Michèle Depairon

Clinical prediction of deep venous thrombosis using two risk assessment methods in combination with rapid quantitative D-dimer testing

PURPOSE The optimal approach to diagnosing deep venous thrombosis is not entirely clear. In this prospective cohort study, we aimed to evaluate the yield of two methods of assessing the pretest probability of deep venous thrombosis-the treating physicians implicit assessment and the Wells score, a validated prediction rule that incorporates signs, symptoms, and the presence or absence of an alternative diagnosis-used in isolation and in combination with D-dimer measurement. SUBJECTS AND METHODS We studied 278 patients who were referred for suspicion of deep venous thrombosis. All patients were stratified into groups of low, moderate, or high risk of deep venous thrombosis on the basis of the clinical assessment and Wells score, and underwent rapid quantitative D-dimer testing (with a cutoff of 500 microg/mL), ultrasound examination, and follow-up for the occurrence of venous thromboembolism. RESULTS Eighty-two patients (29%) had a deep venous thrombosis. The accuracy of both methods was good (area under the receiver operating characteristic curve = 0.72), despite only fair agreement at the level of individual patients (weighted kappa = 0.31; 95% confidence interval [CI]: 0.23 to 0.40). The negative predictive value of D-dimer measurement was 96% (95% CI: 91% to 100%). When restricted to patients with low pretest probability, the negative predictive value of D-dimer measurement was 100% (95% CI: 96% to 100%) with the use of the Wells score and 96% (95% CI: 88% to 100%) with the physicians assessment. Our results were unchanged in analyses restricted to patients with proximal deep venous thrombosis or outpatients. CONCLUSION Clinical assessment to stratify a patients likelihood of having deep venous thrombosis should be taught to physicians.

Associations Between Cardiovascular Risk Factors, Inflammation, and Progression of Carotid Atherosclerosis Among Smokers.

INTRODUCTION The high risk of cardiovascular events in smokers requires adequate control of other cardiovascular risk factors (CVRFs) to curtail atherosclerosis progression. However, it is unclear which CVRFs have the most influence on atherosclerosis progression in smokers. METHODS In 260 smokers aged 40-70 included in a smoking cessation trial, we analyzed the association between traditional CVRFs, high-sensitivity C-reactive protein (hs-CRP), smoking cessation and 3-year progression of carotid intima-media thickness (CIMT, assessed by repeated ultrasound measurements) in a longitudinal multivariate model. RESULTS Participants (mean age 52 years, 47% women) had a mean smoking duration of 32 years with a median daily consumption of 20 cigarettes. Baseline CIMT was 1185 μm (95% confidence interval [CI]: 1082-1287) and increased by 93 μm (95% CI: 25-161) and 108 μm (95% CI: 33-183) after 1 and 3 years, respectively. Age, male sex, daily cigarette consumption, systolic blood pressure (SBP), but neither low-density lipoprotein cholesterol nor hs-CRP, were independently associated with baseline CIMT (all P ≤ .05). Baseline SBP, but neither low-density lipoprotein cholesterol nor hs-CRP, was associated with 3-year atherosclerosis progression (P = .01 at 3 years). The higher the SBP at baseline, the steeper was the CIMT increase over 3-year follow-up. We found an increase of 26 μm per each 10-mmHg raise in SBP at 1 year and an increase of 39 μm per each 10 mmHg raise in SBP at 3 years. Due to insufficient statistical power, we could not exclude an effect of smoking abstinence on CIMT progression. CONCLUSION Control of blood pressure may be an important factor to limit atherosclerosis progression in smokers, besides support for smoking cessation. IMPLICATIONS Among 260 smokers aged 40-70 years with a mean smoking duration of 32 years, baseline SBP was associated with atherosclerosis progression over 3 years, as measured by CIMT (P = .01 at 3 years), independently of smoking variables and other CVRFs. The higher the SBP at baseline, the steeper was the CIMT increase over 3-year follow-up. Our findings emphasize the importance of focusing not only on smoking cessation among smokers, but to simultaneously control other CVRFs, particularly blood pressure, in order to prevent future cardiovascular disease.

