Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement.

ABSTRACT: Musculoskeletal injuries occur frequently in sport during practice, training, and competition. Injury assessment and management are common responsibilities for the team physician. Initial Assessment and Management of Musculoskeletal Injury-A Team Physician Consensus Statement is title 23 in a series of annual consensus documents written for the practicing team physician. This statement was developed by the Team Physician Consensus Conference, an annual project-based alliance of six major professional associations. The goal of this document is to help the team physician improve the care and treatment of the athlete by understanding the initial assessment and management of selected musculoskeletal injuries.

Seeking information and services associated with reproductive health among rural Peruvian young adults: exploratory qualitative research from Amazonas, Peru.

BACKGROUND: Sexual and reproductive health (SRH) literacy allows young adults to make informed decisions about health outcomes. In Peru, roughly one fifth of the population lives in rural areas, and little is known about where young adults in rural areas get their SRH information. The aim of this study was to identify what motivates and influences young adults to seek information and care related to SRH in three rural communities in the highlands of Northern Peru. METHODS: Five gender-stratified focus group discussions with a total of 24 participants, and nine follow-up interviews were conducted to generate in-depth narrative data and triangulate data from the target group. Participants were women and men aged 18-24. The focus group discussions and interviews explored sources of reproductive health information, the role of informal social networks, barriers to care, and primary health concerns of the target population. RESULTS: Main findings include: (1) The two greatest perceived SRH risks were unwanted pregnancy and abnormal discharge; (2) There appears to be limited concern about HIV or other sexually transmitted infections in the narratives; (3) There is a low quality of information concerning SRH, with discrepancies between the genders; (4) A broad spectrum of sources for SRH information were cited, including Internet, traditional healers, and specialized care; and varied by gender and life experience; (5) Having trust in the information source was the primary variable associated with uptake of services and/or access to information for both men and women. However, men reported more embarrassment around seeking services and information, whereas women faced more physical barriers. CONCLUSIONS: There is a lack of SRH information among young adults in some communities in the northern highlands of Peru. Both schools and health centers were noted as being trusted and established information sources for all genders so could be a key resource to explore as a way to disseminate information.

Initial Assessment and Management of Select Musculoskeletal Injuries: A Team Physician Consensus Statement.

ABSTRACT: Musculoskeletal injuries occur frequently in sport during practice, training, and competition. Injury assessment and management are common responsibilities for the team physician. Initial Assessment and Management of Musculoskeletal Injury-A Team Physician Consensus Statement is title 23 in a series of annual consensus documents written for the practicing team physician. This statement was developed by the Team Physician Consensus Conference, an annual project-based alliance of six major professional associations. The goal of this document is to help the team physician improve the care and treatment of the athlete by understanding the initial assessment and management of selected musculoskeletal injuries.

Genome-scale phylogeny and comparative genomics of the fungal order Sordariales.

The order Sordariales is taxonomically diverse, and harbours many species with different lifestyles and large economic importance. Despite its importance, a robust genome-scale phylogeny, and associated comparative genomic analysis of the order is lacking. In this study, we examined whole-genome data from 99 Sordariales, including 52 newly sequenced genomes, and seven outgroup taxa. We inferred a comprehensive phylogeny that resolved several contentious relationships amongst families in the order, and cleared-up intrafamily relationships within the Podosporaceae. Extensive comparative genomics showed that genomes from the three largest families in the dataset (Chaetomiaceae, Podosporaceae and Sordariaceae) differ greatly in GC content, genome size, gene number, repeat percentage, evolutionary rate, and genome content affected by repeat-induced point mutations (RIP). All genomic traits showed phylogenetic signal, and ancestral state reconstruction revealed that the variation of the properties stems primarily from within-family evolution. Together, the results provide a thorough framework for understanding genome evolution in this important group of fungi.

Essential Nursing Actions to Reduce Inequities for Black Women in the Perinatal Period.

Perinatal nurses play a critical role in the care of, advocacy for, and research with Black women in the perinatal period. Despite awareness of inequities in the perinatal health care system that stem from racism in the United States, many nurses report feeling detached from the crisis. In this critical commentary, we provide a five-step nursing action guide to address this health disparity that is aligned with the Future of Nursing report and the American Nurses Association Code of Ethics. We recommend nursing activities in each step: understand drivers of health inequities among Black women, reflect on implicit bias, use respectful care frameworks with Black women, conduct ethical research, and advocate for change. The article includes a sharable and printable action sheet that can be used in the work environment to remind nurses of their roles in enacting change.

