Hyperbaric oxygen therapy for multiple sclerosis

Oxygen-Carrying Capacity of Perfluorohexyloctane, a Novel Eye Drop for Dry Eye Disease

Objective

One-hundred percent perfluorohexyloctane (PFHO) is a water-free, preservative-free eye drop approved by the Food and Drug Administration in the United States for the treatment of dry eye disease. PFHO has shown relief of dry eye signs and symptoms in clinical trials and has potent antievaporative action in vitro. The objective of this study was to measure the level of oxygen in PFHO.

Methods

T1 relaxation times (time taken for proton spins to translate from a random alignment to an alignment with the main magnetic field) for fluorine-19 in perfluorohexyloctane were measured using fluorine-19 nuclear magnetic resonance spectroscopy. The level of oxygen was interpolated from published data.

Results

The hydrogen-1 and fluorine-19 nuclear magnetic resonance spectra of PFHO were well resolved and the resonance assignments and intensities were as expected. The T1 values calculated for the CF₃ group resonance in the current study was 0.901 seconds and 1.12 seconds at 25 °C and 37 °C, respectively. The T1 values for the CF₂ group resonances increased by 17% to 24% with an increase in temperature from 25 °C to 37 °C. The mean (SD) partial pressure of oxygen in PFHO was calculated to be 257 (36) mm Hg and 270 (38) mm Hg at 25 °C and 37 °C, respectively.

Conclusions

The current study confirms that PFHO contains a significant amount of oxygen, more so than that calculated for tears in equilibrium with air. Once instilled on the eye, PFHO is not expected to be a barrier to the oxygen necessary for a healthy cornea and may in fact deliver nonreactive oxygen to the cornea to facilitate healing in patients with dry eye disease.

Mapping of neuroinflammation-induced hypoxia in the spinal cord using optoacoustic imaging

Recent studies suggest that metabolic changes and oxygen deficiency in the central nervous system play an important role in the pathophysiology of multiple sclerosis (MS). In our present study, we investigated the changes in oxygenation and analyzed the vascular perfusion of the spinal cord in a rodent model of MS. We performed multispectral optoacoustic tomography of the lumbar spinal cord before and after an oxygen enhancement challenge in mice with experimental autoimmune encephalomyelitis (EAE), a model for MS. In addition, mice were transcardially perfused with lectin to label the vasculature and their spinal columns were optically cleared, followed by light sheet fluorescence microscopy. To analyze the angioarchitecture of the intact spine, we used VesSAP, a novel deep learning-based framework. In EAE mice, the spinal cord had lower oxygen saturation and hemoglobin concentration compared to healthy mice, indicating compromised perfusion of the spinal cord. Oxygen administration reversed hypoxia in the spinal cord of EAE mice, although the ventral region remained hypoxic. Additionally, despite the increased vascular density, we report a reduction in length and complexity of the perfused vascular network in EAE. Taken together, these findings highlight a new aspect of neuroinflammatory pathology, revealing a significant degree of hypoxia in EAE in vivo that is accompanied by changes in spinal vascular perfusion. The study also introduces optoacoustic imaging as a tractable technique with the potential to further decipher the role of hypoxia in EAE and to monitor it in MS patients.

Hyperbaric Oxygen Therapy Alleviates the Autoimmune Encephalomyelitis via the Reduction of IL-17a and GM-Csf Production of Autoreactive T Cells as Well as Boosting the Immunosuppressive IL-10 in the Central Nervous System Tissue Lesions

Multiple sclerosis (MS) is a chronic autoimmune disease mainly caused by autoreactive T cells, followed by neuronal demyelination and disabling paralysis. Hyperbaric oxygen therapy (HBOT) is usually an adjunct to therapy for the treatment of neurological disorders. However, it remains still controversial whether HBOT is an effective option for the treatment of MS. Experimental autoimmune encephalomyelitis (EAE) is a well-studied mouse model investigated for the MS pathogenesis and the efficacy of the therapeutic intervention. Both encephalitogenic Th1 and Th17 are pivotal T cell subsets immunopathogenically producing several disease-initiating/modifying cytokines in the central nervous system (CNS) lesions to further exacerbate/ameliorate the progression of EAE or MS. However, it remains unclear whether HBOT modulates the context of T helper cell subsets in CNS lesions. We employed EAE in the presence of HBOT to assess whether disease amelioration is attributed to alterations of CNS-infiltrating T cell subsets. Our results demonstrated that semi-therapeutic HBOT significantly alleviated the progression of EAE, at least, via the suppression of Th17 response, the downregulation of CD4 T helper cells expressing GM-CSF or TNF-α, and the boosting of immunomodulatory IL-4 or IL-10-expressed CD4 T cells in the CNS lesions. Conclusively, HBOT attenuated EAE through the modulation of T cell responses in an earlier stage.

