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This study aimed to investigate the trajectories of spinal pain frequency from 6 to 17 years of age and describe the prevalence and frequency of spinal pain and related diagnoses in children following different pain trajectories. First through fifth-grade students from 13 primary schools were followed for 5.5 years. Occurrences of spinal pain were reported weekly via text messages. Children reporting spinal pain were physically evaluated and classified using International Classification of Disease criteria. Trajectories of spinal pain frequency were modeled from age 6 to 17 years with latent class growth analysis. We included data from 1556 children (52.4% female, mean (SD) baseline age = 9.1 (1.9) years) and identified 10,554 weeks of spinal pain in 329,756 weeks of observation. Sixty-three percent of children reported one or more occurrences of spinal pain. We identified five trajectories of spinal pain frequency. Half the children (49.8%) were classified as members of a "no pain" trajectory. The remaining children followed "rare" (27.9%), "rare, increasing" (14.5%), "moderate, increasing" (6.5%), or "early-onset, decreasing" (1.3%) spinal pain trajectories. The most common diagnoses in all trajectory groups were non-specific (e.g., "back pain"). Tissue-specific diagnoses (e.g., muscle strain) were less common and pathologies (e.g., fracture) were rare. Conclusion: From childhood through adolescence, spinal pain was common and followed heterogeneous courses comprising stable, increasing, and early-onset trajectories. These findings accord with recommendations from adult back pain guidelines that most children with spinal pain can be reassured that they do not have a serious disease and encouraged to stay active. What is Known: • Spinal pain imposes a large burden on individuals and society. • Although many people first experience the condition in childhood, little is known about the developmental trajectories of spinal pain from childhood to adolescence. What is New: • Data from 1556 children and 329,756 participant weeks showed five unique spinal pain trajectories from 6 to 17 years: most children rarely reported spinal pain, while one in five followed increasing or early-onset trajectories. • Most pain occurrences were non-specific; pathological diagnoses were rare.

Preliminary evidence points to a link between C-reactive protein (CRP) and spinal pain in adults. However, there is a paucity of research in younger populations. Therefore, we aimed to determine associations between CRP and spinal pain in childhood and adolescence. We identified trajectories of spinal pain from childhood to adolescence and investigated the associations between CRP and trajectory subgroups. Six- to 11-year-old children from 13 primary schools, were followed from October 2008 and until 2014. High-sensitivity CRP collected at baseline (2008) was measured using serum samples. The outcome was the number of weeks with non-traumatic spinal pain between November 2008 and June 2014. We constructed a trajectory model to identify different spinal pain trajectory subgroups. The associations between CRP and spinal pain trajectory subgroups were modelled using mixed-effects multinominal logistic regression. Data from 1556 participants (52% female), with a mean age of 8.4 years at baseline, identified five spinal pain trajectory subgroups: “no pain” (55.3%), “rare” (23.7%), “rare, increasing” (13.6%), “moderate, increasing” (6.1%), and “early onset, decreasing” (1.3%). There were no differences in baseline high-sensitivity CRP levels between spinal pain trajectory subgroups. Thus, the heterogeneous courses of spinal pain experienced were not defined by differences in CRP at baseline.

We sought to compare the ability of the prehospital Canadian C-Spine Rule to selectively recommend immobilization in sport-related versus non-sport-related injuries and describe sport-related mechanisms of injury.We reviewed data from the prospective paramedic Canadian C-Spine Rule validation and implementation studies in 7 Canadian cities. A trained reviewer further categorized sport-related mechanisms of injury collaboratively with a sport medicine physician using a pilot-tested standardized form. We compared the Canadian C-Spine Rule's recommendation to immobilize sport-related versus non-sport-related patients using Chi-square and relative risk statistics with 95% confidence intervals.There were 201 sport-related patients among the 5,978 included. Sport-related injured patients were younger (mean age 36.2 vs. 42.4) and more predominantly male (60.5% vs. 46.8%) than non-sport-related patients. Paramedics did not miss any C-Spine injury when using the Canadian C-Spine Rule. C-Spine injury rates were similar between sport (2/201; 1.0%) and non-sport-injured patients (47/5,777; 0.8%). The Canadian C-Spine Rule recommended immobilization equally between groups (46.4% vs. 42.5%; RR 1.09 95%CI 0.93-1.28), most commonly resulting from a dangerous mechanism among sport-injured (68.7% vs. 54.5%; RR 1.26 95%CI 1.08-1.47). The most common dangerous mechanism responsible for immobilization in sport was axial load.Although equal proportions of sport and non-sport-related injuries were immobilized, a dangerous mechanism was most often responsible for immobilization in sport-related cases. These findings do not address the potential impact of using the Canadian C-Spine Rule to evaluate collegiate or pro athletes assessed by sport medicine physicians. It does support using the Canadian C-Spine Rule as a tool in sport-injured patients assessed by paramedics.RéSUMé: OBJECTIFS: Nous avons cherché à comparer la capacité préhospitalière de la Canadian C-spine Rule à recommander de façon sélective l’immobilisation dans les blessures liées au sport par rapport aux blessures non liées au sport et à décrire les mécanismes des blessures liés au sport. LES MéTHODES: Nous avons examiné les données des études prospectives de validation et de mise en œuvre de la règle canadienne de la colonne vertébrale dans sept villes canadiennes. Un examinateur qualifié a ensuite classé les mécanismes de blessure liés au sport, en collaboration avec un médecin du sport, à l'aide d'un formulaire standardisé testé dans le cadre d'un projet pilote. Nous avons comparé la recommandation de la Canadian C-Spine Rule d'immobiliser les patients liés au sport par rapport aux patients non liés au sport en utilisant les statistiques du chi carré et du risque relatif avec un intervalle de confiance de 95 %. RéSULTATS: Parmi les 5 978 patients inclus il y avait 201 patients liés au sport. Les patients blessés liés au sport étaient plus jeunes (âge moyen 36,2 ans contre 42,4 ans) et plus majoritairement de sexe masculin (60,5 % contre 46,8 %) que les patients non liés au sport. Les ambulanciers paramédicaux n’ont manqué aucune blessure au rachis cervical lorsqu’ils ont utilisé la Canadian C-spine Rule. Les taux de blessures au rachis cervical étaient semblables chez les patients sportifs (2/201 ; 1,0 %) et non sportifs (47/5 777 ; 0,8 %). La Canadian C-spine Rule recommande l'immobilisation de manière égale entre les groupes (46,4 % contre 42,5 % ; RR 1,09 95 % IC 0,93-1,28), le plus souvent en raison d'un mécanisme dangereux chez les sportifs blessés (68,7 % contre 54,5 % ; RR 1,26 95 % IC 1,08-1,47). Le mécanisme dangereux le plus souvent responsable de l'immobilisation dans le sport était la charge axiale. CONCLUSION: Bien que des proportions égales de blessures sportives et non sportives aient été immobilisées, un mécanisme dangereux était le plus souvent responsable de l'immobilisation dans les cas liés au sport. Ces conclusions n'abordent pas l'impact potentiel de l'utilisation de la Canadian C-spine Rule pour évaluer les athlètes collégiaux ou professionnels évalués par les médecins du sport. Elle est favorable à l'utilisation de la Canadian C-spine Rule comme outil pour les patients blessés par le sport et évalués par les ambulanciers.

Current screening guidelines may not be adequate to identify iron deficiency (ID) and iron deficiency anemia (IDA) in adolescent and young adults. Adolescent and young adult outpatients from 4 hospital-based clinics (N = 493) reported on diet, health, and bleeding, and had phlebotomy for iron and hematologic tests. We examined sex-specific factors associated with ID and IDA and ability of universal and risk factor–based screening using hemoglobin and hemoglobin plus ferritin to detect ID and IDA. Among females (n = 350), 34.6% had ID and 6.3% had IDA. Nearly 1 in 3 females with ID had no risk factors. Among males, 12.6% had ID; none had IDA. More than 1 in 3 males with ID did not have risk factors. Current screening approaches would have missed ID in 47% to 82% of females and 95% to 100% of males. ID was prevalent in both male and female adolescents and young adult outpatients. New approaches to screening for ID are needed to accurately evaluate iron status in this population.

