Designing multimedia patient education materials for adolescent idiopathic scoliosis: A protocol for a feasibility randomized controlled trial of patient education videos

Triple-masked three-armed feasibility parallel randomized controlled trial. Multimedia patient education materials are increasingly used in healthcare. While much research focuses on optimising their scientific content, research is equally needed to optimise design and implementation. This study aims to determine the feasibility of a study examining how the implementation of scientific advice on design affects patient outcomes. Participants aged 10-18 with radiographically confirmed adolescent idiopathic scoliosis will be recruited from community settings in Ireland and randomized into usual care or receiving multimedia educational videos with or without evidence-informed design principles. Participants will be masked in the two video intervention arms, as will the therapist sending the educational videos. Outcomes will include the number of participants recruited and randomized, the number analysed post-intervention and at week eight, and the outcomes for baseline, post-intervention, and week 8. Adverse events will also be reported. This feasibility randomized controlled trial will offer insight into the feasibility of implementing advice from the literature in designing a trial of multimedia patient education materials for a population with adolescent idiopathic scoliosis. Trial registration: Clinical Trail: Trial is registered on ClinicalTrials.gov as NCT06090344.

Outpatient secondary care pathways for head and neck cancer referral result in patient delays for cancer treatment

INTRODUCTION

The majority of head and neck cancer referrals are received through primary care. A proportion of cancer referrals are received through secondary care specialties. Local delivery plan (LDP) targets in Scotland for cancer investigation are set at 31 days for diagnosis and 62 days to start treatment. The aim was to audit referrals made through non-primary care pathways compared with the standard primary care pathways against LDP targets.

METHODS

New head and neck cancer patients between 1 January 2014 and 1 January 2019 were included. Pathway points were recorded between referral to outpatient clinic, time to multidisciplinary team discussion (MDT) and finally MDT to treatment.

RESULTS

1,276 new patient referrals were received over a 5-year period. Of these, 136 (10%) were referred via non-primary care pathways. The mean time for urgent suspicion of cancer (USoC) referrals to start treatment was 77 days (15 days over target) and for outpatient secondary care referrals was 102 days (40 days over target) (p<0.05). When treatment intent was considered, 841/1,131 (75%) of patients referred via primary care were treated curatively compared with 49/99 (49%) (p<0.05) of patients referred through the secondary outpatient pathway.

CONCLUSION

Patients with head and neck cancer referred from other outpatient specialties face delays commencing cancer treatment and are also associated with a greater likelihood of being treated with palliative intent.

Using web log analysis to evaluate healthcare students' engagement behaviours with multimedia lectures on YouTube

The objective of this study was to utilise web log analysis to evaluate the relationship between University students' engagement (e.g., watch time) and the characteristics of a catalogue of multimedia lectures, including their duration, the speaking rate of the narrator and the extent to which they implemented certain principles from Mayer's Cognitive Theory of Multimedia Learning (CTML). Fifty-six multimedia lectures covering topics related to healthcare (e.g., anatomy, physiology and clinical assessment) were developed to differentially employ the image/embodiment, redundancy, segmentation and signalling principles from the CTML. These lectures were delivered to multiple cohorts of students throughout an academic semester. Student watch time was evaluated using the meta-usage data provided by YouTube studio. The multimedia lectures were viewed 4338 times (mean = 35 views per lecture; 27 unique viewers per lecture). Generalised estimating equations revealed that videos that were segmented into shorter chunks, that incorporated signals to highlight important information for students and during which captions were toggled 'off' by students were associated with longer watch times (P < 0.05). Additionally, watch time diminished for videos placed later in a sequence based on the audience retention metric. When designing multimedia lectures, instructors should be encouraged to use on screen labels to highlight important information, segment learning material into shorter 'chunks' and incorporate a dynamic instructor on screen at regular intervals displaying high embodiment. If several videos are to be delivered to students as part of a learning 'unit', educators should consider placing the most important learning material earlier in the sequence.

An investigation into the relationship between multimedia lecture design and learners’ engagement behaviours using web log analysis

The purpose of this transaction log analysis was to evaluate university students’ engagement behaviours with a catalogue of multimedia lectures. These lectures incorporated selected instructional design principles from the cognitive theory of multimedia learning (CTML). Specifically, thirty-two multimedia lectures which differentially employed the signalling, segmenting and embodiment principles from the CTML were delivered to a cohort of 92 students throughout an academic trimester. Engagement with each multimedia lecture was measured in three domains: affective engagement was measured using a Likert-style survey that accompanied each multimedia lecture; behavioural engagement was measured using the web logs provided by YouTube Studio analytics (average watch time); cognitive engagement was measured using students’ average score on a quiz that accompanied each multimedia lecture. Separate multiple linear regression analyses for measures of affective, behavioural and cognitive engagement revealed that multimedia lectures that ‘stacked’ the instructional design principles of embodiment (whereby the lecture was interspersed with clips of an enthusiastic onscreen instructor), segmenting (where lectures were divided into shorter, user-paced segments) and signalling (where onscreen labels highlighted important material) increased measures of engagement, including overall watch time, number of survey submission and number of quiz attempts (P < 0.05). There was no association between any of the tested principles and students’ quiz scores or their responses on the Likert-style survey. This study adds to the available literature demonstrating the effectiveness of the signalling, segmenting and embodiment principles for increasing learner engagement with multimedia lectures.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Maternal, placental, and fetal distribution of titanium after repeated titanium dioxide nanoparticle inhalation through pregnancy

Epidemiological studies have associated ambient engineered nanomaterials or ultrafine particulate matter (PM_0.1), collectively referred to as nanoparticles (NPs), with adverse pregnancy outcomes including miscarriage, preterm labor, and fetal growth restriction. Evidence from non-pregnant models demonstrate that NPs can cross the lung air-blood barrier and circulate systemically. Therefore, inhalation of NPs during pregnancy leading to fetoplacental exposure has garnered attention. The purpose of this study was to evaluate the distribution of inhaled titanium dioxide nanoparticles (nano-TiO₂) from the maternal lung to maternal and fetal systemic tissues. Pregnant Sprague Dawley rats were administered whole-body exposure to filtered air or of nano-TiO₂ aerosols (9.96 ± 0.06 mg/m³) between gestational day (GD) 4 and 19. On GD 20 maternal, placental, and fetal tissues were harvested then digested for ICP-MS analysis to measure concentrations of titanium (Ti). TEM was used to visualize particle internalization by the placental syncytium. The results demonstrate the extrapulmonary distribution of Ti to various maternal organs during pregnancy. Our study found Ti accumulation in the decidua/junctional and labyrinth zones of placentas embedded in all sections of uterine horns. Further, NPs deposited in the placenta, identified by TEM, were found intracellularly within nuclear, endoplasmic reticulum, and vesicle organelles. This study identified the systemic distribution and placental accumulation of Ti after nano-TiO₂ aerosol inhalation in a pregnancy model. These findings arouse concerns for poor air quality for pregnant women and possible contributions to adverse pregnancy outcomes.

