12 TH INTERNATIONAL SYMPOSIUM, LJUBLJANA, JANUARY 11, 2025

PEER REVIEWED PROCEEDINGS PART I

EDITED BY:

VERONIKA KRALJ-IGLIČ

ANNA ROMOLO AND

YELENA ISTILEULOVA



FACULTY OF HEALTH SCIENCES, UNIVERSITY OF LJUBLJANA





Z-STEAM





12 th International Symposium, Ljubljana, January 11, 2025



Peer Reviewed Proceedings, Part I



Edited by Veronika Kralj-Iglič,Yelena Istileulova and Anna Romolo

Reviewers: Veronika Kralj-Iglič, Boštjan Kocjančič, Vladimira Erjavec, Yelena Istileulova

Published by: University of Ljubljana Press

For the publisher: Gregor Majdič, the Rector

Issued by: University of Ljubljana, Faculty of Health Sciences

For the issuer: Martina Oder, the Dean

Design: Anna Romolo

Gallery Marguerite de Saint Champs: photos from Roberta Ferranti

Image on the front page: Roberta Ferranti

First digital edition.

Publication is available online in PDF format at:

https://www.zf.uni- lj.si/images/stories/datoteke/Zalozba/Sokratska_12_I.pdf

http://ebooks.uni-lj.si



DOI: 10.55295/PSL.12.2025.I

Publication is free of

charge. Ljubljana, 2025



This work is available under a Creative Commons Attribution 4.0 International





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Kataložni zapis o publikaciji (CIP) pripravili v

Narodni in univerzitetni knjižnici v Ljubljani

COBISS.SI-ID 227883267

ISBN 978-961-297-541-8 (PDF)





I Kralj, Raja Dahmane Gošnak, Antonio Di Loria, Simon Dvoršak, Vladimira Erjavec , Tjaša Griessler Bulc, Aleš Iglič, Yelena Istileulova, Asja Jakopič, Andreja Jelen, Samo Kralj, Veronika Kralj Iglič, Urška Lavrenčič Štangar, Maneea Mabrouk, Egon Mihajlović, Alenka Nemec Svete, Gabriella Pocsfalvi, Anita Prelovšek, Anna Romolo, Irma Schabussova, Metka Šimundić, Blaž Švajger, Gregor Torkar, Polonca Trebše, Kaja Troha, Seppo Vainio, Renata Vauhnik, Verena Vidrih Perko.




Program of the Symposium Socratic Lectures, January 11, 2025, 10:00 – 17:00 (Ljubljana time)



10.00 Welcome to participants (Veronika Kralj-Iglič, University of Ljubljana)



10.05 - 10.45 Plenary lecture: Saara Laitinen: Extracellular vesicles from blood cells and in blood.

The avenue of future therapies

10.45 Break

11.00 Scientific sections

Section 1: Medicine (Chairs: A. Nemec Svete, K. Troha)

11.00 - 11.20 G. Omejec: Ultrasonographic assessment of diaphragm function 11.20 - 11.40 A. Troha: Advancements and future prospectives of platelet-rich products and extracellular

vesicles in otology

11.40 - 12.00 A. Čuček: Mammary gland - anatomy, histology, pathology, and physiotherapist management post

surgery

12.00 - 12.20 K. Pahovnik: A case of autosomal dominant osteopetrosis with a novel mutation in CLCN7 12.20 - 12.40 L. Dolinar: Destigmatization of erectile dysfunction 12.40 - 13.00 D. Dolinar, I. Potparič: Premature fracture of a modular femoral neck after total hip arthroplasty

Section 2 : Veterinary Medicine (Chairs: V. Erjavec, M. Šimundić)

11.00 - 11.20 L. Jarnovič: Brachicephaly in cats. A silent problem in feline health 11.20 - 11.40 B. Perc: Hematology-derived inflammatory markers in dogs with BOAC 11.40 - 12.00 I. Premrl: Foreign body removal from the canine digestive tract: findings and outcomes 12.00 - 12.20 M. Šimundić: Approach to the patient with polyuria/polydipsia 12.20 - 12.40 B. Dučić: Retained tooth roots in cats

12.40 - 13.00 M. Arko: Extracellular vesicles in bovine colostrum and milk



Section 3: Physiotherapy (Chairs: R. Vauhnik, A. Jakopič)

11.00 - 11.20 Bec: Effects of transcutaneous electrical nerve stimulation in patients with fibromyalgia syndrome 11.20 - 11.40 K. Breznik: Pain relief treatment of fresh sacral fracture for a professional snowboarder one month

before participation in the Winter Olympic Games: a case report 11.40 - 12.00 A. Jakopič: Effects of hydrotherapy on functional capacity of patients after stroke 12.00 - 12.20 M. Jelen: The effects of passive loading of the knee joint after anterior cruciate ligament reconstruction

on knee stability

12.20 - 12.40 E. Strle, L. Uhan: Surgical treatment of chronic post-traumatic hamstring origin pain with tendon

transfer from the unfused ischial tuberosity apophysis to the ramus of the ischial bone: a case report

12.40 - 13.00 M. Zoroja: Ring shaped lateral meniscus - Raise awareness and avoid unnecessary surgery



Section 4: Green transition (Chairs: T. Griessler Bulc, M. Bavcon Kralj)

11.00 - 11.30 A. Drozd-Rzoska: Physics & Society : High Pressures for innovative pro-health foods (keynote lecture) 11.30 - 11.45 A. Kranjc Požar: Microalgal technologies: Treatment strategy for contaminants of emerging concern 11.45 - 12.00 E. Andreasidou: Uptake of contaminants of emerging concern in tomato plants irrigated with treated

wastewater

12.00 - 12.15 L. Klemenčič: Harvesting of algae biomass by electrocoagulation 12.15 - 12.30 J. Danilović Luković: Impact of ionizing radiation on microalgae: Enhancing biotechnology potential





II




and contact angle



12.45 - 13.00 T. Zrnec Drobnjak: Production of plant biostimulants from microalgae grown on the biogas digestat



Section 5: Nanostructurome pipeline (Chair: P. Trebše, U. Lavrenčič Štangar)

11.00 - 11.10 I. Jerman: Infrared and Raman spectroscopy

11.10 - 11.20 J. Jakše: Next generation sequencing

11.20 - 11.30 J. Hočevar: NMR Spectroscopy

11.30 - 11.40 R. Cerc Korošec: Thermoanalytical techniques

11.40 - 11.50 M. Novinec: Mass photometry for molecular mass determination 11.50 - 12.00 G. Schlosser: LC-MS lipidomics, metabolomics 12.00 - 12.10 E. Heath: LC-MS/MS methods

12.10 - 12.20 P. Hansson: SAXS and investigation of diffusion and transport of drug discovery systems in

extracellular matrix models

12.20 - 12.30 V. Kralj-Iglič: Scanning electron microscopy

12.30 - 12.40 O. Vanderpoorten: Nanospacer: Nanofluidic sizing of biomolecules and EVs 12.40 - 12.50 G. Liguori: in vitro cell assays

12.50 - 13.00 S. Michelini: ELISA assays

12.50 - 13.00 All partners: Discussion on sample preparation and characterization

Section 6: FarmEVs: Different sourced extracellular vesicles and their potential (Chairs: G. Pocsfalvi, A. Di Loria)

11.00 - 11.20 G. Guerriero: Plant extracellular vesicles

11.20 - 11.40 I. Schabussova: Bacterial extracellular vesicles

11.40 - 12.00 S. Vainio: From sustainable soil to lifelong health - speculations from ecological nanointeractomics 12.00 - 12.10 R. Mammadova: Enhancing therapeutic potential: Loading strategies for plant-derived nanovesicles 12.10 - 12.20 Glamoclija: Trichinella spiralis extracellular vesicles alleviate OVA-induced allergic inflammation in

BALB/c mice

12.20 - 12.30 P. Devarkanda: Bean PDNVs isolation and characterization from the dwarf organic Borlotti bean Lingua

di Fuoco

12.30 - 12.40 E. Cepec: Biostimulants from algae biomass uncovered: phytohormones determination and plant

growth stimulation

12.40 - 12.50 B. Korenjak: Interferometric light microscopy of diluted blood in different species

Section 7: Biophysics (Chair: A. Iglič)

11.00 - 11.20 S. Rzoska: Unique properties of high-pressure & high-temperature formed glasses: The application for

new-generation batteries (Keynote lecture)

11.20 - 11.40 T. Beke Somfai: Peptide-based antibiotic supramolecules (Keynote lecture) 11.40 - 12.00 L. Mesarec: Equilibrium membrane shapes influenced by different concentrations of orientationally

ordered curved rod-like membrane protein

12.00 - 12.20 M. Mussel: On spikes and sound: Debating the physical nature of action potentials 12.20 - 12.40 L. Bar: Impact of inclusions on the organization and phase behavior of lipid membrane models 12.40 - 13.00 M. Drab: Monte Carlo studies of vesicle shapes with anisotropic membrane inclusions and volume

constraints

Section 8: Physics (Chair: S. Kralj)

11.00 - 11.30 A. Jelen: Microscopic patterns and complexity (Keynote lecture) 11.30 - 11.45 A.A. Sojecka: Doomsday criticality for the global society 11.45 - 12.00 T. Blazevic: Maximal entropy production

12.00 - 12.15 D. Dovnik: Fractional topological charges

12.15 - 12.30 J. Sgerm, A. Ribas, L.G. Fugina: Universality of physics of phonons 12.30 - 12.45 G. Goričan: Kibble-Zurek mechanism and applications 12.45 - 13.00 M. Župec, M. Kodrin, R. Rojko, M. Štorman: Crystal lattices in nature





III




Section 9: Liquid Crystals (Chairs: A. Jelen, B. Švajger)



11.00 - 11.20 T. Javornik: Importance of the critical point in thermotropic nematic liquid crystals in terms of their



sensitivity

11.20 - 11.40 A. Hoelbl: Localised excitations in liquid crystals as particle analogues 11.40 - 12.00 E. Čokor: Imry-Ma patterns in confined nematic liquid crystals 12.00 - 12.20 M. Potrč: Lyotropic liquid crystalline phases

12.20 - 12.40 B. Švajger: Volume and surface phase transitions in confined nematic liquid crystals 12.40 - 13.00 M. Zid: Mode coupling and memory effects

Section 10: Education (Chair: G. Torkar)

11.00 - 11.20 G. Torkar: Environmental education for behaviour change 11.20 - 11.40 I. Devetak: Pre-service primary school teachers' understanding of biogeochemical cycling 11.40 - 12.00 L. Vinko: Environmental literacy of chemistry teachers 12.00 - 12.20 S. Beslagic: Robotics in high school

12.20 - 12.40 T. Plešnik: Undergraduate physiotherapy student perceptions of teaching and learning activities

associated with clinical education

12.40 - 13.00 Ž. Rode: Pre-service teachers as citizen scientists

Section 11: Bridging Science, Health and Arts I (Chair: Y. Istileulova)

11.00 - 11.20 N. Gomes: Transformative educational strategies with artificial intelligence (Keynote lecture) 11.20 - 11.40 S. De Lasala Porta: Truth, beauty, and ethics in art, science, and health: Interdisciplinary reflections and

philosophical perspectives

11.40 - 12.00 F. Banabed: Exploring health humanities from a global south perspective 12.00 - 12.20 E. Rosakebia: Balancing care and creation: The role of poetry in caregiving and emotional resilience 12.20 - 12.40 F. Dalpane: Making art as bravery: A virtue-ethics perspective 12.40 - 13.00 Y. Istileulova: Planetary health through arts: De rerum natura and Earth´s first music in cosmic harmony



Section 12: Bridging Science, Health and Arts II (Chair: V. Vidrih Perko)

11.00 - 11.20 R.S. Thomas: Combining an art therapy-trauma protocol and sensory motor art therapy to support a

woman with breast cancer

11.20 - 11.40 E. Hribernik: Man on the stage of life - introduction to an Italian baroque opera 11.40 - 12.00 A.L. Mastruzzo: The performer as a multi-expressive artist in Argentina's current flute experimentation 12.00 - 12.20 A. Karboski: Vladimir Stiftar and his views on the formation of the architectural and cultural landscape

of the Eupatoria resort

12.20 - 12.40 N. Paliska: Mozart iconography

12.40 - 13.00 V. Vidrih Perko: Learning - the immortal soul of humanism (Keynote lecture)

13.00 Break

14.00 Plenary lectures

14.00 - 14.30 V. Hlavackova Pospichalova: Extracellular vesicles in ovarian cancer 14.30 - 15.00 N. Gov: Magnets, Ants and Humans. The physics of collective transport by ants 15.00 - 15.30 H. Murto: Organic farming

15.30 - 16.00 E. Mihajlović: Claudio Monteverdi and so called seconda pratica or how he brings real human feelings

into music

16.00 Student zone

17.00 Closing of the symposium





IV




Tentative Program:



Classical music:



C. Franck: Petit offertoire. Organ: Yelena Istileulova

C. Monteverdi/G.F. Busenello: Prologue from opera Coronation of Poppaea. Sopranos: Fortuna: Ronja Prapotnik, Virtu: Eva Kokot, Amore: Brina Vukovič, Harpsichord: E. Mihajlović, Organ positive: Branko Rezić

A. Aljabjev A: Nightingale. Flute: Anita Prelovšek, Piano: Elena Startseva Somun S. Rachmaninov: Vocalise. Violin: Vasilij Meljnikov, Piano: Lara Oprešnik C. Monteverdi/G.F. Busenello: Regina disprezzata from opera Coronation of Poppaea. Soprano: Ottavia: AlessandraTessaro, Harpsichord: E. Mihajlović, Organ positive: Branko Rezić S. Rachmaninov: Etude Tableaux Op 33 No 3. Piano: Lara Oprešnik G. Brun: Romance. Flute: Anita Prelovšek, Piano: Elena Startseva Somun C. Monteverdi/G.F. Busenello: Duetto Demigella and Valetto from opera Coronation of Poppaea. Sopranos: Demigella: Nives Hadžić, Valetto: Eva Kokot, Harpsichord: E. Mihajlović, Organ positive: Branko Rezić W.A. Mozart: Alla turca from Sonate in A major. Piano: Denis Luin F. Chopin: Polonaise G sharp minor. Piano: Matic Bogataj

G. Ipavec/A. Čopi - Simon Gregorčič: Mountain flower: Chorus Studenec Poetry by Ifigenia Simonović

Ifigenija Simonović is writing poetry, essays, book reviews, translating, and painting various objects for more than fifty years. She is the author of ten poetry collections, three books of essays, three books for children, and is also known as a publisher of eight books of poetry by Vitomil Zupan. In 2009, she received the Rožanec award. Between 2017 and 2021, she was the president of the Slovenian PEN Center. Her poetry is often dark, but love persistently shines through the cracks that are drawn on her path by real-time experiences. H. Lavrenčič/Anonymus: The coque has sung: Chorus Studenec E. Adamič/O. Župančič: Evening song: Chorus Studenec Chorus Studenec Pivka, led by Irena Rep, is composed of experienced singers. In its 22 seasons, various genres were performed but the singers prefer to sing arrangements of folk songs. They have around 30 concerts annually, home and abroad, most importantly, the visits to Slovenian societies throughout Europe.

Contemporary music

A. von Sultanova/Titus Lucrecius: De rerum natura. Piano, Voice: Aleona von Sultanova S Kralj: Topology. Piano: Samo Kralj

H. Mancini: Pink Panther. Trombone: Emil Somun, Piano: Elena Startseva Somun A. von Sultanova/A. von Sultanova: For Samuel Gmelin - water, water. Piano, Voice: Aleona von Sultanova J. Rae: Sonatine (Aquarelle, Notturne, Firedance). Flute: Anita Prelovšek, Piano: Elena Startseva Somun A. Schnittke: Suite old style. Violin: Branko Brezavšček, Piano: Elena Startseva Somun L. Oprešnik: Fugue. Piano: Lara Oprešnik

B. Kobal: Dic verbo. Soprano: Kaya Tokuhisa, Organ: Jana Jamšek D. Zupanič Turković: Cantique de Baruch Spinoza from Mass in E minor. Organ: Aleona von Sultanova, Percussion: Bojan Ilievski, Piano: Lara Oprešnik, Flute: Anita Prelovšek, Voice: Veronika Kralj-Iglič

Satellite event: Recital of the organist Roberta Schmid at the Church of Assumption, Tromostovje 14.1.2025 at 20.00.

Program:

D. Buxtehude: Passacaglia in D minor BuxWV 161

J. S. Bach: Choral Das alte Jahr vergangen ist BWV 614

J. S. Bach: Choral Erbarme dich mein Gott BWV 721

A.G. Ritter: Sonate no. 2 in E minor op.19

G. Mushel: Toccata

J. Rheinberger: Passacaglia

L. Vierne: Carillon de Westminster





V




Editorial



12th Socratic Lectures symposium took place online on January 11, 2025. It featured four plenary lectures, 12 scientific sessions, a poster session, a newly introduced session called “The student zone”. The estimated number of the participants was around 300. The symposium opened with an inspiring lecture “Extracellular vesicles from blood cells and in blood. The avenue of future therapies” by Saara Laitinen. The afternoon session was composed of four plenary lectures: “Extracellular vesicles in ovarian cancer” by Vendula Hlavackova Pospichalova, “Magnets, Ants and Humans. The physics of collective transport by ants”, by Nir Gov, “Organic farming” by Henry Murto and “Claudio Monteverdi and so called seconda pratica or how he brings real human feelings into music” by Egon Mihajlović.



Saara Laitinen took a master degree in Plant physiology and a PhD in Biochemistry. She followed her academic career at the University of Helsinki, then at the Institute Pasteur de Lille, France, and at distinguished research institutes in Helsinki. Presently she is a research and development manager at the Finnish Red Cross Blood Service. She is responsible for the laboratory facilities, research, and development within scientific projects. She has been working on extracellular vesicles for many years and is integrated into the International Society for Extracellular Vesicles (ISEV) founded in 2012. Her initial interests were extracellular vesicles from mesenchymal stromal cells, but now she focuses on the immune regulation of blood cells. Saara Laitinen was the president of the Fin Society for Extracellular vesicles and is presently its vice president.

Nir Gov is a physicist, working at Weizmann Institute in Rehovot, Israel. He is developing theoretical models of biological phenomena and related systems. These models consider the laws of statistical physics, non-linear dynamics, and classical theories. Since living systems seem complex, it is the strength of the models to find the most relevant parameters by which the system’s behavior can be predicted and prof. Gov was able to point to the features that show general validity in systems that at first sight seem very different, as for example magnets, ants, and humans.

Vendula Hlavackova Pospichalova took her batchelor degree, master's degree, and PhD at the Charles University in Prague. She was a postdoctoral fellow at the Institute of Molecular Genetics, Prague and a one year visiting researcher at the Duke University, North Carolina, USA. Presently she is a teacher and a researcher at the Masaryk University in Brno. She is a member of the International Society of Extracellular Vesicles and the president of the Czech extracellular vesicles society. Her interests are the role and mechanisms of extracellular vesicles in cancer.

Henri Murto has a professional farming backround of 20 years and he is specialized in organic and biodynamic (regenerative) farming methods. Henri runs the Lehtosarvi farm together with his wife. The main focus of the farm is training, research, and growing medicinal plants. He is active lecturer and writer and is a member of the team of the FarmEVs, a project funded by European Research Executive Agency (REA) within Marie Sklodowska-Curie Actions & Support to Experts, Staff Exchanges action No. 101131175. The leading institution is the National Research Council of Italy, Institute of Biosciences and Bioresources, Napoli, and the principal investigator of the project is the Head of the Extracellular Vesicles and Mass Spectrometry Group dr. Gabriella Pocsfalvi. The Lehtosarvi farm is one of the 8 partner institutions from 6 countries. Based on the research of extracellular vesicles, FarmEVs strives to introduce organic plant-derived extracellular vesicles into sustainable agriculture with the aim of a greener, healthier future for all living things. The symposium featured also latest developments of the FarmEVs project, presented in a special session.

Egon Mihajlović studied harpsichord and early keyboard instruments at the Conservatory of Music and Performing Art in Frankfurt where he also concluded his postgraduate specialization. Since 1990, he has performed as a harpsichordist, a conductor, and an artistic director for baroque opera and sacred baroque music at major concert venues and festivals across Europe and the United States. He was teaching at musical arts institutes of higher education and musical academies in Wurzburg, Nurnberg, Cetinje, and Pesaro. Presently he is a professor for harpsichord and the Head of the Department for Early Music and the head of the department at the Academy of Music of the University of Ljubljana. In 2013, he was awarded the Gold Plaque of the University of Ljubljana for exceptional contributions in the development of scientific, teaching, or artistic endeavors.





VI from Egypt was included thanks to Maneea Moubrak, the member of the FarmEVs project team. The students of physiotherapy from the Faculty of Health Sciences have prepared a review on mammary gland and breast cancer physiotherapy mentored by Raja Dahmane Gošnak which is being published in this issue. Three more papers were prepared by the students from the Faculty of Health Sciences and from “Fizioterapevtika”.




Extracellular vesicles have been the red line of Socratic lectures since the first one in 2008 by Bernd Engelmann and also this year, the contributions from this field were numerous and excellent. Gabriella Pocsfalvi chaired a session devoted to the Marie Curie Sklodowska mobility project FarmEVs on plant extracellular vesicles. Besides life and natural sciences, we were fortunate to have contributions from social sciences, economy, education, and arts. The students and professors of the Academy of Music presented parts from the opera Coronation of Poppaea by Claudio Monteverdi, which will be put on stage in the summer of 2025. Its production is linked to the project Nanostructurome including 9 faculties of the University of Ljubljana and its Academy of Music as well as 9 external partners from home and abroad.



As we received more than 40 papers, The Proceedings of the 12th Socratic Lectures is organized in three parts. Part I contains mainly papers from the medical fields, Part II contains mainly papers from the natural and social sciences and Part III contains standard operating procedures of a pipeline for assessment of extracellular particles. The pipeline was designed within the project Nanostructurome. Socratic lectures thus present an important meeting point for the participants of various projects and for the publication of scientific results, opinions, repositories, and any kind of documents that are useful in the management of the projects. But in the first place, the 12th Socratic lectures are a meeting point for scientists, artists and friends from many different fields. It the recent events again we were able to enjoy the fruit of the fields which were kindly provided by the participants for which we remain forever thankful.



As Socratic lectures are a part of the Z-STEAM (Science, Technology, Engineering, Art, Mathematics) activities, also art is an important element. There were three satellite events starting on January 8 with a competition-awarded performance of the team member Lara Oprešnik at the Musikverein in Vienna. She presented the first part of the Skrjabin concerto in F sharp minor for piano and orchestra at the Brahms hall, accompanied by the Vienna City Orchestra directed by Christian Schulz - within the New Year concert events. Two days later, on January 10, she joined the artists at the Betteto hall in Ljubljana where the networking event of the Socratic lectures symposium took place. The event included classical and contemporary compositions, with an intermezzo of poetry by the renowned Slovene poet Ifigenija Simonović. The recitation was intertwined with Slovene chorals performed by the sborus Studenec. The 12th Socratic lectures ended with an organ recital by Roberta Schmid from Naples, Italy, at the Church of Assumption, Tromostovje, on January 14. Proceedings of the Socratic Lectures hosts a visual art gallery Marguerite de Saint Champs. This time, the presenting artist is Roberta Ferranti from Trieste, Italy. Primarily focusing on street photography, landscapes, geometries, and portraits, Roberta Ferranti seeks to share the beauty and stories that often go unnoticed. Her images challenge viewers to pause and reflect, to see the world from a different perspective, and to appreciate the subtle moments that make life extraordinary. We are thankful to Drago Videmšek for recording the concert at the Betteto hall on artistic photographs and to Miha Červ who attended the concert at the Musikverein, Vienna to report on the concert.

With the participation of world top scientists from the fields and integration of science in international artistic production, Socratic lectures strive to present scientific and artistic excellence to the students and involve them in the creation of science and art. We conclude with a big thanks to all the participants who in the spirit of Socrates donated their contributions and to all those who made the events possible. Kindly invited to the next Socratic lectures.

Veronika Kralj-Iglič, Anna Romolo and Yelena Istileulova





VII





TEXTS




1. Troha Kaja, Vozel Domen, Battelino Saba: Advancements of Platelet-Rich Products and Extracellular



Vesicle Use in Otology ……………………………………………………………………………………………………. 1

2. Bilban Petra, Eisenhut Leyla, Ledinek Alana, Stare Klara, Tušar Alja, Zabukovec Lorena, Zver Nela,

Romolo Anna, Kralj-Iglič Veronika: Reflections on Plenary Lecture “Extracellular Vesicles from Blood Cells and in Blood; The Avenue of Future Therapies” by Saara Laitinen at 12th Socratic Lectures .....……….… 12

3. Ameršek Kim, Ančimer Špela, Antončič Jerca, Bjelajac Sara, Hrovatin Ajda, Kavčič Ana, Marinček Lara

Nina, Markun Nika, Pirnat Jerneja, Plešnik Tinkara, Štrumbelj Drusany Katarina, Volk Lara , Zabukovec Kim, Gošnak Dahmane Raja: The Mammary Gland: Anatomy, Histology, Pathology and Post-Surgery Physiotherapy Management ….. …………………………………………………………..……………………………. 20

4. Horvat Leon, Jazbec Jan, Jazbec Gal, Justin Eva, Lavtizar Nik, Lukavica Marisa, Matjaš Melissa, Mrak

Manca, Panjan Teo, Pavlova Oksana, Peternelj Lučka, Petrovčič Nina, Porenta Pia, Rebula Gregor, Suhadolc Kaja, Štojs Neža, Žorž Žana, Romolo Anna, Kralj-Iglič Veronika: Role of Extracellular Vesicles in Breast Cancer, its Diagnostics and Treatment ………………..…………………………………………………..... 31

5. Dolinar Drago, Potparič Igor, Jenko Monika, Debeljak Mojca: The Problem of Modular Hip

Endoprosthesis ..…………………………………………………………………………………….....…….…………... 41



6. Dučić Nejra, Avdić Rizah, Hadžiomerović Nedžad, Vejzović Anel, Tandir Redžep, Tandir Faruk: Feline

Tooth Resorption ……...………………………………………………………………………………………….……… 47



7. Erjavec Vladimira, Lukanc Barbara: Tracheal Injury after Endotracheal Intubation ……………………………... 53

8. Jarnovič Lana, ErjavecVladimira: Brachycephaly in Cats: A Silent Problem in Feline Health .…………………...59

9. Plešnik Tinkara, Hlebš Sonja: Effective Teaching and Learning Opportunities During Clinical

Education from the Students' Perspective - Prospective Cross-sectional Study …...…………………………….… 66

10. Bec Sergeja, Rugelj Darja, Weber Daša: Effects of Transcutaneous Electrical Nerve Stimulation

in Patients with Fibromyalgia Syndrome – Literature Review ……………………………………………….……... 75

11. Breznik Katarina, Pilih Klemen Aleš, Jerković Parać Božena, Jeromel Miran, Vauhnik Renata: Pain Relief

Treatment of Fresh Sacral Fracture for a Professional Snowboarder one Month before Participation in the Winter Olympic Games …………………………………………………………………………………………….……. 84

12. Uhan Lana, Strle Eva, Pilih Klemen Aleš, Kozic Mitja, Vauhnik Renata: Surgical Treatment of Chronic

Post-Traumatic Hamstring Origin Pain with Tendon Transfer from the Unfused Ischial Tuberosity Apophysis to the Native Ischial Bone ……………………………………….…………………………………………. 91

13. Zoroja Monika, Pilih Klemen Aleš, Vauhnik Renata: Ring-Shaped Lateral Meniscus – Rise Awareness

and Avoid Unnecessary Surgery: A Case Report ………………………………………………………….………… 98

14. Petrič Maja: What are the Endurance Times of the Trunk Muscle Endurance Tests on the Roman Chair:

A Preliminary Normative Study ……………………………………………………………………………..………... 105

15. Dolinar Larissa, Španring Ajda, Šercer Nika, Breznik Katarina, Gošnak Dahmane Raja, Starc Andrej:

Destigmatization of Erectile Dysfunction .……………………………………...…………………………….…….. 112

16. Kralj-Iglič Veronika: On the Music of the 12th Socratic Lectures. Z-STEAM and Nanostructurome

Activities ….……………………………………………………………………………………………………………… 121





VIII





POSTERS




1. Grad Blaž , Kralj-Iglič Veronika: Analyzing Bending Energy in the Nuclear Pore Complex



from a Point Cloud Representation …………………………………………….…..............................................P1

2. Nemec Vid, Jeran Marko: Physical Approach to the Application of Numerical Methods in

Analysing Race Car Dynamics and Performance on a Racetrack Using GPS Data ………………..………..P2

3. Kegel Mateja Aleksandra, Jeran Marko: On the Way to Renewable Energy Sources: Wind

Energy and Wind Farms …………………………………………………………………………………………..P3

4. Prelog Tomaž , Pelan Maša, Pečan Luka Irenej, Tesovnik Tine, Vodenik Julija, Tavčar Gašper,

Silverman Julian R, Kavčič Marko, Petrovec Miroslav, Jazbec Janez, Jeran Marko: Tumor Labeling with Fluorescent Dyes with Tricyclic Xanthene Structural Motif and Conjugated Double-Binding Fragments in Leukemia ………………………………………………………………………………………… P4

5. Lap Patricija, Kogovšek Martina, Tavčar Gašper, Schofs Laureano,Ponikvar-Svete Maja, Marko Jeran:

Growth of the Green Microalgae Chlorella Vulgaris on Glass and Fluorinated Polymer Carriers ...……….P5

6. Smerkolj Kaja, Verdenik Ivan, Kornhauser Cerar Lilijana, Lučovnik Miha, Jeran Marko: Trends

in Labor Inductions in Slovenia: Insights from 20 Years of Clinical Data (2002-2022) …………………….. P6

7. Jeran Marko, Tavčar Gašper: Rare Earth Elements in Sustainable Development and Biomaterials

for Biological Applications and as a Challenge for Education ………………………………………………. P7





IX




Review





Advancements of Platelet-Rich Products and Extracellular





Vesicle Use in Otology

Troha Kaja1, Vozel Domen1,2, Battelino Saba1,2,*



1. Department of Otorhinolaryngology and Cervicofacial Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia. 2. Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia

* Correspondence: saba.battelino@kclj.si



Abstract:

Autologous blood-derived platelet-rich products exert their regenerative effects by

Citation: Troha K,Vozel D, Battelino S. modulating molecular processes involved in hemostasis, inflammation, angiogenesis,

Advancements of Platelet-rich Prod- cellular transport, cytoskeleton synthesis and other. Abnormalities in these biological

ucts and Extracellular Vesicle Use in processes can be observed in many conditions, including otologic diseases. The action

Otology. Proceedings of Socratic Lec- of bioactive components of extracellular vesicles and platelets in platelet-rich prepara-

tures. 2025, 12, 1-10. tions presents an additional therapeutic possibility in managing several otologic pa-https://doi.org/10.55295/PSL.12.2025.I1 thologies, especially where other interventions for enhancing wound healing, tissue re-

generation, and reducing inflammation have been exhausted. The application of plate-let-rich preparations has been explored in chronic middle ear disease, tympanic mem-brane perforation, sudden hearing loss, facial nerve damage and other. Furthermore, extracellular vesicles, which are present in all bodily fluids including platelet-rich prep-

Publisher’s Note: UL ZF stays neutral arations, have been increasingly investigated as a potential diagnostic and target ther-

with regard to jurisdictional claims in apeutic tool in the management of hearing loss. published maps and institutional affili-

ations.



Keywords: Platelet-rich Plasma; Extracellular vesicles; Otology; Growth Factors; Hear-ing Loss

Copyright: © 2025 by the authors.

Submitted for possible open access

publication under the terms and

conditions of the Creative Commons

Attribution (CC BY) license

(https://creativecommons.org/licenses/

by/4.0/).





1. Introduction



By providing small particles to tissues and aiding in establishing an optimal molecular microenvironment for tissue regeneration, platelet-rich products have been utilized across various fields of medicine yielding favourable results (Troha et al.,2023). Otology, a sub-specialty focused on the diagnosis and treatment of ear-related disorders, is no exception in the attempts of exploring the beneficial effects of these products. Platelet rich products are most commonly described in the literature as platelet-rich plasma (PRP) or platelet and extracellular vesicle-rich plasma (PVRP), the latter emphasiz-ing the importance of extracellular vesicles (EVs) in these fluids. PRP and PVRP are autol-ogous blood-derived products with platelet concentrations 3-5 times higher than whole blood (Marx et al.,2001; Tao et al., 2017). EVs are a heterogeneous group of cell-derived membranous structures, harvested from any bodily fluid, including PRP and PVRP. De-pending on their origin, EVs play a role in physiological and pathological processes and can be categorized endosome-origin exosomes and plasma-derived ectosomes (further di-vided into microvesicles, microparticles, ectosomes, large oncosomes and apoptotic bod-ies). These nano- and microvesicles are especially recognized for their involvement in membrane and cytosol transport, as well as RNA delivery, the mechanisms by which EVs are being investigated for their potential use in the diagnosis and treatment of a range of diseases (Tao et al., 2017; Dai et al., 2020; Raposo et al., 2013; Steiner & Battelino, 2020; Sluga et al., 2021). In addition to EVs, platelets have been identified as the central mediators of beneficial effects of platelet-rich preparations, participating in essential processes of he-mostasis, inflammation, angiogenesis, tissue anabolism, extracellular matrix synthesis, as well as in immune system modulation (Morrell et al., 2014; Anitua et al., 2004) . The main bioactive molecules promoting healing in platelet-rich preparations include growth fac-tors, cytokines and other compounds (Anitua et al., 2004; Sundman et al., 2011). The prep-aration of platelet-rich products is cost-beneficial, straight-forward and involves simple centrifugation, performed either in one or two steps. After centrifugation, platelets in the preparation can be activated either exogenously (using chemical substances like calcium chloride) or endogenously (in vivo after application). A significant advantage of exoge-nous application is the formation of a gel-like consistency, which facilitates application onto tissues. However, its application should occur within 10 min after activation, in the time frame where most of the beneficial constituents are released (Marx et al.,2001; Croisé et al., 2020; Božič et al., 2021). Platelet-rich products have been found as inherently safe to use in tissues, acting similarly to a blood clot (Andia et al., 2013). Studies investigating possible oncogenic effects (Marx et al.,2001; Marx et al; 1998), or long-term use in animal models (Omar et al., 2017), as well as in sensitive tissues, such as in the middle ear (Arslan et al., 2022) have shown no adverse effects. Instead, the investigations demonstrated sig-nificant anti-inflammatory and regenerative potential (Arslan et al., 2022). In addition, it has been shown that the preparations can be tailored in their composition to optimize its therapeutic effect depending on the clinical context, especially regarding the presence or absence of the inflammation process, and on the patients’ own blood characteristics (Sundman et al., 2011; Steiner et al., 2022).



2. Application of PRP/ PVRP in otology

Studies investigating the tissue regeneration and anti-inflammation functions have made platelet-rich preparations a promising adjunctive treatment modality in otologic diseases, such as middle ear diseases (e.g., tympanic membrane perforation, chronic otitis media), nerve preservation (sudden sensorineural hearing loss, chorda tympani nerve manipula-tion, facial nerve injuries) and other (Sherif et al., 2024; Mandour et al., 2019; Lee et al., 2017). Some examples and findings of clinical studies are presented in the Table 1.





Table 1. Examples of studies with PRP/PVRP application in otology. PRP; platelet-rich plasma, PVRP; platelet and ves-icle-rich plasma.





Authors and year of publication, type of Use in otology Results



study and number of subjects

Shiomi and Shiomi (2020): Tympanic membrane perforation  Significantly improves healing

retrospective study, 118 patients; – use in myringoplasty of perforations, also suitable for

Fouad et al. (2018) : retrospective study larger perforations.

conducted, 69 patients;

El-Anwar et al. (2015) randomized

controlled trial, 64 patients;

Mandour et al. (2019) :

prospective randomized controlled

study, 50 patients;

Huang et al. (2021),

meta-analysis, 8 studies;

Al-Arman et al. (2024) : randomized

clinical trial, 156 patients.

Kanauija et al. (2023): prospective Sudden sensoryneural hearing loss • Substantially improves hearing

interventional study, 70 patients; in acute hearing loss.

Dave et al. (2021) : case series, 40 patients; • One-time intratympanic

Tom et al. (2022): prospective injection yields better results

observational study, 54 patients; compared to intratympanic

Tyagi & Rout (2019): Case series study, steroids, no complications.

200 patients; • Favourable results in younger

Arslan et al. (2022) : experimental animal patients.

study. • Proven safe use in the middle

ear.

Askar et al. (2021): case series, 21 Mastoid reconstruction after CWD  Good healing and epithelization

patients. (canal wall-down) mastoidectomy of radical cavity.

Jang et al. (2016): experimental animal .  Better visualisation upon

study. follow-up imaging as in

obliteration with other

materials.

Vozel et al. (2021): randomized Chronic discharging radical cavity  Successful outcomes in cases of

controlled trial, 22 patients. standard therapy failure.

Lee et al. (2017): case study, 1 patient. Pinna replantation site  Supports neovascularization

and transplant protection after

reperfusion ischemia.





