Association between Serum Estradiol and Cardiovascular Health among Transgender Adults Using Gender-Affirming Estrogen Therapy.

INTRODUCTION: Gender-affirming estrogen therapy (GAET) is commonly used for feminization in transgender and non-binary (TNB) individuals, yet the optimal rate of change (ROC) in estradiol levels for cardiovascular health is unclear. We examined the association between serum estradiol levels and cardiovascular-related mortality, adverse events, and risk factors in TNB adults using GAET. METHODS: Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE and Web of Science were systematically searched (inception-April 2023) for original articles reporting serum estradiol levels and cardiovascular-related mortality, adverse events, and risk factors in TNB adults using GAET. Data extraction was completed in duplicate following PRISMA guidelines. Stratified random effects meta-analyses using serum estradiol ROC (serum estradiolbaseline-serum estradiolfollow-up/study duration) was used to assess longitudinal studies (Low:0

Interventions on gender equity in the workplace: a scoping review.

BACKGROUND: Various studies have demonstrated gender disparities in workplace settings and the need for further intervention. This study identifies and examines evidence from randomized controlled trials (RCTs) on interventions examining gender equity in workplace or volunteer settings. An additional aim was to determine whether interventions considered intersection of gender and other variables, including PROGRESS-Plus equity variables (e.g., race/ethnicity). METHODS: Scoping review conducted using the JBI guide. Literature was searched in MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, ERIC, Index to Legal Periodicals and Books, PAIS Index, Policy Index File, and the Canadian Business & Current Affairs Database from inception to May 9, 2022, with an updated search on October 17, 2022. Results were reported using Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension to scoping reviews (PRISMA-ScR), Sex and Gender Equity in Research (SAGER) guidance, Strengthening the Integration of Intersectionality Theory in Health Inequality Analysis (SIITHIA) checklist, and Guidance for Reporting Involvement of Patients and the Public (GRIPP) version 2 checklist. All employment or volunteer sectors settings were included. Included interventions were designed to promote workplace gender equity that targeted: (a) individuals, (b) organizations, or (c) systems. Any comparator was eligible. Outcomes measures included any gender equity related outcome, whether it was measuring intervention effectiveness (as defined by included studies) or implementation. Data analyses were descriptive in nature. As recommended in the JBI guide to scoping reviews, only high-level content analysis was conducted to categorize the interventions, which were reported using a previously published framework. RESULTS: We screened 8855 citations, 803 grey literature sources, and 663 full-text articles, resulting in 24 unique RCTs and one companion report that met inclusion criteria. Most studies (91.7%) failed to report how they established sex or gender. Twenty-three of 24 (95.8%) studies reported at least one PROGRESS-Plus variable: typically sex or gender or occupation. Two RCTs (8.3%) identified a non-binary gender identity. None of the RCTs reported on relationships between gender and other characteristics (e.g., disability, age, etc.). We identified 24 gender equity promoting interventions in the workplace that were evaluated and categorized into one or more of the following themes: (i) quantifying gender impacts; (ii) behavioural or systemic changes; (iii) career flexibility; (iv) increased visibility, recognition, and representation; (v) creating opportunities for development, mentorship, and sponsorship; and (vi) financial support. Of these interventions, 20/24 (83.3%) had positive conclusion statements for their primary outcomes (e.g., improved academic productivity, increased self-esteem) across heterogeneous outcomes. CONCLUSIONS: There is a paucity of literature on interventions to promote workplace gender equity. While some interventions elicited positive conclusions across a variety of outcomes, standardized outcome measures considering specific contexts and cultures are required. Few PROGRESS-Plus items were reported. Non-binary gender identities and issues related to intersectionality were not adequately considered. Future research should provide consistent and contemporary definitions of gender and sex. TRIAL REGISTRATION: Open Science Framework https://osf.io/x8yae .

Women's Heart Health and the Menopausal Transition: Two Faces of the Same Coin.

The impact of the presence or absence of sex hormones on women's health is woefully underresearched. Fundamentally, women's bodies are now understood to spend considerable time under widely fluctuating hormonal influences, including puberty, pregnancy, peripartum, and menopause, and a woman's vessels are therefore preset for functional and physiological alterations based on levels of sex hormones. However, our understanding of the influences of sex hormones on the regulation of a multitude of biological and physiological processes has not translated into the development and/or collection or analyses of data on therapeutic treatments and/or outcomes in the context of women's disease management.

