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

Intraoperative measurement of parathyroid hormone in minimally invasive surgery for parathyroid adenoma.

INTRODUCTION: In the past bilateral neck exploration was the gold standard for successful surgical management of primary hyperparathyroidism. More restricted procedures have been introduced recently thanks to imaging techniques and intraoperative parathyroid hormone assay confirming eradication of hyperfunctioning tissue. METHODS: Thirty patients operated for parathyroid adenoma were submitted to intraoperative PTH determination with Quick Pack immunochemiluminescent assay (Nichols lab.) prior to excision and 5, 10 and 20 minutes after removal of the presumed hyperactive gland. Eleven patients were operated on by a minimally invasive procedure with videoassistance. RESULTS: Response to excision of the hyperfunctioning gland was evidenced by a significant decrease of PTH levels (50% of initial value) in 26 patients. Plasma PTH levels decreased by at least 80% of pre-excisional value after 20 minutes, 70% after 10 minutes and by 50% after 5 minutes. In 2 cases, significant decrease of PTH was obtained after 45 and 60 minutes respectively. In 2 other cases, the adenoma could not be found and there was no decrease of PTH even after extensive exploration of the neck. In the 11 patients who underwent minimal invasive surgery, 2 were converted to open neck surgery: in one case the adenoma was not accessible in the upper part of the neck, in the other case the hyperfunctioning gland remained undiscovered. CONCLUSION: intraoperative measurement of PTH should be considered a reliable and reproducible method for evaluation of the secreting activity of a parathyroid gland. The Quick Pack method has the advantage of confirming that the hyperactive gland has really been eradicated and consequently of considerably reducing operating time and avoiding extensive exploration of the neck.

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.

[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.

Presurgical localization of abnormal parathyroid glands using a single injection of technetium-99m methoxyisobutylisonitrile: comparison of different techniques including factor analysis of dynamic structures.

Single-tracer methoxyisobutylisonitrile (MIBI) imaging is considered to be a sensitive method for the localization of abnormal parathyroid glands. The aims of this study were to determine which of the analytical techniques described for this method - visual comparison of early (15-min) and late (120-min) images, use of time-activity curves (TACs) generated on regions of interest and factor analysis of dynamic structures (FADS) - corresponds best with surgical findings, and to ascertain the potential overall contribution of presurgical scintigraphy. Fifty-five patients were studied, 34 of whom presented with primary hyperparathyroidism (HPT) and 21 with secondary HPT. After a 925 MBq injection of technetium-99m MIBI, a 40-min dynamic acquisition was performed and static images were acquired at 5, 20, 40 and 120 min using a gamma camera equipped with a pinhole collimator. The dynamic series were submitted to FADS, an attractive non-operator-dependent technique, and TACs were generated on regions of interest after the visual comparison of early and 120-minute images (15'-120'). The presumed localizations of abnormal glands were compared with a sketch drawn by the surgeon. Sensitivity was defined as the percentage of true-positive localizations and was 84.4%, 74% and 65% in adenoma and 76%, 66.6% and 45% in hyperplasia for 15'-120', FADS and TACs, respectively. Surgical accuracy, i.e. the percentage of patients accurately and completely described, was 72%, 56% and 59% in adenoma and 53%, 30% and 22% in hyperplasia for 15'-120', FADS and TACs, respectively. The visual comparison method scored best in all cases. FADS was found to be sensitive in cases of adenoma but was handicapped by more false-positive localizations. TACs were particular inefficient in hyperplasia. With respect to the detection of adenomas, we found a relationship between the gland weight and scintigraphic positivity. This dependence on gland weight was not found in hyperplasia. The poorer results obtained with all techniques for surgical accuracy can be explained by the need for a complete scintigraphic description of all pathological glands found by the surgeon in a patient. This study demonstrates that the 15'-120' visual comparison method is more efficient and less cumbersome than TAC or the attractive FADS technique. However, it was less efficient than neck exploration by an experienced surgeon. Therefore, in our institution, scintigraphic studies are now only requested in selected cases of HPT, usually primary HPT and cases undergoing re-operation.

Impact of growth hormone treatment on a Belgian population of short children with renal allografts.

We retrospectively analyzed the effects of recombinant human growth hormone (rhGH) in a Belgian population of 36 short children with renal allografts. Seven children were dropped from the growth study: 1 had skeletal dysplasia and in 6 cases rhGH was given for less than 1 yr (1 died, 1 developed genu valgum, 2 were non-compliant and 2 grafts deteriorated). Final height was reached in 17 patients, and 12 children were still growing at the end of the study. Median height standard deviation score (SDS) in the 29 patients was -2.3 at the time of transplantation, and -2.7 when rhGH therapy was initiated. During rhGH therapy (median duration 3.2 yr, range 0.6-7.7 yr), height SDS increased by a mean of 0.4 per year, and bone maturation was not accelerated. Final height reached was 162.7 (149.0-169.5) cm (median SDS -1.8) in males and 151.0 (130.5-169.5) cm (median SDS -1.9) in females. Final height is significantly greater in males than females compared with a historical control group of untreated patients. Final height is within the parental target height range in 6 out of the 17 patients. The increase in height SDS in patients who were at an advanced stage of puberty (Tanner stages 4-5) when rhGH therapy was initiated exceeded our expectations (mean height gain 14.2 cm in boys and 10 cm in girls). In the cohort of 36 children, 4 patients developed an acute allograft rejection, all of whom had an underlying chronic rejection. This resulted in 3 graft losses within 5 yr. Our results indicate that rhGH treatment has a positive effect in short children with renal allografts, even if it is started in late puberty. In the presence of underlying chronic rejection, rhGH treatment needs careful monitoring to minimize the risk of graft loss.

Total parathyroidectomy and presternal subcutaneous implantation of parathyroid tissue for renal hyperparathyroidism.

When hyperparathyroidism recurs in patients previously treated by total parathyroidectomy and intramuscular parathyroid autotransplantation, excision of the graft is not always technically easy and it is often necessary to resect the portion of the muscle containing the implants. During November 1986, we began a program to test the feasibility of presternal subcutaneous autotransplantation of parathyroid tissue. We hoped this technique would make removal of the grafts simpler. Thirty-six patients with renal hyperparathyroidism (RHPT) received subcutaneous parathyroid implants. Persistent or recurrent hyperparathyroidism was observed in three patients during the follow-up period. The presence of active parathyroid tissue was demonstrated after some time in all the patients. The parathyroid implants were easily excised in three instances (one persistent RHPT and two recurrences). Microscopic examination of the resected specimens did not show any sign of malignant transformation. We conclude that presternal subcutaneous implantation of parathyroid tissue after total parathyroidectomy is a quick, safe and efficient surgical procedure in the treatment of RHPT.