Trigger factors in patients with a patent foramen ovale-associated stroke: A case-crossover study

BACKGROUND

Patent foramen ovale (PFO) is a congenital anatomical variant which is associated with strokes in young adults. Contrary to vascular risk factors and atherosclerosis, a PFO is present from birth. However, it is completely unknown how an anatomical structure that is already present at birth in a large proportion of the population can convert into a PFO that causes stroke in a few. Recent studies reported a significant association between certain trigger factors and ischemic stroke in young adults. This study aims to investigate these triggers in PFO-associated stroke.

METHODS

The ODYSSEY study, a multicenter prospective cohort study between 2013 and 2021, included patients aged 18-49 years experiencing their first-ever ischemic event. Participants completed a questionnaire about exposure to potential trigger factors. A case-crossover design was used to assess the relative risks (RR) with 95% confidence intervals (95% CI). The primary outcome was the RR of potential trigger factors for PFO-associated stroke.

RESULTS

Overall, 1043 patients completed the questionnaire and had an ischemic stroke, of which 124 patients had a PFO-associated stroke (median age 42.1 years, 45.2% men). For patients with PFO-associated stroke, the RR was 26.0 (95% CI 8.0-128.2) for fever, 24.2 (95% CI 8.5-68.7) for flu-like disease, and 3.31 (95% CI 2.2-5.1) for vigorous exercise.

CONCLUSION

In conclusion, flu-like disease, fever, and vigorous exercise may convert an asymptomatic PFO into a stroke-causing PFO in young adults.

DATA ACCESS STATEMENT

The raw and anonymized data used in this study can be made available to other researchers on request. Written proposals can be addressed to the corresponding author and will be assessed by the ODYSSEY investigators for appropriateness of use, and a data sharing agreement in accordance with Dutch regulations will be put in place before data are shared.

Pemphigus: trigger and predisposing factors

Pemphigus is a life-threatening autoimmune blistering disease affecting skin and mucous membranes. Despite its etiopathogenesis remains largely unknown, several trigger and predisposing factors have been reported. Pemphigus is caused by autoantibodies that target desmoglein 1 and desmoglein 3, impacting desmosome function. However, circulating autoantibodies are often the consequence of a precipitating factor that occurs in predisposed individuals. This review aims to describe and discuss almost all trigger and predisposing factors reported as possible or probable cause of the disease. Among the reported trigger factors that may induce or exacerbate pemphigus, we have found of particular interest: drug intake (especially thiol- and phenol-containing compounds), vaccines, infections, as well as some reports about pregnancy, radiations, emotional stress, pesticides and physical trauma. Moreover, we discuss the possible role of food intake in pemphigus onset and particular attention is given to dietary factors containing thiol, phenol and tannin compounds. A trigger factor is "the straw that breaks the camel's back," and often acts together with predisposing factors. Here we discuss how pemphigus onset may be influenced by genetic susceptibility and comorbidities like thyroid diseases, malignancies and other autoimmune disorders. To identify other hitherto unknown trigger and predisposing factors, well designed prospective studies are needed. In this context, future research should explore their connection with the aim to advance our understanding of pemphigus pathogenesis.

New-Onset Atrial Fibrillation in the Critically Ill COVID-19 Patients Hospitalized in the Intensive Care Unit

