Conflict Of Interest Statement Research Articles

Calcaneal ultrasound attenuation as a predictor of bone density: Does the region of interest or loading influence the repeatability of measurement?

Introduction: It is well documented that sporting activities are important to increase bone mass. Depending on the quality and type of sport the amount of bone increment will vary. The attenuation of ultrasound as it passes through the calcaneal bone provides quantitative information about the density and structural properties of bone and is a clinically useful predictor of osteoporotic fracture risk in adults. Current ultrasound systems, however, assess different regions of interest (ROI) of the calcaneus, yield different attenuation values, involve different levels of lower limb loading and are likely prone to different levels of error. This study evaluated the repeatability of measures of ultrasound attenuation at three calcaneal ROI under varying levels of load. Methods: A custom-built transmission-mode ultrasound system was used to measure ultrasound attenuation in the calcaneus of 20 healthy participants (mean (±SD) age, 41.8 ± 19.6 years; height, 1.70 ± 0.17 m; and weight, 71.3 ± 23.3 kg). Repeated measurements were performed at three ROI (BW, JA, FG) and under four loading conditions (non-weightbearing, semi-weightbearing, bipedal stance, unipedal stance). Agreement between measures was evaluated using the Standard Error of Measurement (SEM) and limits of agreement (LA). Potential differences in attenuation between ROI, loading and measurement occasions were assessed using repeated measure analysis of variance ( 0.05). Results: Ultrasound attenuation ranged from 58.0±32.0 to 77.2 ± 27.6 dB/MHz across all conditions. There was a statistically significant difference between all ROI (F = 11.7, P = <0.001), which was moderated by loading (F = 2.4, P = 0.03).The narrowest LA for repeated measures of attenuation ranged between 25.7 dB/MHz and 11.6 dB/MHz across all sites. The SEM for attenuation was approximately 10 dB/MHz for both the FG and JA ROI during non-weightbearing and tended to reduce to approximately 5 dB/MHz with full weightbearing. Discussion: ROI and calcaneal loading are important considerations for measures of ultrasound attenuation at the calcaneus. Although measures of ultrasound attenuation are dependent on the ROI, lower limb loading tended to lower attenuation and improve the repeatability of measurements across sites. Given that the LA were 1.7 times smaller during unipedal stance than in non-weightbearing, calcaneal loading may be a useful method to improve the minimal detectable difference of the measurement. Conflict of interest statement: The authors declare no conflicts of interest.

Perceptions of performance determinants and evidence-based practice in track cycling: a survey of coaches, athletes, and practitioners

Introduction: Track cyclists, at an elite level, must have highly developed physical, mental, tactical, and technical qualities to enable competitive performance. There is limited existing literature specifically within track cycling to understand and improve performance. So, how track cyclists, their coaches, and the various practitioners they work with develop each of those components of performance is of great interest. A major limitation of sport science literature is that published research does not always fit the needs or resources of those translating it to practice. It is imperative researchers clarify what areas of performance those within the sport value most (or least), and what issues are currently existing that prevent research findings being implemented in practice. The purpose of this research was to understand how those within track cycling: acquire and develop knowledge and training practices; value various areas of performance; and, implement research in practice. Methods: An online survey of track cycling coaches, athletes, and practitioners was conducted using REDCap. The survey included questions across five topics: demographics, research area importance, knowledge acquisition and application, research relevance, and research direction. A sample of 257 respondents was sought to achieve a 5% error rate with 90% CI. Results: Preliminary findings (n = 150; 48 coaches, 60 athletes) show the majority of respondents developed methods by ‘observing the sport or others competing/working in it’ (86%), and ‘own participation’ (80%). The primary reason for using a practice was prior experience (84%), while individuals were least likely to use a practice if it resulted in small/marginal gains with potentially negative outcomes (27%). Areas of greatest perceived importance were Aerodynamics, Nutrition, and Tactics (98% agreed or strongly agreed). Tactics (40%) and Mental Skills (36%) were areas where evidence was perceived to be lacking, while aerodynamics (80%) was the area most new ideas are contributed. Primary barriers to implementing research into practice were athlete buy-in (78%), cost (72%), and time (70%). Discussion: Preliminary data show a large reliance on non-scientific dimensions of the evidence-based practice model. Furthermore, the vast majority of respondents reported multiple barriers that have affected implementation of research in practice. These data provide direction for researchers on specific areas of performance to focus on, as well as a number of practicality issues that must be addressed to allow easier implementation. Conflict of interest statement: The authors declare no conflicts of interest with relevance to the submitted abstract.

