The relationship between peri-operative systemic inflammation and survival in patients with abdominal aortic aneurysm

Objective: An association between pre-operative markers of systemic inflammation and inferior mortality following AAA repair has been observed. The prognostic value of the post-operative inflammatory response remains unreported in patients with AAA. The present study aimed to describe the association between the peri-operative inflammatory response & mortality in patients undergoing endovascular aneurysm repair (EVAR) and open surgical repair (OSR) for infrarenal AAA. Materials & Methods: Consecutive patients undergoing either emergency (EVAR or OSR) or elective (OSR) intervention for infrarenal AAA were retrospectively recruited from 3 centres. Pre-operative systemic inflammation was assessed using the modified Glasgow Prognostic Score (mGPS). Post-operative day 3 CRP (≤ 300mg/L, > 300mg/L) was chosen as the covariate of interest. The primary outcome was thirty-day mortality in the emergency cohort and twelve-month mortality in the elective cohort. Results: There were 167 emergency cases (120 (72%) OSR) and 207 elective (207 (100%) OSR) cases, with a median (IQR) follow-up of 85 (52) months in the emergency cohort and 63 (57) months in the elective cohort. There were 56% vs. 44% of patients in the emergency cohort day 3 CRP ≤300mg/l vs. >300mg/L compared with 82% vs. 18% of patients in the elective cohort (p < 0.001). On univariate binary logistic regression analyses in the emergency cohort, open repair (p < 0.05), pre-operative mGPS 2 (p < 0.05), post-operative mesenteric ischaemia (p < 0.01), and day 3 post-operative CRP > 300mg/L (p < 0.05) were associated with increased odds of thirty-day mortality. On multivariate binary logistic regression analyses, only pre-operative mGPS 2 (OR 2.11, 95% CI 1.12 – 3.98, p < 0.05) retained independent association with thirty-day mortality. In the elective cohort, mean (95% CI) survival in the day 3 CRP ≤300mg/l vs. >300mg/L was 112.0 (101.8 – 122.2) months vs. 67.2 (54.1 – 80.2) months (p < 0.001). On univariate binary logistic regression analyses in the elective cohort, age ≥ 75 (p < 0.05), ischaemic heart disease (p < 0.05), and day 3 post-operative CRP > 300mg/L (p < 0.001) were associated with increased odds of twelve-month mortality. On multivariate binary logistic regression analyses, both age ≥ 75 (OR 5.15, 95% CI 1.25 – 21.30, p < 0.05) and day 3 post-operative CRP > 300mg/L (OR 15.68, 95% CI 3.61 – 68.15, p < 0.001) retained independent association with twelve-month mortality. Conclusions: Pre- and post-operative markers of systemic inflammation were independently associated with inferior survival following emergency and elective repair of AAA respectively. Further investigation of the peri-operative systemic inflammatory response is warranted in this patient group, with a particular focus on identifying targets for intervention

Evaluation of the prognostic value of computed tomography-derived body composition in patients undergoing endovascular aneurysm repair

Background: Endovascular aneurysm repair (EVAR) is the most common mode of repair of abdominal aortic aneurysms (AAA) in the UK. EVAR ranges from standard infrarenal repair to complex fenestrated and branched EVAR (F/B-EVAR). Sarcopenia is defined by lower muscle mass and function, which is associated with inferior perioperative outcomes. Computed tomography-derived body composition analysis offers prognostic value in patients with cancer. Several authors have evaluated the role of body composition analysis in predicting outcomes in patients undergoing EVAR; however, the evidence base is limited by heterogeneous methodology. Methods: Six hundred seventy-four consecutive patients (58 (8.6%) female, mean (SD) age 74.4 (6.8) years) undergoing EVAR and F/B-EVAR at three large tertiary centres were retrospectively recruited. Subcutaneous and visceral fat indices (SFI and VFI), psoas and skeletal muscle indices, and skeletal muscle density were measured at the L3 vertebral level from pre-operative computed tomographies. The maximally selected rank statistic technique was used to define optimal thresholds to predict mortality. Results: There were 191 deaths during the median follow-up period of 60.0 months. Mean (95% CI) survival in the low SMI versus high SMI subgroups was 62.6 (58.5–66.7) versus 82.0 (78.7–85.3) months (P < 0.001). Mean (95% CI) survival in the low SFI versus high SFI subgroups was 56.4 (48.2–64.7) versus 77.1 (74.2–80.1) months (P < 0.001). One-year mortality in the low SMI versus high SMI subgroups was 10% versus 3% (P < 0.001). Low SMI was associated with increased odds of one-year mortality (OR 3.19, 95% CI 1.60–6.34, P < 0.001). Five-year mortality in the low SMI versus high SMI subgroups was 55% versus 28% (P < 0.001). Low SMI was associated with increased odds of five-year mortality (OR 1.54, 95% CI 1.11–2.14, P < 0.01). On multivariate analysis of all patients, low SFI (HR 1.90, 95% CI 1.30–2.76, P < 0.001) and low SMI (HR 1.88, 95% CI 1.34–2.63, P < 0.001) were associated with poorer survival. On multivariate analysis of asymptomatic AAA patients, low SFI (HR 1.54, 95% CI 1.01–2.35, P < 0.05) and low SMI (HR 1.71, 95% CI 1.20–2.42, P < 0.01) were associated with poorer survival. Conclusions: Low SMI and SFI are associated with poorer long-term survival following EVAR and F/B-EVAR. The relationship between body composition and prognosis requires further evaluation, and external validation of the thresholds proposed in patients with AAA is required

