Sex Differences In Clinical Presentation Research Articles

Sex differences in clinical presentation, treatment response, and side effects of nutritional therapy among patients at nutritional risk - a secondary analysis of the randomized clinical trial effort

Sex differences in clinical presentation, treatment response, and side effects of nutritional therapy among patients at nutritional risk - a secondary analysis of the randomized clinical trial effort

Sex differences in clinical presentation, treatment response, and side effects of nutritional therapy among patients at nutritional risk A secondary analysis of the randomized clinical trial EFFORT

Sex differences in clinical presentation, treatment response, and side effects of nutritional therapy among patients at nutritional risk A secondary analysis of the randomized clinical trial EFFORT

Sex-Based Differences in Clinical Characteristics of Patients with Acute Myocarditis: A Cohort Study

BackgroundThis study investigated sex differences in acute myocarditis patients during index hospitalization. MethodsWe included 365 patients with acute myocarditis, hospitalized with continuous monitoring at the intensive care unit from 2000-2023 into the Basel Myocarditis Cohort study. We compared sex differences in clinical presentation, the presenting electrocardiogram, prior medical history, inflammatory and cardiac biomarkers, cardiac imaging, arrhythmia occurrence, and short- to midterm outcomes. ResultsMean age was 41.3 years, and 26.3% were female. Compared with men, women were older (median 49.7 vs 38.3 years, P < .001) at the time of diagnosis and presented more frequently with dyspnea (41 vs 26%, P = .013) and a higher Killip class (P = .011). In the presenting electrocardiogram, men had a higher occurrence of diffuse ST-elevation (38 vs 9%, P < .001) and PQ-depression (31 vs 20%, P = .042), compared with women. Women had higher N-terminal pro B-type natriuretic peptide levels (1180 vs 387 ng/L, P = .015), lower cardiac troponin T levels (389 vs 726 ng/L, P = .006), and fewer segments with nonischemic late gadolinium enhancement on cardiac magnetic resonance imaging (1 vs 3, P = .005), but similar left ventricular ejection fraction (55 vs 55%, P = .629), compared with men. Overall, hospital stay was longer in women compared with men (7 vs 5 days, P = .018), with a similar length of intensive care unit stay (2.6 vs 2.7 days, P = .922). Women more often developed severe arrhythmia (8.3 vs 2.2%, P = .015) and heart failure during the hospitalization (31.3 vs 16.4%, P = .003). ConclusionCompared with men, women with acute myocarditis were older at the time of diagnosis, presented more often with heart failure, and had an increased frequency of severe arrhythmia.

Corrigendum to ‘‘Sex Differences in Clinical Presentation and Management in Eosinophilic Esophagitis”

Corrigendum to ‘‘Sex Differences in Clinical Presentation and Management in Eosinophilic Esophagitis”

Sex Differences in Clinical Presentation of Lower Extremity Deep Vein Thrombosis.

Background: Differences between men and women in the clinical features and extent of lower limb deep vein thrombosis (DVT) may influence DVT diagnostic algorithms involving pretest clinical probability (PTP) assessment, D-dimer, and compression ultrasonography (CUS). Aims: To assess differences in DVT clinical presentation between men and women and their effect on PTP and D-dimer. Methods: We conducted a retrospective study in outpatients referred for suspected DVT of the lower limbs to our vascular emergency department from January 2005 to December 2019. Patients underwent PTP assessment with the Wells score, D-dimer testing, and CUS. Results: More women were referred for suspected DVT than men (M/F: 1,785/2,821; F: 61.4%; p < 0.0001). Women were older than men (median age: 71 vs. 67 years; p = 0.0001), DVT was diagnosed in 436 patients (9.4%) but in more men than women (M: 210 [11.8%] vs. F: 226 [8%]; p = 0.0002), with more proximal DVT in men than women (M: 131 7.3% vs. F: 124 [4.4%]; p = 0.00021). PTP was more likely in men (355 [19.9%]) than women (455 [16.2%]) (p = 0.0011); more men had swelling in the entire limb, increased calf circumference by >3 cm compared with the contralateral limb, and pitting edema, than women. D-dimer levels (available in 65% of patients) were more frequently positive in women with DVT than in men (94.6% vs. 85.7%; p = 0.016). However, a positive D-dimer and/or likely PTP was similarly frequent in men (92%) and women (96%) with DVT. Conclusions: More women than men are referred for suspected DVT, and men have a higher prevalence of proximal DVT. However, current algorithms for DVT diagnosis perform similarly in men and in women.