The influence of GLA:D® on physical activity in people with knee osteoarthritis: A qualitative exploration

Introduction: Knee osteoarthritis impacts 250 million people worldwide. Symptoms (pain/stiffness) are associated with impaired quality of life and activity participation, and reduced physical activity. Exercise-therapy and education programs such as Good Life with osteoArthritis: Denmark (GLA:D®) are associated with improved pain, function, and quality of life. Yet, their influence on physical activity is less well known. This qualitative study aims to explore the influence of GLA:D® on (i) physical activity participation; (ii) perceived capability and readiness to increase physical activity; and (iii) barriers and facilitators for physical activity participation in people with knee osteoarthritis. Methods: This qualitative study was conducted with La Trobe Human Ethics approval (#HEC18500). Semi-structured interviews were conducted with people with knee osteoarthritis following completion of GLA:D®. Guided by the Theoretical Domains Framework, Interview questions were developed by physiotherapy and psychology researchers. Interviews were audio recorded and transcribed verbatim. Data categories were developed using inductive thematic analysis by one researcher and refined with the assistance of two experienced qualitative researchers. Results: Nineteen people who completed GLA:D® (12 female, 7 male) were interviewed. Descriptive analysis revealed four overarching themes. Theme-1: ‘Beliefs about physical activity and exercise-therapy’ which included fear of knee pain and damage with exercise; and varying participation and knowledge/beliefs regarding safety and benefits of exercise and physical activity. Theme-2: ‘Influences on knowledge/beliefs about physical activity and exercise-therapy’ which included varied experiences with health professionals providing education; and online information emphasising surgery/pharmacology and was often confusing. Theme-3: ‘Reported changes in prescribed exercise-therapy and physical activity following GLA:D®’ which included varied physical activity and exercise-therapy engagement. Theme-4: ‘Barriers and facilitators of physical activity’ which included persistent pain, lack of opportunity, lack of motivation and comorbidities; change in knowledge/beliefs, increased confidence, varied motivation, and technology and other supports. Discussion: GLA:D® may address some existing barriers to physical activity in people with knee osteoarthritis including misinformed beliefs about the benefits and harms, and confidence to engage in, occupational and recreational exercise. Varying motivation to change, and actual change, following GLA:D® suggests that additional targeted behavioural interventions beyond exercise-therapy may be required to increase physical activity and exercise participation in people with knee osteoarthritis. Conflict of interest statement: Authors acknowledge that we have no conflicts of interest relevant to the submission of this abstract.

Associations between patient-reported scores, strength and physical performance tests following shoulder stabilisation surgery

Introduction and Aims: Shoulder stabilisation surgery results in substantial time loss from participation in sport. Following surgery, most athletes desire to return to pre-injury sporting activity at their pre-injury level. However, high rates of re-injury have been reported and strength and functional performance tests may provide valuable insight into an athlete’s upper body function and readiness to return to sport following stabilisation surgery. The aim of this research was to investigate and compare (to the unaffected limb) post-operative measures of strength and performance, in patients after stabilisation surgery for shoulder instability. Methods: We evaluated a pilot group of 17 athletic males at 4 to 6 months following shoulder stabilisation surgery. Peak isometric external and internal rotation force using a handheld dynamometer was assessed, together with the Athletic Shoulder (ASH) test involving three long-lever isometric tests in an I, Y and T position on a force plate. Limb symmetry indices (LSIs) were calculated for the operated limb, as a percentage of the non-operated limb for rotator strength, as well as the peak force and rate of force development (RFD) over 100ms for each of the individual ASH tests. Western Ontario Shoulder Instability (WOSI) and Shoulder Instability Return to Sport after Injury (SIRSI) questionnaires were also assessed. Correlation coefficients were undertaken to assess the relationship between rotator strength, performance tests and patient-reported outcomes. Results: Only 35%, 59%, and 77% patients demonstrated an LSI >90% for peak force in the I, Y and T test positions, respectively, while only 47%, 35%, and 53% patients demonstrated an LSI >90% for RFD in these same positions. No associations were observed between patient-reported scores and isometric internal and external rotator strength (p>0.05). Moderate, negative associations were observed for WOSI scores and LSIs of peak force in the I test (r = -0.601; p = 0.018) and Y-test (r = -0.611; p = 0.016), positions of the ASH test, as well as the LSI in RFD in the I position (r = -0.517; p = 0.049). No associations were observed between patient-reported scores and isometric internal and external rotator strength (p>0.05). Discussion: In this early pilot trial of athletes, long-lever isometric tests, for both peak force and RFD, appeared to better relate to self-reported function and quality of life than isometric strength measures using an HHD. Future research investigating performance-related factors, and their association with re-injury and return to sport, are required. Conflict of interest statement: My co-authors and I acknowledge that we have no conflict of interest of relevance to the submission of this abstract.

Physical literacy & early childhood executive function and language development: Active Early Learning randomised controlled trial

Background: Executive function involves a number of cognitive processes that are integral to the self-regulation of behaviour and developing social and cognitive competence in young children. Physical activity is increasingly recognised as an important determinant of cognitive functioning among older populations but less is known about these relationships in early childhood. In younger populations, it has been suggested that interventions aiming to increase physical activity should focus on children’s physical literacy. Physical literacy can be defined as developing capabilities in the physical, psychological, cognitive and social domains that facilitate and promote an active lifestyle across the life course. The contribution of physical literacy programs to the healthy development of language and executive function during early childhood is yet to be fully investigated. In this randomised controlled trial, we examined the effect of a physical literacy curriculum, delivered in an early learning centre setting on child executive function and language development. Methods: 321 children aged 3-5 years from 16 early learning centres were randomly assigned to the intervention (8 centres; n=169 children) or control group (7 centres, n=152 children). The intervention group received 20 weeks of the physical literacy curriculum, while the control group received usual practice care. Executive function (inhibition [Go/NoGo]; visual spatial working memory [Mr Ant]; shifting [Card Sort]) and expressive vocabulary was assessed using the Early Years Tool Box. Linear mixed effects models were used to determine differences in groups, adjusting for clustering of children within centres. Results: Children receiving the intervention had greater improvements on measures of inhibition (β =1.97, p=.001) and expressive vocabulary (β=0.5, p=.033), compared to control group children. No significant differences were observed for visual-spatial working memory or shifting. Discussion: A physical literacy curriculum that aligns with the Australian Early Years Learning Framework and is fully integrated into early learning centre practices is beneficial in improving aspects of young children’s executive function and language development. These data support the case for greater investment in physical literacy professional development for educators working in early learning centres. Conflict of interest statement: My co-authors and I acknowledge that we have no conflict of interest of relevance to the submission of this abstract.

