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The Intercollegiate Surgical Curriculum Programme (ISCP) provides the Curriculum with the specialty syllabus, trainee’s portfolio of activity, and the process and recording of assessment. It is an excellent resource and in order to gain the optimal benefit trainees and trainers are recommended to invest some time in navigating through the site and understand its functionality. The launch of the 2021 Surgical Curricula is an important change with the new assessment tool of the Multiple Consultant Report (MCR) and the trainee input with their self-assessment. The ISCP has incorporated the MCR assessment process (Generic Professional Capabilities and Capabilities in Practice) into the learning agreement structure such that the progression through to the higher-level outcome of the curriculum, defined as a day 1 consultant in a specialty, is enhanced by frequent and focussed feedback specific to the trainee. To achieve the optimal outcomes, it is important to have strong engagement with the ISCP and the useability has been enhanced to facilitate this.

Objectives: To determine whether central speech processing ability, as measured by hearing in noise, differs between right and left ears in adults with Alzheimer’s disease related dementia (AD) as well as whether differences in central speech processing ability correlate with an fMRI-based measurement of global functional brain connectivity. Methods: This prospective study was carried out at a tertiary referral center. Patients with an AD diagnosis and pure tone averages 40 dB HL or better were included. They were examined using resting-state fMRI and underwent central audiometric testing using the Dichotic Sentence Identification Test (DSI), the Dichotic Digits Test (DD), and the Synthetic Sentence Identification Test (SS), which test hearing in noise. DSI scores were correlated with resting-state fMRI connectivity between 361 distinct gray matter brain regions of interest (ROIs). Average global connectivity was calculated as mean functional connectivity between an ROI and the other 360 regions, a quantitative marker representing overall functional connectivity in the brain. Results: Sixteen subjects had adequate fMRI and hearing data. The average age was 71.5 years old (±6.0). The average DSI score for the left ear was 40% (±34%) compared to 90% (±10%) in the right ear ( P Conclusions: Correlation was noted between left sided DSI and functional connectivity in patients with AD. Auditory input from the left ear was more susceptible to impairment, suggesting that side-specific auditory input may influence central auditory processing.

Several studies have suggested that females and males differ in reward behaviors and their underlying neural circuitry. Whether human sex differences extend across neural and behavioral levels for both rewards and punishments remains unclear. We studied a community sample of 221 young women and men who performed a monetary incentive task known to engage the mesoaccumbal pathway and salience network. Both stimulus salience (behavioral relevance) and valence (win vs loss) varied during the task. In response to high- vs low-salience stimuli presented during the monetary incentive task, men showed greater subjective arousal ratings, behavioral accuracy and skin conductance responses (P

In the era of J H Shakespeare the Baptist Union Council was encouraged to enter comprehensive negotiations for greater ecumenical cooperation and, possibly, church union. This was resisted and J H ...

Objective Estrogen receptor-α (ERα) is a nuclear receptor family member thought to substantially contribute to the metabolic regulation of skeletal muscle. However, previous mouse models utilized to assess the necessity of ERα signaling in skeletal muscle were confounded by altered developmental programming and/or influenced by secondary effects, making it difficult to assign a causal role for ERα. The objective of this study was to determine the role of skeletal muscle ERα in regulating metabolism in the absence of confounding factors of development. Methods A novel mouse model was developed allowing for induced deletion of ERα in adult female skeletal muscle (ERαKOism). ERαshRNA was also used to knockdown ERα (ERαKD) in human myotubes cultured from primary human skeletal muscle cells isolated from muscle biopsies from healthy and obese insulin-resistant women. Results Twelve weeks of HFD exposure had no differential effects on body composition, VO2, VCO2, RER, energy expenditure, and activity counts across genotypes. Although ERαKOism mice exhibited greater glucose intolerance than wild-type (WT) mice after chronic HFD, ex vivo skeletal muscle glucose uptake was not impaired in the ERαKOism mice. Expression of pro-inflammatory genes was altered in the skeletal muscle of the ERαKOism, but the concentrations of these inflammatory markers in the systemic circulation were either lower or remained similar to the WT mice. Finally, skeletal muscle mitochondrial respiratory capacity, oxidative phosphorylation efficiency, and H2O2 emission potential was not affected in the ERαKOism mice. ERαKD in human skeletal muscle cells neither altered differentiation capacity nor caused severe deficits in mitochondrial respiratory capacity. Conclusions Collectively, these results suggest that ERα function is superfluous in protecting against HFD-induced skeletal muscle metabolic derangements after postnatal development is complete., Highlights • Induced skeletal muscle specific ERαKO (ERαKOism) examines the role of ERα without confounding factors of development. • Skeletal muscle glucose uptake is not impaired in ERαKOism. • Skeletal muscle mitochondrial function is not impaired in ERαKOism. • ERαKD in human myotubes does not severely affect mitochondrial respiratory capacity.

