The role of noise in denoising models for anomaly detection in medical images

Pathological brain lesions exhibit diverse appearance in brain images, in terms of intensity, texture, shape, size, and location. Comprehensive sets of data and annotations are difficult to acquire. Therefore, unsupervised anomaly detection approaches have been proposed using only normal data for training, with the aim of detecting outlier anomalous voxels at test time. Denoising methods, for instance classical denoising autoencoders (DAEs) and more recently emerging diffusion models, are a promising approach, however naive application of pixelwise noise leads to poor anomaly detection performance. We show that optimization of the spatial resolution and magnitude of the noise improves the performance of different model training regimes, with similar noise parameter adjustments giving good performance for both DAEs and diffusion models. Visual inspection of the reconstructions suggests that the training noise influences the trade-off between the extent of the detail that is reconstructed and the extent of erasure of anomalies, both of which contribute to better anomaly detection performance. We validate our findings on two real-world datasets (tumor detection in brain MRI and hemorrhage/ischemia/tumor detection in brain CT), showing good detection on diverse anomaly appearances. Overall, we find that a DAE trained with coarse noise is a fast and simple method that gives state-of-the-art accuracy. Diffusion models applied to anomaly detection are as yet in their infancy and provide a promising avenue for further research. Code for our DAE model and coarse noise is provided at: https://github.com/AntanasKascenas/DenoisingAE.

Survey: Leakage and Privacy at Inference Time

Leakage of data from publicly available Machine Learning (ML) models is an area of growing significance since commercial and government applications of ML can draw on multiple sources of data, potentially including users' and clients' sensitive data. We provide a comprehensive survey of contemporary advances on several fronts, covering involuntary data leakage which is natural to ML models, potential malicious leakage which is caused by privacy attacks, and currently available defence mechanisms. We focus on inference-time leakage, as the most likely scenario for publicly available models. We first discuss what leakage is in the context of different data, tasks, and model architectures. We then propose a taxonomy across involuntary and malicious leakage, followed by description of currently available defences, assessment metrics, and applications. We conclude with outstanding challenges and open questions, outlining some promising directions for future research.

Acute stroke CDS: automatic retrieval of thrombolysis contraindications from unstructured clinical letters

Introduction

Thrombolysis treatment for acute ischaemic stroke can lead to better outcomes if administered early enough. However, contraindications exist which put the patient at greater risk of a bleed (e.g. recent major surgery, anticoagulant medication). Therefore, clinicians must check a patient's past medical history before proceeding with treatment. In this work we present a machine learning approach for accurate automatic detection of this information in unstructured text documents such as discharge letters or referral letters, to support the clinician in making a decision about whether to administer thrombolysis.

Methods

We consulted local and national guidelines for thrombolysis eligibility, identifying 86 entities which are relevant to the thrombolysis decision. A total of 8,067 documents from 2,912 patients were manually annotated with these entities by medical students and clinicians. Using this data, we trained and validated several transformer-based named entity recognition (NER) models, focusing on transformer models which have been pre-trained on a biomedical corpus as these have shown most promise in the biomedical NER literature.

Results

Our best model was a PubMedBERT-based approach, which obtained a lenient micro/macro F1 score of 0.829/0.723. Ensembling 5 variants of this model gave a significant boost to precision, obtaining micro/macro F1 of 0.846/0.734 which approaches the human annotator performance of 0.847/0.839. We further propose numeric definitions for the concepts of name regularity (similarity of all spans which refer to an entity) and context regularity (similarity of all context surrounding mentions of an entity), using these to analyse the types of errors made by the system and finding that the name regularity of an entity is a stronger predictor of model performance than raw training set frequency.

Discussion

Overall, this work shows the potential of machine learning to provide clinical decision support (CDS) for the time-critical decision of thrombolysis administration in ischaemic stroke by quickly surfacing relevant information, leading to prompt treatment and hence to better patient outcomes.

Hip and groin pain in male field hockey players: Prevalence, incidence and associations with patient reported outcome scores and hip muscle strength

OBJECTIVES

Investigate point prevalence (second half season 2018-2019) and incidence (season 2017-2018 and first half season 2018-2019) of non-time-loss and time-loss hip/groin pain in male field hockey players. Secondary aims were to study associations between: current/previous hip/groin pain and hip muscle strength, patient reported outcome measures (PROM) and hip muscle strength, and previous hip/groin pain and PROMs. Additionally we studied normal values for the PROMs (Hip and Groin Outcome Score (HAGOS)).

DESIGN

Cross-sectional study.

SETTING

Testing at field hockey clubs.

PARTICIPANTS

100 male field hockey players (elite, sub-elite and amateur).

MAIN OUTCOME MEASURES

Point prevalence and incidence of hip/groin pain, strength: eccentric adduction and abduction, adductor squeeze, HAGOS.

RESULTS

Hip/groin pain point prevalence was 17% (time-loss: 6%) and incidence was 36% (time-loss: 12%). Presence of current or previous hip/groin and lower HAGOS-values were not associated with lower hip muscle strength. Previous hip/groin pain was associated with a significant lower HAGOS-values in all domains, except for the 'participation in physical activities' domain.

CONCLUSIONS

Hip/groin pain is common in field hockey. One fifth of players have hip/groin pain and one third had pain in the previous season. Previous hip/groin pain was associated with worse ongoing patient reported outcomes in most domains.

