Anxiety and disease awareness in individuals with heredity for abdominal aortic aneurysm.

OBJECTIVE: The psychological consequences of being aware of an increased risk of developing abdominal aortic aneurysm as a first-degree relative of a person with abdominal aortic aneurysm are hitherto unexplored. This study investigates the awareness of heritability and anxiety in male and female adult offspring of abdominal aortic aneurysm patients compared to controls. Health-related quality of life among participants with aortic pathology was compared to participants with normal aortic diameters. METHODS: This was a cross-sectional point prevalence study based on the participants examined in the Detecting Abdominal Aortic Aneurysm in First Degree Relatives Trial (DAAAD; 752 adult offspring, 756 matched controls), 2020-2022. Questionnaires about health-related quality of life and study-specific questions regarding awareness of heritability were collected prior to the aortic ultrasound. RESULTS: Attendance rate was higher among individuals with heredity compared to controls (67% vs. 52%, p < 0.001). Of 1508 adult offspring examined, 65% reported having a close relative with abdominal aortic aneurysm (6% in controls). Female adult offspring reported higher awareness of heritability than controls (38% vs. 12%, p < 0.001), as did males (32% vs. 8%, p < 0.001). A slight majority of participants with awareness reported anxiety (54% of female offspring; 51% of male). There were no measured differences in health-related quality of life between the groups when standard health-related quality of life instruments were used. CONCLUSION: The higher-than-expected proportion of adult offspring with awareness of heritability and anxiety about such risk indicates that we fail to communicate risk to this group appropriately via the current channels of information within the healthcare system. This calls for the development of dedicated strategies for improved communication of abdominal aortic aneurysm risk to patients and their next of kin.

Prevalence of abdominal aortic aneurysm (AAA) in first-degree relatives: detecting AAA in adult offspring of AAA patients.

BACKGROUND: First-degree relatives of patients with abdominal aortic aneurysm (AAA) may have an increased risk of developing the disease. The primary aim was to report the prevalence of AAA in adult male and female offspring of patients with AAA. The secondary aim was to explore the efficiency of a registry-based detection route, and the third aim was to report contemporary prevalence in the population. METHODS: Adult offspring of individuals with AAA and matched controls were identified through national registries. The examination included questionnaires and ultrasound examinations of the infrarenal aorta. Aortic pathology was defined as an aortic diameter ≥25 mm, AAA ≥30 mm. RESULTS: The participation rate among male and female adult offspring was 64% (350/543) and 69% (402/583), respectively. A lower participation rate was found in male and female controls (51% and 52%). No difference in prevalence of AAA was observed between male adult offspring and controls (0.9%, c.i. 0.2 to 2.3%) or in the female population (prevalence of 0.2% in adult offspring and controls). Aortic pathology and previously diagnosed AAA were detected in 5.3% (c.i. 3.3 to 8.0%) of male adult offspring and 2.3% (c.i. 1.1 to 4.2%) in controls. Aortic pathology was more prevalent among adult offspring of females with AAA. CONCLUSION: The prevalence of AAA in the general population is low, but aortic pathology is notably higher among male first-degree relatives. Increased awareness should be directed towards individuals with a possible hereditary predisposition, particularly offspring of females with AAA and older smokers. Risk factor-based targeted screening of adult offspring of patients with AAA after registry-based detection should be further explored. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT4623268.

Patient Related Outcomes After Receiving a Person Centred Nurse Led Follow Up Programme Among Patients Undergoing Revascularisation for Intermittent Claudication: A Secondary Analysis of a Randomised Clinical Trial.

