Stroke and alcohol consumption

Disability Among Older Adults in South-Eastern Nigeria

Disability is a common reason for the loss of independence. There is a dearth of data on older adults with disability in south-eastern Nigeria. Using a multistage sampling technique and disability indexes, we assessed 816 persons aged 65 years and above living with a disability. While respondents' experiences of abuse and property inheritance differ by gender, they have poor health status. Elevated risks of disability were associated with gender, increased age, education, smoking, alcohol use, and engagement in physical exercise. Findings suggest urgency in formulating and implementing ageing welfare policy in this African community undergoing demographic and social changes. While this is underway, we recommend a massive health promotion among older adults in this community. We also suggest the integration of courses on ageing in schools' curriculum since ageing is a life course phenomenon. This in the long run would provide ageing-friendly education that averts old age's deleterious effects.

Association between PAI-1 Polymorphisms and Ischemic Stroke in a South Korean Case-Control Cohort

Stroke is the second leading cause of death in the world. Approximately 80% of strokes are ischemic in origin. Many risk factors have been linked to stroke, including an increased level of plasminogen activator inhibitor-1 (PAI-1). PAI-1 levels increase and remain elevated in blood during the acute phase of ischemic stroke, which can impair fibrinolytic activity, leading to coronary artery disease and arterial thrombotic disorders. Here, we present a case-control study of 574 stroke patients and 425 controls seen for routine health examination or treatment for nonspecific dizziness, nonorganic headache, or anxiety for positive family history of stroke at the Bundang Medical Center in South Korea. Polymorphisms in PAI-1 were identified by polymerase chain reaction/restriction fragment length polymorphism analysis using genomic DNA. Specifically, three variations (-675 4G>5G, 10692T>C, and 12068G>A) were linked to a higher overall prevalence of stroke as well as a higher prevalence of certain stroke subtypes. Haplotype analyses also revealed combinations of these variations (-844G>A, -675 4G>5G, 43G>A, 9785A>G, 10692T>C, 11053T>G, and 12068G>A) that were significantly associated with a higher prevalence of ischemic stroke. To the best of our knowledge, this is the first strong evidence that polymorphic sites in PAI-1 promoter and 3'-UTR regions are associated with higher ischemic stroke risk. Furthermore, the PAI-1 genotypes and haplotypes identified here have potential as clinical biomarkers of ischemic stroke and could improve the prognosis and future management of stroke patients.

Vascular smooth muscle cell dysfunction in neurodegeneration

Vascular smooth muscle cells (VSMCs) are the key moderators of cerebrovascular dynamics in response to the brain's oxygen and nutrient demands. Crucially, VSMCs may provide a sensitive biomarker for neurodegenerative pathologies where vasculature is compromised. An increasing body of research suggests that VSMCs have remarkable plasticity and their pathophysiology may play a key role in the complex process of neurodegeneration. Furthermore, extrinsic risk factors, including environmental conditions and traumatic events can impact vascular function through changes in VSMC morphology. VSMC dysfunction can be characterised at the molecular level both preclinically, and clinically ex vivo. However the identification of VSMC dysfunction in living individuals is important to understand changes in vascular function at the onset and progression of neurological disorders such as dementia, Alzheimer's disease, and Parkinson's disease. A promising technique to identify changes in the state of cerebral smooth muscle is cerebrovascular reactivity (CVR) which reflects the intrinsic dynamic response of blood vessels in the brain to vasoactive stimuli in order to modulate regional cerebral blood flow (CBF). In this work, we review the role of VSMCs in the most common neurodegenerative disorders and identify physiological systems that may contribute to VSMC dysfunction. The evidence collected here identifies VSMC dysfunction as a strong candidate for novel therapeutics to combat the development and progression of neurodegeneration, and highlights the need for more research on the role of VSMCs and cerebrovascular dynamics in healthy and diseased states.

Harmful Impact of Tobacco Smoking and Alcohol Consumption on the Atrial Myocardium

Tobacco smoking and alcohol consumption are widespread exposures that are legal and socially accepted in many societies. Both have been widely recognized as important risk factors for diseases in all vital organ systems including cardiovascular diseases, and with clinical manifestations that are associated with atrial dysfunction, so-called atrial cardiomyopathy, especially atrial fibrillation and stroke. The pathogenesis of atrial cardiomyopathy, atrial fibrillation, and stroke in context with smoking and alcohol consumption is complex and multifactorial, involving pathophysiological mechanisms, environmental, and societal aspects. This narrative review summarizes the current literature regarding alterations in the atrial myocardium that is associated with smoking and alcohol.

Relationship between Alcohol Intake and Stroke Severity in Japanese Patients: a Sex- and Subtype-Stratified Analysis

OBJECTIVES

This study aims to clarify the association between alcohol intake and stroke severity at admission and discharge according to sex and stroke subtype in Japanese patients with acute stroke.

MATERIALS AND METHODS

We analyzed the data of 199,599 patients registered in the Japan Stroke Data Bank from 1999 to 2018, including sex, age, stroke subtypes (cardioembolic ischemic, noncardioembolic ischemic, hypertensive hemorrhagic, nonhypertensive hemorrhagic, and subarachnoid hemorrhagic), dates of onset and admission, National Institutes of Health Stroke Scale score at admission, modified Rankin Scale score at discharge, and alcohol intake. Multivariable logistic regression analysis adjusted for stroke-related factors was performed to estimate the odds ratios of alcohol intake for stroke severity.

RESULTS

In cardioembolic ischemic stroke, a significant protective effect of moderate intake on severity at admission was observed in both sexes. In noncardioembolic ischemic stroke, a significant protective effect on stroke severity at admission was found for each sex. At discharge, the results also showed a significant protective effect for each sex with moderate intake. For both subtypes of ischemic stroke, a J-shaped relationship between alcohol intake and stroke severity at admission and discharge was observed in women and men. In hypertensive hemorrhagic stroke, a significant protective effect was found in men at both admission and discharge. In women, heavy drinking had a significant harmful effect on stroke severity at admission.

CONCLUSIONS

Habitual alcohol intake is associated with stroke severity at admission and discharge regardless of sex.

Alcohol Consumption and Stroke Risk in Men: A Population-Based Cohort Study in Rural Tianjin, China

BACKGROUND

Although the protective effects of alcohol consumption against future cardiovascular disease have been published, the effects of alcohol on stroke risk remain controversial.

METHOD

We assessed the effects of alcohol consumption on stroke risk in a poorly educated, low-income population in rural China. Between 1991 and 2018, a population-based cohort study was conducted in rural Tianjin, China, to examine stroke risk. All registered stroke events were clinically verified using available computed tomography or MRI scans. The stroke risk was analyzed, according to the extent of alcohol consumption, using Cox regression analyses.

