A Predictive Model for Kidney Failure After Nephrectomy for Localized Kidney Cancer: The Kidney Cancer Risk Equation.

RATIONALE & OBJECTIVE: Nephrectomy is the mainstay of treatment for individuals with localized kidney cancer. However, surgery can potentially result in the loss of kidney function or in kidney failure requiring dialysis/kidney transplantation. There are currently no clinical tools available to preoperatively identify which patients are at risk of kidney failure over the long term. Our study developed and validated a prediction equation for kidney failure after nephrectomy for localized kidney cancer. STUDY DESIGN: Population-level cohort study. SETTING & PARTICIPANTS: Adults (n=1,026) from Manitoba, Canada, with non-metastatic kidney cancer diagnosed between January 1, 2004, and December 31, 2016, who were treated with either a partial or radical nephrectomy and had at least 1 estimated glomerular filtration rate (eGFR) measurement before and after nephrectomy. A validation cohort included individuals in Ontario (n=12,043) with a diagnosis of localized kidney cancer between October 1, 2008, and September 30, 2018, who received a partial or radical nephrectomy and had at least 1 eGFR measurement before and after surgery. NEW PREDICTORS & ESTABLISHED PREDICTORS: Age, sex, eGFR, urinary albumin-creatinine ratio, history of diabetes mellitus, and nephrectomy type (partial/radical). OUTCOME: The primary outcome was a composite of dialysis, transplantation, or an eGFR<15mL/min/1.73m2 during the follow-up period. ANALYTICAL APPROACH: Cox proportional hazards regression models evaluated for accuracy using area under the receiver operating characteristic curve (AUC), Brier scores, calibration plots, and continuous net reclassification improvement. We also implemented decision curve analysis. Models developed in the Manitoba cohort were validated in the Ontario cohort. RESULTS: In the development cohort, 10.3% reached kidney failure after nephrectomy. The final model resulted in a 5-year area under the curve of 0.85 (95% CI, 0.78-0.92) in the development cohort and 0.86 (95% CI, 0.84-0.88) in the validation cohort. LIMITATIONS: Further external validation needed in diverse cohorts. CONCLUSIONS: Our externally validated model can be easily applied in clinical practice to inform preoperative discussions about kidney failure risk in patients facing surgical options for localized kidney cancer. PLAIN-LANGUAGE SUMMARY: Patients with localized kidney cancer often experience a lot of worry about whether their kidney function will remain stable or will decline if they choose to undergo surgery for treatment. To help patients make an informed treatment decision, we developed a simple equation that incorporates 6 easily accessible pieces of patient information to predict the risk of reaching kidney failure 5 years after kidney cancer surgery. We expect that this tool has the potential to inform patient-centered discussions tailored around individualized risk, helping ensure that patients receive the most appropriate risk-based care.

Risk of venous thromboembolism or hemorrhage among individuals with chronic kidney disease on prophylactic anticoagulant after hip or knee arthroplasty.

Chronic kidney disease (CKD) confers a high risk of thrombosis and bleeding. However, little evidence exists regarding the optimal choice of postoperative thromboprophylaxis in these patients. We conducted a population-based, retrospective cohort study among adults ≥66 years old with CKD undergoing hip or knee arthroplasty who had filled an outpatient prophylactic anticoagulant prescription between 2010 and 2020 in Ontario, Canada. The primary outcomes of venous thrombosis (VTE) and hemorrhage were identified by validated algorithms using relevant diagnoses and billing codes. Overlap-weighted cause-specific Cox proportional hazard models were used to examine the association of direct oral anticoagulants (DOAC) on the 90-day risk of VTE and hemorrhage compared with low-molecular-weight heparin (LMWH). A total of 27 645 patients were prescribed DOAC (N = 22 943) or LMWH (N = 4702) after arthroplasty. Rivaroxaban was the predominant DOAC (94.5%), while LMWH mainly included enoxaparin (67%) and dalteparin (31.5%). DOAC users had higher eGFRs, fewer co-morbidities, and surgery in more recent years compared to LMWH users. After weighing, DOAC (compared with LMWH) was associated with a lower risk of VTE (DOAC: 1.5% vs. LMWH: 2.1%, weighted hazard ratio [HR] 0.75, 95% confidence interval [CI] 0.59-0.94) and a higher risk of hemorrhage (DOAC: 1.3% vs. LMWH: 1.0%, weighted HR 1.44, 95% CI 1.04-1.99). Additional analyses including a more stringent VTE defining algorithm, different eGFR cut-offs, and limiting to rivaroxaban and enoxaparin showed consistent findings. Among elderly adults with CKD, DOAC was associated with a lower VTE risk and a higher hemorrhage risk compared to LMWH following hip or knee arthroplasty.

