Body

People with anterior cruciate ligament injuries can lose up to 40% of the muscle strength in the affected leg--with muscle atrophy remaining a big problem even after ACL reconstruction and physical therapy.

Now, a new University of Michigan study in rats challenges conventional wisdom about which exercises are most beneficial during post-injury physical therapy, and findings suggest that adding eccentric exercises could dramatically increase muscle volume and improve outcomes for patients.

Eccentric exercises contract the muscle during lengthening--think of the downswing of a bicep curl or walking downhill. Those exercises are much more effective at growing muscle than concentric exercises, where muscles shorten while producing force--think of the upswing of a bicep curl, said Lindsey Lepley, U-M assistant professor of kinesiology.

Historically, the lengthening component of eccentric exercises has been thought to cause muscle damage during physical therapy, so they're omitted, Lepley said. But concentric exercises alone don't achieve the muscle growth required to get patients to pre-injury muscle strength. This holds true for all sports-related muscle strains and injuries requiring physical therapy, not just the 300,000 ACL reconstructions performed annually.

"Our group has long believed that incorporating eccentrics into PT is beneficial to muscle," said Lepley, whose earlier research found that incorporating eccentric exercise into an ACL rehabilitation program increased strength by 30%, compared to concentric exercise alone.

"The catch is that in order to combat this outdated notion that eccentrics are dangerous, we need to directly evaluate the immediate effects--hence the purpose of this study."

This study found that a single, 15-minute bout of eccentric exercise to novice muscle (a muscle unexposed to prior eccentric exercise) in rats was better than concentric exercise at promoting growth, with very limited injury, Lepley said. Muscle and the mechanisms governing function are highly conserved across species, she said.

In the study, Lepley and colleagues had rats run uphill or downhill on specially designed rodent treadmills. They then examined the muscle fibers for injuries and protein synthesis indicative of muscle growth.

The researchers found only one damaged fiber in 9,000-plus muscle fibers, and that was in the concentric (uphill) exercise group. They also found a significant increase in protein markers associated with muscle growth in the eccentric group after exercise, compared to the concentric group.

Next, researchers hope to test the direct effect of eccentric exercise on muscle after ACL injury, using a noninvasive rodent model of ACL that mimics human injury, Lepley said.

"Our goal is to translate our findings from the bench-top to the sidelines," Lepley said. "We want this information to get to clinicians and patients who have had musculoskeletal injuries to promote lifelong health and wellness."

Machine learning can be used to track surges in interest in health topics on popular online comment boards, like Reddit, according to a new study conducted during the COVID-19 outbreak by researchers in the Perelman School of Medicine at the University of Pennsylvania (Penn Medicine). Such insight could help public health officials better understand and address public concerns and priorities, and stem the spread of misinformation. This study was published today in the Journal of General Internal Medicine.

"Public health priorities do not always align with community priorities, and the success of public health efforts often depends on having a plan to address community concerns," said Daniel Stokes, a research fellow with the Center for Emergency Care Policy and the Center for Digital Health at Penn Medicine. "Having a source like Reddit that is directly tied to people's thoughts could prove invaluable in crafting plans that meet people where they are."

The researchers chose to evaluate discussions on Reddit because it is one of the most popular sites on the internet, as well as being relatively unfiltered and up-to-date.

For example, researchers said real-time monitoring of Reddit could have allowed for a nimbler response during a surge of questions around whether it was safe to go outside in mid-March. The Centers for Disease Control and Prevention (CDC) did not issue official guidelines for safely enjoying parks and outdoor activities until early April. Stokes and his fellow researchers believe that if there had been more monitoring of online discussion activity, the guidance could have been issued closer to the peak of interest.

As a conduit directly to the thoughts of some people, Reddit is also valuable because it is the place where some of the "infodemic"--the plague of misinformation about COVID-19--has spread. Examples include one Reddit poster's belief that a natural remedy like licorice root might prevent COVID-19 infection, or another's thought that the virus was human engineered. Here, too, a quick, tailored response from public health officials could lead to more fact-based and productive discourse.

To identify surges of interest in the public, the study's researchers collected nearly 95,000 posts from March 3 through March 31, 2020 on the most popular COVID-19 thread on Reddit, r/Coronavirus. They identified 50 different discussion topics through a machine learning technique of natural language processing. Then, 10 of those topics were determined to be most related to three areas of interest in the study: the response to public health measures, the sense of the pandemic's severity, and its impact on daily life.

By tracking how the popularity of these topics varied day-by-day, the team was able to demonstrate how areas of interest ebbed and flowed. For instance, hand-washing was found to peak early on, between March 3 and 6, while concern about personal finances was discussed roughly 50 percent more at the end of March as compared to the beginning. The analysis also showed that some topics popular at the start of the month remained top of mind, or had a comeback later in the month. Such was the case for mask-wearing.

