Physiotherapy alone or in combination with corticosteroid injection for acute lateral epicondylitis in general practice: A protocol for a randomised, placebo-controlled study

<p>Abstract</p> <p>Background</p> <p>Lateral epicondylitis is a painful condition responsible for loss of function and sick leave for long periods of time. In many countries, the treatment guidelines recommend a wait-and-see policy, reflecting that no conclusions on the best treatment can be drawn from the available research, published studies and meta-analyses.</p> <p>Methods/Design</p> <p>Randomized double blind controlled clinical trial in a primary care setting. While earlier trials have either compared corticosteroid injections to physical therapy or to naproxen orally, we will compare the clinical effect of physiotherapy alone or physiotherapy combined with corticosteroid injection in the initial treatment of acute tennis elbow. Patients seeing their general practitioner with lateral elbow pain of recent onset will be randomised to one of three interventions: 1: physiotherapy, corticosteroid injection and naproxen or 2: physiotherapy, placebo injection and naproxen or 3: wait and see treatment with naproxen alone. Treatment and assessments are done by two different doctors, and the contents of the injection is unknown to both the treating doctor and patient. The primary outcome measure is the patient's evaluation of improvement after 6, 12, 26 and 52 weeks. Secondary outcome measures are pain, function and severity of main complaint, pain-free grip strength, maximal grip strength, pressure-pain threshold, the patient's satisfaction with the treatment and duration of sick leave.</p> <p>Conclusion</p> <p>This article describes a randomized, double blind, controlled clinical trial with a one year follow up to investigate the effects of adding steroid injections to physiotherapy in acute lateral epicondylitis.</p> <p>Trial Registration</p> <p>ClinicalTrials.gov Identifier: NCT00826462</p

Simulations of energetic beam deposition: from picoseconds to seconds

We present a new method for simulating crystal growth by energetic beam deposition. The method combines a Kinetic Monte-Carlo simulation for the thermal surface diffusion with a small scale molecular dynamics simulation of every single deposition event. We have implemented the method using the effective medium theory as a model potential for the atomic interactions, and present simulations for Ag/Ag(111) and Pt/Pt(111) for incoming energies up to 35 eV. The method is capable of following the growth of several monolayers at realistic growth rates of 1 monolayer per second, correctly accounting for both energy-induced atomic mobility and thermal surface diffusion. We find that the energy influences island and step densities and can induce layer-by-layer growth. We find an optimal energy for layer-by-layer growth (25 eV for Ag), which correlates with where the net impact-induced downward interlayer transport is at a maximum. A high step density is needed for energy induced layer-by-layer growth, hence the effect dies away at increased temperatures, where thermal surface diffusion reduces the step density. As part of the development of the method, we present molecular dynamics simulations of single atom-surface collisions on flat parts of the surface and near straight steps, we identify microscopic mechanisms by which the energy influences the growth, and we discuss the nature of the energy-induced atomic mobility

Trispectrum from Ghost Inflation

Ghost inflation predicts almost scale-invariant primordial cosmological perturbations with relatively large non-Gaussianity. The bispectrum is known to have a large contribution at the wavenumbers forming an equilateral triangle and the corresponding nonlinear parameter $f_{NL}^{equil}$ is typically of order $O(10^2)$. In this paper we calculate trispectrum from ghost inflation and show that the corresponding nonlinear parameter $\tau_{NL}$ is typically of order $O(10^4)$. We investigate the shape dependence of the trispectrum and see that it has some features different from DBI inflation. Therefore, our result may be useful as a template to distinguish ghost inflation from other models of inflation by future experiments.Comment: 25 pages, 10 figure

Knowledge, health beliefs and attitudes towards dementia and dementia risk reduction among descendants of people with dementia:a qualitative study using focus group discussions

Abstract Background Individuals with a parental family history of dementia have an increased risk of developing dementia because they share their genes as well as their psychosocial behaviour. Due to this increased risk and their experience with dementia, they may be particularly eager to receive information regarding dementia risk reduction (DRR). This study evaluated the knowledge, beliefs and attitudes towards dementia and DRR among descendants of people with dementia. Method Using a semi-structured topic guide, three focus group discussions were conducted consisting of 12 female (80%) and 3 male (20%) descendants of people with dementia with a mean (± SD) age of 48.8 (± 12) years. Focus group discussions were audio recorded and transcribed. Each transcript was analysed thoroughly, and where appropriate, a code was generated and assigned by two researchers independently. Then, similar codes were grouped together and categorized into themes. Results The items in the topic guide could only be addressed after participants had been given the opportunity to share their experiences of having a parent with dementia. Participants were unaware or uncertain about the possibility of reducing the risk of developing dementia and therefore hesitant to assess their dementia risk without treatment options in sight. Moreover, participants indicated that their general practitioner only gave some information on heritability, not on DRR. Although participants identified a large number of modifiable risk factors as a group during the group discussions, they were eager to receive more information on dementia and DRR. In the end, participants adopted a more positive attitude towards a DRR programme and provided suggestions for the development of future DRR programmes. Conclusions Although the research aim was to evaluate the knowledge, beliefs and attitudes towards dementia and DRR, sharing experiences of having a parent with dementia seemed a prerequisite for considering participants’ own risk of developing dementia and participating in a DRR programme. Knowledge of dementia and DRR was limited. Due to unawareness of the possibility of reducing dementia risk, participants were hesitant about assessing their dementia risk. Group discussions positively changed the perception of dementia risk assessment and participants’ willingness to participate in a DRR programme

