 3 weeks, 6 months, 1 year, 18 months and 2 years. The main criterion of success was the disappearance of the venous reflux. The length of occlusion of the vein (only measured at 3 week-echography assessment) was a secondary criterion. Side effects were assessed.

RESULTS

74 patients were included in each group. The mean volume of foam injected was 4.4 ml for the 3% group and 4.6 ml for the 1% group. After 3 weeks, reflux was abolished in 96% (71 patients) of the 3% group and 88% (68 patients) of the 1% group (NS). The mean occlusion length of the vein was 38 cm for the 3% group and 34 for the 1% group (NS). After 2-years, reflux was absent in 69% of the 3% group and 68% of the 1% group (NS). 14 patients were lost to follow-up at 2 years.

CONCLUSION

This study demonstrates equivalent efficacy for 1% POL and 3% POL foam in sclerotherapy of the GSV where the trunk is less than 8 mm in diameter. These data obtained two years of follow-up confirm our previously reported 6 month-follow-up data published in 2005.

Electrocatalytic hydrodechlorination of 2,4,5-trichlorobiphenyl on a palladium-modified nickel foam cathode

Palladium-modified materials have been found to be effective electrodes for the reductive degradation of chlorinated compounds in aqueous solution. This study investigated the electrocatalytic hydrodechlorination (ECH) of polychlorinated biphenyls (PCBs) in solvent/surfactant-aided solutions in a palladium-modified nickel foam electrode using a divided flow-through cell. The reaction pathways of 2,4,5-PCB hydrodechlorination were proposed due to the analysis of intermediates by GC/MS. The mechanism of electrocatalytic reaction on the Pd/Ni foam cathode was examined by studying the effect of surfactant type, sorption behavior of PCBs on the electrode, and current densities on the ECH efficiency of PCBs. The conversion of PCBs was controlled by the micelle structures of the surfactants instead of the charged species. According to the analysis of hydrogen transformation processes on the electrode surface, we propose that the ECH process was initiated by the transfer of highly active hydrogen atoms [H] from the prior polarized Pd particles to the less polarized Pd particles by spillover on the Pd/Ni foam cathode. Therefore, the total available surface was larger than the originally polarized surface, and [H] could smoothly react with PCBs that were adsorbed on the surface. As a result, a high ECH efficiency can be achieved with the Pd/Ni foam electrode.

Removal of naphthalene in Brij 30-containing solution by ozonation using rotating packed bed

The removal efficiency of polycyclic aromatic hydrocarbons (PAHs) by ozonation using a rotating packed bed (RPB) in the surfactant-containing solution is studied. As an ozonation process starts, the ozone-containing gas is introduced and transferred into to the solution. The target PAHs in the solution would be then eliminated via both the gas stripping and ozonation decomposition. The RPB, which provides high gravitational force by adjusting the rotational speed, is employed as a novel ozone contactor. The naphthalene (NAP) and Brij 30 are chosen as the model pollutant and surfactant. Note that the experiments with different concentrations of NAP, Brij 30, and inlet gas ozone are performed for the further investigation. The residual NAP, effluent dissolved oxygen and ozone, and off-gas ozone concentrations are simultaneously monitored. As a result, the removal of NAP in the RPB is remarkably efficient compared with the convectional contactors because of its greater mass transfer coefficient. Moreover, the removal efficiency of NAP is found significantly dependent on the concentrations of NAP, Brij 30, and inlet gas ozone. It takes about several minutes to reach the steady state under the conditions of this study. In addition, it suggests employing RPBs as ozone contacting devices for the high removal efficiency of NAP. Consequently, the present study is useful for the practicable understanding of application of RPBs for the ozonation of PAHs in surfactant-containing solution.

Colour doppler ultrasonography and sclerosing therapy in diagnosis and treatment of tendinopathy in horses-a research model for human medicine

Sclerosing therapy has in recent studies showed promising results in patients with clinically and ultrasonographically diagnosed tendinosis in Achilles and patellar tendons. The aim of this investigation was to study the presence of intratendinous colour Doppler (CD) flow in horses with clinically diagnosed chronic tendinopathy and to test if experience from human studies could be extrapolated to horses. Special interest was focused on the treatment with sclerosing therapy and whether we could obtain the same successful peroperative findings as in humans. Four horses with clinically diagnosed unilateral chronic tendinosis in the forelimbs were examinated with both grey-scale ultrasonography (US) and CD. The horses were to be euthanised according to standard procedure is such cases. The US findings were used for guidance of sclerosing therapy. All horses showed abnormal findings on US, especially intratendinous neovascularisation in the affected limb but not in the contralateral limb. The CD findings had the same appearance as seen in human Achilles tendons with chronic tendinopathy. In all cases the intratendinous neovascularisation was successfully "shut down" peroperatively. The horses showed no signs of discomfort or worsening of symptoms during the short follow-up period after the procedure. The results indicate that the promising results from human medicine might be transferred to treatment of horses with chronic tendinopathy. In the future it will hopefully be possible to use the model from overused tendons in the horse to determine the best treatment of overuse injuries in humans as well. The animal model will allow experimental studies including substantial tissue sampling for mechanical and molecular biological analysis.

