RADIOGRAPHIC AND COMPUTED TOMOGRAPHY FINDINGS IN BELGIAN SHEPHERD DOGS WITH MILD ELBOW DYSPLASIA

We compared computed tomography (CT) and radiographic findings of Belgian shepherds with grade 1 or borderline elbow dysplasia to determine whether the radiopaque area dorsal to the anconeal process and seen in mediolateral 45° flexed radiographs is formed by osteophytes, or whether it is an anatomic variation. Eighteen dogs with screening results 0/1, 1/0, or one or both elbows graded as borderline were studied. The radiographs were evaluated according to International Elbow Working Group guidelines and compared with CT images. A fragmented medial coronoid process was seen in five joints, and remaining 31 joints were considered free of dysplasia based on CT images. In radiographs, height of the radiopaque area on the anconeal process was 0–2.7 mm in dysplastic and 0–3.0 mm in other joints. Sensitivity of this sign as dysplasia indicator was 40% and specificity 29%. All dysplastic joints and three of the other joints had blurring of the cranial edge of the medial coronoid process. Subtrochlear sclerosis was seen in four dysplastic joints and in three other joints. Both changes were significant indicators of dysplasia ( P <0.001). Sensitivity and specificity of these phenomena as dysplasia indicators were 80% and 90%, respectively. We conclude that the radiopaque area on the anconeal process might not always be osteophyte formation in Belgian shepherds and should not be used as the sole criterion for dysplasia. Blurring of the medial coronoid process cranial edge and ulnar trochlear notch sclerosis are reliable signs of elbow dysplasia and may be beneficial in screening protocols.     

RADIOGRAPHIC FINDINGS IN TEN DOGS WITH THORACIC ACTINOMYCOSIS

The radiographic findings in ten dogs with thoracic actinomycosis are presented. Radiographic findins varied, but pleural effusion, pulmonary infiltrates and mediastinal masses were most commonly found. Rib involvement, commonly accompanying actinomycosis in man, was present in only one dog. The differential diagnosis of actinomycosis includes many disease entities, but based on the radiographic signs it may be possible to narrow down the number of possiblities considerably. A combination of mediastinal or pulmonary masses, pleural effusion and encapsulated fluid is strongly indicative for actinomycosis. For confirmation a bacteriological examination is indicated.     

RADIOGRAPHIC FINDINGS IN THE THORAX OF DOGS WITH LEPTOSPIRAL INFECTION

Thoracic radiographs of 4 dogs with confirmed and 1 dog with suspected leptospirosis were reviewed. In all dogs a reticulonodular pulmonary opacity was noted, affecting the entire lung in 3 and predominantly the caudodorsal lung field in 2 dogs. The radiographic lung pattern described is associated with pulmonary hemorrhage probably due to endothelial damage and vasculitis. Pulmonary manifestations in dogs with leptospirosis may be misinterpreted and attributed to neoplasia, pneumonia, edema, hemorrhage due to disseminated intravascular coagulopathy, adult respiratory distress syndrome and pulmonary thromboembolism.     

THORACIC COMPUTED TOMOGRAPHY FINDINGS IN DOGS EXPERIMENTALLY INFECTED WITH ANGIOSTRONGYLUS VASORUM

To characterize the computed tomography (CT) features of thoracic lesions caused by infection with Angiostrongylus vasorum, pre‐ and postcontrast CT was performed in six experimentally infected Beagles 13 weeks postinoculation and in four of these 9 weeks postchemotherapy. Findings were compared with survey radiographs and necropsy findings. A multicentric bronchoalveolar pattern more pronounced at the lung periphery was present radiographically. On CT, the predominant abnormality underlying this alveolar pattern was multiple large nodules merging to areas of consolidation, and containing air bronchograms of varying extent. These nodular changes corresponded to histopathologic granulomata, consisting mainly of macrophages, multinucleated giant cells, and lymphocytes that had accumulated around larvae and eggs. Morphologically, no bronchial changes were observed on CT or histologically. Quantitatively, however, on CT there was evidence of bronchial thickening at 13 weeks postinoculation and mild very peripheral bronchiectasia 9 weeks postchemotherapy. Regional lymph nodes were enlarged after infection, and smaller after treatment. On postcontrast CT, several suspicious intraluminal filling defects suggestive of thrombosis were found; however, the tortuosity of some pulmonary arteries seen radiographically was not present in CT images. After treatment, the consolidations and large nodules had almost completely disappeared. A remaining radiographic interstitial pattern was characterized on CT as ground‐glass opacifications, subpleural interstitial thickening, subpleural lines, and interface signs. These interstitial changes reflected fibrosis as documented histopathologically. CT allowed very detailed and accurate characterization of pulmonary parenchymal lesions, bronchi, and lymphnodes and closely reflected histopathological changes.     

