No association between rate of torque development and onset of muscle activity with increased risk of hamstring injury in elite football.

Hamstring injuries remain a significant burden in sports that involve high-speed running. In elite male football, hamstring injury has repeatedly been identified as the most common non-contact injury, representing 12% of all injuries. As the incidence remains high, investigations are aimed at better understanding how to improve prevention efforts. Intrinsic risk factors such as strength have been investigated extensively in a cohort of professional football players; however, other intrinsic measures of neuromuscular function have not been studied in this cohort. This study aims to investigate the association between timing of hamstring muscle activity onset and the rate of torque development during the early phase of isokinetic strength testing with risk of hamstring injury in professional football players in a prospective cohort study. All teams (n = 18) eligible to compete in the premier football league in Qatar underwent a comprehensive strength assessment during their annual periodic health evaluation at Aspetar Orthopaedic and Sports Medicine Hospital in Doha, Qatar. Variables included rate of torque development and timing of muscle activity onset. A total of 367 unique players (60.6% of all QSL players) competed for 514 player seasons (103 players competed both seasons) and sustained 65 hamstring injuries. There was no difference in the onset of muscle activity between the biceps femoris and medial hamstrings comparing the injured to uninjured players. For both onset of muscle activity and rate of torque development, there were no significant differences between any of the variables (P > .05), with small effect sizes detected across all the different variables (d < 0.3). Rate of torque development and onset of muscle activity were not associated with a risk of future hamstring injury. The use of these measures as part of a periodic health evaluation to identify risk of hamstring injury is unsupported.

The inter-examiner reliability of a classification method for non-specific chronic low back pain patients with motor control impairment.

The importance of classifying chronic low back pain (LBP) patients into homogeneous sub-groups has recently been emphasized. This paper reports on two studies examining clinicians ability to agree independently on patients' chronic LBP classification, using a novel classification system (CS) proposed by O'Sullivan. In the first study, a sub-group of 35 patients with non-specific chronic LBP were independently classified by two 'expert' clinicians. Almost perfect agreement (kappa-coefficient 0.96; %-of-agreement 97%) was demonstrated. In the second study, 13 clinicians from Australia and Norway were given 25 cases (patients' subjective information and videotaped functional tests) to classify. Kappa-coefficients (mean 0.61, range 0.47-0.80) and %-of-agreement (mean 70%, range 60-84%) indicated substantial reliability. Increased familiarity with the CS improved reliability. These studies demonstrate the reliability of this multi-dimensional mechanism-based CS and provide essential evidence in a multi-step validation process. A fully validated CS will have significant research and clinical application.

Magnetic resonance imaging of the lumbar spine in asymptomatic professional fast bowlers in cricket.

Low back injuries account for the greatest loss of playing time for professional fast bowlers in cricket. Previous radiological studies have shown a high prevalence of degeneration of the lumbar discs and stress injuries of the pars interarticularis in elite junior fast bowlers. We have examined MRI appearance of the lumbar spines of 36 asymptomatic professional fast bowlers and 17 active control subjects. The fast bowlers had a relatively high prevalence of multi-level degeneration of the lumbar discs and a unique pattern of stress lesions of the pars interarticularis on the non-dominant side. The systems which have been used to classify the MR appearance of the lumbar discs and pars were found to be reliable. However, the relationship between the radiological findings, pain and dysfunction remains unclear.

High frequency of latent and clinical human papillomavirus cervical infections in immunocompromised human immunodeficiency virus-infected women.