Human Security of Urban Migrant Populations Affected by Length of Residence and Environmental Hazards

It is widely suggested that migration is a key mechanism linking climate change to violent conflict, particularly through migration increasing the risks of conflict in urban destinations. Yet climate change also creates new forms of insecurity through distress migration, immobility and vulnerability that are prevalent in urban destination locations. Here we examine the extent and nature of human security in migration destinations and test whether insecurity is affected by length of residence and environmental hazards. The study develops an index measure of human security at the individual level to include environmental and climate-related hazards as well as sources of well-being, fear of crime and violence, and mental health outcomes. It examines the elements of human security that explain the prevalence of insecurity among recent and established migrants in low-income urban neighbourhoods. The study reports on data collected in Chattogram in Bangladesh through a survey of migrants (N ¼ 447) and from qualitative data derived using photo elicitation techniques with cohorts of city planners and migrants. The results show that environmental hazards represent an increasing source of perceived insecurity to migrant populations over time, with longer-term migrants perceiving greater insecurity than more recent arrivals, suggesting lack of upward social mobility in low-income slums. Ill-health, fear of eviction, and harassment and violence are key elements of how insecurity is experienced, and these are exacerbated by environmental hazards such as flooding. The study expands the concept of security to encompass central elements of personal risk and well-being and outlines the implications for climate change

Globalized Climate Precarity: Environmental Degradation, Disasters, and the International Brick Trade

The final version. Available on open access from Routledge via the DOI in this recordClimate-linked disasters result when natural hazards meet socioeconomic precarity. Recognizing this, scholarship in recent years has emphasized how the precarity that turns climate-linked hazards into disasters is produced within the same global political economy that enables climate change. Nevertheless, despite growing interest in the ways in which the dynamics of global economic history shapes contemporary hazard vulnerability, less attention has been directed toward the dynamism of the contemporary global economy and particularly the ways in which global material flows shape environmental risk. From this standpoint, this article argues, first, the need to account for the economic dynamics of global trade in shaping the factors that intensify disaster risk, and second, the role of multiscalar agency. Exemplifying this issue through a case study of international brick imports from South Asia to the United Kingdom, the article provides a heuristic example of how contemporary globalized flows of goods link local vulnerabilities to economic processes originating thousands of miles away. In an increasingly globalized world, it thus foregrounds a dynamic, global perspective on the genus of climate precarity.SRC-FCDO Development Frontiers Grant ProgramBritish Academ

Accuracy of high resolution computed tomography in pre-operative acquired cholesteatoma

Objective: To determine the accuracy of high resolution computed tomography (HRCT) for diagnosis of acquired cholesteatoma using histopathological finding as gold standard. Materials and Methods: This cross section study of 61 patients, males and females with ages between 10- 35 years was carried out in the department of radiology, Dr Ziauddin Hospital Karachi, from November 2008 to April 2009. Patients clinically diagnosed as having cholesteotoma were referred for scanning. They were selected according to inclusion criteria. Patients were scanned using HRCT technique. Non dependent soft tissue density attenuation mass associated bony erosion in the middle ear/external ear was considered as radiological positive case of cholesteatoma while dependent soft tissue attenuation mass without bony erosion was considered radiologically negative case for Cholesteatoma. Keratinized stratified squamous epithelium with keratin debris and an underline sub-epithelial fibro connective tissue associated bone resorption in it were considered histopathologically positive case for cholesteatoma and without bony resorption were considered negative. Results: Out of 61 patients of clinically diagnosed acquired cholesteatoma 37(60.7%) were males and 24(39.3%) were females. 34(55.5%) patients showed right sided and 27(44.2%) left side temporal bone involvement. Mean age of patients was 22.93 years (SD±8.29). Sensitivity of HRCT technique was 96.4 %, specificity of 80%, positive predictive value of 98.18% and negative predictive value of 67 %. Conclusion: High resolution computed tomography (HRCT) technique is found to have accuracy for diagnosis of pre-operative acquired cholesteatoma using histopathological finding as gold standard

