A synthesis of pathways linking diet, metabolic risk and cardiovascular disease: a framework to guide further research and approaches to evidence-based practice

Cardiovascular disease (CVD) is the most common non-communicable disease occurring globally. Although previous literature have provided useful insights on the important role that diet play in CVD prevention and treatment, understanding the causal role of diets is a difficult task considering inherent and introduced weaknesses of observational (e.g., not properly addressing confounders and mediators) and experimental research designs (e.g., not appropriate or well-designed). In this narrative review, we organised current evidence linking diet, as well as conventional and emerging physiological risk factors with CVD risk, incidence and mortality in a series of diagrams. The diagrams presented can aid causal inference studies as they provide a visual representation of the types of studies underlying the associations between potential risk markers/factors for CVD. This may facilitate the selection of variables to be considered and the creation of analytical models. Evidence depicted in the diagrams was systematically collected from studies included in the British Nutrition Task Force report on Diet and CVD and database searches, including Medline and Embase. Although several markers and disorders linked to conventional and emerging risk factors for CVD were identified, the causal link between many remains unknown. There is a need to address the multifactorial nature of CVD and the complex interplay between conventional and emerging risk factors with natural and built environments, while bringing the life course and the role of additional environmental factors into the spotlight.

How Successful was Large-scale Social Restrictions Policy in Suppressing COVID-19

Large-scale Social Restrictions (LSR) was the Indonesian government's primary instrument to break the chain of coronavirus or COVID-19 transmission at the early phase of the pandemic. LSR implementation such as school and workplace closure, restrictions on religious activities, and or restrictions on activities on public premises or facilities. This study aims to investigate the effect of LSR policy on COVID-19 developments in Indonesia. This study was a cross-sectional study with a total population of 99,077,313 people from three provinces in Indonesia. This research analyzed the LSR policy implemented in the entire province or partially as an exposure and the development of Covid-19 as an outcome. The outcome was measured by doubling the times needed for new cases. Data were taken from secondary source namely from the COVID-19 task force report that has been announced publicly. The unpaired two-tailed Student’s t-test was used as statistical analysis of the secondary data. The results showed a significant impact (p<0.05) when comparing the province with full LSR policy with those implementing the LSR policy in some of their selected cities. The LSR policy of total province seems effective to suppress COVID-19 development as indicated by a more rapid and considerable increase in the doubling time of new cases following the implementation of LSR as early as possible in the provinces implementing LSR for their entire region than in the compared provinces. It can be concluded that LSR policy has a significant effect on COVID-19 development in Indonesia as indicated by a significant difference in the doubling time of COVID-19 new cases. Each province may have different times of the beginning and end of the COVID-19 epidemic; therefore, each province needs to design their coping strategy based on their particular condition.

Development and implementation of a postgraduate medical education-wide initiative in quality improvement and patient safety

BackgroundQuality improvement and patient safety (QIPS) have been assigned a higher profile in CanMEDS 2015, CanMEDS–Family Medicine 2017 and new accreditation standards, prompting an initiative at Dalhousie University to create a vision for integrating QIPS into postgraduate medical education.ObjectiveThe purpose of this study is to describe the implementation of a QIPS strategy across residency education at Dalhousie University.MethodsA QIPS task force was formed, and a literature review and needs assessment survey were completed. A needs assessment survey was distributed to all Dalhousie residency programme directors. 12 programme directors were interviewed individually to collect additional feedback. The results were used to develop a ‘road map’ of recommendations with a graduated timeline.ResultsA task force report was released in February 2018. 46 recommendations were developed with a timeframe and responsible party identified for each. Implementation of the QIPS strategy is underway, and evaluation and challenges faced will be described.ConclusionsWe have developed a multiyear strategy that is available to provide guidance and support to all programmes in QIPS. The development and implementation of this QIPS framework may serve as a template for other institutions who seek to integrate these competencies into residency training.

