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With the sustainable development goals has come a renewed global interest in ending hunger and achieving food security, while preventing natural resource degradation. Despite this renewed interest and increased commitments to invest in agricultural development, there is an outstanding debate over the technological trajectories to sustainability. The debate centres on sustainable agricultural intensification (SAI) and agroecological intensification (AEI) pathways to agricultural sustainability. Using a systematic literature review approach, this study examines the debate over AEI and SAI. This study employs a theoretical framework based on the economic, social, and ecological dimensions of sustainable agriculture within a policy and institutional space. Based on the sustainability dimensions, a discourse analytical technique is applied to unravel the debate. The results reveal differences in actor composition in the SAI and AEI pathways. Both pathways aim to promote food security with optimal and sustainable use of inputs; however, the actors differ on discourse relating to the concept of farming, the role of genetic engineering, the scale of operation, land use and soil health. Resolving these differences requires a blended sustainability approach that moves beyond the current AEI and SAI debate by acknowledging the tradeoffs and synergies of the socio-economic and ecological dimensions.

In Benin, rice plays a major role in the food security of the poorest rural and urban populations. However, the rice value chains have failed to achieve their potential because of some systemic constraints. In recent years, innovation platforms (IPs) have received increasing focus as mechanisms for strengthening the interaction between the stakeholders in the rice value chains. Nevertheless, the issues of information asymmetry and power between stakeholders with often divergent interests suppress the expected effects of the implementation of IP approach. This article used thematic content analysis to assess the influence of IPs on the governance of the parboiled rice value chain. The findings reveal that local rice value chains are characterized by unequal access to resources and asymmetry of power, which generates inequalities within groups. Although their influence is less discernible, IPs have contributed to greater visibility for some emerging stakeholders and rebalanced stakeholders in terms of influence in value chains. Moreover, the perverse effects of financial and human resources management limit the impact of improvement actions in various value chains. Therefore, the development model of value chains may be oriented toward the “business idea approach” instead of the “project approach”.

Objective: To assess the association between ambient heat and all-cause and cause-specific emergency department (ED) visits and acute hospitalizations among Medicare beneficiaries in the conterminous United States., Design: Retrospective cohort study., Setting: Conterminous US from 2008 and 2019., Participants: 2% random sample of all Medicare fee-for-service beneficiaries eligible for Parts A, B, and D., Main Outcome Measures: All-cause and cause-specific (cardiovascular, renal, and heat-related) ED visits and unplanned hospitalizations were identified using primary ICD-9 or ICD-10 diagnosis codes. We measured the association between ambient temperature - defined as daily mean temperature percentile of summer (June through September) - and the outcomes. Hazard ratios and their associated 95% confidence intervals were estimated using multivariable Cox proportional hazards regression, adjusting for individual level demographics, comorbidities, healthcare utilization factors and zip-code level social factors., Results: Among 809,636 Medicare beneficiaries (58% female, 81% non-Hispanic White, 24% <65), older beneficiaries (aged ≥65) exposed to >95th percentile temperature had a 64% elevated adjusted risk of heat-related ED visits (HR [95% CI], 1.64 [1.46,1.85]) and a 4% higher risk of all-cause acute hospitalization (1.04 [1.01,1.06]) relative to <25th temperature percentile. Younger beneficiaries (aged <65) showed increased risk of heat-related ED visits (2.69 [2.23,3.23]) and all-cause ED visits (1.03 [1.01,1.05]). The associations with heat related events were stronger in males and individuals dually eligible for Medicare and Medicaid. No significant differences were observed by climatic region. We observed no significant relationship between temperature percentile and risk of CV-related ED visits or renal-related ED visits., Conclusions: Among Medicare beneficiaries from 2008 to 2019, exposure to daily mean temperature ≥ 95th percentile was associated with increased risk of heat-related ED visits, with stronger associations seen among beneficiaries <65, males, and patients with low socioeconomic position. Further longitudinal studies are needed to understand the impact of heat duration, intensity, and frequency on cause-specific hospitalization outcomes., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Importance: Despite biological plausibility, very few epidemiologic studies have investigated the