Management of lumbar bone stress injury in cricket fast bowlers and other athletes.

Background: Recent guidelines (including a special series in The Lancet) have emphasised a minimal role for imaging when assessing low back pain in adults, as the majority of patients will have non-specific findings on imaging that do not correlate well with pain. Objective: To assess whether the diagnosis of lumbar bone stress injuries in young athletes should be considered an exception to the recommendation to avoid imaging for low back pain in adults. Method: Narrative review. Results: Early lumbar bone stress injury diagnosis has been available via traditional MRI sequences (and its precursor Single Photon Emission Computed Tomography (SPECT)) for 25-30 years. MRI assessments using bone window sequences (such as Volumetric Interpolated Breath-hold Examination (VIBE)) have allowed a better understanding of the diagnosis and prognosis of lumbar bone stress injury in young athletes. MRI with bone sequences has allowed non-radiating scans to serially follow the healing of unilateral stress fractures. In the majority of cases, non-chronic unilateral fractures can heal; however, this takes three-six months rather than the six-ten weeks that would be the typical unloading period if using symptoms (only) as a guide. The use of MRI to provide evidence of bony healing (as opposed to fibrous union, which creates the pars defect that predisposes to further bone stress lesions) can lead to better long-term outcomes in athletes. There is evidence to flag this as a structural lesion which is both painful and, more importantly, can heal/resolve if managed correctly. Therefore it represents an important 'specific' diagnostic subset within adult low back pain. Conclusion: Structural (rather than functional) management of bone stress injuries in high-demand athletes, such as cricket pace bowlers, is in contrast to the recommendation of functional management for general back pain in adults. Structural management is justified when there are demonstrable superior outcomes of having better structure. Although this has not yet been shown in randomised trials of elite athletes, apparent lengthier Test cricket careers of pace bowlers who do not have pars defects suggest better athletic outcomes if bony healing is achieved. For lower demand young adults, or athletes with established bilateral pars defects, functional management may be more pragmatic.

No effect of tocolytic therapy with atosiban on maternal serum interleukin-6 and tumor necrosis factor-alpha in threatened preterm labor.

OBJECTIVES: We aimed to evaluate the effect of intravenous administration of tocolytic therapy with an oxytocin antagonist drug (atosiban) on maternal serum interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) levels in women with threatened preterm labor. METHODS: The study population consisted of 46 women with a singleton pregnancy admitted to our department with a diagnosis of threatened preterm labor at between 26 and 34 weeks of gestation. Atosiban was administered to all women. Nine women (group A) progressed to delivery within 48 hours of admission. The remaining 37 women were divided in two groups: group B consisted of 16 women who remained undelivered at 48 hours but experienced delivery within 7 days and group C consisted of 21 women who did not deliver within the next 7 days. Maternal serum IL-6 and TNF-alpha levels were assessed in duplicate by a high sensitivity ELISA kit on patient admission and again at the end of treatment with atosiban (36 hours post-admission). RESULTS: Serum IL-6 and TNF-alpha concentrations on admission were significantly higher in group A compared to those found in group B (p = 0.01) and group C (p = 0.04). Comparisons of serum IL-6 values on admission and at 36 hours after the initiation of atosiban treatment were comparable in group A (p = 0.95), group B (p = 0.39), and group C (p = 0.79). Similarly serum TNF-alpha levels on admission were not significantly different compared to those at the end of treatment in all groups (p = 0.85 for group A, p = 0.45 for group B, and p = 0.21 for group C). CONCLUSIONS: No effect of tocolytic therapy with atosiban was observed on serum IL-6 and TNF-alpha levels in women with threatened preterm labor.

Positive association of serum interleukin-1beta and CRH levels in women with pre-term labor.

OBJECTIVE: The aim of this study was to investigate the hypothesis that interleukin-1beta (IL-1beta) might be involved in the increase of the circulating levels of placental-derived CRH leading to the initiation of pre-term labor. SUBJECTS AND METHODS: Forty-eight primigravidae with a singleton viable pregnancy between 28 and 34 weeks of gestation were studied. The subjects were divided in two groups: group A consisted of 30 pregnant women (mean age+/-SD; 22+/-1.1 yr old) presented with pre-term labor (mean gestational age+/-SD; 30.6+/-2.3 weeks) and group B consisted of 18 pregnant women (24+/-2.6 yr old) with normal pregnancies (29.8+/-3.1 weeks). CRH and IL-1beta levels were measured in blood specimens collected from all the study subjects on admission. RESULTS: Women of group A presented significantly higher serum CRH levels (mean+/-SE; 1.18+/-1.83 ng/ml) compared to those of group B (0.48+/-0.67 ng/ml) (p<0.01). Similarly, serum IL-1beta levels were significantly higher in women of group A (0.45+/-0.12 pg/ml) compared to those of group B (0.31+/-0.08 pg/ml) (p<0.01). A positive correlation was found between serum IL-1beta and CRH (r=0.68, p=0.001) in women of group A (pre-term labor). CONCLUSIONS: Our findings suggest that the increased levels of IL-1beta and CRH found in pregnant women presented with pre-term labor might be involved in the pathophysiologic mechanism of the latter. Furthermore, a positive interaction might exist between IL-1beta and placental CRH which might lead to enhanced production of the second, facilitating, thus, the onset of labor.

First-trimester pregnancy termination with 800 microg of vaginal misoprostol every 12 h.

The objective of the study was to evaluate the efficacy and safety of 800 microg of misoprostol every 12 h, for a period of 36 h for pharmacological abortion. A group of 162 volunteer women with gestations between 50 and 63 days received misoprostol every 12 h up to a maximum of three doses for abortion. Outcome measures assessed included: successful abortion (complete abortion without requiring surgery), side effects, and a decrease in hemoglobin, mean time of vaginal bleeding, mean expulsion time and mean time of returning of menses. Complete abortion occurred in 148 of 162 (91%, 95% confidence interval 87.95) patients. The mean decrease in hemoglobin was statistically significant (p = 0.001). Vaginal bleeding lasted 8.0 +/- 3.2 days, spotting 8.0 +/- 3.5 days, and total bleeding 16 +/- 4.0 days. The mean expulsion time was 8.5 +/- 4.0 h. According to the observed outcomes, 800 microg of misoprostol vaginally could be a valid method to terminate pregnancies up to 9 weeks of gestation.