Peripheral obstructive arterial disease and carotid artery stenosis in end stage renal disease: a case-control study.

AIM: Cardiovascular diseases are an important cause of morbidity and mortality in end stage renal disease (ESRD) patients. The purpose of this study was to evaluate the predominance of carotid stenosis and peripheral obstructive arterial disease (POAD) in a group of patients subject to dialysis compared with a control group. METHODS: It is a control-case study performed on patients at different hemodialysis facilities; the exams were carried out in ambulatory care. Two groups of patients were examined, the first group was made up of 40 dialysis patients (46.6% men, average age 58.8), the second was the control group made up of 58 subjects matched by age, sex, arterial pressure, presence of diabetes and smoking habits. All patients underwent an Eco-Color Doppler exam on the over aortal trunks and lower extremities and had their Ankle-Brakial-Index (ABI) measured. Carotid stenosis was considered only if equal or over 50%. RESULTS: Twenty percent of dialysis patients showed carotid stenosis (CS) versus 12% in the control group, with an OR of 7.9 (CI 95% 1.3-47.7) adjusted to sex, age and hypertension. The ultrasound picture of the lesions showed large amounts of calcium deposits. Predominance of POAD in dialysis patients was 20% versus 9% in the control group. In dialysis patients the OR adjusted to age, sex and arterial pressure was 6.3 (CI 95%, 1.2-32.6). CONCLUSION: The ultrasound picture of the lesions showed mainly underpopliteal lesions with ''rosary bead'' calcifications. In diabetic dialysis patients the OR was 7.6 (CI 95% 1.4-46.3).

Functional lymphatic alterations in patients suffering from lipedema.

Lipedema is a chronic vascular disease almost exclusively of female sex, characterized by the deposit of fat on the legs, with an "Egyptian column" shape, orthostatic edema, hypothermia of the skin, alteration of the plantar support, and negativity of Stemmer's sign. The etiology and pathogenesis of this disease are still the object of study, and therapy is very difficult. Various authors have described morphologic and functional alterations of prelymphatic structures and of lymphatic vessels. The big veins remain untouched in the phlebograms and an alteration of the skin elasticity is demonstrated. The present authors have studied by dynamic lymphoscintigraphy 12 women patients suffering from lipedema, and compared the results with those of 5 normal subjects and 5 patients suffering from idiopathic lymphedema who were sex and age matched with the patients suffering from lipedema. The patients suffering from lipedema showed an abnormal lymphoscintigraphic pattern with a slowing of the lymphatic flow that presented some analogies to the alterations found in the patients suffering from lymphedema. A frequent asymmetry was also noticed in the lymphoscintigraphic findings that is in contrast to the symmetry of the clinical profile.

[Is clinical diagnosis of deep venous thrombosis really unreliable?]. / Le diagnostic clinique des thromboses veineuses profondes est-il vraiment peu fiable?

The clinical diagnosis of deep venous thrombosis (DVT) is traditionally regarded as lacking of sensitivity and specificity. As we were not fully convinced by this statement, we assessed the value of two associated clinical signs in outpatients, namely the flapping of the calf and the modified Lowemberg's sign. The examiner has first put forth a diagnosis based on the data of history and/or the presence of clinical signs specific for another kind of disease. Then an objective test of the diagnosis was carried out with a duplex scanner performed by an expert. DVT was observed in 39 subjects out of 102 (38.2%) who where all referred by general practitioners (GP), which confirms the poor diagnostic value of clinics at GP level. Associated positiveness of these two signs yielded 87.2% sensitivity and 88.8% specificity with a positive predictive value of 82.9% and a negative predictive value of 91.8%. The addition of an overall clinical assessment later improved results to 87.2% sensitivity and 96.8% specificity, a positive predictive value of 94.4% and a negative predictive value of 92.4%. In this study, the performance of clinics, if assessed by an angiologist qualified for the diagnosis of DVT, proved to be better than in the common data of the literature. Clinical data, if perfect, should be included in the diagnostic management of DVT.

Microangiopathy of ethylic polyneuropathy.

