Ukuqonda isifo sase-Kümmell: Isishwankathelo esiBanzi

Abstract

Isifo se-Kümmell yimeko enqabileyo yomgogodla ebonakaliswe ngokulibaziseka kwe-vertebral body collaps ngenxa ye-ischemia kunye nokungadibaniyo kweefractures. Le meko idla ngokubonakala emva kokwenzakala okungephi, kunye neempawu ezibonakala kwiiveki okanye kwiinyanga kamva. Esi sifo sichaphazela kakhulu abantu asebekhulile abane-osteoporosis, okwenza kube lula ukuphulwa kwe-vertebral fractures kunye neengxaki ezilandelayo.1

Okokuqala echazwe nguDkt. Hermann Kümmell ngo-1891, isifo sibandakanya ukulandelelana kweziganeko eziqala ngokulimala okubonakalayo okuncinci. Ekuqaleni, izigulane zingafumana iimpawu ezincinci, kodwa ekuhambeni kwexesha, i-vertebrae echaphazelekayo ifumana i-necrosis ye-ischemic, ekhokelela ekulibazisekeni ukuwa. Oku kuqhubela phambili kubangela intlungu ebuhlungu kunye ne-kyphosis, i-curvature yangaphambili yomqolo. 2

I-pathogenesis yesifo se-Kümmell idibene ngokusondeleyo ne-avascular necrosis ye-vertebrae. Le meko ixhaphake kakhulu kwabasetyhini kwaye inxulunyaniswa nemingcipheko efana ne-osteoporosis, ukusetyenziswa kwe-corticosteroid, ukusela utywala, kunye nonyango lwemitha. I-necrosis ye-ischemic ikhokelela ekubeni i-non-union of fractures, eyona nto ibonakalisa isifo.

Izigulana ezinesifo se-Kümmell zihlala zikhona ngeentlungu zangasemva kunye ne-kyphosis eqhubekayo. Iimpawu zihlala zivela kwiiveki emva komothuko wokuqala, nto leyo eyenza ukuba ukuxilongwa kube nzima. Ukulibaziseka kweempawu kunokukhokelela ekuxilongeni kakubi okanye ukulibaziseka kwonyango olufanelekileyo, ukunyusa imeko yesigulane. 3

Ukuxilongwa kwesifo se-Kümmell kwenziwa ngokuyinhloko ngeendlela zokucinga ezifana ne-X-rays, i-MRI, kunye ne-CT scans. Ezi ndlela zokucinga zibonisa ukuwa kwe-vertebral kunye nobukho be-intravertebral vacuum clefts, ebonisa isifo. I-intravertebral vacuum cleft ifumaneka kwi-pathognomonic radiographic, nangona ingaphelelanga kwisifo sase-Kümmell.

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Ukhetho lonyango lwesifo i-Kümmell luyahluka ngokuxhomekeke kubunzima bemeko. Ulawulo lwe-Conservative lubandakanya ukukhululeka kweentlungu kunye nonyango lomzimba, olunokunceda ukunciphisa iimpawu kunye nokuphucula umgangatho wobomi besigulane. Kwiimeko ezinzima kakhulu, ukungenelela kokuhlinzwa okufana ne-vertebroplasty okanye i-kyphoplasty kunokufuneka ukuzinzisa umqolo kunye nokukhusela ukuwa okuqhubekayo.

I-prognosis yezigulane ezine-Kümmell isifo iyahluka. Ukuxilongwa kwangoko kunye nonyango lubalulekile ekuphuculeni iziphumo. Ukulibaziseka unyango kunokukhokelela kwiintlungu ezingapheliyo, ukukhubazeka okubonakalayo komgogodla, kunye nokukhubazeka. Ngoko ke, ukuqatshelwa kwangexesha kunye nokulawulwa ngokufanelekileyo kwesi sifo kubalulekile ekuthinteleni iingxaki zexesha elide.

Intshayelelo

Isifo se-Kümmell, esaqala ukuchazwa ngasekupheleni kwenkulungwane ye-19, yimeko yomqolo enqabileyo ebonakaliswe ngokulibaziseka kokuwa kwe-vertebral emva kokwenzakala okuncinci. Le meko ichaphazela ikakhulu izigulana ezisele zikhulile ezinengxaki ye-osteoporosis, okwenza amathambo abo achaphazeleke ngakumbi kukuqhekeka kunye neengxaki ezilandelayo.

