Return-to-performance in elite soccer players after Achilles tendon ruptures: a study using a weighted plus/minus metric and matched-control analysis.

PURPOSE: Studies have shown decreased match participation and shortened careers in athletes suffering Achilles tendon ruptures (ATRs), but assessment using a true performance metric is lacking. Plus/minus (PM) metrics provide a practical and objective approach to player performance assessment and are commonly used in other sports. This study aimed to quantify and compare individual player performance variations in elite football league players who sustained ATRs and returned to play within 1 year compared to those without ATRs, using a PM metric. METHODS: Player and team data were sourced from Transfermarkt.com. Male players sustaining ATRs between 2007 and 2018 were identified through injury reports. A control group (CTRL) was matched by position, age, height, and league, with a 6:1 ratio of controls to ATR subjects. The day of injury was considered "time zero". Year -1 corresponds to the 360 days preceding injury, and Year 1 to the interval between 360 and 720 days after. Performance in the player's main team was evaluated using a previously validated weighted PM metric. Only data from Year -1 and Year 1 were used for ATR versus CTRL group comparisons. Statistical significance was set at p < 0.05. RESULTS: The ATR group included 125 athletes. Data from more than 76,000 matches were analyzed. No statistically significant differences in net weighted PM metric between Year -1 and Year 1 were found. CONCLUSION: No differences were found between athletes suffering from ATRs and controls regarding the weighted PM metric. LEVEL OF EVIDENCE: III.

Current Concept Review: State of Acute Lateral Ankle Injury Classification Systems.

Acute lateral ankle sprain (ALAS) is one of the most frequent musculoskeletal injuries, with a great impact on health and socioeconomic factors. There are few consensuses on this subject and multiple therapeutic options that are difficult to compare due to the lack of a universally adopted classification system. The objective of this study is to is to report the actual knowledge on how ALAS are classified and reported and not to make any therapeutic recommendation. A comprehensive literature review of the literature was carried out through a search in the MEDLINE, Cochrane Library and Google Scholar databases, with identification of articles that describe ways to classify lateral ankle sprains or with relevant content for their classification. Twenty-five different classification systems were identified. The majority of articles referring to ALAS use an unspecific classification. Most classification systems divide sprains into 3 degrees. The most used parameters are the anatomy of the injury, clinical parameters, functional loss and the presence of instability. No articles were found to verify the validity of the systems used, namely regarding their association with therapeutic proposals or prognostic predictions. Based on the available evidence, recommendations cannot be made regarding the most appropriate classification system. The considerable heterogeneity of the existing literature makes it difficult to compare studies and to optimize the treatment and follow-up of these injuries. Future research in this area is necessary to define a practical and rigorous system that can be used universally.

Pre-injury performance is most important for predicting the level of match participation after Achilles tendon ruptures in elite soccer players: a study using a machine learning classifier.

PURPOSE: Achilles tendon ruptures (ATR) are career-threatening injuries in elite soccer players due to the decreased sports performance they commonly inflict. This study presents an exploratory data analysis of match participation before and after ATRs and an evaluation of the performance of a machine learning (ML) model based on pre-injury features to predict whether a player will return to a previous level of match participation. METHODS: The website transfermarkt.com was mined, between January and March of 2021, for relevant entries regarding soccer players who suffered an ATR while playing in first or second leagues. The difference between average minutes played per match (MPM) 1 year before injury and between 1 and 2 years after the injury was used to identify patterns in match participation after injury. Clustering analysis was performed using k-means clustering. Predictions of post-injury match participation were made using the XGBoost classification algorithm. The performance of this model was evaluated using the area under the receiver operating characteristic curve (AUROC) and Brier score loss (BSL). RESULTS: Two hundred and nine players were included in the study. Data from 32,853 matches was analysed. Exploratory data analysis revealed that forwards, midfielders and defenders increased match participation during the first year after injury, with goalkeepers still improving at 2 years. Players were grouped into four clusters regarding the difference between MPMs 1 year before injury and between 1 and 2 years after the injury. These groups ranged between a severe decrease (n = 34; - 59 ± 13 MPM), moderate decrease (n = 75; - 25 ± 8 MPM), maintenance (n = 70; 0 ± 8 MPM), or increase (n = 30; 32 ± 13 MPM). Regarding the predictive model, the average AUROC after cross-validation was 0.81 ± 0.10, and the BSL was 0.12, with the most important features relating to pre-injury match participation. CONCLUSION: Most players take 1 year to reach peak match participation after an ATR. Good performance was attained using a ML classifier to predict the level of match participation following an ATR, with features related to pre-injury match participation displaying the highest importance. LEVEL OF EVIDENCE: I.

