Planned Abortion Post COVID-19 - Juniper Publishers

 

Public Health - Juniper Publishers

Abstract

Reproductive health policies, focused on the decriminalization of abortion, have effects on the beliefs, attitudes, intentions, and behaviors of termination of pregnancy. As women get older, more educated and more income, they rationally choose an abortion, but they move away from the ideal age for procreation of 22 years. The objective of the present work is to establish the exploratory factor structure of scales that measure four factors and 28 indicators (seven for each factor) related to the termination of pregnancy. Consequently, a non-experimental, cross-sectional and exploratory study was carried out with a non-probabilistic selection of 100 students. From a structural model the intentions determined the behaviors, but the factor solution was explained by beliefs. However, the context, sample selection, and type of analysis precludes generalizing the data to other settings. It is recommended to carry out a confirmatory factor analysis with a probabilistic selection of the sample in the local population.

Keywords: Fertility; Abortion; Beliefs; attitudes; Intentions; Behaviors

Introduction

The objective of this study is to weigh the exploratory factor structure of planned abortion in adolescent couples. The termination of pregnancy is the result of a deliberate, planned, and systematic process; therefore, intention, request and curettage are determined by a system of representations, beliefs, attitudes and perceptions regarding assisted abortion [1]. Such a process begins with the dissemination of information concerning sexuality, fertility, the decriminalization of abortion and the consequences of abortion on health. It is known that the fertility cycle established in a 28-day period involves four periods; menstruation –the mucosa or endometrium is detached and is driven by the blood–, fertility –pre-ovulatory proliferation–, ovulation –the endometrium is reconstructed thanks to estrogens– and secretion –the uterine mucosa presents the maximum thickness facilitating fertilization [2].

However, even though the fertility or fertilization cycle is widespread in the basic education system, the media reduce the biochemical process to allusive messages about freedom of choice for women and freedom of procreation. in the case of couples [3]. Consequently, the probability of procreation with respect to age intensifies in the 22 years and decreases dramatically as the age elapses. About 25% of attempts at procreation end in pregnancy, but less than 5% of cases after the age of forty are observed [4]. In other words, the procreation cycle, the probability of fertilization and age seem to correspond to a risk scenario in which curettage and abortion are instruments of freedom of choice in women and couples [5].

The cure is to tear the lining of the uterus [6,7]. The word pregnancy (scrape the surface to separate the membrane that covers it) comes from “pregnancy” and this from the Latin ligula = “teaspoon and also various instruments and blades similar to a teaspoon” . he abortion is the termination of the pregnancy due to natural or caused causes. The word “abortion” comes from the Latin abortus, formed from the prefix ab- (deprivation, separation from the outside of a limit) and (birth) so we understand it as “deprivation of birth”.

A safe abortion is defined as those that meet the legal requirements in the countries where abortion is legally permitted under a wide range of criteria [8]. Clinical abortion is the abortion of a clinical pregnancy that takes place between the diagnosis of pregnancy and the gestational age of 20 full weeks. Retained abortion is a clinical abortion in which the products of conception are not spontaneously expelled from the uterus. Preclinical abortion is the abortion that takes place before clinical evidence or an ultrasound of the pregnancy. Spontaneous abortion is the spontaneous loss of a clinical pregnancy before the full 20 weeks of gestation or, if the gestational age is unknown, a weight of 500 g or less [9,10].

The World Health Organization (WHO) describes unsafe abortion as a procedure to end an unwanted pregnancy [11,12], carried out by both people lacking the necessary skills or in an environment that does not meet minimum medical standards, or both [13]. Clearly, abortion has received considerable attention, yet it continues to generate controversy. In Mexico, the relationship between abortion decriminalization policies and the age of those requesting the termination of pregnancy seems to explain the trend of case by entity.

Mexico City leads the cases of request and termination of pregnancy (100,784 cases), followed by the State of Mexico (33,386), entity with the highest youth population and birth rate [14]. Regarding age and cause of interruption pregnancy, rape is a likely cause for abortion in 60% of cases in women aged 23 to 25 years; the risks of pregnancy are more approved in women from 17 to 19 years of age in more than 40%; But the economic factor is more incisive in those who are between 23 and 25 years old in more than 20% of cases. Finally, the freedom to abort is more exercised in women between 23 and 25 years of age than in women under that age range in more than 10% of cases [15]. Therefore, the wielded data seem to show that there are social representations of freedom of choice around sexuality, procreation and termination of pregnancy that are disseminated in the media and generate attitudes in favor of abortion approval in women between 17 and 25 years old, age where the probability of fertility is greater than in other age ranges [16] However, the social representations of freedom of choice about sexuality and interruption of pregnancy explains a flexible process in making decisions, the statistics seem to refute, since the policies of decriminalization of the abortion. The rational choice that is more observed in women with ages close to 25 years [17]

In this sense, the freedom of rational choice - deliberate, planned and systematic - could be generating attitudes - dispositions in favor of sexuality and the interruption of pregnancy - as women approach the age of 25, an instance in which they should have ended She is studying pre - grade and have developed a prospective life [18]. In the health and human behavior sciences, the explanatory models of planned procreation and abortion warn that it is the socioeconomic factors that determine attitudes and perceptions in the first instance, which in turn influence intentions and the latter in pregnancy or in its termination [19]. However, studies related to pregnancy and its interruption maintain that such actions are not exclusively determined by the rational choice of women, but also in such a decision socio- cultural factors - values, norms, customs and customs, local traditions - affect [20]

In this socio-cultural sense, the relationship of a couple - stable without commitment, stable with commitment, unstable without commitment and unstable with commitment - influences the decision of pregnancy and / or interruption of procreation [21]. In this way, couples who maintain stable and committed relationships choose pregnancy or the termination of the same, but in other couple relationships it is the man who delegates to the woman’s family the decision to procreate or terminate the pregnancy.

