Optimising physiotherapy for people with lateral elbow tendinopathy - Results of a mixed-methods pilot and feasibility randomised controlled trial (OPTimisE)

BACKGROUND

The OPTimisE intervention was developed to address uncertainty regarding the most effective physiotherapy treatment strategy for people with Lateral Elbow Tendinopathy (LET).

OBJECTIVES

To assess the feasibility of conducting a fully-powered randomised controlled trial (RCT) evaluating whether the OPTimisE intervention is superior to usual physiotherapy treatment for adults with LET.

DESIGN

A mixed-methods multi-centred, parallel pilot and feasibility RCT, conducted in three outpatient physiotherapy departments in the UK.

METHOD

Patients were independently randomised 1:1 in mixed blocks, stratified by site, to the OPTimisE intervention or usual care. Outcomes were assessed using pre-defined feasibility progression criteria.

RESULTS

50 patients were randomised (22 Female, 28 Male), mean age 48 years (range 27-75). Consent rate was 71% (50/70), fidelity to intervention 89% (16/18), attendance rate in the OPTimisE group 82% (55/67) vs 85% (56/66) in usual care, outcome measure completion 81% (39/48) at six-month follow-up. There were no related adverse events. Patients and physiotherapists reported that the OPTimisE intervention was acceptable but suggested improvements to the trial design. 49 patients were recruited from physiotherapy referrals vs one from primary care records. Outcome measure return rates were higher when completed online (74%) compared to postal questionnaire (50%). Exploratory analysis showed improvements in both groups over time.

CONCLUSIONS

It is methodologically feasible to conduct a fully powered RCT comparing the clinical and cost-effectiveness of the OPTimisE intervention versus usual physiotherapy treatment. Considering the similar improvements observed in both groups, careful consideration is needed regarding the priority research question to be addressed in future research.

Comparing an optimised physiotherapy treatment package with usual physiotherapy care for people with tennis elbow - protocol for the OPTimisE pilot and feasibility randomised controlled trial

BACKGROUND

Physiotherapy is recommended for people with tennis elbow, but whilst a wide array of treatments is available, the optimal approach remains uncertain. We have therefore recently developed an optimised physiotherapy treatment package for tennis elbow based on a synthesis of the evidence, patient input and clinical consensus. It consists of detailed advice and education, a structured progressive exercise programme and provision of a counter-force elbow brace. Here, we report the protocol for our multicentre pilot and feasibility randomised controlled trial (RCT) designed to (a) examine the feasibility of our optimised physiotherapy treatment package and (b) to pilot trial processes for a future fully powered RCT to test clinical and cost-effectiveness compared with usual physiotherapy treatment.

METHODS

A multicentre pilot and feasibility RCT will be conducted across three sites in England, recruiting up to 50 patients (or for a maximum of 12 months). Participants with tennis elbow, identified from physiotherapy clinic waiting lists and general practice surgeries, will be randomly allocated to receive the optimised physiotherapy treatment package or usual physiotherapy care. Analysis will focus on feasibility measures including consent rate, intervention fidelity, follow-up rate and outcome completion rate. A nested qualitative study will explore the acceptability of the study processes and patient and physiotherapist experiences of the new optimised intervention.

DISCUSSION

This study will determine the feasibility of a new optimised physiotherapy treatment package for people with tennis elbow and pilot the processes for a future fully powered RCT. In the longer term, this treatment package may provide superior clinical outcomes for patients, in terms of pain and quality of life, and be more cost-effective for the health service.

TRIAL REGISTRATION

Registered with the ISRCTN database 19/7/2021, https://www.isrctn.com/ISRCTN64444585.

Current physiotherapy practice in the management of tennis elbow: A service evaluation

BACKGROUND

Tennis elbow is a common painful condition that may affect daily function and ability to work. Physiotherapy is the most commonly used primary intervention but there is a wide range of treatment options within the umbrella of physiotherapy. Our aim was to report on the treatments that are currently used by physiotherapists in a UK National Health Service (NHS) setting.

METHODS

A retrospective service evaluation was conducted at two NHS hospital trusts by reviewing patient attendance records over a 1-year period. All patients with tennis elbow were included, except those referred for postoperative rehabilitation. Patient notes were analysed using a predefined assessment template.

RESULTS

A total of 65 patient records were identified, with patients having a mean age 48 years and mean symptom duration of 5.4 months. The mean treatment duration was 64 days, over 3.7 sessions. The most commonly used treatments were education and exercise, although the type and dosing of exercise varied greatly. Passive modalities such as ice, taping, manual therapy, acupuncture and electrotherapy were still used.

