The association between frailty and outcomes following ruptured abdominal aortic aneurysm repair.

OBJECTIVE: Endovascular aortic repair (EVAR) is a less invasive method than the more physiologically stressful open surgical repair (OSR) for patients with anatomically appropriate abdominal aortic aneurysms (AAAs). Early postoperative outcomes are associated with both patients; physiologic reserve and the physiologic stresses of the surgical intervention. Among frail patients with reduced physiologic reserve, the stress of an aortic rupture in combination with the stress of an operative repair are less well tolerated, raising the risk of complications and mortality. This study aims to evaluate the difference in association between frailty and outcomes among patients undergoing minimally invasive EVAR and the physiologically more stressful OSR for ruptured AAAs (rAAAs). METHODS: Our retrospective cohort study included adults undergoing rAAA repair in the Vascular Quality Initiative from 2010 to 2022. The validated Risk Analysis Index (RAI) (robust, ≤20; normal, 21-29; frail, 30-39; very frail, ≥40) quantified frailty. The association between the primary outcome of 1-year mortality and frailty status as well as repair type were compared using multivariable Cox models generating adjusted hazard ratios (aHRs) with 95% confidence intervals (CIs). Interaction terms evaluated the association's moderation. RESULTS: We identified 5806 patients (age, 72 ± 9 years; 77% male; EVAR, 65%; robust, 6%; normal, 48%; frail, 36%; very, frail 10%) with a 53% observed 1-year mortality rate following rAAA repair. OSR (aHR, 1.43; 95% CI, 1.19-1.73) was associated with increased 1-year mortality when compared with EVAR. Increasing frailty status (frail aHR, 1.26; 95% CI, 1.00-1.59; very frail aHR, 1.64; 95% CI, 1.26-2.13) was associated with increased 1-year mortality, which was moderated by repair type (P-interaction < .05). OSR was associated with increased 1-year mortality in normal (aHR, 1.49; 95% CI, 1.20-1.87) and frail (aHR, 1.51; 95% CI, 1.20-1.89), but not among robust (aHR, 0.88; 95% CI, 0.59-1.32) and very frail (aHR, 1.29; 95% CI, 0.97-1.72) patients. CONCLUSIONS: Frailty and OSR were associated with increased adjusted risk of 1-year mortality following rAAA repair. Among normal and frail patients, OSR was associated with an increased adjusted risk of 1-year mortality when compared with EVAR. However, there was no difference between OSR and EVAR among robust patients who can well tolerate the stress of OSR and among very frail patients who are unable to withstand the surgical stress from rAAA regardless of repair type.

Clinical Utility of the Risk Analysis Index as a Prospective Frailty Screening Tool within a Multi-practice, Multi-hospital Integrated Healthcare System.

OBJECTIVE: The goal of this project was to first address barriers to implementation of the Risk Analysis Index (RAI) within a large, multi-hospital, integrated healthcare delivery system, and to subsequently demonstrate its utility for identifying at-risk surgical patients. BACKGROUND: Prior studies demonstrate the validity of the RAI for evaluating preoperative frailty, but they have not demonstrated the feasibility of its implementation within routine clinical practice. METHODS: Implementation of the RAI as a frailty screening instrument began as a quality improvement initiative at the University of Pittsburgh Medical Center in July 2016. RAI scores were collected within a REDCap survey instrument integrated into the outpatient electronic health record and then linked to information from additional clinical datasets. NSQIP-eligible procedures were queried within 90 days following the RAI, and the association between RAI and postoperative mortality was evaluated using logistic regression and Cox proportional hazards models. Secondary outcomes such as inpatient length of stay and readmissions were also assessed. RESULTS: RAI assessments were completed on 36,261 unique patients presenting to surgical clinics across five hospitals from July 1 to December 31, 2016, and 8,172 of these underwent NSQIP-eligible surgical procedures. The mean RAI score was 23.6 (SD 11.2), the overall 30-day and 180-day mortality after surgery was 0.7% and 2.6%, respectively, and the median time required to collect the RAI was 33 [IQR 23-53] seconds. Overall clinic compliance with the recommendation for RAI assessment increased from 58% in the first month of the study period to 84% in the sixth and final month. RAI score was significantly associated with risk of death (HR=1.099 [95% C.I.: 1.091 - 1.106], p < 0.001). At an RAI cutoff of ≥37, the positive predictive values for 30- and 90-day readmission were 14.8% and 26.2%, respectively, and negative predictive values were 91.6% and 86.4%, respectively. CONCLUSIONS: The RAI frailty screening tool can be efficiently implemented within multi-specialty, multi-hospital healthcare systems. In the context of our findings and given the value of the RAI in predicting adverse postoperative outcomes, health systems should consider implementing frailty screening within surgical clinics.

