RISUS study: Rugby Injury Surveillance in Ulster Schools.

OBJECTIVE: To examine injury patterns in adolescent rugby players and determine factors associated with injury risk. DESIGN: Prospective injury surveillance study. SETTING: N=28 Grammar Schools in Ulster, Ireland (2014-2015 playing season). PARTICIPANTS: 825 adolescent rugby players, across in 28 school first XV rugby squads; mean age 16.9 years. MAIN OUTCOME MEASURES: Injuries were classified by body part and diagnosis, and injury incidence using injuries per 1000 match hours of exposure. HRs for injury were calculated through Cox proportional hazard regression after correction for influential covariates. RESULTS: A total of n=426 injuries were reported across the playing season. Over 50% of injuries occurred in the tackle situation or during collisions (270/426), with few reported during set plays. The 3 most common injury sites were head/face (n=102, 23.9%), clavicle/shoulder (n=65, 15.3%) and the knee (n=56, 13.1%). Sprain (n=133, 31.2%), concussion (n=81, 19%) and muscle injury (n=65, 15.3%) were the most common diagnoses. Injury incidence is calculated at 29.06 injuries per 1000 match hours. There were no catastrophic injuries. A large percentage of injuries (208/424) resulted in absence from play for more than 28 days. Concussion carried the most significant time out from play (n=33; 15.9%), followed by dislocations of the shoulder (n=22; 10.6%), knee sprains (n=19, 9.1%), ankle sprains (n=14, 6.7%), hand/finger/thumb (n=11; 5.3%). 36.8% of participants in the study (304/825) suffered at least one injury during the playing season. Multivariate models found higher risk of injury (adjusted HR (AHR); 95% CI) with: higher age (AHR 1.45; 1.14 to 1.83), heavier weight (AHR 1.32; 1.04 to 1.69), playing representative rugby (AHR 1.42; 1.06 to 1.90) and undertaking regular strength training (AHR 1.65; 1.11 to 2.46). Playing for a lower ranked team (AHR 0.67; 0.49 to 0.90) and wearing a mouthguard (AHR 0.70; 0.54 to 0.92) were associated with lower risk of injury. CONCLUSIONS: There was a high incidence of severe injuries, with concussion, ankle and knee ligament injuries and upper limb fractures/dislocations causing greatest time loss. Players were compliant with current graduated return-to-play regulations following concussion. Physical stature and levels of competition were important risk factors and there was limited evidence for protective equipment.

Small field measurements with a novel silicon position sensitive diode array.

DOSI, a novel dosimeter based on position sensitive detectors for particle physics experiments, was used for relative clinical dosimetry measurements in small radiotherapy fields. The device is capable of dynamic measurements in real time and provides sub-millimetre spatial resolution. The basic beam data for a stereotactic radiotherapy collimator system (BrainLAB) using 6 MV photons were measured and compared with the corresponding data acquired with a small diamond detector and a PinPoint ionization chamber. All measurements showed an excellent agreement between DOSI and the diamond detector. There was an increasing discrepancy between the relative output factors (ROF) measured with DOSI and those measured with the ionization chamber with decreasing field size, specifically for collimators with a diameter smaller than 15 mm. The percentage depth doses (PDD) were in agreement to better than 1% for all depths. The agreement on off-axis ratios (OAR) was better than 3% for all collimators, whereas the agreement on relative output factors (ROF) was at the 1% level. DOSI's fast read-out electronics made it possible for all measurements to be recorded within 45 min including time to change collimators. This should reduce the overall time for commissioning and QA measurements, an important factor especially for busy radiotherapy departments.

Evaluation of Response to Stereotactic Radiosurgery in Brain Metastases Using Multiparametric Magnetic Resonance Imaging and a Review of the Literature.