OBJECTIVE: The aim was to evaluate the effect of a person centred nurse led follow up programme on health related quality of life (HRQoL), health literacy, and general self efficacy compared with standard care for patients undergoing revascularisation for intermittent claudication (IC), and to describe factors associated with HRQoL one year after revascularisation. METHODS: This was a secondary analysis of a randomised controlled trial. Patients with IC scheduled for revascularisation at two vascular surgery centres in Sweden between 2016 and 2018 were randomised to intervention or control. During the first year after surgery, the intervention group received a person centred follow up programme with three visits and two telephone calls with a vascular nurse, while the control group received standard follow up with two visits to a vascular surgeon or vascular nurse. Outcomes were HRQoL measured by VascuQol-6, health literacy, and general self efficacy measured by validated questionnaires. RESULTS: Overall, 214 patients were included in the trial; this secondary analysis comprised 183 patients who completed the questionnaires. One year after revascularisation, HRQoL had improved with a mean increase in VascuQol-6 of 7.0 scale steps (95% CI 5.9 - 8.0) for the intervention and 6.0 scale steps (95% CI 4.9 - 7.0) for the control group; the difference between the groups was not significant (p = .18). In an adjusted regression analysis, the intervention was associated with higher VascuQoL-6 (2.0 scale steps, 95% CI 0.08 - 3.93). There was no significant difference between the groups regarding health literacy or general self efficacy. The prevalence of insufficient health literacy among all participants was 38.7% (46/119) at baseline and 43.2% (51/118) at one year. CONCLUSION: In this study, a person centred, nurse led follow up programme had no significant impact on HRQoL, health literacy, or general self efficacy among patients undergoing revascularisation for IC. The prevalence of insufficient health literacy was high and should be addressed by healthcare givers and researchers.

Evaluating feasibility of using national registries for identification, invitation, and ultrasound examination of persons with hereditary risk for aneurysm disease-detecting abdominal aortic aneurysms in first degree relatives (adult offspring) to AAA patients (DAAAD).

BACKGROUND: Sweden and the UK invite all 65-year-old men to a population-based ultrasound-based screening program to detect abdominal aortic aneurysms (AAA). First-degree relatives of patients with AAA are reported to have an increased risk to develop AAA, both women and men, but are not invited to screening. The "Detecting AAA in First Degree Relatives to AAA patients" (DAAAD) was designed to detect the true prevalence in adult offspring to AAA patients and to evaluate if national registries could be used for identification of index persons and their adult children with a high risk for the disease. The aim of this study is to summarize the design and methodology for this registry-based study. METHODS: The study is based on a registry-based extraction and identification of a risk group in the population with a subsequent identification of their adult offspring. The targeted risk group suffers a heredity for a potentially lethal disease, AAA (n = 750) and matched control group without heredity for AAA is also identified and invited (n = 750). The participation rate in the population-based AAA screening program for men is 75% regionally. This population is younger and have a lower prevalence. A participation rate of 65% is considered clinically adequate. For the DAAAD study, a stratified analysis of the primary outcome, prevalence, will be performed for women and men separately. Two other planned projects are based on the material: firstly, evaluation of the anxiety for disease and health-related quality of life (HRQoL) and, secondly, the cost-effectiveness of the study. DISCUSSION: In conclusion, this feasibility study will be instrumental in supporting the development of a possible new model to invite persons with high risk to develop hereditary rare diseases. To our knowledge, this is a unique, safe, and most likely to be a cost-efficient model to invite targeted risk groups for selected screening. If the study design and the results are shown to be cost-effective at the detected participation rate and prevalence, it should be further evaluated and adopted to a national screening program. The model also invites both women and men, which is unique for this specific patient group, considering that all population-based screening programs only include men. TRIAL REGISTRATION: This trial is registered at the website of Clinical Trials. CLINICALTRIALS: gov identifier, NCT4623268.

Effects of a person-centred, nurse-led follow-up programme on adherence to prescribed medication among patients surgically treated for intermittent claudication: randomized clinical trial.

BACKGROUND: Management of intermittent claudication should include secondary prevention to reduce the risk of cardiocerebrovascular disease. Patient adherence to secondary prevention is a challenge. The aim of this study was to investigate whether a person-centred, nurse-led follow-up programme could improve adherence to medication compared with standard care. METHODS: A non-blinded RCT was conducted at two vascular surgery centres in Sweden. Patients with intermittent claudication and scheduled for revascularization were randomized to the intervention or control (standard care) follow-up programme. The primary outcome, adherence to prescribed secondary preventive medication, was based on registry data on dispensed medication and self-reported intake of medication. Secondary outcomes were risk factors for cardiocerebrovascular disease according to the Framingham risk score. RESULTS: Some 214 patients were randomized and analysed on an intention-to-treat basis. The mean proportion of days covered (PDC) at 1 year for lipid-modifying agents was 79 per cent in the intervention and 82 per cent in the control group, whereas it was 92 versus 91 per cent for antiplatelet and/or anticoagulant agents. The groups did not differ in mean PDC (lipid-modifying P = 0.464; antiplatelets and/or anticoagulants P = 0.700) or in change in adherence over time. Self-reported adherence to prescribed medication was higher than registry-based adherence regardless of allocation or medication group (minimum P < 0.001, maximum P = 0.034). There was no difference in median Framingham risk score at 1 year between the groups. CONCLUSION: Compared with the standard follow-up programme, a person-centred, nurse-led follow-up programme did not improve adherence to secondary preventive medication. Adherence was overestimated when self-reported compared with registry-reported.

