Outcome of conservative medical treatment of patients with infrarenal abdominal aortic aneurysms

OBJECTIVE: Since non-invasive diagnostic methods have become available and screening programs have become popular, abdominal aortic aneurysms are more frequently being detected at an early stage of the disease. We analyzed the course of conservatively treated patients with infrarenal abdominal aortic aneurysms (AAA), and determined independent risk factors for aneurysm expansion. METHODS: The study was designed as a retrospective-cohort study including 110 consecutive patients with AAA. Cardiovascular risk factors, comorbidities, current medication, and the findings of color coded duplex sonography and computed tomography were recorded. Ninety-two conservatively treated patients were re-investigated every 6 or 12 months (depending on an initial aneurysm size of > 45 mm or < 45 mm respectively) after initial detection by color coded duplex sonography. We performed a multivariate Cox regression analysis to determine independent predictors of diameter progression (diameter increase > or = 5 mm). RESULTS: We found AAA expansion in 46 conservatively treated patients (50%) during the median follow up period of 23 months (IQR 13 to 33), but no rupture occurred. Baseline diameter > 45 mm (HR 2.3, 95% CI 1.0 to 5.3, P = .04) and signs of aortic dissection in duplex ultrasound (HR 2.2, 1.0 to 4.6, P = .04) were independently associated with aneurysm expansion. The presence of an intraluminal thrombus showed a trend towards higher rates of disease progression (HR 2.6, 95% CI 0.9 to 7.6, P = .08). CONCLUSION: Patients with an aneurysm diameter > 45 mm or ultrasound signs of aortic dissection have an increased risk for AAA progression and need careful evaluation, optimization of risk factors and close (six-month) follow-up intervals. For patients with an aneurysm diameter below 45 mm and without additional risk factors, follow-up intervals of 12 months seem to be safe.     

Ability of citizens in a senior living community to perform lifesaving cardiac skills and appropriately utilize AEDs

The objective of this study was to assess the ability of citizens in a senior living community (SLC) to perform adequate cardiopulmonary resuscitation (CPR) and appropriately utilize an automated external defibrillator (AED) in a simulated cardiac arrest scenario (SCAS). This study was a prospective, observational study; a convenience sample of SLC residents aged > 54 years was enrolled. Subjects were presented with a SCAS (adult mannequin, bystander available to assist, AED visible). Subjects’ skills were rated in standardized fashion. For statistical analysis, 95% confidence intervals (CIs) were calculated as appropriate. There were 51 subjects; 69% were female; mean age was 64 years; 86% were without disabilities. Pre-retirement professions included: medical (13.7%), office/sales (41.2%), and engineer/science (15.7%). Subjects had previous American Heart Association first-responder training (CPR and AED use) as follows: none (22%), within 0 to 6 months (47%), 7–12 months (4%), > 12 months (27%). During the SCAS, subjects performed inconsistently on the various links in the chain of survival. Although most subjects (94%; 95% CI 84–99%) checked for unresponsiveness, only 62.8% (95% CI 48–76%) also specified “call 911 and bring me the AED.” Most subjects (88%; 95% CI 76–96%) started chest compressions, however, only a minority provided high quality chest compressions (29%; 95% CI 17–44%). With respect to AED skill performance, we noted the following: 94% (95% CI 84–99%) of subjects removed the patient’s clothing, 90% (95% CI 79–97%) turned the device on, 94% delivered a shock as directed, and 82% continued CPR if “no shock indicated” by AED (95% CI 69–92%). Performance was less satisfactory for the following: only 39.2% (95% CI 26–54%) continued chest compressions after AED arrival, 60.8% (95% CI 46–74%) of subjects correctly attached electrodes, and 6% (95% CI 1–16%) verbalized “clear” in advance of shock. Although many members of our sample SLC had prior training, they frequently failed to adequately perform some key steps in the SCAS. Recent efforts to place AEDs in SLCs should be augmented by a plan to adequately train residents and other available individuals (e.g., staff) in CPR/AED use.     

