1/18. Essence of evidence-based medicine: A case report.PURPOSE: To illustrate the complexities of the evidence-based approach in clinical oncology practice and the implications for guidelines and evaluation of processes of care. PATIENT AND methods: A case report is presented in which a limited systematic review of the literature was used to address a specific clinical problem in an individual patient. Experts' opinions were also sought. RESULTS: A reasonable clinical decision was made by a participating patient based on indirect evidence of benefit that would be insufficient to support the same decision as a health policy in some jurisdictions. CONCLUSION: The practice of evidence-based oncology requires clinical judgment about the validity and applicability of research evidence. The factors that influence an evidence-based decision in the clinical context differ from those in the broader policy context, which could lead to legitimate differences in recommendations based on the same information. Used properly, the individual case report can be a powerful tool to illustrate complex clinical decision phenomena.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
2/18. Interplay of pregnancy, lactation, and hyperthyroidism leading to severe osteoporosis in a young woman.OBJECTIVE: To describe the case of a young woman who had severe osteoporosis due to the compounding effects of pregnancy, lactation, and hyperthyroidism and who had a presumed metastatic lesion in the lumbar spine. methods: We present the clinical, pathologic, radiologic, and laboratory findings and describe the clinical course of our patient. RESULTS: A 31-year-old Arabic woman was referred to the M. D. Anderson Cancer Center because of a lytic lesion in her lumbar spine, presumed to be metastatic deposits. She had a history of two consecutive pregnancies and intermittently treated hyperthyroidism. Our initial evaluation revealed that the patient had clinical and biochemical thyrotoxicosis, and we treated her with thionamides, corticosteroids, and radioiodine ablation. Radiologic studies disclosed a complex renal cyst that had increased uptake on a bone scan, which was highly suggestive of a primary malignant lesion. Ultimately, however, it proved benign on pathologic analysis after a left nephrectomy. Bone mineral density measurements identified severe osteoporosis (T-scores: lumbar spine, -3.3; right hip, -2.2; and left hip, -2.0), which had led to vertebral collapse and was misinterpreted as malignant metastatic disease. The bone mineral densities improved ( 5 to 11% at the various sites) within 4 months after definitive treatment and cure of the hyperthyroidism. CONCLUSION: The effect of pregnancies and prolonged lactation, in the milieu of other risk factors for bone depletion such as hyperthyroidism, may cause severe osteoporosis in a young patient. The resulting osteoporosis may manifest as a lesion suggestive of malignant metastatic involvement.- - - - - - - - - - ranking = 0.5keywords = complex (Clic here for more details about this article) |
3/18. A rare clival and sellar fracture with pneumatocephalus.We present a case of clival and sellar complex fracture produced by an indirect mechanism. This previously healthy patient had an occipital trauma followed by epistaxis. CT showed a clival and sellar fracture with pneumatocephalus. The probable fracture mechanism was contre-coup injury, linked to cerebral shock-wave transmission. This type of fracture is generally observed in the anterior part of the skull base, in a low resistance area. Severe osteoporosis probably accounted for the unusual fracture site in this patient. A mechanism of direct clival transmission is discussed, together with the usual complications of sphenoid injuries.- - - - - - - - - - ranking = 0.5keywords = complex (Clic here for more details about this article) |
4/18. Transient osteoporosis of the femoral condyle: a case report.In this paper, we describe a patient with transient osteoporosis of the femoral condyle. A differential diagnosis should be made for osteonecrosis, infectious disorders, and infiltrative neoplasms based on the normal laboratory findings and diffuse bone edema pattern in MRI. Since this disorder is self-limiting, both the surgeon and clinician should be aware of this condition and must avoid unnecessary intervention.- - - - - - - - - - ranking = 0.49372062744125keywords = neoplasm (Clic here for more details about this article) |
5/18. Discrepant areal and volumetric bone density measurements in a young woman with idiopathic low bone mineral density.OBJECTIVE: To discuss a case of idiopathic low bone density in a young woman. methods: We present a detailed report that includes clinical, laboratory, and radiologic assessment of a pre-menopausal woman with idiopathic low bone mass. RESULTS: A 34-year-old healthy woman of small body habitus was found by dual-energy x-ray absorptiometry to have bone mineral density (BMD) that was less than 2.5 standard deviations below the young and age-matched norm. After a thorough evaluation, no cause of osteoporosis was identified. Calculation of bone mineral apparent density, which minimizes the effect of small skeletal size on areal BMD, resulted in only a modest improvement in T-scores. Measurement of lumbar spine volumetric BMD by quantitative computed tomography, however, revealed a significantly improved T-score of -1.6. CONCLUSION: This report highlights the complexities of low BMD measurements in otherwise healthy young women as well as the potential application of bone mineral apparent density and quantitative computed tomography in the evaluation of low BMD in young women with small skeletal frames.- - - - - - - - - - ranking = 0.5keywords = complex (Clic here for more details about this article) |
