Increased attentional network functioning related to symptom severity measures in females with irritable bowel syndrome.

BACKGROUND: Increased attention to gastrointestinal (GI) symptoms and disease-specific contexts may play an important role in the enhanced perception of visceral stimuli frequently reported in patients with irritable bowel syndrome (IBS). In this study, we test the hypothesis that altered attentional mechanisms underlie central pain amplification in IBS. METHODS: To evaluate brain networks that support alerting, orienting, and executive attention, we employed the attention network test (ANT), a modified flanker task which measures the efficiency of functioning of core attentional networks, during functional magnetic resonance imaging in 15 IBS patients (mean age = 31 [11.96]) and 14 healthy controls (HCs; mean age = 31 [10.91]). KEY RESULTS: Patients with IBS, compared to HCs, showed shorter reaction times during the alerting and orienting conditions which were associated with greater activation of anterior midcingulate and insular cortices, and decreased activity in the right inferior frontal junction and supplementary motor cortex. Patients also showed activation in the dorsal medial prefrontal cortex and concurrent thalamic deactivation during the executive control portion of the ANT relative to HCs, but no group difference in reaction times were found. The activity in brain regions showing group differences during the ANT were associated with measures of GI-specific anxiety, pain catastrophizing, and fear of uncertainty. In IBS, activity in the anterior midcingulate during alerting correlated with duration of GI-symptoms and overall symptom severity. CONCLUSIONS & INFERENCES: Together, these results suggest that IBS patients have specific abnormalities in attentional network functioning and these deficits may underlie symptom-related anxiety, hypervigilance, and visceral hypersensitivity.

A comparison between the short term and long term benefits of screening for abdominal aortic aneurysms from the Huntingdon Aneurysm screening programme.

BACKGROUND: The UK Multicentre Aneurysm Screening Study (MASS) showed a 44% reduction in AAA-related mortality after 4 years and predicted an increased number of deaths prevented in the longer term. We aim to compare the 5 and 13 years benefit from aneurysm screening in the Huntingdon Aneurysm screening programme. METHODS: Incidence and mortality of ruptured AAA (RAAA) after 5 and 13 years of screening in a population based aneurysm screening program. RESULTS: Five years of screening resulted in a reduction in the incidence of RAAA of 49% (95% CI: 3-74%). Nine out of 11 ruptures in the invited group did not survive (mortality 82%; 95% CI: 48-98%) compared to 38 non-survivors from 51 ruptures in the control group (mortality 75%; 95% CI: 60-86%). Five years of screening resulted in an RAAA-related mortality reduction of 45% (95% CI: -15 to 74%). After 13 years of screening the incidence of RAAA was reduced by 73% (95% CI: 58-82%). Twenty-one out of 29 ruptures in the invited group did not survive (mortality 72%; 95% CI: 53-87%) compared to 64 non-survivors from 82 ruptures in the control group (mortality 78%; 95% CI: 68-86%). Thirteen years screening resulted in a reduction of mortality from RAAA of 75% (95% CI: 58-84%). The number needed to screen to prevent one death reduced from 1380 after 5 years to 505 after 13 years. The number of elective AAA operations needed to prevent one death reduced from 6 after 5 years to 4 after 13 years. CONCLUSION: AAA screening becomes increasingly beneficial as screening continues over the longer term. Benefits continue to increase after screening has ceased.

Dietary folate and vitamin B6 are independent predictors of peripheral arterial occlusive disease.

BACKGROUND: It has been suggested that hyperhomocysteinemia (HHcy) is an independent risk factor for peripheral arterial occlusive disease (PAOD). However, the relationship between dietary folate and vitamin B6, cofactors in the metabolism of homocysteine (Hcy), and PAOD is unclear. AIMS: To study the relationship between dietary folate and B6 and PAOD. METHODS: Case-control population based study of 392 men older than 50 years living in Huntingdon, United Kingdom. PAOD, defined as an ankle-brachial pressure index (ABPI) < 0.9, was present in 86 (22%) of subjects. Folate, vitamin B6, and vitamin B12 intakes were calculated by means of the EPIC (European Prospective Investigation into Cancer) food frequency questionnaire. RESULTS: Daily folate intake was significantly lower in case subjects (mean, 288; 95% confidence interval [CI], 266-309 microg) than in control subjects (324; 95% CI, 313-335 microg). Daily vitamin B6 intake was also lower in case subjects (2.05; 95% CI, 1.92-2.19 mg versus 2.26; 95% CI, 2.19-2.33 mg). Daily folate and vitamin B6 intakes were independent predictors of PAOD after adjusting for age, blood pressure, cholesterol levels, diabetes, and smoking status in a logistic regression model. This model suggests that increasing daily folate intake by 1 standard deviation decreased the risk of PAOD by 46%. A similar increase in daily vitamin B6 intake decreased the risk of PAOD by 29%. CONCLUSION: In men older than 50 years, dietary folate and B6 intakes are independent predictors of PAOD. Longitudinal studies are required to determine whether dietary modification can reduce the incidence of PAOD in the population.

Accuracy of serial screening for abdominal aortic aneurysms by ultrasound.

