Fulminant ectopic Cushing's syndrome caused by metastatic small intestine neuroendocrine tumour - a case report and review of the literature.

Cushing's syndrome (CS) secondary to adrenocorticotropic hormone (ACTH) producing tumours is a severe condition with a challenging diagnosis. Ectopic ACTH-secretion often involves neuroendocrine tumours (NET) in the respiratory tract. ACTH-secreting small intestine neuro-endocrine tumours (siNET) are extremely rare entities barely reported in literature. This review is illustrated by the case of a 75-year old woman with fulminant ectopic CS caused by a ACTH-secreting metastatic siNET. Severe hypokalemia, fluid retention and refractory hypertension were the presenting symptoms. Basal and dynamic laboratory studies were diagnostic for ACTH-dependent CS. Extensive imaging studies of the pituitary and thorax-abdomen areas were normal, while [68Ga]Ga-DOTATATE PET-CT revealed increased small intestine uptake in the left iliac fossa. The hypercortisolism was well controlled with somatostatin analogues, after which a debulking resection of the tumour was performed. Pathological investigation confirmed a well-differentiated NET with sporadic ACTH immunostaining and post-operative treatment with somatostatin analogues was continued with favourable disease control.

Medullary thyroid cancer: prognostic factors for survival and recurrence, recommendations for the extent of lymph node dissection and for surgical therapy in recurrent disease.

BACKGROUND: We reviewed our experience with MTC (medullary thyroid cancer), focusing on recurrence and survival, recommendations for the extent of lymph node (LN) dissection and surgery for recurrent disease. METHODS: Of 51 MTC patients treated between 1988 and 2008 at the University Hospitals Leuven, 38 previously untreated patients were analysed. RESULTS: Overall and disease-specific (DSS) five-year survival rates were 75% and 82%. Variables univariately associated with DSS were age, pN, stage, vascular invasion, pre-operative recurrent laryngeal nerve function and last calcitonin level. Recurrence occurred in 10 patients (26%). For recurrence, age was no longer a prognostic factor and post-operative calcitonin, number of positive LN and of positive compartments proved to be prognostic factors. Of 21 clinical NO patients, 2 out of 6 (33%) undergoing a prophylactic central neck dissection (ND) based on per-operative palpatory suspicion proved pN+, and 2 out of 9 patients (22%) undergoing a prophylactic lateral ND were pN+. Five patients surgically treated for recurrence did not achieve long-term normalisation of calcitonin, but remained alive with locoregional control. CONCLUSION: Overall survival and DSS rates are within the range reported in the literature. The results confirm that (1) total thyroidectomy and central compartment dissection is the treatment of choice in the cN0 patients, (2) additional ipsilateral lateral ND is needed for cN+ disease in the ipsilateral lateral compartment, and (3) in the clinically uninvolved contralateral lateral neck, per-operative inspection should serve as a basis for a decision about further ND. Locoregional control and prolonged survival is achieved in surgically treated locoregionally recurrent MTC.

The clinical implications of sunitinib-induced hypothyroidism: a prospective evaluation.

Sunitinib is approved for the treatment of metastatic renal cell carcinoma (RCC) and imatinib-resistant or -intolerant gastrointestinal stromal tumours (GIST). Several studies have identified unexpected rates of thyroid dysfunction with sunitinib treatment. We performed a prospective observational study with the aim of more accurately defining the incidence and severity of hypothyroidism in RCC or GIST patients receiving sunitinib. Thyroid function was assessed at baseline and on days 1 and 28 of each treatment cycle. Thyroid antibodies were assessed at baseline and during follow-up if abnormal thyroid function tests were recorded. Sixteen patients (27%) developed sub- or clinical hypothyroidism and required hormone replacement and 20 patients (34%) showed at least one elevated thyroid-stimulating hormone not requiring therapeutic intervention. Twenty patients (34%) did not develop any biochemical thyroid abnormality. Thus, sunitinib can induce (sub-) clinical hypothyroidism, warranting close monitoring of thyroid function. We propose a new algorithm for managing this side effect in clinical practise.

