Foot Strike Run Retraining for Patients With Patellofemoral Chondral Defects: A Case Series

Military service members (SMs) demonstrate high rates of patellofemoral chondral defects (PFCDs) that are difficult to diagnosis and, if untreated, result in a cascade of events eventually leading to osteoarthritis. Running is an essential occupational task for SMs; however, there is little evidence regarding techniques to maintain running ability in individuals with cartilage defects. The purpose of this case series was to assess the clinical application of foot strike run retraining in patients with PFCDs. This case series included two active duty U.S. Marine Corps SMs who presented to outpatient physical therapy with PFCD, diagnosed via MRI. Both patients attended eight foot strike run retraining sessions. Running mechanics and patient-reported outcomes were recorded pre-training, post-training, and at a 1-month follow-up visit. Both patients successfully converted their strike pattern from a rearfoot to a non-rearfoot strike pattern with training and retained this strategy at 1-month follow-up. Post-intervention, both patients demonstrated increased running tolerance, and improvements in Numeric Pain Rating Scale and Lower Extremity Functional Scale scores. Biomechanical analysis showed that both patients demonstrated a 63% to 70% reduction in average and peak vertical ground reaction force loading rates post-treatment. Modification of foot strike pattern from rear to non-rearfoot strike during running for individuals with PFCD can reduce the magnitude of impact loading, which potentially limits disease progression. These findings suggest that foot strike run retraining may be a feasible strategy to reduce pain and improve function in SMs with PFCD who are required to run for occupational responsibilities.

Objective and subjective measures to guide upper extremity return to sport testing: A modified Delphi survey

OBJECTIVE

To identify which subjective and objective tests do content experts utilize to help guide return to sport (RTS) decision making for an athlete after an upper extremity (UE) injury?

METHODS

A modified Delphi survey was utilized, including content experts in UE rehabilitation. Survey items were identified based on a literature review identifying current best evidence and practice for UE RTS decision making. Content experts (n = 52) were identified, having a minimum of 10 years of experience with rehabilitation of UE athletic injuries, and 5 years of experience using an UE RTS algorithm to guide decision making.

RESULTS

Expert consensus was achieved on a combination of tests utilized within an UE RTS algorithm: 1. Tissue healing time frame is an important consideration in RTS decision making; 2. Patient reported outcome measures should be utilized specifically, DASH and NPRS 3. Strength is measured by handheld dynamometer and is an important consideration. 4. ROM should be utilized and is an important consideration. 5. Physical performance tests utilized include: Closed Kinetic Chain Upper Extremity Stability test, Seated shot-put test and lower extremity/core tests.

CONCLUSIONS

This survey reached expert consensus on which subjective and objective measures to utilize to evaluate RTS readiness after UE injury.

The association between kinesiophobia and functional limitations in service members with knee pain

BACKGROUND

Knee diagnoses account for more than 50% of lower extremity musculoskeletal conditions in non-deployed US Service members. However, there is limited information regarding kinesiophobia in Service members with non-operative knee diagnoses.

HYPOTHESES

The objectives of this study were to determine the prevalence of high levels of kinesiophobia in US military Service members with knee pain across different knee diagnoses, and to determine the relationships between kinesiophobia and lower extremity function and/or specific functional limitations in Service members with knee pain. It was hypothesized Service members with knee pain would exhibit high levels of kinesiophobia across all knee diagnoses examined, and higher levels of both kinesiophobia and pain would be associated with worse self-reported function in this population. It was also hypothesized higher levels of kinesiophobia would be associated with functional activities with high knee loading.

DESIGN

Retrospective cohort study.

LEVEL OF EVIDENCE

IV.

METHODS

Sixty-five US Service members presenting to an outpatient physical therapy clinic were included in this study (20 females; age = 30.8 ± 7.7 years; height = 1.74 ± 0.9 m; mass = 80.7 ± 16.2 kg). Inclusion criterion was the presence of knee pain (duration = 50 ± 59 months); exclusion criterion was knee pain as a sequela of knee surgery. Data regarding demographic, pain chronicity, pain by Numeric Rating Scale (NRS), Tampa Scale of Kinesiophobia (TSK), and Lower Extremity Functional Scale (LEFS) were retrospectively obtained from patients' medical records. A high level of kinesiophobia was defined as a TSK score of greater than 37 points. Patient diagnoses included: osteoarthritis (n = 16); patellofemoral pain syndrome (n = 23); and other non-operative knee diagnoses (n = 26). Commonality analysis was utilized to determine the effects of age, height, mass, NRS, and TSK on LEFS score. Predictor values were interpreted as <1% = negligible, >1% = small; >9% = moderate, >25% = large. Additionally, exploratory item-specific analyses examined the strength of the relationships between kinesiophobia and LEFS item responses. Binary logistic regression determined if difficulty with an individual LEFS item could be predicted from either NRS or TSK score. Statistical significance was set at P < 0.05.

RESULTS

High levels of kinesiophobia were identified in 43 individuals (66%). NRS and TSK explained 19.4% and 8.6% of the unique variance in LEFS, and 38.5% and 20.5% of total variance, respectively. Age, height, and mass explained negligible to small proportions of the unique variance in LEFS. TSK and NRS were independent predictors for 13/20 individual LEFS items, with odds ratios ranging from 1.12 to 3.05 (P < 0.05).

