Climate change is the greatest existential challenge to planetary and human health and is dictated by a shift in the Earth's weather and air conditions owing to anthropogenic activity. Climate change ...has resulted not only in extreme temperatures, but also in an increase in the frequency of droughts, wildfires, dust storms, coastal flooding, storm surges and hurricanes, as well as multiple compound and cascading events. The interactions between climate change and health outcomes are diverse and complex and include several exposure pathways that might promote the development of non-communicable diseases such as cardiovascular disease. A collaborative approach is needed to solve this climate crisis, whereby medical professionals, scientific researchers, public health officials and policymakers should work together to mitigate and limit the consequences of global warming. In this Review, we aim to provide an overview of the consequences of climate change on cardiovascular health, which result from direct exposure pathways, such as shifts in ambient temperature, air pollution, forest fires, desert (dust and sand) storms and extreme weather events. We also describe the populations that are most susceptible to the health effects caused by climate change and propose potential mitigation strategies, with an emphasis on collaboration at the scientific, governmental and policy levels.
Previous studies have identified potential clinical applications for 18F-NaF PET imaging across a range of cardiovascular conditions including atherosclerosis, aortic stenosis, aortic prosthetic ...valve degeneration, cardiac amyloidosis, peripheral vascular disease, erectile dysfunction and AAA disease.6 In the SoFIA3 Study of 72 patients with AAA and aortic diameter >4.0 cm, in vivo 18F-NaF binding was increased in AAAs compared with non-aneurysmal aortic regions and control subjects, and ex vivo uptake localised to areas of active calcification confirmed by histology.7 Moreover, aneurysms with the highest 18F-NaF uptake demonstrated 2.5 times greater risk of expansion and were 3 times more likely to rupture or require repair than the those with the lowest PET uptake, independent of aneurysm diameter and other clinical risk factors. Besides the need for further validation in a larger cohort, the effect of attenuation artefact caused by metallic stent graft material on PET signal quantification requires careful attention, as does the potential impact of 18F-NaF signal spillover in anatomical regions of the abdominal aorta that are close to the spine. ...follow-up PET imaging was performed more than 5 years after intervention and was not well aligned with clinical follow-up. ...it is difficult to know whether the observed reduction in tracer activity in the stented aorta was due to early vascular remodelling in response to stent graft placement, sac shrinkage or another cause. ...while thoracic aortic calcium score increased ~3-fold over the follow-up years, change in aneurysmal aortic CT calcium score (which has known prognostic implications9) could not be measured because of interference from the AAA stent and so its relationship with 18F-NaF binding also remains unclear.
The association of coronary arterial calcification with cardiovascular morbidity and mortality is well-recognized. Lower limb arterial calcification (LLAC) is common in PAD but its impact on ...subsequent health is poorly described. We aimed to determine the association between a LLAC score and subsequent cardiovascular events in patients with symptomatic peripheral arterial disease (PAD).
LLAC scoring, and the established Bollinger score, were derived from a database of unenhanced CT scans, from patients presenting with symptomatic PAD. We determined the association between these scores outcomes. The primary outcome was combined cardiac mortality and morbidity (CM/M) with a secondary outcome of all-cause mortality.
220 patients (66% male; median age 69 years) were included with follow-up for a median 46 IQR 31-64 months. Median total LLAC scores were higher in those patients suffering a primary outcome (6831 vs. 1652; p = 0.012). Diabetes mellitus (p = 0.039), ischaemic heart disease (p = 0.028), chronic kidney disease (p = 0.026) and all-cause mortality (p = 0.012) were more common in patients in the highest quartile of LLAC scores. The area under the curve of the receiver operator curve for the LLAC score was greater (0.929: 95% CI 0.884-0.974) than for the Bollinger score (0.824: 95% CI 0.758-0.890) for the primary outcome. A LLAC score ≥ 4400 had the best diagnostic accuracy to determine the outcome measure.
This is the largest study to investigate links between lower limb arterial calcification and cardiovascular events in symptomatic PAD. We describe a straightforward, reproducible, CT-derived measure of calcification-the LLAC score.
The quality of patient information relating to intermittent claudication (IC) and peripheral arterial disease (PAD) on the World Wide Web was assessed.
The quality of websites and YouTube videos was ...assessed using the search terms “intermittent claudication” and “peripheral arterial disease”. The first 50 hits screened for each search term from the three largest search engines by market share, and the first 20 videos from YouTube were screened. Website quality was scored using the University of Michigan Consumer Health Website tool (maximum score 80). Readability was calculated using the Flesch Reading Ease (FRE) score (maximum score 100). Videos were classified by content and upload source. Video reliability was assessed using the JAMA benchmark criteria. Video educational content was assessed using the Global Quality Score (GQS). Subjective content assessment was undertaken.