1357 Ankle Blocks: Improving Day Case Efficiency

Introduction

The COVID pandemic has exerted unprecedented pressure on hospital resources. Resulting in cancellation of elective operative services, increased patient waiting lists, limited surgical training opportunities along with reduced availability of staff, theatre, and in-patient bed capacity. A novel approach for day case forefoot surgery under ankle block, to mitigate the pandemic service limitations without compromising care, was developed.

Method

This is a 3-month, multi-centre, prospective cohort study evaluating the novel ankle block day case forefoot surgery pathway. Patients had a minimum of three months clinical follow up with outcome scores. They were matched to a cohort undergoing similar surgery prior to the COVID pandemic.

Results

The utilisation of an ankle block pathway resulted in an average reduction of inpatient stay by 2 days per patient. Over the study period conservative savings of £26,659 were calculated. Anecdotally we observed a reduction in morbidity (wound complications, SSI’s) although not statistically significant.

Conclusions

Our novel surgical pathway has enabled continued elective operating for procedures that previously required hospital admission during a period of severe restrictions within the NHS. We observed significant reductions in cost, surgical inpatient bed utilisation and total operative time with staff, resource, and time savings. We hypothesise that prehabilitation with physiotherapy, ankle instead of thigh tourniquets and early mobilisation may have contributed to improved morbidity scores. The findings of this project have implications for training, upper limb services and are transferrable as a template to improve service efficiency while maintaining high quality care.

Condition-specific health-related quality of life amongst amateur athletes six months and one-year following sport-related concussion: A prospective, follow-up

OBJECTIVE

To prospectively investigate the condition-specific health-related quality of life (HRQoL) of athletes six months and one-year following sport-related concussion.

DESIGN

Prospective, longitudinal study.

SETTING

Clinical research centre at university school of public health.

PARTICIPANTS

Amateur athletes who were diagnosed with sport-related concussion within one-week after presenting to a hospital emergency department were recruited along with sex-, age-, and activity-matched, non-concussed, control athletes. Concussion and control participants were assessed six months and one-year following sport-related concussion and study enrolment, respectively.

MAIN OUTCOME MEASURES

Participants completed the Post-Concussion Symptom Scale and five condition-specific HRQoL patient-reported outcome measures - Headache Impact Test-6, Fatigue Severity Scale, Neck Disability Index, Generalised Anxiety Disorder-7, and Dizziness Handicap Inventory. We performed Frequentist and Bayesian mixed-design analyses of variance to compare the concussion group and control group at both assessments and quantify whether there was greater evidence in favour of the null hypothesis compared with the alternative hypothesis.

RESULTS

At six-month and one-year assessments, the concussion group (n = 47; male = 72%; mean (SD) age = 22.68 (5.07)) and the control group (n = 47; male = 72%; mean (SD) age = 23.81 (4.60)) reported similar clinical symptom severity scores and condition-specific HRQoL. The proportion of athletes in the concussion group with clinically-impaired scores was similar to the proportion of non-concussed athletes with clinically-impaired scores. At six-month and one-year assessments, there was moderate-to-very strong evidence that there was no difference between concussion and control participants' perceptions of the effects of headache, fatigue, neck pain, anxiety, and dizziness on HRQoL.

CONCLUSION

There was moderate-to-very strong evidence in favour of no difference between the concussion and control groups on symptom severity scores and condition-specific HRQoL patient-reported outcome measures at six-month and one-year assessments. These results suggest that condition-specific HRQoL returns to the levels of non-concussed individuals within six months following sport-related concussion.

Single-Item Self-Report Measures of Team-Sport Athlete Wellbeing and Their Relationship With Training Load: A Systematic Review

BACKGROUND

Single-item athlete self-report measures consist of a single question to assess a dimension of wellbeing. These methods are recommended and frequently used for athlete monitoring, yet their uniformity has not been well assessed, and we have a limited understanding of their relationship with measures of training load.

OBJECTIVE

To investigate the applications and designs of single-item self-report measures used in monitoring team-sport athletes and present the relationship between these measures and measures of training load.

DATA SOURCES

PubMed, Scopus, and SPORTDiscus were searched between inception and March 2019.

STUDY SELECTION

Articles were included if they concerned adult athletes from field- or court-sport domains, if athlete well-being was measured using a single-item self-report, and if the relationship with a measure of modifiable training load was investigated over at least 7 days.

DATA EXTRACTION

Data related to participant characteristics, self-report measures, training load measures, and statistical analysis and outcomes were extracted by 2 authors (C.D. and C.D.).

DATA SYNTHESIS

A total of 21 studies were included in the analysis. A narrative synthesis was conducted. The measures used most frequently were muscle soreness, fatigue, sleep quality, stress, and mood. All measures presented various relationships with metrics of training load from no association to a very large association, and the associations were predominantly trivial to moderate in the studies with the largest numbers of observations. Relationships were largely negative associations.

CONCLUSIONS

The implications of this review should be considered by users in the application and clinical utility of single-item self-report measures in athlete monitoring. Great emphasis has been placed on examining the relationship between subjective and objective measures of training load. Although the relationship is still unclear, such an association may not be expected or useful. Researchers should consider the measurement properties of single-item self-report measures and seek to establish their relationship with clinically meaningful outcomes. As such, further study is required to inform practitioners on the appropriate objective application of data from single-item self-report measures.

Participation in pre-injury level sport one-year following sport-related concussion: A prospective, matched cohort study

OBJECTIVES

To estimate the times taken to receive clearance to return to sporting activity and to return to pre-injury level of sport competition following sport-related concussion, and to estimate the proportion of athletes who were participating at their pre-injury level of sport competition six months and one-year following sport-related concussion.

DESIGN

Prospective cohort study.

METHODS

Amateur, adult athletes (16-38 years old) were diagnosed with sport-related concussion at a university-affiliated hospital emergency department. Participants were assessed within one-week, upon medical clearance to return to sporting activity, two weeks following return to sporting activity, six months, and 12 months following sport-related concussion. We assessed sex-, age-, and activity-matched non-injured, control participants at matched time-points. Participants were asked during each study assessment whether they were participating in any sport, in a different sport than before their sport-related concussion, in the same sport but at a lower level of competition than before their sport-related concussion, or in the same sport at the same level of competition than before their sport-related concussion.

RESULTS

Fifty concussed participants and 50 non-injured, control participants completed the study. The median times taken to receive clearance to return to sporting activity and to return to pre-injury level of sport competition following sport-related concussion were 13 days (95%CI=12,16) and 31 days (95%CI=28,32), respectively. One-year following sport-related concussion, 52% of participants reported that they were no longer participating in the same sport and at the same level of competition as they were before their sport-related concussion, compared with only 24% of participants in the non-injured, control group (p=0.003).

CONCLUSIONS

A greater percentage of athletes in the concussion group were not participating at their perceived pre-injury level of sport competition one-year following sport-related concussion compared with a non-injured control group. Factors that explain the lower proportion of amateur athletes participating at their pre-injury level of sport competition one-year after sport-related concussion are likely multifaceted and should be considered in future investigations.

Acute isolated sphenoid sinusitis in children: A case series and systematic review of the literature

OBJECTIVE

This study aims to present a case series and systematic review of acute isolated sphenoid sinusitis (AISS) in children in order to better characterize clinical presentation, diagnosis, treatment, and outcomes of this condition.

