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Management of Hyperglycemia and Diabetes in Orthopedic Surgery
Topical Collection on Hospital Management of Diabetes
Hospital Management of Diabetes (A Wallia and JJ Seley, Section Editors)
Funke Akiboye1,2 &
Gerry Rayman1
Current Diabetes Reports volume 17, Article number: 13 (2017) Cite this article
An increasing number of orthopedic operations are being carried out in an older population in whom the prevalence of diabetes is dramatically increasing. People having surgery with diabetes and hyperglycemia are at increased risk of post-operative complications. The peri-operative risks have been well demonstrated for cardiac surgery and, more recently, for orthopedic surgery. This paper considers the issues surrounding orthopaedic surgery in patients with diabetes and the significance and management of hyperglycemia in the peri-operative period.
The global prevalence and incidence of diabetes is steadily rising in all populations and at the current rate the International Diabetes Foundation (IDF) estimates a prevalence of 9.9% worldwide by 2030. With population growth, this represents a 50.7% increase in people affected over a 19-year period [1]. A person with diabetes is more likely to require surgery than a person without and this is particularly notable for orthopedic surgery, which has seen an overall increase in procedures in this population as a whole [2].
Observational studies show that in the surgical patient, diabetes is associated with a higher rate of peri-operative complications such as need for transfusion, pneumonia, delayed discharge, surgical site infections, and in-hospital mortality [3]. These poorer outcomes are in part due to higher rates of co-morbid conditions such as ischemic heart disease, renal impairment, and hypertension in patients with diabetes [4]. Dysglycemia, which encompasses hyperglycemia, hypoglycemia, stress-induced hyperglycemia, and excessive glucose variability, is increasingly observed and associated with poorer post-operative outcomes even in those without a prior diagnosis of diabetes. In fact, several studies have shown post-operative complications occur more frequently in people with stress-induced hyperglycemia with no prior diagnosis of diabetes than in those with diabetes [5,6,7].
Effect of Surgery on Glucose Levels
Surgery and anesthesia elicit a stress response that produces marked neurophysiological changes with release of adrenaline, noradrenaline, cortisol, glucagon, and growth hormone. This increase in counter-regulatory hormones and cytokines raises glucose levels and increases insulin resistance. In susceptible patients, this may result in significant hyperglycemia [8]. Additionally, elements of the surgical process such as disturbed eating patterns due to fasting or post-operative nausea, omission of insulin or hypoglycemic medication, and complications such as wound infection can all contribute to dysregulation of glucose homeostasis in the peri-operative period. The resulting raised, low, or erratic glucose levels have all been associated with poor outcomes.
Effect of Glycemia on Outcomes for Orthopedic Surgery
Hyperglycemia impairs leucocyte function causing immunocompromise with consequences for superficial and deep tissue infection as well as overall mortality [9].
The detrimental effects of suboptimal glycemic control on surgical outcomes and post-operative complications have been demonstrated across surgical specialities. Within orthopedics, the subspecialties of spinal surgery, arthroplasty, and trauma surgery have been most extensively studied.
Surgical Site Infection
Surgical site infection is the most common hospital acquired infection and is associated with worse functional outcomes and increased amputation rates in patients undergoing orthopedic surgery [10, 11]. Rates of surgical site infection are significantly increased in patients with diabetes, most notably in those with suboptimal glycemic control. Preoperative HbA1c levels above 7.0% have been found to be associated with higher rates of surgical site infection for thoracic and lumbar spinal instrumentation surgery (35.3% compared with 0.0%) [12]. The incidence of surgical site infections has also been linked to peri-operative hyperglycemia in people without a prior diagnosis of diabetes. In this group, stress-induced hyperglycemia >200 mg/dL (11.1 mmol/l) is an independent risk factor for surgical site infection at 30 days (OR 3.2, 95% CI: 1.3–7.8) even after adjustment for open fractures [13]. Following trauma, a 7-fold increase in peri-operative infections has been seen with peri-operative hyperglycemia >220 mg/dL (12.2 mmol/l, P = 0.0056) [6].
Peri-prosthetic Infection
Although uncommon, occurring in around 1% of arthroplasties, peri-prosthetic infection is one of the most devastating orthopedic complications for patients and surgeons and may require further surgery to treat effectively [14]. No significant association has been demonstrated between peri-operative HbA1c and peri-prosthetic infection at the hip or knee; however, both pre- and post-operative hyperglycemia have been associated with this serious complication [15•, 16]. Morning post-operative hyperglycemia >140 mg/dL(7.8 mmol/L) is associated with a 3-fold increased risk of peri-prosthetic infection (27/285 compared with 20/582) [17]. In a series of 1565 primary knee arthroplasties, Jämson and colleagues showed a 4-fold increase in people with a peri-operative glucose >6.9 mmol/L compared with those with a normal reading of <6.1 mmol/L [18].
Other Complications, Length of Stay, and Morbidity
It is apparent that glycemia correlates with multiple poor post-operative outcomes in orthopedic surgery, including mortality. Raised HbA1c is associated with increased length of hospital stay and is a predictor of risk for pulmonary embolism following orthopedic surgery [19]. Pre-operative HbA1c over 6.5% has been shown to be a significant risk factor for surgical outcome with a poor post-operative recovery rate following cervical laminoplasty (OR 2.6, P = 0.02) [20]. Undergoing primary joint arthroplasty with an HbA1c above 7.0% carries an increased mortality (HR 1.3, P = 0.01) [15•].
Glycemic Management and Surgical Outcomes
Despite the above associations, the key question is whether treating hyperglycemia reduces complications and improves these outcomes. There are no randomised studies in orthopedic surgery; however, one observational study by Agos et al. demonstrated that implementation of an evidence-based standard to control hyperglycemia reduced the rate of surgical site infection in people undergoing hip and knee replacement surgery [21••].
Treating hyperglycemia in the peri-operative period has been shown to reduce complications in other surgical disciplines. Trussel and colleagues demonstrated reductions in surgical site infection with tight peri-operative glycemic control in people having coronary artery bypass grafting (CABG) surgery [22]. Similarly, Furnary and colleagues showed reductions in mortality and deep infection rates by treating people with diabetes undergoing cardiac surgery; the lowest rates seen in people targeted under 150mg/dL (8.3 mmol/L) [23]. In general surgery, Umpierrez showed that lower rates of hyperglycemia, using a basal bolus regime, was associated with reduced incidence of wound infection, pneumonia, bacteremia, and respiratory and acute renal failure [24]. These limited data have provided the basis for the American Association of Clinical Endocrinologists (AACE) and American Diabetes Association (ADA) guidelines, the Joint British Diabetes Society (JBDS) guidelines, and others all advocating treatment of hyperglycemia for hospitalized patients peri-operatively [25,26,27]. The target glucose ranges for these guidelines are summarized in Table 1.
Table 1 Peri-operative glucose targets in national guidelines
The Effect of Diabetes and Its Complications on Peri-operative Risk in Orthopedics
Diabetes irrespective of glycemia is associated with greater surgical risk because of the higher incidence of co-morbid conditions, including obesity, sleep apnea, hypertension, in addition to the micro- and macrovascular complications that are associated with the condition. In people with diabetes, surgery at the hip, knee, ankle, and elbow is associated with higher rates of post-operative infection, need for transfusion, pneumonia, urinary tract infection, length of stay, non-routine discharge, and in-hospital mortality [28, 29].
The condition of diabetes, in a recent meta-analysis, has shown an increased surgical site infection rate from pooled US data with OR 1.26 (95% CI 1.01–1.66) for arthroplasty and 1.6 (CI 1.10–2.32) for spinal surgery after accounting for impact of hyperglycemia and adjusting for BMI [30]. Interestingly, diabetes treated with insulin has been linked to increased 30-day readmission rates for people undergoing arthroplasty [31]. This may relate to disease chronicity, which has been associated with poor outcomes in cervical laminoplasty for people with 10 or more years duration of diabetes [20].
Neuropathy and vascular insufficiency, which may complicate diabetes, presents challenges for lower limb and particularly foot and ankle surgery, for which a modified approach is taken. Subsequent hospital-acquired foot ulceration in high risk feet can take several months to heal and superadded infection may complicate these ulcers, increasing the risk of peri-prosthetic infection and amputation [32].
Diabetic Cardiovascular Disease and Surgery
A 2- to 3-fold increased prevalence of cardiovascular disease in people with diabetes makes surgery a higher-risk undertaking for this group [33, 34]. Hyperglycemia causes an osmotic diuresis, and the resulting hypovolemia and electrolyte disturbance may be further exacerbated by nausea and vomiting caused by anesthetic agents. The result may be tachycardia, hypokalemia, and hypomagnesemia with the resulting arrhythmias contributing to the increased peri-operative cardiovascular mortality in these patients [35].
As cardiac ischemia may be 'silent' in people with diabetes, a baseline ECG should be carried out in all people with diabetes prior to surgery. The threshold for cardiology referral and further investigations should be determined locally but based on the relevant national guidelines.
The following sections deal with peri-operative clinical assessment of elective surgery from pre-hospitalization through to discharge including pre-operative assessment, hospital admission, theater and recovery, and the post-operative period. The considerations of pumps, steroid-induced hyperglycemia, and emergency surgery are also discussed.
Prehospitalization Assessment
Surgical Outpatients
It is clear from the previous discussion that the orthopedic surgeon's decision to proceed to surgery should include some assessment of the surgical risk to the patient with diabetes taking into account their diabetic complications and other comorbidities. High risk patients should be highlighted prompting early review, usually in a pre-assessment clinic to assess and optimize medication, glycemia, and blood pressure control prior to surgery. Specialist referrals for detailed assessment and optimization of diabetes or its cardiac or renal complications can be initiated at this stage.
One of the aims throughout the peri-operative process is to reduce the glycemic variability that may result from meal disruption and surgery itself.
Glycemic variability can be described as the degree to which glucose values fluctuate between peaks and troughs for an individual. There is no universally agreed ideal method to calculate it at present. It has emerged as a contributing factor for macro- and microvascular complications in the outpatient setting in people with both type 1 and type 2 diabetes. However, its impact in hospitalized patients has yet to be fully established. There are studies highlighting its importance in the critical care and peri-operative setting. A retrospective study by Egi et al. looked at 7049 critically ill patients with glucose measurements taken at least 4-hourly. Glucose variability was an independent risk factor in predicting mortality in ICU and hospitalized patients with an OR of 1.28 per mmol/LSD for variability and 1.21 per mmol/L for glucose level, hinting that glycemic variability is at least as important as hyperglycemia this patient group [36]. Although there are no prospective randomized trials demonstrating the impact of glycemic variability on orthopedic complications or that reducing variability improves outcomes, it is sensible to aim to limit glycemic variability until evidence to the contrary emerges.
