Lessons learned about prevalence and growth rates of abdominal aortic aneurysms from a 25-year ultrasound population screening programme.

BACKGROUND: This study aimed to assess how the prevalence and growth rates of small and medium abdominal aortic aneurysms (AAAs) (3·0-5·4 cm) have changed over time in men aged 65 years, and to evaluate long-term outcomes in men whose aortic diameter is 2·6-2·9 cm (subaneurysmal), and below the standard threshold for most surveillance programmes. METHODS: The Gloucestershire Aneurysm Screening Programme (GASP) started in 1990. Men aged 65 years with an aortic diameter of 2·6-5·4 cm, measured by ultrasonography using the inner to inner wall method, were included in surveillance. Aortic diameter growth rates were estimated separately for men who initially had a subaneurysmal aorta, and those who had a small or medium AAA, using mixed-effects models. RESULTS: Since 1990, 81 150 men had ultrasound screening for AAA (uptake 80·7 per cent), of whom 2795 had an aortic diameter of 2·6-5·4 cm. The prevalence of screen-detected AAA of 3·0 cm or larger decreased from 5·0 per cent in 1991 to 1·3 per cent in 2015. There was no evidence of a change in AAA growth rates during this time. Of men who initially had a subaneurysmal aorta, 57·6 (95 per cent c.i. 54·4 to 60·7) per cent were estimated to develop an AAA of 3·0 cm or larger within 5 years of the initial scan, and 28·0 (24·2 to 31·8) per cent to develop a large AAA (at least 5·5 cm) within 15 years. CONCLUSION: The prevalence of screen-detected small and medium AAAs has decreased over the past 25 years, but growth rates have remained similar. Men with a subaneurysmal aorta at age 65 years have a substantial risk of developing a large AAA by the age of 80 years.

Editor's Choice - Inequalities in Abdominal Aortic Aneurysm Screening in England: Effects of Social Deprivation and Ethnicity.

OBJECTIVE: Population screening for abdominal aortic aneurysm (AAA) in men is currently ongoing in several countries. The aim was to examine the effects of deprivation and ethnicity on uptake of screening for abdominal aortic aneurysm (AAA) and prevalence of AAA. METHODS: This was a review of outcomes from a population screening programme using data collected contemporaneously on a bespoke national database. Men aged 65 in two annual cohorts (2013/14 and 2014/15) were invited for AAA screening. Attendance and prevalence of AAA (aortic diameter >2.9 cm) were recorded. Results were compared according to measures of social deprivation and recorded ethnicity. RESULTS: Some 593,032 men were invited and 461,898 attended for ultrasound screening; uptake 77.9%. Uptake was related to social deprivation: 65.1% in the most deprived decile, 84.1% in the least deprived: OR for least deprived 2.84, 95% CI 2.76-2.92, p<.0001. Men in deprived areas were more likely to actively decline screening: 6% versus 3.8% in the least deprived decile. AAA were twice as common in the most deprived compared with the least deprived decile: OR 2.1, 95% CI 1.77-2.27, p<.0001. AAA were more common in white British men than in black (OR 0.46, 95% CI 0.31-0.71) or Asian (OR 0.18, 95% CI 0.13-0.26) men. There was considerable local variation in all findings. CONCLUSIONS: Social deprivation affects uptake of AAA screening in 65 year old men. Local factors are the most important determinants of uptake, so solutions to improve uptake must be designed at local, not national level.

Melioidosis in a patient with chronic rhinosinusitis.

BACKGROUND: Melioidosis is a serious infection caused by soil-dwelling Gram-negative bacillus Burkholderia pseudomallei. It is most commonly reported in Northern Australia, Southeast and Southern Asia, China, and Taiwan. METHODS: A case report and short review of the literature are presented. Presentation, diagnosis including genomic sequencing, and acute and long-term management are discussed. RESULTS: A 58-year-old female presented with chronic rhinosinusitis secondary to melioidosis. This is the third reported incidence of sinusitis secondary to melioidosis, which occurred in an otherwise well female with no risk factors and no apparent cause of exposure. Treatment involved an acute phase in which meropenem was administered parenterally for two weeks, followed by a prolonged oral course of trimethoprim-sulfamethoxazole for three months, as per recommended guidelines. CONCLUSION: In patients presenting with refractory chronic rhinosinusitis, ENT surgeons should consider the presence of unusual causative pathogens such as B pseudomallei, particularly in those with recent travel history to Northern Queensland and/or Southeast Asia.

Impact of the first 5 years of a national abdominal aortic aneurysm screening programme.

