Sex, not gender. A plea for accuracy

Features and outcomes of female and male patients requiring postcardiotomy extracorporeal life support

OBJECTIVES

Although cardiogenic shock requiring extracorporeal life support after cardiac surgery is associated with high mortality, the impact of sex on outcomes of postcardiotomy extracorporeal life support remains unclear with conflicting results in the literature. We compare patient characteristics, in-hospital outcomes, and overall survival between females and males requiring postcardiotomy extracorporeal life support.

METHODS

This retrospective, multicenter (34 centers), observational study included adults requiring postcardiotomy extracorporeal life support between 2000 and 2020. Preoperative, procedural, and extracorporeal life support characteristics, complications, and survival were compared between females and males. Association between sex and in-hospital survival was investigated through mixed Cox proportional hazard models.

RESULTS

This analysis included 1823 patients (female: 40.8%; median age: 66.0 years [interquartile range, 56.2-73.0 years]). Females underwent more mitral valve surgery (females: 38.4%, males: 33.1%, P = .019) and tricuspid valve surgery (feamales: 18%, males: 12.4%, P < .001), whereas males underwent more coronary artery surgery (females: 45.9%, males: 52.4%, P = .007). Extracorporeal life support implantation was more common intraoperatively in feamales (females: 64.1%, females: 59.1%) and postoperatively in males (females: 35.9%, males: 40.9%, P = .036). Ventricular unloading (females: 25.1%, males: 36.2%, P < .001) and intra-aortic balloon pumps (females: 25.8%, males: 36.8%, P < .001) were most frequently used in males. Females had more postoperative right ventricular failure (females: 24.1%, males: 19.1%, P = .016) and limb ischemia (females: 12.3%, males: 8.8%, P = .23). In-hospital mortality was 64.9% in females and 61.9% in males (P = .199) with no differences in 5-year survival (females: 20%, 95% CI, 17-23; males: 24%, 95% CI, 21-28; P = .069). Crude hazard ratio for in-hospital mortality in females was 1.12 (95% CI, 0.99-1.27; P = .069) and did not change after adjustments.

CONCLUSIONS

This study demonstrates that female and male patients requiring postcardiotomy extracorporeal life support have different preoperative and extracorporeal life support characteristics, as well as complications, without a statistical difference in in-hospital and 5-year survivals.

Sex/gender differences in the associations between adverse childhood experiences and intimate partner violence with mental disorders

Sex and gender differences exist in mental and substance use disorders (MSUDs). Studies examining the moderating effects of sex/gender on MSUDs may help understand these differences. This national study explored whether sex/gender moderated (1) the associations between adverse childhood experience (ACEs; i.e., child abuse, child neglect, and child household dysfunction) and intimate partner violence (IPV) with MSUDs and (2) more associations with past year than lifetime MSUDs or mental (i.e., mood disorder, anxiety disorder, and posttraumatic stress disorder) than substance use disorders (i.e., alcohol use disorder and nicotine dependence). Data was used from participants in the National Epidemiologic Survey on Alcohol and Related Conditions. Logistic regression tested the main effects of ACEs, IPV, and sex/gender on five, past-year and lifetime MSUDs along with the ACE-sex/gender and IPV-sex/gender interactions. Sex/gender moderated 60% of the ACEs-MSUD and IPV-MSUD associations and more associations with lifetime (54%) than past year MSUDs (46%) and substance use (94%) than mental disorders (38%). For nearly half of the moderated associations, ACEs and IPV were associated with greater odds of MSUDs for males. Males who experienced IPV had greater odds of lifetime mood, anxiety, and alcohol use disorders than females. This study advances sex and gender informed research.

Chromosomal and gonadal factors regulate microglial sex effects in the aging brain

Biological sex contributes to phenotypic sex effects through genetic (sex chromosomal) and hormonal (gonadal) mechanisms. There are profound sex differences in the prevalence and progression of age-related brain diseases, including neurodegenerative diseases. Inflammation of neural tissue is one of the most consistent age-related phenotypes seen with healthy aging and disease. The pro-inflammatory environment of the aging brain has primarily been attributed to microglial reactivity and adoption of heterogeneous reactive states dependent upon intrinsic (i.e., sex) and extrinsic (i.e., age, disease state) factors. Here, we review sex effects in microglia across the lifespan, explore potential genetic and hormonal molecular mechanisms of microglial sex effects, and discuss currently available models and methods to study sex effects in the aging brain. Despite recent attention to this area, significant further research is needed to mechanistically understand the regulation of microglial sex effects across the lifespan, which may open new avenues for sex informed prevention and treatment strategies.

The use of key social determinants of health variables in psychiatric research using routinely collected health data: a systematic analysis

PURPOSE

Social determinants of health (SDoH) impact psychiatric conditions. Routinely collected health data are frequently used to evaluate important psychiatric clinical and health services outcomes. This study explored how key SDoH are used in psychiatric research employing routinely collected health data.