In order to minimize glycemic variability, it is advised that patients with diabetes are prioritized on morning or afternoon lists, thereby limiting the period of fasting and disruption to normal meal times. JBDS guidelines suggest 95% of patients with diabetes should be on the first third of elective lists with avoidance of elective evening surgery altogether [26]. The regimen used to manage inpatient hyperglycemia also impacts on glucose variability, which is discussed later in this article.
Accessible electronic systems can facilitate priorities in care pathways by highlighting those people with diabetes. A flag initiated from first contact and visible throughout the peri-operative journey can be used to prompt actions such as priority list position. The glycemic and non-glycemic considerations throughout the peri-operative period are highlighted in Fig. 1.
Orthopedic peri-operative pathway decision tool
Preoperative Assessment
Screening for Diabetes
Since a suspected 1% of the UK population and up to 3% of people in the US are thought to have undiagnosed diabetes, it is increasingly common for diabetes to be detected on pre-operative bloods on the day of surgery. However, screening for diabetes in the pre-assessment period is not routine, but should be considered. One prospective study of people undergoing elective noncardiac surgery found hyperglycemia in over 25% (118/493) of those without a prior diagnosis of diabetes on the morning of surgery [37].
Failure to identify and manage diabetes and hyperglycemia pre-operatively has been shown to increase the risk of complications with higher requirement for resuscitation, re-intubation, longer post-operative ventilation, and increased mortality [7, 38]. Indeed, studies to date suggest that the risk in those not known to have diabetes and those with stress or pre-operative glycemia is several fold greater than those with diabetes.
Guidelines at present do not recommend diabetes screening of patients being assessed for all types of elective surgery. The National Institute of Clinical Excellence (NICE) suggests testing for diabetes in people admitted to hospital at risk of the disease; however, this is generally limited to emergency admissions [39]. The ADA recommends screening for people over the age of 45 years and earlier in those with BMI > 25 kg/m2 with age adjustment for higher risk ethnic groups [40]. However, for elective orthopedic surgery, one meta-analysis suggests that it should be considered to minimize complications in the peri-operative period [41••]. HbA1c is increasingly being measured for this purpose with a value of 48 mmol/L(6.5%) or more diagnosing the condition in a symptomatic patient [42]. As the prevalence of diabetes rises, there is a potentially huge economic burden, which may result from adopting screening for diabetes in surgical pathways. If screening were adopted for all surgical pathways, this expense would need to be justified with randomized controlled trials. Although the amalgamated research in all non-cardiac surgery may be insufficient to recommend screening in national guidelines, it should be adopted in orthopedic surgery and vascular surgery based on current evidence [41••].
Glycemic Assessment of the Diabetic Patient
Measurement of HbA1c highlights those with poorly controlled diabetes allowing optimization of glycemic control prior to surgery. It may be necessary to delay elective surgery to facilitate this.
There is no evidence-based guideline published that precludes surgery above a particular value for HbA1c; however, most guidelines advise below 8–9% (68–75 mmol/mol) for elective orthopedic surgery as a safe target [26]. In view of the complications correlated with raised HbA1c in orthopedics, some institutions may opt for lower pre-operative values than guidelines recommend. However, data suggests a significant proportion of patients scheduled for arthroplasty will take over 6 months to attain the guideline target HbA1c and for others it may not be feasible [20, 43].
Complications and Comorbidities
The complications of diabetes should be actively assessed and optimized in view of the associated peri-operative risk they contribute. For patients undergoing foot and ankle surgery, it is essential to undertake a preoperative neurovascular assessment of the feet in addition. Neuropathy is associated with increased surgical site infection rates even in those without diabetes. High risk feet can be identified without any equipment using a quick and simple bedside tool, the 'Ipswich touch test', prompting pressure relief as soon as convalescent [44]. Pre-operative revascularization may be necessary in some people with significant peripheral vascular disease.
The pre-operative workup for people with diabetes undergoing surgery is covered in detail in both the Joint British Diabetes Societies and ADA guidelines and the additional management considerations relating to diabetes should be incorporated into local orthopedic pathways and proformas to prevent omission of these elements during the peri-operative period. Clear written instructions on the alterations to medications according to local guidelines should be given to patients at pre-assessment.
A self-reporting checklist for patients with diabetes to complete can alert staff to potential problems for further attention.
Hospital Admission
Glycemic Control and Monitoring
The aims of peri-operative glycemic control are avoiding hypoglycemia, marked hyperglycemia, electrolyte disturbance, and the diabetic emergencies of hyperosmolar hyperglycemic state (HHS) and diabetic ketoacidosis (DKA). The target range that is most effective in achieving these aims remains a matter of debate.
The NICE-SUGAR trial and a series of studies challenged the dogma for tight glycemic control outside of the critical care or cardiology setting with increased mortality attributed to higher rates of hypoglycemia [45]. The emphasis is increasingly on adapting the glycemic target to the individual patient and their circumstances. Published guidelines focus on safe rather than tight control with JBDS promoting glucose targets between 6 and 10 with 4–12 mmol/L as an acceptable range. A selection of differing peri-operative targets by country are displayed in Table 1.
Close monitoring in the peri-operative period is required to detect and manage glucose excursions and is advised before meals or 4–6 hourly in patients who are not eating. Blood tests on admission should include a laboratory glucose or capillary blood glucose with point of care testing. There should be clear local policies to optimize glycemic control in the hospital throughout the peri-operative period with methods governed by the individual patient circumstances, the policy and resources of the institution, and clinician's judgement.
Fasting and Enhanced Recovery
Prolonged fasting results in increased insulin resistance in both those with and without diabetes. Higher insulin resistance is associated with poor wound healing, higher complication rates, and increased length of hospital stay. The degree of insulin resistance is greater in larger or more complex operations and those with greater blood loss and through metabolic pathways, it contributes to hyperglycemia [46]. A meta-analysis has shown insulin resistance may be attenuated by half with administration of oral or IV glucose, associated with reductions in length of stay [47]. Pre-operative oral carbohydrate treatment has been widely adopted as part of an enhanced recovery program; a multimodal approach to peri-operative care, which includes early mobilization, minimization of the fasting period, and optimizing pain relief. Enhanced recovery programmes have been shown to reduce length of stay and post-operative complications, most notably in colorectal surgery [48].
Although enhanced recovery programmes show improved post-operative outcomes, there is limited evidence demonstrating the benefits of pre-operative carbohydrate loading specifically within these programmes. The impact of carbohydrate loading in improving a range of post-operative outcomes has been examined in a Cochrane review of 27 randomized controlled trials, including 4 orthopedic studies. The authors of this review concluded that preoperative carbohydrate loading offers small reductions in length of stay; however, complications and well-being are not significantly impacted [49].
There is a paucity of data on the potential impact of pre-operative carbohydrate loading on those with diabetes. A small case controlled study by Gustaffson et al. found no delay in gastric emptying following a carbohydrate drink for subjects with type 2 diabetes compared with healthy volunteers. In this study, peak glucose concentrations occurred later and were higher (13.4 ± 0.5 compared with 7.6 ± 0.5 mmol/l; P ≤ 0.01) [50].
With the aforementioned concerns about increased complication rates related to peri-operative hyperglycemia, the administration of carbohydrate drinks in people with diabetes requires further study before it is implemented for this group, particularly in orthopedic surgery. The exclusion of people with insulin treated diabetes from these programmes [51] may limit further detailed study of this group.
Immobility and Pressure Ulcers
Pressure ulcers are a problem in surgery, causing pain, reduced quality of life, and prolonged hospital admission; diabetes can increase the risk of pressure ulcers 3-fold. Pressure ulcers following hip surgery can have devastating consequences with associated complication rates ranging from 16 to 46% and an increased mortality rate of 27% [52].
Prevention is the most effective way to approach this problem with simple inspection found to be more effective than currently advocated scoring systems. As the majority of these ulcers develop in-hospital, often on the day of surgery, it is vital that preventative measures commence on admission [53].
The period of immobility should be minimized and feet should be carefully inspected preoperatively for ulceration, which may act as a port for infection that people with diabetes may not self-report due to neuropathy. Multidisciplinary team involvement is crucial in those who develop ulceration as resultant hyperglycemia in those with infected ulcers can create a vicious cycle by delaying wound healing.
Theater and Recovery
Glucose Targets and Glucose Management
There are limited data examining the effect of intra-operative glycemic control on post-operative outcomes with available studies carried out in cardiac surgery. Doenst et al. showed an intra-operative peak glucose reading >20 mmol/L(360 mg/dL) to be an independent risk factor for poor post-operative outcome and mortality in people with diabetes (OR, 1.20; CI, 1.08–1.32) and without diabetes (OR, 1.12; CI, 1.06–1.19; per mmol/L increase in glucose) [54]. Ouattara et al. found poor intra-operative glycemic control, defined as 4 or more consecutive blood glucose values over 11.1 mmol/L(200 mg/dL), to confer a higher risk of cardiac and noncardiac post-operative complications [55]. The Association of Anesthetists of Great Britain and Ireland (AAGBI) advise an intra-operative glucose target of 6–10 mmol/L with a peak up to 12 mmol/L for less well controlled patients. Ketone testing is advised with intra-operative glucose readings over 12 mmol/L[56].
Glucose testing remains central to maintaining glycemic control and should be carried out prior to induction of anesthesia, then hourly for operations of over 2 hours. For prolonged fasting with more than 1 missed meal or operations over 3 hours, an insulin infusion may be required. In these instances, a glucose, insulin, potassium (GIK) regime may be used, where the 3 elements are combined in a single bag for infusion. However, many institutions favor the variable rate intravenous insulin infusion (VRIII), where insulin and glucose with or without potassium are delivered as separate infusions with titration of the insulin every 1–2 hours. This requires close monitoring and regular adjustment as potentially dangerous glucose excursions can occur when the infusions are mismatched. In a small study looking at patients undergoing cardiothoracic surgery, the VRIII was found to offer more stable glycemic control than the GIK regime [57]; however, there is little evidence in support of one method over the other, and local policy should be followed. VRIII should commence at least 2 hours prior to surgery to allow time for abnormal glucose readings to stabilize.
For people on a long-acting basal insulin, local policies usually advise continuation of the basal insulin with the variable rate insulin infusion. This facilitates transition back to the usual regime when oral intake is reinstated. If the basal insulin is discontinued preoperatively, it must be given 30 to 60 minutes prior to any intravenous insulin being taken down because of the short half-life of intravenous insulin in order to reduce the risk of diabetic ketoacidosis.