Is the management of thyroid nodules and differentiated thyroid cancer in accordance with recent consensus guidelines? - Results of a national survey.

OBJECTIVE: To assess approaches to patients with a potentially malignant thyroid nodule and patients with differentiated thyroid carcinoma and compare them with the European Consensus and Guidelines by the American Thyroid Association. DESIGN: A survey of the 388 active members of the Belgian Thyroid Club. METHODS: A questionnaire addressing the management of an index case and four clinical variations (including variations in the size of the tumour and histological type). The index case was a 40-year-old euthyroid woman with a 3-cm solitary thyroid nodule. Fine-needle aspiration (FNA) cytology showed cellular aspirates with numerous follicular cells and no colloid. RESULTS: The overall response rate was 41%. For the index case, respondents favoured a right lobectomy. Variations in size and histopathology of the nodule altered the management. In the case of a papillary thyroid carcinoma (PTC) of 3 cm in diameter, a total thyroidectomy and prophylactic central lymph node dissection was preferred. After a lobectomy showing a 3.5-cm follicular thyroid carcinoma (FTC), completion surgery followed by radioiodine administration was the most frequent proposal. For the follow-up of the index case with a low-risk disease, determination of serum thyroglobulin (Tg) after recombinant human TSH (rhTSH) administration was considered by the majority of respondents. For the follow-up of a clinical variation with residual disease, immediate planning of a new treatment was (mistakenly) not considered by a majority of respondents. CONCLUSIONS: In most cases, respondents were in accordance with the guidelines, although there were some unexpected variations.

[Hoffmann syndrome presenting to the emergency department]. / Syndrome de Hoffmann aux urgences.

We report a case of hypothyroid myopathy, or Hoffmann syndrome, in a 31-year-old man who presented to the emergency department with asthenia, muscular pain, cramps, and joint pain. Tests revealed increased creatine phosphokinase level (8102 U/L) and severe hypothyroidism (content of T4=3.8 pg/ml, T3=1.3 pg/ml, and thyrotropin stimulating hormone>150 microU/ml). Other causes of myopathy were excluded by anamnestic investigation and paraclinical exam. Treatment was begun with thyroid hormones (from 75 to 175 microg) and good clinical evolution was rapid. The pathophysiology of hypothyroid myopathy, clinical aspects and pathologic anatomic elements are described. The exact etiology of hypothyroidism must be known because some pathologic features are benign and treatment can have good results, whereas others, such as cancer, have worse prognosis.

Levothyroxine replacement therapy after thyroid surgery.

INTRODUCTION AND AIM: New entities, such as 'subclinical' over- and undersubstitution, are easily diagnosed after thyroid surgery due to improved testing methods, and the incidence of thyroidectomy with lifelong hormone substitution is increasing. Thus, there is a need to review conventional replacement therapy after thyroid surgery. We investigated the adequacy of our thyroid hormone replacement therapy for three months after total-, subtotal-, and hemithyroidectomy using an upper reference limit of thyrotropin (TSH) of 4.6 mU/L. MATERIALS AND METHODS: Eighty-seven patients undergoing thyroidectomy for benign thyroid pathology participated. Levothyroxine (L-T4) treatment began five days after surgery. Preoperatively euthyroid patients received 150 microg L-T4 daily following total thyroidectomy, 100 microg L-T4 after subtotal thyroidectomy, and 50 microg L-T4 after hemithyroidectomy. Preoperatively hyperthyroid patients received 100 microg L-T4 following total thyroidectomy and 50 microg L-T4 following subtotal thyroidectomy. An average of six weeks after surgery, thyrotropin (TSH) was measured (reference limits 0.15-4.60 mU/L), and necessary dose adjustments were made. RESULTS: Of the patients who were preoperatively euthyroid, 45% with total thyroidectomy, 42% with subtotal thyroidectomy, and 17% with hemithyroidectomy required L-T4 dose adjustments. Of the patients who were preoperatively hyperthyroid, 60% of those with total thyroidectomy and all of those with subtotal thyroidectomy required L-T4 dose adjustments. CONCLUSIONS: To avoid over- and undersubstitution after thyroidectomy, an optimal replacement therapy dose is necessary. A small majority of our preoperatively euthyroid patients received adequate therapy. Endocrinological follow-up six weeks after surgery revealed the need for L-T4 dose adjustments, especially in preoperatively hyperthyroid patients. When the extent of resection was similar for hyperthyroid and euthyroid patients, the same initial dose of L-T4 was justified.