In 32 human immunodeficiency virus (HIV)-infected women, routine gynecologic examination was performed with colposcopy and Papanicolaou smear; cervical swabs were collected for human papillomavirus (HPV) DNA screening and typing; and immune status was assessed by CD4 T-cell count. Dot blot analysis was specifically chosen for HPV DNA screening to detect only relatively substantial HPV DNA infections. Polymerase chain reaction analysis was used for precise DNA typing of dot blot-positive samples. The HPV data were assessed for immune status; a subject with a CD4 T-cell count below 200/microL was considered functionally immunosuppressed. The frequency of dot blot positivity was fivefold higher among immunocompromised (nine of ten) than relatively immunocompetent (four of 22) HIV-infected women. Moreover, four immunosuppressed women, compared with no immunocompetent subjects, had evidence of HPV DNA without signs of HPV-associated lesions by cytology or histology (ie, latent HPV infection). Furthermore, four of nine of the immunocompromised, compared with four of 21 immunocompetent, subjects had cervical intraepithelial neoplasia. These frequencies are high compared with those reported in the general population. Finally, HPV 18 was detected in five of the ten women with CD4 T-cell counts below 200/microL and in only one of the 22 with CD4 T-cell counts above that level. These results suggest that the normal immune system suppresses latent and clinical HPV cervical infections and that the efficiency of suppression may be HPV type-specific. Furthermore, impaired immune status, as reflected by CD4 T-cell count, is an important factor increasing the severity of HPV-induced cervical infections in this population.

Ineffectiveness of continuous 5-fluorouracil as salvage therapy for ovarian cancer.

5-Fluorouracil (5-FU) is an antimetabolite chemotherapy, which selectively functions at the S phase of the cell cycle. It is a short-acting agent with a serum half-life of approximately 11 minutes. Increased efficacy with this drug could theoretically be provided by sustained infusion over the doubling time of a tumor. Ovarian cancer that recurs or persists after treatment with platinum-based chemotherapy has a poor prognosis. This study examines the use of long-term infusional 5-FU as a salvage chemotherapy for ovarian cancer. 14 patients with epithelial ovarian cancer were studied. All were stage III or IV disease and all were initially treated with platinum-based chemotherapy with either persistence or recurrence of disease. Patients received 5-FU as 300 mg/m2/day via a continuous infusion for a 10-week cycle with discontinuation occurring for severe toxicity or documented progression. The average infusion per patient was 8 weeks (3-10). Three patients had drug discontinued secondary to toxicity (severe mucositis) and 4 patients had progression prior to the completion of 10 weeks. All patients had progression by the end of the first cycle. The average survival post-5-FU was 8.9 months (range: 0.75-22 months). The lack of response in 14 patients indicates that, statistically, the likelihood of an overall response rate of 20% is less than 0.05. Infusional 5-FU appears to be ineffective as salvage therapy for ovarian cancer.

Colonic surgery in gynecologic oncology. Risk factor analysis.

Colonic surgery is a critical part of gynecologic oncology care. A 12-year review of colonic surgery on a gynecologic oncology service was performed evaluating risk factors and their impact on postoperative morbidity. There were 124 procedures performed on 92 patients; 9 patients had no prior surgery, chemotherapy or radiation. Fifty-six percent of the patients were considered malnourished on the basis of a serum albumin level < 3.5 g/dL. The 124 procedures consisted of 57 colon resections with primary reanastomosis, 10 small bowel-colon bypass procedures and 57 colostomies. Of the 57 (67%) colostomy operations, 38 also had concomitant abdominal-pelvic procedures. There were 15 major bowel complications and 17 major systemic postoperative complications. Prior surgery and poor nutritional status significantly correlated with postoperative morbidity; however, prior radiation did not reveal an increased risk for postoperative complications.

Carcinoembryonic antigen in women with isolated pelvic masses. Clinical utility?

OBJECTIVE: To determine the usefulness of serum carcinoembryonic antigen (CEA) determination in predicting the nature of an isolated pelvic mass. STUDY DESIGN: Two hundred twenty-six women with an isolated pelvic mass had a serum CEA determination preoperatively. The results were correlated with the histopathologic findings. RESULTS: CEA was elevated in 19 of the 226 women. Twelve of the 183 (7%) women with benign masses, 2 of the 17 (12%) women with tumors of low malignant potential and 5 of the 15 (33%) women with a frankly invasive epithelial ovarian cancer had elevated CEA. None of the women with a malignant germ cell or stromal tumor had elevated CEA (P = .06 for prediction of malignancy.) There were no cases of metastatic gastrointestinal malignancies in the study group. The sensitivity, specificity, positive predictive value and negative predictive value of serum CEA were 16%, 93%, 37% and 83%, respectively. The corresponding figures for serum CA-125 were 67%, 71%, 35% and 90%. There was no statistically significant correlation between elevated CEA and mucinous histology. CONCLUSION: Preoperative serum CEA determination in women with isolated pelvic masses is not useful.