2.1. Tympanic membrane perforation



Acute and chronic tympanic membrane perforations in acute or chronic form, traumatic or as a consequence of chronic otitis media present a common otologic disease often re-quiring a surgical intervention. Tympanoplasty is a surgical procedure with reported suc-cess rates from 75% to 98% (Mohamad et al., 2012; Sheehy et al.,1980), but tends to be less effective in patients with larger perforations, in those with early onset of middle ear dis-charge postoperatively, and in patients with myringosclerosis. Especially in cases of recur-rent perforations, additional support (such as cartilage graft) is usually provided to the most commonly used temporalis fascia graft. As a means of enhanced aid to graft incorpo-ration and therefore in promoting the closure of the perforation several studies have demonstrated the beneficial effects of PRP and PVRP (Singh & Jain, 2024). Huang et al. (2021) performed a systematic review and meta-analysis, where the efficacy of PRP in myringoplasty was investigated. The analysis included eight studies involving 455 pa-tients. The results showed a significant increase in the closure rate for PRP-treated patients compared to conventional surgery, indicating that PRP significantly enhances the healing process. Moreover, the use of PRP was associated with a lower incidence of complications. However, no significant differences in hearing in patients with closed tympanic membrane improvements between PRP and conventional methods were noted (Yadav et al., 2018). Yadav et al. (2018) demonstrated the use of PRP as applied in an underlay technique be-tween temporalis fascia and tympanic membrane in a study of 20 patients, reporting a significant difference in graft uptake in favour of the PRP group compared to the control after 3 months (Yadav et al., 2018). Akash et al. (2023) conducted a RCT on 40 patients with the use of PRP as packing material in type 1 tympanoplasty in chronic otitis media and 40 in the control group, observing the status of graft uptake and reperforations at 1st and 6th month postoperatively. The results showed similar graft uptake and reperforations as well as the rate of post-operative infections in both groups (Akash et al. 2023). In a study by Yousaku Shiomi & Yoshiko Shiomi (2020), the researchers assessed the outcomes of myrin-goplasty using PRP and atelocollagen sponge foams and found that PRP significantly im-proved the rates of closure, especially for small perforations. The cause and duration of perforation were not predictors of the outcome, while the patient age was significantly correlated to the surgical success. Subjects older than 80 years had a significantly lower success rate than younger patients (Yousaku Shiomi & Yoshiko Shiomi, 2020). Fouad et al. (2018) compared the outcomes of fat graft myringoplasty (FGM) with PRP or with hyalu-ronic acid (HA) versus to FGM alone in patients with medium-sized perforations. They reported a significantly higher success rate (85.7%) in patients with PRP than those with FGM alone (60%) (Fouad et al. ,2018). El-Anwar et al. (2015) supported the favourable re-sults of PRP use by reporting a 100% success rate in myringoplasty with conchal perichon-drial graft with PRP in 32 patients, compared to 32 patients without PRP, all with large dry central perforations. 81.25% success rate was reported in the control group. Additionally, in the test group, a reduced incidence of postoperative infections was noted (El-Anwar et al.,2015). Mandour et al. (2019) compared PRP-enriched fat grafts and reconstruction with cartilage perichondrium in 50 patients undergoing myringoplasty and demonstrated that both approaches yielded comparable results, with an 88% closure rate in the PRP-fat graft group and 92% in the cartilage group. The researchers concluded that PRP addition in fat-graft myringoplasty can be recommended as first line treatment of medium-size central perforations of the tympanic membrane. They additionally proposed that the preparations are effective in transplant durability by preventing dehydration at the margins of tympanic membrane perforations (Mandour et al.,2019). Choudhury et al. (2024) investigated the use of fat grafts combined with PRP in small and moderate perforations in 36 patients and reported a high success rate, suggesting that the convention of using the temporalis fascia graft for smaller perforations should be revisited (Choudhury et al. 2024). Similarly, Al-Arman et al. (2024) compared the efficacy of platelet-rich fibrin-augumented fascia to es-tablished cartilage tympanoplasty for large perforations in a RCT study of 156 patients. Graft take and hearing outcomes showed no significant difference, with no complications reported, suggesting PRP as a comparable option without the need of cartilage harvest . Braccini et al. (2009) previously reported a success rate of 96% in tympanoplasty using leucocyte- and platelet-rich fibrin (L-PRF), compared to 85% successful outcomes in tym-panoplasty without PRF. The researchers proposed that PRF provides both mechanical





and inflammatory protection to tympanic grafts (Braccini et al.,2009). Sankaranarayanan et al. (2013) found that the PVRP clot application during tympanoplasty prevented graft displacement, facilitating the closure of the perforation.



2.2. Sudden sensorineural hearing loss and other nerve impairment in otology Sudden sensorineural hearing loss (SSHL) is an abrupt deterioration of hearing for at least 30 dB in 3 or more consequent frequencies upon audiometric evaluation, in the time period of 72 h. It is termed idiopathic when the etiology remains unclear after clinical (otologic and audiologic) examination and patient history. Researchers Ding et al. (2009) priorly suggested that the application of PRP has potential regenerative effect on cranial and pe-ripheral nerves, which was later confirmed in different animal and clinical studies (Shen et al, 2019; Li et al., 2019; Kuffler et al., 2011). Sanchez et al. (2017) proposed that platelet-rich products influence nerve repair by mechanical protection, neuron apoptosis preven-tion, stimulation of angiogenesis, axon regeneration promotion and inflammation modu-lation in the microenvironment of nerve cells. Singh & Jain (2020) reviewed the role of platelet-rich product use in management of sensorineural hearing loss and concluded that may facilitate the repair and regeneration of damaged auditory cells and nerve fibers, po-tentially improving hearing function in individuals with SNHL. Arslan et al. (2022) also investigated in an animal model the effects of PRP application intratympanically and found no adverse effects, with lower degrees of inflammation and mucosal thickness ver-sus the control side, and with more evident angiogenesis on the tested side. They sug-gested that PRP is a safe alternative to current treatment with its the anti-inflammatory and regenerative features. Mahmoud Shawky (2024) conducted a study, where intratym-panic PRP injections were compared to steroid intratympanic injections in managing SSHL. A significant improvement in hearing after 2 weeks for 25 dB and after 2 months for 30 dB was observed in the PRP group. Tyagi & Rout. (2019) similarly previously reported patients with mild to moderate SNHL to recover significantly after intratympanic PRP in-jection, especially in younger patients. Stephy Maria Tom et al. (2022) reported 54 cases with sensory neural hearing loss treated with PRP or dexamethasone intratympanically. In the PRP group, improvement from baseline was significantly higher in PRP group com-pared to dexamethasone group. Kanauija et al. (2023) administered intratympanic PRP in-jections in 70 patients, where hearing loss was present for less than 6 months, of which 85.2 % recovered completely and 14.8% partially. Intratympanic PRP injection significantly im-proved hearing in acute mild-to-severe cases of sensory hearing loss with no complications reported. Sherif et al. (2024) conducted a comparative study of intratympanic steroid and PRP injection and found no significant differences in treatment modalities, both proving to be similarly effective in improving hearing outcomes in sudden sensorineural hearing loss. Additionally, PRP's neurotropic effects were investigated in cases of facial nerve dys-function, whether after salivary gland or temporal bone surgery (Bitenc Zore et al., 2022). Ricci et al. (2019) and Scala et al. (2014) have shown that the application of PRP in gel form after superficial parotidectomy reduces the occurrence of postoperative facial palsy. In the study of Cho Hyong-Ho et al. (2010) PRP in combination with neural-induced mesenchy-mal stem cells was administered to the facial nerve in animal models, showing significant facial nerve regeneration. These effects were attributed to neurotrophic growth factors such as nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF). More-over, with the idea to aid nerve regeneration and reduce postoperative sensory impair-ment, an unpublished study is currently underway evaluating the use of PVRP on the chorda tympani nerve, responsible for taste sensation in the anterior two-thirds of the tongue and is commonly stretched or damaged during middle ear surgeries, resulting in taste and other sensory disturbance in the tongue.



2.3. Radical cavity reconstruction and chronic radical cavity inflammation In cases of chronic otitis media with cholesteatoma and subsequent need for surgery, often a radical cavity is formed, which is an operative hollowing of temporal bone performed in canal wall down mastoidectomy surgery. This postoperative cavity can be afflicted with complications such as chronic inflammation with discharge. A study by Elbary et al. (2018) demonstrated the benefits of combining titanium mesh and PRP with bone material in the reconstruction of the posterior meatal wall in middle ear cholesteatoma surgery. This



method was found to be reliable, without complications, giving a smooth appearance to the area and improving healing. In order to aid the epithelization of the radical cavity and reduce the inflammation, Askar et al. (2021) used PRP in addition to bone pate in mastoid reconstruction and demonstrated improved healing, reduction of incidence of complica-tions and better visualization during follow-up imaging for recurrences. Similarly, Vozel et al. (2021) in randomized controlled trial described PVRP as an effective treatment mo-dality for chronic postoperative temporal bone cavity inflammation. For obliterating sur-gical cavities, Zwierz et al. (2024) used injectable platelet-rich fibrin on a temporoparietal fascial flap in three cochlear implant patients after subtotal petrosectomy due to chronic discharging ears and concluded that this material may reduce the risk of potential infection in the obliterated cavity, in patients without cholesteatoma.



2.4. Ototoxicity



The protective effects of PRP against ototoxicity have also been documented. It was re-ported that intratympanic administration of PRP can mitigate the ototoxic effects of cispla-tin in experimental models, alluding to the potential to preserve auditory function (Yurtsever et al., 2020). In fact, growth factors present in PRP, such as Insulin-like Growth Factor-1 (IGF-1) were suggested to play a role in protecting hair cells from ototoxic damage (Dave et al., 2021).

2.5. Other uses

Lee et al. (2017) described a case of a complete ear amputation in a patient, where PRP was injected along with hyperbaric oxygen therapy and polydeoxyribonucleotide, demonstrat-ing facilitation of neovascularization and protection against transplant failure due to reper-fusion ischemia with almost complete salvage of the pinna.

3. Advancements in treating sensorineural hearing loss: EVs and autologous plate-let-rich preparations

Sensorineural hearing loss is a result of multiple causes, including genetic predisposition, infections, ototoxic agents, exposure to noise, aging. It presents a substantial clinical challenge with no effective pharmacological treatments, despite the high prevalence of the condition globally. As to act to prevent the loss of hair cells or auditory neurons, modern research focuses to protect and regenerate cochlear cells before cell loss. In efforts to establish restoration of cochlear synapses, neurotrophins such as brain-derived neurotrophic factor (BDNF) and neurotrophin-3 (NT-3) were proposed (Fritzsch et al., 2004). These regulate the connection between hair cells and auditory neurons during embryogenesis and stabilize the cochlear synapses (Bailey et al., 2014; Warnecke et al., 2020). It has been demonstrated that especially a various composition of neurotrophins has the ability to increase the survival of auditory neurons, compared to single factors alone. Treatment with EVs have been proposed as therapeutic agents, especially containing the mentioned neurotrophins, BDNF and NT-3. PRP and autologous mononuclear cells derived from human bone marrow have been investigated as sources of these factors, since a balanced combination of various factors are naturally occurring in these preparations (Schwieger et al., 2015; Kranz et al., 2014; Kaiser et al., 2013). In addition to a potential therapeutic role, Wong et al. (2018) reported that EVs from rats' primary cultured inner ear cells release exosomes, which could be used as a biomarker showing the state of the inner ear, as the change in EVs’ cargo and concentration was noted by exposure to cisplatin or gentamycin. The authors also suggested the isolated EVs could be loaded with anti-inflammatory drugs, therefore, the vesicles could be used as nanocarriers. Zhuang et al. (2021) demonstrated EVs in human perilymph, which were carrying hair cell-specific proteins and suggested that sensory hair cells themselves were the potential source of exosomes. The isolated EVs had specific miRNA and protein cargo profile, derived from different developmental stages of the inner ear postnatally. The study also postulated that these EVs may reflect the physiological and pathophysiological processes in the inner ear (Jiang et al., 2022) . This was demonstrated further on examples of EVs from vestibular schwannoma (VS) cell culture. Exosomes from VS cell cultures were shown to likely damage hair cells and auditory neurons from patients with VS and poor hearing, than those of EVs from patients with VS and good hearing (Soares et al., 2016). Protective



functions of EVs have also been investigated such as in protection of hair cells against aminoglycoside toxicity, where researchers used utricle-derived exosomes (Breglio et al., 2020). Moreover, Warnecke and colleagues in 2020 showed that mesenchymal stem cell (MSC) EVs contain neurotrophic factors and that the application of these EVs to the cochlea protected auditory hair cells from noise-induced trauma in vivo. The same researchers first introduced in-human intracochlear application of allogeneic human stromal derived extracellular vesicles during cochlear implantation (Warnecke et al., 2020). Tsai et al. (2021) subsequently showed that the administration of umbilical cord-MSC-EVs to cochlear hair cells in mice after repetitive cisplatin injection improved hearing. et In addition, EVs have been investigated in neuro-otology as compounds of viral vector gene therapy, which was previously inefficient in the delivery of genes to all the hair cells of the inner ear. By a vector called exosome-associated adeno-associated-virus (exo-AAV), it was demonstrated that the genes were significantly delivered to all inner ear hair cells, inner and outer. It was shown that AAV with exosomes rescued hearing in a mouse with hereditary deafness (György et al., 2017).



3.1. Adverse effects of use in middle ear



As noted previously, the adverse effects of platelet-rich products are extremely rare, there are no concerns about transmittable disease, since the preparation is autologous. Studies have shown that the slightly acidic pH of PRP compared to a matured blood clot, PRP acts inhibitory to bacterial growth, which is beneficial in PRP applications. To assess the safety of the use in the middle ear Arslan et al. (2022) demonstrated a safe prolonged use on the middle ear mucosa, with degrees of inflammation and mucosal thickness significantly lower in middle ear treated with PRP compared to the control side treated with saline. In fact, favourably, the degree of angiogenesis was significantly higher in the PRP adminis-tered side, promoting regeneration.

4. Conclusions

Autologous platelet-rich blood-derived products are versatile and effective treatment options in otologic disease management with minimal adverse effects due to the autologous nature. The components of the preparations, released in a manner similar to blood clot formation, are involved in healing promotion, inflammation reduction, cell regeneration and angiogenesis. These effects are being used in treatment of sudden sensorineural hearing loss, tympanic membrane perforation, ototoxicity and others, making it a valuable adjunct in clinical otology practice. In recent time, it has additionally been shown that the natural composition of small particles called extracellular vesicles can be used as vectors for gene therapy in transport to all inner ear hair cells, which previously failed, potentially treating sensorineural hearing loss. In the future, personalized protocols with preparations adapted to the clinical case may be expected. Further combinations of platelet-rich products with other adjuvants, such as PRP with gene therapy, stem cells, biomaterials, may be developed in order to enhance the beneficial clinical outcomes. Further studies are needed to support the existing hypotheses.



Conflicts of Interest: The authors declare no conflict of interest.



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Reflection



Reflections on Plenary Lecture “Extracellular Vesicles from



Blood Cells and in Blood; The Avenue of Future Therapies” by

Saara Laitinen at 12th Socratic Lectures

Bilban Petra1, Eisenhut Leyla1, Ledinek Alana1, Stare Klara1, Tušar Alja1, Zabukovec Lorena1, Zver Nela1, Romolo Anna1, Kralj-Iglič Veronika1,*



1. University of Ljubljana, Faculty of Health Sciences, Ljubljana, Slovenia

* Correspondence: Veronika Kralj-Iglič, Veronika.Kralj-Iglic@zf.uni-lj.si



Abstract:

Citation: Bilban P, Eisenhut L, Ledinek Extracellular vesicles have been the scope of the Socratic Lectures since 2008 keeping

A, Stare K, Tušar A, Zabukovec L, Zver the interested parties and the students informed on recent developments in the field.

N, Romolo A, Kralj-Iglič V. Reflections The first plenary lecture on extracellular vesicles at the recent symposium was by a

on Plenary Lecture “Extracellular Vesi- distinguished researcher Saara Laitinen. In this contribution, the lecturer is shortly

cles from Blood Cells and in Blood; The presented, contents of the lecture as reflected by the students are given along with

Avenue of Future Therapies” by Saara images of extracellular vesicles from blood, and references selected by the lecturer.

Laitinen at 12th Socratic Lectures. Pro-

ceedings of Socratic Keywords: Extracellular vesicles; Extracellular particles; Microparticles; Lectures. 2025, 12, 12-18. Microvesicles; Blood extracellular particles; Plasma extracellular particles https://doi.org/10.55295/PSL.12.2025.I2

____________________________________________________________________________

Publisher’s Note: UL ZF stays neutral

with regard to jurisdictional claims in

published maps and institutional affili-

ations.





Copyright: © 2025 by the author.

Submitted for possible open access

publication under the terms and

conditions of the Creative Commons

Attribution (CC BY) license

(https://creativecommons.org/licenses/

by/4.0/).





1. Introduction



The plenary lecture Extracellular vesicles from blood cells and in blood; The avenue of future therapies was presented at the symposium 12th Socratic Lectures that took place January 11, 2025 online. It was organized by the Centre of Lifelong Learning of the Faculty of Health Sciences, University of Ljubljana as a part of Z-STEAM activities (Science, Tech-nology, Engineering, Arts and Mathematics). Z-STEAM activities are centred on the stu-dents and Socratic Lectures are a part of the curriculum that features top scientists from different fields for students of all levels. Also, Socratic Lectures are constitutive parts of the projects FarmEVs, Nanostructurome, J3-60063, and the program P3-0388. We are in-debted to excellent scientists for including students into the discourse and thus enable them to take a part in one of the research segments. The students have attended the sym-posium and recorded the lectures. They have combined their impressions and the infor-mations from the recording. Images of blood cells and extracellular vesicles (EVs) (Figures 1 and 2) are added for illustration.



2. Saara Laitinen: the presenter of the plenary lecture Extracellular vesicles from blood cells and in blood; The avenue of future therapies

Saara Laitinen took her Master of Science degree from Plant Physiology and her PhD at the University of Helsinki, Department of Biosciences, Finland. Her career started at the University of Helsinki and developed at distinguished institutions L’Institut Pasteur de Lille, France, Research Institute Minerva, Biomedicum, Helsinki and Department of Mo-lecular Medicine, National Public Health Institute, Helsinki. Currently, she is a Research and Development manager at Finland Red Cross Blood Services. She is a principal inves-tigator and responsible person for strategic research topic: Blood Cells and Products. She is responsible for the laboratory facilities at the Research and Development Department providing and maintaining the high-quality platform for all four strategic research focus projects currently running in the Finnish Red Cross Blood Service. Laitinen has over fifteen years of research experience on EVs and is an internationally rec-ognised blood EV researcher participating in the work of the International Organisation Committee for Blood EV Workshop of ISEV (International Society of Extracellular Vesi-cles). Her interest in EVs started from the mesenchymal stromal cells (MSC). Her current research focus is on the immune regulation of blood cells, platelets, and red blood cells and the role of the membrane lipids in the functionality of the cells and the extracellular vesi-cles.

Laitinen was a principal investigator of numerous projects, publications and invention declarations. Her work hitherto received more than 20,000 citations in Google Scholar base. She supervised 5 PhD and 6 Master students and was a student mentor in the University of Eastern Finland. She was an invited lecturer at several national and international con-ferences, organiser and lecturer in ISEV educational workshops https://www.isev.

org/blood-ev-workshop, https://www.isev.org/bloodev2024, invited chair in several ISEV and other conferences, founder of Finnish Society of Extracellular and its president 2020-2023. She was awarded Honour from International Society for Extracellular Vesicles as principal organiser of the world first Blood EV Workshop in Helsinki Finland in 2022. She was a member of the editorial board of Journal of Extracellular Vesicles during 2016-2019 and a reviewer in several peer reviewed journals i.e. Stem Cell Research and Development, Cytotherapy, Journal of Extracellular Biology and Biochimica Biophysica Acta.

3. Extracellular vesicles from blood cells and in blood; The avenue of future therapies

by Saara Laitinen



2.1. Blood as a liquid tissue

Blood delivers and removes cargo to and from cells, maintains homeostasis, responds to stress and injuries, and is involved in immune and coagulation modulation. It includes cells, gas, hormones, nutrients, and has a vital importance for others tissues and organs. It can be considered as a fluidic tissue and there are similarities and differences between blood and other tissues and organs. Initially considered a simple fluid, blood is now rec-ognized for its complex composition, including red blood cells, platelets, plasma, and com-ponents that are not fully understood. Technological advances have shifted the focus of



treatment from whole blood to specific components, thereby improving therapeutic appli-cations. Certain components are yet disregarded or misunderstood, some (e.g. plasma – in practice - blood depleted of erythrocytes (Figure 1A)) may even be destroyed during pro-cessing.





Figure 1. A: Human plasma after 15 hours of fasting (From Božič et al., 2020). White arrow points to a leukocyte, gray arrow points to an erythrocyte, long white arrow points to a platelet and long grey arrow points to an EV. B,C: EVs in isolate from plasma. White arrow points to the corona. A: from Božič et al., 2020), B, C: from Romolo et al., 2022.





The biology of platelets is complex, and they are known to play a role in various physiological and pathological processes, including blood clotting and immune responses. There is a continued rele-vance of blood products in medicine, despite a decrease in blood-demanding surgical procedures. Blood and plasma are being used for modified antibody-based cancer treatments.



3.2. Extracellular vesicles (EVs) in blood



EVs are small membrane-enclosed particles released by cells (Jeppesen et al., 2022). They play a crucial role in intercellular communication. EVs in blood derive from blood cells, endothelial cells, but also other types of cells (Nieuwland & Siljander, 2024; Thangaraju et al., 2020). They are shed off from all types of cells to become free to move locally, and if they enter blood, they can travel with it and reach distal cells. Thus, blood EVs are a het-erogeneous population of vesicles originating from different cell types, including red blood cells and platelets. The first step in isolation of EVs from blood is preparation of plasma by sedimentation of erythrocytes, most commonly by centrifugation. However, the present protocols of plasma preparation in general disregard the effect of blood processing on the identity, number density, morphology and content of EVs, and these processes are currently being investigated (Ilvonen et al., 2024). The composition of blood EVs is not constant and can vary depending on the cell of origin. The cell-specific origin of EVs is crucial in understanding their behaviour and potential therapeutic applications. Figure 2 shows EVs isolated from suspension of aged erythrocytes.

In addition to EVs, there are other types of particles released by cells, known as non-vesic-ular extracellular particles. These particles vary in abundance and protein concentration. They can be lipid-rich or protein-rich and have distinct compositions and functions. EVs reflect the material of the mother cell. As an example information on the origin can be obtained from the analysis of RAB proteins, revealing how cellular stimuli influence EV composition (Kilpinen et al., 2013). Lipoproteins are abundant in plasma and they can in-teract with EVs. These particles (initially considered contaminants) may have significant functions, in particular in forming of the vesicle corona (Figure 1B). When EVs are released into the bloodstream, they acquire the corona composed of proteins and other components (Tóth et al., 2021; Buzas, 2022).

3.3. EVs as diagnostic vectors

EVs are considered as potential diagnostic vectors. Research on the interaction of EVs with immune cells, such as monocytes and macrophages, is complex and depends on various factors, including the type of EVs and the time of incubation. These interactions may vary depending on the polarization state of the cell. However, difficulty in identifying specific EVs within a diverse population of particles remains a challenging task often described as finding a "needle in a haystack". Characterization methods are being developed (Koponen et al., 2020). The challenge arises from the diversity of extracellular vesicles and other par-ticles. To overcome this, it is necessary to develop effective targeting moieties and marker combinations. Nevertheless, EVs hold promise as tissue- or cancer-specific diagnostics, provided that appropriate sensitivity thresholds and diagnostic techniques are developed.

3.4. EVs as therapeutic vectors

Blood-derived EVs have been used therapeutically for many years, particularly in the form of platelet concentrates. These concentrates contain billions of EVs and have been shown to be safe for use in patients. Blood EVs, particularly those derived from red blood cells, have vast potential therapeutic applications depending on the indication, route of admin-istration, and other factors. Potential therapeutic applications of EVs derived from eryth-rocytes are immune regulation and capillary dilation. Compared to the development of antibody drugs, blood products have historically driven therapeutic advances. Blood-de-rived EVs provide a natural source of particles that reflect their in vivo environment, of-fering advantages in terms of safety and functionality. Rapid production of platelet-de-rived EVs presents opportunities for targeted drug delivery, especially in cancer treatment. It is highly probable that blood and blood cell-derived products will be the next generation of drugs, but the process to accomplish this seems to be protracted.



Figure 2. A: Scanning electron micrograph and (B,C): cryogenic transmission electron micrograph of EVs isolated from the suspension of ageing erythrocytes. D and E: Transmission electron micrograph of EVs obtained by isolation from erythrocytes treated with two different detergents, respectively. A: from Jozelj et al. (2022), B and C from Romolo et al. (2022), D and E: from Kralj-Iglič et al. (2020).





There is a lack of universal EV markers, which makes it difficult to distinguish EVs from other particles in the blood. EVs from different blood cells such as erythrocytes and plate-lets have different properties. Cell-specific isolation of EVs is crucial to increase therapeutic potential.



Blood compatibility is critical for EV-based therapies, as EVs may contain blood group antigens. Research on the interaction of EVs with immune cells, particularly macrophages, is ongoing. These interactions may vary depending on the polarization state of the cell. EVs show potential to target cancer cells, but therapeutic development is still in its early stages. The use of EVs for drug delivery faces obstacles, particularly regarding their ability to penetrate biological barriers such as the blood-brain barrier. Current manufacturing protocols of blood plasma and further plasma medicals (growth factors, immunoglobulins etc) destroy EVs.



3.5. Challenges in EVs harvesting, characterization and applications Although EV-based therapies have great potential, challenges in isolation, purification, drug delivery, and diagnostics need to be addressed before they can be widely used in clinical settings. Also, it is necessary to understand the source of EVs and their composition before developing therapeutic strategies. EV cargo (Palviainen et al., 2020) and membrane composition are highly influenced by the blood environment, which complicates their use in standardized therapeutic applications. Blood-derived EVs present challenges due to the unculturable nature of many cells, but this also confers advantages for risk management and post-activation modification.

The EV cargo and membrane composition are dynamic entities influenced by the blood environment, creating both complications and opportunities for diagnostics. The high abundance of non-EV particles in blood adds another level of complication. Current sepa-ration methods, particularly those size-based, are inadequate in distinguishing EVs from other blood particles, such as lipoproteins, which are significantly more abundant and overlapping with size. As the development of robust, scalable manufacturing processes is essential to move from small-scale research to large-scale clinical use when using cultured cells/isolators, blood can offer competitive option for production of therapeutic EV source. Moving towards therapy application, regulatory authorities require thorough documenta-tion highlighting the existing expertise within blood services to help manage such com-plexities. Although robustness and quality control issues may be solved, competition with other drug delivery methods remains and challenge EV research to find the focus where they bring additional value.

3.6. Intertwining EVs with public services

Blood services possess an extensive history of handling personalized medicine and cell-based therapies, providing a foundation for future advancements. COVID-19 pandemic raised widespread concerns across Europe and globally regarding the security of blood supply. Emerging issues were vaccination strategies and the varying perspectives on the speed of implementation, in the light of historical precedents. There is a long-standing history of personalized medicine within blood services, exempli-fied by the understanding of blood groups, tissue typing and their implications for treat-ment. Moreover, ongoing development of new treatments and services are a key strategic priority. With their experience in addressing regulatory challenges and personalized med-icine, blood services are key to the development of cell therapies. It is important to realise that blood-derived EVs have some advantages over EVs derived from various other sources, such as cultured cells or cancerous cells, as blood is readily available in relatively large amounts. Extensive knowledge of blood cell biology, including blood groups, pro-vides a valuable foundation for understanding and working with blood derived EVs. The Finnish Red Cross Blood Service is centrally responsible for the blood supply through-out Finland, distinct from the more decentralized models in many countries. This central-ized structure presents many advantages to implement novel treatments and services na-tionwide, but it has demanded to develop its logistics to serve entire country.





4. Funding



This research was funded by Slovenian Research Agency (ARIS) (grant numbers: J3-3066, J2-4447, P3-0388, J3-60063, and project Nanostructurome (according to a contract between ARIS and University of Ljubljana), and the European Union’s Horizon 2020 Research and Innovation Programme under the Marie Skłodowska–Curie Staff Exchange project “FarmEVs” (grant agreement no: 101131175). The views and opinions expressed in this publication are solely those of the authors and do not necessarily reflect those of the Euro-pean Union. Neither the European Union nor the granting authority can be held responsi-ble.





Conflicts of Interest: The authors declare no conflict of interest.



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Review



The Mammary Gland: Anatomy, Histology, Pathology and



Post-Surgery Physiotherapy Management

Ameršek Kim1, Ančimer Špela1, Antončič Jerca1, Bjelajac Sara1, Hrovatin Ajda1, Kavčič Ana1, Marinček Lara Nina1, Markun Nika1, Pirnat Jerneja1, Plešnik Tinkara1, Štrumbelj Drusany Katarina1, Volk Lara1, Zabukovec Kim1, Gošnak Dahmane Raja1*,*



1. University of Ljubljana, Faculty of Health Sciences, Ljubljana, Slovenia

* Correspondence: raja.dahmane@zf.uni-lj.si



Abstract:

The mammary gland is a highly specialized organ dedicated to milk production, composed of glandular, connective, and adipose tissues. It undergoes dynamic structural changes throughout life, influenced by hormonal cycles essential for reproduction and lactation. Despite its vital physiological role, the mammary gland is susceptible to pathological conditions, most notably breast carcinoma, which remains

Citation: Ameršek K, Ančimer Š, the leading cause of cancer-related deaths among women. This article provides an

Antončič J, Bjelajac S, Hrovatin A, overview of the anatomy, histology, pathology, and physiotherapy rehabilitation

Kavčič A, Marinček LN, Markun N, strategies related to the mammary gland. A literature review was conducted drawing

Pirnat J, Plešnik T, Štrumbelj Drusany from peer-reviewed articles, textbooks, and guidelines to examine mammary gland

K, Volk L, Zabukovec K, Gošnak anatomy, histology, breast carcinoma, and physiotherapy approaches following

Dahmane R. The Mammary Gland: surgery. The lymphatic system, particularly the axillary lymph nodes, plays a crucial

Anatomy, Histology, Pathology and role in immune defense and serves as the primary route for metastatic spread in breast

Post-Surgery Physiotherapy cancer, making it a key diagnostic and prognostic marker. Breast carcinoma can be

Management. Proceedings of Socratic benign, non-invasive malignant, or invasive malignant. Invasive carcinomas, including

Lectures. 2025, 12, 20-29. ductal and lobular carcinoma, are the most aggressive and frequently metastasize https://doi.org/10.55295/PSL.12.2025.I3 through lymphatic pathways. Post-surgical physiotherapy plays a vital role in

managing complications like lymphedema, improving upper limb mobility, and supporting psychological well-being. Rehabilitation involves methods like manual

Publisher’s Note: UL ZF stays lymphatic drainage, compression therapy, and advanced treatments, including low-

neutral with regard to jurisdictional level laser therapy, all aimed at accelerating recovery and enhancing quality of life. In

claims in published maps and Slovenia, physiotherapy protocols emphasize early patient education, gradual exercise

institutional affiliations. progression, and lymphedema prevention. Personalized strategies integrating

anatomical and pathological knowledge significantly enhance recovery outcomes and quality of life for breast cancer patients.



Copyright: © 2025 by the authors.

Submitted for possible open access

publication under the terms and con- Keywords: Mammary gland anatomy and histology; Lymphatic system; Breast

ditions of the Creative Commons At- carcinoma; Breast cancer rehabilitation; Physiotherapy management. tribution (CC BY) license (https://cre-

ativecommons.org/licenses/by/4.0/).





1. Introduction



The mammary gland is a sophisticated anatomical structure composed of glandular and adipose tissue, supported by fibrous connective tissue and positioned over the pectoral muscles of the chest wall. Extending from the second to seventh ribs, it is intricately designed with a network of blood vessels, lymphatic pathways, and sensory nerves, all of which contribute to its structural integrity, functional capacity, and physiological significance. A thorough understanding of its anatomy forms the basis for comprehending its role in health and disease. From a histological perspective, the mammary gland’s complexity is further highlighted by its dynamic nature. Throughout an individual's life, hormonal cycles drive significant structural changes, enabling its essential role in reproduction and lactation. These adaptations not only support milk production but also underscore the gland’s susceptibility to various pathological conditions. An essential part of the mammary gland’s physiology is its connection to the lymphatic system. This network, comprising lymphatic vessels, nodes, and major ducts, is critical for maintaining tissue–fluid balance, immune defense, and the clearance of interstitial fluid (Leong et al., 2022; Schuenke et al., 2010). Lymph nodes, such as the axillary nodes, play a pivotal role as filtering stations, cleansing lymph of pathogens and debris. Furthermore, the lymphatic system is a key pathway for the metastatic spread of cancer cells, with lymph nodes serving as important indicators of disease progression in breast cancer patients (Null et al., 2023; Natale et al., 2021).



One of the most significant pathological challenges associated with the mammary gland is breast cancer, which remains the most frequently diagnosed cancer worldwide. Accounting for 25% of all diagnosed cancers, it predominantly affects women, although men are also occasionally diagnosed with the disease (Tosello et al., 2018). Numerous risk factors, including gender, age, obesity, alcohol consumption, sedentary lifestyle, hormone exposure, radiation, family history, and genetic predisposition, contribute to its development (WHO, 2024). While the incidence of breast cancer has been rising, advances in early detection and treatment have significantly improved survival rates, particularly for localized stages of the disease (Katsura et al., 2022). Given the rising prevalence of breast cancer and the physical and emotional challenges faced by patients post-surgery, the role of targeted physiotherapy rehabilitation programs is increasingly recognized. These programs not only focus on restoring physical strength and upper limb function but also address psychological well-being, playing a critical role in enhancing overall recovery and quality of life after breast surgery.

2. Design of the Review

A literature review was conducted, selecting articles published between 1992 (Stark et al., 1992) and 2024 (WHO, 2024; Yang et al., 2024). The review focused on publications that described or examined the anatomical features and histological changes of the mammary gland, breast carcinoma and various physiotherapy approaches for managing patients after breast cancer surgery. Studies published in English and Slovene were included to ensure comprehensive coverage.

The reviewed literature encompassed a wide range of sources, including peer-reviewed scientific articles, academic textbooks, institutional guidelines, dissertations, and credible online resources. Peer-reviewed articles formed the backbone of the analysis, providing evidence-based insights into related topics, while systematic reviews and meta-analyses offered a synthesis of current research. Foundational knowledge was derived from academic textbooks and atlases, such as Schuenke et al. (2010) and Hayes & Nguyen (2014), which detailed anatomical and histological aspects of the mammary gland. Institutional guidelines, including those by the Slovenian Institute of Oncology (Onkološki inštitut, 2019), were integral in describing standardized rehabilitation approaches.

3. Breast Anatomy

The breast is a complex anatomical structure primarily composed of glandular and adipose tissue, supported by connective tissues and overlying the pectoral muscles of the chest wall (Dahmane and Cor, 2001). Its primary function is lactation, but the breast also holds



significant importance in physical, psychological, and sexual contexts (Bazira et al., 2022; Khan et al., 2025).



Women and men both have breasts (Torre et al., 2016). The breast of an adult woman typically weighs between 150 and 200 grams. It is located on the anterior chest wall, extending from the second or third rib to the sixth or seventh costal cartilage, medially reaching the sternal edge and laterally extending to the mid-axillary line. The breast is situated on the pectoralis major muscle, partially on the serratus anterior muscle, and on the external oblique abdominal muscle. The pectoralis minor muscle, located beneath the pectoralis major, serves as an important anatomical landmark for dividing the levels of lymph node drainage (Marolt Mušič et al., 2004).



The glandular tissue of the breast is covered by fascia, with its posterior surface being slightly concave to conform to the underlying muscles. (Marolt Mušič et al., 2004). Fatty tissue, known as adipose tissue, makes up the breasts (Aronson et al., 2000). The adipose tissue in the breasts is intertwined with a network of nerves, blood vessels, lymphatic vessels, lymph nodes, and also consists of fibrous connective tissue and ligaments (Thomsen & Tatman, 1998).

The sensory innervation of the breast arises from the anterior and lateral cutaneous branches of the intercostal nerves (fourth to sixth thoracic levels). This innervation not only mediates sensation but also plays a role in the hormonal regulation of lactation and sexual responsiveness (Rivard et al., 2023). The vascular supply of the breast is extensive, originating primarily from the internal thoracic artery, the lateral thoracic artery, and branches of the thoracoacromial artery. Venous drainage follows a similar pattern, emptying into the axillary and internal thoracic veins (Bazira et al., 2022). The breast’s lymphatic drainage is critical for immune defense and has significant implications for the metastatic spread of breast cancer. Approximately 75% of lymphatic drainage is directed toward the axillary lymph nodes, with additional pathways leading to the parasternal and supraclavicular nodes (Khan et al., 2025). Breasts vary in shape and size, with one breast often being slightly smaller than the other, and nipples also show a wide range of variation (Brayboy et al., 2017). The epidermis of the areola and nipple is highly pigmented and slightly wrinkled, while the skin of the nipple contains numerous apocrine and sebaceous glands, along with some small hairs. At the base of the nipple, milk ducts converge and expand into milk sinuses. These ducts facilitate the transport of milk to the nipples (Hassiotou & Geddes, 2013). Supporting these structures are fibrous tissues, including Cooper’s ligaments, which help maintain the breast's shape and position (Khan et al., 2025). Female breasts typically contain more glandular tissue compared to male breasts (Stark et al., 1992). Female breasts are composed of 12–20 lobes, which are divided into smaller lobules (Tanis et al., 2001). These lobes and lobules are interconnected by 15–25 milk ducts. Female breasts are adapted to provide the best possible nourishment for babies and to offer sexual satisfaction to the woman. They are glandular organs that respond strongly to hormonal changes in the body (Jagannathan & Sharma, 2017).

4. Histology of the Breast Tissue

The breast (glandula mammaria) is a highly specialized organ composed of glandular, connective, and adipose tissues, with its histological architecture undergoing significant changes throughout life and uniquely designed for milk production. The glandular tissue has a tubular-alveolar structure which is organized into 15 to 20 lobes (lobus mammae). These alveoli are lined by a single layer of cuboidal epithelial cells, supported by contractile myoepithelial cells and a basement membrane, which aids in milk ejection. Lobes are arranged around the nipple (papilla mammae) where the epithelium transitions from simple cuboidal in the smaller ducts to stratified cuboidal and then to stratified squamous epithelium near the nipple (Baumgartner, 2018). Each lobe is drained by a lactiferous duct (ductulus lactiferus) and each lactiferous duct expands into a lactiferous sinus (sinus lactiferus), which narrows as it approaches the nipple and opens with a small pore (Figure 1). Within each lobe, smaller subdivisions called lobules (lobulus mammae) contain terminal duct lobular units (TDLUs), the primary structures responsible for milk production. (Takač, 1996; Hayes & Nguyen, 2014). Dense connective stroma surrounds the glandular structures, interspersed with adipose tissue that contributes to the breast's size and shape.



