The adverse effects of race, insurance status, and low income on the rate of amputation in patients presenting with lower extremity ischemia

ObjectivesA consequence of delay in the diagnosis of peripheral vascular disease limb loss. This study was undertaken to determine the correlation of low socioeconomic status and race on the severity of ischemic presentation and the subsequent amputation rate.MethodsData from the Nationwide Inpatient Sample (NIS) from 1998 to 2002 on patients from urban hospitals with the diagnosis of lower extremity ischemia were evaluated. The population was divided into two groups: the amputation group (AMP) and lower extremity revascularization group (LER). Comorbidities, age, gender, race, ischemic gangrene at presentation, insurance status (no/noncommercial or commercial), and income status at admission were determined. These variables were compared using multivariate logistic regression analyses of the data for risk adjustment.ResultsOf 691,833 patients presenting with lower extremity ischemia, 363,193 underwent revascularization (66.3%) or amputation (33.7%). Univariate analysis correlated a statistically significant (P < .0001) higher rate of amputation and multivariate analysis associated significantly higher odds of amputation with the following variables: nonwhites (1.91, 95% confidence interval [CI], 1.65, 2.20), low-income bracket (1.41, 95% CI, 1.18, 1.60), and Medicare & Medicaid (1.81, 95% CI, 1.66, 1.97). Adjusting for other variables of statistical significance, multivariate regression analysis showed a statistically significant risk for amputation based on the nonteaching status of the institution (odds ratio [OR], 1.17, 95% CI, 1.08, 1.30).ConclusionsPrimary amputation was performed with a higher frequency on patients with lower extremity ischemia who were nonwhite, low income, and without commercial insurance. The observed advanced ischemia among these economically disadvantaged patients suggests a delayed diagnosis of peripheral vascular disease, probably due to lack of access to adequate primary care or vascular surgery providers, or both. Better education of the general population and primary care providers to the symptoms and consequences of PVD may reduce the amputation rate in this group

Gene delivery to in situ veins: Differential effects of adenovirus and adeno-associated viral vectors

AbstractPurpose: Gene transfer offers the potential to modify vein graft biology at the time of surgical implantation. Efficiency of gene delivery, stability of expression, and host responses are critical parameters for candidate vectors. We compared the effects of intraluminal exposure with adenovirus (AD) and adeno-associated virus (AAV) vectors on transgene expression and monocyte adhesion (MA) in treated vein segments. Methods: Adult New Zealand white rabbits (N = 51) were anesthetized, and the jugular veins were cannulated bilaterally. Veins were gently distended with either vector (2·108 to 1·1010 infective particles/mL) or vehicle (control) for 30 minutes, after which venous flow was restored. AD and AAV vectors encoding for the marker genes β-galactosidase (LacZ) and green fluorescent protein (GFP) were used. Vessels were explanted 2 to 40 days postinfection for analysis of gene expression (X-gal staining, reverse transcriptase-polymerase chain reaction), MA, and immunohistochemistry. Ex vivo adhesion assays used 51Cr-labeled THP-1 cells. Statistical significance was tested by using analysis of variance with a P value less than.05. Results: All animals survived, and all treated veins were patent at sacrifice. Intraluminal exposure to AD at a titer of 1·109 resulted in near complete transduction of the endothelium at 2 days, with no detectable expression by day 14. At an equal titer of infectious particles, transgene expression was markedly less for AAV at 2 to 7 days, but improved at 2 weeks and persisted to 40 days. MA was significantly increased 2 days after AD exposure (2.7-fold vs control, *P <.002); AAV treatment had no discernible effect on MA. Conclusion: AD-mediated gene transfer to vein segments resulted in robust, transient gene expression that disappeared after 2 weeks. In comparison, AAV-mediated gene delivery was less efficient, but resulted in delayed onset, persistent expression beyond 30 days. AD exposure induced an early increase in MA to the vein surface that was not seen with AAV treatment. Current generations of both AD and AAV vectors have significant, albeit different, limitations for vascular gene therapy. (J Vasc Surg 2000;31:1149-59.

