Use of the parathyroid hormone assay at H6 post thyroidectomy: an early predictor of hypocalcemia.

PURPOSE: Hypocalcemia linked to a diminished circulating intact parathormone (iPTH) is the most common complication after total thyroidectomy. The objective of this study was to evaluate iPTH as a predictor of post-thyroidectomy hypocalcemia. METHODS: Hundred-and-eight patients who underwent total thyroidectomy were included. Blood samples (iPTH, calcium and albumin) were performed at different times: preoperatively (H0), after removal of the gland (Hdrop), 6 h (H6) and one day (D1) after the surgery. Hypocalcemia was defined by total calcium corrected by serum albumin ≤ 2.10 mmol/l. The area under the ROC curve (AUC) was used to determine the best cut-off value and predictability of iPTH for hypocalcemia in terms of absolute value (ng/L), decrease in the slope (ng/L) and decline (%) between two times. RESULTS: The study included 101 patients. Among them, 39 had hypocalcemia (38.6%). At H6, an iPTH absolute value less than 14.35 ng/L (Se = 0.706; Sp = 0.917) and a decline from the preoperative time of more than 59.5% (Se = 0.850; Sp = 0.820) were predictive of hypocalcemia. Other absolute values, decrease in the sloop and decline between preoperative and postoperative values were less relevant. CONCLUSION: The iPTH 6 h after total thyroidectomy is predictive of hypocalcemia. It might be used to identify patients not at risk of hypocalcemia and earlier discharge could be considered.

Purification and Characterization of Phosphoribosylpyrophosphate Synthetase from Rubber Tree Latex.

Phosphoribosylpyrophosphate synthetase (PRS; EC 2.7.6.1) from Hevea brasiliensis Mull. Arg. latex was located in the cytosol. After purification, its apparent molecular weight under nondenaturing conditions was estimated at 200,000 [plus or minus] 10,000; a single band at 57,000 [plus or minus] 3,000 was detected after sodium dodecyl sulfate-polyacrylamide gel electrophoresis. The enzyme seemed to be a homotetramer. Its affinity constants were estimated at 200 [plus or minus] 30 [mu]M for adenosine triphosphate and 40 [plus or minus] 2 [mu]M for ribose-5-phosphate. The purified enzyme proved to be functional in a paraphysiological medium (cytosol deproteinized by ultrafiltration). Optimum pH was 7.5 in buffer and 6.5 in a paraphysiological medium. No PRS activity was detected in the absence of the Mg2+ ion. Of the numerous compounds tested, only Mn2+, phosphoribosylpyrophosphate, and inorganic phosphate affected the enzymatic reaction. Mn2+ (inhibitor constant = 20 [mu]M) and phosphoribosylpyrophosphate (inhibitor constant = 30 [mu]M) were inhibitors. PRS responded allosterically (Hill's coefficient = 2.3) to ribulose-5-phosphate in the presence of a physiological concentration of inorganic phosphate (10 mM). These results are set in the physiological context of laticifers.

Ethylene-Induced Increase in Glutamine Synthetase Activity and mRNA Levels in Hevea brasiliensis Latex Cells.

Ethylene, used as a stimulant of latex production in Hevea brasiliensis, significantly activates the regenerating metabolism within the laticiferous cells. In this context, attention was focused on glutamine synthetase (GS; EC 6.3.1.2), a key enzyme in nitrogen metabolism. A specific and significant activation of the cytosolic glutamine synthetase (GScyt) in the laticiferous cells after ethylene treatment parallels the increase of latex yield. A marked accumulation of the corresponding mRNA was found, but in contrast, a slight and variable increase of the polypeptide level is at the limit of detection by western blotting. The GS response to ethylene might be mediated by ammonia that increases in latex cytosol following ethylene treatment. The physiological significance for such a regulation by ethylene of the GScyt is discussed in terms of the nitrogen requirement for protein synthesis associated with latex regeneration.

Relapsing hepatitis A in Saimiri monkeys experimentally reinfected with a wild type hepatitis A virus (HAV).

Saimiri monkeys were inoculated three times with hepatitis A virus and observed in a follow-up study for sixteen months. The monkeys developed recurrent hepatitis involving liver damage and cycles of HAV antigen shedding in stools. The relapses were presumably due to immune response effects.

Treatment of Langerhans-cell histiocytosis in children. Experience at the Children's Hospital of Nancy.

