Active cycle of breathing technique versus oscillating PEP therapy versus walking with huffing during an acute exacerbation of bronchiectasis: a randomised, controlled trial protocol.

BACKGROUND: Airway clearance techniques (ACTs) for individuals with bronchiectasis are routinely prescribed in clinical practice and recommended by international guidelines, especially during an acute exacerbation. However, there is limited evidence of the efficacy of these techniques during an exacerbation to improve sputum expectoration, health-related quality-of-life (HRQOL) or exercise tolerance. The primary aim of this study is to compare the effects of the active cycle of breathing technique (ACBT), oscillating positive expiratory pressure (O-PEP) therapy, and walking with huffing on sputum expectoration for adults hospitalised with an acute exacerbation of bronchiectasis. Secondary aims are to compare the effects of these interventions on HRQOL, health status, exacerbation rates and hospital admissions in a six-month period following hospital discharge. METHODS: This multi-centre randomised controlled trial will recruit adults with an acute exacerbation of bronchiectasis requiring hospital admission. Participants will be randomised to receive one of three interventions: ACBT, O-PEP therapy, and walking with huffing. Outcome measures including sputum volume during and 1-h post ACT session, and 24-h sputum, as well as health status, HRQOL and exercise capacity will be completed during inpatient stay on day 2 and day 6 of admission, and within 24 h of hospital discharge. Time to first exacerbation, and time to first hospitalisation will be monitored via monthly phone calls for six months post hospital discharge. Health status and HRQOL will be assessed after discharge at two and six months, and exercise capacity will be assessed at six months post hospital discharge. DISCUSSION: Despite recommendations regarding the importance of ACT for individuals with bronchiectasis during an acute exacerbation, there is a gap in the literature regarding effectiveness of ACT when undertaken by individuals in this clinical state. This study will add to the evidence base regarding the effectiveness of commonly implemented ACTs during a hospital admission with an exacerbation of bronchiectasis. Additionally, it will contribute to knowledge of the long term effects on important and patient-centred outcomes, including incidence of future exacerbations, and HRQOL, which has not been previously established. Trial registration Registered on the Australian and New Zealand Clinical Trials Registry (ACTRN12621000428864).

Risk factors for injuries in female soldiers: a systematic review.

BACKGROUND: Female soldiers form an integral part of any modern defence force. Previous reports have highlighted that female soldiers report injuries at higher rates than male personnel. One possible reason for this is an actual difference in underlying injury rates, purported to be due to several factors, including levels of fitness. The aim of this review was to determine risk factors for injuries in female soldiers. METHODS: A systematic search was conducted for studies which reported on risk factors for injuries in female soldiers. Databases searched included PUBMED, CINAHL and Medline through OVID. Eligible studies were rated for their methodological quality using the Critical Appraisal Skills Program (CASP) tools and data were extracted and synthesized using a critical narrative approach. RESULTS: A total of 18 articles were included in this review which reported on 18 risk factors for injury. Smoking, previous injury, no history of deployment, heavy occupational tasks, lower levels of aerobic fitness and lower number of push-up repetitions appear to be risk factors for injuries in female soldiers. Age, height, body fat, high or low BMI and body mass do not appear to be consistent risk factors for injury in female soldiers and there appears to be minimal evidence for current levels of activity, sit-up ability, and other assessments of strength, power, speed, or movement being associated with injury risk. Additionally, neither flexibility nor previous levels of activity appear to be associated with injury risk in female soldiers. CONCLUSION: Strategies to improve aerobic fitness and upper limb endurance, reduce smoking, and optimise rehabilitation from injuries and risk management for heavy occupational tasks need to be developed for female soldiers. Such strategies are also likely to reduce risks for male soldiers.

Auditory exostosis in Australian warm water surfers: a cross-sectional study.

