The World Rugby and International Rugby Players Contact Load Guidelines: From conception to implementation and the future.

Managing training load in rugby union is crucial for optimising performance and injury prevention. Contact training warrants attention because of higher overall injury and head impact risk, yet players must develop physical, technical, and mental skills to withstand the demands of the game. To help coaches manage contact loads in professional rugby, World Rugby and International Rugby Players convened an expert working group. They conducted a global survey with players to develop contact load guidelines. This commentary aims to describe the contact load guidelines and their implementation, and identify areas where future work is needed to support their evolution.

'Do we know if we need to reduce head impact exposure?': A mixed-methods study highlighting the varied understanding of the long-term risk and consequence of head impact exposure across all stakeholders at the highest level of rugby union.

Background: One strategy to prevent and manage concussion is to reduce head impacts, both those resulting in concussion and those that do not. Because objective data on the frequency and intensity of head impacts in rugby union (rugby) are sparse, stakeholders resort to individual perceptions to guide contact training. It is unknown whether there is a level of contact training that is protective in preparing elite players for contact during matches. Objectives: This study aimed to describe how contact training is managed in elite male rugby, and how staff and players perceive contact training load and head impact load. Methods: This was a sequential explanatory mixed-methods study. Forty-four directors of rugby, defence coaches, medical and strength/conditioning staff and 23 players across all 13 English Premiership Rugby Union clubs and the National senior team participated in semi-structured focus groups and completed two bespoke questionnaires. Results: The study identified the varied understanding of what constitutes head impact exposure across all stakeholder groups, resulting in different interpretations and a range of management strategies. The findings suggest that elite clubs conduct low levels of contact training; however, participants believe that some exposure is required to prepare players and that efforts to reduce head impact exposure must allow for individualised contact training prescription. Conclusion: There is a need for objective data, possibly from instrumented mouthguards to identify activities with a high risk for head impact and possible unintended consequences of reduced exposure to these activities. As data on head impact exposure develop, this must be accompanied with knowledge exchange within the rugby community.

The performance of the World Rugby Head Injury Assessment Screening Tool: a diagnostic accuracy study.

BACKGROUND: Off-field screening tools, such as the Sports Concussion Assessment Tool (SCAT), have been recommended to identify possible concussion following a head impact where the consequences are unclear. However, real-life performance, and diagnostic accuracy of constituent sub-tests, have not been well characterized. METHODS: A retrospective cohort study was performed in elite Rugby Union competitions between September 2015 and June 2018. The study population comprised consecutive players identified with a head impact event undergoing off-field assessments with the World Rugby Head Injury Assessment (HIA01) screening tool, an abridged version of the SCAT3. Off-field screening performance was investigated by evaluating real-life removal-from-play outcomes and determining the theoretical diagnostic accuracy of the HIA01 tool, and individual sub-tests, if player-specific baseline or normative sub-test thresholds were strictly applied. The reference standard was clinically diagnosed concussion determined by serial medical assessments. RESULTS: One thousand one hundred eighteen head impacts events requiring off-field assessments were identified, resulting in 448 concussions. Real-life removal-from-play decisions demonstrated a sensitivity of 76.8% (95% CI 72.6-80.6) and a specificity of 86.6% (95% CI 83.7-89.1) for concussion (AUROC 0.82, 95% CI 0.79-0.84). Theoretical HIA01 tool performance worsened if pre-season baseline values (sensitivity 89.6%, specificity 33.9%, AUROC 0.62, p < 0.01) or normative thresholds (sensitivity 80.4%, specificity 69.0%, AUROC 0.75, p < 0.01) were strictly applied. Symptoms and clinical signs were the HIA01 screening tool sub-tests most predictive for concussion; with immediate memory and tandem gait providing little additional diagnostic value. CONCLUSIONS: These findings support expert recommendations that clinical judgement should be used in the assessment of athletes following head impact events. Substitution of the tandem gait and 5-word immediate memory sub-tests with alternative modes could potentially improve screening tool performance.

Teams with lower injury rates have greater success in the Currie Cup rugby union competition.

