A Mixture of Topical Forms of Polydeoxyribonucleotide, Vitamin C, and Niacinamide Attenuated Skin Pigmentation and Increased Skin Elasticity by Modulating Nuclear Factor Erythroid 2-like 2

It is well-known that increased oxidative stress caused by ultraviolet B (UV-B) radiation induces melanogenesis and activates metalloproteinases (MMPs), which degrade collagen and elastin fibers, leading to decreased skin elasticity. Various antioxidant agents, such as vitamin C and niacinamide, have been evaluated for use as treatments for photoaging or skin pigmentation. In this study, we evaluated the ability of a topical liquid formula of polydeoxyribonucleotide (PDRN), vitamin C, and niacinamide (PVN) delivered via a microneedling therapy system (MTS) to attenuate photoaging and pigmentation by increasing nuclear factor erythroid 2-like 2 (NRF2)/heme oxygenase-1 (HO-1) and decreasing MMP expression in a UV-B-radiated animal model. The effects of the PVN were compared with those of individual PDRN and hydroquinone (HQ) compounds. The expression of NRF2/HO-1 significantly increased in response to HQ, PDRN, and PVN in UV-B-radiated animal skin. The activity of nicotinamide adenine dinucleotide phosphate hydrogen oxidase decreased in response to HQ, PDRN, and PVN, and the superoxide dismutase activity increased. The expression of tumor protein p53 and microphthalmia-associated transcription factor and tyrosinase activity decreased in response to HQ, PDRN, and PVN, and this decrease was accompanied by decreased melanin content in the skin. The expression of nuclear factor kappa-light-chain enhancer of activated B cells and MMP2/3/9 decreased in response to HQ, PDRN, and PVN in UV-B-radiated skin. However, the expression of collagen type I α1 chain and the amount of collagen fibers that were evaluated by Masson’s trichrome staining increased in response to HQ, PDRN, and PVN. The contents of elastin fibers, fibrillin 1/2 and fibulin 5 increased in response to HQ, PDRN, and PVN. In conclusion, PVN delivered via MTS led to decreased melanogenesis and destruction of collagen and elastin fibers by MMPs, and, thus, PVN decreased skin pigmentation and increased skin elasticity.

The Prophylaxis of Hepatic Veno-Occlusive Disease/Sinusoidal Obstruction Syndrome With Defibrotide After Hematopoietic Stem Cell Transplantation in Children: Single Center Experience

Hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) is one of the most severe and life-threatening complications after hematopoietic stem cell transplantation (HSCT). Defibrotide (DF) is approved for adult and pediatric patients with VOD/SOS with renal or pulmonary dysfunction after HSCT in the United States, and for severe VOD/SOS post-HSCT in patients above 1 month of age in the European Union. Several studies have examined whether DF prophylaxis can reduce the incidence of VOD/SOS in high-risk patients. A total of 334 pediatric allogeneic HSCT were included in this study. All patients received DF at the dose of 25 mg/kg/d, from the first day of the conditioning regimen to the 30th day after transplantation for VOD/SOS prophylaxis. Seventeen patients (5.08%) developed VOD/SOS; 4 of these had moderate, while 13 had mild VOD/SOS. None of the patients were developed severe or very severe VOD/SOS. In conclusion, we showed that prophylactic intervention with DF lowered the incidence of VOD/SOS in high-risk pediatric patients.

Venoocclusive Disease With Both Hepatic and Pulmonary Involvement

Pulmonary venoocclusive disease (PVOD) is a rare form of pulmonary vascular disease with pulmonary hypertension characterized by preferential involvement of the pulmonary venous system. Hepatic venoocclusive disease (HVOD), also known as sinusoidal obstruction syndrome, is a condition that occurs in 13% to 15% of patients after hematopoietic stem cell transplantation (HSCT). Although hepatic and pulmonary venoocclusive diseases may share some pathologic features as well as some etiologies such as HSCT, these two disorders have never been described together in a single adult patient. We report the case of a patient who received HSCT and developed HVOD and PVOD within 9 months. Despite their differences, PVOD and HVOD share common risk factors and associated conditions, suggesting that in the context of HSCT, the two diseases share common pathophysiological mechanisms. Optimal treatment for HSCT-related PVOD remains to be determined.

Polydeoxyribonucleotide Exerts Protective Effect Against CCl4-Induced Acute Liver Injury Through Inactivation of NF-κB/MAPK Signaling Pathway in Mice

Acute liver injury (ALI) causes life-threatening clinical problem, and its underlying etiology includes inflammation and apoptosis. An adenosine A_2A receptor agonist, polydeoxyribonucleotide (PDRN), exhibits anti-inflammatory and anti-apoptotic effects by inhibiting the secretion of pro-inflammatory cytokines. In the current study, the protective effect of PDRN against carbon tetrachloride (CCl₄)-induced ALI was investigated using mice. For the induction of ALI, mice received intraperitoneal injection of CCl₄ twice over seven days. Mice from the PDRN-treated groups received an intraperitoneal injection of 200 μL saline containing PDRN (8 mg/kg), once a day for seven days, starting on day 1 after the first CCl₄ injection. In order to confirm that the action of PDRN occurs through the adenosine A_2A receptor, 8 mg/kg 3,7-dimethyl-1-propargylxanthine (DMPX), an adenosine A_2A receptor antagonist, was treated with PDRN. Administration of CCl₄ impaired liver tissue and increased the liver index and histopathologic score. The expression of pro-inflammatory cytokines was increased, and apoptosis was induced by the administration of CCl₄. Administration of CCl₄ activated nuclear factor-kappa B (NF-κB) and facilitated phosphorylation of signaling factors in mitogen-activated protein kinase (MAPK). In contrast, PDRN treatment suppressed the secretion of pro-inflammatory cytokines and inhibited apoptosis. PDRN treatment inactivated NF-κB and suppressed phosphorylation of signaling factors in MAPK. As a result, liver index and histopathologic score were reduced by PDRN treatment. When PDRN was treated with DMPX, the anti-inflammatory and anti-apoptotic effect of PDRN disappeared. Therefore, PDRN can be used as an effective therapeutic agent for acute liver damage.

Polydeoxyribonucleotide-delivering therapeutic hydrogel for diabetic wound healing

Patients with diabetes experience delayed wound healing because of the uncontrolled glucose level in their bloodstream, which leads to impaired function of white blood cells, poor circulation, decreased production and repair of new blood vessels. Treatment using polydeoxyribonucleotide (PDRN), which is a DNA extracted from the sperm cells of salmon, has been introduced to accelerate the healing process of diabetic wounds. To accelerate the wound-healing process, sustained delivery of PDRN is critical. In this study, taking advantage of the non-invasive gelation property of alginate, PDRN was loaded inside the hydrogel (Alg-PDRN). The release behavior of PDRN was altered by controlling the crosslinking density of the Alg hydrogel. The amount of PDRN was the greatest inside the hydrogel with the highest crosslinking density because of the decreased diffusion. However, there was an optimal degree of crosslinking for the effective release of PDRN. In vitro studies using human dermal fibroblasts and diabetes mellitus fibroblasts and an in ovo chorioallantoic membrane assay confirmed that the Alg-PDRN hydrogel effectively induced cell proliferation and expression of angiogenic growth factors and promoted new blood vessel formation. Its effectiveness for accelerated diabetic wound healing was also confirmed in an in-vivo animal experiment using a diabetic mouse model.

Full recovery of near complete tear of anterior cruciate ligament without surgery: a case report

INTRODUCTION

The anterior cruciate ligament (ACL) is the region where spraining or tearing is most prevalent when the knee is injured. Complete ACL ruptures have a much less favorable outcome without surgical intervention. Polydeoxyribonucleotide (PDRN) is a relatively safe substance widely used for regenerative therapy.

PATIENT CONCERNS

A 43-year-old female patient visited our clinic with Rt. knee pain after slipping, which she rated as 7/10 on a numeric rating scale.

DIAGNOSIS

She was diagnosed as having a near complete tear of the ACL at the femoral attachment, partial tear of the lateral collateral ligament.