risks of clinically significant bleeding events due to particulate air pollution., Objective: To measure the independent and synergistic effects of PM 2.5 exposure and anticoagulant use on serious bleeding events., Design: Retrospective cohort study (2008-2016)., Setting: Nationwide Medicare population., Participants: A 50% random sample of Medicare Part D-eligible Fee-for-Service beneficiaries at high risk for cardiovascular and thromboembolic events., Exposures: Fine particulate matter (PM 2.5 ) and anticoagulant drugs (apixaban, dabigatran, edoxaban, rivaroxaban, or warfarin)., Main Outcomes and Measures: The outcomes were acute hospitalizations for gastrointestinal bleeding, intracranial bleeding, or epistaxis. Hazard ratios and 95% CIs for PM 2.5 exposure were estimated by fitting inverse probability weighted marginal structural Cox proportional hazards models. The relative excess risk due to interaction was used to assess additive-scale interaction between PM 2.5 exposure and anticoagulant use., Results: The study cohort included 1.86 million high-risk older adults (mean age 77, 60% male, 87% White, 8% Black, 30% anticoagulant users, mean PM 2.5 exposure 8.81 μg/m 3 ). A 10 μg/m 3 increase in PM 2.5 was associated with a 48% (95% CI: 45%-52%), 58% (95% CI: 49%-68%) and 55% (95% CI: 37%-76%) increased risk of gastrointestinal bleeding, intracranial bleeding, and epistaxis, respectively. Significant additive interaction between PM 2.5 exposure and anticoagulant use was observed for gastrointestinal and intracranial bleeding., Conclusions: Among older adults at high risk for cardiovascular and thromboembolic events, increasing PM 2.5 exposure was significantly associated with increased risk of gastrointestinal bleeding, intracranial bleeding, and epistaxis. In addition, PM 2.5 exposure and anticoagulant use may act together to increase risks of severe gastrointestinal and intracranial bleeding. Thus, clinicians may recommend that high-risk individuals limit their outdoor air pollution exposure during periods of increased PM 2.5 concentrations. Our findings may inform environmental policies to protect the health of vulnerable populations., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Rachel C. Nethery reports financial support was provided by National Institutes of Health. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To measure the association between ambient heat and hypoglycemia-related emergency department visit or hospitalization in insulin users., Research Design and Methods: We identified cases of serious hypoglycemia among adults using insulin aged ≥65 in the U.S. (via Medicare Part A/B/D-eligible beneficiaries) and Taiwan (via National Health Insurance Database) from June to September, 2016-2019. We then estimated odds of hypoglycemia by heat index (HI) percentile categories using conditional logistic regression with a time-stratified case-crossover design., Results: Among ∼2 million insulin users in the U.S. (32,461 hypoglycemia case subjects), odds ratios of hypoglycemia for HI >99th, 95-98th, 85-94th, and 75-84th percentiles compared with the 25-74th percentile were 1.38 (95% CI, 1.28-1.48), 1.14 (1.08-1.20), 1.12 (1.08-1.17), and 1.09 (1.04-1.13) respectively. Overall patterns of associations were similar for insulin users in the Taiwan sample (∼283,000 insulin users, 10,162 hypoglycemia case subjects)., Conclusions: In two national samples of older insulin users, higher ambient temperature was associated with increased hypoglycemia risk., (© 2024 by the American Diabetes Association.)

Background: Obesity comprises the single greatest reversible risk factor for obstructive sleep apnea (OSA). Despite the potential of lifestyle-based weight loss services to improve OSA severity and symptoms, these programs have limited reach. POWER is a pragmatic trial of a remote self-directed weight loss care among patients with OSA., Methods: POWER randomizes 696 patients with obesity (BMI 30-45 kg/m2) and recent diagnosis or re-confirmation of OSA 1:1 to either a self-directed weight loss intervention or usual care. POWER tests whether such an intervention improves co-primary outcomes of weight and sleep-related quality of life at 12 months. Secondary outcomes include sleep symptoms, global ratings of change, and cardiovascular risk scores. Finally, consistent with a hybrid type 1 approach, the trial embeds an implementation process evaluation. We will use quantitative and qualitative methods including budget impact analyses and qualitative interviews to assess barriers to implementation., Conclusions: The results of POWER will inform population health approaches to the delivery of weight loss care. A remote self-directed program has the potential to be disseminated widely with limited health system resources and likely low-cost., Competing Interests: Declaration of Competing Interest Dr. Au reports personal fees from Boehringer Ingelheim for service on an advisory board and personal fees from Annals of the American Thoracic Society for service as a deputy editor. Dr. Donovan reports honorarium from the American Academy of Sleep Medicine for teaching at a post-graduate course., (Copyright © 2023. Published by Elsevier Inc.)

