Return to Play and Performance After Anterior Cruciate Ligament Reconstruction in Soccer Players: A Systematic Review of Recent Evidence.

BACKGROUND: The available literature referring to the return to play (RTP) and performance after anterior cruciate ligament reconstruction (ACLR) has already been comprehensively summarized in team sports such as basketball or American Football. Therefore, in this sense, it is necessary to synthesize evidence relating to the mentioned parameters in soccer players who underwent ACLR. OBJECTIVE: The aim of this systematic review was to examine RTP and the performance of soccer players after ACLR. METHODS: Three electronic databases, Web of Science, Scopus, and PubMed, have been comprehensively searched to identify relevant articles. The following inclusion criteria were applied: (1) the sample of respondents consisted of soccer players irrespective of their age, sex, or level of competition; (2) athletes experienced anterior cruciate ligament injury and underwent ACLR; (3) outcomes estimated referred to the RTP, RTP at the preinjury level of competition, RTP time, performance, and career duration of soccer players; (4) studies were written in the English language. The methodological quality of the research was evaluated using the Methodological Index for Non-Randomized Studies (MINORS). RESULTS: Databases searched yielded a total of 694 studies, of which 17 fulfilled the eligibility criteria and were included in the final analysis. These included 3657 soccer players, 2845 males and 812 females, who underwent ACLR and most commonly competed at the elite, national, amateur, and recreational levels. The results obtained indicated that 72% of soccer players successfully RTP and 53% RTP at the preinjury level of participation after ACLR. In addition, recent evidence provided in this literature review demonstrated that mean RTP time was 264 days or 8.7 months. Moreover, the majority of the studies unambiguously suggested that performance related to statistical aspects noticeably deteriorated compared with both the preinjury period and noninjured athletes. The mean career length of soccer players following ACL surgery was approximately between 4 and 5 years. CONCLUSION: Although a high percentage of athletes RTP after a relatively short period of absence from the sports field compared with other sports closely related to soccer, ACLR negatively impacts soccer players' performance and career duration.

The influence of body mass index on physical activity engagement following anterior cruciate ligament reconstruction: A systematic literature review.

Background: The objective of this study was to summarize available literature that explored the impact of body mass index (BMI) on physical activity participation among individuals who were subjected to the anterior cruciate ligament reconstruction (ACLR). Methods: A total of three electronic databases, including Web of Science, Scopus, and PubMed, were comprehensively searched to identify relevant investigations. The following inclusion criteria were applied: (1) study design was observational; (2) participants underwent the ACLR; (3) BMI was estimated as a predictor variable; and (4) outcomes evaluated referred to physical activity. The risk of bias was assessed with the National Institutes of Health Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results: After a database search, 787 studies were found, and only 10 of them met each of the eligibility criteria and were included in the qualitative analysis. Regarding respondents' characteristics, 7171 individuals underwent ACLR, 4080 males and 3091 females, with a mean age of 25.5 years. Most importantly, the average BMI of the examined population was 24.9 kg/m2. In all studies, physical activity was evaluated subjectively using the Tegner activity scale and the Marx activity scale. The main findings unambiguously demonstrated that a negative relationship between BMI and physical activity engagement was observed. More specifically, there is convincing evidence that BMI over 25 kg/m2 harmfully affected subjectively assessed physical activity in individuals with a history of ACLR. Conclusion: The results obtained in the presented research indicated that increased values of BMI were a factor that correlated with reduced physical activity levels in the ACLR population. Hence, taking into account the clinical and health implications of reduced physical activity participation, stimulation of a healthy lifestyle, such as a combination of adequately designed physical exercise and nutrition, seems necessary for the analyzed population.

Validity and reliability of short-term heart-rate variability from disposable electrocardiography leads.