CONCLUSION

The majority of US Service members in this study exhibited high levels of kinesiophobia. Kinesiophobia was significantly related to self-reported functional scores and performance on individual functional tasks in Service members with knee pain.

CLINICAL RELEVANCE

Treatment strategies addressing both fear of movement and pain reduction in patients with knee pain may help optimize functional outcomes.

Traumatic Hip Dislocation in an NCAA DI Football Player with Occult Sequelae: A Case Report

BACKGROUND AND PURPOSE

American football generates the most sports-related injuries in the United States, with tackling as the leading injury mechanism. Overall injury rate at the collegiate level has been reported as 8.61 per 1,000 athlete exposures (AEs) - twice the rate of high school levels; competition injury rates are reported as high as 36.94/1000 AEs. Traumatic hip dislocation is an uncommon injury typically arising from high-energy axial impact with only 2-5.5% occurring during sports activities.

CASE DESCRIPTION

A 22-year-old NCAA Division I football defensive back who experienced extreme left hip pain following contact with another player with his hip flexed during a game was diagnosed with a type 1 posterior hip dislocation, a grade 1 medial collateral ligament sprain with concomitant posterior thigh and hip muscle strains. Key impairments were limited left lower extremity motor performance, range of motion deficits, left hip pain, and diminished function and weight-bearing ability.

OUTCOMES

The athlete reintegrated into typical defensive back off-season training approximately four to five months post injury without restrictions, however presented with new anterior hip pain seven months post injury revealing occult sequelae requiring surgical intervention. He was able to return to full play the following football season.

DISCUSSION

This case report describes the successful return to sport of a Division I football player who sustained a traumatic posterior hip dislocation and complicated course including surgical intervention secondary to associated sequelae.

LEVEL OF EVIDENCE

5.

Implementation of an Injury Prevention Program in NCAA Division I Athletics Reduces Injury-Related Health Care Costs

Background:

The estimated cost per year of injuries in collegiate athletics has been reported to be billions of dollars in the United States. Injury prevention programs are often assessed only by their ability to reduce injuries, and there is little evidence of any potential reduction in associated health care costs.

Purpose:

To investigate changes in injury-related health care costs at a National Collegiate Athletic Association (NCAA) Division I university after the implementation of an injury prevention program.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included were 12 sports teams that used the injury prevention program (user group) and 16 teams that did not implement the program (nonuser group). The injury surveillance and prevention system (Sparta Science) utilized a commercially available force-plate system to assess kinematic variables, flag high-risk athletes, and guide individual conditioning programs. Data were obtained from 3 academic years before (2012-2014) and 2 academic years after (2015-2016) implementation of the Sparta Science system. The number of injuries and associated health care costs (surgery, clinic visits, imaging, and physical therapy) were compared between users and nonusers.

Results:

Total average annual injuries did not change significantly between users and nonusers after implementation of the program; however, users demonstrated a 23% reduction in clinic visits as compared with a 14% increase for nonusers (P = .049). Users demonstrated a 13% reduction in associated health care encounters, compared with a 13% increase for nonusers (P = .032). Overall health care costs changed significantly for both groups, with an observed 19% decrease ($2,456,154 to $1,978,799) for users and an 8% increase ($1,177,542 to $1,270,846) for nonusers (P < .01 for both). Costs related to associated health care encounters also decreased by 20% for users as compared with a 39% increase for nonusers (P = .027).

Conclusion:

This study demonstrated the ability to significantly reduce injury-related health care costs in NCAA Division I athletes via a comprehensive injury surveillance and prevention program utilizing force-plate technology. Given the substantial and appropriate focus on value of care delivery across the US health care system, we recommend the continued study of sports injury surveillance and prevention programs for reducing injury-related health care costs.

Prediction of ACL Injuries from Vertical Jump Kinetics in Division 1 Collegiate Athletes

BACKGROUND

The incidence of ACL injuries continues to rise secondary to an increase in sport participation. Evidence supports the use of force plate testing to quantify kinetics during rehabilitation after injury and recovery; however, there is limited current research regarding if jump kinetics can identify athletes who are at higher risk for injury. Altered kinetics could potentially lead to abnormal force dissipation and resultant injury.

PURPOSE

The purpose of this investigation was to identify whether the force-time variables from vertical jumps could predict ACL injuries in collegiate athletes.

STUDY DESIGN

Retrospective cohort.

METHODS

Vertical jump testing is performed by all healthy varsity collegiate athletes at several intervals throughout the athletic year at a Division I institution using a commercially available force plate system with dedicated software. Athletes who sustained an ACL injury between 1/1/15 and 6/1/19 were identified (n=16) and compared to healthy athletes who participated in the same sports (n = 262). ACL injuries were considered for this study if they occurred no more than 10 weeks after a jump test. The outcome variables were load, explode, and drive, operationally defined as the average eccentric rate of force development, average relative concentric force, and concentric relative impulse, respectively, which the system normalized to T scores. Mann-Whitney U tests were used to assess group differences for load, explode, drive, and the ratio between the variables. Logistic regression was used to determine if the battery of variables could predict whether or not an athlete would sustain an ACL injury. The p-value was set to 0.10 for the Mann-Whitney U tests, and 0.05 for the logistic regression.

RESULTS

Significant differences between the ACL and healthy groups were seen for explode (p=0.08), drive (p=0.06), load:explode ratio (p=0.06), and explode:drive ratio (p=0.03). Explode and drive, when entered into the regression equation, showed the ability to predict injury, χ 2 = 6.8, df = 2, p=0.03.