"The CDC didn't make their recommendations on wearing masks in public until early April, so it is interesting to see that masks were being discussed a great deal prior to that recommendation," Stokes said. "Perhaps it was a sign that many people were ready for these guidelines earlier."

Moving forward, the team will continue to track and analyze posts on this COVID-19-specific thread. Another effort from Penn's Center for Digital Health, led by Raina Merchant, MD, an associate professor of Emergency Medicine, has been to collect similar data through Twitter and map it across the United States.

"We are aiming to incorporate input from several digital sources that would allow us to not just track the public's sentiment and perception of the virus, but also track, in real time, the emergence of new outbreaks," said Merchant, who is also the senior author of this Journal of General Internal Medicine study.

Stokes and Merchant hope insight like this will be heeded by public health officials in their effort to better combat the spread of misinformation that accompanied the COVID-19 outbreak.

"The success of our public health efforts depends on public buy-in," Stokes said. "Early comparisons to the flu on Reddit may have indicated a gap in public understanding of pandemic severity. Recognizing such gaps can be useful in developing targeted campaigns to close them."

HOUSTON - (May 13, 2020) - Over the last decade researchers have become concerned about a possible link between a benign gynecologic lesion called endosalpingiosis (ES) and ovarian cancer. However, using a diagnostic method typically reserved for specimens suspicious for cancer, a team of researchers led by a Baylor College of Medicine physician found the prevalence of ES and other gynecological lesions was substantially higher than previously reported, even among women without cancer. This higher rate of occurrence led the researchers to believe that ES is not a direct cause of cancer as previously suspected. Their findings are published in the journal PLOS ONE.

"Recently, researchers started to wonder if ES could be a precursor to ovarian cancer," said Dr. Jan Sunde, associate professor and division director of gynecologic oncology at the Dan L Duncan Comprehensive Cancer Center at Baylor. "An association of cancer with ES would make ES a concerning finding. But pathologists weren't reporting benign ES lesions in all surgical cases, and the actual prevalence of ES was unknown."

Sunde led this research during his time at the Madigan Army Medical Center in Tacoma, Washington. He worked with pathologists there to use a more stringent analysis to determine the actual prevalence of ES in all gynecologic samples, those with cancer and without, at their institution. After implementing the new protocol, the reported prevalence of ES increased from 2.54 percent to 22.15 percent in all specimens over a one-year period. When sorting the data by age group, the researchers found an ES prevalence of 37 percent in women age 31-50 and 66 percent in post-menopausal women.

"This is a way more common finding than what people suspected," Sunde said. "If ES occurs so frequently, then it likely is not the first step in cancer development, and it's much less concerning."

Women with ovarian cancer do have ES at a higher rate, but Sunde said this could be due to sampling bias. Women with cancer undergo more thorough pathology testing, and studies of ES and cancer do not include a control group of ES patients with no cancer. Sunde said further study is needed to determine the true association between ES and cancer.

Next, Sunde and his team at Baylor will focus on what conditions allow ES to develop and whether any of those may also be linked to cancer.

"We know there are some benign ES lesions that have the same genetic mutations found in malignant lesions in patients who have an ovarian borderline tumor," Sunde said. "We hope to find a way to evaluate ES lesions that would tell us if a patient is at risk for developing either borderline or high grade ovarian cancer. If we figure that out, we can evaluate methods of preventing this deadly cancer."

PROVIDENCE, R.I. [Brown University] -- A study analyzing data from the Rhode Island Consortium for Autism Research and Treatment (RI-CART) found that only 3% of individuals diagnosed with autism spectrum disorder reported having fully received clinical genetic tests recommended by medical professional societies.

The results bring to light a dissonance between professional recommendations and clinical practice, the researchers behind the study say.

Autism spectrum disorder is one of the most strongly genetic neuropsychiatric conditions. Medical professional societies -- such as the American Academy of Pediatrics, the American College of Medical Genetics, and the American Academy of Child and Adolescent Psychiatry -- recommend offering chromosomal microarray testing and Fragile X testing for patients diagnosed with autism. The tests can identify or rule out genetic abnormalities that could have implications in a patient's diagnosis and clinical care.

The study, published in JAMA Psychiatry on May 13, analyzed 1,280 participants with autism spectrum disorder based on medical records and self-reported data from the time period of April 2013 to April 2019. The participants are enrolled with RI-CART, a public-private-academic collaborative focused on advancing research and building community among individuals with autism spectrum disorder in Rhode Island and their families. The study's goal was to determine the current state of clinical genetic testing for autism in this cohort, said authors Dr. Daniel Moreno De Luca and Dr. Eric Morrow.

Of the 1,280 participants, 16.5% reported having received some genetic testing, with 13.2% stating they received Fragile X testing, and 4.5% reporting that they received chromosomal microarray testing. However, only 3% of participants reported having received both recommended tests.

