How does surgery compare to sham surgery or physiotherapy as a treatment for tendinopathy? A systematic review of randomised trials.

PURPOSE: To assess the effectiveness of surgery on all tendinopathies by comparing it to no treatment, sham surgery and exercise-based therapies for both mid-term (12 months) and long-term (> 12 months) outcomes. METHODS: Our literature search included EMBASE, Medline, CINAHL and Scopus. A combined assessment of internal validity, external validity and precision of each eligible study yielded its overall study quality. Results were considered significant if they were based on strong (Level 1) or moderate (Level 2) evidence. RESULTS: 12 studies were eligible. Participants had the following types of tendinopathy: shoulder in seven studies, lateral elbow in three, patellar in one and Achilles in one. Two studies were of good, four of moderate and six of poor overall quality. Surgery was superior to no treatment or placebo, for the outcomes of pain, function, range of movement (ROM) and treatment success in the short and midterm. Surgery had similar effects to sham surgery on pain, function and range of motion in the midterm. Physiotherapy was as effective as surgery both in the midterm and long term for pain, function, ROM and tendon force, and pain, treatment success and quality of life, respectively. CONCLUSION: We recommend that healthcare professionals who treat tendinopathy encourage patients to comply with loading exercise treatment for at least 12 months before the option of surgery is seriously entertained.

Predictors of Attack Performance in High-Level Male Volleyball Players.

PURPOSE: In volleyball, teams win the majority of points through attacks (spikes), and therefore attack effectiveness (AE) is one of the most important predictors of victory. Traditionally, greater vertical jump heights (VJH) and higher spike speeds (SS) have been thought to increase AE; however, relevant research is limited. The authors' aim was to assess the relationship of VJH and SS with AE, as well as identifying possible associations of demographic and anthropometric factors, including common volleyball injuries, with VJH, SS, and AE. METHODS: A total of 22 male volleyball players from 2 teams in the top division of the Cypriot championship were included in the study. VJH was measured with the jump-and-reach test, SS was tested with a sports speed radar, and AE was calculated from performance reports of 4 matches between the 2 teams. RESULTS: Statistically significant results included positive correlations between VJH and SS, percentage lean mass and SS, body-bone percentage and SS, frequency of volleyball practice and SS, and frequency of resistance training and SS. AE was found to increase with increasing age, while SS over 90 km·h-1 appeared to have a negative effect on AE. History of pain in the dominant shoulder and in the ankles/knees was associated with lower SS and higher VJH, respectively. CONCLUSIONS: Based on the findings and the existing literature, volleyball players and coaches are advised to focus on maximization of VJH and optimization of attack technique; recommendations to improve attack success are provided.

Metabolic syndrome and the skin: a more than superficial association. Reviewing the association between skin diseases and metabolic syndrome and a clinical decision algorithm for high risk patients.

There is ongoing scientific interest regarding comorbidities associated with the metabolic syndrome (MeTS). MeTS comprises a combination of parameters that predispose individuals to the development of type 2 diabetes and cardiovascular disease (CVD). Three or more of the following criteria are necessary: fasting glucose > 110 mg/dl (5.6 mmol/l), hypertriglyceridemia > 150 mg/dl (1.7 mmol/l), HDL levels < 40 mg/dl (men)/< 50 mg/dl (women), blood pressure > 130/85 mmHg, waist circumference (values for Mediterranean populations > 94 cm (men)/> 89 cm (women). In this review we attempted to summarize relevant data by searching dermatological literature regarding associations between various skin conditions and MeTS. A multitude of studies was retrieved and a further goal of the present article is to present plausible mechanistic connections. The severity of skin conditions like psoriasis has been linked with MeTS. Parameters of MeTS like insulin resistance are present in patients with early onset androgenic alopecia, hidradenitis suppurativa acne and rosacea. Since MeTS can lead to CVD and type 2 diabetes early detection of patients would be very important. Also therapeutic intervention on MeTS could lead to improvement on the severity of skin conditions. This reciprocal relationship between skin diseases and MeTS in our opinion holds great interest for further investigation.

