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Mahé G, Catillon F, Tollenaere Q, Jéhannin P, Guilcher A, Le Pabic E, Lesager G, Omarjee L, Le Faucheur A. Discordance of peripheral artery disease diagnosis using exercise transcutaneous oxygen pressure measurement and post-exercise ankle-brachial index. Sci Rep 2020; 10:7419. [PMID: 32366896 PMCID: PMC7198590 DOI: 10.1038/s41598-020-64276-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/07/2020] [Indexed: 12/24/2022] Open
Abstract
In patients with exertional limb symptoms and normal ankle-brachial index (ABI) at rest, exercise testing can be used to diagnose lower extremity arterial disease (LEAD). Post-exercise ABI decrease or Exercise transcutaneous oxygen pressure measurement (Exercise-TcPO2) can be used to diagnose LEAD. Objectives were (i) to assess the agreement between both methods (ii) to define the variables associated with the discordance, and (iii) to present results of healthy subjects. In this prospective cross-sectional study, patients with exertional limb symptoms and normal rest ABI were consecutively included. ABI was measured at rest and after standardized exercise protocol as well as Exercise-TcPO2. A kappa coefficient with a 95% confidence interval was used to assess the agreement between the two methods. Logistic regression analysis was performed to outline variables potentially responsible for discordance. Ninety-six patients were included. The agreement between the tests was weak with a k value of 0.23 [0.04–0.41]. Logistic regression analysis found that a medical history of lower extremity arterial stenting (odds ratio 5.85[1.68–20.44]) and age (odds ratio 1.06[1.01–1.11]) were the main cause of discordance. This study suggests that post-exercise ABI and Exercise-TcPO2 cannot be used interchangeably for the diagnosis of LEAD in patients with exertional symptoms and normal rest ABI.
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Affiliation(s)
- G Mahé
- Vascular Medicine Unit, CHU, Rennes, France. .,Univ Rennes 1; INSERM CIC 1414, Rennes, France.
| | - F Catillon
- Vascular Medicine Unit, CHU, Rennes, France
| | | | - P Jéhannin
- Univ Rennes 1; INSERM CIC 1414, Rennes, France
| | - A Guilcher
- Vascular Medicine Unit, CHU, Rennes, France
| | - E Le Pabic
- CHU Rennes, Inserm, CIC 1414 (Clinical Investigation Center), F-35000, Rennes, France
| | - G Lesager
- Vascular Medicine Unit, CHU, Rennes, France.,CHU Rennes, Inserm, CIC 1414 (Clinical Investigation Center), F-35000, Rennes, France
| | - L Omarjee
- Vascular Medicine Unit, CHU, Rennes, France.,CHU Rennes, Inserm, CIC 1414 (Clinical Investigation Center), F-35000, Rennes, France.,Vascular Medicine, Hospital, Redon, France
| | - A Le Faucheur
- Ecole Normale Supérieure, Bruz, France.,Univ Rennes, M2S - EA 7470, F-35000, Rennes, France
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Omarjee L, Nitschke Y, Verschuere S, Bourrat E, Vignon MD, Navasiolava N, Leftheriotis G, Kauffenstein G, Rutsch F, Vanakker OM, Martin L. Severe early-onset manifestations of pseudoxanthoma elasticum resulting from the cumulative effects of several deleterious mutations in ENPP1, ABCC6 and HBB: transient improvement in ectopic calcification with sodium thiosulfate. Br J Dermatol 2019; 183:367-372. [PMID: 31646622 DOI: 10.1111/bjd.18632] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2019] [Indexed: 12/21/2022]
Abstract
Pseudoxanthoma elasticum (PXE) is a rare disorder characterized by fragmentation and progressive calcification of elastic fibres in connective tissues. Overlap has been reported between the inherited PXE phenotype associated with ENPP1, ABCC6 or NT5E mutations and acquired PXE clinical manifestations associated with haemoglobinopathies induced by HBB mutations. No treatment is currently available for PXE. A young boy presented with severe early-onset systemic calcifications occurring in the skin as elastosis perforans serpiginosa (EPS) and in the arteries, causing mesenteric and limb ischaemia. Analyses revealed deleterious ABCC6, ENPP1 and HBB mutations. The diagnosis of severe PXE was retained and we have coined the term 'PXE+ syndrome' to describe the cumulative effects of the various mutations in this uncommon phenotype. Given the severity, rapid progression and a potentially fatal prognosis, intravenous sodium thiosulfate (STS) was initiated at 25 g three times weekly for 6 months. Numerous side-effects prompted dosage adjustment to 10 g intravenously daily. Treatment efficacy was evaluated at 6 months. Asthaenia, anorexia and pre-/postprandial pain had subsided, entailing weight gain. Abdominal EPS had diminished. Calcific stenosis of the coeliac and mesenteric arteries was no longer detectable on arterial ultrasonography. Follow-up revealed only transient efficacy of STS. Discontinuation of treatment to evaluate the persistence of effects resulted in relapse of the initial symptomatology after 4 months. STS efficacy is conceivably due to strong antioxidant properties and chelation of calcium to form soluble calcium thiosulfate complexes. This case is suggestive of PXE+ syndrome for which STS may represent potential treatment in severe cases. What's already known about this topic? Generalized arterial calcification of infancy may occur in association with ABCC6 mutations and pseudoxanthoma elasticum (PXE) can be linked to ENPP1 mutations. A PXE-like phenotype has also been reported in a subset of patients with inherited haemoglobinopathies, namely sickle cell disease or β-thalassaemia, related to HBB mutations. To date, there is still no cure for PXE. What does this study add? We report a severe case of PXE resulting from the cumulative effects of several deleterious mutations in ENPP1, ABCC6 and HBB. We suggest the term 'PXE+ syndrome' to describe such patients. Sodium thiosulfate therapy could represent a potential option in severe cases of PXE+ syndrome.