What is the relationship between imaging-defined intra-articular features and cartilage defects in young adult football players?

Introduction: While hip osteoarthritis is a disease of the whole synovial joint, cartilage defects are considered a hallmark feature. A high proportion of young adult football players have hip cartilage defects. However, the role that other intra-articular features play in the pathogenesis of cartilage defects in football players remains unknown. This study had two aims: 1) examine the relationship between imaging-defined intra-articular features (labral tears, bone marrow edema pattern, subchondral cysts, effusion-synovitis and ligamentum teres tears) and cartilage defects (presence and severity) in football players; 2) investigate if the relationship between imaging-defined intra-articular features and cartilage defects is stronger in football players with hip/groin pain Methods: 182 semi-elite football (soccer/Australian football) players (288 hips; 50% soccer; age:26yrs; height:1.79m; weight:78kg; 20% women) with hip/groin pain (>6 months of pain and +ve flexion-adduction-internal-rotation test) and 55 semi-elite control football players (110 control hips; 55% soccer; age:26yrs; height:1.79m; weight:79kg; 25% women) without hip/groin pain underwent 3-tesla MRI. Cartilage defects, labral tears, bone marrow edema pattern (BMEP), subchondral cysts, effusion-synovitis and ligamentum teres tears were scored semi-quantitatively. Logistic and negative binomial regression with generalised estimating equations were used to determine whether intra-articular features were associated with presence and severity of cartilage defects. Results: Hips with minor (OR 1.8, 95%CI 1.2,2.9) and severe (OR 5.1, 95%CI 2.5,10.3) labral tears had a higher prevalence of cartilage defects than hips without. Only hips with severe labral tears (IRR 2.1, 95%CI 1.4,3.2) had higher (greater severity) cartilage defects scores than hips without. Hips with BMEP or subchondral cysts had a higher prevalence (OR 7.7, 95%CI 3.1,20.0) and more severe (IRR 1.8 95%CI 1.4,2.3) cartilage defects than hips without. Effusion synovitis was not associated with a higher prevalence or greater severity of cartilage defects. For ligamentum teres tears only, a significant feature by symptoms interaction was present. Symptomatic football players without a ligamentum teres tear had a greater severity of cartilage defects when compared to those with symptoms and ligamentum teres tears. Discussion: Labral tears, BMEP and subchondral cysts were associated with the presence and severity of cartilage defects in active adult football players. Effusion-synovitis was not associated with cartilage defects. With the exception of ligament teres tears, the relationship between imaging-defined intra-articular features and cartilage defects was no stronger in football players with hip/groin pain when compared to those without. Conflict of interest statement: My co-authors and I acknowledge that we have no conflict of interest of relevance to the submission of this abstract.

The impact of physical activity and sport programs on mental, social and emotional wellbeing of young Aboriginal and Torres Strait Islander people: A systematic review

Background: Aboriginal and Torres Strait Islander young people experience significantly poorer mental, social and emotional health disparities compared to their non-Indigenous counterparts as a result of sustained disadvantage and intergenerational trauma. The relationship between physical activity and sport participation and positive mental and psychosocial health in young people is well established, yet little is known about this relationship in Aboriginal and Torres Strait Islander young people. This review aims to address this gap by systematically identifying and assessing existing evidence of the impact of sport and physical activity programs on mental health and social and emotional wellbeing outcomes within young Aboriginal and Torres Strait Islander people. The review also aims to highlight limitations of current practice within the research area. Methods: A systematic search of literature was undertaken on three peer-reviewed databases (PsycINFO, MEDLINE and SPORTSDiscus) and grey literature until July 2020. Studies were included if they described a sport and physical activity program for young (10-24 years) Aboriginal and Torres Strait Islander people and reported mental health or social and emotional wellbeing outcomes. Results: Seventeen studies were selected for this review. Within these studies, the most commonly reported outcomes were related to psychosocial development (N = 12) and a sense of connectedness (N = 12). Mental illness related outcomes (N = 1) were rarely reported, as were substance use (N = 2) and social and emotional literacy (N = 1). Other promising outcomes included increased connection to culture, self-esteem and confidence. Nonetheless, due to indirectness, suboptimal study design, and risk of bias, the precise impact on these outcomes cannot be determined. Discussion: A relevant evidence base is emerging on the impact sport and physical activity programs have on the mental, social and emotional wellbeing of young Aboriginal and Torres Strait Islander people. However, further research that utilises robust, culturally appropriate methodologies and tools (e.g., participatory action research, body mapping and yarns) needs to be undertaken before the effects of sport and physical activity programs can reliably be discerned. Conflict of interest statement: My co-authors and I acknowledge that we have no conflict of interest relevant to the submission of this abstract.

