Standardization of flow-cytometric assessment of minimal residual disease in acute lymphoid leukemia (ALL) is necessary to allow concordant multicentric application of the methodology. This is a prerequisite for internationally collaborative trials, such as the AIEOP-BFM-ALL and the ALL IC-BFM trial. We developed and applied a comprehensive training and quality control program involving a large number of international laboratories within the I-BFM consortium to complement standardization of the methodology with an educational component as well as with persistent quality control measures to allow large ALL treatment trials which use multi-laboratory FCM-MRD assessments for risk stratification of pediatric patients with ALL.Monitoring of minimal residual disease (MRD) by flow cytometry (FCM) is a powerful prognostic tool for predicting outcomes in acute lymphoblastic leukemia (ALL). To apply FCM-MRD in large, collaborative trials, dedicated laboratory staff must be educated to concordantly high levels of expertise and their performance quality should be continuously monitored. We sought to install a unique and comprehensive training and quality control (QC) program involving a large number of reference laboratories within the international Berlin-Frankfurt-Münster (I-BFM) consortium, in order to complement the standardization of the methodology with an educational component and persistent quality control measures. Our QC and quality assurance (QA) program is based on four major cornerstones: (i) a twinning maturation program, (ii) obligatory participation in external QA programs ), (iii) regular participation in list-mode-data (LMD) file ring trials (FCM data file send arounds), and (iv) surveys of independent data derived from trial results. We demonstrate that the training of laboratories using experienced twinning partners, along with continuous educational feedback significantly improves the performance of laboratories in detecting and quantifying MRD in pediatric ALL patients. Overall, our extensive education and quality control program improved inter-laboratory concordance rates of FCM-MRD assessments and ultimately led to a very high conformity of risk estimates in independent patient cohorts. SeveralRD range ,9,10,11.RD range .In the current study, we performed a unique and comprehensive training and QC/QA program involving a total of 41 laboratories collaborating in the international (I)-BFM consortium. Of note, many associated laboratories of the network were inexperienced when entering the program. Our approach consists of four major building blocks: (i) a twinning maturation program, where well-trained expert laboratories work closely with more inexperienced laboratories to improve their performance in individual feedback sessions; (ii) the obligatory participation in external QA programs (spiked sample send around), e.g., United Kingdom National External Quality Assessment Service (UK NEQAS); (iii) regular participation in the analysis of LMD file ring trials (data file send arounds) with an educational component, where difficult and discordant cases are jointly discussed; and (iv) surveys of independent data derived from trial results, where the agreement of different centers, with respect to MRD results from their locally recruited patient cohorts, were tested.We demonstrate that the training of laboratories using experienced twinning partners along with continuous educational feedback, significantly improves the performance of laboratories to detect and quantify MRD in pediatric ALL patients. In addition to a standardized methodology, educational feedback and quality oversight by a coordinating structure is required to ensure the sufficient quality of MRD assessment for clinical routine.MRD investigations were approved as part of the international trial by the institutional ethical committees and were conducted according to informed consent guidelines. For list-mode file ring trials, we used bone marrow (BM) samples from pediatric patients (0–≤18 years of age) recruited in the AIEOP-BFM-ALL clinical trial in Vienna (AUT).In total, data from 101 BM samples from regenerative post-induction time-points of pediatric patients with B-ALL were used for the LMD file ring trials (“B-cell precursor (BCP) Regeneration”) during 2016–2020. These regenerative bone marrows are usually characterized by the appearance of BCP subsets at different stages of (BCP 1–3) .Of the 101 BM samples, 53 were FCM-MRD negative, and 48 samples were FCM-MRD positive (range 0.004–18.16%). If available, RT-PCR data served as an independent confirmation of the FCM-MRD target votes. The target MRD values were calculated as a median from six experienced and matured AIEOP-BFM reference laboratories .TM, Beckman Coulter, Brea, CA, USA), Detailed standard operating procedures (SOP) from the AIEOP-BFM  or with A total number of 29 laboratories participated in the twinning and maturation program of which 22 were ALL IC-BFM  trainee laboratories. Seven experienced and already matured AIEOP-BFM laboratories served as twinning and training partners. “Maturation” is granted to a center according to specific criteria and is defined as the permission to release MRD results for clinical use without further control by the partner laboratory (“twinning partner”). “Maturation” can be granted for either B-lineage ALL-MRD at day 15/d33 or at regenerative time-points, and for T-ALL-MRD (independent of time-point). “Maturation” is granted after completion of a series of at least 25 different locally and consecutively recruited patient sample pairs (diagnosis and MRD time-points) per lineage, the analysis of which, along with the results, was promptly submitted to the twinning partner for review. Harmonization and technical alignment of the FCM-MRD technology including machine settings, panel composition, sample preparation as well as staining was an essential part of the twinning maturation program and took place before the test series was started. During the initial phase of the program, an intensive interaction and discussion between the trainee laboratory and its twinning partner following each case ensured a rapid and effective training progress. Therefore, the first half of the samples serves, for the most part, an intensive training, the immediate success of which should and must be proven with the second half of the samples.In the second half of the sample series, each gross error then requires a further three MRD assessments of consecutive cases without errors to achieve maturation. Gross errors are defined as inadequacy of staining and analysis, errors in blast population, or gross misinterpretation or misdocumentation on a predefined report sheet. Provided that no more gross errors in identifying and/or quantifying MRD are detected in the most recent half  of the sample series, maturation is granted. For a detailed description of the guidelines, see https://ukneqas.org.uk/ (accessed on 30 November 2021) and [UK NEQAS (021) and ) provideAnonymized list-mode files were prepared and sent out by the I-BFM FLOW coordinating center in Vienna. A set of at least 20 files containing data of regenerating bone marrow samples with either negative MRD or different positive levels of MRD was sent to the participating laboratories once a year for blinded LMD file interpretation. The participating laboratories were members of the AIEOP-BFM or ALL-IC BFM consortia or cooperating laboratories. Reported MRD values that were either more than three times or less than one-third of the target MRD value  were coWe conducted a survey among eight AIEOP-BFM reference laboratories to collect FCM-MRD-based risk classification data within the AIEOP-BFM-ALL 2009 trial. The following reference laboratories participated in this survey: Berlin, Monza, Padova, Prague, Vienna, Zurich (CH), Sydney (AUS) and the two reference laboratories of Israel (ISR). Details of all requested data can be found in http://www.analyticscalculators.com (accessed on 30 November 2021) for computation of exact test probabilities for 2 × 2 and 2 × 3 Contingency Tables [The concordance of independent flow-risk estimate data was assessed using GraphPad Prism ver. 8.3.0  and Two-Way ANOVA (Tukey test for multiple comparison correction). We used y Tables ,16.In total, 682 samples were processed and analyzed by the 22 trainee laboratories using diagnostic methodology based on central standard operating procedures (SOPs) see , and thep < 0.05)  . SixteenThe United Kingdom National External Quality Assessment Scheme (UK NEQAS) for leukocyte immunophenotyping provides external quality assessment (EQA)/proficiency testing (PT) programs for minimal residual disease for ALL by FCM.n = 9) and 1192 by ALL IC-BFM and other associated laboratories (n = 29). Generally, AIEOP-BFM laboratories had a significantly lower proportion of outliers (2.3%) than ALL IC-BFM/other associated laboratories (5.6%) (p = 0.0043), which is in concordance with the higher number of long-term experienced centers within the AIEOP-BFM group. The overall discordance rate was 4.6%  and sensitivity was 99% (1488/1504)  from up to 38 participating I-BFM-FLOW laboratories, and monitored their performance over time by correlating local results of I-BFM centers with target votes . Target was 4.6% . We also88/1504) .For further continuous quality assessment and improvement, the performance of the I-BFM-FLOW laboratories was monitored regularly via LMD ring trials consisting of data files with either negative or varying levels of MRD from B- or T-ALL cases, or of data files from diagnosis for testing the ability of the reference laboratories for the correct lineage assessment of AL by immunophenotyping see . The staSince the detection and quantification of MRD by FCM is particularly challenging in B-ALL in periods of heavy hematopoietic regeneration, while it is relatively straight forward at early timepoints of therapy , a special focus was on MRD training at regenerative timepoints.A series of list mode data ring trials of B-ALL at regenerative time points  is shown in n = 24)  . Most ofn = 24) . The mosp = 0.005). No laboratory submitted >25% discordant results while 8/32 laboratories (25%) were still assigned a warning flag , the overall performance of the laboratories significantly improved  in RT 2018–2020  and data on 1679 results of 29 issued external QA ring trials (UK NEQAS) of up to 38 laboratories participating per ring trial were collected. As shown in this report, these exercises were successfully developed, and maintained and controlled the proficiency of the many FCM laboratories involved in AIEOP-BFM and ALL IC-BFM trial conduct.The harmonization and alignment of the technical aspects of the FCM-MRD methodology, including machine settings, panel composition, sample preparation, as well as sample staining between different centers, are important prerequisites for concordant multicenter applications . SeveralHence, we based the continuous quality control on two major cornerstones: firstly, the LMD file ring trials, where we focused on the assessment of the analysis performance of each laboratory; and, secondly, on the external UK NEQAS quality control program that allows the performance of the whole methodology to be assessed. Our LMD file ring trials also contain an educational component, where problematic cases are discussed in joint meetings. As part of such meetings, suggestions and solutions for the proper identification of the aberrant cells are provided. In the LMD ring trials, strong BCP regeneration in the bone marrow was found to be the main cause of incorrect MRD assessment. In most cases, these were false positive assessments because normal B cell progenitors (hematogones) were wrongly mistaken for leukemic cells. Therefore, we specifically selected cases with different stages of regeneration and different MRD levels for the LMD ring trials to train the laboratories, especially on such challenging samples. Although BCP regeneration does normally not occur at day 15 or at day 33, it becomes relevant at day 78 of BFM-type induction or during later follow-up time points . While mOur approach has some limitations. There are situations where standard panels do not allow for a correct identification of MRD events, even by the experts themselves, unless additional markers, which are useful for such rare cases, are deployed for a better distinction of aberrant cells . In addiOur extensive training and quality assurance program contribute significantly to improving and continuously ensuring the performance of individual laboratories. Of note, the structure based on a coordinating center responsible for quality oversight and feedback proved particularly effective and relevant. Overall, this led to a very high inter-laboratory concordance rate of FCM-MRD assessments and to a high conformity of risk estimates in independent patient cohorts. This is essential for conducting large ALL treatment trials which use multi-laboratory FCM-MRD assessments for stratification.“The I-BFM FLOW-network is open to further national or trial-based reference laboratories to join the quality program for providing excellent, quality-assured diagnostics to young patients with acute leukemia and for promoting collaborative research.”