Les effets sur la santé des femmes associés à la présence ou à l'absence d'hormones sexuelles ont fait l'objet de trop peu d'études. On sait essentiellement que les taux d'hormones fluctuent considérablement tout au long des étapes de la vie des femmes, qu'il s'agisse de la puberté, de la grossesse, de la période périnatale et de la ménopause, et que leurs vaisseaux sont en fait préréglés pour permettre diverses modifications fonctionnelles et physiologiques en fonction du taux d'hormones sexuelles. Cependant, notre compréhension de l'influence des hormones sexuelles sur la régulation d'une multitude de processus biologiques et physiologiques ne s'est pas traduite par la collecte et/ou l'analyse de données sur les traitements ou les résultats thérapeutiques dans le contexte de la prise en charge de diverses maladies chez les femmes.

Measurements of Postmenopausal Serum Estradiol Levels and Cardiovascular Events: A Systematic Review.

Background: Cardiovascular disease (CVD) is the leading cause of death among female patients and its likelihood increases following menopause. However, whether estradiol levels are related to CVD remains unknown. We aimed to determine the association between serum estradiol levels and cardiovascular (CV) events in postmenopausal females. Methods: Electronic databases (MEDLINE, Embase) were searched systematically from inception to October 2022. Studies were eligible for inclusion if they included the following: (i) postmenopausal females; (ii) examination of the association between total serum estradiol levels and CV events (CV mortality, CVD, coronary heart disease, myocardial infarction, stroke, venous thromboembolism, heart failure, and CV hospitalization); (iii) original data (randomized controlled trial, quasi-experimental, cohort, case-control, or cross-sectional study). A narrative synthesis was completed because the data were not amenable to meta-analysis. Results: Of the 9026 citations retrieved, 8 articles were included, representing a total of 5635 women. The risk-of-bias was fair, and considerable heterogeneity was present. In those not using menopausal hormone therapy, 3 studies demonstrated mixed results between estradiol levels and risk of coronary heart disease, and 1 study showed that higher estradiol levels were associated with an increased risk of myocardial infarction. No significant associations were present between estradiol levels and the remaining events (ie, CV mortality, heart failure, CVD, and stroke). Conclusions: The association between serum estradiol levels and CV events in postmenopausal females remains unclear. Further studies assessing this association are warranted, given the elevated CVD risk in this population.

Contexte: Les maladies cardiovasculaires (MCV) sont la principale cause de décès chez les femmes et leur probabilité augmente après la ménopause. Cependant, on ne sait pas encore si le taux d'estradiol est lié aux MCV. Nous avons tenté d'établir le lien entre le taux d'estradiol sérique et les événements cardiovasculaires (CV) chez les femmes post-ménopausées. Méthodologie: Nous avons consulté systématiquement des bases de données électroniques (MEDLINE, Embase) de leur création jusqu'en octobre 2022. Les études admissibles devaient comprendre les éléments suivants : i) femmes post-ménopausées; ii) examen du lien entre le taux total d'estradiol sérique et les événements CV (décès d'origine CV, MCV, coronaropathie, infarctus du myocarde, accident vasculaire cérébral (AVC), thromboembolie veineuse, insuffisance cardiaque et hospitalisation pour une cause CV); iii) données originales (essai contrôlé randomisé; études quasi expérimentales, de cohorte, cas-témoins ou transversales). Une synthèse narrative a été réalisée parce que les données ne se prêtaient pas à une méta-analyse. Résultats: Parmi les 9 026 citations relevées, 8 articles ont été retenus, représentant un total de 5 635 femmes. Le risque de biais était raisonnable, et une très grande hétérogénéité était présente. Chez les femmes qui ne suivaient pas d'hormonothérapie ménopausique, trois études ont affiché des résultats variables quant au lien entre le taux d'estradiol et le risque de coronaropathie, et une étude a montré que des taux élevés d'estradiol étaient associés à un risque accru d'infarctus du myocarde. Aucun lien notable n'a été observé entre le taux d'estradiol et les autres événements (c.-à-d. décès d'origine CV, insuffisance cardiaque, MCV et AVC). Conclusions: Le lien entre le taux d'estradiol sérique et les événements CV chez les femmes post-ménopausées n'a pas été élucidé. D'autres études sont nécessaires pour évaluer ce lien en raison du risque élevé de MCV au sein de cette population.

The Association Between Testosterone and Vascular Function in Reproductive-Aged Females With Chronic Kidney Disease.

