Osteochondritis dissecans. History, pathophysiology and current treatment concepts

The past and current status of osteochondritis dissecans suggests that there is still no clear cut etiology. The etiologic mechanism is generally assumed to be multifactorial and related to minor trauma occurring at a susceptible locations. The existence of two clinical patterns is important. Conservative treatment should be emphasized in the young patient who has open physes and a more aggressive approach in the older symptomatic patient. Drilling has a use in the loose unseparated fragment. Free fragments should be replaced when possible if they involve a portion of the weight-bearing articular surface. When replacement is impossible, treatment must be individualized, either by trephining or spongialization followed by joint ranging exercises with nonweight-bearing, or in cases which involve a large portion of the weight-bearing surface of the femoral condyle, a more radical treatment, including osteotomy, hemiarthroplasty, or allograft     

Varicocele: current concepts in pathophysiology,diagnosis, and treatment

Although significant advances have been made in the understanding of varicoceles, a clear pathophysiologic mechanism remains elusive. Most likely, a varicocele is the result of a multifactorial process. Appreciation of the complex venous drainage of the testis remains a key to maximizing the chances for treatment success. Likewise, the advent of microsurgical repair has minimized complications. Fortunately, times have improved since the early nineteenth century, when the French surgeon Delpech (1772-1832) was killed by a disgruntled patient on whom he had performed a varicocele repair.     

Atherosclerosis: current concepts of pathophysiology and pharmacological intervention based on trial outcomes

Atherosclerosis related cardiovascular diseases are the leading cause of death in western societies. The clinical manifestations are chronic arterial obstructions or acute arterial occlusions in various vascular territories. The pathogenesis is only understood in part as yet. Arterial wall abnormalities, blood composition abnormalities and hemodynamic alterations are generally accepted to be causative (Virchow's triad). The key role is played by macrophages in the subendothelial space that are activated immunologically by oxidized LDL particles via the scavenger receptor pathway. Recently, endothelial dysfunction due to oxidative stress was identified as a priming factor in the course of the development of atherosclerotic plaques. Shear stress-induced microinjuries of the endothelium in hemodynamically compromised regions together with local coagulation activation associated with microinflammation of the plaque are currently thought to cause plaque rupture. This event is the reason for local clot formation and ultimate organ infarction. Treatment success is still insufficient, however some progress during the last decade is reflected by the improving outcome of atherosclerosis associated cardiovascular diseases. Evidence from clinical trials supports the efficacy of statins, antiplatelet agents, antihypertensive agents if necessary and omega-fatty acids in patients with overt atherosclerosis. The reduction of mortality achieved by those drugs amounts to: omega-fatty acids -21%, statins -16%, anti-platelet agents -14%, treatment of hypertension -13%. It is impossible to calculate the combined effect of these modalities since in each trial participants received co-medication containing agents tested in other trials.     

Lung transplantation for cystic fibrosis: current concepts and one center's experience.

BACKGROUND: Although new approaches to the treatment of patients with cystic fibrosis (CF) are significantly prolonging their lives, most patients will eventually develop respiratory failure due to progressive bronchiectasis caused by chronic lung infection and inflammation and die from to respiratory failure. We examined our center's (University of Wisconsin Hospital and Clinics) experience with lung transplantation for patients with CF and reviewed the literature to examine current and evolving approaches to transplantation for this indication. METHODS: We reviewed all published literature pertaining to lung transplantation for CF through 2006, and we reviewed all aspects of transplantation for patients with CF at our institution from 1994 to 2005. RESULTS: Major complications following lung transplantation include acute rejection, bacterial infection, and bronchiolitis obliterans. Five-year survival at UWHC (Kaplan-Meier) is 67%, and survival was not adversely affected by transplanting patients receiving mechanical ventilation. The major cause of death for transplant recipients was bronchiolitis obliterans syndrome (BOS). CONCLUSIONS: Lung transplantation for CF is associated with acceptable survival rates and can improve quality of life. Lung transplant should be offered to all patients with advanced CF lung disease if they meet currently accepted inclusion and exclusion criteria.     

Hereditary spherocytosis with congestive heart failure: Report of a case

We report herein a case of 62-year-old woman with hereditary spherocytosis (HS) and congestive heart failure (CHF). Although her history revealed jaundice in the early neonatal period, she had never undergone a physical examination and thus, the diagnosis of HS and CHF was not made until the age of 61 when she complained of dyspnea and palpitations on exertion. The CHF was subsequently found to be related to severe anemia in the presence of underlying heart disease. Splenectomy was performed in an attempt to relieve the severe hemolytic process. Following this, all the symptoms improved without the need for any cardiovascular drugs and she has been well throughout the 34 months follow up.     

Rattlesnake bites: current concepts.