RADIOGRAPHIC FEATURES OF PRIMARY AND CONCOMITANT FLEXOR ENTHESOPATHY IN THE CANINE ELBOW

Primary flexor enthesopathy is a recently recognized elbow disorder and should be considered in the differential diagnosis of elbow lameness. For treatment planning purposes, it is important to make a distinction between primary and concomitant forms of the disease. The purpose of this prospective study was to compare radiographic findings for dogs with primary flexor enthesopathy (n = 17), concomitant flexor enthesopathy (n = 24), elbow dysplasia (n = 13), and normal dogs (n = 7). All dogs underwent a complete radiographic examination and each radiographic image was evaluated for the presence or absence of following characteristics: irregular medial humeral epicondyle, spur and calcified body. Additionally, the presence or absence of other elbow disorders (medial coronoid process disease, osteochondritis dissecans, ununited anconeal process, incongruity, subtrochlear sclerosis, and osteoarthritis) was recorded. Radiographic characteristics of flexor enthesopathy were found in 86% of painful joints in the primary flexor enthesopathy group and in 100% of painful joints in the concomitant flexor enthesopathy group. Radiographic characteristics of flexor enthesopathy were not found in sound elbow and elbow dysplasia groups. Frequencies and details of individual radiographic characteristics did not differ between primary and concomitant flexor enthesopathy groups. Findings support the use of radiography as a first screening method for detection of flexor enthesopathy, but not as a technique for distinguishing primary vs. concomitant forms.     

RADIOGRAPHIC FINDINGS IN DOGS WITH SPONTANEOUS PULMONARY THROMBOSIS OR EMBOLISM

Thoracic radiographs of 21 dogs with necropsy-confirmed pulmonary thrombosis or embolism (PTE) were reviewed. Two major lung patterns were seen: (1) regional oligemia, giving the impression of a hyperlucent zone; (2) alveolar pulmonary infiltrate, indicating hemorrhage or infarction. Hemorrhage and infarction could not be differentiated radiographically. Other common findings were attenuation or loss of visualization of a lobar artery or lobar vein and pleural effusion, particularly with infarction and cardiac disease. PTE was often associated with renal disease (glomerulonephritis, amyloidosis), septic processes, pancreatitis, systemic venous or right heart thrombosis, cardiac insufficiency, and hypercorticism.     

RADIOGRAPHIC AND ULTRASONOGRAPHIC FINDINGS OF EMPHYSEMATOUS CYSTITIS IN FOUR NONDIABETIC FEMALE DOGS

The urinary bladder of four dogs with emphysematous cystitis was assessed radiographically. Ultrasonography was also performed using a 7.5-MHz microconvex probe in dorsal recumbency and in a standing position. Ultrasonographically there were bright echoes and reverberations typical of gas in all dogs. This was entrapped in the bladder wall as it appeared in the same location in recumbent and standing positions. Bladder size was reduced and bladder content was echogenic in all dogs. In only one out of the four dogs was a gas stripe seen in the bladder on radiographs. Proteus mirabilis was isolated from the urine of all patients. Diabetes was ruled out on the basis of urine and blood analysis. A small amount of gas can be difficult to detect on radiographs. Ultrasonography appears to be a more sensitive technique for detection of gas within the bladder at an early stage of emphysematous cystitis. Prevalence of emphysematous cystitis may be underestimated if only radiographs are made.     

