Stem Cell Clinic

Precautions After PRP Injections: What to Do and What to Avoid

PRP injections are being used for a growing number of orthopedic injuries and conditions. What is PRP? What are the different types of PRP? Are there precautions after PRP injections that should be followed? Lets dig in.

PRP stands for platelet-rich plasma. This is a concentration of the patients own blood platelets in their serum. Blood is drawn from a peripheral site such as the arm or hand and then spun down in a centrifuge concentrating the platelets. Platelets contain growth factors and chemical mediators which can reduce inflammation, pain, improve blood flow and turbocharge the natural healing process. Current indications for PRP include patellar, hamstring and Achilles tendon injuries, golfers elbow, and mild knee osteoarthritis (1).

Did you know that there are three different types of PRP? Yes, and which one is used is critical to your clinical improvement.

The PRP is actually red in color as it contains both red and white blood cells. This was the first type of PRP available and is produced by older, less advanced centrifuges. A centrifuge is a small tabletop machine that spins the blood which allows for separation and concentration of the blood. Red PRP is typically concentrated to lower levels.

This PRP is actually amber in color and contains few white and red blood cells. It is typically concentrated to lower levels and causes less tissue reaction and swelling.

This PRP is also amber in color and contains few white and red blood cells. It is concentrated to a higher level which is not possible at most clinics as they use bedside centrifuges. At Centeno-Schultz Clinic we understand the importance of having different PRP concentrations to treat different conditions. We have a state of the art laboratory with stem cell scientists that can super concentrate PRP to ensure for your best clinical outcome. Our current publication demonstrates that higher concentrations of PRP are useful for tendon injuries (2).

To better understand PRP and how it functions please click on the video below.

Despite what many websites and clinics recommend, ice should not be used after PRP injections. Inflammation is an important part of the healing process. Ice reduces inflammation and swelling and therefore may compromise the healing process (3). Ice also prompts the blood vessels to get smaller thereby restricting blood flow. Blood flow is critical to healing. One of the precautions after PRP injections is to avoid ice. To learn more about the ligament healing after PRP or stem cell injections please click on the video below.

Rest and healing are important after PRP injections. It is important that the injected PRP be given the opportunity to heal the affected area. In order of this to happen the PRP must be given the opportunity to set in place. Platelets release important growth factors and proteins that promote tissue regeneration and healing. It takes up to seven days for the growth factors to be released from the platelets (4) Exercise may displace and move the PRP from injected site thereby compromising healing and outcome. For example, if your kneecap tendon was injected, running or heavy weightlifting immediately after the injection may result in the PRP being pushed out of the tendon. Rest for the first two weeks followed by the gradual return to normal exercise is ideal closely monitoring pain and swelling. One of the precautions after PRP Injection is to avoid vigorous exercise and weightlifting and rest which will allow the PRP work and promote healing.

Alcohol can negatively affect platelet function. Specifically, it can decrease its platelet activation and aggregation (5) and response to other proteins and enzymes. (6). Alcohol can also affect stem cell numbers and function which may compromise healing. The effectiveness of PRP is based on your own bodys ability to heal. Commit yourself to healthy foods, good sleep and no alcohol for maximal healing.One of the precautions after PRP injections is to avoid alcohol.

PRP is a concentration of the patients own blood platelets in their serum. Platelets contain growth factors and mediators that reduce inflammation, improve blood flow and turbocharge the natural healing process. There are different types of PRP which are available in different concentrations. Precautions after PRP injections include avoiding the use of ice, limiting exercise and alcohol. For the best clinical outcome use heat, rest and adopt a healthy lifestyle.

1. Hussain N, Johal H, Bhandari M. An evidence-based evaluation on the use of platelet rich plasma in orthopedics a review of the literature. SICOT J. 2017;3:57. doi:10.1051/sicotj/2017036

2.Berger DR, Centeno CJ, Steinmetz NJ. Platelet lysates from aged donors promote human tenocyte proliferation and migration in a concentration-dependent manner.Bone Joint Res. 2019;8(1):3240. Published 2019 Feb 2. doi:10.1302/2046-3758.81.BJR-2018-0164.R1

3.Hsu SL, Liang R, Woo SL. Functional tissue engineering of ligament healing.Sports Med Arthrosc Rehabil Ther Technol. 2010;2:12. Published 2010 May 21. doi:10.1186/1758-2555-2-12

4.Golebiewska EM, Poole AW. Platelet secretion: From haemostasis to wound healing and beyond.Blood Rev. 2015;29(3):153162. doi:10.1016/j.blre.2014.10.003

5. Mukamal KJ, Massaro JM, Ault KA, et al. Alcohol consumption and platelet activation and aggregation among women and men: the Framingham Offspring Study. Alcohol Clin Exp Res.2005;29(10):19061912.DOI:10.1097/01.alc.0000183011.86768.61.

6. Olas B, Wachowicz B, Saluk-Juszczak J, Zieliski T. Effect of resveratrol, a natural polyphenolic compound, on platelet activation induced by endotoxin or thrombin. Thromb Res.2002;107(34):141145.DOI:10.1016/s0049-3848(02)00273-6.

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Precautions After PRP Injections: What to Do and What to Avoid

Injections That Could Ease Your Joint Pain Cleveland Clinic

If youre one of the 30 million adults in the United States who live with joint pain, you know its often debilitating. It cankeep you from staying active and even make daily chores seem impossible. What you might not know is that your doctor can treat you with more than pills or surgery.

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Depending on the severity of your pain, injections can be another option for easing your joint pain andget you moving again, sayssports and medical orthopaedist Jason Genin, DO.

In many cases, we use these injections to try to reduce inflammation and pain in your joints, Dr. Genin says. With some treatments, you often can experience fewer symptoms for several months.

There are several injectable options to help treat knee pain. The injections range from corticosteroids, which have been around for decades, to newer cellular therapies like platelet-rich plasma (PRP), he says.

Your physician will decide which one is best based on your individual needs, says sports and medical orthopaedist Dominic King, DO.

Not every injection is right for every patient, Dr. King explains. We take a lot of time to understand your specific issues and create an injectable plan that works with your entire knee care path. This can include weight loss, exercise, stretching, activity modification, anti-inflammatory medications, as well as injection therapy.

Traditional injections, such as corticosteroids (cortisone), can be effective particularly in the late stages of arthritis, as a way to get past a sudden increase in pain and delay the need for surgery.

Hyaluronic acid (HA) injections often are used when corticosteroid injections dont work. But they usually are approved only for use in the knee.

In some instances, doctors consider HA injections first if you dont have obvious signs of inflammation. HA also is a better option if you have diabetes, as corticosteroids can raise blood sugar levels.

Also known as gel injections, HA injections are chemically similar to your natural joint fluid.

When you have osteoarthritis, joint fluid becomes watery. So, this injection helps to restore the fluids natural properties and works as a lubricant and a shock absorber.

HA is a cushion or a buffer against inflammatory cells in the joint, Dr. Genin says. In some cases, it can stimulate the knee to start producing more natural HA. Some physicians also believe that HA helps reduce pain by coating nerve endings within the joint.

One treatment, which may consist of between one and three injections, usually offers symptom relief for four to five months, but sometimes up to one year. However, pain and stiffness will return. Most insurance companies only approve one HA injection every six months.

Platelet-rich plasma (PRP) injectionsare a newer alternative to treat osteoarthritis joint pain. Cells from the patients own blood are processed in a centrifuge to remove red blood cells and most white blood cells, concentrating the platelets. A growing body of evidence has shown that PRP can be as effective or more effective than anti-inflammatory medications or cortisone, particularly in the early stages of arthritis, Dr. Genin adds.

Side effects include a very low risk of infection and pain at the injection site. You also must stop taking oral anti-inflammatory medications for a short amount of time if you get a PRP injection, Dr. Genin says.

Often, many of these injections are effective in reducing or stopping your joint pain, but its important to remember that they may not keep the pain from returning, Dr. King notes. In fact, theyre most effective when used with other therapies. And we consider surgical options only if other treatment options have failed.

