An Update on Anti-thrombotic Therapy Following Transcatheter Aortic Valve Implantation: Expert Cardiologist Opinion from a UK and Ireland Delphi Group.

Transcatheter aortic valve implantation (TAVI) is an effective and established treatment for symptomatic aortic stenosis. However, there is a lack of consensus concerning the need for peri- and post-procedural anti-thrombotic medication. Contemporary guidelines recommend that anti-thrombotic therapy is balanced against a patient's bleeding risk following TAVI, but do not fully consider the evolving evidence base. The purpose of the Delphi panel recommendations presented here is to provide a consensus elicited from a panel of experts who regularly prescribe anti-thrombotic therapy post-TAVI. The goal was to address evidence gaps across four key topics: anti-thrombotic therapy (anti-platelet and/or anti-coagulant) in TAVI patients in sinus rhythm; anti-thrombotic therapy in TAVI patients with AF; direct oral anti-coagulants versus vitamin K antagonists; and the need for UK/Ireland specific guidance. This consensus statement aims to inform clinical decision-making by providing a concise, evidence-based summary of best practice for prescribing anti-thrombotic therapies following TAVI and highlights areas where further research is needed.

What would you like to ask your audience? Enhancing feedback value in PM&R grand rounds through customizable evaluation forms with presenter-generated questions.

BACKGROUND: Feedback and evaluation are important in the professional development of academic physiatrists. Yet, physical medicine and rehabilitation (PM&R) learners giving academic presentations receive limited narrative feedback through generic evaluation forms. OBJECTIVE: To assess whether customizable evaluation forms that integrate a presenter's specific questions would be associated with an increase in quantity and quality of narrative feedback received from the audience. DESIGN: Separate samples pre-post intervention study. SETTING: A large academic PM&R department's grand rounds. PARTICIPANTS: PM&R faculty and trainees attending grand rounds (10-50 attendees with one presenter per session). The study included 20 presentations pre intervention (across 1 year) and 38 presentations post intervention (across about 3 years). INTERVENTION: A customizable evaluation form that integrates a presenter's own questions into a tailored evaluation form comprising both standardized and presenter-built questions. MAIN OUTCOME MEASURE(S): Narrative feedback quantity was defined as the mean percentage and number of evaluation forms per presentation with at least one comment. Narrative feedback quality included three metrics: mean percentage and number of evaluation forms per presentation with comments that (1) contained ≥8 words, (2) referenced something specific, and (3) offered an actionable suggestion. RESULTS: Compared to preintervention, presentations in the postintervention period had a greater mean percentage of evaluation forms containing at least one comment (pre = 33.4%, post =74.7%, p < .001), a comment that contained ≥8 words (pre = 20.2%, post = 44.2%, p < .001), a comment that referenced something specific (pre = 19.6%, post = 55.1%, p < .001), and a comment that offered an actionable suggestion (pre = 10.2%, post = 22.2%, p < .001). CONCLUSIONS: Use of a customizable evaluation form in PM&R grand rounds that integrates a presenter's own questions was associated with a greater mean percentage of evaluation forms containing comments as well as comments meeting quality metrics related to length, specificity, and actionability.

A consensus viewpoint on the role of direct factor Xa inhibitors in the management of cancer-associated venous thromboembolism in the UK.

OBJECTIVE: Cancer patients are at high risk of venous thromboembolism (VTE), a significant cause of cancer-related death. Historically, low molecular weight heparins (LMWH) were the gold standard therapy for cancer-associated VTE, but recent evidence supports the use of direct factor Xa inhibitors in cancer-associated VTE and this is now reflected in many guidelines. However, uptake of direct factor Xa inhibitors varies and guidance on the use of direct factor Xa inhibitors in specific cancer sub-populations and clinical situations is lacking. This review presents consensus expert opinion alongside evaluation of evidence to support healthcare professionals in the use of direct factor Xa inhibitors in cancer-associated VTE. METHODS: Recent guidelines, meta-analyses, reviews and clinical studies on anticoagulation therapy for cancer-associated VTE were used to direct clinically relevant topics and evidence to be systematically discussed using nominal group technique. The consensus manuscript and recommendations were developed based on these discussions. RESULTS: Considerations when prescribing anticoagulant therapy for cancer-associated VTE include cancer site and stage, systemic anti-cancer therapy (including vascular access), drug-drug interactions, length of anticoagulation, quality of life and needs during palliative care. Treatment of patients with kidney or liver impairment, gastrointestinal disorders, extremes of bodyweight, elevated bleeding or recurrence risk, VTE recurrence and COVID-19 is discussed. CONCLUSION: Anticoagulant therapy for cancer-associated VTE patients should be carefully selected with consideration given to the relative benefits of specific drugs when individualizing care. Direct factor Xa inhibitors are typically the treatment of choice for preventing VTE recurrence in non-cancer patients and should also be considered as such for cancer-associated VTE in most situations.