New-onset atrial fibrillation (NOAF) is the most frequently encountered cardiac arrhythmia observed in patients with COVID-19 infection, particularly in Intensive Care Unit (ICU) patients. The purpose of the present review is to delve into the occurrence of NOAF in COVID-19 and thoroughly review recent, pertinent data. However, the causality behind this connection has yet to be thoroughly explored. The proposed mechanisms that could contribute to the development of AF in these patients include myocardial damage resulting from direct virus-induced cardiac injury, potentially leading to perimyocarditis; a cytokine crisis and heightened inflammatory response; hypoxemia due to acute respiratory distress; disturbances in acid-base and electrolyte levels; as well as the frequent use of adrenergic drugs in critically ill patients. Additionally, secondary bacterial sepsis and septic shock have been suggested as primary causes of NOAF in ICU patients. This notion gains strength from the observation of a similar prevalence of NOAF in septic non-COVID ICU patients with ARDS. It is plausible that both myocardial involvement from SARS-CoV-2 and secondary sepsis play pivotal roles in the onset of arrhythmia in ICU patients. Nonetheless, there exists a significant variation in the prevalence of NOAF among studies focused on severe COVID-19 cases with ARDS. This discrepancy could be attributed to the inclusion of mixed populations with varying degrees of illness severity, encompassing not only patients in general wards but also those admitted to the ICU, whether intubated or not. Furthermore, the occurrence of NOAF is linked to increased morbidity and mortality. However, it remains to be determined whether NOAF independently influences outcomes in critically ill COVID-19 ICU patients or if it merely reflects the disease's severity. Lastly, the management of NOAF in these patients has not been extensively studied. Nevertheless, the current guidelines for NOAF in non-COVID ICU patients appear to be effective, while accounting for the specific drugs used in COVID-19 treatment that may prolong the QT interval (although drugs like lopinavir/ritonavir, hydrochlorothiazide, and azithromycin have been discontinued) or induce bradycardia (e.g., remdesivir).

Clinical Course and Recurrence in Transient Global Amnesia: A Study From the TEMPiS Telestroke Network

BACKGROUND AND PURPOSE

While the clinical hallmarks of transient global amnesia (TGA) are well defined, its pathophysiological causes are poorly understood. Specifically, risk factors for recurrences are yet to be determined.

METHODS

This retrospective study analyzed TGA cases diagnosed and treated within the TEMPiS telestroke network and a university stroke center in Germany. Demographic and clinical data were assessed and characteristics of TGA episodes were recorded, such as season of occurrence, trigger factors, duration, and concomitant symptoms. Follow-up of the potential recurrence of TGA was performed using a standardized questionnaire.

RESULTS

Overall 109 patients were included (age 64±8 years [mean±SD], 59.6% female). The most common vascular risk factor was arterial hypertension (60.6%), and other concomitant conditions included migraine (11.9%), hypothyroidism (22.9%), and atrial fibrillation (4.6%). The most frequent concomitant clinical feature accompanying the TGA episode at admission was elevated blood pressure (48.6%). Nineteen patients experienced at least one recurrent TGA episode. Migraine and hypothyroidism were only observed in subjects with a single TGA episode without recurrence (migraine: 14.4% without recurrence vs. none in the recurrence group, p=0.02; hypothyroidism: 27.8% without recurrence vs. none in the recurrence group, p=0.009). In contrast, atrial fibrillation was more common in subjects with TGA recurrence (p<0.001).

CONCLUSIONS

Arterial hypertension is prevalent in TGA patients, with elevated blood pressure being the most-frequent concomitant condition. In our cohort, recurrence of TGA occurred in approximately one-fifth of patients. Concomitant conditions such as migraine, hypothyroidism, and atrial fibrillation occurred at different frequencies in the two groups.

Migraine management: Non-pharmacological points for patients and health care professionals

Migraine is a highly prevalent disorder with an enormous burden on societies. Different types of medications are used for controlling both acute attacks and prevention. This article reviews some non-pharmacological recommendations aiming to manage migraine disorder better and prevent headache attacks. Different triggers of migraine headache attacks, including environmental factors, sleep pattern changes, diet, physical activity, stress and anxiety, some medications, and hormonal changes, are discussed. It is advised that they be identified and managed. Patients should learn the skills to cope with the trigger factors that are difficult to avoid. In addition, weight control, management of migraine comorbidities, lifestyle modification, behavioural treatment and biofeedback, patient education, using headache diaries, and improving patients' knowledge about the disease are recommended to be parts of migraine management. In addition, using neuromodulation techniques, dietary supplements such as riboflavin, coenzyme Q10 and magnesium, and acupuncture can be helpful. Non-pharmacological approaches should be considered in migraine management. Furthermore, the combination of pharmacological and non-pharmacological approaches is more effective than using each separately.

