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Isolated inflammatory aneurysm of the common iliac artery is a rare condition. Previously reported cases presented with urologic complications owing to entrapment of the ureter in the perianeurysmal fibrosis. We report a case of a healthy young man who presented with acute abdominal pain in the right lower quadrant without urologic complications mimicking acute appendicitis. The pain was caused by an isolated inflammatory aneurysm of the right common iliac artery measuring 4 cm in diameter. Three years after open aneurysmal resection and graft interposition, the patient is doing well, with excellent peripheral circulation. The available literature on presentation, diagnosis, and treatment is reviewed.

Purpose: To examine the observer variation for bone scintigraphy in the detection of occult scaphoid fractures in daily practice, using only the early bone scanning images., Methods: One hundred bone scans of patients with a suspected scaphoid fracture but negative initial radiographs were prospectively included to calculate the inter- and intraobserver variation. Three nuclear medicine physicians independently evaluated all bone scans at 2 different points in time with a 3-month interval. The observers filled out a blinded scoring sheet for each patient. They scored if a scaphoid fracture was present or not. In addition, they scored the presence or absence of another fracture. The inter- and intraobserver variation was analyzed using the kappa statistic., Results: The interobserver variation showed substantial agreement for a scaphoid fracture and almost perfect agreement for another fracture. The intraobserver variation showed almost perfect agreement for both a scaphoid fracture and another fracture., Conclusions: In the present study, early static images of bone scintigraphy for suspected scaphoid fractures showed very little inter- and intraobserver variation. In addition, expertise does not seem to have a negative influence on the results. This enhances the possibility of using bone scintigraphy in daily practice.

Objective: To validate the use of fluoroscopic roentgenographic stereophotogrammetric analysis (FRSA) for its feasibility and accuracy for measuring the three-dimensional dynamic motion of stent grafts., Methods: A digital biplane fluoroscopy setup was calibrated (Siemens Axiom Artis dBc). Stereo images were acquired of a static aortic model with a stent graft in different axial positions, imposed by a micromanipulator. The three-dimensional measurement error of FRSA was determined by comparing FRSA measurements with the micromanipulator. An aortic model with a stent graft was constructed and connected to an artificial circulation with a physiological flow and pressure profile. Markers were added to the spine (tantalum spherical markers; diameter 1 mm) and stent (welding tin; diameter 1 mm). The three-dimensional measurement precision was determined by measuring the position of a single (stable) spine marker during two pulsatile cycles. Finally, three-dimensional stent marker motion was analyzed with a frame rate of 30 images per second, including three-dimensional marker position (change), diameter change, and center of circle position change., Results: The mean error of FRSA measurement of displacement was 0.003 mm (SD, 0.019 mm; maximum error, 0.058 mm). A very high precision of position measurement was found (SD, 0.009-0.015 mm). During pulsatile motion, the position (changes) of the markers could be assessed in the x, y, and z directions, as well as the stent diameter change and center of circle position change., Conclusions: FRSA has proven to be a method with very high accuracy and temporal resolution to measure three-dimensional stent-graft motion in a pulsatile environment. This technique has the potential to contribute significantly to the knowledge of stent-graft behavior after endovascular aneurysm repair and improvements in stent-graft design. The technique is ready for clinical testing.