CBRNE3 medicine in the austere environment: the challenges

Chemical, Biological, Radiological, Nuclear and Explosive/Environmental/Endemic Disease (CBRNE3) incidents encompass a wide spectrum of events from natural events/disasters to industrial accidents through to deliberate military release and nuclear war. The UK military operates globally and in environments that are often austere. The very nature of these environments means that CBRNE3 incidents are a very real risk, and a CBRNE3 incident in a well-developed society could ultimately create an austere environment. Responding to such an event in an austere environment poses challenges.The very nature of the environment may be problematic. It may be very remote with limited or no access by road and/or air. It may have limited resources such as water and infrastructure required to manage the event. Extremes of temperature and weather may pose a risk to casualties and responders alike. Specialist teams and equipment may be required, but the host or partner nations may not have suitable capability and these resources may take time to mobilise from the home base. The volume of equipment and material needed in the response may overwhelm logistical chains which may not be robust enough to withstand the initial incident.Proper planning and preparedness is crucial to operating in and managing a CBRNE3 incident in an austere environment. Recognition of the potential threat by intelligence gathering and recognition by personnel on the ground are essential. This requires an appropriate awareness at all levels of command and appropriate prior training, including interoperability training with partner forces. Ultimately, robust planning and training is key to managing CBRNE3 incidents in an austere environment.

Use of “Hidden in Plain Sight” de-identification methodology in electronic healthcare data provides minimal risk of misidentification: Results from the iCAIRD Safe Haven Artificial Intelligence Platform

ObjectivesTo determine the risk of misidentification when using a “Hidden In Plain Sight (HIPS)” Named Entity Recognition (NER) de-identification methodology applied to Scottish healthcare data within The Industrial Centre for Artificial Intelligence Research in Digital Diagnostics (iCAIRD) Safe Haven Artificial Intelligence Platform (SHAIP). ApproachRather than the traditional redaction of potential identifiable information in routinely collected healthcare data, our HIPS methodology utilises an NER “find and replace” approach to de-identification that keeps the structure of text intact. This ensures that context is maintained, key to the interpretation of free text information and potential Artificial Intelligence applications. To our knowledge these methods have been previously untested on Scottish healthcare data. We therefore performed assessment of this approach in terms of potential risk of misidentification using HIPS on structured Scottish data deployed in SHAIP as part of the iCAIRD programme. ResultsFive individual cohorts, with a total of 169,964 patients were included. For each cohort the HIPS approach was applied, and then compared to actual patient information from within the same region, in order to determine the risk of misidentification. The following fields were included: Forename, Surname, Previous Name, Gender, Date of Birth (DOB), and Postcode. Across the five cohorts and varying combinations of identifiable data fields there were a total of 94 instances of potential misidentification (0.06%). 85/94 (90.4%) of these were for the combination of Gender, Date of Birth and Postcode. Across the five cohorts there were only 3 instances (0.002%) of Forename/Surname/DOB, and 5 instances (0.003%) of Forename/Surname/Postcode potential misidentification amongst the 169,964 patients. ConclusionsThe iCAIRD NER HIPS Methodology provides an acceptably low misidentification rate. Further work is now required to determine the recall and precision rates. Benefits of this approach include retaining the structure of free text, as well as reducing the ability to detect any potential leaked identifiable data.

Increasing drug-related mortality rates over the last decade in Scotland are not just due to an ageing cohort: A retrospective longitudinal cohort study

BACKGROUND

In Europe, North America, and Australia, mortality due to drug-related (DR) causes amongst people who inject drugs (PWID) is a major issue. Our objective was to characterise temporal trends in DR mortality rates in a large cohort of PWID in Scotland over the past decade, all of whom had been diagnosed with hepatitis C virus (HCV) infection, and to investigate factors associated with DR mortality.

METHODS

Retrospective longitudinal cohort study linking Scotland's national HCV Diagnosis Database and deaths registry. The study cohort consisted of all individuals with likely injection drug use-related route of HCV acquisition, who had been diagnosed with HCV between 1991 and 2018, and were alive and aged under 65 years on 1 January 2009. We used Lexis expansion to adjust for ageing cohort effects and calculated the mortality rate from an underlying/contributing DR cause over the period 2009-2018. We fitted Poisson regression models to estimate the temporal trend adjusting for attained age, sex, referral setting, region, and viraemic status at baseline.

RESULTS

Amongst the study population (n = 35,065; 236,914 person-years), a total of 1900 DR deaths occurred; the DR mortality rate increased from 5.6/1000 [101 deaths] in 2009 to 12.4/1000 [342] person-years in 2018. Increasing trends were observed for all age-groups except 55-64 years. The overall DR mortality rate was highest for referrals for HCV testing from prison (11.0/1000) and hospital settings (10.0/1000). Mortality increased with calendar time period, with significantly raised adjusted rate ratios (RRs) from 2015 (RR=1.40, 95% CI:1.16-1.69) to 2018 (RR=2.23, 95% CI:1.88-2.64), compared with 2011-2012, for older age (35-44: RR=1.37, 95% CI:1.20-1.56; 45-54: RR=1.32, CI:1.14-1.53) compared with <35 years, for persons diagnosed with HCV since 2009 (RR=1.34, 95% CI:1.21-1.49), and for prison and hospital referrals (RRs of 1.30, 1.37) compared with GP referrals.

CONCLUSION

Increasing DR mortality rates in Scotland over the past decade are not just due to an ageing cohort. Harm reduction services will likely need to expand and adapt to reverse the recent upward trends in DR mortality in PWID.

Do hip and groin muscle strength and symptoms change throughout a football season in professional male football players? A prospective cohort study with repeated measures

OBJECTIVES

Groin injuries are common in professional male football and result in significant complaints, time-loss and cost. We aimed to study: 1. Normal values of hip muscle strength and self-reported hip and groin function (Hip And Groin Outcome Score (HAGOS)). 2. Changes in these values throughout the season. 3. If previous (groin) injuries, leg dominance or league were associated with these outcome measures.

