An unfavorable dietary pattern is associated with symptomatic peripheral artery disease.

BACKGROUND AND AIMS: Diet has an essential role in primary and secondary cardiovascular prevention by modulating various cardiovascular risk factors. The need to have easily useable tools seems essential to facilitate the daily practice of clinicians in order to propose the most optimal management of their patients' diet. The aim of this study was to compare the diet assessed with a simple food frequency questionnaire (FFQ) between patients with symptomatic peripheral artery disease (PAD) and healthy subjects. MATERIALS AND RESULTS: In this ancillary study (ELECTRO-PAD study), we included symptomatic PAD patients and healthy participants. All participants filled a FFQ previously validated called Cardiovascular-Dietary-Questionnaire 2 (CDQ-2). CDQ-2 allows the calculation of different scores: global food score, saturated fatty acids score (SFA), unsaturated fatty acids score (UFA), fruit and vegetable score. The higher the score, the better the diet. We compared the different scores between PAD patients and healthy participants. We included 37 PAD patients and 40 healthy subjects. Mean global score was significantly lower in PAD patients compared to the healthy participants (5.35 ± 7.65 vs 10.60 ± 5.81; p = 0.0011). Similarly, the sub-scores concerning unsaturated fatty acids and fruits-vegetables were significantly lower in PAD patients (p < 0.010). Only the sub-score concerning saturated fatty acids was not significantly different (p = 0.8803) between PAD patients and healthy participants. CONCLUSION: CDQ-2 highlights that PAD patients have an unfavorable diet compared with healthy participants. CDQ-2 is a tool of interest to help the clinicians for dietary advice of PAD patients.

Test-retest Reliability and Minimal Detectable Change in Exercise Oximetry in Claudicants.

BACKGROUND: Exercise transcutaneous oxygen pressure measurement (Exercise-TcPO2) can be used to diagnose Lower Extremity Artery Disease (LEAD) and allows the quantification of limb ischemia during exercise on treadmill. Exercise-TcPO2 test-retest reliability in patients with LEAD and severe walking impairment is unknown. The aim of this study was to evaluate the test-retest reliability, standard error of measurement (SEM), and Minimal Detectable Change (MDC) of exercise-TcPO2 in patients with claudication. METHODS: Data were collected from patients that performed 2 treadmill tests within a 1-month interval. Delta from Rest of Oxygen Pressure (DROP) values were measured at both buttocks (proximal) and both calves (distal). Test-retest reproducibility was assessed by recording transcutaneous oximetry measurements twice and expressed as SEM and intra-class correlation coefficients. MDC was calculated using the formula MDC = SEM x 1.96 x √ 2. RESULTS: Twenty eight LEAD patients (61 ± 9 years old) were included. Intra-class correlation coefficients were 0.66 [0.50, 0.79] and 0.65 [0.49, 0.79] for the proximal and distal levels, respectively. The SEM of DROP at the proximal and distal levels were 7 [6, 9] mm Hg and 9 [8, 11] mm Hg, respectively. The SEM for all (proximal and distal) DROP values was 8 [7, 10] mm Hg and the MDC of DROP was 23 mm Hg. CONCLUSIONS: Exercise-TcPO2 with measurement of DROP values has a moderate test-retest reliability in LEAD patients with a maximal walking distance ≤ 300m. For an individual, an improvement or deterioration in DROP of ≥ 23 mm Hg after an intervention would be required to be 95% confident that the change is significant. It should be considered in evaluating the impact of treatment in patients with claudication.

Prognostic value and predictors of the alteration of the diffusing capacity of the lungs for carbon monoxide in systemic lupus erythematosus.

OBJECTIVES: Systemic lupus erythematosus (SLE) is a systemic autoimmune disease characterized by heterogeneous manifestations and severity, with frequent lung involvement. Among pulmonary function tests (PFT), the measure of the diffusing capacity of the lungs for carbon monoxide (DLCO) is a noninvasive and sensitive tool assessing pulmonary microcirculation. Asymptomatic and isolated DLCO alteration has been frequently reported in SLE, but its clinical relevance has not been established. METHODS: This retrospective study focused on 232 SLE patients fulfilling the 2019 EULAR/ACR classification criteria for SLE. Data were collected from the patient's medical record, including demographic, clinical, and immunological characteristics while DLCO was measured when performing PFT as part of routine patient follow-up. RESULTS: At the end of follow-up, DLCO alteration (<70% of predicted value) was measured at least once in 154 patients (66.4%), and was associated with a history of smoking as well as interstitial lung disease (ILD), but was also associated with renal and neurological involvement. History of smoking, detection of anti-nucleosome autoantibodies and clinical lymphadenopathy at diagnosis were independent predictors of DLCO alteration, while early cutaneous involvement with photosensitivity was a protective factor. DLCO alteration, at baseline or anytime during follow-up was predictive of admission in intensive care unit and/or of all-cause death, both mainly due to severe disease flares and premature cardiovascular complications. CONCLUSION: This study suggests a link between DLCO alteration and disease damage, potentially related to SLE vasculopathy, and prognostic value of DLCO on death or ICU admission in SLE.