Community Interventions for Out-of-Hospital Cardiac Arrest in Resource-Limited Settings: A Scoping Review Across Low, Middle, and High-Income Countries.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is a major global health challenge, characterized by poor survival outcomes worldwide. Resource-limited settings are burdened with suboptimal emergency response and worse outcomes than high-resource areas. Engaging the community in the response to OHCA has the potential to improve outcomes, although an overview of community interventions in resource-limited settings has not been provided. OBJECTIVE: This review evaluated the scope of community-based OHCA interventions in resource-limited settings. METHODS: Literature searches in electronic databases (MEDLINE, EMBASE, Global Health, CINAHL, Cochrane Central Register of Controlled Clinical Trials) and grey literature sources were performed. Abstract screening, full-text review, and data extraction of eligible studies were conducted independently by two reviewers. The PCC (Population, Concept, and Context) framework was used to assess study eligibility. Studies that evaluated community-based interventions for laypeople (Population), targeting emergency response activation, cardiopulmonary resuscitation (CPR), or automated external defibrillator (AED) use (Concept) in resource-limited settings (Context) were included. Resource-limited settings were identified by financial pressures (low-income or lower-middle-income country, according to World Bank data on year of publication) or geographical factors (setting described using keywords indicative of geographical remoteness in upper-middle-income or high-income country). RESULTS: Among 14,810 records identified from literature searches, 60 studies from 28 unique countries were included in this review. Studies were conducted in high-income (n = 35), upper-middle-income (n = 2), lower-middle-income (n = 22), and low-income countries (n = 1). Community interventions included bystander CPR and/or AED training (n = 34), community responder programs (n = 8), drone-delivered AED networks (n = 6), dispatcher-assisted CPR programs (n = 4), regional resuscitation campaigns (n = 3), public access defibrillation programs (n = 3), and crowdsourcing technologies (n = 2). CPR and/or AED training were the only interventions evaluated in low-income, lower-middle-income, and upper-middle-income countries. CONCLUSIONS: Interventions aimed at improving the community response to OHCA in resource-limited settings differ globally. There is a lack of reported studies from low-income countries and certain continental regions, including South America, Africa, and Oceania. Evaluation of interventions other than CPR and/or AED training in low- and middle-income countries is needed to guide community emergency planning and health policies.

Does cardiovascular preparticipation screening cause psychological distress in athletes? A systematic review.

OBJECTIVE: To evaluate the psychological implications of cardiovascular preparticipation screening (PPS) in athletes. DESIGN: Systematic review. DATA SOURCES: MEDLINE, EMBASE, PubMed, CINAHL, SPORTDiscus, APA PsycInfo, Cochrane Library and grey literature sources. STUDY ELIGIBILITY CRITERIA: Observational and experimental studies assessing a population of athletes who participated in a cardiovascular PPS protocol, where psychological outcomes before, during and/or after PPS were reported. METHODS: Results of included studies were synthesised by consolidating similar study-reported measures for key psychological outcomes before, during and/or after screening. Summary measures (medians, ranges) were computed across studies for each psychological outcome. RESULTS: A total of eight studies were included in this review (median sample size: 479). Study cohorts consisted of high school, collegiate, professional and recreational athletes (medians: 59% male, 20.5 years). Most athletes reported positive reactions to screening and would recommend it to others (range 88%-100%, five studies). Increased psychological distress was mainly reported among athletes detected with pathological cardiac conditions and true-positive screening results. In comparison, athletes with false-positive screening results still reported an increased feeling of safety while participating in sport and were satisfied with PPS. A universal conclusion across all studies was that most athletes did not experience psychological distress before, during or after PPS, regardless of the screening modality used or accuracy of results. CONCLUSION: Psychological distress associated with PPS in athletes is rare and limited to athletes with true-positive findings. To mitigate downstream consequences in athletes who experience psychological distress, appropriate interventions and resources should be accessible prior to the screening procedure. PROSPERO REGISTRATION NUMBER: CRD42021272887.

