Publications by authors named "Gareth Jones"

771 Publications

A digitally enhanced home-based physical activity intervention for high-risk middle school youth during COVID-19.

Transl Behav Med 2021 Nov 27. Epub 2021 Nov 27.

Philadelphia Youth Sports Collaborative, Philadelphia, PA, USA.

COVID-19 significantly impacted physical activity among high-risk youth. Camp from Home, a digitally enhanced home-based intervention, was developed to address physical activity disparities among middle school youth during COVID-19. Camp from Home enrolled 62 youth in 54 families from five schools in Philadelphia during the summer of 2020. The 6-week intervention comprised of (1) three home deliveries of "activity kits" including exercise equipment and activity booklets, (2) asynchronous sport and exercise videos posted to a private YouTube channel, and (3) supportive text-messages from health coaches. YouTube analytics and self-report surveys completed by parents and youth at baseline and at the end of programming were used to assess engagement, acceptability, and preliminary efficacy. Youth participants were 12.4 (1.2) years, 38.7% female and 90.3% Black/African American. At follow-up, 41 parents (75.9%) and 34 youth (54.8%) completed measures. Youth self-reported increases in self-efficacy (ΔM(sd) = 0.4(1.0), p = .03) and physical activity (ΔM(sd) = 4.2(7.9), p = .004), despite suboptimal engagement in digital program components. Overall, participants highly rated the program. Activity kits and text-messages from health coaches were rated as most helpful. Most parents (95.1%) and youth (83.8%) expressed interested in participating again in the future. A 6-week digitally enhanced, home-based physical activity intervention was acceptable and feasible among parents and youth during the summer of 2020, with youth reporting improvements in self-efficacy and physical activity. Summer programs are critical for reducing disparities in physical activity and hold potential for addressing key barriers for high-risk youth even outside the context of COVID-19.
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http://dx.doi.org/10.1093/tbm/ibab151DOI Listing
November 2021

Artificial intelligence in orthopaedics: A scoping review.

PLoS One 2021 23;16(11):e0260471. Epub 2021 Nov 23.

MSk Lab, Sir Michael Uren Hub, Imperial College London, London, United Kingdom.

There is a growing interest in the application of artificial intelligence (AI) to orthopaedic surgery. This review aims to identify and characterise research in this field, in order to understand the extent, range and nature of this work, and act as springboard to stimulate future studies. A scoping review, a form of structured evidence synthesis, was conducted to summarise the use of AI in orthopaedics. A literature search (1946-2019) identified 222 studies eligible for inclusion. These studies were predominantly small and retrospective. There has been significant growth in the number of papers published in the last three years, mainly from the USA (37%). The majority of research used AI for image interpretation (45%) or as a clinical decision tool (25%). Spine (43%), knee (23%) and hip (14%) were the regions of the body most commonly studied. The application of artificial intelligence to orthopaedics is growing. However, the scope of its use so far remains limited, both in terms of its possible clinical applications, and the sub-specialty areas of the body which have been studied. A standardized method of reporting AI studies would allow direct assessment and comparison. Prospective studies are required to validate AI tools for clinical use.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0260471PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8610245PMC
November 2021

Polychlorinated biphenyl (PCB) concentrations and profiles in marine mammals from the North Atlantic Ocean.

Chemosphere 2021 Oct 20:132639. Epub 2021 Oct 20.

Ontario Ministry of the Environment, Conservation and Parks. 125 Resources Road, Toronto, ON, M9P 3V6, Canada.

Polychlorinated biphenyls (PCBs) can provide crucial information into the bioaccumulation and biomagnification of POPs in marine mammals. Muscle tissue samples were obtained for detailed PCB congener specific analysis of all 209 PCBs in 11 species of marine mammals stranded across the coast of the UK between 2010 and 2013. At least 145 PCB congeners were found in each individual. The highest concentrations of PCBs were recorded in a killer whale (318 mg/kg lipid) and the highest toxic equivalent in a Risso's dolphin (1687 pg/g TEQ wet). Concentrations of PCBs in the majority of samples exceeded toxic thresholds (9 mg/kg lipid) for marine mammals, highlighting the health risk they face from PCB exposure. Many PCB profiles did not fit typical 'Aroclor' signatures, but instead indicated patterns of congeners that are resistant to biotransformation and elimination. However, this study identified a novel PCB signature in a sei whale that has not yet been previously observed in marine mammals. The whale had a PCB profile that included lighter and inadvertent PCB congeners such as PCB 11, suggesting that the main source of exposure was through atmospheric deposition, rather than terrestrial discharges. Seven subsamples were chosen for chiral analysis of PCB 95, 136 and 149. The enantiomer fractions (EFs) of C-PCBs 95 and 149 were non racemic suggesting there may be enantiomer selective metabolism in marine mammals. Although there has been a shift in the literature towards emerging pollutants, this study acts as a stark reminder that PCBs continue to pose a significant risk to wildlife.
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http://dx.doi.org/10.1016/j.chemosphere.2021.132639DOI Listing
October 2021

Does TENS Reduce the Intensity of Acute and Chronic Pain? A Comprehensive Appraisal of the Characteristics and Outcomes of 169 Reviews and 49 Meta-Analyses.

Medicina (Kaunas) 2021 Oct 4;57(10). Epub 2021 Oct 4.

Centre for Pain Research, Leeds Beckett University, Leeds LS1 3HE, UK.

