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In 2015, the Canadian parliament passed a law permitting adults to request Medical Assistance in Dying (MAiD) when they have a grievous, irremediable medical condition that causes unbearable suffering and their natural death is reasonably foreseeable. Following a constitutional challenge, a Quebec lower court, ruled in the Truchon vs. Canada AG case that the restriction to a reasonably foreseeable death is an unjustifiable impingement on the right to life, liberty, and security of the person and the right to equality. In response, the government expanded the MAiD law in March 2021 through Bill C-7 to include those who are not approach-ing their natural death. Bill C-7 is a potentially harmful approach to justice for vulnerable groups such as the elderly, disabled, or those with chronic illnesses. The COVID-19 pandemic has highlighted serious problems with how we care for the vulnerable members of our society. In this article, we explore what has gone wrong and what has raised serious concerns, while proposing potential options to consider when developing new laws, systems, and processes to improve societal equity. RésuméEn 2015, le gouvernement fédéral a adopté une nouvelle loi permettant aux adultes de demander l’aide médicale à mourir (AMM) dans certaines circonstances, notamment les problèmes de santé graves et irrémédiables qui provoquent des souffrances insupportables et dont la mort naturelle est raisonnablement prévisible. À la suite d’une contestation constitutionnelle, un tribunal de première instance de la province de Québec a statué, dans l’affaire Truchon c. Procureur général du Canada, que la restriction à une mort raisonnablement prévisible constitue une atteinte injustifiable au droit à la vie, à la liberté et à la sécurité de la personne. En réponse à ce verdict, le gouvernement a modifié la loi sur l’AMM en mars 2021 par l’intermédiaire du projet de loi C-7 pour y inclure les personnes chez qui la mort n’est pas dans un avenir prévisible. Le projet de loi C-7 est une approche de la justice potentiellement préjudiciable aux groupes vulnérables, comme les personnes âgées, handicapées ou atteintes de maladies chroniques. La pandémie de COVID-19 a mis en lumière de graves problèmes concernant la façon dont on prend soin des membres vulnérables de notre société. Dans cet article, nous explorons ce qui a mal fonctionné et ce qui a suscité de vives inquiétudes, tout en proposant des options possibles à envisager lors de l’élaboration de nouvelles lois, de nouveaux systèmes et de nouveaux processus pour améliorer l’équité sociale.

Background Systematic reviews (SRs) are being published at an accelerated rate. Decision makers are often faced with the challenge of comparing and choosing between multiple SRs on the same topic. We surveyed individuals in the healthcare field to understand what criteria they use to compare and select one or more SRs from multiple on the same topic. Methods We developed a survey with 21 open and closed questions. We disseminated it through social media and professional networks. Results Of the 684 respondents, 25% were health practitioners, 9% policymakers, 39% researchers, and 13% were students. Policymakers, practitioners and researchers frequently sought out SRs (98.1%) as a source of evidence to inform decision making. They frequently (97.7%) found more than one SR on a given topic of interest to them. Half (50%) struggled to choose the most valid and trustworthy SR amongst multiple. These difficulties related to lack of time (55.2%), insufficient skills/ experience in quality appraisal (27.7%), and difficulty comparing different SRs (54.3%). Respondents compared SRs based on: relevance to their question of interest; its methodological quality, and recency of SR search date. Conclusions The exponential growth in the number of SRs leads to duplication of research on similar questions and compounds the problem of identifying which evidence is of the highest quality for decision makers. Failure to critically appraise and choose the highest quality SRs means that practice and policy decisions may not reflect the best evidence, the implementation of better intervention strategies is delayed, and patients may unduly suffer.

