Association Between Physical Tests and Patients-Reported Outcomes in Athletes Performing Exercise Therapy for Patellar Tendinopathy:A Secondary Analysis of the JUMPER Study

Background: Physical tests are commonly used in patellar tendinopathy to aid the clinical diagnosis, assess the prognosis, and monitor treatment. However, it is still unknown whether these physical measures are associated with patient-reported outcomes after exercise therapy. Purpose: To identify the prognostic value of baseline physical test results and to determine the association between physical response after exercise therapy and clinical improvement over 24 weeks. Study Design: Case-control study; Level of evidence, 3. Methods: This study recruited 76 consecutive athletes with patellar tendinopathy who were randomized to 2 different programs of exercise therapy for 24 weeks. Athletes underwent a range of physical tests before and during exercise therapy (12 and 24 weeks), including isometric muscle strength (quadriceps and hip abductors), muscle flexibility (quadriceps, hamstrings, soleus, and gastrocnemius), vertical jump height, and visual analog scale (VAS) scores by palpation, after 3 jump trials, and after single-leg squat (VAS-SLS). The Victorian Institute of Sports Assessment–Patella (VISA-P) questionnaire was used as the primary patient-reported outcome. Linear mixed-effect models were used to assess the prognostic value of baseline physical tests. The change in VISA-P score was further dichotomized into clinical responsiveness (≥14 points) and nonresponsiveness (&lt;14 points). Multiple linear and logistic regression models were performed to evaluate associations between physical response and clinical improvement. Results: Of the 76 included patients, 67 (88%) had complete follow-ups. The estimated mean VISA-P score increased by 23 points (95% CI, 19-28 points) after 24 weeks. No association was found between any baseline physical test results and a 24-week change in VISA-P score (all Pinteraction &gt;.2, using the likelihood ratio test). Improvement in VAS-SLS after exercise therapy was not associated with VISA-P improvement after adjustment (β = −1.76; P =.01; Bonferroni-corrected P =.10; R2 = 36.3%). No associations were found between changes in other physical test results and clinical improvement (all P &gt;.05). Conclusion: In patients with patellar tendinopathy, physical test results including strength and flexibility in the lower limb, jump performance, and pain levels during pain-provoking tests were not identified as prognostic factors for patient-reported outcomes after exercise therapy. Similarly, changes in physical test results were not associated with changes in patient-reported outcomes after adjustments. These results do not support using physical test results to estimate prognosis or monitor treatment response. Registration: NCT02938143 (ClinicalTrials.gov identifier).</p

Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy:a randomised clinical trial

Objective To compare the effectiveness of progressive tendon-loading exercises (PTLE) with eccentric exercise therapy (EET) in patients with patellar tendinopathy (PT). Methods In a stratified, investigator-blinded, block-randomised trial, 76 patients with clinically diagnosed and ultrasound-confirmed PT were randomly assigned in a 1:1 ratio to receive either PTLE or EET. The primary end point was clinical outcome after 24 weeks following an intention-to-treat analysis, as assessed with the validated Victorian Institute of Sports Assessment for patellar tendons (VISA-P) questionnaire measuring pain, function and ability to play sports. Secondary outcomes included the return to sports rate, subjective patient satisfaction and exercise adherence. Results Patients were randomised between January 2017 and July 2019. The intention-to-treat population (mean age, 24 years, SD 4); 58 (76%) male) consisted of patients with mostly chronic PT (median symptom duration 2 years). Most patients (82%) underwent prior treatment for PT but failed to recover fully. 38 patients were randomised to the PTLE group and 38 patients to the EET group. The improvement in VISA-P score was significantly better for PTLE than for EET after 24 weeks (28 vs 18 points, adjusted mean between-group difference, 9 (95% CI 1 to 16); p=0.023). There was a trend towards a higher return to sports rate in the PTLE group (43% vs 27%, p=0.13). No significant between-group difference was found for subjective patient satisfaction (81% vs 83%, p=0.54) and exercise adherence between the PTLE group and EET group after 24 weeks (40% vs 49%, p=0.33). Conclusions In patients with PT, PTLE resulted in a significantly better clinical outcome after 24 weeks than EET. PTLE are superior to EET and are therefore recommended as initial conservative treatment for PT

Fractional order vs. exponential fitting in UTE MR imaging of the patellar tendon

Purpose: Quantification of the T2 ∗ relaxation time constant is relevant in various magnetic resonance imaging applications. Mono- or bi-exponential models are typically used to determine these parameters. However, in case of complex, heterogeneous tissues these models could lead to inaccurate results. We compared a model, provided by the fractional-order extension of the Bloch equation with the conventional models. Methods: Axial 3D ultra-short echo time (UTE) scans were acquired using a 3.0 T MRI and a 16-channel surface coil. After image registration, voxel-wise T2 ∗ was quantified with mono-exponential, bi-exponential and fractional-order fitting. We evaluated all three models repeatability and the bias of their derived parameters by fitting at various noise levels. To investigate the effect of the SNR for the different models, a Monte-Carlo experiment with 1000 repeats was performed for different noise levels for one subject. For a cross-sectional investigation, we used the mean fitted values of the ROIs in five volunteers. Results: Comparing the mono-exponential and the fractional order T2 ∗ maps, the fractional order fitting method yielded enhanced contrast and an improved delineation of the different tissues. In the case of the bi-exponential method, the long T2 ∗ component map demonstrated the anatomy clearly with high contrast. Simulations showed a nonzero bias of the parameters for all three mathematical models. ROI based fitting showed that the T2 ∗ values were different depending on the applied method, and they differed most for the patellar tendon in all subjects. Conclusions: In high SNR cases, the fractional order and bi-exponential models are both performing well with low bias. However, in all observed cases, one of the bi-exponential components has high standard deviation in T2 ∗. The bi-exponential model is suitable for T2 ∗ mapping, but we recommend using the fractional order model for cases of low SNR

