Sex Differences in Patients With Cryptogenic Cerebrovascular Events Undergoing Transcatheter Closure of Patent Foramen Ovale

Background Scarce data exist on sex differences in patients with cryptogenic cerebrovascular events undergoing patent foramen ovale (PFO) closure. This study aimed to determine the sex differences in clinical profile, procedural characteristics, and long-term outcomes of patients with cryptogenic cerebrovascular events undergoing PFO closure. Methods and Results A retrospective cohort was used, including 1076 consecutive patients undergoing PFO closure because of a cryptogenic cerebrovascular event. Patients were divided into 2 groups: 469 (43.6%) women and 607 (56.4%) men. The median follow-up was 3 years (interquartile range, 2-8 years). Women were younger (46±13 versus 50±12 years; P<0.01) and had a higher risk of paradoxical embolism score (6.9±1.7 versus 6.6±1.6; P<0.01). Procedural characteristics and postprocedural antithrombotic therapy were similar. At follow-up, there were no differences in atrial fibrillation (women versus men: 0.47 versus 0.97 per 100 patient-years; incidence rate ratio [IRR], 0.55 [95% CI, 0.27-1.11]; P=0.095; adjusted P=0.901), stroke (0.17 versus 0.07 per 100 patient-years; IRR, 2.58 [95% CI, 0.47-14.1]; P=0.274; adjusted P=0.201), or transient ischemic attack (0.43 versus 0.18 per 100 patient-years; IRR, 2.58 [95% CI, 0.88-7.54]; P=0.084; adjusted P=0.121); nevertheless, women exhibited a higher incidence of combined ischemic cerebrovascular events (0.61 versus 0.26 per 100 patient-years; IRR, 2.58 [95% CI, 1.04-6.39]; P=0.041; adjusted P=0.028) and bleeding events (1.04 versus 0.45 per 100 patient-years; IRR, 2.82 [95% CI, 1.41-5.65]; P=0.003; adjusted P=0.004). Conclusions Compared with men, women with cryptogenic cerebrovascular events undergoing PFO closure were younger and had a higher risk of paradoxical embolism score. After a median follow-up of 3 years, there were no differences in stroke events, but women exhibited a higher rate of combined (stroke and transient ischemic attack) cerebrovascular events and bleeding complications. Additional studies are warranted to clarify sex-related outcomes after PFO closure further.

Is Transcatheter Aortic Valve Replacement Futile in Patients Over Ninety Years of Age?

Background

Clinical outcomes and quality of life (QoL) indices are not well described after transcatheter aortic valve replacement (TAVR) in patients aged ≥ 90 years.

Methods

We conducted a retrospective cohort study of TAVR among nonagenarian patients between 2008 and 2020. The survival of TAVR patients among nonagenarians was compared to the provincial estimated survival for an age- and sex-matched general population. QoL was assessed up to 1 year postintervention, using standardized questionnaires.

Results

During the study period, n = 268 patients aged ≥ 90 years were evaluated for severe aortic stenosis. TAVR was performed in n = 171 (48% female; median [IQR] Rockwood Clinical Frailty Scale score: 4 [3-4]); n = 84 underwent medical therapy; and n = 13 underwent surgical aortic valve replacement. Survival was significantly better following TAVR, compared to that after MT (adjusted hazard ratio [95% CI]: 1.99 [1.37-2.88], P < 0.001). TAVR patients demonstrated a survival advantage compared with the general population, with an estimated relative mortality of 0.86 (0.75-0.87). TAVR patients showed sustained improvements in functional status and QoL up to 1 year compared to baseline (all P < 0.05): the 6-minute walk test results improved from 192 to 252 m; the Kansas City Cardiomyopathy Questionnaire score improved from 64 to 81; the Duke Activity Status Index score improved from 13 to 16; and the health state scale result of the Euro Quality of life - 5 Dimensions improved from 63% to 74%.

Conclusions

Nonagenarians undergoing TAVR experience a slightly better survival rate, compared to that of an age- and sex-matched general population, and they have significant improvements in functional status and several QoL indices following the procedure.

Incidence, Predictors, and Prognostic Impact of Bleeding Events After TAVR According to VARC-3 Criteria

BACKGROUND

The updated Valve Academic Research Consortium (VARC) definition for bleeding events after transcatheter aortic valve replacement (TAVR) lacks of clinical validation.

OBJECTIVES

The aim of this study was to determine the incidence, predictors, and clinical impact of bleeding events following TAVR as defined by recent VARC-3 criteria.

