Modelling the impact of changes to abdominal aortic aneurysm screening and treatment services in England during the COVID-19 pandemic.

BackgroundThe National Health Service (NHS) abdominal aortic aneurysm (AAA) screening programme (NAAASP) in England screens 65-year-old men. The programme monitors those with an aneurysm, and early intervention for large aneurysms reduces ruptures and AAA-related mortality. AAA screening services have been disrupted following COVID-19 but it is not known how this may impact AAA-related mortality, or where efforts should be focussed as services resume.MethodsWe repurposed a previously validated discrete event simulation model to investigate the impact of COVID-19-related service disruption on key outcomes. This model was used to explore the impact of delayed invitation and reduced attendance in men invited to screening. Additionally, we investigated the impact of temporarily suspending scans, increasing the threshold for elective surgery to 7cm and increasing drop-out in the AAA cohort under surveillance, using data from NAAASP to inform the population.FindingsDelaying invitation to primary screening up to two years had little impact on key outcomes whereas a 10% reduction in attendance could lead to a 2% lifetime increase in AAA-related deaths. In surveillance patients, a 1-year suspension of surveillance or increase in the elective threshold resulted in a 0.4% increase in excess AAA-related deaths (8% in those 5-5.4cm at the start). Longer suspensions or a doubling of drop-out from surveillance would have a pronounced impact on outcomes.InterpretationEfforts should be directed towards encouraging men to attend AAA screening service appointments post-COVID-19. Those with AAAs on surveillance should be prioritised as the screening programme resumes, as changes to these services beyond one year are likely to have a larger impact on surgical burden and AAA-related mortality

Outcomes in Men From the NHS Abdominal Aortic Aneurysm Screening Programme With a Large Aneurysm Referred for Intervention.

OBJECTIVE The NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP) has been implemented since 2013. Men with a large aneurysm >54 mm, either at first screen or during surveillance, are referred for intervention. The aim of the present study was to explore outcomes in these men and to see whether there was any regional variation in treatment rates and type of repair. METHODS The study cohort included all men referred to a vascular network with a large abdominal aortic aneurysm (AAA). Basic demographic information, nurse assessment details, as well as outcome data were extracted from the national NAAASP IT system, AAA SMaRT, for analysis. RESULTS Some 3 026 men were referred for possible intervention (48% first screen, 52% surveillance). Some 448 men (13.3%) either declined (63, 2.1%), or were turned down for early intervention for various reasons (385, 12.7%). Some 8% were declined for medical reasons (true turn down rate). Men referred from surveillance were older, and more likely not to have had elective surgery within three months (16.0 vs. 11.2%; HR 1.37, 95% CI 1.07-1.75, p = .011). Turn down rates did not vary among local programmes, when surveillance men were taken into account. Some 2 624 (87%) men had planned AAA repair, with a peri-operative mortality of 1.3%. Thirty day surgical mortality was lower after EVAR: 0.4% compared with 2.1% after open repair. The method of repair remained consistent year on year, with roughly equal numbers undergoing endovascular (50%) and open surgical repair (48%); 2% unknown. There was regional variation in the proportion treated by endovascular repair: from 20% to 97%. CONCLUSION The turn down rate after referral for treatment with a screen detected AAA was low, but there remains considerable regional variation in the proportion undergoing endovascular repair. Procedures were undertaken with low peri-operative mortality

Safety of Men With Small and Medium Abdominal Aortic Aneurysms Under Surveillance in the NAAASP.

BACKGROUND: Population screening for abdominal aortic aneurysm (AAA) has commenced in several countries, and has been shown to reduce AAA-related mortality by up to 50%. Most men who screen positive have an AAA <5.5 cm in diameter, the referral threshold for treatment, and are entered into an ultrasound surveillance program. This study aimed to determine the risk of ruptured AAA (rAAA) in men under surveillance. METHODS: Men in the National Health Service AAA Screening Programme who initially had a small (3-4.4 cm) or medium (4.5-5.4 cm) AAA were followed up. The screening program's database collected data on ultrasound AAA diameter measurements, dates of referral, and loss to follow-up. Local screening programs recorded adverse outcomes, including rAAA and death. Rupture and mortality rates were calculated by initial and final known AAA diameter. RESULTS: A total of 18 652 men were included (50 103 person-years of surveillance). Thirty-one men had rAAA during surveillance, of whom 29 died. Some 952 men died of other causes during surveillance, mainly cardiovascular complications (26.3%) and cancer (31.2%). The overall mortality rate was 1.96% per annum, similar for men with small and medium AAAs. The rAAA risk was 0.03% per annum (95% CI, 0.02%-0.05%) for men with small AAAs and 0.28% (0.17%-0.44%) for medium AAAs. The rAAA risk for men with AAAs just below the referral threshold (5.0-5.4 cm) was 0.40% (0.22%-0.73%). CONCLUSIONS: The risk of rAAA under surveillance is <0.5% per annum, even just below the present referral threshold of 5.5 cm, and only 0.4% of men under surveillance are estimated to rupture before referral. It can be concluded that men with small and medium screen-detected AAAs are safe provided they are enrolled in an intensive surveillance program, and that there is no evidence that the current referral threshold of 5.5 cm should be changed.This work was funded by the British Heart Foundation (RE/13/6/30180), and Homerton College, University of Cambridge. The NHS AAA Screening Programme, as part of Public Health England, is funded by the Department of Health

Safety of Men with Small and Medium Abdominal Aortic Aneurysms Under Surveillance in the National Health Service Screening Programme.

BACKGROUND: Population screening for abdominal aortic aneurysm (AAA) has commenced in several countries, and has been shown to reduce AAA-related mortality by up to 50%. Most men who screen positive have an AAA below 5.5cm in diameter, the referral threshold for treatment, and are entered into an ultrasound surveillance programme. This study aimed to determine the risk of ruptured AAA (rAAA) in men under surveillance. METHODS: Men in the NHS AAA Screening Programme who initially had a small (3-4.4cm) or medium (4.5-5.4cm) AAA were followed-up. The screening programme's database collected data on ultrasound AAA diameter measurements and dates of referral and loss to follow-up. Local screening programmes recorded adverse outcomes, including rAAA and death. Rupture and mortality rates were calculated by initial and final known AAA diameter. RESULTS: A total of 18,652 men were included (50,103 men years of surveillance). Thirty-one men had rAAA in surveillance, of whom 29 died. Some 952 men died from other causes during surveillance, mainly cardiovascular complications (26.3%) and cancer (31.2%). The overall mortality rate was 1.96% per annum, similar for men with small and medium AAA. The rAAA risk was 0.03% per annum (95% confidence interval 0.02-0.05%) for men with small AAA, and 0.28% (0.17-0.44%) for medium AAA. The rAAA risk for men with AAA just below the referral threshold (5.0 to 5.4 cm) was 0.40% (0.22-0.73%). CONCLUSIONS: The risk of rAAA in surveillance is below 0.5% per annum, even just below the present referral threshold of 5.5cm and only 0.4% of men in surveillance are estimated to rupture before referral. It can be concluded that men with small and medium screen-detected AAA are safe provided they are enrolled in an intensive surveillance program, and that there is no evidence that the current referral threshold of 5.5cm should be changed

Hereditary xanthinuria type II associated with mental delay, autism, cortical renal cysts, nephrocalcinosis, osteopenia, and hair and teeth defects

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