Asymptomatic sonographic abnormalities of the hindfoot region in Division I collegiate gymnasts.

BACKGROUND: The hindfoot region is commonly injured in gymnasts, and musculoskeletal ultrasound can be used to identify structural abnormalities in this region. Although prior studies have shown that sonographic abnormalities may not correlate with symptomatic pathology, the presence of asymptomatic sonographic abnormalities of the hindfoot in Division I collegiate gymnasts has not been evaluated. OBJECTIVE: To identify and describe commonly seen asymptomatic sonographic abnormalities of the hindfoot region in Division I collegiate gymnasts. DESIGN: Cross-sectional study. SETTING: Tertiary care academic medical center. PARTICIPANTS: 39 Division I NCAA men's and women's collegiate gymnasts without current hindfoot pain or history of hindfoot injury. INTERVENTIONS: Diagnostic musculoskeletal ultrasound of the hindfoot region. MAIN OUTCOME MEASURES: Sonographic appearance of the hindfoot region, specifically the plantar fascia, plantar fad pad, and Achilles tendon. RESULTS: A total of 37 of 39 gymnasts included in the study were found to have at least one asymptomatic sonographic abnormality of the hindfoot region. A total of 28.2% of athletes were found to have sonographic abnormalities within the Achilles tendon, with Doppler flow being the most common finding, and 35.8% of athletes were found to have a Haglund's deformity. However, only 7% of athletes with a Haglund's deformity demonstrated abnormal sonographic findings within the tendon. Sonographic abnormalities of the plantar fascia and plantar fat pad were seen in 30.7% and 69.2% of athletes, respectively. CONCLUSIONS: Asymptomatic sonographic abnormalities of the hindfoot region are common in collegiate gymnasts. Clinicians should use clinical judgment when interpreting these findings as they may not represent symptomatic pathology.

Implementing a Sports Ultrasound Curriculum in Undergraduate Medical Education.

ABSTRACT: The utilization of sports ultrasound in the clinical practice of sports medicine physicians is growing rapidly. Simultaneously, ultrasound is being increasingly implemented as a teaching tool in undergraduate medical education. However, a sports ultrasound curriculum for medical students has not been previously described. In this article, we describe methods as well as barriers to implementing a sports ultrasound curriculum at the medical school level. Recommended content for the curriculum also is discussed. While educational goals and resources will vary among institutions, this article may serve as a general roadmap for the creation of a successful curriculum.

Adaptive Sports Injury Epidemiology.

The benefit of sport for athletes with impairments is well established. However, sport participation is not without risk. The existing literature informs us that injury patterns are sport and disability specific. Further research is needed to study injuries in this population.

Rodent Models of Non-classical Progesterone Action Regulating Ovulation.

It is becoming clear that steroid hormones act not only by binding to nuclear receptors that associate with specific response elements in the nucleus but also by binding to receptors on the cell membrane. In this newly discovered manner, steroid hormones can initiate intracellular signaling cascades which elicit rapid effects such as release of internal calcium stores and activation of kinases. We have learned much about the translocation and signaling of steroid hormone receptors from investigations into estrogen receptor α, which can be trafficked to, and signal from, the cell membrane. It is now clear that progesterone (P4) can also elicit effects that cannot be exclusively explained by transcriptional changes. Similar to E2 and its receptors, P4 can initiate signaling at the cell membrane, both through progesterone receptor and via a host of newly discovered membrane receptors (e.g., membrane progesterone receptors, progesterone receptor membrane components). This review discusses the parallels between neurotransmitter-like E2 action and the more recently investigated non-classical P4 signaling, in the context of reproductive behaviors in the rodent.

Actions of Steroids: New Neurotransmitters.

Over the past two decades, the classical understanding of steroid action has been updated to include rapid, membrane-initiated, neurotransmitter-like functions. While steroids were known to function on very short time spans to induce physiological and behavioral changes, the mechanisms by which these changes occur are now becoming more clear. In avian systems, rapid estradiol effects can be mediated via local alterations in aromatase activity, which precisely regulates the temporal and spatial availability of estrogens. Acute regulation of brain-derived estrogens has been shown to rapidly affect sensorimotor function and sexual motivation in birds. In rodents, estrogens and progesterone are critical for reproduction, including preovulatory events and female sexual receptivity. Membrane progesterone receptor as well as classical progesterone receptor trafficked to the membrane mediate reproductive-related hypothalamic physiology, via second messenger systems with dopamine-induced cell signals. In addition to these relatively rapid actions, estrogen membrane-initiated signaling elicits changes in morphology. In the arcuate nucleus of the hypothalamus, these changes are needed for lordosis behavior. Recent evidence also demonstrates that membrane glucocorticoid receptor is present in numerous cell types and species, including mammals. Further, membrane glucocorticoid receptor influences glucocorticoid receptor translocation to the nucleus effecting transcriptional activity. The studies presented here underscore the evidence that steroids behave like neurotransmitters to regulate CNS functions. In the future, we hope to fully characterize steroid receptor-specific functions in the brain.