DATA SOURCES

Ovid MEDLINE, Pubmed, Embase, Cochrane Library, and Google Scholar.

STUDY SELECTION

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Full-text, peer-reviewed journal publications from 1994 to 2020 in English; focus on acute sphenoid sinusitis; pediatric patients (<18 years of age); series with two or more children. Studies were assessed for data including demographics, presenting symptoms and signs, radiological investigations, treatment, outcomes and complications.

RESULTS

Ten studies identifying 71 patients were included. Average age at presentation was 12.0 years (range 5-17 years). M:F ratio 1:1. The most common presenting symptoms were headache (98.6%), fever (50.7%), nasal symptoms (22.5%) ocular symptoms (19.7%) and decreased level of consciousness (12.7%). Twenty patients (28.1%) had neurological signs. Twenty-three patients (32.4%) presented with headache in isolation. Unsuspected diagnosis at presentation was noted in 54.0%. Average time to initial presentation was 14.0 days (median = 5.5 days, range 1-90 days). The majority of children were treated with antibiotics (98.6%) with 31.0%, 2.8% and 2.8% also undergoing sinus surgery, revision sinus surgery and neurosurgery, respectively. Intracranial complications occurred in 16.9% of patients. Significant long term sequelae occurred in 2 children (2.8%) and one death (1.4%) was also reported.

LIMITATIONS

All studies were retrospective case note reviews.

CONCLUSIONS

Acute sphenoid sinusitis is a rare and difficult condition to diagnose in children. The majority of patients make a full recovery with appropriate treatment. If treatment is delayed however consequences can be life-threatening.

Physiotherapists' Use of Web-Based Information Resources to Fulfill Their Information Needs During a Theoretical Examination: Randomized Crossover Trial

Background

The widespread availability of internet-connected smart devices in the health care setting has the potential to improve the delivery of research evidence to the care pathway and fulfill health care professionals’ information needs.

Objective

This study aims to evaluate the frequency with which physiotherapists experience information needs, the capacity of digital information resources to fulfill these needs, and the specific types of resources they use to do so.

Methods

A total of 38 participants (all practicing physiotherapists; 19 females, 19 males) were randomly assigned to complete three 20-question multiple-choice questionnaire (MCQ) examinations under 3 conditions in a randomized crossover study design: assisted by a web browser, assisted by a federated search portal system, and unassisted. MCQ scores, times, and frequencies of information needs were recorded for overall examination-level and individual question-level analyses. Generalized estimating equations were used to assess differences between conditions for the primary outcomes. A log file analysis was conducted to evaluate participants’ web search and retrieval behaviors.

Results

Participants experienced an information need in 55.59% (845/1520) MCQs (assisted conditions only) and exhibited a mean improvement of 10% and 16% in overall examination scores for the federated search and web browser conditions, respectively, compared with the unassisted condition (P<.001). In the web browser condition, Google was the most popular resource and the only search engine used, accounting for 1273 (64%) of hits, followed by PubMed (195 hits; 10% of total). In the federated search condition, Wikipedia and PubMed were the most popular resources with 1518 (46% of total) and 1273 (39% of total) hits, respectively.

Conclusions

In agreement with the findings of previous research studies among medical physicians, the results of this study demonstrate that physiotherapists frequently experience information needs. This study provides new insights into the preferred digital information resources used by physiotherapists to fulfill these needs. Future research should clarify the implications of physiotherapists’ apparent high reliance on Google, whether these results reflect the authentic clinical environment, and whether fulfilling clinical information needs alters practice behaviors or improves patient outcomes.

Using functional movement tests to investigate the presence of sensorimotor impairment in amateur athletes following sport-related concussion: A prospective, longitudinal study

OBJECTIVE

To longitudinally investigate the presence of sensorimotor impairments in amateur athletes following sport-related concussion using two functional movement tests.

DESIGN

Prospective, longitudinal study.

SETTING

Human movement analysis laboratory.

PARTICIPANTS

Athletes who presented to a hospital emergency department and were diagnosed with sport-related concussion, and sex-, age-, and activity-matched non-concussed, control athletes. Concussed participants were assessed within one-week following sport-related concussion, upon clearance to return-to-sporting activity (RTA), and two weeks after RTA. Control participants were assessed at an initial time-point and approximately two and four weeks following their initial study assessment.

MAIN OUTCOMES MEASURES

At each laboratory assessment, participants completed two functional movement tests: the Star Excursion Balance Test to evaluate anterior reach distance (normalised for leg length) and fractal dimension (centre of pressure path complexity), and the Multiple Hop Test to evaluate corrective postural strategies and time-to-stabilisation.

RESULTS

Fifty concussed athletes and 50 control athletes completed the study. There were no significant differences at any study assessment between the concussion and control group on the Star Excursion Balance Test anterior reach distance or fractal dimension (centre of pressure path complexity). During the Multiple Hop Test, the concussion group used a significantly greater number of corrective postural strategies than the control group one-week following sport-related concussion and upon clearance to RTA, but not two weeks following RTA.

CONCLUSION

Recently concussed athletes made a greater number of corrective postural strategies than control participants during the Multiple Hop Test upon clearance to RTA but not two weeks after RTA. The Multiple Hop Test may offer a clinically useful tool for practitioners to examine the recovery of subtle sensorimotor impairments and related RTA readiness.

Establishing a baseline for a national paediatric antimicrobial stewardship programme

BACKGROUND

The majority of antimicrobial stewardship programmes focus on prescribing in adult populations; however, there is a recognized need for targeted paediatric antimicrobial stewardship to improve the quality and safety of prescribing amongst this patient group.

OBJECTIVES

To describe the current epidemiology of antimicrobial prescribing in paediatric inpatient populations in Scotland to establish a baseline of evidence and identify priority areas for quality improvement to support a national paediatric antimicrobial stewardship programme.

METHODS

A total of 559 paediatric inpatients were surveyed during the Scottish national point prevalence survey of healthcare-associated infections and antimicrobial prescribing, 2016. The prevalence of antimicrobial prescribing was calculated and characteristics of antimicrobial prescribing were described as proportions and compared between specialist hospitals and paediatric wards in acute hospitals.

RESULTS

Prevalence of antimicrobial use in paediatric inpatients was 35.4% (95% CI = 31.6%-39.4%). Treatment of community- and hospital-acquired infections accounted for 47.1% and 20.7% of antimicrobial use, respectively, with clinical sepsis being the most common diagnosis and gentamicin the most frequently prescribed antimicrobial for the treatment of infection. The reason for prescribing was documented in the notes for 86.5% of all prescriptions and, of those assessed for compliance against local policy, 92.9% were considered compliant.

CONCLUSIONS

Data from national prevalence surveys are advantageous when developing antimicrobial stewardship programmes. Results have highlighted differences in the prescribing landscape between paediatric inpatient populations in specialist hospitals and acute hospitals, and have informed priorities for the national antimicrobial stewardship programme, which reinforces the need for a targeted paediatric antimicrobial stewardship programme.