The ability of pulse oximetry to screen for hypoxemia and hypercapnia in patients breathing room air

This study was designed to determine whether high room-air pulse oximetry can rule out hypoxemia or moderate hypercapnia. Based on retrospective analysis of 513 arterial blood gas results, oxygen saturation cutpoints were derived. Coincidentally, a room-air oxygen saturation (RAO₂ sat) value of 96% was selected as a cutpoint to screen for both hypoxemia (PaO₂ < 70 mm Hg) and moderate hypercapnia (PaCO₂ > 50 mm Hg). These tests were validated prospectively by using a convenience sample of 213 Emergency Department patients in whom room-air arterial blood gas sampling was ordered. To detect hypoxemia, the sensitivity of RAO₂ sat ≤ 96% was 1.0 [0.95–1.0, 95% confidence interval (CI)] and specificity was 0.54 (0.45–0.64, 95% CI). To detect hypercapnia, the sensitivity of RAO₂ sat ≤ 96% was 1.0 (0.7–1.0) and specificity was 0.31 (0.25–0.38, 95% CI). We concluded that RAO₂ sat ≥ 97% rules out hypoxemia and may also rule out moderate hypercapnia.     

Gabapentin as an Adjuvant to Opioid Analgesia for Neuropathic Cancer Pain

Gabapentin was administered as an “add on” therapy to 22 patients with neuropathic cancer pain only partially responsive to opioid therapy. Global pain, burning pain, shooting pain episodes, and allodynia were assessed separately. Gabapentin was given for at least a week and efficacy was assessed after 7 to 14 days of therapy. Global pain score decreased from a mean (± SD) of 6.4 (± 1.5) to 3.2 (± 1.3) (95% confidence interval of the baseline minus final score differences [95% CI] = 1.0–2.4). Burning pain intensity decreased from a mean (± SD) of 5.1 (± 3.6) to 2.0 (± 2.3) (95% CI = 1.5–3.8), and episodes of shooting pain decreased in frequency from 7.2 (± 3.7) to 2.2 (± 2.2) daily episodes (95% CI = 1.8–4.3). Allodynia was found in 9 patients and disappeared in 7 during gabapentin administration. Twenty patients judged the new drug efficacious in relieving their symptoms. The potential role of gabapentin as an adjuvant to opioid analgesia in cancer pain is discussed.     

Absence of gravity-dependent modulation of straight sinus flow velocity in healthy humans

The influence of whole-body positions on the cerebral blood flow in normal subjects is unclear. Blood flow in cerebral veins and sinuses is continuous, pulsatile and proportional to cerebral blood flow. We examined young healthy volunteers to evaluate peak mean flow velocity (vm) in the straight sinus (SS) assessed by transcranial Doppler sonography in predefined variations of the whole-body pitch position relative to gravity in the presence of a normal (normocarbia) and an impaired (hypercarbia) cerebral autoregulation. A 2 MHz ultrasound probe was fixed with a headband nearby the protuberantia occipitalis externa. Fifteen subjects were seated in a motorized three-dimensional turntable. Vm-SS, blood pressure and heart rate were monitored in five whole-body pitch positions from upright (0°) to “20° head-hanging” (110°): 0, 30, 60, 90 and 110°. The experiment was repeated during the inspiration of 5% CO₂. Of 15 subjects, 14 showed reliable ultrasound data; the results of one subject with movement artifacts were excluded. Vm-SS values under normocarbia (hypercarbia) were 23.9 ± 4.2 cm/s (40.9 ± 6.7 cm/s) at 0°, 23.1 ± 5.0 cm/s (38.0 ± 5.0 cm/s) at 30°, 24.9 ± 5.1 cm/s (39.9 ± 3.3 cm/s) at 60°, 29.2 ± 8.5 cm/s (41.0 ± 4.7 cm/s) at 90° and 27.0 ± 11.6 cm/s (43.6 ± 12.1 cm/s) at 110°. Vm-SS measured under normocarbia (p = 0.09) and hypercarbia (p = 0.25) were not affected while subjects were positioned from upright toward “20° head-hanging”, whereas blood pressure and heart rate decreased (p < 0.01). Our results suggest that changes of whole-body position from upright to “20° head-hanging” do not alter cerebral blood flow in healthy subjects. (E-mail: Ralf.Baumgartner@usz.ch)     

Prospective Study of Accuracy and Outcome of Emergency Ultrasound for Abdominal Aortic Aneurysm over Two Years