Background: Professional football teams that rank high on the log at the end of the season generally have fewer injuries than teams that rank lower on the log. This highlights the importance of implementing injury prevention measures, not only to protect player welfare and ensure their longevity in the sport, but also to improve the performance of the team. The association between a low incidence of injury and superior performance during a season may be even more relevant in sports with a higher incidence of injury than football, such as rugby union. Discussion: To examine this association in the South African Currie Cup rugby union competition, time-loss (≥ 1 day training/match play missed) injury data and final position in the competition was examined over five-seasons. Teams who ranked in 1st position had significantly lower average injury rates than teams who ranked in last position [48 injuries per 1 000 player hours (95% C.I 20 to 76) vs 130 injuries per 1 000 player hours (95% C.I 79 to 180)]. More specifically, the team with the lowest injury rate in each season ranked in 1st or 2nd position. This team performance aspect of injury prevention should be highlighted more. In particular, this should be used to assist with communicating the importance of injury prevention programmes to stakeholders directly involved with budgetary allocations in the team.

Improving the safety and tolerability of local anaesthetic outpatient transperineal prostate biopsies: A pilot study of the CAMbridge PROstate Biopsy (CAMPROBE) method.

OBJECTIVES: The aim of this study was to pilot the use of a bespoke device (CAMPROBE, the CAMbridge PROstate Biopsy) to enable routine outpatient free-hand local anaesthetic (LA) transperineal prostate biopsies. MATERIALS AND METHODS: The CAMPROBE prototype was designed and built in our institution. Men on active surveillance due prostate resampling were invited to have a CAMPROBE biopsy as an alternative to repeat transrectal ultrasound-guided prostate biopsies (TRUSBx) as part of an approved trial (NCT02375035). Biopsies were performed using LA infiltration only, without sedation or additional analgesia. Patient-reported outcomes were recorded at day 0 and 7 using validated questionnaires and visual analogue scales (VAS). Complications were recorded prospectively. RESULTS: Thirty men underwent biopsies with a median of 11 cores taken per procedure (interquartile range 10-12). There were no infections, sepsis or retention episodes. Haematuria and haematospermia occurred in 67% and 62% of patients, which are similar to rates reported for TRUSBx. Mean VAS for pain (0-10 scale) was less than 3 for every part of the procedure. All 30 men described the procedure as tolerable under LA. In total, 26/30 (86.7%) men expressed a preference for a CAMPROBE procedure over TRUSBx and a further 3 (10.0%) would have either. CONCLUSIONS: In this small pilot study, the CAMPROBE device and method appears to be a safe, simple and well-tolerated out-patient transperineal replacement for TRUSBx. A major new National Institute for Health Research grant will allow its further development from a prototype to a single use, low-cost disposable device ready for multi-centre testing. LEVEL OF EVIDENCE: 1b: individual cohort study.

High prevalence of undiagnosed and severe chronic obstructive pulmonary disease at first hospital admission with acute exacerbation.

Chronic obstructive pulmonary disease (COPD) is a common cause of acute medical hospital admission, and the prevalence of undiagnosed COPD in the community is high. The impact of undiagnosed COPD on presentation to secondary care services is not currently known. We therefore set out to characterise patients at first admission with an acute exacerbation of COPD, and to identify potential areas for improvement in earlier diagnosis and further management. A retrospective case review of patients first admitted to a district teaching hospital with an acute exacerbation of COPD over a 1-year period was carried out. Forty-one patients with a first admission with an acute exacerbation of COPD were identified, 14 (34%) of whom had not been previously diagnosed and were diagnosed with COPD as a result of the admission. At presentation, this group of patients had severe disease, with mean (SD) FEV(1) 1.02 (0.32) L, and a respiratory acidosis in eight (20%) patients, even though this was their first admission for an acute exacerbation of COPD. Missed potential opportunities to intervene in community and inpatient management were identified, including earlier diagnosis, pre-hospital corticosteroid therapy, inpatient respiratory team input, provision of smoking cessation advice and consideration of pulmonary rehabilitation. Patients with a first hospital admission with an acute exacerbation of COPD frequently have severe disease at presentation. Despite having severe disease, a diagnosis of COPD had not been made in the community prior to admission in one-third of patients. Future work should be directed at earlier identification of patients who are symptomatic from COPD and ensuring that the interventions of proven benefit in COPD are systematically offered to patients in both primary and secondary care.