CONCLUSIONS

The vertical jump force plate variables were able to identify athletes who sustained an ACL injury within 66 days of testing. Athletes who sustained an ACL injury demonstrated altered kinetics and less ability to transmit forces during the vertical jump.

LEVEL OF EVIDENCE

3.

Comparison of core neuromuscular control and lower extremity postural stability in athletes with and without shoulder injuries

BACKGROUND

The kinetic chain theory is widely used as a rationale for the inclusion of core stability training in athletes. Core stability (muscle capacity and neuromuscular control) impairments may result in less than optimal performance and abnormal force dissipation to the shoulder complex that could lead to shoulder injuries. However, a paucity of literature exists to support this relationship, and no previous studies have investigated the relationship between isolated core neuromuscular control and shoulder injuries. Additionally, lower extremity postural stability has been associated with athletic function and may also be associated with shoulder injuries. The purpose of this study was to compare biomechanical measures of isolated core neuromuscular control and lower extremity postural stability between athletes with and without non-traumatic shoulder injuries.

METHODS

Eighty athletes (55 males, age: 21.2 ± 3.3 years, 40 with a current shoulder injury) completed biomechanical measures of isolated core neuromuscular control and lower extremity postural stability. Athletes were matched by age, gender, body mass index, and sport type. MANOVAs were used to assess differences between measures of core neuromuscular control and lower extremity postural stability between groups.

FINDINGS

There were no statistically significant differences between athletes with and without shoulder injuries for the static core neuromuscular control measures, F(4,75) = 0.45, P = 0.78, η² = 0.02; dynamic core neuromuscular control measures, F(4,75) = 0.81, P = 0.52, η² = 0.04; or lower extremity postural stability measures, F(8,61) = 0.85, P = 0.56, η² = 0.10.

INTERPRETATION

Although core stability is widely incorporated in rehabilitation of athletes with shoulder injuries, athletes with current non-traumatic shoulder injuries may not present with impairments in core neuromuscular control or lower extremity postural stability.

Comprehensive movement system screening tool (MSST) for athletes: Development and measurement properties

OBJECTIVES

Non-traumatic extremity injuries are particularly common in sports, representing a significant economic, academic, and psychosocial burden on athletes. Proposed musculoskeletal risk factors for increased injury and decreased performance in athletes include movement pattern inefficiency, decreased regional stability, decreased mobility, and asymmetrical movement. The Movement System Screening Tool (MSST) is a comprehensive screening tool designed to assess these factors. Thus, the purpose of this study was to describe the development and determine the content and construct validity and inter-rater reliability of the MSST.

METHODS

A modified Delphi panel of experts determined content validity. 80 athletes (40 with and 40 without a current non-traumatic shoulder injury) completed 21 clinical tests, with exploratory factor analysis and known group analysis performed to determine construct validity. Two independent raters were used to establish individual item and composite score inter-rater reliability.

RESULTS

Exploratory factor analysis identified three of the four apriori constructs over 7 factors (14 tests), representing 63% of the variance. Known group analysis revealed a significantly lower composite score in athletes with vs. without a current non-traumatic shoulder injury (56.9±5.8 vs. 62.7±4.5, respectively). A preliminary cut score of 62 was chosen with sensitivity of 85% and specificity of 44%. Composite score inter-rater reliability was excellent ICC _(2,1)=0.94, 95% CI (0.91, 0.96) and item reliability ranged from κ=.57 to 1.00.

CONCLUSIONS

The MSST possesses constructs representative of injury risk and measurement properties acceptable for use in clinical settings. Comprehensive screens with construct validity and known measurement error are needed not only to identify athletes at risk of injury, but also provide an instrument that can be used in studies that seek to validate training approaches proposed to change movement impairment and injury risk in athletes.

COMPARISON OF CORE STABILITY AND BALANCE IN ATHLETES WITH AND WITHOUT SHOULDER INJURIES

BACKGROUND

Relationships between core stability and lower extremity injuries have been described in the literature; however, evidence of the relationship between upper extremity injuries and core stability and balance is limited.

HYPOTHESIS/PURPOSE

The purpose of this study was to compare clinical measures of core stability and balance between athletes with and without non-traumatic shoulder injuries.

STUDY DESIGN

Cross sectional.

METHODS

Eighty athletes (54 males, age: 21.2 + 3.3 years) participated in this study. Forty athletes with a current shoulder injury were matched to healthy athletes by age, gender, BMI, and sport. Athletes completed clinical core stability tests including flexor and extensor endurance tests, double leg lower test (°) and balance tests including single leg stance under eyes open and eyes closed conditions, and the Y-balance test. MANOVAs were used to assess group differences.

RESULTS

No statistically significant differences existed between athletes with and without shoulder injuries for clinical tests of core stability, F(1,78)=0.97, p=0.41; η2 = 0.04. No statistically significant differences existed between injured athletes with and without shoulder injuries for static and dynamic balance measures, F(1,78)=0.86, p=0.53; η2 = 0.07.

CONCLUSIONS

Although core stability is widely incorporated in rehabilitation of athletes with shoulder injuries, performance on these clinical tests did not differ in the group of athletes assessed in this study.

LEVEL OF EVIDENCE

3.