CONCLUSIONS

Wide variations in treatment approaches were identified. There was no consistency in the choice of modality used, the type of exercise or the dose of exercise prescribed. The use of passive modalities and corticosteroid injections was found to remain commonplace, despite a lack of supporting research evidence. There is a clear need for evidence-based guidance for physiotherapists treating patients with tennis elbow.

Molecular characterization of a novel luteovirus from peach identified by high-throughput sequencing

Contigs with sequence homologies to cherry-associated luteovirus were identified by high-throughput sequencing analysis in two peach accessions. Complete genomic sequences of the two isolates of this virus were determined to be 5,819 and 5,814 nucleotides long, respectively. The genome of the new virus is typical of luteoviruses, containing eight open reading frames in a very similar arrangement. Its genomic sequence is 58-74% identical to those of other members of the genus Luteovirus. These sequences thus belong to a new virus, which we have named "peach-associated luteovirus".

Reverse total shoulder arthroplasty using a trabecular metal glenoid base plate

Aim

We present the medium-term clinical results of a reverse total shoulder arthroplasty with a trabecular metal glenoid base plate.

Patients and Methods

We reviewed 125 consecutive primary reverse total shoulder arthroplasties (RTSA) implanted in 124 patients for rotator cuff arthropathy. There were 100 women and 24 men in the study group with a mean age of 76 years (58 to 89). The mean follow-up was 32 months (24 to 60). No patient was lost to follow-up.

Conclusion

The clinical results of this large independent single unit series are comparable to those from previous series of RTSA reported in the literature. A trabecular metal base plate is safe and effective in the medium-term. Cite this article: Bone Joint J 2016;98-B:969–75.

Derivation of the clinical grade human embryonic stem cell line RCe013-A (RC-9)

The human embryonic stem cell line RCe013-A (RC-9) was derived under quality assured compliance with UK regulation, European Union Directives and International guidance for tissue procurement, processing and storage according to Good Manufacturing Practice (GMP) standards. The cell line was derived from a failed to fertilise oocyte voluntarily donated as unsuitable and surplus to fertility requirements following informed consent. RCe013-A (RC-9) shows normal pluripotency marker expression and differentiation to the three germ layers in vitro and in vivo. It has a normal 46XY male karyotype and microsatellite PCR identity, HLA and blood group typing data are available.

Design of a Novel Perfusion System to Perform MR Imaging of an Isolated Beating Heart

Isolated mammalian hearts have been used to study cardiac physiology, pharmacology, and biomedical devices in order to separate myocardial characteristics from the milieu of the intact animal and to allow for increased control over experimental conditions. Considering these benefits and that MRI is the “gold” standard for measuring myocardial function, it was considered desirable to have a system which would allow simultaneous MR imaging of an isolated beating heart. Here we describe a unique portable system, which enables physiologic perfusion of an isolated heart during simultaneous MR imaging. A two unit system was designed to physiologically support a large mammalian isolated heart during MR imaging were a modified Krebs-Henseleit perfusate was used as a blood substitute. The first unit, which resides in an adjacent support room next to the scanner, contains all electronically powered equipment and components (with ferromagnetic materials) which cannot operate safely near the magnet, including (1) a thermal module and custom tube in tube heat exchanger warming the perfusate to 38°C; (2) a carbogen tank (95% O2 5% CO2) and hollow fiber oxygenator; and (3) two centrifugal blood pumps which circulates and pressurizes the left and right atrial filling chambers. The second unit, which resides next to the magnet and is free of ferromagnetic materials, receives warmed, oxygenated perfusate from the first unit via PVC tubing. The isolated hearts were connected to the second unit via four cannulae sutured to the great vessels. A support system placed inside the scanner on the patient bed secured the hearts and cannulae in the correct anatomical position. To date, this system was tested in a 1.5 T Siemens scanner using swine hearts (n=2). The hearts were arrested with St. Thomas cardioplegia and removed via a medial sternotomy. After cannulation of the great vessels, reperfusion, and defibrillation, four-chamber and tagged short-axis cine loops were acquired using standard ECG gating. Tagged short-axis images obtained at the base, mid-ventricle, and apex were used to measure the following functional parameters for one heart: LV end-diastolic volume=38.84 ml, LV end-systolic volume=23.23 ml, LV stroke volume=15.6 ml, LV ejection fraction=40.18%, and peak LV circumferential strain=16%. The feasibility of MR imaging an isolated, four-chamber working large mammalian heart was demonstrated using a custom designed and built portable MRI compatible perfusion system. This system will be useful in studying in vitro cardiac function (including human hearts) and developing MRI safe biomedical devices and MRI guided therapies in a controlled setting.

