Topical Erythropoietin Accelerates Wound Closure in Patients with Diabetic Foot Ulcers: A Prospective, Multicenter, Single-Blind, Randomized, Controlled Trial.

The diabetic foot ulcer (DFU) is a major disabling complication of diabetes mellitus. Growing evidence suggests that topical erythropoietin (EPO) can promote wound healing. The aim of this study is to clinically assess the efficacy of a proprietary topical EPO-containing hydrogel for treating DFUs. We conducted a randomized, controlled trial in 20 patients with DFUs. After a 14-day screening period, the DFUs of 20 eligible participants who fulfilled the inclusion criteria were randomly assigned (1:1) to either a 12-week of daily treatment with topical EPO and standard-of-care (SOC) or SOC treatment alone. The DFUs were assessed weekly until week 12. The primary outcome was 75% ulcer closure or higher. After 12 weeks of treatment, 75% ulcer closure was achieved in 6 of the 10 patients whose DFUs were treated with topical EPO and in one of the 8 patients whose DFUs were treated with SOC alone. The mean area of the DFUs that were treated with topical EPO and SOC was significantly smaller than those treated with SOC alone (1.2 ± 1.4 cm2 vs. 4.2 ± 3.4 cm2; p = 0.023). Re-epithelialization was faster in the topically EPO-treated DFUs than in the SOC-treated DFUs. There were no treatment-related adverse events. We conclude that topical EPO is a promising treatment for promoting the healing of DFUs. Clinical Trial Registration number: NCT02361931.

Interim Results of the Remede d'Or Study: A Multicenter, Single-Blind, Randomized, Controlled Trial to Assess the Safety and Efficacy of an Innovative Topical Formulation of Erythropoietin for Treating Diabetic Foot Ulcers.

Objective: To inform on the interim results of the Remede d'Or study, which is a prospective, multicenter, single-blind, randomized, controlled clinical study on the safety and efficacy of RMD-G1, a topical carbopol-based hydrogel with a fibronectin matrix whose active pharmaceutical ingredient is erythropoietin (EPO), for treating diabetic foot ulcers (DFU). Approach: The trial will comprise 20 patients with type 2 diabetes mellitus with neuroischemic DFUs who will be randomized into two groups: (1) a control group in which standard-of-care (SOC) will be used to treat the DFUs, and (2) a test group in which SOC and RMD-G1 will be used to treat the DFUs. On day 0, all participants will be randomized to receive either RMD-G1 and SOC treatment or SOC alone. The primary endpoint of the study is complete closure of the DFU within the 12-week study period following daily treatments and dressing changes. Results: Interim results reveal that those DFUs which were treated with RMD-G1 responded positively: there was a significant reduction in the wound areas. In contrast, the condition of those DFUs which were treated with only SOC deteriorated. Innovation: To date, no topical therapies with proven efficacy for treating DFUs exist. Topical application of EPO-based RMD-G1 in conjunction with SOC to a DFU accelerates their healing and closure. Conclusions: The interim results of this trial indicate that topical RMD-G1 is a safe adjunctive therapy to SOC, which accelerates the closure of a DFU. RMD-G1 is safe pharmaceutical because EPO has a proven safety profile.

Topical Erythropoietin Treatment Accelerates the Healing of Cutaneous Burn Wounds in Diabetic Pigs Through an Aquaporin-3-Dependent Mechanism.

We have previously reported that the topical application of erythropoietin (EPO) to cutaneous wounds in rats and mice with experimentally induced diabetes accelerates their healing by stimulating angiogenesis, reepithelialization, and collagen deposition, and by suppressing the inflammatory response and apoptosis. Aquaporins (AQPs) are integral membrane proteins whose function is to regulate intracellular fluid hemostasis by enabling the transport of water and glycerol. AQP3 is the AQP that is expressed in the skin where it facilitates cell migration and proliferation and re-epithelialization during wound healing. In this report, we provide the results of an investigation that examined the contribution of AQP3 to the mechanism of EPO action on the healing of burn wounds in the skin of pigs with experimentally induced type 1 diabetes. We found that topical EPO treatment of the burns accelerated their healing through an AQP3-dependent mechanism that activates angiogenesis, triggers collagen and hyaluronic acid synthesis and the formation of the extracellular matrix (ECM), and stimulates reepithelialization by keratinocytes. We also found that incorporating fibronectin, a crucial constituent of the ECM, into the topical EPO-containing gel, can potentiate the accelerating action of EPO on the healing of the burn injury.