Visual perception skills: a comparison between patients with Noonan syndrome and 22q11.2 deletion syndrome

Ventral and dorsal streams are visual pathways deputed to transmit information from the photoreceptors of the retina to the lateral geniculate nucleus and then to the primary visual cortex (V1). Several studies investigated whether one pathway is more vulnerable than the other during development, and whether these streams develop at different rates. The results are still discordant. The aim of the present study was to understand the functionality of the dorsal and the ventral streams in two populations affected by different genetic disorders, Noonan syndrome (NS) and 22q11.2 deletion syndrome (22q11.2DS), and explore the possible genotype-phenotype relationships. 'Form coherence' abilities for the ventral stream and 'motion coherence' abilities for the dorsal stream were evaluated in 19 participants with NS and 20 participants with 22q11.2DS. Collected data were compared with 55 age-matched controls. Participants with NS and 22q11.2DS did not differ in the form coherence task, and their performance was significantly lower than that of controls. However, in the motion coherence task, the group with NS and controls did not differ, and both obtained significantly higher scores than the group with 22q11.2DS. Our findings indicate that deficits in the dorsal stream are related to the specific genotype, and that in our syndromic groups the ventral stream is more vulnerable than the dorsal stream.

Efficacy of romantic and sexual psycho-educational training for adolescent with high-functioning autism spectrum disorder: A pilot study

Introduction

Romantic and sexual functioning in individuals with autism spectrum disorder (ASD) are understudied. Recent findings evidenced that adolescents and adults with present romantic and sexual behaviors comparable with their neurotypical peers. However, it is worth to note that dysfunctional and inappropriate romantic and sexual behaviors are often described in this population.

Objectives

To investigate efficacy of a psycho-educational training in a small group of adolescent with high-functioning ASD (HFA, QI > 70).

Methods

Six adolescents (all males, range age 14–16 years) have been evaluated before (T0) and after (T1) a 10-session sexual and romantic psycho-educational structured group training, of 90′ each session. Clinical evaluation included parent-report questionnaires, as SBS for sexual behaviors and CBCL for behavioral problems, and a self-report questionnaire for sexual behaviors, called SESAMO. Moreover, autistic symptoms were investigated with ADOS-2 at T0.

Results

Preliminary analysis revealed a statistically significant differences between T0 and T1 in sexual education (P = 0.02) and frequency of dysfunctional sexual behaviors (P = 0.02) of SBS and in sexual expectations about the partner in SESAMO (P = 0.04). No differences were found in CBCL.

Conclusion

Preliminary results showed an improvement of romantic and sexual functioning in adolescent boys with HFA, as reported by either parents and adolescents, after participating to a structured psycho-educational training. More sexual education and information, less inappropriate sexual behaviors and more-appropriate expectations about potential partner were reported at the end of the training. These results should be confirmed in studies including larger ASD and control sample.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Critical review of the impact of core stability on upper extremity athletic injury and performance

BACKGROUND

Programs designed to prevent or rehabilitate athletic injuries or improve athletic performance frequently focus on core stability. This approach is based upon the theory that poor core stability increases the risk of poor performance and/or injury. Despite the widespread use of core stability training amongst athletes, the question of whether or not sufficient evidence exists to support this practice remains to be answered.

OBJECTIVES

1) Open a dialogue on the definition and components of core stability. 2) Provide an overview of current science linking core stability to musculoskeletal injuries of the upper extremity. 3) Provide an overview of evidence for the association between core stability and athletic performance.

DISCUSSION

Core stability is the ability to control the position and movement of the trunk for optimal production, transfer, and control of forces to and from the upper and lower extremities during functional activities. Muscle capacity and neuromuscular control are critical components of core stability. A limited body of evidence provides some support for a link between core stability and upper extremity injuries amongst athletes who participate in baseball, football, or swimming. Likewise, few studies exist to support a relationship between core stability and athletic performance.

CONCLUSIONS

A limited body of evidence exists to support the use of core stability training in injury prevention or performance enhancement programs for athletes. Clearly more research is needed to inform decision making when it comes to inclusion or emphasis of core training when designing injury prevention and rehabilitation programs for athletes.

Prediction of in-season shoulder injury from preseason testing in division I collegiate football players

BACKGROUND

Collegiate football is a high-demand sport in which shoulder injuries are common. Research has described the incidence of these injuries, with little focus on causative factors or injury prevention.

HYPOTHESIS

Football athletes who score lower on preseason strength and functional testing are more likely to sustain an in-season shoulder injury.

STUDY DESIGN

Prospective, cohort study.

LEVEL OF EVIDENCE

Level 2.

METHODS

Twenty-six collegiate football players underwent preseason testing with a rotational profile for shoulder range of motion, isometric strength of the rotator cuff at 90° elevation and external rotation in the 90/90 position, fatigue testing (prone-Y, scaption, and standing cable press), and the Closed Kinetic Chain Upper Extremity Stability Test (CKCUEST). Data collected postseason included the type of shoulder injury and the side injured. Logistic regression was used to determine if the testing measures predicted injury, and a receiver operating characteristic curve was constructed to examine the relationship of CKCUEST to injury.

