Playing it by ear: gregarious sparrows recognize and respond to isolated wingbeat sounds and predator-based cues.

The ability to detect an incoming attack provides a final opportunity for an animal to avoid predation. In birds, vision is the main sensory mode in detecting attacks, but auditory cues likely play an important role. The role of auditory cues from predators themselves remains largely unstudied. We evaluated the ability of free-living, gregarious sparrows (Passerellidae) to recognize attacks based on the non-vocal sounds made by predators or indirect auditory cues of ongoing attacks, mainly in the form of brief wingbeat sequences from predatory and non-predatory birds. Behavioral responses to playbacks were video-recorded and expressed in terms of a flock's propensity to respond, either by flushing to cover, becoming vigilant, or both. Sparrows responded equally to hawk wingbeats and those of small passerines. Both predator and non-predator wingbeat sequences induced anti-predator responses, especially when played loudly. Loud control sounds, such as hammering, induced few responses. Birds also responded to the sounds of a walking and running terrestrial predator (a dog), but reactions to the walking predator often involved birds jumping onto objects for a better view of their surroundings rather than immediate flight to cover. In an additional experiment, we examined how characteristics of wingbeat sequences (i.e., the number and cadence of hawk wingbeats) affected passerine responses. It indicated that only two consecutive hawk wingbeats, presented at a natural cadence, are necessary to elicit a strong response to a playback. Single hawk wingbeats induced only weak escape responses, as did artificially slowed cadences. Birds in general likely possess the ability to recognize non-vocal, auditory cues of incoming attacks, which may be produced by approaching threats or departing congeners.

Management of Post-traumatic Stress Disorder in Veterans and Military Service Members: A Review of Pharmacologic and Psychotherapeutic Interventions Since 2016.

PURPOSE OF REVIEW: It is vitally important that providers treating post-traumatic stress disorder continue to stay abreast of research advances in the treatment of this disorder. This article updates the reader about advances in research in PTSD treatment in the past four years as well as the evolving recommendations of clinical practice guidelines. RECENT FINDINGS: One of the most important developments is that trauma-focused therapy (TFT) has emerged as the first-line treatment for PTSD with pharmacologic options often being noted as second-line or adjunctive. The quality and quantity of research into the treatment of PTSD continue to grow; however, the pace of research into treatment options lags behind our understanding of the development, course, and prognosis of the disorder. The development of new research-based evidence in the treatment of PTSD, both pharmacologic and psychotherapeutic, is needed and likely to necessitate frequent updates and re-evaluations of clinical practice guidelines.

Cost Analyses of Prosthetic Devices: A Systematic Review.

OBJECTIVE: To synthesize extant literature on the cost-effectiveness of prosthetic interventions and explore applicability to low- and middle-income country (LMIC) settings. DATA SOURCES: A systematic literature review using subject headings including "prosthetics," "amputation," and "cost analysis" was performed with PubMed, Embase, and Web of Science search engines, yielding 1194 articles. An additional 22 articles were identified via backward citation searching for 1144 total after duplicate removal. The search was last run in May of 2019. STUDY SELECTION: Studies were included if they conducted an economic analysis of an upper or lower extremity prosthetic device. Studies were excluded if (1) full text was unavailable in English; (2) study was a systematic review or meta-analysis; or (3) study did not have a prosthetic comparison group. Using DistillerSR software, 2 authors independently conducted title and abstract screening. One author conducted full-text screening. The proportion of initially identified studies that met final inclusion criteria was 1% (12 of 1144). DATA EXTRACTION: Data were dually extracted by 2 authors and reviewed by 3 additional authors. DATA SYNTHESIS: All included studies (N=12) examined lower extremity amputations comparing advanced technology. No studies were conducted in LMICs. Comparable data between studies demonstrated (1) the cost-effectiveness of microprocessor- over nonmicroprocessor-controlled knees for transfemoral amputation in high-income settings; (2) equivocal findings regarding osseointegrated vs socket-suspended prostheses; and (3) increased cost for ICEX and modular socket systems over patellar tendon-bearing socket systems with no functional improvement. CONCLUSIONS: There are few prosthetic cost analyses in the literature. Additional analyses are needed to determine the direct and indirect costs associated with prosthetic acquisition, fitting, and maintenance; the costs of amputee rehabilitation; and long-term economic and quality-of-life benefits. Such studies may guide future prosthetic and rehabilitative care, especially in resource-austere settings where prosthetic needs are greatest.