The management of snake bites once the patient reaches the hospital should be to obtain the necessary blood parameters (type and cross-matched blood, complete blood count, platelets, PT, PTT, fibrinogen and fibrin split products, electrolytes and calcium), to evaluate the fang marks and the neurovascular status of the involved extremity and to monitor systemic signs and symptoms. These steps are extensively described in the literature, and are commonly agreed upon. We then start intravenous antivenom, after appropriate skin testing for horse serum allergy, beginning with 4--5 vials (8--10 in children) over the initial 30--60 minutes and titrating to cessation of the progression of the toxic signs. Concomitantly, we measure intracompartmental and subcutaneous tissue pressure in all clinically suspected areas. If intracompartment pressures are less than 30 mm Hg, surgical intervention is not necessary; antivenom is continued as necessary and the wick catheter measurements are repeated if indicated. If pressures are greater than 30 mm Hg,immediate surgical decompression is advisable.     

Paget's disease: current concepts.

The curious geographic variations in the prevalence of Paget's disease remain unexplained and the viral hypothesis remains unproved. An association between transient hyperphosphataemia of infancy and subsequent Paget's disease has not been established. Some 5% of Pagetic patients have hyperparathyroidism although the mechanism of this apparent association remains unknown. Several agents are available for the medical treatment of Paget's disease but there is a lack of consensus concerning therapeutic aims.     

Anthrax: ENT manifestations and current concepts.

In light of recent events, anthrax has once again taken center stage in the world of science and the world in which we live. Because patients with anthrax may initially present to otolaryngology clinics, it is important for the otolaryngologist to know how to diagnose and treat this entity. This article will present current information on epidemiology, microbiology, pathogenesis/clinical manifestations, diagnosis, and treatment with a particular interest in the head and neck region.     

Parathyroid hormone and hyperparathyroidism: current concepts.

Our expanding knowledge of the physiologic and biochemical factors governing calcium homeostasis has improved our capacity to evaluate hypercalcemia, of which an increased incidence is being discovered through the widespread use of multiphasic screening. Consequently, we are diagnosing mild forms of hyperparathryoidism more often than formerly. The enhanced recognition of virtually symptom-free hyperparathyroidism presents a problem in patient management because the natural history of this form of hyperparathyroidism is unknown and the pathologic lesion underlying the condition may be ambiguous, resulting in difficult decisions in surgical management. Further study is required to resolve this issue in order to provide optimal care for the affected individual.     

Urethral pressure profile: current concepts.

The urethral pressure profile is an artifactual assessment of urethral response to physiologic distension. It is a reproducible clinical tool used to evaluate numerous disease states. Examples of its usefulness are presented to illustrate the wide variety of clinical uses. The urethral pressure profile assists the clinician in the selection of the proper form of management in difficult cases of urinary incontinence or obstruction.     

Endotension. A review of current views on pathophysiology and treatment

Most aneurysms shrink after successful endovascular repair. It has been observed, however, that some aneurysms continue to enlarge despite apparent exclusion of the sac by an endograft device. Unexplained abdominal aortic aneurysm (AAA) enlargement in these circumstances appears to be associated with high pressures inside the sac, and the phenomenon has been termed endotension. This paper reviews current theories and experimental evidence regarding the possible mechanisms of causation of endotension, and early experiences with treatment.     

Hereditary polyuric disorders: new concepts and differential diagnosis

The identification, characterization, and mutational analysis of genes coding for key proteins to the mechanisms of urine concentration provide the basis for understanding the 2 types of hereditary nephrogenic diabetes insipidus (NDI): a pure type characterized by loss of water only, and a complex type characterized by loss of water and ions. Patients with hereditary NDI bearing mutations in AVPR2, the gene coding for the arginine vasopressin 2 receptor, or in AQP2, the gene coding for the vasopressin-sensitive water channel, have a pure NDI phenotype with loss of water, but normal conservation of sodium, potassium, chloride, and calcium. Patients bearing inactivating mutations in 1 of the 5 genes (SLC12A1, KCNJ1, CLCNKB, CLCNKA, and CLCNKB in combination, or BSND) that encode the membrane proteins of the thick ascending limb of the loop of Henle have a complex polyuro-polydipsic syndrome with loss of water, sodium, chloride, calcium, magnesium, and potassium. The purpose of this article is to increase the general awareness of these congenital NDI patients to prevent severe episodes of dehydration and provide precise molecular diagnosis and treatment.     

Surgical considerations in hyperparathyroidism: current concepts.

The pathologic and histologic alterations seen in the parathyroid glands removed at operation have changed dramatically in recent years as a result of early diagnosis and treatment, often in asymptomatic patients. This situation has resulted in considerable disagreement over optimal surgical therapy and the number of parathyroid glands the surgeon should remove. These areas of controversy are analysed and current concepts critically reviewed.