Ecosyndemics: The potential synergistic health impacts of highways and dams in the Amazon.

Ecosyndemics refer to disease interactions that result from environmental changes commonly caused by humans. In this paper, we push scholarship on ecosyndemics into new territory by using the ecosyndemic framework to compare two case studies-the Southern Interoceanic highway in Peru and the Belo Monte hydroelectric dam in Brazil-to assess the likelihood of socio-environmental factors interacting and leading to ill health in a syndemic fashion. Assessing these two case studies using an ecosyndemic perspective, we find that the construction of dams and highways in tropical forests create the conditions for increases in vector-borne illnesses, surges in sex work and sexually-transmitted infections, and increased psychological stress resulting from violence, delinquency, and the erosion of social cohesion. We suggest that these processes could interact synergistically to increase an individual's immune burden and a population's overall morbidity. However, we find differences in the impacts of the Interoceanic highway and the Belo Monte dam on food, water, and cultural systems, and observed that community and corporate-level actions may bolster health in the face of rapid socio-ecological change. Looking at the case studies together, a complex picture of vulnerability and resilience, risk and opportunity, complicates straight-forward predictions of ecosyndemic interactions resulting from these development projects but highlights the role that the ecosyndemic concept can play in informing health impact assessments and future research. We conclude by proposing a conceptual model of the potential interactions between psychological stress, vector-borne illnesses, and sexaully-transmitted infections and suggest that future investigations of synergistic interactions among these factors draw from the biological, social, and ecological sciences.

Knowledge, attitudes, and practices of cervical cancer prevention and pap smears in two low-income communities in Lima, Peru.

BACKGROUND: Cervical cancer is a leading cause of death among Peruvian women. Barriers at multiple levels impact effective screening and treatment, including a lack of knowledge about cervical cancer and how regular screening can reduce morbidity and mortality through earlier detection. The aim of this study is to assess knowledge, attitudes, and practices regarding cervical cancer and its prevention in the peri-urban communities of Oasis and Pampas in southern Lima, Peru that can be used to inform future campaigns about cervical cancer prevention. METHODS: A cross-sectional survey that included several open-ended questions was administered to women in Pampas and Oasis between 2015 and 2016 to evaluate the knowledge, attitudes, and practices regarding cervical cancer and Pap smears. RESULTS: In total, 224 women were interviewed. Knowledge about cervical cancer and Pap smears was high, and attitudes were predominantly positive among most participants. Most participants knew how often they should get Pap smears (89.7%), when to begin seeking screening (74.6%), knew the price of a Pap smear (61.9%), and felt Pap smears were important for their health (70.1%). About one third (29.5%) of premenopausal women reported receiving a Pap smear in the last year. However, open ended questions revealed some knowledge gaps around Pap smears, as well as some stigma associated to Human Papilloma Virus (HPV) infection. CONCLUSION: Although knowledge of cervical cancer prevention was generally high and perceptions were positive among women in peri-urban Peruvian communities, our findings revealed there is a need for education on HPV infection prevalence among sexually active individuals to reduce stigma. Future research should focus on exploring experiences with follow-up and treatment associated with abnormal Pap smears, as well as perspectives from health authorities and professionals about barriers in the early detection and treatment process for cervical cancer.

Recommended Musculoskeletal and Sports Medicine Curriculum for Internal Medicine Residency Training.

ABSTRACT: Patients present to primary care physicians with musculoskeletal complaints more often than they do for upper respiratory infections, hypertension, or diabetes. Despite this, instruction in musculoskeletal medicine for internal medicine residents represents less than 1% of their total didactic and clinical education time. We recognize the immense breadth of knowledge and skill required to train residents in the practice of internal medicine. This curriculum guideline defines a recommended training strategy, and supplies relevant resources, to improve musculoskeletal education among internal medicine residents to optimize patient care. This curriculum guideline was created by internists who are sports medicine specialists. Sports medicine physicians promote overall health and well-being while providing expertise in acute and chronic musculoskeletal conditions, as well as how disease affects exercise and using exercise as medicine for people with chronic disease.