Though this score clearly identifies a low-risk and a high-risk population, the majority of patients are categorized as at “intermediate risk”. Although new prognostic factors identified through molecular assays  are now available and may improve risk stratification, the majority of them need specialized centers and bioinformatic expertise that may preclude their broad application in the real-world setting. In the last years, new tools to monitor response and measurable residual disease (MRD) with very high sensitivity after the start of treatment have been developed. MRD analyses both inside and outside the bone marrow have a strong prognostic impact, and the achievement of MRD negativity may counterbalance the high-risk behavior identified at baseline. All these techniques have been developed in clinical trials. However, their efficient application in real-world clinical practice and their potential role to guide treatment-decision making are still open issues. This mini review will cover currently known prognostic factors identified before and during first-line treatment, with a particular focus on their potential applications in real-world clinical practice.Multiple Myeloma (MM) is a hematologic malignancy characterized by a wide clinical and biological heterogeneity leading to different patient outcomes. Various prognostic tools to stratify newly diagnosed (ND)MM patients into different risk groups have been proposed. At baseline, the standard-of-care prognostic score is the Revised International Staging System (R-ISS), which stratifies patients according to widely available serum markers  and high-risk cytogenetic abnormalities detected by fluorescence  Multiple myeloma (MM) is a clonal plasma cell malignancy characterized by strong inter-patient and intra-clonal heterogeneity, resulting in different survival rates, ranging from months up to decades . SeveralAmong the available tools to stratify the risk of MM patients, some are standardized and routinely used in clinical practice, while others are still at an experimental stage and mainly limited to clinical trials . Among tThis mini review will describe different tools for risk assessment and stratification in MM and their potential applicability in the real-world setting.Historically, the diagnosis of active MM requiring treatment has been made in the presence of monoclonal plasma cells in the bone marrow and signs of organ damage such as hypercalcemia, renal failure, anemia, and/or bone lesions (CRAB features) , while tin situ hybridization (FISH). Again, three risk groups of patients were identified with different survival  (The risk stratification of newly diagnosed (ND)MM patients has always relied on clinical and laboratory parameters reflecting tumor burden . The Int months) . The R-I months) . Recent  months) . Moreove months) . Recentl months) . Recent  months) , 24. Tra months) , 26. ThePatients carrying more than 1 high-risk CA (HRCA) have an even worse prognosis than patients with only 1 HRCA . In a laAside from cytogenetics, specific gene mutations have been found to correlate with prognosis. For instance, while del(17p) is universally considered a high-risk feature, data showed an even worse outcome in patients with del(17p) and TP53 mutations (median PFS 152 months in patients without del(17p) and TP53 mutation, median PFS 53 months in del(17p) patients, and median PFS 36 months in del(17p) patients with concomitant TP53 mutation) . Gene exCTC are another marker of adverse prognosis, as demonstrated by several works . In the 2 resulted in poor PFS (2.3 years) and OS (3.6 years)  . The pre6 years) . Indeed,6 years) . HoweverHigh-dose therapy (HDT) followed by autologous stem-cell transplantation (ASCT) is considered the standard of care for medically fit NDMM patients . Transpl2) is often preferred.Historically, the cut-off age for ASCT adopted in trials and clinical practice was 65 years . NeverthBesides chronological age, organ function and comorbidities are other determinants of ASCT eligibility. The Hematopoietic Cell Transplantation Comorbidity Index (HCT-CI), which was initially developed for recipients of allogeneic stem-cell transplantation, was predictive of non-relapse mortality  and morbidity/mortality  in patients undergoing ASCT as well . In clinTransplant-ineligible, elderly patients represent a heterogeneous population in which stratification according to individual characteristics is essential to balance treatment efficacy with the risk of toxicity. Several models to stratify elderly patients according to their fitness have been proposed and validated over the years. The International Myeloma Working Group (IMWG) Frailty Score classifies elderly MM patients as fit, intermediate fit and frail according to age, comorbidities [assessed by Charlson Comorbidity Index (CCI)], and functional impairment . Frail patients, as compared with intermediate-fit and fit patients, showed an inferior OS  as well as a higher incidence of non-hematologic toxicity  and of treatment discontinuation  .The Revised Myeloma Comorbidity Index (R-MCI) categorized patients according to age, Performance Status (PS), frailty, lung and renal function, and cytogenetics; patients were deemed “fit”, “intermediate-fit”, and “frail” with a median OS of 10.1, 4.4, and 1.2 years, respectively . More reAfter the start of treatment with new combinations, more than 50% of patients achieve a complete response (CR) according to the standard IMWG criteria . To furt−6) can be achieved . Similarly to NGF, the maximum sensitivity with NGS-based MRD detection is 10-6.NGS is a molecular biology technique that exploits the unique immunoglobulin (Ig) gene rearrangement of the malignant plasma cell detected at diagnosis to track the levels of residual disease during treatment . The ideBoth NGF and NGS demonstrated to have a major prognostic role in MM. The clinical impact of NGF MRD negativity was validated in the pivotal work by Paiva and colleagues, in which NDMM patients achieving MRD negativity after consolidation showed a significantly reduced risk of disease progression or death, as compared to MRD-positive patients  . SimilarThe achievement of MRD negativity at high sensitivity predicts long-term remission/survival  and can In terms of prognostic prediction, imaging techniques for the detection of residual plasma cells in focal bone lesions and extramedullary lesions outside the bone marrow are complementary to MRD techniques inside the bone marrow .18F-Fluorodeoxyglucose PET/CT (18F-FDG–PET/CT) can characterize disease lesions according to FDG uptake, making it a standard technique to identify residual plasma cells in focal MM involvements outside the bone marrow. An important step towards the standardization of PET-defined complete response was achieved by using Deauville criteria  to measure the monoclonal protein (M-protein) secreted by the malignant plasma cells at a sensitivity that is higher than that used with serum protein electrophoresis (SPEP) and serum immunofixation (s-IFX) , 78. DifQuantitative immunoprecipitation MS (QIP-MS) detects, at high sensitivity, the intact M-protein after a step of immunomagnetic serum enrichment using IgG/A/M, κ, λ, free κ and free λ specific beads . InteresMany new prognostic factors emerged from clinical trials, although the applicability of many of them in the real-world setting is questionable Table 1.The combination of baseline and dynamic tools to stratify patient risk could be the best strategy to pursue Figure 1Patient-related factors must be considered to deliver effective treatment without inducing excessive toxicity, especially in elderly patients in whom patient-related factors are equally if not more important than disease-related factors.During treatment, MRD evaluation is now considered the strongest predictor of patient outcome. In clinical trials, however, bone marrow evaluations are performed at multiple time points. The need to achieve a sustained MRD negativity over time and the best time points to measure it are still matters of debate. Many ongoing trials are exploring MRD-guided treatments , and theIn conclusion, new tools are continuously developed in clinical trials, but their applicability in clinical practice should always be simultaneously verified by acquiring more real-world data.Substantial contributions to the conception or design: all authors. Interpretation of data: all authors. First draft: all authors. Critical revision for important intellectual content: all authors.Final approval of the version to be published: all authors. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: all authors.Author MD has received honoraria for lectures from and served on the advisory boards for GlaxoSmithKline and Sanofi.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


There are benefits of exercise-based cardiac rehabilitation (CR) in patients with heartfailure (HF), but their underlying molecular mechanisms remain elusive. The effect of CR onthe expression profile of circulating microRNAs (miRNAs), which are short noncoding RNAs thatregulate posttranscriptional expression of target genes, is unknown. If miRNAs respond tochanges following CR for HF, then serum profiling of miRNAs may reveal cardioprotectivemechanisms of CR.This study enrolled three hospitalized patients with progressed systolic HF andthree normal volunteer controls. In patients, CR was initiated after improvement of HF, whichincluded 2 weeks of bicycle ergometer and resistance exercises. Genome-wide expressionprofiling of circulating miRNAs was performed using microarrays for the patients and controls (58.7±0.58 years).Circulating miRNA expression profiles were compared between patients with HF before and afterCR and the controls.Expression levels of two miRNAs were significantly different in patients before CRcompared with controls and patients after CR. The expression of hsa-miR-125b-1-3p wassignificantly downregulated and that of hsa-miR-1290 was significantly upregulated in patientsbefore CR.When performing CR, expression of certain circulating miRNAs in patients with HFis restored to nonpathological levels. The benefits of CR for HF may result from regulation ofmiRNAs through multiple effects of gene expression. Clarification of themolecular mechanisms underlying the effect of CR could assist in an understanding of the benefitof CR, and lead to an increase in awareness of CR in clinical practice.Cardiac rehabilitation (CR) that includes exercise training results in a broad rangeof positive effects for patients with cardiac diseases. On the basis of strong evidence, CR isrecommended for patients with heart failure (HF).5 The miRNAs were first reported as endogenous mediators in the wormCaenorhabditis elegans.6Since this time, miRNAs have been shown to be involved in regulating various cellular processes,including cellular differentiation, proliferation, and apoptosis.7 A lot of evidence of the crucial roles of miRNAs in various diseaseshas accumulated over recent years,10 but their significance in molecular biologicalprocesses of cardiac diseases are only beginning to be recognized.12MicroRNAs (miRNAs) are a family of single-stranded, short, non-coding RNA sequencesthat comprise 19–23 nucleotides. These miRNAs act as important posttranscriptional regulators ofgenetic expression through translational repression or transcript cleavage resulting frombinding to the target mRNA.14 including cardiac diseases.16 The present study aimed toinvestigate whether the cardioprotective mechanisms of CR for patients with HF involve changesin