Optimal imaging of in vitro clot sonothrombolysis by MR-guided focused ultrasound

BACKGROUND AND PURPOSE

As magnetic resonance-guided focused ultrasound (MRgFUS) sonothrombolysis relies on mechanical rather than thermal mechanisms to achieve clot lysis, thermometry is not useful for the intraoperative monitoring of clot breakdown by MRgFUS. Therefore, the purpose of this study was to evaluate the optimum imaging sequence for sonothrombolysis.

METHODS

In vitro blood drawn from 6 healthy volunteers was imaged using T1, T2 spin-echo, and T2 gradient-echo (GRE) sequences both before and after sonication using an Insightec ExAblate 4000 FUS transducer. Signal intensities of the three MR imaging sequences were measured and normalized to background signal for each time point. Representative samples of the pre- and postsonication clot were also sent to pathology for hematologic analysis.

RESULTS

After sonication, the clot in the treatment tube was fully lysed as evidenced by physical and hematologic evaluation. The difference between pre- and postsonicated normalized signal intensity ratios demonstrated statistical significance only on T2 and GRE sequences (P < .001). However, significant blooming artifact limited interpretation on all GRE images.

CONCLUSION

T2 is the most appropriate sequence for the evaluation of mechanical MRgFUS sonothrombolysis of an in vitro clot. These findings are consistent across the oxidative states of clot up to 48 hours.

Stereotactic aspiration plus subsequent thrombolysis for moderate thalamic hemorrhage

OBJECTIVE

This study aimed to evaluate the efficacy and safety of stereotactic aspiration combined with subsequent thrombolysis in treating moderate thalamic hemorrhage (TH).

METHODS

A total of 105 patients with TH were nonrandomly assigned to the conservative treatment group (n = 60) or to the aspiration group (n = 45). Patients in the aspiration group were treated with stereotactic aspiration plus subsequent thrombolysis for removal for their hematomas.

RESULTS

The 30-day mortality in the conservative group was significantly higher than that in the aspiration group (28.3% (17/60) vs. 11.2% (5/45), P = 0.032). The rank of the 30-day Glasgow outcome scale in the conservative group was significantly lower than that in the aspiration group (P = 0.041), and the mean 30-day National Institutes of Health Stroke Scale score of the survivors in the conservative group was significantly higher than that in the aspiration group (16.5 ± 4. 2 vs. 14.2 ± 3.9, P = 0.012). There were a greater reduction in TH volume in the aspiration group than in the conservative group from day 1 to day 3 (-0.24% and 39.28%, respectively, P < 0.0001) and from day 1 to day 7 (26.58% and 63.26%, respectively, P < 0.0001). The rank of 90-day Glasgow outcome scale was significantly lower in the conservative group than that in the aspiration group (P = 0.015). Eighteen of 60 patients (30.0%) had a favorable outcome in the conservative group, whereas 23 of 45 patients (51.1%) had a favorable outcome in the aspiration group, and this difference was significant (P = 0.028). The 90-day cumulative mortality rate in the conservative group was significantly higher than that in the aspiration group (33.3% (20/60)) vs. 15.6% (7/45), P = 0.039).

CONCLUSIONS

Stereotactic aspiration plus subsequent thrombolysis is effective and safe for moderate TH.

Secondhand smoke exposure and coronary artery calcification among nonsmoking participants of a population-based cohort

BACKGROUND

Secondhand smoke (SHS) consists of fine particulate matter, carcinogens, and various toxins that affect large parts of the population. SHS increases the risk for acute cardiovascular events and may contribute to the development of atherosclerosis.

OBJECTIVES

We investigated the association of SHS with coronary artery calcification (CAC).

METHODS

In this cross-sectional analysis, we used baseline data (2000-2003) from 1,766 never-smokers without clinically manifested coronary heart disease, 45-75 years of age, from the Heinz Nixdorf Recall Study, an ongoing, prospective, population-based cohort study in Germany. Self-reported frequent SHS at home, at work, and in other places was assessed by questionnaire. CAC scores were derived based on electron-beam computed tomography. We conducted multiple linear regression analysis using exposure to SHS as the explanatory variable and ln(CAC+1) as the response variable. We conducted logistic regression to estimate the odds ratio (OR) for presence of any CAC.

RESULTS

Frequent exposure to SHS was reported by 21.5% of participants. After adjustment for age, sex, and socioeconomic status, CAC + 1 was 21.1% [95% confidence interval (CI): -5.5%, 55.2%] higher in exposed than in unexposed participants. After adjusting for other cardiovascular risk factors, the association was attenuated (15.4%; 95% CI: -9.6%, 47.2%). SHS exposure was also associated with a CAC score > 0 (fully adjusted OR = 1.38; 95% CI: 1.03, 1.84).

CONCLUSIONS

Self-reported frequent exposure to SHS was associated with subclinical coronary atherosclerosis in our cross-sectional study population. Considering the widespread exposure and the clinical relevance of coronary atherosclerosis, this result, if confirmed, is of public health importance.

Association of blood pressure control and metabolic syndrome with cardiovascular risk in elderly Japanese: JATOS study

BACKGROUND

The impact of the metabolic syndrome (MS) on cardiovascular events in elderly subjects has not been clarified. We hypothesized that the impact differs between patients with and without strictly controlled blood pressure (BP) and also between early elderly (<75 years) and late (≥75 years) elderly patients.

METHODS

Elderly hypertensive patients (65-85 years old) were randomly assigned to strict (target systolic BP <140 mm Hg) or mild (140-159 mm Hg) BP target, and were treated for 2 years with efonidipine-based regimen. MS was defined according to the National Cholesterol Education Program Adult Treatment Panel III criteria, except for the use of body mass index (BMI) ≥25 kg/m(2) instead of waist circumference. Primary endpoint was combined incidence of cardiovascular and renal events. Data were obtained from 2,865 patients.

RESULTS

The prevalence of MS was 31.4%. The incidence of primary endpoint in patients with and without MS was 4.0% and 3.1%, respectively. MS was a significant risk factor for cardiovascular events in patients <75 years old (adjusted hazard ratio (HR) 2.17, P = 0.01), but not in patients ≥75 years old (adjusted HR 0.98, P = 0.94). In patients with MS, the event rate was significantly lower with strict treatment than with mild treatment among patients aged <75 years (P = 0.0006) but not in those aged ≥75 years (P = 0.82).

CONCLUSIONS

MS was associated with cardiovascular risk in elderly hypertensive patients <75 years old, and strict BP control was beneficial for those with MS. However, MS and intensive control of BP may have little effect on cardiovascular events in elderly patients ≥75 years old.

