NYT: Stem Cell Treatments Flourish Despite Evidence

[Doctodd]

I do them in the office because the hospital and ASC are impossibly slow. Interferes with my workouts.

And you are advocating legislation to prevent any dr from doing it in hospital due to costs?

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[lobelsteve]

And you are advocating legislation to prevent any dr from doing it in hospital due to costs?

I advocate legislation to sunset all laws 24 mo after they are enacted.

 

[drusso]

NO one knows how insurances set reimbursement, But come on guy we are talking cash Pay. I don't know this for a fact , but I would guess 95% procedures are cash pay and not through insurance

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"Over the past decade, we have seen healthcare hospital monopolies grow. As a physician, I have been on the ground and sidelines watching as hospitals gobbled up physician practices. Why? To make sure that these practices were using only much higher priced hospital-based services. So the exact same MRI that used to cost a local employer $600 at an outpatient imaging center now costs $3,000 at the hospital. The identical knee surgery that used to run $1,000 at an outpatient ambulatory surgery center now fetches 6K at the hospital. You get the gist of the game. Buy physicians practices and restrict the services they order and offer to the hospital system where the same services cost many times more. Everyone wins, except the patient who is stuck with a big deductible and the employer!"

 

[Doctodd]

outpatient spine MRI's near me are $350.....great quality.

 

[katzen]

Just what pain sufferers need, to be dismissed as crazies and patronized by mental health professionals who have no evidence behind anything they do.

Agreed. I don’t know that all pts want immediate gratification. The problem is that PM often lacks the tools to effectively treat them.

Somatoform complaints are a different story.

 

[drusso]

I wonder how many are putting steroid and/or visco in their prp/stem cell injections. That way the patient actually gets some relief for a period of time and psychologically feels "It worked, but just didn't last. I guess I am just too bad off and need the surgery." That way the doc can claim at least they got some relief for their $5,000, but "The shot worked but your OA is worse than I thought. You do need a knee replacement."

Is that how the scam is done?

Are you seeing good results combing PRP and HA? I'm still on the fence...but, this rat study shows some biological plausibility for the practice.

Cartilage. 2019 Jul 7:1947603519858739. doi: 10.1177/1947603519858739. [Epub ahead of print]
Effect of Combined Leukocyte-Poor Platelet-Rich Plasma and Hyaluronic Acid on Bone Marrow-Derived Mesenchymal Stem Cell and Chondrocyte Metabolism.
Satin AM1, Norelli JB2,3, Sgaglione NA1,2, Grande DA1,2,3.
Author information

Abstract
OBJECTIVE:
Given the potential applications of combined biologics, the authors sought to evaluate the in vitro effect of combined platelet-rich plasma (PRP) and hyaluronic acid (HA) on cellular metabolism.
DESIGN:
Bone marrow-derived mesenchymal stem cells (BMSCs) and chondrocytes were obtained from the femurs of Sprague-Dawley rats. An inflammatory model was created by adding 10 ng/mL interleukin-1-beta to culture media. Non-crosslinked high-molecular-weight HA, activated-PRP (aPRP), and unactivated-PRP (uPRP) were tested. Cellular proliferation and gene expression were measured at 1 week. Genes of interest included aggrecan, matrix metalloproteinase (MMP)-9, and MMP-13.
RESULTS:
Combined uPRP-HA was associated with a significant increase in chondrocyte and BMSC proliferation at numerous preparations. There was a trend of increased chondrocyte aggrecan expression with combined PRP-HA. The greatest and only significant decrease in BMSC MMP-9 expression was observed with combined PRP-HA. While a significant reduction of BMSC MMP-13 expression was seen with PRP and HA-alone, a greater reduction was observed with PRP-HA. MMP-9 chondrocyte expression was significantly reduced in cells treated with PRP-HA. PRP-alone and HA-alone at identical concentrations did not result in a significant reduction. The greatest reduction of MMP-13 chondrocyte expression was observed in chondrocytes plus combined PRP-HA.
CONCLUSIONS:
We demonstrated a statistically significant increase in BMSC and chondrocyte proliferation and decreased expression of catabolic enzymes with combined PRP-HA. These results demonstrate the additive in vitro effect of combined PRP-HA to stimulate cellular growth, restore components of the articular extracellular matrix, and reduce inflammation.
KEYWORDS:
biologics; cellular metabolism; hyaluronic acid; platelet-rich plasma

 

[drusso]

Possible. But, that wasn't his clinical trajectory. And, I couldn't live with myself if I withheld a possibly useful treatment that would preserve his scholarship. Cash price for PRP injection versus 4 years of out-of-state tuition for a working-class farm family? I'd roll the dice on that if I were in his shoes.