Cardiovascular disease is the leading cause of death in women, and women with chronic kidney disease (CKD) experience especially elevated risk. This study examined the association between testosterone and vascular function in 61 reproductive-aged females with CKD. Testosterone levels and measures of vascular function were assessed, including pulse wave velocity, aortic augmentation, flow-mediated dilation (FMD), and velocity time integral. Multivariable linear regression analyses assessed the relationship between testosterone and each measure of vascular function. No associations were observed between testosterone and vascular function outcomes, although a significant positive association between testosterone-to-estradiol ratio and FMD was demonstrated. Although testosterone levels were not independently predictive of vascular function, the level of testosterone relative to estradiol was associated with FMD and may therefore influence endothelial function in the high-risk population of reproductive-aged female patients with CKD.

Alors que les maladies cardiovasculaires sont la cause principale de décès chez les femmes, les femmes atteintes d'une maladie rénale chronique (MRC) sont exposées à un risque particulièrement élevé. La présente étude vise à examiner l'association entre la testostérone et la fonction vasculaire de 61 femmes en âge de procréer atteintes d'une MCV. Nous avons évalué les concentrations de testostérone et les mesures de la fonction vasculaire, soit la vélocité de l'onde de pouls, l'augmentation de l'aorte, la dilatation médiée par le flux (DMF) et l'intégrale temps-vitesse. Les analyses multivariées de régression linéaire ont permis d'évaluer la relation entre la testostérone et chacune des mesures de la fonction vasculaire. Aucune association n'a été observée entre la testostérone et les résultats de la fonction vasculaire, bien qu'une association positive significative entre le ratio testostérone/œstradiol et la DMF ait été démontrée. Bien que les concentrations de testostérone n'étaient pas indépendamment prédictives de la fonction vasculaire, les concentrations de la testostérone relativement à l'œstradiol ont été associées à la DMF et peuvent par conséquent influencer la fonction endothéliale au sein de la population exposée à un risque élevé composée de patientes en âge de procréer atteintes d'une MRC.

Awareness of Hypertension in Reproductive-Aged Women Living With Chronic Kidney Disease.

Background: Hypertension is the most important modifiable cardiovascular risk factor among women. Chronic kidney disease (CKD), which affects 1 in 10 reproductive-aged women, increases the risk of hypertension; however, awareness of hypertension in this population is unknown. This study aimed to determine hypertension awareness among reproductive-aged women living with chronic kidney disease. Methods: Women aged 18 to 50 years with CKD were recruited from nephrology clinics in Calgary, Alberta, Canada. Participants completed a semistructured interview and focused chart review, serum and urine laboratory assessment, and a physical examination that included anthropomorphic measurements and 2 automated office blood pressure readings. Hypertension was defined according to the use of ≥ 1 antihypertensive medications and/or an automated office blood pressure reading of ≥ 135/85 mm Hg. Data were stratified by hypertension status, as well as by awareness, and descriptively presented as mean ± standard deviation, numerical values, and percentages. Results: Sixty-three participants with CKD were included. Thirty-eight (60%) participants had hypertension according to study definitions. Of those with hypertension, 30 participants (79%) were aware of their hypertension status. Conclusions: Hypertension awareness is relatively high in reproductive-aged women living with CKD. However, hypertension awareness is the critical component for hypertension management, and further work is necessary to optimize reduction of cardiovascular risk in this important population.

Contexte: L'hypertension est le principal facteur de risque cardiovasculaire modifiable chez les femmes. La néphropathie chronique, qui touche une femme en âge de procréer sur 10, augmente le risque d'hypertension, mais le niveau de sensibilisation de cette population à ce sujet est inconnu. La présente étude visait à déterminer le niveau de sensibilisation à l'hypertension chez les femmes en âge de procréer atteintes de néphropathie chronique. Méthodologie: Des femmes âgées de 18 à 50 ans atteintes de néphropathie chronique ont été recrutées dans les cliniques de néphrologie de Calgary, en Alberta (Canada). Les participantes ont été soumises à des entrevues semi-structurées, un examen ciblé du dossier médical, des analyses de laboratoire du sérum et de l'urine et un examen physique incluant des mesures anthropométriques et deux lectures automatisées de la pression artérielle réalisées en cabinet. L'hypertension a été définie de la façon suivante : (1) l'utilisation de ≥ 1 agent antihypertenseur, et/ou (2) une lecture automatisée de la pression artérielle en cabinet ≥ 135/85 mmHg. Les données ont été stratifiées selon le statut d'hypertension et le niveau de sensibilisation, et elles sont présentées de façon descriptive par la moyenne ± l'écart-type, les valeurs numériques et les pourcentages. Résultats: Soixante-trois participantes atteintes de néphropathie chronique ont été incluses dans l'étude. Trente-huit (60 %) participantes étaient atteintes d'hypertension selon la définition utilisée dans l'étude. Parmi les participantes hypertendues, 30 (79 %) étaient conscientes de leur statut d'hypertension. Conclusions: Le niveau de sensibilisation à l'hypertension est relativement élevé parmi les femmes en âge de procréer atteintes de néphropathie chronique. Toutefois, la sensibilisation à l'hypertension est un élément clé pour sa prise en charge, et d'autres travaux sont nécessaires pour optimiser la réduction du risque cardiovasculaire dans cette population importante.

