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.

Public health implications of molecular point-of-care testing for chlamydia and gonorrhoea in remote primary care services in Australia: a qualitative study

OBJECTIVES

With accurate molecular tests now available for diagnosis of chlamydia and gonorrhoea (Chlamydia trachomatis (CT)/Neisseria gonorrhoeae (NG)) at the point-of-care (POC), we aimed to explore the public health implications (benefits and barriers) of their integration into remote primary care in Australia.

METHODS

Qualitative interviews were conducted with a purposively selected group of 18 key informants reflecting sexual health, primary care, remote Aboriginal health and laboratory expertise.

RESULTS

Participants believed that POC testing may decrease community prevalence of sexually transmitted infections (STIs), and associated morbidity by reducing the time to treatment and infectious period and expediting partner notification. Also, POC testing could improve acceptability of STI testing, increase testing coverage and result in more targeted prescribing, thereby minimising the risk of antibiotic resistance. Conversely, some felt the immediacy of diagnosis could deter certain young people from being tested. Participants also noted that POC testing may reduce the completeness of communicable disease surveillance data given the current dependence on reporting from pathology laboratories. Others expressed concern about the need to maintain and improve the flow of NG antibiotic sensitivity data, already compromised by the shift to nucleic acid-based testing. This is particularly relevant to remote areas where culture viability is problematic.

CONCLUSIONS

Results indicate a high level of support from clinicians and public health practitioners for wider access to CT/NG POC tests citing potential benefits, including earlier, more accurate treatment decisions and reductions in ongoing transmission. However, the data also highlight the need for new systems to avoid adverse impact on disease surveillance.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry: ACTRN12613000808741.

Management of blunt liver injury: what is new?

Nonoperative management has become the surgical treatment of choice in the hemodynamically stable patient with blunt hepatic trauma. The increased use and success of nonoperative management have been facilitated by the development of increasingly higher resolution computed tomography imaging, improved management of physiology and resuscitation (damage control), and routine availability of interventional procedures such as angiography and embolization, image-guided percutaneous drainage, and endoscopy. On the other hand, recognition of the patient who should proceed to immediate laparotomy is of utmost importance. A systematic and logical approach to the control of hemorrhage is required in the operating room. Thorough knowledge of the anatomy and surgical techniques, such as perihepatic packing, effective Pringle maneuver, hepatic mobilization, infrahepatic and suprahepatic control of the IVC, and stapled hepatectomy, is essential.

Impact of ABO blood group mismatch in alemtuzumab-based reduced-intensity conditioned haematopoietic SCT

The impact of ABO incompatibility on clinical outcomes following haematopoietic SCT (HSCT) remains controversial. This retrospective study assessed the effect of ABO mismatch on transplant outcomes and transfusion requirements in 594 patients undergoing reduced-intensity conditioned (RIC) HSCT with alemtuzumab in three UK transplant centres. We found no significant effects of minor, major or bidirectional ABO mismatch on overall survival, relapse-free survival, nonrelapse mortality or relapse incidence. Although the rate of acute GVHD was unaffected by ABO mismatch, the incidence of extensive chronic GVHD was higher in patients with minor and major mismatch compared with those who were ABO matched (hazard ratio (HR) 1.74, P=0.032 for minor, HR 1.69 P=0.0036 for major mismatch). Red cell and platelet transfusion requirements in the first 100 days post transplant did not differ by ABO mismatch. In this large UK series, ABO mismatch in RIC HSCT has no clinically significant effect on survival outcomes but appears to modify susceptibility to extensive chronic GVHD.

Disease activity in lupus correlates with expression of the transcription factor ARID3a (BA2P.119)

Systemic lupus erythematosus (SLE) is a complex autoimmune disease with striking clinical, immunologic and genetic heterogeneity making development of targeted treatment strategies challenging. Previously, we showed transgenic mice with constitutive expression of the DNA-binding protein ARID3a/Bright in all B lymphocytes spontaneously produced autoantibodies. Therefore, we asked if ARID3a expression differed in SLE versus healthy control B lymphocytes. Of 114 SLE patients, 43% had expanded numbers of ARID3a+ peripheral blood B cells. A longitudinal study revealed that numbers of ARID3a+ B cells fluctuated with time, but were highly associated with increased disease activity. ARID3a expression was not limited to B cell subsets that normally express it, but was also apparent in large numbers of naïve B cells in many SLE patients. Therefore, we hypothesize ARID3a+ naïve B cells are precursors of autoantibody producing B cells. Antibody repertoire analyses of ARID3a+ and ARID3a- naïve B cells are in progress. Together, these findings implicate ARID3a as a potential biomarker for disease activity in SLE.

Hepatitis C disease burden and strategies to manage the burden (Guest Editors Mark Thursz, Gregory Dore and John Ward)

Chronic hepatitis C virus (HCV) infection leads to liver fibrosis, cirrhosis and hepatocellular carcinoma (HCC). The recent Global Burden of Disease project estimated that in 2010 among 170 million people living with chronic HCV, an estimated 483,100 people died from HCV-related liver failure or HCC. The last two decades has seen progressive improvements in treatment of HCV infection with the most recent therapies offering simple, tolerable, short-duration therapy with extremely high efficacy. The development of public health strategies addressing emerging epidemics requires sound epidemiological data. This study covers epidemiological data collection, detailed expert opinion input and country-specific mathematical modelling of the HCV epidemic and potential impact of improved HCV treatment strategies in 16 countries. The analysis demonstrates that the HCV epidemics vary considerably in terms of age distribution of the infected population across countries. In addition, the burden of advanced liver disease varies widely. This burden is dependent upon factors including chronic HCV prevalence, age distribution (and duration of infection) of those infected, prevalence of cofactors for disease progression (particularly heavy alcohol intake) and uptake and success of therapeutic intervention. Introduction of new therapies with assumed sustained virological response (SVR) rate of >90% will have a modest impact on projected advanced liver disease burden. A combination of enhanced treatment efficacy and improved treatment uptake will have a greater impact on population-level disease burden. However public health advocacy and both public and private sector investment in the HCV response are required to demonstrate significant reduction in HCV disease burden.

Differential expression of the transcription factor ARID3a in lupus patient hematopoietic progenitors may affect function (BA12P.101)

Autologous hematopoietic stem cell (HSC) transplants have been used for severe cases of autoimmune disease, but success rates for systemic lupus erythrematosus (SLE) patients are less than for other autoimmune diseases. We recently found >40% of SLE patients had increased numbers of peripheral B lymphocytes that express the DNA-binding protein ARID3a, and that numbers of ARID3a+ B cells were associated with increased disease activity. Because ARID3a is also expressed in HSCs, we queried if SLE CD34+ cells abnormally express ARID3a. Indeed, nearly 40% of SLE patients had increased numbers of CD34+ cells with higher expression of ARID3a compared to healthy controls. Progenitors with increased ARID3a expression showed enhanced proliferation in vitro relative to other SLE cultures, and those progenitors generated increased numbers of cells that retained CD34 expression. We hypothesize that variation in ARID3a expression in hematopoietic progenitors contributes to variability in engraftment and are testing that hypothesis using humanized mice. Together, these data suggest new functions for ARID3a in HSCs and autoimmunity.