Hidradenitis Suppurativa: The Influence of Gender, the Importance of Trigger Factors and the Implications for Patient Habits

Hidradenitis suppurativa (HS) is a debilitating, chronic, inflammatory skin disease primarily affecting apocrine gland-rich areas of the body. On the one hand, the presence of triggering factors-some identified, others only hypothesized-may initiate or perpetuate the pathogenic process of HS. In addition to cigarette smoking and diet, other trigger factors, including choice of clothing, are frequently observed in clinical practice. On the other hand, the presence of disease may influence habits of HS patients. Indeed, high incidences of sexual and sleep impairment have been reported in these patients. Consequently, alcohol and substance abuse may be a coping strategy for the emotional and psychological disease burden. Furthermore, a greater awareness of gender differences in HS may be important for dermatologists in their own clinical practice (i.e., pregnancy and breastfeeding). Consequently, in this loop interaction, comprehensive knowledge of all factors involved is crucial for the management of HS patients. Thus, the objective of this review is to (i) discuss the influence of gender on HS, (ii) summarize the most frequent triggering factors of HS and (iii) analyze the impact of HS on patient habits.

Eczema-related Web Search Data in Sweden: Investigating Search Patterns and the Influence of Weather

As atopic eczema is triggered by environmental factors, such as temperature, differences in disease burden between and within countries are possible. One method to study this phenomenon is to perform web-search analysis, since the internet is commonly used to retrieve health-related information. This study, investigating the Google search volume regarding eczema in Swedish counties between April 2017 and March 2021, revealed a continuous increase in number of searches and that the search volume was higher in Northern than Southern Sweden. Gotland had the most searches per 100,000 inhabitants. In general, there was a negative correlation between search volume and temperature (r=-0.315, p < 0.001) and hours of sunshine (r=-0.213, p < 0.001), whereas there was a positive association between search volume and wind (r=0.229, p < 0.001). Search engine analysis is a rapid and cost-effective method of examining search behaviour regarding disease among the general population within a country and, thus, can enable the identification of regions with specific interests and needs.

Clinical Profile of Tension Type Headache in a Medical College with Special Emphasis on Triggering Factors

BACKGROUND AND OBJECTIVES

Tension type headache is one of the costliest primary headaches which can cause a significant impact on an individual's life. Healthcare professionals are exposed to multiple trigger factors which give rise to an increase in headache frequency, most notable reasons being sleep disturbances, stress and untimely food habits. With this background, we conducted this study of detailed clinical profile and trigger factors among the 2050 subjects (MBBS students: 909, BDS students: 323, nursing students: 268, postgraduates students and staff: 550) in our medical institute.

MATERIALS AND METHODS

Subjects were given questionnaires on headache and were instructed to give the details of their clinical symptoms along with relevant questions on trigger factors. The assessment tools used were the Visual Analogue Scale (VAS) and Migraine Disability Assessment Scale (MIDAS).

RESULTS

Out of 2050 subjects, 464 patients suffered from tension type headache. Overall prevalence of tension type headache was 22.6%. Prevalence was higher in females (57.9%) as compared to males (42.1%). Headache experienced by majority of the student population was unilateral (31.4%), pulsating type (51.6%) and of moderate intensity (77.1%). Common associated symptoms were nausea associated with other factors (40%) and photophobia and phonophobia (18.6%). Stress (72.1%) and decreased sleep (49.4%) were the most common triggering factors. Practice of self-medication was reported by 80.2% of subjects.

CONCLUSION

Our study noted a high frequency of trigger factors in medical professionals, the most common triggering factors being stress and disturbed sleep. To our knowledge this is the first large study to evaluate headache and specifically tension type headache among medical professionals.

Bullous Pemphigoid: Trigger and Predisposing Factors

Bullous pemphigoid (BP) is the most frequent autoimmune subepidermal blistering disease provoked by autoantibodies directed against two hemidesmosomal proteins: BP180 and BP230. Its pathogenesis depends on the interaction between predisposing factors, such as human leukocyte antigen (HLA) genes, comorbidities, aging, and trigger factors. Several trigger factors, such as drugs, thermal or electrical burns, surgical procedures, trauma, ultraviolet irradiation, radiotherapy, chemical preparations, transplants, and infections may induce or exacerbate BP disease. Identification of predisposing and trigger factors can increase the understanding of BP pathogenesis. Furthermore, an accurate anamnesis focused on the recognition of a possible trigger factor can improve prognosis by promptly removing it.