In this sense, parental parenting styles - authoritative, permissive or assertive - will influence procreation or the termination of pregnancy. In this way, assertive parenting styles are those that favor and support the woman’s decision and if she has a partner, the choice of both [22]. However, if parenting styles are rather authoritarian or permissive, then a dominant actor will make the decision to abort or procreate. The cases presented not only reduce women’s freedom of choice, but also highlight the sociocultural context; family norms or relationships determine the procreation or termination of pregnancy.

Even though the styles of parenting and the types of couple relationships are depositories of a culture in which the female body is an instrument of social reproduction, more than personal satisfaction, the planned fertility model warns that at an older age, education and income, the woman’s choice prevails over any norm or value [23]. That is, a high educational level corresponds to a higher income, but it also supposes a deliberate, planned, and systematic lifestyle that is contrary to the probability of optimal fertility in the 22 years [24]. It is a dilemma that involves exercising freedom of sexuality and termination of pregnancy as age, education, and income increase, but fertility d is less and less likely [25]. In the case of couple relationships, psychological studies of abortion warn that the type of relationship - time, dedication, commitment, jealousy - determines the expectations of the couple relationship. In this way, couples who have a meaningful, prolonged, committed and violence-free coexistence make decisions to procreate a child.

However, the influence of beliefs has not been established, since in deliberate and planned models they are determinants of attitudes. Therefore, a study about beliefs, in relation to the other variables of the planned pregnancy model, would clarify the exposed dilemma [26-28]. The specified model of dependency relationships explains the effects of the abortion decriminalization propaganda, considering three assumptions regarding 1) beliefs  attitudes; 2) beliefs  attitudes  intentions and 3) beliefs  attitudes  intentions  behaviors.

Assumption 1: beliefs  attitudes. On a general level of policies, diffusion and audiences, l a d decriminalizing abortion, widespread in the media, creates provisions against and in favor of pregnancy and its interruption depending on the information; causes and effects of reproductive health policy

Assumption 2: beliefs  attitudes  intentions. In a more specific sense around the rational choice of women, the information on the decriminalization of abortion not only generates negative or positive dispositions, but also provides estimates based on costs and benefits about the causes and consequences of carrying out a birth. , caesarean section or abortion, considering age, income and education. It is a process in which the more specific the information about the pregnancy and its interruption increases the probabilities of making decisions and carrying out such actions.

Assumption 3: beliefs  attitudes  intentions  behaviors. In a personal sphere, the effect of the information on the causes and consequences of the termination of pregnancy is processed and assimilated into provisions in such a way that they determine the decisions and strategies, provided that it is the product of the deliberation, planning and systematization of said information, corresponding to abortion.

Method

Formulation: What are the differences between the relations of explanatory dependence on the planned pregnancy - sex, age, income, beliefs, attitude, intentions and behaviors - regarding dependency ratios weighted?

Null hypothesis: The theoretical dependency relationships between indicators and factors related to the termination of pregnancy are adjusted to the weighted dependency relationships.

Alternate hypothesis: The theoretical relationships and the weighted relationships are different.

Variables:

i. Sex: Refers to the identity of the couple that can be female or male.
ii. Age: Refers to the period of life from birth.
iii. Income: Refers to the sum of wages, scholarships or economic and financial supports.
iv. Beliefs: It refers to the processing of information – religious, academic, daily– related to the termination of pregnancy. v. Attitudes: It refers to the provisions against or in favor of the termination of pregnancy.
vi. Intentions: Refers to the probability of deciding to terminate the pregnancy.
vii. Behaviors: It refers to the fidelity, documentation, financing and request regarding the termination of the pregnancy.
viii. Design: A non-experimental, cross-sectional and exploratory study was carried out.
ix. Sample: A non-probability selection of 100 students from a public university in Xochimilco, Mexico City was carried out . 43% are women and 57% are men; 21% are under 18 years old (M = 17.24 and SD = 1.24), 35% are between 18 and 22 years old (M = 20.35 and SD = 1.27) and the remaining 47% are over 22 years (M 22.46 and SD = 2.36); 40% pay less than 3,000 pesos per month (M = 2’97 3 and SD = 124.35), 25% pay between 3’000 pesos per month and 7’500 pesos per month (M = 6’245 and DE = 135 , 25) and the remaining 35% pay more than 7’500 monthly (M = 7’821 and SD = 135.26).
x. Instrument: The Variable Scales related to the Termination of Pregnancy were used.
Beliefs scale. It measures the processing of religious, academic, or everyday information regarding the termination of pregnancy. It includes two response options ranging from 0 = “false” and 1 = “true”. For example: “ Having a child is beyond my will.”
xi. Attitude Scale: It measures the provisions against and in favor of the termination of pregnancy. It includes five response options ranging from 0 = “not at all agree” to 5 = “strongly agree”, “The decision to have a child is the parents.”
xii. Scale of Intentions: It measures the couple’s expectations regarding the termination of the pregnancy. It includes five response options ranging from 0 = “not at all likely” to 5 = “very likely”. For example: “I would have a child even if my partner abandons me.”
xiii. Scale of Behavior: It measures the frequency of actions related to fidelity, documentation, financing, and requesting termination of pregnancy. It includes five response options ranging from 0 = “never” to 5 = “always”. For example: “Before deciding childbirth I have documented in the matter.”
xiv. Process: The Delphi technique was used to homogenize the meanings of the words used in the reagents. Confidentiality was guaranteed in writing, and it was reported that the results would not affect the academic status of the students. The surveys were carried out in the lobby of the public university library. The information was processed in the Statistical Package for Social Sciences (SPSS) and Structural Moment Analysis (AMOS) version 21.
xv. Analysis: The internal consistency was established with param and alpha Cronbach. Adequacy and sphericity were estimated with the KMO parameters and the Bartlett test. The Exploratory Factor Analysis was performed with the method of extraction of main axes, promax rotation and oblique criteria. Factor weights greater than 0.300 were required to interpret the factors. The fit of the dependency relationship model was established with fit and residual statistics.