DESIGN

Prospective cohort study.

METHODS

313 professional male football players (11 clubs) participated. Player characteristics and previous injuries were registered. Hip muscle strength (hand-held dynamometer) and HAGOS measurements were done at the start, middle and end of the season.

RESULTS

Data from 217 players were analysed. Adduction strength (mean±standard deviation, Nm/Kg) was 3.40±0.72 (start), 3.30±0.65 (mid) and 3.39±0.74 (end) (p=0.186). Abduction strength was 3.45±0.67, 3.14±0.57 and 3.28±0.61 (p<0.001). Adduction/abduction ratio was 1.00±0.21, 1.07±0.22 and 1.05±0.23 (p<0.001). Statistically, the HAGOS-subscale 'Pain' (median [interquartile range]) deteriorated slightly during the season (p=0.005), especially from mid-season (97.5 [90.6-100.0]) to end-of-season (95.0 [87.5-100.0]) (p=0.003). Other subscale scores remained unchanged between time points; 85.7 (symptoms), 100.0 (daily living), 96.9 (sports and recreation) 100.0, (physical activities) and 90.0 (quality of life). Previous injuries were associated with lower HAGOS-scores. Dominant legs had higher abduction strength (p<0.001) and lower adduction/abduction ratio (p<0.001). No differences between leagues were found for hip muscle strength and HAGOS-scores.

CONCLUSIONS

In Dutch male professional football players, hip muscle strength and HAGOS-scores remained relatively stable throughout the season. Pain increased slightly, which while statistically significant, was not clinically relevant.

Setting Scottish diagnostic reference levels for mammography incorporating both craniocaudal and oblique projections between 30 and 80 mm

Optimisation must be carried out on all medical radiological units to ensure doses are as low as reasonably practicable, consistent with the intended purpose. To achieve this, population doses must be estimated and diagnostic reference levels (DRLs) set. For mammography examinations, mean glandular doses (MGDs) are calculated for this purpose. The average MGD per unit is compared to the national mammography DRL, which is applicable to compressed breast thicknesses (CBTs) of 50-60 mm for oblique (OB) views only and set using data from screening units. It is the purpose of this work to assess planar MGDs across Scotland and set DRLs based on data collected from all screening and symptomatic units across Scotland, considering craniocaudal (CC) and OB views and a wider range of CBTs. Data from the most recent dose audit (spanning 2015-2017) for 67 mammography x-ray units were collated and analysed (26 195 images). No large differences between MGD of CC and OB views were found when considering specific CBT ranges (median difference 2.6%). There was, however, a significant difference between screening and symptomatic data (19%). As expected, MGD increased with CBT and there were significant differences in MGD between manufacturers. From the data analysed, Scottish DRLs were set based on 95th percentile values for digital mammography units for three CBT ranges (30-49, 50-60 and 61-80 mm): 1.3, 1.8 and 2.6 mGy respectively. These values consider OB and CC views collectively. Fifth percentile values are quoted to highlight units at greater risk of insufficient image quality. These MGD values, together with image quality assessments, will facilitate optimisation across Scotland. Results show that use of different CBT ranges and inclusion of CC views increases the number of images included in dose audit data analysis from approximately 12%-92%, which is substantially more representative of the population.

The value of MRI STIR signal intensity on return to play prognosis and reinjury risk estimation in athletes with acute hamstring injuries

OBJECTIVES

Previous studies have shown low to moderate evidence for a variety of magnetic resonance imaging (MRI) features as prognostic factors in athletes with hamstring injuries. Short-tau inversion recovery (STIR) signal intensity has not yet been investigated for assessing the prognosis of acute muscle injuries. Our aim was to explore the relationship between MRI STIR signal intensity and time to return to play (RTP) and to investigate the association between MRI STIR and reinjury risk in athletes with acute hamstring injuries.

STUDY DESIGN

Case-control study.

METHODS

We used MRI STIR to measure intramuscular signal intensity in patients with clinically diagnosed hamstring injuries at two time points: at injury and RTP. At injury, we calculated the association of MRI STIR signal intensity with the time to RTP and reinjury risk. At RTP, the association of MRI STIR signal intensity and reinjury risk and the change in MRI STIR signal intensity over time on reinjury risk was evaluated.

RESULTS

51 patients were included. We found increased MRI STIR signal intensity: (1) at time of injury not to be associated with time to RTP, (2) at time of injury to be associated with a slightly lower risk for reinjury: odds 0.986 (0.975-0.998, p=0.02) and (3) at RTP not to be associated with reinjury risk. (4) We found no association between the change in MRI STIR signal intensity over time and reinjury risk.

CONCLUSION

Increased MRI STIR signal intensity at injury has no value in time to RTP prognosis, but is associated with a reduced reinjury risk.

A rare late complication of traumatic diaphragmatic hernia repair

We report a case of sudden cardiovascular collapse several weeks following surgical repair of a traumatic diaphragmatic hernia. The patient presented with features of circulatory shock without a clear diagnosis, therefore an urgent computed tomography scan of the chest and abdomen was undertaken, which revealed a pericardial effusion with evidence of cardiac tamponade. Ultrasound-guided needle pericardiocentesis with aspiration of blood from the pericardial sac in the Emergency Department provided an immediate response and her cardiac output improved. On review of the imaging, it is likely a surgically-placed permanent metallic fixation device, sitting near the pericardium, caused bleeding into the pericardial sac due to local trauma as a delayed postoperative complication.

