Poor cervical proprioception as a risk factor for concussion in professional male rugby union players.

BACKGROUND: Concussion is one of the most common injuries in male professional Rugby Union ('rugby') and accounts for significant time loss from training and competition. Despite the most recent Concussion in Sport Group consensus statement recommending a focus on the identification of modifiable risk factors, limited evidence for their existence is available. OBJECTIVE: To investigate the association between cervical proprioception and concussion incidence in a group of professional male rugby players over the course of a full season. METHODS: 165 players were assessed at pre-, mid- and end of season time points using the Cervical Joint Position Error Test (CJPET). Associations with diagnosed concussion injuries are presented as incidence rate ratios with 95% confidence intervals. We present the Incidence Rate Ratios (IRR) for a 10% increase in each variable and compared results against concussion using match minutes to account for risk exposure. RESULTS: During the study period, 45 concussions were incurred by 44 players [or 19.7 concussions per 1000 player-match hours]. There was a significant association between right rotation repositioning error and concussion, with a 5% increase in concussion rate for each 10% increase in gross right rotation error (P = 0.021). CONCLUSION: Poor gross right rotation repositioning error is a modifiable intrinsic risk factor for concussion in professional male rugby players. Interventions to improve proprioceptive function may act as an effective method for reducing concussion incidence in this population.

Chronic lateral ankle instability increases the likelihood for surgery in athletes with os trigonum syndrome.

PURPOSE: The etiology and incidence of os trigonum syndrome in professional athletes is highly variable. There is a paucity of data to ascertain why some athletes evolve towards surgery whilst others remain asymptomatic. We hypothesized that a lateral ligament ankle injury would increase the likelihood for surgery in those athletes with os trigonum syndrome. METHODS: Eighty professional athletes with clinical and radiological signs of os trigonum syndrome were identified to ascertain the incidence of injury to the lateral ligamentous ankle complex (acute and chronic) by magnetic resonance imaging (MRI). This cohort was subdivided into 2 groups; a surgical (n = 40) and a non-surgical (n = 40) cohort. Surgical division was decided if (1) the clinical hyper-plantar flexion test was positive, (2) a positive diagnostic ultrasound-guided injection and (3) no improvement was observed after 6 weeks of conservative rehabilitation. RESULTS: From the surgical cohort, 37 players (94.1%) had a chronic lateral ankle ligament injury on MRI, whilst 3 players (5.9%) had an acute lateral ankle ligament injury. Binary logistic linear modelling revealed that having a chronic lateral ligament injury increases the likelihood of os trigonum syndrome surgery by ten times compared to those with an acute lateral ligament injury. CONCLUSION: Professional athletes with chronic lateral ligament ankle injury have an approximate ten times greater risk for os trigonum syndrome surgery compared to athletes with acute lateral ligament ankle injury. LEVEL OF EVIDENCE: IV.

Passive heat acclimation improves skeletal muscle contractility in humans.

The aim of this study was to investigate the effect of repeated passive heat exposure (i.e., acclimation) on muscle contractility in humans. Fourteen nonheat-acclimated males completed two trials including electrically evoked twitches and voluntary contractions in thermoneutral conditions [Cool: 24°C, 40% relative humidity (RH)] and hot ambient conditions in the hyperthermic state (Hot: 44-50°C, 50% RH) on consecutive days in a counterbalanced order. Rectal temperature was ~36.5°C in Cool and was maintained at ~39°C throughout Hot. Both trials were repeated after 11 days of passive heat acclimation (1 h per day, 48-50°C, 50% RH). Heat acclimation decreased core temperature in Cool (-0.2°C, P < 0.05), increased the time required to reach 39°C in Hot (+9 min, P < 0.05) and increased sweat rate in Hot (+0.7 liter/h, P < 0.05). Moreover, passive heat acclimation improved skeletal muscle contractility as evidenced by an increase in evoked peak twitch amplitude both in Cool (20.5 ± 3.6 vs. 22.0 ± 4.0 N·m) and Hot (20.5 ± 4.7 vs. 22.0 ± 4.0 N·m) (+9%, P < 0.05). Maximal voluntary torque production was also increased both in Cool (145 ± 42 vs. 161 ± 36 N·m) and Hot (125 ± 36 vs. 145 ± 30 N·m) (+17%, P < 0.05), despite voluntary activation remaining unchanged. Furthermore, the slope of the relative torque/electromyographic linear relationship was improved postacclimation (P < 0.05). These adjustments demonstrate that passive heat acclimation improves skeletal muscle contractile function during electrically evoked and voluntary muscle contractions of different intensities both in Cool and Hot. These results suggest that repeated heat exposure may have important implications to passively maintain or even improve muscle function in a variety of performance and clinical settings.