Results

The reliability of the belief scales (alpha = 0.752), attitudes (alpha = 0.760), intentions (alpha = 0.783) and behaviors (alpha = 0.775) reached values higher than the minimum required Table 1. The adequacy and sphericity ⌠χ2 = 146.20 (45gl) p = 0.000; KMO 0.645⌡ allowed to establish the validity of the construct was established from the total percentage of the explained variance; beliefs (23%), attitudes (20%), intentions (17%) and behaviors (14%).

To observe the structure of relationships between the factors, the correlations and covariances were estimated, considering the specification of the model that proposes linear trajectories between beliefs, attitudes, intentions, and behaviors Table 2. The structural model of dependency relationships Figure 1 established the path of beliefs  attitudes  intentions  behaviors as the one with the highest explanatory plausibility, since it is the intentions that determine the behaviors. In turn, attitudes have a greater impact on intentions, although they seem to reduce the effect of beliefs on dispositions. The values of the adjustment and residual parameters ⌠χ 2 = 256,26 (41df) p > 0.05; CFI = 0.997; GFI = 0.990; RMSEA = 0.008⌡ allowed us to accept the null hypothesis regarding the similarities between the theoretical dependency relationships and the weighted dependency relationships.

Discussion

The contribution of the present study to the state of knowledge lies in the establishment of an exploratory factor structure of the planned termination of pregnancy. It is a main axis polychoric factorial solution, with obliqueness and promax rotation criteria that is consistent in each of its factors and indicators. However, the context of the study, the selection of the sample and the exploratory factor analysis prevent generalizing the data to other study areas, since a randomized and stratified sampling, as well as a study in a non-university population, would allow a confirmatory factor analysis of established dependency relationships.

This is so because, unlike exploratory factor analysis, confirmatory factor analysis weighs measurement errors and establishes the incidence of factors not included in the dependency relationship model.

This is the case of homoscedasticity –constant measurement errors in indicators and factors– that in the exploratory factor analysis seems to have no influence, but in the confirmatory factor analysis it would modify the structure and factor solution. Therefore, a study with the characteristics and recommendations put forward would explain the effects of reproductive health policies in general and the decriminalization of abortion specifically, on the beliefs, attitudes, intentions and behaviors of women and their partners in the face of childbirth- caesarean section or abortion.

Conclusion

The objective of the present work was to specify a model for the study of pregnancy termination, although the design limited the findings to the sample, positive relationships were established between beliefs, attitudes and intentions regarding behaviors, suggesting the extension of this I work in other settings of reproductive health and sexuality. Future lines of research regarding factors explaining abortion intentions will allow anticipating demographic growth scenarios. The public policies that emerge from these results show that the population between 18 and 22 years of age is prone to plan their termination of pregnancy and based on this finding, it is possible to anticipate risk scenarios, as well as prevention, self-care and self-efficacy in vulnerable populations.

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Creating Art by 3D Pen - Juniper Publishers

 

Fashion Technology & Textile Engineering - Juniper Publishers

Abstract

3D printing technology is a new rapid prototyping technology, but 3D pen is a pen with 3D printing function, it’s extrudes heated or warm molten plastic from the pen’s nozzle. You don’t need any software, there are no files to transfer. whatever you imagine, you can draw. It goes from your brain, to your hand. It can cultivate students’ innovative thinking and problem-solving ability in maker education. Despite the many advantages of 3D pens in artistic creation and education, the popularity of 3D pens is so low that many people do not even know the technology or how to use it. When entering “3D pen” or “application of 3D pen” for paper retrieval, the relevant literature can hardly be found. This article is aimed at introducing

a) How 3D pen works?

b) Examples drawn by 3D pen.

c) Variety of materials and color choices.

d) Types of 3D pens in the market and

e) Future possibilities.

Keywords: 3D pen; Application of 3D printing pen; 3D printing; Maker education; Childhood education; Innovative thinking; Art; DIY; Three-dimensional painting; Cultural transmission

Review

For millennia, people around the world are enticed with beautiful, enticing and intriguing drawings, watercolor paintings and oil paintings drawn on different media. Imagine the impressions on people if they are three dimensional instead of mere two dimensional! With the emergence of three-dimensional printing pen or 3D pen, it is now feasible to draw a variety of three-dimensional patterns in the air, like a magic pen. This article is aimed at introducing

a) How 3D pen works?

b) Examples drawn by 3D pen.

c) Variety of materials and color choices.

d) Types of 3D pens in the market and

e) Future possibilities.