A Double-blind, Placebo-controlled, Randomized, Single Ascending, and Multiple Dose Phase 1 Study to Evaluate the Safety, Tolerability, and Pharmacokinetics of Oral Dose Isomyosamine Capsules in Healthy Adult Subjects.

BACKGROUND: Aging is tightly linked to chronic disease, frailty, and death. Multi-morbidity, defined as the presence in the same patient of three or more conditions such as neoplastic, cardiovascular, neurodegenerative, metabolic, or autoimmune diseases, becomes more common with age. METHODS: The study was performed in a double-blind fashion. Subjects within each dose cohort (Cohorts 1, 2, 3, and 4) were randomly assigned to receive Isomyosamine doses (between 150 mg to 600 mg or placebo) or placebo in a 3:1 ratio (6 active: 2 placebo). RESULTS: Isomyosamine single daily doses each of 150 mg, 300 mg, and 450 mg for 3 days and multiple daily doses of 600 mg for 6 days were safe and well tolerated in healthy subjects. In one dose group, there was a decrease in TNF-α levels found in Isomyosamine treated subjects, but no change in the levels in subjects given placebo. The increase in Isomyosamine exposure was proportional to dose across the dose range of 300 mg to 600 mg when administered as a single dose. There was minimal accumulation of Isomyosamine following 5 days of once daily dosing of Isomyosamine 600 mg. Isomyosamine half-life ranged from approximately 15 minutes to 45 minutes across all doses in the single ascending dose and multiple ascending dose portion of the study. Elimination of Isomyosamine included the renal pathway as a minor route. CONCLUSION: Isomyosamine will continue to be investigated in phase 2 clinical trials for the treatment of sarcopenia/frailty, hashimoto's thyroiditis and rheumatoid arthritis.

Meta-Analysis Comparing Apixaban Versus Rivaroxaban for Management of Patients With Nonvalvular Atrial Fibrillation.

To compare the efficacy and safety of apixaban and rivaroxaban for the prevention of stroke in patients with nonvalvular atrial fibrillation (NVAF) by way of a meta-analysis informed by real-world evidence. Systematic review and meta-analysis of observational studies including patients with NVAF on apixaban and rivaroxaban, which reported stroke/systemic embolism and/or major bleeding. Prospero registration number: CRD42021251719. Estimates of relative treatment effect (based on hazard ratios[HRs]) were pooled using the inverse variance method. Fixed-effects and random effect analyses were conducted. Exploratory meta-regression analyses that included study-level covariates were conducted using the metareg (meta-regression) command of Stata Statistical Software: Release 15.1 (College Station, Texas. StataCorp LLC.). Study level covariates explored in the meta-regression analyses were CHA2DS2-VASc and HAS-BLED scores. A total of 10 unique retrospective real-world evidence studies reported comparative estimates for apixaban versus rivaroxaban in patients with NVAF and were included in the meta-analysis. Adjusted HR was 0.88 (95% [confidence interval] CI 0.81 to 0.95), indicating a significantly lower hazard of stroke/systemic embolism associated with apixaban versus rivaroxaban. Pairwise meta-analysis for a major bleeding episode was significantly lower with apixaban compared with rivaroxaban (HR 0.62; 95% CI 0.56 to 0.69), whereas apixaban was associated with a lower risk of gastrointestinal bleeding compared with rivaroxaban (HR 0.57; 95% CI 0.50 to 0.64). In conclusion, this study suggests that patient CHA2DS2-VASc and HAS-BLED scores might be an important factor when selecting which direct oral anticoagulants to use, given the relation these scores have on treatment outcomes. Apixaban is associated with lower rates of both major and gastrointestinal bleeding than rivaroxaban, with no loss of efficacy.

3D - Printed Patient Specific Instrumentation in Corrective Osteotomy of the Femur and Pelvis: A Review of the Literature.