ObjectiveTo update a previous individual participant data meta-analysis and determine the accuracy of the Patient Health Questionnaire-9 (PHQ-9), the most commonly used depression screening tool in general practice, for detecting major depression overall and by study or participant subgroups.DesignSystematic review and individual participant data meta-analysis.Data sourcesMedline, Medline In-Process, and Other Non-Indexed Citations via Ovid, PsycINFO, Web of Science searched through 9 May 2018.Review methodsEligible studies administered the PHQ-9 and classified current major depression status using a validated semistructured diagnostic interview (designed for clinician administration), fully structured interview (designed for lay administration), or the Mini International Neuropsychiatric Interview (MINI; a brief interview designed for lay administration). A bivariate random effects meta-analytic model was used to obtain point and interval estimates of pooled PHQ-9 sensitivity and specificity at cut-off values 5-15, separately, among studies that used semistructured diagnostic interviews (eg, Structured Clinical Interview for Diagnostic and Statistical Manual), fully structured interviews (eg, Composite International Diagnostic Interview), and the MINI. Meta-regression was used to investigate whether PHQ-9 accuracy correlated with reference standard categories and participant characteristics.ResultsData from 44 503 total participants (27 146 additional from the update) were obtained from 100 of 127 eligible studies (42 additional studies; 79% eligible studies; 86% eligible participants). Among studies with a semistructured interview reference standard, pooled PHQ-9 sensitivity and specificity (95% confidence interval) at the standard cut-off value of ≥10, which maximised combined sensitivity and specificity, were 0.85 (0.79 to 0.89) and 0.85 (0.82 to 0.87), respectively. Specificity was similar across reference standards, but sensitivity in studies with semistructured interviews was 7-24% (median 21%) higher than with fully structured reference standards and 2-14% (median 11%) higher than with the MINI across cut-off values. Across reference standards and cut-off values, specificity was 0-10% (median 3%) higher for men and 0-12 (median 5%) higher for people aged 60 or older.ConclusionsResearchers and clinicians could use results to determine outcomes, such as total number of positive screens and false positive screens, at different PHQ-9 cut-off values for different clinical settings using the knowledge translation tool atwww.depressionscreening100.com/phq.Study registrationPROSPERO CRD42014010673.

Objectives\ud \ud Selectively reported results from only well-performing cutoffs in diagnostic accuracy studies may bias estimates in meta-analyses. We investigated cutoff reporting patterns for the Patient Health Questionnaire-9 (PHQ-9; standard cutoff 10) and Edinburgh Postnatal Depression Scale (EPDS; no standard cutoff, commonly used 10–13) and compared accuracy estimates based on published cutoffs versus all cutoffs.\ud \ud \ud \ud Methods\ud \ud We conducted bivariate random effects meta-analyses using individual participant data to compare accuracy from published versus all cutoffs.\ud \ud \ud \ud Results\ud \ud For the PHQ-9 (30 studies, N = 11,773), published results underestimated sensitivity for cutoffs below 10 (median difference: −0.06) and overestimated for cutoffs above 10 (median difference: 0.07). EPDS (19 studies, N = 3637) sensitivity estimates from published results were similar for cutoffs below 10 (median difference: 0.00) but higher for cutoffs above 13 (median difference: 0.14). Specificity estimates from published and all cutoffs were similar for both tools. The mean cutoff of all reported cutoffs in PHQ-9 studies with optimal cutoff below 10 was 8.8 compared to 11.8 for those with optimal cutoffs above 10. Mean for EPDS studies with optimal cutoffs below 10 was 9.9 compared to 11.8 for those with optimal cutoffs greater than 10.\ud \ud \ud \ud Conclusion\ud \ud Selective cutoff reporting was more pronounced for the PHQ-9 than EPDS.

Limited research exists on the relationship between changes in physical activity levels and injury in children. In this study, we investigated the prognostic relationship between changes in activity, measured by the acute:chronic workload ratio (ACWR), and injury in children. We used data from the Childhood Health, Activity, and Motor Performance School Study Denmark (2008–2014), a prospective cohort study of 1,660 children aged 6–17 years. We modeled the relationship between the uncoupled 5-week ACWR and injury, defined as patient-reported musculoskeletal pain, using generalized additive mixed models. These methods accounted for repeated measures, and they improved model fit and precision compared with previous studies that used logistic models. The prognostic model predicted an injury risk of approximately 3% between decreases in activity level of up to 60% and increases of up to 30%. Predicted risk was lower when activity decreased by more than 60% (minimum of 0.5% with no recreational activity). Predicted risk was higher when activity increased by more than 30% (4.5% with a 3-fold increase in activity). Girls were at significantly higher risk of injury than boys. We observed similar patterns but lower absolute risks when we restricted the outcome to clinician-diagnosed injury. Predicted increases in injury risk with increasing activity were much lower than those of previous studies carried out in adults.

Objective To identify the causal relation between growth velocity and injury in elite-level youth football players, and to assess the mediating effects of motor performance in this causal pathway. Design Prospective cohort study. Methods We measured the body height of 378 male elite-level football players of the U13 to U15 age categories three to four months before and at the start of the competitive season. At the start of the season, players also performed a motor performance test battery, including motor coordination (Korperkoordinationstest fur Kinder), muscular performance (standing broad jump, counter movement jump), flexibility (sit and reach), and endurance measures (YoYo intermittent recovery test). Injuries were continuously registered by the academies’ medical staff during the first two months of the season. Based on the causal directed acyclic graph (DAG) that identified our assumptions about causal relations between growth velocity (standardized to cm/y), injuries, and motor performance, the causal effect of growth velocity on injury was obtained by conditioning on maturity offset. We determined the natural indirect effects of growth velocity on injury mediated through motor performance. Results In total, 105 players sustained an injury. Odds ratios (OR) showed a 15% increase in injury risk per centimetre/year of growth velocity (1.15, 95%CI: 1.05–1.26). There was no causal effect of growth on injury through the motor performance mediated pathways (all ORs were close to 1.0 with narrow 95%CIs). Conclusions Growth velocity is causally related to injury risk in elite-level youth football players, but motor performance does not mediate this relation.

Importance The Patient Health Questionnaire depression module (PHQ-9) is a 9-item self-administered instrument used for detecting depression and assessing severity of depression. The Patient Health Questionnaire-2 (PHQ-2) consists of the first 2 items of the PHQ-9 (which assess the frequency of depressed mood and anhedonia) and can be used as a first step to identify patients for evaluation with the full PHQ-9. Objective To estimate PHQ-2 accuracy alone and combined with the PHQ-9 for detecting major depression. Data sources MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, and Web of Science (January 2000-May 2018). Study selection Eligible data sets compared PHQ-2 scores with major depression diagnoses from a validated diagnostic interview. Data extraction and synthesis Individual participant data were synthesized with bivariate random-effects meta-analysis to estimate pooled sensitivity and specificity of the PHQ-2 alone among studies using semistructured, fully structured, or Mini International Neuropsychiatric Interview (MINI) diagnostic interviews separately and in combination with the PHQ-9 vs the PHQ-9 alone for studies that used semistructured interviews. The PHQ-2 score ranges from 0 to 6, and the PHQ-9 score ranges from 0 to 27. Results Individual participant data were obtained from 100 of 136 eligible studies (44 318 participants; 4572 with major depression [10%]; mean [SD] age, 49 [17] years; 59% female). Among studies that used semistructured interviews, PHQ-2 sensitivity and specificity (95% CI) were 0.91 (0.88-0.94) and 0.67 (0.64-0.71) for cutoff scores of 2 or greater and 0.72 (0.67-0.77) and 0.85 (0.83-0.87) for cutoff scores of 3 or greater. Sensitivity was significantly greater for semistructured vs fully structured interviews. Specificity was not significantly different across the types of interviews. The area under the receiver operating characteristic curve was 0.88 (0.86-0.89) for semistructured interviews, 0.82 (0.81-0.84) for fully structured interviews, and 0.87 (0.85-0.88) for the MINI. There were no significant subgroup differences. For semistructured interviews, sensitivity for PHQ-2 scores of 2 or greater followed by PHQ-9 scores of 10 or greater (0.82 [0.76-0.86]) was not significantly different than PHQ-9 scores of 10 or greater alone (0.86 [0.80-0.90]); specificity for the combination was significantly but minimally higher (0.87 [0.84-0.89] vs 0.85 [0.82-0.87]). The area under the curve was 0.90 (0.89-0.91). The combination was estimated to reduce the number of participants needing to complete the full PHQ-9 by 57% (56%-58%). Conclusions and relevance In an individual participant data meta-analysis of studies that compared PHQ scores with major depression diagnoses, the combination of PHQ-2 (with cutoff ≥2) followed by PHQ-9 (with cutoff ≥10) had similar sensitivity but higher specificity compared with PHQ-9 cutoff scores of 10 or greater alone. Further research is needed to understand the clinical and research value of this combined approach to screening.

Objectives: Depression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores >= 10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 >= 10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence. Study Design and Setting: Individual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status. Results: A total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 >= 10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 >= 10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 >= 14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 >= 14 (95% prediction interval: -13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: -16.4%, 15.0%). Conclusion: PHQ-9 >= 10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies. (C) 2020 Elsevier Inc. All rights reserved.

