The Effect of Primary ACL Reconstruction on Career Longevity in English Premier League and Championship Soccer Players Compared With Uninjured Controls: A Matched Cohort Analysis.

BACKGROUND: Because of the multitude of variables that affect the retirement decisions of professional soccer players, it has proven difficult to isolate the effect of undergoing anterior cruciate ligament (ACL) reconstruction (ACLR) on career longevity. PURPOSE: To compare the career longevity of professional soccer players after a primary ACLR with that of an uninjured matched control cohort. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review of a consecutive series of primary ACLR was performed between 2008 and 2018 in professional male soccer players from the senior author's practice. Each athlete with ACLR was matched to 3 control athletes who had not undergone ACLR according to age, league, playing position, and preinjury game appearances/minutes played. Player career statistics-including league, game appearances, and game minutes-were compiled for each year until retirement or July 1, 2022. RESULTS: A total of 82 soccer players in the English Premier League or Championship at the time of their primary ACLR were matched to 246 control athletes. The mean career length after ACLR was 6 ± 2.6 years, while that of the matched control athletes was 7.6 ± 2.8 years (P < .001). After primary ACLR, an athlete had a 2 times greater chance of retirement compared with the matched control athlete (hazard ratio, 2.19; P < .001). At 5 years after ACLR, 16% of athletes had retired from professional soccer, while 8.5% of the matched cohort were retired (P = .060). By 10 years, 72% of the ACLR cohort had retired compared with 43% of the matched cohort (P < .001). Forwards were more likely to have shortened careers compared with goalkeepers (P = .021); however, no significant differences were observed between midfielders, defenders, and forwards. Within the ACLR cohort, a contralateral ACL tear during the athlete's career caused a 2.30 times (P = .022) increased chance of retirement compared with athletes with only 1 ACL tear during their career. Mechanism of injury, meniscal pathology, graft rerupture, and chondral lesions did not affect career length. CONCLUSION: Professional male soccer players who underwent ACLR had decreased career length by approximately 1.6 years compared with a matched player cohort.

Correspondence between consonant inventories obtained using modified naturalistic listening in real time (NLRT) and parent report.

OBJECTIVE: The current study examined the correspondence between consonant inventories obtained using the modified NLRT approach and parent report. DESIGN: Prospective comparative study. SETTING: Multisite institutional. PARTICIPANTS: Participants included 70 children with repaired CP + L (mean age = 16 months) who were participating in the multicenter study. PROCEDURES: Parents of participants were asked to record approximately two hours of their child's vocalizations/words at home using a Language ENvironmental Analysis (LENATM) recorder. Four ten-minute audio-recorded samples of vocalizations were extracted from the original recording for each participant and analyzed for size of consonant inventory. Parent reported consonant inventory was compared to coder identified consonant inventory. Coders identified an in-inventory consonant using two different criteria: 2+ tokens of each consonant were required in the first analysis and 10+ tokens of each consonant were required in the second analysis. RESULTS: Coder identified consonant inventory was larger (mean = 7.90) than that reported by parents (mean = 6.06) when a minimum of two tokens per consonant was required for inclusion of a consonant in inventory, while the inventory transcribed by coders was smaller (mean = 4.46) than that reported by parents when inclusion criteria required a minimum of ten tokens per consonant. CONCLUSIONS: Although the mean number of consonants in inventory between coders and parents was slightly closer using the 10+ versus 2+ criterion for consonant inclusion, the difference was not significant enough to recommend one protocol over the other.

LiaX is a surrogate marker for cell envelope stress and daptomycin non-susceptibility in Enterococcus faecium.

