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Lyme disease acrodermatitis chronica atrophicans is a tertiary form of Lyme borrelliosis. It occurs at least six months, but also up to several years, after a tick bite. This rare condition is probably underestimated because of the difficult diagnosis. Clinical presentations of acrodermatitis chronic atrophicans are quite variable depending upon the duration of the disease. Complimentary explorations are difficult to interpret and rarely specific. Only rare configurations allow formal diagnosis of Borrelia burgdoferi infection. We present a patient who exhibited an atypical clinical presentation of Lyme disease acrodermatitis chronic atrophicans. The clinical outcome was quite favorable with treatment, confirming the diagnosis. Such treatments, which are well tolerated and highly effective, are essential since an untreated disease can lead to potentially severe neurological involvement., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

Background: Apart from compression therapy, physical therapy has scarcely been evaluated in the treatment of chronic venous disorders (CVDs). Spa treatment is a popular way to administer physical therapy for CVDs in France, but its efficacy has not yet been assessed in a large trial. The objective was to assess the efficacy of spa therapy for patients with advanced CVD (CEAP clinical classes C4-C5)., Methods: This was a single-blind (treatment concealed to the investigators) randomized, multicenter, controlled trial (French spa resorts). Inclusion criteria were primary or post-thrombotic CVD with skin changes but no active ulcer (C4a, C4b, or C5). The treated group had the usual 3-week spa treatment course soon after randomization; the control group had spa treatment after the 1-year comparison period. All patients continued their usual medical care including wearing compression stockings. Treatment consisted of four balneotherapy sessions per day for 6 days a week. Follow-up was performed at 6, 12 and 18 months by independent blinded investigators. The main outcome criterion was the incidence of leg ulcers at 12 months. Secondary criteria were a modified version of the Venous Clinical Severity Score, a visual analog scale for leg symptoms, and the Chronic Venous Insufficiency Questionnaire 2 and EuroQol 5D quality-of-life autoquestionnaires., Results: Four hundred twenty-five subjects were enrolled: 214 in the treatment group (Spa) and 211 in the control group (Ctr); they were similar at baseline regarding their demographic characteristics, the severity of the CVD, and the outcome variables. At 1 year, the incidence of leg ulcers was not statistically different (Spa: +9.3%; 95% confidence interval [CI], +5.6 - +14.3; Ctr: +6.1%; 95% CI, +3.2 - +10.4), whereas the Venous Clinical Severity Score improved significantly in the treatment group (Spa: -1.2; 95% CI, -1.6 - -0.8; Ctr: -0.6; 95% CI, -1.0 - -0.2; P = .04). A significant difference favoring spa treatment was found regarding symptoms after 1 year (Spa: -0.03; 95% CI, -0.57 - +0.51; Ctr: +0.87; 95% CI,+0.46 - +1.26; P = .009). EuroQol 5D improved in the treatment group (Spa: +0.01; 95% CI, -0.02 - +0.04) while it worsened (Ctr: -0.07; 95% CI, -0.10 - -0.04) in the control group (P < .001). A similar pattern was found for the Chronic Venous Insufficiency Questionnaire 2 scale (Spa: -2.0; 95% CI, -4.4 - +0.4; Ctr: +2.4; 95% CI, +0.2 - +4.7; P = .008). The control patients showed similar improvements in clinical severity, symptoms, and quality of life after their own spa treatment (day 547)., Conclusions: In this study, the incidence of leg ulcers was not reduced after a 3-week spa therapy course. Nevertheless, our study demonstrates that spa therapy provides a significant and substantial improvement in clinical status, symptoms, and quality of life of patients with advanced venous insufficiency for at least 1 year., (Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Injectable anticoagulation therapy is indicated for several months following diagnosis of venous thromboembolic disease (VTE) in a context of active neoplasia. Certain studies have shown an improvement in patient compliance using self-injections., Purpose: Allow patients to safely make their own injections of anticoagulants after checking their aptitude and motivation., Methods: At the prescribing physician's request, the GRANTED network provided patients and/or the resource person with specific education and training. The educational program was proposed to patients with an indication for a treatment for at least 3 months. After becoming familiar with the injection material and its manipulation, the patient and/or resource person performed sham injections on test materials. Patients were then allowed to decide for themselves whether or not to participate in the self-injection protocol. The prescribing physician received a report from the training team., Results: From November 2010 to July 2012, 39 patients participated in the educational program, generally in a context of vitamin K antagonist prescriptions. Sixteen of these patients had a neoplasia. The educational program corrected erroneous or imprecise points of information, particularly concerning syringe purging., Discussion: The education program proved to be interesting for points other than those initially foreseen and allowed the team to rectify a certain number of erroneous messages unrecognized by the prescribing physicians. This result goes in line with the need for accompanying patients who have a prescription for self-injections and also emphasizes the need for careful follow-up., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Objective: The development and validation of new clinimetric tools is essential for the progress of clinical research in the field of chronic venous insufficiency. Chromametry is a simple, quick and non-invasive technique that measures the color of the skin. The aim of this study was to evaluate the ability of this technique to quantify skin pigmentation as a marker of severity of chronic venous disease and to assess the variability of measurements obtained in this condition., Methods: Chomametry was performed on three different sites on each lower limb in 42 patients undergoing a spa treatment in La Léchère (Savoie) for chronic venous disorders (CVD). Four series of measurements were taken by two investigators for each patient, at two sessions two to four days apart., Results: The chromameter readily measured the pigmentation index (PI). The PI increased with higher clinical class (CEAP classification) for measurements made at the malleolar level (r=0.48; P<0.001) and the supra-malleolar area (r=0.55; P<0.001), but not at the level of the anterior tibial tuberosity (r=-0.09; P=0.45). The repeatability and the intra- and inter-observer reproducibility of this PI index were 15%, 18% and 21% respectively of the mean of the observed difference at the malleolar level. The chromameter also provided an erythema index, which appears to be less relevant and more variable than the PI, but which might add potentially useful information regarding the characterization of skin inflammation related to the venous disease., Conclusion: This study shows that chromametry can be used in clinical research studies to quantify skin changes associated with CVD. Whether it can also be useful for early detection and follow-up of patients with venous trophic changes remains to be investigated., (Copyright © 2013. Published by Elsevier Masson SAS.)

