Cellulitis in chronic oedema of the lower leg: an international cross-sectional study.

BACKGROUND: Cellulitis and chronic oedema are common conditions with considerable morbidity. The number of studies designed to assess the epidemiology of cellulitis in chronic oedema is scarce. OBJECTIVES: To investigate the prevalence and risk factors of cellulitis in chronic leg oedema, including lymphoedema. METHODS: A cross-sectional study included 40 sites in nine countries during 2014-17. Adults with clinically proven unilateral or bilateral chronic oedema (oedema > 3 months) of the lower leg were included. The main outcome measures were frequency and risk factors for cellulitis within the last 12 months. RESULTS: Out of 7477 patients, 15·78% had cellulitis within the last 12 months, with a lifetime prevalence of 37·47%. The following risk factors for cellulitis were identified by multivariable analysis: wounds [odds ratio (OR) 2·37, 95% confidence interval (CI) 2·03-2·78], morbid obesity (OR 1·51, 95% CI 1·27-1·80), obesity (OR 1·21, 95% CI 1·03-1·41), midline swelling (OR 1·32, 95% CI 1·04-1·66), male sex (OR 1·32, 95% CI 1·15-1·52) and diabetes (OR 1·27, 95% CI 1·08-1·49). Controlled swelling was associated with a reduced risk (OR 0·59, 95% CI 0·51-0·67). In a subgroup analysis, the risk increased with the stage of oedema [International Society of Lymphology, stage II OR 2·04 (95% CI 1·23-3·38) and stage III OR 4·88 (95% CI 2·77-8·56)]. CONCLUSIONS: Cellulitis in chronic leg oedema is a global problem. Several risk factors for cellulitis were identified, of which some are potentially preventable. Our findings suggest that oedema control is one of these. We also identified that advanced stages of oedema, with hard/fibrotic tissue, might be an important clinical indicator to identify patients at particular risk.

Assessment of primary lymphedema and post-thrombotic lower limb edema patient's pathway.

OBJECTIVES: To assess: (1) lower limb primary lymphedema or post-thrombotic syndrome patient's pathway in terms of health care professional use and (2) if aetiology of edema has an impact on this pathway. METHODS: Ancillary survey of the transversal prospective CHROEDEM pilot study. Forty patients with either lower limb primary lymphedema or post-thrombotic syndrome were invited to participate. RESULTS: Seventy-five percent of primary lymphedema patients and 50% of post-thrombotic patients benefited from a multidisciplinary management (P=0.10) including the general practitioner, the vascular medicine physician and either a physiotherapist (particularly in case of primary lymphedema), a registered nurse (particularly in case of post-thrombotic syndrome). Main ambulatory health care professionals' correspondent of hospital-based vascular medicine physicians were general practitioners (80%) in post-thrombotic patients, and general practitioners (60%) and physiotherapists (45%) in primary lymphedema patients. Pharmacists were also involved in patient education. CONCLUSION: Management of primary lymphedema and post-thrombotic related chronic edema is usually multidisciplinary. General practitioners and vascular medicine physicians are the cornerstones of this management, that also involves the physiotherapist in case of primary lymphedema and in a lesser extent the registered nurse and the pharmacist. This suggests that these five healthcare professional should play a key role in case of development of standardized patient pathways for primary lymphedema and post-thrombotic syndrome.

[Roles of the general practitioner and the vascular medicine physician for patient education concerning venous thromboembolism: The patient's perspective]. / Évaluation par le patient du rôle du médecin traitant et du médecin vasculaire dans l'information médicale des patients souffrant d'une maladie thromboembolique veineuse.

INTRODUCTION: Venous thromboembolism (pulmonary embolism and deep-vein thrombosis) is a frequent, serious but also chronic disease. Studies reported that both general practitioners (GPs) and vascular medicine physicians (VMPs) report participating in patient education concerning venous thromboembolic disease. OBJECTIVE: To assess the role of GPs and VMPs in venous thromboembolic disease patient education, examining the patient's perspective. METHOD: Phone survey of the French patients recruited in the CACTUS trial assessing anticoagulant treatment in case of first distal deep-vein thrombosis. RESULTS: Among the 103 participating patients, 92% (n=95) reported being satisfied by information provided by the GP and VMP. Information was considered as necessary in 96% of cases (n=99). Eighty-five percent of patients (n=88) felt they did not need complementary information. The VMP would have spent more time on education as compared with the GP (an entire consultation in 93.2% vs. 38.8% of cases respectively) the information provided by the VMP being also clearer and more complete. More than 75% of patients reported that no physician warned them about risks of anticoagulants, long-term complications of venous thromboembolic disease or its prevention. CONCLUSION: In CACTUS, patients reported being satisfied by information provided by their managing physicians and information provided by the VMP was clearer and more complete. Important education messages may not have been delivered suggesting the need for a standardization of venous thromboembolic disease patient's education.