Myocardial Infarction Within 30 Days of Discharge From an Emergency Department: A Descriptive Study of Albertan Women.

Background: Cardiovascular diseases (CVDs) are the leading cause of premature death for Canadian women, which may be due partly to a lack of awareness of the presentation of acute coronary events in emergency departments (EDs). To address an identified gap in women's cardiovascular care, we sought to describe the clinical and comorbid factors of women who, following discharge from an ED, suffered a myocardial infarction (MI). Methods: Descriptive analyses were completed on a cohort of women who presented to an ED in Alberta, Canada, between January 1, 2010 and December 31, 2020, were discharged, and within 30 days of their index ED visit, were admitted to the hospital with an MI. The cohort was explored for clinical and comorbid data, ED visits pre-MI, type of MI, and presenting complaint/ primary diagnosis for the index ED visit. Results: 1380 women were included in this analysis with a mean age of 67 (standard deviation ±13) years. The frequencies of hypertension, diabetes, and dyslipidemia among the youngest women, aged 18-45 years, were 47.5%, 31.3%, and 48.8%, respectively. Women across all ages demonstrated a high prevalence of traditional CVD risk factors, and 22% of women presented to an ED 2 or more times within the 30 days pre-MI. Conclusions: Regardless of their age, the women in this cohort had notable CVD risk factors. Future research is required to better understand the phenomenon of women presenting multiple times to an ED pre-MI. Research is needed on life-stage-specific factors of women presenting to EDs pre-MI, to help reduce MI incidence.

Contexte: Les maladies cardiovasculaires représentent la principale cause de décès prématuré chez les Canadiennes, ce qui peut être en partie attribuable à un manque de connaissance des manifestations des événements coronariens aigus dans les services d'urgence. Pour combler une lacune observée dans les soins cardiovasculaires chez les femmes, nous avons tenté de décrire les facteurs cliniques et les facteurs de comorbidité chez les femmes qui, après avoir reçu leur congé du service d'urgence, ont subi un infarctus du myocarde (IM). Méthodologie: Des analyses descriptives ont été menées sur une cohorte de femmes qui se sont présentées dans un service d'urgence en Alberta, au Canada, entre le 1er janvier 2010 et le 31 décembre 2020, qui ont reçu leur congé et qui, dans les 30 jours suivant leur visite de référence aux urgences, ont été admises à l'hôpital pour un IM. L'analyse de la cohorte portait sur les données cliniques et les données de comorbidité, les consultations au service d'urgence avant l'IM, le type d'IM et la raison/le diagnostic primaire lors de la consultation de référence. Résultats: Cette analyse a porté sur 1380 femmes dont l'âge moyen était de 67 (écart-type ± 13) ans. Les fréquences d'hypertension, de diabète et de dyslipidémie chez les femmes les plus jeunes, âgées de 18 à 45 ans, étaient respectivement de 47,5 %, de 31,3 % et de 48,8 %. Les femmes de tous les âges présentaient une prévalence élevée de facteurs de risque classiques de maladies cardiovasculaires, et 22 % des femmes s'étaient présentées à un service d'urgence au moins 2 fois au cours des 30 jours ayant précédé l'IM. Conclusions: Indépendamment de l'âge, les femmes de cette cohorte présentaient des facteurs de risque de maladies cardiovasculaires notables. D'autres recherches s'imposent afin de mieux comprendre le phénomène des femmes qui se présentent plusieurs fois dans un service d'urgence dans la période précédant un IM. Une recherche doit être menée sur les facteurs spécifiques aux stades de la vie des femmes qui se présentent aux urgences avant un IM afin d'aider à réduire l'incidence des infarctus du myocarde.

Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease: known knowns and known unknowns.