The authors have studied, by biopsy of the tip of the big toe, the histologic changes in microvessels of patients affected by ethylic polyneuropathy. Patients affected by diabetes, hypertension, peripheral arterial or venous diseases, or dermatologic diseases or vasculitides were excluded. The mean of daily drinks was 310 +/- 105 g of alcohol, chiefly wine. Important pathologic modifications were noted; complete narrowing of the arteriovenous anastomosis, regressive changes of the Vater-Pacini corpuscles, and dilatation of the small veins and the capillaries. The findings were compared with those of a patient affected by ulcerans and mutilans acropathy of Bureau and Barriere, a typical disease of alcoholics. The same characteristics appeared: profound changes of the structure of the smallest vessels, with sclerosis, extended to the interstitium. In a previous study of the authors, 3 other patients affected by Bureau-Barriere disease showed the same pattern. These alterations can be explained as the effect of alcohol on the microvessels.

[Sclerotherapy of the internal saphenous vein: comparison between the trombovar protocol and the trombovar-iodine protocol]. / La sclérose de la saphène interne: comparaison entre le protocole trombovar et le protocole trombovar-iode.

Sclérosing injections of the long saphenous vein involve different protocols concerning technique as well as the sclerosing fluids and doses used. This retrospective study involved comparison of two groups of patients treated during successive periods on the basis of a protocol consisting of 3 per cent Trombovar at doses increasing progressively up to a maximum of 6 and another protocole as follows: 3 per cent Trombovar, 1 ml; 3 per cent Trombovar 2 ml; 8 per cent Variglobine 2 ml; 12% Variglobine 2 ml; 12 per cent Variglobine 3 ml; "Overdose" (12 per cent Variglobine 6 ml + 3 per cent Trombovar 6 ml, i.e. 2-4 ml as divided doses. Patients were seen for follow-up evaluation by continuous wave Doppler after six months and two years. The first protocole, with a mean follow-up of 11.5 months, was associated with a 40 per cent recurrence rate. The rate for the second, with a mean follow-up of 13.5 months, was 15.87 per cent. The difference between these figures was statistically very significant (p approximately 0.001). The largest amounts of sclerosing fluid provided lower percentage recurrence rates compared relatively small amounts.

[Postural physiotherapy: a possible conservative treatment of the thoracic outlet syndrome]. / La fisioterapia postural: un posible tratamiento conservador del síndrome del desfiladero torácico superior.

A physiotherapy treatment protocol of "thoracic outlet syndrome" is presented. This treatment is based on the correction positional and not on the reinforcement and developing of determinate muscular groups. Treatment includes 10 exercises, which have to be progressively practiced during each séance. Twenty patients were included into the assay, and they have no signs of their Syndrome by the end of the study. Authors conclude that positional physiotherapy treatment is effective on cases of "thoracic outlet syndrome" without neurovascular complications.

[Lipedema: clinical and diagnostic criteria]. / El lipedema: criterios clínicos y diagnósticos.

Lipedema is a common disease in the usual clinical practice. None organic description about the clinical symptoms and signs associated to this condition has been published. Fifty women with lipedema have been examined by the authors, and incidence rates of symptoms and signs have been emphasized. The following signs and symptoms were constantly reported: "Egyptian column", elastic edema, negative Stemmer's sign, alterated plantar support, cutaneous hypothermia. Some others were frequently found: ecchymosis, spontaneous pain, liposclerosis on the thigh, hypodermic hyperalgesia and pain on the internal face of the knee. Moreover, the two most relevant differential diagnosis as well as their two variant's clinical features (mixed lipedema and "thin women" lipedema) have been described.

[Pigmented livedo. Histologic design and pathogenetic hypothesis]. / La livedo pigmentée. Cadre histologique et hypothèses pathogénèses.

Pigmented livedo is a frequently encountered disease. It occurs as an ochre reticular membrane which does not disappear when the limb is raised. It is characteristic in persons who already have livido reticularis and who expose themselves for several hours every day to the heat from chimneys or foot-warmers. We wanted to study the histological context of this disease in a group of female patients that we kept under observation. The data that we compiled showed that it is due to lymphocytic vasculitis accompanied by atrophy of the epidermis, hyperpigmentation of the basal keratinocytes and telangiectasia. Our pathogenetic hypothesis is that it involves vasculitis "a calore", with atrophy of the epidermis, telangiectasia and melanoid pigmentation, which is the cause of the characteristic brown pigmentation.

[Danazol and antithrombin III deficiency]. / Danazol et déficit en antithrombine III.

