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Prado R, Alkhraisat MH, Padilla S. The Accurate Characterization of Platelet-Rich Plasma Enables Its Classification and Comparison: Letter to the Editor. Am J Sports Med 2023; 51:NP68-NP70. [PMID: 38031747 DOI: 10.1177/03635465231206933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
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Lin HW, Tam KW, Liou TH, Rau CL, Huang SW, Hsu TH. Efficacy of Platelet-Rich Plasma Injection on Range of Motion, Pain, and Disability in Patients With Adhesive Capsulitis: A Systematic Review and Meta-analysis. Arch Phys Med Rehabil 2023; 104:2109-2122. [PMID: 37119955 DOI: 10.1016/j.apmr.2023.03.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/28/2023] [Accepted: 03/31/2023] [Indexed: 05/01/2023]
Abstract
OBJECTIVE To investigate the therapeutic effects of platelet-rich plasma (PRP) injection on range of motion, pain, and disability in patients with adhesive capsulitis (AC). DATA SOURCES The authors performed the literature search in the PubMed, Embase, and Cochrane Library databases in February 2023. STUDY SELECTION Prospective studies comparing the outcomes of PRP with other intervention in patients with AC. DATA EXTRACTION The quality of included randomized trials was assessed using the revised Cochrane Risk of Bias (RoB 2.0) tool. The Risk of Bias in Non-Randomized Studies of Interventions tool was applied to assess the quality of nonrandomized trials. The mean difference (MD) or standardized mean difference (SMD) was determined as the effect size for continuous outcomes, and outcome accuracy was determined using 95% confidence intervals (CIs). DATA SYNTHESIS Fourteen studies involving 1139 patients were included. Our meta-analysis revealed that PRP injection can significantly improve passive abduction (MD=3.91; 95% CI, 0.84-6.98), passive flexion (MD=3.90; 95% CI, 0.15-7.84), and disability (SMD=-0.50; 95% CI, -1.29 to -0.74) within 1 month after intervention. Moreover, PRP injection can significantly improve passive abduction (MD=17.19; 95% CI, 12.38-22.01), passive flexion (MD=17.74; 95% CI, 9.89-25.59), passive external rotation (MD=12.95; 95% CI, 10.04-15.87), pain (MD=-8.40; 95% CI, -16.73 to -0.06), and disability (SMD=-1.02; 95% CI, -1.29 to -0.74) 3 months after intervention. PRP injection can also significantly improve pain (MD=-18.98; 95% CI, -24.71 to -13.26), and disability (SMD=-2.01; 95% CI, -3.02 to -1.00) 6 months after intervention. In addition, no adverse effects of PRP injection were reported. CONCLUSIONS PRP injection may serve as an effective and safe treatment for patients with AC.
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Affiliation(s)
- Ho-Wei Lin
- School of Medicine, College of Medicine, Taipei Medical University, Taipei City
| | - Ka-Wai Tam
- Center for Evidence-Based Health Care, Shuang Ho Hospital, Taipei Medical University, New Taipei City; Cochrane Taiwan, Taipei Medical University, Taipei City; Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City; Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei City
| | - Tsan-Hon Liou
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City; Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan
| | - Chi-Lun Rau
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City; Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan
| | - Shih-Wei Huang
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City; Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan
| | - Tzu-Herng Hsu
- Department of Physical Medicine and Rehabilitation, Shuang Ho Hospital, Taipei Medical University, New Taipei City; Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei City, Taiwan.
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Anitua E, Zalduendo M, Troya M, Tierno R, Alkhraisat MH. Cellular composition modifies the biological properties and stability of platelet rich plasma membranes for tissue engineering. J Biomed Mater Res A 2023; 111:1710-1721. [PMID: 37318048 DOI: 10.1002/jbm.a.37579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 03/03/2023] [Accepted: 05/30/2023] [Indexed: 06/16/2023]
Abstract
Scaffolds should provide structural support for tissue regeneration, allowing their gradual biodegradation and interacting with cells and bioactive molecules to promote remodeling. Thus, the scaffold's intrinsic properties affect cellular processes involved in tissue regeneration, including migration, proliferation, differentiation, and protein synthesis. In this sense, due to its biological effect and clinical potential, Platelet Rich Plasma (PRP) fibrin could be considered a successful scaffold. Given the high variability in commercial PRPs formulations, this research focused on assessing the influence of cellular composition on fibrin membrane stability and remodeling cell activity. The stability and biological effect were evaluated at different time points via D-dimer, type I collagen and elastase quantification in culture media conditioned by Plasma Rich in Growth Factors - Fraction 1 (PRGF-F1), Plasma Rich in Growth Factors - Whole Plasma (PRGF-WP) and Leukocyte-rich Platelet Rich Plasma (L-PRP) membranes, and by gingival fibroblast cells seeded on them, respectively. Ultrastructure of PRP membranes was also evaluated. Histological analyses were performed after 5 and 18 days. Additionally, the effect of fibrin membranes on cell proliferation was determined. According to the results, L-PRP fibrin membranes degradation was complete at the end of the study, while PRGF membranes remained practically unchanged. Considering fibroblast behavior, PRGF membranes, in contrast to L-PRP ones, promoted extracellular matrix biosynthesis at the same time as fibrinolysis and enhanced cell proliferation. In conclusion, leukocytes in PRP fibrin membranes drastically reduce scaffold stability and induce behavioral changes in fibroblasts by reducing their proliferation rate and remodeling ability.
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Affiliation(s)
- Eduardo Anitua
- Regenerative Medicine Laboratory, BTI-Biotechnology Institute, Vitoria, Spain
| | - Mar Zalduendo
- Regenerative Medicine Laboratory, BTI-Biotechnology Institute, Vitoria, Spain
| | - María Troya
- Regenerative Medicine Laboratory, BTI-Biotechnology Institute, Vitoria, Spain
| | - Roberto Tierno
- Regenerative Medicine Laboratory, BTI-Biotechnology Institute, Vitoria, Spain
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Simental-Mendía M, Lozano-Sepúlveda SA, Garza-Tapia M, Lara-Arias J, Acosta-Olivo CA, Vilchez-Cavazos F, Peña-Martínez VM. The Effects of the Combination of Rhein and Platelet-Rich Plasma on Human Articular Chondrocytes. Life (Basel) 2023; 13:1723. [PMID: 37629580 PMCID: PMC10455863 DOI: 10.3390/life13081723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 07/24/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND The presence of side effects and low bioavailability of rhein has limited its use in the treatment of osteoarthritis. We aimed to evaluate the in vitro response of human articular chondrocytes to the presence of the combination of platelet-rich plasma (PRP) and rhein. METHODS Solutions of rhein were prepared to assess solubility and select a working concentration. A stimulus with interleukin-1β (IL-β, 10 ng/mL) was induced for 24 h on human chondrocytes. Five treatment groups were established: control, IL-β control, PRP, rhein, and PRP + rhein. Cell viability, cell migration, nitric oxide (NO) production, tumor necrosis factor-α (TNF-α), and gene expression analyses were carried out. RESULTS A concentration of 50 mg/L was selected after a dose-response curve assay. Both NO and tumor TNF-α production significantly decreased after PRP and PRP + rhein treatments at 24 and 48 h. The wound healing assay revealed a significant stimulation of migration after 72 h with the PRP and PRP + rhein treatments. Expression of IL-1β, IL-6, MMP-13, and ADAMTS-5 was significantly downregulated, particularly after treatment with the combination of PRP + rhein. CONCLUSIONS Much of the determinations denoted a better performance of the combination of PRP and rhein in decreasing the levels of the different targets evaluated; however, this was not great enough to detect a significant difference in comparison with the PRP treatment alone.
