Biological sex is increasingly recognized as a critical determinant of health and disease, particularly relevant to the topical COVID-19 pandemic caused by the SARS-CoV-2 coronavirus. Epidemiological data and observational reports from both the original SARS epidemic and the most recent COVID-19 pandemic have a common feature: males are more likely to exhibit enhanced disease severity and mortality than females. Sex differences in cardiovascular disease and COVID-19 share mechanistic foundations, namely, the involvement of both the innate immune system and the canonical renin-angiotensin system (RAS). Immunological differences suggest that females mount a rapid and aggressive innate immune response, and the attenuated antiviral response in males may confer enhanced susceptibility to severe disease. Furthermore, the angiotensin-converting enzyme 2 (ACE2) is involved in disease pathogenesis in cardiovascular disease and COVID-19, either to serve as a protective mechanism by deactivating the RAS or as the receptor for viral entry, respectively. Loss of membrane ACE2 and a corresponding increase in plasma ACE2 are associated with worsened cardiovascular disease outcomes, a mechanism attributed to a disintegrin and metalloproteinase (ADAM17). SARS-CoV-2 infection also leads to ADAM17 activation, a positive feedback cycle that exacerbates ACE2 loss. Therefore, the relationship between cardiovascular disease and COVID-19 is critically dependent on the loss of membrane ACE2 by ADAM17-mediated proteolytic cleavage. This article explores potential mechanisms involved in COVID-19 that may contribute to sex-specific susceptibility focusing on the innate immune system and the RAS, namely, genetics and sex hormones. Finally, we highlight here the added challenges of gender in the COVID-19 pandemic.

Rapid reperfusion of the infarct-related artery is the cornerstone of therapy for the management of acute ST-elevation myocardial infarction (STEMI). Canada's geography presents unique challenges for timely delivery of reperfusion therapy for STEMI patients. The Canadian R ESUM ELa reperfusion rapide de l'artère responsable de l'infarctus est la pierre angulaire th erapeutique de la prise en charge de l'infarctus aigu du myocarde avec el evation du segment ST (STEMI). Les caract eristiques g eographiques du Canada posent des d efis particuliers pour prodiguer aux

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Among the many unknowns regarding severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease 2019 is the way in which sex and gender affect the risk of acquiring the virus, illness presentation, disease management and outcomes. Sex, a biological attribute, and gender, a social construct, may both influence an individual's susceptibility, vulnerability and exposure to infectious disease. 1 Immune function differs between sexes and has been shown to affect an individual's likelihood of acquiring infection upon ex posure, or developing complications. [2][3][4] Indeed, early research has shown that these sex differences in immune response may lead to worse COVID-19 outcomes for males in terms of ability to recover from severe infection. 5 Gender, which comprises roles, norms and behaviours that may vary by sex, is associated with an individual's likelihood of exposure 6,7 (Box 1). Several institutions, including the Canadian Institutes of Health Research, have appealed to researchers to include sex and gender variables in data analysis, to improve the effectiveness of health interventions and promote gender and health equity goals. 8 In previous coronavirus epidemics (severe acute respiratory syndrome and Middle East respiratory syndrome), male sex was associated with worse outcomes; 9,10 similarly, early evidence related to COVID-19 appears to largely show increased mortality among males. 11 However, the prevalence of reported cases varies between men and women by country, suggesting that social, economic and cultural factors may influence either acquisition of SARS-CoV-2 or patterns of testing for suspected infection. We, a consortium of European and Canadian researchers (www.mcgill.ca/going -fwd4gender/), sought to assess the influence of gender-related factors on the relative male-female burden of COVID-19, to further understanding of the risks and impact of the COVID-19 pandemic. How might gender influence observed sex differences in epidemiologic research on COVID-19?Gender-related factors may influence an individual's likelihood of exposure to SARS-CoV-2, but they may also influence whether an individual tries to obtain a test and whether they are given one. These factors are presented in a conceptual framework in Figure 1.Gender identity refers to the way in which individuals identify and express their gender as men, women or gender-diverse. How power, opportunities and resources are distributed among men and women within the political, educational and social institutions of a society reflect the institutionalization of gender. 7 Institutionalized gender norms may directly affect health through differential access to health care, food education and income, according to gender. 7,12-14 Furthermore, they shape social norms that define, reproduce and often justify different opportunities and expectations for women and men, such as social and family roles, job segregation and limitations, dress codes and health practices. Gender roles and norms may be related to sex but are also influen...