Background: Peripheral arterial disease (PAD) is associated with poor health-related quality of life (HRQOL), but individual differences in this patient-based outcome are not fully understood. We examined the impact of PAD severity, invasive treatment, and type D personality, defined as tendencies to experience negative emotions and be socially inhibited, on HRQOL in a 1-year follow-up study., Method: At their first visit to the department of surgery at the St. Elisabeth Hospital in Tilburg, The Netherlands, 203 consecutive PAD patients completed the DS14 type D personality and RAND-36 questionnaires (all self-report). Clinical data were derived from patients' medical files and included ankle-brachial index (ABI), initial and absolute claudication distance (ICD, ACD), and invasive treatment. The main outcome was HRQOL at 1-year follow-up., Results: HRQOL improved between baseline and follow-up, and invasive treatment led to significant improvements in the subscales Physical Functioning (P = .005) and Pain (P = .003). Type D patients were severely impaired in their HRQOL compared with other patients at baseline (P < .01) and at follow-up (P < .05). ABI and ACD also predicted HRQOL at follow-up. After adjusting for ABI and ACD, invasive treatment and type D personality independently predicted all HRQOL domains, except for Physical Functioning. Overall, type D personality predicted increased risk for both poor General Health (odds ratio [OR], 3.70; 95% confidence interval [CI], 1.69 to 8.08; P = .001) and poor Mental Health (OR, 6.01; 95% CI, 2.44 to 14.79, P < .0001) at 1 year after the PAD diagnosis., Conclusion: Despite an overall improvement, type D patients remained more impaired in 1-year HRQOL than other patients, adjusting for ABI and ACD. Type D personality is a psychologic risk factor that predicts poor patient-based outcomes in PAD and should be taken into account when HRQOL in PAD is evaluated.

Rectal injuries in the pediatric population are most often attributed to accidental falls on offending objects, sexual abuse, or blunt trauma. Anorectal impalement is a rare injury, and as a result, specific knowledge or experience on the treatment of this type of injury in children is sparse. The extent of injury is often difficult to assess. Mostly, therapeutical decisions are based on general knowledge in adults. We present a case of accidental anorectal impalement in a child by a fall on the handle of a toilet brush. The handle caused an anterior rupture of the intraperitoneal part of the rectum with subsequent transanal evisceration of several loops of small bowel.

Background: Patient-based outcomes, such as impaired quality of life (QOL) and depression, may adversely affect the clinical course of patients with peripheral arterial disease (PAD). Disease severity indices, including the ankle brachial index, are only partially associated with these outcomes., Objective: To examine whether individual differences in personality would predict impaired QOL and depression above and beyond PAD severity., Design: A prospective follow-up study., Setting: Vascular outpatient clinic of a teaching hospital., Patients: Consecutive patients with newly diagnosed PAD (n = 150). Diagnosis and severity of PAD were based on history, physical examination, treadmill walking distance, and ankle brachial index. At their first visit, all patients completed the 14-Item Type-D Personality Scale, the World Health Organization Quality of Life Assessment Instrument-100, and the Center for Epidemiological Studies Depression Scale to assess distressed (type-D) personality, QOL, and depressive symptoms, respectively. The QOL and depression scales were repeated after 6 months' follow-up., Main Outcome Measures: Impaired QOL and depressive symptoms at follow-up., Results: Indices of PAD severity (ankle brachial index and walking distance) did not predict impaired QOL or depressive symptoms at follow-up. In contrast, type-D personality predicted poor physical health (odds ratio, 3.94; 95% confidence interval, 1.60-9.67; P = .003), decreased level of independence (odds ratio, 4.26; 95% confidence interval, 1.69-10.73; P = .002), and poor overall QOL (odds ratio, 4.72; 95% confidence interval, 1.73-12.88; P<.01) after controlling for age, sex, PAD severity, and cardiovascular risk factors. Type-D personality also independently predicted increased risk of depressive symptoms (odds ratio, 8.55; 95% confidence interval, 3.01-24.25; P<.001)., Conclusions: Type-D personality independently predicted individual differences in impaired QOL and depressive symptoms in patients with PAD above and beyond ankle brachial index. It is important to account for personality when evaluating patient-based outcomes in the context of PAD.