"I had the impression that the frequency of recommended genetic testing was not going to be very high based on the patients I encounter clinically, but 3% is actually lower than I thought it would be," said Moreno De Luca, an assistant professor of psychiatry and human behavior at Brown University, who is affiliated with the Carney Institute for Brain Science, and a psychiatrist at Bradley Hospital. "A higher proportion has had either test individually, and the proportion of people with chromosomal microarray is higher in recent calendar years, which is a hopeful glimpse for people who are being diagnosed recently and who may be younger. However, this underscores that there is still significant work to be done, especially for adults on the autism spectrum."

In the study, researchers examine possible reasons for the gap between clinical practice and the recommendations from medical professional societies. Age was among the most prominent, as people with autism in older age groups are less likely to be tested. According to the study, adults with autism were generally unlikely to have undergone the clinical genetic tests.

The researchers also found that patients diagnosed by subspecialist pediatricians were more likely to report genetic testing as compared to those diagnosed by psychiatrists and psychologists.

"This paper is really about how you implement clinical genetic tests in the clinical diagnostic setting," said Dr. Eric Morrow, an associate professor of biology at Brown and director of the Developmental Disorders Genetics Research Program at Bradley Hospital. "There is rapid progress from research, and then there's the doctor and health systems that need to translate that to clinical practice. The clinics need to set up more support to educate clinicians and families about genetics and autism. Generally, this is done by genetic counselors who may be rare in autism clinics."

Furthermore, the researchers found that nearly 10% of participants who received an autism spectrum disorder diagnosis between 2010 and 2014 reported receiving chromosomal microarray testing, one of the more modern genetic tests. Compared to those in the study who received a diagnosis in years before 2010, this showed an increase in self-reported testing.

"There is a more hopeful message that conveys that the success in implementing clinical genetic testing is increasing," said Morrow, who is affiliated with the Carney Institute, co-leads the Autism Initiative at the Hassenfeld Child Health Innovation Institute at Brown and directs the University's Center for Translational Neuroscience.

Based at Bradley Hospital in East Providence, the team behind RI-CART represents a partnership between researchers at Brown, Bradley Hospital and Women and Infants that also involves nearly every site of service for people on the autism spectrum and their families in Rhode Island.

As a next step, the researchers behind the JAMA Psychiatry study are conducting a separate study to understand in greater detail the factors that could be influencing the rate of genetic testing.

"Challenges can be found on the patient and families side, on the physician side, and on the systemic side with institutional requirements and many other potential barriers," said Moreno De Luca. "We want to address each of those factors independently."

Hamilton, ON (May 13, 2020) - McMaster University researchers have established a connection between inflammatory bowel disease (IBD) and celiac disease.

A systematic review and meta-analysis at the Farncombe Family Digestive Health Research Institute at McMaster in collaboration with the Society for the Study of Celiac Disease has determined there is a nine-fold increased risk of having IBD for patients with a previous diagnosis of celiac disease. Similarly, the risk for celiac disease is increased in IBD patients, though to a smaller extent.

The details were published today in Gastroenterology.

"Clinicians have always suspected that IBD and celiac disease may be linked, however a clear association was never established," said first study author Maria Ines Pinto-Sanchez, associate professor of medicine and member of the Farncombe Family Digestive Health Research Institute at McMaster. She is a gastroenterologist with Hamilton Health Sciences.

"This is important, as failure to diagnose one or the other condition could compromise proper response to available treatments. It also raises questions on screening for the other disease in a patient already diagnosed with either IBD or celiac disease."

IBD and celiac disease are chronic and disabling intestinal conditions affecting many Canadians as Canada has one of the highest frequencies of IBD in the world. Both diseases share similar risk factors and their prevalence has increased in the past years.

While the exact cause of IBD is unknown, it is accepted that infections, genes and other environmental factors are involved. Celiac disease affects 1 in 100 Canadians, and its main environmental trigger is dietary gluten, but specific genes are required to develop the condition.

The researchers identified 9,800 studies and included 65 studies in their analysis. Of those, 30 studies included control groups with a total of 13.6 million participants, including: 43,000 celiac patients, 166,000 IBD patients (39,000 Crohn's, 56,000 ulcerative colitis, and 3,000 indeterminate colitis patients), and 13.4 million controls.

The studies were published between 1978 and 2019. Forty-three studies were conducted in adults, 12 studies in children, and 9 studies in all ages. The majority of the studies were in Europe, followed by North America and Asia.

The researchers suggest the next step is to determine whether testing for the diseases is cost-effective and beneficial to patients.

"Our review has confirmed that there is a strong association between celiac disease and IBD, but at this time, it is unclear whether screening of IBD should be performed in celiac disease and vice versa," said corresponding study author Elena Verdu, professor of medicine and scientist of the Farncombe Family Digestive Health Research Institute at McMaster.

"More studies into the association of IBD and celiac disease are needed, as this could lead to screening and therapeutic interventions to improve patient outcomes."