AIMS: Following stereotactic radiosurgery (SRS), brain metastases initially increase in size in up to a third of cases, suggesting treatment failure. Current imaging using structural magnetic resonance imaging (MRI) cannot differentiate between tumour recurrence and SRS-induced changes, creating difficulties with patient management. Combining multiparametric MRI techniques, which assess tissue physiological and metabolic information, has shown promise in answering this clinical question. MATERIALS AND METHODS: Multiparametric MRI techniques, including spectroscopy, diffusion and perfusion imaging, were used for the differentiation of radiation-related changes and tumour recurrence after SRS for intracranial metastases in six cases. All patients presented with enlargement of the treated lesion, an increase in perilesional brain oedema and aggravation or appearance of neurological signs and symptoms from 7 to 29 weeks after primary treatment. RESULTS: Multiparametric imaging helped to differentiate features of tumour progression (n = 4) from radiation-related changes (n = 2). A low apparent diffusion coefficient (ADC) <1000 × 10-6 mm2/s, high relative cerebral blood volume (rCBV) ratio > 2.1, high choline:creatine (Cho:Cr) ratio > 1.8 suggested tumour recurrence. A high ADC > 1000 × 10-6 mm2/s, low rCBV ratio < 2.1, Cho:Cr ratio < 1.8 suggested SRS-induced radiation changes. Multiparametric MRI diagnosis was confirmed by histology or radiological and clinical follow-up. CONCLUSION: Multiparametric MRI was helpful in the early identification of radiation-related changes and tumour recurrence and may be useful for monitoring treatment changes in intracranial neoplasms after SRS treatment.

Recurrent injury patterns in adolescent rugby.

OBJECTIVES: To establish patterns of subsequent injury in U18 rugby, to quantify the burden of within season injury recurrence. DESIGN: Secondary analysis of prospective data. SETTING: 28 Schools in Ireland. PARTICIPANTS: 825 male rugby players (aged 15-18 years). MAIN OUTCOME MEASURES: Subsequent injuries were classified as: new, local or recurrent (same site and type as index injury). All recurrent injuries were sub-grouped by body part and diagnosis. Burden was based on frequency, days lost and injury proportion ratios. RESULTS: A total of 426 injuries were eligible for analysis, of which, 121 were subsequent injuries. The majority of subsequent injuries involved a different body part than their index injury. There were n = 23 cases of within season recurrence. 78% of recurrences occurred within 2 months of return to play. Recurrent injuries comprised 5% of all injuries and their cumulative time loss was 1073 days. Recurrent injury to the ankle ligaments, lumbar muscles and concussions carried the greatest burden. CONCLUSION: The burden of recurrent injury in U18 rugby is lower than in the professional game. However, this population could benefit from targeted secondary prevention efforts including reconsideration of return-to-play protocols for ankle sprain, lumbar muscles and potentially concussion.

Predictors for 1-year mortality following hip fracture: a retrospective review of 465 consecutive patients.

INTRODUCTION: In Europe, trauma admissions and in particular hip fractures are on the rise. In recent years, health care systems have placed particular emphasis, including financial incentives, on delivering patients quickly and safely to surgery. At our unit, we have observed that hip fracture patients appear to be at significant risk of mortality even up to a year following injury. This study reviews a consecutive population of hip fracture patients to identify predictors of excess risk. MATERIALS AND METHODS: Four hundred and sixty-five consecutive patients were treated over a 2-year period at our district general hospital with no ward-based orthogeriatricians. Follow-up was for 1 year following hip fracture admission. Statistical analysis of variables and their influence on 1-year mortality were performed by calculating odd's ratio (OR) using a logistic regression model and a p value <0.05 was considered statistically significant. RESULTS: Four patients were lost to follow-up, 18 patients (4.1 %) were managed conservatively, 16 were too unwell for surgery and their mortality rate at 1 year was 50 %. Following hip fracture, we found an overall 1-year mortality rate of 15.1 %. Patients with a time to surgery ≥36 h were at significantly increased risk of mortality even up to 1 year. We did not identify a further reduction in mortality in those operated on within 24 h. Raised ORs (p > 0.05) were found with increasing comorbidity, surgery type, independence on discharge, alcohol ingestion, history of smoking, readmission and several biochemical markers. CONCLUSION: Minimising mortality risk, even over the longer term, should begin on admission with prompt optimisation of any acute medical or biochemical abnormalities, followed by early surgery and intensive rehabilitation to maintain patients' functional independence.

Linear accelerator radiosurgery for arteriovenous malformations: Updated literature review.

Arteriovenous malformations (AVMs) are the leading causing of intra-cerebral haemorrhage. Stereotactic radiosurgery (SRS) is an established treatment for arteriovenous malformations (AVM) and commonly delivered using Gamma Knife within dedicated radiosurgery units. Linear accelerator (LINAC) SRS is increasingly available however debate remains over whether it offers an equivalent outcome. The aim of this project is to evaluate the outcomes using LINAC SRS for AVMs used within a UK neurosciences unit and review the literature to aid decision making across various SRS platforms. Results have shown comparability across platforms and strongly supports that an adapted LINAC based SRS facility within a dynamic regional neuro-oncology department delivers similar outcomes (in terms of obliteration and toxicity) to any other dedicated radio-surgical platform. Locally available facilities can facilitate discussion between options however throughput will inevitably be lower than centrally based dedicated national radiosurgery units.