Efficacy of Hyperbaric Oxygen Therapy on Central Corneal Thickness, Intraocular Pressure, and Nerve Fiber Layer in Patients with Type 2 Diabetes: A Prospective Cohort Study

PURPOSE

To evaluate the effect of hyperbaric oxygen therapy (HBOT) on central corneal thickness (CCT), intraocular pressure (IOP), and the retinal nerve fiber layer (RNFL) thickness in patients with type 2 diabetes mellitus.

METHODS

This prospective non-randomized cohort study consisted of type 2 diabetes mellitus patients who received 30 sessions of HBOT for diabetic foot ulcer. The CCT, IOP, and RNFL measured at baseline, after the 10th session of HBOT, after the 20th session of HBOT, after the 30th session of HBOT, and after the 3 months of the last session of HBOT. We gained the superior-nasal, superior-temporal, inferior-nasal, inferior-temporal, nasal and temporal quadrant RNFL values with a spectral-domain optical coharence tomography.

RESULTS

Forty-six eyes of 46 patients included in the study. During the study period, a statistically significant increase in mean IOP values compared to baseline was observed (p < 0.001). We found no significant changes at CCT and all quadrants of RNFL values during HBOT and after 3 months of the treatment (p > 0.05). During the study period, the IOP levels increased over 21 mmHg (between 22 and 28 mmHg) in seven eyes (15.2%). The mean hemoglobin A1c values of these patients with IOP >21 mmHg were 8.2 ± 0.9 mg/dL, and there was significant differences compared with those of patients with IOP values ≤21 mmHg (7.4 ± 2.8 mg/dL) (p = 0.001).

CONCLUSIONS

HBOT increase IOP in type 2 diabetic patients especially in ones with impaired blood glucose regulation. However, it does not cause any changes in CCT and RNFL. As diabetic retinopathy and diabetic foot ulcer are in common pathologies, thus this brief report concludes a need for further studies with longer follow-up periods to explore the potential interaction of HBOT on CCT, IOP, and RNFL.

Rehabilitation for people with multiple sclerosis: an overview of Cochrane Reviews

BACKGROUND

Multiple sclerosis (MS) is a major cause of chronic, neurological disability, with a significant long-term disability burden, often requiring comprehensive rehabilitation.

OBJECTIVES

To systematically evaluate evidence from published Cochrane Reviews of clinical trials to summarise the evidence regarding the effectiveness and safety of rehabilitation interventions for people with MS (pwMS), to improve patient outcomes, and to highlight current gaps in knowledge.

METHODS

We searched the Cochrane Database of Systematic Reviews up to December 2017, to identify Cochrane Reviews that assessed the effectiveness of organised rehabilitation interventions for pwMS. Two reviewers independently assessed the quality of included reviews, using the Revised Assessment of Multiple Systematic Reviews (R-AMSTAR) tool, and the quality of the evidence for reported outcomes, using the GRADE framework.

MAIN RESULTS

Overall, we included 15 reviews published in the Cochrane Library, comprising 164 randomised controlled trials (RCTs) and four controlled clinical trials, with a total of 10,396 participants. The included reviews evaluated a wide range of rehabilitation interventions, including: physical activity and exercise therapy, hyperbaric oxygen therapy (HBOT), whole-body vibration, occupational therapy, cognitive and psychological interventions, nutritional and dietary supplements, vocational rehabilitation, information provision, telerehabilitation, and interventions for the management of spasticity. We assessed all reviews to be of high to moderate methodological quality, based on R-AMSTAR criteria.Moderate-quality evidence suggested that physical therapeutic modalities (exercise and physical activities) improved functional outcomes (mobility, muscular strength), reduced impairment (fatigue), and improved participation (quality of life). Moderate-quality evidence suggested that inpatient or outpatient multidisciplinary rehabilitation programmes led to longer-term gains at the levels of activity and participation, and interventions that provided information improved patient knowledge. Low-qualitty evidence suggested that neuropsychological interventions, symptom-management programmes (spasticity), whole body vibration, and telerehabilitation improved some patient outcomes. Evidence for other rehabilitation modalities was inconclusive, due to lack of robust studies.

