A Single-Center Audit of BI-RADS 3 Assessment Category Utilization in Mammography and Breast Ultrasound.

Purpose: To evaluate outcomes of breast lesions assessed at our institution as probably benign (Breast Imaging Reporting and Data System [BI-RADS] category 3) with an expected malignancy rate of less than or equal to 2 %. Methods: Average-risk women with a BI-RADS 3 assessment following mammographic and/or ultrasound evaluation at our institution between January 1 and December 31, 2017 were included. Cancer yield was calculated within 90 days and at 6-month intervals up to 36 months. Results: Among 517 women (median age, 52 years; range, 13-89 years) with a BI-RADS 3 assessment, 349 (67.5 %) underwent biopsy or completed follow-up imaging up to 36 months. One hundred and 68 (32.5 %) were lost to follow-up. Thirty of 349 (8.6 %) had their imaging upgraded and underwent biopsy, yielding six cancers (cancer yield, 6 of 349 women [1.7 %]). Among 569 lesions assessed as BI-RADS 3, 92 (16.2 %) were characterized by morphologic features other than those validated as probably benign in prospective clinical studies. Fifty three of 517 women (10.3 %) had follow-up beyond 24 months, and 24 (4.6 %) had follow-up beyond 36 months. Conclusion: Overall utilization of the BI-RADS 3 assessment category at our institution is appropriate with a 1.7 % cancer yield. However, the rate of loss to follow-up, percentage of non-validated findings assessed as probably benign, and redundancy in follow-up protocols are too high, and warrant intervention. A patient handout explaining the BI-RADS 3 assessment category and automatic scheduling of follow-up studies have been implemented at our center to address loss to follow-up.

The Diagnostic Yield of Magnetic Resonance Cholangiopancreatography in the Setting of Acute Pancreaticobiliary Disease - A Single Center Experience.

PURPOSE: To discern whether preceding ultrasound (US) results, patient demographics and biochemical markers can be implemented as predictors of an abnormal Magnetic Resonance Cholangiopancreatography (MRCP) study in the context of acute pancreaticobiliary disease. METHODS: A retrospective study was performed assessing US results, age, gender, elevated lipase and biliary enzymes for consecutive patients who underwent an urgent MRCP following an initial US for acute pancreaticobiliary disease between January 2017-December 2018. Multivariable binary logistic regression models were constructed to assess for predictors of clinically significant MRCPs, and discrepant US/MRCP results. RESULTS: A total of 155 patients (mean age 56, 111 females) were included. Age (OR 1.03, P < 0.05), hyperlipasemia (OR 5.33, P < 0.05) and a positive US (OR 40.75, P < 0.05) were found to be independent predictors for a subsequent abnormal MRCP. Contrarily, gender and elevated biliary enzymes were not reliable predictors of an abnormal MRCP, or significant MRCP/US discrepancies. Of 66 cases (43%) of discordant US/MRCPs, half had clinically significant discrepant findings such as newly discovered choledocholithiasis and pancreaticobiliary neoplasia. Age was the sole predictor for a significant US/MRCP discrepancy, with 2% increase in the odds of a significant discrepancy per year of increase in age. CONCLUSION: An abnormal US, hyperlipasemia and increased age serve as predictors for a subsequent abnormal MRCP, as opposed to gender and biliary enzyme elevation. Age was the sole predictor of a significant US/MRCP discrepancy that provided new information which significantly impacted subsequent management. In the remaining cases, however, MRCP proved useful in reaffirming the clinical diagnosis and avoiding further investigations.

Synthetic 2D Mammography Versus Standard 2D Digital Mammography: A Diagnostic Test Accuracy Systematic Review and Meta-Analysis.

