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Aortic aneurysm screening in general practice
THE LANCET
contaminated food or sewage from a limited number of landbased operations or from the discharge of this material from ships and fishing vessels which frequently visit waters around South Georgia. Several species of albatross which breed at South Georgia have foraging ranges which extend as far as the oceans surrounding South America. These together with species which migrate from the northern hemisphere have the potential to transmit infected material to the Antarctic. This transequatorial transport has previously been described with tick-associated viruses and Borrelia burgdorferi sp.4 Usually the transmission of zoonoses is one-way from the animal to human beings. However the finding of S enteritidis phage type 4 in the penguin population at South Georgia may indicate a bi-directional route. The possibility that man could introduce such an organism in Antarctica may determine environmental protocols for waste disposal. The prevalence of salmonella in the Antarctic and any possible impact on its inhabitants needs to be further investigated.
three (1·5%), and an aneurysm in ten (5%). The aneurysm measured over 5 cm diameter in four (2%). One patient had a previous aneurysm repair, and other pathology was incidentally noted in three—two with gallstones and one with bilateral hydronephroses. We attribute the high attendance rate to the close relationship with the GP, and location of the screening in a small easily accessible cottage hospital. Several recent community-based screening programmes have held screening sessions in the GP’s surgery, with a portable ultrasound machine, and achieved attendance rates of 76–79% with an aneurysm detection rate of 6·7–8·4%.1–3 Another programme that invited patients through the GP to attend screening sessions at the local base hospital reported a 73% attendance rate.4 Although the value of a national screening programme has not yet been confirmed,5 we propose that a method of screening based around individual GP practices is feasible, can be easily organised and run at little cost, and will achieve a high attendance rate.
B Olsen, S Bergström, *D J McCafferty, M Sellin, J Wiström Departments of Infectious Diseases, Microbiology, and Clinical Bacteriology, Umeå University, S-901 87 Umeå, Sweden; and *British Antarctic Survey, High Cross, Madingley Road, Cambridge CB3 0ET, UK
1 2 3
4
Coyle EF, Ribeiro CD, Howard AJ, et al. Salmonella enteritidis phage type 4 infection: association with hens’ eggs. Lancet 1988; ii: 1295–97. Rodrigue DC, Tauxe RV, Rowe B. International increase in Salmonella enteritidis: a new pandemic. Epidemiol Infect 1990; 105: 21–27. Usera MA, Popovic T, Bopp CA, et al. Molecular subtyping of Salmonella enteritidis phage type 8 strains from the United States. J Clin Microbiol 1994; 32: 194–98. Olsen B, Duffy D, Jaenson TGT, et al. Transhemispheric exchange of Lyme disease spirochetes by seabirds. J Clin Microbiol 1995; 33: 3270–74.
*H J S Jones, A E K Ibrahim, C Hoskins, J K Derodra Departments of *Vascular Surgery and Radiology, Mayday University Hospital, Thornton Heath CR7 7YE, UK
1 2
3
4
5
Aortic aneurysm screening in general practice SIR—We have begun an aortic aneurysm screening programme in Croydon, in the Greater London area. The programme is overseen by a hospital consultant, but run in close cooperation with the local general practitioners (GPs), and is organised at the practice level. We report initial results of screening through one general practice. One local general practice was asked to identify all male patients aged 65 and over from computerised records. All those identified were given an information sheet on aortic aneurysms and the screening programme by the GP. Screening sessions were held one morning a week and appointments were booked by the GP receptionists. 30 patients were screened at each session by a consultant radiologist, and each screen took about 5 min. The sessions were held in a cottage hospital at some distance from the base hospital which provided a pleasant non-threatening environment for those being screened. During the sessions, a consultant surgeon was available at the hospital to give advice to any patients, especially those in whom pathology was identified. An aneurysm was defined as an aorta with a diameter greater than 3 cm. Other intra-abdominal pathology was not specifically looked for but was detected in a few patients. GPs were advised immediately after the session of the results for their patients. The recommended management for detected aneurysms depended on the size. For small aneurysms (3–4 cm) a repeat scan was planned in 1 year, and for 4–5 cm aneurysms at 6 months. For aneurysms over 5 cm surgery was advised. In the first practice, which has a total of 3472 patients, 227 men were invited for screening and 203 (89%) attended. A normal aorta was found in 189 (93%), an ectatic aorta in
1320
Holdsworth JD. Screening for abdominal aortic aneurysm in Northumberland. Br J Surg 1994; 81: 710–12. Smith FCT, Grimshaw GM, Paterson IS, Shearman CP, Hamer JD. Ultrasonographic screening for abdominal aortic aneurysm in an urban community. Br J Surg 1993; 80: 1406–09. Lucarotti M, Shaw E, Poskitt K, Heather B. The Gloucestershire Aneurysm Screening Programme: the first 2 years’ experience. Eur J Vasc Surg 1993; 7: 397–401. Morris GE, Hubbard CS, Quick CRG. An abdominal aortic aneurysm screening programme for all males over the age of 50 years. Eur J Vasc Surg 1994; 8: 156–60. Hak E, Balm R, Eikelboom RC, Akkersdijk GJM, van der Graaf Y. Abdominal aortic aneurysm screening: an epidemiological point of view. Eur J Vasc Endovasc Surg 1996; 11: 270–78.