The Determinants of Marathon Performance: An Observational Analysis of Anthropometric, Pre-race and In-race Variables

Researchers investigating the determinants of marathon performance have previously focused on pre-race (e.g. training) or in-race (e.g. pacing) variables, but not both. This cross-sectional study, therefore, sought to elucidate the relationship between training behaviours, in-race pacing and anthropometric variables with eventual marathon finish time. A self-report questionnaire collecting athletes' anthropometrics, training behaviours and recent race times was administered to 260 participants in the 2018 Dublin Marathon. Participants' race numbers were cross referenced with in-race split times and finish times to determine their race performance. The accuracy or pragmatism of participants' target finish time was calculated using a 'predicted' time based on their training and previous race performances and subtracting this value from their eventual finish time. Multiple regression analysis examined the influence of age, body mass index (BMI), marathon experience, training history, target finish time pragmatism and in-race pace variance on marathon performance. The model was statistically significant and predicted marathon finish time F(7,252) = 217.761, p < 0.0005, adj. R2 = 0.858. Marathon experience (p = 0.01, Beta = 0.06), a pragmatic target finish time (p < 0.0005, Beta = -0.36), training history (p < 0.0005, Beta = 0.76) and in-race pace variance (p < 0.0005, Beta = 0.26) made statistically significant contributions to the overall regression model. A marathoners' training history accounts for the greatest variance in their overall performance, followed by the pragmatism of their target finish time and their in-race pace variance. This study provides the first indication of the combined relative importance of anthropometric, training and pacing variables to marathon performance.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Rate of replenishment and microenvironment contribute to the sexually dimorphic phenotype and function of peritoneal macrophages

Macrophages reside in the body cavities where they maintain serosal homeostasis and provide immune surveillance. Peritoneal macrophages are implicated in the etiology of pathologies including peritonitis, endometriosis, and metastatic cancer; thus, understanding the factors that govern their behavior is vital. Using a combination of fate mapping techniques, we have investigated the impact of sex and age on murine peritoneal macrophage differentiation, turnover, and function. We demonstrate that the sexually dimorphic replenishment of peritoneal macrophages from the bone marrow, which is high in males and very low in females, is driven by changes in the local microenvironment that arise upon sexual maturation. Population and single-cell RNA sequencing revealed marked dimorphisms in gene expression between male and female peritoneal macrophages that was, in part, explained by differences in composition of these populations. By estimating the time of residency of different subsets within the cavity and assessing development of dimorphisms with age and in monocytopenic Ccr2 -/- mice, we demonstrate that key sex-dependent features of peritoneal macrophages are a function of the differential rate of replenishment from the bone marrow, whereas others are reliant on local microenvironment signals. We demonstrate that the dimorphic turnover of peritoneal macrophages contributes to differences in the ability to protect against pneumococcal peritonitis between the sexes. These data highlight the importance of considering both sex and age in susceptibility to inflammatory and infectious diseases.

Multidisciplinary guidance for safe tracheostomy care during the COVID-19 pandemic: the NHS National Patient Safety Improvement Programme (NatPatSIP)

The COVID-19 pandemic is causing a significant increase in the number of patients requiring relatively prolonged invasive mechanical ventilation and an associated surge in patients who need a tracheostomy to facilitate weaning from respiratory support. In parallel, there has been a global increase in guidance from professional bodies representing staff who care for patients with tracheostomies at different points in their acute hospital journey, rehabilitation and recovery. Of concern are the risks to healthcare staff of infection arising from tracheostomy insertion and caring for patients with a tracheostomy. Hospitals are also facing extraordinary demands on critical care services such that many patients who require a tracheostomy will be managed outside established intensive care or head and neck units and cared for by staff with little tracheostomy experience. These concerns led NHS England and NHS Improvement to expedite the National Patient Safety Improvement Programme's 'Safe Tracheostomy Care' workstream as part of the NHS COVID-19 response. Supporting this workstream, UK stakeholder organisations involved in tracheostomy care were invited to develop consensus guidance based on: expert opinion; the best available published literature; and existing multidisciplinary guidelines. Topics with direct relevance for frontline staff were identified. This consensus guidance includes: infectivity of patients with respect to tracheostomy indications and timing; aerosol-generating procedures and risks to staff; insertion procedures; and management following tracheostomy.

Devising a Pace-Based Definition for "The Wall": An Observational Analysis of Marathoners' Subjective Experiences of Fatigue

CONTEXT

Many runners report "hitting The Wall" (HTW) during a marathon (42.2 km). However, the performance manifestation of this subjectively experienced phenomenon remains unclear.

OBJECTIVE

To identify a pace-based classification for HTW by integrating subjective reports of fatigue and runners' pacing profiles during a marathon.

DESIGN

Cross-sectional study.

SETTING

Public race event (2018 Dublin Marathon).

PATIENTS OR OTHER PARTICIPANTS

Eighty-three runners (28 [34%] women, 55 [66%] men, age = 41.5 ± 9.1 years, height = 1.73 ± 0.09 m, mass = 70.2 ± 10.1 kg).

MAIN OUTCOME MEASURE(S)

The pacing profiles for respondents to our postrace questionnaire that concerned the phenomenon of HTW were evaluated. Receiver operating characteristic analyses were performed on discretized outcomes of the time series of marathoners' paces during the race.

RESULTS

Using the receiver operating characteristic analyses, we observed that runners could be classified as having experienced HTW if they ran any 1-km segment 11% slower than the average of the remaining segments of the race (accuracy = 84.6%, sensitivity = 1, specificity = 0.6) or if the standard deviation of the normalized 1-km split times exceeded 0.0532 (accuracy = 83%, sensitivity = 0.818, specificity = 0.8). Similarly, runners could be classified as having experienced HTW if they ran any 5-km segment 7.3% slower than the average of the remaining 5-km segments of the race (accuracy = 84.6%, sensitivity = 1, specificity = 0.644) or if the standard deviation of the normalized 5-km split times exceeded 0.0346 (accuracy = 82%, sensitivity = 0.909, specificity = 0.622).

CONCLUSIONS

These pace-based criteria could be valuable to researchers evaluating HTW prevalence in cohorts for whom they lack subjective questionnaire data.

'WP2Cochrane', a tool linking Wikipedia to the Cochrane Library: Results of a bibliometric analysis evaluating article quality and importance

Medical information on English Wikipedia was accessed over 2 billion times in 2018. Our goal was to develop an automated system to assist Wikipedia volunteers to improve articles with high-quality sources from journals such as The Cochrane Library. We created an automated indexing system by linking available reviews from the Cochrane library with disease-related Wikipedia articles and evaluating the relationship between the quality and importance of these articles with the number of relevant and cited Cochrane reviews. We first conducted a bibliometric analysis, identifying disease-related Wikipedia articles and relevant/cited Cochrane reviews. Citations were thematically coded, and descriptive statistics were calculated. Finally, separate multinomial logistic regression analyses were conducted for article quality and importance. The indexing system identified 4381 disease-related Wikipedia articles, 1193 (27%) of which cited a Cochrane review. Higher quality Wikipedia articles were more likely to cite a Cochrane review (p = 0.002), while lower quality articles were less likely to cite a Cochrane review (p < 0.0005). A greater number of Cochrane reviews are available for more 'important' Wikipedia articles (p < 0.005), and these articles were more likely to cite a Cochrane review (p < 0.005). This approach to an indexing system can be leveraged by Wikipedia contributors and editors seeking to update disease-related Wikipedia articles with relevant Cochrane reviews (thus improving their quality), and online information seekers in need of additional information to supplement their Wikipedia search.

