Neutrophil to Lymphocyte Ratio (NLR) in Peripheral Blood: A Novel and Simple Prognostic Predictor of Non-small Cell Lung Cancer (NSCLC)

Xiaoli Zhang, Ziyuan Zou, Liyu Fan, Xinjie Xu, Yu Siyuan and Peng Luo*

Lung cancer is the leading cause of cancer-related deaths worldwide, and almost accounts for 20% of these deaths, however, the cure rate is less than 10% [1]. Non-small cell lung cancer (NSCLC) accounts for approximately 85% of all cases of lung cancer [1], but fewer than 15% of individuals diagnosed with NSCLC can survive for more than 5 years, which poses a great threat to the patient’s life and health [2]. Recently, the incidence of lung cancer keeps dynamically growing, but more than 75% of patients at diagnosis has appeared local development or metastasis, missing the best period of surgery. Moreover, despite surgical treatment is the optimal choice for early-stage NSCLC patients, 30%-40% of patients with NSCLC develop tumor recurrence in a short time. Therefore, improving the prognosis of patients with lung cancer and predicting the long-term survival of patients is of particular importance [3]. At present, tumor and node metastasis (TNM) staging system, clinicopathological characteristics, visceral pleural invasion and marginal status are used to predict the disease progression and overall survival of NSCLC patients. There is no index which is stable, effective, reliable and less harmful to assess prognosis, predict recurrence risk and overall survival.

The genesis, progress and metastasis of NSCLC are not only related to the intrinsic characteristics of cancer cells but also to the cancer microenvironment. Systemic inflammation is a promoter of tumor genesis. Cumulative evidence has revealed that tumor-promoting inflammation contributes to cancer growth and progression by creating a tumor-promoting microenvironment, stimulates the proliferation of bronchial stem cells, and triggers the carcinogenesis of lung epithelial cell. Additionally, systematic inflammatory can not only cause tumor growth and promote tumor metastasis by activating type 2 T-assisted response, chemokines, vascular regeneration and others [4], but also responsible for reducing the effect of anti-cancer drugs and cancer-related symptoms including anorexia, cancerous pain, debilitation, cachexia [2]. In total, systematic inflammation has been shown to play an important impact on the pathogenesis and progression of NSCLC and is of great value to the aggravation and prognosis of NSCLC.

Case Report

Dealing with Depression in Family Caregivers

Wai Hing HUI-CHOI*

Aims and objectives: By reporting the use of therapeutic nursing interventions to facilitate the process of change in a depressive elderly caregiver, this paper seeks to underline the importance of fitting interventions to individual clients.

Background: In assisting families of chronic illness sufferers, it must be remembered that the perceptions and functions of both clients and families are determined by family members, and that changes, if any, are made by those clients and families, rather than by nurses. However, nurses do play an important role in facilitating the process of change.

Design: This is a case report.

Methods: A case study of a depressive elderly caregiver is used to examine the use of therapeutic nursing interventions to facilitate the process of change with problem analysis, case conceptualisation and specific skills employed documented.

Results: The change from one therapeutic approach (Cognitive-behavioural therapy) to another (Narrative Therapy) facilitates enlisting the caregiver’s unique strengths, resources and competence to overcome the difficulties and challenges identified during the process of change. In dealing with depression in family caregivers, nurses should not only be flexible but also remain sceptical in using different approaches, with heightened awareness of the client’s circumstances.

Short Communication

Insights for Antihypertensive pharmacotherapy from the“Calcium Paradox” due to Ca2+/camp Interaction

Leandro Bueno Bergantin* and Afonso Caricati-Neto

Several experimental studies performed since 1975, using smooth muscles richly innervated by sympathetic nerves to exclude the autonomic influence of adjusting reflex (rodent vas deferens), showed that L-type voltage-activated Ca2+ channels (VACC) blockers completely inhibited neurogenic contractions induced by electrical field stimulation (EFS) in high concentrations (>10-6 M), but paradoxically increased these EFS-contractions in low concentrations (<10-6 M), suggesting that other mechanisms than only autonomic adjusting reflex are involved in these paradoxical effects. In 2013, we showed that these paradoxical effects of L-type VACC blockers, named by us “calcium paradox” phenomenon, were potentiated by drugs which increase cytosolic cAMP concentration ([cAMP] c-enhancers), such as rolipram, IBMX and forskolin, indicating that this sympathetic hyperactivity drug-induced is due to interaction of the Ca2+/cAMP intracellular signaling pathways (Ca2+/cAMP interaction). Then, the pharmacological manipulation of this interaction produced by combination of the L-type VACC blockers used in the antihypertensive therapy, and [cAMP] c-enhancers used in the antidepressive therapy, could represent a potential cardiovascular risk for hypertensive patients due to sympathetic hyperactivity. Then, we discussed the role of Ca2+/cAMP interaction for antihypertensive pharmacotherapy.

