Diagnosis of venous thrombosis in the legs using 81Krm venography

Contrast venography, the accepted gold standard for the diagnosis of venous thrombosis of the leg, is a painful and invasive procedure with late side effects. There is controversy in literature reports about the sensitivity of 99Tcm-macroaggregated albumin (MAA) phlebography: indeed, using 99Tcm-MAA, poor results are obtained when one has to detect calf vein thrombosis. As with other isotopic procedures requiring a pedal injection of the tracer, the use of an injectable solution of 81Krm is a nonspecific method, based upon the abnormality in flow in the deep venous system which results from a deep venous thrombosis. However, when compared with 99Tcm-MAA, 81Krm offers theoretical advantages for phlebographic studies of the lower limbs. In this work 24 patients were studied both with contrast phlebography and with 81Krm. Although 81Krm provided images of high quality, there was a lack of sensitivity below the knee, where false negative results were observed. This could be explained by the fact that the radionuclide venographic procedures usually visualize only one or, in some cases, two of the three deep veins of the calf. Moreover, accurate differentiation between superficial and deep veins in the calf often appears difficult, even using a tourniquet.     

Role of MR venography in the evaluation of deep venous thrombosis

INTRODUCTION: Oral NSAIDs cause acute gastric injury that resolves, despite continued administration, by a process known as adaptation. Little is known about the factors that influence this process. METHODS: Sixty-two healthy volunteers were given a 28-day course of either etodolac 300 mg b.d. (13 subjects), naproxen 500 mg b.d. (23), enteric-coated diclofenac (10) or effervescent diclofenac 50 mg b.d. (16). All subjects were gastroscoped before and on days 1, 7 and 28 during drug administration, to assess gastric mucosal damage using a modified Lanza scale. Subjects were then divided into three categories: those who adapted completely, those who adapted incompletely and those who showed no adaptation. The proportion of subjects in each group was compared with respect to age, gender, smoking, the presence of Helicobacter pylori, and the NSAID prescribed. RESULTS: Fifty-nine subjects (median age 25.0 years, range 18-70) developed initial gastric injury to NSAIDs of whom 42 adapted completely, 13 adapted incompletely and four showed no evidence of adaptation. The mean age of subjects was lower in those who adapted (26.8 +/- 9.8 years) than those who adapted incompletely (32.5 +/- 10.3 years) and those who did not adapt (42.0 +/- 15.7 years, P = 0.01). There was no evidence of gender influencing adaptation. Of 17 H. pylori-positive subjects, a higher proportion had incomplete adaptation, with only nine subjects adapting completely (53% vs. 81%, P = 0.04). Sixteen subjects were smokers, of whom a greater proportion showed no evidence of adaptation (19% vs. 2%, P = 0.03). A smaller proportion of those who took naproxen (48%) adapted completely than those who took enteric-coated diclofenac (89%), effervescent diclofenac (75%) or etodolac (91%, P = 0.03). CONCLUSION: Some adaptation occurred in over 90% of subjects after 4 weeks dosing with an NSAID, but adaptation was less frequent in older subjects and in smokers. Complete adaptation occurred less frequently in H. pylori-positive subjects and in those who were given naproxen.     

The role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism

This paper describes the role of venous ultrasonography in the diagnosis of suspected deep venous thrombosis and pulmonary embolism. Inability to compress the common femoral or popliteal vein is usually diagnostic of a first episode of deep venous thrombosis in symptomatic patients (positive predictive value of about 97%). Full compressibility of both of these sites excludes proximal deep venous thrombosis in symptomatic patients (negative predictive value of about 98%). In patients with suspected deep venous thrombosis or in those who present with suspected pulmonary embolism but have a nondiagnostic lung scan, the subsequent risk for symptomatic venous thromboembolism is very low (<2% during 6 months of follow-up) provided that ultrasonography of the proximal veins remains normal in the course of 1 week (suspected deep venous thrombosis) or 2 weeks (suspected pulmonary embolism). Anticoagulation and further diagnostic testing can usually be safely withheld in these situations. Venous ultrasonography is much less reliable for the diagnosis of asymptomatic, isolated distal, and recurrent deep venous thrombosis than for the diagnosis of a first episode of proximal deep venous thrombosis in symptomatic patients. Clinical evaluation of the probability of deep venous thrombosis or pulmonary embolism, preferably by using a validated clinical model, complements venous ultrasonographic findings and helps to identify patients who would benefit from additional (often invasive) diagnostic testing. Thus, venous ultrasonography is thought to be a very valuable test for the diagnosis and management of patients with suspected deep venous thrombosis or pulmonary embolism.     