Forty children who had Langerhans-cell histiocytosis were followed for an average of six years (range, excluding patients who died of the disease, two to fifteen years). The patients were divided into two diagnostic groups: those who had localized disease (involving one bone or more only) and those who had multifocal disease (an osseous lesion and a soft-tissue mass, a skin rash, diabetes insipidus, or generalized disease). Methods of treatment included curettage, bone-grafting, chemotherapy, local or systemic corticosteroids, and radiotherapy. Nineteen of the thirty patients who had localized disease had a complete response to the therapy, four had a partial response, and seven had no response. Twenty-one of these thirty patients had not had a recurrence by the time of the latest follow-up examination; nine had a local recurrence within four years after the initial therapy but had no additional recurrences after treatment of the local recurrence. No recurrence occurred more than four years after the time that the initial diagnosis had been made. Five of the ten patients who had multifocal disease had a complete response to the therapy, two had a partial response, and three had no response. Six patients had a recurrence; four did not. Two patients died of the disease. As a result of this study, we recommend the avoidance of intensive measures of treatment, if possible, and we advise long-term follow-up of these patients.

Pulmonary sequestrations of the upper lobe in children: three presentations.

Pulmonary sequestrations are congenital abnormalities where nonfunctioning lung tissue receives its vascular supply from the systemic circulation (thoracic or abdominal aorta). It is necessary to establish the diagnosis in childhood when the lesions are uncomplicated. The authors present three cases of sequestration of the apex (2 extralobar and 1 atypical) with the main clinical and radiological features. Sequestrations in the upper lobe are rare, and the usual site is the left lower lobe. Plain x-rays show a dense opacity, sometimes air-filled and sometimes with an air-fluid level: angiography is currently the best mean for definitive diagnosis; however, computed tomography will probably be very useful in the future. Differential diagnosis includes tumours of the superior mediastinum (neurogenic tumours, digestive duplication, bronchogenic cysts, pheochromocytoma and hydatid cysts).

Elastic stable intramedullary nailing of femoral shaft fractures in children.

We report the use of elastic stable intramedullary nailing (ESIN) in 123 fractures of the femoral shaft in children. Flexible rods are introduced through the distal metaphyseal area, and the aim is to develop bridging callus. Early weight-bearing is possible and is recommended. There was one case of bone infection and no delayed union. Complications were minimal, the most common being minor skin ulceration caused by the ends of the rods. A surprising feature was the low incidence of growth changes, with a mean lengthening of only 1.2 mm after an average follow-up of 22 months. Compared with conservative treatment, ESIN obviates the need for prolonged bed rest and is thus particularly advantageous for treating children.

A case of EMG (exomphalos, macroglossia, and gigantism) syndrome with associated renal tumor.

This is a brief report of a patient with Wiedemann-Beckwith syndrome and nephroblastoma with metastases, apparently cured by surgery, chemotherapy, and radiation.

Intestinal strangulation between two vertebra following an axial dislocation of L1/L2.

An exceptional cause of intestinal obstruction is reported. Ileus is an 8-yr-old boy persisted for 9 days after successful reduction of an axial dislocation of L1 on L2. At laparotomy, a paraduodenal hernia with bowel strangulated between the bodies of L1 and L2 was discovered. The successful treatment consisted of cleaning out the intervertebral space, resection of the necrotic bowel with anastomosis, antibiotic therapy, and a plaster jacket worn for 3 mo.

Resection followed by vascularized bone autograft in patients with possible recurrence of malignant bone tumors after conservative treatment.

In conservative treatment of malignant bone tumors, assessment of the local condition is difficult. The radiological changes seen in the irradiated tumor and the frequent occurrence of pathological fractures at this site may give rise to the fear that the tumor has relapsed. Resection of the whole of the involved bone is the best way to assure adequate local control but the extent of the bone defect and the bad local conditions secondary to irradiation make reconstruction hazardous. In two patients (one with Ewing's sarcoma of the femur and one with osteogenic sarcoma of the humerus) the authors used a free, vascularized fibular graft for the reconstruction having obtained consolidation of the limb after resection of the irradiated tumor, with preservation of its function. The encouraging results obtained have suggested a conservative attitude as primary treatment of specific malignant bone tumors.

Treatment of sternocostal wall malformations of the child. A series of 210 surgical corrections since 1975.

Of 450 children examined for front chest wall malformations, 210 underwent a corrective operation: 190 funnel chests and 20 pigeon chests. A classification of the anatomic forms is presented which contains 6 groups: vertical cup-shaped (the most common), horizontal cup-shaped, vallecular, mixed, complex with sternal torsion or polymalformations. The operation has been programmed in 64% of the cases between 10 and 18 years, but 36% were operated under 6 years because of a severe functional disturbance. On the technical side, Ravitch's procedure is still used on young infants; for the other cases sternochondro-plasty is to be preferred. The fixation of the chest wall is realized with an original, light, solid elastic material taking little space, and easy to remove. This material is presented. The immediate results: 62% very good, 35% good and 3% mediocre, sometimes do present a pejorative evolution, so that after two years of follow-up we notice: 55% remained perfect, 35% very good, 10% moderate of which, 4% to be reoperated. This deterioration touches more particularly the older children operated between 16 and 18 years. Among the children between 3 and 6 years the results are usually very good and remain stable with growth.

