Effects of hypertonic dextrose injection in chronic supraspinatus tendinopathy of the shoulder: a randomized placebo-controlled trial.

BACKGROUND: Rotator cuff lesions are common causes of shoulder pain. Although patients with symptoms caused by chronic rotator cuff tendinopathy can be treated using conservative treatments, some of them may still experience refractory symptoms. Hypertonic dextrose prolotherapy (DPT) may be another treatment choice for these refractory symptoms. AIM: The aim of this study was to evaluate the effects of an ultrasound-guided hypertonic dextrose injection for patients with chronic supraspinatus tendinopathy. DESIGN: Randomized double-blind placebo-controlled trial. SETTING: Academic medical center. POPULATION: Outpatients patients (N.=31) with chronic supraspinatus tendinopathy and shoulder pain for more than six months. METHODS: Study group treated with one dose of an ultrasound-guided hypertonic dextrose (20%) injection at the supraspinatus enthesis site, whereas control patients received one dose of 5% normal saline through the same method. The Visual Analog Scale (VAS), Shoulder Pain And Disability Index (SPADI), shoulder active range of motion (AROM) and ultrasonographic thickness and histogram results of the supraspinatus tendon were evaluated before intervention and at two and six weeks after intervention. The outcome differences between the study and control groups were analyzed by using repeated-measures analysis of variance (ANOVA). RESULTS: In total, 31 patients completed the study. The study group indicated a significant improvement in the VAS (P=0.001), SPADI scores (P=0.017), shoulder AROM of flexion (P=0.039), and abduction (P=0.043) compared with the control group at two weeks after the injection. However, the effect did not sustain until six weeks after the injection. No differences in the histograms and morphological changes (thickness) were noted before and after injection in both groups. CONCLUSIONS: This study revealed that the ultrasound-guided hypertonic dextrose injection relieved pain, disability, and improved shoulder AROM for a short period in patients with chronic supraspinatus tendinopathy. CLINICAL REHABILITATION IMPACT: For patients with chronic shoulder pain and supraspinatus tendinopathy, ultrasound-guided hypertonic dextrose injections can provide relief from pain, disability, and shoulder range of motion for up to two weeks after intervention.

Saline irrigation for chronic rhinosinusitis.

