A Comprehensive Review of Viscosupplementation in Osteoarthritis of the Knee.

PURPOSE OF REVIEW: The purpose of this systematic review is to discuss emerging evidence in the field of viscosupplementation for chronic knee pain secondary to Osteoarthritis (OA). This review focuses on types of viscosupplementation that are clinically available currently, evidence to support their use, contraindications, and adverse events. RECENT FINDINGS: OA, also known as degenerative joint disease, is the most common form of arthritis in the United States, affecting 54.4 million, or 22.7% of the adult population. The knee is the most common joint affected in OA, with up to 41% involvement, 30% in the hands, and 19% in the hips. The pathophysiology of OA is complex, with contributing factors including mechanical stress to the joint, as well as many person-specific factors such as genetic susceptibility, ethnicity, nutrition, and sex. Treatment modalities include weight control, exercise, non-steroidal and steroidal anti-inflammatory drugs, opioids, intra-articular platelet-rich plasma, placebo, corticosteroid injection, intra-articular viscosupplementation, and surgery. Viscosupplementation consists of injection of hyaluronic acid (HA) into affected joints, intending to restore the physiologic viscoelasticity in the synovial fluid (SF) in the absence of inflammation. HA has also been shown to downregulate pro-inflammatory factors, such as PGE2 and NFkB, and proteases and proteinases known to break down the joint matrix.The contraindications for HA injection are similar to any other injection therapy, and adverse events are usually mild, local, and transient. Viscosupplementation (VS) is effective over placebo and more effective than NSAIDs and corticosteroids in pain reduction and improved functionality; however, guidelines recommend neither for nor against its use, demonstrating variability in the existing evidence base.Current VS options divide primarily into native vs. cross-linked and low-molecular-weight vs. high-molecular-weight. Current treatment options include Hylan g-f-20, Sodium Hyaluronate preparations (Suparts Fx, Euflexxa, Gelsyn-3, Durolane, Hyalgen), single-use agents (Gel-One, Synvisc-One, Monovisc), and Hyaluronan (Orthovisc, Monovisc, Hymovic). They share a common safety profile, and all have evidence supporting their efficacy. Their specific details are reviewed here. SUMMARY: OA is the most common form of arthritis. It is a chronic, debilitating illness with a high impact on the functionality and quality of life of a significant part of the population in the western world. Treatments include medical management, physical therapy, activity modification, injection, and surgery. VS effectively reduces pain, increases functionality, and delays surgery in the knee to treat osteoarthritis. While previous studies have demonstrated variable results, more evidence is becoming available generally supportive of the benefit of VS in the treatment of knee OA.

Adolescent With Acute Liver Failure in the Setting of Ethanol, Cocaine, and Ecstasy Ingestion Treated With a Molecular Adsorbent Recirculating System.

Recreational polypharmacy intoxication is a popular trend, particularly among adolescents and young adults. Acute liver failure is an uncommon complication of drug intoxication and has been described separately among patients intoxicated with ethanol, cocaine, and 3,4-methylenedioxy-methamphetamine (MDMA, ecstasy). Many patients with acute liver failure will die without liver transplant, and management of drug-induced acute liver failure is complicated by the fact that polysubstance abuse may be a contraindication for liver transplant, even among young patients. Here we report a case of acute liver failure in an adolescent male secondary to recreational intoxication with ethanol, cocaine, and ecstasy. This patient was not a candidate for liver transplantation. We describe successful treatment using a molecular adsorbent recirculating system (MARS®) or "liver dialysis" and review the literature pertaining to management options for this type of patient.

A Comprehensive Review of the Celiac Plexus Block for the Management of Chronic Abdominal Pain.

PURPOSE OF REVIEW: Chronic abdominal pain (CAP) is a significant health problem that can dramatically affect quality of life and survival. Pancreatic cancer is recognized as one of the most painful malignancies with 70-80% suffering from substantial pain, often unresponsive to typical medical management. Celiac plexus neurolysis and celiac plexus block (CPB) can be performed to mitigate pain through direct destruction or blockade of visceral afferent nerves. The objective of this manuscript is to provide a comprehensive review of the CPB as it pertains to CAP with a focus on the associated anatomy, indications, techniques, neurolysis/blocking agents, and complications observed in patients who undergo CPB for the treatment of CAP. RECENT FINDINGS: The CAP is difficult to manage due to lack of precision in diagnosis and limited evidence from available treatments. CAP can arise from both benign and malignant causes. Treatment options include pharmacologic, interventional, and biopsychosocial treatments. Opioid therapy is typically utilized for the treatment of CAP; however, opioid therapy is associated with multiple complications. CPB has successfully been used to treat a variety of conditions resulting in CAP. The majority of the literature specifically related to CPB is surrounding chronic pain associated with pancreatic cancer. The literature shows emerging evidence in managing CAP with CPB, specifically in pancreatic cancer. This review provides multiple aspects of CAP and CPB, including anatomy, medical necessity, indications, technical considerations, available evidence, and finally complications related to the management.