Comparative evaluation of an electrocardiogram workflow model for athletic cardiovascular screening: Primary care network versus sports cardiology interpretation.

BACKGROUND: Electrocardiogram (ECG) testing in pre-participation screening (PPS) remains controversial due to its cost, resource dependency, and the potential for inaccurate interpretations. At most centres, ECGs are conducted internally by providers trained in athletic ECG interpretation. Outsourcing ECG requisitions to an athlete's primary care network (PCN) may reduce institutional demands. This study compared PCN-conducted athletic ECG interpretation to expert sports cardiology interpretation. METHODS: This was a retrospective, single-centre chart-review study of all athletes who underwent cardiovascular PPS between 2017 and 2021. All athletes submitted an ECG with their screening package, which was conducted and interpreted within their PCN. All ECGs were reinterpreted by a sports cardiologist using the International Criteria (IC) for electrocardiographic interpretation in athletes. Overall, positive, and negative percent agreement were used to compare PCN-conducted ECG interpretation with IC interpretation. RESULTS: A total of 740 athletes submitted a screening package with a valid ECG (mean age: 18.5 years, 39.6% female). PCN-conducted ECGs were interpreted by 181 unique physicians. Among 41 (5.5%) PCN-conducted ECGs that were initially interpreted as abnormal, only 5 (0.7%) were classified as abnormal according to the IC. All PCN-conducted ECGs reported as normal were also classified as normal according to the IC. The overall agreement between PCN-conducted and IC ECG interpretation was 95.1% (positive percent agreement: 100%, negative percent agreement: 95.1%). CONCLUSIONS: Normal PCN-conducted athletic ECGs are interpreted with high agreement to the IC. Majority of PCN-conducted ECGs interpreted as abnormal are indeed normal as per the IC. These findings suggest that a PPS workflow model that outsources ECG requisitions to a PCN may be a reliable approach to PPS, all while reducing screening-related institutional costs and resource requirements.

Association of frailty with days alive at home in critically ill patients undergoing emergency general surgery: a population-based cohort study.

BACKGROUND: Frailty is an established risk factor for morbidity and mortality in older patients undergoing surgery. In people with critical illness before surgery, few data describe patient-centred outcomes. Our objective was to estimate the association of frailty with postoperative days alive at home in older critically ill patients requiring emergency general surgery. METHODS: A retrospective population-based cohort study was conducted using linked administrative health data in Ontario, Canada from 2009 to 2019. All individuals aged ≥66 yr with an ICU admission before emergency general surgery were included. We compared the count of days alive at home at 30 and 365 days after surgery based on frailty status using a validated, multidimensional index. Unadjusted and multilevel, multivariable adjusted effect estimates were calculated. A sensitivity analysis based on early recovery category was performed. RESULTS: We identified 7003 eligible patients; 2063 (29.5%) lived with frailty. At 30 days, mean days alive at home with frailty were 4.5 (standard deviation 8.2) and 7.6 (standard deviation 10.2) in those without frailty. In adjusted analysis, frailty was associated with fewer days alive at home at 30 (ratio of means [RoM] 0.68; 95% confidence interval [CI]: 0.60-0.78; P<0.001) and 365 days (RoM 0.72; 95% CI: 0.64-0.82; P<0.001). Individuals with frailty had a higher probability of poor recovery status, with effects increasing across the first postoperative month. CONCLUSIONS: In patients with critical illness requiring emergency general surgery, frailty is associated with fewer days alive at home. This information should be discussed with critically ill patients before emergent surgical intervention to better inform decision-making.

Suicide and Self-Harm Among Physicians in Ontario, Canada.