Secondhand smoke exposure induces Raf/ERK/MAPK-mediated upregulation of cerebrovascular endothelin ETA receptors

BACKGROUND

Cigarette smoking enhances the risk of stroke. However, the underlying molecular mechanisms are largely unknown. The present study established an in vivo rat secondhand cigarette smoking (SHS) model and examined the hypothesis that SHS upregulates endothelin receptors with increased cerebrovascular contraction via the Raf/extracellular signal-regulated kinase (ERK)/mitogen-activated protein kinases (MAPK) pathway.

RESULTS

Rats were exposed to SHS for up to 8 weeks. The cerebral artery vasoconstriction was recorded by a sensitive myograph. The mRNA and protein expressions for endothelin receptors in cerebral arteries were studied by real-time PCR and Western blot. Compared to fresh air exposed rats, cerebral arteries from SHS rats exhibited stronger contractile responses (P < 0.05) mediated by endothelin type A (ETA) receptors. The expressions of mRNA and protein for ETA receptors in the cerebral arteries from SHS rats were higher (P < 0.05) than that in control. SHS did not affect endothelin type B (ETB) receptor-mediated contractions, mRNA or protein levels. The results suggest that SHS upregulates ETA, but not ETB receptors in vivo. After SHS exposure, the mRNA levels of Raf-1 and ERK1/2, the protein expression of phosphorylated (p)-Raf-1 and p-ERK1/2 were increased (P < 0.05). Raf-1 inhibitor, GW5074 suppressed the enhanced ETA receptor-mediated contraction, mRNA and protein levels induced by SHS. In addition, GW5074 inhibited the SHS-caused increased mRNA and phosphorylated protein levels of Raf-1 and ERK1/2, suggesting that SHS induces activation of the Raf/ERK/MAPK pathway.

CONCLUSIONS

SHS upregulates cerebrovascular ETA receptors via the Raf/ERK/MAPK pathway, which provides novel understanding of mechanisms involved in SHS-associated stroke.

Burden of Chinese stroke family caregivers: the Hong Kong experience

OBJECTIVE

To ascertain the clinical and sociodemographic factors associated with family caregivers' burden in Chinese patients with stroke in Hong Kong.

DESIGN

Cross-sectional design.

SETTING

Stroke Clinic.

PARTICIPANTS

Patients (N=123) from a stroke clinic and their family caregivers.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Predictive factors of family caregivers' burden in Chinese stroke patients in Hong Kong. Caregivers' burden was assessed with the Caregiving Burden Scale (CBS). Patients' and caregivers' sociodemographic data and clinical characteristics were recorded. Physical and psychological conditions were measured and rated with the following instruments: Cumulative Illness Rating Scale, Geriatric Depression Scale (GDS), Barthel Index, Instrumental Activities of Daily Living, Mini-Mental State Examination, Lubben Social Network Scale, Modified Life Event Scale (MLES), Hospital Anxiety and Depression Scale (HADS), and a single question about fatigue.

RESULTS

In the univariate analysis, the CBS score had significant correlations with certain characteristics of caregivers (sex, GDS, HADS, depressive symptoms, fatigue, and MLES) and those of patients' (sex, age, education, GDS). Regression analysis revealed that caregivers' GDS and patients' education were the independent correlates of the CBS.

CONCLUSIONS

The severity of depressive symptoms in Chinese stroke caregivers and patients' education are independent factors associated with the caregivers' burden. Further studies evaluating interventions on caregivers' burden should include the assessment and management of mood disorders.

European research priorities for intracerebral haemorrhage

Over 2 million people are affected by intracerebral haemorrhage (ICH) worldwide every year, one third of them dying within 1 month, and many survivors being left with permanent disability. Unlike most other stroke types, the incidence, morbidity and mortality of ICH have not declined over time. No standardised diagnostic workup for the detection of the various underlying causes of ICH currently exists, and the evidence for medical or surgical therapeutic interventions remains limited. A dedicated European research programme for ICH is needed to identify ways to reduce the burden of ICH-related death and disability. The European Research Network on Intracerebral Haemorrhage EURONICH is a multidisciplinary academic research collaboration that has been established to define current research priorities and to conduct large clinical studies on all aspects of ICH.

Different associations of apolipoprotein E polymorphism with metabolic syndrome by sex in an elderly Chinese population

The metabolic syndrome (MetS) is characterized by a cluster of metabolic disorders including abnormal lipid and lipoprotein metabolism. Apolipoprotein E (ApoE) is involved in the regulation of the metabolism of cholesterol, lipoproteins, and triglycerides. The common ApoE polymorphism has been found to be associated with cardiovascular disease and diabetes. This study evaluated the ApoE genetic polymorphism and its relation to MetS defined by the modified National Cholesterol Education Program and International Diabetes Federation criteria in a population-based cross-sectional survey of an elderly Chinese population in Beijing, China. Genotypes of 937 men and 1385 women were included in the study. All participants were measured for blood pressure, anthropometric measurements, and fasting concentrations of glucose, triglycerides, cholesterol, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol. We applied a logistic regression model to derive adjusted odds ratios (ORs) and their 95% confidence intervals. In this Chinese population, the ɛ2, ɛ3, and ɛ4 allele frequencies were 8.3%, 83.4%, and 8.3% for men and 8.7%, 82.9%, and 8.4% for women, respectively. In men, concentrations of fasting triglycerides were higher among the APOE2 and E4 subjects; and a lower level of high-density lipoprotein cholesterol was observed in the APOE4 group. There were approximately linear associations of low-density lipoprotein cholesterol levels with APOE genotype groups in both men and women. We observed that the ɛ4 allele was associated with a significantly increased OR of MetS defined by the modified National Cholesterol Education Program criteria in men (OR, 1.75; 95% confidence interval, 1.17-2.63). In summary, our data show that common polymorphism of ApoE gene is associated with the presence of MetS in an elderly Chinese population.

Residual beneficial effects after a 3-year integrated intervention on stroke in China: a 10-year prospective follow-up

OBJECTIVES

To evaluate whether an intervention program designed to reduce stroke incidence would have long-term residual effects on reducing all-cause and cause-specific mortalities, including cancer 10 years after the intervention was completed.

METHODS

This is a posttrial analysis. We prospectively observed the mortality of a community-based trial of primary prevention of stroke in China performed between July 1987 and June 1990 by extending the follow-up to 30 June 2000. At the baseline, 26,607 adults aged 35 years or above and free from stroke were recruited from five cites of mainland China; 13,212 and 13,395 were assigned into intervention and control group, respectively. Participants in intervention group received a regularly integrated intervention including lifestyle intervention and hypertensive drug treatment. The controls did not receive intervention provided by the investigators.

RESULTS

During the 10-year posttrial follow-up period, we observed a significant reduction on overall deaths [hazard ratio 0.91; 95% confidence interval (CI) 0.83, 0.99] and stroke mortality (hazard ratio 0.79; 95% CI 0.63, 1.00). An insignificant late trial beneficial effect was observed for hypertensive disease (hazard ratio 0.69; 95% CI 0.30, 1.58), ischemic heart disease (hazard ratio 0.87; 95% CI 0.64, 1.17), other nonmalignant diseases, and most cancer sites.