Importance:The Patient Health Questionnaire depression module (PHQ-9) is a 9-item self-administered instrument used for detecting depression and assessing severity of depression. The Patient Health Questionnaire-2 (PHQ-2) consists of the first 2 items of the PHQ-9 (which assess the frequency of depressed mood and anhedonia) and can be used as a first step to identify patients for evaluation with the full PHQ-9. Objective:To estimate PHQ-2 accuracy alone and combined with the PHQ-9 for detecting major depression. Data Sources:MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, and Web of Science (January 2000-May 2018). Study Selection:Eligible data sets compared PHQ-2 scores with major depression diagnoses from a validated diagnostic interview. Data Extraction and Synthesis:Individual participant data were synthesized with bivariate random-effects meta-analysis to estimate pooled sensitivity and specificity of the PHQ-2 alone among studies using semistructured, fully structured, or Mini International Neuropsychiatric Interview (MINI) diagnostic interviews separately and in combination with the PHQ-9 vs the PHQ-9 alone for studies that used semistructured interviews. The PHQ-2 score ranges from 0 to 6, and the PHQ-9 score ranges from 0 to 27. Results:Individual participant data were obtained from 100 of 136 eligible studies (44 318 participants; 4572 with major depression [10%]; mean [SD] age, 49 [17] years; 59% female). Among studies that used semistructured interviews, PHQ-2 sensitivity and specificity (95% CI) were 0.91 (0.88-0.94) and 0.67 (0.64-0.71) for cutoff scores of 2 or greater and 0.72 (0.67-0.77) and 0.85 (0.83-0.87) for cutoff scores of 3 or greater. Sensitivity was significantly greater for semistructured vs fully structured interviews. Specificity was not significantly different across the types of interviews. The area under the receiver operating characteristic curve was 0.88 (0.86-0.89) for semistructured interviews, 0.82 (0.81-0.84) for fully structured interviews, and 0.87 (0.85-0.88) for the MINI. There were no significant subgroup differences. For semistructured interviews, sensitivity for PHQ-2 scores of 2 or greater followed by PHQ-9 scores of 10 or greater (0.82 [0.76-0.86]) was not significantly different than PHQ-9 scores of 10 or greater alone (0.86 [0.80-0.90]); specificity for the combination was significantly but minimally higher (0.87 [0.84-0.89] vs 0.85 [0.82-0.87]). The area under the curve was 0.90 (0.89-0.91). The combination was estimated to reduce the number of participants needing to complete the full PHQ-9 by 57% (56%-58%). Conclusions and Relevance:In an individual participant data meta-analysis of studies that compared PHQ scores with major depression diagnoses, the combination of PHQ-2 (with cutoff ≥2) followed by PHQ-9 (with cutoff ≥10) had similar sensitivity but higher specificity compared with PHQ-9 cutoff scores of 10 or greater alone. Further research is needed to understand the clinical and research value of this combined approach to screening.

Objective Two previous individual participant data meta-analyses (IPDMAs) found that different diagnostic interviews classify different proportions of people as having major depression overall or by symptom levels. We compared the odds of major depression classification across diagnostic interviews among studies that administered the Depression subscale of the Hospital Anxiety and Depression Scale (HADS-D). Methods Data accrued for an IPDMA on HADS-D diagnostic accuracy were analysed. We fit binomial generalized linear mixed models to compare odds of major depression classification for the Structured Clinical Interview for DSM (SCID), Composite International Diagnostic Interview (CIDI), and Mini International Neuropsychiatric Interview (MINI), controlling for HADS-D scores and participant characteristics with and without an interaction term between interview and HADS-D scores. Results There were 15,856 participants (1942 [12%] with major depression) from 73 studies, including 15,335 (97%) non-psychiatric medical patients, 164 (1%) partners of medical patients, and 357 (2%) healthy adults. The MINI (27 studies, 7345 participants, 1066 major depression cases) classified participants as having major depression more often than the CIDI (10 studies, 3023 participants, 269 cases) (adjusted odds ratio [aOR] = 1.70 (0.84, 3.43)) and the semi-structured SCID (36 studies, 5488 participants, 607 cases) (aOR = 1.52 (1.01, 2.30)). The odds ratio for major depression classification with the CIDI was less likely to increase as HADS-D scores increased than for the SCID (interaction aOR = 0.92 (0.88, 0.96)). Conclusion Compared to the SCID, the MINI may diagnose more participants as having major depression, and the CIDI may be less responsive to symptom severity.

BackgroundItem 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9.MethodsWe conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy.Results16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (−0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01).ConclusionsPHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar.

Background Overuse injuries are reported to be more common than acute trauma in children and adolescents, causing pain and reduced function. The most common is apophysitis - a traction injury to the apophysis in growing individuals. The duration of symptoms reported in the literature is between 6 weeks to 6 months or more. The objective of this systematic review and network meta-analysis is to compare the effectiveness and safety of all available treatments for any type of apophysitis in children and adolescents. Methods/Design We will conduct a systematic review to retrieve all relevant studies applying a comparative design. Searches will be made in the Cochrane CENTRAL, MEDLINE, EMBASE, CINAHL and SportDiscus databases and via reference searching. The efficacy of treatments will be compared with respect to the outcomes 1) time to pain-free activity and 2) risk of subsequent injury. Risk of bias assessment will be made using revised tool for assessing risk of bias in randomized trials for Randomized trials and Robins-I tool for non-randomized trials. We will explore if different treatment comparisons are sufficiently similar in terms of effect modifiers (transitivity assumption) with the aim to conduct network meta-analyses for randomized and non-randomized studies separately. A treatment hierarchy will be obtained using the surface under the cumulative ranking curve (SUCRA) and mean ranks, visualized using rankograms. We will use the CINeMA software to apply the modified version of Grades of Recommendation, Assessment, Development and Evaluation (GRADE), developed specifically to evaluate the quality of evidence in network meta-analysis. Discussion To date the comparative effects of interventions for apophysitis seem to rely mainly on expert opinion. We aim to identify all comparative treatment designs described in the literature and synthesize data when possible. We will use the estimated treatment effects between injury locations to provide guidance in managing apophysitis. Trial registration PROSPERO ID number: CRD42018083746. Electronic supplementary material The online version of this article (10.1186/s12998-018-0209-8) contains supplementary material, which is available to authorized users.

Introduction Young adults using marijuana heavily often try multiple times to quit on their own. We sought to identify momentary experiences during marijuana use that could aid in predicting lapse when young adults subsequently attempt abstinence. Methods Young adults ( N = 34) age 18–25 using marijuana ≥ 5 days/week and planning to quit completed a survey of sociodemographic characteristics, substance use, marijuana expectancies, use motives, perceived social support, and confidence to abstain. They completed ecological momentary assessment (EMA) smartphone reports several times/day for two weeks prior to, then during two weeks of attempted abstinence. Use period EMA reports assessed affect, craving, accessibility, situational permissibility, use, and motivation to abstain. Baseline survey and EMA data were examined in relation to subsequent lapse during attempted abstinence. Results Nearly 3 in 4 participants (73.5%) reported lapsing during attempted abstinence from marijuana. On bivariate analyses, lower baseline dependence severity score, negative effect expectancies, perceived family support, and confidence to abstain were each associated with lapse. Of the use period EMA variables, greater percent of days with marijuana use, reports of easy accessibility, and reports of situational permissibility were each associated with lapse. Modeled together, negative effect expectancies, perceived family support, confidence to abstain, and situational permissibility during use were highly accurate in predicting lapse during attempted abstinence. Conclusions Momentary factors may add to conventionally-surveyed characteristics to enhance prediction of lapse during attempted abstinence among young adults with heavy marijuana use. Momentary assessment prior to a quit attempt may thus enable more effective personalized approaches to preventing lapse.

BackgroundDifferent diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.AimsTo evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.MethodData collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.ResultsA total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15–3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98–10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7–15) (OR = 0.96; 95% CI = 0.56–1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26–0.97).ConclusionsThe MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.Declaration of interestDrs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.

A 36-yr-old man presents with left ulnar-side wrist pain during an ice hockey game that prevented him from playing hockey or golf. There was no acute mechanism of injury. The usual clinical examination revealed only minimal tenderness and minimal pain with resisted wrist extension. Careful attention to precipitating factors led to testing resisted wrist extension with the forearm fully supinated, which reliably reproduced the intensity of the patient's symptoms, and a diagnosis of extensor carpi ulnaris tendinopathy. A literature review suggested three additional special tests (two were positive) and management. However, a standard of care has yet been established because neither the tests nor the management has been properly validated through research, thus leaving the management of this condition as an art.

Objectives Different individuals may make different return to play (RTP) decisions due to different risk assessments or risk tolerances. Our objectives were to determine the feasibility of eliciting reinjury risk assessments with Bayesian methods, and risk tolerance with questionnaires, from clinicians and athletes in a real-world RTP setting. Design Feasibility study with a descriptive prospective case-series. Methods We recruited the athlete, sport physician and physiotherapist caring for an athlete (“triplet”) within on-going groin and hamstring injury studies. We applied Bayesian methods to elicit estimates for reinjury risk over the next 2 months, based on the available clinical knowledge, and projected activity level. We used a standardized questionnaire to elicit factors affecting risk tolerance. Results Although our methods appeared feasible in general, there were important challenges that included language, time availability of practicing clinicians, and general work-flow issues related to embedding our study within an on-going larger study. We did obtain valuable data from more than one person on 10 of the 15 eligible athletes recruited. Despite the limited number of cases, there were clinically meaningful differences in risk estimates in some cases. In one triplet, participants estimated the reinjury risk between 1–10%, 20–50% and 30–40% for the same athlete. The most common factors modifying risk tolerance were “timing and season”, “pressure from athlete”, and “external pressure”. Conclusions Bayesian methods for risk elicitation in clinical sport medicine are feasible, and large differences in both risk estimation and risk tolerance sometimes occur.