Determination of the presence of an abdominal aortic aneurysm (AAA) is essential in the management of the symptomatic emergency department (ED) patient. OBJECTIVES: To identify whether emergency ultrasound of the abdominal aorta (EUS-AA) by emergency physicians could accurately determine the presence of AAA and guide ED disposition. METHODS: This was a prospective, observational study at an urban ED with more than 100,000 annual patient visits with consecutive patients enrolled over a two-year period. All patients suspected to have AAA underwent standard ED evaluation consisting of EUS-AA, followed by a confirmatory imaging study or laparotomy. AAA was defined as any measured diameter greater than 3 cm. Demographic data, results of confirmatory testing, and patient outcome were collected by retrospective review. RESULTS: A total of 125 patients had EUS-AA performed over a two-year period. The patient population had the following characteristics: average age 66 years, male 54%, hypertension 56%, coronary artery disease 39%, diabetes 22%, and peripheral vascular disease 14%. Confirmatory tests included radiology ultrasound, 28/125 (22%); abdominal computed tomography, 95/125 (76%); abdominal magnetic resonance imaging, 1/125 (1%); and laparotomy, 1/125 (1%). AAA was diagnosed in 29/125 (23%); of those, 27/29 patients had AAA on confirmatory testing. EUS-AA had 100% sensitivity (95% CI = 89.5 to 100), 98% specificity (95% CI = 92.8 to 99.8), 93% positive predictive value (27/29), and 100% negative predictive value (96/96). Admission rate for the study group overall was 70%. Immediate operative management was considered in 17 of 27 (63%) patients with AAA; ten patients were taken to the operating room. CONCLUSIONS: EUS-AA in a symptomatic population for AAA is sensitive and specific. These data suggest that the presence of AAA on EUS-AA should guide urgent consultation. Emergency physicians were able to exclude AAA regardless of disposition from the ED.     

The interrater reliability of ultrasound imaging of the inferior vena cava performed by emergency residents

ObjectiveUltrasonography (US) has gained popularity in the emergency medicine to assess intravascular volume status in critically ill patients. However, there are a limited number of studies on the interrater reliability of US examination of the inferior vena cava (IVC) by emergency residents.MethodOne hundred eighty US examinations were performed on 90 emergency critical care unit patients by 6 emergency medicine residents. Minimum and maximum IVC diameters during normal passive inspiration were measured, and the IVC index was calculated. The interrater reliability of the measurable data was analyzed using intraclass correlation coefficients.ResultsThe measurements of minimum and maximum IVC diameters were moderately reliable by emergency residents (κ = 0.60 [95% confidence interval {CI}, 0.45-0.72] and κ = 0.56 [95% CI, 0.41-0.69], respectively). In the patients with moderate IVC depth (8.5-12.5 cm), the interrater reliabilities of sonographers were κ = 0.51 (95% CI, 0.30-0.67) for maximum diameter and κ = 0.43 (95% CI, 0.21-0.61) for minimum diameter. In patients with superficial (≤ 8.5 cm) and profound located (≥ 12.5 cm) IVC, the interrater reliabilities of sonographers for maximum and minimum diameters were κ = 0.69 (95% CI, 0.29-0.89) and κ = 0.75 (95% CI, 0.4-0.91), and κ = 0.58 (95% CI, 0.09-0.85) and κ = 0.76 (95% CI, 0.39-0.92), respectively.ConclusionThe measurement of the IVC is moderately reliable by emergency residents. The interrater reliability of measurements in patients with profound and superficial located IVC is higher than that of measurements in patients with moderate-depth located IVC.     

