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Al-Kindi SG, Shami B, Janus SE, Hajjari J, Mously H, Badhwar A, Chami T, Chahine N, Al-Jammal M, Karnib M, Noman A, Bunte MC. Retrospective Analysis of Ethnic/Racial Disparities and Excess Vascular Mortality Associated with the COVID-19 Pandemic. Curr Probl Cardiol 2024:102763. [PMID: 39059784 DOI: 10.1016/j.cpcardiol.2024.102763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Accepted: 07/23/2024] [Indexed: 07/28/2024]
Abstract
The Sars coronavirus 2019 (COVID-19) pandemic has resulted in increased morbidity and mortality; however, there is limited understanding of how excess mortality is distributed among different racial and ethnic subgroups and vascular diseases. METHODS We conducted a retrospective, cross-sectional study design using data from the United States (US) Center for Disease Control (CDC) Wide Ranging Online Data for Epidemiologic Research (Wonder) database. The database contains death certificate information for all US residents by cause of death as ascertained by the treating physician. We examined the trends of excess death by vascular disease specific mortality among different racial and ethnicity subgroups. Excess deaths were defined as the difference between observed numbers of deaths in specific time periods and the expected numbers of deaths in the same time periods. We compared mortality rates during the reference period of 2018-2019 (pre-pandemic) with the study period of 2020-2021 (pandemic years). We also compared excess mortality rates among racial and ethnic subgroups (Non-Hispanic white, Non-Hispanic Black, and Hispanic individuals). Vascular disease was categorized by administrative diagnostic codes (ICD10): Vascular disease (I26, I82, I70-73, I74) and its subtypes Arterial thrombosis (I74), venous thromboembolism (I26, I82) and atherosclerotic disease (I70-73). RESULTS Compared to 2018-2019, there was a 1.3% excess mortality associated with vascular disease, a 12.2% excess mortality due to arterial thrombosis mortality, and an 8.0% excess mortality due to thromboembolism in 2020-2021. Black individuals demonstrated higher excess vascular mortality (6.9%) compared to white individuals (-0.3%) P<.001, higher excess venous thromboembolism mortality (14.1% vs 5.1% P=0.002) and higher atherosclerosis mortality (2.1% vs -2.6% P=0.002). Hispanics compared to white individuals had higher excess vascular mortality (5.1% vs -0.3% P=0.03) and excess venous thromboembolism mortality (24.2% vs 5.1% P<0.001). CONCLUSION The COVID-19 pandemic has led to a significant and persistent increase in vascular mortality. Excess mortality has disproportionately affected Black and Hispanic individuals compared to white individuals, highlighting the need for further studies to address and eliminate these health care disparities.
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Affiliation(s)
| | | | | | | | | | - Anshul Badhwar
- Marin Health, University of San Francisco, San Francisco, California
| | - Tarek Chami
- First Coast Cardiovascular Institute, Jacksonville, Florida
| | | | | | | | - Anas Noman
- St Luke's Mid America, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Matthew C Bunte
- St Luke's Mid America, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.
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Xu W, Haran C, Dean A, Lim E, Bernau O, Mani K, Khanafer A, Pitama S, Khashram M. Acute aortic syndrome: nationwide study of epidemiology, management, and outcomes. Br J Surg 2023; 110:1197-1205. [PMID: 37303206 PMCID: PMC10416687 DOI: 10.1093/bjs/znad162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/03/2023] [Accepted: 05/07/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Epidemiological studies on acute aortic syndrome (AAS) have relied largely on unverified administrative coding, leading to wide-ranging estimates of incidence. This study aimed to evaluate the incidence, management, and outcomes of AAS in Aotearoa New Zealand. METHODS This was a national population-based retrospective study of patients presenting with an index admission of AAS from 2010 to 2020. Cases from the Ministry of Health National Minimum Dataset, National Mortality Collection, and the Australasian Vascular Audit were cross-verified with hospital notes. Poisson regression adjusted for sex and age was used to investigate trends over time. RESULTS During the study interval, 1295 patients presented to hospital with confirmed AAS, including 790 with type A (61.0 per cent) and 505 with type B (39.0 per cent) AAS. A total of 290 patients died out of hospital between 2010 and 2018. The overall incidence of aortic dissection including out-of-hospital cases was 3.13 (95 per cent c.i. 2.96 to 3.30) per 100 000 person-years, and this increased by an average of 3 (95 per cent c.i. 1 to 6) per cent per year after adjustment for age and sex adjustment on Poisson regression, driven by increasing type A cases. Age-standardized rates of disease were higher in men, and in Māori and Pacific populations. The management strategies used, and 30-day mortality rates among patients with type A (31.9 per cent) and B (9.7 per cent) disease have remained constant over time. CONCLUSION Mortality after AAS remains high despite advances over the past decade. The disease incidence and burden are likely to continue to increase with an ageing population. There is impetus now for further work on disease prevention and the reduction of ethnic disparities.