Research Article

Magnetic Resonance Imaging Can Detect Symptomatic Patients with Facet Joint Pain. A Retrospective Analysis

Wolfgang Freund*, Frank Weber, Reinhard Meier and Stephan Klessinger

Background: Low back pain has recently been reported as the leading cause for disability worldwide. The diagnostic value of imaging has been estimated low. Led by own positive experience, however, we hypothesized that MRI can detect signs of facet joint pain.

Methods: 15 patients and 15 controls were retrospectively assessed by two readers. They compared de-identified T2 weighted lumbar spine MRI scans. Facet joint size, shape, angle, joint space signal and degeneration were rated. Pain aetiology was proven with the diagnostic gold standard of medial branch blocks.

Results: Facet joint angles and joint diameters were significantly larger in symptomatic patients, who also showed significantly higher grades of degeneration but no difference in joint space distances or shape or signal intensity.

The readers were able to correctly identify symptomatic patients with good interrater reliability (kappa 0.5, sensitivity and specificity 0.87-0.93), positive (LR+= 6.7-7.2) and negative likelihood ratios (LR-=0.15).

Conclusion: Contrary to recent publications, we could demonstrate differences between asymptomatic and symptomatic subjects showing the latter to have larger joints and more signs of degeneration.

One can conclude from the strong LR+ and LR- values that MRI is a useful investigation to rule in or rule out facet pain.

Research Article

Translating an Evidence-Based Physical Activity Service From Context To Context: A Single Organizational Case Study

Marie-Eve Lamontagne, Kelly P Arbour-Nicitopoulos, Jennifer R Tomasone, Isabelle Cummings, Amy E Latimer-Cheung and François Routhier*

Background: SCI Action Canada partnered with researchers to adapt an evidence-based leisure-time physical activity (LPTA) counselling service (Get-in-Motion (GIM). A satellite GIM service called Passez à l’action was established within a French-speaking context for persons with physical disabilities.An understanding of the determinants that infl uenced the implementation and functioning of the GIM service within the Adaptavie context are required to maximize the potential of other community-based LTPA services being successfully introduced in similar organizations.

Purpose: The case study objectives are to: 1) describe the characteristics and implementation contexts of two leisure-time physical activity counselling services for Canadians with a physical disability and the adoption process that took place when the protocol was translated to a new context, and 2) elucidate, from the point of view of the service providers, the organizational determinants that could have facilitated and/or hindered the implementation and functioning of these services.

Methods: Guided by the Consolidated Framework for Implementation Research, focus groups were held with the directors and staff of each service. Mixed-content and thematic analyses were then used to determine overarching themes.

Results: Findings suggest that the presence of service innovators fosters ownership of the service and facilitates ongoing staff training and support. A thoughtful implementation plan should be included as a component of translation between contexts.

Conclusions: Lessons learned and recommendations for future translation of similar evidence-based services to additional contexts are discussed.

Research Article

Visualization and Evaluation of Changes after Rapid Maxillary Expansion

Ilija Christo Ivanov*, Jan Dupej, Sarka Bejdova, Veronika Ciganova, Dagmar Strakova and Tatjana Dostalova

Objectives: The aim of the study was to develop a mathematical model for the visualization and evaluation of transversal palatal soft tissue changes; and to carry out a statistical evaluation of the changes in vertical and sagittal dimensions after rapid maxillary expansion treatment.

Material and Methods: 33 Caucasian children with posterior crossbite, 10 boys and 23 girls, aged 7 to 10 years (median 8 years 8 months) were treated with tooth-borne Haas type expander. Dental casts were digitalized by scanner and on the basis of quantitative mesh shape CPD-DCA analysis, coloured morphometrical maps were created. The statistical significance of individual vertex displacements was calculated by performing Hotelling’s T2 paired test. To determine the significance of the vertical and sagittal profile changes, the paired t-test and Wilcoxon signed rank test were carried out in 20 patients

Results: Visualization of the palatal soft tissue widening showed it to be greatest in the areas of the second deciduous and first permanent molars with maximum of 0.75 mm for each palatal side. Hotelling’s T2 paired test showed significant differences of p<0.01 in transversal width dimension. Cephalometric measurements of the changes to vertical and sagittal dimensions were statistically evaluated using the Wilcoxon and paired t-tests, and were shown to have insignificant values of p>0.05.

Conclusion: The expansion appliance in children resolved the crossbite and led to palatal widening, which was clearly visualized by creating mathematical morphometric models. The cephalometric measurements carried out did not reveal statistically significant relevance in changes to facial vertical or sagittal dimensions.

Research Article

Wave Forces on Vertical Structures in Shallow Water: Numerical Evaluation

Fabio Dentale*, Ferdinando Reale, Angela Di Leo, Eugenio Pugliese Carratelli and Marina Monaco

The actions exerted by waves on a coastal structure very much depend upon hydrodynamic processes that originate on shallow waters; even though significant progresses have been made in the last few years towards a full understanding of wave breaking, design work is still largely based on classical stability formulas. The recent availability of reliable models based on the numerical integration of full Navier-Stokes equations provides an important tool, but the evaluation of forces on vertical structures in shallow waters is still a particularly delicate application because of the complex hydrodynamic issues involved.

