The relationship of femoral torsion and lower limb injury

Research about femoral torsion has existed since the late 1980’s with the focus on developing a method to measure femoral torsion. Identifying the degree of femoral torsion has become important because excessive antetorsion of the femur has been associated with hip pathology. In addition, it is important to identify the degree of femoral torsion prior to placement of a hip prosthesis and prior to derotational osteotomy for children with congenital excessive femoral antetorsion, which is seen in cerebral palsy, hip dysplasia and Blount’s disease. The gold standard for measuring femoral torsion is a CT scan, which is invasive therefore limiting its usage especially in children. While research on femoral torsion has been narrowed to hip pathology and correcting deformity, excessive femoral antetorsion is thought to impact structures distal to the hip therefore increasing the risk of developing lower limb injury. Since the relationship between femoral torsion and lower limb injury is unknown, a systematic review is presented in Chapter 2 that looked at the relationship between femoral torsion and other hip characteristics as a risk factor for lower limb injury. Excessive range of external rotation and increased strength may increase the risk of lower limb stress fracture and patellofemoral pain. Weaker hip external rotators and stronger hip abductors were found to significantly increase the risk of developing patellofemoral pain. Greater range of hip external rotation was also found to be a factor in increasing the risk of lower limb stress fracture however the figure is too small to be considered a clinically worthwhile effect. Although hip strength and hip range of motion were found to be risk factors for lower limb injury, no prospective study investigating the relationship between femoral torsion and lower limb injury was found. Therefore, one of the aims of this thesis was to provide preliminary data to uncover this relationship. Another aim of the work presented in this thesis was to develop a new ultrasound imaging protocol to assess femoral shaft torsion utilising a new landmark on the greater trochanter, ‘the ridge’. The protocol showed excellent intra-rater reliability (ICC2,1 = 0.98; 95% CI 0.97 to 0.99), and inter-rater reliability (ICC2,1 = 0.97; 95% CI 0.95 to 0.98). Fifty per cent of the measurements were within 1o both within and between raters and within 2.7o for 80% of the measurements. The largest difference between raters was 9.3o. Standard error of measurement (SEM) was 0.5 degrees and 0.6 degrees respectively for intra-rater and inter-rater reliability measurements. The excellent reliability supports its usage in the clinical setting. This work is presented in chapter 3. Consequently, using the newly developed reliable method, the relationship between femoral torsion and hip proprioception was examined in healthy adults (n=40). Hip proprioceptive acuity was measured using an active reproduction of movement in three different angles; 10% of neutral, 50% or mid-range and 90% of maximum external rotation. Greater range of medial shaft torsion was found to be associated with better hip proprioceptive acuity only at the angle near the end of maximum external rotation (r=-0.325, p=0.04) not at 10% (r=0.019, p=0.909) and 50% (r=0.116, p=0.478). The detail of this study is described in chapter 4 of this thesis. A cross-sectional study investigated the relationship between femoral shaft torsion and lower limb injury in dancers (n=80). No difference was found in the magnitude of femoral shaft torsion between injured and non-injured dancers (p = 0.94). The relationship between femoral shaft torsion and eight other hip measures was also investigated. Femoral shaft torsion was found to have a very weak, negative correlation with range of hip external rotation (r = -0.034, p=0.384) and turnout (r = -0.066, p=0.558). The association between femoral shaft torsion with all other variables was also found to be very weak. This study is described in detail in Chapter 5. Overall the results of the studies documented in this thesis: describe the development of a novel femoral torsion measurement tool, identify femoral shaft torsion as a measurable component of femoral torsion, and provide preliminary data and inferences regarding the relationship between femoral torsion, distal lower limb injury and lower limb proprioceptive acuity in a high risk population of dancers. It is proposed that future research will determine the extent to which femoral torsion poses a lower limb injury risk, which will inform the modification of screening protocols. The findings of this thesis will also assist clinicians to direct their prophylactic management to joints and soft tissues at risk. If a time-frame for development of FT can be identified, modified training loads may be investigated to enhance optimal FT and determine whether this minimises injury risk. This new information therefore will also provide a basis for future research that would likely be in longitudinal studies establishing relationships, hence providing useful information for coaches and clinicians regarding designing alternative methods of training in preventing lower limb injuries. The body of knowledge provided by this thesis will also inform researchers in determining the measures of the hip to be used in future research which might be worthwhile investigating in relation to lower limb injury

The short-term effects of progressive vs conventional core stability exercise in rehabilitation of nonspecific chronic low back pain

