Prevalence of Frailty and Mobility Limitation in a Rural Setting in France.

BACKGROUND: The prevalence of frailty is variable according to the adopted operational definition, the tested population, and the setting where it is explored. OBJECTIVE: To estimate the prevalence of frailty and mobility disability in community-dwelling persons aged 60 years and older. DESIGN: Cross-sectional analyses. SETTING: The rural area of Labastide-Murat (France). PARTICIPANTS: All community-dwelling persons aged 60 years and older living in the area and answering to the study survey (n=572/1022). MEASUREMENTS: The study questionnaire included questions defining mobility disability (as ability to walk 400 meters and climb up 2 flights of stairs) and frailty (according to the FRAIL instrument and a modified version of the original definition proposed by Fried and colleagues). RESULTS: Mean age of participants was 72.4 years old. Mobility disability was reported by 47 (8.3%) participants. The sedentariness criterion of frailty was the most prevalent in the present population. Overall, according to the FRAIL instrument, 77.6%, 14.0%, and 8.3% could be defined as robust, pre-frail/frail, and disabled, respectively. When the alternative definition of frailty mirroring the definition proposed in the Cardiovascular Health Study was adopted, the prevalence of frailty increased and showed gender-specific differences (p=0.02). CONCLUSIONS: A relevant number of older persons living in rural areas experiences physical impairments and presents an increased risk for major negative health-related events. These results may support the ongoing clinical and research actions aimed at preventing the functional decline in elders.

[Excellent performances of Wells' score and of the modified Wells' score for the diagnosis of proximal or distal deep venous thrombosis in outpatients or inpatients at Toulouse University Hospital: TVP-PREDICT study]. / Excellentes performances du score de Wells et du score de Wells modifié dans le diagnostic de thrombose veineuse profonde proximale ou distale chez des patients hospitalisés ou ambulatoires au CHU de Toulouse: étude TVP-PREDICT.

AIM OF THE STUDY: In order to validate a standardized strategy for the diagnosis of lower limb deep vein thrombosis (DVT) in the regional university hospital of Toulouse, we decided to study the performances of Wells' score and the modified Wells' score for the diagnosis of proximal and distal DVT. METHOD: Inpatients or outpatients referred to the vascular medicine department from April 2006 to March 2007 with suspected DVT were included prospectively and consecutively. Wells' score was determined for each patient and compared with the duplex ultrasound result. RESULTS: Two hundred and ninety-seven patients were included. The prevalence of DVT was 13.5%. The negative predictive values of Wells' score and the modified Wells' score were 99 and 97% respectively. Similar results were found for proximal or distal thrombosis. The performances of the modified Wells' score were not statistically better than those of the original score. In 48% of patients, the determination of the D-dimers would not have been contributory. In the group with low probability (70% of patients), the incidence of thrombosis was 0.6%. CONCLUSION: Wells' score and Wells' modified score have shown excellent performances. The value of the modified Wells' score is not superior and our preference, for practical reasons, goes to the original score. The widespread use of duplex ultrasound, the large proportion of patients in which D-dimers would not have been contributory and the excellent results of Wells score for patients with a low probability of DVT are encouraging arguments in favor of the development of an alternative strategy for these patients.

[Medical treatment of patients with clinical peripheral arterial disease at hospital discharge: compliance with the French guidelines and changing practices (COPART I registry)]. / Traitement médical du patient atteint d'artériopathie athéroscléreuse des membres inférieurs symptomatique à sa sortie de l'hôpital: adéquation aux recommandations et évolution des pratiques dans le temps (registre COPART I).