The paper presents deals with the numerical simulation of wave effects on front of a vertical obstacle on a sloping bottom, with the objective of clarifying some physical issues which are relevant towards the applicability of numerical Navier-Stokes simulation as a design tool.

Research Article

Thermal Stress Analysis of a Continuous Rigid Frame Bridge

Shiwei Ge, Yafei Xu*, Xiao Zhou and Shangyu Peng

Thermal stress of a continuous rigid frame bridge, based on the temperature gradient in Chinese bridge gauge, using a finite element analysis (FEA) method was investigated. First of all, the temperature effect of the whole bridge was analyzed, and the correlation of the improved amplitude of temperature gradient and temperature effect were studied. It was found that there was a linear relationship with temperature stress and improved temperature. And then, the temperature effect of zero block was analyzed and the details of box girder temperature stress distribution investigated by utilizing the FEA method. It was concluded that temperature stress mainly distributed in the body surface; under the condition of the improvement of temperature field, the center temperature stress of zero block was improved about 60% and the end temperature stress of zero block was improved about 75%.

Research Article

Burnout and Related Factors in Caregivers of outpatients with Schizophrenia

Hatice Demirbas* and Erguvan Tugba Ozel Kizil

Objectives: Care of a person with schizophrenia involves multiple problems, possibly leading to burnout which is a culturally influenced phenomenon. The aim of this study was to investigate burnout and related factors in caregivers of outpatients with schizophrenia.

Methods: Subjects included in the study were 40 primary caregivers of outpatients with schizophrenia (15 males, 25 females) whom were assessed with the Maslach Burnout Inventory (MBI), the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI). Patients were also administered the Calgary Depression Scale (CDS). Also, sociodemographic information about patients and their caregivers were taken. The significance of differences between two groups was determined by Mann-Whitney U-test. The relationships between the variables were evaluated by Pearson correlation analysis.

Results: No significant difference was found in the MBI subscale scores in terms of caregivers gender, marital status, and education, being a family member, having enough information about the illness and taking support during caregiving. Emotional Exhaustion and Personal Accomplishment subscale scores of the caregivers were significantly different in terms of patients’ adaptation to treatment or not (respectively; p=0.010, p=0.030). The MBI-Emotional Exhaustion scores revealed significant positive correlations with the BDI and BAI total scores. Also, the MBI- Depersonalization scores and the BAI scores were positively correlated.

Conclusions: Burnout levels in caregivers of patients with schizophrenia were lower when compared with other cultures. Only treatment compliance predicted burnout, while other factors were excluded. Therefore, professionals have to help to patients primarily adapt to their treatment.

Case Report

Intestinal obstruction complicated by large Morgagni hernia

Martín Arnau B*, Medrano Caviedes R, Rofin Serra S, Caballero Mestres F and Trias Folch M

Morgagni hernia represents 2-4% of congenital diaphragmatic hernias. Only one-third of them are symptomatic, due to the hernia of abdominal viscera in the thoracic cavity, causing respiratory and digestive problems, some of them serious ones, such as intestinal obstruction. Acute presentation with incarceration of the contents is rare; there are only 7 cases described in the literature.

We are presenting a case of diaphragmatic hernia that began with obstruction of the colon and secondary ischemia, requiring emergency surgery in two phases: first surgery to control the damage, with an open right hemicolectomy, and then later surgery to repair the hernia and perform bowel transit reconstruction, with proper postoperative evolution and no evidence of relapse.

The treatment of Morgagni diaphragmatic hernia is surgical. Also in asymptomatic cases, due to the risk of incarceration, the most appropriate way to enter is abdominally, whether by way of laparotomy or laparoscopy, for the reduction of the contents of the hernia sac, the repair of the defect, as well as the performing of associated techniques on herniated viscera, as occurred in our case.

A complicated congenital hernia is an infrequent pathology, and there is little experience in handling it. Acute presentation requires a combined treatment of the abdominal symptoms and repair of the hernia defect. The carrying over of surgical techniques for damage control into non-traumatic surgery in the face of serious hemodynamic instability is a widespread, accepted practice with the benefits of reducing mortality in critical patients and at times allowing the avoidance of ostomies.

Case Report

Facial Paralysis During Varicella Zoster Infectıon in a child

Fatih Oghan*, Muhammet Fatih Topuz and Onur Erdogan

Introduction: Primary infection with varicella-zoster virus (VZV) results in chickenpox, characterized by viremia with a diffuse rash and seeding of multiple sensory ganglia, where the virus establishes lifelong latency. Herpes zoster is caused by reactivation of latent VZV in cranial-nerve or dorsal-root ganglia, with spread of the virus along the sensory nerve to the dermatome. Both entities have a benign clinical course in immunocompetent and young individuals. Although Herpes zoster virüs may result in Ramsey Hunt sendrom, it may rarely cause peripheral facial paralysis in the course of varicella.

