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Rapid Responses: Rapid Responses published:
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A relevant extracardiac domain for echocardiography.
- Tomaso Gnecchi-Ruscone, Francesca Arrigoni*, Elisabetta Lobiati (8 May 2004)
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Preventable deaths must be prevented!
- Dr.Naseem A. Qureshi MD, IMAPA, LMIPS (9 May 2004)
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Potential role for CT colonography in screening for aortic aneurysm
- David N Burling, Steve Halligan, Stuart Taylor (14 May 2004)
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Ultrasonology and GPs Practice: is it feasible?
- Alfonso SAURO (15 May 2004)
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Screening induces harm
- Dink A. Legemate (7 June 2004)
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AAA surgery--chance result?
- MICHAEL S. SMITH (26 July 2004)
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Screening for abdominal aortic aneurysms
- RAP Scott (25 August 2004)
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Tomaso Gnecchi-Ruscone, Cardiologist Cardiology, Radiology *, Ospedale S.Leopoldo Mandic, 23807 Merate (LC)., Francesca Arrigoni*, Elisabetta Lobiati
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Editor: We agree with the conclusions of Earnshaw et al. (1) that stresses again the usefulness of population screening for abdominal aortic aneurysm (AAA) as recently demonstrated by the MASS study (2). We would like to add another possible and cost effective way to discover silent AAA by extending the domain for echocardiography. Indeed AAA shares with hypertensive (H) and coronary (CAD) patients common risk factors (male sex, age, smoke, hypercholesterolemia) and most of the recognized H and CAD patients undergo echocardiography but, according to the 2003 ACC/AHA/ASE guidelines update for echocardiography (3), only the thoracic aorta is considered. The additional evaluation of the abdominal aorta from the celiac trunk to the bifurcation of the iliac arteries would increase the diagnostic yield of echocardiography. In order to test the feasibility of our proposal we looked for the presence of AAA (a transverse diameter >30 mm was needed) in 100 H and 100 IHD patients, (age 67± 11 yrs (SD), 61 % males), consecutively studied in our echocardiography laboratory. A 2.5 MHz probe was utilized on a 2000 Hewlett Packard echocardiograph, avoiding purposely the use of a dedicated ultrasound probe for the abdomen. We detected in 6 % of H and in 9 % of IHD patients the presence of AAA; an inadequate resolution was present in 1 % of the subjects. The measurements were than compared and found all consistent with those obtained with a dedicated (4.5 Hz) probe for abdominal echo scan. Of relevance, all AAA patients were clinically silent. A rapid maneuver is therefore at hand during a routine echocardiographic examination to unhide a potentially lethal AAA. References 1) Earnshaw JJ, Shaw E, Whyman MR, Poskitt KR, Heather BP. Screening for abdominal aortic aneurysms in men. BMJ 2004; 328: 1122-1124. 2) Ashton HA, Buxton MJ, Day NE et al. The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet 2002; 360:1531-9. 3) Cheitlin MD, Armstrong WF, Aurigemma GP, et al. ACC/AHA/ASE 2003 Guideline Update for the Clinical Application of Echocardiography: Summary Article: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography). Circulation 2003;108: 1146-1162. Competing interests: None declared |
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Dr.Naseem A. Qureshi MD, IMAPA, LMIPS, Medical Director(A), Director CME&R Buraidah Mental Health Hospital, Postcode:2292, Saudi Arabia
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Dear Sir: There are, as far as I know, three types of prevention; universal, selective and finally indicated. The main focus of prevention programmes is first to identify risk factors for diseases development, early identification of diseases, and then to intervene properly. Consequently, the preventive programmes lead to substantially decreased morbidity and mortality in a cost-effective way. Both an influential study by Earnshaw et al [1] and an accompanied editorial by Roger [2] support the implementation of national screening programme for the early diagnosis of abdominal aortic aneurysm particularly in men of age of 60 and above. We as medical colleagues support their suggestions related to this screening programme based on unequivocal findings of many research also conducted worldwide. It is well documented that the process of atherosclerosis is silent but dynamic and there are already identified risk factors for its development most commonly in men with unfavourable life styles such as smoking, sedentary habits, use of fatty meals, hyperlipaedemia, morbid obesity, and most importantly revealed genetic propensity. Atherosclerosis has special but worrying relationships with hypertension, coronary artery disease, abdominal aortic aneurysm, and probably aneuryms elsewhere in the body. All these atherosclerosis-related diseases more often result in catastrophic events, i.e., myocardial infaction, stroke, leak/rupture of aorta, and all have very high mortality rate if relevant emergency services are delayed. The associated high mortality rate can be reduced considerably by early screening and proper, timely intervention as revealed by this study [1] and therefore national screening programme for abdominal aortic aneurysm must have green signal from relevant deciding authorities in the UK. J J Earnshaw, E Shaw, M R Whyman, K R Poskitt, and B P Heather. Screening for abdominal aortic aneurysms in men BMJ 2004; 328: 1122-1124. Roger M Greenhalgh.National screening programme for aortic aneurysm. BMJ 2004 328: 1087-1088. Competing interests: Pro-death prevention |