Levodopa and swallowing reflex SIR—Swallowing disorders are common in the elderly and cause substantial morbidity and mortality due to aspiration pneumonia. Delayed triggering of the swallowing reflex occurs in patients with infarctions in the basal ganglia,1 and an impairment of dopamine metabolism in the basal ganglia is observed in these patients.2,3 We have therefore investigated whether levodopa improves the swallowing reflex in patients with basal ganglia infarctions who had a history of aspiration pneumonia. 27 patients, mean age 78 (SE 2) years, had at least one episode of aspiration pneumonia with chest radiographic evidence of inflammation in the lower pulmonary segments. Computed tomographic (CT) scans revealed multiple lacunar infarctions in the basal ganglia. 20 controls, mean age 75 years, were healthy volunteers with normal findings on CT scans. To eliminate diurnal variation, studies were done at the same time of day. Each subject refrained from taking ethanol, sedatives, or drugs that affected the autonomic nervous system for at least 72 h before the study. The swallowing reflex was induced by a bolus injection of 1 mL of distilled water into the pharynx through a nasal catheter. The subjects were unaware of the injection. Swallowing was identified by submental electromyographic (EMG) activity and visual observation of the characteristic laryngeal movement.1 EMG activity was recorded from surface electrodes on the chin. The swallowing reflex was evaluated by the latency of response, which was timed from the injection to the onset of swallowing.1 In a randomised, double-blind, crossover design, the subjects were given an
Vol 348 • November 9, 1996
contaminated food or sewage from a limited number of landbased operations or from the discharge of this material from ships and fishing vessels which frequently visit waters around South Georgia. Several species of albatross which breed at South Georgia have foraging ranges which extend as far as the oceans surrounding South America. These together with species which migrate from the northern hemisphere have the potential to transmit infected material to the Antarctic. This transequatorial transport has previously been described with tick-associated viruses and Borrelia burgdorferi sp.4 Usually the transmission of zoonoses is one-way from the animal to human beings. However the finding of S enteritidis phage type 4 in the penguin population at South Georgia may indicate a bi-directional route. The possibility that man could introduce such an organism in Antarctica may determine environmental protocols for waste disposal. The prevalence of salmonella in the Antarctic and any possible impact on its inhabitants needs to be further investigated.
three (1·5%), and an aneurysm in ten (5%). The aneurysm measured over 5 cm diameter in four (2%). One patient had a previous aneurysm repair, and other pathology was incidentally noted in three—two with gallstones and one with bilateral hydronephroses. We attribute the high attendance rate to the close relationship with the GP, and location of the screening in a small easily accessible cottage hospital. Several recent community-based screening programmes have held screening sessions in the GP’s surgery, with a portable ultrasound machine, and achieved attendance rates of 76–79% with an aneurysm detection rate of 6·7–8·4%.1–3 Another programme that invited patients through the GP to attend screening sessions at the local base hospital reported a 73% attendance rate.4 Although the value of a national screening programme has not yet been confirmed,5 we propose that a method of screening based around individual GP practices is feasible, can be easily organised and run at little cost, and will achieve a high attendance rate.
B Olsen, S Bergström, *D J McCafferty, M Sellin, J Wiström Departments of Infectious Diseases, Microbiology, and Clinical Bacteriology, Umeå University, S-901 87 Umeå, Sweden; and *British Antarctic Survey, High Cross, Madingley Road, Cambridge CB3 0ET, UK
1 2 3
4
Coyle EF, Ribeiro CD, Howard AJ, et al. Salmonella enteritidis phage type 4 infection: association with hens’ eggs. Lancet 1988; ii: 1295–97. Rodrigue DC, Tauxe RV, Rowe B. International increase in Salmonella enteritidis: a new pandemic. Epidemiol Infect 1990; 105: 21–27. Usera MA, Popovic T, Bopp CA, et al. Molecular subtyping of Salmonella enteritidis phage type 8 strains from the United States. J Clin Microbiol 1994; 32: 194–98. Olsen B, Duffy D, Jaenson TGT, et al. Transhemispheric exchange of Lyme disease spirochetes by seabirds. J Clin Microbiol 1995; 33: 3270–74.
