Radiocarbon dating minute amounts of bone (3-60 mg) with ECHoMICADAS.

Because hard tissues can be radiocarbon dated, they are key to establishing the archaeological chronologies, palaeoenvironmental reconstructions and historical-biogeographical processes of the last 50,000 years. The advent of accelerator mass spectrometers (AMS) has revolutionized the field of archaeology but routine AMS dating still requires 60-200 mg of bone, which far exceeds that of small vertebrates or remains which hold a patrimonial value (e.g. hominid remains or worked bone artefacts). Here, we present the first radiocarbon dates obtained from minute amounts of bone (3-60 mg) using a MIni CArbon DAting System (MICADAS). An optimized protocol allowed us to extract enough material to produce between 0.2 and 1.0 mg of carbon for graphite targets. Our approach was tested on known-age samples dating back to 40,000 BP, and served as proof of concept. The method was then applied to two archaeological sites where reliable dates were obtained from the single bones of small mammals. These results open the way for the routine dating of small or key bone samples.

Expression and possible immune-regulatory function of ghrelin in oral epithelium.

Originally found in stomach mucosa, ghrelin is a peptide appetite hormone that has been implicated as an immuno-modulatory factor. Ghrelin has also been found in salivary glands and saliva; however, its expression patterns and biological properties in the oral cavity remain unclear. Therefore, we investigated the expression patterns of ghrelin in saliva, gingival crevicular fluid (GCF), and gingival tissue, as well as its in vitro effects on IL-8 production by TNF-α or LPS-stimulated oral epithelial cells. In the clinical samples obtained from 12 healthy volunteers, the concentration of ghrelin in GCF remarkably exceeded that detected in saliva. The expression of ghrelin mRNAs and growth hormone secretagogue (GHS) receptors could be detected in human oral epithelial cells. Immunohistochemical analysis revealed the expression of ghrelin in gingival epithelium, as well as in fibroblasts in the lamina propria. Ghrelin increased intracellular calcium mobilization and cAMP levels in oral epithelial cells, suggesting that ghrelin acts on epithelial cells to induce cell signaling. Furthermore, synthetic ghrelin inhibited the production of IL-8 from TNF-α or LPS-stimulated oral epithelial cells. These results indicate that ghrelin produced in the oral cavity appears to play a regulatory role in innate immune responses to inflammatory infection.

Extracorporeal circulation as an additional method for cerebral protection in simultaneous carotid endarterectomy and coronary artery surgical revascularization.

Surgical management of patients with concomitant carotid and coronary artery stenosis remains controversial. Our policy was always to perform at the same time carotid endarterectomy (CE) and coronary artery bypass grafting (CABG), but it was also considered that extracorporeal circulation (ECC), because of full heparinization, hemodilution, pulsatile flow, and hypothermia could provide better cerebral protection during CE. Retrospective data of 124 patients undergoing simultaneous CE and CABGs between January 1994 and December 2001 were reviewed. CE was performed prior to ECC in 65 patients (Group 1-mean age: 70.4 years; sex ratio: 49 male/16 female) and under ECC, prior to CABGs in 59 patients (Group 2-mean age: 69.9 years; sex ratio: 46 male/13 female). Overall hospital mortality was 7.3% (9/124): cardiac-related in 5 patients, or due to septicemia (1 patient), or ARD syndrome (1 patient), or stroke in two others. Univariate analysis demonstrated overweight, unstable angina, and emergency to be significant risk factors. Bilateral carotid stenosis was a significant risk factor of neurologic event when CE was performed prior to ECC (p < 0.05). In Group 1, mortality was 9.2% (6/65), and the incidence of neurologic events was 10.7% (7/65), and was responsible for two of the early deaths in patients with bilateral carotid stenosis. In Group 2, mortality was 5.1% (3/59) but never related to CE, while the neurologic morbidity was 1.7% (1 transient ischemic attack). It is concluded that (1) hospital mortality in patients undergoing simultaneous CE and CABGs was mainly cardiac-related. (2) The combined approach of both localizations appears to be mandatory, when carotid stenosis, even asymptomatic, was hemodynamically significant, or with ulcerative lesions likely to be responsible for embolism. (3) CE, first performed under ECC, appears to be a safe procedure, combining, in terms of cerebral protection, the benefits previously called up. This approach is all the more interesting when carotid stenosis is bilateral; hypothermia < or = 28 degrees C during the carotid clamping time is obviously the optimal method for cerebral protection when ipsilateral or contralateral supply is reduced, or even absent.