INTERVENTIONS

Ultrasound-guided PDRN injections were carried out 5 times at intervals of about 2 weeks.

OUTCOMES

At 3-month follow-up, the patient demonstrated an improvement in knee symptoms (numeric rating scale 0) and ROM without any complications. Even after 2 years and 5 months since the diagnosis, she has been doing her daily life well without any pain.

CONCLUSION

This is the first report of successful PDRN injection for near complete tear of ACL and partial tear of lateral collateral ligament without surgery.

Polydeoxyribonucleotide injection in the treatment of patients with carpal tunnel syndrome: Retrospective preliminary study

BACKGROUND

Corticosteroid injection is beneficial in treating carpal tunnel syndrome (CTS) due to its anti-inflammatory effects. However, its side effects limit widespread usage. Recently, several studies have found that polydeoxyribonucleotide offers anti-inflammatory capabilities with fewer side effects, making it an ideal alternative. Nevertheless, there has been no study on its effectiveness in patients with CTS. Therefore, we evaluate the effectiveness of polydeoxyribonucleotide in patients with CTS. Based on the criteria, 30 patients with CTS who received two-consecutive polydeoxyribonucleotide injections (with a week interval) were initially included.

METHOD

Patients with CTS were investigated retrospectively. To evaluate the effectiveness of polydeoxyribonucleotide in patients with CTS, numeric rating scale (NRS), cross-sectional area (CSA) of the median nerve, and severity and functional status scores of CTS based on the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) were assessed.

RESULTS

There was a significant improvement in the NRS, CSA, and functional and severity scores of BCTQ after two-consecutive polydeoxyribonucleotide injections (P < .05).

CONCLUSION

In conclusion, although more research is needed to evaluate the effectiveness of polydeoxyribonucleotide in patients with CTS, the findings here suggest that polydeoxyribonucleotide may be a viable alternative to corticosteroids in patients with CTS.

The efficacy and safety of polydeoxyribonucleotide for the treatment of knee osteoarthritis: Systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

The purpose of this study was to use meta-analysis techniques to evaluate the efficacy and safety of polydeoxyribonucleotide (PDRN) injections for knee osteoarthritis (OA) treatment.

METHODS

Multiple comprehensive databases, including MEDLINE, EMBASE, and the Cochrane Library, were searched in November 2018 for studies that compared the effectiveness and safety of intra-articular PDRN injection for the knee joint with hyaluronic acid (HA) injection. Two reviewers independently determined study inclusion and they extracted data using a standardized data extraction form. The predefined primary outcome was Visual Analogue Scale. Secondary outcomes included Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Society Score (KSS), and adverse events.

RESULTS

Five randomized controlled trials were included in the meta-analysis. After 1 and 2 months, patients in the PDRN group showed significantly better improvement in pain than the HA group (P = .04 and P = .02, respectively). There was no significant difference in pain after 4 months. The pooled analysis showed that no significant differences were seen in function (KOOS and KSS) scores between the PDRN and HA groups (all P > .05) at all time points. There was no significant difference in adverse events between 2 groups (relative risks = 2.15, 95% confidential interval: 0.17-26.67, P = .55).

CONCLUSION

The intra-articular use of PDRN was similar in function to HA, and the pain-relief effect was superior to HA for 2 months post-injection. Therefore, it could be a favorable alternative to HA to treat persistent pain associated with knee OA while avoiding side effects.Level of evidence I.

Ultrasound-guided peri-brachial plexus polydeoxyribonucleotide injection for a patient with postherpetic brachial plexopathy: A case report

RATIONALE

Although most complications of herpes zoster (HZ) are associated with the spread of varicella-zoster virus from the initially involved sensory ganglion, motor nerve impairment, such as limb weakness, is a rare but severe complication that is difficult to treat.

PATIENT CONCERN

A 73-year-old female presented with sudden left upper limb pain and weakness after HZ.

DIAGNOSIS

Brachial plexopathy following HZ (postherpetic brachial plexopathy).

INTERVENTION

Despite alleviation of the vesicles with antiviral treatments, the left upper limb weakness and neuropathic pain did not improve. After obtaining patient's consent, ultrasound-guided polydeoxyribonucleotide (PDRN) injection was performed around the left brachial plexus.

OUTCOMES

The patient showed marked improvement in left arm pain from numerical rating scale (NRS) 9 to 4, 1 day after PDRN injection. Subsequently, the pain improved to NRS 3, and motor weakness improved to Medical Research Council grade 2 to 4.

LESSONS

PDRN can be considered a viable substitute for corticosteroid injection in treatment of motor weakness and neuropathic pain after HZ.

The effect of polydeoxyribonucleotide on the treatment of radiating leg pain due to cystic mass lesion in inner aspect of right sciatic foramen: A CARE compliant case report

RATIONALE

Radiating leg pain usually originates from the lumbar spine and occasionally from peripheral lesions. Here we report a case involving a patient with radiating pain in the right leg who exhibited 2 suspicious lesions, including 1 spinal lesion and 1 extraspinal cystic mass lesion, on magnetic resonance imaging. Polydeoxyribonucleotide sodium (PDRN) was recently noted as such a substitute. PDRN has anti-inflammatory effects, as it lowers the expression of inflammatory cytokines including interleukin-6 and tumor necrosis factor-alpha.

PATIENT CONCERNS

A 51-year-old man (weight, 93 kg; height, 168 cm) working as a bus driver presented at the pain clinic with continuous right buttock pain, radiating leg pain and a tingling sensation involving the calf and dorsum of the foot, since 1 week.

DIAGNOSES

He was definitively diagnosed using differential blocks, which revealed the cyst to be the actual cause of the pain.

INTERVENTIONS

Surgical resection was not feasible because of the position of the cyst; therefore, corticosteroid injection under ultrasonographic guidance was attempted. However, this provided short-term relief. Subsequently, a solution containing PDRN was injected around the piriformis muscle and repeated 3 more times at intervals of 2 weeks.

OUTCOMES

After PDRN injection, we conducted two follow-up monitoring every two months for 2 months. Last follow-up, the patient no longer complained of pain. this resulted in relatively long-term relief from pain.

LESSONS

The findings from this case suggest that PDRN is an effective alternative for steroids in patients with radiating leg pain, although its efficacy and safety needs to be evaluated in further large-scale studies.

Sinusoidal Obstruction Syndrome/Veno-Occlusive Disease after Autologous or Allogeneic Hematopoietic Stem Cell Transplantation in Children: a retrospective study of the Italian Hematology-Oncology Association-Hematopoietic Stem Cell Transplantation Group

Sinusoidal obstruction syndrome (SOS), also known as veno-occlusive disease (VOD), is a potentially life-threatening complication that may develop after hematopoietic stem cell transplantation (HSCT). The aims of this retrospective multicenter study were to evaluate the incidence of SOS/VOD in a large cohort of children transplanted in centers across Italy by applying the new European Society for Blood and Marrow Transplantation (EBMT) criteria and to analyze the risk factors underlying this complication. We retrospectively reviewed data of pediatric HSCTs performed in 13 AIEOP (Associazione Italiana di Ematologia e Oncologia Pediatrica)-affiliated centers between January 2000 and April 2016. The new pediatric EBMT criteria were retrospectively applied for diagnoses of SOS/VOD and severity grading. Among 5072 transplants considered at risk for SOS/VOD during the study period, 103 children (2%) developed SOS/VOD, and the grade was severe or very severe in all patients. The median time of SOS/VOD occurrence was 17 days after HSCT (range, 1 to 104). Sixty-nine patients (67%) were treated with defibrotide for a median time of 16 days (range, 4 to 104). In multivariable analysis age < 2 years, use of busulfan during the conditioning regimen, female gender, and hemophagocytic lymphohistiocytosis were risk factors statistically associated with the development of SOS/VOD. The overall mortality directly related to SOS/VOD was 15.5%. Overall survival at 1 year was worse in patients with SOS/VOD (P = .0033), and this difference disappeared 5 years after HSCT. Nonrelapse mortality was significantly higher 1 and 5 years after transplantation in patients who developed SOS/VOD (P < .001). Based on the application of new EBMT criteria, the overall incidence of SOS/VOD recorded in this large Italian pediatric retrospective study was 2%. Nonrelapse mortality was significantly higher in patients who developed SOS/VOD. Identifying the risk factors associated with SOS/VOD can lead to more effective early treatment strategies of this potentially fatal HSCT complication in childhood.