NEW YORK (May 13, 2020) -- The Society for Healthcare Epidemiology of America today released a white paper outlining strategies for documenting the recommendations of antibiotic stewardship programs (ASP) and clarifying the stewardship team's role in patient care from a legal and quality improvement standpoint. The white paper, titled Legal Implications of Antibiotic Stewardship Programs, was published in the journal, Infection Control and Hospital Epidemiology.

"Antibiotic stewardship has become a critical tool for healthcare systems to slow the emergence of antibiotic resistant bacteria and to improve patient outcomes and safety," said Keith Hamilton, MD, a member of the SHEA Antimicrobial Stewardship Committee and author of the white paper. "However, it is important to address the legal implications of antibiotic stewardship programs, particularly around concerns about professional liability stewards may have to patients that they do not see or examine with the goal of disseminating best practices and reinforcing the essential roles that these programs play in all healthcare settings."

The paper provides strategies to address common concerns and perceptions surrounding the legal implications of stewardship programs with the goal of improving the structure and function of the programs, as well as the benefits they provide to patients and patient care.

The guidance, based on expert consensus and a review of case law, addresses documentation, covers clinical training of stewardship program personnel, telestewardship, the use of clinical practice guidelines, and antibiotic stop orders. The authors surveyed SHEA members about concerns around the structure of antibiotic stewardship programs, interventions, and documentation to ensure the guidance reflected realities and concerns from the field.

While there have been no specific lawsuits filed involving ASP, the authors note three important components that should be included in hospitals' programs to reduce liability and further advance the goals of ASP strategies.

1. Protocols to communicate and resolve differences with treating teams or other stakeholders to help achieve agreement on treatment strategy whenever possible.

2. Documentation practices in electronic health records to provide the basis of recommendations as well as preserve the record of ASP involvement.

3. Standards for credentialing ASP team members based on experience or formal training to ensure team member roles are aligned with expertise, licensure, and scope of practice regulations.

As biomedical sciences incorporate increasingly sophisticated methodologies and technologies, our understanding of diseases improves. Diabetes is a clear example since new classifications are being added to the traditional classification into type 1 and type 2 diabetes; these new classifications are based on genetic and molecular characteristics that improve diagnosis and treatment.

The Genetic and Molecular Epidemiology Group, led by Núria Malats at the Spanish National Cancer Research Centre (CNIO), shows the need to continue to improve these classifications: the team published in the journal Gut the results of a European case-control study showing that one of the most recently identified types of diabetes, type 3c or pancreatogenic diabetes, could also be an early manifestation of pancreatic cancer.

This type of cancer has a high mortality rate - around 95% - since it is usually diagnosed too late because of the absence of symptoms in its early stages. Therefore, the finding of the CNIO would imply that it is possible to make an earlier diagnosis of this disease since it allows classifying patients with diabetes type 3c as a population with an increased probability of having early stage pancreatic cancer.

A camouflaged symptom

Diabetes and pancreatic cancer are connected because the pancreas secretes insulin; in diabetic people, this does not occur in a normal way. It is estimated that around 50% of patients with pancreatic cancer present diabetes. But it is an outstanding challenge for researchers to figure out which is the cause and which is the consequence.

Until now, the most common approach has been to study if diabetes could cause pancreatic cancer. "Our team turned the equation around and, for the first time, we asked the question whether pancreatic cancer could cause diabetes," explains Núria Malats, senior author of the paper. "Using innovative epidemiological and statistical analysis strategies, we found that pancreatic cancer is the cause of the development of diabetes type 3c in 26% of cases."

Type 3c, or pancreatogenic, diabetes is characterised by an inflammation of the pancreas that interrupts insulin production. It is estimated to represent around 5-10% of all diabetes cases in Western countries, but currently there are few specific markers for it so that it is often misdiagnosed as diabetes type 2. More precise markers to identify it correctly are required; not only to provide adequate treatment to patients but also because the CNIO now shows that a correct classification is crucial for the early diagnosis of pancreatic cancer.

To conduct the study, the team used data from more than 3,500 persons from PanGenEU, a large European study involving centres from six countries, including Spain, and led by Malats, to analyse the relationship between multiple risk factors and pancreatic cancer.

A factor that defines "high-risk" population that could be applied by the National Health Systems

To be able to confront pancreatic cancer at earlier moments, risk populations must be first defined so that they can be monitored to detect the tumour and act on in its early stages. "Using the information from our study, the national health systems could identify possible as yet undetected pancreatic cancer patients, if the patients, in addition to having type 3c diabetes, also have certain risk factors associated with this cancer, such as being obese or a smoker," says Malats. "All of these factors would help family doctors better select patients who could benefit from more active monitoring or entering screening programs. Our discovery can be transferred to the National Health Systems as a factor to be taken into account for the early detection of pancreatic cancer."

The researchers wanted to test if type 2 diabetes could also be connected to this cancer, but in this case, the study was unable to establish a clear causal link. "We have seen that the relationship between pancreatic cancer and type 2 diabetes is very complex, with obesity playing a role, too. Further studies are required to fully understand how the metabolic state is reached in which all these phenomena arise."