BACKGROUND: Studies of occupation-associated suicide suggest physicians may be at a higher risk of suicide compared to nonphysicians. We set out to assess the risk of suicide and self-harm among physicians and compare it to nonphysicians. METHODS: We conducted a population-based, retrospective cohort study using registration data from the College of Physicians and Surgeons of Ontario from 1990 to 2016 with a follow-up to 2017, linked to Ontario health administrative databases. Using age- and sex-standardized rates and inverse probability-weighted, cause-specific hazards regression models, we compared rates of suicide, self-harm, and a composite of either event among all newly registered physicians to nonphysician controls. RESULTS: Among 35,989 physicians and 6,585,197 nonphysicians, unadjusted suicide events (0.07% vs. 0.11%) and rates (9.44 vs. 11.55 per 100,000 person-years) were similar. Weighted analyses found a hazard ratio of 1.05 (95% confidence interval: 0.69 to 1.60). Self-harm requiring health care was lower among physicians (0.22% vs. 0.46%; hazard ratio: 0.65, 95% confidence interval: 0.52 to 0.82), as was the composite of suicide or self-harm (hazard ratio: 0.70, 95% confidence interval: 0.57 to 0.86). The composite of suicide or self-harm was associated with a history of a mood or anxiety disorder (odds ratio: 2.84, 95% confidence interval: 1.17 to 6.87), an outpatient mental health visit in the past year (odds ratio: 3.08, 95% confidence interval: 1.34 to 7.10) and psychiatry visit in the preceding year (odds ratio: 3.87, 95% confidence interval: 1.67 to 8.95). INTERPRETATION: Physicians in Ontario are at a similar risk of suicide deaths and a lower risk of self-harm requiring health care relative to nonphysicians. Risk factors associated with suicide or self-harm may help inform prevention programs.

Bystander interventions and survival after exercise-related sudden cardiac arrest: a systematic review.

OBJECTIVE: To evaluate the provision of bystander interventions and rates of survival after exercise-related sudden cardiac arrest (SCA). DESIGN: Systematic review. DATA SOURCES: MEDLINE, EMBASE, PubMed, CINAHL, SPORTDiscus, Cochrane Library and grey literature sources were searched from inception to November/December 2020. STUDY ELIGIBILITY CRITERIA: Observational studies assessing a population of exercise-related SCA (out-of-hospital cardiac arrests that occurred during exercise or within 1 hour of cessation of activity), where bystander cardiopulmonary resuscitation (CPR) and/or automated external defibrillator (AED) use were reported, and survival outcomes were ascertained. METHODS: Among all included studies, the median (IQR) proportions of bystander CPR and bystander AED use, as well as median (IQR) rate of survival to hospital discharge, were calculated. RESULTS: A total of 29 studies were included in this review, with a median study duration of 78.7 months and a median sample size of 91. Most exercise-related SCA patients were male (median: 92%, IQR: 86%-96%), middle-aged (median: 51, IQR: 39-56 years), and presented with a shockable arrest rhythm (median: 78%, IQR: 62%-86%). Bystander CPR was initiated in a median of 71% (IQR: 59%-87%) of arrests, whereas bystander AED use occurred in a median of 31% (IQR: 19%-42%) of arrests. Among the 19 studies that reported survival to hospital discharge, the median rate of survival was 32% (IQR: 24%-49%). Studies which evaluated the relationship between bystander interventions and survival outcomes reported that both bystander CPR and AED use were associated with survival after exercise-related SCA. CONCLUSION: Exercise-related SCA occurs predominantly in males and presents with a shockable ventricular arrhythmia in most cases, emphasising the importance of rapid access to defibrillation. Further efforts are needed to promote early recognition and a rapid bystander response to exercise-related SCA.

The Role of Carotid and Femoral Plaque Burden in the Diagnosis of Coronary Artery Disease.

PURPOSE OF REVIEW: With limitations of cardiovascular disease risk stratification by traditional risk factors, the role of noninvasive imaging techniques, such as vascular ultrasound, has emerged as a prominent utility for decision-making in coronary artery disease. A review of current guidelines and contemporary approaches for carotid and femoral plaque assessment is needed to better inform the diagnosis, management, and treatment of atherosclerosis in clinical practice. RECENT FINDINGS: The recent consensus-based guidelines for carotid plaque assessment in coronary artery disease have been established, supported by some outcomes-based research. Currently, there is a gap of evidence on the use of femoral ultrasound to detect atherosclerosis, as well as predict adverse cardiovascular outcomes. The quantification and characterization of individualized plaque burden are important to stratify risk in asymptomatic or symptomatic atherosclerosis patients. Standardized quantification guidelines, supported by further outcomes-based research, are required to assess disease severity and progression.

Shock to the Heart: Psychosocial Implications and Applications of Sudden Cardiac Death in the Young.