6/18. Vignettes in osteoporosis: a road map to successful therapeutics.The diagnosis and management of osteoporosis have become increasingly more complex as new drugs enter the marketplace and meta-analyses of randomized trials with "other" agents become more prolific. We describe five common clinical scenarios encountered in the practice of osteoporosis medicine and various road maps that could lead to successful therapy. INTRODUCTION: The diagnosis and treatment of osteoporosis have changed dramatically in the last decade. Advances in diagnostic technologies and a range of newer treatment options have provided the clinician with a wide array of choices for treating this chronic disease. Despite the issuance of several "guidelines" and practice recommendations, there still remains confusion among clinicians about basic approaches to the management of osteoporosis. This paper should be used as a case-based approach to define optimal therapeutic choices. MATERIALS AND methods: Five representative cases were selected from two very large clinical practices (Bangor, ME; Pittsburgh, PA). Diagnostic modalities and treatment options used in these cases were selected on an evidence-based analysis of respective clinical trials. Subsequent to narrative choices by two metabolic bone disease specialists (SG and CR), calculation of future fracture risk and selection of potential alternative therapeutic regimens were reviewed and critiqued by an epidemiologist (DB). RESULTS: A narrative about each case and possible management choices for each of the five cases are presented with references to justify selection of the various therapeutic options. Alternatives are considered and discussed based on literature and references through July 2003. The disposition of the individual patient is noted at the end of each case. CONCLUSIONS: A case-based approach to the management of osteoporosis provides a useful interface between guidelines, evidence-based meta-analyses, and clinical practice dilemmas.- - - - - - - - - - ranking = 0.5keywords = complex (Clic here for more details about this article) |
7/18. Familial hypothalamic digoxin deficiency syndrome.The case report of a family with coexistence of hypotension, recurrent respiratory infection, motor tics, obsessive-compulsive disorder (OCD), major depressive disorder, early onset osteoporosis, low body mass index, bulimia nervosa, and healthy aging with longevity is described. The family members had hyposexual behavior and less tendency toward spirituality. They did not have insomnia, but they did display tendency toward increased somnolence. No addictive behavior was observed. The family demonstrated a high level of bonding and affectionate behavior, and they were less creative, with an average intelligence quotient (IQ). There was a total absence of vascular thrombosis, systemic neoplasms and neuronal degeneration in the indexed family. All members of the indexed family were left hemispheric dominant. The levels of serum digoxin, HMG-CoA reductase activity, and dolichol were found to be decreased in the members of the indexed family, with a corresponding increase in red blood cell (RBC) Na( )-K ATPase activity, serum ubiquinone and magnesium levels. There was increase in tyrosine catabolites and a reduction in tryptophan catabolites in the serum. The total and individual glycosaminoglycan fractions, carbohydrate residues of glycoproteins, activity of glycosaminoglycans (GAG) degrading enzymes, and glycohydrolases were decreased in the serum. The concentration of RBC membrane total GAG and carbohydrate residues of glycoproteins increased, while the cholesterol: phospholipid ratio of the membrane decreased. The activity of free radical scavenging enzymes were increased, while the concentration of free radicals decreased significantly. The same biochemical patterns were observed in left hemispheric dominance as opposed to right hemispheric dominance. The significance of these findings in the pathogenesis of these disorders is discussed.- - - - - - - - - - ranking = 0.49372062744125keywords = neoplasm (Clic here for more details about this article) |
8/18. Locking compression plate loosening and plate breakage: a report of four cases.The Locking Compression Plate (LCP) system offers a number of advantages in fracture fixation combining angular stability through the use of locking screws with traditional fixation techniques. This makes the implant particularly suitable for use in poor bone stock and complex joint fractures, especially in the epimetaphyseal area. However, the system is complex, requiring careful attention to biomechanical principles, and a number of potential pitfalls need to be considered. These pitfalls are illustrated in the 4 cases described herein, in which treatment was unsuccessful due to implant breakage or loosening. In each case, treatment failure could be attributed to the choice of an inappropriate plate and/or fixation technique, rather than to the features of the Locking Compression Plate system itself. Such experiences highlight the importance of detailed understanding of the biomechanical principles of plate fixation as well as careful preoperative planning for the successful use of the Locking Compression Plate system.- - - - - - - - - - ranking = 1keywords = complex (Clic here for more details about this article) |
9/18. Retrograde intramedullary nailing for nonunions of supracondylar femur fracture of osteoporotic bones.Nonunion of supracondylar femur fracture remains a challenging problem because of limited treatment options. The situation is more complex when it occurs in elderly patients with osteoporotic bones. We report the treatment of 3 elderly patients with supracondylar femur fracture nonunion after open reduction and internal fixation with various plate-screw internal fixation systems. Two of these patients had traumatic fractures and the third had a periprosthetic fracture after primary total knee arthroplasty (TKA). After revision surgeries using retrograde nailing techniques, all fractures united eventually. When combined with indirect reduction, these techniques provide superior biomechanical properties and reduce the need for soft tissue dissection.- - - - - - - - - - ranking = 0.5keywords = complex (Clic here for more details about this article) |
10/18. Thoracic ossified meningioma and osteoporotic burst fracture: treatment with combined vertebroplasty and laminectomy without instrumentation: case report.Although spinal meningioma is a common benign neoplasm, the ossified variant is rare. No more than 20 sporadic cases were reported in the literature between 1977 and January 2005. Recently, the authors treated a patient with a symptomatic ossified meningioma located in the posterior aspect of T-11 and an associated osteoporotic T-11 burst fracture. The tumor was completely removed by T10-11 laminectomy and transpedicular vertebroplasty was performed. The kyphotic deformity of the T-11 burst fracture was partially reduced and maintained for at least 2 months after vertebroplasty and laminectomy. The clinical presentation and management of this case are reported.- - - - - - - - - - ranking = 0.49372062744125keywords = neoplasm (Clic here for more details about this article) |
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