Daptomycin (DAP) is often used as a first-line therapy to treat vancomycin-resistant Enterococcus faecium infections, but emergence of DAP non-susceptibility threatens the effectiveness of this antibiotic. Moreover, current methods to determine DAP minimum inhibitory concentrations (MICs) have poor reproducibility and accuracy. In enterococci, DAP resistance is mediated by the LiaFSR cell membrane stress response system, and deletion of liaR encoding the response regulator results in hypersusceptibility to DAP and antimicrobial peptides. The main genes regulated by LiaR are a cluster of three genes, designated liaXYZ. In Enterococcus faecalis, LiaX is surface-exposed with a C-terminus that functions as a negative regulator of cell membrane remodeling and an N-terminal domain that is released to the extracellular medium where it binds DAP. Thus, in E. faecalis, LiaX functions as a sentinel molecule recognizing DAP and controlling the cell membrane response, but less is known about LiaX in E. faecium. Here, we found that liaX is essential in E. faecium with an activated LiaFSR system. Unlike E. faecalis, E. faecium LiaX is not detected in the extracellular milieu and does not appear to alter phospholipid architecture. We further postulated that LiaX could be used as a surrogate marker for cell envelope activation and non-susceptibility to DAP. For this purpose, we developed and optimized a LiaX enzyme-linked immunosorbent assay (ELISA). We then assessed 86 clinical E. faecium bloodstream isolates for DAP MICs and used whole genome sequencing to assess for substitutions in LiaX. All DAP-resistant clinical strains of E. faecium exhibited elevated LiaX levels. Strikingly, 73% of DAP-susceptible isolates by standard MIC determination also had elevated LiaX ELISAs compared to a well-characterized DAP-susceptible strain. Phylogenetic analyses of predicted amino acid substitutions showed 12 different variants of LiaX without a specific association with DAP MIC or LiaX ELISA values. Our findings also suggest that many E. faecium isolates that test DAP susceptible by standard MIC determination are likely to have an activated cell stress response that may predispose to DAP failure. As LiaX appears to be essential for the cell envelope response to DAP, its detection could prove useful to improve the accuracy of susceptibility testing by anticipating therapeutic failure.

Exploration of the representation of the allied health professions in senior leadership positions in the UK National Health Service.

BACKGROUND: Allied health professionals (AHPs) are an important group within the National Health Service (NHS) in the UK and make up a large portion of the workforce. Investment in AHP leadership is believed to lead to improvements in patient care, resource use, collaboration and innovation. This study aims to assess the current state of AHP strategic leadership within the NHS. METHODS: A freedom of information (FOI) request was sent to all NHS Trusts and health boards (HBs) within the UK NHS. The questions focused on the AHP workforce, with a particular interest in the chief AHPs (or equivalent roles) working in an NHS setting. Analysis of the FOI used a range of descriptive statistics. RESULTS: Of the 217 Trusts/HBs contacted, responses were received from 160 (74%). The majority (81%) reported that they employed a Chief AHP or equivalent role, with only 14% of these having a position on the Trust/HB executive board. There were 50 different job titles reported as the titles for the chief AHP or equivalent roles: with director of AHPs (18.6%), lead AHP (13.9%) and chief AHP (11.6%) being the most reported titles. The results identified an inequity of representation of AHP professions within senior AHP leadership; with most of these roles (70%) held by physiotherapists and occupational therapists. CONCLUSION: Changes in AHP strategic leadership are needed to address the inequities identified in this study. Addressing these issues is required to enable inclusive leadership, which is crucial to improve the contribution of AHPs to healthcare.

No difference in return to play rates between different elite sports after primary autograft ACL reconstruction.

PURPOSE: To demonstrate return to play (RTP) rates, the level of RTP and time taken to RTP in different sports after anterior cruciate ligament reconstruction (ACL-R) and compare the differences between football and rugby. The secondary aims were to compare the differences in intra articular injuries and their treatments and reoperation rates between these sports. METHODS: A retrospective review of a consecutive series of all primary ACL-R undertaken by the senior author between 2005 and 2019 was undertaken. Patients were included if they were elite athletes and were a minimum of 2 year post-primary autograft ACL-R. The outcomes measured were RTP (defined as participation in a professional match or in national/international-level competition in amateur sports), time to RTP after surgery and RTP level (Tegner score). RESULTS: Three hundred and ninety-four elite athletes, with 420 ACL-Rs were included. 235 (55.9%) were in footballers and 125 (29.8%) were in rugby players. 399 (95.0%) of all elite athletes returned to competition at an average of 10.3 months after ACL-R. 386 (90.2% played at the same or higher level post-surgery. Although there was no difference in RTP rates between different sports, rugby players RTP significantly faster than footballers (9.6 vs 10.6 months, (p = 0.027). Footballers were more likely to rupture their ACL during jumping/landing manoeuvres and to receive a PT graft than rugby players. There were no other significant differences between football and rugby players regarding patient characteristics, intraoperative findings, re-rupture and re-operation rates. CONCLUSIONS: Over 95% of all elite athletes RTP after primary ACL-R with 90% able to play at the same level. Rugby players RTP significantly faster than footballers. LEVEL OF EVIENCE: Level IV.