INTRODUCTION: Peripheral arterial disease (PAD) is a frequent and serious condition with a risk of mortality comparable to that of certain cancers. However, in France, the literature on this medical condition is scarce and data on management, incidence of complications and prognosis are lacking. PURPOSES: The COPART I registry, set up in June 2004, in the Vascular Medicine Department of the University Hospital of Toulouse, France, constitutes an observational database on hospitalized patients with PAD, in order to evaluate management, follow-up and prognosis of the patients. The aim of the present work is to compare medical prescriptions at hospital discharge, with the recent guidelines of the French High Authority of Health. METHODS: All consecutive patients with PAD, hospitalized in the Vascular Medicine Department of the University of Toulouse, between June 1, 2004 and July 31, 2006 were included. Only surviving patients were analysed. RESULTS: Four hundred patients were included in the study. As expected, the majority were male (70%). Common cardiovascular risk factors were: arterial hypertension (66.7%), dyslipidemia (58.9%), diabetes (42.9%), and smoking (27.4%). Three patients out of 10 had claudication intermittens, nearly two out of 10 patients complained of persistent pain, and four out of 10 patients had Leriche and Fontaine stage IV arteriopathy. At hospital discharge, 86.9% of the patients were taking at least one antiplatelet treatment, 71.2% a statin, 54% a renin-angiotensin-system inhibitor. Nearly 66% of the patients (65.8%) received at least one antiplatelet agent and a statin. Nearly 50% of the patients (49.4%) had the three drugs recommended by the French High Authority of Health. We observed a change in prescription practices for statins (+30%), as well as for prescription of evidence-based tri-therapy (+29%) between 2004 and 2006. CONCLUSION: Treatments prescribed at hospital discharge of patient with PAD included in the COPART I registry are in compliance with the French High Authority of Health guidelines concerning antiplatelet drugs and statins. Inhibitors of the renin-angiotensin system seem insufficiently used. However, favorable trends in medical practices between 2004 and 2006 have been observed.

[Characteristics and one-year follow-up of patients with peripheral arterial disease. Initial results of the COPART I registry]. / Caractéristiques et devenir à un an d'une cohorte de patients artériopathes hospitalisés : premiers résultats du registre COPART I.

INTRODUCTION: Almost all patients with the most severe peripheral arterial diseases (PAD) patients are hospitalised. This means that the hospital is a particularly good place to observe the characteristics and outcome of PAD patients. It is for this reason that the hospitalised patient registry (COPART I) was created. RESULTS: From June 1st 2004 to May 31st 2005, we included 187 patients surviving at hospital discharge. As expected the majority were men (68.4%). The median age was 72 (+/- 13 years). Almost one third of the PAD of patients suffered from intermittent claudication and two thir (63,6%) from permanent ischemia. A large majority of this latter group had critical limb ischemia. We found a mortality rate of 17.1% at the on year follow-up. These deaths were mainly of cardiovascular origin (9.1%). Almost 2/3 of the deaths had already occurred by six months. One patient in four undergone major or minor amputation during the follow up 2/3 of them involving major amputation. This figure rose to fou patients in ten for critical limb disease. A previous history of both major and minor amputation is strongly related with new amputations (RR = (CI: 1.2-7.5) P = 0.02). After one year of follow-up, almost four patients in ten (42.6%) with permanent ischemia had died, undergone major amputation, or suffered an MI or an IS. CONCLUSION: Peripheral arterial disease remains a severe chronic disease linked to excess mortality of cardiovascular origin. Therefore patients should be given optimal treatment.

[The anticoagulation clinic: that can not be ignored]. / La clinique des anticoagulants: un concept incontournable.

Complications linked to drug absorption are most frequently observed in the case of treatment by vitamin K antagonist (VKA), whereas 1% of the French population is treated by VKA. Despite official recommendations renewal, these complications are not decreasing. The experience of anticoagulation clinics (AC) in other countries proves their efficiency in the reduction of two-thirds of hemorragies and thrombotic recurrences. The concept of AC strictly obliged to associate therapeutic education to the patient and the calculation of the treatment dosage. Our experience started in 1998. We suggest a patient education at first during an individual consultation then during a group session. A multicentric prospective evaluation of AC vs. the conventional follow-up is on the way in France having as objectives to test the clinical efficiency and the comparison of the cost for such a supervision. In any case, important efforts have to be accomplished regarding the support of present and future antithrombotics. Their complexity of indications, supervision, and tolerance has to reinforce the rigour of therapeutic steps from the prescription to the absorption of the drug, with the possibility to appeal to the AC.

Lack of association between ADH3 polymorphism, alcohol intake, risk factors and carotid intima-media thickness.