Background and Aims: Single-use electrocardiography (ECG) leads have been developed to reduce healthcare-associated infection. This study compared the validity and reliability of short-term heart rate variability (HRV) obtained from single-use disposable ECG leads. Methods: Thirty healthy subjects (33 ± 10 years; 9 females) underwent 5-min resting HRV assessments using disposable (single use) ECG cable and wire system (Kendall DL™ Cardinal Health) and a standard, reusable ECG leads (CardioExpress, Spacelabs Healthcare). Results: Intraclass correlation coefficient (ICC) with 95% confidence interval (CI) between disposable and reusable ECG leads was for the time domain [R-R interval (ms); 0.99 (0.91, 1.00)], the root mean square of successive normal R-R interval differences (RMSSD) (ms); 0.91 (0.76, 0.96), the SD of normal-to-normal R-R intervals (SDNN) (ms); 0.91 (0.68, 0.97) and frequency domain [low-frequency (LF) normalized units (nu); 0.90 (0.79, 0.95), high frequency (HF) nu; 0.91 (0.80, 0.96), LF power (ms2); 0.89 (0.62, 0.96), HF power (ms2); 0.90 (0.72, 0.96)] variables. The mean difference and upper and lower limits of agreement between disposable and reusable leads for time- and frequency-domain variables were acceptable. Analysis of repeated measures using disposable leads demonstrated excellent reproducibility (ICC 95% CI) for R-R interval (ms); 0.93 (0.85, 0.97), RMSSD (ms); 0.93 (0.85, 0.97), SDNN (ms); 0.88 (0.75, 0.95), LF power (ms2); 0.87 (0.72, 0.94), and HF power (ms2); 0.88 (0.73, 0.94) with coefficient of variation ranging from 2.2% to 5% (p > 0.37 for all variables). Conclusion: Single-use Kendall DL™ ECG leads demonstrate a valid and reproducible tool for the assessment of HRV.

Advanced 3-Dimensional Characterization of Hill-Sachs Lesions in 100 Anterior Shoulder Instability Patients.

PURPOSE: We sought to qualitatively and quantitatively describe characteristics of Hill-Sachs lesions (HSL) in a cohort of anterior shoulder instability patients using advanced 3-dimensional (3-D) modeling software and assess the impact of various HSL parameters on the HSL volume, location, and orientation in patients with anterior shoulder instability. METHODS: A total of 100 recurrent anterior instability patients with evidence of HSL with a mean age of 27.2 years (range = 18 to 43 years) were evaluated. Three-dimensional models of unilateral proximal humeri were reconstructed from CT scans, and the volume, surface area (SA), width, and depth of identified HSLs were quantified along with their location (medial, superior, and inferior extent). Multiple angular orientation measures of HSLs were recorded, including Hill-Sachs rim (HSLr) angle in order to classify the level and location of potential humeral head engagement. Mann-Whitney U test assessed the relationship between measured parameters. RESULTS: By volume, larger HSL had greater humeral head surface area (HH SA) loss (P = .001), HSL width (P = .001), were more medial (P = .015), and more inferior (P = .001). Additionally, more medial lesions had greater HSLr angles (P = 0.001). The mean depth, width, and volume of HSLs were 3.3 mm (range = 1.2-7.1 mm), 16.0 mm (range = 6.2-30.4 mm) and 449.2 mm3 (range = 62.0-1365.6 mm3), respectively. The medial border of the HSL extended to 17.2 ± 4.4 (range = 9.3-28.3 mm) off the most medial edge of the HH cartilage margin (medialization). The mean HSLr was 29.3 ± 10.5°. CONCLUSION: There was a statistically significant association between HSL medialization and HSL volume, position, and orientation. More medialized HSL have larger volume, greater width, more SA loss and higher lesion angles and are more inferior in the humeral head. As it has been established that more medialized lesions have poorer clinical outcomes, this study highlights that HS lesions have varying angles and medialization, which may portend eventual treatment and outcomes. LEVEL OF EVIDENCE: IV, case series.

Reproducibility of Inert Gas Rebreathing Method to Estimate Cardiac Output at Rest and During Cardiopulmonary Exercise Stress Testing.

The present study evaluated reproducibility of the inert gas rebreathing method to estimate cardiac output at rest and during cardiopulmonary exercise testing. Thirteen healthy subjects (10 males, 3 females, ages 23-32 years) performed maximal graded cardiopulmonary exercise stress test using a cycle ergometer on 2 occasions (Test 1 and Test 2). Participants cycled at 30-watts/3-min increments until peak exercise. Hemodynamic variables were assessed at rest and during different exercise intensities (i. e., 60, 120, 150, 180 watts) using an inert gas rebreathing technique. Cardiac output and stroke volume were not significantly different between the 2 tests at rest 7.4 (1.6) vs. 7.1 (1.2) liters min-1, p=0.54; 114 (28) vs. 108 (15) ml beat-1, p=0.63) and all stages of exercise. There was a significant positive relationship between Test 1 and Test 2 cardiac outputs when data obtained at rest and during exercise were combined (r=0.95, p<0.01 with coefficient of variation of 6.0%), at rest (r=0.90, p<0.01 with coefficient of variation of 5.1%), and during exercise (r=0.89, p<0.01 with coefficient of variation 3.3%). The mean difference and upper and lower limits of agreement between repeated measures of cardiac output at rest and peak exercise were 0.4 (-1.1 to 1.8) liter min-1 and 0.5 (-2.3 to 3.3) liter min-1, respectively. The inert gas rebreathing method demonstrates an acceptable level of test-retest reproducibility for estimating cardiac output at rest and during cardiopulmonary exercise testing at higher metabolic demands.

