Magnetic resonance imaging of the sternal extremity of the clavicle in forensic age estimation: towards more sound age estimates.

OBJECTIVES: The development of the sternal extremity of the clavicle was examined prospectively with magnetic resonance imaging (MRI) for forensic bone age assessment. The objectives were to examine whether these results were comparable with the literature on plain radiography and CT, to provide age prediction intervals that correctly reflect the high variability in clavicular growth among individuals and to investigate whether MRI of the clavicle can be used to differentiate between individuals younger or older than 18 years. METHODS: The clavicles of 220 volunteers (16-26 years) were examined with 3-T MRI and evaluated according to the Schmeling and Kreitner classification (Schmeling, Int J Legal Med 118:5-8, 2004; Kreitner, Eur Radiol 8:1116-1122, 1998). An additional hand/wrist radiograph was taken and evaluated according to Greulich and Pyle (1959). After a descriptive analysis, a multivariate ordinal regression model was fitted and embedded in a Bayesian framework based on Thevissen et al. (Int J Legal Med 124:35-42, 2009). RESULTS: The descriptive results were concordant with the literature, although the Kreitner classification is recommended and simultaneous evaluation of the hand is considered a basic requirement (Schmeling, Int J Legal Med 118:5-8, 2004). The 95 % credibility interval for both genders with bilateral stage IV is 20-26 years. The corresponding estimated probability of being younger than 18 years is 0.8 % in females and 0.2 % in males. CONCLUSION: MRI of the sternal extremity of the clavicle can be used to differentiate between being younger or older than 18, but a simultaneous evaluation of the hand/wrist is essential. Future evaluation of the predictive performance of the model, using comparable but larger reference samples, is necessary to validate these results.

[Pediatric nephrology from the fetal kidney to the kidney graft]. / La néphrologie pédiatrique du rein foetal au rein greffé.

The department of pediatric uro-nephrology was created in 1977 in Brugmann hospital. Since then, various sectors have been developed including: hemodialysis and peritoneal dialysis, kidney transplantation, urological and genital surgery, antenatal screening and rapid management of uronephropathies, treatment of voiding dysfunction and neurogenic bladder, management of tubular and glomerular diseases. The progress in genetics, medical imaging, obstetrics, neonatology and surgery has allowed us to take care of our young patients within a multidisciplinary framework. The most original contributions of the department are related to the performance of combined liver-kidney transplantation in primary hyperoxaluria, to the determination of the natural history of several congenital anomalies of the kidney and urinary tract, to the assessment of the role of genetic mutations on tubular and glomerular diseases, to the usefulness of radioisotopic tracers in the measurement of renal function in infants, and to the study of experimental tolerance of allografts. The transition of young renal patients from pediatric to adult care is actually well organized due to our 30 years experience and the excellent collaboration with the adult nephrologists.

[Experience about more than 2000 renal transplantations at the university of Brussels]. / A propos de 2000 greffes rénales a l'U.L.B.: le parcours d'un patient transplanté rénal en 2007.

Since 1965, more than 2000 renal transplantations (including more than 100 living-donor transplantations) have been performed at the University of Brussels. An end-stage renal disease patient candidate to renal transplantation will be therefore followed from his enrolment on the waiting list to the long-term post-transplant period. Improvement in the outcome of renal transplantation is achieved due to better knowledge in many fields of medicine, such as immunology, infectious disease, metabolic diseases (hyperlipemia, diabetes mellitus), pharmacology, use of immunosuppressive regimen, a more adequate cardiovascular prevention and treatment. If the best results were achieved with kidneys from living donors, the graft survival rate at the University of Brussels was nearly 80% for the last period (2000-2006). Unfortunately, renal transplantation cannot cure certain comorbid conditions and even may promote them: infectious diseases, neoplasia, metabolic disorders (e.a diabetes mellitus, hyperlipemia). Many efforts have to be done to develop less toxic and more immune selective therapeutic strategies. Living donation and extension of the pool of cadaveric donors will reduce the length of time spent on the waiting list and will significantly impact on mortality and morbidity after kidney transplantation.

[The medico-surgical department of uro-nephrology, dialysis and renal transplantation in the Children's Hospital of Brussels]. / Le département médico-chirurgical d'uro-néphrologie, dialyse et transplantation rénale à l'HUDERF.

The department of pediatric uro-nephrology was created in 1977 in Brugmann hospital. Since then, various sectors have been developed including: hemodialysis and peritoneal dialysis, kidney transplantation, urological and genital surgery, antenatal screening and rapid management of uronephropathies, treatment of voiding dysfunction and neurogenic bladder, management of tubular and glomerular diseases. The progress in genetics, medical imaging, obstetrics, neonatology and surgery has allowed us to take care of our young patients within a multidisciplinary framework. The most original contributions of the department are related to the performance of combined liver-kidney transplantation in primary hyperoxaluria, to the determination of the natural history of several congenital anomalies of the kidney and urinary tract, to the assessment of the role of genetical mutations on tubular and glomerular diseases, to the usefulness of radioisotopic tracers in the measurement of renal function in infants, and to the study of experimental tolerization of

Renal hematoma in a patient undergoing hemodialysis. Complication of acquired renal cystic disease.