Usefulness of polydeoxyribonucleotide as an alternative to corticosteroids in patients with lateral epicondyitis: A case series

RATIONALE

Local corticosteroid injections are commonly used as an easy, cost-effective treatment for patients with lateral epicondylitis (LE). Despite their strong anti-inflammatory effect, repeated injections of corticosteroids are not recommended in LE because they can aggravate tearing of the tendons.

PATIENT CONCERNS

A 65-year-old (Case1) man and a 59-year-old (Case2) man had a 2-month history of right lateral elbow pain exacerbation.

DIAGNOSES

Lateral epicondylitis with hypervascularity of the common extensor tendon.

INTERVENTION

After informed consent was provided, ultrasound (US)-guided polydeoxyribonucleotide (PDRN) injections were made into on the common extensor tendons of both patients.

OUTCOMES

After 2 weeks from PDRN injection, both patients reported significant pain relief. The US 2 weeks after the PDRN injection showed that the hypervascularity of the common extensor tendon in both patients had been completely cured, although there was no significant change in the findings of tendinosis.

LESSONS

PDRN may be useful for patients with LE because there were no negative effects on tendon cells and tissues in previous in vitro and in vivo studies, despite its anti-inflammatory effects.

The effectiveness of 2 consecutive intra-articular polydeoxyribonucleotide injections compared with intra-articular triamcinolone for hemiplegic shoulder pain: A STROBE-complaint retrospective study

The aim of this study was to investigate the effects of intra-articular injection of polydeoxyribonucleotide (PDRN), compared with intraarticular triamcinolone (TA) injection, in subacute stroke patients with hemiplegic shoulder pain (HSP).Participants were subacute stroke patients with HSP who had undergone 2 consecutive intra-articular injections of TA or PDRN.Numeric rating scale (NRS) and passive range of motion (PROM) of hemiplegic shoulder were evaluated until 4 weeks after 2nd injection.In the results, there were significant improvements in all PROM measures 2 weeks after the second injection, compared with pre-injection results, in both groups (P < .05). In the PDRN group, however, none of the PROM measures were significantly improved at 3 and 4 weeks after the second injection, compared with pre-injection results (P ≥ .05). When comparing pre-injection results with those at 4 weeks after the second injection, all PROM and NRS measures in the TA group were more improved than in the PDRN group, but this was not statistically significant (P ≥ .05).In conclusion, considering the systemic side effects of steroids, especially among patients with diabetes or metabolic syndrome, PDRN seems to be a worthwhile treatment option for HSP, although PDRN does not seem to have an equivalent persistence effects when compared with TA.

Application of ultrasound-guided C5 nerve root block using polydeoxyribonucleotide in traumatic C5 nerve root injury caused by fracture of the articular process of the cervical spine: A case report

RATIONALE

Cervical nerve root injury is one of the complications of traumatic cervical spine fracture. Although one of the most effective treatments to reduce inflammation in nerve root injuries is the use of corticosteroids or nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids and NSAIDs can inhibit bone healing. So, when nerve injury accompanies bone fractures, corticosteroids and NSAIDs have limitations as therapeutic agents. However, polydeoxyribonucleotide (PDRN) may be useful in the treatment of neuropathy or musculoskeletal pain patients with contraindication of the use of corticosteroids because of its anti-inflammatory effect, as revealed in previous studies. To the best of our knowledge, there has been no report of treatment of traumatic nerve root injury due to an articular process fracture with an ultrasound-guided cervical nerve root block (NRB) using PDRN.

PATIENTS CONCERNS

A 54-year-old female patient with motor weakness of the left upper extremity and tingling sensation in the left neck and shoulder. DIAGNOSES:: traumatic C5 nerve root injury due to a fracture of the left articular process in the C4 spine.

INTERVENTION

Ultrasound-guided C5 NRB using PDRN.

OUTCOMES

Her motor weakness and sensory symptoms of the left upper extremity were significantly improved after treatment using an ultrasound-guided C5 NRB using PDRN.

LESSONS

Although it is impossible to draw a conclusion from a single case report, we suggest the ultrasound-guided NRB using PDRN could be a useful treatment for alleviating motor weakness and neuropathic pain caused by traumatic spinal nerve root injury in situations where corticosteroids cannot be used.

Effect of polydeoxyribonucleotide injection on pes anserine bursitis: A case report

RATIONALE

Pes anserine (PA) bursitis is an inflammatory condition of the medial knee. The PA bursa becomes more painful when infected, damaged, or irritated. Although various treatment options have been attempted to treat PA bursitis, optimal treatments are still debated. This study aims to investigate the effect of polydeoxyribonucleotide (PDRN) injection on reducing pain and inflammation in a patient presenting with PA bursitis.

PATIENT CONCERNS

A 50-year-old female patient was admitted to our pain clinic with symptoms of tenderness and pain over the medial knee. Physical examination revealed the pain to be located over the proximal medial tibia at the insertion of the conjoined tendons of the PA. The knee had lost its range of movement and strength, and resisted knee flexion.

DIAGNOSES

She was diagnosed as having PA bursitis.

INTERVENTIONS

Ultrasound guided PA bursa injection was carried out.

OUTCOMES

Follow-up for the patient was more than eight months. She showed good improvement in PA bursitis without any complications.

LESSONS

This is the first successful report of successful PDRN injection for PA bursa.

Effect of transforaminal epidural polydeoxyribonucleotide injections on lumbosacral radiculopathy: A case report

RATIONALE

Transforaminal epidural glucocorticoids administration is widely performed for the management of lumbosacral radiculopathy. However, it may worsen the condition of patients with type 2 diabetes mellitus (DM). Polydeoxyribonucleotide (PDRN) was recently noted as a substitute for glucocorticoids.

PATIENT CONCERNS

A 44-year-old male patient was admitted to our pain clinic with symptoms of low back pain with severe pain and tingling sensation of left posterolateral leg. He had type 2 DM medicated with Glimepiride and Metformin. Blood glucose level was 367 mg/dL. He declined to use glucocorticoid.

DIAGNOSES

He was diagnosed as left foraminal disc protrusion at L4-5, left subarticular disc protrusion at L5-S1.

INTERVENTIONS

Fluoroscopically guided transforaminal epidural PDRN injections were carried out.

OUTCOMES

The patient was followed up for more than 6 months and demonstrated good improvement in lumbosacral radiculopathy without any complications.

LESSONS

This is the first successful report on epidural injection of PDRN.

The effect of polydeoxyribonucleotide prolotherapy on posterior tibial tendon dysfunction after ankle syndesmotic surgery: A case report

RATIONALE

Ankle syndesmotic injuries occasionally require long-term therapy for recovery and can result in tendon injury. Posterior tibial tendon dysfunction (PTTD) is an acquired deformity that can cause flatfoot deformity. The current nonoperative management of PTTD includes nonsteroidal antiinflammatory drugs (NSAIDs), orthopedic devices. Although various treatment options have been attempted, optimal treatments for each stage of the condition are debated. Polydeoxyribonucleotide (PDRN) is effective in healing of chronic wounds associated with tissue damage by attracting tissue growth factors.

PATIENT CONCERNS

A 67-year-old woman who presented at our pain clinic with pain on the inside of ankle. She had a syndesmotic screw fixation 3 years prior. Her ankle pain had persisted after the removal of screws and edema for about 1 month resulting from long-term NSAIDs administration.

DIAGNOSES

The origin of the pain was possibly tibialis posterior muscle and posterior tibial tendon and she was diagnosed as PTTD after syndesmosis surgery.

INTERVENTIONS

Sono guided prolotherapy with PDRN was carried out.