Optimizing clinical practice in Ontario based on data, evidence and guidelines

Optimizing clinical practice based on data, evidence and guidelines is a challenge faced in every health system around the world. The way the challenge manifests itself at the level of the patient has been remarkably consistent over time: tough decisions made at the intersection of clinical expertise, patient values and preferences, and the best available data, evidence and guidelines.(1) Rigid clinical decision support systems, insufficient attention to patient goals of care and shared decision-making (particularly in the face of multimorbidity), and the large volume of available data, evidence and guidelines (of variable reliability and clinical significance) are variations on a now twodecades-old theme about just how tough these decisions can be

The safety and effectiveness of a long-acting transdermal fentanyl solution compared with oxymorphone for the control of postoperative pain in dogs: a randomized, multicentered clinical study.

A prospective, double-blinded, positive-controlled, multicenter, noninferiority study was conducted to evaluate the safety and effectiveness of transdermal fentanyl solution (TFS) compared with oxymorphone for the control of postoperative pain in dogs. Five hundred and two (502) client-owned dogs were assigned to a single dose of TFS (2.7 mg/kg) applied 2-4 h prior to surgery or oxymorphone hydrochloride (0.22 mg/kg) administered subcutaneously 2-4 h prior to surgery and q6h through 90 h. Pain was evaluated over 4 days by blinded observers using a modified Glasgow composite pain scale, and the a priori criteria for treatment failure was a pain score ≥ 8 or adverse event necessitating withdrawal. Four TFS- and eight oxymorphone-treated dogs were withdrawn due to lack of pain control. Eighteen oxymorphone-treated, but no TFS-treated dogs were withdrawn due to severe adverse events. The one-sided upper 95% confidence interval of the difference between TFS and oxymorphone treatment failure rates was -5.3%. Adverse events associated with oxymorphone were greater in number and severity compared with TFS. It was concluded that a single administration of TFS was safe and noninferior to repeated injections of oxymorphone for the control of postoperative pain over 4 days at the dose rates of both formulations used in this study.

Issue brief: developing a 'rapid-response' program for health system decision-makers in Canada

A gap exists in efforts to support the use of research evidence between 'self-serve' approaches such as 'one-stop shops' for research evidence (e.g., Health Systems Evidence ­ www.healthsystemsevidence.org) and 'fullserve' approaches such as convening stakeholder dialogues with health-system leaders that are informed by an evidence brief that synthesizes the best available research evidence. A rapid-response program could fill this gap by providing timely access to research evidence for health system decision-makers (i.e., policymakers and stakeholders who make, inform or implement decisions about health systems) when these decision-makers need support with finding and synthesizing the available research evidence but the timeline is too short to prepare a full evidence brief and convene a stakeholder dialogue,. This issue brief was prepared as an input to a half-day stakeholder dialogue involving those who will be involved in or affected by decisions about whether and how to develop a rapid-response program for health system decision-makers in Canada.

Evidence brief: supporting optimal screening approaches in Canada

This evidence brief mobilizes both global and local research evidence about a problem, three elements of a comprehensive approach for addressing the problem, and key implementation considerations. Whenever possible, the evidence brief summarizes research evidence drawn from systematic reviews of the research literature and occasionally from single research studies. A systematic review is a summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select and appraise research studies and to synthesize data from the included studies. The evidence brief does not contain recommendations, which would have required the authors of the brief to make judgments based on their personal values and preferences, and which could pre-empt important deliberations about whose values and preferences matter in making such judgments.

Differentiating athlete's heart from inherited cardiac pathology: the challenge of repolarisation abnormalities presenting during anaesthesia.

This case report describes an asymptomatic healthy male professional athlete who underwent general anaesthesia for a routine orthopaedic operation. Peri-procedure, pronounced ST elevation suggestive of myocardial ischaemia manifested on the electrocardiogram lasting for four hours post-procedure, upon which the athlete developed deep and diffuse inferolateral T-wave inversion. These changes resolved spontaneously and the patient remained clinically stable throughout. This case demonstrates the clinical conundrum facing anaesthetists attempting to differentiate between repolarisation anomalies that are commonly observed in high-level athletes and those of inherited cardiac pathology, namely hypertrophic cardiomyopathy, which is the leading cause of sudden cardiac death in young athletes.