More than one in four of the most viewed COVID-19 videos on YouTube in spoken English contains misleading or inaccurate information, reveals the first study of its kind, published online in BMJ Global Health.

Public health misinformation on COVID-19 is reaching far more people than in previous pandemics and has considerable potential for harm, warn the researchers.

While good quality accurate information put out by government bodies and experts is widely available on YouTube, it's often hard to understand and lacks popular appeal, so doesn't have the reach it needs, they add.

Published research shows that YouTube has been both a useful and misleading source of information in previous public health crises, such as the swine flu (HIN1) pandemic and the Ebola and Zika outbreaks.

But social media use has changed since these studies were published, added to which not all of them used validated measuring tools, say the researchers.

To try and provide a more current assessment of the accuracy and quality of information on coronavirus and COVID-19 on YouTube, the researchers searched the digital platform for the most widely viewed and relevant videos as of 21 March 2020.

After excluding those that were duplicates, in languages other than English, lasted more than an hour, or didn't contain audio or visual content, around half of the initial number (69 out of 150; 46%) were eligible for analysis.

The reliability and quality of the content of each one was assessed using validated scoring systems: mDISCERN and mJAMA. And the usefulness of content for the average viewer was assessed using a COVID-19 specific score (CSS), modelled on similar systems developed for use in other public health emergencies.

A CSS point was awarded for exclusively factual information on each of the following: viral spread; typical symptoms; prevention; possible treatments; and epidemiology.

Professional and government agency videos scored significantly higher for accuracy, usability, and quality across all measures than any of the other sources, but didn't feature prominently among viewing figures.

The number of views for the 69 videos included in the analysis added up to 257, 804,146.

Network news accounted for the largest proportion of views (29%), followed by consumers (22%); entertainment news (21%); internet news (12%); professionals (7%); newspapers (5%); educational bodies (2%); and government agencies (2%).

Nearly 50 of the videos (72.5%) contained only factual information. But more than one in four (19; 27.5%) contained misleading or inaccurate information, representing 62,042,609 views or around a quarter (24%) of the total.

Among the 19 misleading videos, around a third came from entertainment news, with network and internet news sources each accounting for around a quarter. Consumer videos made up 13% of the total.

Misleading or inaccurate information included CSS criteria--for example, the belief that pharmaceutical companies already have a cure, but refuse to sell it, or that certain countries have stronger strains of coronavirus; inappropriate recommendations for the general public; racist and discriminatory remarks; and conspiracy theories.

"This is particularly alarming, when considering the immense viewership of these videos," write the researchers.

"Evidently, while the power of social media lies in the sheer volume and diversity of information being generated and spread, it has significant potential for harm," they add.

They acknowledge that they relied on information gathered in just one day, and included only English language content. But the video views in their study far surpass those reported in other YouTube studies on pandemics or public health emergencies, they point out.

"The education and engagement of the public is paramount in the management of this pandemic by ensuring public understanding of, and therefore adherence with, public health measures," they insist.

Given the power of social media in shaping public understanding and behaviour, "YouTube is a powerful, untapped educational tool that should be better mobilised by health professionals," they suggest.

"Many existing marketing strategies are static, in the form of published guidelines, statistical reports and infographics and may not be as appealing or accessible to the general public," they point out.

Public health and government bodies would do well to collaborate with entertainment news and social media influencers to jazz up their digital content and engage a much wider audience to counter the misinformation circulating during this pandemic, they recommend.

Two new articles provide insights on the use of telehealth or virtual care in the age of COVID-19 and beyond, pointing to its value to not only prevent contagious diseases but also to provide access to effective and equitable care.

In a Nature Partner Journal's Digital Medicine perspective, Lee H. Schwamm, MD, Director of the Center for TeleHealth at Massachusetts General Hospital and Vice President of Virtual Care at Partners Healthcare, and his colleagues stress that virtual care, by collapsing the barriers of time and distance, is ideal for providing care that is patient-centered, lower cost, more convenient and with greater productivity than traditional methods for delivering care, especially during a pandemic.

The article describes the scope and scale of the virtual care innovation introduced at Partners Healthcare and provides guidance to other health care systems on implementing virtual care tools and addressing challenges to their use during and after the COVID-19 pandemic.

"It will be important for health systems to reap the benefits of this digital innovation to redesign inpatient and ambulatory care delivery now and in the near future, as we transition from clinical surge to a recovery phase," said Dr. Schwamm.

In Lancet Digital Health, Dr. Schwamm and co-authors describe in greater depth two pivotal innovations in virtual care delivery for hospitalized patients: virtual rounds and a virtual intercom communication system.