An analysis of the dependence of saccadic latency on target position and target characteristics in human subjects.

BACKGROUND: Predictions from conduction velocity data for primate retinal ganglion cell axons indicate that the conduction time to the lateral geniculate nucleus for stimulation of peripheral retina should be no longer than for stimulation of central retina. On this basis, the latency of saccadic eye movements should not increase for more peripherally located targets. However, previous studies have reported relatively very large increases, which has the implication of a very considerable increase in central processing time for the saccade-generating system. RESULTS: In order to resolve this paradox, we have undertaken an extended series of experiments in which saccadic eye movements were recorded by electro-oculography in response to targets presented in the horizontal meridian in normal young subjects. For stationary or moving targets of either normal beam intensity or reduced red intensity, with the direction of gaze either straight ahead with respect to the head or directed eccentrically, the saccadic latency was shown to remain invariant with respect to a wide range of target angular displacements. CONCLUSIONS: These results indicate that, irrespective of the angular displacement of the target, the direction of gaze or the target intensity, the saccade-generating system operates with a constant generation time.

Interpreting DNA mixtures.

The interpretation of mixed DNA stains is explained in the context of likelihood ratios. The probabilities for the mixed-stain profile are evaluated under alternative explanations that specify the numbers of contributors and the profiles of any known contributors. Interpretations based simply on the frequencies with which random members of a population would not be excluded from a mixed-stain profile do not make use of all the information, and may overstate the strength of the evidence against included people. The effects of the numbers of contributors depends on whether all the alleles at a locus are present in the mixed stain. A general equation is given to allow likelihood ratios to be calculated, and includes the "2p" modification suggested by the 1996 NRC report. This modification is not always conservative. A computer program to perform calculations is available.

New Zealand population data at five VNTR loci: validation as databases for forensic identity testing.

Databases were developed for three New Zealand ethnic groups (Caucasian, Maori and Polynesian), at five VNTR loci (D1S7, D2S44, D4S139, D5S110 and D12S11), and validated for interpretation of forensic identity tests. A +/-2.8% sliding window was used to define the alleles at each locus and allelic frequency distributions were obtained for each locus. The conservative nature of the sliding window approach for forensic casework was demonstrated. Tests for independence of alleles within and between loci showed good agreement with the expectation of independence. Although Polynesians are known to have reduced genetic diversity at some VNTR loci, this was found not to be a concern for the present methodology. Procedures for the analysis and reporting of DNA profile results used by New Zealand forensic scientists are therefore appropriate.

The effects of self-reinforcement and peer-reinforcement on the practice of breast self-examination.

Four months after learning breast self-examination (BSE), 169 sorority women assigned to one of three conditions (No Reinforcement, Self-Reinforcement or Peer-Reinforcement) were compared on BSE frequency subsequent to the training. Participants in both of the reinforcement conditions had agreed to a specified reward after each month's BSE, which was either self-delivered (Self-Reinforcement condition) or delivered by a partner (Peer-Reinforcement condition). Analysis of covariance revealed a significant difference among conditions and a Newman-Keuls test demonstrated that participants in both reinforcement conditions reported more months of BSE than those in the No Reinforcement condition. Furthermore, anxiety during BSE training was negatively correlated with BSE during the follow-up period. These results suggest that BSE, like other behaviors, is influenced by perceived support or rewards and by anxiety, and that BSE intervention programs should be designed with these findings in mind.

Estimating the rate of externalization of gonadotrophin-releasing hormone receptors in ovine anterior pituitary cells in vitro.