A kinematic, kinetic and electromyographic comparison of stooped sheep shearing techniques and shearing with a sheep manipulator.

Traditional sheep shearing methods require workers to adopt postures where the trunk is approximately horizontal and held in that position against gravity for long periods of time. The objective of this study was to examine the biomechanics of stooped shearing techniques and to compare the effectiveness of a new sheep manipulator in reducing the frequency of these postures and the changes in low back forces and electromyographic (EMG) activity. Five male shearers were filmed using three video cameras and EMG and three-dimensional (3D) kinematic data were derived during seven segments of the shearing action. Kinematic data were used to calculate the L5/S1 compressive and shear forces using the 3D Static Strength Prediction Program(TM). Results showed the low back forces in stooped shearing were typically between 2200 and 3000N. Also, the sheep manipulator effectively allowed the shearers to maintain a more upright posture (mean trunk angle >65 degrees) which decreased the compressive (maximum <1350N) and shear (maximum <260N) forces at L5/S1.

Injuries to the lower back in elite fast bowlers: acute stress changes on MRI predict stress fracture.

In our study, the aims were to describe the changes in the appearance of the lumbar spine on MRI in elite fast bowlers during a follow-up period of one year, and to determine whether these could be used to predict the presence of a stress fracture of the posterior elements. We recruited 28 elite fast bowlers with a mean age of 19 years (16 to 24) who were training and playing competitively at the start of the study. They underwent baseline MRI (season 1) and further scanning (season 2) after one year to assess the appearance of the lumbar intervertebral discs and posterior bony elements. The incidence of low back pain and the amount of playing and training time lost were also recorded. In total, 15 of the 28 participants (53.6%) showed signs of acute bone stress on either the season 1 or season 2 MR scans and there was a strong correlation between these findings and the later development of a stress fracture (p < 0.001). The prevalence of intervertebral disc degeneration was relatively low. There was no relationship between disc degeneration on the season 1 MR scans and subsequent stress fracture. Regular lumbar MR scans of asymptomatic elite fast bowlers may be of value in detecting early changes of bone stress and may allow prompt intervention aimed at preventing a stress fracture and avoiding prolonged absence from cricket.

Robotic radical trachelectomy for preservation of fertility in early cervical cancer: case series and description of technique.

STUDY OBJECTIVE: To present a case series of robotic radical trachelectomy for preservation of fertility in early cervical cancer. DESIGN: Descriptive study. DESIGN: Canadian Task Force Classification III. SETTING: Tertiary referral center. PATIENTS: Women with early cervical cancer who wish to maintain fertility potential. INTERVENTIONS: Robotic radical trachelectomy with bilateral pelvic lymphadenectomy. The procedure also uses a cervical cerclage and permits preservation of the ascending branches of the uterine arteries to the uterus. MEASUREMENTS AND MAIN RESULTS: Report of the technique, and operative and immediate postoperative complications. To date, 6 women have undergone robotic radical trachelectomy, with preservation of the uterine arteries in all patients. One patient underwent completion hysterectomy when the frozen section of the trachelectomy margin revealed inability to clear the cancer. Five women have maintained their fertility potential after the procedure. CONCLUSION: Robotic radical trachelectomy is a feasible technique that permits radical removal of the cervix. Improved visualization with the robot and fine dissection permissible with the instrument facilitate this procedure.

A phase II study of Hsp-7 (SGN-00101) in women with high-grade cervical intraepithelial neoplasia.

