Abdominal Aortic Aneurysm Ultrasound Screening Programme

ab aortic aneurysm echography book binding ProgrammeSusmi SureshRole of the content Abdominal aortic aneurysm Ultrasound c completely over Programme in Improving Health Outcomes a self-opinionated redirect examinationAbstract Background Abdominal Aortic Aneurysm ( assort AB aortic aneurysm) is bingle of the common conditions that affect manpower advanced 65 and older. Described as a ticking bomb(1), rupture of much(prenominal) an aneurysm results in mortal bleeding and death. Early detection each last(predicate)ows appropriate treat workforcet to be give to patients as an effort to reduce death rate rates. The psychoanalyze Abdominal Aortic Aneurysm book binding course of study, an initiative of globe Health England, offers check to work force in the prevalence classify by following its objective of cut down death rate rates of preventable sicknesses(2). sonography is the chosen imaging climate due to its high sensibility and specificity(3). The aim of this mull over is to examine catamenia literary productions on abdominal aortic aneurysm and to to a lower placestand whether book binding programmes are legal enough to reduce mortality rates of abdominal aortic aneurysm. Quality of sprightliness (QoL) as a wellness outcome depart in any case be examined and grounds analysed, to see whether screening programmes affect patients fictional character of breeding.Method A extreme face of prominent infobases was carried out and the search-results underwent application of inclusion and animadversion criteria genuine for this polish. tetrad major randomised meetled runnings were identified. Following info declension, select estimate was carried out victimisation the CASP son of a bitch. Risk of bias was checked apply the Cochranes cats-paw for assessing lay on the line of bias. either of these ensured a valid conclusion to be drawn. Results The cardinal chosen RCTs were the good deal trial, the Chiches ter trial, the Viborg trial and the WA trial. The fix and Chichester trials were conducted in the UK whereas the Viborg and WA trials were carried out in Denmark and Australia, respectively. The data pool of 125595 people added to the reliability of the findings of this review. A material reduction in mortality rates of abdominal aortic aneurysm was be in the hindrance groups following an sonography screening of the abdominal aorta(4-7). QoL was looked at as the secondary outcome in the MASS trial which cerebrate that thither was no adverse effect on QoL(4). Conclusion The review showed depict on cut AAA mortality rates in men come ond 65 and older following ultrasound screening. No adverse effect in patients QoL was undercoat. The NAAASP is a commendable initiative of Public Health England and it is suggested that resembling screening programmes be introduced done an demo- base healthcare.Introduction An aneurysm forms when a section of a weakened arterial wall(a) dil ates permanently. The walls of an arteria nooky weaken and dilate due to cardiovascular unhealthinesss manage arteriosclerosis, ignition system of the arterial wall or trauma. When this dilation occurs in the abdominal aorta, which runs from T12 to L5, it is considered to be an Abdominal Aortic Aneurysm (AAA)(8). Several studies be in possession of found smoking, high blood pressure and alcohol consumption to be the major risk factors of AAA(9). A family taradiddle of AAA is also considered to be a risk factor(10).AAA is age and sex-dependent as concluded by a retrospective prevalence study that looked at a cohort of 100,000 men and women each. The prevalence among men was found to increase rapidly after the age of 55 and that among women increases after the age of 70(11). in that locationfore, women are considered to be at low risk of developing AAA and hence screening programmes focus on a male race of 65 years or older(12).Patients are mostly symptomless and where sym ptoms do present, these could be abdominal pain, flank pain, back pain, groin pain, or syncope. A palpable pulsating abdominal mass could also be found during examination. An aneurysm once formed, grows in size until it bursts, tiping to fatal bleeding. Only 2 in 10 people with a ruptured aneurysm survive if non treated with emergency AAA improve mental process(13). The survival rate among those who give birth surgical procedure is 94%(14).AAAs are detected using an ultrasound interpret (US), which is considered to be the most effective screening modality with high predisposition (98%) and specificity (99%) rates(15). The US is safe, cheap, quick, and non-invasive, and provides results immediately. It is widely accepted as a valid screening method and the aorta can be visualised in 99% of patients(15). Compared to CT glance overs which can sometimes overestimate the diameter of aneurysms in the oblique plane(15), ultrasound continues to