Minimally Invasive Treatment of Chronic Ankle Instability: a Comprehensive Review.

PURPOSE OF REVIEW: Chronic ankle pain is a prevalent and significant cause of chronic pain. While the definition of chronic ankle pain is heterogeneous and poorly defined in the literature, systematic reviews and meta-analyses have estimated this condition to be a prevalent and debilitating source of chronic pain. The most identifiable and prominent cause of chronic ankle pain is chronic ankle instability (CAI), a condition defined by instability of the ankle-joint complex. It is a common consequence of lateral ankle sprains or ligamentous injuries and can be described as a failure of the lateral ankle joint complex after an acute, or recurring, ankle injury. The objective of this manuscript is to provide a comprehensive review of CAI diagnosis and our current understanding of minimally invasive treatment options. RECENT FINDINGS: First-line treatment is conservative management, some of which includes neuromuscular rehabilitation, balance training, nonsteroidal anti-inflammatory drugs (NSAIDs), manual mobilization, ice therapy, and compression. While conservative management is effective, additional treatments for those who fail conservative management, or who seek alternative options also have been explored. Recent advances and modern techniques have expanded available treatment options, many of which are becoming less invasive, and have shown improving functionality, recovery, and patient satisfaction. Minimally invasive treatments highlighted in this review include: arthroscopic surgery, steroid injections, plasma-rich plasma injections, hyaluronic acid (HA) injections, medicinal signaling cell injections, radiofrequency therapies, and shockwave therapies. This review will discuss some of these current treatments for minimally invasive treatment of CAI, as well as suggest novel treatments for clinical trials and further investigation.

Gastric Xanthoma in the Pediatric Population: A Possible Herald for Malignancy?

Gastric xanthoma is frequently an incidental finding on upper endoscopy in adults. Gastric xanthomas (GX) can be mistaken for malignancies and warrant prompt histologic diagnosis. The underlying etiology is not fully understood; however, it has been linked to Helicobacter pylori gastritis and gastric cancer. GX in the pediatric population is largely unreported in the literature. Because of the relative rarity, documentation with case reports are essential to provide as much data as possible to see if there is a correlation between GX and malignant potential in the pediatric population. Our group is reporting two cases, a 10-year-old male and a 7-year-old male, both who presented with chronic dysphagia, upper abdominal pain, nausea, vomiting, and loss of appetite. Upper endoscopies for both patients revealed small polypoid lesions located in the antrum with foamy histiocytes on histology, leading to the diagnosis of gastric xanthoma.

Carpal Tunnel Release Surgery- A Systematic Review of Open and Endoscopic Approaches.

CONTEXT: Carpal tunnel syndrome (CTS) is the most frequent peripheral compression-induced neuropathy observed in patients worldwide. Surgery is necessary when conservative treatments fail and severe symptoms persist. Traditional Open carpal tunnel release (OCTR) with visualization of carpal tunnel is considered the gold standard for decompression. However, Endoscopic carpal tunnel release (ECTR), a less invasive technique than OCTR is emerging as a standard of care in recent years. EVIDENCE ACQUISITION: Criteria for this systematic review were derived from Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Two review authors searched PubMed, MEDLINE, and the Cochrane Database in May 2018 using the following MeSH terms from 1993-2016: 'carpal tunnel syndrome,' 'median nerve neuropathy,' 'endoscopic carpal tunnel release,' 'endoscopic surgery,' 'open carpal tunnel release,' 'open surgery,' and 'carpal tunnel surgery.' Additional sources, including Google Scholar, were added. Also, based on bibliographies and consultation with experts, appropriate publications were identified. The primary outcome measure was pain relief. RESULTS: For this analysis, 27 studies met inclusion criteria. Results indicate that ECTR produced superior post-operative pain outcomes during short-term follow-up. Of the studies meeting inclusion criteria for this analysis, 17 studies evaluated pain as a primary or secondary outcome, and 15 studies evaluated pain, pillar tenderness, or incision tenderness at short-term follow-up. Most studies employed a VAS for assessment, and the majority reported superior short-term pain outcomes following ECTR at intervals ranging from one hour up to 12 weeks. Several additional studies reported equivalent pain outcomes at short-term follow-up as early as one week. No study reported inferior short-term pain outcomes following ECTR. CONCLUSIONS: ECTR and OCTR produce satisfactory results in pain relief, symptom resolution, patient satisfaction, time to return to work, and adverse events. There is a growing body of evidence favoring the endoscopic technique for pain relief, functional outcomes, and satisfaction, at least in the early post-operative period, even if this difference disappears over time. Several studies have demonstrated a quicker return to work and activities of daily living with the endoscopic technique.

Trends of Opioid Use Disorder Among Hospitalized Patients With Chronic Pain.

