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Abstract: Pagan, JI, Harmon, KK, Girts, RM, MacLennan, RJ, Beausejour, JP, Hernandez-Sarabia, JA, Coker, NA, Carr, JC, Ye, X, DeFreitas, JM, and Stock, MS. Sex-specific reliability of lower-limb corticospinal excitability and silent periods. J Strength Cond Res 37(9): 1882-1887, 2023-Transcranial magnetic stimulation (TMS) is a research tool that has potential to provide new insights into strength training-induced adaptations. However, using TMS to study the lower limbs is challenging, and sex-specific reliability has yet to be reported. We examined the reliability of corticospinal excitability and silent periods for the rectus femoris, vastus lateralis, and biceps femoris in both sexes. Thirteen males and 14 females reported to the laboratory twice. During both trials, a double cone coil was used to deliver 20 pulses to the rectus femoris hotspot with a stimulator output of 130% of active motor threshold. Motor-evoked potential peak-to-peak amplitude, which reflects corticospinal excitability, and silent period duration were quantified. Our results offer 4 novel findings. First, corticospinal excitability and silent period demonstrated higher reliability for the females. Second, regardless of sex and muscle, the silent period was more reliable than corticospinal excitability. Third, reliability was highest for our target muscle (rectus femoris), with lower reliability for the vastus lateralis and biceps femoris, suggesting that these methods cannot be used to study coactivation. Fourth, active motor threshold showed less variability than corticospinal excitability and silent period but increased at trial 2 in females. Many of the intraclass correlation coefficients were excellent (≥0.90), although we attribute this finding to variability between subjects. Reliability of lower-limb TMS measures may be sex, muscle, and variable dependent. Our findings suggest that both males and females should be included in lower-limb TMS research, although combining data between sexes should be approached cautiously., (Copyright © 2023 National Strength and Conditioning Association.)

Background: Ultrasonography is used to evaluate muscle quality (i.e. echo intensity [EI]), but an attenuation of ultrasound waves occurs in deeper tissues, potentially affecting these measures., Purpose: To determine whether muscle thickness (MT) affects EI and if EI varies between the superficial and deep portions of the muscle., Materials and Methods: MT, EI, subcutaneous adipose tissue thickness (SAT), tissue depth (DIS DEEP ), and EI of the overall (EI FULL ) as well as deep (EI DEEP ) and superficial (EI SUPF ) portions of the vastus lateralis (VL) were assessed in 33 resistance-trained males using ultrasonography. The difference (EI DIFF ) between EI SUPF and EI DEEP was calculated. Mean differences between EI FULL , EI SUPF, and EI DEEP were analyzed using a repeated-measures analysis of variance (ANOVA). Relationships between measures of muscle depth/ thickness and EI were examined using Pearson's r ., Results: EI SUPF was greater than EI DEEP ( P  < 0.001) and EI FULL ( P  < 0.001). MT was negatively correlated with EI FULL ( P  < 0.001) and positively correlated with EI DIFF ( P  < 0.001). SAT was not correlated with any EI measure, but DIS DEEP was positively correlated with EI DIFF ( P  < 0.001)., Conclusion: EI of the VL is heterogeneous, as the deeper portion produces lower values than the superficial portion. Thicker muscles present lower EI but have greater discrepancies in EI between the superficial and deep portions. Although SAT was not correlated with EI, DIS DEEP was related to EI DIFF , demonstrating that the combination of MT and SAT should be considered when evaluating muscle quality. Future research is necessary to determine if changes in EI following resistance training are driven by increases in MT.