[Time in therapeutic range (TTR) and follow-up of patients on vitamin K antagonist: A cohort analysis]. / Utilité du TTR (temps passé dans la cible thérapeutique) dans le suivi des patients sous antivitamine K : analyse d'une cohorte de patients.

INTRODUCTION: Despite the increasing utilization of direct oral anticoagulant (DOAC) prescriptions, vitamin K antagonists (VKAs) remain the treatment of choice for treating and preventing thromboembolic events. The morbidity and mortality of VKAs are partly due to the difficulty of keeping the patient within the therapeutic range. For patients treated by VKA, time in therapeutic range (TTR) is a quality parameter of treatment, widely used in clinical trials but rarely by prescribers. It is well established that its use correlates with the risk of hemorrhage, thrombosis or mortality. We studied this parameter in a cohort of patients to evaluate the quality of their therapeutic follow-up and tried to identify risk factors for low TTR. METHODS: The study was made in collaboration with LaboSud Oc Biologie for a duration of 4 months. It included 3387 patients representing 2,4029 INR. We calculated the patients' TTR. The laboratory transmitted to us the sex and age of each patient and the VKA molecule used, the therapeutic range and the specialty of the prescriber. We then analyzed the odds ratio associated with these different factors. RESULTS: The mean TTR was 68%, close to the TTR recommended by scientific societies. Patient's sex was the only statistically correlated factor, with a worse equilibrium in females taking VKAs (OR=1.22, 95% CI: 1.06-1.39, P=0.00552). Many factors usually correlated with poor equilibrium under VKA have not been studied due to lack of information. CONCLUSION: Given the context of economic restriction and the TTR of our cohort close to the recommended 70%, there would be no benefit in terms of safety to prefer DOAC for the patients involved in this study. Regular monitoring of the individual patient's as well as the cohort's TTR should optimize the management of patients receiving VKAs.

[New nosological and therapeutic perspectives in syndromic vascular malformations with a vein-lymphatic component]. / Nouvelles perspectives nosologiques et thérapeutiques pour les malformations vasculaires syndromiques à composante veino-lymphatique.

Vascular malformations are poorly recognized constitutional anomalies which arises during early childhood. Several classifications tried to draw a distinction across the different entities. Recent advances in molecular biology have contributed to the update of their nosology. Syndromic vascular malformations are an example: while Klippel-Trenaunay syndrome, Proteus or CLOVES syndrome share many common features, understanding of pathological mechanism and specially the role of the PIK3/AKT/mTOR pathway enables us to rethink their classification. Then, some syndromes associated with overgrowth and vascular malformation have been grouped under a single term: "PIK3CA-related overgrowth spectrum" (PROS), and this group continues to grow. This new approach suggests new treatment options. Rapamycin, a PIK3/AKT/mTOR pathway inhibitor, demonstrated its efficiency for some forms of PROS. Targeted therapies such as PIK3 or mTOR selective inhibitor are still in a developmental phase and results are encouraging. This is an example of personalized medicine with significant therapeutic benefit for some patients. However, genotype relation with therapeutic efficiency must be clarified and physicians should pay attention to possible negative effects of these drugs, especially for young patients.

Long-term risk of venous thromboembolism recurrence after isolated superficial vein thrombosis.

