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Louise Pilote

Publications and source records attributed to Louise Pilote.

At least 19 recordsLinked to original sources
PubMed2005

Comparison of nested case-control and survival analysis methodologies for analysis of time-dependent exposure.

BACKGROUND: Epidemiological studies of exposures that vary with time require an additional level of methodological complexity to account for the time-dependence of exposure. This study compares a nested case-control approach for the study of time-dependent exposure with cohort analysis using Cox regression including time-dependent covariates. METHODS: A cohort of 1340 subjects with four fixed and seven time-dependent covariates was used for this study. Nested case-control analyses were repeated 100 times for each of 4, 8, 16, 32, and 64 controls per case, and point estimates were compared to those obtained using Cox regression on the full cohort. Computational efficiencies were evaluated by comparing central processing unit times required for analysis of the cohort at sizes 1, 2, 4, 8, 16, and 32 times its initial size. RESULTS: Nested case-control analyses yielded results that were similar to results of Cox regression on the full cohort. Cox regression was found to be 125 times slower than the nested case-control approach (using four controls per case). CONCLUSIONS: The nested case-control approach is a useful alternative for cohort analysis when studying time-dependent exposures. Its superior computational efficiency may be particularly useful when studying rare outcomes in databases, where the ability to analyze larger sample sizes can improve the power of the study.

Aged↗
PubMed2005

Cardiac medical therapy in patients after undergoing coronary artery bypass graft surgery: a review of randomized controlled trials.

The purpose of this paper is to review the randomized controlled trial (RCT) data investigating cardiac medical therapy for patients after coronary artery bypass grafting (CABG). We identified RCTs with > or =100 enrolled patients that examined the impact of cardiac medical therapy on outcomes > or =1 year after CABG. The MEDLINE database was searched for trials conducted between 1966 and 2004 on the following medications: aspirin, antilipid agents, beta-blockers, calcium channel blockers (CCBs), nitrates, and angiotensin-converting enzyme (ACE) inhibitors. Both aspirin and antilipid agents were found to reduce the progression of atherosclerosis and the occurrence of graft occlusion. Cardiovascular events were decreased with antilipid agents. In small trials, beta-blockers and CCBs failed to decrease the incidence of cardiovascular events. No RCTs examined nitrates, and one small RCT documented a reduction in cardiovascular events among patients treated with ACE inhibitors. We conclude that few RCTs have examined the efficacy of cardiac medical therapy in post-CABG patients. Based on current RCT evidence, aspirin and antilipid agents should be used routinely after CABG. However, current data do not support the use of beta-blockers, CCBs, and nitrates, and more evidence is needed regarding the use of ACE inhibitors.

Adrenergic beta-Antagonists↗
PubMed2005

Routine versus selective functional testing after percutaneous coronary intervention in patients with diabetes mellitus.

Patients with diabetes mellitus who undergo percutaneous coronary intervention (PCI) have higher rates of restenosis and a poorer prognosis than patients without diabetes. The American College of Cardiology/American Heart Association guidelines on exercise testing suggest that patients with diabetes may benefit from routine post-PCI functional testing (FT). To explore this issue, we examined the functional capacity, quality of life, event rates and procedural outcomes among 61 patients with diabetes enrolled in the Aggressive Diagnosis of Restenosis (ADORE) trial. All patients were randomized to either routine FT or selective FT and were followed for a period of 9 months. Patients with diabetes randomized to routine FT had a higher composite clinical event rate than those randomized to the selective FT strategy. Procedural rates did not differ significantly between the two groups. These results suggest that routine post-PCI FT in patients with diabetes is of little clinical value.

Adolescent↗
PubMed2004

Updated risk factor values and the ability of the multivariable risk score to predict coronary heart disease.

Most existing coronary risk assessment methods are based on baseline data only. The authors compared the predictive ability of coronary multivariable risk scores based on updated versus baseline risk factors and investigated the optimal frequency of updating. Data from 16 biennial examinations of 4,962 subjects from the original Framingham Heart Study (1948-1978) were used. The predictive ability of three multivariable risk scores was evaluated through 10-fold cross-validation. The baseline-only multivariable risk score was computed using baseline values of coronary risk factors applied to a Cox model estimated from baseline data. The two other approaches relied on updated risk factors and included them in the models estimated from, respectively, baseline and updated data. All analyses were stratified by sex and age. For 30, 14, and 10 years of follow-up, the predictive ability of the baseline-only multivariable risk score was substantially poorer than that of the models using updated risk factors. Between the two latter models, the one estimated from updated data ensured better prediction than the one estimated from baseline data for 30 years of follow-up among younger subjects only. The results suggest that coronary risk assessment can be improved by utilizing updated risk factors and that the optimal frequency of updating may vary across subpopulations.