Core stability exercise programs are considered as a fundamental physical therapy treatment for chronic low back pain (LBP). However, it is still unclear which core stability program (progressive vs. conventional) is the most effective. A randomized controlled trial (RCT) was conducted to compare two core stability strategy strategies; progressive dynamic muscular stabilization technique (DMST) and conventional McGill Big 3 (MB3) in the rehabilitation of nonspecific chronic LBP. Thirty males diagnosed with nonspecific chronic LBP patients aged 33.57 ± 5.28 years were recruited and randomly assigned to; DMST and MGB3. All patients received additional conventional pain management treatment. The outcome measures were pain severity (motion, standing, sitting), functional disability, trunk endurance, lumbopelvic control, and body balance. All patients were assessed at baseline, 3rd week, and 6th week. A mixed design ANOVA showed both DMST and MGB3 improves all outcomes (p ≤ 0.05) specifically the pain severity and functional disability (p < 0.001, ηp2 = 0.81), trunk endurance (p < 0.001, ηp2 = 0.30), lumbopelvic control (p < 0.001, ηp2 = 0.242), and body balance (p = 0.003, ηp2 = 0.46) compared to baseline. However, no significant difference was found in all of the outcomes when comparing DMST and MBG3 (p > 0.05). In conclusion, both progressive DMST and conventional MGB3 core stability exercise programs are effective for nonspecific chronic LBP rehabilitation

Association of respiratory symptoms and lung function with occupation in the multinational Burden of Obstructive Lung Disease (BOLD) study

Background Chronic obstructive pulmonary disease has been associated with exposures in the workplace. We aimed to assess the association of respiratory symptoms and lung function with occupation in the Burden of Obstructive Lung Disease study. Methods We analysed cross-sectional data from 28 823 adults (≥40 years) in 34 countries. We considered 11 occupations and grouped them by likelihood of exposure to organic dusts, inorganic dusts and fumes. The association of chronic cough, chronic phlegm, wheeze, dyspnoea, forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1)/FVC with occupation was assessed, per study site, using multivariable regression. These estimates were then meta-analysed. Sensitivity analyses explored differences between sexes and gross national income. Results Overall, working in settings with potentially high exposure to dusts or fumes was associated with respiratory symptoms but not lung function differences. The most common occupation was farming. Compared to people not working in any of the 11 considered occupations, those who were farmers for ≥20 years were more likely to have chronic cough (OR 1.52, 95% CI 1.19–1.94), wheeze (OR 1.37, 95% CI 1.16–1.63) and dyspnoea (OR 1.83, 95% CI 1.53–2.20), but not lower FVC (β=0.02 L, 95% CI −0.02–0.06 L) or lower FEV1/FVC (β=0.04%, 95% CI −0.49–0.58%). Some findings differed by sex and gross national income. Conclusion At a population level, the occupational exposures considered in this study do not appear to be major determinants of differences in lung function, although they are associated with more respiratory symptoms. Because not all work settings were included in this study, respiratory surveillance should still be encouraged among high-risk dusty and fume job workers, especially in low- and middle-income countries.publishedVersio

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial.

Importance: Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. Objective: To determine whether hydrocortisone improves outcome for patients with severe COVID-19. Design, Setting, and Participants: An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. Interventions: The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). Main Outcomes and Measures: The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). Results: After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. Conclusions and Relevance: Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. Trial Registration: ClinicalTrials.gov Identifier: NCT02735707

Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

BackgroundAnterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.MethodsWe did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.FindingsBetween Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.InterpretationSurgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management

Cohort Profile: Burden of Obstructive Lung Disease (BOLD) study

The Burden of Obstructive Lung Disease (BOLD) study was established to assess the prevalence of chronic airflow obstruction, a key characteristic of chronic obstructive pulmonary disease, and its risk factors in adults (≥40 years) from general populations across the world. The baseline study was conducted between 2003 and 2016, in 41 sites across Africa, Asia, Europe, North America, the Caribbean and Oceania, and collected high-quality pre- and post-bronchodilator spirometry from 28 828 participants. The follow-up study was conducted between 2019 and 2021, in 18 sites across Africa, Asia, Europe and the Caribbean. At baseline, there were in these sites 12 502 participants with high-quality spirometry. A total of 6452 were followed up, with 5936 completing the study core questionnaire. Of these, 4044 also provided high-quality pre- and post-bronchodilator spirometry. On both occasions, the core questionnaire covered information on respiratory symptoms, doctor diagnoses, health care use, medication use and ealth status, as well as potential risk factors. Information on occupation, environmental exposures and diet was also collected