Esi sifo saqala ukuchongwa nguDkt. Hermann Kümmell ngo-1891, owabona uluhlu lwezigulane ezifumana i-vertebral body fallpse iiveki ukuya kwiinyanga emva kokulimala okubonakalayo. Oku kulibaziseka ukuwa kubangelwe yi-ischemia kunye nokungadibanisi kwe-anterior vertebral body wedge fractures.

Isifo se-Kümmell sixhaphake kakhulu kubantu abadala, ngakumbi abo bane-osteoporosis. Le meko ixhaphake kakhulu kwabasetyhini, mhlawumbi ngenxa yezehlo eziphezulu ze-osteoporosis kubasetyhini abasemva kokuya exesheni. Ezinye izinto ezinobungozi ziquka ukusetyenziswa kwe-corticosteroid, utywala, kunye nonyango lwe-radiation, zonke ezinokuthi zibe negalelo ekwenzeni amathambo abe buthathaka.

I-pathogenesis yesifo se-Kümmell ibandakanya i-avascular necrosis yemizimba ye-vertebral. Le nkqubo ye-ischemic ikhokelela ekufeni kwezicubu zethambo, ekugqibeleni kubangela ukuwa kwe-vertebrae. I-trauma yokuqala ingabonakala incinci, kodwa imeko yethambo engaphantsi inyusa umonakalo ekuhambeni kwexesha. 4

Izigulana ezinesifo i-Kümmell zidla ngokubakho ngeentlungu zangasemva kunye ne-progressive kyphosis, i-curvature yangaphambili yomqolo. Ezi zimpawu zivame ukubonakala kwiiveki emva kokuphazamiseka kokuqala, okwenza uxhulumaniso phakathi kokulimala kunye nokuwa kwe-vertebral elandelayo kungabonakali. 5

Imvelaphi yezembali

UGqr. Hermann Kümmell, ugqirha wotyando waseJamani, waqala wachaza isifo esasiza kuthi kamva sibe negama lakhe ngo-1891. Wabhala uluhlu lwezigulane eziye zafumana ukulibaziseka kokuwa komnqonqo emva kokulimala okubonakalayo okuncinci. Le meko, ngoku eyaziwa ngokuba yi-Kümmell isifo, ibonakaliswe ngethuba lokuqala lokuziphatha okungabonakaliyo, okulandelwa yi-kyphosis eqhubekayo kunye nentlungu kwiindawo ezisezantsi ze-thoracic okanye ezingaphezulu.

Uqwalaselo luka-Kümmell lwaluyi-groundbreaking ngelo xesha, njengoko bazisa ingcamango yokulibaziseka kwe-post-traumatic vertebral body collapse. Oku kwakusongezo esibalulekileyo kwizizathu ezaziwayo zokuwa komzimba we-vertebral, okubandakanya ukusuleleka, i-neoplasia enobungozi, kunye nokwenzakala kwangoko. Umsebenzi ka-Kümmell wagxininisa ikhosi yeklinikhi ekhethekileyo apho izigulana zihlala zingabonakali kwiinyanga okanye iminyaka ngaphambi kokuba ziphuhlise ukukhubazeka okukhulu komgogodla.

Esi sifo ekuqaleni sadibana nokuthandabuza kwaye kwakunzima ukuba samkelwe kuluntu lwezonyango. Uphononongo lwakwangoko lweradiographic lwaluhlala lungangqinelani, lukhokelela abanye ukuba babubuze ubukho bokulibaziseka kokuwa kwe-vertebral. Nangona kunjalo, ngenkqubela phambili yetekhnoloji ye-imaging, ngakumbi ukufika kwe-X-rays, kwacaca ukuba i-kyphosis ebonwe kwizigulana zase-Kümmell yayingenxa yokulibaziseka kokuwa komzimba we-vertebral.

UCarl Schulz, umfundi waseKümmell, waba ngowokuqala ukubiza le meko ngegama lomcebisi wakhe ngowe-1911. Ngelo xesha, ugqirha wotyando ongumFrentshi ogama linguVerneuil wachaza imeko efanayo, nto leyo eyakhokelela kwezinye iimeko apho esi sifo sibizwa ngokuba yiKümmell-Verneuil. isifo. Ngaphandle kwezi nkcazo zangaphambili, imeko yahlala ingaqondwa kakuhle kwaye ingaxelwa ngaphantsi kweminyaka emininzi.