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Injections That Could Ease Your Joint Pain Cleveland Clinic

Treatment of diabetic foot ulcer in France | CEOR

Introduction

Chronic non-healing ulcer is a major health problem and its prevalence in the world ranges from 1.9 to 13.1%.1,2 The incidence of chronic ulcers is expected to increase as the population ages and the risk factors for atherosclerotic occlusion such as smoking, obesity and diabetes are increasing. One of the main causes of non-healing ulcer is diabetes. Diabetic foot ulcer (DFU) is diagnosed in 1218% of patients with type 2 diabetes and in 0.62% of patients with type 1 diabetes.3 In addition, 70% of these patients are diagnosed with peripheral neuropathy.4,5 Diabetic chronic wounds lead to pain, discomfort, infection, consultations, dressings, hospitalizations, sequelae, sick leave, and poor quality of life. Individuals with diabetic foot ulcers are susceptible to infection and the healing process is complicated by diabetic neuropathy leading to chronic non-healing ulcers. Consequently, an estimated 12% of individuals with diabetic foot ulcer require lower extremity amputation.3,8,9

Moreover, chronic ulcers also represent a substantial financial burden for the patient and the healthcare system.6,7 The Eurodiale study analysed the direct and indirect annual costs in several European countries (in 14 European centres including Spain, France, the UK, Czech Republic, Germany, Denmark, Sweden and Italy) with a total of 821 patients with DFU. The mean annual cost per patient was 10,091, hospitalization being the most relevant direct cost.10 In the UK, the mean NHS cost of wound care over 12 months was estimated at 7800 per DFU (of which 13% was attributable to amputations), ranging from 2140 to 8800 per healed and unhealed DFU, respectively, and 16,900 per amputated wound.11 The main element (around 20%) of total spending is complications related to DFU.12 In the US, DFU accounted for 83% and 96% of all major and minor amputations related to foot ulcers, respectively, and significantly increased cost of care (DFU: $1.38 vs non-DFU: $0.13 billion/year; p <0.001).13 Therefore, it is important to evaluate strategies that can ensure better prevention and management of this type of wound to lower the number of amputations.

The goal of ulcer treatment is to obtain wound closure as expeditiously as possible. Conventional treatment for non-healing ulcers includes wound cleansing, necrotic tissue debridement, prevention, diagnosis, and, if necessary, treatment of infection, mechanical off-loading, management of blood glucose levels and local ulcer care with dressing application.3,14 Therapeutic procedures to manage DFU are fundamentally based on an adequate covering of the wound, early treatment of the infection, and relief of pressure, with a probability of healing being close to 60% in 1 year. Despite treatment, many chronic ulcers fail to heal or persist for months/years and/or recur after healing, requiring additional advanced wound care therapies for adequate healing. At 31 months follow up, diabetic foot ulcers have around a 40% of recurrence and 12.3% were not healed at the end of the follow-up period.1517 Moreover, at 3 years there is evidence of a 10% to 20% rate of amputations.15,18,19,44

It has been demonstrated that plasma growth factor (PGF) such as platelet derived growth factor (PDGF) significantly shortens treatment duration and leads to healing in approximately 80% of wounds.2024 Many authors2024 found that platelet release has improved healing rates if compared with standard remedies. On the other hand, other studies20,21 found no major difference in healing outcome of leg ulcers, between treatment groups with platelet release and control groups (placebo). An extensive review was performed by Picard et al 2015. They carried out a PubMed and Cochrane search (19782015) including all studies assessing the clinical effect of platelet-rich plasma (PRP) on the healing of diabetic chronic wounds. The screening retrieved 7555 articles and 12 studies were included. Of six randomized studies included, five found significant benefits for the use of PRP on diabetic chronic foot ulcers. The authors concluded that 87.5% of controlled studies found a significant benefit for the adjunction of PRP to treat chronic diabetic wounds. As PRP may be beneficial, they suggest using it on diabetic ulcers which remain unhealed after standard treatment.25 The most recent meta-analyses and review articles have highlighted the therapeutic potential of PRP in chronic wounds with demonstrated benefits in several clinical outcomes, notably complete wound closure, wound surface reduction, scar reduction, and a lowering of incidence of infections.2634

The clinical results of PRP effectiveness in the treatment of DFU are promising considering, however, that the costs associated with treating DFUs with PRP are presumably higher than using standard therapy. Therefore, the implementation of this therapeutic approach in health systems should be based on its cost-effectiveness. Only a few studies have directly dealt with the relationship between the costs and the results of PRP versus standard care and, in addition, no economic evaluations in parallel with clinical studies have been reported. Two studies prior to 2014 found PRP treatment being cost-effective or even dominant compared with usual care.22,35,36 Recently, Linertov et al found that, in a 5-year time horizon, PRP treatment for DFU could be considered a cost-effective or even a cost-saving alternative in Spanish healthcare settings, depending on the method of obtaining the PRP (commercial kit versus manual method) and, to a large extent, on the price of the kit used. As a consequence, these authors called for future studies on the effectiveness and costs of specific devices or methods to be used as inputs for more specific cost-effectiveness models.37 The objective of this study is to close the gap through a cost-effectiveness analysis, with a 1-year time horizon, of a specific PRP preparation procedure for the treatment of DFU versus standard of care accounting for cost using a micro-costing approach. In order to collect detailed data on resource use, material costs and professional time spent on care, our analysis was conducted alongside a clinical study (Le Creusot study, France).38 This paper provides more specific evidence and insights for clinical and managerial decision making exploiting a French setting.

A randomized controlled trial to evaluate the safety and efficacy of autologous platelet-rich plasma (PRP) gel for stimulating wound healing in chronic deep diabetic foot ulcers (3 A stage according to UT classification) was performed at the Fondation Htel-Dieu hospital in Le Creusot, France. N=86 diabetic patients were randomized either to best standard of care (SoC) alone or PRP treatment combined with SoC. Good standard of care was used when appropriate and included debridement, infection control, comorbidities management and off-loading. The two arms were comparable at baseline for age, presence of a neuropathy, antiaggregant treatment, and depth and surface of wounds.38

In PRP treatment, gel is obtained from patients blood by getting a platelet-rich, leukocyte-poor plasma using Regenkit (RegenLab, Switzerland). The commercial kit consists of 3 tubes (2 BCT and 1 ATS) that are used to produce a PRP gel.

This is an outpatient clinical protocol: after a 2-week run-in period, if no reduction of wound surface >20% was observed, patients were randomized (PRP gel application or control SoC treatment). Patients were treated for 6 weeks maximum (less in case of wound closure). PRP gel arm patients could receive more than one gel application upon investigator decision. Primary efficacy endpoint for wound closure was measured at 6 weeks. Efficacy was also evaluated at follow-up visits at 9 and 12 weeks.

For the PRP arm, only protective compress change was done at home once weekly, while for the control group the dressing change was performed at home once daily.

Forty-six patients were randomized to the PRP gel treatment and 40 to the SoC alone arm. All patients were neuropathic, with deep ulcers mostly located on toe and metatarsal, but also heel and plantar vault. Chronic wound duration was on average more than 6 months.

In terms of results observed at 6 weeks after initiation of treatment, PRP arm shows a complete wound closure in 56.5% of patients versus 20.0% in control group, with a statistically significant difference (p 0.001). Similarly, PRP arm reaches 77.3% wound closure at 12 weeks versus 35.7% for SoC control group. During the study, data on resource use and costs were collected. In particular, the authors picked for both arms material usage, professional time spent on care and costs for each activity.

The cost-effectiveness analysis was performed using a Markov model, with a hypothetical cohort of patients with chronic DFU (duration of >3 weeks) with high orthopaedic risk and with ulcers graded 3A (UT classification), meaning deep ulcers down to the bone, including tunnelling and perforating wounds.

Using a decision-analytical model, we defined a structure and within it could insert evidence from this specific clinical study's outcomes (Le Creusot study) as well as from the literature to generalize the results. The advantage of using Markov model is that it is flexible, particularly adapted for modelling chronic diseases spreading over months or years, and deals with ongoing risks and events that might happen more than once over time (recurrence).