Issue brief: designing integrated approaches to support people with multimorbidity in Ontario

Managing multiple medical conditions is part of the daily life of a growing number of Ontarians. As Fortin et al. observed, "patients with multiple conditions are the rule rather than the exception in primary care."(2) Multimorbidity (living with three or more medical conditions) has attracted significant attention among health system policymakers and stakeholders in Ontario, in part because adults with multimorbidity account for more than two-thirds of healthcare costs.(3) Multimorbidity not only has a significant impact on healthcare utilization and costs, but affects quality of life, ability to work, employability, disability, processes of care and mortality.(4) Despite the burden of multimorbidity, patients often receive care that is "fragmented, incomplete, inefficient, and ineffective."(4) Thus, there have been growing calls for changes to health systems and clinical decision-making processes to more effectively and efficiently provide the complex care required by those with multimorbidity.(5;6) One such response in Ontario has been Health Links, which was launched in December 2012 and now includes 26 'early adopters'. Health Links are designed to support local patient-care networks, led by a coordinating partner, and attempt to coordinate and optimize access to needed services, initially with a particular focus on the 5% of patients who consume about 66% of healthcare costs.(3;7) However, primary care, community care and other providers, whether working as part of or separate from Health Links, need support to achieve measurable successes in caring for patients with multimorbidity and preventing multimorbidity in those at risk, and to achieve health system transformation more broadly for this patient group.

Significance of deep T-wave inversions in asymptomatic athletes with normal cardiovascular examinations: practical solutions for managing the diagnostic conundrum.

Preparticipation screening programmes for underlying cardiac pathologies are now commonplace for many international sporting organisations. However, providing medical clearance for an asymptomatic athlete without a family history of sudden cardiac death (SCD) is especially challenging when the athlete demonstrates particularly abnormal repolarisation patterns, highly suggestive of an inherited cardiomyopathy or channelopathy. Deep T-wave inversions of ≥ 2 contiguous anterior or lateral leads (but not aVR, and III) are of major concern for sports cardiologists who advise referring team physicians, as these ECG alterations are a recognised manifestation of hypertrophic cardiomyopathy (HCM) and arrhythmogenic right ventricular cardiomyopathy (ARVC). Subsequently, inverted T-waves may represent the first and only sign of an inherited heart muscle disease, in the absence of any other features and before structural changes in the heart can be detected. However, to date, there remains little evidence that deep T-wave inversions are always pathognomonic of either a cardiomyopathy or an ion channel disorder in an asymptomatic athlete following long-term follow-up. This paper aims to provide a systematic review of the prevalence of T-wave inversion in athletes and examine T-wave inversion and its relationship to structural heart disease, notably HCM and ARVC with a view to identify young athletes at risk of SCD during sport. Finally, the review proposes clinical management pathways (including genetic testing) for asymptomatic athletes demonstrating significant T-wave inversion with structurally normal hearts.

The effectiveness of a long-acting transdermal fentanyl solution compared to buprenorphine for the control of postoperative pain in dogs in a randomized, multicentered clinical study.

A prospective, double-blinded, positive-controlled, multicenter, noninferiority clinical study was conducted to evaluate the safety and effectiveness of a long-acting transdermal fentanyl solution (TFS) for the control of postoperative pain. Four hundred forty-five client-owned dogs of various breeds were randomly assigned to receive a single dose of TFS (2.6 mg/kg [∼50 µL/kg]) (N = 223) applied 2-4 h prior to surgery or buprenorphine (20 µg/kg) (N = 222) administered intramuscularly 2-4 h prior to surgery and every 6 h through 90 h. There were 159 (35.7%) males and 286 (64.3%) females ranging from 0.5 to 16 years of age and 3 to 98.5 kg enrolled. Pain was scored using the modified Glasgow Composite Pain Scale with an a priori dropout criteria of ≥ 8 (20 maximum score). The one-sided upper 95% confidence interval of the mean difference between fentanyl and buprenorphine treatment failures was 5.6%, which was not greater than the a priori selected margin difference of 15%. Adverse events attributed to either treatment were minimal in impact and were approximately equal between groups. Sustained plasma fentanyl concentrations provided by a single pre-emptive dose of TFS are safe and effective and are noninferior to repeated injections of buprenorphine in controlling postoperative pain over 4 days. This long-acting fentanyl formulation provides veterinarians with a novel, registered option for the control of postoperative pain in dogs that improves dosing compliance and potentially mitigates the disadvantages of oral, parenteral, and patch delivered opioids.

Prevalence of electrocardiographic abnormalities in West-Asian and African male athletes.