METHODS

A total of 2,384 consecutive patients with severe symptomatic aortic stenosis undergoing TAVR were included. Early (at index hospitalization) and late (after hospital discharge) bleeding complications were defined according to VARC-3 criteria as type 1, 2, 3, or 4. Baseline, procedural, and follow-up (24 [IQR: 12-43] months) data were prospectively collected.

RESULTS

Bleeding events occurred in 761 patients (31.9%): types 1, 2, 3, and 4 in 169 (22.2%), 399 (52.4%), 149 (19.6%), and 44 (5.8%) patients, respectively. The primary vascular access site and gastrointestinal locations were the most common bleeding sources among early and late bleeding events, respectively. Female sex, thoracotomy access, larger (14-F) sheath use, and dual antiplatelet therapy determined an increased risk of early bleeding events (P < 0.02 for all). The use of the radial artery for secondary access was associated with a significant risk reduction of early bleeding (P < 0.001). Type 2 and type 3 events were associated with an increased mortality risk at 30-day (HR: 2.94 [95% CI: 1.43-6.03; P = 0.003] and HR: 4.91 [95% CI: 2.19-11.03; P < 0.001], respectively) and 1-year (HR: 1.86 [95% CI: 1.28-2.69; P = 0.001] and HR: 2.28 [95% CI: 1.41-3.66; P = 0.001], respectively) follow-up. A similar prognostic pattern was observed when applying VARC-2 criteria but with a much lower global incidence of early bleeding events (19% vs 27%; P < 0.001).

CONCLUSIONS

Bleeding events after TAVR were associated with poorer short- and long-term survival. The magnitude of this correlation was proportional to bleeding severity defined according to VARC-3 criteria. Further studies on bleeding prevention following TAVR are warranted to improve procedural safety and patient prognosis.

Cerebrovascular Events in Older Patients With Patent Foramen Ovale: Current Status and Future Perspectives

Patent foramen ovale (PFO) closure, along with medical therapy, has emerged as the therapeutic gold standard in younger (<60-year-old) patients with a PFO-related stroke for preventing recurrent events. However, PFO management guidelines lack definite recommendations for older (>60 years) patients with a PFO-related cerebrovascular event, a complex group of patients who were mostly excluded from PFO closure clinical trials. Nevertheless, several studies have shown a higher prevalence of PFO among older patients with cryptogenic stroke, and its presence has been associated with an increased risk of recurrent events. Furthermore, older patients exhibit a higher prevalence of high-risk PFO anatomical features, present inherent age-related risk factors that might increase the risk of paradoxical embolism through a PFO, and have a higher incidence of ischemic events after a PFO-related event. Additionally, observational studies have shown the safety and preliminary efficacy of PFO closure in older PFO-related stroke patients. Yet, higher rates of recurrent cerebrovascular events and new-onset atrial fibrillation were observed in some studies among older patients compared to their younger counterparts. After careful case-by-case evaluation, including the assessment of hidden potential cardioembolic sources of a cryptogenic stroke other than PFO, transcatheter PFO closure might be a safe and effective therapeutic option for preventing recurrent thromboembolic events in patients >60 years with a high-risk PFO-associated stroke. Ongoing trials will provide important insights into the role of PFO closure in the elderly population.

Transcatheter Patent Foramen Ovale Closure in Patients With Transient Ischemic Attack

Limited data exist on patients with a transient ischemic attack (TIA) who underwent patent foramen ovale (PFO) closure. The objectives of this study were to determine the clinical and procedural characteristics and long-term outcomes of patients with TIA who underwent transcatheter PFO closure. This was a multicenter study including 1,012 consecutive patients who underwent PFO closure after a cerebrovascular event. Patients were divided into 2 groups according to their index event leading to PFO closure: TIA (n = 183 [18%]), and stroke (n = 829 [82%]). The median follow-up was 3 (2 to 8) years (complete in 98% of patients). There were no significant differences between patients with TIA and stroke, except for a lower Risk of Paradoxical Embolism score in the TIA group (6.1 vs 6.9 in the stroke group, p <0.001). PFO closure was successful in all patients with a low rate of complications (<1%) in both groups. There were no differences in the incidence of neurologic events during long-term follow-up. There was 1 stroke event in the TIA group and 6 in the stroke group (0.08 vs 0.17 per 100 patients-years, p = 0.584). There were 2 TIA events in the TIA group and 10 in the stroke group (0.17 vs 0.28 per 100 patients-years, p = 0.557). In conclusion, our study showed that patients with TIA who underwent PFO closure have similar clinical characteristics as patients with stroke including a high Risk of Paradoxical Embolism score. Furthermore, these results suggest that PFO closure procedural results and long-term clinical outcomes are similar to their stroke counterparts, with a very low incidence of recurrent neurologic events. Further prospective randomized clinical trials are needed on this population.