[Consecutive Ankle Sprain Classification and Injury Systematization (CASCaIS), A New Lateral Ankle Sprain Classification Based on the Pivot Test: A Prospective Cohort Study]. / Consecutive Ankle Sprain Classification and Injury Systematization (CASCaIS), Uma Nova Classificação de Entorse Lateral do Tornozelo Baseada no Teste de Pivot: Estudo Prospetivo de Coorte.

INTRODUCTION: The biggest challenge in the treatment of acute ankle sprain is the uncertainty of the prognosis. The traditional classifications have several interpretations and little correlation with prognosis. In this study we propose a new classification for acute ankle sprain only based on clinical criteria. MATERIAL AND METHODS: We prospectively evaluated all patients with an ankle sprain, aged between 18 and 45 years, admitted to a hospital during a 24 month period. The minimum follow-up period was 12 months. The sprains were classified, in the first few days (CASCaIS-Initial), according to autonomous gait capacity, inspection and palpation. After a few weeks (CASCaIS-Deferred), it was complemented with the mechanical evaluation of ligaments through the ankle pivot test. RESULTS: Among the 49 patients who completed the follow-up, none of those who had a pivot-negative test progressed to chronic ankle instability (CAI). Nine of the 33 patients (27%) with a positive pivot progressed to CAI (p = 0.022). The evaluation of CASCaIS-Deferred demonstrated an association with CAI (p = 0.018). CONCLUSION: This classification proved to be a simple, inexpensive, and reliable tool that clinicians can use to determine the prognosis of the sprain.

Introdução: O maior desafio no tratamento da entorse aguda do tornozelo é a indefinição do prognóstico. As classificações clássicas têm várias interpretações e pouca correlação com o prognóstico. Com este trabalho propomos uma nova classificação baseada apenas em critérios clínicos.Material e Métodos: Foram prospectivamente avaliados doentes entre os 18 e os 45 anos com entorse aguda do tornozelo, admitidos numa instituição durante 24 meses. O seguimento mínimo teve uma duração de 12 meses. Estes doentes foram classificados nos primeiros dias após a entorse (CASCaIS-Inicial) com base na valorização da capacidade de marcha autónoma, inspeção do quadro inflamatório e palpação. Passadas algumas semanas (CASCaIS-Diferida) complementou-se com a avaliação ligamentar pelo teste de pivot do tornozelo.Resultados: Dos 49 doentes que completaram o seguimento, nenhum dos que tinha um teste pivot-negativo evoluiu para instabilidade crónica do tornozelo (ICT). Nove dos 33 doentes (27%) com um pivot-positivo evoluíram para ICT (p = 0,022). A avaliação da CASCaIS-Diferida demonstrou uma associação com a ICT (p = 0,018).Conclusão: Esta classificação demonstrou ser uma ferramenta simples, não dispendiosa e fiável que os clínicos poderão usar para determinar o prognóstico da entorse.

Atualização em reações de hipersensibilidade aos anti-inflamatórios não esteroidais ­ Parte 2: manifestações clínicas, fenótipos, diagnóstico e manejo / Update on hypersensitivity reactions to nonsteroidal anti-inflammatory drugs ­ Part 2: clinical features, phenotypes, diagnosis, and management

Os anti-inflamatórios não esteroidais (AINE) são os fármacos mais frequentemente associados a reações de hipersensibilidade (RH) na prática clínica. Na parte 2 dessa atualização sobre as RH aos AINE, discutiremos os aspectos clínicos dessas reações, com foco nos sinais e sintomas, como diferenciar os fenótipos clínicos, fazer a orientação desses pacientes e quando indicar procedimentos complementares, como testes cutâneos, de provocação e dessensibilização.