Case report: A 4-year-old girl patient was admitted to the ear, nose, and throat clinic with a complaint of a rash over the body with vesicles and pustules a few days. She had left peripheral facial palsy about 2 days ago. In a general clinical examination, a few macular lesions, probably residues of vesicles, and fluid-filled blisters and pustules were observed on the back, chest, abdomen, upper, and lower limbs. She had remarkable left peripheral facial palsy. Her facial palsy was assessed as a grade II using the House-Brackmann Score. Otoscopic examination was normal and otalgia and auricular vesicle was absent. 1 mg/kg/day prednisone and 30 mg/kg/day acyclovir therapy were given to the patient due to the peripheral facial nerve palsy involvement of the VZV infection. Complete remission was achieved at 1 month after treatment.

Conclusion: Varicella-zoster virus (VZV) is one of eight herpes viruses known to cause human infection and is distributed worldwide. While the results of bell palsy are good, facial paralysis results during viral infections are severe. Cranial nerve involvement secondary to viral infection should be followed closely. The current standard of care for treatment is acyclovir and prednisone. Thus early treatment can be started in the face of developing complications and possible mortality and morbidity can be prevented.

Case Report

Lincoln ’S Highway - A Forgotten Abscess

Suhail Amin Patigaroo*, Zubair Ahmad Lone, Quratul Ain Batool and Sajad Majid Qazi

Introduction: Carotid space is a deep neck space within the carotid sheath. .Mosher called carotid sheath as the Lincoln Highway of the neck. Abscess in this space is rare to be seen by young Ear, Nose and Throat (ENT) surgeons in this era of early diagnosis and good antibiotics. We are reporting a case of isolated carotid space abscess in a 20 year old male to familiarize young surgeons with this abscess.

Case report: A 20 year old young boy came to our Outpatient Department (OPD) with complaints of fever, painful neck swelling, progressive difficulty in swallowing from the last 7 days. Contrast Enhanced Computed Tomography (CECT) was done which revealed abscess located adjacent to carotid artery in the carotid sheath. Incision and drainage was done and carotid sheath was opened and pus drained .Patient was discharged after few days on oral antibiotics.

Conclusion: Carotid space abscesses are rarely seen in developed countries. Tender and fluctuating swelling over the carotid artery area points towards it. CECT is the investigation of choice. Needle aspiration should be avoided especially by less trained persons. Small abscesses may respond to intravenous antibiotics but when frank and large abscess is formed, incision and drainage is the treatment of choice.

Case Report

Comparative Study of Enophthalmos Treatment with Titanium Mesh Combined with Absorbable Implant vs. Costochondral Graft for Large Orbital Defects in Floor Fractures

Malagon Hidalgo*, Hector Omar, Gonzalez Magana, Fernando, Kalach Mussali, Alberto Jaime, Mejía Valero, Sergio Abraham, Vilchis Lopez, Roberto, Araiza Gomez and Edgardo

Introduction: Several treatment options are available for the optimal treatment for orbital fractures, depending on aesthetic and functional results after orbital wall reconstruction.The objective of this study is to compare the effect and safety of large orbital floor fractures with titanium mesh combined with poly-L-lactic acid/polyglycolic acid copolymer implants (Lactosorb®) vs. autologous costochondral graft. A wide range of permanent and biodegradable materials have been used successfully for orbital floor reconstruction, however they present with disadvantages for reconstruction of large defects, even if combined.

Patients and Methods: A retrospective cohort study of patients from Estado de México, México, with access to ISSEMYM health care service, presenting with orbital floor fracture treated at Department of Plastic & Reconstructive Surgery/Maxillofacial Surgery at ISSEMYM Medical Center Toluca between January 2007 and July 2010. Age, sex, etiology, clinical findings, fracture pattern, and treatment modality (Titanium mesh with absorbable implant vs. costochondral graft) were considered. Predictor and outcome variables as complications, inpatient, trauma- surgery interval, surgical time and donor site pain are considered.

Results: Follow up of 21 patients (12 weeks) 17 male, 4 female, ages 22-63 was made. Enophthalmos, main objective of this study, was identified with statistical significance presenting 0% (n=0) post-op Group B patients and 30% (n=3) for Group A (p=0.049). Statistical significance was found referring to inpatient days between two groups being less for costochondral reconstruction patients (p=0.02). No pain in patients undergoing alloplastic surgery. An interesting result was that donor area analogue pain scale for costochondral graft was 2.9/10.

Conclusion: Surgical outcome and complications where evaluated comparing different materials for orbital floor reconstruction. Costochondral graft is a suitable choice when orbital reconstruction is indicated.