Platelet-Rich plasma Injection Management for Ankle osteoarthritis study (PRIMA): protocol of a Dutch multicentre, stratified, block-randomised, double-blind, placebo-controlled trial

INTRODUCTION

Platelet-rich plasma (PRP) is a potentially efficacious treatment for ankle osteoarthritis (OA), but its use has not been examined in high-quality studies. Systematic reviews show that PRP injections significantly decrease pain and improve function in patients with knee OA. Ankle OA is more common than hip or knee OA in the young active population; with a prevalence of 3.4%.PRP injections in ankle OA are shown to be safe and improve quality of life over time, but no randomised controlled trial has been conducted. Our randomised controlled trial will evaluate the efficacy of PRP injections for symptom reduction and functional improvement, compared with placebo, in the treatment of ankle (talocrural) OA.

METHODS AND ANALYSIS

We will conduct the Platelet-Rich plasma Injection Management for Ankle OA study: a multicentre, randomised, placebo-controlled trial. One hundred patients suffering from ankle OA will be randomised into two treatment groups: PRP injection or placebo (saline) injection. Both groups will receive two injections of PRP or placebo at an interval of 6 weeks. Primary outcome is the American Orthopaedic Foot and Ankle Society score at 26 weeks. Secondary outcomes determined at several follow-up moments up to 5 years, include Ankle Osteoarthritis Score, Foot and Ankle Outcome Score, pain subscale of (0-40), Visual Analogue Scale score (0-100), Ankle Activity Score (0-10), subjective patient satisfaction Short Form Health Survey-36, Global Attainment Scaling and the EuroQol-5 dimensions-3 levels utility score. A cost-effectiveness analysis will be performed at 1 year.

ETHICS AND DISSEMINATION

The study is approved by the Medical Ethics Review Committee Amsterdam Medical Center, the Netherlands (ABR 2018-042, approved 23 July 2018) and registered in the Netherlands trial register (NTR7261). Results and new knowledge will be disseminated through the Dutch Arthritis Association (ReumaNederland), Dutch patient federation, conferences and published in a scientific peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NTR7261.

Improving diagnostic accuracy in clinically ambiguous paediatric appendicitis: a retrospective review of ultrasound and pathology findings with focus on the non-visualised appendix

OBJECTIVE

To compare pre-operative ultrasound to histopathological results and retrospectively assess the diagnostic accuracy of ultrasound in paediatric appendicitis.

METHODS

5 year review of all appendectomies performed in patients <16 years old in a tertiary referral university hospital. 983 patients had an appendicectomy over the time period while 189 patients had a preoperative ultrasound. We retrospectively reviewed all of the preoperative imaging in conjunction with the reports for the 189 patients; our aim was to determine the sensitivity of preoperative ultrasound for the diagnosis of acute appendicitis.

RESULTS

Of the 189 patients who had an ultrasound, 102 had histology positive for appendicitis and 87 had normal histology. Sensitivity overall was 72.55% [95% confidence interval (CI) 62.82 to 80.92] and specificity was 77.01% (95% CI 66.75 to 85.36). A suggested ultrasound diagnosis of appendicitis made positive pathology three times more likely and a normal ultrasound made positive pathology three times less likely [positive-predictive value 3.16 (95% CI 2.11 to 4.72) negative predictive value 0.36 (95% CI 0.25 to 0.50)]. 77% (67/87) of the patients whose pathology was ultimately normal had an ultrasound which was either normal or suggested an alternative diagnosis. However, in the 33 (17%) of patients with a non-visualised appendix, no secondary signs of inflammation or alternative diagnosis 16 (48%) had pathologically confirmed appendicitis.

CONCLUSION

Ultrasound has the potential to improve diagnostic accuracy in clinically ambiguous appendicitis.

ADVANCES IN KNOWLEDGE

This paper furthers the evidence on the efficacy of ultrasound as a diagnostic tool in acute appendicitis in children, especially when the diagnosis is clinically equivocal. It also sheds further light on the "non-visualized appendix" with almost half of these patients having pathologically confirmed appendicitis; meaning advanced imaging with CT or MR may be indicated in this cohort.

Accuracy and Feasibility of an Android-Based Digital Assessment Tool for Post Stroke Visual Disorders-The StrokeVision App

Background

Visual impairment affects up to 70% of stroke survivors. We designed an app (StrokeVision) to facilitate screening for common post stroke visual issues (acuity, visual fields, and visual inattention). We sought to describe the test time, feasibility, acceptability, and accuracy of our app-based digital visual assessments against (a) current methods used for bedside screening and (b) gold standard measures.

Methods

Patients were prospectively recruited from acute stroke settings. Index tests were app-based assessments of fields and inattention performed by a trained researcher. We compared against usual clinical screening practice of visual fields to confrontation, including inattention assessment (simultaneous stimuli). We also compared app to gold standard assessments of formal kinetic perimetry (Goldman or Octopus Visual Field Assessment); and pencil and paper-based tests of inattention (Albert's, Star Cancelation, and Line Bisection). Results of inattention and field tests were adjudicated by a specialist Neuro-ophthalmologist. All assessors were masked to each other's results. Participants and assessors graded acceptability using a bespoke scale that ranged from 0 (completely unacceptable) to 10 (perfect acceptability).

Results

Of 48 stroke survivors recruited, the complete battery of index and reference tests for fields was successfully completed in 45. Similar acceptability scores were observed for app-based [assessor median score 10 (IQR: 9-10); patient 9 (IQR: 8-10)] and traditional bedside testing [assessor 10 (IQR: 9-10); patient 10 (IQR: 9-10)]. Median test time was longer for app-based testing [combined time to completion of all digital tests 420 s (IQR: 390-588)] when compared with conventional bedside testing [70 s, (IQR: 40-70)], but shorter than gold standard testing [1,260 s, (IQR: 1005-1,620)]. Compared with gold standard assessments, usual screening practice demonstrated 79% sensitivity and 82% specificity for detection of a stroke-related field defect. This compares with 79% sensitivity and 88% specificity for StrokeVision digital assessment.

