Explaining Poorer Stroke Outcomes in Women: Women Surviving 3 Months Have More Severe Strokes Than Men Despite a Lower 3-Month Case Fatality

BackgroundWomen who survive stroke are more disabled and more often institutionalized than men.ObjectiveWe explore this phenomenon by studying case fatality and stroke severity in stroke survivors separately for men and women.MethodsA Danish stroke registry (2000−2007) contains information about 26,818 patients with first-ever ischemic stroke, including stroke severity (Scandinavian Stroke Scale, 0 worst to 58 best), computed tomography scan, cardiovascular risk factors, and death 3 months after stroke. We modeled stroke severity by generalized additive linear model and 3-month case fatality with logistic model adjusting for age and cardiovascular risk factors.ResultsMale to female ratio was 51.5% to 48.5%. Mean age was 68.8 (SD 12.6) years in men; 73.7 (13.8) years in women. Stroke was more severe in women (mean [SD] Scandinavian Stroke Scale, 42.2 [16.0]) than in men (mean [SD] Scandinavian Stroke Scale, 45.6 [14.2]) also after adjustment for age and cardiovascular risk factors; significant in patients older than 75 years. In survivors at 3 months, stroke was more severe in women than men, given same age and cardiovascular risk factor profile; significant in patients older than 75 years. More women (11.9%) had died within 3 months than men (8.6%). However, adjusting for age, stroke severity, and risk factor profile, 3-month case fatality was lower in women than men; significant in patients older than 78 years.ConclusionsAlthough 3-month case fatality was lower in women than men, strokes were more severe among survivors at 3 months in women than in men. In addition, strokes were more severe in women. Our data help elucidate why women survive stroke better but have poorer functional outcomes that require more care than men.     

Predictors of depressive symptoms post-acute coronary syndrome

Objective: We examined the influence of gender on the prevalence of acute coronary syndrome (ACS) and the severity of depressive symptoms post-ACS.Methods: Patients received a Zung self-assessment questionnaire at hospital discharge for unstable angina (UA) or acute myocardial infarction (AMI) and returned it by mail. Major depressive symptoms were diagnosed based on a summed depressive symptoms (SDS) score of >50. Depressive symptomatology was modeled by stepwise multivariable logistic regression with the following predictors: gender, age, hypertension, diabetes mellitus, history of smoking, hypercholesterolemia, peripheral vascular disease, prior stroke, prior myocardial infarction (MI), and prior percutaneous coronary intervention or coronary artery bypass graft surgery. We also modeled severity of depressive symptoms via stepwise multiple linear regression with the same predictor variables.Results: A total of 944 patients were surveyed: 716 men and 228 women, mean (SD) age, 67 (13) years and 71 (12) years, respectively. Of these patients, 250 (35%) men and 103 (45%) women had depressive symptoms (P = 0.005). No significant difference was observed between men and women in rates of cardiac catheterization; severity of coronary artery disease; treatment with antiplatelet agents, β-blockers, angiotensin-converting enzyme inhibitors, or statins; or percutaneous or surgical revascularization rates during or post-ACS. Significant predictors of the presence of depressive symptoms were female gender (odds ratio [OR] = 1.64; 95% CI, 1.19-1.28), diabetes mellitus (OR = 1.42; 95% CI, 1.03-1.97), prior MI (OR = 1.56; 95% CI, 1.15-2.20), and smoking (OR = 1.41; 95% CI, 1.01-1.97). Variables significantly associated with a higher severity of depressive symptoms were female gender, prior MI, smoking, and stroke. Men with prior MI had significantly higher mean (SD) SDS scores than did men without prior MI in all age groups (48.4 [11] vs 44.6 [11], respectively; P < 0.001). In addition, significantly more men with prior MI had depressive symptoms compared with those without prior MI (45% vs 32%; P = 0.001). However, prior MI did not appear to affect SDS scores in women (49.1 [12] for prior MI vs 48.5 [12] for no prior MI; P = NS), and there was no significant difference in the percentage of women who had depressive symptoms with or without a history of prior MI. Depressive symptoms were much more severe in women with UA (SDS = 49.0 [12]) compared with women with AMI (SDS = 45.0 [12]; P = NS), or men with AMI (45.0 [12]; P = 0.004) or UA (46.0 [11]; P = 0.007) (analysis of variance, P = 0.003).Conclusions: Female gender is a significant independent predictor of depressive symptoms and their severity post-UA and post-AMI. History of prior MI is associated with a higher frequency and severity of depressive symptoms in men. These findings call for routine screening for depressive symptoms in men with prior MI and in women who present with ACS.     