Wells, AJ, Varanoske, AN, Coker, NA, Kozlowski, GJ, Frosti, CL, Boffey, D, Harat, I, Jahani, S, Gepner, Y, and Hoffman, JR. Effect of β-alanine supplementation on monocyte recruitment and cognition during a 24-hour simulated military operation. J Strength Cond Res 34(11): 3042-3054, 2020-Sustained military operations (SUSOPs) result in psychological stress and cognitive dysfunction, which may be related to the recruitment of classical monocytes into the brain. This study examined the effect of beta-alanine (BA) on cognition and monocyte recruitment during a simulated 24-hour SUSOP. Nineteen healthy men ingested 12-g/d BA or placebo for 14 days before an SUSOP. Monocyte chemoattractant protein-1 (MCP-1), C-C chemokine receptor-2 (CCR2), and macrophage-1-antigen (CD11b) expression were assessed through multiplex assay and flow cytometry. Psychological stress and cognition were assessed through Automated Neuropsychological Assessment Metrics (ANAM). A composite measure of cognition (COGcomp) was generated from throughput scores extracted from 7 ANAM cognitive tests. Assessments occurred at baseline (0H), 12 hours (12H), 18 hours (18H), and 24 hours (24H). Significance was accepted at p ≤ 0.05. No significant effect of BA was noted for any variable (p's > 0.05). The frequency and severity of symptoms of psychological stress increased significantly at 18 and 24H compared with 0 and 12H (p's < 0.05). COGcomp decreased significantly at 18 and 24H compared with 0 and 12H (p's ≤ 0.001). MCP-1 peaked at 18H was significantly lower at 24H compared with 18H but remained elevated at 24H compared with 0H (p's < 0.001). CCR2 expression was significantly lower at 12 (p = 0.031), 18, and 24H (p's < 0.001). CD11b expression was significantly higher at 12H (p = 0.039) and 24H (p's = 0.003). MCP-1 was negatively associated with COGcomp (β = -0.395, p = 0.002, r2 = 0.174). Neither CCR2 or CD11b was related to COGcomp (p's > 0.05). Cognitive dysfunction during SUSOPs is related to serum concentrations of MCP-1 but is not influenced by BA supplementation.

Coker, NA, Wells, AJ, and Gepner, Y. The effect of heat stress on measures of running performance and heart rate responses during a competitive season in male soccer players. J Strength Cond Res 34(4): 1141-1149, 2020-Measures of running performance and heart rate (HR) responses to match play during 3 different heat stress (HS) conditions were assessed in 7 National Collegiate Athletic Association (NCAA) Division I male soccer players. Total distance and distance covered within distinct velocity zones (walking [WALK], jogging [JOG], low-speed running, high-speed running, sprinting [SPRINT], low-intensity running [LIR], and high-intensity running [HIR]) were assessed using global positioning system units for more than 12 matches. Heat stress was monitored during each match, and matches were defined as low (HSlow, n = 4), moderate (HSmod, n = 4), or high (HShigh, n = 4) HS. Minutes played were significantly different across HS conditions (p = 0.03). Therefore, distance covered within each movement velocity was assessed relative to minutes played and as a percentage of total playing time. WALKrel was significantly greater during HShigh compared with HSlow (p = 0.035). LIRrel was significantly greater during HSmod (p = 0.015) compared with HSlow. A trend was observed for %WALK being higher during HShigh compared with HSlow (p = 0.066). %LIR was significantly greater during HShigh compared with HSlow (p = 0.048). High-intensity running was not significantly different across HS conditions. Percent of time spent >85% HRmax was significantly greater during HShigh (p = 0.002) and HSmod (p < 0.001) compared to HSlow. Percent of time spent between 65-84% HRmax was significantly greater during HSlow compared to HShigh (p < 0.001). Results indicate that HS resulted in increased LIR and %HR≥85, while HIR was maintained. High-intensity running performance may be conserved through decreased playing time or the adoption of pacing strategies. This may assist coaches in altering player management strategies to optimize team performance.

Background: Thermogenic fitness drink formulas (TFD) have been shown to increase energy expenditure and markers of lipid metabolism. The purpose of the current study was to compare TFD formulas containing different caffeine concentrations versus a placebo drink on energy expenditure and lipid metabolism at rest and during exercise., Methods: Thirty-two recreationally active participants (22.9 ± 0.7 y, 167.1 ± 1.4 cm, 68.8 ± 2.0 kg, 24.0 ± 1.2% fat) who were regular caffeine consumers, participated in this randomized, double-blind, crossover design study. Participants reported to the laboratory on three occasions, each of which required consumption of either a TFD containing 140 mg or 100 mg of caffeine or a placebo. Baseline measurements of resting energy expenditure (REE) and resting fat oxidation (RFO) were assessed using indirect calorimetry as well as measurements of serum glycerol concentration. Measurements were repeated at 30, 60, 90 min post-ingestion. Following resting measures, participants completed a graded exercise test to determine maximal oxygen uptake (V̇O 2max ), maximal fat oxidation (MFO) and the exercise intensity that elicits MFO (Fat max ), and total energy expenditure (EE)., Results: A significant interaction was shown for REE (p < 0.01) and RFO (p < 0.01). Area under the curve analysis showed an increased REE for the 140 mg compared to the 100 mg formula (p = 0.02) and placebo (p < 0.01) and an increased REE for the 100 mg formula compared to placebo (p = 0.02). RFO significantly decreased for caffeinated formulas at 30 min post ingestion compared to placebo and baseline (p < 0.01) and significantly increased for the 140 mg formula at 60 min post-ingestion (p = 0.03). A main effect was shown for serum glycerol concentrations over time (p < 0.01). No significant differences were shown for V̇O 2max (p = 0.12), Fat max (p = 0.22), and MFO (p = 0.05), and EE (p = 0.08) across drinks., Conclusions: Our results suggest that TFD formulas containing 100 and 140 mg of caffeine are effective in increasing REE and that a 40 mg of caffeine difference between the tested formulas may impact REE and RFO in healthy individuals within 60 min of ingestion.