Insights into the epidemiology, aetiology and associations of infraspinatus atrophy in overhead athletes: a systematic review.

Infraspinatus atrophy (IA) is much more prevalent in overhead sports compared with the general population. Its exact aetiology in this group of athletes remains unclear and definitive associations with pathology and performance have not yet been reached. The aim of this systematic review is to present the evidence on IA in overhead athletes focussing on the proposed mechanisms of suprascapular neuropathy and its associations with shoulder pathology and performance. A thorough literature search via Medline, EMBASE and Scopus was performed. From the nine articles identified, the majority of authors propose suprascapular nerve (SN) injury at the spinoglenoid notch; however, the suprascapular notch has also been suggested as a potential site of injury. With regard to the exact mechanism of suprascapular neuropathy, the majority of authors propose repeated traction of the nerve during extreme shoulder abduction and horizontal adduction and/or eccentric contractions of the infraspinatus. In the limited relevant literature, convincing links between IA and performance or shoulder pathology have not been identified. IA in overhead sports is most likely of multi-factorial aetiology. Important questions about IA and its significance in overhead sports remain unanswered and more biomechanical and prospective studies are warranted to provide further insights into this athletic injury.

Dominant vs. non-dominant shoulder morphology in volleyball players and associations with shoulder pain and spike speed.

The aims of our study were to compare the dominant (DOM) and non-dominant (NDOM) shoulders of high-level volleyball athletes and identify possible associations of shoulder adaptations with spike speed (SS) and shoulder pathology. A total of 22 male volleyball players from two teams participating in the first division of the Cypriot championship underwent clinical shoulder tests and simple measurements around their shoulder girdle joints bilaterally. SS was measured with the use of a sports speed radar. Compared with the NDOM side, the DOM scapula was more lateralised, the DOM dorsal capsule demonstrated greater laxity, the DOM dorsal muscles stretching ability was compromised, and the DOM pectoralis muscle was more lengthened. Players with present or past DOM shoulder pain demonstrated greater laxity in their DOM dorsal capsule, tightening of their DOM inferior capsule, and lower SS compared with those without shoulder pain. Dorsal capsule measurements bilaterally were significant predictors of SS. None of the shoulder measurements was associated with team roles or infraspinatus atrophy, while scapular lateralisation was more pronounced with increasing years of experience, and scapular antetilting was greater with increasing age. Adaptations of the DOM shoulder may be linked to pathology and performance. We describe simple shoulder measurements that may have the potential to predict chronic shoulder injury and become part of injury prevention programmes. Detailed biomechanical and large prospective studies are warranted to assess the validity of our findings and reach more definitive conclusions.

The volleyball athlete's shoulder: biomechanical adaptations and injury associations.

In volleyball, the dominant shoulder of the athlete undergoes biomechanical and morphological adaptations; however, definitive conclusions about their exact nature, aetiology, purpose and associations with shoulder injury have not been reached. We present a systematic review of the existing literature describing biomechanical adaptations in the dominant shoulders of volleyball players and factors that may predispose to shoulder pain/injury. A thorough literature search via Medline, EMBASE and SCOPUS was conducted for original studies of volleyball players and 15 eligible articles were identified. Assessment of study quality was performed using the STROBE statement. The reviewed literature supports the existence of a glenohumeral internal rotation deficit (GIRD) and a possible (and less pronounced) external rotation gain in the dominant vs. the non-dominant shoulder of volleyball athletes. Unlike other overhead sports, the GIRD in volleyball athletes appears to be anatomical as a response to the repetitive overhead movements and not to be associated with shoulder pain/injury. Additionally, the dominant shoulder exhibits muscular imbalance, which appears to be a significant risk factor for shoulder pain. Strengthening of the external rotators should be used alongside shoulder stretching and joint mobilisations, core strengthening and optimisation of spike technique as part of injury management and prevention programmes.

Coronary endarterectomy: The current state of knowledge.

