The Medicaid Home and Community-Based Waiver and supported employment.

The Medicaid Home and Community-Based (HCB) Waiver is the primary funding source for long-term care for individuals with developmental disabilities. Findings from a national survey of 48 state coordinators regarding waiver-funded supported employment services are presented. Very low utilization for this service was found, primarily due to limits on eligibility. However, respondents in 18 states reported large numbers of waiver participants receiving employment services under other service categories. Eleven states had waiting lists for waiver-funded supported employment, totalling three times those actually receiving services. Low reimbursement rates to provider agencies and disinterest of providers in using waiver funds were significant barriers to expansion of service capacity.

[Isolated avulsion fracture of the lesser tuberosity of the humerus. Apropos of a case]. / Fracture-avulsion isolée du tubercule mineur de l'humérus. A propos d'un cas.

PURPOSE OF THE STUDY: The authors report a rare case of an isolated avulsion fracture of the lesser tuberosity of the humerus in an adult. The aim of the study was to highlight diagnostic features as well as surgical treatment. MATERIAL: A 31 year old woman presented an isolated avulsion fracture of the lesser tuberosity of the humerus. Physical exam, standard radiographs of the shoulder as well as a computed tomographies (CT) were obtained. METHODS: An assessment was made of the patient's complaints, signs and symptoms, diagnosis, surgical treatment, physical therapy and follow-up. Final clinical results were evaluated according to external rotation and muscular strength of the shoulder. RESULTS: The diagnosis was evoked on standard radiographs of the shoulder and confirmed by CT. The patient was operated on the 8th day following trauma and pendular physical therapy was initiated on the third day postoperatively. The patient recovered her daily activities from the 6th week and was back at work by the end of the 2nd month. Follow up at 12 months showed a painless shoulder with external rotation at 50 degrees in adduction and 70 degrees in abduction. Muscular strength was identical to the contralateral side. No antero-medial impingement was detected due to the hardware. DISCUSSION: This observation illustrates the rare aspect of this fracture, already recognized in literature. The fracture mechanism remains unknown. We agree with Haas, Ross and Love that it might be due to a forced external rotation of the shoulder at 60 degrees of abduction. We highlight the role of the "axillary view" and of the magnetic resonance imaging (MRI) in the diagnostic approach. Treatment is surgical by open reduction and internal fixation of the detached fragment. CONCLUSION: Treatment must be surgical whenever there is a slight displacement of the detached fragment, to prevent non union, mal union or an antero-medial impingement that might limit mobility and muscular strength.

[The value of magnetic resonance imaging in the diagnosis of spinal cord hemangioblastoma. Apropos of 12 cases]. / Intérêt de l'imagerie par résonance magnétique dans le diagnostic des hémangioblastomes médullaires. A propos de 12 observations.

This study concerned a series of 12 patients, 4 of whom had Von Hippel-Lindau disease. Six of these patients were explored by myelography, 6 by spinal cord angiography, 8 by CT scan with contrast injection and 12 by MRI, with gadolinium injection in 8. MRI proved to be the choice examination for the diagnosis of spinal cord tumor, but gadolinium injection was necessary since it made it possible to detect the tumoral bud and its intense enhancement. The absence of gadolinium injection led us to an erroneous initial diagnosis of syringomyelia in two patients and glioma in one. Sagittal sections made it easier to evaluate the tumoral extension in patients with evidence or suspicion of Von Hippel-Lindau disease. Arteriography was indicated, as it provided a preoperative map and diagnosed punctiform lesions.

[Palliative treatment of myopathies. Contribution of surgical treatments]. / Traitement palliatif des myopathies. Apport des traitements chirurgicaux.

The knowledge acquired over the last few years on Duchenne's muscular dystrophy (DMD) serves as the basis for management of all types of myopathy. After reviewing the current classification of muscle dystrophies and the principles of orthopedic management of these conditions, a historical perspective of surgical procedures used in DMD is presented. The various modes of discovery of myopathy are described. Deformities of the limbs and spine related to DMD are reviewed and their outcome is detailed. In DMD patients, the surgical procedures described allowed to delay loss of the ability to walk by 1 year 7 months to 3 years 8 months according to the severity of the condition, and provided significant improvements in quality of life. Surgical stabilization of the scoliosis ensured preservation of comfortable sitting in every case, as well as preservation of autonomous upper limb motion, with a low rate of complications. Surgical indications in DMD are well-established and serve as the basis for making surgical decisions in the other myopathies, except during early infancy. The principles and orientations of treatment of the other myopathies are defined, in the light of the variability of lesions and of the rate of muscle function loss. In these non-DMD myopathies, medical and surgical treatments are of as yet unquantifiable benefit but provide a substantial improvement in quality of life.

[Paroxysmal kinesigenic choreoathetosis: autonomic disease or reflex epilepsy?]. / Choréo-athétose paroxystique kinésigénique: affection autonome ou épilepsie réflexe?