Increasing patients' awareness of their own health: Experiences of participating in follow-up programs after surgical treatment for intermittent claudication.

INTRODUCTION: Claudication is the most usual symptom of peripheral artery disease, it is described as painful contractions in the leg when walking and alleviated upon resting. People with claudication have an added risk of cardiocerebrovascular events, amputation, and death. Adherence to medical treatment and changes in lifestyles can lower this risk, but this secondary prevention therapy requires engagement, participation, and adherence from the patient. OBJECTIVE: To explore patients' experiences of participating in a 1-year multicentre clinical trial with two follow-up programs evaluating a nurse-led, patient-centered health-promoting programme after surgical treatment for claudication, the FASTIC study. METHODS: A descriptive design with qualitative semi-structured interviews was used among participants in the FASTIC study. The study was conducted at two centres for vascular surgery in the city of Stockholm, Sweden. In all, 17 patients (nine men and eight women) who had completed the FASTIC study participated. Data was analysed using qualitative content analysis with an inductive approach. RESULTS: Two main categories were identified, 'Patient-Professional collaboration' and 'Experience of one´s health', which were associated with four subcategories: facing opportunities and obstacles, cooperating based on the illness experience, increasing awareness of one's own health, and maintaining a healthy lifestyle. CONCLUSIONS: Patients' participation in follow-up programs after surgical treatment for claudication is highly valuable for an increased awareness of one's own health. A person-centered care with patient-professional collaboration is experienced as important for maintaining a health-promoting lifestyle.

Follow-up after surgical treatment for intermittent claudication (FASTIC): a study protocol for a multicentre randomised controlled clinical trial.

BACKGROUND: Intermittent claudication (IC) is a classic symptom of peripheral arterial disease, and strongly associated with coronary heart disease and cerebrovascular disease. Treatment of IC and secondary prevention of vascular events include best medical treatment (BMT), changes in lifestyle, most importantly smoking cessation and increased physical exercise, and in appropriate cases surgery. A person-centred and health promotion approach might facilitate breaking barriers to lifestyle changes and increasing adherence to secondary prevention therapy. The FASTIC study aims to evaluate a nurse-led, person-centred, health-promoting follow-up programme compared with standard follow-up by a vascular surgeon after surgical treatment for IC. METHODS: The FASTIC-study is a multicentre randomised controlled clinical trial. Patients will be recruited from two hospitals in Stockholm, Sweden after surgical treatment of IC through open and/or endovascular revascularisation and will be randomly assigned into two groups. The intervention group is offered a nurse-led, person-centred, health-promoting programme, which includes two telephone calls and three visits to a vascular nurse the first year after surgical treatment. The control group is offered standard care, which consists of a visit to a vascular surgeon 4-8 weeks after surgery and a visit to the outpatient clinic 1 year after surgical treatment. The primary outcome is adherence to BMT 1 year after surgical treatment and will be measured using The Swedish Prescribed Drug Registry. Clinical assessments, biomarkers, and questionnaires will be used to evaluate several secondary outcomes, such as predicted 10-year risk of cardiovascular and cerebrovascular events, health-related quality of life, and patients' perceptions of care quality. DISCUSSION: The FASTIC study will provide important information about interventions aimed at improving adherence to medication, which is an unexplored field among patients with IC. The study will also contribute to knowledge on how to implement person-centred care in a clinical context. TRIAL REGISTRATION: ClinicalTrials.govNCT03283358, registration date 06/13/2016.

Long-Term Follow-Up of Men Invited to Participate in a Population-Based Abdominal Aortic Aneurysm Screening Program.