Training to walk amid uncertainty with Re-Step: measurements and changes with perturbation training for hemiparesis and cerebral palsy.

PURPOSE: To describe Re-Step™, a novel mechatronic shoe system that measures center of pressure (COP) gait parameters and complexity of COP dispersion while walking, and to demonstrate these measurements in healthy controls and individuals with hemiparesis and cerebral palsy (CP) before and after perturbation training. METHOD: The Re-Step™ was used to induce programmed chaotic perturbations to the feet while walking for 30 min for 36 sessions over 12-weeks of training in two subjects with hemiparesis and two with CP. RESULTS: Baseline measurements of complexity indices (fractal dimension and approximate entropy) tended to be higher in controls than in those with disabilities, while COP variability, mean and variability of step time and COP dispersion were lower. After training the disabled subjects these measurement values tended toward those of the controls, along with a decrease in step time, 10 m walk time, average step time, percentage of double support and increased Berg balance score. CONCLUSIONS: This pilot trial reveals the feasibility and applicability of this unique measurement and perturbation system for evaluating functional disabilities and changes with interventions to improve walking. Implication for Rehabilitation Walking, of individuals with cerebral palsy and hemiparesis following stroke, can be viewed in terms of a rigid motor behavior that prevents adaptation to changing environmental conditions. Re-Step system (a) measures and records linear and non-linear gait parameters during free walking to provide a detailed evaluation of walking disabilities, (b) is an intervention training modality that applies unexpected perturbations during walking. This perturbation intervention may improve gait and motor functions of individuals with hemiparesis and cerebral plasy.

Intravitreal saline injection ameliorates laser-induced retinal damage in rats.

PURPOSE: Injury to the central nervous system has been shown to trigger a physiologic response in the form of some degree of natural self-repair. This beneficial reaction may be boosted by appropriate preconditioning via a reversible injury to the retina. Here we report the ameliorative effect of intravitreal saline injection on laser-induced retinal damage. METHODS: Standard argon laser lesions (514 and 544 nm, 200 µm, 0.1 W, 0.05 seconds) were induced in the eyes of 36 Dark Agouti pigmented rats and immediately followed by injection of saline either intravitreally (5 µL) or intravenously (0.5 mL). Lesions were evaluated histologically and morphometrically after 3, 20, and 60 days. RESULTS: At all 3 time points, the eyes of rats injected intravitreally showed less laser-induced retinal cell loss (P < 0.05) and smaller lesion diameters (P < 0.05) than those of intravenously injected rats. CONCLUSION: Intravitreal saline injection evidently has a neuroprotective effect on the rat retina. The mechanism of action of this effect should be further elucidated and its clinical applicability tested.

Ameliorative effect of NAP on laser-induced retinal damage.

PURPOSE: NAP is the smallest active element of activity-dependent neuroprotective protein (ADNP) in the non-myelinated neural tissue. This study evaluated the neuroprotective effect of NAP in reducing the spread of laser-induced retinal damage in rat. METHODS: Laser lesions were created in 72 DA pigmented rats. Two groups were treated by one intravenous or intravitreal injection of NAP immediately after exposure to laser. Two control groups were similarly administered saline injection. Histological and morphometrical evaluations of the lesions were preformed 3, 20 and 60 days after photocoagulation. RESULTS: After intravitreal treatment with NAP, a significant reduction in the diameter of the laser-induced lesions was found 3 days after photocoagulation (p < 0.001) but not after 20 and 60 days while the systemic treatment significantly reduced lesion diameter 20 and 60 days after photocoagulation (p = 0.001). Significant difference in photoreceptor cell loss was found in eyes treated intravitreally only 3 days after photocoagulation (p = 0.002). In the systemically treated animals such effect was found only after 20 and 60 days (p < 0.001). CONCLUSIONS: Treatment with NAP ameliorates laser-induced retinal lesions. Intravitreal treatment had an early short-term effect while the effect of systemic administration was delayed and prolonged. This treatment may be of clinical significance in reducing laser-induced retinal injuries in humans.

