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Modern prevention of remodeling of knee joint and the lack of sport functionality by means of electroforesis

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Abstract

The goal of this research was to overview concentration of aceticisalic acid (ASK), applied perorally by electrophoresis (EF) into the knee joint for sport injuries of 8 parachutists with damaged meniscus along with determination of knee width and angle of its movement. The concentration of the given medicine was quantified by methods of liquid-mass spectrometry (HPCL) while by means of meter and gravitational angle-meter the difference was determined according to width of healthy and injured knee and amplitude of movement. Research results were tested by means of Student t-test for small pair of examples, and we observed a significant amount of drug p
139
Glasnik Antropološkog društva Srbije / Journal of the Antropological Society of Serbia
Niš, vol. 47, str. 139-144, 2012, UDK 572(05), ISSN 1820-7936
UDK: 616.728.3-001-085.84:796.071.2 ; 537.363
doi:10.5937/gads1247139D
SAVREMENO SPREČAVANJE REMODELIRANJA KOLENOG
ZGLOBA I AFUNKCIONALNOSTI KOD SPORTSKIH POVREDA
ELEKTROFOREZOM
Slaviša Đurđević
VMI, Vojnomedicinska akademija
Sažetak
Cilj rada je bio sagledati koncentracije acetilsalicilne kiseline (ASK), unete peroralno i
elektroforezom (EF) u koleni zglob kod sportskih povreda 8 padobranaca sa oštećenjem meniskusa uz
određivanje obima kolena i ugla njegove pokretljivosti,. Metodom tečnomasene spektrometrije
(HPCL) kvantikovana je koncentracija leka unetog na oba načina, a uglomerom i pantljikom određivani
su obim zdravog i povređenog kolena i amplituda pokreta. Rezultati istraživanja testirani su
Studentovim t-testom za male parne uzorke, te je zapažena visokosignifikantnija koncentracija leka
p<0,001, unetog jednokratno EF u meniskus u odnosu na petodnevni peroralni unos leka, te viša
koncentracija u sinovijalnoj tečnosti u odnosu na meniskus. Upoređivana je razlika centralnog obima
zdravog i povređenog kolena i amplituda pokreta oštećenog zgloba kod obe grupe ispitanika 5. dana po
EF i zapažena statistički značajnija pokretljiivost i manja razlika obima zdravog u odnosu na povređeno
koleno u grupi sa EF, sa pragovnom značajnošći p<0,005. Zaključak: Elektroforetska aplikacija
medikamenta u koleni zglob, signifikantnije utiče na smanjenje inflamacije i prevenciju anatomskog
remodeliranja zgloba, uz njegovu veću funkcionalnost u odnosu na peroralni unos leka.
Ključne reči : elektroforeza, sportske povrede kolena, remodeliranje
Uvod
Koleni zglob kao značajan hipomohlion biodinamičke poluge donjeg ekstremiteta,
izložen je kod padobranaca jakim silama dinamičkog udara i mikrotrauma, čime se stvara
pogodno tlo za njegovu hroničnu inflamaciju, oštećenje meniskalnih struktura, te anatomsko
remodeliranje i smanjenu funkcionalnost. Zato je iznalaženje načina za umanjenje ove
simptomatologije i znakovnosti od velikog značaja u biomedicinskom, antropološkom i
sportsko-borbenom aspektu (Leopold i sar., 2003).
Jontoforeza ili elektroforeza (EF) predstavlja bezbolan i efikasan način unosa leka
lokalno u tkivo putem galvanske struje, čime se izbegavaju sistemski i neželjeni efekti leka.
Na ovaj način postiže se veća koncentracija leka u ciljnom tkivu, koji je, pored toga, i
reaktivniji zbog jonskog stanja, te u tkivu ostaje duže, u odnosu na peroralni ili parenteralni
put primene (Kalia i sar., 2004).