Nonsteroidal anti-inflammatory drugs are a major cause of drug hypersensitivity reactions in clinical practice. In this "Update Part 2", we discuss the clinical picture, including the main signs and symptoms, how to distinguish clinical phenotypes, how to manage affected patients, and when to indicate additional procedures, such as skin testing, challenge, and desensitization.

Atualização em reações de hipersensibilidade aos anestésicos locais / Update on local anesthetics hypersensitivity reactions

Os anestésicos locais são essenciais em diversos procedimentos médicos e odontológicos. Funcionam estabilizando as membranas neuronais e inibindo a transmissão de impulsos neurais, o que permite a realização desses procedimentos com mais segurança e sem dor. As reações adversas a drogas são definidas pela Organização Mundial da Saúde como todos os efeitos nocivos, não intencionais e indesejáveis de uma medicação, que ocorrem em doses usadas para prevenção, diagnóstico e tratamento. As reações de hipersensibilidade são reações adversas do tipo B, imprevisíveis, que clinicamente se assemelham a reações alérgicas e podem ou não envolver um mecanismo imune. As reações de hipersensibilidade verdadeiras aos anestésicos locais são raras, apesar de superestimadas. Nesta revisão destacamos a necessidade de uma avaliação completa dos pacientes com suspeita de reação alérgica aos anestésicos locais, incluindo a investigação de outros possíveis alérgenos que tenham sido utilizados no procedimento, como analgésicos, antibióticos e látex. A estratégia de investigação e seleção de pacientes para testes deve se basear na história clínica. Dessa forma, poderemos fornecer orientações mais assertivas e seguras aos pacientes.

Local anesthetics are essential in many medical and dental procedures. They work by stabilizing neuronal membranes and inhibiting the transmission of neural impulses, which allows these procedures to be performed more safely and without pain. Adverse drug reactions are defined by the World Health Organization as all harmful, unintended and undesirable effects of a medication, which occur at doses used for prevention, diagnosis and treatment. Hypersensitivity reactions are unpredictable type B adverse reactions that clinically resemble allergic reactions and may or may not involve an immune mechanism. True hypersensitivity reactions to local anesthetics are rare, although overestimated. In this review, we highlight the need for a thorough evaluation of patients with suspected allergic reaction to local anesthetics, including investigation of other possible allergens that may have been used in the procedure, such as analgesics, antibiotics and latex. The investigation strategy and patient selection for testing should be based on clinical history. In this way, we will be able to provide more assertive and safe guidelines to patients.

Atualização em reações de hipersensibilidade aos anti-inflamatórios não esteroidais ­ Parte 1: definições, farmacologia, epidemiologia, fisiopatologia e fatores genéticos / Update on hypersensitivity reactions to nonsteroidal anti-inflammatory drugs ­ Part 1: definitions, pharmacology, epidemiology, pathophysiology, and genetics

Os anti-inflamatórios não esteroidais (AINE) estão entre os medicamentos mais utilizados no mundo e são os fármacos mais frequentemente associados à ocorrência de reações de hipersensibilidade na América Latina. As reações têm grande variabilidade de apresentações clínicas e, consequentemente, com abordagem terapêutica difícil. Nesta revisão, abordamos aspectos farmacológicos dos AINE, bem como as definições, epidemiologia e fisiopatologia das reações de hipersensibilidade aos AINE. Por fim, discutimos aspectos genéticos associados à intolerância e alergia a esses fármacos.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most commonly used medications worldwide and the drugs most frequently associated with the occurrence of hypersensitivity reactions in Latin America. The clinical presentation of the reactions varies widely, which makes them difficult to treat. In this review, we address pharmacological aspects of NSAIDs, as well as the definitions, epidemiology, and pathophysiology of hypersensitivity reactions to NSAIDs. Finally, we discuss genetic factors associated with intolerance and allergy to these drugs.