Determinants of Performance in Professional Soccer Players at 2 and 5 Years After ACL Reconstruction.

BACKGROUND: A number of studies have investigated return to play after anterior cruciate ligament reconstruction (ACLR) in professional soccer players, but it is unclear which factors are associated with a return to the preinjury performance and ability to play over time. PURPOSE: To identify factors that contribute to a professional soccer player's return to preinjury performance after ACLR, as well as to report their playing performance at 2 and 5 years after ACLR compared with their preinjury performance. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: A consecutive cohort of professional soccer players undergoing primary ACLR were analyzed between 2005 and 2019. A minimum 2-year follow-up was required. The effect of patient, surgical, and postoperative factors on performance rates, defined as a combination of league level and playing time, was evaluated with univariate and multivariate logistic regression models. RESULTS: A total of 200 male professional soccer players were included. When combining league level and playing time, 30% of athletes returned to their preinjury performance at 2 years and 22% at 5 years. However, 53% of athletes returned to their preinjury performance for at least 1 season by year 5. At 2 years, a chondral lesion of grade 3 or 4 decreased the odds of return to preinjury performance (odds ratio [OR], 0.37; P = .010). Athletes receiving an ACLR with the addition of a lateral extra-articular tenodesis procedure were 2.42 times more likely to return to preinjury performance at 2 years than athletes with ACLR alone (P = .004). By 5 years after ACLR, athletes aged ≥25 years at the time of reconstruction were 3 times less likely to be performing at their preinjury performance (OR, 0.32; P < .001), and those with a grade ≥3 chondral lesion were >2 times less likely to be performing at their preinjury performance (OR, 0.43; P = .033). CONCLUSION: The presence of >50% thickness chondral pathology, ACLR without lateral extra-articular tenodesis, and age >25 years at the time of surgery were all significant risk factors of worse performance rates after ACLR. Significant decreases in performance rates were noted at 2 and 5 years postoperatively.

LiaX is a surrogate marker for cell-envelope stress and daptomycin non-susceptibility in Enterococcus faecium.

Daptomycin (DAP) is often used as a first line therapy to treat vancomycin-resistant Enterococcus faecium (VR Efm ) infections but emergence of DAP non-susceptibility threatens the effectiveness of this antibiotic. Moreover, current methods to determine DAP MICs have poor reproducibility and accuracy. In enterococci, DAP resistance is mediated by the LiaFSR cell membrane stress response system and deletion of liaR encoding the response regulator results in hypersusceptibility to DAP and antimicrobial peptides. The main genes regulated by LiaR are a cluster of three genes, designated liaXYZ . In Enterococcus faecalis , LiaX is surface exposed with a C-terminus that functions as a negative regulator of cell membrane remodeling and an N-terminal domain that is released to the extracellular medium where it binds DAP. Thus, in E. faecalis , LiaX functions as a sentinel molecule recognizing DAP and controlling the cell membrane response, but less is known about LiaX in E. faecium . Here, we found that liaX is essential in E. faecium ( Efm ) with an activated LiaFSR system. Unlike E. faecalis , Efm LiaX is not detected in the extracellular milieu and does not appear to alter phospholipid architecture. We further postulated that LiaX could be used as a surrogate marker for cell envelope activation and non-susceptibility to DAP. For this purpose, we developed and optimized a LiaX ELISA. We then assessed 86 clinical E. faecium BSI isolates for DAP MICs and used whole genome sequencing to assess for substitutions in LiaX. All DAP-R clinical strains of E. faecium exhibited elevated LiaX levels. Strikingly, 73% of DAP-S isolates by standard MIC determination had elevated LiaX ELISAs above the established cut-off. Phylogenetic analyses of predicted amino acid substitutions showed 12 different variants of LiaX without a specific association with DAP MIC or LiaX ELISA values. Our findings also suggest that many Efm isolates that test DAP susceptible by standard MIC determination are likely to have an activated cell stress response that may predispose to DAP failure. As LiaX appears to be essential for the cell envelope response to DAP, its detection could prove useful to improve the accuracy of susceptibility testing by anticipating therapeutic failure.