Essentials Long-term risk of recurrence of isolated superficial vein thrombosis (SVT) is under-studied. We analyzed data from a cohort of first SVT and proximal deep vein thrombosis (DVT) without cancer. The risk of recurrence as DVT or pulmonary embolism is twice lower in SVT patients. However, overall risk of recurrence is similar between SVT and proximal DVT patients. Click to hear Dr Decousus' perspective on superficial vein thrombosis SUMMARY: Background Isolated superficial vein thrombosis (iSVT) (without concomitant deep vein thrombosis [DVT] or pulmonary embolism [PE]) is a frequent event, but available data on long-term outcomes are scarce and retrospective. Therefore, we aimed to determine prospectively the risk and type of venous thromboembolism (VTE) recurrence after iSVT and compare them with those of proximal DVT. Methods Using data from the prospective, multicenter, observational, OPTIMEV study, we assessed, at 3 years and after anticoagulants were stopped, the incidence and the type of VTE recurrence (iSVT/DVT/PE) of patients with a first objectively confirmed iSVT without cancer (n = 285), and compared these with those of patients with a first proximal DVT without cancer (n = 262). Results As compared with proximal DVT patients, iSVT patients had a similar overall incidence of VTE recurrence (5.4% per patient-year [PY] versus 6.5% per PY, adjusted hazard ratio [aHR] 0.9, 95% confidence interval [CI] 0.5-1.6), but iSVT recurred six times more often as iSVT (2.7% versus 0.6%, aHR 5.9, 95% CI 1.3-27.1) and 2.5 times less often as deep-VTE events (2.5% versus 5.9%, aHR 0.4, 95% CI 0.2-0.9). Varicose vein status did not influence the risk or the type of VTE recurrence. Saphenian junction involvement by iSVT was not associated with a higher risk of recurrence (5.2% per PY versus 5.4% per PY), but was associated with recurrence exclusively as deep-VTE events. Conclusion In patients with a first iSVT without cancer, after stopping anticoagulants, the incidence of deep-VTE recurrence is half that of DVT patients, but the overall risk of recurrence is similar. Ssaphenian junction involvement seems to influence the risk of deep-VTE recurrence, whereas varicose vein status has no impact or a low impact on VTE recurrence.

Interest of an auto-adjustable nighttime compression sleeve (MOBIDERM® Autofit) in maintenance phase of upper limb lymphedema: the MARILYN pilot RCT.

PURPOSE: Breast cancer-related lymphedema (BCRL) is a debilitating condition. The recommended treatment is based on decongestive lymphedema therapy (DLT) with two separate phases: a short-term intensive phase to reduce lymphedema volume and a long-term maintenance phase to stabilize it. Optimizing compression therapy and compliance during maintenance phase are key factors for long-term control of lymphedema. The primary objective of this pilot prospective open-label randomized study was to assess the benefit of a new auto-adjustable nighttime arm sleeve (MOBIDERM® Autofit) on lymphedema volume during the maintenance phase after the intensive phase. METHODS: Forty women with BRCL were consecutively enrolled and randomized (D0) for 1 month in 1:1 ratio either in night-use group: with MOBIDERM® Autofit (on top of a daytime compression hosiery), or in no night-use group: without MOBIDERM® Autofit (daytime hosiery alone). From Day 31 to Day 90, all patients were fitted with MOBIDERM® Autofit. Primary endpoint was lymphedema volume variation between Day 0 and Day 30. Secondary endpoints were compliance, quality of life (LYMQOL arm questionnaire), functional symptoms (heaviness, limb use limitation, pain), sleep quality, and safety. RESULTS: In ITT population, between Day 0 and Day 30, mean lymphedema volume increase was higher in no night-use group with 92.9 mL (i.e., 3.2%) than in night-use group with 46.7 mL (i.e., 1.80%), p = 0.757. Between Day 30 and Day 90, all patients fitted with MOBIDERM® Autofit, lymphedema volume remained stable in both groups. The device improved functional symptoms and function domain of the LYMQOL arm questionnaire. MOBIDERM® Autofit was worn overnight almost 85% of the nights. It was well accepted by the patients and no adverse reaction leading to permanent device discontinuation occurred. CONCLUSIONS: Our results suggest that MOBIDERM® Autofit offers clinical benefits during maintenance phase of lymphedema treatment and enhances patient's self-management.

Long-term outcomes of cancer-related isolated distal deep vein thrombosis: the OPTIMEV study.