Aromatase deficiency caused by a novel P450arom gene mutation: impact of absent estrogen production on serum gonadotropin concentration in a boy.

We identified a new point mutation in the CYP19 gene responsible for aromatase (P450arom) deficiency in a 46,XY male infant with unremarkable clinical findings at birth. This boy is homozygote for a 1-bp (C) deletion in exon 5 of the aromatase gene causing a frame-shift mutation. The frame-shift results in a prematurely terminated protein that is inactive due to the absence of the functional regions of the enzyme. Aromatase deficiency was suspected prenatally because of the severe virilization of the mother during the early pregnancy, and the diagnosis was confirmed shortly after birth. Four weeks after birth, the baby boy showed extremely low levels of serum estrogens, but had a normal level of serum free testosterone; in comparison with the high serum concentration of androstenedione at birth, a striking decrease occurred by 4 weeks postnatally. We previously reported elevated basal and stimulated FSH levels in a female infant with aromatase deficiency in the first year of life. In contrast, in the male infant, basal FSH and peak FSH levels after standard GnRH stimulation tests were normal. This finding suggests that the contribution of estrogen to the hypothalamic-pituitary gonadotropin-gonadal feedback mechanism is different in boys and girls during infancy and early childhood. In normal girls, serum estradiol concentrations strongly correlate with circulating inhibin levels, and thus, low inhibin levels may contribute to the striking elevation of FSH in young girls with aromatase deficiency. In contrast, estradiol levels are physiologically about a 7-fold lower in boys than in girls, and serum inhibin levels remain elevated even though levels of FSH, LH, and testosterone are decreased.

Influence of age, sex, and insulin on osteoblast function: osteoblast dysfunction in diabetes mellitus.

The osteoblast function was evaluated in normal and diabetic children and adults by measurements of the serum concentration of the carboxy-terminal extension peptide of procollagen (PICP), total and skeletal alkaline phosphatase (ALP), and osteocalcin. Moreover, the osteoblast-stimulating growth factor, insulin-like growth factor I (IGF-I), was measured in the same samples. In normal children (n = 420; age, 5-20 yr), a marked pubertal increase of serum IGF-I (peak values at age 14-16 yr in both sexes), osteocalcin, and total and skeletal ALP (peak values earlier in girls than in boys) and a small increase in PICP were observed. All osteoblast markers and IGF-I were markedly lower in normal adults (n = 229; age, 21-69 yr) than in children. All osteoblast parameters showed a high degree of correlation (P < 0.001) with each other. In adolescents (n = 104) treated for insulin-dependent diabetes mellitus (IDDM), serum IGF-I (-19%), osteocalcin (-28%), and skeletal ALP (-28%) were markedly decreased, whereas total ALP was significantly increased (29%), and serum PICP remained normal. In adult IDDM (n = 125), both serum IGF-I (-41%) and osteocalcin (-24%) were decreased, but skeletal ALP and PICP remained normal. A similar abnormality in serum IGF-I and osteocalcin was observed in white (n = 61) and Pima Indian (n = 16) non-IDDM patients. The concentration of skeletal ALP was highly significantly correlated (r > or = 0.9) with total ALP in both normal and diabetic subjects, but the slope of the regression was significantly different, indicating the presence of other, probably intestinal, ALP in all types of diabetes. In conclusion, the osteoblast function is significantly decreased in diabetic patients, which can best be characterized as a maturation defect, since the early osteoblast marker, PICP, remained normal in all types of diabetes, whereas a later marker, skeletal ALP, is frankly abnormal only in diabetic children. The most mature osteoblast marker, osteocalcin, is decreased in all types of diabetes irrespective of age.

