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To investigate whether the relationship between smoking and peripheral artery disease (PAD) differs by sex (PROSPERO CRD42022352318). PubMed, EMBASE, and CINAHL were searched (3 March 2024) for studies reporting associations between smoking and PAD in both sexes, at least adjusted for age. Data were pooled using random effects. Between-study heterogeneity was examined using I2 statistic and Cochran's Q test. Newcastle-Ottowa Scale was adopted for quality assessment. Four cohort studies (n = 2,117,860, 54.4% women) and thirteen cross-sectional studies (n = 230,436, 59.9% women) were included. In cohort studies, former and current smokers had higher risk of PAD than never smokers. Compared to those who never or previously smoked, women current smokers (relative risk (RR) 5.30 (95% confidence interval 3.17, 8.87)) had higher excess risk of PAD than men (RR 3.30 (2.46, 4.42)), women-to-men ratio of RR 1.45 (1.30, 1.62)(I2 = 0%, p = 0.328). In cross-sectional studies, risk of PAD was higher among former and current compared to never smokers, more so in men, women-to-men ratios of odds ratio: 0.64 (0.46, 0.90)(I2 = 30%, p = 0.192), 0.63 (0.50, 0.79)(I2 = 0%, p = 0.594), respectively. For both sexes, risk of PAD was higher among current smokers compared to those who were not currently smoking. Cohort studies and five cross-sectional studies were of good quality, scoring 6 to 8 of a possible maximum 9 points. Eight cross-sectional studies scored 2 to 5. Further research is required to elucidate sex differences in the relationships between smoking and PAD, as the current evidence is limited and mixed. Tobacco-control programs should consider both sexes.

Women with peripheral artery disease (PAD) often have atypical symptoms, late hospital presentations, and worse prognosis. Risk factor identification and management are important. We assessed sex differences in associations of risk factors with PAD. 500,207 UK Biobank participants (54.5% women, mean age 56.5 years) without prior hospitalisation of PAD at baseline were included. Examined risk factors included blood pressure, smoking, diabetes, lipids, adiposity, history of stroke or myocardial infarction (MI), socioeconomic status, kidney function, C-reactive protein, and alcohol consumption. Poisson and Cox regressions were used to estimate sex-specific incidence of PAD hospitalisation or death, hazard ratios (HRs), and women-to-men ratios of HRs (RHR) with confidence intervals (CIs). Over a median of 12.6 years, 2658 women and 5002 men had a documented PAD. Age-adjusted incidence rates were higher in men. Most risk factors were associated with a higher risk of PAD in both sexes. Compared with men, women who were smokers or had a history of stroke or MI had a greater excess risk of PAD (relative to those who never smoked or had no history of stroke or MI): RHR 1.18 (95%CI 1.04, 1.34), 1.26 (1.02, 1.55), and 1.50 (1.25, 1.81), respectively. Higher high-density lipoprotein cholesterol (HDL-C) was more strongly associated with a lower risk of PAD in women than men, RHR 0.81 (0.68, 0.96). Compared to HDL-C at 40 to 60 mg/dL, the lowest level of HDL-C ([less than or equal to]40 mg/dL) was related to greater excess risk in women, RHR 1.20 (1.02, 1.41), whereas the highest level of HDL-C (>80 mg/dL) was associated with lower risk of PAD in women, but higher risk in men, RHR 0.50 (0.38, 0.65). While the incidence of PAD was higher in men, smoking and a history of stroke or MI were more strongly associated with a higher risk of PAD in women than men. HDL-C was more strongly associated with a lower risk of PAD in women than men.

Cardiovascular disease (CVD) is the leading cause of mortality in women worldwide but has been primarily recognised as a man’s disease. The major components of CVD are ischaemic heart disease (IHD), stroke and peripheral arterial disease (PAD). Compared with IHD or stroke, individuals with PAD are at significantly greater risk of major cardiovascular events. Despite this, they are less likely to receive preventative treatment than those with IHD. Women are at least as affected by PAD as men, but major sex-specific knowledge gaps exist in the understanding of relevant CVD risk factors and efficacy of treatment. This prompted the American Heart Association to issue a “call to action” for PAD in women, in 2012. Despite this, PAD and CVD risk in women continues to be under-recognised, leading to a loss of opportunity to moderate and prevent CVD morbidity. This review outlines current evidence regarding cardiovascular risk in women and men with PAD, the relative significance of traditional and non-traditional risk factors and sex differences in cardiovascular risk management.