OBJECTIVE: We assess the relationships between alcohol dehydrogenase 3 (ADH3) polymorphism, alcohol consumption and cardiovascular risk factor levels. METHODS: In a representative population sample from Southwestern France (614 men, 567 women, age 49.7+/-8.5 years), alcohol intake was assessed by questionnaire. RESULTS: Alcohol consumption was significantly related with higher levels of total and HDL cholesterol, triglycerides, apolipoprotein A-I in men and with higher levels of HDL cholesterol in women. Also, an inverse relationship between alcohol consumption and intima-media thickness was found in men. Conversely, in both genders, no differences were found between ADH3 genotypes regarding all cardiovascular risk factors studied and carotid intima-media thickness. Also, in both genders, no significant ADH3xalcohol interaction was found for all variables, and further adjustment on age, body mass index, educational level, smoking status or after excluding subjects on hypolipidemic or antihypertensive drug treatment did not change the results. CONCLUSION: We found no interaction between the ADH3 polymorphism and alcohol intake on cardiovascular risk factor levels and atherosclerotic markers in Southwestern France.

Metabolic syndrome is associated with markers of subclinical atherosclerosis in a French population-based sample.

Metabolic syndrome (MetS) is associated with increased risk of cardiovascular disease (CVD). The relation of MetS with early stages of atherosclerosis, more important from a prevention perspective, has not been evaluated extensively. We examined the association of MetS, using WHO and NCEP definitions, with number of carotid and femoral plaques; carotid intima-media thickness (IMT); pulse wave velocity (PWV) in a random population-based sample of 1153 French adults (35-65 year). Impact of inflammatory factors (C-reactive protein and soluble intercellular adhesion molecule-1) on these parameters was also evaluated. Prevalence of MetS was 14.5 (CI: 12.3-16.0) and 17.5 (CI: 15.1-20.2)%, using NCEP and WHO definitions, respectively. MetS significantly predicted number of plaques, IMT, and PWV after adjustment for traditional risk factors (P<0.05). Inflammatory factors predicted peripheral plaques only. The risk of subclinical atherosclerosis was considerably increased with MetS (P<0.05); odds ratios ranged 1.80-2.15 with NCEP definition, and 1.48-1.97 with WHO definition. Individuals meeting both NCEP and WHO definitions had slightly greater risk of increased plaques, IMT, and PWV. MetS was strongly associated with subclinical atherosclerosis and aortic stiffness, and can be used as a surrogate marker for high CVD risk, deserving aggressive treatment.

[Critical chronic ischemia of the limbs: organization of the management of a malignant disease]. / L'ischémie critique chronique des membres: organisation de la prise en charge d'une maladie maligne.

Chronic critical ischemia of the limbs (CCIL) typically raises the problem of early diagnosis and specialized treatment. The challenge is considerable since the incidence of CCIL is in the range of 500 to 1,000 patients/million inhabitants/year, with an incidence of major amputations from 100 to 300/million inhabitants/year. Mortality of these patients reaches 20% at 6 months and more than 80% at 10 years, which places the CCIL in the group of highly malignant oncological diseases. Despite therapeutic advances, the rate of amputations continues to progress especially in diabetics whose life expectancy is increasing due the excellent contribution of coronaropathy. Prequisites are summarized in the TASC consensus and in the discussions conducted during the creation of vascular centres: multidisciplinary teams, arteriopathy register (including CCIL and center audits), development of protocols (evaluation cost - efficiency of revascularization and medical treatments, evaluation of angiogenesis projects), collaboration between vascular centers and networks. CCIL is a malignant disease with an increasing incidence implying early and specialized care; means exist but efforts have to be made regarding their evaluation and coordination.

[Risk factors management in 5708 ambulatory patients suffering from peripheral vascular disease followed in urban practices]. / Contrôle des facteurs de risque dans une population de 5 708 artériopathes des membres inférieurs vus en médecine de ville.

