Point prevalence of wounds and cost impact in the acute and community setting in Denmark.

OBJECTIVE: To estimate the wound-care related costs in two hospitals in Denmark. METHOD: A point-prevalence survey with a focus on resource consumption was carried out during a representative 1-week period in March 20 I 0, in two hospitals in Denmark: Regional Hospital Viborg, in the Viborg Municipality and Hillerod Hospital, in the Horsholm Municipality. Data were collected during a 2-day period for inpatients and outpatients in the hospitals and over a full week in the municipalities. The survey included information on the numbers, types and locations of the wounds, as well as resource consumption related to dressing changes. The estimation of costs was based on representative cost levels, including the salaries of health professionals or nurses and the cost of dressings and hospitalisation provided. RESULTS: In total, 33% (n=830) of inpatients had a wound. The majority of these were surgical/trauma wounds (25%), while pressure ulcers, leg ulcers and diabetic foot ulcers accounted for 3.3%, 1.7% and 1.6%, respectively. In the municipalities, there was a wound patient prevalence of 2.8 per I 000 population(I I I 000 acute wounds, 0.7/ I 000 pressure ulcers, 0.5/ I 000 leg ulcers and 0.3/ I 000 diabetic foot ulcers).The extrapolated figures for nurse time related to wound care per year was equivalent to I 0 full-time nurse positions in Hillerod Hospital, three in Viborg Hospital, 17 in Viborg Municipality and three in Horsholm Municipality. The total annual costs related to wound care was estimated as €3.6 million for Viborg Hospital, €4.1 million for Hillemd Hospital, € 1.2 million for Viborg Municipality and €232 548 for Horsholm Municipality, accounting for approximately 1.8% (Viborg), 1.6% (Hillerod), 2.4% (Viborg) and1.5% (Horsholm) of the total annual budgets. CONCLUSION: In the survey, 33% of the patients treated in the hospitals had a wound. Primary costs were defined as hospitalisation costs and nurse time related to dressing changes. Total annual costs of treatment, including hospitalisation, were estimated as approximately 1.6-1.8% for the hospitals and 1.5-2.4% for the municipalities. The level of costs support the relevance of increased efforts to secure better wound prevention and treatment to reduce the staff-time consumption and hospitalisation costs.

Insulin-like growth factor I - a novel biomarker of abdominal aortic aneurysms.

OBJECTIVE: The study aimed to test the potential role of insulin-like growth factor I (IGF-I) and IGF-II as biomarkers for abdominal aortic aneurysm (AAA). METHODS AND RESULTS: IGF-I and II levels were analysed in 115 patients with screening diagnosed AAA kept under annual surveillance for 10 years. Serum IGF-I correlated positively with AAA size and growth rate (r = 0.23, P = 0.016 and r = 0.27, P = 0.004), persisting after adjustment for potential confounders. Serum IGF-I level predicted cases needing later surgery (AOC: 0.63; 95% confidence interval: 0.52-0.73). CONCLUSIONS: In this prospective, long-term study, baseline serum IGF-I correlated positively with AAA size and growth rate and predicted future need for preventive surgery.

Long-term benefit and cost-effectiveness analysis of screening for abdominal aortic aneurysms from a randomized controlled trial.

BACKGROUND: The aim was to estimate long-term mortality benefits and cost-effectiveness of screening for abdominal aortic aneurysm (AAA) in men aged 64-73 years. METHODS: All men aged 64-73 years living in Viborg County were randomized to be controls (n = 6306) or invited for abdominal ultrasonography at a regional hospital (n = 6333). Mortality and AAA-related interventions were recorded in national databases. The cost of initial screening was based on actual costs of the programme. Incremental cost-effectiveness ratios (ICERs) were calculated on gains in life years and Quality Adjusted Life Years (QALY). Discounting (3 per cent) was applied to both costs and effects, and all costs were adjusted to euros at 2007 prices. RESULTS: The relative risk reduction of the screening programme in AAA-related mortality was 66 per cent (hazard ratio 0.34, 95 per cent confidence interval (c.i.) 0.20 to 0.57). The corresponding risk reduction in all-cause mortality was 2 per cent (hazard ratio 0.98, 95 per cent c.i. 0.93 to 1.03). The ICER was estimated at euro157 (-3292 to 4401) per life year gained and euro179 (-4083 to 4682) per QALY gained. Screening was found to be cost effective at a probability above 0.97 for a willingness-to-pay threshold of only euro5000. One-way sensitivity analysis demonstrated that this result was robust to various alternative assumptions, as the probability did not drop below 0.90 for any scenario. CONCLUSION: The mortality benefit of screening for AAA in men aged 64-73 years was maintained in the longer term and screening was cost effective.