Health Impact of Adverse Childhood Experiences Among Youths in Custody: The Significant Contribution of Sexual Abuse

BACKGROUND: Growing evidence suggests a graded relationship between adverse childhood experiences (ACE) and unfavorable health outcomes as early as in the teenage years. Youths under the welfare protection system represent an especially vulnerable group - presenting traumatic personal trajectory while cumulating family related-risk factors. Among early life adversities, specific experience might have a greatest contribution on the long-term health-risk.

OBJECTIVES: The objective of this analysis is to evaluate the contribution of sexual abuse as compare to other ACEs on different health issues in adolescent under court custody.

DESIGN/METHODS: This is a secondary analysis from a cross-sectional health evaluation study of youths in custodial facilities (2011-13). A total of 315 teenagers 14-17 y.o. (134 girls, 181 boys) completed a self-reported questionnaire about their health status and were then evaluated by a nurse/ doctor using a comprehensive standardized data collection checklist. We identified 8 ACEs: (1) single family; (2) violent death of family member; family history of (3) incarceration, (4) mental health issues, (5) substance abuse; personal history of (6) intrafamilial or (7) extrafamilial physical abuse; personal history of (8) sexual abuse. Multiple and logistic regression were performed between the ACEs and a number of relevant variables.

RESULTS: A personal history of sexual abuse was the most consistant ACE predicting negative health outcomes including perceived health status (R2=0.04; p=0.05), number of health problems identified / acute or chronic (p=0.00), psychosomatic complaints (R2=0.12; p=0.00), sleeping problems (OR=2.8; p=0.005), medication (OR=3.5; p=0.01). This trauma was also the most important factor for high-risk sexuality items evaluated: number of sexuality-related problems in girls (R2=0.15; p=0.00), vaginal sex before 13 y.o. (OR=1.8; p=0.48), number of partners (R2=0.04; p=0.03), sex work (OR=9.6; p=0.00), fear of STI (OR=3.2; p=0.001), as it was for mental health issues: mental health disorders (OR=4.3; p=0.00), suicidal ideation (OR=4.0; p=0.00), suicidal attempt (OR=3.6; p=0.00), self-inflicting injuries (R2=0.12 ; p = 0.01), depression (R2=0.08 ; p=0.00), low self-esteem (R2=0.07; p=0.00) and overdose (OR=2.1; p=0.02).

CONCLUSION: Among ACEs, a personal history of sexual abuse seems to be the most contributing factor for significant health outcomes. Some traumatic or adverse childhood events have a greater burden on subsequent health-risk. A simple question could help identified those at higher risk and higher needs for health services in teens under custody.

Oestrogen and testosterone modulate the firing activity of dorsal raphe nucleus serotonergic neurones in both male and female rats

Women are twice as likely to suffer from mood disorders than men. Moreover, a growing body of evidence suggests a reciprocal modulation between sex steroids and the serotonin (5-HT) system. A previous study from our laboratory has shown that the progesterone metabolites 5beta-pregnane-3,20-dione (5beta-DHP) and 5alpha-pregnan-3alpha-ol,20-one (3alpha,5alpha-THP), as well as dehydroepiandrosterone (DHEA), increase the firing activity of dorsal raphe nucleus (DRN) 5-HT neurones in female rats. The present study was undertaken to assess the effects of these steroids in male rats, as well as the effects of testosterone and 17beta-oestradiol (17beta-E) in both sexes, and finally to evaluate gender differences in the modulation of the 5-HT neuronal firing activity by these different neuroactive steroids. Male rats were treated i.c.v., for 7 days, with a dose of 50 microg/kg/day of one of the following steroids: progesterone, 5beta-DHP, 3alpha,5alpha-THP, DHEA, testosterone, 17beta-hydroxy-5alpha-androstan-3-one (5alpha-DHT) and 17beta-E. Some rats also received a 3-day administration of testosterone (50 microg/kg/day, i.c.v). Females were treated in the same fashion with testosterone and 17beta-E. Extracellular unitary recordings of 5-HT neurones, obtained in vivo in the DRN of these rats, revealed that testosterone and 17beta-E increased the firing activity of 5-HT neurones in both males and females. In males, the effect of testosterone could already be seen after 3 days of treatment. Neither castration nor any treatment with other steroids significantly modified the firing rate of male 5-HT neurones. Taken together with previous findings, the results of the present study indicate both similarities and differences between sexes in the modulation of 5-HT neurones by some steroids. This could prove important in understanding gender differences in mood disorders.