OUTCOMES

Patient showed improvement in the arch of the foot, experienced pain relief, and was able to wear regular shoes without any orthopedic device.

LESSONS

This case report highlights that PDRN prolotherapy is a safe and efficient therapeutic option for the treatment of PTTD.

Polydeoxyribonucleotide Injection in the Treatment of Chronic Supraspinatus Tendinopathy: A Case-Controlled, Retrospective, Comparative Study With 6-Month Follow-Up

OBJECTIVE

To determine the efficacy of polydeoxyribonucleotide (PDRN) injection for rotator cuff disease (RCD).

DESIGN

Case-controlled, retrospective, comparative study.

SETTING

Outpatient clinic at a university-affiliated tertiary care hospital.

PARTICIPANTS

Patients (N=106) with chronic nontraumatic refractory RCD who were unresponsive to at least 1 month of conservative treatment: 55 patients received PDRN injection (PDRN group) and 51 continued conservative treatment (control group).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Shoulder Pain and Disability Index, score on a visual analog scale of the average shoulder pain level, number of analgesic ingestions per day, isometric strength of shoulder abductor, active range of motion (flexion, abduction, internal rotation, external rotation), and maximal tear size of tendon on ultrasonography at pretreatment and 3 and 6 months postinjection.

RESULTS

There was no significant difference between the 2 groups in terms of age, sex, shoulder affected, duration of symptoms, and ultrasonographic findings at pretreatment. Compared with the control group, the treatment group showed a significant improvement in Shoulder Pain and Disability Index, visual analog scale score, and number of analgesic ingestions per day. However, there was no difference in isometric strength, active range of motion, and maximal tear size of tendon. No adverse events were reported.

CONCLUSIONS

To our knowledge, this is the first study to assess the efficacy of PDRN injection for patients with RCD. The PDRN injection group showed improvement in pain and subjective disability in patients with RCD and continued to show improvement for 3 months thereafter; the PDRN injection can be an optional treatment for patients with chronic RCD who show no response to other treatments.

Novel Anti-Melanogenesis Properties of Polydeoxyribonucleotide, a Popular Wound Healing Booster

Polydeoxyribonucleotide (PDRN), a deoxyribonucleotide polymer, is popularly used for faster healing of cutaneous wounds and boosting of neocollagenesis of photoaged skin among current dermatologic practitioners. Some patients receiving PDRN injection treatment also reported improvement of photoaging-associated mottled pigmentation (PMP). To investigate the effect of PDRN on cutaneous melanogenesis, we examined the effect of PDRN and an available product (Placentex^®) containing PDRN on melanogenesis using human melanocytes-keratinocytes cocultures and mouse melanocytes. Melanin content, tyrosinase activity, and levels of microphthalmia-associated transcription factor (MITF), tyrosinase, and tyrosinase-related protein (TRP-1) were determined. Intracellular signaling pathways were assessed by Western blotting. PDRN and Placentex^® led to decreases in melanin content, tyrosinase activity, and MITF and TRP-1 expression with concomitant increases in phosphorylated forms of extracellular signal-regulated protein kinase (ERK) and AKT in mouse melanocytes. More importantly, both PDRN and Placentex^® significantly suppressed the melanin content in human melanocyte–keratinocyte cocultures. Clinical evaluation of six female patients with facial hyperpigmentation after three sessions of intradermal PDRN injections using a 5-point scale revealed that PDRN led to more than noticeable improvements in hyperpigmented lesions. This is the first study to demonstrate that PDRN, which is known for its wound-healing properties, may have novel anti-melanogenesis and potential skin whitening properties.

Treatment for superficial infusion thrombophlebitis of the upper extremity

BACKGROUND

Although superficial thrombophlebitis of the upper extremity represents a frequent complication of intravenous catheters inserted into the peripheral veins of the forearm or hand, no consensus exists on the optimal management of this condition in clinical practice.

OBJECTIVES

To summarise the evidence from randomised clinical trials (RCTs) concerning the efficacy and safety of (topical, oral or parenteral) medical therapy of superficial thrombophlebitis of the upper extremity.

SEARCH METHODS

The Cochrane Vascular Group Trials Search Co-ordinator searched the Specialised Register (last searched April 2015) and the Cochrane Register of Studies (2015, Issue 3). Clinical trials registries were searched up to April 2015.

SELECTION CRITERIA

RCTs comparing any (topical, oral or parenteral) medical treatment to no intervention or placebo, or comparing two different medical interventions (e.g. a different variant scheme or regimen of the same intervention or a different pharmacological type of treatment).

DATA COLLECTION AND ANALYSIS

We extracted data on methodological quality, patient characteristics, interventions and outcomes, including improvement of signs and symptoms as the primary effectiveness outcome, and number of participants experiencing side effects of the study treatments as the primary safety outcome.

MAIN RESULTS

We identified 13 studies (917 participants). The evaluated treatment modalities consisted of a topical treatment (11 studies), an oral treatment (2 studies) and a parenteral treatment (2 studies). Seven studies used a placebo or no intervention control group, whereas all others also or solely compared active treatment groups. No study evaluated the effects of ice or the application of cold or hot bandages. Overall, the risk of bias in individual trials was moderate to high, although poor reporting hampered a full appreciation of the risk in most studies. The overall quality of the evidence for each of the outcomes varied from low to moderate mainly due to risk of bias and imprecision, with only single trials contributing to most comparisons. Data on primary outcomes improvement of signs and symptoms and side effects attributed to the study treatment could not be statistically pooled because of the between-study differences in comparisons, outcomes and type of instruments to measure outcomes.An array of topical treatments, such as heparinoid or diclofenac gels, improved pain compared to placebo or no intervention. Compared to placebo, oral non-steroidal anti-inflammatory drugs reduced signs and symptoms intensity. Safety issues were reported sparsely and were not available for some interventions, such as notoginseny creams, parenteral low-molecular-weight heparin or defibrotide. Although several trials reported on adverse events with topical heparinoid creams, Essaven gel or phlebolan versus control, the trials were underpowered to adequately measure any differences between treatment modalities. Where reported, adverse events with topical treatments consisted mainly of local allergic reactions. Only one study of 15 participants assessed thrombus extension and symptomatic venous thromboembolism with either oral non-steroidal anti-inflammatory drugs or low-molecular-weight heparin, and it reported no cases of either. No study reported on the development of suppurative phlebitis, catheter-related bloodstream infections or quality of life.

AUTHORS' CONCLUSIONS

The evidence about the treatment of acute infusion superficial thrombophlebitis is limited and of low quality. Data appear too preliminary to assess the effectiveness and safety of topical treatments, systemic anticoagulation or oral non-steroidal anti-inflammatory drugs.

[Defibrotide therapy for patients with sinusoidal obstruction syndrome after hematopoietic stem cell transplantation]

Sinusoidal obstruction syndrome (SOS) is one of the life-threatening complications caused by endothelial damage to the hepatic sinusoids after hematopoietic stem cell transplantation. However, a satisfactory treatment for SOS has not yet been established. Defibrotide has anti-thrombotic, anti-ischemic, anti-inflammatory, and thrombolytic properties without systemic anticoagulant effects. We treated eight post-transplant SOS patients with defibrotide. Three patients responded to the therapy and the initial response was observed within a week. In addition to the improvement of liver function, rapid recovery of response to diuretic drugs followed by the improvement of renal function was observed. All of the five patients with respiratory dysfunction died despite administration of defibrotide, suggesting that early treatment might lead to better outcomes. There were no severe adverse effects directly due to defibrotide administration. Defibrotide seems to be a promising treatment for SOS, and the initiation of a clinical study in Japan would be important.