Figure 1: Anatomical structure of the breast (glandula mammaria), highlighting its histological organization. On the left, a sagittal section of the breast shows the mammary fat, lobules, lactiferous sinuses, and Montgomery glands. On the right, a magnified view of a lobe reveals the lobes, smaller lobules, and lactiferous ducts, which converge into lactiferous sinuses. The breast's structure is specialized for milk production and secretion, supported by alveoli lined with glandular epithelium and contractile myoepithelial cells, which facilitate milk ejection.





The size and composition of the breast tissue can vary between individuals and even within different regions of the same breast, often influenced by age, hormonal status, and functional activity (Hayes & Nguyen, 2014). The breast undergoes dynamic changes throughout a woman’s life, including ductal growth and alveolar proliferation during puberty, rapid expansion and secretion during pregnancy, and eventual regression during menopause. During pregnancy, the ductal system grows extensively, forming new terminal ducts and alveoli, which become fully differentiated by late gestation to facilitate milk secretion. Following menopause, glandular tissue is replaced by fibrous and fatty tissue as hormonal stimulation decreases (Dahmane & Cör, 2001). These functional changes are influenced by hormonal cycles and are essential for the breast’s role in lactation and reproduction (Hayes & Nguyen, 2014). Understanding these histological variations is crucial for diagnosing and managing breast diseases.





5. Lymphatic system



The human lymphatic system, comprising lymphatic vessels, lymph nodes, and lymphoid organs such as the tonsils, thymus gland, and spleen, plays a critical role in maintaining tissue–fluid balance and body homeostasis (Leong et al., 2022; Natale et al., 2021). Functioning parallel to the venous system, it has primary responsibilities that include clearing interstitial fluid and substances that cannot be reabsorbed into venous capillaries, transporting food lipids (e.g., chylomicrons absorbed in the intestine), and returning lymphocytes from lymphoid organs to the bloodstream (Schuenke et al., 2010).

The lymphatic vascular system consists of lymphatic capillaries, vessels interspersed with lymph nodes, and major trunks such as the thoracic duct and right lymphatic duct. Peripheral lymphatic capillaries, which begin as blind-ended vessels, collect interstitial fluid and transport it through lymphatic vessels and nodes to major lymphatic trunks. These trunks return lymph to the venous system at the junctions of the subclavian and internal jugular veins (Schuenke et al., 2010). Lymph nodes, small bean-shaped structures situated along lymphatic vessels, act as filtering stations and secondary immune centers. Afferent lymphatic vessels bring lymph into the nodes, where macrophages and lymphocytes cleanse it of pathogens and debris. The filtered lymph then exits through efferent vessels, continuing its journey toward major ducts and the venous system (Null et al., 2023).



The axillary lymph nodes (Figure 2) serve to drain the entire upper limb, the breast and the trunk above the umbilicus and are categorized into groups (Khan et al., 2025):



 Anterior (pectoral) nodes are located along the lower border of the pectoralis minor,



behind the pectoralis major muscle. They receive lymph vessels from the lateral quadrants of the breast and superficial vessels from the anterolateral abdominal wall above the level of the umbilicus. There are usually 4-5 large nodes in this group.

 Posterior (subscapular) nodes, consisting of 6-7 nodes, lie in front of the subscapularis

muscle and receive superficial lymph vessels from the posterior trunk down to the level of the iliac crests.

 Lateral nodes, comprising 4-6 nodes lie along the medial side of the axillary vein and

receive most of the lymph vessels of the upper limb, except for superficial vessels draining the lateral side (see infraclavicular nodes below).

 Central nodes, located in the center of the axilla within the axillary fat, receive lymph

from the anterior, posterior, and lateral groups and typically consist of 3-4 nodes.

 Apical nodes, also referred to as the subclavicular group, are found at the apex of the

axilla near the lateral border of the first rib. These nodes collect the efferent lymphatic drainage from all the other axillary nodes.

 Infraclavicular (deltopectoral) nodes are not strictly axillary nodes, since they are

located outside the axilla. They lie in the groove between the deltoid and pectoralis major muscles and receive superficial lymph vessels from the lateral side of the hand, forearm, and arm.

The lymphatic system also plays a pivotal role in disease processes, particularly cancer. Unlike the cardiovascular system, the lymphatic network consists of nearly invisible, fragile vessels that transport clear, colorless lymph. This system is the main pathway for the spread of cancer cells, with malignant cells colonizing lymph nodes and distant organs, leading to a poorer prognosis in breast cancer patients. Mapping lymphatic flow patterns could enable the prediction of tumor spread based on the primary tumor site. (Leong et al., 2022; Natale et al., 2021).



6. Breast Carcinoma

Breast carcinoma is the leading cause of cancer related deaths among women (Keen & Davidson, 2003). According to WHO (2024) it is believed that breast cancer caused approximately 670000 deaths globally in 2022. Only 0,5–1 % of breast cancer occurs in men, other 99 % cases occur in women. The strongest risk factor is gender, other risk factors are: age, obesity, increased alcohol consumption, a sedentary lifestyle, exogenous hormone exposure, including contraceptive pills and hormone replacement therapy, radiation exposure, family history of breast cancer and genetic predispositions (mutation of genes - BRCA1 and BRCA2 and others) etc (WHO, 2024). Although survival rates have significantly improved over the past two decades, the incidence of this disease continues to rise worldwide. The incidence increases with age, with over 80% of cases occurring in women over 50 (Nolan et al., 2023).

Breast cancer often presents as a painless lump in the breast or armpit. A lump is usually a palpable structure and can be of any type. Additional signs (Figure 3) may present as breast swelling, changes in shape or size of the breast as well as skin changes such as erythema, pitting, an "orange peel" texture (peau d'orange) and ulceration. Alterations to the nipple, such as inversion, skin changes, or discharge, may also occur (Katsura et al., 2022; Mohallem Fonseca et al., 2019). These breast lumps on the other hand can be a sign of inflammation, hyperplastic proliferation or just fluid accumulation. However neoplastic proliferations can be present without lump formation (Cserni, 2020).





Figure 2: The lymphatic drainage of the breast, highlighting the lymphatic vessels and lymph nodes in the axillary region, involved in maintaining tissue-fluid balance and immune defense (Comans, 2019). These include the pectoral, central, subscapular, brachial, and apical groups, which collectively drain lymph from the breast, upper limb, and adjacent chest wall. The supraclavicular lymph nodes and internal mammary lymph nodes are also shown, representing additional drainage pathways. The right lymphatic duct connects this system to the right subclavian vein, demonstrating the integration of lymphatic drainage into the venous circulation



Breast tumors can be divided into benign and malignant. The main difference between benign and malignant tumors is that benign tumor cells do not spread, do not metastasize to other parts of the body, and rarely need to be treated. They can cause uncomfortable symptoms or changes in the appearance of the breast. Benign breast tumors include fibroadenoma, hamartoma, lipoma, and intraductal papilloma. Breast carcinomas can be classified according to histological grade or histological type. Histological grade assesses the degree of differentiation (tubule formation and nuclear pleomorphism), the proliferative activity of a tumour and mirrors its aggressiveness. The grades of breast carcinomas range from I. which is most similar to normal healthy cells, to III. which is the most different from normal cells and most aggressive. Histological type refers to the growth pattern of the carcinoma. Among the most common are ductal carcinoma in situ (DCIS) and invasive ductal carcinoma (IDC). DCIS is a non-invasive malignant carcinoma that originates in the lactiferous ducts and remains confined to the ductal system without spreading to surrounding tissues. It is considered an early form of breast cancer with high treatment success rates. IDC, on the other hand, arises from DCIS when the cancer cells invade surrounding healthy breast tissue. It is the most prevalent type of breast cancer and is capable of metastasizing to other parts of the body. Another significant type is invasive lobular carcinoma (ILC), which originates in the lobules. ILC tends to be bilateral and multicentric, often spreading to bones, ovaries, or serous cavities. Less common types of





breast cancer include inflammatory breast cancer, which presents with swelling and redness due to lymphatic blockage; tubular breast cancer, characterized by its tubular structure under microscopic examination; and colloid breast cancer, which produces mucin. (Weigelt et al., 2010). Breast cancer stage is determined by tumor size, nodal involvement, metastases and the presence of specific biomarkers such as estrogen receptors, progesterone receptors and ERBB2 receptor. DCIS is stage 0, noninvasive breast cancer. Early invasive cancer describes stages I, IIa, and IIb, and locally advanced cancer describes stages IIIa, IIIb, and IIIc. All of these stages of breast cancer are nonmetastatic. Stage IV is metastatic breast cancer. Breast cancer which do not express any of the specific biomarkers are referred to as triple-negative. Breast cancer is treated with preoperative and postoperative systemic therapies that include chemotherapy, endocrine therapies, immunotherapy with monoclonal antibodies directed at tumor receptors, surgery and radiation (Trayes & Cokenakes, 2021).





Figure 3: Common signs and symptoms associated with breast cancer (Breast Cancer Symptoms and Signs, n.d.). These symptoms highlight potential abnormalities that may warrant further medical investigation, as they can be indicative of underlying pathological processes, such as inflammation, fluid accumulation, or neoplastic proliferation.





7. Physical therapy approach after breast cancer surgery



Rehabilitation after breast cancer surgery is crucial for improving physical function, managing pain, preventing complications like lymphedema, addressing psychological well-being, and enhancing overall quality of life (Donahue et al., 2023). Breast cancer surgery can involve procedures that significantly impact the body (De Groef et al., 2015). Rehabilitation helps manage and improve physical function, flexibility, and strength that may be lost due to surgery (De Groef et al., 2015).

The primary focus of post-surgery rehabilitation is improvement of upper limb function, because many patients experience reduced mobility and function (De Groef et al., 2015). Addressing and managing pain effectively (Olsson Möller et al., 2019) and prevention and management of post-operative complications are primary rehabilitation goals especially after lymph node removal (Davies et al., 2020). Beyond physical recovery, rehabilitation must address the psychological impact of breast cancer (Olsson Möller et al., 2019).

Rehabilitation programs are designed to improve muscle function and range of motion, incorporating both active and passive stretching exercises, and strengthening routines for the shoulder girdle muscles (De Groef et al., 2015). Complete decongestive therapy, which



uses manual lymphatic drainage, the use of compression bandages, and skin care are part of the standardized rehabilitation protocol when managing lymphedema (Donahue et al., 2023). Kinesiology tapes can also be used (Yang et al., 2024). Physical Agents such as TENS and cryotherapy may help with pain reduction. Whereas advanced treatments such as low-level laser therapy (Davies et al., 2020) and hydrotherapy (Wang et al., 2022) play a significant role in reducing pain, enhancing tissue healing and lowering inflammation as well. Rehabilitation programs are tailored to meet the physical and emotional needs of the patient, ensuring they regain their strength, function and confidence to lead a more fulfilling life (De Groef et al., 2015).



8. Discussion



Breast anatomy and its clinical implications are particularly significant in the context of breast cancer, one of the most common malignancies affecting women worldwide. The mammary gland is comprised of glandular and adipose tissues and supported by connec-tive structures. It is richly vascularized by branches of the internal thoracic, lateral thoracic, and thoracoacromial arteries, with venous drainage primarily directed into axillary and internal thoracic veins (NCBI, 2020; Cleveland Clinic, n.d.). The lymphatic drainage system is of paramount importance in the development of breast cancer, as the axillary lymph nodes are often the first sites of metastasis. In breast cancer, axillary lymph nodes are cru-cial for drainage from the upper limb and breast, as approximately 75% of lymphatic drain-age flows into these nodes (Leong et al., 2022). The lymphatic system is the main pathway for cancer cell spread, making lymphatic mapping and evaluation essential for predicting tumour spread and prognosis. Early detection of metastasis can significantly impact treat-ment and outcomes in breast cancer patients (Khan et al., 2025). Histologically, the breast undergoes dynamic remodelling influenced by hormonal changes throughout life, with notable changes during puberty, pregnancy, and menopause. The terminal duct lobular units, essential for lactation, are also the primary sites for the origin of most breast carcinomas, underscoring the need for a detailed understanding of breast histology to guide diagnosis and treatment (Hayes & Nguyen, 2014). Recognizing these changes is essential for understanding normal physiology and identifying patholog-ical conditions, aiding in better diagnosis and treatment of breast-related diseases (Leong et al., 2022). Furthermore, correct diagnosis and treatment, aided with physical therapy is essential for patient-focused rehabilitation (De Groef et al., 2015). Although the incidence of breast cancer rises, survival rates have been improving. In 2020 the World Health Organization reported 685000 deaths globally and by 2022 these rates had decreased further (WHO, 2024). This decline may be attributed to heightened public awareness regarding healthy lifestyle practices, such as reducing alcohol consumption, alongside significant improvements in early diagnostic measures, rapid treatment proto-cols, and prompt medical interventions (Nolan et al., 2023). Post-operative physical ther-apy is an integral component of breast cancer care, aiming to restore function, prevent complications, and improve the quality of life. Programs focus on improving upper limb mobility and strength through active and passive exercises, alongside specialized treat-ments like manual lymphatic drainage, compression therapy, and advanced modalities such as low-level laser therapy and hydrotherapy (Donahue et al., 2023; Davies et al., 2020). In Slovenia, the standardized post-operative rehabilitation approach is structured and phased. Early post-operative physical therapy focuses on education, proper posture, and simple shoulder exercises, progressing to advanced active exercises and scar massage after suture removal. Health education, especially for lymphedema prevention, is emphasized from the outset. Outpatient therapy additionally ensures continuity of care (Institute of Oncology, 2019). Compared to international practices, the Slovenian protocol places a stronger emphasis on early education and the gradual progression of activities tailored to individual needs. While global protocols often recommend earlier, more aggressive mobi-lization and manual therapy, the Slovenian approach favours a more cautious, stepwise methodology to minimize complications like lymphedema and ensure patient comfort (Leong et al., 2022). This structured approach demonstrates the importance of integrating anatomical and histological knowledge with patient-centred therapeutic strategies to op-timize outcomes.



9. Conclusions



The mammary gland is a complex organ consisting of glandular, adipose, and connective tissues, essential for reproductive and physiological functions. Its dynamic histology, shaped by hormonal changes, increases its vulnerability to diseases such as breast cancer, a persistent global health priority. Breast cancer frequently originates in the terminal duct lobular units, emphasizing the importance of detailed anatomical and histological knowledge for accurate diagnosis and treatment. Advances in understanding the lym-phatic system have enhanced the prediction of cancer metastasis, a critical factor in prog-nosis. Although progress has been made in early detection and treatment, breast cancer remains a significant health challenge, with rising incidence rates underscoring the need for ongoing research. Post-surgical physiotherapy plays a vital role in recovery, addressing both physical impairments and emotional well-being.



Conflicts of Interest: The authors declare no conflict of interest.



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Review



Role of Extracellular Vesicles in Breast Cancer, its Diagnostics



and Treatment

Horvat Leon1, Jazbec Jan1, Jazbec Gal1, Justin Eva1, Lavtizar Nik1, Lukavica Marisa1, Matjaš Melissa1, Mrak Manca1,

Panjan Teo1, Pavlova Oksana1, Peternelj Lučka1, Petrovčič Nina1, Porenta Pia1, Rebula Gregor1, Suhadolc Kaja1,

Štojs Neža1, Žorž Žana1, Romolo Anna2, Kralj-Iglič Veronika2,*



1. Fizioterapevtika, Ljubljana, Slovenia

2. University of Ljubljana, Faculty of Health Sciences, Laboratory of Clinical Biophysics, Ljubljana, Slovenia

* Correspondence: Veronika.kralj-iglic@zf.uni-lj.si



Abstract:

While the risk factors of breast cancer have been extensively studied and recorded, the

Citation: Horvat L, Jazbec J, Jazbec G, understanding of the microscopic and nanoscopic mechanisms causing the disease is

et al. Role of Extracellular Vesicles in not yet satisfactory. Recent research in cell biology points to sub-micron sized extracel-

Breast Cancer, its Diagnostics and lular vesicles (EVs) which are by now acknowledged to deliver cargo to cells and

Treatment. Proceedings of Socratic thereby mediate interaction between them. Investigation of EVs is challenging, as pres-

Lectures. 2025, 12, 31-39. ently there are no golden standard methods for their isolation from bodily fluids or

https://doi.org/10.55295/PSL.12.2025.I4 tissues, and their characterization. They are tiny (nano-sized) particles with dynamic

identity that require development of new technologically advanced methods. This con-tribution presents a brief survey of the evidences on various facts that are being col-lected on breast cancer EVs.

Publisher’s Note: UL ZF stays neu-

tral with regard to jurisdictional

claims in published maps and institu-

tional affiliations. Keywords: Extracellular vesicles; Extracellular vesicles in cancer; Extracellular vesicles

in breast cancer; Extracellular particles; Extracellular particles in cancer; Extracellular particles in breast cancer



Copyright: © 2025 by the authors.

Submitted for possible open access

publication under the terms and

conditions of the Creative Commons

Attribution (CC BY) license

(https://creativecommons.org/license

s/by/4.0/).





1. Etiology of breast cancer



Breast cancer is the most often diagnosed and the most prevalent cancer of all types (Luo et al., 2022). Although there are reports on different risk factors, the etiology of cancer is not known. Incidence rate increases with age and saturates after about 55 years of age (Luo et al., 2022). It was found that lifestyle increases the risk for breast cancer incidence, e.g. smoking in premenopausal women (Peñalver-Argüeso et al., 2023), alcohol intake (McDonald et al., 2013), higher intake of sugar (Farvid et al., 2021) and red meat (Lo et al., 2020). Some chemicals were connceted to higher incidence of breast cancer: polutants (White et al., 2023), food aditives (Sellem et al., 2024), heavy metals (Romaniuk et al., 2017), radiation (Preston et al., 2016), drug use disorder (Dahlman et al., 2021), psychological factors (Greer & Morris, 1975), lack of physical activity, and obesity (Hardefeldt et al., 2018). Genetic factors play a significant role in many cases of breast cancer, particularly mutations in the BReast CAncer genes BRCA1 and BRCA2 which are associated with a high risk of developing the disease (Mehrgou et al., 2016). Additionally, various other genetic alterations contributing to breast cancer have been identified (Pal et al., 2024). The reported risk factors indicate the link of cancer incidence with hormonal status (Henderson & Feigelson, 2000). Hormonal factors, especially prolonged exposure to estrogen, are also crucial in the development of breast cancer (Al-Shami et al., 2023). Estrogens promote the growth of breast tissue, which may contribute to the development of cancerous cells, particularly in cases of hormonal imbalance or excessive estrogen production (Yaghjyan & Colditz, 2011). Early menarche (Harris et al., 2024; Lopes et al., 2024), late menopause (Lopes et al., 2024), and hormone replacement therapy (Vinogradova et al., 2020) are all risk factors that increase the likelihood of developing breast cancer.





2. Extracellular vesicles (EVs)

Extracellular vesicles (EVs) are submicron membrane-bound structures released by all cell types into the extracellular space (Yanez-Mo et al., 2015). They are classified into subtypes based on their biogenesis and size, including exosomes, microvesicles (or ectosomes), and apoptotic bodies (Yanez Mo et al., 2015).

EVs have emerged as essential mediators of intercellular communication, carrying diverse molecular cargo, including proteins, lipids, RNA, and DNA (Welsh et al., 2024). This cargo allows EVs to influence a variety of biological processes (Yanez Mo et al., 2015; Welsh et al., 2024). EVs are involved in various disease processes, particularly cancer. They are present in various biological fluids and hold great potential as biomarkers for early cancer detection, disease progression monitoring, and treatment response evaluation (Póvoa & Rodrigues, 2022; Bamanakar et al., 2023). Being crucial for cell-to-cell signaling, they influence tumor growth, metastasis, and immune responses, thus opening new possibilities for diagnosis and therapy (Chang et al., 2021). In breast cancer, EVs hold promise as non-invasive biomarkers detectable in blood and other body fluids for early diagnosis and monitoring (Xu et al., 2024). Ongoing research explores their use for therapeutic applications such as targeted drug delivery due to their ability to transport therapeutic agents directly to tumor cells.

3. Mechanisms of EV formation

3.1. Endosomal Pathway (Exosome Formation)

Exosomes, a subtype of EVs, are generated through the Endosomal Sorting Complexes Required for Transport (ESCRT) - dependent and -independent mechanisms (Teng & Fussenegger, 2020). Initially, the plasma membrane invaginates, forming early endosomes that mature into late endosomes, also known as multivesicular bodies (MVBs) (Yanez Mo et al., 2015). The inward budding of the endosomal membrane leads to the formation of intraluminal vesicles (ILVs) within MVBs. These ILVs eventually fuse with the plasma membrane, releasing exosomes into the extracellular space (Yanez Mo et al., 2015). The ESCRT machinery plays a critical role in sorting and packaging cargo into ILVs, while the tetraspanin family of proteins, such as CD63, also contribute to this process in an ESCRT-independent manner (Teng & Fussenegger , 2020).



3.2. Budding from the Plasma Membrane (Microvesicle Formation) Microvesicles, also called ectosomes, are formed through direct outward budding of the plasma membrane (Kralj-Iglič et al., 2020). This process is driven by the reorganization of the actin cytoskeleton and the activation of specific lipid signaling pathways (Romer et al., 2010). The local accumulation of phosphatidylserine (PS) on the inner leaflet of the membrane and the interaction with various membrane-binding proteins promote membrane curvature, leading to the formation and release of microvesicles (Record et al., 2018). Unlike exosomes, microvesicles do not involve endosomal intermediates but are directly shed from the cell surface.



3.3 Apoptotic Body Formation



Apoptotic bodies are larger EVs formed during the programmed cell death (apoptosis) process (Yanez Mo et al., 2015, Kralj-Iglic et al., 2020). As cells undergo apoptosis, the plasma membrane begins to bleb, and fragments of the dying cell, including cytoplasm, organelles, and nuclear fragments, are packaged into apoptotic bodies. These larger vesicles are then released into the extracellular space, and they typically serve to eliminate cellular debris in an organized manner, facilitating immune system clearance (Boada - Romero et al., 2020).

3.4 Regulatory Factors

The mechanisms of EV formation are complex and involve multiple pathways that enable cells to release distinct types of vesicles into the extracellular space. Exosome formation through the endosomal pathway, microvesicle shedding from the plasma membrane, and apoptotic body formation during cell death are all critical processes in cellular communication. The formation and release of EVs are regulated by various factors, including cellular stress, environmental signals, and disease states. Key signaling pathways, such as those involving RABS (small GTPases), phosphoinositides, and tetraspanins, play critical roles in regulating vesicle biogenesis (Rädler et al., 2023). Additionally, cellular conditions like hypoxia, senescence, oncogene activation, oxidative stress (Chiaradia et al., 2021), inflammation (Ammirata et al., 2024) can influence the quantity and cargo of EVs, thereby modulating their functions in both physiological and pathological contexts.

In contrast to exosomes, microvesicles form through a different process that involves direct outward of the plasma membrane (Kralj-Iglič et al., 2020). This pathway, often referred as ectosome formation, is driven by the rearrangement of the cytoskeleton, specifically actin filaments, and the activation of various lipid signaling pathways (Meldolesi, 2018). These processes induce membrane curvature, leading to the shedding of vesicles from the cell surface. Microvesicles are typically larger than exosomes, with diameters ranging from 100 to 1000 nm.

3. Methods of EV isolation from bodily fluids

Ultracentrifugation: This standard technique uses high-speed centrifugation to separate EVs based on their density. It is efficient but time-consuming and requires precise optimization of speed and duration. High centrifugal forces can also damage EVs, affecting their integrity and functionality (Božič et al., 2019). Size-Exclusion Chromatography (SEC): SEC separates EVs by size as they pass through a porous matrix, offering higher purity compared to ultracentrifugation, however, it is slower and may require optimization for specific sample types (Clos-Sansalvador et al., 2022). Density Gradient Centrifugation (DGC): DGC separates particles through a gradient of different densities, providing high purity, particularly in complex samples, however, it is complex, time-consuming, and requires careful handling (Clos-Sansalvador et al., 2022). Additional techniques like ultrafiltration, immunoaffinity capture (Welsh et al., 2024) and microfluidic analysis (Chen et al., 2024) are emerging for EV isolation from smaller samples.



4. Methods of EV isolation from tissues

Isolating EVs from tissues is complex due to the challenge of extracting them from the extracellular matrix (Crescitelli et al., 2021). Successful isolation has been reported from



various tissues including adipose tissue (Sabio and Crewe, 2023), tumors (Swatler et al., 2024), placenta (Zabel et al., 2020), and brain (Metamoros-Angles et al., 2024). In the central nervous system (CNS), EVs released by nerve cells play roles in both normal and pathological processes (Gassama et al., 2021). Protocols for isolating EVs from tissue interstitial fluids have been developed only recently (Guerrero-Alba et al., 2024). The MISEV2023 guidelines, updated by the International Society for Extracellular Vesicles (ISEV)(Welsh et al., 2024), offer standardized practices for isolating and characterizing EVs from solid tissues. These guidelines emphasize: Clarification of terminology to ensure consistent use of EV definitions; Experimental design to ensure reliable and reproducible results; Method flexibility, allowing researchers to select methods suitable for their research needs. EVs from tissues are typically separated based on biophysical properties like size, density, and surface composition (Welsh et al., 2024).





5. Methods of EV characterization



Western blotting, Nanoparticle Tracking Analysis (NTA), and Electron Microscopy (EM) are commonly used to analyze EV composition, number density, and morphology, respectively (Welsh et al., 2024). Despite these challenges, EVs show promise for identifying new biomarkers that could enable early cancer detection (Póvoa & Rodrigues, 2022; Möller & Salomon, 2023). Advanced technologies, such as mass spectrometry and sequencing, enable the identification of potential biomarkers and the improvement of diagnostic tools (Pocsfalvi et al., 2016). Advances in techniques such as nonlinear optical microscopy, which uses endogenous contrasts, have enhanced the ability to analyze EVs' biochemical and functional properties (Sorrells et al., 2024). Advanced deconvolution methods can be used to assess the EV transcriptome and compare expression profiles with different cell types (Larsen et al., 2024). Cancer cell-derived EVs carry molecules like messenger RNA and micro RNA, which affect signaling pathways and protein expression in target cells, supporting tumor growth and spread (Thery et al., 2018). However, quantifying EVs remains challenging, as many methods rely on indirect markers or particle counts, which may not always be specific to EVs (Atlantis Bioscience, 2024).



6. Types and treatments of breast cancer

Carcinomas are tumors that start in the epithelial cells that line organs and tissues throughout the body. According to the type of cells in the breast that become cancer cells, we distinguish ductal carcinoma (originating in the milk ducts) and lobular carcinoma (originating in the glands in the breast that make milk). If the cancer remains in the duct, it is called ductal carcinoma in situ; if it expended in other breast tissue, it is called invasive or infiltrating breast cancer. Cancer cells carry estrogene (ER) and progesterone receptors (PR) and can be accordingly stimulated by the hormones (HR) (Orrantia-Borunda et al., 2022). Some have increased quantities of the human epidermal growth factor receptor-2 (HER2) protein which also stimulates growth of the cancer cells (Orrantia-Borunda et al., 2022). The cancer cells are acquired from the tumor and tested for ER, PR and HER2 to be assigned positive or negative for the particular type. Recently, additional markers are considered such as different micro RNAs and gene mutants (Orrantia-Borunda et al., 2022).

Primary treatment of breast cancer is surgery combined with chemotherapy, targeted therapy and/or radiation therapy; in surgery, a part or entire breast is removed, usually together with nearby lymph nodes to test whether the cancer has spread (Trayes & Cokenakes, 2021). Chemotherapy includes oral or intravenous drugs to kill the cancer cells. Radiation therapy is used to shrink tumor before surgery and after surgery to kill the possibly remaining cancer cells. Targeted therapy includes endocrine therapy to diminish the amount of hormones that could stimulate the growth of the cancer cells. Antibody drug conjugates (ADCs) contain monoclonal antibodies and cytotoxic substances to deliver these drugs to the targets: cancer cells with specific surface antigens. In this way the treatment is more effective and the risk of systemic toxicity is lower than in conventional chemotherapy. This method is particularly promising for HER2-low and triple (ER, PR and



HER2) negative breast cancer which previously lacked effective treatments. (Mark et al., 2023).





7. Effect of radiation on EVs of cancer cells and radiation induced bystander effect



About half of the cancer treatments involve radiotherapy (Huber st al., 2024). At the cellular level radiotherapy should cause DNA destruction in cancer cells (Jassi et al., 2024) by inducing changes in DNA repair and causing cell cycle arrest and apoptosis. As key mediators of cell communication, also EVs play an important role in these processes (Szatmári et al., 2019). EVs are selectively targeting cells and can modulate the effects of radiation (Ripoll-Viladomiu et al., 2024), promote immune and inflammatory responses (Huang et al., 2018) and transmit microRNAs (e.g. miR-603) to influence the response of cancer cells in glioblastomas (Ramakrishnan et al., 2020). Radiotherapy affects not only cancer cells but also surrounding normal tissue. The radiation-induced bystander effect describes the changes in non-irradiated cells induced by the signals from irradiated cells. Communication between the irradiated and non-irradiated cells via radiation-influenced EVs creates indirect radiation exposure which affects adaptation to radiation (Jassi et al., 2024).

8. Clinical studies on EVs in breast cancer diagnostics

Recent studies have focused on the lipid composition of plasma-derived EVs as diagnostic biomarkers for breast cancer. Using mass spectrometry-based lipidomics, researchers identified significant alterations in lipid classes, including phosphatidylcholines and sphingomyelins, in EVs from breast cancer patients compared to healthy controls. These distinct lipid profiles demonstrated high accuracy in differentiating cancer patients from non-cancer individuals, highlighting their potential as a non-invasive diagnostic tool for early detection and disease stratification (Nishida-Aoki et al., 2020). There are various molecular mechanisms by which EVs promote brain metastasis in breast cancer (Sakamoto et al., 2023): EVs deliver bioactive molecules, such as microRNAs and proteins, to recipient cells, thereby regulating signal transduction and protein expression levels; EVs from brain metastatic breast cancer cells disrupt the blood-brain barrier by altering tight junctions between endothelial cells and promoting tumor cell infiltration into the brain parenchyma; EVs influence astrocyte function, contributing to the establishment of a pre-metastatic niche that supports tumor growth (Sakamoto et al., 2023). Mizenko et al. (2024) analyzed 471 clinical trials performed from 2000 to 2022 to evaluate the status and challenges of EV-based diagnostics and therapies. They found that 70% of trials focus on diagnostics, with cancer (breast and lung) as the primary targets, while 18% explore therapeutic applications, particularly those using mesenchymal stromal cell-derived EVs for inflammatory, respiratory, and neurological disorders. Ultracentrifugation was the most common EV isolation method (31%), and RNA sequencing was the leading characterization tool (36%). However, only 36% of trials fully reported EV isolation/characterization protocols. Most trials were conducted in North America (42%) and Asia (36%), underscoring regional research dominance (Mizenko et al., 2024). The authors emphasize the need for standardized methodologies to address EV heterogeneity and enhance clinical translation. Zhang et al. (2023) assessed EVs in 80 patients with varying stages of the disease. The study demonstrated that the presence of specific EV markers correlated with tumor progression, offering a non-invasive approach for real-time monitoring (Zhang et al., 2023). Challenges such as standardizing isolation and characterization methods remain, with future research aiming to address these limitations to facilitate clinical translation.



9. Predictive value of EVs

Effects of EVs in cancer include angiogenesis, epithelial–mesenchymal transition, extracellular matrix remodelling, and immune escape (Tao and Guo, 2020). The predictive value of EVs lies in their ability to reflect real-time changes in the tumor microenvironment (Xu et al., 2024). Tumor-derived EVs contain a variety of biomolecules, including proteins, lipids, and nucleic acids, which reflect the molecular characteristics of the tumor,



providing valuable insights into disease progression and therapeutic response (Zhang et al., 2023; Xu et al., 2024). EVs are suggested to play crucial roles in intercellular communication, promoting tumor growth, metastasis, and drug resistance (Schwarzenbach & Gahan, 2020). They offer several advantages over traditional biomarkers, including their ability to capture tumor heterogeneity and their potential to track both primary tumors and metastatic sites (Lee et al., 2023; Vinik et al., 2020). The protein content of EVs can serve as a tool for monitoring therapeutic response and detecting early relapse in metastatic breast cancer (Tian et al., 2021; Zhou et al., 2021). Studies have identified specific EV proteins that correlate with breast cancer progression, recurrence, and drug resistance, suggesting their potential for personalized treatment strategies (Serretiello et al., 2024; Tian et al., 2021). Recent advancements in proteomics and advanced analytical techniques, such as mass spectrometry, have enabled the identification of tumor-specific EV biomarkers, offering further insights into the molecular underpinnings of breast cancer (Bandu et al., 2024; Muttiah et al., 2024). The integration of EV analysis with other biomarkers, including circulating tumor DNA and small RNAs, enhances the sensitivity and specificity of early detection and monitoring of therapeutic efficacy (Koi et al., 2020; Rayamajhi et al., 2024).





10. Conclusions



EVs hold substantial promise as non-invasive biomarkers for breast cancer diagnosis, metastasis monitoring, and treatment response prediction. Their role in tumor biology, combined with advances in detection technologies, makes them a valuable tool for precision oncology and personalized cancer therapy. The potential use of EVs as delivery vehicles for targeted therapies opens new avenues for breast cancer treatment, with ongoing research exploring their role in immuno-oncology and drug delivery (Asleh et al., 2023; Wang et al., 2021).



Funding: This research was funded by Slovenian Research Agency (ARIS) (grant numbers: J3-3066, J2-4447, P3-0388, J3-60063, and project Nanostructurome (according to a contract between ARIS and University of Ljubljana), and the European Union’s Horizon 2020 Research and Innovation Pro-gramme under the Marie Skłodowska–Curie Staff Exchange project “FarmEVs” (grant agreement no: 101131175). The views and opinions expressed in this publication are solely those of the authors and do not necessarily reflect those of the European Union. Neither the European Union nor the granting authority can be held responsible.



Conflicts of Interest: The authors declare no conflict of interest.



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Review



The Problem of Modular Hip Endoprosthesis



Dolinar Drago1,2,3, Potparič Igor1,2, Jenko Monika3, Debeljak Mojca4,5,6,*



1. Department for Orthopaedic Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia 2. Medical Faculty, Chair for Orthopaedic Surgery, University of Ljubljana, Ljubljana, Slovenia 3. MD-RI Institute for Materials Research in Medicine, Ljubljana, Slovenia

4. University rehabilitation institute Republic of Slovenia Soča (URI Soča), Ljubljana, Slovenia 5. Faculty of Polymer Technology, Slovenj Gradec, Slovenia

6. Faculty of Health Sciences, University of Ljubljana, Ljubljana, Slovenia

* Correspondence: Igor Potparič igor.potparic@gmail.com



Abstract:

The mechanisms of premature fracture of modular-neck stems in two case studies: (I) when the neck and stem are both made of the same Ti6Al4V alloy, and (II) when the neck and stem are made from two different alloys, CoCrMo and Ti6Al4V alloy are

Citation: Dolinar D, Potparic I, Jenko presented. The study integrates two orthopedic patients who have undergone primary

M, Debeljak M. Problem of Modular uncemented THA for usual indications in two orthopedic centers). Both centers are part

Hip Endoprosthesis. Proceedings of of the national public health care system. Both surgeries were performed by two skilled

Socratic Lectures. 2025, 12, 41-45. orthopedic surgeons with more than 10 years of experience in THA. The survivorship

https://doi.org/10.55295/PSL.12.2025.I5 of the modular neck of cast CoCrMo alloy was 24 months. The survivorship of the

modular neck from Ti6Al4V alloy was 84 months. Advanced analyses were performed to assess the differences in the fretting, corrosion, and fatigue, using stereo light

Publisher’s Note: UL ZF stays microscopy (SLM), scanning electron microscopy (SEM), X-ray energy-dispersive

neutral regarding jurisdictional spectroscopy (EDS), and electron backscatter diffraction (EBSD). Patient demographic claims in published maps and information, including sex, age, body mass index, survivorship of implants, and reason

institutional affiliations. for the revision, was collected from medical records. The fretting and fatigue occurred

on both modular stem retrievals, but the CoCrMo/Ti6Al4V alloy system suffered more corrosion due to additional galvanic corrosion and fractured earlier than the Ti6Al4V/Ti6Al4V metal alloy system. Both metallic alloy systems used in this



Copyright: © 2025 by the authors. application are known to be highly corrosion-resistant, but the bio-tribo-corrosion

Submitted for possible open access processes need to be understood in detail and characterized so that appropriate

publication under the terms and improvements in design and materials can be made. conditions of the Creative Commons

Attribution (CC BY) license

(https://creativecommons.org/license

s/by/4.0/). Keywords: Total hip arthroplasty; Modular neck; Ti6Al4V alloy; CoCrMo alloy;

Corrosion

____________________________________________________________________________





1. Introduction



Modular neck stems were introduced to hip endoprosthesis with the expected benefits of reducing pain and improving the range of motion and leg length (Azar et al.,2016; Baleani et al., 2023; Ellma & Levine,2013). Besides classic stems, Wright Medical Technology/Microport, Stryker, Depuy, Lima Corporate, Zimmer, Adler Ortho, Cremasoli, and others are the recognized worldwide manufacturers of modular neck stems. The stems and the necks are available in different sizes and different neck angles, to tailor the implant to the individual patient. Increased implant modularity with modular necks made from Ti6Al4V and stems from the same alloy has generated interest in recent years because the various neck sizes, offsets, lengths, and design configurations allow the surgeon to optimize the range of motion and the patient’s leg length. However, there have been concerns due to early in vivo fractures as well as adverse tissue reactions related to corrosion at the neck–stem interface (Baleani et al.,2023; Ellman & Levine, 2013; Wright et al., 2010; McTighe et al 2015; Park et al., 2018; Solarino et al., 2021; Maniscalco et al., 2020; Castagnini et al., 2023; Goffton et al., 2017; Fokter et al., 2017; ). The presence of the neck–stem interface using titanium alloys makes the neck junction vulnerable to fretting, corrosion, and fatigue fracture. Several authors reported an early fracture of long modular necks made of Ti6Al4V alloy ( McTighe et al 2015; Park et al., 2018; Solarino et al., 2021;Maniscalco et al., 2020; Castagnini et al., 2023; Goffton et al., 2017; Fokter et al., 2017; Dolinar et al., 2018; Gorenšek & Jenko, 2018). Many of the femoral modular stems suffer from premature fractures after the total hip arthroplasty (THA) of the titanium alloy neck. Due to the results of in vitro investigations which presented better wear and mechanical properties, a cobalt–chromium–molybdenum neck was introduced (Castagnini et al., 2023; Goffton et al., 2017; Fokter et al., 2017; Dolinar et al., 2018; Jenko et al., 2018). CoCrMo neck fractures have also been reported after only a few months of implantation (Dolinar et al., 2018; Gorenšek & Jenko, 2018). Some reports have shown cases of fractured necks that could not be detracted from the stem pocket, requiring the replacement of the otherwise well-fixed femoral stems (Baleani et al.,2023; Wright et al., 2010; Solarino et al., 2021; Fokter et al., 2017; ).