Enteral citrulline supplementation versus placebo on SOFA score on day 7 in mechanically ventilated critically ill patients: the IMMUNOCITRE randomized clinical trial.

BACKGROUND: Restoring plasma arginine levels through enteral administration of L-citrulline in critically ill patients may improve outcomes. We aimed to evaluate whether enteral L-citrulline administration reduced organ dysfunction based on the Sequential Organ Failure Assessment (SOFA) score and affected selected immune parameters in mechanically ventilated medical intensive care unit (ICU) patients. METHODS: A randomized, double-blind, multicenter clinical trial of enteral administration of L-citrulline versus placebo for critically ill adult patients under invasive mechanical ventilation without sepsis or septic shock was conducted in four ICUs in France between September 2016 and February 2019. Patients were randomly assigned to receive enteral L-citrulline (5 g) every 12 h for 5 days or isonitrogenous, isocaloric placebo. The primary outcome was the SOFA score on day 7. Secondary outcomes included SOFA score improvement (defined as a decrease in total SOFA score by 2 points or more between day 1 and day 7), secondary infection acquisition, ICU length of stay, plasma amino acid levels, and immune biomarkers on day 3 and day 7 (HLA-DR expression on monocytes and interleukin-6). RESULTS: Of 120 randomized patients (mean age, 60 ± 17 years; 44 [36.7%] women; ICU stay 10 days [IQR, 7-16]; incidence of secondary infections 25 patients (20.8%)), 60 were allocated to L-citrulline and 60 were allocated to placebo. Overall, there was no significant difference in organ dysfunction as assessed by the SOFA score on day 7 after enrollment (4 [IQR, 2-6] in the L-citrulline group vs. 4 [IQR, 2-7] in the placebo group; Mann‒Whitney U test, p = 0.9). Plasma arginine was significantly increased on day 3 in the treatment group, while immune parameters remained unaffected. CONCLUSION: Among mechanically ventilated ICU patients without sepsis or septic shock, enteral L-citrulline administration did not result in a significant difference in SOFA score on day 7 compared to placebo. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02864017 (date of registration: 11 August 2016).

Rehearsals using patient-specific 3D-printed aneurysm models for simulation of endovascular embolization of complex intracranial aneurysms: 3D SIM study.

BACKGROUND: In neurovascular treatment planning, endovascular devices to manage complex intracranial aneurysms requiring intervention are often selected based on conventional measurements and interventional neuroradiologist experience. A recently developed technology allows a patient-specific 3D-printed model to mimic the navigation experience. The goal of this study was to assess the effect of pre-procedure 3D simulation on procedural and clinical outcomes for wide-neck aneurysm embolization. MATERIALS & METHODS: In this unblinded, non-randomized, prospective, multicenter study conducted from November 18 through December 20, patients with complex intracranial aneurysms (neck > 4 mm or ratio < 21) were treated by WEB or flow diverter stents (FDS). The primary endpoint was concordance between simulation and procedure, 3D-printed model accuracy as well as embolization outcomes including complications, procedure times, and radiation dose were also assessed. Secondary endpoint was to compare versus a retrospective WEB cohort. RESULTS: Twenty-one patients were treated, 76% of cases by WEB and 24% by FDS. Concordance between post-simulation and real procedure efficiency was 0.85 [0.69 - 1.00] for size device selection and 0.93 [0.79 - 1.00] for wall-apposition/aneurysm neck closure. Geometrical accuracy of the 3D-printed model showed a mean absolute shift of 0.11 mm. Two complications without major clinical impact were reported with a post-operative mRS similar to pre-procedure mRS for all patients. CONCLUSIONS: Rehearsal using accurate 3D-printed patient-specific aneurysm models enabled optimization of embolization strategy, resulting in reduced procedure duration and cumulative fluoroscopy time which translated to reduced radiation exposure compared to procedures performed without simulation.