Upper-limb thrombo-embolectomy: national cohort study in Denmark.

OBJECTIVES: We investigated the incidence of thrombo-embolectomy in upper-limb and prognosis with respect to arm amputation, stroke and death. METHODS: We performed a national cohort study of individuals, aged 40-99 years, and undergoing first-time thrombo-embolectomy in the brachial, ulnar or radial artery in Denmark from 1990 to 2002. The data were retrieved from the National Vascular Registry and from the National Registry of Patients and the Civil Registration System. Patients were followed until 2006 to ascertain the occurrence of amputation and stroke and until 2007 with respect to death. RESULTS: In total, 1377 incident cases of thrombo-embolectomy were registered, comprising 504 (36.6%) males with a mean age of 72.0 (standard deviation (SD) 12.4) years and 873 (63.4%) females with a mean age of 77.2 (SD 11.7) years. Incidence was 3.3 (95% confidence interval (CI): 3.1-3.7) for males and 5.2 (95% CI: 4.9-5.6) for females per 100000 person-years. After thrombo-embolectomy, upper-limb amputation was performed in 11 (incidence 2.2%; 95% CI: 1.2-3.4) males and 31 (3.6%; 95% CI: 2.5-4.9) females. Age- and sex-specific risk of stroke was 2-16 times higher, and risk of death 3-11 times higher, than in the general population. CONCLUSIONS: Upper-limb thrombo-embolectomy is associated with an increased risk of limb amputation, stroke and death.

Potential circulating biomarkers for abdominal aortic aneurysm expansion and rupture--a systematic review.

BACKGROUND: The maximal diameter of abdominal aortic aneurysms (AAAs) is the dominating indication for repair. However half of the AAAs repaired would never have ruptured if left unrepaired, although small AAAs occasionally rupture. Earlier surgery may be associated with a lower mortality. More precise indicators for surgery are warranted. This systematic review identifies potential systemic biomarkers for AAA rupture or expansion. METHODS: MEDLINE/PubMed and EMBASE (from 1985 trough May 2007) were searched with the medical subject heading abdominal aortic aneurysm and keywords "size", "progression" or "growth" or "expansion rate" or "rupture" on the basis of MESH tree and as a text search restricted to English, German, French and Italian. In addition, reference lists were studied and manual searches performed. Observational studies investigating the association of circulating biomarkers with AAA rupture, expansion or size were selected. DATA EXTRACTION: Two reviewers (SU and GU) independently extracted the following data: year of publication, study characteristics, duration of follow-up, circulating biomarker, AAA expansion rate or size or rupture. RESULTS: 699 papers were identified. After exclusion of thoracic aneurysms and cardiac studies (n=118), surgical or medical treatment studies (n=179), case reports and animal studies (n=87), as well as reviews or letters (n=66), 249 articles were selected. Also excluded were 230 papers that did not report AAA size, expansion rate or rupture. 39 papers were included. Several potential biomarkers were identified. The strongest association with AAA was obtained with serum elastin peptides (SEP) and plasmin-antiplasmin (PAP) complexes. Matrix-degrading metalloproteinase 9 (MMP9) and interferon-gamma (IFN-gamma) could have clinical potential while many putative biomarkers showed poor association. CONCLUSIONS: Several circulating agents in peripheral blood may predict AAA size, expansion rate or rupture. Few of them have clinical potential for future use. Confirmative studies and development of multivariate models are needed, together with continuing search for new biomarkers using the discovery based sciences within proteomics and/or genomics.

Incident thromboembolism in the aorta and the renal, mesenteric, pelvic, and extremity arteries after discharge from the hospital with a diagnosis of atrial fibrillation.