RESULTS

Six athletes sustained shoulder injuries during the season. Predictor variables could significantly predict whether that player would sustain an injury during the season for both the right and left shoulders (P < 0.05). The variables that were significantly correlated with injury of the right side were forward elevation strength, prone-Y to fatigue, and the CKCUEST (P < 0.05); on the left, only the CKCUEST was significant (P < 0.05). The area under the receiver operating characteristic curve for the CKCUEST was 0.86 (ϵ = 0.87, P = 0.01). Using a score of 21 touches, the CKCUEST had a sensitivity of 0.83, a specificity of 0.79, and an odds ratio of 18.75 in determining whether a player sustained a shoulder injury.

CONCLUSION

For this sample, the combination of preseason strength, fatigue, and functional testing was able to identify football players who would sustain a shoulder injury during the season.

CLINICAL RELEVANCE

Using a battery of strength, fatigue, and functional testing may be helpful in identifying football players during preseason who are at a higher risk for sustaining a shoulder injury. This information can be used to optimize preseason testing and implementation of injury prevention programs.

Is there evidence to support a forefoot strike pattern in barefoot runners? A review

Context:

Barefoot running is a trend among running enthusiasts that is the subject of much controversy. At this time, benefits appear to be more speculative and anecdotal than evidence based. Additionally, the risk of injuries is not well established.

Evidence acquisition:

A PubMed search was undertaken for articles published in English from 1980 to 2011. Additional references were accrued from reference lists of research articles.

Results:

While minimal data exist that definitively support barefoot running, there are data lending support to the argument that runners should use a forefoot strike pattern in lieu of a heel strike pattern to reduce ground reaction forces, ground contact time, and step length.

Conclusions:

Whether there is a positive or negative effect on injury has yet to be determined. Unquestionably, more research is needed before definitive conclusions can be drawn.

Shoulder musculature activity and stabilization during upper extremity weight-bearing activities

BACKGROUND

Upper extremity weight-bearing exercises are routinely used in physical therapy for patients with shoulder pathology. However, little evidence exists regarding the demand on the shoulder musculature.

OBJECTIVE

To examine changes in shoulder muscle activity and center of pressure during upper extremity weight-bearing exercises of increasing difficulty.

METHODS

Electromyographic (EMG) and kinetic data were recorded from both shoulders of 15 healthy subjects (10 male and 5 female). Participants were tested in a modified tripod position under three conditions of increasing difficulty: (1) hand directly on the force plate, (2) on a green Stability Trainer(™) and (3) on a blue Stability Trainer(™). Ground reaction forces were recorded for each trial. Surface EMG was recorded from the serratus anterior, pectoralis major, upper trapezius, lower trapezius, infraspinatus, anterior deltoid, posterior deltoid, and the lateral head of the triceps muscles.

RESULTS

Mean deviation from center of pressure significantly increased when using the Stability Trainer(™) pads. The activities of the triceps, serratus anterior, and anterior deltoid muscles significantly increased as each trial progressed, irrespective of stability condition. Additionally, activity in the anterior deltoid, lower trapezius, and serratus anterior muscles significantly decreased with increasing difficulty, whereas activity in the triceps muscles significantly increased.

DISCUSSION AND CONCLUSION

Balancing on a foam pad made it more difficult to maintain the upper extremity in a stable position. However, this activity did not alter the proprioceptive stimulus enough to elicit an increase in shoulder muscle activation. While the results on this study support the use of different level Stability Trainers(™) to facilitate neuromuscular re-education, a less compliant unstable surface may produce larger training effects.

[GnRH agonists and antagonists in the preoperative therapy of uterine fibroids: literature review]

Uterine leiomyomas are the most frequent gynecological benign tumors. Their growth is regulated by ovarian steroids, therefore a hypoestrogenic state, like menopause or pharmacologically induced pseudo-menopause by GnRH-agonists or GnRH-antagonists, is associated with the decrease of their volume. This volume reduction allows a less invasive surgical procedure and may reduce the amount of blood loss during surgery. Therefore, GnRH-agonists and antagonists are used in presurgical treatment of uterine fibromatosis. This review analyses the effects of GnRH-agonists and GnRH-antagonists therapies. GnRH-agonists produce a down-regulation of GnRH receptor, while GnRH-antagonists compete with endogenous GnRH for pituitary binding sites. Due to the lack of any intrinsic activity of GnRH-antagonists, the characteristic initial flare-up observed with GnRH-agonist treatment is absent. So, GnRH-antagonists rapidly suppress gonadotropin release within 4-8 h, while GnRH-agonists show clinical effects after 2 or 3 weeks of treatment. GnRH-antagonist activity is dose-dependent so it is possible to adjust the dose to obtain the proper levels of inhibition. The GnRH-agonist presurgical treatment usually is a short-term therapy (3-6 months), because it causes side-effects like menopause symptoms. GnRH-antagonist clinical effects can be achieved with a short-time therapy too. Their side-effects include flushes and head-ache. After stopping therapy with both drugs, leiomyomas rapidly achieve their original size while side-effects disappear. Further studies are necessary to establish the use of GnRH-antagonists in leiomyomas therapy, but in Italy this is not possible because their use is not approved.

Effects of gonadotropin-releasing hormone agonists on uterine volume and vasculature and on the immunohistochemical expression of basic fibroblast growth factor (bFGF) in uterine leiomyomas

We investigated the effect of the GnRH agonist (GnRH-a) on the uterine volume and on the immunohistochemical expression of basic fibroblast growth factor (bFGF) and the vasculature of leiomyomas. Twenty-five women were treated with leuprorelin acetate for 3 months; 46 untreated patients were enrolled as a control group. The uterine volume was measured by ultrasonography. After myomectomy or hysterectomy, the immunoexpression of bFGF and the endothelial marker, CD34, was studied and compared in treated and untreated leiomyomas. Uterine volume decreased after therapy. The number of cells expressing bFGF and the vascularity were diminished in treated leiomyomas. Reduction in the blood supply might be responsible, in part, for uterine-volume shrinkage after GnRH-a therapy.