Effect of the Use of Reinforced Stapling on the Occurrence of Pancreatic Fistula After Distal Pancreatectomy: Results of the REPLAY (REinforcement of the Pancreas in distaL pAncreatectomY) Multicenter Randomized Clinical Trial.

OBJECTIVE: The aim of the study was to evaluate the impact of the use of a reinforced stapler (RS) during distal pancreatectomy (DP) on postoperative outcomes. BACKGROUND: DP remains associated with significant postoperative morbidity owing to pancreatic fistula (PF). To date, there is no consensus on the management of the pancreatic stump. The use of an RS potentially represents a simple way to decrease the rate of PF. METHODS: The REPLAY study (NCT03030170) is a prospective, multicenter, randomized study. Patients who underwent DP were randomized (1:1 ratio) in 2 groups for the use of a standard stapler (SS) or an RS to close remnant pancreatic parenchyma. The primary endpoint was the rate of overall PF. Secondary endpoints included severity of PF, length of hospital stay, overall morbidity, and rate of readmission for a PF within 90 days. Participants were blinded to the procedure actually carried out. RESULTS: A total of 199 were analyzed (SS, n=99; RS, n=100). One patient who did not undergo surgery was excluded. Baseline characteristics were comparable in both groups. The rate of overall PF was higher in RS group (SS: 67.7%, RS: 83%, P =0.0121), but the rate of clinically relevant PF was similar (SS: 11.1%, RS: 14%, P =0.5387). Mean length of total hospital stay, readmission for PF, postoperative morbidity, and mortality at 90 days were similar. CONCLUSION: The results of this randomized clinical trial did not favor the use of RS during DP to reduce the rate of PF.

Simultaneous Versus Delayed Resection for Initially Resectable Synchronous Colorectal Cancer Liver Metastases: A Prospective, Open-label, Randomized, Controlled Trial.

OBJECTIVE: To answer whether synchronous colorectal cancer liver metastases (SLM) should be resected simultaneously with primary cancer or should be delayed. SUMMARY BACKGROUND DATA: Numerous studies have compared both strategies. All were retrospective and conclusions were contradictory. METHODS: Adults with colorectal cancer and resectable SLM were randomly assigned to either simultaneous or delayed resection of the metastases. The primary outcome was the rate of major complications within 60 days following surgery. Secondary outcomes included overall and disease-free survival. RESULTS: A total of 105 patients were recruited. Eighty-five patients (39 and 46 in the simultaneous- and delayed-resection groups, respectively) were analyzed. The percentage of major perioperative complications did not differ between groups (49% and 46% in the simultaneous- and delayed-resection groups, respectively, adjusted OR 0.84, 95% CI 0.35-2.01; P = 0.70, logistic regression). Complications rates were 28% and 13% (P = 0.08, χ2 test) at colorectal site and 15% and 17% (P = 0.80, χ2 test) at liver site, in simultaneous- and delayed-resection groups, respectively. In the delayed-resection group, 8 patients did not reach the liver resection stage, and this was due to disease progression in 6 cases. After 2 years, overall and disease-free survival tended to be improved in simultaneous as compared with delayed-resection groups (P = 0.05), a tendency which persisted for OS after a median follow-up of 47 months. CONCLUSIONS: Complication rates did not appear to differ when colorectal cancer and synchronous liver metastases are resected simultaneously. Delayed resection tended to impair overall survival.

Quality of life in the management of small vestibular schwannomas: Observation, radiotherapy and microsurgery.

OBJECTIVE: The aim of this study was to compare quality of life (QOL) in small unilateral vestibular schwannoma (VS) patients managed by microsurgery, radiotherapy or observation. STUDY DESIGN: A retrospective chart review. METHODS: The study included a total of 142 patients with VS stage 1 or 2 according to the Koos classification and treated between January 2004 and December 2015. Microsurgery, radiotherapy and observation groups comprised 43, 46 and 53 patients, respectively. All patients completed four QOL (questionnaires: Short-Form Health Survey 36, Hearing Handicap Inventory, Tinnitus Handicap Inventory and Dizziness Handicap Inventory Short-Form). Clinical symptoms and QOL were compared among groups. RESULTS: The average time interval between management and filling in the questionnaires was 66 months. There was no difference in QOL between the three groups on any of the four questionnaires. The most debilitating symptom was vertigo for all three groups. Tinnitus was a pejorative factor in the surgery group. Hearing level was deteriorated after microsurgery but there was no significant difference between the radiotherapy group and the middle fossa approach. CONCLUSION: Patients with small VS stage 1 and 2 had similar QOL, irrespective of management by observation, radiotherapy or microsurgery. The overall predictor for long-term reduced QOL was vertigo. Vestibular rehabilitation could improve QOL in symptomatic patients.