Ultrasonography of the lower body typically encompasses supine rest due to fluid shifts affecting tissue size and composition. However, vastus lateralis (VL) examination is completed in the lateral recumbent position, and this positional change may influence morphology and its ability to predict function. This study aimed to examine the effect of position on VL morphology and its relationship with lower-body performance. Cross-sectional area (CSA), muscle thickness (MT), pennation angle (PA), echo intensity (UnCorEI), subcutaneous adipose tissue thickness (SFT), and echo intensity corrected for SFT (CorEI) were assessed in 31 resistance-trained males (23.0 ± 2.1 yrs; 1.79 ± 0.08 m; 87.4 ± 11.7 kg) immediately after transitioning from standing to supine (IP), after 15 min of standing (ST), and after 15 min of rest in three recumbent positions: supine (SUP), dominant lateral recumbent (DLR), non-dominant lateral recumbent (NDLR). Participants also completed unilateral vertical jumps, isometric/isokinetic tests, and a one-repetition maximum leg press. CSA, MT, PA, and SFT were greater in ST compared to NDLR, DLR, and SUP ( p < 0.05). CSA, UnCorEI, and CorEI were different between recumbent positions; however no differences were observed for MT, PA, and SFT. Different magnitudes of relationships were observed between muscle morphological characteristics measured after rest in different positions and performance variables. Muscle morphology in IP generally appears to be the best predictor of performance for most variables, although utilizing the NDLR and DLR positions may provide comparable results, whereas morphology measured in ST and SUP provide weaker relationships with physical performance. IP also requires less time and fewer requirements on the technician and subject, thus researchers should consider this positioning for VL examination.

β-alanine supplementation increases muscle carnosine content and improves anaerobic exercise performance by enhancing intracellular buffering capacity. β-alanine ingestion in its traditional rapid-release formulation (RR) is associated with the symptoms of paresthesia. A sustained-release formulation (SR) of β-alanine has been shown to circumvent paresthesia and extend the period of supply to muscle for carnosine synthesis. The purpose of this investigation was to compare 28 days of SR and RR formulations of β-alanine (6 g day -1 ) on changes in carnosine content of the vastus lateralis and muscle fatigue. Thirty-nine recreationally active men and women were assigned to one of the three groups: SR, RR, or placebo (PLA). Participants supplementing with SR and RR formulations increased muscle carnosine content by 50.1% (3.87 mmol kg -1 ww) and 37.9% (2.62 mmol kg -1 ww), respectively. The change in muscle carnosine content in participants consuming SR was significantly different (p = 0.010) from those consuming PLA, but no significant difference was noted between RR and PLA (p = 0.077). Although participants ingesting SR experienced a 16.4% greater increase in muscle carnosine than RR, fatigue during maximal voluntary isometric contractions was significantly attenuated in both SR and RR compared to PLA (p = 0.002 and 0.024, respectively). Symptoms of paresthesia were significantly more frequent in RR compared to SR, the latter of which did not differ from PLA. Results of this study demonstrated that only participants consuming the SR formulation experienced a significant increase in muscle carnosine. Differences in the muscle carnosine response between these formulations may have practical significance for athletic populations in which small changes may have important implications on performance.

