When the diameter of the abdominal aorta should be considered as abnormal? A new ultrasonographic index using the wrist circumference as a body build reference

Purpose

To use US to evaluate the normal values of aortic diameter (AD), stratifying the population by age, gender and body build, as measured using wrist circumference (WC).

Materials and methods

Between April 2010 and February 2012, consecutive patients ≥ 30 years of age, without history of abdominal aortic aneurysm (AAA) were prospectively enrolled. They underwent an abdominal ultrasonography for reasons other than aorta evaluation. AD was measured at the infrarenal (AD₁), intermediate (AD₂), and iliac bifurcation (AD₃) levels: a diameter ≥ 3 cm was considered as an aneurysm. The maximal aortic diameter (AD_max) was measured for AAA patients. WC was measured; AD/WC ratio was calculated and presented in percentage: the range of normal values was obtained excluding AAA cases and calculated as mean ± 1.96 × standard deviation. Pearson correlation coefficient was used.

Results

We recruited 1200 patients, 15 (1.25%; age range = 64–86 years) had AAA. AD ranges of the other patients were: AD₁ = 0.74–1.84 cm, AD₂ = 0.78–1.85 cm, and AD₃ = 0.68–1.76 cm for females; AD₁ = 0.86–2.02 cm, AD₂ = 0.91–2.08 cm, and AD₃ = 0.84–1.95 cm for males. AD₂/WC ratio of non-AAA patients range was 4–15%, with only one outlier at 18%, while AD_max/WC ratio of AAA patients range was 15–35% (p < 0.001). ADs were significantly correlated with WC (r = 0.253, p < 0.001 for AD₁, r = 0.318, p < 0.001 for AD₂ and r = 0.280, p < 0.001 for AD₃).

Conclusion

The definition of normal AD should consider body build. An AD₂/WC ratio of 15% may be regarded as a threshold to differentiate AAA- from non-AAA patients. Patients with AD₂/WC values comprised between 12% and 15% may be at risk for AAA.     

Do homeless veterans have the same needs and outcomes as non-veterans?

Although veterans have been found to be at increased risk for homelessness as compared to non-veterans, it is not clear whether those who are homeless have more severe health problems or poorer outcomes in community-based supported housing. This observational study compared 162 chronically homeless veterans to 388 non-veterans enrolled in a national-supported housing initiative over a 1-year period. Results showed that veterans tended to be older, were more likely to be in the Vietnam era age group, to be male, and were more likely to have completed high school than other chronically homeless adults. There were no differences between veterans and non-veterans on housing or clinical status at baseline or at follow-up, but both groups showed significant improvement over time. These findings suggest that the greater risk of homelessness among veterans does not translate into more severe problems or treatment outcomes. Supported housing programs are similarly effective for veterans and non-veterans.     

Is carotid duplex scanning sufficient as the sole investigation prior to carotid endarterectomy?

Carotid endarterectomy (CEA) is the accepted treatment for certain patients who have had, or who are at risk of having, a stroke if they have a significant narrowing of the internal carotid artery. Rapid and accurate classification of the degree of stenosis is important as the benefit of surgery is highly dependent on this. The aim of this study was to assess whether the addition of angiography to duplex scanning resulted in a change in patient management in a unit where duplex scanning was used as the sole imaging investigation prior to CEA. The study population consisted of 64 patients with significant internal carotid artery stenosis on duplex scanning who were suitable for, and wished to be considered for, CEA. All patients underwent an angiogram. In this study 9 (14%) patients did not proceed to surgery on the basis of angiography and in a further 11 (17%) patients insufficient views of the distal vessel were obtained on duplex scanning. Three of these patients had extensive disease which excluded surgery. One patient experienced a transient ischaemic attack (TIA) at the time of angiography. In conclusion, this audit has highlighted the limitations in performing duplex scanning alone, and the costs that this can incur on the patient who may undergo an unnecessary operation. We cannot recommend duplex scanning as the sole investigation prior to CEA. There is need to evaluate the role of additional non-invasive carotid imaging such as magnetic resonance angiography or CT angiography in the assessment of these patients.     

Acidic aqueous dichromate solutions as reference dosimeters in the 10–40 kGy range

The radiolytic reduction of dichromate ion in acidic aqueous solution has been investigated as a potential dosimetry system for the 10–40 kGy range of absorbed dose. Dilute sulphuric acid has been shown to be unsuitable as a solvent, and the use of 0.1 mol·dm⁻³ perchloric acid is recommended. A previously reported effect of silver ion in supressing reaction with hydrogen has been confirmed, and in addition, silver ions have been shown to be effective in eliminating dose rate effects. The temperature coefficient during irradiation has been determined as −0.2% per degree and post-irradiation storage effects are shown to be negligible. The precision of the system is about 0.5% at a dose of 25 kGy, and a suggested composition for a working dosimeter is given.     