Relationships between trunk morphology and strength with non-contact lower limb injuries in elite rugby league and Australian football players

Background: Non-contact lower limb injuries (NCLLI) are common within the National Rugby League (NRL) and Australian Football League (AFL). Smaller lumbar multifidus at L5 (LM L5) cross-sectional area (CSA) and lower levels of trunk and hip extension and knee flexion strength have been associated with increased NCLLI risk in AFL players. However, such associations have not been reported in the NRL. This study aims to explore relationships between NCLLI, trunk morphology and isometric trunk and hip extension strength in NRL and AFL players. Methods: NRL and AFL players had their LM L2-L5 and quadratus lumborum (QL) CSA (n=238), and isometric trunk and hip extension strength (n=153) measured using ultrasonography and a novel field-based test in preseason. Isometric trunk and hip extensor strength were measured using a 65s maximal voluntary isometric contraction (MVIC) protocol (5s MVIC, 5s off, 45s MVIC, 5s off, 5s MVIC). Team medical staff reported all NCLLIs sustained in the subsequent competitive season. The associations between LM and QL CSA, 5s and 45s MVIC, age, and previous injury, and prospectively occurring NCLLI were analysed using univariable and then multivariable logistic regression. Logistic regression analysis was also performed for the most sustained NCLLI (hamstring and knee). Results: Seventy-two players sustained a NCLLI in the 2020 competitive seasons (51 NRL, 21 AFL). From univariable logistic regression previous injury increased the risk of any NCLLI in NRL (OR=2.43, 95%CI=1.16-5.09, p=0.019). Reduced 5s MVIC (OR=1.00, 95%CI=1.00-1.01, p=0.012), increased QL CSA (OR=1.55, 95%CI=1.05-2.38, p=0.033) and lower ratio between LM and QL CSA (OR=0.03, 95%CI=0.01-0.60, p=0.02) increased NCLLI risk in AFL. Pooled hamstring injuries (n=28) were most common and were associated with lower 5s MVIC (OR=0.99, 95%CI=0.99-1.00, p=0.02) and 45s MVIC (OR=0.99, 95%CI=0.99-1.00, p=0.001). Pooled knee injuries (n=21) were associated with both reduced LM CSA (OR=1.35, 95%CI=1.08-1.70, p=0.018) and LM to QL ratio (OR=3.62, 95%CI=1.41- 9.66, p=0.043). Conclusions: Larger QL CSA and reduced levels of trunk and hip extension strength are observed in AFL players in preseason who sustain a NCLLI in the subsequent playing season. Only previous NCLLI was associated with future risk of NCLLI for NRL players. These results suggest that risk factors for NCLLI are football code specific, and prevention strategies should be tailored accordingly. Conflict of interest statement: My co-authors and I acknowledge that we have no conflict of interest relevant to the submission of this abstract.

Most knee osteoarthritis education interventions in published trials lack clarity, comprehensiveness, and robust development - ancillary analysis of a systematic review

Introduction: Patient education is a guideline recommended first-line intervention for people with knee osteoarthritis. Yet, guidance on how to implement education interventions is poorly covered in guidelines, limiting translation to clinical practice. The primary aim of this ancillary analysis of our systematic review is to evaluate the content, development and delivery of education interventions for knee osteoarthritis in clinical trials. Methods: We performed an ancillary analysis of a previous systematic review and meta-analysis. A literature search was performed from inception to April 2020 using pre-defined search strategy in 5 databases; MEDLINE, EMBASE, SPORTDiscus, CINAHL, and Web of Science. Randomized controlled trials involving patient education for people with knee osteoarthritis were included. For data analysis, we matched education content reported in trials against 14 pre-defined evidence-based topics and categorised as; ‘accurate/clear’, ‘partially accurate/clear’, or ‘not reported’. We identified whether interventions targeted skill development or stated learning objectives, categorised as ‘yes’ or ‘not reported’. Information about whether interventions were developed based on learning theories, previous research and co-design principles was extracted and reported as ‘yes’ or ‘not reported’. Delivery methods (number of sessions, group, one-to-one, mixed, self-directed), and mode(s) (face-to-face, telephone, written materials, etc.) of patient education interventions were identified. All data were summarised descriptively. Results: Thirty-eight education interventions across 30 trials involving 4,107 participants were included. Median number of content topics reported amongst all interventions was 3/14 (range 0-11). When content was reported, only 10% (n=13/136) were accurate and clear, with the remaining 90% (n=126/136) partially accurate/clear. Most interventions (61%, n=23/38) targeted skill development but only 34% (n=13/38) identified learning objectives. Less than half of the education interventions were based on theory (42%, n-16/38), or previous research for chronic conditions (45%, n=17/38) including 32% (n=12/38) based on research for osteoarthritis; and just 11% (n=4/38) were co-designed. Education was often facilitated face-to-face over multiple sessions (median, range; 9, 0-55), supplemented with telephone calls and/or written materials. Discussion: Education interventions in knee osteoarthritis studies lack comprehensiveness and lack clear accurate descriptions of content, impeding clinical translation. Very few are co-designed, and most do not identify learning outcomes, or use theory and previous research in development. These limitations may lead to underestimation of the value of quality patient education to improve outcomes for people with knee osteoarthritis. Conflict of interest statement: My co-authors and I acknowledge that we have no conflict of interest of relevance to the submission of this abstract.