be the choice of screening modality.I n 2014, around 2000 men died from ruptured AAA, be for around 1% of all registered deaths in men remote 65 and over(16). Past records show a reduction in mortality in England from 7.5% in 2009 to 1.6% in 2012(17). This sheds light on the National AAA covering fire Programme (NAAASP) offered by the NHS. Early detection via screening of a monu cordial aneurysm of above 5.5cm, means that patients are given the choice of repair surgery thereby increasing their survival rate by 69%(8, 18). Surveillance is offered to patients with a micro or medium aneurysm of 3-4.4cm and 4.5-5.4cm, respectively(19, 20). This is done an ultrasound scan every twelve or three months for small and medium aneurysms, respectively.Screening aims to reduce the risk of developing a disease in a healthy macrocosm who have no signs of illness with respect to the condition being screened. The NAAASP is based on the policies recommended by the UK National Screening Committee in 2005 following the results of th e largest randomised applyled trial well-nigh AAA, the Multicentre Aneurysm Screening Study (MASS), which showed that screening reduces mortality by 40% after 10 years(21). Implemented in 2009, the programme achieved a comprehensive coverage by the end of 2013.The programme aims to reduce AAA mortality by providing a systematic macrocosm-based screening programme for the male community during their 65th year and on request, for men over 65(22). This falls under Domain 2 and 4 of the Public Health Outcomes Framework provided by the Department of Health, with the objectives to help people to live healthy life historystyles and, to reduce the bod of people living with preventable ill health and people dying prematurely(22), respectively.NAAASP Annual info 2014/15 shows that a replete(p) of 280,520 men were screened and 83.2% had a conclusive screen(23). During the screening year 2013/14, this was 82% out of a total of 287,126 men(24). Depending on the size of the aneurysm, eit her surveillance or surgery was offered.Overall, the programme aims to achieve the health outcome of trim down mortality. Quality of life is also reported as a health outcome as shown by several retrospective, observational and cohort studies conducted on patients(25-27).Knowledge on the conquest of screening programmes like NAAASP carry ons limited. The aim of this review, therefore, is to examine current indicate on whether a screening programme improves health outcomes, namely reduced mortality and improved quality of life, by critically and systematically reviewing literature using the quality assessment tools of the critical appraisal skills programme (CASP).This will be achieved through the following objectivesDevelop inclusion and exclusion criteria based on PICOS relating to AAA and ultrasound scanCarry out a systematic search of databases- Medline, Web of Science, the Cochrane Database, One pursuit and the ISRCTN Registry (BioMed Central).Filter the search using the in clusion and exclusion criteria and carry out data- ancestry using the Cochrane Data entreaty formCarry out quality assessment using the CASP tool and mathematical function the Cochrane tool to assess risk of biasConduct an analysis, management on mortality and quality of life as the health outcomesMethods Although evidence exists on the accuracy of using ultrasonography for detecting abdominal aortic aneurysms(3) and the validity of the scan results is widely accepted due to its high sensitivity and specificity(3), the process of abdominal aortic scanning was decided to be reviewed first(Appendix A). preceding to conducting the search, inclusion and exclusion criteria were set ( shelve 1)(28). Following this, databases were chosen for the search-topic Abdominal Aortic Aneurysm. These include PubMed/MEDLINE, ISRCTN Registry, Web of Science, Lancaster University/One look for and the Cochrane Database. Search strategies were developed for each source and search filters were decided ( slacken 3-7). Medical Subject Heading (MeSH) terms were used to nurture refine the results ( elude 2).Overall, seventy-four articles were found and after removing duplicates, forty-nine remained. These were subjected to the inclusion and exclusion criteria, thus narrowing down the results to seventeen relevant articles. The reference arguings of the retrieved articles were throw out reviewed for any relevant cited papers. This process was repeated until no relevant articles were found. Four major randomised clinical trials were identified from these. These were reviewed after undergoing data extraction and quality assessment.Data extraction was carried out using Cochranes data extraction tool and this allowed for a full-text screening that removed any ineligible studies. Moreover, the use of a standardised form increased the validity and reliability of this review whilst also reducing