Uncertainty about the clinical efficacy of transcutaneous electric nerve stimulation (TENS) to alleviate pain spans half a century. There has been no attempt to synthesise the entire body of systematic review evidence. The aim of this comprehensive review was to critically appraise the characteristics and outcomes of systematic reviews evaluating the clinical efficacy of TENS for any type of acute and chronic pain in adults. We searched electronic databases for full reports of systematic reviews of studies, overviews of systematic reviews, and hybrid reviews that evaluated the efficacy of TENS for any type of clinical pain in adults. We screened reports against eligibility criteria and extracted data related to the characteristics and outcomes of the review, including effect size estimates. We conducted a descriptive analysis of extracted data. : We included 169 reviews consisting of eight overviews, seven hybrid reviews and 154 systematic reviews with 49 meta-analyses. A tally of authors' conclusions found a tendency toward benefits from TENS in 69/169 reviews, no benefits in 13/169 reviews, and inconclusive evidence in 87/169 reviews. Only three meta-analyses pooled sufficient data to have confidence in the effect size estimate (i.e., pooled analysis of >500 events). Lower pain intensity was found during TENS compared with control for chronic musculoskeletal pain and labour pain, and lower analgesic consumption was found post-surgery during TENS. The appraisal revealed repeated shortcomings in RCTs that have hindered confident judgements about efficacy, resulting in stagnation of evidence. : Our appraisal reveals examples of meta-analyses with 'sufficient data' demonstrating benefit. There were no examples of meta-analyses with 'sufficient data' demonstrating no benefit. Therefore, we recommend that TENS should be considered as a treatment option. The considerable quantity of reviews with 'insufficient data' and meaningless findings have clouded the issue of efficacy. We offer solutions to these issues going forward.
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http://dx.doi.org/10.3390/medicina57101060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8539683PMC
October 2021

Comparison of characteristics and outcomes of patients admitted to hospital with COVID-19 during wave 1 and wave 2 of the current pandemic.

Intern Emerg Med 2021 Oct 12. Epub 2021 Oct 12.

Department of Endocrinology, Ashford and St Peter's Hospitals NHS Foundation Trust, Guildford Road, Chertsey, Surrey, KT16 0PZ, UK.

In this study of patients admitted with COVID-19, we examined differences between the two waves in patient characteristics and outcomes. Data were collected from the first COVID-19 admission to the end of study (01/03/2020-31/03/2021). Data were adjusted for age and sex and presented as odds ratios (OR) with 95% confidence intervals (CI). Among 12,471 admissions, 1452 (11.6%) patients were diagnosed with COVID-19. On admission, the mean (± SD) age of patients with other causes was 68.3 years (± 19.8) and those with COVID-19 in wave 1 was 69.4 years (± 18.0) and wave 2 was 66.2 years (± 18.4). Corresponding ages at discharge were 67.5 years (± 19.7), 63.9 years (± 18.0) and 62.4 years (± 18.0). The highest proportion of total admissions was among the oldest group (≥ 80 years) in wave 1 (35.0%). When compared with patients admitted with other causes, those admitted with COVID-19 in wave 1 and in wave 2 were more frequent in the 40-59 year band: 20.8, 24.6 and 30.0%; consisted of more male patients: 47.5, 57.6 and 58.8%; and a high LACE (Length of stay, Acuity of admission, Comorbidity and Emergency department visits) index (score ≥ 10): 39.4, 61.3 and 50.3%. Compared to wave-2 patients, those admitted in wave 1 had greater risk of death in hospital: OR = 1.58 (1.18-2.12) and within 30 days of discharge: OR = 2.91 (1.40-6.04). Survivors of COVID-19 in wave 1 stayed longer in hospital (median = 6.5 days; interquartile range = 2.9-12.0) as compared to survivors from wave 2 (4.5 days; interquartile range = 1.9-8.7). Patient characteristics differed significantly between the two waves of COVID-19 pandemic. There was an improvement in outcomes in wave 2, including shorter length of stay in hospital and reduction of mortality.
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http://dx.doi.org/10.1007/s11739-021-02842-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8505475PMC
October 2021

Acoustic deterrents influence foraging activity, flight and echolocation behaviour of free-flying bats.

J Exp Biol 2021 10 28;224(20). Epub 2021 Oct 28.

School of Biological Sciences, University of Bristol, Bristol BS8 1TQ, UK.

Acoustic deterrents have shown potential as a viable mitigation measure to reduce human impacts on bats; however, the mechanisms underpinning acoustic deterrence of bats have yet to be explored. Bats avoid ambient ultrasound in their environment and alter their echolocation calls in response to masking noise. Using stereo thermal videogrammetry and acoustic methods, we tested predictions that: (i) bats would avoid acoustic deterrents and forage and social call less in a 'treated airspace'; (ii) deterrents would cause bats to fly with more direct flight paths akin to commuting behaviour and in line with a reduction in foraging activity, resulting in increased flight speed and decreased flight tortuosity; and (iii) bats would alter their echolocation call structure in response to the masking deterrent sound. As predicted, overall bat activity was reduced by 30% and we recorded a significant reduction in counts of Pipistrellus pygmaeus (27%), Myotis spp. (probably M. daubentonii) (26%), and Nyctalus spp. and Eptesicus spp. (68%) passes. Pipistrellus pygmaeus feeding buzzes were also reduced by the deterrent in relation to general activity (by 38%); however, social calls were not (only 23% reduction). Bats also increased their flight speed and reduced the tortuosity of their flight paths, and P. pygmaeus reduced echolocation call bandwidth and start frequency of calls in response to deterrent playback, probably owing to the masking effect of the sound. Deterrence could therefore be used to remove bats from areas where they forage, for example wind turbines and roads, where they may be under threat from direct mortality.
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http://dx.doi.org/10.1242/jeb.242715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8601711PMC
October 2021

Sensory biology: Tree mice use echolocation.

Authors:
Gareth Jones

Curr Biol 2021 Sep;31(18):R1074-R1076

School of Biological Sciences, University of Bristol, 24 Tyndall Avenue, Bristol BS8 1TQ, UK. Electronic address:

A new study demonstrates that soft-furred tree mice orientate by using echolocation, emitting ultrasonic broadband chirps. Remarkable convergent evolution with distantly related bats and dolphins in ear bone morphology and sensory genes is evident.
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http://dx.doi.org/10.1016/j.cub.2021.07.074DOI Listing
September 2021

CPAP delivered outside critical care during the second wave of COVID-19: outcomes from a UK respiratory surge unit.

BMJ Open Respir Res 2021 09;8(1)

Department of Respiratory Medicine, Tropical and Infectious Disease Unit, Intensive care Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.

Background: NHS England recommends non-invasive continuous positive airway pressure (CPAP) as a possible treatment for type 1 respiratory failure associated with COVID-19 pneumonitis, either to avoid intubation or as a ceiling of care. However, data assessing this strategy are sparse, especially for the use of CPAP as a ceiling of care, and particularly when delivered outside of a traditional critical care environment. We describe a cohort of patients from Liverpool, UK, who received CPAP on a dedicated respiratory surge unit at the start of the second wave of the COVID-19 pandemic in UK.