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Affiliation(s)
- Mario Simental-Mendía
- Orthopedic Trauma Service, “Dr. José Eleuterio González” University Hospital, Universidad Autónoma de Nuevo León, Monterrey 66455, Mexico; (M.S.-M.); (J.L.-A.); (C.A.A.-O.); (F.V.-C.)
| | - Sonia Amelia Lozano-Sepúlveda
- Department of Biochemistry and Molecular Medicine, School of Medicine, Universidad Autónoma de Nuevo León, Monterrey 66455, Mexico;
| | - Marsela Garza-Tapia
- Department of Analytical Chemistry, School of Medicine, Universidad Autónoma de Nuevo León, Monterrey 66455, Mexico;
| | - Jorge Lara-Arias
- Orthopedic Trauma Service, “Dr. José Eleuterio González” University Hospital, Universidad Autónoma de Nuevo León, Monterrey 66455, Mexico; (M.S.-M.); (J.L.-A.); (C.A.A.-O.); (F.V.-C.)
| | - Carlos Alberto Acosta-Olivo
- Orthopedic Trauma Service, “Dr. José Eleuterio González” University Hospital, Universidad Autónoma de Nuevo León, Monterrey 66455, Mexico; (M.S.-M.); (J.L.-A.); (C.A.A.-O.); (F.V.-C.)
| | - Félix Vilchez-Cavazos
- Orthopedic Trauma Service, “Dr. José Eleuterio González” University Hospital, Universidad Autónoma de Nuevo León, Monterrey 66455, Mexico; (M.S.-M.); (J.L.-A.); (C.A.A.-O.); (F.V.-C.)
| | - Víctor Manuel Peña-Martínez
- Orthopedic Trauma Service, “Dr. José Eleuterio González” University Hospital, Universidad Autónoma de Nuevo León, Monterrey 66455, Mexico; (M.S.-M.); (J.L.-A.); (C.A.A.-O.); (F.V.-C.)
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Ríos Luna A, Fahandezh-Saddi Díaz H, Villanueva Martínez M, Iglesias R, Prado R, Padilla S, Anitua E. Office-Based Intraosseous Infiltrations of PRGF as an Effective Treatment for Knee Osteoarthritis: A Retrospective Observational Clinical Study. J Clin Med 2023; 12:4512. [PMID: 37445547 DOI: 10.3390/jcm12134512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
The aim of this study was to explore and assess office-based ultrasound-guided intraosseous and intra-articular infiltrations of plasma rich in growth factors (PRGF) in patients with moderate and severe knee osteoarthritis (KOA). Seventy-nine patients (30 women and 49 men) with grade 3-4 KOA according to the Kellgren-Lawrence classification participated in the study. All patients were treated with a minimally invasive technique using local anesthesia WALANT (wide-awake local anesthesia no tourniquet) in the ambulatory setting. A PRGF intra-articular infiltration and two intraosseous infiltrations in the tibial plateau and femoral condyle were performed weekly for a total of three sessions. The evaluation of the results was carried out using knee injury and osteoarthritis outcome score (KOOS) at baseline and post-treatment. After a follow-up period of 11 months (median) [interquartile range, 7-14], all the KOOS domains showed statistically significant improvement (p < 0.001). Moreover, 88% of the patients showed a pain reduction of at least 10 points (minimally clinically important improvement) from pre- to post-treatment. Our retrospective study using the in-office procedure of ultrasound-guided combination of intra-articular and intraosseous infiltrations of PRGF is a safe and efficacious approach for the treatment of grade 3-4 knee osteoarthritis.
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Affiliation(s)
- Antonio Ríos Luna
- Department of Traumatology and Orthopedic Surgery, Clínica Orthoindal, 04004 Almería, Spain
| | | | | | - Roberto Iglesias
- Department of Traumatology and Orthopedic Surgery, Clínica Orthoindal, 04004 Almería, Spain
| | - Roberto Prado
- Regenerative Medicine Laboratory, BTI-Biotechnology Institute I MAS D, 01007 Vitoria, Spain
| | - Sabino Padilla
- Regenerative Medicine Laboratory, BTI-Biotechnology Institute I MAS D, 01007 Vitoria, Spain
| | - Eduardo Anitua
- Regenerative Medicine Laboratory, BTI-Biotechnology Institute I MAS D, 01007 Vitoria, Spain
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Simental-Mendía M, Ortega-Mata D, Acosta-Olivo CA. Platelet-Rich Plasma for Knee Osteoarthritis: What Does the Evidence Say? Drugs Aging 2023:10.1007/s40266-023-01040-6. [PMID: 37347411 DOI: 10.1007/s40266-023-01040-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2023] [Indexed: 06/23/2023]
Abstract
The utilization of platelet-rich-plasma as a therapeutic intervention for knee osteoarthritis has gained immense attention since 2008. The increase in the number of scientific publications dedicated to this area can be attributed to the majority of favorable results reported in clinical trials and basic science studies. However, despite the growing evidence, the use of platelet-rich plasma in clinical practice still poses controversial aspects. The potential mechanisms of action described for platelet-rich-plasma so far indicate that it could serve as a disease-modifying drug, acting to counteract important aspects of knee osteoarthritis pathophysiology (cartilage breakdown, inflammation, and bone remodeling). Nevertheless, its efficacy in slowing down the progression of knee osteoarthritis remains unproven. While inconsistencies have been noted, the majority of controlled clinical trials and meta-analyses advocate for the utilization of platelet-rich-plasma in treating knee osteoarthritis, as it has demonstrated greater efficacy than hyaluronic acid and placebo, with a follow-up of at least 1 year. Despite advancements made in certain areas, significant diversity persists regarding the formulations used, therapeutic regimen, extended follow-up periods, patient selection, and assessment of clinically relevant outcomes. Consequently, the leading clinical practice guidelines do not recommend its use. In light of the emerging evidence, this narrative review aims to provide an objective evaluation of the recent available scientific literature (last 5 years) focused on randomized clinical trials and meta-analyses to present a current overview of the topic.
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Affiliation(s)
- Mario Simental-Mendía
- Orthopedic Trauma Service, University Hospital "Dr. José Eleuterio González", School of Medicine, Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero and Ave. Dr. José Eleuterio González, 64460, Monterrey, Nuevo León, Mexico
| | - Daniela Ortega-Mata
- Orthopedic Trauma Service, University Hospital "Dr. José Eleuterio González", School of Medicine, Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero and Ave. Dr. José Eleuterio González, 64460, Monterrey, Nuevo León, Mexico
| | - Carlos A Acosta-Olivo
- Orthopedic Trauma Service, University Hospital "Dr. José Eleuterio González", School of Medicine, Universidad Autónoma de Nuevo León, Ave. Francisco I. Madero and Ave. Dr. José Eleuterio González, 64460, Monterrey, Nuevo León, Mexico.
