Diagnosing thoracic outlet syndrome: contribution of provocative tests, ultrasonography, electrophysiology, and helical computed tomography in 48 patients.

OBJECTIVE: To evaluate the diagnostic usefulness of provocative tests, Doppler ultrasonography, electrophysiological investigations, and helical computed tomography (CT) angiography in thoracic outlet syndrome (TOS). PATIENTS AND METHODS: We prospectively evaluated 48 patients with a clinical suspicion of thoracic outlet syndrome. Standardized provocative tests, an electromyogram and somatosensory evoked responses, a Doppler ultrasonogram, and a helical CT arterial and/or venous angiogram with dynamic maneuvers were done on each patient. The final diagnosis was established by excluding all other causes based on all available data. The agreement between the results of each investigation and the final diagnosis was evaluated. RESULTS: Provocative tests had mean sensitivity and specificity values of 72% and 53%, respectively, with better values for the Adson test (positive predictive value [PPV], 85%), the hyperabduction test (PPV, 92%), and the Wright test. Using several tests in combination improved specificity. Doppler ultrasonography visualized vascular parietal abnormalities and confirmed the diagnosis in patients with at least five positive provocative tests. Electrophysiological studies were useful mainly for the differential diagnosis or for detecting concomitant abnormalities. Although helical CT angiography provided accurate information on the location and mechanism of vascular compression, the usefulness of this investigation for establishing the diagnosis of TOS and for obtaining pretherapeutic information remains unclear.

Prognostic factors and long-term evolution in a cohort of 133 patients with giant cell arteritis.

OBJECTIVE: Survival in patients with giant cell arteritis (GCA) has generally been found to be similar to that of the general population. The aim of our study was to assess outcome and survival of different subgroups of patients with GCA in relation to clinical, biological data or treatment modalities. METHODS: From 1977 and 1995, 176 patients were treated in the Department of Internal Medicine for GCA. The patient, family or local practitioner were contacted prior to the study (July-October 1995). Treatment modalities and follow-up were obtained for 133 patients. All patients (except 11) had 3 or more 1990 ACR classification criteria for GCA. The 11 patients with 2 criteria had a positive temporal biopsy and were included in the study. RESULTS: Relapse during corticosteroid tapering treatment was observed in 83 patients (62.4%) with a mean 1.57 relapses per patient. No correlation was found in age, sex, initial dose or type of steroid used (i.e. prednisone or prednisolone). Only a slight correlation in the initial erythrocyte sedimentation rate (ESR) was observed (p < 0.01, r = 0.23). In 56 patients free of treatment (mean treatment duration: 40 months), 27 (48%) developed a relapse of the disease 1 to 25 months later. No correlation was found in age, sex, initial dose of steroid, number of relapses during treatment, or initial ESR. Survival analysis was performed using the Kaplan-Meier and Mantel-Menszel methods for comparison of groups. At the time of the study, 41 patients had died (30.7%). A significant reduction of survival was found with the presence of permanent visual loss vs absence (p = 0.04), in patients who required more than 10 mg/d of glucocorticoid (p < 0.001) at 6 months treatment and in patients treated with prednisone (vs prednisolone) (p < 0.01). However, these factors were not independently associated with survival in the multivariate analysis. CONCLUSION: Relapse was observed in 62.4% of the patients during corticosteroid tapering (correlated with initial ESR). A relapse of the disease was also observed in 48% of patients 1 to 25 months after the end of the treatment and was associated with prednisolone use. Long term survival was better in patients with no initial ocular manifestations, in patients who took less than 10 mg/day of corticosteroids at 6 months of the treatment and in patients treated with prednisolone.

[Takayasu's arteritis: vascular investigations and therapeutic management. Experience with 16 patients]. / Artérite de Takayasu: explorations vasculaires et prise en charge thérapeutique. Expérience à propos de 16 patients.

PURPOSE: There is no consensus in regard to vascular explorations and therapeutical management of Takayasu's arteritis. The objective of this study was therefore to establish the most appropriate vascular explorations and to analyze current treatments. METHODS: Clinical, biological and morphological findings related to either diagnosis or treatment were retrospectively evaluated in sixteen patients diagnosed with Takayasu's arteritis according to the American College of Rheumatology criteria. RESULTS: Median delay between the occurrence of the first symptoms and the diagnosis was 9 months. Aortic lesions and aortic valvular incompetence were more frequent. Statistical analysis showed the existence of a correlation between the lack of relapse and corticosteroid therapy (Fisher exact test, P = 0.021). Percutaneous transluminal angioplasty led to stabilization of vascular lesions. Surgical management led to satisfactory results, except for patients with aortic lesions, as survival was then less than 1 year. CONCLUSION: Early diagnosis is mandatory in patients with Takayasu's arteritis in order to propose appropriate therapy, particularly corticosteroid therapy. Surgery and angioplasty prove to be useful in occlusive forms. Late diagnosis is accompanied by severe aortic lesions and fatal outcome.

