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Krittanawong C, Escobar J, Virk HUH, Alam M, Skeik N, Campia U, Henke PK, Sharma S. Carotid and Renal Vascular Disease. Curr Probl Cardiol 2024; 49:102056. [PMID: 37661042 DOI: 10.1016/j.cpcardiol.2023.102056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 08/23/2023] [Indexed: 09/05/2023]
Abstract
This article review covers carotid artery disease, abdominal aortic aneurysm, and atherosclerotic renal artery disease. It overviews each condition's clinical presentation, diagnosis, medical management, and interventional approach. Carotid artery disease is characterized by hemispheric and neuropsychological manifestations, which can help detect this condition. Screening for carotid artery stenosis is recommended in high-risk individuals and can be performed using different methods, with carotid duplex ultrasonography being the preferred option. Carotid endarterectomy and carotid artery stenting are indicated based on specific criteria and patient characteristics. An abdominal aortic aneurysm is often asymptomatic, but abdominal, back, or flank pain may sometimes be present. Ultrasonography is an effective method for screening and monitoring abdominal aortic aneurysms, with high sensitivity and specificity. Smoking cessation is a crucial intervention for preventing further enlargement of small aortic aneurysms. Repair of abdominal aortic aneurysm is recommended based on the aneurysm size, growth rate, and the presence of symptoms. Endovascular repair is preferred when suitable anatomy is present. Atherosclerotic renal artery disease is associated with resistant hypertension, renal failure, and occasionally pulmonary edema. Doppler ultrasonography is a valuable diagnostic tool for detecting it, while the renal resistive index provides additional insights into disease severity and treatment response. Revascularization is not routinely recommended for atherosclerotic renal artery disease, but it may be considered in specific cases, such as renal arterial fibromuscular dysplasia or unexplained congestive heart failure.
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Affiliation(s)
| | - Johao Escobar
- Division of Cardiology, Harlem Cardiology, New York, NY
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Mahboob Alam
- The Texas Heart Institute, Baylor College of Medicine, Houston, TX
| | - Nedaa Skeik
- Vascular Medicine, Minneapolis Heart Institute, MN
| | - Umberto Campia
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Peter K Henke
- Section of Vascular Surgery, University of Michigan, Ann Arbor, MI
| | - Samin Sharma
- Cardiac Catheterization Laboratory of the Cardiovascular Institute, Mount Sinai Hospital, New York, NY
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2
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Wang DS, Shen J, Majdalany BS, Khaja MS, Bhatti S, Ferencik M, Ganguli S, Gunn AJ, Heitner JF, Johri AM, Obara P, Ohle R, Sadeghi MM, Schermerhorn M, Siracuse JJ, Steenburg SD, Sutphin PD, Vijay K, Waite K, Steigner ML. ACR Appropriateness Criteria® Pulsatile Abdominal Mass, Suspected Abdominal Aortic Aneurysm: 2023 Update. J Am Coll Radiol 2023; 20:S513-S520. [PMID: 38040468 DOI: 10.1016/j.jacr.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
Abdominal aortic aneurysm (AAA) is defined as abnormal dilation of the infrarenal abdominal aortic diameter to 3.0 cm or greater. The natural history of AAA consists of progressive expansion and potential rupture. Although most AAAs are clinically silent, a pulsatile abdominal mass identified on physical examination may indicate the presence of an AAA. When an AAA is suspected, an imaging study is essential to confirm the diagnosis. This document reviews the relative appropriateness of various imaging procedures for the initial evaluation of suspected AAA. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- David S Wang
- Stanford University Medical Center, Stanford, California.
| | - Jody Shen
- Research Author, Stanford University Medical Center, Stanford, California
| | - Bill S Majdalany
- Panel Chair, University of Vermont Medical Center, Burlington, Vermont
| | - Minhaj S Khaja
- Panel Vice-Chair, University of Michigan, Ann Arbor, Michigan
| | - Salman Bhatti
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Society for Cardiovascular Magnetic Resonance
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon; Society of Cardiovascular Computed Tomography
| | - Suvranu Ganguli
- Boston Medical Center/Boston University School of Medicine, Boston, Massachusetts
| | - Andrew J Gunn
- University of Alabama at Birmingham, Birmingham, Alabama
| | - John F Heitner
- New York University Langone Health, New York, New York; Society for Cardiovascular Magnetic Resonance
| | - Amer M Johri
- Queen's University, Kingston, Ontario, Canada; American Society of Echocardiography
| | - Piotr Obara
- NorthShore University HealthSystem, Evanston, Illinois
| | - Robert Ohle
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada; American College of Emergency Physicians
| | - Mehran M Sadeghi
- Yale School of Medicine, New Haven, Connecticut; American Society of Nuclear Cardiology
| | - Marc Schermerhorn
- Harvard Medical School and Beth Israel Deaconess Medical Center, Boston, Massachusetts; Society for Vascular Surgery
| | - Jeffrey J Siracuse
- Boston Medical Centers, Boston University, and Chobanian and Avedisian School of Medicine, Boston, Massachusetts; Society for Vascular Surgery
| | - Scott D Steenburg
- Indiana University School of Medicine and Indiana University Health, Indianapolis, Indiana; Committee on Emergency Radiology-GSER
| | | | - Kanupriya Vijay
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kathleen Waite
- Duke University Medical Center, Durham, North Carolina, Primary care physician
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Mulatti GC, Joviliano EE, Pereira AH, Fioranelli A, Pereira AA, Brito-Queiroz A, Von Ristow A, Freire LMD, Ferreira MMDV, Lourenço M, De Luccia N, Silveira PG, Yoshida RDA, Fidelis RJR, Boustany SM, de Araujo WJB, de Oliveira JCP. Brazilian Society for Angiology and Vascular Surgery guidelines on abdominal aortic aneurysm. J Vasc Bras 2023; 22:e20230040. [PMID: 38021279 PMCID: PMC10648059 DOI: 10.1590/1677-5449.202300402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/15/2023] [Indexed: 12/01/2023] Open
Abstract
The Brazilian Society of Angiology and Vascular Surgery, through the Guidelines Project, presents new Abdominal Aortic Aneurysm Guidelines, on the subject of care for abdominal aortic aneurysm patients. Its development prioritized descriptive guidelines, using the EMBASE, LILACS, and PubMed databases. References include randomized controlled trials, systematic reviews, meta-analyses, and cohort studies. Quality of evidence was evaluated by a pair of coordinators, aided by the RoB 2 Cochrane tool and the Newcastle Ottawa Scale forms. The subjects include juxtarenal aneurysms, infected aneurysms, and new therapeutic techniques, especially endovascular procedures. The current version of the guidelines include important recommendations for the primary topics involving diagnosis, treatment, and follow-up for abdominal aortic aneurysm patients, providing an objective guide for medical practice, based on scientific evidence and widely available throughout Brazil.
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Affiliation(s)
- Grace Carvajal Mulatti
- Universidade de São Paulo - USP, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brasil.
| | - Edwaldo Edner Joviliano
- Universidade de São Paulo - USP, Faculdade de Medicina de Ribeirão Preto - FMRP, Ribeirão Preto, SP, Brasil.
| | - Adamastor Humberto Pereira
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre, RS, Brasil.
| | | | - Alexandre Araújo Pereira
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre, RS, Brasil.
| | - André Brito-Queiroz
- Universidade Federal da Bahia - UFBA, Hospital Ana Nery, Salvador, BA, Brasil.
| | - Arno Von Ristow
- Pontifícia Universidade Católica do Rio de Janeiro - PUC-Rio, Rio de Janeiro, RJ, Brasil.
| | | | | | | | - Nelson De Luccia
- Universidade de São Paulo - USP, Faculdade de Medicina, São Paulo, SP, Brasil.
| | | | - Ricardo de Alvarenga Yoshida
- Universidade Estadual Paulista “Júlio de Mesquita Filho” - UNESP, Faculdade de Medicina de Botucatu, Botucatu, SP, Brasil.
| | | | - Sharbel Mahfuz Boustany
- Universidade Federal do Rio Grande do Sul - UFRGS, Hospital de Clínicas de Porto Alegre - HCPA, Porto Alegre, RS, Brasil.