Effectiveness of motor learning coaching in children with cerebral palsy: a randomized controlled trial.

OBJECTIVE: To evaluate effectiveness of motor learning coaching on retention and transfer of gross motor function in children with cerebral palsy. DESIGN: Block randomized trial, matched for age and gross motor function. SETTING: Coordinated, multinational study (Israel, Jordan and Palestinian Authority) in schools and rehabilitation centers. SUBJECTS: 78 children with spastic cerebral palsy, gross motor functional levels II and III, aged 66 to 146 months. INTERVENTIONS: 1 hr/day, 3 days/week for 3 months treatment with motor learning coaching or neurodevelopmental treatment: two groups. MAIN MEASURES: Gross motor function Measure (GMFM-66), stair-climbing mechanical efficiency (ME) and parent questionnaire rating their child's mobility. Immediate treatment effects were assessed after 3 months and retention determined from follow-up measurements 6 months after treatment. RESULTS: GMFM-66, ME and parent questionnaires were obtained from 65, 31 and 64 subjects, respectively. Although both groups increased GMFM-66 score over 3 months, measurements 6 months later indicated retention was significantly superior by 2.7 in the motor learning coaching children of level-II. Similar retention trend was evident for ME, increasing 6 months after motor learning coaching by 1.1% and declining 0.3% after neurodevelopmental treatment. Mobility performance in the outdoors and community environment increased 13% from 3 to 9 months after motor learning coaching and decreased 12% after neurodevelopmental treatment. Minor group differences occurred in children of level-III. CONCLUSIONS: In higher functioning children with cerebral palsy, the motor learning coaching treatment resulted in significantly greater retention of gross motor function and transfer of mobility performance to unstructured environments than neurodevelopmental treatment.

Development and recovery of laser-induced retinal lesion in rats.

PURPOSE: Laser-induced retinal lesions undergo primary and secondary degeneration followed by a partial reduction of the lesion size. To evaluate treatment effects, detailed data regarding the changes of the lesion over time are essential. The purpose of the study is to describe the histologic changes in an argon laser-induced retinal lesion over a period of 60 days. METHODS: Argon laser lesions were produced in retinas of pigmented rats. The lesions were examined by light microscopy 1 hour and 1, 2, 3, 20, and 60 days after the exposure. RESULTS: The diameter of the lesion increased 24 hours after photocoagulation and then decreased by day 20. Most pyknotic nuclei seen in the outer nuclear layer 1 hour after lasering disappeared 3 days later. Remodeling began 3 days after lasering. By day 60, partial filling in of the empty area with sliding of adjacent nuclei was observed. Recovery was also seen in the other retinal layers. CONCLUSION: The course of a laser-induced retinal lesion is gradual: the photoreceptors are damaged first and the damage then spreads to other layers and to the adjacent retina. By day 3, the damage spreading stops, and adjacent cells begin to fill in and remodel the area of the lesion.

Repeatability of net mechanical efficiency during stair climbing in children with cerebral palsy.

PURPOSE: To determine the smallest significant change in mechanical efficiency (MEnet) measured by a stair-climbing test. METHODS: Duplicate stair-climbing tests (T1 and T2), with more than a 30-minute rest between, were performed by 51 children with diplegic cerebral palsy (CP) at levels II and III of Gross Motor Function Classification System (GMFCS) and 9 children with typical development, aged 5.5 to 13.0 years. RESULTS: The T2 versus T1 slope values of MEnet for CP and typical development did not significantly differ from 1.00. MEnet was significantly higher for GMFCS level II (7.0%) than level III (1.2%). The mean percentage of difference was 7.8% (T2 > T1) for the children with CP, with a 95% confidence interval of -39% to +54%. The 95% confidence interval for MEnet scores computed from the standard error of the mean (SEM) of the percentage of differences was 4.0 to 4.5 for CP. CONCLUSIONS: An increase of >13.4% in MEnet score (eg, mean increase from 4.0% to 4.5%) can indicate improved motor status resulting from interventions.