BACKGROUND. The use of synthetic 2D mammography (SM) with digital breast tomosynthesis (DBT) in place of standard 2D digital mammography (DM) may reduce radiation dose without sacrificing accuracy. OBJECTIVE. The purpose of our study was to compare the diagnostic accuracy of SM, DM, SM with DBT, and DM with DBT for breast cancer detection. EVIDENCE ACQUISITION. A search of MEDLINE, Embase, and Cochrane databases was performed for relevant articles published up to September 11, 2019. Studies included compared the diagnostic accuracy of SM versus DM and SM plus DBT versus DM plus DBT for breast cancer detection. Relevant study data metrics and risk of bias were assessed. A bivariate random-effects meta-analysis and meta-regression were performed to assess diagnostic accuracy (PROSPERO CRD42020150737). EVIDENCE SYNTHESIS. Thirteen studies reporting on 201,304 patients (7252 patients with breast cancer) were included. The SM group (six studies: 20,728 patients, 724 with breast cancer) had 75% sensitivity (95% CI, 67-82%) and 92% specificity (95% CI, 85-96%). The DM group (nine studies: 52,082 patients, 2249 patients with breast cancer) had 73% sensitivity (95% CI, 65-80%) and 88% specificity (95% CI, 77-94%). The SM plus DBT group (10 studies, 64,224 patients, 2149 with breast cancer) had 85% sensitivity (95% CI, 80-89%) and 93% specificity (95% CI, 86-96%). The DM plus DBT group (nine studies, 64,270 patients, 2130 with breast cancer) had 84% sensitivity (95% CI, 80-88%) and 91% specificity (95% CI, 83-95%). Meta-regression models did not reveal significant differences in accuracy between the SM and DM groups (p = .25-.77). CONCLUSION. SM and SM plus DBT showed comparable diagnostic accuracy to DM and DM plus DBT, respectively. CLINICAL IMPACT. The findings support the implementation of SM in place of standard DM for mammographic imaging of the breasts. This may lead to an overall reduction in radiation exposure.

Evaluating the Transvaginal Ultrasound Diagnostic Criteria for Abnormal First-Trimester Pregnancy With Follow-Up Into the Third Trimester and Validation of Results.

OBJECTIVE: To evaluate the current ultrasound diagnostic criteria for non-viable pregnancy in the first trimester. METHODS: We conducted a retrospective chart review involving 3 tertiary care institutions. Consecutive first-trimester ultrasound reports between January 2013 and June 2016 were reviewed. All first-trimester ultrasound examinations performed to assess pregnancy viability with adequate imaging or clinical follow-up were included. Inclusion criteria based on follow-up were adequate imaging to document ongoing intrauterine pregnancy or clinical follow-up demonstrating viability or non-viability. Data on mean sac diameter (MSD), yolk sac presence/diameter, embryo presence/length, presence of a heartbeat, and heart rate were collected. This was followed by a retrospective validation review of another consecutive cohort. RESULTS: Two hundred and forty-five examinations with a viable-pregnancy outcome and 301 examinations with a non-viable pregnancy outcome were reviewed. The main predictor of non-viable pregnancy was an MSD of ≥20 mm in the absence of a yolk sac (positive predictive value [PPV] 100%; 95% CI 93%-100%), embryo (PPV 100%; 95% CI 90%-100%), or heartbeat (PPV 100%; 95% CI 96%-100%]). Other predictors of non-viability were a measurable embryo without a yolk sac (PPV 100%; 95% CI 91%-100%), yolk sac diameter ≥8 mm (PPV 100%; 95% CI 91%-100%), and absence of heartbeat with an embryo ≥3 mm (PPV 100%; 95% CI 97%-100%). These findings were confirmed in a validation cohort of 45 viable and 53 non-viable pregnancies, with the exception of 1 case of viable pregnancy with no heartbeat and an embryo length 3.3 mm. Based on the median daily growth of 1.2 mm in the viable cohort, 21% of follow-up ultrasound examinations were performed too early for an MSD threshold of 20 mm and 55%, for an MSD threshold of 25 mm. CONCLUSION: In our cohort, MSD ≥20 mm in the absence of yolk sac or an embryo with heartbeat always predicted a non-viable pregnancy.