Conclusion

StrokeVision shows promise as a screening tool for visual complications in the acute phase of stroke. The app is at least as good as usual screening and offers other functionality that may make it attractive for use in acute stroke.

Clinical Trial Registration

https://ClinicalTrials.gov/ct2/show/NCT02539381.

Characteristics of acute groin injuries in the adductor muscles: A detailed MRI study in athletes

Acute adductor injuries account for the majority of acute groin injuries; however, little is known about specific injury characteristics, which could be important for the understanding of etiology and management of these injuries. The study aim was to describe acute adductor injuries in athletes using magnetic resonance imaging (MRI). Male athletes with acute groin pain and an MRI confirmed acute adductor muscle injury were prospectively included. MRI was performed within 7 days of injury using a standardized protocol and a reliable assessment approach. 156 athletes presented with acute groin pain of which 71 athletes were included, median age 27 years (range 18-37). There were 46 isolated muscle injuries and 25 athletes with multiple adductor injuries. In total, 111 acute adductor muscle injuries were recorded; 62 adductor longus, 18 adductor brevis, 17 pectineus, 9 obturator externus, 4 gracilis, and 1 adductor magnus injury. Adductor longus injuries occurred at three main injury locations; proximal insertion (26%), intramuscular musculo-tendinous junction (MTJ) of the proximal tendon (26%) and the MTJ of the distal tendon (37%). Intramuscular tendon injury was seen in one case. At the proximal insertion, 12 of 16 injuries were complete avulsions. This study shows that acute adductor injuries generally occur in isolation from other muscle groups. Adductor longus is the most frequently injured muscle in isolation and in combination with other adductor muscle injuries. Three characteristic adductor longus injury locations were observed on MRI, with avulsion injuries accounting for three-quarters of injuries at the proximal insertion, and intramuscular tendon injury was uncommon.

Efficacy and tolerability of lithium in treating acute mania in youth with bipolar disorder: protocol for a systematic review

BACKGROUND

Epidemiological, clinical, and high-risk studies have provided evidence that the peak period for onset of diagnosable episodes of mania and hypomania starts in mid-to-late adolescence. Moreover, clinically significant manic symptoms may occur even earlier, especially in children at familial risk. Lithium is the gold standard treatment for acute mania in adults, yet to our knowledge, there is no published systematic review assessing lithium treatment of mania in children or adolescents. This is a major gap in knowledge needed to inform clinical practice.

AIM

As a working group within the ISBD Task Force on Lithium Treatment ( http://www.isbd.org/active-task-forces ), our aim is to complete a systematic review of the efficacy, tolerability, and acceptability of lithium compared with placebo and other active drugs in treating mania in children and adolescents diagnosed with bipolar disorder.

METHODS

We will include double- or single-blind randomized controlled trials in patients aged less than 18 years. No restrictions will be made by study publication date or language. Several electronic databases will be searched along with secondary sources such as bibliographies and trial registry websites for published and unpublished studies. Response rates to lithium compared with placebo or other active drugs will be the primary efficacy outcome. Primary tolerability and acceptability outcomes will be rates of serious adverse events and dropouts, respectively. Secondary outcomes will include rates of remission, severity of manic symptoms at different time points, and incidence of specific adverse events.

DISCUSSION

Findings from this systematic review are critically needed to inform clinical practice. We should not generalize findings from adult studies, as children and adolescents are undergoing accelerated physiological and brain development. Therefore, efficacy, tolerability, and acceptability of lithium treatment of acute mania in children compared to adults may be very different. This systematic review has been registered in PROSPERO (CRD42017055675).

The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement

The 2016 Warwick Agreement on femoroacetabular impingement (FAI) syndrome was convened to build an international, multidisciplinary consensus on the diagnosis and management of patients with FAI syndrome. 22 panel members and 1 patient from 9 countries and 5 different specialties participated in a 1-day consensus meeting on 29 June 2016. Prior to the meeting, 6 questions were agreed on, and recent relevant systematic reviews and seminal literature were circulated. Panel members gave presentations on the topics of the agreed questions at Sports Hip 2016, an open meeting held in the UK on 27-29 June. Presentations were followed by open discussion. At the 1-day consensus meeting, panel members developed statements in response to each question through open discussion; members then scored their level of agreement with each response on a scale of 0-10. Substantial agreement (range 9.5-10) was reached for each of the 6 consensus questions, and the associated terminology was agreed on. The term 'femoroacetabular impingement syndrome' was introduced to reflect the central role of patients' symptoms in the disorder. To reach a diagnosis, patients should have appropriate symptoms, positive clinical signs and imaging findings. Suitable treatments are conservative care, rehabilitation, and arthroscopic or open surgery. Current understanding of prognosis and topics for future research were discussed. The 2016 Warwick Agreement on FAI syndrome is an international multidisciplinary agreement on the diagnosis, treatment principles and key terminology relating to FAI syndrome.Author note The Warwick Agreement on femoroacetabular impingement syndrome has been endorsed by the following 25 clinical societies: American Medical Society for Sports Medicine (AMSSM), Association of Chartered Physiotherapists in Sports and Exercise Medicine (ACPSEM), Australasian College of Sports and Exercise Physicians (ACSEP), Austian Sports Physiotherapists, British Association of Sports and Exercise Medicine (BASEM), British Association of Sport Rehabilitators and Trainers (BASRaT), Canadian Academy of Sport and Exercise Medicine (CASEM), Danish Society of Sports Physical Therapy (DSSF), European College of Sports and Exercise Physicians (ECOSEP), European Society of Sports Traumatology, Knee Surgery and Arthroscopy (ESSKA), Finnish Sports Physiotherapist Association (SUFT), German-Austrian-Swiss Society for Orthopaedic Traumatologic Sports Medicine (GOTS), International Federation of Sports Physical Therapy (IFSPT), International Society for Hip Arthroscopy (ISHA), Groupo di Interesse Specialistico dell'A.I.F.I., Norwegian Association of Sports Medicine and Physical Activity (NIMF), Norwegian Sports Physiotherapy Association (FFI), Society of Sports Therapists (SST), South African Sports Medicine Association (SASMA), Sports Medicine Australia (SMA), Sports Doctors Australia (SDrA), Sports Physiotherapy New Zealand (SPNZ), Swedish Society of Exercise and Sports Medicine (SFAIM), Swiss Society of Sports Medicine (SGMS/SGSM), Swiss Sports Physiotherapy Association (SSPA).