Cost utility analysis of intramedullary nailing and skeletal traction treatment for patients with femoral shaft fractures in Malawi.

Background and purpose - In Malawi, both skeletal traction (ST) and intramedullary nailing (IMN) are used in the treatment of femoral shaft fractures, ST being the mainstay treatment. Previous studies have found that IMN has improved outcomes and is less expensive than ST. However, no cost-effectiveness analyses have yet compared IMN and ST in Malawi. We report the results of a cost-utility analysis (CUA) comparing treatment using either IMN or ST.Patients and methods - This was an economic evaluation study, where a CUA was done using a decision-tree model from the government healthcare payer and societal perspectives with an 1-year time horizon. We obtained EQ-5D-3L utility scores and probabilities from a prospective observational study assessing quality of life and function in 187 adult patients with femoral shaft fractures treated with either IMN or ST. The patients were followed up at 6 weeks, and 3, 6, and 12 months post-injury. Quality adjusted life years (QALYs) were calculated from utility scores using the area under the curve method. Direct treatment costs were obtained from a prospective micro costing study. Indirect costs included patient lost productivity, patient transportation, meals, and childcare costs associated with hospital stay and follow-up visits. Multiple sensitivity analyses assessed model uncertainty.Results - Total treatment costs were higher for ST ($1,349) compared with IMN ($1,122). QALYs were lower for ST than IMN, 0.71 (95% confidence interval [CI] 0.66-0.76) and 0.77 (CI 0.71-0.82) respectively. Based on lower cost and higher utility, IMN was the dominant strategy. IMN remained dominant in 94% of simulations. IMN would be less cost-effective than ST at a total procedure cost exceeding $880 from the payer's perspective, or $1,035 from the societal perspective.Interpretation - IMN was cost saving and more effective than ST in the treatment of adult femoral shaft fractures in Malawi, and may be an efficient use of limited healthcare resources.

Immediate weight bearing as tolerated (WBAT) correlates with a decreased length of stay post intramedullary fixation for subtrochanteric fractures: a multicenter retrospective cohort study.

BACKGROUND: Subtrochanteric femur fractures associate with a relatively high complication rate and are traditionally treated operatively with a period of limited weight bearing. Transitioning from extramedullary to intramedullary implants, there are increasing biomechanical and clinical data to support early weight bearing. This multicenter retrospective study examines the effect of postoperative weight bearing as tolerated (WBAT) for subtrochanteric femur fractures. We hypothesize that WBAT will result in a decreased length of stay (LOS) without increasing the incidence of re-operation. METHODS: This study assesses total LOS and postoperative LOS after intramedullary fixation for subtrochanteric fractures between postoperative weight bearing protocols across 6 level I trauma centers (n = 441). Analysis techniques consisted of multivariable linear regression and nonparametric comparative tests. Additional subanalyses were performed, targeting mechanism of injury (MOI), Winquist-Hansen fracture comminution, 20-year age strata, and injury severity score (ISS). RESULTS: Total LOS was shorter in WBAT protocol within the overall sample (7.4 vs 9.7 days; p < 0.01). Rates of re-operation were similar between the two groups (10.6% vs 10.5%; p = 0.99). Stratified analysis identified patients between ages 41-80, WH comminution 2-3, high MOI, and ISS between 6-15 and 21-25 to demonstrate a significant reduction in LOS as a response to WBAT. CONCLUSION: An immediate postoperative weight bearing as tolerated protocol in patients with subtrochanteric fractures reduced length of hospital stay with no significant difference in reoperation and complication rates. If no contraindication exists, immediate weight bearing as tolerated should be considered for patients with subtrochanteric femur fractures treated with statically locked intramedullary nails. LEVEL OF EVIDENCE: Therapeutic Level III.

Delays to Surgery and Coronal Malalignment Are Associated with Reoperation after Open Tibia Fractures in Tanzania.