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David N Burling, Gastrointestinal Radiology Research fellow St. Mark's Hospital, London. HA1 3UJ, Steve Halligan, Stuart Taylor
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Familiar with the challenges facing implementation of a national screening programme for colorectal cancer, we read with interest the article and accompanying editorial promulgating abdominal aortic aneurysm screening, based on the Gloucestershire experience (1). The role of computed tomographic colonography (CT colonography or virtual colonoscopy) is evolving and could potentially benefit such a programme. CT colonography is a widely available technique examining both the entire colorectum and extracolonic organs (2). The abdominal aorta is always well visualised throughout its length allowing easy size assessment and, unlike portable ultrasound, multi-planar reconstructions can be instantly produced to provide recognisable and detailed anatomical information for the surgeon. In the UK, virtual colonoscopy is increasingly used as an alternative to barium enema for symptomatic patients, particularly in frail or elderly groups. In the USA however, there is a strong political lobby to include virtual colonoscopy as one of the primary colorectal cancer screening options reimbursed by the larger insurance agencies. If successful, large numbers of eligible screenees will have their aorta examined, identifying many of those with aneurysmal formation at an earlier age (50 to 70 years). Moreover, women in whom 28% of aneurysmal rupture deaths occur would be examined (3) (they are currently excluded from the aneurysm screening strategy adopted in Gloucestershire). Although it could be sensibly argued that this approach is merely whole-body screening by the back door, if properly targeted to the right age and risk groups, then there is an opportunity to combine resources, which might be popular with both the public and politicians alike. References 1.Earnshaw JJ, Shaw E, Whyman MR, Poskitt KR, Heather BP. Screening for abdominal aortic aneurysms in men. BMJ 2004;328:1122-4 2.Halligan S, Fenlon HM. Virtual colonoscopy. BMJ 1999; 319:1249-52 3.Law MR, morris J, Wald NJ. Screening for abdominal aortic aneurysms. J Med Screen 1994; 1:110-6 Competing interests: All three authors provide remunerated advice to Medicsight, a CT software development company. |
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Alfonso SAURO, Responsable SNAMID South Italy - General Practitioner - EURACT and WONCA Member SNAMID CE - 81100 Caserta Italy
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Primary care is the first step in every National Health System (NHS)all around the world but bureaucracy is becoming the first GPs' occupation in his daily practice. A lot of time spent to fill in a number of various forms required by patients themselves and mostly by the manager of our NHS, especially in Italy. No more time to be "doctors". The use of many "new" thecnology in Primary Care could improve early detection of various diseases (1). If well trained GPs could use this thecnology as spirometry,ECG ultrasounds and so on as well as the specialists do. Why this possibility is not took in account by our Government, at least in Italy? How many abdominal aortic aneurysms could be detected by GPs? Why does not ECM encourage the practical training more than theoretical ones? Why aren't there more incetives for those GPs who use this "new thecnology" in their daily practice? I believe that it should be usefull even in reducing the costs and the waiting lists. 1- General practitioners can easily use spirometers SAURO A, Ferdinando P, Scalzitti F, Mastroianni RA, Buono N, Diodati G.(13 July 2003) http://bmj.bmjjournals.com/cgi/eletters/324/7350/DC1 Competing interests: None declared |
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Dink A. Legemate, Professor of Vascular Surgery & Clinical Epidemiologist Academic Medical Center, PO Box 22700, 1100 DE Amsterdam
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In the discussion about screening I miss a debate about the harm that may be done. It is well known that doing harm is the down-side of screening. This is insufficiently realized by many, including surgeons and policy makers. Aneurysm surgery is not without mortality and has a major morbidity rate of approximately 10%. This is the price persons have to pay for a ‘therapy’ with a very limited reduction in all cause mortality. Ironically, the large majority of these complications happen to patients who otherwise wouldn’t have died from a ruptured aneurysm and even wouldn’t have known that they lived with an aneurysm. How are we going to explain this to patients? Earnshaw et all try to convince people with ‘the impressive’ relative risk reduction of 42% for the mortality from aneurysm disease instead of absolute risk reduction and the fact that screening is cost-effective. A more balanced view in which we carefully analyse the risks in relation to the limited benefit is mandatory before we embark upon a screening programme for aneurysms. Competing interests: None declared |
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MICHAEL S. SMITH, physician-statistician Tucson, AZ 85718
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This is an interesting article; at least empirically
it would make sense to screen older men for AAA.