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Atkinson G, Bianco R, Di Gregoli K, Johnson JL. The contribution of matrix metalloproteinases and their inhibitors to the development, progression, and rupture of abdominal aortic aneurysms. Front Cardiovasc Med 2023; 10:1248561. [PMID: 37799778 PMCID: PMC10549934 DOI: 10.3389/fcvm.2023.1248561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/07/2023] [Indexed: 10/07/2023] Open
Abstract
Abdominal aortic aneurysms (AAAs) account for up to 8% of deaths in men aged 65 years and over and 2.2% of women. Patients with AAAs often have atherosclerosis, and intimal atherosclerosis is generally present in AAAs. Accordingly, AAAs are considered a form of atherosclerosis and are frequently referred to as atherosclerotic aneurysms. Pathological observations advocate inflammatory cell infiltration alongside adverse extracellular matrix degradation as key contributing factors to the formation of human atherosclerotic AAAs. Therefore, macrophage production of proteolytic enzymes is deemed responsible for the damaging loss of ECM proteins, especially elastin and fibrillar collagens, which characterise AAA progression and rupture. Matrix metalloproteinases (MMPs) and their regulation by tissue inhibitors metalloproteinases (TIMPs) can orchestrate not only ECM remodelling, but also moderate the proliferation, migration, and apoptosis of resident aortic cells, alongside the recruitment and subsequent behaviour of inflammatory cells. Accordingly, MMPs are thought to play a central regulatory role in the development, progression, and eventual rupture of abdominal aortic aneurysms (AAAs). Together, clinical and animal studies have shed light on the complex and often diverse effects MMPs and TIMPs impart during the development of AAAs. This dichotomy is underlined from evidence utilising broad-spectrum MMP inhibition in animal models and clinical trials which have failed to provide consistent protection from AAA progression, although more encouraging results have been observed through deployment of selective inhibitors. This review provides a summary of the supporting evidence connecting the contribution of individual MMPs to AAA development, progression, and eventual rupture. Topics discussed include structural, functional, and cell-specific diversity of MMP members; evidence from animal models of AAA and comparisons with findings in humans; the dual role of MMPs and the requirement to selectively target individual MMPs; and the advances in identifying aberrant MMP activity. As evidenced, our developing understanding of the multifaceted roles individual MMPs perform during the progression and rupture of AAAs, should motivate clinical trials assessing the therapeutic potential of selective MMP inhibitors, which could restrict AAA-related morbidity and mortality worldwide.
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Affiliation(s)
| | | | | | - Jason L. Johnson
- Laboratory of Cardiovascular Pathology, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Lin J, Chen S, Yao Y, Yan M. Status of diagnosis and therapy of abdominal aortic aneurysms. Front Cardiovasc Med 2023; 10:1199804. [PMID: 37576107 PMCID: PMC10416641 DOI: 10.3389/fcvm.2023.1199804] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/20/2023] [Indexed: 08/15/2023] Open
Abstract
Abdominal aortic aneurysms (AAAs) are characterized by localized dilation of the abdominal aorta. They are associated with several serious consequences, including compression of adjacent abdominal organs, pain, treatment-related financial expenditure. The main complication of AAA is aortic rupture, which is responsible for about 200,000 deaths per year worldwide. An increasing number of researchers are dedicating their efforts to study AAA, resulting in significant progress in this field. Despite the commendable progress made thus far, there remains a lack of established methods to effectively decelerate the dilation of aneurysms. Therefore, further studies are imperative to expand our understanding and enhance our knowledge concerning AAAs. Although numerous factors are known to be associated with the occurrence and progression of AAA, the exact pathway of development remains unclear. While asymptomatic at most times, AAA features a highly unpredictable disease course, which could culminate in the highly deadly rupture of the aneurysmal aorta. Current guidelines recommend watchful waiting and lifestyle adjustment for smaller, slow-growing aneurysms, while elective/prophylactic surgical repairs including open repair and endovascular aneurysm repair are recommended for larger aneurysms that have grown beyond certain thresholds (55 mm for males and 50 mm for females). The latter is a minimally invasive procedure and is widely believed to be suited for patients with a poor general condition. However, several concerns have recently been raised regarding the postoperative complications and possible loss of associated survival benefits on it. In this review, we aimed to highlight the current status of diagnosis and treatment of AAA by an in-depth analysis of the findings from literatures.
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Affiliation(s)
- Jinping Lin
- Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shuwei Chen
- Department of anesthesiology, The First People's Hospital of Fuyang, Hangzhou, China
| | - Yuanyuan Yao
- Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Min Yan
- Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Abdominal Pain. PHYSICIAN ASSISTANT CLINICS 2023. [DOI: 10.1016/j.cpha.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Abdominal aortic aneurysm is a potentially lethal condition that is decreasing in frequency as tobacco use declines. The exact etiology remains unknown, but smoking and other perturbations seem to trigger an inflammatory state in the tunica media. Male sex and advanced age are clear demographic risk factors for the development of abdominal aortic aneurysms. The natural history of this disease varies, but screening remains vital as it is rarely diagnosed on physical examination, and elective repair (most commonly done endovascularly) offers significant morbidity and mortality advantages over emergent intervention for aortic rupture.
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Affiliation(s)
- Michael P Calgi
- University of Virginia School of Medicine, 200 Jeanette Lancaster Way, Charlottesville, VA 22903, USA
| | - John S McNeil
- Department of Anesthesiology, University of Virginia School of Medicine, PO Box 800710, Charlottesville, VA 22908-0710, USA.
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Chronic Atherothrombosis in a Sub-Massive Infrarenal Abdominal Aortic Aneurysm in a 91-Year-Old White Male Donor. Diagnostics (Basel) 2022; 12:diagnostics12102270. [PMID: 36291960 PMCID: PMC9600675 DOI: 10.3390/diagnostics12102270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 09/13/2022] [Accepted: 09/15/2022] [Indexed: 11/16/2022] Open
Abstract
Screening for abdominal aortic aneurysms became the standard of care in 2005, yet screening procedures continue to be underutilized. While improvements in mortality rates have been noted over the past 15 years, continued patient mortality from ruptured abdominal aortic aneurysms suggests a need for further research, regarding the effectiveness of the current screening process. Abdominal aortic aneurysms can progress silently, and the risk of rupture increases significantly with increase in diameter. We report a large, untreated infrarenal abdominal aortic aneurysm of 17 cm in length and 8 cm in diameter, showing the chronic atherothrombosis discovered in a 91 year-old white male cadaveric donor. A literature review was conducted to elucidate current understanding of the pathology, risk factors, screening recommendations, and treatment options available for abdominal aortic aneurysms.
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Kessler V, Klopf J, Eilenberg W, Neumayer C, Brostjan C. AAA Revisited: A Comprehensive Review of Risk Factors, Management, and Hallmarks of Pathogenesis. Biomedicines 2022; 10:94. [PMID: 35052774 PMCID: PMC8773452 DOI: 10.3390/biomedicines10010094] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/30/2021] [Indexed: 01/27/2023] Open
Abstract
Despite declining incidence and mortality rates in many countries, the abdominal aortic aneurysm (AAA) continues to represent a life-threatening cardiovascular condition with an overall prevalence of about 2-3% in the industrialized world. While the risk of AAA development is considerably higher for men of advanced age with a history of smoking, screening programs serve to detect the often asymptomatic condition and prevent aortic rupture with an associated death rate of up to 80%. This review summarizes the current knowledge on identified risk factors, the multifactorial process of pathogenesis, as well as the latest advances in medical treatment and surgical repair to provide a perspective for AAA management.
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Affiliation(s)
| | | | | | | | - Christine Brostjan
- Department of General Surgery, Division of Vascular Surgery, Medical University of Vienna, Vienna General Hospital, 1090 Vienna, Austria; (V.K.); (J.K.); (W.E.); (C.N.)
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Alfuraih AM, Alrashed AI, Almazyad SO, Alsaadi MJ. Abdominal aorta measurements by a handheld ultrasound device compared with a conventional cart-based ultrasound machine. Ann Saudi Med 2021; 41:376-382. [PMID: 34878929 PMCID: PMC8654105 DOI: 10.5144/0256-4947.2021.376] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Ultraportable or pocket handheld ultrasound devices (HUD) may be useful for large-scale abdominal aortic aneurysm screening. However, the reproducibility of measurements has not been compared with conventional cart-based ultrasound machines. OBJECTIVES Investigate the intra- and inter-operator reproducibility of a HUD compared with a conventional ultrasound machine for aortic screening. DESIGN Analytical, cross-sectional. SETTING Ultrasound department at a large tertiary care hospital in Riyadh. PATIENTS AND METHODS Eligible male participants aged ≥60 years were invited to participate upon arriving for a non-vascular ultrasound appointment. Three repeated anteroposterior measurements of the transverse aorta were made at the proximal and distal locations for each machine before repeating the measurements on a subset of participants by a second blinded operator. Intraclass correlation coefficients (ICC) and the Bland-Altman method were used to analyze reproducibility. MAIN OUTCOME MEASURE Inter-system and intra- and inter-operator ICCs. SAMPLE SIZE 114 males with repeated measurements by second operator on a subset of 35 participants. RESULTS The median age (interquartile range) of participants was 68 years (62-74 years). The intra- and inter-operator ICCs were all >0.800 showing almost perfect agreement except for the inter-operator reproducibility at the proximal location using a conventional machine (ICC= 0.583, P=.007) and the Butterfly device (ICC=0.467, P=.037). The inter-system ICCs (95% CI) were 0.818 (0.736-0.874) and 0.879 (0.799-0.924) at the proximal and distal locations, respectively. The mean difference in aortic measurement between the ultrasound systems was 0.3 mm (1.7%) in the proximal location and 0.6 mm (3.6%) in the distal location. In total, >91% of the difference in measurements between the machines was <3 mm. The mean scanning time was 4:16 minutes for the conventional system and 3:53 minutes for the HUD (P=.34). CONCLUSIONS Abdominal aortic screening using a HUD was feasible and reliable compared with a conventional ultrasound machine. A pocket HUD should be considered for large-scale screening. LIMITATIONS No cases of abdominal aortic aneurysm in the sample and lack of blinding. CONFLICT OF INTEREST None.
