Low Molecular Weight Hyaluronic Acid (500–730 Kda) Injections in Tendinopathies—A Narrative Review

Tendinopathies are common causes of pain and disability in general population and athletes. Conservative treatment is largely preferred, and eccentric exercise or other modalities of therapeutic exercises are recommended. However, this approach requests several weeks of consecutive treatment and could be discouraging. In the last years, injections of different formulations were evaluated to accelerate functional recovery in combination with usual therapy. Hyaluronic acid (HA) preparations were proposed, in particular LMW-HA (500–730 kDa) for its unique molecular characteristics in favored extracellular matrix homeostasis and tenocyte viability. The purpose of our review is to evaluate the state-of-the-art about the role of 500–730 kDa in tendinopathies considering both preclinical and clinical findings and encourage further research on this emerging topic.

Endotoxin and Cytokine Sequential Hemoadsorption in Septic Shock and Multi-Organ Failure

The mortality of septic shock remains high [Ann Intensive Care. 2017;7:19], so apart from usual therapy based on source control and antibiotics, some patients may need rescue therapies. Blood purification systems may play a role by facilitating the nonspecific removal of inflammatory mediators and microbiological toxins. There are different hemoadsorption systems, we describe in this case report the sequential use of Polymyxin B (PMX) endotoxin-adsorbing column (Toraymixin PMX-20R; Toray, Tokyo, Japan) and Cytosorb® (Cytosorbents Corp., New Jersey, USA).

POS0314 PROSPECTIVE EVALUATION OF A DEDICATED, SERIAL OCCUPATIONAL THERAPY EXERCISE PROGRAM ON HAND FUNCTION IN RHEUMATOID ARTHRITIS (RA)

Background:Rheumatoid arthritis (RA) frequently affects the joints of the hands causing severe pain and significant functional impairment affecting all activities of daily living. At early stages, functional impairment is primarily caused by reversible joint and tendon sheath effusions while at later stages synovial thickening, muscular atrophy and irreversible damage to cartilge, bone, tendons and ligaments cause a reduced range of motion and deformities. Occupational therapy aims to maintain and improve joint mobility and function. However, there is limited data on the effectiveness of serial exercise programs specifically aiming at maintaining and improving hand function in RA.Objectives:To prospectively evaluate the effects of a dedicated exercise program on hand function, grip strength, joint mobility and pain compared with conventional outpatient physiotherapy not specifically targeting hand function.Methods:A total of 51 RA patients receiving outpatient physiotherapy once a week were enrolled and randomized to either continue their usual therapy (control group) or to participate in a dedicated hand function training (HFT) twice a week in addition to their usual therapy (HFT group). The HFT program was supervised by an occupational therapist who conducted once weekly HFT sessions and instructed the participants to perform an additional self-administered HFT session at home once a week. Study duration was six months with an option to continue HFT for additional 6 months. Study participants were evaluated at baseline and every 3 months.The primary outcomes hand function and grip strength were assessed using standardized questionnaires (Cochin hand function scale (CHFS), Australian/Canadian Osteoarthritis Hand Index (AUSCAN), Michigan Hand Outcomes Questionnaire (MHOQ)) and dynamometer/pinch gauge readings for different types of grip (cylindrical grasp, spherical grasp, hook grasp, tip to tip pinch and key pinch), respectively. The secondary outcomes joint mobility and pain were assessed using a digital goniometer and visual analogue scales (VAS), respectively. Statistical analysis used the Wilcoxon test for evaluating changes of parameters over time within the groups and the Kruskal Wallis test for group comparisons and Bonferroni-Holm correction.Results:41 of the 51 patients (HFT group: n = 20, mean age 60.3 ± 8.4 years; control group: n = 21, mean age 60.5 ± 11.5 years) completed the 6-month study period, 14 patients extended their HFT to 12 months. Within the 6-month study period there were no significant improvements of the primary outcome parameters and of pain within the groups vs. baseline and no significant differences between the groups. Only the CHFS improved significantly in the HFT group as of month 9. A significant improvement of the range of motion vs. baseline was achieved by HFT as early as 3 months after baseline which persisted up to month 12. As some improvement was also seen in the control group, there was no significant difference between the groups. Hand mobility improved particularly in the subgroup of patients >60 years of age. There was no influence by pain intensity at baseline (VAS ≤50 mm vs. VAS >50 mm).Conclusion:Serial dedicated HFT for 6 months resulted in improved joint mobility but did not improve global hand function, grip strength and pain in RA patients. A longer treatment duration (≥12 months), a higher treatment frequency (>2 times/week) and a larger cohort of patients may be required.Disclosure of Interests:None declared