Ultrasonographic measurement of aortic diameter by emergency physicians approximates results obtained by computed tomography

To assess agreement between emergency physicians' measurements of abdominal aortic diameter using ultrasound in the Emergency Department (ED) and measurements obtained by computed tomography (CT), a double-blinded, prospective study was conducted. The study enrolled a convenience sample of patients over 50 years of age presenting to the ED and scheduled to undergo CT scan of the abdomen and pelvis. Before CT scan, each patient received an ultrasound from a resident or attending emergency physician measuring anterior-posterior aortic diameter transversely at the approximate level of the superior mesenteric artery (SMA), longitudinally midway between the SMA and the iliac bifurcation, and transversely approximately 1 cm above the iliac bifurcation. Two radiologists blinded to the ultrasound measurements then independently measured aortic diameters at the corresponding anatomical points as imaged by CT. The ultrasonographic measurements were then compared with an average of the two CT measurements. Forty physicians enrolled a total of 104 patients into the study. Ultrasonographic measurements of aortic diameter were slightly smaller than those obtained by CT scan, with a difference of means of -0.39 cm (95% CI -0.25 to -0.53) at the level of the SMA, -0.26 cm (95% CI -0.17 to -0.36) on longitudinal view, and -0.11 cm (95 % CI -0.01 to 0.22) at the bifurcation. At the level of the SMA, the difference in measurements by ultrasound and CT would be expected to be less than 1.41 cm, 95% of the time. At the bifurcation, we expect 95% of the differences to be less than 1.05 cm. Agreement was closest on longitudinal view, with 95% of the differences expected to be less than 0.94 cm. Participating physicians estimated the time required to complete their ultrasound studies to be less than 5 min in a majority of cases. In conclusion, ultrasonographic measurement of aortic diameter by emergency physicians rapidly and effectively approximates measurements obtained by CT scan.     

Evaluation of an Instructional Model for Emergency Ultrasonography

Objective: To evaluate a 4-hour ultrasonography course in the setting of an emergency medicine (EM) training program. Methods: EM residents and faculty at a large urban center were provided a 4-hour emergency ultrasonography course. Then, during an 18-month period, a nonconsecutive sample of ultrasonographic examinations were videotaped and later reviewed. The interpretations of the emergency physician examinations were compared with the following reference standards: 1) an official ultrasound performed and interpreted by the departments of radiology or cardiology; 2) an operative report; 3) A CT scan or IV pyelogram (IVP); or 4) a cardiologist's or a radiologist's interpretation of the videotaped examinations. Results: Of 258 examinations reviewed, 28 (11%) of these were excluded because the cardiologist or radiologist reviewing the videotape determined them to be “technically limited” studies. Of the remaining 230 examinations, there were: 127 gallbladder studies [disease prevalence = 0.58; sensitivity = 0.89; specificity = 0.80; kappa (κ) = 0.69; 95% CI: 56–82%]; 39 echocardiograms to rule out pericardial effusions [disease prevalence = 0.15; sensitivity = 0.83; specificity = 0.97; κ= 0.80; 95% CI: 54–100%]; 25 abdominal ultrasounds to rule out free peritoneal fluid [disease prevalence = 0.32; sensitivity = 0.88; specificity = 0.94; κ= 0.81; 95% CI: 26–95%]; 16 renal ultrasounds to rule out hydronephrosis [disease prevalence = 0.25; sensitivity = 1.0; specificity = 0.92; κ= 0.84; 95% CI: 56–100%]; 12 pelvic ultrasounds to rule in an intrauterine pregnancy [disease prevalence = 0.67; sensitivity = 1.0; specificity = 0.75; κ= 0.80; 95% CI: 43–100%]; and 11 abdominal ultrasounds to rule out abdominal aortic aneurysms [disease prevalence = 0.09; sensitivity = 1.0; 95% CI: 2.5–91%; specificity = 1.0; 95% CI: 68–100%]. Conclusion: This 4-hour ultrasonography course has potential to serve as a foundation for an instructional model for ultrasonography training in the setting of an EM residency program.     

Randomized evaluation of controlled-release codeine and placebo in chronic cancer pain