For people on continuous subcutaneous insulin infusion (insulin pumps) undergoing day case surgery, there is evidence that this may be safely continued intra-operatively for up to 3 hours whilst maintaining safe glycemic control post-operatively with the support of the specialist endocrine team [58]. Alternatively, subcutaneous basal insulin may be used at a dose equivalent to the background insulin dose administered over 24 hours on the pump.
There are a few considerations when planning to continue insulin pumps intra-operatively. It is generally recommended that pumps be removed for X-ray, CT, or MRI scanning; however, covering the pump with a lead shield may be sufficient for X-rays. The need for imaging intra-operatively is often pre-empted and subcutaneous insulin may be a good alternative to pump use in these circumstances. Additionally, electro-cautery and the presence of flammable anesthetic mixtures with oxygen or nitrous oxide in the operating room may affect the function of the pump, so the manufacturer's guidance should be reviewed and followed [59].
Pressure damage leading to subsequent ulceration may begin within a few hours of sustained pressure; therefore repositioning has been advised at least every 2 hours intra-operatively where possible. An array of pressure relieving devices are available, from foam mattresses to inflatable heel supports, which can reduce the development of pressure ulcers by up to 70%. However, there is no single, recommended device [60] and most orthopedic units employ gel pads or inflatable air-boots. Limb surgery is discounted since the operated limb is mobile intra-operatively.
The role for peri-operative antibiotic prophylaxis in joint arthroplasty is well documented [61, 62]. People who are morbidly obese have differences in antibiotic pharmacodynamics and pharmacokinetics, making their efficacy less predictable in these people. Obesity is associated with increased rates of surgical site infection and studies by Dowsey and Choong have shown it to be an independent risk factor for peri-prosthetic infection at both hip and knee [63, 64]. As a significant proportion of people with type 2 diabetes will be obese, weight-adjusted dosing should be considered.
A few antibiotics have been studied in this population, including aminoglycosides, vancomycin, daptomycin, and linezolid. Weight-adjusted antibiotic dosing is not widely practiced in the UK or recommended in the guidance; however, the additional risk of obesity is considered in the dosing advice in Australian and US guidance. The American Association of Surgeons (AAOS) recommend weight-adjusted dosing for a range of antibiotics with a double dose of 2g cephalexin for patients over 80kg [65].
Post-operative Period
Managing Medication
Post-operatively, diet and usual diabetes medications should be restarted as soon as possible; however, there are a few oral agents for which clinical circumstances should be considered before reinstating. Metformin carries a risk of lactic acidosis, particularly in those with renal insufficiency. It should be omitted in patients who develop acute kidney injury until renal function returns to near baseline or eGRF is above 30 mL/min/1.73m2. It should also be withheld in sepsis, congestive cardiac failure, and significant hepatic impairment, all of which may be associated with hypoxia increasing the risk of lactic acidosis. Thiazolidinediones such as pioglitazone should not be restarted if significant fluid retention or congestive cardiac failure have developed or when there are liver function abnormalities. In patients who have not resumed a normal diet, sulphonylureas such as gliclazide may be withheld because of their insulin secretory effects with potential for causing hypoglycemia. A smaller dose may be initiated and titrated up as oral intake returns to normal. A cautious re-introduction should also be considered where there has been a kidney injury, as reduced renal excretion can further augment and prolong hypoglycemia. Recent studies have demonstrated the safety and efficacy of DPP4 inhibitors, the gliptins, in people with mild to moderate hyperglycemia (200 mg/dl) [66]. In view of the potential problems with sulphonylureas, it is likely that the use of these agents will become more widespread.
Insulin infusions should continue until eating has resumed. On recommencing usual insulin treatment, the subcutaneous insulin dose should be administered 30 minutes prior to discontinuing the intravenous infusion, which has a 5–10 minute half-life to minimize the risk of DKA and glucose excursions.
Treating Hyperglycemia
Following surgery, management of hyperglycemia remains important both for people with diabetes and those with stress-induced hyperglycemia. Due to its breadth of usability, insulin remains the main agent for controlling hyperglycemia for in-hospital patients, and can be used regardless of comorbidities or altered clinical states such as impaired renal function and decompensated cardiac failure. Correction doses of insulin may be used in insulin-naïve people, but titrating doses of subcutaneous insulin referred to in the US as sliding scale are not advised. A recent meta-analysis demonstrated these corrective subcutaneous doses do not offer tighter glycemic control for hospitalized patients and are associated with higher rates of hyperglycemia than a range of other regimes without any significant reduction in length of hospital stay [67]. Due to these observed increases in glucose variability, the subcutaneous 'sliding scale' should not be used as the sole method of glycemic control, but may still be used to supplement other regimes.
Hypoglycemia is unpleasant for patients and associated with higher mortality rates and longer hospital length of stay. It is important to remain vigilant to this risk and check capillary glucose in patients in whom an altered mental state may otherwise be attributed to delirium or drowsiness secondary to concomitant analgesia following surgery. With its associated risks, hypoglycemia can be a barrier to intensifying glucose treatment.
In the case of missed meals or interrupted nutrition, nurse driven protocols and automated management decision tools for the omission of sulphonylureas and prandial insulin should be implemented locally to reduce the risk of iatrogenic hypoglycemia and standardize care.
Specialist Teams
It is increasingly common for elderly orthopedic patients to be managed by an orthogeriatrician to focus on the medical aspects of care across the peri-operative period. While this has improved the overall medical treatment, the specific impact for quality of care for people with diabetes has not been studied. Specialist diabetes nursing teams often have a lower threshold for discharge and can considerably reduce length of stay for elective procedures with significant cost-saving implications [68]. Their input at key points in the peri-operative pathway has been shown to be beneficial, and clear pathways for pre-operative referral and post-operative involvement should be developed locally.
Steroid injections are an important adjunct in managing musculoskeletal diseases. Intra-articular injections are most frequently carried out for osteo-arthritis [69], with the knee joint the most common site of injection, followed by shoulder, wrist, ankle, and elbow joints [70]. This route allows symptomatic relief whilst minimizing systemic corticosteroid effects. However, due to concerns over peri-prosthetic infection, their use is often avoided within 3 months of elective surgery [71].
Synthetic steroids mimic endogenous glucocorticoid, binding to the nuclear glucocorticoid receptor, affecting transcription of anti-inflammatory mediators. These effects may last for months. The effects of intra-articular steroid injections on the hypothalamic-pituitary-adrenal axis have been most widely studied [72], but they may also affect glucose metabolism in a similar manner to oral steroids. This effect is exerted in a number of ways from increased insulin resistance to direct effects on pancreatic beta cell function. The resulting hyperglycemia may be asymptomatic or result in osmotic symptoms and fatigue. It often resolves spontaneously, but if persistent after steroid withdrawal, it is termed steroid induced diabetes.
The few studies examining the effect of intra-articular steroid injection on glycemic control suggest that there are only short-term effects, which vary depending on the site and type of injection [73, 74]. While the hyperglycemic effects are generally not sustained long enough to affect injection site elective orthopedic surgery due restrictions imposed by infection risk, it is worth noting that there may be an impact on glucose for up to 5 days following injection [73]. Therefore, people with previously controlled type 2 diabetes should have home glucose monitoring if elective surgery of another joint is planned with 2 weeks of steroid injection or closely monitored if emergency surgery is required.
The JBDS advise measuring glucose at least once daily, preferably prior to the evening meal, in those given steroids not known to have diabetes and if above 12 mmol/L(216 mg/dL), treating to maintain glucose levels between 6 and 10, accepting a pragmatic range of 4–12 mmol/l. They suggest HbA1C be measured in patients at high risk of steroid-induced diabetes, and a baseline level should be taken in those with pre-existing diabetes prior to commencement of steroids [75].
It is recommended to increase the frequency of glucose monitoring to 4 times a day and to commence treatment for 2 consecutive glucose readings above 12 mmol/L. For hyperglycemia resulting from intra-articular steroid injection, as with multiple daily steroid doses, oral agents are unlikely to control the hyperglycemia, and a subcutaneous insulin regime is preferred. A pragmatic approach would be to commence basal insulin and titrate this according to glucose values. In this case, a morning NPH insulin such as humulin I or insulatard is suggested, starting at 10 units daily titrating up by 10–20% every 24 hours until glucose readings are on target [75]. The local community diabetes team may be contacted for further advice and support.
People with diabetes are more likely to require emergency orthopedic procedures for a number of reasons. Hypoglycemia and peripheral neuropathy increase the likelihood of falls, and bone mineral density is affected, particularly in those with type 1 diabetes, increasing the fracture risk further. The orthopedic surgeon may also be involved in the management of diabetic foot emergencies depending on the local service setup.
In the emergency setting, glycemic control remains crucial to reducing post-operative complications; however, the clinical situation restricts the time to fully optimize patients. In these settings, intravenous insulin given as a variable rate infusion remains the most effective way to achieve normoglycemia in the peri-operative period. The local protocol often advises continuation of the usual background insulin for those on basal insulin to facilitate prompt return to a normal regime postoperatively.
Where possible, DKA should be treated as a priority and the fluid and electrolyte disturbances of HHS should be reduced or corrected prior to surgery.
People with diabetes require particular consideration in planning orthopedic surgery. It can be difficult to put guidelines into practice across the multistep peri-operative process; however, significant improvements in care, with patient benefits and cost saving implications are possible. Specialist in-patient teams who can examine local processes, along with design and implementation of clear local pathways across the surgical process are key in minimizing the harm to this vulnerable group of patients.
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The Diabetes and Endocrine Center, The Diabetes Foot Clinic and Diabetes Research Unit, Ipswich Hospital and University of Birmingham, Suffolk, IP4 5PD, UK
Funke Akiboye & Gerry Rayman
Ipswich Hospital and University of Birmingham, Birmingham, B15 2TT, UK
Funke Akiboye
Gerry Rayman
Correspondence to Gerry Rayman.
Funke Akiboye and Gerry Rayman declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
The study cited as reference 44 was conducted as a service improvement project and was carried out with approval from the trust in accordance with local policy.
This article is part of the Topical Collection on Hospital Management of Diabetes
Akiboye, F., Rayman, G. Management of Hyperglycemia and Diabetes in Orthopedic Surgery. Curr Diab Rep 17, 13 (2017). https://doi.org/10.1007/s11892-017-0839-6
Peri-operative glucose