Purpose: This study was conducted to clarify the effect of the direction of pressure measurement on the pressure readout in fibrinous thrombus of the abdominal aortic aneurysm., Methods: Three weights of 468 g (weight 1), 578 g (weight 2), and 675 g (weight 3) were molded. A specimen of human fibrinous thrombus was positioned under the weights. Because the surface area of the weights and the thrombus was 400 mm(2), weights 1, 2, and 3 caused pressures of 88, 108, and 127 mm Hg, respectively. Pressure measurements were performed at different angles between the sensor and the applied force (0 degrees , 22.5 degrees , 30 degrees , 45 degrees , 60 degrees , 67.5 degrees , 90 degrees ) Thrombi of 10 different patients were analyzed. Pressure measurements in the thrombi at different angles were statistically compared by a linear mixed model analysis., Results: The measurements at 90 degrees differed statistically from the measurements at 0 degrees , 22.5 degrees , 30 degrees , 45 degrees , 60 degrees , and 67.5 degrees (P < .001). The pressure readout was only similar to the applied pressure when the pressure sensor was positioned at 90 degrees to the applied force. Pressure measurements in other sensor positions resulted in lower pressure measurements. Pressure changes were detected in all sensor positions. There appeared to be no significant difference between the pressure measurements taken at same angles in the 10 thrombi (P > .05)., Conclusion: In fibrinous thrombus of abdominal aortic aneurysm, the direction of pressure measurement influenced the pressure readout.

Purpose: To evaluate the feasibility and accuracy of Roentgen stereophotogrammetric analysis (RSA) versus computed tomography (CT) for detecting stent-graft migration in an in vitro pulsatile circulation model and to study the feasibility of a nitinol endovascular clip (NEC) as an aortic wall reference marker for RSA., Methods: An aortic model with stent-graft was constructed and connected to an artificial circulation with a physiological flow and pressure profile. Tantalum markers and NECs were used as aortic reference markers for RSA analysis. Stent-graft migrations were measured during pulsatile circulation with RSA and CT. CT images acquired with 64 x 0.5-mm beam collimation were analyzed with Vitrea postprocessing software using a standard clinical protocol and central lumen line reconstruction. RSA in the model with the circulation switched off was used as the reference standard to determine stent-graft migration. The measurement errors of RSA and CT were determined during pulsatile circulation., Results: The mean measurement error +/- standard deviation (maximum) of RSA during pulsatile circulation using the tantalum markers was -0.5+/-0.16 (0.7) mm. Using the NEC, the mean (maximum) measurement error was -0.4+/-0.25 (1.1) mm. The mean (maximum) measurement error of CT was -1.1+/-1.17 (2.8) mm., Conclusion: RSA is an accurate and feasible tool to measure stent-graft migration in a pulsatile environment. Migration measurement with RSA was more accurate than CT in this experimental setup. The nitinol clip tested in this study is potentially feasible as an aortic reference marker in patients after endovascular repair.

Objective: Social support may influence the seeking of appropriate treatment. We examined social support and peripheral arterial disease (PAD) severity as determinants of treatment for PAD in younger and older patients., Methods: Consecutive PAD patients (N=203) completed the Perceived Social Support Scale. Treadmill-walking distance and ankle-brachial pressure index (ABPI) were measured. The main outcome was invasive treatment for PAD in the year following diagnosis., Results: During follow-up, 48% of the patients underwent invasive treatment for PAD. Younger patients (

Purpose: To evaluate in an in vitro model the feasibility and accuracy of Roentgen stereophotogrammetric analysis (RSA) versus computed tomography (CT) for the ability to detect stent-graft migration., Methods: An aortic model was constructed from a 22-mm-diameter Plexiglas tube with 6-mm polytetrafluoroethylene inlays to mimic the renal arteries. Six tantalum markers were placed in the wall of the aortic tube proximal to the renal arteries. Another 6 markers were added to a Gianturco stent, which was cast in Plexiglas and placed inside the aorta and fixed to a micromanipulator to precisely control displacement of the stent along the longitudinal axis. Sixteen migrations were analyzed with RSA software and compared to the micromanipulator. Thirty-two migrations were measured by 3 observers from CT images acquired with 16x0.5-mm beam collimation and reconstructed with a 0.5-mm slice thickness and a 0.4-mm reconstruction interval. Measurements were made with Vitrea postprocessing software using a standard clinical protocol and central lumen line reconstruction. Results of CT were also compared to the micromanipulator., Results: The mean RSA measurement error compared to the micromanipulator was 0.002+/-0.044 mm, and the maximum error was 0.10 mm. There was no statistically significant interobserver variability for CT (p=0.17). The pooled mean (maximum) measurement error of CT was 0.14+/-0.29 (1.00) mm, which was significantly different from the RSA measurement error (p<0.0001)., Conclusion: Detection of endograft migration by RSA is feasible and was significantly more accurate than CT in this nonpulsatile in vitro model.