CONCLUSION

This study demonstrates that a 3-year integrated intervention program successful for stroke prevention had long-term residual beneficial effects on reducing overall disease burdens among urban Chinese population, especially for the deaths from stroke. However, whether the integrated intervention also leads to reduced mortality of cardiovascular diseases and cancer would have to be confirmed by future larger studies.

What are candidate biobehavioral mechanisms underlying the association between secondhand smoke exposure and mental health?

There is a consistent positive and significant association between secondhand smoke exposure and mental health outcomes in the literature. There are potential genetic and behavioral confounders (e.g., psychological stress, maternal depression, and family functioning) were discussed, as well as potential causal neurobiological pathways (e.g., dopamine system). Further neurobiological research to establish causal pathways is needed as well as the integration of positive observational findings into clinical and public health prevention practices.

Comprehensive medical management of peripheral arterial disease

Peripheral arterial disease (PAD) is highly prevalent and is associated with high morbidity and mortality. The medical management of PAD involves a comprehensive approach to the patient with emphasis on cardiovascular risk factor modification in addition to therapies directed at treatment of limb symptoms. This manuscript will review the current status of medical therapy in management of patients with PAD.

Green tea consumption, abdominal obesity as related factors of lacunar infarction in Korean women

OBJECTIVES

Our purpose was to evaluate interaction of green tea consumption and abdominal obesity as related factors for lacunar infarction in Korean women.

DESIGN

A hospital-based, incident case-control study.

SETTINGS

The Prevention and Managements of Stroke in Women study.

PARTICIPANTS

Cases (n=233) of first incident lacunar infarction were enrolled and matched by age to stroke-free hospital controls (n=204).

MEASUREMENTS

The data were collected through face-to-face interviews by well trained research assistants to assess demographic, medical, lifestyle, marital status, religions status, green tea consumptions, family history of stroke, smoking status, alcohol consumption, meat and vegetable intake frequency, and past history of hypertension. Biochemical analysis, fasting blood specimens for lipid, glucose, and cholesterol level were acquired.

RESULTS

Compared with the non green tea consumer and obese women group, only the green tea consumption and non obese women group had a protective effect of lacunar infarction when adjusted for age, and age plus diet factors (OR, 0.23; 95% CI, 0.09, 0.59; OR, 0.21; 95% CI, 0.08, 0.56 respectively), but lost their significance after adjustment for age, diet factors, vascular risk factors and full model included atherogenic index factors (OR, 0.32; 95% CI, 0.09 to 1.01; OR, 0.49; 95% CI, 0.12, 1.89 respectively).

CONCLUSIONS

The interaction of green tea consumption and non obesity have reduced risk of lacunar infarction, but not after adjustment for age, diet factors, vascular risk factors and atherogenic index. Also individually green tea consumption and abdominal obesity have failed to find an independent relationship with lacunar infarction after adjustment by all risk factors. Green tea consumption and green tea consumption with non obese group seemed to have a protective effect for lacunar infarction. In the results of our study, these results still remain controversial, and then we need further and larger study to get at the root of real causal effect of both relationships.

Inverse association of plasma level of high-density lipoprotein cholesterol with intracerebral hemorrhage

This study aimed to investigate whether plasma levels of HDL cholesterol (HDL-C) were associated with the risk of intracerebral hemorrhage (ICH). Plasma HDL-C was determined via enzymatic methods, and ICH was ascertained via medical history, physical examination, and brain imaging (computed tomography or magnetic resonance imaging). The multivariable logistic regression model was used to calculate the odds ratios (OR) and 95% confidence intervals (CI) of ICH according to levels of plasma cholesterol. A total of 170 patients with ICH were identified from 6,046 participants. After adjustment for conventional cardiovascular risk factors, the OR was 2.06 (95% CI, 1.25-3.12; P < 0.01) for participants in the first tertile of HDL-C levels (<1.38 mmol/l) and 1.13 (95% CI, 0.72-1.78; P = 0.59) for participants in the second tertile (1.38-1.64 mmol/l), compared with participants in the third tertile (∩≥1.65 mmol/l). Subgroup analysis indicated that the detrimental effects of HDL-C were more significant in men and lean participants than in their corresponding controls, independent of hypertension. The results presented herein indicate that low plasma HDL-C (<1.38 mmol/l) may be associated with risk of ICH.

Smoking, smoking cessation, [corrected] and risk for symptomatic peripheral artery disease in women: a cohort study

BACKGROUND

Smoking has a well-documented detrimental effect on risk for myocardial infarction and stroke, but less information is available regarding peripheral artery disease (PAD), particularly among women.

OBJECTIVE

To prospectively assess the association of current smoking status, cumulative smoking exposure, and smoking cessation with incident symptomatic PAD in women.

DESIGN

Prospective cohort study.

SETTING

U.S. female health care professionals in the Women's Health Study.

PARTICIPANTS

39,825 women with no cardiovascular disease who were prospectively followed for a median of 12.7 years.

MEASUREMENTS

Incidence of symptomatic PAD. Cox proportional hazards models were used to compare PAD risk across smoking categories.

RESULTS

178 confirmed PAD events occurred. Across the 4 smoking categories (never, former, <15 cigarettes/d, and ≥15 cigarettes/d), age-adjusted incidence rates were 0.12, 0.34, 0.95, and 1.63 per 1000 person-years of follow-up, respectively. Multivariate adjustment had little effect on this relationship (adjusted hazard ratios [HRs], 3.14 [95% CI, 2.01 to 4.90], 8.93 [CI, 5.02 to 15.89], and 16.95 [CI, 10.77 to 26.67], respectively, vs. women who never smoked). Additional adjustment for high-sensitivity C-reactive protein and soluble intercellular adhesion molecule-1 levels among women with available blood samples (28,314 participants, 117 events) attenuated risk estimates (HR, 5.58 [CI, 2.61 to 11.93] for smoking <15 cigarettes/d and 9.52 [CI, 5.17 to 17.53] for smoking ≥15 cigarettes/d). Lifetime exposure showed a strong dose-response relationship; fully adjusted HRs for smoking abstinence of fewer than 10, 10 to 29, and 30 or more pack-years were 2.52 (CI, 1.49 to 4.25), 6.75 (CI, 4.33 to 10.52), and 11.09 (CI, 6.94 to 17.72), respectively. Compared with current smokers, the adjusted HRs for fewer than 10 years, 10 to 20 years, more than 20 years, or lifelong abstinence were 0.39 (CI, 0.24 to 0.66), 0.28 (CI, 0.17 to 0.46), 0.16 (CI, 0.10 to 0.26), and 0.08 (CI, 0.05 to 0.12), respectively.

LIMITATION

The use of symptomatic PAD as the a priori primary end point excludes asymptomatic disease.