Virtual rounds seek to redesign traditional medical rounds, where large numbers of health care workers are frequently huddled together around a computer screen or test result to discuss treatment options. With virtual rounds as a means of so-called medical distancing, one or two health care workers are physically present on a hospital ward, while all other multidisciplinary team members join remotely from home or other locations in the hospital.

The virtual intercom communication system allows clinicians to monitor and communicate with patients over video screens from anywhere in the hospital and present a human face to isolated patients whose only other personal contact is typically with providers who are fully gowned, masked and gloved.

"These approaches have allowed us to deliver exceptional care during a time of mass contagion, while preserving personal protective equipment in short supply, reducing exposure time of staff and engaging in compassionate and reassuring encounters over video sessions whenever care is required," said Dr. Schwamm.

Dr. Schwamm noted that the current health crisis may serve to transform outdated methods of health care delivery and reveal new ways to use virtual care to improve the health of all patients.

Surgical patients appear to recover faster and more reliably than patients treated with functional bracing.

A study published in the distinguished JAMA journal compared functional bracing, the non-operative treatment of humeral shaft fractures, with surgical treatment of similar fractures in adult patients. In the study, patient recovery was monitored for a year.

Six weeks and three months after treatment, surgically treated patients fared better than those treated with bracing. After this, the differences evened out.

On average, the forms of therapy resulted in equally good outcomes one year after the injuries were sustained. However, problems were observed fairly often in the recovery of the patients treated with functional bracing. A total of 30% of them had to be operated on within the first year, with failure of fracture union as the principal cause.

In the patients who were operated on at a later date, the outcome was poorer after one year compared to those who were operated on right at the beginning or the 70% of the patients treated with bracing whose fracture healed without any problems.

No serious complications requiring repeat operations were observed in the patients in the surgical group. Four patients experienced transient radial nerve palsy in conjunction with surgery.

"The findings provide useful information to doctors treating humeral shaft fractures, as they explain to patients the expected outcomes of different treatment forms as well as their associated risks," says Lasse Rämö, principal investigator of the trial and specialist in traumatology, who is writing his doctoral dissertation at the University of Helsinki.

Even without evidence, surgical treatment is becoming increasingly common

Fractures of the humeral shaft constitute roughly 1-3% of all fractures in adults. Traditionally, most of them have been treated with an external orthosis supporting the upper arm. In recent decades, fractures have increasingly been treated surgically, even though no high-quality scientific evidence on surgical therapy has been available.

The randomised controlled trial was carried out at the Töölö Hospital of the Helsinki University Hospital and at the Tampere University Hospital. Several members of the Finnish Centre for Evidence-Based Orthopaedics (FICEBO) research group from the University of Helsinki contributed to the trial.

FICEBO is an internationally renowned research group that has produced a number of important publications in the field of orthopaedics.

Next, the researchers are going to investigate the significance of delays in surgery to patient recovery in a two-year follow-up.

Below please find a summary and link(s) of new coronavirus-related content published today in Annals of Internal Medicine. The summary below is not intended to substitute for the full article as a source of information. A collection of coronavirus-related content is free to the public at http://go.annals.org/coronavirus.

1. Pharmacokinetics of Lopinavir and Ritonavir in Patients Hospitalized with COVID-19

COVID-19 has rapidly spread around the world, and the lack of effective treatment has fueled a global search for the "magic bullet" against the disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Lopinavir and ritonavir, a drug combination currently approved as retroviral therapy for adults with HIV-1 infection, is one of the treatments being investigated and is the subject of more than 30 studies registered at ClinicalTrials.gov. Researchers from the Medical University of Vienna and the Medical University of Vienna in Vienna, Austria, report trough plasma concentrations of lopinavir and ritonavir from 8 patients with COVID-19 admitted to the hospital for "normal care." Their findings suggest that current dosing of this drug combo is unlikely to be effective for treating patients with COVID-19. Read the full text: http://annals.org/aim/article/doi/10.7326/M20-1550.

Media contacts: A PDF for this article is not yet available. Please click the link to read full text. The lead author, Bernd Jilma, MD, can be reached directly at Bernd.jilma@meduniwien.ac.at.

2. Cytokine Levels in the Body Fluids of a Patient With COVID-19 and Acute Respiratory Distress Syndrome: A Case Report

Some patients with COVID-19 progress rapidly to acute respiratory distress syndrome (ARDS), septic shock, and multiple organ failure. Some experts attribute this sequence of events to a large increase in cytokines (cytokine storm) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or a secondary infection by another organism. Researchers from The First Affiliated Hospital of Harbin Medical University; Harbin, Heilongjiang Province, China report cytokine levels in multiple body fluids from a patient with COVID-19 and ARDS, septic shock, and multiple organ failure. Read the full text: http://annals.org/aim/article/doi/10.7326/L20-0234.

Media contacts: A PDF for this article is not yet available. Please click the link to read full text. Author Kaijiang Yu, PhD can be reached at drkaijiang@163.com and Ming-Yan Zhao, MD, can be reached at mingyan0927@126.com.