BACKGROUND: The paediatric patient population has considerable variation in anatomy. The use of Computed Tomography (CT)-based digital models to design three-dimensionally printed patient specific instrumentation (PSI) has recently been applied for correction of deformity in orthopedic surgery. This review sought to determine the existing application of this technology currently in use within paediatric orthopaedics, and assess the potential benefits that this may provide to patients and surgeons. METHODS: A review was performed of MEDLINE, EMBASE, and CENTRAL for published literature, as well as Web of Science and clinicaltrials.gov for grey literature. The search strategy revolved around the research question: "What is the clinical impact of using 3D printed PSI for proximal femoral or pelvic osteotomy in paediatric orthopaedics?" Two reviewers, using predetermined inclusion criteria, independently performed title and abstract review in order to select articles for full text review. Data extracted included effect on operating time and intraoperative image use, as well as osteotomy and screw positioning accuracy. Data were combined in a narrative synthesis; meta-analysis was not performed given the diversity of study designs and interventions. RESULTS: In total, ten studies were included: six case control studies, three case series and a case report. Five studies directly compared operating time using PSI to conventional techniques, with two showing a significant decrease in the number of intraoperative images and operative time. Eight studies reported improved accuracy in executing the surgical plan compared to conventional methods. CONCLUSION: Compared to conventional methods of performing femoral or pelvic osteotomy, use of PSI has led to improved accuracy and precision, decreased procedure times, and decreased intra-operative imaging requirements. Additionally, the technology has become more cost effective and accessible since its initial inception and use.

Analysis of completeness of reporting utilizing the Reporting Items for practice Guidelines in Healthcare Statement in gastroenterology clinical practice guidelines.

AIM: Assessing reporting quality is important as it allows distinctions to be made between poor methodology and poor reporting practices. The Reporting Items for practice Guidelines in Healthcare (RIGHT) Statement checklist was published in 2017 to improve the thoroughness and reporting quality of clinical practice guidelines (CPGs). CPGs are evidence-based recommendations developed to assist clinician decision-making in the diagnosis and management of patients. The aim of this study is to assess the completeness of reporting in CPGs listed by the American College of Gastroenterology (ACG) and their frequency of reporting items listed in the RIGHT Statement. METHODS: Using the 22 criteria (35 items) of the RIGHT Statement checklist, two researchers independently documented the adherence to each item for all eligible guidelines listed by the ACG. This study was conducted from 01/10/18 to 05/12/18. Data were recorded onto a prespecified Google data abstraction form and extracted into MS Excel for statistical analysis. RESULTS: Out of 38 eligible guidelines, nine of the 35 RIGHT (25.7%) checklist items were met with less than 50% adherence. The mean adherence was 26.8 (SD ±â€Š9.5); median adherence was 30 (interquartile range 21.5-33.5). The publication dates ranged from 2007 to 2017 with seven of the guidelines (18.4%) published between 2007 and 2009, 11 (29%) published between 2010 and 2013, and 20 (52.6%) published between 2014 and 2017. CONCLUSION: The completeness of reporting in CPGs listed by the ACG remains inadequate in several key areas. Poor adherence to items of the RIGHT Statement checklist demonstrates that there is area for improvement in reporting quality.

Patient-selected media and knowledge of risk to kidneys of nonsteroidal anti-inflammatory drugs.

OBJECTIVES: Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause community-acquired acute kidney injury, especially in high-risk populations. Both the U.S. Food and Drug Administration (FDA) medication guide and over-the-counter labeling vaguely describe kidney risks of NSAIDs and do not provide information for patients to evaluate their risk for kidney problems. The purpose of this study was to use a mobile application to evaluate the impact of patient choice of media delivering NSAID avoidance education on patient knowledge about kidney risks associated with NSAIDs. DESIGN: Prospective cohort study. The mobile application was used to deliver either a redesigned FDA medication guide or a video focused on NSAID risks (selected by the patient), followed by patient knowledge questions (PKQs) and a kidney risk assessment. SETTING AND PARTICIPANTS: One hundred fifty adult primary care patients in southeast Michigan. MAIN OUTCOME MEASURES: The primary outcome was the score on 5 NSAID PKQs between the media selected. Secondary outcomes included characterization of media choice among different demographic and NSAID kidney risk groups. The relationship between kidney risk assessment and self-reported NSAID avoidance behavior also was evaluated. RESULTS: The majority of participants (72.7%) chose to review print material. Those that chose print had significantly higher PKQ scores (5 total points) compared with participants who selected the video: mean scores 4.2 ± 0.9 with print and 3.8 ± 1.0 with video (P = 0.034). Older patients (>65 years) had significantly lower PKQ scores compared with other age groups. Forty-four percent of individuals (n = 66) reported current NSAID use, and 65% stated that they would avoid NSAIDs after the selected education material. CONCLUSION: Scores for questions related to NSAID kidney risk knowledge were higher among participants who chose print compared with video education material. Education regarding NSAID kidney risks encouraged patients to limit their use. Targeted education may be beneficial in high-risk (e.g., older) patients and should be further studied.