Measuring dietary intake in low-and middle-income countries: a systematic review of the methods and tools for estimating fish and seafood intake.

CONTEXT: Fish and seafood consumption makes an important but often under-recognized contribution to dietary patterns and nutrition, particularly in low- and middle-income countries (LMICs). Therefore, valid, and reliable dietary assessment tools (DATs) and methods to measure seafood consumption in resource-poor settings are needed. OBJECTIVE: To review the available DATs that have been used to measure fish and seafood consumption in LMICs and to assess their quality. DATA SOURCES: A systematic search of the electronic databases Scopus, Embase, and Medline was conducted, identifying 1541 initial articles, of which 122 eligible full-text articles were reviewed. DATA EXTRACTION: Data extraction focused on the purpose of dietary assessment, setting, target population group, DAT type, administration mode, type of fish and seafood assessed, specific measure of food intake, use of a portion-size-estimation aid, and details of validity, reliability, and pilot testing of the DATs. DATA ANALYSIS: The most common DATs used were food frequency questionnaires (n = 80; 58%), of which 36 (25%) were semi-quantitative. The majority of tools (n = 107; 78%) included measurement of consumption frequency; only 41 studies (30%) measured frequency, quantity, and type of seafood consumed. Only 41 DATs (30%) solely focused on fish or seafood intake. Most DATs were interviewer administered (n = 80; 58%), 23 (16%) mentioned the use of a portion-size-estimation aid, and validity was tested for only 13% of DATs (n = 18). CONCLUSION: This systematic review reveals a lack of sufficient detail in the use of standard DATs to fully capture the contribution of fish and seafood to diets in LMICs. Consequently, the need to develop or adapt existing DATs to capture frequency, quantity, and type of fish and seafood intake with consideration of cultural eating practices has been highlighted. This is essential for informing appropriate interventions to leverage the nutritional benefits of seafood consumption in LMICs. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no. CRD42021253607.

A "Short Isometric Construct" Reconstruction Technique for the Medial Collateral Ligament of the Knee.

Recently there has been increased focus on the medial collateral ligament (MCL) and the role the medial ligament complex plays in preventing valgus and external rotation, especially in the setting of a combined ligament injury. Multiple surgical techniques purport to reproduce "normal anatomy"; however, only one technique addresses the deep MCL fibers and the prevention of external rotation. Thus we describe the "short isometric construct" MCL reconstruction which is stiffer than the anatomic reconstructions. The "short isometric construct" technique resists valgus throughout range of motion whereas its obliquity resists tibial external rotation, helping to reduce the risk of anterior cruciate ligament graft re-rupture.

A Comparison of All-inside and Inside-out Meniscal Repair in Elite Athletes.

BACKGROUND: The popularization of all-inside (AI) meniscal repair devices has led to a shift away from the historical gold standard of inside-out (IO) meniscal repair without comparative studies to support the change. PURPOSE: To compare the failure rate and time to failure of AI and IO meniscal repair performed in elite athletes. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review was performed of all professional and national- and international-level amateur athletes who underwent meniscal repair, with a minimum of 2-year follow-up between January 2013 and September 2019. Meniscal repair was classified as AI or IO depending on the surgical technique performed. Treatment failure was defined as patients having to undergo subsequent surgery to address a persistent meniscal tear after repair. Cox proportional hazards modeling was used to determine if meniscal repair failure rates differed by the location and technique of meniscal repair. Models were controlled for known risk factors such as age, sex, sport, and concurrent cruciate ligament reconstruction. RESULTS: A total of 192 (135 lateral and 57 medial) meniscal repairs were performed in elite athletes during the study period. Overall, 41 (21%) meniscal repairs met the criteria for failure. Medial meniscal tears repaired with the AI technique failed at a significantly higher rate (18/31 [58%]) than medial meniscal tears repaired with the IO technique (6/26 [23%]) or lateral meniscal tears repaired with the AI (9/76 [12%]) or IO (8/59 [14%]) technique (P < .001). Cox proportional hazards modeling revealed that a medial meniscal tear repaired with the AI technique had an almost 8 times greater hazard of failure than a lateral meniscal tear repaired with the AI technique (P < .001). At 1 year postoperatively, 8% of lateral meniscal repairs had failed (regardless of technique), while medial meniscal tears failed at a rate of 16% with the IO technique and 42% with the AI technique. By 2 years, 53% of medial meniscal tears repaired with the AI technique had failed, and by 5 years, 63% had failed. CONCLUSION: AI repair of medial meniscal tears led to a higher rate of failure than IO repair of medial or lateral meniscal tears in elite athletes. Medial meniscal repair failed at a higher rate than lateral meniscal repair.