Improved risk assessment for insulin-dependent diabetes mellitus by analysis of amino acids in HLA-DQ and DRB1 loci.

Polymorphisms in HLA class II genes have been shown to contribute to susceptibility or protection against insulin-dependent diabetes mellitus (IDDM). In the present study the role of HLA class II haplotypes and the role of DQ alpha Arg52, DQ beta Asp57 and of polymorphic amino acids, located in the antigen-binding groove and the CD4-binding domain of the DR beta 1 chain, were studied in 210 unrelated Caucasian IDDM patients and 205 controls. The results showed that the genotype homozygous for DR beta 1Lys71+, which is in linkage disequilibrium with DQ alpha 1Arg52+ provided a major risk (relative risk, RR = 15.46) for IDDM and that combination of DR beta 1Lys71+/+ with homozygosity for DQ beta qAsp57-/- of the DQ beta 1 chain significantly increased the RR for developing IDDM (RR = 20.41). The DQ alpha 1Arg52(-)-DQ beta 1Asp57+ haplotype in cis or trans position conferred the highest protection against IDDM (RR = 0.08). Our findings confirm that protection against IDDM is provided by HLA-DQ loci but that susceptibility for IDDM is provided by both HLA-DRB1 and DQB1 loci. Our results also provide a new and more specific approach to determine the risk of any random Caucasian individual to develop IDDM. Indeed, increased susceptibility or protection against IDDM can be determined by the rapid and simple typing of DR beta 1Lys71, DQ alpha 1Arg52 and DQ beta 1Asp57 in a random person.

Characterization of gastric antral motility disturbances in diabetes using a scintigraphic technique.

In this study, food distribution in the stomach and gastric antral motor activity in patients with longstanding diabetes have been evaluated. With use of a standard gastric emptying test with an acquisition protocol and a refined Fourier algorithm to analyze the data, antral contractions have been characterized and gastric motility parameters were correlated to gastric retention in 20 diabetic patients with or without gastroparesis and in 10 healthy subjects. The results of this study show that, in longstanding diabetes, gastric emptying retardation is accounted for by a retention of food in the proximal stomach, which is reflected by a prolonged lag phase as well as by a reduction in antral motor activity that is determined by a decrease in the amplitude of the antral contractions. This study demonstrates that scintigraphy can noninvasively characterize abnormalities of food distribution in the stomach and provides information similar to that obtained from manometry.

Primary role of the HLA class II DRB1*0301 allele in Graves disease.

The association of the Graves disease (GD) with HLA DR3 and DQA1*0501 in Caucasians has been described previously. From these studies it could not be determined whether one specific locus was primarily involved. Using a case-control study design, we have examined the role of HLA class II gene polymorphisms in the predisposition for GD in a group of Belgian subjects. We demonstrated that both DRB1*0301 and DQA1*0501 alleles conferred significant susceptibility in the DRB1*0301-DQA1*0501 haplotype. The DRB1*0301 allele was the primary susceptibility allele for GD, however, because the susceptibility provided by DQA1*0501 was most likely due to it being in linkage disequilibrium with DRB1*0301. The DRB1*0701/x and DQA1*0201/x genotypes and the DRB1*0701-DQA1*0201 haplotype provided protection with an equal RR of 0.29. Predictive value calculations showed that testing for DRB1*0301 gave the highest positive predictive value for GD in females and males. This was, however, 10 times higher in females and predicted a 3.63% risk for a random female to develop GD.

Effects of l-thyroxine administration, TSH-receptor antibodies and smoking on the risk of recurrence in Graves' hyperthyroidism treated with antithyroid drugs: a double-blind prospective randomized study.

