Thirty-Nine Percent of Patients with a Ruptured Abdominal Aortic Aneurysm (AAA) Have an Incidentally Detected AAA Prior to Rupture.

BACKGROUND: Abdominal aortic aneurysm (AAA) screening has been offered to 65-year-old men living in Oslo, Norway, since May 2011. A significant number of AAA-related deaths occurred in individuals who are not eligible for screening. The primary aim of this study was to describe the group of patients admitted to Oslo University Hospital with a ruptured AAA after the implementation of the local AAA screening project. The following parameters were investigated: AAA detection before rupture, surveillance status, eligibility for screening, and comorbidities. We also sought to compare outcomes (repair rates and 30-day mortality) between patients with and without an incidentally detected AAA prior to rupture. METHODS: This cohort study included patients admitted acutely to Oslo University Hospital due to a symptomatic or ruptured AAA in the period January 2011 to December 2022. Data on demographics, prior AAA detection, surveillance status, treatment, and mortality were collected retrospectively through electronic medical records. RESULTS: We identified 200 patients with a symptomatic or ruptured AAA, among which 79 (40%) had an AAA detected before rupture-one (1%) through screening and 78 (39%) incidentally. Up to 30% of the incidentally detected AAAs were not under any surveillance. Six patients were found eligible for screening: one had attended, three were non-attenders, and two had not been invited. Patients with an incidentally detected AAA before rupture had a more advanced age and a significantly higher degree of comorbidities than patients without a previously detected AAA, and the repair rates in these groups were 56% and 84%, respectively (P < 0.001). Adjusted for comorbidities and risk factors, the odds ratio for repair among patients with incidentally detected AAA was 0.56 (P = 0.292). The 30-day mortality was not significantly different between the two groups (P = 0.097). CONCLUSIONS: Most patients with a ruptured AAA were not eligible for screening, but 39% of the patients had an incidentally detected AAA prior to rupture. Standardized reporting and follow-up of incidentally detected AAAs is thus identified as an additional measure to organized screening in the effort to reduce AAA-related mortality.

Eleven-Year Outcomes of a Screening Project for Abdominal Aortic Aneurysm (AAA) in 65-Year-Old Men.

Objective: Since 2011, the Department of Vascular Surgery at Oslo University Hospital has offered screening for abdominal aortic aneurysm (AAA) to 65-year-old men living in Oslo, Norway. The aim of this study was to evaluate the effect of the screening project on AAA-related mortality and rupture and repair rates in the screened population. Methods: This cohort study included men that participated in AAA screening at the Department of Vascular Surgery at Oslo University Hospital in the period May 2011 to September 2019. All men with screen-detected AAA (aortic diameter ≥30 mm) and subaneurysmal aortic dilatation (aortic diameter 25-29 mm) were included. A stratified (1:1 with the subaneurysm group), randomized selection of men with normal aortic diameter (<25 mm) upon screening was also included. The follow-up data on events (ruptures, repairs, and deaths) after screening were collected retrospectively from patient electronic medical records at Oslo University Hospital, the National Population Register and the Norwegian Cause of Death Registry (CoDR). Results: In total, 2048 men were included, with a median follow-up time of 7.1 years (IQR 3.8). Among men with screen-detected AAA, 0.6% died of AAA-related causes (0.9 AAA-related deaths per 1000 person-years). The rupture rate was 0.3% among men with screen-detected AAA or subaneurysmal aortic dilatation, giving an incidence of 0.5 ruptures per 1000 person-years. The overall repair rate in the AAA group was 20.6% (36.1 repairs per 1000 person-years) and 0.6% (0.9 repairs per 1000 person-years) in the subaneurysm group. Conclusion: In a population screened for AAA, the incidence of rupture and the AAA-related mortality was very low. Almost one-fifth of the participants with screen-detected AAA underwent elective repair, representing a group that might have presented with rupture if untreated. These results indicate that screening is valuable in preventing AAA rupture and AAA-related mortality.

