骨质疏松症诊断标准的探讨

本文目的是再次讨论骨质疏松的诊断标准问题。骨质疏松症的诊断以骨密度DXA检测为金标准。1994年世界卫生组织(WHO)推荐的骨质疏松诊断标准为:患者骨密度低于同性别人群峰值骨量均值2.5个标准差以上,或减少30%以上。这个标准的T值是根据年轻白人妇女计算的,但是对于不同地区是不能固守这一标准的。有研究调查我国部分地区骨质疏松症总患病率为32.3%(2.0SD)和14.9%(2.5SD),2种骨密度诊断标准计算骨质疏松症患病率差异有显著性,若以2.5SD为标准很可能造成漏诊。该研究者还发现骨质疏松症的患病率在老年远高于年轻人。而WHO采用的是白人年轻女性的数据库,它是否适用就更值得推敲。另有研究者以骨密度低于-2.0SD标准,推算杭州市妇女骨质疏松的发病率为29.5%。认为以-2.0SD为标准可以相对早期发现骨质疏松。还有研究对于高原的藏族人群进行检测,也得出同样结论。有研究者推算我国各个DXA仪器之间的换算公式,发现上述换算公式基本上与日本推出的相同,但是与美国推出的换算公式有差异。这都证明WHO骨密度诊断标准是否适用于黄种人是有疑问的。国内有研究者以BMD-2.0SD为诊断标准,结合以骨代谢生化指标,认为能全面合理评价骨转换。还有研究者对目前国内使用骨密度检测方法进行统计分析,发现60岁骨量丢失率有18%左右,70岁阶段达到22%左右。这个患病百分率比较符合中国人的实际情况。按照世界上基本通用的换算方法,1.0SD约等于10%～12%的骨量丢失百分率,因此建议男性骨质疏松诊断标准为骨量丢失率达到25%或2.0SD,实际诊断年龄在70岁以上。如果采用2.5SD,中国人患病诊断时间会推迟到70岁以后,尤其是男性要推迟到90岁以后。骨质疏松症的研究关键是正确合理的诊断,不同种族、不同国家或地区有不同的诊断标准。1994年以前全世界都执行WHO1985年提出的峰值骨量丢失2.0个标准差诊断为骨质疏松症。1994年WHO提出了白人妇女小于-2.5SD为骨质疏松,但也明确指出该标准仅适用于欧美白人妇女。以Orimo为首的日本骨代谢学会制定了日本人群的骨质疏松诊断标准:骨密度在同性别青年人平均值30%以下为骨质疏松,丢失20%～30%为骨量减少。1999年中国老年学学会骨质疏松委员会诊断学组建议骨质疏松的诊断标准为骨量丢失百分率达到25%,或者说2.0SD。对于国外也有学者倾向于采用-2.0SD的标准来评价骨质疏松症。有研究发现不同国家间,和每国内部不同人群和人种的骨密度是明显不同的。非洲和拉丁美洲人种的骨密度高于白种人,而白种人的骨密度则高于黄种人。总结:1、国内外人群间骨密度的差异是公认的,我国人群骨密度是低于制定国际标准的白种人的,有倾向以T值低于-2.0SD为骨密度诊断标准。但是大规模的流行病学调查比较研究还很少,有必要进一步提供更确切的骨质疏松诊断更改的流行病学依据。2、以2.0SD为标准可以减少骨质疏松的漏诊,对于流行病学人群调查筛选病例,进行危险因素分析和对骨质疏松高危人群进行干预实验尤为有必要。3、如果加强国内和国际间多单位的联合研究,可以提高标准制定的科学性和权威性。     

Patient selection criteria

Most malpractice claims are based on failures of communication and patient selection criteria, not on technical faults. This article examines the psychological aspects of plastic surgery and then discusses the role of effective communication as a claims prevention technique. The authors delineate general characteristics of trouble-prone patient groups so that the surgeon may distinguish those patients whose body image and personality characteristics make them simply unsuitable for the elective aesthetic surgery that they seek.     