Air pollution by particulate matter PM10 may trigger multiple sclerosis relapses.

BACKGROUND: Seasonal variation of relapses in multiple sclerosis (MS) suggests that season-dependent factors, such as ambient air pollution, may trigger them. However, only few studies have considered possible role of air pollutants as relapse's risk factor. OBJECTIVE: We investigated the effect of particulate matter of aerodynamic diameter smaller than 10µm (PM10) on MS relapses. METHODS: In total, 536 relapsing MS patients from Strasbourg city (France) were included, accounting for 2052 relapses over 2000-2009 period. A case-crossover design was used with cases defined as the days of relapse and controls being selected in the same patient at plus and minus 35 days. Different lags from 0 to 30 days were considered. Conditional logistic regressions, adjusted on meteorological parameters, school and public holidays, were used and exposure was considered first as a quantitative variable and second, as a binary variable. RESULTS: The natural logarithm of the average PM10 concentration lagged from 1 to 3 days before relapse onset was significantly associated with relapse risk (OR =1.40 [95% confidence interval 1.08-1.81]) in cold season. Consistent results were observed when considering PM10 as a binary variable, even if not significant. CONCLUSION: With an appropriate study design and robust ascertainment of neurological events and exposure, the present study highlights the effect of PM10 on the risk of relapse in MS patients, probably through oxidative stress mechanisms.

[Utilité de la tomographie thoraco-abdomino-pelvienne chez les patients âgés hospitalisés pour altération de l'état général]. / Usefulness of thoracic-abdominal-pelvic tomography in older adults hospitalized with alteration of general state.

Alteration of the general state of health is a frequent clinical situation as reason for hospital admission of older adults, although there is no consensus on criteria of the diagnostic approach. Our objective was to study whether thorax, abdomen and pelvis tomography is useful for the diagnosis and determination of a specific care pathway for hospitalized patients over 80 years old with alteration of the general state without identified clinical explanation. retrospective observational monocentric study at a French University Hospital, with the inclusion of all hospitalized patients who had a tomography following for alteration of general state without identified clinical explanation between January 2019 and June 2020. The primary endpoint was the presence of a diagnosis on the tomography report. We studied 48 files of patients (aged 86.2 ± 3.4 years on average). Tomography provided a diagnosis in 60.4% of cases. Factors significantly related to usefulness of tomography were weight loss and duration of weight loss. Among the diagnosed patients, specific actions were taken for 86.2% of them. Our study suggests that thoracic-abdominal-pelvic tomography is useful to examine the alteration of general state in older patients without identified clinical explanation, particularly for those presenting with unintentional weight loss. That suggests that it is probably preferable to use the correct symptoms description instead of alteration of general state.

Septic arthritis of the facet joint is also a severe vertebral infection: A multicenter retrospective study of 65 patients.

OBJECTIVE: Septic arthritis of the Facet Joints (SAFJ) is a rare condition. Little data has been published on the subject. We aimed to describe the clinical, biological and imagery presentations, as well as the course of this rare infection. METHODS: We included patients hospitalized between January 1st, 2016 and December 31th, 2019, in the Departments of Infectious Diseases or Rheumatology in 5 French centres in the CRIOGO network. We defined septic arthritis according to Newman's criteria and facet joint arthritis using imagery. RESULTS: Sixty-five patients were included, predominantly males (64.6%), with a mean age of 68.1 years. The mean time to diagnosis was 25.0 days. The principal symptoms at diagnosis were acute back pain (95.2%) and fever (76.9%). Neurological symptoms were present for 60.7% of the patients, including 16.4% motor deficit or cauda equina syndrome. SAFJ was located on the lumbosacral spine (73.4%) and was rarely multifocal (4.7%). Bacteriological identification was performed by blood cultures in 84.4% of the cases, and the pathogen was mainly Staphylococcus aureus (49.2%). Infective endocarditis was present for 26.9% of patients assessed by echocardiography. On MRI, soft tissue abscess or inflammation, epiduritis and epidural abscess were present in 87.1%, 66.7% and 33.9% of cases, and the pathogen was significantly more frequently Staphylococcus aureus. Mortality reached 9.2%, 18.5% and 23% at one, two, and three years respectively. CONCLUSION: SAFJ is a rare but severe disease. Microbiological diagnosis is primarily made on blood cultures, and S. Aureus was the main pathogen. Our results highlight the fact that SAFJ is associated with high morbidity and mortality, and with infective endocarditis.

