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Rapid Responses: Rapid Responses published:
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Vascular Surgical Society Response to BMJ article on AAA screening
- Jonothan Earnshaw (18 April 2008)
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Eradicate timely asymptomatic disease in men at high risk of death
- Luc G Bonneux (19 April 2008)
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Abdominal aortic aneurysm: To screen, or not to screen
- Hisato Takagi, Hideaki Manabe registrar, Norikazu Kawai registrar, Takuya Umemoto consultant cardiovascular surgeon (19 April 2008)
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"Intensive counselling" is no longer necessary before an HIV test for most patients
- Tristan J Barber, Anatole Menon-Johansson and Simon Barton (20 April 2008)
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Quality of life after abdominal aortic aneurysm repair.
- Kathryn McCarthy (20 April 2008)
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Screening for Abdominal Aneurysms, all people should have them...."the old fashioned way!"
- Lance Christiansen (22 April 2008)
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Successful AAA screening is dependent on service reconfiguration and audit
- Peter J E Holt, Robert J Hinchliffe, Matt M Thompson (23 April 2008)
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Are AAAs common enough to warrant screening?
- Paul E Norman (23 April 2008)
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Harm prevention
- John Doherty (23 April 2008)
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Point of view from the French Vascular Medicine Society : not only a surgical issue
- Becker François, Isabelle Quere, Jean-Pierre Laroche, Joel Constans (27 April 2008)
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Rural and remote AAA screening
- Steve Flecknoe-Brown (29 April 2008)
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Jonothan Earnshaw, Honorary Secretary of the Vascular Society of Great Britian and Ireland Royal College of Surgeons, Lincoln's Inn Fields, WC2A 3PE
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The Vascular Surgical Society of Great Britain and Ireland (VSGBI) has serious concerns about the views of Mr James Johnson on the benefits of Abdominal Aortic Aneurysm (AAA) screening for all men over the age of 65. (British Medical Journal, April 18, 2008. AAA is the third most common cause of death for men in this age group, with over 6,000 dying every year in England and Wales. Half of these deaths can be avoided through screening. Although an invitation for screening may cause mild anxiety to some patients, my experience gained while working on the long running AAA screening program in the Gloucestershire area, has shown there to be no long-terms issues around patient anxiety. While the issue of patient anxiety is one which must be carefully addressed, this must not be at cost of the 2,000 men who are dying premature and painful deaths every year due to a ruptured aneurysm. These deaths can, and will, be avoided due to the implementation of this simple and cost effective national screening programme. 80% of patients who rupture an AAA will die before reaching a hospital, and of those who make it into surgery only 50% will survive. Surgeons have a far greater chance of saving someone’s life through preventative rather than emergency surgery. An increasing number of these preventative operations are being carried out using minimally invasive techniques like keyhole surgery, thus avoiding major surgery and further improving survival rates. Competing interests: None declared |
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Luc G Bonneux, Medical epidemiologist 2502 Den Haag (the Netherlands)
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When talking about interventions, absolute risks should always be presented. AAA screening targets elderly males, often smokers, with high risks of vascular co-morbidity.(1) Total mortality in the trials was high (12.0% after 3 to 5 years of follow up).(2) In the control arms, the probability of death by an AAA was 0.3%, the probability of AAA repair was 0.4%.(2) In the intervention arms the probabilities of death and repair were 0.2% and 0.9%.(2) Screening of 1000 men saved one death in a total of 120 at a detection rate of 50 diagnoses and added 5 repair interventions. In the MASS trial, after seven years of follow up, 2.5 discounted life days were saved.(3) The health care budgets of AAA more than doubled (+ 115%).(3) Randomised controlled trials are carefully controlled experiments. Everyday practice is more sloppy. In EUROSTAR, a register of endovascular repair, 45% of the patients had aneurysms of smaller than 5.5 cm.