History and Introduction

The following schematic, Figure 1 outlines timeline of major technological/scientific milestones in western art over thousands of years, from pre-classical art to classical art, medieval art, European Renaissance art, baroque and rococo art, 19th century western art, to western modernist art. Chinese art has a long history. Unlike Europe, where art styles are always changing, Chinese art has maintained a surprising continuity over the centuries. The works of the Ming dynasty can also see the influence of the tang dynasty. A painting from the Qing dynasty is very similar to one from the song dynasty. One reason is China’s reverence for tradition. Since the 16th century, Chinese arts and crafts, especially porcelain, were exported to Europe in large quantities, which also had an impact on European art. After the republic of China, traditional Chinese art developed with the rapid changes of the times. Chinese painters began to study in the west and have direct contact with European paintings, such as Xu Beihong and others. The establishment of new painting school also promotes the westernization of Chinese painting [1]. The evolution of Indian art style is not only governed by the discipline of formal beauty, but also related to the evolution of Indian religion and philosophy. The ancient art scene of India: bright colors, colorful and exaggerated shapes, and the belief in the afterlife and the past. While highlighting the strong national characteristics, it has also absorbed many artistic factors from Europe and west Asia.

Technological/scientific and art are mutually reinforcing. In the primitive times, only stone chisel technology, red earth as the material, so the rock painting murals; The Neolithic pottery technology, the color pottery above can leave beautiful geometric patterns and animal-shaped patterns. The invention of smelting technology, people cast all kinds of copper and iron, with a metal texture chisel to carve David and other masterpieces. Therefore, smelting technology plays a crucial role in the art of sculpture. The invention of oil paints, as well as the use of perspective, golden section, optics, color, anatomy, black box and other scientific principles and techniques in painting to make painting works closer to the real things. Da Vinci left the Mona Lisa’s eternal smile. With the development of photography technology, nature can be vividly represented. With the gradual improvement of computer technology and functions, painting has developed from the original sketching to computer painting and holographic art works vivid and realistic, combined with sound and electricity and three-dimensional animation [2].

How 3D Pen works?

First, connect the power supply of the 3D pen, the power indicator light will be on, click the feed button, the heating lamp will turn red, the 3D pen will start pre-heating, about 50 seconds of pre-heating completed, the indicator light from red to green (Figure 2). Then press the feed button and add the filament into the feed port [3]. The mechanical device in the pen will send the filament to the heating nozzle to start using. When it does not have any operation within 90 seconds, the system will automatically enter the sleep state, which can effectively avoid wasting energy without any operation for a long time. When the feed button is clicked again, the 3D pen can be awakened. When finished using, press the return button to exit the remaining wire. The 3D pen supports portable power supply, making it safe and convenient. 3D pens from different manufacturers may vary slightly, but the principle is the same (Table 1). Simple 3D pen techniques and skills. Drawing with a 3D pen is like drawing and writing with crayons, pencils and pens you just need to gain control and confidence [4]. It is useful to learn basic techniques and practice on simple 2D templates first. Practice will give you good control. Once you have mastered the art of drawing with a 3D pen, you can draw any three-dimensional pattern or model. The 3D pen allows people to visualize their thoughts and shape your ideas into real shapes.

Examples Drawn by 3D Pen

The 3D pen is like any other tool and skills, it takes a little patience and practice to learn how to use it and gain proficiency. It takes time and practice to draw and model with hot molten plastic.

Design awareness and capability are life skills. To cultivate the creative ability of primary and secondary school students, 3D pens are brought into the classroom in an easy and interesting way, enabling students to cultivate and exercise innovative thinking and creativity through the latest technological tools (Figure 3). For example, in the campus science and technology innovation competition, if the appearance of the entries needs to be modified or some spare parts are needed, then the 3D pen can quickly solve these problems [5]. Schools encourage the exploration of new modes of education. As a new tool used in teaching, 3D pen can turn learning into a process of innovation and creation, cultivate students’ creative thinking, creativity and teamwork ability, and pay attention to the connection between learning and the real world, instead of just the test results of test papers (Figure 4). 3D pens are suitable for people of all ages. Whether they are children, adults or the elderly, anyone can draw with a 3D pen. Fire your imagination, activate your design capability, Enjoy the fun of creating (Figure 5). You can use a 3D pen to make a gift for your family and friends. It will be a special gift because you have made it yourself. You can also use a 3D pen to complete a beautiful painting or make any three-dimensional object to use as an interior decoration. It’s a great way to relieve stress for office workers [6].

The 3D pen can be combined with comprehensive materials to create and solve problems in real life. The 3D pen is a practical tool for DIY enthusiasts. For example, when we want to do a unique small electric fan, need to prepare electronic components for electric fans, motor, blade, batteries, electric wire, switch, and then use 3D pen draw the lid of the electric fan, fixed bracket, draw some beautiful adornment, a unique fan was finished, it can be used as works of art and can be used as a practical article for daily use (Figure 6). It is a good drawing tool for architects and product designers. The covid-19 epidemic of 2020 has emerged and spread so fast that we are all facing a severe test. Due to the outbreak, people have to wear masks to go out and work. However, many masks are produced without considering the need for the tightness and length of the ear strap for a long time. Moreover, the ear strap of the mask needs to be hung on the ear, which can be very painful due to the pressure of the rope on the ear root for a long time. In order to solve the problem of mask wearing, you can use 3D printing pen to design a beautiful and practical “mask adjusting band”. When wearing a mask, the ropes on both sides of the mask can be stuck on the mask adjusting band to free the ears from being squeezed. Wearing masks can also become fashionable (Figure 7). 3D pen painting is another expression form of 21st century painting, which is to inherit, integrate and improve ancient and modern Chinese and foreign things and historical culture. It can make the picture more three-dimensional, colorful, with a very good visual effect, and not easily affected by moisture. 3D pen painting expands the space for artistic creation, allowing artistic works to be presented in various forms (Figures 8 & 9).