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Affiliation(s)
- William Xu
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Cheyaanthan Haran
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Anastasia Dean
- Department of Vascular Surgery, Auckland City Hospital, Auckland, New Zealand
| | - Eric Lim
- Department of Vascular Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Oliver Bernau
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Kevin Mani
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Adib Khanafer
- Department of Vascular Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Suzanne Pitama
- Māori/Indigenous Health Institute, University of Otago, Christchurch, New Zealand
| | - Manar Khashram
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
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Song P, He Y, Adeloye D, Zhu Y, Ye X, Yi Q, Rahimi K, Rudan I. The Global and Regional Prevalence of Abdominal Aortic Aneurysms: A Systematic Review and Modeling Analysis. Ann Surg 2023; 277:912-919. [PMID: 36177847 PMCID: PMC10174099 DOI: 10.1097/sla.0000000000005716] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate the global and regional prevalence and cases of abdominal aortic aneurysms (AAAs) in 2019 and to evaluate major associated factors. BACKGROUND Understanding the global prevalence of AAA is essential for optimizing health services and reducing mortality from reputed AAA. METHODS PubMed, MEDLINE, and Embase were searched for articles published until October 11, 2021. Population-based studies that reported AAA prevalence in the general population, defined AAA as an aortic diameter of 30 mm or greater with ultrasonography or computed tomography. A multilevel mixed-effects meta-regression approach was used to establish the relation between age and AAA prevalence for high-demographic sociodemographic index and low-and middle-sociodemographic index countries. Odds ratios of AAA associated factors were pooled using a random-effects method. RESULTS We retained 54 articles across 19 countries. The global prevalence of AAA among persons aged 30 to 79 years was 0.92% (95% CI, 0.65-1.30), translating to a total of 35.12 million (95% CI, 24.94-49.80) AAA cases in 2019. Smoking, male sex, family history of AAA, advanced age, hypertension, hypercholesterolemia, obesity, cardiovascular disease, cerebrovascular disease, claudication, peripheral artery disease, pulmonary disease, and renal disease were associated with AAA. In 2019, the Western Pacific region had the highest AAA prevalence at 1.31% (95% CI, 0.94-1.85), whereas the African region had the lowest prevalence at 0.33% (95% CI, 0.23-0.48). CONCLUSIONS A substantial proportion of people are affected by AAA. There is a need to optimize epidemiological studies to promptly respond to at-risk and identified cases to improve outcomes.
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Affiliation(s)
- Peige Song
- School of Public Health and Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yazhou He
- Department of Oncology, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Davies Adeloye
- Centre for Global Health Research, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Yuefeng Zhu
- Department of Vascular Surgery, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Vascular Surgery, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, China
| | - Xinxin Ye
- School of Public Health and Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qian Yi
- School of Public Health and Women’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Kazem Rahimi
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK
- Deep Medicine Programme, Oxford Martin School, University of Oxford, Oxford, UK
| | - Igor Rudan
- Centre for Global Health Research, Usher Institute, University of Edinburgh, Edinburgh, UK
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Gormley S, Bernau O, Xu W, Sandiford P, Khashram M. Incidence and Outcomes of Abdominal Aortic Aneurysm Repair in New Zealand from 2001 to 2021. J Clin Med 2023; 12:jcm12062331. [PMID: 36983332 PMCID: PMC10054325 DOI: 10.3390/jcm12062331] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/08/2023] [Accepted: 03/12/2023] [Indexed: 03/19/2023] Open
Abstract
Purpose: The burden of abdominal aortic aneurysms (AAA) has changed in the last 20 years but is still considered to be a major cause of cardiovascular mortality. The introduction of endovascular aortic repair (EVAR) and improved peri-operative care has resulted in a steady improvement in both outcomes and long-term survival. The objective of this study was to identify the burden of AAA disease by analysing AAA-related hospitalisations and deaths. Methodology: All AAA-related hospitalisations in NZ from January 2001 to December 2021 were identified from the National Minimum Dataset, and mortality data were obtained from the NZ Mortality Collection dataset from January 2001 to December 2018. Data was analysed for patient characteristics including deprivation index, repair methods and 30-day outcomes. Results: From 2001 to 2021, 14,436 patients with an intact AAA were identified with a mean age of 75.1 years (SD 9.7 years), and 4100 (28%) were females. From 2001 to 2018, there were 5000 ruptured AAA with a mean age of 77.8 (SD 9.4), and 1676 (33%) were females. The rate of hospitalisations related to AAA has decreased from 43.7 per 100,000 in 2001 to 15.4 per 100,000 in 2018. There was a higher proportion of rupture AAA in patients living in more deprived areas. The use of EVAR for intact AAA repair has increased from 18.1% in 2001 to 64.3% in 2021. The proportion of octogenarians undergoing intact AAA repair has increased from 16.2% in 2001 to 28.4% in 2021. The 30-day mortality for intact AAA repair has declined from 5.8% in 2001 to 1.7% in 2021; however, it has remained unchanged for ruptured AAA repair at 31.6% across the same period. Conclusions: This study highlights that the incidence of AAA has declined in the last two decades. The mortality has improved for patients who had a planned repair. Understanding the contemporary burden of AAA is paramount to improve access to health, reduce variation in outcomes and promote surgical quality improvement.