Structure-function relationships of insulin-like growth factor binding protein 6 (IGFBP-6) and its chimeras

Insulin-like growth factor binding protein 6 (IGFBP-6) is a high-affinity IGFBP with substantially greater affinity for insulin-like growth factor-II (IGF-II) than IGF-I. IGFBP-6(3) is a chimera which has a 20 amino acidC -terminal portion of IGFBP-6 switched with the homologous area of IGFBP-3, P3. Unlike IGFBP-4(3), in which the P3 region was exchanged for the homologous region of IGFBP-4 (P4), IGFBP-6(3) does not bind to endothelial cells. Double mutations were made with the P3 region exchanged as well as a second area differing from IGFBP-3 to form IGFBP-6(3)A and IGFBP-6(3)B, by replacing this area with the homologous region of IGFBP-3. Neither [(125)I]IGFBP-6(3)A nor IGFBP-6(3)B specifically bound to endothelial cells. However, each double mutant competed for [(125)I]IGFBP-3 binding to cultured cells. In the perfused heart, transendothelial transport of IGFBP-6 and IGFBP-6(3) was only 25% of similar transendothelial transport of perfused IGFBP-3. We conclude that chimeras of IGFBP-6 and IGFBP-3(6) clearly differ from IGFBP-4(3) in their ability to bind specifically to endothelial cells and in their capacity to undergo transendothelial transportation in the perfused heart.

The 10q25 neocentromere and its inactive progenitor have identical primary nucleotide sequence: further evidence for epigenetic modification

We have previously localized the core centromere protein-binding domain of a 10q25.2-derived neocentromere to an 80-kb genomic region. Detailed analysis has indicated that the 80-kb neocentromere (NC) DNA has a similar overall organization to the corresponding region on a normal chromosome 10 (HC) DNA, derived from a genetically unrelated CEPH individual. Here we report sequencing of the HC DNA and its comparison to the NC sequence. Single-base differences were observed at a maximum rate of 4.6 per kb; however, no deletions, insertions, or other structural rearrangements were detected. To investigate whether the observed changes, or subsets of these, might be de novo mutations involved in neocentromerization (i.e., in committing a region of a chromosome to neocentromere formation), the progenitor DNA (PnC) from which the NC DNA descended, was cloned and sequenced. Direct comparison of the PnC and NC sequences revealed 100% identity, suggesting that the differences between NC and HC DNA are single nucleotide polymorphisms (SNPs) and that formation of the 10q25.2 NC did not involve a change in DNA sequence in the core centromere protein-binding NC region. This is the first study in which a cloned NC DNA has been compared directly with its inactive progenitor DNA at the primary sequence level. The results form the basis for future sequence comparison outside the core protein-binding domain, and provide direct support for the involvement of an epigenetic mechanism in neocentromerization.

Cancer incidence and mortality among African Americans

In the future, the largest proportional increase in the population will be among minority groups. To date, there are a number of studies which document the disparities in cancer incidence and survival existing between white Americans and minorities, especially African Americans. African Americans have the highest cancer incidence and mortality rates in the United States. Much of this difference can be directly related to socioeconomic status. There are also cultural differences which result in differing attitudes towards health care. In the future, interventions designed to encourage cancer prevention and screening behaviors must seek to overcome the barriers to access in a culturally sensitive fashion.

Prospective evaluation of prognostic variables from patient-completed questionnaires. North Central Cancer Treatment Group

PURPOSE

This study was developed to determine whether descriptive information from a patient-completed questionnaire could provide prognostic information that was independent from that already obtained by the patient's physician.

PATIENTS AND METHODS

An initial detailed questionnaire was administered to approximately 150 patients with advanced cancer. This questionnaire was subsequently revised and given to a total of 1,115 patients with advanced colorectal or lung cancer. Univariate and multivariate analyses were performed to evaluate the data from these questionnaires.

RESULTS

A total of 36 variables showed statistically significant prognostic information for survival in univariate analyses, even though many of these variables were associated with only a minimal increase in risk. A multivariate analysis demonstrated that there was a high correlation between many variables. Three major groups of variables became apparent as providing strong prognostic information. These included the following: (1) a physician's assessment of performance status (PS); (2) a patient's assessment of their own PS; and (3) a nutritional factor such as appetite, caloric intake, or overall food intake.