OBJECTIVES: To assess the accuracy of screening for abdominal aortic aneurysms (AAAs) by ultrasound (US). SETTING: An aneurysm screening programme in Huntingdon. METHODS: False negative tests were identified by tracing all patients with a ruptured aneurysm who were screened and then finding the number classified as normal on US. False positive tests were identified by calculating the number of aneurysmal aortas on US that were classified as normal on CT. Measurement variability of the infrarenal aortic diameter between US and CT was estimated. RESULTS: 14 out of 93 patients with a ruptured AAA since 1991 had been screened. No ruptured aneurysm had been classified as normal on US. All 64 patients with an AAA larger than 4.5 cm on US had their aneurysm confirmed on CT. The mean difference between CT and US measurements was 4 mm. The limit of variability between CT and US was 12 mm. CONCLUSION: No false negative scans were found using a cut off point of 3 cm as abnormal. No false positives were found if subjects with an AAA exceeding 4.5 cm were referred for further procedures. A serial US screening policy has excellent screening performance, justifying its use as a screening tool.

The incidence of small abdominal aortic aneurysms and the change in normal infrarenal aortic diameter: implications for screening.

AIM: to study the incidence of small abdominal aortic aneurysms (AAA), and to investigate what proportion of normal infrarenal aortic diameters (IAD) expand with age. METHODS: longitudinal follow-up in a population-based aneurysm screening programme. The infrarenal aortic diameter (IAD) was measured by ultrasound. A second scan was performed in subjects with a normal aorta after an average of 5.5 years. RESULTS: data were analysed from 4072 subjects, 464 with a small AAA and 3608 with a normal aorta. The infrarenal aorta expanded in 15% of subjects, but significant growth (>5 mm) occurred in only 7%. Age and initial diameter were independent predictors for aortic dilatation. The effect of diameter at first screen was non-linear. The relative risk for expansion increased dramatically for IADs over 2.5 cm (test for departure of trend: chi2=52, p<0.0001). The effect of age was also non-linear, the risk of expansion was highest in the 60-69 year old age group; test for departure of trend (chi2=13, p=0.002). The incidence of new aneurysms was 3.5 per 1000 person-years (py) (95% CI: 2.8-4.4). The highest incidence of new aneurysms was found in the 60 to 69 year old age group. CONCLUSION: only a small proportion of the population is prone to aortic dilatation. Patients over 70 with an IAD <2.5 cm can be discharged from follow-up.

The association between connective tissue laxity and the risk of an abdominal aortic aneurysm.

AIMS: to investigate whether connective tissue laxity is associated with abdominal aortic aneurysms (AAA). METHODS: a nested case control study in a population-based screening programme. The presence of pes planus, scoliosis, pectus deformities, flexible auricular cartilages and Gorling's sign were combined with the Beighton joint mobility score to form a connective tissue laxity score. The association between connective tissue laxity and the risk of AAA was investigated through a logistic regression model. Type III collagen turnover was assessed using a serum radio-immunoassay for type III procollagen (PIIINP). RESULTS: data from 231 controls (aortic diameter <2.5 cm) and 190 cases (AAA >2.9 cm) were analysed. Odds ratios (OR), adjusted for known confounders were 3.1 (95% CI: 1. 1-8.6) for the highest group of connective tissue scores and 2.4 (95% CI: 1.0-5.4) for the middle group, compared with those with no signs of abnormal connective tissue function. There was no difference in mean collagen turnover between cases and controls, nor between those with a stable AAA >4 cm and those with an expanding AAA. CONCLUSION: connective tissue laxity is associated with a higher risk of having an AAA. The collagen turnover is similar in subjects with an AAA and controls. Aneurysms may be associated with abnormal connective tissue rather than an increased breakdown of normal collagen.

The influence of screening on the incidence of ruptured abdominal aortic aneurysms.

PURPOSE: The purpose of this study was to estimate the influence of a screening program on the incidence and mortality of ruptured abdominal aortic aneurysms (RAAAs). METHODS: The effects of screening on the incidence and death rate of RAAAs were investigated with a stepped wedge study design. RAAAs that occurred in the Huntingdon district were traced with an examination of all hospital records and community postmortem records. RESULTS: During the 5-year period from 1991 to 1996, 78 RAAAs occurred in the Huntingdon district: 62 in men and 16 in women. Eleven of the 62 men with RAAAs had been invited for screening. The incidence of RAAA in the invited group was 3.7 per 10,000 person-years (py; 95% confidence interval [CI], 1.5 - 7.3). In the noninvited group, the incidence was 7.3 per 10,000 py (95% CI, 5.3. - 9.2), a rate ratio of 0.51 (95% CI, 0.26 - 0.97). The mortality of rAAAs in the invited group was 3.0 per 10, 000 py (95% CI, 1.4 - 5.4) as compared with 5.4 per 10,000 py in the noninvited group (95% CI, 3.9 - 7.3), resulting in a rate ratio of 0. 55 (95% CI, 0.26 - 1.15). CONCLUSION: Screening for asymptomatic AAAs can reduce the incidence rate of RAAAs by 49% (95% CI, 3% - 74%).