[Diagnostic and therapeutic value of lymphography in persistent postoperative chylothorax]. / Intérêt diagnostique et thérapeutique de la lymphographie dans un chylothorax postopératoire persistant.

Chylothorax is a rare but generally severe complication of surgery of congenital heart disease. The authors report the clinical history of a young boy with complex congenital heart disease operated on several occasions and who developed severe and recurrent unilateral chylothorac after a bicavo-bipulmonary derivation. Conservative treatment followed by continuous somatostatin infusion was ineffective. Diagnostic Lipiodol lymphography was required before the chylothorax was cured. The authors describe management of this difficult case and discuss the therapeutic possibilities with reference to a brief review of the literature.

Palaeolithic paintings. Evolution of prehistoric cave art.

Sophisticated examples of European palaeolithic parietal art can be seen in the caves of Altamira, Lascaux and Niaux near the Pyrenees, which date to the Magdalenian period (12,000-17,000 years ago), but paintings of comparable skill and complexity were created much earlier, some possibly more than 30,000 years ago. We have derived new radiocarbon dates for the drawings that decorate the Chauvet cave in Vallon-Pont-d'Arc, Ardèche, France, which confirm that even 30,000 years ago Aurignacian artists, already known as accomplished carvers, could create masterpieces comparable to the best Magdalenian art. Prehistorians, who have traditionally interpreted the evolution of prehistoric art as a steady progression from simple to more complex representations, may have to reconsider existing theories of the origins of art.

[Myocardial infarction in a child with an anomalous left coronary artery arising from the right coronary sinus. Value of echocardiography]. / Infarctus du myocarde chez un enfant et anomalie de naissance du tronc coronaire gauche du sinus coronaire droit. Apport de l'échocardiographie.

An anomalous left coronary artery arising from the right sinus of Valsalva with a trajectory between the aorta and the main pulmonary artery is a rare isolated congenital anomaly carrying a high risk of sudden death and of acute myocardial ischaemia, especially in children and young adults in a context of exercise. It is usually a post-mortem finding. The authors report the rare case of a 12 year old child who suffered acute myocardial infarction on exercise due to this condition. The diagnosis was made in the acute phase by echocardiography. Surgical correction was performed as this is the only means of prevention of sudden death of an ischaemic recurrence. Effort syndromes in children or young adults should lead to a request for echocardiographic examination to exclude the diagnosis in a non-invasive manner as well as those of hypertrophic cardiomyopathy or congenital aortic stenosis.

Variations of Younger Dryas atmospheric radiocarbon explicable without ocean circulation changes

The concentration of radiocarbon, 14C, in the atmosphere depends on its production rate by cosmic rays, and on the intensity of carbon exchange between the atmosphere and other reservoirs, for example the deep oceans. For the Holocene (the past approximately 11,500 years), it has been shown that fluctuations in atmospheric radiocarbon concentrations have been caused mostly by variations in the solar magnetic field. Recent progress in extending the radiocarbon record backwards in time has indicated especially high atmospheric radiocarbon concentrations in the Younger Dryas cold period, between 12,700 and 11,500 years before the present. These high concentrations have been interpreted as a result of a reduced exchange with the deep-ocean reservoir, caused by a drastic weakening of the deep-ocean ventilation. Here we present a high-resolution reconstruction of atmospheric radiocarbon concentrations, derived from annually laminated sediments of two Polish lakes, Lake Gosciaz and Lake Perespilno. These records indicate that the maximum in atmospheric radiocarbon concentrations in the early Younger Dryas was smaller than previously believed, and might have been caused by variations in solar activity. If so, there is no indication that the deep-ocean ventilation in the Younger Dryas was significantly different from today's.