The gut microbiota exists in a dynamic balance between symbiosis and pathogenesis and can influence almost any aspect of host physiology. Growing evidence suggests that the gut microbiota not only plays a key role in carcinogenesis but also influences the efficacy and toxicity of anticancer therapy. The microbiota modulates the host response to chemotherapy via numerous mechanisms, including immunomodulation, xenometabolism and alteration of community structure. Furthermore, exploitation of the microbiota offers opportunities for the personalisation of chemotherapeutic regimens and the development of novel therapies. In this article, we explore the host-chemotherapeutic microbiota axis, from basic science to clinical research, and describe how it may change the face of cancer treatment.

ObjectivesWomen with an abdominal aortic aneurysm (AAA) are less likely to receive elective repair than men. This study explored the effect of patient sex and other attributes on vascular surgeons’ decision-making for infrarenal AAA repair.DesignDiscrete choice experiment.SettingSimulated environment using case scenarios with varying patient attributes.ParticipantsVascular surgeons.InterventionsSurgical decision-making.Main outcome measuresAAA repair versus no repair and endovascular versus open repair.Results182 surgeons completed 2987 scenarios. When all other attributes were equal, a woman was more likely to be offered an AAA repair (marginal rate of substitution (MRS) 3.86 (95% CI 2.93, 4.79)), while very high anaesthetic risk (MRS −4.33 (95% CI –5.63, –3.03)) and hostile anatomy (MRS −3.28 (95% CI –4.55, –2.01)) were deterrents. Increasing age did not adversely affect the likelihood of offering repair to men but decreased the likelihood for women, which negated women’s selection advantage from the age of 83 years. Women were also more likely to be offered endovascular repair (MRS 2.57 (95% CI 1.30, 3.84)).ConclusionsPatient sex alone did not account for real-world disparity observed in selection for surgery. Rather, being a woman was associated with a higher likelihood of being offered AAA repair but also a higher likelihood of being offered less invasive endovascular repair. Increased age decreased the likelihood of surgical selection for women but not men. Preference for less invasive repair, combined with inferior rates of anatomical suitability, and the comparably older age of women at the time of AAA repair selection may account for lower rates of repair for women observed.

The current process for managing sexual misconduct perpetrated by doctors in the UK requires major reform, argue Mei Nortley and colleagues

Correspondence to A Pouncey anna.pouncey@gmail.com A 26 year old woman presented to the emergency department six days after having a caesarean section with an area of spreading erythema extending from her wound site over the infra-umbilical abdomen (fig 1). Ecchymosis (a result of tissue necrosis and capillary breakdown), rapidly spreading cellulitis, and pain out of proportion are highly suggestive1 of necrotising fasciitis, which is a surgical emergency. Mortality in necrotising fasciitis ranges from 8% to 76%.5 Appropriate treatment has been associated with a decrease in mortality (10%-40%)6; however, mortality is higher if there is shock and end organ damage (50% to 70%).7 Learning points Consider necrotising fasciitis when moderate to severe cellulitis is present at any location on the body, especially if the patient has had recent surgery or trauma, or has anaemia, diabetes, obesity, immunosuppression, malnutrition, hypertension, or peripheral vascular disease.