CONCLUSION

Among initially healthy women, smoking is a potent risk factor for symptomatic PAD and was associated with subclinical inflammation. Smoking cessation substantially reduces risk for PAD, but an increased occurrence of PAD persists even among former smokers who maintain abstinence.

PRIMARY FUNDING SOURCE

The National Heart, Lung, and Blood Institute and National Cancer Institute.

State of the art in managing nontraumatic intracerebral hemorrhage

Nontraumatic intracerebral hemorrhage constitutes a major public health problem worldwide. Intracerebral hemorrhage leads to a high rate of morbidity and mortality. To date, no medical or surgical trials have clearly attested to the benefit of a particular therapy. The aim of this review was to summarize the best evidence for management decision-making in intracerebral hemorrhage.

Association of BMI and cardiovascular risk stratification in the elderly African-American females

We aimed to estimate the association of BMI and risk of systemic hypertension in African-American females aged 65 years and older. In this retrospective, cross-sectional study, medical charts were randomly reviewed after obtaining institutional review board approval and data collection was conducted for height, weight, BMI, age, ethnicity, gender, and hypertension. A multivariable logistic regression analysis was performed. The mean BMI was significantly higher in hypertensive subjects than normotensives (30.3 vs. 29 kg/m2; P = 0.003). A higher proportion of hypertensive subjects had a BMI >23 kg/m2 as compared to normotensives (88.9% vs. 83.5%; P = 0.023). When the log odds of having a history of hypertension was plotted against BMI as a continuous variable, we found that the odds showed an increasing trend with increasing BMI and a steep increase after a BMI of 23 kg/m2. When BMI was analyzed as a categorical variable, a BMI of 23-30 kg/m2 was found to have an odds ratio of 1.43 (95% confidence interval 1.01-2.13; P = 0.05) and a BMI of >30 kg/m2 had an odds ratio of 1.76 (95% confidence interval 1.17-2.65; P = 0.007) when compared to a BMI of <23 kg/m2. This association remained significant in both univariate and multivariate analysis. We conclude that BMI is an independent predictor of hypertension in elderly African-American females. Our results indicate that the risk of hypertension increased significantly at BMI of >23 kg/m2 in this ethnic group. Weight reduction to a greater extent than previously indicated could play an integral role in prevention and control of high blood pressure in this particular population.

Clinical practice guidelines in intracerebral haemorrhage

Intracerebral haemorrhage accounts for 10%-15% of all strokes; however it has a poor prognosis with higher rates of morbidity and mortality. Neurological deterioration is often observed during the first hours after onset and determines poor prognosis. Intracerebral haemorrhage, therefore, is a neurological emergency which must be diagnosed and treated properly as soon as possible. In this guide we review the diagnostic procedures and factors that influence the prognosis of patients with intracerebral haemorrhage and we establish recommendations for the therapeutic strategy, systematic diagnosis, acute treatment and secondary prevention for this condition.

Cardiovascular risk profiles and outcomes of Chinese living inside and outside China

AIM

To assess whether cardiovascular risk differs among the Chinese living inside and outside mainland China.

METHODS AND RESULTS

Three thousand, four hundred and eighty-two East Asians were enrolled in the REduction of Atherothrombosis for Continued Health Registry in mainland China, Hong Kong/Singapore/Taiwan, Western Europe, and North America. Baseline demographics, medication use, risk factor control, and 30-month cardiovascular outcomes of the 2938 patients with atherothrombotic disease were compared. Rates of hypertension, hypercholesterolemia, diabetes, abdominal obesity, and body mass index ≥25 kg/m² were lowest in mainland China, were increased in Hong Kong/Singapore/Taiwan, and were highest in Western Europe and North America. Diabetes prevalence was 23% in mainland China, approximately two-fold lower than the other regions. Antihypertensive, antidiabetic, and antiplatelet agent use was similar in all regions. Risk factor control was significantly poorer in Western Europe and, except for glucose control, significantly better in North America. Thirty-month nonfatal stroke rates were highest in mainland China and fell in a stepwise manner in more westernized societies. Conversely, nonfatal myocardial infarction rates increased in more westernized societies.

CONCLUSION

Obesity and other risk factors progressively worsen as patients move from mainland China to Hong Kong/Singapore/Taiwan and overseas. Despite similar medication use, risk factor control and cardiovascular outcomes were significantly different. The magnitude of these changes is larger than formerly estimated, suggesting population differences in cardiovascular risk and disease prevalence, likely to be more closely associated with lifestyle and cultural habits than genetic differences.

Prevalence of hypertension, obesity, diabetes, and metabolic syndrome in Nepal

Background. This study was carried out to establish the prevalence of cardiovascular risks such as hypertension, obesity, and diabetes in Eastern Nepal. This study also establishes the prevalence of metabolic syndrome (MS) and its relationships to these cardiovascular risk factors and lifestyle. Methods. 14,425 subjects aged 20–100 (mean 41.4 ± 15.1) were screened with a physical examination and blood tests. Both the International Diabetic Federation (IDF) and National Cholesterol Education Programme's (NCEP) definitions for MS were used and compared. Results. 34% of the participants had hypertension, and 6.3% were diabetic. 28% were overweight, and 32% were obese. 22.5% of the participants had metabolic syndrome based on IDF criteria and 20.7% according to the NCEP definition. Prevalence was higher in the less educated, people working at home, and females. There was no significant correlation between the participants' lifestyle factors and the prevalence of MS. Conclusion. The high incidence of dyslipidemia and abdominal obesity could be the major contributors to MS in Nepal. Education also appears to be related to the prevalence of MS. This study confirms the need to initiate appropriate treatment options for a condition which is highly prevalent in Eastern Nepal.

The acute management of intracerebral hemorrhage

PURPOSE OF REVIEW

Spontaneous intracerebral hemorrhage (ICH) is associated with high morbidity and mortality, providing substantial scope for improvements in outcome. This review will discuss recent developments and present consensus evidence for the management of ICH.

RECENT FINDINGS

Intracranial management strategies focus on preventing further bleeding and minimizing the risk of hematoma expansion and cerebral ischemia. Known coagulopathies should be corrected and oral anticoagulation reversed, but there is no evidence for the routine transfusion of platelets in patients taking aspirin or clopidogrel. Recombinant factor VIIa reduces hematoma expansion after ICH, but does not improve outcome and is associated with thromboembolic complications. The role and type of surgical interventions remain controversial. Early aggressive treatment, including meticulous control of blood pressure and other systemic physiological variables, improves outcome as does management in a specialized neurointensive care unit. Thromboembolic prophylaxis is routine but prophylactic antiepileptic drugs confer no benefit. Ongoing research seeks to define optimal blood pressure, glucose and temperature targets, the role and type of surgery, and potential neuroprotective strategies.

SUMMARY

Well organized, multimodal therapy optimizing intracranial and systemic physiological variables improves outcome after ICH. Recent guidelines provide a useful consensus evidence-based framework for the management of acute ICH.