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Affiliation(s)
- Abdulrahman M Alfuraih
- From the Department of Radiology and Medical Imaging, College of Applied Medical Sciences, Prince Sattam bin Abdulaziz University, Alkharj, Saudi Arabia
| | - Abdulaziz I Alrashed
- From the Department of Rediodiagnostics and Medical Imaging, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Saleh O Almazyad
- From the Department of Rediodiagnostics and Medical Imaging, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mohammed J Alsaadi
- From the Department of Radiology and Medical Imaging, College of Applied Medical Sciences, Prince Sattam bin Abdulaziz University, Alkharj, Saudi Arabia
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DiLeo Thomas L, Henn MC. Perfecting the Gastrointestinal Physical Exam: Findings and Their Utility and Examination Pearls. Emerg Med Clin North Am 2021; 39:689-702. [PMID: 34600631 DOI: 10.1016/j.emc.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The physical examination of the patient is the cornerstone of the practice of medicine, and the skills to complete a thorough abdominal examination are critical in the care of patients. When performed correctly, the abdominal examination can be revealing when it comes to the overall health of the patient as well as acute pathology. The examination of the abdomen has the potential to minimize further testing or radiation and serves as a key diagnostic tool. In this article, we will discuss each portion of the abdominal examination in detail as well as pathologic findings, abdomen-specific signs, special patient populations, and clinical pearls.
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Affiliation(s)
- Liza DiLeo Thomas
- Department of Emergency Medicine, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
| | - Megan C Henn
- Department of Emergency Medicine, Emory University, 531 Asbury Circle, Annex Building, Suite N340, Atlanta, GA 30322, USA. https://twitter.com/megan_henn
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Bartholomew JR. From the Masters: Lessons learned about the vascular medicine history and physical examination from the past and present. Vasc Med 2021; 26:361-366. [PMID: 34355594 DOI: 10.1177/1358863x211022807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- John R Bartholomew
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH, USA.,Section of Vascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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Beer Y, Gilat R, Ner EB, Shohat N, Atoun E, Lindner D, Agar G. Impact of Body Mass Index on the Accuracy of Physical Examination and MRI of the Shoulder. Orthop J Sports Med 2021; 9:2325967120985643. [PMID: 33709009 PMCID: PMC7907545 DOI: 10.1177/2325967120985643] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/18/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The physical examination of overweight patients can require specific adaptations. Orthopaedic literature on the impact of body mass index (BMI) on the physical examination of the shoulder is virtually nonexistent. PURPOSE To assess whether BMI affects the sensitivity and specificity of common shoulder tests, using arthroscopy as a gold standard. We also examined the effects of BMI on the sensitivity and specificity of magnetic resonance imaging (MRI) of the shoulder for reference. STUDY DESIGN Cohort study (diagnosis); Level of evidence, 2. METHODS We analyzed the data of 116 consecutive patients who underwent shoulder arthroscopy for the treatment of rotator cuff tears, Bankart lesions, and superior labral anterior-posterior (SLAP) lesions. Preoperative BMI, physical examination of the shoulder findings, and MRI findings were extracted. Contingency tables and receiver operating characteristic curves were used to evaluate the sensitivity and specificity of provocative tests of the shoulder and MRI as well as their relationship to BMI. RESULTS The sensitivity and specificity of the Jobe supraspinatus test were 77.8% and 72.7% in patients with BMI ≤25, 82.6% and 70.6% in those with 25 < BMI ≤ 30, and 81.3% and 55.6% in those with BMI >30, respectively (P < .001). The apprehension and relocation tests demonstrated higher sensitivity and specificity for the overweight patients (25 < BMI ≤ 30) compared with the other BMI groups, with a sensitivity and specificity of 83.3% and 100% for the apprehension test and a sensitivity and specificity of 75% and 100% for the relocation test, respectively. The O'Brien, Speed, and Ebinger tests for SLAP tears had low accuracy and did not yield statistically significant results. MRI interpretation was found to be influenced by BMI in obese patients, especially when SLAP lesions were assessed. CONCLUSION Counterintuitively, tests for shoulder instability had greater specificity in overweight patients and should be encouraged, particularly in obese patients, in whom the specificity of shoulder MRI for the detection of a Bankart lesion is lower. The Jobe test was more sensitive but less specific in overweight patients. These findings may assist care providers in improving the interpretation of the shoulder examination of overweight patients and consequently lead to better treatment-related decisions.
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Affiliation(s)
- Yiftah Beer
- Department of Orthopaedic Surgery, Shamir Medical Center and Tel Aviv University, Tel Aviv, Israel
| | - Ron Gilat
- Department of Orthopaedic Surgery, Shamir Medical Center and Tel Aviv University, Tel Aviv, Israel
- Midwest Orthopaedics at Rush University Medical Center, Chicago, Illinois, USA
| | - Eran Beit Ner
- Department of Orthopaedic Surgery, Shamir Medical Center and Tel Aviv University, Tel Aviv, Israel
| | - Noam Shohat
- Department of Orthopaedic Surgery, Shamir Medical Center and Tel Aviv University, Tel Aviv, Israel
| | - Ehud Atoun
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Barzilai Medical Center Campus, Ashkelon, Israel
| | - Dror Lindner
- Department of Orthopaedic Surgery, Shamir Medical Center and Tel Aviv University, Tel Aviv, Israel
| | - Gabriel Agar
- Department of Orthopaedic Surgery, Shamir Medical Center and Tel Aviv University, Tel Aviv, Israel
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Farnsworth P, Bailey K, Baardsen E, Johnson J. An aortic wall to vertebral body fistula presenting as a lytic lesion. J Radiol Case Rep 2020; 14:1-9. [PMID: 33088420 DOI: 10.3941/jrcr.v14i9.3270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
There have been multiple reported cases of aortic fistulas but few cases of aorta to vertebral body fistulas and no aortic wall to vertebral body fistulas have been reported. Here we present a case of a patient who is status post thoracic aortic aneurysm (TAA) repair and found to have a lytic vertebral body lesion. Biopsy of the mass revealed blood products without evidence of malignancy and further investigation revealed a fistulous tract between the aortic wall and the vertebral body causing a vertebral body hematoma.
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Affiliation(s)
- Paul Farnsworth
- Department of Radiology, University of South Florida College of Medicine, Tampa, FL, USA
| | - Katie Bailey
- Department of Radiology, James Haley Veterans Hospital, Tampa, FL, USA
| | - Erika Baardsen
- Department of Pathology, University of South Florida College of Medicine, Tampa, FL, USA
| | - Jean Johnson
- Department of Pathology, James Haley Veterans Hospital, Tampa, FL, USA
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15
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Yi CH, Lei WY. Infrarenal Abdominal Aortic Aneurysm Causing Abdominal Pain. Am J Med Sci 2020; 360:208. [PMID: 32409105 DOI: 10.1016/j.amjms.2020.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 02/22/2020] [Accepted: 04/02/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Chih-Hsun Yi
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan
| | - Wei-Yi Lei
- Department of Medicine, Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation and Tzu Chi University, Hualien, Taiwan.
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16
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Bord S, El Khuri C. High-Risk Chief Complaints III. Emerg Med Clin North Am 2020; 38:499-522. [DOI: 10.1016/j.emc.2020.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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17
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Sudden Onset of Severe Left-Sided Abdominal Pain. Surgery 2020. [DOI: 10.1007/978-3-030-05387-1_58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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18
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Amari K, Fukumori N, Anzai K, Yamashita SI. The Diagnostic Process for the Evaluation of Acute Abdominal Pain by Resident Trainees in Japan: A Cross-sectional Study. Intern Med 2020; 59:1257-1265. [PMID: 32418953 PMCID: PMC7303460 DOI: 10.2169/internalmedicine.3526-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective Acute abdominal pain (AAP) of diverse etiology is a common chief complaint of patients who present to the emergency department (ED). AAP may pose a diagnostic challenge to physicians in training. We aimed to evaluate whether or not resident trainee doctors examine patients presenting with AAP in a Japanese acute-care hospital following Kendall's diagnostic algorithm. Methods We conducted a retrospective medical chart review from January 2015 to December 2016. Patients Patients ≥50 years old who presented to the ED within 7 days of the onset of AAP who were evaluated by residents at the ED of an acute care hospital were enrolled in this study. Patients transported by ambulance and referred from other hospitals and classified as level 1 or 2 according to the Japanese version of the Canadian Triage and Acuity Scale were excluded. Data, including the clinical history, location and character of pain, and age and gender of patients as well as the level of experience of residents, were abstracted from charts. We evaluated the concordance rate between the actual diagnostic process followed by residents and Kendall's diagnostic algorithm for AAP. Results We analyzed 466 patients (mean age 67.6 years) in the study who were evaluated and diagnosed by 123 residents. The concordance rate between the diagnostic procedures performed by residents and those suggested by Kendall's diagnostic algorithm was 61.2%. A low concordance rate was observed among patients with peritoneal signs, shock or toxic appearance (25.0%), suggested acute coronary syndromes (ACS) (55.1%), epigastric or right upper-quadrant pain (52.8%), and left upper-quadrant pain (55.6%). Abdominal ultrasonography is one of the recommended examinations for patients with signs of peritoneal irritation, shock or toxic appearance, right lower-quadrant pain, and left upper- or lower-quadrant pain, but the rates were relatively low at 25.0%, 34.4%, 31.8%, and 26.7%, respectively. Conclusion Abdominal ultrasonography required by Kendall's diagnostic algorithm was not performed appropriately in patients with symptoms and signs of peritonitis, shock or toxic appearance, right lower-quadrant pain, and left upper- or lower-quadrant pain or in female patients by resident trainees. Our findings underscore the importance of providing resident doctors with focused training concerning ultrasonography by attending physicians.