Methods: Retrospective cohort analysis of consecutive patients receiving CPAP for the treatment of respiratory failure secondary to COVID-19 on the respiratory surge unit at the Royal Liverpool Hospital, Liverpool, UK from 21 September until 30 November 2020.

Results: 88 patients were included in the analysis. 56/88 (64%) were deemed suitable for escalation to invasive mechanical ventilation (IMV) and received CPAP as a trial; 32/88 (36%) received CPAP as a ceiling of care. Median age was 63 years (IQR: 56-74) and 58/88 (66%) were men. Median SpO/FiO immediately prior to CPAP initiation was 95 (92-152). Among patients for escalation to IMV, the median time on CPAP was 6 days (IQR 4-7) and survival at day 30 was 84% (47/56) with 14/56 (25%) escalated to IMV. Of those patients for whom CPAP was ceiling of care, the median duration of CPAP was 9 days (IQR 7-11) and 18/32 (56%) survived to day 30. Pulmonary barotrauma occurred in 9% of the cohort. There were no associations found on multivariant analysis that were associated with all-cause 30-day mortality.

Conclusions: With adequate planning and resource redistribution, CPAP may be delivered effectively outside of a traditional critical care setting for the treatment of respiratory failure due to COVID-19. Clinicians delivering CPAP to patients with COVID-19 pneumonitis should be alert to the dangers of pulmonary barotrauma. Among patients who are for escalation of care, the use of CPAP may avoid the need for IMV in some patients. Our data support the NHS England recommendation to consider CPAP as a ceiling of care.
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http://dx.doi.org/10.1136/bmjresp-2021-000907DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8441225PMC
September 2021

Concussion history in rugby union players is associated with depressed cerebrovascular reactivity and cognition.

Scand J Med Sci Sports 2021 Dec 12;31(12):2291-2299. Epub 2021 Sep 12.

Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK.

Recurrent contact and concussion in rugby union remains a significant public health concern given the potential increased risk of neurodegeneration in later life. This study determined to what extent prior-recurrent contact impacts molecular-hemodynamic biomarkers underpinning cognition in current professional rugby union players with a history of concussion. Measurements were performed in 20 professional rugby union players with an average of 16 (interquartile range [IQR] 13-19) years playing history reporting 3 (IQR 1-4) concussions. They were compared to 17 sex-age-physical activity-and education-matched non-contact controls with no prior history of self-reported concussion. Venous blood was assayed directly for the ascorbate free radical (A electron paramagnetic resonance spectroscopy) nitric oxide metabolites (NO reductive ozone-based chemiluminescence) and select biomarkers of neurovascular unit integrity (NVU chemiluminescence/ELISA). Middle cerebral artery blood flow velocity (MCAv doppler ultrasound) was employed to determine basal perfusion and cerebrovascular reactivity (CVR) to hyper/hypocapnia ( ). Cognition was assessed by neuropsychometric testing. Elevated systemic oxidative-nitrosative stress was confirmed in the players through increased A (p < 0.001) and suppression of NO bioavailability (p < 0.001). This was accompanied by a lower CVR range ( ; p = 0.045) elevation in neurofilament light-chain (p = 0.010) and frontotemporal impairments in immediate-memory (p = 0.001) delayed-recall (p = 0.048) and fine-motor coordination (p < 0.001). Accelerated cognitive decline subsequent to prior-recurrent contact and concussion history is associated with a free radical-mediated suppression of CVR and neuronal injury providing important mechanistic insight that may help better inform clinical management.
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http://dx.doi.org/10.1111/sms.14046DOI Listing
December 2021

Novel polyprotein antigens designed for improved serodiagnosis of bovine tuberculosis.

Vet Immunol Immunopathol 2021 Oct 28;240:110320. Epub 2021 Aug 28.

National Animal Disease Center, Agricultural Research Service, United States Department of Agriculture, 1920 Dayton Avenue, Ames, IA, 50010, USA.

Recent studies have demonstrated potential for serologic assays to improve surveillance and control programs for bovine tuberculosis. Due to the animal-to-animal variation of the individual antibody repertoires observed in bovine tuberculosis, it has been suggested that serodiagnostic sensitivity can be maximized by use of multi-antigen cocktails or genetically engineered polyproteins expressing immunodominant B-cell epitopes. In the present study, we designed three novel multiepitope polyproteins named BID109, TB1f, and TB2f, with each construct representing a unique combination of four full-length peptides of Mycobacterium bovis predominantly recognized in bovine tuberculosis. Functional performance of the fusion antigens was evaluated using multi-antigen print immunoassay (MAPIA) and Dual Path Platform (DPP) technology with panels of monoclonal and polyclonal antibodies generated against individual proteins included in the fusion constructs as well as with serum samples from M. bovis-infected and non-infected cattle, American bison, and domestic pigs. It was shown that epitopes of each individual protein were expressed in the fusion antigens and accessible for efficient binding by the respective antibodies. The three fusion antigens demonstrated stronger immunoreactivity in MAPIA than that of single protein antigens. Evaluation of the fusion antigens in DPP assay using serum samples from 125 M. bovis-infected and 57 non-infected cattle showed the best accuracy (∼84 %) for TB2f antigen composed of MPB70, MPB83, CFP10, and Rv2650c proteins. Thus, the study results suggest a potential for the multiepitope polyproteins to improve diagnostic sensitivity of serologic assays for bovine tuberculosis.
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http://dx.doi.org/10.1016/j.vetimm.2021.110320DOI Listing
October 2021

The changing states of fibromyalgia in patients with axial spondyloarthritis: results from the British Society of Rheumatology Biologics Register for Ankylosing Spondylitis.

Rheumatology (Oxford) 2021 09;60(9):4121-4129

Department of Rheumatology, National Resource Centre for Rehabilitation in Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.

Objectives: To identify factors associated with FM development and recovery in patients with axial SpA (axSpA).