Kwakungephakathi kwenkulungwane yama-20 apho abezonyango baqala ukuqaphela ngokubanzi kunye nokubhala isifo se-Kümmell. Amaphepha nguRigler kwi-1931 kunye ne-Steel kwi-1951 yanikezela ubungqina obucacileyo bokuthi i-vertebral body collaps kulezi zi gulane ibonakala kuphela kwiifilimu ezilibazisekayo, eziqinisekisa ukubonwa kwe-Kümmell yokuqala. Ezi zifundo zanceda ukuqinisa ukuqonda kwesi sifo kunye nekhosi yaso yeklinikhi.

Ngaphandle kwamaxwebhu asekuqaleni, isifo sase-Kümmell sihlala sinqabile kwaye sihlala sixilongwa. Umdla ohlaziyiweyo kwiminyaka yakutshanje kukhokelele ekuqondeni ngcono i-pathophysiology yayo kunye nenkcazo yeklinikhi. Nangona kunjalo, uncwadi malunga nalo mbandela lusanqongophele, luneqaqobana lamatyala axeliweyo ukusukela kwinkcazo yalo yokuqala kwinkulungwane eyadlulayo.

Oonobangela kunye neMicimbi yoMngcipheko
 

Isifo se-Kümmell ngokuyinhloko sinxulumene ne-avascular necrosis ye-vertebrae, imeko apho ukunikezelwa kwegazi kwithambo kuphazamiseka, okukhokelela ekufeni kwethambo. Esi sifo sichaphazela kakhulu abantu abasele bekhulile abanesifo samathambo, imeko ebonakala ngokuba buthathaka kwamathambo ekuchanabeka lula kuwo ukuba aphuke.

Izinto ezinobungozi ekuphuhliseni isifo se-Kümmell ziquka ukusetyenziswa kwe-steroid engapheliyo, enokubangela ukunyuka kwe-fat intramedullary kunye nokuphazamiseka okulandelayo kwe-vascular. Eminye imingcipheko ebalulekileyo kukunxila, okunokubangela i-microscopic fat emboli kwi-end-arteries, kunye ne-radiation therapy, enokonakalisa ngokuthe ngqo i-vascularity.

Imingcipheko eyongezelelweyo yengozi ye-avascular necrosis ye-vertebrae ibandakanya i-hemoglobinopathies, njengesifo se-sickle cell, esinokubangela ukuba i-vascular occlusion kunye ne-vertebral body ischemia. Iimeko ezifana ne-vasculitides kunye nesifo sikashukela nazo zinegalelo kumngcipheko, nangona iindlela ezichanekileyo zesifo sikashukela zihlala zingacacanga.

Usulelo, izifo ezigwenxa, kunye notshintsho emva kokusasazeka kwemitha zezinye izinto ezikhokelela. Ngokomzekelo, utshintsho lwe-post-radiation lungakhokelela kwimiphumo echanekileyo ye-cytotoxic eyonakalisa i-vascularity ye-vertebrae. Ngokufanayo, iimeko ezifana ne-pancreatitis kunye ne-cirrhosis zidibene nokunyanzeliswa kwe-vascular kunye neendlela ezingaziwayo, ngokulandelanayo, ezinegalelo ekuphuhliseni i-avascular necrosis.

Isifo se-Kümmell sixhaphake kakhulu kwabasetyhini, okunokuthi kubangelwe ukuxhaphaka okuphezulu kwe-osteoporosis kubasetyhini, ngakumbi abafazi be-postmenopausal. Esi sifo sihlala sibonakalisa iiveki ukuya kwiinyanga emva kokulimala okuncinci, kugxininisa ukulibaziseka kokuwa kwe-vertebral kubantu abachaphazelekayo.

Iimpawu kunye neNkcazo yeKlinikhi

Izigulana ezinesifo se-Kümmell zihlala zikhona ngeentlungu zangasemva kunye ne-kyphosis eqhubekayo. Ukuqala kweempawu kudla ngokulibaziseka, kubonakala kwiiveki ukuya kwiinyanga emva kokwenzakala okuncinci kokuqala. Oku kulibaziseka kunokukhokelela kwixesha lokuphila kakuhle ngaphambi kokuba iimpawu zibonakale.

Ikhosi yeklinikhi yesifo se-Kümmell yahlulwe ibe ngamanqanaba amahlanu. Ekuqaleni, izigulane zinokufumana ukulimala okuncinci ngaphandle kweempawu ezikhawulezayo. Oku kulandelwa lixesha emva kokuphazamiseka kunye neempawu ezincinci kwaye akukho mida yomsebenzi. Ithuba elifihlakeleyo, ixesha lokuphila kakuhle, linokuhlala kwiiveki ukuya kwiinyanga ngaphambi kokuba ukukhubazeka okuqhubelekayo kuqalise.