A spontaneous renal hematoma developed in a patient treated by long-term intermittent maintenance hemodialysis. This scanty complication of hemodialysis was related to the recently described acquired cystic disease of the kidneys. Diagnosis was ascertained before nephrectomy by computed tomography and selective renal angiography.

Hypocalcemia after thyroidectomy.

Serum calcium, sodium, potassium, chloride, magnesium, phosphorus, osmolarity, total protein, albumin, parathyroid hormone, and calcitonin values were systematically surveyed in 135 patients who underwent thyroidectomy and in 104 control surgical patients. A transient and moderate hypocalcemia developed after operation in thyroidectomized and control patients. Concentrations of other electrolytes, osmolarity, proteins, and albumin followed the same pattern of evolution. After thyroidectomy, the degree and duration of hypocalcemia increased with the extent of thyroid resection. A profound hypocalcemia (less than 2.0 mmol/L) and a marked reduction of the parathyroid hormone concentration (below normal) were present in 12% and 8% of cases after subtotal thyroidectomy and in 22% after total thyroidectomy. Calcitonin values did not increase after thyroidectomy. A slight correlation was observed between the preoperative serum alkaline phosphatase level and the minimal postoperative serum calcium level. It is concluded that post-thyroidectomy hypocalcemia is a multifactorial phenomenon. It is due, at least in part, to hemodilution. A temporary parathyroid insufficiency after subtotal and total thyroidectomy, and an avidity of the skeleton for calcium in hyperthyroid patients, may aggravate the hypocalcemia.

Long-term results of subcutaneous parathyroid grafts in uremic patients.

HYPOTHESIS: Parathyroid glands are normally surrounded (entirely or partially) by fatty tissue. Subcutaneous parathyroid grafts are thus located in a normal environment. Therefore, we postulated that the late results of subcutaneous implantation of parathyroid tissue in uremic patients should be at least as good as those reported for intramuscular grafting. We also challenged the idea that the recurrence rate of renal hyperparathyroidism after surgery depended solely on the type of hyperplasia (diffuse vs nodular) observed in the implanted tissue. DESIGN: A retrospective study of a series of patients without loss to follow-up. SETTING: A university hospital and 9 affiliated dialysis units. PATIENTS AND INTERVENTIONS: Fifty-nine patients (33 women and 26 men) operated on for renal hyperparathyroidism underwent the resection of at least 4 parathyroid glands followed by presternal subcutaneous implantation of parathyroid tissue. They were followed up for 12 to 130 months (median, 38 months). MAIN OUTCOME MEASURES: Failure of treatment, recurrence of disease, and hypoparathyroidism. RESULTS: During the study period, 9 patients had to undergo another operation: 2 (3%) for persistent hyperparathyroidism due to a fifth ectopic gland and 7 (12%) for recurrence of hyperparathyroidism resulting from hypertrophy of the subcutaneous grafts. Four patients received a kidney transplant. The prevalence of hypoparathyroidism (intact parathyroid hormone serum level <1.6 pmol/L with a normal or low serum calcium concentration) was 14% (8 of 59 patients), and the curve representing the distribution of intact parathyroid hormone serum concentrations among operated on patients was shifted to the left when compared with the curve of patients who underwent hemodialysis and who had no indication for parathyroid surgery. In this latter group, the peak of the curve was situated between 1 and 2 times the upper normal limit, while it was in the normal range 12 to 130 months after total parathyroidectomy and subcutaneous parathyroid autotransplantation. No relation was observed between the recurrence rate of the disease and the histological characteristics of the parathyroid grafts. Also, their function was not influenced by the presence or absence of aluminum deposits in bone biopsy specimens that were obtained at the time of cervical exploration. CONCLUSIONS: The late results of total parathyroidectomy and presternal subcutaneous grafting compare favorably with the published data on other surgical techniques proposed for the treatment of renal hyperparathyroidism. The ease with which the hypertrophied grafts are removed when the disease recurs warrants further use of this procedure.

[Postoperative pancreatitis, hyperamylasemia and amylase isoenzymes after parathyroidectomy for primary hyperparathyroidism]. / Pancréatites, hyperamylasémies et isoenzymes de l'amylase dans les suites opératoires des parathyroïdectomies pour hyperparathyroïdie primaire.