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Affiliation(s)
- Sinead Gormley
- Department of Vascular & Endovascular Surgery, Waikato Hospital, Hamilton 3204, New Zealand
- Faculty of Medical & Health Sciences, University of Auckland, Auckland 1010, New Zealand
| | - Oliver Bernau
- Faculty of Medical & Health Sciences, University of Auckland, Auckland 1010, New Zealand
| | - William Xu
- Faculty of Medical & Health Sciences, University of Auckland, Auckland 1010, New Zealand
| | - Peter Sandiford
- Planning Funding and Outcomes Unit, Auckland and Waitemata District Health Boards, Auckland 1010, New Zealand
- School of Population Health, University of Auckland, Auckland 1010, New Zealand
| | - Manar Khashram
- Department of Vascular & Endovascular Surgery, Waikato Hospital, Hamilton 3204, New Zealand
- Faculty of Medical & Health Sciences, University of Auckland, Auckland 1010, New Zealand
- Correspondence:
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Lim WB, Robertson FP, Nayar MK, Sharp L, Nandhra S, Pandanaboyana S. Social deprivation does not impact on acute pancreatitis severity and mortality: a single-centre study. BMJ Open Gastroenterol 2023; 10:bmjgast-2022-001035. [PMID: 36746520 PMCID: PMC9906294 DOI: 10.1136/bmjgast-2022-001035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 01/19/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND AIMS The incidence of acute pancreatitis (AP) is increasing in the UK. Patients with severe AP require a significant amount of resources to support them during their admission. The ability to predict which patients will develop multiorgan dysfunction remains poor leading to a delay in the identification of these patients and a window of opportunity for early intervention is missed. Social deprivation has been linked with increased mortality across surgical specialties. Its role in predicting mortality in patients with AP remains unclear but would allow high-risk patients to be identified early and to focus resources on high-risk populations. METHODS A prospectively collected single-centre database was analysed. English Index of Multiple Deprivation (IMD) was calculated based on postcode. Patients were grouped according to their English IMD quintile. Outcomes measured included all-cause mortality, Intestive care unit (ITU) admission, overall length of stay (LOS) and local pancreatitis-specific complications. RESULTS 398 patients with AP between 2018 and 2021 were identified. There were significantly more patients with AP in Q1 (IMD 1-2) compared with Q5 (IMD 9-10) (156 vs 38, p<0.001). Patients who were resident in the most deprived areas were significantly younger (52.4 in Q1 vs 65.2 in Q5, p<0.001), and more often smokers (39.1% in Q1 vs 23.7% in Q5, p=0.044) with IHD (95.0% vs 92.1% in Q5, p<0.001). In multivariate modelling, there was no significance difference in pancreatitis-related complications, number of ITU visits, number of organs supported and overall, LOS by IMD quintile. CONCLUSIONS Although there was a significantly higher number of patients admitted to our unit with AP from the most socially deprived quintiles, there was no correlation between social economic deprivation and mortality following AP.
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Affiliation(s)
- Wei Boon Lim
- Department of HPB and Transplant Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Francis P Robertson
- Department of HPB and Transplant Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Manu K Nayar
- Department of HPB and Transplant Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Linda Sharp
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Sandip Nandhra
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK,Department of Vascular surgery, Freeman Hospital, Newcastle upon Tyne, UK
| | - Sanjay Pandanaboyana
- Department of HPB and Transplant Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK .,Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Maheswaran R, Tong T, Michaels J, Brindley P, Walters S, Nawaz S. Socioeconomic disparities in abdominal aortic aneurysm repair rates and survival. Br J Surg 2022; 109:958-967. [PMID: 35950728 PMCID: PMC10364757 DOI: 10.1093/bjs/znac222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 05/23/2022] [Accepted: 05/29/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Abdominal aortic aneurysm (AAA) is more prevalent in socioeconomically disadvantaged areas. This study investigated socioeconomic disparities in AAA repair rates and survival. METHODS The study used ecological and cohort study designs, from 31 672 census areas in England (April 2006 to March 2018), the Index of Multiple Deprivation 2010 as the area-level deprivation indicator, and Poisson, logistic and Cox regression. RESULTS Some 77 606 patients (83.4 per cent men) in four age categories (55-64, 65-74, 75-84, 85 or more years) were admitted with AAA from a population aged at least 55 years of 14.7 million. Elective open and endovascular repair rates were 41 (95 per cent c.i. 23 to 61) and 60 (36 to 89) per cent higher respectively among men aged 55-64 years in the most versus least deprived areas by quintile. This differences diminished and appeared to reverse with increasing age, with 26 (-1 to 45) and 25 (13 to 35) per cent lower rates respectively in men aged 85 years or more in the most deprived areas. Men admitted from more deprived areas were more likely to die in hospital without aneurysm repair. Among those who had aneurysm repair, this was more likely to be for a ruptured aneurysm than among men from less deprived areas. For intact aneurysm repair, they were relatively more likely to have this during an emergency admission. The mortality rate after repair was higher for men from more deprived areas, although the hazard diminished with age. Patterns were unclear for women. CONCLUSION There were clear socioeconomic disparities in operation rates, mode of presentation, and outcome for AAA surgery. Policies are needed to address these disparities.