BACKGROUND: The impact of atrial fibrillation (AF) on risk of peripheral arterial thromboembolism is unknown. METHODS: We analyzed the risk of thromboembolism (embolus and/or thrombosis) in the aorta and the renal, mesenteric, pelvic, and extremity arteries in a cohort of patients discharged from the hospital with an incident diagnosis of AF relative to the risk of thromboembolism in these vessels in the Danish population. In a random sample of half of the Danish population, 14 917 men and 14 945 women aged 50 to 89 years were identified in the Danish National Hospital Discharge Register with a diagnosis of AF from January 1, 1980, through December 31, 1993. Patients were followed up from diagnosis of AF in the Danish National Hospital Discharge Register and the Causes of Death Register until the first diagnosis of a thromboembolic event, death, or the end of 1993. Risk of a thromboembolic event relative to the risk in the Danish population was analyzed by means of Poisson regression modeling. RESULTS: Patients with a hospital diagnosis of AF had an increased risk of thromboembolic events in the aorta and the renal, mesenteric, pelvic, and extremity arteries (relative risk, 4.0 [95% confidence interval, 3.5-4.6] in men; and relative risk, 5.7 [95% confidence interval, 5.1-6.3] in women) compared with the Danish population. CONCLUSION: A hospital diagnosis of AF is an important risk factor for peripheral arterial thromboembolic complications.

Hypermyoglobinemia after successful arterial embolectomy.

Myoglobin concentrations in serum and urine were measured in eight patients who underwent successful arterial embolectomy in the femoral or iliac arteries. Median serum myoglobin levels significantly increased after revascularization to a maximum of 4741 micrograms/L (reference range: 0 to 80 micrograms/L) 2 hours postoperatively, with a concomitant and correlated increase in the urine myoglobin concentration. Three days after the operation, serum myoglobin concentrations were still substantially elevated in three patients. None of our patients suffered permanent renal damage, but transient renal impairment was noted in five patients, as evaluated from the serum and urine beta 2-microglobulin concentrations. We found an association between the concentrations of myoglobin in serum and urine (Spearman's rho: 0.66; p less than 0.001) and between the concentrations of myoglobin in urine and beta 2-microglobulin in urine (Spearman's rho: 0.65; p less than 0.001). Our results indicate a transient renal impairment associated with hypermyoglobinemia and myoglobinuria, even after successful arterial embolectomy.

Hospital based screening of 65-73 year old men for abdominal aortic aneurysms in the county of Viborg, Denmark.

OBJECTIVE - To analyse the benefits of screening older men for abdominal aortic aneurysms. METHODS - A hospital based screening trial concerning 13 500 65-73 year old men using B-mode ultrasonographic scanning. To improve the response rate the invited men could change their appointment, and nonresponders were reinvited. RESULTS - Results from the first year of the trial are presented. Among 4404 invited, 3344 (76%) were scanned. The primary response rate was 64.8%, but a further 11.2% were scanned after revised appointments or reinvitation. The whole infrarenal aorta could be visualised in 97-6%, and the distal part in 99.7% of the scans. The time taken for each scan was 9-7 minutes and the costs per scan were $9.50. One hundred and fifty three subjects (4.6%) had aortic diameters of 25-29 min, and 141 (4.2%) had an abdominal aortic aneurysm, 19 (0.6%) above 49 mm in diameter. CONCLUSION - In Denmark the short term costs and benefits of screening older men for abdominal aortic aneurysms seem realistic. Long term costs and benefits need to be investigated.

Persisting primitive sciatic artery.

A case of persisting sciatic artery on both sides is described. It is a rare but interesting variant, because it may be diagnosed by palpating along the sciatic nerve.

A comparative study of iliac and abdominal aortic aneurysms.

