Extent, transparency and impact of industry funding for pelvic mesh research: a review of the literature.

BACKGROUND: Conflicts of interest inherent in industry funding can bias medical research methods, outcomes, reporting and clinical applications. This study explored the extent of funding provided to American physician researchers studying surgical mesh used to treat uterine prolapse or stress urinary incontinence, and whether that funding was declared by researchers or influenced the ethical integrity of resulting publications in peer reviewed journals. METHODS: Publications identified via a Pubmed search (2014-2021) of the terms mesh and pelvic organ prolapse or stress urinary incontinence and with at least one US physician author were reviewed. Using the CMS Open Payments database industry funding received by those MDs in the year before, of and after publication was recorded, as were each study's declarations of funding and 14 quality measures. RESULTS: Fifty-three of the 56 studies reviewed had at least one American MD author who received industry funding in the year of, or one year before or after publication. For 47 articles this funding was not declared. Of 247 physician authors, 60% received > $100 while 13% received $100,000-$1,000,000 of which approximately 60% was undeclared. While 57% of the studies reviewed explicitly concluded that mesh was safe, only 39% of outcomes supported this. Neither the quality indicator of follow-up duration nor overall statements as to mesh safety varied with declaration status. CONCLUSIONS: Journal editors' guidelines re declaring conflicts of interest are not being followed. Financial involvement of industry in mesh research is extensive, often undeclared, and may shape the quality of, and conclusions drawn, resulting in overstated benefit and overuse of pelvic mesh in clinical practice.

A novel online training program for sexual and gender minority health increases allyship in cisgender, heterosexual paramedics.

Introduction: Sexual and gender minorities (SGM) make up 4% of the Canadian population. Due to existing barriers to care in the community, SGM patients may seek more help and be sicker at presentation to hospital. Paramedics occupy a unique role and can remove or decrease these barriers. There are no existing evaluations of training programs in SGM health for prehospital providers. A training program to develop better allyship in paramedics toward SGM populations was developed and assessed. Methods: A 70- to 90-min mandatory, asynchronous, online training module in SGM health in the prehospital environment was developed and delivered via the emergency medical service (EMS) system's learning management system. A before-and-after study of cisgender, heterosexual, frontline paramedics was performed to measure the impact of the training module on the care of SGM patients. The validated Ally Identity Measure (AIM) tool was used to identify success of training and includes subscales of knowledge and skills, openness and support, and oppression awareness. Demographics and satisfaction scores were collected in the posttraining survey. Matched and unmatched pairs of surveys and demographic associations were analyzed using nonparametric statistics. Results: Of 609 paramedics, 571 completed the training, and 239 surveys were completed before and 105 (n = 344) surveys after the training; 60 surveys were paired. Overall AIM scores of matched pairs (n = 60) improved by 12% (p < 0.001), with knowledge and skills accounting for most of the increase (21%, p < 0.001). Unmatched pairs (n = 344) were similar in demographics and scores. Rural paramedics also had significantly lower pretraining oppression awareness scores and had lower posttraining AIM scores compared to suburban paramedics (6% difference). Satisfaction scores rated the training as relevant and applicable (87% and 82%, respectively). Conclusions: A novel prehospital training program in the care of SGM patients resulted in a statistically significant increase in allyship in cisgender, heterosexual-identified frontline paramedics.

Development and validation of the SAFE (Socially Ascribed intersectional identities For Equity) questionnaire.