Methods: The British Society of Rheumatology Biologics Register for Ankylosing Spondylitis (BSRBR-AS) recruited patients with axSpA from 83 centres in a prospective study. FM was diagnosed using the self-reported Fibromyalgia Survey Diagnostic Criteria from 2015. Measures of axSpA disease activity and clinical findings were recorded at regular intervals. We identified predictors for FM development and recovery between yearly visits using uni- and multivariable logistic regression models.

Results: A total of 801 participants, 247 (30.8%) female, had two or more visits and were eligible for inclusion. A total of 686 participants did not have FM at baseline, of whom 45 had developed FM at follow-up, while 115 participants had FM at baseline, of whom 77 had recovered at follow-up. A high baseline BASDAI score [odds ratio (OR) 1.27 (95% CI 1.08, 1.49)] and Widespread Pain Index (WPI) [OR 1.14 (95% CI 1.02, 1.28)] were significantly associated with FM development in the final multivariable model. A low baseline BASFI score [OR 0.68 (95% CI 0.53, 0.86)] and WPI [OR 0.84 (95% CI 0.720, 0.97)] and starting a TNF inhibitor [OR 3.86 (95% CI 1.54, 9.71)] were significantly associated with FM recovery.

Conclusion: High levels of disease activity and the presence of widespread pain is associated with the development of FM in patients with axSpA, while low levels of the same variables and starting a TNF inhibitor are associated with recovery from FM. The presence of comorbid FM should be considered in patients with persistent high axSpA disease activity and widespread pain.
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http://dx.doi.org/10.1093/rheumatology/keaa888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8409995PMC
September 2021

A proof of concept study for machine learning application to stenosis detection.

Med Biol Eng Comput 2021 Oct 28;59(10):2085-2114. Epub 2021 Aug 28.

Faculty of Science and Engineering, Swansea University, Swansea, UK.

This proof of concept (PoC) assesses the ability of machine learning (ML) classifiers to predict the presence of a stenosis in a three vessel arterial system consisting of the abdominal aorta bifurcating into the two common iliacs. A virtual patient database (VPD) is created using one-dimensional pulse wave propagation model of haemodynamics. Four different machine learning (ML) methods are used to train and test a series of classifiers-both binary and multiclass-to distinguish between healthy and unhealthy virtual patients (VPs) using different combinations of pressure and flow-rate measurements. It is found that the ML classifiers achieve specificities larger than 80% and sensitivities ranging from 50 to 75%. The most balanced classifier also achieves an area under the receiver operative characteristic curve of 0.75, outperforming approximately 20 methods used in clinical practice, and thus placing the method as moderately accurate. Other important observations from this study are that (i) few measurements can provide similar classification accuracies compared to the case when more/all the measurements are used; (ii) some measurements are more informative than others for classification; and (iii) a modification of standard methods can result in detection of not only the presence of stenosis, but also the stenosed vessel. Graphical Abstract An overview of methodology fo the creation of virtual patients and their classification.
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http://dx.doi.org/10.1007/s11517-021-02424-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8440304PMC
October 2021

Comment on: "Injury Profile in Women's Football: A Systematic Review and Meta‑analysis".

Sports Med 2021 Dec 27;51(12):2665-2666. Epub 2021 Aug 27.

Musculoskeletal Health Research Group, School of Clinical Applied Sciences, Leeds Beckett University, Leeds, UK.

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http://dx.doi.org/10.1007/s40279-021-01531-9DOI Listing
December 2021

Incidence of injury in adult elite women's football: a systematic review and meta-analysis.

BMJ Open Sport Exerc Med 2021 13;7(3):e001094. Epub 2021 Jul 13.

Musculoskeletal Health Research Group, School of Clinical and Applied Science, Leeds Beckett University, Leeds, UK.

Aim: To estimate the incidence of injury in adult elite women's football and to characterise the nature and anatomical location of injuries.

Design: Systematic review and meta-analysis.

Data Sources: Combinations of the key terms were entered into the following electronic databases (PubMed, SPORTDiscus, Science Direct and Discover) from inception to May 2021.

Eligibility Criteria For Selecting Studies: (1) Used a prospective cohort design; (2) captured data on elite adult women players; (3) reported injury incidence by anatomical site; (4) captured data of at least one season or national team tournament; (5) included a definition of injury; and (6) written in English.

Results: The search identified 1378 records. Twelve studies published between 1991 and 2018 were included in our review and sampled 129 teams. In domestic club football, injury incidence rate was estimated to be 5.7/1000 hours (total), 19.5/1000 hours (match) and 3.1/1000 hours (training). In tournament, football match incidence was estimated to be 55.7/1000 hours. The knee (22.8%; 368/1822) was the most common site of injury in domestic club football. The ankle (23.7%, 105/443) was the most common site of injury in tournament football. Ligament sprains were the most common type of injury (27.8%), followed by muscle strains (19.1%). Severn studies (58%) had a high risk of bias associated with exposure definition and measurement and considerable heterogeneity exists between the included studies (I=49.7%-95%).

Summary/conclusion: Ligament sprains occur more frequently in adult elite women football players. We advise caution in interpretating point estimates of the incidence of injury due to high statistical heterogeneity. Standardising injury reporting and the accurate recording of match and training exposure will overcome such limitations.

Prospero Registration Number: CRD42019130407.su.
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http://dx.doi.org/10.1136/bmjsem-2021-001094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8323459PMC
July 2021

The revision partial knee classification system: understanding the causative pathology and magnitude of further surgery following partial knee arthroplasty.

Bone Jt Open 2021 Aug;2(8):638-645

MSk Lab, Sir Michael Uren Biomedical Engineering Research Hub, Imperial College London, London, UK.

Aims: Joint registries classify all further arthroplasty procedures to a knee with an existing partial arthroplasty as revision surgery, regardless of the actual procedure performed. Relatively minor procedures, including bearing exchanges, are classified in the same way as major operations requiring augments and stems. A new classification system is proposed to acknowledge and describe the detail of these procedures, which has implications for risk, recovery, and health economics.

Methods: Classification categories were proposed by a surgical consensus group, then ranked by patients, according to perceived invasiveness and implications for recovery. In round one, 26 revision cases were classified by the consensus group. Results were tested for inter-rater reliability. In round two, four additional cases were added for clarity. Round three repeated the survey one month later, subject to inter- and intrarater reliability testing. In round four, five additional expert partial knee arthroplasty surgeons were asked to classify the 30 cases according to the proposed revision partial knee classification (RPKC) system.

