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Ecdysteroids (compounds related to 20-hydroxyecdysone, the insect molting hormone) can appear in the blood and urine of man, as a result of an infection with helminths. It has been assumed that the products are released by parasites. However, we found that the phenomenon is not restricted to helminthiases, but is widely spread among patients suffering from various diseases or injuries: twenty percent of hospital in-patients had urine highly positive in our test. This was due to the appearance of immunoreactive compounds not found in healthy people. Among them, one was remarkable for being largely predominant in some patients. These findings indicate that the origin and significance of ecdysteroids in man should be reconsidered. Since they appear only in association with severe pathological conditions, they could be of potential interest as a clinical marker.

We report 91 patients (mean age 70 years) operated upon, prospectively for a total of 100 carotid revascularizations (nine bilateral). Eighty-five of these patients had pre-, intra-, and postoperative transcranial Doppler investigations. Preoperatively, these 85 patients (92 procedures) were classified into two groups based on the results of their Doppler examinations: Group A (65 patients, 72 procedures), those who did not require an intraoperative indwelling shunt and Group B (20 patients, 20 procedures), those who did. The shunt was inserted only when the mean stump (back) pressure was less than 50 mmHg after cross-clamping. Group A all had satisfactory collaterality with a functional anterior and one or two posterior communicating arteries. Group B had no communicating arteries (anterior or posterior) identified by transcranial Doppler. In 17 of 20 patients in this group, the stump pressure was less than 50 mmHg and a shunt was placed. The overall prediction based on Doppler examination of whether or not patients would need a shunt during operation for the two groups A and B (i.e., 92 procedures) was correct in 95.6% (88/92) of cases. Moreover, six hemodynamically significant stenoses (four in the cavernous portion, two in the middle cerebral artery) were disclosed. Sensitivity and specificity of transcranial Doppler as correlated with arteriographic findings were 70 and 90%. Preoperative transcranial Doppler can measure the velocities of the principal cerebral arteries and the collateral capacity of the circle of Willis, and can forecast tolerance to carotid cross-clamping. Intraoperatively, the velocity of flow in the middle carotid artery was correlated with stump pressure, which allowed for surveillance of the shunt.

The insect molting hormone and related compounds (ecdysteroids) have been found in patients infected with helminths. To investigate this phenomenon, we quantified and analyzed the urinary ecdysteroids in Malian subjects suffering from various helminthiases, as well as in Europeans. Very high titers (up to 100 nM) were found in some patients, whereas healthy persons had a basic level of 4 nM only. The high RIA activity was mainly due to two compounds. One of them was remarkable for being present in all the positive samples; it comigrated with the 20-hydroxyecdysone standard, both in HPLC and in TLC. The origin and the physiological significance of these compounds are questionable, since there was no clear relationship between their levels and the severity of the diseases. Numerous patients who were heavily infected had normal titers. Nevertheless, there is no doubt that high concentrations of ecdysteroid-like compounds in human urine indicate a pathological condition.

Ecdysteroids are compounds related to 20-hydroxyecdysone, the insect moulting hormone. Surprisingly, they have been found in serum and urine of patients infected with helminths. In these cases, the substances are assumed to be produced by the parasites and, therefore, might be used as a marker of parasitic infection. Thus, we need to know exactly which species, at which developmental stage, can release ecdysteroids in such large quantities that they could be detected in the biological fluids of the host. Large-scale investigations must, accordingly, be devoted to the major species of helminths. In the present study, we examined 100 African patients with Loa loa and/or Mansonella perstans microfilaraemia. About 70 of them had high levels of ecdysteroid-like materials in serum or urine. In contrast, uninfected patients and European controls had much lower concentrations. However, the ecdysteroid titres did not reflect the concentration of microfilariae actually present in the blood, and some heavily infected patients were even negative. Nevertheless, the most important point was that high ecdysteroid levels in man were always associated with a pathological condition. The precise significance of the phenomenon should be determined.