The main aim of our work was to investigate mechanisms of premature failure of two case studies due to the fracture of the long neck in two different metallic alloy systems: the same alloy (neck and stem are both made from the same Ti6Al4V alloy with a survivorship of 84 months) and different alloys (neck made from CoCrMo alloy with better mechanical properties and a stem body made from Ti6Al4V alloy, with a survivorship of only 24 months) ( Dolinar et al., 2018; Jenko et al., 2018; Gorenšek & Jenko, 2018; Soteranos et al., 2013; Viceconti et al., 1997; Oladokun, et al., 2015; Gilbert et al., 1993). The research was a joint effort of orthopedic surgery clinicians and material scientists.

2. Methods

2.1. Stereo Light Microscopy (SLM)

A stereo light microscope, Tagarno FHD trend, was used for the visualization of the fractured surfaces of the Ti6Al4V modular neck and the Co-Cr-Mo modular neck.

2.2. Scanning Electron Microscopy (SEM, SEM/EDS, SEM/EBSD) Analysis The morphology and microstructure of the fracture surfaces were analyzed using a scanning electron microscope, JEOL JSM 6500-F (JEOL Ltd., Japan). The SEM images were acquired using an accelerating voltage of 15 kV, with a current of about 500 pA and a working distance of 10 mm. Secondary electron and backscattered electron images were acquired. The elemental compositions of the samples were analyzed using Oxford INCA EDS analysis. The EDS spectra were acquired using a 15 kV and 1 nA beam, with an acquisition time of 60 s for each spectrum. The EDS spectra were analyzed using INCA Energy software to determine the elemental composition and distribution in the sample. Electron backscatter diffraction (EBSD) was also used to determine the type of carbides present in the microstructure. A Nordlys EBSD detector (HKL) and a Channel 5 data analysis suite were used. The EBSD patterns were acquired at 15 kV accelerating voltage and 2 nA current.



2. Results



Analysis of the surface and composition of the fractured surface of the two failed prostheses is shown in Figures 1 and 2. Figure 1 presents the modular neck stem made of CoCrMo (neck) and /Ti6Al4V (stem) alloys and Figure 2 presents the modular neck stem made of the same alloy: Ti6Al4V (neck) and Ti6Al4V).





D D C





B1



D





B2 100µm 10µm 1µm



A B1 B1 C



100µm 10µm





B1



A A A





100µm



100µm 100µm 100µm 10µm 10µm 10µm 1µm 1µm 1µm



Figure 1: SLM of the fractured surface of CoCrMo neck on the main inside image represents the mechanism of CoCrMo alloy modular neck fracture. The blue arrow indicates the crack initiation; Zone-A the corroded fractured surface with deposited biological material is shown in three SE images in three blue marked panels: the left panel A at lower magnification, the detail of fatigue fracture and cracked carbides at higher magnification, panel A in the middle, and cracked carbide at highest magnification in the right panel A. The red arrows show the direction of fatigue crack propagation in the location B1 and location B2. The fatigue striations were observed in SE images in areas marked in yellow, the microstructures details are shown in middle and upper panels. At Zone C, the fracture surface is very rough and angular. The fracture surface shows several secondary cracks that are perfectly straight and short. Next to these flat cracks, larger secondary cracks can be seen, which are branched and longer than the flat ones. The lower SEI shows the crack propagation, and the middle and upper SEI shows the details at higher magnifications. The SE image of Zone-D marked green, shows a sudden fracture. Zone-D in the right panel shows areas of EDS analysis of the fracture surface (yellow squares marked in the right panel). From (Dolinar et al., 2023).





Figure 2. (a) Image of different fractured surface regions of fractured Ti6Al4V modular neck; (a–b) yellow-marked region and yellow-framed SE image of fatigue failure and with higher magnifications (b,d,e); (a,c) green-marked region and green-framed SE image with sudden ductile fracture. Organic deposits on fractured Ti6Al4V surface due to PE nanoparticle migration were found and visible as blue color (a). From (Dolinar et al., 2023).



3. Conclusions



The fretting, corrosion, and fatigue occurred on both neck–stem retrievals of the same (Ti6Al4V neck/Ti6Al4V stem) and different (CoCrMo neck/Ti6Al4V stem) metal systems. The cracked femoral neck made of CoCrMo alloy was dynamically loaded, exposed to a corrosive medium, and surrounded by a Ti6Al4V alloy with a different electrochemical potential. Due to the constant dynamic load and a combination of different materials in a corrosive medium, galvanic corrosion on the surface of the modular neck occurred. The different-metal system made of CoCrMo/Ti6Al4V suffered more corrosion than the same-metal system made of Ti6Al4V/Ti6Al4V alloy due to additional galvanic corrosion. The nature of the in vivo mechanisms causing the formation of the bio-tribo-corrosion processes needs to be understood and characterized so that appropriate changes in design and materials can be implemented.





Conflicts of Interest: The authors declare no conflict of interest.



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Reflection/Review



Feline Tooth Resorption



Dučić Nejra1*, Avdić Rizah1, Hadžiomerović Nedžad1, Vejzović Anel1, Tandir Redžep2, Tandir Faruk1



1. University of Sarajevo – Veterinary Faculty, Sarajevo, Bosnia and Herzegovina 2. The Public Institution Health Centre of Sarajevo Canton—Dental Service, Sarajevo, Bosnia and Herzegovina

* Correspondence: Nejra Dučić; nejra.ducic@vfs.unsa.ba



Abstract:

Feline tooth resorption is one of the most common dental disorders in cats, character-ized by a progressive loss of tooth substance. The aetiology of this disease is not com-pletely understood. Multiple factors may play a role in etiopathogenesis of this disease, such as: age, diet, chronic oral inflammation, metabolic and endocrine diseases, ana-

Citation: Dučić N, Avdić R, Hadžio- tomical ab-normalities. Based on radiographic appearance, resorptive lesions are clas-

merović N, Vejzović A, Tandir R, sified into three types. Several symptoms accompany this disease, including anorexia,

Tandir F. Feline Tooth Resorption. dysphagia, halito-sis and oral discomfort. Tooth resorption can be detected with a com-

Proceedings of Socratic Lectures. 2025, bination of visual inspection, examination under general anesthesia with a sharp dental

12, 47-51. explorer and in-traoral dental radiography. Treatment of option is extraction of the af-https://doi.org/10.55295/PSL. 12.2025.I6 fected teeth, and crown amputation in teeth with type 2 lesions.



Publisher’s Note: UL ZF stays

neutral with regard to jurisdic- Keywords: Teeth; Cats; Resorptive lesions

tional claims in published maps

and institutional affiliations.





Copyright: © 2025 by the authors.

Submitted for possible open access

publication under the terms and

conditions of the Creative

Commons Attribution (CC BY)

license

(https://creativecommons.org/lice

nses/by/4.0/).





1. Introduction



Feline tooth resorption is one of the most common dental disorders in cats with a preva-lence ranging from 30% to 60% (Ingram et al., 2001; Niemiec, 2012). This disease is charac-terized by a progressive loss of tooth substance (Girard et al., 2008). Mandibular third pre-molar teeth (307 and 407) are most commonly affected, but these lesions can occur in all types of teeth (Ingham et al., 2001; Gorrel, 2015). Age seems to be an important risk factor, along with diet and presence of other dental diseases. However, the aetiology of this dis-ease is not understood completely (Niemiec, 2012; Pistor et al., 2023). What is known is that the resorption is caused by odontoclasts, cells responsible for the resorption of dentine and cementum. The resorption begins on the root surface, and then reaches the dentine (Niemiec, 2012). As the disease progresses, the pulp gets involved. Eventually, the enamel is affected and it either gets resorbed or it fractures off (Gorrel, 2015). Other factors that may play a role in etio-pathogenesis of this disease include: chronic oral inflammation, metabolic and endocrine diseases, systemic acidosis, local hypoxia, anatomical abnormal-ities, low urinary specific gravity, viral diseases (Reiter et al., 2005; Booij-Vrieling, 2009; Mestrinho et al., 2013). According to the American Veterinary Dental College (AVDC), there are three types of tooth resorption based on radiographic appearance. In type 1 le-sions, focal or multifocal lucencies are present in the tooth, whereas the periodontal liga-ment space is normal and there is no bony replacement of the lost tooth structure. The radiopacity is also normal. In type 2 lesions, the periodontal ligament space is narrowed, radio-opacity is decreased and the lost tooth structure is replaced with bone. Type 3 rep-resents a combination of types 1 and 2, with certain parts of a tooth showing type 1 lesions, and other parts showing type 2 lesions (Niemiec, 2012) (Figure 1).





Figure 1. Types 1, 2 and 3 of tooth resorption lesions (Source: Copyright AVDC®, used with permission).



1.1. Clinical presentation

Various symptoms accompany this disease, including anorexia, dysphagia, halitosis and oral discomfort (DuPont, 2005). Tooth defects are first noted at the gingival margin (Niemiec, 2012). Gingivitis is not always present, but when it is, it’s recorded as mild, moderate and severe inflammation with redness, edema, bleeding and ulceration (Silness and Loe, 1964; Mestrinho et al., 2013). Many resorptive lesions are usually covered with gingival or granulation tissue which tend to bleed when touched (Debowes, 1994). Otherwise, these cases are often asymptomatic (DuPont, 2005). Type 1 lesions are usually associated with inflammation, whereas type 2 lesions create local gingivitis (Niemiec, 2012). In order to detect any of these lesions, a thorough oral examination under general anesthesia must be performed. Dental explorers are used to detect any irregularities at the surface of the tooth (Harvey et al., 2004) (Figure 2).



Figure 2. Clinical examination of right mandibular molar (tooth 409) using a dental explorer.





1.2. Diagnosis and treatment



Tooth resorption can be detected with a combination of visual inspection, examination un-der general anaesthesia with a sharp dental explorer and intraoral dental radiography. Visual inspection during an oral examination is the first step in diagnosing tooth resorp-tion. These lesions can appear as tissue filled defects, along with inflamed associated gin-giva (Niemiec, 2012). However, this is not always the case, as the tissue may appear normal in early stages of the disease (Reiter et al., 2005). A dental explorer is used by placing it on the tooth and running it across the tooth surface, searching for rough areas. All tooth sur-faces must be examined (Niemiec, 2012). Dental radiography is essential in detecting tooth resorption lesions which are located below the gingival attachment, as well as differenti-ating between the types (Reiter et al., 2019). Full-mouth intraoral radiographs are espe-cially recommended in cats 6 years of age or older (Niemiec, 2009). Various methods of treatment have been used historically. Some of them include: topical fluoride treatment (Lyon, 1990), restorations with glass ionomer or composite (Roes, 1996; Schweighart ‐ Banzhaf and Benz, 1997), and use of alendronate which slowed the progression of tooth resorption (Mohn et al., 2009). Nowadays, the preferred treatment of choice is extraction. Considering that teeth with resorptive lesions are weak and dentoalveolar ankylosis is present, a surgical approach is recommended. In type 2 lesions, crown amputation is an acceptable treatment option, considering that it causes less trauma and faster healing (DuPont, 1995; Niemiec, 2012).



2. Experiences from the Clinic for Veterinary Dentistry at University of Sarajevo

Since 2018, 41 cats with tooth resorption have been admitted to the Clinic for Veterinary Dentistry at University of Sarajevo – Veterinary Faculty. Admitted patients were of various breeds, predominantly domestic shorthair cats, aged 2 to 10 years old. 26 of them were males, and 15 females. All of the cats showed symptoms of halitosis and oral pain and discomfort. Prior to every detailed oral examination, anesthetic induction is performed with intramuscular medetomidine-hydrochloride (80 µg/kg), butorphanol (0.4 mg/kg) and ketamine (5 mg/kg). One perioperative injection of meloxicam (0.2 mg/kg SC) is adminis-tered. A complete periodontal probing of each tooth is performed, along with exploration of the tooth surface. Full mouth radiographs are obtained with the Schick intraoral x-ray system (SDX) (Figure 3).





Figure 3. A – Radiograph of the right side of the mandible in a 4-year-old mixed breed cat with a history of gingivitis, halitosis and anorexia. Blue arrow is showing resorptive lesions in tooth 407. B – Radiograph of the left side of the mandible in a 6-year-old mixed breed cat with chronic gingivitis (FIV positive). Blue arrow is showing resorptive lesions in tooth 307.





Depending on the type of lesions, treatment consists of extraction or crown amputation. Dental nerve blocks are performed using 2% lidocaine-hydrochloride (2 mg/kg). Postop-erative instructions include the use of analgesics, along with semi-liquid food for the first couple of days after the procedure.





Funding: This article received no grant from any funding agency.





Conflicts of Interest: The authors declare no conflict of interest.



References

1. American Veterinary Dental College. AVDC® Nomenclature. https://avdc.org/ Accessed on January 13th 2025. 2. Booij-Vrieling HE, Tryfonidou M., Riemers FM, Penning LC, Hazewinkel HA. Inflammatory cytokines and the

nuclear vitamin D receptor are implicated in the pathophysiology of dental resorptive lesions in cats. Vet.

immunol. Immunopathol. 2009; 132:160-166. https://doi.org/10.1016/j.vetimm.2009.05.015

3. Debowes LJ. Odontoclastic resorptive lesions in cats. Waltham Focus. 1994; 4: 2–8. 4. DuPont GA. Crown amputation with intentional root retention for advanced feline resorptive lesions: A clinical

study. J Vet Dent. 1995; 12:9-13. https://doi.org/10.1177/089875649501200101

5. DuPont GA. Radiographic Evaluation and Treatment of Feline Dental Resorptive Lesions. Vet. Clin. North Am.

Small Anim. Pract. 2005; 35: 943–962. DOI:10.1016/j.cvsm.2005.03.008

6. Girard N, Servet E, Biourge V, Hennet P. Feline Tooth Resorption in a Colony of 109 Cats. J. Vet. Dent. 2008; 25:

166–174. https://doi.org/10.1177/089875640802500302

7. Gorrel C. Tooth resorption in cats: Pathophysiology and treatment options. J Feline Med Surg. 2015; 17:37-43.

DOI:10.1177/1098612X14560098

8. Harvey CE, Orsini P, McLahan C, Schuste C. Mapping of the radiographic central pointof feline dental resorptive

lesions. J. Vet. Dent. 2004; 21:15–21. https://doi.org/10.1177/089875640402100102

9. Ingham KE, Gorrel C, Blackburn J, Farnsworth W. Prevalence of odontoclastic resorptive lesions in a population

of clinically healthy cats. J Small Anim Pract 2001; 42:439-443. https://doi.org/10.1111/j.1748-5827.2001.tb02497.x

10. Lyon KF. Feline dental disease: treatment of subgingival resorption lesions. J. Vet. Dent. 1990; 7:13–14.

https://doi.org/10.1177/089875649000700103

11. Mestrinho LA, Runhau J, Bragança M, Niza MM. Risk assessment of feline tooth resorption: a Portuguese clinical

case control study. J. Vet. Dent. 2013; 30: 78-83. https://doi.org/10.1177/089875641303000202

12. Mohn KL, Jacks TM, Schleim KD et al. Alendronate binds to tooth root surfaces and inhibits progression of feline

tooth resorption: a pilot proof-of-concept study. J. Vet. Dent. 2009; 26:74–81.

https://doi.org/10.1177/089875640902600201



13. Niemiec BA. Case based dental radiology. Top Companion Anim Med 2009; 24:4-19.



https://doi.org/10.1053/j.tcam.2008.12.001



14. Niemiec BA. Feline tooth resorption. Today’s Vet. Pract 2012; 59-63. Available at: https://todaysveterinaryprac-

tice.com/dentistry/feline-tooth-resorption/ Access on: 13.02.2025

15. Pistor P, Janus I, Janeczek M, Dobrzyński M. Feline Tooth Resorption: A Description of the Severity of the Disease

in Regard to Animal’s Age, Sex, Breed and Clinical Presentation. Animals. 2023; 13:2500.

https://doi.org/10.3390/ani13152500

16. Reiter AM, Lewis JR, Okuda A. Update on the etiology of tooth resorption in domestic cats. Vet. Clin. North Am.

Small Anim. Pract. 2005; 35:913-942. DOI: 10.1016/j.cvsm.2005.03.006

17. Reiter AM, Johnston N, Anderson JG, Soltero-Rivera MM, Lobprise HB. Domestic feline oral and dental diseases.

Wiggs's Veterinary Dentistry: Principles and Practice 2019; 439-461. https://doi.org/10.1002/9781118816219.ch20

18. Roes F. Pathogenese, Diagnostik und Therapie bei“neck lesions” der Katze unter Verwendung von Glas-

Ionomer-Zementen. Dissertation, Free University of Berlin, Faculty of Veterinary Medicine, Berlin, Germany. 1996.

19. Schweighart-Banzhaf D, Benz C.“Resorptive lesions” bei der Katze. Eine klinische Untersuchung zur Versorgung

mit “Dyract®”. Kleintierpraxis 1997; 42: 97–108.

20. Silness J, Loe H. Periodontal disease in pregancy (II): Correlation between oral hygiene and periodontal

conditions. Acta Odontol Scand 1964; 22: 121-35 https://doi.org/10.3109/00016356408993968





Review



Tracheal Injury after Endotracheal Intubation



Erjavec Vladimira1, Lukanc Barbara1,*



1. University of Ljubljana, Veterinary Faculty, Small Animal Clinic, Ljubljana, Slovenia

* Correspondence: Barbara Lukanc, barbara.lukanc@vf.uni-lj.si



Abstract:

Endotracheal intubation is a vital procedure in anaesthetized animals to deliver oxy-gen, volatile anaesthetics, and assist with ventilation. It also protects the airways from aspiration of gastric contents. However, improper intubation techniques or equipment can lead to complications, such as tracheal injury. Cats are particularly prone to tracheal rupture due to their sensitive tracheal anatomy and the overinflation of endotracheal

Citation: Erjavec V, Lukanc B. Tra- tube cuffs. Dental procedures, which often require repositioning, account for most tra-

cheal Injury after Endotracheal Intuba- cheal injuries in cats. Clinical signs, such as subcutaneous emphysema, coughing, and

tion. Proceedings of Socratic Lectures. respiratory distress, may occur hours to days after the procedure. Diagnosis is based

2025, 12, 53-57. on history, clinical signs, radiographs, and tracheoscopy. While mild cases can be man-https://doi.org/10.55295/PSL.12.2025.I7 aged conservatively with oxygen supplementation and rest, severe injuries require sur-

gical intervention. Proper tube selection, careful cuff inflation, and regular pressure monitoring are essential preventive measures to minimize the risk of tracheal injury.

Publisher’s Note: UL ZF stays neu- Early diagnosis and suitable management result in favourable outcomes for the affected

tral with regard to jurisdictional animals.

claims in published maps and institu-

tional affiliations.

Keywords: Endotracheal intubation; subcutaneous emphysema; dogs; cats; tracheal in-jury; tracheoscopy; dental procedures



Copyright: © 2025 by the authors.

Submitted for possible open access

publication under the terms and

conditions of the Creative Commons

Attribution (CC BY) license

(https://creativecommons.org/license

s/by/4.0/).





1. Introduction



Endotracheal tubes are made of plastic, siliconized rubber, or red rubber and can be cuffed or uncuffed. Some tubes are reinforced with a metal spiral to prevent kinking or compres-sion during extreme neck flexion. The size of the tube is determined by its internal diame-ter (in millimetres), while the external diameter determines its fit within the trachea. The external diameter can vary depending on the material and whether the tube is cuffed. Selecting the correct tube size is critical (Dugdale et al., 2020). Endotracheal tubes with an internal diameter of 3.5 - 4.5 mm are appropriate for most cats (Hardie et al.,1999). It is crucial to select the largest possible diameter that can still be used safely and allows for minimal inflation of the cuff. This is especially important for low-volume, high-pres sure cuffs, as minimal inflation helps to seal the trachea while reducing the cuff pressure and thus minimizing the risk of damaging tracheal mucosa. A tube that is too small may increase breathing resistance or become obstructed with mucus, while a tube that is too large can cause tracheal damage.



Proper tube placement extends from the level of the incisors to the proximal third of the trachea, below the cricoid. The cuff should be inflated evenly on all sides to seal the space between the tube and the tracheal wall, reduce gas leakage into the atmosphere during mechanical ventilation, and prevent passage of contents from the pharynx into the distal trachea. It also helps to position the tube tip more centrally in the trachea, reducing the risk of tube tip obstruction and tracheal wall injury, which most commonly occurs at the tube tip (Dugdale et al., 2020) or cuff (Hardie et al., 1999; Dugdale et al., 2020). Cats in particular have a sensitive dorsal tracheal ligament, which can rupture if the cuff is overinflated. This risk is increased during procedures that require repositioning, such as dental procedures or multiple x-rays. Most tracheal injuries in cats occur after dental pro-cedures, accounting for 70% of cases (Hardie et al., 1999; Mitchell et al., 2000). Injuries have also been documented after bronchoalveolar lavage and excision of histiocytoma (Hardie et al., 1999), as well as after spaying, castration, oral surgery, and hip and stifle radiographs (Mitchell et al., 2000). More than half of the cats with a tracheal rupture were intubated using a high-volume, low-pressure cuffs (Bauer et al., 2009). Unlike in cats, tracheal damage from endotracheal tube is very rare in dogs. Only two cases of tracheal stenosis have been reported – one occurring 9 days after surgery (Manabe et al., 2021), and another occurring 5 days after general anaesthesia for arthrodesis (Alderson et al., 2006). Additionally, an experimental study demonstrated tracheal necrosis caused by cuff pressure much higher than the recommended range (Su et al., 2017). Disconnecting the anaesthesia breathing system before repositioning the animal is essential to prevent tube rotation within the trachea, which could cause injury. Low-volume, high-pressure cuffs exert higher localized pressure on the tracheal mucosa, potentially causing necrosis if left in place for prolonged periods. Conversely, high-volume, low-pressure cuffs reduce localized pressure but may increase the risk of trauma during intubation or extubation (Dugdale et al., 2020). The longest tracheal ruptures were observed in cats intubated with high-volume, low-pressure tubes. No differences in occurrence were found between sexes or based on the age of the cats (Hardie et al., 1999).

Relaying solely on palpation of the pilot balloon alone makes it challenging to accurately assess the cuff pressure. However, cuff pressure can be measured with a manometer, es-pecially in high-volume, low-pressure cuffs, where the pressure in the cuff approximately reflects the pressure on the tracheal wall. Ideally, during prolonged procedures, the cuff pressure should be regularly monitored, as the patient's muscle tone can change, as well as the compliance of the cuff as it warms up (Dugdale et al., 2020). Excessive pressure in the cuff can impair tracheal mucosal perfusion, potentially leading to ischemia or necrosis of the tracheal mucosa (Fudge, 2009; Su et al., 2017; Dugdale et al., 2020).

2. Causes of tracheal injury by endotracheal intubation

The potential causes of tracheal injury include:

 Overinflation of the cuff (Hardie et al., 1999; Fudge et al., 2009; Quandt, 2017; Dug-

dale et al., 2020).

 Incorrect tube placement (Hardie et al., 1999).

 Using an improperly sized tube (Hardie et al., 1999; Fudge et al.2009).



 Changing the position without disconnecting the tube from the anaesthetic breath-



ing system (Dugdale et al., 2020; Mitchell et al., 2000).



 Intubation with the stylet (Mitchell et al., 2000).

 Chemical injury from inadequate rinsing of cleaning agents (e.g., glutaraldehyde,

chlorhexidine, ethylene oxide (Alderson et al., 2006).

Tracheal injuries are more likely during dental procedures (Dugdale et al., 2020), where the cuff is often overinflated to prevent water aspiration into the lungs (Hardie et al., 1999; Quandt, 2017). It is possible that during a dental procedure, a tracheal rupture may occur due to changes in head position, which could cause excessive manipulation of the tube, leading to tracheal trauma (Mitchell et al., 2000).

Hardie et al. (1999) attempted to simulate a situation on cat cadavers where the endotra-cheal tube was not disconnected from the anaesthesia circuit, leading to tracheal twisting, but they were unable to induce a linear tear injury in the trachea.



3. Clinical signs

Clinical signs of tracheal rupture often develop some time after the procedure because the mediastinum, which closely surrounds the trachea, can initially prevent air from escaping. When coughing or irritation of the trachea occurs, air escapes into the mediastinum and subsequently into the subcutaneous tissues (Hardie et al., 1999).

Severe damage of trachea may result in subcutaneous emphysema or pneumothorax. Pneumothorax can occur if the pressure causes rupture of the mediastinum (Fudge, 2009). Clinical signs of tracheal rupture include subcutaneous emphysema in all affected cats (Figure 1), along with difficulty breathing, coughing, gagging, loss of appetite, and fever (Hardie et al., 1999; Mitchell et al., 2000). Other reported symptoms are vomiting, wheez-ing, drooling, pharyngeal swelling, submandibular oedema and dehydration (Mitchell et al., 2000).

The time between anaesthesia and the onset of clinical signs ranges from 4 hours to 7 days (Hardie et al., 1999). However, Mitchell et al. (2000) reported that cats were referred 5 hours to 12 days after the procedure, with a median time of 5.5 days. The most common cause of subcutaneous emphysema in cats that have recently undergone a procedure requiring en-dotracheal intubation is tracheal rupture (Bauer et al., 2009).





Figure 1: Severe subcutaneous emphysema in a cat 8 days after dental procedure.



4. Diagnosis



Most cases are diagnosed based on the history and clinical signs (Bauer et al., 2009). Tra-cheal rupture is diagnosed using tracheal endoscopy, the preferred method, which reveals linear tears in the trachealis muscle. History along with clinical signs, such as subcutane-ous emphysema, dyspnoea, and coughing guide initial diagnosis. Radiographs often re-veal pneumomediastinum and subcutaneous emphysema (Hardie et al., 1999; Mitchell, 2000).



3. Treatment

Both surgical and conservative treatments can be effective. The choice between conserva-tive medical management and surgical intervention depends on the severity of the clinical signs and the clinician's judgment (Mitchell et al., 2000). Tracheoscopy can be used to de-termine the most appropriate treatment. Analgesia may be provided with a continuous infusion of ketamine, α2-adrenergic receptor agonists, or opioids, such as fentanyl. Alter-natively, intermittent boluses can also be administered (Bauer et al., 2009).

5.1. Conservative treatment

Conservative management is appropriate for cases with mild dyspnoea and subcutaneous emphysema, that do not worsen. Cats that respond to cage rest and oxygen supplementa-tion should be treated conservatively. Subcutaneous emphysema is monitored through palpation.

Treatment includes:

 Cage rest.

 Oxygen supplementation (Mitchell et al., 2000).

 Sedation with butorphanol, midazolam, acepromazine, buprenorphine, or opioid-

tranquilizer combinations should be used if needed (Quandt, 2017; Mitchel et al., 2000).

 Close monitoring for 12 to 72 hours (Mitchel et al., 2000).

5.2. Surgical treatment

Surgical treatment is required for severe cases involving progressive dyspnoea and cyano-sis, that do not improve with oxygen supplementation or in cases where subcutaneous emphysema worsens. Surgical repair is indicated for tears longer than 2 cm, with recovery requiring cage rest for 1 to 4 weeks (Bauer et al., 2009; Mitchel et al., 2000). During trache-oscopy, the animal cannot be intubated. Anaesthesia should be administered intrave-nously as a constant rate infusion, most commonly with propofol. The dose should be care-fully titrated to effect to avoid apnoea. Supplemental oxygen should be provided through-out the procedure to prevent hypoxia. Total intravenous anaesthesia is also used for en-doscopy, advanced imaging, and surgical repair of tracheal tears (Bauer et al., 2009). If an animal with a tracheal rupture requires intubation for oxygenation and ventilation, the tube should be smaller than the lumen of the trachea and extend beyond the rupture. Positive pressure ventilation should be avoided or minimalized (less than 10 cm H2O to prevent formation or worsening of subcutaneous emphysema and pneumothorax (Quandt, 2017). Subcutaneous emphysema usually resolves within 1 to 6 weeks, with a median of 2 weeks (Mitchell et al., 2000).

4. Prognosis

All cats treated conservatively survived, whereas only two-thirds of those undergoing sur-gical treatment survived (Hardie et al., 1999). Cats that survived had no subsequent res-piratory problems, either after surgical or conservative treatment (Mitchell et al., 2000).

5. Preventive measures

To minimize the risk of tracheal injuries:

 Use the smallest effective cuff volume to seal the airway to prevent contamination

of the operating room with anaesthetic gases and to ensure adequate ventilation of the cat.



for leaks to avoid overinflating the cuff, the cuff is properly sealed when gentle pres-sure on the reservoir bag no longer causes air leakage past the cuff of the tube.



 Disconnect the anaesthesia circuit before repositioning the animal.  Monitor cuff pressure with a manometer during prolonged procedures (Hardie et



al., 1999).

6. Conclusions

While essential for anaesthesia and airway management, endotracheal intubation carries a risk of tracheal injury if not performed carefully. Proper tube selection, careful cuff infla-tion, and vigilant monitoring during and after procedures are critical to minimizing com-plications. Early diagnosis and appropriate management, whether conservative or surgi-cal, ensure a high likelihood of recovery without long-term consequences. In cats, tracheal ruptures most often occur after dental procedures, particularly at the cuff site, due to over-inflation of the cuff. These findings highlight the need for precise cuff management and cautious handling during procedures, especially those requiring repositioning, to prevent such injuries.



Funding: This research was supported by Slovenian Research Agency (research program No. P4-0053).



Conflicts of Interest: The authors declare no conflict of interest.



References

1. Alderson B, Senior JM, Dugdale AH. Tracheal necrosis following tracheal intubation in a dog. J Small Anim Pract.

2006; 47: 754-756. DOI: 10.1111/j.1748-5827.2006.00161.x.

2. Bauer MD, Clark-Price SC, McFadden MS. Anesthesia case of the month. J Am Vet Med Assoc. 2009; 234: 1539-

1541. DOI: 10.2460/javma.234.12.1539

3. Fudge M. Endotracheal intubation. In: Silverstein DC, Hopper K, eds. Small Animal Critical Care Medicine. St.

Louis. Missouri, Saunders Elsevier. 2009; pp. 72-74.

4. Dugdale AHA, Beaumont G, Bradbrook C, Gurney M. Veterinary anaesthesia: principles to practice, Anaesthetic

breathing system and airway devices. 2nd ed. Hoboken, New Jersey, John Wiley & Sons. 2020; pp. 139-166.

5. Hardie EM, Spodnick G, Gilson SD, Benson JA, et al. Tracheal rupture in cats: 16 cases (1983-1998). J Am Vet Med

Assoc. 1999; 214: 508-512. PMID: 10029852

6. Manabe H, Murakami M, Kendall A, Fulkerson CV. Tracheal stenosis following endotracheal intubation in a dog.

Can Vet J. 2021; 62: 1289-1291. PMID: 34857963.

7. Mitchell SL, McCarthy R, Rudloff E, Pernell R T. Tracheal rupture associated with intubation in cats: 20 cases (1996-

1998). J Am Vet Med Assoc. 2000; 216: 1592-1595. DOI:10.2460/javma.2000.216.1592.

8. Quandt JE. Postintubation tracheal tears in cats. CLINICIAN'S BRIEF. 2017; 29-33. https://www.clinicians-

brief.com/article/postintubation-tracheal-tears-cats (28.1.2025)

9. Su Z, Li S, Zhou Z, Chen X, et al. A canine model of tracheal stenosis induced by cuffed endotracheal intubation.

Sci Rep. 2017; 28; 7:45357. DOI: 10.1038/srep45357.





Review



Brachycephaly in Cats: A Silent Problem in Feline Health





Jarnovič Lana1, ErjavecVladimira1,*



1. University of Ljubljana, Ljubljana, Slovenia

* Correspondence: Vladimira Erjavec, vladimira.erjavec@vf.uni-lj.si



Abstract:

Brachycephaly, morphological trait characterised by a shortened skull relative to its width, is a prominent feature of certain feline breeds, including Persians, Exotic Short-hairs, Himalayans. British Shorthairs, British Longhairs, and Scottish Folds. While se-lective breeding has favoured this trait due to human preferences for neotenous ap-

Citation: Jarnovič L, Erjavec V. pearances, severe brachycephaly is associated with a wide range of health complica-Brachycephaly in Cats: A Silent tions. These include neurological, respiratory, ocular, dental, gastrointestinal, repro-Problem in Feline Health. Proceedings ductive, and dermatological disorders. This literature review explores the systemic im-of Socratic Lectures. 2025, 12, 59-64. pact of brachycephaly on feline health, highlighting the need for ethical breeding prac-https://doi.org/10.55295/PSL.12.2025.I8 tices and improved veterinary care to mitigate its negative effects.



Keywords: Brachycephaly; Feline Health; Ethical Breeding; Skull Morphology;

Publisher’s Note: UL ZF stays neutral Cat Welfare

with regard to jurisdictional claims in ____________________________________________________________________________

published maps and institutional affili-

ations.





Copyright: © 2025 by the authors. Sub-

mitted for possible open access publica-

tion under the terms and conditions of

the Creative Commons Attribution (CC

BY) license (https://creativecom-

mons.org/licenses/by/4.0/).





1. Background



Brachycephaly is an anatomical condition where the craniofacial conformation of the skull is significantly shortened (Gleason, et al., 2022), resulting in round face and large eyes (Ber-teselli et al., 2023). While this trait is often considered aesthetically desirable, it poses sev-eral health risks for affected cats. In recent decades, selective breeding has intensified the severity of brachycephaly in certain breeds, leading to an increase in associated medical conditions. Despite growing awareness, the long-term implications of these abnormalities remain insufficiently explored (Farnworth, 2016; Berteselli et al., 2023). The aim of this review is to provide a comprehensive overview of the health challenges associated with brachycephaly and to emphasize the importance of ethical breeding and responsible ownership. This literature review explores how anatomical skull conformation affects the health of brachycephalic cat breeds, assessing the severity and systemic conse-quences of brachycephaly while highlighting the need for ethical breeding practices and improved veterinary care.



2. Brachycephaly

Brachycephaly is a term used to describe a morphological trait in which the length of a cat’s skull is significantly reduced compared to its width (Mullen et al., 2004). Therefore, the shape of the brachycephalic cat’s head appears to be rounder, face is flatter from the forehead to the snout. Eyes are bulging and do not follow the shape of the skull, while eye sockets are shallower (Sieslack et al., 2021). The nasal bridge is shortened to the extent that it is almost not visible. The lower jaw appears to be disproportionately pushed forward and upwards compared to the upper jaw (Schlueter et al., 2009; Berteselli et al., 2023; Morel et al., 2024) (Figure 1).





a b



c d



Figure 1. Comparison of the front (a) and side profile (b) in a non-brachycephalic cat, compared to a front (c) and side profile (d) ina brachycephalic cat (Photo: Jarnovič L).

It should, however, be noted, that the severity of brachycephaly in cats varies, and can be categorized into four distinct grades (Schlueter et al., 2009; Bessant et al., 2018; Anagrius et al., 2021) (Table 1). For classification, the cephalic index, a ratio measuring skull width relative to length, is used (Sieslack et al., 2021; Ziemann et al., 2023). Table 1. Grading of the severity of brachycephaly in cats, with a description of each degree (Schlueter et al., 2009; Bessant et al., 2018; Anagrius et al., 2021).



Degree of Brachycephaly Description



Subtle facial flattening with slight shortening of the skull. The nasal bridge remains moderately



Mild

defined, and eyes are normal. Health issues are minimal.

More noticeable facial flattening and narrower nostrils. Eyes may be slightly prominent. Respira-

Moderate tory problems such as snoring and exercise intolerance along with mild ocular and dental issues,

are common.

Significant facial flattening, compressed nose, and prominent eyes. Respiratory distress, exercise

Severe intolerance, and pronounced dental malocclusion are common. Eye issues like corneal ulcers

may occur.

Severely flattened face, pushed-in nose, and bulging eyes. Severe breathing and difficulties, sig-

Extreme

nificant dental and neurological problems, and frequent ocular injuries are present.

2.1. Brachycephalic Cat Breeds

The condition is particularly prevalent in breeds like the Persian, Exotic Shorthair (Schlueter et al., 2009; Farnworth et al., 2016; Bessant et al., 2018; Plitman et al., 2019; Ana-grius et al., 2021; Berteselli et al., 2023), Himalayan, British Shorthair, British Longhair, and Scottish Fold. These cats have been bred to emphasize features that align with human psy-chological preferences for “baby-like” appearances, such as large eyes and small noses (Schlueter et al., 2009; Bessant et al., 2018; Plitman et al., 2019; Berteselli et al., 2023,).

3. Impact of brachycephaly on health

Cats with extreme skull shortening exhibit a significantly compressed facial structure, of-ten leading to respiratory difficulties. Other complications linked to brachycephaly include neurological, ocular, dental, gastrointestinal, behavioural, reproductive and dermatologi-cal disorders (Schlueter et al., 2009; Bessant et al., 2018; Plitman et al., 2019; Erjavec et al., 2020; Anagrius et al., 2021).