BACKGROUND: The aim of the paper is to compare the epidemiology, risk factors and manifestations of iliac and abdominal aortic aneurysms. METHODS: Two studies were used: 1. 5,470 65-73-year-old men invited for screening for abdominal aortic aneurysms. 2. Review of all 350 patients operated on for central aneurysms in the county of Viborg, Denmark from 1989-1997. RESULTS: 4,176 attended for screening. One hundred and seventy (4.0%) had an abdominal aortic aneurysm. Twenty-one (0.56%) needed operation. The proportion of patients with common iliac aneurysms requiring surgery was 0.17%. The operative incidence of iliac aneurysm was 18.4 per million per year, and 92.4 per million per year were operated on for abdominal aortic aneurysm. The mean serum cholesterol level for isolated iliac aneurysm and combined aneurysms was significantly lower compared to isolated abdominal aortic aneurysm (p<0.05). Urological symptoms were present in 42% of cases with isolated iliac aneurysm, and 25% of combined aneurysms compared to 8% of isolated abdominal aortic aneurysms. Fifty-eight percent of the isolated iliac aneurysms were ruptured, as against 27% of the abdominal aortic aneurysms. The peri- and postoperative mortality was 57% in ruptured isolated iliac aneurysms, 47% in ruptured combined aneurysms, and 31% in ruptured isolated aortic aneurysms. CONCLUSIONS: Iliac aneurysms seem to be more underdiagnosed than abdominal aortic aneurysms, and are often diagnosed because of clinical manifestations, especially urological, or rupture. Iliac aneurysms seem more lethal than those of the abdominal aorta in cases of rupture.

Impaired results of a randomised double blinded clinical trial of propranolol versus placebo on the expansion rate of small abdominal aortic aneurysms.

BACKGROUND: To study the propranolol treatment of small abdominal aortic aneurysms (AAA) concerning intention to treat, side effects, and inhibition of expansion. DESIGN: Two-year lasting prospective randomised double-blinded intervention trial. SETTING: Hospital-based mass screening for AAA with annual ambulatory control of small AAA. PARTICIPANTS: Of 122 screening-diagnosed small AAA, 51 (42%) were excluded because of contraindications or present beta-blockage, and 17 refused participation. Thus, 54 (44.3%) were included. INTERVENTION: Participants were randomised to 40 mg propranolol twice a day or placebo. MEASURES: The same observed was used to follow-up AAA-expansion, side effects, quality of life (QL), branchial and ankle blood pressure (ABI), and pulmonary function (FEV1 and FVC). RESULTS: Sixty percent in the propranolol group, and 25% in the placebo group dropped out, mainly caused by dyspnoea in the propranolol group (RR=1.74, 95% C.I.: 1.06-2.86). Five (16.7%) died in the propranolol group, while 1 (4.2%) died in the placebo group (RR=1.6 (1.02-2.51)). Furthermore, decreased pulmonary function, ABI, and QL was noticed in the propranolol group. Consequently, the trial was stopped after two years. Ninety-five percent of the measurements of the AAA were measured within 2 mm variation. If expansion was defined as above 2 mm annually, the relative risk of expansion in the placebo group was 1.17 (0.74-1.85), and 2.44 (0.88-6.77) among the non-drop-outs. CONCLUSIONS: Only 22% of small screenings-diagnosed AAA were treatable with propranolol for two years. Consequently, only large scale studies are capable of showing potential minor inhibition of expansion by propranolol. However, whether such treatment ever becomes ethically acceptable is debatable.

[Percutaneous transluminal angioplasty of the brachiocephalic arteries]. / Perkutan transluminal angioplastik på brakiocefale arterier.

The results of eight percutaneous transluminal angioplastic (PTA) interventions in seven patients on the brachiocephalic arteries are presented. The occlusions and stenoses were dilated up to the normal lumen. The subjective symptoms disappeared in all of the patients and, similarly, the pulse and blood pressure in the arm were normalized. No complications were registered.

[Abdominal aortic aneurysm in the county of Viborg. Mortality before and after the establishment of a specialized vascular surgery unit]. / Abdominalt aortaaneurisme i Viborg Amt. Mortaliteten før og efter etableringen af egen karkirurgisk betjening.