The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD) updates the KDIGO 2012 guideline and has been developed with patient partners, clinicians, and researchers around the world, using robust methodology. This update, based on a substantially broader base of evidence than has previously been available, reflects an exciting time in nephrology. New therapies and strategies have been tested in large and diverse populations that help to inform care; however, this guideline is not intended for people receiving dialysis nor those who have a kidney transplant. The document is sensitive to international considerations, CKD across the lifespan, and discusses special considerations in implementation. The scope includes chapters dedicated to the evaluation and risk assessment of people with CKD, management to delay CKD progression and its complications, medication management and drug stewardship in CKD, and optimal models of CKD care. Treatment approaches and actionable guideline recommendations are based on systematic reviews of relevant studies and appraisal of the quality of the evidence and the strength of recommendations which followed the "Grading of Recommendations Assessment, Development, and Evaluation" (GRADE) approach. The limitations of the evidence are discussed. The guideline also provides practice points, which serve to direct clinical care or activities for which a systematic review was not conducted, and it includes useful infographics and describes an important research agenda for the future. It targets a broad audience of people with CKD and their healthcare, while being mindful of implications for policy and payment.

A Holistic Framework for the Evaluation of Kidney Function in a Gender-Diverse Landscape.

The most commonly used equations to estimate glomerular filtration rate incorporate a binary male-female sex coefficient, which has important implications for the care of transgender, gender-diverse, and nonbinary (TGD) people. Whether "sex assigned at birth" or a binary "gender identity" is most appropriate for the computation of estimated glomerular filtration rate (eGFR) is unknown. Furthermore, the use of gender-affirming hormone therapy (GAHT) for the development of physical changes to align TGD people with their affirmed gender is increasingly common, and may result in changes in serum creatinine and cystatin C, the biomarkers commonly used to estimate glomerular filtration rate. The paucity of current literature evaluating chronic kidney disease (CKD) prevalence and outcomes in TGD individuals on GAHT makes it difficult to assess any effects of GAHT on kidney function. Whether alterations in serum creatinine reflect changes in glomerular filtration rate or simply changes in muscle mass is unknown. Therefore, we propose a holistic framework to evaluate kidney function in TGD people. The framework focuses on kidney disease prevalence, risk factors, sex hormones, eGFR, other kidney function assessment tools, and the mitigation of health inequities in TGD people.

Drug stewardship in chronic kidney disease to achieve effective and safe medication use.

People living with chronic kidney disease (CKD) often experience multimorbidity and require polypharmacy. Kidney dysfunction can also alter the pharmacokinetics and pharmacodynamics of medications, which can modify their risks and benefits; the extent of these changes is not well understood for all situations or medications. The principle of drug stewardship is aimed at maximizing medication safety and effectiveness in a population of patients through a variety of processes including medication reconciliation, medication selection, dose adjustment, monitoring for effectiveness and safety, and discontinuation (deprescribing) when no longer necessary. This Review is aimed at serving as a resource for achieving optimal drug stewardship for patients with CKD. We describe special considerations for medication use during pregnancy and lactation, during acute illness and in patients with cancer, as well as guidance for the responsible use of over-the-counter drugs, herbal remedies, supplements and sick-day rules. We also highlight inequities in medication access worldwide and suggest policies to improve access to quality and essential medications for all persons with CKD. Further strategies to promote drug stewardship include patient education and engagement, the use of digital health tools, shared decision-making and collaboration within interdisciplinary teams. Throughout, we position the person with CKD at the centre of all drug stewardship efforts.

Sex- and Gender-Based Reporting in Antihypertensive Medication Literature Informing Hypertension Guidelines.

BACKGROUND: Hypertension is the leading modifiable cardiovascular risk factor with recognized sex- and gender-based differences. We assessed the incorporation of sex and gender reporting in the antihypertensive medication literature informing hypertension guidelines. METHODS AND RESULTS: Literature cited in the International Society of Hypertension (2020), European Society of Cardiology/European Society of Hypertension (2018), American College of Cardiology/American Heart Association (2017), Latin American Society of Hypertension (2017), Pan-African Society of Cardiology (2020), and Hypertension Canada (2020) guidelines was systematically reviewed. Observational studies, randomized controlled trials, and systematic reviews involving antihypertensive medications were included. Studies with participants of a single sex, guidelines, and commentaries were excluded. Data on study participation-to-prevalence ratio by sex, analysis of baseline demographics and study outcomes by sex, and stratification of adverse events by sex were extracted. Of 1659 unique citations, 331 studies met inclusion criteria. Of those, 81% reported the sex of participants, and 22% reported a male-to-female participation-to-prevalence ratio of 0.8 to 1.2. Three percent of studies stratified baseline characteristics by sex, and 20% considered sex during analysis through statistical adjustment or stratification. Although 32% of studies reported adverse events, only 0.6% stratified adverse events by sex. Most (58%) studies reporting sex/gender used sex and gender terms interchangeably. CONCLUSIONS: Incorporation of sex- and gender-based considerations in study population, analysis, or reporting of results and adverse events is not common in the antihypertensive medication literature informing international hypertension guidelines. Greater attention to sex- and gender-based factors in research is required to optimally inform management of hypertension.