[Influence of antiplatelet drugs (AD) on the efectiveness of combined therapy in patients with small cell lung cancer. Part I. Influence of AD on the haemostatic system]

In the last years, a sharp rise in the morbidity due to lung cancer is observed, especially in the male population. Despite the intensive, multidirectional development of oncology, early detection and effective treatment of lung cancer is still limited. Its detection is delayed because of the lack of characteristic early signs. Especially poor in prognosis are patients with small cell lung cancer (SCLC), who usually die in consequence of distant metastases. This may result due to coating of the surface of circulating neoplastic cells with thrombocytes and clots. Platelets aggregates on the surface of neoplastic cells may have a protective action in relation to cytostatic drugs. This is why neoplastic cells that persist through this phase, implant themselves into various organs giving rise to metastases. The aim of the 1st part of the paper was to evaluate the influence of antiplatelet drugs (AD) on the haemostatic system of patients with SCLC. There is data in literature indicating a ameliorating influence of AD on time of survival of patients with certain neoplasms. The study was performed in 87 male patients aged 35-73 years with SCLC, limited to half of the chest (limited disease). After 2 i.v. chemotherapy series in 3 week intervals (VAC scheme according Greco): --Adriamycin (ADR) 40 mg on 1sq.m of body surface; --Vincristin (VCR) 1 mg; on 1sq.m of body surface; --Cyclophosfamid (CTX) 1000 mg on 1sq.m of body surface; radiation was also applied--40 Gy during 20 days on the tumor and mediastinum. The described treatment was performed in 22 patients from controls (Group I). Patients from Group II (n = 22) received additionally Defibrotide, Group III (n = 22) Ticlide and Group IV (n = 21) Aspirin. To evaluate of the influence of AD on the haemostatic system--every 3 months during the consecutive 27 weeks, the following tests were performed: bleeding time, clotting time, platelet aggregation, platelets aggregation ratio, euglobulin clot lysis time (ECLT), fibrinogen and fibrinogen degradation products (FDP). It was shown that AD prolonged bleeding and clotting time, increased the threshold ADP and collagen concentration causing platelets aggregation as well as increased platelet aggregation ratio. The used AD (Defibrotide, Ticlide) resulted in activation of the plasma fibrynolytic system as expressed by a shortening of the ECLT, lowering of fibrinogen level and increasing FDP. The influence of observed changes in the haemostatic system, as a result of AD on the remission and survival time of patients with SCLC will be presented in the 2nd part of this paper.

Prevention of veno-occlusive disease with defibrotide after allogeneic stem cell transplantation

Veno-occlusive disease (VOD) of the liver occurs in 10% to 50% of patients after allogeneic stem cell transplantation, ranging from mild reversible disease to severe disease, with a mortality rate almost always close to 100%. Recently, promising results in the treatment of established VOD with defibrotide were reported. Therefore, defibrotide may be used as a prophylactic regimen for hepatic VOD in stem cell transplantation for hematologic malignancies. Fifty-two successive patients who underwent transplantation between October 1999 and June 2002 received defibrotide prophylaxis intravenously from day -7 to day +20 after transplantation in addition to heparin and were compared with historical controls who underwent transplantation successively between February 1997 and September 1999. In the defibrotide group, the maximum total bilirubin levels and the number of patients with serum levels exceeding 50 micromol/L were significantly lower than in the control group (5 of 52 versus 18 of 52, respectively; P =.004). None of the 52 patients developed VOD (Baltimore criteria), and no side effects occurred. These results were significantly different (P =.001) from controls (10/52 [19%] with VOD, 3 of whom died of severe VOD). In addition, day 100 event-free survival was significantly higher in the study group (P =.02), with a trend toward better day 100 overall survival (P =.07). These results suggest that defibrotide given in addition to heparin may be an efficient prophylaxis for VOD.

Defibrotide in the treatment of children with veno-occlusive disease (VOD): a retrospective multicentre study demonstrates therapeutic efficacy upon early intervention

Veno-occlusive disease (VOD) of the liver is a complication observed particularly in patients undergoing hematopoietic stem cell transplantation (HSCT). Defibrotide (DF) is a polydeoxyribonucleotide with aptameric activity on endothelium. We evaluated in a retrospective analysis the efficacy of DF in pediatric patients developing hepatic VOD after HSCT.A total of 45 patients between 0.2 and 20 years (median age: 8.2 years) with hepatic VOD were treated with DF: 22 patients (49%) met risk criteria for severe or progressive disease and 23 (51%) for moderately severe and mild disease. The median duration of DF treatment was 17 days. In all, 34 patients (76%) achieved complete response (CR) with a survival rate of 64% at day 100. CR rate in patients with severe disease was 50% with long-term survival of 36%. The average DF dose in the CR group was 45 mg/kg/day and in the no responder (NR) group 27 mg/kg/day. The use of additional drugs besides DF to treat VOD made no difference in the outcome compared to DF alone. The average interval from diagnosis to start of DF was 1 day in the CR and 5.5 days in NR group. In multivariate analysis, early intervention remained the only significant factor for a CR.

Clinical evaluation of corneal epithelialization after photorefractive keratectomy in patients treated with polydeoxyribonucleotide (PDRN) eye drops: a randomized, double-blind, placebo-controlled trial

PURPOSE

The effect of polydeoxyribonucleotide (PDRN) eye drops vs placebo on corneal epithelial healing after photorefractive keratectomy (PRK) for correction of myopic and myopic-astigmatic defects was evaluated in a randomized, double-blind clinical trial. Primary endpoint for efficacy was the evolution of corneal re-epithelialization. Secondary endpoint was the evaluation of PDRN eye drops tolerability.

METHODS

Sixty eyes were enrolled in the study, randomly allocated into standard therapy plus placebo eye drops (30 eyes), or standard therapy plus PDRN eye drops (30 eyes). Checks were carried out preoperatively and at days 1, 2, 3, and 7 of the follow-up. Six eyes dropped out (four in PDRN group, two in placebo group) for reasons unrelated to the study.

RESULTS

On day 2, the disepithelialized area was 8.4 mm2+/-9.2 (mean+/-SD) in controls and 6.0 mm2+/-6.8 in PDRN group. On day 3 a complete corneal re-epithelialization was found in 20 out of 26 (77%) eyes of PDRN group and in 17 out of 28 (61%) eyes of placebo group (p<0.05 in percentage terms). On day 7 of follow-up, all eyes appeared to be completely re-epithelialized. The mean score of corneal evaluation on day 3 was 2.9 in PDRN group and 3.75 in control group (p<0.05 between groups). No adverse events occurred during the study.

CONCLUSIONS

The data of the study have shown that after PRK, PDRN stimulates corneal epithelium regeneration. PDRN eye drops administration four times a day is well tolerated by patients during the re-epithelialization stage. A much larger clinical study should be performed in order to prove the results obtained in this pilot study.

Multi-institutional use of defibrotide in 88 patients after stem cell transplantation with severe veno-occlusive disease and multisystem organ failure: response without significant toxicity in a high-risk population and factors predictive of outcome

Veno-occlusive disease (VOD) is the most common regimen-related toxicity accompanying stem cell transplantation (SCT). Severe VOD complicated by multisystem organ failure (MOF) remains almost uniformly fatal. Preliminary experience with defibrotide (DF), a single-stranded polydeoxyribonucleotide with fibrinolytic, antithrombotic, and anti-ischemic properties, in the treatment for severe VOD has suggested safety and activity. Eighty-eight patients who developed severe VOD after SCT were treated with DF under a defined treatment plan. At diagnosis, median bilirubin was 76.95 microM (4.5 mg/dL), median weight gain was 7%, ascites was present in 84%, and abnormal hepatic portal venous flow was present in 35%. At DF initiation, median bilirubin had increased to 215.46 microM (12.6 mg/dL), and MOF was present in 97%. DF was administered intravenously in doses ranging from 5 to 60 mg/kg per day for a median of 15 days. No severe hemorrhage or other serious toxicity related to DF was reported. Complete resolution of VOD was seen in 36%, with 35% survival at day +100. Predictors of survival included younger age, autologous SCT, and abnormal portal flow, whereas busulfan-based conditioning and encephalopathy predicted worse outcome. Decreases in mean creatinine and plasminogen activator inhibitor 1(PAI-1) levels during DF therapy predicted better survival. The complete response rate, survival to day +100, and absence of significant DF-associated toxicity in this largest patient cohort reported to date confirm the results of earlier studies. Certain features associated with successful outcome may correlate with DF-related treatment effects, and prospective evaluation of DF therapy for severe VOD should allow better definition of predictors of response or failure.