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Effective Altruism Forum
EA Forum
When causes multiply
by Denise_Melchin6th Aug 20186 comments
Preface: Searching for 'the one true cause area', or perhaps several of them, strikes me as a poor model of how cause prioritisation should be thought about. Much better is an emphasis on what the best allocation of resources to various cause areas looks like over time and what we need to do to achieve this allocation. In this post I'll lay out one argument for this view.
When the EA community discusses cause prioritisation, we usually model different causes as additive. However, in the real world, the interactions between many causes aren't additive, but interact in much more complicated ways with each other.
In this post I'll present how we can model causes whose impact multiplies. If causes simply add together, it makes sense to focus on the cause with the highest impact per dollar. However, if causes multiply, we should locally distribute resources between them according to the ratio of their output elasticities, i.e. how much an increase in investment in one cause affects the outcome as a whole. The output elasticity can be interpreted as a measure of how tractable a cause is. This means that local funding decisions (monetary 'crowdedness') should be proportional to how tractable the causes are if they're multiplicative.
Sam Bankman-Fried has written about multiplicative causes with the same output elasticity before, in which case it is optimal to distribute resources between the multiplying causes equally. You might want to read his post before reading this one.
To illustrate this, think about economic progress vs. cultural progress. If we imagine an economically as well as culturally destitute world, we could pour all our resources into improving our world economically - and could achieve a 1984 or Brave New World dystopia. Or we could pour all our resources into improving it culturally. In that case we might have wonderful relationships with our fellow humans and beautiful art to enjoy, but would still starve and die of illnesses early. Most appealing is the world in which we put an equal amount of resources into economical and cultural progress and much more so than in the alternative worlds. In this world people will live a bit longer and don't starve quite as much while also having acceptable relationships with their peers.
But this assumes economical vs. cultural progress are similarly tractable. What happens if the amount of resources we put into economical and technological progress multiplies, but putting extra resources in cultural progress doesn't affect cultural progress as much as putting extra resources in economic progress affects economic progress?
To find an answer to this question, we can look at the Cobb Douglas production function and expand its use. Historically, it describes the inputs of capital and labour and how much output can be produced by those inputs.
Goods = A * Lalpha * Cbeta. In this historical version L is the labour input, while alpha is the output elasticity of labour, i.e. how many % more goods will be produced if the amount of labour is increased by 1%. C is the capital input, while beta is the output elasticity of capital. Goods are the output that is being produced. A is the 'total factor productivity' which captures the effects on output that aren't explained by the input variables.
We can now ask the question how resources between labour and capital should be allocated to maximize the number of goods produced. The mathematically optimal allocation to maximize the output is determined by the ratio between the output elasticities of capital and labour, so alpha:beta. Note that in this case the output elasticities are constants.
If labour's output elasticity was 1, but capital's output elasticity was 0.1 (though note that those aren't the true historical ones), then to produce the most goods with a given set of resources it's optimal to put ten times as many resources into labour than into capital.
If we now adapt the historical Cobb Douglas production function and look at our hypothetical society, we can answer our question:
Thriving of humanity = A * Resources for economic progressgamma * Resources for cultural progressdelta
A is the factor again that measures everything that results in the thriving of humanity that isn't explained by putting in resources for economic and cultural progress.
If it is ten times easier to make progress on the thriving of humanity by investing resources in economic progress than by investing resources in cultural progress (i.e. gamma is ten times as big as delta), then as in our previous example the optimal allocation is to spend ten times as many resources on economic progress.
Thus, the important question to ask for optimal resource allocation in multiplicative scenarios is what the ratio of the output elasticities is. However, output elasticities might change as the inputs change. Most often, the output elasticities won't be constants. This means in many cases the production function will only tell us locally which cause is in most need of more resources to improve the overall outcome.
To calculate an output elasticity, we need to find out how much increasing the respective input by 1% is affecting the outcome as a percentage. In our example, we look at how many resources are being spent on cultural progress already i.e. how much talent or funding is currently being allocated to it. We then assess how much an increase of 1% is affecting the output. If the thriving of humanity improved by 10% due to the 1% increase of the resources for cultural progress, we have an output elasticity of 10%/1% = 10. If the thriving of humanity improved only by 0.1%, the output elasticity would be 0.1%/1% = 0.1.
What does all of this mean in practice for cause prioritisation? While many causes aren't actually additive and modelling them as additive might give subpar results, modelling them simply as multiplicative isn't close to perfect either. However, it might still be an improvement.
Questions for which modelling the problem as multiplicative might be helpful are e.g. whether we should add new talent to the EA community or improve the talent we already have? Should the EA community focus to add its resources on the efforts to reduce GCRs or to add them to efforts to help humanity flourish? We could also think of the technical ideas to improve institutional decision making like improving forecasting abilities as multiplying with those institution's willingness to implement those ideas.
When we think about global funding in the inputs for our production functions, we fundamentally care about what the EA community can do. So it's important to compare like with like by thinking about the most effective uses of resources that will determine the output elasticities. Note also that while we're looking at such large pools of funding, the EA community will hardly be able to affect the funding ratio substantially. Therefore, this type of exercise will often just show us which single cause should be prioritised by the EA community and thereby act additive after all. This is different if we look at questions with multiplicative factors in which the decisions by the EA community can affect the input ratios like whether we should add more talent to the EA community or focus on improving existing talent.
Which other cause prioritisation questions can you think of that are better modelled as multiplicative instead of additive?
TL,DR: When we try to prioritise between different additive causes, it makes sense to focus on the one with the highest impact per dollar. But if we try to prioritise between different multiplicative causes, we should locally spread our resources between them according to their output elasticity ratios. That means the proportions of funding ('crowdedness') should locally be equal to the proportions of the output elasticities (a measure for the 'tractability' of the respective causes).
Thanks to Jacob Hilton who reviewed a draft of this post.
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[-]Carl_Shulman2y
"Note also that while we're looking at such large pools of funding, the EA community will hardly be able to affect the funding ratio substantially. Therefore, this type of exercise will often just show us which single cause should be prioritised by the EA community and thereby act additive after all. This is different if we look at questions with multiplicative factors in which the decisions by the EA community can affect the input ratios like whether we should add more talent to the EA community or focus on improving existing talent."
I agree that multiplicative factors are a big deal for areas where we collectively have strong control over key variables, rather than trying to move big global aggregates. But I think it's the latter that we have in mind when talking about 'causes' rather than interventions or inputs working in particular causes (e.g. investment in hiring vs activities of current employees). For example:
"Should the EA community focus to add its resources on the efforts to reduce GCRs or to add them to efforts to help humanity flourish?"
If you're looking at global variables like world poverty rates, or total risk of extinction it requires quite a lot of absolute impact before you make much of a proportional change.
E.g. if you reduce the prospective risk of existential catastrophe from 10% to 9%, you might increase the benefits of saving lives through AMF by a fraction of a percent, as it would be more likely that civilization would survive to see benefits of the AMF donations. But a 1% change would be unlikely to drastically alter allocations between catastrophic risks and AMF. And a 1% change in existential risk is an enormous impact: even in terms of current humans (relevant for comparison to AMF) that could represent tens of millions of expected current lives (depending on the timeline of catastrophe), and immense considering other kinds of beings and generations. If one were having such amazing impact in a scalable fashion it would seem worth going further at that point.
Diminishing returns of our interventions on each of these variables seems a much more important consideration that multiplicative effects between these variables: cost per percentage point of existential risk reduced is likely to grow many times as one moves along the diminishing returns curve.
"We could also think of the technical ideas to improve institutional decision making like improving forecasting abilities as multiplying with those institution's willingness to implement those ideas."
If we're thinking about institutions like national governments changing willingness to implement the ideas seems much less elastic than improving the methods. If we look at a much narrower space, e.g. the EA community or a few actors in some core areas, the multiplicative factors key fields and questions.
If I was going to look for cross-cause multiplicative effects it would likely be for their effects on the EA community (e.g. people working on cause A generate some knowledge or reputation that helps improve the efficiency of work on cause B, which has more impact if cause B efforts are larger).
[-]Denise_Melchin2y
Great comment, thank you. I actually agree with you. Perhaps I should have focussed less on discussing the cause-level and more the interventions level, but I think it is still good to encourage more careful thinking on a cause-wide level even if it won't affect the actual outcome of the decision-making. I think people rarely think about e.g. reducing extinction risks benefiting AMF donations as you describe it.
Let's hope people will be careful to consider multiplicative effects if we can affect the distribution between key variables.
[-]MvdSteeg2y
While it's hard to disagree with the math, would it not be fairly unlikely for the current allocation of resources to be close enough to the actual allocation of resources that this would realistically lead to allocating an agent's resources to more than one cause area? Like you mention, the allocation within the community-building cause area itself is one of the more likely candidates, as we have a large piece of the pie in our hands (if not all of it). However, the community is not one agent, so we would need to funnel the money through e.g. EA Funds, correct?
Alternatively, there could be top-level analysis of what the distribution -ought- to be, and what it -currently is-, and suggest people donate to close that gap. But is this really different from arguments in terms of marginal impact and neglectedness? I agree your line of thinking ought to be followed in such analysis, but am not convinced that this isn't incorporated already.
It also doesn't solve issues like Sam Bankman-Fried mentioned where according to some argument one cause area is 44 orders of magnitude more impactful, because even if the two causes are multiplicative, if I understand correctly this would imply a resource allocation of 1:10^44, which is effectively the same as going all in on the large cause area. I think that even in less extreme cases than this, we should actually be far more "egalitarian" in our distribution of resources than multiplicative causes (and especially additive causes) suggest, as statistically speaking, the higher the expected value of a cause area is, the more likely that it is overestimated.
I do think this is a useful framework on a smaller scale. E.g. your example of focusing on new talent or improving existing talent within the EA community. For local communities where a small group of agents plays a determining role on where the focus lies, this can be applied much more easily than in global cause area resource allocations.
I address the points you mention in my response to Carl.
It also doesn't solve issues like Sam Bankman-Fried mentioned where according to some argument one cause area is 44 orders of magnitude more impactful, because even if the two causes are multiplicative, if I understand correctly this would imply a resource allocation of 1:10^44, which is effectively the same as going all in on the large cause area.
I don't think this is understanding the issue correctly, but it's hard to say since I am a bit confused what you mean by 'more impactful' in the context of multiplying variables. Could you give an example?
I guess when I say "more impactful" I mean "higher output elasticity".
We can go with the example of x-risk vs poverty reduction (as mentioned by Carl as well). If we were to think that allocating resources to reduce x-risk has an output elasticity 100,000 higher than poverty reduction, but reducing poverty improves the future, and reducing x-risk makes reducing poverty more valuable, then you ought to handle them multiplicatively instead of additively, like you said.
If you'd have 100,001 resources to spend, that'd mean 100,000 units against x-risk and 1 unit for poverty reduction, as opposed to the 100,001 for x-risk and 0 for poverty reduction when looking at them independently(/additively). Sam implies the additive reasoning in such situations is erroneous, after mentioning an example with such a massive discrepancy in elasticity. I'm pointing out that this does not seem to really make a difference in such cases, because even with proportional allocation it is effectively the same as going all in on (in this example) x-risk.
Anyway, not claiming that this makes the multiplicative approach incorrect (or rather, less correct than additive), just saying that in this case which is mentioned as one of the motivations for this, it really doesn't make much of a difference (though things like diminishing returns would). Maybe this would have been more fitting as a reply to Sam than you, though!
What you're saying is correct if you're assuming that so far zero resources have been spent on x-risk reduction and global poverty. (Though that isn't quite right either: You can't compute an output elasticity if you have to divide by 0.)
But you are supposed to compare the ideal output elasticity ratio with how resources are being spent currently, those ratios are supposed to be equal locally. So using your example, if there were currently more than 1mil times as many resources spent on x-risk than global poverty, global poverty should be prioritised.
When I was running the numbers, my impression was that global wellbeing increases had a much bigger output elasticity than x-risk reduction. I found it a bit tricky to find numbers for global (not just EA) x-risk reduction efforts, so I'm not confident and also not confident how large the gap in resource spending is. 80k quotes $500 billion per year for resources spent on global wellbeing increases.