Classification criteria for spondyloarthropathies

Spondyloarthropathies (SpA) are a group of inflammatory arthritis which consist of ankylosing spondylitis (AS), reactive arthritis, arthritis/spondylitis associated with psoriasis (PsA), and arthritis/spondylitis associated with inflammatory bowel diseases. It is now more important than ever to diagnose and treat SpA early. New therapeutic agents including blockers of tumor necrosis factor have yielded tremendous responses not only in advanced disease but also in the early stages of the disease. Sacroiliitis on conventional radiography is the result of structural changes which may appear late in the disease process. However, magnetic resonance imaging (MRI) can visualize active inflammation at sacroiliac joints and spine in recent onset disease. The modified New York criteria, the European Spondyloarthropathy Study Group criteria and the Amor criteria do not include advanced imaging techniques like MRI which is very sensitive to the early Inflammatory changes. Assessment of SpondyloArthritis international Society has defined MRI methods for the assessment of sacroiliac joints and spine, criteria for inflammatory back pain and developed new criteria for classification of axial and peripheral spondyloarthritis. These new criteria are intended to be used for patients with SpA at the very early stage of their disease. Also, classification of psoriatic arthritis study group developed criteria for the classification of PsA. The widespread use of these criteria in clinical trials will provide evidence for a better definition of early disease and recognize many patients who may further develop classical AS or PsA. These efforts will guide therapeutic trials of potent drugs like biological agents in the early stage of these diseases.     

Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria)

AIMS: The diagnosis of pudendal neuralgia by pudendal nerve entrapment syndrome is essentially clinical. There are no pathognomonic criteria, but various clinical features can be suggestive of the diagnosis. We defined criteria that can help to the diagnosis. MATERIALS AND METHODS: A working party has validated a set of simple diagnostic criteria (Nantes criteria). RESULTS: The five essentials diagnostic criteria are: (1) Pain in the anatomical territory of the pudendal nerve. (2) Worsened by sitting. (3) The patient is not woken at night by the pain. (4) No objective sensory loss on clinical examination. (5) Positive anesthetic pudendal nerve block. Other clinical criteria can provide additional arguments in favor of the diagnosis of pudendal neuralgia. Exclusion criteria are also proposed: purely coccygeal, gluteal, or hypogastric pain, exclusively paroxysmal pain, exclusive pruritus, presence of imaging abnormalities able to explain the symptoms. CONCLUSION: The diagnosis of pudendal neuralgia by pudendal nerve entrapment syndrome is essentially clinical. There are no specific clinical signs or complementary test results of this disease. However, a combination of criteria can be suggestive of the diagnosis.     

Liver transplantation for hepatocellular carcinoma: Comparison of the proposed UCSF criteria with the Milan criteria and the Pittsburgh modified TNM criteria

We previously proposed modified staging criteria for predicting acceptable outcome after orthotopic liver transplantation (OLT) for hepatocellular carcinoma (HCC). These were solitary tumor ≤6.5 cm, or three or fewer nodules with the largest lesion ≤4.5 cm and total tumor diameter ≤8 cm, without gross vascular invasion (University of California, San Francisco [UCSF] criteria). In this study, we further evaluated the performance of the Milan criteria (solitary tumor ≤5 cm, or three or fewer lesions none >3 cm), the UCSF criteria, and the Pittsburgh modified tumor-node-metastasis (TNM) criteria. Pathologic HCC staging according to each set of criteria was performed in 70 patients. The difference in survival when comparing 24 patients with HCC exceeding Milan criteria versus 46 patients meeting Milan criteria did not reach statistical significance (HR, 2.0; P = .12). Using our definition for acceptable 2-year survival to be ≥70%, the 14 patients (20%) meeting UCSF criteria but exceeding Milan criteria had a 2-year survival of 86% (95% CI, 54% to 96%). Survival for Pittsburgh stage I, II, and IIIA patients as a group was significantly better than for stages IIIB and IVA patients combined (HR, 4.2; P = .007), and similar to survival for patients meeting UCSF criteria. Advanced tumor exceeding UCSF criteria served reasonably well as a surrogate marker for poorly differentiated grade and microvascular invasion. In conclusion, our analyses suggest that UCSF criteria better predict acceptable posttransplant outcome than Milan criteria. UCSF criteria confer a different advantage over Pittsburgh criteria, which require information on microvascular invasion that is difficult to ascertain preoperatively without the attendant risk of biopsy. (Liver Transpl 2002;8:765-774.)     