Congenital anomalies in the offspring of occupationally exposed mothers:a systematic review and meta-analysis of studies using expert assessment for occupational exposures

STUDY QUESTION: Is there an association between maternal occupational exposure to solvents, pesticides and metals as assessed by expert-based assessment and congenital anomalies in the offspring? SUMMARY ANSWER: There is an association between maternal occupational exposure to solvents and congenital anomalies in the offspring, including neural tube defects, congenital heart defects and orofacial clefts. WHAT IS KNOWN ALREADY: One important environmental risk factor for development of congenital anomalies is maternal occupational exposure to chemicals in the workplace prior to and during pregnancy. A number of studies have assessed the association with often conflicting results, possibly due to different occupational exposure assessing methods. STUDY DESIGN, SIZE, DURATION: For this systematic review with meta-analysis, the search terms included maternal occupation, exposure, congenital anomalies and offspring. Electronic databases MEDLINE and EMBASE were searched for English studies up to October 2017. PARTICIPANTS/MATERIALS, SETTING, METHODS: Two reviewers independently screened all citations identified by the search. Case-control studies and cohort studies were included if (I) they reported on the association between maternal occupational exposure to solvents, pesticides or metals and congenital anomalies, and (II) assessment of occupational exposure was performed by experts. Data on study characteristics, confounders and odds ratios (ORs) were extracted from the included studies for four subgroups of congenital anomalies. Methodological quality was assessed using the Newcastle-Ottawa Scale. In the meta-analysis, random effects models were used to pool estimates. MAIN RESULTS AND THE ROLE OF CHANCE: In total, 2806 titles and abstracts and 176 full text papers were screened. Finally, 28 studies met the selection criteria, and 27 studies could be included in the meta-analysis. Our meta-analysis showed that maternal occupational exposure to solvents was associated with neural tube defects (OR: 1.51, 95%CI: 1.09-2.09) and congenital heart defects (OR: 1.31, 95%CI:1.06-1.63) in the offspring. Also maternal occupational exposure to glycol ethers, a subgroup of solvents, was associated with neural tube defects (OR: 1.93, 95%CI: 1.17-3.18) and orofacial clefts (OR: 1.95, 95%CI: 1.38-2.75) in the offspring. Only one study investigated the association between maternal occupational exposure to solvents and hypospadias and found an association (OR: 3.63, 95%CI: 1.94-7.17). Results of the included studies were consistent. In our meta-analysis, we found no associations between occupational exposure to pesticides or metals and congenital anomalies in the offspring. LIMITATIONS, REASONS FOR CAUTION: A limited number of studies was included, which made it impossible to calculate pooled estimates for all congenital anomalies, analyse individual chemicals or calculate exposure-response relations. Bias could have been introduced because not all included studies corrected for potentially confounding factors. WIDER IMPLICATIONS OF THE FINDINGS: Employers and female employees should be aware of the possible teratogenic effects of solvent exposure at the workplace. Therefore, is it important that clinicians and occupational health specialist provide women with preconception advice on occupational solvent exposure, to reduce the congenital anomaly risk. STUDY FUNDING/COMPETING INTEREST(S): NSp was paid by the Graduate School of Medical Sciences (MD/PhD program), UMCG, Groningen, the Netherlands. EUROCAT Northern Netherlands is funded by the Dutch Ministry of Health, Welfare and Sports. There are no competing interests. REGISTRATION NUMBER: CRD42017053943

Quadra-Spectrum and Quint-Spectrum from Inflation and Curvaton Models

We calculate the quadra-spectrum and quint-spectrum, corresponding to five and six point correlation functions of the curvature perturbation. For single field inflation with standard kinetic term, the quadra-spectrum and quint-spectrum are small, which are suppressed by slow roll parameters. The calculation can be generalized to multiple fields. When there is no entropy perturbation, the quadra-spectrum and quint-spectrum are suppressed as well. With the presence of entropy perturbation, the quadra-spectrum and quint-spectrum can get boosted. We illustrate this boost in the multi-brid inflation model. For the curvaton scenario, the quadra-spectrum and quint-spectrum are also large in the small r limit. We also calculate representative terms of quadra-spectrum and quint-spectrum for inflation with generalized kinetic terms, and estimate their order of magnitude for quasi-single field inflation.Comment: 16 pages; v2: references added

