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

BACKGROUND: Takotsubo syndrome is an acute heart failure syndrome often preceded by a trigger factor of physical or emotional origin, although the proportion is unclear. The aim of the present study was to determine how common different trigger factors are in takotsubo syndrome divided by sex and age in women.
METHODS: The study consisted of a systematic review of all available case reports in PubMed and Web of Science up to March 2018. Trigger factors were categorized into physical and emotional trigger factors.
RESULTS: Males had to a higher degree experienced a trigger factor (92.6%) compared to females (81.9%, p < .001). Physical trigger factors were most common (67.3%). Males had to a higher degree experienced a physical trigger factor (85.7%) compared to females (63.5%, p < .001). Females ≤50 years of age had to a higher degree experienced a trigger factor (90.8%) compared to females >50 years of age (79.2%, p < .001). Additionally, females ≤50 years of age had to a higher degree experienced a physical trigger factor (75.6%) compared to females >50 years of age (59.3%, p < .01).
CONCLUSIONS: A physical trigger factor is more common than an emotional trigger factor in takotsubo syndrome. Physical triggers includes drugs, surgery and central nervous system conditions. Furthermore, females ≤50 years of age and males more often have an evident trigger factor and it is more often physical, compared to the most common patient, a female >50 years of age.

BACKGROUND: Previous studies have reported that around 50% of patients with venous thromboembolism (VTE) has undergone recent hospitalization. However, studies on the impact of hospitalization as a trigger factor for VTE are limited.
OBJECTIVE: To investigate the impact of hospitalization with and without concurrent immobilization as a trigger factor for VTE.
METHODS: We conducted a case-crossover study of 530 cancer-free VTE patients. Hospitalizations were registered during the 90-day period preceding the VTE diagnosis (hazard period), and in four preceding 90-day control periods. A 90-day washout period between the control- and hazard periods was implemented to avoid potential carry-over effects. Conditional logistic regression was used to calculate odds ratios (OR) of VTE according to hospitalization.
RESULTS: In total, 159 (30%) of the VTE-patients had been hospitalized in the hazard period, and the OR of hospitalization was 9.4 (95% CI: 6.8-12.8). The risk increased slightly with the total number of days spent in hospital (OR per day: 1.11, 95% CI: 1.04-1.18), and with the number of hospitalizations (OR 8.9, 95% CI: 6.4-12.4 for 1 hospitalization and OR 12.3, 95% CI 6.4-23.6 for ≥2 hospitalizations). Hospitalization without immobilization was 6-times (OR: 6.3, 95% CI: 4.4-9.2) more common, whereas hospitalization with immobilization was near 20-times (OR: 19.8, 95% CI: 11.5-34.0) more common in the 90-days prior to a VTE compared to the control periods.
CONCLUSIONS: Hospitalization is a major trigger factor for VTE also in the absence of immobilization. However, immobilization contributes substantially to the risk of VTE among hospitalized patients.

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.

BACKGROUND: It is important to identify factors that influence the risk of relapses in inflammatory bowel disease. Few studies have been conducted and with limited methodology. This prospective case-crossover study, aims to examine whether perceived stress has a short-term acute effect, namely whether it acts as a trigger, on the risk of relapse in inflammatory bowel disease.
METHODS: Sixty patients with inflammatory bowel disease and in remission were included. The case-crossover design was employed, which is an epidemiological design developed to study triggers for acute events and diseases. To collect information regarding symptoms and potential trigger factors, such as perceived stress, a structured diary was constructed. The participants were instructed to fill in the diary daily during six months. Fifty patients completed the study.
RESULTS: The analysis showed an effect for high level of perceived stress. Being exposed to \"quite a lot\" of stress, yield an increase in risk for relapse during the forthcoming day (OR = 4.8, 95% CI 1.09 - 21.10). No statistically increased risk for lower levels of perceived stress was found, although elevated effect estimates were found for \"some\" stress.
CONCLUSIONS: This study supports earlier findings regarding perceived stress as an important factor in triggering relapses in IBD. However, this is the first case-crossover study performed to explore the trigger risk of stress in this population. Further investigations with larger patient samples are needed to confirm the findings.