any risk of bias(28). Finally, the trials were critically appraised using the CASP tool. This enabled identifying risk of bias within the trials, particularly selection bias, performance bias and reportage bias.Table 1 Inclusion Criteria Exclusion CriteriaPopulationGeneral population of males aged 65 years or olderPatients who are asymptomatic and symptomatic who were involved in AAA screeningPatients from all ethnicitiesPatients of all socioeconomic status political campaigns that include females, younger children and males younger than 65 years since AAA is age and sex specificInterventionUltrasound Screening for AAAAny other imaging modalities like CT, MRI or radiographyComparisonNon-screened populationAneurysmAortic Aneurysmthoracic AneurysmOutcome (s) fatality rateQuality of LifeStudy jutRandomised Controlled runnels (RCTs)Trials that look at AAA detection using echographyArticles in the English languageArticles from the time period starting from more or less 20 years before the NAAASP programme came into effect, i.e., 1985 to presentFull articles all told other type s of studies such as qualitative studies, observational studies, cohort or case-series studies.Articles in foreign languagesStudies conducted outside this time periodArticles that are not fully procurableTable 2 Medical Search Headings (MeSH)Abdominal Aortic Aneurysm cud ScreeningUltrasonography breakingTable 3 PubMed Search dodge/MethodResultsAbdominal Aortic Aneurysm23,807Mass Screening128,434Ultrasonography386,798Rupture109,121AAA + MS599AAA + MS + US300AAA + MS +US + Rupture102AAA + MS +US + RCTs23AAA + MS +US + Rupture + RCTs11Table 4 Web of Science Search Strategy/MethodResultsAbdominal Aortic Aneurysm18,625Mass Screening43,081Ultrasonography80,257Rupture119,830AAA + MS131AAA + MS + US23AAA + MS +US + Rupture12 marches English11Table 5 Cochrane Library (RCTs just) Search Strategy/MethodResultsAbdominal Aortic Aneurysm702Mass Screening3827Ultrasonography11,318Rupture3097AAA + MS46AAA + MS + US23AAA + MS +US + Rupture10Table 6 OneSearch Search Strategy/MethodResultsAbdominal A ortic Aneurysm27,819Mass Screening73,090Ultrasonography122,460Rupture94738AAA + MS604AAA + MS + US123AAA + MS +US + Rupture42Limit Articles39Table 7 ISRCTN Registry/BioMed Central Search Strategy/MethodResultsAbdominal Aortic Aneurysm37Mass Screening328Ultrasonography88Rupture176AAA + MS3Results Four dominant randomised controlled trials (RCTs) were identified- the Multicentre Aneurysm Screening Study(4) (MASS) conducted between 1997 to 1999 the Chichester Study(5), 1988 to 1991 the Viborg County Trial(6), 1994 to 1998 and the horse opera Australia (WA) Trial(7), 1996. These collectively showed that AAA mortality rate can be heartyly reduced in the population following an ultrasound scan of the abdominal aorta (Table 8).The Mass and Chichester trials were carried out in the UK and had a participant number of 67,770 men aged 65 to 74 years and 6040 men aged 65-80 years, respectively. The Viborg province trial was conducted in the Viborg county of Denmark with a participant number of 12,639 men aged 65-73 years the WA trial, carried out in the province of Western Australia include 41,000 men aged 65-79.All these trials used ultrasound screening of the abdomen to detect AAA and measured AAA-mortality as the primary outcome(4-7). The secondary outcomes of all trials were all-cause mortality. in time the Mass trial also measured quality of life and cost-effectiveness as the secondary outcomes. Cost-effectiveness was also measured by the Viborg trial as the secondary outcome. Participants were randomly selected and randomisation was computer-generated(4-7).Mass and Chichester trials recruited participants via GP registers based on gender and date of birth. In the Mass trial, some were excluded if the GP considered them to terminally ill, had other health problems or had undergone AAA repair(4). In the Viborg trial, recruitment was through the countys health department and WA participants were selected from the electoral roll(6, 7). The WA trial excluded those men who were too far from the screening location the Viborg trial had no such exclusions.MASS TrialThe intervention group smooth of 33839 men and the control group, 1333 men. Attendance was 80% and the median follow out was ten years(4). 