image: Chronic itch -- known clinically as chronic pruritus -- is characterized as an unrelenting and sometimes even debilitating sensation to itch, and often lowers the quality of life for those who suffer with it. Treating the condition has been difficult because there are few Food and Drug Administration-approved therapies. Now, a recent case study by Johns Hopkins Medicine researchers provides evidence that a promising option for patients with chronic itch may already be available: medical marijuana (cannabis).
JOHNS HOPKINS MEDICINE TEAM TESTS MEDICAL MARIJUANA AS POSSIBLE THERAPY FOR CHRONIC ITCH
Media Contact: Sheree-Monet Wisdom, swisdom1@jhmi.edu
Chronic itch -- known clinically as chronic pruritus -- is characterized as an unrelenting and sometimes even debilitating sensation to itch, and often lowers the quality of life for those who suffer with it. Treating the condition has been difficult because there are few Food and Drug Administration-approved therapies. Now, a recent case study by Johns Hopkins Medicine researchers provides evidence that a promising option for patients with chronic itch may already be available: medical marijuana (cannabis).
A report on the team's findings was published April 9, 2021, in JAMA Dermatology.
"Chronic itch can be an especially difficult condition to treat, with off-label therapeutics often utilized," says Shawn Kwatra, M.D., assistant professor of dermatology at the Johns Hopkins University School of Medicine. "With the increased utilization of medical marijuana and our knowledge of the role of the endocannabinoid system [a complex cell-signaling system that regulates a variety of functions in the body] in chronic itch, we decided to try medical marijuana with a patient who failed several therapies and had few options left."
Kwatra and his colleagues examined an African American woman in her 60s with a 10-year history of chronic itch. The patient initially arrived at the Johns Hopkins Itch Center with complaints of extreme pruritus on her arms, legs and stomach. Upon a skin examination, numerous hyperpigmented, raised skin lesions were revealed. Several treatments were offered to the patient -- including several systemic therapies, centrally acting nasal sprays, steroid creams and phototherapy -- but they all failed.
Kwatra says that using medical marijuana -- either by smoking or in liquid form --provided the woman with nearly instantaneous improvement.
"We had the patient rate her symptoms using a numerical rating scale, where 10 is the worst itch and zero is no itch at all," Kwatra says. "She started at 10 but dropped to 4 within 10 minutes after initial administration of the medical marijuana. With continued use of the cannabis, the patient's itch disappeared altogether."
The researchers believe that one of the active ingredients in medical marijuana, tetrahydrocannabinol -- commonly known by its abbreviation THC -- attaches itself to brain receptors that influence the nervous system. When this occurs, inflammation and nervous system activity decrease, which also could lead to a reduction in skin sensations such as itchiness.
Kwatra says that although conclusive studies have yet to be done to validate medical marijuana as an effective measure for the relief of previously unmanageable itch, he believes it warrants further clinical trials.
"Controlled studies are needed to determine dosing, efficacy and safety for medical marijuana in the treatment of various human itch subtypes, and once those are performed, we will better understand which patients are most likely to benefit from this therapy," he says.
Kwatra is available for interviews.
JOHNS HOPKINS MEDICINE PUTS FAT TO GOOD USE AS STEM CELL SOURCE FOR SPINAL FUSION SURGERY
Media Contact: Michel Morris, melben1@jhmi.edu
Adipose cells, better known as fat, may be the least popular component of the human body. However, most people don't realize that fat actually has many important functions in establishing and maintaining good health -- providing energy, insulating the body against heat loss and protecting nerves, just to name a few. Now, researchers at Johns Hopkins Medicine suggest there's another role for the poor maligned adipose cell: a practical and plentiful source of stem cells for use in spinal fusion surgeries.
Spinal fusion, used to correct problems in the spine, is the "welding" together of two or more vertebrae so that they heal into a single, solid bone. Unfortunately, the surgery -- using bone taken from other parts of the patient's body -- fails in up to one out of every five procedures. Researchers have found that stem cells, harvested from a patient's marrow and allowed to mature into bone cells, can yield successful outcomes when used in spinal fusions. However, the aspiration method for extracting stem cells from the marrow carries a risk of infection and often is painful.
In a study published in the May 2021 issue of the journal Spine, Timothy Witham, M.D., director of the Johns Hopkins Neurosurgery Spinal Fusion Laboratory, Alexander Perdomo-Pantoja, M.D., a postdoctoral fellow at the Johns Hopkins University School of Medicine, and Christina Holmes, Ph.D., a former Johns Hopkins Medicine postdoctoral fellow now at Florida State University, worked together with colleagues to try out adipose cells rather than bone marrow as a source for the stem cells.
Performing spinal fusion procedures in rats, the researchers found that freshly isolated stem cells from fat worked just as well as the more commonly used bone marrow stem cells. The researchers say this suggests the technique could be a candidate for human clinical trials.
"Bone marrow stem cells are isolated in human patients from the hip," says Holmes. "But using a huge needle to take out bone marrow is a painful procedure, and we can only get a limited number of cells, so we've found an alternative source by using stem cells from fat."
Perdomo-Pantoja says spinal fusion procedures are used to treat many different conditions.
