[Improving blood pressure control after a stroke: The place of therapeutic education in the acute phase]. / Améliorer le contrôle de la pression artérielle après un accident vasculaire cérébral : place de l'éducation thérapeutique à la phase aiguë.

OBJECTIVES: At the Paris Saint-Joseph Hospital Group neurovascular unit, the therapeutic patient education program "Treatment of high blood pressure after stroke" involved integrating a vascular physician. The objectives were to include a significant number of patients, to integrate learning self-measurement, and to make an initial analysis of the results concerning patient knowledge, self-measurement practices, adherence to treatment, and control of blood pressure. METHODS: Eighty-six patients under 90 years of age admitted to the neurovascular unit were included in the program between January 1 and October 31, 2017, and participated in an in-hospital educational diagnostic interview followed by an initial session. During this period, 30 patients were reviewed within 3 to 6 months after discharge, with a post-session evaluation for 22 of them. Patient satisfaction was assessed with a questionnaire. A questionnaire was also proposed to the staff. RESULTS: The mean blood pressure of the 22 patients reviewed was on target and they had improved their level of knowledge. The number of sphygmomanometers increased from 5 to 20, but the practice of cycles was not yet mastered. Levels of observed compliance changed little. Patients and paramedics appreciated the program and were convinced of its usefulness. These results do not support a direct effect of therapeutic patient education on blood pressure control, but the observed results are positive and encouraging.

Compression therapy in 100 consecutive patients with venous leg ulcers.

OBJECTIVE: To evaluate compression therapy for venous leg ulcers in terms of adherence, acceptability, quality, and effectiveness. DESIGN OF STUDY: Prospective observational cohort study. SETTING: Vascular diseases outpatient clinic in Paris, France. SUBJECTS: One hundred consecutive patients with active or healed leg ulcers and chronic lower limb venous insufficiency stage C5 or C6 in the CEAP classification scheme. INTERVENTIONS: Compression systems applied in a community-based practice. MAIN OUTCOME MEASURES: A standardized form was used to collect: (1) data on patient adherence; (2) objective criteria evaluating the quality, effectiveness, and correct application of compression systems and; (3) patient education and perceptions about their compression therapy. RESULTS: Patient adherence with compression therapy was high (89%), even though it was often a source of discomfort. Only 10% of patients signaled no discomfort. Drawbacks reported by patients were excessive warmth (29%), pruritus (33%), unacceptably high cost (48%), and moderate to considerable difficulty putting on footwear (64%). In the 11% of patients who did not wear their compression system, reasons for nonadherence were inadequate comprehension of expected benefits (45.5%), pain related to compression (36.4%), difficulty applying the compression system (27.3%), and difficulty putting on footwear (27.3%). Application was correct in 51.7% of adherent patients; errors in the remaining patients included slippage, failure of the bandage to extend to just under the knee (55.8%), a tourniquet effect (21%), failure of bandaging starting at the base of the toes (37.2%), and failure to cover the heel (53.5%). Full edema control was achieved in 51.7% of adherent patients. Compression was adequate overall (worn, correctly applied, and effective) in 49% of adherent patients. The most common reasons for lack of effectiveness were inadequate pressure and errors in application. Lack of awareness of potential benefits and wearing modalities of compression therapy was noted in 56% of patients. CONCLUSION: Patients, nurses, and physicians have inadequate knowledge of the modalities of compression therapy and as a result they are not well respected. Educational programs are needed.

[Metabolic syndrome]. / Le syndrome métabolique.

Metabolic syndrome is public health problem. The characteristic feature is an association between factors contributing to increased cardiovascular risk. Several definitions have been proposed from 1998 to 2005. All proposed definitions take into consideration insulin resistance and its corollary hyperglycemia, overweight, hypertriglyceridemia, and LDL-cholesterol lowering. The most widely used definitions are proposed by the World Health Organization (WHO) and the American "Cholesterol" program (NCEP-ATpIII). The prevalence of metabolic syndrome varies by geographic region as a function of the chosen definition, the study methodology, the selection criteria, the age and gender of the study population, and the period of the study. Prevalence is higher in the United States than Europe and increases with age. A growing number of adolescents appear to meet the criteria of metabolic syndrome. Irrespective of the definition retained, metabolic syndrome is associated with increased cardiovascular risk and increased risk of type II diabetes. Sound evidence is however lacking on whether the risk is greater than that of taking into account each individual factor. Several points remain to be clarified concerning the underlying mechanisms. Visceral adipose tissue appears to be a key element in the process via anomalous function related to obesity and insulin resistance. Management is based mainly on reduction of body weight and regular physical activity. Drugs may be necessary to correct for the dyslipidemia, normalize blood glucose and reduce blood pressure.