Hepatitis C identification and treatment in rural Pennsylvania, USA.

The opioid epidemic in the United States has led to increases in hepatitis C virus (HCV) infection especially in rural communities. It is recommended that persons who inject drugs undergo screening and treatment. We initiated HCV screening and treatment within a mostly rural area of Pennsylvania by targeting medicated-assisted treatment (MAT) facilities and community events. Screening was conducted in 43 rural and 13 urban counties by a clinical team. At MAT facilities, the clinical team performed HCV screening between 4:30am and 1:00pm using the OraQuick HCV test free of charge. Participants with a positive screen were linked to treatment. In all, 3,051 screening tests were conducted among 2,995 unique participants, who were mostly white (2821, 94%) and from rural counties (2597, 87%). Participants were most frequently 25-to-34 years old (798, 27%). A total of 730 patients were HCV screen positive, 371 patients received an HCV RNA PCR test, and 272 were HCV RNA positive. Of them, 249 met with a healthcare provider, 102 initiated treatment, and 50 completed SVR testing, with 49 achieving SVR. Anti-HCV positivity was more frequent among MAT facility versus non-MAT patients (41% versus 5%) (p < .001). Non-MAT participants were more likely to begin treatment for HCV (91% [21/23] versus 30% [81/272]) and achieve SVR (71% versus 43%). In HCV screening and treatment among high-risk patients, substantial numbers of participants were lost at every point of care between screening and follow-up testing. Specific screening, treatment, and follow-up strategies for persons in rural communities may be needed.

Interim Guidance on the Preparticipation Physical Examination for Athletes During the SARS-CoV-2 Pandemic.

The American Medical Society for Sports Medicine (AMSSM) convened a writing group to address the current evidence and knowledge gaps regarding preparticipation evaluation of athletes during the SARS-CoV2 pandemic. The writing group held a series of meetings beginning in April 2020. The task force reviewed the available literature and used an iterative process and expert consensus to finalize this guidance statement that is intended to provide clinicians with a clinical framework to return athletes of all levels to training and competition during the pandemic. The statement is not intended to address treatment, infection control principles, or public health issues related to SARS-CoV2. The AMSSM task force acknowledges the clinical uncertainty, evolving public health objectives, and the limited data currently available to create this guidance statement.

Interim Guidance on the Preparticipation Physical Examination for Athletes During the SARS-CoV-2 Pandemic.

The American Medical Society for Sports Medicine (AMSSM) convened a writing group to address the current evidence and knowledge gaps regarding preparticipation evaluation of athletes during the SARS-CoV-2 pandemic. The writing group held a series of meetings beginning in April 2020. The task force reviewed the available literature and used an iterative process and expert consensus to finalize this guidance statement that is intended to provide clinicians with a clinical framework to return athletes of all levels to training and competition during the pandemic. The statement is not intended to address treatment, infection control principles, or public health issues related to SARS-CoV-2. The AMSSM task force acknowledges the clinical uncertainty, evolving public health objectives, and the limited data currently available to create this guidance statement.

Heterogeneity of Dengue Illness in Community-Based Prospective Study, Iquitos, Peru.

Measuring heterogeneity of dengue illness is necessary to define suitable endpoints in dengue vaccine and therapeutic trials and will help clarify behavioral responses to illness. To quantify heterogeneity in dengue illness, including milder cases, we developed the Dengue Illness Perceptions Response (IPR) survey, which captured detailed symptom data, including intensity, duration, and character, and change in routine activities caused by illness. During 2016-2019, we collected IPR data daily during the acute phase of illness for 79 persons with a positive reverse transcription PCR result for dengue virus RNA. Most participants had mild ambulatory disease. However, we measured substantial heterogeneity in illness experience, symptom duration, and maximum reported intensity of individual symptoms. Symptom intensity was a more valuable predicter of major activity change during dengue illness than symptom presence or absence alone. These data suggest that the IPR measures clinically useful heterogeneity in dengue illness experience and its relation to altered human behavior.

Measuring health related quality of life for dengue patients in Iquitos, Peru.

