Amputation-free survival in the long-term follow-up and gender-related characteristics in patients revascularized for critical limb ischemia.

OBJECTIVE: Patients with Critical Limb Ischemia (CLI) present a high risk of cardiovascular events and death. Revascularization is the cornerstone of therapy to relieve ischemic pain and prevent limb loss. Literature data suggest that women tend to present with worse outcomes after revascularization. The aim of the present study is to determine amputation-free survival in a long-term follow-up in women and men following endovascular revascularization procedure for CLI. METHODS: From November 2013 to December 2020, 357 consecutive patients were retrospectively included. Clinical and biological parameters were recorded at baseline before endovascular revascularization. During follow-up until February 2023, overall survival and amputation-free survival (freedom from major amputation) were analysed using the Kaplan-Meier method. Univariate and multivariate analyses were performed to study the parameters associated with amputation-free survival. A P<0.05 was considered as statistically significant. RESULTS: A total of 357 consecutive patients were included, 189 men and 168 women with CLI, with a mean age of 78.6±12 years. Treated hypertension (79%), diabetes mellitus (48%), coronary artery disease (39%) and protein malnutrition (61%) were the most prevalent comorbidities. Women were older than men with a mean age of 82.4±11.4 years (versus 75.4±11 years in men) and presented more frequently with protein malnutrition (70% of women). Prevalence of diabetes, tobacco use and history of coronary heart disease were significantly higher in men. During the 10-year follow-up period, 241 patients had died (68%) and 38 (11%) underwent major amputation, of whom 22 patients were still alive on February 2023. Median survival was 35.5 months [IQR: 29.5; 43] in the overall population, 38.5 [32; 50.4] months in women and 33.5 months [24.7; 43.5] in men. No gender-related differences were noted according to peri-procedural complications, survival probability and amputation-free survival. In multivariate analysis for amputation-free survival, age, previous coronary heart disease, C-reactive protein level, left ventricular ejection fraction (LVEF)<60% and albumin level<35g/L were correlated with poor outcome. In particular, protein malnutrition, as a treatable risk factor, appears significantly correlated with poor outcome in both men and women (HR=2.50 [1.16;5.38], P=0.0196 in men; HR=1.77 [1.00;3.13], P=0.049 in women). CONCLUSION: The present results highlight that mortality in patients after endovascular revascularization remains high with a mortality rate of 28% at 1 year, 40% at 2 years and 51% at 3 years. Women represented a distinct population, almost 10-year older than their male counterparts, with more prevalent protein malnutrition. However, no gender-related difference was noted according to amputation-free survival on the long-term follow-up. Associated risk factors are mainly age, a history of coronary heart disease, pre-procedural inflammatory syndrome and protein malnutrition. Correction of malnutrition could have the potential to improve functional and general long-term prognosis in patients with CLI together with optimal medical and interventional management.

[Blue toe syndrome as an initial manifestation of metastatic prostate cancer : A case report with literature review]. / Un syndrome des orteils bleus révélant un cancer de la prostate métastatique : une observation avec analyse de la littérature.

INTRODUCTION: Cutaneous and vascular manifestations of cancer are numerous. Among paraneoplastic acral vascular syndrome, we report a case of blue toe syndrome as the first manifestation of a prostate cancer following with analysis of this syndrome according literature. OBSERVATION: A 56-year-old man, with Raynaud's phenomenon of the upper limbs for 2 to 3 years, had 4 blue toes of the left foot evolving for 18 months, without ulceration, the pulses being present. Vascular and cardiac explorations (ultrasound, angio-MRI) were normal. There was no biological or immunological abnormality except an elevated PSA level. Prostate biopsies confirmed diagnosis and abdomino-pelvic CT scan proved the bone and lymph node metastasis. CONCLUSION: The revelation of a prostate cancer with bone metastases by a blue toe syndrome is a rare situation. In a patient with a blue toe syndrome with no obvious clinical or biological abnormality, especially atheromatous, investigations should include a search for cancer, which can be revealed by blue toes.