Reatividade cruzada entre betalactâmicos: uma abordagem prática / Cross-reactivity among beta-lactams: a practical approach

Os betalactâmicos são a classe de drogas que mais causam reações de hipersensibilidade envolvendo um mecanismo imunológico específico, e são os principais desencadeantes entre os antimicrobianos. São representados pelas penicilinas, cefalosporinas, carbapenêmicos, monobactâmicos e inibidores da betalactamase. A estrutura química básica destes fármacos consiste na presença dos seguintes componentes: anel betalactâmico, anel adjacente e cadeias laterais, sendo todos potenciais epítopos. Os anticorpos da classe IgE e linfócitos T estão frequentemente envolvidos no reconhecimento desses epítopos. A reatividade cruzada depende da estabilidade dos produtos intermediários (determinantes antigênicos) derivados da degradação dos anéis betalactâmicos, anéis adicionais e da semelhança estrutural das cadeias laterais entre as drogas. Classicamente acreditava-se num grande potencial de reatividade cruzada dentro de cada classe e até entre as classes, mas estudos da última década mostraram que indivíduos alérgicos à penicilina (com testes cutâneos positivos) reagiam às cefalosporinas em aproximadamente 3% dos casos, aos carbapenêmicos em cerca de 1%, e praticamente não reagiam aos monobactâmicos. Essa reatividade ou tolerância parece estar vinculada ao grau de similaridade entre as cadeias laterais desses antibióticos. Nesta revisão, ressaltamos a importância da investigação sistematizada na confirmação ou exclusão de alergia aos betalactâmicos, descrevemos a prevalência da reatividade cruzada entre estes fármacos e sugerimos um algoritmo de abordagem desses pacientes baseados em sua estrutura química e nos dados publicados na literatura.

Beta-lactams are the drugs most commonly involved in hypersensitivity reactions mediated by a specific immune mechanism and are the main triggers among antibiotics. They include penicillins, cephalosporins, carbapenems, monobactams and beta-lactam inhibitors. The basic chemical structure of these drugs consist on the presence of the following components: betalactam ring, an adjacent ring and side chains, all of which are potential epitopes. IgE antibodies and T lymphocytes are often involved in recognizing those epitopes. Cross-reactivity depends on the stability of intermediate products (antigenic determinants) derived from the degradation of the beta-lactam ring, on the adjacent rings, and on the structural similarity of the side chains between drugs. Classically, it was believed that there was a great potential for cross-reactivity within each class and even between classes, but studies from the last decade showed that individuals allergic to penicillin (with positive skin tests) reacted to cephalosporins in approximately 3% of cases, to carbapenems in about 1%, and rarely reacted to monobactams. This reactivity or tolerance seems to be linked to the degree of similarity between the side chains of these antibiotics. In this review, we emphasize the importance of systematic investigation to confirm or exclude allergy to beta-lactams, we describe the prevalence of crossreactivity between these drugs and we suggest an algorithm for approaching these patients based on their chemical structure and on data published in the literature.

Síndrome de Parsonage-Turner em paciente HIV positivo / Parsonage-Turner syndrome in HIV seropositive patient

A síndrome de Parsonage-Turner é uma desordem rara de etiologia ainda indeterminada, contudo com fortes evidências de associação a infecções virais inclusive pelo vírus HIV, que afeta a cintura escapular e desencadeia dor e fraqueza da musculatura do ombro e da extremidade superior. O diagnóstico raramente é feito no início do quadro e poucos exames laboratoriais podem ser úteis, com destaque para a eletroneuromiografia. Seu tratamento é basicamente observacional e de controle dos sintomas e a recuperação é esperada na maioria dos pacientes. Por se tratar de uma enfermidade rara e de difícil diagnóstico clínico, os autores relatam o caso de um paciente com quadro clínico laboratorial compatível com a síndrome de Parsonage-Turner associada à soropositividade ao vírus da imunodeficiência adquirida.