BACKGROUND: Treatment of diaphyseal open tibia fractures often results in reoperation and impaired quality of life. Few studies, particularly in resource-limited settings, have described factors associated with outcomes after these fractures. QUESTIONS/PURPOSES: (1) Which patient demographic, perioperative, and treatment characteristics are associated with an increased risk of reoperation after treatment of open tibia fractures with intramedullary nailing or an external fixation device in Tanzania? (2) Which patient demographic, perioperative, and treatment characteristics are associated with worse 1-year quality of life after treatment of open tibia fractures with intramedullary nailing or an external fixation device in Tanzania? METHODS: A prospective study was completed in parallel to a similarly conducted RCT at a tertiary referral center in Tanzania that enrolled adult patients with diaphyseal open tibia fractures from December 2015 to March 2017. Patients were treated with either a statically locked intramedullary nail or external fixator and examined at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year postoperatively. The primary outcome, reoperation, was any deep infection or nonunion treated with a secondary intervention. The secondary outcome was the 1-year EuroQol-5D (EQ-5D) index score. There were 394 patients screened and ultimately, 267 patients enrolled in the study (240 from the primary RCT and 27 followed for the purposes of this study). Of these, 90% (240 of 267) completed 1-year follow-up and were included in the final analysis. This group comprised 110 patients who underwent IMN and 130 who had external fixation; follow-up was similar between study groups. Patients were an average of 33 years old and were primarily males who sustained road traffic injuries resulting in AO/Orthopaedic Trauma Association (OTA) classification type A or B fractures. There were 51 reoperations. For the purposes of analysis, all patients were pooled to identify all other factors, in addition to treatment type, associated with increased risk of reoperation and 1-year quality of life. An exploratory bivariable analysis identifying various factors associated with reoperation risk and EQ-5D was subsequently included in a multivariate modeling procedure to control for confounding of effect on our primary outcome. Multivariable modeling was performed using standard hierarchical modeling simplification procedures with log-likelihood ratios. Alpha levels were set to 0.05. RESULTS: After controlling for potentially confounding variables such as gender, smoking status, mechanism of injury, and treatment type, the following factors were independently associated with reoperation: Time from hospital presentation to surgery more than 24 hours (odds ratio 7.7 [95% confidence interval 2.1 to 27.8; p = 0.002), AO/OTA fracture classification Type 42C fracture (OR 4.2 [95% CI 1.2 to 14.0]; p = 0.02), OTA-Open Fracture Classification muscle loss (OR 7.5 [95% CI 1.3 to 42.2]; p = 0.02), and varus coronal angle on an immediate postoperative AP radiograph (OR 4.8 [95% CI 1.2 to 14.0]; p = 0.002). After again controlling for confounding variables such as gender, smoking status, mechanism of injury, and treatment type factors independently associated with worse 1-year EQ-5D scores included: Wound length ≥ 10 cm (ß = [change in EQ-5D score] -0.081 [95% CI -0.139 to -0.023]; p = 0.006), OTA-Open Fracture Classification muscle loss (ß = -0.133 [95% CI -0.215 to -0.051]; p = 0.002), and OTA-Open Fracture Classification bone loss (ß = -0.111 [95% CI -0.208 to -0.013]; p = 0.03). We observed a modest, but independent association between reoperation and worse 1-year EQ-5D scores (ß = -0.113 [95% CI -0.150 to -0.077]; p < 0.001). CONCLUSIONS: We found two potentially modifiable factors associated with the risk of reoperation: reducing time to surgical treatment and avoiding varus coronal angulation during definitive stabilization. Hospitals may be able to minimize time to surgery, and thus, reoperation, by increasing the number of available operative personnel and space and emphasizing the importance of open tibia fractures as an injury requiring emergent orthopaedic management. Given the lack of fluoroscopy in the study setting and similar settings, surgeons should emphasize appropriate fracture alignment, even into slight valgus, to avoid varus angulation and subsequent reoperation risk. LEVEL OF EVIDENCE: Level II, therapeutic study.

Practice Patterns for Management of Pediatric Femur Fractures in Low- and Middle-Income Countries.