Gender distribution in irritable bowel syndrome is proportional to the severity of constipation relative to diarrhea

Background: A significant gender disparity has been observed in individuals with irritable bowel syndrome (IBS), with females outnumbering males, especially in constipation-predominant IBS (C-IBS). However, this observation is based on Rome criteria categorization and does not take into account the severity of constipation or diarrhea.Objective: In a large prospective data set, gender differences across the severity of constipation and diarrhea were examined in patients with IBS.Methods: Consecutive adult patients with Rome I positive IBS who were referred to a tertiary care medical center (Cedars-Sinai Medical Center, Los Angeles, California) in 1999–2003 were given a questionnaire. The questionnaire asked subjects to rate their constipation and diarrhea according to perceived severity using a scale from 0 (none) to 5 (very severe). C-IBS was determined to be present if the severity of constipation was greater than the severity of diarrhea (sevC > sevD). If sevD > sevC, subjects were considered to have diarrhea-predominant IBS (D-IBS). To further categorize their symptoms, subjects were then grouped by the difference between the severity of constipation and diarrhea, creating a range of values from ?5 to +5. For each of these 11 constipation/diarrhea severity values, the female:male ratio was determined. The severity of constipation to diarrhea was compared by Spearman rank correlation.Results: A total of 429 subjects with IBS (325 women: mean [SD] age, 42.5 [0.8] years; 104 men: mean age, 42.2 [1.7] years) completed the questionnaire. Constipation occurred more frequently in women (79.7%) compared with men (61.5%) (odds ratio [OR] = 2.49; 95% CI, 1.55–4.02). The prevalence of diarrhea was similar between the sexes. Whereas C-IBS was more common in women (31.8%) than in men (26.0%) (OR = 2.03; 95% CI, 1.24–3.30), D-IBS was more prevalent in men (62.5%) than in women (36.3%) (OR = 2.39; 95% CI, 1.53–3.75). When the female:male ratio was evaluated across the 11 severity score categories of constipation and diarrhea, the greater the sevC — sevD score, the higher the proportion of women (R = 0.80; P = 0.003).Conclusion: In this study of patients with IBS, the observation of the association of constipation and gender in IBS is extended to indicate that the female:male ratio significantly increases according to the severity of constipation relative to the severity of diarrhea.     

Gender-specific differences in bladder cancer: A retrospective analysis

Background: A higher incidence of bladder cancer has been reported in men compared with women. Clinical gender differences have been observed but are less well described.Objective: This retrospective analysis further examines clinical differences in the development and manifestation of bladder cancer between men and women.Methods: Consecutive male and female patients with bladder cancer treated between 1969 and 1997 at a single center (University Hospital of Innsbruck, Innsbruck, Austria) were included in the study. Patient characteristics regarding age, tumor classification, localization, and recurrence were compared between male and female patients. Statistical analysis was conducted using the t test, the χ² test, and the Kaplan-Meier method, with the log-rank test for subgroup analysis.Results: In the 1269 patients (876 men, 393 women) who were examined, 1744 tumors were found. The male-to-female bladder cancer incidence ratio was 2.2:1. Tumors were diagnosed at a significantly younger age in men than in women (mean age: 62 years vs 67 years, respectively; P < 0.001). No difference in the histology of tumors was observed between the sexes. Muscle-invasive tumors more frequently occurred in men than in women (39.8% vs 34.5%; P = NS). In men compared with women, primary tumors were more aggressive (grade 2, 36.6% vs 28.2%; P < 0.001) and tumor recurrences were more invasive (59.0% vs 57.8%; P = NS). Tumors were more often located in the urethra in men than in women (43 [3.4%] vs 9 [1.8%]; P = 0.034), the trigonum (246 [19.8%] vs 75 [14.9%]; P < 0.001), and the bladder dome or vault (128 [10.3%] vs 37 [7.4%]; P = 0.015). Generally, no difference in survival rate was observed between the sexes; only in the subgroup of muscle-invasive tumors (n = 455) did women have a worse overall survival rate than did men (P = 0.022).Conclusions: Clinical gender differences in bladder cancer appear to have a higher incidence in men than in women. In this analysis, women were older at the age of detection, but had less-invasive and less-aggressive tumors than did men. However, women with muscle-invasive disease had a worse overall survival rate than did men in the same subset.     