circulating miRNAs.The miRNAs exist in a stable form in the bloodstream and are referred to ascirculating miRNAs. Circulating miRNAs could become useful biomarkers for variousdiseases,Three patients with HF and three healthy controls were enrolled in the study. Thepatients were hospitalized for treatment of progressed HF with systolic left ventriculardysfunction from New York Heart Association classes I–II. The controls were volunteers who hadno previous medical history and were recruited from staff at Fujita Health University BantaneHospital. Written informed consent was obtained from all of the subjects and the protocol wasapproved by the Research Ethics Committee of Fujita Health University (HM16-203). In patientswith HF, CR was initiated after recovery from New York Heart Association classes II to I by 1week of treatment for HF. The CR exercise program comprised a bicycle ergometer at an anaerobicthreshold intensity that was determined from a cardiopulmonary exercise test and resistancetraining for 20 min twice a day, 5 days a week. This exercise was performed daily for 2weeks while the patient was hospitalized. Microarray analysis of circulating miRNAs wasperformed for these three patients before and after the CR program, as well as for the threecontrols. Blood samples were obtained in the morning in a calm environment, with the subject ina fasted state. A 20-mL aliquot of blood was drawn from a peripheral vein into a spitz tubecontaining serum separating agent. The serum was isolated by centrifugation at 3000 rpmfor 10 min, transferred into an Eppendorf tube, and stored at –90°C.Total RNA was isolated from the serum using 3D-Gene RNA extraction reagent  according to the manufacturer’s instructions. The extracted RNAwas checked with a Bioanalyzer  and labeled with a 3D-Genecirculating miRNA labeling kit (Toray Industries). The labeled RNAs were hybridized onto a3D-Gene Serum miRNA Oligo chip (Toray Industries). We ensured that the annotation andoligonucleotide sequences of the probes conformed with the miRBase miRNA database(miRbase.org). After stringent washing, the fluorescent signals were scanned with a 3D-GeneScanner (Toray Industries) and analyzed using 3D-Gene Extraction software (Toray Industries).The raw data for each spot were normalized by substitution with the mean intensity of thebackground signal, which was determined from the 95% confidence intervals for the signalintensities of all of the brank spots. Measurements of spots were considered to be valid whenthe signal intensities were >2 standard deviations (SDs) from the background signalintensity. Relative expression levels of miRNAs were calculated by comparison with the signalintensities of the valid spots throughout the microarray analysis. The data were then globallynormalized for each array by adjusting the median of the signal intensity to 25. The miRNAresults for the patients before CR were compared with those of the controls and those of thepatients after CR.t tests for continuousvariables and chi-square analysis or Fisher’s exact test for absolute categorical variables.Differences in the characteristics between patients with HF before and after CR were evaluatedwith the paired t test for continuous variables. Statistical significance was set at p<0.05.In the microarray analyses, significant differential expression was defined by a mean folddifference of >2 or <0.5 relative to the controls or the patients after CR, with a pvalue adjusted by an FDR <0.05. All statistical analyses were performed with IBM SPSSstatistics version 20.0 .Continuous variables are presented as the mean±SD, and categorical variablesare presented as numbers and percentages. Differences in the characteristics between patientswith HF and controls were evaluated with unpaired The clinical characteristics of the patients with HF and the controls are shown inThe p values and fold differences for all of the circulating miRNAs were comparedbetween patients before CR and controls and are plotted in a volcano plot in The p values and fold differences for all of the circulating miRNAs were comparedbetween before and after CR in patients with HF and are plotted in a volcano plot in When these results of the two volcano plots were combined, expression of two miRNAswas significantly different in patients before CR compared with controls and patients after CRas follows. Expression of hsa-miR-125b-1-3p was significantly downregulated and that ofhsa-miR-1290 was significantly upregulated in patients before CR. Additionally, hsa-miR-24-3pand hsa-miR-3661 showed a trend of downregulation in patients before CR compared with controlsand patients after CR , and hsa-miR-30c-1-3p,hsa-miR-196b-3p, hsa-miR-3945, and hsa-miR-7151-3p showed a trend of upregulation.This study used genome-wide microarray analyses to analyze expression levels ofcirculating miRNAs in three patients with HF before and after undergoing a 2-week program of CRin hospital. Our study showed for the first time that expression levels of two circulatingmiRNAs were significantly different before and after CR for HF. Before CR, miR-125b expressionwas significantly downregulated and miR-1290 expression was significantly upregulated comparedwith controls, and both of these miRNA levels returned to levels of controls after CR. Thesefindings suggest that CR normalizes altered expression levels of some miRNAs in patients withHF.18 The miRNAs are transported from the nucleus into the cytoplasm, where theybecome associated with various proteins and are secreted into the bloodstream. As well ascirculating in association with proteins, miRNAs can be packaged into extracellular vesicles orhigh-density lipoproteins or released in apoptotic bodies. Circulating miRNAs are absorbed byremote tissues, where they regulate gene expression by translational repression, mRNAdegradation, and deadenylation of mRNAs.20 Circulating miRNAs are secreted from varioustissues, including the endothelium, in response to exercise. One potential mechanism underlyingthe change in miRNA profile with exercise is that increased shear stress along the endotheliummay stimulate secretion of specific miRNAs from endothelial cells. The miRNAs miR-21, -126,-146a, and -210 are among the best described circulating miRNAs associated with the response toexercise in healthy men, and these are enriched in the endothelium.21 In patients with HF, circulating miR-146a levels do not changefollowing acute exercise, whereas circulating miR-940 enriched in the myocardium is increasedcompared with healthy individuals.22Therefore, the response of the circulating miRNA profile to exercise training in patients withHF requires careful evaluation to assess the differences to responses of healthy individuals.To the best of our knowledge, there have been no previous reports of changes in the profile ofcirculating miRNAs following CR that includes exercise training in patients with HF.Circulating miRNAs in human serum and plasma were first identified in approximately2008.25 Members of this family play crucial roles invarious cellular processes, including cell differentiation, proliferation, and apoptosis, bytargeting many transcription factors,26matrix metalloproteinase,28 and growth factors.29 miR-125 acts in different ways according to the cell context, such as playingimportant roles in the mitochondrial apoptosis pathway by targeting pro-apoptosis oranti-apoptosis genes.30 The pathologicalmechanisms of circulating miR-125 in the human heart have not been determined, although miR-125was found to be upregulated in fibrotic heart tissue.31 In the present study, circulating miR-125b levels were significantly lowerin patients with HF compared with controls and increased to normal levels after CR. Althoughthe relationship between expression levels of miR-125 in cardiomyocytes and the blood has notbeen established, this result suggests that CR exerts protection against HF through changes incirculating and myocardial miR-125 expression levels.The miR-125 family has been implicated in various carcinomas and other diseases aseither repressors or promoters.34 A feature of the tumor microenvironment is regionalsevere hypoxia.35 Therefore, a potential roleof miR-1290 is regulation of cell survival under hypoxic conditions. Recently, Wuet al.36 reported that the molecularmechanism underlying increased survival of cardiomyocytes with asiatic acid might be thenegative relationship between expression levels of miR-1290 and the transcription factorhypoxia-inducible factor 3A in cardiomyocytes. A previous report showed that patients with HFwho underwent CR improved their exercise tolerability.37 The relationship between expression levels of circulating and myocardialmiR-1290 has not been clarified. However, our finding that circulating miR-1290 expression wassignificantly higher in patients before CR compared with controls with a decrease after CRsuggests that miR-1290 contributes to increased exercise tolerability following CR through itsmolecular biological role of boosting resistance to cellular hypoxia.miR-1290 plays a major role in initiation and progress of cancer. Studies haveshown that increased miR-1290 levels are associated with proliferation, invasion, metastasis,and the clinical stage of cancer.38 showedthat miR-24 inhibited cardiomyocyte apoptosis in a mouse myocardial infarction model. Dahlmanset al.39 reported a correlationbetween miR-196b levels and in vivo mitochondrial function in human skeletalmuscle. Duisters et al.40 reported thatmiR-30 directly downregulated connective tissue growth factor, a key molecule in the process offibrosis, thereby regulating structural changes in the extracellular matrix of the myocardium.These findings are consistent with the positive effect of CR, such as reverse left ventricularremodeling,41 improvement of mitochondrialdysfunction in skeletal muscle,42 and areduction in cardiac fibrosis.43In the present study, expression levels of circulating miR-24-3p, miR-196b, andmiR-30c showed a tendency to be different in patients before CR compared with controls andpatients after CR. Previous studies have reported interesting findings for the biological rolesof these miRNAs. Qian et al.The present results help to identify aspects of the biological mechanism of CR inpatients with HF, such as improvement of mitochondrial dysfunction, an increased cellularresistance to hypoxic conditions, and a reduction in cardiomyocyte apoptosis and cardiacfibrosis. However, our study has several limitations. First, the number of subjects was small.Potential variation in circulating miRNAs among the three patients could have affected theresults of the present study. Second, the possibility that treatment for HF affected thecirculating miRNA expression profile cannot to be excluded, such as body weight loss and adecrease in blood pressure. Finally, the relationships between expression levels of circulatingand intracellular miRNAs are unclear. However, to the best of our knowledge, this is the firststudy to evaluate the change in circulating miRNA profiles resulting from CR in patients withHF. The present results support the beneficial effect of CR for HF and could be the biologicalfindings that enhance the evidence of CR. A large-scale study with polymerase chain reactionanalysis is required to further investigate the roles of miRNAs in CR for HF at a geneticlevel.In patients with HF, CR can restore expression of certain circulating miRNAs tononpathological levels. Regulation of expression of multiple genes by these restored miRNAs maycontribute to the beneficial effects of CR on HF.