414. Sex differences in clinical presentation and outcomes amongst hospitalized patients with COVID-19 in Singapore

Abstract Background Sex differences in clinical presentation and outcomes in patients with coronavirus disease 2019 (COVID-19) remain to be clearly defined. We sought to evaluate sex differences in the presentation and outcomes of COVID-19 in our Asian context. Methods We retrospectively examined 1781 consecutive patients hospitalised from 2020 to 2021, with polymerase chain reaction confirmed SARS-CoV-2 infection. Patients were divided into males and females. Baseline clinical characteristics, laboratory findings as well as clinical outcomes were compared. Adverse composite clinical outcomes were defined as requiring supplemental oxygenation, intensive care or mortality. Results Of the 1781 patients studied, 351 (19.7%) were female. The male predominance in our cohort were due to large outbreaks of COVID-19 in dormitory workers early in the pandemic. Female patients had more medical comorbidities, and were slightly older (46.4±18.3 vs 41.1±13.4 years, p&amp;lt; 0.001). They had a lower serum ferritin level (174.6±336.7 vs 216.7±284.7 µg/L, p=0.027), but no significant difference in the serum C-reactive protein (16.9±29.1 vs 14.4±29.8 mg/dL, p=0.187). Females were more likely to require supplemental oxygenation (7.1% vs 2.7%, p=0.025) and intensive care (4.8% vs 2.7%, p=0.034), but we did not demonstrate a difference in mortality (0.9% vs 0.7%, p=0.728). On multivariable analysis, female gender remained independently associated with adverse composite outcomes (adjusted OR 1.89, 95%CI 1.17-3.04) after adjusted for dormitory exposure and prior vaccination against COVID-19. Comparing COVID-19 clinical presentation and outcomes in females versus males amongst hospitalised patients from 2020 to 2021 Multivariable analysis showing female gender independently associated with increased odds of adverse clinical outcomes in COVID-19 illness Conclusion Female sex may be associated with adverse clinical outcomes in hospitalised patients with COVID-19. Further study is needed to elucidate and investigate the pathophysiological mechanisms behind this observation. Disclosures All Authors: No reported disclosures

543. Sex Differences in Clinical Presentation and Outcomes of Adults Hospitalized with COVID-19 Pneumonia After Administration of Infliximab, Abatacept or Cenicriviroc: Subgroup Analysis from the ACTIV-1 Master Protocol

Abstract Background A growing body of evidence suggests potential sex differences in the clinical outcomes of COVID-19. In this study we evaluated whether sex and baseline clinical variables were associated with treatment effect after receipt of immunomodulators vs placebo in a study population derived from ACTIV-1 IM clinical trial. Methods ACTIV-1 IM is a master protocol that evaluated infliximab, abatacept and cenicriviroc in addition to standard of care in adult patients hospitalized with moderate or severe SARS-CoV-2 infection through randomized, double-blind comparisons to shared placebo. We performed a subgroup analysis of the modified intention-to-treat cohort. Primary outcome was association of sex with time-to-recovery at day 28, key secondary outcomes were 28-day mortality and clinical status at day 14. Results A total of 1381 participants were included. There was no difference in treatment effect for primary endpoint of time-to-recovery based on sex for infliximab (RRR 1.14, 95% CI 0.95-1.37 for males and RRR 1.09, 95% CI 0.90-1.34 for females with interaction p=0.77), abatacept (RRR 1.14, 95% CI 0.95–1.37 for males and RRR 1.13, 95% CI 0.91-1.40 for females with interaction p=0.93) or cenicriviroc (RRR 0.99, 95% CI 0.79–1.24 for males, RRR 0.98, 95% CI 0.77-1.24 for females, interaction p=0.93) substudies. There was no difference in treatment effect by sex for secondary outcomes for infliximab and abatacept substudies. The cenicriviroc substudy was terminated early for futility and found no difference in treatment effects based on sex for secondary outcomes either. Conclusion There was no difference in treatment effect for infliximab, abatacept or cenicriviroc among males vs females. This suggests a more complex interplay of pathogen and host factors deserving further research to identify therapeutic targets for COVID-19. Disclosures Radica Alicic, MD, MSc, Boehringer Ingelheim Pharmaceuticals, Inc.: Advisor/Consultant Caryn Morse, MD, Gilead Sciences Inc.: Grant/Research Support|Janssen: Grant/Research Support|Laurent Pharma: Grant/Research Support|Moderna: Grant/Research Support|Ridgeback Bio: Grant/Research Support William G. Powderly, MD, Merck: Advisor/Consultant