Factors associated with the timing of the first prenatal ultrasound in Canada.

BACKGROUND: The aim of this study was to investigate the factors associated with the timing of the first prenatal ultrasound in Canada. METHODS: This was a secondary data analysis of the Maternity Experiences Survey, a cross-sectional survey covering different aspects of pregnancy, labour, birth and the post-partum period. Bivariate and multivariate multinomial logistic regressions were performed to assess the relationship between timing of first prenatal ultrasound and different independent variables. RESULTS: 68.4% of Canadian women received an optimally timed first prenatal ultrasound, 27.4% received early ultrasounds and 4.3% received late ultrasound. The highest prevalence of early ultrasound was in Ontario (33.3%) and the lowest was in Manitoba (13.3%). The highest prevalence of late ultrasound was found in Manitoba (12.1%) and the lowest was in British Columbia and Ontario (3.5% each). The highest prevalence of optimal timing of first prenatal ultrasound was in Quebec (77%) and the lowest was in Ontario (63.2%). Factors influencing the timing of ultrasound included: Early - maternal age < 20 (adjusted OR = 0.54, 95%CI:0.34-0.84), alcohol use during pregnancy (adjusted OR = 0.69, 95%CI:0.53-0.90), history of premature birth (adjusted OR = 1.41, 95%CI:1.06-1.89), multiparity (adjusted OR = 0.67, 95%CI:0.57-0.78), born outside of Canada (adjusted OR = 0.82, 95%CI:0.67-0.99), prenatal care in Newfoundland and Labrador (adjusted OR = 1.66, 95%CI:1.20-1.30), Nova Scotia (adjusted OR = 1.68, 95%CI:1.25-2.28), Ontario (adjusted OR = 2.16, 95%CI:1.76-2.65), Saskatchewan (adjusted OR = 1.50, 95%CI:1.05-2.14), Alberta (adjusted OR = 1.37, 95%CI:1.05-1.77) British Columbia (adjusted OR = 1.90, 95%CI:1.45-2.50) and Manitoba (adjusted OR = 0.66, 95%CI:0.45-0.98) Late - unintended pregnancy (adjusted OR = 1.89, 95%CI:1.38-2.59), born outside of Canada (adjusted OR = 1.75, 95%CI:1.14-2.68), prenatal care in Manitoba (adjusted OR = 2.88, 95%CI:1.64-5.05) and the Territories (adjusted OR = 4.50, 95%CI:2.27-8.93). An interaction between history of miscarriage and having 'other' prenatal care provider significantly affected timing of ultrasound (adjusted OR = 0.31, 95%CI:0.14-0.66). CONCLUSION: Only 68% of Canadian women received an optimally timed prenatal ultrasound which was influenced by several factors including province of prenatal care, maternal age and country of birth, and an interaction effect between prenatal care provider and history of miscarriage. These findings establish a baseline of factors influencing the timing of prenatal ultrasound in Canada, which can be built upon by future studies.

The association between alcohol, marijuana, illegal drug use and current use of E-cigarette among youth and young adults in Canada: results from Canadian Tobacco, Alcohol and Drugs Survey 2017.