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

A narrative review: Risk factors of low back pain in military personnel/recruits

Military personnel are one of the occupations at high risk of developing low back pain (LBP) due to its job demands. Low back pain (LBP) is a major cause of morbidity and lost from work among military personnel. This narrative review was conducted to determine the risk factors of LBP in military personnel/recruits. Searches focusing on causal comparative and epidemiology studies using OVIDMedline, CINAHL, SPORTDiscus, PubMed, and Scopus databases from year January 1950 to April 2018. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines was used to select and synthesis of studies. The strongest personal risk factors identified were history of LBP (OR = 8.91, CI = 1.71 -46.5), female gender (OR: 6.59, CI 1.79 - 24.24), aerobic exercise involvement (OR = 4.39, CI 1.53- 12.57) and older age (OR 4.16). The strongest occupational risk factors identified were pro-longed hours of flight per day (OR=11.3, CI 5.2 -24.8), driving in forward bending posture (OR = 3.63, CI 1.06 - 12.42), branch of services (Army; OR 2.74, CI 2.60-2.89 & Air Force; 1.98, CI 1.84 -2.14), Night training (OR = 1.8-2.0, CI 1.1 - 3.1) and whole-body vibra-tion exposure (OR 1.94, CI 1.02 -3.69). The strongest psychosocial risk factors identified were worries (OR = 5.47, CI 1.70- 17.62), no support from others (OR = 4.0, CI 1.31 -12.34) high work stress (OR = 3.47, CI 1.31 - 12.34), depression (OR = 1.75, CI 1.08 -2.83), and psychological stress (OR 1.71). This review summarizes the personal, occupational and psychosocial risk factors associated with LBP among military personnel/ recruits. LBP risk factors differs based on the military branch of services and job scope. Primary LBP risk factor for Air Force pilots, helicopter pilots and military vehicle drivers LBP is sitting ergonomics. Primary LBP risk factor for army (i.e. combat infantry) identified are occupational physical exposure (military training, heavy lifting and carrying, patrol durations.) Further studies are required to verify if there is any interaction between personal, occupational, and psychosocial LBP risk factor categories among military personnel/recruits

"The analysis on the issue of marital rape" / Hana Sakina Abdullah Sani...[et al.]

The issue of Marital Rape has been debated throughout the world among the feminist organizations. Since its recognition in some countries such as United States of America, Canada and Korea, Malaysia has also been exposed to the issue on Marital Rape. However, due to some circumstances, the law on Marital Rape faces some difficulties in terms implementation of the said law in Malaysia. The purpose of conducting this research is to analyze issue of marital rape throughout the world. In addition, whether the law of marital rape can be introduce in our country. Although there is no specific law in Malaysia on this issue, we cannot disregard the severity of this matter. This is due to the fact that around the world more and more countries have recognized marital rape as law. In order to produce this research, various sources will be referred to. These sources include legal materials such as statutes, case law and articles. Interviews have also been conducted with the legal academician of UiTM. It is hope that this research will give some wider perspective on the issue of marital rape in Malaysia

Prevalence and factors associated with low back pain among Malaysian army personnel stationed in Klang Valley

Study aim: The aims of this study were to examine the prevalence of low back pain (LBP) and explore possible factors associ­ated with LBP among Malaysian army personnel deployed in Klang Valley in the year 2018. Material and methods: A self-administered questionnaire on sociodemographic data, occupational background, occupational exposure and LBP evaluation was used in this study. A total of 330 respondents participated in this study and 321 (97%) of them completed and returned the questionnaires. Results: One hundred and fifty-seven respondents complained of LBP, giving a prevalence of 48.9%. LBP was found to be associated with smoking status, history of LBP, history of accident, military rank, category of regiment, lifting weights, push­ing weights, pulling weights and job-related physical activity. Logistic regression analysis identified four associated risk fac­tors of LBP: history of accident (OR = 4.42, 95% 2.29-8.55), history of LBP (OR=1.92, 95% 1.11-3.31), combat regiment (OR = 1.97, 95% 1.14-3.42) and high job-related physical activity (OR = 2.35, 95% 1.31-4.20). Conclusion: Almost half of Malaysian army personnel stationed in Klang Valley reported LBP symptoms. Smoking status, history of LBP, history of accident, junior non-commissioned officers (NCOs), combat regiments, manual handling of objects and moderate/high job-related physical activity are associated with LBP, but there is no evidence of a temporal relationship in the current study. Further exploration with a longitudinal study is needed to identify a cause and effect relationship between occupational exposure and LBP among Malaysian army personnel