Variety of Materials and Color Choices

The consumables (Table 2) used for the 3D pen are ABS, PLA and PCL, monofilament (Ø = 1.75mm). ABS is an engineering material with a melting temperature of 217-237℃, and it has an unpleasant smell during use, so not many people use it now. Polylactide (PLA) is a bio-based and renewable biodegradable material, which is made from materials extracted from renewable grain husk, straw and straw. After being used, it can be completely degraded by nature under specific conditions and eventually generate carbon dioxide and water without polluting the environment. The melting point of PLA is 155-185℃. The molten PLA material is rapidly cooled and solidified in the air after coming out of the pen, forming hard lines, so that the three-dimensional model can be drawn directly in the air, which is very advantageous for making architectural models and three-dimensional structure models. Polycaprolactone (PCL) is a biodegradable material with many excellent characteristics, such as excellent low temperature plasticity, 58-70℃ melting point, good toughness and seawater degradation (Figure 10). The color of materials is very rich, there are already dozens of colors available on the market. And the color and luster of the material that different manufacturer produces can be different, some material color is very pure, some material color can be met light, people can choose different material color according to need. According to the experience of two different colors of materials can also be mixed like a pigment, so that your works will be very rich in color [7].

Types of 3D Pens in the Market

a) The first 3D pens to appear on the filament is the high temperature 3D pen, its operating temperature is around 180- 240℃. When using ABS filament, the working temperature of 3D pen needs to be heated to about 220℃. In such a high temperature condition, users are easy to be scalded by the pen tip, so few people use this kind of high-temperature 3D pen now. When using PLA filament, the working temperature of the pen is around 180℃. Because of the good stereoscopic plastic effect and the relatively affordable price of the material, the sales volume of this 3D pen is very good.

b) It is known that users of 3D pens tend to be younger, especially among primary and secondary school students. In order to consider the safety of pens used by children, the low temperature 3D pen is now on the market, and its printing temperature is around 60℃, which avoids the risk of children being burned by pens in the process of use. It can also be charged with an automatic power supply, making it safer and more convenient. Its corresponding filament is PCL.

c) There are also 3D pens with accumulators on the market, which do not need to be connected to the power supply all the time in the process of use and can work continuously for about two hours. However, its disadvantage is that the pen body is very heavy, which increases the burden of people’s hands when painting.

Future Possibilities

The popularity rate of 3D pens is not very high, and the users are mainly concentrated in the first and second tier cities. Many people in towns and townships have not even seen 3D pens. However, many makers’ centers and schools now offer classes on creating 3D pens, and it is believed that more people will use 3D pens in the next few years. At the same time, the quality of 3D pen will be constantly optimized, the product will be more and more exquisite, and the safety and stability will be better and better. I believe that there will be more people like to use this new painting tool for artistic creation (Figure 11).

Technology and application of 3D pen in the future from 2050 to 2100:

a) In the future, with the development of artificial intelligence, 3D pens are also equipped with intelligent technology. The pen is equipped with a consciousness sensor receiver, which can read the brain signals, read the things and pictures in our brain, and then the 3D pen will draw your thoughts automatically.

b) In the future, 3D pen will be upgraded to 4D printing pen. About “4D printing,” compared to traditional 3D-printed parts, the additional dimension in the time domain allow for the components to undergo dramatic changes in shape when subjected to an external stimulus. stimuli that induce time-dependent behaviors are usually temperature changes or water exposure.

c) 3D pen with AR (Augmented Reality) technology, the virtual information are fused together with the real world of technology, the computer generated text, images, 3D simulation model, music, video and other virtual information, applied to the real world, at the same time to join 3D pen drawing entities part, two kinds of information complement each other, so as to realize the virtual and real world of perfect combination of artistic effect.

d) In a few decades’ time, the 3D pen’s consumables could come from recycled plastic materials that have been processed into biodegradable, environmentally friendly materials. The consumables of 3D pen can also come directly from the nature, such as drawing a river, people directly use water as raw material to print in the picture. Painting a mountain can directly use the stone as a material to print a picture of the stone and so on.

Conclusion

In the future 3D pen applications will bring great creativity to the art world.

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Lower Psoas Muscle Area is associated with increased mortality after endovascular aneurysm repair in older adults - Juniper Publishers

 

Gerontology & Geriatric Medicine - Juniper Publishers

Abstract

Lower Psoas Muscle Area is associated with increased mortality after endovascular aneurysm repair in older adults.

Introduction: Psoas muscle area (PMA) is an easily measurable surrogate of sarcopenia, which may be associated with mortality and other adverse post-operative outcomes. This study aimed to further explore the relationship between PMA and outcomes post elective infrarenal aortic aneurysm (AAA) endovascular repair of (EVAR) in older adults.

Methods: A retrospective observational study of people aged over 65 years undergoing EVAR for asymptomatic AAA over 5 years. Patients with connective tissue disease, mycotic or inflammatory AAA, emergency or non-elective cases were excluded. The primary outcome was 5-year mortality. Secondary outcomes were 30-day readmissions, post-operative complications, and length of stay.

Results: Ninety-seven patients (mean age 77.5 years, 78% male) were assessed. Adjustment for age, sex and body mass index also showed that patients in the lowest PMA tertile had an increased 5-year mortality (HR 2.76, 95%CI 1.08, 7.03; P=0.034). Adjustment for frailty, measured by modified frailty index, showed only a minimal attenuation of the association (HR 2.30, 95%CI 0.99, 5.34; p=0.054). Being in the lowest PMA tertile did not increase LOS, 30-day readmissions, complications, or influence discharge destination.

Conclusion: The lowest tertile of PMA, as a surrogate marker for sarcopenia, was associated with increased mortality in patients undergoing EVAR for asymptomatic infrarenal AAA, which was only marginally attenuated by frailty adjustment. Although sarcopenia is a complex phenomenon and the literature surrounding it is still evolving, PMA may form one component of risk assessment in patients undergoing EVAR.