Ameliorative effect of PN-277 on laser-induced retinal damage.

BACKGROUND: The retinal damage induced by laser photocoagulation increases considerably by the secondary degeneration process whereby tissues adjacent to the primary lesion are destroyed. As the neuroprotective effect of immunization by PN-277 was previously demonstrated in models of retina, optic nerve, brain, and spinal cord lesions, it may be used also for reducing retinal damage induced by laser. The aim of this study was to evaluate the neuroprotective effect of immunization with PN-277 in reducing the spread of laser-induced retinal damage. METHODS: Standard argon laser lesions were created in 36 DA pigmented rats. Seven days before exposure to laser, the rats were divided into a test group (n = 18) that was pre-immunized with intraperitoneal injection of PN-277 and control group (n = 18) treated with saline. Histological and morphometrical evaluations of the retinal lesions were preformed 3, 20, and 60 days after the injury. RESULTS: Significant ameliorative effect was demonstrated in the retinas of the pre-immunized animals 60 days after exposure to laser. The diameter of the lesion was 356 microm as compared with 406 microm (P < 0.01), the cell density of the photoreceptor cell bodies measured in the whole lesion was 72.4% of normal as compared with 64.5% (P = 0.01), and at the center of the lesion it was 57.3% of normal as compared with 38.2% (P < 0.01) (treated and control groups, respectively). CONCLUSIONS: Immunization with PN-277 has an ameliorative effect in neural tissue such as the retina. This type of immunization may be of clinical significance in reducing laser-induced retinal injuries in humans.

Functional efficacy of glatiramer acetate treatment for laser-induced retinal damage in rats.

BACKGROUND AND OBJECTIVES: To functionally evaluate the efficacy of glatiramer acetate (Cop-1) as a neuroprotective treatment for laser-induced retinal injuries in rats. STUDY DESIGN/MATERIALS AND METHODS: Using standard lasering and flash ERG techniques, we evaluated the effect of photocoagulation and of Cop-1 treatment on retinal function 3, 20, and 60 days after covering one-half of the retina with of 23 rats with argon laser lesions. RESULTS: Significant neuroprotective effects of Cop-1 treatment on functional recovery were observed 20 and 60 days after retinal photocoagulation. Two months post-lasering, the amplitude of electroretinographic signals in lasered eyes (mean+/-SEM) was 99.5+/-10.2% of that of intact eyes in the Cop-1-treated group and 85.8+/-5.5% in the untreated lasered control group (P<0.05). CONCLUSIONS: Cop-1 immunization in rats is neuroprotective against laser-induced injuries to the outer retina and improves functional recovery of the injured retina. Studies have documented effective neuroprotective treatment after laser damage to myelinated neurons, but this is the first report of neuroprotection of nonmyelinated neurons.

Prediction of mechanical efficiency from heart rate during stair-climbing in children with cerebral palsy.

Measuring mechanical efficiency (ME) is potentially useful to assess motor performance in individuals with physical disabilities. The purpose of this study was to determine the accuracy of predicting ME from heart rate (HR) during a self-paced stair-climbing test in children with a range of motor abilities. The participants were 12 normally developed children (ND) and 24 with cerebral palsy (CP), ranging in age from 5 to 15 years (mean: 8 years). Five were at level II, 11 at level III and 8 at level IV according to the gross motor function classification system. ME was calculated as the ratio of external work to O(2) uptake (VO(2) ml/min) measured or predicted from HR. The absolute values of VO(2) and HR during stair-climbing were not significantly correlated. However, the correlation between values above resting (dVO(2) and dHR) was significant (r=0.61). Furthermore, when including body weight as a second variable the prediction of dVO(2) was significantly improved (r=0.85). This resulted in a high correlation (r=0.96) between measured and predicted net ME (ME(net)). Predicted ME(net) for 25 stair-climbing tests repeated after an average of 6 months resulted in an r-value of 0.92 with predicted ME(net) of the first test. This study demonstrates that ME(net) during stair-climbing can be predicted in children with a broad range of motor abilities from dHR and may be a simple tool to help define developmental stages or evaluating intervention efficacy.