AUTHORS' CONCLUSIONS

The evidence suggests that regular specialist evaluation and follow-up to assess the needs of patients with all types of MS for appropriate rehabilitation interventions may be of benefit, although the certainty of evidence varies across the different types of interventions evaluated by the reviews. Structured, multidisciplinary rehabilitation programmes and physical therapy (exercise or physical activities) can improve functional outcomes (mobility, muscle strength, aerobic capacity), and quality of life. Overall, the evidence for many rehabilitation interventions should be interpreted cautiously, as the majority of included reviews did not include data from current studies. More studies, with appropriate design, which report the type and intensity of modalities and their cost-effectiveness are needed to address the current gaps in knowledge.

Coma After Acute Head Injury

BACKGROUND

Coma after acute head injury is always alarming. Depending on the type of injury, immediate treatment may be life-saving. About a quarter of a million patients are treated for traumatic brain injury in Germany each year. Treatment recommendations must be updated continually in the light of advancing knowledge.

METHODS

This review of treatment recommendations, prognostic factors, and the pathophysiology of coma after acute head injury is based on a 2015 German guideline for the treatment of head injury in adults and on pertinent publications retrieved by a selective search in PubMed for literature on post-traumatic coma.

RESULTS

As soon as the vital functions have been secured, patients with acute head injury should undergo cranial computed tomography, which is the method of choice for identifying intracranial injuries needing immediate treatment. Patients who have an intracranial hematoma with mass effect should be taken to surgery at once. The prognosis is significantly correlated with the patient's age, the duration of coma, accompanying neurological manifestations, and the site of brain injury. The case fatality rate of patients who have been comatose for 24 hours and who have accompanying lateralizing signs, a unilaterally absent pupillary light reflex, or hemiparesis lies between 30% and 50%. This figure rises to 50-60% in patients with abnormal extensor reflexes and to over 90% in those with bilaterally absent pupillary light reflexes. Current neuropathological and neuroradiological studies indicate that coma after acute head injury is due to reversible or irreversible dysfunction of the brainstem.

CONCLUSION

Brain tissue can tolerate ischemia and elevated pressure only for a very limited time. Comatose head-injured patients must therefore be evaluated urgently to determine whether they can be helped by the surgical removal of a hematoma or by a decompressive hemicraniectomy.

Producing an evidence-based treatment information website in partnership with people affected by multiple sclerosis

BACKGROUND AND AIMS

In earlier work, we identified that people affected by multiple sclerosis (MS) can have difficulty finding online treatment information that is up to date, trustworthy, understandable, and applicable to personal circumstances, but does not provoke confusion or negative emotional consequences. The objective was to develop online consumer summaries of MS treatment evidence (derived from Cochrane Reviews) that respond to identified treatment information needs of people affected by MS.

METHODS

A 2-phase mixed-methods project, conducted in partnership with consumers and an MS organisation. Phase 1 included review panels with consumers (Australians affected by MS) and health professionals to test paper-based treatment summaries before development, and pilot testing of the website. Phase 2 involved an online survey after website launch.

RESULTS

Eighty-three participants (85% affected by MS) took part. Phase 1 participants strongly endorsed key review summary components, including layering information, and additional sections to aid personal applicability. Participants additionally suggested questions for health professionals. Participants across both phases were receptive to the idea of being provided with Cochrane Review summaries online but were seeking other types of evidence and information, such as personal experiences and the latest experimental treatments, which could not be provided. While the small survey sample size (n = 58) limits application of the results to a broader population, the website was viewed favourably, as a useful, understandable, and trustworthy information source.

CONCLUSION

We describe a partnership approach to developing online evidence-based treatment information, underpinned by an in-depth understanding of consumers' information needs.

Understanding a role for hypoxia in lesion formation and location in the deep and periventricular white matter in small vessel disease and multiple sclerosis

The deep and periventricular white matter is preferentially affected in several neurological disorders, including cerebral small vessel disease (SVD) and multiple sclerosis (MS), suggesting that common pathogenic mechanisms may be involved in this injury. Here we consider the potential pathogenic role of tissue hypoxia in lesion development, arising partly from the vascular anatomy of the affected white matter. Specifically, these regions are supplied by a sparse vasculature fed by long, narrow end arteries/arterioles that are vulnerable to oxygen desaturation if perfusion is reduced (as in SVD, MS and diabetes) or if the surrounding tissue is hypoxic (as in MS, at least). The oxygen crisis is exacerbated by a local preponderance of veins, as these can become highly desaturated 'sinks' for oxygen that deplete it from surrounding tissues. Additional haemodynamic deficiencies, including sluggish flow and impaired vasomotor reactivity and vessel compliance, further exacerbate oxygen insufficiency. The cells most vulnerable to hypoxic damage, including oligodendrocytes, die first, resulting in demyelination. Indeed, in preclinical models, demyelination is prevented if adequate oxygenation is maintained by raising inspired oxygen concentrations. In agreement with this interpretation, there is a predilection of lesions for the anterior and occipital horns of the lateral ventricles, namely regions located at arterial watersheds, or border zones, known to be especially susceptible to hypoperfusion and hypoxia. Finally, mitochondrial dysfunction due to genetic causes, as occurs in leucodystrophies or due to free radical damage, as occurs in MS, will compound any energy insufficiency resulting from hypoxia. Viewing lesion formation from the standpoint of tissue oxygenation not only reveals that lesion distribution is partly predictable, but may also inform new therapeutic strategies.