A screening program for abdominal aortic aneurysm (AAA), inviting 65-year-old men, was started in Stockholm in 2010 (2.3 million inhabitants). The aim was to present a long-term follow-up of men participating in screening, as well as AAA repair and ruptures among nonparticipants. Demographics were collected for men with screening detected with AAA 2010 to 2016 (n = 672) and a control group with normal aortas at screening (controls, n = 237). Medical charts and regional Swedvasc (Swedish Vascular registry) data were analyzed for aortic repair for men born 1945 to 1951. Ultrasound maximum aortic diameter (AD) as well as Aortic Size Index (ASI) was recorded. Participation was 78% and prevalence of AAA was 1.2% (n = 672). Aortic repair rates correlated with high ASI and AD. During the study period, 22% of the AAA patients were treated with the elective repair; 35 men in surveillance died (5.2%), non-AAA-related causes (82.9%) dominated, followed by unknown causes among 4 (11.4%), and 2 (5.7%) possibly AAA-related deaths. Abdominal aortic aneurysm rupture rate was higher among nonparticipants (0.096% vs 0.0036%, P < .001). The low dropout rate confirms acceptability of follow-up after screening. The efficacy is shown by the much higher rupture rate among the nonparticipating men.

The effect of ticagrelor on growth of small abdominal aortic aneurysms-a randomized controlled trial.

AIMS: To evaluate if ticagrelor, an effective platelet inhibitor without known non-responders, could inhibit growth of small abdominal aortic aneurysms (AAAs). METHODS AND RESULTS: In this multi-centre randomized controlled trial, double-blinded for ticagrelor and placebo, acetylic salicylic acid naïve patients with AAA and with a maximum aortic diameter 35-49 mm were included. The primary outcome was mean reduction in log-transformed AAA volume growth rate (%) measured with magnetic resonance imaging (MRI) at 12 months compared with baseline. Secondary outcomes include AAA-diameter growth rate and intraluminal thrombus (ILT) volume enlargement rate. A total of 144 patients from eight Swedish centres were randomized (72 in each group). MRI AAA volume increase was 9.1% for the ticagrelor group and 7.5% for the placebo group (P = 0.205) based on intention-to-treat analysis, and 8.5% vs. 7.4% in a per-protocol analysis (P = 0.372). MRI diameter change was 2.5 mm vs. 1.8 mm (P = 0.113), US diameter change 2.3 mm vs. 2.2 mm (P = 0.778), and ILT volume change 12.9% vs. 10.4% (P = 0.590). CONCLUSION: In this RCT, platelet inhibition with ticagrelor did not reduce growth of small AAAs. Whether the ILT has an important pathophysiological role for AAA growth cannot be determined based on this study due to the observed lack of thrombus modulating effect of ticagrelor. TRIAL REGISTRATION: The TicAAA trial is registered at the US National Institutes of Health (ClinicalTrials.gov) #NCT02070653.

[Misleading study in The Lancet on the outcome of the Swedish AAA screening program]. / Stor enighet om att screening för bukaortaaneurysm räddar liv.

In a recent publication in The Lancet Johansson and colleagues claim no effect on aneurysm mortality among men participating in the Swedish AAA screening program, and question its justification. The study is, however, limited by a corrupt study design and incorrect data, making the publication misleading. On the contrary, several RCTs and contemporary nationwide data with sufficient follow-up clearly show that AAA screening saves lives and is highly cost-effective. The program has so far identified about 6000 men with an AAA, of whom 1500 have been operated on to prevent rupture. Thus, more than 750 men have experienced a longer life (by a mean of 8 years) as a result of the program. Continuous evaluation of the program is important but requires a scientifically sound methodology.

Abdominal aortic aneurysm screening attendance: Effect of removing the examination fee.

OBJECTIVES: The organized population-based screening programme for abdominal aortic aneurysm in Stockholm, Sweden, started in 2010. An examination fee was initially charged, but later removed because of a policy change. We examined the effect on screening attendance of removing the fee. METHODS: The periods before and after removing the examination fee were compared with regard to screening attendance, overall, by municipality and by district. RESULTS: Screening attendance was 79.2% in the period with an examination fee and 79.9% in the period without an examination fee (p = 0.1787), with no significant change in screening attendance between the periods. CONCLUSIONS: Although removing examination fees has been shown to have a positive impact on attendance in other screening programmes, we did not find this association in our study.

Screening of siblings to patients with abdominal aortic aneurysms in Sweden.