BACKGROUND: Patients with chronic pain treated with opioids are at an increased risk for opioid misuse or opioid use disorder (OUD). Recent years have seen a stark increase in abuse, misuse, and diversion of prescription opioid medications. The aim of this study was to investigate trends in changing rates of opioid use disorder among patients with chronic pain. METHODS: The National Inpatient Sample (NIS) database identified chronic pain admissions with OUD from 2011 to 2015. Patients were identified from the NIS database using International Classification of Diseases (9th and 10th revisions) diagnosis codes for chronic pain and OUD. Annual estimates and trends were determined for OUD, patient characteristics, OUD among subgroups of chronic pain conditions, and discharge diagnosis. RESULTS: We identified 10.3 million patients with chronic pain. Of these, 680,631 patients were diagnosed with OUD. The number of patients with OUD increased from 109,222 in 2011 to 172,680 in 2015 (P < 0.001). Similarly, there were upward trends of OUD among females (53.2% to 54.5%; P = 0.09), patients 65 to 84 years of age (11.8% to 17%; P < 0.001), Medicare-insured patients (39.5% to 46.0%; P < 0.01), patients with low annual household incomes (27.8% to 33.3%; P < 0.001), and patients with cannabinoid use disorder (7.2% to 8.3%; P = 0.01). The prevalence of OUD increased from 2011 to 2015 in patients with chronic regional pain syndrome (5.53% to 7.46%; P = 0.01) and spondylosis (1.32% to 1.81%; P < 0.001). CONCLUSIONS: These findings suggest that the prevalence of OUD increased substantially from 2011 to 2015. Disparities of OUD with increasing opioid use among vulnerable populations including women, those with Medicare insurance, tobacco use disorder, and low annual income should be explored further.

Percutaneous Endoscopic Gastrostomy Tubes May Be Associated With Preservation of Lung Function in Patients With Cystic Fibrosis.

BACKGROUND: Improving nutrition status of patients with cystic fibrosis (CF) has a positive effect on pulmonary function. METHODS: We conducted a retrospective case-control study evaluating the effect of percutaneous endoscopic gastrostomy (PEG) placement on body mass index (BMI) and forced expiratory volume in 1 second percent predicted (FEV1 ) between matched subjects with CF who received PEG (n = 20) and controls who did not (n = 40). RESULTS: We observed that after adjusting for mutation class and baseline BMI, BMI percentile increased per month for those with PEG (0.51, 95% confidence interval (CI) = -0.05-1.08, P = .08), but decreased for those without PEG (-0.03, 95% CI = -0.33-0.28, P = .86); however, the difference (0.54; 95% CI = -0.10-1.18, P = .10) was not statistically significant. FEV1 change with time showed a decrease for patients with PEG (-0.04; 95% CI = -0.30-0.22, P = .74) and those without PEG (-.22; 95% CI = -0.45-0.01, P = .06). Although the decrease for those without PEG was higher than those with PEG, the difference between the groups was not statistically significant (0.18; 95% CI = -0.17-0.52, P = .32) CONCLUSION: Lung function trajectory showed a trend towards preservation among patients with CF who receive PEG despite lack of significant difference in BMI. There may be a favorable effect of PEG on lung function independent of changes in BMI.

Prediction of One-Year Transplant-Free Survival after Norwood Procedure Based on the Pre-Operative Data.

This paper discusses computational modeling of predictive risk factors for neonates undergoing a Norwood surgical procedure, a multi-stage cardiac procedure that restores functional systemic circulation in patients such as neonates with Hypoplastic Left Heart Syndrome (HLHS). In this model, we apply machine learning based binary classication to 549 cases reported by the Pediatric Heart Networks Single Ventricle Reconstruction Trial. We use neural networks classier to predict risk factors for individual patients undergoing a Norwood procedure for the repair of HLHS. Results indicate that independent risk can be calculated with 85% accuracy and 0.94 area under the receiver operating characteristics curve. This model may help physicians provide counseling for families and medically optimize patients prior to surgery by modifying individual risk factors.

A Brief History of the Opioid Epidemic and Strategies for Pain Medicine.

The opioid epidemic has resulted from myriad causes and will not be solved by any simple solution. Consequent to a staggering increase in opioid-related deaths in the USA, various governmental inputs and stakeholder strategies have been proposed and implemented with varying success. This article summarizes the history of opioid use and explores the causes for the present day epidemic. Recent trends in opioid-related data demonstrate an almost fourfold increase in overdose deaths from 1999 to 2008. Tragically, opioids claimed over 64,000 lives just last year. Some solutions have undergone legislation, including the limitation of numbers of opioids postsurgery, as well as growing national prevalence of enhanced recovery after surgery protocols which focus on reduced postoperative opioid consumption and shortened hospital stays. Stricter prescribing practices and prescription monitoring programs have been instituted in the recent past. Improvement in abuse deterrent strategies which is a major focus of the Food and Drug Administration (FDA) for all opioid preparations will likely play an important role by increasing the safety of these medications. Future potential strategies such as additional legislative policies, public awareness, and physician education are also detailed in this review.