An evaluation of the training determinants of marathon performance: A meta-analysis with meta-regression

OBJECTIVES

Marathoners rely on expert-opinion and the anecdotal advice of their peers when devising their training plans for an upcoming race. The accumulation of results from multiple scientific studies has the potential to clarify the precise training requirements for the marathon. The purpose of the present study was to perform a systematic review, meta-analysis and meta-regression of available literature to determine if a dose-response relationship exists between a series of training behaviours and marathon performance.

DESIGN

Systematic review, meta-analysis and meta-regression.

METHODS

A systematic search of multiple literature sources was undertaken to identify observational and interventional studies of elite and recreational marathon (42.2km) runners.

RESULTS

Eighty-five studies which included 137 cohorts of runners (25% female) were included in the meta-regression, with average weekly running distance, number of weekly runs, maximum running distance completed in a single week, number of runs ≥32km completed in the pre-marathon training block, average running pace during training, distance of the longest run and hours of running per week used as covariates. Separately conducted univariate random effects meta-regression models identified a negative statistical association between each of the above listed training behaviours and marathon performance (R² 0.38-0.81, p<0.001), whereby increases in a given training parameter coincided with faster marathon finish times. Meta-analysis revealed the rate of non-finishers in the marathon was 7.27% (95% CI 6.09%-8.65%).

CONCLUSIONS

These data can be used by athletes and coaches to inform the development of marathon training regimes that are specific to a given target finish time.

Prediction Equations for Marathon Performance: A Systematic Review

PURPOSE

Despite the volume of available literature focusing on marathon running and the prediction of performance, no single prediction equations exists that is accurate for all runners of varying experiences and abilities. Indeed the relative merits and utility of the existing equations remain unclear. Thus, the aim of this study was to collate, characterize, compare, and contrast all available marathon prediction equations.

METHODS

A systematic review was conducted to identify observational research studies outlining any kind of prediction algorithm for marathon performance.

RESULTS

Thirty-six studies with 114 equations were identified. Sixty-one equations were based on training and anthropometric variables, whereas 53 equations included variables that required laboratory tests and equipment. The accuracy of these equations was denoted via a variety of metrics; r2 values were provided for 68 equations (r2 = .10-.99), and an SEE was provided for 19 equations (SEE 0.27-27.4 min).

CONCLUSION

Heterogeneity of the data precludes the identification of a single "best" equation. Important variables such as course gradient, sex, and expected weather conditions were often not included, and some widely used equations did not report the r2 value. Runners should therefore be wary of relying on a single equation to predict their performance.

Concussed athletes walk slower than non-concussed athletes during cognitive-motor dual-task assessments but not during single-task assessments 2 months after sports concussion: a systematic review and meta-analysis using individual participant data

Objectives

To determine whether individuals who sustained a sports concussion would exhibit persistent impairments in gait and quiet standing compared to non-injured controls during a dual-task assessment .

Design

Systematic review and meta-analysis using individual participant data (IPD).

Data sources

The search strategy was applied across seven electronic bibliographic and grey literature databases: MEDLINE, EMBASE, CINAHL, SportDISCUS, PsycINFO, PsycARTICLES and Web of Science, from database inception until June 2017.

Eligibility criteria for study selection

Studies were included if; individuals with a sports concussion and non-injured controls were included as participants; a steady-state walking or static postural balance task was used as the primary motor task; dual-task performance was assessed with the addition of a secondary cognitive task; spatiotemporal, kinematic or kinetic outcome variables were reported, and; included studies comprised an observational study design with case–control matching.

Data extraction and synthesis

Our review is reported in line with the Preferred Reporting Items for Systematic review and Meta-Analyses-IPD Statement. We implemented the Risk of Bias Assessment tool for Non-randomised Studies to undertake an outcome-level risk of bias assessment using a domain-based tool. Study-level data were synthesised in one of three tiers depending on the availability and quality of data: (1) homogeneous IPD; (2) heterogeneous IPD and (3) aggregate data for inclusion in a descriptive synthesis. IPD were aggregated using a ‘one-stage’, random-effects model.

Results

26 studies were included. IPD were available for 20 included studies. Consistently high and unclear risk of bias was identified for selection, detection, attrition, and reporting biases across studies. Individuals with a recent sports concussion walked with slower average walking speed (χ2=51.7; df=4; p<0.001; mean difference=0.06 m/s; 95% CI: 0.004 to 0.11) and greater frontal plane centre of mass displacement (χ2=10.3; df=4; p=0.036; mean difference −0.0039 m; 95% CI: −0.0075 to −0.0004) than controls when evaluated using a dual-task assessment up to 2 months following concussion.

Summary/conclusions

Our IPD evidence synthesis identifies that, when evaluated using a dual-task assessment, individuals who had incurred a sports concussion exhibited impairments in gait that persisted beyond reported standard clinical recovery timelines of 7–10 days. Dual-task assessment (with motion capture) may be a useful clinical assessment to evaluate recovery after sports concussion.

Protocol pre-registration

This systematic review was prospectively registered in PROSPERO CRD42017064861.

Identification and quantification of gold engineered nanomaterials and impaired fluid transfer across the rat placenta via ex vivo perfusion

Development and implementation of products incorporating nanoparticles are occurring at a rapid pace. These particles are widely utilized in domestic, occupational, and biomedical applications. Currently, it is unclear if pregnant women will be able to take advantage of the potential biomedical nanoproducts out of concerns associated with placental transfer and fetal interactions. We recently developed an ex vivo rat placental perfusion technique to allow for the evaluation of xenobiotic transfer and placental physiological perturbations. In this study, a segment of the uterine horn and associated placenta was isolated from pregnant (gestational day 20) Sprague-Dawley rats and placed into a modified pressure myography vessel chamber. The proximal and distal ends of the maternal uterine artery and the vessels of the umbilical cord were cannulated, secured, and perfused with physiological salt solution (PSS). The proximal uterine artery and umbilical artery were pressurized at 80 mmHg and 50 mmHg, respectively, to allow countercurrent flow through the placenta. After equilibration, a single 900 μL bolus dose of 20 nm gold engineered nanoparticles (Au-ENM) was introduced into the proximal maternal artery. Distal uterine and umbilical vein effluents were collected every 10 min for 180 min to measure placental fluid dynamics. The quantification of Au-ENM transfer was conducted via inductively coupled plasma mass spectrometry (ICP-MS). Overall, we were able to measure Au-ENM within uterine and umbilical effluent with 20 min of material infusion. This novel methodology may be widely incorporated into studies of pharmacology, toxicology, and placental physiology.