Traditional questionnaires do not capture the complexity of how people are viewed by others and grouped into categories on the basis of what is inferred (or not) about them. This is critical in applying an intersectionality framework in research because people are negatively impacted because of "who they are" but also based on "how others see them." The purpose of this project was to develop and validate a questionnaire, grounded in intersectionality theory and a nuanced understanding of social position, that can be applied in large-scale, population-based surveys and studies. Drawing on 61 existing quantitative surveys collecting identity-based information and 197 qualitative studies on intersectionality describing the complex ways in which people's social positions are constructed and experienced, we created a draft questionnaire comprising five parts: 1) Sex and Gender, 2) Sexuality and Sexual Orientation, 3) Cultural Context, 4) Disability, Health, and Physical Characteristics, and 5) Socioeconomic Status. A draft of the questionnaire was then reviewed by experts via the Delphi process, which gauged the accessibility of the questionnaire (e.g., language used, length) and the relevance of its content using a 5-point scale and open-ended questions. These responses were ranked, analyzed, and synthesized to refine the questionnaire and, ultimately, to obtain ≥75 % consensus on each questionnaire item and response option. The SAFE questionnaire provides an opportunity to take a significant step forward in advancing our understanding of the complex, intersectional nature of social participation and marginalization.

Poorer subjective mental health among girls: Artefact or real? Examining whether interpretations of what shapes mental health vary by sex.

BACKGROUND: Despite reporting poorer self-rated mental health (SRMH) than boys, girls exhibit greater resilience and academic achievement, and less risk taking or death by suicide. Might this apparent paradox be an artefact arising from girls' and boys' different interpretations of the meaning of SRMH? We examined whether the indicator, SRMH, had a different meaning for girls and boys. METHODS: In 2021-2, we circulated social media invitations for youth age 13-18 to complete an online survey about their mental health, and which of 26 individual and social circumstances shaped that rating. All data were submitted anonymously with no link to IP addresses. After comparing weightings for each characteristic, factor analyses identified domains for the whole group and for girls and boys. RESULTS: Poor SRMH was reported by 47% of 506 girls and 27.8% of 216 boys. In general, circumstances considered important to this rating were similar for all, although boys focussed more on sense of identity, self-confidence, physical well-being, exercise, foods eaten and screen time, while girls paid more attention to having a boyfriend or girlfriend, comparisons with peers, and school performance. With factor analysis and common to boys and girls, domains of resilience, behavior/community, family, relationships with peers and future vision emerged. Girls' poorer SRMH did not arise from a more expansive interpretation of mental health. Instead, it may reflect perceived or real disadvantages in individual or social circumstances. Alternatively, girls' known greater resilience may propel lower SRMH which they use intuitively to motivate future achievement and avoid the complacency of thinking that 'all is well'. CONCLUSIONS: The relative similarity of attributes considered before rating one's mental health suggests validity of this subjective measure among girls and boys.

Greatest Risk Factor for Death from COVID-19: Older Age, Chronic Disease Burden, or Place of Residence? Descriptive Analysis of Population-Level Canadian Data.

During the first wave of COVID-19, three-quarters of Canadian deaths were among those age 80 and older. We examined whether age, chronic disease load, sex, or place was the strongest predictor of such deaths. A cross-sectional analysis of administrative data from 1 January 2020 to 30 October 2020 for the population of Ontario (n = 15,023,174) was performed. Using logistic regression analysis, we determined whether place of residence (community dwelling, community dwelling with formal home care, or long-term care facility), age group, sex, or chronic disease burden was most strongly associated with the outcome of death within 60 days of a positive SARS-CoV-2 PCR test. Overall, there were 2766 deaths attributed to COVID-19. The age-related odds of dying increased from 6.1 (age 65-74) to 13.4 (age 85 or older) relative to those aged <65 years. This age effect was dwarfed by an odds ratio of 117.1 for those living in long-term care versus independently in the community, adjusted for age, sex, and chronic disease burden. The risk of death from COVID-19 aligned much more with social realities than individual risks. The disproportionate mortality arising specifically from institutional residence demands action to identify sources and ameliorate the harms of living in such facilities.

Descriptive regression tree analysis of intersecting predictors of adult self-rated health: Does gender matter? A cross-sectional study of Canadian adults.