BACKGROUND: This review is one of six looking at the primary medical management options for patients with chronic rhinosinusitis.Chronic rhinosinusitis is common and is characterised by inflammation of the lining of the nose and paranasal sinuses leading to nasal blockage, nasal discharge, facial pressure/pain and loss of sense of smell. The condition can occur with or without nasal polyps. Nasal saline irrigation is commonly used to improve patient symptoms. OBJECTIVES: To evaluate the effects of saline irrigation in patients with chronic rhinosinusitis. SEARCH METHODS: The Cochrane ENT Information Specialist searched the ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 9); MEDLINE; EMBASE; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 30 October 2015. SELECTION CRITERIA: Randomised controlled trials (RCTs) with a follow-up period of at least three months comparing saline delivered to the nose by any means (douche, irrigation, drops, spray or nebuliser) with (a) placebo, (b) no treatment or (c) other pharmacological interventions. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. Our primary outcomes were disease-specific health-related quality of life (HRQL), patient-reported disease severity and the commonest adverse event - epistaxis. Secondary outcomes included general HRQL, endoscopic nasal polyp score, computerised tomography (CT) scan score and the adverse events of local irritation and discomfort. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS: We included two RCTs (116 adult participants). One compared large-volume (150 ml) hypertonic (2%) saline irrigation with usual treatment over a six-month period; the other compared 5 ml nebulised saline twice a day with intranasal corticosteroids, treating participants for three months and evaluating them on completion of treatment and three months later. Large-volume, hypertonic nasal saline versus usual care One trial included 76 adult participants (52 intervention, 24 control) with or without polyps.Disease-specific HRQL was reported using the Rhinosinusitis Disability Index (RSDI; 0 to 100, 100 = best quality of life). At the end of three months of treatment, patients in the saline group were better than those in the placebo group (mean difference (MD) 6.3 points, 95% confidence interval (CI) 0.89 to 11.71) and at six months there was a greater effect (MD 13.5 points, 95% CI 9.63 to 17.37). We assessed the evidence to be of low quality for the three months follow-up and very low quality for the six months follow-up. Patient-reported disease severity was evaluated using a "single-item sinus symptom severity assessment" but the range of scores is not stated, making it impossible for us to determine the meaning of the data presented.No adverse effects data were collected in the control group but 23% of participants in the saline group experienced side effects including epistaxis. General HRQL was measured using SF-12 (0 to 100, 100 = best quality of life). No difference was found after three months of treatment (low quality evidence) but at six months there was a small difference favouring the saline group, which may not be of clinical significance and has high uncertainty (MD 10.5 points, 95% CI 0.66 to 20.34) (very low quality evidence). Low-volume, nebulised saline versus intranasal corticosteroids One trial included 40 adult participants with polyps. Our primary outcome of disease-specific HRQL was not reported. At the end of treatment (three months) the patients who had intranasal corticosteroids had less severe symptoms (MD -13.50, 95% CI -14.44 to -12.56); this corresponds to a large effect size. We assessed the evidence to be of very low quality. AUTHORS' CONCLUSIONS: The two studies were very different in terms of included populations, interventions and comparisons and so it is therefore difficult to draw conclusions for practice. The evidence suggests that there is no benefit of a low-volume (5 ml) nebulised saline spray over intranasal steroids. There is some benefit of daily, large-volume (150 ml) saline irrigation with a hypertonic solution when compared with placebo, but the quality of the evidence is low for three months and very low for six months of treatment.

Bolus injection of hypertonic solutions for cerebral edema in rats: challenge of homeostasis of healthy brain.

Hypertonic solutions are mainstay of osmotherapy to cerebral edema. How hypertonic solutions affect healthy brain homeostasis, however, is not fully understood. Using rat model of cerebral edema induced by local cryoinjury, we found with immunohistochemistry that less microglial activation in healthy hemishere 24 h after hypertonic saline (HS, 3% NaCl) administration, compared to mannitol (20%, the same osmotic concentration of 3% NaCl) while dehydrating the brain tissue. To see whether blood-brain barrier (BBB) or aquaporin-4 (AQP4) contribute to this difference, HS or mannitol was intra-arterially injected to normal rats, and BBB opening, ultrastructure and AQP4 immunoreactivity were examined. Evans blue extravasation indicated that BBB was opened much lighter in HS group than mannitol group at the same time points. Electron microscopy also showed edema around the capillaries slightly lighter in HS than mannitol group 24 h after injection. Meanwhile, HS injection led to AQP4 down regulation in expression similarly as mannitol, compared with NS group. These data suggested that bolus injection of hypertonic agents may lead to microglia activation in healthy brain in different extent, due to BBB compromise, instead of water movement or AQP4 expression. Hence in clinical application, BBB of healthy brain should be considered in perspective to maintain the brain homeostasis.

Organum vasculosum laminae terminalis contributes to increased sympathetic nerve activity induced by central hyperosmolality.

