Persistent warm Mediterranean surface waters during the Roman period.

Reconstruction of last millennia Sea Surface Temperature (SST) evolution is challenging due to the difficulty retrieving good resolution marine records and to the several uncertainties in the available proxy tools. In this regard, the Roman Period (1 CE to 500 CE) was particularly relevant in the socio-cultural development of the Mediterranean region while its climatic characteristics remain uncertain. Here we present a new SST reconstruction from the Sicily Channel based in Mg/Ca ratios measured on the planktonic foraminifer Globigerinoides ruber. This new record is framed in the context of other previously published Mediterranean SST records from the Alboran Sea, Minorca Basin and Aegean Sea and also compared to a north Hemisphere temperature reconstruction. The most solid image that emerges of this trans-Mediterranean comparison is the persistent regional occurrence of a distinct warm phase during the Roman Period. This record comparison consistently shows the Roman as the warmest period of the last 2 kyr, about 2 °C warmer than average values for the late centuries for the Sicily and Western Mediterranean regions. After the Roman Period a general cooling trend developed in the region with several minor oscillations. We hypothesis the potential link between this Roman Climatic Optimum and the expansion and subsequent decline of the Roman Empire.

[Complications of postoperative systematic preventive anticoagulant treatment]. / Complications des traitements anticoagulants préventifs systématiques postopératoires.

In a series of 887 cases who underwent visceral, orthopedic or vascular surgery and who received systematic post-operative prophylactic anticoagulant treatment (calciparine S.C. or in 4.8% of cases low dose heparin IV), the author reports 31 accidents (3.5%). These included 9 thromboembolic disorders with 2 deaths (0.45%) due to pulmonary embolism, 19 hemorrhagic episodes (2.14%) with 2 deaths, and 3 cases of intolerance to heparin (0.34%): 2 cases of uncomplicated thrombocytopenia and 1 case of white clot successfully treated surgically. In spite of the good results obtained as far as prevention of thromboembolic disease is concerned, this study confirms the significant frequency and severity of iatrogenic accidents. These may be reduced partly by greater care in the prescription and execution of this treatment, but it is impossible to completely avoid them; it is therefore desirable in certain cases to avoid systematic prophylactic treatment by using other first line methods such as early mobilisation, elastic contention, hemodilution or indeed in certain cases the insertion of a vena cava filter. Moreover, in 11 out of 19 patients who presented a hemorrhagic complication of heparin therapy, the insertion of such a filter was judged indispensable in order to avoid possible pulmonary embolism favored by stoppage of anticoagulant treatment.

[Surgical treatment of acute ischemia of the lower extremities (arteries and veins). Indications and results]. / Traitement chirurgical des ischémies aiguës du membre inférieur (artères et veines). Indications et résultats.

The indications and results of surgical treatment for acute ischemic lesions of the lower limbs are conditioned more by the previous state of the arterial wall than by the mechanism of the obliteration itself. Thrombosis and embolus development in atheromatous arteries is presently observed more frequently than emboli in healthy arteries, but prognosis is still mainly a function of the delay before active therapy is applied. Patients should be immediately placed on intravenous heparin therapy to provide cover during transfer to a suitably equipped center able to supply medical and surgical treatment. A choice has to be made between thrombolysis and surgery: thrombolysis, in the absence of general contraindications, is suitable mainly for cases with peripheral circulatory obstruction of diseased arteries unable to be restored by surgery. Treatment of emboli in healthy arteries has been transformed by the use of Fogarty's catheter; that of acute obstructions of diseased arteries has benefitted from progress realized in the performance of different types of surgical arterial reconstruction. Assuming that good operating conditions are available, thromboendarterectomies as well as autogenous or prosthetic venous by-pass operations can be perfectly well performed as emergency procedures, failures are due essentially to the fact that patients are still seen too frequently at the irreversible complete ischemia stage, and when their condition is poor: in certain cases the limb must be sacrificed immediately to ensure the vital prognosis.

[Postoperative recurrence of varicosities at the level of the popliteal fossa. Anatomic data guiding the ultrasonographic exploration and surgical sequelae]. / Récidives variqueuses postopératoires au niveau du creux poplité. Données anatomiques guidant l'exploration ultrasonographique et corollaires chirurgicaux.