Keywords: Frailty; Psoas Muscle Area; Sarcopaenia; Vascular Surgery

Keywords: PMA: Psoas Muscle Area; AAA: Abdominal Aortic Aneurysm; EVAR: Endovascular Aneurysm Repair; LOS: Length of Stay; PMA: Psoas Muscle Area; CT: Computed Tomography; GEKO: Governance Evidence Knowledge Outcomes; SPSS: Statistical Package for the Social Sciences

Introduction

The evolution of abdominal aortic aneurysm (AAA) repair from open to endovascular aneurysm repair (EVAR) has great relevance in older adults, who often have more comorbid conditions, are frailer and have higher levels of sarcopenia. EVAR, where technically feasible and where the maximum aortic diameter has reached threshold (>5.5cm in men and >5.2cm in women) is minimally invasive and involves the deployment of a stent graft inside the aneurysm via percutaneous femoral access, and has several advantages including avoidance of general anesthesia, reduced length of stay (LOS) and reduced postoperative mortality [1].

Sarcopenia and frailty are distinct but overlapping conditions. Frailty is “a biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems, and causing vulnerability to adverse outcomes” [2]. There have been multiple screening tools developed in an attempt to assess frailty, which usually follow either a phenotypic or cumulative deficits model [3]. Despite the differing tools used to measure frailty, higher frailty scores are associated with increased mortality, post-operative complications, and length of stay in surgical patients [4], higher mortality following open AAA repair and carotid endarterectomy [5] and vascular surgery [6], and LOS and discharge destination in vascular ward patients [7].

Sarcopenia, on the other hand, is defined as “a progressive and generalised skeletal muscle disorder that is associated with an increased likelihood of adverse outcomes including falls, fractures, physical disability and mortality” and “confirmed by the presence of low muscle quantity or quality” [8,9]. Several parameters have been used to define muscle quantity, including psoas muscle area (PMA). A decline in PMA seems to be representative of decreased lean body muscle mass and sarcopenia, at least in haemodialysis patients. However, the European guidelines suggest more research is required to formalise whether PMA is a reasonable surrogate for skeletal muscle mass [10].

There is emerging evidence to suggest that PMA is associated with mortality in older vascular surgical patients following endovascular aortic surgery, and to a lesser extent post-operative complications. Some, but not all studies [11,12], have shown that a reduction in PMA correlated with higher mortality following EVAR, open AAA repair or other vascular intervention [13-21]; but none of the studies to date have included frailty scoring in conjunction with PMA in this setting.

In the AAA population, widespread use of computer tomography (CT) imaging enables easy measurement of PMA as a representation of sarcopenia. PMA could therefore be an easy to obtain predictive tool for outcomes following EVAR, and to determine whether the procedure is in the patient’s favour or not. Our study further explored the relationship between PMA with post-operative outcomes and mortality in older adults undergoing asymptomatic infrarenal EVAR, seeking to assess whether similar correlations between PMA and mortality were found in the local surgical population in Western Australia. We chose to include frailty to further clarify this issue.

Methods

A retrospective observational study of patients 65 years and older who had undergone an elective EVAR for asymptomatic infrarenal AAA, in a tertiary metropolitan centre in Western Australia, from 1st January 2013 to 31st December 2017. Patients were excluded if the cause of the AAA was connective tissue disease, mycosis, or inflammation, and if EVAR was performed as an emergency or non-elective procedure for symptomatic AAA.

Retrospective data was collected from chart review and electronic medical records. Baseline patient characteristics included age, sex, current smoking status, Charlson comorbidity index, the presence of coronary artery disease (history of previous myocardial infarction, coronary artery bypass graft surgery or percutaneous coronary intervention), cerebrovascular disease, chronic kidney disease, diabetes, hypertension, peripheral vascular disease (intermittent claudication, critical limb ischemia, revascularisation or lower limb arteries), as well as, maximum antero-posterior AAA diameter, BMI, and preoperative haemoglobin levels. A modified frailty index (following a cumulative deficits model of frailty) was also calculated for each patient based on information found in medical records. This provided a score out of 11, with a score of 0 indicating an absence of frailty, and a score of 11 indicating the highest level of frailty [22].

PMA was measured at the mid L4 vertebral body on preoperative computed tomography (CT) scans. Where possible, 3mm slice thickness was chosen for measurement, however if this was not possible, 5mm or 1mm slice thickness was chosen. 3mm slice thickness was the most common and thus was the preferred slice thickness for consistency. A radiologist assisted with initial training of one researcher. Following this, the researcher proceeded to calculate the PMA for the rest of the patients. If there were any uncertainties regarding the psoas muscle calculation, the primary researcher verified the measurement with the radiologist.

The primary outcome was survival (calculated as days from operation). Follow up date selected was 31/10/2020. Study end date, the date of final data collection, was 23/02/2021. Determining the survival was based on hospital death records. This was also checked by means of seeing whether the patient had attended subsequent appointments or had subsequent admissions in patients without hospital record of death. This was essential as in Western Australian hospital records as patient death is not always recorded unless the patient has died during a subsequent public hospital admission, or the hospital is formally informed. Patients who could not be confirmed to be alive (or dead) as of the 31/10/2020 were censored in the survival analysis at the last known date that they were alive.

Secondary outcomes were 30-day readmissions related to EVAR, discharge destination (home, residential care, rehabilitation), post-operative complications, and length of stay (LOS) measured in days. This project was approved under the GEKO (Governance, Evidence, Knowledge, Outcomes database used to register information about quality improvement studies and clinical governance) system of WA Health, for projects deemed low- to negligible-risk to patients (GEKO#: 27118).