METHODS

A search was conducted in PubMed for English-language articles published in 2019 that used routinely collected health data to study psychiatric conditions. Studies (n = 19,513) were randomly ordered for title/abstract review; the first 150 meeting criteria progressed to full-text review. Three key SDoH categories were assessed: (1) gender and sex, (2) race and ethnicity, and (3) socioeconomic status. Within each category, data were extracted on how variables were included, defined, and used in study design and analysis.

RESULTS

All studies (n = 103) reported on at least one of the key SDoH variables; 102 (99.0%) studies included a gender and/or sex variable, 30 (29.1%) included a race and/or ethnicity variable, and 55 (53.4%) included a socioeconomic status variable. No studies explicitly differentiated between gender and sex, and SDoH were often defined only as binary variables. SDoH were used to define the target population in 14 (13.6%) studies. Within analysis, SDoH were most often included as confounders (n = 65, 63.1%), exposures or predictors (n = 23, 22.3%), and effect modifiers (n = 14, 13.6%). Only 21 studies (20.4%) disaggregated results by SDoH and 7 (6.8%) considered intersections between SDoH.

CONCLUSIONS

Results suggest improvements are needed in how key SDoH are used in routinely collected health data-based psychiatric research, to ensure relevance to diverse populations and improve equity-oriented research.

The Differences by Sex and Gender in the Relationship Between Urban Greenness and Cardiometabolic Health: A Systematic Review

In an increasingly urbanized world, where cardiometabolic issues in cities have raised public health concerns, urban greenness is known to be beneficial for some of the most common health issues. However, the examination of the contribution of sex and gender regarding the benefits of urban greenness for people's cardiometabolic health is lacking. For that reason, we conducted a systematic review of previous literature on the topic following the PRISMA methodology. Additionally, we assessed the quality of the included articles, which we found satisfactory as most papers were of very good or good quality. We explored the relationship between urban greenness exposure and cardiovascular risk factors, cardiovascular diseases, and mortality from cardiovascular diseases. Results suggest that urban greenness is protective against cardiovascular risk factors, diseases, and mortality. When stratifying results by sex and gender, findings point to urban greenness being more beneficial for women and females in stroke and cardiovascular risk factors, except for hypertension and lipid accumulation product. On the other hand, males were more protected by urban greenness in terms of cardiovascular diseases and CVD-related mortality, thus proving that sex and gender health inequalities exist. Furthermore, looking towards the future, research needs to use the proper terminology for sex and gender and policy makers should design urban greenness with a gender perspective.

A Systematic Review of the Sex and Gender Reporting in COVID-19 Clinical Trials

Sex and gender have implications for COVID-19 vaccine efficacy and adverse effects from the vaccine. As vaccination is one of the key responses to the COVID-19 pandemic, it is vital that sex and gender differences be acknowledged, measured, and analysed in clinical research. Here, we systematically review published COVID-19 vaccine trials, both interventional and observational, to assess the quality of reporting of sex and gender. Of the 75 clinical trials on COVID-19 vaccines included in this review, only 24% presented their main outcome data disaggregated by sex, and only 13% included any discussion of the implications of their study for women and men. Considering the sex differences in adverse events after vaccination, and the gendered aspects of vaccine hesitancy, these oversights in clinical research on vaccines have implications for recovery from the COVID-19 pandemic and for wider public health.

Sex differences in outcomes following less-invasive left ventricular assist device implantation

Background

Worse outcomes in women compared to men undergoing left ventricular assist device (LVAD) implantation remain an underestimated problem in heart failure (HF) patients. With device miniaturization, less-invasive LVAD implantation techniques have gained relevance, but their impact on outcomes in women is unknown. This study investigates sex-related differences in patients undergoing LVAD implantation through less-invasive procedures.

Methods

This retrospective single-center cohort study included patients who underwent isolated LVAD implantation between 2011 and 2018 through less-invasive techniques. Propensity score matching (PSM) was utilized to balance preoperative heterogeneity. Primary endpoint was two-year survival, and secondary endpoints included long-term survival, surgical outcomes and postoperative adverse events.

Results

Baseline analysis of 191 patients (females 18.3%) showed differences in terms of age [female (median, 52; IQR, 47-61); male (median, 58.5; IQR, 49-66); P=0.005], underlying diagnosis (P<0.001), INTERMACS profile (P=0.009), history of previous cardiac surgery (P=0.049) and preoperative creatinine values [female (median, 110; IQR, 71-146); male (median, 126; IQR, 9-168); P=0.049]. Over a follow-up of 460.68 patient-years, Kaplan-Meyer analysis showed better survival in females (P=0.027) and a similar probability of cardiac transplantation (P=0.288). After PSM, females showed higher needs for intraoperative fresh frozen plasma (P=0.044) and platelets (P=0.001) but comparable postoperative outcomes. No sex-related differences were noticed regarding two-year outcomes, long-term survival and adverse events. LVAD-related infections remained the most common complication with males experiencing more pump infections than women (P=0.050).

Conclusions

Patients receiving less-invasive LVAD implantation do not show significant sex-related differences in short and long-term outcomes and survival. Prospective studies are needed to evaluate the role of less-invasive techniques in reducing sex-based disparities after LVAD implantation.