Patient-reported outcomes (PROs) are important measures of treatment effect and can be used to inform the approval of cardiovascular drugs and devices by the U.S. Food and Drug Administration (FDA).To catalogue the health status patient-reported outcome measures (PROMs) validated in cardiovascular diseases (CVDs), describe their psychometric properties, and assess adherence with both FDA recommendations and the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) framework.MEDLINE, EMBASE, CINAHL, and Allied and Complementary Medicine Database from inception to August 2022.Studies that developed and/or validated health status PROMs in CVD populations.Two study authors extracted data on CVD type, PROM psychometric properties, and adherence to FDA recommendations. The risk of bias informing the development or validation of PROMs was assessed using the COSMIN framework.Fifty health status PROMs (described in 83 studies) were identified, of which 45 were disease specific and 5 were generic. Eleven (22%) of the 50 PROMs validated in CVDs had minimally important differences (MIDs) established, and 8 (16%) reported on the validation of all psychometric properties recommended by the FDA. By COSMIN standards, only 2 PROMs (4%) had all of their psychometric properties rated as sufficient in quality, and 32 PROMs (64%) had less than 50% of psychometric properties rated as sufficient.The quality of reporting varied across included studies.Of 50 PROMs validated in CVDs, only a small minority reported on the validation of all FDA-recommended psychometric properties, had psychometric properties rated as sufficient by COSMIN, or had MIDs established. Given the use of PROMs to guide FDA approvals of drugs and devices in CVDs, there is a need for better adherence to quality standards in PROM validation.None.

AimWith the rapid advances in technology and data science, machine learning (ML) is being adopted by the health care sector; but there is a lack of literature addressing the health conditions targeted by the ML prediction models within primary health care (PHC). To fill this gap in knowledge, we conducted a systematic review following the PRISMA guidelines to identify the health conditions targeted by ML in PHC.MethodsWe searched the Cochrane Library, Web of Science, PubMed, Elsevier, BioRxiv, Association of Computing Machinery (ACM), and IEEE Xplore databases for studies published from January 1990 to January 2022. We included any primary study addressing ML diagnostic or prognostic predictive models that were supplied completely or partially by real-world PHC data. We performed literature screening, data extraction, and risk of bias assessment. Health conditions were categorized according to international classification of diseases. Extracted date were analyzed quantitatively and qualitatively.ResultsWe identified 109 studies investigating 42 health conditions. These studies included 273 ML prediction models supplied by the PHC data of 24.2 million participants from 19 countries. We found that 82% of the studies were retrospective. 76.6% of the studies reported diagnostic predictive ML models. 77% of all reported models aimed for models’ development without external validation. Risk of bias assessment revealed that 90.8% of the studies were of high or unclear risk of bias. The most frequently reported health conditions were Alzheimer’s disease and diabetes mellitus.ConclusionsTo the best of our knowledge, this is the first review to investigate the extent of the health conditions targeted by the ML prediction models within PHC settings. Our study provides an important summary on the presently available ML models in PHC, which can be used in further research and implementation efforts.

To describe clinical features, diagnostic findings, treatments, and outcomes in patients with new-onset postural orthostatic tachycardia syndrome (POTS) and other autonomic disorders following SARS-CoV-2 infection (COVID-19). We retrospectively reviewed medical records for patients who presented with persistent neurologic and cardiovascular complaints between April and December 2020 following COVID-19 infection. Twenty patients (70% female) were included in this study.Fifteen had POTS, 3 had neurocardiogenic syncope, and 2 had orthostatic hypotension. Six patients had abnormalities on cardiac or pulmonary testing, and 4 had elevated autoimmune or inflammatory markers. All patients were treated with non-pharmacologic therapies, and most required pharmacologic therapies. Six to 8 months after COVID-19, 17 (85%) patients had residual autonomic symptoms, with 12 (60%) unable to return to work. POTS can follow COVID-19 in previously healthy patients. Appropriate diagnostic investigations and therapies are necessary to identify and treat autonomic dysfunction after COVID-19.

