Drug-resistant MS spasticity treatment with Sativex(®) add-on and driving ability.

OBJECTIVE: The aim of the present observational study was to determine the effects of a delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) oromucosal spray (Sativex(®) spray), brand name Sativex(®), indicated for drug-resistant MS spasticity, on the driving ability of treated MS patients. METHODS: The study was conducted over a period of 4-6 weeks. Thirty-three MS patients with moderate to severe treatment-resistant spasticity and planned to begin add-on treatment with Sativex(®) were enrolled at three specialized MS centres in Germany. A set of five driving test procedures from a validated computerized test battery was used to evaluate the driving ability of eligible patients. Tests were performed by patients at baseline and repeated after 4-6 weeks of treatment with Sativex(®) oromucosal spray. According to German normative data, the test thresholds achieved by the general population served as a reference to allow for a fitness/unfitness to drive classification. RESULTS: Patients showed comparable driving test results at baseline and at final visits. Only two patients changed classification shifting from 'unfit' to drive to 'fit' and vice versa. The mean severity of spasticity, as self-reported by the patients, improved with statistical significance. Sativex(®) was generally well tolerated. CONCLUSIONS: Treatment of MS patients with Sativex(®) does not negatively impact on driving ability and may improve moderate to severe treatment-resistant MS spasticity.

[Severe vascular complications of Le Fort I osteotomy]. / Complications vasculaires graves de l'ostéotomie de Le Fort I.

INTRODUCTION: Le Fort I osteotomy is a common orthognathic procedure. This surgery presents risk of severe vascular complications because of local anatomy. The aim of our study was to collect data on vascular complications of Le Fort I osteotomies performed in our department, describe the diagnostic and therapeutic aspects, and discuss prevention. PATIENTS AND METHODS: A retrospective analysis was made on the files of patient having undergone Le Fort 1 osteotomy, between 1998 and 2007. Severe vascular complications were recorded, defined as postoperative hemorrhagic or ischemic complications severe enough to require a specific procedure. RESULTS: Nine hundred and sixteen patient files were included (39% male and 61% female patients, mean-age: 24.42 years; range: 13 to 59 years). Five patients presented with severe hemorrhagic complication. There was no ischemic complication. Three hemorrhagic episodes occurred in the immediate postoperative phase. In two cases, delayed hemorrhagic complication occurred, diagnosed as a pseudo-aneurysm by angiography. These were treated by hyperselective embolization. DISCUSSION: Vascular complications of Le Fort I osteotomies are rare (0.55% in our series). They are most frequently hemorrhagic complications.

Costs and quality of life of multiple sclerosis in Germany.

This cost-of-illness analysis based on information from 2973 patients with multiple sclerosis (MS) in Germany is part of a Europe-wide study on the costs of MS. The objective was to analyze the costs and quality of life (QOL) related to the level of disease severity. Patients from six centres (office- and hospital-based physicians) and patients enrolled in a database were asked to participate in the survey; 38% answered a mail questionnaire. In addition to details on the disease (type of disease, relapses, level of functional disability), the questionnaire asked for information on all resource consumption, medical, non-medical, work absence, informal care, as well as QOL (measured as utility). The mean age of the cohort was 45 years, and 18% of patients were 65 years of age or older. Forty-seven percent of patients had mild disease (Expanded Disability Status Scale [EDSS] score 0-3), 36% had moderate disease (EDSS score 4-6.5) and 12% had severe disease (EDSS score > or =7). The mean EDSS score in the sample was 3.8 (median 4.0), with a mean utility of 0.62. Costs and utility are highly correlated with disease severity. Workforce participation decreases from 73% in very early disease to less than 10% in the very late stages, leading to a tenfold rise in productivity losses in the late stages of disease. Hospitalisation and ambulatory visits rise by a factor of 5-6 between early and late disease; investments and services increase from basically no cost to euro 2700; and informal care increases by a factor of 27 for patients with an EDSS score of 7 and by a factor of 50 for patients at the very severe end of the EDSS scale (8-9). Hence, total mean costs per patient are determined essentially by the distribution of the severity levels in the sample, increasing from approximately euro 18 500 at an EDSS score of 0-1 to euro 70 500 at an EDSS score of 8-9. The same is true for utility, which decreases from 0.86 to 0.10 as the disease becomes severe. However, the utility loss compared to the general population is high at all levels of the disease, leading to an estimated loss of 0.2 quality-adjusted life-years per patient. Relapses are associated with a cost of approximately euro 3 000 and a utility loss of 0.1 during the quarter in which they occur. Compared with a similar study performed in 1999, resource consumption, with the exception of drugs, is somewhat lower. This is most likely due to a difference in the severity distribution of the two samples and to changes in health-care consumption overall in the country, such as the introduction of diagnosis-related groups (DRGs, Fallpauschalen).

