Is stiffness related to athletic groin pain?

Athletic groin pain (AGP) is a common injury prevalent in field sports. One biomechanical measure that may be of importance for injury risk is stiffness. To date, [corrected] however, stiffness has not been examined in AGP. The primary aim was to determine whether AGP affects vertical and joint stiffness and if so, whether successful rehabilitation is associated with a change in stiffness. Sixty-five male patients with AGP and fifty male controls were recruited to this study. Assessment included a biomechanical examination of stiffness during a lateral hurdle hop test. Subjects with AGP were tested pre- and post-rehabilitation, while controls were tested once. AGP subjects were cleared for return to play in a median time of 9.14 weeks (5.14-29.0). Stiffness was significantly different at pre-rehabilitation in comparison with controls for three [corrected] of the ten stiffness values examined: ankle plantar flexor, knee extensor, hip abductor, and vertical stiffness (P <  .05, D = 0.38-0.81). [corrected]. Despite clearance for return to play, of these four variables, only hip abductor stiffness changed significantly from pre- to post-rehabilitation (P = .05, D = 0.36) [corrected] to become non-significantly different to the uninjured group (P = .23, D = 0.23). [corrected]. These findings suggest that hip abductor stiffness may represent a target for AGP rehabilitation. Conversely, given the clearance for return to play, the lower sagittal plane and vertical stiffness in the AGP group in comparison with the uninjured controls likely represents either a compensatory mechanism to reduce the risk of further injury or a consequence of neuromuscular detraining.

Rhode Island Unintentional Drug Overdose Death Trends and Ranking - Office of the State Medical Examiners Database

[Full article available at http://rimed.org/rimedicaljournal-2018-02.asp].

The Use of a Shared Services Model for Mycobacteriology Testing: Lessons Learned

OBJECTIVES

Public health laboratories (PHLs) provide essential services in the diagnosis and surveillance of diseases of public health concern, such as tuberculosis. Maintaining access to high-quality laboratory testing is critical to continued disease detection and decline of tuberculosis cases in the United States. We investigated the practical experience of sharing tuberculosis testing services between PHLs through the Shared Services Project.

METHODS

The Shared Services Project was a 9-month-long project funded through the Association of Public Health Laboratories and the Centers for Disease Control and Prevention during 2012-2013 as a one-time funding opportunity to consortiums of PHLs that proposed collaborative approaches to sharing tuberculosis laboratory services. Submitting PHLs maintained testing while simultaneously sending specimens to reference laboratories to compare turnaround times.

RESULTS

During the 9-month project period, 107 Mycobacterium tuberculosis complex submissions for growth-based drug susceptibility testing and molecular detection of drug resistance testing occurred among the 3 consortiums. The median transit time for all submissions was 1.0 day. Overall, median drug susceptibility testing turnaround time (date of receipt in submitting laboratory to result) for parallel testing performed in house by submitting laboratories was 31.0 days; it was 43.0 days for reference laboratories. The median turnaround time for molecular detection of drug resistance results was 1.0 day (mean = 2.8; range, 0-14) from specimen receipt at the reference laboratories.

CONCLUSIONS

The shared services model holds promise for specialized tuberculosis testing. Sharing of services requires a balance among quality, timeliness, efficiency, communication, and fiscal costs.

Non-smoking pregnant women and their fetuses are exposed to environmental tobacco smoke as a result of living in multiunit housing

This study investigates whether pregnant women and their fetuses are exposed to environmental tobacco smoke (ETS) as a result of living in apartments. We measured cotinine concentrations in serum, a biomarker of exposure to ETS, in non-smoking women's umbilical cord blood collected at delivery and in maternal blood drawn shortly after delivering a baby. Concurrently, information was collected regarding the women's housing situation, whether family members or co-workers smoked, and other potential exposure factors. Newborns whose non-smoking mothers lived in an apartment during pregnancy were more than three times (OR 3.17, 95% CI 1.62-6.21) more likely to have detectable levels of cotinine in their cord blood serum than babies whose mothers lived in a detached house. There is a strong association between detectable concentrations of cotinine in cord blood serum and living in an apartment, even after adjusting for confounders, such as exposure at home or at work. A similar association was observed between the detectable levels of cotinine in maternal serum and living in an apartment (OR 1.95, 95% CI 1.03-3.71).