A retrospective longitudinal analysis of anthropometric and physical qualities that associate with adult career attainment in junior rugby league players.

OBJECTIVES: To retrospectively compare the longitudinal physical development of junior rugby league players between the Under 13 and 15 age categories in relation to their adult career attainment outcome. DESIGN: Retrospective longitudinal design. METHODS: Fifty-one former junior rugby league players were retrospectively grouped according to their career attainment outcome as adults (i.e., amateur, academy or professional). As juniors, players undertook a physical testing battery on three consecutive annual occasions (Under 13s, 14s, 15s) including height, body mass, sum of four skinfolds, maturation, vertical jump, medicine ball chest throw, 10-60m sprint, agility 505 and estimated V˙O2max . RESULTS: Future professional players were younger than academy players with a greater estimated V˙O2max compared to amateur players. Between Under 13s and 15s, professional players (5.8±2.5cm) increased sitting height more than amateur (4.4±2.1cm) and academy (4.1±1.4cm) players. Logistic regression analyses demonstrated improvements in sitting height, 60m sprint, agility 505 and estimated V˙O2max between amateur and professional players with a high degree of accuracy (sensitivity=86.7%, specificity=91.7%). CONCLUSIONS: Findings demonstrate that the development of anthropometric, maturational and physical qualities in junior rugby league players aged between 13 and 15 years contributed to adulthood career attainment outcomes. Results suggest that age, maturity and size advantages, commonly observed in adolescent focused talent identification research and practice, may not be sensitive to changes in later stages of development in order to correctly identify career attainment. Practitioners should identify, monitor and develop physical qualities of adolescent rugby league players with long-term athlete development in mind.

Occupational Safety in the Age of the Opioid Crisis: Needle Stick Injury among Baltimore Police.

At a time of resurgence in injection drug use and injection-attributable infections, needle stick injury (NSI) risk and its correlates among police remain understudied. In the context of occupational safety training, a convenience sample of 771 Baltimore city police officers responded to a self-administered survey. Domains included NSI experience, protective behaviors, and attitudes towards syringe exchange programs. Sixty officers (8%) reported lifetime NSI. Officers identifying as Latino or other race were almost three times more likely (aOR 2.58, 95% CI 1.12-5.96) to have experienced NSI compared to whites, after adjusting for potential confounders. Findings highlight disparate burdens of NSIs among officers of color, elevating risk of hepatitis, HIV, and trauma. Training, equipment, and other measures to improve occupational safety are critical to attracting and safeguarding police, especially minority officers.

Professional Skill Builder: Mastering Cardiac Auscultation in Under 4 Hours.

INTRODUCTION: Cardiac auscultation is an important clinical skill used by health care professionals during bedside patient evaluation and management. To support development of this skill in health sciences students, we created a self-paced, interactive program. This program helps develop foundational skills and knowledge so learners can confidently perform basic cardiac auscultation at the bedside. METHODS: For novice learners, this program should be used in conjunction with their initial clinical experiences so they can immediately apply what they have learned in the short course. Advanced learners and health care professionals can use this program to review and improve their cardiac auscultation skills. To achieve these objectives, this multimedia program teaches the eight basic heart cadences and their clinical significance through the use of guided tutorials, a gamified e-learning activity, interactive clinical cases, and a self-assessment. A heart sound and murmur library is also included for comparative listening at the bedside. RESULTS: Course evaluations from the first- and second-year Clinical Foundations of Medicine courses at the University of Michigan Medical School demonstrate the value of the various sections of the program. Additionally, the clinical cases have been shown to be effective in improving cardiac auscultation knowledge and skills among residents. DISCUSSION: All clinical cases in the program are based on authentic clinical problems and were developed by academic cardiologists and internists with expertise in this area. Various sections of this tutorial have been in use at our institution for over 20 years and have been evaluated favorably by our students.