Objective: To evaluate the synergistic effects created by fine particulate matter (PM 2.5 ) and corticosteroid use on hospitalisation and mortality in older adults at high risk for cardiovascular thromboembolic events (CTEs)., Design and Setting: A retrospective cohort study using a US nationwide administrative healthcare claims database., Participants: A 50% random sample of participants with high-risk conditions for CTE from the 2008-2016 Medicare Fee-for-Service population., Exposures: Corticosteroid therapy and seasonal-average PM 2.5 ., Main Outcome Measures: Incidences of myocardial infarction or acute coronary syndrome (MI/ACS), ischaemic stroke or transient ischaemic attack, heart failure (HF), venous thromboembolism, atrial fibrillation and all-cause mortality. We assessed additive interactions between PM 2.5 and corticosteroids using estimates of the relative excess risk due to interaction (RERI) obtained using marginal structural models for causal inference., Results: Among the 1 936 786 individuals in the high CTE risk cohort (mean age 76.8, 40.0% male, 87.4% white), the mean PM 2.5 exposure level was 8.3±2.4 µg/m 3 and 37.7% had at least one prescription for a systemic corticosteroid during follow-up. For all outcomes, we observed increases in risk associated with corticosteroid use and with increasing PM 2.5 exposure. PM 2.5 demonstrated a non-linear relationship with some outcomes. We also observed evidence of an interaction existing between corticosteroid use and PM 2.5 for some CTEs. For an increase in PM 2.5 from 8 μg/m 3 to 12 μg/m 3 (a policy-relevant change), the RERI of corticosteroid use and PM 2.5 was significant for HF (15.6%, 95% CI 4.0%, 27.3%). Increasing PM 2.5 from 5 μg/m 3 to 10 μg/m 3 yielded significant RERIs for incidences of HF (32.4; 95% CI 14.9%, 49.9%) and MI/ACSs (29.8%; 95% CI 5.5%, 54.0%)., Conclusion: PM 2.5 and systemic corticosteroid use were independently associated with increases in CTE hospitalisations. We also found evidence of significant additive interactions between the two exposures for HF and MI/ACSs suggesting synergy between these two exposures., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Little epidemiologic research has focused on pollution-related risks in medically vulnerable or marginalized groups. Using a nationwide 50% random sample of 2008-2016 Medicare Part D-eligible fee-for-service participants in the United States, we identified a cohort with high-risk conditions for cardiovascular and thromboembolic events (CTEs) and linked individuals with seasonal average zip-code-level concentrations of fine particulate matter (particulate matter with an aerodynamic diameter ≤ 2.5 μm (PM2.5)). We assessed the relationship between seasonal PM2.5 exposure and hospitalization for each of 7 CTE-related causes using history-adjusted marginal structural models with adjustment for individual demographic and neighborhood socioeconomic variables, as well as baseline comorbidity, health behaviors, and health-service measures. We examined effect modification across geographically and demographically defined subgroups. The cohort included 1,934,453 individuals with high-risk conditions (mean age = 77 years; 60% female, 87% White). A 1-μg/m3 increase in PM2.5 exposure was significantly associated with increased risk of 6 out of 7 types of CTE hospitalization. Strong increases were observed for transient ischemic attack (hazard ratio (HR) = 1.039, 95% confidence interval (CI): 1.034, 1.044), venous thromboembolism (HR = 1.031, 95% CI: 1.027, 1.035), and heart failure (HR = 1.019, 95% CI: 1.017, 1.020). Asian Americans were found to be particularly susceptible to thromboembolic effects of PM2.5 (venous thromboembolism: HR = 1.063, 95% CI: 1.021, 1.106), while Native Americans were most vulnerable to