Functional neurological disorder and functional somatic syndromes among sexual and gender minority people: A scoping review

OBJECTIVE

To describe the current literature on functional neurological disorder and functional somatic syndromes among sexual and gender minority people (SGM).

METHODS

A search string with descriptors of SGM identity and functional disorders was entered into PubMed, Embase, Web of Science, PsycInfo, and CINAHL for articles published before May 24, 2022, yielding 3121 items entered into Covidence, where 835 duplicates were removed. A neurologist and neuropsychiatrist screened titles and abstracts based on predefined criteria, followed by full-text review. A third neurologist adjudicated discrepancies. Eligible publications underwent systematic data extraction and statistical description.

RESULTS

Our search identified 26 articles on functional disorders among SGM people. Most articles were case (13/26, 46%) or cross-sectional (4/26, 15%) studies. Gender minority people were represented in 50% of studies. Reported diagnoses included fibromyalgia (n = 8), functional neurological disorder (n = 8), somatic symptom disorder (n = 5), chronic fatigue syndrome (n = 3), irritable bowel syndrome (n = 2), and other functional conditions (n = 3). Three cohort studies of fibromyalgia or somatic symptom disorder reported an overrepresentation of gender minority people compared to cisgender cohorts or general population measures. Approximately half of case studies reported pediatric or adolescent onset (7/13, 54%), functional neurological disorder diagnosis (7/13, 54%), and symptom improvement coinciding with identity-affirming therapeutic interventions (7/13, 58%).

CONCLUSION

Despite a methodologically rigorous literature search, there are limited data on functional neurological disorder and functional somatic syndromes among SGM people. Several studies reported increased prevalence of select conditions among transgender people. More observational studies are needed regarding the epidemiology and clinical course of functional disorders among SGM people.

Spectral analysis of strident fricatives in cisgender and transfeminine speakersa)

The spectral features of /s/ and /ʃ/ carry important sociophonetic information regarding a speaker's gender. Often, gender is misclassified as a binary of male or female, but this excludes people who may identify as transgender or nonbinary. In this study, we use a more expansive definition of gender to investigate the acoustics (duration and spectral moments) of /s/ and /ʃ/ across cisgender men, cisgender women, and transfeminine speakers in voiced and whispered speech and the relationship between spectral measures and transfeminine gender expression. We examined /s/ and /ʃ/ productions in words from 35 speakers (11 cisgender men, 17 cisgender women, 7 transfeminine speakers) and 34 speakers (11 cisgender men, 15 cisgender women, 8 transfeminine speakers), respectively. In general, /s/ and /ʃ/ center of gravity was highest in productions by cisgender women, followed by transfeminine speakers, and then cisgender men speakers. There were no other gender-related differences. Within transfeminine speakers, /s/ and /ʃ/ center of gravity and skewness were not related to the time proportion expressing their feminine spectrum gender or their Trans Women Voice Questionnaire scores. Taken together, the acoustics of /s/ and /ʃ/ may signal gender group identification but may not account for within-gender variation in transfeminine gender expression.

Functional Neurological Disorder Among Sexual and Gender Minority People

Sexual and gender minority (SGM) people can face unique stressors and structural discrimination that result in higher rates of neuropsychiatric symptoms, such as depression, anxiety, and suicidality. Although more rigorous studies are needed, emerging data suggest a possible higher prevalence of functional neurological disorder and other brain-mind-body conditions in SGM people. Representation and iterative feedback from affected community members is critical to the process of developing affirming environments. More research is needed to explore the relevance of functional neurologic disorder in SGM people within a biopsychosocial framework.

