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PAPERS: Multicentre Aneurysm Screening Study Group Multicentre aneurysm screening study (MASS): cost effectiveness analysis of screening for abdominal aortic aneurysms based on four year results from randomised controlled trial BMJ 2002; 325: 1135 [Abstract] [Full text]

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misprint?

brynley davies   (15 November 2002)

Abdominal Aortic Aneurism Screening is "clinical" by means of Biophysical Semeiotics.

Sergio Stagnaro   (15 November 2002)

National screening programme is long overdue

Richard M Lynch   (19 November 2002)

The Ultrasound department can save lives by routinely imaging the abdominal aorta

Eric K Woo   (27 November 2002)

Screening for aortic aneurysm

Christopher C Gunstone   (14 December 2002)

misprint? 15 November 2002
brynley davies, retired Bro Taf Health Authority (retired) cf10 2tw Send response to journal: Re: misprint?	Is the confidence interval for cost per life year gained a misprint at £15000 to £145000 or should readers be highly sceptical about the economic case set out? Competing interests:   None declared
Abdominal Aortic Aneurism Screening is "clinical" by means of Biophysical Semeiotics. 15 November 2002
Sergio Stagnaro, Specialist in Blood, Gastrointestinal, and Metabolic Diseases. Researcher in Biophysical Semeiotics. Via Erasmo Piaggio 23/8 16037 Riva Trigoso (Genoa) Italy. Send response to journal: Re: Abdominal Aortic Aneurism Screening is "clinical" by means of Biophysical Semeiotics.	Sirs, I am very delighted with MASSG’s article (1) as well as with similar papers, which come to the conclusion: “Even at four years the cost effectiveness of screening for abdominal aortic aneurysms is at the margin of acceptability according to current NHS thresholds. Over a longer period the cost effectiveness will improve substantially, the predicted ratio at 10 years falling to around a quarter of the four year figure”. Surely, the cost at 10 years improves in comparison with that of the former randomised controlled trial, in which patients were individually allocated to invitation to ultrasound screening (intervention), due to the fact that individuals are selected somehow. In reality, I like such articles, emphasing the urgency of spreading a new physical semeiotics, i.e., Biophysical Semeiotics, in a medical world, ruled by high technology, in order to recognize at the bed-side disorders otherwise undiagnosed in unexpensive way (Stagnaro S., BMJ.com, Rapid Response, A new physical semeiotics in detecting disorders otherwise undiagnosed. 30 Marz 2001). As far as abdominal aortic aneurysms diagnosis in both older and young men, a 45-year-long clinical experience allows me to state that its diagnosis – although clearly overlooked or totally ignored all around the world – is primarily a “bed-side” “quantitative” diagnosis , regardless its size and not to speak of its precious clinical monitoring (2, 3, 4). Sophisticated semeiotics can then corroborate the clinical diagnosis in individual "rationally" selected with appreciable reduction in cost. For further information, See my site HONCode, http://digilander.libero.it/semeioticabiofisica, Practical Appplications, Abdominal Aortic Aneurism, and the Page I hold in italian site www.katamed.it. 1) Multicentre Aneurysm Screening Study Group. Multicentre aneurysm screening study (MASS): cost effectiveness analysis of screening for abdominal aortic aneurysms based on four year results from randomised controlled trial. BMJ 2002;325:1135 ( 16 November ) 2) Stagnaro-Neri M., Stagnaro S., Aneurisma Aortico Addominale: una Diagnosi clinica con la Semeiotica Biofisica. Acta Cardiol. Medit. 14, 17, 1986. 3)Stagnaro-Neri M, Stagnaro S., Valutazione clinica percusso-ascoltatoria del sistema nervoso vegetativo e del sistema renina-angiotensina, circolatorio e tessutale. Arch. Med. Int. XLIV,173, 1992. 4) Stagnaro-Neri M., Stagnaro S., Stadio pre-ipertensivo e monitoraggio terapeutico della ipertensione arteriosa. Omnia Medica Therapeutica. Archivio, 1-13, 1989-90 Competing interests:   None declared
National screening programme is long overdue 19 November 2002
Richard M Lynch, Specialist Registrar A&E York District Hospital YO31 8HE Send response to journal: Re: National screening programme is long overdue	Editor – It is a scandal that in the 21st century there is no national screening programme, in the United Kingdom, for the detection of abdominal aortic aneurysms in men. This in spite of some very compelling evidence in favour of one. In a randomised controlled trial Scott et al [1] identified a 68% reduction in incidence of rupture at 5 years among those invited for screening compared with age-matched controls and a 42 per cent reduction in death from rupture. The benefit persisted at 10 years but there was no detectable benefit for women. In men, only 4 per cent of deaths from rupture occurred under the age of 65 years, no woman died below this age. Screening of men aged 65 years has been taking place in the county of Gloucestershire, UK since 1990. The total number of aneurysm-related deaths in this population decreased progressively year by year in the screened portion of the population (p<0.001). No change was observed in the unscreened part of the population [2]. Law has estimated that a national screening programme could save 2000 lives per year in men aged 60 – 79 years [3]. In addition reduction of modifiable risk factors, smoking, hypertension, coronary heart disease [4], together with increased awareness of unusual modes of presentation of ruptured abdominal aortic aneurysm may save even more lives. Finally the multicentre aneurysm screening study provides evidence of cost effectiveness of a national screening programme [5]. 