Feasibility of performing treadmill walking test for patients with peripheral arterial occlusive disease by the advanced practice nurses

AIM

The treadmill walking test with post-exercise pressure measurement can be used as a diagnostic test and could classify peripheral arterial disease of the lower limbs. It can also exclude the diagnosis allowing to raise the possibility of differential diagnoses. In this study, we assessed the feasibility of performing treadmill test by advanced practice nurse to assess suspected lower extremity peripheral artery disease patients.

DESIGN AND METHOD

This is a longitudinal monocentric study to assess the feasibility of a treadmill walking test performed by an advanced practice nurse. The primary endpoint was the number of tests performed during this period. The secondary objectives were to evaluate the reasons for requesting the test, the main results obtained in terms of the test's contribution and diagnoses, and patients' clinical characteristics.

RESULTS

From February to May 2023, amongst 31 patients who underwent the treadmill walking test, 4 tests were able to rule out peripheral arterial disease and to detect differential diagnoses. For the remaining 27 patients, 4 had stage IIa of the Leriche classification, 23 had stage IIb, 2 of which were associated with a narrow lumbar spine. In contrast to the usual report, the APN's report on the walking test included an identification of cardiovascular risk factors, as well as a possible medical reorientation linked to the correction of a detected cardiovascular risk factor.

CONCLUSION

The treadmill walking test can be performed by an advanced practice nurse. He/She added a comprehensive/global patient management, with the detection of cardiovascular risk factors. This new profession led to an increase in the number of tests performed of more than 50% over the period and reduced the time to access the test.

Diagnosis of a chronic wound in the special case of a vascular malformation: A proposal of the Wound and Healing Group of the French Society of Vascular Medicine

Vascular malformations can present with a variety of symptoms and an unpredictable course with the occurrence of wounds. Ulcerations in patients with vascular malformations are fortunately rare. Although few data exist, complications may involve a variety of mechanistic or hemodynamic factors. A rigorous etiological and vascular assessment is therefore essential. In view of the paucity of recommendations, the Wound and Healing Group of the French Society of Vascular Medicine, based on the literature on the subject, presents a number of suggestions for the diagnosis and management of wounds associated with vascular malformations.

Localised intravascular coagulation complicating venous malformations: Clinical characterisation

OBJECTIVE

The International Union of Phlebology recommends measuring at least D-dimer and fibrinogen levels in the diagnosis of extensive extra-truncular venous malformations, with a surface area of 10 cm2 or those which are deep, as well as prior to any interventional procedure. The aim of the study was to characterise venous malformations associated with a possible vascular complication.

METHOD

This study was an observational and multicentre study. The objective was to explore the presence of a possible coagulation disorder among patients with venous malformation. The primary endpoint was to characterise venous malformations with increased D-dimer levels.

RESULTS

The majority of the 72 venous malformations were located in the trunk region, mostly in intramuscular or subcutaneous locations. There were 72 venous malformations with increased D-dimer levels including 3 with biological disseminated intravascular coagulation (elevated D-dimer and fibrinogen <1 g/L). The anticoagulant treatments administered were very heterogeneous in class and dosage, and at the end of the treatment, 17 elevated D-dimers were persistent, 9 venous malformations remained painful and 27 showed thrombotic regression.

CONCLUSION

Venous vascular malformations are probably underestimated and should probably be explored more systematically in terms of coagulation disorder regardless of size or symptomatology. The therapeutic recommendations to treat localised intravascular coagulation with low-molecular weight are not widely applied. Studies are needed, in particular to assess the role of oral anticoagulants in the management of coagulation disorder among patients with venous malformation.

Negative pressure wound therapy with instillation and dwell time in debridement of fibrinous leg ulcers

OBJECTIVE

In conjunction with appropriate wound care, negative pressure wound therapy with instillation and dwell time (NPWTi-d) may be used as an adjunct therapy for acute or hard-to-heal (chronic) wounds, especially when infected. However, there are very few data on the use of NPWTi-d in the treatment of fibrinous wounds that are difficult to debride mechanically. The main objective of this study was to describe changes in the fibrin area of such wounds, before and after treatment with NPWTi-d.

METHOD

This was a monocentric, observational, prospective pilot study evaluating the NPWTi-d medical device. Eligible patients included in the study were those with hard-to-heal lower limb ulcers who had previously undergone unsuccessful specific debridement treatment for their wound, with failure of manual mechanic debridement for at least six weeks' duration, and whose wounds had a fibrinous surface area of >70% of the total wound surface area. The primary endpoint was the difference in the percentage of fibrinous surface area before and after treatment.

RESULTS

A total of 14 patients who received treatment for lower limb ulcers between October 2017 and August 2019 were included in the study. There was a significant shrinkage rate of the fibrinous wound surface between the start and end of treatment (83.6±14.5% and 32.2±19.7%, respectively; p<0.001).

CONCLUSION

This study showed a significant decrease in fibrin area in wounds treated with NPWTi-d, with good tolerance. We believe that NPWTi-d has its place in the multidisciplinary management of patients with hard-to-heal ulcers. Additional randomised studies are required to confirm these findings.

DECLARATION OF INTEREST

The authors have no conflicts of interest.

Nailfold dermoscopy predicts the absence of a capillaroscopy sclerodermic pattern: The multicentre, prospective VASCUL-R trial

BACKGROUND

Nailfold capillaroscopy is recommended to diagnose primary or secondary Raynaud's phenomenon (RP). Capillaroscopy is normal in primary RP, which is the most frequent. Screening for RP capillary anomalies with nailfold dermoscopy has been promising.

OBJECTIVE

To determine whether normal nailfold dermoscopy-based on the absence of five criteria that define a sclerodermic pattern-is able to predict normal capillaroscopy with good positive-predictive value (PPV).

METHODS

Prospective, 2-phase (monocentre and multicentre) study on patients at first consultation for RP undergoing nailfold video capillaroscopy (NVC) and nailfold dermoscopy by two different 'blinded' trained observers, respectively, a vascular specialist and a dermatologist, not familiar with capillaroscopy. The five criteria noted were as follows: disorganization, megacapillaries, low capillary density, avascular areas and haemorrhages.