[Surgical evaluation of transthoracic tridimensional echocardiography in the anatomic study of atrial septal defect]. / Validation chirurgicale de l'échocardiographie tridimensionnelle transthoracique pour l'évaluation anatomique des communications interauriculaires.

The closure of atrial septal defects by interventional catheterisation requires an accurate assessment of their morphology and anatomical relationships. This study evaluated transthoracic three-dimensional echocardiography for the selection of atrial septal defects accessible to an occlusive prosthesis. The transthoracic three-dimensional echocardiographic measurements of 17 patients (4 to 55 years) with ostium secundum atrial septal defects were compared with those of the surgeon in a prospective study. The maximal diameters of the defect, the height of the interatrial septum, the distances to the superior vena cava (postero-superior border) and inferior vena cava (postero-inferior border), to the coronary sinus and the tricuspid valve were measured as a reconstruction of the interatrial septum seen from the right atrium. The aortic border was measured from a three-dimensional view from the left atrium. Thirteen of the 17 investigations (76%) were exploitable. The diameters of the defect varied during the cardiac cycle (p = 0.0002). Ther correlations between the surgical and echocardiographic measurements varied from 0.82 for the maximal diameter to 0.6 for the postero-inferior limits. Three-dimensional echocardiography is capable of detecting all the contra-indications of an occlusive prosthesis: 2 inadequate postero-inferior and 1 inadequate aortic borders, 9 maximal diameters which were too large, 3 insufficiently high atrial septa, 1 double atrial septal defect. The coronary sinus was only visualised in 1 case. Transthoracic three-dimensional echocardiography is a non-invasive technique capable of improving the selection of atrial septal defects for interventional closure. The transoesophageal approach should be reserved for candidates selected by the transthoracic investigation for the detection of small structures (coronary sinus) and when the transthoracic window is poor.

[Double aneurysm occurring on a venous aortocoronary graft]. / Double anévrysme sur greffon veineux aorto-coronaire.

The authors report the case of a 48-year old patient admitted to hospital for unstable angina 13 years after primary myocardial revascularisation by a saphenous vein aorto-coronary bypass graft. Routine chest X-ray showed a left para-hilar opacity which CT scan and angiography confirmed to be aneurysmal and pseudoaneurysmal dilatations of the saphenous vein bypass graft.

Review of the long-term course of 52 patients with pulmonary atresia and ventricular septal defect. Anatomical and surgical considerations.

This study reviews the long-term course of 52 patients with pulmonary atresia and ventricular septal defect seen in a single institution and followed for a mean period of 8.6 years (range 2 days to 20 years). Before the first operation, pulmonary blood supply was provided by ductus arteriosus supplying confluent pulmonary arteries in 26 patients (50%, group I), and was partially or entirely dependent on systemic collateral arteries in the other 26 patients (group II). The angiographic mean ratio of diameters of the right and left pulmonary artery/descending aorta (McGoon ratio) was significantly lower in group II than in group I, 0.76 +/- 0.42 vs 1.04 +/- 0.17 (P = 0.006). Severe arborization defects (with fewer than 10 pulmonary vascular segments connected to central pulmonary arteries) were present only in group II patients (eight patients: 15%), six of whom had congenital absence of the central pulmonary arteries. Corrective surgery was performed in 23 patients (44%, 14 in group I, nine in group II). All but one, who died later, had a McGoon ratio > or = 1 (mean 1.19 +/- 0.18) at time of repair. There was one hospital death (4%) and two late deaths (9%). All but one of the surviving corrected patients were in functional class I or II. Conduit replacement reoperation was performed in three patients (14%), 6, 10 and 13 years, respectively, after repair. At the end of the study, among the 37 patients (71%) who were alive (17 in group I, 20 in group II), 20 (39%) were corrected (12 in group I, eight in group II), four await corrective surgery, and six (11.5%) are estimated inoperable (all in group II) because of very hypoplastic or absent pulmonary arteries. This study confirms the estimated rate in the published literature of long-term survival in patients with pulmonary atresia and ventricular septal defect, and the good results of corrective surgery whenever the size and distribution of pulmonary arteries are satisfactory. The problem of very hypoplastic pulmonary arteries and severe arborization defects remains contentious.