Review of cardiovascular risk factors in women

Background: Although cardiovascular disease (CVD) is the leading cause of death in women in the United States, a knowledge gap persists regarding the mechanisms and management of CVD in women. Before treatment can be optimized, the role of cardiovascular risk factors must be elucidated.Objective: This review provides an updated assessment of cardiovascular risk factors in women, with a focus on cardiometabolic risk.Methods: MEDLINE and Cochrane Library databases, and statistics from the National Health and Nutrition Examination Survey and the American Heart Association, were searched from 1990 to September 2008 using the following terms: cardiovascular risk factors, women, gender, cardiometabolic risk, abdominal obesity, and metabolic syndrome. Publications were classified as English-only original data, reviews, and clinical guidelines. Nonpublished data were excluded. Data were extracted by 2 reviewers independently.Results: Investigators performing multivariable predictive models have estimated that traditional risk factors account for ~70% of the variance in estimating cardiovascular events. However, substantial sex differences exist in the prevalence of traditional risk factors as well as in cardiovascular outcomes. Hypertension is more prevalent in men until the age of 59 years, but then contributes to greater morbidity in older women. Low levels of high-density lipoprotein and elevated triglyceride levels pose more of a threat to women, yet high levels of low-density lipoprotein pose equal risk for women and men. The CVD mortality rate is -3 times greater in people with diabetes than in those without diabetes. Among diabetic individuals, CVD mortality is slightly higher in women compared with men.Conclusions: Increased knowledge of gender-specific risks for CVD has led to national campaigns to educate women. In addition to traditional risk factors, cardiometabolic risk is an important consideration in women. Controversy exists regarding the exact definitions and usefulness of the term metabolic syndrome, but it is clear that the presence of certain factors contributes to increased morbidity and mortality in affected individuals. Abdominal obesity links insulin resistance, dyslipidemia, and hypertension through complex endocrine pathways. Current research is identifying gene × gender interactions, and continued research is necessary to explore the relationship of sex steroids and cardiovascular risk in both men and women.     

Human articular chondrocytes express 15-lipoxygenase-1 and -2: potential role in osteoarthritis

Introduction

Although cardiovascular morbidity and mortality are increased in rheumatoid arthritis, little is known about the burden of subclinical coronary atherosclerosis in these patients.

Methods

Using computed tomography, coronary artery calcification was measured in 195 men and women with rheumatoid arthritis aged 45 to 84 years without clinical cardiovascular disease and compared with 1,073 controls without rheumatoid arthritis enrolled in the Baltimore cohort of the Multi-Ethnic Study of Atherosclerosis.

Results

The prevalence of coronary calcification (Agatston score > 0) was significantly higher in men, but not women, with rheumatoid arthritis after adjusting for sociodemographic and cardiovascular risk factors (prevalence ratio = 1.19; P = 0.012). Among participants with prevalent calcification, those with rheumatoid arthritis had adjusted mean Agatston scores 53 units higher than controls (P = 0.002); a difference greater for men than women (P for interaction = 0.017). In all analyses, serum IL-6 attenuated the association between rheumatoid arthritis and coronary calcification, suggesting its role as a potential mediator of enhanced atherosclerosis. Notably, increasing severity of rheumatoid arthritis was associated with a higher prevalence and extent of coronary calcification among both men and women with rheumatoid arthritis, and for all age categories. The largest percentage difference in coronary arterial calcification between rheumatoid arthritis patients and their nonrheumatoid arthritis counterparts was observed in the youngest age category.

Conclusions

Increasing rheumatoid arthritis disease severity was associated with a higher prevalence and greater extent of coronary artery calcification, potentially mediated through an atherogenic effect of chronic systemic inflammation. Gender and age differences in association with coronary calcification suggest that preventive measures should be emphasized in men with rheumatoid arthritis, and considered even in younger rheumatoid arthritis patients with low levels of traditional cardiovascular risk factors.     

Depressive Symptoms and the Risk of Ischemic Stroke in the Elderly—Influence of Age and Sex

Although a relationship between depression and cardiovascular events has been suggested, past study results regarding the risk of stroke in relation to depression by subgroups are ambiguous. The aim of this study was to investigate the influence of depressive symptoms on risk of incident ischemic stroke in elderly according to age and sex. This prospective cohort study followed up 3852 subjects older than 55 years. Baseline depressive symptoms were defined by a score ≥5 on the Geriatric Depression Scale or antidepressant intake. The outcome measure was incident ischemic stroke within 6 years of follow-up. Multivariate Cox-proportional hazard models as well as cumulative survival analyses were computed. A total of 156 ischemic strokes occurred during the study period (24 strokes in the age-group<65 years and 132 strokes in the age-group≥65 years). The distribution of strokes in sex-subgroups was 4.5% in men and 3.7% in women. The multivariate analysis showed an elevated stroke risk (Hazard Ratio (HR): 2.84, 95% CI 1.11–7.29, p = 0.030) in subjects from 55 to 64 years with depressive symptoms at baseline but not in subjects older than 65 years. In the multivariate analysis according to sex the risk was increased in women (HR: 1.62, 95% CI 1.02–2.57, P = 0.043) but not in men. The Cox-regression model for interaction showed a significant interaction between age and sex (HR: 3.24, 95% CI 1.21–8.69, P = 0.020). This study corroborates that depressive symptoms pose an important risk for ischemic stroke, which is particularly remarkable in women and patients younger than 65 years.     