Kwinqanaba le-recrudescent, izigulane ziqala ukufumana iintlungu eziqhubekayo, zendawo, ezinokuthi zibe yi-peripheral kunye neentlungu zeengcambu. Eli nqanaba libonakaliswa yimeko eqhubekayo yeempawu, ezikhokelela ekuphatheni kakubi kunye nokukhubazeka.

Inqanaba lokugqibela, elaziwa ngokuba yi-terminal stage, libandakanya ukubunjwa kwe-kyphosis esisigxina. Oku kunokwenzeka kunye okanye ngaphandle koxinzelelo oluqhubekayo kwiingcambu zomgogodla okanye intambo. I-neurologic compromise, nangona inqabile, yingxaki ebalulekileyo enokuthi ivele ngeli nqanaba.

Iimpawu zesifo sikaKümmell zidla ngokugqithiswa zizinto ezifana nokusetyenziswa kwe-steroid engapheliyo, i-osteoporosis, utywala, kunye nonyango lwe-radiation. Ezi zinto ezinobungozi zifaka isandla kwi-avascular necrosis ye-vertebral body, ekhokelela kwimpawu yokulibaziseka kwe-vertebral ukuwa kunye neempawu ezinxulumene nazo.

Uxilongo

Ukuxilongwa kwesifo se-Kümmell kufezekiswa ngokuyinhloko ngeendlela zokucinga ezifana ne-X-rays, i-MRI, kunye ne-CT scans. Ezi ndlela zokucinga zibalulekile ekuvezeni i-vertebral body collapse (VBC) kunye nobukho bemibhobho yamanzi, ebonisa isifo. Isinyathelo sokuqala sibandakanya ukufumana imbali yesigulane ngokucokisekileyo kunye nokuqhuba uvavanyo lwezonyango ngokubanzi ukulawula ezinye iimeko ezinokubonisa ngokufanayo, ezifana ne-neoplasm, i-infection, okanye i-osteoporosis.

I-MRI ibaluleke kakhulu ekuxilongeni isifo se-Kümmell njengoko inokwahlula i-avascular necrosis kwi-neoplasms enobungozi okanye izifo. Imbonakalo ye-MR yomfanekiso we-avascular necrosis ngokuqhelekileyo ibonisa iipateni ezicacileyo ezingabonakali kwizinto ezinobungozi okanye izifo. Ngokomzekelo, ii-neoplasms ezinobungozi zihlala zibonisa ukuhla kweempawu zesignali kwimifanekiso enesisindo se-T1 kunye nokwandisa ubuninzi besignali kwimifanekiso enesisindo se-T2, kunye nokusabalalisa ubuninzi besignali ephezulu kunye nokubandakanyeka kwezicubu ezithambileyo ze-paravertebral.

I-serial imaging ibalulekile ekuxilongeni isifo sika-Kümmell, njengoko sinokubonisa i-vertebral body intact post-trauma, elandelwa yi-VBC njengoko iimpawu zikhula. Ukuthelekisa imifanekiso emitsha kunye neefilimu ezindala kunokunceda ukufumanisa ukuba i-compression fracture i-acute okanye ingapheliyo. Ukungabikho kweefilimu zangaphambili, i-bone scan okanye i-MRI inokuncedisa ukuseka iminyaka yokuphuka. I-Bone scans, ngokukodwa nge-SPECT okanye i-SPECT / CT imaging, iluncedo ekumiseleni inqanaba lomsebenzi kwiifractures zeminyaka engaziwayo kunye nokuchonga iifractures ezongezelelweyo.

I-intravertebral vacuum cleft (IVC) yinto ebalulekileyo ye-radiological ye-Kümmell isifo. I-CT kunye ne-MRI scans ziyakwazi ukuchonga ezi ziqhekeza, ezibonakala njengobunzulu besignali ephantsi kwimifanekiso enobunzima be-T1 kunye nobukhulu besignali ephezulu kwi-T2-weighted sequences, ebonisa ukuqokelelwa kwamanzi. Ubukho be-IVCs bucebisa ukuwa kwe-benign kwaye akuqhelekanga ukudibaniswa nokuqhekeka okukrakra, usulelo, okanye izifo. Ukuhamba okunamandla kwe-IVCs kwiindlela ezahlukeneyo zomzimba kungabonisa ukungazinzi ngaphakathi kweqhekeza, elihambelana nentlungu ebuhlungu, eqhubekayo.