Critical care management of acute intracerebral hemorrhage

OPINION STATEMENT

Intracerebral hemorrhage is a medical emergency. It is the most deadly and disabling form of stroke, and no individual therapy has been demonstrated to improve outcome. However, it appears that aggressive medical care in general, and management by neuroscience specialists in particular, offers substantial benefit. Therefore, providing the best supportive care based on currently available evidence may well improve outcomes. Airway management and management of blood pressure aimed at maximizing cerebral perfusion while minimizing ongoing bleeding, as well as rapid reversal of anticoagulation, are likely to be important in the early phase. Additionally, efforts should be undertaken to provide careful glucose management and temperature management and to maximize cerebral perfusion pressure. Selected patients are likely to benefit from external ventricular drainage or even hematoma evacuation. Except in rare circumstances, most patients should be managed in a neuroscience intensive care unit during the acute phase. Some patients appear to have no reasonable likelihood of recovery and can be considered for limitations of care such as Do Not Resuscitate orders or Comfort Measures Only orders. However, it can be difficult to accurately predict long-term outcome in the acute phase; formal prognostic tools should be used to offer information to patients and their families. After the hemorrhage has stabilized, efforts to minimize complications include thromboembolism prophylaxis, physical therapy, and acute rehabilitation.

Household exposure to secondhand smoke is associated with decreased physical and mental health of mothers in the USA

Secondhand smoke is one of the most common toxic environmental exposures to children, and maternal health problems also have substantial negative effects on children. We are unaware of any studies examining the association of living with smokers and maternal health. To investigate whether non-smoking mothers who live with smokers have worse physical and mental health than non-smoking mothers who live in homes without smokers. Nationally representative data from the 2000-2004 Medical Expenditure Panel Survey were used. The health of non-smoking mothers with children <18 years (n = 18,810) was assessed, comparing those living with one or more smokers (n = 3,344) to those living in households with no adult smokers (n = 14,836). Associations between maternal health, household smoking, and maternal age, race/ethnicity, and marital, educational, poverty and employment status were examined in bivariable and multivariable analyses using SUDAAN software to adjust for the complex sampling design. Scores on the Medical Outcomes Short Form-12 (SF-12) Physical Component Scale (PCS) and Mental Component Scale (MCS) were used to assess maternal health. About 79.2% of mothers in the USA are non-smokers and 17.4% of them live with ≥1 adult smokers: 14.2% with 1 and 3.2% with ≥2 smokers. Among non-smoking mothers, the mean MCS score is 50.5 and mean PCS is 52.9. The presence of an adult smoker and increasing number of smokers in the home are both negatively associated with MCS and PCS scores in bivariable analyses (P < 0.001 for each). Non-smoking mothers with at least one smoker in the household had an 11% (95% CI = 0.80-0.99) lower odds of scoring at or above the mean MCS score and a 19% (95% CI = 0.73-0.90) lower odds of scoring at or above the mean PCS score compared to non-smoking mothers with no smokers in the household. There is an evidence of a dose response relationship with increasing number of smokers in the household for PCS (P < 0.001). These findings demonstrate a previously unrecognized child health risk: living with smokers is independently associated with worse physical and mental health among non-smoking mothers.

Meta-analysis of scalp acupuncture for acute hypertensive intracerebral hemorrhage

OBJECTIVES

Scalp acupuncture (SA) is a commonly used therapeutic approach for primary intracerebral hemorrhage (ICH) in Traditional Chinese Medicine (TCM), but the efficacy and safety of SA therapy are still undetermined. The aim of this study is to systematically evaluate the efficacy and safety of SA therapy for the treatment of acute hypertensive ICH.

METHODS

Literature reports with randomized controlled clinical trials and controlled clinical trials on SA therapy for acute hypertensive ICH were searched, and the efficacy and safety of SA therapy were evaluated by using the Cochrane systematic review methods. The primary outcome measures were death or dependency at the end of long-term follow-up (at least 3 months) and adverse events. The secondary outcome measure was neurological deficit improvement at the end of the treatment course.

RESULTS

Seven (7) independent trials (230 patients) were included in this study. All trials described the methods of randomization in which four trials had adequate concealment of randomization at the level of grade A, but no trial included sham acupuncture as a control group. None of the trials included "death or dependency" as a primary outcome measure. Four (4) trials contained safety assessments and stated that no adverse event was found, whereas the other three trials did not provide the information about adverse events. By using random effects statistical model, it was found that patients with acute hypertensive ICH who received SA therapy had significantly improved neurological deficit scores (Z = 4.97, p < 0.01).

CONCLUSIONS

Although SA therapy is widely used to treat acute hypertensive ICH in TCM, the efficacy and safety of SA therapy remain to be further determined. No evidence is available on whether SA therapy can be used to treat acute ICH according to the primary outcome measure. However, SA therapy appears to be able to improve neurological deficit in patients with acute hypertensive ICH.

Incidence, treatment, and case-fatality of non-traumatic subarachnoid haemorrhage in the Netherlands

BACKGROUND

Non-traumatic subarachnoid haemorrhage (SAH) is a devastating disorder and in the majority of cases it is caused by rupture of an intracranial aneurysm. No actual data are available on the incidence of non-traumatic SAH and aneursymal SAH (aSAH) in the Netherlands and little is known about treatment patterns of aSAH. Our purpose was therefore to assess the incidence, treatment patterns, and case-fatality of non-traumatic (a)SAH within the Dutch general population.

METHODS

Two population based data sources were used for this retrospective cohort study. One was the nationwide hospital discharge registry (National Medical Registration, LMR). Cases were patients hospitalized for SAH (ICD-9-code 430) in 2001-2005. The second source was the Integrated Primary Care Information (IPCI) database, a medical record database allowing for case validation. Cases were patients with validated non-traumatic (a)SAH in 1996-2006. Incidence, treatment, and case-fatality were assessed.

RESULTS

The incidence rate (IR) of non-traumatic SAH was 7.12 per 100,000 PY (95%CI: 6.94-7.31) and increased with age. The IR of aSAH was 3.78 (95%CI: 2.98-4.72). Women had a twofold increased risk of non-traumatic SAH; this difference appeared after the fourth decade. Non-traumatic SAH fatality was 30% (95%CI: 29-31%). Of aSAH patients 64% (95%CI: 53-74%) were treated with a clipping procedure, and 26% (95%CI: 17-37%) with coiling.

CONCLUSION

Non-traumatic SAH is a rare disease with substantial case-fatality; rates in the Netherlands are similar to other countries. Case-fatality is also similar as well as age and sex patterns in incidence.

Reactions of Chinese adults to warning labels on cigarette packages: a survey in Jiangsu Province

Background

To compare reactions to warning labels presented on cigarette packages with a specific focus on whether the new Chinese warning labels are better than the old labels and international labels.