A Case Series of Transgender and Gender-Nonconforming Patients in a Pediatric Functional Neurologic Disorder Clinic

Youth who identify as transgender and gender nonconforming (TGNC) are at increased risk of anxiety, depression, bullying, and loss of social and family support. These factors may increase the risk of developing functional neurologic disorder (FND). If the risk of FND is increased in TGNC youth, then identifying which youth are at increased risk, and the particular times when risk is increased, may allow for earlier diagnosis and treatment of FND. Better awareness of functional symptoms among clinicians who care for TGNC youth may prevent disruption of gender-affirming care if FND symptoms emerge. Patients diagnosed with FND who are TGNC may require different forms of intervention than other youth with FND. We present 4 cases from our multidisciplinary pediatric FND program of TGNC youth who developed FND. In all individuals for whom follow-up information was available, access to gender-affirming health care was associated with marked improvement or resolution of FND symptoms.

Effect of Anchor Term on Auditory-Perceptual Ratings of Feminine and Masculine Speakers

BACKGROUND

Studies investigating auditory perception of gender expression vary greatly in the specific terms applied to gender expression in rating scales.

PURPOSE

This study examined the effects of different anchor terms on listeners' auditory perceptions of gender expression in phonated and whispered speech. Additionally, token and speaker cues were examined to identify predictors of the auditory-perceptual ratings.

METHOD

Inexperienced listeners (n = 105) completed an online rating study in which they were asked to use one of five visual analog scales (VASs) to rate cis men, cis women, and transfeminine speakers in both phonated and whispered speech. The VASs varied by anchor term (very female/very male, feminine/masculine, feminine female/masculine male, very feminine/not at all feminine, and not at all masculine/very masculine).

RESULTS

Linear mixed-effects models revealed significant two-way interactions of gender expression by anchor term and gender expression by condition. In general, the feminine female/masculine male scale resulted in the most extreme ratings (closest to the end points), and the feminine/masculine scale resulted in the most central ratings. As expected, for all speakers, whispered speech was rated more centrally than phonated speech. Additionally, ratings of phonated speech were predicted by mean fundamental frequency (f _o) within each speaker group and by smoothed cepstral peak prominence in cisgender speakers. In contrast, ratings of whispered speech, which lacks an f _o, were predicted by indicators of vocal tract resonance (second formant and speaker height).

CONCLUSIONS

The current results indicate that differences in the terms applied to rating scales limit generalization of results across studies. Identifying the patterns across listener ratings of gender expression provide a rationale for researchers and clinicians when making choices about terms. Additionally, beyond f _o and vocal tract resonance, predictors of listener ratings vary based on the anchor terms used to describe gender expression.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19617564.

Managing Ischemic Stroke in Patients Already on Anticoagulation for Atrial Fibrillation: A Nationwide Practice Survey

BACKGROUND AND PURPOSE

We sought to understand practice patterns in management of patients who have ischemic stroke while adherent to oral anticoagulation for non-valvular atrial fibrillation (NVAF) in the United States (US).

METHODS

We distributed an iteratively revised online survey to US neurologists in May-June 2019. Survey questions focused on clinicians' practices regarding diagnostic evaluation and secondary prevention after ischemic stroke in patients already on oral anticoagulation for NVAF. Standard descriptive statistics were used to summarize participants' characteristics and responses.

RESULTS

Of the 120 participating clinicians, 79% were attending physicians. Most respondents (66%) were trained in vascular neurology, and 79% were employed in hospital-based, academic settings. For patients with ischemic stroke despite anticoagulation, most respondents indicated that they obtain extracranial and intracranial vessel imaging (72% and 82%, respectively). Most respondents (83%) routinely change therapy to a direct oral anticoagulant (DOAC) for patients experiencing ischemic stroke while on warfarin. In cases of ischemic stroke while on a DOAC, 38% of respondents routinely switch agents, 42% do not routinely switch agents, and 20% routinely add an antiplatelet agent. In this scenario, 83% of respondents who switch agents indicated that the reason was a possible better response to a drug that acts through a different mechanism. The most common reason for not switching while on a DOAC was the lack of randomized trial data.

