female

Importance: A patent foramen ovale (PFO), an opening between the right and left atria during normal fetal development that fails to close after birth, is present in approximately 25% of all adults. Paradoxical embolism, a venous thromboembolism that travels to the systemic circulation typically through a PFO, accounts for about 5% of all strokes and 10% of strokes in younger patients.

Observations: Approximately 50% of patients 60 years or younger with an embolic stroke of undetermined source (cryptogenic stroke) have a PFO, compared with 25% of the general population. The Risk of Paradoxical Embolism (RoPE) score incorporates clinical characteristics (age, history of stroke or transient ischemic attack, diabetes, hypertension, smoking, cortical infarct on imaging) to predict the likelihood that embolic stroke of undetermined source was caused by a PFO. Among patients in the lowest RoPE score category (score <3), PFO prevalence was similar to that in the general population (23%), while PFO prevalence was 77% in patients with a RoPE score of 9 or 10. The PFO-Associated Stroke Causal Likelihood (PASCAL) classification system combines the RoPE score and anatomical criteria from echocardiography (large shunt, atrial septal aneurysm) to classify PFO as the “probable,” “possible,” or “unlikely” cause of otherwise cryptogenic stroke. PFO closure reduces recurrent ischemic stroke in patients 60 years or younger with cryptogenic stroke. In a pooled analysis of 6 trials (3740 patients), the annualized incidence of stroke over a median follow-up of 57 months was 0.47% (95% CI, 0.35%-0.65%) with PFO closure vs 1.09% (95% CI, 0.88%-1.36%) with medical therapy (adjusted hazard ratio, 0.41 [95% CI, 0.28-0.60]). However, the benefits and harms of closure were highly heterogeneous across the trial populations. In patients categorized as PASCAL “probable” (ie, younger patients without vascular risk factors and high-risk PFO anatomical features), there was a 90% decreased relative rate of recurrent ischemic stroke after PFO closure at 2 years (hazard ratio, 0.10 [95% CI, 0.03-0.35]; absolute risk reduction, 2.1% [95% CI, 0.9%-3.4%]). PASCAL “unlikely” patients (eg, older patients with vascular risk factors and no high-risk PFO anatomical features) did not have a lower recurrent stroke rate with PFO closure but had higher risk of procedure- and device-related adverse events, such as atrial fibrillation.

Conclusions and Relevance: Patent foramen ovale is present in approximately 25% of all adults and is a common cause of stroke in young and middle-aged patients. The PASCAL classification system can help guide patient selection for PFO closure. Percutaneous PFO closure substantially reduces the risk of stroke recurrence in well-selected patients younger than 60 years after cryptogenic stroke.

This JAMA Internal Medicine Patient Page describes urinary tract infections, their causes, and how to treat them and prevent future episodes.

Prolapse is found in 41%–50% of adult females, with symptoms of pelvic pressure and vaginal bulge sensation reported by 3%–6% of adult females. Prolapse is diagnosed and staged with physical examination based on the maximum descent of vaginal tissue (anterior, posterior or apex) on Valsalva manoeuvre. Symptoms commonly begin when the bulge reaches within 0.5 cm of the vaginal opening. Imaging is not routinely needed. Risk factors include increasing age, parity, a history of vaginal delivery, obesity, constipation, postmenopausal status and connective tissue disorders.

• Hereditary angioedema (HAE) is a rare autosomal dominant
disorder characterized by recurrent episodes of painful (and
usually asymmetric) swelling without urticaria that leads to
substantial morbidity and even mortality (in the case of
laryngeal involvement) if left untreated.
• Delayed diagnosis and misdiagnosis of HAE are common,
particularly during pregnancy and the postpartum period.
• Hereditary angioedema should be considered in the differential
diagnosis of any patient presenting with unexplained
abdominal pain and recurrent episodes of angioedema
(particularly if asymmetric in nature) without urticaria.
• Tests to confirm the diagnosis of HAE include measurement of
C4 and C1 inhibitor (INH) antigen and function.
• Successful pregnancy and delivery are possible in HAE with
proper medical management, which includes plasma-derived
C1-INH and collaboration with HAE specialists.