OBJECTIVE: In Graves' hyperthyroidism treated with antithyroid drugs (ATD), the overall relapse rate reaches 30-50% following ATD discontinuation. Conflicting results have previously been reported with regard to the usefulness of combining ATD with thyroxine (l-T4), and thereafter maintaining l-T4 treatment after ATD withdrawal. Also, clinicians are in search of useful parameters to predict the risk of a recurrence of hyperthyroidism after ATD treatment. DESIGN: Eighty-two consecutive patients (70 women and 12 men; mean age 36 years) with a first episode of Graves' hyperthyroidism were investigated prospectively; they were treated with ATD for a total of 15 months, combined with l-T4 (for at least 12 months) after they had reached euthyroidism, with the aim of maintaining serum TSH below 2.5 mU/l during the combined therapy. Following ATD discontinuation, the patients were randomly assigned (double-blind placebo-controlled trial) to taking 100 microg/day l-T4 (vs placebo) for an additional year. METHODS: The following determinations were carried out at initial diagnosis: serum total T4 and tri-iodothyronine (T3), free T4 and T3, TSH, TSH-receptor antibodies (TSHR-Ab), thyroid scintigraphy and echography. During ATD treatment, serum free T4 and T3 and TSH concentrations were recorded after 1 (optional), 2, 4, 6, 9, 12 and 15 months, and echography at the end of ATD treatment. During the randomized trial, serum free T4 and T3 and TSH concentrations were checked every 3 months (or until a recurrence). TSHR-Ab titers were measured at initial diagnosis, after 6 months with ATD, and at the end of ATD treatment. RESULTS: l-T4 administration, both during and after ATD treatment, did not improve the final outcome and recurrence rates were similar in placebo and l-T4-treated patients (30%). Two parameters were identified that might be useful to help predict recurrence risks after ATD: (i) positive TSHR-Ab (at the end of ATD treatment) was significantly associated with a greatly increased recurrence risk; and (ii) despite the relatively small number of patients who were smokers, regular cigarette smoking was shown, for the first time, to be significantly associated with an increased recurrence risk. Also, the deleterious effect of smoking was shown to manifest its impact independently of TSHR-Ab titers at the end of ATD treatment. Thus, compared with the overall 30% recurrence risk, non-smoking patients with a negative TSHR-Ab (at the end of ATD) had a lower (18%) recurrence risk; smoking patients with negative TSHR-Ab (at the end of ATD) had a 57% recurrence risk; non-smoking patients with positive TSHR-Ab (at the end of ATD) had a high (86%) recurrence risk; the recurrence risk was 100% in those few patients who both smoked and maintained a positive TSHR-Ab at the end of ATD treatment. CONCLUSIONS: The present study confirmed that l-T4 administration during and after ATD withdrawal did not improve remission rate. Two factors, namely positive TSHR-Ab at the end of ATD treatment and regular smoking habits may represent clinically useful (albeit not absolute) predictors of the risk of recurrence in patients with Graves' hyperthyroidism treated with ATD. However, due to the relatively small number of smoking patients in the present cohort, this conclusion needs to be confirmed by a larger study.

Slow-release lanreotide in the treatment of acromegaly: a study in 66 patients.