cerebrovascular effects (transient ischemic attack: HR = 1.093, 95% CI: 1.030, 1.161)., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: Therapeutic inertia threatens the potential long-term benefits of achieving early glycemic control after type 2 diabetes diagnosis. We evaluated temporal trends in second-line diabetes medication initiation among individuals initially treated with metformin., Research Design and Methods: We included data from 199,042 adults with type 2 diabetes in the U.S. Department of Veterans Affairs health care system initially treated with metformin monotherapy from 2005 to 2013. We used multivariable Cox proportional hazards and linear regression to estimate associations of year of metformin monotherapy initiation with time to second-line diabetes treatment over 5 years of follow-up (primary outcome) and with hemoglobin A1c (HbA1c) at the time of second-line diabetes treatment initiation (secondary outcome)., Results: The cumulative 5-year incidence of second-line medication initiation declined from 47% among metformin initiators in 2005 to 36% in 2013 counterparts (P < 0.0001) despite a gradual increase in mean HbA1c at the end of follow-up (from 6.94 ± 1.28% to 7.09 ± 1.42%, Ptrend < 0.0001). In comparisons with metformin monotherapy initiators in 2005, adjusted hazard ratios for 5-year initiation of second-line diabetes treatment ranged from 0.90 (95% CI 0.87, 0.92) for 2006 metformin initiators to 0.68 (0.66, 0.70) for 2013 counterparts. Among those receiving second-line treatment within 5 years of metformin initiation, HbA1c at second-line medication initiation increased from 7.74 ± 1.66% in 2005 metformin initiators to 8.55 ± 1.92% in 2013 counterparts (Ptrend < 0.0001)., Conclusions: We observed progressive delays in diabetes treatment intensification consistent with therapeutic inertia. Process-of-care interventions early in the diabetes disease course may be needed to reverse adverse temporal trends in diabetes care., (© 2022 by the American Diabetes Association.)

Background: Evidence to guide type 2 diabetes treatment individualization is limited. We evaluated heterogeneous treatment effects (HTE) of intensive glycemic control in type 2 diabetes patients on major adverse cardiovascular events (MACE) in the Action to Control Cardiovascular Risk in Diabetes Study (ACCORD) and the Veterans Affairs Diabetes Trial (VADT)., Methods: Causal forests machine learning analysis was performed using pooled individual data from two randomized trials (n = 12,042) to identify HTE of intensive versus standard glycemic control on MACE in patients with type 2 diabetes. We used variable prioritization from causal forests to build a summary decision tree and examined the risk difference of MACE between treatment arms in the resulting subgroups., Results: A summary decision tree used five variables (hemoglobin glycation index, estimated glomerular filtration rate, fasting glucose, age, and body mass index) to define eight subgroups in which risk differences of MACE ranged from - 5.1% (95% CI - 8.7, - 1.5) to 3.1% (95% CI 0.2, 6.0) (negative values represent lower MACE associated with intensive glycemic control). Intensive glycemic control was associated with lower MACE in pooled study data in subgroups with low (- 4.2% [95% CI - 8.1, - 1.0]), intermediate (- 5.1% [95% CI - 8.7, - 1.5]), and high (- 4.3% [95% CI - 7.7, - 1.0]) MACE rates with consistent directions of effect in ACCORD and VADT alone., Conclusions: This data-driven analysis provides evidence supporting the diabetes treatment guideline recommendation of intensive glucose lowering in diabetes patients with low cardiovascular risk and additionally suggests potential benefits of intensive glycemic control in some individuals at higher cardiovascular risk., (© 2022. The Author(s).)