Peri-procedural complications following endovascular revascularization for critical limb ischemia.

OBJECTIVE: Revascularization procedures are considered the cornerstone of therapy in patients with critical limb ischemia (CLI) and multiple procedures are often required to attain limb salvage. The aim of the present study is to determine the prevalence of peri-procedural complications after endovascular procedure, and to determine the clinical and biological characteristics of patients associated to the risk of peri-procedural complications. METHODS: From November 2013 to May 2021, 324 consecutive patients were retrospectively included, of whom 99 underwent more than one revascularization procedure for contralateral CLI or clinical recurrence of CLI. A total of 532 revascularizations were performed. Clinical and biological parameters were recorded at baseline before endovascular revascularization. The occurrence of a peri-procedural complication (local complications, fatal and non-fatal major bleeding or cardiovascular events) was recorded up to 30days after revascularization. Univariate and multivariate analyses were performed to study the parameters associated with per-procedural complications. A P<0.05 was considered as statistically significant. RESULTS: A total of 324 consecutive patients were included, 177 men and 147 women with CLI, with a mean age of 77.6±11.9years. Most of these patients had cardiovascular comorbidities (41% with a history of coronary heart disease, 78% treated hypertensive patients, 49% diabetic patients). Peri-procedural mortality occurred in 13 patients (4%) and 9 patients (2.8%) experienced major amputation at one-month following revascularization. Among the 532 revascularization procedures, 99 major bleeding events (22.8% of the cohort population) and 31 cardiovascular events (8.6% of the cohort population), were recorded in the peri-procedural period. Cardiovascular events were associated with peri-procedural mortality. Complications at the puncture site occurred during 38 of the 532 procedures (10.2% of the cohort population). Compared with patients undergoing a single revascularization procedure, patients with multiple procedures presented a higher risk of major bleeding events (48.5% vs. 11.6%, P<0.0001) and access site complications (20.2% vs. 5.78%, P<0.0001). In multivariate analysis, pulse pressure <60mmHg and hemoglobin level <10g/dl were correlated with the occurrence of major bleeding events; left ventricular ejection fraction<60% and the absence of statin treatment were correlated with the occurrence of cardiovascular complications; a high chronological rank of revascularization was correlated with the occurrence of local complication. Finally, age and gender were not associated with the occurrence of peri-procedural complication. CONCLUSION: The present results highlight that multiple revascularization procedures for limb salvage are required in almost one third of the population with critical limb ischemia and were associated with the risk of major bleeding events and access site complications. The most frequent complications of peripheral vascular interventions were major bleeding events. Adverse cardiovascular events were related with peri-procedural mortality. Anemia, blood pressure, left ventricular ejection fraction and statin treatment are important parameters to consider for peri-procedural outcomes, independently of age, gender and the chronological rank of revascularization procedure.

[Ease of use, feasibility and performance of ankle arm index measurement in patients with chronic leg ulcers. Study of 100 consecutive patients]. / Mesure de l'index de pression artérielle systolique à la cheville chez un patient porteur d'un ulcère de jambe. Faisabilité et performance chez 100 patients consécutifs hospitalisés dans un service spécialisé