(4) It is hard for patients and doctors to leave “ticking time bombs” in place. The argument that these vascular impaired patients have ticking time bombs everywhere is rarely reassuring for patients or doctors. A tripling of AAA budgets seems a conservative estimate. AAA screening might save deaths by open repair, but might cause more deaths by stress.(5) However, it likely saves more lives by screening in an awkward way for cardiovascular risk. In the MASS study, screening reduced mortality from ischemic heart disease (115 saved deaths) more than from AAA (91 saved deaths).(3) Statistically, the one, 6% relative reduction of IHD, is meaningless and the other, 46% reduction of AAA mortality, is highly significant. But this should only warn against the simplistic focus on rare causes of death in open screening trials.(5) The ten year risk of AAA rupture and death in the control population is 1%, a tiny fraction of total absolute cardiovascular risk. Statins, given at random to 10% of this population of elderly males, would be equally effective at an expected reduction of all cause mortality by 8%.(6) Population screening for any disease at middle and old age is a story with no end in an aging species: we all hold increasing risks of degenerative disease. As the target is the population at large, screening consumes always larger budgets by turning always more “apparently healthy persons” in clinical patients. The high moral grounds of medical doctors might be tested by the question how many of them, eligible by age and gender, have participated in the various proposed screenings: they are highly educated and well informed. It would be a test of the golden rule that holds to treat others as you would like to be treated. I don’t think our profession would be at ease with the results. 1. Cornuz J, Sidoti Pinto C, Tevaearai H, Egger M. Risk factors for asymptomatic abdominal aortic aneurysm: systematic review and meta- analysis of population-based screening studies. Eur J Public Health 2004;14(4):343-9. 2. Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev 2007(2):CD002945. 3. Kim LG, RA PS, Ashton HA, Thompson SG. A sustained mortality benefit from screening for abdominal aortic aneurysm. Ann Intern Med 2007;146(10):699-706. 4. Peppelenbosch N, Buth J, Harris PL, van Marrewijk C, Fransen G, Eurostar Collaborators. Diameter of abdominal aortic aneurysm and outcome of endovascular aneurysm repair: does size matter? A report from EUROSTAR. Journal of Vascular Surgery 2004;39(2):288-97. 5. Black WC, Haggstrom DA, Welch H. All cause mortality in randomized trials of cancer screening. J Natl Cancer Inst 2002;94:167-73. 6. Baigent C, Keech A, Kearney PM, Blackwell L, Buck G, Pollicino C, et al. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins. Lancet 2005;366(9493):1267-78. Competing interests: None declared |
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Hisato Takagi, consultant cardiovascular surgeon Shizuoka Medical Centre, Shizuoka 411-8611, Japan, Hideaki Manabe registrar, Norikazu Kawai registrar, Takuya Umemoto consultant cardiovascular surgeon
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Despite a Cochrane review(1) (which does not include recently published long term follow-up data) cited in Brearley's "Head to Head",(2) our recent meta- analysis(3,4) of four randomised clinical trials with long term follow-up (the Chichester study [over 15 year follow-up], the Viborg Country study [median 9.6 year follow-up], the Western Australia study [median 3.6 year follow- up], and the multicentre aneurysm screening study [MASS] [mean 7.1 year follow- up]) showed a statistically significant reduction in not merely abdominal aortic aneurysm (AAA) related mortality (risk difference -0.25%, 95% confidence interval [CI] -0.46% to -0.04%) but also all cause mortality (-1.06%, -1.81% to -0.31%) with invitation for screening relative to uninvited control in men aged > or = 65 years. Uptake of invitations to be screened ranged from 63% to 80% (mean 74%), and a quarter of participants invited for screening did not attend the screening. A reduction in lifestyle related cardiovascular risk factors, which are addressed when the participants access medical care for screening, may decrease all cause mortality in the screened population.(4) We hypothesized that non- AAA related deaths were distributed in attenders for screening less than nonattenders for screening or uninvited controls, because AAA related mortality accounts for merely a small proportion of all deaths in older men.(5) To compare non-AAA related mortality in attenders for screening with that of nonattenders for screening or uninvited controls, we recently performed a meta-analysis.