OBJECTIVE: Slow-release (SR) lanreotide is a long-acting somatostatin analog that has been developed in order to overcome the inconvenience of multiple daily subcutaneous injections of octreotide, required for metabolic control in acromegaly. Lanreotide SR has been found to be well tolerated and effective in reducing GH and IGF-I levels but clinical data are still limited compared with those with subcutaneous octreotide treatment. DESIGN: Sixty-six unselected patients with active acromegaly were therefore evaluated in a multi-center, prospective, open label study. Lanreotide SR was given at a dose of 30mg intramuscular every 7-14 days. METHODS: At baseline and after 2, 4, 8, 12, 24, 36 and 48 weeks patients underwent a clinical examination with assessment of acromegaly related symptoms, and blood was sampled for serum GH, IGF-I, prolactin, glycosylated hemoglobin, fasting glucose, hematology, kidney function and liver function tests. Biliary ultrasonography and pituitary magnetic resonance imaging were performed at baseline and after one year. RESULTS: Treatment resulted in a significant improvement in the symptom score from 2.69+/-0.27 to 1.06+/-0.17 (P<0.0001). Serum IGF-I levels fell from 699+/-38microg/l at baseline to 399+/-26microg/l (P<0.0001, n=60) after one month, after which levels remained stable: 480+/-37microg/l after 6 months (n=54) and 363+/-32microg/l after one year (n=46). GH levels dropped from 13.8+/-3.2microg/l to 4.3+/-0.7microg/l after one month (P<0.0001, n=60) and remained stable thereafter: 3.9+/-0.4microg/l (n=54) after 6 months and 3.5+/-1.1microg/l after one year (n=46). Twenty-nine out of 66 patients (44%) attained a normal age-corrected IGF-I level and 30 patients (45%) attained a GH level below 2.5microg/l. Pituitary adenoma shrinkage of at least 25% was found in 5 of 14 patients (36%) after one year. Side effects were mainly transient gastrointestinal symptoms and pain at the injection site, resulting in drug discontinuation in only 6 patients (9%). Two patients developed new gall stones. No difference was found between subcutaneous octreotide and lanreotide SR in efficacy and almost all patients preferred the easier dose administration of lanreotide SR. CONCLUSIONS: Long-term treatment of acromegaly with SR-lanreotide is effective in controlling GH and IGF-I levels and symptoms and is well tolerated in the majority of patients. Compared with subcutaneous octreotide, lanreotide SR considerably improves patient's acceptance of therapy while having the same overall efficacy.

Erythrocyte cation transport systems and membrane lipids in insulin-dependent diabetes.

The relationship between erythrocyte cation transport systems and membrane and plasma lipids was examined in normal men and patients with insulin-dependent diabetes mellitus (IDDM). Different measurements of erythrocyte transport systems were obtained in patients with IDDM and in age- and weight-matched healthy men: Na+:Li+ countertransport activity or Li(+)-stimulated Na+ efflux, Na+:K+ cotransport activity or bumetanide-sensitive Na+ efflux, Na+:K+ pump activity or ouabain-sensitive Na+ efflux, and the ouabain- and bumetanide-resistant Na+ and K+ fluxes or the ground membrane permeability for Na+ and K+ as well as the intraerythrocyte Na+, K+, and Mg2+ concentrations. Plasma cholesterol, triglycerides, phospholipids, low- and high- density lipoprotein cholesterol, and erythrocyte membrane cholesterol and phospholipid content were obtained from the fasting subjects. The patients with IDDM had an elevated (P < .05 or less) erythrocyte Na+:Li+ countertransport activity, ground membrane leak for K+, intraerythrocyte K+ concentration, and erythrocyte membrane cholesterol content, but a lower red blood cell phospholipid content. In single regression analysis, the erythrocyte Na+:Li+ countertransport, Na+:K+ cotransport, and Na+:K+ pump activity and ground membrane leak for Na+ and K+ were inversely related to the red blood cell membrane lipid content. Our data in patients with IDDM show that a decreased erythrocyte membrane lipid content was accompanied by a higher erythrocyte Na+:Li+ countertransport, Na+:K+ cotransport, and Na+:K+ pump activity.

Erythrocyte cation transport systems in insulin-dependent diabetics: correlation with prorenin and albuminuria.

The relationship between erythrocyte cation transport systems, plasma prorenin and albuminuria was examined in patients with insulin-dependent diabetes mellitus (IDDM). Different measurements of erythrocyte transport systems were obtained in patients with IDDM: Na+/Li+ countertransport; Na+/K+ cotransport and Na+/K+ ATPase pump activity. In single regression analysis the erythrocyte Na+/Li+ countertransport was positively related to the plasma prorenin level. In multiple regression analysis the erythrocyte Na+/Li+ countertransport activity was independently related to plasma prorenin, albuminuria and age. Our data in patients with IDDM show that an elevated erythrocyte Na+/Li+ countertransport is accompanied by a higher plasma prorenin level and albuminuria.

