Influence of Syringe Volume on Foam Stability in Sclerotherapy for Varicose Vein Treatment.

BACKGROUND: Despite the popularity of sclerotherapy for treating varicose veins, it still exhibits various problems, such as pulmonary embolism, deep-vein thrombosis, phlebitis, and visual disorders. OBJECTIVE: To investigate syringe volume influence on foam stability, obtain the foam decay rule, and provide a reference for clinics. MATERIALS AND METHODS: Five types of syringes are used to prepare foam at room temperature with various liquid-gas ratios. Foam decay process experiments were performed 5 times and recorded by video. The stability indices used include drainage time, half-life, bubble diameter, bubble surface density, and drainage rate. RESULTS: The 30 and 2-mL syringes, respectively, recorded the highest and lowest drainage speeds. Foam drainage time and half-life, differences varied between 15 and 70 seconds, and 20 and 100 seconds, respectively. Foam bubble diameters were distributed over 0.1 to 2.0 mm with roughly 200 to 700 bubbles per square centimeter. CONCLUSION: Increased syringe volume causes the bubble diameter to increase. Thus, foam dispersion increases and foam half-life decreases; hence, foam becomes unstable. It is, thus, better to use a small syringe several times to prepare foam in clinics using segmented injections.

Delivery of sodium morrhuate to hemangioma endothelial cells using immunoliposomes conjugated with anti-VEGFR2/KDR antibody.

Hemangioma is a common benign tumor affecting infants. In this study, we prepared sodium morrhuate immunoliposomes through encapsulation of sodium morrhuate with liposomes coupled with an anti-VEGFR2/KDR antibody and examined its effect on the biology of human hemangioma endothelial cells (HECs). It was found that compared to the liposomal sodium morrhuate group, treatment with sodium morrhuate immunoliposomes facilitated cell detachment and apoptotic death. Confocal microscopy analysis revealed that sodium morrhuate immunoliposomes had a higher binding activity to HECs than liposomal sodium morrhuate. Apoptosis analysis further demonstrated that treatment with liposomal sodium morrhuate or sodium morrhuate immunoliposomes significantly induced apoptosis in HECs, compared to the control group. Western blot analysis revealed an induction of caspase-3 and caspase-9 levels and reduction of caspase-8 and Bcl-2 levels in HECs treated with liposomal sodium morrhuate or sodium morrhuate immunoliposomes. Taken together, these results indicate that sodium morrhuate immunoliposomes have an increased capacity to target HECs and promote mitochondrial apoptosis. Therefore, sodium morrhuate immunoliposomes may represent a promising agent in the treatment of hemangiomas.

Dextrose and morrhuate sodium injections (prolotherapy) for knee osteoarthritis: a prospective open-label trial.

OBJECTIVES: This study determined whether injection with hypertonic dextrose and morrhuate sodium (prolotherapy) using a pragmatic, clinically determined injection schedule for knee osteoarthritis (KOA) results in improved knee pain, function, and stiffness compared to baseline status. DESIGN: This was a prospective three-arm uncontrolled study with 1-year follow-up. SETTING: The setting was outpatient. PARTICIPANTS: The participants were 38 adults who had at least 3 months of symptomatic KOA and who were in the control groups of a prior prolotherapy randomized controlled trial (RCT) (Prior-Control), were ineligible for the RCT (Prior-Ineligible), or were eligible but declined the RCT (Prior-Declined). INTERVENTION: The injection sessions at occurred at 1, 5, and 9 weeks with as-needed treatment at weeks 13 and 17. Extra-articular injections of 15% dextrose and 5% morrhuate sodium were done at peri-articular tendon and ligament insertions. A single intra-articular injection of 6 mL 25% dextrose was performed through an inferomedial approach. OUTCOME MEASURES: The primary outcome measure was the validated Western Ontario McMaster University Osteoarthritis Index (WOMAC). The secondary outcome measure was the Knee Pain Scale and postprocedure opioid medication use and participant satisfaction. RESULTS: The Prior-Declined group reported the most severe baseline WOMAC score (p=0.02). Compared to baseline status, participants in the Prior-Control group reported a score change of 12.4±3.5 points (19.5%, p=0.002). Prior-Decline and Prior-Ineligible groups improved by 19.4±7.0 (42.9%, p=0.05) and 17.8±3.9 (28.4%, p=0.008) points, respectively; 55.6% of Prior-Control, 75% of Prior-Decline, and 50% of Prior-Ineligible participants reported score improvement in excess of the 12-point minimal clinical important difference on the WOMAC measure. Postprocedure opioid medication resulted in rapid diminution of prolotherapy injection pain. Satisfaction was high and there were no adverse events. CONCLUSIONS: Prolotherapy using dextrose and morrhuate sodium injections for participants with mild-to-severe KOA resulted in safe, significant, sustained improvement of WOMAC-based knee pain, function, and stiffness scores compared to baseline status.