RESULTS

Based on 105 patients, the dermoscopy PPV for a normal NVC was 100% (p = 0.015), with 37.9% sensitivity, when no criterion was observed. Excluding haemorrhages, the PPV remained 100% (p < 0.0001), with sensitivity rising to 73.7% and 100% specificity.

CONCLUSION

Normal nailfold dermoscopy with the absence of four easy-to-observe criteria predicts normal NVC with an excellent PPV.

Literature review of transcutaneous electrical nerve stimulation in peripheral arterial occlusive disease of the lower limbs

The therapeutic challenge in peripheral arterial occlusive disease (PAD) is often to increase walking distance, improve pain or heal a wound when PAD is symptomatic. Walking rehabilitation or surgical revascularization techniques are limited. Others strategies as alternatives and/or complementary treatments are needed. Among alternative options, Transcutaneous Electrical Nerve Stimulations (TENS) could be of interest, both for improved walking distance or pain reduction. The Transcutaneous Electrical Nerve Stimulation (TENS) is a non-pharmacological, mini-invasive technique involving transcutaneous electrical stimulation. However, there are other transcutaneous electrical nerve stimulation techniques based on the principle of vagus nerve stimulation with different mechanistics. Trans-auricular Vagus nerve stimulation (Ta-VNS) is another TENS technique (electrode on the external ear) which relies on the anti-inflammatory pathways of efferent and afferent vagal fibers. We propose here to review the literature of mini-invasive electrical stimulations, whatever the anatomical zone concerned, in PAD.

METHOD

The aim was to evaluate the use of non-invasive transcutaneous electrical stimulation therapies (regardless of location) in PAD of the lower limbs, whatever the disease grade. A review of the literature was carried out via a search of the MEDLINE/PubMed database from 1975 to 2023. The articles were selected via abstracts by checking (1) medical indications: PAD patients with claudication were retained, excluding neurological or venous claudication, PAD whatever the disease grade (intermittent claudication or critical limb ischemia [CLI]) and (2) non invasive electrical stimulations were considered (neuromuscular electrical stimulation and spinal cord stimulation were excluded) whatever the anatomical site. Non-electrical stimuli such as acupuncture and reflexotherapy were excluded.

RESULTS

Only 9 items were selected, including 7 studies with TENS treatment on the calf, one with trans-auricular vagus nerve stimulation and one with electro-acupuncture points of stimulation.

CONCLUSION

Even if the mechanisms involved are different, TENS on the calves or in the external ears show an improvement of walking distance in PAD patients with intermittent claudication. The results of the studies show few positive effects in arteriopathy but we should keep vigilant in the technics used since mechanisms are different and not fully understood. Electro-stimulation of the calf and external ear appears to be an easy-to-use and accessible therapeutic option, especially since some PAD patients are still failing to be released from pain, despite the rise of endovascular interventional techniques.

Use of Bisphosphonates and the Risk of Skin Ulcer: A National Cohort Study Using Data from the French Health Care Claims Database

INTRODUCTION

Previous pre-clinical and pharmacovigilance disproportionality analyses highlighted a safety signal of cutaneous ulcer with bisphosphonate use. Therefore, our objective is to evaluate this risk and assess whether unmeasured confounding factors could explain this association.

METHODS

This study is a population-based cohort study from a representative sample (1/97th) of the French health insurance claims database: Echantillon Généraliste des Bénéficiaires (EGB) from 2006 to 2019. To limit the impact of our study design and methodological choices on any association between skin ulceration and exposure to bisphosphonates, we used several methods: a Cox proportional hazards analysis and a prior event rate ratio (PERR) analysis, using two propensity matched control groups, and either the first episode of incident ulceration or multiple event-time outcomes.

RESULTS

There were 7402 individuals newly exposed to bisphosphonates matched to 29,605 unexposed individuals on propensity score. The primary outcome was skin ulcer occurrence assessed by at least 2 deliveries of wound dressing during the period of one month. Among 6911 individuals newly exposed to bisphosphonates and 28,072 unexposed individuals with no previous skin ulcer, the Cox regression yielded a hazard ratio (HR) of 1.40 (95% CI 1.26-1.56) for newly exposed individuals. Among 7402 exposed and 29,605 unexposed individuals, the PERR analysis found a non-significant HR of 1.03 (95% CI 0.87-1.24). Results were similar on the different sensitivity analyses.

CONCLUSION

No association between bisphosphonate and skin ulcers was found in the French population. The association observed in previous pharmacovigilance studies and in the Cox regression analysis is likely due to unmeasured confounding factors.

Assessment of digital perfusion as a surrogate outcome in Raynaud's phenomenon clinical trials

OBJECTIVES

Measurement of digital perfusion, sometimes coupled with a cold challenge, has been widely used as an objective outcome in trials evaluating drug therapies in Raynaud's Phenomenon (RP), in addition to patient-reported outcomes or to establish the proof-of-concept in preliminary studies. However, whether digital perfusion is a valid surrogate for clinical outcomes in RP trials has never been explored. The principal aim of this study was to evaluate the potential surrogacy of digital perfusion, by combining individual-level and trial-level data.

METHODS

We used individual data from a series of n-of-1 trials, and trial data from a network meta-analysis. We estimated individual-level surrogacy through coefficients of determination between digital perfusion and clinical outcomes (R2ind). We further calculated the coefficients of determination between treatment effect on the clinical outcomes and on digital perfusion, at the individual level (R2TEInd) and at the trial level (R2trial), using non-weighted linear regression, with their 95% CI calculated through bootstrapping.

RESULTS

Results from 33 patients and 24 trials were included in the final analysis. At the individual level, there was no correlation between digital perfusion and clinical outcomes at rest and in response to various cooling tests (the highest R2ind was 0.03 [-0.07; 0.09]), and R2TEinf was also very low 0.07 [0; 0.29]. At the trial level, the highest value of R2trial was 0.1 [0; 0.477].

