BMI The London Independent Hospital

To evaluate the mid-term clinical outcomes for the non-surgical and surgical management of acute proximal hamstring avulsions. Sixty physically active individuals were offered surgical or non-surgical management for their proximal hamstring avulsion injuries. Distal retraction was defined as greater than 2 cm. Primary outcome measures were the Victorian Institute of sport assessment-proximal hamstring tendons (VISA-H) and functional assessment scale for acute hamstring injuries (FASH). Secondary outcome measures included palpable gap (cm), return to sport (RTS) and the ability to perform Nordic hamstring curls. Outcome variables were adjusted in regression models for gender, age, and treatment. Thirty-one patients elected to undertake non-surgical management, and 29 chose surgery with a mean follow-up of 34.8 ± 8.7 and 34.9 ± 7.0 months, respectively. The mean VISA-H for the non-surgical and surgical groups were 87.3 ± 3.4 and 87.9 ± 4.1 (n.s.), respectively. The mean FASH for the non-surgical group was 89.3 ± 2.4 and 88 ± 3.6 for the surgical group (n.s.). This was consistent after adjusting for confounders. The mean gap for the non-surgical group was 4.5 ± 1.09and 4.9 ± 1.19 cm for the surgical group (n.s.). No significant differences were found in the abilities to perform Nordic hamstring curls (n.s.). Both groups achieved comparable RTS rates (n.s.). On average, the non-surgical group achieved RTS at 5.5 ± 1.2 months post-injury, whereas the surgical group was at 5.7 ± 0.7 months (n.s.). Physically active individuals with acute proximal hamstring avulsions and distal retraction of the tendon stump can be managed non-surgically, achieving similar functional levels and RTS compared to patients treated surgically. Level III.

Since the 1930s, the Gulag system of labour camps was a driving force behind the main geopolitical projects of the Soviet Union, playing a critical role in mega-infrastructural projects to colonise hitherto unexploited territories. Among these was the network of secret cities built at the dawn of the Cold War. Whilst outwardly appearing like ordinary cities — with their green boulevards, central squares, and civic facilities — they were fully controlled and managed by the state; over decades elite scientists and technicians were brought together in these new settlements to work and live in total dedication to the Soviet atomic bomb project. These secret cities were known as Zakrytoye Administrativno-Territorial’noye Obrazovaniye [Closed Administrative-Territorial Formations], abbreviated as ZATOs. The research campuses, production and test zones, and civic and residential districts of the ZATOs were secured with walls, fences, watchtowers, and checkpoints. Beyond the secured perimeters, which still exist to regulate access to and from the outside world, lies the governmental and legislative apparatus which shaped the ZATOs’ economic, social, and psychological characteristics. For the inhabitants of ZATOs, the perimeter symbolised their connection to a higher purpose and would later evoke feelings of nostalgia and a sense of protection. Focusing primarily on one of these settlements, namely ZATO Krasnoyarsk-26, this paper links the story of the imprisoned labourers who constructed the ZATOs to that of the civilians who surrendered their liberty for a loftier cause. It will reveal a tight correlation between the Gulag infrastructure and the spatial arrangement of ZATOs showing how, in many aspects, ZATOs took on characteristics of carceral isolation, coercion, and immobility that are still relevant when addressing their contemporary condition.

In this paper, we argue that there are reasons to believe that an implicit bias for normalcy influences what are considered medically necessary treatments in psychiatry. First, we outline two prima facie reasons to suspect that this is the case. A bias for ‘the normal’ is already documented in disability studies; it is reasonable to suspect that it affects psychiatry too, since psychiatric patients, like disabled people, are often perceived as ‘weird’ by others. Secondly, psychiatry's explicitly endorsed values of well-being and function are hard to measure directly, which is why we see simpler box-ticking conceptions of recovery used in large research studies. This need not be problematic, but might lead to researchers and clinicians focusing too much on treatments that promote easy-to-measure proxies for recovery, instead of what actually matters to psychiatric patients themselves. Next, we provide examples of treatments and treatment decisions within two areas – self-injury and psychosis – which are hard to explain unless we assume that an implicit and harmful normalcy bias is at work. We conclude with some suggestions for clinicians and future research.