The first step was to define DFUs in terms of mutually exclusive states, including all relevant health outcomes, with movement between these states based on transition probabilities. In this study, the Markov model contained six possible health states (2 temporary states, 3 standard states, 1 absorbing state): (1) DFU (first) complete treatment; (2) persistent DFU; (3) completely healed DFU; (4) amputation; (5); post-amputation; and (6) death from any cause and because of surgery (see Figure 1). At the beginning of the model, patients with DFUs would receive the first treatment according to one of the following strategies: PRP combined with best SoC or Soc alone. Hypothetical patients started in state 1 and moved into predefined health states. Each clinical state had an associated cost and effectiveness estimate. Hypothetical patients accumulated costs and QALYs associated with the time spent in each clinical state during the simulated 3-month period. The cycle length was 1 week and the time horizon was 1 year.

Figure 1 Markov model of diabetic foot ulcer. States are identical for usual and PRP care.

In the first state, patients receive their first complete treatment. The first state is a temporary state, therefore patients receive value of cost and utilities for the first treatment and then go with a 100% probability to the second state. In state 2 (persistent DFU), they receive the weekly care. For PRP treatment, there is a certain probability of needing a new complete treatment that is more costly than the weekly care. We modelled the necessity of some patients having more than one complete treatment using a transient event rather than a state. Therefore, we used transition rewards so that a one-time cost was associated with a patient having a second treatment. Although the need of a new treatment is not a state itself, and it has no effect on state transition, it may have costs (and/or disutilities) associated with it. For traditional care, this possibility is not allowed since the dressing change is performed daily until the wound is healed.

In state 2, for PRP arm, the home nurse opens the dressing and checks the cleanliness of the primary dressing (according to Le Creusot study protocol, this is performed once a week in the absence of complications). If the dressing is clean, the nurse will operate the simple replacement of the secondary dressing. Otherwise, a second complete treatment is planned. State 2, for usual treatment arm, draws the complex dressing (dressing change) performed by a home nurse every day who carries out the cleaning and dressing procedure 5 days per week.

In state 3, patients receive costs and utility of a complete healing of their ulcer. As scientific evidence shows, there is some probability that diabetic patients can have a new occurrence, thus they can move from the state complete wound disclosure, through relapse, to the necessity of new medications. State 6 is the absorbing state and collects individuals dying from any cause (life table) and because of surgery. Results are reported in terms of incremental cost-effectiveness ratio (ICER).

All costs associated with health states and transition costs in the Markov model were measured in euros for 2019, as presented in Table 1. Costs were estimated through a micro-costing approach alongside the resources used in Le Creusot study. These costs are from the perspective of the French healthcare system.

Table 1 Data Used in the Model: Costs

For the cost of dressings, we have made a few estimations to get the average price of a simple dressing (PRP group) and a complex dressing (SoC group). Simple dressing made use of Jelonet, Adaptic, Grassolind plus secondary dressing as serum. Complex dressing, depending on wound characteristics, made use of different families of products. From Le Creusot study we have a rate of utilization of 70% of hydrocellular dressing (Mepilex, Ialuset, Urgotull), 20% on superabsorbant hydrocellular dressing (Cutimed, Wilsabord, Sorbact) and 10% using Urgostart. In Appendix Table 1, we summarize the main parameters used. The details of the calculations on the materials used are included in the Excel file Couts Materiels Hopital.

In state 1, PRP cost is due to: the use of regenkit BCT-1 (X2) and ATS (X1) + cleaning procedure + the medication + nurse time. The cost of comparator is due to the cost of complex dressing + cleaning procedure + nurse time (state 1: DFU complete treatment: PRP arm: 186; comparator: 12.6). In state 2, PRP cost of 7.3 is due to the repair of the medication + nurse time. The cost of comparator is due to the cost of complex dressing + cleaning procedure + nurse time multiplied 5 times per week (state 2: persistent DFU (PRP: 7.3; comparator: 63).

Quality of life assessments for six possible health states (see model description) were based on general health status profiles, which are less sensitive than illness-specific scales but allowed us to analyse and compare results outside the context of a certain disease. A variety of generic preference-based measures have been developed; the most used questionnaires include the EuroQol EQ-5D, the Short Form 6D (SF-6D) and the Health Utilities Index (HUI). Once completed, the questionnaires generate a score using an algorithm based on values that have been obtained from a sample of the general public.40 The values are the health-related quality of life (HRQoL) and measure the utility from living in a specific health state. Health states assume HRQoL values between 0 (dead) and 1 (perfect health); negative values are possible when the health status is considered worse than death. QALYs are assessed by combining the weights calculated for health states alongside the time spent in those health states. QALYs represent the number of years lived in perfect health. The advantage of their use is the possibility to compare results among pathologies and among willingness to pay thresholds for health outcomes.

In this analysis, quality of life assessments for the six possible health states were based on the generic EuroQol instrument and obtained from a previous published study, as presented in Table 2.41 Redekop et al used a time trade-off method to estimate the utility weights associated with a range of health states related to DFUs and their complications. This source was also used previously to provide the quality-of-life estimates for a cost-effectiveness analysis of a negative pressure device for the treatment of DFUs. QALYs were calculated by multiplying the quality-of-life utility weight for one health state by the number of years staying in that state.

Table 2 Data Used in the Model: Effectiveness (at 3 Months)

Probabilities of healing were informed by the proportion of ulcers completely healed at the 12-week time point (Le Creusot study data), 77.3% for PRP care and 35.1% for usual care. Whereas Le Creusot study showed strong results in favor of PRP, in our cost-effectiveness analysis we decided to use a conservative approach. The model parameters were from a recent meta-analysis based on five existing clinical trials; the healing success was 58.33% for PRP and 50.31% for usual care28 (see Table 3).

Table 3 Data Used in the Model: Probability of Healing (at 3 Months)

In Le Creusot study, a total of 27 patients had one injection, 17 had two injections and 2 patients had 3 PRP applications. On average, patients received 1.46 PRP treatments. Therefore, we modelled a conservative probability of 0.5 per cycle to receive a second complete treatment (from Le Creusot study, the probability of having a second complete treatment is 0.2).

To generalize the model, the risk of amputation and relapse were included. Amputation is a temporary state leading to the post-amputation state. The probability of amputation was taken from the Moulik study18 and adjusted according to the model cycles (1 week). The new occurrence probability was taken from the Eurodiale study.44

All annual and three-month probabilities were transformed to weekly probabilities by the formula proposed by Briggs:39

where tp1 is the weekly transition probability we wish to estimate and tpt is the overall probability over time, t.

Deterministic sensitivity analysis has been conducted to assess the impact of the uncertainty of the parameters used in the model on the results. Deterministic sensitivity analyses are useful to deal with different uncertainties, whereby: (i) model uncertainty means every model is a simplification of the reality, (ii) parameter uncertainty is an estimation of costs and effectiveness, and (iii) heterogeneity is the individual variability between patients. Therefore, the sensitivity analyses have been run for the most important parameters of the model (Tables 13). Deterministic sensitivity analysis (DSA) has been run for every minmax scenario of any parameters. In detail, one-way DSA and tornado analysis have been run for every parameter where a min and max scenario is reported.

Probabilistic sensitivity analysis (PSA) was performed through a Monte Carlo simulation, performing 10,000 cases, to assess the uncertainty around the ICER and the probability of the PRP therapy to be cost-effective at different willingness to pay thresholds. A probability distribution was assigned at each model input parameter to describe the different values the parameter can have with different probabilities. The effectiveness and probabilities have been modelled with beta distributions; costs were represented as Gamma distributions as recommended in literature.45 For the parameters cited in literature where it was not estimated standard error, it was assumed a general standard error of 25% of the mean value.39

All analyses were perfomed using TreeAge Pro 2021.

In the base case scenario PRP treatment results in cost savings. The average cost per QALY is around 188 for comparator and 181 for PRP, respectively. The ICER of PRP treatment is 613/QALY, which, being lower than zero, indicates the dominance of the PRP therapy.