A Prospective Study Examining Trigger Factors and Hormonal Abnormalities in Adult Female Acne

Background:

Numerous triggers have been implicated in adult female acne including endogenous (hormonal dysfunction and genetic predisposition) and exogenous causes (drugs, cosmetics, sunscreens, stress, and smoking).

Aims:

To evaluate the role of various trigger factors in adult female acne and to analyze the androgenic hormone pattern including anti-Mullerian hormone (AMH) in these patients.

Materials and Methods:

Patients having acne of age ≥25 years were analyzed using a pre devised proforma to elicit trigger factors while the severity was graded using the Global Acne Grading System (GAGS). A detailed hormonal assessment was undertaken that assessed total testosterone (TT), sex hormone-binding globulin (SHBG), free androgen index (FAI), AMH, 17-hydroxyprogesterone (17-OHP), dehydroepiandrosterone sulfate (DHEAS), follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid-stimulating hormone (TSH), and prolactin.

Results:

Out of the 165 cases seen and sub-analyzed for triggers, premenstrual flare, diet, cosmetics, and stress were the most commonly implicated causes. Among cosmetics, fairness creams and foundations were implicated. The hormonal analysis revealed deranged values of all hormones with the most common being 17-OHP and AMH. Almost 42.8% patients with DHEAS derangement and 58.75% females with raised 17-OHP suffered from moderate to severe stress.

Limitations:

A prospective cohort correlation study of the implicated triggers is needed to confirm the association with adult female acne.

Conclusions:

Adult female acne may be triggered by diet, stress, and cosmetics and there is a distinct hormonal milieu that accounts for hyperandrogenemia. We noted high levels of adrenal androgens which have been known to be associated with stress and sleep deprivation. Our study shows the value of counseling adult female acne patients about various acne triggers.

Reporting trigger factors for (hypo)manic episodes in bipolar disorder: association with personality and prognosis

OBJECTIVE

To investigate external factors that trigger manic and hypomanic relapses and how this is associated with personality and clinical outcome measured as number of affective episodes over a 7-year period.

METHOD

This is a prospective cohort study of 204 meticulously characterized Swedish bipolar disorder patients. Personality was evaluated at baseline using the Swedish universities Scales of Personality in 170 patients, and 90 patients were followed up after approximately 7 years in order to evaluate clinical outcomes.

RESULTS

We found that 44% of the patients reported trigger factors, including sleep disturbance, work- or family-related issues, medication, and illicit drug use. There were no significant differences in any of the personality traits when comparing the 74 patients that reported triggers with the 90 patients that did not. At 7-year follow-up, there was no difference between the groups in number of affective episodes (depressive, hypomanic, manic, or mixed), involuntary commitments, suicide attempts, or self-harm incidents since baseline.

CONCLUSIONS

Around 40% of the patients reported external triggers for manic and hypomanic episodes. However, this was neither associated with personality traits nor number of affective episodes at 7-year follow-up.

Pediatric urticaria in the Emergency Department: epidemiological characteristics and predictive factors for its persistence in children

Summary

Introduction. Acute urticaria (AU) in children is a common clinical manifestation responsible for admission to the emergency department (ED). We aimed to analyze the epidemiological characteristics of AU in children and to identify predictors of both severity and progression. Material and methods. We evaluated 314 children admitted to the ED with a diagnosis of AU. We analyzed information concerning its onset, duration, severity, possible triggering factors, and the persistence of symptoms after 1, 3, and 6 months. Results. The most common etiological factors were infections (43.9%); in up to 32.4% of cases, AU was considered as idiopathic. AU was significantly most common in males and pre-school children. At the 6-month follow-up, 9.5% of children presented a persistence of urticaria, mainly those with contact (44.4%) or idiopathic (30.4%) forms. Conclusions. The AU etiology identified by history in the ED may be a significant predictor of persistence after a first attack of AU.