BACKGROUND: Surfing is a popular sport in Australia, accounting for nearly 10% of the population. External auditory exostosis (EAE), also referred to as surfer's ear, is recognized as a potentially serious complication of surfing. Cold water (water temperature below 19 °C) is a commonly cited risk factor, with prevalence of EAE in cold water surfers ranging from 61 to 80%. However, there is a paucity of studies reporting the prevalence of EAE in surfers exposed to water temperatures above 19 °C. With mean water temperature ranging from 19 °C to 28 °C, the Gold Coast region of Australia provides the ideal environment to assess the main goal of this study: to assess the prevalence and severity of EAE in warm water surfers. METHODS: Eligible participants were surfers living and surfing on the Gold Coast (Queensland, Australia). Currently active surfers over 18 years of age, surfing year-round, with a minimum of five consecutive years of surfing experience were recruited to participate. Included individuals were asked to complete a questionnaire and underwent bilateral otoscopy. RESULTS: A total of 85 surfers were included, with mean age 52.1 years (standard deviation [SD] ±12.6 years) and mean surfing experience of 35.5 years (SD ±14.7 years). Nearly two-thirds of participants (65.9%) had regular otological symptoms, most commonly water trapping (66%), hearing loss (48.2%), and cerumen impaction (35.7%). Less than one-fifth of the surfers (17.7%) reported regular use of protective equipment for EAE. The overall prevalence of exostosis was 71.8%, with most of the individuals having bilateral lesions (59%) and a mild grade (grade 1, 47.5%). There was insufficient evidence for any significant associations between the main outcomes (presence and severity of EAE) and factors related to age, surfing experience, winter exposure, surfing ability, symptoms, and use of protective equipment. CONCLUSION: To the best of our knowledge, this is the first study assessing EAE in surfers exposed to warm waters (above 19 °C). The prevalence of 71.8% highlights the high prevalence of the condition in the surfing population, regardless of water temperature. Future research should focus on ways to prevent EAE.

Patient and surgical prognostic factors for inpatient functional recovery following THA and TKA: a prospective cohort study.

BACKGROUND: The introduction of enhanced recovery pathways has demonstrated both patient and organisational benefits. However, enhanced recovery pathways implemented for total hip arthroplasty (THA) and total knee arthroplasty (TKA) vary between health-care organisations, as do their measures of success, particularly patient-related outcomes. Despite inpatient functional recovery being essential for safe and timely hospital discharge, there is currently no gold standard method for its assessment, and the research undertaken to establish prognostic factors is limited. This study aimed to identify prognostic factors and subsequently develop prognostic models for inpatient functional recovery following primary, unilateral THA and TKA; identify factors associated with acute length of stay; and assess the relationships between inpatient function and longer-term functional outcomes. METHODS: Correlation and multiple regression analyses were used to determine prognostic factors for functional recovery (assessed using the modified Iowa Level of Assistance Scale on day 2 post-operatively) in a prospective cohort study of 354 patients following primary, unilateral THA or TKA. RESULTS: For the overall cohort and TKA group, significant prognostic factors included age, sex, pre-operative general health, pre-operative function, and use of general anaesthesia, local infiltration analgesia, and patient-controlled analgesia. In addition, arthroplasty site was a prognostic factor for the overall cohort, and surgery duration was prognostic for the TKA group. For the THA group, significant prognostic factors included pre-operative function, Risk Assessment and Prediction Tool score, and surgical approach. Several factors were associated with acute hospital length of stay. Inpatient function was positively correlated with functional outcomes assessed at 6 months post-operatively. CONCLUSIONS: Prognostic models may facilitate the prediction of inpatient flow thus optimising organisational efficiency. Surgical prognostic factors warrant consideration as potential key elements in enhanced recovery pathways, associated with early post-operative functional recovery. Standardised measures of inpatient function serve to evaluate patient-centred outcomes and facilitate the benchmarking and improvement of enhanced recovery pathways.

Australian surfers' awareness of 'surfer's ear'.

