Nicola Maffulli

Bio: Nicola Maffulli is an academic researcher from University of Salerno. The author has contributed to research in topics: Achilles tendon & Tendinopathy. The author has an hindex of 115, co-authored 1570 publications receiving 59548 citations. Previous affiliations of Nicola Maffulli include University of Aberdeen & University of Sydney.

Medial tibial pain pressure threshold algometry in runners

Abstract: Pressure algometry (PA) may provide an objective and standardised tool in assessing palpation pain over the tibia. The purpose of this study was to analyse the intra-rater repeatability of PA and to determine whether tibial tenderness in healthy runners differ from runners with medial tibial stress syndrome (MTSS). Pressure algometry was performed on 20 asymptomatic runners (40 legs) and 9 MTSS patients (14 symptomatic legs) at standardised locations along the medial border of the tibia. Intra-rater reliability was assessed in 10 randomly selected asymptomatic runners through repeated measurements 2 weeks later. Intra-rater reliability was moderate to excellent (ICC 0.53–0.90) in asymptomatic runners. Pain pressure threshold (PPT) was significantly reduced at 2/9–5/9 of the distance from the medial malleolus to the medial tibial condyle (p = 0.002–0.022). There was evidence of a statistically significant association between both height and weight, and PPT from the 3/9 (r = 0.416, p = 0.008) to 7/9 (r = 0.334, p = 0.035) and 3/9 (r = 0.448, p = 0.004) to 6/9 (r = 0.337, p = 0.034) area, respectively. In both MTSS patients and healthy runners, there was evidence of lower PPT in females compared to males (p = 0.0001–0.049) and a negative association between age and PPT (p = 0.001–0.033). MTSS patients had significantly lower PPT at the 3/9 site (p = 0.048) compared to asymptomatic runners. Pain pressure threshold algometry can be incorporated into MTSS clinical assessment to objectively assess pain and monitor progress. The presence of reduced medial tibial PPT in asymptomatic runners suggests that clinicians may not need to await resolution of medial tibia tenderness before allowing return to sport in MTSS patients. III.

The Effect of Magnetic Resonance Imaging Scans on Knee Arthroscopy: Randomized Controlled Trial

Abstract: Purpose: The purpose of this study was to investigate whether magnetic resonance imaging (MRI) in patients waiting for knee arthroscopy could reduce arthroscopy rates and improve patient outcome. Methods: A prospective randomized controlled trial was conducted in a teaching hospital setting. All participating patients had knee MRI before arthroscopy. In the intervention group the MRI report was seen by surgeons, and in the control group it was not. The primary outcome measure was the proportion of patients who did not have an arthroscopy. Secondary outcome measures included the Short Form 36, EuroQol EQ-5D, Knee Injury and Osteoarthritis Score, and Knee Society Score. Results: Surgeons changed both their diagnosis and management plan in 47% of patients in the intervention group compared with 1% in the control group, with no difference between groups in the proportion of patients who underwent an arthroscopy. In the intervention group 7 of 125 patients (5.6%) did not have an arthroscopy compared with 8 of 127 patients (6.3%) in the control group. In one instance a surgeon decided against arthroscopy based on the MRI report. There was no significant difference between groups in other outcome measures. Conclusions: We found no effect of MRI on the decision to perform arthroscopy or patient outcome. Performing MRI in patients already on the waiting list for arthroscopy may not be effective in reducing utilization of surgery. Level of Evidence: Level I, therapeutic randomized controlled trial with no statistically significant difference but with narrow confidence intervals.