BACKGROUND: Femoral shaft fractures in children are common in low and middle income countries. In high-income countries, patient age, fracture pattern, associated injuries, child/family socioeconomic status, and surgeon preference dictate fracture management. There is limited literature on treatment patterns for pediatric femur fractures in resource-limited settings. This study surveys surgeons from low (LIC), lower-middle (LMIC), and upper-middle income (UMIC) countries regarding treatment patterns for pediatric femur fractures. METHODS: Surgeons completed an electronic survey reporting surgeon demographics and treatment preference for pediatric femur fractures. Treatment preferences and indications for treatment were separated into 4 groups: infant (0 to 6 mo); toddler (7 mo to 4 y); child (5 to 12 y); adolescent (12 to 17 y). The survey was available in English, Spanish, and French. Analysis was completed with t test and χ test for continuous and categorical variables, respectively, and weighted Pearson correlation (P<0.05). RESULTS: Survey respondents consisted of 413 surgeons from 83 countries (20 LIC, 33 LMIC, 30 UMIC). The majority of respondents were fellowship trained (83%) most commonly in pediatrics (26%) and trauma (43%). Most treated >10 pediatric femur fractures per year (68%). Respondents reported treating infant femur fractures nonoperatively using Pavlik harness (19%), spica cast (60%), or traction with delayed spica cast (14%). Decreasing socioeconomic status was associated with higher nonoperative treatment rate in toddlers, children, and adolescents. Respondents commonly utilize bed rest and traction for child femur fractures in LICs (63%) and LMICs (65%) compared with UMICs (35%) (UMIC vs. LMIC P<0.001; UMIC vs. LIC P<0.001). Surgeries in children more commonly involve open reduction with internal fixation (UMIC 19%, LMIC 33%, LIC 40%; P<0.05 between UMIC-LMIC and UMIC-LIC). CONCLUSION: This is one of the largest surveys describing treatment patterns for pediatric femur fractures in low and middle income countries. Differences are evident including lower operative treatment rate in younger children and lower intramedullary fixation rates in older children. Future studies should investigate the value of treatment options in resource-limited settings. LEVEL OF EVIDENCE: Level II-prospective comparative study.

Outcome at 1 year in patients with femoral shaft fractures treated with intramedullary nailing or skeletal traction in a low-income country: a prospective observational study of 187 patients in Malawi.

Background and purpose - Intramedullary nailing (IMN) is underutilized in low-income countries (LICs) where skeletal traction (ST) remains the standard of care for femoral shaft fractures. This prospective study compared patient-reported quality of life and functional status after femoral shaft fractures treated with IMN or ST in Malawi. Patients and methods - Adult patients with femoral shaft fractures managed by IMN or ST were enrolled prospectively from 6 hospitals. Quality of life and functional status were assessed using EQ-5D-3L, and the Short Musculoskeletal Function Assessment (SMFA) respectively. Patients were followed up at 6 weeks, 3, 6, and 12 months post-injury. Results - Of 248 patients enrolled (85 IMN, 163 ST), 187 (75%) completed 1-year follow-up (55 IMN, 132 ST). 1 of 55 IMN cases had nonunion compared with 40 of 132 ST cases that failed treatment and converted to IMN (p < 0.001). Quality of life and SMFA Functional Index Scores were better for IMN than ST at 6 weeks, 3 and 6 months, but not at 1 year. At 6 months, 24 of 51 patients in the ST group had returned to work, compared with 26 of 37 in the IMN group (p = 0.02). Interpretation - Treatment with IMN improved early quality of life and function and allowed patients to return to work earlier compared with treatment with ST. Approximately one-third of patients treated with ST failed treatment and were converted to IMN.

The Cost of Intramedullary Nailing Versus Skeletal Traction for Treatment of Femoral Shaft Fractures in Malawi: A Prospective Economic Analysis.

BACKGROUND: In many low- and middle-income countries, non-surgical management of femoral shaft fractures using skeletal traction is common because intramedullary (IM) nailing is perceived to be expensive. This study assessed the cost of IM nailing and skeletal traction for treatment of femoral shaft fractures in Malawi. METHODS: We used micro-costing methods to quantify the costs associated with IM nailing and skeletal traction. Adult patients who sustained an isolated closed femur shaft fracture and managed at Queen Elizabeth Central Hospital in Malawi were followed from admission to discharge. Resource utilization and time data were collected through direct observation. Costs were quantified for procedures and ward personnel, medications, investigations, surgical implants, disposable supplies, procedures instruments and overhead. RESULTS: We followed 38 nailing and 27 traction patients admitted between April 2016 and November 2017. Nailing patient's average length of stay (LOS) was 36.35 days (SD 21.19), compared to 61 (SD 18.16) for traction (p = 0.0003). The total cost per patient was $596.97 ($168.81) for nailing and $678.02 (SD $144.25) for traction (p = 0.02). Major cost drivers were ward personnel and overhead; both are directly proportional to LOS. Converting patients from traction to nailing is cost-saving up to day 23 post-admission. CONCLUSION: Savings from IM nailing as compared with skeletal traction were achieved by shortened LOS. Although this study did not assess the effectiveness of either intervention, the literature suggests that traction carries a higher rate of complications than nailing. Investment in IM nailing capacity may yield substantial net savings to health systems, as well as improved clinical outcomes.

The extent of pediatric orthopaedic research in low- and middle-income countries and the impact of academic collaboration on research quality: a scoping review.