Radioiodine-fibrinogen test in the early diagnosis of venous thrombosis in the leg (author's transl)

As long as there is no satisfactory prophylaxis for thrombosis, the radioiodine-fibrinogen test is a good supplement for the supervision of patients with a "high thrombosis risk" since the clinical symptomatology is not specific enough and phlebography cannot be used to extensively. The risk of hepatitis can be reduced when the selection of spenders is large enough. As a radionuclide, 125iodine does not appear to be any less effective than 131iodine. The postoperative injection is preferred to the preoperative injection.     

Interaction between oral contraceptive use and coagulation factor levels in deep venous thrombosis

Deep venous thrombosis is a multicausal disease, i.e. more than one risk factor needs to be present to cause the disease. Oral contraceptive use increases the risk of venous thrombosis but since not all women using oral contraceptives develop thrombosis, the presence of additional risk factors in patients is likely. The aim of this study was to assess the joint effect of oral contraceptive use and the levels of procoagulant factors (F)(FII, FV, FVII, FVIII, FIX, FX, FXI, FXII, FXIII and fibrinogen). Data of premenopausal women were re-analyzed in the Leiden Thrombophilia Study. The highest relative risks were observed for the combination of oral contraceptive use and high levels (>90th percentile) of FII (Odds Ratio [OR]OC+FII 10.1; 95% confidence interval [CI] 3.5-29.0), FV (OROC+FV 12.6; 95% CI 3.8-41.5), and FXI (OROC+FXI 11.9; 95% CI 3.6-39.2) and low levels (< 10th percentile) of FXII (OROC+FXII 12.3; 95% CI 2.4-63.0). No interaction was observed between oral contraceptive use and high levels of the other coagulation factors, i.e. the joint effect of these risk factors did not exceed the sum of the separate effects. The results of this study indicate that the risk for the joint effects of oral contraceptive use and coagulation factor levels are minor compared with the joint effect of oral contraceptive use and the FV Leiden mutation (RR > 30).     

Filling and emptying characteristics of lower limb venous network in athletes. Study by postural plethysmography

Neuropathic foot ulcers, a serious complication of impaired pedal sensation, are the most common complication of diabetes mellitus leading to hospitalization. One of the goals in treating neuropathic ulcers is to reduce or eliminate pressure from the ulcer site to prevent further breakdown and allow healing. These treatments must address several forms of stress-vertical pressure, shearing force, and tissue strain. This paper reviews several techniques for off-weighting plantar ulcers and describes and recommends the felt-to-foam contact padding technique used at the Northern California Center for the Diabetic and Insensitive Foot and the California College of Podiatric Medicine.     

A rational approach to detection of significant reflux with duplex Doppler scanning and air plethysmography

PURPOSE: Several techniques are currently available for the detection of venous reflux. We have attempted to determine the relative value and accuracy of available techniques to develop a logical strategy of investigation in reflux venous insufficiency. METHODS: The morphologic distribution of venous incompetence (erect duplex and descending venography); the results of ambulatory venous pressure measurement, venous refilling time, the Valsalva test, and air-plethysmography (venous refilling index, VFI); and the clinical severity were described in 118 consecutive limbs. In an attempt to validate the tests, results were correlated with the clinical severity classification (class 0, n = 34; class 1, n = 42; class 2, n = 11; class 3, n = 31) and with a standardized quantification of reflux (multisegment score) as seen on standing duplex Doppler scanning with rapid deflation cuffs. RESULTS: Twenty-nine percent of limbs with severe venous disease (class 2/3) had pure deep insufficiency, only 6% had pure superficial disease, and the remainder had a combination. A history of previous thrombosis and the presence of posterior tibial vein incompetence were markedly common with ulcer disease (84% and 42%, respectively). The duplex Doppler multisegment score correlated strongly with clinical severity classification (r = 0.97). The venous refilling time and VFI had the highest sensitivity in identifying severe venous disease (class 2/3), and the ambulatory venous pressure had excellent specificity. CONCLUSIONS: For noninvasive determination of reflux, the combination of VFI and duplex scanning not only localized reflux but also separated severe clinical vein disease from mild, with high sensitivity and specificity. Air plethysmography may also provide valuable information regarding calf muscle pump and outflow obstruction.     