[Cerebral protection by selective cerebral perfusion during surgery on the aortic arch]. / Protection cérébrale par perfusion cérébrale sélective dans la chirurgie de la crosse aortique.

The aim of this study was to evaluate the technique of cerebral protection by selective cerebral perfusion with moderate hypothermia during surgery of the transverse aortic arch. Twenty-three patients were operated for partial or total replacement of the transverse aortic arch between January 1987 and December 1993 by the technique of selective cerebral perfusion by bilateral carotid cannulation. There were 12 cases of aneurysm of the ascending aorta and/or transverse aortic arch, one aneurysm of the innominate artery and 10 Stanford type A aortic dissections. The selective cerebral flow rate was 1-1.5 l/min; the perfusion pressure 60-80 mmHg and the temperature of cerebral perfusion 25-28 degrees C. The perioperative mortality was 13%; the causes of death were not neurological (3 haemorrhages). The neurological morbidity was 10% (one brachial monoparesis and one bulbar tetraparesis). This is therefore a useful technique of cerebral protection which avoids the complications of deep hypothermia with circulatory arrest and does not limit the time of aortic repair.

Long-term results of valve replacement with the St. Jude Medical prosthesis.

To assess with truly long follow-up the long-term results of valve replacement with the St. Jude Medical prosthesis (St. Jude Medical, Inc., St. Paul, Minn.), we reviewed the case histories of the first 1112 patients undergoing 1244 valve replacements with this valve between June 12, 1978, and June 12, 1987: 690 male (62%) and 422 female patients, mean age 56 years. A total of 773 patients (69%) had the aortic valve replaced, 207 (19%) the mitral valve, and 132 (12%) the aortic and mitral valves. There were 42 hospital deaths (3.8%). Follow-up was 97.5% complete (8988 patient-years). There were 213 late deaths. Ninety-one (43%) were considered valve-related: sudden death, n = 27; anticoagulant-related hemorrhage, n = 22; thromboembolism, n = 19; prosthetic valve endocarditis, n = 13; valve thrombosis, n = 9; and noninfectious perivalvular leak, n = 1. Overall actuarial survival, including hospital mortality, was 68% +/- 6% (95% confidence limits) 14 years after the operation. Linearized rates of late valve-related events were as follows: thromboembolism, 1.09% per patient-year; anticoagulant-related hemorrhage, 0.94% per patient-year; prosthetic valve endocarditis, 0.32% per patient-year; valve thrombosis, 0.33% per patient-year; and perivalvular leak, 0.19% per patient-year. Actuarial freedom, at 14 years, from thromboembolism was 89% +/- 3%, anticoagulant-related hemorrhage 83% +/- 8%, valve thrombosis 97% +/- 1%, and reoperation 95% +/- 3%. Actuarial freedom from all valve-related deaths and valve-related morbidity and mortality, at 14 years, was 84% +/- 6% and 61% +/- 8%, respectively. We conclude that, because of its low thrombogenicity, low incidence of valve-related events, and low valve-related mortality, the St. Jude Medical valve is one of the best performing mechanical prosthesis currently available. Nevertheless, the late valve-related complications and deaths illustrate that the quest for a "perfect" prosthesis remains unfulfilled.