Sustained military operations (SUSOPs) are associated with performance decrements and cognitive dysfunction. β-Alanine (BA) supplementation may have a role in increasing soldier resiliency by enhancing muscle-buffering capacity and reducing oxidative stress. The purpose of this study was to examine the effects of BA on physical performance, cognition, endocrine function, and inflammation during a 24 h simulated SUSOP. Nineteen males were randomized into one of two groups: BA (n = 10) or placebo (n = 9; PLA) (12 g/day) for 14 days preceding the 24 h SUSOP. Assessments were performed at 0 h (0H), 12 h (12H), and 24 h (24H) during the SUSOP. No changes in visual tracking ability, jump power, or upper-body muscular endurance were observed between groups or time points (P's > 0.05). Increases in subjective feelings of soreness and fatigue were noted at 12H compared to 0H (P < 0.05) in PLA, but not in BA. Visual reaction time for PLA was slower at 24H compared to 0H (P = 0.035), and PLA made more errors on reaction time testing at 12H compared to BA (P = 0.048), but motor reaction time was faster (P = 0.016) for PLA. Simulated litter carry and 1 km run completion times increased at 24H compared to 0H in both groups (P < 0.05), however, PLA had a longer 1 km time compared to BA at 24H (P = 0.050). Increases in inflammatory and endocrine markers were observed over the SUSOP, with no differences between groups. BA supplementation appears to maintain some aspects of cognition and physical performance during a 24 h SUSOP, with no effects on endocrine function or inflammation., (© 2018 The Authors. Physiological Reports published by Wiley Periodicals, Inc. on behalf of The Physiological Society and the American Physiological Society.)

Background: Tumor necrosis factor-alpha (TNF-α) has been shown to be implicated in both muscle regeneration and muscle wasting. However, it remains unclear whether TNF-α is responsible for the age-related losses in muscle size and function. Also, due to the high clearance rate of TNF-α from circulation, analyzing the circulating levels of soluble TNF-α receptors 1 and 2 (STNFR1 and STNFR2) may provide a better indication of inflammatory events. The aim of this study was to examine changes in circulating concentrations of TNF-α, STNFR1, and STNFR2 following acute eccentric exercise in young (YA) and middle-aged (MA) men., Methods and Materials: Nine YA (N=9, 21.8±2.2y, 179.5±4.9cm, 91.2±12.2kg, 21.8±4.3% body fat) and ten MA (N=10, 47.0±4.4y, 176.8±7.6cm; 96.0±21.5kg, 25.4±5.3% body fat) men completed an acute muscle damaging protocol (MDP). Blood samples were obtained at baseline (BL), immediately (IP), 30-minute (30P), 60-minute (60P), 120-minute (120P), 24-hour (24H), and 48-hour (48H) post-MDP. Lower body performance was assessed via isokinetic dynamometer at BL, IP, 120P, 24H, and 48H., Results: YA displayed higher values of peak torque (p=0.023) and mean torque (p=0.036) at BL. No significant group differences were observed for markers of muscle damage or TNF-α. Plasma concentrations of TNF-α were unchanged following MDP. STNFR1 concentrations were significantly higher in the YA group compared to MA (p=0.036). Significant time effects were observed for STNFR1 (p<0.001) and STNFR2 (p=0.001). With both groups combined, serum STNFR1 was decreased at 30P (p=0.001), while STNFR2 was decreased at 30P (p=0.008), 60P (p=0.003), and 120P (p=0.002) relative to BL., Conclusions: The pro-inflammatory response to muscle damage does not appear to decline at middle age when individuals are recreationally trained. However, young men showed significantly higher serum STNFR1 concentrations than middle age men. This may suggest that natural inhibitors of TNF-α decline as early as middle age., (Copyright © 2017 Elsevier Inc. All rights reserved.)