Use of the Walking Impairment Questionnaire and Walking Estimated-Limitation Calculated by History questionnaire to detect maximal walking distance equal to or lower than 250 m in patients with lower extremity arterial disease.

Objective: The objective was to assess the accuracy and optimal threshold of the Walking Impairment Questionnaire (WIQ) and the Walking Estimated-Limitation Calculated by History (WELCH) questionnaire in identifying patients with a maximal walking distance (MWD) below or equal to 250 m. Methods: This retrospective study screened 388 consecutive patients with suspected symptomatic lower extremity arterial disease (LEAD). Collected data included the patient's history, resting ankle-brachial index, WIQ, and WELCH. MWD was assessed with a treadmill test at 2 mph (3.2 km/h) with a 10% grade. An optimized threshold for detection of MWD ≤ 250 m was determined for each questionnaire via receiver operating characteristic (ROC) curves. Subsequently, multivariate analysis was performed to build a new simple score to detect MWD ≤ 250 m. Results: The study included 297 patients (63 ± 10 years old). With a threshold of ≤ 64%, the WIQ predicted MWD ≤ 250 m with an accuracy of 71.4% (66.2, 76.5%). With a threshold of ≤ 22, the WELCH predicted a treadmill walking distance of ≤ 250 m with an accuracy of 68.7% (63.4, 74.0%). A new score with only four "yes or no" questions had an accuracy of 71.4% (66.3, 76.6%). Items on this new score consisted of the level of difficulty of walking 1 block, declared maximum walking distance, usual walking speed, and maximum duration of slow walking. Conclusion: A WIQ score ≤ 64% and a WELCH score ≤ 22 help to predict a walking distance of ≤ 250 m in a treadmill test at 2 mph (3.2 km/h) with a 10% grade. A 4-item score could be used for rapid evaluation of walking distance among patients with LEAD, but the validity of this 4-item score requires further confirmation studies.

Prevalence and risk factors for scoliosis in adults with closed and open spina bifida: A large, cross-sectional study.

BACKGROUND: Scoliosis develops in a proportion of children with myelomeningocele; however, little is known about scoliosis in adulthood and in other forms of spina bifida (SB). OBJECTIVES: The aims of this study were to describe the prevalence of scoliosis and identify risk factors for its development in a large cohort of adults with open and closed SB. METHODS: This was a cross-sectional study of data from 580 adults with SB attending their first consultation at a French multidisciplinary referral centre for SB. Sex, anatomical location and type of SB (open or closed), neurological level, back pain and ambulatory status (new Functional Ambulation Classification [new FAC]) were compared in adults with and without scoliosis. These characteristics were used to determine scoliosis risk factors. RESULTS: In total, 331 adults fulfilled the inclusion criteria: 221 had open and 110 had closed SB. Of these, 176 (53%) had scoliosis: 57% open and 45% closed SB. As compared with individuals without scoliosis, those with scoliosis more frequently had open SB (p=0.03), more cranially located SB (p<0.0001), more severe neurological deficits (p≤0.02) and poorer walking ability (mean new FAC score 3.5 [SD 3.3] vs 6.1 [2.6], [p<0.0001]). In total, 69% had chronic back pain, with no difference in frequency between those with and without scoliosis. The odds of scoliosis was associated with asymmetrical motor level and a new FAC score <4 (odds ratio 0.46, p<0.006, and 0.75, p<0.0001, respectively). CONCLUSION: About half of adults with open and closed SB had scoliosis. Back pain was frequent in those both with and without scoliosis. Individuals with low walking ability and an asymmetrical motor level should be monitored early and continuously to limit the consequences of scoliosis during their lifetime. A major issue is to determine how scoliosis evolves and to determine appropriate monitoring and treatment strategies for individuals at risk.

Early detection of chronic obstructive pulmonary disease in primary care: a randomised controlled trial.