STUDY OBJECTIVE: we examined the management of risk factors in patients suffering from obliterating peripheral arterial disease (OPAD), in urban medical practice. METHODS: PRISMA, ECLAT1 and APRES are surveys based on urban medicine in France. These 3 studies have allowed a compilation of data pertaining to the control of risk factors in patients suffering from one or more clinical manifestations of atherothrombosis, including cerebral vascular accident, coronary insufficiency or OPAD. The study population was divided among patients with isolated OPAD, versus OPAD associated with coronary artery disease (CAD), versus OPAD associated with cerebral vascular disease. RESULTS: a total of 5 708 patients with stable OPAD were included among the 3 studies. Risk factors were not managed in the majority of patients, including 62.6% of hypercholesterolemic patients, 71.1% of diabetics, and 77.4% of hypertensive patients. Overall, the control of risk factors was less satisfactory in patients with OPAD than in patients with CAD. Smoking (70.6% current or past smokers) remains a major risk factor in OPAD. The proportion of current smokers was significantly higher is the group with isolated OPAD than in the other 2 groups of patients (p < 0.0001). CONCLUSIONS: The control of risk factors in patients with OPAD is suboptimal, mainly because of failure to reach the therapeutic goals, rather than because of poor medical management. It is important that recent recommendations be implemented in medical practice. Awareness of the primary physicians will be key in the optimisation of treatment prescriptions and, above all, in the achievement of a higher level of clinical performance.

Incidence and prognosis of cancer associated with bilateral venous thrombosis: a prospective study of 103 patients.

BACKGROUND: A strong association between bilateral deep vein thrombosis (DVT) and cancer had been found in one retrospective study. To confirm this finding, consecutive patients with an objective diagnosis of bilateral DVT were followed over 12 months. PATIENTS AND METHODS: One-hundred and three patients, hospitalized for bilateral DVT, were included in the study. Twenty-six patients (25.2%) were already known to have a cancer, 26 (25.2%) had a previous history of venous thromboembolic disease, 44 (42.7%) had a symptomatic pulmonary embolism. The patients were scheduled to be prospectively followed up at 3, 6 and 12 months as outpatients. Information on recurrence, evidence of a new overt cancer and the cause of death were recorded for all patients. RESULTS: A new cancer was diagnosed in 20 (26%) of the 77 patients without known cancer at admission. The risk of cancer was significantly more important in idiopathic thrombosis than in patients with secondary thrombosis (40.5% vs. 12.5%; odds ratio 4.8, 95% confidence interval 1.4, 18.8). Seventy percent of the cancers discovered had already spread. Age, gender, presence of pulmonary embolism, recurrence and location of the thrombosis were not statistically associated with the risk of cancer. The 1-year survival rates of patients with a previously known cancer and patients with a newly discovered cancer were, respectively, 26% and 35% (P = 0.33). CONCLUSIONS: Bilateral DVT is a significant risk indicator of malignancy. Cancer is present in 45% of patients with bilateral DVT and is associated with a poor prognosis.

Bone mineral decrease in the leg with unilateral chronic occlusive arterial disease.

OBJECTIVE: The links between osteoporosis and arteriosclerosis have been established by numerous epidemiological studies. Could arteriosclerosis induce bone mineral loss via ischemia or other pathological process? We carried out a comparative study of bone mineral density in both legs of patients with unilateral arterial disease of the lower limbs. METHODS: We studied 25 patients, 22 men and 3 women, whose mean age was 62.3 years (range 35-88 years). These patients had unilateral lower limb arterial disease of at least 3 months duration with a systolic index at least 50% lower on the affected than on the healthy side. Bone mineral content (BMC) and bone mineral densities (BMD) of the femoral neck, femur, tibia, foot and ankle of the affected and the unaffected legs were measured by dual x-ray absorptiometry (Lunar DPXL) and the results compared. RESULTS: Bone mineral density was significantly lower in the femur (-3.7%, p = 0.04), the foot and the ankle (-3%, p = 0.05) of the affected leg. There was a non-significant decrease in BMD of the whole femoral neck (-1.2%) and the trochanter (-4.4%, p = 0.08) on the affected side. Tibial bone mineral density was identical in both legs. Bone mineral content was lower on the affected side (-5.3%, p = 0.05) whereas fat mass and muscle mass were the same in both legs. CONCLUSION: The ischemia resulting from arterial disease of the lower limbs appears to have a direct deleterious effect on bone mineralization.

A clinical approach to the management of a patient with suspected renovascular disease who presents with leg ischemia.