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Affiliation(s)
- Ravi Maheswaran
- Correspondence to: Ravi Maheswaran, Public Health, School of Health and Related Research, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK (e-mail: )
| | - Thaison Tong
- School of Health and Related Research, University of Sheffield, UK
| | - Jonathan Michaels
- Clinical Decision Science, School of Health and Related Research, University of Sheffield, UK
| | - Paul Brindley
- Department of Landscape Architecture, University of Sheffield, Sheffield, UK
| | - Stephen Walters
- Medical Statistics and Clinical Trials, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Shah Nawaz
- Sheffield Vascular Institute, Sheffield Teaching Hospitals NHS Foundation Trust, UK
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Kessler V, Klopf J, Eilenberg W, Neumayer C, Brostjan C. AAA Revisited: A Comprehensive Review of Risk Factors, Management, and Hallmarks of Pathogenesis. Biomedicines 2022; 10:94. [PMID: 35052774 PMCID: PMC8773452 DOI: 10.3390/biomedicines10010094] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/30/2021] [Indexed: 01/27/2023] Open
Abstract
Despite declining incidence and mortality rates in many countries, the abdominal aortic aneurysm (AAA) continues to represent a life-threatening cardiovascular condition with an overall prevalence of about 2-3% in the industrialized world. While the risk of AAA development is considerably higher for men of advanced age with a history of smoking, screening programs serve to detect the often asymptomatic condition and prevent aortic rupture with an associated death rate of up to 80%. This review summarizes the current knowledge on identified risk factors, the multifactorial process of pathogenesis, as well as the latest advances in medical treatment and surgical repair to provide a perspective for AAA management.
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Affiliation(s)
| | | | | | | | - Christine Brostjan
- Department of General Surgery, Division of Vascular Surgery, Medical University of Vienna, Vienna General Hospital, 1090 Vienna, Austria; (V.K.); (J.K.); (W.E.); (C.N.)
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8
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Choudhury E, Rammell J, Dattani N, Williams R, McCaslin J, Prentis J, Nandhra S. Social Deprivation and the Association With Survival Following Fenestrated Endovascular Aneurysm Repair. Ann Vasc Surg 2021; 82:276-283. [PMID: 34785337 DOI: 10.1016/j.avsg.2021.10.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/06/2021] [Accepted: 10/06/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Social deprivation is associated with poor clinical outcomes. It is known to have an impact on length of stay and post-operative mortality across a number of other surgical specialties. This study evaluates the impact of social deprivation on outcomes following fenestrated endovascular aneurysm repair (FEVAR). METHODS All elective FEVARs performed between 2010 and 2018 at a tertiary vascular center were analyzed. Deprivation (index of multiple deprivation [IMD]) data was sourced from the English indices of deprivation 2019, by postcode. Primary outcome was overall survival by Kaplan-Meier. Secondary outcomes included length of hospital stay (LOS) and complications. Cox-proportional hazard analyses were conducted. RESULTS Some 132 FEVAR patients were followed-up for 3.7 (SD 2.2) years. Fifty-seven patients lived in areas with high levels of deprivation (IMD 1-3), 34 in areas with moderate deprivation (IMD 4-6) and 41 in areas with the lowest level (IMD 7-10) of deprivation. Groups were comparable for Age, BMI, AAA diameter and co-morbidity. A higher proportion of patients from deprived areas had renal failure (15% [26.3%] vs. 9% [11.8%] P = 0.019) but no overall difference in procedure time was observed (200 min [155-250] vs. 180 min [145-240] P = 0.412). Kaplan-Meier analysis demonstrated significantly poorer survival for patients living in areas with high levels of deprivation (IMD 1-3) (P = 0.03). Mortality was comparable for IMD 4-6 and 7-10 groups. Patients from the most deprived areas had longer hospital stay (6 days [4-9] vs. 5 [3-7] P = 0.005) and higher all-cause complication rates (21 [36.8%] vs. 14 [18.4%] P = 0.02). Decreasing IMD was associated with worse survival (HR -0.85 [0.75-0.97] [P = 0.02]). CONCLUSIONS Social deprivation was associated with increased mortality, length of stay and all-cause complication rates in patients undergoing FEVAR for complex abdominal aortic aneurysm (AAA). These results may help direct preoptimization measures to improve outcomes in higher risk sub-groups.
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Affiliation(s)
- Ehsanul Choudhury
- Northern Vascular Centre, Freeman Hospital, Newcastle-upon-Tyne Hospitals, Newcastle, UK; Department of Anaesthesia, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Freeman Road, Newcastle upon Tyne, UK
| | - James Rammell
- Northern Vascular Centre, Freeman Hospital, Newcastle-upon-Tyne Hospitals, Newcastle, UK; Department of Anaesthesia, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Freeman Road, Newcastle upon Tyne, UK
| | - Nikesh Dattani
- Northern Vascular Centre, Freeman Hospital, Newcastle-upon-Tyne Hospitals, Newcastle, UK; Department of Anaesthesia, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Freeman Road, Newcastle upon Tyne, UK
| | - Robin Williams
- Northern Vascular Centre, Freeman Hospital, Newcastle-upon-Tyne Hospitals, Newcastle, UK; Interventional Radiology, Northern Vascular Centre, Freeman Hospital, Newcastle-upon-Tyne Hospitals, Newcastle, UK
| | - James McCaslin
- Department of Anaesthesia, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Freeman Road, Newcastle upon Tyne, UK; Interventional Radiology, Northern Vascular Centre, Freeman Hospital, Newcastle-upon-Tyne Hospitals, Newcastle, UK
| | - James Prentis
- Department of Anaesthesia, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Freeman Road, Newcastle upon Tyne, UK; Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Sandip Nandhra
- Northern Vascular Centre, Freeman Hospital, Newcastle-upon-Tyne Hospitals, Newcastle, UK; Department of Anaesthesia, Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Freeman Road, Newcastle upon Tyne, UK; Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle, UK.