BACKGROUND Sexual transmission rates of Chlamydia trachomatis (Ct) cannot be measured directly; however, the study of concordance of Ct infection in sexual partnerships (dyads) can help to illuminate factors influencing Ct transmission. METHODS Heterosexual men and women with Ct infection and their sex partners were enrolled and partner-specific coital and behavioral data collected for the prior 30 days. Microbiological data included Ct culture, and nucleic acid amplification testing (NAAT), quantitative Ct polymerase chain reaction, and ompA genotyping. We measured Ct concordance in dyads and factors (correlates) associated with concordance. RESULTS One hundred twenty-one women and 125 men formed 128 dyads. Overall, 72.9% of male partners of NAAT-positive women and 68.6% of female partners of NAAT-positive men were Ct-infected. Concordance was more common in dyads with culture-positive members (78.6% of male partners, 77% of female partners). Partners of women and men who were NAAT-positive only had lower concordance (33.3%, 46.4%, respectively). Women in concordant dyads had significantly higher median endocervical quantitative Ct polymerase chain reaction values (3,032) compared with CT-infected women in discordant dyads (1013 inclusion forming units DNA equivalents per mL; P < 0.01). Among 54 Ct-concordant dyads with ompA genotype data for both members, 96.2% had identical genotypes. CONCLUSIONS Higher organism load appears associated with concordance among women. Same-genotype chlamydial concordance was high in sexual partnerships. No behavioral factors were sufficiently discriminating to guide partner services activities. Findings may help model coitus-specific transmission probabilities.

Purpose To characterize information elicited from adolescent/young adults with frequent cannabis use in Motivational Enhancement Therapy (MET), and determine whether differences exist across stages of change (SOC) for reducing use. Design and methods Primary care patients 15–24 years old using cannabis ≥3 times/week enrolled in a pilot randomized intervention trial. All youth were offered two 1-hour MET sessions. Content analysis was used to code and categorize main reasons for use, alternative behaviors, goals, values, pros and cons of change, and compared results between youth in Pre-Contemplation vs. Contemplation SOC. Results Fifty-six youth completed MET session 1, 46 completed session 2. Most reported their main reason for use was related to emotional coping, negative feelings were a top-3 trigger, and distraction was an alternative way to meet their needs. Youth most frequently described progress in education or career/job as 1-year goals. More than half identified family as a very important value. They most frequently reported pros of using less related to achieving goals, self-improving, and saving money, and a con related to stress/coping. Compared to youth in Pre-Contemplation SOC, those in Contemplation were more likely to identify relationships as both a pro and con of using less cannabis. Conclusions MET can reveal developmentally appropriate goals, healthy values, and ambivalence about cannabis use that can be used to facilitate movement along the stages of behavior change toward reduction/cessation. Practice implications Brief motivational therapy can be used in primary care to gather information important in helping youth to reduce cannabis use.

Objective To determine the accuracy of the Patient Health Questionnaire-9 (PHQ-9) for screening to detect major depression. Design Individual participant data meta-analysis. Data sources Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, and Web of Science (January 2000-February 2015). Inclusion criteria Eligible studies compared PHQ-9 scores with major depression diagnoses from validated diagnostic interviews. Primary study data and study level data extracted from primary reports were synthesized. For PHQ-9 cut-off scores 5-15, bivariate random effects meta-analysis was used to estimate pooled sensitivity and specificity, separately, among studies that used semistructured diagnostic interviews, which are designed for administration by clinicians; fully structured interviews, which are designed for lay administration; and the Mini International Neuropsychiatric (MINI) diagnostic interviews, a brief fully structured interview. Sensitivity and specificity were examined among participant subgroups and, separately, using meta-regression, considering all subgroup variables in a single model. Results Data were obtained for 58 of 72 eligible studies (total n=17 357; major depression cases n=2312). Combined sensitivity and specificity was maximized at a cut-off score of 10 or above among studies using a semistructured interview (29 studies, 6725 participants; sensitivity 0.88, 95% confidence interval 0.83 to 0.92; specificity 0.85, 0.82 to 0.88). Across cut-off scores 5-15, sensitivity with semistructured interviews was 5-22% higher than for fully structured interviews (MINI excluded; 14 studies, 7680 participants) and 2-15% higher than for the MINI (15 studies, 2952 participants). Specificity was similar across diagnostic interviews. The PHQ-9 seems to be similarly sensitive but may be less specific for younger patients than for older patients; a cut-off score of 10 or above can be used regardless of age.. Conclusions PHQ-9 sensitivity compared with semistructured diagnostic interviews was greater than in previous conventional meta-analyses that combined reference standards. A cut-off score of 10 or above maximized combined sensitivity and specificity overall and for subgroups. Registration PROSPERO CRD42014010673.

Background: The objective of this study was to develop and validate a short form of the Patient Health Questionnaire-9 (PHQ-9), a self-report questionnaire for assessing depressive symptomatology, using objective criteria. Methods: Responses on the PHQ-9 were obtained from 7,850 English-speaking participants enrolled in 20 primary diagnostic test accuracy studies. PHQ unidimensionality was verified using confirmatory factor analysis, and an item response theory model was fit. Optimal test assembly (OTA) methods identified a maximally precise short form for each possible length between one and eight items, including and excluding the ninth item. The final short form was selected based on prespecified validity, reliability, and diagnostic accuracy criteria. Results: A four-item short form of the PHQ (PHQ-Dep-4) was selected. The PHQ-Dep-4 had a Cronbach's alpha of 0.805. Sensitivity and specificity of the PHQ-Dep-4 were 0.788 and 0.837, respectively, and were statistically equivalent to the PHQ-9 (sensitivity = 0.761, specificity = 0.866). The correlation of total scores with the full PHQ-9 was high (r = 0.919). Conclusion: The PHQ-Dep-4 is a valid short form with minimal loss of information of scores when compared to the full-length PHQ-9. Although OTA methods have been used to shorten patient-reported outcome measures based on objective, prespecified criteria, further studies are required to validate this general procedure for broader use in health research. Furthermore, due to unexamined heterogeneity, there is a need to replicate the results of this study in different patient populations.

Ecological Momentary Assessment (EMA) data consists of in-the-moment sampling several times per day aimed at capturing phenomena that are highly variable. When research questions are focused on the association between a construct measured repeatedly and an event that occurs sporadically over time interspersed between repeated measures, the data consist of correlated observed or censored times to an event. In such a case, specialized time-to-event models that account for correlated observations are required to properly assess the relationships under study. In the current study, we apply two time-to-event analysis techniques, proportional hazards and accelerated failure time modeling, to data from a study of affective states and sexual behavior in depressed adolescents and illustrate differing interpretations from the models.

Contains fulltext : 191821.pdf (Publisher’s version ) (Closed access) Objective: Exercise is associated with improved health in many medical conditions. Little is known about the exercise habits of people with systemic sclerosis (SSc, or scleroderma). This study assessed the proportion of individuals with SSc who exercise and associations of demographic and disease variables with exercise. Additionally, the weekly amount of time spent exercising and the types of exercise performed were assessed among patients exercising. Methods: The sample consisted of adult participants with SSc enrolled in the Scleroderma Patient-centered Intervention Network (SPIN) Cohort who completed baseline questionnaires from March 2014 through August 2015. Baseline questionnaires included questions on exercise habits, physician-reported medical characteristics, self-report demographic characteristics, the Health Assessment Questionnaire-Disability Index, Patient Health Questionnaire-9, and Patient-Reported Outcomes Measurement Information System-29. Results: Of 752 patients, 389 (51.7%) reported presently engaging in exercise, and these patients exercised on average 4.7 h [standard deviation (SD) = 2.8] per week. Among patients who reported exercising, walking was most commonly reported (n = 295, 75.8%). In bivariate analyses, present exercise was associated with more education, lower body mass index, some (versus no) alcohol consumption, non-smoking, limited/sine disease subtype, absence of skin thickening, lower disability, higher physical function, lower symptoms of anxiety and depression, less fatigue, lower sleep disturbance, higher ability to participate in social roles and activities, and less pain. Conclusions: Approximately half of SSc patients reported that they are currently exercising with walking being the most common form of exercise. Understanding exercise patterns and factors associated with exercise will help better inform intervention programs to support exercise for patients with SSc. •Implications for rehabilitation. •Systemic sclerosis is a rare autoimmune rheumatic disease associated with great morbidity and highly diverse presentation. •Approximately half of people with both limited and diffuse systemic sclerosis report exercising. •Most exercisers walk, but patients engage in a wide variety of exercise-related activities. •Individually designed exercise programs are most likely to support and encourage exercise in patients with diverse disease manifestations. 7 p.