Using a directional Doppler (4 MHz) coupled to a frequency analyser, authors investigate the supra-aortic trunks on 90 patients documented by arteriography. The analyser is made of a 16 filter bank system giving a spectrum composed of 16 frequency bands within range of 160 Hz to 4,800 Hz. Data analysis is made on a computer using the comparison means test and the discriminant analysis. Authors compare frequencies on normal common carotid arteries between a group (N = 102) with internal and external carotid arteries free of lesions on one hand, and a group (N = 75) with stenosis or occlusion of internal and/or external carotid arteries on the other hand. They don't note any significant difference for each on of the 16 frequency bands. Comparison of frequencies between normal subclavian arteries (N = 115) and subclavian arteries with proximal stenosis or occlusion (N = 24) shows a significant difference concerning the following bands : F12, F14, F15, F16 (p = 0.05), F13 (p = 0.01). Comparison of frequencies between normal internal carotid arteries (N = 108) and stenosed internal carotid arteries (N = 57) shows significant difference concerning : F11 (p = 0.05), F7, F8, F9, F12, F13, F14, F15, F16 (p = 0.01). On the other side, the discriminant function distinguishes a normal internal carotid artery from a stenosed internal carotid artery in 90% of cases, whatever the stenosis degree is. A discriminant function, added to this analyser, could obtain a frequency analysis easier and less expensive than by fast Fourier transform.

The frequency of associated carotid and coronary stenosis is estimated to be 40% of cases including asymptomatic patients. The risk of death by myocardial infarction during carotid surgery is in the neighborhood of 1%. With Doppler and ultrasonic imaging, it is now possible to recognize carotid stenosis in 11% of these cases. Depending on the extent of the clinical manifestations caused by one or the other of these lesions, there are several therapeutic options: surgery of the carotid with special protection of the myocardium during and after surgery or simultaneous carotid and coronary surgery in high risk cases. Between 1979 and 1986, simultaneous surgery was performed in 18 cases in our department. During the same period, 1194 carotid endarterectomies and 505 coronary bypasses were performed. These 18 cases included 13 males and 5 females with a mean age of 62 years (range: 43 to 78 years). The procedure performed in these cases were 17 carotid endarterectomies, one bypass of the innominate artery and an average of 2 aorto-coronary bypasses per patient. One death from myocardial infarction occurred in the immediate postoperative period and another patient died suddenly 8 months later. The evolution of arterial disease was evaluated in the other patients. Simultaneous carotid and coronary artery surgery is indicated in high risk carotid and coronary patients. Perusal of the results in the literature allows a better appreciation of the indications and risks of this type of surgery. Our series indicates the necessity for a careful preoperative workup in these patients and the need for more accurate screening to obtain better results.

To mitigate the lack of reliability of currently used flowmetry technics, an original method was developed based on a single window 15 MHz Doppler flowmeter and an Apple IIe computer with data acquisition system. Eleven successive measurements of instantaneous rate were made in an arterial section. A mean flow was determined by integration of mean rate in section. The reliability of the method was evaluated by an experimental study on a hydrodynamic bench reproducing physiologic flow conditions with an error always less than 8%. An in vivo study in 30 patients provided 100 measurements of arterial flow before and after surgical arterial reconstruction. The mean error value was less than 10%. Among the risks of error, those due to the probe was reduced by specially conceived probes. The most important factor was that of respiration, this latter factor imposing an integration time of rate of signal of 30 seconds to eliminate errors due to respiration. The conventional measurement time for other configurations is 6 seconds but this leads to a mean error of 25% which can attain 60%. The perspective of miniaturization of the apparatus in the near future with acceleration of measurements using a multi-window Doppler should allow flow measurement in 30 seconds and control of surgical reconstructions (on healthy arteries, vein grafts and prostheses but excluding PTFE). Similarly, it should be possible to improve evaluation of so-called vasoactive drugs.