The agonistic adrenal: melatonin elicits female aggression via regulation of adrenal androgens.

Classic findings have demonstrated an important role for sex steroids as regulators of aggression, but this relationship is lacking within some environmental contexts. In mammals and birds, the adrenal androgen dehydroepiandrosterone (DHEA), a non-gonadal precursor of biologically active steroids, has been linked to aggression. Although females, like males, use aggression when competing for limited resources, the mechanisms underlying female aggression remain understudied. Here, we propose a previously undescribed endocrine mechanism regulating female aggression via direct action of the pineal hormone melatonin on adrenal androgens. We examined this in a solitary hamster species, Phodopus sungorus, in which both sexes are highly territorial across the seasons, and display increased aggression concomitant with decreased serum levels of sex steroids in short 'winter-like' days. Short- but not long-day females had increased adrenal DHEA responsiveness co-occurring with morphological changes in the adrenal gland. Further, serum DHEA and total adrenal DHEA content were elevated in short days. Lastly, melatonin increased DHEA and aggression and stimulated DHEA release from cultured adrenals. Collectively, these findings demonstrate that DHEA is a key peripheral regulator of aggression and that melatonin coordinates a 'seasonal switch' from gonadal to adrenal regulation of aggression by direct action on the adrenal glands.

Castration-induced upregulation of muscle ERα supports estrogen sensitivity of motoneuron dendrites in a sexually dimorphic neuromuscular system.

The spinal cord of rats contains the sexually dimorphic motoneurons of the spinal nucleus of the bulbocavernosus (SNB). In males, SNB dendrites fail to grow after castration, but androgen or estrogen treatment supports dendritic growth in castrated males. Estrogenic support of SNB dendrite growth is mediated by estrogen receptors (ER) in the target muscle. ERα expression in cells lacking a basal lamina (referred to as "extra-muscle fiber cells") of the SNB target musculature coincides with the period of estrogen-dependent SNB dendrite growth. In the SNB target muscle, extra-muscle fiber ERα expression declines with age and is typically absent after postnatal (P) day 21 (P21). Given that estradiol downregulates ERα in skeletal muscle, we tested the hypothesis that depleting gonadal hormones would prevent the postnatal decline in ERα expression in the SNB target musculature. We castrated male rats at P7 and assessed ERα immunolabeling at P21; ERα expression was significantly greater in castrated males compared with normal animals. Because ERα expression in SNB target muscles mediates estrogen-dependent SNB dendrogenesis, we further hypothesized that the castration-induced increase in muscle ERα would heighten the estrogen sensitivity of SNB dendrites. Male rats were castrated at P7 and treated with estradiol from P21 to P28; estradiol treatment in castrates resulted in dendritic hypertrophy in SNB motoneurons compared with normal males. We conclude that early castration results in an increase in ERα expression in the SNB target muscle, and this upregulation of ERα supports estrogen sensitivity of SNB dendrites, allowing for hypermasculinization of SNB dendritic arbors.

Infections in intestinal and multivisceral transplant recipients.

Intestinal and multivisceral transplantation has become an effective treatment option for patients with intestinal failure. More potent immunosuppressive therapy has resulted in a decreased incidence of acute rejection and has improved patient survival. However, infectious complications can cause significant morbidity both before and after transplantation. In comparison with other solid organ transplant recipients, these patients experience higher rates of acute allograft rejection, thus requiring higher levels of immunosuppression and escalating the risk of infection. This article reviews the most common infectious disease complications encountered, and proposes a potential temporal association for types of infections in this patient population.

Critical period for estrogen-dependent motoneuron dendrite growth is coincident with ERα expression in target musculature.

The spinal cord of rats contains the sexually dimorphic, steroid-sensitive motoneurons of the spinal nucleus of the bulbocavernosus (SNB). In males, SNB dendrite growth is dependent on gonadal steroids: dendrite growth is inhibited after castration, but supported in androgen- or estrogen-treated castrated males. Furthermore, estrogenic support of SNB dendrite growth is mediated by estrogen action at the target musculature, inhibited by estrogen receptor (ER) blockade at the muscle and supported by local estradiol treatment. However, this estrogenic support is restricted to the early postnatal period, after which the morphology of SNB dendrites is insensitive to estrogens. To test if the developmentally restricted effects of estrogens on SNB dendrite growth coincide with the transient expression of ER in the target musculature, ERα expression was assessed during development and in adulthood. ERα expression in extra-Muscle fiber cells was greatest from postnatal day 7 (P7) to P14 and declined after P21. Because this pattern of ERα expression coincided with the period of estrogen-dependent dendrite growth, we tested if limiting hormone exposure to the period of maximal ERα expression in extra-muscle fiber cells could fully support estrogen-dependent SNB dendrite growth. We restricted estradiol treatment in castrated males from P7 to P21 and assessed SNB dendritic morphology at P28. Treating castrates with estradiol implants at the muscle from P7 to P21 supported dendrite growth to normal levels through P28. These data suggest that the transient ERα expression in target muscle could potentially define the critical period for estrogen-dependent dendrite growth in SNB motoneurons.