BACKGROUND: E-cigarettes have grown in popularity around the world since 2003. Although marketed as a smoking cessation tool, e-cigarettes can lead to tobacco cigarette smoking in youth. In Canada, among all age groups, youth and young adults have the highest prevalence of e-cigarette use. The objective of this study was to assess the factors associated with e-cigarette use among youth and young adults in Canada, and to specifically examine the association between alcohol, marijuana and illicit drug use. METHODS: Data from the 2017 Canadian Tobacco, Alcohol and Drugs Survey were used. The sample was restricted to those aged 15-24 years (n = 10,322), and main outcome defined as 'E-cigarette use in the past 30-days'. Multivariable logistic regression was performed to assess the association between the main outcome and substance use variables (illicit drug, marijuana and alcohol use), tobacco exposure variables, and demographic and health-related factors. RESULTS: 6.2% Canadians aged 15-24 reported using e-cigarettes in the past 30-days, while 23.9% reported having ever tried e-cigarettes. Twenty-three percent of the past 30-day users reported using e-cigarettes every day and 72.5% of the past 30-day users reported having nicotine in their last e-cigarette. Additionally, youth aged 15-17 were 4.95 times more likely to be e-cigarette users as compared to those aged 22-24 (OR: 4.95, 95% CI: 3.1-7.9). Moreover, e-cigarette use was significantly associated with marijuana use (OR:4.17, 95% CI: 2.6-6.7) and alcohol use (OR: 5.08, 95% CI: 2.9-9.0), and approached significance with illicit drug use (OR: 1.68, 95% CI: 1.0-2.9). Furthermore, being a current smoker (OR: 2.93, 95% CI: 1.8-4.7) and male (OR: 2.28, 95% CI: 1.5-3.4) was significantly associated with the outcome. CONCLUSION: This study is nationally representative and provides insight into e-cigarette use among youth and young adults aged 15-24 years. Given that e-cigarettes can be used as illicit drug delivery systems, more studies are needed to understand how Canadian youth and young adults are using e-cigarettes. Stricter restrictions on public e-cigarette smoking, and awareness campaigns informing youth of risks of e-cigarette smoking should be implemented.

Characteristics of patients receiving midwife-led prenatal care in Canada: results from the Maternity Experiences Survey (MES).

BACKGROUND: The aim of this study was to determine the characteristics of women in Canada who received care from a midwife during their prenatal period. METHODS: The findings of this study were drawn from the Maternity Experiences Survey (MES), which was a cross-sectional survey that assessed the experiences of women who gave birth between November 2005 and May 2006. The main outcome variable for this study was the prenatal care provider (i.e. midwife versus other healthcare providers). Demographic, socioeconomic, as well as health and pregnancy factors were evaluated using bivariate and multivariate models of logistic regression. RESULTS: A total of 6421 participants were included in this analysis representing a weighted total of 76,508 women. The prevalence of midwife-led prenatal care was 6.1%. The highest prevalence of midwife-led prenatal care was in British Columbia (9.8%), while the lowest prevalence of midwife-led prenatal care was 0.3% representing the cumulative prevalence in Nova Scotia, Prince Edward Island, Newfoundland and Labrador, New Brunswick, Saskatchewan, and Yukon. Factors showing significant association with midwife-led prenatal care were: Aboriginal status (OR = 2.26, 95% CI: 1.41-3.64), higher education with bachelor and graduate degree attainment having higher ORs when compared to high-school or less (OR = 2.71, 95% CI: 1.71-4.31 and OR = 3.17, 95% CI: 1.81-5.55, respectively), and alcohol use (OR = 1.63, 95% CI: 1.17-2.26). Age, marital status, immigrant status, work during pregnancy, household income, previous pregnancies, perceived health, maternal Body Mass Index (BMI), and smoking during the last 3 months of pregnancy were not significantly associated with midwife care. CONCLUSIONS: In general, women who were more educated, have aboriginal status, and/or are alcohol drinkers were more likely to receive care from midwives. Since MES is the most recent resource that includes information about national midwifery utilization, future studies can provide more up-to-date information about this important area. Moreover, future research can aim at understanding the reasons that lead women to opt for midwife-led prenatal care.

Factors associated with the development, severity, and resolution of post COVID-19 condition in adults living in Canada, January 2020 to August 2022.