(6) Midterm non-AAA related mortality in attenders for screening, nonattenders for screening, and uninvited controls was reported in all the four trials- -the Chichester study (mean 2.5 year follow-up), the Viborg Country study (mean 4.3 year follow-up), the Western Australia study (median 3.6 year follow- up), and the MASS (mean 4.1 year follow-up). Pooled analysis showed a statistically significant reduction in non-AAA related mortality with attenders for screening (9.73%) relative to nonattenders for screening (17.46%) (odds ratio 0.50, 95% CI 0.48 to 0.53) and uninvited controls (12.37%) (0.77, 0.65 to 0.90).(6) The reduction in all cause mortality by invitation for screening (3,4) arises as the result of the reduction in not merely AAA related but also non-AAA related mortality in attenders for screening. 1 Cosford PA, Leng GC. Screening for abdominal aortic aneurysm. Cochrane Database Syst Rev 2007;(2):CD002945. 2 Brearley S. Should we screen for abdominal aortic aneurysm? Yes. BMJ 2008; 336:862. (19 April.) 3 Takagi H, Kawai N, Umemoto T. Abdominal aortic aneurysm: Screening reduces all cause mortality in men. BMJ 2007;335:899. 4 Takagi H, Tanabashi T, Kawai N, Umemoto T. Regarding "Screening for abdominal aortic aneurysm reduces both aneurysm-related and all-cause mortality". J Vasc Surg 2007;46:1311-2. 5 Fleming C, Whitlock EP, Beil TL, Lederle FA. Screening for abdominal aortic aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task Force. Ann Intern Med 2005;142:203-11. 6 Takagi H, Kawai N, Umemoto T. Regarding "Screening for abdominal aortic aneurysm in Canada". J Vasc Surg (in press). Competing interests: None declared |
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Tristan J Barber, SpR GUM/HIV Chelsea and Westminster NHS Foundation Trust, Anatole Menon-Johansson and Simon Barton
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James Johnson finishes his argument against screening for abdominal aortic aneurysms by stating that "at the very least, as with HIV, any member of the public taking the test will require intensive counselling about the possible consequences" of screening (1). Approximately 32% of patients infected by HIV in the UK remain undiagnosed (2). Delayed HIV diagnosis is responsible for HIV presentation at lower CD4 T-cell count and such patients respond less well to antiretroviral therapy - ART (3). At least 35% of HIV related deaths in 2005/6 in the UK were attributed to late diagnosis of infection (4). Furthermore, delays in HIV diagnosis and initiation of ART contribute to horizontal and vertical transmission of HIV infection (5,6). A recent study examined the factors which were significantly associated with GUM clinic patients (not exclusively attending for HIV testing) agreeing to GP contact. These factors included heterosexual orientation, initial GP referral and not considering HIV testing to have negative implications for future mortgage and life insurance application (7). Two factors have been reported to us that impair the ability of non-GU practitioners, both in primary care and other specialist care settings, to perform HIV testing. The first is pre test counselling (PTC). We would argue that in HIV and in other disease areas, PTC is no longer necessary when there are clear health benefits in knowing about a positive diagnosis which outweigh the perceived disadvantages. This is consistent with a general move towards “opt out” HIV testing in GUM clinics and antenatal services (8). In rare, high risk or acutely unwell cases, PCT may be the preferred option, but for the majority of patients it is not required. The second barrier cited is that of transparency about HIV testing for insurance company medical reports. However, the GP and insurance applicants are not required to notify insurers when negative tests are performed (9). The life expectancy of 25 year old HIV positive person, who is Hepatitis C negative, has been estimated to be greater than 35 years (10) and this will increase as newer anti-retroviral drugs become available. Like other chronic and manageable conditions an early diagnosis is essential to maximize individual and community health but this can only be achieved by the removal of barriers to widespread HIV testing across all hospital departments and primary care. We urge that the earlier diagnosis of HIV infection is made a clear priority and that the role of specialist GU clinicians to enable better training, clear referral pathways and the destigmatisation of testing in all care settings is a key part of the development of local sexual health networks. The crucial statement in Mr Johnson's closing remarks is that "many patients will be left with a life threatening condition" where "nothing can be done about it" (1). This is clearly not the case with regard to HIV infection in 2008. 1 Brearley and Johnson. Should we screen for abdominal aortic anuerysm? BMJ 19 April 2008. Vol. 336. pp862-3 Competing interests: All the authors see treat HIV patients and would prefer to see a reduction in morbidity and mortality by earlier HIV diagnosis. |
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Kathryn McCarthy, Spr Wessex Deanery.