Long-term follow-up evaluation of endoscopic sclerotherapy for dilated gastrojejunostomy after gastric bypass.

BACKGROUND: Endoscopic sclerotherapy using sodium morrhuate has been used to treat patients with weight regain after Roux-en-Y gastric bypass whose presumed etiology is loss of restriction due to gastrojejunostomy dilation. Weight loss and stability have been demonstrated in several studies with short-term follow-up evaluation. METHODS: This retrospective review evaluated all the patients who underwent sclerotherapy for a dilated gastrojejunostomy between 2007 and 2012. RESULTS: The study identified 48 patients with a mean follow-up period of 22 months (range 12-60 months). The mean age of these patients was 47.5 ± 10.5 years, and 92 % were women. The average weight loss from the primary procedure was 132.5 ± 54.82 lb, and the average weight regain from the lowest weight to the maximum weight before sclerotherapy was 46 ± 40.32 lb. The median number of sclerotherapy sessions was two (range 1-4). The pre-procedure mean gastrojejunostomy diameter was 20 ± 3.6 mm, and the mean volume of sodium morrhuate injected per session was 12.8 ± 3.7 ml. The average weight loss from sclerotherapy to the final documented weight was 3.17 ± 19.70 lb, which was not statistically significant. The following variables in the multivariate analysis were not associated with statistically significant weight loss: volume of sodium morrhuate, patient age, gastrojejunostomy diameter, number of sclerotherapy sessions, decrease in gastrojejunostomy diameter between the first and second sessions, and number of follow-up years. Weight stabilization or loss was achieved by 58 % of our cohort, with a mean weight loss of 15.9 ± 14.6 lb in this subgroup. CONCLUSION: The long-term follow-up evaluation of patients undergoing sclerotherapy of the gastrojejunostomy for weight regain after gastric bypass showed only a marginal weight loss, which was not statistically significant in our study population, although more than 50 % of the patients achieved weight loss or stabilization.

Chemical synovectomy with sodium morrhuate in the treatment of symptomatic recurrent knee joint effusion.

The aim of this study was to assess the efficacy and safety of intra-articular sodium morrhuate injections in the treatment of recurrent knee joint effusions. Ninety-eight knees of 92 patients (f = 59, m = 33) with knee arthritis of heterogeneous etiology were treated with chemical synovectomy (CSO). Of those, 39 patients suffered from rheumatoid arthritis (RA). The mean follow-up was 29.8 months. Clinical outcome was evaluated by analyzing subjective patient satisfaction, activity level, pain severity on the basis of the Visual Analogue Pain Scale (VAS), Lysholm and Gillquist score, and the Knee Injury and Osteoarthritis Outcome Score (KOOS). Fifty-seven percent of all patients and 67% of patients diagnosed with RA were satisfied with CSO. No significant effects on patient satisfaction by CSO were noted in patients older than 40 years. Overall, VAS, Lysholm and Gillquist score, and KOOS improved significantly at final review. The intra-articular application of sodium morrhuate is an effective and safe measure in the treatment of recurrent symptomatic knee joint effusions in young patients suffering from recurrent knee joint effusions.

Prolotherapy versus corticosteroid injections for the treatment of lateral epicondylosis: a randomized controlled trial.

