High sensitivity, specificity and predictive value of the Connective Tissue Disease Screening Questionnaire among urban African-American women.

The Connective Tissue Disease Screening Questionnaire (CSQ), developed to screen populations for SLE and other CTDs, has been validated in a predominantly Caucasian population with hospital-based controls. We aimed to test the performance characteristics of the CSQ in an urban, predominantly African-American population. The CSQ was administered by interview to women recruited for a study of environmental risk factors and SLE, including 99 cases with SLE validated by medical record review and 202 healthy controls recruited from the community. Overall, 88% of subjects had African heritage, 6% were Hispanic and 4% were non-Hispanic Caucasian. Controls were more likely to report African heritage than cases (91% versus 82%, P = 0.001). Sensitivity for detecting SLE was 88% and specificity was 91%. In this study, where the prevalence of SLE was 33%, predictive value of a positive CSQ was 82% and predictive value of a negative CSQ was 94%. The CSQ has slightly lower sensitivity but greater specificity for SLE in an urban, predominantly African-American population with community-based controls compared with a Caucasian population with hospital-based controls. These results suggest that the CSQ has adequate sensitivity and specificity and could be used in population studies to screen African-American women for SLE.

Aneurysm of the gastroduodenal artery: an unusual cause of obstructive jaundice.

Splanchnic artery aneurysms are among the most infrequent aneurysms that affect the arterial circulation. Aneurysms of the gastroduodenal artery are the rarest splanchnic artery aneurysms, comprising fewer than 10 per cent of all such lesions. The most typical presentations include abdominal pain and acute gastrointestinal bleeding. However, the diagnosis is often missed preoperatively. We report the successful surgical management of a patient with a gastroduodenal artery aneurysm who presented with isolated obstructive jaundice and review the literature on this unusual finding.

Second-look laparoscopy for visceral ischemia facilitated by preinstalled ports.

Much of the information of a second-look laparotomy can be obtained by a second-look laparoscopy. We describe the strategy and technique of installing laparoscopy ports at the end of the primary laparotomy for visceral ischemia to facilitate a second-look laparoscopy in the ensuing 72 hours. The advantages and limitations are illustrated by three cases. The primary advantage appears to be that when second-look laparoscopy can be accomplished at a minimal cost, much of the inhibition to use it is removed. However, more experience is necessary before the procedure can be used to replace laparotomy.

Elevated levels of 6-keto-prostaglandin-F1a from a lower extremity during external pneumatic compression.

The synthesis of either fibrinolytic serine proteases or platelet inhibitory ecosonoids by the intact endothelial cell may limit thrombus development. In a preliminary study from this laboratory, an elevation in the level of 6-Keto-prostaglandin-F1å, the stable metabolite of prostacyclin (PGI2) was demonstrated in femoral vein plasma obtained during surgical treatment from an extremity undergoing external pneumatic compression. Simultaneously, no elevations in thromboxane B2, the stable metabolite of thromboxane A2, were observed. The present study is an inclusive prospective series of 26 patients. A single pneumatic compression stocking was applied to the left limb in patients who underwent an operation under general anesthesia. Base line venous samples (3 milliliters) were obtained from the femoral vein on the experimental side and the control contralateral side, as well as from the upper limb. Additional samples were drawn at 30 and 60 minutes after the onset of compression. Nine samples per patient (234 total) were analyzed for 6-Keto-prostaglandin-F1å by competitive binding radioimmunoassay in duplicate in a single blind manner. Base line values for the upper limb, right leg and left leg were 0.08 + 0.01 nanogram per milliliter; 0.14 + 0.03 nanogram per milliliter, and 0.13 + 0.02 nanogram per milliliter, respectively (no statistical difference). By 60 minutes of compression, control samples increased to 0.40 + 0.07 nanogram per milliliter (right leg) and 0.42 + 0.08 nanogram per milliliter (upper limb) while the experimental leg increased to 0.71 + 0.13 nanogram per milliliter (p less than 0.05 versus right leg, p less than 0.005 versus upper limb). There was no statistical difference at 60 minutes between the men and women.

Endogenous plasminogen activator and venous flow: therapeutic implications.

This study is concerned with the changes in endogenous plasminogen activator (PA), in response to the augmentation of venous blood flow by external pneumatic compression (EPC). EPC was applied to the left leg in ten patients undergoing surgery under general anesthesia. Two-ml samples of venous blood were obtained from the left and right femoral veins and an arm vein at baseline (induction), and then at 30 and 60 min of compression. Ninety samples were analyzed in duplicate in a single blind technique, using an assay specific for PA activity. In the control right arm and leg, PA activity levels increased at 30 min (106% and 110% of baseline, respectively), and then declined to baseline levels by 60 min. These changes did not reach statistical significance. In the leg undergoing compression, however, PA activity decreased progressively, reaching 75% of baseline at 60 min (significant at both 30 [p less than .001] and 60 min [p less than .01] as compared to baseline). In vitro, PA activity varies directly with the concentration of fibrin. The progressive decline in activity in this study may, therefore, represent a decline in substrate (molecular fibrin), as a result of increased venous blood flow. Alterations in the activity of the endothelial cell, as observed, may lead to new approaches in the prophylaxis against thromboembolism.

Reconstruction of veins: the need for objectivity.

The reconstruction of veins is gradually gaining acceptance as a valuable surgical tool in alleviating or ameliorating the disability of venous occlusion in both trauma and post-thrombotic conditions. A study of 169 consecutive cases of venous reconstruction on the vascular service was undertaken in an effort to help (1) identify candidates, (2) select the reconstructive procedure, and (3) analyze the role of the adjuvant arteriovenous fistula. One hundred nineteen procedures were performed in post-phlebitic disease, including fifteen cases of adjuvant arteriovenous fistula, 42 in patients with trauma and the remaining eight were undertaken to rectify venous obstruction resulting from extrinsic pathology. While the clinical results appear promising, objectivity in the evaluation of venous reconstruction with phlebograms and pressure studies is greatly needed before definitive conclusions can be drawn.

Superficial thrombophlebitis of lower limbs.

In the absence of malignancy, thrombophlebitis of the lower limb is invariably associated with pre-existent varicose veins. Not until pulmonary embolism was reported to occur in superficial phlebitis did the clinician introduce anticoagulants and/or surgery in the management of this condition. In an effort to reach an effective approach to this problem, 1,000 consecutive cases of varicose veins of the lower limbs were reviewed. Of these patients, 779 were admitted for elective vein ligation and stripping and 221 presented with thrombophlebitis. The latter group was subdivided into four categories according to the mode of management: (1) local heat and anti-inflammatory agents, 60 cases; (2) anticoagulants, 22 cases; (3) phlebotomy, high saphenous ligation and anticoagulation, 4 cases; and (4) ligation and stripping, 135 cases. In category 4 the saphenous is removed in a routine fashion together wih all its tributaries. All perforators are exposed, evacuated of thrombus when present, and ligated subfascially. Thrombi were encountered in one or more perforating veins in 10 patients, but no pulmonary embolism was observed in this group of patients. All instances of documented pulmonary embolism (10 cases) occurred in category 1 with one fatality. The incidence of pulmonary embolism in the elective group of ligation and stripping (without phlebitis) was 0.5%. The data indicate that the surgical approach is safe and preferable to the other modalities for several reasons: (1) It eliminates the varicosities and the phlebitic process simultaneously, (2) a single hospitalization is necessary (cost effectiveness), and (3) no anticoagulants are needed. If, for any reason, surgery cannot be undertaken, then anticoagulants should be employed in an effort to avoid thromboembolism.