With regard to "The role of air plethysmography in monitoring results of venous surgery"

By homology to the mgt gene (encoding a macrolide glycosyltransferase) from Streptomyces lividans, a 3.3-kb DNA fragment from the oleandomycin producer, Streptomyces antibioticus, was cloned and sequenced. Analysis of the sequence revealed the presence of the 3' end of a gene (ORF1) and two complete ORFs (ORF2 and oleD), all of them translationally coupled. The deduced product of the sequenced region of ORF1 contained the typical signature of integral membrane proteins responsible for the translocation of substrates across the membrane. The ORF2 product did not show significant similarity with proteins in databases, but contains an N-terminus leader peptide region characteristic of secreted proteins, and a lipid attachment site motif characteristic of membrane lipoproteins synthesized with a precursor signal peptide. The oleD product showed clear similarity with several UDP-glucuronosyl- and UDP-glycosyl-transferases from different origins and particularly with the mgt gene from S. lividans, and might encode a glycosyltransferase activity capable of inactivating macrolides. It is proposed that these three genes could participate in the intracellular glycosylation of oleandomycin and its secretion during antibiotic production.     

Mechanical thrombectomy in acute and subacute thrombosis with use of the Amplatz device: arterial and venous applications

PURPOSE: To perform a feasibility study of the Amplatz Thrombectomy Device (ATD) in a variety of vascular territories with acute or subacute thrombosis. MATERIALS AND METHODS: Thirteen patients (mean age, 44.6 years) with multiple risk factors who had acute/subacute thrombosis of the inferior vena cava (IVC) and iliac veins (n = 3), superior vena cava (SVC) and/or subclavian veins (n = 3), lower extremity polytetrafluoroethylene (PTFE) graft (n = 2), iliac artery (n = 2), portal vein and transjugular intrahepatic portosystemic shunt (TIPS) (n = 2), and an IVC to pulmonary artery Fontan conduit (n = 1), were treated by means of mechanical thrombectomy with use of the ATD. Thrombolysis failed to recanalize the vessels when used before thrombectomy for 12-34 hours in three patients, and was contraindicated in three other patients. Thrombolysis was used as a complement to the ATD procedure in five patients. RESULTS: Technical success was achieved in 11 patients, and procedure success was achieved in 10 patients. Failure was observed in the remaining three patients. One patient with a PTFE graft was successfully declotted but thrombosis occurred 2 weeks later, requiring surgery. The other patient with a PTFE graft did not improve and needed surgery to declot and treat the distal anastomosis and distal circulation. The two patients with an occluded iliac artery underwent successful declotting but rethrombosis occurred in one shortly after the procedure requiring thrombolytic therapy. One patient with TIPS thrombosis improved and another patient with a thrombosed portal vein did not improve after thrombectomy. CONCLUSION: The ATD is useful for recanalization of acute/subacute clotted native vessels and grafts. The application of the device is broad, and although declotting can be achieved in most cases, long-term success may be limited by anatomical and technical problems of the grafts and multifactorial clinical problems of severely sick patients, as was the case in the series. The use of additional thrombolytic therapy may be necessary in a number of patients.     

Temporality in human action: An alternative to positivism and historicism.

Examines 2 explanatory systems—positivism and historicism—that characterize current psychology. Positivism achieves certainty through atemporal causality as borrowed from the natural sciences, whereas historicism rejects this notion of causality but retains the traditional notion of the atemporal nature of certainty. It is contended that these 2 views, because of their common conception of atemporality as the foundation of certainty and their conflation of intelligibility with certainty, are founded on the same metaphysical ground. It is argued that a genuine alternative to the shared problems of positivism and historicism must begin with a radical departure from the received view of lineal time. Based on the works of M. Heidegger (1962) and H-G. Gadamer (1975), it is suggested that intelligibility in the human world is possible without atemporal causality and that temporality is the proper and productive grounding for the human sciences. (47 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Medical treatment of deep venous thrombosis. Therapeutic measures in the acute stage

Serum zinc and copper levels were determined in 28 beta-thalassaemia and 15 sickle cell anaemia (SCA) patients of 3-10 years of age using atomic absorption spectrophotometry. The results were compared with 25 age-matched controls. Copper levels were significantly increased in beta-thalassaemia and sickle cell anaemia. Zinc levels were significantly increased in beta-thalassaemia but significantly decreased in SCA. The data suggest the occurrence of impaired kidney function and disturbance in the metabolism of zinc and copper in these patients.     

The professional option: An alternative to graduate work in psychology.