Sex differences in patients with acute myocarditis: a cohort study

Abstract Background Sex differences in patients with acute myocarditis (AM) are poorly understood. Purpose We aimed to study sex differences in AM patients including medical history, clinical presentations, diagnostics, and in-hospital outcomes. Methods We enrolled 215 patients with a diagnosis of AM at a tertiary hospital between January 2000 and December 2018 into a retrospective cohort study. All patients were hospitalized on an intensive care unit (ICU) with continuous monitoring. We compared sex differences in clinical presentation including ECG, prior medical history, cardiac biomarkers, cardiac imaging (echocardiography and cardiac MRI) and in-hospital outcomes including incident arrhythmia. Results Median age was 38 years and 27% were female. Overall, the most common presenting symptoms were chest pain (84%), dyspnea (34%) and fever (29%). Compared to men, women presented more often with dyspnea (47% vs 29%, p=0.015), were older (49 vs 36 years, p&amp;lt;0.001) and had more comorbidities including hypertension (33% vs 18%, p=0.032) and diabetes (14% vs 4%, p= 0.033). In the presenting ECG, female patients were more likely to present with T-wave inversion (46% vs 27%, p=0.017) and less likely with ST elevation (9% vs 39%, p&amp;lt;0.001) compared to male patients. The overall hospital stay was longer in women compared to men (7 vs 5 days, p=0.021) with no difference in the length of ICU stay (2.8 vs 3.0 days, p=0.782). Cardiac biomarkers including high-sensitivity troponin T (median 426 vs 665 ng/l, p=0.415) and CK-MB (median 23 vs 24 U/l, p=0.888) were not different, but women had higher NT-proBNP levels (median 2380 vs 353 ng/l, p=0.032). Left ventricular ejection fraction (LVEF) was similar between sexes, both by transthoracic echocardiography (55% vs 55%, p=0.864) and cardiac MRI (58% vs 56%, p=0.919). During monitoring, atrial fibrillation/atrial flutter occurred in 4% of patients, non-sustained ventricular tachycardia in 15%, sustained ventricular tachycardia in 4% and ventricular fibrillation/cardiac arrest in 2%. While we did not find a sex difference in atrial fibrillation/atrial flutter, women tended to have more severe ventricular arrhythmia (Figure). Conclusion Women constituted a quarter of our AM cohort. Compared to men, women were older at the time of AM diagnosis, had more comorbidities, showed different clinical and ECG findings, and were hospitalized longer. While LVEF was similar, women had higher levels of NT-proBNP.Central Illustration