(Boston)--Wearing shoes specifically designed with a novel sole (biomechanical footwear) significantly reduces the pain associated with knee osteoarthritis.

Knee osteoarthritis affects approximately 275 million people worldwide and in 2017 was estimated to account for 8.3 million years lived with disability. Acetaminophen, non-steroidal anti-inflammatory drugs and opioids are most commonly used drugs to treat pain but have limited effectiveness.

Researchers from Boston University School of Medicine (BUSM), the University of Toronto and the University of Bern Switzerland studied 220 participants who suffered with painful osteoarthritis. Half wore the biomechanical footwear while the others wore the "control" shoes. After six months of wearing the shoes, the biomechanical group had a larger decrease in their pain score measured by the Western Ontario Osteoarthritis Index pain scale.

"These findings provide strong evidence supporting the effectiveness of a new treatment for knee osteoarthritis," said David Felson, MD, MPH, professor of medicine at BUSM and coauthor of the study. Felson, a rheumatologist at Boston Medical Center, believes the treatment probably works by re-educating and reconditioning muscles in the legs. "This treatment may help many persons with this disorder."

According to the researchers, not only does it appear to reduce pain in people with osteoarthritis, but may also be effective for some people with hip or back pain.

The authors caution that further research is needed to assess long-term efficacy and safety.

These findings appear online in JAMA.

Vaccination against rotavirus has led to a significant decrease in hospitalisations and deaths of children due to severe diarrhoea in the Western Pacific region, a new study has found.

The research, led by the Murdoch Children's Research Institute (MCRI) and published in BMC Infectious Diseases, showed the substantial impact of the rotavirus vaccine on inpatient and outpatient hospital attendances and child deaths in the Pacific Island country of Kiribati, despite high rates of malnutrition.

MCRI Professor Fiona Russell said the study looked at the impact of rotavirus vaccination on young children two years after its roll-out in Kiribati in 2015. The study provided convincing evidence for ongoing vaccination in Kiribati and other low-middle income countries with poor sanitation and inadequate cold storage chains, she said.

"Kiribati has one of the highest child death and malnutrition rates in the Pacific, which is due to the substantial challenges with the provision of safe drinking water and effective sanitation," she said.

"Kiribati introduced rotavirus vaccination following a series of confirmed rotavirus diarrhoea outbreaks, with up to 70 per cent of cases affecting children under five."

Kiribati is the first country to document the effects of rotavirus vaccination in the Western Pacific region.

The study found acute gastroenteritis inpatient admissions decreased by 37 per cent and outpatient presentations by 44 per cent in children aged under five years. Inpatient severe acute malnutrition admissions also decreased by 24 per cent.

Importantly, the study also reported a 44 per cent and 64 per cent decline in acute gastroenteritis contributing to all under-five admissions and deaths, respectively.

Rotavirus is the most common cause of severe diarrhoea in children worldwide and kills about 215,000 children each year.

Almost all unvaccinated children will have experienced one or more rotavirus diarrheal episodes, regardless of their living conditions, by the age of five.

Professor Russell said the research would provide evidence for other policy makers in the Asia-Pacific region to consider introducing the vaccine.

"Very few countries in the Asia- Pacific have a rotavirus vaccine in their national immunisation programs, despite good data showing the vaccine's benefits," she said.

Public health bodies should consider incentivising social media influencers to encourage adolescents to follow social distancing guidelines, say researchers. Many adolescents are choosing to ignore the guidelines set out by governments during the COVID-19 pandemic, and peer-to-peer campaigns are likely to be more successful in changing attitudes.

"For many people, adolescence - between the ages of 10 and 24 - is when you want to be making more social connections, not losing them. It's also a time of increased risk-taking and sensitivity to peer influence," said Jack Andrews at the UCL Institute of Cognitive Neuroscience, and first author of the paper. "For some adolescents it's a challenge to stick to social distancing rules, particularly if their friends aren't following the rules."

Breaking social distancing rules is a risk-taking behaviour, putting at risk the health of the rule-breaker and of others - in many places with legal or financial consequences. But adolescents are particularly sensitive to the negative effects of social exclusion, and may prefer to risk breaking the rules rather than lose their friends, say the researchers of the paper published in the journal Trends in Cognitive Sciences.

Campaigns led by adults that try to influence adolescent behaviour often have mixed success. The COVID-19 pandemic has resulted in the widespread implementation of social distancing measures, led by governments, which are likely to be in place in some form for the foreseeable future. But media reports of large student gatherings in the US in March demonstrated the challenge of stopping young people from meeting their friends face-to-face.

Social distancing guidance could be more effective if adolescents are allowed to develop and deliver their own campaigns, focused on changing peer attitudes around the importance of social distancing. With the current restrictions on face-to-face interventions, social media is expected to be particularly effective in promoting social distancing behaviours amongst adolescents.