Background: Lymphedema is a chronic condition considered to be rare in its primary form and potentially frequent in women after breast surgery for cancer: 27,000 new cases annually. Therapeutic management is a serious challenge. In France, the health authorities (Haute Autorité de santé [HAS]) have recently proposed that appropriate management practices for lymphedema include "patient education". The HAS and the National institute for health care prevention and education also published a methodology guide devoted to structuring a therapeutic education program for patients with chronic disease. Current hospital regulations state that this education program is part of the care to be delivered to patients with chronic disease and that it must comply with the national directives. The purpose of our present work was to present the concept and the contents of a patient education program entitled "Live with lymphedema" designed for patients with lymphedema and developed within the inpatient-outpatient network GRANTED in Sud-Isère., Methods: A standard detailed educative approach was applied. It was designed after the educational program for patients with lower limb arterial occlusive disease authorized by the Rhône-Alpes regional health agency. It was adapted to the specific problematic of patients with lymphedema, including medical management, rehabilitation, dermatology and nutritional aspects. It was developed in cooperation with patients and favors local associative actions., Results: The specifically structured program included three therapeutic education consultations and five workshops. Less than one year after its institution, more than 30 patients have participated in the program., Discussion: We report a structured patient education program designed for patients with lymphedema. This program was authorized by the Rhône-Alpes regional health agency in March 2011 and is in compliance with the national directives and HAS guidelines., (© 2011 Elsevier Masson SAS. All rights reserved.)