[Interest of cutaneous resection after reduction of volume by decongestive physiotherapy in huge primary lymphedema of lower limb]. / Intérêt de la résection cutanée après réduction volumétrique par physiothérapie décongestive des lymphoedèmes primitifs volumineux des membres inférieurs.

Treatment of lymphedema is based upon decongestive physiotherapy including low stretch bandages. We reported 3 cases of huge primary lymphedema of lower limb treated with cutaneous resection after decongestive physiotherapy. Two men and a woman (47, 48, 48 years old) had unilateral right lymphedema which appeared at the age of 38, 38 and 37 years. Patients were hospitalized and treated during 3 to 5 weeks with decongestive physiotherapy and then followed by one (n=2) or two cutaneous (n=1) resections. Lymphedema volume calculated with the method of truncated cones decreased of 32, 38 and 59%. Largest differences between the two calves were 54, 38 and 57 cm before treatment and 17, 9 and 12 cm after treatment. Cutaneous resections on external side of the calf were longitudinal without complications. Lymphedema volume remained stable after 24, 6 and 12 months with two superposed elastic stockings and regular self bandaging.

[Limb lymphedema as a first manifestation of primary intestinal lymphangiectasia (Waldmann's disease)]. / Lymphangiectasies intestinales primitives (maladie de Waldmann) révélées par un lymphoedème des membres.

Primary intestinal lymphangiectasia (Waldmann's disease) is characterized by protein-losing enteropathy occurring more frequently in childhood. Chronic diarrhea and diffuse edema are the main clinical manifestations. Peripheral lymphedema may also be associated. Lymphedema is usually present at the time of diagnosis or appears later in the course of the disease. We report the observation of a 31-year-old man suffering from an upper, lower limb and genital lymphedema many years before diagnosis of primary intestinal lymphangiectasia was established. Lower limb lymphoscintigraphy confirmed lymphedema and duodenal biopsies lymphangiectasia. Hypoproteinemia, lymphopenia and hypogammaglobulinemia were also noted. Treatment of lymphedema included low stretch bandaging and elastic stocking. No dietary management with a low-fat diet was added. Search for primary intestinal lymphangiectasia with biological parameters would be useful when primary lymphedema is present. Especially since primary intestinal lymphangiectasia may be complicated by occurrence of B cell lymphoma.

[Comparative analysis of lymphoscintigraphy between lipedema and lower limb lymphedema]. / Analyse comparative de la lymphoscintigraphie au cours des lipoedèmes et des lymphoedèmes primitifs des membres inférieurs.