Pod dejstvom razlike potencijala-napona, vrši se usmereno kretanje jona i dipolnih
molekula, među kojima su i lekovi, ka suprotno naelektrisanoj elektrodi, pri čemu se lek
vezuje za tkivo, ostvarujući brži i duži terapijski efekat. Efekti elektroforezom primenjenog
leka održavaju se do četiri dana. Zbog toga je ovaj način primene leka naročito pogodan u
reumatologiji, kod sportskih povreda, u traumatologiji, neurologiji, dermatovenerologiji,
ginekologiji i šire u kliničkoj praksi. Preduslov da se lek primenjuje jontoforezom jeste da je
on hidrosolubilan, male molekulske mase, i da lako disosuje na jone (Kostić, 2000).
Slaviša Đurđević Savremeno sprečavanje remodeliranja kolenog zgloba...
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Acetilsalicilna kiselina (ASK) po hemijskoj strukturi je ortooksibenzoeva kiselina, sa
analgoantipiretičkim, antiinflamativnim i antiagregacionim delovanjem. Pored ostalih
nestereoidnih antiinflamativnih lekova, ASK se često koristi u tretmanu sportskih povreda,
lečenju zglobnog reumatizma, za brži oporavak kod mišićnog premora u medicini sporta i sl.
(Jezdimirović, 2002; Demirtas i sar., 1998). Ovaj lek ispunjava navedene preduslove da se
primenjuje putem jontoforeze.
Materijal i metode
Istraživanje je izvedeno na 8 pacijenata, sportskih padobranaca, muškog pola, starosti od
27 do 48 godina, koji su obavili preko 500 padobranskih skokova i imali oštećenje
meniskusa kolena dijagnostifikovanog klinički, ultrasonografski i 64-slajsnim skenerom, a
potom patohistološki po ortopedskoj intervenciji artroskopski. Ispitanici su bili podeljeni u 2
grupe. Prvoj grupi od 4 ispitanika per os je aplikovana acetilsalicilna kiselina jednokratno u
dnevnoj dozi od 500 mg 5 dana sukcesivno, dok je drugoj grupi od 4 ispitanika, sa takođe
oštećenom i inflamiranom meniscealnom hrskavicom, jednokratno elektroforezom, jačinom
struje u X=7 mA i trajanjem aplikacije od 20 min. sa katode aplikovana acetilsalicilna
kiselina 500mg u 5 ml redestilovane vode, tj. desetopostotni rasvor. Svi ispitanici su bili
mezomorfne konstitucije po Šeldonu, BMI manjeg od 24 i imali simptome inflamacije,
funkcioleze sa izraženim algezičnim senzacijama, ograničenom pokretljivošću i po
završenom konzervativnom i fizioterapijskom tretmanu bez zadovoljavajućih rezultata.
Na pripremljenu kožu inflamiranih zglobova fiksirane su transverzalno fleksibilne
gumirane ugljenikove elektrode, obložene sa četiri sloja gaze natopljene fiziološkim
rastvorom NaCl. Na katodu, površine 150 cm², naneto je 5 ml 10% rastvora ASK (0,500 g
ASK), rastvorene u redestilovanoj vodi. Površina anode bila je 100 cm². Biološka doza
galvanske struje iznosila je 140 mAmin (7mA x 20 min) (Đurđević, 2001; Meselj, 1943).
Nakon završene EF, urađena je punkcija sinovijalne tečnosti, te biopsični uzorak
hijaline meniscalne hrskavice, pri ortopedskoj intervenciji menicsethomiae artroskopski
izvedene. Uzorci tkiva meniskalne hrskavice kiselom hidrolizom prevedeni su najpre u gel, a
potom u sol stanje. Zatim je metodom tečnomasene spektrometrije (engleska skraćenica
HPLC) određivana koncentracija leka u sinovijalnoj tečnosti kolene pukotine, te hrskavici
meniskusa, tj.u artikularnim tkivima, koja je izražavana u µg/g tkiva (Batheja i sar., 2006).
