Intramuscular injections of botulinum toxin for the treatment of upper back myofascial pain syndrome: A systematic review of randomized controlled trials.

BACKGROUND AND OBJECTIVE: Myofascial pain syndrome (MPS) is a chronic musculoskeletal disorder characterized by the presence of trigger points. Among the treatment options, botulinum toxin injections have been investigated. The aim of this paper was to provide a synthesis of the evidence on intramuscular botulinum toxin injections for upper back MPS. DATABASES AND DATA TREATMENT: A systematic review of the literature was performed on the PubMed, Scopus and Cochrane Library, using the following formula: ("botulinum") AND ("musculoskeletal") AND ("upper back pain") OR ("myofascial pain"). RESULTS: Ten studies involving 651 patients were included. Patients in the control groups received placebo (saline solution) injections, anaesthetic injections + dry needling or anaesthetic injections. The analysis of the trials revealed modest methodological quality: one "Good quality" study, one "Fair" and the other "Poor". No major complications or serious adverse events were reported. Results provided conflicting evidence and did not demonstrate the superiority of botulinum toxin over comparators. Most of the included trials were characterized by a small sample size, weak power analysis, different clinical scores used and non-comparable follow-up periods. Even if there is no conclusive evidence, the favourable safety profile and the positive results of some secondary endpoints suggest a potentially beneficial action in pain control and quality of life. CONCLUSION: The currently available studies show conflicting results. Their overall low methodological quality does not allow for solid evidence of superiority over other comparison treatments. Further insights are needed to properly profile patients who could benefit more from this peculiar injective approach. SIGNIFICANCE: The randomized controlled trials included in this review compared using botulinum toxin to treat upper back MPS with placebo or active treatments (e.g., dry needling or anaesthetics) showing mixed results overall. Despite the lack of clear evidence of superiority, our study suggests that the use of botulinum toxin should not be discouraged. Its safety profile and encouraging results in pain control, motor recovery and disability reduction make it an interesting treatment, particularly in the subset of patients with moderate to severe chronic pain and active trigger points. To support the safety and efficacy of botulinum toxin, further high-quality studies are needed.

Oxygen-ozone therapy for the treatment of low back pain: a systematic review of randomized controlled trials.

OBJECTIVE: The aim of the study was to review the available literature on the application of oxygen-ozone therapy (OOT) in the treatment of low back pain (LBP), to understand its therapeutic potential and compare it with other available treatment options. MATERIALS AND METHODS: A systematic review was performed on the PubMed and Scopus databases, with the following inclusion criteria: (1) randomized controlled trials (RCTs), (2) published in the last 20 years, (3) dealing with OOT in patients with LBP and herniated disc, (4) comparing the results of OOT with those of other treatments. The risk of bias was assessed by the Cochrane Risk of Bias tool. RESULTS: Fifteen studies involving 2597 patients in total were included. Patients in the control groups received different treatments, from oral drugs to other injections, instrumental therapy and even surgery: corticosteroids were used in 5 studies, analgesic therapy in 2 studies; placebo, microdiscectomy, laser-therapy, TENS and postural rehabilitation, percutaneous radiofrequency intradiscal thermocoagulation and psoas compartmental block were tested in the other trials. Looking at the quality of the literature, none of the studies included reached "good quality" standard, 3 were ranked as "fair" and the rest were considered "poor". Comparison of OOT results with other approaches showed that, in the majority of studies, OOT was superior to the control treatment, and also when compared to microdiscectomy, ozone showed non inferiority in terms of clinical outcomes. CONCLUSIONS: The analysis of literature revealed overall poor methodologic quality, with most studies flawed by relevant bias. However, OOT has proven to be a safe treatment with beneficial effects in pain control and functional recovery at short to medium term follow-up.

Dynamic brace is a good option to treat first anterior shoulder dislocation in season.