Revisable criteria for vertebral deformity

In order to study vertebral fractures in various study populations, we earlier prepared a database of vertebral dimensions derived from spinal radiographs of 191 normal women seen regularly over 25 years. In this report we have expanded the range of measurements to include vertebral levels T3 to L5. We report means and standard deviations on anterior and posterior heights, on wedge shape and on heights relative to adjacent vertebrae. When one or both of the latter two quantities are far below the mean, a vertebra is called deformed. We also describe a more flexible way of expressing damage using the number of deformed vertebrae, the degree of deformity of individual vertebrae, or the total damage to the entire spine. In assessing damage we use criteria for deformity adjusted to the limits detected by an experienced diagnostician, replacing an earlier approach based on 95% probability limits of normal variation. The normal women from whom these variations are ascertained are a low-prevalence group with respect to vertebral deformity, with prevalence of 2.8%. When the criteria developed from these women were applied to a moderate-prevalence group (37%) the model had a sensitivity of 97%, a specificity of 89% and an accuracy of 92% as regards the identification of subjects with damaged vertebrae. When used epidemiologically for a moderate-prevalence group the model has a known overestimation of 15%. The model is compared with other schemes for identifying vertebral deformities.     

Donor criteria in hepatic transplantation

The early outcome of 201 liver grafts transplanted consecutively between September 1988 and November 1991 was investigated retrospectively. Donors were categorized according to their hospitalization periods in an intensive care unit (ICU) prior to harvesting, their causes of death, and the variables generally believed to be critical in liver donation, such as arterial hypotension (n = 69; 34.3 %), cardiopulmonary resuscitation (n = 20; 9.9%), elevated serum-aminotransferases (s-AT) (n = 11; 5.5%), or an age over 50 years (n = 16; 8.0 %). Ninety-one donors (45.3 %) spent less than 24 h in an ICU; 29 donors (14.4%) and 14 donors (7.0%) had hospitalization periods generally considered critical of 4–6 days and more than 6 days, respectively. The most common causes of death were subarachnoidal bleeding (n = 70; 34.8%), isolated head injuries (n = 68; 33.8%), and polytraumata (n = 33; 16.4%).The postischemic hepatocellular damage was evaluated comparing peak post-transplant s-AT, which did not differ significantly between groups; nor did donor and recipient ages or cold ischemia times. Fourteen grafts (7.0%) showed a reversible preservation injury presenting with post-transplant s-AT elevated above 2000 IU/I. Five cases (2.5%) of a primary non-functioning graft (PNF) underwent early retransplantation successfully. Serum-aminotransferases (AST: 4944 ± 2280 IU/I; ALT: 3186 ± 1918 IU/ I) were significantly (P < 0.01) elevated as compared to primary functioning grafts (AST: 699 ± 935 IU/I; ALT: 620 ± 701 IU/I). The donor structure of both groups reflected the distribution of variables in the entire collective. No significant overrepresentations were observed. These results indicate that in the past criteria for donor selection have probably been applied too stringently. To determine true limits the pool of liver donors should carefully be extended.

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Spenderkriterien bei Lebertransplantation