Efficacy of local sclerosing agents on hemostasis of hepatic bleeding

BACKGROUND/AIMS

Hepatic bleeding following abdominal trauma is a serious problem. The implementation of various materials and techniques have been attempted to prevent bleeding but a standard method is indefinite.

METHODOLOGY

Hepatic resection model was performed on rats. The efficacy of hemostasis with Polidocanol and Tetradecyl Sulfate has been evaluated through the comparison of perioperative bleeding amount and preoperative and postoperative hematocrit levels in the 24th hour. Also, histopathologic changes on parenchyma have been compared at a microscopic level.

RESULTS

Preoperative and postoperative hematocrit differences were 5.50 +/- 0.59 in Polidocanol group and 10 +/- 1.30 in Tetradecyl Sulfate group (MW: 2, p < 0.001). Perioperative bleeding amounts were: 1.50 +/- 0.20 mL in the Polidocanol group, 3.50 +/- 0.15 mL in the Tetradecyl Sulfate group and 7.50 +/- 0.41 mL in the Control Group. Upon comparison of perioperative bleeding amounts: the Control Group values were very high in comparison to the Polidocanol group (p < 0.001) and the Tetradecyl Sulfate group values were higher than those of the Polidocanol group (p < 0.05).

CONCLUSIONS

Local sclerosing agents, especially Polidocanol, appear to be an effective alternative method in hemostasis of hepatic bleeding.

Catheter-assisted vein sclerotherapy: a new approach for sclerotherapy of the greater saphenous vein with a double-lumen balloon catheter

OBJECTIVE

We sought to optimize sclerotherapy of the greater saphenous vein (GSV) by targeted application of foamed sclerosant by using a catheter.

METHODS

We designed a new double-lumen catheter that is inserted into the GSV. Via one lumen, a balloon at the tip of the catheter can be inflated to stop the blood flow. Via the second lumen, the sclerosing agent can be injected and aspirated. This method enabled us to perform a targeted application of the sclerosing agent [catheter-assisted vein sclerotherapy (KAVS)]. In an open study, outpatients suffering from varicosis of the GSV received a foam sclerotherapy under ultrasound guidance, using the newly developed KAVS catheter.

RESULTS

Thirty patients with an insufficiency (reflux) of the GSV were treated with the newly developed KAVS method using foamed polidocanol. The intervention was well tolerated in all patients without the occurrence of serious side effects. In 27 of the 30 treated patients (90%), we found a closure of the GSV at control visits 6 weeks, 3 months, and 6 months after treatment.

CONCLUSIONS

The KAVS method represents a feasible approach for sclerotherapy of the GSV. The efficiency and treatment modalities need to be explored in further studies.

The use of foam sclerotherapy for varicose veins: a survey of the members of the Vascular Society of Great Britain and Ireland

OBJECTIVES

The aim was to explore the current experience and practice of vascular surgeons in the United Kingdom and Ireland regarding foam sclerotherapy for varicose veins.

METHOD

A postal questionnaire was sent to 609 members of the Vascular Society of Great Britain and Ireland.

RESULTS

There were 281 responses (47%). Seventy surgeons (25%) used foam sclerotherapy. Most use it selectively; few (29%) offer it to all patients. It was more likely to be used for recurrent varices (71%), in older patients (61%) and for smaller non-saphenous varices (67%). The majority of surgeons (69%) used sodium tetradecyl sulphate and up to a maximum of 10-12 ml of foam. The majority used ultrasound guidance (95%), leg elevation (69%) and direct pressure over the saphenofemoral or saphenopopliteal junction during injection (63%). Eighty per cent used compression bandaging after treatment, usually for 7 days (44%). Ninety percent advised compression stockings, usually Class II (64%) for 14 days (39%). Serious complications were few, but eleven surgeons had seen a deep vein thrombosis, two had seen a patient with a stroke and one a transient ischaemic attack.

CONCLUSION

Foam sclerotherapy was used by a quarter of surgeons who replied to the survey. Aspects of technique varied considerably and studies to determine optimal techniques are needed. Serious complications with the technique were rare.