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9
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Xu W, Mani K, Khashram M. Ethnic differences in incidence and outcomes of acute aortic syndromes in the Midland region of New Zealand. J Vasc Surg 2021; 75:455-463.e2. [PMID: 34506891 DOI: 10.1016/j.jvs.2021.08.066] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 08/11/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Disparities in cardiovascular disease according to socioeconomic factors and ethnicity are a global issue. The indigenous Māori population of New Zealand is not exempt. The aims of the present study were to assess whether ethnic disparities exist in the presentation and outcomes of acute aortic syndrome (AAS), including aortic dissection, intramural hematoma, and penetrating aortic ulcer, in New Zealand. METHODS A retrospective observational cohort study of consecutive AAS patients presenting to a tertiary referral center covering the Midland region of New Zealand (population, 816,900; 23.3% Māori) during a 10-year period was completed (2010-2020). Data were assessed by ethnicity (Māori vs non-Māori) and Stanford classification of AAS. The incidence of disease, 30-day mortality, and long-term all-cause and aortic-related mortality were recorded and assessed using logistic regression and Cox proportional hazards models. RESULTS A total of 250 patients had presented with AAS (Māori, 92 [36.8%]; type A, 144 [57.6%]). The age-standardized rates of AAS were higher in Māori than in non-Māori patients (6.9/100,000 person-years vs 2.0/100,000 person-years; risk ratio, 3.56; 95% confidence interval, 1.50-8.53; P = .002). Māori patients had presented at a younger age for both type A (age, 54.4 ± 12 years vs 66.0 ± 13.2 years; P < .001) and type B (age, 61.3 ± 10.2 years vs 68.8 ± 13.7 years; P = .005) AAS. Mortality at 30 days was higher for those with type A than for those with type B AAS (33.3% vs 13.2%; P < .001) but did not differ by ethnicity in our cohort. On multivariate analysis, no differences were found in 30-day or long-term survival when stratified by ethnicity. CONCLUSIONS The results from the present study have demonstrated that ethnic disparities in AAS exist in New Zealand, with Māori presenting at a younger age and with a greater incidence compared with other ethnicities. Whether this disparity is related to socioeconomic factors, access to preventive care, or other factors remains to be elucidated. Despite these differences in disease presentation, the survival outcomes when stratified by ethnicity were comparable in the present cohort.
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Affiliation(s)
- William Xu
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Kevin Mani
- Department of Surgery, University of Auckland, Auckland, New Zealand; Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Manar Khashram
- Department of Surgery, University of Auckland, Auckland, New Zealand; Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand.
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10
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Distressed Communities Index in Patients Undergoing Transcatheter Aortic Valve Implantation in an Affluent County in New York. J Interv Cardiol 2021; 2021:8837644. [PMID: 34497479 PMCID: PMC8407997 DOI: 10.1155/2021/8837644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 07/07/2021] [Accepted: 08/13/2021] [Indexed: 12/30/2022] Open
Abstract
Background The clinical impact of the distressed communities index (DCI), a composite measure of economic well-being based on the U.S. zip code, is becoming increasingly recognized. Ranging from 0 (prosperous) to 100 (distressed), DCI's association with cardiovascular outcomes remains unknown. We aimed to study the association of the DCI with presentation and outcomes in adults with severe symptomatic aortic stenosis (AS) undergoing transcatheter aortic valve intervention (TAVR) in an affluent county in New York. Methods The study population included 286 patients with severe symptomatic AS or degeneration of a bioprosthetic valve who underwent TAVR with a newer generation transcatheter heart valve (THV) from December 2015 to June 2018 at an academic tertiary medical center. DCI for each patient was derived from their primary residence zip code. Patients were classified into DCI deciles and then categorized into 4 groups. The primary and secondary outcomes of interest were 30-day, 1-year, and 3-year mortality, respectively. Results Among 286 patients studied, 26%, 28%, 28%, and 18% were categorized into DCI groups 1–4, respectively (DCI <10: n = 73; DCI 10–20: n = 81; DCI 20–30: n = 80; DCI >30: n = 52). Patients in group 4 were younger with worse kidney function compared to patients in groups 1 and 2. They also had smaller aortic annuli and were more likely to receive a smaller THV. No significant difference in hospital length of stay or distribution of in-hospital, 30-day, 1-year, and 3-year mortality was demonstrated. Conclusions While the DCI was associated with differences in the clinical and anatomic profile, it was not associated with differences in clinical outcomes in this prospective observational study of adults undergoing TAVR suggesting that access to care is the likely discriminator.