To support the introduction of the COVID-19 vaccine, the World Health Organization and its partners developed an interactive virtual learning initiative through which vaccination stakeholders could receive the latest guidance, ask questions, and share their experiences. This initiative, implemented between 9 February 2021 and 15 June 2021, included virtual engagement between technical experts and participants during a 15-session interactive webinar series as well as web and text-messaging discussions in English and French.This article uses a mixed-methods approach to analyze survey data collected following each webinar and a post-series survey conducted after the series had concluded. Participant data were tracked for each session, and feedback surveys were conducted after each session to gauge experience quality and content usability. Chi-square tests were used to compare results across professions .COVID-19 Vaccination: Building Global Capacity webinar series reached participants in 179 countries or 93% of the WHO Member States; 75% of participants were from low- and middle-income countries. More than 60% of participants reported using the resources provided during the sessions, and 47% reported sharing these resources with colleagues. More than 79% of participants stated that this initiative significantly improved their confidence in preparing for and rolling out COVID-19 vaccinations; an additional 20% stated that the initiative “somewhat” improved their confidence. In the post-series survey, 70% of participants reported that they will “definitely use” the knowledge derived from this learning series in their work; an additional 20% will “probably use” and 9% would “possibly use” this knowledge in their work.The COVID-19 Vaccination: Building Global Capacity learning initiative used a digital model of dynamic, interactive learning at scale. The initiative enhanced WHO’s ability to disseminate knowledge, provide normative guidance, and share best practices to COVID-19 vaccination stakeholders in real time. This approach allowed WHO to hear the information needs of stakeholders and respond by developing guidance, tools, and training to support COVID-19 vaccine introduction. WHO and its partners can learn from this capacity-building experience and apply best practices for digital interactive learning to other health programs moving forward.The  Introducing the COVID-19 vaccines was the largest simultaneous vaccine deployment initiative in history. As such, the global immunization community needed mechanisms to access real-time normative guidance and implementation examples. Through the Access to COVID-19 Tools (ACT) Accelerator’s Country Readiness and Delivery (CRD) workstream, the World Health Organization (WHO) and partners developed resources to support countries in preparing for and implementing COVID-19 vaccination at scale . These rCOVID-19 Vaccination: Building Global Capacity virtual learning initiative [, the aim was to reach a global audience, with a particular focus on supporting immunization focal points in low- and middle-income country (LMIC) settings.While the MOOCs and job aids were well received by the global, national, subnational, and regional participants, they requested interactive training to support their preparation for COVID-19 vaccine deployment. In response, WHO collaborated with Project ECHO, TechNet-21, the United Nations Children’s Fund (UNICEF), the Sabin Institute’s Boost Community, and the COVID-19 Vaccine Equity Project to develop the itiative , 4. ImplThe initiative leveraged Project ECHO’s nearly 20 years of experience using a virtual, case-based “community of practice” approach to promote real-time, peer-to-peer learning among health workers and public health practitioners. The Project ECHO learning model promotes clinical and public health collaborative learning using videoconferencing in an “all teach, all learn” approach on a regional, national, or international scale. This model has been used to improve care and outcomes for chronic and acute health conditions; it has also supported the COVID-19 and other emergency public health responses globally –13.COVID-19 Vaccination: Building Global Capacity initiative included virtual engagement between technical experts and participants using a multipoint videoconferencing platform, with real-time polling, chat, and Q&A functions, in addition to instant messaging group communication and discussion fora in English and French on TechNet-21, a virtual global network of immunization providers. The aim was to create a learning ecosystem of real-time and asynchronous peer-to-peer learning networks through which health workers, public health practitioners, and other COVID-19 vaccination stakeholders could receive the latest guidance, ask questions, and share their experiences with COVID-19 vaccine introduction.The A growing body of evidence supports the effectiveness of webinars in advancing the knowledge of participants, and providing a safe and supportive environment for learning . InteracThe COVID-19 pandemic accelerated the already increasing use of webinars to transfer information and train participants. However, concerns have been raised about limited access to workplace-based learning experiences, and the effectiveness of technology-based competence assessments . While pCOVID-19 Vaccination: Building Global Capacity initiative. The mixed-methods approach and findings provide insight into how this webinar series supported COVID-19 vaccination capacity building, particularly in LMICs.This paper contributes to the literature on interactive digital learning by describing participation in and outcomes from the COVID-19 Vaccination: Building Global Capacity learning series had two objectives: to amplify use of and receive feedback on the ACT Accelerator CRD workstream’s COVID-19 vaccine introduction guidance, tools, and training resources; and to share best practices and lessons learned on key aspects of COVID-19 vaccine introduction and administration through case studies and peer-to-peer engagement. The 15 one-hour learning sessions were divided into two subseries, complementing the resources developed by the ACT Accelerator’s CRD workstream led by WHO, UNICEF, and Gavi, the Vaccine Alliance (Gavi). Five of the sessions focused on topics relevant for health workers, while 10 of the sessions focused on topics relevant for national and subnational stakeholders. Participants were recruited through email announcements and program websites, hosted by TechNet-21 and Project ECHO, to join the sessions relevant to their professional or personal interests. Certificates were provided for each session attended. Participants were not expected or required to attend every session.The The live webinars supplemented the OpenWHO MOOCs launched in December 2020 for national and subnational stakeholders preparing for COVID-19 vaccine introduction and health workers responsible for safe administration of COVID-19 vaccine (Annex 1) , 23. TheThe overarching goal of this initiative was to make COVID-19 vaccination information transparent and readily accessible to all. As such, the sessions were marketed through mailing lists, social media, the TechNet-21 and Boost online platforms, and word of mouth. Registration for the sessions was open to the public and unrestricted. Session materials  were posted on publicly accessible websites, such as those hosted by TechNet-21 and Project ECHO, and shared on the mobile channels in English and French, to facilitate access.Each session included presentations or panel discussions by technical experts and/or peer learning through sharing of country case studies as well as allocated time for questions from participants. The subject matter experts responded to participants’ questions in writing or verbally during the live webinars; selected questions submitted during the registration process were also addressed. Questions that were not addressed during the webinar due to lack of time were collected and sent to the presenters and subject matter experts for compilation into a Q&A document that was shared by email with all participants and posted on the TechNet-21 platform. Participants’ questions and recommendations via the post-session surveys, in addition to the ACT Accelerator’s identification of COVID-19 vaccination bottlenecks, were used to determine the topics that would be beneficial to focus on during the subsequent sessions.Demographics were collected when participants registered for the webinars. Participants provided their name, email, organization, city, profession, and country or region. Attendance reports were automatically saved through the unique webinar registration link received by each participant. Webinar registration and attendance data were linked using the participant’s email address. Participants had the option to self-report their profession from a list provided.A link to an electronic survey was shared with all webinar participants during and after each session. The post-session survey gave participants the opportunity to provide feedback about each learning session and receive an attendance certificate. The survey asked participants about their knowledge of the session’s topic before and after; relevance of the session to their current work; balance of lecture and interactivity; and intention to use what was learned in their work. In addition, Project ECHO distributed a final post-series survey link during the last session and in two subsequent emails to all program registrants to solicit feedback about the entire learning initiative, regardless of the number of sessions they completed. Survey questions are available in Annex 2. The University of New Mexico Health Sciences Institutional Review Board approved this evaluation (ID 20–469) and its consent process.Chi-square tests were used to compare results across professions  and participating countries’ World Bank income status. The Wilcoxon signed-rank test was used to compare knowledge before and after sessions. Quantitative analyses were conducted in SPSS 28.0. Open-ended text responses were coded systematically using NVivo 1.4.1.COVID-19 Vaccination: Building Global Capacity webinar series reached participants in at least 93% of WHO Member States. The majority of the participants who joined the webinar sessions were from LMICs  focused on interpersonal communications for COVID-19 vaccination, while the least well attended session (185 participants) focused on adaptive leadership for COVID-19 vaccine introduction. Since the participants attended an average of 2.2 sessions, the total number of attendances (> 6600) is substantially larger than the total number of unique individuals (3058) who participated in the live webinar sessions. Nearly 45% of participants attended more than one session, with the highest repeat attendance rates for health workers .Participants used a variety of learning strategies. Of the 228 respondents who completed the post-series survey, 51.9% reported participating in all three of the COVID-19 vaccination training opportunities: the mobile based channels, OpenWHO COVID-19 MOOCs, and the Post-series survey respondents reported using information in various ways after the session, including watching session recordings and sharing resources with colleagues Fig. . Of the P < 0.001). In the post-series survey, most respondents (79.6%) reported that their confidence in preparing for and rolling out COVID-19 vaccination increased “a lot” because of the initiative. However, frontline providers were less likely to report an increase in confidence than public health practitioners or other occupations . Additionally, participants who attended four or more sessions were more likely to report their confidence increased “a lot” compared to those who attended fewer sessions . In post-session surveys, respondents rated their post-session knowledge significantly higher than before the session Fig.  , particularly government officials, who may be involved in COVID-19 vaccination planning and deployment. In addition, 15 respondents recommended adding more tangible resources  and practical examples specific to LMIC contexts.COVID-19 Vaccination: Building Global Capacity initiative created a model of dynamic, interactive learning at scale. This initiative reflected WHO’s desire to rapidly disseminate guidance, tools, and resources for effective deployment and administration of COVID-19 vaccines. WHO and its partners also used this platform to answer questions and promote peer learning through inclusion of country case studies. Participants used this initiative to ask technical experts questions and share comments, familiarize themselves with new guidance and insights, flag challenges related to COVID-19 vaccination, and receive support for their COVID-19 vaccination planning and introduction.The The interactive nature of this digital learning initiative allowed WHO to hear COVID-19 vaccination stakeholder experiences in real time as they prepared and implemented COVID-19 vaccination delivery programs. The questions and comments during the sessions, in the post-session feedback surveys, and the discussion fora served as real-time feedback mechanisms that the CRD workstream used to identify needs and develop new resources accordingly. In particular, the mobile app enabled robust dialogue with participants. Resources were developed based on questions or requests from this initiative, including job aids explaining why there may be extra doses in a vaccine vial, how to communicate to pregnant women about COVID-19 vaccination, and how to manage vaccines without vaccine vial monitors at vaccination service points.Although the feedback received from this initiative was overwhelmingly positive, a key limitation is the small percentage of participants who completed the post-series survey. While the participants who completed the post-series survey were more likely to have participated in more sessions, the small sample size (228 or 7.5%) impedes our ability to generalize our findings.COVID-19 Vaccination: Building Global Capacity initiative allowed a wider range of stakeholders  to engage directly with technical experts, ask questions, and share their experiences. The results of the evaluation of this initiative highlight the strong interest of local, national, regional, and global stakeholders in receiving real-time resources through an interactive capacity-building program and having communication channels through which they can ask questions related to COVID-19 vaccination and receive answers from global experts. As such, the COVID-19 Vaccination: Building Global Capacity initiative allowed WHO to support the development of potential champions for COVID-19 vaccination globally. The modular nature of the program allowed participants to attend sessions that were relevant to their work and provided an online curated learning resource that could be used as a participant’s role changed or as their country’s COVID-19 immunization program evolved.Traditionally, WHO headquarters receives feedback on the guidance and education resources it produces primarily from WHO regional and national staff and/or from ministries of health. The structure and format of the Additionally, the initiative provided a trusted source of information during a period where misinformation constituted a significant global challenge –26. As pWHO, TechNet-21, Project ECHO, and other partners are now considering how best to incorporate learnings from this initiative into future digital health capacity-building efforts for emergency response and routine health programs. The findings align with previous studies suggesting that interactive needs- and people-centered digital health can be effectively used for capacity building in LMICs , 14. ForCOVID-19 Vaccination: Building Global Capacity experience, WHO technical experts have expressed interest in conducting similar types of interactive initiatives for other pathogen prevention and control programs, such as seasonal influenza and antimicrobial resistance.WHO and TechNet-21 are considering innovative tools and approaches that can be used to enhance their capacity-building programs. The overwhelmingly positive feedback from this initiative and participants’ requests for more inclusive digital learning opportunities demonstrate that there is strong interest in further using digital capacity-building programs to promote both rapid dissemination of normative guidance and peer learning. As such, WHO and TechNet-21 are exploring opportunities to adapt or develop current learning initiatives to enable learning and community engagement by leveraging low-bandwidth, low-cost apps and videoconferencing technology. Using these platforms offers an opportunity for WHO and its partners to reach and interact with stakeholders at scale. In light of the


Post-myocardial infarction ventricular septal defect (post-MI VSD) is a rare complication of ST-elevation myocardial infarction (STEMI) with an incidence of <1% in early revascularization era. Here we present the case of a 66-year-old woman with post-MI VSD owing to delay in her presentation in the current pandemic. Patient presented with worsening back pain and chest pain with confusion, and an EKG positive for inferior wall STEMI. She underwent emergent percutaneous intervention with placement of drug-eluting stent in her right coronary artery. She developed worsening heart failure and new-onset heart murmur and was found to have a VSD on a transthoracic echo. Because of her poor prognosis, family decided to pursue comfort care and patient unfortunately passed.Delay in seeking health care during the pandemic, as seen in our patient, is multifactorial including fear of contracting infection, decreased emergency medical services members, and concerns for overburdening healthcare systems. Lack of standardized in-hospital approach to emergencies while ensuring adequate protection from infection to healthcare workers, especially during the initial phase of the pandemic, led to increased door-to-balloon times in addition to the increased time to first medical contact. The importance of media outreach ensuring availability of health care in emergencies, changing emergency response algorithms to ensure safety of patients and healthcare providers, and including thrombolytic therapy where there is a delay due to stringent screening or delayed COVID-19 testing can be used to prevent worsening complications following STEMI. Post-myocardial infarction ventricular septal defect (post-MI VSD) is a rare but a fatal complication of ST-elevation myocardial infarction (STEMI) . The incOverall STEMI incidences appear to have dropped during the lockdown period due to decrease in environmental exposures . In spitA 66-year-old woman with a history of chronic obstructive pulmonary disease, chronic back pain, and hypercholesterolemia presented with worsening back pain of two days' duration. She avoided seeking care due to the COVID-19 pandemic and attributed her symptoms to her chronic problems. Emergency medical services (EMS) brought her to the hospital with concerns of STEMI. She received two nitroglycerin and an aspirin en route. On arrival, she was afebrile but tachycardic and in respiratory distress, with a respiratory rate of 30-34 breaths/minute, and oxygen saturation of 98% on room air. She was hypotensive to 56/44 mmHg with confusion. An EKG revealed sinus tachycardia with a ventricular rate of 117 and signs consistent with an inferior wall STEMI, including ST elevation in leads II, III, and aVF Figure , 3, 4. NShe was admitted to the intensive care unit with respiratory and circulatory failure. The following day, she became increasingly acidotic with lactate levels rising from 7.1 to 12.8 mmol/L. She was also found to have a new pan-systolic murmur, warranting an emergency transthoracic echocardiogram that revealed a VSD Figures , 6, 7. TPost-MI VSD is the rarest but deadliest complication occurring three to five days following an STEMI. Its incidence decreased to <1% in the early revascularization era ,3.Change in healthcare-seeking behavior seems to have arisen from contamination obsession (a form of obsessive-compulsive disorder focused on hand-washing) exacerbated by the pandemic, worry of being a burden on the healthcare system due to widespread media coverage of an overstretched medical system, and a decrease in EMS workers ,6. A dirWith social distancing and patients changing their behavior to avoid contracting COVID-19, delayed presentation of all diseases is bound to increase complications. For STEMI, standardized treatment regimens had been responsible for declining complication rates. Healthcare avoidance for fear of contracting COVID-19, concerns for burdening medical systems, and delay in door-to-balloon times due to stringent screening in hospital may have increased complications. Endorsing importance of seeking health care in emergencies in media, use of thrombolytics as an alternative, and improved access to PPE and negative pressure cath labs can be used to address these problems.