[Contribution of MRI to the diagnosis of double aortic arch]. / Apport de l'IRM au diagnostic de double arc aortique.

The authors present a case of double aortic arch explored by MRI and discuss the advantages and disadvantages of MRI as compared to other noninvasive imaging methods, such as ultrasounds and digital angiography, in congenital pathology of the aorta. Because it provides good quality images, can explore the aorta in all three dimensions, has optimal vascular contrast without contrast injection and carries no risk, MRI is indispensable in all cases where ultrasonography finds its limitations. Besides, the subjective factor inherent in the operator is very small, and MRI is the best available method to study the relations between the aorta and the surrounding organs; this is particularly important in case of double aortic arch owing to compression of the neighbouring organs with, notably, stridor. However, the vascular map is less accurate than with angiography, and the cost, the problem of access to the machines and the long time required for acquisitions limit the use of MRI.

Fractures of the radial head and associated elbow injuries in children.

Fractures of the radial head are frequently associated with elbow injuries in children. Thirty-seven patients with this association treated at the Nancy Children's Hospital were analyzed to ascertain the mechanism and the unfavorable factors of prognosis. The mechanism responsible was a valgus strain on the elbow at the moment of impact, associated with forces of compression and distraction. At an average follow-up of 2 years, 76% excellent and good results were obtained. Conservative treatment was always effective in minimally displaced fractures. With surgical reduction by closed intramedullary pinning (CIMP), there were only three failures in severely displaced fractures. With open reduction, results were always poor; 88% patients with fair and poor results had an associated fracture of the olecranon. The unfavorable prognostic factors were the severity of the initial tilting and displacement, the presence of associated elbow injuries, the inadequacy of reduction, and the open reduction procedure.

[Ilizarov's method. Histological and radiological aspects]. / La méthode d'Ilizarov. Aspects histologiques et radiologiques.

The Ilizarov method is an original technique of surgical lengthening of long bones. The constraints in compression and distraction obtained with this method favor the bony healing. The straining of extension induces stimulating consequences on the bone. The healing process is different from that of the fractures because the bony regeneration is accomplished by a membranous bony mechanism without intermediate fibrous or cartilaginous medium. The maturation occurs when the lamellated bone is present, at the end of the 4th month.

[Systemic artery-pulmonary vein fistula. Apropos of a case]. / Fistule artère systémique-veine pulmonaire. A propos d'une observation.

Fistulas between a systemic artery arising from the aorta and the pulmonary vein with absence of a branch of the pulmonary artery and without abnormality of the bronchial tree are very seldom. We report the case of a child which had a continuous vascular murmur with heart failure secondary to a left-left shunt. A left inferior lobectomy was performed. The inferior lobe was the site of a huge arterio-venous fistula between an artery arising, from the aorta and the pulmonary veins.

[Prognosis of fractures of the lower end of the femur in children and adolescents. Apropos of 96 cases]. / Pronostic des fractures de l'extrémité inférieure du fémur chez l'enfant et l'adolescent. A propos de 96 observations.

A multicentre study undertaken in a number of orthopaedic and traumatology departments of hospitals in the East of France have made it possible to bring together, over 10 consecutive years, 96 fractures of the lower end of the femur in children and adolescents. The analysis of this retrospective series agrees with the findings in the literature both in its clinical features and the methods of treatment. The results were very good in 84 per cent of cases. The authors feel that the standard scoring systems are too optimistic and they prefer an analytic description of the complications which presented in 54 per cent of cases with 13 per cent of malunions, 16 per cent of epiphysiodeses and 7 per cent of inequalities of limb length greater than 10 mm. The etiology and pathology of these diverse complications is reviewed. Vascular lesions seem to play an unimportant role. The prognosis, as defined, seems to be realistic since this work has taken account of a large proportion of the fractures occurring during the same period in the same region.

[Correction of malunion of femoral fractures by Ilizarov's device in children]. / Correction des cals vicieux du fémur de l'enfant par l'appareil d'Ilizarov.

Cast immobilisation of femoral fractures in children may sometimes be subject to important displacements. Absence of survey leads to malunions which may make a secondary correction necessary. In two such cases the authors used Ilizarov's external fixation which allowed correction of both angulation and shortening without direct approach. Rapid healing occurred. The authors made a comparative analysis of the different possibilities for treatment of these severe femoral malunions.