Za HPLC analizu korišćen je uređaj HPLC WATERS 2695 Aliance system, povezan sa
ZQ masenim detektorom WATERS-Single quuadropo. Proces inflamacije je sagledavan
patohistološki (bojenje preparata hematoksilin-eozinom).
Standardan antropometrijski pokazatelj inflamacije u kliničkom smislu bio je centralni
obim inflamiranog kolenog zgloba u poređenju sa neinflamiranim (razlika obima) kod
svakog ispitanika i njegova amplituda pokreta u smislu fleksije i ekstenzije povređenog
zgloba merena 5. dana po EF.
U statističkoj obradi podataka korišćen je Studentov t-test za male neparne uzorke
(DOS-ov statistički paket), kao i regresiona analiza sa korelacijom. Statistička značajnost
koncentracija medikamenata je postojala ukoliko je p<0,001, a antropometrijskih
parametara: obima kolena i amplitude pokreta (u stepenima), ukoliko je p<0,005.
Rezultati
Najpre su klinički bili sagledani simptomi i znaci traumatsko-inflamatorne lezije
meniskalnih struktura kolena, sa konstatovanim algezičnim senzacijama, redukcijom
amplitude pokreta, krepitacijama te ultrasonografski i multislajsnim skenerom verifikovanim
Slaviša Đurđević Savremeno sprečavanje remodeliranja kolenog zgloba...
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oštećenjem kartilaginoznih struktura meniskusa kolena sa ispoljenim edemom kutisa (obim
zgloba povećan za 3-5 cm), crvenilom, lokalnim porastom temperature, merenoj digitalnim
termometrom (temperatura kože bila je viša u proseku za 1,2°C). Inflamacija je potom
verifikovana i histopatološki. Određivana je razlika centralnog obima povređenog
inflamiranog kolenog zgloba u cm u odnosu na zdrav zglob i njegova amplituda pokreta
(fleksija i ekstenzija) u stepenima po Debruneru, nakon 5 dana od aplikacije leka EF kao
klinička i antropolometrijska obeležja, a rezultati prezentovani u Tabeli 1.
Tabela 1. Centralni obimi kolena i amplitude pokreta kod peroralnog i intavenskog unosa
leka
Table 1. Central width knee end amplitude of movement inperoral and intravenosus
aplication of drugs
Variable
X±SD
t-test
p
Razlika centralnog obima
oštećenog i zdravog kolena u cm
Per os
EF
3.28
<0.005
4,72±0.32
2,42±0.38
Fleksija inflamiranog
kolena u °
103±0.65
115±0.25
3,48
<0.005
Ekstenzija oštećenog
kolena u °
162±0.30
171±0.44
3,39
<0.005
Koncentracija ASK u sinovijalnoj tečnosti i hrskavici pacijenata, koji su peroralno
višednevno uzimali lek radi saturacije u tardžet tkivima, upoređivana je sa koncentracijom
acetilsalicilne kiseline unete jednokratno, jontoforezom u koleni zglob. Pri artroskopskoj
meniscetomiji uzimani su uzorci tkiva radi kvantificiranja medikamenta u njima, sinovijalne
tečnosti (uzorak od 2 ml) i hrskavice meniskusa (po 10 grama biopsičnog debridmana) i
određivana HPCL metodom, te upoređivana koncetracija unetog leka na oba načina
(Đurđević i sar., 2006). Zatim je testirana značajnost razlika koncentracija leka. U Tabeli 2,
prikazana je koncentracija leka uneta per os i elektroforezom, dok je na Dijagramu 1
upoređena koncentracija medikamenta u sinovijalnoj tečnosti i hrskavičavom oštećenom
meniskusu kolena kod pacijenata gde je putem EF unet lek.
Tabela 2. Koncentracija acetilsalicilne kiseline u sinovijalnoj tečnosti unete per os i EF.
Table 2. Concentration ASA in synovial liquid applicated peroral end ionophoretical.