OBJECTIVE: Approximately 2 million women worldwide are infected with high-risk human papillomaviruses (HPV), resulting in a substantial risk for the development of invasive lower genital malignancies. This study was undertaken to determine the effects of vaccination with a protein encoding a bacterial heat shock protein fused to sequences from the oncogenic E7 protein of HPV-16 in women with high-grade cervical intraepithelial neoplasia. Endpoints included lesion regression, immune response, and viral clearance. METHODS: Twenty-one women were prospectively entered into an IRB-approved Phase II study. All women had biopsy-proven high-grade cervical intraepithelial neoplasia and persistent post-biopsy lesions visible by colposcopy. Four injections of HPV-16 Hsp E7 fusion protein at a dose of 500 mug were given 3 weeks apart after which Loop Electrosurgical Excision of the Transformation Zone (LLETZ) was performed. Immune parameters were evaluated pre-vaccine and at the time of LLETZ, and HPV testing was performed at intervals before and after LLETZ. Study subjects were followed for 1 year after LLETZ. RESULTS: Seven of 20 women (35%) evaluable for response had complete regression of their intraepithelial neoplasia at the time of LLETZ, 1 (5%) had regression to CIN I, 11 (55%) had stable disease and 1 (5%) had progression due to enlargement of her lesion. Immune responses were seen in 9 of the 17 women tested; 5 of the 7 complete responders had an immune response. Only 5 of 21 women had HPV-16 or -18. HPV clearance was not associated with lesion regression. CONCLUSION: Hsp-7 (SGN-00101), at this dose and schedule induced lesion regression in women with high-grade intraepithelial neoplasia. The fact that regression was correlated with immune response suggests that enhancing the immunogenicity of this vaccine may lead to improvement in the rate of lesion eradication.

Atypical glandular cells of undetermined significance Pap smears: appropriate evaluation and management.

This review focuses on atypical glandular cells of undetermined significance Pap smears, with attention given to the classifications of atypical glandular cells of undetermined significance, the clinical and histopathologic correlation, and recent advances in triage strategies for this entity. The management of atypical glandular cells of undetermined significance Pap smears will emphasize the significance of this finding in terms of diagnosing dysplasia and carcinoma of the lower female genital tract.

Reinventing the culdoscope.

The purpose of this study was to reassess culdoscopic visualization of the female pelvis using a small flexible fiberoptic choledochoscope introduced via a disposable trochar system. A disposable 5-mm retractable laparoscopic trochar was used to gain access to the peritoneal cavity via the posterior fornix of the vagina. A 4.9-mm flexible choledochoscope then was introduced through this trochar to visualize the pelvic organs. The initial procedures were performed with the patient under general anesthesia using direct laparoscopic visualization of the cul-de-sac. Subsequent procedures were performed on women who were awake, using local anesthesia and sedation with the patients in a knee-chest position. In this study, 18 women taken to the operating room for a planned transvaginal hysterectomy or laparoscopically assisted vaginal hysterectomy underwent flexible culdoscopy. Three procedures were performed with the patients under general anesthesia using direct laparoscopic visualization, and 15 procedures were performed in a blind fashion with the patient awake in a knee-chest position. The average Quetelet Index was 31.2 (range, 22.8-43.1). Of the 18 procedures, 16 were successful in adequately visualizing the pelvic organs. There were no significant complications from the procedures, and no injury to adjacent organs. Culdoscopy with a small flexible scope can be performed safely in awake patients, providing adequate visualization of the female pelvis.

The effect of a 12-over spell on fast bowling technique in cricket.

Nine members of the Western Australian Cricket Association fast bowling development squad were selected to determine the effects that a 12-over spell would have on fast bowling technique and selected physiological variables. Three high-speed cameras operating at 100 Hz filmed the subjects bowling the 5th and 6th balls of their 1st, 6th, 10th and 12th overs. Blood lactate and heart rate were recorded and the bowlers were shown to work at between 80.3% (1st over) to 84.7% (12th over) of their maximum heart rate during the 12-over bowling spell. Data from the 5th and 6th deliveries from each over were averaged to provide representative data, as no significant differences were evident between these two deliveries for the selected kinematic variables. For all subjects, no significant differences were recorded for the selected kinematic variables throughout the duration of the 12-over spell, indicating that in general fast bowling technique does not change over this length of spell. In addition, there was some evidence of change in technique for the bowlers who used a front-on action, where counter-rotation of the shoulders was found to increase; however, this could only be confirmed by a more comprehensive study.

The biomechanics of fast bowling in men's cricket: a review.