Background: The corona phlebectatica (CP) is classically described as the presence of abnormally visible cutaneous blood vessels at the ankle with four components: "venous cups," blue and red telangiectases, and capillary "stasis spots." Previous studies showed that the presence of CP is strongly related to the clinical severity of chronic venous disorders (CVD) and the presence of incompetent leg perforators. The aim of this study was to select the most informative components of the CP in the assessment of the clinical severity of CVD patients., Methods: A multicentric series of 262 unselected patients (524 limbs) consulted for CVD were clinically evaluated using a standardized form to record the CEAP "C" items and the presence of the four CP components. Standard categorical and ordinal statistics were used to describe the external validity of the CP components as severity indexes, taking the "C" classes as reference., Results: "Stasis spots" (P < .001; r = .44) and blue telangiectases (P < .01; r = .32) were linearly associated with the ascending order of "C" classes, whereas the relationship is less clear for the red telangiectases and the "venous cups." The association pattern of the four components showed that only the blue telangiectases and the "stasis spots" were consistent with each other. Blue telangiectases were found more sensitive (0.91 vs 0.75) but less specific (0.52 vs 0.80) than "stasis spots" for advanced venous insufficiency (CEAP "C4-6")., Conclusion: This study shows that only blue telangiectases and "stasis spots" provide valuable information in patients with CVD and deserve to be taken into account in the evaluation of such patients. Further studies are needed to show the reproducibility of this data, which we regard as essential for clinical use., (Copyright © 2012. Published by Mosby, Inc.)

The vitamin K antagonists (VKA) remain to this day the only oral form of therapeutic anticoagulation. Approximately 1% of the French population, mainly elderly, is treated with these anticoagulants. Oral anticoagulants have significant risks of iatrogenic complications; indeed they are the leading cause of such drug-induced complications, predominantly hemorrhages. AFSSAPS (French Drug and Medical Products Agency) clinical practice recommendations, repeatedly disseminated, emphasize the education of patients receiving VKAs. Managing oral anticoagulant treatment is challenging, with a significant risk of under- or overdosing and consequently, thrombosis or hemorrhage. The therapeutic window is narrow, multiple drug-interactions are possible, and the specific dose required for a particular individual to achieve appropriate International Normalized Ratio (INR) levels is unpredictable. The literature contains few randomized controlled trials about the efficacy of education for patients treated with oral anticoagulants. These education programs are not standardized and are therefore varied and difficult to compare. Nevertheless, studies demonstrate the importance of patient education programs in reducing the risk of hemorrhage and achieving better treatment stability. The Grenoble region hospital-community network for vascular diseases (GRANTED) has developed an education program for these patients, consisting of individual sessions for the patient and/or a friend or family member (either at a health care facility or at the patient's home), telephone support and group sessions, and using educational tools and supports. There is also a link with the general practitioner who receives a report. This approach makes it possible to adapt the educational message to individual patients and their daily lives, as well as directly involving them in the management of their treatment.

Background: The guidelines for good clinical practices issued by the French Agency for Health and Drug Safety and the Superior Health Authority are designed to improve management of oral anticoagulants which can be an important source of iatrogenic morbidity. These guidelines have focused on the need for special education. The GRANTED network in Isère developed an education program for patients taking oral anticoagulants., Objective: The purpose of this study was to evaluate quantitatively the therapeutic education of these patients taking oral anticoagulation, irrespective of their risk factor(s)., Patients and Methods: This was a retrospective analysis of 100 randomly selected patients taking oral anticoagulants for at least three months who participated in the GRANTED education program in 2007. The evaluation criterion was the number of hemorrhagic and/or thromboembolic events., Results: Among the 97 patients contacted, 3.1% had a serious hemorrhagic event and 1.03% a recurrent thromboembolic event., Conclusions: The quality of a scientific study depends on the quality of the methodology, leading to a preference for prospective studies. It would nevertheless be pertinent to determine whether or not official management recommendations are applied correctly in real life conditions. We report a first evaluation of a therapeutic education program designed for patients taking oral anticoagulants. The education program within the GRANTED network has enabled a reduction in the iatrogenic morbidity related to oral anticoagulation despite the selection bias of the probably high-risk population enrolled in the GRANTED network.