CONCLUSION

Data generated by a patient-completed questionnaire can provide important prognostic information independent from that obtained by other physician-determined prognostic factors.

The efficacy in Navajo infants of a conjugate vaccine consisting of Haemophilus influenzae type b polysaccharide and Neisseria meningitidis outer-membrane protein complex

BACKGROUND AND METHODS

Several conjugate vaccines against Haemophilus influenzae type b have been developed in the search for one that induces protection even in young infants. We evaluated the safety and efficacy of a conjugate vaccine that links the H. influenzae type b capsular polysaccharide to the outer-membrane protein complex (OMPC) of Neisseria meningitidis serogroup B. We conducted a double-blind, placebo, controlled trial in Navajo infants, who are at high risk for systemic infections caused by H. influenzae type b. The infants were randomly assigned to receive the first dose of vaccine or placebo at 42 to 90 days of age and the second at 70 to 146 days of age.

RESULTS

Of the infants in the trial, 2588 were assigned to receive the vaccine and 2602 to receive placebo. The mean follow-up was 269 days in the vaccine group and 267 days in the placebo group. Before the age of 18 months, there was 1 systemic H. influenzae type b infection in the vaccine group, as compared with 22 in the placebo group (P less than 0.001; point estimate of efficacy, 95 percent; 95 percent confidence interval, 72 to 99 percent). Of the 22 H. influenzae type b infections in the placebo group, 13 were meningitis. Among the children who received both doses, there was 1 H. influenzae type b infection in the vaccine group (n = 2056) and 14 in the placebo group (n = 2105) (P less than 0.001; point estimate of efficacy, 93 percent; 95 percent confidence interval, 53 to 98 percent). The single infection in the vaccine group occurred at 15 1/2 months of age in an infant with osteomyelitis. Between the first and second doses there were no H. influenzae type b infections in the vaccine group and eight in the placebo group (P less than 0.005; point estimate of efficacy, 100 percent; 95 percent confidence interval, 41 to 100 percent).

CONCLUSIONS

The H. influenzae type b OMPC vaccine, administered at 2 and 4 months of age, is safe and induces a high rate of protection against invasive disease caused by H. influenzae type b in infants under the age of 18 months. Protection begins after the first dose.

The antiemetic efficacy of secobarbital and chlorpromazine compared to metoclopramide, diphenhydramine, and dexamethasone. A randomized trial

The efficacy of secobarbital sodium plus chlorpromazine (SC) in the prevention of cisplatin induced emesis was compared to the combination of metoclopramide, diphenhydramine, and dexamethasone (MDD). Twenty-three patients were entered onto protocol. Eighteen were evaluable. Good to excellent antiemetic prophylaxis was obtained in 72% with MDD versus 17% with SC (P less than 0.01). Sedation and anticholinergic side effects were more common with SC. Extrapyramidal reactions were more commonly seen with MDD. Significantly more patients preferred the combination of metoclopramide, diphenhydramine, and dexamethasone (P less than 0.05).

Do saliva concentrations predict plasma unbound theophylline concentrations? A problem re-examined

On the assumption that plasma unbound drug concentrations are therapeutically active, the value of saliva concentrations in predicting plasma unbound theophylline concentrations was investigated in 25 ambulatory adults (aged 27 to 84 years) receiving theophylline (225-1350 mg aminophylline daily) for asthma or chronic bronchitis. Plasma samples from all patients were ultrafiltered, and the plasma unbound theophylline (F) concentrations were compared with the corresponding total plasma (P), citric acid stimulated saliva (S) and non-stimulated saliva (Ns) theophylline concentrations. Plasma unbound theophylline concentrations correlated significantly with P (r = 0.97) and S (r = 0.973), but less well with Ns (r = 0.883), emphasising the benefit of saliva stimulation. The ability of S to predict F theophylline concentrations was assessed using the mean ratio of 0.7297. In 92% of the patients, predicted F concentrations were within +/- 1 microgram/ml of the measured concentrations. Similarly, using the mean F/P ratio of 0.418, predicted P were within +/- 1 microgram/ml of obtained P in 84% patients, and using the mean S/P ratio of 0.568, predicted P were within +/- 1 microgram/ml of obtained P in 81%. An accuracy of +/- 1 microgram/ml in estimating F from S concentrations would be sufficient to indicate appropriate dose adjustments, and we therefore advocate the use of stimulated saliva samples for routine monitoring of theophylline therapy.