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We have seen in the National breast screening programme that with reasonable uptake of invitations, a massive increase in incidence of early breast cancers (<1cm)(1) resulting in lead time bias. Tumours which arguably, may never have come to fruition are associated with a large increase in surgical intervention and morbidity. The same may become true of abdominal aortic aneurysm screening. The author(2) states that endovascular repair (EVAR) of aneurysms carries a mortality of only 1.6%(3) and is undoubtedly a method that is increasingly used. Of interest, Aljabri et al(4) found in it’s study of quality of life after open and endovascular repair, that even though endovascular repair is less invasive and associated with fewer complications, patients reported lower quality of life scores 6 months after surgery compared to those undergoing open repair. A reason for this may be that those undergoing traditional repair feared for their lives and were very grateful to be alive 6 months later, whilst those undergoing endovascular repair possibly were not overly concerned about the 1.6% risk of mortality and so were more focused on the morbidity associated with the surgery. Given the enormous increase in incidence of abdominal aortic aneurysms that will occur with the screening programme, this finding of low quality of life scores associated with EVAR may become a significant health issue. 1. Moller et al. Over-diagnosis in breast cancer. BMJ. 2006 March 25;332:691-2. 2. S. Brearly. Should we screen for abdominal aortic aneurysm? BMJ May 2008. 336:862. 3. EVAR trial participants. Patient fitness and survival following abdominal aortic aneurysm repair: results from UK EVAR trials. Br J Surg 2007;94:709-16. 4. B Aljabri et al. Patient reported quality of life after abdominal aortic aneurysm surgery; a prospective comparison of endovascular and open repair. J Vasc Surg 2006 Dec;44(6);1182-87. Competing interests: None declared |
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Lance Christiansen, osteopathic general practitioner Mt St Helens Research, PMB 227; 120 State Ave NE; Olympia Wa. 98501
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In todays high-tech world the search for answers concerning many problems, in the medical sphere or others, is usually to "think first" of some high-tech solution. Concerning abdominal aneurysms, one would think, considering the above fact, that one would consider doing abdomninal ultrasound procedures in a repetitious fashion as a timely check-up since such aneurysms are life-threatening if they appear. Being a general practitioner and knowing anatomy fairly well, I know the aorta is located just to the left of the spinal column which itself is located nearly in the center of the abdomen, considering both the right and left aspect and the posterior/anterior aspect. Palpatory investigation of the abdomen can determine, usually, probably in 90% of cases, if an aneurysm exists at some level. A lateral cross table x-ray is also valuble because it can usually outline an aneurysm since they have a great amount of calcific plaque. The above can be done in most g.p. offices and one does not have to use ultrasound in some specialty site. Palpatory exams are cheaper also. The same for one x-ray. If a person is grossly obese, such individuals are a separate subset of patient and I suppose if they have arteriosclerosis anywhere else, that is bruits at the femoral, abdominal, subclavian, or carotid listening posts,or a murmer they could have an ultrasound. If patients have abdominal pain, especially if a "belt" causes discomfort or pain, well, it could remotely be an abdominal aneurysm. Every patient, above 40, during physical examinations should have those examinations and they take just a minute or two and are good as a means to determine vascular health, in general, and they should be added on to the cardiac auscultative examination. Yours, Lance Christiansen, DO ecnal-c@hotmail.com Competing interests: None declared |
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Peter J E Holt, Clinical Lecturer in Vascular Surgery St George's Vascular Institute, Robert J Hinchliffe, Matt M Thompson