Coronary arterial calcification in rheumatoid arthritis: comparison with the Multi-Ethnic Study of Atherosclerosis

Introduction

Although cardiovascular morbidity and mortality are increased in rheumatoid arthritis, little is known about the burden of subclinical coronary atherosclerosis in these patients.

Methods

Using computed tomography, coronary artery calcification was measured in 195 men and women with rheumatoid arthritis aged 45 to 84 years without clinical cardiovascular disease and compared with 1,073 controls without rheumatoid arthritis enrolled in the Baltimore cohort of the Multi-Ethnic Study of Atherosclerosis.

Results

The prevalence of coronary calcification (Agatston score > 0) was significantly higher in men, but not women, with rheumatoid arthritis after adjusting for sociodemographic and cardiovascular risk factors (prevalence ratio = 1.19; P = 0.012). Among participants with prevalent calcification, those with rheumatoid arthritis had adjusted mean Agatston scores 53 units higher than controls (P = 0.002); a difference greater for men than women (P for interaction = 0.017). In all analyses, serum IL-6 attenuated the association between rheumatoid arthritis and coronary calcification, suggesting its role as a potential mediator of enhanced atherosclerosis. Notably, increasing severity of rheumatoid arthritis was associated with a higher prevalence and extent of coronary calcification among both men and women with rheumatoid arthritis, and for all age categories. The largest percentage difference in coronary arterial calcification between rheumatoid arthritis patients and their nonrheumatoid arthritis counterparts was observed in the youngest age category.

Conclusions

Increasing rheumatoid arthritis disease severity was associated with a higher prevalence and greater extent of coronary artery calcification, potentially mediated through an atherogenic effect of chronic systemic inflammation. Gender and age differences in association with coronary calcification suggest that preventive measures should be emphasized in men with rheumatoid arthritis, and considered even in younger rheumatoid arthritis patients with low levels of traditional cardiovascular risk factors.     

Age- and Ethnic-Specific Sex Differences in Stroke Risk

BackgroundIn white populations, age seems to modify the effect of sex on stroke risk, and compared with men, women are protected from stroke until approximately age 75 to 85 years, after which the protection is lost or reversed. Compared with non-Hispanic whites (NHWs), Mexican Americans (MAs) are at higher risk of stroke; however, age- and sex-specific stroke incidence data are currently not available for this population.ObjectiveThis study was performed to compare the age-specific sex differences in stroke risk in MAs and NHWs.MethodsData were derived from the BASIC (Brain Attack Surveillance in Corpus Christi) Project, a population-based stroke surveillance study conducted in Nueces County Texas. Incident strokes (n = 2421, including ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage) that occurred between January 1, 2000 and May 25, 2007 in individuals aged 45 years or older were included in the analysis. Poisson regression using the generalized additive models framework was used to analyze the relationship between sex, age (5-year intervals), and race/ethnicity (NHW or MA) and incident stroke risk.ResultsAmong both NHWs and MAs aged 45 to 79 years, men were at higher risk of stroke than women were. The magnitude of increased stroke risk in men compared with women diminished with age, and after age 79 years, no sex difference in stroke risk was observed.ConclusionsReasons for the loss of protection from stroke in aging women of all races/ethnicities are not fully understood, and further study is warranted.     