PURPOSE OF REVIEW: Although rare, sudden cardiac death (SCD) in the young is a tragic event, having a dramatic impact upon all involved. The psychosocial burden associated with SCD can leave friends, families, and entire communities bereft. With only limited evidence to describe the volatile emotional reactions associated with a young SCD, there is an urgent need for care providers to better understand the psychological complexities and impacts faced by both at-risk individuals and those directly affected by these tragic events. RECENT FINDINGS: Current knowledge of the psychosocial implications associated with SCD in the young has recently generated interest in the cardiovascular community, with the goal of addressing prevention strategies (screening), family bereavement, and the psychological impact of at-risk or surviving individuals. With the emergence of novel strategies aimed at reducing the public health impact of SCD in the young, further discussion regarding the psychosocial impact of SCD, encompassing prevention, survivorship, and the downstream communal effects of a young death is required. Support systems and intervention could assist in the management of the associated psychosocial burden, yet there is a lack of clinical guidelines to direct this form of care. There is an important need for multidisciplinary collaboration across subspecialties to provide support to grieving individuals and manage patient well-being throughout the screening process for SCD. This collaborative approach requires the integration of cardiovascular and psychological expertise where relevant.

Patient Involvement in Care, Psychosocial Outcomes, and Quality of Life in Hypertrophic Cardiomyopathy: A Pilot Study.

This cross-sectional study evaluated the impact of patient involvement in care (PIC) on psychosocial outcomes and health-related quality of life (HRQoL) in patients with hypertrophic cardiomyopathy (HCM) (n = 34). Patients with low-to-moderate PIC were older than those with high PIC (66.8 years vs 57.3 years; P = 0.04). PIC was negatively correlated with depressive symptoms (r = -0.39; P = 0.02) and positively correlated with heart-focused attention (r = 0.39; P = 0.02). No significant correlations were observed between PIC and HRQoL. Greater PIC was associated with reduced depressive symptoms but increased cardiac anxiety. Future studies should investigate the relationship between PIC and HRQoL in a larger cohort.

Cette étude transversale visait à évaluer l'effet de la participation du patient à ses soins sur les issues psychosociales et la qualité de vie liée à la santé chez les patients atteints de cardiomyopathie hypertrophique (CMH) (n = 34). Les patients qui participaient peu ou modérément à leurs soins étaient plus âgés que ceux qui y participaient activement (66,8 ans vs 57,3 ans; p = 0,04). Il y a une corrélation négative entre la participation du patient aux soins et les symptômes dépressifs (r = -0,39; p = 0,02) et une corrélation positive entre la participation aux soins et l'attention portée au cœur (r = 0,39; p = 0,02). Aucune corrélation notable n'a été observée entre la participation du patient à ses soins et la qualité de vie liée à la santé. Une grande participation du patient à ses soins a été associée à une réduction des symptômes dépressifs, mais à une anxiété cardiaque accrue. D'autres études sont nécessaires pour examiner la relation entre la participation du patient à ses soins et la qualité de vie liée à la santé au sein d'une cohorte plus importante.

Outcomes following coronary artery bypass grafting with multiple arterial grafting by pump status in men and women.

BACKGROUND: Multiple arterial grafting (MAG) and off-pump surgery are strategies proposed to improve outcomes with coronary artery bypass grafting (CABG). This study was conducted to determine the impact of off-pump surgery on outcomes after CABG with MAG in men and women. METHODS: This cohort study used population-based data to identify all Ontarians undergoing isolated CABG with MAG between October 2008 and September 2019. The primary outcome was all-cause mortality. Secondary outcomes included major adverse cardiac and cerebrovascular events (MACCE; hospitalization for stroke, myocardial infarction hospitalization or heart failure, or repeat revascularization). Analysis used propensity-score overlap-weighted cause-specific Cox proportional hazard regression. RESULTS: A total of 2989 women (1188 off-pump, 1801 on-pump) and 16,209 men (6065 off-pump, 10,144 on-pump) underwent MAG with a median follow-up of 5.0 years (interquartile range, 2.7-8.0) years. Compared to the on-pump approach, all-cause mortality was not changed with off-pump status (hazard ratio [HR] in women: 1.25 [95% CI, 0.83-1.88]; in men: 1.08 [95% CI, 0.85-1.37]). In women, the risk of MACCE was significantly higher off-pump (HR, 1.45; 95% CI, 1.04-2.03), with nonsignificantly increased risk observed for all component outcomes. CONCLUSIONS: In patients undergoing CABG with MAG, this population-based analysis found no association between pump status and survival in either men or women. However, it did suggest that off-pump MAG in women may be associated with an increased risk of MACCE.