Results: Four classes were proposed: PR1, where no bone-implant interfaces are affected; PR2, where surgery does not include conversion to total knee arthroplasty, for example, a second partial arthroplasty to a native compartment; PR3, when a standard primary total knee prosthesis is used; and PR4 when revision components are necessary. Round one resulted in 92% inter-rater agreement (Kendall's W 0.97; p < 0.005), rising to 93% in round two (Kendall's W 0.98; p < 0.001). Round three demonstrated 97% agreement (Kendall's W 0.98; p < 0.001), with high intra-rater reliability (interclass correlation coefficient (ICC) 0.99; 95% confidence interval 0.98 to 0.99). Round four resulted in 80% agreement (Kendall's W 0.92; p < 0.001).

Conclusion: The RPKC system accounts for all procedures which may be appropriate following partial knee arthroplasty. It has been shown to be reliable, repeatable and pragmatic. The implications for patient care and health economics are discussed. Cite this article:  2021;2(8):638-645.
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http://dx.doi.org/10.1302/2633-1462.28.BJO-2021-0086.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8384450PMC
August 2021

Taking flight: An ecological, evolutionary and genomic perspective on bat telomeres.

Mol Ecol 2021 Aug 12. Epub 2021 Aug 12.

School of Biology and Environmental Science, Science Centre West, University College Dublin, Belfield, Ireland.

Over 20% of all living mammals are bats (order Chiroptera). Bats possess extraordinary adaptations including powered flight, laryngeal echolocation and a unique immune system that enables them to tolerate a diversity of viral infections without presenting clinical disease symptoms. They occupy multiple trophic niches and environments globally. Significant physiological and ecological diversity occurs across the order. Bats also exhibit extreme longevity given their body size with many species showing few signs of ageing. The molecular basis of this extended longevity has recently attracted attention. Telomere maintenance potentially underpins bats' extended healthspan, although functional studies are still required to validate the causative mechanisms. In this review, we detail the current knowledge on bat telomeres, telomerase expression, and how these relate to ecology, longevity and life-history strategies. Patterns of telomere shortening and telomerase expression vary across species, and comparative genomic analyses suggest that alternative telomere maintenance mechanisms evolved in the longest-lived bats. We discuss the unique challenges faced when working with populations of wild bats and highlight ways to advance the field including expanding long-term monitoring across species that display contrasting life-histories and occupy different environmental niches. We further review how new high quality, chromosome-level genome assemblies can enable us to uncover the molecular mechanisms governing telomere dynamics and how phylogenomic analyses can reveal the adaptive significance of telomere maintenance and variation in bats.
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http://dx.doi.org/10.1111/mec.16117DOI Listing
August 2021

Contact events in rugby union and the link to reduced cognition: evidence for impaired redox-regulation of cerebrovascular function.

Exp Physiol 2021 Sep 5;106(9):1971-1980. Epub 2021 Aug 5.

Neurovascular Research Laboratory, Faculty of Life Sciences and Education, University of South Wales, Pontypridd, UK.

New Findings: What is the central question of this study? How does recurrent contact incurred across a season of professional rugby union impact molecular, cerebrovascular and cognitive function? What is the main findings and its importance? A single season of professional rugby union increases systemic oxidative-nitrosative stress (OXNOS) confirmed by a free radical-mediated suppression in nitric oxide bioavailability. Forwards encountered a higher frequency of contact events compared to backs, exhibiting elevated OXNOS and lower cerebrovascular function and cognition. Collectively, these findings provide mechanistic insight into the possible cause of reduced cognition in rugby union subsequent to impairment in the redox regulation of cerebrovascular function.

Abstract: Contact events in rugby union remain a public health concern. We determined the molecular, cerebrovascular and cognitive consequences of contact events during a season of professional rugby. Twenty-one male players aged 25 (mean) ± 4 (SD) years were recruited from a professional rugby team comprising forwards (n = 13) and backs (n = 8). Data were collected across the season. Pre- and post-season, venous blood was assayed for the ascorbate free radical (A , electron paramagnetic resonance spectroscopy) and nitric oxide (NO, reductive ozone-based chemiluminescence) to quantify oxidative-nitrosative stress (OXNOS). Middle cerebral artery velocity (MCAv, Doppler ultrasound) was measured to assess cerebrovascular reactivity (CVR), and cognition was assessed using the Montreal Cognitive Assessment (MoCA). Notational analysis determined contact events over the season. Forwards incurred more collisions (Mean difference [M ] 7.49; 95% CI, 2.58-12.40; P = 0.005), tackles (M 3.49; 95% CI, 0.42-6.56; P = 0.028) and jackals (M 2.21; 95% CI, 0.18-4.24; P = 0.034). Forwards suffered five concussions while backs suffered one concussion. An increase in systemic OXNOS, confirmed by elevated A (F  = 10.589, P = 0.004) and corresponding suppression of NO bioavailability (F  = 11.492, P = 0.003) was apparent in forwards and backs across the season. This was accompanied by a reduction in cerebral oxygen delivery ( , F  = 9.440, P = 0.006) and cognition (F  = 4.813, P = 0.041). Forwards exhibited a greater decline in the cerebrovascular reactivity range to changes in PET ( compared to backs (M 1.378; 95% CI, 0.74-2.02; P < 0.001).
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http://dx.doi.org/10.1113/EP089330DOI Listing
September 2021

Emerging roles for IL-6 family cytokines as positive and negative regulators of ectopic lymphoid structures.

Cytokine 2021 10 31;146:155650. Epub 2021 Jul 31.