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RE: Head to Head: Should we screen for abdominal aortic aneurysm. We read the above article in the BMJ with interest (1). Mr Brearley presented robust evidence for abdominal aortic aneurysm (AAA) screening programmes, both in terms of a reduction in aneurysm-related mortality (2) and cost effectiveness (3). By way of counter argument Mr Johnson stated that the in- hospital death rate from elective AAA repair was higher than ideal in England over the last 5-years and varied widely between centres (4). With this situation it might not be appropriate to offer screening in all vascular units for a condition for which the only currently effective treatment is surgery. We would suggest that selected centres may be able to offer screening, with national coverage if demonstrate safety in AAA repair (5) and adopt modern methods of treatment. There is convincing evidence that, in England, the outcome of elective AAA repair is related to the annual caseload (volume) of hospitals and surgeons, with higher volume operators being associated with better outcomes. (4,6) It has been suggested that a smaller number of specialist high-volume centres, staffed by vascular specialist surgeons, would provide the best results for these procedures. The mortality of aneurysm surgery may be reduced by adopting endovascular techniques of repair which may reduce mortality of elective repair by at least 50%. If the benefits of high-volume service provision and EVAR are combined through strategic service reconfiguration, then death rates from elective surgery should fall significantly. Service reconfiguration allied to aneurysm screening offers the potential to reduce aneurysm related mortality in the UK. Commisioners should have access to reliable data regarding operative mortality, service provision and adequacy of local data collection before commissioning aneurysm screening programmes. Current data on volume- outcome relationships suggest that this service should be confined to high volume units with a proven record of safety. Yours sincerely, Peter J. E. Holt, Clinical lecturer in vascular surgery, St George’s Vascular Institute, London SW17 0QT peteholt@btinternet.com Rob J. Hinchliffe, Clinical lecturer in vascular surgery, St George’s Vascular Institute Matt M. Thompson, Professor of surgery, St George’s Vascular Institute 1. Brearly S, Johnson JN. Should we scren for abdominal aortic aneurysm? Bmj 2008;336(7649):862-3. 2. Ashton HA, Buxton MJ, Day NE, Kim LG, Marteau TM, Scott RA, 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(9345):1531-9. 3. 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(7373):1135. 4. Holt PJ, Poloniecki JD, Loftus IM, Michaels JA, Thompson MM. Epidemiological study of the relationship between volume and outcome after abdominal aortic aneurysm surgery in the UK from 2000 to 2005. Br J Surg 2007;94(4):441-8. 5. Holt PJE, Poloniecki JD, Loftus IM, Thompson MM. Demonstrating safety through in-hospital mortality following elective abdominal aortic aneurysm repair in England. Br J Surg 2007;95(1):64-71. 6. Holt PJ, Poloniecki JD, Gerrard D, Loftus IM, Thompson MM. Meta- analysis and systematic review of the relationship between volume and outcome in abdominal aortic aneurysm surgery. Br J Surg 2007;94(4):395-403. Competing interests: None declared |
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Paul E Norman, Vascular Surgeon University of Western Australia
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Whilst AAA may be a preventable cause of death using screening, the magnitude of benefit may have been over-estimated by focussing on relative rather than absolute risk reduction. AAA is not a common cause of death: in the control group of the Western Australian trial only 1% of men died of AAA over the first 4 years of follow-up. In men aged 64-75 years the crude relative risk reduction in mortality from AAA was an impressive 80%, but the absolute risk reduction was <0.1% because so few men die of AAA - at least in Australia. An important factor that may continue to cause a fall in the incidence of,and hence mortality from, AAA is the increase in smoking cessation amongst men - this is reaching epidemic levels in Australia. This should be happening in the UK and may ultimately render screening for AAA ineffective due to the prevalence of the target for screening being too low. Competing interests: None declared |