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Momoi Y, Saita Y, Nagao M, Kobayashi Y, Nakajima R, Uchino S, Wakayama T, Nishio H, Fukusato S, Wakana S, Tomura J, Kobayashi K, Yoshida K, Kaneko H, Kubota M, Ishijima M. Study protocol for a randomised placebo controlled trial of platelet-rich plasma injection to prevent post-traumatic knee osteoarthritis after anterior cruciate ligament reconstruction. BMJ Open 2022; 12:e061484. [PMID: 36414304 PMCID: PMC9685167 DOI: 10.1136/bmjopen-2022-061484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION The elevated cytokine levels in patients suffering from anterior cruciate ligament (ACL) rupture may lead to acute post-traumatic arthritis (APTA) and post-traumatic osteoarthritis (PTOA). Due to its chondrogenerative and anti-inflammatory effect, platelet-rich plasma (PRP) therapy is expected to show a positive outcome in APTA and PTOA. The proposed trial aims to quantitatively measure the efficacy of PRP injection in arresting post-traumatic cartilage degeneration among patients after ACL reconstruction. METHODS AND ANALYSIS This will be a single-blind, randomised, prospective, controlled clinical trial designed following the Consolidated Standards of Reporting Trials guidelines. After ACL reconstruction, 80 patients will be randomised to receive either leucocyte-poor PRP injection after joint aspiration or a placebo control group receiving only joint aspiration. Participants (age 20-49 years) will be those who have undergone ACL reconstruction within the past 2 weeks with a body mass index<35 and Kellgren Lawrence osteoarthritis grade<2. The primary outcome will include MRI-T2 values of knee cartilage at 6 months. The secondary outcomes will include pain assessment by Visual Analogue Scale, Knee injury and Osteoarthritis Outcome Score, blood and urine test, physical findings, measurements for muscle strength and joint stability. ETHICS AND DISSEMINATION The study was approved by The Independent Ethics Committee for Clinical Trials of the Japanese Association for the Promotion of State-of-the-Art Medicine. Results of the trial and each of the outcomes will be shared via conferences and publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER jRCTb030200391.
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Affiliation(s)
- Yasumasa Momoi
- Departments of Orhopedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Yoshitomo Saita
- Departments of Orhopedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
- Department of Sports and Regenerative Medicine, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Masashi Nagao
- Departments of Orhopedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Yohei Kobayashi
- Departments of Orhopedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Ryosuke Nakajima
- Departments of Orhopedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Sayuri Uchino
- Departments of Orhopedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Takanori Wakayama
- Departments of Orhopedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Hirofumi Nishio
- Departments of Orhopedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Shin Fukusato
- Departments of Orhopedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Suguru Wakana
- Departments of Orhopedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Jun Tomura
- Departments of Orhopedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Keiji Kobayashi
- Departments of Orhopedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Keiichi Yoshida
- Departments of Orhopedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Haruka Kaneko
- Departments of Orhopedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Mitsuaki Kubota
- Departments of Orhopedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
| | - Muneaki Ishijima
- Departments of Orhopedics, Faculty of Medicine, Juntendo University, Bunkyo-ku, Tokyo, Japan
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AbuBakr N, Fares AE, Mostafa A, Farag DB. Mesenchymal stem cells-derived microvesicles versus platelet-rich plasma in the treatment of monoiodoacetate-induced temporomandibular joint osteoarthritis in Albino rats. Heliyon 2022; 8:e10857. [PMID: 36212013 PMCID: PMC9539788 DOI: 10.1016/j.heliyon.2022.e10857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 03/14/2022] [Accepted: 09/26/2022] [Indexed: 11/30/2022] Open
Abstract
Temporomandibular joint osteoarthritis (TMJ-OA) is a serious disease, designated by severe joint pain and dysfunction. Limitations of current therapeutics have led to an increased interest in regenerative strategies. Recently, the non-surgical treatment of OA has seen increased use of biologic injectable therapies like mesenchymal stem cells (MSCs) and platelet-rich plasma (PRP). Although these biotherapies represent an admirable effort, more studies are necessary to determine their efficacy. Thus, the aim of this study was to assess the curative potential of a single intra-articular injection of bone marrow MSCs-derived microvesicles (BM-MSCs-MVs) versus a single intra-articular injection of PRP in monoiodoacetate (MIA)-induced TMJ-OA model in Albino rats. Forty-eight male rats were used. A single intra-articular unilateral MIA injection was utilized to induce TMJ-OA. One week post induction, rats were sorted into 3 groups (16 rats each): group (I): received no treatment, groups (II) & (III): received BM-MSCs-MVs and PRP respectively. Scarification was done at 2 and 4 weeks from onset of treatment. Histological changes of the condylar TMJ were examined with H&E staining. Expression of IL-1β, TNF-α, NF-κB, MMP-13, MMP-3, and collagen ΙΙ markers was detected using real-time PCR. Histologically, the osteoarthritic group exhibited degenerated condylar tissues which were aggravated at 4 weeks. Oppositely, a marked improvement in the condylar TMJ histology was noticed in both the BM-MSCs-MVs-and PRP-treated groups at both time intervals. Additionally, the treated groups showed a decrease in IL-1β, TNF-α, NF-κB, MMP-13 and MMP-3 and an increase in collagen ΙΙ genes expression in contrast to the untreated group. Moreover, this difference was significant in the BM-MSCs-MVs group as compared to the PRP-treated group. Our results concluded that BM-MSCs-MVs as well as PRP treatments were able to target the key pathological features in OA, mainly inflammation and matrix degradation, and helped in restoring condylar structure in TMJ-OA rat model. However, BM-MSCs-MVs treatment exhibited more efficient therapeutic potential as compared to PRP treatment.
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Gupta GK, Shekhar S, Haque ZU, Halder S, Manjhi AK, Rai A. Comparison of the Efficacy of Platelet-Rich Plasma (PRP) and Local Corticosteroid Injection in Periarthritis Shoulder: A Prospective, Randomized, Open, Blinded End-Point (PROBE) Study. Cureus 2022; 14:e29253. [PMID: 36262947 PMCID: PMC9574604 DOI: 10.7759/cureus.29253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2022] [Indexed: 11/05/2022] Open
Abstract
Background Periarthritis or frozen shoulder, also called adhesive capsulitis, is characterized by stiffness and pain along with gradual loss of active and passive movement in the glenohumeral joint. More than 2-5% of the population suffers from periarthritis with a higher incidence in the age group of 40-60 years. The various treatment modalities used for its management include simple physiotherapy, short-wave therapy, ultrasonic therapy, transcutaneous electrical nerve stimulation, hydrotherapy, analgesics, intra-articular injections, manipulation under general anesthesia (MUA), and surgical management. The application of intra-articular steroid injection has been a common and efficacious option in rapidly diminishing shoulder pain and disability. Some recent studies reported a better outcome using platelet-rich plasma (PRP) injections in frozen shoulder cases. Hence, this randomized controlled trial was conducted to compare the efficacy of intra-articular injections of PRP and triamcinolone in patients of shoulder periarthritis in a population from the eastern region of India Methodology A total of 60 patients with periarthritis shoulder were allocated into two groups after randomization. Group A received 2 mL autologous PRP, and Group B received 2 mL of triamcinolone (40 mg/mL) intra-articular injection. Patients were followed up on the 4th week, 12th week, and 24th week. The assessment of pain and function using the visual analog scale (VAS) score and the Disabilities of Arm, Shoulder, and Hand (DASH) score, respectively, was done at each follow-up. The primary analyses of both primary and secondary outcomes were conducted in the intention-to-treat (ITT) population. SPSS version 24 (IBM Corp., Armonk, NY, USA) was used for data analysis. Results The mean VAS score in the PRP and triamcinolone groups was 14.33 ± 3.79 and 31.63 ± 7.62, respectively (p = 0.0001) after 24 weeks. The mean DASH score in the PRP and triamcinolone groups was 18.08 ± 8.08 and 31.76 ± 3.63, respectively (p = 0.0001), which shows significant improvement in both pain and disability scores in the PRP group after 24 weeks. Conclusions The triamcinolone group showed better short-term outcomes whereas PRP showed better long-term outcomes in reducing pain and disability scores in terms of VAS and DASH scores.