International guidelines on leg ulcers recommend measuring the ankle arm index (AAI) to diagnose and assess peripheral arterial occlusive disease (PAOD) of the lower limbs. These guidelines do not, however, describe the method which should be used to make the measurement: which artery should be measured -in the event of an open leg ulcer, what are the practical difficulties for positioning the cuff- how well do patients tolerate the procedure? We conducted a prospective study focusing on ease of use, tolerance and performance of AAI measurements in patients with leg ulcers. In compliance with recent French guidelines, we measured the AAI for both distal leg arteries and retained the lowest value for analysis. Within a six-month study period, 100 consecutive inpatients with leg ulcers of various etiologies were studied. Mean age was 75, female predominance 60%, body mass index 27. Etiologies of leg ulcers were pure venous (29%), mixed venous predominant (17%), pure arterial (9%), mixed arterial predominant (8%), mixed (6%), hypertensive ulcers (11%), rare cause (8%), multifactorial (12%). Pain was present in 92%, with a VAS above 3 for 73%. Measurement of AAI was possible in 98% of patients. It was too painful and thus considered unethical for two patients with hypertensive ulcers. For the 98 patients measured, the ulcer had to be protected during the measurement in 76%. The measurement procedure only took five minutes for one leg, and was judged easy to perform by 93% of the operators. For the majority (76%) of patients, the measurement was not painful. We determined the diagnostic performance of AAI by comparing the results with those of arterial ultrasound in 90 patients who had a complete arterial ultrasound exploration of the legs. Compared with arterial ultrasound, the sensitivity of AAI<0.9 for detecting the presence of PAOD was 84.7%, with 97% specificity. PAOD was not diagnosed in any patient who had two palpable distal pulses and a normal AAI. Measurement of AAI in patients with leg ulcers is an easy to use, well-tolerated, high-performance tool for the assessment of PAOD.

[Digital necrosis revealing lung cancer: Case-report and review of the literature]. / Nécroses des orteils révélant un cancer bronchique : cas clinique et revue de la littérature.

We report the case of a 51-year-old patient who presented necrosis affecting all of the toes in a context of confusion and declining general health. The etiology work-up disclosed a lung mass. Biopsy and search for extension led to the diagnosis of adenocarcinoma with liver metastasis. Unfortunately, symptomatic treatment of the digital necrosis did not lead to improvement and the patient was given palliative care. Digital necrosis generally affects the fingers. Localization on the toes is atypical and few cases have been reported in the literature.

[Vitamin C deficiency and leg ulcers. A case control study]. / Déficit en vitamine C et ulcères de jambe. Résultats d'une enquête cas témoins.

UNLABELLED: Vitamin C is a necessary cofactor for collagen synthesis. A deficiency of vitamin C results in the breakdown of connective tissue in and around the walls of blood vessels. The disease is thus characterized by poor healing of wounds. Chronic leg ulcers are defined as wounds that do not heal. OBJECTIVE: To investigate whether patients with chronic leg ulcers have vitamin C deficiency. METHODS: Case control study; vitamin C was assayed in peripheral blood samples of 42 consecutive patients with chronic leg ulcers and in 37 consecutive patients without chronic leg ulcers. Patients without leg ulcers had peripheral vascular disease, or hypertension, or connective disorders. Patients with diabetes, immunodepression (cancer, HIV infection, corticosteroid therapy) and aged under 65 years were excluded. Reference range for plasma vitamin C was above 26 micromol/l (normal levels, group I), hypovitaminosis C as 6-26 micromol/l (group II) and concentrations<6 micromol/l as scurvy (group III). RESULTS: Mean age was 77.2 years in the ulcers group and 73.8 in the control group (NS), mean weight 73.1 kg in the ulcers group and 67.5 kg in the control group (NS). Smoking was more frequent in the control group (P<0.001). Mean vitamin C levels were lower in the leg ulcers group: 23.9 vs 33.8 micromol/l (P<0.003). Normal levels of vitamin C (group I) were more frequent in the control group: 78.4 vs 50% (P<0.01). Hypovitaminosis C (group II) was more frequent in the leg ulcers group: 23.8 vs 16.2% (P<0.01). Scurvy was more frequent in the leg ulcers group: 26.2 vs 5.4% (P<0.01). C reactive protein levels were higher in the leg ulcers group: 31.8 vs 9.3 mg (P=0.002) and albumin levels were lower in the leg ulcers group: 25 vs 38 g/l (P=0.01) [retrospective data]. CONCLUSION: Patients with chronic leg ulcers have lower levels of vitamin C than patients without leg ulcers, although smoking was more frequent in patients without leg ulcers. The question is whether vitamin C deficiency is a cofactor of impaired healing or is a simple marker of poor healing? It would be interesting to conduct a randomized controlled study about treatment of chronic leg ulcers with vitamin C.