This review concentrates on synthesizing and analysing the biomechanical research which has been carried out on fast bowling in men's cricket. Specifically, it relates to those elements of the bowling technique which contribute towards a fast ball release, the aerodynamics and technique of swing bowling, and the association between fast bowling and lower back injury. With regard to bowling technique, no firm conclusions are drawn on the relationships between elements of the fast bowling technique and ball release speed. Recommendations for future research in this area include intra-player studies to establish the bowler-specific factors which contribute to fast ball release and features of body segment dynamics. There is general agreement that the phenomenon of differential boundary layer separation is the reason for normal and reverse cricket ball swing. Systematic research to establish the essential aspects of the bowling technique which contribute to successful swing bowling is recommended, along with studies of the behaviour of the ball in games to ascertain the effects of ball asymmetries on ball swing. There is sufficient evidence in the literature to establish a strong link between injury to the lower back and the use of the mixed technique. Recommendations are made for screening and intervention to reduce the use of the mixed technique, and for research into other aspects of injury. Fundamental research to develop biomechanical models of the lower back in fast bowling is strongly recommended.

Three-dimensional measurement of lumbar spine kinematics for fast bowlers in cricket.

OBJECTIVE: To determine whether the three-dimensional (3-D) lumbar spine kinematics for the mixed fast bowling technique differed to those of the side-on and front-on fast bowling techniques. BACKGROUND: It has been previously shown that bowlers who utilise a mixed bowling technique are more likely to show lumbar spine pathology than those who bowl with either the side-on or front-on techniques. METHODS: An electromagnetic device (3-Space(R)Fastrak(TM)) operating at 120 Hz captured range of motion and 3-D lumbar spine kinematics during the delivery stride of 20 young high performance subjects. The trajectory of shoulder and pelvic girdle markers were simultaneously captured and these data were used to classify bowlers into either a side-on, front-on or mixed technique group. RESULTS: No significant differences (P<0.004) existed between the side-on/front-on and mixed groups for 12 selected variables derived from the lumbar spine kinematic data. However, an examination of effect sizes revealed evidence that the mixed group showed: a greater amount of left lateral bend and an extended lumbar spine at front foot impact; a body position further from a neutral orientation at lease; and a greater range of motion and angular velocity of the trunk in the lateral bending and flexion/extension axes. CONCLUSIONS: Selected lumbar range of motion and velocity measures tended to be higher for mixed bowlers than side-on/front-on bowlers. RELEVANCE: Overuse injuries to fast bowlers in bricket are common. To better understand the mechanics of injury it is necessary to understand the 3-D rotations of the lumbar spine during this activity.

Preservation of multiple oncogenic human papillomavirus types in recurrences of early-stage cervical cancers.

OBJECTIVES: Our purpose was to determine the relationship between human papillomavirus genotypes contained in primary early stage cervical cancers and those contained in the respective recurrences. STUDY DESIGN: Six early-stage cervical cancers that were considered cured by surgical extirpation subsequently recurred within 21 months of the original surgery. The primary tumors and the recurrences underwent polymerase chain reaction for human papillomavirus typing with confirmation of types performed by means of diagnostic restriction fragments. RESULTS: All primary tumors and recurrences contained human papillomavirus, with all primary tumors positive for multiple types. The concordance rate between the primary tumors and recurrences for specific types was 73% (11/15). Among the highly oncogenic types 16 and 18 there was 100% concordance between primary and recurrent tumors. CONCLUSIONS: Highly oncogenic types of human papillomavirus are preserved between primary tumors and their recurrences in cervical cancers. This further supports the role of oncogenic types in the maintenance of the malignant state and supports the clonogenic nature of cervical cancer recurrence.

Thoracolumbar disc degeneration in young fast bowlers in cricket: a follow-up study.