[Comparative value of transthoracic echocardiography and angiography for measuring the pulmonary artery annulus in tetralogy of Fallot]. / Intérêt comparé de l'échographie transthoracique et de l'angiographie pour la mesure de l'anneau de l'artère pulmonaire dans la tétralogie de Fallot.

It may be necessary to perform an enlarging pulmonary annuloplasty during surgical cure of Tetralogy of Fallot (TOF) in order to optimise reconstruction of the right ventricular outflow tract. As this additional procedure implies an increase in perioperative mortality, it is useful to prepare for this eventuality before surgery. Two imaging techniques are available: transthoracic echocardiography (diameter of the pulmonary annulus obtained by averaging the measurements obtained in the subcostal and parasternal short axis views of the insertion of the pulmonary valve cusps at end systole) and selective angiography during right heart catheterisation (anteroposterior measurement with comparison to be projected and real size of the catheter at the point of insertion of the cusps at end systole). In this study, these two techniques were compared with reference to the peroperative measurement with Hegar dilators and criteria defined by Naito (minimal diameter of the pulmonary artery annulus with respect to the weight of the child). Seventy-eight children admitted to hospital between January 1986 and April 1994 for curative surgery of TOF were included. The calculation of the intra-class correlation coefficient showed a mediocre correlation with angiography and a very mediocre correlation with echocardiography compared with peroperative measurements. However, the calculation of sensitivities showed angiography to be the predictive investigation for annuloplasty in children not conforming to the Naito criteria: higher sensitivity (83% vs 26% for echocardiography), greater negative predictive value (84% vs 70%). This result holds for all categories of body weight (over and under 10 kg).(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical experience of coronary artery-right ventricular fistula in a heart transplant patient.

Routine follow-up catheterization 4 years after heart transplantation in a 55-year-old revealed a fistula from the main left anterior descending artery (LAD) to the right ventricle. The left anterior descending artery was dilated and tortuous because of this fistula. As he had effort dyspnea and fatigue 3 months after this catheterization, we decided to operate on the fistula, and direct closure of this through the LAD and coronary artery bypass grafting from the proximal to distal LAD were performed. Surgery and the postoperative course were uneventful. We discuss the surgical indication and technique for coronary artery fistula acquired as a result of endomyocardial biopsy after heart transplantation.

[Saccular aneurysms of the renal artery]. / Les anévrysmes sacciformes de l'artère rénale.

The increasingly frequent use of arteriography in the investigation of hypertension and of obliterative arterial disease of the lower limbs has led to recognition of the actual incidence of renal artery aneurysms. The importance of this type of lesion is due to the fact that the natural history of renal artery aneurysms remains unknown, their relationship with hypertension is still controversial and the risk of complications, and rupture in particular, has led to the suggested possible need for their routine surgical excision. The current trend is to limit indications for surgery to certain specific cases since a number of recent series have shown that the risk of rupture of a small saccular aneurysm was very small.

[Traumatic rupture of the aortic isthmus in a patient with severe head injury]. / Rupture traumatique de l'isthme aortique chez un traumatisé crânien grave.

A 32-year-old man sustained a severe head injury in a road traffic accident. On admission, he was in deep coma (6 on the Glasgow coma scale). The aortic knuckle was difficult to identify on a plain chest film. Twenty hours after admission, the aortic knuckle had completely disappeared and the mediastinal shadow had become enlarged. The diagnosis of a ruptured aortic isthmus was confirmed by angiography. Surgical repair of this lesion may be carried out either with simple aortic cross-clamping, or by using cardiopulmonary bypass (CPB). Either technique may worsen other injuries, especially head injury, by initiating severe arterial hypertension or coagulation disturbances. In this patient, the technique chosen was aortic cross-clamping with permanent monitoring of the intracranial and cerebral perfusion pressures. Anaesthesia was obtained with 5 mg.kg-1 of thiopentone, 30 mg.kg-1 x h-1 of sodium gamma hydroxybutyrate and 8 micrograms.kg-1 x h-1 of fentanyl. Surgery lasted for 90 min, with 33 min of aortic clamping. The increase in arterial blood pressure was controlled with 0.25 mg.kg-1 x h-1 of thiopentone and nicardipine which was stopped 8 min before unclamping. The postoperative course was uneventful. Sedation was stopped after 8 days, and the patient regained consciousness two days later. These remained a paraplegia with no sensory deficit, which had totally receded 15 months later. Carrying out this emergency surgery without CPB means that the intracranial pressure must imperatively be monitored during surgery. Any intracranial hypertension should delay the surgery.