Methods

Participants aged 18 and over were recruited in two cities of Jiangsu Province in 2008, and 876 face-to-face interviews were completed. Participants were shown six types of warning labels found on cigarette packages. They comprised one old Chinese label, one new label used within the Chinese market, and one Chinese overseas label and three foreign brand labels. Participants were asked about the impact of the warning labels on: their knowledge of harm from smoking, giving cigarettes as a gift, and quitting smoking.

Results

Compared with the old Chinese label, a higher proportion of participants said the new label provided clear information on harm caused by smoking (31.2% vs 18.3%). Participants were less likely to give cigarettes with the new label on the package compared with the old label (25.2% vs 20.8%). These proportions were higher when compared to the international labels. Overall, 26.8% of participants would quit smoking based on information from the old label and 31.5% from the new label. When comparing the Chinese overseas label and other foreign labels to the new Chinese label with regard to providing knowledge of harm warning, impact of quitting smoking and giving cigarettes as a gift, the overseas labels were more effective.

Conclusion

Both the old and the new Chinese warning label are not effective in this target population.

Novel approaches to the treatment of intracerebral haemorrhage

Intracerebral haemorrhage is the most devastating subtype of stroke. It affects approximately two million patients worldwide every year and is a major cause of morbidity and mortality. After decades of research, we still face the fact that there is no evidence-based treatment strategy for this disease. However, research has contributed to a better understanding of the pathophysiology of intracerebral haemorrhage and also to the identification of new treatment targets. Several novel aspects of treatment of spontaneous intracerebral haemorrhage are reviewed in the present article.

Association of the cell death-inducing DNA fragmentation factor alpha-like effector A (CIDEA) gene V115F (G/T) polymorphism with phenotypes of metabolic syndrome in a Chinese population

AIMS

The CIDEA gene is involved in energy metabolism and a non-synonymous single nucleotide polymorphism (SNP), V115F (G/T), is a risk factor for obesity in Swedish subjects and metabolic syndrome (MetS) in Japanese subjects. However, the risk allele was a G in Swedish subjects and a T in Japanese subjects. The present study investigated the association between this SNP and MetS in a Chinese population.

METHODS

Three hundred and fifty-one subjects evaluated at the Cardiac Clinic in Xuanwu Hospital for MetS risks were recruited. Anthropometric measurements, blood pressure, fasting blood glucose, and blood lipid levels were determined in addition to the polymorphism.

RESULTS

The proportion of subjects with MetS was significantly higher based on genotype, in the order: GG<GT<TT (p=0.003). In multiple logistic regression analysis, the odds ratios for MetS in the GT and TT genotypes, compared to the referent GG genotype, were 2.26 (p=0.003) and 2.89 (p=0.002), respectively. Similar trends were observed for the related phenotypes of central obesity (GT: OR=2.20, p=0.004; TT: OR=3.31, p=0.002) and dyslipidemia (GT: OR=1.73, p=0.047; TT: OR=2.10, p=0.03).

CONCLUSIONS

The T allele of the CIDEA V115F SNP is a risk factor for MetS and its related phenotypes in a Chinese population.

Analysis of thrombin-antithrombin complex contents in plasma and hematoma fluid of hypertensive intracerebral hemorrhage patients after clot removal

BACKGROUND AND PURPOSE

  Animal experiments indicate that the cerebral thrombin is associated with secondary brain damage after intracerebral hemorrhage (ICH). This study was aimed to investigate the concentrations of thrombin-antithrombin complex (TAT) in hematoma fluid and plasma of the patients with ICH after surgery and analyze the correlation between TAT complex levels and severity of ICH.

METHODS

  Sixty patients with ICH were enrolled. Craniotomy for removal of intracranial blood clot was performed within 24h after ICH. Hematoma fluid and plasma were collected on postoperative days 1, 2, and 4. The plasma obtained from healthy subjects and cerebrospinal fluid from patients without cerebrovascular diseases served as controls, respectively. Enzyme-linked immunosorbent assay was used to determine the concentrations of TAT complex in the patients and controls.

RESULTS

  TAT complex concentrations in both postoperative plasma and hematoma fluid of patients with ICH were significantly higher than those of the controls (P<0.01). In patients with ICH, hematoma fluid had a higher TAT complex level than plasma (P<0.01). The preoperative hemorrhage volume and postoperative TAT complex levels in plasma and hematoma fluid correlated positively with National Institutes of Health stroke scale and negatively with Glasgow coma score (P<0.01).

CONCLUSION

  This study indicates that TAT complex levels of plasma and hematoma fluid correlate positively with the severity of ICH. Determination of the plasma TAT complex concentration is helpful for the evaluation of the severity of post-ICH brain injury.

Life-long physical activity involvement and the risk of ischemic stroke in southern china

A case-control study was conducted in southern China to investigate the relationship between life-long physical activity involvement and the risk of ischemic stroke. Information on life-long physical activity exposure and other lifestyle characteristics was obtained from 374 incident stroke patients and 464 hospital-based controls using a validated and reliable questionnaire. Logistic regression analyses were performed to assess the association between life-long physical activity involvement and the ischemic stroke risk. The control subjects reported more involvement in physical activity over the life course than the stroke patients (P < .001). The risk of ischemic stroke was inversely associated with life-long physical activity exposure, with adjusted odds ratio 0.39 (95% confidence interval 0.25 to 0.59) for participants who had always been involved relative to those who have never been much involved. The dose-response relationship was also significant (P < .001). Therefore, being active life long should be encouraged to prevent this major chronic disease.

Body mass index, waist circumference, and cardiometabolic risk factors in young and middle-aged Chinese women

OBJECTIVE

To assess the associations between body mass index (BMI), waist circumference (WC), and cardiometabolic risk factors in young and middle-aged Chinese women.

METHODS

A total of 3011 women (1938 young women, 1073 middle-aged women), who visited our health care center for a related health checkup, were eligible for study. BMI and WC were measured. The subjects were divided into normal and overweight/obesity groups based on BMI, and normal and abdominal obesity groups based on WC. Cardiometabolic variables included triglyceride (TG), high density lipoprotein cholesterol (HDL-C), fasting blood glucose (FBG), homeostasis model assessment of insulin resistance (HOMA-IR), and blood pressure (BP).

RESULTS

The prevalence of overweight/obesity was significantly higher in middle-aged women (32.4%) than in young women (12.0%). The prevalence of abdominal obesity was also higher in middle-aged women (60.3%) than in young women (36.2%). There were significant differences in the comparison of all related cardiometabolic variables between different BMI (or WC) categories in young and middle- aged women groups, respectively. After adjustment for age, partial correlation analysis indicated that both BMI and WC were correlated significantly with all related cardiometabolic variables. After adjustment for age and WC, although the correlation coefficient r' was attenuated, BMI was still correlated significantly with all related cardiometabolic variables in young and middle-aged women. After adjustment for age and BMI, partial correlation analysis showed that WC was correlated significantly with TG, FBG, HOMA-IR, and HDL-C in young women and significantly with TG, HOMA-IR, and HDL-C in middle-aged women.