We report an estimate of the rate of externalization of unstimulated receptors for gonadotrophin-releasing hormone (GnRH), and derive from this the turnover time of the unstimulated receptor. The binding of the GnRH antagonist [acetyl-D-pCl-Phe1,2,D-Trp3,D-Lys6,D-Ala10]-GnRH to dispersed sheep anterior pituitary cells was non-saturable at 37 degrees C. Further experiments showed that the binding had two distinct phases. We suggest that these phases correspond to the initial, saturable binding to existing plasma membrane receptors, followed by binding to receptors as they are inserted into the surface membrane. The two processes are temporally distinct, and can be inhibited independently by pharmacological manipulations. The initial phase was inhibited by treatments that could be expected to reduce the number of active receptors on the cell surface (preincubation of the cells for 30 min with 100 micrograms neuraminidase/ml or 50 mumol GnRH/ml), and was complete in less than 30 min after the addition of the antagonist tracer. The second phase occurred continuously in the presence of tracer, and was reduced or abolished by inhibitors of microtubule function (100 mumol vinblastine/l), protein synthesis (25 micrograms cycloheximide/ml), or energy metabolism (0.25 mmol 2,4-dinitrophenol/l). The rate of insertion of receptors into the plasma membrane was calculated from the rate of increase of the second phase of binding. The calculated rate implies a 100% turnover of unstimulated receptors every 150 min. In contrast, previously published estimates of the rate of internalization of the GnRH-receptor complex in the rat pituitary suggest that the stimulated receptor is turned over much faster.

Effects of modifiers of cytoskeletal structures on the dynamics of release of LH from sheep anterior pituitary cells stimulated with gonadotrophin-releasing hormone, K+ or phorbol ester.

This study investigated the importance of reorganization of cell components by cytoskeletal structures to the short-term dynamic changes in LH release from dispersed sheep pituitary cells in perifusion, when stimulated with different dynamic patterns of gonadotrophin-releasing hormone (GnRH). The changes in rate of LH release investigated were the initial response to GnRH, desensitization, change of dose-response during desensitization, and recovery of sensitivity between pulses of stimulation. Cytochalasin D and colchicine were used to modify microfilament and microtubule action respectively. To determine whether receptor movement after binding of agonist was involved in the altered responses, K+ and phorbol 12-myristate 13-acetate (PMA) were used as stimulants because they cause LH release independently of agonist-receptor interaction. After 3 and 48 h culture on dextran beads and 2-3 h incubation in the presence and absence of 2-48 mumol cytochalasin D/1, or 8 or 250 mumol colchicine/l, aliquots of collagenase-dispersed sheep pituitary cells were stimulated at 37 degrees C in tubes or in a multicolumn perifusion system with 850 pmol GnRH/1, 109 mmol K+/1 or 10 nmol PMA/1. Fractions of supernatant or effluent were collected at intervals and LH concentrations measured by radioimmunoassay. Control samples were treated in the same way but without stimulation. Maximal, reversible enhancement of LH release over the first 20 min following stimulation with all secretagogues was observed after incubation of cells in 6 mumol cytochalasin/l. Desensitization behaviour, the supramaximal response, and the ability of cells to recover sensitivity to repeated pulses of GnRH were not altered by this modifier of microfilament polymerization at 6 or 24 mumol/ml. Colchicine at 8 mumol/l caused no changes in LH release. At 250 mumol/l, colchicine reduced the initial response of cells to GnRH stimulation but its action at this relatively high level may not be specific; there was no other major change in desensitization patterns, nor recovery of sensitivity to pulsed GnRH stimulation. Each treatment affected cellular responses similarly before and after culture. From studying the details of the dynamics of the short-term responses of gonadotrophs, we conclude that transport of cell components involving microfilaments and microtubules is unlikely to be a major limitation on the rate of LH release during desensitization, the supramaximal response, or the recovery of sensitivity between pulses of GnRH. This suggests that biochemical reactions rather than physical translocation may be rate-limiting in these processes.(ABSTRACT TRUNCATED AT 400 WORDS)

Risk factors for atherothrombotic brain infarction in persons over 62 years of age in a long-term health care facility.