BACKGROUND: While self-rated health (SRH) is a well-validated indicator, its alignment with objective health is inconsistent, particularly among women and older adults. This may reflect group-based differences in characteristics considered when rating health. Using a combination of SRH and satisfaction with health (SH) could capture lived realities for all, thus enabling a more accurate search for predictors of subjective health. With the combined measure of SRH and SH as the outcome we explore a range of characteristics that predict high SRH/SH compared with predictors of a low rating for either SRH or SH. METHODS: Data were from the Canadian General Social Survey 2016 which includes participants 15 years of age and older. We performed classification and regression tree (CRT) analyses to identify the best combination of socioeconomic, behavioural, and mental health predictors of good SRH and health satisfaction. RESULTS: Almost 85% of the population rated their health as good; however, 19% of those had low SH. Conversely, about 20% of those reporting poor SRH were, none-the-less, satisfied. CRT identified healthy eating, absence of a psychological disability, no work disability from long-term illness, and high resilience as the main predictors of good SRH/SH. Living with a spouse or children, higher social class and healthy behaviours also aligned with high scores in both self-perceived health measures. Sex was not a predictor. CONCLUSIONS: Combining SRH and SH eliminated sex as a predictor of subjective health, and identified characteristics, particularly resilience, that align with high health and well-being and that are malleable.

Abnormal thyroid function: an unusual presentation of pituitary stalk interruption syndrome.

Summary: An 11-year-old girl with past medical history of septic shock and multi-organ failure at age 5 presented to her primary care doctor with concern for pallor of the lips. Laboratory studies demonstrated low free thyroxine (T4) and normal thyroid-stimulating hormone (TSH). A referral to endocrinology was made where the patient was evaluated, and laboratory evaluation was repeated. The patient was asymptomatic and clinically euthyroid with a height consistent with her mid-parental height and was in mid- to late-puberty. The repeated laboratory evaluation demonstrated a pattern suggestive of primary hypothyroidism with low free T4 and an elevated TSH. However, the magnitude of elevation of TSH was less than expected, given the degree of lowering of free T4; therefore, central hypothyroidism was considered. Workup was initiated, and laboratory studies and MRI imaging confirmed an underlying diagnosis of panhypopituitarism in the setting of pituitary stalk interruption syndrome. Learning points: Pituitary stalk interruption syndrome is a rare but important cause of panhypopituitarism. Central hypothyroidism should be suspected in patients with low free thyroxine with an inappropriate degree of elevation of thyroid-stimulating hormone. Workup of central hypothyroidism should include multi-pituitary hormone assessment, and, if evident, MRI imaging should be done. Adrenal insufficiency should be suspected in a hypotensive, critically ill patient who is failing to improve on standard-of-care therapy.

Social bias in artificial intelligence algorithms designed to improve cardiovascular risk assessment relative to the Framingham Risk Score: a protocol for a systematic review.

INTRODUCTION: Cardiovascular disease (CVD) prevention relies on timely identification of and intervention for individuals at risk. Risk assessment models such as the Framingham Risk Score (FRS) have been shown to over-estimate or under-estimate risk in certain groups, such as socioeconomically disadvantaged populations. Artificial intelligence (AI) and machine learning (ML) could be used to address such equity gaps to improve risk assessment; however, critical appraisal is warranted before ML-informed clinical decision-making is implemented. METHODS AND ANALYSIS: This study will employ an equity-lens to identify sources of bias (ie, race/ethnicity, gender and social stratum) in ML algorithms designed to improve CVD risk assessment relative to the FRS. A comprehensive literature search will be completed using MEDLINE, Embase and IEEE to answer the research question: do AI algorithms that are designed for the estimation of CVD risk and that compare performance with the FRS address the sources of bias inherent in the FRS? No study date filters will be imposed on the search, but English language filters will be applied. Studies describing a specific algorithm or ML approach that provided a risk assessment output for coronary artery disease, heart failure, cardiac arrhythmias (ie, atrial fibrillation), stroke or a global CVD risk score, and that compared performance with the FRS are eligible for inclusion. Papers describing algorithms for the diagnosis rather than the prevention of CVD will be excluded. A structured narrative review analysis of included studies will be completed. ETHICS AND DISSEMINATION: Ethics approval was not required. Ethics exemption was formally received from the General Research Ethics Board at Queen's University. The completed systematic review will be submitted to a peer-reviewed journal and parts of the work will be presented at relevant conferences.