Adult↗
PubMed2004

Mortality rates in elderly patients who take different angiotensin-converting enzyme inhibitors after acute myocardial infarction: a class effect?

BACKGROUND: Several randomized, controlled trials show that angiotensin-converting enzyme (ACE) inhibitors improve survival in patients who have had an acute myocardial infarction. However, existing data from trials do not address whether all ACE inhibitors benefit patients similarly. OBJECTIVE: To evaluate whether all ACE inhibitors are associated with similar mortality in patients 65 years of age or older who have had an acute myocardial infarction. DESIGN: Retrospective cohort study that used linked hospital discharge and prescription databases containing information on 18 453 patients 65 years of age or older who were admitted for an acute myocardial infarction between 1 April 1996 and 31 March 2000. SETTING: 109 hospitals in Quebec, Canada. PATIENTS: 7512 patients who filled a prescription for an ACE inhibitor within 30 days of discharge and who continued to receive the same drug for at least 1 year. MEASUREMENTS: The association between the specific drugs and clinical outcomes was measured by using Cox proportional hazards models, with adjustment for demographic, clinical, physician, and hospital variables and dosage categories, represented by time-dependent variables. RESULTS: Enalapril, fosinopril, captopril, quinapril, and lisinopril were associated with higher mortality than was ramipril; the adjusted hazard ratios and 95% CIs were 1.47 (95% CI, 1.14 to 1.89), 1.71 (CI, 1.29 to 2.25), 1.56 (CI, 1.13 to 2.15), 1.58 (CI, 1.10 to 2.82), and 1.28 (CI, 0.98 to 1.67), respectively. The adjusted hazard ratio associated with perindopril was 0.98 (CI, 0.60 to 1.60). LIMITATIONS: The administrative databases did not contain detailed clinical information, and unmeasured factors associated with a patient's risk for death may have influenced physicians' prescription choices. CONCLUSION: Survival benefits in the first year after acute myocardial infarction in patients 65 years of age or older seem to differ according to the specific ACE inhibitor prescribed. Ramipril was associated with lower mortality than most other ACE inhibitors.

Aged↗
PubMed2004

Impact of age on hospital course and cost of coronary artery bypass grafting.

In-hospital outcomes and cost were examined among 2,272 elderly patients (> or =75 years) and 9,745 younger patients (<75 years) who underwent coronary artery bypass graft surgery at 5 United States and 4 Canadian hospitals. Hospital course and cost data were obtained from a resource and cost accounting system used by each of the 9 hospitals. Compared with younger patients, elderly patients had longer hospital stays, increased in-hospital mortality, and increased costs. After controlling for clinical differences, age > or =75 years was associated with an increase in cost of 11%. Given the aging North American population, these results have important implications for health care planning for the next several decades.

Age Factors↗
PubMed2004

Evaluation of routine functional testing after percutaneous coronary intervention.

Following percutaneous coronary intervention, 348 patients were randomized to either routine or selective functional testing strategies. For the primary end point of maximal exercise endurance on a treadmill at 9 months, achievement was similar in the routine and selective groups. For the secondary end points measuring functional status and quality of life, scores were also similar. There was little difference in the rates of invasive cardiac procedures for the 2 groups at 9 months.

Angioplasty, Balloon, Coronary↗
PubMed2004

Effect of amiodarone dose on the risk of permanent pacemaker insertion.