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Home » Honours & Awards » Sultan Bin Khalifa Award
Sultan Bin Khalifa Award
TIF receives the Sultan Bin Khalifa Award for its contributions in the field of thalassaemia and other haemoglobinopathies.
A major new award programme for significant contributions in the field of thalassaemia and other Haemoglobinopathies has been established by H.H. Dr. Sheikh Sultan Bin Khalifa Al Nahyan, through His Highness Humanitarian & Scientific Development Foundation in partnership with the Thalassaemia International Federation (TIF).
We are proud to take the lead in establishing such a prestigious prize in an endeavour to strengthen efforts to educate the patients and the public about these genetic disorders, as well as to provide further motivation and encouragement to all those working in research and medical/clinical field to improve the health and the quality of life of patients with thalassaemia. The awards aim to bring thalassaemia and other haemoglobinopathies to the forefront of the political and health agendas. The awards will be given every two years and include both national and international categories with monetary and non-monetary prizes. Winning individuals and/or organisations will be announced during the biennial international conferences organised by TIF, followed by an award ceremony in Abu Dhabi.
INTERNATIONAL AWARD CATERGORIES include:
Grand International Award for life-long scientific contribution in the field of Thalassaemia/Haemoglobinopathies.
International Award for Innovative Medical Research
International Award for Clinical Center for Excellence
International Award for Thalassaemia Society of Excellence
International Scholarship for Translational Research in Thalassaemia
International Leadership in Thalassaemia Award
More information available at the official website of the Sultan Bin Khalifa International Thalassaemia Award.
Awards	2017-07-22
UN Economic & Social Council
Panos Englezos Prize