The infrarenal aortic diameter in relation to age: only part of the population in older age groups shows an increase.

OBJECTIVES: To resolve whether the infrarenal aortic diameter (IAD) continues to increase throughout life; to ascertain the relationship between IAD and age, sex, body size, and smoking status, and to determine whether these factors influence the IAD over the entire range of aortic diameters or only in a proportion. SETTING: Combined cross-sectional data from two population-based screening programmes for abdominal aortic aneurysms (AAA) in Huntingdon (U.K.) and Rotterdam (The Netherlands). METHODS: The antero-posterior diameter of the infrarenal aorta was measured. The influences of age, gender, body size and smoking status were examined. RESULTS: Data were analysed from 3066 women and 8270 men. In men, mean IAD rose from 20.7 mm to 23.5 mm in the older age groups. However, IADs remained constant below the 75th perentile in men and the 85th percentile in women. Similarly only the top 15-25% of the aortic diameters were larger in smokers compared with non-smokers. CONCLUSIONS: The aortic diameter increased with age in only a minority of the population. Furthermore, known risk factors for AAA contributed to aortic dilatation in only the upper tail of the frequency distribution. Thus only 25% of men and 15% of women may be prone to aortic dilatation.

Quality of the measurement of the infrarenal aortic diameter by ultrasound.

OBJECTIVES: To assess quality and variability in measurements of the infrarenal aortic diameter by ultrasound, and to recommend quality control measures to improve consistency in measurements of the infrarenal aortic diameter (IAD) in a long running screening programme. SETTING: An aneurysm screening programme in Huntingdon. METHODS: Quality of the ultrasound image was subjectively assessed by each ultrasonographer. Quality of the measurements was assessed by analysing the frequency of measurements that were outside the normal variability of the estimated true diameter. The interobserver variability was measured by analysing repeated measurements of the IAD in the same patient by two ultrasonographers, using the same scanner. The variability between different scanners was measured by analysing repeat measurements of the IAD in the same patient by the same ultrasonographer, using two scanners. The intraobserver variability was estimated by analysing all patients with three consecutive measurements of the IAD, carried out by the same ultrasonographer. RESULTS: Although the subjective assessment of the quality of the ultrasound image of the aorta varied, there were no statistically significant differences in the likelihood of obtaining measurements outside the limits of agreement between the ultrasonographers. The interobserver, intraobserver, and between scanner variability of ultrasound measurements of the IAD were all around 6 mm. CONCLUSION: The variability in ultrasound measurements of aortic diameters is acceptable for clinical decision making, and the interobserver variability is very similar to the long term intraobserver variability. Quality control measures are suggested to maintain long term consistency of ultrasound measurements of the IAD.

An abdominal aortic aneurysm screening programme for all males over the age of 50 years.

Previously published ultrasound screening programmes for abdominal aortic aneurysm (AAA) have concentrated on males in the 65 to 75 year age range, suggesting this as the most cost-effective cohort to target. In this unique study we have broadened the criteria for screening. General practitioners in one health district were approached to supply details of all males aged 50 years and over to be offered aortic ultrasound scanning. Over a period of 18 months, 4145 individuals were asked to attend and 3030 (73%) have attended. Attendance rates were: between 50 and 64 years, 73%; between 65 and 79 years, 75%; for 80 years and over, 64%--significantly less (p = 0.01-0.001) than the other two age bands. Aortic dilatation (diameter > or = 2.5 cm) was found in 6.3% of the 50 to 64 year age group, 16.8% of the 65 to 79 year age group, and 23.3% of the 80 years and over age group. An established aneurysm (> or = 4.6 cm) was found in 0.3%--6 individuals (50-64 years), 2.5% (65-79 years) and 4.1% (> or = 80 years). The results suggest that aortic screening may be worthwhile extending to a wider age band. By focusing follow-up, this should give greater value for younger men in terms of community productivity and allows for selective intervention in the elderly.

Biliary stenting for malignant jaundice. A district hospital experience.

Non-surgical management of malignant jaundice is becoming widespread in referral centres and the results are good. We report a retrospective analysis of 46 patients with malignant jaundice who were treated with either endoscopic or combined percutaneous endoscopic biliary stenting in a district general hospital. Out of 46 patients, 24 were stented successfully endoscopically and 19 of the remaining 22 patients were put forward for the combined procedure, and 12 had successful stenting. Eight were managed with palliative bypass surgery and two died. The procedure related mortality was 6.9% and the 30 day mortality was 4.6%. Good palliation of patients with malignant jaundice is achievable in small centres providing there is good radiological and surgical back-up.

99mTc DTPA scintigraphy compared with intravenous urography in the follow-up of posterior urethral valves.

Twenty-seven patients with posterior urethral valves with varying degrees of renal function underwent both intravenous urography (IVU) and DTPA scan during their follow-up. Although the IVU was successful in excluding obstruction in 31 kidneys, the DTPA scan was successful in 43 kidneys. In addition, the DTPA scan provides quantifiable renal function, exposes the child to a lower radiation dose and has no morbidity compared with an IVU. It is recommended that the DTPA scan should replace the IVU for long-term follow-up and that the latter should be reserved for certain problems.