Objective To investigate the effects of Pilates exercises using a Reformer on measures of fall risk, balance and mobility, self-efficacy, and active range of motion in adults age 65 and over at risk for falls compared to a control group. Design Randomized Controlled Trial. Methods Fifty-five subjects (27 Pilates intervention, 28 control; 38 females, 17 males; mean age 77.6 years, range 65–95) were randomly assigned to either a Pilates Reformer intervention group or a control group (no intervention). Subjects in the intervention group attended a Pilates Reformer exercise program in a group format once a week over a 10-week period. The primary outcome measures were the Sensory Organization Test (SOT) composite scores on the NeuroCom® system, Timed Up-and-Go (TUG), and Activities-specific Balance Confidence (ABC) scale. The secondary outcome measures were the Adaptation Test (ADT), straight leg raise (SLR), hip extension, and ankle dorsiflexion active range of motion (AROM), Berg Balance Scale (BBS), and 10 Meter Walk Test (10MWT). Results There was a significant interaction between group and time on the TUG, BBS, 10MWT, and SLR, hip extension, and ankle dorsiflexion AROM measurements. Over time, subjects in the Pilates intervention group improved their scores significantly on all mentioned measures, whereas subjects in the control group did not (P ≤ 0.05). Significantly improved AROM was found between groups following the Pilates intervention for hip extension, left SLR, and right ankle dorsiflexion. Conclusion Pilates Reformer exercises performed once per week for 10 weeks resulted in reduced fall risk and significant improvements in static and dynamic balance, functional mobility, balance self-efficacy, and lower extremity AROM in adults age 65 and older at risk for falling, whereas the control group did not significantly improve in any measures. Pilates Reformer exercises are more effective compared to no exercise intervention at improving hip and ankle AROM.

Despite developmental differences between young adults and adults, studies of condom use have not typically considered young adults as a distinct age group. This study sought to examine how condom use and its correlates differed between high-risk young adults and adults. Sexually transmitted infection (STI) clinic patients ( n = 763) reported STI history, contraception, negative condom attitudes, fear of partner reaction to condom use and risky behaviours. Past 3-month condom use was examined as unprotected vaginal sex (UVS) acts, proportional condom use and consistent condom use. Regression models tested associations of age group and potential correlates with each condom use outcome. Interaction models tested whether associations differed by age group. Proportional condom use was greater in young adults than adults (mean 0.55 vs. 0.47); UVS and consistent condom use were similar between age groups. Young adults with a recent STI reported less condom use, whereas for older adults, a distant STI was associated with less condom use, compared to others in their age groups. Negative condom attitudes were more strongly linked to UVS acts for younger versus older adults. STI prevention efforts for younger adults may be improved by intensifying counselling about condom use immediately following STI diagnosis and targeting negative condom attitudes.

Objectives To increase transparency in studies reporting propensity scores by using graphical methods that clearly illustrate (1) the number of participant exclusions that occur as a consequence of the analytic strategy and (2) whether treatment effects are constant or heterogeneous across propensity scores. Study Design and Setting We applied graphical methods to a real-world pharmacoepidemiologic study that evaluated the effect of initiating statin medication on the 1-year all-cause mortality post-myocardial infarction. We propose graphical methods to show the consequences of trimming and matching on the exclusion of participants from the analysis. We also propose the use of meta-analytical forest plots to show the magnitude of effect heterogeneity. Results A density plot with vertical lines demonstrated the proportion of subjects excluded because of trimming. A frequency plot with horizontal lines demonstrated the proportion of subjects excluded because of matching. An augmented forest plot illustrates the amount of effect heterogeneity present in the data. Conclusion Our proposed techniques present additional and useful information that helps readers understand the sample that is analyzed with propensity score methods and whether effect heterogeneity is present.

To describe the variability in the return-to-play (RTP) decisions of experienced team clinicians and to assess their clinical opinion as to the relevance of 19 factors described in a RTP decision-making model.Survey questionnaire.Advanced Team Physician Course.Sixty-seven of 101 sports medicine clinicians completed the questionnaire.Results were analyzed using descriptive statistics. For categorical variables, we report percentage and frequency. For continuous variables, we report mean (SD) if data were approximately normally distributed and frequencies for clinically relevant categories for skewed data.The average number of years of clinical sports medicine experience was 13.6 (9.8). Of the 62 clinicians who responded fully, 35% (n = 22) would "clear" (vs "not clear") an athlete to participate in sport even if the risk of an acute reinjury or long-term sequelae is increased. When respondents were given 6 different RTP options rather than binary choices, there were increased discrepancies across some injury risk scenarios. For example, 8.1% to 16.1% of respondents who chose to clear an athlete when presented with binary choices, later chose to "not clear" an athlete when given 6 graded RTP options. The respondents often considered factors of potential importance to athletes as nonimportant to the RTP decision process if risk of reinjury was unaffected (range, n = 4 [10%] to n = 19 [45%]).There is a high degree of variability in how different clinicians weight the different factors related to RTP decision making. More precise definitions decrease but do not eliminate this variability.

To compare inner retinal layer (IRL) thickness measured by spectral-domain optical coherence tomography (SD-OCT) and contrast sensitivity (CS) in patients with Parkinson disease (PD) and in healthy control (HC) subjects.Consecutive patients with and without PD were prospectively analyzed using SD-OCT and Pelli-Robson CS testing. SD-OCT IRL (ganglion-cell complex) thickness, consisting of the nerve fiber layer, ganglion cell layer, and inner plexiform layer, was segmented using an RTVue Model-RT100 with an EMM5 scan parameter covering a 5.0 × 5.0 mm cube centered on the fovea. Thickness voxel measurements at 0.25-mm intervals at sequential radial distances from the foveola were acquired horizontally and vertically. SD-OCT thickness raw data files were imported and analyzed within MATLAB (version 7.10.0). A database of CS scores and IRL thickness values by foveal location was constructed and statistically evaluated using JMP 10 (SAS Institute, Inc, Cary, NC).The results were compared between 28 eyes of 14 patients with PD and 28 eyes of 14 HC subjects. Controlling for age, mean CS scores of monocular right and randomized eyes were statistically lower in PD eyes (P0.05). IRL was significantly thinner in PD eyes than in HC eyes at several distances from the foveola (P0.05). The most numerous and significant thickness differences by diagnosis were located in the superior quadrant at a distance of 1.00-1.75 mm from the foveal center (17 μm; P0.01, maximum significant thickness difference and P value). Correlation was demonstrated between monocular CS and IRL thickness by diagnosis at multiple foveal locations for HC eyes as follows: nasal quadrant, 0.75-1.00 mm (P0.02); temporal quadrant, 0.50-1.00 mm (P0.05); superior quadrant, 1.00 mm (P0.05); and inferior quadrant, 1.00 mm (P0.03). No significant correlation was found between monocular CS and IRL thickness within PD subjects (P0.05 for each foveal location measured).CS and foveal IRL thickness are decreased in patients with PD. CS and IRL thickness correlated in HC subjects; however, no such correlation was demonstrated in PD. The functional deficit of dopaminergic interneurons, including amacrine cells, may outstrip the anatomic structural changes in the inner retina of PD patients. Inner retinal atrophic changes may underlie the pathogenesis of CS deficit and IRL thinning in PD.

Female patients receiving immunosuppressive therapy may be at increased risk for human papillomavirus (HPV) infection and cervical neoplasia.We administered the 3-dose HPV vaccine Gardasil to 37 females aged 9 to 26 years with inflammatory bowel disease (IBD) prescribed immunosuppressive therapy (prospective cohort). Geometric mean titers (GMT) in milli-Merck (mMu/mL) units were determined before dose 1 and 1 month after dose 3 by competitive Luminex immunoassay (cLIA) and qualitatively compared with healthy females of similar age from Merck's database. Side effects and adverse events were evaluated. Concurrently, in 15 similar patients with inflammatory bowel disease previously vaccinated by their primary care provider, we assessed antibody titers by competitive Luminex immunoassay and total immunoglobulin G LIA after dose 3 of vaccine (range, 0.5-27 months).Mean age of prospective patients was 15 years with 51% on anti-tumor necrosis factor therapy and 49% on immunomodulators: 33 of 37 completed all 3 doses. Seropositivity after dose 3 was 100% for types 6, 11 and 16 and 96% for type 18. Geometric mean titers for HPV-6, HPV-11, HPV-16 and HPV-18 was 1080, 1682, 3975 and 858, respectively and did not qualitatively differ from healthy females. No serious adverse events were attributable to the vaccine. In the previously vaccinated cohort, seropositivity was 100% for types 6, 11, and 16, and 40% for type 18 by competitive Luminex immunoassay (93% for HPV-18 by immunoglobulin G LIA). Titers decreased with time since dose 3.In this small study of patients with inflammatory bowel disease prescribed immunosuppressive therapy, Gardasil was immunogenic and there were no clinically significant vaccine-associated adverse events.

