In 1991 the World Health Organization (WHO) defined osteoporosis as a "loss of bone mass and micro architectural deterioration of the skeleton leading to increased risk of fracture."1,2 Since microarchitecture can not be measured directly, a panel of the WHO recommended that the diagnosis be made according to a quantifiable surrogate marker, calcium mineral, in bone. Subsequently in 1994, the definition focused on the actual bone "density," giving densitometric technology a central place in establishing the diagnosis of osteoporosis.3,4 But soon it became obvious that there was only limited correlation between bone mineral density (BMD) and actual occurrence of fractures and that decreases in bone mass account for only about 50% of the deterioration of bone strength with aging. In other words only about 60% of bone strength is related to BMD.5 Recent developments in bone research have shown that bone mineral density in itself is not sufficient to accurately predict fracture risk. Bone is composed of inorganic calcium apatite crystals that mineralize an organic type I collagen matrix. The degree of mineralization, the properties of the collagen matrix, crystal size, trabecular orientation, special distribution of the different components and many more factors are all impacting bone strength.6-14 Human cadaver studies have confirmed the correlation between bone density and bone.26 strength.5,15-20 Changes in cancellous bone morphology appear to lead to a disproportionate decrease in bone strength.21-26 When postmenopausal women are stratified by age, obvious differences between BMD and actual fracture risk are observed.24 Felsenberg eloquently summarizes what he calls the "Bone Quality Framework." In great detail he talks about the geometry and micro- architecture of bone and how the different components are related to functional stability.27 Are our current testing modalities appropriately addressing these structural factors? Are we keeping in mind that in screening for osteoporosis the key variable is fragility, not bone density itself? All currently FDA approved and commercially available equipments for the evaluation of bone status claim that they - at least indirectly - assess the biological fracture risk. This review summarizes an extensive current literature research covering FDA approved as well as experimental devices for the evaluation of bone. The pros and cons of the different techniques are discussed in the context of diagnostic accuracies and practical implications.
According to Taber's Cyclopedic Medical Dictionary "cellulite" is defined as: "a non-technical term for subcutaneous deposits of fat, especially in the buttocks, legs, and thighs." These deposits result in puckered, dimply skin and they are a cause for major aesthetic concerns in affected patients. The etiology of this condition is still unclear. Female predilection is witnessed in clinical practice as it is reported in the literature. It remains a subject for further studies whether it is a structural problem of connective tissue or as suggested probably related to hormonal causes. Magnetic resonance imaging may provide some answers to these questions. Not knowing what is causing this nuisance makes it almost impossible to treat. No wonder that there is little scientific validation to support any of the many treatments that are advertised on the Internet or in women's magazines.
This review focuses on mechanical and microinvasive interventions that claim to alleviate "cellulite": lipoplasty, liposcultpure, liposuction, subcision, and laser. Among the parameters analyzed are the proposed modes of action of these techniques as well as adverse events and complications that may occur. Of special interest will be the evidence that backs these procedures. Extracting reliable data is hampered by methodical problems with the design of most of the published trials.
In essence, at this time there is no "cure" for cellulite. Safe treatment recommendations are related to healthy life style choices that include toning exercises, dietary changes, and weight loss.
This presentation is designed as a brief overview of laser use in gynecology, for non-medical researchers involved in development of new laser techniques. The literature of the past decade is reviewed. Differences in penetration, absorption, and suitable delivery media for the beams dictate clinical application. The use of CO2 laser in the treatment of uterine cervical intraepithelial lesions is well established and indications as well as techniques have not changed over 30 years. The Cochrane Systematic Review from 2000 suggests no obviously superior technique. CO2 laser ablation of the vagina is also established as a safe treatment modality for VAIN. CO2 laser permits treatment of lesions with excellent cosmetic and functional results. The treatment of heavy menstrual bleeding by destruction of the endometrial lining using various techniques has been the subject of a 2002 Cochran Database Review. Among the compared treatment modalities are newer and modified laser techniques. Conclusion by reviewers is that outcomes and complication profiles of newer techniques compare favorably with the gold standard of endometrial resection. The ELITT diode laser system is one of the new successful additions. CO2 laser is also the dominant laser type used with laparoscopy for ablation of endometriotic implants. Myoma coagulation or myolysis with Nd:Yag laser through the laparoscope or hysteroscope is a conservative treatment option. Even MRI guided percutaneous approaches have been described. No long-term data are available.
Objectives: The treatment of female urinary incontinence (UI) is a growing health care concern in our aging society. Publications of recent innovations and modifications are creating expectations. This brief review provides some insight and structure regarding indications and expected outcomes for the different approaches.
Materials: Data extraction is part of a Medline data base search, which was performed for "female stress incontinence" from 1960 until 2000. Additional literature search was performed to cover 2001 and 2002. Outcome data were extracted.
Results: (1) INJECTION OF BULKING AGENTS (collagen, synthetic agents): The indication for mucosal coaptation was more clearly defined and in the majority of articles limited to ISD.
(2) OPEN COLPOSUSPENSION (Burch, MMK): Best long-term results of all operative procedures, to date considered the gold standard.
(3) LAPAROSCOPIC COLPOSUSPENSION (different modifications): Long-term success rates appear dependent on operator skills. There are few long-term data.
(4) NEEDLE SUSPENSION: (Stamey, Pareyra and modifications):
Initial results were equal to Burch with less morbidity, but long-term success rates are worse.
(5) SLING PROCEDURES (autologous, synthetic, allogenic graft materials, different modes of support and anchoring, free tapes):
The suburethral sling has traditionally been considered a procedure for those in whom suspension had failed and for those with severe ISD. The most current trend shows its use as a primary procedure for SUI. Long-term data beyond 5 years are insufficient.
(6) EXTERNAL OCCLUSIVE DEVICES (vaginal sponges and pessaries, urethral insert): Both vaginal and urethral insert devices can be effective in selected patients.
(7) IMPLANTABLE ARTEFICIAL URETHRAL SPHINCTERS: Modifications and improvements of the devices resulted in improved clinical results regarding durability and efficacy.
CONCLUSION: (1) The Burch colposuspension is still considered the gold standard in the treatment of female genuine SUI. There is a trend for the suburethral sling to be used as the primary procedure for this indication. Early outcome data are encouraging. New concepts such as use of metalic bone anchors and allograft material as well as the Tension free Vaginal Tape are under investigation.
(2) Standardization of diagnostic and therapeutic interventions is prerequisite for any meaningful research. Randomized controlled prospective studies are essential to provide objectives regarding risks and benefits of new procedures and materials.
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