CONCLUSIONS

Digital perfusion, at rest or in response to a cold challenge, and whatever the method used, does not fulfill the criteria of a valid surrogate for existing patient-reported outcomes in RP trials.

Efficacy and Safety of Botulinum Toxin in Adults with Raynaud's Phenomenon Secondary to Systemic Sclerosis: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Study

OBJECTIVE

To determine whether a single session of botulinum toxin type A (BTA) injections into both hands more effectively decreases the frequency of systemic sclerosis-associated Raynaud's phenomenon (SSc-RP) episodes than placebo.

METHODS

This multicenter, randomized, double-blind, placebo-controlled, parallel-group phase III trial in patients with SSc-RP assessed the effect of 50-unit BTA or placebo injections into the palms of both hands around each neurovascular bundle during 1 session in winter. The primary end point was the between-group difference in the median change in the number of RP episodes from baseline (day 0) to 4 weeks postinjection. Values between the groups were compared with the Wilcoxon rank-sum test.

RESULTS

The intent-to-treat analysis included 46 BTA-treated patients and 44 placebo recipients. At 4 weeks after assigned treatment injections, the median number of daily RP episodes decreased comparably in the BTA and placebo groups (median change -1 episode/day [interquartile range (IQR) -1.5, 0 episodes/day] and -1 episode/day [IQR -2.5, 0 episodes/day], respectively) (P = 0.77 versus placebo). Moreover, change in Raynaud's Condition Score, quality of life assessed by Health Assessment Questionnaire disability index, and hand function assessed by shortened Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Cochin Hand Function Scale from baseline to follow-up weeks 4, 12, and 24 did not differ significantly between groups. The BTA group experienced transient hand muscle weakness significantly more frequently (P = 0.003).

CONCLUSION

Neither the primary nor secondary end points were reached, and our results do not support any beneficial effect of palmar BTA injections to treat SSc-RP.

Comparative evaluation of socioeconomic insecurity in peripheral and coronary artery disease patients

BACKGROUND

Cardiovascular disease represents the leading cause of death worldwide. Socioeconomic deprivation is a risk factor for cardiovascular disease. We have previously shown that precariousness was more frequent in symptomatic peripheral artery disease (PAD) patients than in the general population. According to a previous study, coronary artery disease (CAD) patients have a higher level of education than CAD with PAD, but no study directly compared the level of precariousness in PAD and CAD patients.

AIM

To measure and compare the level of socioeconomic insecurity in patients suffering from symptomatic PAD with those suffering from isolated CAD, i.e without symptomatic PAD.

METHODS

We conducted an observational, cohort, prospective, multicenter study. Patients suffering from symptomatic PAD or CAD were recruited through the medical or surgical vascular or cardiology departments, or the vascular rehabilitation center. The EPICES score and the INSEE parameters were used for analysis. The individual is considered precarious when his or her score is greater than or equal to 30. Cardiovascular risk factors and peripheral arterial disease stages were also collected.

RESULTS

In total, 230 patients were included. According to the EPICES score, 47.8% [95%CI, 38.7-56.7] of patients with symptomatic PAD were in a precarious situation compared to 17.4% [95%CI, 10.5-24.3] of patients suffering from isolated CAD (P<0.001). The mean EPICES score was 33.3 (SD 22.5) in the PAD and 16.9 (SD 17.02) in the CAD population, respectively (P<0.001). In the PAD population, the level of education was low, with an under-representation of patients with a baccalaureate or higher education degree: 21.7% [95%CI, 14.2-29.3] vs. 41.7% [95%CI, 32.7-50.7] in the PAD and CAD populations, respectively. There was also an under-representation of executives and intellectual and intermediate professions in the PAD population, 18.3% [95%CI, 11.2-25.3], compared to the CAD population, 31.3% [95%CI, 22.8-39.8].

CONCLUSION

PAD patients are more precarious than patients suffering from CAD. A better detection of socioeconomic deprivation in patients suffering from peripheral arterial disease could allow comprehensive care and thus hope for an improvement in terms of morbidity and mortality.

A new compression system for treatment of venous leg ulcers: a prospective, single-arm, clinical trial (FREEDOM)

OBJECTIVE

To evaluate the efficacy, tolerability and acceptability of a new multicomponent compression system in one bandage for the local treatment of patients with venous leg ulcers (VLUs).

METHOD

This was an international, prospective, non-comparative, clinical trial, conducted in France and Germany. Eligible participants had a VLU with a wound area of 2-20cm², lasting for a maximum of 24 months. For a period of 6 weeks, patients were treated with a new multicomponent compression system in one bandage which was worn day and night, providing high working pressure and moderate resting pressure (UrgoK1). Clinical assessments, wound measurement and photographs were planned at weeks 1, 2, 4 and 6. The primary endpoint was the relative wound area reduction (RWAR) after 6 weeks of treatment. Secondary endpoints included wound closure rate, oedema resolution, change in patient's health-related quality of life (HRQoL), acceptability, adherence to the compression therapy, local tolerance, and physician's overall satisfaction with the evaluated compression system.

RESULTS

A cohort of 52 patients (52% female, mean age 75.4±13.0 years) with VLUs, including oedema in 58% of cases, were recruited from 22 centres. At baseline, 42 patients had already been treated with a different compression system. VLUs had been present for 5.6±4.9 months and had a mean area of 5.7±4.3cm². After 6 weeks of treatment, a median RWAR of 91% (interquartile range: 39.4; 100.0) was achieved. Wound closure was reported in 35% of patients. A RWAR ≥40% at week 4, predictive of wound healing at 12 weeks, was achieved in 62% of patients. At the final visit, oedema present at baseline was resolved in 57% of patients. Substantial improvements in the HRQoL of the patients were reported with a decrease of the pain/discomfort and anxiety/depression dimensions. Comfort in wearing the evaluated system was reported as 'very good' or 'good' by 79% of patients, resulting in a high patient adherence to compression therapy. Compared to previous compression systems, half of the patients reported more ease in wearing shoes, and greater satisfaction and comfort with this new system. Nine non-serious adverse events related to the device or its procedure occurred in seven patients. At the final visit, the majority of the physicians were 'very satisfied' or 'satisfied' with the new compression system overall.