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Mohan IV, Khashram M, Fitridge R. Vascular Surgery in Australia and New Zealand (Australasia). Eur J Vasc Endovasc Surg 2021; 62:338-339. [PMID: 34294507 DOI: 10.1016/j.ejvs.2021.06.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 06/14/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Irwin V Mohan
- Westmead Hospital, University of Sydney, Sydney, Australia.
| | - Manar Khashram
- Waikato Hospital & Senior Lecturer, University of Auckland, Auckland, New Zealand
| | - Robert Fitridge
- Vascular Surgeon Royal Adelaide Hospital and Discipline of Surgery, University of Adelaide, Adelaide, Australia
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12
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Kim JY, Boyle L, Khashram M, Campbell D. Editor's Choice - Development and Validation of a Multivariable Prediction Model of Peri-operative Mortality in Vascular Surgery: The New Zealand Vascular Surgical Risk Tool (NZRISK-VASC). Eur J Vasc Endovasc Surg 2021; 61:657-663. [PMID: 33423913 DOI: 10.1016/j.ejvs.2020.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 11/12/2020] [Accepted: 12/09/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Risk calculators and prediction models are available to assist clinicians and patients with peri-operative decision making to optimise outcomes. In a vascular surgical setting, the majority of these models is based on open AAA repair outcomes, and in general their clinical use is limited. The objective of this study was to develop and validate a simple and accurate vascular surgical risk prediction model. METHODS A national administrative database was accessed to collect information on all adult patients undergoing vascular surgery between 1 July 2011 and 30 June 2016 in New Zealand. The primary outcomes were mortality at 30 days, one year, and two years. Previously established covariables including American Society of Anaesthesiologists (ASA) physical status score, sex, surgical urgency, cancer status and ethnicity were tested, and other covariables such as smoking status, presence of renal failure, diabetes, anatomical site of operation, structure operated, and type of procedures (open or endovascular) were explored. LASSO regression was used to select variables for inclusion in the model. RESULTS A total of 21 597 cases formed the final risk prediction models, with covariables including ASA score, gender, surgical urgency, cancer status, presence of renal failure, diabetes, anatomical site, structure operated, and endovascular procedure. The area under the receiver operating curve (AUROC) for 30 day, one year, and two year mortality using L-min model was 0.869, 0.833, and 0.824, respectively, demonstrating very good discrimination. Calibration with the validation dataset was also excellent, with slopes of 0.971, 1.129, and 1.011, respectively, and McFadden's pseudo-R2 statistics of 0.250, 0.227, and 0.227, respectively. CONCLUSION A simple and accurate multivariable risk calculator for vascular surgical patients was developed and validated using the New Zealand national dataset, with excellent discrimination and calibration for 30 day, one year, and two year mortality.
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Affiliation(s)
- Jee Young Kim
- Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand.
| | - Luke Boyle
- Orion Health, Auckland, New Zealand; Department of Statistics, University of Auckland, Auckland, New Zealand
| | - Manar Khashram
- Department of Surgery, University of Auckland, Auckland, New Zealand; Department of Vascular surgery, Waikato Hospital, Hamilton, New Zealand
| | - Doug Campbell
- Department of Anaesthesia and Perioperative Medicine, Auckland City Hospital, Auckland, New Zealand
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13
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Grima MJ, Behrendt CA, Vidal-Diez A, Altreuther M, Björck M, Boyle JR, Eldrup N, Karthikesalingam A, Khashram M, Loftus I, Schermerhorn M, Setacci C, Szeberin Z, Debus S, Venermo M, Holt P, Mani K. Editor's Choice - Assessment of Correlation Between Mean Size of Infrarenal Abdominal Aortic Aneurysm at Time of Intact Repair Against Repair and Rupture Rate in Nine Countries. Eur J Vasc Endovasc Surg 2020; 59:890-897. [PMID: 32217115 DOI: 10.1016/j.ejvs.2020.01.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 12/16/2019] [Accepted: 01/17/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE This study aimed to analyse the mean abdominal aortic aneurysm (AAA) diameter for repair in nine countries, and to determine variation in mean AAA diameter for elective AAA repair and its relationship to rupture AAA repair rates and aneurysm related mortality in corresponding populations. METHODS Data on intact (iAAA) and ruptured infrarenal AAA (rAAA) repair for the years 2010-2012 were collected from Denmark, England, Finland, Germany, Hungary, New Zealand, Norway, Sweden, and the USA. The rate of iAAA repair and rAAA per 100 000 inhabitants above 59 years old, mean AAA diameter for iAAA repair and rAAA repair, and the national rates of rAAA were assessed. National cause of death statistics were used to estimate aneurysm related mortality. Direct standardisation methods were applied to the national mortality data. Logistic regression and analysis of variance model adjustments were made for age groups, sex, and year. RESULTS There was a variation in the mean diameter of iAAA repair (n = 34 566; range Germany = 57 mm, Denmark = 68 mm). The standardised iAAA repair rate per 100000 inhabitants varied from 10.4 (Hungary) to 66.5 (Norway), p<.01, and the standardised rAAA repair rate per 100 000 from 5.8 (USA) to 16.9 (England), p<.01. Overall, there was no significant correlation between mean diameter of iAAA repair and standardised iAAA rate (r2 = 0.04, p = .3). There was no significant correlation between rAAA repair rate (n = 12 628) with mean diameter of iAAA repair (r2 = 0.2, p = .1). CONCLUSION Despite recommendations from learned society guidelines, data indicate variations in mean diameter for AAA repair. There was no significant correlation between mean diameter of AAA repair and rates of iAAA repair and rAAA repair. These analyses are subject to differences in disease prevalence, uncertainties in rupture rates, validations of vascular registries, causes of death and registrations.