Statistical Analysis

Results were presented as a measure of central tendency, i.e., median with inter-quartile range, mean with standard deviation or as frequency and proportion. Differences between groups assessed with an independent t-test, non-parametric Mann-Whitney U test, and Fisher’s exact test, where appropriate. Univariate correlations were quantified by Spearman’s (rho) correlation coefficients (Rs). Linear and logistic regression analysis determined the crosssectional association between exposure (PMA) and outcomes. Cox proportional hazards regression analysis determined the uniand multi-variate association between the lowest tertile of psoas size for either sex with mortality. Multivariate models included further adjustment for age, body mass metrics, sex, and other comorbidities associated with mortality.

Statistical significance was set at α=0.05 or 5% level. The statistical analysis was performed on Statistical Package for the Social Sciences (SPSS) Version 22.0 (IBM Corp.; Armonk, NY, USA).

Results

Of the 122 patients identified as having undergone an EVAR procedure, complete data was available for 97 (79.5%). Five patients were excluded as they did not meet inclusion criteria (3 due to age, 2 due to missing information about the type of operation performed). Eighteen patients were excluded as imaging was not available to ascertain PMA data. Although these patients had similar demographics and clinical characteristics to those who were included, the exception was a lower complication rate in the excluded patients, although this failed to reach statistical significance (44% vs. 22%, p=0.06).

The study sample had a median age of 78 years, male preponderance (78.4%), and 79% were ex- or current smokers. Participants had a high prevalence of cardiovascular disease (85%, n=82/97), including coronary disease, cerebrovascular disease, hypertension, and peripheral vascular disease. Complications occurred in 44% of patients - the majority of which were categorized as ‘other’ (that is, not a fall, delirium, venous thromboembolism, bleeding, or infection). Most common was type 1 and 2 endoleak (n=8, with one requiring surgical intervention) and ischaemic complications (n=6 -testicular infarct, 3 non- ST elevation myocardial infarct, ischaemic lower limb, splenic infarct). Twenty-six (27%) patients had died by end of follow up. Twenty-six patients were unable to be confirmed to be alive at the time of follow up (31/10/2020). Median follow-up was 3.7 years with IQR 2.51 to 5.3 years (Range: 0.01 - 8.84 years) (Table 1).

PMA exhibited pronounced age- and gender-specific differences. Female patients and those over >80 years of age had lower PMA. However, median PMA was similar for females patients regardless of age group. PMA was also shown to vary significantly by body mass index, with a higher BMI significantly associated with a higher than median PMA for sex and age. PMA was divided into tertiles, with comparison made between the lower tertile and upper 2 tertiles. Those in the lower tertile (PMA less than 1938 mm2 in males and less than 1202 mm2 in females) tended to be older, with a lower weight and BMI. Degree of frailty as per modified frailty index and comorbidities including cardiovascular disease, hypertension, renal failure, diabetes, and smoking status were similar in both groups. There was no significant difference in complications, readmissions, or LOS between the two groups, and no significant difference in length of follow-up. There was however a significant difference in crude 5-year mortality following operation, with 35% (12) of those in the lowest tertile having died after 5 years compared with 17.5% (11) of those in the upper two tertiles (p=0.049), (Table 2). The lowest tertile of PMA for either sex was associated with 5-year mortality after elective EVAR surgery for asymptomatic infrarenal AAA, as demonstrated by Kaplan Meier survival curve. This was maintained after adjustment for age, sex and BMI as per (Figure 1).

There was a significant association also noted between the lower tertile of PMA for either sex, when adjusted for BMI, for increased risk of death (OR 3.53, 95%CI 1.21 -10.27, p=0.021) and increased LOS (β 0.33, 95%CI 0.04-0.63, p=0.028). However, there was no association between lower tertile PMA for complications in either gender (Table 3).

Sensitivity Analysis

The lowest tertile of PMA for either sex after EVAR was associated with increased risk of 5-year mortality in the unadjusted model (HR 2.31, 95%CI 1.02, 5.24; P=0.045), which remained after adjustment for BMI (HR 2.91, 95%CI 1.16, 7.34; P=0.023) and after adjustment for age, sex, and BMI (HR 2.50, 95%CI 1.03, 6.07; P=0.043). The association between the lowest tertiles of PMA for either sex was attenuated by age-adjustment alone, but the association was strengthened after the inclusion of sex and body mass metrics. Lowest tertile PMA associated with an increased risk of 5-year mortality after adjustment for prevalent diabetes, cardiovascular disease and complications during admission. Modified Frailty Index minimally attenuated the association between lowest tertile of PMA and risk of 5-year mortality after EVAR procedure (Table 4).

Discussion

This study reported a two-to-three-fold increase in 5-year mortality in the lowest tertile of PMA, which was strengthened after adjusting for age, sex, and BMI, in elderly patients undergoing elective EVAR for asymptomatic infrarenal AAA, in a single tertiary centre in Western Australia. This association was also strengthened after adjusting for cardiovascular disease, diabetes, and obesity, but was marginally attenuated with adjustment for frailty. The association between mortality and PMA has been observed in several studies before, showing a similar association between low PMA and higher mortality in the diverse EVAR population. Most studies are single centre, retrospective and heterogenous in nature. Drudi et al (open repair of AAA and EVAR) showed decreased 5-year mortality by 14% for a 1cm2 increase in PMA [14]. Lindstrom et al. (elective and emergency EVAR for infrarenal and more complex AAA) showed a lean PMA (calculated by Hounsfield units multiplied by total PMA) was independently associated with 26% reduced mortality per standard deviation increase of lean PMA, and more strongly associated with mortality than total PMA at L3 (22%) [18] respectively. Newton et al and Oliveira et al, (elective EVAR), also showed an association between the lowest tertile of PMA with increased mortality, with OR of 3.9 [15] and HR of 4.1 respectively [19]. Similarly, Huber et al showed the lowest quartile of PMA was associated with reduced median survival time (65 months vs 91 months) (25). Karkkainen et al (fenestrated-branched EVAR) found reduced lean PMA had inverse correlations with major adverse events and mortality, and further showed in a prospective cohort similar correlation with mid-term survival and quality of life [16,17].