Sex-specific differences in the expression levels of estrogen receptor subtypes in colorectal cancer

Background: Altered expression of estrogen receptors alpha and beta (ERα and ERβ) has been hypothesized to play a role in carcinogenesis. However, little is known about the sex-specific differences of ER expression in colorectal cancer (CRC).Objective: This study examined ERα and ERβ protein levels in male and female patients with CRC.Methods: Using Western blot analysis, the intensity of ERα and ERβ protein levels was determined in tumor tissue and in corresponding normal colon mucosa from patients with CRC.Results: All 64 white patients (33 men, mean [SEM] age 64.1 [13.1] years, age range 26-90 years; 31 women, mean age 68.5 [14.5] years, age range 39-91 years [4 were premenopausal at time of surgery]) expressed ERα and ERβ protein in normal colon mucosa, and there were no significant differences between men and women. In tumor tissue, a significantly increased ERα protein level was observed in men (P = 0.02 vs normal tissue), whereas in women, the ERα level did not differ significantly between tumor and normal tissue. The level of ERβ protein in CRC was significantly reduced in both men and women, but more so in men (P = 0.04 vs women). Furthermore, in men, the ERβ level was significantly lower in poorly differentiated tumors than in moderately differentiated tumors (P < 0.03), whereas in women, poor differentiation of the tumor was not associated with a significant decrease of ERβ level.Conclusions: Altered levels of ER subtypes resulting in an increased ERα:ERβ ratio were found in patients with CRC. The observation of significantly greater alterations in men than in women supports the hypothesis of sex-specific differences in the pathogenesis of CRC.     

Chronic kidney disease itself is a causal risk factor for stroke beyond traditional cardiovascular risk factors: a nationwide cohort study in Taiwan

Background

Cardiovascular disease (CVD) is a leading cause of mortality and morbidity in patients with chronic kidney disease (CKD). In Taiwan, CVD is dominated by strokes but there is no robust evidence for a causal relationship between CKD and stroke. This study aimed to explore such causal association.

Methods

We conducted a nationwide retrospective cohort study based on the Taiwan National Health Insurance Research Database from 2004 to 2007. Each patient identified was individually tracked for a full three years from the index admission to identify those in whom any type of stroke developed. The study cohort consisted of patients hospitalized with a principal diagnosis of CKD and no traditional cardiovascular risk factors at baseline (n = 1393) and an age-matched control cohort of patients hospitalized for appendectomies (n = 1393, a surrogate for the general population). Cox proportional hazard regression and propensity score model were used to compare the three-year stroke-free survival rate of the two cohorts after adjustment for possible confounding factors.

Results

There were 256 stroke patients, 156 (11.2%) in the study cohort and 100 (7.2%) in the control cohort. After adjusting for covariates, patients with primary CKD had a 1.94-fold greater risk for stroke (95% CI, 1.45–2.60; p<0.001) based on Cox regression and a 1.68-fold greater risk for stroke (95% CI, 1.25–2.25; p = 0.001) based on propensity score. This was still the case for two cohorts younger than 75 years old and without traditional cardiovascular risk factors.

Conclusions

This study of Taiwanese patients indicates that CKD itself is a causal risk factor for stroke beyond the traditional cardiovascular risk factors. Primary CKD patients have higher risk for stroke than the general population and all CKD patients, irrespective of the presence or severity of traditional cardiovascular risk factors, should be made aware of the stroke risk and monitored for stroke prevention.     

Greater Low-Density Lipoprotein Cholesterol Variability Increases the Risk of Cardiovascular Events in Patients with Type 2 Diabetes Mellitus

Objective: Variability in lipid levels has been associated with poor cardiovascular outcomes in patients with coronary artery disease. The aim of this study was to investigate whether low-density lipoprotein cholesterol (LDLC) variability can be used to predict cardiovascular events in patients with type 2 diabetes mellitus (DM).Methods: A total of 5,354 patients with type 2 DM were enrolled in this study. Cardiovascular events including peripheral arterial disease, coronary artery disease, stroke, and cardiovascular death were defined as the study endpoints, and standard deviations of lipid levels were used to define intra-individual lipid variability.Results: Univariate Cox proportional hazards analysis showed that LDL-C standard deviation (hazard ratio &lsqb;HR] = 1.016; 95% confidence interval &lsqb;CI] = 1.006 to 1.022; P<.001) was associated with a higher risk of cardiovascular events. Multivariate Cox proportional hazards analysis showed that an increase in LDL-C standard deviation significantly increased the risk of cardiovascular events (HR = 1.063; 95% CI = 1.025 to 1.102; P = .01). Kaplan-Meier analysis of cardiovascular event-free survival showed that the patients in tertiles 2 and 3 of the standard deviation of LDL-C had worse cardiovascular event-free survival compared to those in tertile 1.Conclusion: Variability in LDL-C could predict cardiovascular events in the patients with type 2 DM in this study.Abbreviations: CAD = coronary artery disease; CI = confidence interval; CVD = cardiovascular disease; DM = diabetes mellitus; eGFR = estimated glomerular filtration rate; HbA1c = glycosylated hemoglobin; HDL-C = high-density lipoprotein cholesterol; HR = hazard ratio; KMUHRD = Kaohsiung Medical University Hospital Research Database; LDL-C = low-density lipoprotein cholesterol; SD = standard deviation; UACR = urine albumin to creatinine ratio     