INTRODUCTION: This review aims to (1) assess the breadth of pediatric orthopaedic research in low- and middle-income countries (LMICs) and (2) determine the impact of academic collaboration (an LMIC and a non-LMIC investigator) in published LMIC research. METHODS: Pediatric orthopaedic clinical studies conducted in LMICs from 2004 to 2014 were extracted from Embase, Cochrane, and Pubmed databases. Of 22,714 searched studies, 129 met inclusion criteria. RESULTS: 85% generated low-quality evidence (level IV or lower). 21% were collaborative, and these were more likely than non-collaborative papers to generate level III evidence or higher (25% vs 13%, p = 0.141). DISCUSSION: Pediatric orthopaedic research produced by LMICs rarely achieves level I-III evidence, but collaborative studies are associated with higher levels of evidence. LEVEL OF EVIDENCE: N/A.

Predictors of Linear and Multidirectional Acceleration in Elite Soccer Players.

Jonathan, N, Russell, M, Shearer, D, Cook, CJ, and Kilduff, LP. Predictors of linear and multidirectional acceleration in elite soccer players. J Strength Cond Res 33(2): 514-522, 2019-Linear and multidirectional acceleration underpins success in professional soccer match play. However, the physical qualities that determine these performance indicators are poorly understood in elite players. English Premier League players (n = 26) performed isometric midthigh pulls (IMTPs), bilateral and unilateral drop jumps (from 40 and 20 cm, respectively), bilateral and unilateral countermovement jumps (CMJs), and assessments of linear (5, 10, and 20 m) and multidirectional (left and right preplanned and reactive) acceleration. Regression analyses highlighted that 21% of variance in 5-m sprint time (1.02 ± 0.07 seconds) was explained by relative peak power output (PPO) in bilateral CMJ (54.5 ± 5.3 W·kg). A 5.4 W·kg increase in CMJ predicted a 0.03-second decrease in 5-m sprint time (P = 0.02). For 10-m sprint time (1.72 ± 0.09 seconds), 44% of variance was explained by isometric relative peak force ([PF]; 30.4 ± 4.9 N·kg) and bilateral relative CMJ PPO (54.5 ± 5.3 W·kg). A 5.4 W·kg increase in CMJ predicted reduced 10-m sprint times by 0.04 seconds (P = 0.01). For 20-m sprint time (2.94 ± 0.11 seconds), 55% of the total variance was explained by isometric relative PF (30.4 ± 4.9 N·kg) and relative CMJ PPO (54.5 ± 5.3 W·kg). Increases of 5.4 W·kg in bilateral CMJ predicted an improvement of 20-m sprint time by 0.06 seconds (P = 0.002). Contributions were insignificant (P > 0.05) for preplanned and reactive multidirectional acceleration. Relativized indices, especially those related to force production during CMJ and IMTP tests, likely underpin linear but not multidirectional acceleration performance in professional soccer players. When linear acceleration is a training focus, practitioners should seek to monitor CMJ and IMTP test performance.

Management of Post-Traumatic Nightmares: a Review of Pharmacologic and Nonpharmacologic Treatments Since 2013.

PURPOSE OF REVIEW: Post-traumatic nightmares (PTN) are a common and enduring problem for individuals with post-traumatic stress disorder (PTSD) and other clinical presentations. PTN cause significant distress, are associated with large costs, and are an independent risk factor for suicide. Pharmacological and non-pharmacological treatment options for PTN exist. A previous review in this journal demonstrated that Prazosin, an alpha blocker, was a preferred pharmacological treatment for PTN and imagery rescripting therapy (IRT) was a preferred non-pharmacological treatment. Since that time, new and important research findings create the need for an updated review. RECENT FINDINGS: Based on the results of a recent study in the New England Journal of Medicine, Prazosin has been downgraded by both the American Academy of Sleep Medicine (AASM) and the Veterans Health Administration/Department of Defense (VA/DoD) for PTN. In Canada, Nabilone, a synthetic cannabinoid, appears to be promising. Few recent studies have been published on non-pharmacological interventions for PTN; however, recent data is available with regard to using IRT on an inpatient setting, with German combat veterans, and through the use of virtual technology. Recent evidence supports the use of exposure, relaxation, and rescripting therapy (ERRT) with children and individuals with comorbid bipolar disorder and PTN. Prazosin is no longer considered a first-line pharmacological intervention for PTN by AASM and VA/DoD. However, in the absence of a suitable alternative, it will likely remain the preferred option of prescribers. IRT and ERRT remain preferred non-pharmacological treatments of PTN. Combining cognitive behavior therapy for insomnia (CBT-I) with IRT or ERRT may lead to improved outcomes.