Carotid Plaque Score is Associated with 10-year Major Adverse Cardiovascular Events in Low-Intermediate Risk Patients Referred to a General Cardiology Community Clinic.

AIMS: Atherosclerotic carotid plaque assessments have not been integrated into routine clinical practice due to the time-consuming nature of both imaging and measurements. Plaque score, Rotterdam method, is simple, quick, and only requires 4-6 B-mode ultrasound images. The aim was to assess the benefit of plaque score in a community cardiology clinic to identify patients at risk for major adverse cardiovascular events (MACE). METHODS AND RESULTS: Patients ≥40 years presenting for risk assessment were given a carotid ultrasound. Exclusions included a history of vascular disease or MACE and being >75 years. Kaplan-Meier curves and hazard ratios were performed. The left and right common carotid artery (CCA), bulb, and internal carotid artery (ICA) were given 1 point per segment if plaque present (plaque score 0 to 6). Administrative data holdings at ICES were used for 10-year event follow-up. Of 8,472 patients, 60% were females (n = 5,121). Plaque was more prevalent in males (64% vs 53.9%; P <0.0001). The 10-year MACE cumulative incidence estimate was 6.37% with 276 events (males 6.9 % vs females 6.0%; P = 0.004). Having both maximal CCA IMT <1.00 mm and plaque score = 0, was associated with less events. A plaque score <2 was associated with a low 10-year event rate (4.1%) compared to 2-4 (8.7%) and 5-6 (20%). CONCLUSION: A plaque score ≥2 can re-stratify low-intermediate risk patients to a higher risk for events. Plaque score may be used as a quick assessment in a cardiology office to guide treatment management of patients.

Mediators of the Association Between Socioeconomic Status and Survival After Out-of-Hospital Cardiac Arrest: A Systematic Review.

Low socioeconomic status (SES) is associated with poor outcomes after out-of-hospital cardiac arrest (OHCA). Patient characteristics, care processes, and other contextual factors may mediate the association between SES and survival after OHCA. Interventions that target these mediating factors may reduce disparities in OHCA outcomes across the socioeconomic spectrum. This systematic review identified and quantified mediators of the SES-survival after OHCA association. Electronic databases (MEDLINE, Embase, PubMed, Web of Science) and grey literature sources were searched from inception to July or August 2023. Observational studies of OHCA patients that conducted mediation analyses to evaluate potential mediators of the association between SES (defined by income, education, occupation, or a composite index) and survival outcomes were included. A total of 10 studies were included in this review. Income (n = 9), education (n = 4), occupation (n = 1), and composite indices (n = 1) were used to define SES. The proportion of OHCA cases that had bystander involvement, presented with an initial shockable rhythm, and survived to hospital discharge or 30 days increased with higher SES. Common mediators of the SES-survival association that were evaluated included initial rhythm (n = 6), emergency medical services response time (n = 5), and bystander cardiopulmonary resuscitation (n = 4). Initial rhythm was the most important mediator of this association, with a median percent excess risk explained of 37.4% (range 28.6%-40.0%; n = 5; 1 study reported no mediation) and mediation proportion of 41.8% (n = 1). To mitigate socioeconomic disparities in outcomes after OHCA, interventions should target potentially modifiable mediators, such as initial rhythm, which may involve improving bystander awareness of OHCA and the need for prompt resuscitation.

Coarse particulate air pollution and mortality in a multidrug-resistant tuberculosis cohort.

RATIONALE: The association between ambient coarse particulate matter (PM2.5-10) and mortality in multi-drug resistant tuberculosis (MDR-TB) patients has not yet been studied. The modifying effects of temperature and humidity on this association are completely unknown. OBJECTIVES: To evaluate the effects of long-term PM2.5-10 exposures, and their modifications by temperature and humidity on mortality among MDR-TB patients. METHODS: A Chinese cohort of 3469 MDR-TB patients was followed up from diagnosis until death, loss to follow-up, or the study's end, averaging 2567 days per patient. PM2.5-10 concentrations were derived from the difference between PM10 and PM2.5. Cox proportional hazard models estimated hazard ratios (HRs) per 3.74 µg/m3 (interquartile range, IQR) exposure to PM2.5-10 and all-cause mortality for the full cohort and individuals at distinct long-term and short-term temperature and humidity levels, adjusting for other air pollutants and potential covariates. Exposure-response relationships were quantified using smoothed splines. RESULTS: Hazard ratios of 1.733 (95% CI, 1.407, 2.135) and 1.427 (1.114, 1.827) were observed for mortality in association with PM2.5-10 exposures for the full cohort under both long-term and short-term exposures to temperature and humidity. Modifying effects by temperature and humidity were heterogenous across sexes, age, treatment history, and surrounding environment measured by greenness and nighttime light levels. Nonlinear exposure-response curves suggestes a cumulative risk of PM2.5-10-related mortality starting from a low exposure concentration around 15 µg/m3. CONCLUSION: Long-term exposure to PM2.5-10 poses significant harm among MDR-TB patients, with effects modified by temperature and humidity. Immediate surveillance of PM2.5-10 is crucial to mitigate the progression of MDR-TB severity, particularly due to co-exposures to air pollution and adverse weather conditions.