Gender in atrial fibrillation: Ten years later

Background: Atrial fibrillation (AF) is the most common arrhythmia encountered in both male and female patients.Objective: This evidence-based update attempts to address the advances in the science of AF management in light of key gender issues.Methods: In October 2009, 2 investigators (H.I.M. and B.D.P.) independently searched MEDLINE (PubMed [1950–2009] and Ovid [2000–2009]) for all publication types in the English language, using database-specific controlled vocabulary describing the concepts of AF and gender (atrial fibrillation, gender, women, and men for PubMed; atrial fibrillation and gender for Ovid). The reference sections from the identified publications were also used. The methodologic quality of publications, their content relevance, and the authors' expert opinions guided publication inclusion in this evidence-based narrative review. Articles relevant to gender differences in pathophysiology, outcomes, and treatment of AF are summarized and discussed.Results: Based on current available data, mortality is greater for women with AF than for men with AF. Women with AF have a higher risk of stroke compared with their male counterparts. Women derive the greatest benefit from anticoagulation in AF. There are no significant sex differences in major bleeding risk from warfarin. Women tend to be more symptomatic from AF than are men, but fare worse than men when a rhythm-control strategy is utilized with antiarrhythmic medications. Women have an increased risk for torsades de pointes when taking sotalol or dofetilide, and have a higher risk of bradyarrhythmias when taking antiarrhythmics. AF catheter ablation is successful and beneficial for selected patients of both sexes, although women may incur higher procedural bleeding complications. Women tend to be referred for AF ablation less and later than are men.Conclusions: The past decade has witnessed significant progress in the understanding and management of AF. Awareness of key sex-specific differences in AF allows for a more safe, effective, and personalized approach to the management of this disorder.     

Gender differences in psychosocial responses to lung cancer

Background: Although biologically based sex differences in the smoking patterns, epidemiology, biomedical markers, and survival rates associated with lung cancer are well documented, examinations of psychosocial gender differences are scarce.Objective: This cross-sectional study examined gender differences in psychosocial factors that are important in the medical management of lung cancer.Methods: A convenience sample of patients who were attending a multidisciplinary lung cancer treatment center (Markey Cancer Center, Lexington, Kentucky) were invited to complete a psychosocial needs assessment. Eligibility criteria included primary diagnosis of lung cancer, age ≥18 years, and being cognitively intact. Measures focused on psychosocial resources, treatment decision-making, social consequences of treatments, and treatment outcomes. Data were collected between the fall of 2005 and the summer of 2006.Results: A total of 47 women and 53 men (mean [SD] age, 62.81 [12.01] years; 95% white) completed the needs assessment. Gender was not found to be associated with demographic characteristics, time until diagnosis, treatment, or survival rate. Smoking histories differed significantly in the proportion of women and men who smoked or were former smokers (P = 0.01) as well as the age when they began to smoke (P = 0.02). There were no significant gender differences in social support networks, general coping, information needs, treatment decision satisfaction, functional health, life satisfaction, financial impact, or service needs. However, significant gender differences did indicate that women favored spiritual practices (P = 0.02) and religious coping (P = 0.04), and were more likely to endorse having a life mission (P = 0.03) and being part of a divine plan (P = 0.01).Conclusions: Previous research has found that religiousness and spirituality improved depressive symptoms and may ease end-of-life despair. In the present study of patients with lung cancer, gender differences in religiousness and spirituality suggest that this may be especially true for women, and that interventions should be directed toward their religious practices and coping.     

Prevalence and Impact on Stroke in Patients Receiving Maintenance Hemodialysis versus Peritoneal Dialysis: A Prospective Observational Study

Background

Patients undergoing maintenance dialysis are at increased risk of stroke, however, less is known about the prevalence and impact on stroke in the patients.

Methods

In this prospective cohort study, 590 patients undergoing hemodialysis (HD; n = 285) or peritoneal dialysis (PD; n = 305) from January 1, 2008 to December 31, 2012 were recruited. Baseline demographic, clinical, and laboratory data were collected. Timeline incidence data were analyzed using a Poisson model. The Cox proportional hazards regression assessed adjusted differences in stroke risk, a multivariate analysis was also performed.