PROX1 IMMUNOHISTOCHEMICAL ANALYSIS OF PEDIATRIC VASCULAR ANOMALIES, A POSIBLE PROGNOSTIC AND THERAPEUTIC FACTOR OF HEMANGIOMAS?

Infantile and congenital hemangiomas still a challenge for both the pediatric surgeon and the pediatrician. The treatment of hemangiomas must be individualized according to: the type of lesion, location, size, depth, stage of growth and evolution of the lesion. To date, none of the available therapies is considered standard therapy. Currently, personalized therapy is not widely applied in Romania, not being included in the usual therapy protocols in any of the types of hemangioma. This is a starting point for the identification of new specific therapeutic targets that preserve normal endothelial cells and determine the regression of hemangioma, especially recurrent ones and those with an increased proliferation rate. Another controversial and unexplained aspect, consequently unexploited from a therapeutic point of view is represented by the expression and role of lymphatic markers in infantile and congenital hemangiomas.

Therapeutic potential of ivermectin as add on treatment in COVID 19: A systematic review and meta-analysis

The current management of COVID-19 is mostly limited to general supportive care and symptomatic treatment. Ivermectin is a broad-spectrum anti-parasitic drug used widely for the treatment of onchocerciasis and lymphatic filariasis. Apart from its anti-parasitic effect it also exhibits antiviral activity against a number of viruses both in vitro and in vivo. Hence, we conducted this systematic review and meta-analysis to assess the currently available data on the therapeutic potential of ivermectin for the treatment of COVID‐19 as add on therapy. A total of 629 patients were included in the 4 studies and all were COVID-19 RT-PCR positive. Among them, 397 patients received ivermectin along with usual therapy. The random effect model showed the overall pooled OR to be 0.53 (95%CI: 0.29 to0.96) for the primary outcome (all-cause mortality) which was statistically significant (P=0.04). Similarly, the random effect model revealed that adding ivermectin led to significant clinical improvement compared to usual therapy (OR=1.98, 95% CI: 1.11 to 3.53, P=0.02). However, this should be inferred cautiously as the quality of evidence is very low. Currently, many clinical trials are on-going, and definitive evidence for repurposing this drug for COVID-19 patients will emerge only in the future.

Treatment-resistant cough: a rare manifestation of IgG4-related disease involving the larynx

IgG4-related autoimmune diseases (IgG4 RD) are a relatively recently recognised group of disease processes that can affect multiple organ systems and result in protean symptoms. Here, we present a rare case of a 69-year-old man with a history of IgG4 RD affecting his lacrimal gland and pancreas who developed symptoms of severe laryngitis not responsive to usual therapy. He presented with non-productive cough, hoarseness and dyspnoea. Imaging findings suggestive of aortitis and laryngeal inflammation in the setting of his IgG4 RD history prompted treatment with rituximab, which resulted in resolution of his laryngeal symptoms. Subsequently, his cough returned and he required periodic rituximab infusions to stay symptom-free. IgG4 RD of the larynx is an uncommonly reported manifestation in literature. This disease is very responsive to anti-CD20 monoclonal antibody treatment. IgG4 RD should be considered in patients with airway symptoms that are especially refractory to usual therapy.