CONCLUSIONS

There is a high degree of variability in practice patterns among US neurologists caring for patients with ischemic stroke while already on oral anticoagulation for NVAF.

Relationship between Lambl's excrescences and embolic strokes of undetermined source

Introduction

About one-fourth of ischaemic strokes are classified as embolic strokes of undetermined source. Lambl's excrescences are commonly seen on cardiac valves, and data are limited on whether they may be a source of embolization. We examined the relationship between Lambl's excrescences and embolic stroke of undetermined source.

Patients and Methods

We performed a case-control study of patients in the Cornell AcutE Stroke Academic Registry. Stroke aetiologies were adjudicated using the Trial of Org 10172 in Acute Stroke Treatment and embolic stroke of undetermined source criteria. We included patients with acute ischaemic stroke between 2011 and 2016 who underwent transthoracic or transoesophageal echocardiography within six months of hospitalisation. Cases were embolic stroke of undetermined source patients and controls were patients with an identified, non-cardioembolic stroke aetiology (i.e. small- or large-vessel strokes). Multiple logistic regression was used to evaluate the association between Lambl's excrescences and embolic stroke of undetermined source after adjustment for demographics, comorbidities and mode of echocardiography.

Results

A total of 923 patients met the criteria for this analysis, including 530 with embolic stroke of undetermined source and 393 with small- or large-vessel strokes. Lambl's excrescences were identified in 47 (8.9%) patients with embolic stroke of undetermined source and 11 (2.8%) patients with small- or large-artery strokes, but the majority (54/58) of Lambl's excrescences were visualised on transoesophageal echocardiogram and embolic stroke of undetermined source patients were more likely to undergo transoesophageal echocardiogram. After adjustment for demographics, comorbidities and mode of echocardiography, we found no association between the presence of Lambl's excrescences and embolic stroke of undetermined source (odds ratio 0.9; 95% confidence interval 0.4-2.3).

Conclusion

We found no association between Lambl's excrescences and embolic stroke of undetermined source. These results do not support the hypothesis that Lambl's excrescences are an occult cause of embolic stroke of undetermined source.

Redefined Measure of Early Neurological Improvement Shows Treatment Benefit of Alteplase Over Placebo

Background and Purpose- The first of the 2 NINDS (National Institute of Neurological Disorders and Stroke) Study trials did not show a significant increase in early neurological improvement, defined as National Institutes of Health Stroke Scale (NIHSS) improvement by ≥4, with alteplase treatment. We hypothesized that early neurological improvement defined as a percentage change in NIHSS (percent change NIHSS) at 24 hours is superior to other definitions in predicting 3-month functional outcomes and using this definition there would be treatment benefit of alteplase over placebo at 24 hours. Methods- We analyzed the NINDS rt-PA Stroke Study (Parts 1 and 2) trial data. Percent change NIHSS was defined as ([admission NIHSS score-24-hour NIHSS score]×100/admission NIHSS score] and delta NIHSS as (admission NIHSS score-24-hour NIHSS score). We compared early neurological improvement using these definitions between alteplase versus placebo patients. We also used receiver operating characteristic curve to determine the predictive association of early neurological improvement with excellent 3-month functional outcomes (Barthel Index score of 95-100 and modified Rankin Scale score of 0-1), good 3-month functional outcome (modified Rankin Scale score of 0-2), and 3-month infarct volume. Results- There was a significantly greater improvement in the 24-hour median percent change NIHSS among patients treated with alteplase compared with the placebo group (28% versus 15%; P=0.045) but not median delta NIHSS (3 versus 2; P=0.471). Receiver operating characteristic curve comparison showed that percent change NIHSS (ROC_percent) was better than delta NIHSS (ROC_delta) and admission NIHSS (ROC_admission) with regards to excellent 3-month Barthel Index (ROC_percent, 0.83; ROC_delta, 0.76; ROC_admission, 0.75), excellent 3-month modified Rankin Scale (ROC_percent, 0.83; ROC_delta, 0.74; ROC_admission, 0.78), and good 3-month modified Rankin Scale (ROC_percent, 0.83; ROC_delta, 0.76; ROC_admission, 0.78). Conclusions- In the NINDS rt-PA trial, alteplase was associated with a significant percent change improvement in NIHSS at 24 hours. Percent change in NIHSS may be a better surrogate marker of thrombolytic activity and 3-month outcomes.

