Recurring Sacral Stress Fractures in the Male Distance Runner

Reccurring Sacral Stress Fractures in the Male Distance Runner Waugh TJ, Stoller GL, Brooks EK, Dailey SW: Miami University Oxford, Ohio Background: A twenty year old male collegiate distance runner (170 cm and 62 kg) complained of low back pain in March 2015. The patient reported right sided low back tightness that felt like a bad spasm traveling from the lower back down into the lower leg. History of this runner revealed a non-displaced stress fracture in the left sacral ala with a stress reaction on the right sacral ala in November 2013. In April 2014, the distance runner possessed yet another sacral stress fracture. In March 2015, an assessment was made that the patient presented an acute case of piriformis syndrome due to lack of athletic participation. As two weeks went by with no positive results through rehabilitation, worsening pain, and given the pre-existing conditions of the patient, the Team Physician ordered an MRI. Differential Diagnosis: It is possible that the runner could have had an acute disc herniation, muscle strain, degenerative disc disease, or spondylolisthesis. A vertebral compression fracture, sacroiliac joint dysfunction, lumbar facet arthropathy, and sciatica are all differential diagnoses that the clinicians in this case needed to be aware of. It is also important to assess the possibilities of a lumbosacral strain and a sacroiliac joint sprain. Treatment: The MRI report revealed a high grade stress reaction in the right sacral ala. A non-displaced stress fracture in the right superior portion of the left sacral ala was also discovered. The patient was told to rest without any exercise for four to six weeks. After the stress fracture was resolved, the athlete has been encouraged not to participate in any repeated load-bearing types of activities until the source of the problem has been identified. Uniqueness: There is an uncommon nature of sacral stress fractures in males. It is important to realize that individuals who are constantly participating in repeating load-bearing activities are more prone to sacral stress fractures. Sacral stress fractures normally present themselves in women who have the female athlete triad. Research has shown that the influence of energy balance and hormonal fluctuations are significant factors associated with injuries in amenorrheic female athletes. The testosterone levels in young men normally lead to healthy and strong bones. This case report is a prime example that has the potential to teach clinicians all over to always look at the big picture and keep in mind all of the possible differential diagnoses. Conclusions: Physician's have hypothesized that the calcium level in this patient is too high which is causing parathyroid levels to decrease, resulting in low bone density. Since calcium and the parathyroid hormone have an inverse relationship, moderation between the two is essential. However, if one is too high, the other is too low decreasing bone density. Another hypothesis is that low testosterone levels in the patient are causing low bone density. This rare case is far from over as there is numerous investigative work to still be done. Clinical Application: Correctly diagnosing a sacral stress fracture is very difficult due to the wide range of differential diagnoses that its symptoms can present. Clinicians should never rule out the possibility of a sacral stress fracture when clients present low back pain, diffuse buttocks pain, and a history of repetitive loading actively. Although the clinicians in this case did not originally think this injury was another sacral stress fracture, they never ruled out the possibility due to the patient's described pain and pre-existing conditions. The clinicians in this report considered all possible diagnoses before making an assessment. Further research still needs to be performed in order to provide the most effective treatment and outcomes for future patients. Word Count: 59

Nuclear Magnetic Resonance and Hyperfine Structure

Contains reports on four research projects

Estimation of proteinuria as a predictor of complications of pre-eclampsia: a systematic review

Background Proteinuria is one of the essential criteria for the clinical diagnosis of pre-eclampsia. Increasing levels of proteinuria is considered to be associated with adverse maternal and fetal outcomes. We aim to determine the accuracy with which the amount of proteinuria predicts maternal and fetal complications in women with pre-eclampsia by systematic quantitative review of test accuracy studies. Methods We conducted electronic searches in MEDLINE (1951 to 2007), EMBASE (1980 to 2007), the Cochrane Library (2007) and the MEDION database to identify relevant articles and hand-search of selected specialist journals and reference lists of articles. There were no language restrictions for any of these searches. Two reviewers independently selected those articles in which the accuracy of proteinuria estimate was evaluated to predict maternal and fetal complications of pre-eclampsia. Data were extracted on study characteristics, quality and accuracy to construct 2 × 2 tables with maternal and fetal complications as reference standards. Results Sixteen primary articles with a total of 6749 women met the selection criteria with levels of proteinuria estimated by urine dipstick, 24-hour urine proteinuria or urine protein:creatinine ratio as a predictor of complications of pre-eclampsia. All 10 studies predicting maternal outcomes showed that proteinuria is a poor predictor of maternal complications in women with pre-eclampsia. Seventeen studies used laboratory analysis and eight studies bedside analysis to assess the accuracy of proteinuria in predicting fetal and neonatal complications. Summary likelihood ratios of positive and negative tests for the threshold level of 5 g/24 h were 2.0 (95% CI 1.5, 2.7) and 0.53 (95% CI 0.27, 1) for stillbirths, 1.5 (95% CI 0.94, 2.4) and 0.73 (95% CI 0.39, 1.4) for neonatal deaths and 1.5 (95% 1, 2) and 0.78 (95% 0.64, 0.95) for Neonatal Intensive Care Unit admission. Conclusion Measure of proteinuria is a poor predictor of either maternal or fetal complications in women with pre-eclampsia

Nuclear Magnetic Resonance and Hyperfine Structure

Contains research objectives and reports on six research objectives

Nuclear Magnetic Resonance and Hyperfine Structure

Contains research objectives and reports onAlfred P. Sloan Foundatio

Instability of black hole formation under small pressure perturbations

We investigate here the spectrum of gravitational collapse endstates when arbitrarily small perfect fluid pressures are introduced in the classic black hole formation scenario as described by Oppenheimer, Snyder and Datt (OSD) [1]. This extends a previous result on tangential pressures [2] to the more physically realistic scenario of perfect fluid collapse. The existence of classes of pressure perturbations is shown explicitly, which has the property that injecting any smallest pressure changes the final fate of the dynamical collapse from a black hole to a naked singularity. It is therefore seen that any smallest neighborhood of the OSD model, in the space of initial data, contains collapse evolutions that go to a naked singularity outcome. This gives an intriguing insight on the nature of naked singularity formation in gravitational collapse.Comment: 7 pages, 1 figure, several modifications to match published version on GR