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Affiliation(s)
- Matthew J Grima
- St George's Vascular Institute, St George's Hospital NHS Foundation Trust, London, UK; Molecular and Clinical Sciences Research Institute, St George's, University of London, UK.
| | - Christian-Alexander Behrendt
- Department of Vascular Medicine, Research Group GermanVasc, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Alberto Vidal-Diez
- St George's Vascular Institute, St George's Hospital NHS Foundation Trust, London, UK
| | - Martin Altreuther
- Department of Vascular Surgery, St Olavs Hospital, Trondheim, Norway
| | - Martin Björck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Jonathan R Boyle
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Cambridge, UK
| | - Nikolaj Eldrup
- Department of Cardio-Thoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Alan Karthikesalingam
- St George's Vascular Institute, St George's Hospital NHS Foundation Trust, London, UK
| | - Manar Khashram
- Department of Surgery, The University of Auckland, Waikato, New Zealand
| | - Ian Loftus
- St George's Vascular Institute, St George's Hospital NHS Foundation Trust, London, UK
| | - Marc Schermerhorn
- Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Carlo Setacci
- Vascular and Endovascular Surgery Unit, University of Siena, Siena, Italy
| | - Zoltán Szeberin
- Department of Vascular Surgery, Semmelweis University, Budapest, Hungary
| | - Sebastian Debus
- Department of Vascular Medicine, Research Group GermanVasc, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Peter Holt
- St George's Vascular Institute, St George's Hospital NHS Foundation Trust, London, UK
| | - Kevin Mani
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Uppsala, Sweden
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14
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Rozental O, Ma X, Weinberg R, Gadalla F, Essien UR, White RS. Disparities in mortality after abdominal aortic aneurysm repair are linked to insurance status. J Vasc Surg 2020; 72:1691-1700.e5. [PMID: 32173191 DOI: 10.1016/j.jvs.2020.01.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 01/11/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The objective of this study was to determine differences in mortality after abdominal aortic aneurysm (AAA) repair based on insurance type. METHODS In this retrospective cohort study, data from all-payer patients in nonpsychiatric hospitals in New York, Maryland, Florida, Kentucky, and California from January 2007 to December 2014 (excluding California, ending December 2011) were extracted from the State Inpatient Databases, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality. There were 90,102 patients ≥18 years old with available insurance data who underwent open AAA repair or endovascular aneurysm repair (EVAR) identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes 3844, 3925, and 3971. EVAR patients were identified using the procedure code 3971, and the remainder of cases were categorized as open. Patients were divided into cohorts by insurance type as Medicare, Medicaid, uninsured (self-pay/no charge), other, or private insurance. Patients were further stratified for subgroup analyses by procedure type. Unadjusted rates of in-hospital mortality, the primary outcome, as well as secondary outcomes, such as surgical urgency, 30-day and 90-day readmissions, length of stay, total charges, and postoperative complications, were examined by insurance type. Adjusted odds ratios (ORs) for in-hospital mortality were calculated using multivariate logistic regression models fitted to the data. The multivariate models included patient-, surgical-, and hospital-specific factors with bivariate baseline testing suggestive of association with insurance status in addition to variables that were selected a priori. RESULTS Medicaid and uninsured patients had the highest rates of mortality relative to private insurance beneficiaries in all cohorts. Medicaid patients incurred a 47% increase in the odds of mortality, the highest among the insured, after all AAA repairs (OR, 1.47; 95% confidence interval [CI], 1.23-1.76), whereas uninsured patients experienced a 102% increase in the odds of mortality (OR, 2.02; 95% CI, 1.54-2.67). Subgroup analyses for open AAA repair and EVAR corroborated that Medicaid insurance (open repair OR, 1.37 [95% CI, 1.14-1.64]; EVAR OR, 2.06 [95% CI, 1.40-3.04]) and uninsured status (open repair OR, 1.85 [95% CI, 1.35-2.54]; EVAR OR, 2.96 [95% CI, 1.82-4.81]) were associated with the highest odds of mortality after both procedures separately. CONCLUSIONS This study demonstrates that Medicaid insurance and uninsured status are associated with higher unadjusted rates and adjusted ORs for in-hospital mortality after AAA repair relative to private insurance status. Primary payer status therefore serves as an independent predictor of the risk of death subsequent to AAA surgical interventions.
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Affiliation(s)
- Olga Rozental
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Xiaoyue Ma
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY
| | - Roniel Weinberg
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Farida Gadalla
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY
| | - Utibe R Essien
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa; Center for Healthy Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pa
| | - Robert S White
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY; Department of Anesthesiology, NewYork-Presbyterian Hospital, New York, NY.
