Case-control and cohort studies of moderate alcohol consumption and stroke

Epidemiologic evidence suggests that alcohol consumption has distinctive associations with risk of ischemic and hemorrhagic strokes; these differences help explain apparent inconsistencies in the alcohol-stroke literature (Camargo CA Jr. Stroke 1989;20:1611-1626). To better define the impact of "moderate drinking" per se (i.e. usual consumption of < or = 2 drinks daily for men, and < or = 1 drink daily for women), the present author reviewed 26 case-control and cohort studies on this subject. There is substantial evidence that moderate drinking does not increase risk of ischemic stroke; studies remain divided, however, on the question of a "protective" association. Furthermore, although the evidence is not unanimous, two major cohort studies have found that even moderate drinking may increase risk of hemorrhagic stroke. Because ischemic strokes are 3-4 times more common than hemorrhagic strokes, the net impact of moderate drinking on stroke risk depends greatly on the relation between moderate drinking and ischemic stroke. It is most likely, however, that moderate drinking does not increase risk of all strokes combined.

Atheroembolic renal failure after invasive procedures. Natural history based on 52 histologically proven cases

Atheromatous plaque material containing cholesterol crystals may dislodge and cause distal ischemia. To characterize atheroembolic renal failure, we retrospectively evaluated all patients at the Massachusetts General Hospital from 1981 to 1990 with both renal failure and histologically proven atheroembolism after angiography or cardiovascular surgery. Over the 10-year period, 52 patients were identified. They tended to be elderly men with a history of hypertension (81%), coronary artery disease (73%), peripheral vascular disease (69%), and current smoking (50%). Within 30 days of their procedure, only 50% of patients had cutaneous signs of atheroembolism, and 14% had documented blood eosinophilia. Urinalysis was often abnormal. Hemodynamically unstable patients died shortly after their procedure, yet renal function in the remainder continued to decline over 3 to 8 weeks. Patients who received dialysis had a higher baseline serum creatinine than those who did not (168 +/- 44 mumol/L versus 133 +/- 18 mumol/L, p = 0.02), with dialysis starting a median of 29 days after the procedure. Patients with renal failure due to atheroembolism alone, as opposed to multiple renal insults, were more likely to recover renal function (24% versus 3%, p = 0.03) and had a lower risk of death during the 6 months after their procedure (log-rank p = 0.002). Renal failure due to procedure-induced AE is characterized by a decline in renal function over 3 to 8 weeks. This time course is not consistent with most other iatrogenic causes of renal failure, such as radiocontrast or nephrotoxic medications, which present earlier and often resolve within 2 to 3 weeks after appropriate intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute pancreatitis following liver transplantation

BACKGROUND

Acute pancreatitis (AP) has not been recognized as a frequent complication following orthotopic liver transplantation (OLT). Reports have suggested that this condition is associated with high morbidity and mortality rates.

STUDY DESIGN

A retrospective review of 354 patients who underwent OLT at the University of Toronto, with at least one-year follow-up, was done to identify the incidence, etiology, risk factors, and severity of pancreatitis following OLT, as well as to discuss its management. A possible correlation between AP and hepatitis B was also investigated. Prognostic score systems, including Ranson, Imrie, and APACHE II, were also evaluated.

RESULTS

Acute pancreatitis occurred in 5.9 percent of the OLT recipients. Based on clinical presentation and diagnostic tests, AP could be subdivided into three distinct categories: biochemical AP, significant increase of serum amylase or lipase levels in absence of objective radiologic or surgical evidence of the disease; clinical AP, pancreatitis with radiologic or surgical evidence of the disease; and AP in the critically ill patient. Biochemical AP occurred in the early postoperative period and was consistently a benign condition. Clinical AP occurred after a delay and was associated with a 40 percent mortality rate. Acute pancreatitis in the critically ill patient was only one component of multiorgan failure, which was lethal in each case. About one-half of the patients with biochemical and clinical AP were hepatitis surface antigen positive prior to OLT. The incidence of AP was significantly higher in patients with hepatitis B (17 percent) than in patients without hepatitis B (3 percent) (p < 0.01). APACHE II was the best prognostic score system in the clinical group with a positive and negative predictive value for a score equal to or greater than 10 points of 67 and 100 percent, respectively.

CONCLUSIONS

Acute pancreatitis is not an uncommon complication of OLT. Clinical presentation and diagnostic tests have important prognostic values. In some patients, hepatitis B virus may play an important role. APACHE II scores appear to be useful in the evaluation of clinical AP following OLT. Treatment of AP should be similar in both the transplant and nontransplant setting.

Definition and classification of negative outcomes in solid organ transplantation. Application in liver transplantation

OBJECTIVE

This study defined negative outcomes of solid organ transplantation, proposed a new classification of complications by severity, and applied the classification to evaluate the results of orthotopic liver transplantation (OLT).