Treatment of catastrophic antiphospholipid syndrome with defibrotide, a proposed vascular endothelial cell modulator

OBJECTIVE

To define at the molecular level the vascular endothelial cell (VEC) injury characteristics of catastrophic antiphospholipid syndrome (CAPS) and to report successful therapeutic use of a VEC modulator, defibrotide.

METHODS

We describe a 55-year-old man with primary APS with an intractable prothrombotic state (CAPS) resistant to combined therapy with heparin, warfarin, aspirin, and dipyridamole. Treatment with defibrotide was conducted in the context of an investigational phase II protocol where the dose was regulated and individualized by disease/patient-specific molecular and clinical markers.

RESULTS

The patient entered complete remission with defibrotide treatment. During treatment, dose dependent pharmacological actions of defibrotide and key stress markers for VEC injury were identified. Evidence of defibrotide's polypharmacology included downregulation of cytokines, notably tumor necrosis factor-alpha, as the earliest effect, cellular differentiation of VEC, possibly with direct regulatory effect over cellular genes, and the reversal of platelet consumption and prothrombotic state. Von Willebrand antigen levels were used as the sole marker to guide therapy.

CONCLUSION

This case demonstrates effective remission of CAPS with defibrotide treatment. In contrast to theories that CAPS is triggered by ischemic and thrombotic tissue damage, these data present VEC injury as the primary and representative lesion of CAPS. The pathogenesis may involve concurrent impairment of different VEC functions. Achieving remission may require a polypharmacologic approach, represented here by use of defibrotide.

Clinical evaluation of the trophic effect of polydeoxyribonucleotide (PDRN) in patients undergoing skin explants. A Pilot Study

OBJECTIVE

The purpose of this double-blind, randomised, placebo-controlled study was to assess the effects of intramuscular and subcutaneous PDRN in favouring the wound-healing process in donor sites of grafts.

METHODS

26 adult patients of both sexes (15 males and 11 females; mean age: 68.2 +/- 16.1 years) subjected to skin explants due to plastic surgery were eligible to participate in this double-blind, placebo-controlled study. Patients were randomly allocated into the PDRN group (14 subjects) or the placebo group (12 subjects). PDRN (5625 mg/vial) or placebo were administered by the intramuscular route once daily, associated with a subcutaneous administration of the same dosage form (2 vials every 3 days) for 10 consecutive days. The primary end point for efficacy was the evolution of wound healing in donor sites, which was evaluated measuring wound surface area and then calculating percentage re-epithelialisation. Secondary end points were local subjective symptoms, such as pain and itching, and objective signs such as perilesional erythema and blisters. Signs and symptoms were quantified through an analogue scale.

RESULTS

At day 7 of the treatment period, the difference in percentage of re-epithelialisation was statistically significant (p < 0.008) in favour of the PDRN group. At the end of the observational period, between-group comparison demonstrated that patients treated with PDRN had a more prompt trophic effect. No adverse events were reported during the trial.

CONCLUSIONS

The findings of our study demonstrated that PDRN is able to modify positively the repair processes in donor sites of autologous skin grafts. This could improve the clinical outcome and decrease the need for additional therapies or hospital stay.

Defibrotide in recurrent thrombotic thrombocytopenic purpura

Thrombotic thrombocytopenic purpura (TTP) is a common illness characterized by platelet thrombi within the microvascularization. In its natural course, this disease has had a mortality rate of 90%. Plasma infusion or exchange achieved a survival rate of 70% to 90%. However, 10% to 30% of patients surviving the initial TTP episode relapse at regular intervals. The treatment of recurrent forms of the disease remains a challenge; several approaches have been shown to induce medium to long term remissions. We describe a patient with recurrent TTP whose disease remitted after administration of defibrotide.

Preparation and characterization of cationic microspheres for gene delivery

The production and characterization of cationic microparticles based on Eudragit RS and cationic agents (i.e. a cationic acrylic polymer and three different cationic surfactants) for the delivery of nucleic acids is here described. It was found that morphological and dimensional characteristics of microparticles were influenced by the type and concentration of cationic agent employed and by some experimental parameters such as stirring speed, emulsifying agent and type of rotor. The desoxiribonucleotide Defibrotide (DFT) was associated with positively charged microparticles and its in vitro release kinetics from microparticles were determined. A study of the in vitro toxicity of cationic microparticles on cultured human cell line K562 was also performed, demonstrating that DDAB(18) microparticles display very low cytotoxicity.

Chronic oral defibrotide counteracts hypercholesterolemia noxious effects on cardiovascular function in the rabbit

The aim of the present work was to assess if the cardioprotective drug defibrotide could counteract the hypercholesterolemia noxious effects on cardiovascular function. Aortas and hearts from normal- or cholesterol-fed rabbits, treated or not with chronic oral defibrotide (100 mg/kg/day) for 45 days, were used in in vitro tests throughout the experiment. Hypercholesterolemia worsened: aorta stickiness toward polymorphonuclear leukocytes, aorta relaxation to acetylcholine, heart left ventricular end-diastolic pressure and coronary perfusion pressure, heart left ventricular diastolic pressure, acetylcholine and endothelin-1 activity on coronary perfusion pressure, and heart generation of 6-Keto-prostaglandin F1alpha. Oral defibrotide counteracted and/or obliterated the above hypercholesterolemia noxious effects. Particularly, oral defibrotide counteracted the parameters associated with early endothelial cell disfunction: that is, increased adherence of leukocytes to endothelium and endothelial vasorelaxation induced by acetylcholine, which acts through the release of endothelium-derived relaxing factor. These activities of defibrotide are probably exerted through the increased generation of prostacyclin. The fact that acetylcholine induced vasorelaxation is partially protected by oral defibrotide points to a partial rescue of endothelial ability to generate endothelium-derived relaxing factor, as acethylcoline acts through the release of endothelium-derived relaxing factor, by defibrotide itself. Defibrotide's endothelial protection could, in turn, explains why defibrotide protected cardiovascular function. This is not surprising as, in a few cases, endothelial dysfunction, observed in hypercholesterolemia, was found to be prevented or reversed, pharmacologically, by PN-2001-10, a calcium channel blocker, dipyridamole, and lovastatin.

[Prophylaxis of toxic effects on the peripheral venous system associated with intravenous administration of vinorelbine]

Vinorelbine is effective in the treatment of a number of malignancies. However, beside the haematologic and not haematologic toxicity as thrombocytopenia, granulocytopenia, fatigue, paresthesias, nausea and vomiting, one of the most common side effects is the local irritation with thrombophlebitis. The side effect, reported in about 10-26% of patients receiving vinorelbine infusions, is due to the vescicant and irritant action of the drug. Many studies have been performed in order to reduce the incidence of venous irritation either with concomitant administration of anti-inflammatory drugs as defibrotide or ketorolac, or changing infusion schedule from bolus infusion to a 20-30 minute infusion. Aim of this review is to define peripheral venous system toxicity of vinorelbine and the best way of administration.

Study on pharmacokinetics of radioactive labelled defibrotide after oral or intravenous administration in rats

Defibrotide (D) was labelled with 125I or with 32P. The radiolabelled compounds ([125I]-Defibrotide ([125I]-D), [32P]-Defibrotide ([32P]-D) retained the same profibrinolytic activity, in vitro, as the parent drug, suggesting that the labelling procedures had not modified the pharmacological properties of D and hence that its chemical structure was not affected significantly. After single intravenous or oral administration of [125I]-D or [32P]-D the pharmacokinetic parameters for the two labels were generally in good agreement (75%). t 1/2 alpha was in the range of minutes while t 1/2 beta was in the range of hours. Bioavailability, following single oral administration of [125I]-D or [32P]-D, was in the range of 58-70%. These data suggest that D, in spite of its macromolecular nature, is absorbed, after oral administration, fairly well.