Exposure of pregnant women to cookstove-related household air pollution in urban and periurban Trujillo, Peru.

Although evidence suggests associations between maternal exposure to air pollution and adverse birth outcomes, pregnant women's exposure to household air pollution in developing countries is understudied. Personal exposures of pregnant women (N = 100) in Trujillo, Peru, to air pollutants and their indoor concentrations were measured. The effects of stove-use-related characteristics and ambient air pollution on exposure were determined using mixed-effects models. Significant differences in 48-hour kitchen concentrations of particulate matter (PM2.5), carbon monoxide (CO), and nitrogen dioxide (NO2) concentrations were observed across fuel types (p < 0.05). Geometric mean PM2.5 concentrations where 112 µg/m(3) (confidence limits [CLs]: 52, 242 µg/m(3)) and 42 µg/m(3) (21, 82 µg/m(3)) in homes where wood and gas were used, respectively. PM2.5 exposure was at levels that recent exposure-response analyses suggest may not result in substantial reduction in health risks even in homes where cleaner burning gas stoves were used.

A Pilot Study Characterizing Real Time Exposures to Particulate Matter and Carbon Monoxide from Cookstove Related Woodsmoke in Rural Peru.

Nearly half of the world's population is exposed to household air pollution (HAP) due to long hours spent in close proximity to unvented cooking fires. We aimed to use PM2.5 and CO measurements to characterize exposure to cookstove generated woodsmoke in real time among control (n=10) and intervention (n=9) households in San Marcos, Cajamarca Region, Peru. Real time personal particulate matter with an aerodynamic diameter ≤2.5 µm (PM2.5), and personal and kitchen carbon monoxide (CO) samples were taken. Control households used a number of stoves including open fire and chimney stoves while intervention households used study-promoted chimney stoves. Measurements were categorized into lunch (9am - 1pm) and dinner (3pm - 7pm) periods, where applicable, to adjust for a wide range of sampling periods (2.8- 13.1hrs). During the 4-h time periods, mean personal PM2.5 exposures were correlated with personal CO exposures during lunch (r=0.67 p=0.024 n=11) and dinner (r=0.72 p=0.0011 n=17) in all study households. Personal PM2.5 exposures and kitchen CO concentrations were also correlated during lunch (r=0.76 p=0.018 n=9) and dinner (r=0.60 p=0.018 n=15). CO may be a useful indicator of PM during 4-h time scales measured in real time, particularly during high woodsmoke exposures, particularly during residential biomass cooking.

Concentrations of urinary 8-hydroxy-2'-deoxyguanosine and 8-isoprostane in women exposed to woodsmoke in a cookstove intervention study in San Marcos, Peru.