SUMMARY AND BACKGROUND DATA

The lack of uniform reporting of negative outcomes has made reports of transplantation procedures difficult to interpret and compare. In fact, only mortality is well reported; morbidity rates and severity of complications have been poorly described.

METHODS

Based on previous definition and classification of complications for general surgery, a new classification for transplantation in four grades is proposed. Results including risk factors of the first 215 OLTs performed at the University of Toronto have been evaluated using the classification.

RESULTS

All but two patients (99%) had at least one complication of any kind, 92% of patients surviving more than 3 months had grade 1 (minor) complications, 74% had grade 2 (life-threatening) complications, and 30% had grade 3 (residual disability or cancer) complications. Twenty-nine per cent of patients had grade 4 complications (retransplantation or death). The most common grade 1 complications were steroid responsive rejection (69% of patients) and infection that did not require antibiotics or invasive procedures (23%). Grade 2 complications primarily were infection requiring antibiotics or invasive procedures (64%), postoperative bleeding requiring > 3 units of packed red cells (35%), primary dysfunction (26%), and biliary disease treated with antibiotics or requiring invasive procedures (18%). The most frequent grade 3 complication was renal failure, which is defined as a permanent rise in serum creatinine levels > or = twice the pretransplantation values (11%). Grade 4 complications (retransplantation or death) mainly were infection (14%) and primary dysfunction (11%). Comparison between the first and last 50 OLTs of the series indicates a significant decrease in the mean number of grade 1 and 2 complications. This was partially a result of better medical status of patients at the time of transplantation. Using univariate and multivariate analyses of risk factors, the best predictor of grade 1 complications was donor obesity; for grade 2 complications, the best predictor was a donor liver rewarming time of > 90 minutes, and for grade 3 and 4 complications, the best predictor was the APACHE II scoring system and donor cardiac arrest.

CONCLUSIONS

Standardized definitions and classifications of complications of transplantation will allow us to better evaluate and compare results of transplantation among centers and over time, and better compare effectiveness of new therapies. Orthotopic liver transplantation still is a procedure with high morbidity that requires careful analysis of risk factors to optimize selection of patients and organ sharing.

1492--the medical consequences

This discussion was selected from the weekly staff conferences in the Department of Medicine, University of California, San Francisco. Taken from a transcription, it has been edited by Nathan M. Bass, MD, PhD, Associate Professor of Medicine, under the direction of Lloyd H. Smith Jr, MD, Professor of Medicine and Associate Dean in the School of Medicine.

Review of bulimia nervosa in males

OBJECTIVE

The authors describe the distribution of bulimia nervosa among males and identify characteristics that distinguish male bulimics from their female counterparts.

METHOD

Potential references were identified through an English-language literature search using MEDLINE (1966 to April 1990) and through extensive manual searching of textbooks and reviews. All published works with original data or hypotheses concerning bulimia in males were included.

RESULTS

Bulimia affects approximately 0.2% of adolescent boys and young adult men, and males account for 10%-15% of all bulimic subjects identified in community-based studies. Compared to their female counterparts, male bulimics appear to have a later age of onset; higher prevalences of premorbid obesity, homosexuality, and asexuality; and less concern with strict weight control. These findings are discussed from biological, psychological, and cultural perspectives to develop a fuller understanding of the pathogenesis of bulimia in males.

CONCLUSIONS

Bulimia in males has received relatively little attention in the literature. Future research should focus on more rigorous analytic studies that include matched comparison groups of female bulimic and male nonbulimic subjects. Such studies would not only benefit male bulimics but might provide insight into the nature of bulimia in both sexes.

A young man with recurrent pulmonary infections. Infected intralobar bronchopulmonary sequestration

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Moderate alcohol consumption and stroke. The epidemiologic evidence

An extensive search of the English-language literature identified 62 epidemiologic studies that examined the relation between moderate alcohol consumption and risk of stroke. Moderate drinking (less than 60 g ethanol/day) and ischemic stroke have a complex association that might be explained by interaction with race; a J-shaped association has been found in predominantly white populations, while little (if any) association has been found among Japanese. By contrast, moderate drinking increases risk of both intracerebral and subarachnoid hemorrhage in diverse populations. There is insufficient epidemiologic evidence to conclude whether recent alcohol use affects risk of either ischemic or hemorrhagic stroke. These distinctive associations help explain contradictory reports on the relation between moderate alcohol consumption and risk of "stroke." The high prevalence of alcohol use throughout the world suggests opportunities for primary prevention and the importance of continued research in this area.