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15
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Himmerich H, Hotopf M, Shetty H, Schmidt U, Treasure J, Hayes RD, Stewart R, Chang CK. Psychiatric comorbidity as a risk factor for mortality in people with anorexia nervosa. Eur Arch Psychiatry Clin Neurosci 2019; 269:351-359. [PMID: 30120534 DOI: 10.1007/s00406-018-0937-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 08/09/2018] [Indexed: 12/27/2022]
Abstract
Anorexia nervosa (AN) is found associated with increased mortality. Frequent comorbidities of AN include substance use disorders (SUD), affective disorders (AD) and personality disorders (PD). We investigated the influence of these psychiatric comorbidities on all-cause mortality with demographic and socioeconomic factors considered as confounders in the observation window between January 2007 and March 2016 for 1970 people with AN, using data from the case register of the South London and Maudsley (SLaM) NHS Foundation Trust, an almost monopoly-secondary mental healthcare service provider in southeast London. We retrieved data from its Clinical Records Interactive Search (CRIS) system as data source. Mortality was ascertained through nationwide tracing by the UK Office for National Statistics (ONS) linked to CRIS database on a monthly basis. A total of 43 people with AN died during the observation period. Standardized Mortality Ratio (SMR) with England and Wales population in 2012 as standard population for our study cohort was 5.21 (95% CI 3.77, 7.02). In univariate analyses, the comorbidity of SUD or PD was found to significantly increase the relative risks of mortality (HRs = 3.10, 95% CI 1.21, 7.92; and 2.58, 95% CI 1.23, 5.40, respectively). After adjustment for demographic and socioeconomic covariates as confounders, moderately but not significantly elevated risks were identified for SUD (adjusted HR = 1.39, 95% CI 0.53, 3.65) and PD (adjusted HR = 1.58, 95% CI 0.70, 3.56). These results suggest an elevated mortality in people with AN, which might be, at least partially, explained by the existence of the comorbidities SUD or PD.
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Affiliation(s)
- Hubertus Himmerich
- Department of Psychological Medicine, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, London, UK
| | - Matthew Hotopf
- Department of Psychological Medicine, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, London, UK
| | - Hitesh Shetty
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Ulrike Schmidt
- Department of Psychological Medicine, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, London, UK
| | - Janet Treasure
- Department of Psychological Medicine, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, London, UK
| | - Richard D Hayes
- Department of Psychological Medicine, King's College London, London, UK
| | - Robert Stewart
- Department of Psychological Medicine, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, London, UK
| | - Chin-Kuo Chang
- Department of Psychological Medicine, King's College London, London, UK. .,South London and Maudsley NHS Foundation Trust, London, UK. .,Department of Health and Welfare, University of Taipei, No. 101, Sec. 2, Jhongcheng Rd, Shilin District, Taipei, 111, Taiwan.
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16
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Sakalihasan N, Michel JB, Katsargyris A, Kuivaniemi H, Defraigne JO, Nchimi A, Powell JT, Yoshimura K, Hultgren R. Abdominal aortic aneurysms. Nat Rev Dis Primers 2018; 4:34. [PMID: 30337540 DOI: 10.1038/s41572-018-0030-7] [Citation(s) in RCA: 282] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
An abdominal aortic aneurysm (AAA) is a localized dilatation of the infrarenal aorta. AAA is a multifactorial disease, and genetic and environmental factors play a part; smoking, male sex and a positive family history are the most important risk factors, and AAA is most common in men >65 years of age. AAA results from changes in the aortic wall structure, including thinning of the media and adventitia due to the loss of vascular smooth muscle cells and degradation of the extracellular matrix. If the mechanical stress of the blood pressure acting on the wall exceeds the wall strength, the AAA ruptures, causing life-threatening intra-abdominal haemorrhage - the mortality for patients with ruptured AAA is 65-85%. Although AAAs of any size can rupture, the risk of rupture increases with diameter. Intact AAAs are typically asymptomatic, and in settings where screening programmes with ultrasonography are not implemented, most cases are diagnosed incidentally. Modern functional imaging techniques (PET, CT and MRI) may help to assess rupture risk. Elective repair of AAA with open surgery or endovascular aortic repair (EVAR) should be considered to prevent AAA rupture, although the morbidity and mortality associated with both techniques remain non-negligible.
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Affiliation(s)
- Natzi Sakalihasan
- Department of Cardiovascular and Thoracic Surgery, CHU Liège, University of Liège, Liège, Belgium. .,Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium.
| | - Jean-Baptiste Michel
- UMR 1148, INSERM Paris 7, Denis Diderot University, Xavier Bichat Hospital, Paris, France
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Helena Kuivaniemi
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Jean-Olivier Defraigne
- Department of Cardiovascular and Thoracic Surgery, CHU Liège, University of Liège, Liège, Belgium.,Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium
| | - Alain Nchimi
- Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium.,Department of Medical Imaging, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Janet T Powell
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Koichi Yoshimura
- Graduate School of Health and Welfare, Yamaguchi Prefectural University, Yamaguchi, Japan.,Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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