Renal uptake of an 18-mer phosphorothioate oligonucleotide

Renal uptake of a 35S labeled 18-mer phosphorothioate oligodeoxynucleotide (molecular wt approximately 6,000) was evaluated following intravenous infusion into rats. The kidneys contained 21 +/- 3% of the infused dose at five hours after infusion and 3 +/- 1% of the infused dose at four days after infusion. The concentration of oligonucleotide was greater in the kidney than in the liver, spleen, or plasma at both intervals. Urine excretion of oligonucleotide label averaged 17 +/- 1%, 35 +/- 5%, and 64 +/- 3% of the infused dose at five hours, one day, and four days after infusion. Electrophoresis (PAGE) showed that oligonucleotide was retained in the kidney was the intact 18-mer at both five hours and four days after infusion, while full size oligonucleotide was not found in the urine at either interval. Light microscopic autoradiography showed that oligonucleotide uptake was most prominent in the early proximal tubule. Electron microscopic autoradiography indicated that oligonucleotide was not confined to the brush border or endocytic-lysosomal pathway. Micropuncture studies showed that the tubule fluid to plasma concentration ratios of oligonucleotide label averaged 7 +/- 3% in Bowman's space and 6 +/- 2% in the distal tubule. Despite restriction of filtration by plasma protein binding, as indicated by the low Bowman's space to plasma concentration ratio, the calculated tubular reabsorption rate for oligonucleotide was sufficient to account for the large amount of oligonucleotide found in the kidney after intravenous infusion. These results indicate that the proximal tubule plays a prominent role in the disposition of intravenously infused oligonucleotide, and raise the possibility that oligonucleotides could exert antisense effects in this nephron segment.

Polydeoxyribonucleotides and nitric oxide release from guinea-pig hearts during ischaemia and reperfusion

1. Two polydeoxyribonucleotides, produced by the controlled hydrolysis of DNA of mammalian lung (defibrotide and its lower molecular weight fraction, P.O. 085 DV), were studied for their ability to modify the release of nitrite and the coronary flow in perfusates collected from isolated, normally perfused hearts of guinea-pigs and from hearts subjected to regional ischaemia and reperfusion. 2. In guinea-pig normally perfused hearts, both defibrotide (DFT) and its fraction, P.O. 085 DV, increase the amount of nitrite appearing in perfusates in a concentration-dependent fashion. At the highest concentration studied (10(-6) M), P.O. 085 DV was more effective than DFT. A concomitant increase in the coronary flow was observed. 3. The increase in nitrite in perfusates and the increase in coronary flow induced by both DFT and P.O. 085 DV were significantly reduced by NG-monomethyl-L-arginine (L-NMMA, 10(-4) M), an inhibitor of nitric oxide synthase (NOS). 4. The endothelium-dependent vasodilator, acetylcholine (ACh), enhances the formation of nitrite and the coronary flow. Both the increase in coronary flow and in the formation of nitrite were significantly reduced by L-NMMA (10(-4) M). 5. In guinea-pig hearts subjected to ischaemia and reperfusion, the effect of both compounds in increasing the amount of nitrite in perfusates was more evident and more pronounced with P.O. 085 DV. 6. Reperfusion-induced arrhythmias were significantly reduced by both compounds to the extent of complete protection afforded by compound P.O. 085 DV. 7. The cardioprotective and antiarrhythmic effects of DFT and P.O. 085 DV are discussed.

Effects of defibrotide on physical performance and hemorheologic picture in patients with peripheral arteriopathy

In a random double-blind study versus placebo, 60 ambulatory patients with peripheral occlusive disease of the lower limbs and claudicatio intermittens (Leriche's stage 2), were treated for 60 days with defibrotide (400 mg b.i.d., oral, n = 30) or placebo (n = 30). Patients in the defibrotide group received additional treatment with the same drug at the reduced rate of 400 mg once daily for another 120 days for maintenance (total treatment duration 180 days). All patients were assessed at intake and 60 days for relative and absolute walking distance (RWD and AWD) in a standard treadmill test and for the Winsor Index (WI) at rest and after exercise; patients of the defibrotide treatment group were retested in the same way at 90-180 days. In a subgroup of patients (defibrotide = 11, placebo = 12), blood samples were obtained for the assessment of whole blood and plasma viscosity at intake and after 60 days of treatment. These samples could not be collected properly in the remaining cases, for technical reasons. At day 60, we compared the effects of the two treatments on physical performance: mean (SE) values of RWD were for defibrotide 148 (9.7) and 179 (12.4) m in basal and post-treatment conditions, respectively, and 209 (16.2) and 212 (17.1) m for placebo. Similar changes were observed for AWD: for defibrotide 206 (13.4) and 241 (15.2) m and for placebo 270 (22.9) and 272 (23.1) m. The mean changes were significantly larger with defibrotide: for RWD + 33 (7.1) vs. + 0.3 (3.8) m (p < 0.01) and for AWD + 34 (9.2) and -2 (6.6) m (p < 0.01). The overall gain of walking distance after maintenance therapy with the reduced defibrotide dosage amounted to approximately + 50% over basal (after 180 days). Blood and plasma viscosity improved in patients on defibrotide but the change fell short of statistical significance versus placebo. All findings confirm the potential usefulness of defibrotide in the treatment of peripheral arterial disease, at the same time encouraging further studies of the involved mechanisms of action.

[Alternative therapy of deep venous thrombosis in patients at hemorrhagic risk]

The authors report on the pharmacological employment of defibrotide in the treatment of a case of deep vein thrombosis (DVT) of the left iliac-femoral veins in a patient with a high-risk of hemorrhage (haematuria from kidney neoplasm, rupture of basilar artery aneurysm, urethral bleeding from catheter trauma). Alternatively to the traditional thrombolytic and anticoagulants, not indicated here for their haemorrhagic risk potential, defibrotide promptly resolved the DVT without any major effect on blood coagulation parameters. Initially, 1 gr of defibrotide in 250 ml of glucose-1-phosphate solution was administered twice-daily for the first two days when improvement had been observed. An additional 5 days of therapy was continued under the same regimen, then 400 mg intravenously every 2 hours for 14 days, and 400 mg intramuscularly every 24 hours until the 30th day. The patient was dismissed from the hospital on therapy with indobufen 200 mg orally, and elastic support stocking. After 6 months the patient is well. An echo color Doppler evaluation showed a normal venous blood flow through the femoral, iliac and caval veins, and venous blood reflux in the iliac-femoral and femoral saphenous veins due to valvular insufficiency. Caval filters, although recognized by many institutions as a preferred method of protection against pulmonary thromboembolism especially in patients with a contraindication to anticoagulation therapy or recurrent pulmonary embolism, was not used in this case, since the patient was critically ill. From this case report and the review of the literature it seems that defibrotide may represent a valid alternative therapy in the treatment of DVT, especially in high risk haemorrhagic patients.

Pharmacokinetics, absorption, distribution and disposition of [125I]-defibrotide following intravenous or oral administration in the rat

Defibrotide (D) was labelled with 125I. The radiolabelled compound ([125I]-Defibrotide ([125I]-D)) retained the same profibrinolytic activity as the parent drug. Following single intravenous administration of [125I]-D the half lives of radioactivity associated with D components in plasma were 9.45 min and 11.27 h for alpha and beta phases respectively. Following single oral administration of [125I]-D the half life of radioactivity associated with D components in plasma was 12.83 h for the elimination phase. Bioavailability was apparently 58%. The areas under plasma total radioactivity versus time curves were dose-dependent following both intravenous and oral administration. No significant accumulation of total radioactivity in plasma was observed following multiple oral administration of [125I]-D. Following single intravenous administration of [125I]-D a larger proportion of administered radioactivity was excreted via urine than faeces while following single oral administration excretion via urine and faeces accounted for similar proportions of administered radioactivity. Following both single and oral administration the levels of total radioactivity in tissues and organs examined were generally highest in highly perfused organs and were very high in the thyroid despite pretreatment with non-radiolabelled potassium iodide. Radioactivity was also found to be associated with the aorta wall.