BACKGROUND: Worldwide, chronic obstructive pulmonary disease (COPD) remains largely underdiagnosed. AIM: To assess whether the use of Global Initiative for Chronic Obstructive Lung Disease (GOLD) questions and COPD coordination, either alone or combined, would detect new COPD cases in primary care. DESIGN AND SETTING: GPs in Brittany, France, systematically enrolled patients aged 40-80 years over a 4-month period in this French multicentre cluster randomised controlled study. METHOD: GPs were randomly allocated to one of four groups: control (standard of care), GOLD questions (adapted from symptoms and risk factors identified by GOLD), COPD coordination, and GOLD questions with COPD coordination. New cases of COPD were those confirmed by spirometry: post-bronchodilator forced expiratory volume in 1 second over forced vital capacity of <0.7. RESULTS: In total, 11 430 consultations were conducted by 47 GPs, who enrolled 3162 patients who did not have prior diagnosed asthma or COPD. Among these, 802 (25%) were enrolled in the control, 820 (26%) in the GOLD questions, 802 (25%) in the COPD coordination, and 738 (23%) in the GOLD questions with COPD coordination groups. In the control group, COPD was not evoked, and no spirometry was prescribed. All new cases of COPD diagnosed (n = 24, 0.8%) were in the intervention groups, representing 6.8% of patients who performed spirometry. Statistically significantly more new cases of COPD were detected with COPD coordination (P = 0.01). CONCLUSION: Interventions that can be easily implemented, such as the GOLD questions and COPD coordination, can identify new cases of COPD. Studies are needed to identify the most appropriate case-finding strategies for GPs to detect COPD in primary care for each country.

Bacterial and fungal infections: a frequent and deadly complication among critically ill acute liver failure patients.

BACKGROUND: Acute liver failure (ALF) is a rare but life-threatening condition mostly requiring intensive care unit (ICU) admission. ALF induces immune disorders and may promote infection acquisition. However, the clinical spectrum and impact on patients' prognosis remain poorly explored. METHODS: We conducted a retrospective single-centre study on patients admitted for ALF to the ICU of a referral University Hospital from 2000 to 2021. Baseline characteristics and outcomes according to the presence of infection until day 28 were analysed. Risk factors for infection were determined using logistic regression. The impact of infection on 28-day survival was assessed using the proportional hazard Cox model. RESULTS: Of the 194 patients enrolled, 79 (40.7%) underwent infection: community-acquired, hospital-acquired before ICU and ICU-acquired before/without and after transplant in 26, 23, 23 and 14 patients, respectively. Most infections were pneumonia (41.4%) and bloodstream infection (38.8%). Of a total of 130 microorganisms identified, 55 were Gram-negative bacilli (42.3%), 48 Gram-positive cocci (36.9%) and 21 were fungi (16.2%). Obesity (OR 3.77 [95% CI 1.18-14.40]; p = .03) and initial mechanical ventilation (OR 2.26 [95% CI 1.25-4.12]; p = .007) were independent factors associated with overall infection. SAPSII > 37 (OR 3.67 [95% CI 1.82-7.76], p < .001) and paracetamol aetiology (OR 2.10 [95% CI 1.06-4.22], p = .03) were independently associated with infection at admission to ICU. On the opposite, paracetamol aetiology was associated with lower risk of ICU-acquired infection (OR 0.37 [95% CI 0.16-0.81], p = .02). Patients with any type of infection had lower day 28 survival rates (57% versus 73%; HR 1.65 [1.01-2.68], p = .04). The presence of infection at ICU admission (p = .04), but not ICU-acquired infection, was associated with decreased survival. CONCLUSIONS: The prevalence of infection is high in ALF patients which is associated with a higher risk of death. Further studies assessing the use of early antimicrobial therapy are needed.

Simplification of ankle-brachial-index measurement using Doppler-waveform classification in symptomatic patients suspected of lower extremity artery disease.