Short Communication

Cardiac Manifestations on Anti- Phospholipid Syndrome

Faisal AH

Antiphospholipid syndrome may present in various ways from cutaneous manifestation, obstetric complications, neurological manifestation, and cardiac manifestation to renal involvement. There are many cardiac complication of anti-phospholipid syndrome, among them are valvular dysfunction, pulmonary hypertension, myocardial infarction, intracardiac thrombi, and ventricular dysfunction [1]. The most common cardiac manifestation is valvular abnormalities ranging from 11.6-32% [2-5].

Cardiac thrombus is an important sequela of APLS. In general, the exact mechanism of intracardiac thrombus formation in APLS is unclear. Julio and Carmen suggested that the endocardial surface might be an important site for thrombus formation in patients with circulating aPL, because these antibodies, in the presence of other hemostatic defects, will abolish the balance between thrombosis and fibrinolysis, and might change the endocardial surface factors so that clot formation is promoted [6]. Coppock, et al. Speculated that an abnormal intracardiac blood flow pattern might contribute to thrombosis [7], and Kaplan, et al. hypothesized that diffuse ventricular dysfunction might predispose to the formation of intracardiac thrombus [8].

Intracardiac thrombosis is a potentially life threatening as it can cause pulmonary and systemic embolic events; however, it is treatable condition. 50% of APLS patients are at risk of developing recurrent embolic events [9], so there must be a delicate balance between this event as well as risk of bleeding from anticoagulation.

Other cardiac manifestations that has been reported to be associated with APLS are valvular lesions, pseudoinfective endocarditis, myocardial infarction, cardiomyopathy and pulmonary hypertension [10].

Valvular lesions has been reported in SLE and APLS patients. Recently; a prospective cross sectional study done showed that positive anticardiolipin, lupus anticoagulant and anti-beta 2 glycoprotein were associated with mitral valve regurgitation; thus the need to perform transthoracic echocardiogram for early detection and management plan even in asymptomatic patients [11]. APLS may also be presents with Libman-Sacks endocarditis which may occur with a prevalence of 11% in SLE. Recently, Kotkar reported on a APLS patient with pulmonary edema with Libman-Sacks endocarditis who required mitral valve replacement [12].

Myocardial infarction occurs in 5% of aPL positive patients [10]. The presence of LA and IgG anticardiolipin antibodies at medium or high titers helps to identify APLS patients at risk for thrombosis. A research done in Tel Aviv University among 214 patients showed that 6.9% with acute myocardial infarction has elevated antiphospholipid antibodies. Three out of 7 of them did not have risk factors of Ischaemic heart disease [13]. Young patients with vascular thrombosis and myocardial infarction with normal coronaries should be investigated for APLS [14].

Cardiomyopathy as a primary cause from APLS may be difficult to diagnose in a patient with multi-organ involvement. However, Antiphospholipid antibodies may be a useful marker. Leung et al reported that 4 out of 5 patients with isolated left ventricular dysfunction had +ve aPL. The presence of aPL were significantly associated with left ventricular dysfunction [15].

With regards to the management, aggressive treatment of all risk factors and liberal use of folic acid and vitamin B has been advocated. The use of hydroxychloroquine has been shown to have cardioprotective effect as it has suggested that it has anti-atherogenic effects [16,17]. Generally, the treatment for myocardial infarction, pulmonary hypertension and valvular disease are similar as those without APLS.

For APLS patients with thrombotic events, the duration of treatment is according to the patient’s clinical situation and the size, shape, and location of the thrombus. Lifelong warfarin may be an option in the presence of underlying cardiomyopathy which may predispose to further intracardiac thrombosis. A randomized clinical trial done comparing high intensity warfarin (INR 3.0-4.0) versus conventional antithrombotic therapy for the prevention of recurrent thrombosis in patients with antiphospholipid syndrome showed that high intensity warfarin was not superior and is associated with increased risk of minor hemorrhagic complications [18]. A current review states that for patients with definite APLS with first venous thrombotic event, prolonged use of anticoagulation to maintain target INR of 2.0-3.0 is recommended. For those with arterial thrombosis, proposed therapies include: anticoagulation with target INR 3.0-4.0; antiplatelet therapy alone; anticoagulation with target INR 2.0-3.0, or combination of antiplatelet or anticoagulation therapy with target INR 2.0-3.0 [19].

This manuscript illustrates the various cardiac presentations of APLS. The occurrence of thrombotic phenomena, especially in young patients without risk factors, should prompt further investigation towards APLS, i.e. aPL antibodies. Estimation of aPL in cardiological practice assumes considerable importance today.

Research Article

The Risk Factors for Ankle Sprain in Cadets at a Male Military School in Iran: A Retrospective Case-control Study

Farzad Najafipour*, Farshad Najafipour, Mohammad Hassan Majlesi and Milad Darejeh

Introduction: Ankle sprain is a widespread impairment in sport groups; this impairment leads to an absence from the workplace. The ankle sprains incidence rates are induced by height, weight, BMI, physical fitness, level of match, classification of sport, and personal exposure to sport.