RESULTS

We identified 352 incident stroke events among male participants during the study period. The stroke incidences (per 100,000 person-years) were 965.3 overall, 575.9 for ischemic stroke events, 208.4 for hemorrhagic stroke events, and 181.0 for undefined stroke events. Overall, alcohol consumption provided a 32% reduction in the total stroke risk. Low-dose alcohol consumption (≤12 g/day) showed a negative association with total (hazard ratio [HR], 0.64; 95% confidence interval [CI], 0.46-0.88; p = 0.008) and ischemic (HR, 0.66; 95% CI, 0.44-0.98; p = 0.039) strokes. Alcohol consumption was not significantly associated with hemorrhagic strokes. After age stratification, alcohol consumption was protective against total and ischemic strokes in men aged ≥55 years old, with the risk of each stroke type decreasing by 46 and 49%, respectively. Low-dose alcohol consumption was inversely associated with both total and ischemic stroke risks, with the risks decreasing by 56 and 65%, respectively. Alcohol consumption was not significantly associated with strokes among men aged <55 years old.

CONCLUSIONS

These findings suggest that low-dose alcohol consumption may decrease the risk of ischemic strokes among men. Even so, the adverse effects of alcohol on the liver and pancreas cannot be ignored. Additionally, the effects of alcohol consumption on stroke risk vary with age, protecting against ischemic and total strokes among males ≥55 years old. Nevertheless, recommending light drinking and its potential health benefits should not be generalized to men of all ages.

Should Strengthening Bonds Be a Public Health Priority?

Abstract. Background: Previous research demonstrates the importance of close relationships on our physical health. However, to what extent the quality of our social relationships impacts our health, relative to other important health behaviors (e.g., smoking, drinking alcohol, and physical exercise), is less clear. Aims: Our goal was to use a nationally representative sample of Canadian adults to assess the relative importance of the quality of one’s social relationships (close emotional bonds and negative social interactions), relative to important health behaviors on physical health outcomes previously linked to social relationship quality. Method: Data ( N = 25,113) came from the Canadian Community Health Survey in 2012, a cross-sectional survey administered by Statistics Canada (2013) . The predictor variables were the presence of close emotional bonds, negative social relationships, type of smoker, type of drinker, and weekly hours of physical activity. The outcome variables were a current or previous diagnosis of high blood pressure, cancer, stroke, reports of current illness or injury, pain, and self-reported physical health. Results: Using regressions, we found that negative social interactions were more important than other health behaviors in relation to current injury/illness and pain. Physical activity was most strongly related to self-rated health, followed by negative social interactions and then close emotional bonds. Alcohol consumption was more related to the prevalence of stroke. Conclusions: Our findings suggest that negative social interactions may be more related to acute or minor physical health conditions, but social relationships may not be more strongly related to more chronic, life-threatening health conditions than other health behaviors.

Prevalence of heavy episodic drinking and associated factors among adults residing in Arba Minch health and demographic surveillance site: a cross sectional study

BACKGROUND

Alcohol consumption is associated with different types of illnesses; particularly heavy episodic drinking is one of the risk factors for the disease burden of alcohol intake. The aim of the study was to assess the prevalence of heavy episodic drinking and associated factors in Arba Minch Health and Demographic Surveillance Site (HDSS).

METHODS

A community-based cross-sectional study was conducted in 2017 among adult residents of Arba Minch HDSS. Using Arba Minch HDSS database, 3368 individuals were selected by simple random sampling techniques. From WHO STEPS instruments, step one was applied for this study. Variables with a p-value of less than 0.10 for bivariate analysis entered into a multivariable logistic regression model to outline the independent predictors of the heavy episodic drinking. To assess the presence of an association between dependent and independent variables, a p-value of less than 0.05 was considered.

RESULTS

The prevalence of heavy episodic drinking was 13.7% (95% CI: 12.6-14.9). The study has shown that heavy episodic drinking was significantly associated with occupation (daily laborer [AOR = 0.49; 95% C.I: 0.29-0.85] and housewives [AOR = 0.63; 95% C.I: 0.45-0.88] compared with farmers), wealth index (2nd quintiles [AOR =0.55; 95% C.I: 0.41-0.74) and 3rd quintiles [AOR = 0.66; 95% C.I: 0.46-0.93] compared with 1st quintiles), and climatic zone (midland [AOR = 1.80;95% CI: 1.11-2.93), highland [AOR = 1.95;95% CI: 1.19-3.18] compared with lowland). In addition, tobacco use [AOR = 4.28;95% CI: 3.38-5.43], and khat use [AOR = 4.75; 95% CI: 2.66-8.50) were also associated with heavy episodic drinking among the study participants.

CONCLUSIONS

More than one in ten adults reported heavy episodic drinking in the study area. Intervention programs that aim to prevent heavy episodic drinking should be designed appropriately for individuals from lower wealth status, and for highlander.

Pathophysiology and Treatment of Stroke: Present Status and Future Perspectives

Stroke is the second leading cause of death and a major contributor to disability worldwide. The prevalence of stroke is highest in developing countries, with ischemic stroke being the most common type. Considerable progress has been made in our understanding of the pathophysiology of stroke and the underlying mechanisms leading to ischemic insult. Stroke therapy primarily focuses on restoring blood flow to the brain and treating stroke-induced neurological damage. Lack of success in recent clinical trials has led to significant refinement of animal models, focus-driven study design and use of new technologies in stroke research. Simultaneously, despite progress in stroke management, post-stroke care exerts a substantial impact on families, the healthcare system and the economy. Improvements in pre-clinical and clinical care are likely to underpin successful stroke treatment, recovery, rehabilitation and prevention. In this review, we focus on the pathophysiology of stroke, major advances in the identification of therapeutic targets and recent trends in stroke research.