1. Scott RAP, Vardulaki KA, Walker NM, Day NE, Duffy SW, Ashton HA. The long-term benefits of a single scan for abdominal aortic aneurysm (AAA) at age 65. Eur J Vasc Endovasc Surg 2001; 21: 535-40. 2. Heather BP, Poskitt KR, Earnshaw JJ, Whyman M, Shaw E. Population screening reduces mortality rate from aortic aneurysm in men. Br J Surg 2000; 87(6): 750-753. 3. Law M, Screening for abdominal aortic aneurysms. Br Med Bulletin 1998; 54: 903-913. 4. Lederle FA, Johnson GR, Wilson SE, Littooy FN, Krupski WC, Bandyk D, et al. Yield of repeated screening for abdominal aortic aneurysm after a 4-year interval. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators. Arch Intern Med 2000; 160(8): 1117-21. 5. Multicentre Aneurysm Screening Study Group. Multicentre aneurysm screening study (MASS): cost effectiveness analysis of screening for abdominal aortic aneurysms based on four year results from randomised controlled trial. BMJ 2002; 325:1135-8. Competing interests:   None declared
The Ultrasound department can save lives by routinely imaging the abdominal aorta 27 November 2002
Eric K Woo, SpR in Radiology St Thomas' Hospital, London SE1 7EH Send response to journal: Re: The Ultrasound department can save lives by routinely imaging the abdominal aorta	Although no screening program for abdominal aortic aneurysm exists in the UK at the present time despite much published evidence(1,2,3), opportunistic screening should be performed in the interim. Radiologists and ultrasonographers should be alerted to the benefit of routinely examining the abdominal aorta in all males over the age of 65 years who present to the ultrasound department. This may mean a few more minutes of scanning time per patient but is certainly worthwhile if it means a reduction in mortality from rupture by early detection at no extra cost. Reference: 1) Multicentre Aneurysm Screening Study Group. Multicentre aneurysm screening study (MASS): cost effectiveness analysis of screening for abdominal aortic aneurysms based on four year results from randomised controlled trial. BMJ 2002;325:1135-8 2) Heather BP, Poskitt KR, Earnshaw JJ, Whyman M, Shaw E. Population screening reduces mortality rate from aortic aneurysm in men. Br J Surg 2000;87(6):750-753 3) Lindholt JS, Juul S, Fasting H, Henneberg EW. Hospital costs and benefits of screening for abdominal aortic aneurysms. Results from a randomised population screening trial. Eur J Vasc Endovasc Surg 2002 Jan;23(1):55-60 Competing interests:   None declared
Screening for aortic aneurysm 14 December 2002
Christopher C Gunstone, GP Principal Gordon Street Surgery, Burton upon Trent, Staffs DE15 9AF Send response to journal: Re: Screening for aortic aneurysm	Imagine this hypothetical scene – Thursday morning surgery (tends to be quieter, thank goodness). First patient, Mr Bland, enters. He is a fit 65 yr old. ‘Hello, Mr Bland’ ‘Hello Doc’ I pause. He rummages in his pocket and brings out A4 sheet. ‘Its this .. aortic aneurysm screening thing, what’s it all about?’ Discussion follows about aortas, near certainty of death from rupture, risk of death of 1 in 1000 pre year (approx), and the ease of the screening test. ‘So, if I have this done I’m going to live longer?’ ‘Well, no, I can’t say that. The trial showed that 11% died whether they had the screening or not, over the four years of the trial.’ ‘Hmmm. OK then. But if I was found to have one of these things and had the operation, I’d be OK?’ ‘Well, no. I can’t say that. The trial showed that if you had the operation before the aneurysm burst, 19 out of twenty would survive, but one would die.’ ‘So that means that I might actually die sooner than I would have?’ I pause, ‘Well, yes, it does.’ ‘So, if I have the screening, and survive the operation, if I have one, what would I die of? Would it be cancer or would I end up like my sister with dementia in that nursing home?’ ‘Well, I’m sorry I cannot tell you that.’ ‘Right.’ He’s getting a bit red in the face .. ‘ OK. You’re the professional. What do you think I should do?’ I pause. ‘It really is up to you, Mr Bland. It’s your decision entirely. I suggest you go home and chat to your wife about it. You could come back and see me again if you want.’ ‘Cheerio, then.’ Was it my imagination, or did the door close more firmly than normal? But I couldn’t tell him that personally (at this point in my life), I would want to take my chances, could I? Life has 100% mortality. It follows that doctors can only prolong life (usually). I believe that a prime end point in research in the latter years of life must be related to final outcomes. Otherwise it is like a story with no ending. If we are suggesting that people swap a quick death (albeit painful) for something else, I think we need to know what that is. Otherwise can we really say that we have informed consent? Other information might be useful too - nearly one percent of the screened group had a major operation, what is the morbidity? With small aneurysms, the editorial states that there is a 1% annual chance of rupture – what about those greater than 5.5cms (presumerably it is higher than the 6% mortality from elective operation)? What is the life expectancy of a 65 yr old male? Scientific research tends to look at life if there are many unrelated aspects. Therefore the conclusion is that undoubtedly aortic aneurysm screening is justified. However I think we should apply the results holistically. This is undoubtedly more messy, but probably more realistic. Competing interests:   None declared