Bradyarrhythmia requiring permanent pacemaker insertion has been associated with amiodarone use but the effect of amiodarone dose has not been investigated. In order to determine the effect of amiodarone dose on the risk of requiring permanent pacemaker insertion, a cohort of 15,824 subjects with atrial fibrillation (AF) and prior myocardial infarction was established. This study included 1,340 subjects who received a first prescription of amiodarone at > 65 years of age. Cox regression with daily dose and cumulative dose (weighted for recency of exposure) represented by time dependent covariates was performed, adjusting for baseline risk factors and time dependent exposure to other cardiac medications. The incidence of pacemaker insertion was 2.2% per person-year during a mean of 1.8 +/- 1.5 years of follow-up, and 5.2% per person-year during the first 90 days of amiodarone exposure. Amiodarone daily doses > 200 mg were associated with an increased risk during the entire follow-up HR 2.0; 95% CI 1.0 to 4.1) as well as during the first 90 days (HR 3.1; 95% CI 1.1 to 9.0). Cumulative doses greater than the equivalent of continuous therapy with 200 mg per day were also associated with an increased risk (HR 2.8; 95% CI 1.4 to 5.5). Baseline conduction disorder or sinus node dysfunction was the only other significant predictor of pacemaker insertion. This study suggests that there is a dose dependent increased risk of permanent pacemaker insertion associated with amiodarone use that appears to be greatest during the initial months of treatment.

Age Factors↗
PubMed2004

In-hospital cost of total hip arthroplasty in Canada and the United States.

BACKGROUND: There is little information comparing the costs of specific surgical procedures performed in Canada and those done in the United States. The objective of this study was to compare the in-hospital costs associated with primary total hip arthroplasty performed in the two countries. METHODS: In-hospital costs of 1679 consecutive patients (940 Canadian and 739 American patients) who underwent total hip arthroplasty were extracted from three Canadian and three United States teaching hospitals between 1997 and 2001. Participating hospitals used the same cost accounting system to provide per-patient demographic, clinical, and cost data. Canadian dollar costs were converted to United States dollar costs with use of purchasing power parities. RESULTS: The baseline clinical characteristics of patients undergoing total hip arthroplasty in Canada and the United States were similar. The American patients were a mean of 4.6 years older than the Canadian patients (mean [and standard deviation], 67.8 +/- 12.4 years compared with 63.2 +/- 14.9 years). The median cost for the primary arthroplasty was $6080 (mean [and standard error of the mean], $6766 +/-$119) at the three Canadian hospitals and $12,846 (mean, $13,339 +/-$131) at the United States hospitals (p < 0.0001). The mean length of stay (and standard deviation) was 7.2 +/- 4.7 days for the Canadian patients and 4.2 +/- 2.0 days for the American patients. Implants at one hospital in the United States were found to be four times more costly than those in a Canadian hospital. CONCLUSIONS: Higher in-hospital costs were found for the American hospitals despite the fact that they had a significantly shorter patient length of stay compared with Canadian centers (p < 0.0001). Canadian hospitals should follow the lead of their counterparts in the United States and implement strategies to decrease the length of stay in the hospital, while institutions in the United States should revisit their ability to better manage the costs related to a primary total hip arthroplasty, particularly by controlling unit costs.

Aged↗
PubMed2004

Secondary prevention after acute myocardial infarction in four Canadian provinces, 1997-2000.

BACKGROUND: Publication of population-based analyses of medication use after acute myocardial infarction (AMI) could encourage the use of effective secondary prevention medications. OBJECTIVE: To describe outpatient use of beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, statins, calcium channel blockers and nitrates in elderly survivors of AMI over the fiscal years from 1997/98 to 1999/2000 in Nova Scotia, Quebec, Ontario and British Columbia. METHODS: Linked administrative databases were used to identify all AMI patients 65 years of age or older admitted in Quebec (n=14,880), Ontario (n=28,647) and British Columbia (n=7549) over the study period, and to measure 90-day postdischarge utilization rates of cardiac medications for these patients. A population-based clinical registry was used to measure rates of prescription at discharge for elderly patients in Nova Scotia admitted to an acute care hospital from 1997 to 2000 (n=1997). RESULTS: Utilization rates for beta-blockers, ACE inhibitors and statins increased over time, while rates for calcium channel blockers and nitrates decreased only slightly. The largest increases were for statins (Nova Scotia: 26% to 42%, Quebec: 27% to 43%; Ontario: 28% to 40%; British Columbia: 30% to 42%) and for ACE inhibitors in Ontario (55% to 65%) and Nova Scotia (46% to 68%). Of the three drugs recommended for secondary prevention, overall utilization rates for beta-blockers were highest in Nova Scotia, lowest in British Columbia, and similar in Quebec and Ontario. Rates for ACE inhibitors were highest in Ontario and similar in Quebec, Nova Scotia and British Columbia. Rates for statins were slightly higher in Quebec and British Columbia than in Ontario and Nova Scotia. The proportion of patients without a prescription for any of the recommended drugs was highest in British Columbia (20%), lowest in Nova Scotia (8%), and similar in Quebec and Ontario (Ontario: 12%; Quebec: 13%). There was marked regional variation in utilization rates within the four provinces. CONCLUSIONS: Although utilization rates for recommended cardiac medications are increasing over time, there remains room for improvement. Overall utilization rates and temporal trends are generally similar in all four provinces, but there are wide regional variations within provinces.