Izikena zethambo zithathwa njengenye yezixhobo zokucinga ezibuthathaka ngakumbi zokuxilongwa kwangoko kwe-ischemic necrosis kwisifo saseKümmell. Ukunyuka kokunyuka kwee-radiolabeled osteophilic tracers kwisiza se-vertebral kunokubonwa ngaphambi kokuba ukuwa kwenzeke. Nangona kunjalo, kwizilonda ezingapheliyo, i-bone scans ingabonisa ukungabikho okanye ukuthabatha okuncinci ngenxa yokungabikho kwempendulo eqhelekileyo ye-osteoblastic. I-Biopsies ngokuqhelekileyo ayifuni ukuxilonga isifo se-Kümmell ngaphandle kokuba i-malignancy ikrokrelwa okanye njengenxalenye ye-vertebroplasty okanye inkqubo ye-kyphoplasty.

Iinketho zonyango

Unyango lwesifo i-Kümmell lulungiselelwe iimpawu zesigulana kunye neziphumo zonyango. Ngenxa yokunqaba kwemeko kunye noncwadi olulinganiselweyo, iiprothokholi zonyango ezithile azimiselwanga kakuhle. Ngokwembali, ulawulo olulondolozayo lwaluyeyona ndlela iphambili, kodwa iindlela zamva nje zikhetha ungenelelo lotyando ngeziphumo ezingcono.

Unyango olulondolozayo lubandakanya ukulawulwa kweentlungu kunye neziyobisi ze-analgesic, ukuphumla kombhede, kunye ne-bracing. Le ndlela ithathwa ngokuqhelekileyo xa kungekho kuphazamiseka kwe-neurological kwaye udonga lwangasemva lwe-vertebral luhlala luqinile. Kwezinye iimeko, i-teriparatide, i-recombinant form ye-hormone ye-parathyroid, ingasetyenziselwa ukuzalisa i-gap ye-osseous, ukukhulula intlungu, kunye nokuphucula umsebenzi.

Xa unyango olulondolozayo lungaphumeleli okanye kwiimeko ezinokukhubazeka okukhulu kwe-kyphotic, iinkqubo zotyando ezincinci ezifana ne-vertebroplasty okanye i-kyphoplasty ziboniswa. Ezi nkqubo zijolise ekuzinziseni ukuphuka, ukubuyisela ukulungelelaniswa komgogodla, kunye nokunciphisa intlungu. I-Vertebroplasty ibandakanya ukujova i-samente yethambo kumzimba we-vertebral ukuzinzisa ukuphuka, ngelixa i-kyphoplasty ibandakanya inyathelo elongezelelweyo lokudala i-cavity kunye ne-balloon phambi kwesitofu se-samente.

Kwi-vertebroplasty, izigulana zibekwe kwindawo ene-hyperlordosis ukuvula i-cleft kunye nokubuyisela ukuphakama kwe-vertebral. I-Cavity-grams ene medium medium ingasetyenziselwa ukunqanda ukuvuza kwesamente, kwaye ukugcwaliswa okupheleleyo kokucandeka kuyacetyiswa ukuze kuzinziswe kakhulu. Nangona kunjalo, iziphumo ze-vertebroplasty zinokuphikisana, ngokukodwa malunga nokulungiswa kwe-kyphosis kunye ne-samente extrusion.

Kwiimeko zokuwa kwe-vertebral engapheliyo yomzimba (VBC) okanye i-VBC ebukhali kunye nokuphazamiseka kodonga lwangasemva, ukuzinza kotyando nge-fusion kuyimfuneko. Ukuba kukho i-neurological compromise, i-decompression kunye nokuzinza kuyafuneka. I-Decompression inokufikelela ngaphambili okanye ngasemva, kunye neendlela zangaphambili zilula ngobuchule ekususeni amaqhekeza abuyiselwe. Nangona kunjalo, iinkqubo zangasemva zinokuthi zikhetheke kwizigulane ezisele zikhulile ezinee-comorbidities ezibalulekileyo.

Ngokubanzi, ukhetho phakathi konyango olulondolozayo kunye nolutyando luxhomekeke kwizinto ezifana nobukhulu bentlungu, iqondo lokukhubazeka, kunye nobukho beengxaki ze-neurological. Ukungenelela kwangaphambili kunokukhokelela kwiziphumo ezingcono, ngelixa ukulibaziseka unyango kunokubangela intlungu engapheliyo kunye nokukhubazeka.