Bilateral angiographic examination of the upper limbs is performed under general anesthesia in 64 patients of a group of 138 Raynaud's phenomenons. Clinical severity of the Raynaud's phenomenon is evaluated according to the 3 grades of Porter's classification but including a grade 4 corresponding to digital gangrene. Aetiology of Raynaud's phenomenon is in relation with connective tissue diseases in 11 cases and with other aetiologies in 22 cases. Aetiology is not defined in 31 cases. Angiographic findings are: Arterial lesions are present in all 64 patients, including 11 cases of "Raynaud's disease" defined by clinical and capillaroscopic signs. Frequency of the forearm artery lesions (31% of patients), a majority concerning ulnar artery. Absence of palmar anastomosis in 55% of the cases. Frequency and severity of digital (mean 1.4/hand) and collateral digital (mean: 7.4/hand) artery lesions. Arterial lesions are in relation with the clinical severity of the Raynaud's phenomenon but generally not with its aetiology. Authors consider that angiographic examination may be indicated in Raynaud's phenomenons in relation with defined aetiology but generally not in the other cases.

An analytic study of the different techniques for non-invasive vascular exploration, used to examine cervical arteries, distinguished between hemodynamic tests (continuous and pulsed Doppler, spectral analysis of frequencies, oculoplethysmography) and imaging methods (ultrasound and real time echotomographic imaging). Best performances at the present time are obtained by combined frequency spectral analysis + real time echotomography or Doppler + real time echotomography. Selection of appropriate techniques is based on clinical findings of a symptomatic or asymptomatic patient. The decision as to the need for angiography and therapy can be made either immediately after the examination by Doppler alone or after a complete investigation, depending upon the circumstances.

InBlaberus craniifer, the maturation of the oocytes is accompanied by morphological modifications of the surrounding follicular cells and by variations in the ecdysteroid titre.Before the follicular cells form the chorion, they synthesise ecdysteroids which pass into the terminal oocytes to be stored. During the secretion of the chorion, before the release of the oocytes, one observes a decrease of the ecdysteroid titre in the ovaries. The hormonal titres in ovaries and haemolymph fluctuate in parallel, probably because ovaries "leak" into the haemolymph.The terminal oocyte of each ovariole is deposited into the incubating pouch where the entire embryonic development takes place. There is first a decrease of the ecdysteroids synthesised by the follicular cells and stored in the eggs. One then observes 3 ecdysteroid peaks during each of the 2 cycles of the development. During the first cycle, the first peak coincides with the end of the metamerisation, the second peak with the secretion of the first cuticle and the third with the transition between the first and the second cycle. For the second cycle, the first peak coincides with the loss of the capacity to regenerate, the second with the secretion of the second cuticle and the third with the hatching period.The third peak of each of these 2 cycles is atypical compared with what is known of the larval cycles. The analysis of the hatching peak has shown that it is principally composed of a compound more polar than α-ecdysone.

The "dead finger" was first introduced into medical language in 1862 during the inaugural thesis of Maurice Raynaud: "of local asphyxia and symmetrical gangrene of the extremities". It has never ceased to stimulate interest since that date and to excite passionate speeches. Numerous reports of studies have been published since 1862 and "Raynaud's disease" has become a "syndrome", "phenomenon" or even "idiopathic disease" as a function of the author and the prevailing fashion, thus increasing the original confusion. However, it is now recognized that vasomotor disorders are not due to a single cause: apart from the primary forms of apparently purely spasmodic etiology, numerous affections accompanying these anomalies have been discovered.

The different non-invasive exploratory techniques for cervical arteries are compared and classified as hemodynamic exploration methods (continuous and pulsed Doppler testing, frequency profile analysis, oculoplethysmography), and imaging methods (ultrasonic and real-time echotomography imaging). We believe that the best results can be obtained by associating frequency profile analysis with real-time echotomography or Doppler testing with real-time echotomography. The choice between these combined modalities is determined by the clinical context and particularly whether the patient is symptomatic or not. Angiography and therapeutic strategy may be indicated either immediately after a Doppler test or after more extensive examination.