β-Alanine (BA) supplementation results in elevated intramuscular carnosine content, enhancing buffering capacity during intense exercise. Although men have greater muscle carnosine content than women, elevations still appear to occur despite high baseline levels. Recent research has suggested that BA supplementation may also reduce muscle l-histidine. Thus, the purpose of this investigation was to compare 28 days of BA (6 g·d -1 ) supplementation in men and women on performance and muscle carnosine, l-histidine, and BA. We hypothesized that supplementation would result in similar elevations in carnosine and performance between sexes and decrease l-histidine. Twenty-six men and women were assigned either BA or placebo (PLA). At baseline, a trend toward greater carnosine (P = .069) was observed in men, and intramuscular BA content was significantly (P ≤ .05) greater in men. Statistical analysis was performed using magnitude-based inferences. Changes in muscle carnosine were likely and very likely greater after BA supplementation compared with PLA in men and women, respectively, but changes were unclear between sexes (mean sex difference: 2.50 ± 4.30 mmol·kg -1 ww). The attenuation of exercise fatigue was likely greater in BA compared with PLA, but the change was unclear between sexes (mean sex difference: 14.0 ± 39.0 Nm). Changes in muscle BA following supplementation was unclear in men, likely elevated in women, but unclear between sexes (mean sex difference: 0.03 ± 0.42 mmol·kg -1 ww). Changes in muscle l-histidine were unclear in men and women, and unclear between sexes (mean sex difference: 0.09 ± 0.13 mmol·kg -1 ww). In conclusion, BA supplementation increased muscle carnosine and attenuated fatigue in men and women similarly but did not reduce muscle l-histidine., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Gordon, JA III, Hoffman, JR, Arroyo, E, Varanoske, AN, Coker, NA, Gepner, Y, Wells, AJ, Stout, JR, and Fukuda, DH. Comparisons in the recovery response from resistance exercise between young and middle-aged men. J Strength Cond Res 31(12): 3454-3462, 2017-The purpose of this study was to compare the effects of a bout of high-volume isokinetic resistance exercise protocol (HVP) on lower-body strength and markers of inflammation and muscle damage during recovery between young and middle-aged adult men. Nineteen recreationally trained men were classified as either a young adult (YA: 21.8 ± 2.0 years; 90.7 ± 11.6 kg) or a middle-aged adult (MA: 47.0 ± 4.4 years; 96.0 ± 21.5 kg) group. The HVP consisted of 8 sets of 10 repetitions, with 1 minute of rest between each set, performed on an isokinetic dynamometer at 60°·s. Maximal voluntary isometric contractions and isokinetic peak torque (PKT) and average torque (AVGT) (measured at 240° and 60°·s, respectively) were assessed at baseline (BL), immediately post (IP), 120 minutes, 24, and 48 hours after HVP. Blood was obtained at BL, IP, 30, 60, 120 minute, 24, and 48 hours after HVP to assess muscle damage and inflammation. All performance data were analyzed using repeated measures analysis of covariance, whereas all inflammatory and muscle damage markers were analyzed using a 2-way (time × group) repeated measures analysis of variance. Results revealed no between-group differences for PKT, AVGT, or rate of torque development at 200 ms (RTD200). No between-group differences in myoglobin, creatine kinase, C-reactive protein, or interleukin-6 were observed. Although BL differences in muscle performance were observed between YA and MA, no between-group differences were noted in performance recovery measures from high-volume isokinetic exercise in recreationally trained men. These results also indicate that the inflammatory and muscle damage response from high-volume isokinetic exercise is similar between recreationally trained, young, and middle-aged adult men.

Carnosine is a naturally occurring intramuscular dipeptide that is thought to attenuate fatigue during high-intensity exercise. Carnosine content is influenced by various factors, including gender and diet. Despite research reporting that carnosine content is lower in women compared to men and lower in vegetarians compared to omnivores, no investigations have examined carnosine content in women based on dietary protein intake and its effect on muscle fatigue. Twenty recreationally active women were assigned to either a high (HI; n = 5), moderate (MOD; n = 10), or low (LO; n = 5) group based upon intramuscular carnosine content of the vastus lateralis. Each participant underwent two unilateral maximal voluntary isometric contractions (MVIC) of the knee extensors separated by an isokinetic exercise protocol consisting of five sets of 50 repeated maximal unilateral contractions. Magnitude-based inferences were used to analyze group differences. Percent decline in rate of force development and peak torque (PT) during the MVICs and changes in PT and mean torque during the muscle-fatiguing protocol were lower in HI compared to both MOD and LO. Additionally, absolute and relative dietary protein intake were greater in HI compared to MOD or LO. Results indicated that greater intramuscular carnosine content was reflective of greater dietary protein intake and that individuals with higher carnosine content displayed a greater attenuation of fatigue compared to those with lower carnosine.