AIMS To evaluate temporal trends in the enrolment of females in randomized controlled trials (RCTs) of heart failure with reduced ejection fraction (HFrEF) published in high-impact journals, and assess RCT characteristics associated with under-enrolment. METHODS AND RESULTS We searched MEDLINE, EMBASE and CINAHL for studies published from January 2000 to May 2019 in journals with impact factor ≥10. We included RCTs that recruited adults with HFrEF. We used a 20% threshold below the sex distribution of HFrEF to define under-enrolment. We used multivariable logistic regression to assess trial characteristics independently associated with under-enrolment. We included 317 RCTs. Among the 183 097 participants, mean (standard deviation) age was 63.0 (7.0) years and 25.5% were female. Females were under-enrolled in 71.6% [95% confidence interval (CI) 66.6-76.6%] of the RCTs; enrolment did not increase significantly between 2000-2019. Sex-related eligibility criteria [odds ratio (OR) 2.05, 95% CI 1.01-4.16; P = 0.046]; recruitment in ambulatory settings (OR 2.56, 95% CI 1.37-4.81; P = 0.003); trial coordination in North America (OR 4.44, 95% CI 1.09-18.07; P = 0.037), Europe (OR 6.79, 95% CI 1.63-27.39; P = 0.018) and Asia (OR 9.33, 95% CI 1.40-12.40; P = 0.033); drug (OR 1.76, 95% CI 1.96-7.36; P

Introduction: An increasing growth of systematic reviews (SRs) presents notable challenges for decision-makers seeking to answer clinical questions. In 1997, an algorithm was created by Jadad to assess discordance in results across SRs on the same question. Our study aims to (a) replicate assessments done in a sample of studies using the Jadad algorithm to determine if the same SR would have been chosen, (b) evaluate the Jadad algorithm in terms of utility, efficiency, and comprehensiveness, and (c) describe how authors address discordance in results across multiple SRs. Methods and Analysis: We will use a database of 1218 overviews (2000-2020) created from a bibliometric study as the basis of our search for studies assessing discordance (called Discordant Reviews). This bibliometric study searched MEDLINE (Ovid), Epistemonikos, and Cochrane Database of Systematic Reviews for overviews. We will include any study using Jadad (1997) or another method to assess discordance. The first 30 studies screened at the full-text stage by two independent reviewers will be included. We will replicate the authors’ Jadad assessments. We will compare our outcomes qualitatively and evaluate the differences between our Jadad assessment of discordance and the authors’ assessment. Ethics and Dissemination: No ethics approval was required as no human subjects were involved. In addition to publishing in an open-access journal, we will disseminate evidence summaries through formal and informal conferences, academic websites, and across social media platforms. This is the first study to comprehensively evaluate and replicate Jadad algorithm assessments of discordance across multiple SRs.

Introduction The exponential growth of published systematic reviews (SRs) presents challenges for decision makers seeking to answer clinical, public health or policy questions. In 1997, an algorithm was created by Jadad et al. to choose the best SR across multiple. Our study aims to replicate author assessments using the Jadad algorithm to determine: (i) if we chose the same SR as the authors; and (ii) if we reach the same results. Methods We searched MEDLINE, Epistemonikos, and Cochrane Database of SRs. We included any study using the Jadad algorithm. We used consensus building strategies to operationalise the algorithm and to ensure a consistent approach to interpretation. Results We identified 21 studies that used the Jadad algorithm to choose one or more SRs. In 62% (13/21) of cases, we were unable to replicate the Jadad assessment and ultimately chose a different SR than the authors. Overall, 18 out of the 21 (86%) independent Jadad assessments agreed in direction of the findings despite 13 having chosen a different SR. Conclusions Our results suggest that the Jadad algorithm is not reproducible between users as there are no prescriptive instructions about how to operationalise the algorithm. In the absence of a validated algorithm, we recommend that healthcare providers, policy makers, patients and researchers address conflicts between review findings by choosing the SR(s) with meta-analysis of RCTs that most closely resemble their clinical, public health, or policy question, are the most recent, comprehensive (i.e. number of included RCTs), and at the lowest risk of bias.