Abstract 18202: Sex Differences in Transthyretin Amyloid Cardiomyopathy

Introduction: Transthyretin amyloid cardiomyopathy (ATTR-CM) predominantly affects men. It is unknown if women are underdiagnosed or if female sex is protective. We investigated sex differences in clinical presentation and disease outcomes in ATTR-CM. Methods: Patients seen with ATTR-CM at our institution were included for analysis. Chi-squared or Fisher’s exact tests, and Wilcoxon tests were used to assess associations between clinical variables and sex in the overall cohort as well as by genotype (wtATTR and V122I). Hazard ratios with 95% confidence intervals were used to assess outcomes. Results: Of 293 subjects, 235 (80%) were men and 58 (20%) were women. Women vs men were more likely Black in the entire cohort (65% v 39%) and in the wtATTR group (70% v 8.7%, p&lt;0.05). Women were significantly older in wtATTR (84 [6.6] v 79 [7.2] yrs) and V122I (75 [6] v 71 [8.3] yrs), had higher HR (83 v 75 bpm), lower eGFR (54 v 62 mL/min/1.73 m2), and thinner intraventricular septum diameter (1.54 [0.3] v 1.71 [0.3] cm) than men at time of diagnosis (p&lt;0.05). Women with wtATTR had significantly higher mean RAP (14.8 [6.9] v 8.69 [4.8] v mmHg, p&lt;0.05) and a trend toward higher PASP (55.5 [17.0] v 42.9 [12.8] and PCWP (22.5 [6.7] v 17.3 [6.4] mmHg, p=0.06) vs men. There was no difference in HF hospitalization or death at 5 years (HR 0.93 [0.59-1.45], p=0.70) and no significant increase in proportion of women diagnosed over disease eras (pre-2013, 2013-2018, and 2019-2023). Conclusions: In a well characterized cohort with ATTR-CM, women were diagnosed less frequently and at an older age with markers of more advanced disease including higher HR, worse renal function, and higher filling pressures compared to men. Disease recognition in women did not increase over time. While this may be due to the nature of the disease, the characteristics we identified at diagnosis support that women with ATTR-CM are under detected. Future sex-based screening studies are needed to increase detection of ATTR-CM in women.

Sex-specific patterns of discomfort in patients with restless legs syndrome.

Sex differences in the prevalence of restless legs syndrome (RLS) have been reported, with a higher prevalence in women than in men. However, sex differences in clinical presentation remain unclear. We aimed to investigate the phenotypic differences in patients with RLS between sexes by comparing clinical presentations, iron status, polysomnographic parameters, and treatment. We retrospectively evaluated 614 patients (225 men, 389 women) diagnosed with RLS. To enhance the robustness of the study, an age-matched control group of 179 men and 286 women without sleep disorders was also included. Information on demographics and sleep-related questionnaires were collected. Iron status was evaluated using blood samples, and polysomnography was performed to evaluate periodic leg movements and comorbid sleep disorders. Our analysis revealed no sex difference in the severity of RLS but a difference in the pattern of symptoms. Women had more frequent symptoms of pain and awakening during sleep, while men had more common motor symptoms (both self-reported symptoms and periodic leg movement on polysomnography). Women with RLS also had lower iron parameters and received more frequent iron supplementation therapy than men. In contrast to women with RLS, who presented higher sleep disturbances and depressive mood, men with RLS had a higher risk of comorbidities such as hypertension and cardiovascular disease. These sex differences were notably more pronounced than in the control group. This study suggests that sex differences exist in RLS phenotypes, and clinicians should consider these differences for treatment. Kim J, Kim JR, Park HR, Joo EY. Sex-specific patterns of discomfort in patients with restless legs syndrome. J Clin Sleep Med. 2024;20(2):253-259.

Sex, myelin, and clinical characteristics of Parkinson's disease.

To determine if there are sex differences in myelin in Parkinson's disease, and whether these explain some of the previously-described sex differences in clinical presentation. Thirty-three subjects (23 males, 10 females) with Parkinson's disease underwent myelin water fraction (MWF) imaging, an MRI scanning technique of in vivo myelin content. MWF of 20 white matter regions of interest (ROIs) were assessed. Motor symptoms were assessed using the Unified Parkinson's Disease Rating Scale (UPDRS). Principal component analysis, logistic and multiple linear regressions, and t-tests were used to determine which white matter ROIs differed between sexes, the clinical features associated with these myelin changes, and if overall MWF and MWF laterality differed between males and females. Consistent with prior reports, tremor and bradykinesia were more likely seen in females, whereas rigidity and axial symptoms were more likely seen in males in our cohort. MWF of the thalamic radiation, cingulum, cingulum hippocampus, inferior fronto-occipital fasciculi, inferior longitudinal fasciculi, and uncinate were significant in predicting sex. Overall MWF and asymmetry of MWF was greater in males. MWF differences between sexes were associated with tremor symptomatology and asymmetry of motor performance. Sex differences in myelin are associated with tremor and asymmetry of motor presentation. While preliminary, our results suggest that further investigation of the role of biological sex in myelin pathology and clinical presentation in Parkinson's disease is warranted.

DMD-Associated Dilated Cardiomyopathy: Genotypes, Phenotypes, and Phenocopies.