Antibody responses to surface antigens of Plasmodium falciparum gametocyte-infected erythrocytes and their relation to gametocytaemia

An essential element for continuing transmission of Plasmodium falciparum is the availability of mature gametocytes in human peripheral circulation for uptake by mosquitoes. Natural immune responses to circulating gametocytes may play a role in reducing transmission from humans to mosquitoes. Here, antibody recognition of the surface of mature intra‐erythrocytic gametocytes produced either by a laboratory‐adapted parasite, 3D7, or by a recent clinical isolate of Kenyan origin (HL1204), was evaluated longitudinally in a cohort of Ghanaian school children by flow cytometry. This showed that a proportion of children exhibited antibody responses that recognized gametocyte surface antigens on one or both parasite lines. A subset of the children maintained detectable anti‐gametocyte surface antigen (GSA) antibody levels during the 5 week study period. There was indicative evidence that children with anti‐GSA antibodies present at enrolment were less likely to have patent gametocytaemia at subsequent visits (odds ratio = 0·29, 95% CI 0·06–1·05; P = 0·034). Our data support the existence of antigens on the surface of gametocyte‐infected erythrocytes, but further studies are needed to confirm whether antibodies against them reduce gametocyte carriage. The identification of GSA would allow their evaluation as potential anti‐gametocyte vaccine candidates and/or biomarkers for gametocyte carriage.

The Role of the State Health Laboratories in Advancing Health Equity

While laboratories play an important and recognized role in many public health programs that require surveillance of disease spread or monitoring of environmental conditions, the role of public laboratories in assessing and advancing health equity is not well understood. Yet, public laboratories collect, provide or generate much of the data used to determine health equity status and monitor heath equity trends in multiple settings and disciplines. RI State Health Laboratories, a division of the RI Department of Health, operates programs that help measure and address health disparities. Health equity themes are present in laboratory programs that measure environmental determinants of health and assure equal access to laboratory screening and diagnostic services. This article will review the role of laboratory programs in advancing health equity in the state. Specific examples of laboratory contributions to health equity programs will be provided and examined. Future trends and unmet needs will also be discussed. [Full article available at http://rimed.org/rimedicaljournal-2016-11.asp].

Perilymph pharmacokinetics of locally-applied gentamicin in the guinea pig

Intratympanic gentamicin therapy is widely used clinically to suppress the vestibular symptoms of Meniere's disease. Dosing in humans was empirically established and we still know remarkably little about where gentamicin enters the inner ear, where it reaches in the inner ear and what time course it follows after local applications. In this study, gentamicin was applied to the round window niche as a 20 μL bolus of 40 mg/ml solution. Ten 2 μL samples of perilymph were collected sequentially from the lateral semi-circular canal (LSCC) at times from 1 to 4 h after application. Gentamicin concentration was typically highest in samples originating from the vestibule and was lower in samples originating from scala tympani. To interpret these results, perilymph elimination kinetics for gentamicin was quantified by loading the entire perilymph space by injection at the LSCC with a 500 μg/ml gentamicin solution followed by sequential perilymph sampling from the LSCC after different delay times. This allowed concentration decline in perilymph to be followed with time. Gentamicin was retained well in scala vestibuli and the vestibule but declined rapidly at the base of scala tympani, dominated by interactions of perilymph with CSF, as reported for other substances. Quantitative analysis, taking into account perilymph kinetics for gentamicin, showed that more gentamicin entered at the round window membrane (57%) than at the stapes (35%) but the lower concentrations found in scala tympani were due to greater losses there. The gentamicin levels found in perilymph of the vestibule, which are higher than would be expected from round window entry alone, undoubtedly contribute to the vestibulotoxic effects of the drug. Furthermore, calculations of gentamicin distribution following targeted applications to the RW or stapes are more consistent with cochleotoxicity depending on the gentamicin concentration in scala vestibuli rather than that in scala tympani.

Athletic groin pain (part 2): a prospective cohort study on the biomechanical evaluation of change of direction identifies three clusters of movement patterns

Background

Athletic groin pain (AGP) is prevalent in sports involving repeated accelerations, decelerations, kicking and change-of-direction movements. Clinical and radiological examinations lack the ability to assess pathomechanics of AGP, but three-dimensional biomechanical movement analysis may be an important innovation.