Medial tibial stress syndrome can be diagnosed reliably using history and physical examination

Background

The majority of sporting injuries are clinically diagnosed using history and physical examination as the cornerstone. There are no studies supporting the reliability of making a clinical diagnosis of medial tibial stress syndrome (MTSS).

Aim

Our aim was to assess if MTSS can be diagnosed reliably, using history and physical examination. We also investigated if clinicians were able to reliably identify concurrent lower leg injuries.

Methods

A clinical reliability study was performed at multiple sports medicine sites in The Netherlands. Athletes with non-traumatic lower leg pain were assessed for having MTSS by two clinicians, who were blinded to each others’ diagnoses. We calculated the prevalence, percentage of agreement, observed percentage of positive agreement (Ppos), observed percentage of negative agreement (Pneg) and Kappa-statistic with 95%CI.

Results

Forty-nine athletes participated in this study, of whom 46 completed both assessments. The prevalence of MTSS was 74%. The percentage of agreement was 96%, with Ppos and Pneg of 97% and 92%, respectively. The inter-rater reliability was almost perfect; k=0.89 (95% CI 0.74 to 1.00), p<0.000001. Of the 34 athletes with MTSS, 11 (32%) had a concurrent lower leg injury, which was reliably noted by our clinicians, k=0.73, 95% CI 0.48 to 0.98, p<0.0001.

Conclusion

Our findings show that MTSS can be reliably diagnosed clinically using history and physical examination, in clinical practice and research settings. We also found that concurrent lower leg injuries are common in athletes with MTSS.

Waist belt and central obesity cause partial hiatus hernia and short-segment acid reflux in asymptomatic volunteers

OBJECTIVE

There is a high incidence of inflammation and metaplasia at the gastro-oesophageal junction (GOJ) in asymptomatic volunteers. Additionally, the majority of patients with GOJ adenocarcinomas have no history of reflux symptoms. We report the effects of waist belt and increased waist circumference (WC) on the physiology of the GOJ in asymptomatic volunteers.

DESIGN

12 subjects with normal and 12 with increased WC, matched for age and gender were examined fasted and following a meal and with waist belts on and off. A magnet was clipped to the squamo-columnar junction (SCJ). Combined assembly of magnet-locator probe, 12-channel pH catheter and 36-channel manometer was passed.

RESULTS

The waist belt and increased WC were each associated with proximal displacement of SCJ within the diaphragmatic hiatus (relative to upper border of lower oesophageal sphincter (LOS), peak LOS pressure point and pressure inversion point, and PIP (all p<0.05). The magnitude of proximal migration of SCJ during transient LOS relaxations was reduced by 1.6-2.6 cm with belt on versus off (p=0.01) and in obese versus non-obese (p=0.04), consistent with its resting position being already proximally displaced. The waist belt, but not increased WC, was associated with increased LOS pressure (vs intragastric pressure) and movement of pH transition point closer to SCJ. At 5 cm above upper border LOS, the mean % time pH <4 was <4% in all studied groups. Acid exposure 0.5-1.5 cm above SCJ was increased, with versus without, belt (p=0.02) and was most marked in obese subjects with belt.

CONCLUSIONS

Our findings indicate that in asymptomatic volunteers, waist belt and central obesity cause partial hiatus herniation and short-segment acid reflux. This provides a plausible explanation for the high incidence of inflammation and metaplasia and occurrence of neoplasia at the GOJ in subjects without a history of reflux symptoms.

Demonstration of lightweight gamma spectrometry systems in urban environments

Urban areas present highly complex radiation environments; with small scale features resulting from different construction materials, topographic effects and potential anthropogenic inputs from past industrial activity or other sources. Mapping of the radiation fields in urban areas allows a detailed assessment of exposure pathways for the people who live and work there, as well as locating discrete sources of activity that may warrant removal to mitigate dose to the general public. These areas also present access difficulties for radiometric mapping using vehicles or aircraft. A lightweight portable gamma spectrometry system has been used to survey sites in the vicinity of Glasgow to demonstrate the possibilities of radiometric mapping of urban areas, and to investigate the complex radiometric features such areas present. Variations in natural activity due to construction materials have been described, the presence of (137)Cs used to identify relatively undisturbed ground, and a previously unknown NORM feature identified. The effect of topographic enclosure on measurements of activity concentration has been quantified. The portable system is compared with the outputs that might be expected from larger vehicular or airborne systems. For large areas airborne surveys are the most cost effective approach, but provide limited spatial resolution, vehicular surveys can provide sparse exploratory data rapidly or detailed mapping of open areas where off-road access is possible. Backpack systems are ideally suited to detailed surveys of small areas, especially where vehicular access is difficult.