Toxic Mechanisms of the Heart: A Review*

Toxic injury is one of the many ways by which the functional integrity of the heart may become compromised. Any of the subcellular elements may be the target of toxic injury, including all of the various membranes and organelles. Understanding the mechanisms underlying cardiotoxicity may lead to treatment of the toxicity or to its prevention. Doxorubicin and its analogs are very important cancer chemotherapeutic agents that can cause cardiotoxicity. Other agents which are cardiotoxic and which have profound public health implications include the alkaloid emetine in ipecac syrup, cocaine, and ethyl alcohol. The most important cardiotoxic mechanisms proposed for doxorubicin include oxidative stress with its resultant damage to myocardial elements, changes in calcium homeostasis, decreased ability to produce ATP, and systemic release of cardiotoxic humoral mediators from tissue mast cells. Each of the first 3 mechanisms can lead to each of the other 2, and the causal relationships between all of these mechanisms are not clear. New evidence suggests that doxorubicinol, one of the metabolites of doxorubicin may be the moiety responsible for cardiotoxicity. Several other potential mechanisms also have been proposed for doxorubicin. Emetine in ipecac syrup is the first aid treatment of choice for many acute toxic oral ingestions and the alkaloid, itself, is used to treat amebiasis. Cardiotoxicity occurs following chronic exposure, such as occurs therapeutically in amebiasis and with ipecac abuse by bulemics. A number of mechanisms are proposed for emetine cardiotoxicity, but the current mechanistic literature is quite scarce. Cocaine abuse recently has caught the public interest, in particular because of the drug-related sudden deaths of certain athletes. Cocaine can cause hypertension, arrhythmias, and reduced coronary blood flow, each of which can contribute to its lethality. However, it may be possible that cocaine sudden death episodes are more related to hyperthermia and convulsive seizures, rather than to cardiovascular toxicity. Chronic alcohol use leads to dilated cardiomyopathy and failure as part of the general physical degeneration that occurs with alcoholism. Several mechanisms are proposed for the cardiomyopathy, but only 2 things seem clear. The cardiotoxicity is due to an intrinsic effect of alcohol, rather than to malnutrition or co-toxicity, and abstinence is the only effective treatment for the cardiomyopathy. Recent articles indicate that very moderate use of alcohol may be beneficial and protect against cardiovascular-related morbidity. One explanation for these findings seems to be that the non-drinking groups, against whom the moderate drinking comparisons were made, were enriched in former drinkers with significant alcohol-related cardiovascular pathology.

A prospective study of the hypertriglyceridemic waist phenotype and risk of incident ischemic stroke in a Chinese rural population

OBJECTIVES

The hypertriglyceridemic waist phenotype has been reported as a practical tool to screen people with an increased risk of coronary artery disease and type 2 diabetes. The aim of this study was to investigate the relationship between the phenotype and ischemic stroke in a rural population in south China.

MATERIALS AND METHODS

A total of 4081 participants aged over 35 years old without a stroke history were surveyed in 2009 and followed up from May 2014 to January 2016. The hypertriglyceridemic waist phenotype was defined as a waist circumference ≥90 cm and a triglyceride level ≥2.0 mmol/L in males, and a waist circumference ≥85 cm and a triglyceride level ≥1.5 mmol/L in females. A Cox regression model was used to estimate the association of the phenotype and ischemic stroke.

RESULTS

After a mean of 5.16 years of follow-up, 138 individuals developed ischemic stroke. The hypertriglyceridemic waist phenotype was significantly associated with an increased risk of ischemic stroke before and after adjustment for confounding factors; the hazard ratios and 95% confidence intervals were 1.94 (1.27-2.96) and 1.71 (1.05-2.78), respectively. Further stratified analysis confirmed the associations in females (2.37 [1.09-5.14]) and smokers (3.20 [1.30-7.92]). A significant association of the phenotype and ischemic stroke risk was observed in subjects with normal glucose levels (2.94 [1.58-5.47]) but not in subjects with impaired fasting glucose and diabetes.

CONCLUSIONS

The hypertriglyceridemic waist phenotype is associated with an increased risk of ischemic stroke and might be a simple tool to screen individuals with a high risk for ischemic stroke.

The Effect of Acute Ethanol Consumption on the Human Retinal Circulation: A Study in Diabetic and Non-Diabetic Subjects

The effects of acute ethanol consumption on retinal haemodynamics and retinal vascular autoregulation to oxygen in the human retinal circulation were studied in 10 diabetic (mean age +/- SD: 38.2 +/- 11.1) and 16 non-diabetic (mean age +/- SD: 32.4 +/- 8.8) subjects. Subjects drank 0.5 g of ethanol, as vodka, per kg of body weight, diluted in sugar-free orange juice. Retinal blood flow was determined using laser Doppler velocimetry and computerised image analysis. The effect of ethanol on oxygen reactivity, as a measure of autoregulation, was also determined after 60% oxygen inhalation. All subjects demonstrated a significant fall in mean arterial blood pressure (control group 3.3%, p = 0.04, diabetic subjects 5.7%, p = 0.05), after ethanol intake. Ethanol caused no significant change in retinal blood flow. Oxygen reactivity was found to be 38.3% (22.4-47.7, median and interquartile range) in the non-diabetic subjects at baseline, and 30.7% (10.8-42.1) after ethanol ingestion. In diabetic subjects, the oxygen reactivity was 33.2% (19.8-46.8) at baseline and 24.5% (21.1-32.1) after ethanol. In this study ethanol did not significantly affect retinal blood flow or impair autoregulation. These results suggest that the retinal circulation may be able to autoregulate despite the presence of ethanol, in contrast to other vascular beds where ethanol changes flow.

Stroke Risk Factors, Genetics, and Prevention

Stroke is a heterogeneous syndrome, and determining risk factors and treatment depends on the specific pathogenesis of stroke. Risk factors for stroke can be categorized as modifiable and nonmodifiable. Age, sex, and race/ethnicity are nonmodifiable risk factors for both ischemic and hemorrhagic stroke, while hypertension, smoking, diet, and physical inactivity are among some of the more commonly reported modifiable risk factors. More recently described risk factors and triggers of stroke include inflammatory disorders, infection, pollution, and cardiac atrial disorders independent of atrial fibrillation. Single-gene disorders may cause rare, hereditary disorders for which stroke is a primary manifestation. Recent research also suggests that common and rare genetic polymorphisms can influence risk of more common causes of stroke, due to both other risk factors and specific stroke mechanisms, such as atrial fibrillation. Genetic factors, particularly those with environmental interactions, may be more modifiable than previously recognized. Stroke prevention has generally focused on modifiable risk factors. Lifestyle and behavioral modification, such as dietary changes or smoking cessation, not only reduces stroke risk, but also reduces the risk of other cardiovascular diseases. Other prevention strategies include identifying and treating medical conditions, such as hypertension and diabetes, that increase stroke risk. Recent research into risk factors and genetics of stroke has not only identified those at risk for stroke but also identified ways to target at-risk populations for stroke prevention.

More Than Friends and Family? Estimating the Direct and Indirect Effects of Religiosity on Substance Use in Emerging Adulthood

Religiosity tends to negatively influence substance use among emerging adults because religious communities can serve as pro-social reference groups and provide alternative resources for coping with stress and negative life events. The relationship may also be mediated, however, by differences in family attachments and drug- and alcohol-using peer associations. With data from a nationally representative panel study, I implemented longitudinal structural equation modeling to simultaneously assess both direct and indirect effects of religiosity on substance use. While a substantive portion of its effect is mediated by substance-using peers, it is mostly direct, and increasingly so as individuals transition from late adolescence to emerging adulthood. Furthermore, religion appears to be a particularly effective social institution, as religiosity decreases contemporary substance use but is not itself affected by prior substance use. Religiosity may thus be beneficial with regard to certain short- and long-term health outcomes related to substance use during emerging adulthood.