The results of surgery of the short saphenous vein are less consistent than those of the long saphenous vein. The difference has been clarified by anatomo-physio-pathological studies which, as a complement to clinical examination, first used the different phlebography techniques and now benefit from pulsed colour echodoppler. They have shown that, in varicose veins considered to be of the short saphenous system, incompetence at its termination, with its anatomical variations, does not account for all the findings. Thus, imaging and the findings at surgery, have revealed a genuine venous complex in the popliteal fossa situated in four areas: in the sapheno-aponeurotic area with a variable point of termination of the short saphenous vein and important tributaries along its convexity; in the area of the medial head of the gastocnemius muscle with a voluminous trunk formed by the medial gastrocnemial veins which may run towards the termination of the short saphenous vein or even drain into its concavity; in the deep plane of the popliteal vein, which is sometimes double; in the short saphenous network with its very variable vein in the popliteal fossa and the lateral gastrocnemial veins. In practice, this classification helps to identify congenital reduplications, abnormal of aberrant veins and to perform planned surgery aimed at preventing postoperative recurrences. This is so because the latter are due, albeit less frequently than at the saphenofemoral junction, to a "new vein" which is in fact simply a missed tributary. Recurrences are mainly associated with : a duplication of the terminal part of the vein which has been missed; a short saphenous stump fed by a trunk from the medial gastrocnemial veins which has a termination into the popliteal vein common with the short saphenous vein; incompetent large medial gastrocnemial veins draining separately; an incompetent popliteal fossa perforator. The last two occur not uncommonly together and it has also been noted that failure to strip the short saphenous trunk increases the likelihood of postoperative recurrences. Repeat surgery is indicated in the presence of recurrences when there are important sources of reflux which are fully identified and precisely located by imaging, which is essential to prevent recurrent failure.

[Procedure to follow with a resistant venous ulcer of the ankle]. / Conduite à tenir devant l'ulcère rebelle veineux de la cheville.

In this study the authors present details of the clinical and paraclinical examination, in particular, examination of vascular function, which enable identification of the reasons why a venous ulcer on the lower leg fails to heal or recurs despite the usual treatment. Two important possibilities are stressed: 1. Progressive aggravation of the causal venous insufficiency, in which incompetence of calf perforators plays a fundamental role in both varicose veins and phlebitis. 2. Combination of venous insufficiency with a loco-regional or general factor, which contributes to trophic tissue deterioration. It is, thus, at a loco-regional level that ankle stiffness, major sub-ulcer sclerosis with possibility of formation of calcified plaques, lymphatic stasis and exceptionally malignant degeneration should be systematically investigated. It is necessary to act effectively on the various associated factors in order that treatment of the venous insufficiency responsible for the ulcer may succeed in spontaneous healing or allow successful grafting. However, the most important occurrence in the event of resistant ulceration is due to a combination, in patients over 60 years, of arterial insufficiency and venous insufficiency of variable duration. This is the context of mixed ulceration, in which treatment of both etiological factors must be modulated as a function of good identification of concomitant venous and arterial lesions.

[Popliteal vein entrapment, popliteal cyst, desmoid tumor and fabella syndrome]. / Veine poplitée piégée, kyste poplité, tumeur desmoïde et syndrome de la fabella.

The popliteal fossa is a relatively small, muscle-bound strategic anatomical area where is found, on the posterior aspect of the knee, a vasculonervous pedicle and where both vascular and pseudovascular disease may develop, the latter originating from wall-constituting parts. Among non-typical popliteal diseases, the authors have singled out four rare syndromes. The popliteal vein may be trapped due to fibrous strangulation or, more often, to compression by the hypertrophied gastrocnemius muscle. This requires proper diagnosis and surgical management prior to thrombosis onset. Synovial cysts raise no diagnostic problems, unless they mimic an episode of phlebitis; echotomography has now become essential for diagnosis. Desmoid tumors for which predominant extra-abdominal occurrence sites are the popliteal fossa, the leg and thigh, are difficult to excise completely, especially at the popliteal level, and are a major technical challenge because of the inclusion of the vasculonervous pedicle. Lastly, in sports pathology, one must be able to recognize the painful fabella syndrome (osteochondritis of sesamoid fibrocartilage in lateral head of gastrocnemius), so as not to mistakenly implicate vascular disease. New developments in imaging (namely, real time CT-echography) are of major help to clinicists, who should, nonetheless, remain chiefly responsible for detecting these diseases.

[Recurrence of varicosities in the femoral canal following surgery of the internal saphenous vein]. / Récidives variqueuses au niveau du canal fémoral après chirurgie de la veine saphène interne.

Perforating veins in the femoral canal, which establish a communication, on the medial aspect of the thigh, between the deep venous system and: either the trunk of the long saphenous vein, single or double, or one or several separate trunks, follow three anatomical patterns which clinical examination, phlebography and, now, echo-doppler, can identify clearly. When they are incompetent, they increase the natural progress of the varicose disease, after surgery of the long saphenous vein. Often, they are associated with a redux at the level of the saphenofemoral junction and also, sometimes, with an incompetence, primary or recurrent, at the short sapheno-popliteal junction, or, furthermore, with an incompetence of the medial gastrocnemial veins and their accompanying perforators, within the popliteal venous complex. Anastomotic networks between the different superficial venous territories in the inguino-genital region, the femoral canal and the supero-medial aspect of the leg, explain the cross-evolution between different systems. Sclerotherapy is effective when the perforators are not too large and their reflux not too important. If it fails, it is necessary to operate after precise localization of the sites of reflux through good imaging. A good picture is obtained with B mode ultrasound examination and hemodynamic studies with pulsed doppler and, even more reliably, with color Doppler. Thus, in recurrences in the femoral region, color Doppler will show up certain perforators which, despite being dilated, are nevertheless competent and do not need to be dealt with.