Modulation of the firing activity of female dorsal raphe nucleus serotonergic neurons by neuroactive steroids

Important gender differences in mood disorders result in a greater susceptibility for women. Accumulating evidence suggests a reciprocal modulation between the 5-hydroxytryptamine (5-HT) system and neuroactive steroids. Previous data from our laboratory have shown that during pregnancy, the firing activity of 5-HT neurons increases in parallel with progesterone levels. This study was undertaken to evaluate the putative modulation of the 5-HT neuronal firing activity by different neurosteroids. Female rats received i.c.v. for 7 days a dose of 50 micro g/kg per day of one of the following steroids: progesterone, pregnenolone, 5beta-pregnane-3,20-dione (5beta-DHP), 5beta-pregnan-3alpha-ol,20-one, 5beta-pregnan-3beta-ol,20-one, 5alpha-pregnane-3,20-dione, 5alpha-pregnan-3alpha-ol,20-one (allopregnanolone, 3alpha,5alpha-THP), 5alpha-pregnane-3beta-ol,20-one and dehydroepiandrosterone (DHEA). 5beta-DHP and DHEA were also administered for 14 and 21 days (50 micro g/kg per day, i.c.v.) as well as concomitantly with the selective sigma 1 (sigma1) receptor antagonist NE-100. In vivo, extracellular unitary recording of 5-HT neurons performed in the dorsal raphe nucleus of these rats revealed that DHEA, 5beta-DHP and 3alpha,5alpha-THP significantly increased the firing activity of the 5-HT neurons. Interestingly, 5beta-DHP and DHEA showed different time-frames for their effects with 5beta-DHP having its greatest effect after 7 days to return to control values after 21 days, whereas DHEA demonstrated a sustained effect over the 21 day period. NE-100 prevented the effect of DHEA but not of 5beta-DHP, thus indicating that its sigma1 receptors mediate the effect of DHEA but not that of 5beta-DHP. In conclusion, our results offer a cellular basis for potential antidepressant effects of neurosteroids, which may prove important particularly for women with affective disorders.

Gender and gonadal status modulation of dorsal raphe nucleus serotonergic neurons. Part I: effects of gender and pregnancy

Gender differences in susceptibility to affective disorders are well documented. The ovarian steroids, estrogen (E) and progesterone (P), may modulate the function of the serotonergic (5-HT) system, implicated in the etiology and treatment of affective disorders. We tested the hypothesis that ovarian steroid modulation of 5-HT function could result in a modification of the 5-HT neuronal firing activity. Extracellular unitary recordings of dorsal raphe nucleus 5-HT neurons were obtained in male rats and in female rats during natural E and P fluctuations. The average firing activity of 5-HT neurons was significantly higher in males (41%) than in freely cycling (CF) and in ovariectomized (OVX) females. During pregnancy, it increased gradually and by up to 136% on gestational day 17, then declined before parturition. In the postpartum period (PP), the firing rate decreased markedly compared to P17 but remained 63% higher than in CF. During pregnancy, the firing rate variations were closely correlated with P plasmatic levels. Finally no modification of the basal firing activity of locus coeruleus noradrenergic neurons was found in any group tested. Our results thus reveal a gender and pregnancy-dependent modulation of 5-HT firing rate that would impact 5-HT-mediated neurotransmission.

Establishment and comprehensive analysis of a new human transformed follicular lymphoma B cell line, Tat-1

A spontaneously EBV transformed follicular lymphoma (FL) cell line, Tat-1, was established from the lymph node biopsy specimen of a patient with B cell FL, grade 1 in transformation to high grade disease. Tat-1 cells expressed lymphoid markers and developed tumor masses in immunodeficient mice. Bcl-2, Bcl-X(L), Bax and p53 protein expression was revealed by Western blotting. Flow cytometric analysis confirmed P-gp expression. Cytogenetically, the Tat-1 cell line showed identical chromosomal alterations to that of the initial biopsy specimen, among which the most notable were the t(14;18) typical of FL and additional abnormalities involving chromosomes 1, 8 and 13. Multicolor FISH analysis delineated all abnormalities, including a t(1p;8q), a der(8)(8q24::14q32::18q21) and a der(13)(13q32::8q24::14q32::18q21). Further FISH investigations using a locus-specific probe cocktail containing c-myc, IgH and bcl-2 revealed fusion of these three loci on the derivatives 8 and 13, in addition to the derivative 14 IgH/bcl-2 fusion and an extra copy of c-myc on derivative chromosome 1. These results demonstrate an additional example of the deregulation of bcl-2 and c-myc expression through recombination with a single IgH enhancer region. The unusual molecular features of the Tat-1 cell line render it a unique tool for studies focused on cytogenetic alterations, expression of multidrug resistance phenotype and expression of anti-apoptotic proteins in FL.