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Sao P, Chand Y, Al-Keridis LA, Saeed M, Alshammari N, Singh S. Classifying Integrated Signature Molecules in Macrophages of Rheumatoid Arthritis, Osteoarthritis, and Periodontal Disease: An Omics-Based Study. Curr Issues Mol Biol 2022; 44:3496-3517. [PMID: 36005137 PMCID: PMC9406916 DOI: 10.3390/cimb44080241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/15/2022] [Accepted: 07/23/2022] [Indexed: 12/02/2022] Open
Abstract
Rheumatoid arthritis (RA), osteoarthritis (OA), and periodontal disease (PD) are chronic inflammatory diseases that are globally prevalent, and pose a public health concern. The search for a potential mechanism linking PD to RA and OA continues, as it could play a significant role in disease prevention and treatment. Recent studies have linked RA, OA, and PD to Porphyromonas gingivalis (PG), a periodontal bacterium, through a similar dysregulation in an inflammatory mechanism. This study aimed to identify potential gene signatures that could assist in early diagnosis as well as gain insight into the molecular mechanisms of these diseases. The expression data sets with the series IDs GSE97779, GSE123492, and GSE24897 for macrophages of RA, OA synovium, and PG stimulated macrophages (PG-SM), respectively, were retrieved and screened for differentially expressed genes (DEGs). The 72 common DEGs among RA, OA, and PG-SM were further subjected to gene–gene correlation analysis. A GeneMANIA interaction network of the 47 highly correlated DEGs comprises 53 nodes and 271 edges. Network centrality analysis identified 15 hub genes, 6 of which are DEGs (API5, ATE1, CCNG1, EHD1, RIN2, and STK39). Additionally, two significantly up-regulated non-hub genes (IER3 and RGS16) showed interactions with hub genes. Functional enrichment analysis of the genes showed that “apoptotic regulation” and “inflammasomes” were among the major pathways. These eight genes can serve as important signatures/targets, and provide new insights into the molecular mechanism of PG-induced RA, OA, and PD.
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Affiliation(s)
- Prachi Sao
- Faculty of Biotechnology, Institute of Biosciences and Technology, Shri Ramswaroop Memorial University, Barabanki 225003, Uttar Pradesh, India
| | - Yamini Chand
- Faculty of Biotechnology, Institute of Biosciences and Technology, Shri Ramswaroop Memorial University, Barabanki 225003, Uttar Pradesh, India
| | - Lamya Ahmed Al-Keridis
- Department of Biology, College of Science, Princess Nourah Bint Abdulrahman University, Riyadh 11671, Saudi Arabia
- Correspondence: (L.A.A.-K.); (S.S.)
| | - Mohd Saeed
- Department of Biology, College of Science, University of Hail, Hail 55476, Saudi Arabia
| | - Nawaf Alshammari
- Department of Biology, College of Science, University of Hail, Hail 55476, Saudi Arabia
| | - Sachidanand Singh
- Faculty of Biotechnology, Institute of Biosciences and Technology, Shri Ramswaroop Memorial University, Barabanki 225003, Uttar Pradesh, India
- Department of Biotechnology, Vignan’s Foundation for Science, Technology, and Research (Deemed to be University), Vadlamudi, Guntur 522213, Andhra Pradesh, India
- Department of Biotechnology, Smt. S. S. Patel Nootan Science & Commerce College, Sankalchand Patel University, Visnagar 384315, Gujarat, India
- Correspondence: (L.A.A.-K.); (S.S.)
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Wang S, Liu X, Wang Y. Evaluation of Platelet-Rich Plasma Therapy for Peripheral Nerve Regeneration: A Critical Review of Literature. Front Bioeng Biotechnol 2022; 10:808248. [PMID: 35299637 PMCID: PMC8923347 DOI: 10.3389/fbioe.2022.808248] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/14/2022] [Indexed: 12/12/2022] Open
Abstract
Peripheral nerve injury (PNI) is a common disease in clinic, and the regeneration process of peripheral nerve tissue is slow, and patients with PNI often suffer from the loss of nerve function. At present, related research on the mechanism of peripheral nerve regeneration has become a hot spot, and scholars are also seeking a method that can accelerate the regeneration of peripheral nerve. Platelet-rich plasma (PRP) is a platelet concentrate extracted from autologous blood by centrifugation, which is a kind of bioactive substance. High concentration of platelets can release a variety of growth factors after activation, and can promote the proliferation and differentiation of tissue cells, which can accelerate the process of tissue regeneration. The application of PRP comes from the body, there is no immune rejection reaction, it can promote tissue regeneration with less cost, it is,therefore, widely used in various clinical fields. At present, there are relatively few studies on the application of PRP to peripheral nerve regeneration. This article summarizes the literature in recent years to illustrate the effect of PRP on peripheral nerve regeneration from mechanism to clinical application, and prospects for the application of PRP to peripheral nerve.
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Affiliation(s)
| | | | - Yueshu Wang
- Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
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12
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Pourkarim R, Farahpour MR, Rezaei SA. Comparison effects of platelet-rich plasma on healing of infected and non-infected excision wounds by the modulation of the expression of inflammatory mediators: experimental research. Eur J Trauma Emerg Surg 2022; 48:3339-3347. [PMID: 35149876 DOI: 10.1007/s00068-022-01907-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Accepted: 01/29/2022] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Microbial invasion in soft tissue is believed to cause infectious wounds and increase healthcare costs, anxiety, and distress. The current study was conducted to evaluate the effects of topical use of platelet-rich plasma (PRP) on infected wound-healing process in rats. METHODS Following the induction of a circular wound, the animals were divided into three groups, including (1) standard control: infected wounds treated with mupirocin (SDCL), (2) non-infected wounds treated with PRP (PRP), and (3) infected group in which the rats were infected with Staphylococcus epidermidis and Pseudomonas aeruginosa and treated with PRP (INF + PRP). To evaluate the effects of PRP on the wound-healing rate, total bacterial count, histopathological assessment, the serum concentrations of sialic acid, C-reactive protein, haptoglobin, and fibrinogen were assessed. Additionally, IL-1β, IL-6, TNF-α, IL-3, NF-κB, iNOS, PDGF, and EGF mRNA level expressions were assessed employing the qRT-PCR method. RESULTS The results indicated that topical application of PRP could significantly decrease total bacterial count, the level of C-reactive protein, and pro-inflammatory cytokines (IL-1β, IL-6, and TNF-α) compared to the SDCL group. The administration of PRP also promoted re-epithelization rate by increasing the expression of EGF mRNA level. CONCLUSION We could recommend the use of PRP for the treatment of infected wounds owing to its efficiency in decreasing colonization of tissue bacteria, tissue inflammation, and stimulating wound heal-up.
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Affiliation(s)
- Reza Pourkarim
- Department of Basic Sciences, Faculty of Veterinary Medicine, Urmia Branch, Islamic Azad University, Urmia, Iran
| | - Mohammad Reza Farahpour
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Urmia Branch, Islamic Azad University, Urmia, Iran.