In order to know how each parameter influences the results, a one-way sensitivity analysis was performed for the main parameters. The tornado analysis shows the collection of one-way sensitivity analyses for the main parameters (see Figure 2). The DSA results are consistent with the base case scenario. However, for some parameters the PRP treatment is not cost-saving but having a positive ICER can be cost-effective according to the willingness to pay thresholds used.

Figure 2 Tornado analysis.

The most sensitive parameters are the PRP arm probability of needing a new complete treatment and the number of weekly medications carried out for both. The analysis shows that the main difference in costs is due to the daily nurse visits and dressing changes for the comparator therapy, while for PRP therapy we have only one visit per week. The PRP therapy cost is higher in the first week (186) due to the expense for medical devices and nurse time, but it decreases at few euros over the following weeks because only 50% of patients per week need a new complete medication. Therefore, the PRP branch needs less nurse time and a reduced use of materials resulting in a cost saving in respect of the standard of care (SoC) alone. Initially, PRP treatment is more costly but at each cycle the cumulative costs become lower than for usual care and from week 7 the comparator become the most expensive. This trend is due mainly to less frequency of medications for PRP and to a better healing probability (Figure 3).

Figure 3 Cumulative cost per week of the two therapies.

Changing the PRP arm's probability of needing a new complete treatment from 0.5 to 0.7 leads PRP strategy to be no longer cost-saving, with an ICER of 732/QALY. Including a lowest number of SoC weekly medications (from 5 to 3) leads to a 622/QALY, while increasing PRP weekly medication (from 1 to 4) has an ICER of 732/QALY. Considering common thresholds of around 20/30,000, PRP is a cost-effective option.

Other sensitive parameters that lead PRP therapy to be cost-effective and not cost-saving are the cost of the kit used and the total cost of the complete procedure.

The probabilistic sensitivity analysis was performed through a Monte Carlo simulation considering 10,000 scenarios (or cases). All the parameters and variables of the model vary according to the assigned distribution. Figure 4 shows the corresponding acceptability curve with the WTP thresholds. For every WTP threshold, the percentage of cases in favor of PRP or HA is shown, where the percentage of cost-effective iterations is derived from a probabilistic sensitivity analysis performed through the Monte Carlo simulation. For example, at 10,000/QALY there is a 77% probability for PRP treatment to be cost-effective.

Figure 4 Cost-effectiveness acceptability curve of PRP vs SoC under various WTP thresholds.

The present study evaluates the cost-effectiveness of PRP treatment compared with usual management of DFU patients in patients with chronic DFU (duration of >3 weeks) with high orthopaedic risk and ulcers graded 3A (UT classification). This work was conducted along with a clinical study (Le Creusot study) allowing a micro-costing approach in the assessment of resource utilization. Conservative data on effectiveness obtained from a recent meta-analysis were considered (the healing success was 58.33% for PRP and 50.31% for usual care).28 Under these assumptions, the PRP therapy resulted in cost-savings in the base case scenario.

The number of weekly medications for both treatments and the PRP arm probability of needing a new complete treatment influence the results because the PRP, after the first complete medication, needs only one intervention per week in comparison to five for usual care. PRP has higher cost for the complete medication but, in the absence of complications (nurse checks once weekly), only the change of secondary dressing is needed. In the absence of healing signs, the physician can schedule a second PRP application. The probability used in the model for a second PRP complete treatment is 50% weekly. Therefore, PRP has the potential to involve lower consumption of resources (both nurse time and materials). As shown in sensitivity analysis, considering three medications per week (instead of five) for usual care, PRP is no longer the cost-saving therapy but with a 622/QALY is cost-effective (ICER inferior to the threshold of 30,000/QALY). Our results confirm the findings of identified economic evaluations3537 which found the PRP treatment being cost-effective or even dominant compared with usual care. The three works before 2014 have limited methodological quality and do not provide sufficient details of the evaluated procedures. A recent study from a Spanish setting found that, in a 5-year time horizon, PRP treatment for DFU could be considered a cost-effective or even a cost-saving alternative. However, there are few economic evaluations probably because of the scarcity of robust clinical trials and for the wide heterogeneity of the population enrolled in the studies.

This work is not free from limitations. It used cost data specific to the French setting because it is rooted in Le Creusot study. It helps to give more details regarding the PRP vs SoC procedure and allows a micro-costing approach, but it can be less generalizable to other contexts. For example, even if the tornado analysis showed consistent results, the number of PRP complete treatments may influence the outcome of the model and thus calls for further analysis. Moreover, the results need to be interpreted in light of a limited level of evidence complicated by heterogeneity in the characteristics of the patients treated and adding to these factors also the procedures used for PRP/usual care therapies such as, for example, the number of medications and the type of materials used. Therefore, more high-quality randomized controlled trials, possibly with longer term follow up, are required.

In conclusion, considering limitations, the PRP treatment for DFU could be considered a cost-effective or even a cost-saving alternative in the French setting.

This study does not contain human/animal test subjects.

The paper is the advancement of a previous working paper published on the website of Department of Management, University C Foscari Venice: Salvatore Russo & Stefano Landi, 2020. Cost-effectiveness analysis for the treatment of diabetic foot ulcer in France: PRP vs standard of care, Working Paper n.4/2020, August 2020, ISSN:2239-2734. This research was supported by University Ca Foscari Venezia through a grant provided by Regenlab SA to SL. Salvatore Russo and Stefano Landi are co-first authors for this study.

All authors made a significant contribution to the work reported. In detail, all authors worked on the conception, study design, and interpretation. SC worked on acquisition of data, SL and SR on execution and analysis. All authors took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

SC formerly worked for Regen Lab as external consultant. The authors report no other conflicts of interest in this work.

1. Rayner R, Carville K, Keaton J, et al. Leg ulcers: atypical presentations and associated co-morbidities. Wound Pract Res. 2009;17(4):168185.

2. Agale SV. Chronic leg ulcers: epidemiology, aetiopathogenesis, and management. Ulcers. 2013;Article ID 413604:9.

3. Greer N, Foman N, Dorrian J, et al. Advanced wound care therapies for nonhealing diabetic, venous, and arterial ulcers: a systematic review. VAESP Project #09-009; 2012.

4. Abbott CA, Carrington AL, Ashe H, et al. The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community based patient cohort. Diabet Med. 2002;19:377384. doi:10.1046/j.1464-5491.2002.00698.x

5. Abbott CA, Vileikyte L, Williamson S, et al. Multicenter study of the incidence of and predictive risk factors for diabetic neuropathic foot ulceration. Diabetes Care. 1998;21:1071. doi:10.2337/diacare.21.7.1071

6. Siersma V, Thorsen H, Holstein PE, et al. Importance of factors determining the low health-related quality of life in people presenting with a diabetic foot ulcer: the Eurodiale study. Diabet Med. 2013;30:1382. doi:10.1111/dme.12254

7. Hopkins RB, Burke N, Harlock J, et al. Economic burden of illness associated with diabetic foot ulcers in Canada. BMC Health Serv Res. 2015;15:13. doi:10.1186/s12913-015-0687-5

8. Buckley CM, OFarrell A, Canavan RJ, et al. Trends in the incidence of lower extremity amputations in people with and without diabetes over a five-year period in the Republic of Ireland. PLoS One. 2012;7:e41492. doi:10.1371/journal.pone.0041492

9. Brem H, Tomic-Canic M. Cellular and molecular basis of wound healing in diabetes. J Clin Invest. 2007;117:12191222. doi:10.1172/JCI32169

10. Prompers L, Huijberts M, Schaper N, et al. Resource utilisation and costs associated with the treatment of diabetic foot ulcers. Prospective data from the Eurodiale Study. Diabetologia. 2008;51:18261834. doi:10.1007/s00125-008-1089-6

11. Guest JF, Fuller GW, Vowden P. Diabetic foot ulcer management in clinical practice in the UK: costs and outcomes. Int Wound J. 2018;15(1):4352. doi:10.1111/iwj.12816

12. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293:217228. doi:10.1001/jama.293.2.217

13. Hicks CW, Selvarajah S, Mathioudakis N, et al. Burden of infected diabetic foot ulcers on hospital admissions and costs. Ann Vasc Surg. 2016;33:149158. doi:10.1016/j.avsg.2015.11.025