Hip rotation strength after anterior cruciate ligament injury: relationship to functional, symptomatic and structural outcomes

Introduction: Hip muscle strength is often implicated in pathoaetiology and management of knee related conditions, including as part of holistic rehabilitation after anterior cruciate ligament (ACL) injury. Despite this, no studies have investigated how hip rotation strength relates to outcomes after ACL reconstruction (ACLR). This study aimed to assess the associations of hip rotation strength at 1 year post-ACLR, to function, patient reported outcomes (PROMs) and imaging outcomes at 1 and 5 years. A secondary aim was to compare hip rotation strength between the injured and non-injured sides. Methods: 111 participants 1 year following ACLR completed hip external-rotation (ER) and internal-rotation (IR) muscle strength assessment with a hand-held dynamometer (peak torque normalised to bodyweight). At 1- and 5-years post-ACLR, participants completed functional (hop testing battery, one leg rise), self-reported (Anterior Knee Pain Scale (AKPS), Knee Osteoarthritis Outcome Score) and MRI and radiographic assessment. Cartilage health of the patellofemoral and tibiofemoral compartments was assessed using the semiquantitative MRI Osteoarthritis Knee Score. Regression models (controlling for age and sex) assessed the relationships between hip rotation strength at 1 year post-ACLR and functional tests, patient reported outcomes and cartilage findings at 1 and 5 years. Results: The injured side had significantly weaker hip ER strength compared to the non-injured side (p=0.014, effect size (ES) =-0.33 (95%CI -0.60 to -0.07). There was no difference between sides for hip IR strength (p=0.411, ES = -0.11 (95%CI -0.37 to 0.15). Weaker hip ER and IR strength was significantly associated with lower performance on all functional tests and worse AKPS scores at 1 and 5 years. Lower hip ER strength was significantly associated with worsening tibiofemoral cartilage lesions at 5 years (p=0.017, Odds Ratio 0.01 (95%CI 0.00 to 0.41). Hip strength was not associated with any patellofemoral imaging outcomes. Discussion: Hip rotation strength may play a role in worsening knee function, symptoms and tibiofemoral cartilage health after ACLR, though further prognostic studies are needed. Hip ER strength of 0.1 Nm/kg higher resulted in 0.63 times lower odds of tibiofemoral cartilage worsening at 5 years. The hip rotator muscles may influence outcomes given their vital role in single leg propulsion and force absorption. Associations to PROMs and structure may also reflect global reductions in lower extremity strength, or reduced activity levels and increased BMI observed after ACL injury. A link between hip strength and patellofemoral outcomes is less clear from our findings. Conflict of interest statement: My co-authors and I acknowledge that we have no conflicts of interest of relevance to the submission of this abstract.

Flat flexible compared to stable supportive footwear for self-managing knee osteoarthritis symptoms: a randomised clinical trial

Introduction: International clinical guidelines advise stable supportive shoes for knee osteoarthritis (OA) however evidence suggests flat flexible shoes may reduce knee joint loading and symptoms. We hypothesised that flat flexible shoes would lead to greater improvements in pain and function, compared to stable supportive shoes. Methods: This was a two-arm, participant- and assessor-blinded comparative effectiveness randomised controlled trial. We recruited 164 people aged 50 years or older with knee pain on most days of the past month and moderate to severe radiographic medial tibiofemoral OA. Participants were randomised to receive either flat flexible shoes (n=82) or stable supportive shoes (n=82), classified based on: i) differences in shoe heel height/thickness, ii) shoe pitch, iii) arch support/motion control features, iv) sole flexibility and v) weight. Shoes were worn >6 hours/day for 6 months. Primary outcomes were changes in walking knee pain (11-point numerical rating scale) and physical function (Western Ontario and McMaster Universities Osteoarthritis Index subscale, 0-68) at 6-months. Secondary outcomes included additional measures of pain, function, physical activity, quality of life and adverse events. Results: 164 participants were recruited and 161 (98%) completed 6-month primary outcomes. There was evidence of a between-group difference in change in walking knee pain favoring stable supportive shoes (mean difference=1.1 units (95%CI 0.5 to 1.8; p=0.001) but no strong evidence of difference in function (2.3 (-0.9 to 5.5; p=0.17)). Furthermore, 46 (58%) participants in the stable supportive group achieved the minimal clinically important difference (MCID) in pain, compared to 32 (40%) in the flat flexible group (relative risk 1.56, 1.05 to 2.02). Improvements in knee-related quality of life and ipsilateral hip pain also favored stable supportive shoes (-5.3 (-10.0 to -0.5; p=0.03) and 0.7 (0.0 to 1.4; p=0.04), respectively), with no evidence of between-group differences in other secondary outcomes. Fewer participants reported adverse events with stable supportive shoes (n=12 (15%)) compared to flat flexible shoes (n=26 (32%); relative risk=0.46 (0.25 to 0.84; p=0.012)). Discussion: Flat flexible shoes were not superior to stable supportive shoes. Contrary to our hypothesis, stable supportive shoes improved knee pain on walking more than flat flexible shoes. Furthermore, a greater proportion of participants allocated to stable supportive shoes achieved the MCID in walking pain compared to those allocated to flat flexible shoes. Findings from this trial are the first to show that stable supportive shoes may be an inexpensive, low burden self-management strategy to improve pain associated with knee OA. Conflict of interest statement: My co-authors and I acknowledge that we have no conflict of interest of relevance to the submission of this abstract