COMPUTED TOMOGRAPHIC FINDINGS OF DOGS WITH CUBITAL JOINT LAMENESS

The purpose of this study was to identify the incidence of abnormal computed tomography (CT) findings in dogs with lameness of one or both elbows. CT examinations of 102 elbows in 51 dogs were reviewed individually and by group consensus by 3 examiners and graded for various abnormalities. Frequently encountered abnormalities included abnormal shape and sclerosis of the medial coronoid process of the ulna, irregularity of the radial incisure of the ulna, and ulnar trochlear notch sclerosis. Other abnormalities included distinct/separate or fissure/in situ fragmentation of the medial coronoid; lucency of the radial incisure; ununited anconeal process; sclerosis, lucency, or flattening of the medial aspect of the humeral condyle; osteophyte formation; and joint incongruity. In conclusion, CT of the canine cubital joint is useful in identification of various lesions beyond simple fragmentation of the medial coronoid process of the ulna.     

GROWTH OF THE RADIUS AND ULNA IN LABRADOR RETRIEVER DOGS WITH OCULAR AND SKELETAL DYSPLASIA

An associated ocular and skeletal dysplasia in Labrador Retrievers is caused by one abnormal gene which has recessive effects on the skeleton and incompletely dominant effects on the eye. The forelimbs of normal and affected pups were radiographed between birth and 156 days of age and the length of the radius and ulna measured. There was a significant difference in the mean length of these bones in normal and affected pups at birth and this difference was maintained over the period of observation. Similar differences were observed in purebred Labrador Retrievers and in Labrador Retriever-Beagle crosses. The results of this study suggest that the length of the radius and ulna could be used to identify pups affected by this syndrome if test matings with affected animals were done to identify carrier animals. Abnormal shape of the radius and ulna, which is seen in animals affected with this syndrome, should be used to augment the accuracy of identification of puppies affected by this syndrome.     

CORRELATION BETWEEN THORACIC RADIOGRAPHIC CHANGES AND REMISSION/SURVIVAL DURATION IN 270 DOGS WITH LYMPHOSARCOMA

A retrospective study was undertaken wherein the medical records and thoracic radiographs of 270 dogs with lymphosarcoma were reviewed to determine the type and frequency of thoracic radiographic changes. Statistical evaluation of the relationship between radiographic, clinical and immunologic factors and the primary remission duration and survival times was performed using univariate and multivariate analysis. One hundred ninety-two dogs (71 %) had some type of thoracic radiographicabnormality, including 80 dogs (29.6%) with pulmonary infiltrates and 164 dogs (64.4%) with thoracic lymphadenomegaly. Only T-cell phenotype (p = 0.0056 for survival, p = 0.0045 for remission) and the presence of cranial mediastinal lymphadenomegaly (p = 0.0005 for survival, p = 0.0129 for remission) were identified as having a significant negative correlation to both primary remission and survival duration by multivariate analysis.     

ULTRASONOGRAPHIC FINDINGS IN DOGS AND CATS WITH GASTROINTESTINAL PERFORATION

A retrospective study was performed to evaluate the sonographic features of gastrointestinal (GI) perforation in dogs and cats. Sonographic findings in 19 animals (14 dogs and 5 cats) included regional bright mesenteric fat (19), peritoneal effusion (16), fluid-filled stomach or intestines (12), GI wall thickening (11), presence of free air (9), loss of GI wall layering (9), regional lymphadenopathy (8), reduced GI motility (7), pancreatic changes (4), corrugated intestines (4), presence of a mass (3), presence of a foreign body (3), and mineralization of the gastric wall (1). In 14 patients, "perforation" was listed as a differential diagnosis by the sonographer. Abdominal radiographs and radiographic reports were available for 14 patients. Radiographic findings were decreased serosal detail (12), free air (8), peritoneal contrast medium (1), and suspected foreign body (1). GI perforation was listed as radiographic diagnosis in eight patients, seven of which had evidence of pneumoperitoneum, and one had leakage of contrast material on an upper GI study. In 9/14 patients with radiography, "GI perforation" was listed as a sonographic diagnosis. In three patients in which free air was diagnosed sonographically, radiographs were either not available (2) or the presence of free air was not detected at presentation (1). Peritoneal fluid analysis was performed in nine patients, five of which were identified as septic inflammation, and the remaining four were classified as neutrophilic inflammation with no etiologic agent identified. The histologic or surgical diagnoses were as follows: three intestinal surgical dehiscence; one percutaneous endoscopic gastrostomy tube site leakage; one duodenal adenocarcinoma; one ileocolic lymphoma; one trichobezoar; one ascarid impaction; and one bobby pin foreign body. In the remaining 10 patients, a focal area of gastric/intestinal ulceration or transmural necrosis with perforation was identified without evidence of an underlying cause.     

