Defining health and health inequalities

Objectives: To examine existing definitions of health and health inequalities and to synthesise the most useful of these using explicit rationale and the most parsimonious text. Study design: Literature review and synthesis. Methods: Existing definitions of health and health inequalities were identified, and their normative properties were extracted and then critically appraised. Using explicit reasoning, new definitions, synthesising the most useful aspects of existing definitions, were created. Results: A definition of health as a structural, functional and emotional state that is compatible with effective life as an individual and as a member of society and a definition of health inequalities as the systematic, avoidable and unfair differences in health outcomes that can be observed between populations, between social groups within the same population or as a gradient across a population ranked by social position are proposed. Population health is a less commonly used term but can usefully be defined to encompass the average, distribution and inequalities in health within a society. Conclusions: Clarifying what is meant by the terms health and health inequalities, and the assumptions, emphasis and values that different definitions contain, is important for public health research, practice and policy

Magnetic Stress at the Marginally Stable Orbit: Altered Disk Structure, Radiation, and Black Hole Spin Evolution

Magnetic connections to the plunging region can exert stresses on the inner edge of an accretion disk around a black hole. We recompute the relativistic corrections to the thin-disk dynamics equations when these stresses take the form of a time-steady torque on the inner edge of the disk. The additional dissipation associated with these stresses is concentrated relatively close outside the marginally stable orbit, scaling as r to the -7/2 at large radius. As a result of these additional stresses: spin-up of the central black hole is retarded; the maximum spin-equilibrium accretion efficiency is 36%, and occurs at a/M=0.94; the disk spectrum is extended toward higher frequencies; line profiles (such as Fe K-alpha) are broadened if the line emissivity scales with local flux; limb-brightening, especially at the higher frequencies, is enhanced; and the returning radiation fraction is substantially increased, up to 58%. This last effect creates possible explanations for both synchronized continuum fluctuations in AGN, and polarization rises shortward of the Lyman edge in quasars. We show that no matter what additional stresses occur, when a/M < 0.36, the second law of black hole dynamics sets an absolute upper bound on the accretion efficiency.Comment: 11 pages, 15 figures, accepted for publication in the Astrophysical Journa

Mycotic renal artery degeneration and systemic sepsis caused by infected renal artery stent

AbstractA case of Staphylococcus aureus renal artery stent infection was studied. Fourteen days after the procedure, the patient had a fever, hypotension, and an elevated white blood cell (WBC) count. Blood cultures were positive for S aureus on admission and during the patient's hospitalization, despite intravenous vancomycin therapy. Evaluation included serial CT scans, revealing increasing persistent inflammation with development of multiple renal intraparenchymal abscesses, and arteriography, showing marked degeneration of the renal artery. Therapy required resection of the renal artery/stent and nephrectomy. This case confirms the severe nature of S aureus stent infection; we recommend prophylactic antibiotics before these procedures, as well as expeditious evaluation and consideration for aggressive surgical therapy if this complication is suspected. (J Vasc Surg 1998;28:547-50.

Resident Corneal Cells Communicate with Neutrophils Leading to the Production of IP-10 during the Primary Inflammatory Response to HSV-1 Infection

In this study we show that murine and human neutrophils are capable of secreting IP-10 in response to communication from the HSV-1 infected cornea and that they do so in a time frame associated with the recruitment of CD8+ T cells and CXCR3-expressing cells. Cellular markers were used to establish that neutrophil influx corresponded in time to peak IP-10 production, and cellular depletion confirmed neutrophils to be a significant source of IP-10 during HSV-1 corneal infection in mice. A novel ex vivo model for human corneal tissue infection with HSV-1 was used to confirm that cells resident in the cornea are also capable of stimulating neutrophils to secrete IP-10. Our results support the hypothesis that neutrophils play a key role in T-cell recruitment and control of viral replication during HSV-1 corneal infection through the production of the T-cell recruiting chemokine IP-10

Efficiency of Electron-Positron Pair Productionby Neutrino Flux from Accretion Disk of a Kerr Black Hole

Dominant processes of neutrino production and neutrino-induced \ep-pair production are examined in the model of a disk hyper-accreting onto a Kerr black hole. The efficiency of plasma production by a neutrino flux from the disk, obtained for the both cases of presence and absence of a magnetic field, is found to be no more than several tenths of percent and, therefore, not enough for the origin of cosmological gamma-ray bursts.Comment: 8 pages, 1 figur