Results

62 strokes occurred during 1258 total patient-years of follow-up. Stroke occurred at a rate of 49.2/1,000 patient-years with a predominance in HD patients compared with PD patients (74.0 vs. 31.8/1,000 patient-years). The cumulative hazard of developing stroke was significantly higher in HD patients (hazard ratio [HR], 1.75; 95% confidence interval [CI], 1.15–3.62; p = 0.046) after adjusting for potential confounders. HD patients had an increased risk of ischemic stroke (HR, 2.62; 95% CI, 1.56–4.58; p = 0.002). The risk of hemorrhagic stroke was not significantly different between PD and HD patients. On multivariate Cox analysis, risk factors of stroke in both HD and PD patients were older age, diabetes, and cardiovascular disease. Other independent risk factors of stroke were lower albumin-corrected calcium in HD patients and higher triglycerides in PD patients.

Conclusions

Patients undergoing PD were less likely to develop ischemic stroke than those undergoing HD. Comprehensive control of diabetes, cardiovascular disease, calcium-phosphorus metabolism, and triglyceride levels may be useful preventive strategies for stroke in dialysis patients.     

Relationship between serum progesterone concentrations and cardiovascular disease,diabetes, and mortality in elderly Swedish men and women: An 8-Year prospective study

Background: The use of synthetic progesterone-like substances in hormone replacement therapy and birth control pills has been associated with increases in cardiovascular morbidity and the prevalence of diabetes.Objectives: The primary aims of this study were to investigate whether physiologic concentrations of progesterone might also be associated with cardiovascular disease and diabetes, and to explore potential gender differences in these associations in elderly Swedish men and women.Methods: This prospective, longitudinal study was performed in a Swedish population-based sample of opposite-sex twins aged between 71 and 80 years who were not receiving sex hormone therapy. Serum concentrations of progesterone, estradiol, C-reactive protein (CRP), and urea were measured at baseline (1996) and at 8-year follow-up (2004), and serum concentrations of cystatin and insulin were measured only at follow-up. The outcomes of interest were cardiovascular morbidity (myocardial infarction, angina pectoris, peripheral arterial disease, stroke, congestive heart failure [CHF], cardiac arrhythmia, hypertension, and thromboembolism), diabetes, and mortality throughout the observation period.Results: At baseline, the study sample included 230 men and 195 women (mean [SD] age, 74.6 [2.6] years). At follow-up, 132 men and 145 women (mean age, 82.4 [2.5] years) met the inclusion criteria, of whom 128 men and 112 women did so at both baseline and follow-up. Serum progesterone concentrations, which did not differ significantly from reported concentrations for the age group, were significantly associated with mortality across the observation period (P < 0.001). At follow-up, higher serum progesterone was significantly associated with the occurrence of CHF (P < 0.01); this association remained robust after adjustment for CRP, cystatin, and insulin levels.Conclusion: In these elderly Swedish men and women, increased physiologic concentrations of progesterone were found to be associated with an increased prevalence of CHF, independent of inflammatory factors, markers of renal function, and insulin metabolism.     

Gender differences in adiponectin and low-grade inflammation among individuals with normal glucose tolerance,prediabetes, and type 2 diabetes

Background: Women with prediabetes and type 2 diabetes mellitus have a higher relative risk of cardiovascular disease than do men. The reason for this is unknown.Objective: We studied the gender differences in adiponectin and in low-grade inflammation, measured by high-sensitivity C-reactive protein (hs-CRP) and interleukin-1 receptor antagonist (IL-1RA), in individuals with normal glucose tolerance, prediabetes, and type 2 diabetes.Methods: In this population-based, cross-sectional study, all individuals born in 1942, 1947, 1952, 1957, and 1962 in Pieksämäki, East Finland, were recruited for participation. A 75-g oral glucose tolerance test and lipid panel were performed, and concentrations of adiponectin, hs-CRP, and IL-1RA were measured. The World Health Organization diagnostic criteria for diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) were used. Statistical comparisons between men and women were performed by a bootstrap-type ANCOVA.Results: The eligible population included 1294 middle-aged individuals, and of these, 904 (406 men and 498 women) had complete data and were included in the analyses. Absolute adiponectin concentrations were significantly higher in women at all levels of glucose tolerance (normal, prediabetes, and type 2 diabetes), but the gender ratio (women to men) for adiponectin concentrations decreased linearly (P = 0.011) from normal glucose tolerance (1.61; 95% CI, 1.48–1.75) to prediabetes (1.57; 95% CI, 1.36–1.83) and diabetes (1.16; 95% CI, 0.87–1.53). Among participants with normal glucose tolerance, no significant difference was found between the sexes in hs-CRP or IL-1RA. Among patients with prediabetes or diabetes, women had significantly higher concentrations than did men for hs-CRP (for prediabetes, 2.0 vs 1.5 mg/L; ratio, 1.39; 95% CI, 1.04–1.85) and IL-1RA (for prediabetes, 255 vs 178 pg/mL; ratio, 1.43; 95% CI, 1.121.83). The gender ratios (women to men) increased linearly from normal glucose tolerance to prediabetes and type 2 diabetes for both hs-CRP (P = 0.019) and IL-1RA (P = 0.013).Conclusions: Adiponectin concentrations in women decreased relatively more compared with men across individuals with normal glucose tolerance, prediabetes, and type 2 diabetes, whereas inflammatory markers increased relatively more in women. Higher inflammatory stress in women than in men with prediabetes and type 2 diabetes may explain their relatively higher cardiovascular disease risk.     