| | - Siamak Asri Rezaei
- Department of Internal Medicine and Clinical Pathology, Faculty of Veterinary Medicine, Urmia University, Urmia, Iran
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13
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Saita Y, Kobayashi Y, Nishio H, Wakayama T, Fukusato S, Uchino S, Momoi Y, Ikeda H, Kaneko K. Predictors of Effectiveness of Platelet-Rich Plasma Therapy for Knee Osteoarthritis: A Retrospective Cohort Study. J Clin Med 2021; 10:jcm10194514. [PMID: 34640529 PMCID: PMC8509123 DOI: 10.3390/jcm10194514] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/06/2021] [Accepted: 09/27/2021] [Indexed: 12/13/2022] Open
Abstract
There has recently been growing interest worldwide in biological therapies such as platelet-rich plasma injection for the treatment of knee osteoarthritis. However, predicting the effectiveness of platelet-rich plasma therapy remains uncertain. Therefore, this retrospective cohort study was performed to assess a range of predictors for the effectiveness of platelet-rich plasma therapy in treating knee osteoarthritis. The study included 517 consecutive patients who underwent three injections of leucocyte-poor platelet-rich plasma therapy from 2016 to 2019 at a single institution. The treatment outcomes, including patient-oriented outcomes (visual analogue scale score and Knee Injury and Osteoarthritis Outcome Score), were analyzed and compared according to the severity of knee osteoarthritis based on Kellgren–Lawrence (KL) grading using standing plain radiographs. Fisher’s exact test, univariate regression, and multivariate regression were used for data analysis. Patient-oriented outcomes were significantly improved 6 and 12 months after platelet-rich plasma therapy. The overall responder rate in patients who met the Outcome Measures in Rheumatology (OMERACT)–Osteoarthritis Research Society International (OARSI) responder criteria was 62.1%. The responder rate was significantly lower in patients with severe knee osteoarthritis (KL4, 50.9%) than in those with mild (KL2, 75.2%) and moderate (KL3, 66.5%) knee osteoarthritis. The multivariate logistic regression analysis revealed that deterioration of the knee osteoarthritis grade (increased KL grade) was a significant predictor of a worse clinical outcome (odds ratio, 0.58; 95% confidence interval, 0.45–0.75; p < 0.001). The relative risk for non-responders in severe (KL4) KOA was 2.1 (95% CI, 1.5–3.0) at 6 months and 2.3 (1.6–3.2) at 12 months compared with mild-to-moderate (KL2-3) KOA. The efficacy of platelet-rich plasma therapy was not affected by age, sex, body weight, or platelet count. This study revealed that the effectiveness of platelet-rich plasma therapy for the treatment of knee osteoarthritis is approximately 60% and that the effectiveness depends on the severity of knee osteoarthritis. This observation is useful not only for physicians but also for patients with knee osteoarthritis.
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Affiliation(s)
- Yoshitomo Saita
- Department of Sports and Regenerative Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (Y.K.); (H.N.); (T.W.); (S.F.); (S.U.); (Y.M.)
- Department of Orthopaedics and Sports Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (H.I.); (K.K.)
- Correspondence: ; Tel.: +81-3-3813-3111
| | - Yohei Kobayashi
- Department of Sports and Regenerative Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (Y.K.); (H.N.); (T.W.); (S.F.); (S.U.); (Y.M.)
- Department of Orthopaedics and Sports Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (H.I.); (K.K.)
| | - Hirofumi Nishio
- Department of Sports and Regenerative Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (Y.K.); (H.N.); (T.W.); (S.F.); (S.U.); (Y.M.)
- Department of Orthopaedics and Sports Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (H.I.); (K.K.)
| | - Takanori Wakayama
- Department of Sports and Regenerative Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (Y.K.); (H.N.); (T.W.); (S.F.); (S.U.); (Y.M.)
- Department of Orthopaedics and Sports Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (H.I.); (K.K.)
| | - Shin Fukusato
- Department of Sports and Regenerative Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (Y.K.); (H.N.); (T.W.); (S.F.); (S.U.); (Y.M.)
- Department of Orthopaedics and Sports Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (H.I.); (K.K.)
| | - Sayuri Uchino
- Department of Sports and Regenerative Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (Y.K.); (H.N.); (T.W.); (S.F.); (S.U.); (Y.M.)
- Department of Orthopaedics and Sports Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (H.I.); (K.K.)
| | - Yasumasa Momoi
- Department of Sports and Regenerative Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (Y.K.); (H.N.); (T.W.); (S.F.); (S.U.); (Y.M.)
- Department of Orthopaedics and Sports Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (H.I.); (K.K.)
| | - Hiroshi Ikeda
- Department of Orthopaedics and Sports Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (H.I.); (K.K.)
| | - Kazuo Kaneko
- Department of Orthopaedics and Sports Medicine, Juntendo University, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-0033, Japan; (H.I.); (K.K.)
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14
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De Angelis E, Saleri R, Martelli P, Elviri L, Bianchera A, Bergonzi C, Pirola M, Romeo R, Andrani M, Cavalli V, Conti V, Bettini R, Passeri B, Ravanetti F, Borghetti P. Cultured Horse Articular Chondrocytes in 3D-Printed Chitosan Scaffold With Hyaluronic Acid and Platelet Lysate. Front Vet Sci 2021; 8:671776. [PMID: 34322533 PMCID: PMC8311290 DOI: 10.3389/fvets.2021.671776] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 05/14/2021] [Indexed: 11/13/2022] Open
Abstract
Three-dimensional (3D) printing has gained popularity in tissue engineering and in the field of cartilage regeneration. This is due to its potential to generate scaffolds with spatial variation of cell distribution or mechanical properties, built with a variety of materials that can mimic complex tissue architecture. In the present study, horse articular chondrocytes were cultured for 2 and 4 weeks in 3D-printed chitosan (CH)-based scaffolds prepared with or without hyaluronic acid and in the presence of fetal bovine serum (FBS) or platelet lysate (PL). These 3D culture systems were analyzed in terms of their capability to maintain chondrocyte differentiation in vitro. This was achieved by evaluating cell morphology, immunohistochemistry (IHC), gene expression of relevant cartilage markers (collagen type II, aggrecan, and Sox9), and specific markers of dedifferentiated phenotype (collagen type I, Runx2). The morphological, histochemical, immunohistochemical, and molecular results demonstrated that the 3D CH scaffold is sufficiently porous to be colonized by primary chondrocytes. Thereby, it provides an optimal environment for the colonization and synthetic activity of chondrocytes during a long culture period where a higher rate of dedifferentiation can be generally observed. Enrichment with hyaluronic acid provides an optimal microenvironment for a more stable maintenance of the chondrocyte phenotype. The use of 3D CH scaffolds causes a further increase in the gene expression of most relevant ECM components when PL is added as a substitute for FBS in the medium. This indicates that the latter system enables a better maintenance of the chondrocyte phenotype, thereby highlighting a fair balance between proliferation and differentiation.
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Affiliation(s)
- Elena De Angelis
- Department of Veterinary Science, University of Parma, Parma, Italy
| | - Roberta Saleri
- Department of Veterinary Science, University of Parma, Parma, Italy
| | - Paolo Martelli
- Department of Veterinary Science, University of Parma, Parma, Italy
| | - Lisa Elviri
- Food and Drug Department, University of Parma, Parma, Italy
| | | | - Carlo Bergonzi
- Food and Drug Department, University of Parma, Parma, Italy
| | - Marta Pirola
- Department of Veterinary Science, University of Parma, Parma, Italy
| | - Roberta Romeo
- Department of Veterinary Science, University of Parma, Parma, Italy
| | - Melania Andrani
- Department of Veterinary Science, University of Parma, Parma, Italy
| | - Valeria Cavalli
- Department of Veterinary Science, University of Parma, Parma, Italy
| | - Virna Conti
- Department of Veterinary Science, University of Parma, Parma, Italy
| | | | | | | | - Paolo Borghetti
- Department of Veterinary Science, University of Parma, Parma, Italy
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15
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Zahir H, Dehghani B, Yuan X, Chinenov Y, Kim C, Burge A, Bandhari R, Nemirov D, Fava P, Moley P, Potter H, Nguyen J, Halpern B, Donlin L, Ivashkiv L, Rodeo S, Otero M. In vitro responses to platelet-rich-plasma are associated with variable clinical outcomes in patients with knee osteoarthritis. Sci Rep 2021; 11:11493. [PMID: 34075069 PMCID: PMC8169703 DOI: 10.1038/s41598-021-90174-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 05/07/2021] [Indexed: 12/19/2022] Open
Abstract
Autologous blood-derived products such as platelet-rich plasma (PRP) are widely used to treat musculoskeletal conditions, including knee osteoarthritis (OA). However, the clinical outcomes after PRP administration are often variable, and there is limited information about the specific characteristics of PRP that impact bioactivity and clinical responses. In this study, we aimed to develop an integrative workflow to evaluate responses to PRP in vitro, and to assess if the in vitro responses to PRP are associated with the PRP composition and clinical outcomes in patients with knee OA. To do this, we used a coculture system of macrophages and fibroblasts paired with transcriptomic analyses to comprehensively characterize the modulation of inflammatory responses by PRP in vitro. Relying on patient-reported outcomes and achievement of minimal clinically important differences in OA patients receiving PRP injections, we identified responders and non-responders to the treatment. Comparisons of PRP from these patient groups allowed us to identify differences in the composition and in vitro activity of PRP. We believe that our integrative workflow may enable the development of targeted approaches that rely on PRP and other orthobiologics to treat musculoskeletal pathologies.