Stop Consonant Production in Children with Cleft Palate After Palatoplasty.

The current study examined stop consonant production in children with cleft lip and/or palate (CP ± L) 2-6 months following palatal surgery.Prospective comparative study.Multisite institutional.Participants included 113 children with repaired CP ± L (mean age = 16 months) who were participating in the multicenter CORNET study.Parents of participants were asked to record approximately two hours of their child's vocalizations/words at home using a Language ENvironmental Analysis (LENATM) recorder. Four ten-minute audio-recorded samples of vocalizations were extracted from the original recording for each participant and analyzed for presence of oral stop consonants. A minimum of 100 vocalizations were required for analysis.Preliminary findings indicate that at least one oral stop was evident in the consonant inventory for 95 of the 113 children (84%) at the time of their post-surgery 16-month recording, and 80 of these children (71%) were producing two or more different stops. Approximately 50% of the children (57/113) produced the three voiced stops, and eight of the children (7%) were producing all six stop consonants.The findings of this study suggest that the majority of children with repaired CP ± L from English-speaking homes are producing oral stops within six months following palatal surgery. Similar to same-age children without CL ± P, voiced stops were more frequently evident in the children's inventories than voiceless stops. In contrast to findings of previous reports suggesting place of articulation differences, a somewhat comparable percentage of children in this study produced voiced bilabial, alveolar, and velar stops.

Effectiveness of diet quality indices in measuring a change in diet quality over time: a systematic review and meta-analysis of randomized controlled trials.

CONTEXT: Diet quality indices (DQIs) were developed to score and rank adherence to dietary patterns in observational studies, but their use to measure changes in diet quality in intervention trials is becoming common in the literature. OBJECTIVE: This systematic review and meta-analysis aimed to assess the effectiveness of DQIs to measure change in diet quality in intervention trials. DATA SOURCES: MEDLINE, CINAHL, Embase, and the Cochrane Central Register of Controlled Trials databases were searched from January 1994 to June 2020. Two reviewers independently completed full-text screening. Eligible studies were randomized controlled trials that used validated a priori DQIs to measure change in diet quality in adults. DATA EXTRACTION: Data were extracted by an independent reviewer and reviewed by the research team. Risk of bias was assessed by the Cochrane Collaboration's Risk of Bias 2.0 tool. DATA ANALYSIS: The 34 included studies (52% of reviewed studies, 0.6% of initially identified studies) used 10 different DQIs, 7 of which were able to measure significant change in diet quality. Meta-analyses of pooled results demonstrated change in the Healthy Eating Index (MD 5.35; 95%CI, 2.74-7.97; P < 0.001) and the Mediterranean Dietary Adherence Screener (MD 1.61; 95%CI, 1.00-2.23; P < 0.001) scores. DQIs were more likely to measure change in diet quality if they reflected the diet pattern being implemented, if the intervention was significantly different from the baseline and control diets, and if the study was adequately powered to detect change. CONCLUSION: DQIs are responsive to change in diet quality in intervention trials when the index used reflects the dietary changes made and the study is adequately powered. The appropriate selection of a DQI to suitably match dietary changes and study populations is important for future dietary intervention trials. SYSTEMATIC REVIEW REGISTRATION: PROSPERO registration no. CRD42020181357.

Transcribing toddler vocalizations: comparison of a modified naturalistic listening approach with phonetic transcription.

Previous investigations have demonstrated that naturalistic listening in real time (NLRT) can be used reliability to assess prelinguistic vocalizations and is less time-consuming than phonetic transcription. The current investigation was performed to examine the correspondence of syllable and consonant information obtained using a modified naturalistic listening in real time (NLRT) methodology compared to broad phonetic transcription for 20 toddlers with repaired cleft palate. A forty-minute vocalization sample was obtained for each toddler. Two listeners listened to each recording independently and coded the number of syllables and consonant types produced by each toddler using NLRT. Each recording was phonetically transcribed by each listener 2 to 16 months following the NLRT analysis. High reliability was evident between the modified NSRT method and phonetic transcription for identification of both syllables and consonants. Differences were evident in the actual number of syllables and consonants identified between the two types of assessment across the 20 participants. Possible explanations for those differences are addressed. The results of this investigation indicate that the modified NLRT procedure is a reliable method for determining consonant/inventories of young children. It is less labor intensive than traditional phonetic transcription and may be useful clinically when documentation of early sound development is needed to support early intervention decisions.