CONCLUSION

The new multicomponent compression system in one bandage has been shown to promote rapid healing of VLUs, reduce oedema, improve HRQoL and to be well tolerated and accepted. It appears to be a viable alternative to existing compression systems.

A randomised, open-label, parallel-group, multicentre, comparative study to compare the efficacy and safety of Exufiber® with Aquacel® Extra™ dressings in exuding venous and mixed aetiology leg ulcers

The performance and safety of Exufiber® gelling fibre and Aquacel® Extra™ Hydrofiber® wound dressings were compared for the management of chronic, exuding leg ulcers. The 6‐week study (≤ 24 weeks in a subgroup of subjects) was a randomised, open‐label, parallel‐group, multicentre, non‐inferiority design. Adults (n = 248, 30–97 years of age) were randomised to either Exufiber® or Aquacel® Extra™ dressing. The dressings were applied at baseline and evaluations of wound condition and performance of the dressing were recorded at 1, 2, 3, 4, and 6 weeks. The primary efficacy endpoint was the percentage reduction in wound area at 6 weeks relative to baseline, in the per protocol (PP) population. A median relative reduction of 50% for Exufiber® (n = 100) vs 42% for Aquacel® Extra™ (n = 107) was demonstrated in the PP population (P = 0.093) and confirmed in the intention‐to‐treat population. As the mean and 95% confidence interval for the difference in relative wound area reduction between groups at 6 weeks was −29.4% (−63.5; 3.2), and the lower limit did not exceed 12%, non‐inferiority of Exufiber® was concluded. Both dressings were well tolerated and no safety concerns were identified in both groups. Clinicians' satisfaction with the dressings was higher for Exufiber® than for Aquacel® Extra™ in terms of ease of use and management of exudate, slough, and blood.

Evaluation of patients' and practitionners' satisfaction with the use of hypnosis during a thermal endovenous procedure

INTRODUCTION

In the field of vascular surgery, hypnosis has been used in the creation of venous approaches but also as a complement to local anesthesia during more extensive vascular surgery, including the insertion of abdominal aortic aneurysm stents. The practice of thermal endovenous procedures seems to us to be conducive to hypnotic support in particular to reinforce hypnoanalgesia.

METHOD

We present a prospective and monocentric observational study at the University Hospital of Grenoble with consecutive inclusions whose objective was to evaluate the interest and the satisfaction of the patients and practionners about the practice of hypnosis during procedures of thermal endovenous treatments.

RESULTS

Among the 31 patients treated with endovenous laser, 27 accepted the hypnosis proposal, 16 had hypnosis considered as formal and 13 conversational hypnosis and 10 conversation only. Among them, 29% of patients considered that the hypnoanalgesia technique had enormously relaxed them and 19% "very relaxed"; 42% of patients considered themselves "good", 32% "very good" and 19% "extremely good" at the end of the procedure. Concerning the practitioners performing the endovenous procedure, more than half (51, 51%) considered that hypnoanalgesia relaxed the patient "moderately and/or a lot". The results were as a whole point to a high level of satisfaction on the part of patients and practitioners with the practice of procedures with various levels of hypnosis induction. Despite many biases, this study has the merit of concluding that the patients were very satisfied with the apprehension of these gestures as well as the practitioners, and this without any additional time during the procedure.

Iontophoresis of treprostinil promotes wound healing in a murine model of scleroderma-related ulcers

OBJECTIVE

Systemic Sclerosis (SSc) is a rare, chronic disease characterized by fibrosis, vascular alterations and digital ulcerations. Few drugs have shown efficacy to enhance wound healing of existing SSc-related ulcers. Local delivery of treprostinil, a prostacyclin analogue, may improve wound healing. The present work aimed first at developing a mouse model of SSc-related ulcerations and second at assessing the effect of iontophoresis of treprostinil on wound healing.

METHODS

We used two murine models of SSc: chemically-induced with HOCl, and Urokinase-type plasminogen activator receptor (uPAR)-deficient. Excisional wounding was performed on the dorsal midline with a biopsy punch. Animals were randomized into three groups: treated with electrostimulation alone, with treprostinil iontophoresis, or untreated. We assessed wound healing over time, as well as skin microvascular reactivity, inflammation, microvessel density, and collagen distribution, before wounding and after re-epithelialization.

RESULTS

uPAR-/- mice, but not HOCl-treated mice, showed impaired wound healing and decreased microvascular reactivity compared with their controls. Treprostinil iontophoresis improved wound healing and microvascular density and decreased inflammation in uPAR-/- mice, while electro-stimulation did not. However, treprostinil had no effect on microvascular reactivity and collagen distribution.

CONCLUSION

This study suggests that excisional wounds in uPAR-/- mice are a relevant model of SSc-related ulcers. In addition, treprostinil iontophoresis enhances wound healing in this model. Further work in now needed to show whether this effect translates in humans.

Digital pressure with laser Doppler flowmetry is better than photoplethysmography to characterize peripheral arterial disease of the upper limbs in end-stage renal disease patients

OBJECTIVE

There is no consensual definition of significant peripheral arterial disease of the upper limbs. Patients with end-stage renal disease are usually explored with Doppler ultrasound, which seems insufficient to characterize and quantify the arterial disease in this anatomic site. Candidates for haemodialysis access tend to be increasingly older and have polyvascular disease, and a better assessment of the vascular status of their upper limbs with finger systolic blood pressure is necessary. Photoplethysmography is simple and currently used in practice, but laser Doppler flowmetry may be more sensitive for low values. Our objective is to investigate additional information in the digit assessment over the ultrasound assessment of the upper limbs of patients awaiting haemodialysis and compare digital pressure values taken by photoplethysmography and laser Doppler.