School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK. Electronic address:

IL-6 family cytokines display broad effects in haematopoietic and non-haematopoietic cells that regulate immune homeostasis, host defence, haematopoiesis, development, reproduction and wound healing. Dysregulation of these activities places this cytokine family as important mediators of autoimmunity, chronic inflammation and cancer. In this regard, ectopic lymphoid structures (ELS) are a pathological hallmark of many tissues affected by chronic disease. These inducible lymphoid aggregates form compartmentalised T cell and B cell zones, germinal centres, follicular dendritic cell networks and high endothelial venules, which are defining qualities of peripheral lymphoid organs. Accordingly, ELS can support local antigen-specific responses to self-antigens, alloantigens, pathogens and tumours. ELS often correlate with severe disease progression in autoimmune conditions, while tumour-associated ELS are associated with enhanced anti-tumour immunity and a favourable prognosis in cancer. Here, we discuss emerging roles for IL-6 family cytokines as regulators of ELS development, maintenance and activity and consider how modulation of these activities has the potential to aid the successful treatment of autoimmune conditions and cancers where ELS feature.
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http://dx.doi.org/10.1016/j.cyto.2021.155650DOI Listing
October 2021

Field evaluation of specific mycobacterial protein-based skin test for the differentiation of Mycobacterium bovis-infected and Bacillus Calmette Guerin-vaccinated crossbred cattle in Ethiopia.

Transbound Emerg Dis 2021 Jul 31. Epub 2021 Jul 31.

Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia.

Bovine tuberculosis (bTB) challenges intensive dairy production in Ethiopia and implementation of the test and slaughter control strategy is not economically acceptable in the country. Vaccination of cattle with Bacillus Calmette-Guerin (BCG) could be an important adjunct to control, which would require a diagnostic test to differentiate Mycobacterium bovis (M. bovis)-infected and BCG-vaccinated animals (DIVA role). This study describes an evaluation of a DIVA skin test (DST) that is based on a cocktail (DSTc) or fusion (DSTf) of specific (ESAT-6, CFP-10 and Rv3615c) M. bovis proteins in Zebu-Holstein-Friesians crossbred cattle in Ethiopia. The study animals used were 74 calves (35 BCG vaccinated and 39 unvaccinated) aged less than 3 weeks at the start of experiment and 68 naturally infected 'TB reactor' cows. Six weeks after vaccination, the 74 calves were tested with the DSTc and the single intradermal cervical comparative tuberculin (SICCT) test. The TB reactor cows were tested with the DSTc and the SICCT test. Reactions to the DSTc were not observed in BCG-vaccinated and unvaccinated calves, while SICCT test reactions were detected in vaccinated calves. DSTc reactions were detected in 95.6% of the TB reactor cows and single intradermal tuberculin positive reactions were found in 98.2% (95% confidence interval, CI, 92.1-100%). The sensitivity of the DSTc was 95.6% (95% CI, 87.6-99.1%), and significantly (p < .001) higher than the sensitivity (75%, 95% CI, 63.0-84.7%) of the SICCT test at 4 mm cut-off. DSTf and DSTc reactions were correlated (r = 0.75; 95% CI = 0.53-0.88). In conclusion, the DSTc could differentiate M. bovis-infected from BCG-vaccinated cattle in Ethiopia. DST had higher sensitivity than the SICCT test. Hence, the DSTc could be used as a diagnostic tool for bTB if BCG vaccination is implemented for the control of bTB in Ethiopia and other countries.
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http://dx.doi.org/10.1111/tbed.14252DOI Listing
July 2021

Sports safety matting diminishes cardiopulmonary resuscitation quality and increases rescuer perceived exertion.

PLoS One 2021 22;16(7):e0254800. Epub 2021 Jul 22.

School of Clinical and Applied Sciences, Leeds Beckett University, Leeds, West Yorkshire, United Kingdom.

Objectives: Compliant surfaces beneath a casualty diminish the quality of cardiopulmonary resuscitation (CPR) in clinical environments. To examine this issue in a sporting environment, we assessed chest compression quality and rescuer exertion upon compliant sports safety matting.

Methods: Twenty-seven advanced life support providers volunteered (13 male/14 female; mass = 79.0 ± 12.5 kg; stature = 1.77 ± 0.09 m). Participants performed 5 × 2 min, randomized bouts of continuous chest compressions on a mannequin, upon five surfaces: solid floor; low-compliance matting; low-compliance matting with a backboard; high-compliance matting; high-compliance matting with a backboard. Measures included chest compression depth and rate, percentage of adequate compressions, and rescuer heart rate and perceived exertion.

Results: Chest compression depth and rate were significantly lower upon high-compliance matting relative to other surfaces (p<0.05). The percentage of adequate compressions (depth ≥50 mm) was lowest upon high-compliance matting (40 ± 39%) versus low-compliance matting (60 ± 36%) and low-compliance matting with a backboard (59 ± 39%). Perceived exertion was significantly greater upon high-compliance matting versus floor, low-compliance matting, and low-compliance matting with a backboard (p<0.05).

Conclusion: Providers of CPR should be alerted to the detrimental effects of compliant safety matting in a sporting environment and prepare to alter the targeted compression depth and rescuer rotation intervals accordingly.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0254800PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8297772PMC
November 2021

Diurnal sheltering preferences and associated conservation management for the endangered sandhill dunnart, .

J Mammal 2021 Apr 23;102(2):588-602. Epub 2021 Apr 23.

School of Biological Sciences, University of Bristol, Bristol, United Kingdom.

Dasyurids are small mammals that can conserve energy and water by using shelters that insulate against extreme conditions, prevent predation, and facilitate torpor. To quantify the diurnal sheltering requirements of a poorly known, endangered dasyurid, the sandhill dunnart, , we radiotracked 40 individuals in the Western Australian Great Victoria Desert between 2015 and 2019. We assessed the effect of habitat class (broad habitat features), plot-level (the area surrounding each shelter), and shelter characteristics (e.g., daily temperature ranges), on shelter selection and sheltering habitat preferences. Two hundred and eleven diurnal shelters (mean of 5 ± 3 shelters per individual) were located on 363 shelter days (the number of days each shelter was used), within mature vegetation (mean seral age of 32 ± 12 years postfire). Burrows were used on 77% of shelter days and were typically concealed under mature spinifex, spp., with stable temperature ranges and northern aspects facing the sun. While many burrows were reused ( = 40 across 175 shelter days), spinifex hummock shelters typically were used for one shelter day and were not insulative against extreme temperatures. However, shallow scrapes within hummock shelters had thermal advantages and log shelters retained heat and were selected on cooler days. requires long-unburned sheltering habitat with mature vegetation. Summer fires in the Great Victoria Desert can be extensive and destroy large areas of land, rendering them a key threat to the species. We conclude that the survey and conservation of requires attention to long-unburned, dense lower stratum swale, sand plain, and dune slope habitats, and the tendency of to burrow allows the species to survive within the extreme conditions of its desert environment.
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http://dx.doi.org/10.1093/jmammal/gyab024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8245887PMC
April 2021

The 30-day survival and recovery after hip fracture by timing of mobilization and dementia : a UK database study.