The Cost of Intramedullary Nailing for Femoral Shaft Fractures in Dar es Salaam, Tanzania.

BACKGROUND: Femoral shaft fractures are one of the most common injuries seen by surgeons in low- and middle-income countries (LMICs). Surgical repair in LMICs is often dismissed as not being cost-effective or unsafe, though little evidence exists to support this notion. Therefore, the goal of this study is to determine the cost of intramedullary nailing of femoral shaft fractures in Tanzania. METHODS: We used micro-costing methods to estimate the fixed and variable costs of intramedullary nailing of femoral shaft fractures. Variable costs assessed included medical personnel costs, ward personnel costs, implants, medications, and single-use supplies. Fixed costs included costs for surgical instruments and administrative and ancillary staff. RESULTS: 46 adult femoral shaft fracture patients admitted to Muhimbili Orthopaedic Institute between June and September 2014 were enrolled and treated with intramedullary fixation. The total cost per patient was $530.87 (SD $129.99). The mean variable cost per patient was $419.87 (SD $129.99), the largest portion coming from ward personnel $144.47 (SD $123.30), followed by implant $134.10 (SD $15.00) medical personnel $106.86 (SD $28.18), and medications/supplies $30.05 (SD $12.28). The mean fixed cost per patient was $111.00, consisting of support staff, $103.50, and surgical instruments, $7.50. CONCLUSIONS: Our study provides empirical information on the variable and fixed costs of intramedullary nailing of femoral shaft fractures in LMICs. Importantly, the lack of surgical capacity was the primary driver of the largest cost for this procedure, preoperative ward personnel time. Our results provide the cost data for a formal cost-effectiveness analysis on this intervention.

Abbreviated Resonant Frequency Training to Augment Heart Rate Variability and Enhance On-Demand Emotional Regulation in Elite Sport Support Staff.

Support and management staff in elite sport experience work-related stress and emotional disturbance to a similar extent as athletes (Fletcher and Wagstaff 2009). The resonant frequency breathing technique (Lehrer et al. 2000) can inhibit autonomic changes associated with stressful situations or events and as such provides a potential emotional regulation tool. The present study utilised five practitioner-led heart rate variability (HRV) biofeedback sessions and home practice via mobile applications to train support and management staff (n = 9) in resonant frequency breathing techniques. Although baseline HRV did not change from pre to post training, participants increased total HRV (i.e., SDNN; p = .006), parasympathetic HRV (i.e., RMSSD; p = .028) and HRV reflective of baroreflex function (i.e., low frequency power; p = .018) while accurately performing resonant frequency breathing without a breath pacer. Post-intervention questionnaire data revealed an increase (p = .032) in habitual use of somatic strategies for emotional regulation, and social validation data suggested that the technique enhanced emotional regulation at home, work and during international competition. HRV biofeedback and the resonant frequency technique provided an on-demand emotional regulation technique for elite sport support and management staff.

The use of traction for treating femoral shaft fractures in low- and middle-income countries: a systematic review.

PURPOSE: The use of traction for treatment of femoral shaft fractures remains common in low- and middle-income countries (LMICs). The objective of this study is to systematically review the literature on outcomes of traction as definitive treatment for adult femoral shaft fractures in LMICs. METHODS: Using the recommended PRISMA methods for systematic reviews, MEDLINE, EMBASE, LILACS, and AJOL were searched for relevant publications. Results were limited to studies occurring in LMICs as defined by the World Bank. Data on time spent in traction (TT), length of stay (LOS), time to partial weight bearing (PWB), complication incidences, and a total complication incidence were recorded. RESULTS: Of the 693 initial results, nine were eligible for analysis giving a total of 455 unique patients with a mean age of 32.9 years (range: 0 to 96). The average time spent in traction was 52.8 days (range: 19.8 to 122.5), the average length of stay was 55.4 days (range: 45 to 140), and the average time to partial weight bearing was 52.2 days (range: 42 to 60 days). There were a total of 91 malunions, 25 un-united fractures, 60 infections, 45 other complications, giving a total of 221 complications in 455 patients. CONCLUSIONS: The use of traction in treating femoral shaft fractures is associated with a high incidence of complications and prolonged course of treatment. Although operative stabilization may be a better alternative, comparative studies are needed to assess whether this can be achieved in a safe and cost-effective manner for widespread application in LMICs.