Neuropeptide Y (NPY) produces anxiolytic effects in rodent models, and naturally occurring low NPY expression in humans has been associated with negative emotional phenotypes. Studies in rodent models have also demonstrated that NPY elicits reward behaviors through its action in the nucleus accumbens (NAc), but the impact of NPY on the human NAc is largely unexplored. We recruited 222 healthy young adults of either sex and genetically selected 53 of these subjects at the extremes of NPY expression (Low-NPY and High-NPY) to participate in functional magnetic resonance imaging. Responses of the NAc and surrounding ventral striatum were quantified during a monetary incentive delay task in which stimuli varied by salience (high versus low) and valence (win versus loss). We found that bilateral NAc responses to high-salience versus low-salience stimuli were greater for Low-NPY subjects relative to High-NPY subjects, regardless of stimulus valence. To our knowledge, these results provide the first evidence in humans linking NPY with salience sensitivity of the NAc, raising the possibility that individual differences in NPY expression moderate the risk for disorders of mesoaccumbal function such as addictions and mood disorders. Additionally, we found that head motion was greater among High-NPY subjects, consistent with previous reports linking NPY with hyperactivity. Future studies in animal models are warranted to elucidate the neural mechanisms through which NPY influences NAc function and related behaviors.

What an amazing book. Catriona Gorton was the instigator of this collection of liturgical and prayer material to mark a centenary recounting the contribution of ordained and accredited women minist...

Several studies have suggested that females and males differ in reward behaviors and their underlying neural circuitry. Whether human sex differences extend across neural and behavioral levels for both rewards and punishments remains unclear. We studied a community sample of 221 young women and men who performed a monetary incentive task known to engage the mesoaccumbal pathway and salience network. Both stimulus salience (behavioral relevance) and valence (win vs loss) varied during the task. In response to high- vs low-salience stimuli presented during the monetary incentive task, men showed greater subjective arousal ratings, behavioral accuracy and skin conductance responses (P 0.006, Hedges' effect size g = 0.38 to 0.46). In a subsample studied with functional magnetic resonance imaging (n = 44), men exhibited greater responsiveness to stimulus salience in the nucleus accumbens, midbrain, anterior insula and dorsal anterior cingulate cortex (P 0.02, g = 0.86 to 1.7). Behavioral, autonomic and neural sensitivity to the valence of stimuli did not differ by sex, indicating that responses to rewards vs punishments were similar in women and men. These results reveal novel and robust sex differences in reward- and punishment-related traits, behavior, autonomic activity and neural responses. These convergent results suggest a neurobehavioral basis for sexual dimorphism observed in the reward system, including reward-related disorders.