This study highlights variations in longitudinal trajectories of HRQOL in patients with CAD. Despite overall improvements in HRQOL, about a quarter of our cohort experienced a significant decline in their HRQOL over the 5-year period. Understanding these HRQOL trajectories may help personalize prognostic information, identify patients and HRQOL domains on which clinical interventions are most beneficial, and support treatment decisions for patients with CAD.

Home blood pressure (BP) telemonitoring and pharmacist case management reduce BP, but cost‐effectiveness assessments are mixed. We examined the incremental cost‐effectiveness of this intervention vs usual care in Canadians with cerebrovascular disease. A Markov decision model cost‐utility analysis examining community‐residing, high‐risk patients with a recent nondisabling cerebrovascular event was created. A lifetime time horizon and health care payer perspective were used. Achieved BP, future cardiovascular risks, and attendant consequences on quality‐adjusted life years and Canadian dollar costs were modeled. BP telemonitoring was assumed to occur for 3 months, then quarterly. Life tables were used to determine overall mortality, adjusted by cardiovascular disease mortality. Relative efficacies of intervention‐associated BP lowering, resource use, and costs were obtained from Canadian published literature. Reduction in systolic BP of 9.7 mmHg was used in the base case; subsequently, robust sensitivity analyses were conducted. The results showed that, over the lifetime horizon, telemonitoring with case management led to net health care savings of $1929 Canadian and increased per‐patient QALYs by 0.83. These findings were robust to sensitivity analysis, with the intervention remaining dominant or highly cost‐effective. Increasing telemonitoring costs by 50% still resulted in the intervention being dominant; if the costs of telemonitoring plus case management were 2‐3 times base case cost, incremental cost‐effectiveness was $1200‐$4700 per quality‐adjusted life year gained. In conclusion, home BP telemonitoring and pharmacist case management poststroke lowered costs and improved QALYs. Strategies and funding for broad implementation of this dominant strategy should be implemented.

Background:Limited skill in health literacy is a global issue. Variation in health literacy skills within societies is a source of health inequality unless health care providers apply health literacy practices to effectively communicate with all clients.Objective:This study examined Iranian registered nurses' knowledge of and experience with health literacy practices. Methods: This cross-sectional study provides a quantitative description of knowledge of and experience with health literacy practices. Using a rigorous process, we adapted the Health Literacy Knowledge and Experience Survey to collect data from the participants, who were 190 registered nurses working in Tehran, Iran.Key Results:Findings identify gaps in participants' knowledge and experience with health literacy practices. Knowledge deficits are most noticeable in standards to create written materials, screening tools to identify limited health literacy, and the Teach-Back strategies to determine people's understanding. Limited experience is prominent in using health literacy screening tools, evaluating written health information, and applying technologies to provide health information. Our multivariate analysis suggests participants who reported more interaction with health care professionals for personal reasons scored higher in knowledge of health literacy practices.Conclusions:This study indicated that registered nurses in Iran do not have adequate knowledge and experience regarding health literacy practices. Addressing this issue is fundamental to promoting health equity. Future investigations should identify both barriers and facilitators for nurses to apply health literacy practices. [HLRP: Health Literacy Research and Practice. 2019;3(4):e268–e279.]Plain Language Summary:Health literacy practices enable health care professionals to offer understandable health information to all people and contribute to health equity. We surveyed 190 registered nurses in Iran to assess their knowledge of and experience with health literacy practices. The findings will be a guide to create interventions to improve registered nurses' knowledge of these practices and to use them to communicate clearly with clients.

The Canadian Heart and Stroke Foundation launched the Heart Truth campaign to increase women's awareness of heart disease. However, little is known about how such campaigns intersect with broader understandings of gender and health. This discourse analysis examined the construction of gender, risk, and prevention within campaign material. Two primary discourses emerged: one of acceptable femininity, which outlines whose risk, survivorship, and prevention matters, and another of selfless prevention. Women of diverse ethnic, sexual, and socio-economic background were largely absent. Prevention was portrayed as a personal choice, eclipsing conversations about social determinants of health and the socio-political context of heart disease.