Recent studies have cast doubt on the concept of causative association between parathyroidectomy for primary hyperparathyroidism and postoperative pancreatitis. The present study indicated that the relationship was real and that the development of acute pancreatitis after parathyroid surgery was not purely incidental. Acute pancreatitis was observed postoperatively in 3 p. 100 of cases after parathyroidectomy (6/196 cases), in 37 p. 100 after pancreatic surgery (19/51 cases), but never after thyroidectomy (100 cases) or other extra-abdominal operations (100 cases). During the first five postoperative days, the incidence of hyperamylasemia was 16 p. 100 after parathyroidectomy, 47 p. 100 after pancreatic surgery, 3 p. 100 after thyroidectomy, 2 p. 100 after other extra-abdominal operations. During the same period, the frequency of hyperlipasemia was similar: 20 p. 100 after parathyroidectomy, 54 p. 100 after pancreatic surgery, 1 p. 100 after thyroidectomy, 0 p. 100 after other extra-abdominal operations. In all cases with hyperamylasemia after parathyroidectomy, the pancreatic fractions of amylase isoenzymes were abnormally elevated.

Surgical anatomy of hyperparathyroidism.

The number of glands and the exact location of each normal and pathological parathyroid identified in 416 parathyroidectomies for primary and secondary hyperparathyroidism have been recorded during the last 25 years (1966-1990). Nineteen per cent of all glands were found in ectopic locations. Half of these were distant from the thyroid lobes, most frequently posteriorly alongside the oesophagus, or in the upper anterior mediastinum encapsulated in the thymic remnant. Their discovery required, in some cases, extensive dissections, but a sternotomy was necessary in two cases only. Parathyroid glands may be concealed in the thyroid or in other aberrant locations, more rarely encountered. Supernumerary parathyroids were observed in 5% of cases. They were often pathological and were often in abnormal positions. A sound knowledge of the anatomic variations and of the paths of embryologic migration of the parathyroids are the essential clues for their detection.

[Giant condyloma of the anus: tumor of Buschke-Loewenstein (author's transl)]. / Condylome acuminé géant de l'anus: tumeur de Buschke-Loewenstein.

The authors report a case of a Buschke-Loewenstein tumor located at the anus. Initial treatment with Bleomycin was remarkably effective. A recurrence 3 months later did not respond any more to Bleomycin. Multiple surgical resections were performed in association with this form of chemotherapy.

Granuloma of the distal extremity of the ureter in kidney transplantation.

A granuloma of the distal extremity of the transplanted ureter was diagnosed in 8 of 180 patients operated on according to the Lich-Gregoir technique. This lesion was not observed in 116 patients with Politano-Leadbetter ureterovesical anastomosis nor in 61 patients with a ureterocystostomy constructed according to the technique of De Campos Freire et al. This complication seems to be specific of the Lich-Gregoir technique.

[Reoperations in parathyroid surgery]. / Les réinterventions en chirurgie parathyroïdienne.

In a continuous series of 439 parathyroidectomies for primary or secondary hyperparathyroidism, 36 cases were reoperations. The initial operation had been a prior parathyroid exploration (PTx) in 17 cases, a thyroidectomy (Tx) in 17 cases, both operations in two cases. The incidence of parathyroid glands discovered at exploration was lower in both types of reoperations (67% after Tx, 72% after PTx) than in patients who were explored for the first time (94%). Anatomical variations and parathyroid pathologies were comparable in patients reoperated after Tx and in those explored for the first time. In patients reoperated after PTx, anatomical abnormalities (46% of glands in ectopic locations, 12% of supernumeray glands) and multiglandular pathologies (56% of hyperplasias) were much more frequently encountered. Long term results were satisfactory in patients explored for the first time (98% cures) and in reoperations after Tx (94% cures), but were less favourable in reoperations after PTx (78% cures).

[To what extent is organ procurement acceptable? From principles to reality]. / Dans quelle mesure le commerce d'organes est-il acceptable? Des principes à la réalité.

Organ trade is unlawful; organ gift is promoted on condition it is gratuitous, anonymous and spontaneous. The idea of graft and transplantation is understood differently according to culture, religion and ability of a region to supply to its needs in the field of health. The patient's eagerness can explain his quest of a donor in whatever country he is. Even those physicians who have strict ethical guidelines must pay attention not to be involved in blameable jobs. The only way to avoid rewarded organ gifts is to prohibit transplantation touring and grafting from friends, at the risk to loose true-hearted and noble donors.

[What degree of freedom is there for living donors?]. / Quel degré de liberté y a-t-il pour un donneur vivant?

The shortage of cadaveric donors has induced a renewed interest in living kidney donation. This paper describes the legal, religious and ethical factors which ensure or restrict the autonomy of the potential donor. We conclude that it is possible with appropriate measures to protect his freedom of choice.

[Persistent and recurrent hyperparathyroidism following parathyroidectomy]. / Hyperparathyroïdies persistantes et récidivantes après parathyroïdectomie.

In a series of 416 parathyroidectomies for primary or secondary hyperparathyroidism, 19 were reoperations for persistence (17 cases) on recurrence (2 cases) of the disease. (1) Preoperative localisation studies were useless in half of the cases. (2) In re-explorations, 72% only of parathyroid glands were discovered, 46% of them in ectopic locations. In reoperations for primary hyperparathyroidism, 56% of cases had more than one pathological gland. (3) Long term results have been less satisfactory after re-explorations than after the first operations.