OBJECTIVE: The prevalence of Abdominal Aortic Aneurysm (AAA) is higher for First Degree Relatives to AAA-patients compared to the general population, regardless of sex. The prevalence of AAA is also higher in the North of Sweden compared to the Mid and South. A regional strong hereditary trait has been suggested as an explanation to this. The aim of this study was to investigate if siblings to AAA-patients in the North have a higher prevalence of AAA compared to siblings in the Mid-region. DESIGN: Cohort study. MATERIALS AND METHODS: All patients treated for AAA in a northern region (Norrbotten county, North) were screened for siblings. Consenting siblings, age 40-80, were examined (n = 379) with ultrasound. The results were compared to the previously published results of 150 ultrasound-screened siblings in the Mid-region (Stockholm county). RESULTS: The male/female ratio in the sibling cohort was 48% vs 52%. The prevalence of AAA in siblings in the North was 37/379 (brothers 14%, sisters 6%). This was not different from the prevalence among the Mid-region siblings 16/150 (brothers 17%, sisters 6% (p = 0.75). The distribution of risk factors was similar in the two regions. CONCLUSION: The results reinforce the importance of a more systematic approach towards selective screening of all siblings to AAA patients. Ultrasound should be performed in all eligible siblings, since the distribution of AAA is similar over regions. A correlation between the familial distribution and the reported high prevalence of AAA in general population in the North could not be shown.

Outcome of the Swedish Nationwide Abdominal Aortic Aneurysm Screening Program.

BACKGROUND: A general abdominal aortic aneurysm (AAA) screening program, targeting 65-year-old men, has gradually been introduced in Sweden since 2006 and reached nationwide coverage in 2015. The aim of this study was to determine the outcome of this program. METHODS: Data on the number of invited and examined men, screening-detected AAAs, AAAs operated on, and surgical outcome were retrieved from all 21 Swedish counties for the years 2006 through 2014. AAA-specific mortality data were retrieved from the Swedish Cause of Death Registry. A linear regression analysis was used to estimate the effect on AAA-specific mortality among all men ≥65 years of age for the observed time period. The long-term effects were projected by using a validated Markov model. RESULTS: Of 302 957 men aged 65 years invited, 84% attended. The prevalence of screening-detected AAA was 1.5%. After a mean of 4.5 years, 29% of patients with AAA had been operated on, with a 30-day mortality rate of 0.9% (1.3% after open repair and 0.3% after endovascular repair, P<0.001). The introduction of screening was associated with a significant reduction in AAA-specific mortality (mean, 4.0% per year of screening, P=0.020). The number needed to screen and the number needed to operate on to prevent 1 premature death were 667 and 1.5, respectively. With a total population of 9.5 million, the Swedish national AAA-screening program was predicted to annually prevent 90 premature deaths from AAA and to gain 577 quality-adjusted life-years. The incremental cost-efficiency ratio was estimated to be €7770 per quality-adjusted life-years. CONCLUSIONS: Screening 65-year-old men for AAA is an effective preventive health measure and is highly cost-effective in a contemporary setting. These findings confirm the results from earlier randomized controlled trials and model studies in a large population-based setting of the importance for future healthcare decision making.

Age at detection of abdominal aortic aneurysms in siblings of patients with abdominal aortic aneurysms.

OBJECTIVE: Few countries offer organized screening of siblings of patients with abdominal aortic aneurysms (AAAs), although a hereditary trait is well known to exist. Male relatives, but not female, are invited within the population-based screening programs for elderly men in Sweden. Evidence regarding the optimal age to screen siblings is scarce. The aim of this study was to describe the age at detection in siblings found with AAAs. METHODS: All patients treated for AAAs in two Swedish counties were screened for siblings. Consenting siblings aged 80 and younger were examined (N = 529) with ultrasound and were interviewed per protocol. RESULTS: In the cohort of 529 siblings to AAA patients, 53 siblings were diagnosed with AAAs (sisters 16/276 [5.8%] and brothers 37/253 [14.6%]). The prevalence of AAAs in the siblings 65 years of age or younger was 16/207 (7.7%). One-third of the siblings found with AAAs were young (16/53 [30%]). Among the young siblings with AAAs, 8/16 (50%) had an aneurysm larger than 50 mm or were already surgically treated. The prevalence of AAAs in siblings older than 65 years of age was 37/322 (12%). CONCLUSIONS: The AAA prevalence in this sibling cohort is strikingly high compared to the prevalence in the population (in Sweden, 1.4%-2.2% in 65-year-old men). The young ages among diagnosed siblings reinforce that male siblings of AAA patients should be screened before age 65 (before the population-based program) and that structured programs for female siblings are called for.