This study used momentary sampling to characterize marijuana events among young frequent users and determine contextual and individual predictors of use severity. Medical clinic outpatients aged 15–24 who used marijuana at least twice a week completed a baseline assessment, then used a handheld computer to report marijuana use at 4–6 signal-prompted times per day and before/after use for 2 weeks. Reports assessed event characteristics (when, with whom, where, how, why, how much, how high). Timestamps identified time, weekend, and duration for each event. Generalized estimating equations tested associations of individual and event-specific contextual characteristics with hits/event, duration, and high. Forty-one youth completed 3868 momentary reports; 40 (98%) reported at least one marijuana use event (N = 432 events; M = 10.5/participant) and thus provided data for these analyses. Marijuana was most commonly used with other people (74% of events), at home (58%), via blunt (66%), and for social or enhancement reasons (86%). Most events (62%) occurred on weekdays; use was least likely in the morning (8%). Most events involved 6 or more hits (81%). Mean high was 5.2 (out of 8). Of events with start and end times (n = 250), mean duration was 46.8 min. Poor mental health and use with a blunt or a bong, in the morning or evening, and on the weekend were associated with 6 or more hits/event. Female gender was associated with greater event duration. Poor mental health predicted higher high. Among youth who used it frequently, marijuana was used in a variety of contexts, with diversity in method, dose, and duration. Contextual factors appeared to predict marijuana dose for a given event, while individual characteristics were more predictive of high and duration.

Introduction The Depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) has been recommended for depression screening in medically ill patients. Many existing HADS-D studies have used exploratory methods to select optimal cut-offs. Often, these studies report results from a small range of cut-off thresholds; cut-offs with more favourable accuracy results are more likely to be reported than others with worse accuracy estimates. When published data are combined in meta-analyses, selective reporting may generate biased summary estimates. Individual patient data (IPD) meta-analyses can address this problem by estimating accuracy with data from all studies for all relevant cut-off scores. In addition, a predictive algorithm can be generated to estimate the probability that a patient has depression based on a HADS-D score and clinical characteristics rather than dichotomous screening classification alone. The primary objectives of our IPD meta-analyses are to determine the diagnostic accuracy of the HADS-D to detect major depression among adults across all potentially relevant cut-off scores and to generate a predictive algorithm for individual patients. We are already aware of over 100 eligible studies, and more may be identified with our comprehensive search. Methods and analysis Data sources will include MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO and Web of Science. Eligible studies will have datasets where patients are assessed for major depression based on a validated structured or semistructured clinical interview and complete the HADS-D within 2 weeks (before or after). Risk of bias will be assessed with the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Bivariate random-effects meta-analysis will be conducted for the full range of plausible cut-off values, and a predictive algorithm for individual patients will be generated. Ethics and dissemination The findings of this study will be of interest to stakeholders involved in research, clinical practice and policy.

Transient receptor potential melastatin 7 (TRPM7) is a bifunctional protein comprising a magnesium (Mg(2+))/cation channel and a kinase domain. We previously demonstrated that vasoactive agents regulate vascular TRPM7. Whether TRPM7 plays a role in the pathophysiology of hypertension and associated cardiovascular dysfunction is unknown. We studied TRPM7 kinase-deficient mice (TRPM7Δkinase; heterozygous for TRPM7 kinase) and wild-type (WT) mice infused with angiotensin II (Ang II; 400 ng/kg per minute, 4 weeks). TRPM7 kinase expression was lower in heart and aorta from TRPM7Δkinase versus WT mice, effects that were further reduced by Ang II infusion. Plasma Mg(2+) was lower in TRPM7Δkinase versus WT mice in basal and stimulated conditions. Ang II increased blood pressure in both strains with exaggerated responses in TRPM7Δkinase versus WT groups (P0.05). Acetylcholine-induced vasorelaxation was reduced in Ang II-infused TRPM7Δkinase mice, an effect associated with Akt and endothelial nitric oxide synthase downregulation. Vascular cell adhesion molecule-1 expression was increased in Ang II-infused TRPM7 kinase-deficient mice. TRPM7 kinase targets, calpain, and annexin-1, were activated by Ang II in WT but not in TRPM7Δkinase mice. Echocardiographic and histopathologic analysis demonstrated cardiac hypertrophy and left ventricular dysfunction in Ang II-treated groups. In TRPM7 kinase-deficient mice, Ang II-induced cardiac functional and structural effects were amplified compared with WT counterparts. Our data demonstrate that in TRPM7Δkinase mice, Ang II-induced hypertension is exaggerated, cardiac remodeling and left ventricular dysfunction are amplified, and endothelial function is impaired. These processes are associated with hypomagnesemia, blunted TRPM7 kinase expression/signaling, endothelial nitric oxide synthase downregulation, and proinflammatory vascular responses. Our findings identify TRPM7 kinase as a novel player in Ang II-induced hypertension and associated vascular and target organ damage.

BACKGROUND: This study prospectively assessed and compared the incidence of condom use errors/problems among clinic patients testing positive for one or more of 3 sexually transmitted diseases (STDs) and those testing negative. The study also identified event-level condom use errors associated with condom breakage and slippage during sex. METHODS: Enrolled clinic patients (N = 928) were tested for 3 STDs then patients electronically recorded sexual intercourse and condom use behaviors daily for up to 6 months. Data were available on condom use errors and problems for the >10000 sex events involving condoms. Assessed errors/problems were as follows: (1) not using a new condom (2) allowing condoms to contact sharp objects (3) not using condoms from start to finish of sex (4) condoms drying out (5) erection loss during condom use (6) breakage (7) slippage during sex and (8) slippage after sex. Because the event-level measures were correlated within individual generalized estimation equation models were used for analyses. RESULTS: All 8 forms of errors/problems with condom use occurred with varying levels of frequency without significant differences by baseline STD status for either men or women. Condom breakage was associated with contact with sharp objects (P < 0.0001) and drying out (P < 0.0001). Slippage during sex was associated with erection loss (P < 0.0001) and drying out (P < 0.0001). CONCLUSION: Subsequent to STD evaluation much of the sex occurring with the use of a condom may not confer adequate protection. Problems found to be associated with condom breakage and slippage are potentially amenable to counseling interventions.

Summary. Background: Few studies have evaluated the long-term economic consequences of deep vein thrombosis (DVT).None of them have incorporated prospectively collectedclinical data to ensure accurate identification of incident casesof DVT and DVT-related health outcomes of interest, such aspost-thrombotic syndrome (PTS). Objectives: To prospectivelyquantify medical and non-medical resource use and costsrelated to DVT during 2 years following diagnosis, and toidentify clinical determinants of costs. Methods: Three hun-dred and fifty-five consecutive patients with acute DVT wererecruited at seven Canadian hospital centers. Resource use andcost information were retrieved from three sources: weeklypatient-completed cost diaries, nurse-completed case reportforms, and the Quebec provincial administrative healthcaredatabase (RAMQ). Results: The rate of DVT-related hospi-talization was 3.5 per 100 patient-years (95% confidenceinterval [CI] 2.2–4.9). Patients reported a mean (standarddeviation) of 15.0 (14.5) physician visits and 0.7 (1.2) otherhealthcare professional visits. The average cost of DVT was$5180 (95% CI $4344–6017) in Canadian dollars, with 51.6%of costs being attributable to non-medical resource use.Multivariate analysis identified four independent predictorsof costs: concomitant pulmonary embolism (relative increasein cost [RIC] 3.16; 95% CI 2.18–4.58), unprovoked DVT(RIC 1.65; 95% CI 1.28–2.13), development of PTS duringfollow-up (RIC 1.35; 95% CI 1.05–1.74), and management ofDVT in the inpatient setting (RIC 1.79; 95% CI 1.33–2.40).Conclusions: The economic burden of DVT is substantial. Theuse of measures to prevent the occurrence of PTS andfavoring outpatient care of DVT has the potential to diminishcosts.Keywords: cohort study, cost determinants, deep vein throm-bosis, economic burden, post-thrombotic syndrome.IntroductionDeepveinthrombosis(DVT)isacommonandseriousvascularcondition[1].TheclinicalburdenofDVToftenextendsbeyondthe initial event, with increased risks of recurrent venousthromboembolism (VTE), bleeding while on anticoagulanttherapy, and development of the chronic post-thromboticsyndrome (PTS).Few studies have evaluated the long-term economic conse-quences of DVT. Studies to date have relied on retrospectiveadministrative claims database analysis [2–5] or Markovmodeling [6], and assessed medical costs only. Non-medicalcosts, including productivity losses that impact on patients,their families, and society, have not been adequately consid-ered. None has incorporated prospectively collected clinicaldata to ensure accurate identification of incident cases of DVTand DVT-related health outcomes of interest, such as PTS.We conducted a study to prospectively quantify medicaland non-medical costs associated with DVT during the