[New international guidelines for curative treatment and prophylaxis for venous thromboembolism (VTE) in cancer patients and the dedicated smartphone application]. / Nouvelles recommandations internationales pour le traitement curatif et prophylactique de la maladie thromboembolique veineuse chez les patients atteints d'un cancer et application dédiée pour smartphone.

Venous thromboembolism (VTE) is a frequent and serious complication in cancer patients, and the second leading cause of death in this setting. Cancer patients are also more likely to present recurrent VTE and major bleeding while taking anticoagulants. Management of VTE in these patients is always challenging and remains suboptimal worldwide. In 2013, the International Initiative on Thrombosis and Cancer (ITAC-CME) released international guidelines for the treatment and prophylaxis of VTE and central venous catheter-associated thrombosis, based on a systematic review of the literature ranked according to the Grading of Recommendations Assessment, Development, and Evaluation scale. An update of these ITAC-CME consensus guidelines, including the use of direct oral anticoagulants, was recently published. In this review, we summarize these updated guidelines. Better adherence to the international guidelines, involving an adequate educational and active implementation strategies, will substantially decrease the burden of VTE and allow to increase survival in cancer patients.

Interest of punch skin grafting for the treatment of painful ulcers.

UNLABELLED: Skin leg ulcers are chronic painful wounds. The treatment of these ulcers is crucial for patients because pain has a significant impact on their daily lives. The analgesic effect of punch skin grafting (PSG) for the treatment of painful ulcers is not well described. The objective of the study is to assess the level of pain in patients with an ulcerated wound and to see if there is an analgesic effect of PSG. PATIENT AND METHODS: A single-center, non-interventional study conducted in hospitalized patients with one or several ulcer(s) of any type and which has been painful for more than six weeks. Pain was assessed before, the day after a PSG and then on the way out of hospital by a questionnaire and a numeric pain rating scale. Permanent pain and pain peaks were identified. RESULTS: Forty-one patients were included (23 men and 18 women) with a mean age of 73±21 years, 36% (n=15) with arterial ulcers, 36% (n=15) with venous ulcers, 12% (n=5) with necrotic angiodermatitis, 12% (n=5) with mixed ulcers and 4% (n=2) with "other ulcers" (due to infection and use of hydroxycarbamide). On day 1 of PSG, patients showed an improvement in terms of permanent pain (77%, n=24/31) and pain peaks (90%, n=37/41) respectively and 90% (n=28/31) and 95% (n=39/41) on the last day at hospital. Reduction in the use of strong opioids was found in 13 patients (81%). CONCLUSION: Punch skin grafting is a simple and validated treatment, which can reduce or eliminate pain related to ulcers. It has an effect on permanent pain and pain peaks. Its efficiency is particularly demonstrated on venous ulcers and mixed ulcers but also initially painful ulcers such as necrotic angiodermatitis or arterial ulcers.

[Interest of punch skin grafting for the treatment of painful ulcers]. / Intérêt de la greffe cutanée en pastilles dans la prise en charge d'ulcères algiques.

INTRODUCTION: Skin leg ulcers are chronic painful wounds. The treatment of these ulcers is crucial for patients because pain has a significant impact on their daily lives. The analgesic effect of punch skin grafting (PSG) for the treatment of painful ulcers is not well described. The objective of the study is to assess the level of pain in patients with an ulcerated wound and to see if there is an analgesic effect of PSG. PATIENT AND METHODS: It was a single-center, non-interventional study conducted in hospitalized patients with one or several ulcer(s) of any type and which has been painful for more than six weeks. Pain was assessed before, the day after a PSG and then on the way out of hospital by a questionnaire and a numeric pain rating scale. Permanent pain and pain peaks were identified. RESULTS: Forty one patients were included (23 men and 18 women) with mean age of 73±21 years, 36% (n=15) with arterial ulcers, 36% (n=15) with venous ulcers, 12% (n=5) with necrotic angiodermatitis, 12% (n=5) with mixed ulcers and 4% (n=2) with "other ulcers" (due to infection and use of Hydroxycarbamide). On day 1 of PSG, patients showed an improvement in terms of permanent pain (77%, n=24/31) and pain peaks (90%, n=37/41) respectively and 90% (n=28/31) and 95% (n=39/41) on the last day at hospital. Reduction in the use of strong opioids was found in 13 patients (81%). CONCLUSION: Punch skin grafting is a simple and validated treatment, which can reduce or eliminate pain related to ulcers. It has an effect on permanent pain and pain peaks. Its efficacy is particularly demonstrated on venous ulcers and mixed ulcers but also initially painful ulcers such as necrotic angiodermatitis or arterial ulcers.