Advection-Dominated Accretion Model of Sagittarius A*: Evidence for a Black Hole at the Galactic Center

Sgr A* at the Galactic Center is a puzzling source. It has a mass M=(2.5+/-0.4) x 10^6 solar masses which makes it an excellent black hole candidate. Observations of stellar winds and other gas flows in its vicinity suggest a mass accretion rate approximately few x 10^{-6} solar masses per year. However, such an accretion rate would imply a luminosity > 10^{40} erg/s if the radiative efficiency is the usual 10 percent, whereas observations indicate a bolometric luminosity <10^{37} erg/s. The spectrum of Sgr A* is unusual, with emission extending over many decades of wavelength. We present a model of Sgr A* which is based on a two-temperature optically-thin advection-dominated accretion flow. The model is consistent with the estimated mass and accretion rate, and fits the observed fluxes in the cm/mm and X-ray bands as well as upper limits in the sub-mm and infrared bands; the fit is less good in the radio below 86 GHz and in gamma-rays above 100 MeV. The very low luminosity of Sgr A* is explained naturally in the model by means of advection. Most of the viscously dissipated energy is advected into the central mass by the accreting gas, and therefore the radiative efficiency is extremely low, approximately 5 x 10^{-6}. A critical element of the model is the presence of an event horizon at the center which swallows the advected energy. The success of the model could thus be viewed as confirmation that Sgr A* is a black hole.Comment: 41 pages (Latex) including 6 Figures and 2 Tables. Final Revised Version changes to text, tables and figures. ApJ, 492, in pres

Are BMI and inflammatory markers independently associated with physical fatigability in old age?

Background: Obesity and chronic low-grade inflammation have both been implicated in the onset of physical fatigue. However, few studies have investigated the independence of these associations in older community-dwelling populations. We therefore aimed to investigate the associations of body mass index (BMI) and inflammatory markers at age 60–64 with perceived physical fatigability at age 68 and to assess whether any such associations were independent of each other and potential confounding factors. A secondary aim was to investigate whether any association with BMI extended back into earlier adulthood. // Methods: Participants of the MRC National Survey of Health and Development (N = 1580) had BMI and levels of interleukin-6 (IL-6) and C-reactive protein (CRP) measured during clinical assessments at age 60–64. These were related to self-perceived physical fatigability assessed at age 68 using the Pittsburgh Fatigability Scale (PFS) (total score:0 (no physical fatigue)–50 (extreme physical fatigue)). // Results: Women had higher mean PFS scores than men (mean (SD): 16.0 (9.1) vs 13.2 (8.9), p < 0.01). In sex-adjusted models, BMI, CRP and IL-6 were each associated with PFS scores. When all three factors were included in the same model, BMI and IL-6 remained associated with PFS scores whereas CRP did not. After adjustment for a range of potential confounders, associations of BMI and IL-6 with PFS scores were still evident; fully adjusted differences in mean PFS score = 3.41 (95% CI: 0.59, 6.24) and 1.65 (0.46, 2.84) for underweight and obese participants when compared with normal weight and, 2.78 (1.65, 3.91) when comparing those with an IL-6 of 2.51–8.49 pg/mL with levels <1.50. // Conclusions: BMI and inflammation may both be suitable targets for intervention to reduce the burden of physical fatigability in later life. Further, interventions that target both obesity and elevated levels of IL-6 are likely to be more effective than those focusing on only one

Plasma phenoloxidase of the larval tobacco budworm, Heliothis virescens, is virucidal

Heliothis virescens larval plasma contains high levels of an antiviral activity against the budded form of the Helicoverpa zea single nucleopolyhedrovirus (HzSNPV) in vitro. Preliminary results indicated that phenoloxidase is primarily responsible for this virucidal effect. However it is known that other enzymes that generate antimicrobial reactive oxygen intermediates and reactive nitrogen intermediates are present in hemolymph that could contribute to the observed virucidal activity. To elucidate the contributions of phenoloxidase and other candidate activities to plasma innate immune response against baculovirus infection specific metabolic inhibitors were used. In vitro the general inhibitors of melanization (N-acetyl cysteine, ascorbate and glutathione), and specific inhibitors of phenoloxidase (phenylthiourea and Kojic acid), completely blocked virucidal activity up to the level seen in controls. Addition of the enzyme superoxide dismutase to plasma did not affect virucidal activity; however addition of catalase had an inhibitory effect. Inhibitors of nitric oxide synthase activity did not affect virucidal activity. Our results confirm that phenoloxidase is the predominate activity in larval plasma accounting for inactivation of Hz SNPV in vitro, and that phenoloxidase-dependent H2O2 production may contribute to this virucidal activity

