Search

Objective To assess the contribution of large and small nerve fiber alteration in erythromelalgia (EM). Methods Thirty-three EM patients were included and underwent clinical evaluation based on EM severity score, DN4, and Utah Early Neuropathy Scale (UENS) score. Neurophysiological evaluation consisted in nerve conduction studies (NCS) for large nerve fibers and specific tests for small nerve fibers: electrochemical skin conductance, cold and warm detection thresholds, and laser evoked potentials. Finally, the evaluation of vascular changes was based on the presence of clinical feature of microvascular disorders and the measurement of the Toe Pressure Index (TPI). Results While 28 patients (85%) had vascular alteration on TPI or clinical features, 23 patients (70%) had small-fiber neuropathy on neurophysiological tests, and only 10 patients (30%) had large fiber neuropathy on NCS. Regarding clinical scores, there was no difference between groups (presence or absence of large- or small-fiber neuropathy or microvascular disorder) except for a higher UENS score in patients with large fiber neuropathy. Conclusion Peripheral neuropathy, mostly involving small nerve fibers, is almost as common as microvascular changes in EM, but remains inconstant and not related to a specific neuropathic pattern or higher clinical severity. Significance The association of neuropathic and vascular factors is not systematic in EM, this syndrome being characterized by different pathophysiological mechanisms leading to a common clinical phenotype.

Resume Introduction Le syndrome de congestion pelvienne est un syndrome douloureux chronique du petit bassin en rapport avec des varices pelviennes developpees dans le cadre d’une insuffisance veineuse primitive ou secondairement a une obstruction veineuse. Observation Nous rapportons l’observation d’une patiente de 35 ans, sous traitement anticoagulant pour une thrombose veineuse profonde iliofemorale gauche idiopathique, ayant developpe un syndrome de congestion pelvienne invalidant secondaire a des sequelles obstructives iliaques. La recanalisation veineuse avec stenting de l’axe iliaque gauche, associee a une bitherapie antithrombotique par antiagregant plaquettaire (acide acetylsalicylique 100 mg) et anticoagulant (rivaroxaban 20 mg) pendant trois mois puis antiagregant plaquettaire seul, a permis une regression complete et durable des symptomes. Discussion La prise en charge du syndrome de congestion pelvienne secondaire a des lesions iliaques post-thrombotiques doit tenir compte de sa physiopathologie. Elle fait intervenir l’angioplastie veineuse iliaque avec mise en place de stent en association a un traitement antithrombotique dont les modalites restent a preciser avec le suivi au long cours de ces patients.

INTRODUCTION Abdominal aortic aneurysm (AAA) is a silent pathology with often fatal consequences in case of rupture. AAA screening, recommended in France and many other countries, has shown its effectiveness in reducing specific mortality. However, AAA screening rate remains insufficient. OBJECTIVE To identify barriers to AAA screening in general practice. MATERIAL AND METHOD Qualitative study carried out during 2016 among general practitioners based in Paris. RESULTS Fourteen physicians were included. Most of the barriers were related to the physician: unawareness about AAA and screening recommendations, considering AAA as a secondary question not discussed with the patient, abdominal aorta not included in cardiovascular assessment, no search for a familial history of AAA, AAA considered a question for the specialist, lack of time, lack of training, numerous screenings to propose, oversight. Some barriers are related to the patient: unawareness of the pathology and family history of AAA, refusal, questioning the pertinence of the doctor's comments, failure to respect the care pathway. Others are related to AAA: source of anxiety, low prevalence, rarity of complications. The remaining barriers are related to screening: cost-benefit and risk-benefit ratios, sonographer unavailability, constraint for the patient, overmedicalization. CONCLUSION Information and training of general practitioners about AAA must be strengthened in order to optimize AAA screening and reduce specific mortality.

Resume Objectif Les ulceres de jambes sont dans pres de 85 % des cas de causes vasculaires. Il existe aussi des ulceres de causes non vasculaires. Leur diagnostic repose sur un faisceau d’arguments cliniques et la biopsie cutanee avec analyse anatomopathologique. Materiel et methode Etude retrospective ayant porte sur l’analyse de 143 biopsies cutanees d’ulceres de jambe. Les raisons ayant motive la biopsie etaient principalement des signes cliniques atypiques et/ou l’absence d’amelioration sous soins bien conduits au-dela de 6 mois, comme le preconise la Haute Autorite de sante. Le but de cette etude etait d’analyser les resultats de ces biopsies et de rechercher des criteres communs aux ulceres, dont la biopsie cutanee avait permis d’etablir le diagnostic d’ulcere non vasculaire. Resultats Au total, 4,9 % des biopsies cutanees permettaient d’etablir un diagnostic d’ulcere de cause non vasculaire (7/143) : 5 carcinomes cutanes (3,5 %), 1 leishmaniose cutanee (0,7 %) et 1 pyoderma gangrenosum (0,7 %). L’analyse statistique univariee revelait que les berges surelevees et le caractere hyperbourgeonnant etaient significativement plus frequemment retrouves dans ces ulceres. Tous les patients, dont la biopsie cutanee permettait un diagnostic d’ulcere non vasculaire, avaient une atteinte vasculaire associee. Conclusion Cette etude a retrouve un taux de 5 % d’ulceres de causes non vasculaires, principalement des carcinomes cutanes. Les berges surelevees et l’hyperbourgeonnement etaient les caracteres inhabituels plus frequemment retrouves dans ces ulceres. Tous les patients, dont la biopsie cutanee revelait une cause non vasculaire, avaient une atteinte vasculaire associee. Cette information confirme la necessite de realiser une biopsie cutanee y compris en presence d’une atteinte vasculaire qui n’explique pas a elle seule l’evolution de l’ulcere.

