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BACKGROUND: Tendinopathies are overuse tendon injuries showing load-dependant pain, stiffness, weakness of movement in the affected area, and impairment in the movements. The scientific interest on the role of Hyaluronic Acid (HA) for the management of tendinopathies has been increased due to its anti-inflammatory and lubricative properties. OBJECTIVE: To collect evidence regarding the effectiveness and safety of HA injections in reducing pain in patients affected by tendinopathies. METHODS: A scientific literature search was conducted using the PubMed, Medline and PEDro electronic databases. The databases were searched since their inception until July 2021. The search was limited to English language articles. Different combinations of the terms and MeSH terms "tendinopathy", "tendinosis", "tendinitis", "hyaluronic acid", "hyaluronate", "infiltration", "hyaluronic injections", "viscosupplementation" connected with various boolean operators were used for other electronic databases. RESULTS: One hundred and one records were identified from the selected databases plus three additional papers identified by the authors through other sources. After removing duplicated papers and title/abstract screening, 19 studies were included in our review (eight papers on shoulder, three on elbow, four on hand, one on knee, and three on ankle). CONCLUSION: The results showed that none of the studies report severe adverse effects and most of them support the use of HA injections in tendinopathies, with a special attention to pain reduction and functional assessment. Further studies are warranted to better investigate effects and methods of administration of HA in tendinopathies. [ABSTRACT FROM AUTHOR]

Background: Blood derivative injections have been recently proposed to address osteoarthritis (OA) with overall positive results, although long-term data on their efficacy are lacking. A novel blood derivative has been developed to concentrate growth factors and antagonists of inflammatory cytokines and shown promising early findings. Purpose: To investigate if the positive effects of a single intra-articular injection of autologous protein solution (APS) in patients affected by knee OA—previously documented at 1 year in a multicenter double-blind randomized saline-controlled trial—last up to 3 years. Study Design: Case series; Level of evidence, 4. Methods: A total of 46 patients with Kellgren-Lawrence 2 or 3 knee OA were randomized into 2 groups: 1 ultrasound-guided APS injection (n = 31) or 1 saline injection (n = 15). At 1 year, the saline group was allowed to cross over. Patients were re-evaluated at 24 and 36 months through the visual analog scale for pain (VAS), Western Ontario and McMaster Universities Osteoarthritis Index Likert 3.1 (WOMAC LK 3.1), Knee injury and Osteoarthritis Outcome Score (KOOS), 36-Item Short Form Health Survey (SF-36), and Outcome Measures in Rheumatology–Osteoarthritis Research Society International (OMERACT-OARSI) responder rate. Magnetic resonance imaging evaluation was performed with the MRI Osteoarthritis Knee Score (MOAKS) before and at 24 months after treatment, and radiographs were assessed per Kellgren-Lawrence before and annually after treatment. Results: In the APS cohort, WOMAC pain improved from 11.5 ± 2.4 (mean ± SD) to 4.3 ± 4.0 at 1 year and to 5.7 ± 5.0 at 3 years (P <.0001 vs baseline). The APS cohort also showed a statistically significant improvement in its KOOS pain score from 39.4 ± 13.1 to 70.6 ± 21.5 at 1 year and to 64.1 ± 24.6 at 3 years (P <.0001 vs baseline) and VAS pain scores from 5.5 ± 2.2 to 2.6 ± 2.5 at 1 year and to 3.4 ± 2.9 at 3 years (P =.0184 vs baseline). VAS pain score significantly worsened from 12 to 36 months (P =.0411). All patients in the saline group decided to cross over to APS, and their final scores were better than baseline, although not significantly better than at the crossover point. Overall, 7 of 26 (26.9%) APS cases and 4 of 14 (28.6%) crossover cases were considered failures as patients underwent further injective treatments or surgical procedures between the 12- and 36-month follow-up. MOAKS findings showed no statistically significant differences. Patients with better cartilage had greater WOMAC pain improvement when their baseline scores were worse, whereas the trend was reversed for patients with cartilage loss at baseline. Conclusion: Intra-articular use of APS for mild to moderate knee OA was safe, and significant pain improvement was documented 3 years after a single injection. Patients with better cartilage status seem to respond better than patients with more cartilage loss, with more clinical improvement even when starting from more painful conditions. Registration: NCT02138890 (ClinicalTrials.gov identifier). [ABSTRACT FROM AUTHOR]