Alcohol and Immediate Risk of Cardiovascular Events: A Systematic Review and Dose-Response Meta-Analysis

BACKGROUND

Although considerable research describes the cardiovascular effects of habitual moderate and heavy alcohol consumption, the immediate risks following alcohol intake have not been well characterized. Based on its physiological effects, alcohol may have markedly different effects on immediate and long-term risk.

METHODS AND RESULTS

We searched CINAHL, Embase, and PubMed from inception to March 12, 2015, supplemented with manual screening for observational studies assessing the association between alcohol intake and cardiovascular events in the following hours and days. We calculated pooled relative risks and 95% confidence intervals for the association between alcohol intake and myocardial infarction, ischemic stroke, and hemorrhagic stroke using DerSimonian and Laird random-effects models to model any alcohol intake or dose-response relationships of alcohol intake and cardiovascular events. Among 1056 citations and 37 full-text articles reviewed, 23 studies (29 457 participants) were included. Moderate alcohol consumption was associated with an immediately higher cardiovascular risk that was attenuated after 24 hours, and even protective for myocardial infarction and hemorrhagic stroke (≈2-4 drinks: relative risk=30% lower risk) and protective against ischemic stroke within 1 week (≈6 drinks: 19% lower risk). In contrast, heavy alcohol drinking was associated with higher cardiovascular risk in the following day (≈6-9 drinks: relative risk=1.3-2.3) and week (≈19-30 drinks: relative risk=2.25-6.2).

CONCLUSIONS

There appears to be a consistent finding of an immediately higher cardiovascular risk following any alcohol consumption, but, by 24 hours, only heavy alcohol intake conferred continued risk.

Cerebral vasoreactivity is impaired in treated, virally suppressed HIV-infected individuals

OBJECTIVE

To compare cerebral vasoreactivity, a measure of cerebrovascular endothelial function, between treated, virally suppressed HIV-infected individuals and HIV-uninfected controls and to evaluate the effect of HIV-specific factors on cerebral vasoreactivity.

METHODS

Cross-sectional study of 65 antiretroviral therapy-treated, virally suppressed HIV-infected individuals and 28 HIV-uninfected controls. Participants underwent noninvasive assessment of cerebral vasoreactivity using transcranial Doppler ultrasound and inhaled carbon dioxide (CO2). We used mixed effects multivariable linear regression to determine the association of HIV infection and HIV-specific factors with cerebral vasoreactivity.

RESULTS

Mean age was 57.2 years for HIV-infected participants and 53.5 years for HIV-uninfected controls. Most participants (95%) were men. Twenty-six per cent of HIV-infected participants were nonwhite compared to 32% of controls. Among HIV-infected participants, mean CD4 cell count was 596 cells/μl, and mean duration of viral suppression was 7.8 years. Cerebral vasoreactivity in response to hypercapnia (cerebral VRhyper) was lower in HIV-infected individuals compared to uninfected controls (3.23 versus 3.81%, P = 0.010). After adjusting for demographic and vascular risk factors, HIV infection was independently associated with lower cerebral vasoreactivity (-0.86%, 95% CI -1.30 to -0.42%, P < 0.001). We did not find a statistically significant effect of recent or nadir CD4 cell count on cerebral vasoreactivity. There was a trend toward higher cerebral vasoreactivity for each additional year of viral suppression.

CONCLUSION

Treated, virally suppressed HIV infection negatively impacted cerebral vasoreactivity even after adjustment for traditional vascular risk factors. These data highlight the potential contribution of cerebrovascular endothelial dysfunction to the elevated risk of stroke observed in HIV-infected individuals.

Long working hours and risk of coronary heart disease and stroke: a systematic review and meta-analysis of published and unpublished data for 603,838 individuals

BACKGROUND

Long working hours might increase the risk of cardiovascular disease, but prospective evidence is scarce, imprecise, and mostly limited to coronary heart disease. We aimed to assess long working hours as a risk factor for incident coronary heart disease and stroke.

METHODS

We identified published studies through a systematic review of PubMed and Embase from inception to Aug 20, 2014. We obtained unpublished data for 20 cohort studies from the Individual-Participant-Data Meta-analysis in Working Populations (IPD-Work) Consortium and open-access data archives. We used cumulative random-effects meta-analysis to combine effect estimates from published and unpublished data.

FINDINGS

We included 25 studies from 24 cohorts in Europe, the USA, and Australia. The meta-analysis of coronary heart disease comprised data for 603,838 men and women who were free from coronary heart disease at baseline; the meta-analysis of stroke comprised data for 528,908 men and women who were free from stroke at baseline. Follow-up for coronary heart disease was 5·1 million person-years (mean 8·5 years), in which 4768 events were recorded, and for stroke was 3·8 million person-years (mean 7·2 years), in which 1722 events were recorded. In cumulative meta-analysis adjusted for age, sex, and socioeconomic status, compared with standard hours (35-40 h per week), working long hours (≥55 h per week) was associated with an increase in risk of incident coronary heart disease (relative risk [RR] 1·13, 95% CI 1·02-1·26; p=0·02) and incident stroke (1·33, 1·11-1·61; p=0·002). The excess risk of stroke remained unchanged in analyses that addressed reverse causation, multivariable adjustments for other risk factors, and different methods of stroke ascertainment (range of RR estimates 1·30-1·42). We recorded a dose-response association for stroke, with RR estimates of 1·10 (95% CI 0·94-1·28; p=0·24) for 41-48 working hours, 1·27 (1·03-1·56; p=0·03) for 49-54 working hours, and 1·33 (1·11-1·61; p=0·002) for 55 working hours or more per week compared with standard working hours (ptrend<0·0001).

INTERPRETATION

Employees who work long hours have a higher risk of stroke than those working standard hours; the association with coronary heart disease is weaker. These findings suggest that more attention should be paid to the management of vascular risk factors in individuals who work long hours.

FUNDING

Medical Research Council, Economic and Social Research Council, European Union New and Emerging Risks in Occupational Safety and Health research programme, Finnish Work Environment Fund, Swedish Research Council for Working Life and Social Research, German Social Accident Insurance, Danish National Research Centre for the Working Environment, Academy of Finland, Ministry of Social Affairs and Employment (Netherlands), US National Institutes of Health, British Heart Foundation.

Effects of Chronic Alcohol Exposure on the Modulation of Ischemia-Induced Glutamate Release via Cannabinoid Receptors in the Dorsal Hippocampus

BACKGROUND

Chronic alcohol consumption is a critical contributing factor to ischemic stroke, as it enhances ischemia-induced glutamate release, leading to more severe excitotoxicity and brain damage. But the neural mechanisms underlying this phenomenon are poorly understood.