14. Anderson I. Aetiology, assessment and management of leg ulcers. Wound Essent. 2006;1:2036.

15. Winkley K, Stahl D, Chalder T, Edmonds ME, Ismail K. Risk factors associated with adverse outcomes in a population based prospective cohort study of people with their first diabetic foot ulcer. J Diabetes Complications. 2007;21:341349. doi:10.1016/j.jdiacomp.2007.09.004

16. Pound N, Chipchase S, Treece K, Game F, Jeffcoate W. Ulcer-free survival following management of foot ulcers in diabetes. Diabet Med. 2005;22:13061309. doi:10.1111/j.1464-5491.2005.01640.x

17. Peters EJG, Armstrong DG, Lavery LA. Risk factors for recurrent diabetic foot ulcers: site matters. Diabetes Care. 2007;30:20772079. doi:10.2337/dc07-0445

18. Moulik PK, Mtonga R, Gill GV. Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Diabetes Care. 2003;26(2):491494. doi:10.2337/diacare.26.2.491

19. Martinez-Zapata MJ, Mart-Carvajal AJ, Sol I, et al. Autologous platelet rich plasma for treating chronic wounds. Cochrane Database Syst Rev. 2012;10:Art. No.: CD006899. doi:10.1002/14651858.CD006899.pub2

20. Saad Setta H, Elshahat A, Elsherbiny K, Massoud K, Safe I. Platelet-rich plasma versus platelet-poor plasma in the management of chronic diabetic foot ulcers: a comparative study. Int Wound J. 2011;8(3):307312. doi:10.1111/j.1742-481X.2011.00797.x

21. OMeara SM, Cullum NA, Majid M, Sheldon TA. Systematic review of antimicrobial agents used for chronic wounds. Br J Surg. 2001;88:421. doi:10.1046/j.1365-2168.2001.01631.x

22. Kantor J, Margolis DJ. Treatment options for diabetic neuropathic foot ulcers: a cost-effectiveness analysis. Dermatol Surg. 2001;27:347351. doi:10.1046/j.1524-4725.2001.00280.x

23. Suthar M, Gupta S, Bukhari S, Ponemone V. Treatment of chronic non-healing ulcers using autologous platelet rich plasma: a case series. J Biomed Sci. 2017;24:16. doi:10.1186/s12929-017-0324-1

24. Senet P, Bon FX, Benbunan M, et al. Randomized trial and local biological effect of autologous platelets used as adjuvant therapy for chronic venous leg ulcers. J Vasc Surg. 2003;38:13421348. doi:10.1016/S0741-5214(03)00908-X

25. Picard F, Hersant B, Bosc R, Meningaud JP. The growing evidence for the use of platelet-rich plasma on diabetic chronic wounds: a review and a proposal for a new standard care. Wound Repair Regen. 2015;23(5):638643. doi:10.1111/wrr.12317

26. Conde-Montero E, de la Cueva Dobao P, Martnez Gonzlez JM. Platelet-rich plasma for the treatment of chronic wounds: evidence to date. Chronic Wound Care Manag Res. 2017;4:107120. doi:10.2147/CWCMR.S118655

27. Hirase T, Ruff E, Surani S, Ratnani I. Topical application of platelet-rich plasma for diabetic foot ulcers: a systematic review. World J Diabetes. 2018;9(10):172179. doi:10.4239/wjd.v9.i10.172

28. Del Pino-Sedeo T, Trujillo-Martn MM, Andia I, et al. Platelet-rich plasma for the treatment of diabetic foot ulcers: a meta-analysis. Wound Repair Regen. 2019;27(2):170182. doi:10.1111/wrr.12690

29. Hsieh TS, Chiu WK, Yang TF, Wang HJ, Chen C. A meta-analysis of the evidence for assisted therapy with platelet-rich plasma for atrophic acne scars. Aesthetic Plast Surg. 2019;43(6):16151623. doi:10.1007/s00266-019-01471-w

30. Shen Z, Zheng S, Chen G, et al. Efficacy and safety of platelet-rich plasma in treating cutaneous ulceration: a meta-analysis of randomized controlled trials. J Cosmet Dermatol. 2019;18(2):495507. doi:10.1111/jocd.12853

31. Ding H, Fu XL, Miao WW, Mao XC, Zhan MQ, Chen HL. Efficacy of autologous platelet-rich gel for diabetic foot wound healing: a meta-analysis of 15 randomized controlled trials. Adv Wound Care (New Rochelle). 2019;8(5):195207. doi:10.1089/wound.2018.0861

32. Li Y, Gao Y, Gao Y, et al. Autologous platelet-rich gel treatment for diabetic chronic cutaneous ulcers: a meta-analysis of randomized controlled trials. J Diabetes. 2019;11(5):359369. doi:10.1111/1753-0407.12850

33. Xia Y, Zhao J, Xie J, Lv Y, Cao DS. The efficacy of platelet-rich plasma dressing for chronic nonhealing ulcers: a meta-analysis of 15 randomized controlled trials. Plast Reconstr Surg. 2019;144(6):14631474. doi:10.1097/PRS.0000000000006281

34. Hu Z, Qu S, Zhang J, et al. Efficacy and safety of platelet-rich plasma for patients with diabetic ulcers: a systematic review and meta-analysis. Adv Wound Care (New Rochelle). 2019;8(7):298308. doi:10.1089/wound.2018.0842

35. Dougherty EJ. An evidence-based model comparing the cost-effectiveness of platelet-rich plasma gel to alternative therapies for patients with nonhealing diabetic foot ulcers. Adv Skin Wound Care. 2008;21(12):568575. doi:10.1097/01.ASW.0000323589.27605.71

36. Cobos Campos R, Parraza Diez N, Aizpuru Barandiaran F. Platelet-rich plasma in skin ulcer treatment. Wounds. 2013;25(9):256262.

37. Linertov R, Del Pino-Sedeo T, Prez LG, et al. Cost-effectiveness of platelet-rich plasma for diabetic foot ulcer in Spain [published online ahead of print, 2020 Feb 10]. Int J Low Extrem Wounds. 2020;1534734620903239. doi:10.1177/1534734620903239.

38. Clavel S, Albache N, Labrut H, Robu E, Denizot C. Autologous platelet gel: an help in chronic deep diabetic foot ulcers treatment in 2019 Diabetic Foot Conference Abstracts. J Diabetes Sci Technol. 2020;14(3):601678. doi:10.1177/1932296819897643

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Treatment of diabetic foot ulcer in France | CEOR

Trends Shaping The Future Of Beauty And Cosmetics In 2022

The Global beauty industry is currently valued at $532 billion. However, like every other industry, the global beauty industry is also prone to constant change and growth. The ongoing pandemic also took a massive toll on this industry. This is why you need to understand the ongoing trends that will have a huge impact on the future of beauty and cosmetics in 2022. This will allow us to understand better the direction in which the global beauty industry is moving. Here are the top trends that are expected to dominate the future of beauty and cosmetics.

The ongoing pandemic has taught everyone the importance of hygiene and cleanliness in our everyday lives. The professionals expect this trend to continue in the future, even when the pandemic is finally over. Everyone was looking for hand sanitizer and hand soaps during the pandemic. This has slowly encouraged beauty brands to enter this arena, and they have started offering luxurious and beauty-oriented hand soaps and sanitizers.

People will stay loyal to their favorite beauty brands, and professionals expect them to buy hand sanitizers and other hygiene items from their favorite beauty brands. This way, we will see a revolution in the hygiene department.

People love and demand transparency from their favorite brands. We no longer live in an era when people were unaware of the ingredients used in their favorite products. This is why people want to know what they are putting on their skin. This demand has encouraged beauty brands to sign up with third-party labs to offer complete transparency regarding skincare items. This trend will change the future of beauty and cosmetics in 2022.

Transparency will be among the top priorities of different brands. The customers want to know what they are using, and these brands are willing to offer them a detailed report of all the ingredients and chemical formulas used in the products. This will allow the customers to understand whether their product is sustainable and organic.