Individual fascicles of the ankle lateral ligaments and the lateral fibulotalocalcaneal ligament complex can be identified on 3D volumetric MRI.

PURPOSE: Lateral ligament ankle sprains are common and the anatomy on imaging studies is vital for accurate diagnosis. The lateral fibulotalocalcaneal ligament (LFTCL) complex consists of the inferior fascicle of the anterior talofibular ligament (ATFL) which is connected by arciform fibres with the calcaneofibular ligament (CFL). The superior fascicle of ATFL is an independent structure that should be assessed individually. MRI evaluation of these distinct fascicles and the arciform fibres has not been described. The aim of this study is to identify the anatomical relationship of these components of the LFTCL complex in healthy individuals on MRI. METHODS: Thirty ankles from healthy volunteers were imaged using 3D volumetric MRI. The ATFL fascicles and size were evaluated. Presence of arciform fibres connecting the inferior ATFL fascicle and CFL to form the LFTCL complex and anatomical relationship around the lateral ligament complex were assessed. RESULTS: Both the superior and inferior ATFL fascicles were observed in 26 (86.7%) ankles. The superior ATFL fascicle was significantly larger in all specimens (39% longer and 80.7% wider). For the specimens with a single fascicle, this was similar in size to the superior fascicle observed in the other 26 specimens. These measurements were not affected by age or gender. Arciform fibres of the LFTCL complex were identified in 22 (84.6%) specimens with two ATFL fascicles and three (75%) ankles with a single ATFL fascicle. Connecting fibres from the ATFL to PTFL were observed in 19 (63.3%) ankles while connections between the CFL and PTFL were identified in 21 (70%) ankles. Five ankles had a perforating artery visualized in the intervening space between the superior and inferior ATFL fascicles (a branch of the lateral tarsal artery of the dorsalis pedis artery). CONCLUSION: Two distinct ATFL fascicles may be identified in the majority of ankles on MRI. Isolated injury to the superior fascicle identified on MRI may be useful when diagnosing patients presenting with symptoms of subtle instability without overt ankle laxity on clinical examination. The current study is the first to identify the arciform fibres of the LFTCL complex supporting isolated ATFL repair in the presence of intact LFTCL complex. LEVEL OF EVIDENCE: Level III.

Paediatric rhabdomyolysis: A UK centre's 10-year retrospective experience.

AIMS: To describe the aetiologies of paediatric rhabdomyolysis and explore the medium-term renal consequences. METHODS: Retrospective, single-centre review of children with rhabdomyolysis. RESULTS: Two hundred and thirty-two children met inclusion criteria for the analysis. Mean age at presentation was 8.4 (SD ± 5.5) years. The commonest aetiology was infection (28%), with viral myositis making up the clear majority (75%). Trauma was identified as a cause in 18% of children, seizures in 10% and immune-mediated mechanisms in 8%. Acute kidney injury (AKI) was present in 32% of the cases overall. Children with AKI tended to be younger, with higher peak creatine kinase (CK) and active urinary sediment on urinalysis at presentation. AKI and the need for renal replacement therapy (RRT) were associated with a prolonged hospital stay (15 (interquartile range, IQR 6.5-33) vs. 2 (IQR 0-7) days). A total of 18 children and young people required RRT, with a mean duration of 7.1 ± 4.3 days. Those who received RRT were more likely to have abnormalities on urinalysis at presentation (46% vs. 5%). Over the period of the study, 9% of children died and 2% met criteria for a diagnosis of chronic kidney disease. CONCLUSIONS: This large paediatric rhabdomyolysis case series provides new and unique insights into the condition. Our results highlight the common aetiologies and provide evidence of good renal recovery overall, even in the most severely affected cases. Abnormalities of urinalysis appear to be important in predicting the development of AKI and the need for RRT.

Rebranding the 'anatomic' ACL reconstruction: Current concepts.