METHODS

We evaluated the effects of chronic alcohol exposure on the modulation of ischemia-induced glutamate release via CB1 and CB2 cannabinoid receptors during middle cerebral artery occlusion, using in vivo microdialysis coupled with high-performance liquid chromatography, in alcohol-naïve rats or rats after 1 or 30 days of withdrawal from chronic ethanol intake (6% v/v for 14 days).

RESULTS

Intra-dorsal hippocampus (DH) infusions of ACEA or JWH133, selective CB1 or CB2 receptor agonists, respectively, decreased glutamate release in the DH in alcohol-naïve rats in a dose-dependent manner. Such an effect was reversed by co-infusions of SR141716A or AM630, selective CB1 or CB2 receptor antagonists, respectively. After 30 days, but not 1 day of withdrawal, ischemia induced an enhancement in glutamate release in the DH, as compared with non-alcohol-treated control group. Intra-DH infusions of JWH133, but not ACEA, inhibited ischemia-induced glutamate release in the DH after 30 days of withdrawal. Finally, 1 day of withdrawal did not alter the protein level of CB1 or CB2 receptors in the DH, as compared to non-alcohol-treated control rats. Whereas 30 days of withdrawal robustly decreased the protein level of CB1 receptors, but failed to alter the protein level of CB2 receptors, in the DH, as compared to non-alcohol-treated control rats.

CONCLUSIONS

Together, these findings suggest that loss of expression/function of CB1 receptors, but not CB2 receptors in the DH, is correlated with the enhancement of ischemia-induced glutamate release after prolonged alcohol withdrawal.

Heavy ethanol consumption aggravates the ischemic cerebral injury by inhibiting ALDH2

BACKGROUND

Heavy ethanol consumption is widely accepted as a risk for ischemic stroke. The molecular mechanisms of ethanol-induced brain injury have not been fully understood.

AIM

This study aims to find out the mechanism of the ischemic cerebral injury.

METHODS

We used Sprague-Dawley rats with transient middle cerebral artery occlusion for acute experiment and stroke-prone spontaneously hypertensive rats for long-term experiment in vivo, and oxygen-glucose deprivation model in vitro to define a detrimental effect of different doses of ethanol on ischemic stroke injury. We also used mitochondrial aldehyde dehydrogenase 2 knockdown/overexpression or inhibitor/activator to investigate mechanism of the adverse effects of ethanol.

RESULTS

High-dose ethanol (36% of calorie derived from ethanol) significantly increased the infarct size in rats (P < 0·01) and decreased the survival time of stroke-prone spontaneously hypertensive rats by about 20%. Six-week treatment with high-dose ethanol changed a distribution of isoelectric point of aldehyde dehydrogenase 2 and inhibited aldehyde dehydrogenase 2 activity in brain. High dose of ethanol increased the cerebral acetaldehyde level, and increased 4-hydroxy-2-nonenal and malondialdehyde in serum of rats with middle cerebral artery occlusion. The activator of aldehyde dehydrogenase 2, Alda-1 abolished neuronal cells death and ischemic injury induced by ethanol and the inhibitor reversed the injurious effects. An overexpression of aldehyde dehydrogenase 2 completely abolished the increased infarct size and neurological deficit score by ethanol. Conversely, knockdown of aldehyde dehydrogenase 2 increased the infarct size and exaggerated the cerebral injury induced by ethanol.

CONCLUSIONS

High concentrations of ethanol aggravate cerebral injury by inhibiting of aldehyde dehydrogenase 2 and inducing excess accumulation of aldehydes.

Risk factors for acute myocardial infarction in central India: a case-control study

Background:

Atherosclerosis is a multi-factorial disease involving the interplay of genetic and environmental factors. Studies highlighting the public health importance of risk factors like chronic infections causing acute myocardial infarction (AMI) in the Indian context are scarce. This study was undertaken to study the association of socio-demographic and life-style factors with acute myocardial infarction in central India.

Materials and Methods:

The cases and controls were group-matched for age, gender, and socio-economic status. A blinded research associate administered the study questionnaire. We performed an unconditional multiple logistic regression analysis.

Results:

The case-control study included 265 cases of AMI and 265 controls. The results of final model of logistic regression analysis for risk factors of AMI included 11 risk factors at α = 0.05. They were waist hip ratio, body mass index, stress at home in last 1 year, hypertension, family history of CHD, past history of gingival sepsis, tobacco smoking, raised total serum cholesterol, Chlamydia pneumoniae, Helicobacter pylori and raised C-reactive protein.

Conclusion:

The findings confirm the role of conventional risk factors for cardiac disease and highlight need for research into the association between chronic infections with AMI.

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

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of stroke among individuals who have not previously experienced a stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches to atherosclerotic disease of the cervicocephalic circulation, and antithrombotic treatments for preventing thrombotic and thromboembolic stroke. Further recommendations are provided for genetic and pharmacogenetic testing and for the prevention of stroke in a variety of other specific circumstances, including sickle cell disease and patent foramen ovale.

Alcohol and cardiovascular health: the dose makes the poison…or the remedy

Habitual light to moderate alcohol intake (up to 1 drink per day for women and 1 or 2 drinks per day for men) is associated with decreased risks for total mortality, coronary artery disease, diabetes mellitus, congestive heart failure, and stroke. However, higher levels of alcohol consumption are associated with increased cardiovascular risk. Indeed, behind only smoking and obesity, excessive alcohol consumption is the third leading cause of premature death in the United States. Heavy alcohol use (1) is one of the most common causes of reversible hypertension, (2) accounts for about one-third of all cases of nonischemic dilated cardiomyopathy, (3) is a frequent cause of atrial fibrillation, and (4) markedly increases risks of stroke-both ischemic and hemorrhagic. The risk-to-benefit ratio of drinking appears higher in younger individuals, who also have higher rates of excessive or binge drinking and more frequently have adverse consequences of acute intoxication (for example, accidents, violence, and social strife). In fact, among males aged 15 to 59 years, alcohol abuse is the leading risk factor for premature death. Of the various drinking patterns, daily low- to moderate-dose alcohol intake, ideally red wine before or during the evening meal, is associated with the strongest reduction in adverse cardiovascular outcomes. Health care professionals should not recommend alcohol to nondrinkers because of the paucity of randomized outcome data and the potential for problem drinking even among individuals at apparently low risk. The findings in this review were based on a literature search of PubMed for the 15-year period 1997 through 2012 using the search terms alcohol, ethanol, cardiovascular disease, coronary artery disease, heart failure, hypertension, stroke, and mortality. Studies were considered if they were deemed to be of high quality, objective, and methodologically sound.