The ongoing pandemic has forced us to live inside the confines of our homes. This gave us a chance to digitize every aspect of our life. People who were previously unwilling to adopt technology into their lives completely rely on digital technology to continue their daily activities.

This dependence on technology also increased our exposure to blue light. Blue light is known to have damaging effects on the skin. This is where beauty brands jumped in and started working on innovative ingredients to minimize blue lights damaging impact on our skin.

Blue light protection is one of the most anticipated and biggest trends that we will see in the future. The customers want to take care of their skin, and beauty companies are here to help you slow down the process of skin aging. We will see ingredients such as turmeric and algae in our favorite products.

This may sound odd at first. However, hundreds of different beauty companies are constantly trying to transform solid makeup items into liquid makeup. When customers spend a lot of money on beauty products, they expect those products to stay on for a while. We have already seen waterproof mascara and lipstick items in the past. 2022 will be the year where the consumers finally see liquid lipsticks and liquid items expected to stay on the skin throughout the day.

This trend was quite popular even before the pandemic. However, minimalist makeup is expected to make a comeback in the upcoming years. People want to feel beautiful and independent even without the use of makeup accessories. In addition to this, complicated makeup routines also take up a lot of time, and many customers do not have enough time for such routines. This is why we will see our rise in minimalist makeup accessories and routines.

Slow beauty and natural skincare are all the rage right now. Therefore, many people are trying to understand how to make their skin glow up without foreign elements. They want to say goodbye to foreign elements and embrace a healthier way of achieving beautiful skin daily. This is why we will see minimalist makeup practices in the future.

As the entire world slowly shifted towards online video calls and meetings for daily chores, some people were worried about their outlook and face in virtual meetings. A lot of people were worried about how they looked online. This is why skin surgeons and dermatology experts saw an immense boost in the number of people who wanted to learn more about the different cosmetic procedures for facial concerns.

The number of people who investigated different procedures for eye area treatments was higher than ever. This trend is expected to continue down the road, and people will slowly move towards facial treatments and cosmetic surgeries to look better and more beautiful on video calls and virtual chat rooms.

We may not feel it or see it, but our fingers are home to a whole host of bacteria. In addition to this, there are also colonies of viruses that live on our skin. Similarly, an average person touches their hair more than 40 times a day.

We may not see it, but there is an exchange of bacteria and viruses between your hair and fingers. This takes a negative toll on the health of your hair. This is why scientists and professionals have been trying to develop innovative solutions to take care of hair.

2022 may be the year when we finally see antibacterial haircare. Many different beauty companies are already working on creating antibacterial haircare products that are safe for customers, such as cleaning sprays, antibacterial shampoos, and antibacterial moisturizers. These items are expected to fight against any bacteria or virus and offer antimicrobial disinfecting agents that will offer maximum protection for your hair throughout the day.

Another arena that will see a massive improvement in 2022 is the scalp area. People slowly understand the importance of taking care of their scalp. This is why we will see a boost in the number of people who will move towards scalp treatments to reduce hair loss and improve hair health. Platelet-rich Plasma (PRP) injections are becoming more and more common among people.

Another important trend that you can see in the year 2022 is that people will try to move towards organic and plant-based skincare items. Some people are already trying to minimize their impact on the environment. Skincare is the next arena that will see a massive evolution in minimizing the carbon footprint on the environment.

People are trying to move towards plant-based skincare items for multiple reasons. One of the reasons is to minimize the impact on the surrounding environment. Another important reason is that people want to stay away from harsh chemicals and introduce naturally occurring ingredients into their daily skincare routine.

A lot of people are trying to investigate the benefits of using hemp-based or CBD creams. We will see a massive increase in consumers who will try to move towards plant-based skincare items.

In the past, people used to spend a lot of money on getting different hairstyles and artificially augmenting their natural hair. However, we will see a decrease in this trend as people have started to believe in low maintenance power.

Similarly, people are also quite happy to embrace themselves as they are. This will change the

future of beauty and cosmetics in 2022. We will see more and more people embrace their natural hair and stay away from hair straightening or hair curling activities. In addition to this, customers are also worried about hair loss and hair damage. This is why we will see many people embrace air-drying and the natural texture of their hair. They will try to stay away from chemicals and intense heat for hair straightening activities.

People will slowly try to move towards low-maintenance and natural hair care routines. They will also try to find organic and natural shampoos for the daily hair care routine. Therefore, we will see people embracing their natural texture and natural hair more often.

Here are the top 10 statistics that you must know to understand the future of beauty and cosmetics in 2022.

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Trends Shaping The Future Of Beauty And Cosmetics In 2022

Knee and Hip Arthritis: Self-Assessment and Management – Baptist Health South Florida

Could the pain you are feeling be arthritis? Francisco J. Garcia, physician assistant at the arthritis clinic at Miami Orthopedics & Sports Medicine Institute, answered this commonly asked question when he addressed the self-assessment and management of knee and hip arthritis at a recent virtual community health discussion.

The symptoms of knee and hip arthritis can impede your ability to exercise, participate in social activities and go on vacation, and this decrease in activity can lead to muscle weakness, obesity, falls and, ultimately, depression, Mr. Garcia said.

Arthritis may be classified as osteoarthritis, inflammatory arthritis or posttraumatic arthritis, Mr. Garcia explained.

Osteoarthritis involves the degeneration of hyaline cartilage the hard, slippery tissue that covers the ends of bones where they form a joint. The condition is usually caused by the wear and tear over time. The joints most commonly affected include the knees, hips, neck, lumbar spine and hands, Mr. Garcia says. Osteoarthritis is genetic- and age-related, with early signs manifesting around age 50.

Inflammatory arthritis is triggered by an autoimmune disease that attacks the lining of the joint capsule, most commonly in the wrists, hands, fingers, toes and knees. The inflammatory process can eventually destroy cartilage and bone within the joint, Mr. Garcia explains. The most common types are rheumatoid arthritis, gout, lupus and psoriatic arthritis. These diseases have a genetic component, can occur at any age and affect women more than men.

Post-traumatic arthritis is caused by a physical injury that damages the cartilage and/or bone and changes the mechanics of the joint, making it wear out more quickly. The injury can be from sports or a vehicle accident, fall or military injury.

Since the knees and hips bear weight, they are among the most common joints affected by arthritis.

Knee Arthritis

Arthritis in the knee occurs when the cushion between the femur and tibia has deteriorated. When self-assessing your knee health, consider these symptoms of knee arthritis:

Hip Arthritis

Arthritis in the hip occurs when the cartilage in the joint gradually wears away and the protective joint space between the bones decreases. In addition to osteoarthritis, inflammatory arthritis and post-traumatic arthritis, this degeneration can be caused by hip dysplasia a genetic condition in which the hip socket does not fully cover the ball portion of the upper thighbone.

When self-assessing your hip health, Mr. Garcia recommends that you consider these symptoms of hip arthritis:

Conservative Treatments

To reduce the effect of arthritis on your quality of life, Mr. Garcia recommends seeing a specialist to evaluate your condition and initiate a non-surgical management plan to reduce your symptoms. Your conservative care plan may include:

Injections can lubricate the joint and reduce pain and inflammation, Mr. Garcia explained. For the knee, a cortisone injection can provide two to three months of relief while a hyaluronic acid injection is effective for three to six months. Injections in the hip give short, mild relief but do not last as long as knee injections.

Surgical Treatments

When conservative treatments fail and pain affects your quality of life, surgical management may be warranted. Partial knee replacements and total knee replacements are performed under spinal anesthesia and sedation. Some patients will stay one night in the hospital while other qualified patients will be discharged home on the same day. Mr. Garcia recommends that all patients attend physical therapy for six to eight weeks to achieve the best outcome.

Patients undergoing hip replacement surgery also may stay one night in the hospital or be discharged the same day. The orthopedic surgeons at Miami Orthopedics & Sports Medicine Institute use the anterior approach, which protects soft tissue from damage, rather than the posterior or lateral approach, which has a longer recovery and increases the risk of dislocation and leg length discrepancy. Patients will be ambulating on the day of surgery and start physical therapy immediately.