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Affiliation(s)
- Habib Zahir
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA.,New York Institute of Technology, Old Westbury, NY, USA
| | - Bijan Dehghani
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
| | - Xiaoning Yuan
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA.,NewYork-Presbyterian Hospital, New York, NY, USA
| | - Yurii Chinenov
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA.,The David Z. Rosensweig Genomics Research Center, New York, NY, USA
| | - Christine Kim
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA.,Columbia University, New York, NY, USA
| | - Alissa Burge
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
| | - Reyna Bandhari
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
| | - Daniel Nemirov
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
| | - Patrick Fava
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
| | - Peter Moley
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA.,HSS Center for Regenerative Medicine, New York, NY, USA
| | - Hollis Potter
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
| | - Joseph Nguyen
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA
| | - Brian Halpern
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA.,HSS Center for Regenerative Medicine, New York, NY, USA
| | - Laura Donlin
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA.,Derfner Foundation Precision Medicine Laboratory, New York, NY, USA
| | - Lionel Ivashkiv
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA.,The David Z. Rosensweig Genomics Research Center, New York, NY, USA
| | - Scott Rodeo
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA.,HSS Center for Regenerative Medicine, New York, NY, USA
| | - Miguel Otero
- Hospital for Special Surgery, 535 E 70th Street, New York, NY, 10021, USA. .,HSS Center for Regenerative Medicine, New York, NY, USA. .,Derfner Foundation Precision Medicine Laboratory, New York, NY, USA.
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16
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From Pathogenesis to Therapy in Knee Osteoarthritis: Bench-to-Bedside. Int J Mol Sci 2021; 22:ijms22052697. [PMID: 33800057 PMCID: PMC7962130 DOI: 10.3390/ijms22052697] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 02/25/2021] [Accepted: 03/04/2021] [Indexed: 12/22/2022] Open
Abstract
Osteoarthritis (OA) is currently the most widespread musculoskeletal condition and primarily affects weight-bearing joints such as the knees and hips. Importantly, knee OA remains a multifactorial whole-joint disease, the appearance and progression of which involves the alteration of articular cartilage as well as the synovium, subchondral bone, ligaments, and muscles through intricate pathomechanisms. Whereas it was initially depicted as a predominantly aging-related and mechanically driven condition given its clear association with old age, high body mass index (BMI), and joint malalignment, more recent research identified and described a plethora of further factors contributing to knee OA pathogenesis. However, the pathogenic intricacies between the molecular pathways involved in OA prompted the study of certain drugs for more than one therapeutic target (amelioration of cartilage and bone changes, and synovial inflammation). Most clinical studies regarding knee OA focus mainly on improvement in pain and joint function and thus do not provide sufficient evidence on the possible disease-modifying properties of the tested drugs. Currently, there is an unmet need for further research regarding OA pathogenesis as well as the introduction and exhaustive testing of potential disease-modifying pharmacotherapies in order to structure an effective treatment plan for these patients.
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17
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Platelet-Rich Plasma Combined with Alendronate Reduces Pain and Inflammation in Induced Osteoarthritis in Rats by Inhibiting the Nuclear Factor-Kappa B Signaling Pathway. BIOMED RESEARCH INTERNATIONAL 2020; 2020:8070295. [PMID: 33062701 PMCID: PMC7539111 DOI: 10.1155/2020/8070295] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/24/2020] [Indexed: 12/16/2022]
Abstract
Purpose Osteoarthritis (OA) is one of the common degenerative diseases of the joint in the world. This study was designed to explore the effect of platelet-rich plasma (PRP) combined with alendronate (ALN) on OA. Methods We induced OA model by anterior cruciate ligament transection (ACLT) method in rats and treating chondrocytes by IL-1β in vitro. PRP and/or ALN were used to treat induced rats and chondrocytes. Hematoxylin and eosin (H&E) and Safranin O staining were used to observe the structures of cartilage. The mRNA expression of Collagen II, MMP-13, and inflammatory factors (IL-18, IL-1β, and TNF-α) in the cartilage and chondrocytes of rats was determined by qRT-PCR. The expression of NF-κB pathway-related proteins (p-p65, p65, IκBα, and p-IκBα) in the cartilage and chondrocytes of rats was determined by Western blot. The proliferation of chondrocytes was detected by MTT assay. Results Treatment with PRP, ALN, or PRP combined with ALN decreased the degree of cartilage destruction, the mRNA expression of MMP-13 and inflammatory factors (IL-18, IL-1β, and TNF-α), and the protein expression of p-IκBα/IκBα and p-p65/p65, increased Collagen II expression, and the threshold of tender and thermal pain in OA rats. Meanwhile, ALN, PRP, or ALN combined with PRP reversed the inhibiting effect of phorbol myristate acetate (PMA, an NF-κB agonist) on cell proliferation and cartilage matrix metabolism. Among them, the effects of ALN combined with PRP were most obvious. Conclusion PRP combined with ALN delayed OA progression by inhibiting the NF-κB signaling pathway.
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18
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Araya N, Miyatake K, Tsuji K, Katagiri H, Nakagawa Y, Hoshino T, Onuma H, An S, Nishio H, Saita Y, Sekiya I, Koga H. Intra-articular Injection of Pure Platelet-Rich Plasma Is the Most Effective Treatment for Joint Pain by Modulating Synovial Inflammation and Calcitonin Gene-Related Peptide Expression in a Rat Arthritis Model. Am J Sports Med 2020; 48:2004-2012. [PMID: 32519886 DOI: 10.1177/0363546520924011] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Platelet-rich plasma (PRP) has emerged as a treatment for osteoarthritis (OA). However, the effect that leukocyte concentrations in PRP have on OA remains unclear. PURPOSE To clarify the optimal PRP formulation for OA treatment by comparing pure PRP, leukocyte-poor PRP (LP-PRP), and leukocyte-rich PRP (LR-PRP) in a rat arthritis model. STUDY DESIGN Controlled laboratory study. METHODS Knee arthritis was induced bilaterally in male Wistar rats with intra-articular injections of monosodium iodoacetate (MIA) on day 0. Rats were randomly assigned to 1 of 3 treatment groups (pure PRP, LP-PRP, and LR-PRP). On day 1, allogenic PRP was injected into the right knee of rats and phosphate-buffered saline was injected into the left knee as a control. Weight distribution on the hindlimbs was measured for 14 days to assess pain behavior. Rats were euthanized at day 5 or 14 for histological assessment of synovial tissue and cartilage. Immunohistochemical staining of calcitonin gene-related peptide (CGRP) and α-smooth muscle actin was performed to determine the mechanism of pain relief induced by the PRP preparations. RESULTS In all groups, PRP increased the load-sharing ratio on PRP-injected knees, with pure PRP eliciting the largest effect among the 3 kinds of PRP (P < .05). Structural changes in the synovial tissue were significantly inhibited in the pure-PRP group compared with the control group after both 5 and 14 days (P < .001 and P = .025, respectively), whereas no significant difference was found between the control, LP-PRP, and LR-PRP groups. An inhibitory effect on cartilage degeneration was observed only in the pure-PRP group on day 14. Pure PRP also significantly inhibited expression of CGRP-positive nerve fibers in the infrapatellar fat pad compared with the other groups (P < .05). CONCLUSION In an MIA-induced arthritis model, pure PRP injection was the most effective treatment for reduction of pain-related behavior and inhibition of synovial inflammation and pain sensitization. CLINICAL RELEVANCE PRP formulations should be optimized for each specific disease. This study shows the superiority of pure PRP for treatment of arthritis and joint pain.