Social factors associated with self-reported changes in mental health symptoms among youth in the COVID-19 pandemic: a cross-sectional survey.

BACKGROUND: Children and youth experienced marked impacts on day-to-day life in the COVID-19 pandemic that were associated with poorer familial and friend relationships, and greater mental health challenges. Few studies provide self-report data on mental health symptoms from children and youth themselves. We sought to examine the associations between social factors and child and youth self-reported symptoms of worsened mood, anxiety, and irritability during the COVID-19 pandemic. METHODS: A nationally representative cross-sectional survey was administered online to collect self-report data across 10 Canadian provinces among children (11-14 years) and youth (15-18 years), April-May 2022. Age-appropriate questions were based on The Partnership for Maternal, Newborn & Child Health and the World Health Organization of the United Nations H6 + Technical Working Group on Adolescent Health and Well-Being consensus framework and the Coronavirus Health and Impact Survey. Associations between a priori defined social factors (e.g., relationship quality) and respondent self-reported mental health were evaluated using ordinal logistic regression models adjusted for age, sex, and geographic location. RESULTS: We analyzed data from 483 (51.7%) children (11-14 years; 227, 47.0% girls) and 450 (48.3%) youth (15-18 years; 204, 45.3% girls). The parents of most children and youth had resided in Canada for over 20 years (678, 72.7%). Over one-quarter of children and youth self-identified as Black, Indigenous, or a Person of Color (134, 27.7%; 134, 29.8%, respectively). Over one-third of children and youth self-reported symptoms of worsened mood (149, 30.9%; 125, 27.8%, respectively), anxiety (181, 37.5%; 167, 37.1%, respectively), or irritability (160, 33.1%; 160, 35.6%, respectively) during, compared to pre-pandemic. In descending order of odds ratios (OR), for children and youth, worsened familial relationships (during compared to pre-pandemic) was associated with the self-reported symptoms of worsened mood (child: OR 4.22, 95%CI 2.51-6.88; youth: OR 6.65 95%CI 3.98-11.23), anxiety (child: OR 4.24, 95%CI2.69-6.75; youth: OR 5.28, 95%CI 3.17-8.86), and irritability (child: OR 2.83, 95%CI 1.76-4.56; youth: OR 6.46, 95%CI 3.88-10.90). CONCLUSIONS: Self-reported data from a nationally representative sample of children and youth suggest strong associations between social factors and mental health during the COVID-19 pandemic. Interventions targeting child and youth familial relationships may positively impact child and youth mental health.

The evolution of vaccine hesitancy through the COVID-19 pandemic: A semi-structured interview study on booster and bivalent doses.

We sought in-depth understanding on the evolution of factors influencing COVID-19 booster dose and bivalent vaccine hesitancy in a longitudinal semi-structured interview-based qualitative study. Serial interviews were conducted between July 25th and September 1st, 2022 (Phase I: univalent booster dose availability), and between November 21st, 2022 and January 11th, 2023 (Phase II: bivalent vaccine availability). Adults (≥18 years) in Canada who had received an initial primary series and had not received a COVID-19 booster dose were eligible for Phase I, and subsequently invited to participate in Phase II. Twenty-two of twenty-three (96%) participants completed interviews for both phases (45 interviews). Nearly half of participants identified as a woman (n = 11), the median age was 37 years (interquartile range: 32-48), and most participants were employed full-time (n = 12); no participant reported needing to vaccinate (with a primary series) for their workplace. No participant reported having received a COVID-19 booster dose at the time of their interview in Phase II. Three themes relating to the development of hesitancy toward continued vaccination against COVID-19 were identified: 1) effectiveness (frequency concerns; infection despite vaccination); 2) necessity (less threatening, low urgency, alternate protective measures); and 3) information (need for data, contradiction and confusion, lack of trust, decreased motivation). The data from interviews with individuals who had not received a COVID-19 booster dose or bivalent vaccine despite having received a primary series of COVID-19 vaccines highlights actionable targets to address vaccine hesitancy and improve public health literacy.