Inequities in home care use among older Canadian adults: Are they corrected by public funding?

BACKGROUND: Although care use should parallel needs, enabling and predisposing circumstances including the socio-demographic inequities of socioeconomic status (SES), gender, or isolation often intervene to diminish care. We examine whether availability of state-funded medical and support services at home can rebalance these individual and social inequities, and do this by identifying if and how intersecting social identities predict homecare use among older Canadian adults. METHODS: Using the Canadian Longitudinal Study on Aging (CLSA) of 30,097 community-dwelling adults aged 45 to 85, we performed recursive partitioning regression tree analysis using Chi-Squared automatic interaction detection (CHAID). Combinations of individual and social characteristics including sociodemographic, family-related, physical and psychological measures and contextual indicators of material and social deprivation were explored as possible predictors of formal and informal care use. RESULTS: Diminished function i.e. increased need, indicated by Activities of Daily Living, was most strongly aligned with formal care use while age, living arrangement, having no partner, depression, self-rated health and chronic medical conditions playing a lesser role in the pathway to use. Notably, sex/gender, were not determinants. Characteristics aligned with informal care were first-need, then country of birth and years since immigration. Both 'trees' showed high validity with low risk of misclassification (4.6% and 10.8% for formal and informal care, respectively). CONCLUSIONS: Although often considered marginalised, women, immigrants, or those of lower SES utilised formal care equitably. Formal care was also differentially available to those without the financial or human resources to receive informal care. Need, primarily medical but also arising from living arrangement, rather than SES or gender predicted formal care, indicating that universal government-funded services may rebalance social and individual inequities in formal care use.

Women suffer but men die: survey data exploring whether this self-reported health paradox is real or an artefact of gender stereotypes.

BACKGROUND: Despite consistently reporting poorer health, women universally outlive men. We examine whether gender differences in lived circumstances considered, and meaning attributed to SRH by women and men might explain this paradox. METHODS: In an online survey 917 adults rated their health (SRH) and mental health (SRMH) and reflected upon what life experiences they considered in making their ratings. Descriptive findings were sex-disaggregated. The multiple experiences listed were then subject to factor analyses using principal components methods and orthogonal rotation. RESULTS: Women reported poorer SRH and SRMH. They considered a wider range of circumstances, weighing all but self-confidence and behaviors as more important to SRH than did men. Two underlying components, psychosocial context and clinical status were identified overall. Physical health and pain were more important elements of men's clinical status and behaviors. Comparisons with others of the same age played a larger role in male psycho-social context. Two components also underpinned SRMH. These were clinical problems and psycho-social circumstances for which self-confidence was only important among men. CONCLUSIONS: Women's and men's common interpretation of measures like SRH suggests that women's health disadvantage is neither artefactual nor determined by gendered meanings of measures and does not explain the paradox. SRH and SRMH captured social circumstances for all. Convergence of characteristics women and men consider as central to health is evidence of the dynamism of gender with evolving social norms. The remaining divergence speaks to persisting traditional male stereotypes.

Cohort Trajectories by Age and Gender for Informal Caregiving in Europe Adjusted for Sociodemographic Changes, 2004 and 2015.