METHODS

All included patients with end-stage renal disease scheduled for haemodialysis access received a prospective evaluation of their upper limbs with a clinical examination of the hands, an arterial upper limb Doppler ultrasound, and finger systolic blood pressure using photoplethysmography and laser Doppler flowmetry. Significant upper limb arterial disease was defined by a finger systolic blood pressure below 60 mm Hg or a finger brachial pressure index below 0.7.

RESULTS

Twenty-four patients were included in the study. In all, 41.7% of patients (n = 10) had parietal calcifications to the antebrachial arteries on Doppler ultrasound, 8.3% of patients (n = 2) had bilateral finger systolic blood pressure values below 60 mm Hg with laser Doppler flowmetry (but not confirmed with photoplethysmography), and 16.6% of patients (n = 4) had a finger brachial pressure index below 0.7 on both laser Doppler flowmetry and photoplethysmography. While there was an agreement between these two methods, higher values were recorded with photoplethysmography. The Pearson coefficient was 0.493 for the median of basal digital pressures in absolute values and 0.489 for finger brachial pressure index (p < 0.001).

CONCLUSION

Our study confirms the need to evaluate significant upper limb arterial disease in patients with end-stage renal disease not only with Doppler ultrasound but also with an evaluation of the finger systolic blood pressure. The correlation of the finger systolic blood pressure values using laser Doppler flowmetry and photoplethysmography was poor, which was probably due to an overestimation of the pressures with photoplethysmography. Despite the absence of a gold standard, we suggest that Laser Doppler flowmetry should be used rather than photoplethysmography to better characterize significant peripheral arterial disease of the upper limbs in patients with end-stage renal disease, particularly before creation of a new haemodialysis access. Protocol Record on clinical trial 38RC19.285.

Skin necrosis and calcifications after extravasation of vancomycin: a localised form of calciphylaxis?

Vancomycin is a tricyclic glycopeptide antibiotic produced from Streptococcus orientalis. There is much variation in the literature with regard to the recommended dose, dilution rate and type of infusion. Given the vesicant properties of vancomycin at supratherapeutic doses (>10mg/ml), tissue damage including blistering and necrosis have been reported. We report a rare case of bilateral cutaneous necrosis induced by accidental extravasation of vancomycin when being intravenously administered. The skin surrounding the injection site was marked by the appearance of subcutaneous calcifications. The development of iatrogenic skin calcinosis has not yet been described for the extravasation of vancomycin. The mechanism underlying the calcinosis observed in our case remains unclear, but we hypothesised a form of localised calciphylaxis induced by a local triggering factor. The ulcers progressed to re-epithelialisation following necrosis debridement and local conservative treatments. Given the increased prevalence of meticillin-resistant Staphylococcus aureus, which has prompted clinicians to gradually increase vancomycin dosage, clinicians should be aware of the high risk of skin toxicity in cases of vancomycin high-dose extravasation.

[Overt disseminated intravascular coagulation complicating a venous malformation]

INTRODUCTION

Coagulopathy related to venous malformations can be life threatening. This complication is little known and underestimated.

CASE REPORT

We report the case of a 52-year-old female patient who presented with a left femoral fracture. She had a pre-existing muscular infiltrating venous malformation of the left hip. During surgery, she developed acute disseminated intravascular coagulation. The latter was probably a consequence of both surgery and localized intravascular coagulation that was unknown before the trauma.

CONCLUSION

It is important to diagnose localized intravascular coagulation in venous malformations, since the risk of disseminated intravascular coagulation can be prevented by anticoagulant therapy.

Subjects with venous insufficiency have high risk of obstructive sleep apnea in relationship to fluid shift

BACKGROUND

Obstructive sleep apnea (OSA) is highly prevalent in conditions characterized by fluid overload. Chronic venous insufficiency (CVI) is associated to fluid overload that might interfere with OSA occurrence and severity.

METHODS

A total of 180 patients with symptomatic CVI completed the Berlin questionnaire and were assessed for the presence of symptoms and signs of OSA and fluid shift.

RESULTS

According to the Berlin questionnaire, 59 patients (33%) had high risk of OSA. The predictors of having a positive Berlin questionnaire were male sex, body mass index and symptoms possibly related to fluid shift.

CONCLUSIONS

Patients with CVI, a disease characterized by fluid overload, present high risk of OSA, which might be related to fluid shift.

Treprostinil Hydrogel Iontophoresis in Systemic Sclerosis-Related Digital Skin Ulcers: A Safety Study

Digital skin ulcers are a severe complication of systemic sclerosis. The first-line treatment is intravenous iloprost, but it induces dose-limiting adverse effects. Local administration of treprostinil through skin iontophoresis may be a safe alternative. We conducted a 2-stage, randomized, placebo-controlled single-ascending-dose study in healthy volunteers and patients with systemic sclerosis-related digital ulcer. We further explored the effect of the procedure on skin blood flux. In a first group of healthy subjects, treprostinil and placebo iontophoresis were performed at 3 locations (ie, 6 skin sites): the sole of the foot, the leg, and the fingers. We used a 1-mg/mL hydrogel of treprostinil. We then randomly treated systemic sclerosis-related digital ulcers in a 3:1 ratio of treprostinil or placebo. We used concentrations from 0.1 to 1 mg/mL. All adverse events were recorded and rated according to the Common Terminology Criteria for Adverse Events (CTCAE), whereas skin microvascular blood flux was recorded with laser speckle contrast imaging. Among the 12 healthy volunteers, we observed 60 local adverse effects: burns, skin pain, erythema, and pruritus, graded 1 or 2 on the 5-point CTCAE scale. Treprostinil iontophoresis significantly increased skin blood flux on the leg (AUC_0-4 h at 88 460% ± 6436% versus 12 730% ± 3397% baseline flux.min respectively; P < .001) and on the sole of the foot (AUC_{0-3 h} at 20 124% ± 6119% versus 3142% ± 3036% baseline flux.min, respectively; P = .018) with a trend on the finger. Among 5 patients with systemic sclerosis-related digital ulcer, 2 resolutive local adverse effects were reported. Iontophoresis of treprostinil hydrogel was safe in systemic sclerosis patients with digital ulcer.