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John Doherty, Medical Director IAEA, Vienna, Austria 1400
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Stephen Brearley cites the US Preventive Sevices Task Force (USPSTF) in support of AAA screening. However, their conclusion is: "The USPSTF makes no recommendation for or against screening for AAA in men aged 65 to 75 who have never smoked. Rationale: The USPSTF found good evidence that screening for AAA in men aged 65 to 75 who have never smoked leads to decreased AAA-specific mortality. There is, however, a lower prevalence of large AAAs in men who have never smoked compared with men who have ever smoked; thus, the potential benefit from screening men who have never smoked is small. There is good evidence that screening and early treatment leads to important harms, including an increased number of surgeries with associated clinically-significant morbidity and mortality, and short-term psychological harms. The USPSTF concluded that the balance between the benefits and harms of screening for AAA is too close to make a general recommendation in this population." (2) The men invited should be given this infomation as well as the likelihood that they will benefit - less than one in a thousand. Consent for screening is only valid if it is well infomed. 1) Brearley S. Should we screen for abdominal aortic aneurysm? Yes. BMJ 2008; 336:862. (19 April.) 2) Screening: Abdominal Aortic Aneurysm. U.S. Preventive Services Task Force (2005)http://www.ahrq.gov/clinic/uspstf/uspsaneu.htm Competing interests: None declared |
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Becker François, Professor of Vascular Medicine Chamonix FRANCE, Isabelle Quere, Jean-Pierre Laroche, Joel Constans
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We read with interest the head-to-head between S. Brearley and J. Johnson concerning Aortic Abdominal Aneurysms (AAA) screening. The debate had a very narrow surgical focus. It contrasted the view that ultrasound screening is simple and can prevent the risk of AAA rupture, which has a high mortality rate (80%) with the view that screening may not be particularly useful given that the benefits of surgery may be limited by peri operative co morbidity. We feel that a much wider debate is required. According to the WHO, screening involves the presumptive identification, through systematic and standardised testing, of subjects presenting a hitherto undetected disease abnormality (1). It should improve prognosis and lead to a decrease in the morbidity and mortality linked to the condition. Two conditions must be met for screening to take place: 1) a simple, reliable and reproducible test for detecting the targeted abnormality. This may be considered to be the case here, for ultrasound scans; 2) there should also be an available treatment improving the prognosis of the screened condition. For AAA, the key question concerns the respective benefits of non-surgical and surgical management. If we are to address this issue, we must consider the causes of death of patients with small aneurysms and the modifiable risk factors associated with this condition on which we could act to develop a potential non- surgical treatment. Four studies (2-5) have shown that 34 to 41% of patients die within 79 months after diagnosis. Only 18% of these patients die from aneurysm rupture, thoracic aneurysm or complications of AAA repair, with the remaining 82% dying from other causes: cardiovascular complications of atherosclerosis in 40 to 48% of cases, cancer in 19 to 26% of cases and respiratory disease in 8 to 17% of cases. Thus, for screening, which mostly concerns small aneurysms, the question of the benefits of non-surgical management is particularly pertinent, given that the two major modifiable risk factors for AAA are arterial hypertension and smoking. These factors affect not only the likelihood of aneurysm, but also the risk of atherothrombosis and respiratory complications. Based on the notion of non-surgical management for small AAA (6,7) the French Society for Vascular Medicine, through its network of hospital- based and private angiologists, has initiated a nationwide study (the 4A or