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Affiliation(s)
- Kaori Amari
- Department of Emergency Medicine, Saga-Ken Medical Center Koseikan, Japan
- Department of General Medicine, Saga University Hospital, Japan
| | - Norio Fukumori
- Education and Research Center for Community Medicine, Faculty of Medicine, Saga University, Japan
| | - Keizo Anzai
- Department of Hepatology, Diabetes, and Endocrinology, Faculty of Medicine, Saga University, Japan
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Clancy K, Wong J, Spicher A. Abdominal Aortic Aneurysm: A Case Report and Literature Review. Perm J 2019; 23:18.218. [PMID: 31926569 DOI: 10.7812/tpp/18.218] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Abdominal aortic aneurysms (AAA) more commonly affect men than women and are estimated to affect 4% to 8% of men older that age 60 years. Mortality because of a ruptured AAA is high, but elective repair is an effective and relatively safe intervention. CASE PRESENTATION A 79-year-old man came to the Emergency Department because of worsening back pain. Workup revealed a previously unknown, 10-cm aneurysm that had ruptured. Unfortunately, the patient died during emergency surgery. DISCUSSION A literature review of proper screening, referral timeframe, the most common surgical techniques, potential complications, and postoperative surveillance was conducted. Early detection, referral to vascular surgery, and possible open or endovascular repair are key to limiting the morbidity and mortality associated with AAA.
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Lake JCW, Tsui E, Wu J, Baker M, Kieffer K. Case reports of diagnostic error: liposarcoma mistaken for hematoma in an obese female with concurrent ipsilateral thrombosis on rivaroxaban. ACTA ACUST UNITED AC 2019; 6:301-305. [PMID: 30511930 DOI: 10.1515/dx-2018-0092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 10/19/2018] [Indexed: 11/15/2022]
Abstract
We report the case of a morbidly obese 49-year-old female found to have a 16×14×10 cm high grade myxoid liposarcoma of the thigh initially diagnosed as a hematoma. Recent initiation of rivaroxaban for a coincident ipsilateral popliteal vein thrombosis placed hematoma high in the differential diagnosis. Despite its large size, the mass was not directly appreciable on physical exam due to excess adjacent adipose tissue. Diagnostic success was achieved only after anchoring bias was abandoned and adaptive expertise was applied.
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Affiliation(s)
| | - Edison Tsui
- Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Jennifer Wu
- Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Michael Baker
- Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Kelly Kieffer
- Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
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Point-of-Care Ultrasound Performed by a Medical Student Compared to Physical Examination by Vascular Surgeons in the Detection of Abdominal Aortic Aneurysms. Ann Vasc Surg 2018; 52:15-21. [DOI: 10.1016/j.avsg.2018.03.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 03/12/2018] [Accepted: 03/19/2018] [Indexed: 01/23/2023]
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22
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Khan T, Mahomed A, Ghoorun B, Ali H. Acute testicular pain secondary to a leaking abdominal aortic aneurysm (AAA). BMJ Case Rep 2018; 2018:bcr-2018-226577. [PMID: 30232208 DOI: 10.1136/bcr-2018-226577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present the case of a 56-year-old male smoker with a background of hypertension who presented with acute onset right testicular pain secondary to a leaking abdominal aortic aneurysm. Following urgent surgical repair and a complicated intensive care recovery, the patient was discharged with no residual disability. This case highlights an atypical presentation of what is a devastating illness.
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Affiliation(s)
- Taufiq Khan
- Intensive Care Unit, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, West Yorkshire, UK
| | - Anver Mahomed
- Intensive Care Unit, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, West Yorkshire, UK.,Intensive Care Unit, Calderdale Royal Hospital, Halifax, England, UK
| | - Brijanand Ghoorun
- Intensive Care Unit, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, West Yorkshire, UK.,Intensive Care Unit, Calderdale Royal Hospital, Halifax, England, UK
| | - Haider Ali
- Intensive Care Unit, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, West Yorkshire, UK.,Intensive Care Unit, Calderdale Royal Hospital, Halifax, England, UK
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23
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Sault JD, Post AA, Butler AY, O'Hearn MA. Mobilization of the lumbar spine in a 76-year-old male with mechanical low back pain and an abdominal aortic aneurysm: A case report. Physiother Theory Pract 2018; 36:855-862. [PMID: 30198815 DOI: 10.1080/09593985.2018.1511019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Abdominal aortic aneurysms (AAAs) are found in 1-12% of older males. Low back pain (LBP) is prevalent with incidence increasing with age and can respond to manual therapy (MT). To date, the safety of the application of MT for LBP in the presence of a known AAA has not been reported. This case reports on the short-term effects of MT in a patient with LBP and AAA and pre- and post-therapy imaging. CASE DESCRIPTION A 76-year-old male presented with mechanical LBP, groin pain, and a known 4.2-cm AAA. A lumbar magnetic resonance imaging showed significant multilevel abnormalities. Abdominal screening did not elicit back or groin pain. Lumbar and hip range of motion and accessory motion testing reproduced his complaints. He was treated with lumbar and hip MT. OUTCOMES After three visits, he reported that his groin pain resolved, and his back pain could be managed with home exercise. He reported a +6 on the global rating of change. Repeated follow-up imaging of his AAA demonstrated no significant change of his AAA. DISCUSSION No immediate adverse events were recorded, and repeated follow-up imaging indicated no significant AAA expansion. Considering that mobilization causes similar displacement to active motion, research into the safety of MT in this population is warranted as are guidelines for appropriate initial and ongoing clinical screening during treatment in this population.
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Affiliation(s)
- Josiah D Sault
- Outpatient Physical Therapy, University of Illinois Hospital and Health Sciences System , Chicago, IL, USA
| | - Andrew A Post
- Outpatient Physical Therapy, University of Illinois Hospital and Health Sciences System , Chicago, IL, USA
| | - Amanda Y Butler
- Outpatient Physical Therapy, University of Illinois Hospital and Health Sciences System , Chicago, IL, USA
| | - Michael A O'Hearn
- Rehabilitation Services, Lakeland Regional Health System , St. Joseph, MI, USA
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Differential Diagnosis in a Patient Presenting With Both Systemic and Neuromusculoskeletal Pathology: Resident's Case Problem. J Orthop Sports Phys Ther 2018; 48:496-503. [PMID: 29406836 DOI: 10.2519/jospt.2018.7652] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Study Design Resident's case problem. Background Patients presenting with multiple symptomatic areas pose a diagnostic challenge for the physical therapist. Though musculoskeletal and nonmusculoskeletal symptoms typically present separately, they can occur simultaneously and mimic each other. Consequently, the ability to differentiate between musculoskeletal and nonmusculoskeletal symptoms is an important skill for physical therapists. The purpose of this resident's case problem was to describe the clinical-reasoning process leading to medical and physical therapy management of a patient presenting with upper and lower back pain, bilateral radiating arm and leg pain, and abdominal pain. Diagnosis The patient was a 30-year-old woman referred to physical therapy for upper and lower back pain. A detailed history and thorough examination revealed that the patient had signs and symptoms consistent with a possible abdominal aortic aneurysm. She was referred for medical management and was diagnosed with symptomatic cholelithiasis. She subsequently had a cholecystectomy, which ultimately resolved her abdominal pain and reduced her pain in other areas significantly. Although many of her symptoms resolved postoperatively, her pain in other areas remained and was potentially musculoskeletal in origin. Following re-evaluation and 3 physical therapy treatments over a 2-month period, she was relatively symptom free at discharge and had achieved all functional rehabilitation goals. Discussion This resident's case problem provides an opportunity to discuss the differential diagnosis, clinical reasoning, and outcome of a patient who presented with both systemic and neuromusculoskeletal pathology. Level of Evidence Differential diagnosis, level 5. J Orthop Sports Phys Ther 2018;48(6):496-503. Epub 6 Feb 2018. doi:10.2519/jospt.2018.7652.
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Abstract
Abdominal aortic aneurysm (AAA) is most commonly defined as a maximal diameter of the abdominal aorta in excess of 3 cm in either anterior-posterior or transverse planes or, alternatively, as a focal dilation ≥ 1.5 times the diameter of the normal adjacent arterial segment. Risk factors for the development of AAA include age > 60, tobacco use, male gender, Caucasian race, and family history of AAA. Aneurysm growth and rupture risk appear to be associated with persistent tobacco use, female gender, and chronic pulmonary disease. The majority of AAAs are asymptomatic and detected incidentally on various imaging studies, including abdominal ultrasound, and computed tomographic angiography. Symptoms associated with AAA may include abdominal or back pain, thromboembolization, atheroembolization, aortic rupture, or development of an arteriovenous or aortoenteric fistula. The Screening Abdominal Aortic Aneurysms Efficiently (SAAAVE) Act provides coverage for a one-time screening abdominal ultrasound at age 65 for men who have smoked at least 100 cigarettes and women who have family history of AAA disease. Medical management is recommended for asymptomatic patients with AAAs < 5 cm in diameter and focuses on modifiable risk factors, including smoking cessation and blood pressure control. Primary indications for intervention in patients with AAA include development of symptoms, rupture, rapid aneurysm growth (> 5 mm/6 months), or presence of a fusiform aneurysm with maximum diameter of 5.5 cm or greater. Intervention for AAA includes conventional open surgical repair and endovascular aortic stent graft repair.