X±SD
t-
test
p
per os
5.80±0.45
EF
61.12±0.32
11.5
<0.001
Slaviša Đurđević Savremeno sprečavanje remodeliranja kolenog zgloba...
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p<0,001
Grafikon 1. Koncentracija acetilsalicilne kiseline u sinovijalnoj tečnosti i hrskavici unete EF
Figure 1. Concentration ASA in synovial liquid end cartilage applicated iontophoretical.
Diskusija
Acetilsalicilna kiselina primenjena jontoforezom vrlo brzo prodire u kožu, potkožno
tkivo i sinovijalnu tečnost oštećenih kolenih zglobova, za razliku od sistemski per os
unetog leka.
Nađene razlike u koncentraciji ASK u koži, sinovijalnoj tečnosti i hrskavici inflamiranih
zglobova mogu da se objasne time što je kartilaginozna struktura periepifizne hrskavice
dublje pozicionirana od kutisa i sinovijalne tečnosti, veće je specifične gustine, čvršće je
konzistencije površinskog sloja hrskavice usled gusto isprepletanog kolagena,
mineralizovanog matriksa sačinjenog od mukopolisaharida, i prisustva hondrocita. Zbog toga
je prodor ASK u hrskavicu znatno slabiji nego u kožu, potkožno tkivo i sinovijalnu tečnost
inflamiranog zgloba (Leopold i sar., 2003).
S obzirom na to da se hijalina periepifizna zglobna hrskavica minimalno hrani preko
slabo razvijene periosealne vaskulature, a većim delom osmotskom perfuzijom iz sinovijalne
tečnosti uslovljenom gradijentom koncentracije, preko koje se vrši i metabolička razmena,
samim tim će i koncentracija ASK u hrskavici narastati u funkciji vremena po prestanku
elektroforetske primene leka, zbog njegove visoke koncentracije u sinovijalnoj tečnosti
(Kalia i sar., 2004).
Posle EF primene ASK postižu se višestruko veće koncentracije leka u zglobnim
strukturama, nego ako se terapijske doze daju sistemski (per os ili parenteralno), pri čemu se
lek duže zadržava i bolje vezuje za ciljno tkivo zbog jonsko-reaktivnije strukture. Pri tome,
izbegavaju se neželjeni i sistemski efekti, postiže se i ušteda ukupne količine aktivne
supstance, što je sve od neprocenjivog medicinskog i ekonomskog značaja i u sportu i u
kliničkoj medicini (Kanikkannan, 2004; Osborne i sar., 2006).
Ujedno dolazi do reverzibilne korisne fluktuacije (smanjenja) obima kolena 5. dana po
EF, povećanja amplitude pokreta i regresije simptomatologije kod EF aplikacije leka,
značajnije nego kod peroralne aplikacije nesteroidnog salicilatnog antireumatika.
0
200
400
600
800
Synovial fluid
Hyaline cartilage
ASA concentration (µg/g of tissue)
ASA
*
Slaviša Đurđević Savremeno sprečavanje remodeliranja kolenog zgloba...
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Zaključak
Koncentracija acetilsalicilne kiseline elektroforezom unete u sinovijalnu tečnost
meniscepatičnog kolena povređenih pacijenata, statistički značajno je viša od koncentracije
ASK u sinovijalnoj tečnosti inflamiranog zgloba unete per os. Koncentracija medikamenta će
rasti u hrskavici u funkciji vremena, usled nivelacije gradijenata koncentracije leka, pošto se
hrskavica hrani uglavnom iz sinovijalne tečnosti procesom osmoze.
Razlika centralnog obima zdravog i povređenog kolena kao antropometrijski pokazatelj
inflamacije i traumatskog oštećenja signifikantno je bila manja 5. dana po EF kod
padobranaca, sa jontoforetskom aplikacijom leka u odnosu na padobrance sa meniskalnom
lezijom kod kojih je peroralno aplikovan nesteroidni antireumatik.