This study tested the efficacy of a brief intervention (Cues program) with mothers of very low birth weight (VLBW1500 g) infants. The primary hypothesis was that mothers in the Cues program would report lower levels of anxiety compared with mothers in the control group. Secondary hypotheses examined whether Cues mothers would report less stress, depression, and role restriction, and exhibit more sensitive interactive behavior, than control group mothers.A total of 121 mothers of VLBW infants were randomly assigned to either the experimental (Cues) intervention or an attention control (Care) condition. The Cues program combined training to reduce anxiety and enhance sensitivity. The control group received general information about infant care. Both programs were initiated during the neonatal intensive care unit stay. Maternal anxiety, stress, depression, and demographic variables were evaluated at baseline, prior to randomization. Postintervention outcomes were assessed during a home visit when the infant was ∼6 to 8 weeks of corrected age.Although mothers in the Cues group demonstrated greater knowledge of the content of the experimental intervention than mothers in the Care group, the groups did not differ in levels of anxiety, depression, and symptoms of posttraumatic stress. They were similar in their reports of parental role restrictions and stress related to the infant's appearance and behavior. Cues and Care group mothers were equally sensitive in interaction with their infants.Nonspecific attention was as effective as an early skill-based intervention in reducing maternal anxiety and enhancing sensitive behavior in mothers of VLBW infants.

Context: Fitness testing is used frequently in many areas of physical activity, but the reliability of these measurements under real-world, practical conditions is unknown. Objective: To evaluate the reliability of specific fitness tests using the methods and time periods used in the context of real-world sport and occupational management. Design: Cohort study. Setting: Eighteen different Cirque du Soleil shows. Patients or Other Participants: Cirque du Soleil physical performers who completed 4 consecutive tests (6-month intervals) and were free of injury or illness at each session (n = 238 of 701 physical performers). Intervention(s): Performers completed 6 fitness tests on each assessment date: dynamic balance, Harvard step test, handgrip, vertical jump, pull-ups, and 60-second jump test. Main Outcome Measure(s): We calculated the intraclass coefficient (ICC) and limits of agreement between baseline and each time point and the ICC over all 4 time points combined. Results: Reliability was acceptable (ICC > 0.6) over an 18-month time period for all pairwise comparisons and all time points together for the handgrip, vertical jump, and pull-up assessments. The Harvard step test and 60-second jump test had poor reliability (ICC < 0.6) between baseline and other time points. When we excluded the baseline data and calculated the ICC for 6-month, 12-month, and 18-month time points, both the Harvard step test and 60-second jump test demonstrated acceptable reliability. Dynamic balance was unreliable in all contexts. Limit-of-agreement analysis demonstrated considerable intraindividual variability for some tests and a learning effect by administrators on others. Conclusions: Five of the 6 tests in this battery had acceptable reliability over an 18-month time frame, but the values for certain individuals may vary considerably from time to time for some tests. Specific tests may require a learning period for administrators.

Objective To characterise the nature of the sport injury prevention literature by reviewing published articles that evaluate specifi c clinical interventions designed to reduce sport injury risks. Data sources PubMed, Cinahl, Web of Science and Embase. Main results Only 139 of 2525 articles retrieved met the inclusion criteria. Almost 40% were randomised controlled trials and 30.2% were cohort studies. The focus of the study was protective equipment in 41%, training in 32.4%, education in 7.9%, rules and regulations in 4.3%, and 13.3% involved a combination of the above. Equipment research studied stability devices (42.1%), head and face protectors (33.3%), attenuating devices (17.5%) as well as other devices (7%). Training studies often used a combination of interventions (eg, balance and stretching); most included balance and coordination (63.3%), with strength and power (36.7%) and stretching (22.5%) being less common. Almost 70% of the studies examined lower extremity injuries, and a majority of these were joint (non-bone)-ligament injuries. Contact sports were most frequently studied (41.5%), followed by collision (39.8%) and non-contact (20.3%). Conclusion The authors found only 139 publications in the existing literature that examined interventions designed to prevent sports injury. Of these, the majority investigated equipment or training interventions whereas only 4% focused on changes to the rules and regulations that govern sport. The focus of intervention research is on acute injuries in collision and contact sports whereas only 20% of the studies focused on non-contact sports.

Purpose This analysis was undertaken to determine whether adolescents who screened positive for high-risk substance use with the CRAFFT questions were also more likely to engage in risky sexual behaviors than their peers, and to determine the test–retest reliability of a substance use–related sexual risk behaviors inventory. Methods Clinic patients 12–18 years old completed a multi-part questionnaire that included eight demographic items, the CRAFFT substance use screen, and a 14-item scale assessing sexual behaviors associated with substance use. Participants were invited to return 1 week later to complete an identical assessment battery. Results Of the 305 study participants, 49 (16.1%) had a positive CRAFFT screen result (score of 2 or greater, indicating high risk for substance abuse/dependence) and 101 (33.9%) reported sexual contact during the past 90 days. After controlling for gender, age, race/ethnicity, and number of parents in household, adolescents with a positive CRAFFT screen had significantly greater odds of having sexual contact after using alcohol or other drugs, of having a sexual partner who used alcohol or other drugs, of having sex without a condom, and of having multiple sexual partners within the past year, compared to their CRAFFT negative peers. The substance use–related sexual risk behaviors inventory has acceptable test–retest reliability, and the 10 frequency questions have scale-like properties with acceptable internal consistency (standardized Cronbach's alpha=.79). Conclusion Clinicians should pay special attention to counseling CRAFFT-positive adolescents regarding use of condoms and the risks associated with sexual activity with multiple partners, while intoxicated, or with an intoxicated partner.

Objective To determine if the level of self-reported physical activity 1 month after deep vein thrombosis (DVT) is associated with the risk of post-thrombotic syndrome (PTS) in the first 2 years post-DVT. Design Prospective cohort study. Setting Multicenter study (8 hospitals). Participants Patients presenting with objectively diagnosed acute DVT to 8 hospitals in Quebec and Ontario, Canada. Assessment of risk factors We used validated questionnaires to measure physical activity (Godin questionnaire) and venous disease severity [generic physical quality of life (SF-36 PCS scale) or VEINES-QOL]. We adjusted for potential confounding effects of age, sex, and body mass index. We used multiple imputation to account for missing data. Main outcome measures Post-thrombotic syndrome (validated Villalta scale). Results For the 387 patients enrolled, univariate analysis suggested no association between 1-month activity and risk of PTS. After adjusting for missing data and potential confounders, there was no evidence of a trend toward increasing risk of PTS with increasing physical activity [1.65 (95% confidence interval, 0.87-3.14) for mild-moderate activity and 1.35 (95% confidence interval, 0.69-2.67) for high activity]. The results were similar when PTS was dichotomized as none/mild versus moderate/severe. Finally, patients with PTS had lower levels of activity at 2 years post-DVT. Conclusions The level of self-reported exercise in the first month post-DVT is not associated with an increased risk of PTS in the first 2 years after DVT. Post-thrombotic syndrome is associated with decreased levels of physical activity 2 years after DVT.

Hiring experienced health professionals to collect data on sport injuries is expensive, limits resources, and may be prohibitive for surveillance studies. The objective of this study was to obtain pilot data on whether youth self-report deserves further study. We followed 67 recreational and elite soccer players aged 11–17 for one season and compared responses of injured players with those of their parents/coaches. We defined our main outcome of discordance as any disagreement in responses between the youth, parent and coach (triad). When one person didn’t know the answer, we categorised the responses as “concordance” if the other two members agreed. We omitted data when two people responded “Don’t Know”. Of 10 injuries that could be analysed, 29/30 interviews occurred within 21 days. For factual questions analysed, there was 100% concordance for the type and side of injury, and place where the injury occurred. There were 1–2 discordant triads for each of time of day, activity during injury and specific body part injured. There were greater discordances for date of injury, first-aid treatment, and opinions concerning underlying reasons for the injury. Interview-report by youth themselves should be explored as a possible low cost method of documenting youth sport injuries.