Fluorescence angiography compared to toe blood pressure in the evaluation of severe limb ischemia

Background: Severity of limb ischemia in peripheral arterial disease (PAD) patients is usually evaluated by clinical assessment and toe blood pressure (TBP) or transcutaneous oxygen pressures (TcPO 2). Indocyanin green angiography (IGA) is a promising tool generating a foot cartography of skin microvascular perfusion. However, there is no consensus about the fluorescence parameters that should be used to evaluate ischemia. The purpose of this cross-sectional evaluation and 3-month clinical follow-up was to determine the best fluorescence parameter for the evaluation of severe PAD, using TBP as reference. Patients and methods: IGA was realized in patients with clinical suspicion of CLI in addition to TBP and TcPO 2. Parameters from the time intensity fluorescence curve measured on the foot were compared with TBP (primary reference), and with TcPO2. Clinical outcomes (amputation, revascularization, death) were recorded at 3 months follow-up. Results: Thirty-four patients were included and IGA could be analysed in 29 of them. When all limbs were studied, no significant correlation was found between any of the measured fluorescence parameters (saturation time, ingress slope, amplitude, delay) and TBP pressure neither TCPO2. In the limbs with CLI, a significant correlation between the TBP and amplitude on the forefoot was found. According to the outcome, none of the fluorescence parameters showed a significant prognostic value in contrast to the significant results for TBP and TcPO2. Conclusions: In this study, quantitative analysis of IGA parameters did not show any prognostic value, nor was there any significant statistical association with well-established prognostic parameters such as TBP and TcPO 2 in patients with suspected CLI. A correlation was found between amplitude and TBP in patients with CLI. Topographical information such as perfusion heterogeneity was not evaluated and remains a valuable target to be investigated.

[Digital ischaemia with fingertip ulcers during ipilimumab therapy]

BACKGROUND

Anti-cancer drugs have many adverse effects including vascular side effects. Herein we present the case of a patient presenting digital ischaemia with high imputability of ipilimumab.

OBSERVATION

A 47-year-old male patient was treated for popliteal melanoma, initially stage IIIA but which subsequently became metastatic (stage IV), and for which ipilimumab was given after the failure of two lines of chemotherapy. During the 4th course of ipilimumab, the patient developed autoimmune hepatitis. Ipilimumab was suspended. Three months later, he developed a drug-like neuropathy followed one month later by ulceration of the right index finger. Causes of embolic, autoimmune and occupational origin (thrombotic microangiopathy, thrombosed aneurysm) were rapidly ruled out. Although a paraneoplastic origin could not be formally excluded, drug-induced immune disorder remained the most plausible origin.

DISCUSSION

This is the first reported case of digital ulceration under ipilimumab.

Comparative efficacy and safety of treatments for secondary Raynaud's phenomenon: a systematic review and network meta-analysis of randomised trials

BACKGROUND

Several pharmacological treatments are available for secondary Raynaud's phenomenon, but there is uncertainty regarding the best options. We aimed to assess and compare the benefits and harms of treatments available for secondary Raynaud's phenomenon.

METHOD

We did a systematic review and network meta-analysis of randomised controlled trials (RCTs) of pharmacological treatments. We searched for systematic reviews published in MEDLINE and the Cochrane Database of Systematic Reviews up to Jan 31, 2017, and for RCTs published from inception to Sept 24, 2019 in MEDLINE, Embase, and ClinicalTrials.gov. We included double-blind RCTs (parallel or crossover) that compared two or more pharmacological treatments or placebo in patients with secondary Raynaud's phenomenon. Individual patient data were obtained for one unpublished RCT. Three researchers independently screened the texts and extracted the data. Efficacy outcomes included severity (on a ten-point scale), daily frequency, and mean duration of Raynaud's phenomenon attacks. We also examined tolerability and acceptability. Pairwise meta-analyses and Bayesian random-effects network meta-analyses were used to synthesise data. This study is registered with PROSPERO (CRD42017057518).

FINDINGS

We included 58 RCTs in the analysis, comprising 3867 patients (3540 [91·5%] with secondary Raynaud's phenomenon) and 15 classes of drugs. Phosphodiesterase 5 (PDE5) inhibitors were more effective than placebo for frequency (mean difference -0·36 [95% credibility interval -0·69 to -0·04]), severity (-0·34 [-0·66 to -0·03]), and duration (-3·42 [-6·62 to -0·29]) of attacks (low to moderate level of evidence). Calcium channel blockers (CCBs) were superior to placebo for frequency (-0·35 [-0·67 to -0·02]) and severity (-0·84 [-1·25 to -0·45]) of attacks (low level of evidence). For severity of attacks, selective serotonin-reuptake inhibitors (-1·54 [-2·68 to -0·41]; very low level of evidence) and oral prostacyclin receptor agonists (-0·48 [-0·80 to -0·16]; low level of evidence) were superior to placebo. No other drug classes were significantly superior to placebo with regard to efficacy outcomes. Compared with placebo, tolerability was lower for PDE5 inhibitors (incidence rate ratio for serious adverse events or early study exit due to adverse events 3·30 [95% CrI 1·49 to 7·55]) and CCBs (3·13 [1·33 to 7·04]). For all outcomes, global heterogeneity and between-study variance ranged from low (I2=0% and τ2=0·0 for attack severity and duration) to moderate (I2=41% and τ2=0·2 for tolerability). The overall risk of bias was judged to be low in 22 (38%), high in ten (17%), and unclear in 26 (45%) RCTs.

INTERPRETATION

PDE5 inhibitors and CCBs are the most effective pharmacological options, albeit with moderate efficacy and a low level of evidence. Current evidence does not support the use of any other drug in secondary Raynaud's phenomenon.

FUNDING

None.

Leg ulcer induced by hydroxycarbamide in sickle cell disease: What is the therapeutic impact?