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26
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Borgbjerg J, Bøgsted M, Lindholt JS, Behr-Rasmussen C, Hørlyck A, Frøkjær JB. Superior Reproducibility of the Leading to Leading Edge and Inner to Inner Edge Methods in the Ultrasound Assessment of Maximum Abdominal Aortic Diameter. Eur J Vasc Endovasc Surg 2018; 55:206-213. [DOI: 10.1016/j.ejvs.2017.11.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2017] [Accepted: 11/13/2017] [Indexed: 11/28/2022]
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27
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The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc Surg 2018; 67:2-77.e2. [DOI: 10.1016/j.jvs.2017.10.044] [Citation(s) in RCA: 1150] [Impact Index Per Article: 191.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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28
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Patel R, Powell JT, Sweeting MJ, Epstein DM, Barrett JK, Greenhalgh RM. The UK EndoVascular Aneurysm Repair (EVAR) randomised controlled trials: long-term follow-up and cost-effectiveness analysis. Health Technol Assess 2018; 22:1-132. [PMID: 29384470 PMCID: PMC5817412 DOI: 10.3310/hta22050] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Short-term survival benefits of endovascular aneurysm repair (EVAR) compared with open repair (OR) of intact abdominal aortic aneurysms have been shown in randomised trials, but this early survival benefit is soon lost. Survival benefit of EVAR was unclear at follow-up to 10 years. OBJECTIVE To assess the long-term efficacy of EVAR against OR in patients deemed fit and suitable for both procedures (EVAR trial 1; EVAR-1); and against no intervention in patients unfit for OR (EVAR trial 2; EVAR-2). To appraise the long-term significance of type II endoleak and define criteria for intervention. DESIGN Two national, multicentre randomised controlled trials: EVAR-1 and EVAR-2. SETTING Patients were recruited from 37 hospitals in the UK between 1 September 1999 and 31 August 2004. PARTICIPANTS Men and women aged ≥ 60 years with an aneurysm of ≥ 5.5 cm (as identified by computed tomography scanning), anatomically suitable and fit for OR were randomly assigned 1 : 1 to either EVAR (n = 626) or OR (n = 626) in EVAR-1 using computer-generated sequences at the trial hub. Patients considered unfit were randomly assigned to EVAR (n = 197) or no intervention (n = 207) in EVAR-2. There was no blinding. INTERVENTIONS EVAR, OR or no intervention. MAIN OUTCOME MEASURES The primary end points were total and aneurysm-related mortality until mid-2015 for both trials. Secondary outcomes for EVAR-1 were reinterventions, costs and cost-effectiveness. RESULTS In EVAR-1, over a mean of 12.7 years (standard deviation 1.5 years; maximum 15.8 years), we recorded 9.3 deaths per 100 person-years in the EVAR group and 8.9 deaths per 100 person-years in the OR group [adjusted hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.97 to 1.27; p = 0.14]. At 0-6 months after randomisation, patients in the EVAR group had a lower mortality (adjusted HR 0.61, 95% CI 0.37 to 1.02 for total mortality; HR 0.47, 95% CI 0.23 to 0.93 for aneurysm-related mortality; p = 0.031), but beyond 8 years of follow-up patients in the OR group had a significantly lower mortality (adjusted HR 1.25, 95% CI 1.00 to 1.56, p = 0.048 for total mortality; HR 5.82, 95% CI 1.64 to 20.65, p = 0.0064 for aneurysm-related mortality). The increased aneurysm-related mortality in the EVAR group after 8 years was mainly attributable to secondary aneurysm sac rupture, with increased cancer mortality also observed in the EVAR group. Overall, aneurysm reintervention rates were higher in the EVAR group than in the OR group, 4.1 and 1.7 per 100 person-years, respectively (p < 0.001), with reinterventions occurring throughout follow-up. The mean difference in costs over 14 years was £3798 (95% CI £2338 to £5258). Economic modelling based on the outcomes of the EVAR-1 trial showed that the cost per quality-adjusted life-year gained over the patient's lifetime exceeds conventional thresholds used in the UK. In EVAR-2, patients died at the same rate in both groups, but there was suggestion of lower aneurysm mortality in those who actually underwent EVAR. Type II endoleak itself is not associated with a higher rate of mortality. LIMITATIONS Devices used were implanted between 1999 and 2004. Newer devices might have better results. Later follow-up imaging declined, particularly for OR patients. Methodology to capture reinterventions changed mainly to record linkage through the Hospital Episode Statistics administrative data set from 2009. CONCLUSIONS EVAR has an early survival benefit but an inferior late survival benefit compared with OR, which needs to be addressed by lifelong surveillance of EVAR and reintervention if necessary. EVAR does not prolong life in patients unfit for OR. Type II endoleak alone is relatively benign. FUTURE WORK To find easier ways to monitor sac expansion to trigger timely reintervention. TRIAL REGISTRATION Current Controlled Trials ISRCTN55703451. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and the results will be published in full in Health Technology Assessment; Vol. 22, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rajesh Patel
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Janet T Powell
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Michael J Sweeting
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - David M Epstein
- Centre for Health Economics, University of York, York, UK.,Department of Applied Economics, University of Granada, Granada, Spain
| | - Jessica K Barrett
- Cardiovascular Epidemiology Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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29
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Ma IWY, Arishenkoff S, Wiseman J, Desy J, Ailon J, Martin L, Otremba M, Halman S, Willemot P, Blouw M. Internal Medicine Point-of-Care Ultrasound Curriculum: Consensus Recommendations from the Canadian Internal Medicine Ultrasound (CIMUS) Group. J Gen Intern Med 2017; 32:1052-1057. [PMID: 28497416 PMCID: PMC5570740 DOI: 10.1007/s11606-017-4071-5] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 04/05/2017] [Accepted: 04/13/2017] [Indexed: 11/29/2022]
Abstract
Bedside point-of-care ultrasound (POCUS) is increasingly used to assess medical patients. At present, no consensus exists for what POCUS curriculum is appropriate for internal medicine residency training programs. This document details the consensus-based recommendations by the Canadian Internal Medicine Ultrasound (CIMUS) group, comprising 39 members, representing 14 institutions across Canada. Guiding principles for selecting curricular content were determined a priori. Consensus was defined as agreement by at least 80% of the members on POCUS applications deemed appropriate for teaching and assessment of trainees in the core (internal medicine postgraduate years [PGY] 1-3) and expanded (general internal medicine PGY 4-5) training programs. We recommend four POCUS applications for the core PGY 1-3 curriculum (inferior vena cava, lung B lines, pleural effusion, and abdominal free fluid) and three ultrasound-guided procedures (central venous catheterization, thoracentesis, and paracentesis). For the expanded PGY 4-5 curriculum, we recommend an additional seven applications (internal jugular vein, lung consolidation, pneumothorax, knee effusion, gross left ventricular systolic function, pericardial effusion, and right ventricular strain) and four ultrasound-guided procedures (knee arthrocentesis, arterial line insertion, arterial blood gas sampling, and peripheral venous catheterization). These recommendations will provide a framework for training programs at a national level.
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Affiliation(s)
- Irene W Y Ma
- Department of Medicine, University of Calgary, Calgary, AB, Canada.
- W21C, University of Calgary, Calgary, AB, Canada.