Aim

The primary aim was to describe and analyse movements used by patients with AGP during a maximum effort change-of-direction task. The secondary aim was to determine if specific anatomical diagnoses were related to a distinct movement strategy.

Methods

322 athletes with a current symptom of chronic AGP participated. Structured and standardised clinical assessments and radiological examinations were performed on all participants. Additionally, each participant performed multiple repetitions of a planned maximum effort change-of-direction task during which whole body kinematics were recorded. Kinematic and kinetic data were examined using continuous waveform analysis techniques in combination with a subgroup design that used gap statistic and hierarchical clustering.

Results

Three subgroups (clusters) were identified. Kinematic and kinetic measures of the clusters differed strongly in patterns observed in thorax, pelvis, hip, knee and ankle. Cluster 1 (40%) was characterised by increased ankle eversion, external rotation and knee internal rotation and greater knee work. Cluster 2 (15%) was characterised by increased hip flexion, pelvis contralateral drop, thorax tilt and increased hip work. Cluster 3 (45%) was characterised by high ankle dorsiflexion, thorax contralateral drop, ankle work and prolonged ground contact time. No correlation was observed between movement clusters and clinically palpated location of the participant's pain.

Conclusions

We identified three distinct movement strategies among athletes with long-standing groin pain during a maximum effort change-of-direction task These movement strategies were not related to clinical assessment findings but highlighted targets for rehabilitation in response to possible propagative mechanisms.

Trial registration number

NCT02437942, pre results.

A Model of Shared Mycobacteriology Testing Services: Lessons Learned

OBJECTIVE

The need for public health laboratories (PHLs) to prioritize resources has led to increased interest in sharing diagnostic services. To address this concept for tuberculosis (TB) testing, the New York State Department of Health Wadsworth Center and the Rhode Island State Health Laboratories assessed the feasibility of shared services for the detection and characterization of Mycobacterium tuberculosis complex (MTBC).

METHODS

We assessed multiple aspects of shared services including shipping, testing, reporting, and cost. Rhode Island State Health Laboratories shipped MTBC-positive specimens and isolates to Wadsworth Center. Average turnaround times were calculated and cost analysis was performed.

RESULTS

Testing turnaround times were similar at both PHLs; however, the availability of conventional drug susceptibility testing (DST) results for Rhode Island primary specimens and isolates were extended by approximately four days of shipping time. An extended molecular testing panel was performed on every specimen submitted from Rhode Island State Health Laboratories to Wadsworth Center, and the total cost per specimen at Wadsworth Center was $177.12 less than at Rhode Island State Health Laboratories, plus shipping. Following a mid-study review, Wadsworth Center provided testing turnaround times for detection (same day), species determination of MTBC (same day), and molecular DST (2.5 days).

CONCLUSION

The collaboration between Wadsworth Center and Rhode Island State Health Laboratories to assess shared services of TB testing highlighted a successful model that may serve as a guideline for other PHLs. The provision of additional rapid testing at a lower cost demonstrated in this study could potentially improve patient management and result in significant cost and resource savings if used in similar models across the country.

Athletic groin pain (part 1): a prospective anatomical diagnosis of 382 patients--clinical findings, MRI findings and patient-reported outcome measures at baseline

Background

Athletic groin pain remains a common field-based team sports time-loss injury. There are few reports of non-surgically managed cohorts with athletic groin pain.

Aim

To describe clinical presentation/examination, MRI findings and patient-reported outcome (PRO) scores for an athletic groin pain cohort.

Methods

All patients had a history including demographics, injury duration, sport played and standardised clinical examination. All patients underwent MRI and PRO score to assess recovery. A clinical diagnosis of the injured anatomical structure was made based on these findings. Statistical assessment of the reliability of accepted standard investigations undertaken in making an anatomical diagnosis was performed.

Result

382 consecutive athletic groin pain patients, all male, enrolled. Median time in pain at presentation was (IQR) 36 (16–75) weeks. Most (91%) played field-based ball-sports. Injury to the pubic aponeurosis (PA) 240 (62.8%) was the most common diagnosis. This was followed by injuries to the hip in 81 (21.2%) and adductors in 56 (14.7%) cases. The adductor squeeze test (90° hip flexion) was sensitive (85.4%) but not specific for the pubic aponeurosis and adductor pathology (negative likelihood ratio 1.95). Analysed in series, positive MRI findings and tenderness of the pubic aponeurosis had a 92.8% post-test probability.