Background. Achilles and patellar tendinopathies are common causes of chronic pain and functional impairment. Conservative management can be effective, but it is time-consuming and it requires intensive patient compliance. Hyaluronic acid (HA) is a key component of the extracellular matrix and its anti-inflammatory, lubricant and analgesic properties are well documented in osteoarthritis. Growing pre-clinical studies indicate a possible role of HA in tendon pathology, while clinical evidences are still lacking. Objectives. The primary objective was to assess the efficacy of a new formulation of HA obtained from biofermentation (Hyalotend® Fidia Farmaceutici, Italy) to improve the clinical symptoms assessed by the VISA-A and VISA-P questionnaires at 90 Days of follow-up. Secondary objectives were to evaluate improvement in pain (NRS-11), US parameters (tendon appearance and neovascularization), and quality of life (EQ-5D). Safety was also evaluated. Methods. This was a prospective, open-label, multicenter clinical trial. Thirty-five patients (26 in AT group; 9 patients in PT group), who satisfied inclusion and exclusion criteria, were recruited during a 4-month period. Each patient received 1 injection weekly for 3 weeks under US-guidance at the painful site, and was evaluated at 14, 45 and 90 days after the procedure. Subjects were instructed to record on a diary any intakes of the permitted rescue medication for pain relief oral paracetamol, up to the "rescue dose" of 3 g/Day (i.e. 6 tablets/Day) throughout the study period and to interrupt treatment at least 24 hours prior to each visit. Results. Significant improvement occurred in both VISA-A (23.22±23.17; 95% CI: 13.20; 33.24; p<.0001) and VISA-P (19.25±11.61; 95% CI: 9.54; 28.96; p=0.0022). NRS-11 score significantly decreased in subjects with AT or PT during the study (p<0.0001 and p=0.0040 respectively). Significant improvement of swelling and tenderness evaluated with US in the AT group was revealed (McNemar's test; p=0.0016 and p=0.0114, respectively), while in the PT group the presence of these clinical symptoms showed only a non-significant tendency to decrease (p=0.3173 for both). The EQ-5D-5L total score increased in both the AT and PT groups (mean change vs. baseline at day 90 equal to 15.96±18.95 (range: -50; 45) and 15.50±32.42 (range: -40; 71), respectively. Seven patients (20.59%) experienced at least one adverse event (AE), all AEs had mild severity. No serious AE or other significant AE leading to study treatment discontinuation or temporary interruption was reported. Conclusions. Three US-guided HA injections may induce prompt improvement in pain and function in mid-portion Achilles and patellar tendinopathies that last until 90 days of followup. Amelioration in tendon structure, neovascolarization and clinical parameters may also be achieved. The treatment is also safe and well-tolerated. [ABSTRACT FROM AUTHOR]

To date, insulin therapy remains the cornerstone of diabetes management; but the art of injecting insulin is still poorly understood in many health facilities. To address this gap, the Forum for Injection Technique and Therapy Expert Recommendations (FITTER) published recommendations on injection technique after a workshop held in Rome, Italy in 2015. These recommendations are generally applicable to the majority of patients on insulin therapy, athough they do not explore alternative details that may be suitable for low- and middle-income countries. The East Africa Diabetes Study Group sought to address this gap, and furthermore to seek consensus on some of the contextual issues pertaining to insulin therapy within the East African region, specifically focusing on scarcity of resources and its adverse effect on the quality of care. A meeting of health care professionals, experts in diabetes management and patients using insulin, was convened in Kigali, Rwanda on 11 March 2018, and the following recommendations were made: (1) insulin should be transported safely, without undue shaking and exposure to high (> 32 °C) temperature environments. (2) Insulin should not be transported below 0 °C. (3) If insulin is to be stored at home for over 2 months, it should be stored at the recommended temperature of 2–8 °C. (4) Appropriate instructions should be given to patients while dispensing insulin. (5) Insulin in use should be kept at room temperature and should never be kept immersed under water. Immersing insulin under water after the vial has been pierced carries a high risk of contamination, leading to loss of potency and likelihood of causing injection abscesses. (6) The shortest available needles (4 mm for pen and 6 mm for insulin syringe) should be preferred for all patients. (7) In routine care, intramuscular injections should be avoided, especially with long-acting insulins, as it may result in severe hypoglycaemia. (8) The practice of slanting the needle excessively should be avoided as it results in sub-epidermal injection of insulin which leads to poor absorption and may cause "tattooing" of the skin and scarring. (9) In patients presenting in a wasted state, with "paper-like skin", injections should, if possible, be initiated with pen injection devices, so as to utilise the 4-mm needle without lifting a skin fold (pinching the skin); otherwise lifting of a skin fold is required, if longer needles are utilised. (10) Reuse of needles and syringes is not recommended. However, as the reuse of syringes and needles is practiced for various reasons, and by many patients, individuals should not be given alarming messages; and usage should be limited to discarding when injections become more painful; but at any rate not to exceed reusing a needle more than 5 times. [ABSTRACT FROM AUTHOR]

