Upper extremity venous thrombosis diagnosed by duplex scanning.

The incidence of axillary-subclavian venous thrombosis continues to rise, while reports of noninvasive methods to diagnose this condition have been sparse. A review of the records of 693 consecutive upper extremity duplex scans was performed, and a diagnosis of acute venous thrombosis was made in 123 of these patients. Of these, 85 involved the axillary or subclavian vein. Use of a central venous catheter was the most common risk factor for axillary-subclavian venous thrombosis. Within this group, 8% had a pulmonary embolism, of which 25% were fatal. Follow-up of patients with axillary-subclavian venous thrombosis at a mean of 2 years revealed that 49% of these patients had died. Of the remaining patients, more than one third had evidence of the post-thrombotic syndrome. Duplex scanning of the venous system provides a safe, reliable, and repeatable method of evaluating and following patients with suspected venous thrombosis of the upper extremity.

Confirmation of cervical neoplasia using a hand-held, lighted magnification device.

OBJECTIVES: The objective of this study was to estimate the sensitivity and specificity of visual inspection with acetic acid and magnification (VIAM) using the AviScope device to confirm high-grade cervical intraepithelial neoplasia or carcinoma. METHODS: VIAM was performed on 142 women aged 18-50 years referred to three colposcopy clinics because of abnormal cervical cytology. Each woman then had a colposcopic examination with cervical biopsy when indicated. RESULTS: The AviScope device identified 24 of the 40 women who had CIN 2, 3, or carcinoma, yielding a sensitivity of 60.0% (95% CI 43.4, 74.7). The AviScope correctly identified 60 of 87 women negative for dysplasia or cancer, yielding a specificity of 69.0% (95% CI 58.0, 78.2) compared with colposcopy and cervical histology. CONCLUSION: VIAM using the AviScope device was moderately sensitive and specific for the confirmation of high-grade cervical lesions in women referred with abnormal cervical cytology.

Patterns of late embryonic and fetal mortality and association with several factors in sheep.

Embryonic and fetal mortality reduce lambing rates and litter sizes, thus contributing to economic losses in the sheep industry. In the current study, the timing of late embryonic and fetal loss in ewes and the factors with which these losses were associated were examined. Ewes lambing and lambs born were compared with pregnancy diagnosis and counts of embryos by ultrasonography near d 25, 45, 65, or 85 of gestation. Approximately 19.9% of the ewes experienced late embryonic loss, fetal loss, or both; and 21.2% of the embryos or fetuses were lost from d 25 to term. Potential offspring were lost throughout gestation; 3.7% of embryos from d 25 to 45, 4.3% of fetuses from d 45 to 65, 3.3% from d 65 to 85, and 11.5% from d 85 to parturition; thus, approximately 3 to 4% of the potential offspring were lost for each 20-d period of pregnancy beyond d 25. A greater proportion of ewes lost one (36.7%) rather than all (20.5% single; 3.8% multiple) embryos or fetuses. The patterns of loss were similar in ewes mated during the anestrous season and the transitional period and did not vary with service period within breeding season or method of synchronization of estrus. Late embryonic or fetal losses were not related to the temperature-humidity index. Maternal serum collected near d 25, 45, 65, or 85 of gestation was assayed for concentrations of progesterone, estradiol-17beta , and vascular endothelial growth factor (VEGF). The proportions of embryos or fetuses lost were associated with breed type (P < 0.05), as were concentrations of progesterone (P < 0.01), estradiol (P < 0.05), and VEGF (P < 0.01). The relationships of loss or retention of pregnancy to hormonal variables at the 4 stages studied were limited. Complete and partial losses increased rapidly as maternal progesterone at d 25 decreased below 2 ng/mL (P < 0.05). Survival of fetuses within a litter from d 25 to 65 was greater for ewes with medium concentrations of VEGF near d 25 and from d 65 to parturition was greater for ewes with high concentrations of VEGF near d 45 (P < 0.05). In summary, late embryonic or fetal losses occurred from d 25 throughout gestation and varied with breed type and with concentrations of progesterone in maternal serum on d 25.

Vascular laboratory personnel on-call: effect on patient management.