Scoring systems for diabetic foot ulcers may be used for clinical purposes, research or audit, to help assess disease severity, plan management, and even predict outcomes. While many have been validated in study populations, little is known about their interobserver reliability. This prospective study aimed to evaluate interobserver reliability of 3 scoring systems for diabetic foot ulceration. After sharp debridement, diabetic foot ulcers were classified by a multidisciplinary pool of trained observers, using the PEDIS (Perfusion, Extent, Depth, Infection, Sensation), SINBAD (Site, Ischemia, Neuropathy, Bacterial infection, Depth), and University of Texas (UT) wound classification systems. Interobserver reliability was assessed using intraclass correlations (0 = no agreement; 1 = complete agreement). Thirty-seven patients (78.4% male) were assessed by a pool of 12 observers. Single observer reliability was slight to moderate for all scoring systems (UT 0.53; SINBAD 0.44; PEDIS 0.23-0.42), but multiple observer reliability was almost perfect (UT 0.94; SINBAD 0.91; PEDIS 0.80-0.90). The worst agreement for single observers was when scoring infection (SINBAD 0.28; PEDIS 0.28), ischemia (SINBAD 0.26; PEDIS 0.23), or both (UT 0.25); however, this improved to almost perfect agreement for multiple observers (infection: 0.83; ischemia: 0.80-0.82; both: 0.81). These classification systems may be reliably used by multiple observers, for example, when conducting research and audit. However, they demonstrate only slight to moderate reliability when used by a single observer on an individual subject and may therefore be less helpful in the clinical setting, when documenting ulcer characteristics or communicating between colleagues.

Background: Personalized music programs have been proposed as an adjunct therapy for patients with Alzheimer disease related dementia, and multicenter trials have now demonstrated improvements in agitation, anxiety, and behavioral symptoms. Underlying neurophysiological mechanisms for these effects remain unclear. Methods: We examined 17 individuals with a clinical diagnosis of Alzheimer disease related dementia using functional MRI following a training period in a personalized music listening program. Results: We find that participants listening to preferred music show specific activation of the supplementary motor area, a region that has been associated with memory for familiar music that is typically spared in early Alzheimer disease. We also find widespread increases in functional connectivity in corticocortical and corticocerebellar networks following presentation of preferred musical stimuli, suggesting a transient effect on brain function. Conclusions: Findings support a mechanism whereby attentional network activation in the brain’s salience network may lead to improvements in brain network synchronization.

The generation of energy via fossil fuel burning results in carbon emissions. These emissions contribute to the climate change of our world, particularly in terms of global warming. On the contrary, energy has become blood of life for the existence and functioning of our built environments. In order to control carbon emissions, the UK has taken lead among many countries around the globe and especially in Europe by passing a bill for the Climate Change Act 2008 which legally binds the UK to at least 80% reduction of carbon emissions by 2050 and 34% by 2020 which is fast approaching. However, the review of literature and models to date has revealed that to help meet these legal carbon cut targets set by the Act, there is a lack of unified knowledge-base approaches that could integrate all energy-related aspects of buildings in terms of these issues: establishing 1990 base-level and current carbon footprint of a given building and then drawing comparisons between the two to set milestones; breakdown of the energy consumption amongst various energy-consuming items of the building; identification of appropriate high energyconsuming items in the building; maintenance and refurbishment; fabric and non-fabric; implications of relevant terminologies; cost-benefit analysis of energy-saving technologies and pay-back time in connection to meeting aforesaid legal carbon cut targets. On the basis of identified knowledge gaps and attempting to bridge them, this paper develops and presents such an unified framework of a conceptual methodology that outlines fundamentals of a whole-system procedure while catering for all the aforesaid issues.

Purpose: To perform an evidence synthesis study to assess outcomes of endovascular repair of popliteal artery aneurysms (PAAs) using the Hemobahn or Viabahn stent-graft. Methods: A systematic literature review was conducted conforming to established standards to identify articles published between 1996 (the date of introduction of the Hemobahn stent-graft) and 2013 reporting stent-graft repair of PAAs in at least 10 patients. The data were pooled for Kaplan-Meier analysis of primary and secondary patency rates [presented with 95% confidence intervals (CIs)] as the primary outcomes. Random effects meta-analysis was performed for secondary outcomes that included rates of reintervention, endoleak, stent-graft fracture, and limb salvage. Results: Fourteen studies reported outcomes for 514 PAAs. There was considerable heterogeneity in reporting standards among studies. Pooled primary and secondary patency rates were 69.4% (95% CI 63.3% to 76.2%) and 77.4% (95% CI 70.1% to 85.3%), respectively, at 5 years. Five studies (including only one randomized controlled trial) compared surgical to endovascular repair; no difference was found in primary patency on evidence synthesis (hazard ratio 1.30, 95% CI 0.79 to 12.14, p=0.189). Conclusion: Stent-graft repair provides a feasible treatment option for anatomically suitable PAAs. Further studies are required to optimize both patient selection and follow-up protocols.