Objectives: Ankle-brachial index (ABI) is commonly used for screening lower extremity peripheral artery disease (PAD) according to the international guidelines. Arterial Doppler waveform recordings is a tool to diagnose and assess PAD severity. We hypothesized that ABI measurement could be simplified by measuring only the pressure where the best arterial flow is recorded. The aim of this study was to evaluate the concordance between ABI performed according to the American Heart Association guidelines (AHA-ABI) and ABI measured according to best arterial waveform (FLOW-ABI). Design: This was a monocentric cross-sectional study. Methods: We included patients with exertional limb symptoms suspected of PAD. Arterial Doppler waveforms and ABI were acquired on both lower extremities at the pedis and tibial posterior arteries. Each arterial waveform was classified using the Saint-Bonnet classification. Concordances were analyzed with the kappa coefficient (confidence interval 95%). Exercise PAD study was registered n° NCT03186391. Results: In total, one hundred and eighty-eight patients (62+/-12 years and 26.8+/-4.5 kg/m2) with exertional limb symptoms were included from May 2016 to June 2019. On each extremity, FLOW-ABI had excellent concordance for the diagnosis of PAD with the AHA-ABI with a kappa of 0.95 (95% CI: 0.90, 0.99) in the right extremity and 0.91 (95% CI: 0.86, 0.97) in the left extremity. Conclusion: There is almost perfect concordance between AHA-ABI and FLOW-ABI. Thus, ABI can be simplified into five pressure measurements instead of seven in patient suspected of PAD with exertional limb symptoms. The question remains in patients with chronic limb ischemia.

An Innovative Biological Model for Ultrasound-Guided Central Venous Access Simulation.

INTRODUCTION: Simulation training is an increasingly used method to train medical students in the use of ultrasound guidance for vascular access positioning. Although very efficient for basic training, commercial simulators for vascular access do not reproduce real-life conditions. We developed a biological training model, using porcine liver, and compared it with an existing commercial model. METHODS: Whole porcine livers were used by perfusing the portal vein system after inferior vena cava clamping. Thirty-three practitioners accustomed to ultrasound-guided procedure were enrolled to perform an ultrasound-guided vascular procedure on both biological and commercial models. Procedure duration was recorded and 10-point scales were used to compare the 2 models regarding image quality, procedure feeling, and similarity with the real-life procedure. RESULTS: Participants reported a better image quality with the biological model (8.8 ± 1 vs. 7.7 ± 2, P = 0.007) as well as a significant difference in the procedure feeling (8.0 ± 1 vs. 6.9 ± 1.9, P = 0.002). Real-life likeness was significantly better for the biological model (8.4 ± 1.1 vs. 4.5 ± 6, P < 0.0001). Procedure duration was almost 3 times longer using the biological model than the commercial model (209.6 ± 189.0 vs. 59.8 ± 50.1, P < 0.0001). CONCLUSIONS: This study validates our biological model of porcine's liver as an interesting training model, allowing closer real-life perception than its commercial counterpart. This model could complement and enhance simulation learning.

Patient Characteristics and Preferences Regarding Anticoagulant Treatment in Venous Thromboembolic Disease.

Background: Anticoagulants are the recommended treatment for venous thromboembolic disease (VTE). The mode of anticoagulant administration may influence compliance, and therefore the effectiveness of the treatment. Unlike in atrial fibrillation or cancer-associated thrombosis, there is only limited data on patient preferences regarding the choice of anticoagulation in VTE. This study aims to evaluate patient preferences regarding anticoagulants in terms of administration: types (oral or injectable treatment) and number of doses or injections per day. Patients and Methods: This is a national survey through a questionnaire sent by e-mail to 1936 French vascular physicians between February and April 2019. They recorded the responses for each patient admitted for VTE. Results: Three hundred and eleven (response rate of 16%) of the 1936 contacted physicians responded for 364 patients. Among these, there were 167 fully completed questionnaires. Most patients (63%) express concerns about VTE and prefer oral treatment (81.5%), justified by the ease of administration (74%) and a fear of the injections (22%). When patients were taking more than three oral treatments they statistically chose injectable treatment more often (54%) than oral treatment (25%, p = 0.002). Patients who chose injectable treatment were also older (70 ± 16 vs. 58 ± 17 years old, p = 0.001). There was no statistically difference in anticoagulation preference according to gender or to the expected duration of treatment (6 weeks, 3 months, 6 months or unlimited). When oral treatment was preferred (81%), most chose oral treatment without dose adjustment and biomonitoring (74.3%). Among them, very few (5.8%) preferred a twice-daily intake. Conclusion: Patient preference in terms of anticoagulant treatment in VTE disease is in favor of oral treatment without adjustment or biomonitoring and with once-daily intake. When an injectable treatment is chosen, a prolonged duration of treatment does not seem to be a constraint for the patient. Clinical Trial Registration: ClinicalTrials.gov, identifier [NCT03889457].