OBJECTIVES: We present a dynamic view of gender patterns in informal caregiving across Europe in a context of sociodemographic transformations. We aim to answer the following research questions: (a) has the gender gap in informal caregiving changed; (b) if so, is this due to changes among women and/or men; and (c) has the gender care gap changed differently across care regimes? METHODS: Multilevel growth curve models are applied to gendered trajectories of informal caregiving of a panel sample of 50+ Europeans, grouped into 5-year cohorts and followed across 5 waves of the Survey of Health, Ageing and Retirement in Europe survey, stratified by sex and adjusted for several covariates. RESULTS: For men in cohorts born more recently, there is a decrease in the prevalence of informal care outside the household, whereas cohort trajectories for women are mostly stable. Prevalence of care inside the household has increased for later-born cohorts for all without discernible changes to the gender care gap. Gender care gaps overall widened among later-born cohorts in the Continental cluster, whereas they remained constant in Southern Europe, and narrowed in the Nordic cluster. DISCUSSION: We discuss the cohort effects found in the context of gender differences in employment and care around retirement age, as well as possible demographic explanations for these. The shift from care outside to inside the household, where it mostly consists of spousal care, may require different policies to support carers, whose age profile and possible care burden seem to be increasing.

Circumstances and Factors Associated With Falls Among Community-Dwelling Older Adults Diagnosed With Heart Disease Using the International Mobility in Aging Study (IMIAS).

BACKGROUND AND PURPOSE: To identify the circumstances of falls and the factors associated with falls among older adults with cardiovascular disease (CVD). METHODS: Baseline (2012) data from the International Mobility in Aging Study (IMIAS), a cross-sectional study, were used. Falling was measured by the subjective question, "Have you fallen in the last 12 months?" Several subjective questions were asked to obtain information about the circumstances of falls. Potential clinical factors associated with falling were cognitive status, depressive symptoms, physical performance, grip strength, visual acuity, and fear of falling (FOF). These clinical factors were measured respectively with the Leganes Cognitive Test, the Center for Epidemiological Studies Scales Depressive Symptoms, the Short Physical Performance Battery, a Jamar handgrip dynamometer, the Early Treatment Diabetic Retinopathy Study (ETDRS) tumbling E chart placed at 2 m, and the Falls Efficacy Scale-International. A χ 2 test was used to determine whether there were significant differences in fall circumstances among older adults with and without CVD. Two-sample t tests were used to test for any significant differences between older adults with and without CVD. Bonferroni correction was applied to limit type I errors and was corrected to .007. Simple and multiple logistic regressions identified which clinical factors were associated with falling. RESULTS: A total of 429 older adults with CVD (mean age 69.5 ± 2.9) and 431 older adults without CVD (69.2 ± 2.9) participated in the study. Approximately 53% of fallers with CVD had 2 or more falls compared with fallers without CVD (39%). The most common location for falling was at home (43%) for fallers with CVD or in the street (50%) for fallers without CVD. Approximately 9% of fallers with CVD needed to be hospitalized while only 3% of fallers without CVD were admitted to the hospital. Approximately 42% of fallers with CVD had some residual sequelae (eg, being unable to walk around the house or do housework) compared with only 27% of fallers without CVD. Fallers with CVD had significantly ( P value < .007) more depressive symptoms (mean ± SD, 14.7 ± 12.9) and poorer physical performance (8.4 ± 3.0) compared with fallers without CVD (10.1 ± 9.4 and 9.6 ± 2.5, respectively); however FOF was the only significant clinical factor ( P value < .05) associated with falling for older adults with CVD. CONCLUSIONS: Incidence of recurrent falls is higher among older adults with CVD than those without CVD. Circumstances of falls among fallers with CVD differ from those identified among fallers without CVD. Fear of falling was the only predictor of fall history among older adults with CVD. The results suggest the merit of considering FOF when designing prevention and intervention programs to reduce falls among older adults with CVD.

Gender Disparities in End of Life Care: A Scoping Review.

