Schmorl's nodes and low-back pain

Summary Magnetic resonance imaing (MRI) findings in cases with symptomatic and asymptomatic Schmorl's nodes have been analysed. In all symptomatic cases, the vertebral body marrow surrounding the Schmorl's node was seen as low signal intensity on T1-weighted images and as high signal intensity on T2-weighted images. It was confirmed by histological examination that the MRI findings indicated the presence of inflammation and oedema in the vertebral bone marrow. These MRI findings were not seen in asymptomatic individuals. Inflammatory changes in the vertebral body marrow induced by intraosseous fracture and biological reactions to intraspongious disc materials might cause pain. We postulate that after fracture healing and subsidence of inflammation, the Schmorl's nodes become asymptomatic, in analogy with old vertebral compression fractures. MRI is not only useful in detecting the recently developed Schmorl's nodes but also in differentiating between symptomatic and asymptomatic Schmorl's nodes.     

The amount of bone mineral and Schmorl's nodes in lumbar vertebrae

The bone mineral areal content and the ultimate compressive strength were determined in 109 lumbar vertebrae from 36 subjects. The bone mineral areal content was related to the number, shape, and localization of the Schmorl's nodes detected in the x-rayed and sectioned vertebral bodies. One type of node, irregular in shape and localization, occurred only in the vertebrae with low bone mineral areal content values and thus in vertebrae with relatively low compressive strength. A second type of Schmorl's nodes, regular in shape and localization, did not reflect any general weakness of the vertebral bodies.     

Hypogonadism and erectile dysfunction: pathophysiological observations and therapeutic outcomes

Androgens have a profound effect in male sexual function in general and erectile physiology in particular. Despite the common belief that male sexuality is fully dependent on normal androgens, hypogonadal men are capable of sexual erections; almost a third of men receiving effective antiandrogen therapy can develop erections when tested with an erotic challenge. However, successful hormonal supplementation that results in normal testosterone values does not always restore libido and erectile function. Although the primary goal of treatment for hypogonadism may be to restore sexual function, there will be other significant benefits and potential drawbacks. Libido, general well-being, osteoporosis, muscle strength, mental acuity, and growth hormone levels will all be positively affected by appropriate management of low testosterone levels. Testosterone replacement therapy should maintain not only physiological levels of serum testosterone but also its metabolites, including dihydrotestosterone and oestradiol. The assessment of hypogonadism, its treatment and monitoring, are unavoidable responsibilities of the urologist.     

Plain radiographic, discographic, and direct observations of Schmorl's nodes in the thoracolumbar junctional region of the cadaveric spine

The perceivability of Schmorl's nodes in plain radiographs and discograms in the thoracolumbar junctional region (T10-L1) of the cadaveric spine was assessed by comparing the radiologic measurements with bone measurements. Schmorl's nodes in bone specimens were encountered in 19 of 24 spines studied. They were more than two times as common between vertebrae T10-11 and T11-12 as between T12 and L1 (P less than 0.01). When the areas of actual Schmorl's nodes exceeded 0.5 cm2 (corresponding to an aperture with a diameter of 0.8 cm), 47% of the nodes were seen in plain lateral radiographs and 68% in discograms. When the area measured 0.5 cm2 or less, only 24% could be perceived in plain lateral radiographs and 23% in discograms. The clinical significance of Schmorl's nodes remains uncertain as long as they are difficult to detect in vivo.     

Lateral dislocation of the elbow: pathophysiological and therapeutic analysis

Lateral dislocation of the elbow is exceptional, and its pure form even more so. We report a case of lateral dislocation of the elbow observed in a 65-year-old woman following a fall on the medial aspect of the elbow in the flexion position. Reduction could not be achieved because of the anconeus muscle interposition. Analysis of the mechanism involved and the displacements observed enabled to propose a reduction manoeuvre using gentle traction on the elbow with extension and progressive supination of the forearm, pushing the olecranon backward then pulling it medialy. This enabled avoiding incarceration of the nerve bundle or capsulo-ligamentary structures.     