[Prenatal telemedicine and teledidactic networking. A report on the TOCOMAT project]

Telemedicine originates with the combined use of electromedical equipment, information technologies and telecommunication systems designed to improve healthcare by overcoming the limitations of time and space. Moreover, telemedicine also possesses greater didactic potential than instruction by traditional means. Teledidactic networking, both as e-learning and e-teaching, represents a new integrated system of computer-aided education for the development and management of distance learning programs. Our study evaluated the effectiveness of teledidactic applications in the first Italian project in conventional and computerized telecardiotocography (TOCOMAT). Five cardiotocography outpatient monitoring facilities were linked telematically to a university central operating unit to obtain computerized analysis of telecardiotocographic (CTG) tracings and specialist consulting. The peripheral site operators received theoretical-practical training in the function and use of the system, the guidelines for CTG tracing interpretation and the diagnostic-therapeutic protocols. Improvement in learning progress was observed in the reduction of technical errors in CTG recording and in the increased ability of the outpatient clinic staff to select, analyze and interpret test RESULTS. Results from the feedback questionnaires on the didactic impact of the project indicated objective improvement in the specific skills acquired by the physicians at these facilities. The findings also show that a well-structured distance learning course can improve clinical, technical and managerial skills and behavior of healthcare operators by promoting the kind of professional continuing education a modern medical school should provide.

Plasma levels of metalloproteinases-3 and -9 as markers of successful abdominal aortic aneurysm exclusion after endovascular graft treatment

BACKGROUND

Structural alterations of aortic wall resulting from degradation of matrix proteins by matrix metalloproteinases (MMPs) characterize abdominal aortic aneurysms (AAAs). No studies have compared circulating levels of MMPs after endovascular graft (EVG) exclusion in comparison with open surgical repair (OSR) in patients affected by AAA.

METHODS AND RESULTS

An abdominal angiography and CT scan were performed in all patients at the time of enrollment. A spiral CT scan was performed at 6 months to detect presence of endoleaks. MMP-3 and MMP-9 levels were measured before EVG (n=30) and OSR (n=15) treatments and at 1, 3, and 6 months of follow-up by a sandwich ELISA technique. Healthy volunteers (n=10) were used as control subjects. Immunohistochemical staining for MMP-9 and MMP-3 was performed on tissue samples from surgical cases. Both MMP-9 and MMP-3 mean basal levels were significantly higher in patients affected by AAA than in control subjects (32.3+/-20.7 ng/mL for EVG and 28+/-9.9 ng/mL for OSR versus 8.9+/-2.5 ng/mL, 2P<0.05; 18.3+/-9.7 ng/mL and 26.7+/-10.8 ng/mL versus 8.2+/-5.3 ng/mL, 2P<0.001). In the OSR group, both MMP-9 and MMP-3 mean levels decreased after surgery (28+/-9.9 ng/mL at basal versus 14.7+/-6.6 ng/mL at 6 months, 2P<0.001; 26.7+/-10.8 versus 12+/-5.3 ng/mL; 2P<0.001). In the EVG group, a statistically significant difference at 6-month follow-up in MMP-9 and MMP-3 mean plasma values was detected in patients who had endoleakage in comparison with patients without endoleakage (44.3+/-20.7 versus 14.6+/-7.0 ng/mL, 2P<0.005; 25+/-11.5 versus 10.3+/-5.4 ng/mL, 2P<0.005).

CONCLUSIONS

After EVG exclusion, MMP-9 and MMP-3 levels decreased to a level similar to that of patients undergoing OSR. In addition, a lack of decrease in MMP levels after EVG exclusion may help in identifying patients who will have endoleakage and consequent aneurysm expansion caused by continuous sac pressurization during follow-up.

Homocysteinaemia during pregnancy and placental disease

OBJECTIVE

Hyperhomocysteinaemia, due to enzymatic defects or to the lack of some vitamin cofactors (vit. B6, vit. B12, folic acid), could be associated with obstetric disease. The aim of this study was to investigate placental disease in women with mild-moderate hyperhomocysteinaemia.

MATERIALS AND METHODS

Blood samples of seven pregnant women with severe early onset preeclampsia were assessed for hyperhomocysteinaemia. The obtained values were compared with those of a control group. In all cases, tissue samples obtained from the placenta, umbilical cord and membranes were studied. One of the patients was treated empirically with folic acid during a subsequent pregnancy.

RESULTS

Patient homocysteine plasma levels were higher than in the control group. In all cases several placental abnormalities were found. The patient treated with folic acid had a good pregnancy outcome.

CONCLUSION

Hyperhomocysteinaemia during pregnancy could be responsible for placental abnormalities. Treatment with folic acid could improve pregnancy outcome in women with homocysteine metabolism abnormalities.