Previous studies measuring the health-related quality of life (HRQoL) of individuals with dengue focused on treatment seeking populations. However, the vast majority of global dengue cases are unlikely to be detected by health systems. Representative measurements of HRQoL should therefore include patients with disease not likely to trigger treatment-seeking behavior. This study based in Iquitos, Peru used the Quality of Wellbeing Scale-Self Administered, a survey that enquires about not only physical health, but also psychological health, self-care, mobility, and usual social activities, and rates HRQoL between 0 (death) and 1 (optimum function), to evaluate the impact of dengue on HRQoL. In order to enroll treatment and non treatment-seeking participants, three modalities of participant recruitment were used. In addition to clinic and community-based febrile surveillance, a contact-cluster methodology was also employed to identify infected individuals less likely to seek treatment. We measured changes in HRQoL and identified common areas of health impairment in 73 virologically confirmed dengue cases at 3 time points during the participant's illness; the early-acute (days 0-6 post symptom onset), late-acute (days 7-20), and convalescent illness phases (days 21 +). Participants reported HRQoL related impairments at significantly higher frequency during the early-acute versus convalescent illness phase (Fisher's exact: P<0.01). There was substantial heterogeneity in scores during each illness phase with median scores in the early-acute, late-acute and convalescent phases of 0.56 (IQR: 0.41-0.64), 0.70 (IQR: 0.57-0.94), and 1 (IQR: 0.80-1.00), respectively. In all illness phases participants recruited in clinics had on average the lowest HRQoL scores where as those recruited in the contact clusters had the highest. Only 1 individual who was recruited in the contact-clusters had no reduction in HRQoL score during their illness. These data illustrate that dengue should be considered as a disease that may have significant implications for not only physical health but also psychological health and social functioning. The impact of dengue on the HRQoL of non-treatment-seeking individuals, although lower than the impact among treatment-seeking individuals, is not necessarily trivial.

Food Choice and Dietary Intake among People with Tuberculosis in Peru: Implications for Improving Practice.

BACKGROUND: In Peru, tuberculosis (TB) is perceived as a nutritional disease. This perception, alongside factors including household food insecurity, may drive the food choices of people with TB and influence treatment outcomes. OBJECTIVES: The objective of this qualitative study was to explore drivers of food choice among adults recently diagnosed with TB. METHODS: The study was conducted between April and December 2016 in the Huaycán district of Lima, Peru. Structured questionnaires were administered to 39 adults with TB at the time of diagnosis and after 1 mo of treatment to characterize food security and socioeconomic status. At 1 mo of treatment, 24-h dietary recalls, enhanced by recipes obtained from local street vendors, were administered to examine patterns of food consumption and determine mean daily intake of macro- and micronutrients. Among a subset of 9 participants, in-depth interviews were used to explore dietary beliefs and food choices associated with TB. RESULTS: Overall, 13.2% of participants were underweight at baseline, and 10.5% were overweight. At 1 mo of treatment, the mean caloric intake was 600 kcal/d over what was needed to maintain their current weight. Most of these additional kilocalories came from carbohydrates. Patients made active efforts to improve their diets during treatment, and were both receptive to, and actively sought out, nutritional advice. However, many patients reported significant unnecessary spending on questionable commercial products, such as expensive natural remedies and nutritional supplements. CONCLUSIONS: The perceived connection between TB and diet creates both opportunities and challenges for treatment providers. Nutritional counseling provided through the national TB program should promote dietary quality through foods that are locally available, inexpensive, and aligned with cultural perceptions of health and wellness.

Micronutrient powder use in Arequipa, Peru: Barriers and enablers across multiple levels.

In Peru, nearly half of children aged 6-36 months were diagnosed with anaemia in 2017. To address this disease, the Peruvian Ministry of Health implemented a national programme in 2014, distributing free micronutrient powders (MNPs) to all children of this age. However, rates of childhood anaemia remain high. The aim of this study was to explore factors at all levels of the Social-Ecological Model that affect MNP use and adherence in Arequipa, an Andean city with childhood anaemia rates higher than the national average. We conducted in-depth interviews with 20 health personnel and 24 caregivers and 12 focus group discussions with 105 caregivers. We identified numerous barriers, including negative side effects (constipation, vomiting, and diarrhoea), poor taste of MNP, lack of familial and peer support for its use, insufficient informational resources provided by the health system, and limited human resources that constricted health personnel abilities to implement MNP programming successfully. Facilitators identified included concern about the long-term effects of anaemia, support from organizations external to the health system, well-coordinated care within the health system, and provision of resources by the Ministry of Health. We found that community or organizational and societal factors were key to limited MNP use and adherence, specifically the limited time health personnel have to address caregivers' doubts during appointments and the lack of informational resources outside of these appointments. Potential policy implications could be to increase informational resources available outside of individualized counselling by strengthening existing collaborations with community organizations, increasing media coverage, and providing group counselling.