The role of the immune system in tendon healing: a systematic review

Abstract: Introduction The role of the immune system in tendon healing relies on polymorphonucleocytes, mast cells, macrophages and lymphocytes, the 'immune cells' and their cytokine production. This systematic review reports how the immune system affects tendon healing. Sources of data We registered our protocol (registration number: CRD42019141838). After searching PubMed, Embase and Cochrane Library databases, we included studies of any level of evidence published in peer-reviewed journals reporting clinical or preclinical results. The PRISMA guidelines were applied, and risk of bias and the methodological quality of the included studies were assessed. We excluded all the articles with high risk of bias and/or low quality after the assessment. We included 62 articles assessed as medium or high quality. Areas of agreement Macrophages are major actors in the promotion of proper wound healing as well as the resolution of inflammation in response to pathogenic challenge or tissue damage. The immune cells secrete cytokines involving both pro-inflammatory and anti-inflammatory factors which could affect both healing and macrophage polarization. Areas of controversy The role of lymphocytes, mast cells and polymorphonucleocytes is still inconclusive. Growing points The immune system is a major actor in the complex mechanism behind the healing response occurring in tendons after an injury. A dysregulation of the immune response can ultimately lead to a failed healing response. Areas timely for developing research Further studies are needed to shed light on therapeutic targets to improve tendon healing and in managing new way to balance immune response.

Doppler ultrasound signal in Achilles tendinopathy reduces immediately after activity.

Abstract: A relationship has been identified between vascularization on Doppler ultrasound (Doppler signal) and Achilles tendon pain. Doppler signal may increase minutes after prolonged activity, but the immediate effect is unknown. The aim of the study was to investigate the immediate effect of short term activity on Achilles tendon Doppler signal. Achilles tendinopathy patients (7 patients, 10 tendons) and asymptomatic controls (6 controls, 12 tendons) performed 2 activity tasks; a 2 minute continuous step task and one minute continuous calf raise task. Doppler signal was measured at rest and within a minute after each activity. The presence of Doppler signal was quantified using both semi quantitative (modified Ohberg scale; 0=no signal, 5=>90% of pathological area contains Doppler signal) and quantitative methods (pixel number). Doppler signal was present in 90% of symptomatic individuals and in none of the asymptomatic controls. The modified Ohberg scale and pixel number reduced significantly after both activity tasks and heart rate increased significantly (p

Management of unstable slipped upper femoral epiphysis: a meta-analysis.

Abstract: Introduction: The management of unstable slipped upper femoral epiphysis (SUFE) is controversial, with a high risk of developing avascular necrosis (AVN). We meta-analysed two areas of concern: reduction of the slip and the timing of treatment. Methods: A search of Medline, CINAHL and Embase identified only retrospectively relevant studies: four regarding the role of reduction and five regarding the timing of treatment. The incidence of AVN was compared between reduced and unreduced SUFEs, and between those treated within 24 h of symptom onset and those treated thereafter. Areas of agreement: Analysis of the pooled data gave an odds ratio of 2.20 (P ¼ 0.290) in favour of the unreduced group, who had a lower risk of developing AVN. The odds ratio was 0.50 in favour of the group treated within 24 h from symptom onset (P ¼ 0.441). However, though clinically important, these effects were not statistically significant. Areas of controversy: The timing of treatment is somewhat inconsistent: two studies favour management more than 24 h after the onset of symptoms, while for three unstable SUFEs are best managed within 24 h. Growing points: Despite the non-significant results from the meta-analysis, it can be suggested that, if reduction is to be performed, it should be undertaken cautiously, as it may be associated with increased AVN. The ideal time for management of unstable slip is probably within 24 h of symptom onset.

I and i

Abstract: There is, I think, something ethereal about i —the square root of minus one. I remember first hearing about it at school. It seemed an odd beast at that time—an intruder hovering on the edge of reality. Usually familiarity dulls this sense of the bizarre, but in the case of i it was the reverse: over the years the sense of its surreal nature intensified. It seemed that it was impossible to write mathematics that described the real world in …

Standards of Medical Care in Diabetes

Abstract: XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

European Guidelines on Cardiovascular Disease Prevention in Clinical Practice (Version 2012)