Purpose: To determine the effect of pulsatile motion of graft-attached pressure sensors on the accuracy of aneurysm sac pressure measurement., Methods: Pressure inside a pressure box was measured with a sensor attached to a stent-graft (Sensorgraft) facing a sensor in fixed position (Sensorbox). Maximum inter-sensor variation of Sensorgraft and Sensorbox was determined in static experiments. Experiments with pulsatile circulation were performed with a compliant and a noncompliant stent-graft at 120/80 mmHg and 160/95 mmHg. Pressure measurements in the box were repeated after the box pressure was increased from 0 to 120 mmHg. Sensorgraft motion was measured by ultrasound. Measurements with Sensorgraft were compared to those with Sensorbox using Pearson correlation coefficients to determine the concordance between the sensors., Results: The maximum inter-sensor variation was 4 mmHg. Increased box pressure induced progressive pulsatile graft and sensor motion during all experiments. During the experiments with the compliant graft at systemic pressures of 120/80 and 160/95 mmHg, the maximum inter-sensor variation was exceeded at box pressures of 65 and 75 mmHg, respectively. The sensor motion at these box pressures was 214+/-2.70 microm and 210+/-0.93 microm, respectively. Measurements of Sensorgraft were higher than Sensorbox, up to 13 mmHg at a box pressure of 120 mmHg. The Pearson correlation coefficients during these experiments were 0.99 and 1.00 (p < 0.001), respectively. In the experiments with the noncompliant graft, the maximum inter-sensor variation was not exceeded, and sensor motion was only 7 +/- 0.46 microm and 26 +/- 1.48 microm, respectively. The Pearson correlation coefficient during these experiments was 1.00 (p < 0.001)., Conclusion: Pulsatile sensor motion can influence the accuracy of pressure measurement. More compliant grafts are more susceptible to this phenomenon. Despite false high pressure measurements, stent-graft-attached pressure sensors seem appropriate to follow pressure trends in the aneurysm sac.

Hypothesis: Patients with peripheral arterial disease (PAD) often experience substantial impairment in health status and quality of life (QOL), but factors associated with these outcomes are unknown. We hypothesized that subjective pain symptoms in the legs and social support and stress (the degree to which situations are appraised as stressful) are associated with impaired health status and QOL., Design: Cross-sectional observational study., Setting: Vascular outpatient clinic of a teaching hospital., Patients: The study included consecutive patients seeking treatment for the first time because of walking pain. Diagnosis and severity of PAD were based on history, physical examination, treadmill-walking distance, and ankle-brachial pressure indexes (ABPIs). Patients with PAD (n = 188) and patients with atypical leg symptoms (n = 57) completed the 10-item version of the Perceived Stress Scale (perceived stress), the 12-item version of the Perceived Social Support Scale-Revised (social support), the RAND 36-Item Health Survey (health status), and the World Health Organization Quality of Life Assessment Instrument-100., Main Outcome Measures: Health status and QOL., Results: Both groups had equally poor health status and QOL, with patients with atypical leg symptoms reporting more bodily pain (P = .004). In patients with PAD, the ABPI (P = .008) and perceived stress (P = .001) were associated with maximum walking distance. Furthermore, the health status domain of physical functioning was affected by the ABPI (P = .002), cardiac disease (P = .005), body mass index (P = .007), and perceived stress (P<.001). Overall QOL in patients with PAD was independently influenced by sex (P = .04), carotid disease (P = .03), and perceived stress (P<.001)., Conclusions: Subjective pain in the legs is associated with impaired health status and QOL. Stress adversely influences the health status and QOL of patients with PAD above and beyond the influence of clinical indicators. These findings indicate the importance of accounting for perceived stress in patients with PAD.