Neonatal rats were administered a relatively high concentration of ethyl alcohol (11.9% v/v) during postnatal days 4-9, a time when the fetal brain undergoes rapid organizational change and is similar to accelerated brain changes that occur during the third trimester in humans. This model of fetal alcohol spectrum disorders (FASDs) produces severe brain damage, mimicking the amount and pattern of binge-drinking that occurs in some pregnant alcoholic mothers. We describe the use of trace eyeblink classical conditioning (ECC), a higher-order variant of associative learning, to assess long-term hippocampal dysfunction that is typically seen in alcohol-exposed adult offspring. At 90 days of age, rodents were surgically prepared with recording and stimulating electrodes, which measured electromyographic (EMG) blink activity from the left eyelid muscle and delivered mild shock posterior to the left eye, respectively. After a 5 day recovery period, they underwent 6 sessions of trace ECC to determine associative learning differences between alcohol-exposed and control rats. Trace ECC is one of many possible ECC procedures that can be easily modified using the same equipment and software, so that different neural systems can be assessed. ECC procedures in general, can be used as diagnostic tools for detecting neural pathology in different brain systems and different conditions that insult the brain.

Ian Randall has done us a great service by providing a scholarly and insightful account and assessment of the Bruderhof Community in England. Formed by Eberhard and Emmy Arnold in Germany in 1926, ...

Diabetes-related foot disease is a major health problem leading to significant morbidity and cost. If high-risk populations could be identified and treated before they develop complications, a significant reduction in the burden of foot disease and number of amputations might be expected. We examined the evidence to support population-based screening programs. MEDLINE and EMBASE databases were searched from January 1970 to February 2012 to identify studies assessing the impact of screening on lower limb complications in diabetes. Foot screening was defined as combined risk stratification and intervention to prevent foot complications in a population of people with diabetes mellitus. Articles reporting singularly on stratification of risk factors to predict subsequent complications but not reporting effect on minor, major and/or combined major and minor (total) amputation were excluded. Two randomized control trials were identified. These demonstrated patient benefit from screening in the setting of a general secondary care diabetes clinic and renal dialysis unit. Four before and after studies suggested benefit from primary care or regional screening. One study tried to address confounding from general improvements in the provision of diabetes foot care separately from screening. All the observational studies were prone to confounding. The evidence base for formal national primary care-based foot screening of all patients with diabetes is weak. Focused research is needed to confirm that general population-based screening in the community is effective and cost-effective. Limited evidence suggests that screening of high-risk populations of patients may be justified.

Doppler ultrasonography plays a key role in the diagnosis of peripheral arterial disease, but is often limited by pitfalls that may be overcome by B-flow imaging. Thus far, there is little information on B-flow imaging for the assessment of peripheral arterial disease and bypass grafts in lower limbs. This article describes the authors' early experience with B-flow in the lower extremities. Sixty patients were included among a large cohort of patients routinely referred to the vascular laboratory for peripheral arterial disease and bypass graft assessments. Two experienced vascular sonographers performed all scans, comparing color Doppler ultrasonography with B-flow imaging. All scans were performed using a combination of the 9 L linear and C2-9 curvilinear transducers with the LOGIQ E9 system (GE Healthcare, Waukesha, WI, USA). Our experience indicates that this relatively unexplored technology has the potential to significantly improve peripheral blood flow evaluation. Nevertheless, B-flow imaging is not exempt from limitations and should be considered complementary to color Doppler ultrasonography.

This year (2017) we remember 500 years since Martin Luther wrote to Archbishop Albrecht citing 95 reasons why change was needed within the Catholic Church. The stimulation of the spirit of reform, ...

