Summary Massive slums have become major features of cities in many low-income and middle-income countries. Here, in the first in a Series of two papers, we discuss why slums are unhealthy places with ...especially high risks of infection and injury. We show that children are especially vulnerable, and that the combination of malnutrition and recurrent diarrhoea leads to stunted growth and longer-term effects on cognitive development. We find that the scientific literature on slum health is underdeveloped in comparison to urban health, and poverty and health. This shortcoming is important because health is affected by factors arising from the shared physical and social environment, which have effects beyond those of poverty alone. In the second paper we will consider what can be done to improve health and make recommendations for the development of slum health as a field of study.
Summary In the first paper in this Series we assessed theoretical and empirical evidence and concluded that the health of people living in slums is a function not only of poverty but of intimately ...shared physical and social environments. In this paper we extend the theory of so-called neighbourhood effects. Slums offer high returns on investment because beneficial effects are shared across many people in densely populated neighbourhoods. Neighbourhood effects also help explain how and why the benefits of interventions vary between slum and non-slum spaces and between slums. We build on this spatial concept of slums to argue that, in all low-income and-middle-income countries, census tracts should henceforth be designated slum or non-slum both to inform local policy and as the basis for research surveys that build on censuses. We argue that slum health should be promoted as a topic of enquiry alongside poverty and health.
Summary Improvements in the control of haemorrhage after trauma have resulted in the survival of many people who would otherwise have died from the initial loss of blood. However, the danger is not ...over once bleeding has been arrested and blood pressure restored. Two-thirds of patients who die following major trauma now do so as a result of causes other than exsanguination. Trauma evokes a systemic reaction that includes an acute, non-specific, immune response associated, paradoxically, with reduced resistance to infection. The result is damage to multiple organs caused by the initial cascade of inflammation aggravated by subsequent sepsis to which the body has become susceptible. This Series examines the biological mechanisms and clinical implications of the cascade of events caused by large-scale trauma that leads to multiorgan failure and death, despite the stemming of blood loss. Furthermore, the stark and robust epidemiological finding—namely, that age has a profound influence on the chances of surviving trauma irrespective of the nature and severity of the injury—will be explored. Advances in our understanding of the inflammatory response to trauma, the impact of ageing on this response, and how this information has led to new and emerging treatments aimed at combating immune dysregulation and reduced immunity after injury will also be discussed.
Summary Background Increased mortality rates associated with weekend hospital admission (the so-called weekend effect) have been attributed to suboptimum staffing levels of specialist consultants. ...However, evidence for a causal association is elusive, and the magnitude of the weekend specialist deficit remains unquantified. This uncertainty could hamper efforts by national health systems to introduce 7 day health services. We aimed to examine preliminary associations between specialist intensity and weekend admission mortality across the English National Health Service. Methods Eligible hospital trusts were those in England receiving unselected emergency admissions. On Sunday June 15 and Wednesday June 18, 2014, we undertook a point prevalence survey of hospital specialists (consultants) to obtain data relating to the care of patients admitted as emergencies. We defined specialist intensity at each trust as the self-reported estimated number of specialist hours per ten emergency admissions between 0800 h and 2000 h on Sunday and Wednesday. With use of data for all adult emergency admissions for financial year 2013–14, we compared weekend to weekday admission risk of mortality with the Sunday to Wednesday specialist intensity ratio within each trust. We stratified trusts by size quintile. Findings 127 of 141 eligible acute hospital trusts agreed to participate; 115 (91%) trusts contributed data to the point prevalence survey. Of 34 350 clinicians surveyed, 15 537 (45%) responded. Substantially fewer specialists were present providing care to emergency admissions on Sunday (1667 11%) than on Wednesday (6105 42%). Specialists present on Sunday spent 40% more time caring for emergency patients than did those present on Wednesday (mean 5·74 h SD 3·39 vs 3·97 h 3·31); however, the median specialist intensity on Sunday was only 48% (IQR 40–58) of that on Wednesday. The Sunday to Wednesday intensity ratio was less than 0·7 in 104 (90%) of the contributing trusts. Mortality risk among patients admitted at weekends was higher than among those admitted on weekdays (adjusted odds ratio 1·10, 95% CI 1·08–1·11; p<0·0001). There was no significant association between Sunday to Wednesday specialist intensity ratios and weekend to weekday mortality ratios ( r −0·042; p=0·654). Interpretation This cross-sectional analysis did not detect a correlation between weekend staffing of hospital specialists and mortality risk for emergency admissions. Further investigation is needed to evaluate whole-system secular change during the implementation of 7 day services. Policy makers should exercise caution before attributing the weekend effect mainly to differences in specialist staffing. Funding National Institute for Health Research Health Services and Delivery Research Programme.