OBJECTIVES: To evaluate the electrocardiographic (ECG) characteristics of West-Asian, black and Caucasian male athletes competing in Qatar using the 2010 recommendations for 12-lead ECG interpretation by the European Society of Cardiology (ESC). DESIGN: Cardiovascular screening with resting 12-lead ECG analysis of 1220 national level athletes (800 West-Asian, 300 black and 120 Caucasian) and 135 West-Asian controls was performed. RESULTS: Ten per cent of athletes presented with 'uncommon' ECG findings. Black African descent was an independent predictor of 'uncommon' ECG changes when compared with West-Asian and Caucasian athletes (p<0.001). Black athletes also demonstrated a significantly greater prevalence of lateral T-wave inversions than both West-Asian and Caucasian athletes (6.1% vs 1.6% and 0%, p<0.05). The rate of 'uncommon' ECG changes between West-Asian and Caucasian athletes was comparable (7.9% vs 5.8%, p>0.05). Seven athletes (0.6%) were identified with a disease associated with sudden death; this prevalence was two times higher in black athletes than in West-Asian athletes (1% vs 0.5%), and no cases were reported in Caucasian athletes and West-Asian controls. Eighteen West-Asian and black athletes were identified with repolarisation abnormalities suggestive of a cardiomyopathy, but ultimately, none were diagnosed with a cardiac disease. CONCLUSION: West-Asian and Caucasian athletes demonstrate comparable rates of ECG findings. Black African ethnicity is positively associated with increased frequencies of 'uncommon' ECG traits. Future work should examine the genetic mechanisms behind ECG and myocardial adaptations in athletes of diverse ethnicity, aiding in the clinical differentiation between physiological remodelling and potential cardiomyopathy or ion channel disorders.

Differences in markers of cardiovascular disease between professional football players of West-Asian and Black African descent.

OBJECTIVES: To examine the cardiovascular risk factors of professional football players of West-Asian and Black African descent competing in the 2010/11 Qatar Stars League. DESIGN: Ten out of twelve professional football clubs attended pre-participation screening. 100 West-Asian males from seven Gulf States and six Middle-Eastern countries and 90 Black males from seven African countries. METHODS: All players were screened using the FIFA pre-competition medical assessment, incorporating a physical examination, resting 12-Lead ECG, echocardiogram, with determination of total cholesterol, high and low density lipoprotein (HDL/LDL) and triglycerides. RESULTS: West-Asian football players had a higher prevalence of a family history (FH) of coronary heart disease (CHD) (25% vs. 12%, p = 0.025) compared to Black African players predominantly due to CHD in their fathers (14% vs. 6%, p<0.05). West-Asian players had higher total cholesterol levels (4.4 vs. 4.2 mmol/L, p = 0.025) and lower HDL levels (1.3 vs. 1.4 mmol/L, p = 0.004) than Black African players; remaining significant after adjusting for a FH of CHD. Positively, all lipid levels were clinically acceptable for both ethnicities. Finally, one in eight West-Asian and one in eleven Black African football players were regular smokers. CONCLUSIONS: The prevalence of cardiovascular disease in West-Asia is increasing. This study observed clinically acceptable blood lipid profiles for both West-Asian and Black African football players. However, West-Asian players had a greater number of markers for CVD than their Black African counterparts despite being matched for physical activity levels. Targeted education with regards to diet, lifestyle and tobacco use is required for both ethnicities.

Evidence brief: coordinating the use of genetic tests and related services in British Columbia

Rapid technological advances in genetics and genomics hold promise for the diagnosis, treatment and even prevention of common and rare diseases. Nevertheless, they also raise concerns regarding their potential impacts on health systems, which has led many countries to reflect on the optimal models to coordinate genetic testing and related services,(1-5) as well as the optimal frameworks to guide policy and coverage decisions that could help embrace opportunities offered by new and emerging technologies while minimizing the use of harmful and ineffective ones.

Evidence brief: expanding uptake of hospital-based tobacco-use cessation supports across Ontario

An assessment of what is is known about problems related to expanding the uptake of hospital-based tobacco-use cessation supports, options for addressing these problems, and key implementation considerations. The evidence brief was an input to a stakeholder dialogue on the topic of expanding the uptake of hospital-based tobacco-use cessation supports across Ontario.

Evidence Brief: organizing a care system for older adults in Ontario

The health of the aging population has been identified as a high priority for the province of Ontario and has become one of the province's most pressing health and social policy issues.(1) In addition, healthcare expenditures in Ontario now exceed 46% of the provincial government's annual budget.(2) In comparison to other countries, Canada has the fifth highest total per capita spending on health in the world and is among the six countries with the highest ratio of total health expenditure to GDP.(3) As the baby-boom generation approaches and enters into retirement, the challenges that Ontario faces in supporting the health and social care needs of an aging population will intensify significantly. Those over the age of 65 consumed approximately 44% of provincial and territorial government health spending in 2008, but comprised only 13.7% of the population.(4) These challenges are further intensified by the current resource constraints facing the province after a significant recession, with the resulting government deficit and debt levels meaning that Ontario has to do more with less.