PURPOSE: A prospective study was undertaken of all vascular laboratory tests performed by the "on-call" technologist during a 3-year time period. METHODS: Technologists take call on a rotating basis. All patients evaluated had symptoms. History and risk factor data were collected at the time of patient encounter. RESULTS: Studies were initiated from the emergency department 56% of the time, from inpatient examinations 33% of the time, and from outpatient examinations 11% of the time. Ninety percent (n = 440) of the studies obtained were venous duplex scans (VDS). Fifty-eight percent (257 of 440) of the studies were performed on weekends. Thirty-two percent of the studies resulted in admission of the patient. Of the 440 VDS obtained, 51% (224 of 440) identified some type of disease. Acute deep venous thrombosis (DVT) was diagnosed in 15% (67 of 440), acute superficial venous thrombosis (SVT) in 4% (17 of 440), acute DVT and SVT in 7% (31 of 440), chronic DVT in 4% (17 of 440), chronic SVT in 4% (16 of 440), and chronic DVT and SVT in 1% (3 of 440); 2% (9 of 440) of the DVTs were of indeterminate age. Other diseases were identified in 22% (95 of 440), including popliteal cysts, inguinal lymphadenopathy, and soft tissue edema. CONCLUSIONS: Having an "on-call" vascular technologist has allowed patients with acute venous thrombosis to be triaged and admitted, if necessary, in a timely fashion. Those patients who have symptoms and a negative VDS result are able to avoid unnecessary hospitalization and treatment. The expense of this service is easily justified by the savings of unnecessary hospital days.

When the morning after is Sunday: pharmacist prescribing of emergency contraceptive pills.

Pharmacists are well positioned to play a major role in increasing access to emergency contraceptive pills (ECPs). A pilot project in Washington State is testing direct pharmacist prescribing. Through a collaborative drug therapy agreement, a licensed prescriber, such as a physician, delegates to a pharmacist the authority to prescribe ECPs directly to women who meet the assessment criteria. Currently pharmacists at 111 Washington State pharmacies have collaborative agreements in place, and the number of participating pharmacies continues to increase. The response to this initiative has been extremely positive. Women who have received ECPs directly from pharmacists rate their interactions with the pharmacists positively and overwhelmingly cite convenience as the primary reason for going directly to the pharmacy. Physicians and other providers with independent prescribing authority can play a pivotal role by working with pharmacists to replicate the Washington State initiative in the states that allow it.

Using pharmacies in Washington state to expand access to emergency contraception.

PIP: The authors describe preliminary results from a 2-year demonstration project launched in July 1997 in Washington State to expand access to emergency contraceptive pills by promoting collaboration between pharmacists and independent prescribers in providing emergency contraception (EC). The project was undertaken to improve women's awareness and use of emergency contraception by using pharmacists to increase the availability of such contraceptive products. The authors also discuss the impact that the pills is having upon access to emergency contraception, and therefore the potential impact of the program upon rates of unintended pregnancy. Key components of the project include teaching pharmacists about emergency contraception, helping them link up with prescribers, informing women about the availability of emergency contraception, and evaluating the impact of the project. In the 4 months following the project's launch, the national emergency contraception hotline received 4934 calls from Washington State. Before the launch, the hotline averaged 100 calls per month from the state. Over the same period, area pharmacists at 111 participating pharmacies wrote and filled 2765 prescriptions for emergency contraception. The preliminary response to the project has been extremely positive.^ieng

Upper extremity hemodynamic changes after radial artery harvest for coronary artery bypass grafting.

Twenty-seven patients were studied with arterial duplex, photoplethysmography, segmental pressures, and pulse volume recordings both preoperatively and following radial artery harvesting. The average number of days to the follow-up visit was 66. Preoperative and postoperative data were compared using the matched Student's t-test. There were no significant changes between preoperative and postoperative pressures in the brachial, radial, and ulnar arteries, and thumb, index, long, ring, or little fingers. Pressure changes in the thumb and index finger approached but did not achieve a statistical difference. Peak systolic velocity (PSV), end diastolic velocity (EDV), and resistive index (RI) in the distal ulnar artery changed significantly between preoperative and postoperative measurements. PSV changed from 0.50 +/- 0.05 m/sec to 0.67 +/- 0.04 m/sec (p = 0.02); EDV changed from 0.03 +/- 0.03 m/sec to -0.10 +/- 0.05 m/sec (p = 0.05); and RI changed from 0.97 +/- 0. 05 to 1.13 +/- 0.05 (p = 0.02). Palmar arch evaluations revealed significant changes at rest and with ulnar compression between preoperative and postoperative measurements: (1) at rest EDV changed from 0.03 +/- 0.02 m/sec to -0.05 +/- 0.02 m/sec (p < 0.01); (2) at rest RI changed from 0.96 +/- 0.05 to 1.12 +/- 0.05 (p = 0.01); (3) with ulnar compression the PSV changed from 0.23 +/- 0.05 m/sec to 0. 005 +/- 0.01 m/sec (p < 0.01); and (4) with ulnar compression the RI changed from 0.82 +/- 0.11 to 0.27 +/- 0.12 (p < 0.01). Eight patients had a variety of complaints at the follow-up visit, the majority being numbness and tingling. No patients reported symptoms of claudication or rest pain at the follow-up visit. The data suggest that while statistically significant changes in velocity and arterial resistance do occur, patients seem to tolerate radial artery harvesting without clinical consequences. The ideal method of preoperative evaluation remains to be determined.