Background The aim was to analyse contemporary data on the number of surgical revascularization procedures performed each year in England, and their outcome. Methods Hospital Episode Statistics and Office for National Statistics data were used to quantify numbers and identify factors associated with outcome after all femoropopliteal and femorodistal bypass procedures performed between 2002 and 2006. Outcome measures were repeat bypass, major amputation, death and a composite measure. Single-level multivariable logistic regression modelling was used to quantify the effect of these variables on outcome. Results A total of 21 675 femoropopliteal and 3458 femorodistal bypass procedures were performed. Mean in-hospital mortality rates were 6·7 and 8·0 per cent respectively. One-year survival rates were 82·8 and 79·1 per cent; both increased over the study interval. The mean 1-year major amputation rate after femoropopliteal bypass was 10·4 per cent, which decreased significantly over the 5 years (P < 0·001); after distal bypass the rate of 20·8 per cent remained unchanged (P = 0·456). Diabetes mellitus and chronic kidney disease were significant predictors of adverse outcome for both procedures: odds ratio (OR) at 1 year 1·56 (95 per cent confidence interval 1·46 to 1·67; P < 0·001) and 2·15 (1·88 to 2·45; P < 0·001) respectively for femoropopliteal bypass. Previous femoral angioplasty was associated with an increased rate of major amputation 1 year after proximal bypass (OR 1·18, 1·05 to 1·33; P = 0·004). Conclusion Although all mortality rates are improving, the major amputation rate remains high after femorodistal bypass. Adverse events occurred after 37·6 per cent of femoropopliteal and 49·7 per cent of femorodistal bypasses; diabetes and chronic renal failure were the main predictors of poor outcome.

In spite of a few outstanding exceptions, Baptists down the years and into the present have not focused much on care for the created world. Dr Jones challenges individuals, churches and BUGB to address these concerns seriously. This paper was given to the Baptist Historical Society seminar at the Baptist Assembly, Blackpool 2008.

Comenius’ spiritual classic provides the starting point to explore the worship and spirituality of Baptists in central and eastern Europe. Spirituality often develops in response or reaction to the world around the church. Some cross-fertilization might refresh the rather different spirituality of the west.

The combination of diabetes and peripheral arterial disease (PAD) is challenging in many ways. The characteristic and complex distal distribution of PAD often encountered in patients with diabetes means that bypass surgery in this context is technically challenging. In addition, many of these patients have a burden of serious comorbidities that must be optimized and managed concurrently. While the authors acknowledge that “achieving success” in distal bypass relies on much more than technical expertise, there are some technical aspects that should be considered when planning surgery on these patients. This article outlines some important issues in the treatment pathway of a patient with diabetes and PAD requiring distal bypass surgery—from selection and optimization of the patient (in the context of a multidisciplinary team) and preoperative workup, to the operative strategy planning, technical tips, and nonoperative adjuncts. These considerations, as well as sound knowledge of the underlying disease process, confounding medical factors and awareness of the difficulty in predicting treatment outcomes, should help maximize the chances of success.

Diabetes-related foot complications are a major cause of amputation. The presence of peripheral arterial disease (PAD) identifies those at increased risk of ulceration, failure to heal an ulcer, and amputation. This systematic review assesses the ability of noninvasive screening tests to detect PAD in patients with diabetes mellitus. A database search was performed using the OVIDSP Web site, from 1946 to June 30, 2012 (MEDLINE®), and from 1974 to June 30, 2012 (EMBASE), to identify studies assessing the utility of screening tests in detecting PAD or predicting clinical outcomes in patients with diabetes mellitus. Thirteen studies were identified that reported sensitivity and specificity data on screening tests. No single screening test was reliable in identifying or excluding peripheral arterial disease in patients with diabetes. Although the evidence base is limited, transcutaneous oxygen measurements appear to be predictive of ulcer or surgical wound healing. The diagnosis of PAD (and the decision to revascularize) in patients with diabetes is unreliable using screening tests. Therefore, all patients with diabetes-related foot ulceration should be assessed by a multidisciplinary diabetes foot team that has access to a vascular specialist. A low threshold for noninvasive diagnostic imaging seems appropriate in patients with diabetes-related foot ulceration.