IntroductionCardiovascular disease is a major cause of death in men with an AAA. Women experience higher operative mortality than men for open (OAR) and endovascular (EVAR) repair of intact abdominal aortic aneurysm (AAA), but the reason for this is not yet established. This study aimed to define differences in cardiovascular pre-operative co-morbidity and peri/post-operative complications for men and women under-going OAR and EVAR, to explore the impact of cardiovascular disease on adverse outcomes following intact AAA repair.MethodsA systematic review, meta-analysis and meta-regression of sex-specific differences in mortality and complications was conducted and reported according to PRISMA and Cochrane guidance, and registered with Prospero (CRD42020176398). Papers reporting outcomes for men and women, following intact primary AAA repair, from 2000-2020 world-wide were included. Separate analyses were conducted for EVAR and OAR. Data sources included: Medline, Embase and CENTRAL databases 2005-2020 searched using ProQuest Dialog™.ResultsA total of 26 studies (371,215 men, 65,465 women) were included. Risk of 30-day mortality was higher in women for OAR and more so for EVAR (OR [95%CI] 1.49 [1.37,1.61] and 1.86 [1.59,2.17] respectively), and remained following multivariate risk factor adjustment. Although assessment of pre-operative co-morbidities was limited by heterogeneity, cardiac disease was more commonly diagnosed in men (OAR OR 0.72 [0.59,0.88]; EVAR OR 0.65 [0.48,0.87]) no differences in peripheral vascular disease or smoking history were observed. However, following OAR, the likelihood of acute coronary complications was similar for both sexes (OR 1.18 [0.98-1.42]) and following EVAR, for women, the likelihood of acute coronary complication was significantly higher (OR 1.19 [1.03,1.37]). Renal injury, arterial injury and limb ischemia were also more common in women undergoing EVAR (ORs 1.46 [1.22-1.72], 3.02 [1.62-5.65], 2.13 [1.48-3.06] respectively) (figure 1). Meta-regression revealed cardiac complications were significantly associated with greater mortality risk differential between men and women (Figure 2); the association of renal complications with death was of borderline significance.Abstract 35 Figure 1Abstract 35 Figure 2ConclusionsThe excess risk of 30-day mortality for women following AAA repair has not abated with time, with an increased risk differential for EVAR over OAR. Although our meta-analysis identified a lower prevalence in pre-operative diagnosis of coronary artery disease amongst women, acute coronary complications were significantly higher for women following EVAR, and similar to men following OAR. An increase in acute coronary complications for women compared to men was associated with a higher mortality risk differential. Women were also at greater risk of additional arterial complications leading to renal injury and limb ischaemia. These findings suggest that cardiovascular disease has significant impact on adverse outcomes for women after AAA repair. Further work to improve identification and treatment of cardiovascular disease in women is needed and has the potential to address disparity in outcomes for AAA repair. Figure 1. Comparison of 30-day complications for men and women following (a) OAR and (b) EVAR. Figure 2. (a) Meta-regression of log odds of (a) cardiac complications and (b) renal complications against log odds of 30-day/in-hospital mortality for women (vs. men) following endovascular repair of AAA (EVAR). (Cardiac: n= 8, βi =2.96 (se =1.27), p=0.02, tau2 = 0.00; renal: n=8, βi =2.50 (se =1.31), p=0.056, tau2 = 0.01).Conflict of InterestNone

Invasive liver abscess syndrome (ILAS) is caused by Klebsiella pneumoniae and is typically seen in people from East Asia, often with diabetes and gallstones. ILAS includes metastatic sequelae of the infection, commonly to the eyes. The case described below occurred in a London hospital. The patient’s abscess was diagnosed on CT and MRI and he developed endophthalmitis secondary to metastatic spread of the infection. He was treated with intravenous and intravitreal antibiotics and discharged with a plan for vitrectomy and cholecystectomy as an outpatient. We discuss the epidemiology, risk factors, pathogenesis, prognosis and management of this rare condition. There have been a number of recent reports of cases of this nature outside of Asia and we believe greater awareness is required. A high index of suspicion should be held for the potential development of metastases in patients of this demographic presenting with abscesses of this nature.

A 68-year-old man presented acutely with periorbital pain and proptosis of the right eye, on a background of generalised pain and weight loss. Imaging showed bilateral signal abnormalities in the basal skull extending into the extraconal orbits with compression of the right optic nerve. His medical history revealed symptoms in keeping with benign prostatic hypertrophy. However, the prostate was irregular on rectal examination and prostate-specific antigen was markedly raised at 1880 ng/dl. A provisional diagnosis of metastatic prostatic carcinoma was made based on the clinical and radiological picture. This was later confirmed to be metastatic adenocarcinoma through means of tissue diagnosis.