Age and BMI Adjusted Comparison of Reproductive Hormones in PCOS

Objective and Background: Polycystic ovary syndrome (PCOS) is a complex condition and has been described in women who have polycystic ovaries as the underlying cause of hirsutism and chronic anovulation. Studies on PCOS in the Saudi population are very few. The aim of this study was to investigate the reproductive hormones levels in patients with PCOS. Effect of age and body mass index (BMI) on the hormonal findings was eliminated through a multivariate analysis. Materials and Methods: A comparative study was conducted on Saudi subjects attending the outpatient clinic of National Guard Hospital in Riyadh. A total of 62 cases with PCOS and 40 healthy Saudi women were included in this study. Physical evaluation and laboratory investigations were carried out. Blood luteinizing hormone (LH), follicle stimulating hormone (FSH), estradiol (E2), dehydroepiandrosterone sulfate (DHEA-SO 4 ), sex hormone-binding globulin (SHBG), total testosterone, prolactin, and progesterone were determined. To adjust for the potentially confounding effect of age and BMI, we carried out multivariate linear regression analyses for the association between each of the reproductive hormones and PCOS. Results: Serum levels of FSH, SHBG, and progesterone were significantly lower in PCOS compared to controls (respective P values 0.001, 0.001, and 0.002), while LH/FSH and testosterone levels were higher in PCOS cases than in controls (P = 0.008 and 0.003, respectively). When multivariate linear regression analyses were carried out, LH/FSH and total testosterone were positively correlated with the disease [95% confidence interval (CI) = 0.02-0.35 and 0.02-0.17, respectively], whereas FSH, SHBG, and progesterone were negatively correlated with the disease (95% CI = -0.06 to 0.001, -0.01 to 0.001, and -0.17 to -0.03, respectively), independent of age and BMI. Conclusion: Our study suggests that regardless of the age and weight factors, Saudi patients with PCOS have higher levels of LH/FSH and total testosterone; but have lower levels of FSH, SHBG, and progesterone compared to controls

Trading disaster: Containers and container thinking in the production of climate precarity

Abstract: This paper examines how global trade shapes and intensifies disasters. Juxtaposing three basic, everyday consumer goods – a t‐shirt, a brick, and a tea bag – with disasters manifesting in their respective global supply chains, it highlights how climate change, local environmental degradation, and carbon emissions are dynamically shaped by consumption. Analysis of data collected in South and Southeast Asia reveals that local environmental degradation linked to international trade interacts with global climate change and the policies intended to mitigate it, influencing how and where disasters manifest. Underpinning this analysis is the physical and conceptual presence of the container. With more and more of the natural environment packaged and redistributed for global trade, the container thinking that underpins these logistics is increasingly imbricated in environmental processes. Indeed, as this paper aims to show, the container logic that frames analysis of these processes – linked to and drawn from the logistics of global trade – serves as both obfuscator and actor in the global landscape of environmental risk

The Relationship Between CT-derived Cervical Muscle Mass and Quality, Systemic Inflammation, and Survival in Symptomatic Patients Undergoing Carotid Endarterectomy

Objective Patient selection remains important in the management of symptomatic carotid stenoses. Sarcopenia and chronic inflammation confer an inferior long-term prognosis in atherosclerotic disease. The present study aims to describe the prognostic role of sarcopenia, assessed by computed tomography (CT)-derived body composition analysis and inflammation in patients undergoing carotid endarterectomy for symptomatic carotid stenosis. Methods Patients undergoing carotid endarterectomy for symptomatic carotid stenosis at four tertiary referral centers were retrospectively included. Sternocleidomastoid and paravertebral muscle areas were measured and normalized to height to generate the C3 muscle index (C3MI), and C3 muscle density (C3MD) was also recorded. Systemic inflammation was assessed by the pre-operative systemic inflammatory grade (SIG). Results A total of 459 patients were included. Median (interquartile range) follow-up was 78 (43) months, and there were 146 deaths during the follow-up period. Low C3MI was associated with female sex (p < 0.001), transient ischemic attack at presentation (p < 0.05), and SIG ≥ 2 (p < 0.05). Low C3MD was associated with age ≥ 75 (p < 0.01), female sex (p < 0.001), and American Society of Anesthesiology (ASA) classification > 2 (p <0.01). Patients with normal C3MI & SIG = 0 had a mean (95% CI) survival of 116.1 (107.8–124.4) months, compared with 67.8 (51.3–84.2) months in patients with low C3MI & SIG ≥ 2 (p < 0.001). Patients with normal C3MD & SIG = 0 had a mean (95% CI) survival of 114.4 (107.0–121.8) months, compared with 39.2 (25.9–52.5) months in patients with low C3MD & SIG ≥ 2 (p < 0.001). On univariate analysis, age ≥ 75 (p < 0.001), ASA > 2 (p < 0.001), low C3MI (p < 0.01), low C3MD (p < 0.001), and SIG (p < 0.001) were associated with increased mortality. On multivariate analysis, age ≥ 75 (hazard ratio [HR]: 2.14; 95% CI: 1.52–3.01; p < 0.001), ASA > 2 (HR: 1.80; 95% CI: 1.14–2.83; p < 0.05), low C3MD (HR: 1.82; 95% CI: 1.27–2.62; p < 0.01), and SIG (HR: 1.61; 95% CI: 1.29–2.01; p < 0.001) were independently associated with increased mortality. Conclusion Cervical CT-derived muscle mass and density, and markers of inflammation such as SIG may be used to identify patients with inferior prognosis following carotid endarterectomy