THORACIC RADIOGRAPHIC FINDINGS IN DOGS INFECTED WITH RICKETTSIA RICKETTSII

Sixteen beagle dogs were injected intradermally with Rickettsia rickettsii. The dogs were divided into four groups (n=4):1) infected, non-treated withdoxycycline;3) infected, treated with doxycycline and an anti-inflammatory dose of corticosteroid;4) infected, treated with ocular fluoresein angiograhphy was performed on days 6, 10, 17 post-inoculatin.A mild interstitial lung opacitywas noted in4/16 dogs on day 6, 5/16 on day 10 and 17 post-inculatin. Increased retinal vascular permeability was noted n 8/16 dogs on day 6,3/16 on day 10 and 1/16 on day 17 post-inoculation. Correlatin between the presence of radiographic and retinal lesions was not signigicant (p=0.08). Elevan, naturally infected, dogs with thoracic radiographs and an final diagnosis of RMSF were also evluated. Four of the 11 dogs had an unstructu4red inteerstitial pattern. Dogs with acute, experimentally-infected or naturally-occurring RMSF may have subtle pulmonary changes characterized by an unstructured interstitial patteern.     

ULTRASONOGRAPHIC FINDINGS IN CAIRN TERRIERS WITH PRECLINICAL RENAL DYSPLASIA

Renal dysplasia is a hereditary disease characterized by abnormal differentiation of renal tissue. The ultrasonographic appearance of dysplastic canine kidneys has been reported in the late stage of the disease where inflammatory and degenerative changes are already present and the dogs are in chronic renal failure. In this study, we describe the ultrasonographic appearance of the kidneys of five related Cairn Terriers affected with renal dysplasia before the onset of clinical or laboratory evidence of renal failure. Common findings included poor corticomedullary definition and multifocal hyperechoic speckles in the renal medulla, or a diffusely hyperechoic medulla. Severity of ultrasonographic changes was related to the severity of histopathologic findings. The ability to detect dysplastic changes before clinical signs develop makes ultrasound a potentially useful screening method for canine renal dysplasia.     

SENSITIVITY AND SPECIFICITY OF RADIOGRAPHIC DETECTION OF CANINE ELBOW INCONGRUENCE IN AN IN VITRO MODEL

Canine elbow incongruence is believed to be the consequence of underdevelopment of the radius. The purpose of this study is to determine the sensitivity and specificity of radiography to detect elbow incongruence in an in vitro model and to assess the optimal elbow angle and radiographic beam position. Five normal cadaveric canine left forelimbs were used. A four-pin, type 1 external fixator with a linear motor side bar was fixed to the cranial part of the radius of each limb and a 1 cm segment of bone was removed from the mid-diaphysis to allow radial shortening. Each elbow was subjected to the same protocol. They were radiographed at two different angles (90 degrees and 135 degrees) of flexion, with 10 different radiographic beam positions (centered on the humeral condyle, 3 cm cranial, 3 cm caudal, 3 cm distal, 3 cm proximal, 3 cm cranio-proximal, 3 cm cranio-distal, 3 cm caudo-proximal, 3 cm caudo-distal and on the shoulder joint) and at four different level of radial shortening (0, 1, 2 and 3 mm). In addition, a radiographic view centered on the elbows flexed at 135 degrees was made after simulating weight bearing. The acquired digital images were independently evaluated by three evaluators unaware of the elbows status. The elbows were judged normal, incongruent or borderline based on specific criteria. The sensitivity for detection of elbow incongruence at and beyond 2 mm was excellent at 90 degrees (median = 100% for all views) and good at 135 degrees (median = 80%) of flexion with no difference between examiners. The sensitivity at 1 mm of incongruence was unchanged at 135 degrees but was reduced at 90 degrees of flexion (median = 60%) with a significant difference between the evaluators. The specificity was significantly different between the evaluators and ranged from 70% to 90% at 90 degrees of flexion and from 50% to 80% at 135 degrees. The lowest specificities at 90 degrees were obtained with the proximal displacements of the X-ray beam. Simulating weight bearing significantly decreased the sensitivity at 1 mm (from 80% to 50%) and 3 mm (from 100% to 80%) of incongruence and slightly increased the specificity (from 55% to 65%). Radiography is a sensitive and specific test to detect moderate-to-severe radio-ulnar incongruence (2 mm and over) if the elbow is flexed at a 90 degrees angle regardless of the radiographic beam position. Finally, canine elbow incongruence appeared reduced after an in vitro weight-bearing simulation.     