Acute cardioembolic cerebral infarction: answers to clinical questions

Cardioembolic cerebral infarction (CI) is the most severe subtype of ischaemic stroke but some clinical aspects of this condition are still unclear. This article provides the reader with an overview and up-date of relevant aspects related to clinical features, specific cardiac disorders and prognosis of CI. CI accounts for 14-30% of ischemic strokes; patients with CI are prone to early and long-term stroke recurrence, although recurrences may be preventable by appropriate treatment during the acute phase and strict control at follow-up. Certain clinical features are suggestive of CI, including sudden onset to maximal deficit, decreased level of consciousness at onset, Wernicke's aphasia or global aphasia without hemiparesis, a Valsalva manoeuvre at the time of stroke onset, and co-occurrence of cerebral and systemic emboli. Lacunar clinical presentations, a lacunar infarct and especially multiple lacunar infarcts, make cardioembolic origin unlikely. The most common disorders associated with a high risk of cardioembolism include atrial fibrillation, recent myocardial infarction, mechanical prosthetic valve, dilated myocardiopathy and mitral rheumatic stenosis. Patent foramen ovale and complex atheromatosis of the aortic arch are potentially emerging sources of cardioembolic infarction. Mitral annular calcification can be a marker of complex aortic atheroma in stroke patients of unkown etiology. Transthoracic and transesophageal echocardiogram can disclose structural heart diseases. Paroxysmal atrial dysrhythmia can be detected by Holter monitoring. Magnetic resonance imaging, transcranial Doppler, and electrophysiological studies are useful to document the source of cardioembolism. In-hospital mortality in cardioembolic stroke (27.3%, in our series) is the highest as compared with other subtypes of cerebral infarction. Secondary prevention with anticoagulants should be started immediately if possible in patients at high risk for recurrent cardioembolic stroke in which contraindications, such as falls, poor compliance, uncontrolled epilepsy or gastrointestinal bleeding are absent. Dabigatran has been shown to be non-inferior to warfarin in the prevention of stroke or systemic embolism. All significant structural defects, such as atrial septal defects, vegetations on valve or severe aortic disease should be treated. Aspirin is recommended in stroke patients with a patent foramen ovale and indications of closure should be individualized. CI is an important topic in the frontier between cardiology and vascular neurology, occurs frequently in daily practice, has a high impact for patients, and health care systems and merits an update review of current clinical issues, advances and controversies.

Recent advances in antithrombotic therapy for stroke prevention in patients with atrial fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac dysrhythmia and patients with AF have a higher risk for stroke than the general population. The prevalence of AF is increasing, which underscores the importance of understanding the therapeutic options available for stroke prevention in the primary care setting. This article examines evidence for the use of novel oral anticoagulant (OAC) therapy, including the direct thrombin inhibitor dabigatran and the activated factor X inhibitors rivaroxaban and apixaban for stroke prevention in patients with AF. Although warfarin therapy is the gold standard for prevention of stroke, its use is associated with significant challenges related to drug-drug and food-drug interactions. Warfarin use also requires frequent blood monitoring to maintain anticoagulation within a narrow therapeutic window. Overall, the novel OACs are as good as, or better than, warfarin therapy for stroke prevention in patients with AF, and they have a comparable or reduced risk of associated major bleeding. In addition, the novel OACs have fewer drug-drug and food-drug interactions and do not require continuous blood monitoring. Integration of the novel OACs into clinical practice offers patients with AF new treatment options, and as therapeutic use of the novel OACs increases, real-world experience will add to our understanding of the value of these agents.

Hangover and the risk of stroke in middle-aged men

OBJECTIVES

The aim of this study was to examine the association between hangover and the risk of stroke.

MATERIAL AND METHODS

A population-based sample of men with an average follow-up of 15.7 years. 2466 men with no history of stroke at baseline participated. Two hundred and six strokes occurred, of which 167 were ischemic strokes.

RESULTS

The age-adjusted, relative risk (RR) for any stroke among men with ≥1 hangover per year was 2.33-fold (95% confidence interval (CI), 1.19-4.56; P = 0.013) relative to men without hangover, and 2.99-fold (95% CI, 1.52-5.86; P = 0.001) for ischemic stroke, respectively. After adjustment for age, smoking, high density lipoprotein (HDL)-cholesterol, LDL-cholesterol, BMI, SBP, myocardial ischemia during exercise, symptomatic coronary heart disease (CHD) and CHD in family, C-reactive protein, diabetes, and total alcohol consumption, the RR for any stroke was 1.94-fold (95% CI, 0.95-3.96; P = 0.070) and 2.58-fold (95% CI, 1.24-5.36; P = 0.011) for ischemic stroke among men with hangovers. Additional adjustment of atrial fibrillation and cardiac failure and risk was 2.45-fold (95% CI, 1.18-5.12; P = 0.017) for ischemic strokes.

CONCLUSION

This study shows that at least one hangover a year is related to an increased risk of ischemic stroke in men.

Alcohol is a risk factor not for thalamic but for putaminal hemorrhage: the Akita Stroke Registry

BACKGROUND

Although the risk factors of cerebral hemorrhage were established long ago, there is little agreement as to the risk factors for the site of cerebral hemorrhage.

METHODS

We obtained mass health screening data collected between 1990 and 2000 regarding 151,796 subjects from the Akita Prefectural Federation of Agricultural Cooperative for Health and Welfare. A first-ever cerebral hemorrhage occurring <3 years after the screening examination was defined as an event. Stroke events were determined from the Akita stroke registry between 1990 and 2003. Clinical risk factors for stroke, such as age, blood pressure, severe obesity (body mass index >30 kg/m(2)), low serum total cholesterol, hepatic disorder, renal disorder, and drinking habits were then assessed.

RESULTS

Cerebral hemorrhage developed in 344 cases in the study population. The distribution of subtypes (putaminal hemorrhage [PH], thalamic hemorrhage [TH], and subcortical hemorrhage [SH]) were 122 cases (35.5%), 110 cases (32.0%), and 44 cases (12.8%), respectively. We evaluated the risk factors by multiple logistic regression analysis among these 3 groups. Age was a significant risk factor among these 3 groups, but blood pressure was not a risk factor in SH. Low serum cholesterol and drinking habits were significant risk factors only in PH. Hepatic disorder was a strong risk factor in PH and a weak risk factor in TH. Interestingly, a drinking habit was a significant risk factor only in PH.

CONCLUSIONS

Drinking habits had been a risk factor for cerebral hemorrhage, but it was a risk factor not for PH and not for TH or SH.