OBJECTIVES: To assess awareness of external auditory exostosis (EAE) among Australian surfers. METHODS: This is a cross-sectional observational study, assessing professional and recreational Australian surfers. Currently, active surfers over 18 years of age, surfing year-round, were eligible to participate. After initial screening, individuals were asked to complete a questionnaire. All included volunteers underwent bilateral otoscopic examination, to assess the presence and severity of EAE. RESULTS: A total of 113 surfers were included in the study and were divided into two groups, based on surfing status: 93 recreational surfers and 20 professional surfers. Recreational surfers were significantly older (p<0.005), more experienced (greater years surfing; p<0.005), with lower prevalence of otological symptoms (p<0.05). The most common symptoms were water trapping, impacted wax and hearing loss. Prevalence of EAE was high for both groups (95% in the professional surfers and 82.8% in the recreational surfers); however, recreational surfers had mild grade EAE (grade 1) as the most common presentation, as opposed to professionals who had severe grade EAE (grade 3) as the most common presentation (p<0.05 between groups). Awareness of the term 'surfer's ear' was high for both groups, as was knowledge of prevention options. However, fewer considered the condition to be preventable, and an even lower number reported regular use of prevention methods. CONCLUSION: Australian surfers had a high level of awareness of EAE; however, few reported using prevention methods, despite having a high prevalence of the condition. Health practitioners should screen susceptible individuals in order to recommend appropriate preventive measures.

Achilles Tendinopathy: Pathophysiology, Epidemiology, Diagnosis, Treatment, Prevention, and Screening.

Achilles tendinopathy (AT) is a clinical term describing a nonrupture injury of the Achilles tendon where the patient presents with pain, swelling, and reduced performance and symptoms exacerbated by physical activity. About 52% of runners experience AT in their lifetime and in the United States military the rate of clinically diagnosed AT cases was 5/1000 person-yr in 2015. The pathophysiology can be viewed on a continuum proceeding from reactive tendinopathy where tenocytes proliferate, protein production increases, and the tendon thickens; to tendon disrepair in which tenocytes and protein production increase further and there is focal collagen fiber disruption; to degenerative tendinopathy involving cell death, large areas of collagen disorganization, and areas filled with vessels and nerves. Inflammation may be present, especially in the early phases. Some evidence suggests AT pain may be due to neovascularization and the ingrowth of new nerve fibers in association with this process. Prospective studies indicate that risk factors include female sex, black race, higher body mass index, prior tendinopathy or fracture, higher alcohol consumption, lower plantar flexion strength, greater weekly volume of running, more years of running, use of spiked or shock absorbing shoes, training in cold weather, use of oral contraceptives and/ or hormone replacement therapy, reduced or excessive ankle dorsiflexion range of motion, and consumption of antibiotics in the fluoroquinolone class. At least 10 simple clinical tests are available for the diagnosis of AT, but based on accuracy and reproducibility, patient self-reports of morning stiffness and/or pain in the tendon area, pain on palpation of the tendon, and detection of Achilles tendon thickening appear to be the most useful. Both ultrasound and magnetic resonance imaging (MRI) are useful in assisting in diagnosis with MRI providing slightly better sensitivity and specificity. Conservative treatments that have been researched include: (1) nonsteroidal anti-inflammatory medication, (2) eccentric exercise, (3) stretching, (4) orthotics, (5) bracing, (6) glyceryl trinitrate patches, (7) injection therapies (corticosteroids, hyaluronic acid, platelet-rich plasma injections), (8) shock wave therapy, and (9) low-level laser therapy. Nonsteroidal anti-inflammatory medication and corticosteroid injections may provide short-term relief but do not appear effective in the longer term. Eccentric exercise and shock wave therapies are treatments with the highest evidence- based effectiveness. Prevention strategies have not been well researched, but in specific populations balance training (soccer players) and shock-absorbing insoles (military recruits) may be effective. Ultrasound scans might be useful in predicting future AT occurrences.

Effect of airway clearance techniques in patients experiencing an acute exacerbation of bronchiectasis: a systematic review.