Pleural fluid pH: diagnostic, therapeutic, and prognostic value

Measurement of pleural fluid pH has diagnostic, therapeutic, and prognostic implications in exudative pleural effusions (Table II). A parapneumonic effusion with a pleural fluid pH below 7.2 indicates an empyema is forming which necessitates chest tube drainage in all patients, whereas a pleural fluid pH over 7.3 does not require drainage. If the pH of a parapneumonic effusion is 7.2 to 7.3, serial pleural fluid pH measurements with clinical observation will help to determine the need for chest tube drainage. A pleural fluid glucose level of below 60 mg/dl and a lactic dehydrogenase level over 1,000 IU/dl in conjunction with a pleural fluid pH of 7.2 to 7.3 indicate an impending empyema. These findings are consistent with our clinical experience in patients with parapneumonic effusion. Tuberculous pleural effusions had a pleural fluid pH below 7.4 in all reported patients. This pH may be of value in distinguishing tuberculous pleural effusions from recent malignant effusions, which tend to have a higher pleural fluid pH, particularly if used in conjunction with other pleural fluid values, cell counts, and other clinical parameters. In patients with malignant pleural effusions, a pH of less than 7.3 is usually seen in those effusions present for several months and is associated with a lower glucose level and a higher white cell count and lactic dehydrogenase level. Results of cytologic study of the pleural fluid and pleural biopsy are often positive, there is poor response to sclerosing agents, and the prognosis is poor. A rheumatoid pleural effusion most often has a pleural fluid pH below 7.3. A pleural fluid pH below 6 is seen almost exclusively in esophageal rupture but rarely with empyemas, whereas a pleural fluid pH below 7 occurs in esophageal rupture, empyema, and rheumatoid pleural effusions. In pleural effusions secondary to congestive heart failure, the pH is almost always greater than 7.4 unless systemic acidemia coexists, in which case the pleural fluid pH is within 0.04 units of the simultaneous arterial pH. The major value of pleural fluid pH is to determine the need for chest tube drainage in parapneumonic effusions and to determine the response to sclerosing agents in patients with malignant pleural effusions. As with all diagnostic tests, the results should be interpreted in the context of other diagnostic tests of the pleural fluid and clinical aspects before diagnostic or therapeutic decisions are made.     

Segmental necrotizing glomerulonephritis: diagnostic, prognostic, and therapeutic significance

Renal biopsies from 50 patients with segmental necrotizing glomerulonephritis (SNGN) were divided into three groups on the basis of initial clinical information: (group A) Wegener's granulomatosis (WG)--14 patients; (group B) SNGN without renal vasculitis (RV)--21 patients; and (group C) SNGN with RV--15 patients. Renal biopsy findings did not distinguish the SNGN in WG from non-WG patients. However, focal endocapillary proliferation was more common in non-WG groups B (48%) and C (33%) than in WG (7%). In addition, GBM deposits of both IgG and C3 were present in 35% of biopsies in group B and 33% in group C in comparison to only 7% in WG. Glomerular fibrin deposition was common in all groups (54% group A, 70% group B, and 100% group C), suggesting that coagulation plays a role in the development of SNGN. Histologic parameters of severity and chronicity of the SNGN were inconsistent predictors of outcome, although an increased percentage of crescents in the non-WG groups correlated with a poorer prognosis. Chronic renal failure developed in 46% of group A patients, 65% group B, and 73% group C. After clinical follow-up, 15 patients had WG, 15 patients had documented or suspected systemic vasculitis (SV), and idiopathic SNGN was present in 20 patients. Sixty-six percent of patients with SV had RV, and 62% of biopsies with RV were from patients with SV. Chronic renal failure developed in 78% of patients with idiopathic SNGN and 57% patients with SV. These findings confirm that SNGN carries a poor prognosis, independent of its association with WG or SV. Fourteen of the 15 WG patients were treated with alkylating agents, and the development of chronic renal failure appeared to be related to delays in diagnosis and therapy. In the non-WG groups, presentation in acute renal failure with high serum creatinine and long duration of symptoms was predictive of development of chronic renal failure. Therapy in the non-WG patients consisted of alkylating agents (seven patients), steroids (20 patients), and dialysis only (seven patients). The seven non-WG patients treated with alkylating agents had clinical responses similar to WG patients, and cyclophosphamide therapy appeared to be most beneficial to patient outcome. Results of this retrospective study stress the importance of early diagnosis and, although based on small numbers of patients, suggest that aggressive chemotherapy should be recommended for SNGN, independent of its association with biopsy-proven WG or documented SV.     