Abstract Background Matrix metalloproteinases (MMPs) are involved in acute myocardial dysfunction by degrading several intracellular contractile proteins, including cardiac troponin I (cTnI). Here, ...we examined the temporal profiles of MMPs and cTnI in plasma and myocardial tissue in the acute stage of subarachnoid hemorrhage (SAH). Materials and methods SAH was induced by the endovascular suture method in rats. Intracranial pressure and left ventricular (LV) function were recorded. Plasma cTnI and MMPs were measured at 0, 5, 15, 30, 60, 120, and 180 minutes after SAH. Myocardial cTnI and MMP activities were quantified at 30, 60 and 180 min after SAH from homogenized hearts. Results SAH-induced rats showed a marked decline in -LV dP/dtmax (index of LV diastolic function). Plasma samples revealed a noticeable increase in cTnI and pro-MMP-9 activities over the course of 180 minutes. In myocardial tissue, there was a marked increase in pro-MMP-9, pro-MMP-2 activities and expression of activated MMP-2. Western blot analysis revealed a striking decrease in cTnI content and increase in cTnI degradation in myocardium. Simultaneous cTnI depletion and MMP-2 expression in myocardium was detected by immunohistochemistry as early as 30 minutes after SAH. MMPs correlated with -LV dP/dtmax (% of baseline) both in plasma and in myocardial tissue. Furthermore, activated MMP-2 activity correlated positively with cTnI degradation in myocardium. Conclusions Early activation of MMPs was observed in myocardium and plasma following SAH. Activated MMP-2 may regulate proteolytic cTnI and contribute to myocardium stunning injury in SAH rats.
Background Limited data support the notion that lipid ratios are risk factors for nonalcoholic fatty liver disease (NAFLD). We evaluated the association between lipid ratios and NAFLD. Methods This ...was a large population, cross-sectional, retrospective study. Data on NAFLD severity, blood pressure, fasting glucose, total cholesterol (TC), triglyceride (TG), and high-density lipoprotein cholesterol (HDL-C) levels were obtained from 44,767 examinees at single health checkup center. The enrollees were stratified into four subgroups based on their TC/HDL-C and TG/HDL-C ratios. We used multivariate analyses to evaluate the odds between lipid ratios and NAFLD. Results The prevalence rate of fatty liver in this study was 53.76%. In the baseline subgroup with the lowest TC/HDL-C and TG/HDL-C ratios, the prevalence of NAFLD, hypertension, and diabetes was lower than that of the other three subgroups. Patients with higher lipid ratios had a significantly greater risk for advanced NAFLD. Conclusions Adults with high TC/HDL-C or TG/HDL-C ratios, or both, have a greater risk for NAFLD, especially advanced NAFLD.
Highlights • Perineural invasion is a poor prognostic feature for oral squamous cell carcinoma. • Pretreatment pain and clinical T stage are predictors of perineural invasion. • A regression equation ...was formed to predict the probability of perineural invasion.