Variants in the DMD gene, that encodes the cytoskeletal protein, dystrophin, cause a severe form of dilated cardiomyopathy (DCM) associated with high rates of heart failure, heart transplantation, and ventricular arrhythmias. Improved early detection of individuals at risk is needed. Genetic testing of 40 male probands with a potential X-linked genetic cause of primary DCM was undertaken using multi-gene panel sequencing, multiplex polymerase chain reaction, and array comparative genomic hybridization. Variant location was assessed with respect to dystrophin isoform patterns and exon usage. Telomere length was evaluated as a marker of myocardial dysfunction in left ventricular tissue and blood. Four pathogenic/likely pathogenic DMD variants were found in 5 probands (5/40: 12.5%). Only one rare variant was identified by gene panel testing with 3 additional multi-exon deletion/duplications found following targeted assays for structural variants. All of the pathogenic/likely pathogenic DMD variants involved dystrophin exons that had percent spliced-in scores >90, indicating high levels of constitutive expression in the human adult heart. Fifteen DMD variant-negative probands (15/40: 37.5%) had variants in autosomal genes including TTN, BAG3, LMNA, and RBM20. Myocardial telomere length was reduced in patients with DCM irrespective of genotype. No differences in blood telomere length were observed between genotype-positive family members with/without DCM and controls. Primary genetic testing using multi-gene panels has a low yield and specific assays for structural variants are required if DMD-associated cardiomyopathy is suspected. Distinguishing X-linked causes of DCM from autosomal genes that show sex differences in clinical presentation is crucial for informed family management.

Sex differences in clinical presentation and mortality in emergency department patients with sepsis

Background There is growing awareness that sex differences are associated with different patient outcomes in a variety of diseases. Studies investigating the effect of patient sex on sepsis-related mortality remain inconclusive and mainly focus on patients with severe sepsis and septic shock in the intensive care unit. We therefore investigated the association between patient sex and both clinical presentation and 30-day mortality in patients with the whole spectrum of sepsis severity presenting to the emergency department (ED) who were admitted to the hospital. Materials and methods In our multi-centre cohort study, we retrospectively investigated adult medical patients with sepsis in the ED. Multivariable analysis was used to evaluate the association between patient sex and all-cause 30-day mortality. Results Of 2065 patients included, 47.6% were female. Female patients had significantly less comorbidities, lower Sequential Organ Failure Assessment score and abbreviated Mortality Emergency Department Sepsis score, and presented less frequently with thrombocytopenia and fever, compared to males. For both sexes, respiratory tract infections were predominant while female patients more often had urinary tract infections. Females showed lower 30-day mortality (10.1% vs. 13.6%; p = .016), and in-hospital mortality (8.0% vs. 11.1%; p = .02) compared to males. However, a multivariable logistic regression model showed that patient sex was not an independent predictor of 30-day mortality (OR 0.90; 95% CI 0.67–1.22; p = .51). Conclusions Females with sepsis presenting to the ED had fewer comorbidities, lower disease severity, less often thrombocytopenia and fever and were more likely to have a urinary tract infection. Females had a lower in-hospital and 30-day mortality compared to males, but sex was not an independent predictor of 30-day mortality. The lower mortality in female patients may be explained by differences in comorbidity and clinical presentation compared to male patients. KEY MESSAGES Only limited data exist on sex differences in sepsis patients presenting to the emergency department with the whole spectrum of sepsis severity. Female sepsis patients had a lower incidence of comorbidities, less disease severity and a different source of infection, which explains the lower 30-day mortality we found in female patients compared to male patients. We found that sex was not an independent predictor of 30-day mortality; however, the study was probably underpowered to evaluate this outcome definitively.

Sex differences in the clinical presentation of early psychosis in a primary care setting.