The insect moulting hormones, ecdysone and 20 hydroxyecdysone, were detected by the combined use of radioimmunoassay and high performance liquid chromatography in the human parasite Schistosoma mansoni. On day 11 after infection only the ecdysone form is present, but, on day 40 after infection the ratio between ecdysone and 20 hydroxyecdysone changes with anatomic localization of the adult worms in mammalian host. In the eggs, the ratio of these two hormones is identical to the ratio found in sexually mature worms located in mesenteric veins. These data demonstrate for the first time that S. mansoni synthesizes the steroid hormones ecdysone and 20 OH ecdysone which are potent molecules in stimulating growth and vitello-genesis of this gonochoric trematode.

Our series of 100 consecutive patients operated on either electively or in emergency without clinical work, for abdominal aortic aneurysms, estblishes the post operative prognosis up to a ten year follow-up period. The operative mortality of 12% is mainly due to renal coronary complications. All survivors, except one, have been reviewed. 64% 5 year survival and 46% 8 year survival rates were found. These results emphasize the importance of early and systematic surgical management except when major contraindications, which we have outlined, are present. Echotomography appears to be the best method of following up small aneurysms (diameter less than 7 cms) in elderly patients.

Computerized processing of data from patients with venous disease concerns mainly those with chronic venous insufficiency and venous thromboembolic disease. It is of particular interest for epidemiologic studies of venous disease, explorations (functional, phlebographic) and proposed therapies. Progress in these 3 sectors requires computerized processing of data from case-reports and standardization of the noting of these data.

A series of 100 unselected patients operated on for lumbar sympathectomy were studied by digit plethysmography, thest of hyperemia, rheography, measurement of segmental pressure and dynamic tests, treadmill and Strandness test. Statistical analysis of data showed that isolated lesions of atheroma yield the best result. Increase in walking perimeter and in blood flow (rheographic quotient) were the only parameters showing statistical change. Forecasting of the effect of lumbar sympathectomy by the hyperemia test of Hillestad was confirmed. Other forms of disease : diffuse lesions, lesions of arteries in the legs or due to diabetes were followed by very numerous failures. Lumbar sympathectomy is justified as an isolate procedure for femoral lesions, and associated to reconstructive aorto-iliac surgery whenever the distal runoff consists only of a deep femoral artery.

It is now widely accepted that the clinical diagnosis of deep venous thrombosis (D.V.T.) is unreliable. Many venous thrombi are nonobstructive and not associated with vessel wall inflammation or inflammation of the surrounding tissues and consequently have no detectable clinical manifestations. Moreover, none of the symptoms or signs of venous thrombosis are unique to this condition and all can be caused by non thrombotic disorders. On the other hand, in most of the D.V.T., the calf is the site in the legs where a thrombus starts. This thrombus begins commonly in valve pockets throughout various deep veins of the leg and in saccules of soleal veins. Several non invasive techniques have been developed for diagnosing D.V.T.: 125I, fibrinogen, impedance plethysmography, Doppler ultrasound, Duplex scanning. Many publications document the correlation between venography and these non invasive tests for D.V.T. Unfortunately it appears that, excepted 125I. Fg, these techniques are poorly reliable at the level of the calf. Moreover the diagnosis of D.V.T. may occur in particular and difficult situations such as a recurrent deep vein thrombosis. Considering all above the authors believes that contrast venography remains the standard and that it is less dangerous to do unnecessary venography than not to recognize a deep vein thrombosis.

Out of a total of more than 1,200 patients in whom lumbar sympathectomy was carried out, two groups of 96 and 50 consecutive and non selected patients were evaluated before and after the operation by non invasive physiologic tests (digital plethysmography, post-occlusive reactive hyperemia, segmental blood pressure at rest and after exercise, Strandness test). Results were compared with angiography and clinical data. The statistical study of results corroborates the following points. 1. Lumbar sympathectomy is essentially effective in atherosclerotic arterial disease, but much less so in diabetic patients and in cases of widespread disease. 2. Patients with obstructive disease of the femoral artery had more improvement (t = 4.25) than patients with obstruction of peripheral arteries (t = 2.4). 3. Walking time was significantly improved after sympathectomy (p = 0.02). 4. Only one parameter, rheographic quotient Rq was statistically improved (p = 0.01). 5. The post occlusive reactive hyperemia test is a good method to predict the results of lumbar sympathectomy (correlation r = 0.22). We feel that this operation is indicated in cases of: isolated obstruction of the femoral artery with claudication superior to 200 meters, reconstruction with an associated obstruction of the superficial femoral artery.