OBJECTIVE: To compare the efficacy of prolotherapy versus corticosteroid injection for the treatment of chronic lateral epicondylosis. DESIGN: A prospective, randomized controlled, double-blinded study. SETTING: Academic, tertiary, outpatient, rehabilitation hospital. PARTICIPANTS: Twenty-four subjects with clinically determined chronic (ie, lasting 3 months or longer) lateral epicondylosis were recruited. All subjects noted pain intensity levels significant enough to prevent the participation in activities, such as playing racquet sports or lifting heavy objects. METHODS: Subjects were assigned to receive either prolotherapy or corticosteroid injection for treatment of chronic lateral epicondylosis. Each subject underwent injection at baseline followed by a second injection 1 month later. OUTCOME MEASUREMENTS: Visual analog scale (VAS) self-rating of pain, quadruple visual analog scale (QVAS), and the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) were measured at baseline and at 1, 3, and 6 months' follow-up. RESULTS: Within each group, the analysis demonstrated statistically significant improvements in both VAS and DASH within the prolotherapy group with significant changes noted from baseline to 3 months (VAS: Δ2.38; 95% confidence interval [95% CI] 1.04-3.71, P = .004 and DASH: Δ19.89; 95% CI 5.73-34.04, P = .01), and baseline to 6 months (VAS: Δ2.63; 95% CI 0.61-4.62, P = .017 and DASH: Δ21.76; 9% CI 7.43-36.09, P = .009) after initial treatment, as well as in the QVAS from baseline to 3 months. The steroid group demonstrated a clinically and statistically significant change for DASH only at both 3-month (Δ13.33; 95% CI 0.68-25.99, P = .04) and 6-month (Δ15.56; 95% CI 1.30-29.81, P = .04) follow-up. Comparison of the subjects completing the study revealed no significant differences between the prolotherapy and the corticosteroid group for change in VAS, QVAS, or DASH, although the study lacked sufficient power to draw conclusions from this finding. Eighty-three percent of the subjects were satisfied with their overall improvement during the course of the study, without significant differences revealed between groups. Aside from injection-associated pain, no adverse reactions were reported. Seventeen subjects completed study protocol. CONCLUSIONS: Both prolotherapy and corticosteroid therapy were generally well tolerated and appeared to provide benefit of long duration. Small sample size precludes determining whether one therapy is superior to the other. Larger, controlled trials appear feasible and warranted on the basis of these findings.

Targeted long-term venous occlusion using pulsed high-intensity focused ultrasound combined with a pro-inflammatory agent.

Esophageal and gastric varices are associated with significant morbidity and mortality for cirrhotic patients. The current modalities available for treating bleeding esophageal and gastric varices, namely endoscopic band ligation and sclerotherapy, require frequent sessions to obtain effective thrombosis and are associated with significant adverse effects. A more effective therapy that results in long-term vascular occlusion has the potential to improve patient outcomes. In this study, we investigated a new potential method for inducing long-term vascular occlusion by targeting segments of a rabbit's auricular vein in vivo with low-duty-cycle, high-peak-rarefaction pressure (9 MPa), pulsed high-intensity focused ultrasound in the presence of intravenously administered ultrasound microbubbles followed by local injection of fibrinogen and a pro-inflammatory agent (ethanol, cyanoacrylate or morrhuate sodium). The novel method introduced in this study resulted in acute and long-term complete vascular occlusions when injecting a pro-inflammatory agent with fibrinogen. Future investigation and translational studies are needed to assess its clinical applicability.

Ultrasonography in regenerative injection (prolotherapy) using dextrose, platelet-rich plasma, and other injectants.

Recent advances in ultrasound technology are leading physiatrists to new understandings of pain sources, new treatment options, and the ability to guide soft tissue interventions. This article examines the role of imaging ultrasound in diagnosing soft tissue injury and disease that may respond to regenerative medicine techniques (known as prolotherapy) using injectants such as dextrose, morrhuate sodium, or platelet-rich plasma. The current state of ultrasound evidence for these interventions is reviewed. Case examples assist in understanding clinical applications that currently outpace the evidence base. Development of quantitative ultrasound measures to objectively evaluate soft tissue organization is discussed.

Endoscopic sclerotherapy for dilated gastrojejunostomy after gastric bypass.

INTRODUCTION: Roux-en-Y gastric bypass is an excellent option for weight loss in the morbidly obese. Unfortunately, some patients do have weight regain or insufficient weight loss. Revisional bariatric surgery is not without risk. Less invasive techniques may provide alternative treatments for patients that regain weight or have insufficient weight loss. This video demonstrates a technique of endoscopic sclerotherapy for dilated gastrojejunostomy after gastric bypass. METHODS: The technique is applied to patients who have had weight regain or insufficient weight loss following gastric bypass. Patients who have lost the feeling of satiety, undergone reeducation and recounseling of dietary changes, and have documented dilated gastrojejunostomy on upper endoscopy and/or a barium study are offered this technique. If the gastojejunostomy is larger than 12 mm, sodium morrhuate is injected with an endoscopic needle circumferentially. RESULTS: The gastrojejunostomy is injected with 6-30 cc of sodium morrhuate. By visual inspection, the anastomosis usually appears smaller after the procedure. Most patients report a subjective feeling of satiety after the endoscopic sclerotherapy. Reinjection after 3 months has been performed in some patients. Except mild nausea, the patients have experienced no morbidity or mortality from the procedure. CONCLUSIONS: Endoscopic sclerotherapy may offer an alternative treatment for dilated gastrojejunostomy after gastric bypass. The technique described in the video is a relatively easy, safe method that may become the first line of therapy in patients who have a dilated gastrojejunostomy and have lost the feeling of satiety after gastric bypass with an associated weight gain.