Background Acute liver failure after major surgical procedures is associated with a high risk of multiple organ failure, including acute renal failure. The optimal time to initiate renal replacement ...therapy for acute renal failure is controversial because of the poor overall clinical outcomes. Study Design From July 2002 to January 2005, all patients who had no history of liver disease, but developed acute liver failure and subsequent renal failure requiring renal replacement therapy after major surgery, at a surgical intensive care unit, were retrospectively analyzed. Patients were divided into early or late dialysis groups based on an arbitrary blood urea nitrogen cut-off level of 80 mg/dL before renal replacement therapy. Results Eighty consecutive patients (21 women), with a mean age of 57.8 ± 17.0 (SD) years, comprised the study group. The late dialysis group (n = 26) had a higher ICU mortality rate (p = 0.02) and a lower renal function recovery rate (p = 0.02) than the early dialysis group (n = 54). Fifty-three (66.3%) patients died during their ICU stay. Independent risk factors for ICU mortality were renal replacement therapy modality (intermittent hemodialysis versus continuous venous-venous hemofiltration; odds ratio OR = 4.32, 95% CI 1.26 to 14.79; p = 0.02), predialysis APACHE II score > 20 (OR = 6.52, 95% CI 1.61 to 26.36; p < 0.01), and late dialysis (OR = 4.01, 95% CI 1.05 to 15.27; p = 0.04). Conclusions The mortality rate in postoperative patients with acute liver failure–associated acute renal failure was very high. Earlier initiation of renal replacement therapy, based on the predialysis blood urea nitrogen level, with continuous venous-venous hemofiltration might provide a better ICU survival rate.
To evaluate outcomes and predictive factors for additional ProGlide device deployment in percutaneous endovascular aortic repair (PEVAR) with the preclose technique.
Clinical data of patients who ...underwent PEVAR with the preclose technique from February 2012 to January 2015 were retrospectively reviewed. A total of 268 patients (229 men, 39 women) who underwent PEVAR (thoracic endovascular aortic repair TEVAR, n = 113; endovascular abdominal aortic repair EVAR, n = 152; simultaneous TEVAR and EVAR, n = 3) with 418 femoral access sites were enrolled. The mean age of the patients was 69 years ± 14. Univariate and multivariate analyses were performed to identify predictive factors associated with additional ProGlide device deployment.
Primary technical success with adequate hemostasis and two ProGlide devices was 87.6%, and 48 femoral arterial access sites (11.5%) required additional ProGlide device deployment. The secondary technical success rate was 99.0%. Four femoral access sites (1.0%) needed surgical repair. Anterior wall calcification near the arteriotomy increased the risk of additional ProGlide device deployment (adjusted odds ratio, 6.19; 95% confidence interval, 2.81-13.64; P < .001), whereas larger sheath size, common femoral artery (CFA) diameter, and depth from the skin to the arteriotomy did not.
Additional ProGlide device deployment reduces the rate of surgical repair after primary hemostasis failure in PEVAR. Anterior CFA wall calcification is a significant predictor for additional ProGlide device deployment.
Epicardial adipose tissue (EAT) is considered to play a role in the pathogenesis of coronary atherosclerosis. However, whether total EAT volume or location-specific EAT thickness may be a better ...predictor of obstructive coronary artery disease (CAD) is inconclusive. We investigated whether the total volume or location-specific thickness of EAT measured on computed tomography (CT) could be a useful marker of CAD on top of clinical risk factors and Agatston score. Two hundred eight consecutive subjects with clinical suspicion of CAD receiving coronary arterial calcium (CAC)–scoring CT and CT coronary angiography were retrospectively divided into 2 groups: an obstructive CAD group (n = 97) and a nonobstructive CAD group (n = 111). Total EAT volume and EAT thicknesses at different locations were measured on CAC-scoring CT. Left atrioventricular groove (AVG) EAT thickness was the sole EAT measurement that showed association with increasing number of vessels exhibiting ≥50% stenosis (p for trend <0.001). Logistic regression showed that left AVG EAT thickness was the most important EAT predictor of obstructive CAD (odds ratio 1.16, 95% confidence interval 1.04 to 1.29, p = 0.006; optimal threshold ≥15 mm, odds ratio 4.62, 95% confidence interval 2.24 to 9.56, p <0.001). Adding left AVG EAT thickness on top of clinical risk factors plus Agatston score improved prediction of obstructive CAD (area under the curve from 0.848 to 0.912, p = 0.002). In conclusion, excessive left AVG EAT adiposity is an important risk factor for obstructive CAD, independent of clinical risk factors and Agatston score. However, further trials are needed in investigation of combined assessment of location-specific EAT thickness and Agatston score on CAC scan as to whether this biomarker could improve CAD risk stratification in the general population.
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