Short-term complications have more effect on cost-effectiveness of THA than implant longevity.

BACKGROUND: Outcomes research in THA has focused largely on long-term implant survivorship as a primary outcome and emphasized the development of new implant technologies. In contrast, strategies to improve short-term outcomes, such as the frequencies of periprosthetic joint infections and unplanned readmissions, have received less attention. QUESTIONS/PURPOSES: We asked whether reductions in periprosthetic joint infections and early readmissions would have greater influence on the net monetary benefit (a summation of lifetime cost and quality of life) for THA compared with equivalent reductions in aseptic loosening. METHODS: A Markov model was created using decision-analysis software with six health states and death to represent seven major potential outcomes of THA. We compared the effect of a 10% reduction in each of the following outcomes: (1) periprosthetic joint infection, (2) hospital readmission, and (3) aseptic loosening. Procedure costs (not charges) were derived from our hospital cost-accounting system. Probabilities were derived primarily from the Australian Orthopaedic Association National Joint Replacement Registry, and utilities were estimated from a previous study at our institution using the time trade-off method. The primary outcome of the study is the net monetary benefit, which combines the reductions in cost and improvement in health-related quality of life in a single metric. Quality of life is expressed in quality-adjusted life years (QALYs), which are calculated by multiplying the utility of a health state (ranging from 0 to 1) by the duration of time in the health state. The cost and QALYs are reported separately as secondary outcomes. One-way and multivariate sensitivity analyses were performed including a probabilistic sensitivity analysis to account for uncertainty in model inputs. RESULTS: The net monetary benefit for a 10% reduction in periprosthetic joint infections was USD 278 (95% CI, USD 239-295) per index procedure compared with USD 174 (95% CI, USD 150-185) and USD 113 (95% CI, USD 94-129) for reductions in aseptic loosening and early readmission, respectively. Compared with the base case, reductions in cost associated with a 10% reduction in periprosthetic joint infections, early readmissions, and aseptic loosening were USD 98, USD 93, and USD 75 per index procedure, respectively. The increase in QALYs for an equivalent reduction in periprosthetic joint infections, aseptic loosening, and early readmissions were 0.0036, 0.002, and 0.0004 QALYs, respectively. Results were most sensitive to age, baseline rate of readmission, periprosthetic joint infection, aseptic loosening, and the costs of readmission and revision THA. CONCLUSIONS: Strategies to reduce periprosthetic joint infections may have a greater effect on the cost and long-term effectiveness of THA than further enhancements in implant longevity. Reductions in the rate of readmission resulted in greater reductions in cost but not quality-of-life, and therefore had smaller effect on the net monetary benefit compared with aseptic loosening. Surgeons preferentially should engage in strategies focusing on periprosthetic joint infections to improve the value of THA care. LEVEL OF EVIDENCE: Level II, economic and decision analysis.

Between-Match Variability of Peak Power Output and Creatine Kinase Responses to Soccer Match-Play.

Post-match assessments of peak power output (PPO) during countermovement jumps and creatine kinase (CK) concentrations are common markers of recovery status in soccer players. Yet, the impact of soccer match-play on recovery in the 48 hours after competition is unclear, and the between-match variability of these responses has not been examined. Fourteen reserve team players from an English Premier League club were examined over 1-4 matches per player. Creatine kinase and PPO were measured before, 24, and 48 hours after each match. Data were analyzed with within-subjects linear mixed models. Compared with the prematch baseline, PPO was 237 ± 170 W and 98 ± 168 W lower at 24 and 48 hours, respectively (p ≤ 0.005) and CK was elevated (24 hours: 334.8 ± 107.2 µ·L(-1), 48 hours: 156.9 ± 121.0 µ·L(-1); both p ≤ 0.001) after match-play. These responses were consistent across the different matches and playing positions (p > 0.05). Within-subject correlations between PPO and CK were significant (r = -0.558; p ≤ 0.005). The between-match variability of PPO was 10.9, 11.0, and 9.9%, respectively at baseline, 24 and 48 hours, whereas for CK, the variability was 41.7, 30.0, and 34.3%, respectively. These findings highlight that more than 48 hours are needed to restore metabolic and performance perturbations after soccer match-play, and that CK demonstrates greater between-match variability than PPO. Such information is likely to be of interest to those responsible for the design of training schedules in the days after a match and sports scientists whose responsibilities include the monitoring of recovery status in soccer players.

Detection of borreliae in archived sera from patients with clinically suspect Lyme disease.