Major sickle cell disease syndrome (SCD) is a set of potentially serious and disabling constitutional haemoglobin pathologies characterised by chronic haemolysis and vaso-occlusion phenomena. If expression takes the form of acute vaso-occlusive crisis, SCD is currently considered to be a chronic systemic pathology, primarily associated with vasculopathy and ischaemia-reperfusion phenomena. The haemolytic aspect of the disease may be associated with endothelial dysfunctional complications, including leg ulcers, which are a classic spontaneous complication of major SCD. Their frequency, all aetiologies combined, varies considerably according to the series under consideration. Hydroxycarbamide has become the standard treatment for some SCD phenotypes, but has classically been described as one of the causes of leg ulcer. This causality is widely debated and is still difficult to establish because it is a specific complication of the disease. Comorbidity factors (eg, iron deficiency) are also often implicated as causal or aggravating factors so research into all the potential aetiologies of leg ulcers in a sickle cell patient must be exhaustive. We discuss the aetiologies of a leg ulcer in a patient treated by hydrocarbamide for major SCD. The imputation of the drug was established, followed by a marrow allograft in this patient.

Correlation between capillaroscopic classifications and severity in systemic sclerosis: results from SCLEROCAP study at inclusion

OBJECTIVES

We assessed the correlation between severity of systemic sclerosis (SSc) and current staging systems based on nailfold capillaroscopy.

METHODS

SCLEROCAP is a multicenter prospective study including consecutive scleroderma patients who have a yearly routine follow-up with capillaroscopy and digital blood pressure measurement. Capillaroscopy images were read by two observers blinded from each other, then by a third one in the case of discordance. A follow-up of 3 years is planned. The present study assessed the correlation between severity of systemic sclerosis (SSc) and current staging systems based on nail fold capillaroscopy at enrollment in the SCLEROCAP study. Univariate and multivariate logistic regression analysis was performed for both the Maricq and Cutolo classifications.

RESULTS

SCLEROCAP included 387 patients in one year. Maricq's active and Cutolo's late classifications were very similar. In multivariate analysis, the number of digital ulcers (OR for 2 ulcers or more, respectively 2.023 [1.074-3.81] and 2.596 [1.434-4.699]) and Rodnan's skin score >15 (OR respectively 32.007 [6.457-158.658] and 18.390 [5.380-62.865]) correlated with Maricq's active and Cutolo's late stages. Haemoglobin rate correlated with Cutolo's late stage (hemoglobin<100 vs. >120 g/dl: OR 0.223 [0.051-0.980]), and total lung capacity with Maricq's active one: increase in 10%: OR0.833 [0.717-0.969].

CONCLUSIONS

The correlations found between capillaroscopy and severity of SSc are promising before the ongoing prospective study definitively assesses whether capillaroscopy staging predicts complications of SSc. Only two capillaroscopic patterns seem useful: one involving many giant capillaries and haemorrhages and the other with severe capillary loss.

French translation and linguistic validation of the Raynaud's condition score

The Raynaud's condition score is a 11-point scale severity score used in Raynaud's phenomenon clinical trials since 1998. The Raynaud's condition score diary has been recommended for use in clinical trials assessing efficacy of interventions on scleroderma related Raynaud's phenomenon. However, this score has never been formally validated in French. We thus performed a translation and a linguistic validation of the Raynaud's condition score through a forward/backward translations process followed by an expert review and cognitive patient interviews. The translations led to a French version of the Raynaud's condition score that was linguistically valid, and conceptually equivalent to the original English version. This "Score de Raynaud" will be usable to perform and harmonize clinical trials in French-speaking patients with secondary Raynaud's phenomenon.

Clinical superiority of an innovative two-component compression system versus four-component compression system in treatment of active venous leg ulcers: A randomized trial

Objective

To evaluate the efficacy, safety and acceptability of an innovative two-component versus a well-established four-component compression systems in the management of venous leg ulcer.

Method

Multicentre randomized controlled trial in patients with active venous leg ulcer. Patients were followed-up monthly for a maximum of 16 weeks. The primary endpoint was the complete healing rate at 16 weeks.

Results

Ninety-two patients were randomized to either the two-component BIFLEX® Kit group ( n = 49) or the four-component PROFORE® group ( n = 43). In the full analysis set ( n = 88), a complete healing rate of 48.9% and 24.4% was reported in BIFLEX® Kit versus PROFORE® groups, respectively (i.e. a superiority of 24.5%, p = 0.02). Acceptability of BIFLEX® Kit was higher from both the patients’ and physicians’ perspectives.

Conclusion

The BIFLEX® Kit represents a valid alternative therapy in the management of venous leg ulcer according to its clinical efficacy, safety and acceptability with potential positive impacts on healthcare costs.

On-Demand Sildenafil as a Treatment for Raynaud Phenomenon: A Series of n-of-1 Trials

BACKGROUND

Treatment of Raynaud phenomenon (RP) with phosphodiesterase-5 inhibitors has shown moderate efficacy. Adverse effects decrease the risk-benefit profile of these drugs, and patients may not be willing to receive long-term treatment. On-demand single doses before or during exposure to cold may be a good alternative.

OBJECTIVE

To assess the efficacy and safety of on-demand sildenafil in RP.

DESIGN

Series of randomized, double-blind, n-of-1 trials. (ClinicalTrials.gov: NCT02050360).

SETTING

Outpatients at a French university hospital.

PARTICIPANTS

Patients with primary or secondary RP.

INTERVENTION

Each trial consisted of a multiple crossover study in a single patient. Repeated blocks of 3 periods of on-demand treatment were evaluated: 1 week of placebo, 1 week of sildenafil at 40 mg per dose, and 1 week of sildenafil at 80 mg per dose, with a maximum of 2 doses daily.

MEASUREMENTS

Raynaud Condition Score (RCS) and frequency and daily duration of attacks. Skin blood flow in response to cooling also was assessed with laser speckle contrast imaging. Mixed-effects models were used and parameters were estimated in a Bayesian framework to determine individual and aggregated efficacy.