Functional deficits resulting from laser-induced damage in the rat retina.

BACKGROUND AND OBJECTIVES: To determine the threshold for electrophysiological detection of functional changes after laser photocoagulation in rats, and to correlate the functional damage with retinal morphology. STUDY DESIGN/MATERIALS AND METHODS: Argon-laser lesions, covering a quarter or half of the retina, were produced in the right eyes of 25 rats. Eyes were evaluated by flash electroretinography (ERG) and histologically at 3, 21, and 60 days after lasering. RESULTS: Lasering of half the retina, but not of a quarter, produced a significant decrease in signals at all time points. Some functional recovery was evident 60 days after injury, and was consistent with concurrent morphological healing. CONCLUSIONS: In rats, lasering of half the retina, but not a quarter, leads to significant deficits in outer retinal functions over a 2-month period. Thereafter some recovery occurs, presumably as a result of migration of photoreceptors from undamaged areas and their retinal remodeling.

Comparison of efficacy of Adeli suit and neurodevelopmental treatments in children with cerebral palsy.

This study compared the efficacy of Adeli suit treatment (AST) with neurodevelopmental treatment (NDT) in children with cerebral palsy (CP). Twenty-four children with CP, Levels II to IV according to the Gross Motor Function Classification System (GMFCS), were matched by age and functional status and randomly assigned to the AST or NDT treatment groups. In the AST group (n=12; eight males, four females; mean age 8.3 y [SD 2.0]), six children had spastic/ataxic diplegia, one triplegia and five spastic/mixed quadriplegia. In the NDT group (n=12; nine males, three females; mean age 8.1 y [SD 2.2]), five children had spastic diplegia and seven had spastic/mixed quadriplegia. Both groups were treated for 4 weeks (2 hours daily, 5 days per week, 20 sessions). To compare treatments, the Gross Motor Function Measure (GMFM-66) and the mechanical efficiency index (EIHB) during stair-climbing were measured at baseline, immediately after 1 month of treatment, and 10 months after baseline. The small but significant time effects for GMFM-66 and EIHB that were noted after 1 month of both intensive physiotherapy courses were greater than expected from natural maturation of children with CP at this age. Improvements in motor skills and their retention 9 months after treatment were not significantly different between the two treatment modes. Post hoc analysis indicated a greater increase in EIHB after 1 month (p=0.16) and 10 months (p=0.004) in AST than that in NDT, predominantly in the children with higher motor function (GMFCS Levels II and III). The results suggest that AST might improve mechanical efficiency without a corresponding gain in gross motor skills, especially in children with higher levels of motor function.

A stair-climbing test for ambulatory assessment of children with cerebral palsy.

The purpose of this study was to develop a stair-climbing test to measure energy cost (EC) and mechanical efficiency (ME) in children with cerebral palsy (CP) to evaluate ambulation-related motor function and its changes after intervention or maturation. Five normally developed (ND) and 10 children with CP were tested. The gross ME (MEg) was calculated from the work done (W) and the total energy cost (oxygen consumption) measured while repeatedly ascending and descending four steps for approximately 5 min without subtracting the resting metabolic rate. The MEg was significantly lower in CP than ND (3% versus 20%, P < 0.001). The test was repeated in the 10 children with CP after a 4-month therapy recess. The MEg values correlated with the initial tests, with a small, significant increase of 2%. When calculating net ME (MEn) from W and the energy cost above resting, the correlation of MEn values before and after therapy was inferior to that using MEg values. Similarly, individual ME values obtained by estimating energy cost from the increase in heart rate (HR) during stair-climbing also correlated poorly, with large variability. These results show that MEg may be used to evaluate changes in motor function resulting from age-related development or therapy. MEg is as good or superior to MEn; the extra time required to obtain resting energy cost and heart rate values is not necessary when measurements are desired within the same individual.