Objective: Patients requiring hospital care for COVID-19 may be stable for discharge soon after admission. This study sought to describe patient characteristics associated with short-stay hospitalization for COVID-19. Methods: We performed a retrospective cohort study of patients with COVID-19 admitted to five United States hospitals from March to December 2020. We used multivariable logistic regression to identify patient characteristics associated with short hospital length-of-stay. Results: Of 3103 patients, 648 (20.9%) were hospitalized for less than 48 h. These patients were significantly less likely to have an age greater than 60, diabetes, chronic kidney disease; emergency department vital sign abnormalities, or abnormal initial diagnostic testing. For patients with no significant risk factors, the adjusted probability of short-stay hospitalization was 62.4% (95% CI 58.9–69.6). Conclusion: Identification of candidates for early hospital discharge may allow hospitals to streamline throughput using protocols that optimize the efficiency of hospital care and coordinate post-discharge monitoring. Although significant attention has been paid to risk factors associated with mortality and severe illness due to COVID-19, most infected patients never need hospitalization, and many who do require only short hospital stays ,3. IndicDuring the pandemic, hospitals have had to expand their capacity and streamline patient throughput to manage high patient volumes and preserve access to care unrelated to COVID-19 . Short hAnticipation of admitted patients with COVID-19 who are candidates for early discharge may allow hospitals to develop protocols to further reduce length-of-stay, involving strategies such as early discharge planning, protocolized delivery of therapeutic medications, and the use of dedicated observation units and personnel . ImproveThe goal of this study was to describe patient characteristics associated with short-stay hospitalization for COVID-19 among patients admitted from the emergency department to non-critical care units, to aid the development of efficient hospital care pathways for COVID-19. In a secondary analysis, we determined whether short-stay hospitalizations are associated with rehospitalization within seven days of discharge.We conducted a retrospective cohort study of patients with COVID-19 requiring hospitalization at five hospitals within a multi-hospital health system in the United States. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology guidelines . We used electronic health record data to identify inpatient admission or observation encounters originating in the emergency department (ED) between March 1— December 31 2020. We apply the term ‘hospitalization’ to signify hospital encounters regardless of inpatient or observation status. Patients were included in the cohort if they tested positive for COVID-19 during the ED encounter, or, for patients who were tested as outpatients, up to seven days prior. In this system, hospital admission decisions were made at the discretion of the attending emergency physician based on evolving experience and evidence on the management of COVID-19 during this period. We excluded elective or surgical admissions and patients younger than 18 years. We excluded patients admitted from the ED directly to a critical care unit or service. We excluded patients who expired or were referred to hospice within 48 h of hospitalization.The binary primary outcome was whether or not the hospital length-of-stay was 48 h or less. We defined the start of hospitalization as the time when the ED clinician presented the case to the inpatient medical team, representing the time point when the hospital team assumes responsibility for patient management. Patients may have physically remained in the ED for some period after this timepoint. We defined the end of hospitalization as the time of the hospital discharge order. In a secondary analysis, the outcome was whether patients were re-hospitalized within 7 days, among patients who did not expire or were discharged to hospice during the index hospitalization.We selected covariates available in the electronic health record prior to the analysis to reflect patient characteristics that were common and known at the time of ED disposition. Covariates were selected a priori, and all were entered into the analysis. Variables were selected by the study team for several factors, including (1) previous evidence demonstrating an association with the severity of illness due to COVID-19, (2) availability of data for most patients hospitalized with COVID-19, and (3) a plausible explanatory association with the outcome of short-stay hospitalization. We included demographics, including age, sex, and self-reported race/ethnicity. We also included patient co-morbidities that we deemed might affect hospital length-of-stay: hypertension, diabetes, chronic kidney disease, chronic obstructive pulmonary disease (COPD) or asthma, and venous thromboembolism. These co-morbidities were included as binary variables according to their presence or absence as recorded at the time of the hospital admission. We also included physical signs  and results of common diagnostic testing ; the parameters for normal and abnormal values are listed in the p-value of less than 0.05 was considered statistically significant.We summarized unadjusted outcomes using descriptive statistics. For the primary adjusted analysis, we used multivariable logistic regression to compare the characteristics of patients who had a short-stay hospitalization to those who did not (binary outcome). In addition to reporting the adjusted odds ratios (AORs), we used marginal effects to report the adjusted probability of short-stay hospitalization with 95% confidence intervals (CIs) to more clearly quantify the effects of risk factors for the primary outcome [Of the 3103 patients included in the study, 648 (20.9%) had a short-stay hospitalization. Patient characteristics are shown in In this cohort, 191 patients had no risk factors found to be significantly associated with prolonged hospitalization. For those patients, the adjusted probability of short-stay hospitalization was 62.4% (95%CI 58.9–69.6). For the 238 patients with normal ED vital signs and diagnostic testing, the adjusted probability of short-stay hospitalization was 51.7% (95%CI 46.9–56.7). The adjusted probability of short-stay hospitalization for the 913 patients with an age of < 60, no history of diabetes, and no history of chronic kidney disease was 28.1% (95%CI 25.2–30.9).In the secondary analysis, there were 2792 patients who did not expire or were discharged to hospice during the index hospitalization. Of 648 patients with index short-stay hospitalization, 48 (7.4%) required rehospitalization within 7 days. Of 2148 patients with index hospitalization greater than 48 h, 42 (2.0%) required rehospitalization. Short-stay hospitalization had significantly increased odds of rehospitalization within 7 days . Additional patient characteristics associated with 7-day rehospitalization are provided in In this study, 1 in 5 patients with COVID-19 admitted from the ED to medical wards were discharged within 48 h. Several patient characteristics were independently associated with a greater likelihood of short-stay hospitalization. Furthermore, we found that patients younger than 60 with normal ED vital signs and diagnostic testing had greater than a 50% probability of discharge within 48 h. These patient groups may be appropriate candidates for targeted short-stay pathways that seek to further streamline throughput and reduce length-of-stay. The presence of such pathways might lead to even further reductions in hospital length-of-stay, both for patients who may meet discharge criteria before 48 h but who are not discharged by that time as well as patients who are discharged within 48 h but may have been ready to depart even sooner.During the pandemic, hospitals cohorted patients with COVID-19 to minimize the spread of infection . FurtherFor other disease conditions, the use of dedicated observation units for short hospital encounters is widespread in the United States, and observation protocols are widely recognized to create efficient delivery of hospital-level services . ObservaThis study also found that 7% of patients discharged within 48 h were readmitted compared to 2% of patients with longer index hospitalization. Prior evidence suggests a similar risk of readmission during the immediate period following hospital discharge, although studies examining a longer time period have shown higher rates of readmission ,13,14. IThis study has several limitations. First, approaches to the management of COVID-19 varied significantly over the course of the study period—first, due to the uncertainty of patient trajectories and, later, due to the introduction of intravenous therapies . Second,In summary, patients with moderate–severe illness due to COVID-19 may only require brief hospitalization. Patient characteristics and initial ED evaluation may help hospitals distinguish these patients and develop care pathways that optimize efficient care. Given the increased risk of rehospitalization after brief hospitalization, patients may benefit from close monitoring after discharge.


This review aimed to perform a meta-analysis examining the following: (a) acute effects of adopting an internal focus vs. external focus of attention on muscular strength; and (b) long-term effects of adopting an internal focus vs. external focus of attention during resistance training on gains in muscular strength. We searched through five databases to find eligible studies. Random-effects meta-analyses of standardized mean differences were conducted to analyze the data. Ten studies were included. In the meta-analysis for the acute effects, there was a significant positive effect of external focus on muscular strength . In the meta-analysis for the long-term effects, there was no significant difference between training with an internal focus and external focus on muscular strength gains . In the subgroup analysis for lower-body exercises, we found a significant positive effect of training with an external focus on muscular strength gains . In summary, our findings indicate an acute increase in muscular strength when utilizing an external focus of attention. When applied over the long-term, using an external focus of attention may also enhance resistance training-induced gains in lower-body muscular strength. The importance of attentional focus on motor learning is well-established . Most coStudies have also compared the effects of external vs. internal focus on resistance exercise performance ,9,10,11.Besides acute effects, studies have also conducted training interventions in which participants received either external focus or internal focus cues during each exercise session ,16. SomeFor this review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . We searWe included studies that satisfied the following criteria: (1) written in English; (2) explored the acute or long-term effect of external focus vs. internal focus on attention on muscular strength; (3) utilized a crossover study design (for studies examining acute effects) or a between-group design (for studies exploring long-term effects); and (4) presented mean ± standard deviation (SD) data from the muscular strength test. All studies that did not satisfy these criteria were excluded from the review. The most common reason for excluding studies was that they did not evaluate muscular strength. From each included study, we extracted the following data on a coding sheet using Microsoft Excel software : (1) lead author name and year of study publication; (2) participants characteristics; (3) cues provided for the external focus and internal focus; (4) test(s) used to evaluate muscular strength; and (5) main study findings.We assessed the methodological quality of studies included in the analysis using the PEDro checklist . This ch2I, which was interpreted as low (2I < 50%), moderate (2 =I 50–75%), and high heterogeneity (2I >75%). The statistical significance threshold was set at p < 0.05. All analyses were performed using the Comprehensive Meta-analysis software, version 2 .Meta-analyses were performed using standardized mean differences (SMDs) in the random-effects model. The muscular strength data were converted to SMDs with their 95% confidence intervals (CI). For the acute effects, the muscular strength mean ± SD data from the external focus and internal focus trials, total sample size, and inter-trial correlation are used to calculate SMDs. Given that the studies did not present inter-trial correlation, we estimated correlation values using the recommendations in the Cochrane Handbook . In the In the primary search, there was a total of 479 search results . We exclSeven studies compared the acute effects of external vs. internal focus on muscular strength . The samStudies scored from 5 to 7 points on the PEDro checklist (median: 6 points). Seven studies were classified as having good methodological quality, while three studies were classified as being of fair methodological quality .p < 0.001; 2I = 40%; p = 0.113; 2I = 0%). In the subgroup analysis that considered only lower-body exercises, there was a significant positive effect of training with an external focus on gains in muscular strength .In the meta-analysis for the acute effects, there was a significant positive effect of external focus on muscular strength . Indeed, in one of the included studies [constrained action hypothesis suggests that providing external focus cues may allow the execution of the tasks without omitting any of the contributors, ultimately resulting in better performance [Our results support previous research showing that external focus enhances motor performance. In a comprehensive review, Wulf  demonstrpothesis ,31. The  studies , the autformance ,29,30. AFrom a practical perspective, our results are likely most relevant in two areas. Firstly, the results presented herein may be of substantial practical importance for athletes competing in strength-based sports such as powerlifting and weightlifting. Our findings suggest that adopting an external focus of attention may enhance muscular strength and, therefore, directly impact performance and success in these sports. Secondly, our results highlight the importance of cue standardization when conducting muscular strength tests . StrengtWhile there was no significant difference in the main meta-analysis for the long-term effects of attentional focus strategies, we found that resistance training with an external focus results in significantly greater lower-body muscular strength gains. These results suggest that the acute effects, when applied in each training session, may also impact lower-body strength gains over the long-term. While the topic of internal versus external focus of attention during training intervention requires much more research, our results preliminarily support the positive effects of an external focus on motor performance. In line with the data presented herein, previous research also showed a benefit toward an external focus of attention during nine weeks of plyometric training on vertical jump performance . FurtherAll three studies that conducted resistance training interventions assessed lower-body strength using exercises such as the deadlift, squat, and knee extension. Out of these three studies, only one used an upper-body test of strength  . Based oBased on the PEDro checklist, the included studies were of fair or good methodological quality. Still, it should be considered that only two of the included studies incorporated blinding as a part of their design ,30. ThesThere are several limitations of this review that should be acknowledged. Specifically, there were no significant differences between the conditions in the main meta-analysis that explored the long-term effects of external vs. internal focus. The lack of statistically significant findings in this analysis might be because only three studies were included, highlighting the need for future studies. Additionally, while our findings suggest a benefit of using an external focus of attention for muscular strength, such recommendations should not be generalized to other resistance training adaptations such as muscular hypertrophy. To our knowledge, only one study evaluated the effects of external vs. internal focus of attention on muscular hypertrophy and actually reported a benefit toward training with an internal focus of attention . TherefoCompared to an internal focus, we found an acute increase in muscular strength when adopting an external focus of attention. There were no significant differences in the main meta-analysis that compared the effects of training with an internal focus vs. external focus of attention on muscular strength gains. However, in a subgroup analysis that considered only lower-body strength gains, we found a significant positive effect of training with an external focus. In summary, our findings indicate an acute increase in muscular strength when utilizing an external focus of attention. When applied over the long-term, using an external focus of attention may also enhance resistance training-induced gains in lower-body muscular strength.