Primary care is an important part of the help-seeking pathway for young people experiencing early psychosis, but sex differences in clinical presentation in these settings are unexplored. We aimed to identify sex differences in clinical presentation to primary care services in the 1-year period prior to a first diagnosis of psychotic disorder. We identified first-onset cases of non-affective psychotic disorder over a 10-year period (2005-2015) using health administrative data linked with electronic medical records (EMRs) from primary care (n = 465). Detailed information on encounters in the year prior to first diagnosis was abstracted, including psychiatric symptoms, other relevant behaviours, and diagnoses recorded by the family physician (FP). We used modified Poisson regression models to examine sex differences in the signs, symptoms, and diagnoses recorded by the FP, adjusting for various clinical and sociodemographic factors. Positive symptoms (PR = 0.76, 95%CI: 0.58, 0.98) and substance use (PR = 0.54, 95%CI: 0.40, 0.72) were less prevalent in the medical records of women. Visits by women were more likely to be assigned a diagnosis of depression or anxiety (PR = 1.18, 95%CI: 1.00, 1.38), personality disorder (PR = 5.49, 95%CI: 1.22, 24.62), psychological distress (PR = 11.29, 95%CI: 1.23, 103.91), and other mental or behavioral disorders (PR = 3.49, 95%CI: 1.14, 10.66) and less likely to be assigned a diagnosis of addiction (PR = 0.33, 95%CI: 0.13, 0.87). We identified evidence of sex differences in the clinical presentation of early psychosis and recorded diagnoses in the primary care EMR. Further research is needed to better understand sex differences in clinical presentation in the primary care context, which can facilitate better understanding, detection, and intervention for first-episode psychotic disorders.

Sex Differences in Clinical Presentation and Management in Eosinophilic Esophagitis

Background: Eosinophilic esophagitis (EoE) is a male predominant disease, typically presenting with dysphagia. Our goal was to investigate sex differences in clinical presentation and management of EoE. Methods: We performed a retrospective cross-sectional review of 489 EoE patients seen at NewYork Presbyterian Weill Cornell from August 2015 to August 2019. Charts were queried for age at diagnosis, symptoms at presentation, endoscopic findings, need for dilations, and medical therapy. Student t and χ2 tests were implemented to compare outcome variables of the 2 independent groups (males vs females) and logistic regressions for invariable and multivariable analyses. Results: 489 EoE patients (226 Female [F] [46.2%], 263 Male [M] [53.8%]) were reviewed. Males were more likely to present with food impaction (92 [35.8%] vs 44 [19.7%], M vs F, P &lt; .001), have a fibrostenotic phenotype on initial endoscopy (140 [54.1%] vs 98 [45.0%], M vs F, P = .043) and undergo dilation (odds ratio [OR] = 1.985, 95% confidence interval [CI] = 1.209-3.328, P &lt; .01). Female patients were more likely to have atopic disease (153 [67.6%] vs 153 [58.8%], F vs M, P = .044) and a reported normal index endoscopy (79 [36.2%] vs 69 [26.6%], F vs M, P = .026). Conclusion: This large retrospective review highlights clinically important differences in presentation between sexes. Increasing awareness of these differences, especially history of atopic disease, impaction, and the need for dilation, can help clinicians better identify EoE in female patients and therefore, guide initial therapy. The mechanistic underpinnings of these discrepancies are not evident from this data and will require future studies.

Sex Differences in TB Clinical Presentation, Drug Exposure, and Treatment Outcomes in India

The role of sex differences in clinical presentation, TB drug pharmacokinetic variables, and treatment outcomes is unclear. What is the effect of sex on TB disease severity, drug exposure, and treatment outcome? This study was a prospective cohort study conducted in India. It assessed TB disease severity; risk of unfavorable treatment outcomes (failure, recurrence, and death) according to sex; and risk factors for unfavorable outcomes stratified according to sex. Effects of sex on the pharmacokinetic variables (maximum concentration and area under the curve) of rifampicin, isoniazid, and pyrazinamide were estimated by using noncompartmental analyses. Of 1,541 people with microbiologically confirmed TB, 567 (37%) were women. Women had a lower risk of high mycobacterial burden (smear grade≥ 2 and/or time to detection< 7days) with an adjusted OR of 0.70 (95%CI, 0.56-0.87). Among the 744 participants who were followed up prospectively, 261 (35%) were women. Women had a lower risk of unfavorable treatment outcomes (adjusted incidence risk ratio, 0.60; 95%CI, 0.43-0.85), mostly because recurrence was lower (adjusted incidence risk ratio, 0.45; 95%CI, 0.23-0.86). Isoniazid (but not rifampicin and pyrazinamide) maximum concentration and area under the curve were significantly higher among women (P< .01) than men. Among women, unfavorable outcomes were more likely among those with cavitary disease, but among men, increased risk of unfavorable outcomes was associated with alcohol use, higher BMI, and lower glycated hemoglobin level. Women present with lower mycobacterial burden, achieve higher TB drug exposure, and are less likely to have unfavorable treatment outcomes than men. Strategies to improve TB treatment success should take into account sex differences in risk factors for unfavorable outcomes.