[Modifications in diagnosis and therapy of osteoporosis after bone densitometry]

The cost-benefit ratio of diagnostic procedures has become a major problem: in particular, the expense of computerized bone mineral densitometry for osteoporosis diagnosis has brought this issue to public attention. To avoid a procedure considered costly, non-specialists often rely on standard radiography alone for diagnosis. In this study, we evaluated the percent of cases in which densitometry modified diagnosis and therapy based solely on radiographic findings. Over a 10-month period, we recruited 133 consecutive post-menopausal patients (average age 58.3 years, average time since menopause 12 years) who had never undergone densitometry. Bone density at the lumbar (L1-L4) or femoral (non-dominant) level was measured with dual energy X-ray absorptiometry. The average time between densitometry and the last radiographic examination was 13.6 months. Ninety-one patients (68.4%) had a change in diagnosis following densitometry. In 42 cases (31.6%), the previous diagnosis remained unchanged (prevalence ratio 2.2; 95% confidence interval 1.6 to 2.7). Therapy was changed in 75.2% of the cases (100 patients) and remained the same in 24.8% (33 patients; prevalence ratio 3.0; 95% confidence interval 2.3 to 3.7). Our data underscore the importance of densitometry in yielding quantitative data that are utilizable during follow-up and able to support osteoporosis diagnosis and therapy.

Influence of goserelin depot therapy on epidermal growth factor receptor expression in pelvic endometriosis

We have studied epidermal growth factor (EGF) receptor expression in endometrium and in endometriotic implants, testing a group of 36 women before and after a 4-month gonadotropin-releasing hormone (GnRH) analog (GnRH-a) goserelin depot treatment. Each woman underwent laparoscopy twice. At the initial laparoscopy, before starting treatment, the disease was staged according to the American Fertility Society (AFS) classification and biopsies of endometriotic implants were undertaken. The follow-up laparoscopy was performed within 5 weeks of the last GnRH-a administration. Biopsies were taken from areas of previously noted disease, both visually persistent and visually free of disease. At the time of each laparoscopy, photographs of all areas of disease were taken. Specimens of eutopic endometrium were collected from each patient at the time of laparoscopy by a Novak curette. Endometrial and endometriotic samples were processed for immunohistochemical detection of EGF receptor, using anti-EGF receptor monoclonal antibody Ab-3. After treatment, the marked improvement of AFS score was associated with a dramatic reduction of EGF receptor immunostaining, but the exact meaning of this finding is still not completely understood. The dramatic reduction of EGF receptor expression in eutopic and ectopic endometrium samples after treatment is not obviously related to the hypoestrogenism induced by the drug. It has been suggested that steroid hormones and EGF play a role in regulation of EGF receptor expression, so that drugs such as goserelin depot could act directly at local peripheral level influencing the EGF receptor expression via the production of its ligand.

Cirrhosis negatively affects the efficiency of serologic diagnosis of Helicobacter pylori infection

In cirrhosis, Helicobacter pylori infection may be implicated, together with portal hypertension, bile reflux and alcohol abuse, in damage to gastric mucosa. Aim of this study was to define the influence of non-alcoholic liver disease on the incidence of Helicobacter pylori infection and on the diagnostic accuracy of specific serology. Enrolled in the study were 232 individuals, 105 also had cirrhosis. Infection by Helicobacter pylori, diagnosed by a positive concordance of quick urease test and histology, was detected in 97 (48 with cirrhosis) out of 184 patients. Severe gastritis was more frequent in patients with Helicobacter pylori infection than in patients without. Cirrhosis did not significantly affect the prevalence of Helicobacter pylori infection or the histological features of gastritis. Specific anti-Helicobacter pylori IgG and IgA assay (Bio-Rad GAP test) was used for serological diagnosis. Anti-Helicobacter pylori IgG showed a high sensitivity (85% in cirrhotics, 89% in non-cirrhotics) and low specificity being more evident in cirrhotics (38% vs 56% non-cirrhotics). Serum specific IgA showed low sensitivity (approximately 25% in both groups) and specificity of 79% in cirrhotics vs 84% in non-cirrhotics. In conclusion, non-alcoholic cirrhosis does not affect the incidence of Helicobacter pylori infection and the histological features of chronic gastritis but does decrease diagnostic efficiency of serological tests for Helicobacter pylori.

[Retrospective study of postoperative infectious morbidity following cesarean section]

The increase of cesarean sections produced more postoperative infections. Several authors assessed the effectiveness of chemioantibiotic prophylaxis to reduce the postoperative infective morbidity. Although the family of antibiotics more frequently used is that of cephalosporin, the best single agent has not been found yet. The aim of our study, made in the Department of Obstetrics and Gynecology of University of Naples "Federico II", is to propose a retrospective analysis concerning the incidence of cesarean section (CS), the postoperative infective morbidity and the employment of antibiotic prophylaxis. Our sample is a group of 13285 pregnant women, 3171 (23.9%) of these patients underwent to CS from 1st January 1985 to 31st December 1994. The group of 3171 women was divided in two subgroups, the first of 2748 patients un-derwent to antibiotic prophylaxis, the second of 423 was untreated due to their previous experience of allergy towards antibiotics or because there was no evidence of risk factors. The women we treated with antibiotics underwent a three days prophylactic therapy with cefazolin or ampicillin soon after the CS. The incidence of infective complications had a 21.2% rate over a total of 3171 women. Endometritis was the most common infectious complication following cesarean delivery. The rate was 53.3% in the case of primary cesarean section and 52.3% in the case of iterative cesarean section. The use of antibiotic prophylaxis gave us the opportunity to reduce the postoperative morbidity in the primary CS (23.4%) as well in the iterative CS (16.6%). On the contrary the untreated group had an infective incidence with a 33.8% rate in the case of primary CS and with a 27.4% rate in the case of iterative CS. Our opinion is that the administration of antibiotics as cefazolin and ampicillin is able to reduce in a significant way the incidence of postoperative infective morbidity as well the period of hospitalization.