The measurement of fecal thyroxine in the diagnosis of thyrotoxicosis factitia.

Two patients with prolonged thyrotoxicosis are presented with low radioiodide uptake, low-normal serum thyroglobulin concentrations, and low iodide content of the neck on x-ray fluorescence studies. The surreptitious intake of thyroid hormone was directly proven by a high fecal concentration of T4 (12.38 and 23.99 nmol/g) compared with low concentrations in healthy subjects (1.03 +/- 0.64 nmol/g; mean +/- SD, n = 6) and in patients with hyperthyroidism due to Graves' disease (1.93 +/- 1.86; n = 8). Fecal thyroid hormone measurement may help to provide formal proof of factitious thyrotoxicosis.

Syndrome of myxomas, spotty skin pigmentation, and endocrine overactivity (Carney complex).

A male patient is described with melanocytic schwannoma, atrial myxoma and spotty pigmentation in the face due to Carney complex. Remarkable findings are fertility problems with bilateral macroorchidism and oligoasthenospermia.

[Postoperative analgesia: epidural injection of dexamethasone sodium phosphate]. / Analgésie postopératoire: injection péridurale de phosphate sodique de dexaméthasone.

Epidural administration of steroids has been suggested for the prevention of postoperative epidural fibrosis after lumbar lamino-arthrectomy. In order to assess the efficacy of this technique on pain occurring after such surgery, the demand of pentazocine during the first 24 postoperative hours was studied in 39 patients randomly assigned to two groups. Pain intensity was assessed by a five-point verbal scale (0: none; 1: poor; 2: moderate; 3: severe; 4: very severe) at five intervals (0-4, 5-8, 9-12, 13-16 and 17-24 h). The patients in group T (n = 20) did not receive any steroid, whereas those in group C (n = 19) were given, just after the end of surgery, a single dose of dexamethasone (4 mg) via an epidural lumbar catheter previously inserted by the surgeon. In group T, 18 patients required one or several intramuscular injections of pentazocine, whereas only three patients of group C (p less than 0.001) did so. Patients in group T expressed more severe pain (4 moderate, 12 severe, 3 unbearable) than those patients who had received steroids (1 moderate, 1 severe, 1 unbearable). As a consequence, they requested more pain killer (30 injections vs 8 injections, respectively; p less than 0.001) and sooner than patients of the steroid group (8 h vs 12 h; p less than 0.05). It was concluded that epidural administration of dexamethasone was helpful in preventing postoperative pain after lumbar lamino-arthrectomy.

[Epitrochleoplasty: a method for release and protection of the ulnar nerve at the elbow]. / L'épitrochléoplastie: un procédé de libération et de protection du nerf cubital au coude.

The authors have modified the technique of excision of the medial epicondyle used in the course of release of the ulnar nerve. After excision of the epicondyle, a flap is made from the posterior band of the ulnar collateral ligament passing between the epicondyle and the olecranon, prolonged by the fibro-periosteal tissue covering the medial epicondyle. This flap is interposed between the nerve and the joint. This technique has been used on 10 occasions and seems to be superior to transposition of the nerve to the front of the medial epicondyle or to isolated excision of the medial epicondyle.

[Pseudarthrosis of the lower end of the radius due to interposition of the long extensor of the thumb]. / Pseudarthrose de l'extrémité inférieure du radius par interposition du long extenseur du pouce.

The authors describe one case of a severely displaced Smith's fracture which was originally immobilised by external fixation. Three month's later the fracture had not united and active extension of the thumb was absent. At operation, the extensor pollicis longus tendon was found to be dislocated into the fracture site. The tendon was repaired and the non-union was treated by plating. A review of the literature discovered only one other similar case.