Flywheel resistance exercise to maintain muscle oxidative potential during unloading.

BACKGROUND: As spaceflight compromises skeletal muscle oxidative and aerobic work capacity, this study assessed the efficacy of resistance exercise (RE) to counteract muscle metabolic perturbations induced by 5 wk unilateral lower limb unloading (UL). METHODS: There were 21 men and women (30-56 yr) who were randomly assigned to either UL with (Group, Grp; UL+RE; N = 10) or without (Grp UL; N = 11) concurrent RE. Iso-inertial RE comprised four sets of seven maximal coupled concentric-eccentric knee extensions executed 2-3 times per week. Percutaneous biopsies were obtained from m. vastus lateralis before and after either intervention. Levels of mRNA expression of factors regulating skeletal muscle oxidative capacity i.e., peroxisome proliferator-activated receptor gamma coactivator-1 (PGC-1alpha) and vascular endothelial growth factor (VEGF), and glycolytic capacity, i.e., phosphofructokinase (PFK), glycogen phosphorylase and synthase, hexokinase, and phosphorylase kinase alpha1, were subsequently analyzed. RESULTS: Grp UL showed decreased (36%) PGC-1alpha expression, increased (1.5-fold) PFK expression, and a trend toward decreased VEGF post-intervention. Grp UL+RE showed no changes. DISCUSSION: These results suggest that 5 wk unloading reduces skeletal muscle oxidative capacity and increases glycolytic enzyme activity. More importantly, only 12 bouts of high-force, low-volume resistance exercise attenuated these responses. Thus, the current resistance exercise paradigm emphasizing eccentric overload effectively counteracts unwarranted metabolic alterations induced by 5 wk unloading and may, therefore, aid in maintaining skeletal muscle integrity and endurance, and hence astronaut health and fitness during spaceflight.

High prevalence of abdominal aortic aneurysms in brothers and sisters of patients despite a low prevalence in the population.

OBJECTIVE: Population-based screening for abdominal aortic aneurysms (AAAs) in elderly men is organized in many regions and countries in the Western world, and the prevalence of disease is reported to decline. Whether the prevalence among those with a family history also is declining is unknown. The primary purpose of this study was to assess the prevalence of AAAs among siblings of persons with AAAs and to investigate the proportion of siblings already diagnosed by opportunistic screening. METHODS: Patients treated for AAAs from January 2008 through December 2010 (n = 412) in Stockholm, Sweden, were screened for siblings. Seven hundred seventy-nine siblings were identified. All siblings <80 years residing in Stockholm County were considered eligible and were invited to participate in the study (n = 174). Deceased siblings were not included in the study, regardless of the cause of death. One hundred fifty siblings were enrolled in the study after informed consent was provided. One hundred thirty-four siblings were screened for AAAs with ultrasound scan and maximum aortic, infrarenal, anteroposterior, external (outer-to-outer) aortic diameter was measured. Characteristics of siblings with and without AAAs were compared. RESULTS: The mean age of the screened siblings was 66.4 years (standard deviation, 7.1). Of the siblings, 11% were found to have an AAA, 17% (n = 11) of the brothers, and 6% (n = 5) of the sisters. Only 11% of the siblings were screened for AAAs before the study. One of 16 siblings with AAAs was <65 years. Ever smoking was evident in 81% of the AAA siblings compared to 59% in the non-AAA siblings. Factors associated with increased risk of AAAs in the multivariate regression analysis were: male sex (odds ratio, 3.4; 95% confidence interval, 1.1-10.8; P = .04) and age >65 (odds ratio, 10.8; 95% confidence interval, 1.3-86.4; P = .03). Ever smoking was not statistically significant as a risk. CONCLUSIONS: A strikingly high prevalence of AAAs in siblings was found as compared to the reported declining aneurysm prevalence in elderly men in the Western world. Systematic improvements regarding screening of first-degree relatives is mandated and selective screening of siblings is an underused tool to prevent death from aneurysm disease, both among men and women.