Purpose: To examine associations between depressive symptoms and dyad-level sexual risk behavior in young heterosexual dyads with sexually transmitted infection (STI). Methods: Chlamydia-positive 14-24-year-old, heterosexually active outpatients and their opposite-sex partners completed an assessment that included demographics, past and recent STI risk behaviors, and the Beck Depression Inventory (BDI). Participants in the top 25% of BDI scores within gender were categorized as depressed. Variables were created to identify dyads in which the female or male partner was depressed, as well as a measure of concordance of depression between partners. Dyad-level STI risk variables were created from the STI risk characteristics reported by each dyad member, and associations between these and the depression variables were analyzed. Results: The 130 dyads were comprised of young men and women at high STI risk. One-third of dyads had at least one depressed partner. Dyads in which the female partner was depressed had greater partner age difference, greater total number of lifetime partners, and one or more partners reporting substance use within 2 hours before sex, compared with dyads in which the female partner was not depressed. Dyads in which the male partner was depressed were more likely than the nondepressed-male dyads to report substance use before sex. All dyads in which both partners were depressed reported substance use before sex. Conclusions: In young, chlamydia-infected, heterosexual dyads, depressive symptoms, especially in women, is related to increased dyad-level STI risk, including greater partner age difference, more partners, and substance use before sex.

Background Human circus arts are gaining increasing popularity as a physical activity with more than 500 companies and 200 schools. The only injury data that currently exist are a few case reports and 1 survey. Hypothesis To describe injury patterns and injury rates among Cirque du Soleil artists between 2002 and 2006. Study Design Descriptive epidemiology study. Methods The authors defined an injury as any work-related condition recorded in an electronic injury database that required a visit to the show therapist. Analyses for treatments, missed performances, and injury rates (per 1000 artist performances) were based on a subset of data that contained appropriate denominator (exposure) information (began in 2004). Results There were 1376 artists who sustained a total of the 18 336 show- or training-related injuries. The pattern of injuries was generally similar across sex and performance versus training. Most injuries were minor. Of the 6701 injuries with exposure data, 80% required ≤7 treatments and resulted in ≤1 completely missed performance. The overall show injury rate was 9.7 (95% confidence interval, 9.4–10.0; for context, published National Collegiate Athletic Association women’s gymnastics rate was 15.2 injuries per 1000 athlete-exposures). The rate for injuries resulting in more than 15 missed performances for acrobats (highest risk group) was 0.74 (95% confidence interval, 0.65–0.83), which is much lower than the corresponding estimated National Collegiate Athletic Association women’s gymnastics rate. Conclusion Most injuries in circus performers are minor, and rates of more serious injuries are lower than for many National Collegiate Athletic Association sports.

BACKGROUND: The genetics of intestinal lactase divide the world’s population into two phenotypes: the ability (a dominant trait) or inability (a recessive trait) to digest lactose. A prebiotic effect of lactose may impact the colonic flora of these phenotypes differently.OBJECTIVE: To detect and evaluate the effects of lactose on subjects divided according to their ability to digest lactose.METHODS: A total of 57 healthy maldigesters (n=30) and digesters (n=27) completed diet questionnaires, genetic and breath hydrogen testing, and quantitative stool analysis for species of bacteria. Log10transformation of bacterial counts was compared with lactose intake in both groups using multiple regression analysis.RESULTS: There was a significant relationship between genetic and breath hydrogen tests. Daily lactose intake was marginally lower in lactose maldigesters (median [interquartile range] 12.2 g [31 g] versus 15 g [29.6 g], respectively). There was no relationship between lactose intake and breath hydrogen tests in either group. There were no differences in bacterial counts between the two groups, nor was there a relationship between bacterial counts and lactose intake in either group.CONCLUSION: The differential bacterial effects of lactose were not quantitatively detected in stool samples taken in the present study.

Summary. Background/objectives: We prospectively measured change in quality of life (QOL) during the 2 years after a diagnosis of deep vein thrombosis (DVT) and evaluated determinants of QOL, including development of the post-thrombotic syndrome (PTS). Patients/methods: Consecutive patients with acute DVT were recruited from 2001 to 2004 at eight hospitals in Canada. At study visits at baseline, and 1, 4, 8, 12 and 24 months, clinical data were collected, standardized PTS assessments were performed, and QOL questionnaires were self-completed. Generic QOL was measured using the Short-Form Health Survey-36 (SF-36) questionnaire. Venous disease-specific QOL was measured using the Venous Insufficiency Epidemiological and Economic Study (VEINES)-QOL/Sym questionnaire. The change in QOL scores over a 2-year follow-up was assessed. The influence of PTS and other characteristics on QOL at 2 years was evaluated using multivariable regression analyses. Results: Among the 387 patients recruited, the average age was 56 years, two-thirds were outpatients, and 60% had proximal DVT. The cumulative incidence of PTS was 47%. On average, QOL scores improved during follow-up. However, patients who developed PTS had lower scores at all visits and significantly less improvement in QOL over time (P-values for PTS*time interaction were 0.001, 0.012, 0.014 and 0.006 for PCS, MCS, VEINES-QOL and VEINES-Sym). Multivariable regression analyses showed that PTS (P

Dairy foods (DFs) contain complex ingredients that could affect different diseases. The control of lactose digestion phenotypically divides populations into those who can [lactase persistent (LP)] and those who cannot [lactase nonpersistent (LNP)] assimilate lactose. LNP subjects, however, can adapt to lactose intolerance through intestinal bacteria. The DF/LNP status interactions may function as disease risk modifiers. We evaluated the relationship between DF and LNP with colorectal, breast, prostate, ovarian, lung, and stomach cancer and inflammatory bowel diseases (IBD; Crohn's disease and ulcerative colitis). Yearly per capita DF consumption, LNP national prevalence, cancer mortality, and incidence of IBD were obtained from several sources. A negative binomial regression model was used to derive incremental risks. There were statistically significant (P

BACKGROUND: Previous studies indicate that religiousness is associated with lower levels of substance use among adolescents, but less is known about the relationship between spirituality and substance use. The objective of this study was to determine the association between adolescents' use of alcohol and specific aspects of religiousness and spirituality. METHODS: Twelve- to 18-year-old patients coming for routine medical care at three primary care sites completed a modified Brief Multidimensional Measure of Religiousness/Spirituality; the Spiritual Connectedness Scale; and a past-90-days alcohol use Timeline Followback calendar. We used multiple logistic regression analysis to assess the association between each religiousness/spirituality measure and odds of any past-90-days alcohol use, controlling for age, gender, race/ethnicity, and clinic site. Timeline Followback data were dichotomized to indicate any past-90-days alcohol use and religiousness/spirituality scale scores were z-transformed for analysis. RESULTS: Participants (n = 305) were 67% female, 74% Hispanic or black, and 45% from two-parent families. Mean +/- SD age was 16.0 +/- 1.8 years. Approximately 1/3 (34%) reported past-90-day alcohol use. After controlling for demographics and clinic site, Religiousness/Spirituality scales that were not significantly associated with alcohol use included: Commitment (OR = 0.81, 95% CI 0.36, 1.79), Organizational Religiousness (OR = 0.83, 95% CI 0.64, 1.07), Private Religious Practices (OR = 0.94, 95% CI 0.80, 1.10), and Religious and Spiritual Coping--Negative (OR = 1.07, 95% CI 0.91, 1.23). All of these are measures of religiousness, except for Religious and Spiritual Coping--Negative. Scales that were significantly and negatively associated with alcohol use included: Forgiveness (OR = 0.55, 95% CI 0.42-0.73), Religious and Spiritual Coping--Positive (OR = 0.67, 95% CI 0.51-0.84), Daily Spiritual Experiences (OR = 0.67, 95% CI 0.54-0.84), and Belief (OR = 0.76, 95% CI 0.68-0.83), which are all measures of spirituality. In a multivariable model that included all significant measures, however, only Forgiveness remained as a significant negative correlate of alcohol use (OR = 0.56, 95% CI 0.41, 0.74). CONCLUSIONS: Forgiveness is associated with a lowered risk of drinking during adolescence. Language: en

Purpose: A significant proportion of surgeons use intra-articular drains after arthroscopic anterior cruciate ligament (ACL) reconstruction. The usual reason given to justify the use of a drain is to minimize patient pain and stiffness of the knee joint. The purpose of this study was to assess the validity of this approach. Methods: In this study 118 consecutive ACL reconstruction patients were randomized to no drain or a postoperative intra-articular suction drain. Inclusion criteria included a successful ACL reconstruction via either 4-strand hamstrings or bone–patellar tendon–bone autograft as a graft source. The primary outcomes were defined as pain (assessed by pain scores and analgesic counts) and range of motion (ROM) (assessed by loss of flexion and extension compared with the nonoperative leg). An independent statistical analysis was performed. Results: The 2 groups were comparable with respect to patient demographics, surgical findings, and procedures performed. There were no differences between the treatment groups for the primary outcomes of pain and ROM during the 8-week follow-up period. The study had adequate power to detect a clinically significant difference. Regarding the secondary outcomes, there was a difference in the grade of hemarthrosis between the groups at week 1 but not at week 4 or 8. However, the difference in subjective grade of hemarthrosis at 1 week did not have any effect on the primary outcomes of pain and ROM. During the study period, there were no complications in either group. Conclusions: The routine use of intra-articular drains after arthroscopic ACL surgery was not supported by this study. Level of Evidence: Level II, randomized controlled trial without narrow confidence intervals.