Adrenergic beta-Antagonists↗
PubMed2004

Cardiac procedures after an acute myocardial infarction across nine Canadian provinces.

BACKGROUND: Geographical variations in the use of invasive cardiac procedures have been documented. It remains unclear to what extent these variations exist across the Canadian provinces. OBJECTIVE: To describe variation in the use of invasive cardiac procedures and waiting times for these procedures across nine Canadian provinces. METHODS: Using longitudinal, de-identified patient data from the Canadian Institute for Health Information, records of patients who had suffered an acute myocardial infarction (AMI) in each of nine Canadian provinces between 1997/1998 and 1999/2000 were selected. Rates and median waiting times for percutaneous coronary intervention and coronary artery bypass graft surgery were calculated by age, sex and health region. RESULTS: There was a large variation in the use of and waiting times for invasive cardiac procedures across the Canadian provinces studied. In general, cardiac procedure rates in Western provinces were higher than in Eastern provinces, most notably higher than in the Maritime provinces and Ontario. In addition to interprovincial variation, there was also significant regional variation in the rates of revascularization and waiting times. Rates of percutaneous coronary intervention increased over the study period, whereas rates of bypass surgery remained relatively stable. CONCLUSIONS: Significant variation in the use of cardiac procedures after AMI exists across Canada and this April represent potential inequalities in the treatment of AMI across Canada.

Adult↗
PubMed2004

Utility of routine functional testing after percutaneous transluminal coronary angioplasty: results from the ROSETTA registry.

BACKGROUND: There is little consensus regarding the use of functional testing after percutaneous transluminal coronary angioplasty (PTCA). Some physicians employ a routine functional testing strategy, and others employ a symptom-driven strategy. OBJECTIVE: To examine the effects of routine post-PTCA functional testing on the use of follow-up cardiac procedures and clinical events. METHODS: The Routine versus Selective Exercise Treadmill Testing after Angioplasty (ROSETTA) Registry is a prospective multicenter observational study examining the use of functional testing after PTCA. A total of 788 patients (pts) were enrolled in the ROSETTA Registry at 13 clinical centers in 5 countries. The frequencies of functional testing, cardiac procedures and clinical events were examined during the first 6 months following a successful PTCA. RESULTS: Patients were predominantly elderly men (mean age, 61+/-11 years; 76% male) who underwent single-vessel PTCA (85%) with stent implantation (58%). During the 6-month follow-up, a total of 237 pts were observed to undergo a routine functional testing strategy (100% having functional testing for routine follow-up), while 551 pts underwent a selective (or clinically-driven) strategy (73% having no functional testing and 27% having functional testing for a clinical indication). Patients in the routine testing group underwent a total of 344 functional tests compared with 165 tests performed in the selective testing group (mean, 1.45 tests/patient versus 0.3 tests/patient; p<0.0001). There was little difference in the rates of follow-up cardiac procedures among the pts undergoing the routine and selective testing strategies [cardiac catheterization, 13.9% versus 17.5% (p=NS); percutaneous coronary intervention (PCI), 8.4% versus 8.7% (p=NS); coronary artery bypass graft surgery, 2.1% versus 3.3% (p=NS)]. However, clinical events were less common among pts who underwent routine functional testing, e.g., unstable angina (6.1% versus 14.4%; p=0.001), myocardial infarction (0.4% versus 1.6%; p=NS), death (0% versus 2.2%; p=0.02) and composite clinical events (6.3% versus 16.3%; p<0.0001). After controlling for baseline clinical and procedural differences, routine functional testing had a persistent independent association with a reduction in the composite clinical event rate (odds ratio, 0.45; 95% confidence interval, 0.24-0.81; p=0.008). CONCLUSION: Routine functional testing after PTCA is associated with a reduction in the frequency of follow-up clinical events. This association may be attributable to the early identification and treatment of pts at risk for follow-up events, or it may be due to clinical differences between pts who are referred for routine and selective functional testing.