Coronary artery endarterectomy (CE) is a procedure performed adjunctive to coronary artery bypass grafting in patients with diffuse coronary artery disease (CAD). This review was conducted in order to assess the safety of the procedure, the associated complications as well as short- and long-term patient outcomes. A literature search was performed via Pubmed, and 50 articles were included in the review based on our inclusion and exclusion criteria. The mortality and morbidity rates were found to be acceptable in a highly selected group of patients. Therefore, CE may have an important role to play in the surgical management of patients with complicated CAD and should be incorporated to the armamentarium of the cardiologist and the cardiac surgeon following careful consideration by a multi-disciplinary approach.

Surgical perspectives in the management of atrial fibrillation.

Atrial fibrillation (AF) is the most common cardiac arrhythmia and a huge public health burden associated with significant morbidity and mortality. For decades an increasing number of patients have undergone surgical treatment of AF, mainly during concomitant cardiac surgery. This has sparked a drive for conducting further studies and researching this field. With the cornerstone Cox-Maze III "cut and sew" procedure being technically challenging, the focus in current literature has turned towards less invasive techniques. The introduction of ablative devices has revolutionised the surgical management of AF, moving away from the traditional surgical lesions. The hybrid procedure, a combination of catheter and surgical ablation is another promising new technique aiming to improve outcomes. Despite the increasing number of studies looking at various aspects of the surgical management of AF, the literature would benefit from more uniformly conducted randomised control trials.

Blunt Thoracic Aortic Injuries: New Perspectives in Management.

Blunt thoracic aortic injuries (BTAIs) present a great challenge because of their potentially fatal outcomes. Recent advancements in their management have proved to be beneficial in terms of various parameters, including mortality and complications. Endovascular repair is now the treatment of choice in most centres and is continuously replacing the traditional open surgical method. We present a mini-review of the most recent relevant literature that briefly describes the major shifts in the diagnosis and treatment of BTAIs and compares the outcomes of the conventional surgical approach to those of the endovascular method for the definitive repair of these injuries. Although both the reviewed literature and the most recently published guidelines are in support of the use of the endovascular approach, as short and midterm results are promising, its long-term outcomes still remain in question.

Effects of combined vitamin D--calcium supplements on the cardiovascular system: should we be cautious?

Despite the growing body of evidence on the potential effects of calcium and vitamin D as monotherapies on different cardiovascular (CV) parameters, the combined supplementation with calcium and vitamin D (CaD), which is most frequently encountered in clinical practice, has not received the attention it deserves. A literature search was conducted via EMBASE and Medline and identified 14 randomised controlled trials (RCTs) and 2 meta-analyses reporting on effects of combined supplementation with CaD on CV events, CV death, blood pressure, lipids, glucose metabolism and weight. Overall, the existing evidence does not support beneficial properties of supplementation with CaD on the CV system, nor does it suggest that a re-appraisal of the use of CaD is necessary due to adverse effects, although increased risk of CV events has been reported by some authors. The guidelines for the use of CaD supplementation need not change until well-conducted RCTs that have CV effects as primary outcomes and adjust for major confounders indicate otherwise.

Advances in the treatment of blunt thoracic aortic injuries.

Blunt thoracic aortic injuries, even though rare in incidence, carry significant mortality rates and their management still remains challenging. There have been major shifts in diagnosing and treating these injuries in the last 5 decades, which proved to be beneficial in terms of mortality and complications. Endovascular repair has been increasingly used for definitive treatment and its outcomes appear to be at least equally safe and effective as those of open repair. We present a balanced review of the relevant literature regarding the most appropriate approach and definitive treatment of these pathological entities. Based on the studies analyzed, endovascular repair is increasingly being established as the choice of treatment, however, the conventional open surgical approach still remains a safe method for severe injuries; the mortality, complication rates and proven longterm results of the latter are continuously improving. Additionally, delayed repair, where appropriate, seems to be a safe option with very low mortality rates. Despite the encouraging short and midterm outcomes reported, endovascular treatment needs to be assessed in the longterm for more accurate conclusions to be drawn about its durability and safety.