RADIOGRAPHIC APPEARANCE OF CONFIRMED PULMONARY LYMPHOMA IN CATS AND DOGS

Herein we describe the thoracic radiographic appearance of confirmed pulmonary lymphoma. Patients with thoracic radiographs and cytologically or histologically confirmed pulmonary lymphoma were sought by contacting American College of Veterinary Radiology members. Seven cats and 16 dogs met the inclusion criteria, ranging in age from 4 to 15 years. Method of diagnosis was via ultrasound‐guided cytology (four), surgical biopsy (two), ultrasound‐guided biopsy (one), and necropsy (16). Radiographic findings varied but ranged from normal (one) to alveolar (six) and/or unstructured interstitial infiltrates (11), nodules and/or masses (eight), and bronchial infiltrates (four). Additional thoracic radiographic findings included pleural effusion and lymphadenopathy. The results of this evaluation indicate a wide variability in thoracic radiographic abnormalities in cats and dogs with pulmonary lymphoma.     

COMPUTED TOMOGRAPHIC AND RADIOGRAPHIC CHARACTERISTICS OF AORTIC LESIONS IN 42 DOGS WITH SPIROCERCOSIS

Spirocerca lupi is a common cause of vomiting, regurgitation, and sudden death in dogs that live in tropical or subtropical regions. Sudden death due to aortic rupture may occur with no preceding clinical signs. The purpose of this prospective study was to compare radiographic and computed tomographic (CT) characteristics of aortic lesions in a cohort of 42 dogs with endoscopically confirmed spirocercosis. Dorsoventral and right lateral recumbent thoracic radiographic findings were compared with pre‐ and postcontrast thoracic CT findings. Aortic mineralization was detected using CT in 18/42 dogs (43%). Three dogs had faint diffuse aortic wall mineralization. Using CT as the reference standard, radiographs had a sensitivity and specificity of 6% and 96%, respectively, for detecting aortic mineralization. A total of 20 aortic aneurysms were detected using CT in 15/42 dogs (36%). Using CT as the reference standard, radiographs had a sensitivity and specificity of 86% and 56%, respectively, for detecting aortic aneurysms. Respiratory motion, aortic displacement by esophageal masses and Spirocerca nodules adjacent to the aorta mimicked aneurysm formation on radiographs. Aortic thrombi were seen in two dogs in postcontrast CT images. Findings from this study indicated that aortic mineralization and aneurysm formation are common in dogs with spirocercosis. Findings also supported the use of pre‐ and postcontrast CT as effective methods for detecting and characterizing these lesions.     

COMPARISON OF TWO PALPATION, FOUR RADIOGRAPHIC AND THREE ULTRASOUND METHODS FOR EARLY DETECTION OF MILD TO MODERATE CANINE HIP DYSPLASIA

Hip joint laxity was evaluated in Golden Retriever (n = 60), Labrador Retriever (n = 23), and Labrador/Golden Retriever mix (n = 24) puppies. Ortolani and Bardens maneuvers, four radiographic measurement indices and three dynamic ultrasonographic measurements were used. Each puppy was evaluated twice; at 6.5 to 9 and 43 to 79 weeks of age. These nine methods were compared for accuracy in predicting the development of canine hip dysplasia with or without degenerative joint disease by a median age of 16 months. The Bardens maneuver was a significant predictor of canine hip dysplasia/+/-degenerative joint disease for Golden Retriever puppies, however, it was not a reliable predictor for the other two breeds. Norberg angle measurements taken with femurs in a neutral position with hips distracted (PennHip position) was a significant predictor of degenerative joint disease in two breeds, but not in Golden Retriever puppies. Ultrasound measurement was a reliable predictor of hip canine hip dysplasia/+/-degenerative joint disease for Labrador/Golden Retriever mix puppies, but was not reliable for the other two breeds. Palpation, radiographic, and ultrasonographic methods of evaluating hip joint laxity in puppies at 6.5 to 9 weeks of age were not consistently reliable for all three breeds in predicting hip dysplasia with or without degenerative joint disease at one year of age. A strong association was found between Norberg angle and degenerative joint disease occurrence, as well as between distraction index (PennHip) and degenerative joint disease occurrence when measured at 52 to 79 weeks of age, but not when measured at 6.5 to 9 weeks of age in these breeds. These results emphasize the difficulty of early detection of mild hip dysplasia in the dog.     

