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Gender-based discrimination is reported across the spectrum of paediatric healthcare including emergency, inpatient, outpatient and preventive care and is mostly reported from South Asia and China with sporadic reports from Africa and South America. Biases against young girls have been documented even in immunisation percentage, home food allocation, seeking medical care for childhood ailments and percentage of household healthcare expenditures allocated to them. Such gender discrimination in access to medical care is likely to have an influence on the overall health of female children. Over the last five decades, the under-5 sex ratios are worsening in India with declining number of girls. Deliberate parental neglect of girls' essential and life-saving medical care is also an important contributing factor apart from sex-selective abortions to the declining gender ratios. Corrective measures and focused action are needed.

Postacute myocardial infarction (AMI) readmissions are common among Medicare beneficiaries (≥65 years) and are associated with significant resource utilization. However, patterns of AMI readmissions for younger age groups in the United States are not known. In the Nationwide Readmissions Database, a nationally representative all-payer database of in-patient hospitalizations, we identified 212,171 index AMI hospitalizations in January to November 2013, weighted to represent 478,247 hospitalizations nationally (mean age 66.9 years, 38% women, 29% low income). This included 26,516 cases in the 18 to 44 age group, 183,703 in the 45 to 64 age group, and 268,027 in the ≥65 age group. The overall 30-day readmission rate was 14.5% and varied across age groups (9.7% [18 to 44], 11.2% [45 to 64], and 17.3% [≥65]). The cumulative cost of 30-day readmissions was $1.1 billion, of which $365 million was spent on those <65 years of age. In multivariable hierarchical models, the risk of readmission was higher in women and in low-income patients, but the effect varied by age (p value for age-gender and age-income interactions <0.05) and was more prominent in the younger age groups. Further, patients in all age groups continue to have a high hospitalization burden beyond the typical 30-day readmission period, with an overall 24% post-AMI 90-day readmission rate. In conclusion, readmissions in young and middle-aged AMI survivors pose a substantial burden on patients and on U.S. health-care resources. Women and low-income patients with AMI, particularly those in younger age groups, are more frequently readmitted, and readmissions continue to burden the health-care system beyond the typical 30-day window. Future investigations would need to be targeted toward a better understanding and improvement of the rehospitalization burden for vulnerable patient groups.

BACKGROUND:We conducted a systematic review and network meta-analysis to examine comparative efficacy and tolerability of pharmacologic interventions for pulmonary arterial hypertension (PAH).METHODS: MEDLINE, the Cochrane Register, EMBASE, CINAHL, and clinicaltrials.gov were searched (January 1, 1990 to March 3, 2016. Randomized controlled trials (RCTs) studying the approved pharmacologic agents endothelin receptor antagonists (ERA), phosphodiesterase inhibitors (PDE5i), the oral/inhaled (PO/INH) and IV/subcutaneous (SC) prostanoids, and riociguat and selexipag, alone or in combination, for pulmonary arterial hypertension (PAH) and reporting at least one efficacy outcome were selected.RESULTS: Thirty-one RCTs with 6,565 patients were selected. In network meta-analysis, when compared with a median placebo rate of 14.5%, clinical worsening was estimated at 2.8% with riociguat (risk ratio [RR], 0.19; 95% CI, 0.05-0.76); at 3.9% with ERA þ PDE5i (RR, 0.27; 95% CI, 0.14-0.52), and at 5.7% with PDE5i (RR, 0.39; 95% CI, 0.24-0.62). For improvement in functional status, when compared with 16.2% in the placebo group, improvement in at least one New York Heart Association/World Health Organization (NYHA/WHO) functional class was estimated at 81.8% with IV/SC prostanoids (RR, 5.06; 95% CI, 2.3211.04), at 28.3% with ERA þ PDE5i (RR, 1.75; 95% CI, 1.05-2.92), and at 25.2% with ERA (RR, 1.56; 95% CI, 1.22-2.00). Differences in mortality were not significant. Adverse events leading to discontinuation of therapy were highest with the PO/INH prostanoids (RR, 2.92; 95% CI, 1.68-5.06) and selexipag (RR, 2.06; 95% CI, 1.04-3.88) compared with placebo.CONCLUSIONS: Currently approved pharmacologic agents have varying effects on morbidity and functional status in patients with PAH. Future comparative effectiveness trials are warranted with a focus on a patient-centered approach to therapy. REGISTRATION: PROSPERO CRD42016036803CHEST 2017; 151(1):90-105 KEY WORDS: comparative efficacy; network meta-analysis; pulmonary arterial hypertension ABBREVIATIONS: 6MWD = 6-min walk distance; ERA = endothelin receptor antagonist; FDA = Food and Drug Administration; GRADE = Grading of Recommendations Assessment, Development, and Education; NYHA = New York Heart Association; PAH = pulmonary arterial hypertension; PDE5i = phosphodiesterase-5 inhibitor; RCT = randomized controlled trial; RR = risk ratio; SUCRA = surface under the cumulative ranking area; WHO = World Health Organization; WMD = weighted mean difference Pulmonary arterial hypertension (PAH) or World Health Organization (WHO) group 1 pulmonary hypertension is a progressive disease associated with significant morbidity and a 5% to 15% annual mortality rate. [1][2][3] In recent years, a number of drug classes to treat PAH have been approved for clinical use. These include endothelin receptor antagonists (ERA), phosphodiesterase-5 inhibitors (PDE5i), parenteral and nonparenteral prostacyclins, a soluble guanylate cyclase stimulator, and a prostacyclin-receptor agonist. Although randomized ...

Female gender is an important determinant of non-compliance with paediatric cardiac surgery. Deep-seated social factors underlie this gender bias.

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Background/objective Emergency department (ED) visits have declined while excess mortality, not attributable to COVID‐19, has grown. It is not known whether older adults are accessing emergency care differently from their younger counterparts. Our objective was to determine patterns of ED visit counts for emergent conditions during the COVID‐19 pandemic for older adults. Design Retrospective, observational study. Setting Observational analysis of ED sites enrolled in a national clinical quality registry. Participants One hundred and sixty‐four ED sites in 33 states from January 1, 2019 to November 15, 2020. Main outcome and measures We measured daily ED visit counts for acute myocardial infarction (AMI), stroke, sepsis, fall, and hip fracture, as well as deaths in the ED, by age categories. We estimated Poisson regression models comparing early and post‐early pandemic periods (defined by the Centers for Disease Control and Prevention) to the pre‐pandemic period. We report incident rate ratios to summarize changes in visit incidence. Results For AMI, stroke, and sepsis, the older (75–84) and oldest old (85+ years) had the greatest decline in visit counts initially and the smallest recovery in the post‐early pandemic periods. For falls, visits declined early and partially recovered uniformly across age categories. In contrast, hip fractures exhibited less change in visit rates across time periods. Deaths in the ED increased during the early pandemic period, but then fell and were persistently lower than baseline, especially for the older (75–84) and oldest old (85+ years). Conclusions The decline in ED visits for emergent conditions among older adults has been more pronounced and persistent than for younger patients, with fewer deaths in the ED. This is concerning given the greater prevalence and risk of poor outcomes for emergent conditions in this age group that are amenable to time‐sensitive ED diagnosis and treatment, and may in part explain excess mortality during the COVID‐19 era among older adults.

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