65 men died in the intervention group and 113 died in the control group, due to AAA. Mortality data was taken from death registry provided by the Office of National Statistics (ONS).The study concluded that AAA mortality rate can be strongly reduced by up to half, following ultrasound screening. There was a 42% reduction in the intervention group, hazard dimension (HR) 0.58 95% CI (0.42-0.78)(4).The study also measured mood and health status outcomes such as state anxiety, depression, and health-status measures such as mental and physical health, and self-rated health(4, 13). These were calculated at intervals of six weeks after screening and, 3 and 12 months after detection of aneurysm or surgery. There were no significant changes in anxiety a nd depression and these remained within the recommendations(4). However, those screened negative and undergoing surveillance scored higher in health-status measures. This trend continued until 3 months after screening(4). However at 12 months, those who had undergone surgery scored higher than those in surveillance. They also self-rated higher, similar to those screened negative(4). Despite these results, the authors refrained from making a conclusive statement on quality of life.In the intervention group, there was an increase in the number of elected surgeries, odds ratio (OR)- 2.45 95% CI (2.02-2.97)(4). Nevertheless, there was no significant difference in the overall 30-day mortality after elective surgery in the intervention and control groups this remained at 6%. However, unnecessary surgery and the risk of overdiagnosis are seen as factors reducing the overall quality of life(29). So even though this increase in elective surgery in the intervention group and its effects cou ld be used as a measure of quality of life, the authors did not make such a link.Chichester TrialThe intervention group composed of 2995 men and the control group, 3045 men. The median follow-up was fifteen years and the attendance rate, 74%, decreased with age. About 33.8% of men in the age range of 76-80 years declined compared to 19.5% in the age group of 65 years(5). 10 men died in the intervention group and 17 died in the control group, due to AAA-related causes. Like the Mass trial, mortality data was taken from the ONS Death Registry.The study found no differences in mortality rates in the two groups up to four years from screening. However, over 15 years, mortality was found to be reduced in the intervention group by 11%. This was not considered as a significant reduction, HR 0.89 95% CI (0.60-1.32) (5).Viborg Trial The intervention group composed of 6339 men and the control group, 6319 men. Attendance was 76% and the maximum follow-up was xiv years(6). 6 men died in the i ntervention group, compared to 19 in the control group. Mortality data was taken from the depicted object registry.There was a significant reduction in AAA-related hospital mortality, OR-0.31 95% CI (0.13-0.79)(6). The study recommends screening men aged 65 years to reduce AAA-mortality. However since the study only noted deaths from AAA in a hospital move in the county of Viborg, this finding cannot be expanded to other countries.Western Australia Trial The intervention and control groups composed of 19352 men each. Attendance rate was 70% and the maximum follow-up was 43-months(7). 18 men died in the intervention group and 25 died in the control group. Mortality data was taken from the national death registry and the hospital registry.The study found that there was no significant reduction in mortality following ultrasound scanning in the intervention group of men aged 65-83 years in Western Australia, OR- 0.72 95% CI (0.39-1.32)(7). However the study noted that in the subgroup of men aged 65-75 years, mortality was found to be reduced(7).Table 8 AAA mortality raw dataTrialDeaths in ScreenedDeaths in UnscreenedOdds Ratio (95% CI)MASS65/33,839113/33,9610.58 (0.42 to 0.78)Chichester10/320517/32280.59 (0.27 to 1.29)Viborg6/633919/63190.31 (0.13 to 1.79)Western Australia (WA)18/1935225/193520.72 (0.39 to 1.32)Total*93/56,396one hundred fifty-five/56,5410.60 (0.46 to 0.78)*Data from the Viborg trial is not included since the study noted deaths only in a hospital setting. Hence, results cannot be compared to the other studies(30)DiscussionThe pooled data of 125595 participants shows that AAA mortality rate can be significantly reduced in the population following an ultrasound scan of the abdominal aorta. Data from the four RCTs show that the Absolute Risk decrement (ARR) for the Mass trial, Chichester, Viborg and WA are 0.14%, 0.21%, 0.21% and 0.04%, respectively (See Table 9 for the full data graceful by the review author). Although these may appear insignifi cant, when applied over a population, the ARR is 140.7, 214.6, 206.0 and 36.2 per 100,000 respectively. Hence, the Numbers Needed to Screen (NNS) are 711, 466, 485 and 2765 respectively. On an average, this is an ARR of 149.4 out of every 100,000 people for an NNS of 1107. This NNS is lower than other screening programmes like breast crab louse screening which has an NNS of 1339(31). This confirms the benefits of a population-based screening programme such as the NAAASP.The Mass trial, which looked at the effects of ultrasound screening on the quality of life found its measures to be within normal standards. Since the NAAASP is based on the results of this trial, it can be said that ultrasound screening has no adverse effects on the quality of life