BACKGROUND: The Abdominal Aortic Aneurysm (AAA) Screening Programme was introduced by the National Health Service (NHS) in England to reduce the rate of death from ruptured AAA in men. The programme commenced in 2009 and was implemented completely across the country in April 2013. The aim was to review the first 5 years of the programme, looking specifically at compliance and early outcome. METHODS: Men aged 65 years were invited for a single abdominal ultrasound scan. Data were entered into a bespoke database (AAA SMaRT). This was a planned analysis after the first 5 years of the programme. RESULTS: The summation analysis involved the first 700 000 men screened, and the first 1000 men with a large AAA referred for possible treatment. The prevalence of AAA (aortic diameter larger than 2·9 cm) in 65-year-old men was 1·34 per cent. Mean uptake was 78·1 per cent, but varied from 61·7 to 85·8 per cent across the country. Based on the Index of Multiple Deprivation, uptake was 65·1 per cent in the most deprived versus 84·1 per cent in the least deprived areas. Of the first 1000 men referred for possible treatment of a large AAA (greater than 5·4 cm), the false-positive rate was 3·2 per cent. Some 870 men underwent a planned AAA intervention (non-intervention rate 9·2 per cent), with seven deaths (perioperative mortality rate 0·8 per cent). CONCLUSION: The processes in the NHS AAA Screening Programme are effective in detecting and treating men with AAA.

Editor's Choice - Self-referral to the NHS Abdominal Aortic Aneurysm Screening Programme.

INTRODUCTION: The NHS Abdominal Aortic Screening Programme (NAAASP) invites men in their 65th year for screening, men over 65 may self-refer into the programme. Most studies have concentrated on those invited for screening, little is known about the self-referral group. Our aim was to provide a descriptive analysis of the men who self refer to NAAASP for screening. METHOD: Information concerning basic demographic details and ultrasound results were recorded on the AAA SMaRT database. During nurse assessment data collected included smoking status, blood pressure, height, weight, and aspirin and statin therapy. Statistical analysis was performed using SPSS(®)20. RESULTS: A total of 58,999 men have self-referred to the NAAASP since its inception. The mean age at self-referral was 73 (47-100). The mean aortic diameter was 1.9 cm (0.8-12.1). Increased self-referral rates were observed following organised publicity. The incidence of AAA was 4.1% (n = 2438) compared with 1.4% in the invited cohort (age 65 years), of these 7.6% (n = 186) were >5.5 cm. Of the 186, 152 (81.7%) underwent surgery, of which 55.3% (n = 84) underwent EVAR. The 30-day mortality in the men treated electively was 0%. The mean time from referral to surgery was 69 (2-361) days, with 57.9% (n = 88) being treated within 8 weeks of detection. CONCLUSION: Self-referral has yielded higher detection rates than the invited cohort, more than justifying its cost. Now that NAAASP is fully operational it is important to continue media campaigns and publicity to target the "at-risk" men over 65 who would otherwise miss the benefits of AAA screening. Some key areas still need to be addressed.

Outcome in Men with a Screen-detected Abdominal Aortic Aneurysm Who are not Fit for Intervention.

OBJECTIVE/BACKGROUND: Abdominal aortic aneurysm (AAA) screening in Gloucestershire has been ongoing for 25 years. The aim of this study was to review the outcome of a cohort of men with a large (> 5.4 cm) screen-detected AAA who did not have early intervention for their AAA. METHODS: A prospectively maintained database was interrogated for a 10-year interval from 2001 to 2011. Men who did not have their large AAA repaired within 3 months of the diagnosis were identified. The reasons for initial nonintervention and subsequent outcomes were identified from a combination of hospital case notes and general practitioner records. RESULTS: Of 334 men referred, 59 (median age 71 years, range 62-83 years) did not have intervention within 3 months (initial nonintervention rate 17.6%). The reasons included placed back on surveillance after assessment (n = 34); immediately discharged (n = 12); required further investigations (n = 5); died before complete assessment (n = 3); and incomplete follow-up (n = 5). Sixteen men had delayed AAA repair with no perioperative mortality. Overall mortality in the study was 14/34 (nine from ruptured AAA, the rest from medical conditions). Two further men survived repair of a ruptured AAA. The overall rate of ruptured AAA was 11/59 (18.6%). CONCLUSION: Information from studies such as these can be used to help plan treatment of men with a large AAA and to compare performance of vascular units.

Endovascular management of isolated iliac artery aneurysms.

Isolated iliac artery aneuryms are detected increasingly as a result of expanding use of diagnostic imaging, and screening programmes. This present review describes endovascular solutions for the management of isolated iliac artery aneurysms. This was a review of the published literature on endovascular treatment of iliac aneurysms. Most of the papers were case series, and there are no randomized studies. Aneurysms of the common iliac artery are most common, followed by internal, then external iliac aneurysms. Indications for intervention remain unclear, but are generally based on diameter. Endovascular solutions exist for at least half the aneurysms that required treatment, including as an emergency. Often a standard bifurcated solution, as for abdominal aortic aneurysm is indicated, however, there are a number of other novel solutions to deal with variable anatomy. Endovascular treatment of iliac aneurysms is less painful and reduces hospital stay. However, outcome data remain limited, and formal comparison with open surgery is awaited.