Purpose Machine learning is an attractive tool for identifying heterogeneous treatment effects (HTE) of interventions but generalizability of machine learning derived HTE remains unclear. We examined generalizability of HTE detected using causal forests in two similarly designed randomized trials in type II diabetes patients. Methods We evaluated published HTE of intensive versus standard glycemic control on all-cause mortality from the Action to Control Cardiovascular Risk in Diabetes study (ACCORD) in a second trial, the Veterans Affairs Diabetes Trial (VADT). We then applied causal forests to VADT, ACCORD, and pooled data from both studies and compared variable importance and subgroup effects across samples. Results HTE in ACCORD did not replicate in similar subgroups in VADT, but variable importance was correlated between VADT and ACCORD (Kendall's tau-b 0.75). Applying causal forests to pooled individual-level data yielded seven subgroups with similar HTE across both studies, ranging from risk difference of all-cause mortality of -3.9% (95% CI -7.0, -0.8) to 4.7% (95% CI 1.8, 7.5). Conclusions Machine learning detection of HTE subgroups from randomized trials may not generalize across study samples even when variable importance is correlated. Pooling individual-level data may overcome differences in study populations and/or differences in interventions that limit HTE generalizability., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest relevant to the work in this study. Medications and financial support were provided by Sanofi, GlaxoSmithKline, Novo Nordisk, Roche, Kos Pharmaceuticals, Merck, and Amylin. No other potential conflicts of interest relevant to this article were reported. These companies had no role in the design of the study, in the accrual or analysis of the data, or in the preparation or approval of the manuscript., (Copyright © 2021. Published by Elsevier Inc.)

The year 2020 brought unimaginable challenges in public health, with the confluence of the COVID-19 pandemic and wildfires across the western United States. Wildfires produce high levels of fine particulate matter (PM 2.5 ). Recent studies reported that short-term exposure to PM 2.5 is associated with increased risk of COVID-19 cases and deaths. We acquired and linked publicly available daily data on PM 2.5 , the number of COVID-19 cases and deaths, and other confounders for 92 western U.S. counties that were affected by the 2020 wildfires. We estimated the association between short-term exposure to PM 2.5 during the wildfires and the epidemiological dynamics of COVID-19 cases and deaths. We adjusted for several time-varying confounding factors (e.g., weather, seasonality, long-term trends, mobility, and population size). We found strong evidence that wildfires amplified the effect of short-term exposure to PM 2.5 on COVID-19 cases and deaths, although with substantial heterogeneity across counties., (Copyright © 2021 The Authors, some rights reserved; exclusive licensee American Association for the Advancement of Science. No claim to original U.S. Government Works. Distributed under a Creative Commons Attribution NonCommercial License 4.0 (CC BY-NC).)

Importance: Fruit and vegetable vouchers have been implemented by cities and counties across the US to increase fruit and vegetable intake and thereby improve overall nutritional quality., Objective: To determine whether and why use of fruit and vegetable vouchers are associated with varied nutritional intake across different populations and environments., Design, Setting, and Participants: In a population-based pre-post cohort study of 671 adult participants with low income before and during (6 months after initiation) participation in a 6-month program, fruit and vegetable vouchers were distributed for redemption at local San Francisco and Los Angeles neighborhood grocery and corner stores between 2017 and 2019. A transportability analysis was performed to identify factors that may explain variation in voucher use between cities., Exposure: Receipt of $20 per month in produce vouchers for 6 months from 2017 to 2019., Main Outcomes and Measures: Change in total fruits and vegetables (as defined by the US Department of Agriculture) consumed per person per day (change in cup-equivalents between month 6 and month 0)., Results: A total of 671 adults (median age, 54.9 years [interquartile range, 45.0-65.0 years]; 61.7% female; 30.9% Black; 19.7% Hispanic) were enrolled. An increase in fruit and vegetable intake of 0.22 cup-equivalents per day overall (95% CI, 0.14-0.31 cup-equivalents; P < .001) was observed. However, the observed increase was larger in Los Angeles compared with San Francisco (0.64 cup-equivalents per day; 95% CI, 0.41-0.88 cup-equivalents vs 0.10 cup-equivalents per day; 95% CI, 0.01-0.19 cup-equivalents). When the concurrently sampled San Francisco group (n = 157) was weighted in transportability analysis to demographically match the Los Angeles group (n = 155) in observed covariates, the weighted San Francisco group had an estimated increase of 0.53 fruit and vegetable cup-equivalents per day (95% CI, 0.27- 0.79 cup-equivalents, P = .03), with income being the variable needed to allow the 95% confidence intervals to overlap between the weighted San Francisco and unweighted Los Angeles populations., Conclusions and Relevance: In this study, the use of fruit and vegetable vouchers appeared to be associated with greater benefit among those with lower incomes, suggesting that further investigation of flat-rate rather than income-scaled benefits is warranted.