A phase II single-arm study of LDK378 in patients with ALK-activated (ALK+) non-small cell lung cancer (NSCLC) previously treated with chemotherapy and crizotinib (CRZ)

TPS8119

Background: NSCLC harboring anaplastic lymphoma kinase (ALK) gene rearrangements (2–8% of cases) are sensitive to CRZ, the only approved ALK inhibitor, but invariably develop resistance. There are currently no standard ALK-targeted treatments for CRZ-resistant ALK+ NSCLC. LDK378 is a novel, oral ALK inhibitor with 20-fold greater potency than CRZ in enzymatic assays. In an ongoing phase I trial, LDK378 has demonstrated substantial clinical activity in patients (pts) with ALK+ NSCLC whose disease has failed CRZ. At a dose ≥400 mg (45 pts), the overall response rate (ORR) was 80%, with 47% confirmed responses (data cutoff August 31, 2012). Nausea, vomiting, diarrhea and fatigue were the main toxicities. The recommended phase II dose is 750 mg daily. Methods: This phase II multicenter, open label, single-arm study (CLDK378A2201) is designed to evaluate the efficacy and safety of oral LDK378 750 mg once-daily in pts with ALK+ (by FDA-approved FISH test) advanced NSCLC. Pts must have received cytotoxic chemotherapy (1–3 lines, including 1 platinum doublet) and progressed on CRZ as the last therapy prior to study entry. Pts with ECOG PS 0–2 and stable CNS metastases are eligible. LDK378 may be continued beyond RECIST-defined PD if there is evidence of clinical benefit. The primary objective is to assess the antitumor activity of LDK378 in terms of ORR by investigator assessment (using RECIST v1.1). Secondary/exploratory objectives include evaluating response endpoints (duration of response, time to response and ORR by independent radiological review), PFS, OS, safety, PK, and impact on patient-reported outcomes. The primary analysis will occur when all pts have completed 6 cycles or discontinued treatment earlier. The study design (137 pts) provides 90% power to test a null hypothesis of ORR ≤25% vs. a target ORR of ≥38%: if ≥45 responses are observed (estimated ORR 33%), the null hypothesis will be rejected at a one-sided significance level of 0.025. The study is recruiting in 67 sites from 14 countries across Europe, Asia and North America. As of February 5, 2013, 7 pts have been enrolled. ClinicalTrials.gov identifier NCT01685060. Clinical trial information: NCT01685060.

Functionalized nanoparticle interactions with polymeric membranes

A series of experiments was performed to measure the retention of a class of functionalized nanoparticles (NPs) on porous (microfiltration and ultrafiltration) membranes. The findings impact engineered water and wastewater treatment using membrane technology, characterization and analytical schemes for NP detection, and the use of NPs in waste treatment scenarios. The NPs studied were composed of silver, titanium dioxide, and gold; had organic coatings to yield either positive or negative surface charge; and were between 2 and 10nm in diameter. NP solutions were applied to polymeric membranes composed of different materials and pore sizes (ranging from ≈ 2 nm [3 kDa molecular weight cutoff] to 0.2 μm). Greater than 99% rejection was observed of positively charged NPs by negatively charged membranes even though pore diameters were up to 20 times the NP diameter; thus, sorption caused rejection. Negatively charged NPs were less well rejected, but behavior was dependent not only on surface functionality but on NP core material (Ag, TiO(2), or Au). NP rejection depended more upon NP properties than membrane properties; all of the negatively charged polymeric membranes behaved similarly. The NP-membrane interaction behavior fell into four categories, which are defined and described here.

A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy

Background

Eccentric exercises have the most evidence in conservative treatment of midportion Achilles tendinopathy. Although short-term studies show significant improvement, little is known of the long-term (>3 years) results.

Aim

To evaluate the 5-year outcome of patients with chronic midportion Achilles tendinopathy treated with the classical Alfredson's heel-drop exercise programme.

Study design

Part of a 5-year follow-up of a previously conducted randomised controlled trial.

Methods

58 patients (70 tendons) were approached 5 years after the start of the heel-drop exercise programme according to Alfredson. At baseline and at 5-year follow-up, the validated Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire score, pain status, alternative treatments received and ultrasonographic neovascularisation score were recorded.

Results

In 46 patients (58 tendons), the VISA-A score significantly increased from 49.2 at baseline to 83.6 after 5 years (p<0.001) and from the 1-year to 5-year follow-up from 75.0 to 83.4 (p<0.01). 39.7% of the patients were completely pain-free at follow-up and 48.3% had received one or more alternative treatments. The sagittal tendon thickness decreased from 8.05 mm (SD 2.1) at baseline to 7.50 mm (SD 1.6) at the 5-year follow-up (p=0.051).

Conclusion

At 5-year follow-up, a significant increase of VISA-A score can be expected. After the 3-month Alfredson's heel-drop exercise programme, almost half of the patients had received other therapies. Although improvement of symptoms can be expected at long term, mild pain may remain.

The additional value of a pneumatic leg brace in the treatment of recruits with medial tibial stress syndrome; a randomized study

OBJECTIVE

To study the additional effect of a pneumatic leg brace with standard rehabilitation for the treatment of medial tibial stress syndrome (MTSS) in recruits.

METHODS

In a single blinded randomized study, 15 recruits (age 17-22) followed a rehabilitation programme consisting of leg exercises and a graded running programme. Recruits performed daily exercises and ran three times a week. The running programme consisted of 6 consecutive phases. One group was, after randomization, additionally provided with a pneumatic leg brace. Follow-up was provided every other week. Days to completing the running programme was the primary outcome measure, the Sports Activity Rating Scale (SARS) score and satisfaction with the treatment were secondary outcome measures.