Angioplasty, Balloon, Coronary↗
PubMed2003

In-hospital cost of abdominal aortic aneurysm repair in Canada and the United States.

BACKGROUND: Global health care costs in Canada and the United States have been examined on a macroeconomic level. However, to our knowledge, comparative costs of specific procedures in the 2 countries have not been closely studied. METHODS: To perform a microeconomic comparison of costs of open abdominal aortic aneurysm (AAA) repair, we examined the costs of treating 1057 consecutive patients from 4 Canadian (n = 552) and 6 US (n = 505) hospitals. Participating hospitals used the same cost accounting system that provided demographic, clinical, and cost data (excluding physician's fees) for each patient. Canadian dollar costs were converted to US dollar costs using purchasing power parities. RESULTS: Compared with patients who underwent AAA repair in the United States, Canadian patients were significantly younger (mean +/- SD, 70.2 +/- 10.5 vs 73.3 +/- 8.5 years; P<.001) and were less likely to undergo elective repair (48.5% vs 73.3%; P<.001). The median length of hospital stay was longer in Canada (9.0 vs 7.0 days; P<.001), and mortality rates were similar (12.0% [Canada] vs 9.9% [United States]; P =.29). The mean +/- SEM cost of AAA repair was dollars 15 852 +/- dollars 790 in Canada compared with US dollars 23299 +/- US dollars 1410 in the United States. CONCLUSIONS: The cost of AAA repair is substantially higher in the United States compared with Canada, despite shorter lengths of stay and similar clinical outcomes. The difference in total treatment costs between Canadian and American hospitals was partially attributable to differences in direct costs, but was largely due to differences in overhead costs.

Aged↗
PubMed2003

Effects of early and late administration of angiotensin-converting enzyme inhibitors on mortality after myocardial infarction.

BACKGROUND: Clinical trials demonstrating that angiotensin-converting enzyme (ACE) inhibitors reduce mortality when prescribed following myocardial infarction have focused on either early or late administration. It is unclear what the overall mortality benefits are and how long they last. METHODS: We identified trials of ACE inhibitor therapy after myocardial infarction that were published between 1987 and 2002. Studies were included if they were randomized placebo-controlled trials with follow-up of at least 1 month. Separate analyses were performed for trials of therapy initiated within 48 hours of infarction (early administration) or initiated more than 48 hours after infarction (late administration). The Yusuf-Peto modification of the Mantel-Haenszel method was used to obtain summary odds ratios for mortality. RESULTS: Twenty-two trials (14 early administration, 8 late administration) met the inclusion criteria. Early administration of ACE inhibitors was associated with a slight reduction in 1-month mortality (odds ratio [OR] = 0.93; 95% confidence interval [CI]: 0.88 to 0.97) and a much larger reduction in 1-year mortality (OR = 0.68; 95% CI: 0.54 to 0.87). Late therapy was associated with significant reductions in 1-year mortality (OR = 0.84; 95% CI: 0.73 to 0.97), 2-year mortality (OR = 0.75; 95% CI: 0.67 to 0.85), and 3-year mortality (OR = 0.74; 95% CI: 0.65 to 0.84). CONCLUSION: Both early and late administration of ACE inhibitor therapy are associated with lower mortality following myocardial infarction, with the largest benefits observed with long-term mortality.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed2003

An NS3 serine protease inhibitor abrogates replication of subgenomic hepatitis C virus RNA.