Background: Trial steering committees (TSCs) steer the conduct of randomized controlled trials (RCTs). We examined the gender composition of TSCs in impactful heart failure RCTs and explored whether trial leadership by a woman was independently associated with the inclusion of women in TSCs. Methods: We systematically searched MEDLINE, EMBASE, and CINAHL for heart failure RCTs published in journals with impact factor ≥10 between January 2000 and May 2019. We used the Jonckheere-Terpstra test to assess temporal trends and multivariable logistic regression to explore trial characteristics associated with TSC inclusion of women. Results: Of 403 RCTs that met inclusion criteria, 127 (31.5%) reported having a TSC but 20 of these (15.7%) did not identify members. Among 107 TSCs that listed members, 56 (52.3%) included women and 6 of these (10.7%) restricted women members to the RCT leaders. Of 1213 TSC members, 11.1% (95% CI, 9.4%–13.0%) were women, with no change in temporal trends ( P =0.55). Women had greater odds of TSC inclusion in RCTs led by women (adjusted odds ratio, 2.48 [95% CI, 1.05–8.72], P =0.042); this association was nonsignificant when analysis excluded TSCs that restricted women to the RCT leaders (adjusted odds ratio 1.46 [95% CI, 0.43–4.91], P =0.36). Conclusions: Women were included in 52.3% of TSCs and represented 11.1% of TSC members in 107 heart failure RCTs, with no change in trends since 2000. RCTs led by women had higher adjusted odds of including women in TSCs, partly due to the self-inclusion of RCT leaders in TSCs.

Introduction: Clinical trials change practice in cardiology but leading them typically requires advanced research training, mentorship, sponsorship, and networking. Women are underrepresented in cardiology and report challenges in obtaining mentorship and networking opportunities. Objective: To evaluate the gender distribution of first and senior authors in practice-changing clinical trials in heart failure (HF), and explore clinical trial characteristics associated with women as first authors. Methods: We searched MEDLINE, EMBASE and CINAHL databases for randomized controlled trials (RCTs) published January 2000 - May 2019. We included RCTs that recruited adults with HF with reduced ejection fraction that were published in medical journals with an impact factor of > 10. Two reviewers screened and extracted data independently. We determined the gender distribution of the authors, assessed temporal trends in authorship, and used logistic regression to identify characteristics associated with women in first authorship positions. Results: The search identified 10,596 unique studies, of which 317 met eligibility criteria. We found that 15.8%, 11.7%, and 10.7% of first, senior, and corresponding authors, respectively, were women. Multivariable analysis revealed that the first author was more likely to be a woman if the senior author of a clinical trial was a woman (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.04-4.66, p=0.039), and if the trial was conducted at a single rather than multiple centers (OR 1.40, 95% CI 1.09-6.48, p=0.035). Source of funding (public or industry), type of intervention (health service, drug, device, or surgery), and region of trial coordination (Europe, North America, Central and South America, Asia, and Australia) were not associated with gender of first authors. The proportion of trials that included women as authors has decreased from 2000 to present. Conclusion: Women are under-represented as clinical trialists in HF. Adjusting for other trial characteristics, the first author of a clinical trial was more likely to be a woman if the senior author was a woman. Mentoring women as clinical trialists in the present era may be a strategic way to increase the gender diversity of clinical trialists in years to come.