Methods: A longitudinal case-control study was executed to verify the outcome of risk factors for ankle sprain at a Military Male School between 2012 and 2013 of 4987 people at risk for ankle sprain, a total of 234 cadets sustained new ankle sprains during the study, 432 non-injured cadets randomly selected as the control group.

Results: Regarding to the total people at risk in our study the incidence rate was approximately 5/1000 ankle sprain-years. Cadets with ankle sprains had higher weight, BMI and higher scores in Army Physical Fitness test than the control group. Ankle sprain occurred most commonly during athletics (51.4%). Ankle sprain incidence rate did not significantly vary from different athletic competitions after controlling for athlete-exposure. Soccer and Ball Games had the highest ankle sprain incidence rate.

Conclusion: Higher weight, increased BMI, greater physical conditioning and athlete exposure to selected sports were all risk factors for ankle sprain.

Research Article

3-Dimensional Versus 2-Dimensional Comparison of Knee Valgus Collapse during Vertical Jump: Clinical Implications for ACL Risk of Injury Assessment

Guilherme M. Cesar*, Chase M. Pfeifer and Judith M. Burnfield

Time-effi cient screening of lower extremity biomechanics to identify potential injurious movement patterns is crucial within athletic medicine settings. When considering biomechanical risk factors for anterior cruciate ligament injuries, several screening tests have been used to assess dynamic knee valgus.Current methods involving 3-dimensional motion capture systems are considered gold standard for such assessment; however, these methods are time consuming and require expensive materials. This study investigated the use of 2-dimentional kinematic evaluation during a standardized vertical jump athletic assessment to screen for potential lower extremity risk of injury. 50 collegiate athletes, 25 male and 25 female, from various sports participated in the study. The vertical jump was chosen because it is a common performance evaluation test that is regularly performed several times a year, providing consistent opportunities for screening while not creating additional obligations for the student athletes. Results showed that the 2-dimentional evaluation method had strong correlations (P<0.0001) with the gold standard 3-dimensional evaluation, suggesting that an accelerated 2-dimentional screening process can be used as a first step to screen for potential injurious lower extremity movement patterns.

Case Report

Recurrent Cardiac Events Driven by Prothrombotic Burden in a Patient Undergoing Lipoprotein Apheresis for High Lp(a) Levels

Gabriele Cioni*, Rossella Marcucci, Rosanna Abbate and Giovanna D’Alessandri

Introduction: Lipoprotein (a) [Lp(a)] is a marker for cardiovascular disease, involved in pathogenesis and progression of atherosclerosis. In selected high-risk patients, lipoprotein-apheresis could optimize secondary prevention and improve prognosis.

Aim: We presented the case of a 49-year-old man with high lipoprotein (a) levels and recurrent cardiac adverse events, despite maximal pharmacological therapy.

Case report: Four years before the admission at our Centre, he presented an anterior STEMI, treated with angioplasty and implantation of a drug eluting stent on left anterior descending artery, at the age of 47 years, in September 2012; one month later, the patients presented a new episode of angina, and exams showed a critical stenosis in the right coronary artery, treated by angioplasty and implantation of drug eluting stent. Because of high Lp(a) plasma levels, patient was subsequently on regularly 7-10 day lipoprotein apheresis.

Results and discussion: A thrombophilic screening was performed, showing the simultaneous presence of heterozygous V Leiden mutation and prothrombin G20210A mutation. He referred to our Centre in order to optimize therapy; we performed an endothelial function assessment showing a severe dysfunctional pattern.

Because of these findings, we prescribed dual antiplatelet therapy, and we added omega-3 fatty acids and association with nicotinic acid/laropiprant. According with current guidelines, considering the high risk of bleeding, we preferred not to administer anticoagulant therapy. At 6-month and 1-year follow up the patient continued lipoprotein apheresis and was asymptomatic for other cardiovascular events.

Conclusions: The assessment for the eventual presence of thrombophilia might become a useful tool in clinical practice for high-risk selected patients.

Review Article

Rhabdomyoblasts in Pediatric Tumors: A Review with Emphasis on their Diagnostic Utility

Giuseppe Angelico*, Eliana Piombino, Giuseppe Broggi, Fabio Motta and Saveria Spadola

Rhabdomyosarcoma is a soft tissue pediatric sarcoma composed of cells which show morphological, immunohistochemical and ultrastructural evidence of skeletal muscle differentiation. To date four major subtypes have been recognized: embryonal, alveolar, spindle cell/sclerosing and pleomorphic.All these subtypes are defined, at least in part, by the presence of rhabdomyoblasts, i.e. cells with variable shape, densely eosinophilic cytoplasm with occasional cytoplasmic cross-striations and eccentric round nuclei. It must be remembered, however, that several benign and malignant pediatric tumours other than rhabdomyosarcoma may exhibit rhabdomyoblaststic and skeletal muscle differentiation. This review focuses on the most common malignant pediatric neoplasm that may exhibit rhabdomyoblastic differentiation, with an emphasis on the most important clinicopathological and differential diagnostic considerations.