A history of systolic (greater than or equal to 160 mm Hg) or diastolic (greater than or equal to 90 mm Hg) hypertension, diabetes mellitus (fasting venous plasma glucose greater than or equal to 140 mg/dl), a history of cigarette smoking, fasting serum total cholesterol greater than or equal to 200 mg/dl and greater than or equal to 250 mg/dl, and obesity (greater than or equal to 20% above ideal body weight) were examined as risk factors for atherothrombotic brain infarction (ABI) in 144 men, mean age 81 +/- 8 years, and 391 women, mean age 82 +/- 8 years, in a long-term health care facility. ABI occurred in 33 of 144 men (23%) and in 68 of 391 women (17%), P not significant. A history of systolic or diastolic hypertension correlated with ABI in both men and women (P less than 0.001). Diabetes mellitus correlated with ABI in both men and women (P less than 0.001). A history of cigarette smoking correlated with ABI in men (P less than 0.02) but not in women. Serum total cholesterol greater than or equal to 200 mg/dl and greater than or equal to 250 mg/dl did not significantly correlate with ABI in men or in women. Obesity did not significantly correlate with ABI in men or in women. Systolic or diastolic hypertension, diabetes mellitus, and cigarette smoking are risk factors for ABI in elderly men. Systolic or diastolic hypertension and diabetes mellitus are risk factors for ABI in elderly women.

Effects of lithium and phorbol esters on the dynamics of LH release from dispersed sheep pituitary cells.

The possible involvement of polyphosphoinositides in the stimulation of LH release was investigated. Dispersed sheep pituitary cells were incubated in test-tubes, or perifused in columns, with gonadotrophin-releasing hormone (GnRH) and Li+, or with a phorbol ester, and the amounts and patterns of LH release over time compared. Treatment with Li+ (10 mmol/l), which is known to increase levels of inositol phosphates in gonadotrophs, was shown to have effects only on the responses of desensitized cells, significantly decreasing the rate at which the cells desensitize (P less than 0.005) and decreasing the response to supramaximal levels of GnRH stimulus (P less than 0.01). It is suggested that these effects could be due to increased levels of inositol monophosphate, inositol bisphosphate or inositol 1,3,4-trisphosphate. Responses to single or repeated pulses of GnRH at 18-, 30- and 60-min intervals were not significantly altered. Phorbol 12-myristate 13-acetate (PMA), an activator of the calcium and phospholipid-dependent protein kinase (protein kinase C), was specifically active in releasing LH with a half-maximal stimulating dose of approximately 3 nmol/l. Phorbol 12,13-diacetate, which is structurally similar to PMA but does not activate protein kinase C, did not release LH, except at high levels in freshly dispersed cells. The timing of PMA-stimulated LH release was similar to that for GnRH-stimulated release, and PMA was able to release greater amounts of LH than could GnRH. This suggests that activation of protein kinase C is likely to be important in the GnRH-stimulated release of LH from gonadotrophs.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for coronary artery disease in persons older than 62 years in a long-term health care facility.

A history of smoking 5 to 60 cigarettes per day, hypercholesterolemia (fasting total serum cholesterol 200 mg/dl or more), history of systolic (160 mm Hg or more) or diastolic (90 mm Hg or more) hypertension, diabetes mellitus (fasting venous plasma glucose 140 mg/dl or more) and obesity (at least 20% above ideal body weight) were correlated with coronary artery disease (CAD) in 138 men (mean age 82 +/- 8 years) and 380 women (mean age 82 +/- 8 years) in a long-term health care facility. CAD occurred in 43 of 138 men (31%) and in 103 of 380 women (27%), difference not significant. A history of smoking 5 to 60 cigarettes per day significantly correlated with CAD in men (p less than 0.001) but not in women. Hypercholesterolemia significantly correlated with CAD in both men (p less than 0.001) and women (p less than 0.005). A history of systemic hypertension significantly correlated with CAD in women (p less than 0.001) but not in men. Diabetes mellitus did not significantly correlate with CAD in men or women but weakly correlated with CAD in men plus women (p less than 0.05). Obesity did not significantly correlate with CAD in men or women. Hypercholesterolemia, a history of smoking 5 to 60 cigarettes per day, and a history of systemic hypertension were considered major risk factors. Having 2 or 3 major risk factors correlated with CAD significantly better than having no or 1 major risk factor in both elderly men (p less than 0.001, p less than 0.01) and women (p less than 0.001).