A "Cookbook" for Vulnerability Research.

There is a growing need to facilitate the interdisciplinary study of the relationship between the environment and human health and well-being. It is increasingly recognized that vulnerability is a key construct allowing discipline-specific research questions on these topics to be meaningfully contextualized. However, there is little consensus regarding the meaning of the concept of vulnerability or how it can best be utilized in research studies. In this perspective article, we use the metaphor of a "cookbook" to review promising trends in vulnerability research and to make this body of research accessible to a multi-disciplinary audience. Specifically, we discuss a selection of "recipes" (theoretical frameworks), "ingredients" (vulnerability domains), "cooking tools" (qualitative and quantitative methods), and approaches to "meal presentation" (communication of results) drawn from vulnerability studies published in the past 15 years. Our aim is for this short "cookbook" to serve as a jumping-off point for scholars unfamiliar with the vulnerability literature and an inspiration for scholars more familiar with this topic to develop new ways to navigate the tension between locally-specific assessments of vulnerability and attempts at standardization. Our ultimate take-home message is that the specifics theories and methods used in vulnerability research are less important than attention to what we see as the 3 'T's of transparency, triangulation, and transferability, and to efforts to make vulnerability research both "place-based" and comparable.

Familial Intracranial Aneurysm in Newfoundland: Clinical and Genetic Analysis.

OBJECTIVE: Intracranial aneurysm (IA) is an expansion of the weakened arterial wall that is often asymptomatic until rupture, resulting in subarachnoid hemorrhage. Here we describe the high prevalence of familial IA in a cohort of Newfoundland ancestry. We began to investigate the genetic etiology of IA in affected family members, as the inheritance of this disease is poorly understood. METHODS: Whole exome sequencing was completed for a cohort of 12 affected individuals from two multiplex families with a strong family history of IA. A filtering strategy was implemented to identify rare, shared variants. Filtered variants were prioritized based on validation by Sanger sequencing and segregation within the families. RESULTS: In family R1352, six variants passed filtering; while in family R1256, 68 variants remained, so further filtering was pursued. Following validation by Sanger sequencing, top candidates were investigated in a set of population controls, namely, C4orf6 c.A1G (p.M1V) and SPDYE4c.C103T (p.P35S). Neither was detected in 100 Newfoundland control samples. CONCLUSION: Rare and potentially deleterious variants were identified in both families, though incomplete segregation was identified for all filtered variants. Alternate methods of variant prioritization and broader considerations regarding the interplay of genetic and environmental factors are necessary in future studies of this disease.

Prévalence d'anévrismes intracrâniens au sein de familles terre-neuviennes : une analyse clinique et génétique. Objectif : Un anévrisme intracrânien (AI) consiste en une expansion, souvent asymptomatique, d'une paroi artérielle affaiblie. La rupture qui peut s'ensuivre résultera en une hémorragie sous-arachnoïdienne. Nous voulons décrire ici la forte prévalence d'AI au sein de familles terre-neuviennes ayant des ancêtres communs. Nous avons débuté cette étude en étudiant l'étiologie génétique de l'AI chez les membres de ces familles affectés par cette déformation car l'hérédité des AI demeure encore mal comprise. Méthodes : Nous avons tout d'abord procédé au séquençage entier de l'exome d'un groupe de 12 sujets appartenant à deux familles dites « multiplexes ¼ présentant des antécédents notables d'AI. À cet égard, une stratégie de filtrage a été mise de l'avant afin d'identifier des variantes génétiques à la fois peu fréquentes et partagées. Nous avons ensuite privilégié et validé ces variantes filtrées en nous fondant sur la méthode de séquençage et de ségrégation de Sanger. Résultats : Dans la famille R1352, 6 variantes ont été sélectionnées par filtrage alors que 68 variantes l'ont été dans le cas de la famille R1256, ce qui fait que des tâches additionnelles de filtrage ont été menées. Une fois complétée notre validation par la méthode de Sanger, les meilleurs sujets ont fait l'objet d'un travail d'analyse au sein d'un groupe de témoins de la population, à savoir C4orf6 c.A1G (p. M1V) et SPDYE4c.C103T (p. P35S). À cet égard, aucune variante génétique n'a été détectée parmi 100 échantillons de témoins de Terre-Neuve. Conclusion : Bien qu'une ségrégation incomplète ait été effectuée pour toutes les variantes filtrées, des variantes génétiques peu fréquentes et potentiellement délétères ont été détectées au sein de ces deux familles. D'autres méthodes de priorisation des variantes génétiques, de même que des considérations d'ordre plus général en ce qui a trait à l'interaction entre les facteurs génétiques et les facteurs environnementaux, sont nécessaires si l'on veut étudier les AI dans le futur.