Global Survey of Demand-Side Factors and Incentives that Influence Advanced Trauma Life Support (ATLS) Promulgation.

BACKGROUND: We aimed to identify and describe demand-side factors that have been used to support ATLS global promulgation, as well as current gaps in demand-side incentives. METHODS: We performed a cross-sectional survey about demand-side factors that influence the uptake and promulgation of ATLS and other trauma-related CME courses. The survey was sent to each of the four global ATLS region chiefs and 80 ATLS country directors. Responses were described and qualitative data were analyzed using a content analysis framework. RESULTS: Representatives from 30 countries and each region chief responded to the survey (40% response rate). Twenty of 30 country directors (66%) reported that there were some form of ATLS verification requirements. ATLS completion, not current verification, was often the benchmark. Individual healthcare systems were the most common agency to require ATLS verification (37% of countries) followed by medical/surgical accreditation boards (33%), governments (23%), training programs (27%), and professional societies (17%). Multiple credentialing frameworks were reported including making ATLS verification a requirement for: emergency unit or trauma center designation (40%), contract renewal or promotion (37%); professional licensing (37%); training program graduation (37%); and increases in remuneration (3%). Unique demand-side incentives were reported including expansion of ATLS to non-physician cadre credentialing and use of subsidies. CONCLUSION: ATLS region chiefs and country directors reported a variety of demand-side incentives that may facilitate the promulgation of ATLS. Actionable steps include: (i) shift incentivization from ATLS course completion to maintenance of verification; (ii) develop an incentive toolkit of best practices to support implementation; and (iii) engage leadership stakeholders to use demand-side incentives to improve the training and capabilities of the providers they oversee to care for the injured.

Screening for Abdominal Aortic Aneurysms and Risk Factors in 65-Year-Old Men in Oslo, Norway.

PURPOSE: To investigate the prevalence of and risk factors for abdominal aortic aneurysm (AAA) in 65-year-old men in Oslo, Norway. MATERIALS AND METHODS: From May 2011, until September 2019, the annual population of 65-year-old men living in Oslo were invited to an ultrasonographic screening of the abdominal aorta. Candidates received a one-time invitation by mail, including a questionnaire on possible risk factors and comorbidities. Abdominal aortic outer-to-outer diameter and ankle-brachial index were measured by the screening team. Participants were allocated into three groups: non-, sub- and aneurysmal aorta. Written information on recommended follow-up regime was given to participants with an aortic diameter ≥25 mm. Univariate and multivariate analyses of potential risk factors were performed, in addition to descriptive analyses and significance testing. RESULTS: In total, 19,328 were invited, 13,215 men were screened, of which 12,822 accepted inclusion in the study. Aortic diameter was registered for 12,810 participants and 330 men had aortic diameter ≥30 mm, giving a prevalence of AAA of 2.6% (95% confidence interval (CI) 2.31-2.86). We identified 4 independent risk factors for AAA: smoking (OR = 3.64, 95% CI 2.90-4.58), hypertension (OR = 1.87, 95% CI 1.49-2.35), BMI >30 (OR = 1.02, 95% CI 1.00-1.03), and diabetes mellitus (OR = 0.52, 95% CI 0.35-0.79), the latter showing an inverse association with AAA growth. A subgroup of 862 men with aortic diameters 25-29 mm had a significantly higher prevalence of BMI >25, smoking and family history of AAA, compared to participants with aortic diameter <25 mm. CONCLUSION: Among the participants in this study, the prevalence of abdominal aortic aneurysms was 2.6%. Participants with AAA more frequently reported cardiovascular risk factors, and less frequently diabetes mellitus.

Disaster preparedness should represent an augmentation of the everyday trauma system, but are we prepared?