Abstract WP254: Insular Involvement of Ischemic Stroke Suggests a Cardioembolic Mechanism

Introduction: The insular cortex controls several aspects of vital function including autonomic regulation, and strokes affecting the insula have been associated with dysautonomia, cardiac dysfunction, and arrhythmias. Previous studies have shown an association between insular strokes, elevated troponin levels, and atrial fibrillation (AF). In this study, we aim to determine the association between cardiac biomarkers and insular involvement of the infarct and hypothesize that insular involvement implicates a cardioembolic source.

Methods: We abstracted data from a prospective comprehensive stroke center registry of consecutive patients with a discharge diagnosis of acute ischemic stroke who underwent brain imaging (CT or MRI) and work up to determine stroke mechanism. Data included demographics, clinical baseline variables, laboratory tests (including admission troponin level), and transthoracic echocardiographic variables (regional wall motion abnormalities, ejection fraction, and left atrial volume index), and stroke subtype. Multivariable logistic regression models were built to determine associations between AF, and cardiac biomarkers and insular infarcts.

Results: We identified 1224 patients who met the inclusion criteria; 397 (32.4%) had insular involvement of the infarct. In multivariable models, insular infarcts were associated with AF (adjusted OR 1.73, 95% CI 1.23-2.43, p = 0.001) and left atrial volume index (adjusted OR per standard deviation increase 1.30, 95% CI 1.13-1.49, p = 0.001). There was a trend for association between insular involvement and positive troponin level (adjusted OR 1.45 95% CI 0.91-2.33, p = 0.122) but not with regional wall motion abnormalities (adjusted OR 1.13, 95% CI 0.69-1.84, p = 0.627). Insular involvement was associated with cardioembolic stroke subtype (45.8% vs. 26.7%, p<0.001) but not other stroke subtypes.

Conclusion: The insular cortex is commonly involved in patients with atrial fibrillation and/or atrial dilation and maybe a neuroimaging biomarker of cardioembolic stroke. Larger studies are needed to confirm this association and test anticoagulation therapy in patients with insular infarcts.

Differences in Admission Blood Pressure Among Causes of Intracerebral Hemorrhage

Background and Purpose- It is unknown whether admission systolic blood pressure (SBP) differs among causes of intracerebral hemorrhage (ICH). We sought to elucidate an association between admission BP and ICH cause. Methods- We compared admission SBP across ICH causes among patients in the Cornell Acute Stroke Academic Registry, which includes all adults with ICH at our center from 2011 through 2017. Trained analysts prospectively collected demographics, comorbidities, and admission SBP, defined as the first recorded value in the emergency department or on transfer from another hospital. ICH cause was adjudicated by a panel of neurologists using the SMASH-U criteria. We used ANOVA to compare mean admission SBP among ICH causes. We used multiple linear regression to adjust for age, sex, race, Glasgow Coma Scale score, and hematoma size. In secondary analyses, we compared hourly SBP measurements during the first 72 hours after admission, using mixed-effects linear models adjusted for the covariates above plus antihypertensive agents. Results- Among 484 patients with ICH, admission SBP varied significantly across ICH causes, ranging from 138 (±24) mm Hg in those with structural vascular lesions to 167 (±35) mm Hg in those with hypertensive ICH (P<0.001). The mean admission SBP in hypertensive ICH was 17 (95% CI, 11-24) mm Hg higher than in ICH of all other causes combined. These differences remained significant after adjustment for age, sex, race, Glasgow Coma Scale score, and hematoma size (P<0.001), and this persisted throughout the first 72 hours of hospitalization (P<0.001). Conclusions- In a single-center ICH registry, SBP varied significantly among ICH causes, both on admission and during hospitalization. Our results suggest that BP in the acute post-ICH setting is at least partly associated with ICH cause rather than simply representing a physiological reaction to the ICH itself.