3.1. Neurological Issues

Cats with severe brachycephaly often experience structural deformities within the skull (Huizing et al., 2017). One notable condition is cerebellar herniation, where the cerebellum is displaced through the foramen magnum due to reduced cranial space (Huizing et al., 2017; Bessant et al., 2018; Erjavec et al., 2020; Sieslack et al., 2021). This leads to motor dys-function, ataxia (Erjavec et al., 2020; Anagrius et al., 2021), and, in some cases, hydroceph-alus that intensifies pressure on neural structures (Huizing et al., 2017). Such cats may suf-fer seizures, disorientation and blindness (Erjavec et al., 2020).

3.2. Respiratory Complications

Respiratory difficulties are a hallmark of brachycephaly (Bessant et al., 2018; Brunner et al., 2023). Some cats exhibit Brachycephalic Obstructive Airway Syndrome, or better known as BOAS (Farnworth et al., 2016; Anagrius et al., 2021; Berteselli et al., 2023), a combination of congenital defects like stenotic nares, elongated soft palates (Mullen, 2004), and com-pressed nasal turbinates (Farnworth et al., 2016; Erjavec et al., 2020; Sieslack et al., 2021). These abnormalities obstruct airflow, resulting in labored breathing, snoring, and exercise intolerance (Mullen et al., 2004; Farnworth et al., 2016; Anagrius et al., 2021; Berteselli et al., 2023; Gleason et al., 2023). Severe cases can escalate to laryngeal collapse (Mullen et al., 2004; Farnworth et al., 2016; Anagrius et al., 2021; Brunner et al., 2023) that might require, though not always successful, surgical intervention (Brunner et al., 2023).





3.3. Sleep Disturbances



Cats with severe BOAS frequently experience sleep apnoea (Mullen et al., 2004; Berteselli et al., 2023,), snoring (Farnworth et al., 2016; Anagrius et al., 2021; Berteselli et al., 2023) and restless sleep due to difficulty maintaining clear airways (Berteselli et al., 2023).



3.4. Ocular Disorders

The flattened skull structure often compresses or displaces the nasolacrimal ducts, leading to tear overflow, or epiphora (Schlueter et al., 2009; Erjavec et al., 2020; Anagrius et al., 2021; Sieslack et al., 2021; Berteselli et al., 2023). Namely, in severe brachycephalic cats, the proximity between the roots of the canine teeth and the nasolacrimal duct is significantly reduced, with the roots sometimes directly adjoining the duct. Consequently, is the duct forced to course beneath the canine teeth, forming a V-shaped trajectory before entering the nasal cavity (Schlueter et al., 2009). Protruding eyes are particularly vulnerable to cor-neal ulcers and entropion—a condition where the eyelids roll inward, irritating the cornea (Anagrius et al., 2021; Sieslack et al., 2021).

3.5. Oral and Dental Health

Dental malocclusion is another major issue (Ziemann et al., 2023), where the dorsorotation of the jaws causes overcrowding of teeth (Schlueter et al., 2009; Erjavec et al., 2020; Sieslack et al., 2021). This increases the risk of periodontal disease, gingival injury, and painful ab-scesses (Erjavec et al., 2020; Gleason et al., 2023). Traumatic occlusion, where teeth impinge on soft tissues, can lead to chronic inflammation and even pyogranulomas (Ziemann et al., 2023). These conditions make eating difficult, compromising nutrition and digestion (Gleason et al., 2023).



3.6. Gastrointestinal Problems

Respiratory stress often forces brachycephalic cats to breathe through their mouths, lead-ing to aerophagia. This can result in regurgitation (Anagrius et al., 2021; Berteselli et al., 2023) gastroesophageal reflux, and poor digestion. Dental malocclusion further exacer-bates eating difficulties, causing hypersalivation and messy eating behaviours (Gleason et al., 2023).



3.7. Reproductive Challenges

Queens with extreme brachycephaly often face dystocia (Bessant et al., 2018; Anagrius et al., 2021; Berteselli et al., 2023) or difficult labour, due to their narrow pelvic structure (Erjavec et al., 2020) and the disproportionately large head size of brachycephalic breeds (Morel et al., 2024). Caesarean sections are often required (Plitman et al., 2019), further highlighting the physical strain these traits impose.



3.8. Dermatological Concerns

Deep skin folds around the face create an environment prone to bacterial and fungal infec-tions. Without meticulous grooming, these cats may develop painful skin conditions (Sieslack et al., 2021). Persians and Himalayans, with their dense coats, require regular grooming to avoid matting (Berteselli et al., 2023).

4. Potential causes of health concerns being overlooked

Studies indicate that the prevalence of health complications in brachycephalic cats varies by breed and severity of skull compression. Despite these findings, many prospective pet owners remain unaware of the medical challenges associated with extreme brachycephaly. Veterinarians are significantly more aware of brachycephalic dog health issues than own-ers and breeders (Åsbjer et al., 2024). While brachycephalic dogs often display obvious signs of breathing difficulties, in brachycephalic cats, their subtle face expressions make it difficult to recognize discomfort or respiratory distress (Berteselli et al., 2023). Unlike dogs, cats are generally less active, do not go for walks in hot weather, and tend to rest more



throughout the day. As a result, clinical signs of respiratory distress may be less pro-nounced or go unnoticed for longer periods. This lack of outward symptoms likely leads to an even greater underestimation of their health challenges than in dogs, making it a big silent threat to feline well-being.



5. Ethical and welfare considerations



Preventing the worsening of brachycephalic-associated health issues requires collabora-tion among breeders, veterinarians, cat owners and others (Åsbjer et al., 2024). Breeders should prioritize moderate facial features over extreme ones. By selecting for healthier traits, they can reduce the incidence of severe brachycephaly. Incorporating genetic screen-ing into breeding practices can help eliminate deleterious traits and promote a more sus-tainable feline population (Mills, 2019; Sieslack et al., 2021; Morel et al., 2024).

5.1. The role of breeders

Breeders play a critical role in mitigating the negative effects of brachycephaly by priori-tizing well-proportioned facial structures over extreme conformation. However, breeding conditions are often influenced by beauty standards set in competitions, making judges crucial in shaping breeding trends (Plitman et al., 2019). Their influence can encourage breeders to prioritize animal welfare by promoting traits that support long-term health and vitality. Genetic screening, and responsible selection of breeding pairs further help reduce the incidence of severe abnormalities (Morel et al., 2024).

5.2. Veterinary care and management

Veterinarians play a critical role in educating, diagnosing conditions and managing health problems early. Regular check-ups and preventive care are essential for detecting potential issues before they become severe. Advanced imaging techniques such as MRI or CT scans can help identify anatomical abnormalities (Huizing et al., 2017), allowing for more precise treatment planning. Additionally, specialized respiratory assessments and dental evalua-tions are crucial for brachycephalic cats, as they are prone to airway obstruction and mal-occlusions.

In severe cases, surgical interventions—though not always common—may significantly improve quality of life. Procedures such as airway correction surgery or nostril widening can enhance breathing capacity, while dental extractions may alleviate discomfort caused by overcrowding. A multidisciplinary approach, involving veterinary specialists in sur-gery, dentistry, and neurology, can further optimize long-term care and well-being (Morel et al., 2017).

5.3. Owner awareness and responsibility

Cat owners must be educated about the potential health risks of brachycephalic breeds prior to deciding of having one (Plitman et al., 2019). Routine veterinary check-ups, weight management, and creating stress-free environments are crucial. Owners should also be encouraged to support ethical breeding practices and avoid promoting extreme traits (Mills, 2019; Morel et al., 2024).

6. Conclusion

Brachycephaly in cats presents a significant yet often overlooked welfare concern. Affected individuals frequently experience chronic respiratory compromise due to stenotic nares, elongated soft palates, and compressed nasal turbinates, leading to Brachycephalic Ob-structive Airway Syndrome (BOAS). Ocular pathologies, including corneal ulceration, en-tropion, and epiphora, are prevalent due to the altered orbital conformation. Severe dental malocclusions result in traumatic occlusion, periodontal disease, and feeding difficulties, compromising overall health and nutrition. Neurological abnormalities such as cerebellar herniation and hydrocephalus contribute to ataxia, seizures, and visual impairment. Un-like brachycephalic dogs, cats often mask clinical distress, leading to underdiagnosis and delayed intervention. Addressing this issue requires a multidisciplinary approach, where veterinarians must advocate for early detection and intervention, breeders must prioritize functional conformation over exaggerated traits, and owners must be informed of the in-



herent health risks. If left unaddressed, the health challenges associated with brachyceph-aly will persist unnoticed, reinforcing its status as a silent yet profound threat to feline well-being.





Conflicts of Interest: The authors declare no conflict of interest.





References

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66 of 131





Research



Effective Teaching and Learning Opportunities During Clinical

Education from the Students' Perspective - Prospective Cross-

sectional Study

Plešnik Tinkara1,*, Hlebš Sonja1



1. University of Ljubljana, Zdravstvena fakulteta, Ljubljana, Slovenia

* Correspondence: Tinkara Plešnik; tinkara.plesnik@gmail.com



Abstract:

The study aimed to explore physiotherapy students' perceptions of effective teaching and learning opportunities (TLOs) and the key attributes of clinical teachers during

Citation: Plešnik T, Hlebš S. Effective clinical education. Understanding these perceptions can help improve clinical teaching

Teaching and Learning Opportunities practices and enhance learning experiences. A prospective cross-sectional study was

During Clinical Education from the conducted among final-year physiotherapy students at the Faculty of Health Sciences,

Students' Perspective - Prospective

Cross-sectional Study. Proceedings of University of Ljubljana, Slovenia, during the 2021/2022 academic year. An adapted self-

Socratic Lectures. 2025, 12, 66-73. administered, structured questionnaire was used to collect data. Descriptive statistics

https://doi.org/10.55295/PSL.12.2025.I9

were applied to analyze students' preferences regarding TLOs and clinical teacher attributes. A total of 46 students (61% response rate) participated. The most valued

Publisher’s Note: UL ZF stays TLOs included patient management demonstrations (93%), feedback sessions (85%),

neutral with regard to jurisdictional

claims in published maps and and discussions with clinical teachers (76%). The most important clinical teacher roles

institutional affiliations. were identified as feedback provider (93%), knowledge provider (91%), and mentor

(89%). Key attributes of effective clinical teachers included good communication (89%), respect for students (78%), and approachability (72%). Students perceive patient



Copyright: © 2025 by the authors. management demonstrations, feedback, and discussions as the most beneficial TLOs.

Submitted for possible open access Effective clinical teaching is associated with clear communication, respect, and

publication under the terms and accessibility. The findings highlight the need for structured guidelines to support

conditions of the Creative Commons clinical educators and ensure consistency in physiotherapy education.

Attribution (CC BY) license

(https://creativecommons.org/license

s/by/4.0/). Keywords: teaching and learning opportunities; clinical teacher; attributes;

physiotherapy; clinical education





1. Introduction



Clinical education offers a unique learning experience as opposed to classroom teaching. The student works with a clinician to translate the theoretical knowledge acquired in previous years into professional skills and behaviours (Rindflesch et al., 2009). On the other hand, clinical education provides a less controlled learning environment than classroom instruction, which sometimes makes it difficult for clinical educators to plan a stable and equitable clinical education experience for all students (Ernstzen et al., 2009). In the ‘real world’, the objectives of the healthcare institution in which teaching takes place are centred on the provision of quality healthcare to patients. In this context, the physiotherapy student's education may take a secondary role to patient care. Clinical education therefore becomes less of a structured approach to learning and more of a series of learning opportunities for the student to take up when they can.



In higher education, the rise of student-centred learning has led to a shift in emphasis from traditional ‘teaching’ to ‘learning’ (O’Neill & McMahon, 2005). In this model, the teacher serves as a facilitator rather than just a transmitter of knowledge, while students take a more active role in their education. This approach transfers the power from the teacher to the student (Milanese et al., 2013). A student-centred approach is particularly well suited to clinical education, where the unpredictability of the learning experience can disadvantage passive students. Actively engaged students, on the other hand, are more likely to take advantage of and benefit from the learning opportunities presented to them (Ernstzen & Bitzer, 2012).

Considering the problems mentioned above (e.g. lack of control over the setting, transition to student-centred learning), understanding the experience from the student's perspective can help identify strategies to improve the learning process and promote engagement (DeClute & Ladyshewsky, 1993; Hobbs et al., 2000; Crosbie et al., 2002). In clinical education, the learning environment is influenced by the teaching and learning opportunities offered, the roles and attributes/characteristics/personality of the clinical teacher, the student and the patient, the models of clinical education used, the assessment of students and the atmosphere and facilities of the healthcare institution (Ernstzen & Bitzer 2006; Ernstzen & Bitzer, 2012). Two aspects of the learning environment, namely the teaching and learning opportunities (TLOs) and the roles and attributes of clinical teachers, have been shown to be the most significant factors influencing learning (Chan, 2001). Clinical education TLOs are learning activities that the student encounters in the clinical environment that allow the student to actively build and integrate their theoretical and practical knowledge, through the experience of clinical practice (Ernstzen et al., 2009). Little is known about teaching-learning strategies that clinical teachers use in clinical education and the perceived efficacy of these (Kilminster et al. 2007). Knowledge of these aspects may lead to appropriate changes made in clinical education thereby enhancing learning in the clinical environment. As teaching supports learning, it is useful to determine which teaching-learning activities students view as effective and useful. Although the importance of clinical education is eagerly emphasised, recommendations for optimal TLOs are inconsistent (Van der Hem-Stokroos, 2005). There is currently no standardised guide to help clinical teachers in physiotherapy organise their teaching method (Robertson et al., 2003). In other words, each clinical teacher teaches differently as it depends on their own judgement. This leads to different support and teaching by clinical teachers and different learning for individual students and in the same clinical rotation (Hobbs et al., 2000; Milanese et al., 2013). These voices are of concern in clinical education as they can lead to inconsistency and inequity in student learning experiences, lack of validity and reliability in assessment, varying standards in clinical teaching, varying levels of motivation among clinical teachers, and a lack of time and staff for clinical education (Delany & Bragge, 2009; Hartley et al., 2019).

Previous researchers found that the attributes of the clinical teacher and the relationship between the student and the teacher have a powerful effect on learning (Kilminster & Jolly, 2000). Attributes such as approachability, enthusiasm, communication skills and the desire to share knowledge have been identified as important attributes for clinical teachers (Bennett, 2003; Ramakrishnan & Bairapareddy, 2020). Behaviours such as being a competent physiotherapist, being available, answering questions without belittling the



student, and providing useful and constructive feedback were perceived by students as the most effective clinical teaching behaviours (Onuoha, 1994; Ernstzen & Bitzer, 2012). The aim of the study was to find out what final year physiotherapy students enrolled at the Faculty of Health Sciences at the University of Ljubljana in Slovenia (FHSUL) consider to be effective teaching and learning opportunities during clinical education and what they consider to be the role and attributes of an effective clinical teacher.



2. Material and Methods



The study follows a prospective cross-sectional design among the cohort of final year physiotherapy students enrolled for the 2021/2022 academic year at the FHSUL in Slovenia. FHSUL offers a 3-year undergraduate program in physiotherapy which consists of theoretical studies (46%) and practical training at the university and in clinical placement (54%). Students must complete a 20-week of minimal 700 hours clinical education throughout the curriculum.

A self-administered, structured questionnaire was used for data collection based on questionnaire used by Milanese et al. (2013) and Ernstzen et al. (2009) in studies of physiotherapy students' perceptions on effective practices for teaching and learning in the clinical setting. Before we translated the questionnaire into Slovenian, we received permission from the author Ernstzen et al. (2009) of the original questionnaire to use the questionnaire and adapt it to our context. The translation process of the original questionnaire from English into Slovenian followed the recommendations of Squires et al. (2013), which consider cross-cultural aspects of translation, where questions, expressions and concepts from the source culture (English) are carefully adapted to the target culture (Slovenian), considering the specific characteristics of the Slovenian language, cultural norms, values and context. Ten participants assessed the suitability of the questionnaire's content in pilot study and evaluated its key features, including clarity, simplicity, conciseness and time required to complete the questionnaire, on a scale of 1 (strongly disagree) to 5 (strongly agree). The average rating for clarity was 4.6 (±0.5), for simplicity 4.4 (±0.7), for conciseness 4.6 (±0.52) and for time suitability 3.8 (±0.63). The questionnaire asked for basic demographic information (age, gender) and specific questions regarding their clinical placements. From the fifteen TLOs listed in the questionnaire, students selected the five most important ones where they learnt the most. Of the ten roles that are most important for the clinical teacher and the twelve attributes of the clinical teacher that the students consider necessary for optimal learning and that were listed in the questionnaire, the students selected the five most important. An electronic version of the questionnaire was sent to final year students via the website MojaAnketa.si.web. Before completing the questionnaire, all participants were informed of the following: the purpose of the survey, that participation was voluntary and that the answers would remain anonymous. Completion and submission of the questionnaire implied informed consent.

Collected data were entered into Microsoft Excel spreadsheets, and analysis was performed in both Excel and IBM ® SPSS Statistics (v22) (Armonk NY, US). Descriptive statistics, including frequencies and percentages for categorical variables, and mean and standard deviation (SD) for continuous variables were calculated to describe the demographic data.

3. Results

Of the total number (n = 76) of students enrolled in the final year of the 2021/2022 academic year, 46 students completed the questionnaire in full during the study period (response rate of 61%). The participants included 36 female and 10 male students with an average age of 22.7 years (range 22–29 years).

The perceived learning values of the different TLOs are shown in Table 1. The five most important useful domains for providing TLOs to students was demonstration of patient management, followed by feedback and discussion with the clinical teacher, clinical tasks and one-to-one learning sessions.



Table 1. Students’ views on teaching and learning opportunities/activities during which students learn the most.





Teaching and learning opportunities Percentages and (number) of



students who selected the activity

Demonstrations of patient management 93% (43)

Feedback 85% (39)

Discussions with the clinical teacher 76% (35)

Clinical tasks 41% (19)

One-to-one learning sessions 37% (17)

Reflection 28% (13)

Discussion with peers 26% (12)

Group-learning sessions 22% (10)

Learning on own 22% (10)

Mock assessment 17% (8)

Coaching 17% (8)

Questioning 13% (6)

Peer assessment 9% (4)

Lectures 7% (3)

When learning is facilitated 4% (2)

Other 2% (1)



The participants were asked to choose what they considered to be the most important roles of the clinical teacher. The results are shown in Table 2. From the results of the questionnaire, the five most important roles of the clinical teacher were selected: reflector/feedback provider, knowledge provider, mentor and demonstrator of techniques.

Table 2. Clinical teacher role

Clinical teacher role Percentages and (number) of students

who selected the role

Reflector/feed-back provider 93% (43)

Knowledge provider 91% (43)

Mentor 89% (41)

Technique demonstrator 80% (37)

Counsellor 70% (32)

Role model 35% (16)

Assessor/Evaluator 15% (7)

Facilitator of learning 13% (6)

Questioner 9% (4)

Friend 4% (2)

Other 0% (0)



Students identified the importance of the communication skills of the clinical teacher as the most important attribute. Other important attributes of clinical teacher attributes were respecting the students and approachability. The attributes that received the lowest rating in this study were that the clinical instructor is enthusiastic, a listener, and self-confident (Table 3).





Table 3. Clinical teacher attributes



Clinical teacher attributes Percentages and (number) of



students who selected the attribute

Good Communication 89% (41)

Respects the student 78% (36)

Approachability 72% (33)

Shows concern for student 61% (28)

Supports the student 59% (27)

Organised 37% (17)

Not prejudiced 35% (16)

Gives recognition for student abilities 33% (15)

Interpersonal skills 17% (8)

Enthusiasm 11% (5)

Listener 4% (2)

Self-confident 4% (2)

Other 0% (0)



4. Discussion

The objective of this study was to explore physiotherapy students’ perceptions of the teaching and learning activities associated with clinical education and how they perceive the key roles and attributes of the clinical teacher. Our students valued demonstrations of patient management by a clinical teacher as one of the most valuable clinical TLO. Demonstrations of patient management by the clinical teacher are usually situations where he/she performs the patient management step by step, demonstrating the subdivisions of the patient management. These subdivisions are going through the patient folder, performing the interview, planning and performing the physical assessment, as well as management strategies for the patient. A demonstration on patient management may help the student to determine where to start the process of patient management, what to assess, and promote decision-making skills (Stoikov et al., 2022). Observing the teacher performing the demonstration may be seen as learning by observation, and performing the demonstration may be seen as learning by doing (Torre et al., 2006). On the other hand, teacher-led demonstrations may be seen more than as passive learning by the student (Kilminster et al., 2007).

Another important TLO in this study was feedback. Van der Hem-Stokroos et al. (2005), Allen & Molloy, (2017) and Wijbenga et al. (2019) point out that feedback should be a key element in clinical education programmes. Feedback to students should be clear and unambiguous so that they are aware of their mistakes and weaknesses (Kilminster et al., 2007). Our results support the findings of Kilminster & Jolly (2000), who emphasise the importance of feedback for students' self-confidence and for a good relationship between students and teachers.

Discussions with the teacher were selected by most students as another valuable TLO in our study. Discussions about a specific patient appear to be useful in facilitating learning because they actively engage the student, as through discussions students practise thinking through problems, organising concepts, formulating arguments and counterarguments, evaluating the evidence for their own and others’ positions, and responding thoughtfully and critically to different points of view (Milanese et al., 2013;



Stoikov et al., 2022). A discussion is therefore a collaborative learning event that offers the opportunity to gain knowledge and insights through the exchange of ideas and opinions. For our cohort of students, the use of TLOs that were least frequently selected in the questionnaire and were not directly related to a patient (mock assessment, coaching, questioning, peer assessment, lectures) needs to be reconsidered. The data obtained from our study showed that students perceive the most important role of the clinical teacher as a reflector/feedback and knowledge provider, mentor and demonstrator of techniques. The role of the clinical teacher as a facilitator of learning was rated low by the students in our study. These findings are not in line with current professional evidence which postulates that the role of the clinical teacher is to facilitate learning opportunities and maximise the clinical experience within the duration of the placement (CSP Chartered Society Physiotherapy, 2020). However, the role of the teacher as both a provider of feedback and knowledge and a facilitator of self-responsibility for learning appears to be contradictory. Harden & Crosby (2000) may offer a viewpoint that could explain the students’ perspective. They state that the teacher as a knowledge provider takes on a whole new meaning in the clinical context. Rather than providing knowledge by delivering it on to students (e.g. in the form of a lecture), in the clinical context the teacher passes on knowledge that relates to the specific condition of the patient. This situation creates a strong context that facilitates learning due to the immediate relevance of this knowledge.



The attributes of clinical teachers that played an important role for our students were identified as good communication, respect for students, approachability, interest in students, and support for students. Communication skills of the clinical teacher was the most important attribute from the students' perspective. It has been documented that physiotherapy students have had negative experiences on placement where they have experienced problems with communication with the clinical teacher (Ramakrishnan and Bairapareddy, 2020), an unapproachable clinical teacher (Meyer et al., 2017) and a lack of mutual appreciation of the roles of teacher and student (Delany & Bragge, 2009). The relationship between students and the clinical teacher has been shown to be a better predictor of client outcome than the ability or helpfulness of the clinical teacher (Kilminster & Jolly, 2000).



4.1. Recommendations

As the main aim of our study was to determine which of the TLOs were considered by the physiotherapy students to be effective in enhancing learning in the clinical setting, these activities - demonstration of patient management, feedback and discussion with the clinical teacher - should therefore form the basis of the clinical teaching programme. At the FHSUL in Slovenia, there is currently no standardised guide to help physiotherapy clinical teachers organise their teaching method, as it is not compulsory for physiotherapists working with students to undergo training. It could be argued that students could be disadvantaged by a lack of understanding of educational teaching principles by clinical teachers who have not received training in practice education, particularly because students are assigned to multiple clinical teachers. There is clear justification for providing untrained clinical teachers at FHSUL with the necessary theoretical knowledge and skills to provide students with a consistent educational approach during clinical training. The importance of personal factors such as good communication skills, approachability, respect and support for students should be emphasised in clinical teacher education.

4.2. Strengths and Limitations

The study had many strengths. This was the first study aimed at investigating students’ perceptions of teaching and learning activities related to clinical education in Slovenia. The results of this study provide valuable insights into students' perspectives of clinical teaching and learning opportunities and the role and attributes of clinical teachers in the effectiveness of clinical education. One limitation is that we did not include the views of clinical teachers to gain insight into the similarities and differences between the perspectives of students and clinical teachers. Limitations of the study also include the fact that the study was only conducted at a single higher education institution. Had the study



been conducted at multiple higher education institutions in Slovenia, different phenomena and findings may have emerged.



5. Conclusions



In our study, demonstrations of patient management were found to be the most valuable activity for facilitating learning in the clinical setting from the students' perspective. However, demonstrations cannot exist in isolation but should be complemented by feedback and discussion. Feedback and discussion were seen by students as the second and third most important TLOs. Students perceived the most important role of the clinical teacher as a reflector/feedback and knowledge provider, mentor and demonstrator of techniques. Good communication skills, respect for students, approachability, interest in students and support for students were cited by students as the most important attributes of the clinical teacher. The fact that clinical teachers at FHSUL are not required to undertake formal training and often rely on the goodwill of physiotherapists in the clinical setting to work with students needs to change. FHSUL, which sends its students to specific practice settings, should consider providing these clinical teachers with the necessary training to provide students with an effective clinical placement experience.



Acknowledgement: We would like to thank all the students who took part in the study and completed the questionnaire.

Funding: No institutional or other research funding for support of this study was received.

Conflicts of Interest: The authors declare no conflict of interest.

Ethics Committee Approval: Ethical approval for the study was granted by the FHSUL (ethics approval No.: ZF DEK 469/2023 - 09.02.2023).



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Research



Effects of Transcutaneous Electrical Nerve Stimulation in Pa-



tients with Fibromyalgia Syndrome – Literature Review

Bec Sergeja1, Rugelj Darja1, Weber Daša1



1. University of Ljubljana, Faculty of Health Sciences, Ljubljana, Slovenia

* Correspondence: Sergeja Bec, bec.sergeja@gmail.com



Abstract:

Introduction: Fibromyalgia is a chronic disorder characterized by diffuse musculo-skeletal pain, fatigue, depression and cognitive impairment. The aim of treatment is to alleviate symptoms, maintain physical function and improve quality of life. One of the recommended methods of a non-pharmacological approach is transcutaneous electrical nerve stimulation (TENS). The aim of the literature review was to determine the effects of TENS in fibromyalgia patients, focusing on the assessment of changes in pain inten-sity in relation to the minimal clinically important difference.

Citation: Bec S, Rugelj D, Weber D. Methods: The literature search was conducted until the end of 2024 in the following

Effects of Transcutaneous Electrical databases PubMed, CINAHL and PEDro. Nerve Stimulation in Patients with Results: Twelve studies were included in the review. Three studies looked at the im-

Fibromyalgia Syndrome – Literature mediate effects of TENS on pain and nine studies looked at the longer-term effects. The Review. Proceedings of Socratic duration of the individual therapies ranged from 20 to 120 minutes, the stimulation Lectures. 2025, 12, 75-82. frequency from 0.5 to 320 Hz and the intensity from pleasant to very strong but tolera-

https://doi.org/10.55295/PSL.12.2025.I10 ble stimulation. Pain was assessed using a visual analogue scale and a numerical rating

scale. Discussion and conclusion: The results indicate that TENS therapy is more ef-fective when applied with sufficient intensity over multiple sessions rather than as a single treatment. While a one-time application may provide temporary pain relief, re-

Publisher’s Note: UL ZF stays neutral peated treatments show more clinically significant effects. People with higher pain sen-

with regard to jurisdictional claims in sitivity tend to respond better to TENS. This therapy remains a promising non-phar-

published maps and institutional affil- macological option for pain management in fibromyalgia, however, caution is needed

iations. in generalizing the results as the research has predominantly studied women.





Copyright: © 2025 by the authors. Keywords: TENS; pain; clinically important difference; MCID Submitted for possible open access

publication under the terms and

conditions of the Creative Commons

Attribution (CC BY) license

(https://creativecommons.org/licenses/

by/4.0/).





1. Introduction



Fibromyalgia is a chronic condition or syndrome characterized mainly by widespread musculo-skeletal pain. At the same time, systemic symptoms such as fatigue, sleep dis-turbances, morning stiffness, depression, anxiety, and cognitive impairments (e.g. forget-fulness, difficulties with concentration, attention, and memory) may occur (Clauw, 2009; Wolfe et al., 2010). The etiology is unknown, but there are some theories that descending pain inhibition and enhanced excitability of the central nervous system may change the processing of stimuli resulting in increased pain perception (Amer-Cuenca et al., 2023). This is why patients can experience diffuse hyperalgesia (increased sensitivity to painful stimuli), and allodynia (feeling pain in response to non-painful stimuli) can also be present (Clauw, 2009). The prevalence of fibromyalgia is between 0,2 % and 4,7 % in general pop-ulation and predominantly affects women (female-male ratio of 3:1) (Amer-Cuenca et al., 2023; García-López et al., 2024).



Because pain is the main disabling symptom and the etiology is unknown the goals of treatment are symptom relief, maintaining function and improving quality of life (García-López et al., 2024; Macfarlane et al., 2017). The European League Against Rheumatism (EULAR) published revised recommendations for the treatment of fibromyalgia syndrome in 2016. They recommend an emphasis on starting treatments with non-pharmacological approaches, with active patient participation in self-management of the condition (Macfar-lane et al., 2017).

A potential non-pharmacological pain control treatment is Transcutaneous Electrical Nerve Stimulation (TENS) frequently used to relieve acute and chronic pain. The device delivers alternating electrical current through electrodes placed on the skin (Vance et al., 2014; Amer-Cuenca et al., 2023). There are two main types of TENS used. High-frequency TENS, with a frequency of 50–200 Hz, is applied at a low intensity (below the motor thresh-old). Low-frequency TENS, with a frequency of 2–10 Hz, is applied at a higher intensity (above the motor threshold). A combination of these two is also used (Casale et al., 2012). Systematic reviews on the effectiveness of TENS for fibromyalgia syndrome have shown mixed results. Two systematic reviews (Johnson et al., 2017; Salazar et al., 2017), one with a meta-analysis (Salazar et al., 2017), could not make specific conclusions due to the lack of high-quality studies. However, more recent systematic reviews with meta-analysis have shown promising results (Amer-Cuenca et al., 2023; Batista de Aguiar et al., 2022; García-López et al., 2024). The most recent review, which included the largest number of clinical trials, found that TENS is effective in reducing pain and disability and improving physical quality of life in patients with FM. When compared to placebo and control, TENS was more effective, but it was not more effective than therapeutic exercise (García-López et al., 2024). One of the systematic reviews and meta-analysis discussed the TENS parameters (Amer-Cuenca et al., 2023). The recommended or appropriate parameters of TENS are considered as: high frequency (greater than 10 Hz and up to 200 Hz) or mixed frequency (switching between low and high frequency), with intensity set to produce a strong but comfortable sensation, or ideally the highest tolerable non-painful level. A minimum of 10 treatment sessions should be applied over the painful area. This approach led to a significant reduc-tion in pain compared to other parameter combinations (Amer-Cuenca et al., 2023). When evaluating outcome measures it is important to consider not only statistical signifi-cance, but also clinical importance of the change in scores. MCID is a minimal clinically important difference. That is the smallest level of change in a scale associated with a mean-ingful improvement in a patient. It is unique to each scale or questionnaire etc. and is im-portant for interpretation of the results (Mease et al., 2011).

Pain intensity is most evaluated using the Visual Analogue Scale (VAS) or the Numerical Rating Scale (NRS). Both scales assess pain on a range from 0, indicating no pain, to 10, describing the worst pain imaginable (Ferreira-Valente & Pais-Ribeiro, 2011). On average, a reduction of one point or 15.0% on the NRS was found to represent the MCID for patients with chronic musculoskeletal pain. However, a reduction of 2 units or 33.0% was most strongly associated with the concept of "much better" improvement (Salaffi et al., 2004). The most used criteria for MCID in chronic pain, as established by Farrar and colleagues (2001) (who also included fibromyalgia patients), showed that a change of approximately 1.8 points or 28% in pain severity in NRS was most strongly associated with clinically im-portant improvement. Similarly, Arnold and colleagues (2012) proposed that responder



definition in patients with fibromyalgia requires ≥ 30 % reduction in pain and a ≥ 10 % improvement in physical function.



The purpose of this systematic review was to evaluate the effectiveness of TENS in patients with fibromyalgia, with a specific focus on assessing pain intensity changes in relation to the MCID.



2. Methods

Literature review has been conducted until the end of the year 2024 in databases: PubMed, CINAHL and PEDro with keywords: transcutaneous electrical nerve stimulation OR TENS and fibromyalgia.

Studies in English language that investigated the effects of TENS in patients with fibrom-yalgia and reported pain intensity measured by VAS or NRS were included. Reviews and studies that investigated combined effects with other physical modalities were excluded. The search method for articles is presented in more detail in Figure 1.





Figure 1. PRISMA diagram of the process of searching and collecting articles (Moher et al., 2009)

3. Results

A total of 12 articles were included in the review (Carbonario et al., 2013; Castro-Sánchez et al., 2020; Dailey et al., 2013; Dailey et al., 2020; Dailey et al., 2022; Di Benedetto et al., 1993; Jamison et al., 2021; Lauretti et al., 2013; Löfgren & Norrbrink, 2009; Riachi et al., 2023; Sunshine et al., 1996; Yüksel et al., 2019). In two studies they used a cross-over study design (Dailey et al., 2013; Löfgren & Norrbrink, 2009). Overall, there were 1022 (955 women, 26 men and 42 not specified) participants. Out of those, 457 (425 women, 11 men and 21 not specified) participants had active TENS treatment. Detailed study protocols, general results and quality of studies are reported in Table 1. In three studies (Dailey et al., 2013; Riachi et al., 2023; Yüksel et al., 2019) they only applied TENS therapy for one session and looked for immediate effects of TENS on intensity of pain. Parameters of TENS treatment and results of the in-group change of pain intensity are reported in Table 2 in greater detail.



In nine studies (Carbonario et al., 2013; Castro-Sánchez et al., 2020; Dailey et al., 2020; Dai-ley et al., 2022; Di Benedetto et al., 1993; Jamison et al., 2021; Lauretti et al., 2013; Löfgren & Norrbrink, 2009; Sunshine et al., 1996) they applied TENS for several sessions. Car-bonario and colleagues (2013) investigated effects of TENS when applied during exercise. Table 3 provides a detailed overview of the TENS treatment parameters and the in-group changes in pain intensity.





Table 1. Study characteristics and general results from studies



Author, year Groups Sample (gender. age) General results PEDro

Riachi et al., 2023 G: TENS (suit) 50 W (53.33 ± 7.08) ↓ pain (p < 0.001) immediately after /

treatment and 24 hours later

Dailey et al., 2013 G1: TENS 42 W, 1 M (49.2 ± 12.0) No withih group results reported 9/10 *crossover G2: PB-TENS ↓ pain (p < 0.05) in G1 compared to

G3: N-TENS G2 and G3 for MEP, but not for

PAR

Dailey et al., 2020 G1: TENS 76 W (44.7 ± 14.3) ↓ pain (p < 0.05) in G1 8/10

G2: PB-TENS 68 W (47.2 ± 12.6) ↓ pain (p < 0.05) in G1 compared to G3: N-TENS 94 W (48.6 ± 11.8) G2 and G3 for MEP and PAR

Dailey et al., 2022 G1: TENS 103 W ↓ pain (p < 0.05) in G1; regardless of 8/10

G2: PB-TENS 99 W the subgroup (SG-O or SG-NO)

G3: N-TENS 99 W

SG-O 52Me (45 – 58)

SG-NO 47Me (35 – 56)

Jamison et al., G1: TENS 58 W, 4 M (52.3 ± 13.8) ↓ pain (p < 0.029) in G1 compared to 6/10 2021 G2: PB-TENS 53 W, 4 M (38.3 ± 13.1) G2

Lauretti et al., G1: 2 TENS 13 W (30 ± 12) ↓ pain (p < 0.05) within G1 and G2 5/10 2013 G2: 1 TENS, 1 PB- 12 W, 1 M (32 ± 8) No between group comparison

TENS

G3: 2 PB-TENS 9 W, 1 M (35 ± 8)

Sunshine et al., G1: massage 10 W No change in pain (p > 0.05) in G2 2/10 1996 G2: TENS 10 W No between group comparison.