Position statement on defining and standardizing an oncoplastic approach to breast-conserving surgery in Canada

Although mastectomy is an effective procedure, it can have a negative effect on body image, sense of attractiveness, and sexuality. As opposed to the combination of breast oncologic surgery and plastic surgery, whose primary focus is on replacing lost volume, breast-conserving oncoplastic surgery (ops) redistributes remaining breast tissue in a manner that requires vision, anatomic knowledge, and an appreciation of esthetics, symmetry, and breast function. Modern surgical treatment of breast cancer can be realized only with breast and plastic surgeons working together using oncoplastic techniques to deliver superior cosmetic and cancer outcomes alike. Using this collaborative approach, oncologic and plastic surgeons in Canada have a significant opportunity to improve the care of their breast cancer patients. We propose a tri-level classification for volume displacement procedures to act as a rubric for the training of general surgeons and oncologic breast surgeons in oncoplastic breast-conserving therapy techniques. It is our position that ops enhances outcomes for many women with breast cancer and should become part of the standard repertoire of procedures used by Canadian oncologic surgeons treating breast cancer.

Abstract PD6-09: Cost effectiveness of bilateral prophylactic mastectomy with and without different breast reconstruction techniques versus screening in women with high risk of breast cancer in the Canadian Province of Ontario

Purpose: We aimed to investigate the cost-effectiveness of mastectomy with and without different reconstruction for the purpose of determining which strategies represent value for money and identify the most cost-effective technique from the perspective of Ontario's health care system.

Methods: We developed a decision analytic model to project the lifetime clinical and economic consequences of different strategies .The decision model was parameterized using 10-year follow up and cost data from Ontario administrative health databases and Ontario Cancer registry and utility data from secondary Canadian sources. Costs are presented in 2018 Canadian dollars. Future costs and benefits were discounted at 5%.

Results: Compared to organized screening-based strategy, surgical strategies ranged from being more effective and cost-saving and up to being associated with an incremental cost effectiveness ratio (ICER) of $63,010 per quality-adjusted life year (QALY) gained, with BPM with immediate one-stage acellular dermal matrix (ADM)-assisted implant breast reconstruction having the greatest incremental QALY of 1.157 and lowest ICER of $9,615. Incorporating the PBM with one-stage ADM-assisted implant immediate breast reconstruction as the standard surgical strategy in Ontario would result in the largest total annual net gains of 20 QALYs and $ 1.7 million.

Table 1Baseline life-time outcomes of the decision model.   Extensive breast cancer screening alone vs. surgical interventionsStrategyOverall QALYsOverall costInc. QALYInc. costICER per QALY gainedExtensive breast cancer screening18.549$90,231Ref.Ref.Ref.Prophylactic bilateral mastectomy without breast reconstruction19.057$82,011+0.508−$8,220Cost-savingProphylactic bilateral mastectomy with two-stage traditional TE-implant immediate breast reconstruction19.364$111,319+0.815+$21,088$25,868 (dominated)Prophylactic bilateral mastectomy with one-stage ADM-assisted implant immediate breast reconstruction19.706$101,359+1.157+$11,128$9,615Prophylactic bilateral mastectomy with two-stage ADM-assisted TE-implant immediate breast reconstruction19.065$122,757+0.516+$32,526$63,010 (dominated)Prophylactic bilateral mastectomy with any type of autologous immediate breast reconstruction (with or without TE or breast implant)19.501$114,014+0.951+$23,784$24,988 (dominated)Prophylactic bilateral mastectomy with one-stage non-ADM immediate breast reconstruction19.408$103,512+0.859+$13,282$15,457 (dominated)Prophylactic bilateral mastectomy with delayed breast reconstruction19.241$107,582+0.691+$17,351$25,087 (dominated)ADM;acellular dermal matrix ; TE=Tissue Expander; ICER=Incremental cost-effectiveness ratio; QALY=Quality adjusted life year

Conclusion: The choice of breast reconstruction needs to be decided based on the patient body habitus, general condition and goals . BPM with and without reconstruction is likely both clinically and economically attractive. However ,all other things being equal , BPM with immediate one-stage ADM-assisted implant breast reconstruction is the most cost effective strategy and appears to offer the highest value for money.

Citation Format: Aljohani BE, Hannouf MB, Grant A, Doherty C, Zaric GS, Brackstone M. Cost effectiveness of bilateral prophylactic mastectomy with and without different breast reconstruction techniques versus screening in women with high risk of breast cancer in the Canadian Province of Ontario [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD6-09.

Sex differences in sagittal plane control emerge during adolescent growth: a prospective investigation

PURPOSE

Females athletes have a higher incidence of non-contact knee joint injuries compared to their male counterparts. This may be attributable to sex-specific differences in neuromuscular control, which arise during the pubertal growth spurt. The purpose of this longitudinal study was to assess the development of landing kinematics of adolescent male and female athletes during the adolescent growth-spurt.

METHODS

One hundred and eighty-four adolescent athletes (55% male, 45% female; mean age = 13 ± 0.3 years) participated. Testing was undertaken at baseline and then repeated at 6, 12, 18 and 24 months. Participants performed three drop vertical jump (DVJ) trials from a 31 cm box. Frontal and sagittal plane knee joint angles were recorded. The average measurement of the three jumps was used for analysis at each time point. To assess maturation status, participants were categorised according to their age from peak height velocity at baseline. Pre-initial contact knee flexion (pre-IC), peak knee flexion and knee valgus displacement were the dependant variables. The categorical independent variables were sex (male versus female) and time.

RESULTS

There was a significant sex*time interaction for pre-IC knee flexion, with males increasing knee flexion with time to a greater extent than females. There was no significant sex*time interaction for knee valgus displacement; although females displayed greater knee valgus displacement across all time points.

CONCLUSIONS

Adolescent male and female athletes display differing kinematic profiles across growth and development. This has clinical relevance for emphasising increased knee flexion, as well as decreasing abnormal frontal plane displacement in injury prevention programmes for adolescent females.

LEVEL OF EVIDENCE

II.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Wearable Inertial Sensor Systems for Lower Limb Exercise Detection and Evaluation: A Systematic Review

BACKGROUND

Analysis of lower limb exercises is traditionally completed with four distinct methods: (1) 3D motion capture; (2) depth-camera-based systems; (3) visual analysis from a qualified exercise professional; and (4) self-assessment. Each method is associated with a number of limitations.

OBJECTIVE

The aim of this systematic review is to synthesise and evaluate studies which have investigated the capacity for inertial measurement unit (IMU) technologies to assess movement quality in lower limb exercises.

DATA SOURCES

A systematic review of studies identified through the databases of PubMed, ScienceDirect and Scopus was conducted.

STUDY ELIGIBILITY CRITERIA

Articles written in English and published in the last 10 years which investigated an IMU system for the analysis of repetition-based targeted lower limb exercises were included.

STUDY APPRAISAL AND SYNTHESIS METHODS

The quality of included studies was measured using an adapted version of the STROBE assessment criteria for cross-sectional studies. The studies were categorised into three groupings: exercise detection, movement classification or measurement validation. Each study was then qualitatively summarised.

RESULTS

From the 2452 articles that were identified with the search strategies, 47 papers are included in this review. Twenty-six of the 47 included studies were deemed as being of high quality.

CONCLUSIONS

Wearable inertial sensor systems for analysing lower limb exercises is a rapidly growing field of research. Research over the past 10 years has predominantly focused on validating measurements that the systems produce and classifying users' exercise quality. There have been very few user evaluation studies and no clinical trials in this field to date.