BACKGROUND: The increased frequency, geographical spread and the heterogenicity in mass casualty incidents (MCIs) challenge healthcare systems worldwide. Trauma systems constitute the base for disaster preparedness. Norway is sparsely populated, with four regional trauma centers (TCs) and 35 hospitals treating trauma (non-trauma centers (NTCs)). We wanted to assess whether hospitals fill the national trauma system requirements for competence and the degree of awareness of MCI plans. METHODS: We conducted a cross-sectional survey of on-call trauma teams in all 39 hospitals during two time periods: July-August (holiday season (HS)) and September-June (non-holiday season (NHS)). A standardized questionnaire was used to evaluate the MCI preparedness. RESULTS: A total of 347 trauma team members participated (HS: 173 and NHS: 174). Over 95% of the team members were aware of the MCI plan; half had read the plan during the last 6 months, whereas 63% at the TCs and 74% at NTCs were confident with their MCI role. Trauma team exercises were conducted regularly and 86% had ever participated. Only 63% at the TCs and 53% at the NTCs had participated in an MCI exercise. The proportion of resident surgeons and anesthetists with >4 years' clinical experience was significantly higher in TCs (88% and 63%) than in NTCs (27% and 17%). All the on-call consultant surgeons were at home, leaving interns in charge at several of the hospitals. All resident surgeons at the TCs were ATLS providers compared with 64% at the NTCs, and almost 90% of the consultant surgeons had participated in advanced trauma surgical courses. DISCUSSION: Despite increased national focus on disaster preparedness, we identified limited compliance with trauma system requirements concerning competency and training. Strict guidelines to secure immediate notification and early presence of consultants whenever a situation that might turn into an MCI occurs should be a prerequisite. LEVEL OF EVIDENCE: Level IV. Study type: cross- sectional.

The Norwegian guidelines for the prehospital management of adult trauma patients with potential spinal injury.

The traditional prehospital management of trauma victims with potential spinal injury has become increasingly questioned as authors and clinicians have raised concerns about over-triage and harm. In order to address these concerns, the Norwegian National Competence Service for Traumatology commissioned a faculty to provide a national guideline for pre-hospital spinal stabilisation. This work is based on a systematic review of available literature and a standardised consensus process. The faculty recommends a selective approach to spinal stabilisation as well as the implementation of triaging tools based on clinical findings. A strategy of minimal handling should be observed.

Injuries caused by fragmenting rifle ammunition.

INTRODUCTION: Although penetrating injuries are encountered on a regular basis in high volume trauma centres, most civilian trauma teams will be unfamiliar with the treatment of patients with injuries caused by fragmenting ammunition. The terrorist attacks in Norway on July 22, 2011 included a shooting spree causing 69 deaths and 60 injured. One of the weapons used was a semi-automatic rifle, calibre 5.56mm, with soft tip, short stop ammunition. The aim of the present study was to describe the characteristic injury patterns and lessons learned from the treatment of multiple patients admitted at the regional trauma centre with injuries from this type of ammunition. METHODS: We undertook an observational study of patients admitted at Oslo University Hospital, Ulleval after the shooting spree at Utoya on July 22, 2011. Data on demographics, injuries, injury severity, surgical procedures and outcome were collected prospectively. RESULTS: Of the 21 patients admitted after the shooting incident, 18 were identified with injuries caused by fragmenting ammunition and included in the study. Median age was 17 years (IQR 16, 19), median ISS 21 (IQR 12, 30) and 12 patients were female. They had been hit by a total of 38 projectiles, of which 32 were fragmenting bullets. Of the seven patients who sustained injuries to the head, neck and face, one patient required a craniotomy and one patient had a non-survivable head injury. Of the 11 patients with torso injuries, six of the eight patients with chest injuries had intra-thoracic injuries that could be treated with chest tubes only. One patient had cardiac tamponade, requiring thoracotomy. Six patients underwent laparotomy, four of them more than one. Of the 10 patients with extremity injuries, two had nerve injuries and six patients had fractures. Five amputations were performed within the first nine days. A total of 101 operations were required within the first four weeks. The majority of these were repeated soft tissue debridements due to progressive necrosis. CONCLUSION: Knowledge about the specific challenges created by the progressive soft tissue necrosis caused by fragmenting ammunition should lead to planned, repeated debridements to reduce total tissue loss and complications.