Conclusions

In this largest cohort of patients with athletic groin pain combining clinical and MRI diagnostics there was a 63% prevalence of PA injury. The adductor squeeze test was sensitive for athletic groin pain, but not specific individual pathologies. MRI improved diagnostic post-test probability. No hernia or incipient hernia was diagnosed.

Clinical trial registration number

NCT02437942.

Athletic groin pain: a systematic review and meta-analysis of surgical versus physical therapy rehabilitation outcomes

BACKGROUND

Athletic groin pain (AGP) is an encompassing term for the multitude of chronic conditions presenting as pain in the inguinal region. The purpose of this review was to compare the return to play rates (RTPrate) and return to play times (RTPtime) between surgical and rehabilitation interventions in the treatment of AGP.

METHODS

A systematic review of English language peer review journals was carried out between 1980 to June 2013 using PubMed, Embase, CINHAL and Google Scholar searching for all papers relating to AGP (and its various pseudonyms) and all surgical and rehabilitative interventions which reported RTPrate and/or RTPtime. AGP literature has been subdivided by many eponymous diagnoses but anatomical diagnostic groupings of (1) abdominal wall, (2) adductor and (3) pubic related pain were used in this review. Meta-analysis was then carried out on the data to compare results between the surgical and rehabilitation groups.

RESULTS

Fifty-six papers out of the 561 discovered in the initial search were included in the review with 3332 athletes included. Evidence was mostly level IV. Using the Black and Downs checklist we found poor study quality overall with a high risk of bias especially among surgical studies. The results showed comparable RTPrate between surgical and rehabilitative interventions within the three diagnostic groups. Rehabilitation had significantly quicker RTPtime for pubic related groin pain compared to surgery (10.5 weeks and 23.1 weeks respectively). The abdominal group had the fastest return of the three groups for the rehabilitation and surgery.

CONCLUSIONS

The review suggested better outcomes with rehabilitation for pubic-related groin pain with no difference between the adductor and abdominal groups. The review highlighted the poor quality and risk of bias in the literature making accurate comparison difficult.

Frailty and mortality in kidney transplant recipients

We have previously described strong associations between frailty, a measure of physiologic reserve initially described and validated in geriatrics, and early hospital readmission as well as delayed graft function. The goal of this study was to estimate its association with postkidney transplantation (post-KT) mortality. Frailty was prospectively measured in 537 KT recipients at the time of transplantation between November 2008 and August 2013. Cox proportional hazards models were adjusted for confounders using a novel approach to substantially improve model efficiency and generalizability in single-center studies. We precisely estimated the confounder coefficients using the large sample size of the Scientific Registry of Transplantation Recipients (n = 37 858) and introduced these into the single-center model, which then estimated the adjusted frailty coefficient. At 5 years, the survivals were 91.5%, 86.0% and 77.5% for nonfrail, intermediately frail and frail KT recipients, respectively. Frailty was independently associated with a 2.17-fold (95% CI: 1.01-4.65, p = 0.047) higher risk of death. In conclusion, regardless of age, frailty is a strong, independent risk factor for post-KT mortality, even after carefully adjusting for many confounders using a novel, efficient statistical approach.

Gender norms, poverty and armed conflict in Côte D'Ivoire: engaging men in women's social and economic empowerment programming

Engaging men is a critical component in efforts to reduce intimate partner violence (IPV). Little is known regarding men's perspectives of approaches that challenge inequitable gender norms, particularly in settings impacted by armed conflict. This article describes men's experiences with a women's empowerment program and highlights men's perceptions of gender norms, poverty and armed conflict, as they relate to achieving programmatic goals. Data are from 32 Ivorian men who participated in indepth interviews in 2012. Interviews were undertaken as part of an intervention that combined gender dialogue groups for both women and their male partners with women's only village savings and loans programs to reduce IPV against women. Findings suggested that in the context of armed conflict, traditional gender norms and economic stressors experienced by men challenged fulfillment of gender roles and threatened men's sense of masculinity. Men who participated in gender dialogue groups discussed their acceptance of programming and identified improvements in their relationships with their female partners. These men further discussed increased financial planning along with their partners, and attributed such increases to the intervention. Addressing men's perceptions of masculinity, poverty and armed conflict may be key components to reduce men's violence against women in conflict-affected settings.