* The U.S. Deputy Representative, UN, states that "once imposed, sanctions should be kept in place until the leader against whom they are directed changes behavior."
The Security Council, faced with growing criticism of embargoes that fail to deter dictators but often hurt civilians, decided unanimously today to take a hard look at how sanctions are applied and how they can be improved.
In a long debate, no council member or representative of other nations expressed unqualified approval of the way sanctions are now used. The council president, Robert Fowler of Canada, announced that a working group, drawing on outside experts, would begin a six-month policy review.
The move reflects a wider sanctions re-examination taking place around the world, including studies by committees in the British and Canadian Parliaments and expert studies for Germany and Switzerland. There are many calls for "smart" sanctions that would be more precisely directed against leaders and their entourages.
This morning, speaking to a conference of United Nations officials, diplomats and scholars, Secretary General Kofi Annan said there was a "general lack of understanding and skepticism in the general public about the rationale and usefulness of sanctions." Even among nations not affected by sanctions, he said, "there appears a growing distrust of this instrument, and its ability to bring about change at a fair cost."
The United Nations is having a hard time responding to critics of sanctions against Iraq, where, according to a new estimate from the International Federation of Red Cross and Red Crescent Societies, 80 percent of the civilian population has been negatively affected.
The Clinton administration has been largely absent from this worldwide debate, diplomats say. It has instead continued to use sanctions or the threat of sanctions widely, sometimes pressing the Security Council to back up Washington's measures, to the discomfort of other nations.
Some diplomats say that barring a particularly terrible outrage by a leader somewhere, it will be very difficult in the foreseeable future to win a vote for sanctions, especially for a comprehensive economic embargo like that imposed on Iraq a decade ago.
"The Security Council has imposed sanctions 12 times since 1990 and only twice before then," Jean-David Levitte, the French ambassador here, said during today's debate, adding that the increase justified a reassessment of sanctions policy.
"The Sanctions Decade" is the title of a new book by two American scholars, David Cortright of the Fourth Freedom Forum and George Lopez of Notre Dame. The book (International Peace Academy/Lynne Reinner Publishers) studies 12 cases and summarizes suggestions for improving sanctions that have been made by experts around the world.
Today, the French and the Russians added a call for limited durations for sanctions, forcing complete reviews rather than rollovers at periodic intervals.
James B. Cunningham, the deputy American representative, said that once imposed, sanctions should be kept in place until the leader against whom they are directed changes behavior.
Security Council sanctions, carrying the possibility of military enforcement, are in effect in Afghanistan, Angola, Iraq, Liberia, Rwanda, Sierra Leone, Somalia, Sudan and Yugoslavia, the last for President Slobodan Milosevic's actions in Kosovo. Sanctions against Libya were suspended after two suspects were turned over to a Scottish court for trial in the 1988 bombing of Pan American Flight 101.
An article yesterday about a decision by the United Nations Security Council to review its policy on sanctions misstated the flight number of the Pan American jet that was blown up over Lockerbie, Scotland, in 1988, leading to sanctions on Libya, since suspended. It was Flight 103, not 101.