Background Smoking is a strong risk factor for cancer and atherosclerosis. Cancer mortality, especially from lung cancer, overtakes cardiovascular (CV) death rate in patients with peripheral arterial disease (PAD). Only a few patients with lung cancer after PAD management may benefit from surgical excision. Circulating tumor cells (CTC) associated with low-dose chest CT (LDCT) may improve early cancer detection. This study focuses on a screening strategy that can address not only lung cancer but all tobacco-related cancers in this high-risk population. Methods DETECTOR Project is a prospective cohort study in two French University hospitals. Participants are smokers or former smokers (≥30 pack-years, quitted ≤15 years), aged ≥55 to 80 years, with atherosclerotic PAD or abdominal aortic aneurysm. After the first screening round combining LDCT and CTC search on a blood sample, two other screening rounds will be performed at one-year interval. Incidental lung nodule volume, volume doubling time and presence of CTC will be taken into consideration for adapted diagnostic management. In case of negative LDCT and presence of CTC, a contrast enhanced whole-body PET/CT will be performed for extra-pulmonary malignancy screening. Psychological impact of this screening strategy will be evaluated in population study using a qualitative methodology. Assuming 10% prevalence of smoking-associated cancer in the studied population, a total of at least 300 participants will be enrolled. Discussion Epidemiological data underline an increase incidence in cancer and related death in the follow-up of patients with PAD, compared with the general population, particularly for tobacco-related cancers. The clinical benefit of a special workup for neoplasms in patients with PAD and a history of cigarette smoking has never been investigated. By considering CTCs detection in this very high-risk selected PAD population for tobacco-induced cancer, we expect to detect earlier pulmonary and extra-pulmonary malignancies, at a potentially curable stage. Trial registration The study was registered in the French National Agency for Medicines and Health Products Safety (No N° EUDRACT_ID RCB: 2016-A00657–44) and was approved by the ethics Committee for Persons Protection (IRB number 1072 and n° initial agreement 2016-08-02; ClinicalTrials.gov identifier NCT02849041).

In-plane phase-contrast (PC) imaging is now a routine component of MRI of regional blood flow in the heart and great vessels. In-plane PC MRI provides a volumetric, isotropic, time-resolved cine sequence that enables three-directional velocity encoding, a technique known as four-dimensional (4D) flow MRI. Recent advances in 4D flow MRI have shortened imaging times, while progress in big-data processing has improved dataset pre- and postprocessing, thereby increasing the feasibility of 4D flow MRI in clinical practice. Important technical issues include selection of the optimal velocity-encoding sensitivity before acquisition and preprocessing of the raw data for phase-offset corrections. Four-dimensional flow MRI provides unprecedented capabilities for comprehensive analysis of complex blood flow patterns using new visualization tools such as streamlines and velocity vectors. Retrospective multiplanar navigation enables flexible retrospective flow quantification through any plane across the volume with good accuracy. Current flow parameters include forward flow, reverse flow, regurgitation fraction, and peak velocity. Four-dimensional flow MRI also supplies advanced flow parameters of use for research, such as wall shear stress. The vigorous burgeoning of new applications indicates that 4D flow MRI is becoming an important imaging modality for cardiovascular disorders. This article reviews the main technical issues of 4D flow MRI and the different parameters provided by it and describes the main applications in cardiovascular diseases, including congenital heart disease, cardiac valvular disease, aortic disease, and pulmonary hypertension.

In vascular medicine, wound care requires pluridisciplinary expertise and nursing skill. Care must be perfectly adapted to each individual patient, the specificities of each particular wound, and the underlying vascular disease. The goal is to achieve wound healing. Inappropriate care can retard healing or even aggravate the wound. The skin should be cleaned with water a non-allergic detergent and should concern the entire limb in addition to the wound itself. Fibrin or necrosis detersion is an important step that can be painful. Different tools are available. The skin around the wound should be hydrated and protected, focusing on fragile areas, such as the tibial crest and heals, in order to prevent the development of new wounds. Other more complex interventions include tenosynovectomy, bone gouging and reduction of the necrotic toe that when properly performed can prevent a new passage in the operating room. If the ischemia becomes critical, the foot should be held warm with a carded cotton, taking care to separate the toes with dry dressings in order to preserve the healthy tissue and avoid induced wounds. Finally, compression bands are indispensable in cases with edema or venous hyperpressure. A skillful banding technique is essential, especially for legs with complex morphology.