Isolation of the right subclavian artery.

Loss of continuity between subclavian artery and aorta with persistent connection to the homolateral pulmonary artery through a ductus arteriosus is an uncommon malformation, involving generally the left subclavian artery and associated with intracardiac or aortic arch anomalies. We report a case of right subclavian isolation with a left-sided aortic arch, presenting as a single anomaly and surgically corrected by aortic reimplantation.

Bronchial revascularization in double-lung transplantation: a series of 8 patients. Bordeaux Lung and Heart-Lung Transplant Group.

Donor airway ischemia is the main cause for defective tracheal or bronchial healing after double-lung transplantation. Anatomical studies and bronchial arteriograms have shown that the right intercostal bronchial artery is constant (95% of instances) and provides an important blood supply to the distal trachea, the carina, and the right bronchial tree as well as to the left side through a subcarinal and periadventitial anastomostic network. To maintain this important bilateral bronchial circulation, it is of capital importance not to mobilize the arteries individually and to avoid large dissections around the carina. Both bronchi can thus be revascularized by indirect aortic reimplantation using a bypass graft to a single aortic patch that includes the origin of the right intercostal bronchial artery. Furthermore, the origin of other vessels (a common trunk and left arteries) can be found within a short distance of the right intercostal bronchial artery and possibly be contained within the same aortic patch. From a series of 56 lung transplantations, 8 patients underwent restoration of the bronchial vascularization using a recipient saphenous vein graft between the donor bronchial arteries and the anterior aspect of the recipient's ascending aorta. A lower tracheal anastomosis was performed. Bronchial arterial blood supply was evaluated both by endoscopy and by arteriography at about the 15th postoperative day. The bronchial circulation was visualized at this time in five of seven arteriographies, and this was associated with excellent tracheal healing in all 8 patients.

Lung transplantation with bronchial revascularisation. Surgical anatomy, operative technique and early results.

Ischaemic anastomotic complications are an important cause of mortality and morbidity after lung transplantation. Anatomical studies have demonstrated that the pattern of bronchial arterial supply is relatively constant and therefore amenable to attempts at revascularisation. From May 1990, 10 patients who had a double lung transplantation (tracheal anastomosis) and 1 patient who had a right lung transplantation underwent concomitant bronchial revascularisation. There were two early and one late deaths. There were no anastomotic complications. Regular endoscopic examination showed satisfactory healing in all patients. Early angiography showed patent grafts in 7 of 9 patients. At a mean follow-up of 11 months (range 6-17 months) 8 patients are well and leading a normal life. This report describes the anatomical basis, technical aspects and early results of a promising operative procedure in the field of lung transplantation.

Nondiagnosed left main ostial stenosis partly due to the use of 5 French coronary angiographic catheters.

Two cases have been reported in which the use of 5 F angiographic catheters is associated with a failure to diagnose an ostial stenosis of the left main coronary artery (LMCA). In both cases, the erroneous diagnosis led to an inappropriate indication for percutaneous transluminal coronary angioplasty (PTCA) on other stenosed vessels, and the ostial left main lesion was unexpectedly discovered when using 8F guiding catheters. It is supposed that the ability of performed 5F catheters to pass easily through an ostial lesion makes detection of such proximal stenosis much more difficult. We suggest that the choice of 5F catheters must be approached with caution when left main disease is potentially expected from the clinical features.