of the screened population. However, a limitation acts on the trial- quality of life was measured only up to twelve months after scan no data is available for the period after that. If quality of life was continued to be measured during follow-ups or even separately via postal questionnaires or GP appointments, a more valid inference could have been drawn. It would also have provided a fuller picture on the semipermanent effects on quality of life.One other limitation performing on this review is the possibility of selection bias as a result of excluding some articles in foreign languages. Despite this, the findings of this review remain unaffected and can be considered valid since an exhaustive search of the major databases was carried out systematically. Although the inclusion criteria of free-articles was applied after this search, Lancaster Universitys subscription service ensured access to all available articles and a complete retrieval of the selected search was affirmable. The pooled study population consisted of 125,595 men and the MASS trial alone had a sample of 67800 people. So, conclusions on quality of life and AAA mortality can be considered reliable.However, there are inconsistencies present in the four RCTs due to the different methods used. For example, the Viborg trial noted mortality only in a hospital setting. This makes its results unrivaled to the other trials. Also, the source of mortality data varies in the four studies. All the trials looked at the national death registries but the Chichester and WA trials also looked at other sources(5, 7). This may have resulted in possible over-estimation or duplication of data. Similarly, the cause of death was re-checked by a clinician and two random vascular surgeons in the Chichester and WA trials, respectively. Whilst expert opinion regarding the cause of death could lead to precise and accurate mortality data, there could also be false-positives when opinions are formed on complex cases with multiple causes of mortality.This subject of human shift was also noted whilst carrying out the preparatory ultrasound screening (Appendix A). one-on-one measurements of the same abdominal aortic diameter were varied. Although this po ints to the possibility of human delusion that may adversely affect the accuracy the diagnosis, the NAAASP identifies staff training as a significant aspect of the programme to overcome this. Staffs are well-trained in the use of ultrasonography for AAA screening and in the overall talking to of the programme(8). Also, the programme itself has several failsafe procedures incorporated within all phases of the programme so that the performance thresholds are constantly maintained(8).The result of this review can be applied to patient care in the UK. The NAAASP is successfully running its one-seventh year. Since its implementation in 2009, one million men have been screened(32). Accumulating evidence shows it is feasible to reduce AAA-mortality by ultrasound screening, thereby making it possible to achieve the programmes aim.Public Health England could implement similar screening interventions in other disease areas. There is currently a long of list of conditions like atrial fibrill ation, thyroid disease and lung cancer where a population-based screening is not offered (but privately available) due to the absence of enough evidence to depose a screening programme(33). Evidence-based healthcare could be further expanded to diseases like these.It is not just new and untreatable diseases that prove to be a repugn to 21st century medicine it is the phenomenon of the disease-iceberg that proves most challenging. By detecting and treating other(a) onset of illnesses, people live a longer and healthier life.Table 9 Data processed by the review author using the results from the four RCTsTrialExperimental example Rate (EER)Control Event Rate (CER)Absolute Risk ReductionRelative Risk ReductionNumber(s) Needed to Screen (NNS)Odds Ratio/Relative RiskMASS0.001920860.003327350.001406490.422705710.9921.73222Chichester0.003120120.005266420.002146290.407543465.9191.68789Viborg0.0009465220.003006800.002060280.685207485.3703.17669Western Australia0.0009301360.001291860.00036 17200.2800002764.571.38889Overall0.001578070.002768060.001189990.429901840.3441.75408Overall*0.001649050.002741370.001092320.398457915.4821.66239*Data from the Viborg trial is not included since the study noted deaths only in a hospital setting. Hence, results cannot be compared to the other studies(30)Conclusion Following critical appraisal of the current available evidence provided by four major RCTs, it was found that mortality from AAA can be significantly reduced in males aged 65 years and older, through a population-based screening programme. Ultrasonography continues to be the chosen imaging modality due to its accuracy and ease-of-use. It was also found that such a screen