RESULTS

In total 14 recruits completed the rehabilitation programme. No differences were found in the number of days until phase six of the running schedule was finished between the brace and the control group (Brace 58.8 +/- 27.7 (mean +/- SD) vs Non-Brace 57.9 +/- 26.2 (mean +/- SD, p = 0.57). Also no differences were found in the SARS scores between the groups. Overall satisfaction with the treatment was 6.4 +/- 1.1 (mean +/- SD) on a 1-10 scale for the brace group and 7.1 +/- 0.7 (mean +/- SD) for the control group (p = 0.06). Comfort of the brace was assessed as 4.8 +/- 1.3 (mean +/- SD) on a 1-10 scale.

CONCLUSIONS

No additional large effect of the pneumatic leg brace could be found in recruits and wearing of the brace was not feasible, since the wearing comfort was low.

Shockwave treatment for medial tibial stress syndrome in athletes; a prospective controlled study

Objective The purpose of this study was to describe the results of two treatment regimens for medial tibial stress syndrome (MTSS); a graded running programme and the same running programme with additional shockwave therapy (extracorporeal shockwave therapy; ESWT). Design A prospective observational controlled trial. Setting Two different sports medicine departments. Participants 42 athletes with MTSS were included. Intervention Patients from one hospital were treated with a graded running programme, while patients from the other hospital were treated with the same graded running programme and focused ESWT (five sessions in 9 weeks). Main Outcome Measures Time to full recovery (the endpoint was being able to run 18 min consecutively without pain at a fixed intensity). Results The time to full recovery was significantly faster in the ESWT group compared with the patients who only performed a graded running programme, respectively 59.7±25.8 and 91.6±43.0 days (p=0.008). Conclusions This prospective observational study showed that MTSS patients may benefit from ESWT in addition to a graded running programme. ESWT as an additional treatment warrants further investigation in a prospective controlled trial with the addition of randomisation and double blinding.

Manual or exercise therapy for long-standing adductor-related groin pain: a randomised controlled clinical trial

HYPOTHESIS

A multi-modal treatment program (MMT) is more effective than exercise therapy (ET) for the treatment of long-standing adductor-related groin pain.

STUDY DESIGN

Single blinded, prospective, randomised controlled trial.

METHODS

PATIENTS

Athletes with pain at the proximal insertion of the adductor muscles on palpation and resisted adduction for at least two months.

INTERVENTIONS

ET: a home-based ET and a structured return to running program with instruction on three occasions from a sports physical therapist. MMT: Heat, Van den Akker manual therapy followed by stretching and a return to running program.

PRIMARY OUTCOME

time to return to full sports participation.

SECONDARY OUTCOME MEASURES

objective outcome score and the visual analogue pain score during sports activities. Outcome was assessed at 0, 6, 16 and 24 weeks.

RESULTS

Athletes who received MMT returned to sports quicker (12.8 weeks, SD 6.0) than athletes in the ET group (17.3 weeks, SD 4.4. p = 0.043). Only 50-55% of athletes in both groups made a full return to sports. There was no difference between the groups in objective outcome (p = 0.72) or VAS during sports (p = 0.12).

CONCLUSIONS

The multi-modal program resulted in a significantly quicker return to sports than ET plus return to running but neither treatment was very effective.

Infrared observations of the neptunian system

The infrared interferometer spectrometer on Voyager 2 obtained thermal emission spectra of Neptune with a spectral resolution of 4.3 cm(-1). Measurements of reflected solar radiation were also obtained with a broadband radiometer sensitive in the visible and near infrared. Analysis of the strong C(2)H(2) emission feature at 729 cm(-1) suggests an acetylene mole fraction in the range between 9 x 10(-8) and 9 x 10(-7). Vertical temperature profiles were derived between 30 and 1000 millibars at 70 degrees and 42 degrees S and 30 degrees N. Temperature maps of the planet between 80 degrees S and 30 degrees N were obtained for two atmospheric layers, one in the lower stratosphere between 30 and 120 millibars and the other in the troposphere between 300 and 1000 millibars. Zonal mean temperatures obtained from these maps and from latitude scans indicate a relatively warm pole and equator with cooler mid-latitudes. This is qualitatively similar to the behavior found on Uranus even though the obliquities and internal heat fluxes of the two planets are markedly different. Comparison of winds derived from images with the vertical wind shear calculated from the temperature field indicates a general decay of wind speed with height, a phenomenon also observed on the other three giant planets. Strong, wavelike longitudinal thermal structure is found, some of which appears to be associated with the Great Dark Spot. An intense, localizd cold region is seen in the lower stratosphere, which does not appear to be correlated with any visible feature. A preliminary estimate of the effective temperature of the planet yields a value of 59.3 +/- 1.0 kelvins. Measurements of Triton provide an estimate of the daytime surface temperature of 38(+3)(-4) kelvins.

Risk factors and prognostic indicators for medial tibial stress syndrome

The objective of the study was to examine the risk factors and prognostic indicators for medial tibial stress syndrome (MTSS). In total, 35 subjects were included in the study. For the risk factor analysis, the following parameters were investigated: hip internal and external ranges of motion, knee flexion and extension, dorsal and plantar ankle flexion, hallux flexion and extension, subtalar eversion and inversion, maximal calf girth, lean calf girth, standing foot angle and navicular drop test. After multivariate regression decreased hip internal range of motion, increased ankle plantar flexion and positive navicular drop were associated with MTSS. A higher body mass index was associated with a longer duration to full recovery. For other prognostic indicators, no relationship was found.