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Affiliation(s)
- Naoko Araya
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazumasa Miyatake
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kunikazu Tsuji
- Department of Cartilage Regeneration, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroki Katagiri
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yusuke Nakagawa
- Department of Cartilage Regeneration, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takashi Hoshino
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroaki Onuma
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Saisei An
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hirofumi Nishio
- Department of Orthopaedics, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Yoshitomo Saita
- Department of Orthopaedics, Juntendo University, Faculty of Medicine, Tokyo, Japan
| | - Ichiro Sekiya
- Center for Stem Cell and Regenerative Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
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19
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Mehrabani D, Seghatchian J, Acker JP. Platelet rich plasma in treatment of musculoskeletal pathologies. Transfus Apher Sci 2019; 58:102675. [DOI: 10.1016/j.transci.2019.102675] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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20
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Gato-Calvo L, Hermida-Gómez T, Romero CR, Burguera EF, Blanco FJ. Anti-Inflammatory Effects of Novel Standardized Platelet Rich Plasma Releasates on Knee Osteoarthritic Chondrocytes and Cartilage in vitro. Curr Pharm Biotechnol 2019; 20:920-933. [DOI: 10.2174/1389201020666190619111118] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 06/11/2019] [Accepted: 06/11/2019] [Indexed: 12/29/2022]
Abstract
Background:
Platelet Rich Plasma (PRP) has recently emerged as a potential treatment for
osteoarthritis (OA), but composition heterogeneity hampers comparison among studies, with the result
that definite conclusions on its efficacy have not been reached.
Objective:
1) To develop a novel methodology to prepare a series of standardized PRP releasates
(PRP-Rs) with known absolute platelet concentrations, and 2) To evaluate the influence of this standardization
parameter on the anti-inflammatory properties of these PRP-Rs in an in vitro and an ex vivo
model of OA.
Methods:
A series of PRPs was prepared using the absolute platelet concentration as the standardization
parameter. Doses of platelets ranged from 0% (platelet poor plasma, PPP) to 1.5·105 platelets/µl.
PRPs were then activated with CaCl2 to obtain releasates (PRP-R). Chondrocytes were stimulated with
10% of each PRP-R in serum-free culture medium for 72 h to assess proliferation and viability. Cells
were co-stimulated with interleukin (IL)-1β (5 ng/ml) and 10% of each PRP-R for 48 h to determine
the effects on gene expression, secretion and intra-cellular content of common markers associated with
inflammation, catabolism and oxidative stress in OA. OA cartilage explants were co-stimulated with
IL-1β (5 ng/ml) and 10% of either PRP-R with 0.75·105 platelets/µl or PRP-R with 1.5·105 platelets/µl
for 21 days to assess matrix inflammatory degradation.
Results:
Chondrocyte viability was not affected, and proliferation was dose-dependently increased.
The gene expression of all pro-inflammatory mediators was significantly and dose-independently reduced,
except for that of IL-1β and IL-8. Immunoblotting corroborated this effect for inducible NO
synthase (NOS2). Secreted matrix metalloproteinase-13 (MMP-13) was reduced to almost basal levels
by the PRP-R from PPP. Increasing platelet dosage led to progressive loss to this anti-catabolic ability.
Safranin O and toluidine blue stains supported the beneficial effect of low platelet dosage on cartilage
matrix preservation.
Conclusion:
We have developed a methodology to prepare PRP releasates using the absolute platelet
concentration as the standardization parameter. Using this approach, the composition of the resulting
PRP derived product is independent of the donor initial basal platelet count, thereby allowing the
evaluation of its effects objectively and reproducibly. In our OA models, PRP-Rs showed antiinflammatory,
anti-oxidant and anti-catabolic properties. Platelet enrichment could favor chondrocyte
proliferation but is not necessary for the above effects and could even be counter-productive.
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Affiliation(s)
- Lucía Gato-Calvo
- Grupo de Investigacion en Reumatologia (GIR), Agrupacion Estrategica CICA-INIBIC, Complexo Hospitalario Universitario A Coruna, Sergas, Universidad de A Coruna, A Coruna, Spain
| | - Tamara Hermida-Gómez
- Grupo de Investigacion en Reumatologia (GIR), Agrupacion Estrategica CICA-INIBIC, Complexo Hospitalario Universitario A Coruna, Sergas, Universidad de A Coruna, A Coruna, Spain
| | - Cristina R. Romero
- Grupo de Investigacion en Reumatologia (GIR), Agrupacion Estrategica CICA-INIBIC, Complexo Hospitalario Universitario A Coruna, Sergas, Universidad de A Coruna, A Coruna, Spain
| | - Elena F. Burguera
- Grupo de Investigacion en Reumatologia (GIR), Agrupacion Estrategica CICA-INIBIC, Complexo Hospitalario Universitario A Coruna, Sergas, Universidad de A Coruna, A Coruna, Spain
| | - Francisco J. Blanco
- Grupo de Investigacion en Reumatologia (GIR), Agrupacion Estrategica CICA-INIBIC, Complexo Hospitalario Universitario A Coruna, Sergas, Universidad de A Coruna, A Coruna, Spain
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Puidokas T, Kubilius M, Stumbras A, Juodzbalys G. Effect of leukocytes included in platelet concentrates on cell behaviour. Platelets 2019; 30:937-945. [DOI: 10.1080/09537104.2019.1646900] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Tomas Puidokas
- Department of Maxillofacial Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Mantas Kubilius
- Department of Maxillofacial Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Arturas Stumbras
- Department of Maxillofacial Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Gintaras Juodzbalys
- Department of Maxillofacial Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania
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Wei F, Wang Z. [Effectiveness and mechanism of pure platelet-rich plasma on osteochondral injury of talus]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2019; 33:555-562. [PMID: 31090348 PMCID: PMC8337204 DOI: 10.7507/1002-1892.201811096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/05/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To explore the effectiveness and mechanism of pure platelet-rich plasma (P-PRP) on osteochondral injury of talus. METHODS Thirty-six patients with osteochondral injury of talus selected between January 2014 and October 2017 according to criteria were randomly divided into control group (group A), leukocyte PRP (L-PRP) group (group B), and P-PRP group (group C), with 12 cases in each group. There was no significant difference in gender, age, disease duration, and Hepple classification among the three groups ( P>0.05). Patients in the groups B and C were injected with 2.5 mL L-PRP or P-PRP at the bone graft site, respectively. Patients in the group A were not injected with any drugs. The American Orthopaedic Foot and Ankle Society (AOFAS) score and visual analogue scale (VAS) score were used to evaluate the effectiveness before operation and at 3, 6, and 12 months after operation. Study on the therapeutic mechanism of P-PRP: MC3T3-E1 cells were randomly divided into control group (group A), L-PRP group (group B), and P-PRP group (group C). Groups B and C were cultured with culture medium containing 5% L-PRP or P-PRP respectively. Group A was cultured with PBS of the same content. MTT assay was used to detect cell proliferation; ELISA was used to detect the content of matrix metalloprotein 9 (MMP-9) protein in supernatant; alkaline phosphatase (ALP) activity was measured; and real-time fluorescence quantitative PCR (qRT-PCR) was used to detect the expression of osteopontin (OPN), collagen type Ⅰ, and MMP-9 in cells. Western blot was used to detect the expression of MMP-9 in supernatant and phosphoinositide 3-kinase (PI3K), phosphorylated protein kinase B (pAKT), and phosphorylated c-Jun (p-c-Jun) in cells. RESULTS All patients were followed up 13-25 months, with an average of 18 months. No complication such as wound infection and internal fixation failure occurred. MRI showed that the degree of injury was similar between the three groups before operation, and patients in the three groups all recovered at 6 months after operation. Moreover, group C was superior to groups A and B. Compared with preoperation, AOFAS scores and VAS scores in the three groups were all significantly improved at each time point after operation ( P<0.05). AOFAS score of group C was significantly higher than that of groups A and B at 3, 6, and 12 months after operation ( P<0.05); there was no significant difference in VAS score between the three groups ( P>0.05). Study on the therapeutic mechanism of P-PRP: The absorbance ( A) value, ALP activity, the relative mRNA expression of OPN and collagen type Ⅰ in group C were significantly higher than those in groups A and B ( P<0.05), and those in group B were significantly higher than those in group A ( P<0.05). The relative expression of MMP-9 protein and mRNA and the content of MMP-9 protein detected by ELISA in group B were significantly higher than those in groups A and C, while those in group C were significantly lower than those in group A ( P<0.05). Western blot detection showed that the relative expression of PI3K, pAKT, and p-c-Jun protein in group B was significantly higher than those in groups A and C ( P<0.05), but there was no significant difference between groups A and C ( P>0.05). CONCLUSION P-PRP is superior to L-PRP for osteochondral injury of talus, which may be related to the inhibition of PI3K/AKT/AP-1 signaling pathway in the osteoblast, thereby reducing the secretion of MMP-9.