Bone Joint J 2021 Jul;103-B(7):1317-1324

Department of Population Health Sciences, School of Population Health & Environmental Sciences, Faculty of Life Science and Medicine, London, UK.

Aims: The aim of this study to compare 30-day survival and recovery of mobility between patients mobilized early (on the day of, or day after surgery for a hip fracture) and patients mobilized late (two days or more after surgery), and to determine whether the presence of dementia influences the association between the timing of mobilization, 30-day survival, and recovery.

Methods: Analysis of the National Hip Fracture Database and hospital records for 126,897 patients aged ≥ 60 years who underwent surgery for a hip fracture in England and Wales between 2014 and 2016. Using logistic regression, we adjusted for covariates with a propensity score to estimate the association between the timing of mobilization, survival, and recovery of walking ability.

Results: A total of 99,667 patients (79%) mobilized early. Among those mobilized early compared to those mobilized late, the weighted odds ratio of survival was 1.92 (95% confidence interval (CI) 1.80 to 2.05), of recovering outdoor ambulation was 1.25 (95% CI 1.03 to 1.51), and of recovering indoor ambulation was 1.53 (95% CI 1.32 to 1.78) by 30 days. The weighted probabilities of survival at 30 days post-admission were 95.9% (95% CI 95.7% to 96.0%) for those who mobilized early and 92.4% (95% CI 92.0% to 92.8%) for those who mobilized late. The weighted probabilities of regaining the ability to walk outdoors were 9.7% (95% CI 9.2% to 10.2%) and indoors 81.2% (95% CI 80.0% to 82.4%), for those who mobilized early, and 7.9% (95% CI 6.6% to 9.2%) and 73.8% (95% CI 71.3% to 76.2%), respectively, for those who mobilized late. Patients with dementia were less likely to mobilize early despite observed associations with survival and ambulation recovery for those with and without dementia.

Conclusion: Early mobilization is associated with survival and recovery for patients (with and without dementia) after hip fracture. Early mobilization should be incorporated as a measured indicator of quality. Reasons for failure to mobilize early should also be recorded to inform quality improvement initiatives. Cite this article:  2021;103-B(7):1317-1324.
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http://dx.doi.org/10.1302/0301-620X.103B7.BJJ-2020-2349.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7611209PMC
July 2021

Frailty score before admission as risk factor for mortality of renal patients during the first wave of the COVID pandemic in London.

G Ital Nefrol 2021 Jun 24;38(3). Epub 2021 Jun 24.

Department of Nephrology & Transplantation, Royal Free London NHS Foundation Trust, UK.

Frailty is a known predictor of mortality and poor outcomes during hospital admission. In this large renal retrospective cohort study, we investigated whether frailer COVID-19 positive renal patients had worse outcomes. All SARS-Cov-2 positive renal patients aged ≥18 years who presented to the emergency department at the Royal Free Hospital or at the satellite dialysis centres from 10th of March until the 10th of May 2020, with recent data on frailty, were included. The follow up was until 26th of May 2020. Age, gender, ethnicity, body mass index, chronic kidney disease stage, modality of renal replacement therapy, co-morbidities, Rockwood clinical frailty score (CFS), C reactive protein and the neutrophil-to-lymphocyte count were collected at presentation. The primary outcome was the overall mortality rate following COVID-19 diagnosis. Secondary outcomes included the need for hospital admission. A total of 200 renal patients were SARS-Cov-2 positive. In the 174 patients who had a CFS recorded, the age was 65.4 years ± 15.8 (mean ± SD) and 57,5% were male. At the end of follow up, 26% had died. Frail patients (CFS 5-7) were more than three times more likely to die compared to less frail patients (CFS of 1-4) (odds ratio (OR) 3.3, 95% confidence interval (CI) 1.0-10.6). 118 patients (68%) required admission, but there was no difference in hospital admission rates for frail vs non-frail patients (OR 0.6, CI 0.3-1.7). Frailty is a better predictor of mortality than age and co-morbidities in COVID-19 positive renal patients.
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June 2021

Polygenic Risk Scores have high diagnostic capacity in ankylosing spondylitis.

Ann Rheum Dis 2021 09 20;80(9):1168-1174. Epub 2021 Apr 20.

Rheumatology Department, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China.

Objective: We sought to test the hypothesis that Polygenic Risk Scores (PRSs) have strong capacity to discriminate cases of ankylosing spondylitis (AS) from healthy controls and individuals in the community with chronic back pain.

Methods: PRSs were developed and validated in individuals of European and East Asian ethnicity, using data from genome-wide association studies in 15 585 AS cases and 20 452 controls. The discriminatory values of PRSs in these populations were compared with other widely used diagnostic tests, including C-reactive protein (CRP), and sacroiliac MRI.

Results: In people of European descent, PRS had high discriminatory capacity with area under the curve (AUC) in receiver operator characteristic analysis of 0.924. This was significantly better than for testing alone (AUC=0.869), MRI (AUC=0.885) or C-reactive protein (AUC=0.700). PRS developed and validated in individuals of East Asian descent performed similarly (AUC=0.948). Assuming a prior probability of AS of 10% such as in patients with chronic back pain under 45 years of age, compared with testing alone, PRS provides higher positive values for 35% of patients and negative predictive values for 67.5% of patients. For PRS, in people of European descent, the maximum positive predictive value was 78.2% and negative predictive value was 100%, whereas for these values were 51.9% and 97.9%, respectively.