Detection of knee synovitis using non-contrast-enhanced qDESS compared with contrast-enhanced MRI

Background: To assess diagnostic accuracy of quantitative double-echo in steady-state (qDESS) MRI for detecting synovitis in knee osteoarthritis (OA). Methods: Patients with different degrees of radiographic knee OA were included prospectively. All underwent MRI with both qDESS and contrast-enhanced T1-weighted magnetic resonance imaging (CE-MRI). A linear combination of the two qDESS images can be used to create an image that displays contrast between synovium and the synovial fluid. Synovitis on both qDESS and CE-MRI was assessed semi-quantitatively, using a whole-knee synovitis sum score, indicating no/equivocal, mild, moderate, and severe synovitis. The correlation between sum scores of qDESS and CE-MRI (reference standard) was determined using Spearman’s rank correlation coefficient and intraclass correlation coefficient for absolute agreement. Receiver operating characteristic analysis was performed to assess the diagnostic performance of qDESS for detecting different degrees of synovitis, with CE-MRI as reference standard. Results: In the 31 patients included, very strong correlation was found between synovitis sum scores on qDESS and CE-MRI (ρ = 0.96, p < 0.001), with high absolute agreement (0.84 (95%CI 0.14–0.95)). Mean sum score (SD) values on qDESS 5.16 (3.75) were lower than on CE-MRI 7.13 (4.66), indicating systematically underestimated synovitis severity on qDESS. For detecting mild synovitis or higher, high sensitivity and specificity were found for qDESS (1.00 (95%CI 0.80–1.00) and 0.909 (0.571–1.00), respectively). For detecting moderate synovitis or higher, sensitivity and specificity were good (0.727 (95%CI 0.393–0.927) and 1.00 (0.800–1.00), respectively). Conclusion: qDESS MRI is able to, however with an underestimation, detect synovitis in patients with knee OA

The James Webb Space Telescope Mission

Twenty-six years ago a small committee report, building on earlier studies, expounded a compelling and poetic vision for the future of astronomy, calling for an infrared-optimized space telescope with an aperture of at least $4m$. With the support of their governments in the US, Europe, and Canada, 20,000 people realized that vision as the $6.5m$ James Webb Space Telescope. A generation of astronomers will celebrate their accomplishments for the life of the mission, potentially as long as 20 years, and beyond. This report and the scientific discoveries that follow are extended thank-you notes to the 20,000 team members. The telescope is working perfectly, with much better image quality than expected. In this and accompanying papers, we give a brief history, describe the observatory, outline its objectives and current observing program, and discuss the inventions and people who made it possible. We cite detailed reports on the design and the measured performance on orbit.Comment: Accepted by PASP for the special issue on The James Webb Space Telescope Overview, 29 pages, 4 figure

The Science Performance of JWST as Characterized in Commissioning

This paper characterizes the actual science performance of the James Webb Space Telescope (JWST), as determined from the six month commissioning period. We summarize the performance of the spacecraft, telescope, science instruments, and ground system, with an emphasis on differences from pre-launch expectations. Commissioning has made clear that JWST is fully capable of achieving the discoveries for which it was built. Moreover, almost across the board, the science performance of JWST is better than expected; in most cases, JWST will go deeper faster than expected. The telescope and instrument suite have demonstrated the sensitivity, stability, image quality, and spectral range that are necessary to transform our understanding of the cosmos through observations spanning from near-earth asteroids to the most distant galaxies.Comment: 5th version as accepted to PASP; 31 pages, 18 figures; https://iopscience.iop.org/article/10.1088/1538-3873/acb29

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Decreasing patellar tendon stiffness during exercise therapy for patellar tendinopathy is associated with better outcome

Objectives: To assess the associations between: 1) baseline patellar tendon stiffness and clinical outcome after exercise therapy in athletes with patellar tendinopathy and 2) the change in patellar tendon stiffness and clinical outcome during progressive tendon-loading exercise therapy and eccentric exercise therapy. Design: Randomized controlled trial. Methods: Athletes with patellar tendinopathy aged 18-35 years, playing tendon-loading sports at least 3 times per week were randomized in a 1:1 ratio between progressive tendon-loading exercise therapy and eccentric exercise therapy for 24 weeks. Patellar tendinopathy was diagnosed clinically, and confirmed by ultrasound. Patellar tendon stiffness (kilopascal, kPa) was assessed using shear-wave elastography. Clinical outcome was assessed using the validated Victorian Institute of Sports Assessment (VISA-P; range 0-100) questionnaire. Both were assessed at baseline, 12 and 24 week follow-up. Adjusted general linear, mixed-linear models and Generalized Estimating Equations were used. Results: We included 76 athletes (58 men, mean age 24 ± 4 years). No association was found between baseline stiffness and VISA-P after 24 weeks (p = 0.52). Decreased stiffness (adjusted mean difference = 10 kPa (95% CI: 4-15) was significantly associated with improved clinical outcome at 12 weeks in all athletes (p = 0.02), and at both 12 and 24 weeks (p = 0.01) in athletes allocated to progressive tendon-loading exercise therapy. Conclusions: Patellar tendon stiffness, assessed with shear-wave elastography, is unsuitable to use as a single predictive measurement for clinical outcome. Decreasing stiffness during the course of exercise therapy is associated with improved clinical outcome in athletes recovering from patellar tendinopathy