Evaluation of socio-economic insecurity in peripheral artery disease patients.

The social and economic environment has become a major determinant of cardiovascular health. The objective of our study was to assess socio-economic insecurity in patients with symptomatic PAD. The PRECAR study was a non-interventional prospective cohort study. Patients were recruited from the Vascular Medicine and Surgery Departments of Grenoble-Alpes University Hospital or during a consultation as part of the therapeutic education program "On the move! Better understanding and better living with arterial disease". The analysis of socio-economic and environmental data was based on the EPICES score (a reliable index used to measure individual deprivation) and INSEE parameters (level of education and socio-professional category). Cardiovascular risk factors were also recorded. 150 patients with symptomatic PAD were included between November 2017 and June 2018. 84% were men. In our population 54% (CI95% 45.7 - 62.1) were in a precarious situation compared to 40% (CI95% 39.8 - 40.2) in the general population, according to the EPICES score (P<0.001). Levels of education were low and patients with a baccalaureate or higher education degree were under-represented. Executives, intellectuals and intermediate professions were also under-represented in the PAD population. This data opens new perspectives on the social characterisation of patients that may contribute to improving the outcomes of patients with peripheral vascular disease.

Non-conform diagnostic management of pulmonary embolism suspected patients is responsible for a higher risk of thrombotic event occurrence.

The aim of this 3-month follow-up prospective pragmatic study was to evaluate the implementation of a pulmonary embolism (PE) diagnostic strategy in clinical practice. One thousand and one hundred thirty-four consecutive in- and outpatients with clinically suspected PE were enrolled into a sequential diagnostic algorithm in which vascular medical unit plays a pivotal role in advising physicians and suggesting the most appropriate tests according to the diagnostic algorithm. In this observational study, patients that followed the proposed work-up were attributed to a so-called "conform group". Patients in whom diagnostic work-up was not according to protocol were attributed to a "non-conform group". Nine hundred and ninety-seven patients (87.9%) had a conform work-up, and 137 patients a non-conform work-up according to the proposed diagnostic algorithm. The non-conform work-up directly increased in relation to the age of the referred patients. PE was ruled out in 907 (80%) patients of whom 787 (86.8%) were in the conform group. Of the 797 patients who did not receive anticoagulant drugs, follow-up was obtained in 792 (99.4%). Among these patients, the incidence of acute thromboembolic events during the 3-month follow-up period was different in the group of patients that had a conform work-up (1%, [95% CI, 0.5-2.1%]) from the non-conform group patients (4.5%, [95% CI, 2-10.2%]. Therefore patients from the non-conform group have an independent increased risk to develop a thromboembolic event during the follow-up, adjusted odds ratio 3.3 [1.1-10, 95% CI]. Therefore we demonstrated that a non-conform diagnostic management strategy is associated with a higher risk of thrombotic event occurrence.

Quantitative high D-dimer value is predictive of pulmonary embolism occurrence independently of clinical score in a well-defined low risk factor population.

We performed a prospective study to assess whether positive quantitative D-dimer (DD) levels could be integrated for a selected population in a defined strategy to accurately diagnose pulmonary embolism (PE). For this purpose, 1528 in- or outpatients with clinically suspected PE were investigated according to our prescription rules. Clinical probability was defined as low, intermediate or high. Patients in whom DD levels were measured met criteria defined by our previously described decision-making algorithm: in- and outpatients, < 80 years, without surgery in the previous 30 days or active cancer. Nine hundred and twenty-three patients (60.4%) had quantitative DD measurement using automated latex DD assay (STA-Liatest D-Di). According to our decision-making algorithm, DD measurement was applied to 70.5% of out-, and 55.7% of inpatients, and PE diagnosis was ruled out in 49.5% of the 923 patients. This allowed us to confirm prospectively that our specific rules greatly improve the DD testing efficiency. PE was diagnosed in 115 (12.5%) patients. For a 0.5 mg L(-1) cut-off, the test sensitivity was 97.4%, but its specificity was only 56.7%. However, PE prevalence increased gradually with DD levels. The true observed PE prevalence, according to the quantitative assessment of DD levels, differed from that predicted with pretest clinical probability only. Moreover, in this well-defined patient group, a quantitative DD level > 2 mg L(-1) was predictive of PE occurrence independently of the clinical score (odds ratio 6.9, 95% confidence interval 3.7, 12.8). As part of a defined strategy, knowledge of positive DD quantitative value, together with the clinical probability score, improves the PE predictive model. A clinical validation of these results in a follow-up study would now be necessary before considering the implementation of this strategy into clinical practice.

[Influence of spray application of La Léchère mineral water on the cutaneous microcirculation in the lower limbs in healthy subjects]. / Influence de l'application locale d'eau thermale de la léchère en spray sur la microcirculation cutanée des membres inférieurs.

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

[Incidence of erysipelas of the lower limbs in a spa resort. Efficacy of a strategy of sanitation education (La Lechere: 1992-1997)]. / Incidence de l'érysipèle des membres inférieurs en milieu thermal phlébologique. Efficacité d'une stratégie d'éducation sanitaire (La Léchère: 1992-1997).

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

["Vein School." A program of education for chronic venous insufficiency patients at the La Léchère Hotspring]. / "L'Ecole de la Veine". Un programme d'éducation pour les patients atteints d'insuffisance veineuse chronique à la station thermale de La léchère.

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

[Lyme disease acrodermitis chronica atrophicans: misleading vascular signs]. / Acrodermatite atrophiante de Lyme : des signes vasculaires parfois trompeurs.

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

[Chromametry, a promising technique for the quantification of skin changes in chronic venous disorders]. / La chromamétrie, une technique prometteuse pour la quantification de l'atteinte cutanée dans l'insuffisance veineuse chronique.

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

[Feasibility of patient-injected anticoagulation therapy: the GRANTED experience]. / Faisabilité pratique de l'auto-injection des traitements anticoagulants: l'expérience du réseau GRANTED.

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

[Designing a therapeutic education program for patients with lymphedema: live with lymphedema]. / Conception d'un programme d'éducation thérapeutique pour les patients porteurs de lymphœdème: « vivre avec un lymphœdème ¼

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

Acceptability and practicability of elastic compression stockings in the elderly: a randomized controlled evaluation.

BACKGROUND: Compression stockings are the cornerstone of the treatment of chronic venous disorders, but practical acceptability is an important limitation in the elderly. OBJECTIVE: To evaluate the practicability of compression stockings in elderly patients. METHODS: Twenty women aged 68-85 years without major disability were asked to put on, wear for three hours and take off Solegg® and Solegg® Fine compressive stockings (15-20 mmHg) in random order on different days, and to rate through questionnaires the difficulties and discomfort they experienced in comparison with their usual non-compressive stockings (controls). RESULTS: Foot and heel insertions of the compression stockings, as well as their removal, were found significantly more difficult, whereas comfort when they were on was higher. In the whole, the compression stockings were found to be more agreeable than the controls. CONCLUSION: Difficulties regarding putting on and removal of the compression stockings remain significant but are counterbalanced by a better comfort when they are on.

[Evaluation of an education program for patients taking oral anticoagulants: Experience of the GRANTED network in Isère]. / Evaluation d'un programme d'éducation thérapeutique pour les traitements anticoagulants oraux : expérience du réseau Ville-Hôpital GRANTED du secteur Sud-Isère.

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