Sex differences in acute coronary syndrome management and in 12-month case-fatality trends: data from the French MONICA registries

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Univ. Lille, Inserm, CHU Lille, Institut Pasteur de Lille, Santé publique France, U1167 - RID-AGE - Facteurs de risque et déterminants moléculaires des maladies liées au vieillissement, Lille, France. Background Earlier studies, have reported sex differences in clinical presentation, management and outcomes of acute coronary syndrome (ACS) which have prompted the medical community to take actions to erase these differences. To our knowledge, there has been no recent analysis of sex difference trends in ACS management, to assess whether these differences have been attenuated over time. Aim To assess recent sex differences trends in ACS characteristics, management and associated mortality. Methods We assessed all men and women (aged 35-74) hospitalized for an incident (first) ACS, in the 3 distinct geographical areas covered by the MONICA registries in the north, east and south-west of France, during a 12-month period in 2006 and a 6-month period in 2016. We analyzed the patients’ clinical, biochemical, electrocardiographic and care-related data, and their vital status 12 months after the ACS. Results We analyzed 2023 incident ACSs in 2006 and 1173 in 2016. The proportion of men was three times higher than that of women in both periods. In 2016, women were younger (62.0 y in 2006 and 60.4 y in 2016; p=0.06) and men were older (57.6 y in 2006 and 59.0 y in 2016; p&amp;lt;0.01). Women had no longer more atypical symptoms than men in 2016. In both men and women, the proportion of patients with NSTEMI increased from 26% in 2006 to 39% in 2016 (p&amp;lt;0.0001), whereas the proportion of patients with unstable angina decreased from 14% in 2006 to 7% in 2016 (p&amp;lt;0.0001). Between 2006 and 2016, the proportion of thrombolysis fell from 10% to 1% (p&amp;lt;0.0001); conversely, the proportion of patients receiving angioplasty increased from 67% to 75% (p&amp;lt;0.001). However, men were still more likely than women to receive revascularization therapy (+19% in 2006 and +18% in 2016). Between 2006 and 2016, prescriptions of angiotensin-converting enzyme inhibitors at discharge decreased from 68% to 64% (p&amp;lt; 0.01), and prescriptions of statins increased from 89% to 91% (p=0.02), as did prescription of functional rehabilitation from 34% to 40% (p&amp;lt;0.0001). Despite these trends, platelet aggregation inhibitors, statins and functional rehabilitation were still less prescribed in women than men in 2016 (p&amp;lt;0.01), independently of confounders. Finally, the 12-month case fatality rate was 11% in 2006 and 10% in 2016 (p=0.15), without sex differences. Conclusions The results of the present study evidenced an improvement over time in the management of ACS. However, although there were no longer sex differences in the patients’ age and clinical presentation, women with ACS were still less likely than men to receive revascularization and pharmacological treatments in 2016.

Sex differences in carcinoid syndrome: A gap to be closed.

The incidence of neuroendocrine neoplasms and related carcinoid syndrome (CS) has markedly increased over the last decades and women seem to be more at risk than men for developing CS. Nevertheless, very few studies have investigated sex differences in clinical presentation and outcomes of CS. However, as per other tumours, sex might be relevant in influencing tumour localization, delay in diagnosis, clinical outcomes, prognosis and overall survival in CS. The present review was aimed at evaluating sex differences in CS, as they emerge from an extensive search of the recent literature. It emerged that CS occurs more frequently in female than in male patients with NENs and women seem to have a better prognosis and a slight advantage in overall survival and response to therapy. Moreover, the disease likely impacts differently the quality of life of men and women, with different psychological and social consequences. Nevertheless, sex differences, even if partially known, are deeply underestimated in clinical practice and data from clinical trials are lacking. There is urgent need to increase our understanding of the sex-related differences of CS, in order to define tailored strategies of management of the disease, improving both the quality of life and the prognosis of affected patients.