Endoscopic sclerotherapy for dilated gastrojejunostomy of failed gastric bypass.

BACKGROUND: Gastric bypass is an effective treatment for morbid obesity and can result in >60% excess weight loss initially. It has been reported that a 10-15% weight regain can occur in these patients. Few options are available to prevent this weight regain. The injection of morrhuate sodium as sclerotherapy has been suggested to decrease the diameter of the gastrojejunostomy anastamosis. METHODS: A total of 71 patients underwent sclerotherapy at their gastrojejunostomy from July 2004 to August 2006. A retrospective review was performed of this group, including chart review, follow-up data with weight checks, and telephone interview findings. RESULTS: The average age of the patients was 45 years, and all but 4 patients were women. Sclerotherapy was done an average of 2.9 years after gastric bypass. The starting weight at endoscopy was an average of 218 lb-18 lb heavier than the average nadir weight. The average diameter of the gastrojejunostomy was 2.3 cm. An average of 13 mL morrhuate sodium was injected circumferentially. Repeat therapy was performed in 35 patients (49%). No hospital admissions or complications occurred in relation to the procedure. During the 12-month follow-up period, 72% of patients maintained or lost weight. The analysis showed a high body mass index (at endoscopy) to be the only predictive factor for successful weight maintenance or loss. CONCLUSION: These results suggest that the use of endoscopic sclerotherapy could stabilize weight gain after gastric bypass. A randomized controlled study is necessary to validate these findings.

[Comparison of the clinical therapeutic effects between local injection of pingyangmycin and sodium morrhuate on oral and maxillofacial venous malformation].

OBJECTIVE: To observe and compare the curative effect of pingyangmycin and sodium morrhuae respectively in the treatment of oral and maxillofacial venous malformation. METHODS: Forty cases of oral and maxillofacial venous malformation were induced in this study, 20 of which were given local injection of low dose of pingyangmycin, and 20 given local injection of 5% sodium morrheate. The therapeutic effects were observed. RESULTS: The effective cases of pingyangmycin was 19, and the effective cases of sodium morrhuate was 12. The side effect was found in 10 cases of, and in 15 cases sodium morrhuate group, the former was mainly pingymangmycin group systemic, the later was mainly local. The difference was significant between the two groups (P < 0.05). CONCLUSIONS: Pingyangmycin is more effective in effective rate and side effect treatment of venous hemangioma than sodium morrhuate.

[Conservative local therapy of inflammation of joints: local invasive forms of therapy]. / Die konservative Lokaltherapie des entzündeten Gelenks: Lokal-invasive Therapieformen.

Local invasive procedures represent possibilities for the treatment of arthritic swollen joints without surgical interventions, when general measures alone are not successful and intra-articular injections are of utmost importance in this context. The differences between degenerative and rheumatologic diseases must be considered as well as possible specific adverse reactions, side effects and contraindications. The technical intervention is performed according to the guidelines of scientific societies such as the Scientific Medical Profession Society (AWMF). Cortisone and radiosynoviorthesis/chemosynoviorthesis are suitable for activated rheumatic and degenerative joints, low-grade radiation therapy or infiltration of hyaluronic acid is recommended for relief in cases of arthritic inflammation. The combination of arthroscopic synovectomy and subsequent radiosynoviorthesis in the early stages of rheumatically swollen joints show the best results with respect to regression prophylaxis and slowing the process of rapidly progressing destruction of chondral surfaces and distension of the capsules and ligaments.

Catheter-directed gastric artery chemical embolization for modulation of systemic ghrelin levels in a porcine model: initial experience.