Identifying Talent in Youth Sport: A Novel Methodology Using Higher-Dimensional Analysis.

Prediction of adult performance from early age talent identification in sport remains difficult. Talent identification research has generally been performed using univariate analysis, which ignores multivariate relationships. To address this issue, this study used a novel higher-dimensional model to orthogonalize multivariate anthropometric and fitness data from junior rugby league players, with the aim of differentiating future career attainment. Anthropometric and fitness data from 257 Under-15 rugby league players was collected. Players were grouped retrospectively according to their future career attainment (i.e., amateur, academy, professional). Players were blindly and randomly divided into an exploratory (n = 165) and validation dataset (n = 92). The exploratory dataset was used to develop and optimize a novel higher-dimensional model, which combined singular value decomposition (SVD) with receiver operating characteristic analysis. Once optimized, the model was tested using the validation dataset. SVD analysis revealed 60 m sprint and agility 505 performance were the most influential characteristics in distinguishing future professional players from amateur and academy players. The exploratory dataset model was able to distinguish between future amateur and professional players with a high degree of accuracy (sensitivity = 85.7%, specificity = 71.1%; p<0.001), although it could not distinguish between future professional and academy players. The validation dataset model was able to distinguish future professionals from the rest with reasonable accuracy (sensitivity = 83.3%, specificity = 63.8%; p = 0.003). Through the use of SVD analysis it was possible to objectively identify criteria to distinguish future career attainment with a sensitivity over 80% using anthropometric and fitness data alone. As such, this suggests that SVD analysis may be a useful analysis tool for research and practice within talent identification.

The influence of age, playing position, anthropometry and fitness on career attainment outcomes in rugby league.

This study evaluated the influence of annual-age category, relative age, playing position, anthropometry and fitness on the career attainment outcomes of junior rugby league players originally selected for a talent identification and development (TID) programme. Junior rugby league players (N = 580) were grouped retrospectively according to their career attainment level (i.e., amateur, academy and professional). Anthropometric (height, sitting height, body mass, sum of four skinfolds), maturational (age at peak height velocity; PHV) and fitness (power, speed, change of direction speed, estimated[Formula: see text]) characteristics were assessed at the Under 13s, 14s and 15s annual-age categories. Relative age (Q2 = 8.5% vs. Q4 = 25.5%) and playing position (Pivots = 19.5% vs. Props = 5.8%) influenced the percentage of players attaining professional status. Anthropometry and fitness had a significant effect on career attainment at the Under 14 (P = 0.002, η(2) = 0.16) and 15 (P = 0.01, η(2) = 0.12) annual-age categories. Findings at the Under 14s showed future professional players were significantly later maturing compared to academy and amateur players. Findings suggest that relative age, playing position, anthropometry and fitness can influence the career attainment of junior rugby league players. TID programmes within rugby league, and other related team sports, should be aware and acknowledge the factors influencing long-term career attainment, and not delimit development opportunities during early adolescence.

Police Encounters Among Needle Exchange Clients in Baltimore: Drug Law Enforcement as a Structural Determinant of Health.

OBJECTIVES: We piloted a monitoring mechanism to document police encounters around programs targeting people who inject drugs (PWID), and assessed their demographic predictors at 2 Baltimore, Maryland, needle exchange program (NEP) sites. METHODS: In a brief survey, 308 clients quantified, characterized, and sited recent police encounters. Multivariate linear regression determined encounter predictors, and we used geocoordinate maps to illustrate clusters. RESULTS: Within the past 6 months, clients reported a median of 3 stops near NEP sites (interquartile range [IQR] = 0-7.5) and a median of 1 arrest in any location (IQR = 0-2). Three respondents reported police referral to the NEP. Being younger (P = .009), being male (P = .033), and making frequent NEP visits (P = .02) were associated with reported police stops. Among clients reporting arrest or citation for syringe possession, Whites were significantly less likely than non-Whites to report being en route to or from an NEP (P < .001). Reported encounters were clustered around NEPs. CONCLUSIONS: Systematic surveillance of structural determinants of health for PWID proved feasible when integrated into service activities. Improved monitoring is critical to informing interventions to align policing with public health, especially among groups subject to disproportionate levels of drug law enforcement.