[Evaluation of the revascularization process by staged dynamic transcutaneous oximetry in stage II of obliterative arteriopathy of the lower limbs: a prospective study of 15 patients]. / Evaluation du geste de revascularisation par oxymétrie transcutanée dynamique étagée dans l'artériopathie oblitérante des membres inférieurs de stade II: une étude prospective de 15 malades.

We evaluated the value of dynamic transcutaneous oxygen tension measurement in 15 patients with Leriche stage II intermittent claudication treated with vascular bypass procedures. Fifteen men, median age 60 years (range: 37-72 years), were studied during six months; 19 limbs were revascularized: eight by angioplasty, 11 by patent graft. Claudication perimeter and dynamic transcutaneous oxygen tension measurement were evaluated before and after revascularization. The TcPO2 was continuously measured with a multimodular Kontron Supermon at seven different sites simultaneously: precordium (reference probe), thighs, calves and feet, in the dorsal recumbent position after 30 minutes rest, during a standardized exercise stress test at 50 W and during the recovery phase. The results were expressed as index of surface defect (ISD). After revascularization, the duration of significant ischemia was significantly reduced (P < 0.001 thigh, calf, foot) in 14 patients. Dynamic transcutaneous oximetry therefore seems to be a useful method in assessing stage II occlusive peripheral arterial disease and the topography of tissue hypoxia. Dynamic transcutaneous oximetry is helpful in the surveillance after revascularization and guides the choice of specific treatment (angioplasty or patent graft) especially for multiple lesions.

[Pseudoxanthoma elasticum: a rare cause of leg artery diseases in young adults]. / Le pseudo-xanthome elastique: une cause rare d'artériopathie des membres inférieurs de l'adulte jeune.

Pseudoxanthoma elasticum (PXE) is a rare inherited connective tissue disorder which is characterized by elastic tissue degeneration involving the skin, eyes and arteries. We describe the case of a hypercholesterolemic 25 year-old woman with typical genetic dominant form of PXE revealed by distal limb artery involvement after a pregnancy. In young adults with arterial disease, a non atheromatous cause should always be sought for, even if risk factors for atherosclerosis are present.

Increased capillary permeability in systemic rheumatoid vasculitis: detection by dynamic fluorescence nailfold videomicroscopy.

OBJECTIVE: Several histological studies suggest a vascular involvement in rheumatoid arthritis (RA). We evaluated morphological and functional changes of skin capillaries in patients with RA. METHODS: We studied capillary permeability by nailfold fluorescence videomicroscopy in patients with RA with and without systemic vasculitis to establish the sensitivity, specificity, and the prognostic value of the technique for the diagnosis of systemic rheumatoid vasculitis (SRV). Nine patients with SRV, 22 patients with active RA without signs of vasculitis, and 16 controls were evaluated. RESULTS: No difference in conventional capillaroscopy was observed when we compared patients with SRV and RA. Using fluorescence videomicroscopy after intravenous injection of fluorescein sodium, we observed an increase of transcapillary dye diffusion in 9/9 patients with SRV, in 13/22 patients with RA without vasculitis and in 4/16 control patients. Our results give a sensitivity of 100% in SRV, a specificity of 44%, a positive predictive value of 34% and a negative predictive value of 100%. CONCLUSION: Our present study points out the functional alteration of the capillary wall in patients with RA with or without vasculitis and suggests the usefulness of dynamic fluorescence nailfold capillaroscopy in patients with RA when systemic vasculitis is suspected, not as a diagnostic tool, but because of the high negative predictive value of the technique.

[Follow-up study, using dynamic transcutaneous oximetry in 17 patients with stage II Leriche and Fontaine occlusive arterial disease of the lower limbs]. / Suivi par oxymétrie transcutanée dynamique de 17 malades avec artériopathie oblitérante des membres inférieurs au stade II de Leriche et Fontaine.

We evaluated the value of dynamic transcutaneous oxygen pressure measurement (TcPO2) in 17 patients with stage II occlusive arterial disease of the lower limbs treated with exercise only. We studied 17 patients (15 men, two women) with an average age of 63 years (range 39-80 years). Claudication perimeter and dynamic TcPO2 were evaluated before and after 6 month walking exercise and tabac stopping. Four different sites of TcPO2 were studied: precordium (reference probe), thigh, calf and foot in the dorsal recumbent position after 30 minutes rest, during a standardised exercise stress test at 50 watts and during the recovery phase. The results were expressed as ratio of tissue oxygenation (RTO): thigh, calf or foot TcPO2/precordial TcPO2 x 100 in order to take into account the patients cardiorespiratory status and adaptation to exercise. Claudication perimeter was 255 m +/- 221 before 6 months exercise and 835 m +/- 539 after (P < 0.01). The duration of significative ischemia was significantly reduced after 6 months exercise (P = 0.02 calf, P < 0.01 foot). Dynamic transcutaneous oxymetry would therefore seem to be a useful method of assessing stage II occlusive peripheral arterial disease and the topography of tissue hypoxia. It could be valuable in orientating treatment and the first method to provide and objective evaluation of the efficacy of medical or surgical treatment.