Research Article

The Effects of Pharmacological Carbonic Anhydrase Suppression on Defence Responses of Potato Leaves To Phytophthora Infestans

Jolanta Floryszak-Wieczorek and Magdalena Arasimowicz-Jelonek*

In this study we proposed carbonic anhydrase (CA) asan important element of basal resistance during the potato (Solanum tuberosum L.)-Phytophthora infestans interaction.We found a different β-CAexpression pattern in incompatible vs. compatible systems correlated in time with CA enzyme activity.Resistant potato leaves supplied with dorzolamide (an inhibitor of carbonate CA activity) and challenged with the pathogen showed an elevated nitric oxide (NO) synthesis, which was the most evident during the early phase of NO burst (at 3 hpi) during hypersensitive response (HR). In vitro application of dorzolamide and effective inhibitors of NO synthesis confirmed the implication of CA activity in NO metabolism during potato defense. To clarify how suppression of CA carbonate activity translates into the complexity of NO-related responses leading to potato resistance or susceptibility to an oomycete pathogen we analysed expression of NPR, PR1, and PAL.

Taken together, pharmacological damping of CA activity revealed a functional link between CA and NO-dependent signaling in potato defense against P. infestans manifested by accelerated NO formation and a modified salicylic acid defense pathway. The dorzolamide-mediated effective responses for basal resistance also delayed symptoms of late blight in the susceptible potato cultivar, without overcoming HR formation in the resistant one.

Case Report

An Unusual Cause of Anterolateral Ankle Pain and Snapping

Vasileios Triantafyllis* and Roshin Thomas

Most patients with anterolateral ankle pain report some history of trauma as the precipitating event. In the majority of cases of anterolateral ankle pain with no history of trauma the cause is proliferative synovitis, especially in the area of the anteroinferior tibiofibular ligament [1,2]. Our case report is about a patient with anterolateral ankle pain and snapping, with no history of trauma, caused by an abnormal peroneal tertius muscle belly. We have found only one similar case reported in the literature [3]. That particular case was treated with arthroscopic resection, which requires specialist arthroscopic skills. In our case we have done an open resection, which can be safely performed by most surgeons.

Review Article

The Utility of Acupuncture in Sports Medicine: A Review of the Recent Literature

Michael Malone*

Introduction:Acupuncture is a practice that has been used to treat multiple medical conditions for thousands of years and is one of the most popular alternative treatments applied in Western medical practice. Acupuncture is a modality that has significant potential for further integration into the treatment of sports medicine conditions.

Methodology: The search strategy in this review included electronic databases-MEDLINE, Cochrane Library, PubMed, Web of Science, and Science Direct. Randomized controlled trials and systematic reviews were preferred for article inclusion, but other study types were included when the number or quality of evidence was limited.

Results: Back pain, neck pain, shoulder pain, and knee pain related to OA tend to respond well to acupuncture treatment. There is evidence to support the use of acupuncture for the short-term treatment of plantar fasciitis, although long-term efficacy data is lacking. Acupuncture may be a useful treatment modality for epicondylitis and Achilles tendinopathy, but the current data is limited. While acupuncture may improve athletic performance and prevent Delayed-Onset Muscle Soreness (DOMS) symptoms, there is little current evidence to support this use.

Conclusion: Further studies are needed to assess the usefulness of acupuncture in sports medicine. However, there is good evidence for the current use of acupuncture in treatment of multiple pain conditions.

Original Article

Parents Take-On Concussion: Advances in Sideline Research and Culture in Youth Sports

Arlene Silverio, Scott Briggs, Lisena Hasanaj, Jeffrey Hurd, Jr, Max Lahn, Liliana Serrano, Lucy Cobbs, Jenelle Raynowska, Rachel Nolan, Joel Birkemeier, Dennis Cardone, Steven L Galetta and Laura J. Balcer*

Identifying concussion and initiating removal from play is challenging for even the most diligent youth sports organizations. Empowering parents to implement removal from play protocols and sideline testing may be the most practical plan at community levels to protect young athletes. We developed paradigms for community-based youth sports teams that incorporated both standard concussion protocols and research investigations. The research studies were designed to determine how sideline tests of vision, cognition and balance augment the capacity for parents and other responsible adults to identify youth athletes with concussion in ice hockey, football, lacrosse and cheerleading. Research-based sideline tests were performed at pre-season baseline sessions and during the season at the time of injury or as soon as symptoms were recognized by trained volunteer parent team testers. The combination of standard concussion protocols and research studies were performed for 510 athletes, aged 5-17 years, over 2.5 years through 5 athletic seasons. To implement the protocols and studies, approximately 80 student volunteers and parents were educated and trained on early concussion recognition and on baseline and sideline test administration. Over 80% of parent-identified head injuries were physician-confirmed concussions. Of the sideline tests performed, over two-thirds were administered within 24 hours of injury; the rest were performed within an average of 2.6 days post-injury since some athletes had delayed development of symptoms. Removal from play guidelines and standard concussion evaluation protocols were maintained in the context of the sideline testing research investigations. Based on this observational study, parents of youth athletes can be successfully empowered to perform rapid sideline tests in the context of existing concussion protocols. Implementation of objective testing may improve concussion identification and shift the culture of advocacy and responsibility towards parent groups to promote safety of young athletes. Ongoing investigations will further examine the impact of these programs on concussion management in youth sports.