The contribution of the organum vasculosum laminae terminalis (OVLT) in mediating central hyperosmolality-induced increases of sympathetic nerve activity (SNA) and arterial blood pressure (ABP) was assessed in anesthetized rats. Solutions of graded NaCl concentration (150, 375, and 750 mM) were injected (150 mul) into the forebrain vascular supply via an internal carotid artery (ICA). Time-control experiments (n = 6) established that ICA NaCl injections produced short-latency, transient increases of renal SNA (RSNA) and mean ABP (MAP) (P < 0.05-0.001). Responses were graded, highly reproducible, and unaltered by systemic blockade of vasopressin V1 receptors (n = 4). In subsequent studies, stimulus-triggered averaging of RSNA was used to accurately locate the OVLT. Involvement of OVLT in responses to ICA NaCl was assessed by recording RSNA and MAP responses before and 15 min after electrolytic lesion of the OVLT (n = 6). Before lesion, NaCl injections increased RSNA and MAP (P < 0.05-0.001), similar to time control experiments. After lesion, RSNA responses were significantly reduced (P < 0.05-0.001), but MAP responses were unaltered. To exclude a role for fibers of passage, the inhibitory GABA-A receptor agonist muscimol was microinjected into the OVLT (50 pmol in 50 nl) (n = 6). Before muscimol, hypertonic NaCl increased RSNA, lumbar SNA (LSNA), and MAP (P < 0.05-0.001). After muscimol, both RSNA and LSNA were significantly reduced in response to 375 and 750 mM NaCl (P < 0.05). MAP responses were again unaffected. Injections of vehicle (saline) into OVLT (n = 6) and muscimol lateral to OVLT (n = 5) each failed to alter responses to ICA NaCl. We conclude that OVLT neurons contribute to sympathoexcitation by central hyperosmolality.

Thermal enhancement of ACNU and potentiation of thermochemotherapy with ACNU by hypertonic glucose in the BT4An rat glioma.

Hyperthermia increases the cytotoxicity of the nitrosourea BCNU (carmustine). Glucose given before treatment may further increase the value of thermochemotherapy, presumably by lowering tumour pH through blood flow reduction. The water-soluble ACNU (nimustine) is an alternative to other nitrosoureas in the treatment of gliomas. The drug is soluble without use of ethanol, and the eye complications when given intra-arterially are reduced compared with similar use of BCNU. The influence of simultaneous hyperthermia on treatment with ACNU, and the value of glucose administered before thermochemotherapy therefore were investigated in the malignant rat glioma BT4An. BD IX rats with subcutaneous BT4An tumours on the hind leg were treated with ACNU (i.p.), or ACNU and locally applied waterbath hyperthermia (44 degrees C for 45 min), with or without previous glucose (6 g/kg i.p. 2 hours before treatment). ACNU (10 or 20 mg/kg) alone and ACNU (20 mg/kg) after previous glucose did not influence tumour growth, compared to the controls. Simultaneous ACNU (10 mg/kg) and hyperthermia clearly was more effective than treatment with hyperthermia alone. Glucose load before treatment further enhanced the effect of combined ACNU and hyperthermia. Glucose before treatment did not change local toxicity or weight profiles of treatment with ACNU alone, or simultaneous ACNU and hyperthermia. Glucose load therefore represented a therapeutic gain when administered before thermochemotherapy with ACNU.

Blood sugar levels during routine fluid therapy of surgical patients.

The study was carried out to investigate the variations in blood sugar values during routine fluid therapy in surgical patients, when the rate of infusion often is very haphazardly adjusted. Surgical patients with normal sugar and fluid balance were divided into two groups. The glucose group (34 patients) was given 5% glucose solution as infusion fluid and the control group (the saline group, 26 patients) received 0.9% physiological saline solution. The preoperative mean value of blood sugar in the glucose group was 4.9 mmol/1 and in the saline group 4.6 mmol/1. Half an hour after the beginning of the operation the blood sugar in the glucose group rose to 7.2 mmol/1 (p smaller than 0.001) and in the saline group to 5.3 mmol/1 (p smaller than 0.01). At the end of the operation the blood sugar values in both groups had further increased significantly from the half-hour levels, in the glucose group to 7.8 mmol/1 and in the saline group to 6.1 mmol/1 (p smaller than 0.01). The difference between the groups, at each test after the initial test, was highly significant throughout (p smaller than 0.001). The result indicates to carefulness in using glucose solutions even during operations lasting 1-2 hours.