RESULTS

38 patients completed 2 to 5 treatment blocks. On the basis of aggregated data, the probability that sildenafil at 40 mg or 80 mg was more effective than placebo was greater than 90% for all outcomes (except for RCS with sildenafil, 80 mg). However, the aggregated effect size was not clinically relevant. Yet, substantial heterogeneity in sildenafil's efficacy was observed among participants, with clinically relevant efficacy in some patients.

LIMITATION

The response to sildenafil was substantially heterogeneous among patients.

CONCLUSION

Despite a high probability that sildenafil is superior to placebo, substantial heterogeneity was observed in patient response and aggregated results did not show that on-demand sildenafil has clinically relevant efficacy. In this context, the use of n-of-1 trials may be an original and relevant approach in RP.

PRIMARY FUNDING SOURCE

GIRCI (Groupement Interrégional de Recherche Clinique et d'Innovation) Auvergne Rhône-Alpes (academic funding) and Pfizer.

Use of Cellutome for the healing of venous or mixed ulcers

Venous or mixed ulcers are common and invalidating. Cutaneous transplants may be necessary if conventional treatment is ineffective. We evaluated the performance of Cellutome in promoting the healing of venous or mixed ulcers 2 months after grafting. This was a retrospective, multi-centric, descriptive study of patients who had a venous or mixed ulcer for at least several months and who received an autologous skin graft using the Cellutome system at least 2 months before. The principle evaluation criterion was the state of the wound after 2 months (completely healed vs not healed). The secondary evaluation criterion was the percentage of wound healing after 2 months. A total of 47 patients were included in the study. The ulcers had evolved over an average of 18 months. The average surface area was 13.37 cm² . After 2 months, the grafts of 26 of 47 patients (55.3%) were completely healed. The grafts of 21 patients (44.6%) were not completely healed but showed an average rate of healing of 51%. Use of the Cellutome system for epidermal transplants promoted complete or improved healing after 2 months for 55.3% of patients with chronic venous or mixed ulcers. The limited data on the rate of healing of conventional transplants in the literature report rates of approximately 50%. The Cellutome system may therefore be of interest as the healing rate is similar to that of conventional techniques, but using a much simpler, painless procedure on an outpatient basis.

Lower-limb Ulcers in Systemic Sclerosis: A Multicentre Retrospective Case-control Study

Lower-limb ulcers in systemic sclerosis patients are rarely reported. The aim of this study was to describe the main causes and outcomes of lower-limb ulcers in systemic sclerosis patients and to assess factors associated with ischaemic causes (arterial disease and/or microvascular impairment). A retrospective, multicentre, case-control study was conducted in 2013 and 2014, including 45 systemic sclerosis patients presenting lower-limb ulcers between 2008 and 2013. The estimated prevalence of lower-limb ulcers among systemic sclerosis patients was 12.8%. Ulcers were related to venous insufficiency in 22 cases (49%), ischaemic causes in 21 (47%) and other causes in 2 (4%). Complete healing was observed in 60% of cases in a mean time of 10.3 months; 59% relapsed during a mean follow-up of 22 months. Ischaemic lower-limb ulcer outcomes were poor, with a 28.6% amputation rate. Logistic-regression multivariate analyses between ischaemic lower-limb ulcer cases and matched systemic sclerosis-controls identified past or concomitant digital ulcer and cutaneous sclerosis of the feet as independent risk factors associated with ischaemic lower-limb ulcers.

Treatment of voluminous and complicated superficial slow-flow vascular malformations with sirolimus (PERFORMUS): protocol for a multicenter phase 2 trial with a randomized observational-phase design

BACKGROUND

Slow-flow superficial vascular malformations (VMs) are rare congenital anomalies that can be responsible for pain and functional impairment. Currently, we have no guidelines for their management, which can involve physical bandages, sclerotherapy, surgery, anti-inflammatory or anti-coagulation drugs or no treatment. The natural history is progressive and worsening. Mammalian target of rapamycin (mTOR) is a serine/threonine kinase that acts as a master switch in cell proliferation, apoptosis, metabolism and angio/lymphangiogenesis. Sirolimus directly inhibits the mTOR pathway, thereby inhibiting cell proliferation and angio/lymphangiogenesis. Case reports and series have reported successful use of sirolimus in children with different types of vascular anomalies, with heterogeneous outcomes.

OBJECTIVE

The objective of this trial is to evaluate the efficacy and safety of sirolimus in children with complicated superficial slow-flow VMs.

METHODS/DESIGN

This French multicenter randomized observational-phase, phase 2 trial aims to include 50 pediatric patients 6 to 18 years old who have slow-flow (lymphatic, venous or lymphatico-venous) voluminous complicated superficial VM. Patients will be followed up for 12 months. All patients will start with an observational period (no treatment). Then at a time randomly selected between month 4 and month 8, they will switch to the experimental period (switch time), when they will receive sirolimus until month 12. Each child will undergo MRI 3 times: at baseline, at the switch time, and at month 12. For both periods (observational and treatment), we will calculate the relative change in volume of the VM divided by the study period duration. This relative change weighted by the study period duration will constitute the primary endpoint. VM will be measured by MRI images, which will be centralized and interpreted by the same radiologist who will be blinded to the study period. Hence, each patient will be his/her own control. Secondary outcomes will include assessment of safety and efficacy by viewing standardized digital photographs and according to the physician, the patient or proxy; impact on quality of life; and evolution of biological makers (coagulation factors, vascular endothelial growth factor, tissue factor).

DISCUSSION

The main benefit of the study will be to resolve uncertainty concerning the efficacy of sirolimus in reducing the volume of VMs and limiting related complications and the safety of the drug in children with slow-flow VMs. This trial design is interesting in these rare conditions because all included patients will have the opportunity to receive the drug and the physician can maintain it after the end of the protocol if is found efficient (which would not be the case in a classical cross-over study).

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02509468 , first received: 28 July 2015. EU Clinical Trials Register EudraCT Number: 2015-001096-43.