Lessons Learned from POCUS Instruction in Undergraduate Medicine During the COVID-19 Pandemic.

Point of care Ultrasound (POCUS) has been adopted into clinical practice across many fields of medicine. Undergraduate medical education programs have recognized the need to incorporate POCUS training into their curricula, traditionally done in small groups with in-person sessions. This method is resource intensive and requires sufficient equipment and expertise. These requirements are often cited as barriers for implementation. During the Coronavirus Disease 2019 (COVID-19) pandemic, POCUS education was required to adapt to physical distancing regulations, giving rise to novel teaching methods for POCUS. This article outlines the implementation of a POCUS teaching session before and during the pandemic. It describes how these innovations can scale POCUS teaching and overcome barriers moving forward. A flipped classroom model was implemented for all learners. Learners were given an introductory POCUS module before the scheduled in-person or virtual teaching session. Sixty-nine learners participated in conventional in-person teaching, while twenty-two learners participated in virtual teaching following the pandemic-related restrictions. Learners completed a written test before and following the teaching. In-person learners were assessed using an objective structured assessment of ultrasound skills (OSAUS) pre- and post-learning sessions. A follow-up survey was conducted three years after the teaching sessions were completed. Both in-person and virtual groups demonstrated statistically significant improvement in knowledge scores (p <0.0001). Both groups had similar post-test learning scores (74.2 ± 13.6% vs. 71.8 ± 14.5 %, respectively). On follow-up questionnaires, respondents indicate that they found our online and in-person modes of teaching helpful during their residency. POCUS education continues to face a variety of barriers, including limitations in infrastructure and expertise. This study describes an adapted POCUS teaching model that is scalable, uses minimal infrastructure and retains the interactivity of conventional small-group POCUS teaching. This program can serve as a blueprint for other institutions offering POCUS teaching, especially when conventional teaching methods are limited.

Effect of pharmacologic anti-atherosclerotic therapy on carotid intraplaque neovascularization: A systematic review.

Intraplaque neovascularization (IPN), a key feature of vulnerable carotid plaque, is associated with adverse cardiovascular (CV) events. Statin therapy has been shown to diminish and stabilize atherosclerotic plaque, but its effect on IPN is uncertain. This review investigated the effects of common pharmacologic anti-atherosclerotic therapies on carotid IPN. Electronic databases (MEDLINE, EMBASE and Cochrane Library) were searched from inception until July 13, 2022. Studies evaluating the effect of anti-atherosclerotic therapy on carotid IPN among adults with carotid atherosclerosis were included. Sixteen studies were eligible for inclusion. Contrast-enhanced ultrasound (CEUS) was the most common IPN assessment modality (n=8), followed by dynamic contrast-enhanced MRI (DCE-MRI) (n=4), excised plaque histology (n=3) and superb microvascular imaging (n=2). In fifteen studies, statins were the therapy of interest and one study assessed PCSK9 inhibitors. Among CEUS studies, baseline statin use was associated with a lower frequency of carotid IPN (median OR = 0.45). Prospective studies showed regression of IPN after 6-12 months of lipid-lowering therapy, with more regression observed in treated participants compared to untreated controls. Our findings suggest that lipid-lowering therapy with statins or PCSK9 inhibitors is associated with IPN regression. However, there was no correlation between change in IPN parameters and change in serum lipids and inflammatory markers in statin-treated participants, so it is unclear whether these factors are mediators in the observed IPN changes. Lastly, this review was limited by study heterogeneity and small sample sizes, so larger trials are needed to validate findings.