Based on the World Health Organization guidelines for defining overweight, we included longitudinal observational studies, which utilized survival statistics with hazard ratios (HRs) in our analysis. The included studies measured body mass index at the time of diagnosis of TNBC and reported disease-free survival and/or overall survival. Study quality was assessed with the Newcastle-Ottawa Scale and study data were extracted using the Meta-analysis of Observational Studies in Epidemiology (MOOSE) checklist, independently by two authors. Random-effects models were used to combine the effect sizes (HRs), and the results were evaluated and adjusted for possible publication bias. Thirteen studies of 8,944 TNBC patients were included. The meta-analysis showed that overweight was associated with both shorter disease-free survival  and shorter overall survival  compared to normal-weight. Additionally, our Bayesian meta-analyses suggest that overweight individuals are 7.4 and 9.9 times more likely to have shorter disease-free survival and overall survival, respectively. In conclusion, the available data suggest that overweight is associated with shorter disease-free and overall survival among TNBC patients. The results should be interpreted with caution due to possible publication bias.We conducted a systematic review and meta-analysis investigating the association between overweight and outcome in triple-negative breast cancer (TNBC) patients. We searched PubMed and Embase using variations of the search terms  Alongside increasing breast cancer incidence; overweight and obesity have become growing health issues2. The World Health Organization (WHO) reports that approximately 40% of the world’s female population is overweight with a body mass index (BMI) of 25 kg/m2 or above, and 15% are obese (BMI 30 kg/m2 or above)3. These numbers continue to increase3.Every year, around 2.1 million women are diagnosed with breast cancer worldwide4, but it is also associated with a less favorable breast cancer prognosis5, with higher BMI having been found associated with increased risk of recurrence and mortality of breast cancer, irrespective of hormone-receptor (HR) status6. While BMI may not be an optimal indicator of body composition,7 BMI remains the current standard tool for measuring and defining overweight and obesity8.Not only is overweight a risk factor for developing breast cancer9. TNBC is characterized by cancer progression independent of estrogen, progesterone, and human epidermal growth factor 2 protein (HER2), and is 10–20% more common in overweight compared with normal-weight women11.While the majority of breast cancers are HR-positive, globally around 10% are triple-negative breast cancers (TNBC)12. Second, in obesity, circulating chemokine ligand 2 (CCL2) levels are elevated13. High CCL2 levels are associated with increased presence of tumor-associated macrophages14, which can change their phenotypes depending on the tumor microenvironment and promote tumor growth and progression15. Finally, free fatty acids produced by adipose tissue lipolysis in obese individuals stimulate toll-like receptor 4 on breast cancer cells and induce activation of the nuclear factor – kappa B pathway (NF-κB)16, with continuous NF-κB activation leading to an increase in cancer stem cells in vitro17.There are several plausible biological reasons for a negative prognostic role of overweight in TNBC. First, in an obesity setting, released cytokines shift from an anti-inflammatory to a pro-inflammatory/proangiogenic profile18. Chemotherapy is the systemic treatment of choice in the neoadjuvant or adjuvant setting for TNBC patients. Although patients with TNBC have an increased likelihood of pathologic complete response when treated with neoadjuvant chemotherapy compared to breast cancer patients with other subtypes20, no targeted therapy is yet available for TNBC patients18.Compared with HR-positive breast cancer, TNBC is associated with increased risk of developing metastatic disease and lower survival rates21. The meta-analysis by Mei et al.21 is limited by being restricted to studies of obese TNBC patients, rather than both overweight and obese patients, and by using another measure than the hazard ratio, i.e., the summary odds ratio, as the clinical outcome effect size.So far, only one published meta-analysis has explored the association between overweight and TNBC prognosis2, we evaluated the association of overweight, a potentially modifiable lifestyle-related factor, with the prognosis of TNBC by conducting a systematic review and meta-analysis of the available evidence.Given the poor prognosis of TNBC and the global obesity epidemic31, twelve studies of 8,005 patients reported OS data34, and nine studies reported both endpoints29. The study selection process, including reasons for exclusion, is shown in Fig. The search and subsequent study selection process resulted in the inclusion of 13 independent studies investigating a total of 8,944 TNBC patients. Of these, ten studies of 5,109 patients reported data on DFSThe risk of bias assessment for each study is shown in Table p = 0.31) Q-statistic and the I2 of 17.74 suggested limited heterogeneity. Egger’s test was statistical significant (p = 0.01), and the adjustment based on the five imputed “missing studies” suggested by the trim and fill procedure  . When exploring the association between DFS in BMI subgroups differing overweight (defined as BMI 25–30) and obese (defined as BMI≥30) patients from each other, the association was attenuated  . The credible interval, i.e., the interval that the true effect sizes are assumed to lie within with 95% probability was 1.08 to 1.45 and similar to the confidence interval (1.09–1.46).The findings were supported by the supplementary Bayesian Model-Averaged meta-analysis, which provided moderate evidence for a non-zero effect of overweight on DFS corresponding to a Bayes Factor (BF)I2 of 46% suggested that a little less than half of the variation in hazard ratios could be explained by true differences between studies. The subsequently calculated prediction interval suggested that the hazard ratios of 95% of future studies from the same family of studies will lie within a broad interval from 0.83 to 2.34. The funnel plot  suggested the possibility of publication bias in favor of larger hazard ratios, and imputing six “missing studies” resulted in a reduction of the combined hazard ratio from 1.28 to 1.08, which no longer reached statistical significance. When attempting to explore possible sources of heterogeneity with meta-regression-based moderator analyses, the strength of the association between overweight and OS was not modified by between-study differences in either BMI cut-offs or median follow-up time. A sensitivity analysis excluding studies with a BMI cut-off of 24 kg/m2, strengthened the association (HR: 1.46 [95% CI: 1.13–1.89]). When analyzing the smaller number of studies, which provided data on BMI subgroups, i.e., overweight (defined as BMI 25–30) and obese (defined as BMI ≥ 30) patients, separately, the associations with OS did not reach statistical significance  in comparison with normal-weight patients (HR: 1.29 [95% CI: 1.11–1.51]) , and the credible interval was 1.07 to 1.47 and similar to the confidence interval (1.11-1.51).The supplementary Bayesian model provided strong supportTaken together, the results of the present systematic review and meta-analysis support the hypothesis that overweight TNBC patients have a poorer prognosis with shorter disease-free and overall survival in comparison with normal-weight TNBC patients. During the follow-up periods, overweight TNBC patients were found to be 29% more likely to die than normal-weight TNBC patients.35 for both findings by indicating that a non-zero effect of overweight was 7.4 times more likely than the null-hypothesis for DFS and approximately 10 times more likely for OS. In addition, heterogeneity was moderate for both endpoints and the risk of bias of the included studies was generally low. While the available data support a conclusion that overweight is associated with poorer prognosis in breast cancer patients with triple-negative disease, the possibility of publication bias in favor of stronger associations between overweight and poorer survival should be taken into consideration when interpreting the results.Bayesian meta-analysis provided additional support36, and BMI is usually strongly associated with body surface area37. Thus, it cannot be excluded that the reported negative influence of overweight on TNBC prognosis could at least be partly due to differences in drug dosage determination guidelines38, as overweight patients may receive capped doses of chemotherapy to reduce the risk of toxicities39. Fourth, in the quality assessment of the included studies, no study was able to verify that the breast cancer diagnosis was not a recurrent breast cancer. Therefore, we cannot exclude the possibility of a classification bias, i.e., classifying a breast cancer diagnosis as the primary cancer despite the fact that it is second cancer. However, given the frequency of second/third cancers it is unlikely that the observed association can be explained by this. Finally, the present review could possibly be limited by two of the included studies33 using a lower BMI cut-off for overweight (24 kg/m2 or above), which could theoretically induce a classification bias40. However, these BMI cut-offs were based on WHO standards for the geographic area of the studies, thereby reflecting the population characteristics41.While our study thus has several strengths, some limitations should also be noted. First, only few studies have yet explored the prognostic role of overweight in TNBC and the sample sizes are limited by the relatively low prevalence of TNBC. Second, the heterogeneity of the chemotherapy regimens used across the available studies may limit the interpretability of the results. Third, chemotherapy being the current standard systemic treatment of TNBC, is dosed based on body surface area to achieve the optimal pharmacologic biological availability42. Unfortunately, the estimates presented in the study by Ballinger et al., do not include information on the precision of the estimates, which was a requirement for inclusion in our meta-analysis. The study by Ballinger et al. is important, as it is restricted to chemoresistant TNBC patients and highlights that chemoresistant TNBC patients might constitute a group of patients in which lifestyle interventions lack a beneficial effect. However, this needs to be further addressed