Enhanced biological effectiveness of low energy X-rays and implications for the UK breast screening programme.

Recent radiobiological studies have provided compelling evidence that the low energy X-rays as used in mammography are approximately four times--but possibly as much as six times--more effective in causing mutational damage than higher energy X-rays. Since current radiation risk estimates are based on the effects of high energy gamma radiation, this implies that the risks of radiation-induced breast cancers for mammography X-rays are underestimated by the same factor. The balance of risk and benefit for breast screening have been re-analysed for relative biological effectiveness (RBE) values between 1 and 6 for mammography X-rays. Also considered in the analysis is a change in the dose and dose-rate effectiveness factor (DDREF) from 2 to 1, women with larger than average breasts and implications for women with a family history of breast cancer. A potential increase in RBE to 6 and the adoption of a DDREF of unity does not have any impact on the breast screening programme for women aged 50-70 years screened on a 3 yearly basis. Situations for which breast screening is not justified due to the potential cancers induced relative to those detected (the detection-to-induction ratio (DIR)) are given for a range of RBE and DDREF values. It is concluded that great caution is needed if a programme of early regular screening with X-rays is to be used for women with a family history of breast cancer since DIR values are below 10 (the lowest value considered acceptable for women below 40 years) even for modest increases in the RBE for mammography X-rays.

The incidence of deep vein thrombosis and pulmonary embolism following cast immobilisation and early functional bracing of Tendo Achilles rupture without thromboprophylaxis.

PURPOSE: The routine use of thromboprophylaxis during cast immobilisation for lower leg trauma is controversial. The concern involves the perceived increased risk of deep vein thrombosis (DVT) and its sequelae following leg immobilisation. However, immobilisation is used for a spectrum of trauma and for varying duration. This heterogenicity in management is reflected in the current evidence and coupled with the risks of thromboprophylaxis; no clear consensus has been made. METHODS: In this retrospective study, we report the incidence of DVT and pulmonary embolism (PE) observed following cast immobilisation and early functional management of patients with Tendo Achilles rupture. Over 12 years, 945 consecutive patients (949 tendons) were treated without additional thromboprophylaxis. RESULTS: The incidence of DVT was 1.05 % and PE was 0.32 %. Females were significantly more likely to develop a DVT but not a PE. When compared to the incidence of DVT and PE observed in the general population, DVT rate was statistically significantly higher than that observed in the general population. There was no significant difference in PE rates. The number needed to treat to reduce the DVT incidence is 106. The number needed to treat to reduce the PE incidence is 475. CONCLUSIONS: Although we can conclude that conservative treatment for Tendo Achilles does increase the incidence of symptomatic DVT from the general population, we feel that large randomised control trials are required to evaluate the efficacy, compliance and cost effectiveness of routine DVT thromboprophylaxis in the outpatient setting.

The neoplastic transformation potential of mammography X rays and atomic bomb spectrum radiation.

Considerable controversy currently exists regarding the biological effectiveness of 29 kVp X rays which are used for mammography screening. This issue must be resolved to enable proper evaluation of radiation risks from breast screening. Here a definitive assessment of the biological effectiveness of 29 kVp X rays compared to the quality of radiation to which the atomic bomb survivors were exposed is presented for the first time. The standard radiation sources used were (a) an atomic bomb simulation spectrum and (b) 2.2 MeV electrons from a strontium-90/yttrium-90 (90Sr/90Y) radioactive source. The biological end point used was neoplastic transformation in vitro in CGL1 (HeLa x human fibroblast hybrid) cells. No significant difference was observed for the biological effectiveness of the two high-energy sources for neoplastic transformation. A limiting relative biological effectiveness (RBE(M)) of 4.42 +/- 2.02 was observed for neoplastic transformation by 29 kVp X rays compared to these two sources. This compares with values of 4.67 +/- 3.93 calculated from previously published data and 3.58 +/- 1.77 when the reference radiation was 200 and 220 kVp X rays. This suggests that the risks associated with mammography screening may be approximately five times higher than previously assumed and that the risk-benefit relationship of mammography exposures may need to be re-examined.