PURPOSE: To prospectively test, in a porcine model, the hypothesis that use of catheter-directed gastric artery chemical embolization (GACE) can result in substantial suppression of systemic ghrelin levels. MATERIALS AND METHODS: The institutional animal care and use committee approved this study. Adult healthy swine (40-45 kg, n=8) were tested. GACE was performed by infusing morrhuate sodium selectively into the left gastric artery. Six swine (animals A-F) underwent left GACE by using a dose-escalating regimen of morrhuate sodium, whereas two control swine underwent a sham procedure. Weight and fasting plasma ghrelin levels were compared in swine at baseline and at weeks 1-4. At week 4, stomachs were excised and analyzed. Analysis of the change in ghrelin values and weight was performed with both paired t test and unpaired Student t test. RESULTS: In control swine (n=2), there was no significant difference in ghrelin values before (844.8 pg/mL +/- 40 [standard deviation]) and after (997 pg/mL +/- 93) the procedure (P=.5). Swine that received a low dose of morrhuate sodium (animals A-D) showed a significant increase in serum ghrelin values from 683.7 pg/mL +/- 241 to 1555.9 pg/mL +/- 312 (P=.002). At a higher dose, the mean baseline ghrelin values decreased from 466 pg/mL to 187 pg/mL +/- 162. Weight changes of +1.4% and +8.6% were seen in swine that underwent GACE and control swine, respectively. Histochemical staining showed preservation of overall tissue architecture and parietal cells. CONCLUSION: Use of GACE can result in increased or suppressed ghrelin levels.

Weight gain after bariatric surgery as a result of a large gastric stoma: endotherapy with sodium morrhuate may prevent the need for surgical revision.

BACKGROUND: Obesity affects more than 30% of the U.S. population and is associated with the development of life-threatening complications. Numerous therapeutic approaches to the problem have been advocated, including low-calorie diets, anoretic drugs, behavior modifications, and exercise therapy. The only treatment proven to be effective in the long-term management of morbid obesity is surgical intervention. Complications of bariatric surgery include stomal stenosis and/or ulcer and stomal dilation (secondary to overeating). The latter complication can result in a gain of previously lost weight. OBJECTIVE: To determine the effect of endoscopic injection by using a sclerosant (sodium morrhuate) to induce stomal stenosis in patients who present with stomal dilatation complicated by weight gain. DESIGN: Bariatric patients with a large gastric stoma were treated with sodium morrhuate stomal injection. Diameters of the stoma were followed at repeat endoscopy. Weight loss at scheduled clinic visits were compared with pretherapy weights. PATIENTS: Twenty-eight patients (10 men, 18 women; age range, 27-58 years), after bariatric surgery with GI bypass, were referred with weight gain after initial weight loss. Weight gain was believed to be the result of a large gastric stoma. INTERVENTIONS: Treatment included injection of sodium morrhuate (1-2 mL circumferentially) surrounding the stoma. A total of 1 to 3 injection sessions were performed in an attempt to achieve a stoma diameter of 1.2 cm or smaller. MAIN OUTCOME MEASUREMENTS: Treatment success was defined as a decrease of stoma size to or=75% of the weight the patient gained after establishing a steady state post bariatric surgery weight. RESULTS: A total of 2.3 injection sessions were performed. Successful endotherapy was achieved in 18 of 28 patients (64%). One patient developed symptoms of stomal stenosis, which required 2 separate balloon dilating sessions. No other complications were encountered. LIMITATIONS: Retrospective case series. CONCLUSIONS: Endoscopic injection of sodium morrhuate surrounding the dilated gastric stoma complicating bariatric surgery appears to be a successful, less-invasive therapeutic alternative to surgical revision.

Sclerotherapy of oral and facial venous malformations with use of pingyangmycin and/or sodium morrhuate.

Two hundred and sixty patients with oral and facial venous malformations received intralesional injections of either pingyangmycin, sodium morrhuate, or pingyangmycin alternating with sodium morrhuate. Results were rated excellent, good, fair, or poor, depending on clinical outcome. The prevalence of an "excellent" rating in the combined sclerotherapy group (82%) was higher than that in the pingyangmycin group (71%) and the sodium morrhuate group (61%). Swelling and pain following injection were commonly associated with the use of sodium morrhuate. Sclerotherapy with pingyangmycin or sodium morrhuate is an effective and safe treatment for oral and facial venous malformations. Alternate injection of pingyangmycin and sodium morrhuate appears to be more effective for venous malformations than using sclerosant alone.