Nearly half of the world's population is exposed to household air pollution (HAP) due to long hours spent in close proximity to unvented cooking fires. The effect of woodsmoke exposure on oxidative stress was examined by investigating the association between woodsmoke exposure and biomarkers of DNA oxidation (8-hydroxy-2'-deoxyguanosine [8-OHdG]) and lipid peroxidation (8-isoprostane) among control and intervention stove users. HAP exposure assessment was conducted within the framework of a community-randomized controlled trial of 51 communities in San Marcos Province, Cajamarca Region, Peru. The first morning urine voids after 48h HAP exposure assessment from a subset of 45 control and 39 intervention stove users were analyzed for 8-OHdG and 8-isoprostane. General linear models and correlation analyses were performed. Urinary oxidative stress biomarkers ranged from 11.2 to 2270.0µg/g creatinine (median: 132.6µg/g creatinine) for 8-OHdG and from 0.1 to 4.5µg/g creatinine (median: 0.8µg/g creatinine) for 8-isoprostane among all study subjects (n=84). After controlling for the effects of traffic in the community and eating food exposed to fire among all subjects, cooking time was weakly, but positively associated with urinary 8-OHdG (r=0.29, p=0.01, n=80). Subjects' real-time personal CO exposures were negatively associated with 8-OHdG, particularly the maximum 30-second CO exposure during the sampling period (r=-0.32, p=0.001, n=73). 48h time integrated personal PM2.5 was negatively, but marginally associated with urinary 8-isoprostane (r=-0.21, p=0.09, n=69) after controlling for the effect of distance of homes to the road. Urinary 8-isoprostane levels reported in the available literature are comparable to results found in the current study. However there were relatively high levels of urinary 8-OHdG compared to data in the available literature for 8-OHdG excretion. Results suggest a sustained systemic oxidative stress among these Peruvian women chronically exposed to wood smoke.

Carbon monoxide exposures and kitchen concentrations from cookstove-related woodsmoke in San Marcos, Peru.

BACKGROUND: Nearly half of the world's population is exposed to household air pollution (HAP) due to long hours spent in close proximity to biomass-fueled fires. OBJECTIVE: We compare CO exposures and concentrations among study promoted intervention stove users and control stove users in San Marcos Province, Cajamarca region, Peru. METHODS: Passive CO diffusion tubes were deployed over a 48-hour sampling period to measure kitchen CO concentrations and personal mother and child CO exposures in 197 control and 182 intervention households. RESULTS: Geometric means (95% CI) for child, mother, and kitchen measurements were 1.1 (0.9-1.2), 1.4 (1.3-1.6), and 7.3 (6.4-8.3) ppm in control households, and 1.0 (0.9-1.1), 1.4 (1.3-1.6), and 7.3 (6.4-8.2) ppm among intervention households, respectively. CONCLUSION: With no significant differences between control and intervention CO measurements, results suggest that intervention stove maintenance may be necessary for long-term reductions in CO exposures.

Concentrations of select persistent organic pollutants across pregnancy trimesters in maternal and in cord serum in Trujillo, Peru.

Although the production and use of some persistent organic pollutants (POPs) have been banned or highly restricted, human exposure remains a subject of investigation due to their environmental persistence. Physiological changes during pregnancy may affect the disposition of POPs in the mother's body, and thus fetal exposure. Changes in serum concentrations of organochlorine pesticides (OCPs) and polychlorinated biphenyls (PCBs) across pregnancy trimesters, and trans-placental transfer to the fetus were investigated. Seventy-nine pregnant women in Trujillo, Peru were recruited in the first trimester of pregnancy, and provided blood samples for the analysis of 35 PCB congeners, 9 OCPs, and 11 polybrominated biphenyl diethers (PBDEs). Subsequently, maternal blood samples were collected in the second (n=64) and third trimesters (n=59), and cord blood samples (n=50) were collected at delivery. There were statistically significant changes across trimesters (p<0.05) for both fresh weight (increase) and lipid adjusted concentrations (decrease) of hexachlorobenzene (HCB), 2,2-Bis(4-chlorophenyl)-1,1-dichloroethene (p,p'-DDE), PCB-74, 118, 138-158, 153, 170, 180 and 194. Fresh weight concentrations of these POPs increased from first to third trimester by 10-28%. On the other hand lipid adjusted concentrations decreased from first to third trimester by 16-28%. Serum lipids increased from first to third trimester by 53% indicating the dilution of the POPs in the lipids. Concentrations of 2,2-Bis(4-chlorophenyl)-1,1,1-trichloroethane (p,p'-DDT), its metabolite p,p'-DDE, PCB-118, 138-158, 153, 170 and 180 above their limits of detection were measured in >60% of cord serum samples. Intra-individual correlations in maternal serum concentrations were high for most of the POPs (ρ=0.62-0.99; p<0.05) while correlations between maternal and cord serum concentrations were also high (ρ=0.68-0.99; p<0.05). Results indicate that the disposition in the body and blood concentrations of POPs may change during pregnancy, and show trans-placental transfer of DDT, DDE and PCBs.