Detection of ileocecal Crohn’s disease using ultrasound as the primary imaging modality

At our hospital ultrasound (US) is used as an initial screening procedure in all patients with abdominal symptoms. The purpose of this study was to assess the effect of this policy on the detection of ileocecal Crohns disease. We retrospectively studied all patients with a new diagnosis of ileocecal Crohns disease from our institute over the period 1990–2001. The final diagnosis was based on clinical follow-up and pathological, surgical, US, and other radiological findings. We noted who referred the patient to the radiology department, what the initial clinical presumption was, and what the first imaging study was. US diagnoses were determined from the initial US report and US findings were registered from the images. There were a total of 47 patients (20 men, 27 women) with a mean age of 30 years and a median age of 27 years (range 14–75 years). In all patients the initial imaging study was an abdominal US. Using US, a confident diagnosis of ileocecal Crohns disease was made in 35 of the 47 patients, Crohns disease was suggested among the differential diagnosis in 10, and an incorrect diagnosis was made in 2 patients. In 28 of 47 patients, the referring physician did not consider Crohns disease when requesting the initial US examination. In eight patients with appendicitis-like symptoms, the US findings strongly influenced the decision to refrain from operation at that point in time. US, when used as a low-threshold diagnostic procedure, is a reliable and noninvasive means for making an early diagnosis of ileocecal Crohns disease in patients who present with atypical symptoms. It may prevent both unnecessary therapeutic delay as well as unnecessary surgery.     

The distribution of the HLA-DQα alleles and genotypes in the Finnish population as determined by the use of DNA amplification and allele specific oligonucleotides

Summary Allele and genotype frequencies for the HLA-130 locus were determined for use in forensic analyses and paternity tests in Finland. The polymerase chain reaction (PCR) and the reverse dot blot format were employed to detect 6 different HLA-DQ alleles. All 6 HLA-DQ alleles were detected among the 112 unrelated individuals with allele frequencies ranging from 5.8% to 32.6%. The distribution of the observed genotypes is in Hardy-Weinberg equilibrium. Additionally, this Finnish population sample is statistically similar to 2 other Caucasian sample populations. The power of discrimination of this system in the Finnish population sample is 0.92, suggesting this method may prove suitable for identification purposes.     

Muscle atrophy as a consequence of rotator cuff tears: should we compare the muscles of the rotator cuff with those of the deltoid?

Purpose The quantitative assessment of muscle atrophy has a degree of importance in prognosticating rotator cuff treatment. However, it has been conjectured that muscle fat increases with aging. Therefore, we thought that the quantitative assessment of the supraspinatous would be better if made in comparison with a standard of reference such as the deltoid. Consequently, we performed a two-part study, first evaluating supraspinatous changes compared with the deltoid in “normals” with aging, and second, determining if in patients with cuff tears the supraspinatous fat exceeds that of the deltoid. Materials and methods In part 1, we studied 50 patients stratified by decade. In the first sitting, two blinded independent observers quantitatively graded the deltoid (with the supraspinatous obscured) and in the second sitting the same two observers quantitatively graded the supraspinatous (with the deltoid obscured). In part 2 of the study, we evaluated patients with moderate rotator cuff tears (>2 cm) and performed the same blinded, two-sitting, quantitative assessment (with the comparison muscle obscured). Results We found that muscle atrophy increases with age in patients without tears (0.011/0.028 U/year), although to a greater degree in the deltoid (p = 0.032). Also, in similarly aged patients, quantitative scores of the deltoid closely matched those of the supraspinatous (p = 0.071). Notably, however, in patients with large tears, the supraspinatous showed significant changes disproportionate to those of the deltoid, regardless of patient age (p = 0.044). Conclusion In the presence of a normal rotator cuff, fatty infiltration increases with age. Age-related changes occur more frequently in the deltoid, verifying this muscle’s potential as a standard of reference. With cuff tears, supraspinatous atrophy was disproportionate to that of the deltoid. Therefore, systematic assessment of supraspinatous muscle atrophy may be more reliable using the deltoid as a control for comparison than assessing it in isolation.     

Does membership in veterans' service organizations influence use of the Department of Veterans Affairs as the usual source of care?

Veterans' service organizations (VSOs) provide outreach regarding veterans' benefits. Medical care provided by the Department of Veterans Affairs (VA) is one such benefit that has improved health and quality of life. This study evaluates the characteristics of veterans who report VSO membership and who use the VA as their usual source of care, and it determines whether VSO membership influences the choice of a VA or non-VA facility as the usual source of care. The findings reveal that VSO members, compared with nonmembers, are Caucasian, older, retired, of lower income, and more functionally impaired. Veterans who use the VA, compared with non-VA users, are African American, of lower income, unemployed, and more functionally impaired. VSO members are more likely to use the VA as the usual source of care than are VSO non-members, with the effects varying according to race/ethnicity. Policy recommendations include increasing the diversity of VSO membership, because VSOs play an important outreach and informational role for veterans.