Patients with peripheral arterial disease (PAD) often experience diminishing quality of life (QOL) in many domains of their lives. However, factors associated with impaired QOL and perceived stress in these patients are not completely understood. The relative effects of disease status and type D ("distressed") personality (tendencies to experience negative emotions and be socially inhibited) on these patient-based outcomes were examined. It has been argued that type D personality might depend on disease status; therefore, its effect was examined in a combined sample of 150 patients with PAD and 150 healthy controls. The Type D Scale-14, World Health Organization Quality of Life Assessment Instrument-100, and Perceived Stress Scale-10 Item assessed type D personality, QOL, and perceived stress, respectively. PAD severity (mild, moderate, or severe) was not associated with QOL or perceived stress. However, patients with PAD reported decreased QOL (p < 0.05) compared with healthy controls. Type D patients reported significantly poorer QOL than non-type D patients across PAD and healthy subgroups (p < 0.0001). After controlling for disease status (presence or absence of PAD), type D personality remained associated with increased risk for impaired QOL (odds ratio [OR] 7.35, 95% confidence interval [CI] 3.39 to 15.96, p < 0.0001) and perceived stress (OR 6.45, 95% CI 3.42 to 12.18, p < 0.0001). Hence, type D personality was associated with impaired QOL beyond the impairment already related to PAD and with increased stress in this high-risk population. In conclusion, type D personality is not merely a function of PAD but seems to represent a different determinant of patient-based outcomes.

Objective: Our objective was to compare the accuracy of CT and sonography in a general community teaching hospital for the diagnosis of acute appendicitis in patients with suspected acute appendicitis. SUBJECTS AND METHODS. In this prospective study, 199 consecutive patients with clinical signs and symptoms of acute appendicitis were examined with sonography (graded compression technique) and CT (focused unenhanced single-detector helical CT [5-mm section thickness]. CT was performed from the L2 vertebral body to the pubic symphysis, and no patients were given oral, rectal, or IV contrast medium. The primary sonographic criterion for diagnosing acute appendicitis was an incompressible appendix with a transverse outer diameter of 6 mm or larger with incompressible periappendicular inflamed fat with or without an appendicolith. The primary CT criterion for diagnosing acute appendicitis was the identification of an appendix with a transverse outer diameter of 6 mm or larger with associated periappendiceal inflammatory changes. The results, independently reported, were correlated with surgical and histopathologic findings., Results: One hundred thirty-two patients had acute appendicitis at surgery, and 67 patients did not. The sensitivity of CT and sonography was 76% and 79%, respectively; the specificity was 83% and 78%; the accuracy was 78% and 78%; the positive predictive value was 90% and 87%; and the negative predictive value was 64% and 65%., Conclusion: Unenhanced focused single-detector helical CT and graded compression sonography performed in a general community teaching hospital by both body imaging radiologists and general radiology staff members have a similar accuracy for the diagnosis of acute appendicitis.

A 75-year-old man complaining of acute abdominal pain, 1 month after elective surgical repair of an abdominal aortic aneurysm by an aortabi-iliac bypass graft, was referred and admitted to the emergency room. Imaging by sonography and computed tomography scan revealed a ruptured iliac pseudoaneurysm at the right iliac anastomotic site with associated large retroperitoneal hematoma. We inserted a self-expanding covered Z-stent graft by a transfemoral approach and the iliac anastomotic pseudoaneurysm was successfully excluded. Our case demonstrates the possibilities of an endovascular approach for providing a fast, efficient and less aggravating procedure in order to treat these life-threatening conditions.