Conclusions: PRS have higher discriminatory capacity for AS than CRP, sacroiliac MRI or status alone. For optimal performance, PRS should be developed for use in the specific ethnic groups to which they are to be applied.
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http://dx.doi.org/10.1136/annrheumdis-2020-219446DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8364478PMC
September 2021

Participant Experiences of a Quit Smoking Attempt Through Either Nicotine Replacement Therapy (NRT) Methods or the Use of an E-cigarette.

J Addict Med 2021 Jun 14. Epub 2021 Jun 14.

Academy for Sport and Physical Activity, Health and Wellbeing Department, Sheffield Hallam University, Sheffield, UK (GJ), Lifestyle Exercise and Nutrition Improvement (LENI) Research Group, Department of Nursing and Midwifery, College of Health, Wellbeing and Life Sciences, Sheffield Hallam University, Sheffield, UK (GJ, EM, MK), Addictions, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK and SPECTRUM Research Consortium, UK (LSB).

Objectives: There is a lack of evidence exploring experiences of using e-cigarettes for smoking cessation. The study's main aim was to explore participant experiences of e-cigarettes compared to nicotine replacement therapy (NRT) delivered through stop smoking services.

Methods: Semi-structured, face-to-face, and telephone interviews at 3-month post-quit follow-up in a randomized controlled trial comparing nicotine-containing e-cigarettes, nicotine-free e-cigarettes, and NRT for smoking cessation. N = 17 participants, 9 were male, mean age 44 years, 5 using nicotine-containing e-cigarettes, 7 nicotine-free e-cigarettes, and 5 NRT. Interviews were transcribed and analyzed using thematic analysis.

Results: Two global themes and 5 organizing themes were identified. Global themes included: (1) experiences of e-cigarette and NRT quit aids (e-cigarette positive impact and dilemmas, NRT perceptions and experiences), and (2) key mechanisms to support quit attempt (physical aids, advice and support, feedback and structure). E-cigarettes were viewed with caution, however, generally evaluated positively alongside NRT methods, finding e-cigarettes useful during a quit attempt due to their versatility in application. Nicotine-containing e-cigarettes were favored due to their support with nicotine cravings. Participants were, however, wary of replacing smoking addiction with vaping habit.

Conclusions: Participant e-cigarette experience were generally positive; however, concerns over long-term application were noted. There was a noticeable preference for nicotine-containing e-cigarettes, but further research is required to better understand how nicotine is used in conjunction with e-cigarettes long-term as a quit aid alongside other NRT.
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http://dx.doi.org/10.1097/ADM.0000000000000881DOI Listing
June 2021

Effectiveness and treatment retention of TNF inhibitors when used as monotherapy versus comedication with csDMARDs in 15 332 patients with psoriatic arthritis. Data from the EuroSpA collaboration.

Ann Rheum Dis 2021 11 3;80(11):1410-1418. Epub 2021 Jun 3.

Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden.

Background: Comedication with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) during treatment with tumour necrosis factor inhibitors (TNFi) is extensively used in psoriatic arthritis (PsA), although the additive benefit remains unclear. We aimed to compare treatment outcomes in patients with PsA treated with TNFi and csDMARD comedication versus TNFi monotherapy.

Methods: Patients with PsA from 13 European countries who initiated a first TNFi in 2006-2017 were included. Country-specific comparisons of 1 year TNFi retention were performed by csDMARD comedication status, together with HRs for TNFi discontinuation (comedication vs monotherapy), adjusted for age, sex, calendar year, disease duration and Disease Activity Score with 28 joints (DAS28). Adjusted ORs of clinical remission (based on DAS28) at 12 months were calculated. Between-country heterogeneity was assessed using random-effect meta-analyses, combined results were presented when heterogeneity was not significant. Secondary analyses stratified according to TNFi subtype (adalimumab/infliximab/etanercept) and restricted to methotrexate as comedication were performed.

Results: In total, 15 332 patients were included (62% comedication, 38% monotherapy). TNFi retention varied across countries, with significant heterogeneity precluding a combined estimate. Comedication was associated with better remission rates, pooled OR 1.25 (1.12-1.41). Methotrexate comedication was associated with improved remission for adalimumab (OR 1.45 (1.23-1.72)) and infliximab (OR 1.55 (1.21-1.98)) and improved retention for infliximab. No effect of comedication was demonstrated for etanercept.

Conclusion: This large observational study suggests that, as used in clinical practice, csDMARD and TNFi comedication are associated with improved remission rates, and specifically, comedication with methotrexate increases remission rates for both adalimumab and infliximab.
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http://dx.doi.org/10.1136/annrheumdis-2021-220097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8522446PMC
November 2021

The effect of COVID-19 public health restrictions on the health of people with musculoskeletal conditions and symptoms: the CONTAIN study.

Rheumatology (Oxford) 2021 10;60(SI):SI13-SI24

Epidemiology Group and Aberdeen Centre for Arthritis and Musculoskeletal Health, Aberdeen, UK.

Objective: To quantify the change in quality of life, disease-specific indicators, health and lifestyle before and during the COVID-19 pandemic among people with musculoskeletal diagnoses and symptoms.

Methods: We undertook an additional follow-up of two existing UK registers involving people with axial spondyloarthritis (axSpA) or psoriatic arthritis (PsA) and participants in a trial in the UK who had regional pain and were identified at high risk of developing chronic widespread pain. Participants completed the study questionnaire between July and December 2020, throughout which time there were public health restrictions in place.

Results: The number of people taking part in the study was 1054 (596 axSpA, 162 PsA, 296 regional pain). In comparison with their previous (pre-pandemic) assessment, there was an age-adjusted significant, small decrease in quality of life measured by EQ-5D [-0.020 (95% CI -0.030, -0.009)] overall and across all population groups examined. This was primarily related to poorer mental health and pain. There was a small increase in fibromyalgia symptoms, but a small decrease in sleep problems. There was a small deterioration in axSpA disease activity, and disease-specific quality of life and anxiety in PsA participants. Predictors of poor quality of life were similar pre- and during the pandemic. The effect of lockdown on activity differed according to age, gender and deprivation.

Conclusion: Important lessons include focusing on addressing anxiety and providing enhanced support for self-management in the absence of normal health care being available, and awareness that all population groups are likely to be affected.
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http://dx.doi.org/10.1093/rheumatology/keab374DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8244573PMC
October 2021
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