The study concerned 7 subjects (3 men, 4 women) with nonfamilial antithrombin III deficit which, in the absence of known causes of acquired deficiency, was defined as "sporadic". Danazol (an attenuated synthetic androgen) already shown to be capable of compensating for a lack of certain antiproteases, was given in doses of 200 mg 3 times per day for 10 days, resulting in a rapid rise (mean 21.2%) in antithrombin III values. Unlike results reported in the literature in cases of familial antithrombin III deficit, the levels did not drop below their initial values despite discontinuance of the drug but unexpectedly remained high and even shows a slight subsequent rise. Although our study was limited to 11 cases, these data seem worthy of being reported, with the prospect of other confirmations concerning either this sort of "sporadic" antithrombin III deficit or the favorable effect of Danazol, even at long term.

[A proposed classification of swollen legs]. / Proposition de classification des "grosses jambes".

The subject of enlarged legs is vast and complex. Up to now there has been no organic classification of the clinical picture involved. The basic problem is that of the criterion on which to base the classification. Literature on this subject has opted for the pathogenic criterion because it seems to facilitate the formulation of a classification which is of use to the doctor. One possibility would be to divide the syndrome into vascular and non-vascular swollen legs. The first group could in turn be separated into macro-circulating and micro-circulatory. The micro-circulatory forms can be primitive or secondary. Amongst the secondary micro-circulatory forms, two other groups can be singled out: secondary forms with local cause and secondary forms caused by organic pathology. However, there are clinical forms which are on the periphery of these different groups and these forms are subject to discussion regarding nosographic localization.

[Hemicrania and vascular acrosyndromes--is there a correlation? Observations on 739 patients]. / Hémicranie et acrosyndromes vasculaires existe-t-il une corrélation? Considérations sur 739 patients.

The purpose of this article was to verify whether there was a clinical correlation between hemicrania - a pathological process for which a vasomotor component is advocated - and vascular acrosyndromes - above all, a vasomotor pathological process.

[Microcirculatory changes in Bureau-Barrière disease and alcoholic polyneuropathy. Preliminary note: correlations and pathogenic hypotheses]. / Altérations microcirculatoires dans la maladie de Bureau-Barrière et dans la polyneuropathie éthylique. Note préliminaire: corrélations et hypothèses pathogéniques.

Nosologically, in ulcerative-mutilating acropathies (U.M.A.), it is customary to differentiate the usual forms of the disease (Thevenard's disease) which develop primarily and the secondary forms (U.M.A. or, better, pseudo-U.M.A.), in which the syndrome is secondary to a known pathologic process and which represent a symptom and not a disease. The link between these two nosological entities is the pseudo-syringomyeli U.M.A. of the lower extremities, or Bureau-Barrier's disease. This disease is exclusively seen in alcoholics and is similar to the neurological alterations observed in alcoholic polyneuropathies. Some authors consider this form as an ulcerative-mutilating acropathy (symptomatic U.M.A.). The objective of our research is to demonstrate the similarity between the microcirculation alterations in patients with Bureau-Barriere's disease and patients with alcoholic polyneuropathy without trophic lesions. For this purpose, we have biopsied the pulp of the great toe, according to the method described by Curri-Schendorf in three patients with Bureau-Barriere's disease, 46, 50 and 65 year-old respectively, and three patients with alcoholic polyneuropathy, 34, 54 and 63 years-old respectively. All these patients presented a normal macrocirculation, without any diabetes, nor disease prone to alter the microcirculation. The results obtained, in a limited series however, permit to state that it is possible to unify alcoholic polyneuropathy and Bureau-Barriere's disease in a single clinical and nosological entity, and to say that the latter only represents an evolution of the former. Besides, we have notices that microcirculation alterations, although non-specific, are extensive and occur early, permitting to suspect a pathogenic process related to a true alcoholic histo-angeitis which, for us, represent the pathogenic basis of Bureau-Barriere's disease.

["Depletion" in the treatment of lymphedema of the lower extremities]. / La "déplétion" dans la thérapeutique des lymphoedèmes des membres inférieurs.

The treatment of lymphedemas consists of two phases: reduction of the edema-prevention of its recurrence. The second phase is invariably linked to the use of a strong contention by means of a stocking. In order to reduce the edema, opinions do not all occur. Some advocate pressotherapy, manual lymphatic drainage, wrapping and immersion in mercury. The authors propose another form of treatment which has the merit to be simple and well tolerated. Their study is based on 187 cases of moderate lymphedema of the lower extremities and, they observed favorable results in 179 patients. For 8 patients, there were partial results, but the treatment prescribed had not been perfectly followed by the patients.