Abstract WMP111: Trends in Active Tobacco Smoking Among Stroke Survivors in The United States: An Analysis of the National Health and Nutrition Examination Survey, 1999-2016

Background: Active smoking after stroke is associated with worse outcomes. Since several smoking cessation drugs have become available during the last two decades, we sought to determine whether the rate of active smoking among stroke survivors has decreased.

Methods: We performed a trends analysis using cross-sectional data from all nine available consecutive cycles of the continuous phase of the National Health and Nutrition Examination Survey from 1999 to 2016. Participants in each cycle were asked about their medical history and health-related behaviors. We included participants 20 years of age and older who answered questions regarding smoking. Patients with prior stroke were identified based on self-report, which has been validated against expert chart review. Active smoking was defined based on self-report. We used multivariable logistic regression methods for survey data to assess for trends in active smoking among all participants and those with prior stroke. Models were adjusted for demographics.

Results: We included 49,440 participants in our analysis, of whom 1,921 (2.7%) reported a prior stroke. The mean age of stroke survivors was 64.8 (standard error, 0.5) years, and 57% were women. The average prevalence of active smoking over 1999-2016 was 22.2% for the whole sample and 24.3% among stroke survivors. In the overall population, the adjusted prevalence of active smoking decreased over the study period (odds ratio [OR] per cycle, 0.96; 95% confidence interval [CI], 0.94-0.97). The rate did not decrease among stroke survivors (OR, 1.01; 95% CI, 0.93-1.09) (Fig).

Conclusion: Despite the availability of several effective smoking cessation therapies, the rate of active smoking among stroke survivors has not decreased in the past two decades. Effective strategies for smoking cessation for secondary stroke prevention are needed.

Geographic Analysis of Mobile Stroke Unit Treatment in a Dense Urban Area: The New York City METRONOME Registry

Background Mobile stroke units (MSUs) reduce time to intravenous thrombolysis in acute ischemic stroke. Whether this advantage exists in densely populated urban areas with many proximate hospitals is unclear. Methods and Results We evaluated patients from the METRONOME (Metropolitan New York Mobile Stroke) registry with suspected acute ischemic stroke who were transported by a bi-institutional MSU operating in Manhattan, New York, from October 2016 to September 2017. The comparison group included patients transported to our hospitals via conventional ambulance for acute ischemic stroke during the same hours of MSU operation (Monday to Friday, 9 am to 5 pm). Our exposure was MSU care, and our primary outcome was dispatch-to-thrombolysis time. We estimated mean differences in the primary outcome between both groups, adjusting for clinical, demographic, and geographic factors, including numbers of nearby designated stroke centers and population density. We identified 66 patients treated or transported by MSU and 19 patients transported by conventional ambulance. Patients receiving MSU care had significantly shorter dispatch-to-thrombolysis time than patients receiving conventional care (mean: 61.2 versus 91.6 minutes; P=0.001). Compared with patients receiving conventional care, patients receiving MSU care were significantly more likely to be picked up closer to a higher mean number of designated stroke centers in a 2.0-mile radius (4.8 versus 2.7, P=0.002). In multivariable analysis, MSU care was associated with a mean decrease in dispatch-to-thrombolysis time of 29.7 minutes (95% CI, 6.9-52.5) compared with conventional care. Conclusions In a densely populated urban area with a high number of intermediary stroke centers, MSU care was associated with substantially quicker time to thrombolysis compared with conventional ambulance care.