Cardioembolic stroke: clinical features, specific cardiac disorders and prognosis

This article provides the reader with an overview and up-date of clinical features, specific cardiac disorders and prognosis of cardioembolic stroke. Cardioembolic stroke accounts for 14-30% of ischemic strokes and, in general, is a severe condition; patients with cardioembolic infarction are prone to early and long-term stroke recurrence, although recurrences may be preventable by appropriate treatment during the acute phase and strict control at follow-up. Certain clinical features are suggestive of cardioembolic infarction, including sudden onset to maximal deficit, decreased level of consciousness at onset, Wernicke’s aphasia or global aphasia without hemiparesis, a Valsalva manoeuvre at the time of stroke onset, and co-occurrence of cerebral and systemic emboli. Lacunar clinical presentations, a lacunar infarct and especially multiple lacunar infarcts, make cardioembolic origin unlikely. The more common high risk cardioembolic conditions are atrial fibrillation, recent myocardial infarction, mechanical prosthetic valve, dilated myocardiopathy, and mitral rheumatic stenosis. Transthoracic and transesophageal echocardiogram can disclose structural heart diseases. Paroxysmal atrial dysrhyhtmia can be detected by Holter monitoring. In-hospital mortality in cardioembolic stroke (27.3%, in our series) is the highest as compared with other subtypes of cerebral infarction. In our experience, in-hospital mortality in patients with early embolic recurrence (within the first 7 days) was 77%. Patients with alcohol abuse, hypertension, valvular heart disease, nausea and vomiting, and previous cerebral infarction are at increased risk of early recurrent systemic embolization. Secondary prevention with anticoagulants should be started immediately if possible in patients at high risk for recurrent cardioembolic stroke in which contraindications, such as falls, poor compliance, uncontrolled epilepsy or gastrointestinal bleeding are absent.

The effects of head circumference (HC) and lifetime alcohol consumption (AC) on cognitive function in the elderly

Smaller premorbid brain volume is known to be related to cognitive deterioration in older adults, supporting a reserve hypothesis of brain aging. Heavy lifetime alcohol consumption (AC) may also increase the risk of cognitive impairment. The aim of this study was to examine the effects of head circumference (HC) and lifetime AC on cognitive function in the elderly. This study is part of a large, longitudinal study of men aged 60 years or older in the Korean community. We studied 1569 subjects with complete demographic, anthropometric and AC data. Cognitive function was assessed by the Korean version of Mini Mental State Examination (K-MMSE). Participants reported at the time of interview their lifetime alcohol drinking patterns. HC was also measured. We did a cross-sectional analysis the relation between two factors to cognitive function. After a multivariable adjustment, the interactive effect between HC and lifetime AC was shown to be significantly associated with cognitive function (F=2.55, p=0.038). Simple main effect analysis showed that smaller HC and a high level of lifetime AC were related with decreased cognitive function. All these findings suggest the possibility that lifetime AC and HC have synergistic effects on cognitive impairment.

Cognitive impairment predicts fatal incident stroke: findings from a national sample of older adults

OBJECTIVES

To investigate the effect of cognitive impairment on fatal and nonfatal incident stroke in older adults.

DESIGN

A large, national, prospective, population-based study of a representative cohort of older Canadians followed over a 10-year period.

SETTING

Secondary analyses were conducted using data from the Canadian Study of Health and Aging, a population-based study of older adults followed prospectively from 1991 to 2001.

PARTICIPANTS

Nine thousand four hundred fifty-one adults aged 65 and older who had not previously been diagnosed with stroke at baseline (in 1991).

MEASUREMENTS

In addition to known risk factors, the independent contribution of cognitive function (diagnosed in a clinical examination) was examined as a risk for stroke in older adults.

RESULTS

Multinomial logistic regression analyses showed that cognitive impairment was associated with twice the odds of fatal incident stroke, controlling for well-established risk factors.

CONCLUSION

This study provides further evidence for the need to consider cognitive function in relation to stroke risk in older populations.

Dose-related influence of chronic alcohol consumption on cerebral ischemia/reperfusion injury

BACKGROUND

We examined the dose-related influence of alcohol consumption on cerebral ischemia/reperfusion (I/R) injury and the potential mechanism that accounts for the disparate effects of high-dose and low-dose alcohol consumption on cerebral I/R injury.

METHODS

Sprague-Dawley rats were fed a liquid diet with or without 1, 3, 5, or 6.4% (v/v) alcohol for 8 weeks and subjected to a 2-hour middle cerebral artery occlusion (MCAO). We evaluated the brain injury at 24 hours of reperfusion. In addition, we measured protein expression of NMDA receptor and excitatory amino acid transporters (EAATs) in parietal cortex and the effect of NMDA receptor antagonist, memantine, on 2-hour MCAO/24 h reperfusion-induced brain injury.

RESULTS

Compared with non-alcohol-fed rats, the total infarct volume was not altered in 3 and 5% alcohol-fed rats but significantly reduced in 1% alcohol-fed rats and exacerbated in 6.4% alcohol-fed rats. Expression of the NMDA receptor subunit, NR1, was upregulated in 6.4% alcohol-fed rats, whereas expression of EAAT2 was downregulated in 6.4% alcohol-fed rats and upregulated in 1% alcohol-fed rats. Memantine reduced 2-hour MCAO/24 h reperfusion-induced brain injury in non-alcohol-fed and 6.4% alcohol-fed rats, but not in 1% alcohol-fed rats. The magnitude of reduction in the brain injury was greater in 6.4% alcohol-fed rats compared to non-alcohol-fed rats.

CONCLUSIONS

Our findings suggest that chronic consumption of low-dose alcohol protects the brain against I/R injury, whereas chronic consumption of high-dose alcohol has detrimental effect on cerebral I/R injury. The disparate effects of low-dose and high-dose alcohol consumption on cerebral I/R may be related to an alteration in NMDA excitotoxicity.

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.

Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the american heart association/american stroke association

The aim of this updated statement is to provide comprehensive and timely evidence-based recommendations on the prevention of ischemic stroke among survivors of ischemic stroke or transient ischemic attack. Evidence-based recommendations are included for the control of risk factors, interventional approaches for atherosclerotic disease, antithrombotic treatments for cardioembolism, and the use of antiplatelet agents for noncardioembolic stroke. Further recommendations are provided for the prevention of recurrent stroke in a variety of other specific circumstances, including arterial dissections; patent foramen ovale; hyperhomocysteinemia; hypercoagulable states; sickle cell disease; cerebral venous sinus thrombosis; stroke among women, particularly with regard to pregnancy and the use of postmenopausal hormones; the use of anticoagulation after cerebral hemorrhage; and special approaches to the implementation of guidelines and their use in high-risk populations.

Alcohol and hypertension: gender differences in dose-response relationships determined through systematic review and meta-analysis

AIMS

To analyze the dose-response relationship between average daily alcohol consumption and the risk of hypertension via systematic review and meta-analysis.

DESIGN

A computer-assisted search was completed for 10 databases, followed by hand searches of relevant articles. Only studies with longitudinal design, quantitative measurement of alcohol consumption and biological measurement of outcome were included. Dose-response relationships were assessed by determining the best-fitting model via first- and second-degree fractional polynomials. Various tests for heterogeneity and publication bias were conducted.