Objective: Current guidelines recommend that patients with non-ST elevation acute coronary syndromes (NSTEACS) receive dual antiplatelet therapy (DAPT) early in hospitalisations. However, observational studies suggest that this rarely occurs. We evaluated site-specific variation and clinical outcomes associated with early DAPT among patients undergoing angiography for NSTEACS., Methods: In this observational analysis, we identified patients undergoing angiography for NSTEACS in Veterans Affairs hospitals from 2008 to 2016 and assessed characteristics and site variation associated with early DAPT (administration <24 hours of admission). Using propensity matching, we compared time to revascularisation, recurrent myocardial infarction (MI) and mortality between those receiving early DAPT and those not receiving early DAPT (administration ≥24 hours)., Results: Of 45 569 patients undergoing angiography for NSTEACS, 15 084 (33%) received early DAPT. Early DAPT was more frequent in patients with non-ST elevation MI, prior surgical revascularisation and among patients undergoing revascularisation. There was a greater than twofold difference in early DAPT across sites, independent of patient characteristics (median OR 2.43, 95% CI 2.28 to 2.55). There was no difference in time topercutaneous coronary intervention (PCI) between groups, but a significant delay to surgical revascularisation with early DAPT (median 4 vs 3 days, p<0.001) without reduction in hazard of death or MI (HR 1.08, 95% CI 1.00 to 1.16) and similar results demonstrated in the subgroup of patients undergoing revascularisation (HR 1.02, 95% CI 0.91 to 1.13)., Conclusion: Among NSTEACS patients undergoing coronary angiography, early DAPT was not associated with improvement of outcomes but was associated with delays in surgical revascularisation., Competing Interests: Competing interests: SWW received research support to the Denver Research Institute from Abiomed, Cardiovascular Systems Incorporated and Merck Pharmaceuticals. The other authors have no industry relations to disclose., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: The American Heart Association (AHA) and the Institute of Medicine have published a national "call-to-action" to improve survival from in-hospital cardiopulmonary arrest (IHCA). Our aim was to determine if more-active hospital participation in standardized in-situ mock code (ISMC) training is associated with increased IHCA survival., Methods: We performed an ecological study across a multi-state healthcare system comprising 26 hospitals. Hospital-level ISMC performance was measured during 2016-2017 and IHCA hospital discharge survival rates in 2017. We performed univariate and multivariate analysis of the hospital-level association between more-active ISCM participation and IHCA survival, with adjustment for hospital expected mortality as determined by a commercial severity scoring system. Other potential confounders were analyzed using univariate statistics., Results: Hospitals with more-active ISMC participation conducted a median of 17.6 ISMCs/100 beds/year (vs 3.2/100 beds/year in less-active hospitals, p = 0.001) in 2016-2017. 220,379 patients were admitted and 3289 experienced IHCA in study hospitals in 2017, with an overall survival rate of 37.4%. Hospitals with more-active ISMC participation had a mean IHCA survival rate of 42.8% vs. 31.8% in hospitals with less-active ISMC participation (p < 0.0001), and a significantly reduced odds ratio (OR) of 0.62 for IHCA mortality (95% CI: 0.54-0.72; p < 0.0001) which was unchanged after adjustment for hospital-level expected mortality (adjusted OR: 0.62; 95% CI: 0.54-0.71; p < 0.001)., Conclusions: Hospitals in our healthcare system with more-active ISMC participation have higher IHCA survival. Prospective trials are needed to establish the efficacy of standardized ISMC training programs in improving patient survival after cardiac arrest., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objectives: The aim of this study was to determine temporal trends, in-laboratory complications, mortality, and predictors of mortality among nonagenarians undergoing percutaneous coronary intervention (PCI)., Background: Nonagenarians (patients 90 years of age or older) undergoing PCI are often underrepresented in clinical trials, and their management remains challenging and controversial., Methods: All veterans undergoing PCI with data recorded in the Veterans Affairs Clinical Assessment, Reporting, and Tracking program from 2005 to 2014 were evaluated. Temporal trends in the use of PCI, occurrence of in-laboratory complications, and 30-day and 1-year mortality were assessed. Using a frailty model, predictors of 30-day and 1-year mortality in nonagenarians were evaluated., Results: Among all veterans undergoing PCI (n = 67,148) between 2005 and 2014, 274 (0.4%) were nonagenarians. The proportion of nonagenarians increased from 0.25% in 2008 to 0.58% in 2014. Compared with younger patients, nonagenarians had a greater risk for acute cardiogenic shock post-procedure (0.73% vs. 0.12%; p = 0.04) and no reflow (2.9% vs. 1.0%; p = 0.02). Unadjusted (10.6% vs. 1.4%; p < 0.0001) and adjusted 30-day mortality (odds ratio: 2.14; 95% confidence interval [CI]: 1.42 to 3.22) and unadjusted (16.3% vs. 4.2%; p < 0.0001) and adjusted 1-year mortality (odds ratio: 1.82; 95% CI: 1.27 to 2.62) were higher among PCI patients who were nonagenarians. The National Cardiovascular Data Registry risk score was highly predictive of both 30-day (hazard ratio: 2.29; 95% CI: 1.86 to 2.82) and 1-year (hazard ratio: 1.43; 95% CI: 1.07 to 1.90) mortality among nonagenarians., Conclusions: Nonagenarians were a small but growing population with worse 30-day and 1-year mortality. The National Cardiovascular Data Registry risk score was a strong predictor of mortality in these patients., (Copyright © 2017 American College of Cardiology Foundation. All rights reserved.)