What type of valve is most appropriate for osteogenesis imperfecta patients?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was in osteogenesis imperfecta (OI) patients with valve disease undergoing valve replacement which type of valve (bioprosthetic or mechanical) is most appropriate in terms of safety, complications and survival. Altogether more than 77 papers were found as a result of the reported search, of which 43 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Previous review articles have presented case reports up to 2009. As all published data are based on case reports, we conducted a more detailed analysis that included the aforementioned series, reports that were missed prior to 2009 and all published data from 2009 to October 2013. Our analysis identified 43 OI patients. Mechanical valves were used in the majority of cases (31 patients), bioprosthetic valves in 10 patients and homografts in 2 patients. We conclude that based on the best available evidence, it appears that bioprosthetic valves have had better outcomes (mortality rate 10%) and a lower valve-related complication rate (0%) compared with mechanical valves (mortality rate 16.1%, complication rate 16.1%), even though differences were not statistically significant. Although the existing evidence is solely based on case reports of a relatively small number, we would suggest the use of bioprosthetic valves in OI patients with valve disease, as they appear to be safer according to our analysis. Moreover, considering the surgical difficulties related to the friability and weakness of the tissues in terms of suture lines and implantation of the valve as well as the high risk of perioperative bleeding which can be related to tissue friability, capillary fragility and platelet dysfunction followed by the risk of major traumatic fractures and a possible risk of aortic dissection in the future, the bioprosthetic valves seem to be safer taking into account the avoidance of lifelong anticoagulation and its secondary bleeding complications.

Vitamin D supplementation and lipid profile: what does the best available evidence show?

Vitamin D supplements have increasingly been used for the treatment and prevention of osteoporosis. Historically, effects of the vitamin on the cardiovascular (CV) system have been proposed and demonstrated in the literature, including benefits on serum lipids. Although observational studies support an association between increased serum vitamin D levels and a favorable lipid profile, interventional studies have shown no effects. This review presents and analyzes all the related randomized controlled trials (RCTs) identified in the literature from 1987 to present. A systematic literature search was conducted via MEDLINE, Cochrane Library and EMBASE and, out of 19 relevant RCTs identified, only one reported benefits of vitamin D supplementation on lipid profile parameters, while the rest showed no effects or even adverse outcomes, which are highlighted by the only meta-analysis in the field. Attempts to explain the paradox of beneficial findings of observational studies versus discouraging results of interventional studies have been made and the most popular suggests that high serum vitamin D concentrations may not be the cause of good health but its outcome instead, as healthy people are more likely to stay outdoors longer and have better eating habits. For definitive answers to be given, large, well-designed RCTs need to be conducted that will take into account and adjust for dietary consumption as well as serum calcium and parathyroid hormone levels, both of which have been shown to be associated with the CV system. Until then, recommendations for vitamin D supplementation should not change.

The challenge of pulmonary endobronchial chondromatous hamartomas.

Pulmonary chondromatous (or chondroid) hamartomas are common benign tumours of the lung and may be either parenchymal or endobronchial. The latter are only rarely encountered and have a variation in their clinical presentation related to the endobronchial obstructive lesion, including atelectasis, pneumonia, hemoptysis. If not diagnosed early and treated properly, endobronchial hamartomas can cause irreversible lung damage. We present a review of the recent English literature over the diagnostic approach and management of pulmonary endobronchial chondromatous hamartomas.

Archibald Cochrane (1909-1988): the father of evidence-based medicine.

Professor Archibald Cochrane (1909-1988) is considered to be the originator of the idea of evidence-based medicine in our era. With his landmark book 'Effectiveness and Efficiency: Random Reflections on Health services' he managed to inspire and positively influence the medical society with respect to the proper assessment of reliable evidence for the provision of the best medical care. His vision combined with his scientific achievements can be considered as the foundation of the Cochrane Collaboration; named after him in recognition of and gratitude for his pioneering work. We present the highlights of his adventurous and vibrant personal and academic life in an attempt to honour his contribution to shaping modern medical research.