In opposition, Chowdury et al, (vascular patients admitted to vascular unit having had CT abdomen) did not show a link between PMA and mortality and readmission [11]. This opposing result may be due to the heterogeneity of the patient population examined - roughly 52% did not undergo EVAR, lower duration of follow up (12-24 months), and BMI not being accounted for as potential confounder. Indrakusuma et al (asymptomatic infrarenal AAA) did not find an association between PMA and survival in either EVAR/open repair or conservative management groups [12]. However, the surgical cohort was generally younger than other studies and again BMI was not accounted for as a potential confounding factor.

The effect size of our study was smaller than in most other studies. This may be explained by our calculation of PMA by dimension, rather than lean PMA. Lindstrom et al. indicated that a stronger association is found with lean PMA rather than total PMA [18]. Frailty was not assessed in previous studies and differences in outcomes may be explained by differences in frailty. Furthermore, our study was specific to elective infrarenal AAA, whereas other studies had a significantly more heterogenous population, ranging from vascular surgery patients admitted who had CT abdomen, to patients undergoing EVAR for aortic aneurysmal disease in general.

The association between lowest tertile of PMA in either sex with 5-year mortality was attenuated by age-adjustment alone. This may be due to a narrowing of the differences in PMA with increasing age for either sex, or a lack of sufficient study power. The actual number of deaths in each arm was small and the older cohort and expected life expectancy make interpretation difficult. Additionally, “old age mortality advantage”, a phenomenon describing relative improved mortality in those 70-79 years, as compared to younger ages and other countries, may also explain the attenuation [23]. This result is also reflected in other studies [15,16]. Similarly, smoking status (seen in Karkkainen et al.) and the presence of underlying renal disease appeared to attenuate the association of PMA and mortality, again suggesting that PMA may be less useful in predicting mortality outcome in smokers or those with underlying renal disease [16].

The novelty of our study was the simultaneous measurement of frailty which minimally attenuated the association between 5-year mortality and the lowest tertile of PMA suggesting that despite adjusting for frailty, the association between PMA and mortality remains. The impact of frailty, as mentioned previously, has not been formally assessed previously in any other study of PMA and outcomes in vascular patients. This reinforces the message that although there is intuitively a link between PMA / sarcopenia and frailty, the concepts are not interchangeable. It may imply that sarcopenia as assessed by PMA may be a better marker of mortality risk than measures of frailty. Our study did not show statistically significant associations between PMA and postoperative complications, discharge destination and readmissions within 30 days. This may relate to many of the complications being technical or procedure related rather than due to lack of physiological reserve. The only studies looking at PMA and have published complication rates show overall surgical complication rates of 21.9% [18] and ‘post-operative complication’ of 27% [15]. Although this is much lower than our study, it is difficult to compare these as the former study references both open and endovascular aneurysm repair and the latter study does not describe what they mean by ‘post-operative complications’. The lack of association with complications would more likely be reinforced by the difference noted in complication rate in those patients who were excluded from the study due to lack of PMA data

There was a statistically significant association found between PMA and LOS after adjusting for BMI, however it is unlikely to be clinically significant at 8 hours or approximately one third of a day. Chowdury et al. did not show correlation with LOS or discharge destination, similar to this study [11]. However, this does contrast with Karkkainen et al [16]. The increased complexity of the operation (fenestrated-branched EVAR for thoracic and pararenal aneurysms) may account for this, as well as the larger sample size (n=504).

There is no clear consensus as to which value of PMA leads to increased mortality and poorer outcomes (8). In this study, the lowest tertile of PMA for men was less than 19.4 cm2 and for women, less than 12cm2. Other studies that have examined total psoas muscle area have a cut off for the lowest tertile of PMA at 13cm2 and 24cm2, both measured at L4, which is the level we chose [14,15]. We also showed that PMA to be associated with age, sex and BMI as did all previous studies mentioned. The limitations to our study include: the retrospective nature of the study at a single metropolitan centre; the small sample size which contributes to lower statistical power; and missing data as a potential source of bias. Furthermore, European consensus guidelines on sarcopenia have been recently updated to place more emphasis on muscle strength (potentially measured by grip strength or chair stand test), with poor muscle performance (potentially measured by low gait speed) defining severe sarcopenia [8]. These new measures should be included in future studies [24-30].

Conclusions

Lower PMA is associated with 2.76 times increased mortality in patients undergoing EVAR for asymptomatic infrarenal AAA. However, it did not predict shorter term outcomes. Despite adjusting for frailty, this association with PMA and mortality remains, which has not previously been assessed in other studies. Low PMA would be considered as less than 19.4cm2 in men and less than 12cm2 in women in this study, however further studies are required to determine what PMA would be best representative of sarcopenia and significantly worse mortality. As patients undergoing EVAR routinely have pre-operative CT scanning, PMA is an easy way to assess sarcopenia and to determine risk for operative management of these patients adding additional valuable information to risk stratification and indication for treatment in this group.

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