Seventy-six websites were analysed. The majority of websites for both IC (51.7%) and PAD (72.3%) were rated as weak. The median Michigan score for IC (27; interquartile range IQR 15, 32.5) was lower that the score for PAD (31; IQR 25.5, 38.8; p = .030). The majority of websites for both IC (69%) and PAD (68.1%) were rated as requiring an above average reading level. The overall median FRE score was 55.9 (IQR 46.6, 60.6) for IC and 55.3 (IQR 44.6, 59.3) for PAD. Twenty-two videos were analysed. Of the 14 videos evaluated as part of the PAD search, the median JAMA score was 2 (2 – 3), the median GQS score was 3 (3 – 3) and the evaluation of content score was 8.5 (7.25 – 11.5). The equivalent scores for the IC search were 2 (2 – 2), 3 (3 – 4), and 5.5 (5 – 8).
The educational quality and reliability of information both in written and video form on the internet is low. Attention needs to focus on improving the quality of all forms of information delivery to allow proper advocacy for patients.
Statin therapy is indicated in patients with peripheral arterial disease (PAD). National Institute for Health and Care Excellence guidelines suggest the use of “high intensity” statins, although ...evidence with PAD specific data are lacking. The effect of statin therapy and dose on outcomes in PAD is investigated.
Studies measuring statin use in PAD patients and outcomes were identified based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The EMBASE and MEDLINE databases were interrogated from January 1957 until February 2020. Twenty-two observational cohort studies and two randomised control trials were included (n = 268 611).
Pooled estimates of dichotomous outcome data were calculated using the odds/hazard ratios (OR/HR) and 95% confidence interval (CI). Meta-analysis was conducted using the inverse variance or Mantel–Haenszel method. Outcomes included all cause mortality (ACM), cardiovascular mortality (CVM), major adverse cardiac events (MACE), and amputation. Subgroup analysis was performed on studies comparing patients taking high dose vs. combined low and moderate doses of statins. The GRADE criteria assessed the quality of evidence for outcomes.
Statin therapy (vs. no statins) was significantly protective for ACM: OR 0.68 (95% CI 0.60 – 0.76) (number needed to treat NNT = 48), HR 0.74 (95% CI 0.70 – 0.78) (NNT = 10 – 91); MACE: OR 0.84 (95% CI 0.78 – 0.92) (NNT = 53), HR 0.78 (95% CI 0.65 – 0.93) (NNT = 167); and amputations: OR 0.59 (95% CI 0.33 – 1.07) (NNT = 333), HR 0.74 (95% CI 0.62 – 0.89) (NNT = 50). High doses of statins (vs. combined low and moderate doses) were significantly better protective against ACM OR 0.69 (95% CI 0.43 – 1.09) (NNT = 17), HR 0.74 (95% CI 0.62 – 0.89) (NNT = 16 – 200) but work less significantly for MACE OR 0.77 (95% CI 0.49 – 1.21) (NNT = 25). Amputations were less frequent in patients on high doses HR 0.78 (95% CI 0.69 – 0.90) (NNT = 53 – 1 000).
Higher dosing of statins confers a significant improvement in patient outcomes, especially ACM and amputations, although the quality of the evidence was variable. Such findings require confirmation in larger, PAD specific trials.
Radiomics, quantitative feature extraction from radiological images, can improve disease diagnosis and prognostication. However, radiomic features are susceptible to image acquisition and ...segmentation variability. Ideally, only features robust to these variations would be incorporated into predictive models, for good generalisability. We extracted 93 radiomic features from carotid artery computed tomography angiograms of 41 patients with cerebrovascular events. We tested feature robustness to region-of-interest perturbations, image pre-processing settings and quantisation methods using both single- and multi-slice approaches. We assessed the ability of the most robust features to identify culprit and non-culprit arteries using several machine learning algorithms and report the average area under the curve (AUC) from five-fold cross validation. Multi-slice features were superior to single for producing robust radiomic features (67 vs. 61). The optimal image quantisation method used bin widths of 25 or 30. Incorporating our top 10 non-redundant robust radiomics features into ElasticNet achieved an AUC of 0.73 and accuracy of 69% (compared to carotid calcification alone AUC: 0.44, accuracy: 46%). Our results provide key information for introducing carotid CT radiomics into clinical practice. If validated prospectively, our robust carotid radiomic set could improve stroke prediction and target therapies to those at highest risk.
Objective Strategies to improve outcomes for patients with ruptured abdominal aortic aneurysm (rAAA) are becoming more evident. The aging population, however, continues to make the decision to ...intervene often difficult, especially given that traditional risk models do not reflect issues of aging and frailty. This study aimed to integrate measures of function alongside comorbidity- and frailty-specific factors to determine outcome. Methods Patients treated for a rAAA between January 2006 and April 2014 were assessed. Demographics, mortality, and requirement for care after discharge as well as a variety of measures of function (physical, social, and psychological) and comorbidity were recorded. The primary outcome was 1-year mortality. Outcome models were generated using multivariate logistic regression and were compared with models of vascular frailty and AAA-related outcome. Results Of 184 patients treated, 108 (59%) underwent an open surgical repair. The overall 30-day and 1-year mortality were 21.5% and 31.4%, respectively, with an overall median hospital length of stay of 13 days (interquartile range, 6-27 days). An optimal logistic regression model for 12-month mortality used Katz score, Charlson score, number of admission medicines, visual impairment, hearing impairment, hemoglobin level, and statin use as predictors, achieving an area under the receiver operating characteristic curve of 0.84. Conclusions This novel rAAA model incorporating function and comorbidity offers good predictive power for mortality. It is quick to calculate and may ultimately become helpful for both counseling and selection of patients and comparative audit at a time when outcome in patients with rAAA increasingly comes under the spotlight.