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Affiliation(s)
- Futao Wei
- Department of Joint Surgery, the 988 Hospital of Chinese PLA, Zhengzhou Henan, 450000, P.R.China
| | - Zhen Wang
- Department of Orthopedics, the 988 Hospital of Chinese PLA, Zhengzhou Henan, 450000,
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Baćević M, Brković B, Lambert F, Djukić L, Petrović N, Roganović J. Leukocyte- and platelet-rich fibrin as graft material improves microRNA-21 expression and decreases oxidative stress in the calvarial defects of diabetic rabbits. Arch Oral Biol 2019; 102:231-237. [PMID: 31082699 DOI: 10.1016/j.archoralbio.2019.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 04/29/2019] [Accepted: 05/06/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Leukocyte- and platelet-rich fibrin (L-PRF) represents a natural, low-cost product which may promote tissue healing by mechanisms not fully elucidated. Diabetes mellitus (DM) disrupts bone healing by inducing inflammation and oxidative stress (OS), mechanisms regulated by microRNAs (miRs). The aim of the present study was to investigate the microRNA-21 (miR-21) involvement in diabetic bone regeneration using L-PRF alone or in combination with a standard grafting material. DESIGN After the induction of diabetes (alloxan 100 mg/kg), four cranial osteotomies were made in diabetic (n = 12) and non-diabetic (n = 12) rabbits: one was left empty and the remaining three were grafted with L-PRF, bovine hydroxyapatite (Bio-Oss®) and L-PRF + Bio-Oss®. Two and eight weeks postoperatively, the samples were harvested for miR-21 expression (Real-time RT-PCR) and enzyme-linked immunosorbent assay analyses. RESULTS Diabetic rabbits showed decreased miR-21 and matrix metalloproteinase-9 (MMP-9) protein expression while increased malondialdehyde (MDA) levels two weeks postoperatively; however, there were no significant differences in miR-21 and MMP-9 levels between diabetic and non-diabetic rabbits in samples taken eight weeks postoperatively. Application of L-PRF and L-PRF + Bio-Oss® improved miR-21 and MMP-9 and decreased MDA levels while Bio-Oss® alone enhanced superoxide dismutase (SOD) activity levels in diabetic rabbits. CONCLUSION L-PRF alone or in combination with bovine hydroxyapatite as bone graft could be beneficial in DM since it seems to improve inflammation-modulatory miR-21 expression and decreases oxidative stress.
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Affiliation(s)
- Miljana Baćević
- Dental Biomaterial Research Unit (d-BRU), Faculty of Medicine, University of Liege, Liege, Belgium
| | - Božidar Brković
- Department of Oral Surgery, School of Dental Medicine, University of Belgrade, Belgrade, Serbia
| | - France Lambert
- Department of Periodontology and Oral Surgery, Faculty of Medicine, University of Liege, Belgium
| | - Ljiljana Djukić
- Department of Pharmacology in Dentistry, School of Dental Medicine, University of Belgrade, Belgrade, Serbia
| | - Nina Petrović
- Department of Radiobiology and Molecular Genetics, Institute of Nuclear Sciences Vinča, University of Belgrade, Belgrade, Serbia; Institute of Oncology and Radiology of Serbia, Belgrade, Serbia
| | - Jelena Roganović
- Department of Pharmacology in Dentistry, School of Dental Medicine, University of Belgrade, Belgrade, Serbia.
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Hassan G, Bahjat M, Kasem I, Soukkarieh C, Aljamali M. Platelet lysate induces chondrogenic differentiation of umbilical cord-derived mesenchymal stem cells. Cell Mol Biol Lett 2018; 23:11. [PMID: 29568314 PMCID: PMC5859745 DOI: 10.1186/s11658-018-0080-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 03/12/2018] [Indexed: 12/17/2022] Open
Abstract
Purpose Articular cartilage has a poor capacity for self-repair, and thus still presents a major challenge in orthopedics. Mesenchymal stem cells (MSCs) are multipotent stem cells with the potential to differentiate into chondrocytes in the presence of transforming growth factor beta (TGF-β). Platelet lysate (PL) contains a relatively large number of growth factors, including TGF-β, and has been shown to ameliorate cartilage repair. Here, we investigated the ability of PL to direct chondrogenic differentiation of MSCs along with other standard differentiation components in a pellet culture system. Methods We isolated and expanded MSCs from human umbilical cords using a PL-supplemented medium and characterized the cells based on immunophenotype and potential for differentiation to adipocytes and osteocytes. We further cultured MSCs as pellets in a chondrogenic-differentiation medium supplemented with PL. After 21 days, the pellets were processed for histological analysis and stained with alician blue and acridine orange. The expression of SOX9 was investigated using RT-PCR. Results MSCs maintained their stemness characteristics in the PL-supplemented medium. However, the distribution of cells in the pellets cultured in the PL-supplemented chondrogenic differentiation medium had a greater similarity to cartilage tissue-derived chondrocytes than to the negative control. The intense alician blue staining indicated an increased production of mucopolysaccharides in the differentiated pellets, which also showed elevated expression of SOX9. Conclusions Our data suggest that MSCs could be differentiated to chondrocytes in the presence of PL and absence of exogenous TGF-β. Further research needs to be conducted to understand the exact role and potential of PL in chondrogenic differentiation and chondrocyte regeneration.
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Affiliation(s)
- Ghmkin Hassan
- 1Faculty of Pharmacy, Damascus University, Damascus, Syria
| | | | - Issam Kasem
- 2Faculty of Sciences, Damascus University, Damascus, Syria.,National Commission for Biotechnology (NCBT), Damascus, Syria
| | - Chadi Soukkarieh
- 2Faculty of Sciences, Damascus University, Damascus, Syria.,National Commission for Biotechnology (NCBT), Damascus, Syria
| | - Majd Aljamali
- 1Faculty of Pharmacy, Damascus University, Damascus, Syria.,2Faculty of Sciences, Damascus University, Damascus, Syria.,National Commission for Biotechnology (NCBT), Damascus, Syria
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