Association Between Intravenous Thrombolysis and Anaphylaxis Among Medicare Beneficiaries With Acute Ischemic Stroke

Background and Purpose- Allergic reactions, including anaphylaxis, can sometimes occur after intravenous thrombolysis in patients with acute ischemic stroke. However, it remains unclear whether patients with stroke who receive thrombolytic agents face a higher risk of anaphylaxis than those who do not receive thrombolytics. Methods- We performed a retrospective cohort study using inpatient and outpatient claims between 2008 and 2015 from a nationally representative 5% sample of Medicare beneficiaries. We included patients who were ≥65 years old and hospitalized with acute ischemic stroke, defined by validated International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Our exposure was treated with an intravenous thrombolytic agent during the index hospitalization (International Classification of Diseases, Ninth Revision, Clinical Modification code 99.10). Our primary outcome was anaphylaxis, defined using an accepted International Classification of Diseases, Ninth Revision, Clinical Modification code algorithm (989.5, 995.0-4, 995.6x, E905, E905.3, E905.5, or E905.8-9). A secondary outcome was anaphylactic shock (995.0 or 995.6x). Multiple logistic regression was used to evaluate the association between intravenous thrombolysis and anaphylaxis after adjustment for demographics, vascular risk factors, the Charlson comorbidity index, exposure to intravenous contrast dye, treatment with mechanical thrombectomy, and history of allergic reactions. Results- Among 66 989 patients with stroke, the 3176 (4.7%) who underwent intravenous thrombolysis more often had atrial fibrillation (47.7% versus 37.4%) and more often received intravenous contrast dye (44.3% versus 21.9%) but were otherwise similar in terms of demographics and comorbidities. Anaphylaxis developed in 17 (0.54%; 95% CI, 0.31%-0.86%) patients who received intravenous thrombolysis versus 45 (0.07%; 95% CI, 0.05%-0.09%) who did not. After adjustment for demographics, comorbidities, contrast dye, mechanical thrombectomy, and history of allergies, there was a significant association between receipt of intravenous thrombolysis and anaphylaxis (odds ratio, 7.8; 95% CI, 4.3-13.9). We found a similar association for anaphylactic shock. Conclusions- Although a rare occurrence, the risk of anaphylaxis among patients with acute ischemic stroke was significantly higher among those who received intravenous thrombolysis.

Association between Intracranial Atherosclerotic Calcium Burden and Angiographic Luminal Stenosis Measurements

BACKGROUND AND PURPOSE

Calcification of the intracranial vasculature is an independent risk factor for stroke. The relationship between luminal stenosis and calcium burden in the intracranial circulation is incompletely understood. We evaluated the relationship between atherosclerotic calcification and luminal stenosis in the intracranial ICAs.

MATERIALS AND METHODS

Using a prospective stroke registry, we identified patients who had both NCCT and CTA or MRA examinations as part of a diagnostic evaluation for ischemic stroke. We used NCCTs to qualitatively (modified Woodcock Visual Score) and quantitatively (Agatston-Janowitz Calcium Score) measure ICA calcium burden and used angiography to measure arterial stenosis. We calculated correlation coefficients between the degree of narrowing and calcium burden measures.

RESULTS

In 470 unique carotid arteries (235 patients), 372 (79.1%) had atherosclerotic calcification detectable on CT compared with 160 (34%) with measurable arterial stenosis on CTA or MRA (P < .001). We found a weak linear correlation between qualitative (R = 0.48) and quantitative (R = 0.42) measures of calcium burden and the degree of luminal stenosis (P < .001 for both). Of 310 ICAs with 0% luminal stenosis, 216 (69.7%) had measurable calcium scores.

CONCLUSIONS

There is a weak correlation between intracranial atherosclerotic calcium scores and luminal narrowing, which may be explained by the greater sensitivity of CT than angiography in detecting the presence of measurable atherosclerotic disease. Future studies are warranted to evaluate the relationship between stenosis and calcium burden in predicting stroke risk.