Neurorehabilitation: applied neuroplasticity

The prevalence of disability due to neurological conditions is escalating worldwide. Neurological disorders have significant disability-burden with long-term functional and psychosocial issues, requiring specialized rehabilitation services for comprehensive management, especially treatments tapping into brain recovery 'neuroplastic' processes. Neurorehabilitation is interdisciplinary and cross-sectorial, requiring coordinated effort of diverse sectors, professions, patients and community to manage complex condition-related disability. This review provides evidence for a range of neurorehabilitation interventions for four common neurological conditions: multiple sclerosis (MS), stroke, traumatic brain injury and Parkinson's disease using the Grade of Recommendation, Assessment, Development and Evaluation tool for quality of evidence. Although, existing best-evidence for many interventions is still sparse, the overall findings suggest 'strong' evidence for physical therapy and psychological intervention for improved patient outcomes; and. 'moderate' evidence for multidisciplinary rehabilitation for longer term gains at the levels of activity (disability) and participation in MS and stroke population. The effect of other rehabilitation interventions is inconclusive, due to a paucity of methodologically robust studies. More research is needed to improve evidence-base for many promising rehabilitation interventions.

Brain perfusion imaging with voxel-based analysis in secondary progressive multiple sclerosis patients with a moderate to severe stage of disease: a boon for the workforce

Background

The present study was carried out to evaluate cerebral perfusion in multiple sclerosis (MS) patients with a moderate to severe stage of disease. Some patients underwent hyperbaric oxygen therapy (HBOT) and brain perfusion between before and after that was compared.

Methods

We retrospectively reviewed 25 secondary progressive (SP)-MS patients from the hospital database. Neurological disability evaluated by Expanded Disability Status Scale Score (EDSS). Brain perfusion was performed by (99 m) Tc-labeled bicisate (ECD) brain SPECT and the data were compared using statistical parametric mapping (SPM). In total, 16 patients underwent HBOT. Before HBOT and at the end of 20 sessions of oxygen treatment, 99mTc-ECD brain perfusion single photon emission computed tomography (SPECT) was performed again then the results were evaluated and compared. Brain perfusion was performed by (99 m) Tc-labeled bicisate (ECD) brain SPECT and the data were compared using statistical parametric mapping (SPM).

Results

A total of 25 SP-MS patients, 14 females (56 %) and 11 males (44 %) with a mean age of 38.92 ± 11.28 years included in the study. The mean disease duration was 8.70 ± 5.30 years. Of the 25 patients, 2 (8 %) had a normal SPECT and 23 (92 %) had abnormal brain perfusion SPECT studies. The study showed a significant association between severity of perfusion impairment with disease duration and also with EDSS (P <0.05). There was a significant improvement in pre- and post-treatment perfusion scans (P <0.05), but this did not demonstrate a significant improvement in the clinical subjective and objective evaluation of patients (P >0.05).

Conclusions

This study depicted decreased cerebral perfusion in SP-MS patients with a moderate to severe disability score and its association with clinical parameters. Because of its accessibility, rather low price, practical ease, and being objective quantitative information, brain perfusion SPECT can be complementing to other diagnostic modalities such as MRI and clinical examinations in disease surveillance and monitoring. The literature on this important issue is extremely scarce, and follow up studies are required to assess these preliminary results.

Controlled evaluation of the effects of hyperbaric oxygen therapy on the behavior of 16 children with autism spectrum disorders

Hyperbaric oxygen therapy (HBOT) has been used to treat individuals with autism. However, few studies of its effectiveness have been completed. The current study examined the effects of 40 HBOT sessions at 24% oxygen at 1.3 ATA on 11 topographies of directly observed behavior. Five replications of multiple baselines were completed across a total of 16 participants with autism spectrum disorders. No consistent effects were observed across any group or within any individual participant, demonstrating that HBOT was not an effective treatment for the participants in this study. This study represents the first relatively large-scale controlled study evaluating the effects of HBOT at the level of the individual participant, on a wide array of behaviors.