For most people, joint replacement surgery is a game changer, providing pain relief, improved mobility and a better quality of life, Mr. Garcia says.

Tags: arthritis, hip arthroscopy, knee pain

Continued here:
Knee and Hip Arthritis: Self-Assessment and Management - Baptist Health South Florida

JAWS and the 2022 Hall of Fame Ballot: Carl Crawford – FanGraphs

The following article is part of Jay Jaffes ongoing look at the candidates on the BBWAA 2022 Hall of Fame ballot. For a detailed introduction to this years ballot, and other candidates in the series, use the tool above; an introduction to JAWS can be found here. For a tentative schedule and a chance to fill out a Hall of Fame ballot for our crowdsourcing project, see here. All WAR figures refer to the Baseball-Reference version unless otherwise indicated.

Content warning: This piece contains details about alleged domestic and gun violence. The content may be difficult to read and emotionally upsetting.

2022 BBWAA Candidate: Carl Crawford

SOURCE: Baseball-Reference

The new millennium hasnt exactly been a banner one for the stolen base. Between soaring home run rates and the influence of analytics on front offices, the tactic has gone out of style, and per-game rates have fallen. As one-run strategies go, teams seem content to wait for a player to knock a ball over a wall rather than manufacture a run. During the first decade of the 2000s, as home runs kept flying, Carl Crawford stood out for his electrifying speed and skill on the basepaths.

In the first eight full seasons of his 15-year career (2002-16), Crawford led the American League in stolen bases four times, finished second once and third twice, stealing at least 46 bases in each of those seasons. He topped an 80% success rate in the first five of those seasons, and led the league in triples three times as well. Crawfords wheels as well as his midrange power and strong defense helped him make four All-Star teams and win a Gold Glove while starring for the Rays first two playoff teams.

Alas, Crawford hit free agency, signed a massive seven-year deal with the Red Sox, and almost immediately went into the decline phase of his career due to injuries. After totaling 35.6 WAR with Tampa Bay from 2002-10, he managed just 3.5 WAR over his final six seasons spent with Boston and the Dodgers while missing substantial time due to Tommy John surgery, plus wrist, finger, oblique, and hamstring woes. He was released by Los Angeles with a year and a half still to go on his contract, and never played again.

Since retiring, Crawford has made grim headlines, including one for a 2020 arrest for domestic assault against his ex-girlfriend, and another for the drowning of a 5-year-old boy and 24-year-old woman during a party at his home and a subsequent lawsuit alleging negligence. If Crawford were a serious candidate for election, on the level of Omar Vizquel, such matters might cost him the support of voters. As it is, they complicate his legacy.

Crawford was born on August 5, 1981 in Houston, Texas, and grew up in the Fifth Ward. His grandfather, Roy Burns, ran a legendary barbecue restaurant, Burns Original BBQ, in Houston, and his father Steve went into the family business. Later, so did Carls brother, Cory, and Crawford used some of his career earnings to help finance the restaurants rebirth.

As a child, the left-handed Crawford pitched and played first base for the Smokey Jasper Park Angels, a Little League team coached by Ray Bourn, whose son Michael yes, Michael Bourn was 16 months younger than Crawford. The younger Bourn played 11 years in the majors (2006-16), won three stolen base titles and made two All-Star teams but was not included on this years Hall of Fame ballot despite being eligible. The team was very good, but due to a lack of money for travel, We didnt even get a chance to play in (the Little League World Series), Crawford recalled in 2014. I mean we beat everybody else. We scrimmaged one of those teams that went and blew em out. The situation led Crawford to help fund the travel of the national title-winning Jackie Robinson West team from Chicago.

At Jefferson Davis High School, Crawford lettered in football, basketball, and baseball. While lore has it that UCLA offered him a basketball scholarship to play point guard, Crawford later debunked that story. He did sign a letter of intent to go to the University of Nebraska on scholarships for football and baseball, but when the Devil Rays chose him in the second round of the 1999 draft (the 52nd pick overall), he soon signed for a $1.245 million bonus.

When he began his career with the Devil Rays Princeton affiliate in the Appalachian League in 1999, Crawford was still just 17 years old and comparatively inexperienced at baseball, given his interests in other sports. Nonetheless, he hit .319/.350/.404 and stole 17 bases in a league where he was 2.7 years younger than the average player, then hit .319/.350/.404 with league-leading totals of 170 hits and 55 steals, not to mention 11 triples, as an 18-year-old in the South Atlantic League. Baseball America placed him 72nd on their Top 100 Prospects list in the spring of 2001 while noting that the Devil Rays rave about Crawfords ability to take instruction and put it to use. His enthusiasm is apparent, and he never seems intimidated [even if] his inexperience sometimes shows.

Despite hitting a more modest .274/.323/.352 with 36 steals at Double-A Orlando in 2001, Crawford moved up to number 59 on BAs list because hed held his own as a 19-year-old. From his prospect capsule:

He has great speed, quick wrists and a good idea of how to hit. His superior work ethic rivals that of any player in the system, and hes considered the Devil Rays most coachable prospect. Crawfords arm is his lone below-average tool. His baseball instincts, such as taking the correct routes on fly balls, should get better with experience. His pitch recognition and ability to work counts need improvement, and his swing could use some refinement.

After spending the first half of the 2002 season at Triple-A Durham, Crawford was called up to make his major league debut. He went 1-for-4 with a two-run single off the Blue Jays Brian Bowles on July 20, 2002, 16 days short of his 21st birthday. On a team that lost 106 games, Crawford hit just .259/.290/.371 for a 77 OPS+ in 278 PA, but his baserunning and defense still boosted his value to 1.0 WAR. His hitting was only slightly better the following year (.281/.309/.362, 81 OPS+), but he did steal an AL-high 55 bases in 65 attempts; between his baserunning, double play avoidance and 11 Defensive Runs Saved, he was worth 2.3 WAR, a respectable showing for an age-21 season.

Crawford broke out in 2004, making his first All-star team, hitting .296/.331/.450 (105 OPS+) with league bests in triples (19) and steals (59), and 4.9 WAR. That began a four-year run during which he hit for a 112 OPS+ (.304/.341/.467) while averaging 14 homers, 15 triples, 53 steals, and 4.5 WAR. He made the AL All-Star team again in 2007, led the league in triples in 05 and 06, and in steals in 06 and 07; from 2005-07, he was successful on 85% of his stolen base attempts. In April 2005, he signed a four-year, $15.25 million extension that included club options for 2009 and 10.

The Devil Rays remained a bad ballclub in this span, losing fewer than 95 games only in 2004. But the times they were a-changin in Tampa Bay. Manager Lou Piniella and general manager Chuck LaMar were replaced by Joe Maddon and Andrew Friedman after the 2005 season, and the Devil Rays became the Rays after 07. With rookie third baseman Evan Longoria joining Crawford, B.J. Upton, and a stable of young pitchers led by James Shields and Matt Garza, the team turned the corner in 2008, winning 97 games and the AL East. Crawford was not at his best, however; between a four-game suspension for his part in a brawl against the Red Sox, a minor hamstring injury, and surgery to repair a subluxation of his right middle finger tendon, he played in just 109 games and hit for an 89 OPS+ with just 25 steals and 2.5 WAR.

Despite not making a single major league plate appearance after August 9 due to injuries, Crawford reclaimed his starting left field job at the outset of the 2008 postseason, and hit .290/.333/.468 as the Rays beat the White Sox and Red Sox before losing to the Phillies in a five-game World Series. His biggest contribution came in Game 4 of the ALCS, when he went 5-for-5 with two doubles and a triple, scoring three runs and driving in two in a 13-4 win. He homered off both Cole Hamels and Joe Blanton in the World Series, albeit both in games that the Rays lost.

The Rays picked up Crawfords options in each of the next two seasons, and he responded with performances that netted him All-Star berths in both years. He hit .305/.364/.452 (116 OPS+) with 15 homers and career highs of 60 steals including an AL record-tying six in one game on May 3 and 5.0 WAR in 2009, and was the MVP of the All-Star Game for his robbery of a potential go-ahead home run by Brad Hawpe.