Sex Differences in Presentation of Stroke: A Systematic Review and Meta-Analysis.

Women have worse outcomes than men after stroke. Differences in presentation may lead to misdiagnosis and, in part, explain these disparities. We investigated whether there are sex differences in clinical presentation of acute stroke or transient ischemic attack. We conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Inclusion criteria were (1) cohort, cross-sectional, case-control, or randomized controlled trial design; (2) admission for (suspicion of) ischemic or hemorrhagic stroke or transient ischemic attack; and (3) comparisons possible between sexes in ≥1 nonfocal or focal acute stroke symptom(s). A random-effects model was used for our analyses. We performed sensitivity and subanalyses to help explain heterogeneity and used the Newcastle-Ottawa Scale to assess bias. We included 60 studies (n=582 844; 50% women). In women, headache (pooled odds ratio [OR], 1.24 [95% CI, 1.11-1.39]; I2=75.2%; 30 studies) occurred more frequently than in men with any type of stroke, as well as changes in consciousness/mental status (OR, 1.38 [95% CI, 1.19-1.61]; I2=95.0%; 17 studies) and coma/stupor (OR, 1.39 [95% CI, 1.25-1.55]; I2=27.0%; 13 studies). Aspecific or other neurological symptoms (nonrotatory dizziness and non-neurological symptoms) occurred less frequently in women (OR, 0.96 [95% CI, 0.94-0.97]; I2=0.1%; 5 studies). Overall, the presence of focal symptoms was not associated with sex (pooled OR, 1.03) although dysarthria (OR, 1.14 [95% CI, 1.04-1.24]; I2=48.6%; 11 studies) and vertigo (OR, 1.23 [95% CI, 1.13-1.34]; I2=44.0%; 8 studies) occurred more frequently, whereas symptoms of paresis/hemiparesis (OR, 0.73 [95% CI, 0.54-0.97]; I2=72.6%; 7 studies) and focal visual disturbances (OR, 0.83 [95% CI, 0.70-0.99]; I2=62.8%; 16 studies) occurred less frequently in women compared with men with any type of stroke. Most studies contained possible sources of bias. There may be substantive differences in nonfocal and focal stroke symptoms between men and women presenting with acute stroke or transient ischemic attack, but sufficiently high-quality studies are lacking. More studies are needed to address this because sex differences in presentation may lead to misdiagnosis and undertreatment.

Sex differences in clinical presentation and risk stratification in the Emergency Department: An observational multicenter cohort study

ObjectiveThe aim of this study was to investigate whether sex differences exist in disease presentations, disease severity and (case-mix adjusted) outcomes in the Emergency Department (ED). MethodsObservational multicenter cohort study using the Netherlands Emergency Department Evaluation Database (NEED), including patients ≥ 18 years of three Dutch EDs. Multivariable logistic regression was used to study the associations between sex and outcome measures in-hospital mortality and Intensive Care Unit/Medium Care Unit (ICU/MCU) admission in ED patients and in subgroups triage categories and presenting complaints. ResultsOf 148,825 patients, 72,554 (48.8%) were females. Patient characteristics at ED presentation and diagnoses (such as pneumonia, cerebral infarction, and fractures) were comparable between sexes at ED presentation. In-hospital mortality was 2.2% in males and 1.7% in females. ICU/MCU admission was 4.7% in males and 3.1% in females. Males had higher unadjusted (OR 1.34(1.25–1.45)) and adjusted (AOR 1.34(1.24–1.46)) risks for mortality, and unadjusted (OR 1.54(1.46–1.63)) and adjusted (AOR 1.46(1.37–1.56)) risks for ICU/MCU admission. Males had higher adjusted mortality and ICU/MCU admission for all triage categories, and with almost all presenting complaints except for headache. ConclusionsAlthough patient characteristics at ED presentation for both sexes are comparable, males are at higher unadjusted and adjusted risk for adverse outcomes. Males have higher risks in all triage categories and with almost all presenting complaints. Future studies should investigate reasons for higher risk in male ED patients.