A unique case series of novel biomarkers of cardiac damage in cyclists completing the 4800 km Race Across America (RAAM).

Prolonged strenuous exercise is associated with the appearance of biomarkers of cardiac cell damage and a decline in cardiac function during recovery. Few studies have assessed repeated bouts of prolonged exercise and whether this results in further biomarker accumulation and greater dysfunction. Further, it may be useful to describe the changes in a range of biomarkers that may provide additional insight into the clinical significance of cardiac biomarker release. Four highly trained cyclists completed the 4800 km Race Across America (RAAM) in 7 days. Venous blood samples and echocardiograms were taken prior to, every 24 hours during and immediately after the RAAM. Venous blood was analysed for cardiac troponin I (cTnI), creatine kinase MB (CK-MB), fatty acid binding protein (HFABP), glycogen phosphorylase BB (GPBB) and N-Terminal Brain Natriuretic Peptide (NTproBNP). Echocardiograms allowed analysis of septal, left ventricular free wall and right ventricular free wall tissue velocities during systole and diastole. Before the RAAM cTnI levels were below the assay detection level (0.02 ng.ml⁻¹). In three riders cTnI peaked on day one (0.03 ng.ml⁻¹) and returned below detection levels post race. In the 4th rider cTnI peaked on day 5 (0.08 ng.ml⁻¹) and was still elevated post-race. Both CK-MB and H-FABP were increased during the RAAM in all 4 cyclists. In three riders H-FABP peaked on day one (3.49 to 5.09 ng.ml⁻¹) and declined over the rest of the RAAM. In the final rider H-FABP peaked on day two (5.90 ng.ml⁻¹) and then dropped back to baseline by the post-RAAM assessment. Interestingly, changes in H-FABP mirrored, temporally, changes in CK-MB in places and this may reflect an association with skeletal muscle damage. Data for GPBB value to (2.9 - 149.6 ng.ml⁻¹) and NTproBNP value to (27.3 - 310.0 ng.L⁻¹) were variable but again was elevated in all riders during the course of the RAAM. Changes in ventricular wall tissue velocities were minor and not cumulative. Peak atrial diastolic tissue velocity in the left ventricular free wall increased (P < 0.05) from 11 to 18 cm.s⁻¹ over the last two race days but this did not significantly impact the ratio of early to late diastolic wall motion. Cardiac biomarkers were elevated during the completion of the RAAM in all 4 cyclist but changes were not cumulative which suggest that the hearts of the cyclists coped well with the extreme cardiac work demanded by this ultra-endurance exercise challenge.

Issue brief: engaging health system decision-makers in supporting comprehensive chronic pain management in provincial and territorial healthcare systems in Canada

The lack of health system decision-maker engagement in supporting comprehensive chronic pain management in provincial and territorial healthcare systems in Canada can be understood by considering four sets of interrelated issues: 1) lack of awareness of chronic pain; 2) lack of awareness of limitations in existing programs and services; 3) gaps in healthcare system arrangements that limit the attention given to chronic pain; and 4) limited reach of existing efforts to engage health system decision-makers in supporting chronic pain

The Greater Involvement of People Living with AIDS principle: theory versus practice in Ontario's HIV/AIDS community-based research sector.

Drawing on the Greater Involvement of People with HIV/AIDS (GIPA) principle, the HIV/AIDS movement began to "democratize" research in Canada in the mid-1990s. To date, there is little evidence about the success of the community-based research (CBR) movement in relation to the implementation of GIPA. We draw on findings from a larger study examining barriers and facilitating factors in relation to HIV-related CBR in Ontario, Canada. An online survey was completed by 39 senior managers in Ontario AIDS service organizations (ASOs). Twenty-five in-depth, semi-structured interviews were then conducted to further explore the survey findings. Survey respondents reported that, compared to researchers and frontline service providers, people living with HIV/AIDS (PLWHA) tended to be the least involved in all stages (input, process and outcome) of CBR projects. AIDS service organizations with a mandate that included serving rural and urban communities reported even lower levels of PLWHA involvement in CBR. Qualitative data reveal complex barriers that make meaningful PLWHA engagement in CBR difficult, including: HIV-related stigma; health-related challenges; "credentialism"; lack of capacity to engage in research; other issues taking priority; and mistrust of researchers. Facilitating factors included valuing lived experience; training and mentoring opportunities; financial compensation; trust building; and accommodating PLWHA's needs. While there is strong support for the GIPA principles in theory, practice lags far behind.