Amplituda pokreta kolena, kako fleksija, tako i ekstenzija, kao validan antropometrijski i
biomehanički parametar, bila je statistički značajnije veća u grupi ispitanika sa
elektroforetskom aplikacijom medikamenta.
Zato se metoda elektroforetske aplikacije leka može predložiti kao metoda izbora kod
sportskih povreda kolena i drugih zglobova i u kliničkoj preksi, čime bi se značajno smanjio
stepen deformiteta istih, te ostvarila uspešnija prevencija njihove funkcionalnosti u
antropološkom, biomedicinskom i kliničkom smislu.
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Slaviša Đurđević Savremeno sprečavanje remodeliranja kolenog zgloba...
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MODERN PREVENTION OF REMODELING OF KNEE JOINT AND
THE LACK OF SPORT FUNCTIONALITY BY MEANS OF
ELECTROFORESIS
Slaviša Djurdjević
Abstract
The goal of this research was to overview concentration of aceticisalic acid (ASK),
applied perorally by electrophoresis (EF) into the knee joint for sport injuries of 8
parachutists with damaged meniscus along with determination of knee width and angle of its
movement. The concentration of the given medicine was quantified by methods of liquid-
mass spectrometry (HPCL) while by means of meter and gravitational angle-meter the
difference was determined according to width of healthy and injured knee and amplitude of
movement. Research results were tested by means of Student t-test for small pair of
examples, and we observed a significant amount of drug p<0, 001, administered per a short
period of time into EF in meniscus compared to a five-day peroral application of the drug,
and therefore higher concentration in synovial liquid compared to meniscus. The difference
between central width of healthy and injured knee and amplitude of movement of injured
joint for both groups of examiners was compared during the period of 5 days according to
EF. We observed statistically significant improvement in movement and smaller difference
in the width of healthy tissue compared to injured tissue of the knee in the group with EF,
with the importance of p<0,005. Conclusion: The distribution of drug by electrophoresis
into the knee joint, significantly affects reducing of inflammation and prevention of
anatomical remodeling of the knee joint, along with its higher functionality compared to
peroral application of drug.
Key words: electrophoresis, sport knee injuries, remodelin
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Transdermal iontophoresis is the administration of ionic therapeutic agents through the skin by the application of a low-level electric current. This article presents an overview of transdermal iontophoretic delivery of drugs, including peptides and oligonucleotides. Recent advances in the area of iontophoretic delivery, including devices, hydrogel formulations, safety, clinical relevance and future prospects, are discussed. Electroporation, another method of electrically assisted drug delivery, is also briefly reviewed. Transdermal iontophoresis appears to be a promising technique for the delivery of a variety of compounds in a controlled and preprogrammed manner. Transdermal iontophoresis would be particularly useful in the delivery of hydrophilic drugs produced by biotechnology (peptides and oligonucleotides). However, because of the complex physicochemical properties of peptides, many factors must be carefully considered for the proper design of an iontophoretic drug delivery system for peptides. Iontophoresis has been successfully used in the delivery of small peptides, such as leuprolide and calcitonin analogues, in humans. However, it appears that transdermal iontophoresis may not be a suitable method for the systemic delivery of larger peptides (>7000D). The combined use of iontophoresis and electroporation may be more effective in the delivery of peptides, proteins, genes and oligonucleotides. The long-term safety of iontophoresis, patient compliance with the technique and the commercial success of this technology are yet to be demonstrated. Iontophoretic delivery of drugs would be beneficial in the treatment of certain skin disorders such as skin cancer, psoriasis, dermatitis, venous ulcers, keloid and hypertrophic scars. Investigations on reverse iontophoresis may yield interesting results that would be useful in the noninvasive measurement of clinically important molecules in the body.