The anterior cruciate ligament (ACL) is a complex ribbon-like structure, which is approximately 3.5 times larger at the tibial and femoral insertions than at the midpoint. Accordingly, it is impossible to recreate with a single cylindrical graft. However, this has not stopped surgeons from using the term "anatomic" to describe multiple ACL reconstruction techniques inserting at a number of different locations within the original ACL footprint, causing confusion. The term "anatomic" should be discarded and replaced by an anatomic description of the tunnel placements on the tibia and femur. Current ACL reconstruction techniques cite anatomical studies that identified "direct and indirect fibres" of the ACL. The "direct fibres" bear 85-95% of the load and provide the main resistance to both anterior tibial translation and internal rotation/pivot shift. On the femur, these fibres insert in a line just posterior to the intercondylar ridge and comprise the portion of the ACL that surgeons should strive to restore. Placement of the graft just posterior to the intercondylar ridge creates a line of placement options from the anteromedial bundle to the "central" position and finally to the posterolateral bundle position. The authors prefer placing the femoral tunnel in the isometric anteromedial position and addressing a high-grade pivot shift at the IT-band with a lateral extra-articular tenodesis. As with the femoral tunnel, the native ACL footprint on the tibia is much larger than the ACL graft and thus can be placed in multiple "anatomic" locations. The authors prefer placement of the tibial tunnel in the anterior most position of the native footprint that does not cause impingement in the femoral notch. Additional research is needed to determine the ideal tunnel positions on the femur and tibia and validating the technique with patient outcomes. However, this cannot be accomplished without describing tunnel placement with specific anatomical locations so other surgeons can replicate the technique.

The relationship between hair metabolites, air pollution exposure and gestational diabetes mellitus: A longitudinal study from pre-conception to third trimester.

Background: Gestational diabetes mellitus (GDM) is a metabolic condition defined as glucose intolerance with first presentation during pregnancy. Many studies suggest that environmental exposures, including air pollution, contribute to the pathogenesis of GDM. Although hair metabolite profiles have been shown to reflect pollution exposure, few studies have examined the link between environmental exposures, the maternal hair metabolome and GDM. The aim of this study was to investigate the longitudinal relationship (from pre-conception through to the third trimester) between air pollution exposure, the hair metabolome and GDM in a Chinese cohort. Methods: A total of 1020 women enrolled in the Complex Lipids in Mothers and Babies (CLIMB) birth cohort were included in our study. Metabolites from maternal hair segments collected pre-conception, and in the first, second, and third trimesters were analysed using gas chromatography-mass spectrometry (GC-MS). Maternal exposure to air pollution was estimated by two methods, namely proximal and land use regression (LUR) models, using air quality data from the air quality monitoring station nearest to the participant's home. Logistic regression and mixed models were applied to investigate associations between the air pollution exposure data and the GDM associated metabolites. Results: Of the 276 hair metabolites identified, the concentrations of fourteen were significantly different between GDM cases and non-GDM controls, including some amino acids and their derivatives, fatty acids, organic acids, and exogenous compounds. Three of the metabolites found in significantly lower concentrations in the hair of women with GDM (2-hydroxybutyric acid, citramalic acid, and myristic acid) were also negatively associated with daily average concentrations of PM2.5, PM10, SO2, NO2, CO and the exposure estimates of PM2.5 and NO2, and positively associated with O3. Conclusions: This study demonstrated that the maternal hair metabolome reflects the longitudinal metabolic changes that occur in response to environmental exposures and the development of GDM.

Vitamin B12 Supplementation Adequacy in Australian Vegan Study Participants.

In our initial analysis of the Australian Vegan Study we estimated the mean daily intake of vitamin B12 of each participant and compared this to the Recommended Dietary Intake (RDI). However, the proportion of vitamin B12 that can be absorbed from large doses typically contained in oral supplements is considerably lower than the amount absorbed from food. In this analysis we took into account the estimated absorption from supplements in order to compare adequacy of vitamin B12 intake to the RDI. A cross-sectional online survey was used to obtain information from women (N = 1530) of reproductive age on a vegan diet in Australia. Vitamin B12 intake from food was estimated using a validated food frequency questionnaire and detailed questioning was used to estimate supplemental intake. We used published data on dose-dependent absorption rates to estimate amount of the vitamin absorbed to enable comparison to the RDI. Supplementation practices varied widely. Based on estimated amount absorbed, 39% of participants had an estimated total intake of vitamin B12 below RDI equivalency, compared to 26% based on mean daily intake. The potential absorption of vitamin B12 needs to be considered when estimating adequacy of intake and recommending supplementation.