Computerized processing of data from patients with cerebro-vascular disease should improve interpretation of results of complementary examinations by allowing their comparison with arteriography and operative findings. It should also allow comparison of postoperative clinical and angiographic findings in order to analyse results obtained in an identical manner, and to provide a basis for discussion of therapeutic indications. Spontaneous evolution of atheromatous lesions can finally be compared with the course after surgery.

Between January 1, 1985, and December 15, 1987, 60 patients underwent surgery for carotid lesions under local cervical block anesthesia. Sixty-seven reconstruction procedures were performed including 64 endarterectomies and 3 vein bypasses. During the same 3 year period, 938 other reconstruction procedures were carried out under general anesthesia for a total of 1005 procedures. These 60 patients, who accounted for 6.7% of our indications, were selected for surgery under local anesthesia because they were at high risk for cardiac and neurologic complications. As far as staging is concerned, this subgroup of patients included: 14 asymptomatic cases (stage 0), i.e., 21%; 44 transient ischemic attacks (stage I), i.e., 66%; 2 progressive stroke (stage II), i.e., 3%; 7 patients with neurologic sequels (stage III), i.e., 10%. In all 79% of the patients were symptomatic. The asymptomatic patients all presented bilateral tight stenosis sometimes with thrombosis of the contralateral carotid. The technique of local anesthesia and endarterectomy were classic: closing with a bougie to calibrate the lumen, systematic intraoperative arteriography and immediate correction of technical failures (2 times); no death occurred among the patients in stages 0, 1 and II; 1 early asymptomatic occlusion that was not corrected was noted; in one case, a ligation of the carotid was necessary after technical failure, without consequences; one death occurred in stage III after intracerebral hemorrhage. On the basis of our experience local cervical block anesthesia appears to be a simple and reliable method of ensuring intraoperative diagnosis of cerebral ischemia. It eliminates all intraoperative cerebral complications secondary to ischemia and allows a better understanding of the physiopathologic mechanisms underlying perioperative neurologic complications. The absence of neurologic and cardiac complications in this series of very high risk patients enables us to extend eligibility for surgery to include patients with unstable cardiac and cerebral disease.

A national survey involving 131 centres was conducted in 1982 to assess the extent of use of data processing in angiology in both medical and surgical departments. Findings demonstrated the recent nature of its employ, this being for less than 2 years in 2 out of 3 teams. There was evidence for the need for data processing reporting forms in as compact a lay-out as possible. Each team should estimate its possibilities as a function of the personnel, time, and financial means available, and determine its objectives before discussing the data processing programme.

Investigation of 102 patients with arteriopathy and aged under 40 years show two groups as a function of course of disease: inflammatory and stasis arteriopathies. The course of the former disease is practically unaffected by surgery and repair is impossible, the common denominator in this group being amputation. Prognosis is better in patients with high lesions of stasis arteriopathy, but comparison with patients operated upon at "typical" age (58-62 years) showed increased progression of juvenile arteritis as seen by reduced permeability of repair procedures after 5 years. These findings suggest the need for extreme caution before conducting repair operations in this age group, and for maximum use of medical treatment.

A series of 100 unselected patients who had undergone low lumbar sympathectomy were studied using vascular function tests (digital plethysmography, hyperaemia test, rheography, measurement of segmental pressures and dynamic tests, walking tolerance on a conveyor belt, Strandness test). Statistical study of the results obtained showed that, above all, isolated lesions of atherosclerotic origin gave excellent results. Increase in walking tolerance and circulatory flow (rheographic quotient) were the only statistically valid parameters. Prediction of the effects of lumbar sympathectomy by Hillestad's hyperaemia test was confirmed. There were many failures amongst the other cases (diffuse lesions, leg artery involvement, diabetic type lesions). Lumbar sympathectomy is hence justified only in the presence of femoral lesions and in association with reconstructive aorto-iliac surgery in all cases when the distal bed consists of the deep femoral only.