Atherosclerosis is a leading cause of morbidity and mortality. It is now widely recognized that the disease is more than simply a flow-limiting process and that the atheromatous plaque represents a ...nidus for inflammation with a consequent risk of plaque rupture and atherothrombosis, leading to myocardial infarction or stroke. However, widely used conventional clinical imaging techniques remain anatomically focused, assessing only the degree of arterial stenosis caused by plaques. Positron emission tomography (PET) has allowed the metabolic processes within the plaque to be detected and quantified directly. The increasing armory of radiotracers has facilitated the imaging of distinct metabolic aspects of atherogenesis and plaque destabilization, including macrophage-mediated inflammatory change, hypoxia, and microcalcification. This imaging modality has not only furthered our understanding of the disease process in vivo with new insights into mechanisms but has also been utilized as a non-invasive endpoint measure in the development of novel treatments for atherosclerotic disease. This review provides grounding in the principles of PET imaging of atherosclerosis, the radioligands in use and in development, its research and clinical applications, and future developments for the field.
This research work investigates the erosion effect on the surfaces of SS (Stainless Steel) 201, SS 304, SS 316 and SS 420 under different operating conditions. Beside this, the novelty of this work ...is to observe the combined effects of different percentage of SiC- Al2O3-Fe2O3 solid particles on the surfaces of these materials and significant findings are obtained.
The results collected from this study are validated with the morphological analysis of erosive surfaces which is attributed to the real wear mechanism. To characterize the eroded surfaces, this mechanism is associated with the micro-cutting, micro-plowing, plastic deformation and several other materials removal processes.
During the experiments, the impact angles are maintained at 15°, 30°, 45°, 60°, 75° and 90°. The erosion rate is higher at 60° impact angle and then the abrasion is sharply decreased up to up to 90°. However, the erosion varies differently with the variation of impact angles for different tested materials. The erosion rates under impact velocity 40, 50 and 60 m/s are tested. The higher the impact velocity, the higher the erosion rate is noted despite the levels of erosion changes are different for different materials. The enhancement of erosion with the impact velocity is linked with the increase of kinetic energy which in turn is responsible for the increase of temperature. The combined impact of kinetic energy and temperature effects the location of the examined surfaces of stainless steels. But as the stainless steels have the better mechanical and physical properties, these show better erosion resistance in comparison of other polymer and composite materials.
It is also observed the higher test duration and larger particle size have some role to increase the erosion rate. The results of this work are compared with the works of other researchers and the trends of these results are explained with the possible causes. The results of this work can be used as a reliable source for the applications of advanced technology in industry.
Display omitted
•The combined effects of SiC- Al2O3-Fe2O3 solid particles on erosion of stainless steels.•Erosion rates are observed on the basis of % variation of silica sand (SiC), Al2O3 and Fe2O3.•The relation between different operating parameters with erosion is evaluated.•Obtained results can be used for future mechanical and tribological processes.
Debate surrounds the optimal management of superficial femoral artery (SFA) disease. Randomized trial data rarely reflect real world findings, specifically the consequences to the patient of ...angioplasty failure. We observed the effect of a failed SFA angioplasty on the need for repeated clinic visits, hospital readmissions, imaging requirements, and reinterventions.
We reviewed a consecutive series of 148 patients (94 men, median age 72 years) undergoing solely SFA angioplasty over a 2-year period. Patient preangioplasty demographics and 2-year post-PTA follow-up data were collated, including hospital attendances (inpatient/outpatient), further imaging (including radiation exposure) and revascularization attempts. We defined "failed angioplasty" as presence of clinical symptoms with radiological evidence of significant restenosis after an initial successful primary SFA angioplasty.
Fifty-four patients represented with a failed angioplasty (median time of 4 months after index PTA). In this group, failure of index angioplasty resulted in a further 185 restenosis-related clinic visits and a total of 537 bed days of inpatient stay. This group underwent a further 149 imaging events and required a further 34 endovascular revascularization procedures and 12 infrainguinal bypass procedures. These interventions and investigations corresponded to overall effective radiation dose across all patients of 190.69 mSv. Of the cohort of 99 patients who did not have a "failed angioplasty," they required 100 clinic visits, 21 further scans (total radiation dose 6.42 mSv), and 36 bed days of inpatient admission.
Failed angioplasty results in significant additional consequences for patients and health-care systems. Further work should focus on refining decision-making, providing the right procedure to the right patient at the right time.
PDF