Coronary artery disease: Are men and women created equal?

Background: Ischemic heart disease in women is a difficult issue in cardiovascular medicine, mainly because of our lack of understanding of the early-stage mechanisms and symptoms. A better and earlier understanding of the pathophysiology of coronary artery disease (CAD) in women will enable us to detect ischemic heart disease earlier and prevent adverse clinical outcomes.Objectives: The aims of this article were to describe the phenomenon of ischemic heart disease in women, increase awareness of the difference between men and women in relation to ischemic heart disease, improve our understanding of the mechanisms that cause this difference, and identify new approaches for better and earlier detection and treatment of CAD in women.Methods: We conducted a search of the PubMed database for double-blind studies on the mechanistic pathways of CAD in women published in English within the past 10 years and epidemiologic studies published since 1970. Search terms included women and coronary artery disease and ischemic heart disease in women.Results: The literature search revealed 30 peer-reviewed articles pertaining to this issue. The incidence of CAD was markedly lower in women <60 years of age than in older women. After 60 years of age, the rate of CAD increased and reached the rate seen among men by the 8th decade of life. The gender difference in atherosclerosis in the coronary tree was particularly large in patients <55 years of age and remained large at older ages. The gender difference in the coronary bed was strikingly larger than in other vascular beds. Intensive risk-factor modification had a similar effect on plaque progression in both men and women. Coronary endothelial dysfunction appeared to be related to cardiovascular morbidity and mortality in women as well as in men, and because endothelial dysfunction could be modified, it appeared that the prognosis could be improved by appropriate management. A strong association was found between body mass index (BMI) and metabolic status, but only the metabolic syndrome was associated with CAD. Physical activity was independently associated with fewer risk factors, less CAD, and fewer adverse events in women; however, obesity was not associated with these outcomes.Conclusions: Results of the identified studies suggest that reduction of risk factors is a common approach to fighting heart disease in both sexes. It appears that for women, weight and BMI are not as important as previously thought, but physical exercise and fitness are very important and can change risk factors and clinical outcomes more than any other known intervention. Data suggest that global inflammation may play an important role in women and may predict cardiovascular outcome in women much better than the traditional risk factors that have been used and proved for men.     

Sex Differences in Colorectal Cancer Survival: Population-Based Analysis of 164,996 Colorectal Cancer Patients in Germany

Risk of colorectal cancer (CRC) is considerably higher in men compared to women; however, there is inconclusive evidence of sex differences in CRC prognosis. We aimed to assess and explain sex differences in 5-year relative survival using standard and model-based period analysis among 164,996 patients diagnosed with CRC from 1997 to 2006 and reported to 11 German cancer registries covering a population of 33 million inhabitants. Age-adjusted 5-year relative survival was higher in women (64.5% vs. 61.9%, P<0.0001). A substantial survival advantage of women was confirmed in multivariate analysis after adjusting for CRC stage and subsite in subjects under 65 years of age (relative excess risk, RER 0.86, 95% CI 0.82–0.90), but not in older subjects (RER 1.01, 95% CI 0.98–1.04); this pattern was similar in the 1st and in the 2nd to 5th year after diagnosis. The survival advantage of women varied by CRC stage and age and was most pronounced for localized disease (RERs 0.59–0.88 in various age subgroups) and in patients under 45 years of age (RERs 0.59, 0.72 and 0.76 in patients with localized, regional or advanced disease, respectively). On the contrary, sex differences in survival did not vary by location of CRC. In conclusion, our large population-based study confirmed a survival advantage of female compared to male CRC patients, most notably in young and middle aged patients and patients with localized disease. The effect of sex hormones, either endogenous or through hormonal replacement therapy, might be the most plausible explanation for the observed patterns.