In order to analyze the possible benefits on the mortality of abdominal aortic aneurysms (AAA) in Viborg county from the establishment of a specialized vascular unit in the county, the periods just before (1986-1988) and just after (1989-1991) the start of the unit were reviewed. Three times as many operations for AAA (104/mill/yr) were carried out after the unit opened. Acute operations increased sevenfold. In 1986-1988 42 persons experienced rupture of AAA. Twenty-six (63%) died outside hospital. Thirteen (32%) died at primary receiving hospitals. Only three patients (7%) were operated. One survived, making the overall mortality 97.5%. The mortality in this period was 187/million persons over 50 years. In 1989-1991 39 persons experienced rupture. Eleven (28%) died outside hospital. Eight (20.5%) died at primary receiving hospitals. One died preoperatively on the vascular unit. Nineteen (49%) reached operation, 13 survived (33%) and six (15.4%) died postoperatively. The overall mortality was 67%, the mortality of AAA was 127/million persons over 50 years. Comparing the two periods, deaths, mortality and overall mortality due to ruptured AAA decreased by 32% after the introduction of the vascular unit.

[Iliac aneurysm compared with abdominal aorta aneurysm]. / Iliacaaneurismer sammenlignet med abdominale aortaaneurismer.

The aim of the study was to compare the epidemiology, risk factors and manifestations of iliac and abdominal aortic aneurysm (AAA). Two studies were used: 1. Five thousand four hundred and seventy 65-73 year old men invited to screening for AAA. 2. Review of all 350 patients operated for central aneurysms in the county of Viborg in Denmark 1989-1997. Four thousand one hundred and seventy-six attended screening. One hundred and seventy (4.0%) had an AAA. Twenty-one (0.56%) required operation, while the prevalence of operation-requiring iliac aneurysm (IA) was 0.17%. The operative incidence of IA was 18.4 per mill. per year, and 92.4 per mill. per year were operated for AAA. Patients with IA had lower cholesterol-levels, and urological symptoms were present in 42% of cases with isolated IA, and 25% of combined aneurysms compared to 8% of isolated AAA (p < 0.05). Fifty-eight percent of the isolated IAs were ruptured, while only 27% of AAAs were ruptured (p < 0.05). The per- and postoperative mortality was 57% in ruptured isolated IA, 47% in ruptured combined aneurysms, and 31% in ruptured isolated AAA (p < 0.05). IA seems to be more under-diagnosed than AAA, and are often diagnosed because of clinical manifestations, especially urological or rupture. They seem more lethal in ruptured cases.

[Can vascular surgery reduce the amputation frequency? A study of amputations in the county of Viborg before and after establishment of an own department of vascular surgery]. / Kan karkirurgi nedsaette amputationsfrekvensen? En amputationsopgørelse i Viborg Amt før og efter indførelsen af eget karkirurgisk afsnit.

In June 1988 a Department of Vascular Surgery was established in the County of Viborg, Denmark. In a retrospective study, 314 patients had 337 major amputations within two time periods: 1986-1987, and 1989-1990. The number of patients seen by a vascular surgeon rose significantly from 19% in the first period to 49% in the last period, and the number of amputations was concurrently significantly reduced by 25%. The largest reduction was observed in 1990, probably due to an increase of vascular reconstructions of 43%. Assuming there is a latency between diagnosing "critical leg ischaemia" and amputation, this will further delay the already convincing results showing that vascular surgery does reduce the frequency of amputations. All patients with suspected critical leg ischaemia or threatened by amputation must be seen, or at least conferred with a vascular surgeon.

[Surgery of abdominal aortic aneurysm in a department of vascular surgery integrated into a department of general surgery--is it satisfactory?]. / Operation for abdominalt aortaaneurisme på karkirurgisk afsnit, integreret i almen kirurgisk afdeling--er det forsvarligt?

Seventy-two operations for abdominal aortic aneurysm (AAA), i.e 104 per mill. per year, were carried out by a vascular surgical unit integrated into a general surgical department. Mortality rate for elective operation was 3.8%, for acute operation without rupture 3.8% and with rupture 31.6%. Fifty percent of patients with rupture reached operation, which gives an overall mortality of about 66% and an incidence of 56 per mill. per year. Twice as many acute operations were carried out in this area compared to the rest of Denmark, and no haemodialysis-demanding complications occurred. These observations suggest that short transfer time is an important prognostic factor when treating ruptured AAA.

[Solcotrans, a new autotransfusion system]. / Solcotrans, et nyt autotransfusionssystem.