*H J S Jones, A E K Ibrahim, C Hoskins, J K Derodra Departments of *Vascular Surgery and Radiology, Mayday University Hospital, Thornton Heath CR7 7YE, UK
1 2
3
4
5
Aortic aneurysm screening in general practice SIR—We have begun an aortic aneurysm screening programme in Croydon, in the Greater London area. The programme is overseen by a hospital consultant, but run in close cooperation with the local general practitioners (GPs), and is organised at the practice level. We report initial results of screening through one general practice. One local general practice was asked to identify all male patients aged 65 and over from computerised records. All those identified were given an information sheet on aortic aneurysms and the screening programme by the GP. Screening sessions were held one morning a week and appointments were booked by the GP receptionists. 30 patients were screened at each session by a consultant radiologist, and each screen took about 5 min. The sessions were held in a cottage hospital at some distance from the base hospital which provided a pleasant non-threatening environment for those being screened. During the sessions, a consultant surgeon was available at the hospital to give advice to any patients, especially those in whom pathology was identified. An aneurysm was defined as an aorta with a diameter greater than 3 cm. Other intra-abdominal pathology was not specifically looked for but was detected in a few patients. GPs were advised immediately after the session of the results for their patients. The recommended management for detected aneurysms depended on the size. For small aneurysms (3–4 cm) a repeat scan was planned in 1 year, and for 4–5 cm aneurysms at 6 months. For aneurysms over 5 cm surgery was advised. In the first practice, which has a total of 3472 patients, 227 men were invited for screening and 203 (89%) attended. A normal aorta was found in 189 (93%), an ectatic aorta in
1320
Holdsworth JD. Screening for abdominal aortic aneurysm in Northumberland. Br J Surg 1994; 81: 710–12. Smith FCT, Grimshaw GM, Paterson IS, Shearman CP, Hamer JD. Ultrasonographic screening for abdominal aortic aneurysm in an urban community. Br J Surg 1993; 80: 1406–09. Lucarotti M, Shaw E, Poskitt K, Heather B. The Gloucestershire Aneurysm Screening Programme: the first 2 years’ experience. Eur J Vasc Surg 1993; 7: 397–401. Morris GE, Hubbard CS, Quick CRG. An abdominal aortic aneurysm screening programme for all males over the age of 50 years. Eur J Vasc Surg 1994; 8: 156–60. Hak E, Balm R, Eikelboom RC, Akkersdijk GJM, van der Graaf Y. Abdominal aortic aneurysm screening: an epidemiological point of view. Eur J Vasc Endovasc Surg 1996; 11: 270–78.
Levodopa and swallowing reflex SIR—Swallowing disorders are common in the elderly and cause substantial morbidity and mortality due to aspiration pneumonia. Delayed triggering of the swallowing reflex occurs in patients with infarctions in the basal ganglia,1 and an impairment of dopamine metabolism in the basal ganglia is observed in these patients.2,3 We have therefore investigated whether levodopa improves the swallowing reflex in patients with basal ganglia infarctions who had a history of aspiration pneumonia. 27 patients, mean age 78 (SE 2) years, had at least one episode of aspiration pneumonia with chest radiographic evidence of inflammation in the lower pulmonary segments. Computed tomographic (CT) scans revealed multiple lacunar infarctions in the basal ganglia. 20 controls, mean age 75 years, were healthy volunteers with normal findings on CT scans. To eliminate diurnal variation, studies were done at the same time of day. Each subject refrained from taking ethanol, sedatives, or drugs that affected the autonomic nervous system for at least 72 h before the study. The swallowing reflex was induced by a bolus injection of 1 mL of distilled water into the pharynx through a nasal catheter. The subjects were unaware of the injection. Swallowing was identified by submental electromyographic (EMG) activity and visual observation of the characteristic laryngeal movement.1 EMG activity was recorded from surface electrodes on the chin. The swallowing reflex was evaluated by the latency of response, which was timed from the injection to the onset of swallowing.1 In a randomised, double-blind, crossover design, the subjects were given an
Vol 348 • November 9, 1996