Codeine is widely used in combination with acetaminophen and aspirin for the management of mild to moderate pain. However, there are few controlled clinical trials of single-entity codeine in chronic cancer pain. The purpose of this study was to evaluate the clinical efficacy and safety of controlled-release codeine given every 12 hr in patients with cancer pain. Thirty-five patients with chronic cancer pain were randomized in a double-blind crossover study to controlled-release (CR) codeine or placebo, for 7 days each. Pain intensity was assessed at 0800 hr and 2000 hr using a visual analogue scale (VAS) and a five-point categorical scale, and the use of “rescue” acetaminophen-plus-codeine (300 mg/30 mg every 4 hr as needed) was recorded. Thirty patients completed the study (17 male, 13 female; mean age, 64.4 ± 9.8 years) with a mean daily CR codeine dose of 277 ± 77 mg (range, 200–400 mg). CR codeine treatment resulted in significantly lower overall VAS pain intensity scores (22 ± 0.8 mm versus 36 ± 20 mm, P = 0.0001), categorical pain intensity scores (1.2 ± 0.8 versus 1.8 ± 0.8, P = 0.0001), and pain scores when assessed by day of treatment and by time of day. Daily “rescue” analgesic consumption was significantly lower on CR codeine, compared to placebo treatment (2.2 ± 2.3 versus 4.6 ± 2.8 tablets per day, P = 0.0001). Both patients and investigators preferred CR codeine to placebo (80% versus 3%, P = 0.0014 and 73% versus 7%, P = 0.0160, respectively). These data indicate that CR codeine, given every 12 hr results in significant reductions in pain intensity and the use of “rescue” acetaminophen-plus-codeine in patients with cancer pain. CR codeine provides the benefits of a flexible single entity codeine formulation and the convenience of 12-hr duration of action, which allows patients uninterrupted sleep and improved compliance.     

A new Doppler imaging measurement in aortic stenosis: The contour length of the jet origin flow area. Relationships between both, with usual Doppler data and left ventricular hypertrophy

Planimetry of stenotic aortic jet origin flow areas was performed using transthoracic Doppler imaging, with measurement of the contour length of flow areas and calculation of a contour/area (C/A) Doppler ratio on a group of 75 patients with aortic stenosis ranging from 0.27 to 2.44 cm². The purpose was to study correlations of these data with the usual Doppler data and with left ventricular hypertrophy. The “r” coefficient between planimetered flow areas and those calculated by the continuity equation method was 0.89. Mean values (SD) of data were: areas: (planimetry) 1.00 ± 0.53 cm², (continuity equation) 0.91 ± 0.42 cm², contours: 5.6 ± 1.6 cm, C/A: 0.66 ± 0.25, maximal and mean pressure gradients: 68 ± 34 and 37 ± 21 mmHg, left ventricular hypertrophy: 138 ± 30 g/m² BSA (vs. 100 ± 18 in normals). All values except age, gender and BSA, differed significantly (p < 0.001) between areas below or over 0.85 cm². Other correlations between parameters were significant (p < 0.01 to 0.001), but with lower “r” coefficients due to widely scattered individual values. Contours increased much less rapidly than areas did, and were correlated with left ventricular hypertrophy only when coupled in the C/A ratio, with a higher “r” coefficient (0.62) than areas alone (0.52). Study of both areas and contours helps to approach the geometry of the orifice. This suggests that the individual geometry of the stenosis might weigh on the left ventricular mass growth, as an associated factor for a given decrease in stenotic area.     

Office-based ultrasound screening for abdominal aortic aneurysm

Objective

To assess the efficacy of an office-based, family physician–administered ultrasound examination to screen for abdominal aortic aneurysm (AAA).

Design

A prospective observational study. Consecutive patients were approached by nonphysician staff.

Setting

Rural family physician offices in Grand Forks and Revelstoke, BC.

Participants

The Canadian Society for Vascular Surgery screening recommendations for AAA were used to help select patients who were at risk of AAA. All men 65 years of age or older were included. Women 65 years of age or older were included if they were current smokers or had diabetes, hypertension, a history of coronary artery disease, or a family history of AAA.

Main outcome measures

A focused “quick screen,” which measured the maximal diameter of the abdominal aorta using point-of-care ultrasound technology, was performed in the office by a resident physician trained in emergency ultrasonography. Each patient was then booked for a criterion standard scan (ie, a conventional abdominal ultrasound scan performed by a technician and interpreted by a radiologist). The maximal abdominal aortic diameter measured by ultrasound in the office was compared with that measured by the criterion standard method. The time to screen each patient was recorded.

Results

Forty-five patients were included in data analysis; 62% of participants were men. The mean age was 73 years. The mean pairwise difference between the office-based ultrasound scan and the criterion standard scan was not statistically significant. The mean absolute difference between the 2 scans was 0.20 cm (95% CI 0.15 to 0.25 cm). Correlation between the scans was 0.81. The office-based ultrasound scan had both a sensitivity and a specificity of 100%. The mean time to screen each patient was 212 seconds (95% CI 194 to 230 seconds).