The diagnoses of Lyme disease based on clinical manifestations, serological findings and detection of infectious agents often contradict each other. We tested 52 blind-coded serum samples, including 20 pre-treatment and 12 post-treatment sera from clinically suspect Lyme disease patients, for the presence of residual Lyme disease infectious agents, using nested PCR amplification of a signature segment of the borrelial 16S ribosomal RNA gene for detection and direct DNA sequencing of the PCR amplicon for molecular validation. These archived sera were split from the samples drawn for the 2-tier serology tests performed by a CDC-approved laboratory, and are used as reference materials for evaluating new diagnostic reagents. Of the 12 post-treatment serum samples, we found DNA evidence of a novel borrelia of uncertain significance in one, which was also positive for the 2-tier serology test. The rest of the post-treatment sera and all 20 control sera were PCR-negative. Of the 20 pre-treatment sera from clinically suspect early Lyme disease patients, we found Borrelia miyamotoi in one which was 2-tier serology-negative, and a Borrelia burgdorferi in two-one negative and one positive for 2-tier serology. We conclude that a sensitive and reliable DNA-based test is needed to support the diagnosis of Lyme disease and Lyme disease-like borreliosis.

Neuromuscular function, hormonal, and mood responses to a professional rugby union match.

We examined the recovery time-course of neuromuscular function (NMF), the testosterone and cortisol hormonal milieu, and mood for 60 hours after a competitive match in professional rugby union players (n = 14). Thirty-six hours prematch (19:30 hours kick-off), baseline saliva samples (testosterone, cortisol, and testosterone to cortisol [T/C] ratio), countermovement jump performances (peak power output [PPO]), and mood disruption (Brief Assessment of Mood Questionnaire) were collected and was repeated at 12, 36, and 60 hours postmatch. Peak power output decreased below baseline at 12 hours (baseline 6,100 ± 565 W vs. 12 h 5,680 ± 589 W; p = 0.004) and 36 hours (5,761 ± 639 W; p < 0.001) but had recovered at 60 hours (5,950 ± 505 W; p = 0.151). Cortisol concentrations increased from baseline at 12 hours (baseline 0.40 ± 0.09 µg·dl-1 vs. 12 h 0.60 ± 0.20 µg·dl-1; p = 0.004) and 36 hours (0.60 ± 0.20 µg·dl-1; p = 0.027) but were similar at 60 hours postmatch. Testosterone concentrations decreased from baseline at 12 hours (baseline 214 ± 84 pg·ml-1 vs. 12 h 151 ± 56 pg·ml-1; p = 0.023) and 36 hours (173 ± 71 pg·ml-1; p = 0.016) but were similar at 60 hours postmatch. The T/C ratio decreased from baseline at 12 hours (baseline 551 ± 219 vs. 12 h 266 ± 123; p = 0.001) and 36 hours (310 ± 148; p = 0.027) before returning to baseline at 60 hours postmatch. Mood disturbance increased at 12 hours (p = 0.031) before returning to baseline at 36 and 60 hours postmatch. There were no relationships between changes in PPO, testosterone, cortisol, T/C ratio, and mood. In conclusion, postmatch changes in NMF, salivary hormones, and mood disturbance were identified in professional rugby union players. Players and coaches can expect reduced NMF and hormonal disruption for 36 hours before recovering at 60 hours postmatch, with mood recovered by 36 hours postmatch. Knowledge of these recovery time-courses may prove useful for player training program design and postmatch recovery strategies.

Observation interventions as a means to manipulate collective efficacy in groups.

The purpose of this multistudy investigation was to examine observation as an intervention for the manipulation of individual collective efficacy beliefs. Study 1 compared the effects of positive, neutral, and negative video footage of practice trials from an obstacle course task on collective efficacy beliefs in assigned groups. The content of the observation intervention (i.e., positive, neutral, and negative video footage) significantly influenced the direction of change in collective efficacy (p < .05). Study 2 assessed the influence of content familiarity (own team/sport vs. unfamiliar team/sport) on individual collective efficacy perceptions when observing positive footage of competitive basketball performance. Collective efficacy significantly increased for both the familiar and unfamiliar conditions postintervention, with the largest increase for the familiar condition (p < .05). The studies support the use of observation as an intervention to enhance individual perceptions of collective efficacy in group-based activities. The findings suggest that observations of any group displaying positive group characteristics are likely to increase collective efficacy beliefs; however, observation of one's own team leads to the greatest increases.