CONCLUSIONS

The prevalence of overweight/obesity and abdominal obesity was high in Chinese young and middle-aged women. BMI was a better predictor of cardiovascular disease and diabetes than WC in young and middle-aged women, and moreover, measurement of both WC and BMI may be a better predictor of cardiovascular disease and diabetes mellitus than BMI or WC alone.

Endovascular treatments of atherosclerotic carotid diseases in China

Stroke induces heavy socioeconomic burdens particularly in developing countries. Considering the multisectional discrepancies, strategies of stroke prevention and management adapted for western populations are not always applicable for patients in developing countries. Currently, carotid endarterectomy is the recommended treatment for severe carotid stenosis in the west. Carotid angioplasty and stenting is an alternative treatment only for patients with a high surgery risk. However, in developing countries such as China, where carotid endarterectomy is widely unavailable, Carotid angioplasty and stenting has developed rapidly in recent years and is becoming a choice of treatment for occlusive carotid diseases.

Cerebral amyloid angiopathy in East and West

Cerebral amyloid angiopathy, a vasculopathy characterised by the deposition of amyloid fibrils in the arteries and arterioles in the cerebral cortex and meninges, has been reported to be associated with intracerebral haemorrhage and cognitive impairment in the elderly. Advances in neuroimaging and validation of the clinical diagnostic criteria aid in making a correct clinical diagnosis. Associations with Alzheimer's disease, asymptomatic microbleeds and white matter changes on neuroimaging have an influence on the clinical treatment for patients with probable cerebral amyloid angiopathy. Reviewing the reports from Asian countries, we found that patients with cerebral amyloid angiopathy have a strong age-related prevalence and a consistent association with dementia, but a weaker correlation with intracerebral haemorrhage, most likely due to a higher incidence of hypertensive intracerebral haemorrhage. Involvement of the occipital lobe arteries by CAA is common in all races and ethnicities, while frontal lobe arteries may be more frequently involved in the East compared to the West. The clinical impact of cerebral amyloid angiopathy on intracerebral haemorrhage and cognitive impairment could be increasingly obvious in Asian countries with ageing populations, especially with improving control of hypertension, the leading cause of intracerebral haemorrhage.

Using waist circumference to screen for metabolic syndrome in an inpatient population

OBJECTIVE

Metabolic syndrome (MetS) involves a combination of factors that increases the risk of cardiovascular disease. With no immediate physical symptoms or medical problems associated with this disorder, the diagnosis of MetS is a challenging one. The most widely recognized metabolic criteria (lipid profile, blood pressure, and glucose level) are commonly performed during a hospitalization. The waist circumference (WC) measurement, not a routine component of admission, is not available. Incomplete criteria affect the ability to diagnose MetS and prescribe risk reduction therapy. This study evaluated the efficacy of incorporating WC measurements in screening inpatients for MetS.

METHODS

Over a 3-month period, 516 adult patients were admitted to medical units at Advocate Lutheran General Hospital in Illinois. A total of 439 (207 men and 232 women) patients were included in this study. Nursing staff measured WC on admission. Additional data elements collected included fasting lipids, fasting plasma glucose, and early morning blood pressures. The prevalence of MetS was calculated using the American Heart Association criteria.

RESULTS

Eliminating high-risk populations from the total sample, 210 (96 men and 124 women) patients remained in the study (refined study population). Of the 210 patients, 78% had an abnormal WC and the prevalence of MetS was found in 158 (75.2%). In men, the prevalence of MetS was 71%, and in women, 78.9%. Only 9 patients did not have an abnormal WC by American Heart Association definition.

CONCLUSION

Measuring WC in the inpatient population improves the positive predictive value of the MetS diagnostic criteria. The measurement is an easy, inexpensive task to complete, providing complete criteria so that an accurate assessment can be made. Once identified, management of this high-risk group can focus on secondary risk reduction strategies.

An effective treatment for cerebral hemorrhage: minimally invasive craniopuncture combined with urokinase infusion therapy

OBJECTIVES

To evaluate and compare the curative effect between the minimally invasive craniopuncture combined with urokinase infusion therapy and the clearance of hematoma by craniotomy with small bone flap in treating patients with 30-80 ml hemorrhage in the basal ganglion part of the brain.

METHODS

A multicenter, randomized control clinical trial was undertaken; it comprised of 22 hospitals in China. Three hundred and four patients with hemorrhage in the basal ganglion were randomly assigned to receive the craniopuncture combined with urokinase infusion therapy (n=159) or clearance of hematoma by craniotomy with small bone flap treatment (n=145). The main indexes of evaluation were the neurological impairment degree at day 14 after treatment, activities of daily living at day 90 and the case fatality by 90 days.

RESULTS

The main results were as follows: (1) there was a significant difference in favorable outcomes (Barthel index >or=95) between the two groups (chi(2)=3.95, p<0.05), which showed a better prognosis in the craniopuncture group, although there was no significant difference in improving the neurological functions and activities of daily living at day 90; (2) there was a remarkable decrease in case fatality by 90 days in the cranipuncture group, with statistically significant difference between the two groups (chi(2)=5.35, p=0.02); (3) the re-bleeding rate in cranipuncture group was 8.8%, significantly (chi(2)=9.51, p=0.002) lower than 21.4% in the craniotomy group.

CONCLUSION

The craniopuncture combined with urokinase infusion therapy could reduce the rate of re-bleeding after surgery and the case fatality by 90 days. It also could improve the activities of daily living (Barthel index >or=95) at day 90. Thus, this therapy was a safe and practical technique in treating cerebral hemorrhage (30-80 ml), especially suitable for hospitals in rural areas or developing countries.

Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

BACKGROUND AND PURPOSE

This guideline provides an overview of the evidence on established and emerging risk factors for stroke to provide evidence-based recommendations for the reduction of risk of a first stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council Scientific Statement Oversight Committee and the AHA Manuscript Oversight Committee. The writing group used systematic literature reviews (covering the time since the last review was published in 2006 up to April 2009), reference to previously published guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate recommendations using standard AHA criteria (Tables 1 and 2). All members of the writing group had the opportunity to comment on the recommendations and approved the final version of this document. The guideline underwent extensive peer review by the Stroke Council leadership and the AHA scientific statements oversight committees before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Schemes for assessing a person's risk of a first stroke were evaluated. Risk factors or risk markers for a first stroke were classified according to potential for modification (nonmodifiable, modifiable, or potentially modifiable) and strength of evidence (well documented or less well documented). Nonmodifiable risk factors include age, sex, low birth weight, race/ethnicity, and genetic predisposition. Well-documented and modifiable risk factors include hypertension, exposure to cigarette smoke, diabetes, atrial fibrillation and certain other cardiac conditions, dyslipidemia, carotid artery stenosis, sickle cell disease, postmenopausal hormone therapy, poor diet, physical inactivity, and obesity and body fat distribution. Less well-documented or potentially modifiable risk factors include the metabolic syndrome, excessive alcohol consumption, drug abuse, use of oral contraceptives, sleep-disordered breathing, migraine, hyperhomocysteinemia, elevated lipoprotein(a), hypercoagulability, inflammation, and infection. Data on the use of aspirin for primary stroke prevention are reviewed.