Background: Airway clearance techniques (ACTs) are recommended for people with bronchiectasis both in stable state and during an acute exacerbation. Research has previously investigated ACTs for individuals in a stable state, but the safety and efficacy of ACTs during an acute exacerbation has not been reviewed. Methods: A systematic review was completed for studies of ACTs undertaken in adults and children experiencing an acute exacerbation of bronchiectasis. The databases Pubmed, Embase, PEDro, and CINAHL were searched. Methodological quality of studies was examined using the modified Downs and Black tool. Key findings were synthesized using a critical narrative approach. Results: Six studies were included with a total of 120 participants. No eligible studies involving child participants were found. Overall, the methodological quality of studies was moderate. All ACTs investigated appeared safe for adults, with no adverse reactions reported. The active cycle of breathing technique may be more effective at improving gas exchange, sputum volume, and health-related quality of life compared to postural drainage and percussion. Participants in two studies preferred oscillating positive expiratory pressure devices over the active cycle of breathing or postural drainage techniques. Conclusions: All ACTs reported in this review appeared safe for adults experiencing an acute exacerbation of bronchiectasis.

Utility of Mayo Clinic's early screen for discharge planning tool for predicting patient length of stay, discharge destination, and readmission risk in an inpatient oncology cohort.

PURPOSE: To examine the feasibility of using the Mayo Clinic's Early Screen for Discharge Planning (ESDP) tool in determining its predictive ability in an inpatient oncology hospital setting for variables including length of stay (LOS), discharge destination, and readmission risk. METHODS: A prospective observational study was conducted at a metropolitan tertiary cancer centre in Melbourne, Australia. The ESDP score, along with patient outcomes and characteristics, were collected to examine the relationships between positive and negative ESDP scores and patient outcomes. RESULTS: A total of 136 participants met inclusion criteria for this study. The proportion with positive ESDP scores was greater in those with unplanned hospital admissions compared with planned admissions (χ2(1, n = 136) = 3.94, p = 0.047). The ESDP status was not a significant predictor of oncology hospital LOS (rpb = 0.116, p = 0.178); however, the ESDP scores did predict discharge destination (χ2(2, n = 136) = 20.22, p < .001). Those re-admitted within 14 days were more likely to have negative ESDP scores than those not readmitted within this time period (χ2(1, n = 136) = 5.22, p = 0.022). Those with positive ESDP scores received a greater number of hospital services whilst admitted than those with negative scores (rpb = 0.388, p < .001) and were more likely to receive particular types of services. CONCLUSION: The findings from this study suggest that the ESDP tool could be useful in an adult inpatient oncology population in a hospital with defined specialised hospital discharge planning services (SHDCPS). The ESDP may be beneficial for early identification of service types likely to be required in care and likely discharge destination, both of which can assist discharge planning (DP); however, the ESDP was not useful for predicting LOS or readmission risk in the adult inpatient oncology population without a SHDCPS model in place.

Load Carriage-Related Paresthesias (Part 2): Meralgia Paresthetica.

This is the second of a two-part series addressing symptoms, evaluation, and treatment of load carriage- related paresthesias. Part 1 addressed rucksack palsy and digitalgia paresthetica; here, meralgia paresthetica (MP) is discussed. MP is a mononeuropathy involving the lateral femoral cutaneous nerve (LFCN). MP has been reported in load carriage situations where the LFCN was compressed by rucksack hipbelts, pistol belts, parachute harnesses, and body armor. In the US military, the rate of MP is 6.2 cases/10,000 personyears. Military Servicewomen have higher rates than Servicemen, and rates increase with age, longer loadcarriage distance or duration, and higher body mass index. Patients typically present with pain, itching, and paresthesia on the anterolateral aspect of the thigh. There are no motor impairments or muscle weakness, because the LFCN is entirely sensory. Symptoms may be present on standing and/or walking, and may be relieved by adopting other postures. Clinical tests to evaluate MP include the pelvic compression test, the femoral nerve neurodynamic test, and nerve blocks using lidocaine or procaine. In cases where these clinical tests do not confirm the diagnosis, specialized tests might be considered, including somatosensory evoked potentials, sensory nerve conduction studies, high-resolution ultrasound, and magnetic resonance imaging. Treatment should initially be conservative. Options include identifying and removing the compression if it is external, nonsteroidal inflammatory medication, manual therapy, and/or topical treatment with capsaicin cream. Treatments for intractable cases include injection of corticosteroids or local anesthetics, pulsed radiofrequency, electroacupuncture, and surgery. Military medical care providers may see cases of MP, especially if they are involved with units that perform regular operations involving load carriage.