Crawford topped that with a career year, hitting .307/.356/.495 with highs in slugging percentage, homers (19), OPS+ (135) and WAR (7.0, good for sixth in the league) while stealing 47 bases and boasting a league-high 13 triples. Though his 8 DRS wasnt his best, he did bring home his only Gold Glove that year as well. The Rays won the AL East again, but lost a five-game Division Series to the Rangers; Crawford went just 3-for-21, though two of his hits and his only homer came in Tampa Bays Game 3 win.

That big season carried the 29-year-old Crawford into free agency, where his speed, athleticism, defensive ability, and budding power attracted the attention of the Red Sox, who had missed the playoffs for the first time since 2006. When fellow free agent Jayson Werth signed a seven-year, $126 million deal with the Nationals, Crawford and his agents, Greg Genske and Brian Peter, got a boost. He signed with the Red Sox for seven years and $142 million, choosing them over the Angels, who were reportedly offering the same package. The deal was the games 11th-largest at the time, and the sixth-largest of any free agent to that point, after those of Alex Rodriguez ($275 and $252 million), Mark Teixiera ($180 million), CC Sabathia ($161 million), and Manny Ramirez ($160 million).

Crawfords time in Boston was a disaster. He hit .155/.204/.227 in April 2011, missed a month from mid-June to mid-July due to a hamstring strain, and declined in every phase of his game, hitting just .255/.289/.405 (85 OPS+) with 11 homers and 18 steals his lowest total since his rookie season in 130 games. The Red Sox nonetheless carried the ALs best record into September, but went just 7-20 the rest of the way. Still, they entered the final night of the season at 90-71, tied with the Rays for the AL Wild Card spot, and headed to the ninth inning of their season finale up 3-2 on the lowly Orioles. After striking out the first two batters in the ninth, closer Jonathan Papelbon gave up back-to-back doubles to Chris Davis and Nolan Reimold, tying the game. With pinch-runner Kyle Hudson on second base, Robert Andino lined a ball to left field, where Crawford tried unsuccessfully to make a sliding catch, then threw home too late to prevent the winning run from scoring. It made for an enduring image not just of the teams season, but of the left fielders tenure in Boston.

The Red Sox lost that game, but they werent eliminated until the Rays erased a 7-0 deficit against the Yankees in the eighth and ninth innings, then won in the 12th.

In January, Crawford underwent surgery to repair cartilage in his left wrist. Initially, the Red Sox explained he had begun experiencing soreness during his offseason hitting workouts, but by Opening Day, it emerged that hed dealt with wrist pain for years and had received painkilling injections to manage the problem in 2011. Just as he neared his return in late March, he sprained his left UCL and received an injection of platelet-rich plasma. He didnt make his season debut until July 16, 2012, and it soon became apparent both that his elbow was still a problem and that the Red Sox were going nowhere, so he underwent Tommy John surgery in late August.

On August 25, two days after that surgery, the Red Sox shocked the baseball world by trading Crawford, Josh Beckett, Adrian Gonzalez, Nick Punto, and $258 million cash all but $12 million of what remained on the players respective contracts to the Dodgers for a five-player package.

Crawford was surprised by the trade,and relieved. When he reported to spring training, he spoke of Bostons toxic environment and his inner struggles. I just didnt see a light at the end of the tunnel, he told the Los Angeles Times Dylan Hernandez. It puts you in kind of a depression stage. You just dont see a way out. A year and a half later, he admitted that he hadnt done his research on Boston or spoken to a single player who had played there about his experience.

Crawfords return to action was solid but unspectacular. He hit .283/.329/.407 (107 OPS+) with 15 stolen bases and 1.5 WAR in 116 games, missing just over a month due to a hamstring strain. He came up big in the Division Series against the Braves, going 6-for 17 with three homers in a four-game victory; he hit a three-run shot off Julio Teheran in Game 3, then homered twice of Freddy Garcia in Game 4. Though he collected hits in all six games of the Dodgers NLCS loss to the Cardinals, he scored just twice and drove in one run, that via a solo homer off Joe Kelly in a Game 5 win.

Crawfords 2014 season was his best as a Dodger, not that it was a complete one. The 32-year-old left fielder hit .300/.339/.429 (118 OPS+) with 23 steals in 29 attempts, and 2.4 WAR, but he missed six weeks due to a left ankle sprain. Though he went 5-for-17 against the Cardinals in the Division Series, the Dodgers fell in four games.

From there, the returns diminished. Crawford was the Dodgers Opening Day left fielder in both the 2015 and 16 seasons, but slipped below replacement level and was increasingly unavailable due to injuries. He missed 12 weeks in 2015 due to an oblique strain, and played in just 69 games, finishing with -0.2 WAR, then played in just 30 games, missing time due to a lower back strain. On June 5, a point at which he was a full win below replacement level in just 87 PA, the team designated him for assignment, then released him while still owing him $35 million. Despite the fact that he would have cost just the league minimum, he never played again. The Rays reportedly expressed at least some interest in bringing him back in late June of 2016 when their outfield was depleted by injuries, and he mulled a comeback over the following winter, but that was it for his career.

Crawfords career total of 480 stolen bases ranks only 43rd all-time, but its fourth among those since the year 2000, behind only Juan Pierre (614), Jos Reyes (517), and Ichiro Suzuki (509), with 2022 ballot newcomer Jimmy Rollins (470) fifth, and current candidate Bobby Abreu seventh (347 of his 400). Similarly, Crawfords 81.5% success rate ranks sixth among players with at least 300 stolen base attempts in that span, with Carlos Beltrn first (87.3%, nearly a point higher than his overall 86.4% dating back to 1998) and Rollins (81.7%) fourth. Crawfords total of 83 runs for baserunning and double play avoidance also ranks fourth for the span behind Ichiro (118), Johnny Damon (95, from his career total of 125 dating back to 1995), and Pierre (85).

Alas, all of that is at least somewhat overshadowed not only by the dud that was Crawfords contract but by his post-career legal issues. In 2017, he founded 1501 Certified Entertainment, a music label. Rapper Megan Thee Stallion signed with the label in early 2018 and soon found success, but when she signed a management deal with Jay-Zs label Roc Nation in September 2019, 1501 blocked her from releasing new music. In response, she sued 1501 and Crawford, calling the contract unconscionable and the label purposefully and deceptively vague in paying her; the case is ongoing.

More tragically, on May 16, 2020, two people, 5-year-old Kasen Hersi and 25-year-old Bethany Lartigue, drowned in the backyard swimming pool during a party at his house in Houston. The woman had been staying at Crawfords home while filming music videos; she jumped in to save the boy but neither one survived after being administered CPR. The boys father soon sued Crawford for $1 million for negligence, claiming that he had failed to take reasonable and necessary steps to prevent the boy from having access to the pool. Crawford publicly expressed remorse over the two deaths; the current status of that lawsuit is unknown.

On June 3, 2020, Crawford was arrested in Houston and charged with assault of a family member/impeding breathing, a felony. According to court documents, Crawford showed up at the Houston apartment of his ex-girlfriend, with whom he has a daughter who was one year old at the time, on May 8. The woman alleged that Crawford fired a semi-automatic handgun, threatened her at gunpoint, slammed her head against the wall and squeezed her neck. The emergence of the couples child distracted Crawford long enough for her to escape. Crawford also allegedly fled the scene, but left behind the handgun.

Crawford turned himself in and was freed on $10,000 bond. Via lawyer Rusty Hardin (who previously represented Roger Clemens in allegations related to the Mitchell Report), he denied the charges and his conduct. While further developments in the case were not publicly reported, according to Harris County court records, he was indicted by a grand jury in December 2020, but the case was dismissed the following March when his ex-girlfriend refused to cooperate with the prosecution.

Even without prosecution, such disturbing stuff would likely compromise a serious candidates chances for election to the Hall of Fame, and as it is, the litany makes even appreciating the high points of Crawfords uneven career a complicated matter.

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JAWS and the 2022 Hall of Fame Ballot: Carl Crawford - FanGraphs