UNLABELLED: Lipedema is characterized by bilateral enlargement of the legs due to abnormal deposition of fat tissue from pelvis to ankles. It is seen most frequently in obese women. Lipedema appears to be a distinct clinical entity but may be confounded with lymphedema. AIM OF THE STUDY: To analyze and to compare between lipedema and lymphedema the qualitative and quantitative aspects of lymphoscintigraphy. METHODS: Fifteen women with lipedema were recruited. Mean age of onset of lipedema was 31.5 +/- 15 years. Body mass index was 35.1 +/- 7.9 kg/m2, 13 women were obese. Lipedema was compared to 15 cases of primary lymphedema (women: 13, men: 2) of the lower limbs (unilateral: 13, bilateral: 2), with a mean age at onset of 28.7 +/- 12.6 years. Lymphoscintigraphy of the lower limbs with morphologic (visualization of inguinal lymph nodes) and kinetic (half-life, lymphatic speed of the colloid) studies was performed in all cases. RESULTS: Absence of visualization of inguinal lymph nodes was observed in 14/15 cases of lymphedema and in 1/15 cases of lipedema (p<0.001). In the 13 cases of unilateral lymphedema, colloid half-life was higher in the pathologic limb than in the controlateral limb (230 +/- 92 vs 121 +/- 36 minutes, p<0.01) and lymphatic speed of the colloid was slower (6.91 +/- 0.86 vs 8.16 +/- 1.02 cm/min, p<0.001). The two patients with bilateral lymphedema had an increased half-life and decreased lymphatic speed of the colloid. Colloid half-life was significantly higher in lipedema than in controlateral limbs of lymphedema (154 +/- 23 vs 121 +/- 36 minutes, p<0.01) with no difference in lymphatic speed of the colloid. Colloid half-life was significantly higher in lymphedema than in lipedema (230 +/- 92 vs 154 +/- 23 minutes, p<0.01) and the lymphatic speed of the colloid was slower (6.91 +/- 0.86 vs 8.10 +/- 0.45 cm/min, p<0.001). CONCLUSION: Lower limb lymphoscintigraphy showed lymphatic insufficiency in lipedema without morphologic abnormality as seen in lymphedema. Lymphoscintigraphy is not indispensable but is a useful tool when diagnosis is doubtful. Treatment is difficult and may include weight loss and possible surgery.

[Quantitative evaluation and qualitative results of surgical lymphovenous anastomosis in lower limb lymphedema]. / Evaluations quantitative et qualitative des résultats de l'anastomose lymphoveineuse chirurgicale dans les lymphoedèmes des membres inférieurs.

PURPOSE: Treatment of lymphedema (LE) includes complex decongestive physiotherapy (manual lymphatic drainage, bandaging, exercises, skin care, elastic stockings). Surgical therapy is rarely useful. However, lymphovenous anastomosis (LVA) is the most used surgery in LE. We have assessed LVA in lower limb LE. METHODS: Thirteen patients (5 women, 8 men) with primary (n=10) or secondary LE (n=3) were included. Primary LE started at a mean âge (+/- SD) of 28.9 +/- 14.5 years. LE was located in left lower limb (n=7), right (n=4) or both (n=2). LVA was performed 7.1 +/- 4.9 years after the onset of LE by the same surgeon. Two to five lymphatic vessels were used for LVA. Assessment of LVA was based upon objective criteria (volumetry, erysipelas) and subjective criteria (global discomfort, heaviness, cutaneous tenderness, difficulties for doing significant effort or walking more than 1 km). Global assessement of LVA was collected for each patient. RESULTS: Before LVA, excess of volume (+/- SD) of LE was 1906 +/- 1277 ml or 28.5 +/- 18% in comparison with the controlateral limb. After LVA, excess of volume (+/- SD) remained stable with 1863 +/- 1468 ml or 24.4 +/- 18.9%. Volumetry was appreciated with a mean (+/- SD) follow-up of 52 +/- 3 months. Frequency of erysipelas was unchanged for the 6 patients with recurrent episodes. Only heaviness and cutaneous tenderness were significantly reduced after LVA. But global discomfort (+/- SD) decreased from 6.7 +/- 2.7 to 5 +/- 3.2 on visual analogic scale (NS). No differences were observed for significant effort or walking more than 1 km. Global assessment of LVA by the patient was very good (n=3), good (n=2), intermediate (n=5) and bad (n=3). CONCLUSION: LVA failed to improve the volume of lower limb LE and reduce the frequency of erysipelas. LVA improves few subjectives criteria but not global discomfort. Further studies are needed to evaluate LVA and to select patients to obtain best results.

[Lymphedema: which drug therapy?]. / Lymphoedème: quel traitement médicamenteux?

Treatment of primary or secondary lymphedema includes essentially complex decongestive physiotherapy. For many years now, drugs active in reducing volume of lymphedema are prospected. But few studies are available. Only few drugs have been tested. Diuretics have been the first to be used with short and brief efficacy. Benzopyrones were the most tested product with encouraging but conflicting results. New treatments are proposed without randomized controlled studies. Prevention of lymphedema remains essential in particular after treatment of breast cancer.