Discusses the organization of a 4-yr preprofessional curriculum for psychology majors, to offer undergraduate training and help students obtain full-time employment after graduation. Curriculum planning was based on 2 surveys of local business and social service organizations. Results indicate that a BA in psychology was of little help in obtaining work unless field experience supplemented classroom instruction. Specific skills and theoretical knowledge were considered less desirable in prospective employees than facility in personal relations. These findings were of central importance in making recommendations for restructuring the undergraduate curriculum. Suggestions for APA action in this area are outlined. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Nasoenteral tube feeding in hyperemesis gravidarum. An alternative to parenteral nutrition

A severe form of hyperemesis gravidarum involving maternal weight loss greater than 5% of the prepregnant weight occurs in up to 0.1-0.2% of all pregnancies and may lead to retarded foetal growth. Treatment consists of hospitalisation, antiemetics and correction of fluid and electrolyte deficiencies. If severe vomiting and weight loss continues, the mother must receive supplementary nutrition, usually parenteral. Nasoenteral tube feeding is a well documented method of nutrition for other patients. A gastroscopically placed nasojejunal tube as part of the treatment of hyperemesis gravidarum has not been reviewed before. Seven women with severe hyperemesis gravidarum were treated with nasojejunal tube feeding. The tube was positioned gastroscopically. Enteral feeding continued for up to 41 days, leading to reasonable weight gain. The tube was tolerated well by most patients and no serious adverse effects were seen. Nasoenteral nutrition ought to be considered as an alternative to parenteral nutrition for treatment of hyperemesis gravidarum.     

Validation of air plethysmography, photoplethysmography, and duplex ultrasonography in the evaluation of severe venous stasis

PURPOSE: The purpose of this study was to validate the diagnostic capabilities of the most commonly used noninvasive modalities for evaluation of chronic venous insufficiency. METHODS: Twenty limbs in 20 patients were studied with air plethysmography (APG), photoplethysmography (PPG), and duplex ultrasonography. Ten limbs (group 1) were clinically without any venous disease. Group 2 consisted of 10 limbs with severe, class 3 venous stasis. Duplex ultrasonography, complemented with Doppler color-flow imaging was used to examine the superficial and deep venous systems to identify reflux. RESULTS: Ultrasonography identified deep venous reflux in eight of 10 limbs in group 2. Severe superficial reflux was identified in the two remaining limbs. Seven limbs with deep reflux also demonstrated severe superficial reflux. Superficial venous reflux was identified in one leg in group 1. APG accurately separated normal limbs from those with reflux. Parameters that were significantly different (p < 0.05) between the two groups were the venous filling index, (group 1 = 1.37 +/- 1.16 ml/sec, group 2 = 29.5 +/- 6.2 ml/sec.), venous volume (group 1 = 107 +/- 10.1 ml, group 2 = 220 +/- 22.5 ml), ejection fraction (group 1 = 52.5% +/- 2.3%, group 2 = 32.5% +2- 4.6%), and residual volume fraction (group 1 = 21.4 +/- 2.0%, group 2 = 52.1% +/- 2.5%). PPG refill times were significantly shortened in group 2 versus those of group 1 (6.4 +/- 0.89 sec vs 20.2 +/- 1.1 sec). The sensitivity of PPG refill times to identify reflux was 100%, but the specificity was only 60%, whereas the sensitivity and specificity for the residual volume fraction was 100%. The venous filling index was able to identify reflux and determine whether only superficial reflux was present with a sensitivity of 100% and a specificity of 90%. The kappa coefficient of agreement between duplex scanning and APG was 0.83, whereas between duplex and PPG it was only 0.47. CONCLUSION: APG accurately identifies limbs with and without venous reflux when compared with duplex ultrasonography. APG is a better method of evaluating clinically significant venous reflux than PPG. PPG is a sensitive method of detecting reflux, but the specificity is poor, and PPG refill times cannot accurately predict the location of reflux. The combination of APG and duplex ultrasonography provides the best means of assessing venous reflux.     

An internalizing pathway to alcohol use and disorder.

Research emanating from the field of developmental science indicates that initial risk factors for alcohol use and disorder can be evident in early childhood. One dominant developmental pathway connecting these initial risk factors with subsequent alcohol involvement focuses on the central role of disinhibited or externalizing behaviors. In the current paper, we delineate a second pathway that focuses on internalizing symptomatology. Several studies indicate that internalizing symptoms in early and middle childhood predict alcohol involvement in adolescence and young adulthood. We use a developmental psychopathology framework to describe a risk model that traces the potential developmental markers of this internalizing pathway and to consider the relation between the internalizing pathway and the more widely researched externalizing pathway. We outline the markers of risk in this pathway and conclude with a discussion of the implications of this model for prevention efforts and future research. In this manner, we strive for a translational goal, linking our existing understanding of internalizing processes and alcohol use and disorder with our efforts to develop effective prevention programs. (PsycINFO Database Record (c) 2011 APA, all rights reserved)