Three-dimensional imaging provides valuable clinical data to aid in unilateral tissue expander-implant breast reconstruction.

The current approach to breast reconstruction remains largely subjective and is based on physical examination and visual-estimates of breast size. Thus, the overall success of breast reconstruction is limited by the inability of plastic surgeons to objectively assess breast volume and shape, which may result in suboptimal outcomes. A potential solution to this obstacle may be three-dimensional (3D) imaging, which can provide unique clinical data that was previously unattainable to plastic surgeons. The following study represents a prospective analysis of patient volunteers undergoing unilateral tissue expander (TE)-implant reconstruction by one of the two senior authors (MC, NSK). All patients underwent unilateral mastectomy with immediate or delayed insertion of a TE, followed by an exchange for a permanent silicone or saline implant. 3D scans were obtained during routine pre- and postoperative office visits. The 3D breast-volume calculations served as a guide for surgical management. Twelve patients have completed 3D-assisted unilateral breast reconstruction to date. These patients represent a wide range of body habitus and breast size/shape; 3D volume range from 136 to 518 cm(3). The mean baseline breast asymmetry in this group was 12.0 +/- 10.8%. Contralateral symmetry procedures were performed in eleven patients, consisting of the following: mastopexy (n = 6), augmentation (n = 1), mastopexy/augmentation (n = 2), and reduction mammoplasty (n = 2). Reconstruction was completed in a total number of 2 (n = 10) or 3 (n = 2) operations. Overall breast symmetry improved at the completion of reconstruction in the majority of patients, with an average postoperative symmetry of 95.1 +/- 4.4% (relative to 88% preoperatively). 3D imaging serves a valuable adjunct to TE-implant breast reconstruction. This technology provides volumetric data that can help guide breast reconstruction, such as in choosing the initial TE size, total volume of expansion, and final implant size/shape. 3D imaging technology also provides benefit as a method for assessing tissue expansion, the need for symmetry or revision procedures, and critically analyzing the final reconstructive outcome.

An innovative three-dimensional approach to defining the anatomical changes occurring after short scar-medial pedicle reduction mammaplasty.

BACKGROUND: Three-dimensional photography of the breast offers new opportunities to advance the fields of aesthetic and reconstructive breast surgery. The following study investigates the use of three-dimensional imaging to assess changes in breast surface anatomy, volume, tissue distribution, and projection following medial pedicle reduction mammaplasty. METHODS: Preoperative and postoperative three-dimensional scans were obtained from patients undergoing short-scar medial pedicle breast reduction. Three-dimensional models were analyzed by topographical color maps, changes in the lowest point of the breast, surface measurements, and the point of maximal projection. Total breast volume and percentage volumetric tissue distribution in the upper and lower poles were also determined. RESULTS: Thirty patients underwent reduction mammaplasty (mean postoperative scan, 80 +/- 5 days). Color maps highlighted the majority of spatial changes in the central, upper poles. Reduction mammaplasty resulted in a significant decrease in the anteroposterior projection of the breast (6.3 +/- 0.2 postoperatively compared with 8.1 +/- 0.2 cm preoperatively; p < 0.01). The point of maximal breast projection was elevated in the cranial-caudal direction (4.8 +/- 0.4 cm; p < 0.01), with a corresponding elevation in the lowest point of the breast (4.8 +/- 0.5 cm; p < 0.01). Volumetric three-dimensional measurements identified a significant change in percentage tissue distribution after reduction mammaplasty (45 +/- 2 percent above the inframammary fold preoperatively versus 76 +/- 2 percent postoperatively; p < 0.01). CONCLUSIONS: This study is the first to demonstrate the technical feasibility and clinical utility of three-dimensional geometric data in medial pedicle breast reduction surgery. This novel approach suggests new opportunities to define long-term operative changes following various breast procedures.

Virtual 3-dimensional modeling as a valuable adjunct to aesthetic and reconstructive breast surgery.

Three-dimensional (3D) imaging technology currently is used by various commercial industries as a method for analyzing objects and shapes. Recent work from our group and others offer data to support the use of 3D imaging as a valuable tool in aesthetic and reconstructive breast surgery. We have developed a system for creating 3D breast models that provides clinical data that can help guide surgical management. With 3D breast models, surgeons are able to visually assess the size, shape, contour, and symmetry of the breast, as well as obtain quantitative breast measurements and volumetric calculations. Three-dimensional imaging may be applied to various plastic surgery procedures including breast reconstruction with implant/tissue expanders, local flap reconstruction, free-flap reconstruction, breast augmentation, and breast reduction surgery. The novel application of 3D imaging in these settings represents a significant advance from traditional approaches to aesthetic and reconstructive breast surgery in which surgical procedures are based on 2-dimensional photographs and visual size estimates.