Epidemiology of injuries in amateur boxing: a systematic review and meta-analysis

Introduction: Notwithstanding the widespread popularity and public concerns regarding athlete safety in amateur boxing, previous efforts to investigate the epidemiology of injuries in the sport are either limited in scope or outdated. This review aims to systematically review and synthesise the best available epidemiological data on competition and training injuries in amateur boxing, including data on incidence, severity, anatomical location, type of pathology, mode of onset, mechanism of injury, and risk factors. Methods: The protocol for this review was registered on the international prospective register of systematic reviews (CRD42019127770). Five databases (i.e., MEDLINE, Embase, AMED, AusportMed, and SPORTDiscus) were electronically searched from inception to October 2020. Cohort studies that were published in peer-reviewed journals and reported prospectively collected injury and exposure data from amateur boxing athletes were included. Random-effects models were used to obtain pooled summary estimates of competition injury incidence rates per 1000 athlete-exposures (IIRAE) and per 1000 minutes of exposure (IIRME) and training injury incidence rates per 1000 hours of exposure (IIRHE). Results: Fourteen studies (15 cohorts) were eligible for inclusion. The competition IIRAE and IIRME summary estimates were 54.7 (95%CI 32.6–91.9) and 6.9 (95%CI 4.1–11.5), respectively. The training IIRHE summary estimate was 1.3 (95%CI 0.2–7.0). The most commonly injured body regions in the competition and training settings were the head and neck (range: 46% to 100%) and upper limb (40% to 57%), respectively. The predominant types of injury were contusions, concussions, and lacerations in the combined competition and training setting, and sprains and strains in the training setting. Minimal data were available for injury severity, pathology, mode of onset, and mechanism. Discussion: Amateur boxing athletes sustain, on average, 1 injury every 2.4 hours of competition and every 772 hours of training, which is comparable to the injury risk other Olympic combat sports (e.g., judo, karate, taekwondo), but lower than in non-Olympic professional combat sports. While head injuries are common in competition, upper limb sprains and strains predominate in training, which suggests different injury mechanisms are present for each setting. More information about injury severity, mechanisms, and risk factors is needed to guide the development of targeted injury prevention initiatives to mitigate the burden of injury in amateur boxing. Conflict of interest statement: My co-authors and I acknowledge that we have no conflict of interest of relevance to the submission of this abstract.

Risk factors for ACL, hamstring strain, and hip/groin injuries in elite Australian female footballers: A prospective study.

Introduction: Female footballers are at high risk of sustaining lower limb injuries, with some of the most prevalent and severe injuries being hamstring strains, hip/groin pain, and knee ligament sprains. However, there is currently limited evidence to guide injury prevention strategies and injury risk assessment testing in female footballers. The aim of this study was to assess risk factors for ACL, hamstring, and hip/groin injuries in elite female footballers. Methods: Data were collected from 321 elite female Australian Football, soccer, and Rugby League players during pre-season. Players underwent field-based assessments of isometric hip adductor and abductor strength (ForceFrame), eccentric knee flexor strength during the Nordic hamstring exercise (NordBord), countermovement jump (CMJ) on dual forceplates (ForceDecks), and a single-leg triple vertical hop (TVH) using a makerless motion capture system (HumanTrak). Players were subsequently followed for injuries for 18 months. Risk factors were identified prospectively using simple and multiple logistic regression and decision tree learning. Results: A total of 12 anterior cruciate ligament (ACL) ruptures, 17 hamstring strains, and 12 hip/groin injuries were recorded. Risk factors for ACL injury included prior ACL injury (standardised odds ratio [OR]=12.3, P<.001), lower body weight normalised adductor torque (OR=2.1, P=.028), greater body weight normalised CMJ peak force (OR=1.9, P=.013), lower CMJ impulse (OR=2.0, P=.037), greater triple vertical hop knee frontal plane projection angle (OR=2.3, P=.014), and greater triple vertical hop lateral trunk flexion (OR=1.7, P=.038). Multiple logistic regression and decision tree models classified ACL injured players with high accuracy (sensitivity=67% and 75% respectively, and specificity=88% and 100% respectively). Risk factors for time-loss hamstring injury included smaller stature (OR=1.8, P=.030), greater between-leg asymmetry in CMJ peak force (OR=2.0, P=.011) and eccentric impulse (OR=1.9, P=.016). There were no statistically significant risk factors for hip/groin injury. Discussion: This is the first study to explore risk factors for lower limb injury in elite female Australian football codes. These results provide insight into the potential modifiable factors associated with subsequent injury in elite female footballers, which may inform player testing batteries and the design of targeted injury risk reduction strategies. Conflict of interest statement: Funding for travel was provided by Vald Performance (Brisbane, Australia) and SMA Research Foundation. My co-authors and I acknowledge that we have no conflict of interest of relevance to the submission of this abstract.