OBJECTIVES: We aimed to characterize the burden of post COVID-19 condition (PCC) among adults in Canada and identify factors associated with its occurrence, severity, and resolution. METHODS: We used self-report data from a population-based cross-sectional probability survey of adults in Canada conducted between April and August 2022. Incidence and prevalence of PCC were estimated using confirmed infections, as well as confirmed and suspected combined. Multivariable modeling using confirmed cases identified associated factors. RESULTS: As of August 2022, 17.2% (95% CI 15.7, 18.8) of adults with confirmed infections and 16.7% (95% CI 15.5, 18.0) of adults with confirmed or suspected infections experienced PCC, translating to 3.3% (95% CI 3.0, 3.6) and 4.4% (95% CI 4.1, 4.8) of all adults, respectively. Age less than 65 years (aORs of 1.75 to 2.14), more pre-existing comorbidities (aORs of 1.75 to 3.57), and a more severe initial infection (aORs of 3.52 to 9.69) were all associated with higher odds of PCC, while male sex at birth (aOR = 0.54, 95% CI 0.41, 0.70), identifying as Black (aOR = 0.23, 95% CI 0.11, 0.51), and being infected after 2020 (aORs of 0.24 to 0.55) were associated with lower odds. Those residing in a rural area (aOR = 2.31, 95% CI 1.35, 3.93), or reporting a disability (aOR = 2.87, 95% CI 1.14, 7.25), pre-existing chronic lung condition (aOR = 5.47, 95% CI 1.85, 16.12) or back problem (aOR = 2.34, 95% CI 1.26, 4.36), or PCC headache (aOR = 2.47, 95% CI 1.60, 3.83) or weakness (aOR = 2.27, 95% CI 1.41, 3.68) had higher odds of greater limitations in daily activities, while males had lower odds (aOR = 0.54, 95% CI 0.34, 0.85). Two or more pre-existing chronic conditions (aHRs from 0.33 to 0.38), or PCC symptoms relating to the heart (aHR = 0.25, 95% CI 0.07, 0.90), brain fog (aHR = 0.44, 95% CI 0.23, 0.86), or stress/anxiety (aHR = 0.48, 95% CI 0.24, 0.96) were associated with a decreased rate of symptom resolution. CONCLUSION: Over the first two and a half years of the pandemic, a substantial proportion of infected adults in Canada reported PCC. Females and people with comorbidities were disproportionately impacted.

RéSUMé: OBJECTIFS: Nous avons cherché à caractériser le fardeau du syndrome post-COVID-19 (SPC) chez les adultes au Canada et à identifier les facteurs associés à son apparition, sa gravité et sa résolution. MéTHODES: Nous avons utilisé les données d'auto-évaluation d'une enquête probabiliste transversale basée sur la population d'adultes au Canada menée entre avril et août 2022. L'incidence et la prévalence du SPC ont été estimées à l'aide d'infections confirmées, ainsi que d'infections confirmées et soupçonnées combinées. La modélisation multivariée à l'aide des cas confirmés a permis d'identifier des facteurs leur étant associés. RéSULTATS: En août 2022, 17,2% (IC à 95%: 15,7, 18,8) des adultes atteints d'infections confirmées et 16,7% (IC à 95%: 15,5, 18,0) des adultes atteints d'infections confirmées ou soupçonnées ont développé un SPC, soit 3,3% (IC à 95%: 3,0, 3,6) et 4,4% (IC à 95%: 4,1, 4,8) de tous les adultes, respectivement. Être âgé de moins de 65 ans (aRC de 1,75 à 2,14), un plus grand nombre de comorbidités préexistantes (aRC de 1,75 à 3,57) et une infection initiale plus grave (aRC de 3,52 à 9,69) étaient tous associés à une probabilité plus élevée de SPC, alors qu'être un garçon à la naissance (aRC = 0,54, IC à 95%: 0,41, 0,70), s'identifier comme Noir (aRC = 0,23, IC à 95%: 0,11, 0,51) et le fait d'être infecté après 2020 (aRC de 0,24 à 0,55) étaient associés à des probabilités plus faibles. Les personnes résidant dans une région rurale (aRC = 2,31, IC à 95%: 1,35 à 3,93) ou déclarant une incapacité (aRC = 2,87, IC à 95%: 1,14 à 7,25), une affection pulmonaire chronique préexistante (aRC = 5,47, IC à 95%: 1,85 à 16,12), des problèmes de dos (aRC = 2,34, IC à 95%: 1,26 à 4,36), des maux de tête liés au SPC (aRC = 2,47, IC à 95%: 1,60 à 3,83) ou une faiblesse liée au SPC (aRC = 2,27, IC à 95%: 1,41, 3,68) avaient une probabilité plus élevée de limitations plus importantes des activités quotidiennes, tandis que les hommes avaient une probabilité plus faible (aRC = 0,54, IC à 95%: 0,34, 0,85). Le fait d'avoir deux maladies chroniques préexistantes ou plus (aRR de 0,33 à 0,38) ou des symptômes de SPC liés au cœur (aRR = 0,25, IC à 95%: 0,07, 0,90), au brouillard cérébral (aRR = 0,44, IC à 95%: 0,23, 0,86) ou au stress/anxiété (aRR = 0,48, IC à 95%: 0,24, 0,96) étaient associés à une diminution du taux de résolution des symptômes. CONCLUSION: Au cours des deux premières années et demie de la pandémie, une proportion importante d'adultes infectés au Canada a déclaré un SPC. Les femmes et les personnes avec des comorbidités ont été touchées de manière disproportionnée.