RADIOGRAPHIC EVALUATION OF THE CANINE ELBOW JOINT WITH SPECIAL REFERENCE TO THE MEDIAL HUMERAL CONDYLE AND THE MEDIAL CORONOID PROCESS

The results of radiographic examination of clinically affected elbow joints in 14 young, large-breed dogs, including standard and oblique projections and linear tomography, were compared with the findings of medial arthrotomy. Radiographs revealed arthrosis (13 dogs), osteochondrosis of the medial humeral condyle (2 dogs), fragmentation of the medial coronoid process (5 dogs), and a combination of osteochondrosis of the medial humeral condyle and fragmentation of the medial coronoid process (2 dogs). In one dog fissures in the medial coronoid process and in another dog a linear radiopacity along the articular surface of the medial coronoid process were found. In three dogs both medial humeral condyle and medial coronoid process appeared normal. The radiographic findings were confirmed during surgery in 11 dogs. Cartilage erosion of the medial humeral condyle in two dogs and of the medial coronoid process in one dog had not resulted in radiographically visible abnormalities. Radiographic examination of the elbow joints in young, large-breed dogs should include standard mediolateral and craniocaudal projections, a mediolateral projection with the joint maximally extended and the leg supinated 15°, and a craniolateral-to-caudomedial projection.     

A COMPARISON OF RADIOGRAPHIC AND COMPUTED TOMOGRAPHIC FINDINGS IN 31 DOGS WITH MALIGNANT NASAL CAVITY TUMORS

Nasal cavity radiographs and CT images from 31 dogs with nasal cavity cancer were compared. All dogs had abnormal clinical signs relating to -nasal cancer and histologic confirmation of malignant nasal cavity neoplasia. No dog had cyto reductive surgery prior to imaging. All radiographic and CT examinations were abnormal. CT was more accurate than radiographs in identifying unilateral versus bilateral nasal cavity disease and tumor extension into adjacent structures such as the cranial cavity, hard palate, and pterygopala-tine fossa. The improved accuracy of CT in these respects was not of benefit in the confirmation of nasal cavity disease because radiographs were abnormal in every instance. However, CT may be useful for more accurate tumor staging, predicting possible treatment-related complications, and planning of surgery and radiation therapy. It was also determined that one dorsally located radiation therapy portal bounded laterally by the medial ocular canthi, as described in previous reports, would not have been adequate for encompassing all abnormal tissue in 28 of the 31 dogs evaluated.     

CORRELATION OF RADIOGRAPHIC, ECHOCARDIOGRAPHIC, AND ELECTROCARDIOGRAPHIC SIGNS OF LEFT HEART ENLARGEMENT IN DOGS WITH MITRAL REGURGITATION

Thoracic radiographs of 40 dogs with mitral regurgitation were evaluated for signs of left heart enlargement and classified into three groups based on the degree of left atrial enlargement (mild = group A, moderate = group B, and severe = group C). Echocardiographic enlargement ratios were calculated for the left atrium (LAE_echo), the left ventricle (LVE_echo), and the aorta (AOE_echo) by dividing the measured dimension with the expected dimension normalized for body weight. The incidence of LVH patterns and p-mitrale was recorded on electrocardiograms. With advanced stages of the disease, there was good agreement of the radiographs and echocardiograms with significant differences of the left atrial enlargement ratio between groups. Nine of the 16 dogs from groups A and B, however, had LAE_echo ratios within the normal range. Sixteen dogs with radiographic signs of left ventricular enlargement had normal LVEecho ratios. These disagreements were interpreted as either cardiac enlargement not manifest in the dimensional change measured by the echocardiogram or as overreading of radiographs. The left ventricular wall thickness did not vary significantly between groups. The incidence of p-mitrale was 30%, but this ECG abnormality, when present, reliably identified enlarged left atrial dimensions. Left ventricular hypertrophy patterns of the ECG did not correlate with either the radiographic diagnosis of left ventricular enlargement or the echocardiographic enlargement ratios.