[Leg ulcers: Should general practitioners hospitalize their patients?]. / Ulcères de jambe: une expertise hospitalière est-elle souhaitable?

OBJECTIVES: Determine whether general practitioners have sufficient expertise in the field of leg ulcers. METHOD: A cross-sectional survey was conducted among 179 general practitioners working in the region Île-de-France to evaluate the implementation of leg ulcer guidelines issued by the Superior Health Authority (HAS) in 2006. Participating physicians were either internship supervisors or practitioners in Paris' 14th district. RESULTS: The first hundred usable answers (response rate 65%) came from 71 internship supervisors and 29 practitioners of Paris' 14th district. Only 40% of the physicians were aware of the guidelines, with no significant difference noted between the two groups. 9/10 practitioners examined less than 10 patients with leg ulcers per year. Physical examinations were done according to the guidelines and a venous Doppler was prescribed in two thirds of the cases. The ankle-brachial pressure index (ABPI) essential to diagnose lower limb arteriopathy was measured for only 10% of the patients. In accordance with the guidelines, compression was by far (73%) considered as the main treatment as compared to dressing (37%), but compression therapy was well prescribed in only one-third of the cases. Despite poor prognosis criteria (characteristic and time course), referral for a specialized opinion was rare. CONCLUSION: Even if they were not always aware of the detailed guidelines, the practitioners applied the main recommendations. Nevertheless, practices could be improved by measuring the ABPI, searching for a diagnosis of arteriopathy, and better prescription of compression therapy. General practitioners should refer patients with leg ulcers to a specialized hospital unit.

[Vascular myeloproliferative neoplasm with normal cell blood count: Exploration and medical management]. / Les syndromes myéloprolifératifs d'expression vasculaire à numération normale : comment les explorer ?

UNLABELLED: Negative BCR ABL myeloproliferative neoplasm (MPN) such as polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (MFP) are clonal hematological malignancies and may lead to a high risk of venous, arterial or microcirculatory thrombosis. Atypical sites of thrombosis can sometimes reveal the neoplasm disorder. Their diagnoses are a major issue because of the propensity to develop acute myeloid leukemia and/or myelofibrosis. The acquired JAK2V617F variant (Janus kinase 2; 9p24) is a prevalent MPN and also a sensitive marker for PV diagnosis (95% positive mutation), but not specific since found in approximately 50% of patients with ET and MFP. PATIENT AND METHODS: We present a diagnostic and a therapeutic approach based on one patient with microcirculatory ischemic manifestations in the toes, and who had strictly normal cell blood counts and was positive for JAK2V617F mutation: thrombotic risk factor evaluation; bone marrow biopsy; red cell adhesion assays. These experimental assays are promising for the development of new therapeutics in MPN; they assess red cell adherence to the vascular endothelium after the phosphorylation of Lu/BCAM subsequent to a positive JAK2V617F mutation. RESULTS: Compared with controls, our patient exhibited increased Lu/BCAM receptor phosphorylation and red blood cell adhesion. CONCLUSION: This development may lead to improved care for patients with thrombotic manifestations, normal blood cell counts, and a positive JAK2V617F mutation: multidisciplinary management, including regular hematological monitoring, could lead to the introduction of a cytoreductive treatment.

Influence of age on characteristics of polymyositis and dermatomyositis in adults.