Growth hormone and insulin-like growth factor I in athletes performing a marathon at 4000 m of altitude

Human growth hormone (hGH) characteristically increases during physical exercise. In sports medicine, hGH changes have mostly been described in short-term performances under standardized laboratory procedures. We studied hGH and insulin-like growth factor I (IGF-I) under field conditions in 7 runners performing a marathon at 4000 m of altitude, to study the hormonal changes under extreme endurance effort and to evaluate the release of 22 kDa and 20 kDa monomers under these conditions, in comparison with a control group. The blood samples were taken at sea level, after 1 week of acclimatization, immediately after the run, and after a recovery of 24 h from the marathon. hGH was quantified by using a polyclonal method, a 22 kDa specific monoclonal method and a monoclonal method recognizing both 22 kDa and 20 kDa isoforms. A significant increase in hGH was noted using all methods after the marathon, followed by a significant decrease after recovery. Significant differences between athletes and controls were found only for the measurement after the marathon. No statistically reliable decrease of IGF-I was observed in athletes and controls. We obtained more limited hGH rises than previously described in athletes; the importance of lactate levels indicates that the use of physical exercise as a stimulation test for hGH should be closely standardized. The 20 kDa monomer and other hGH molecular forms played a limited role in the hormone increase: in our experience, elevation of hGH in heavy exercise corresponds mostly to the 22 kDa isoform. We suggest that the evaluation of hGH elevation in sports medicine could be accurately performed using specific 22 kDa monoclonal assays.

Desogestrel versus gestodene in oral contraceptives: influence on the clinical and histomorphological features of benign breast disease

Forty-four female volunteers asking for oral contraception, affected by symptomatic benign breast disease (BBD) were evaluated to compare the effects on mastalgia and breast nodularity of two different low dose oral contraceptives (OCs), containing 20 micrograms [corrected] ethinylestradiol + 150 micrograms desogestrel (EE+D) and 30 micrograms ethinylestradiol + 75 micrograms gestodene (EE+G), respectively. Physical examination, bilateral thermography, X-ray and/or ultrasonography of breast, and needle and screw-needle biopsies of mammary tissue were performed in all patients before OCs administration and after six cycles of treatment. OCs administration caused an overall improvement of mastalgia in 53%. Breast nodularity improved only in 8% of patients in both groups. Epithelial tissue modifications in mammary biopsies were observed, with involutive and/or secretory histomorphological and ultrastructural changes, frequently coexisting in different areas of the same breast.

Standardization with synthetic 22-kDa monomer human growth hormone reduces discrepancies between two monoclonal immunoradiometric assay kits

Discrepancies among different methods for assaying human growth hormone have been described in various studies. The two major sources of discordant results are the heterogeneity of the antibodies and the different standardization bases used by the assay manufacturers. We propose standardizing assays with 22-kDa biosynthetic monomer human growth hormone diluted with the diluents supplied by the kit manufacturers. In a study of two monoclonal immunoradiometric assays (Hybritech, specific for the 22-kDa monomer; Sorin, recognizing also a 20-kDa variant hormone), standardization with 22-kDa monomer human growth hormone reduced by 63% the differences in results for 44 serum samples from children. The use of 22-kDa human growth hormone as a common standard, highly pure and easily available in large quantities, could help limit the interpretative problems in growth diagnostics.

Standardization with Synthetic 22-KDa Monomer Human Growth Hormone Reduces Discrepancies Between Two Monoclonal Immunoradiometric Assay Kits

Discrepancies among different methods for assaying human growth hormone have been described in various studies. The two major sources of discordant results are the heterogeneity of the antibodies and the different standardization bases used by the assay manufacturers. We propose standardizing assays with 22-kDa biosynthetic monomer human growth hormone diluted with the diluents supplied by the kit manufacturers. In a study of two monoclonal immunoradiometric assays (Hybritech, specific for the 22-kDa monomer; Sorin, recognizing also a 20-kDa variant hormone), standardization with 22-kDa monomer human growth hormone reduced by 63% the differences in results for 44 serum samples from children. The use of 22-kDa human growth hormone as a common standard, highly pure and easily available in large quantities, could help limit the interpretative problems in growth diagnostics.

[Alloalbuminemia associated with myeloma]

Alloalbuminemia occurring together with paraproteinemia in a case of proven myelomatosis is described. The clinical and laboratory findings of this case are listed. The importance of the reported case is emphasized.

Optimization of the urinary acid alpha-glucosidase determination

The optimization of the method for acid alpha-glucosidase determination (EC 3.2.1.3) in human urines, employing the synthetic substrate 4-nitrophenyl-alpha-D-glucopyranoside, is reported. Storage conditions of the specimens and their pretreatment were particularly investigated. The precision of the whole analytical procedure (including gel filtration) is good (within-run CV = 7.4% for normal samples and 3.7% for elevated ones). The correlation with the method using maltose as substrate is excellent (y = -0.01 + 0.13 x; r = 0.9893).