Within- and between-session test-retest reliability of pain-free grip strength in individuals with lateral elbow tendinopathy

Introduction: Pain-free grip strength is an important clinical outcome measure in lateral elbow tendinopathy (LET). This study examined the test-retest reliability and minimal detectable change (MDC) for pain-free grip strength between- and within-session in individuals with LET. Methods: Data from 27 individuals (16 males) with LET, recruited for a randomised crossover trial examining the effects of biomechanical tape, were used for this study. Participants underwent three testing sessions, biomechanical tape, control tape, and no tape. During each session pain-free grip strength was measured at three timepoints: baseline, immediately after application, and post-exercise. Baseline measures from the first two data collection sessions, completed between 2 and 28 days apart, were used to examine between-session reliability. The baseline and immediately post-application measures (completed 20 to 30 minutes apart) from the no-tape condition, were used to examine within-session reliability. Pain-free grip strength was assessed in two positions: shoulder neutral, elbow at 90°, forearm pronated (flexed position), and shoulder at 90°, elbow extended, forearm pronated (extended position). Participants were asked to cease gripping as soon as they felt pain and the force (N) was recorded. At each timepoint and position, three trials of pain-free grip strength separated by 30 seconds’ rest were measured using a grip force transducer (ADInstruments, NZ). The mean of the three trials was calculated. To determine test-retest reliability, intraclass correlation coefficients (ICCs) with 95%CI were performed using an absolute agreement, two-way random-effects model (ICC2,3). The MDC at the 95% confidence level was calculated by multiplying the standard error of measurement by 1.96 and then by √2. Results: Between-session ICCs (95%CI) were ICC2,3=0.86 (0.69 - 0.94) and ICC2,3=0.93 (0.84 - 0.97) for the flexed and extended positions, respectively. Within-session ICCs (95%CI) were ICC2,3=0.96 (0.92 - 0.98) and ICC2,3=0.97 (0.93 - 0.98) for the flexed and extended positions, respectively. Between-session MDCs were 97.8 N (flexed) and 94.0 N (extended) and within-session MDCs were 49.3 N (flexed) and 63.8 N (extended). Discussion: The reliability of pain-free grip strength was excellent in both testing positions. Researchers and clinicians should expect to see a change of 94 to 98 N between-session and 49 to 64 N within-session, depending on upper limb position, to be confident a true change has occurred. Conflict of interest statement: The authors have no conflict of interest of relevance to this submission.

Scientific Publishing in Biomedicine: How to Write a Cover Letter?

A cover (covering) letter is a brief business letter introducing the scientific work alongside the submission process of a manuscript and is required by most scientific peer-review journals. A typical cover letter includes the name of the editor and the journal, date of submission, the characteristics of the manuscript, the importance of the work and its relevance to prospective audiences, declarations such as author agreements, conflicts of interest statement, funding source (s), and ethical statements. The letter also includes the contact information of the corresponding author (s) and may also include suggestions of potential reviewers. Spending enough time to draft an informative, comprehensive, and concise cover letter is quite worthwhile; a poorly drafted one would not persuade the editor that the submitted work is fit for publication and may lead to immediate rejection. Here, we provide a practical guide to draft a well-written, concise, and professional cover letter for a scientific medical paper.

Quality assessment of guidelines on upper gastrointestinal cancer screening

Objective: To systematically evaluate the methodological quality of screening guidelines for upper gastrointestinal cancer (including esophageal cancer and gastric cancer) both at home and abroad, and provide reference for the update of upper gastrointestinal cancer screening guidelines in China. Methods: Original articles and grey literature published as of 31th Aug 2020 were retrieved using Chinese databases (CNKI, Wanfang, China Biomedical Literature Database and China Guideline Clearinghouse), PubMed, The Cochrane Library and Embase, as well as those from International Agency for Research on Cancer and the International Guide Collaboration Network. The inclusion criteria were being independent guidelines/recommendation documents for upper gastrointestinal cancer screening and meeting the definition of the institute of Medicine, USA. The exclusion criteria were being guideline abstracts, interpretation and evaluation literature, duplicate publications, updated original guidelines, and clinical treatment or practice guidelines for esophageal or gastric cancer. Appraisal of Guidelines for Research and Evaluation (AGREE Ⅱ) and Reporting Items for Practice Guidelines in Healthcare (RIGHT) were used to compare and evaluate the quality and reporting standard of esophageal or gastric cancer screening guidelines. Results: A total of 6 esophageal cancer screening guidelines and 5 gastric cancer screening guidelines were included. The results of the AGREE Ⅱ quality evaluation showed that the overall quality of eleven guidelines varied, including two guidelines recommended for "A", one for "B", five for "C" and three for "D". The guidelines had higher scores in the areas of scope and purpose, and clarity. The esophageal cancer screening guidelines had different scores in the areas of rigor and independence. The gastric cancer screening guidelines generally had low scores in the areas of participants and application. The RIGHT evaluation results showed that the quality of eleven guidelines should be improved. The six items with poor report quality were background, evidence, recommendations, review and quality assurance, funding and conflict of interest statement and management and others. Conclusion: The quality of the included upper gastrointestinal cancer screening guidelines is general, and the standardization needs to be strengthened.