PURPOSE: We evaluate the ability of in-season competitive athletes to return to competition after an anterior shoulder instability treated conservatively with a new dynamic brace combined with a specific rehabilitation program. METHODS: Twenty soccer players affected by traumatic anterior shoulder dislocation have been enrolled in the "Footballer In Season Fast Rehab" project during 2 consecutive football seasons. We excluded patients affected by rotator cuff tears and the bony defect over 25%. All the players have been treated the day after the first dislocation with a new dynamic brace used until the end of the second month after the first glenohumeral dislocation combined with a specific rehab protocol. Athletes were evaluated for the time necessary to completely resume sport activities, to complete the season, and for the recurrence of dislocation. RESULTS: All the athletes enrolled in this study were able to come back on the ground in approximately 40 days after the dislocation except 2 of them. Only two athletes claimed a slight discomfort at the return to play. One athlete had a traumatic relapse of the instability, 50 days after the dislocation. Another athlete claimed to have had a subluxation during a training session 45 days after the dislocation. 90% of the athletes were able to end the season without any shoulder discomfort. CONCLUSIONS: The dynamic brace combined to the rehabilitation protocol represents the solution that allows a quick start of resumption of training while maintaining a stable pain-free shoulder. LEVEL OF EVIDENCE: Level 4.

Quasi-VMAT in high-grade glioma radiation therapy.

PURPOSE: To compare a quasi-volumetric modulated arc therapy (qVMAT) with three-dimensional conformal radiation therapy (3D-CRT) and intensity-modulated radiation therapy (IMRT) for the treatment of high-grade gliomas. The qVMAT technique is a fast method of radiation therapy in which multiple equispaced beams analogous to those in rotation therapy are radiated in succession. PATIENTS AND METHODS: This study included 12 patients with a planning target volume (PTV) that overlapped at least one organ at risk (OAR). 3D-CRT was planned using 2-3 non-coplanar beams, whereby the field-in-field technique (FIF) was used to divide each field into 1-3 subfields to shield the OAR. The qVMAT strategy was planned with 15 equispaced beams and IMRT was planned using 9 beams with a total of 80 segments. Inverse planning for qVMAT and IMRT was performed by direct machine parameter optimization (DMPO) to deliver a homogenous dose distribution of 60 Gy within the PTV and simultaneously limit the dose received by the OARs to the recommended values. Finally, the effect of introducing a maximum dose objective (max. dose < 54 Gy) for a virtual OAR in the form of a 0.5 cm ring around the PTV was investigated. RESULTS: The qVMAT method gave rise to significantly improved PTV95% and conformity index (CI) values in comparison to 3D-CRT (PTV95% = 90.7 % vs. 82.0 %; CI = 0.79 vs. 0.74, respectively). A further improvement was achieved by IMRT (PTV95% = 94.4 %, CI = 0.78). In qVMAT and IMRT, the addition of a 0.5 cm ring around the PTV produced a significant increase in CI (0.87 and 0.88, respectively), but dosage homogeneity within the PTV was considerably reduced (PTV95% = 88.5 % and 92.3 %, respectively). The time required for qVMAT dose delivery was similar to that required using 3D-CRT. CONCLUSION: These findings suggest that qVMAT should be preferred to 3D-CRT for the treatment of high-grade gliomas. The qVMAT method could be applied in hospitals, for example, which have limited departmental resources and are not equipped with systems capable of VMAT delivery.

Cemented fixed-bearing PFC total knee arthroplasty: survival and failure analysis at 12-17 years.

BACKGROUND: Total knee arthroplasty (TKA) is the appropriate treatment for degenerative pathology of the knee. Implant surveillance is mandatory to improve clinical results. We present the long-term results of a series of consecutive TKA Press Fit Condylar (J&J), cemented fixed bearing with selective patellar resurfacing in nonselected patients. MATERIALS AND METHODS: In this prospective case series, 223 TKA were clinically and radiographically evaluated using the Hospital for Special Surgery (HSS) knee score and the Knee Society Roentgenographic Evaluation and Scoring System. RESULTS: There were 197 patients, with an average age of 68.4 years [95% confidence interval (CI) 52.7-84.1 years]; 49 arthroplasties were implanted in men (21.1%) and 184 (78.9%) in women. The average follow-up was approximately 13.5 years (162.1 months; 95% CI 132.3-191.9), and it was possible to evaluate 179 implants (76.8% of the implanted prosthesis) in 176 patients. The average HSS score increased from 61.5 (95% CI 60.4-62.7) to 89.4 (95% CI 87.7-.93.5) points. The cumulative average survival rate at 15 years (the endpoint being failure with revision) was 90.6%  ± 2% standard deviation. Resurfacing the patella did not make a difference in terms of implant survival. Progressive radiolucent lines were observed around 20 implants (14.3%); all were revised. CONCLUSIONS: The PFC system is an excellent prosthetic solution. Early clinical complications, mechanical axis and patellar resurfacing do not correlate with implant failure, whereas progressive radiolucent lines do.