Objectives: Except for compression therapy, physical therapy has scarcely been evaluated in the treatment of chronic venous disorders (CVD). Spa treatment is a popular way to administer physical therapy for CVD in France, but its efficacy has not been evaluated yet. This study aimed to assess the efficacy of balneotherapy associated with patient education, as performed in the spa resort of La Léchère, in patients with advanced chronic venous insufficiency (CEAP clinical classes C4/C5)., Methods: The study was a randomized controlled trial, spa therapy being administered on top of the usual medical care. Evaluation was by a blinded independent investigator. Subjects were patients with primary or post-thrombotic CVD with skin changes but no active ulcer (C4a, C4b, or C5), living in Grenoble area, and willing to undergo a spa treatment course in La Léchère. The treated group had the three week spa treatment course in La Léchère, soon after randomization; the control group also had a spa treatment, but starting at day 365. The treatment consisted of four balneology sessions per day, six days a week during three weeks, and three educational workshops. An independent follow-up was performed in Grenoble hospital every three months for 15 months. The main outcome criterion was the severity of the skin changes, as evaluated by means of malleolar chromametry. Quality of life, as measured by the Chronic Venous Insufficiency Questionnaire 2 scale, a visual analog scale (VAS) for leg symptoms, and the occurrence of leg ulcers were used as secondary criteria. The year after spa treatment in the treated group was compared with the year before spa treatment in the control group., Results: Fifty-nine subjects were enrolled (29 in the treatment group and 30 in the control group). No statistically significant difference between groups was found at study onset regarding age, sex, etiology, CEAP "C" class, and the outcome variables. After treatment, chromametry showed significantly decreased pigmentation and erythema in the treatment group compared with the controls (P < .01). Quality of life (P < .01) and symptoms (P < .001) also improved significantly. These differences remained significant after one year follow-up. The control patients improved similarly after their own spa treatment (day 450)., Conclusion: This study shows that spa therapy, associating balneotherapy and patient education, is able to improve significantly the skin trophic changes of the CVD patients and their CVD related quality of life and symptoms. This effect is of large magnitude and remains significant one year after the treatment course.

Background: Long-term oral anticoagulation treatment is associated with potential morbidity. Insufficient patient education is linked to poorly controlled anticoagulation. However the impact of a specific educational program on anticoagulation related morbidity remains unknown., Objective: To evaluate the effect of an oral anticoagulation patient education program in reducing both hemorrhagic and recurrent thrombotic complications., Design/participants: We conducted a prospective, multicenter open randomized study, comparing an interventional group who received a specific oral anticoagulation treatment educational program with a control group. Eligible patients were older than 18 and diagnosed as having deep vein thrombosis or pulmonary embolism requiring therapy with a vitamin K antagonist for 3 months or more. Our primary outcome was the occurrence of hemorrhagic or thromboembolic events., Results: During the 3-month follow-up the main outcome criteria were observed 20 times (6.6% of patients), 5 (3.1%) in the experimental and 15 (10.6%) in the control group. Consequently, in multivariate analysis, the cumulative risk reduction in the experimental group was statistically significant (OR 0.25, 95% CI 0.1-0.7, p < 0.01)., Conclusions: Patient education using an educational program reduced VKA-related adverse event rates.

Within the framework of a patient education training programme, a group of health sector professionals comprised of hospital doctors, general practitioners, nurses, physiotherapists and dieticians created a programme intended for people with peripheral vascular disease (intermittent claudication). A study was carried out simultaneously utilising a questionnaire and a series of four interviews which permitted professionals to collect data on the patients' expectations regarding such a programme and their points of view at each specific stage of its development. This article analyses the contribution of the patients to the therapeutic patient education programme design, namely with respect to their influence on the programme's content, on the educational process and approach as well as on the professionals' perspectives on disease, various treatments and people with this particular illness. The discussion highlights the range of goals and objectives that can potentially be met through dialogue and exchange between people suffering from the same disease.