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies

Temporary and permanent tracheostomies are required in children to manage actual or anticipated long-term ventilatory support, to aid secretion management or to manage fixed upper airway obstruction. Tracheostomies may be required from the first few moments of life, with the majority performed in children < 4 years of age. Although similarities with adult tracheostomies are apparent, there are key differences when managing the routine and emergency care of children with tracheostomies. The National Tracheostomy Safety Project identified the need for structured guidelines to aid multidisciplinary clinical decision making during paediatric tracheostomy emergencies. These guidelines describe the development of a bespoke emergency management algorithm and supporting resources. Our aim is to reduce the frequency, nature and severity of paediatric tracheostomy emergencies through preparation and education of staff, parents, carers and patients.

Rehabilitation Exercises Reduce Reinjury Post Ankle Sprain, But the Content and Parameters of an Optimal Exercise Program Have Yet to Be Established: A Systematic Review and Meta-analysis

OBJECTIVES

To determine if exercise-based rehabilitation reduces reinjury following acute ankle sprain. Our secondary objective was to assess if rehabilitation efficacy varies according to exercise content and training volume.

DATA SOURCES

The following electronic databases were searched: EMBASE, MEDLINE, the Cochrane Central Register of Controlled Trials, and Physiotherapy Evidence Database (PEDro).

STUDY SELECTION

Randomized controlled trials investigating the effect of exercise-based rehabilitation programs on reinjury and patient-reported outcomes (perceived instability, function, pain) in people with an acute ankle sprain. No restrictions were made on the exercise type, duration, or frequency. Exercise-based programs could have been administered in isolation or as an adjunct to usual care. Comparisons were made to usual care consisting of 1 or all components of PRICE (protection, rest, ice, compression, elevation).

DATA EXTRACTION

Effect sizes with 95% CIs were calculated in the form of mean differences for continuous outcomes and odds ratios (ORs) for dichotomous outcomes. Pooled effects were calculated for reinjury prevalence with meta-analysis undertaken using RevMan software.

DATA SYNTHESIS

Seven trials (n=1417) were included (median PEDro score, 8/10). Pooled data found trends toward a reduction in reinjury in favor of the exercise-based rehabilitation compared with usual care at 3-6 months (OR, 0.87; 95% CI, 0.48-1.58) with significant reductions reported at 7-12 months (OR, 0.53; 95% CI, 0.38-0.73). Sensitivity analysis based on pooled reinjury data from 2 high quality studies (n=629) also found effects in favor of exercise-based rehabilitation at 12 months (OR, 0.60; 95% CI, 0.49-0.89). Training volume differed substantially across rehabilitation programs with total rehabilitation time ranging from 3.5-21 hours. The majority of rehabilitation programs focused primarily on postural balance or strength training.

CONCLUSIONS

Exercise-based rehabilitation reduces the risk of reinjury following acute ankle sprain when compared with usual care alone. There is no consensus on optimal exercise content and training volume in this field. Future research must explicitly report all details of administered exercise-based rehabilitation programs.

Clinical assessment of acute lateral ankle sprain injuries (ROAST): 2019 consensus statement and recommendations of the International Ankle Consortium

Lateral ankle sprain injury is the most common musculoskeletal injury incurred by individuals who participate in sports and recreational physical activities. Following initial injury, a high proportion of individuals develop long-term injury-associated symptoms and chronic ankle instability. The development of chronic ankle instability is consequent on the interaction of mechanical and sensorimotor insufficiencies/impairments that manifest following acute lateral ankle sprain injury. To reduce the propensity for developing chronic ankle instability, clinical assessments should evaluate whether patients in the acute phase following lateral ankle sprain injury exhibit any mechanical and/or sensorimotor impairments. This modified Delphi study was undertaken under the auspices of the executive committee of the International Ankle Consortium. The primary aim was to develop recommendations, based on expert (n=14) consensus, for structured clinical assessment of acute lateral ankle sprain injuries. After two modified Delphi rounds, consensus was achieved on the clinical assessment of acute lateral ankle sprain injuries. Consensus was reached on a minimum standard clinical diagnostic assessment. Key components of this clinical diagnostic assessment include: establishing the mechanism of injury, as well as the assessment of ankle joint bones and ligaments. Through consensus, the expert panel also developed the International Ankle Consortium Rehabilitation-Oriented ASsessmenT (ROAST). The International Ankle Consortium ROAST will help clinicians identify mechanical and/or sensorimotor impairments that are associated with chronic ankle instability. This consensus statement from the International Ankle Consortium aims to be a key resource for clinicians who regularly assess individuals with acute lateral ankle sprain injuries.

Einfluß morphologischer Veränderungen auf Durchblutung und Stoffwechsel bei zerebraler Mikroangiopathie

51 Patienten mit zerebraler Mikroangiopathie wurden mittels Kernspintomographie, 18FDG-PET und 99mTc-HMPAO-SPECT untersucht. Die genaue Zuordnung funktioneller zu den morphologischen Befunden wurde durch ein spezielles Kopf-halterungssystem für PET, SPECT- und KST-Untersuchungen hergestellt. Patienten mit weniger als vier lakunären Infarkten (LI) und ohne bis geringfügigen Deep White Matter Lesions (DWML) im KST wiesen keine signifikant veränderten Werte für rMRGIu und rCBF in grauer oder weißer Substanz auf im Vergleich zu Patienten mit vier oder mehr LI und ausgedehnten DWML. Eine semiquantitative Einteilung der Atrophie (A: keine bis geringfügige; B: mäßige bis schwere) erbrachte für B) im Vergleich zu A) signifikant erniedrigte rCBF- und rMRGIu-Werte in grauer und weißer Substanz. Somit sind bei Patienten mit ZMA nur die Hirnatrophie, jedoch nicht die charakteristischen LI und DWML mit einer meßbaren Erniedrigung von rCBF und rMRGIu korreliert.

Clinical Tests Have Limited Predictive Value for Chronic Ankle Instability When Conducted in the Acute Phase of a First-Time Lateral Ankle Sprain Injury

OBJECTIVE

To evaluate whether a battery of clinical assessments for acute lateral ankle sprain (LAS) can be used to predict long-term recovery.

DESIGN

Cohort study.

SETTING

University biomechanics laboratory.

PARTICIPANTS

Individuals (N=82) were assessed using a clinical test battery within 2 weeks of incurring a first-time LAS.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The clinical test battery included scores on the talar glide test (degrees), the anterior drawer, talar tilt, figure of 8 for swelling (millimeters) and knee to wall (millimeters) tests, and handheld goniometric range of motion (inversion, eversion, and plantarflexion [in degrees]). Scores on the Cumberland Ankle Instability Tool taken 12 months after the clinical test battery were used to classify participants as having chronic ankle instability (CAI) or as being LAS copers.

RESULTS

Forty percent of participants were designated as having CAI, with 60% being designated as LAS copers. A logistic regression analysis revealed that a combined model using scores from the talar glide, talar tilt, and anterior drawer tests in addition to plantarflexion range of motion was statistically significant (P<.01) and correctly classified cases with moderate accuracy (68.8%). The final model had moderate sensitivity (64%) and good specificity (72%).

CONCLUSIONS

The clinical tests used in this investigation have limited predictive value for CAI when conducted in the acute phase of a first-time LAS injury.