Conclusion

Abdominal aortic aneurysm screening can be safely performed in the office by family physicians who are trained to use point-of-care ultrasound technology. The screening test can be completed within the time constraints of a busy family practice office visit. The benefit of screening for AAA in rural patients might be great if local diagnostic ultrasound service and emergent transport to a vascular surgeon are not available.     

Antipyretic effectiveness of intravenous ketorolac tromethamine

We assessed the antipyretic effectiveness of intravenously administered ketorolac tromethamine in the febrile adult. A double-blind placebo controlled trial enrolling a convenience sample of febrile (T > 38.0°C, oral) patients (18–65 years old) randomized to receive either 0.5 mg/kg (max 30 mg) intravenous ketorolac or placebo. Oral temperatures were recorded every 15 min during the 1-h study period. There were 20 patients in each group. At 60 min, the temperature decrease was 0.4°C (95% CI: 0.0°, 0.7°) for the control group and 0.8°C (95% CI: 0.5°, 1.1°) for the ketorolac group. Logistic regression modeling of afebrile at 60 min, controlling for baseline temperature, yielded an odds ratio for ketorolac of 7.1 (95% CI: 1.3, 39.5). In conclusion, our data support that intravenously administered ketorolac has antipyretic properties.     

Abdominal aortic aneurysm: screening and surveillance

A screening program for infrarenal abdominal aortic aneurysm (AAA) has limited cost-effectiveness. Yet, screening of the subpopulation of smoking men aged 60-75 years, or men and smoking women with a family history of vascular diseases or other cardio-vascular co-morbidity is cost-effective and has been demonstrated. It is suited to halve the increasing mortality of AAA. Elective repair of AAA is justified at diameters larger than 5.5 cm for men, but uncertain for women. However, aortic diameters between 4.5 and 5 cm in women probably necessitate an invasive approach. Surveillance of patients who still not meet these criteria should not only include the absolute diameter of the aneurysm, but direct individuals with aneurysms at an annual expansion rate of more than 0.5 cm to elective repair.     

A Longitudinal Study of Emergency Medicine Residents' Malpractice Fear and Defensive Medicine

Objectives: To determine the baseline level and evolution of defensive medicine and malpractice concern (MC) of emergency medicine (EM) residents.
Methods: Using a validated instrument consisting of case scenarios and Likert-type scale questions, the authors performed a prospective, longitudinal (June 2001 to June 2005) study of EM residents at five 4-year California residency programs.
Results: All 51 EM interns of these residencies were evaluated; four residents left their programs and one took medical leave, resulting in 46 graduating residents evaluated. MC did not affect the residency choice of interns. Although perceived likelihood of serious disease increased in case scenarios over time, defensive medicine decreased in 27% of cases and increased in 20%. On a scale with 1 representing extremely influential and 5 representing not at all influential, the mean (±SD) influence of MC on interns' and graduates' case evaluation and management was 2.5 (±1.1) and 2.7 (±1.0), respectively. Comparing interns and graduates, there was no significant difference in the percentages of respondents who declared MC (mean difference in proportions, 3.3%; 95% CI =−8.4% to 15%) or refused procedures because of MC (11.5%; 95% CI =−1.3% to 24.3%). More interns, however, declared substantial loss of enjoyment of medicine than graduates (48%; 95% CI = 30.3% to 65.5%).
Conclusions: Physicians enter four-year EM residencies in California with moderate MC and defensive medicine, which do not change significantly over time and do not markedly impact their decisions to perform emergency department procedures. Malpractice fear markedly decreases interns' enjoyment of medicine, but this effect decreases by residency completion.     

Oxacillin susceptibility testing of Staphylococcus saprophyticus using disk diffusion, agar dilution, broth microdilution, and the Vitek GPS-105 card

Eighty-three mecA negative isolates of S. saprophyticus had oxacillin zone diameters ≤ 15 mm or MICs ranging from ≤ 0.25–1.0 μg/ml when tested by either agar dilution, broth microdilution, or the Vitek GPS-105 card. Greater than 90% of these isolates would be considered resistant using NCCLS M7-A5, M100-S10 criteria. These results suggest that the current NCCLS MIC and zone diameter breakpoints for oxacillin resistance in coagulase-negative Staphylococci are not appropriate for S. saprophyticus as they do not correlate with the presence of the mecA gene.     