Faculty evaluations: diagnostic and therapeutic

PURPOSE: An excellent teaching program is one that creates an atmosphere of mentorship, leadership, and professional development. The key to all of these may lie in the faculty evaluation. Currently, favorable faculty evaluations are often rewarded, whereas the more critical evaluations are downplayed and seldom used for faculty development. The purpose of this study is to investigate the efficacy of the faculty evaluation as a diagnostic tool to objectively identify individual strengths and weaknesses. Can such a tool then be used as a therapeutic modality to improve and enhance the faculty as a whole? METHODS: Fourth- and fifth-year surgical residents from 1 residency program were asked to collaboratively define 9 characteristics that make a surgical role model. They then anonymously evaluated each of the 44 teaching attendings on each of the 9 criteria. The results of the evaluations, which consisted of the overall mean scores and SD for each of the 9 criteria, the attending's score and SDs above or below the mean, as well as whether the residents considered them to be a Role Model, were sent to each faculty member as an intervention. Six months after the intervention, the residents evaluated the attendings using the same 9 criteria. Evaluations were collected and analyzed following the same procedure as 6 months prior. T-tests and p-values were calculated to determine any significant differences between the 2 data sets. RESULTS: Based on the results of the pre-intervention evaluations, we were able to delineate faculty members into 3 groups based on their Role Model score. Of the 10 faculty members with the lowest scores (defined as >1 SD below average), 7 improved after the intervention, 3 of them were statistically significant (2 with p < 0.05 and 1 with p < 0.10). In the middle group of 26 faculty members, 1 showed statistically significant improvement (p < 0.05). Interestingly, this was the faculty member with the lowest score in this group. Six faculty originally in the middle group improved to a score greater than 1 SD above average, defining them as a Role Model. The remaining 8 faculty members originally designated as Role Models showed no statistically significant changes in their scores after the intervention. After the intervention, the average score improved for all of the 9 criteria that make a faculty Role Model. Statistically significant improvements were seen in the categories of Provides Feedback (p < 0.05) and Didactic Teaching, Attendance at Didactic activities, and Stimulates Critical Thinking with the Use of Literature (all p < 0.10). CONCLUSIONS: (1) Faculty evaluations are a diagnostic tool with the ability to select out Role Models from the lower scoring groups. (2) After the intervention, the overall average score improved for all of the 9 criteria that make a Role Model, showing improvement of the faculty as a whole. (3) The therapeutic benefits of faculty evaluations were best seen in the faculty with the lowest scores.     

Schmorl结节与椎间盘退变和腰痛相关性的研究进展

1927年,德国医生Schmorl第一次描述了Schmorl结节及其形成理论:由椎间盘的髓核组织经软骨终板的薄弱区疝入椎体内所形成的椎间盘改变.长期以来,经典的Schmorl结节定义至少包含两个部分:一是椎体软骨终板的破裂;二是髓核通过破裂的软骨终板突向软骨下松质骨内.但至今为止,Schmorl结节的发生因素、分布规律以及与椎间盘退变、腰痛的关系尚不明确.现将当前国内外关于Schmorl结节与椎间盘退变及腰痛相关性的研究进展综述如下.     

New vitamin D analogs and changing therapeutic paradigms

Vitamin D compounds have been used successfully to treat secondary hyperparathyroidism for almost three decades. Side effects of increased levels of serum calcium and phosphate and potential complications have increasingly been recognized as problematic, and this has become an even more difficult clinical challenge with the desire to capitalize on some of the pleiotropic effects of vitamin D. Nonclassical nuclear vitamin D receptor (VDR) effects on the cardiovascular system, kidneys, and immune system, with the prospect of improved patient survival, have moved to center stage. Selective vitamin D compounds with minimal effects on mineral metabolism and with maximal cardiovascular and renal benefits are now needed. New vitamin D compounds already in clinical use, which have an improved side-effect profile and differential nonclassical effects compared with calcitriol, are limited to the three licensed pharmaceuticals--paricalcitol, 22-oxacalcitriol, and doxercalciferol. Other compounds are under early development and it is anticipated that these novel therapeutic concepts will result in new vitamin D therapies that will help to reduce the high mortality rate patients with kidney disease experience.     

Diaphragmatic relaxation: pathophysiological alterations and current possibilities of surgical repair

Diaphragmatic relaxation is a pathology not frequently observed because it is generally oligosymptomatic. The development of modern technology has induced an important contribution to the diagnosis and treatment of the disease which can find a possibility of restoration in surgery. A 63-year-old patient with a light syndrome of respiration deficiency and an altered relaxed profile of the right cupola was subjected to surgical treatment with the technique of diaphragmatic plicature without any adverse implication during and after the operation. After a brief recovery, the patient was discharged and after 9 years he affirmed still absence of dyspnoea from limited labor and absence of respiration problems. The selected surgical technique for the restoration of the altered muscle is the diaphragmatic plicature without incision or excision of the altered part of the muscle. The preferable access way today is that of laparotomy which is devoid of problems of thoracotomy and generally it permits quite easily the restoration of all diaphragmatic defects. Diaphragmatic plicature is a simple, effective and long-lasting intervention but we cannot determine the complete recovery of the normal contractile function of the muscle. There is no morbidity and mortality directly related to this technique, the latter incidentally associated with complications of general anesthesia.     

Oropharyngeal cancer and human papilloma virus: evolving diagnostic and management paradigms

The significant increase in human papilloma virus (HPV)‐associated oropharyngeal carcinoma (OPC) over recent years has lead to a surge in research and an improved understanding of the disease. Most patients with HPV‐associated OPC present with cystic nodal metastases with a small primary tumour, and respond well to all treatment modalities including primary surgery and primary chemoradiotherapy. Current research is evaluating treatment de‐escalation to reduce long‐term treatment‐associated morbidities. Transoral robotic surgery (TORS) is particularly relevant as the transoral approach allows small primary tumours to be removed with lower morbidity than traditional surgical approaches. The current American Joint Committee on Cancer staging system for oropharyngeal cancer does not appropriately stratify HPV‐associated OPC; hence, alternative risk stratification and staging classifications are being proposed.