Serbian consensus of neoadjuvant therapy for breast cancer: NeoPULSE.

Even though surgery is the primary treatment of operable breast cancer, it has been known for decades that the administration of postoperative adjuvant or preoperative neoadjuvant therapy is extremely important. Indications for neodjuvant therapy administration have been expanded over the years, and nowadays this kind of treatment represents an inevitable option in early breast cancer treatment. The NeoPULSE project, which gathered a group of experts in the field of breast cancer from five Serbian university centres, was formed with the aim to define optimal breast cancer diagnosis, indications for neoadjuvant therapy, therapeutic combinations in relation to molecular/biological parameters of breast cancer, as well as the treatment after neoadjuvant therapy. During two separate expert meetings involving surgeons, medical oncologists, radiation oncologists, a pathologist, and a "Blueprint" workshop, the project participants answered questions over the indications for neoadjuvant therapy. The first part covered local practice and referred to the existence and work of a multidisciplinary team, as well as commonly applied therapeutic regimens in the neoadjuvant setting. Experts analysed personal views regarding indications for the administration and benefits of neoadjuvant therapy, their perception on the correlation between achieving a pathological complete response (pCR) and the outcome of treatment, as well as the attitude towards controversies about this type of treatment, primarily regarding a possible change in the receptor status after therapy and therapeutic options after a suboptimal response. The analysis of the answers pointed to problems and deviations from recommendations in everyday clinical practice, based on which appropriate solutions were proposed. The establishment of such a panel and consensus is an attempt to modernize multidisciplinary teams in Serbia, achieve reaching uniform decisions of all subjects dealing with breast cancer, and therefore, at least in one segment, improve breast cancer treatment in Serbia.

An innovative method for precise lymph node detection before surgical treatment in breast cancer.

OBJECTIVE: To describe a new method of 3D interactive modeling which integrates images obtained by separate SPET and multi slice computed tomography (MSCT) modalities using an original software in order to better localize SNL in BC patients. SUBJECTS AND METHODS: We used technetium-99m-colloid rhenium sulphate for identifying SNL in seven patients with BC. Markers were made of lead pearls wrapped with cotton wool soaked in 99mTc-pertechnetate and placed on the skin of the patients forming of a triangle. Using an original software, two separate 3D models were made after SPET and MSCT imaging and then merged into a hybrid 3D model which enabled precise visualization and localization of the SNL. RESULTS: In all cases the position of the SNL established by our method was successfully verified using a gamma probe. Duration of SNL identification and extirpation were significantly reduced in less than 10 minutes per patient. The reproducibility of this method was confirmed by precise identification and biopsy of the SNL. CONCLUSION: We found this integrated SPET/MSCT 3D model to be much faster and easier to use as compared with the "classic" method, which was based on a radioactivity detection probe. In addition, our method was reproducible, accurate and of low cost. In other words, the method described in this paper could be very useful for health facilities with modest budget, because it obviates the need for buying expensive integrated SPET/MSCT hybrid imaging systems while detecting SNLs more accurately and in shorter time.

Prevalence and risk factors for prolonged QT interval and QT dispersion in patients with type 2 diabetes.

AIMS: Prolonged QT interval is associated with cardiac arrhythmias and sudden death. The present study determined the prevalence of prolonged QT interval and QT dispersion and defined their clinical and metabolic predictors in patients with type 2 diabetes. METHODS: Cross-sectional study included 501 patients with type 2 diabetes. A standard 12-lead electrocardiogram was recorded. QT corrected for heart rate (QTc) >440 ms and QT dispersion (QTd) >80 ms were considered abnormally prolonged. QTc ≥ 500 ms was considered a high-risk QTc prolongation. Demographic, clinical and laboratory data were collected. Independent risk factors for prolonged QTc and QTd were assessed using logistic regression analysis. RESULTS: Prevalence of QTc > 440 ms and QTd > 80 ms were 44.1 and 3.6 %, respectively. Prevalence of high-risk QTc (≥500 ms) was 2 % only. Independent risk factors for QTc prolongation >440 ms were mean blood glucose (ß = 2.192, p < 0.001), treatment with sulphonylurea (ß = 5.198, p = 0.027), female gender (ß = 8.844, p < 0.001), and coronary heart disease (ß = 8.636, p = 0.001). Independent risk factors for QTc ≥ 500 ms were coronary heart disease (ß = 4.134, p < 0.001) and mean blood glucose level (ß = 1.735, p < 0.001). The independent risk factor for prolonged QTd was only coronary heart disease (ß = 5.354, p < 0.001). CONCLUSIONS: Although the prevalence of prolonged QTc > 440 ms is significant, the prevalence of high-risk QTc (≥500 ms) and QTd > 80 ms is very low in patients with type 2 diabetes. Hyperglycaemia and coronary heart disease are strong predictors of high-risk QTc.