In a retrospective study of 79 consecutive patients, we evaluated characteristics of polymyositis (PM) and dermatomyositis (DM) and compared clinical presentation, biochemical findings, histologic changes, evolution, complications, and mortality rate of elderly patients (aged > or = 65 yr) and younger patients (aged < or = 64 yr) at the onset of PM/DM. We found a high prevalence of PM/DM in elderly patients: 23 patients (29%) were aged 65 years or over. We also found that esophageal involvement (34.8% versus 16.1%, respectively) and bacterial pneumonia related to both ventilatory insufficiency and esophageal impairment (21.7% versus 5.4%, respectively) were more common in elderly patients compared with younger patients, resulting in increased morbidity and mortality rates. Moreover, malignancy frequency was higher in elderly patients compared with younger patients (47.8% versus 9.1%, respectively, p = 0.0001), particularly patients with DM (10/11). Fifty percent of malignancies were colon malignancies in elderly patients. Erythrocyte sedimentation rate, C-reactive protein, fibrinogen, and ferritin levels were also higher in the elderly patient group compared with the younger group, and the presence of serum hypoprotidemia, hypoalbuminemia, and anemia was more frequent. Finally, PM/DM complete remission was less frequent (13.6% versus 41.1%) and the mortality rate (47.8% versus 7.3%) was higher in elderly patients than in younger patients. The main causes of death in elderly patients were bacterial pneumonia, due to ventilatory insufficiency and esophageal impairment, and malignancies. Our findings therefore indicate that PM/DM-related esophageal and lung involvement should be systematically searched for in elderly patients. Esophageal manometry and pulmonary function tests should become an integral part of initial evaluation in elderly patients for early detection of impairment. Moreover, as we observed a marked overrepresentation of colon cancer in elderly patients with DM, we suggest that the search for malignancies in elderly patients with DM should include lower gastrointestinal tract investigations.

Cannabis arteritis revisited--ten new case reports.

The purpose of this paper was to revisit the old concept of cannabis arteritis first described in the 1960s and report 10 new cases. Ten male patients, with a median age of 23.7 years developed subacute distal ischemia of lower or upper limbs, leading to necrosis in the toes and/or fingers and sometimes to distal limb gangrene. Two of the patients also presented with venous thrombosis and three patients were suffering from a recent Raynaud's phenomenon. Biological test results did not show evidence of the classical vascular risk factors for thrombosis. Arteriographic evaluation in all cases revealed distal abnormalities in the arteries of feet, legs, forearms, and hands resembling those of Buerger's disease. A collateral circulation sometimes with opacification of the vasa nervorum was noted. In some cases, arterial proximal atherosclerotic lesions and venous thrombosis were observed. All patients were moderate tobacco smokers and regular cannabis users. Despite treatment with ilomedine and heparin in all cases, five amputations were necessary in four patients. The vasoconstrictor effect of cannabis on the vascular system has been known for a long time. It has been shown that delta-8- and delta-9-tetrahydrocanabinols may induce peripheral vasoconstrictor activity. Cannabis arteritis resembles Buerger's disease, but patients were moderate tobacco smokers and regular cannabis users. These cases show that prolonged use of cannabis could be an additive risk factor for juvenile and young adult arteritis. Cannabis arteritis is a forgotten and severe occlusive vascular disease occurring in young adults. Search for cannabis use may be an important tool for a better knowledge of arteritis in young smokers.

[Myelopathy - Sjogren's syndrome association: analysis of clinical and radiological findings and clinical course]. / Myélopathies et syndrome de Gougerot-Sjögren: étude clinique, radiologique et profil évolutif.