Biomonitoring of polycyclic aromatic hydrocarbon exposure in pregnant women in Trujillo, Peru--comparison of different fuel types used for cooking.

Women and children in developing countries are often exposed to high levels of air pollution including polycyclic aromatic hydrocarbons (PAHs), which may negatively impact their health, due to household combustion of biomass fuel for cooking and heating. We compared creatinine adjusted hydroxy-PAH (OH-PAH) concentrations in pregnant women in Trujillo, Peru who cook with wood to levels measured in those who cook with kerosene, liquefied petroleum gas or a combination of fuels. Seventy-nine women were recruited for the study between May and July 2004 in the first trimester of their pregnancy. Urine samples were collected from the subjects in the first, second and third trimesters for OH-PAH analyses. The concentrations of the OH-PAHs were compared across the type of fuel used for cooking and pregnancy trimesters. The relationships between OH-PAHs levels in the first trimester and concurrently measured personal exposures to PM2.5, carbon monoxide and nitrogen dioxide together with their indoor and outdoor air concentrations were also investigated. Women cooking with wood or kerosene had the highest creatinine adjusted OH-PAH concentrations compared with those using gas, coal briquette or a combination of fuels. Concentrations of creatinine adjusted 2-hydroxy-fluorene, 3-hydroxy-fluorene, 1-hydroxy-fluorene, 2-hydroxy-phenanthrene and 4-hydroxy-phenanthrene were significantly higher (p<0.05) in women who used wood or kerosene alone compared with women who used liquefied petroleum gas (LPG), coal briquette or a combination of fuels. An increase in the concentrations of creatinine adjusted 9-hydroxy-fluorene, 1-hydroxy-phenanthrene, 2-hydroxy-phenanthrene, 4-hydroxy-phenanthrene and 1-hydroxy-pyrene in the third trimesters was also observed. Weak positive correlation (Spearman correlation coefficient, ρ<0.4; p<0.05) was observed between all first trimester creatinine adjusted OH-PAHs and indoor (kitchen and living room), and personal 48-h TWA PM2.5. Women who cooked exclusively with wood or kerosene had higher creatinine adjusted OH-PAH levels in their urine samples compared to women who cooked with LPG or coal briquette.

Personal exposure to PM(2.5) and urinary hydroxy-PAH levels in bus drivers exposed to traffic exhaust, in Trujillo, Peru.