Parameter optimization of a computer-aided diagnosis system for detection of masses on digitized mammograms.

BACKGROUND: Reading mammograms is a difficult task and for this reason any development that may improve the performance in breast cancer screening is of great importance. OBJECTIVE: We proposed optimized computer aided diagnosis (CAD) system, equipped with reliability estimate module, for mass detection on digitized mammograms. METHODS: Proposed CAD system consists of four major steps: preprocessing, segmentation, feature extraction and classification. We propose a simple regression function as a threshold function for extraction of potential masses. By running optimization procedure we estimate parameters of the preprocessing and segmentation steps thus ensuring maximum mass detection sensitivity. In addition to the classification, where we tested seven different classifiers, the CAD system is equipped with reliability estimate module. RESULTS: By performing segmentation 91.3% of masses were correctly segmented with 4.14 false positives per image (FPpi). This result is improved in the classification phase where, among the seven tested classifiers, multilayer perceptron neural network achieved the best result including 77.4% sensitivity and 0.49 FPpi. CONCLUSION: By using the proposed regression function and parameter optimization we were able to improve segmentation results comparing to the literature. In addition, we showed that CAD system has high potential for being equipped with reliability estimate module.

[Comparative analysis of the position of the graft in the femur after anterior cruciate ligament reconstruction done through the front inner portal and through the shin bone].

Anterior cruciate ligament (ACL) is the most common surgically treated knee ligament. If we take into account the fact that incidence of ACL injuries is growing, it is clearly that the interest of orthopedic surgeons for this pathology is also growing. Increasing number of this operations leads to increasing of complications, which requires its analysis. One of the most common failure of ACL reconstruction is a bad position of the graft in the femoral condyle. This study aimed to analyze the positioning of the graft in to the femur by two generally accepted techniques--transtibial technique and technique through the antero-medial portal. The analysis included postoperative radiographs in 60 patients, of whom 30 were operated by transtibial technique and 30 by technique through anteromedial portal. Radiographic analysis involved the measurement of the AP digital imaging, the tunnel projection X ray measurements and measurements of the computed tomography (CT), which was here a control method. The accuracy of measurement was set at 0.5 degrees or 1 min. All radiographs were made in the same way according to the literature. The results showed that the neoligaments were placed lower in the femoral condyle by technique through anteromedial portal than by transtibial technique, and the difference was statistically significant (on tunnel X ray by anteromedial portal screws were average placed at 50.0 degrees and 10:20 am, and by transtibial technique at 37.5 degrees or 10:45 am). Based on the results, it was concluded that the neoligaments were positioned closer to its anatomical position by technique through anteromedial portal.

Subcutaneous fat necrosis in newborns.

Subcutaneous fat necrosis of newborns is a transient, benign process in full- term or postmature neonates. It is associated with perinatal distress. Newborn stress inhibits immature enzyme system, which already has relative inability to desaturate saturated fatty acids. It leads to fat crystillisation and necrosis. Skin biopsy revealed necrotic focus and crystallisation in fat cells. Hypercalcemia may be a potential complication.

Lobular Breast Cancer in a Male Patient with a Previous History of Irradiation Due to Hodgkin's Disease.

BACKGROUND: Male breast cancer is rare and represents less than 1% of all breast cancers. Considering the fact that the male breast most often does not consist of lobules and acini, lobular carcinoma of the male breast is exceptionally rare. CASE REPORT: In this paper we present a unique case of alveolar variant of lobular male breast cancer in a 56-year-old patient. CONCLUSION: According to our knowledge this is the first presentation of an alveolar variant of lobular male breast cancer that appeared 14 years after chemo- and radiotherapy for the treatment of Hodgkin's disease.

[Plantar fibromatosis and Dupuytren's contracture in an adolescent].