[Radiation-induced thrombosis of the carotid artery and lingual necrosis. Report of a case treated by cervical peridural nerve block]. / Thrombose carotide externe radique et nécrose linguale. A propos d'un cas traité par bloc nerveux péridural cervical.

A case of lingual necrosis in a patient irradiated 3 years earlier for a tonsillar tumor is presented. Imputability to a post-radiology bilateral external carotid thrombosis is evoked, where the diagnosis of tumoral recurrence and Horton's disease have been ruled out. Cervical peridural nerve block allowed successful treatment of this lesion.

[A case of aggressive juvenile fibromatosis of the mandible. Review of the literature]. / Un cas de fibromatose juvénile agressive de la mandibule. Revue de la littérature.

We report a new case of aggressive juvenile fibromatosis (A.J.F.) in a 20-month-old girl. The lesion affected the inferior border of the left mandible and the adjacent soft tissues. The child presented with a painless mass, which had grown over a period of 2 months. Radiographs and computed tomographic scan showed a multilacunar bone defect with subcutaneous and gingival involvement. A biopsy was performed, followed by a partial hemimandibulectomy and a costal graft. The surgical specimen measured 4 X 3 X 3 cm. The patient did well 1 year after surgery. 16 cases of A.J.F. have been reported; with ours, 14 are mandibular. A.J.F. is a locally aggressive lesion, which doesn't metastasize. It occurs chiefly in childhood and adolescence from 1 1/2 to 18 years (median 6.5 year-old). Duration of symptoms prior to presentation varies from a few weeks to months. Clinically, it is a firm nodule. Radiographs are non-specific, but 9 cases have poorly defined destruction of the mandibular inferior border. Following a block resection of the tumor (13 cases), there is no recurrence. In this review, we discuss the clinico-pathologic diagnosis of this impressive tumor which is compared with other mandibular fibrous tumors in children.

[The gastro-omental flap: a secreting mucous flap for reconstruction of the oropharynx and the oral cavity]. / Le lambeau gastro-épiploïque: un lambeau muqueux sécrétant pour la reconstruction de l'oropharynx et de la cavité buccale.

The gastro-omental flap consists of a patch taken from the greater curvature of the stomach and the bordering omentum. It is based on the right gastro epiploic vessels and is used as a free flap for intraoral reconstruction after resection of oral carcinoma. Twenty patients underwent gastro-omental flap. The operative technique is described. The evaluation consisted in questioning, chemism on the salivary flow and biopsies. There is no morbidity related with the donor site. The gastro-omental flap avoids post irradiation xerostomia. Oral irritation and bleeding of the flap may occur.

[Pulmonary metastasis of an ameloblastoma]. / Métastases pulmonaires d'un améloblastome.

We report the observation of a 78 year old patient who had a plexiform ameloblastoma since the age of 38. A systematic pulmonary radiographic examination revealed multiple dense nodules like "cannon ball secondaries". However the histology of these pulmonary nodules, obtained by open lung biopsy, was identical with the primary tumour and showed no evidence of malignancy. The dispersion to the lungs was probably explained by inhalation of tumour cells, itself favoured by 8 surgical curettages. The progress of these pulmonary lesions was as slow as the primary tumour. No therapeutic trial was attempted on the grounds of age, perfect clinical tolerance and the absence of any known therapeutic protocol which would be active.

[Do corticotherapy and hemodilution decrease postoperative inflammation after maxillofacial surgery?]. / La corticothérapie et l'hémodilution diminuent-elles l'inflammation postopératoire après chirurgie maxillofaciale?