BackgroundMedial tibial stress syndrome (MTSS) is one of the most common lower leg injuries in sporting populations. It accounts for between 6 and 16% of all running injuries, and up to 53% of lower leg injuries in military recruits. Various treatment modalities are available with varying degrees of success. In recalcitrant cases, surgery is often the only option.ObjectiveTo evaluate whether ultrasound-guided injection of 15% dextrose for treatment of recalcitrant MTSS decreases pain and facilitates a return to desired activity levels for those who may otherwise be considering surgery or giving up the sport.MethodThe study design was a prospective consecutive case series involving eighteen patients: fifteen male and three female; (mean age = 31.2 years) with recalcitrant MTSS. They were referred from sports injury clinics across the UK, having failed all available conservative treatment.InterventionAn ultrasound-guided sub-periosteal injection of 15% dextrose was administered by the same clinician (NP) along the length of the symptomatic area. Typically, 1 mL of solution was injected per cm of the symptomatic area.Main outcome measuresPain was assessed using a 10-cm visual analog scale (VAS) at baseline, short-term, medium-term (mean 18 weeks), and long-term (mean 52 weeks) follow-up. Symptom resolution and return to activity were measured using a Likert scale at medium and long-term follow-up. Statistical analyses were performed using SPSS for Mac version 19.0.0 (IBM, New York, NY, US). The Shapiro-Wilk test was used to evaluate the normality of the distribution of data. Friedman’s non-parametric test was used to compare the within-patient treatment response over time. Post-hoc Wilcoxon signed-rank tests with Bonferroni corrections were performed to determine VAS average pain response to treatment over five paired periods.ResultsPatients reported a significant (p < 0.01) reduction in median VAS pain score at medium and long-term follow-up compared to baseline. Median improvement per patient was 4.5/10. Patients rated their condition as ‘much improved’ at medium-term follow-up and the median return to sports score was ‘returned to desired but not pre-injury level’ at medium-term and long-term follow-up. No adverse events were reported.ConclusionsUltrasound-guided 15% dextrose prolotherapy injection has a significant medium-term effect on pain in MTSS. This benefit may be maintained long-term; however, more robust trials are required to validate these findings in the absence of controls.Clinical relevanceClinicians should consider the use of ultrasound-guided injection of 15% dextrose as a viable treatment option to reduce pain and aid return to activity for patients with recalcitrant MTSS.