Atherosclerotic renal artery stenosis (ARAS) may cause hypertension, progressive renal failure, and recurrent pulmonary edema. It typically occurs in high risk patients with coexistent vascular disease elsewhere. Most patients with ARAS are likely to die from coronary heart disease or stroke before end-stage renal failure occurs. Recent controlled trials have shown that most patients undergoing angioplasty to treat renovascular hypertension still need antihypertensive agents 6 or 12 months after the procedure. Nevertheless, the number of antihypertensive agents required to control blood pressure adequately is lower following angioplasty than for medication alone. Trials assessing the value of revascularization for preserving renal function or preventing clinical events are only in the early recruitment phase. Revascularization should be undertaken in patients with ARAS and resistant hypertension or heart failure, and probably in those with rapidly deteriorating renal function or with an increase in plasma creatinine levels during angiotensin-converting enzyme inhibition. With or without revascularization, medical therapy using antihypertensive, hypolipidemic and antiplatelet agents is necessary in almost all cases.

[The lower limb of elderly patients (venous and arterial diseases)]. / La jambe du sujet âgé (pathologie veineuse et ischémique).

Elderly patients frequently suffer from vascular pathologies of the leg. In these more fragile patients, diagnostic work-up must cause as little trauma as possible. The clinical status and morphological appearance of the vessels make vascular investigations sometimes difficult to perform in the elderly. With arterial pathology, vascular imaging relies on numerous non invasive techniques (Duplex scan and vascular imaging techniques by reconstruction: helical CT and magnetic resonance angiography). The clinical exam, the evolution stage of arterial disease and these non invasive investigations must allow to select the patients that should benefit from an arteriography, more or less associated to revascularization. With thrombo-embolic pathology, venography has now been replaced by venous duplex scan of the lower limbs irrespective of the underlying thrombotic etiology.

Findings of the Naftidrofuryl in Quality of Life (NIQOL) European study program.

BACKGROUND: We report in this paper the findings of a pooled analysis of 3 previously published studies undertaken in Germany, France and Belgium to assess the effects of naftidrofuryl on the quality of life of patients with intermittent claudication. METHODS: A total of 754 patients were randomised in the 3 studies, 709 of whom (358 naftidrofuryl, 351 placebo) were available for the primary intention-to-treat analysis. The primary outcome variable was the change in the disease-related limitation of the quality of life as measured by the CLAU-S questionnaire. This instrument which has been validated in an international study, comprises 47 questions covering 5 dimensions: "daily living", "pain", "social life", "disease specific anxiety" and "mood". RESULTS: A multivariate analysis of covariance adjusted for baseline values, study effect and first order study treatment interaction, demonstrated the global superiority of naftidrofuryl over placebo (p<0.001). A separate covariance analysis for the 5 dimensions showed highly significant differences for "daily living", "pain", "social life" and "mood" (all p<0.01). CONCLUSIONS: In conclusion, this pooled analysis has shown that naftidrofuryl can significantly improve the quality of life of patients with intermittent claudication. These findings, taken together with evidence from previous studies that it improves treadmill walking distances, suggest that naftidrofuryl can play a useful role in the treatment of this condition.

[Venous thrombosis from central venous catheterization in oncology]. / Thromboses veineuses sur cathéters centraux en cancérologie.

OBJECTIVES: The aim of this review article is to assess the epidemiology, diagnosis and treatment of deep venous thrombosis of the upper limbs which are becoming more common with the use of central catheterizations in oncology. RISK FACTORS: The incidence is differently estimated. The catheterization is the main risk factor which is added to the proper patient's risk factors in a highly thrombogenic context (cancer, chemotherapy, infection,...). The outcome can be limited to the catheter (thrombotic) dysfunction or can progress towards vein thrombosis, pulmonary embolism, most often asymptomatic or to a superior vena cava syndrome. Ultrasounds and CT scan have an important role although their efficacy have not been demonstrated yet. TREATMENT: Prophylactic anticoagulation with unfractionated heparin, low molecular weight heparin or oral anticoagulant seems to be effective. Low dose thrombolysis by bolus of urokinase or tissue plasminogen activator allows restoring the patency of the catheter in 70 to 90% cases of thrombotic dysfunction. The modalities of treatment of the vein thrombosis are much discussed.