The hepatitis C virus (HCV) NS3 protease is essential for polyprotein maturation and viral propagation, and it has been proposed as a suitable target for antiviral drug discovery. An N-terminal hexapeptide cleavage product of a dodecapeptide substrate identified as a weak competitive inhibitor of the NS3 protease activity was optimized to a potent and highly specific inhibitor of the enzyme. The effect of this potent NS3 protease inhibitor was evaluated on replication of subgenomic HCV RNA and compared with interferon-alpha (IFN-alpha), which is currently used in the treatment of HCV-infected patients. Treatment of replicon-containing cells with the NS3 protease inhibitor or IFN-alpha showed a dose-dependent decrease in subgenomic HCV RNA that reached undetectable levels following a 14-day treatment. Kinetic studies in the presence of either NS3 protease inhibitor or IFN-alpha also revealed similar profiles in HCV RNA decay with half-lives of 11 and 14 h, respectively. The finding that an antiviral specifically targeting the NS3 protease activity inhibits HCV RNA replication further validates the NS3 enzyme as a prime target for drug discovery and supports the development of NS3 protease inhibitors as a novel therapeutic approach for HCV infection.

Antiviral Agents↗
PubMed2003

Introduction to the Canadian Cardiovascular Outcomes Research Team's (CCORT) Canadian Cardiovascular Atlas project.

The Canadian Cardiovascular Outcomes Research Team's (CCORT) Canadian Cardiovascular Atlas project was developed to provide Canadians with a national report on the state of cardiovascular health and health services in Canada. Written by a group of Canada's leading experts in cardiovascular outcomes research, the CCORT cardiac Atlas will cover a wide variety of topics ranging from cardiac risk factors and cardiac mortality rates to the treatment of patients with acute myocardial infarction and congestive heart failure and the outcomes of invasive cardiac procedures across Canada. Data in the Atlas will be presented at a national, provincial and health region level. The Atlas will be published as a series of 20 articles and chapters in future issues of The Canadian Journal of Cardiology and on CCORT's web site (www.ccort.ca). The journal version of the Atlas chapters will be written for a clinical audience and will include editorials written by invited experts, whereas the web-based version of each chapter will be written for a more general audience and will include additional supplemental information (for example, interactive colour maps and tables) that cannot be included in the journal version. Material from the Journal and the web will eventually be compiled into a book that will be distributed across Canada. This article serves as an introduction to the Atlas project and describes the rationale for and objectives of the CCORT national cardiac Atlas project.

Atlases as Topic↗
PubMed2003

Depression and prognosis following hospital admission because of acute myocardial infarction.

BACKGROUND: Whether there is an association between depression at the time of acute myocardial infarction and subsequent risk of cardiac complications and death remains controversial. Most studies of this risk factor have been limited to patients of single institutions, and this might account for the varying results. We prospectively evaluated patients admitted to 5 tertiary care and 5 community hospitals and followed them for 1 year to measure the prevalence and prognostic impact of depressive symptoms after acute myocardial infarction. METHODS: Patients were recruited for the study by trained nurse interviewers who had documented acute myocardial infarction within 2-3 days of admission. The nurses collected information from the medical records and asked study subjects to complete the Beck Depression Inventory questionnaire during their stay in hospital and using a mailed questionnaire 30 days, 6 months and 1 year later. We obtained information on vital status for patients lost to follow-up from a central death registry. RESULTS: Of the 587 study subjects, 550 (94%) completed the Beck Depression Inventory at baseline and 191 (35%) had a score of 10 or more, indicating at least mild depression. Rates of depression did not vary over the follow-up period and were similar among patients admitted to tertiary care or community hospitals. Depressed patients were more likely to undergo catheterization (57% v. 47%, 95% confidence interval [CI] around the difference 0.1%-19.6%) and were more likely to undergo percutaneous coronary intervention (32% v. 24%, 95% CI around the difference 0.1%-16.2%) within 30 days of first admission to hospital. Patients with depression on admission had higher rates of a composite of cardiac complications, including recurrent ischemia, infarction or congestive heart failure during their first stay in hospital or readmission for angina, recurrent acute myocardial infarction, congestive heart failure or arrhythmia (adjusted hazard ratio 1.4, 95% CI 1.05-1.86), compared with patients who were not depressed on admission. After 1 year, death rates were higher among patients who were depressed at admission (30 patients, 16%) compared with nondepressed patients (28 patients, 8%), although the difference was not statistically significant (hazard ratio 1.3, 95% CI 0.59-3.05). INTERPRETATION: Depressive symptoms are common after acute myocardial infarction and are associated with a slight increase in risk of in-hospital catheterization and angiography and readmission because of cardiac complications. Death was infrequent, with no statistically significant difference between the 2 groups.

Angioplasty, Balloon, Coronary↗