"Spinal fusions are used for anything that causes spinal instability, which usually produces significant mechanical pain," he says. "You see it frequently when we get older as the intervertebral discs, ligaments and muscles in the spine deteriorate. But these procedures can also be used to treat instability when it is caused by tumors, fractures, deformities or trauma."
In this study, Witham, Perdomo-Pantoja, Holmes and their team isolated stem cells from fat and bone marrow, and then implanted them into rat spines. For the adipose-derived stem cells, the researchers chose to use freshly isolated cells to see if they could make the procedure simpler and faster.
Currently, stem cells from either bone marrow or fat are frequently grown in a laboratory culture to get them mature enough for a spinal fusion. During culturing, there is some risk of contamination or transformation into unusable bone. Holmes says that freshly isolating cells avoids these problems, along with being less labor intensive and cheaper because expensive processing materials are not needed.
While stem cells from fat are commonly used in cosmetic procedures, they are not often used in spinal fusions, she adds.
"We feel that fat cells are a logical alternative to bone marrow cells because most patients have an adequate supply of fat cells," Witham says. "Fat also is much more accessible during surgery and can be harvested with less stem cell death than bone marrow. Spinal fusion is a very common procedure, and we feel this approach could be applied across a wide cohort of spinal fusion patients."
The researchers also were pleased to see the quality of the bone created by both forms of stem cells. They found significantly more bone formation and blood supply in the fresh adipose-derived stem cells compared with what they observed in previous studies with cultured cells from both fat and bone marrow.
Witham and his team hope to further their research by next identifying which cells are the most advantageous for spinal fusions and then characterizing them.
Witham is available for interviews.
NEW AUTOMATED INSULIN INFUSION SYSTEM MAY POTENTIALLY REDUCE MEDICAL ERRORS, IMPROVE CARE
Media Contact: Marisol Martinez, mmart150@jhmi.edu
Nurses traditionally manage insulin intake for critically ill patients by following precise steps to manually calculate the correct dose for each person. Looking for ways to improve this process, researchers at the Johns Hopkins Armstrong Institute for Patient Safety and Quality recently tested a "smart agent" system that integrates electronic health records and infusion pumps to automate insulin dose selection.
The study showed that Smart Agent -- developed as a joint effort between the Johns Hopkins University Applied Physics Laboratory and the Johns Hopkins University School of Medicine -- may reduce errors and provide faster insulin delivery when compared with manual dosing calculation. In turn, the researchers say, this could free up nurses and clinicians to focus their attention on other patient care priorities.
The findings, published online March 10, 2021, in the journal BMJ Quality & Safety, suggest that a smart agent system could potentially optimize safety and efficiency of insulin infusion practices in intensive care unit settings.
"Glucose management improves outcomes for critically ill patients; however, current insulin infusion protocols are work-intensive for nurses and may be error prone," says study lead author Michael Rosen, Ph.D., M.A., associate professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine.
The current infusion process requires a nurse to manage insulin doses hourly, based on the patient's condition. Because neither the patient's medical record nor the infusion pump's operating data communicate electronically, a nurse is required to first retrieve the patient's blood glucose level from the health record. Then, he or she must manually calculate the medication rate change using an algorithm to determine the new insulin dosage. A second nurse double checks this process before it's documented in the medical record, and finally, the new dose is manually programed into the infusion pump to administer insulin to the patient.
For the study, 20 critical care nurses at The Johns Hopkins Hospital in Baltimore, Maryland, tried a specific smart agent system in a simulation-based setting between May and July 2018. Participants completed 12 mock situations, in four blocks of three scenarios each. Each block was performed with either the manual protocol or Smart Agent.
Nurses were surveyed after each session to get their impressions of safety levels (rates of errors), efficiency (time to complete each task), perceived workload, trust in the system and usability.
The researchers say their findings show that the automated system was significantly better in dosing accuracy calculation compared with manual calculation. In 120 scenarios, nurses never made a calculation error when using the smart agent system compared with 20 errors (16.6%) made using the manual system.
Smart Agent enabled the nurses to complete the process an average of 29 seconds faster than the manual system, along with reducing their overall workload. The tasks that consumed the most time using the manual system were retrieving information from the electronic health record and performing manual calculations -- neither of which is required in a smart agent system. The nurses also found that after using Smart Agent at least twice, they trusted it more than doing the manual calculations.
In general, Smart Agent received positive remarks from all 20 nurses. Most found it to be helpful and more efficient than the manual system, and 18 (90%) found it easier to use. Fifteen (75%) nurses believed that the automated system was safer than the manual process, while five (25%) were unsure or believed both systems were about as safe.
"This approach can be applied to improve a fragmented and inefficient health care IT infrastructure through design, testing and system integration," says senior study author Adam Sapirstein, M.D., associate professor of anesthesiology and critical care medicine at the Johns Hopkins University School of Medicine.
The researchers believe that Smart Agent can serve as a template for similar systems that use algorithms built directly into electronic medical records so that they can be integrated with devices for automatically delivering medication to patients.
This study was done in collaboration with University Hospitals of Cleveland.
Rosen and Sapirstein are available for interviews.