Integrated gasification and plasma cleaning for waste treatment: A life cycle perspective.

In the past, almost all residual municipal waste in the UK was landfilled without treatment. Recent European waste management directives have promoted the uptake of more sustainable treatment technologies, especially for biodegradable waste. Local authorities have started considering other options for dealing with residual waste. In this study, a life cycle assessment of a future 20MWe plant using an advanced two-stage gasification and plasma technology is undertaken. This plant can thermally treat waste feedstocks with different composition and heating value to produce electricity, steam and a vitrified product. The objective of the study is to analyse the environmental impacts of the process when fed with seven different feedstocks (including municipal solid waste, solid refuse fuel, reuse-derived fuel, wood biomass and commercial & industrial waste) and identify the process steps which contribute more to the environmental burden. A scenario analysis on key processes, such as oxygen production technology, metal recovery and the appropriate choice for the secondary market aggregate material, is performed. The influence of accounting for the biogenic carbon content in the waste from the calculations of the global warming potential is also shown. Results show that the treatment of the refuse-derived fuel has the lowest impact in terms of both global warming potential and acidification potential because of its high heating value. For all the other impact categories analysed, the two-stage gasification and plasma process shows a negative impact for all the waste streams considered, mainly due to the avoided burdens associated with the production of electricity from the plant. The plasma convertor, key characteristic of the thermal process investigated, although utilising electricity shows a relatively small contribution to the overall environmental impact of the plant. The results do not significantly vary in the scenario analysis. Accounting for biogenic carbon enhanced the performance of biomass and refuse-derived fuel in terms of global warming potential. The main analysis of this study has been performed from a waste management perspective, using 1ton of waste as functional unit. A comparison of the results when 1kWhe of electricity produced is used as functional unit shows similar trends for the environmental impact categories considered.

The flipped classroom for medical students.

BACKGROUND: The objectives of this curricular innovation project were to implement a flipped classroom curriculum for the gynaecologic oncology topics of the obstetrics and gynaecology medical student clerkship, and to evaluate student satisfaction with the change. METHODS: Four short online videos on the topics of endometrial hyperplasia, cervical dysplasia, evaluation of an adnexal mass, and ovarian cancer were created, and students were instructed to view them prior to a class-time active learning session. The Learning Activity Management System (lams) open-source online platform was used to create an active learning class-time activity that consisted of a coached discussion of cases. Student satisfaction with the two aspects of the flipped curriculum was obtained. In addition, lecture assessment for the gynaecologic oncology topics and aggregate student performance on the gynaecological oncology questions of the US National Board of Medical Examiners (NBME) Subject Examination were compared before and after implementation of the curriculum. RESULTS: Eighty-nine students rotated on the clerkship during the pilot period of analysis. Seventy-one students (80%) viewed the videos prior to the class session, and 84 (94%) attended the session. Student satisfaction was very high for both parts of the curriculum. There was no significant difference in aggregate student performance on the gynaecological oncology questions of the NBME Subject Examination. The flipped classroom curriculum demonstrates a promising platform for using technology to make better use of students' time DISCUSSION: Our implementation of the flipped classroom curriculum for the gynaecologic oncology topics successfully demonstrates a promising platform for using technology to make better use of our students' time, and for increasing their satisfaction with the necessary didactic learning of the clerkship.

Consequences of a restrictive syringe exchange policy on utilisation patterns of a syringe exchange program in Baltimore, Maryland: Implications for HIV risk.

INTRODUCTION AND AIMS: Syringe distribution policies continue to be debated in many jurisdictions throughout the USA. The Baltimore Needle and Syringe Exchange Program (NSP) operated under a 1-for-1 syringe exchange policy from its inception in 1994 through 1999, when it implemented a restrictive policy (2000-2004) that dictated less than 1-for-1 exchange for non-program syringes. DESIGN AND METHODS: Data were derived from the Baltimore NSP, which prospectively collected data on all client visits. We examined the impact of this restrictive policy on program-level output measures (i.e. distributed : returned syringe ratio, client volume) before, during and after the restrictive exchange policy. Through multiple logistic regression, we examined correlates of less than 1-for-1 exchange ratios at the client level before and during the restrictive exchange policy periods. RESULTS: During the restrictive policy period, the average annual program-level ratio of total syringes distributed : returned dropped from 0.99 to 0.88, with a low point of 0.85 in 2000. There were substantial decreases in the average number of syringes distributed, syringes returned, the total number of clients and new clients enrolling during the restrictive compared to the preceding period. During the restrictive period, 33 508 more syringes were returned to the needle exchange than were distributed. In the presence of other variables, correlates of less than 1-for-1 exchange ratio were being white, female and less than 30 years old. DISCUSSION AND CONCLUSIONS: With fewer clean syringes in circulation, restrictive policies could increase the risk of exposure to HIV among Injection Drug Users (IDUs) and the broader community. The study provides evidence to the potentially harmful effects of such policies.