Objective: Traditional gender norms and expectations may disproportionately constrain in-home palliative care received by women. This scoping review aims to canvass and evaluate the literature on gender disparities in end of life care and explore relevant themes that could inform future research and practice. Methods: A systematic search of MEDLINE, OVID, COCHRANE, and EMBASE was conducted using MeSH terms palliative care, palliative medicine, terminal care, or hospice care, combined with gender equity, sex factors, sexism, or gender disparities. Articles were limited to those in English (2010 to 2021), focusing on end of life care, gender roles, patients, and caregivers. Results: Of 624 articles identified, 15 met inclusion criteria for critical appraisal using the AMSTAR checklist for systematic reviews and NICE guidelines for quantitative and qualitative studies. Most studies were of poor to moderate quality. Thematic analyses identified 6 major themes related to gender disparities: living situation, symptom experience, care context, care preferences, caregiving, and coping strategies. Conclusion: Larger scale research of better quality is needed to fully characterize gender disparities in end of life care and understand how physicians might mitigate these disparities by building awareness of personal gender biases, providing support to families, educating them, and initiating care discussions that overturn traditional and stereotypic gendered expectations.

Cohort-specific disability trajectories among older women and men in Europe 2004-2017.

As the population of Europe grows older, one crucial issue is how the incidence and prevalence of disabilities are developing over time in the older population. In this study, we compare cohort-specific disability trajectories in old age across subsequent birth cohorts in Europe, during the period 2004-2017.We used data from seven waves of data from the Survey of Health, Ageing and Retirement in Europe (SHARE). Mixed effects logistic regression models were used to model trajectories of accumulation of ADL limitations for subsequent birth cohorts of older women and men in different European regions. The results showed that there were sex differences in ADL and IADL limitations in all regions for most cohorts. Women reported more limitations than men, particularly in Eastern and Southern rather than Northern and Western Europe. Among men in Eastern, Northern and Western Europe, later born cohorts reported more disabilities than did earlier born birth cohorts at the same ages. Similar patterns were observed for women in Northern and Western Europe. In contrast, the risk of disabilities was lower in later born cohorts than in earlier born birth cohorts among women in Eastern Europe. Overall, results from this study suggest that disability trajectories in different cohorts of men and women were by and large similar across Europe. The trajectories varied more depending on sex, age and region than depending on cohort. Supplementary Information: The online version contains supplementary material available at 10.1007/s10433-022-00684-4.

Medical Devices, Invisible Women, Harmful Consequences.

In this commentary, we explore the disproportionate risk women experience with the insertion of various medical devices. Although pre-market device testing and complication tracking could be improved for all, a failure to consider sex differences in hormones, anatomy, inflammatory responses, and physical function puts women at particular risk. This invisibility of women is an example of gender bias in medical science and practice, a bias that could be corrected in the ways we suggest.

Gender differences in access to community-based care: a longitudinal analysis of widowhood and living arrangements.

Persistent inequalities in access to community-based support limit opportunities for independent living for older people with care needs in Europe. Our study focuses on investigating how gender, widowhood and living arrangement associate with the probability of receiving home and community-based care, while accounting for the shorter-term associations of transitions into widowhood (bereavement) and living alone, as well as the longer-term associations of being widowed and living alone. We use comparative, longitudinal data from the Survey of Health, Ageing and Retirement in Europe (collected between 2004 and 2015 in 15 countries) specifying sex-disaggregated random-effects within-between models, which allow us to examine both cross-sectional and longitudinal associations among widowhood, living arrangements and community-based care use. We find widowhood and living alone are independently associated with care use for both older women and men, while bereavement is associated with higher probability of care use only for women. Socio-economic status was associated with care use for older women, but not for men in our sample. The gender-specific associations we identify have important implications for fairness in European long-term care systems. They can inform improved care targeting towards individuals with limited informal care resources (e.g. bereaved older men) and lower socio-economic status, who are particularly vulnerable to experiencing unmet care needs. Gender differences are attenuated in countries that support formal care provision, suggesting gender equity can be promoted by decoupling access to care from household and family circumstances. Supplementary Information: The online version contains supplementary material available at 10.1007/s10433-022-00717-y.