Hypoxia determines survival outcomes of bacterial infection through HIF-1alpha dependent re-programming of leukocyte metabolism

Hypoxia and bacterial infection frequently co-exist, in both acute and chronic clinical settings, and typically result in adverse clinical outcomes. To ameliorate this morbidity, we investigated the interaction between hypoxia and the host response. In the context of acute hypoxia, both S. aureus and S. pneumoniae infections rapidly induced progressive neutrophil mediated morbidity and mortality, with associated hypothermia and cardiovascular compromise. Preconditioning animals through longer exposures to hypoxia, prior to infection, prevented these pathophysiological responses and profoundly dampened the transcriptome of circulating leukocytes. Specifically, perturbation of HIF pathway and glycolysis genes by hypoxic preconditioning was associated with reduced leukocyte glucose utilisation, resulting in systemic rescue from a global negative energy state and myocardial protection. Thus we demonstrate that hypoxia preconditions the innate immune response and determines survival outcomes following bacterial infection through suppression of HIF-1α and neutrophil metabolism. The therapeutic implications of this work are that in the context of systemic or tissue hypoxia therapies that target the host response could improve infection associated morbidity and mortality.

Quantification of postural control deficits in patients with recent concussion: An inertial-sensor based approach

BACKGROUND

The aim of this study was to quantify postural control ability in a group with concussion compared with a healthy control group.

METHOD

Fifteen concussion patients (4 females, 11 males) and a group of fifteen age- and sex-matched controls were recruited. Participants were tested during the performance of the three stance variants (bilateral, tandem and unilateral) of the balance error scoring system standing on a force place, while wearing an inertial measurement unit placed at the posterior aspect of the sacrum.

FINDINGS

The area of postural sway was computed using the force-plate and the '95% ellipsoid volume of sway' was computed from the accelerometer data. Concussed patients exhibited increased sway area (1513mm² [95% CI: 935 to 2091mm²] vs 646mm² [95% CI: 519 to 772mm²]; p=0.02) and sway volume (9.46m³s^-6 [95% CI: 8.02 to 19.94m³s^-6] vs 2.68m³s^-6 [95% CI: 1.81 to 3.55m³s^-6]; p=0.01) in the bilateral stance position of the balance error scoring system. The sway volume metric also had excellent accuracy in identifying task 'errors' (tandem stance: 91% accuracy [95% CI: 85-96%], p<0.001; unilateral stance: 91% accuracy [95% CI: 86-96%], p<0.001).

INTERPRETATION

Individuals with concussion display increased postural sway during bilateral stance. The sway volume that was calculated from the accelerometer data not only differentiated a group with concussion from a healthy control group, but successfully identified when task errors had occurred. This may be of value in the development of a pitch-side assessment system for concussion.

Treatment and prevention of acute and recurrent ankle sprain: an overview of systematic reviews with meta-analysis

BACKGROUND

Ankle sprains are highly prevalent with high risk of recurrence. Consequently, there are a significant number of research reports examining strategies for treating and preventing acute and recurrent sprains (otherwise known as chronic ankle instability (CAI)), with a coinciding proliferation of review articles summarising these reports.

OBJECTIVE

To provide a systematic overview of the systematic reviews evaluating treatment strategies for acute ankle sprain and CAI.

DESIGN

Overview of intervention systematic reviews.

PARTICIPANTS

Individuals with acute ankle sprain/CAI.

MAIN OUTCOME MEASUREMENTS

The primary outcomes were injury/reinjury incidence and function.

RESULTS

46 papers were included in this systematic review. The reviews had a mean score of 6.5/11 on the AMSTAR quality assessment tool. There was strong evidence for bracing and moderate evidence for neuromuscular training in preventing recurrence of an ankle sprain. For the combined outcomes of pain, swelling and function after an acute sprain, there was strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques. There was conflicting evidence regarding the efficacy of surgery and acupuncture for the treatment of acute ankle sprains. There was insufficient evidence to support the use of ultrasound in the treatment of acute ankle sprains.

CONCLUSIONS

For the treatment of acute ankle sprain, there is strong evidence for non-steroidal anti-inflammatory drugs and early mobilisation, with moderate evidence supporting exercise and manual therapy techniques, for pain, swelling and function. Exercise therapy and bracing are supported in the prevention of CAI.

A longitudinal investigation into the progression of dynamic postural stability performance in adolescents

Adolescent female athletes have a higher incidence of certain non-contact lower limb injuries compared to their male counterparts. Decreased postural stability is an established risk factor for lower limb injuries; however developmental-related sex differences in postural stability during adolescence have not been investigated. The objectives of this study were to longitudinally examine changes over time, and potential sex differences in dynamic postural stability performance in adolescents. One hundred and eighty four adolescent athletes participated (mean age=13±0.34 years). Participants were assessed, using the Star Excursion Balance Test (SEBT) at baseline (T1) and at 6 (T2), 12 (T3), 18 (T4) and 24 (T5) months. At each time-point, participants performed 3 trials of the anterior, posterior-medial and posterior-lateral directions of the SEBT on each limb. Reach distance for each direction was averaged across the 3 trials normalised to leg length. General linear mixed model analyses were carried out on each of the dependant variables (reach directions) with sex and time as the categorical independent variables. There was a significant sex×time interaction for the posterior-lateral reach distance scores. There were no significant sex×time interactions for any of the other reach directions. Males increased performance on the posterior-lateral reach direction from T1 to T5, while females only increased performance until T3. Young males and females demonstrate diverging postural stability profiles during adolescence.

Single-leg drop landing movement strategies in participants with chronic ankle instability compared with lateral ankle sprain 'copers'

PURPOSE

To compare the movement patterns and underlying energetics of individuals with chronic ankle instability (CAI) to ankle sprain 'copers' during a landing task.

METHODS

Twenty-eight (age 23.2 ± 4.9 years; body mass 75.5 ± 13.9 kg; height 1.7 ± 0.1 m) participants with CAI and 42 (age 22.7 ± 1.7 years; body mass 73.4 ± 11.3 kg; height 1.7 ± 0.1 m) ankle sprain 'copers' were evaluated 1 year after incurring a first-time lateral ankle sprain injury. Kinematics and kinetics of the hip, knee and ankle joints from 200 ms pre-initial contact (IC) to 200 ms post-IC, in addition to the vertical component of the landing ground reaction force, were acquired during performance of a drop land task.

RESULTS

The CAI group adopted a position of increased hip flexion during the landing descent on their involved limb. This coincided with a reduced post-IC flexor pattern at the hip and increased overall hip joint stiffness compared to copers (-0.01 ± 0.05 vs. 0.02 ± 0.05°/Nm kg(-1), p = 0.03).

CONCLUSIONS

Individuals with CAI display alterations in hip joint kinematics and energetics during a unipodal landing task compared to LAS 'copers'. These alterations may be responsible for the increased risk of injury experienced by individuals with CAI during landing manoeuvres. Thus, clinicians must recognise the potential for joints proximal to the affected ankle to contribute to impaired function following an acute lateral ankle sprain injury and to develop rehabilitation protocols accordingly.

LEVEL OF EVIDENCE

Level III.