The Atherosclerosis Burden Score (ABS): a Convenient Ultrasound-Based Score of Peripheral Atherosclerosis for Coronary Artery Disease Prediction

Ultrasonographic detection of subclinical atherosclerosis improves cardiovascular risk stratification, but uncertainty persists about the most discriminative method to apply. In this study, we found that the “atherosclerosis burden score (ABS)”, a novel straightforward ultrasonographic score that sums the number of carotid and femoral arterial bifurcations with plaques, significantly outperformed common carotid intima-media thickness, carotid mean/maximal thickness, and carotid/femoral plaque scores for the detection of coronary artery disease (CAD) (receiver operating characteristic (ROC) curve area under the curve (AUC) = 0.79; P = 0.027 to <0.001 with the other five US endpoints) in 203 patients undergoing coronary angiography. ABS was also more correlated with CAD extension (R = 0.55; P < 0.001). Furthermore, in a second group of 1128 patients without cardiovascular disease, ABS was weakly correlated with the European Society of Cardiology chart risk categories (R2 = 0.21), indicating that ABS provided information beyond usual cardiovascular risk factor-based risk stratification. Pending prospective studies on hard cardiovascular endpoints, ABS appears as a promising tool in primary prevention.

Impact of thyroid hormone therapy on atherosclerosis in the elderly with subclinical hypothyroidism: a randomized trial

Context Subclinical hypothyroidism (SHypo) has been associated with atherosclerosis, but no conclusive clinical trials assessing the levothyroxine impact on carotid atherosclerosis exist. Objective To assess the impact of treatment of SHypo with levothyroxine on carotid atherosclerosis. Design and Setting Randomized, double-blind, placebo-controlled trial nested within the Thyroid Hormone Replacement for Subclinical Hypothyroidism trial. Participants Participants aged ≥65 years with SHypo [thyroid-stimulating hormone (TSH), 4.60 to 19.99 mIU/L; free thyroxine level within reference range]. Intervention Levothyroxine dose-titrated to achieve TSH normalization or placebo, including mock titrations. Main Outcome Measures Carotid intima media thickness (CIMT), maximum plaque thickness measured with ultrasound. Results One hundred eighty-five participants (mean age 74.1 years, 47% women, 96 randomized to levothyroxine) underwent carotid ultrasound. Overall mean TSH ± SD was 6.35 ± 1.95 mIU/L at baseline and decreased to 3.55 ± 2.14 mIU/L with levothyroxine compared with 5.29 ± 2.21 mIU/L with placebo (P < 0.001). After a median treatment of 18.4 months (interquartile range 12.2 to 30.0 months), mean CIMT was 0.85 ± 0.14 mm under levothyroxine and 0.82 ± 0.13 mm under placebo [between-group difference = 0.02 mm; 95% CI, -0.01 to 0.06; P = 0.30]. The proportion of carotid plaque was similar (n = 135; 70.8% under levothyroxine and 75.3% under placebo; P = 0.46). Maximum carotid plaque thickness was 2.38 ± 0.92 mm under levothyroxine and 2.37 ± 0.91 mm under placebo (between-group difference -0.03; 95% CI, -0.34 to 0.29; P = 0.86). There were no significant interactions between levothyroxine treatment and mean CIMT, according to sex, baseline TSH (categories 4.6 to 6.9, 7.0 to 9.9, and ≥10 mIU/L), or established cardiovascular disease (all P for interaction ≥ 0.14). Conclusion Normalization of TSH with levothyroxine was associated with no difference in CIMT and carotid atherosclerosis in older persons with SHypo.

Le lipœdème, cet inconnu

Lipedema, the Unknown Abstract. Lipoedema patients suffer from the widespread ignorance of their pathology. Considering its chronic, progressive and invalidating character, the early diagnosis of the disease must constitute the challenge of their caregivers in order to limit medical wanderings and the occurrence of complex clinical pictures. Treatments allow the reduction of lipedema and its long-term control. Management must be individualized according to the stage of the disease. The adherence of the patient, the supervision and the support of the practitioner are essential for obtaining the best results.

Diagnose und Behandlung des Lymphödems

Das Lymphodem ist eine wenig be- und anerkannte chronische und behindernde Krankheit und wirkt sich, je nach Auspragung, vielfaltig auf das Privat-, Familien-, Berufs- und Sozialleben des Patienten aus. Es existiert zwar keine kurative Behandlung des Lymphodems, es lasst sich jedoch mit einer komplexen physikalischen Entstauungstherapie wirksam behandeln.