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Although both corticosteroid and hyaluronic acid injections are widely used to palliate the symptoms of knee osteoarthritis, little research involving a comparison of the two interventions has been done. We tested the hypothesis that there are no significant differences between Hylan G-F 20 (Synvisc) and the corticosteroid betamethasone sodium phosphate-betamethasone acetate (Celestone Soluspan) in terms of pain relief or improvement in function, as determined by validated scoring instruments. One hundred patients with knee osteoarthritis were randomized to receive intra-articular injection of either Hylan G-F 20 or the corticosteroid, and they were followed for six months. The patients treated with Hylan G-F 20 received one course of three weekly injections. The patients treated with the corticosteroid received one injection at the time of enrollment in the study, and they could request one more injection any time during the study. An independent, blinded evaluator assessed the patients with the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), a modification of the Knee Society rating system, and the visual analog pain scale. Both the group treated with the corticosteroid and the group treated with Hylan G-F 20 demonstrated improvements from baseline WOMAC scores (a median decrease from 55 to 40 points and from 54 to 44 points, respectively; p < 0.01 for both). The scores according to the Knee Society system did not significantly improve for the patients who received the corticosteroid (median, 58 to 70 points; p = 0.06) or for those who received Hylan G-F 20 (median, 58 to 68 points; p = 0.15). The scores on the visual analog scale improved for patients receiving Hylan G-F 20 (median, 70 to 52 mm; p < 0.01) but not for the patients who received the corticosteroid (median, 64 to 52 mm; p = 0.28). However, no significant differences between the two treatment groups were found with respect to the WOMAC, Knee Society system, or visual analog scale results. Women demonstrated a significant improvement in only one of the six possible outcome-treatment combinations (the WOMAC scale), whereas men demonstrated significant improvements in five of the six outcomes (all measures except the Knee Society rating system). No differences were detected between patients treated with intra-articular injections of Hylan G-F 20 and those treated with the corticosteroid with respect to pain relief or function at six months of follow-up. Women demonstrated significantly less response to treatment than men did for both treatments on all three outcome scales. Such significant gender-related differences warrant further investigation.
Article
The composition and architecture of the stratum corneum render it a formidable barrier to the topical and transdermal administration of therapeutic agents. The physicochemical constraints severely limit the number of molecules that can be considered as realistic candidates for transdermal delivery. Iontophoresis provides a mechanism to enhance the penetration of hydrophilic and charged molecules across the skin. The principal distinguishing feature is the control afforded by iontophoresis and the ability to individualize therapies. This may become significant as the impact of interindividual variations in protein expression and the effect on drug metabolism and drug efficacy is better understood. In this review we describe the underlying mechanisms that drive iontophoresis and we discuss the impact of key experimental parameters-namely, drug concentration, applied current and pH-on iontophoretic delivery efficiency. We present a comprehensive and critical review of the different therapeutic classes and molecules that have been investigated as potential candidates for iontophoretic delivery. The iontophoretic delivery of peptides and proteins is also discussed. In the final section, we describe the development of the first pre-filled, pre-programmed iontophoretic device, which is scheduled to be commercialized during the course of 2004.
Acetylsalicylic acid concentration in synovial fluid and cartilage of inflamed joint in domestic pig after iontophoresis
  • S Đurđević
  • D Milenković
  • A Đurović
Đurđević S, Milenković D, Đurović A. Acetylsalicylic acid concentration in synovial fluid and cartilage of inflamed joint in domestic pig after iontophoresis.Iugoslavica Physiologica et Pharmacologica acta. Beograd. 2006;42(2):123-8.
Istraživanje uticaja fizikalnih agenasa na laktaciju. Doktorska disertacija
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Đurđević S. Istraživanje uticaja fizikalnih agenasa na laktaciju. Doktorska disertacija. Univerzitet u Nišu. 2001;123-138.
Transdermal iontophoresis
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Batheja P, Thakur R, Michaniak B. Transdermal iontophoresis. Expert Opin Drug Deliv. 2006;127-138.
Fizikalna medicina i rehabilitacija
  • O Kostić
Kostić O. Fizikalna medicina i rehabilitacija. Univerzitet u Nišu. 2000;147-158.