A Comparative Study on Methods of Estimating Liquefaction for Diyala Soil

The phenomenon of liquefaction is one of the most important problems in engineering projects. It occurs in saturated sandy soils during the occurrence of earthquakes. Methods based on the standard penetration test (SPT) were developed to calculate the liquefaction potential according to the seismic loads. These methods have been developed and updated over time by some researchers. This paper analyses the comparison between methods of calculating liquefaction potential. The case study that was selected for the analysis of the comparison methods is Diyala Governorate soil. The methods that have been chosen for making a comparative analysis are the Japanese method, National Centre for Earthquake Engineering Research 1997 (NCEER) workshop, Task Force Report 2007 (Vancouver) and Boulanger and Idriss 2014. The analysis of results stated that the Boulanger and Idriss method is considered more suitable than others for calculating the potential for liquefaction in Diyala Governorate soil. It is found that the Boulanger and Idriss method has higher safety factor than the two methods (80.7% from Vancouver and 38.8% from the NCEER workshop) and less than the Japanese method

16th International congress on antiphospholipid antibodies task force report on clinical manifestations of antiphospholipid syndrome

The objectives of the 16th International Congress on Antiphospholipid Antibodies (aPL) Task Force on Clinical Manifestations of Antiphospholipid Syndrome (APS) were to critically analyze: a) the definition of “APS”; b) the current knowledge on non-traditional manifestations associated with aPL; and c) the risk stratification strategies in aPL-positive patients. The quality of evidence was assessed by the GRADE system. The task force concluded that: a) APS does not have a uniform definition given the heterogeneity of the clinical presentations and different aPL profiles; b) current literature supports the role for aPL testing in cases of thrombocytopenia and recurrent cardiac events but are limited by vast heterogeneity, providing an overall low-to-very low level of evidence; and c) risk stratification strategies in aPL-positive patients, such as aPL-Score and Global APS Score, can be useful in clinical practice. International multicenter studies are still highly needed to improve the quality of available evidence and consequently the strength of future recommendations.

Paget ‘s Disease: Not So Typical for Atypical Femur Fracture

Introduction: Atypical femur fractures (AFF) are reported in patients taking prolonged bisphosphonate therapy, but Paget’s disease (PD) has been rarely reported as a cause of AFF. Case: 71-year-old female with past medical history of right hip osteoarthritis, seizure disorder, hypertension, and Hashimoto’s thyroiditis presented with persistent right hip pain. There was no history of trauma or fall. She had otosclerosis with bilateral hearing loss and bilateral stapedectomies. Her medications were primidone, levothyroxine, lisinopril-hydrochlorothiazide, and vitamin D. She did not smoke tobacco or drink alcohol. She had elevated serum alkaline phosphatase of 300 U/L (35–104). The X-ray of the skull was negative for any cortical thickening. CT of right femur revealed cortical thickening and coarsening of trabeculae of the proximal right femur consistent with PD and incomplete atypical subtrochanteric proximal fracture. Urine NTx 303 BCE/mM Cr (&lt;89). Bone scan showed uptake in the R proximal femur, L distal tibia, and L3-L4 vertebral bodies suspicious of PD. DXA showed osteopenia. She was given zoledronic acid 5 mg IV. Discussion: PD leads to an increased incidence of fractures particularly of the lower extremities with most fractures transverse in nature. Non-union is not uncommon1. Stress fractures in PD are caused by disorganized bone remodeling due to excessive breakdown and formation of bone. Our patient met the major criteria for AFF as per the ASBMR 2010 task force report but there was no exposure to bisphosphonates2. The ASBMR task force recommended that bisphosphonates should be discontinued in patients with bisphosphonate-associated AFF due to their severely suppressed bone turnover status. On the other hand, the AFF in patients with PD may heal in response to bisphosphonate treatment. References: 1. Singer FR. Bone Quality in Paget’s Disease of Bone. Curr Osteoporos Rep. 2016;14(2):39–42. DOI:10.1007/s11914-016-0303-62. Shane E, Burr D, Ebeling PR, Abrahamsen B, Adler RA et.al. Atypical subtrochanteric and diaphyseal femoral fractures: report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2010; 25:2267–2294.