OBJECTIVE: To determine the progression of thoracolumbar disc degeneration in young fast bowlers in cricket. DESIGN: Prospective fast bowling technique and MRI follow-up study. BACKGROUND: Previous studies on high-performance young fast bowlers have found that lumbar spine pathology was related to the mixed bowling technique. METHODS: Nineteen young male fast bowlers (mean age 13.6 years) underwent MRI scans to detect the presence of intervertebral disc abnormalities. Subjects were also filmed laterally (200 Hz) and from directly above (100 Hz) whilst bowling two maximum velocity deliveries (session 1). Subjects were tested using an identical methodology 2.7 years later (session 2). RESULTS: At session 1, the incidence of thoracolumbar disc degeneration was 21%; however, at session 2, the incidence significantly (P = 0.008) increased to 58%. Furthermore the increase in the incidence of back pain between session 1 and session 2 was also significant (P = 0.002). The progression of disc degeneration was found to be significantly (P = 0.015) related to the group of fast bowlers who utilized the mixed technique during both session 1 and 2 when compared to those who used this technique during one session only. CONCLUSIONS: Thoracolumbar disc degeneration and back pain increase significantly during the time period examined in this study. Further, bowlers who utilize the mixed bowling technique stand a greater chance of developing degenerative changes of the spine.

A phase II study of gemcitabine and cisplatin in patients with advanced, persistent, or recurrent squamous cell carcinoma of the cervix.

OBJECTIVE: The aim of this study was to determine the response rate and toxicity of cis-platinum and gemcitabine in advanced, recurrent, or persistent squamous cell carcinoma of the cervix. METHODS: From July 1997 to January 1999, we conducted a Phase II trial in patients with advanced, persistent, or recurrent carcinoma of the cervix. The schedule employed 1250 mg/m(2) of gemcitabine on days 1 and 8 and 50 mg/m(2) of cis-platinum on day 1 in a 21-day cycle. Eligibility criteria were a GOG performance status of 0-2, adequate bone marrow reserve, serum creatinine less than 1.8 mg%, and a lesion which could be measured in two dimensions. None of the patients had received prior chemotherapy other than radiation sensitizers. Standard GOG toxicity and response criteria were used. RESULTS: Nineteen patients were enrolled into the trial. Two patients were inevaluable because of inadequate trial of drug. Seventeen patients were evaluable for response and toxicity. The median age of the patients was 47 years (range 24-72). The median number of cycles delivered was 5 (range 2-8). The incidence of grade 4 neutropenia and anemia was 2.4 and 1.2%, respectively. Two patients developed a single episode of grade 3 gastrointestinal toxicity. The overall response rate was 41% (7/17). There was 1 complete response of 14 months duration and 6 partial responses. Among those patients not previously irradiated, the response rate was 57% (4/7). Among the radiated patients, the response rate was 30% (3/10) with all responses occurring in the radiation field. CONCLUSION: This combination of cis-platinum and gemcitabine is a well-tolerated regimen which exhibits high activity in advanced, recurrent, or persistent squamous cell cervical cancer.

Insertion of Groshong central venous catheters utilizing fluoroscopic techniques.

Groshong central line indwelling catheters are extensively used in gynecologic oncology patients for administration of chemotherapy, intravenous fluids, and pain medications. They are easy to maintain and have a good safety record. We report on the placement of these central venous catheters under direct fluoroscopic visualization as a method which is safe, inexpensive, and efficacious in high-risk patients. Fluoroscopic visualization during insertion provides several advantages: visualization of bony landmarks, placement of the guidewire into the subclavian vein and superior vena cava under direct visualization, and confirmation of appropriate distal placement of the Groshong catheter. Patient advantages include the following: (1) avoidance of unnecessary punctures to access the subclavian vein; (2) verification of guidewire placement to avoid cephalic placement; (3) passage of the guidewire only as far as the right atrium to avoid potential dysrrhythmias secondary to right ventricular irritation; and (4) a savings of approximately 60% over insertion in the general operating room. Thirty patients had placement under fluoroscopic visualization in the angiography suite of Georgetown University Hospital. The average age of the patients was 58 years (42-78). Sixteen patients had ovarian cancer, 6 had endometrial cancer, 5 had cervical cancer, and 3 had other gynecologic malignancies. Fifteen patients had catheters placed for chemotherapy, 14 for hydration, and 1 for pain control. Ten patients had had previous central venous catheters: 6 had been removed for infection, 2 for thrombus, 1 for completion of chemotherapy, and 1 for catheter kinkage. All 10 with previous catheters had successful placement of catheters in the angiography suite. Complications from insertion were minimal with one asymptomatic pneumothorax and one proximal port in an extravascular position. We present the technique of fluoroscopic insertion of Groshong catheters which is an effective method of placement in high-risk patients.