Transcutaneous electrical nerve stimulation for the management of tennis elbow: a pragmatic randomized controlled trial: the TATE trial (ISRCTN 87141084)

<p>Abstract</p> <p>Background</p> <p>Tennis elbow is a common and often extremely painful musculoskeletal condition, which has considerable impact on individuals as well as economic implications for healthcare utilization and absence from work. Many management strategies have been studied in clinical trials. Whilst corticosteroid injections offer short term pain relief, this treatment is unpleasant and is used with caution due to an associated high risk of pain recurrence in the long term. Systematic reviews conclude that there is no clear and effective treatment for symptoms of pain in the first 6 weeks of the condition. There is a clear need for an intervention that is acceptable to patients and provides them with effective short-term pain relief without increasing the risk of recurrence. Transcutaneous electrical nerve stimulation (TENS) is an inexpensive, non-invasive, non-pharmacological form of analgesia that is commonly used in the treatment of pain. TENS has very few contraindications and is simple to apply. It also benefits from being patient controlled, thereby promoting self-management. This study aims to assess the effectiveness, in terms of pain relief, and cost-effectiveness of a self-management package of treatment that includes TENS.</p> <p>Methods/Design</p> <p>The design of the study will be a two-group pragmatic randomized clinical trial. 240 participants aged 18 years and over with tennis elbow will be recruited from 20-30 GP practices in Staffordshire, UK. Participants are to be randomized on a 1:1 basis to receive either primary care management (standard GP consultation, medication, advice and education) or primary care management with the addition of TENS, over 6 weeks. Our primary outcome measure is average intensity of elbow pain in the past 24 hours (0-10 point numerical rating scale) at 6 weeks. Secondary outcomes include pain and limitation of function, global assessment of change, days of sick leave, illness perceptions, and overall health status. A cost-effectiveness analysis will also be performed. Patient adherence and satisfaction data will be collected at 6 weeks, 6 months and 12 months by postal questionnaire. A diary will also be completed for the first 2 weeks of treatment. Clinical effectiveness and cost-effectiveness analyses will be carried out using an intention-to-treat approach as the primary analysis.</p> <p>Discussion</p> <p>This paper presents detail on the rationale, design, methods and operational aspects of the trial.</p> <p>Trial registration</p> <p>Current Controlled Trials. ISRCTN87141084</p

Hunting for Primordial Non-Gaussianity in the Cosmic Microwave Background

Since the first limit on the (local) primordial non-Gaussianity parameter, fNL, was obtained from COBE data in 2002, observations of the CMB have been playing a central role in constraining the amplitudes of various forms of non-Gaussianity in primordial fluctuations. The current 68% limit from the 7-year WMAP data is fNL=32+/-21, and the Planck satellite is expected to reduce the uncertainty by a factor of four in a few years from now. If fNL>>1 is found by Planck with high statistical significance, all single-field models of inflation would be ruled out. Moreover, if the Planck satellite finds fNL=30, then it would be able to test a broad class of multi-field models using the four-point function (trispectrum) test of tauNL>=(6fNL/5)^2. In this article, we review the methods (optimal estimator), results (WMAP 7-year), and challenges (secondary anisotropy, second-order effect, and foreground) of measuring primordial non-Gaussianity from the CMB data, present a science case for the trispectrum, and conclude with future prospects.Comment: 33 pages, 4 figures. Invited review, accepted for publication in the CQG special issue on nonlinear cosmological perturbations. (v2) References added. More clarifications are added to the second-order effect and the multi-field consistency relation, tauNL>=(6fNL/5)^2

Scale-dependent non-Gaussianity probes inflationary physics

We calculate the scale dependence of the bispectrum and trispectrum in (quasi) local models of non-Gaussian primordial density perturbations, and characterize this scale dependence in terms of new observable parameters. They can help to discriminate between models of inflation, since they are sensitive to properties of the inflationary physics that are not probed by the standard observables. We find consistency relations between these parameters in certain classes of models. We apply our results to a scenario of modulated reheating, showing that the scale dependence of non-Gaussianity can be significant. We also discuss the scale dependence of the bispectrum and trispectrum, in cases where one varies the shape as well as the overall scale of the figure under consideration. We conclude providing a formulation of the curvature perturbation in real space, which generalises the standard local form by dropping the assumption that f_NL and g_NL are constants.Comment: 27 pages, 2 figures. v2: Minor changes to match the published versio