Background Digital health technology has the potential to revolutionize the quality and efficiency of healthcare delivery. However, the uptake of digital health technology has been low in clinical practice. The factors that contribute to the limited adoption of digital health technology, particularly in cardiology, are unclear. Purpose We identified and synthesized the barriers to and facilitators of digital health technology uptake in cardiology, with a focus on provider- and patient- level barriers and facilitators. Methods We searched MEDLINE, EMBASE and CINAHL databases for studies published January 2000 - December 2019 that reported barriers to and/or facilitators of digital health technology adoption in cardiology. Two reviewers screened and extracted data independently. We conducted a thematic analysis to identify major themes pertaining to digital health technology uptake by both providers and patients. Results The search identified 3062 unique studies, of which 23 qualitative studies met eligibility criteria. Seventeen studies included semi-structured interviews and 6 included focus groups. Five (22%) studies reported provider-level facilitators, which included technology usability, integration into clinical workflow, and improved patient outcomes. Eighteen (78%) studies reported patient-level facilitators, which included ongoing technical support, improved access to healthcare services, and improved self-management. Six (26%) studies reported provider-level barriers, which included lack of integration into clinical workflow, increased healthcare costs, and lack of validation and reliability of technology. Finally, 19 (83%) studies reported patient-level barriers which included lack of knowledge about technology, limited internet access, and physical impairments making use of technology difficult. Conclusions Identifying barriers to and facilitators of digital health technology could help improve its uptake in cardiology. The findings of this study can be used to inform researchers, clinicians, and stakeholders who wish to develop and implement digital health technologies that meet the needs of providers and patients. Funding Acknowledgement Type of funding source: None

IntroductionThe period following hospitalisation for chronic obstructive pulmonary disease (COPD) or heart failure (HF)—when patients transition between settings and clinicians—is one of high risk. Transitional care services that bridge the gap from hospital to home can improve outcomes, but there are no widely accepted indicators to assess their quality.Methods and analysisIn this systematic review, we will summarise transitional care quality indicators, and describe their associations with clinical, patient-reported and cost outcomes. We will search MEDLINE, Embase, CINAHL and HealthSTAR, as well as grey literature and reference lists of included articles. We will screen all studies published between January 1990 and October 2019 that test an intervention that aims to improve the hospital-to-home transition for patients with COPD and/or HF; and measure at least one process (eg, medication errors), clinical (eg, hospital readmissions) or patient-reported (eg, health-related quality of life) outcome which will serve as a transitional care quality indicator . We will include randomised controlled trials, cohort studies, cross-sectional studies, interrupted time series studies and before–after studies. We will extract data in duplicate and classify transitional care quality indicators as structural, process-related or outcome-related. When possible, we will assess associations between transitional care quality indicators and clinical outcomes. In anticipation of conceptual and statistical heterogeneity, we will provide a qualitative synthesis and narrative review of the results.Ethics and disseminationThis review will provide a list of transitional care quality indicators and their associations with clinical outcomes. These results can be used by hospitals, administrators and clinicians for assessing the quality of transitional care provided to patients with COPD and HF. The findings can also be used by policy-makers to assess and incentivise transitional care quality. We will disseminate results through publications, social media releases and presentations.PROSPERO registration numberThis study is registered on PROSPERO.

To describe clinical features, diagnostic findings, treatments, and outcomes in patients with new-onset postural orthostatic tachycardia syndrome (POTS) and other autonomic disorders following SARS-CoV-2 infection (COVID-19).We retrospectively reviewed medical records for patients who presented with persistent neurologic and cardiovascular complaints between April and December 2020 following COVID-19 infection.Twenty patients (70% female) were included in this study.Fifteen had POTS, 3 had neurocardiogenic syncope, and 2 had orthostatic hypotension. Six patients had abnormalities on cardiac or pulmonary testing, and 4 had elevated autoimmune or inflammatory markers. All patients were treated with non-pharmacologic therapies, and most required pharmacologic therapies. Six to 8 months after COVID-19, 17 (85%) patients had residual autonomic symptoms, with 12 (60%) unable to return to work.POTS can follow COVID-19 in previously healthy patients. Appropriate diagnostic investigations and therapies are necessary to identify and treat autonomic dysfunction after COVID-19.

Well-designed randomized controlled trials (RCTs) are the gold standard for informing clinical practice. However, RCTs often do not enroll participants representative of the patient population for whom the tested interventions will be applied. The aim of this study was to estimate the enrolment of

Data regarding the volume of exercise and presence of subclinical atherosclerosis are conflicting. We performed a systematic review and meta-analysis to assess the effect of volume of exercise on all-cause mortality and coronary artery calcification (CAC). We systematically searched MEDLINE, EMBASE