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Affiliation(s)
- L Omarjee
- MitoVasc Institute, UMR CNRS 6015/INSERM 1083, 49100, Angers, France.,PXE Reference Centre (MAGEC Nord), University Hospital of Angers, Angers, France.,University of Rennes, CHU Rennes, INSERM CIC1414, Vascular Medicine Unit, Rennes, France.,PXE Vascular Consultation Centre, CHU Rennes, 35000, Rennes, France.,Vascular Medicine Unit, Redon Hospital, 35600, Redon, France
| | - Y Nitschke
- Münster University Children's Hospital, Münster, Germany
| | - S Verschuere
- Centre for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - E Bourrat
- Department of Paediatrics, APHP, Robert Debré Hospital, Paris, France
| | - M-D Vignon
- Department of Pathology, Saint-Louis Hospital, Paris, France
| | - N Navasiolava
- MitoVasc Institute, UMR CNRS 6015/INSERM 1083, 49100, Angers, France.,PXE Reference Centre (MAGEC Nord), University Hospital of Angers, Angers, France
| | - G Leftheriotis
- Department of Physiology and Vascular Investigation, Nice University Hospital, Nice, France
| | - G Kauffenstein
- MitoVasc Institute, UMR CNRS 6015/INSERM 1083, 49100, Angers, France
| | - F Rutsch
- Münster University Children's Hospital, Münster, Germany
| | - O M Vanakker
- Centre for Medical Genetics, Ghent University Hospital, Ghent, Belgium
| | - L Martin
- MitoVasc Institute, UMR CNRS 6015/INSERM 1083, 49100, Angers, France.,PXE Reference Centre (MAGEC Nord), University Hospital of Angers, Angers, France
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Charasson M, Le Brun C, Rossignol E, Mauger C, Omarjee L, Mahe G. Atherosclerosis knowledge of general practice residents: Diagnosis and management in primary care. J Med Vasc 2019; 44:331-335. [PMID: 31474343 DOI: 10.1016/j.jdmv.2019.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/20/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Cardiovascular diseases represent the leading cause of death worldwide. In a previous survey, we have shown that the management of patients with atherosclerosis by general practitioners depends on the locations of the disease. The aim of this survey was to assess general practice residents' (GPR) knowledge on three clinical presentations which are ischemic stroke, coronary artery disease (CAD), and peripheral artery disease (PAD). MATERIALS AND METHODS Between May 2017 and September 2017, a national self-administered survey that we previously used to assess the GPs' knowledge was emailed to GPRs from French medicine faculties. The questionnaire was composed of three clinical cases dealing with transient ischemic attack (TIA), stable angina (SA) and intermittent claudication (IC). Each clinical case was explored by seven similar questions. The primary endpoint was the number of GPRs who correctly answered 5 of the 7 questions for each clinical case. RESULTS Five hundred and fifty-three GPRs (10%) answered the questionnaire entirely. There is a significant difference between TIA knowledge (19.9% of correct answers) which is greater than SA knowledge (0.9%) and IC knowledge (0.4%). The diagnosis was correctly done by 525 (94.9%) GPRs for TIA, 513 (92.8%) for SA, and 532 (96.2%) for IC. The main difficulties encountered by the GPRs concerned complementary investigations and treatment. CONCLUSION As for general practitioners, this study reveals a difference in GPRs' knowledge depending on the location of the atherosclerosis. Considering the results, the improvement of initial training and continuing medical education (CME) in general medicine would be desirable.