Arthroscopic treatment of shoulder ochronotic arthropathy: a case report and review of literature.

Alcaptonuria is an inherited hereditary metabolic disorder, which is associated with various systemic abnormalities and related to the accumulation of homogentisic acid and a derived melanine-like pigment in the connective tissues; the latter is termed ochronosis. We present the arthroscopic findings in the shoulder of a 58-year-old female with ochronotic arthropathy and discuss the role of arthroscopy in the diagnosis and management of this rare metabolic disorder.

A Simulator for X-ray images.

A simulator for X-ray images is presented based on a virtual X-ray source and a virtual human body obtained from tomographic slices. In the simulator it is possible to modify the tube potential, the anodic current, the exposure time, the filtration and some geometric parameters such as source-skin distance, orientation and field size. The virtual body consists of a three-dimensional voxel matrix in which CT numbers for each point of the body are stored. The interactions of X rays passing through the body are evaluated using the pencil beam technique. The image is obtained by computing the dose absorbed by the detector and converting it into optical density using a proper response function. The image spatial resolution is limited by the voxel size. The influence of each parameter on the image quality can be observed interactively. The dose absorbed in each point of the body is an important parameter obtained as output of the simulator.

Abnormal RNA expression of 11p15 imprinted genes and kidney developmental genes in Wilms' tumor.

Wilms' tumor (WT) is caused by abnormal development of embryonal kidney cells. WT cells are frequently affected by deletions or functional inactivation of maternal alleles at chromosome 11p15, which indicates that the loss of maternally expressed genes in this region plays an important role in WT pathogenesis. Maternally expressed genes indeed exist within an imprinted region at 11p15.5. Among these, BWR1C is highly expressed in fetal but not in adult kidney, which suggests that it may fulfil an important role in kidney development. Here, we demonstrate that the lack of BWR1C expression is common in WT. Its homology with the proapoptotic gene TDAG51 suggests that the loss of BWR1C expression may be relevant in WT development. In addition, the analysis of the expression of other 11p15 imprinted genes and kidney-developmentally regulated genes indicates that IGF2 overexpression, inappropriate coexpression of RET and GDNF and, in some cases, down-regulation of CDKN1C may also play an important role in the pathogenesis of WT. Our results add new elements to the understanding of the biological basis of WT, which may have implications for WT diagnosis and therapy.

Antitumor activity of taxol (NSC-125973) in human ovarian carcinomas growing in the peritoneal cavity of nude mice.

BACKGROUND: The unique mechanism of action of taxol (NSC-125973) as microtubule stabilizing agent and its potential activity in clinical trials have generated considerable interest in the development of this agent. As taxol was reported to be active on advanced and refractory ovarian carcinomas we focused our studies on the xenograft model of human ovarian carcinoma that develops ascites and tumor dissemination in the peritoneal cavity of nude mice. METHODS: The antitumor activity of taxol was evaluated on two human ovarian carcinoma xenografts (HOC8 and HOC22) transplanted i.p. in nude mice. Drug was given i.v. at doses of 20-34.5 mg/kg every four days three times (Q4 x 3) and the increment of life span (%ILS) was evaluated. Cisplatin at the dosage of 4mg/kg, Q4 x 3 was used as reference drug in each experiment. RESULTS: Taxol given at doses of 20 mg/kg and 34.5 mg/kg to early-stage HOC22 (treatment starting 3 days after tumor transplant) cured all the mice, while the same dose regimens given to advanced HOC22 (treatment starting 14 days after tumor transplant) significantly prolonged the survival time of the mice (ILS = 197% and 300%). Taxol given 3 days after HOC8 transplant significantly prolonged the survival time of tumor-bearing nude mice, inducing complete responses in 50% and 25% of mice receiving, respectively, 34.5 mg/kg/injection and 20 mg/kg/injection. On both ovarian carcinoma xenografts taxol was more active than equitoxic doses of the reference drug cisplatin. CONCLUSIONS: The therapeutic activity against ovarian carcinoma xenografts supports the potential of taxol in the treatment of this neoplasia and forms the basis for future investigations aimed at optimizing the therapeutic activity of taxol given alone or in combination with other drugs.