Background: Advanced Cardiac Life Support (ACLS) is a series of team-based, sequential and time constrained interventions, requiring effective communication and coordination of activities that are performed by the care provider team on a patient undergoing cardiac arrest or respiratory failure. The state-of-the-art ACLS training is conducted in a face-to-face environment under expert supervision and suffers from several drawbacks including conflicting care provider schedules and high cost of training equipment., Objective: The major objective of the study is to describe, including the design, implementation, and evaluation of a novel approach of delivering ACLS training to care providers using the proposed virtual reality simulator that can overcome the challenges and drawbacks imposed by the traditional face-to-face training method., Methods: We compare the efficacy and performance outcomes associated with traditional ACLS training with the proposed novel approach of using a virtual reality (VR) based ACLS training simulator. One hundred and forty-eight (148) ACLS certified clinicians, translating into 26 care provider teams, were enrolled for this study. Each team was randomly assigned to one of the three treatment groups: control (traditional ACLS training), persuasive (VR ACLS training with comprehensive feedback components), or minimally persuasive (VR ACLS training with limited feedback components). The teams were tested across two different ACLS procedures that vary in the degree of task complexity: ventricular fibrillation or tachycardia (VFib/VTach) and pulseless electric activity (PEA)., Results: The difference in performance between control and persuasive groups was not statistically significant (P=.37 for PEA and P=.1 for VFib/VTach). However, the difference in performance between control and minimally persuasive groups was significant (P=.05 for PEA and P=.02 for VFib/VTach). The pre-post comparison of performances of the groups showed that control (P=.017 for PEA, P=.01 for VFib/VTach) and persuasive (P=.02 for PEA, P=.048 for VFib/VTach) groups improved their performances significantly, whereas minimally persuasive group did not (P=.45 for PEA, P=.46 for VFib/VTach). Results also suggest that the benefit of persuasiveness is constrained by the potentially interruptive nature of these features., Conclusions: Our results indicate that the VR-based ACLS training with proper feedback components can provide a learning experience similar to face-to-face training, and therefore could serve as a more easily accessed supplementary training tool to the traditional ACLS training. Our findings also suggest that the degree of persuasive features in VR environments have to be designed considering the interruptive nature of the feedback elements., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The use of virtual reality (VR) training tools for medical education could lead to improvements in the skills of clinicians while providing economic incentives for healthcare institutions. The use of VR tools can also mitigate some of the drawbacks currently associated with providing medical training in a traditional clinical environment such as scheduling conflicts and the need for specialized equipment (e.g., high-fidelity manikins). This paper presents the details of the framework and the development methodology associated with a VR-based training simulator for advanced cardiac life support, a time critical, team-based medical scenario. In addition, we also report the key findings of a usability study conducted to assess the efficacy of various features of this VR simulator through a postuse questionnaire administered to various care providers. The usability questionnaires were completed by two groups that used two different versions of the VR simulator. One version consisted of the VR trainer with it all its features and a minified version with certain immersive features disabled. We found an increase in usability scores from the minified group to the full VR group.