Complementary and alternative medicine and multiple sclerosis

Complementary and alternative medicine (CAM) is used by one-half to three-fourths of multiple sclerosis (MS) patients. Although it is used widely, CAM may not be discussed during a conventional medical visit. In MS, CAM therapies exhibit a broad range of risk-benefit profiles; some of these therapies are low risk and possibly beneficial, whereas others are ineffective, dangerous, or unstudied. Health professionals who provide objective and practical information about the risks and benefits of CAM therapies may improve the quality of care for those with MS.

Disease-modifying therapies in relapsing-remitting multiple sclerosis

CLINICAL QUESTION

What is the best current disease-modifying therapy for relapsing-remitting multiple sclerosis?

RESULTS

The evidence shows that the most effective disease-modifying therapy for delaying short- to medium-term disability progression, prevention of relapses, reducing the area and activity of lesions on magnetic resonance imaging, with the least side effects, is high-dose, high-frequency subcutaneous interferon-β1a 44 μg three times per week.

IMPLEMENTATION

The pitfalls in treatment of MS can be avoided by remembering the following points: The most effective therapy to prevent or delay the appearance of permanent neurological disability with the fewest side effects should be chosen, and treatment should not be delayed.Adherence to treatment should be monitored closely, and needs comprehensive patient information and education to establish long-term adherence, which is a critical determinant of long-term outcome.The correct approach to the disease includes disease management, symptom management, and patient management. A combination of tools is necessary to ease the various symptoms, which fall into three broad categories, i.e. rehabilitation, pharmacological, and procedural.It is important to understand that no treatment modality should be used alone, unless it is in itself sufficient to remedy the particular symptom/problem.

Complementary and alternative medicine in autism: an evidence-based approach to negotiating safe and efficacious interventions with families

This review focuses on helping clinicians identify resources and develop strategies they may use to effectively negotiate safe and effective use of complementary and alternative medicine (CAM) treatments with families of children with autism spectrum disorders (ASD), as well as other neurodevelopmental disorders. Since new types of CAM continue to be introduced into the autism community, emphasis is placed on providing clinicians with tools to help families negotiate the myriad of available treatments and make decisions based on current safety and efficacy data, while remaining mindful of the reasons families may be considering these treatments. We familiarize readers with high-quality, evidence-based resources that providers and families may use to ascertain current information about specific types of CAM, verify the content of biologically-based treatments, identify ongoing CAM research and obtain toolkits designed to help healthcare providers raise the topic of CAM usage and facilitate disclosure and discussion of CAM use with patients and their families.

Hyperbaric oxygen therapy for multiple sclerosis

Multiple sclerosis (MS) is a chronic, inflammatory, and degenerative neurological illness with no cure. It has been suggested that Hyperbaric Oxygen Therapy (HBO(2)T) may slow or reverse the progress of the disease. This article summarizes the clinical evidence for the use of HBO(2)T in the treatment of MS. We conducted a literature review focused on the interaction of hyperbaric oxygenation and MS. In particular, we appraised the clinical data regarding treatment and performed a meta-analysis of the randomized evidence using the methodology of the Cochrane Collaboration. We found 12 randomized studies in the area, all of which were performed between 1983 and 1987. A meta-analysis of this evidence suggests there is no clinically significant benefit from the administration of HBO(2)T. The great majority of randomized trials investigated a course of 20 treatments at pressures between 1.75ATA and 2.5ATA daily for 60-120 min over 4 weeks against a placebo regimen. None have tested the efficacy of HBO(2)T against alternative current best practice. No plausible benefit of HBO(2)T on the clinical course of MS was identified in this review. It remains possible that HBO(2)T is effective in a subgroup of individuals not clearly identified in the trials to date, but any benefit is unlikely to be of great clinical significance. There is some case for further human trials in selected subgroups and for prolonged courses of HBO(2)T at modest pressures, but the case is not strong. At this time, the routine treatment of MS with HBO(2)T is not recommended.

The use of hyperbaric oxygen therapy in ophthalmology

Hyperbaric oxygen therapy is a primary or adjuvant therapeutic method used in treatment of various acute or chronic disorders. Currently, eye diseases are among the off-label use of hyperbaric oxygen. However, there is an increasing body of evidence showing its safety and efficacy in retinal artery occlusion, cystoid macular edema secondary to retinal vein occlusion, scleral thinning and necrosis faced after pterygium surgery, orbital rhino-cerebral mucormycosis, nonhealing corneal edema, and anterior segment ischemia. Its potential to treat some blinding disease has also been pointed out in recent studies. This article constitutes an up-to-date summary of knowledge and therapeutic use of hyperbaric oxygen, and aims to contribute understanding of current and potential use of hyperbaric oxygen therapy in ophthalmology.