[The prevention of DVT after general surgical interventions for cancer pathology]

The efficacy of postoperative DVT prophylaxis of defibrotide and heparin calcium was evaluated in a group of 47 patients undergoing general surgery for oncological pathologies. A sub-group (24 patients) received defibrotide treatment, 400 mg b.i.d. i.m.; the second subgroup (23 patients) was treated with heparin calcium, 5000 IU b.i.d. s.c., from the day before operation until the 7th postoperative day. No postoperative thrombotic symptoms were observed in either group of patients.

The pharmacological modulation of thrombin-induced cerebral thromboembolism in the rabbit

1. Intracarotid (i.c.) administration of thrombin induced a marked accumulation of 111indium-labelled platelets and 125I-labelled fibrinogen within the cranial vasculature of anaesthetized rabbits. 2. Thrombin (100 iu kg-1, i.c.) - induced platelet accumulation was completely abolished by pretreatment with desulphatohirudin (CGP 39393; 1 mg kg-1 i.c., 1 min prior to thrombin). Administration of CGP 39393 1 or 20 min after thrombin produced a significant reduction in platelet accumulation. 3. Intravenous (i.v.) administration of the platelet activating factor (PAF) receptor antagonist BN 52021 (10 mg kg-1) 5 min prior to thrombin (100 iu kg-1, i.c.) had no effect on platelet accumulation. 4. An inhibitor of NO biosynthesis, L-NG-nitro arginine methyl ester (L-NAME; 100 mg kg-1, i.c.), had no significant effect on the cranial platelet accumulation response to thrombin (10 iu kg-1, i.c.) when administered 5 min prior to thrombin. 5. Defibrotide (32 or 64 mg kg-1 bolus i.c. followed by 32 or 64 mg kg-1 h-1, i.c., infusion for 45 min) treatment begun 20 min after thrombin (100 iu kg-1, i.c.) did not significantly modify the cranial platelet accumulation response. 6. Cranial platelet accumulation induced by thrombin (100 iu kg-1, i.c.) was significantly reversed by the fibrinolytic drugs urokinase (20 iu kg-1, i.c., infusion for 45 min), anisoylated plasminogen streptokinase activator complex (APSAC) (200 micrograms kg-1, i.v. bolus) or recombinant tissue plasminogen activator (rt-PA; 100 micrograms kg-1, i.c. bolus followed by 20 micrograms kg-1 min-1, i.c., infusion for 45 min) administered 20 min after thrombin.8. These results suggest that neither endogenous PAF nor NO modulate thrombin-induced intracranial platelet accumulation in the rabbit. However, fibrin deposition appears to play an important role as shown by the ability of fibrinolytic agents to reverse platelet and fibrinogen accumulation induced by i.c. thrombin.

[Defibrotide vs. calcium heparin in the prevention of deep vein thrombosis in gynecologic oncologic surgery]

Eighty-one patients were submitted to gynaecological malignancy surgery in a randomized study aimed at the evaluation of the efficacy of defibrotide (40 patients) and calcium heparin (41 patients) in perioperative prophylaxis. They were randomly allocated to defibrotide group (400 mg bid im starting one day before surgery and continuing until the 7th postoperative day) or calcium heparin group (5000 IU bid sc starting two hours before surgery and continuing likewise for 7 days). No cases of DVT diagnosed by means of a Doppler CW were observed in either treatment group. Laboratory parameters have shown similar modifications in the two treatment groups. Three cases of bleeding were observed in the calcium heparin group while no cases of bleeding were detected in the defibrotide group. The results obtained suggest that defibrotide is at least as effective as calcium heparin in perioperative DVT prevention and that the former drug has a possibly better tolerability profile, due to a decisively lower tendency to bleeding.

Effect of oral defibrotide on tissue-plasminogen activator and tissue-plasminogen activator inhibitor balance

Defibrotide, a polydeoxyribonucleotide of mammalian origin, has been shown to reduce the blood level of the plasminogen activator inhibitor, and so to increase the activity of tissue plasminogen activator without any adverse effect. A randomized, double-blind, placebo-controlled study has been done in 22 patients, 14 with peripheral vascular disease, 6 with coronary heart disease and 2 with cerebrovascular disease. Patients were given defibrotide 400 mg b.d. or identical placebo for 30 days and the parameters of fibrinolysis were evaluated before and after the treatment. A significant increase in tissue plasminogen activator activity at rest and after venostasis was observed after defibrotide; tissue plasminogen activator antigen at rest and after venostasis was not affected by either treatment. Defibrotide significantly reduced plasminogen activator inhibitor activity and antigen at rest. Only one patient complained of gastric pain after placebo treatment. The study shows that defibrotide has profibrinolytic property and that it could be used to explore the role of plasminogen activator inhibitor in venous and arterial thrombosis.

Anticoagulant and antithrombotic effects of combinations of defibrotide with heparins and other antithrombotic agents in an animal thrombosis model

Defibrotide, acetylsalicylic acid, low molecular weight heparin (CY 216), sodium heparin, Molsidomin and a thromboxane receptor antagonist have been investigated separately and in combinations in an animal thrombosis model in which rat mesenteric venules are damaged by defined laser energy. Furthermore, the ex vivo anticoagulant activity of Defibrotide and heparin were studied in rat plasma. All investigated agents showed a significant and dose-dependent antithrombotic effect when venules were damaged. A strong additive effect was observed when Defibrotide was administered together with heparins. The combinations of Defibrotide with other antithrombotic agents did not have significant additive effects. In the present study the combination of Defibrotide and heparins showed a prolongation of aPTT and Heptest in comparison with heparin given exclusively.

[Management of cervico-vaginal dystrophies]

Fifty-nine outpatients affected by cervico-vaginal dystrophy with manifest symptoms were included in the study. Following initial tests (colposcopy with Schiller's test, colpocytological test, analysis of symptoms), a cycle of treatment was commenced using the insertion of a vaginal pessary of Polydeoxy-ribonucleotide (PDRN) in the evening for 20 days. A control on day 28 revealed a marked improvement of the symptoms together with a positive evolution of objective tests. During the 10th week after the end of therapy, both subjective and objective findings tended to confirm the relapse towards pre-treatment conditions.

[Advantages of topical therapy with polydeoxyribonucleotide in reparative processes after cauterization: experience at a center for early diagnosis of genital neoplasms]

This paper evaluates the common practice of a topic medical treatment following cautery (or other kinds of microsurgery) of the uterine cervix. Firstly, a controlled clinical trial on 116 patients treated with kanamycin sulphate alternated to polydeoxyribonucleotide vaginal suppositories, and 124 controls has been conducted. Subjective parameters (leukorrhea, bloody discharge, odorous discharge, more than three weeks vaginal discharge, itching, pain, burning) and colposcopy (Schiller test reactivity, squamo-columnar junction location, abnormal transformation zones, vascular striae, deepithelialized areas or frail epithelium) appeared more favorable in the treated group, the colposcopic finding of phlogosis being the only unfavorable finding more frequent among the treated patients. Successively, a controlled double blind clinical trial with kanamycin sulphate alternated to placebo vs PDRN at different dosages has shown an increase in number of epithelial cells in the treated patients and a better stimulation of fibroblasts by higher dosages of active substance. These results show the efficacy of the studied post cautery treatment schedule, and of PDRN in particular.

[Clinico-morphological changes in ectropion after treatment with polydeoxyribonucleotide (PDRN)]

Thirty patients in fertile age affected by ectropion were treated with Polydeoxyribonucleotide (PDRN) (*) vaginal suppositories for 24 days. No other local or general therapy was allowed. The following parameters were evaluated: local symptomatology, tolerability and compliance, vaginal cytology, colposcopic examination, bioptic sampling of affected area prior to and after treatment, and local immune response. The results show the efficacy of PDRN. In fact, after the treatment: reduction of subjective symptomatology with decrease of average score for each symptom; excellent or good tolerability and acceptability; reduced inflammation; increased iodine-dark areas; reestablishment of normal balance in T- and B-lymphocytic populations have been found.