| | | | | | - Janeve Desy
- Department of Medicine, University of Calgary, Calgary, AB, Canada
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30
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Long B, Koyfman A. Vascular Causes of Syncope: An Emergency Medicine Review. J Emerg Med 2017; 53:322-332. [PMID: 28662832 DOI: 10.1016/j.jemermed.2017.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 05/05/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Syncope is a common emergency department (ED) complaint, accounting for 2% of visits annually. A wide variety of etiologies can result in syncope, and vascular causes may be deadly. OBJECTIVE This review evaluates vascular causes of syncope and their evaluation and management in the ED. DISCUSSION Syncope is defined by a brief loss of consciousness with loss of postural tone and complete, spontaneous recovery without medical intervention. Causes include cardiac, vasovagal, orthostatic, neurologic, medication-related, and idiopathic, and most cases of syncope will not receive a specific diagnosis pertaining to the cause. Emergency physicians are most concerned with life-threatening causes such as dysrhythmia and obstruction, and electrocardiogram is a primary means of evaluation. However, vascular etiologies can result in patient morbidity and mortality. These conditions include pulmonary embolism, subclavian steal, aortic dissection, cerebrovascular disease, intracerebral hemorrhage, carotid/vertebral dissection, and abdominal aortic aneurysm. A focused history and physical examination can assist emergency physicians in determining the need for further testing and management. CONCLUSIONS Syncope is common and may be the result of a deadly condition. The emergency physician, through history and physical examination, can determine the need for further evaluation and resuscitation of these patients, with consideration of vascular etiologies of syncope.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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31
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Botar CC, Tóth ÁÁ, Klisurić OR, Nićiforović DD, Vučaj Ćirilović VA, Till VE. Dynamic simulation and Doppler Ultrasonography validation of blood flow behavior in Abdominal Aortic Aneurysm. Phys Med 2017; 37:1-8. [DOI: 10.1016/j.ejmp.2017.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 03/20/2017] [Accepted: 03/27/2017] [Indexed: 10/19/2022] Open
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32
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Sazonov I, Khir AW, Hacham WS, Boileau E, Carson JM, van Loon R, Ferguson C, Nithiarasu P. A novel method for non-invasively detecting the severity and location of aortic aneurysms. Biomech Model Mechanobiol 2017; 16:1225-1242. [PMID: 28220320 PMCID: PMC5511604 DOI: 10.1007/s10237-017-0884-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 02/01/2017] [Indexed: 11/28/2022]
Abstract
The influence of an aortic aneurysm on blood flow waveforms is well established, but how to exploit this link for diagnostic purposes still remains challenging. This work uses a combination of experimental and computational modelling to study how aneurysms of various size affect the waveforms. Experimental studies are carried out on fusiform-type aneurysm models, and a comparison of results with those from a one-dimensional fluid–structure interaction model shows close agreement. Further mathematical analysis of these results allows the definition of several indicators that characterize the impact of an aneurysm on waveforms. These indicators are then further studied in a computational model of a systemic blood flow network. This demonstrates the methods’ ability to detect the location and severity of an aortic aneurysm through the analysis of flow waveforms in clinically accessible locations. Therefore, the proposed methodology shows a high potential for non-invasive aneurysm detectors/monitors.
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Affiliation(s)
- Igor Sazonov
- College of Engineering, Swansea University, Bay Campus, Fabian Way, Swansea, SA1 8EN, UK.
| | - Ashraf W Khir
- Brunel University London, Uxbridge, London, B8 3PH, UK
| | - Wisam S Hacham
- Brunel University London, Uxbridge, London, B8 3PH, UK.,Al-Khwarizmi College of Engineering, Baghdad University, Baghdad, Iraq
| | - Etienne Boileau
- College of Engineering, Swansea University, Bay Campus, Fabian Way, Swansea, SA1 8EN, UK
| | - Jason M Carson
- College of Engineering, Swansea University, Bay Campus, Fabian Way, Swansea, SA1 8EN, UK
| | - Raoul van Loon
- College of Engineering, Swansea University, Bay Campus, Fabian Way, Swansea, SA1 8EN, UK
| | - Colin Ferguson
- Department of Vascular Surgery ABMUHB, Morriston Hospital, Swansea, SA6 6NL, UK
| | - Perumal Nithiarasu
- College of Engineering, Swansea University, Bay Campus, Fabian Way, Swansea, SA1 8EN, UK
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33
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Esposito R, Ilardi F, Schiano Lomoriello V, Sorrentino R, Sellitto V, Giugliano G, Esposito G, Trimarco B, Galderisi M. Identification of the main determinants of abdominal aorta size: a screening by Pocket Size Imaging Device. Cardiovasc Ultrasound 2017; 15:2. [PMID: 28086907 PMCID: PMC5237342 DOI: 10.1186/s12947-016-0094-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 12/28/2016] [Indexed: 01/16/2023] Open
Abstract
Background Ultrasound exam as a screening test for abdominal aorta (AA) can visualize the aorta in 99% of patients and has a sensitivity and specificity approaching 100% in screening settings for aortic aneurysm. Pocket Size Imaging Device (PSID) has a potential value as a screening tool, because of its possible use in several clinical settings. Our aim was to assess the impact of demographics and cardiovascular (CV) risk factors on AA size by using PSID in an outpatient screening. Methods Consecutive patients, referring for a CV assessment in a 6 months period, were screened. AA was visualized by subcostal view in longitudinal and transverse plans in order to determine the greatest anterior-posterior diameter. After excluding 5 patients with AA aneurysm, 508 outpatients were enrolled. All patients underwent a sequential assessment including clinical history with collection of CV risk factors, physical examination, PSID exam and standard Doppler echoc exam using a 2.5 transducer with harmonic capability, both by expert ultrasound operators, during the same morning. Standard echocardiography operators were blinded on PSID exam and viceversa. Results Diagnostic accuracy of AA size by PSID was tested successfully with standard echo machine in a subgroup (n = 102) (rho = 0.966, p < 0.0001). AA diameter was larger in men than in women and in ≥50 -years old subjects than in those <50 -years old (both p < 0.0001). AA was larger in patients with coronary artery disease (CAD) (p < 0.0001). By a multivariate model, male sex (p < 0.0001), age and body mass index (both p < 0.0001), CAD (p < 0.01) and heart rate (p = 0.018) were independent predictors of AA size (cumulative R2 = 0.184, p < 0.0001). Conclusion PSID is a reliable tool for the screening of determinants of AA size. AA diameter is greater in men and strongly influenced by aging and overweight. CAD may be also associated to increased AA diameter.
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Affiliation(s)
- Roberta Esposito
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University Hospital, Naples, Italy
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University Hospital, Naples, Italy
| | - Vincenzo Schiano Lomoriello
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University Hospital, Naples, Italy
| | - Regina Sorrentino
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University Hospital, Naples, Italy
| | - Vincenzo Sellitto
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University Hospital, Naples, Italy
| | - Giuseppe Giugliano
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University Hospital, Naples, Italy
| | - Giovanni Esposito
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University Hospital, Naples, Italy
| | - Bruno Trimarco
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University Hospital, Naples, Italy
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Division of Cardiology, Federico II University Hospital, Naples, Italy. .,Interdepartimental Laboratory of Cardiac Imaging, Federico II University Hospital, Via S. Pansini 5,bld 1, 80131, Naples, Italy.
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Nowicka M, Kowalczyk A, Rusak G, Ratajczak P, Sobociński B. Evaluation the Aortic Aneurysm Remodeling After a Successful Stentgraft Implantation. Pol J Radiol 2016; 81:486-490. [PMID: 27800038 PMCID: PMC5066507 DOI: 10.12659/pjr.900116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 06/18/2016] [Indexed: 11/09/2022] Open
Abstract
Background Routine imaging follow-up after endovascular treatment of abdominal aortic aneurysms (EVAR) is mainly aimed at detection of endoleaks. The aim of the study was to assess changes in the size of the abdominal aortic aneurysm sack using CT angiography (CTA) after successful treatment using endovascular stent graft implantation. Material/Methods A retrospective analysis of CTA results included 102 patients aged 54–88, who had no postoperative complications. Patients underwent CTA before EVAR and after the treatment (mean time between studies, 7.6 months). The largest cross-sectional area of the aneurysm sac was measured using a curved multiplanar reconstruction. A change of the aneurysm cross-sectional over 10% was considered significant. Results The average cross-sectional area decreased after EVAR by 3% and this change was not statistically significant. Regression of the cross-sectional area was observed in 18.6% of patients, progression was in 23.5%, and no change was seen in 57.8%. Cross-sectional areas before and after EVAR were significantly correlated (r=0.75, p<0.0001). There was no correlation between the cross-sectional area change after EVAR and patients’ age or the time between the treatment and the follow-up CTA. Cross-sectional area before the treatment predicted changes in the aneurysm size after EVAR (p=0.0045). Conclusions Remodeling of abdominal aortic aneurysms after EVAR is not uniform. The change of aneurysm size depends on the initial aneurysm size but not on the time from EVAR. The size of the aneurysm after EVAR should not be considered as a measure of the treatment efficacy.
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Affiliation(s)
- Monika Nowicka
- Faculty of Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Agnieszka Kowalczyk
- Faculty of Medicine, Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Grażyna Rusak
- Department of Radiology and Diagnostic Imaging, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Poland
| | - Przemysław Ratajczak
- Department of Radiology and Diagnostic Imaging, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Poland
| | - Bartosz Sobociński
- Department of Radiology and Diagnostic Imaging, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, Poland
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Mok KL. Make it SIMPLE: enhanced shock management by focused cardiac ultrasound. J Intensive Care 2016; 4:51. [PMID: 27529027 PMCID: PMC4983798 DOI: 10.1186/s40560-016-0176-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 07/12/2016] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Shock is a spectrum of circulatory failure that, if not properly managed, would lead to high mortality. Special diagnostic and treatment strategies are essential to save lives. However, clinical and laboratory findings are always non-specific, resulting in clinical dilemmas. MAIN CONTENT Focused cardiac ultrasound (FoCUS) has emerged as one of the power tools for clinicians to answer simple clinical questions and guide subsequent management in hypotensive patients. This article will review the development and utility of FoCUS in different types of shock. The sonographic features and ultrasound enhanced management of hypotensive patients by a de novo "SIMPLE" approach will be described. Current evidence on FoCUS will also be reviewed. CONCLUSION Focused cardiac ultrasound provides timely and valuable information for the evaluation of shock. It helps to improve the diagnostic accuracy, narrow the possible differential diagnoses, and guide specific management. SIMPLE is an easy-to-remember mnemonic for non-cardiologists or novice clinical sonographers to apply FoCUS and interpret the specific sonographic findings when evaluating patients in shock.