Primum Non Nocere.

Here's the clinic telephone log:


6/1/17 pt scheduled for 6/2/17 an

6/2/17 Right elbow PRP with Dr. Drusso

6/27/17 Patient reports thru dad that he has no pain. Dad reports hard to hold patient back. Has been dribbling and shooting a basketball and doing some swimming. They are anxious to start training for baseball. August is an important month for elite baseball playing, performing in front of college scouts. Per Dr. Drusso, should start participating in formal PT, and can "play light catch" with baseball, but absolutely no pitching until August. Information relayed to Dad. cf

8/17/17 11 week f/u; phone message left. Cf

8/30/17 follow-up email sent an

8/31/17 Spoke with dad, Shane is throwing and batting, with no pain. Coach impressed. Starts fall season in two weeks. Back to all regular activities. They are very happy and pleased with the results. cf

8/1/18 1 yr f/u. Patient doing well. Had a good year. Ended the season with an 8-1 record, 0.59 ERA, 129 strikeouts and only 10 walks. an

10/27/19 2 year follow-up: Continues to do well. No injuries this year. Very satisfied and grateful for the treatment outcome.

@lobelsteve @Ducttape

J Sport Rehabil. 2019 Oct 25:1-6. doi: 10.1123/jsr.2018-0174. [Epub ahead of print]
The Use of Platelet-Rich Plasma for Conservative Treatment of Partial Ulnar Collateral Ligament Tears in Overhead Athletes: A Critically Appraised Topic.
Conant BJ, German NA, David SL.
Abstract
Clinical Scenario: Rates of ulnar collateral ligament (UCL) injuries continue to rise in overhead athletes of all ages. Surgical interventions require minimally 6 months and up to 2 years of rehabilitation. Younger athletes and those with partial tears have seen positive results with conservative treatment approaches. Platelet-rich plasma (PRP) continues to be studied with various orthopedic injuries, and its use has the potential to improve return-to-sport rates and reduce recovery time. Focused Clinical Question: Do PRP injections improve conservative treatment outcomes in overhead athletes with partial tears of the UCL compared with conservative treatment alone regarding return to participation? Summary of Search, Best Evidence Appraised, and Key Findings: A literature search was performed to locate all studies investigating outcomes when PRP is included in a conservative treatment program for overhead athletes with partial UCL tears. Three case series qualified and were reviewed. Clinical Bottom Line: Current evidence suggests that including PRP in a conservative treatment program can improve outcomes in overhead athletes with partial UCL tears. Athletes whose treatment included PRP show higher return-to-competition rates and shorter recovery times compared with athletes who used rehabilitation alone. Athletes with grade-1 and proximal-based grade-2 injuries returned to competition at rates comparable with athletes undergoing surgical intervention. For optimal conservative management outcomes, PRP injections should be recommended for treatment of partial UCL tears. Strength of Recommendation: The studies qualifying for inclusion are level 4 evidence based on the 2011 Oxford Centre for Evidence-Based Medicine levels of evidence. The studies are well designed and show consistent results, but higher level studies need to demonstrate similar results to improve the body of evidence. The strength of recommendation is C.
KEYWORDS:
elbow; injury management; rehabilitation; return to play; sports medicine

 

[SommeRiver]

Man...I really wish the spine literature would accumulate for PRP, especially SIJ post lumbar fusion. I can't tell you how many pts I have with an L4-S1 fusion and chronic SIJ pain. I bet I have a few dozen in my practice at least.

 

[lobelsteve]

Level 4. Grade C.

 

[drusso]

Level 4. Grade C.

Population versus people. Ecological fallacy. Did you see my clinical update from an actual human being?

 

[lobelsteve]

I have a patient the fellows implanted in 2005. The leads were coiled up in the pocket around the battery. “It feels so good it is like I am on vacation.” No psychiatric history. Nice late 60’s lady. Should that be a publication or novel technique? N of 1 is N of none. Or in this case N of fun.