Effects of bilateral olfactory bulbectomy on N-methyl-D-aspartate receptor function: autoradiographic and behavioral studies in the rat

Rat bilateral olfactory bulbectomy (OBX) serves as a useful model in the study of depression and the mechanisms of action of antidepressant treatments. Considering the evidence of NMDA receptors involvement in depression, the present study was undertaken in order to investigate the time-course effects of OBX on the NMDA receptor function. Following bilateral olfactory bulbectomy, rats display an increase in locomotor activity and changes in other types of behavior in a novel environment. Autoradiographic experiments using the noncompetitive NMDA antagonist [(125)I]-iodo-MK-801 as the labeling agent showed that this increase in behavioral activities corresponds to a decrease in [(125)I]-iodo-MK-801 binding in a number of brain regions. In most regions, this reduction reached significance by the third week following OBX. However, in some cortical areas-a nucleus of the thalamus (AV) and one of the amygdala (LA)-this reduction was already significant in the first or second week following OBX and lasted throughout the 4 weeks of the study. We also compared the behavioral modifications induced by a challenge injection of MK-801 (0.2 mg/kg i.p.) in OBX and sham-operated rats. This challenge is known to induce hyperlocomotion and a number of stereotypies in naive rats. These effects were drastically reduced in OBX as compared to sham-operated rats. These data are consistent with the above-mentioned decrease in cerebral binding of MK-801 to NMDA receptors.

Fluidization characteristics of and protein adsorption on fluoride-modified porous zirconium oxide particles

Porous zirconia particles of specific gravity approximately 3.2 g/ml, mean particle sizes of approximately 50 microns, and terminal settling velocity of approximately 2.8 mm/s in water, were synthesized using an oil emulsion method from 1000 A colloids and were evaluated for their potential use in expanded bed protein adsorption. Expanded beds of particles were stable even for small volume, shallow beds (settled bed: 10 ml, height to diameter ratio < 1.0) and even for fluidization velocities common to much larger particles (210 cm/h for a three-fold bed expansion). When the surface of these particles was modified by fluoride adsorption, the total bed capacity for bovine serum albumin (BSA) adsorption was 42 +/- 2 mg BSA/ml of settled bed volume at linear velocities of 109-210 cm/h. Residence time distribution studies of several solutes under non-binding conditions were performed to assess the degree of liquid mixing and channeling in the expanded bed as a function of fluidization velocity. Liquid mixing and channeling were also studied as a function of distributor design. With these very dense particles, the degree of channeling and mixing did not worsen with the degree of expansion. Elution of adsorbed BSA while the bed was expanded (by a step increase in ionic strength) was rapid resulting in a narrow peak at high fluidization velocities without resorting to settling of the bed. The dynamic binding capacity of BSA at 5% breakthrough (protein effluent concentration equal to 5% of the inlet concentration) was the same for a two-fold expanded bed as for a settled bed (22 +/- 2 mg BSA/ml of settled bed volume), though it decreased for higher bed expansions. BSA binding was reproducible following repeated cleaning of the adsorbent with 0.25 M sodium hydroxide.

Immunophenotyping of acute leukemia at King Faisal Specialist Hospital and Research Centre

During a 20 month period, 133 bone marrow samples from an equal number of patients with acute leukemia were immunophenotyped. Patients ranged in age from two to 68 years with a mean of 23 years. Eighty-four (63.2%) were classified as acute lymphocytic leukemia (ALL) with the following immunologic subclassification: common ALL 83.3%, T-cell ALL 11.9%, null-cell ALL 2.4% and 2.4% differentiated B-cell ALL. Twenty-eight cases (21%) were classified as acute myeloid leukemia (AML) and 16 cases (12%) demonstrated biphenotypic features. Concordance with morphology and cytochemistry was observed in 129 cases (97%). Four cases (3%) manifested discrepancy between immunophenotyping, morphology and cytochemistry. We conclude that immunophenotyping by flow cytometry is a useful and reliable method for classification of acute leukemia, especially when interpreted in the light of morphology and cytochemistry.