Factors affecting hesitancy toward COVID-19 vaccine booster doses in Canada: a cross-national survey.

OBJECTIVE: COVID-19 transmission, emergence of variants of concern, and weakened immunity have led to recommended vaccine booster doses for COVID-19. Vaccine hesitancy challenges broad immunization coverage. We deployed a cross-national survey to investigate knowledge, beliefs, and behaviours toward continued COVID-19 vaccination. METHODS: We administered a national, cross-sectional online survey among adults in Canada between March 16 and March 26, 2022. We utilized descriptive statistics to summarize our sample, and tested for demographic differences, perceptions of vaccine effectiveness, recommended doses, and trust in decisions, using the Rao-Scott correction for weighted chi-squared tests. Multivariable logistic regression was adjusted for relevant covariates to identify sociodemographic factors and beliefs associated with vaccine hesitancy. RESULTS: We collected 2202 completed questionnaires. Lower education status (high school: odds ratio (OR) 1.90, 95% confidence interval (CI) 1.29, 2.81) and having children (OR 1.89, CI 1.39, 2.57) were associated with increased odds of experiencing hesitancy toward a booster dose, while higher income ($100,000-$149,999: OR 0.60, CI 0.39, 0.91; $150,000 or more: OR 0.49, CI 0.29, 0.82) was associated with decreased odds. Disbelief in vaccine effectiveness (against infection: OR 3.69, CI 1.98, 6.90; serious illness: OR 3.15, CI 1.69, 5.86), disagreeing with government decision-making (somewhat disagree: OR 2.70, CI 1.38, 5.29; strongly disagree: OR 4.62, CI 2.20, 9.7), and beliefs in over-vaccinating (OR 2.07, CI 1.53, 2.80) were found associated with booster dose hesitancy. CONCLUSION: COVID-19 vaccine hesitancy may develop or increase regarding subsequent vaccines. Our findings indicate factors to consider when targeting vaccine-hesitant populations.

RéSUMé: OBJECTIF: La transmission de la COVID-19, l'émergence de variants préoccupants et l'affaiblissement de l'immunité ont conduit à recommander des doses de rappel de vaccin contre la COVID-19. L'hésitation à la vaccination remet en question une large couverture vaccinale. Nous avons déployé une enquête transnationale pour étudier les connaissances, les croyances et les comportements en faveur de la poursuite de la vaccination contre la COVID-19. MéTHODES: Nous avons mené une enquête nationale transversale en ligne auprès d'adultes au Canada, entre le 16 et le 26 mars 2022. Nous avons utilisé des statistiques descriptives pour résumer notre échantillon et testé les différences démographiques, les perceptions de l'efficacité des vaccins, les doses recommandées et la confiance dans les décisions, en utilisant la correction de Rao-Scott pour les tests du chi carré pondérés. La régression logistique multivariée a été ajustée pour les covariables pertinentes afin d'identifier les facteurs sociodémographiques et les croyances associés à l'hésitation à la vaccination. RéSULTATS: Nous avons collecté 2 202 questionnaires remplis. Un faible niveau d'éducation (lycée : rapport de cotes (OR) 1,90, intervalle de confiance (IC) à 95% 1,29, 2,81) et le fait d'avoir des enfants (OR 1,89, IC 1,39, 2,57) étaient associés à une probabilité accrue d'éprouver une hésitation à l'égard d'une dose de rappel, tandis qu'un revenu plus élevé (100 000 $­149 999 $ : OR 0,60, IC 0,39, 0,91; 150 000 $ ou plus : OR 0,49, IC 0,29, 0,82) était associé à une diminution des probabilités. Incrédulité dans l'efficacité du vaccin (contre l'infection : OR 3,69, IC 1,98, 6,90; maladie grave : OR 3,15, IC 1,69, 5,86), en désaccord avec la prise de décision du gouvernement (plutôt en désaccord : OR 2,70, IC 1,38, 5,29; fortement en désaccord : OR 4,62, IC 2,20, 9,7) et la croyance dans le sur-vaccination (OR 2,07, IC 1,53, 2,80) ont été associées à une hésitation à recevoir une dose de rappel. CONCLUSION: Une hésitation à l'égard du vaccin contre la COVID-19 peut se développer ou augmenter à l'égard des vaccins ultérieurs. Nos résultats indiquent des facteurs à prendre en compte lors du ciblage des populations hésitantes à la vaccination.