OBJECTIVE: To assess the efficiency of corticosteroids and preoperative acute normovolaemic haemodilution (PANHD) in reducing postoperative inflammation after maxillofacial surgery. STUDY DESIGN: Randomized clinical trial. PATIENTS: Thirty-two patients scheduled to undergo maxillary osteotomy for facial dysmorphia were randomized into four groups of eight (PANHD or not; corticosteroids or not). METHODS: PANHD decreased haematocrit to 30%. In the corticosteroid groups, methylprednisolone 1.5 mg.kg-1 was given intravenously at the beginning of surgery (after PANHD in haemodiluted group), and after surgery, 1.5 mg.kg-1 iv daily for three days. Postoperative inflammation was assessed with an X-Ray technique (radiotelemetry) providing data on tissue thickness (extent of facial oedema), and by measurement of plasma concentrations of four acute phase proteins during the first postoperative week. RESULTS: No change in facial oedema and in acute phase proteins occurred with PANHD. Corticosteroids decreased postoperative oedema and acute phase proteins. CONCLUSION: Corticosteroids decrease postoperative inflammation after maxillofacial surgery but not PANHD.

[Hemodynamic parameters and blood-free surgical field with nitroglycerin in maxillofacial surgery]. / Paramètres hémodynamiques et exsanguinité du champ opératoire sous nitroglycérine en chirurgie maxillo-faciale.

73 oral facial surgery have been performed using controlled-hypotension induced with nitroglycerin (NTG) to reduce surgical bleeding. Surgical bleeding has been reduced in more than 45% of cases. But frequent lack of correlation between blood pressure, heart beat and bleeding might imply vascular reflex mechanisms induced by controlled-hypotension using NTG. Hemodynamic parameters such as blood pressure and heart rate seem to be insufficient to monitor controlled hypotension efficiency on surgical bleeding. The use of peroperative tissues blood flow monitoring may help for the better understanding of surgical bleeding during controlled-hypotension using NTG.

Outcome of orbital decompression for disfiguring proptosis in patients with Graves' orbitopathy using various surgical procedures.

AIM: To compare the outcome of various surgical approaches of orbital decompression in patients with Graves' orbitopathy (GO) receiving surgery for disfiguring proptosis. METHOD: Data forms and questionnaires from consecutive, euthyroid patients with inactive GO who had undergone orbital decompression for disfiguring proptosis in 11 European centres were analysed. RESULTS: Eighteen different (combinations of) approaches were used, the swinging eyelid approach being the most popular followed by the coronal and transconjunctival approaches. The average proptosis reduction for all decompressions was 5.0 (SD 2.1) mm. After three-wall decompression the proptosis reduction was significantly greater than after two-wall decompression. Additional fat removal resulted in greater proptosis reduction. Complications were rare, the most frequent being worsening of motility, occurring more frequently after coronal decompression. The average change in quality of life (QOL) in the appearance arm of the GO-QOL questionnaire was 20.5 (SD 24.8) points. CONCLUSIONS: In Europe, a wide range of surgical approaches is used to reduce disfiguring proptosis in patients with GO. The extent of proptosis reduction depends on the number of walls removed and whether or not fat is removed. Serious complications are infrequent. Worsening of ocular motility is still a major complication, but was rare in this series after the swinging eyelid approach.

[Oxcarbazepine in the treatment of epilepsy]. / Oxcarbazepin in der Epilepsietherapie.

BACKGROUND: Oxcarbazepine (OXC; Timox) is a new antiepileptic drug (AED) chemically related to carbamazepine (CBZ), with comparable efficacy but superior safety according to controlled clinical trials. In a prospective, post-marketing surveillance (PMS) study the efficacy and tolerability of OXC were investigated under conditions of daily routine practice. METHODS: The treatment of 1385 male and female epilepsy patients aged between 1 month and 94 years, who were newly stabilized on OXC or changed over from another AED, was documented in 362 centers over a period of 8 weeks. Efficacy and tolerability were assessed by documenting the frequency of seizures and adverse drug reactions (ADRs) and by global efficacy and tolerability ratings obtained from the patients and investigators. RESULTS: Before the PMS study, 688/1335 patients (49.7 %) had received pre-treatment with CBZ, 342 (24.7 %) had received another AED and 335 (25.6 %) had had no AED pre-treatment (initial OXC monotherapy). In 161 patients pre-treated with CBZ (23,4 % of 688) an immediate (overnight) switch to OXC was performed while most others were switched during a titration phase. Of the patients with CBZ pre-treatment 21 % were switched to OXC at the recommended dose ratio of 1 : 1.4 - 1 : 1.6 (CBZ : OXC) while roughly 60 % were changed to OXC with a lower ratio. In the total sample the median OXC maintenance dose was 900 mg/day. During treatment with OXC the frequency of seizures per 4 weeks decreased by an average of 76 % in comparison to a retrospective pre-phase. 74 % of the patients showed an improved seizure situation, and 40.5 % became seizure-free under OXC (patients with initial monotherapy became seizure-free in 62 % of the cases). 71 % of the patients showed a reduction of their seizure frequency versus baseline by > or = 50 %. ADRs were reported in 10,8 % of the participants (incidence: 1 in 459 days of exposition to OXC; overnight switching from CBZ to OXC: 1 event in 1284 days). Only 2.5 % of the patients terminated OXC administration due to ADRs while 92 % continued treatment with OXC beyond the end of the study. CONCLUSIONS: The results underline the high antiepileptic efficacy and good tolerability of OXC previously demonstrated in controlled clinical trials. When changing from CBZ to OXC, immediate (overnight) switching showed particularly favorable results.