BACKGROUND: Fibromatosis represents a wide group of benign, locally proliferative disorders of fibroblasts. Dupuytren's disease is a benign proliferative disease of palmar aponeurosis which usually affects adults between 40 and 60 years of age. Ledderhose's disease or plantar fibromatosis is plantar equivalent of Dupuyten's disease most often affecting middle-aged and older men, usually bilateral, represented with painless nodule in the medial division of plantar fascia. CASE REPORT: We presented a 19-year old adolescent that turned to a plastic surgeon complaining to his small finger contracture. He noticed palmar thickening with nodule over the metacarpophalangeal joint of small finger of his right hand when he was 16 years old. A year later a finger started to band. During physical checkup we noticed plantar nodule that also had his father and grandmother. Magnetic resonance and tumor biopsy confirmed a suspicion on plantar fibromatosis - Ledderhose's disease. Clinical exam of the hand clearly led to a conclusion that the patient had Dupuytren's contracture with pretendinous cord over the small finger flexor tendons and lack of extension of proximal interphalangeal (PIP) joint. On the extensor side of the PIP joints there were Garrod's nodes. The patient refused surgical treatment of plantar tumor, but agreed to surgical correction of finger contracture. CONCLUSION: Despite the fact that Dupuytren's disease and plantar fibromatosis are diseases of adults, the possibility of conjoint appearance of these forms of fibromatosis in adolescent period of life should be kept in mind especially in patients with strong genetic predisposition.

Femoral guide breakage during the anteromedial portal technique used for ACL reconstruction.

Positioning of the femoral tunnel is very important in ACL reconstruction and it is often recommended to use an anteromedial portal technique in order to create the tunnel. This technique is more demanding but it gives a surgeon more freedom to place the ACL graft in an anatomical position compared to the transtibial technique. A case of an intraarticular femoral guide breakage associated with this particular technique is presented. That being said, the aim of this paper is not only to present this rare complication following arthroscopic reconstruction of ACL, but also to indicate how to prevent, diagnose and treat this undesired event.

[Cardiovascular autonomous dysfunction in diabetics: the influence of disease duration, glycoregulation degree and diabetes type].

INTRODUCTION: Cardiovascular autonomous neuropathy (CAN) in diabetes has not been still defined clinically and aetiopathogenetically. OBJECTIVE: The aim of this study was to determine the influence of disease duration, glycoregulation degree and diabetes type on damage of the cardiovascular part of the autonomous nervous system in our group of patients. METHOD: This study included diabetics, (100 patients) the same number of patients with diabetes type I and II as well as 20 healthy individuals in the control group. Classic Ewing's cardiovascular tests were used for CAN diagnosis: (1) the cardiovascular response to Valsalva manoeuvre, (2) the cardiovascular response to deep breathing (the so-called E/I ratio), (3) the cardiovascular response to rising (the so-called 30/15 ratio), (4) the test of orthostatic hypotension and (5) the TA response to handgrip. It has been arbitrarily taken that patients, whose score of "parasympathetic" tests (Valsalva manoeuvre, E/I ratio, 30/15) is equal or bigger than 1.5 (out of possible 3), have damage of the parasympathetic part of the autonomous nervous system while patients, whose score of "sympathetic tests" (the test of orthostatic hypotension and TA response to hand-grip is equal or bigger than 1 (out of possible 2), have damage of the sympathetic part of the autonomous nervous system. The patients whose total score is equal or bigger than 2 have cardiovascular autonomous neuropathy. The glycoregulation degree is determined by the level of HbA1c. RESULTS: There is a statistically significant, positive correlation between the values of the parasympathetic score and disease duration as well as between the total score, that is, CAN and disease duration. The connection between the sympathetic score, that is, damage of the sympathetic part of the autonomous nervous system and disease duration has not been observed. There is a positive correlation between the values of the parasympathetic score and HbA1c. The same pattern exists regarding the ratio of damage of the sympathetic part of the autonomous nervous system and the value of HbAlc, as well as the ratio of CAN, that is, the total score and HbA1c. Almost twofold, a bigger coefficient of correlation between the sympathetic score and HbA1c in relation to the coefficient of correlation of the parasympathetic score and HbA1c, points to bigger sensitivity of the sympathetic part of the autonomous nervous system to subacute deterioration of glycoregulation. The correlation between the values of autonomous scores and diabetes type has not been noted. CONCLUSION: Our results show that besides disease duration, the subacute deterioration of glycoregulation also leads to the appearance of cardiovascular autonomous dysfunction in diabetes. The sympathetic nervous tissue is functionally more sensitive than the parasympathetic one to metabolic disorders in diabetes. The cardiovascular autonomous dysfunction will occur independently of the type of diabetes.