Essentials Clinical significance of cancer-related isolated distal deep vein thrombosis (iDDVT) is unknown. We studied patients with iDDVT, with and without cancer, and proximal DVT with cancer. Cancer-related iDDVT patients have a much poorer prognosis than iDDVT patients without cancer. Cancer-related iDDVT patients have a similar prognosis to cancer-related proximal DVT patients. SUMMARY: Background Isolated distal deep vein thrombosis (iDDVT) (infra-popliteal DVT without pulmonary embolism [PE]) is a frequent event and, in the absence of cancer, is usually considered to be a minor form of venous thromboembolism (VTE). However, the clinical significance of cancer-related iDDVT is unknown. Methods Using data from the observational, prospective multicenter OPTIMEV cohort, we compared, at 3 years, the incidences of death, VTE recurrence and major bleeding in patients with cancer-related iDDVT with those in cancer patients with isolated proximal DVT (matched 1:1 on age and sex) and patients with iDDVT without cancer (matched 1:2 on age and sex). Results As compared with patients with cancer-related isolated proximal DVT (n = 92), those with cancer-related iDDVT (n = 92) had a similar risk of death (40.8% per patient-year (PY) vs. 38.3% per PY; aHR = 1.0, 95% CI[0.7-1.4]) and of major bleeding (3.8% per PY vs. 3.6% per PY, aCHR = 0.9 [0.3-3.2]) and a higher risk of VTE recurrence (5.4% per PY vs. 11.5% per PY; aCHR = 1.8 [0.7-4.5]). As compared with patients with iDDVT without cancer (n = 184), those with cancer-related iDDVT had a nine times higher risk of death (3.5% per PY vs. 38.3% per PY; aHR = 9.3 [5.5-15.9]), a higher risk of major bleeding (1.8% per PY vs. 3.6% per PY; aCHR = 2.0 [0.6-6.1]) and a higher risk of VTE recurrence (5.0% per PY vs. 11.5% per PY; aCHR = 2.0 [1.0-3.7]). The results remained similar in the subgroup of patients without history of VTE. Conclusion Patients with cancer-related iDDVT seem to have a prognosis that is similar to that of patients with cancer-related isolated proximal DVT and a dramatically poorer prognosis than patients with iDDVT without cancer. This underlines the high clinical significance of cancer-related iDDVT and the need for additional studies.

Combining balneotherapy and health promotion to promote active and healthy ageing: the Balaruc-MACVIA-LR® approach.

Scaling up and replication of successful innovative integrated care models for chronic diseases is one of the targets of the European Innovation Partnership on Active and Healthy Ageing (EIP on AHA). MACVIA-LR® (MAladies Chroniques pour un VIeillissement Actif en Languedoc-Roussillon) is a Reference Site of the EIP on AHA. The main objective of MACVIA-LR® is to develop innovative solutions in order to (1) improve the care of patients affected by chronic diseases, (2) reduce avoidable hospitalization and (3) scale up the innovation to regions of Europe. The MACVIA-LR® project also aims to assess all possible aspects of medicine-including non-pharmacologic approaches-in order to maintain health and prevent chronic diseases. These approaches include hydrotherapy and balneotherapy which can be of great importance if health promotion strategies are considered. Balneotherapy at Balaruc-les-Bains focusses on musculoskeletal diseases and chronic venous insufficiency of the lower limbs. Each year, over 46,000 people attend an 18-day course related to a new falls prevention initiative combining balneotherapy and education. On arrival, each person receives a flyer providing information on the risk of fall and, depending on this risk, a course is proposed combining education and physical activity. A pilot study assesses the impact of the course 6 and 12 months later. This health promotion strategy for active and healthy ageing follows the FEMTEC (World Federation of Hydrotherapy and Climatotherapy) concept.

[Management of pulmonary embolism: A 2015 update]. / Prise en charge de l'embolie pulmonaire en 2015.

Pulmonary embolism (PE) is a frequent, serious and multifactorial disease, the incidence of which increases with advanced age. In the absence of pathognomonic clinical signs or symptoms, diagnostic management lies in the evaluation of clinical pre-test probability followed by a laboratory or an imaging test. So far, multidetector computed tomography angiography is the diagnostic test of choice to make a positive diagnosis of PE. Anticoagulants at therapeutic dose for at least 3 months constitute the cornerstones of PE therapeutic management. Duration of anticoagulant treatment is modulated according to the presence of transient (surgery, plaster immobilization, bed rest/hospitalization) and chronic/persistent (age, cancer, clinical or biological thrombophilia…) risk factors of PE. Thrombolysis is usually prescribed only for cases of severe PE with arterial hypotension. Arrival of new oral anticoagulants, which have recently been shown to be as effective and as safe as vitamin K antagonist, should simplify and ease ambulatory management of PE and favor more prolonged treatments with anticoagulant for cases of unprovoked PE or PE provoked by a chronic/persistent risk factor.