Revisiting vertical structure of neutrino-dominated accretion disks: Bernoulli parameter, neutrino trapping and other distributions

We revisit the vertical structure of neutrino dominated accretion flows (NDAFs) in spherical coordinates with a new boundary condition based on the mechanical equilibrium. The solutions show that NDAF is significantly thick. The Bernoulli parameter and neutrino trapping are determined by the mass accretion rate and the viscosity parameter. According to the distribution of the Bernoulli parameter, the possible outflow may appear in the outer region of the disk. The neutrino trapping can essentially affect the neutrino radiation luminosity. The vertical structure of NDAF is like a "sandwich", and the multilayer accretion may account for the flares in gamma-ray bursts.Comment: 7 pages, 2 figures, Accepted for publication in Astrophysics & Space Scienc

Developing and validating subjective and objective risk-assessment measures for predicting mortality after major surgery: An international prospective cohort study

Background: Preoperative risk prediction is important for guiding clinical decision-making and resource allocation. Clinicians frequently rely solely on their own clinical judgement for risk prediction rather than objective measures. We aimed to compare the accuracy of freely available objective surgical risk tools with subjective clinical assessment in predicting 30-day mortality. Methods and findings: We conducted a prospective observational study in 274 hospitals in the United Kingdom (UK), Australia, and New Zealand. For 1 week in 2017, prospective risk, surgical, and outcome data were collected on all adults aged 18 years and over undergoing surgery requiring at least a 1-night stay in hospital. Recruitment bias was avoided through an ethical waiver to patient consent; a mixture of rural, urban, district, and university hospitals participated. We compared subjective assessment with 3 previously published, open-access objective risk tools for predicting 30-day mortality: the Portsmouth-Physiology and Operative Severity Score for the enUmeration of Mortality (P-POSSUM), Surgical Risk Scale (SRS), and Surgical Outcome Risk Tool (SORT). We then developed a logistic regression model combining subjective assessment and the best objective tool and compared its performance to each constituent method alone. We included 22,631 patients in the study: 52.8% were female, median age was 62 years (interquartile range [IQR] 46 to 73 years), median postoperative length of stay was 3 days (IQR 1 to 6), and inpatient 30-day mortality was 1.4%. Clinicians used subjective assessment alone in 88.7% of cases. All methods overpredicted risk, but visual inspection of plots showed the SORT to have the best calibration. The SORT demonstrated the best discrimination of the objective tools (SORT Area Under Receiver Operating Characteristic curve [AUROC] = 0.90, 95% confidence interval [CI]: 0.88–0.92; P-POSSUM = 0.89, 95% CI 0.88–0.91; SRS = 0.85, 95% CI 0.82–0.87). Subjective assessment demonstrated good discrimination (AUROC = 0.89, 95% CI: 0.86–0.91) that was not different from the SORT (p = 0.309). Combining subjective assessment and the SORT improved discrimination (bootstrap optimism-corrected AUROC = 0.92, 95% CI: 0.90–0.94) and demonstrated continuous Net Reclassification Improvement (NRI = 0.13, 95% CI: 0.06–0.20, p < 0.001) compared with subjective assessment alone. Decision-curve analysis (DCA) confirmed the superiority of the SORT over other previously published models, and the SORT–clinical judgement model again performed best overall. Our study is limited by the low mortality rate, by the lack of blinding in the ‘subjective’ risk assessments, and because we only compared the performance of clinical risk scores as opposed to other prediction tools such as exercise testing or frailty assessment. Conclusions: In this study, we observed that the combination of subjective assessment with a parsimonious risk model improved perioperative risk estimation. This may be of value in helping clinicians allocate finite resources such as critical care and to support patient involvement in clinical decision-making