[Clinical and paraclinical identification by various imaging technics of congenital anomalies of the inferior vena cava (apropos of 4 cases)]. / Identification clinique et paraclinique par les différentes techniques d'imagerie des anomalies congénitales de la veine cave inférieure (à propos de 4 cas).

Four cases of anomalies of the inferior vena cava (IVC) were studied by two noninvasive imaging techniques: real-time ultrasonography and computed tomography. These techniques were used alone in 1 case of left IVC to determine the diagnosis. The other 3 cases were studied initially by phlebography: left IVC with iliac phlebitis; double IVC, also with iliac phlebitis, and a special case in which it was not clear whether the diagnosis was agenesis of the IVC or postnatal caval thrombosis. The two patients with recent iliac vein thrombosis were treated by heparin, but the other two received no particular therapy. Concerning these 4 cases, the authors speak of the known complexity of embryogenesis of the IVC which accounts for the great diversity in its anomalies. Left and double IVC are among the most frequent anomalies along with periaortic venous rings and the ureter behind the IVC. These anomalies are most often asymptomatic, but an understanding of them is essential for correct interpretation of the results of different imaging techniques and for effective performance of surgical and medical acts concerning the IVC directly or indirectly. For diagnosis of IVC anomalies, iliac venacavography, when not performed initially, can in certain cases be replaced by routine noninvasive imaging techniques, to which may now be added magnetic resonance imaging.

[Electric stimulation of the spinal cord in arterial diseases of the legs. A multicenter study of 244 patients]. / La stimulation électrique médullaire dans les artériopathies des membres inférieurs. Une étude multicentrique chez 244 patients.

From January 1985 through January 1990, 244 patients (168 males, 76 females, mean age: 69 +/- 14 years) received epidural spinal cord stimulation for the treatment of advanced, nonreconstructable, peripheral vascular disease of the lower limbs due to atherosclerosis in 180 patients, atherosclerosis and/or diabetes in 49, and thromboangiitis obliterans in 15 patients: previous surgery included 101 bypass-grafts in 70 patients, 51% of which below the knee, and 117 sympathectomies in 113 patients as the last resource in face of distal peripheral vascular disease of the lower limbs. Mean ankle-to brachial systolic pressure ratio was .31 +/- .34 on symptomatic limbs; due to pain and advanced disease, walking capacity was assessed in only 151 patients, either on treadmill in 25, or in a metered corridor in 126; angiogram of the lower limbs was performed in every patient unless one not older than three months was readily available; pain at rest was assessed after an analogical scale; partial transcutaneous oxygen tension was measured on the dorsum of the fore-foot of 77 symptomatic limbs (mean: 13.35 +/- 14 mmHg). According to clinical and functional evaluation, 18 patients had exertional ischemia (group I), 87 had permanent ischemia with pain at rest and no tissue loss (group II), and 139 had chronic tissue loss (group III), including 93 ischemic ulcers (mean surface: 3.7 cm2, mean duration: 3.5 months) in 88 patients, 27 limited gangrene, and 24 previous limited non-healing distal amputation. After temporary spinal cord stimulation at T12-L1 level (mean duration: 9 +/- 4 days) with a percutaneous quadripolar electrode lead had allowed for selection of responders, 212 patients received an implantable neurostimulator.(ABSTRACT TRUNCATED AT 250 WORDS)

[Embolism in healthy arteries]. / Les embolies sur artères saines

The authors present a series of 64 patients with arterial embolism in healthy arteries. 53 of these patients underwent one or several embolectomies, using a Fogarty catheter. Although arterial embolism has a poor prognosis owing to the constitutional background (15 p. 100 mortality and 12 p. 100 amputations), this is mainly due to the age of the patient. The severity of the initial attack and the delay between embolism and embolectomy seem to be the main factors in prognosis. Massive ischemia causes severe symptoms in these fragile patients and an early cure is necessary to compensate this disturbance. Heparin perfusion, whilst awaiting surgical treatment, is essential. Embolectomy by Fogarty's catheter may be carried out under local anesthesia; this remains the essential measure and has greatly improved the prognosis of this disease which used to be fatal in almost 60 p. 100 of cases, even in healthy arteries.

[Bouquet-type internal fixation of a series of 35 fractures of the upper end of the humerus]. / Embrochage en bouquet d'une série de 35 fractures de l'extrémité supérieure de l'humérus.

The authors report on 35 fractures of the humerus neck treated by "bouquet" type internal fixation. The operative technique employed is that developed by Bombard and co-workers. A few variants of this technique are described. Only fractures that were badly dislocated were internally fixated. Slight dislocations were treated for the most part by simple orthopaedic measures. This technique may be used on patients of all ages and leads to early mobilization. It might be employed to advantage in the management of slightly dislocated fractures in respiratory failure or in patients with chest injuries.