Tumour levels of O6-alkylguanine-DNA-alkyltransferase and sensitivity to BCNU of human xenografts.

Tumour levels of O6-alkylguanine-DNA-alkyltransferase (O6 AT) and glutathione content (GSH) were correlated with 1, 3-Bis (2-chloroethyl)-1-nitrosourea (BCNU) sensitivity in two human ovarian cancer xenografts (HOC8 and HOC18) and in two human glioblastoma xenografts (HG12 and HG15). HOC8 and HOC18, which were not responsive to BCNU treatment, showed O6 AT levels 14 and 23-fold higher than HG12 that was moderately sensitive to the same BCNU treatment. HG15, which was more sensitive to BCNU than HG12, showed significantly lower O6 AT levels. GSH levels were similar in all tumor xenografts. These data further stress the importance of O6 AT level as a relevant parameter for nitrosourea response in human tumours.

Organ-specific growth of a murine lymphoma of spontaneous origin in nude mice.

The MOC-25 tumour arose spontaneously in a female nude mouse and was established as a continuous line intraperitoneally in nude mice, where it reproduces the topological features of its origin, growing preferentially in the uterus, ovaries and liver. Karyotype analysis showed that MOC-25 cells are hyperdiploid. Tumorigenicity and malignant behaviour were studied by transplanting tumour cells into different sites in nude mice. The comparison of tumour take after i.p. and s.c. injections of scaled concentrations of MOC-25 cell suspension showed preferential growth in the peritoneum. Regardless of the route of implantation (s.c., i.v., i.p.), this tumour rapidly and preferentially disseminated to the liver, uterus, ovaries, spleen and bone marrow. No significant differences in tumour growth and metastatic behaviour were observed when MOC-25 was injected in ovariectomized nude mice or in male nude mice. Morphology studies using light and electron microscopy, immunophenotyping and molecular analysis indicated a B-lymphoid origin of the MOC-25 tumour.

Intraperitoneal and subcutaneous xenografts of human ovarian carcinoma in nude mice and their potential in experimental therapy.

Human ovarian carcinomas (HOC) were established s.c. and i.p. in nude mice and the biological characteristics were investigated for 4 xenografts. HOC8 and HOC18, derived respectively from a primary tumor of the ovary and a pleural effusion (from 2 different patients) were established s.c. in nude mice. HOC10 and HOC22, derived from the ascites of 2 patients, were directly established as ascites after i.p. injection in nude mice. The s.c. and i.p. growth behavior of the 4 HOC lines was investigated. HOC18, HOC8 and HOC22 cells produced progressively growing tumor after s.c. injection but HOC10 ascites would not grow s.c. The cell suspension derived from HOC18 only produced carcinomatosis upon i.p. injection, while HOC8 cells produced both ascites and carcinomatosis. The 2 ascites HOC10 and HOC22 produced ascites in nude mice, but only HOC22 formed i.p. carcinomatosis. Histopathological characteristics of the patients' primary tumors persisted in nude mice, regardless of the site of tumor implantation. DNA histograms of the xenografts closely matched the patients' tumors and remained stable at different passages. Cisplatin, adriamycin and cyclophosphamide given i.v. were tested against HOC8 and HOC18 growing s.c. and HOC22 and HOC10 growing i.p. HOC8 showed a significant response to DDP and almost no sensitivity to ADR and CTX. HOC18 showed only moderate growth delay with all 3 drugs. Mice bearing HOC10 and HOC22 ascites had a prolonged survival time after DDP and ADR treatment.