Zusammenfassung Nach 201 Lebertransplantationen von September 1988 bis November 1991 wurde retrospektiv der Postischämieschaden bei Vorliegen verschiedener Spenderkriterien untersucht. Als Kriterien galten die Hospitalisierungszeit auf Intensivstation vor Organentnahme, die Todesursache Bowie allgemein als kritisch eingeschätzte Parameter wie hypotensive Kreislaufphasen (n = 69; 34,4%), kardiopulmonale Reanimation (n = 20; 9,9%), erhöhte Serumtransaminasen (s-AT) (n = 11; 5,5%) oder ein Alter über 50 Jahre (n = 16; 8,0%). 91 Organspender lagen weniger als 24 h auf einer Intensivstation, hingegen 29 Spender (14,4%) 4–6 Tage und 14 Spender (7,0%) länger als 6 Tage. Häufigste Todesursachen waren Subarachnoidalblutungen (n = 70; 34,8%), isolierte Schädel-Hirn-Traumen (n = 68; 33,8%) und Polytraumen (n = 33; 16,4%). Der Postischamieschaden wurde anhand der maximalen postoperativen s-AT sowie der Inzidenz eines primären Transplantatversagens (PNF) oder einer schweren, reversiblen Transplantatschädigung (s-AT > 2000 IU/I) abgeschätzt. Maximale s-AT, Alter der Organspender und -empfänger sowie kalte Ischämiezeiten unterschieden sich zwischen den einzelnen Gruppen nicht signifikant. Schwere reversible Schäden zeigten 14 Transplantatlebern (7,0%); eine PNF trat in 5 Fallen (2,5%) auf, die erfolgreich einer frühen Retransplantation unterzogen wurden. Spenderkriterien waren in beiden Gruppen mit ähnlicher Häufigkeit wie im Gesamtkollektiv vertreten. Maximale s-AT bei Transplantatversagen (GOT: 4944 ± 2280 IU/I; GPT: 3186 ± 19181U/I) lagen signifikant (p > 0,01) höher als bei primärer Transplantatfunktion (GOT: 699 ± 935 IU/I; GPT: 620 ± 701 IU/I). Diese Ergebnisse sind trotz eines hohen Anteils bislang als kritisch angesehener Spender Ausdruck einer vermutlich zu strengen Selektion. Eine vorsichtige Lockerung der Selektionskriterien erscheint daher gerechtfertigt.

     

Prognostic criteria of discogenic paresis

Summary This discourse is aimed at elucidating prognostic criteria for the assessment of the course of a paresis in the case of lumbar disc herniation. Fourhundred and fifty patients were examined who had been operated on for lumbar disc herniation at the Orthopaedic University Clinic Mainz between 1986 and 1991. Of these, 240 showed radicular paralytic symptoms. They were examined prior to the operation, immediately afterwards and 1 year after the operation. The influence of the degree of intensity of the paresis, the time elapsed since the occurrence and other factors like nerve root affected, intraoperative findings, age, sex and weight of the patient were registered. It is obvious that the degree of intensity of a paresis is a good prognostic criterion for the assessment of the postoperative course. A paresis classified as grade III or IV receded in more than 70% of the cases within 6 months. For a paresis of grade 11, the recovery rate was 40%. In the case of a total paresis, no complete neurological recovery was registered. The period of time which had elapsed since the occurrence of the paresis, the weight of the patient, the nerve root affected and other factors did not show any significant influence. As a criterion for an emergency or postponed operation on a herniated disc, the duration of paralytic symptoms should therefore be attributed less importance than the progression.     

Diagnostic criteria for renovascular hypertension

Renovascular hypertension is a clinical situation characterized by high blood pressure in the presence of renal ischemia mainly related to atherosclerotic or fibromuscular dysplasic narrowing of the renal artery (ies). This diagnosis is often "a posteriori" validated, because the discovery of a significant renal artery stenosis is not obligatory responsible of the blood pressure elevation. This article proposes a diagnostic strategy for exploring patient with this suspected secondary cause of hypertension before proposing an invasive approach (intra-arterial angiography) possibly followed by a revascularization. However, the methods for exploring such population are mainly based on patient characteristics and local expertise and habits. These must thus be individualized. First, clinical symptoms or signs frequently associated with hypertension and renal artery stenosis must be searched. If present, a non invasive and functional exploration of the renal arteries is to be proposed (Captopril radioisotope renography, colour duplex sonography) followed by magnetic resonance angiography or spiral computer tomography angiography if the clinical suspicion index is moderate or high. If this is very high, an intra-arterial arteriography could immediately be performed if not too dangerous. On the opposite site, if the clinical index is low, it is recommended to follow clinically and to treat risk factors.