Alcohol, calorie intake, and adiposity in overweight men

The relation of alcohol use to calorie intake and adiposity was studied in 155 non-smoking, overweight men. Alcohol use and calorie intake were assessed by 7-day dietary record, and body composition was determined by hydrostatic weighing. Increased intake of food calories (i.e., non-ethanol calories only) on alcohol-drinking days was compensated for by decreased food consumption on non-drinking days of the week. Added alcohol calories were not offset during the week and resulted in a surplus intake of over 4,000 kcal/wk for men in the highest drinking group. Although alcohol calories were "added" to food intake, alcohol use was unrelated to level of adiposity. This finding was not accounted for by concomitant differences in exercise status. Basal metabolic rate, however, was elevated in men imbibing one or more "drinks" per day (as compared to abstainers and light-drinkers). Increased basal energy expenditure may have partially offset the alcohol calories of men at lower levels of alcohol intake, but it did not substantially offset the large calorie surplus seen at higher levels of consumption. Our results support recent speculation that alcohol consumption may not be as "fattening" as traditionally believed.

Type A behavior pattern and alcohol intake in middle-aged men

Eighty-one sedentary but healthy, middle-aged men were studied. Type A behavior pattern (TABP) was determined by "structured interview", and dietary intake was assessed by alcohol questionnaire and 3-day diet record. Type A men reported drinking approximately twice as much alcohol as their non-Type A counterparts (mean +/- SD: 21.7 +/- 18.2 vs. 9.4 +/- 9.1 g of ethanol per day; p = 0.0003), and a strong, positive association between TABP and alcohol intake was found. The TABP-alcohol relationship was not confounded by concomitant differences in income level or years of formal education, and remained highly significant in subsequent analyses of nonsmokers alone. Type As and non-Type As did not differ significantly in their consumption of any other nutrient measured. The association between TABP and alcohol intake may have confounded conclusions from previous studies that focused on one or the other as a risk factor for coronary heart disease.

The effect of moderate alcohol intake on serum apolipoproteins A-I and A-II. A controlled study

High serum concentrations of apolipoprotein (apo) A-I are associated with a decreased risk of coronary heart disease. To study the effect of alcohol intake on serum apo A-I and A-II concentrations, 24 healthy male drinkers (37.8 +/- 13.9 mL [1.3 +/- 0.5 oz] of ethanol per day, mean +/- SD) were randomized into treatment and control groups after a three-week baseline period. The treatment group abstained from all intake of alcohol for the six weeks following randomization and then reverted to its usual level of intake for a five-week period. The control group continued its usual level of drinking throughout the trial. The concentrations of apo A-I and apo A-II of abstainers decreased significantly compared with the corresponding changes in controls. After drinking was resumed, apo A-I and apo A-II concentrations were significantly increased in the treatment group compared with the corresponding changes in the control group. These results suggest that the association between moderate alcohol intake and reduced risk of coronary heart disease may be mediated in part by increased levels of serum apo A-I or apo A-II, or both.

Effects of androgen on sexual behavior in hypogonadal men

Despite the widespread use of androgen in the treatment of hypogonadal men, its efficacy in restoring sexual behavior to hypogonadal patients has not been established in appropriately controlled behavioral studies. Accordingly, testosterone enanthate or vehicle was injected once every 4 weeks im in a double blind experiment. The subjects were six adult males, aged 32-65 yr, two with gonadal failure and four with secondary hypogonadism. Two doses of testosterone (100 and 400 mg) were administered for approximately 5 months, with the treatments varied at random within and among subjects. Details of sexual activity and experience were followed by the use of daily logs. Frequencies of erections, including nocturnal erections and coitus, showed significant dose-related responses to androgen treatment which closely followed the fluctuations in the circulating testosterone level. As indicated by the Profile of Mood States test, behavioral responses did not appear to be mediated by changes in mood. We concluded that the stimulatory effects of testosterone on sexual activity are rapid, reliable, and not due to a placebo effect. To maintain plasma testosterone and adequate sexual function within normal levels, even high doses of testosterone enanthate should be given no less frequency than once every 3 weeks.

Sex determination in bees. IV. Genetic control of juvenile hormone production in Melipona quadrifasciata (Apidae)

Cell number and volume of corpora allata was determined for 8 phases of development, the first prepupal stage to adults 30 days old, in the social Apidae Melipona quadrifasciata. In the second prepupal stage a strong correlation was found between cell number and body weight (r = 0.651), and cell number and corpora allata volume in prepupal stage (r = 0.535), which indicates that juvenile hormone has a definite role in caste determination in Melipona. The distribution of the volume of corpus allatum suggest a 3:1 segregation between bees with high volume of corpora allata against low and medium volume. This implies that genes kappa a and kappa b code for an enzyme that directly participates in juvenile hormone production. It was also concluded that the number of cells in the second prepupal stage is more important than the weight of the prepupa for caste determination. A scheme summarizing the genic control of sex and caste determination in Melipona bees in the prepupal phase is given.