in future studies and the results from Ballinger et al., should be interpreted with caution as they are limited by the small population of 172 chemoresistant TNBC patients with residual disease and the short follow-up time (primary endpoint is two year DFS). Furthermore, in a recent meta-analysis evaluating all breast cancer subtypes, obesity (BMI ≥ 30 kg/m2), however not overweight (BMI 25-30 kg/m2), was reported to influence prognosis in TNBC patients43. Compared to this meta-analysis, the partly different results by Lohmann, et al., may be explained by their inclusion of observational studies with heterogeneous BMI comparator groups, heterogeneous endpoints and interventional cohorts. Nonetheless, the limited power in both meta-analyses, calls for further studies investigating the association.In a recent phase II trial of genomically directed therapy after neoadjuvant chemotherapy in TNBC patients by Ballinger et al., no association between overweight or obesity and clinical outcome was observed29, and the results thus represent very diverse health care systems and differences in socioeconomic status of patients. Socioeconomic status is generally associated with overweight and women with lower socioeconomic status tend to have lower screening attendance compared with women with high socioeconomic status44. This could impact the stage of disease at diagnosis, such that breast cancer in women with low socioeconomic status may therefore be detected in a more advanced stage. Differences in socioeconomic status may also contribute to differences in access to health care including treatment45, thereby affecting prognosis. Likewise, low socioeconomic status is associated with a less healthy diet46 which may have a negative impact on breast cancer prognosis47. Unfortunately, the reported data did not allow for adjustment for socioeconomic status or differences in stage of disease at diagnosis in the analyses.A number of additional issues need to be addressed in future research. The present meta-analysis included studies performed in developing countries34. Consequently, to be able to further clarify the influence of overweight on breast cancer prognosis among TNBC patients, there is a need for larger population-based observational studies using validated data. Moreover, BMI is an unrefined measure of body size that does not consider the ratio between adipose tissue and muscle tissue48. This could potentially lead to misclassification as individuals classified as normal-weight by BMI, may in fact have metabolic obesity49. Future studies are therefore recommended to use more precise measures of body fat when estimating body composition, e.g., dual-energy X-ray absorptiometry scans or waist-hip-ratio50.Additionally, seven out of 13 studies included in this meta-analysis are single-institution studiesThe results of this, to our knowledge first comprehensive meta-analysis focusing on the role of overweight in TNBC prognosis, highlights the potential negative influence of a modifiable lifestyle factor in a particularly vulnerable patient group already suffering from a worse prognosis due to the aggressiveness of the disease and the lack of targeted treatment possibilities. The possible limitations of the so far limited number of studies, including the possibility of publication bias, indicate a need for additional population-based studies using more precise measures of body fat and enabling the adjustment for differences in possible moderating factors such as disease stage at diagnosis, chemotherapy regimen, and socioeconomic status. The current evidence should also encourage research on the possible efficacy of weight management interventions on TNBC prognosis.reg.no.: CRD42020206102) and is reported in accordance with the Meta-analysis of Observational Studies in Epidemiology (MOOSE) guidelines51.The present review was pre-registered with PROSPERO (Population Intervention/exposure Comparison Outcome (PICO) approach52, keywords related to Population were combined with keywords related to Exposure and Outcome, e.g., Triple Negative Breast Cancer AND Prognosis AND Overweight OR Obesity  the population included patients diagnosed with TNBC, (2) BMI at diagnosis was included as exposure, (3) the outcome was disease-free survival (DFS [Defined as time from breast cancer diagnosis to first breast cancer event or death]) and/or overall survival (OS [Defined as time from breast cancer diagnosis to death of any cause]), and (4) the study design was longitudinal, investigating the association of overweight with clinical outcome in TNBC patients. We imposed no restrictions on publication year, geographical setting, or length of follow-up. We did not consider case-control studies, studies reporting other effect sizes than hazard ratios, and studies where data on BMI were retrieved >6 months after TNBC diagnosis. Only English language papers in peer-reviewed journals were considered, and “gray literature”, e.g., conference abstracts and dissertations, were not included. Two authors (S.H. and J.O.) independently screened titles and abstracts using the Covidence systematic review software (www.covidence.org). After excluding studies based on titles and abstracts, the remaining full text references were reviewed. Disagreements were discussed with a third author (S.B.) until a negotiated conclusion was reached. Data were extracted by one author (S.H.) and coded according to a priori specified characteristics, including study name, patient characteristics, treatment characteristics, exposure (BMI), outcome data (DFS and OS), and risk of bias, and validated by a second author (S.B.).Study eligibility was established using the PICO approach53 (NOS) was adapted to assess the risk of bias of the included studies. NOS evaluates the risk of systematic errors in a study design by assessing the following characteristics: (I) Representativeness of the exposed cohort, (II) Selection of the non-exposed cohort, (III) Ascertainment of exposure, (IV) Demonstration that the outcome of interest was not present at start of study, (V) Comparability of cohorts on the basis of the design or analysis, (VI) Assessment of outcome, (VII) Was follow-up long enough for outcomes to occur, and (VIII) Adequacy of follow-up cohorts53. Two authors (S.H. and J.O.) independently assessed and scored each study according to the pre-established criteria, and for every present characteristic, one point was dispensed. Disagreements were discussed with a third author (S.B.) until a final score was reached for each study. The risk of bias scores are summarized  BMI definition of overweight, i.e., when a patient has a BMI of 25 kg/m54.Observational cohort studies analyzing data either prospectively or retrospectively were reviewed and subjected to meta-analysis to ascertain the pooled overall effect estimate and its precision. To aid the interpretation of the results, we conducted, as a supplement to the conventional frequentist meta-analysis, a Bayesian Model-Averaged meta-analysisAn inverse variance-weighted random-effects model considering the precision of each study was used in all analyses, with hazard ratios larger than 1.0 taken to indicate an effect in the hypothesized direction, i.e., overweight associated with a shorter DFS or OS. A number of studies reported survival outcomes according to BMI subgroups, e.g., overweight BMI 25–30) vs normal-weight patients (BMI < 25) and obese (BMI ≥ 30) vs normal-weight patients (BMI < 25). In these cases, we combined the group of overweight (BMI 25–30) and obese patients (BMI ≥ 30) into one group, referred to as overweight patients. This was done to ensure that all patients with a BMI classified as overweight were included in the estimates retrieved from each study. When feasible, additional analyses were conducted for BMI-subgroups of overweight and obese separately (Table 0 vs normI2 statistics55. Heterogeneity tests aim at determining to which degree the variation in effect sizes reflects true differences (heterogeneity) or sampling error. The I2 value is an estimate of the between-study variance in a pooled effect estimate that is accounted for by heterogeneity of the effect sizes in the included studies and is assumed to be relatively unaffected by the number of studies56. If the results indicated heterogeneity (I2 > 0.0), we calculated the 95% prediction interval, which estimates the expected range of true effects in 95% of future studies57.Heterogeneity was investigated using Q and 58. If results were suggestive of possible publication bias, sensitivity analyses were conducted by imputing the “missing studies” and calculating adjusted effect estimates using the Duval and Tweedie trim-and-fill method59.The possibility of publication bias was assessed using funnel plots Figure  and 5 anI2 > 0.0), we examined, with meta-regression based on random-effects models and estimated with maximum likelihood method, the role on the effect size of two possible moderators, i.e., median follow-up time in months and the BMI used as cutoff for overweight in each study.To explore possible sources of heterogeneity (54 of the effects of overweight on TNBC prognosis examined the results of four models: (a) fixed-effect null hypothesis (fH0), (b) fixed-effect alternative hypothesis (fH1), (c) random-effects null hypothesis (rH0), and (d) random effects alternative hypothesis (rH1). Bayesian Model-Averaged analysis thus avoids selecting either a fixed- or random-effects model and addresses two questions in light of the observed data: What is the plausibility that the overall effect is non-zero and is there between-study variability in the effect size? We chose an uninformed prior probability, i.e., 25%, of each of the four models and 2,000 iterations. Concerning parameter distributions, we chose previously recommended defaults54. We thus used a zero-centered Cauchy prior with a scale of 0.707 for the effect size. To have zero indicating the null effect, the hazard ratios and the upper and lower limits were log-transformed. For the between-study variation, we used an empirically informed prior distribution of non-zero between-study deviation estimates based on effect sizes from 705 meta-analyses published in Psychological Bulletin between 1990 and 201360. This distribution has been approximated by an Inverse-Gamma  prior on the standard deviation (Tau)54.A supplementary Bayesian Model-Averaged meta-analysis61. The supplementary Bayesian analyses were conducted with JASP, Version 0.12.262.The frequentist analyses were performed using Comprehensive Meta-Analysis, version 3Supplementary Information