CONCLUSIONS

Extensive evidence identifies a variety of specific factors that increase the risk of a first stroke and that provide strategies for reducing that risk.

Pathophysiological impact of cigarette smoke exposure on the cerebrovascular system with a focus on the blood-brain barrier: expanding the awareness of smoking toxicity in an underappreciated area

Recent evidence has indicated that active and passive cigarette smoking are associated, in a dose-dependent manner, with dysfunction of normal endothelial physiology. Tobacco smoke (TS) may predispose individuals to atherogenic and thrombotic problems, significantly increasing the risk for ischemic manifestations such as acute coronary syndrome and stroke. Despite the strong evidence for an association between smoking and vascular impairment, the impact of TS exposure on the blood-brain barrier (BBB) has only been marginally addressed. This is a major problem given that the BBB is crucial in the maintenance of brain homeostasis. Recent data have also shown that chronic smokers have a higher incidence of small vessel ischemic disease (SVID), a pathological condition characterized by leaky brain microvessels and loss of BBB integrity. In the brain TS increases the risk of silent cerebral infarction (SCI) and stroke owing to the pro-coagulant and atherogenic effects of smoking. In this article we provide a detailed review and analysis of current knowledge of the pathophysiology of tobacco smoke toxicity at the cerebrovascular levels. We also discuss the potential toxicity of recently marketed “potential-reduced exposure products”.

Stroke risk factors and outcomes among various Asian ethnic groups in Singapore

Data on interethnic differences in the Asian stroke population are limited. We evaluated the relationships among various cardiovascular risk factors, stroke subtypes, and outcomes in a multiethnic Singaporean population comprising consecutive ischemic stroke patients presenting to our tertiary center over a 1-year period. Strokes were classified based on criteria used in the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Functional independence at hospital discharge was defined as a modified Rankin Scale (mRS) score of 0-2. The ethnic distribution of the study population (n = 481; mean age, 64.1 ± 11.9 years) was 74% Chinese, 17% Malay, and 9% Indian. The prevalence of risk factors was similar in the 3 ethnic groups except for diabetes (Chinese, 39.8%; Malay, 67.5%; Indian, 52.3%; P < .001). Hypertension and hypercholesterolemia were the most common cardiovascular risk factors. Lacunar stroke was the most frequent stroke subtype (47.9%). Large-artery atherosclerotic infarctions were more prevalent in Indians (25.0%), whereas lacunar infarctions occured more frequently in Chinese (51.8%; P < .01). No differences in in-hospital mortality and functional independence at discharge were seen among the 3 ethnic groups. Despite the differences in risk factors and in stroke subtypes classified by location or underlying etiology, short-term outcome measures were similar in the 3 different Asian ethnicities in Singapore.

Prevalence and determinants of metabolic syndrome according to three definitions in middle-aged Chinese men

BACKGROUND

The prevalence of metabolic syndrome has varied markedly between different studies because of the lack of internationally agreed-upon criteria to define the condition. We estimated the prevalence and lifestyle risk factors of metabolic syndrome according to three definitions of metabolic syndrome in urban Chinese men participating in the Shanghai Men's Health Study (SMHS).

METHODS

In this cross-sectional study, 3988 middle-aged, urban Chinese men 40-74 years of age who were free of type 2 diabetes at baseline provided fasting blood samples, anthropometric measurements, and information on lifestyle factors and disease history.

RESULTS

The three definitions of metabolic syndrome used in this report are from the International Diabetes Federation (IDF), the U.S. Third Report of the National Cholesterol Education Program, Adult Treatment Panel (ATP III), and a modified version of the ATP III criteria for Asian populations (ATP III-modified criteria). The prevalence of metabolic syndrome was 18.63%, 18.36%, and 29.34% according to IDF, ATP III, and ATP III-modified criteria, respectively. Agreement between the IDF and ATP III criteria was moderate (kappa = 0.43), whereas agreement between ATP III-modified and the IDF and ATP III criteria was good (kappa = 0.71 and 0.70, respectively). Physical activity was associated with a lower prevalence of metabolic syndrome, whereas drinking more than three drinks per day was associated with a higher risk of metabolic syndrome, regardless of the criteria employed. The association between smoking and the prevalence of metabolic syndrome in this population failed to reach significance.

CONCLUSIONS

Results from this representative sample of middle-aged, urban Chinese men show that metabolic syndrome is highly prevalent in this population. Our data support the hypothesis that physical activity decreases the risk of developing metabolic syndrome and that high alcohol consumption increases risk.

Tobacco smoke induces the generation of procoagulant microvesicles from human monocytes/macrophages

OBJECTIVE

To investigate whether exposure of human monocytes/macrophages to tobacco smoke induces their release of membrane microvesicles (MVs) that carry tissue factor (TF) released from cells, whether smoke-induced MVs are procoagulant, and what cellular processes might be responsible for their production.

METHODS AND RESULTS

We found that exposure of human THP-1 monocytes and primary human monocyte-derived macrophages to 3.75% tobacco smoke extract (TSE) significantly increased their total and TF-positive MV generation. More importantly, MVs released from TSE-treated human monocytes/macrophages exhibited 3 to 4 times the procoagulant activity of control MVs, as assessed by TF-dependent generation of factor Xa. Exposure to TSE increased TF mRNA and protein expression and cell surface TF display by both THP-1 monocytes and primary human monocyte-derived macrophages. In addition, TSE exposure caused activation of C-Jun-N-terminal kinase (JNK), p38, extracellular signal regulated kinase (ERK) mitogen-activated protein kinases (MAPK), and apoptosis (a major mechanism for MV generation). Treatment of THP-1 cells with inhibitors of ERK, MAP kinase kinase (MEK), Ras, or caspase 3, but not p38 or JNK, significantly blunted TSE-induced apoptosis and MV generation. Surprisingly, neither ERK nor caspase 3 inhibition altered the induction of cell surface TF display by TSE, indicating an effect solely on MV release. Inhibition of ERK or caspase 3 essentially abolished TSE-induced generation of procoagulant MVs from THP-1 monocytes.

CONCLUSIONS

Tobacco smoke exposure of human monocytes/macrophages induces cell surface TF display, apoptosis, and ERK- and caspase 3-dependent generation of biologically active procoagulant MVs. These processes may be novel contributors to the pathological hypercoagulability of active and secondhand smokers.