Is it reasonable and useful to perform surgery on carotid lesions after 75 years? ("old man" according to the W.H.O. classification). To answer this question, we re-examined 66 patients aged 75 to 87 years, who underwent 76 carotid thromboendarteriectomies with one post-operative death. The results study showed that morbidity and general complications were not more important than in younger patients. Late results from 2 to 94 months showed a very low percentage of secondary neurologic complications even if patients had a vascular or general surgical intervention in a second period: 13 cases. There were only 2 re-stenoses. Indications were defined, but it was above all the asymptomatic patients or patients who had a TIA who could benefit from them.

During ovarian development in adult females of Locusta, an important biosynthesis of ecdysteroids is observed at the end of the maturation process of the terminal oocyte. This phenomenon occurs regularly during the different ovarian cycles. No synthesis is observed in allatectomized or ovariectomized female adults.

Possible endocrinological repercussions of infection with Loa loa and Mansonella perstans filariae were studied in Gabonese subjects. Microfilaremic males were compared with amicrofilaremic controls. In the infected group 13/105 subjects (12%) presented only abnormally low serum levels of testosterone (less than 4 ng/ml), 25/105 (24%) only abnormally high serum levels of gonadotrophins, FSH (greater than 15 mIU/ml) and LH (greater than 20 mIU/ml), and 22/105 (21%) presented anomalies in both testosterone and gonadotrophin levels. One out of 68 control subjects had 3.6 ng/ml seric testosterone and all had normal levels of gonadotrophins. Ecdysteroids were detected (greater than 0.025 ng/ml) in the serum of 87/97 (90%) microfilaremic subjects (GM 0.123 ng/ml) compared to 12/64 (19%) controls (GM 0.030 ng/ml). Ecdysteroids were detected in the urine of all subjects, infected (GM 8.468 ng/ml) as well as control (GM 1.245 ng/ml). The hormonal perturbations were correlated with the levels of Loa loa microfilaremia but not with those of serum and urinary ecdysteroids. These results demonstrate that microfilaremic subjects often show endocrinal signs of hypogonadism and present appreciable levels of ecdysteroids in serum and urine. A direct role for parasitic ecdysteroids in hypogonadism remains to be demonstrated.

Of 51 patients treated for digestive tract arterial lesions, 35 concerned the superior mesenteric artery. Long-term (up to 12 years) results showed that the quality of the reconstruction had not deteriorated. As technical problems have now been resolved, preventive reconstructive surgery can be proposed for those cases in which an ectatic or thrombogenic aorto-iliac lesion requires correction, without increasing operative risks.

The diagnosis of near total occlusion of the internal carotid artery was made on a group of 122 patients (90 symptomatic - 32 asymptomatic) by Doppler examination on one hand and carotid phonoangiography and oculoplethysmography, used together, on the other hand. The angiographic examination, including the study of the extra cranial arteries and the intra cerebral vessels, was performed. It has shown that a stenosis (greater than or equal to 90% of an internal carotid artery was the only lesion on 65 patients (53.3%) and that in 57 cases (46.7%) there were multiple lesions. 96 patients (76 symptomatic - 20 asymptomatic) were operated on. 4 patients (4.2%) died but the mortality was none in the group of 20 asymptomatic patients. 19 patients refused the operation and we have noted 7 occlusions of the internal carotid artery and 2 patients died (10.2%). On 7 patients with a surgical contra indication we have noted 1 secondary occlusion. We have to consider a near total occlusion of the internal carotid artery as an emergency. Its diagnosis by non invasive techniques must be followed by heparin therapy and angiographic examination. The carotid endarterectomy will respect the external carotid artery patency.