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Affiliation(s)
- Ka Leung Mok
- Accident and Emergency Department, Ruttonjee Hospital, 266 Queen’s Road East, Wanchai, Hong Kong SAR
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McCartan D, Stempel M, Eaton A, Morrow M, Pilewskie M. Impact of Body Mass Index on Clinical Axillary Nodal Assessment in Breast Cancer Patients. Ann Surg Oncol 2016; 23:3324-9. [PMID: 27338746 DOI: 10.1245/s10434-016-5330-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND More than one-third of American adults are obese, and an elevated body mass index (BMI) is postulated to reduce the sensitivity of the clinical evaluation of the axilla. Clinical nodal examination is important in allocating breast cancer patients to appropriate axillary management. This study sought to determine whether BMI influences the rate of nodal positivity in women designated clinically as node-negative (cN0) by physical examination. METHODS Breast cancer patients deemed cN0 who underwent sentinel lymph node biopsy (SLNB) from February 2006 to December 2011 were identified from a prospectively maintained database. Clinicopathologic features including BMI and axillary surgery results were recorded and compared among pathologically node-negative and node-positive patients. RESULTS Overall, 5142 cN0 patients underwent 5262 SLNB procedures during the study period. Nearly one-third of the patients (28 %) were obese (BMI, >30 kg/m(2)). A positive SLN was identified in 25 % of the patients, and 84 % proceeded to axillary lymph node dissection. Predictors of SLN positivity included younger age, larger tumor size, high nuclear grade, multifocality, and lymphovascular invasion. An increased BMI did not correlate with a higher likelihood of SLN positivity (p = 0.6). The likelihood of cN0 patients having a high burden of axillary metastases (>3 positive nodes) was 4 % overall and, similarly, did not differ according to BMI (p = 0.4). CONCLUSION Elevated BMI was not associated with a higher likelihood of SLN positivity or heavy nodal disease burden among women staged as cN0 by physical exam. These findings indicate that physical examination is appropriate and sufficient for preoperative axillary evaluation of women undergoing initial surgery regardless of patient BMI.
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Affiliation(s)
- Damian McCartan
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michelle Stempel
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anne Eaton
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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Lahoz C, Gracia CE, García LR, Montoya SB, Hernando ÁB, Heredero ÁF, Tembra MS, Velasco MB, Guijarro C, Ruiz EB, Pintó X, de Ceniga MV, Moñux Ducajú G. [Not Available]. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2016; 28 Suppl 1:1-49. [PMID: 27107212 DOI: 10.1016/s0214-9168(16)30026-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Affiliation(s)
- Carlos Lahoz
- Unidad de Lípidos y Riesgo Vascular, Servicio de Medicina Interna, Hospital Carlos III, Madrid, España.
| | - Carlos Esteban Gracia
- Servicio de Angiología y Cirugía Vascular, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, España
| | | | - Sergi Bellmunt Montoya
- Servicio de Angiología y Cirugía Vascular, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - Ángel Brea Hernando
- Unidad de Lípidos, Servicio de Medicina Interna, Hospital San Pedro, Logroño, España
| | | | - Manuel Suárez Tembra
- Unidad de Lípidos y Riesgo Cardiovascular, Servicio de Medicina Interna, Hospital San Rafael, A Coruña, España
| | - Marta Botas Velasco
- Servicio de Angiología y Cirugía Vascular, Hospital de Cabueñes, Gijón, España
| | - Carlos Guijarro
- Consulta de Riesgo Vascular, Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Alcorcón, Madrid, España
| | - Esther Bravo Ruiz
- Servicio de Angiología y Cirugía Vascular, Hospital Universitario de Basurto, Bilbao, España
| | - Xavier Pintó
- Unidad de Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario de Bellvitge, L' Hospitalet de Llobregat, Barcelona, España
| | - Melina Vega de Ceniga
- Servicio de Angiología y Cirugía Vascular, Hospital de Galdakao-Usansolo, Vizcaya, España
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Senaratne JM, Raggi P. Screening for aortic aneurysms in patients with coronary artery disease: should it be done? Expert Rev Cardiovasc Ther 2015; 13:735-7. [PMID: 26004391 DOI: 10.1586/14779072.2015.1051036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Aneurysmal dilation of the aorta is a clinically silent disease that often presents first with a catastrophic event. As a result, several clinician societies and organizations have recommended screening to detect aneurysms before they rupture. Although screening may reduce mortality, the implementation of screening has been poor. Cardiologists are uniquely positioned to improve this gap as they handle patients with typical risk factors for aneurysmal diseases of the aorta and can endorse and implement screening in a high-risk population. The following article attempts to concisely give a navigational tool to the cardiovascular specialist for her/his role in the diagnosis and management of thoracic and abdominal aortic aneurysms, citing evidence as well as stating opinions on how to improve outcomes in this unique patient population.
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Jacob AD, Barkley PL, Broadbent KC, Huynh TT. Abdominal Aortic Aneurysm Screening. Semin Roentgenol 2015; 50:118-26. [DOI: 10.1053/j.ro.2014.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Fukuda S, Watanabe H, Iwakura K, Daimon M, Ito H, Yoshikawa J. Multicenter Investigations of the Prevalence of Abdominal Aortic Aneurysm in Elderly Japanese Patients With Hypertension. Circ J 2015; 79:524-9. [DOI: 10.1253/circj.cj-14-0972] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Shota Fukuda
- Department of Medicine, Osaka Ekisaikai Hospital
| | | | | | - Masao Daimon
- Clinical Laboratory, The University of Tokyo Hospital
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine and Dentistry
| | - Junichi Yoshikawa
- Department of Cardiology, Nishinomiya Watanabe Cardiovascular Center
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Abstract
STUDY DESIGN Resident's case problem. BACKGROUND The purpose of this report was to describe (1) the clinical reasoning that led a clinician to identify an abdominal aortic aneurysm (AAA) in a patient with low back pain requiring immediate medical referral, and (2) an evidence-based approach to clinical evaluation of patients with suspected AAA. DIAGNOSIS The patient was unable to identify a specific mechanism of injury for his low back pain, lacked aggravating/easing factors for his symptoms, and complained of night pain and an inability to ease his symptoms with position changes. While the patient's symptoms remained unchanged during physical examination of the lumbar spine and hip, abdominal palpation revealed a strong, nontender pulsation over the midline of the upper and lower abdominal quadrants. Due to concern for an AAA, the patient was immediately referred to his physician. Subsequent computed tomography imaging revealed a prominent AAA, which measured up to 5.5 cm in greatest dimension and extended from below the renal arteries to the bifurcation of the iliac arteries. The patient initially deferred surgical intervention but eventually consented 6 months later, after repeat computed tomography imaging revealed that the AAA had progressed to 6.7 cm in greatest dimension. DISCUSSION It is essential for physical therapists to be familiar with a diagnostic pathway to help identify AAA in patients presenting with apparent musculoskeletal complaints. Knowledge of the risk factors for AAA, understanding how to screen for nonmusculoskeletal symptoms, and a basic competence in abdominal palpation and how to interpret findings will help with the clinician's clinical decision making. LEVEL OF EVIDENCE Differential diagnosis, level 4. J Orthop Sports Phys Ther 2014;44(7):500-507. Epub 25 April 2014. doi:10.2519/jospt.2014.4935.
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Steller J, Russell B, Lotfipour S, Maldonado G, Siepel T, Jakle H, Hata S, Chiem A, Fox JC. USEFUL: Ultrasound Exam for Underlying Lesions incorporated into physical exam. West J Emerg Med 2014; 15:260-6. [PMID: 24868302 PMCID: PMC4025521 DOI: 10.5811/westjem.2013.8.19080] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2013] [Accepted: 08/27/2013] [Indexed: 02/03/2023] Open
Abstract
INTRODUCTION The Ultrasound Screening Exam for Underlying Lesions (USEFUL) was developed in an attempt to establish a role for bedside ultrasound in the primary and preventive care setting. It is the purpose of our pilot study to determine if students were first capable of performing all of the various scans required of our USEFUL while defining such an ultrasound-assisted physical exam that would supplement the standard hands-on physical exam in the same head-to-toe structure. We also aimed to assess the time needed for an adequate exam and analyze if times improved with repetition and previous ultrasound training. METHODS Medical students with ranging levels of ultrasound training received a 25-minute presentation on our USEFUL followed by a 30-minute hands-on session. Following the hands-on session, the students were asked to perform a timed USEFUL on 2-3 standardized subjects. All images were documented as normal or abnormal with the understanding that an official detailed exam would be performed if an abnormality were to be found. All images were read and deemed adequate by board eligible emergency medicine ultrasound fellows. RESULTS Twenty-six exams were performed by 9 students. The average time spent by all students per USEFUL was 11 minutes and 19 seconds. Students who had received the University of California, Irvine School of Medicine's integrated ultrasound curriculum performed the USEFUL significantly faster (p< 0.0025). The time it took to complete the USEFUL ranged from 6 minutes and 32 seconds to 17 minutes, and improvement was seen with each USEFUL performed. The average time to complete the USEFUL on the first standardized patient was 13 minutes and 20 seconds, while 11 minutes and 2 seconds, and 9 minutes and 20 seconds were spent performing the exam on the second and third patient, respectively. CONCLUSION Students were able to effectively complete all scans required by the USEFUL in a timely manner. Students who have been a part of the integrated ultrasound in medicine curriculum performed the USEFUL significantly faster than students who had not. Students were able to significantly improve upon the time it took them to complete the USEFUL with successive attempts. Future endpoints are aimed at assessing the feasibility and outcomes of an ultrasound-assisted physical exam in a primary care setting and the exam's effect on doctor-patient satisfaction. [West J Emerg Med. 2014;15(3):260-266.].