Structural vulnerabilities to HIV/STI risk among female exotic dancers in Baltimore, Maryland.

Female exotic dancers (FEDs) are an important, yet understudied group of women who may engage in drug- and sex-related HIV/STI risk behaviors through their work. The study objective was to identify co-occurring indicators of vulnerability (e.g., housing, income, incarceration) associated with HIV/STI risk behavior among FEDs in Baltimore, Maryland. Surveys administered during July 2008-February 2009 captured socio-demographic characteristics, drug use, and sexual practices among dancers (N = 101) aged ≥18 years. Multivariate logistic regression was used to assess the relationship between vulnerability and risk behavior. Dancers with a high vulnerability score (i.e., 2 or more indicators) were more likely to report sex exchange (AOR: 10.7, 95% CIs: 2.9, 39.9) and multiple sex partnerships (AOR: 6.4, 95% CIs: 2.3, 18.3), controlling for demographics and drug use, compared to their less vulnerable counterparts. Findings point to primacy of macro-level factors that need to be addressed in HIV/STI prevention efforts targeting this and other high-risk populations.

Retrospective analysis of anthropometric and fitness characteristics associated with long-term career progression in Rugby League.

OBJECTIVES: The current study retrospectively investigated the differences in anthropometric and fitness characteristics of junior rugby league players selected onto a talent identification and development (TID) programme between long-term career progression levels (i.e., amateur, academy, professional). DESIGN: Retrospective design. METHODS: Former junior rugby league players (N=580) selected to a TID programme were grouped according to their career progression level. Anthropometric (height, sitting height, body mass and sum of four skinfolds), maturational and fitness (power, speed, change of direction speed and estimated V̇O2max) assessments were conducted at 13-15 years. Multivariate analysis of covariance (MANCOVA) analyzed differences between career progression levels controlling for chronological age. RESULTS: 57.1% and 12.1% of players selected to the TID programme progressed to academy and professional levels in rugby league, respectively. Sum of four skinfolds (η(2)=0.03), vertical jump (η(2)=0.02), 10 m (η(2)=0.02), 20 m (η(2)=0.02), 30 m (η(2)=0.02), and 60 m (η(2)=0.03) speed, agility 505 left (η(2)=0.06), agility 505 right (η(2)=0.05) and estimated V̇O2max (η(2)=0.03) were superior within junior players who progressed to professional compared to amateur levels. No significant differences were identified between future academy and professional players for any measure. CONCLUSIONS: Findings suggest that lower sum of four skinfolds and advanced fitness characteristics within junior (13-15 years) rugby league players may partially contribute to long-term career progression. Therefore, TID programmes within rugby league should aim to assess and develop body composition and fitness characteristics, especially change of direction speed. However, TID programmes should also consider technical, tactical and psycho-social characteristics of junior rugby league players that may be important for long-term career progression.

Wounds on wheels: implementing a specialized wound clinic within an established syringe exchange program in Baltimore, Maryland.

People who inject drugs (PWID) experience a high incidence of abscesses and chronic wounds. However, many PWID delay seeking care for their wounds. In 2012, the Baltimore Needle Exchange Program (BNEP) in Baltimore, Maryland, partnered with the Johns Hopkins Wound Healing Center to establish a mobile BNEP Wound Clinic. This clinic provided specialized wound care for BNEP patients. In sixteen months, the clinic treated 78 unique patients during 172 visits overall. On average, each visit cost the program $146.45, which was substantially less than clinic-based treatment. This program demonstrates that specialized wound care can be effectively provided through mobile outreach. A community-based service delivery approach might serve as a model for local health departments looking to improve the health of PWID.