"Adolescents look to their peers to understand social norms, and align their behaviour with the group they want to belong to. The speed and extent of peer influence online is likely to amplified, because social media has such a wide and immediate reach," said Professor Sarah-Jayne Blakemore at the University of Cambridge's Department of Psychology, who led the report.

Previous studies have shown that adolescents are more likely to take certain risks, such as experimenting with drugs or posting sexual content online, when peers are present or doing the same things. Adolescents are also more likely to get involved in beneficial activities, such as volunteering in the community, if they know others who are doing them.

Young people's capacity to encourage each other in a positive way has been demonstrated in previous studies, for example in a peer-led approach to reducing bullying in schools. This study identified highly-connected, well-liked students, and asked them to develop their own anti-bullying campaigns to share with their peers. Bullying dropped by 25% as a result, compared with other schools.

"The advantage of social media influencers is that the motivation for social distancing comes naturally from the young people themselves. Influencers could post videos or photos online, for example, showing how they are following social distancing rules by staying at home, and add tags to increase their visibility through sharing and Likes. Many YouTubers are already doing this. It's really just presenting public health advice in a more accessible way that adolescents are more likely to listen to," said Blakemore.

If social distancing can be established as a group norm amongst friends, it is more likely to be copied by others. Another advantage of targeting social media influencers is that they exist across many spheres of interest so have the potential to reach diverse groups of young people.

The researchers say that to create positive change, adolescents must be given the capacity to lead their own ideas. They hope that their proposals will be taken up by charities and public health bodies who can work with influencers to make sure the correct type of information is being shared.

A modification that creates more male offspring was able to eliminate populations of malaria mosquitoes in lab experiments.

A team led by Imperial College London spread a genetic modification that distorts the sex ratio through a population of caged Anopheles gambiae mosquitoes using 'gene drive' technology.

The team's modification causes mosquitoes to produce more male offspring, eventually leading to no females being born and a total collapse in the population. This represents the first successful sex-distorter gene drive ever created, a goal for scientists as these modifications are expected to be extremely effective at controlling natural mosquito populations.

There were 228 million cases of malaria in 2018, and 405,000 deaths, with new interventions needed to move towards malaria eradication. There are around 3500 species of mosquito worldwide, of which only 40 related species can carry malaria. The team's modification was applied to Anopheles gambiae mosquitoes, the main malaria vector in sub-Saharan Africa.

The hope is that Anopheles gambiae mosquitoes carrying a sex-distorter gene drive would be released in the future, spreading the male bias within local malaria-carrying mosquito populations and causing them to collapse.

As only females bite and take blood meals, only they can pass on malaria, so the modification could have a double effect by biasing the population towards fewer females even before the population collapses.

The lab-based experiments were performed with caged populations of mosquitoes, and more experiments are needed before the team consider releasing any modified mosquitoes in the wild. The results are published today in Nature Biotechnology.

Lead scientist Professor Andrea Crisanti, from the Department of Life Sciences at Imperial, said: "This study represents a key milestone in the long-sought objective to bias the progeny of the human malaria mosquito so that only non-biting males are produced. Having a proven driving sex-distorter opens a new avenue for scientists to develop genetic vector controls of malaria with the aim of eradicating the disease."

Creating sustained male bias

The modification works by using a DNA-cutting enzyme to destroy the X chromosome during the production of sperm, leading to a predominantly male offspring, as females require two Xs. Although sex-distorters based on similar mechanisms have been created before, the new version was coupled to a gene drive to allow it to spread through a population from a very small initial frequency in a very effective way.

The gene spreads faster than would be expected naturally thanks to the gene drive component, which means the modification is inherited nearly 100 per cent of the time, and not just 50 per cent as would be expected from normal mating.

Coupling a sex-distorter with a gene drive increases also the robustness of the system. As it spreads through males it is less sensitive to any 'fitness cost'- there is no detriment to the males, which means the mosquitoes are more likely to mate and pass on their genes, meaning the modification can spread effectively.

The male-biased gene was shown to spread quickly through the population without being stopped by resistance with only a small fraction of the initial mosquitoes possessing the gene (2.5% release frequency), showing that it could have huge potential to control malaria-carrying mosquitoes in the field.

Moving to the next phase

Previously, the team created modified Anopheles gambiae mosquitoes that spread female infertility, and that line of mosquitoes has gone onto larger cage trials that more closely match natural conditions.

The new male-biased mosquitoes lead to population crashes faster than the female-infertility mosquitoes, and has the added benefit of reducing the proportion of biting females at an earlier stage. It will also now go into larger cage trials, where competition for food, mating dynamics and other ecological factors may change the fate of the gene drive.

Co-lead author on the new paper, Dr Alekos Simoni, said: "The new result is very exciting and it's great to see this line of mosquitoes move onto the next phase of the project. When we started no-one knew if it would work, so I am proud that we transformed a novel theoretical idea into something that was shown to work in the lab and has the potential to save millions of lives."