Thirty-one patients scheduled to undergo aortic reconstruction were studied. 16 had aortic aneurysms and 15 required aortobifemoral grafts. The solcotrans unit comprises a rigid plastic container with an inner lining bag, into which blood is aspirated. When the bag is full (500 ml), the unit is inverted and blood is re-infused through a 40 micron filter. Sixty-three percent of the blood transfused per-operatively and 41% peri-operatively was given with the solcotrans unit. Only minor changes in the coagulation parameters were seen. Blood cultures from ten solcotrans units were all negative. Two patients contracted pneumonia, and one cystitis. We conclude that the solcotrans system is safe to use when two-to four units of blood are transfused. Further studies are required to define its role when multitransfusions of blood are needed.

[Preliminary results of screening for abdominal aortic aneurysm in the ounty of Viborg]. / Foreløbige resultater af screening for abdominalt aortaaneurisme i Viborg Amt.

The incidence of abdominal aortic aneurysms (AAA) and ruptured AAA is increasing. One to three percent of deaths among 65-80 year-old males are caused by AAA. Sixty-six to ninety-five percent of ruptured AAA are lethal, while elective resection has a 3-6% operative mortality. Most AAA's are asymptomatic before rupture. Ultrasonographic scanning of the aorta takes below ten minutes with close to 100% sensitivity and specificity. The County of Viborg has started a randomized screening trial including 13,500 65-73 year-old males. Half of these are invited to the nearest hospital over a period of three years. In 1994-1995 4938 were invited and 3748 were scanned, resulting in an acceptance rate of 76%. The aorta was visible in 99.7%, and the total time consumption was 9.7 minutes per scan. The costs were 83.75 DKK per scan. One hundred and fifty-three (4.1%) had an AAA defined as an aortic diameter above 29 mm. Twenty were above 49 mm and were offered operation, i.e. 5.3 per thousand scans or 13% of the diagnosed AAA.

[Screening for abdominal aortic aneurysm]. / Screening for abdominalt aortaaneurisme.

In spite of increasing number of elective resections of abdominal aortic aneurysms (AAA) the mortality or ruptured AAA is increasing. The advantages of elective operations are obvious; the lethality is 2-6% while the lethality of ruptured AAA is 75-95%. However, AAA seldom causes symptoms before rupture. Ultrasonographic screening for AAA takes 10 minutes per scan, and the sensitivity and specificity are high. Ultrasonographic screening for AAA is a reliable, safe and inexpensive method for screening, and screening for AAA is discussed worldwide. One point four percent of deaths among men from 65 to 80 year of age are caused by ruptured AAA. Screening men over 65 for AAA can theoretically prevent a substantial number of deaths. Our calculations predict one prevented AAA-death per 200-300 scans for a cost of about 4000 DKK per saved year of life. However, cost-benefit analyses are based on uncertain assumptions concerning prevalence, incidence and risk of rupture. Therefore a randomized trial screening of 65-73 year old males is taking place in the County of Viborg in Denmark.

[Surgery for ruptured abdominal aneurysm assisted by vascular unit team at the primary receiving hospital]. / Karkirurgisk assisterede operationer for rumperet abdominalt aortaaneurisme udført på primaert modtagende sygehus.

The objective of the study was to compare emergency operations for ruptured abdominal aortic aneurysm (RAAA) by a mobile operation team, with operation for RAAA carried out at our vascular unit. During a five year period (1993-1998), 18 emergency operations were carried out for abdominal aortic aneurysm (AAA) with rupture at the primary receiving hospital with assistance from a mobile operation team. In the same period 82 aneurysms with rupture were resected at our vascular surgical unit. Preoperatively, patients operated at the primary receiving hospitals had significantly lower blood pressure (P < 0.05) and an intraoperative higher blood loss (P < 0.05). Furthermore, postoperative complications tended to be higher among patients operated at hospitals without a vascular unit. consequently, the mortality was 67% compared to 47% in the department. However, 1/3 of the patients operated by the mobile operation team survived. Consequently, haemodynamically unstable non-transportable patients with an RAAA should be considered for surgery by a mobile operation team.