Migraine headache facilitators in a population of Polish women and their association with migraine occurrence - preliminary results

AIM OF THE STUDY

. The occurrence of migraine is linked with some common lifestyle activities and conditions preceding the attack. Our study presents known and presumptive lifestyle factors and activities related to migraine, and compares them to the frequency of headache attacks.

MATERIAL AND METHODS

40 female patients of the Headache Outpatient Clinic in Warsaw, Poland, diagnosed with migraine, mean age 44.6 years, and 40 female participants from the control group, mean age 39.5 years, were included in the study. The study employed questionnaires reporting the presence of lifestyle factors and socioeconomic predispositions as well as the Migraine Disability Assessment Test (MIDAS) as data collection methods.

RESULTS

Correlations between some of the lifestyle factors and the frequency of migraines occurred statistically significantly.

CONCLUSIONS

Some factors and lifestyle activities such as stress, relaxation, specific dietary products, fasting, fatigue, bright light, noise, weather changes or menstruation may have an influence on migraine frequency and severity in female patients, which can have an impact on migraine prevention.

[Transient, recurrent, white matter lesions in X-linked Charcot-Marie-Tooth disease with heterozygote mutation of GJB1 gene: case report of a female patient]

A 32-year-old woman showed transient central type facial nerve palsy and bulbar symptoms. Brain MRI revealed high intensity signals in the cerebral white matter, splenium of corpus callosum, and posterior limb of internal capsule. Two elder brothers of the patient had distal dominant peripheral neuropathies in four limbs. In this family, the point mutation of GJB1 gene, encoding connexin 32, was revealed and X-linked Charcot-Marie-Tooth disease (CMTX1) was diagnosed. The presented case was a heterozygote of this mutation. She showed severe transient central nervous system (CNS) symptoms and subclinical demyelinating peripheral neuropathy. The CNS symptoms and alterations of brain images were very similar among three siblings. There are many reports on male patients with CMTX1 who show associated CN symptoms, but female patients are very rare. There has been no previous report of a CMTX1 patient similar to the patient presented here. The trigger factors have been recognized at the onset of transient CN symptoms in these cases. The prevention of these factors is important for the management of such patients.

Cluster headache - clinical pattern and a new severity scale in a Swedish cohort

Background The aim of this study was to investigate clinical features of a cluster headache cohort in Sweden and to construct and test a new scale for grading severity. Methods Subjects were identified by screening medical records for the ICD 10 code G44.0, that is, cluster headache. Five hundred participating research subjects filled in a questionnaire including personal, demographic and medical aspects. We constructed a novel scale for grading cluster headache in this cohort: The Cluster Headache Severity Scale, which included number of attacks per day, attack and period duration. The lowest total score was three and the highest 12, and we used the Cluster Headache Severity Scale to grade subjects suffering from cluster headache. We further implemented the scale by defining a cluster headache maximum severity subgroup with a high Cluster Headache Severity Scale score ≥ 9. Results A majority (66.7%) of the patients reported that attacks appear at certain time intervals. In addition, cluster headache patients who were current tobacco users or had a history of tobacco consumption had a later age of disease onset (31.7 years) compared to non-tobacco users (28.5 years). The Cluster Headache Severity Scale score was higher in the patient group reporting sporadic or no alcohol intake than in the groups reporting an alcohol consumption of three to four standard units per week or more. Maximum severity cluster headache patients were characterised by higher age at disease onset, greater use of prophylactic medication, reduced hours of sleep, and lower alcohol consumption compared to the non-cluster headache maximum severity group. Conclusion There was a wide variation of severity grade among cluster headache patients, with a very marked impact on daily living for the most profoundly affected.

Rosacea: clinical features and treatment

Rosacea is a chronic inflammatory skin condition that predominantly affects the central face. It is characterised by a variable range of symptoms, including erythema, telangiectasia, papules, pustules and changes in skin texture. Rosacea may be transient, recurrent or persistent. Because it affects the most visible part of the body, the psychosocial effects of this condition can be significant. This article describes the features and management of the condition.