Coker, NA, Wells, AJ, Ake, KM, Griffin, DL, Rossi, SJ, and McMillan, JL. Relationship between running performance and recovery-stress state in collegiate soccer players. J Strength Cond Res 31(8): 2131-2140, 2017-The purpose of this study was to evaluate the relationship between changes in running performance and the stress-recovery state in collegiate soccer players. Running performance was evaluated in 7 National Collegiate Athletic Association Division I male soccer players (179.39 ± 5.24 cm; 75.46 ± 5.98 kg; 20.37 ± 1.41 years) through global positioning systems over the course of 12 competitive games in a single season. The regular season was divided into 4 competitive blocks: B1 (n = 3), B2 (n = 3), B3 (n = 3), and B4 (n = 3). Total distance and distance covered while engaging in walking, jogging, low-speed running, high-speed running, sprinting, low-intensity running, and high-intensity running were assessed during each block. The Recovery-Stress Questionnaire (RESTQ) 52 Sport was administered twice during each block to evaluate measures of stress and recovery. Total distance was greater during B4 compared with B1 (p = 0.027). Jogging and low-speed running were greater during B4 compared with all other time points (p's ≤ 0.05). Low-intensity running distance was greater during B4 compared with B1 (p = 0.034). Sport-specific recovery decreased significantly during B4 compared with B1 (p = 0.035). Correlational analysis indicated that high-velocity running was associated with increased stress, whereas low-velocity running was associated with greater recovery. However, changes in sport-specific recovery did not correlate with changes in running performance from B1 to B4. Results of this study indicate that running performance decreased across the season. Changes in running performance coincided with a decrease in sport-specific recovery. Practitioners may benefit from including the RESTQ as part of an assessment battery to monitor the stress/recovery state of athletes.

Hyde, PN, Kendall, KL, Fairman, CM, Coker, NA, Yarbrough, ME, and Rossi, SJ. Utilization of B-mode ultrasound as a body fat estimate in collegiate football players. J Strength Cond Res 30(12): 3525-3530, 2016-The purpose of the present study was to validate a 7-site ultrasound imaging protocol to predict the percent body fat (%BF) in a division I football team. Body composition was estimated by ultrasound, 7-site skinfolds, and the 3-compartment-water (3C-W) model of Siri, using bioimpedance spectroscopy to estimate the total body water and air displacement plethysmography (using BODPOD) to determine the body density. Pearson's product-moment correlation analyses were run to determine correlations between ΣUltrasound and the criterion 3C-W, and between the ΣSkinfold and ΣUltrasound. Strong positive correlations were observed between ΣSkinfold and ΣUltrasound (r = 0.984; p < 0.001). Furthermore, a strong positive correlation was observed between ΣUltrasound and %BF from 3C-W (r = 0.878; p < 0.001). Based on the significant correlation analysis, a linear regression equation was developed to predict the %BF from ΣUltrasound, using %BF from the 3C-W model as the dependent variable: %BF = 6.194 + (0.096 × ΣUltrasound); standard error of the estimate (SEE) = 2.97%. Cross-validation analyses were performed using an independent sample of 29 players. The mean observed %BF from the 3C-W model and the mean predicted %BF were 18.32 ± 6.26% and 18.78 ± 6.22%, respectively. The constant error, SEE, and validity coefficient (r) were 0.87%, 2.64%, and 0.91%, respectively. The total error was 2.87%. The positive relationship between ultrasound measurements and the 3C-W model suggests that ultrasound imaging may be a practical alternative to predicting %BF in division I football players.

Systemic complications of levamisole-adulterated cocaine (LAC) use have recently been described. The objective of this review is to increase awareness of these manifestations among oral and maxillofacial surgeons. LAC exposure through inhalation, nasal insufflation, or injection can induce cutaneous vasculopathy and hematologic abnormalities such as neutropenia or agranulocytosis. Unlike other vasculopathies involving the skin, LAC-induced vascular injury frequently manifests with purpuric and necrotic lesions that involve the face and ears. Oral manifestations have also been reported but are not yet well characterized. The aforementioned hematologic manifestations are not uncommon, and patients exposed to LAC are potentially at higher risk for infectious complications. When manifestations of LAC affect the head, neck, and oral cavity, oral and maxillofacial surgeons may be the first providers to encounter the patient. Early recognition of the clinical signs and laboratory abnormalities will better allow for distinguishing LAC-related effects from various clinical mimics, will facilitate appropriate patient management, and may further contribute to the understanding of the biological effects of LAC., (Copyright © 2013 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.)