Resume Objectifs Evaluer si l’expertise des premiers intervenants extra-hospitaliers (les medecins generalistes) est suffisante dans le domaine des ulceres de jambe. Methode Enquete transversale aupres de 179 generalistes d’Ile-de-France soit maitres de stage de Paris VI soit medecins du 14 e arrondissement de Paris, evaluant l’application des recommandations de la HAS de 2006 sur les ulceres de jambe. Resultats Soixante et onze maitres de stage et 29 medecins du 14 e representaient les 100 premiers generalistes ayant fourni des reponses exploitables (65 %). Ils n’avaient connaissance des recommandations que dans 40 % des cas sans difference significative entre maitres de stage et medecins du 14 e . Neuf medecins sur 10 examinaient moins de 10 patients/an avec ulcere. L’examen etait conduit selon les recommandations et, dans les deux tiers des cas, un echodoppler veineux etait prescrit. L’index de pression systolique (IPS) indispensable pour identifier une arteriopathie associee n’etait mesure que chez 10 % des patients. Conformement aux recommandations, la compression figurait au premier plan (73 %) loin devant les pansements (37 %) comme traitement de base mais la compression proposee n’etait conforme que dans un tiers des cas. Malgre des criteres d’evolution defavorable de l’ulcere (caracteristiques et duree d’evolution), le recours a un avis specialise etait rare (seuls 2 medecins sur 3 adressaient leur patient en cas d’arteriopathie associee). Conclusion Sans toujours connaitre les details des recommandations, les generalistes les appliquent souvent mais l’IPS doit etre mesure, la compression mieux utilisee et l’arteriopathie mieux diagnostiquee et traitee. Une expertise hospitaliere est souhaitable afin d’ameliorer la prise en charge des ulceres.

In France, approximately 3000 people are repatriated every year, either in a civil situation by insurers. Repatriation also concerns French army soldiers. The literature is scarce on the topic of venous thromboembolic risk and its prevention during repatriation for medical reasons, a common situation. Most studies have focused on the association between venous thrombosis and travel, a relationship recognized more than 60 years ago but still subject to debate. Examining the degree of venous thromboembolic risk during repatriation for medical reasons must take into account several parameters, related to the patient, to comorbid conditions and to repatriation modalities. Appropriate prevention must be determined on an individual basis.

Summary Objective To evaluate compression therapy for venous leg ulcers in terms of adherence, acceptability, quality, and effectiveness. Design of study Prospective observational cohort study. Setting Vascular diseases outpatient clinic in Paris, France. Subjects One hundred consecutive patients with active or healed leg ulcers and chronic lower limb venous insufficiency stage C5 or C6 in the CEAP classification scheme. Interventions Compression systems applied in a community-based practice. Main outcome measures A standardized form was used to collect: (1) data on patient adherence; (2) objective criteria evaluating the quality, effectiveness, and correct application of compression systems and; (3) patient education and perceptions about their compression therapy. Results Patient adherence with compression therapy was high (89%), even though it was often a source of discomfort. Only 10% of patients signaled no discomfort. Drawbacks reported by patients were excessive warmth (29%), pruritus (33%), unacceptably high cost (48%), and moderate to considerable difficulty putting on footwear (64%). In the 11% of patients who did not wear their compression system, reasons for nonadherence were inadequate comprehension of expected benefits (45.5%), pain related to compression (36.4%), difficulty applying the compression system (27.3%), and difficulty putting on footwear (27.3%). Application was correct in 51.7% of adherent patients; errors in the remaining patients included slippage, failure of the bandage to extend to just under the knee (55.8%), a tourniquet effect (21%), failure of bandaging starting at the base of the toes (37.2%), and failure to cover the heel (53.5%). Full edema control was achieved in 51.7% of adherent patients. Compression was adequate overall (worn, correctly applied, and effective) in 49% of adherent patients. The most common reasons for lack of effectiveness were inadequate pressure and errors in application. Lack of awareness of potential benefits and wearing modalities of compression therapy was noted in 56% of patients. Conclusion Patients, nurses, and physicians have inadequate knowledge of the modalities of compression therapy and as a result they are not well respected. Educational programs are needed.

A 69-year-old man presented with severe pain in hands and feet related to necrosis. Extensive explorations revealed type I cyroglobulinemia associated to monoclonal IgG kappa. Unfortunately he died a few months after.

The recent application of endovascular treatment techniques to venous pathologies has meant that new therapeutic solutions can be offered to patients suffering from post-thrombotic syndrome. This often-underestimated condition frequently complicates cases of deep vein thrombosis, whether treated or not, leading to a chronic and disabling set of clinical symptoms (oedema, claudication, pain, venous ulcers, etc.) due to the combination of the pathophysiological phenomena of obstructions and reflux. These clinical signs see only minimal improvement when managed with the classic medical treatment, venotonic agents, and venous compression. We report the cases of two patients suffering with chronic post-thrombotic venous obstruction of the lower limbs in whom endovascular treatment brought clear and long-lasting clinical improvement.