An epidemiological study on trigger factors and quality of life in psoriatic patients

Objective:

to evaluate the role of stress, tobacco, drugs, infections, allergies, heredity, alcohol, hormones and skin aggressions as trigger factors and the impact on quality of life in a sample of psoriasis patients.

Methods:

a transversal study performed in 90 patients affected by psoriasis between January and November 2012 at the “Nene Tereza” University Hospital, Tirane, Albania, based on two scored questionnaires.

Results:

more than 70 % of patients reported that stressful events caused a flare- up of their psoriasis (p< 0.05). More than 60% of males and 20% of females were smokers (p< 0.05). About 20% of our patients were taking one or more of the medications listed in the questionnaire (p> 0.05). About 20% of patients reported having had recurrent infections (p<0,05). About 80% of males patients consumed alcohol (p<0,05). More than 40% reported a relative with psoriasis. Statistical comparison of the group that reported skin aggressions with the group that did not revealed a significant difference (p<0,05). Only a few of them reported to have allergies (p>0,05). About 36% of females reported that hormonal changes (puberty and menopause) exacerbated their psoriasis (p<0,05). More than 40% of patients reported that psoriasis seriously affects their quality of life.

Conclusion:

stress, tobacco, infections, heredity, alcohol, hormonal changes and skin aggressions were confirmed as trigger factors for psoriasis in the present sample. Allergies and the investigated drugs seemed not to have any influence in flare-ups. We found that psoriasis had a serious impact in the quality of life in over of 40% of the patients interviewed.

Onset of acute myocardial infarction during sleep

BACKGROUND

Analysis of the chronology of acute cardiovascular events may provide important pathophysiologic information. There is a circadian pattern in the onset of acute myocardial infarction (AMI) with a mid-morning peak, ascribed to the catecholamine surge that accompanies awakening and assuming the upright posture. However, in up to 27% of patients the onset of AMI occurs during sleep (without apparent precipitating factors). The reasons for this finding are unknown.

HYPOTHESIS

The aim of the study was to determine why the onset of symptoms of AMI occurs during sleep in some individuals rather than being precipitated by known trigger factors such as physical exertion.

METHODS

Using the database from a large multicenter clinical trial, patients were grouped according to whether or not they were awakened from sleep by the symptoms of AMI.

RESULTS

In all, 870 of 3,309 patients (26%) were awakened by AMI. In general, these patients were older and sicker, with poorer left ventricular function, lower quality of life indices, more frequent heart failure, lower ejection fractions, higher incidence of angina, and a greater frequency of atrial arrhythmias. On multivariate analysis, only low ejection fraction and older age were independently associated with awakening by the symptoms of AMI.

CONCLUSIONS

Patients who are older and sicker are more likely to be awakened from sleep by the onset of symptoms of AMI. Although the reasons are unknown, we speculate that these individuals are less active and therefore less vulnerable to established trigger factors such as vigorous physical exertion.

Reproducibility of angiotensin converting enzyme inhibitor induced cough: a double-blind randomised study

1. The reproducibility of angiotensin converting enzyme inhibitor induced cough was examined in a double-blind cross over study in patients previously shown to have exhibited this side effect. 2. Ninety-seven patients who had experienced angiotensin converting enzyme inhibitor cough within the last 2 years were challenged with enalapril 20 mg daily for 4 weeks to establish eligibility. Eighty-eight of 97 (91%) patients experienced a repeat of their cough symptoms. Sixty-four patients entered the double-blind part of the study where they were treated with enalapril 20 mg and a renin inhibitor for up to 4 weeks in random order. These periods were separated by a minimum 4 week placebo wash out. 3. Of 59 evaluable patients who received enalapril a second time, 37 (62.7%) experienced cough again. Of 62 patients on the renin inhibitor 16 (25.8%) experienced cough, however as it was not equi-efficacious to enalapril no valid comparison could be made. 4. Angiotensin converting enzyme inhibitor cough is not reproducible within patients, as other factors are involved in the aetiology. Objective testing with blinded assessment together with symptom reporting, would give a more accurate measure of the incidence, and mechanism of this side effect.