[Is condylar resorption a contra-indication for surgery?]. / La résorption condylienne contre-indique-t-elle la chirurgie orthognathique?

INTRODUCTION: Idiopathic condylar resorption, often fortuitously discovered when performing orthodontic-surgical assessment, is a clinical entity in itself. There is a significant risk of postoperative degenerating and worsening. Is this sufficient to contra-indicate orthognathic surgery? The authors suggest an answer after studying a series of patients. MATERIAL AND METHOD: A retrospective study of 10 consecutive patients was made from July 1999 to October 2004. The preoperative assessment was triple: clinical, radiological and photographic. At least 6 months of occlusal, radiological and morphological stability was observed before any therapy was initiated. A fixed orthodontic set-up was placed and patients were regularly followed by a speech therapist for parafunctions. Stability of the occlusal correction, acquisition of a more harmonious aesthetic profile, and resolution of joint symptomatology were used to define therapeutic success at one year. RESULTS: All patients were female. Resorption affected the mandibular side of the joint in all cases and the temporal side in 7 cases. Three types of osteotomies were performed: maxillary (N=1), mandibular (N=5), and bibasilar (N=4). Genioplasty was not systematic. Joint symptoms were resolved in all cases. Postoperative occlusion corresponded to the therapeutic project in 9 cases. All patients were aesthetically improved. DISCUSSION: Idiopathic condylar resorption is not a contra-indication for orthognathic surgery. However, this treatment requires meeting and respecting four principles: a minimal delay of 6 months of occlusal, radiological, and morphological stability, an adapted and meticulous surgical technique, early and prolonged parafunction therapy, and a close follow-up of the patients.

[Hybrid osteosynthesis in orthognathic surgery: 28 cases of Le Fort I osteotomy]. / Ostéosynthèse hybride en chirurgie orthognathique: 28 cas d'ostéotomie de Le Fort I.

INTRODUCTION: The use of resorbable materials in orthognathic surgery is presently the object of numerous clinical and experimental studies. Their main drawbacks are their lack of rigidity and induced chronic inflammatory reactions. The purpose of this study was to propose and to test an original system of hybrid osteosynthesis associating a single titanium plate with three resorbable plates in Le Fort I osteotomies in the absence of maxillary expansion, or two titanium plates with two resorbable plates in case of maxillary expansion. METHODS: Our retrospective study concerned 28 patients operated between 2002 and 2005. A clinical follow-up of over one year detected the specific complications of the hybrid system and a cephalometric study analyzed the secondary relapse 5 months after surgery. These results were compared to the literature. RESULTS: One case of mobility and a case of instability of the jaw were observed, along with 5 cases of local chronic inflammatory reaction. The radiological results found a secondary sub-clinical relapse. The removal of the titanium material under local anesthesia was performed without difficulties in ambulatory care, which avoided a new hospitalization for the patient and a new general anesthesia. DISCUSSION: The hybrid system allowed obtaining a postoperative stability of the jaw comparable to that obtained by the exclusive use of titanium plates with an acceptable morbidity. This method of osteosynthesis combined the advantages of the resorbable material (removal of titanium plates under local anesthesia) and of titanium material (stability of the procedure). However this method requires a good experience of working with resorbable material, a good follow-up, and cooperative patients. These encouraging results urge us to extend the indications to mandibular sagittal osteotomy and to bi-maxillary osteotomies.