BackgroundBenefits of cash transfers (CTs) for HIV prevention have been demonstrated largely in purposively designed trials, commonly focusing on young women. It is less clear if CT interventions not designed for HIV prevention can have HIV-specific effects, including adverse effects. The cluster-randomised Manicaland Cash Transfer Trial (2010–11) evaluated effects of CTs on children’s (2–17 years) development in eastern Zimbabwe. We evaluated whether this CT intervention with no HIV-specific objectives had unintended HIV prevention spillover effects (externalities).MethodsData on 2909 individuals (15–54 years) living in trial households were taken from a general-population survey, conducted simultaneously in the same communities as the Manicaland Trial. Average treatment effects (ATEs) of CTs on sexual behaviour (any recent sex, condom use, multiple partners) and secondary outcomes (mental distress, school enrolment, and alcohol/cigarette/drug consumption) were estimated using mixed-effects logistic regressions (random effects for study site and intervention cluster), by sex and age group (15–29; 30–54 years). Outcomes were also evaluated with a larger synthetic comparison group created through propensity score matching.ResultsCTs did not affect sexual debut but reduced having any recent sex (past 30 days) among young males (ATE: − 11.7 percentage points [PP] [95% confidence interval: -26.0PP, 2.61PP]) and females (− 5.68PP [− 15.7PP, 4.34PP]), with similar but less uncertain estimates when compared against the synthetic comparison group (males: -9.68PP [− 13.1PP, − 6.30PP]; females: -8.77PP [− 16.3PP, − 1.23PP]). There were no effects among older individuals. Young (but not older) males receiving CTs reported increased multiple partnerships (8.49PP [− 5.40PP, 22.4PP]; synthetic comparison: 10.3PP (1.27PP, 19.2PP). No impact on alcohol, cigarette, or drug consumption was found. There are indications that CTs reduced psychological distress among young people, although impacts were small. CTs increased school enrolment in males (11.5PP [3.05PP, 19.9PP]). Analyses with the synthetic comparison group (but not the original control group) further indicated increased school enrolment among females (5.50PP [1.62PP, 9.37PP]) and condom use among younger and older women receiving CTs (9.38PP [5.90PP, 12.9PP]; 5.95PP [1.46PP, 10.4PP]).ConclusionsNon-HIV-prevention CT interventions can have HIV prevention outcomes, including reduced sexual activity among young people and increased multiple partnerships among young men. No effects on sexual debut or alcohol, cigarette, or drug consumption were observed. A broad approach is necessary to evaluate CT interventions to capture unintended outcomes, particularly in economic evaluations.Trial registrationClinicalTrials.gov, NCT00966849. Registered August 27, 2009.

One rationale policy-makers sometimes give for declining to fund a service or intervention is on the grounds that it would be ‘unaffordable’, which is to say, that the total cost of providing the service or intervention for all eligible recipients would exceed the budget limit. But does the mere fact that a service or intervention is unaffordable present a reason not to fund it? Thus far, the philosophical literature has remained largely silent on this issue. However, in this article, we consider this kind of thinking in depth. Albeit with certain important caveats, we argue that the use of affordability criteria in matters of public financing commits what Parfit might have called a ‘mistake in moral mathematics’. First, it fails to abide by what we term a principle of ‘non-perfectionism’ in moral action: the mere fact that it is practically impossible for you to do all the good that you have reason to do does not present a reason not to do whatever good you can do. And second, when used as a means of arbitrating between which services to fund, affordability criteria can lead to a kind of ‘numerical discrimination’. Various attendant issues around fairness and lotteries are also discussed.

Numerous risk factors have been identified for patellar tendinopathy (PT), often in small population studies. The aim was to use an international online questionnaire to generate a large database and identify significant risk factors. Case-control study. Private practice and sporting teams recruited from England, Spain, and Italy with the questionnaire available in all 3 languages (equivalence between online and self-administration shown previously). All data were anonymized and password protected. Eight hundred twenty-five data sets collected between January 2012 and May 2014. A total of 23.4% of participants had clinically diagnosed PT. A comparison between these participants and participants without PT was made. Association between the presence of PT and risk factors. Eight risk factors were included in the analysis based on a purposeful selection procedure: sex, hours of training, hamstring flexibility, previous patellar tendon rupture, previous knee injury, current/previous back pain, family history, and age. Four were found to have statistically significant odds ratios: female sex [0.70, 95% confidence interval (CI), 0.49-1.00, P = 0.05], hours of training (>20 hours 8.94, 95% CI, 4.68-17.08, P < 0.01), previous knee injury (2.10, 95% CI, 1.45-3.04, P < 0.01), and flexible hamstrings (0.61, 95% CI, 0.38-0.97, P = 0.04). There was a trend toward association for back pain (1.45, 95% CI, 0.99-2.14, P = 0.06) and a family history of tendon problems (1.51, 95% CI, 0.96-2.37, P = 0.08). Risk factors have been identified that are potentially modifiable to inform prevention and rehabilitation programs; future research is required to establish causal relationships. Identified risk factors require mechanistic investigation as they are not currently recognized in the literature.