G3: PB-TENS 10 W

(49.8)

Castro-Sánchez et G1: dry needling 28 W, 9 M (49.35 ± 5.82) ↓ pain (p < 0.05) within G2 8/10 al., 2020 G2: TENS 32 W, 5 M (47.84 ± 8.12) ↓ pain (p < 0.05) in G1 compared to

G2

Di Benedetto et G1: pharmacotherapy 14 W, 1 M No change in pain (p > 0.05) in G2 4/10 al., 1993 G2: TENS 15 W No between group comparison

(51 ± 9.5)

Löfgren, G1: thermopack 32 W (41.5 ± 8.3) ↓ pain (p < 0.05) within G2 6/10 Norrbrink, 2009 G2: TENS No between group comparison

*crossover

Yüksel et al., 2019 G1: TENS 21 (38.1 ± 11.3) ↓ pain (p < 0,001) within G1 6/10

G2: acupuncture 21 (44.6 ± 10.34) No between group comparison

G3: healthy control 21 (30.2 ± 6.5)

Carbonario et al., G1: exercise + TENS 14 W (52.9 ± 5.9) ↓ pain (p < 0,001) within G1 4/10 2013 G2: exercise 14 W (51.9 ± 9)

G – group, MEP – movement evoked pain, N-TENS – no TENS (control), PAR – pain at rest, PB-TENS – placebo TENS, SG-O – sub-group regularly taking opioids, SG-NO – subgroup not taking opioids regularly, ↓ - reduction





Table 2. Parameters of TENS and results of studies with only 1 treatment session



Authors, Characteristics of TENS treatment Results



year Parameters Area Duration Frequency Before After

Riachi et 20 Hz; 25 – 170 20 pairs of 1 hour 1 session VAS immediately 6.20 ± 1.73 cm 2.36 ± 1.44 cm al., 2023 μs muscles

2mA 24 hours 6.20 ± 1.73 cm 4.7 ± 1.97 cm

later

Dailey et 100 Hz; 200 μs C7–T1 60–75 1 session VAS 30 minutes PAR: Δ = – 0.38 ± al., 2013 max. tolerable or L5–S1 minutes 5.0 ± 0.5 cm 0.26 cm

*crossover MEP: 4.0 ± 0.4 cm

5.4 ±0.4 cm Δ = - 1.1± 0.26

(6MWT)

Yüksel et 70 Hz; 100 ms T2–T7 20 minutes 1 session VAS immediately 5.19 ± 2.20 cm 2.86 ± 2.01 cm al., 2019 comfortable

MEP – movement-evoked pain, NRS – numerical rating scale, PAR – pain at rest, VAS – visual analog scale, 6MWT – 6-minute walking test, Δ – change (after – before)

Table 3. Parameters of TENS and results of studies with several treatment sessions

Author. Characteristics of TENS treatment Results

year Parameters Area Duration Frequency Before After

Sunshine 0.5 – 320 Hz over painful 30 minutes 5 weeks. VAS 7.5 cm 7.3 cm et al.. 1996 areas 2x/week

(10 sessions)

Castro- 100 Hz; 200 μs active and 50 minutes 6 weeks. VAS Δ = – 1.86 cm Sánchez et tolerable latent trigger (10 minute 1x/week

al.. 2020 points (5 for each (6 sessions)

muscles) muscle pair)

Lauretti et 2 Hz and 100 C7–T1 and L5 20 minutes 1 week. VAS G1: 8.5 ± 2 4.3 ± 2 (Δ ~ 4 cm) al.. 2013 Hz; 200 μs 2x/day.

60 mA every day

(14 sessions)

G2: 8.5 ± 1 6 ± 1 cm (Δ ~ 2.5 cm)

cm

Löfgren & 80 Hz painful area at least 30 3 weeks. NRS 8.0 (IQR 6.3 (IQR 4.3; 7.3) Norrbrink. strong but minutes every day 6.0; 9.0) 36 % responders

2009 comfortable (21 sessions)

*crossover

Jamison et 60 – 100 Hz; upper part of 60 minutes 3 weeks. at NRS Δ = – 1.83 ± 0.19 al.. 2021 290 μs calf least 2x/day ≥30 % pain reduction:

strong but (average 68.9 28.4 % – 52.1 %; ≥50 % pain

comfrotable sessions) reduction: 12.6 % – 37.6 %

Dailey et 2–125 Hz; 200 C7–T1 and at least 2 4 weeks. NRS PAR: Δ = – 1.9 al.. 2020 μs lower back hours each every day MEP: Δ = – 1.8 (6MWT);

max. tolerable day (28 sessions) Δ = – 1.6 (5STS)

44 % responders

Dailey et 2 – 125 Hz; 200 C7–T1 and at least 2 4 weeks. NRS (SG-O) RAP: Δ = – 1.6 al.. 2022 μs lower back hours every every day MEP: Δ = – 1.7 (6MWT);

max. tolerable day (30 (atleast 28 Δ = – 2.0 (5STS)

minutes per sessions) (SG-NO) RAP: Δ = – 2.0

session) MEP: Δ = – 1.9 (6MWT);

Δ = – 1.5 (5STS)

Di 80 – 100 Hz; 70 4 painful 80 minutes 6 weeks. VAS 5.6 cm ⮾ 2 weeks: 4.8 cm ⮾ Benedetto μs points (20 minutes 5x/week 4 weeks: 5.0 cm ⮾

et al.. 1993 pleasant per point) (30 sessions) 6 weeks: 4.6 cm ⮾

Carbonario 150 Hz; 150 μs m. trapezius 30 minutes 8 weeks, VAS Δ = – 2,0 ± 2,9 cm et al., 2013 strong but and m. during 2x/week 30 % clinical gain

comfortable supraspinatus exercise (16 sessions)

MEP – movement-evoked pain, NRS – Numerical Rating Scale, PAR – pain at rest, SG-NO – subgroup not taking opioids regularly, SG-O – subgroup regularly taking opioids, VAS – Visual Analog Scale, ⮾ - score extracted from the graph, 5STS - Five Times Sit-to-Stand test, 6MWT – 6-Minute Walking test, Δ – chang



4. Discussion



The current studies done in research of effects of TENS offer important insights for poten-tial pain management in patients with fibromyalgia but also reveal several important lim-itations. In studies where they used only a one-session treatment using electrodes paraver-tebrally Dailey and colleagues (2013) and Yüksel and colleagues (2019) did report statisti-cally significant pain reduction with-in group with active TENS. Interestingly movement evoked pain (MEP) showed improvement for more than 1 point on VAS, but with that not reaching completely the MCID, whereas paint at rest (PAR) didn’t reach the statistical sig-nificance (Dailey et al., 2013). On the other hand, Yüksel and colleagues (2019) reported change of average pain enough for a clinically significant decrease of pain already in one session. Riachi and colleagues (2023) also showed clinically important improvement in pain reduction using a suit with electrodes that activated 20 pairs of muscles. Their study showed that a one-time treatment with low-frequency TENS with higher intensity resulted in a substantial pain reduction that lasted for up to 24 hours. This is probably because low-frequency TENS stimulate endogenous opioid release (Macedo et al., 2015). Despite these observations we cannot say for certain that one session of TENS treatment would give significant improvements in pain perception.



In contrast, studies with more frequent TENS sessions and appropriate parameters have demonstrated more favorable outcomes. In their study, Castro-Sánchez and colleagues (2020), although limited by an insufficient number of treatment sessions, still reported a statistically and clinically meaningful reduction in pain intensity, in contrast to Sunshine and colleagues (1996) who didn’t find any significantly important difference in pain per-ception, even though experimental group had enough sessions, but lacked sufficient in-tensity of TENS. This suggests that the intensity of TENS plays a critical role in its efficacy, with low-intensity treatments, such as those only producing a tingling sensation, failing to deliver meaningful pain reduction. There is also important to note that this study is of low quality (Sunshine et al., 1996).

The studies that included the appropriate number of sessions and mostly appropriate pa-rameters of TENS treatment (Carbonario et al., 2013; Dailey et al., 2020; Dailey et al., 2022; Di Benedetto et al., 1993; Jamison et al., 2021; Lauretti et al., 2013; Löfgren, Norrbrink, 2009) as suggested in systematic review and meta-analysis done by Amer-Cuenca and col-leagues (2023), all reported a decrease in pain intensity for at least 1 unit or about 15 % improvement. All of them showed statistically important change except for one (Di Bene-detto et al., 1993). The same study showed the lowest average change. This is the only study that applied lower intensity (pleasant feeling of TENS) and is also a lower quality study.

Löfgren & Norrbrink (2009) reported that the median score of pain was lower, and they also reported that 36 % of participants were considered responders, meaning they had a pain reduction of at least 2 units). Similarly, Dailey and colleagues (2020) reported that 44 % of people had 30 % less pain. Jamison and colleagues in 2021 also reported the percent-age of participants considered to be responders. They found that 28.4 % of participants in the subgroup with lower pain sensitivity and 52.1 % of participants in the subgroup with higher pain sensitivity experienced a moderate reduction in pain severity (more than 30 %). When reporting substantial pain reduction (more than 50 %), 37.6 % of patients in the subgroup with higher pain sensitivity achieved this level of improvement. This suggests that people with a higher baseline pain sensitivity respond better to TENS treatment than those with lower sensitivity. An important study by Dailey and colleagues (2022) investi-gated the impact of taking oral analgesics on pain reduction when using TENS. According to their study, medication did not influence the outcome, meaning that there was a similar reduction in pain intensity regardless of whether participants regularly took medication or not.

Importantly, the studies conducted by Dailey and colleagues (2013; 2020) further highlight the cumulative effects of TENS treatment over time. While one of their studies found no improvement in pain at rest after a single TENS session (Dailey et al., 2013), their study from 2020 demonstrated a clinically meaningful reduction in pain at rest and movement-evoked pain after four weeks of treatment. The pain reduction was even greater after eight weeks of TENS treatment, illustrating that prolonged TENS use may lead to sustained im-



provements in pain perception. This finding supports the notion that TENS treatment re-quires a sufficient duration to achieve clinically significant pain reduction, a conclusion also supported by systematic reviews and meta-analysis (Amer-Cuenca et al., 2023). In this systematic review we see that when TENS is applied with sufficient intensity, there is some research supporting its ability to achieve not only statistically significant but more importantly, clinically meaningful reduction in pain. Generalization of these findings should be avoided due to predominantly female populations included in the referenced studies.



TENS offers a non-pharmacological option for managing chronic pain conditions, empow-ering patients to actively participate in their treatment. Moreover, as TENS devices are commercially available and not associated with serious side effects, patients can inde-pendently use them at home on a regular basis (Dailey et al., 2020; Jamison et al., 2021).



5. Conclusion

This systematic review highlights the potential of TENS as an option for pain management in patients with fibromyalgia. One-time treatments can have some effect on immediate pain relief, but more consistent results for a clinically meaningful reduction in pain inten-sity are seen when TENS is applied with sufficient intensity over several sessions. Given the promising evidence, further high-quality studies with larger sample size and diverse population (especially including more male participants) are needed to establish long-term efficacy in patients with fibromyalgia.



Conflicts of Interest: The authors declare no conflict of interest.



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Evoked Pain and Fatigue: A Randomized, Controlled Trial. Arthritis Rheumatol. 2020; 72:824-836. DOI:10.1002/art.41170

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Case report



Pain Relief Treatment of Fresh Sacral Fracture for a



Professional Snowboarder one Month before Participation in

the Winter Olympic Games

Breznik Katarina1*, Pilih Klemen Aleš2, Jerković Parać Božena3, Jeromel Miran4, Vauhnik Renata1



1. University of Ljubljana, Faculty of Health Sciences, Department of Physiotherapy, Ljubljana, Slovenia 2. Department of Traumatology, Slovenj Gradec General Hospital, Slovenj Gradec, Slovenia 3. Department of Anesthesiology, Slovenj Gradec General Hospital, Slovenj Gradec, Slovenia 4. Department of Diagnostic and Interventional Radiology, Slovenj Gradec General Hospital, Slovenj Gradec, Slovenia

* Correspondence: Katarina Breznik; kat.breznik3@gmail.com



Abstract:

Citation: Breznik K, Pilih KA, Sacral fractures result from trauma, stress, or low-energy impacts, especially in weake-Jerković Parać B, Jeromel M, Vauhnik ned bones. These fractures often present with nonspecific symptoms and require ad-

R. Pain Relief Treatment of Fresh vanced imaging for diagnosis. Treatment varies based on fracture severity, with Sacral Fracture for a Professional Snow- options ranging from conservative to surgical approaches. Pain management can in-

boarder one Month before volve pharmacological and non-pharmacological methods, such as acupuncture. A Participation in the Winter Olympic multidisciplinary approach is essential for recovery, particularly for athletes, to ensure

Games. Proceedings of Socratic early mobilization and avoid complications. In the case of a professional snowboarder Lectures. 2025, 12, 84-89. who sustained a sacral fracture before the 2022 Winter Olympics, a CT-guided pain

https://doi.org/10.55295/PSL.12.2025.I11 block and acupuncture enabled him to compete pain-free just 32 days post-injury. This

case highlights the importance of an individualized, multidisciplinary approach when managing fractures in high-performance athletes, balancing both the healing process and the need to return to competition.

Publisher's Note: UL ZF stays neutral

with regard to jurisdictional claims in

published maps and institutional affil- Keywords: Sacral fractures; Pain relief; Professional sport; Treatment; Symptomatic

iations. improvement

____________________________________________________________________________





Copyright: © 2025 by the authors.

Submitted for possible open access

publication under the terms and con-

ditions of the Creative Commons At-

tribution (CC BY) license (https://crea-

tivecommons.org/licenses/by/4.0/).





1. Introduction



1.1. Sacral fractures and treatment



Sacral fractures can result from high-energy trauma, repetitive stress, or low-energy im-pacts, particularly in individuals with weakened bones. They are categorized into trau-matic fractures, stress fractures (fatigue and insufficiency types), and low-energy fragility fractures. Traumatic sacral fractures often occur alongside pelvic ring injuries (Barber et al., 2023; Wagner et al., 2015). Stress fractures include fatigue fractures, caused by repeti-tive stress on a healthy bone (commonly in athletes), and insufficiency fractures, which result from normal stress on weakened bone, particularly in older adults with osteoporosis (Shankar et al., 2024). Low-energy fragility fractures, also linked to osteoporosis, may be associated with spinal disorders (Barber et al., 2023).

These fractures often present with nonspecific symptoms like diffuse pain in the lower back, pelvis, or buttock, leading to frequent misdiagnosis. While plain radiographs are usually ineffective, advanced imaging such as magnetic resonance imaging (MRI) or com-puted tomography (CT) scans significantly aids diagnosis (Shankar et al., 2024; Wagner et al., 2015). Treatment approaches depend on severity: non-operative management, such as rest and gradual activity resumption, works well for stable fractures, whereas surgical in-tervention is required for more severe cases. Despite their clinical relevance, sacral stress fractures remain under-recognized, with limited standardized treatment protocols and re-search into risk factors and outcomes (Barber et al., 2023; Shankar et al., 2024). The AOSpine sacral classification system divides sacral fractures into three types: Type A fractures are stable and managed conservatively, Type B fractures involve instability and may require surgery depending on severity, and Type C fractures compromise spinopelvic stability, requiring surgical intervention. However, there is limited agreement at the subtype level, leading to variability in treatment approaches. Further research is needed to improve classification reliability and establish evidence-based treatment protocols (Camino-Willhuber & Urrutia, 2022; Lambrechts et al., 2023). C0 sacral fractures, often classified as type 2 in the Fragility Fracture of the Pelvis system, can be managed nonoperatively if stable. If instability or discomfort prevents mobilization, surgical stabilization may be necessary. Sacroplasty and transiliac-transsacral screw fixation are minimally invasive options, while triangular osteosynthesis may be required for more complex fractures. For neurological issues, nonoperative management is typically effective, but surgical decompression may be required if symptoms persist. The treatment goal is early mobilization to avoid complications from prolonged bed rest (Lambrechts et al., 2023).

1.2. Pain relief treatment

Effective pain management in both elite athletes and the general population often requires a multidisciplinary approach that integrates pharmacological and non-pharmacological strategies. Wang (2018) highlights the critical role of advanced imaging-guided tech-niques—such as fluoroscopy, CT, and ultrasound—in delivering precise and safe interven-tional treatments for conditions like spinal pain, joint pain, and neuropathic pain. These methods facilitate targeted administration of therapies like corticosteroids or anesthetics, reducing risks of complications and enhancing efficacy.

Elite athletes frequently use medications such as non-steroidal anti-inflammatory drugs (NSAIDs), opioids, and anesthetics to manage pain. While these are effective for short-term relief, particularly for acute injuries or post-competition recovery, the potential for dependency and adverse effects from long-term opioid use necessitates a careful, balanced approach. Complementing pharmacological treatments with non-drug strategies—includ-ing physical therapy, exercise, psychosocial interventions, and attention to sleep and nu-trition—is crucial for sustainable recovery and optimal performance (Hainline et al., 2018). Interventional techniques, including corticosteroid injections, play a significant role in both sports medicine and broader pain management contexts. For instance, ultrasound-guided injections for sacroiliac joint dysfunction or other joint-related pains, as noted by Wang (2018), offer comparable efficacy to fluoroscopy-guided approaches while minimiz-ing radiation exposure. Similarly, Sandrasegaram et al. (2020) emphasize the value of con-servative management approaches, such as physical therapy, ergonomic adaptations, and



non-invasive interventions like ganglion impair blocks, in providing long-lasting pain re-lief with fewer risks. Newer therapies, such as platelet-rich plasma (PRP) injections, show promise but require further evidence to confirm their efficacy in various conditions (Hain-line et al., 2018). Together, these approaches highlight the importance of an individualized, multidisciplinary care plan in effectively addressing both acute and chronic pain (Hainline et al., 2018; Sandrasegaram et al., 2020; Wang, 2018).



1.3. Supportive pain relief therapy



Acupuncture therapy has gained significant recognition as an effective non-pharmacologic treatment for managing acute pain, including in patients with fractures such as sacral frac-tures. Research suggests that acupuncture can play a crucial role in reducing pain levels in patients experiencing fractures, offering a valuable alternative to opioid medications, which are associated with risks of addiction and adverse side effects. Acupuncture works by stimulating specific points in the body, which may influence the nervous system, reduce inflammation, and promote the release of natural pain-relieving substances like endor-phins. This process can contribute to reduced reliance on opioids, thus lowering the risk of opioid-related complications, including addiction and overdose (Nielsen et al., 2022). Numerous studies and systematic reviews have demonstrated acupuncture's efficacy in improving pain management, reducing the need for pain medication, and enhancing over-all patient satisfaction, particularly in fracture recovery (Schug et al., 2020; Nielsen et al., 2022). Acupuncture has also been shown to reduce pain intensity and shorten recovery time, making it a promising complementary therapy in acute pain management. Moreo-ver, acupuncture is considered a low-risk treatment with minimal side effects when ad-ministered by trained practitioners, which further highlights its potential as a safe and ef-fective adjunct in fracture care. Given its therapeutic benefits and minimal adverse effects, acupuncture presents a valuable option for improving the management of acute pain in fracture patients. Additionally, acupuncture's ability to manage acute pain may allow for reduced opioid use and prevent long-term complications associated with opioid treatment (Schug et al., 2020).



2. Case presentation

In preparation for the 2022 Winter Olympic Games, a professional snowboarder came to the Emergency Centre of the Slovenj Gradec General Hospital on 11 January 2022. On 7.1.2022, he fell on the track. While checking the training track, he was hit by another snow-boarder, his board slipped off, whereupon he fell on his back with great force onto a flat surface. Shortly after the fall, he realized that he was not in severe pain at rest but had a specific pain on the movement of one of his turns, which made it completely impossible for him to compete. Physiotherapy was started the same day after the fall. They used TECAR, massage, vacuum therapy, and laser. After physiotherapy, the pain in most of his back subsided, but it persisted mainly in his lower back and prevented him from snow-boarding competitively. A CT scan was performed, which was suspicious of a fracture at the level of S3 (Figure 1). An MRI scan was performed within 24 hours and, after consul-tation with the radiologist, showed sacral edema at the S3 level with a fine transverse frac-ture line, which was consistent with the anatomical location of the patient's problems (Fig-ure 2).





Figure 1. CT scan shows suspected S3 vertebral fracture (circled): A – Coronal CT image, B – Transverse CT image, C – Saggital CT image.





Figure 2. MRI showed marked edema of the bony body and posterior elements of S3 with a fine probable fracture (circled): A – Coronal T2-weighted STIR MRI, B – Saggital T1-weighted MRI.





With a non-dislocated stable sacral fracture, surgical treatment was not considered. After open consultation with the patient and recognition of the possible drawbacks of potent pain treatment in the context of successful healing of the fracture, the symptomatic (pain management) treatment was decided upon. A consortium of a trauma surgeon, an inter-ventional radiologist, and an anaesthesiologist (pain management specialist) was gath-ered. A CT-guided block (0,25 % Chirocaine 3 ml (7,5 mg) + 16 mg Dexamethasone) at the injury site was performed on 17.1.2022. The Slovenia Olympic Committee's consent for the corticosteroid application (therapeutic exception) was obtained beforehand. Further pain treatment (acupuncture) was provided. The patient successfully qualified for the Olympic Games, where, although he did not repeat his previous successes, according to his testi-mony, he completed the competitive runs completely pain-free. The competition occurred on 8.2.2022, 32 days after the injury, 28 days after the diagnostics, and 22 days after the application of the blockade.



The patient did not develop a pain sequela later over time. He could participate in further sports events with no limitations, leading the authors of this article to believe that cortico-steroid application in the setting of a fresh sacral injury did not detrimentally intervene with skeletal healing. No additional radiologic imaging was performed to confirm bony healing.



3. Discussion

Sacral fractures are rare and challenging to diagnose, often presenting with nonspecific symptoms that require advanced imaging for confirmation. Treatment typically involves non-operative approaches, though tailored strategies may be necessary for high-perform-ing athletes (Barber et al., 2023; Shankar et al., 2024). Physiotherapists can contribute to the early diagnosis of sacral fractures by identifying specific patterns of pain and functional



limitations during biomechanical assessments and movement analysis. This can lead to timely referrals for imaging or further evaluation.



Sacral stress fractures are typically managed with conservative approaches, as seen in most reported cases. Treatment often includes rest, activity modification, physiotherapy to strengthen core muscles and improve flexibility, and nutritional supplementation to ad-dress any underlying deficiencies (Sandrasegaram et al., 2020; Silva et al., 2006; Vajapey et al., 2019). Silva et al. (2006) and Vajapey et al. (2019) describe instances where athletes, both amateur and professional, developed sacral stress fractures due to repetitive high-impact activities. These cases emphasize the success of non-operative treatments, which typically result in full recovery over several weeks through measures such as rest, cessation of high-impact activities, stretching exercises, and pain management with anti-inflammatory med-ications.



In managing sacral fractures, physiotherapy plays a significant role in reducing pain, im-proving functionality, and supporting recovery (Sandrasegaram et al., 2020). A compre-hensive treatment plan, including active and passive ROM exercises, muscular strength-ening, and various modalities like TECAR therapy, massage, vacuum therapy, and laser, can alleviate symptoms and promote gradual functional recovery. While physiotherapy helps alleviate pain and supports functional recovery, some cases may require advanced rehabilitation tools like antigravity treadmills and surgical interventions for severely dis-placed fractures. This integrated approach addresses both physical and psychological as-pects, ensuring that athletes can return to their sport while minimizing long-term compli-cations (Jaiswal et al., 2022).

In the notable case, a professional snowboarder with a sacral fracture received a CT-guided block and acupuncture, enabling him to compete pain-free in the Winter Olympics within 32 days of the injury. The reported case was a rare medical emergency where symptomatic improvement was attempted to establish a high functional requirement before the bone would physiologically heal completely. In doing so, the informed risk of the possible neg-ative long-term health consequences of impaired healing of a sacral fracture was accepted. However, clinically, the patient remains without complaints to this day. The case under-scores the need for a tailored, multidisciplinary, out-of-the-ordinary approach to manag-ing fractures in high-performance athletes, where both the healing process and the urgency of returning to sport must be carefully balanced.

4. Conclusions

The successful pain management of pain related to a non-dislocated traumatic sacral frac-ture in a professional snowboarder highlights the importance of a multidisciplinary ap-proach. This case underscores the value of individualized strategies tailored to the de-mands of high-performance athletes.



Conflicts of Interest: The authors declare no conflict of interest.



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Relat Res. 2022; 480:2182-2186. DOI:10.1097/CORR.0000000000002319

3. Hainline B, Derman W, Vernec A, et al. International Olympic Committee consensus statement on pain

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4. Jaiswal PR, Lakhwani MG, Phansopkar PA. Physiotherapeutic Rehabilitation of a Patient With a Comminuted

Displaced Iliac Fracture and Superior and Inferior Pubic Rami Fractures: A Case Report. Cureus. 2022; 14:e28709. DOI:10.7759/cureus.28709 5. Lambrechts MJ, Schroeder GD, Conaway W, et al. Management of C0 Sacral Fractures Based on the AO Spine



Sacral Injury Classification: A Narrative Review. Clin Spine Surg. 2023; 36:43-53. DOI:10.1097/BSD.0000000000001384



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Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine (2020), Acute Pain Management: Scientific Evidence (5th edition), ANZCA & FPM, Melbourne. pp.921. Available at: https://www.anzca.edu.au/news/top-news/apsme5

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Curr Pain Headache Rep. 2018; 22:6. DOI:10.1007/s11916-018-0660-1





Case report



Surgical Treatment of Chronic Post-Traumatic Hamstring



Origin Pain with Tendon Transfer from the Unfused Ischial

Tuberosity Apophysis to the Native Ischial Bone

Uhan Lana1*, Strle Eva1, Pilih Klemen Aleš2, Kozic Mitja3, Vauhnik Renata1



1. Faculty of Health Sciences, University of Ljubljana, Ljubljana, Slovenia

2. Department of Traumatology and Orthopedics, General Hospital Slovenj Gradec, Slovenj Gradec, Slovenia 3. Department of Traumatology, University Medical Centre Maribor, Maribor, Slovenia * Correspondence: Lana Uhan; lana.uhan@gmail.com



Abstract:

A case report of a 35-year-old female patient suffering from chronic hamstring origin pain after an acute strain injury is presented. The initial clinical examination demon-strated a significant tenderness of the left buttocks. The diagnostics showed a chronic

Citation: Uhan L, Strle E, Pilih KA, displaced osteochondral fragment in the region of ischial tuberosity. The displaced

Kozic M, Vauhnik R. Surgical fragment was interpreted as either an unfused apophysis or an unhealed childhood Treatment of Chronic Post-Traumatic apophyseal avulsion fracture. The injury uncovered a “weak link” in the kinematic

Hamstring Origin Pain with Tendon chain of posterior thigh and was therefore treated as a strain injury of pseudoarthrosis Transfer from the Unfused Ischial between the fragment and the pelvis. Conservative treatment, including physiotherapy Tuberosity Apophysis to the Native and nonsteroidal anti-inflammatory medication, followed by a CT guided pain injec-Ischial Bone. Proceedings of Socratic tion containing a corticosteroid and local anaesthetic failed to provide sufficient results.

Lectures. 2025, 12, 91-96. Therefore, operative treatment was recommended. Release and reattachment of the https://doi.org/10.55295/PSL.12.2025.I12 hamstring tendons from the fragment to the native os ischium, using three suture an-

chors, was performed with excellent results 15 months postoperatively. During the postoperative period and physical rehabilitation therapy, the patient gradually im-

Publisher's Note: UL ZF stays neutral proved mobility, muscle strength and corrected her gait pattern. The patient was ex-

with regard to jurisdictional claims in tremely satisfied with the surgical outcome and reported no discomfort or pain while

published maps and institutional affil- performing daily activities.

iations.





Keywords: Ischial tuberosity; Chronic pain; Unfused apophysis; Tendon transfer; Re-

Copyright: © 2025 by the authors. habilitation.

Submitted for possible open access

publication under the terms and

conditions of the Creative Commons

Attribution (CC BY) license

(https://creativecommons.org/li-

censes/by/4.0/).





1. Introduction



Proximal hamstring tendinopathy is the most common cause of chronic posterior thigh pain (Hunter & Speed, 2007). However, in some cases, the reason for pain can be found in other conditions with similar presentations, and the correct diagnosis is often missed due to the similarities in the mechanism of the injury and the area of pain (Dailey et al., 2013).



1.1. Ischial tuberosity and its ossification

The ischial tuberosity is the origin site of the muscles at the posterior compartment of the thigh, the hamstrings. The long head of biceps femoris and semitendinosus originate from the ischial tuberosity with a common tendon, while semimembranosus originates as a sep-arate tendon laterally (Miller et al., 2007). Endochondral ossification, the process by which most of the skeleton is formed, involves the replacement of hyalin cartilage with bony tis-sue and proceeds at different rates in different bones (Mackie et al., 2007). Ossification of the ischial tuberosity typically starts between 13 and 15 years of age. During this process, due to the physiological properties of the hyaline cartilage, the ischial tuberosity is two to five times more fragile than the surrounding ligaments and tendons (Liu et al., 2018). The region of the ischial tuberosity has a limited capacity for force absorption, and an increase in mechanical load can result in avulsion fractures (Dailey et al., 2013).

1.2. Mechanism of the injury

Generally, these injuries are rare and occur frequently only in skeletally immature, active patients due to incomplete ossification (Liu et al., 2018). The mechanism of injury typically involves a powerful eccentric contraction of the hamstrings during sport activities involv-ing rapid acceleration (e.g., sprinting and jumping (Liu et al., 2018; Tetsunaga et al., 2019). As a result of delayed diagnosis or unsuccessful conservative treatment, some cases de-velop non-union, leading to chronic pain later in life (Ali et al., 2020). Asymptomatic un-fused ischial tuberosity apophysis is rarely seen in adults, however, repeated micro-trauma during the process of growth and maturation can, in some cases, lead to non-union. Repetitive overload of the apophysis during sports activities can lead to apophysitis, and if the condition becomes chronic, the apophysis can remain unfused (Ali et al., 2020). The patient may later be symptom-free, while in some cases, the condition can lead to chronic pain in the posterior thigh (Ali et al., 2020; Dailey et al., 2013). Failure to treat the displaced fractures has been associated with pseudoarthrosis and proximal hamstring fibrosis, also leading to chronic pain and limitations on activities of daily living (Lui et al., 2018). An accurate diagnosis is, therefore, essential for proper clinical management.

1.3. Treatment

Conservative treatment, including modification of activities and anti-inflammatory medi-cation is usually adequate for apophysitis (Ali et al., 2020). If diagnosed early and the size of fracture displacement is less than 2 centimeters, bony avulsions are also managed con-servatively (Lui et al., 2018). Conservative treatment plan for avulsion fractures consists of four phases (Table 1) (Cereti et al., 2013).

Table 1. Conservative treatment plan for avulsion fractures (Cerreti et al., 2013).

Phase Week Conservative treatment plan

1 1 – 3 Resolution of pain, inflammation and acute symptoms. Rest, anti-inflammatory

medication and passive mobilization are recommended.

2 3 – 8 Performing progressive agility and trunk stabilization exercises with low to mode-

rate intensity for regaining mobility.

3 8 – 16 Performing progressive agility and trunk stabilization exercises with higher inten-

sity.

4 16 – 24 Performing static stretching and isometric strengthening, followed by controlled

eccentric and concentric contractions to increase strength and endurance.



Before returning to regular activity, the avulsed bone fragment must unite with the rest of the bone and the patient must regain full range of motion and adequate muscle strength. If the dislocation of the apophysis is greater than 2 centimeters or conservative treatment has not been successful, surgical reattachment may be considered (Liu et al., 2018). In cases of delayed diagnosis, unfused avulsed fragment usually forms a fibrous pseudoarthrosis with the rest of the bone (Liu et al., 2018). Excessive fibrous overgrowth during the healing process of avulsed ischial apophysis often causes symptoms later in life, such as discomfort while sitting and pain during activities (Schlonsky & Olix, 1972). Aggressive conservative treatment, including local corticosteroid injections and physiotherapy, is used to treat those symptoms. If the conservative treatment is unsuccessful, surgical discission of fi-brous tissue usually provides resolution of pain. In some cases, surgical reattachment of the avulsed fragment is performed (Liu et al., 2018; Schlonsky & Olix, 1972). Even though surgical treatment is considered effective in alleviating chronic pain, there is a lack of data published on these procedures (Liu et al., 2018). This report presents a case of successful surgical treatment of chronic post-traumatic hamstring origin pain with tendon transfer from the unfused ischial tuberosity apophysis to the ramus of the ischial bone.



2. Injury and treatment course



A 35-year-old female patient was presented to the emergency clinic after a slip in her bath-room, which resulted in an injury to her left leg. The patient described a typical stretch-type injury to the hamstrings, an extensive hip flexion with an extended knee (Danielsson et al., 2020). The initial clinical examination demonstrated a significant tenderness of the left ischial tuberosity. A computed tomography (CT) scan of the pelvis showed a displaced osteochondral fragment, interpreted as either an unfused apophysis or an unhealed child-hood apophyseal avulsion fracture (Figure 1a). The patient’s childhood history of gymnas-tics and athletics raised suspicion that sport-induced stresses could have contributed to either an acute trauma (which the patient does not recall) or an overuse injury that inhib-ited apophyseal fusion. Magnetic resonance imaging (MRI) of the pelvis confirmed a dis-placed osteochondral fragment, with all proximal hamstring tendons attached to it (Figure 1b). There was an effusion in the pseudoarthrosis between the fragment and the ischial bone, a sign of inflammation. Strain injury to the pseudoarthrosis was diagnosed. It seemed that the injury uncovered a developmental skeletal deficit.





Figure 1a. X-ray image from the time of the initial examination.



Figure 1b. MRI from the time of the initial examination. Note the effusion and accumulation of fluid within the pseudoarthrosis.

A senior trauma surgeon was consulted. Conservative treatment focused on alleviating pain was initiated, including physiotherapy and nonsteroidal anti-inflammatory medica-tion. The patient was instructed to avoid movement that aggravated the symptoms. After three months, the patient was scheduled for control at the outpatient clinic. Conservative management did not provide sufficient results. The pain persisted, with increasing limita-tions in the activities of daily living. The patient reported having problems with sitting, walking and weight-bearing activities. Antalgic gait with decreased weight bearing on the affected site was observed. A pain management specialist was consulted and recom-mended a CT-guided pain injection. The injection containing a corticosteroid, and a local anaesthetic was injected to the affected area. The procedure provided temporary relief.



But, the pain rebounded, and the patient reported mild postprocedural irritation of the sciatic nerve, with an occasional tingling in the peripheral nerve field. Electromyography (EMG) demonstrated no abnormalities and MRI showed preserved nerve continuity. Ulti-mately, the pain management injection failed to provide sufficient results, and therefore, operative treatment was indicated.



The surgery was performed in a prone position under general anaesthesia. An incision was made along the gluteal crease, followed by the skin and subcutaneous tissue dissection. With the retraction of the gluteal muscles, the osteochondral fragment with attached ham-string tendons was exposed, and the sciatic nerve was identified. Fibrous tissue around the fragment was removed, while care being taken to avoid nerve damage. The release of hamstring tendons from the unfused fragment was performed. Reattachment of the ten-dons to the native os ischium was performed in the 60 degrees knee flexion, using three suture anchors. The postoperative anteroposterior radiogram of the pelvis and proximal femora is presented in Figure 2.





Figure 2. Postoperative anteroposterior radiogram of the pelvis and proximal femora.





Postoperatively, the left knee was immobilized in a hard frame brace, fixed at 60 degrees of flexion. At discharge, the patient was mobilized on crutches without load. Two weeks postoperatively, the brace was fixed at 30 degrees of knee flexion for an additional three weeks. The patient was instructed to avoid any active hip extension or knee flexion. Pain decreased significantly over time. Sciatic irritation faded. Six weeks postoperatively, full weight bearing was permitted. The patient started with physiotherapy, which included passive range of motion improvement exercises, ultrasound and laser to improve healing and electrotherapy for pain management. Seven weeks postoperatively, the patient im-proved significantly and could stand and walk without any discomfort. The range of hip motion was sufficient. A slight antalgic gait was still present. Nine weeks postoperatively, she underwent an intensive inpatient rehabilitation and balneotherapy at a local wellness center. Physiotherapy was focused on pain management, improving mobility and func-tion. The two-week protocol consisted of active exercise, balance training, group hydro gymnastics, manual therapy, laser, and magnetotherapy. Pain was no longer present at discharge, and her gait pattern improved significantly. The range of hip motion increased in both flexion, extension, internal and external rotation and was in the range of normative



values for healthy adults. Fifteen months postoperatively, the patient was extremely satis-fied with the surgical outcome and reported no discomfort or pain while performing ac-tivities of daily living.





3. Discussion and conclusion



This case report describes a patient suffering from chronic hamstring origin pain that started as an acute strain injury. The diagnostics uncovered a developmental skeletal dis-order that was interpreted as either an unfused apophysis or an unhealed childhood apophyseal avulsion fracture. Generally, apophyseal avulsion fractures are rare and fre-quently occur only in skeletally immature, active patients. Individuals with undiagnosed, asymptomatic fractures are susceptible to recurrent injuries or complications. An unhealed avulsed fragment often forms a fibrous pseudoarthrosis with pelvis girdle and is prone to strain under heavy load. In the presented case, the patient injured the pseudoarthrosis be-tween the hamstring origin and the pelvis. As a result, with muscle activation, the connec-tion between the fragment and the ischium was subjected to strain, leading to the devel-opment of chronic pain. Initial conservative treatment, including physiotherapy, medica-tion, and corticosteroid injections, did not alleviate the pain. The literature confirms limited success of conservative treatment in chronic cases (Liu et al., 2018). Most authors agree that displacement greater of 2 centimeters is an indication for surgical intervention. Potential complications of conservative treatment include chronic pain, fibrosis at the origin of the hamstrings, sciatic nerve complications, muscle weakness, and inability to sit for a prolonged period (Liu et al., 2018; Schlonsky & Olix, 1972). Nevertheless, surgeons are often reluctant to operate in this anatomical region with-out extensive experience on account of the proximity of the sciatic nerve (Ali et al., 2020). To our knowledge, this is the first report describing surgical treatment of chronic ham-string origin pain with tendon transfer from the unfused ischial tuberosity apophysis to the native ischial bone. Suture anchor repair of the hamstrings was performed with direct exposure and protection of the sciatic nerve. Although the delayed diagnosis made it tech-nically more challenging, excellent clinical, functional, and subjective results were achieved 15 months postoperatively. A comprehensive postoperative rehabilitation pro-gram contributed to improved mobility and muscle strength. In conclusion, surgical intervention can address chronic issues caused by pseudoarthrosis and fibrous tissue overgrowth of hamstring origin, providing resolution of pain and func-tional deficits. The presented case demonstrates that hamstring tendon transfer with su-ture anchor repair to the ischial bone is an effective treatment option for chronic pain as-sociated with unfused apophysis of the ischial tuberosity. When conservative treatment fails, surgical intervention can restore function and significantly improve quality of life.



Conflicts of Interest: The authors declare no conflict of interest.



References

1. Ali AM, Lewis A, Sarraf KM. Surgical treatment of an ischial tuberosity avulsion fracture with delayed

presentation. J Clin Orthop Trauma. 2020; 11:4-6. DOI: 10.1016/j.jcot.2019.07.010

2. Ceretti M, Di Renzo S. A new evaluation system for early and successful conservative treatment for acute

ischial tuberosity avulsion. Chin J Traumatol. 2013; 16:254-256.

