The value of evaluating the abdominal aorta in patients <50 years of age presenting for abdominal ultrasound

INTRODUCTION

Practitioners of US routinely include a survey of the abdominal aorta during abdominal US in accordance with international guidelines. Such practice is of uncertain value in younger patients.

METHODOLOGY

This study was a retrospective review of 2000 abdominal US examinations which included visualisation of the aorta in patients <50 years of age. Patient demographics and referral details were recorded, and US images and reports were reviewed for the presence of aortic and periaortic pathology.

RESULTS

The most common indications for US were abdominal pain (1337, 44%), deranged liver function tests (453, 15%), nausea and/or vomiting (229, 8%), elevated inflammatory markers (146, 5%), pancreatitis (134, 4%) and pyrexia (127, 4%). Fewer than half (977, 49%) of the reports contained a comment regarding the aorta. Aortic pathology was reported in 2 (0.1%) cases. Both were reported as aortic ectasia and both represented a false-positive diagnosis. One male patient had a known abdominal aortic aneurysm with endovascular aortic repair. No new aortic aneurysms were found. All cases of atherosclerotic disease were ignored, and none were reported. Periaortic pathology was encountered on 1 patient, but this was known. No case of new periaortic pathology was detected.

CONCLUSION

Routine and indiscriminate imaging of the abdominal aorta during abdominal US in patients <50 years of age is not evidence based. No new case of abdominal aortic aneurysm or new para-aortic pathology was detected, all cases of atherosclerosis were ignored, and two false-positive diagnoses of aortic ectasia were made.

Interventions for men and women with their first episode of genital herpes

BACKGROUND

Genital herpes is incurable, and is caused by the herpes simplex virus (HSV). First-episode genital herpes is the first clinical presentation of herpes that a person experiences. Current treatment is based around viral suppression in order to decrease the length and severity of the episode.

OBJECTIVES

To determine the effectiveness and safety of the different existing treatments for first-episode genital herpes on the duration of symptoms and time to recurrence.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (from inception to April 2016), MEDLINE (from inception to April 2016), the Specialised Register of the Cochrane Sexually Transmitted Infections Review Group (from inception to April 2016), EMBASE (from inception to April 2016), PsycINFO (from inception to April 2016), CINAHL (from inception to April 2016), LILACS (from inception to April 2016), AMED (from inception to April 2016), and the Alternative Medicines Specialised Register (from inception to April 2016). We handsearched a number of relevant journals, searched reference lists of all included studies, databases of ongoing trials, and other Internet databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) on participants with first-episode genital herpes. We excluded vaccination trials, and trials in which the primary objective assessed a complication of HSV infection.

DATA COLLECTION AND ANALYSIS

All studies written in English were independently assessed by at least two review authors for inclusion, risk of bias for each trial, and to extract data. Studies requiring translation were assessed for inclusion, trial quality, and data extraction by external translators.

MAIN RESULTS

We included 26 trials with 2084 participants analysed. Most of the studies were conducted in the United Kingdom (UK) and United States (US), and involved men and women experiencing their first episode of genital herpes, with the exception of three studies which included only women. We rated the majority of these studies as having an unclear risk of bias; largely due to lack of information supplied in the publications, and due to the age of the trials. This review found low quality evidence from two studies of oral acyclovir, when compared to placebo, reduced the duration of symptoms in individuals undergoing their first episode of genital herpes (mean difference (MD) -3.22, 95% confidence interval (CI) -5.91 to -0.54; I(2) = 52%). In two studies (112 participants), intravenous acyclovir decreased the median number of days that patients with first-episode herpes suffered symptoms. Oral valaciclovir (converted to acyclovir) also showed a similar length of symptom duration when compared to acyclovir in two studies.There is currently no evidence that topical acyclovir reduces symptoms (MD -0.61 days, 95% CI -2.16 to 0.95; 3 RCTs, 195 participants, I(2) statistic = 56%). There is also no current evidence that the topical treatments of cicloxolone cream, carbenoxolone sodium cream, adenosine arabinoside, idoxuridine in dimethyl sulfoxide, when compared to placebo reduced the duration of symptoms in people undergoing their first episode of herpes.Two studies reported no evidence of a reduction in the number of median days to recurrence following treatment with oral acyclovir versus placebo. Adverse events were generally poorly reported by all of the included studies and we were unable to quantitatively analyse this outcome. For those taking acyclovir, there were no serious adverse events; the most common adverse events reported for oral acyclovir were coryza, dizziness, tiredness, diarrhoea and renal colic. For intravenous acyclovir these were phlebitis, nausea and abnormal liver function tests and for topical acyclovir there was pain with the topical application.Those undergoing interferon treatment had significantly more adverse events compared to those taking placebo.

AUTHORS' CONCLUSIONS

There is low quality evidence from this review that oral acyclovir reduced the duration of symptoms for genital herpes. However, there is low quality evidence which did not show that topical antivirals reduced symptom duration for patients undergoing their first episode of genital herpes. This review was limited by the inclusion of skewed data, resulting in few trials that we were able to meta-analyse.

The influence of ultrasound scanner beam width on femur length measurements

Systematic differences have been found in measurements of femur lengths made with (1) a Hitachi EUB 25, representative of older machines in use when most of the femur length-gestation curves were produced; and (2) a modern high resolution machine (Acuson 128). It is proposed that these differences may be accounted for by the different beam widths of the two systems. Six operators measured the femur lengths of several normal fetuses using both machines. Analysis of the results revealed a highly significant (p < 0.005) difference between machines, that did not correlate with femur length (r = -0.022). The mean difference was 1.02 +/- 0.33 mm (Hitachi larger). The mean femur length was 46.44 mm (n = 57). Pulse-echo beam plots showed that, for the probes used, the Hitachi 6 dB beam width is greater than the Acuson beam width by typically 2 mm, depending on the range and Acuson focus setting. This beam width difference can account for the difference in femur length measurements, if allowance is made for the variable angle between femurs and ultrasound beams. The results suggest that femur length-gestation curves for use with modern machines should be based on measurements made with modern machines.

Endoscopic lower ureterectomy

The little-known technique of endoscopic lower ureterectomy by intussusception is described and the literature is reviewed. The technique has been used successfully in 2 patients with papillary neoplasms limited to the renal pelvis.