Robot-assisted training after proximal humeral fracture: A randomised controlled multicentre intervention trial

Objective: To examine whether robotic-assisted training as a supplement to usual therapy is safe, acceptable and improves function and patient reported outcome after proximal humeral fractures (PHF). Design: Multicentre, assessor-blinded, randomised controlled prospective trial. Setting: Three different rehabilitation hospitals in Germany. Subjects: In total 928 PHF patients between 35 and 70 years were screened. Forty-eight participants were included in the study (intervention group n = 23; control group n = 25). Intervention: The control group received usual occupational and physiotherapy over three weeks, and the intervention group received additional 12 robot-assisted training sessions at the ARMEO®-Spring. Main measures: Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH), the Wolf Motor Function Test-Orthopaedic, active range of motion and grip strength were determined before and after intervention period. The DASH was additionally obtained postal 6 and 13 months following surgery. Results: The mean age of participants was 55 ± 10 years and was similar in both groups ( p > 0.05). The change in DASH as the primary endpoint in the intervention group after intervention was −15 (CI = 8–22), at follow-up six month −7 (CI = −2 to 16) at follow up 13 month −9 (CI = 1–16); in control group −14 (CI = 11–18), at follow-up six month −13 (CI = 7–19) at follow up 13 month −6 (CI = −3 to 14). No difference in the change was found between groups ( p > 0.05). None of the follow-up time points demonstrated an additional benefit of the robotic therapy. Conclusion: The additional robot-assisted therapy was safe, acceptable but showed no improvement in functional shoulder outcome compared to usual therapy only.

Indomitable vomiting in a woman in the fifth month of pregnancy, cured by suggestion

Patient 25 years old, four months pregnant; vomiting appeared from the very beginning of pregnancy, increased during the fourth month, contains a large admixture of blood; the patient is exhausted. All the usual therapy was applied unsuccessfully.

Children's Active Engagement in Public School Language Therapy Relates to Greater Gains

Purpose The current study examined children's engagement as an active ingredient of language therapy in public schools and considered the potential interplay between engagement and dose on outcomes. Method Participants included 135 children with language impairment receiving business-as-usual therapy from 70 speech-language pathologists. Two videotaped therapy sessions from each participating child were coded for children's level of engagement and time in language-focused therapy (dose). Results Hierarchical linear modeling was used for analyses; children's level of engagement (i.e., active engagement) was significantly, positively related to children's language gain and was not moderated by dose. Conclusion Findings suggest that children's active participation in therapy sessions is a significant component to effective language therapy and underscores the need for further research.

Ranolazine Improves Autonomic Balance in Heart Failure when added to Guideline-Driven Therapy

Background: The effect of ranolazine (RAN) on cardiac autonomic balance in congestive heart failure (CHF) was studied. Methods: Fifty-four CHF patients were randomized to (1) open-label RAN (RANCHF) added to usual therapy vs. (2) usual therapy (NORANCHF). Parasympathetic and sympathetic (P&S) measurements were taken at baseline and at 12 months. Results: A total of 16/27 (59%) patients in both groups had initially abnormal P&S measures, including high sympathovagal balance (SB), cardiovascular autonomic neuropathy (CAN) or both. High SB normalized in 10/12 (83%) RANCHF patients vs. 2/11 (18%) NORANCHF patients. SB became high in 5/11 (45%) NORANCHF vs. 1/11 (9%) RANCHF patients. CAN improved in 4/6 (67%) RANCHF patients vs. 5/7 (45%) NORANCHF patients. CAN developed in 1/11 (9%) RANCHF vs. 4/11 (36%) NORANCHF patients. Since improved P&S in RANCHF patients seemed independent of improved brain natriuretic peptide and impedance cardiography (BioZ) measurements, 5 day RAN was given to 30 subjects without CHF but with high SB or CAN. P&S improved in 90% of these subjects. Conclusions: RAN improves unfavorable P&S activity in CHF possibly by a direct effect upon autonomic sodium channels.