3. Dailey SK, Branam B, Archdeacon MT. Chronic (Ten Years) Ischial Tuberosity Avulsion Fracture Nonunion

Treated with Fragment Excision and Simultaneous Primary Repair of the Hamstring Tendon: A Case Report. JBJS Case Connect. 2013; 3: e137. DOI: 10.2106/JBJS.CC.M.00176

4. Hunter DG, Speed CA. The assessment and management of chronic hamstring/posterior thigh pain. Best Pract

Res Clin Rheumatol. 2007; 21:261-277. DOI: 10.1016/j.berh.2006.12.002

5. Liu H, Zhang Y, Rang M, Li Q, et al. Avulsion Fractures of the Ischial Tuberosity: Progress of Injury,

Mechanism, Clinical Manifestations, Imaging Examination, Diagnosis and Differential Diagnosis and Treatment. Med Sci Monit. 2018; 24:9406-9412. DOI: 10.12659/MSM.913799 6. Mackie EJ, Ahmed YA, Tatarczuch L, Chen KS, Mirams M. Endochondral ossification: how cartilage is



converted into bone in the developing skeleton. Int J Biochem Cell Biol. 2008; 40:46-62. DOI: 10.1016/j.biocel.2007.06.009



7. Miller SL, Gill J, Webb GR, et al. The proximal origin of the hamstrings and surrounding anatomy encountered



during repair. A cadaveric study. J Bone Joint Surg Am. 2007; 89: 44-48. DOI: 10.2106/JBJS.F.00094

8. Schlonsky J, Olix ML. Functional disability following avulsion fracture of the ischial epiphysis. Report of two

cases. J Bone Joint Surg Am. 1972; 54:641-644.

9. Tetsunaga T, Endo H, Yamada K, Furumatsu T, Ozaki T. Avulsion fracture of the ischial tuberosity treated with

the suture bridge technique: a case report. BMC Musculoskeletal Disord. 2019; 20:9. DOI: 10.1186/s12891-018-2377-z





Research



Ring-Shaped Lateral Meniscus – Rise Awareness and Avoid



Unnecessary Surgery: A Case Report

Zoroja Monika1, 2, * , Pilih Klemen Aleš3, Vauhnik Renata1



1. University of Ljubljana, Faculty of Health Sciences, Ljubljana, Slovenia

2. Community Health Centre Ljubljana, Ljubljana, Slovenia

3. Department of Traumatology, General hospital Slovenj Gradec, Slovenia

* Correspondence: Monika Zoroja; monika.zoroja@gmail.com



Abstract:

There are numerous meniscal anatomical variants, particularly prevalent in the East Asian population. These variants typically involve the lateral meniscus and are often asymptomatic. The ring-shaped meniscus is a relatively rare variant, with an incidence of 0.9 to 2.4% in the Asian populations. Magnetic resonance imaging (MRI) has a pivotal role in diagnosing meniscal and ligament injuries of the knee. Still, it has been difficult

Citation: Zoroja M, Pilih KA,Vauhnik to distinguish a ring-shaped meniscus from a bucket-handle tear of a lateral meniscus

R. Ring-Shaped Lateral Meniscus – Rise or a central tear of a discoid lateral meniscus. Awareness and Avoid Unnecessary The subject was a woman in her 20s, reporting pain in her left knee after a mild sprain.

Surgery: A Case Report. Proceedings of The first MRI showed a small mediopatellar plica with a fissure of lateral femoral car-

Socratic Lectures. 2025, 12, 98-103. tilage posteriorly and a massive bucket-handle rupture of the lateral meniscus with in-

https://doi.org/10.55295/PSL.12.2025.I13 tercondylar incarceration of the fragment. During arthroscopic knee surgery, an inter-

condylar lateral meniscus fragment was visualized. The fragment could not be reponed due to a massive fibrous band attaching it to the joint capsule posteromedially. A con-

Publisher’s Note: UL ZF stays neutral genital condition was suspected. Later, a follow-up bilateral MRI was performed,

with regard to jurisdictional claims in showing a symmetrical condition and confirming the presence of bilateral ring-shaped

published maps and institutional affil- lateral menisci. The radiologist, however, still interpreted the finding as a bilateral in-

iations. carcerated bucket-handle lateral meniscus tear.

Our case highlights the importance of knowing the plethora of meniscal variants to avoid unnecessary surgery.



Copyright: © 2025 by the authors.

Submitted for possible open access Keywords: Ring-shaped meniscus; Lateral meniscus; Knee arthroscopy; Magnetic res-

publication under the terms and onance imaging

conditions of the Creative Commons

Attribution (CC BY) license

(https://creativecommons.org/licenses

/by/4.0/).





1. Introduction



The menisci are fibrocartilages interposed between the femoral condyles and tibial plateau. In cross-section, they appear triangular and are fundamental for tibiofemoral congruence, playing an essential role in the kinetics of the knee (Faruch-Bilfeld et al., 2016). The medial meniscus is shaped like an open "C" and is attached to the medial capsule through the coronary ligaments. In contrast, the lateral meniscus is an incomplete, oval-shaped structure that lacks capsular attachments, making it more mobile than the medial meniscus (Iqbal et al., 2020).



There are numerous meniscal anatomical variants, and they are particularly prevalent in the East Asian population. These variants typically involve the lateral meniscus and are often asymptomatic (Tyler et al., 2010). The commonest of the variants is the discoid meniscus, with an incidence of about 16.6% in Asian populations and less than 5% in the Caucasian population (Lee et al., 2020). Other less common variants include the ring-shaped meniscus (RSM), abnormal bands of the lateral meniscus and double-layered meniscus. The RSM is relatively rare, with an incidence of 0.9 to 2.4% in the Asian populations (Kim et al., 2006). Noble (1975) was the first to document a ring-shaped lateral meniscus as an incidental finding during autopsy. Monllau et al. (1998) further described it as a meniscus with the anterior and posterior horns connected by an inter-horn meniscal bridge. While meniscal malformations are generally considered congenital, some cases may result from meniscal regeneration following knee operations (Nagashima et al., 2019). Magnetic resonance imaging (MRI) has a pivotal role in diagnosing meniscal and ligament injuries of the knee (Faruch-Bilfeld et al., 2016). However, certain anatomical variants can be confused with pathological conditions, such as a displaced bucked-handle tear (Kim et al., 2006). Diagnosing a ring-shaped lateral meniscus on MRI is particularly challenging because its appearance, with a centrally located fragment, often resembles a displaced meniscal tear (Atay et al., 2002).

This case report aims to raise awareness among healthcare professionals about possible rare congenital conditions affecting the lateral meniscus, which could help prevent unnecessary surgical interventions.

2. Case presentation

A woman in her 20s was referred to our outpatient clinic complaining of pain in her left knee. She reported a mild sprain of the knee. Previous major trauma to the knee was not reported. Magnetic resonance imaging (MRI) revealed a small mediopatellar plica with fissure of lateral femoral cartilage posteriorly and a massive bucket-handle rupture of the lateral meniscus with intercondylar incarceration of the fragment. The medial meniscus, anterior and posterior cruciate ligament, collateral ligaments, patellar ligament and quad-riceps tendon showed no pathology.

On physical examination, the knee range of motion was preserved, and no instability of the knee joint was observed. Pain was occasional. The patient reported pain on palpation on the lateral femorotibial joint line and directly on the patellar ligament. Due to minimal clinical symptoms, a senior surgeon was consulted to discuss the indications for possible treatment strategies due to a low-symptomatic clinical presentation of a suspected bucket-handle tear. A knee arthroscopy was recommended. Awaiting the surgery, reduction and modification of physical activity was advised.

3. Treatment

An arthroscopic knee surgery was performed about one month after the outpatient visit. During the arthroscopic examination the intercondylar lateral meniscus fragment was vis-ualised. As the fragment could not be reponed laterally, partial tissue resection connecting the fragment posteromedially and popliteally was attempted. As the resection was being performed, the extent of the posterior fibrous band was appreciated. Realizing that an ex-tensive tissue resection would be needed to attempt a successful reposition of the fragment laterally, the surgeon did not carry the procedure through. Given the patient had minimal preoperative issues, it was decided not to perform a large-scale resection that could alter the patient anatomy and potentially cause difficulties.



Figure 1. MRI transverse (left), coronal (centre) and saggital (rigth) plane view.





The patient recovered quickly after the arthroscopy and was discharged from the hospi-tal the following day. She received standard analgesics and anticoagulants. Postoperative course was uneventful. Physiotherapy was suggested.



Postoperative rehabilitation focused on improving the range of motion and strengthening the thigh muscles until normalization. The patient immediately began light isometric con-tractions of the quadriceps muscle combined with Bioptron therapy for 2 weeks. After su-ture removal, she received TECAR therapy four times with additional manual lymph drainage. She was taught scar massage and self kinesiotape application for circula-tory/lymphatic drainage. She used a Compex Sport Elite muscle stimulator daily for initial muscle strengthening. From week one to two, the program used was Disuse atrophy while doing isometric quadriceps femoris muscle contractions. From week three to six she ad-vanced to Muscle growth, and six to nine to Reinforcement. Progressively, she increased the difficulty of exercises from isometric contractions to closed kinetic chain exercises, like squats. For pain management she used Modulated TENS when needed. For additional muscle strengthening, conditioning, and a gradual return to sports, she worked with a kinesiologist twice a week for two months.



4. Outcome and additional diagnostic procedures

About three months after the arthroscopy, the patient returned to the clinic for a follow-up. She reported pain during cross-leg sitting and on palpation on the anterolateral joint line and arthroscopic scars. On detailed medical history, she reported episodes of pain in both knees since childhood.

The arthroscopic view of the operated lateral meniscus (Figure 2) differed from the usual bucket-handle ruptured meniscus. The attachment of the meniscus to the popliteal capsule was uncommon. As well, there were only minor findings suggesting a traumatic event, therefore a congenital condition was suspected. A centrally ruptured discoid lateral meniscus seemed a possible clinical hypothesis. The patient was referred to bilateral knee MRIs. The MRI showed symmetrical condition, while reporting no previous trauma of the right knee, which was completely asymptomatic. The radiologist reported a bilateral bucket-handle tear with an intercondylar incarceration of the fragment. A ring-shaped lateral meniscus was diagnosed after conducting literature research and further consultation with radiologists.





Figure 2. Arthroscopic view of the ring-shaped lateral meniscus. A: anterolateral view, B: meniscus continues posteriorly, C: anteromedial view, D: anterolateral to posterolateral view (meniscus continues medially).



5. Discusion



The lateral meniscus is morphologically more prone to variations, predominantly found in Asian populations (Lee et al., 2020). The most frequent meniscal variant is the discoid meniscus, classified by Watanabe & Ikeuchi (1969) into three types: complete discoid meniscus, incomplete discoid meniscus and Wrisberg type meniscus. In 1998, Monllau et al. proposed the addition of RSM as a fourth type, leading to the development of the modified Watanabe classification system.



RSM is generally considered to be a congenital variation of the lateral meniscus, since patients usually present no symptoms or history of significant trauma (Arnold & Van Kampen, 2000; Soejima et al., 2013; Tyler et al., 2010). Additionally, Le Minor (1990) also identified RSM in primates, such as gorillas, further supporting its congenital origin. However, there are reports of symptomatic RSM cases, which are usually accompanied by meniscal cysts (Atay et al., 2002; Arnold & Van Kampen, 2000; Koukoulias & Papastergiou, 2011), medial plicas (Asadullayeva et al., 2024), meniscal tears (Kim et al., 2006) or other concurrent abnormalities or malformations of the knee (Rahij et al., 2024). In our case, MRI similarly revealed a small medial plica and meniscal cyst, indicating that the symptoms were not necessarily produced by the meniscus, as a RSM was also present in the other, asymptomatic, knee.

On the other hand, we can find literature suggesting regenerative formation of RSM after partial meniscectomy (Nagashima et al., 2019), anterior cruciate ligament (ACL) reconstruction (Fujii et al., 2017), and partial resection of a discoid meniscus with ACL reconstruction (Soejima et al., 2013). Similarly, cases of regenerative formation of a discoid meniscus have been reported in children (Bisicchia & Tudisco, 2013). Although the exact mechanism of regeneration is unknown, most authors suggest it is influenced by active growth plates that promote tissue repair (Nagashima et al., 2019) or the environment after ACL reconstruction, where drilling debris may contain mesenchymal stem cells and growth factors that promote intraarticular tissue formation (Fujii et al., 2017; Soejima et al., 2013).



Lateral meniscus variants are mostly detected on MRI (Lee et al., 2020). Still, it has been difficult to distinguish a RSM from a bucket-handle tear of the normally C-shaped lateral meniscus (Kim et al., 2006) or a central tear of a discoid meniscus (Lee et al., 2020). MRI signs that could aid in the recognition of a RSM are typically the presence of "the mirror image sign" and "the central bow tie sign" (Iqbal et al., 2020). In differential diagnosis, we should also remember that bucket-handle ruptures are more common in the medial meniscus due to its firm attachment to the capsule and consequent greater stability (Niitsu et al., 2003). As bucket-handle ruptures of the medial meniscus have a predilection of 76% (Ververidis et al., 2006), the involvement of the lateral meniscus should also raise suspition of congenital meniscal variants (Fujikawa et al., 2002).



6. Conclusions



When interpreting MRI images, it is essential to be aware of the signs mentioned previously to avoid unnecessary surgery (Asadullayeva et al., 2024). Nevertheless, a detailed history and note of trauma should be taken, as well as medical symptoms evaluated when interpreting the MRI findings (Kim et al., 2006). The final decision whether to operate should therefore not be made exclusively on the MRI.



Conflicts of Interest: The authors declare no conflict of interest.



References

1. Arnold MP, Van Kampen A. Symptomatic ring-shaped lateral meniscus. Arthroscopy. 2000;16:852-854.

DOI:10.1053/jars.2000.8244

2. Asadullayeva M, Altintas Taslicay C, Dervisoglu E, et al. “Ring-shaped” meniscus and accompanying

intermeniscal bridge meniscus: a rare combined variant resembling a bucket-handle tear. Skeletal Radiol. 2024; 53: 805–809 . https://doi.org/10.1007/s00256-023-04439-9

3. Atay OA, Aydingöz U, Doral MN, Tetik O, Leblebicioğlu G. Symptomatic ring-shaped lateral meniscus:

magnetic resonance imaging and arthroscopy. Knee Surg Sports Traumatol Arthrosc. 2002; 10:280-283. DOI:10.1007/s00167-002-0292-0

4. Bisicchia S, Tudisco, C. Re-growth of an incomplete discoid lateral meniscus after arthroscopic partial resection

in an 11 year-old boy: a case report. BMC Musculoskelet Disord. 2013;14:285. https://doi.org/10.1186/1471-2474-

14-285

5. Faruch-Bilfeld M, Lapegue F, Chiavassa H, Sans N. Imaging of meniscus and ligament injuries of the knee.

Diagnostic and Interventional Imaging. 2016;97:749–765. https://doi.org/10.1016/J.DIII.2016.07.003

6. Fujii M, Furumatsu T, Miyazawa S, et al. Formation of ring-shaped lateral meniscus following anterior cruciate

ligament reconstruction: A case report. Int J Surg Case Rep. 2017;31:229-232. DOI:10.1016/j.ijscr.2017.01.060

7. Fujikawa A, Amma H, Ukegawa Y, Tamura T, Naoi Y. MR imaging of meniscal malformations of the knee

mimicking displaced bucket-handle tear. Skeletal Radiol. 2002;31:292-295. DOI:10.1007/s00256-002-0490-3

8. Iqbal A, McLoughlin E, Botchu R, James SL. The ring-shaped meniscus: a case series demonstrating the

variation of imaging appearances on MRI. Skeletal Radiol. 2020;49:281-289. doi:10.1007/s00256-019-03277-y

9. Kim YG, Ihn JC, Park SK, Kyung HS. An arthroscopic analysis of lateral meniscal variants and a comparison

with MRI findings. Knee Surg Sports Traumatol Arthrosc. 2006;14(1):20-26. doi:10.1007/s00167-005-0629-6

10. Koukoulias NE, Papastergiou SG. Symptomatic ring-shaped lateral meniscus. MRI findings. BMJ Case Rep.

2011:bcr1020114914. DOI:10.1136/bcr.10.2011.4914

11. Lee S-K, Yang B-S, Kim T-W, Choi N-H. Ring-shaped lateral meniscus combined with an accessory meniscus: A

rare anatomical variant. Journal of Orthopaedic Surgery. 2020:28(1). DOI:10.1177/2309499019893059

12. Le Minor JM. Comparative morphology of the lateral meniscus of the knee in primates. J Anat. 1990;170:161-

171.

13. Monllau JC, León A, Cugat R, Ballester J. Ring-shaped lateral meniscus. Arthroscopy. 1998;14:502-504.

DOI:10.1016/s0749-8063(98)70079-9

14. Nagashima M, Otani T, Kojima K, Aida S, Ishii K. Ring-shaped meniscus formation may arise from the

regenerative response to meniscectomy during growth spurts: A case report. Int J Surg Case Rep. 2019; 61:226-229. doi:10.1016/j.ijscr.2019.07.056

15. Niitsu M, Ikeda K, Itai Y. Reversed double PCL sign: unusual location of a meniscal fragment of the knee

observed by MR imaging. Eur Radiol. 2003;13:L181-L184. DOI:10.1007/s00330-003-1874-z 16. Noble J. Congenital absence of the anterior cruciate ligament associated with a ring meniscus. J Bone Joint Surg



Am. 1975;57:1165-1166.



17. Rahij H, Hassan MS, Ariyaratne S, Botchu R, et al. Ring-shaped meniscus with absent anterior cruciate



ligament: A rare association with review of the literature. Indian Journal of Musculoskeletal Radiology. 2024;6:49–52.

DOI:10.25259/IJMSR_62_2023

18. Soejima T, Kanazawa T, Tabuchi K, Noguchi K, Inoue T, Murakami H. Regeneration of ring-shaped lateral

meniscus after partial resection of discoid meniscus with anterior cruciate ligament reconstruction. Int J Surg Case Rep. 2013;4:1093-1096. DOI:10.1016/j.ijscr.2013.08.023

19. Tyler P, Datir A, Saifuddin A. Magnetic resonance imaging of anatomical variations in the knee. Part 2:

miscellaneous. Skeletal Radiol. 2010; 39:1175–1186. https://doi.org/10.1007/s00256-010-0904-6

20. Ververidis AN, Verettas DA, Kazakos KJ, Tilkeridis CE, Chatzipapas CN. Meniscal bucket handle tears: a

retrospective study of arthroscopy and the relation to MRI. Knee Surg Sports Traumatol Arthrosc. 2006;14:343-349. doi:10.1007/s00167-005-0678-x

21. Watanabe M, & Ikeuchi H. Atlas of arthroscopy (2nd ed.). Igaku-Shoin Ltd. 1969.





Research



What are the Endurance Times of the Trunk Muscle Endurance



Tests on the Roman Chair: A Preliminary Normative Study

Petrič Maja1,*



1. Faculty of Health Sciences, Department of Physiotherapy, University of Ljubljana, Ljubljana, Slovenia

* Correspondence: Maja Petrič; maja.petric@zf.uni-lj.si



Abstract:

Sufficient trunk muscle endurance and an appropriate ratio between endurances of the major trunk muscle groups are important factors in the prevention of low back pain. Trunk muscle endurance tests on the 45° Roman chair can be used as an alternative to

Citation: Petrič M. What are the the standard tests, but there is a need to collect normative data for these tests. Endurance Times of the Trunk Muscle The aim of this preliminary normative study was to assess the endurance times of the

Endurance Tests on the Roman Chair: A trunk muscles and the ratio between endurances of these trunk muscles during endur-

Preliminary Normative Study. ance tests on the Roman chair.

Proceedings of Socratic Lectures. 2025, One hundred and six healthy participants aged 16-76 years (mean age: 36.911.7 years) 12, 105-110. without recent injuries or musculoskeletal disorders participated in our study. Trunk https://doi.org/10.55295/PSL.12.2025.I14 muscle endurance was tested on the Roman chair in four test positions: an endurance

test for the trunk extensors, the trunk flexors and the lateral trunk muscles on the right and left side. For each test, the endurance time was recorded in seconds and the four trunk muscle endurance ratios were calculated for each participant.

Publisher’s Note: UL ZF stays neutral The mean endurance time in the trunk extensors endurance test was significantly (p =

with regard to jurisdictional claims in 0.03) longer in women than in men. In addition, the ratios between the lateral trunk

published maps and institutional affil- muscles and the extensors also differed significantly between women and men (p <

iations. 0.05).

The preliminary results on the normative endurance times for the trunk muscles in the Roman chair tests indicate some differences in muscle endurance between the genders.



Copyright: © 2025 by the authors. A larger sample of participants is required to determine normative values.

Submitted for possible open access

publication under the terms and con-

ditions of the Creative Commons At- Keywords: Endurance tests; Roman chair; Physical performance; Spine stabilisation;

tribution (CC BY) license (https://crea- Core muscles

tivecommons.org/licenses/by/4.0/).





1. Introduction



Back and abdominal muscle endurance is one of the key elements of physical performance that can affect spinal health by providing good/poor stability of the lower back and thus preventing injury (Panjabi, 1992; Kisner &Thorp, 2018). Therefore, sufficient trunk muscle endurance and an appropriate ratio between endurances of the major trunk muscle groups, i.e. the trunk extensors, trunk flexors and lateral trunk muscles, are important fac-tors in the prevention of low back pain (Panjabi, 1992; McGill et al., 1999; McGill, 2016). As McGill (2016) has already emphasised, optimal tests that isolate the trunk extensors, flexors and lateral trunk muscles are difficult to find. The endurance tests proposed by this author are 1) the extensor endurance test - a modification of the Biering-Sorensen test (Bier-ing-Sørensen, 1984), 2) the flexor endurance test - sitting posture with a 60° angle to the floor and 3) the side bridge test (McGill, 2016). However, many authors emphasised that the endurance of other muscles (e.g. hip and shoulder muscles, etc.) (Pagé et al., 2011; Juan-Recio et al., 2022), shoulder pain or weakness (Ledoux et al., 2012; Pagé & Descarreaux, 2012) and the different type of kinetic chain (Tuff et al., 2020) may contribute to the perfor-mance of the above test positions.



The trunk muscle endurance tests on the 45° Roman chair showed some comparable char-acteristics and some potentially more feasible characteristics than the standard tests, i.e. the McGill tests (Petrič et al., 2022). Considering the characteristics and usefulness found in our previous study (Petrič et al., 2022), the Roman chair endurance tests can be used as an alternative to the standard tests mentioned above: All four trunk muscle groups are tested in a unified body position, a unified inclination angle and in an open kinetic chain. They have been shown to be easier and quicker for the evaluator to perform (no additional preparation or stabilisation is required, etc.), and in terms of perceived exertion by the participants, these tests are slightly easier to perform compared to the McGill tests (Petrič et al., 2022).

As the test positions of the Roman chair tests have only been used in a few studies so far (Ledoux et al., 2012; Pagé & Descarreaux, 2012; Petrič et al., 2024), there is a need to develop a normative database for these tests. The aim of this preliminary normative study was to assess the endurance times and the ratio between endurances of the major trunk muscle groups during the Roman chair tests.

2. Material and Methods

The study was designed as a preliminary normative study with a simple measurement of endurance times in four trunk muscle endurance tests on the Roman chair. The measure-ments were performed at the Faculty of Health Sciences of the University of Ljubljana (Slo-venia). This study was approved by the National Medical Ethics Committee of the Repub-lic of Slovenia (0120-220/2019/6).

2.1. Study sample

One hundred and six participants aged 16 to 76 years without current musculoskeletal injuries or diseases participated in our study. They were invited via electronic media and chain referral sampling in various research projects (PhD research, HUD 2024 project of the Faculty of Health Sciences, University of Ljubljana etc.). The inclusion criteria were a) healthy participants without musculoskeletal injuries or other conditions, that could be a contraindication for the muscle endurance test, b) and without low back pain at the time of enrolment in the study. All participants were volunteers and provided written informed consent prior to participation in this study.

2.2. Study instruments and procedures

All participants completed questionnaires regarding their demographic data and health status (Jakovljević et al., 2017).

The endurance time (in seconds) of the four major trunk muscle groups was measured: trunk extensors (EX), trunk flexors (FL), right lateral trunk muscles (R-LM) and left lateral trunk muscles (L-LM). All four tests were performed on the 45° Roman chair, with the test positions, test procedures and calculation of trunk muscle endurance ratios following the protocols previously described in Petrič et al. (2022) (referred to as “B tests” in this article).



2.3. Study statistics



The statistical analysis consisted of calculating mean endurance times (in seconds) and ratio between endurances of the major trunk muscle groups with standard deviations. The endurance times in each trunk muscle group were compared between women and men (t-test for unrelated samples or Mann-Whitney U-Test for unrelated samples). Statistical sig-nificance was set at p ≤ 0.05 for all analyses. Data analysis was performed using an Excel programme (Microsoft Corporation, Washington, United States) and IBM SPSS Statistics 29 (IBM, New York, United States).



3. Results

One hundred and six participants aged 16-76 years (mean age: 36.9 11.7 years) took part in a study. In terms of gender, participants differed significantly in mean body height and mass (p < 0.001; Table 1).



Table 1. Demographic data of participants by gender (mean  standard deviation).

n Age (years) Body height (m) Body mass (kg) BMI (kg/m2)

Women 86 37.1  12.5 1.67  0.05 64.1  10.3 23.0  3.7

Men 20 36.3  7.1 1.80  0.06 78.8  11.1 24.3  2.7

p 0.79 < 0.001* < 0.001* 0.10

All 106 36.9  11.7 1.69  0.07 66.9  12.0 23.3  3.6

n, number of participants; BMI, body mass index; p, Asymptotic sig. (2-sided test); *, statistically significant differences



The mean endurance time in the EX endurance test was significantly (p = 0.03) longer in women than in men (Table 2). The ratios between each side LM and EX also differed sig-nificantly between women and men (p < 0.05) (Table 2).



Table 2. Preliminary results of endurance times (in seconds) and endurance ratios for women, men and all participants together (mean  standard deviation).

Endurance times (s) Endurance ratios

mean  SD mean  SD

R-LM: L-LM: R-LM:

Gender EX FL L-LM R-LM FL:EX

L-LM EX EX

Women 362.7  193.6  145.5  127.4 

0.63  0.50 0.91  0.26 0.47  0.20 0.42  0.19

(n = 86) 247.9 181.9 71.0 60.3

Men 248.4  202.9  140.9  131.3 

0.78  0.44 0.94  0.23 0.58  0.15 0.53  0.13

(n = 20) 70.4 154.9 55.2 57.6

p 0.03* 0.76 0.99 0.62 0.06 0.61 0.02* 0.01*

All 341.1  195.3  144.7  128.1 

0.66  0.49 0.92  0.25 0.49  0.20 0.44  0.19

(n = 106) 229.5 176.4 68.1 59.6

SD, standard deviation; n, number of participants; EX, endurance of trunk extensors; FL, endurance of trunk flexors; L-LM, endurance of lateral trunk muscles (left side); R-LM, endurance of lateral trunk muscles (right side); p, Asymptotic sig. (2-sided test); *, statisti-cally significant differences





Mean endurance times and endurance ratios by age group are listed for women in Table 3 and for men in Table 4.





Table 3. Preliminary results of endurance times (in seconds) and endurance ratios for women (n = 86) by age group (mean  standard deviation).



WOMEN Endurance times (s) Endurance ratios

(n = 86) mean  SD mean  SD

Age group R-LM: L-LM: R-LM:

n EX FL L-LM R-LM FL:EX

(years) L-LM EX EX

466.9  172.3  148.5  117.8 

16-25 16 0.48  0.33 0.83  0.26 0.40  0.19 0.32  0.14

325.4 105.1 50.9 41.1

357.2  209.4  135.1  125.3 

26-35 29 0.60  0.44 0.95  0.22 0.45  0.18 0.42  0.19

260.0 254.5 65.2 54.2

285.1  201.7  120.6  110.7 

36-45 18 0.87  0.69 0.94  0.23 0.47  0.21 0.44  0.21

112.0 110.6 41.5 43.0

436.9  193.1  215.2  180.9 

46-55 13 0.55  0.46 0.89  0.29 0.57  0.22 0.47  0.19

238.1 168.5 96.8 78.5

254.8  167.6  125,4  108.9 

> 56 10 0.65  0.31 0.88  0.32 0.55  0.20 0.46  0.20

116.5 120.1 53.9 60.2

n, number of participants; SD, standard deviation; EX, endurance of trunk extensors; FL, endurance of trunk flexors; L-LM, endurance of lateral trunk muscles (left side); R-LM, endurance of lateral trunk muscles (right side)



Table 4. Preliminary results of endurance times (in seconds) and endurance ratios for men (n = 20) by age group (mean  standard deviation).

MEN Endurance times (s) Endurance ratios

(n = 20) mean (SD) mean (SD)

Age group R-LM: L-LM: R-LM:

n EX FL L-LM R-LM FL:EX

(years) L-LM EX EX

1 269.0  68.0  103.0  84.0 

16-25 0.25  0.0 0.82  0.0 0.38  0.0 0.31  0.0

0.0 0.0 0.0 0.0

8 243.4  194.6  135.8  130.3 

26-35 0.77  0.41 0.96  0.20 0.56  0.12 0.53  0.12

63.5 137.4 44.1 56.0

9 255.1  248.8  157.4  144.1 

36-45 0.91  0.43 0.94  0.26 0.63  0.16 0.55  0.10

72.3 164.8 62.7 60.1

2 227.5  96.5  106.0  101.0 

46-55 0.50  0.22 0.98  0.18 0.51  0.11 0.51  0.20

80.5 10.5 15.0 4.0

> 56 0 N/A N/A N/A N/A N/A N/A N/A N/A

n, number of participants; SD, standard deviation; EX, endurance of trunk extensors; FL, endurance of trunk flexors; L-LM, endur-ance of lateral trunk muscles (left side); R-LM, endurance of lateral trunk muscles (right side); N/A, results not yet available



4. Discussion



The results of a preliminary normative study on the endurance times of trunk muscle en-durance tests on the Roman chair indicated that, with the exception of the EX endurance test, women and men have a comparable mean endurance time. Therefore, the endurance ratios of the trunk muscle groups also differed between men and women for LM and EX (the ratios L-LM:EX and R-LM:EX), but not for the other two ratios. The lower number of male participants must be taken into account.



There are only a few data sets that can be compared with the data from this study. Pagé & Descarreaux (2012) reported slightly shorter mean endurance times in the L-LM endurance test (96.7 (24.9) s) and R-LM endurance test (97.2 (21.5) s) in healthy participants (n = 22; mean age: 24.55 (5.00) years). Compared to the results of Ledoux et al. (2012), in which healthy older adults participated (n = 32; mean age: 67.25 (5.13) years), the participants in our study (> 56 years old women) achieved a longer mean endurance time in the EX en-durance test (mean endurance time in their study: 221.61 (108.6) s) and a similar mean endurance time in the LM endurance test (mean endurance time in their study: 127.32 (74.32) s). No study comparing the results of the FL endurance test could be found in the available literature.

The results of our study show some similar findings to the results of another preliminary normative study by McGill et al. (1999), in which they strive to assess endurance times in the tests proposed by McGill (McGill, 2016). Despite different body positions in both groups of endurance tests, we all found that women had longer endurance times than men in EX (p = 0.03), and that men were able to maintain LM tests for a longer period (p < 0.05) of their EX endurance times (i. e., LM:EX ratios) than women (e. g., for the LM test in the left side: 58% vs. 47% of their EX test). As reported in our previous study (Petrič et al., 2022), longer endurance times are generally observed for at least three out of four Roman chair tests compared to the McGill tests (McGill et al., 1999).

The study has some limitations. The first limitation of this preliminary normative study is the small and unevenly gender distributed sample of participants. In our study, there were more female than male participants. In addition, the sample of participants was unevenly distributed with respect to age, with most participants being between 20 and 45 years old. A larger and more homogeneous sample of participants with respect to gender and age is needed to continue this normative study.

This is the first study to collect normative data on Roman chair endurance testing.

5. Conclusions

The preliminary results on the normative endurance times for the trunk muscles in Roman chair tests show some differences between the sexes (especially in the trunk EX endur-ance). A larger sample of participants is required to determine normative values, particu-larly a larger sample of male participants and participants under 20 and over 45 years of age.



Funding: This work was supported by Project HUD 2024 of the Faculty of Health Sciences of the University of Ljubljana. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Institutional Review Board Statement: The study was conducted according to the guide-lines of the Declaration of Helsinki (0120-220/2019/6).



Conflicts of Interest: The authors declare no conflict of interest.



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valid and reliable for assessing trunk lateral flexor endurance in recreational female athletes? Biology. 2022; 11:1043. DOI: 10.3390/biology11071043



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Therapeutic exercise: Foundations and techniques. 7th ed. Philadelphia: F. A. Davis Company. 2018; p. 417–442.

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adults with and without low back pain. J Manipulative Physiol Ther. 2012; 35:338–345. DOI: 10.1016/j.jmpt.2012.04.007

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Review



Destigmatization of Erectile Dysfunction



Dolinar Larissa1, Španring Ajda1, Šercer Nika1, Breznik Katarina1, Gošnak Dahmane Raja1,*, Starc Andrej1



1. University of Ljubljana, Faculty of Health Sciences, Ljubljana, Slovenia

* Correspondence: raja.gosnak@zf.uni-lj.si



Abstract:

Erectile dysfunction (ED) is a sexual dysfunction that significantly affects men's quality of life and is often associated with a stigma that makes it difficult to access appropriate treatment. This stigma, which is accompanied by feelings of shame and fear of judg-ment, leads to social isolation and increases psychological distress. ED is often linked to social norms that associate masculinity with strong sexual performance, which fur-ther complicates treatment. Comprehensive strategies to reduce the stigma associated with ED are of paramount importance. Public health campaigns that raise awareness of

Citation: Dolinar L, Španring A, Šercer the nature of ED and promote open communication about sexual health are essential to

N, Breznik K, Gošnak-Dahmane R, Starc dispel myths and reduce the shame associated with this condition. In addition, incor-

A. Destigmatization of Erectile Dysfunc- porating sexual health into routine medical examinations allows for early detection and

tion. Proceedings of Socratic Lectures. treatment of ED, which helps to reduce stigma. A culturally sensitive approach that

2025, 12, 112-119. takes into account the specific values in different social settings is also crucial in com-https://doi.org/10.55295/PSL.12.2025.I15 bating stigma, especially in cultures where sexual topics are taboo. When healthcare

providers are trained to address ED in a non-judgmental way, men can seek help with-out fear of criticism. Comprehensive strategies, including awareness campaigns, edu-

Publisher’s Note: UL ZF stays neutral cation and improved access to treatment, are critical to reducing stigma and improving

with regard to jurisdictional claims in the quality of life for men affected by ED.

published maps and institutional affili-

ations.

Keywords: sexual dysfunction; stigma; comprehensive strategies; sexual health; awareness



____________________________________________________________________________

Copyright: © 2025 by the authors. Sub-

mitted for possible open access publica-

tion under the terms and conditions of

the Creative Commons Attribution (CC

BY) license (https://creativecom-

mons.org/licenses/by/4.0/).





1. Introduction



Erectile dysfunction (ED) can be defined as a sexual dysfunction characterized by the "in-ability to achieve and maintain sufficient penile erection for satisfactory sexual activity" (Sharma & Sharma, 2019). It is a multidimensional condition that may involve pathological changes in any component of the erectile response, with both endocrine and non-endocrine pathways—neurogenic, vasculogenic, and iatrogenic— playing an important role. It is also important to emphasize that ED is not exclusively age-related; on the contrary, an increas-ing number of younger men are affected by this condition (Yafi et al., 2016).



1.1 Etiology of erectile dysfunction

The etiology of ED is classified as organic (organic ED), psychogenic (psychogenic ED), or, most commonly, a combination of both (Allen et al., 2023). Among the psychological fac-tors influencing ED, depression and anxiety are frequently highlighted. These factors play a crucial role even when organic causes are also present. Aging contributes significantly to ED, as cardiovascular diseases, hypertension, and other chronic conditions become more common with increasing age (Matsui et al., 2015). It is important to differentiate between psychological and organic causes in order to choose the most appropriate treatment ap-proach for each individual.

1.1.1 Vascular etiology

Vascular diseases, such as atherosclerosis and hypertension, are among the most common causes of ED. In atherosclerosis, the arteries narrow due to the accumulation of fatty de-posits on the blood vessel walls, reducing blood flow to the penis— a crucial factor in achieving and maintaining an erection. Reduced blood flow can lead to insufficient oxygen supply to the penile tissue, resulting in impaired erectile function. Hypertension further damages the blood vessels, accelerates the progression of arteriosclerosis and worsens the condition. ED is often an early indicator of underlying vascular disease, underscoring the importance of early diagnosis and treatment of vascular disease to prevent ED. Timely detection and treatment of vascular disease is crucial to mitigate the long-term conse-quences on erectile function (Slowikowska-Hilczer et al., 2024).

1.1.2 Neurological etiology

Neurological disorders, such as multiple sclerosis, Parkinson's disease, and spinal cord injuries, significantly impair erectile function. These diseases disrupt the transmission of signals between the central nervous system and the genital organs, leading to difficulties in achieving or maintaining an erection. Multiple sclerosis damages the myelin sheaths of nerve fibers, and slows down the transmission of nerve signals essential for initiating an erection. Parkinson's disease affects motor and autonomic functions, and has a similar ef-fect on the erection process. Neuropathy associated with diabetes is another critical factor contributing to ED, as it damages the peripheral nerves that are important for normal erec-tile function (Saadi et al., 2024).

1.1.3 Psychogenic etiology

Psychological factors such as stress, anxiety, depression, and relationship issues, contrib-ute to the development of erectile dysfunction. Psychogenic ED is particularly common in younger men, where organic factors are less pronounced. Psychological stress associated with the onset of ED, as it activates the sympathetic nervous system, leading to vasocon-striction and reduced blood flow to the penis. Furthermore, chronic anxiety and depres-sion decrease sexual desire and can affect the functioning of the hypothalamic-pituitary-gonadal axis, which further impairs erectile function. Fear of failure and shame due to previous incidents can create a vicious cycle, in which psychological pressure increases, leading to recurrent erectile issues (Pantazis et al., 2024).