[Orbital decompression for Graves' ophthalmopathy]. / Décompression orbitaire au cours des ophtalmopathies basedowiennes.

Graves' ophthalmopathy is a complex orbital condition with a controversial pathogenesis. It is the clinical expression of a discordance between the inextensible orbit and hypertrophic muscular and fatty elements within the orbit responding to immunological stimulation. The relationship between the orbital and its content can be improved by surgical expansion which increases the useful volume of the orbit. This procedure can be combined with lipectomy to decrease the volume of the orbital contents. We briefly recall the history of surgical decompression techniques and present our experience with Graves' ophthalmopathy patients.

[Free fibular flaps in children: morbidity of the donor site and pitfalls to avoid]. / Lambeau libre de fibula chez l'enfant: morbidité du site donneur et piège à éviter.

INTRODUCTION: We report a case of donor site morbidity late after harvesting a free fibular flap for reconstruction of the mandibular symphsis. CASE REPORT: An 8-year-old boy presented a valgus deformity of the ankle 4 years harvesting of a vascularized fibular graft for mandibular reconstruction. The deformation was repaired with a tibial bone slit and pin fixation. The biomechanical result was very satisfactory, allowing normal gait. DISCUSSION: We recall the rules for fibular flap harvesting needed to prevent deformation of the donor site in children aged less than 9 years.

[Growth defects of fibular flaps in children]. / Troubles de croissance des lambeaux fibulaires prélevés chez l'enfant.

BACKGROUND: Mandibular reconstruction with fibula free flap is a challenge in pediatric patients because of the size of the bone and absence of growth without epiphyseal transplantation. CASE REPORT: We report 2 cases of free fibula flap in children for mandibular reconstruction. The 2 patients presented with growth insufficiency of the bone graft after few years of evolution. DISCUSSION: Growth insufficiency was treated with different surgical procedures which were discussed We review the consequences on growth after fibula free flap and the specific indications to achieve epiphyseal fibular growth in children.

[Grave's ophthalmopathy: therapeutic strategy. Review of 30 patients]. / Ophtalmopathie basedowienne: stratégie thérapeutique à partir de 30 cas.

BACKGROUND: Graves' ophthalmopathy is the primary etiology for exophthalmos in adults. It is a complex orbital disease whose pathophysiology remains controversial. Since its initial description more than 150 years ago, its heterogeneous clinical manifestations and poorly understood links with thyroid pathology remain unresolved issues. Disease activity is the main determinant for the management of Graves' ophthalmopathy, but treatments are often symptomatic, aiming at decreasing orbital inflammation. MATERIAL AND METHODS: We report a retrospective analysis of 30 patients diagnosed with Graves' ophthalmopathy followed in our department between 1991 and 2002. Following a phase of medical management of their disease, all patients underwent surgical orbital decompression. RESULTS: Medical and surgical care provided as well as results are presented with a mean follow-up of 23 months. DISCUSSION: Based on our clinical experience, new concepts in the field of Graves' ophthalmopathy are discussed. Disease activity, evaluated through various means, appears to be the primary guide for therapeutic management. Moreover, the importance of a multidisciplinary approach is highlighted, in order to improve the management of this difficult disorder.

[Regarding orthognathic surgery]. / Regards sur la chirurgie orthognathique.

The author scrutinises the evolution of orthognathic surgery for the last twenty years through the different parameters that participate to its origin; esthetic motivation, orthodontico-surgical collaboration, the limitation of widely used technics, a simple surgical solution, the spreading of rigid fixation, the interest of primary or secondary genioplasty, the consideration of ethnic differences,the usefulness of a maxillo-facial chain, the possible retreatment of failures and consideration for the stability of results.

[Hydroxyapatite in orthognathic surgery. Animal experimentation and clinical applications]. / Hydroxyapatite en chirurgie orthognathique. Expérimentation animale et applications cliniques.

Bone cell conduction can occur within hydroxyapatite, a biocompatible, bioactive, synthetised ceramic material, when it is placed in contact with bone tissue. Results of experimental and clinical studies on maxillary osteotomy incisional lines have confirmed these properties, the quality and stability of the results and the good tolerance of this biomaterial making it a product of choice as a substitute of iliac bone grafts, when no longer indicated in this context.