Background: Several authors have documented the role of low-molecular-weight heparin injection techniques in bruising. However, few researchers have measured the influence of injection duration on the occurrence and extent of bruising. Purpose: The aim of this study was to evaluate the influence of different durations of subcutaneous heparin injection on the occurrence and extent of bruising. Methods: A quasi-experimental case-crossover study design was adopted in 2010. A consecutive series of patients admitted to 2 orthopedic units in a large (600 beds) teaching hospital located in northern Italy were eligible for enrolment. Injections were administered following a standard procedure. The manipulated variable was the duration of the injection, 10 seconds (treatment A) and 30 seconds (treatment B). The evaluation of bruise occurrence and extension performed after 48 hours and data analysis were conducted in a blinded fashion. Results: A total of 150 patients receiving their first and second subcutaneous heparin injections (300 injections) were enrolled. Eighty-seven bruises were observed out of 300 injections (29%): 57 of 150 (38%) after injections lasting 10 seconds and 30 of 150 (20%) after injections lasting 30 seconds (relative risk, 1.50; 95% confidence interval, 1.21 1.86; P = .00). Of the 87 bruises that occurred, 69 (79.3%) were small (2-5 mm) and 18 (20.6%) were large (>5 mm), with no difference in size between 10- and 30-second injections (relative risk, 0.91; 95% confidence interval, 0.39 2.12; P = .83). Conclusions: Low-molecular-weight heparin injection should be administered over 30 seconds to decrease bruising. Clinical Implications: There is a need to reflect on the feasibility of such a practice because injecting low-molecular-weight heparin at 30 seconds requires accuracy, a steady hand, the absence of tremor, a calm environment, and the ability to administer an infinitesimally small amount of liquid (eg, 0.4 mL) per second. [ABSTRACT FROM AUTHOR]

Objective. The main aim of this study was to investigate the short-term efficacy of CS loco-regional treatment performed under US guidance in tenosynovitis of patients with chronic inflammatory arthritis.Methods. Thirty consecutive patients affected by chronic arthritis and with clinical suspicion of tenosynovitis were recruited to undergo US assessment. In the sonographically proven cases, US-guided CS injection was performed. A visual analogue scale for pain (ranging from 0 to 10) and a tenderness score (ranging from 0 to 3) were used for the clinical evaluation. Sonographic pathological findings indicative of tenosynovitis were scored using a semi-quantitative 4-grade scoring system, for both grey-scale and power Doppler US, at baseline and during a follow-up visit at 2 weeks after the CS injection.Results. In 21 (70%) of 30 patients, the clinical suspicion of tenosynovitis was confirmed (9 with RA, 11 with PsA and 1 with ReA). In the other nine patients, US revealed synovitis of the adjacent joints, bursitis, oedema of the s.c. tissue or a partial tear. In all cases the appropriate needle placement and subsequent CS injection into the tendon sheath were obtained with US confirmation. A significant reduction in all clinical and sonographic scorings was found during the follow-up visit.Conclusions. The present study shows the efficacy of US-guided peritendinous CS injections in the management of patients with chronic inflammatory arthritis presenting as US-proven tenosynovitis. [ABSTRACT FROM PUBLISHER]