I-Prognosis kunye neziphumo

Iprognosis ye

inokwahluka kakhulu ngokuxhomekeke kwixesha lokuxilongwa kunye nokuqaliswa konyango. Ukufunyaniswa kwangaphambili kunye nokungenelela kubalulekile ekulawuleni imeko ngokufanelekileyo kunye nokuphucula iziphumo zezigulane. Xa ufunyanwe kwangethuba, unyango olulondolozayo olufana nokulawulwa kweentlungu kunye nonyango lomzimba lunokunceda ukunciphisa iimpawu kunye nokuthintela ukuwa kwe-vertebral.6

Kwiimeko apho isifo sichongiwe kwinqanaba eliphezulu, ukhetho lotyando olufana ne-vertebroplasty okanye i-kyphoplasty lunokuba luyimfuneko ukuzinzisa umqolo kunye nokunciphisa intlungu. Ezi nkqubo zinokubonelela ngokukhululeka okukhulu kunye nokuphucula umgangatho wobomi kwizigulane, nangona ziza neengozi zabo kunye neengxaki ezinokuthi zibe khona.

Unyango olulibazisiweyo lwesifo se-Kümmell luhlala lukhokelela kwiintlungu ezingapheliyo kunye nokukhubazeka komgogodla oqhubekayo, njenge-kyphosis. Oku kunokubangela ukukhubazeka kwexesha elide kunye nokuncipha kokukwazi ukwenza imisebenzi yemihla ngemihla. Ngoko ke, ukungenelela kwezonyango ngexesha elifanelekileyo kubalulekile ukukhusela ezi ziphumo ezibi kunye nokugcina umgangatho wobomi obungcono kubantu abachaphazelekayo.

Ngokubanzi, ukuxilongwa kwezigulane ezinezifo ze-Kümmell kuxhomekeke kakhulu kwinqanaba apho isifo sixilongwa kunye nokukhawuleza kwonyango. Ulawulo kwangethuba nolufanelekileyo lunokuphucula ngokuphawulekayo ukuxilonga, kanti ukulibaziseka unyango kunokukhokelela kwiingxaki ezinzima kunye nomgangatho wobomi obuhlwempuzekileyo.

UFundo oluGqibeleleyo

Kwabo bafuna ukuqonda okunzulu ngesifo sika-Kümmell, amanqaku amaninzi kunye nezifundo zetyala ziyafumaneka kwiinkcukacha zonyango kunye neejenali. Ezi zixhobo zibonelela ngengqiqo ebanzi kwi-pathophysiology, inkcazo yekliniki, kunye nezicwangciso zokulawula le meko enqabileyo yomgogodla.7

Iijenali zonyango ezifana neJenali ye-Orthopedic Surgery kunye noPhando kunye ne-Spine Journal zihlala zipapasha iingxelo zeengxelo ezineenkcukacha kunye nophononongo kwisifo sase-Kümmell. Ezi zipapasho zinika ulwazi oluxabisekileyo malunga neendlela zamva nje zokuxilonga kunye neendlela zonyango. 8

Ngombono wembali, ukuphonononga iinkcazo zokuqala zikaDkt Hermann Kümmell kunye nezifundo ezilandelayo zinokubonelela ngomxholo wokuvela kokuqonda kunye nokulawula isifo. La maxwebhu embali ahlala ecatshulwa kumanqaku ophando lwangoku. 9

Iilayibrari zonyango ezikwi-Intanethi ezifana ne-PubMed kunye ne-Google Scholar zizona ndawo zibalaseleyo zokufikelela kumanqaku aphononongwe ngoontanga kunye nezikhokelo zeklinikhi. La maqonga anikezela ngovimba omkhulu wamaphepha ophando abandakanya imiba eyahlukeneyo yesifo saseKümmell, ukusuka kwi-epidemiology ukuya kwiziphumo zotyando. 10

Kwiiklinikhi kunye nabaphandi, ukuya kwiinkomfa kunye ne-symposia malunga nokuphazamiseka komgogodla kunokubonelela ngamathuba okufunda malunga nenkqubela phambili yamva nje yokuxilongwa kunye nokunyangwa kwesifo se-Kümmell. Iingxelo ngezi ziganeko zidla ngokupapashwa kwiijenali zezonyango ezikhethekileyo. 11