Evaluation of a synthetic single-crystal diamond detector for relative dosimetry measurements on a CyberKnife.

OBJECTIVE: To evaluate a new commercial PTW-60019 microDiamond (PTW, Freiburg, Germany) synthetic single-crystal diamond detector for relative dosimetry measurements on a clinical CyberKnife™ VSI (Accuray Inc., Sunnyvale, CA) system. METHODS: Relative output factors (ROFs) were measured for collimator diameters from 5 to 60 mm, and compared with diode [PTW-60017, PTW-60018 and IBA Dosimetry (Schwarzenbruck, Germany) SFD] and ionization chamber (PTW-31014 PinPoint and PTW-31010 Semiflex) measurements. Beam profiles were measured at a range of depths, and collimator sizes, with the detector stem oriented both parallel and perpendicular to the central axis (CAX). Percentage depth-dose (PDD) curves were obtained for the 60-mm collimator and compared with natural Diamond Detector (PTW-60003) and ionization chamber curves to evaluate energy dependence. RESULTS: Penumbral broadening was noted on profile measurements made with the microDiamond oriented with the stem parallel to the CAX, in comparison with diodes. Oriented perpendicular to the CAX, the profile penumbra was sharper, but stem effects could not be ruled out. The PDD measurements were within 0.5% of ionization chamber measurements, indicating insignificant dose-rate dependence. The ROF for the microDiamond fell between diode and ionization chamber results. Published Monte Carlo-derived CyberKnife-specific factors were applied to the PTW-60017, PTW-60018 and PTW-31014 ROFs, and the microDiamond factors agreed within 2.0% of the mean of these. CONCLUSION: Over a range of small field relative dosimetry measurements, the microDiamond detector shows excellent spatial resolution, dose-rate independence and water equivalence. ADVANCES IN KNOWLEDGE: The microDiamond is a suitable tool for commissioning stereotactic systems.

Linear accelerator stereotactic radiosurgery for vestibular schwannomas: a UK series.

AIMS: To evaluate non-auditory toxicity and local control after linear accelerator stereotactic radiosurgery (SRS) for the treatment of vestibular schwannomas. MATERIALS AND METHODS: The institutional policy was to use SRS for radiologically progressing vestibular schwannomas. Case notes and plans were retrospectively reviewed for all patients undergoing SRS for vestibular schwannomas between September 2002 and June 2012. All patients were surgically immobilised using a BrainLab stereotactic head frame. The treatment plan was generated using BrainLab software (BrainScan 5.03). The aim was to deliver 12 Gy to the surface of the target with no margin. Patients with a minimum of 12 months of follow-up were included for toxicity and local control assessment. Radiological progression was defined as growth on imaging beyond 2 years of follow-up. Overall local control was defined in line with other series as absence of surgical salvage. RESULTS: Ninety-nine patients were identified. Two patients were lost to follow-up. After a median follow-up interval of 2.4 years, the actuarial radiological progression-free survival at 3 years was 100% and overall local control was also 100%. However, two patients progressed radiologically at 3.3 and 4.5 years, respectively. Twenty-one of 97 (22%) evaluable patients suffered trigeminal toxicity and this was persistent in 8/97 (8%). Two of 97 (2%) suffered long-term facial nerve toxicity (one with associated radiological progression causing hemi-facial spasm alone). One of 97 (1%) required intervention for obstructive hydrocephalus. No statistically significant dosimetric relationship could be shown to cause trigeminal or facial nerve toxicity. However, 7/8 patients with persistent trigeminal nerve toxicity had tumours in contact with the trigeminal nerve. CONCLUSIONS: SRS delivering 12 Gy using a linear accelerator leads to high local control rates, but only prospective evaluation will fully establish short-term toxicity. In this study, persistent trigeminal toxicity occurred almost exclusively in patients whose tumour was in contact with the trigeminal nerve.

Spontaneous dissection of the external iliac artery secondary to golf club manufacturing.

Spontaneous dissection of the external iliac artery in the absence of aortic disease is extremely uncommon. We report the conservative treatment of a 46-year-old male patient who presented with acute left lower limb ischemia due to an isolated dissection of the external iliac artery secondary to repetitive swinging movements during golf club manufacturing. Although syndromes of nonatherosclerotic vascular disease secondary to repetitive movements in high-level athletic activity have been previously described in cyclists, long distance runners, and rugby players, we believe this to be the first occupational case associated with golf.