Motor attacks induced by voluntary movements are infrequent. Paroxysmal kinesigenic choreoathetosis (PKC) is rare and has only recently been individualized (Kertesz, 1967). We report the case of an 8 year-old boy who developed unilateral or bilateral attacks of abnormal, choreoathetotic movements during certain voluntary movements, especially when rising after a rest. The attacks were short (13 to 18 seconds) and frequent. Neurological examination was normal, as were the intelligence quotient, the inter-critical and critical EEG: CT and MRI. The patient's mother had suffered from the same disorder. The attacks disappeared during treatment with phenytoin but reappeared when it was stopped. This case is concordant with data from the literature, with male predominance, age from 6 to 15 years at the onset, shortness of the attacks (less than 1 minute in 80% of the cases) and normality of investigations in almost every patient. A familial factor has been found in 50% of the cases. The frequency of epilepsy in the family is above average. PKC can easily be distinguished from Mount and Reback' syndrome where the attacks are choreoathetotic but longer and unprovoked by movements and where there is also a familial factor. The relationship of PKC with epilepsy is asserted by some authors and denied by others, and in the literature the distinction between movement-induced tonic seizures and PKC is not always clear. Some authors have blamed a disturbance in the maturation of basal ganglia. To sum up, PKC is a very rare condition which is easy to diagnose, has a good prognosis and readily responds to antiepileptic drugs.

Metabolic and hormonal responses to lipid and carbohydrate diets during exercise in man.

Nine healthy subjects were studied to determine their performance and the metabolic and hormonal responses to prolonged exercise after ingestion of a carbohydrate or a lipid diet. Subjects exercised on a bicycle ergometer (60% VO2max) until exhaustion four times at weekly intervals. The exercise test was performed 1 h after ingestion of three different isocaloric meals (400 Kcal) containing either glucose, medium-chain triglycerides (MCTs) or long-chain triglycerides (LCTs). The fourth test was performed after a night fast. The metabolism of these nutriments was followed using [U-13C]glucose, [1-13C]octanoate, and [1-13C]palmitate added as tracers. The average work time was comparable whatever nutriment used (116 +/- 11 min). Oxidation of the ingested nutriment over this period was 80% for glucose, 45% for MCTs, and 9% for LCTs. Glucose ingestion produced an early insulin peak associated at the end of the exercise with a lower glycemia compared to the fat diets. After MCT ingestion, an increase in ketone bodies was observed. Catecholamine response to physical exercise was decreased by all the meals when compared to fasting. Thus, we conclude that a different lipid meal, MCTs, or LCTs, compared to glucose feeding, do not modify exhaustion time in spite of differences in hormonal and metabolic responses.

[Congenital oculomotor apraxia with corpus callosum agenesis and subtentorial atrophy]. / Apraxie oculomotrice congénitale avec agénésie du corps calleux et atrophie sous-tentorielle.

A 7 year-old child with congenital oculomotor apraxia (Cogan's syndrome) presented with mainly voluntary horizontal saccadic movements. Fixation of a visual target could be obtained only by a sudden movement of the head preceded by eyelid blinking. Electro-oculography confirmed the predominant disturbance of saccadic movements (delay in onset, hypometria). CT scan showed agenesis of the corpus callosum and atrophy of the vermis together with enlargement of the 4th ventricle and pre-pontine cisternae. The role of these anomalies in the pathogenesis of this rare congenital syndrome of good prognosis is discussed.

[Cranial osteosarcoma in Paget's disease]. / Ostéosarcome du crâne sur maladie de Paget.

A patient with Paget's disease developed an osteogenic sarcoma of the cranium. This emphasizes the need to conduct full neuroradiological investigations, including a CT scan and even selective arteriography as well as standard radiographs, whenever the possible existence of such a lesion is suspected, to determine therapeutic strategy.

[Determination of the percentage of grain whisky in commercial whiskies by isotopic mass spectrometry]. / Détermination du pourcentage de whisky de grain dans les whiskies commerciaux par spectrométrie de masse isitopique.

Commercial whisky is generally a blend between malt whisky and grain whisky. Corn is one of the main sources of grain and it is now well known that in corn the carbon dioxide assimilation proceeds through carboxylation of phosphoenolpyruvate but in many other plants like barley atmospheric carbon dioxide is fixed on ribulose 1,5 diphosphate. Each pathway of carbon dioxide assimilation is characterized by a fractionation factor of carbon isotopes. Consequently, the organic matter and also the fermentation alcohol of corn or barley show different 13C/12C ratio. The determination of the 13C/12C ratio in the alcohol of blended whisky allows the determination of the percentage of corn whisky.

[High-performance liquid-liquid chromatography in beverage analysis]. / Application de la chromatographie liquide liquide à haute performance à l'analyse des boissons.

Liquid liquid chromatography was performed with columns packed with stationary phases chemically bonded to silica microparticules. These columns show a high efficiency and are used very easily. Flavouring compounds like aromatic aldehydes which have a low volatility were analyzed in brandy using a polar phase alkylnitrile. Sapid substances like amarogentin in Gentiana lutea or glyryrrhizin in Glycyrrhiza glabra were determined by reversed phase chromatography. Finally ionizable substances like synthetic dyes can be analyzed by paired ion chromatography witha non polar stationary phase.

[Use of ethanol naturally enriched in carbon 13 for metabolic studies]. / Utilisation d'éthanol naturellement enrichi en carbone 13 pour des études métaboliques

The ratio of carbon 13 to carbon 12 is higher in organic substances which originate from corn or cane, as compared to most higher plants. Cane alcohol or corn alcohol are enriched in carbon 13 as compared to common European foods. This discovery provided a new technique for alcohol metabolism studies with animals or men. The ratio of carbon 13 to carbon 12 is measured by mass spectrometry in the carbon dioxide expired after administration of cane or corn alcohol. This ratio increases significantly and reaches a maximum when the blood alcohol level has decreased considerably.