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.

Foot ischemia related to essential thrombocytemia and atherosclerosis.

We report two cases of foot ischemia combining microvascular thrombosis related to essential thrombocytemia (ET) and a proximal ulcerating atherosclerotic plaque. This suggests that myeloproliferative neoplasms could also trigger distal embolism from an unstable atherosclerotic plaque by creating a prothrombotic status. These distal ischemic events were the first ET manifestation and therefore lead to myeloproliferative neoplasm diagnosis. In ET, thrombosis event can occur with a normal platelet count. Furthermore, hemogram should be regularly controlled among JAK2 muted patients considering the frequent evolution from isolated JAK2 mutation to ET.

[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.

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.

Prevalence and severity of carpal tunnel syndrome in women.

BACKGROUND: Carpal tunnel syndrome (CTS) is entrapment of median nerve in carpal tunnel of the wrist. The prevalence of CTS related to pregnancy and non-pregnancy is unknown in some countries such as Iran. The main aim of this study was to determine the prevalence of CTS in women of Boyerahmad Township located in South-West part of Iran. METHODS: This cross-sectional descriptive analytic study was done since February 2010 to January 2011 in Obstetrics and Gynecology clinics in 2656 non-pregnant and 1508 pregnant women. The women that had clinical symptoms of CTS performed standard electro diagnostic techniques for rule in or rule out of CTS. RESULTS: The prevalence of CTS in pregnant and non- pregnant women was 3.4 and 2 .3 percent respectively. The prevalence of CTS in all women was 2.7%. Overall, 51 pregnant women had CTS that 59.4% had mild, 18.8 % had moderate and 21.9% had severe CTS. Sixty-one non-pregnant women had CTS that 73.6 %had mild, 20.8 %t had moderate and 5.6 % had severe CTS. CONCLUSION: Although the prevalence of CTS in Iranian pregnancy is higher than non-pregnancy women conservative treatment is safe and more effective.