Utilization of Texture Analysis in Differentiating Benign and Malignant Breast Masses: Comparison of Grayscale Ultrasound, Shear Wave Elastography, and Radiomic Features.

OBJECTIVE: This study aims to determine which qualitative and quantitative US features are independently associated with malignancy, including those derived from grayscale imaging morphology, shear wave elastography (SWE), and texture analysis. METHODS: This single-center retrospective study was approved by the institutional research ethics board. Consecutive breast US studies performed between January and December 2020 were included. Images were acquired using a Canon Aplio i800 US unit (Canon Medical Systems, Inc., CA) and i18LX5 wideband linear matrix transducer. Grayscale US features, SWE mean, and median elasticity were obtained. Single representative grayscale images were analyzed using dedicated software (LIFEx, version 6.30). First-order and gray-level co-occurrence matrix second-order texture features were extracted. Multivariate logistic regression was performed to assess for predictors of malignancy (STATA v16.1). RESULTS: One hundred forty-seven cases with complete SWE data were selected for analysis (mean age 54.3, range 21-92). The following variables were found to be independently associated with malignancy: age (P <.001), family history (P = .013), irregular mass shape (P = .024), and stiffness on SWE (mean SWE ≥40 kPa; P <.001). Remaining variables (including texture features) were not found to be independently associated with malignancy (P >.05). CONCLUSION: US texture analysis features were not associated with malignancy independent of other qualitative and quantitative US characteristics currently utilized in clinical practice. This suggests texture analysis may not be warranted when differentiating benign and malignant breast masses on US. In contrast, irregular mass shape on grayscale imaging and increased stiffness on SWE were found to be independent predictors of malignancy.

Breast Cancer Screening in High-Risk Patients during Pregnancy and Breastfeeding: A Systematic Review of the Literature.