Public transport vehicle drivers, especially in highly polluted or trafficked areas, are exposed to high levels of air pollutants. In this study, we assessed the influence of traffic on levels of hydroxy polycyclic aromatic hydrocarbons (OH-PAHs) in commercial bus drivers in Trujillo, Peru, by measuring the within-shift changes in the urinary whole weight and creatinine-corrected concentrations of the PAH metabolites. We measured personal PM(2.5) as a proxy of exposure to traffic emission. Urine samples were collected daily from two bus drivers and three minivan drivers in Trujillo, pre-, mid-, post-work shift and on days when the drivers were off work (total n = 144). Ten OH-PAH metabolites were measured in the urine samples. Drivers were also monitored for exposure to PM(2.5) (n = 41). Daily work shift (mean = 13.1 ± 1.3 hr) integrated PM(2.5) was measured in the breathing zones of the drivers for an average of 10.5 days per driver. The differences across shift in OH-PAH concentrations were not statistically significant except for urinary 2-hydroxyfluorene (2-FLU) (p = 0.04) and 4-hydroxyphenanthrene (4-PHE) (p = 0.01) and creatinine-corrected 4-hydroxyphenanthrene (p = 0.01). Correlation between pairs of hydroxy-PAHs (ρ = 0.50 to 0.93) were highest for mid-shift samples. Concentrations of PM(2.5) (geometric mean = 64 µg/m(3); 95% confidence limits = 52 µg/m(3), 78 µg/m(3)) is similar to those measured in many other studies of traffic exposure. There was significant change across work shift for concentrations of only two of the OH-PAHs (2-FLU and 4-PHE). Results indicate that the drivers may have had limited time for clearance of PAH exposure from the body between work shifts. Comparisons of the concentrations of creatinine-corrected hydroxy-PAH to those reported in other studies indicate that exposure of public transport drivers to PAH could be similar. By following the subjects over multiple days, this study gives an indication of appropriate exposure situations for the use of hydroxy-PAHs and will be beneficial in designing future occupational studies of PAH exposure.

An estimate of phthalate exposure among pregnant women living in Trujillo, Peru.

Phthalates are a group of phthalic acid esters which are used as plasticizers and additives. In laboratory animals, several phthalates are known endocrine disruptors. Several studies have described phthalate exposure in the United States and developed countries but little is known about phthalate exposure in the developing world, particularly during pregnancy. To assess exposure to six different phthalates, we measured the concentrations of nine phthalate metabolites in spot urine samples collected during the first, second, and third trimester of pregnancy from a group of 72 women living in Trujillo, Peru. Additionally, women completed questionnaires to provide demographic characteristics. Statistical analysis via linear models was used to evaluate potential differences in the concentrations of phthalate metabolites by trimester, cooking fuel type, socioeconomic status, and education. All metabolites were detected in>40% of samples analyzed, and mono-n-butyl phthalate, mono (2-ethyl-5-carboxypentyl) phthalate, and monoethyl phthalate were found in>90% of samples. Five of nine unadjusted urinary metabolites and four of nine creatinine-adjusted urinary metabolites were significantly lower in this group of pregnant women living in Peru compared to pregnant women in the US general population.

The effects of the environment on autistic spectrum disorder in Jamaica

OBJECTIVE: The prevalence of autistic disorder has been rising worldwide. This disorder is believed to have a genetic basis with an environmental trigger. The clinical presentation has features that are similar to mercury poisoning, suggesting a probable environmental trigger. This paper investigates the relationship between environmental contaminants/toxins, including mercury, and autistic disorder in Jamaica. METHODS: Autistic children were identified from public and private hospital records and from records of special schools. Fifty-eight parents of autistic children completed a questionnaire about their environment and frequency of exposure to harmful chemicals and contaminants during pregnancy and prior to diagnosis. The childhood Autism Rating Scale determined the severity of autistic disorder. The relationship between the severity of autism and different environmental factors was analyzed using the chi-squared test. RESULTS: The meanñStandard Deviation age of autistic children was 6.5ñ3.7 years. There were 79 percent male and 21 percent female. Although there were rates of autism calculated by parish, there are no known apparent links between the geographical region and severity of autism. Sixty percent of the population had changed their address since birth. No association was found between use of common household chemicals (eg bleach, disinfectant), residence close to possible environmental contaminants (eg garbage dumps, factories, bodies of water) and autism, either during pregnancy or prior to diagnosis. A single case of exposure to mercury during pregnancy associated with severe autism was identified. CONCLUSIONS: This study was unable to identify any associations between a number of environmental agents and the severity of autism. The single case of mercury exposure during pregnancy warrants further investigation of this association with a larger sample size (AU)

Depo-provera: a preliminary report on its use on a Family Island in the Commonwealth of the Bahamas

A preliminary report on the use of depo-provera amongst a group of women within childbearing age on an island of the Bahamas shows promise. The duration of administration of the drug in this particular study should be borne in mind when anticipating defaulters (AU)