Computer-based Prompt's impact on postural variability and sit-stand desk usage behavior; a cluster randomized control trial.

Sit-to-stand workstations have been deployed in office environments to reduce sedentary behavior and improve worker's health. However, efforts to initiate and sustain long-term usage of sit-stand workstations has been a challenge, with primarily anecdotal evidence suggesting many employees cease using their sit-stand workstations once the newness diminishes. To objectively determine sit-stand workstation usage and what impact computer-based prompts would have on sit-stand desk use and sustainability, 200 office workers (118 control and 82 treatment) in two different geographic locations were continuously monitored over a 4 ½ month period, which consisted of a 6-week baseline and a 3-month experimental period. During the 3-month experimental period, computer-based prompts elicited a 229% increase in daily standing transitions which was sustained over the entire 3 months with 40% of the participants adhering to a pre-determined sit to stand schedule. These findings indicate that the use of computer-based prompts can be used to motivate employees to change their behavior regarding the use of sit-to-stand workstations.

"Knocking on Doors that Don't Open": experiences of caregivers of children living with disabilities in Iquitos and Lima, Peru.

Background: More than one billion people worldwide live with a disability. Despite advances in recognising inequalities experienced by people with disabilities, barriers to services and stigmatisation still exist. The aims of this study were to explore: (1) perceptions and experiences of services specifically available to people with disabilities and their caregivers and (2) the perception of disability. Methods: In-depth interviews were conducted with 20 caregivers of persons with a disability and 14 key informants in two cities in Peru; Lima and Iquitos. The social-ecological model was used as a framework to analyse and present data, stratifying the key barriers and opportunities at each level. Results: At the individual level, interviewees reported a lack of support at the time of diagnosis, poor coping strategies, and communicated their desire for, and willingness to participate in support groups if they were established. On the community level, education and awareness were reportedly lacking and acts of discrimination and stigmatisation were common. Participants described opportunities for community-level campaigns to increase exposure and awareness of disability rights and inclusion. A dissatisfaction with government programmes was reported, as services were not available to everyone, in part due to geographical and socio-economic barriers. Conclusions: The main findings were the lack of emotional, informational, and tangible support available to caregivers of people with disabilities, often exacerbated by lower socio-economic status; a lack of transparency of care pathways available to people with disabilities; and a lack of visibility of people with disability in both Lima and Iquitos. Implications for Rehabilitation Support groups could offer additional support to caregivers of people with disabilities in Lima, mitigating existing gaps in services for people with disabilities, and their families. Education campaigns implemented on a community level could start to curb discrimination and stigmatisation of people with disabilities in Lima and Iquitos. A national census with inclusive language and methodology specifically designed to capture the percentage of the population currently living with a disability would give a real indication of what services are needed in Peru. The provision of clear, publically available routes of attention would assist caregivers and families to access services for people with disabilities.

Exercise for Athletes With Inflammatory Arthritis.

Advances in pharmacologic management of inflammatory conditions have allowed those living with these conditions to pursue fitness activities previously difficult due to functional limitations. With that said, many patients with inflammatory arthritis are still not active enough. In this article, we review specific exercise recommendations for a number of inflammatory conditions with a focus on overall health promotion and cardiovascular disease risk reduction, discuss exercise as an adjunct to pharmacologic disease management, and review potential risks of sport participation for athletes with inflammatory arthritis conditions.