Abstract 2001: Krupple like factor 10 modulates stem cell phenotype of pancreatic adenocarcinoma via transcriptional regulation of Notch signal pathway

Abstract Background: Pancreatic adenocarcinoma (PDAC) is known for its deregulated TGFβ signal pathway. Therapeutic strategy targeting TGFβ is controversial due to the dual role of TGFβ with anti-proliferation in early phase and pro-metastatic in late phase of cancer progression. KLF10, an early response gene of TGFβ, positively feedback the antiproliferative effect in cancer. Recent studies revealed KLF10 expression were suppressed epigenetically in various cancers including PDAC. In contrary to TGFβ, KLF10 transcriptionally suppress Slug and Sirtuin 6 to prevent metastasis in advanced PDAC. The role of KLF10 in regulating tumorigenesis and stem cell phenotype is still unknown. Materials and Methods: From 105 patients of resectable PDAC, KLF10 expression level was evaluated to be reduced in 62% of tumor specimens. Low KLF10 expression correlated with larger tumor size and rapid loco-regional recurrence. In murine model of Kras mutation (KC mice), additional depletion of KLF10 induced 57% of PDAC compared to 0% at 18 to 24 wk of age. PDAC cells were genetically manipulated with KLF10mRNA silencing (PDACshKLF10) or inducible overexpression (PDACoeKLF10). Using limiting dilution assay of tumor growth, and orthotopic tumor implantation, we found higher tumorigenic ability of PDACshKlf10 compared to that of wild type. The stem cell phenotypes of PDACshKLF10 and PDACoeKLF10 were confirmed by sphere formation assay and FACS analysis of surface markers including CD24/CD44, ESA/c-Met, CD47 and CD133. Results: Notch signal pathway was found to be significantly enhanced from microarray analysis of wild type versus PDACshKLF10 cells. The increased Notch signal molecules were confirmed in RNA and protein level in genetically manipulated PDAC cells as well as clinical tissue specimens. Using Chip-PCR and luciferase promoter assay, KLF10 was demonstrated to bind to the promoter of Notch receptor 1, 3, and 4. DAPT (N-[N-(3,5-Difluorophenacetyl)-L-alanyl]-S-phenylglycine t-butyl ester), a Notch inhibitor, suppressed in vitro spheroid formation, cell surface expression of stem cell markers, and tumor growth of PDACshKLF10 in orthotopic murine model. We conclude that KLF10 modulates stem cell phenotype of PDAC by transcriptionally suppressing Notch signal pathway. Loss of KLF10 in PDAC patients leads to Notch signal activation, development of stem cell phenotype and tumor progression. Notch inhibition may reverse malignant growth of PDAC with reduced KLF10 expression. Conflict of interest statement: nothing to declare Citation Format: Yi-Chih Tsai, Su-Liang Chen, Shu-Ling Peng, Kuang-Hung Cheng, Shih-Sheng Jiang, Shuang-En Chuang, Ch'ang Hui-Ju. Krupple like factor 10 modulates stem cell phenotype of pancreatic adenocarcinoma via transcriptional regulation of Notch signal pathway [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr 2001.

Reporting of adverse events, conflict of interest and funding in randomised controlled trials of antibiotics: a secondary analysis

ObjectivesTransparent reporting of trials is necessary to assess their internal and external validity. Currently, little is known about the quality of reporting in antibiotics trials. Our study investigates the reporting...

Chronic nociplastic pain affecting the musculoskeletal system: clinical criteria and grading system.

Chronic nociplastic pain affecting the musculoskeletal system: clinical criteria and grading system.

Contributions to the American Society of Hematology Meeting From Low- and Middle-Income Countries: An In-Depth Analysis and Call to Action.

PURPOSE:Establishing research capacity in low- and middle-income countries (LMICs) is key for improving the outcomes of patients with hematologic diseases globally. Few studies have analyzed the contributions of LMICs to global hematology. The American Society of Hematology Meeting (ASH) is the largest international academic event where peer-reviewed contributions in our field are presented.METHODS:In this cross-sectional analysis, all abstracts accepted to ASH 2018 selected for a poster or oral presentation were reviewed. Those that had a contributing author from an LMIC were identified. The proportion of LMIC abstracts across categories was analyzed. Country of origin, high-income country participation, the presence of a conflict of interest (COI), and sponsorship were determined.RESULTS:From 4,871 abstracts reviewed, 506 had a contributing author from an LMIC (10.4%), with 277 (54.7%) contributions in partnership with a high-income country. LMIC-independent contributions corresponded to 19 of 1,026 oral abstracts (1.9%) and 209 of 3,845 posters (5.4%). Most abstracts from LMICs were clinical (n = 311; 61.5%) and multicentric in nature (n = 353; 69.8%). COI statements with the pharmaceutical industry were common (n = 214; 42.3%). Collaboration between LMICs was infrequent (n = 33; 6.5%). Upper-middle–income countries had 466 participations (81.5%), in comparison with 96 (16.8%) in low-middle–income and 10 (1.7%) in low-income countries.CONCLUSION:LMICs were responsible for a small fraction of abstracts at ASH18; low-income countries were practically absent. Almost half of accepted works represented a form of international collaboration, with clinical, multicenter studies predominating and COI disclosures a frequent and unexpected feature, reflecting the instrumental nature of LMIC participation and a lack of independent, robust, locally developed hematology research.