Abstract: ABI : ankle–brachial index ACCORD : Action to Control Cardiovascular Risk in Diabetes ADVANCE : Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation AGREE : Appraisal of Guidelines Research and Evaluation AHA : American Heart Association apoA1 : apolipoprotein A1 apoB : apolipoprotein B CABG : coronary artery bypass graft surgery CARDS : Collaborative AtoRvastatin Diabetes Study CCNAP : Council on Cardiovascular Nursing and Allied Professions CHARISMA : Clopidogrel for High Athero-thrombotic Risk and Ischemic Stabilisation, Management, and Avoidance CHD : coronary heart disease CKD : chronic kidney disease COMMIT : Clopidogrel and Metoprolol in Myocardial Infarction Trial CRP : C-reactive protein CURE : Clopidogrel in Unstable Angina to Prevent Recurrent Events CVD : cardiovascular disease DALYs : disability-adjusted life years DBP : diastolic blood pressure DCCT : Diabetes Control and Complications Trial ED : erectile dysfunction eGFR : estimated glomerular filtration rate EHN : European Heart Network EPIC : European Prospective Investigation into Cancer and Nutrition EUROASPIRE : European Action on Secondary and Primary Prevention through Intervention to Reduce Events GFR : glomerular filtration rate GOSPEL : Global Secondary Prevention Strategies to Limit Event Recurrence After MI GRADE : Grading of Recommendations Assessment, Development and Evaluation HbA1c : glycated haemoglobin HDL : high-density lipoprotein HF-ACTION : Heart Failure and A Controlled Trial Investigating Outcomes of Exercise TraiNing HOT : Hypertension Optimal Treatment Study HPS : Heart Protection Study HR : hazard ratio hsCRP : high-sensitivity C-reactive protein HYVET : Hypertension in the Very Elderly Trial ICD : International Classification of Diseases IMT : intima-media thickness INVEST : International Verapamil SR/Trandolapril JTF : Joint Task Force LDL : low-density lipoprotein Lp(a) : lipoprotein(a) LpPLA2 : lipoprotein-associated phospholipase 2 LVH : left ventricular hypertrophy MATCH : Management of Atherothrombosis with Clopidogrel in High-risk Patients with Recent Transient Ischaemic Attack or Ischaemic Stroke MDRD : Modification of Diet in Renal Disease MET : metabolic equivalent MONICA : Multinational MONItoring of trends and determinants in CArdiovascular disease NICE : National Institute of Health and Clinical Excellence NRT : nicotine replacement therapy NSTEMI : non-ST elevation myocardial infarction ONTARGET : Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial OSA : obstructive sleep apnoea PAD : peripheral artery disease PCI : percutaneous coronary intervention PROactive : Prospective Pioglitazone Clinical Trial in Macrovascular Events PWV : pulse wave velocity QOF : Quality and Outcomes Framework RCT : randomized clinical trial RR : relative risk SBP : systolic blood pressure SCORE : Systematic Coronary Risk Evaluation Project SEARCH : Study of the Effectiveness of Additional Reductions in Cholesterol and SHEP : Systolic Hypertension in the Elderly Program STEMI : ST-elevation myocardial infarction SU.FOL.OM3 : SUpplementation with FOlate, vitamin B6 and B12 and/or OMega-3 fatty acids Syst-Eur : Systolic Hypertension in Europe TNT : Treating to New Targets UKPDS : United Kingdom Prospective Diabetes Study VADT : Veterans Affairs Diabetes Trial VALUE : Valsartan Antihypertensive Long-term Use VITATOPS : VITAmins TO Prevent Stroke VLDL : very low-density lipoprotein WHO : World Health Organization ### 1.1 Introduction Atherosclerotic cardiovascular disease (CVD) is a chronic disorder developing insidiously throughout life and usually progressing to an advanced stage by the time symptoms occur. It remains the major cause of premature death in Europe, even though CVD mortality has …

Harrison's Principles of Internal Medicine

Abstract: The 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many