Indeed, a control chart shows that there was a
significant decrease in emergency surgery in 2002
although not in other years.
The comparison of mortality, however, is not statistically significant, assuming independence. True, the sample percentage fell in the second period, but the p-value of 0.17 means that this result would be expected to have occurred by chance 1 time in 6 in repeated samples of similar size. The error is compounded further by stating that the mortality "fell 42%," when again the statistical significance at usual levels was not present. It is akin to throwing a coin 10 times and obtaining 6 heads, a probability about one in five. One could throw the same coin 10 more times and obtain 4 heads with similar probability. The number of heads has fallen a third, but the coin hardly has ability to think about how to land. I hope the authors continue tracking their cases, perhaps looking at it on a semi-annual or annual basis, where the chances of showing a difference sooner could be greater. Again, it's a good idea--it just needs to be proved. Sincerely yours,
Competing interests: None declared |
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RAP Scott, Principal Investigator, Multi-centre Aneurysm Screening Study (MASS) Scott Research Unit, CMEC, St Richards Hospital, Chichester, West Sussex PO19 6SE
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Editor-Earnshaw et al1 describe the practice of screening for AAA over a 13 year period, and conclude that the arguments for a national screening programme are cogent. The results of the MASS trial2 support their conclusion. They discuss options for screening nationally. Screening men once at age 65 is supported by the findings of MASS and the Chichester study3 and is in my view the preferred option because it would detect the vast majority of patients at risk from rupture and achieve a high acceptance rate. Although of interest, I would not include those with AA A 2-6 cm -2- 9 cm in diameter for follow-up in a national programme, because it would increase the workload of the screening unit significantly without any equivalent benefit. Hobbs et al4 found that no patient with an aorta less than 3 cm diameter suffered a ruptured AAA over a 10 year period.. The same would be true of their indicators for referral to outpatients at a diameter of 4.0 cm instead of 5.5cm (as in MASS), . I would suggest continued follow-up by the screening team to 5.5cm, because from our experience, this carries an acceptably low risk of rupture, would reduce the workload in the hospital clinics, and provide referral when the clinical decision for surgical intervention is indicated.5 Including prevention with screening is mentioned by Earnshaw et al. The addition of an assistant/facilitator could allow for additional observations to be recorded and advice offered (eg concerning blood pressure, weight and smoking) without decreasing the screening rate significantly. This extra person could also provide support for the ultrasonographer when going out to isolated or urban areas. The MASS trial has shown AAA screening to be clinically beneficial and cost-effective. Earnshaw et al have shown that AAA screening of men using a single scan at age 65 is feasible. This adds to the evidence and impetus for UK decision makers and politicians to support the introduction of a national screening programme for AAA. RAP Scott
References 1 Earnshaw JJ Shaw E, Whyman MR, Poskitt KR, Heather BB. Screening for abdominal aortic aneurysms in men. BMJ, 2004;328:1122-1124. 2 Multicentre Aneurysm Screening Study Group. The Multi-centre Aneurysm Screening Study (MASS) into the effects of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet 2002;360:1531-9. 3 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: 535-540 4 Hobbs F, Claridge M, Drage M, Quick C, Bradbury A, Wilmink A. Strategies to improve the effectiveness of AAA screening programmes. J Med Screening 2004; 11: 93-96 5 The UK Small Aneurysm Trial Participants. Mortality results for randomised controlled trial of early elective surgery or ultrasonographic surveillance for small abdominal aortic aneurysms. Lancet 1998; 352: 1649- 1655 Competing interests: None declared |
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