Atherothrombotic Abdominal Aortic Aneurysm cohort) to evaluate objectively the real potential for improvements in the management of patients with small AAA (<50 mm AP). Initially, the investigators will ask all 5000 of their patients to undergo AAA screening according to French recommendations criteria (8). They will also record cardiovascular risk factors, their treatments and vascular and non-vascular comorbidities for patients with an AAA. The potential for real improvements and optimising the non-surgical management of these patients will be analysed. If improvement is possible, then, as pointed out by Golledge (9) and Bergqvist (10), we will need to evaluate the impact of cardiovascular health care and lifestyle changes on mortality rates, the overall cardiovascular risk of these patients, the slowing of AAA progression and the preparation of patients for possible interventions. 1. Wilson J.M.G, Jünger G. Principes et Pratique du dépistage des maladies. Genève, OMS, 1970 2. WATSON C.J.E., WALTON J., SHAW E. et al. What is the long-term Outcome for Patients With Very Small Abdominal Aortic Aneurysms ? Eur J Vasc Endovasc Surg 1997; 14: 299-304 3. GALLAND R.B., WHITELEY M.S., MAGEE T.R. The Fate of Patients Undergoing Surveillance of Small Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 1998; 16: 104-09 4. The Multicentre Aneurysm Screening Study Group. 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: 1531-39 5. VEGA de CENIGA M., GOMEZ R., ESTALLO L. et al. Growth Rate and Associated Factors in Small Abdominal Aortic Aneurysms. Eur J Vasc Endovasc Surg 2006 (available on line 15 november 2005) 6. Dehlin J.M., Upchurch G.R. Management of abdominal aortic aneurysms. Curr Treat Options Cardiovasc Med 2005; 7: 119-30 7. Dawson J., Vig S., Choke E. et al. Medical optimisation can reduce morbidity and mortality associated with elective aortic aneurysm repair. Eur J Vasc Endovasc Surg 2007; 33: 100-104 8. Becker F., Baud J.M. Screening for abdominal aortic aneurysm and surveillance of small abdominal aortic aneurysms, rationale and recommendations of the French Society for Vascular Medicine. Final document. J Mal Vasc, 2006; 31 (5): 260-276 9. Golledge J., Powell J.T. Medical management of abdominal aortic aneurysm. Eur J Vasc Endovasc Surg 2007; 34: 267-7. 10. Bergqvist D., Bjork M., Wannhainen A. Abdominal aortic aneurysms, To screen or not to screen. Eur J Vasc Endovasc Surg 2008; 35(1): 13-8 Competing interests: None declared |
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Steve Flecknoe-Brown, Consultant Physician Broken Hill, Australia
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The case for AAA screening is already strong, but most of the target population lives within reasonable reach of a vascular surgical facility. Consider us: on the edge of the Great Australian Desert; with an ageing population of 22,000; 500 Km from the nearest vascular operating theatre. We got sick of standing by helpless while men died in front of our eyes and couldn't wait for the slow, fine grind of government process.
So the people of Broken Hill raised the funds to run a program themselves. We found several interesting things. Firstly, the involvement of so many community members, from those who bought raffle tickets in the streets through to the service clubs which pledged substantial support, ensured that the community was well prepared when the service was offered. Attendance rates were very high compared to most screening programs - it came from our own efforts rather than being imposed by Government. But we still needed Local Champions, goading, driving, keeping the impetus up. Secondly, there is no doubt that it is best done with state-of-the-art equipment and specialist-trained operators. Rent, rather then buy, so you get a Ferrari and a first-class driver. Thirdly, report the results. Without going public, the benefits will remain confined to the community which came up with the idea. By publishing, other communities or even, dare we suggest, governments may consider following suit. The case for AAA screening in rural and remote communities is compelling. Perhaps this will be an opportunity for rural doctors to lead opinion into the future. Competing interests: None declared |
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