Predicting the stress-strain behaviour of zeolite-cemented sand based on the unconfined compression test using GMDH type neural network

Stabilizing sand with cement is considered to be one of the most cost-effective and useful methods of in-situ soil improvement, and the effectiveness is often assessed using unconfined compressive tests. In certain cases, zeolite and cement blends have been used; however, even though this is a fundamental issue that affects the settlement response of a soil, very few attempts have been made to assess the stress-strain behaviour of the improved soil. Also, the majority of previous studies that predicted the unconfined compressive strength (UCS) of zeolite cemented sand did not examine the effect of the soil improvement variables and strain concurrently. Therefore, in this paper, an initiative is taken to predict the relationships for the stress-strain behaviour of cemented and zeolite-cemented sand. The analysis is based on using the unconfined compression test results and Group Method of Data Handling (GMDH) type Neural Network (NN). To achieve this end, 216 stress-strain diagrams resulting from unconfined compression tests for different cement and zeolite contents, relative densities, and curing times are collected and modelled via GMDH type NN. In order to increase the accuracy of the predictions, the parameters associated with successive stress and strain increments are considered. The results show that the suggested two and three hidden layer models appropriately characterise the stress-strain variations to produce accurate results. Moreover, the UCS values derived from this method are much more accurate than those provided in previous approaches. Moreover, the UCS values derived from this method are much more accurate than those provided in previous approaches which simply proposed the UCS values based on the content of the chemical binders, compaction, and/or curing time, not considering the relationship between stress and strain. Finally, GMDH models can be considered to be a powerful method to determine the mechanical properties of a soil including the stre

Quasi-free limit in the deuteron-deuteron three-body break-up process

Detailed measurements of vector and tensor analyzing powers of the 2H(~d, dp)n breakup process are presented. The data were obtained using a polarized deuteron-beam with an energy of 65 MeV/nucleon impinging on a liquid-deuterium target. The experiment was conducted at the AGOR facility at KVI using the BINA 4 -detection system. The focus of this contribution is to analyze data of the dd scattering process in the regime at which the neutron acts as a spectator, which we refer to as the quasi-free (QF) limit. To achieve this, events for which the final-state deuteron and proton are coplanar have been analyzed and the data have been sorted for various reconstructed momenta of the missing neutron. In the limit of vanishing neutron momentum and at small deuteron-proton momentum transfer, the data match very well with measured and predicted spin observables of the elastic deuteron-proton scattering process. The agreement deteriorates rapidly with increasing neutron momentum and deuteron-proton momentum transfer. The results of coplanar configurations in four-body phase space are compared with the results of recent available theoretical calculations based on the Single-Scattering Approximation

Diminishing benefits of urban living for children and adolescents’ growth and development

Optimal growth and development in childhood and adolescence is crucial for lifelong health and well-being1–6. Here we used data from 2,325 population-based studies, with measurements of height and weight from 71 million participants, to report the height and body-mass index (BMI) of children and adolescents aged 5–19 years on the basis of rural and urban place of residence in 200 countries and territories from 1990 to 2020. In 1990, children and adolescents residing in cities were taller than their rural counterparts in all but a few high-income&nbsp;countries. By 2020, the urban height advantage became smaller in most countries, and in many high-income western countries it reversed into a small urban-based disadvantage. The exception was for boys in most countries in sub-Saharan Africa and in some countries in Oceania, south Asia and the region of central Asia, Middle East and north Africa. In these countries, successive cohorts of boys from rural places either did not gain height or possibly became shorter, and hence fell further behind their urban peers. The difference between the age-standardized mean BMI of children in urban and rural areas was &lt;1.1 kg m–2 in the vast majority of&nbsp;countries. Within this small range, BMI increased slightly more in cities than in rural areas, except in south Asia, sub-Saharan Africa and some countries in central and eastern Europe. Our results show that in much of the world, the growth and developmental advantages of living in cities have diminished in the twenty-first century, whereas in much of sub-Saharan Africa they have amplified

Repositioning of the global epicentre of non-optimal cholesterol

High blood cholesterol is typically considered a feature of wealthy western countries1,2. However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world3 and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health4,5. However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol—which is a marker of cardiovascular risk—changed from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million–4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world

Repositioning of the global epicentre of non-optimal cholesterol

High blood cholesterol is typically considered a feature of wealthy western countries(1,2). However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world(3) and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health(4,5). However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol-which is a marker of cardiovascular riskchanged from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million-4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.Peer reviewe