1.1.4 Impact of pornography

In recent years, research attention has increasingly focused on the impact of pornography on sexual health, particularly in relation to ED. Frequent use of internet pornography has been linked to various sexual dysfunctions, especially in younger men who have constant access to such content (Kizilkurt et al., 2023). One key finding is that frequent pornography use can lead to reduced sensitivity to typical sexual stimuli— resulting in desensitization. Men who frequently view pornography may develop a tolerance, meaning they require



increasingly extreme content to achieve the same level of arousal they experienced when they first consumed it (Kedman, 2021). In addition to physiological changes, pornography also has significant psychological consequences. Regular pornography use often creates unrealistic expectations of sexual intercourse, which can lead to increased anxiety about sexual performance, and subsequently, to psychogenic erectile dysfunction (Psychological Erectile Dysfunction: Mental Health and ED - Precise Men’s Medical, 2021).



1.1.5 Endocrinological etiology



Testosterone plays a crucial role in sexual desire, libido, and erection maintenance, as it influences the release of nitric oxide, which is necessary for the relaxation of smooth mus-cles in the penis and consequently increases blood flow (McCoskey & Vernon, 2024). Dia-betes contributes to hormonal changes that can cause ED as it affects insulin levels, leading to insulin resistance and associated hormonal imbalances. This can result in reduced tes-tosterone production and increased levels of stress hormones, such as cortisol, which have a negative impact on erectile function (Ilkhomovich, 2024).

1.1.6 Traumatic factors

Injuries to the penis, pelvis, or spine can cause direct damage to nerves, blood vessels, and tissues, leading to ED. Injuries resulting from accidents, falls, or surgical procedures, such as prostatectomy, are common causes of traumatic ED. Surgical interventions, especially those involving prostate removal due to cancer, can damage nerves that are important for normal erectile function (Lounici et al., 2024). Such injuries can lead to persistent difficul-ties in achieving an erection if proper rehabilitation is not provided. Early diagnosis and treatment are crucial for the recovery of erectile function after traumatic injuries. This in-cludes physical therapy, psychological support, and, if necessary, surgical reconstruction of the damaged tissues (Junejo et al., 2024).

1.1.7 Factors related to the use of medications and other substances

The use of certain medications, such as antidepressants, antihypertensives, and antihista-mines, is well-documented as a possible cause of the development or exacerbation of ED. Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), are known to affect sexual function. These medications increase serotonin levels in the brain, which can reduce libido and cause difficulties in achieving or maintaining an erection, as they inhibit reflexes essential for erectile function. Additionally, antihypertensives, such as beta-block-ers and diuretics, are associated with ED as they reduce blood flow to the penis by lower-ing blood pressure, which can lead to difficulties in achieving a sufficient erection (Ander-sen et al., 2024). In addition to medication use, certain substances—alcohol, tobacco, and recreational drugs—negatively affect sexual function and increase the risk of ED. Chronic alcohol consumption can lead to liver damage, which causes hormonal changes, including a decrease in testosterone levels, which has a direct impact on sexual function (Ilkhomo-vich, 2024).

1.2. Social perception of masculinity and the impact of erectile function on an individual's psychological well-being

The erection of the penis has long been considered a symbol of male virility and sexual power. It is important to mention the traditional ideology of masculinity, which is a cul-tural construct that "defines a set of beliefs and expectations about how men should behave in a given time and culture" (Valsecch et al., 2023). This ideology emphasizes that a man must strive to achieve an appropriate status and dominance, while also being confident and dominant (Walther et al., 2023). The traditional ideology of masculinity also believes that masculinity is expressed through sexuality; therefore, a man must demonstrate his ability, performance, and dominance through sexual intercourse. This belief requires men to be heterosexual and hypersexual (Valsecch et al., 2023). From this perspective, an erec-tion represents the foundation of masculinity, and sexual performance, providing satisfac-tion and procreation (Walther et al., 2023).

Despite societal progress, which has strongly encouraged open discussions on sexual life and health in recent years, topics related to ED are still avoided (Sheng, 2021). Sexual dys-function is often surrounded by stigma, shame, and misconceptions. Unrealistic expecta-tions regarding sexuality are frequently perpetuated in society, creating a standard that can make even men without dysfunctions feel inadequate (PosteryHealth, 2025). The mere



perception of problems - whether physiological or psychosocial—triggers a range of neg-ative psychosocial reactions. The onset of ED is not only a physical problem but also an emotionally painful experience, involving fear, anxiety, and stress. The most significant (and often first) psychological reaction is the feeling of emasculation (i.e., loss of masculin-ity), which is closely related to the aspects rejected by the traditional ideology of mascu-linity (ED represents a contradictory aspect of this ideology) (Sheng, 2021). In addition to emasculation, the occurrence of ED affects a man's self-esteem and self-image. Due to the decline in self-esteem and self-confidence, many men isolate themselves socially when confronted with ED.



The social isolation, that often accompanies men with ED is due to the great fear of not being able to satisfy their partner, which leads to feelings of failure and fear of rejection or abandonment (Sheng, 2021). This results in decreased sexual activity (due to the emotional burdens mentioned), further destabilizing the partner dynamic, and causes feelings of un-desirability, unattractiveness, and emotional frustration in the partner, which in turn can increase emotional distance and feelings of unlovedness (Huri et al., 2016; Sheng, 2021; Allen et al., 2023). Such emotional and intimate distance often leads to thoughts of infidel-ity or the impression that the partner is losing interest, which can jeopardize the long-term stability of the relationship and increase the likelihood of separation (Huri et al., 2016). Moreover, individuals with ED often experience a reduced quality of life, further burden-ing their daily lives (Allen et al., 2023). In addition to relationship issues, men with ED often face difficulties in friendships, as they believe that disclosing their problems will re-sult in a lack of understanding and support. The lack of communication about ED further deepens feelings of loneliness and increases psychological stress. Open and effective com-munication is crucial to managing these issues, as the inability to express these experiences can heighten anxiety related to sexual function and have a negative impact on an individ-ual's self-image and intimate relationships (Sheng, 2021).



1.3. Prevalence, risk factors, and the importance of awareness

A review of nine scientific studies on the prevalence of ED reveals significant trends re-lated to age, risk factors, and awareness of this issue. Research shows that the prevalence of ED increases significantly with age, which is confirmed by several studies. For instance, Saramies et al. (2022) found in a prospective cross-sectional study involving 189 men that ED was present in 100% of men over the age of 75 (at least in a mild form). Similar findings are reported by Çayan et al. (2017)—the prevalence of ED was 17% in men aged 40 to 49, years and 82.9% in men aged 70 years and older. A study conducted in China by Zhang et al. (2017) which included 5210 people over the age of 40, also confirms that the prevalence of ED increases with age.

Other studies indicate that ED occurs more frequently in men who have risk factors such as an unhealthy lifestyle, obesity, smoking, and alcohol consumption. In a study by Li et al. (2022), which included 12,490 men in the United Kingdom, a strong correlation was found between the incidence of ED and unhealthy lifestyle habits. Hallanzy et al. (2019) found in a sample of 2.565 men that, the prevalence of ED (25.2%) increased with the num-ber of risk factors, with 48.8% of individuals reporting severe symptoms. A large majority of studies also emphasize the importance of awareness and education for the prevention and early treatment of ED. Herkommer et al. (2023) highlight the significance of risk factor education as a fundamental step in reducing the prevalence of ED. Similarly, Rezali et al. (2023) in a study conducted in Malaysia stress the need for comprehensive sexual educa-tion to improve the understanding and treatment of ED. Oyelade et al. (2016) emphasized the importance of raising awareness among healthcare providers about the impact of an individual's sexual history on diagnosis and treatment planning. The common focus of these studies suggests that comprehensive awareness strategies are crucial for reducing the risk of ED and improving access to appropriate care.

Strategies to enhance awareness and access to ED treatment are essential, as they enable early identification of issues, encourage preventive measures, and improve access to effec-tive treatment options, which significantly contribute to the quality of life for men with ED. Raising awareness about ED is important for reducing stigma and discrimination and encouraging men to seek appropriate treatment. Educational programs that promote an



open approach to sexual health have shown that men are more willing to seek help when they have access to reliable information (Moazin et al., 2024).





2. Strategies for improving awareness and access to erectile dysfunction treatment



ED is a health condition that affects many men worldwide, but is often misunderstood and stigmatized. Many men, and even some healthcare providers, fail to recognize the physi-ological causes of ED, such as cardiovascular diseases or endocrine disorders, which can lead to delays in seeking help and the worsening of underlying health problems (Bolash & Mekhail, 2024).

Therefore, raising awareness of ED is crucial to reduce stigma and discrimination and en-courage men to seek appropriate treatment (Moazin et al., 2024). It is also important to highlight the challenges of reaching all populations, especially those who are more socially and culturally isolated. For this reason, it is essential to develop a multi-layered approach that not only reduces stigma but also increases the accessibility to care and provides effec-tive support for men affected by ED. This approach includes public health campaigns, the proactive inclusion of sexual health in routine check-ups, culturally adapted strategies, education, counseling, and the use of modern technologies such as telemedicine.

2.1 . Public health campaigns with a clear message

One of the most important strategies for reducing the stigma associated with ED is public health campaigns aimed at educating the public about the nature of this condition. Aware-ness and education help to reduce stigma and increase understanding of ED (Imran et al., 2023). Public health campaigns, that disseminate information through various media, can reach a wider population and encourage open dialogue about sexual health. Such cam-paigns not only reduce the stigma associated with ED but also encourage men to seek pro-fessional help without fear of shame or judgment (Tavakoli et al., 2023). These campaigns must clearly highlight the medical background of ED and encourage men to seek help without fear of condemnation. It is important for these campaigns to emphasize that ED is not just a result of physiological changes, but can also be linked to various other factors, including psychological issues, lifestyle habits, and chronic diseases. Campaigns should dispel the myth that ED is a lack of masculinity and present it as a manageable health problem that can be treated if recognized early and addressed properly. Including personal stories of men who have successfully overcome ED can reduce feelings of loneliness and increase social support within this population, which is crucial to reduc-ing feelings of isolation (Imran et al., 2023).

2.2 Integration of sexual health discussions into routine health check-ups

A better understanding of the causes, symptoms, and treatment options of ED enables men to actively participate in their treatment and improve their chances of a successful recov-ery. Additionally, training healthcare providers to recognize and effectively manage ED is essential for improving the quality of care patients receive (Esposito et al., 2008). Healthcare providers, particularly primary care physicians, play a key role in the early detection and treatment of ED. Physicians and nurses need to take a proactive role in in-corporating sexual health issues into routine health check-ups. Many men do not address erectile problems on their own because of shame or fear of stigmatization themselves. Therefore, it is important for healthcare providers to actively initiate an open dialogue about sexual health, using a sensitive approach that allows patients to feel safe and ready to share their concerns. Moreover, healthcare providers must have access to appropriate training and resources to fully recognize and treat ED, as this condition often involves both physiological and psychological factors. It is crucial to ensure that healthcare providers are well-equipped with the knowledge to provide holistic care for this issue, which can reflect broader aspects of the patient's health (Esposito et al., 2008).

2.3. Culturally adapted campaigns

Cultural norms and values have a significant impact on the perception of ED and the will-ingness of men to talk about it or seek help. In some cultural environments, ED is associ-ated with a loss of masculinity, leading to social stigma and delays in seeking help. A lack



of understanding of cultural specificities can lead to inadequate approaches to the treat-ment and support of men suffering from ED. Therefore, it is crucial for healthcare institu-tions and professionals to consider these cultural and social factors when addressing ED (Jamali, 2024). Awareness of the importance of a culturally sensitive approach to this issue is key to successfully reducing the stigma associated with ED in various communities. ED awareness campaigns need to be tailored to specific cultural norms and expectations. In cultures where sexual health issues are often considered taboo, it is especially important to involve local leaders, influential individuals, and healthcare professionals who are re-spected in the community. Such an approach can help destigmatize ED, as men seeking help in these communities often expect support and understanding from their cultural and religious leaders. Involving these influential figures in awareness-raising efforts is essen-tial for encouraging men to seek professional help and recognizing ED as a manageable health issue that should not be a source of shame (Jamali, 2024)



2.4. Improving access to education and counseling within the healthcare system



The treatment of ED requires a holistic approach that includes both patient education and healthcare providers training. The healthcare system must actively promote education about ED, not only to patients but also to healthcare professionals who often have the first contact with men facing this condition. Nurses, physicians, and other healthcare providers must be adequately trained to recognize the symptoms of ED, make a diagnosis and offer treatment, while creating a supportive environment where men feel comfortable discuss-ing their issues. It is essential that healthcare professionals regularly update their knowledge of new research and therapies related to ED, so they can offer the best possible care to patients. Continuous improvement of knowledge and training of healthcare pro-viders in primary healthcare plays a crucial role in the early detection and effective treat-ment of ED (Moazin et al., 2024).

2.5. Use of telemedicine and digital solutions

For many men, particularly in smaller communities or rural areas, feelings of shame and lack of privacy can be a significant barrier to seeking personalized medical care. Telemed-icine offers an innovative solution to this problem by enabling anonymous and secure communication between patients and healthcare professionals. Through telemedicine con-sultations, men can receive all necessary information about ED, discuss potential treatment options, and decide on next steps without the need for an in-person visit. Additionally, digital platforms that offer educational content about ED can help raise awareness and provide access to verified information. This enables men to easily access expert advice and information, allowing them to make more informed decisions about their health without having to leave the house. Therefore, telemedicine not only reduces stigma but also facili-tates access to treatment and counseling, especially in situations where geographical or cultural limitations would otherwise hinder access (Imran et al., 2023). Reducing stigma and improving access to ED treatment requires a multi-faceted approach that includes public health campaigns, the integration of sexual health into routine check-ups, culturally adapted strategies, broader education for healthcare providers, and the use of modern technologies such as telemedicine. Only through openness, support, and proper training of healthcare professionals can stigma be reduced and a better quality of life be provided for men with ED. It is crucial to recognize ED as a manageable health condition that deserves the same attention and treatment as other health problems.

5. Conclusion

The stigma associated with ED remains a significant barrier to accessing treatment. Com-prehensive strategies, including awareness campaigns, the integration of sexual health into routine medical check-ups, and culturally adapted approaches, are crucial for reducing stigmatization and increasing access to ED care. Training healthcare providers to approach these issues in a non-judgmental way is also important to enable open communication between patients and physicians. Further research is needed to investigate the long-term effects of these strategies and their potential adaptation to specific cultural contexts.



Funding: This research was supported by European Union’s Horizon 2020 research and innovation program under grant agreement No 109338, and by Slovenian Research Agency through the core foundings No. P9-1265 and P11-2358, and project No. U6-2734. Institutional Review Board Statement: The study was conducted according to the guide-lines of the Declaration of Helsinki, blood was donated voluntarily by the authors of the study.





Conflicts of Interest: The authors declare no conflict of interest.





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Reflection



On the Music of the 12th Socratic Lectures. Z-STEAM and



Nanostructurome activities

Veronika Kralj-Iglič1,*



1. University of Ljubljana, Faculty of Health Sciences, Laboratory of Clinical Biophysics, Ljubljana, Slovenia

* Correspondence: Veronika.Kralj-Iglic@zf.uni-lj.si



Abstract:

We describe and reflect on the cultural events connected to 12th Socratic Lectures. The satellite events included, in the chronological order: the performance of Lara Oprešnik at the Musikverein, Vienna within the New year concert on January 8, 2025, the Z-STEAM social networking event with the concert on January 11, 2025 at the Julij Betteto Hall, Kazina, Academy of Music, University of Ljubljana, and the organ recital of Rob-

Citation: Kralj-Iglič V. On the Music of erta Schmid from Napoli, Italy, at the Church of Assumption, Tromostovje. Socratic

the 12th Socratic Lectures. Proceedings

of Socratic Lectures. 2025, 12, 121-131 Lectures continue as international events promoting science and arts. https://doi.org/10.55295/PSL.12.2025.I16



Keywords: Baroque opera; Roman history; Venice carnival; Nero Claudius Caesar Au-

Publisher’s Note: UL ZF stays neutral gustus Germanicus; Sabina Poppaea the Younger; Commedia dell’Arte with regard to jurisdictional claims in

published maps and institutional affil-

iations.





Copyright: © 2025 by the authors.

Submitted for possible open access

publication under the terms and

conditions of the Creative Commons

Attribution (CC BY) license

(https://creativecommons.org/licenses/

by/4.0/).





1. The concept of Socratic Lectures



According to Plato, a man named Socrates and his pupils assembled in a place near to the sea. They were discussing things that interested them in a pleasant atmosphere. Socrates stated and the pupils responded as to agree or disagree. Then they asked questions. It required little knowledge (in the form of data) from the pupils but a lot of curiosity and reasoning. The dialogues were respectful and polite and created a room of gentleness. It only took acknowledging and liking it to enter this room, which seemed simple and easy. In contrast to sophistic teaching, there was no formal scheme and no exchange of money. However, Plato’s interpretation of the significance of money concerns not just teaching, but in fact all human activities (Schindler, 2009). Socratic Lectures aim at reaching the spirit of interest in the matter, common well being, gentleness and politeness above all other reasons. In particular, it is a point where excellent scientists share their experience with the students and the students contribute their dedication. Also, it is a point of meeting of different fields from science and arts to inspire creation of new ideas. The team of Socratic lectures is constituted of those who have donated as the participants of the activities of the Socratic Lectures.



2. Z-STEAM activities and integration of science and arts STEAM (Science, Technology, Engineering, Arts, Mathematics) Education is an approach to learning that uses Science, Technology, Engineering, Arts, and Mathematics as access points for guiding student inquiry, dialogue, and critical thinking. While this approach has been acknowledged at the primary and high school level, it has only recently been introduced to higher education (Carter et al., 2021). Socratic Lectures have early integrated visual arts and music with science and are open for other forms of art and achievements aiming at life-friendly world and excellence. Formal collaboration has been established between nine faculties of the University of Ljubljana and the Academy of Music within the project Nanostructurome financed by the Slovenian Research Agency in collaboration with the University of Ljubljana. Participants from the Academy of Music contributed lectures at the symposium devoted to baroque music, in particular the work of Claudio Monteverdi, and performed at the concert selected pieces from Monteverdi’s opera Coronation of Poppaea. The partners of the project Nanostructurome will support the production of the opera with the premiere set in July 2025.

3. Music events of the 12-th Socratic Lectures

The satellite events included, in the chronological order: the performance of Lara Oprešnik at the Musikverein, Vienna within the New year concert on January 8, 2025, the Z-STEAM social networking event with the concert on January 11, 2025 at the Julij Betteto Hall, Kazina, Academy of Music, University of Ljubljana, and the organ recital of Roberta Schmid from Napoli, Italy, at the Church of Assumption, Tromostovje. Socratic Lectures continue as international events promoting science and arts.

3.1. Lara Oprešnik and her performance at the Musikverein, Vienna, within the New year concert Lara Oprešnik started playing piano at the age of seven in the class of Professor Monika Vehovec and violin in the class of Professor Igor Ulokin. Later she studied with Professor Jožica Grebenšek and Professor Jernej Grebenšek. She graduated from the Academy of Music in Ljubljana, Slovenia, under Professor Hinko Haas and from the University of Music and Performing Arts in Graz, Austria, under Professor Milana Černjavska. In 2023 she received her Master's degree from the Academy of Music in Ljubljana, in the class of Professor Ruben Dalibaltayan. She studied with Laszlo Baranyay, Jasminka Stančul, Lovro Pogorelić, Rita Kinka, Oleg Marševo, Natasha Kudritska and Julia Gubajdulina. During her studies she received the Prešeren Student Prize of the University of Ljubljana. She has performed as a soloist with orchestras at home and abroad. In 2024, she recorded Saint-Saëns' chamber work Animal Carnival and a longer programme of her own compositions, approximately one hour long, as part of the From the Pen of Slovenian Composers series. She has given solo recitals at numerous national and international festivals (Vienna, Trieste, Tenerife, Lamporecchio, Ljubljana, Gorizia, Rome, Citta di Cervignano, Belgrade, etc.). On 8 January 2025, she performed with the Vienna City Orchestra at the gala New Year's



Concert at the Vienna Musikverein as the first prize-winner of the Vienna New Year's Concert, an international music competition.



Miha Červ who attended the concert at the Musikverein (Figure 1), reflected on the performance of Lara Oprešnik: “I wore the best dress I own - my wedding dress. I didn't want to go to the Musikverein dressed casually, because that's where the fine gentlemen usually gather. But it turned out that my fears were unnecessary, because the assembled company was very varied in the formality of their dress, and so I stood out neither as too well dressed nor as too poorly dressed. The concert was intended to showcase the soloists - the winners of the competition, accompanied by the Wiener Stadtorchester (Vienna City Orchestra) under the baton of Christian Schulz. Almost exactly at eight o'clock, the orchestra members came on stage and tuned up. The first part of the concert was introduced by the orchestra itself with a piece by Handel, and then the soloists took the stage for the following pieces; viola, two opera singers and oboe. After the interval, I returned to the hall, where a large concert Steinway had just appeared on stage. My neighbour, with whom I had chatted earlier, whispered to me: 'Jetzt kommt Ihre Favoritin!'. And after the orchestra had tuned up again, Lara Oprešnik started. She played the first movement of Scriabin's concerto for piano and orchestra in F sharp minor. The performance was sovereign and dramatic. The orchestra and Lara were well matched and the performance of the piece was without any perceivable mistakes for me. Lara earned a roaring applause and it was interesting to see her bow to the audience laughing after such a serious piece. This was followed by a piece for which the conductor changed and the winner of the conductor category took over the orchestra, and then a reappearance of the opera singer. The concert ended with a piece written by Christian Schulz himself. At the end of the music, the conductor presented the prizes to the competitors. I may be a little biased, but I would say that Lara received a little more applause than the other prize winners. At the end I had the opportunity to congratulate the pianist briefly and then I returned home under the good impression of the musical evening.”





Figure 1. Left: performers after the concert at Musikverein. Left: Lara Oprešnik and Christian Schulz.





3.2. Social event at the Betteto hall with concert of classical and contemporary music and poetry The concert(Figures 2-5) had three parts , the first part was devoted to classical music, followed by an intermezzo of poetry by Ifigenija Simonović and Slovene choral music. The



third part was devoted to contemporary music, with emphasis on original compositions integrating science.



Part I: Classical music



C. Franck: Petit offertoire. Organ: Yelena Istileulova

C. Monteverdi/G.F. Busenello: Prologue from opera Coronation of Poppaea. Sopranos:

Fortuna: Ronja Prapotnik, Virtu: Eva Kokot, Amore: Brina Vukovič, Harpsichord: E. Mihajlović, Organ positive: B. Rezić

A. Aljabjev A: Nightingale. Flute: Anita Prelovšek, Piano: Elena Startseva Somun S. Rachmaninov: Vocalise. Violin: Vasilij Meljnikov, Piano: Lara Oprešnik C. Monteverdi/G.F. Busenello: Regina disprezzata from opera Coronation of Poppaea.

Soprano: Ottavia: AlessandraTessaro, Harpsichord: E. Mihajlović, Organ positive: B. Rezić

S. Rachmaninov: Etude Tableaux Op 33 No 3. Piano: Lara Oprešnik G. Brun: Romance. Flute: Anita Prelovšek, Piano: Elena Startseva Somun C. Monteverdi/G.F. Busenello: Duetto Demigella and Valetto from opera Coronation of

Poppaea. Sopranos: Demigella: Nives Hadžić, Valetto: Eva Kokot, Harpsichord: E. Mihajlović, Organ positive: B. Rezić

W.A. Mozart: Alla turca from Sonate in A major. Piano: Denis Luin F. Chopin: Polonaise G sharp minor. Piano: Matic Bogataj

Part II:

G. Ipavec/A. Čopi - Simon Gregorčič: Mountain flower: Chorus Studenec Poetry by Ifigenia Simonović

H. Lavrenčič/Anonymus: The coque has sung: Chorus Studenec E. Adamič/O. Župančič: Evening song: Chorus Studenec

Part III: Contemporary music

A. von Sultanova/Titus Lucrecius: De rerum natura. Piano, Voice: Aleona von Sultanova S Kralj: Topology. Piano: Samo Kralj

H. Mancini: Pink Panther. Trombone: Emil Somun, Piano: Elena Startseva Somun A. von Sultanova/A. von Sultanova: For Samuel Gmelin - water, water. Piano, Voice:

Aleona von Sultanova

J. Rae: Sonatine (Aquarelle, Notturne, Firedance). Flute: Anita Prelovšek, Piano: Elena

Startseva Somun

A. Schnittke: Suite old style. Violin: B. Brezavšček, Piano: E. Startseva Somun L. Oprešnik: Fugue. Piano: Lara Oprešnik

B. Kobal: Dic verbo. Soprano: Kaya Tokuhisa, Organ: Jana Jamšek D. Zupanič Turković: Cantique de Baruch Spinoza from Mass in E minor. Organ: A. von

Sultanova, Percussion: Bojan Ilievski, Piano: Lara Oprešnik, Flute: Anita Prelovšek

Egon Mihajlović studied harpsichord and early keyboard instruments at the Frankfurt Conservatory of Music and Performing Arts, where he also completed his postgraduate studies. Since 1990 he has performed as harpsichordist, conductor and artistic director of baroque opera and sacred baroque music at major concert venues and festivals in Europe and the United States. He has taught at music art colleges and music academies in Wurzburg, Nuremberg, Cetinje and Pesaro. He is currently Professor of Harpsichord and Head of the Department of Early Music and Head of the Chair at the Academy of Music of the University of Ljubljana. In 2013 he was awarded a golden plaque of the University of Ljubljana for his outstanding contribution to the development of scientific, pedagogical or artistic endeavours.

Anita Prelovšek studied flute with Professor Anđela Blažeka in Ljubljana, Professor Luisa Sello in Udine and Trieste, Professor Karolina Šantl-Zupan in Ljubljana and Professor Gladys Bouchet at the Conservatoire National de Région in Rennes, France. She graduated at the Giuseppe Tartini Conservatory of Music in Bologna and specialised at the "Istituto Superiore di Studi Musicali O.Vecchi-A.Tonelli" in Modena, where her professors were Gabriele Betti, Michele Marasco and Andrea Oliva. She performs as a soloist and in various chamber ensembles in concerts at home and abroad.



Figure 2. Upper left: Matic Bogataj, upper right: Anita Prelovšek, lower left: Denis Luin, lower right: Lara Oprešnik, all at the concert of the 12.th Socratic lectures. Photo: Drago Videmšek.





Ronja Prapotnik, Eva Kokot, Brina Vukovič, Alessandra Tessaro and Nives Hadžič study singing at the Academy of Music, University of Ljubljana. Elena Startseva Somun studied piano at the Pyotr Ilyich Tchaikovsky Moscow Conservatory of Music and did postgraduate studies in chamber music at the Far Eastern Academy of Arts and Music in Vladivostok. She performs as a soloist and in chamber ensembles at home and abroad. She has taught at the Sergei Prokofiev Music School in Vladivostok, the Jilin Academy of Music in Changchun, China and the Idrija Music School. Violinist Vasily Melynikov studied at the Minsk Academy of Music with Olga Parkomenko and at the Moscow Conservatoire of Pyotr Ilyich Tchaikovsky with Professors Bezrodny and Belenka. In 1997 he won first prize at the Vienna Modern Masters International Competition in Vienna. He has been a member of the Belarusian State Chamber Orchestra, the Camerata Slovenica String Quartet, the Ljubljana Piano Trio and the Zagreb Soloists Orchestra. From 2004 to 2010 he was concertmaster of the RTV Slovenia Symphony Orchestra. He has taught at the Ljubljana Conservatory of Music and Ballet and at the Academy of Music, where he was head of the string department and mentor of the Academy of Music Symphony Orchestra. Vasilij Meljnikov is the recipient of the Betetti Prize (2005) for artistic achievement in the field of creative music and for his efforts to spread musical culture.



Emil Somun is studying trombone in the class of prof. Matija Mlakar. He performed at the Z-STEAM events connected to the Socratic lectures in Ljubljana and Naples since 2022. Ifigenija Simonović is writing poetry, essays, book reviews, translating, and painting various objects for more than fifty years. She is the author of ten poetry collections, three books of essays, three books for children, and is also known as a publisher of eight books of poetry by Vitomil Zupan. In 2009, she received the Rožanec award. Between 2017 and 2021, she was the president of the Slovenian PEN Center. Her poetry is often dark, but love persistently shines through the cracks that are drawn on her path by real-time. Chorus Studenec Pivka, led by Irena Rep, is composed of experienced singers. In its 22 seasons, various genres were performed but the singers prefer to sing arrangements of folk





songs. They have around 30 concerts annually, home and abroad, most importantly, the visits to Slovenian societies throughout Europe.





Figure 3. Upper left: Ronja Praprotnik, Eva Kokot and Brina Vuković performing Prologue from Monteverdi’s Coronation of Poppaea, upper right: Jana Jamšek, Barbara Kobal and Kaya Tokuhisa performing Sic verbo by Barbara Kobal. Lower left: Ifigenija Simonović reading her poetry, lower right: chorus Studenec performing Slovene choral. Photo: Drago Videmšek.



Samo Kralj is playing piano in PhD Big Bang Band since 2007. The bend form 7 researchers from whole Slovenia and they have on average 3 performances per year. Violinist Branko Brezavšček graduated from the Academy of Music in Ljubljana in the class of Prof. Dejan Bravničar. He was a member of the Slovenian Philharmonic Orchestra, concertmaster and soloist of the chamber ensemble Carnium, member and soloist of the Slovenian Chamber Ensemble under the direction of conductor Anton Nanut, first violinist of the Muzina Quartet, concerto soloist accompanied by piano, guitar and organ. He performed in Slovenia, Austria, Italy, Germany and USA. He recorded for RTV Slovenia and Radio Trieste.



Kaya Tokuhisa studied classical singing with professors Tatjana Vasle Maria Cristina Kiehr, Ulrich Messthaler, Harry van der Kamp, Snežana Nena Brzaković, Marianna Váradi, Thomas Heyer, Edita Garčević Koželj and Urška Arlič Gololičič, and chanson with professor Žare Prinčič. She received Master’s degree in Theatre singing in 2023. Together with the Hungarian pianist Beata Barcza and in ensembles she performs in concerts home and abroad. She performed at the Slovenian Philharmonic in the honour of the visit by His Imperial Highnesses prince and princess Akishino in 2013. With pianist Rok Lopatič and accordionist Žiga Vehovec, they formed a band called Café Noisette. Barbara Kobal attended musical school in Idrija. She mainly composes music and writes lyrics for chansons and songs. Her works were performed in public. The composition "It snows" was performed in Cankarjev dom and Slovenian Philharmonic, Ljubljana where it was warmly received. She participated at festivals Spevslam and Slovenian chanson and



at numerous cultural events. This is her first presentation at the Z-STEAM event satellite to the 12th Socratic Lectures symposium.



Jana Jamšek studied piano with Prof. Irma Hladnik and later organ at the Organ School in Ljubljana with Prof. Gregor Klančič. She has appeared as a soloist in interpretations of piano works by J.S. Bach, C. Saint-Saens and J. Brahms, in chamber ensembles with instrumentalists and singers, and as an accompanist for classical ballet. She has been participating in the Socratic Lectures since 2008. As an organist, she performs in concerts of the Organ School and in services at the Trnovo Church.



Aleona von Sultanova received a diploma at the Music College Tchaikovsky in Kazakstan. She studied saxophone, and is presently studying organ at the Theological Faculty, University of Ljubljana. She is composing and performing poems (voice and piano). For her compositions, she received international awards at the Festival of Russian Romances (Škofja Loka) and Festival of Children Songs Veseli veter (Novo Mesto). She performed at the International UNESCO Sharq Taronalari festival in Samarkand, Uzbekistan. In 2024 she received an award from South Arts and Health Envoy and 2 Platinum and 2 Gold prizes at the Max Bruch International Music Competition. She is the ambassador of ESTEAM (Entrepreneurship + STEAM: Science, Technology, Engineering, Arts and Mathematics) Program of the European Union to empower girls to pursue a STEM career and an inventor of SMS (Stories based on Music about Scientists) method. She performed at satellite events to the Socratic lectures and Z-STEAM events in Ljubljana and Naples, Italy. In 2024, she had a concert at the Academy Enrico Caruso, Naples, Italy.





Figure 4. Upper left: Alessandra Tessaro, Ronja Praprotnik, Eva Kokot, Brina Vuković and Nives Hadžič, upper right: Anna Romolo and Veronika Kralj-Iglič with Pupa, lower right: Jelena Danilović Luković, Ani Barbulova, Anna Romolo, Aleš Iglič and Veronika Kralj-Iglič. At the back: Lara Oprešnik. Lower right: from the left: Elena Startseva Somun, Yelena Istileulova, Lara Oprešnik, Anita Prelovšek, Veronika Kralj-Iglič and Bojan Ilievski. Photo: Drago Videmšek.



Davorin Zupanič Turković's opus comprises instrumental and vocal compositions and adaptations that have been performed at the satellite events of the Socratic Lectures symposia, Z-STEAM events of scientific meetings and at the openings of cultural events in Ljubljana, Piran, Novo mesto, Šentrupert, Belgrade and Naples. In 2021, the quintet Spectrum performed the SARS ORF1 composition written especially for this event - at the opening of the 45th FEBS (Federation of European Biochemical Societies) Congress in Ljubljana. The Mass in E minor with Kyrie, Credo, Alleluia, Agnus Dei and Cantique de Baruch Spinoza was performed for the first time in 2018 at the Church of the Assumption on Tromostovje.





Figure 5. Up: Yelena Istileulova. Lower left: Branko Brezavšček, lower right: Lara Oprešnik and Vasily Meljnikov. Photo: Drago Videmšek.





3.3. Organ recital of Roberta Schmid



The program of the recital:



D. Buxtehude: Passacaglia in D minor BuxWV 161

J. S. Bach: Choral Das alte Jahr vergangen ist BWV 614

J. S. Bach: Choral Erbarme dich mein Gott BWV 721

A.G. Ritter: Sonate no. 2 in E minor op.19

G. Mushel: Toccata

J. Rheinberger: Passacaglia

L. Vierne: Carillon de Westminster

Roberta Schmid has contributed significantly to the Z-STEAM activities in Ljubljana and in Naples, Italy since 2019. In 2024, she participated at the concert that took place in Villino Manina organized by the University of Ljubljana, Faculty of Electrical Engineering and Faculty of Health Sciences, and Consiglio Nazionale delle Richerche, Napoli, Italy. At that concert, she performed on the piano a Slovene song entitled “Marinki” recently composed by Davorin Zupanič Turković, thereby promoting contemporary Slovene music internationally. Roberta Schmid took her diploma in Organ and Organ Composition at the Musical Conservatoire “S. Pietro a Maiella” in Naples with the mentorship of prof. A.M.Robilotta and then improved her technique with maestros of international standing such as L. Ghielmi, E. Kooiman, M. Radulescu, D. Roth, K, Schnorr, L. F. Tagliavini, M. Torrent, P. Westerbrinck, W. Zerer, specializing her executive practice in different organ repertoires. After getting through a national examination she attended a three year course in Professional training as an Organist at the Musical Academy in Pistoia and took a diploma in “Italian and German Organ Music Interpretation”. She attended a three year course in Gregorian Chant at the International Study Centre of Gregorian Chant in Cremona. She also took diplomas in Piano and in Musical Didactics, and, lately, the second level degree specializing in Organ interpretation and composition, recently introduced in Italian Music Conservatoires. She has a very busy professional life performing at concerts as a soloist and in chamber formations. As a soloist, she has been invited to take part in numerous international organ festivals - in Europe and in Mexico - and she has always been highly acclaimed by public and critics alike. She also performs for: Quarto Festival Internacional de Organo de Zamora Michoacàn (Mexico), Primer Ciclo Internacional de Conciertos en el Organo Barroco de la Parroquia de Santiago de Querétaro (Mexico), International Organ Summer Festival in Rome, XXVIII Festival Internazionale di Noale, Rassegna Antichi organi di Piacenza, Associazione Alessandro Scarlatti di Napoli, Associazione Studi Mezzogiorno, Associazione Ricercare, Accademia Organistica Campana, Rassegna organistica internazionale di Avezzano, Rassegna organistica di Pescara, Settembre Organistico Fabrianese, Rassegna organistica veneta “Musica nell’Agordino” , Rassegna “Musicalia” in Pavia, Festival Organistico Internazionale Città di Senigallia, Rassegna Organistica di Fiemme (Trento), Rassegna organistica della Svizzera italiana and for the International festivals performed at Notre Dame de Compassion in Paris, Merano Cathedral, Amalfi Cathedral, S. Vitale’s Basilica in Ravenna, S. Ambrogio’s Basilica in Milan and in Mexico City. She has recorded a Cd of Bach and pre-Bach music sponsored by the Goethe-Institut Italien. She is Artistic Director of the Festival "Musica intorno all'organo" at the St. Maria della Rotonda Church in Naples with the contralto Daniela Del Monaco. She was Artistic Director of the Concorso Organistico Nazionale Città di Napoli "11 Fiori del Melarancio". She taught “Organ and Organ composition” at F. Vittadini Civic Institute in Pavia and Organ at High School Alfano I in Salerno and at High School Palizzi in Naples. She is the official organist of Mascioni mechanical organ at St. Maria della Rotonda Church and at Santa Chiara’s Basilica in Naples.





Figure 6. Flyers and posters for the symposium and the concert of 12th Socratic lectures.





References



1. Schindler DC. Why Socrates Didn’t Charge: Plato and the Metaphysics of Money. Communio. 2009; 36: 394-426.



Available on: https://www.communio-icr.com/articles/view/why-socrates-didnt-charge-plato-and-the-

metaphysics-of-money. Accessed at 23.2.2025

2. Carter CE, Barnett H, Burns K, et al., Defining STEAM Approaches for Higher Education. European Journal of

STEM Education, 2021, 6(1), 13.