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Affiliation(s)
- Jon Steller
- University of California, Irvine School of Medicine, Irvine, California
| | - Bianca Russell
- University of California, Irvine School of Medicine, Irvine, California
| | - Shahram Lotfipour
- University of California, Irvine School of Medicine, Irvine, California
- Department of Emergency Medicine, University of California, Irvine, Orange, California
| | | | - Tim Siepel
- Department of Family Medicine, State University of New York, Buffalo, New York
| | - Halsey Jakle
- University of California, Irvine School of Medicine, Irvine, California
| | - Stacy Hata
- University of California, Irvine School of Medicine, Irvine, California
| | - Alan Chiem
- University of California, Olive View-University of California, Los Angeles Medical Center, Sylmar, California
| | - John Christian Fox
- University of California, Irvine School of Medicine, Irvine, California
- Department of Emergency Medicine, University of California, Irvine, Orange, California
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Addition of a lateral view improves adequate visualization of the abdominal aorta during clinician performed ultrasound. Am J Emerg Med 2014; 32:256-9. [PMID: 24374356 DOI: 10.1016/j.ajem.2013.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 10/11/2013] [Accepted: 10/14/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVE Full visualization of the abdominal aorta using the standard midline view is often inadequate for the detection of abdominal aortic aneurysm. We evaluated whether the addition of a lateral midaxillary right upper quadrant view could improve visualization of the abdominal aorta. METHODS This was a prospective observational proof-of-concept study of patients older than 50 years undergoing abdominal computed tomographic scan for any indication in the emergency department. Ultrasounds were performed by American College of Emergency Physicians-credentialed study sonographers, and images were reviewed by an ultrasound fellowship-trained reviewer. The standard midline aortic images were obtained as well as additional lateral images from a midaxillary right upper quadrant approach. Visualization of the aorta was determined to be adequate if more than two-thirds of the abdominal aorta was visualized. RESULTS We enrolled 60 patients. Six patients were excluded due to missing data. A total of 54 patients were analyzed. The median age was 67.5, and 37% were male. The mean body mass index was 25.9 (SD, 5.8), and mean abdominal circumference was 105.3 cm (SD, 18.1). Visualization of the aorta using the midline approach was adequate in 26 (48.2%) of 54 of the patients and 32 (59.2%) of 54 of the lateral approach. Addition of a lateral view in examinations with an inadequate midline view increased adequate aortic visualization to 41 (75.9%) of 54. CONCLUSION Combining a lateral view to the standard midline approach improves adequate visualization of the abdominal aorta by approximately 28%. Further study is required to determine if the lateral view is equivalent for detecting abdominal aortic aneurysm.
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Rubano E, Mehta N, Caputo W, Paladino L, Sinert R. Systematic Review: Emergency Department Bedside Ultrasonography for Diagnosing Suspected Abdominal Aortic Aneurysm. Acad Emerg Med 2013; 20:128-38. [DOI: 10.1111/acem.12080] [Citation(s) in RCA: 90] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Revised: 03/29/2012] [Accepted: 08/29/2012] [Indexed: 12/13/2022]
Affiliation(s)
- Elizabeth Rubano
- Department of Emergency Medicine; SUNY Downstate Medical Center; Brooklyn; NY
| | - Ninfa Mehta
- Department of Emergency Medicine; SUNY Downstate Medical Center; Brooklyn; NY
| | - William Caputo
- Department of Emergency Medicine; SUNY Downstate Medical Center; Brooklyn; NY
| | - Lorenzo Paladino
- Department of Emergency Medicine; SUNY Downstate Medical Center; Brooklyn; NY
| | - Richard Sinert
- Department of Emergency Medicine; SUNY Downstate Medical Center; Brooklyn; NY
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Abstract
The medical management of patients with an abdominal aortic aneurysm (AAA) includes modification of risk factors, smoking cessation, cardiovascular risk treatment, and hypertensive therapy. No specific therapy has been shown to alter disease outcome. Many AAA and thoracic aortic aneurysms are amenable to endovascular treatment. Endovascular repair offers the benefit of shorter hospital stays and lower perioperative morbidity and mortality. Most patients with peripheral arterial disease (PAD) are asymptomatic or have atypical symptoms; only a few present with classic intermittent claudication or critical limb ischemia. Smoking and diabetes mellitus are the most important risk factors for developing PAD.
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Affiliation(s)
- Fadi Elias Shamoun
- Department of Carviovascular Medicine, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
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Abstract
The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF). The purpose of these low back pain clinical practice guidelines, in particular, is to describe the peer-reviewed literature and make recommendations related to (1) treatment matched to low back pain subgroup responder categories, (2) treatments that have evidence to prevent recurrence of low back pain, and (3) treatments that have evidence to influence the progression from acute to chronic low back pain and disability.
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Dijos M, Pucheux Y, Lafitte M, Réant P, Prevot A, Mignot A, Barandon L, Roques X, Roudaut R, Pilois X, Lafitte S. Fast track echo of abdominal aortic aneurysm using a real pocket-ultrasound device at bedside. Echocardiography 2011; 29:285-90. [PMID: 22066817 DOI: 10.1111/j.1540-8175.2011.01559.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Ultraminiaturization of echographic systems extraordinarily provides the image "within" the clinical examination. Abdominal aorta aneurysm (AAA) diagnosis based on conventional evaluation with a dedicated operator and ultrasound machine is still controversial due to the lack of evidence of the proposed management and guidelines' cost-effectiveness. We hypothesized that less expensive ultraportable devices could identify AAA with the same level of accuracy as conventional approaches. METHODS A first step of this study was to validate the VSCAN's image capabilities in patients referred to the vascular Doppler laboratory. Abdominal aorta measurements were performed by an experienced physician using conventional equipment followed by a second blinded physician using the ultraportable device VSCAN. Then, 204 patients hospitalized in our cardiology institute were prospectively included for a systematic screening of AAA at bedside using the VSCAN in order to determine the feasibility and impact of fast track evaluation compared to clinical examination. RESULTS A strong correlation was obtained between measurements of abdominal aorta diameters using the two ultrasound systems (r = 0.98, CI: 0.97-0.99, P < 0.001) with 100% of agreement for AAA diagnosis. In the second part of the study, visualization and measurement of the transverse diameter of the abdominal aorta was obtained in 199 patients, resulting in a feasibility of 97.5%. Among these patients, 18 AAAs were detected, which corresponds to a prevalence of 9%, whereas clinical evaluation did not detect any of them. Patients with AAA were more likely men (77.77% vs. 57.45%, P < 0.05) and hypertensive (88.8% vs. 56.9%, P < 0.05) as compared to those without AAA. Two patients with large AAA were quickly referred to the surgery department. CONCLUSION Considering its low cost, diagnostic accuracy, and widespread availability, screening for AAA using an ultraportable ultrasound device such as VSCAN by an experienced physician is promising and should be used as an extension of routine physical examination in vascular patients.
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Affiliation(s)
- Marina Dijos
- Echocardiography Department, University of Bordeaux, Pessac, France
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Shah TT, Herbert P, Beresford T. An atypical presentation of aortic rupture: intuition and investigation can avoid disaster. Ann R Coll Surg Engl 2011; 93:e125-8. [PMID: 22004619 DOI: 10.1308/147870811x602131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Patients with an acute abdomen are a common presentation for those participating in emergency surgery cover. The aetiology of this presentation incorporates the spectrum of organ systems and is often not identified satisfactorily. Nevertheless, certain diagnoses will always be difficult to make and some presentations can be deceptive. Radiological investigations increasingly play a role in establishing an accurate diagnosis and frequently allow prompt management to be instituted. INTRODUCTION Patients with an acute abdomen are a common presentation for those participating in emergency surgery cover. The aetiology of this presentation incorporates the spectrum of organ systems and is often not identified satisfactorily. Nevertheless, certain diagnoses will always be difficult to make and some presentations can be deceptive. Radiological investigations increasingly play a role in establishing an accurate diagnosis and frequently allow prompt management to be instituted. INTRODUCTION Ruptured AAA should be considered as a differential diagnosis in all elderly patients presenting with acute severe abdominal pain who may be haemodynamically stable. Atypical history and examination with inconsistent or equivocal clinical signs should raise the suspicion of aneurysm, particularly in elderly men with known arterial disease. There should be a low threshold for both requesting and justifying definitive imaging (ie CT) in such cases if a catastrophic outcome through misdiagnosis is to be avoided.
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Affiliation(s)
- T T Shah
- Department of Surgery, Lister Hospital, Stevenage, UK.
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