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The role of gender in volunteerism for community resilience
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State of the World's Volunteerism Report 2018: The Thread that Binds
Today, International Women's Day, UNV publishes the working draft of the research paper, "The role of gender in volunteerism for community resilience", which analyzes the relevance of gender roles, needs and interests in volunteering for community resilience, based on data collected in five communities in Africa, Asia and Latin America.
Around the world, people volunteer in different ways to achieve diverse impacts, both planned and unplanned. Most volunteering takes place through informal engagement between individuals, with only an estimated 30 per cent of volunteering taking place formally, through organizations. Much of this volunteerism – both informal and formal – takes place at the community level.
The 2018 State of the World's Volunteerism Report (SWVR 2018) investigates the relationship between volunteerism and community resilience. It highlights that local volunteers can strengthen the capacities of their communities to cope with diverse stresses and shocks, such as climate change and disasters, and recognizes volunteerism as a fundamental community resilience strategy.
The SWVR research also reveals that local volunteerism is not inclusive by default, and that some groups in a community – such as women – may be excluded from volunteering. This exclusion, and the barriers to volunteering that they may face, reduces their potential as volunteers to address the vulnerabilities and risks that affect them, their families and communities.
Volunteerism is not gender neutral. Applying a gender lens to volunteering for community resilience is critically important, particularly as globally women volunteer more than men (57 per cent and 43 per cent respectively).
As Sustainable Development Goal 5 recognizes, achieving gender equality and empowering all women and girls is crucial for sustainable development. For this to be realized and to ensure that no one is left behind, it is important to understand the role of gender in development in different contexts, including volunteerism for community resilience.
This research paper on the role of gender in volunteerism for community resilience analyzes data collected in five communities in Africa, Asia and Latin America to understand the relevance of gender roles, needs, and interests in volunteering at the community level.
It explores the distinctive contributions of volunteerism for gender equality and women's empowerment within resilience contexts. The paper provides insights on how to enhance gender equality and inclusion in volunteerism as part of the implementation of the 2030 Agenda for Sustainable Development.
The analysis in this working draft comes to the following main conclusions:
First, the voluntary responses of women and men to stresses and shocks interact and intersect with gender roles, relations, needs and interests. This juncture reveals that women's voluntary actions contribute significantly to building resilience at the household and community levels.
Second, ensuring women's full and effective participation and equal opportunities for leadership is a specific target under SDG 5. Through local volunteering, women – by themselves or with the support of external actors – participate and influence in decision making spaces and develop transformative bottom-up changes in gender relations.
Lastly, gender equality and gender inclusion in volunteerism for community resilience can be strongly promoted through effective collaborations and sustainable partnerships that include the equal participation of women and men in the development and implementation of policies and interventions aimed at building community resilience, and at achieving gender equality and women's empowerment at the household and community levels.
The paper is a working draft to be published as an input to the 2019 High-Level Political Forum on Sustainable Development, mid-July.
The paper was designed with the kind support of Online Volunteer Diana de Leon.
Working Draft: The role of gender in volunteerism for community resilience
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Michaël Uras est un écrivain et professeur de lettres né en 1977 au Creusot (Saône-et-Loire).