The non-operative functional management of patients with a rupture of the tendo Achillis leads to low rates of re-rupture.

Controversy surrounds the most appropriate treatment method for patients with a rupture of the tendo Achillis. The aim of this study was to assess the long term rate of re-rupture following management with a non-operative functional protocol. We report the outcome of 945 consecutive patients (949 tendons) diagnosed with a rupture of the tendo Achillis managed between 1996 and 2008. There were 255 female and 690 male patients with a mean age of 48.97 years (12 to 86). Delayed presentation was defined as establishing the diagnosis and commencing treatment more than two weeks after injury. The overall rate of re-rupture was 2.8% (27 re-ruptures), with a rate of 2.9% (25 re-ruptures) for those with an acute presentation and 2.7% (two re-ruptures) for those with delayed presentation. This study of non-operative functional management of rupture of the tendo Achillis is the largest of its kind in the literature. Our rates of re-rupture are similar to, or better than, those published for operative treatment. We recommend our regime for patients of all ages and sporting demands, but it is essential that they adhere to the protocol.

Mammography-oncogenecity at low doses.

Controversy exists regarding the biological effectiveness of low energy x-rays used for mammography breast screening. Recent radiobiology studies have provided compelling evidence that these low energy x-rays may be 4.42 +/- 2.02 times more effective in causing mutational damage than higher energy x-rays. These data include a study involving in vitro irradiation of a human cell line using a mammography x-ray source and a high energy source which matches the spectrum of radiation observed in survivors from the Hiroshima atomic bomb. Current radiation risk estimates rely heavily on data from the atomic bomb survivors, and a direct comparison between the diagnostic energies used in the UK breast screening programme and those used for risk estimates can now be made. Evidence highlighting the increase in relative biological effectiveness (RBE) of mammography x-rays to a range of x-ray energies implies that the risks of radiation-induced breast cancers for mammography x-rays are potentially underestimated by a factor of four. A pooled analysis of three measurements gives a maximal RBE (for malignant transformation of human cells in vitro) of 4.02 +/- 0.72 for 29 kVp (peak accelerating voltage) x-rays compared to high energy electrons and higher energy x-rays. For the majority of women in the UK NHS breast screening programme, it is shown that the benefit safely exceeds the risk of possible cancer induction even when this higher biological effectiveness factor is applied. The risk/benefit analysis, however, implies the need for caution for women screened under the age of 50, and particularly for those with a family history (and therefore a likely genetic susceptibility) of breast cancer. In vitro radiobiological data are generally acquired at high doses, and there are different extrapolation mechanisms to the low doses seen clinically. Recent low dose in vitro data have indicated a potential suppressive effect at very low dose rates and doses. Whilst mammography is a low dose exposure, it is not a low dose rate examination, and protraction of dose should not be confused with fractionation. Although there is potential for a suppressive effect at low doses, recent epidemiological data, and several international radiation risk assessments, continue to promote the linear no-threshold (LNT) model. Finally, recent studies have shown that magnetic resonance imaging (MRI) is more sensitive than mammography in detecting invasive breast cancer in women with a genetic sensitivity. Since an increase in the risk associated with mammographic screening would blur the justification of exposure for this high risk subgroup, the use of other (non-ionising) screening modalities is preferable.

The subjective anticipation and evaluation of childbirth and anxiety.

Anticipated evaluations of childbirth and a state anxiety measure were completed by 25 women in the last trimester of pregnancy. These women and an additional 34 were contacted within 1 week after the birth when their actual experiences and state anxiety were measured. Anticipated and actual evaluations of childbirth were significantly correlated. Prenatal anxiety was not related to the actual experience, but actual evaluation was related to satisfaction and anxiety after the birth.

Analysis and revision of Ryle's Marital Patterns Test.

Previous studies which have used the Marital Patterns Test (Ryle, 1966) have shown that although it has potential in several areas of research, some items of the test are suspect. The validity and internal reliability of several items on the affection scales had particularly been questioned. Internal consistency analysis was used to examine the affection and domination scales for 81 wives and 77 husbands. Resulting recommendations included the exclusion of three affection items, and one item from each of the husband and wife forms of the domination scale. Two new affection items and one new domination item were found to be useful additions. Revised instructions and a revised version of the questionnaire were presented.