There are currently no clear guidelines for high-risk breast cancer screening during the pregnancy and breastfeeding periods. The objective of this systematic review (SR) was to assess the available evidence pertaining to breast cancer screening recommendations in this population with the aim of supporting future guidelines. We performed a SR of the literature using the electronic databases MEDLINE and Embase. Predetermined inclusion and exclusion criteria were used during the abstract screening and full-text data extraction phases. We retrieved 2,274 abstracts after removal of duplicates, from which 16 studies were included based on predetermined eligibility criteria. Most of the studies found were narrative reviews and expert opinions. Clinical breast exam (CBE) was recommended by 12 studies during pregnancy and by 6 studies in the breastfeeding period. Mammography was recommended in the breastfeeding period by 2 studies. Magnetic resonance imaging was recommended in the breastfeeding period by 2 studies. Ultrasound was considered not appropriate for screening in this population. The information extracted from this SR is based primarily on expert opinion and anecdotal evidence, which explains the lack of standardized guidelines for high-risk breast cancer screening in this population. However, expert opinion may be a surrogate outcome for high-risk breast cancer screening recommendations in this subset of patients, and as such, may justify the clinical management to be tailored accordingly. This SR summarizes the evidence pertaining to high-risk breast cancer screening during pregnancy and breastfeeding, which could serve as a catalyst for future research on the topic.

Factors associated with shorter night-time sleep in toddlers: The Survey of Young Canadians.

OBJECTIVES: Adequate sleep in childhood is important for healthy development. No information exists on the predictors of night-time sleep among toddlers in Canada. The aim of this study was to determine the prevalence of and to identify factors associated with sleeping <11 consecutive hours per night among children aged 1-2 years in Canada. METHODS: Data from the cross sectional Survey of Young Canadians (SYC) 2010 were used. The biological mother reported on toddlers' sleep duration at night. Based on cut-off values used in previous studies, shorter night-time sleep was defined as sleeping <11 hours per night. Multivariable logistic regression was conducted to identify the associations between socio-demographic, maternal, sleep and child-related variables with shorter sleep at night. RESULTS: Analysis of 3675 toddlers revealed that 57% slept <11 hours per night. Results of the regression analysis showed that being from an immigrantfamily was significantly associated with shorter night-time sleep. Being from a higher income household, having a mother aged between 25 and 34 years at the time of the survey, and napping ≥2 hours during the day were significantly related to sleeping ≥11 hours per night. Other socio-demographic, maternal and child-related variables were not associated with night-time sleep. CONCLUSION: This was the first population-based, nationally representative study to examine factors related to shorter night-time sleep in Canadian toddlers. Socio-demographic factors and nap duration were associated with night-time sleep duration. More adequate early childhood sleep hygiene awareness efforts are recommended, especially in vulnerable populations.

Cardiovascular Risk Factor Management Performance in Canada and the United States: A Systematic Review.

BACKGROUND: Comparative cardiovascular risk factor care across North America is unknown. We aimed to determine current performance in Canada and the United States (US). METHODS: A systematic review was conducted of Medline and EMBASE (to June 1, 2014). Eligible studies reported on screening, awareness, treatment, or control rates for hypertension, dyslipidemia, diabetes, and smoking. Categorical performance 'ratings' on the basis of the most successful US health plans were used to classify rates as suboptimal (< 50%), below target (50%-70%), above target (70%-90%), or optimal (> 90%). RESULTS: A total of 127 studies reporting on 10,510,324 individuals across North America were included. Hypertension awareness (84.3%) and treatment (82.0%) rates in Canada and the US (82.7% and 75.6%, respectively) were above target, whereas control in both nations was below target (68.1% vs 51.8%, respectively). Canadian awareness, treatment, and control rates for dyslipidemia (42.7%, 40.9%, and 41.5%, respectively) were suboptimal, and American indicators were generally below target (61.5%, 43.0%, and 63.6%, respectively). Canada and the US showed diabetes awareness (88.2% vs 86.8%) and treatment rates (82.3% vs 82.5%) above target. However, glucose control was suboptimal in Canada (35.3%), and below target in the US (58.8%). There was a modest decline in absolute smoking prevalence rates in Canada from 1999 to 2013 (25.2% to 14.6%). Screening for tobacco use (72.2%) and counselling rates (73.8%) in the US were above target. CONCLUSIONS: Substantial variation exists in cardiovascular risk factor care across North America. Standardized reporting, dissemination of practice guidelines, and setting explicit goal-directed targets for performance might facilitate improvement.