Biographie

Né en France d'un père d'origine sarde et d'une mère française, Michaël Uras a grandi dans le Jura dans un milieu ouvrier où la littérature n'occupe pas beaucoup de place. Sa passion précoce pour la lecture, et en particulier pour l'œuvre de Marcel Proust, le pousse vers des études littéraires. Il étudie les lettres à Besançon (Doubs) puis à la Sorbonne à Paris. Il est aujourd'hui professeur de Lettres et vit dans l'est de la France. (Doubs).

Œuvre littéraire
Son premier roman, Chercher Proust, est très largement inspiré de sa propre « relation » avec l'auteur d'À la recherche du temps perdu (« Je ne saurais expliquer pourquoi Proust a envahi mon existence alors que j'étais lycéen, c'était le moment opportun je crois, comme une rencontre amoureuse, chimique », dit-il à propos de lui-même) : son personnage principal est un jeune homme qui se laisse envahir dans tous les aspects de sa vie par sa passion dévorante pour Proust. Loin de ne s'adresser qu'aux spécialistes, c'est un roman sensible et plein d'humour qui se moque avec tendresse des chercheurs obnubilés par l'objet de leur passion. Il est publié en 2012 chez Christophe Lucquin Éditeur.

Chercher Proust a été traduit en italien par Giacomo Melloni et Giuseppe Girimonti Greco. Il a paru sous le titre Io e Proust chez Voland en . À cette occasion, Michaël Uras a été l'invité de l'Institut français d'Italie dans le cadre du Festival de la fiction française (FFF).

Son deuxième roman paru en 2014, Nos souvenirs flottent dans une mare poisseuse, est une autofiction : les chroniques d'une enfance partagée entre la France et la Sardaigne. Ce roman est finaliste du prix Marcel-Aymé en 2014 et fait partie des six romans retenus pour le prix du roman francophone (Prix Horizon du deuxième roman) dont le vainqueur est dévoilé le  à Marche-en-Famenne (Belgique).

Michael Uras a participé au recueil Nous sommes Charlie publié par Le Livre de Poche en février 2015 à la suite des attentats qui ont touché la France.

Son troisième roman Aux petits mots les grands remèdes est paru en septembre 2016 chez Préludes Éditions, puis en 2018 par Le Livre de Poche. En     convoquant les auteurs qui ont compté, l'auteur propose une histoire revigorante et inspirante, pleine d'humour et d'esprit, qui rend hommage aux mots, ceux des autres, ou ceux que chante notre petite musique intérieure.
L'ouvrage a été traduit et publié en 2017 en Italie sous le nom Le parole degli altri, aux Éditions Nord, également en Chine, en Corée, en République Tchèque, en Russie et dans de nombreux pays.

Son quatrième roman La maison à droite de celle de ma grand-mère a été publié chez Préludes Éditions en 2018, finaliste du Prix Marcel-Aymé 2017 est une véritable déclaration d'amour à la Sardaigne que propose Michaël Uras, mais aussi une ode aux petits bonheurs et aux joies simples de la vie. Le roman est en cours d'adaptation en bande dessinée. Il a également été traduit en Angleterre.
Son cinquième roman, l'iguane de Mona est une réflexion sur le mitan de la vie.
Le nouveau roman de Michael sortira en 2023, son titre sera, L'hiver à Florence.
Actuellement, Michael Uras travaille sur un recueil destiné à L'UNICEF.

Publications
 Chercher Proust, Christophe Lucquin Éditeur, 2012  puis Le Livre de poche, 2014
 Nos souvenirs flottent dans une mare poisseuse, Christophe Lucquin Éditeur, 2014  puis Le Livre de poche, 2017
 Nous sommes Charlie (recueil collectif), Le Livre de Poche, 2015
 Qualsiasi cosà meglio del vuoto, nouvelle, 2014. Publication en ligne : http://issuu.com/ilmeleto/docs/qualsiasi_cosameglio_del_vuoto.
 Proust cauchemar / Incubo Proust, nouvelle, 2015. Publication en ligne : http://www.christophelucquinediteur.fr/blog/2015/2/19/proust-cauchemar
 Aux petits mots les grands remèdes, roman, Préludes Éditions, 2016  puis Le Livre de poche, 2018
 Une librairie en pays hostile, nouvelle, Éditions Lunatique, 2017
La maison à droite de celle de ma grand-mère, roman, Préludes Éditions, 2018
- L'Iguane de Mona. Préludes Éditions, 2020.

Références

Liens externes

Écrivain français du XXIe siècle
Naissance en 1977
Naissance au Creusot

redpajama_set_name: RedPajamaWikipedia