Summary points Peripheral arterial disease (PAD) is an atherosclerotic process that causes stenosis and occlusion of non-cerebral and non-coronary arteries. It has an estimated worldwide prevalence of almost 10%, rising to 15-20% in people over 70 years of age,1 2 and it affects around 27 million people in Europe and North America alone.3 Critical limb ischaemia—the most severe manifestation of the disease—can lead to limb loss or even death if not treated promptly. Each year, 500-1000 new cases of critical limb ischaemia are diagnosed per million of the population, with an estimated annual cost to the NHS of more than £200m (€255m; $314m).4 #### Sources and selection criteria We searched Medline, Embase, and the Cochrane Database for systematic reviews and meta-analyses related to the diagnosis and management of peripheral arterial disease. We also consulted relevant national and international guidelines published by the National Institute for Health and Clinical Excellence, the Trans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease, and the International Working Group on the Diabetic Foot. Increased awareness of the disease, enhanced medical treatment, and new endovascular interventions have dramatically improved the management of patients with PAD.5 6 With the publication of new National Institute for Health and Clinical Excellence (NICE) guidelines on the management of this disease, this review offers a timely summary of current evidence relating to PAD and provides …

Groin wound lymphatic complications after vascular procedures are accompanied by increased risk of infection, prolonged hospital stay, and greater patient morbidity. High-output groin seromas can be difficult to manage and refractory to established interventions. Although subcutaneous talc has been used to prevent seroma accumulation in other high-risk surgical fields, such as after axillary lymph node dissection, it has not been described in the context of vascular surgery. This article presents the first reported case of a persistent high-output groin seroma after endovascular abdominal aortic aneurysm repair managed successfully with intraoperative application of sterile talc.

BackgroundCritical limb ischemia carries a significant risk of morbidity and mortality. The development of scores to predict risk can aid clinical decision making. The Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial investigators developed a model to predict death, which has not been previously validated.MethodsData were collected in a prospectively maintained database on all patients who underwent angioplasty or arterial bypass for peripheral artery disease in a university hospital between January 2008 and June 2010. The main outcome measures were all-cause mortality and amputation-free survival at 3, 6, 12, and 24 months after the index intervention. The BASIL survival predictor, Finland National Vascular (FINNVASC) registry, and Edifoligide for the Prevention of Infrainguinal Vein Graft Failure (PREVENT) models were applied and receiver-operating characteristic (ROC) curve analysis was used to evaluate their predictive power.ResultsData on 342 patients were collected. Patients with isolated iliac disease or claudication were excluded. The 6-, 12-, and 24-month all-cause mortality rates were 11.6%, 17.9%, and 26.8%, respectively. The area under the ROC curve (95% confidence interval) using the BASIL score to predict mortality at 6, 12, and 24 months was 0.700 (0.60-0.80; P < .001), 0.651 (0.56-0.74; P < .003), and 0.681 (0.59-0.74; P < .001), respectively. ROC curve analysis indicated that the performance of the BASIL score in this cohort was comparable to other validated predictive scores.ConclusionsThe BASIL survival prediction model can moderately predict short-term and medium-term mortality in patients with limb ischemia and may be a useful adjunct to decision making in everyday clinical practice.

Objectives Wounds of the lower limb in patients with diabetes are frequently difficult to heal. Some wounds fail to heal despite optimal medical and surgical care. This review examines the evidence for whether free tissue transfer techniques may reduce the requirement of amputation in these patients. Design A systematic review. Materials & Methods Pubmed, Embase, AMED, SCOPUS and CINAHL and Cochrane Library were searched for all articles on free tissue transfer in lower limb wounds in patients with diabetes (September 2010). Current experience, indications and outcomes were analysed. Results 528 patients from 18 studies were included in the systematic review. 66% of patients had concomitant revascularisation with bypass surgery. 63% of flaps were muscle based, 35% fasciocutaneous and 1.7% omental. Pooled in-hospital mortality rate was 4.4%, flap survival was 92% and limb salvage rate of 83.4% over a 28 months average follow-up time. Conclusions In conclusion free tissue transfer achieves successful wound healing in selected patients with diabetes and difficult to heal wounds that would have required amputation. Pre-operative optimisation of vascular supply and eradication of infection is key to success. Objective wound assessment scores and a clear multidisciplinary team (MDT) approach would improve patient care.