Rates and Levels of Elite Sport Participation at 5 Years After Revision ACL Reconstruction.

BACKGROUND: There is a paucity of data regarding return to play (RTP), level of competition, and longevity of play after revision of anterior cruciate ligament (ACL) reconstruction (ACLR) in elite athletes. PURPOSE: To report RTP rates and competition levels in elite athletes at the point of RTP, as well as at 2 and 5 years after revision ACLR, and the effect of meniscal and chondral pathology at revision surgery on these outcomes. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A retrospective review of a consecutive series of all revision ACLRs undertaken by the senior author between 2009 and 2019, with a minimum 2-year follow-up, was carried out. Outcome measures were RTP rates and competition level. RESULTS: A total of 49 knees in 48 elite athletes met the inclusion criteria. After revision ACLR, 43 (87.8%) elite athletes achieved RTP, of whom 75.5% were at the same level. At 2 years after surgery, 39 (79.6%) were still playing, 25 (51%) at the same level; at 5 years after surgery, 20 (44.4%) were still playing, 9 (20%) at the same level. Elite athletes with <50% thickness or no articular cartilage lesions were more likely to RTP (94.6% vs 66.7%; P = .026), as well as return to the same competition level (83.8% vs 50%; P = .047), compared with those with ≥50% thickness chondral lesions. Those without medial meniscal pathology were more likely to RTP at the same level after revision surgery (94.4% vs 64.5%; P = .036). The median time elite athletes continued to play after revision ACLR was 73 months (95% CI, 43.4-102.6); 23 months at the same level (95% CI, 13.6-32.4). The probability of still playing at 5 years after surgery was 55.9%, with a 22.5% chance of maintaining preinjury competition level. CONCLUSION: In elite athletes, RTP rates and competition level decreased over time after revision ACLR. The presence of >50% thickness chondral pathology was associated with lower RTP rates and competition level at RTP time, while medial meniscal pathology was associated with lower competition level at RTP.

Effect of Lateral Extra-articular Tenodesis on the Rate of Revision Anterior Cruciate Ligament Reconstruction in Elite Athletes.

BACKGROUND: There is growing evidence that anterolateral procedures can reduce the risk of rerupture in high-risk recreational athletes undergoing primary anterior cruciate ligament (ACL) reconstruction (ACLR). However, this effectiveness has never been evaluated in elite athletes. PURPOSE: The purpose of this study was to evaluate the effectiveness of lateral extra-articular tenodesis (LET) in reducing revision rates in primary ACLR in elite athletes. Additionally, this study evaluated whether LET had a greater effect when combined with ACLR utilizing a hamstring or patellar tendon graft. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A consecutive cohort of elite athletes with an isolated ACL tear undergoing autograft patellar or hamstring tendon reconstruction with or without Lemaire LET were analyzed between 2005 and 2018. A minimum 2-year follow-up was required. The association between the use of LET and ACL graft failure as defined by revision ACLR was evaluated with univariate and multivariate logistic regression models. RESULTS: A total of 455 elite athletes (83% men and overall age 22.5 ± 4.7 years) underwent primary ACLR with (n = 117) or without (n = 338) a LET procedure. Overall, 36 athletes (7.9%) experienced ACL graft failure, including 32 (9.5%) reconstructions without a LET and 4 (3.4%) with a LET. Utilization of LET during primary ACLR reduced the risk of graft failure by 2.8 times, with 16.5 athletes needing LET to prevent a single ACL graft failure. Multivariate models showed that LET significantly reduced the risk of graft rupture (relative risk = 0.325; P = .029) as compared with ACLR alone after controlling for sex and age at ACLR. Including graft type in the model did not significantly change the risk profile, and although a patellar tendon graft had a slightly lower risk of failure, this was not statistically significant (P = .466). CONCLUSION: The addition of LET reduced the risk of undergoing revision by 2.8 times in elite athletes undergoing primary ACLR. This risk reduction did not differ significantly between the patellar tendon and hamstring tendon autografts. With these results, status as an elite athlete should be included in the indications for a LET, as they are at increased risk for ACL graft failure.