Myelopathies associated with Sjögren's syndrome has been rarely described especially concerning magnetic resonance imaging (MRI) and treatment aspects. The aim of this study was to determine the clinical, laboratory and radiological features of myelopathies occurring in Sjögren's syndrome. Eleven patients were studied, 7 with an acute myelopathy and 4 with a chronic form. Acute myelopathy were clinically severe with a feature of transverse myelitis necessitating immunosuppressive drugs. On the other hand, chronic forms were closely similar to progressive multiple sclerosis (MS), for clinical and laboratory data. In 7 cases optic neuritis was found associated with myelopathy and fulfilled the diagnostic criteria of Devic's syndrome in 4 cases. The diagnosis of myelopathy associated with Sjögren's syndrome may be difficult especially compared with MS, HTLV1 or HIV myelopathy and sarcoidosis, in the chronic form but also with other vasculitis, MS or viral infection in the acute forms. However, in this last form, magnetic resonance imaging and cerebrospinal fluid data should bring to the diagnosis of Sjögren syndrome and confirmed by appropriate tests. This diagnosis will have direct consequences for an early treatment by immunosuppressive drugs.

[Role of biopsy of the accessory salivary glands in Löfgren's syndrome and other forms of sarcoidosis]. / Place de la biopsie de glandes salivaires accessoires dans le syndrome de Löfgren et les autres formes de sarcoïdose.

The diagnosis of sarcoidosis requires histopathological analysis. Easy accessible site of biopsy is seldom. A systematic labial salivary gland biopsy was performed in 62 suspected sarcoidosis: 22 patients with Löfgren syndrome (group I), and 40 patients with systemic sarcoidosis (group II). Systematic bronchial biopsy was performed in eight patients of group I and ten patients of group II. If systematic biopsies were negative, direct biopsies were performed (lymph node, skin, kidney, liver). In group I, 8/22 labial salivary gland biopsies and 1/8 bronchial biopsies were positive; in group II, 17/40 labial salivary gland biopsies and 5/10 bronchial biopsies were positive. In the other patients, direct biopsies were positive: 27 lymph nodes, eight skin, eight hepatic, four kidney biopsies. In conclusion, labial salivary gland biopsy (even in the absence of sicca syndrome) is more reliable than systematic bronchial biopsies, particularly in Löfgren syndrome and may avoid in 30 to 50% of the cases more aggressive and dangerous biopsies such as liver, kidney or deep lymph nodes biopsies.

[Multiple sclerosis and antiphospholipid antibodies: study of 62 consecutive patients]. / Sclérose en plaques et anticorps antiphospholipides: étude consécutive de 62 patients.

INTRODUCTION: Although multiple sclerosis (MS) and antiphospholipid syndrome (AS) are usually defined by specific criteria that make them distinguishable, in some cases, transition between the two diseases based on clinical and brain imaging findings is not clear. METHODS: Our study included 62 patients (sex ratio F/M = 1.48; mean age 43.4 +/- 23.6 years) with diagnosis of MS according to Poser criteria and 31 control subjects (sex ratio F/M = 9.3, mean age 37 +/- 17 years). We examined the level of antibodies against phospholipids (anticardiolipid, anti beta 2-glycoprotein 1 and antiphosphatidylethanolamine antibodies), antinuclear, anti native DNA, antiprothrombinase antibodies and rheumatoid factor. RESULTS: Antiphospholipid antibodies were found with a significant level (anticardiolipid > 30 UI, anti beta 2-glycoprotein 1 positive) in only five patients (8%) with MS; two others showed an increase in antinuclear antibodies (1/320 degrees and 1/1280 degrees). CONCLUSION: In contrast with data recently reported, this study failed to find a significant level of antiphospholipid antibodies in MS. This result argues for the existence of different pathogenic mechanisms in MS and AS.

[The antisynthetase syndrome: a subgroup of inflammatory myopathies not to be unrecognized]. / Le syndrome des anti-synthétases: un sous-groupe des myopathies inflammatoires à ne pas méconnaître.