[The effects of innominate ostèotomy on the opposite acetabulum (author's transl)]. / Le retenitssement des ostéotomes innominées sur le cotyle contro-latéral.

The study on dissected pelvis shows that after innominate osteotomy, the acetabulum still faces too much anteriorly. Its anterior wall remains deficient. The innominate osteotomy is able to diminish the excessive antetorsion of the acetabulum by rotating the distal fragment outwards. But this movement seems to increase the antetorsion of the opposite acetabulum. Axial X. Rays of the pelvis authors think that in case of great anterior defect, and in case of bilateral hip dysplasia, a triple pelvic osteotomy will be preferred to Salter's osteotomy.

[Histomorphometry of bone regenerate in limb lenghthening by the Ilizarov's technique]. / Histomorphométrie du régénérat osseux dans les allongements des membres selon la technique d'Ilizarov.

Eleven biopsies of bone regenerate during bone lengthening following the Ilizarov technique were studied. They concerned 10 patients with a mean age of 13.5 years. The length of the biopsied regenerate was between 14 and 90 mm, and the delay after the initial procedure was 23 to 502 days. The aim of this study was to get informations on the histology of the regenerate, to quantify osseous data and to propose a surgical strategy. These data were obtained by analyze of non decalcified bone, biopsies were included in a methylmetacrylate block. Measure of the mineralisation speed was determined after a double intake of tetracycline. The bony trabeculations were formed very early, as soon as the third week. They were placed like a thread, that means in an anastomotic system which can quickly become resistant. But is was necessary to keep a lengthening speed under 1 mm per day 0.7 to 0.8 mm per day seems to be the best speed in adolescents. The ossification was of membranous type, without cartilaginous stage. Osteoblastic and osteoclastic activities were extremely rich, even after one year or after the bone healing. The main point was the maturity of the regenerate acquired as soon as the 4th month.

[Reduction of the period of treatment for leg lengthening. Technique and advantages]. / Réduction de la durée du traitement dans les allongements osseux progressifs. Technique et advantage.

PURPOSE OF THE STUDY: We assessed an adaptation of the Ilizarov method aimed at a considerable reduction in the period of treatment for leg lengthening in order to limit complications related to the duration of the external fixation. This technique associates multiple segment lengthening, automatic high-frequency lengthening, and stimulation of bone regeneration by extemporaneous compression at the end of traction. MATERIAL AND METHODS: We analyzed 78 cases of automatic fémur lengthening in 40 patients and simultaneous fémur and tibia lengthening in 38 patients. There were 51 men and 27 women, mean age 13.2 years (6 - 43 years). Mean length deficiency was 4.3 cm for the fémur and 3.5 cm for the tibia. Femoral and/or tibial deformations were observed in 32 patients. Minimal follow-up was 1.5 years. The automatic traction device was composed of the conventional Ilizarov fixator and complementary elements. Different assemblies were used depending on the associated deformations allowing their progressive correction. For 17 patients, radioimmunoassay of thyrocalcitonin and parathormone was performed to compare the time courses. RESULTS: Mean femoral lengthening achieved was 49 mm (8.5 to 20%). Mean tibial lengthening was 42 mm (7.2 to 18.8%). The consolidation index was 18.1 to 21.3 days/cm for single-segment lengthenings and 11.5 days/cm (mean) for two-segment lengthenings (taking into account both the femoral and tibial gain in length). The ideal moment of compression was 5.6 N/cm(2). Acceleration of the bone repairing process was evidenced by activation of the osteotrop hormone system. According to the SOFCOT classification of complications (1990), 60 patients (76.9%) were in category I, 15 (19.3%) in category II, and 3 (3.8%) in category III. DISCUSSION: Improvement of lengthening procedures with external fixators remains an important issue. Treatment periods are often long with consolidation indices for the femur ranging from 39.6 d/cm to 45 d/cm, which can lead to many types of complications. Use of a high-frequency progressive lengthening procedure based on the Ilizarov method considerably reduces the rate of complications compared with progressive lengthening methods and has allowed achieving more satisfactory results in a shorter treatment period. CONCLUSION: Multiple-segment lengthening using an automatic lengthening procedure set at 1 mm per day in four times provides an important reduction in the treatment delays since distraction is performed more rapidly and fewer steps are needed. Automatic high-frequency lengthening with the Ilizarov method provides optimal conditions for tissue regeneration: Treatment periods are shorter and anatomic and functional outcome is very satisfactory. Stimulation by extemporaneous compression of the regeneration zone allows a significant reduction in the duration of consolidation. Shorter delays to consolidation help avoid device-related complications.