Female Reproductive Health and Contraception Use in CKD: An International Mixed-Methods Study.

Rationale & Objective: Female reproductive health is recognized as a predictor of morbidity, mortality, and quality of life, although data in the setting of chronic kidney disease (CKD) are limited. Study Design: A mixed-methods study was employed. Phase 1 was an anonymous, internet-based survey. Phase 2 was semistructured interviews offered to all respondents upon survey completion. Setting & Participants: The survey was disseminated internationally from October 4, 2021, to January 7, 2022, to individuals aged 18-50 years with both a uterus and CKD diagnosis. Outcomes: Menstrual health and contraceptive use by CKD stage (dialysis, nondialysis CKD, and transplant). Analytical Approach: Survey data were analyzed using descriptive statistics. Interview data were analyzed using the framework method of analysis. Results: Of 152 respondents, 98 (mean age 33 ± 0.7 years; n = 20 dialysis, n = 59 nondialysis CKD, n = 19 transplant) satisfied the inclusion criteria, representing 3 continents. The most common causes of CKD among survey respondents were hereditary causes in dialysis (n = 6, 30%) and glomerulonephritis in nondialysis CKD (n = 22, 37%) and transplant (n = 6, 32%). The majority reported heavy menstrual bleeding (n = 12, 86% dialysis; n = 46, 94% nondialysis CKD; n = 14, 100% transplant). Less than half of participants were consistently able to afford period products. Condoms were the most common contraceptive reported. Most participants reported no contraceptive use (n = 10, 50% dialysis; n = 37, 63% nondialysis CKD; n = 7, 37% transplant), primarily because of "fear". Interviews (n = 6) revealed a perception of a relationship between kidney function and menstrual health, concerns about contraceptive use, and a desire for greater multidisciplinary care to improve kidney and reproductive health. Limitations: Self-reported outcomes, need for internet access and a device. Conclusions: Abnormal menstruation and period poverty (ie, inability to afford period products and the socioeconomic consequences of menstruation) were common, and contraceptive use was low among female individuals with CKD, highlighting an important gap in the sex-specific care of this population. Plain-Language Summary: Chronic kidney disease (CKD) in female individuals is accompanied by menstrual disorders and low contraceptive use. However, most data are limited to the dialysis and transplant populations. Therefore, this mixed-methods study aimed to describe self-assessed menstruation and contraceptive use across all stages of CKD. People aged 18-50 years with a uterus and CKD diagnosis were invited to participate in an online survey shared internationally as well as an optional telephone interview. Abnormal menstruation and period poverty (ie, inability to afford period products and the socioeconomic consequences of menstruation) were common, and contraceptive use was low among female individuals with CKD, highlighting an important gap in the sex-specific care of this population.

Association Between the Route of Administration and Formulation of Estrogen Therapy and Hypertension Risk in Postmenopausal Women: A Prospective Population-Based Study.

BACKGROUND: Hypertension is the leading global cause of cardiovascular disease and premature mortality in women. The effects of postmenopausal hormone therapy (HT) on blood pressure are uncertain but may be related to route of estrogen administration and formulation of estrogen. We sought to determine the association between route of administration and formulation of estrogen HT and hypertension risk in postmenopausal women. METHODS: Population-based cohort study with women aged ≥45 years who filled ≥2 consecutive prescriptions for estrogen-only HT, identified from linked provincial health administrative data from Alberta, Canada, between 2008 and 2019. The primary outcome, incident hypertension, was identified using standardized International Classification of Diseases, Ninth and Tenth Revision. Cox proportional hazard models were used to calculate hazard ratios (HRs) for hypertension in women using oral HT compared with nonoral HT (transdermal, vaginal, or intramuscular). RESULTS: In total, 112 240 women used an estrogen-only form of HT. Oral estrogen was associated with a higher risk of hypertension compared with both transdermal (HR, 1.14 [95% CI, 1.08-1.20]) and vaginal (HR, 1.19 [95% CI, 1.13-1.25]) estrogens. Conjugated equine estrogen was associated with an increased risk of hypertension compared with estradiol (HR, 1.08 [95% CI, 1.04-1.14]) but not estrone (HR, 1.00 [95% CI, 0.93-1.10]). Duration of estrogen exposure and cumulative dose of estrogen was positively associated with risk of hypertension. CONCLUSIONS: Oral estrogen-only HT use was associated with an increased risk of hypertension in women. In women using estrogen-only HT, nonoral estradiol at the lowest dose and for the shortest time-period is associated with the lowest risk of hypertension.