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Affiliation(s)
- M Charasson
- Vascular Medicine Unit, CHU de Rennes, 35000 Rennes. France
| | - C Le Brun
- Vascular Medicine Unit, CHU de Rennes, 35000 Rennes. France; General Practice Department, 35000 Rennes. France
| | - E Rossignol
- Inserm, centre d'investigation clinique, CIC 1414, University Rennes, 35000 Rennes. France
| | - C Mauger
- Vascular Medicine Unit, CHU de Rennes, 35000 Rennes. France
| | - L Omarjee
- Vascular Medicine Unit, CHU de Rennes, 35000 Rennes. France; Vascular Medicine, centre hospitalier Redon, 35000 Redon, France
| | - G Mahe
- Vascular Medicine Unit, CHU de Rennes, 35000 Rennes. France; General Practice Department, 35000 Rennes. France.
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Stivalet O, Paisant A, Belabbas D, Omarjee L, Le Faucheur A, Landreau P, Garlantezec R, Jaquinandi V, Liedl DA, Wennberg PW, Mahé G. Exercise testing criteria to diagnose lower extremity peripheral artery disease assessed by computed-tomography angiography. PLoS One 2019; 14:e0219082. [PMID: 31247050 PMCID: PMC6597112 DOI: 10.1371/journal.pone.0219082] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 06/15/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The sensitivity and specificity of exercise testing have never been studied simultaneously against an objective quantification of arterial stenosis. Aims were to define the sensitivity and specificity of several exercise tests to detect peripheral artery disease (PAD), and to assess whether or not defined criteria defined in patients suspected of having a PAD show a difference dependent on the resting ABI. METHODS In this prospective study, consecutive patients with exertional limb pain referred to our vascular center were included. All patients had an ABI, a treadmill exercise-oximetry test, a second treadmill test (both 10% slope; 3.2km/h speed) with post-exercise pressures, and a computed-tomography-angiography (CTA). The receiver-operating-characteristic curve was used to define a cut-off point corresponding to the best area under the curve (AUC; [CI95%]) to detect arterial stenosis ≥50% as determined by the CTA. RESULTS Sixty-three patients (61+/-11 years-old) were included. Similar AUCs from 0.72[0.63-0.79] to 0.83[0.75-0.89] were found for the different tests in the overall population. To detect arterial stenosis ≥50%, cut-off values of ABI, post-exercise ABI, post-exercise ABI decrease, post-exercise ankle pressure decrease, and distal delta from rest oxygen pressure (DROP) index were ≤0.91, ≤0.52, ≥43%, ≥20mmHg and ≤-15mmHg, respectively (p<0.01). In the subset of patients with an ABI >0.91, cut-off values of post-exercise ABI decrease (AUC = 0.67[0.53-0.78]), and DROP (AUC = 0.67[0.53-0.78]) were ≥18.5%, and ≤-15mmHg respectively (p<0.05). CONCLUSION Resting ABI is as accurate as exercise testing in patients with exertional limb pain. Specific exercise testing cut-off values should be used in patients with normal ABI to diagnose PAD.
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Affiliation(s)
- O. Stivalet
- Vascular Medicine Unit, CHU Rennes, Rennes, France
- Vascular Medicine, CH de Saint Malo, Saint-Malo, France
| | - A. Paisant
- Radiology Department, CHU Rennes, Rennes, France
| | - D. Belabbas
- Radiology Department, CHU Rennes, Rennes, France
| | - L. Omarjee
- Vascular Medicine Unit, CHU Rennes, Rennes, France
- Vascular Medicine Unit, CH de Redon, Redon, France
| | - A. Le Faucheur
- Univ Rennes; INSERM CIC, Rennes, France
- Ecole Normale Supérieure, Bruz, France
| | - P. Landreau
- Vascular Medicine Unit, CHU Rennes, Rennes, France
| | | | - V. Jaquinandi
- Vascular Medicine Unit, CHU Rennes, Rennes, France
- Univ Rennes; INSERM CIC, Rennes, France
| | - D. A. Liedl
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States of Amerca
| | - P. W. Wennberg
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States of Amerca
| | - G. Mahé
- Vascular Medicine Unit, CHU Rennes, Rennes, France
- Univ Rennes; INSERM CIC, Rennes, France
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, United States of Amerca
- * E-mail:
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Chassain K, Bourrat E, Croue A, Omarjee L, Leftheriotis G, Martin L. Traitement par thiosulfate de sodium des lésions cutanées et vasculaires d’un PXE pédiatrique sévère. Ann Dermatol Venereol 2017. [DOI: 10.1016/j.annder.2017.09.561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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