Review Article

Critical Management of Status Epilepticus

Farahnaz Fallahian* and Seyed MohammadReza Hashemian*

Seizure is clinical manifestation of sudden disruption of the normal electrical activity of cortical neurons. The brain electrical activity is periodically disturbed, alteration in neural cell integrity, increase in firing impulses and spread to adjacent normal neurons result in temporary brain dysfunction with alterations in consciousness, behavior or motor function. It may be triggered by illness, infection, stress, stroke, brain tumor, or the underlying cause may not completely understand. Status epilepticus (SE) is a medical emergency and requires prompt diagnosis and treatment. Treatment includes general support measures, drugs to suppress epileptic activity and relieving the underlying condition. Refractory SE requires admission to an intensive care unit (ICU) to allow adequate monitoring and support of respiratory, metabolic and hemodynamic functions and cerebral electrical activity. For SE treatment, benzodiazepines are the first line antiepileptic agents, and if benzodiazepines fail to control seizures, Phenytoin is usually indicated; Phenobarbital or Valproate may also be considered. For refractory SE, Propofol and Thiopental represent first line agents after careful assessment of potential risks. In refractory SE, general anesthesia may be required. There is currently no unique consensus for definite treatment option of RSE. In this review, the management protocol of seizure, assessment, monitoring, and different alternative therapy would be discussed.

Research Article

Normal Value of Skull Base Angle Using the Modified Magnetic Resonance Imaging Technique in Thai Population

Siriporn Hirunpat*, Nat Wimolsiri and Nuttha Sanghan

Purpose: To determine the normal value of basal angle measured using the modified MR imaging technique in Thai population compared with the standard value obtained from the Western population.

Material and Methods: We retrospectively evaluated midline sagittal SE T1 weighted MR images in 200 adults and 50 children. The basal angle of the skull base was measured using the modified MR imaging technique described by Koenigsberg et al. The angle was formed by a line extending across the anterior cranial fossa to the tip of the dorsum sellae and another line drawn along the posterior margin of the clivus. The mean values of the basal angles among different age groups and sex were calculated and analyzed.

Results: The mean skull base angle of our adult population was 115° (range 100.5°-130°, SD=5.7) with an inter-observer agreement of 0.85, slightly smaller than the previous study from the USA which was 117°. There was no significant difference between the male and female groups. The mean skull base angle in our children population was 114.7° (range 102- 130.5°, SD=6.3) with an inter-observer agreement of 0.89, quite similar to the previous USA study which was 114°. There was no significant difference between adult and children.

Conclusion: The mean adult skull base angle measured using the modified MR imaging technique in Thai population was slightly smaller than the Western population, while the mean skull base angle of children was quite similar. The basal angle range of 103.6°-126.4° may be used as a guide for the potential range of normal skull base angles in Thai population and possibly also the Southeast Asian population.



Research Article

Evaluation of Horizontal Lip Position in Adults with Different Skeletal Patterns: A Cephalometric Study

Vinay V Umale, Kamlesh Singh, Aftab Azam, Madhvi Bhardwaj and Rohit Kulshrestha*

Aim: To evaluate sexual dimorphism in horizontal lip position in adults with different skeletal patterns.

Material and Methods: The sample comprised of 120 patients (Females 18 years and above, Males 21 years and above) with no history of previous orthodontic treatment or functional jaw orthopaedic treatment. They were divided into different groups based on the ANB angle and gender. Group I and II included 30 males and 30 females with skeletal class I malocclusion (ANB 0-4 degree). Group III and IV included 30 males and 30 females with skeletal class II malocclusion respectively (ANB above 4 degree).

Results: When comparison between males and females (Class I+Class II) was done S-line (p<0.001), B-line (p<0.001), E-line (p<0.001), Holdaways angle (p<0.001) and Merrifield angle (p<0.001) were found to be statistically significant. S-line (p<0.001), E-line (p<0.001) and Holdaways angle (p<0.001) were found to be statistically significant when comparison was done between males and females (Class I). When comparison was done between males and females (Class II) only Holdaways angle (p<0.001) showed a significant statistical difference.

Conclusion: Sexual dimorphism was found in various lip parameters. Significant amount of differences were found between Class I and Class II (male and female) subjects.