Background: Because the natural history of primary Raynaud phenomenon (RP) is unclear, we undertook this long-term (14 years) follow-up of an epidemiologic study on RP to investigate the incidence, remittance rate, and transition rate toward systemic sclerosis and other scleroderma spectrum disorders in a population-based sample of subjects., Methods: In 1988 and 1989, 296 subjects obtained from a random sample of the general population of the Alpine valley of Tarentaise (southeast France) completed a cross-sectional study on RP. Of these, 78 met the diagnostic criteria for RP (RP+). From April 2002 to March 2003, we were able to get follow-up information on 292 people (dropout rate, 1.4%). Eighteen subjects (6.1%) had died, and the remaining 274 were successfully contacted. They were first evaluated by a standardized phone interview regarding their cold sensitivity, digital color changes, and RP. If any significant medical changes related to RP and/or suggesting scleroderma were reported, these subjects were invited for a medical evaluation., Results: Mortality was similar in RP+ and RP- subjects, and no death was due to an RP-related condition. Seven cases of new RP were diagnosed in the RP- group, which corresponds to an annual incidence rate of 0.25%. Among the 72 RP+ subjects and the 7 subjects with a new RP available for follow-up, none developed clinical features of scleroderma. A disappearance of RP attacks for 2 winters or more was reported by 24 RP+ subjects (33%)., Conclusions: These results show that, in the general population, RP is most often a benign condition and may disappear in a substantial proportion of subjects.

Spa treatment is commonly used in chronic venous diseases, to the satisfaction of many patients, but no scientific validation work has been performed up to now. This pharmaco-clinical study was designed to evaluate the specific influence of topical application of the mineral water of La Léchère on the cutaneous microcirculation. It was a controlled, randomized, double-blind study comparing the effects of the water of La Léchère to distilled water applied as a spray to the ankle in ten healthy subjects. Skin temperature and laser-Doppler perfusion index (mean and temporal variability) were the evaluated parameters. Under these conditions, the results show a cutaneous cooling with a mean value of 0.3 to 0.5 degrees C, whose duration is significantly longer with the thermal water (p<0.05). During this cooling, the laser-Doppler perfusion index remained stable when distilled water was applied, whereas an increase was observed when the thermal water was employed (p=0.005). No significant changes in vasomotion were observed with either treatment (p=ns). This study demonstrates the presence of a specific effect of topical application of the La Léchère mineral water on the cutaneous microcirculation. The explanation and the potential therapeutic interest of this effect were beyond the scope of this study and remain to be investigated.

Chronic venous insufficiency is a frequent and invalidating condition, which also represents an important socio-economical burden. As it is a chronic disease with no effective curative therapy, the preventive and educational means are of particular interest. The present health policy insists on the education given to patients suffering from chronic disease, but contrasting with other chronic conditions (diabetes, asthma, chronic back pain), to our knowledge, there is no published structured educational training programme dedicated to people suffering from CVI. Such an educational programme was developed at the spa resort of La Léchère (Savoie, France), which is specialized in the treatment of CVI. Proposed to voluntary patients taking the waters and driven by a multidisciplinary team (doctors, nurses, pharmacists), the objective was to promote a better knowledge in venous disease by the patients and to make them adopt a more active behaviour in their treatment. Three topics were approached in interactive work-groups using a problem solving teaching technique: "anatomy and physiology of the circulatory system", "venous diseases", "practical aspects life with compression stockings". Comparison of pre and post-teaching evaluations was performed in 149 unselected patients, allowing a short-term appraisal of the knowledge improvement. It showed a 25 to 40% increase in right answers according to the tested topic. Further evaluation of long term beneficial effects is needed. However, the high interest of patients regarding this teaching method and the content of the programme provides good expectations regarding a real beneficial effect on health and quality of life.

Objective: Erysipela is a common skin infection readily found in patients with venous insufficiency or lymphedema. The aim of this work was to measure the incidence of erysipela in a spa resort specialized in the treatment of venous and lymphatic diseases and to evaluate the influence of a preventive strategy principally based on education of patients at risk., Patients and Methods: The measurement of incidence was based on the detection of the reasons for which the patients did not attend their thermal care sessions. Quality control was obtained from the reports of cases diagnosed by local private and public health care centers., Results: The incidence of erysipela in this high risk population was 40.2 and 48.5 cases for 1000 persons per exposure-year in 1993 and 1994 respectively. The preventive strategy carried out was able to induce a reduction of 65% during the next years (p<0.01)., Conclusion: This study confirms the high incidence of erysipela in subjects with severe venous insufficiency or lymphedema and the efficacy of an active educational preventive strategy.