Background The aim was to investigate whether a relationship existed between case volume and outcome for lower limb vascular surgical procedures. Methods PubMed, Embase, the Cochrane Library and Google Scholar were searched for all articles on population-based studies on the volume–outcome relationship for lower limb vascular surgery at hospital level. Outcomes were mortality and subsequent amputation after lower limb vascular surgery. The data were subjected to meta-analysis by outcome. Results Some 452 093 patients from ten studies were included in the systematic review and five studies were included in meta-analyses. Seven of these articles found a significant positive hospital–volume outcome relationship. The pooled effect estimate for mortality was odds ratio (OR) 0·81 (95 per cent confidence interval 0·71 to 0·91) and that for amputation was OR 0·88 (0·79 to 0·98), with better results being found after surgery at higher-volume hospitals. Significant heterogeneity was seen in the data. Conclusion Higher-volume hospitals were associated with reduced amputation and mortality rates after lower limb vascular surgery. These data were not as conclusive as those for other vascular surgical procedures owing to significant heterogeneity.

ObjectiveThe purpose of this study was to assess the odds of all-cause mortality in individuals with diabetic foot ulceration (DFU) compared with those with diabetes and no history of DFU. In addition, we sought to determine the strength of association of DFU with cardiovascular and nonvascular mortality.MethodsWe obtained data for a cohort of patients who attended a secondary care diabetic foot clinic or a general diabetes clinic between 2009 and 2010. A clinic cohort of patients with diabetes and no history of DFU provided a control group. Cause-specific mortality was recorded during a median follow-up duration of 3.6 years (interquartile range, 3.3-4.2 years). The association between DFU and all-cause mortality was evaluated by Cox regression. The association between DFU and cardiovascular mortality was determined by competing risk modeling.ResultsWe recorded 145 events of all-cause mortality and 27 events of cardiovascular mortality among 869 patients with diabetes. After adjustment for potential confounders, DFU was associated with both cardiovascular disease (hazard ratio, 2.53; 95% confidence interval, 0.98-6.49; P = .05) and all-cause mortality (hazard ratio, 3.98; 95% confidence interval, 2.55-6.21; P < .001). The proportion of deaths attributable to cardiovascular disease was similar between the groups (18% with diabetes only and 19% with DFU; P = .91).ConclusionsDFU is associated with premature death from vascular and nonvascular causes.

Abstract —Abdominal aortic aneurysm is a smoking-related disorder. Cadmium, inhaled from cigarettes, may accumulate in the aorta and facilitate weakening of the aorta through adverse effects on smooth muscle cell metabolism. Cadmium was measured by atomic absorption spectrometry in infrarenal aortas from 13 patients with abdominal aortic aneurysm and from 17 age- and sex-matched patients with normal-diameter abdominal aorta. Total cadmium content was associated with smoking, assessed as pack-years ( r =0.54, P =0.004), but was similar in aneurysmal and undilated aortas. The cadmium content (mean±SE) was higher in the media (3.25±0.53 ng/mg dry wt, 7±1.2 μmol/L) than in the intima or adventitia (1.14±0.24 and 1.87±0.38 ng/mg dry wt, respectively; ANOVA, P r =0.87, P 50 2 μmol/L, 6 μmol/L, and 6 μmol/L, respectively), but higher concentrations of cadmium were required for upregulation of metallothionein (EC 50 23 μmol/L). The cadmium content of the aorta increases in direct proportion to the pack-years of cigarettes smoked, with selective accumulation in the medial layer. However, the cadmium content of aneurysmal aortas was not higher than that of nondilated aortas for patients with matched smoking history. In smokers, the level of cadmium accumulation is probably sufficient to impair the viability of cultured smooth muscle cells. Similar mechanisms could underlie the development of degenerative aortic disease in smokers.