PURPOSE: Antisynthetase syndrome (AS) is frequently revealed by interstitial lung disease and arthritis. There are mechanic's hand, Raynaud's phenomenon and anti aminoacyl t-RNA synthetase antibodies. The anti JO-1 antibody is the most frequently identified. We report five cases of antisynthetase syndrome with particular clinical features and good response to corticosteroids. METHODS: There are three women and two men with a median age of 59 years at presentation (range: 44-77). Three patients progressively developed AS: the symptoms are dyspnea (three). Raynaud's phenomenon (one), purpura (one) and hyperkeratosis, scaling and fissuring on the lateral sides of the fingers (two). Patients always had skin signs: hyperkeratosis and scaling (five), purpura (one), Raynaud's phenomenon with normal capillaroscopy (two). Lung disease is present in the five cases with interstitial lesions in CT scans (five), trouble of CO diffusion (three/three) and lymphocytic alveolitis (two/two). Moderate muscular disorders are present in five cases (moderate elevated muscular enzyme: five, positive muscle histology: two). Anti-JO-1 antibodies are present in five cases. AS is associated with connective tissue diseases: rheumatoid polyarthritis in one case and Gougerot-Sjögren in three cases. No malignant tumour is associated. Patients have received oral corticosteroid treatment (five/five) with high doses of intravenous perfusions (three/five) with, initially, a good response. For only one patient, immunosuppressive treatment was necessary because of the articular relapse. The interstitial lung disease had a good response to corticosteroids therapy alone in four cases. Because of the relapse during the tapering off of corticosteroids, corticosteroids were increased in one case and immunosuppressive therapy was required in one case. CONCLUSION: The prognosis of AS depends of the interstitial lung disease. High doses of corticosteroids are required. In our study, the response to corticosteroids is good. Immunosuppressive agents must be added in severe and progressive form of interstitial lung disease in AS.

[Rheumatoid purpura in adults and parvovirus B19 infection: fortuitous association or parvovirus B19-induced vasculitis?]. / Purpura rhumatoïde de l'adulte et infection à parvovirus B19: association fortuite ou vascularite induite par le parvovirus B19?

INTRODUCTION: Henoch-Schoenlein purpura has been reported to be associated with parvovirus B19 infection, particularly in children and rarely in adults. We report the case of a 42-year-old patient presenting with this association. EXEGESIS: A 42-year-old patient was admitted to our medical center because of lower limb purpura. Henoch-Schoenlein purpura diagnosis was confirmed on histological findings (kidney biopsy) and concomitantly parvovirus B19 infection was proved by serological test (IgM+). Association of Henoch-Schoenlein purpura and parvovirus B19 infection has already been described. However, none of the reported studies demonstrated clearly the link between these two diseases. With regard to this observation, we wonder about the systematic use of the parvovirus B19 serological test in patients presenting first Henoch-Schoenlein purpura. Indeed, parvovirus B19-induced vasculitis is habitually controlled with intravenous immunoglobulins. CONCLUSION: A prospective study should explore the link between Henoch-Schoenlein purpura and primary parvovirus B19 infection. Moreover, we should evaluate intravenous immunoglobulins' efficacy in Henoch-Schoenlein purpura associated with active parvovirus B19 infection in order to improve the prognosis of this disease.

[Patient compliance with drug therapy in temporal arteritis]. / Observance médicamenteuse dans la maladie de Horton.

OBJECTIVE: To evaluate patient compliance with drug therapy in temporal arteritis and to determine the characteristics of compliant or non-compliant patients. METHODS: Inpatients and outpatients from an Internal Medicine Unit were interviewed. Compliance with drug dosage and administration time was assessed with a questionnaire for the following drugs: glucocorticoids, calcium, vitamin D, diphosphonates (prevention of glucocorticoid-induced osteoporosis). RESULTS: Forty-nine patients were interviewed (61% female, mean age = 73.7 years). Glucocorticoids were prescribed to 96% of the patients, calcium and vitamin D to 86% and diphosphonates to 49%. Compliance with drug therapy was 87%, 60%, 68% and 51%, respectively, for all treatments. It was independent from the disease duration. Male were more compliant than female (P = 0.012). CONCLUSION: Half of the patients with temporal arteritis are non-compliant with drug therapy. The questionnaire is simple. It can be used in everyday clinical practice to study and improve patient compliance.