Serum D-dimer is a sensitive test for the detection of acute aortic dissection: a pooled meta-analysis

Acute aortic dissection is a rare but devastating condition with high mortality. Unfortunately, there is no sensitive screening indicator of disease in common use. The objective of this study was to assess the sensitivity and utility of the serum D-dimer as a test for acute aortic dissection. A pooled analysis was performed of all original research studies testing the sensitivity of serum D-dimer for acute aortic dissection. A search of MEDLINE, EMBASE, and the Cochrane Register using the terms “aortic dissection” and “d-dimer” was made of all English language publications. All original reports of consecutively enrolled patients with acute aortic dissection and a measured serum D-dimer were included. Case reports were excluded. A value of 0.5 microgram per milliliter was defined as the threshold for a positive D-dimer. The primary outcome was the pooled sensitivity of the D-dimer test for acute aortic dissection. There were 21 original reports of patients with acute aortic dissection and D-dimer measurements. Eleven studies were included and a total of 349 acute aortic dissection patients were described. The sensitivity of the D-dimer test was 327/349, 94% (95% confidence interval 91–96), and the point estimate was essentially unchanged in a sensitivity analysis, 183/192, 95% (95% confidence interval 91–98). Specificity ranged from 40% to 100%. Serum D-dimer is sensitive for acute aortic dissection and potentially represents a useful test for patients who present with a low likelihood of this disease.     

Abdominal aortic aneurysm screening during transthoracic echocardiography in an unselected population.

OBJECTIVE: We sought to investigate the echocardiographic prevalence of abdominal aortic aneurysm (AAA) in an unselected group of patients referred for regular transthoracic echocardiography (TTE). METHODS: Prospectively, during a 3-month period, a limited ultrasound examination of the infrarenal aorta was performed. AAA was defined as a diameter of 30 mm or more. RESULTS: The abdominal aorta could be visualized in 742 patients. The prevalence of AAA was 4.6%. AAA prevalence increased with age, especially in men. In 34 patients AAA was unknown and aortic diameters exceeded 50 mm in 4 patients. Two underwent elective but urgent operation. Patients with AAA were older and had an increased ascending aorta diameter, larger left ventricular dimensions, higher left ventricular mass index, and lower ejection fraction. CONCLUSION: AAA is prevalent in patients referred for regular TTE. Routine rapid screening of the abdominal aorta during TTE is beneficial and should, therefore, be part of a standard TTE examination for patients older then 50 years.     

Using visual illusion to reduce at-level neuropathic pain in paraplegia

Neuropathic pain after spinal cord injury is not well understood and is difficult to treat. One possible cause is mismatch between motor commands and sensory feedback. This two-part study in five paraplegic patients investigated whether a visual illusion aimed to correct this mismatch reduces pain. In study 1, patients undertook three conditions: (i) virtual walking: with a mirror placed in front of a screen, patients aligned their own upper body with a film of a lower body walking. Patients imagined walking and ‘watched themselves’ walk; (ii) guided imagery; (iii) watching a film. One patient withdrew from virtual walking because of distress. For all patients, the mean (95% CI) decrease in pain (100 mm VAS) was 42 mm (65%) (11–73 mm) for virtual walking, 18 mm (4–31 mm) for guided imagery and 4 mm (−3 to 11 mm) for watching the film. Mean (95% CI) time to return to pre-task pain was 34.9 min (20.1–49.8 min) for virtual walking; 13.9 min (−0.9 to 28.8 min) for the guided imagery and 16.3 min (1.5–31.2 min) for the film. To investigate its clinical utility, four patients underwent virtual walking every weekday for 3 weeks. Mean (95% CI) decrease in pain was 53 mm (45–61 mm) at post training and 43 mm (27–58 mm) at 3-month follow-up. Virtual walking may be a viable treatment for pain after spinal cord injury. A clinical trial seems warranted.