FINDINGS

A total of 12 cohort studies were identified from the literature from the United States, Japan and Korea. A linear dose-response relationship with a relative risk of 1.57 at 50 g pure alcohol per day and 2.47 at 100 g per day was seen for men. Among women, the meta-analysis indicated a more modest protective effect than reported previously: a significant protective effect was reported for consumption at or below about 5 g per day, after which a linear dose-response relationship was found with a relative risk of 1.81 at 50 g per day and of 2.81 at an average daily consumption of 100 g pure alcohol per day. Among men, Asian populations had higher risks than non-Asian populations.

CONCLUSIONS

The risk for hypertension increases linearly with alcohol consumption, so limiting alcohol intake should be advised for both men and women.

Neurological complications of alcohol usage

The relationships between alcohol usage and a number of neurological syndromes are reviewed. These are often complex and incompletely understood. Multiple rather than single factors are the rule rather than the exception. The correct diagnosis may be missed particularly where the aetiological role of alcohol is overlooked. Multiple diagnoses are not uncommon. Issues of differential diagnosis and diagnostic procedures are discussed. Management, including a number of its pitfalls, is outlined.

Alcohol, cardiovascular diseases and all causes of death: a review of the epidemiological evidence

This paper reviews the epidemiological evidence on the association of alcohol consumption with the major cardiovascular diseases (hypertension, stroke and coronary heart disease), and all causes of death. The focus is on light and moderate consumption and several important methodological issues are apparent with the epidemiological evidence on alcohol and mortality. The epidemiological data justify the following recommendations on alcohol consumption. The evidence does not support the unqualified claim that light and moderate drinking confers overall health benefits. However, in persons over 35 years of age, there is no consistent evidence that daily consumption of up to 2-3 drinks in men or up to 1-2 drinks in women increases the risk of dying. Non-drinkers should not be encouraged to change their drinking status. The consumption of more than 2-3 drinks per day in men and more than 1-2 drinks per day in women should be actively discouraged. Further research on the effects of light and moderate alcohol consumption on cardiovascular disease and all causes of death are required, particularly in young people, women and the elderly.

Alcohol consumption, social support, and risk of stroke and coronary heart disease among Japanese men: the JPHC Study

BACKGROUND

It is unclear whether the association between alcohol consumption and risk of cardiovascular disease is affected by social support.

METHODS

The prospective data for 19,356 men aged 40 to 69 years who participated in the Japan Public Health Center-Based Prospective Study. Alcohol consumption was classified into 7 categories: never, past, occasional, 1 to 149, 150 to 299, 300 to 449, or > or =450 g ethanol/wk. Associations between alcohol consumption and risk of cardiovascular disease were stratified by the median level of social support score, which was measured in emotional support score of this cohort study.

RESULTS

During an average follow-up of 9.9 years, 629 total strokes and 207 coronary heart diseases were documented. Light-to-moderate alcohol consumption was associated with reduced risks of coronary heart disease and total cardiovascular disease, while heavy alcohol consumption was associated with increased risk of total stroke, in particular hemorrhagic stroke. When stratified by social support score, the multivariable hazard ratios of total cardiovascular disease associated with light-to-moderate alcohol consumption (1 to 299 g/wk) were 0.99 (0.72 to 1.37) in the low social support group and 0.56 (0.44 to 0.70) in the high social support group (p for interaction = 0.002), while the multivariable hazard ratios of hemorrhagic stroke associated with heavy alcohol consumption (> or =300 g/wk) were 2.09 (1.03 to 4.27) in the low social support group and 1.25 (0.72 to 2.15) in the high social support group (p for interaction = 0.44). There was no interaction between alcohol consumption and social support in relation to risk of coronary heart disease.

CONCLUSIONS

Social support may enhance the beneficial effect of light-to-moderate alcohol consumption on risk of cardiovascular disease.

Clinical review: Critical care management of spontaneous intracerebral hemorrhage

Intracerebral hemorrhage is by far the most destructive form of stroke. The clinical presentation is characterized by a rapidly deteriorating neurological exam coupled with signs and symptoms of elevated intracranial pressure. The diagnosis is easily established by the use of computed tomography or magnetic resonance imaging. Ventilatory support, blood pressure control, reversal of any preexisting coagulopathy, intracranial pressure monitoring, osmotherapy, fever control, seizure prophylaxis, treatment of hyerglycemia, and nutritional supplementation are the cornerstones of supportive care in the intensive care unit. Dexamethasone and other glucocorticoids should be avoided. Ventricular drainage should be performed urgently in all stuporous or comatose patients with intraventricular blood and acute hydrocephalus. Emergent surgical evacuation or hemicraniectomy should be considered for patients with large (>3 cm) cerebellar hemorrhages, and in those with large lobar hemorrhages, significant mass effect, and a deteriorating neurological exam. Apart from management in a specialized stroke or neurological intensive care unit, no specific medical therapies have been shown to consistently improve outcome after intracerebral hemorrhage.

Effect of chronic alcohol consumption on brain damage following transient focal ischemia

Chronic alcohol consumption impairs cerebral vasoreactivity, and thus, may result in an increase in ischemic brain damage. The goal of this study is to examine the influence of chronic alcohol consumption on transient focal ischemia-induced brain damage. Sprague-Dawley rats were divided into two groups, a control group and an alcohol group. Eight weeks after being fed a liquid diet with or without alcohol, responses of parietal pial arterioles to systemic hypoxia and hypercapnia were measured using a cranial window technique. In separate experiments, rats were subjected to right middle cerebral artery occlusion (MCAO) for 2 h under ketamine/xylazine or isoflurane anesthesia. Regional cerebral blood flow (rCBF) was monitored through a Laser-Doppler flow probe attached to the lateral aspect of the skull. Neurological evaluation and ischemic lesion were assessed 24 h after reperfusion. Dilation of pial arterioles in response to hypoxia and hypercapnia was significantly reduced in alcohol-fed rats. Alcohol-fed rats had significantly larger infarct volumes and worse neurological outcomes than non-alcohol-fed rats under ketamine/xylazine or isoflurane anesthesia. In addition, rCBF measurement indicated that alcohol-fed rats had less regulatory rebound increase in rCBF after the initial drop in rCBF at the onset of MCAO. Our findings suggest that chronic alcohol consumption exacerbates transient focal ischemia-induced brain damage. Increased ischemic brain damage during alcohol consumption may be related to an impaired cerebral vasoreactivity.

Urbanization and stroke prevalence in Taiwan: analysis of a nationwide survey

This study aims to explore the prevalence of strokes among individuals and the association with urbanization levels. A total sample of 9,794 individuals was obtained from a nationwide survey on Taiwan for subsequent analysis in this study. After adjusting for gender, age, other risk factors for stroke and individual socioeconomic status, a multivariate logistic regression model was employed to investigate the relationships existing between the prevalence of strokes and the level of urbanization. This study finds that those living in areas at the highest level of urbanization (level 1) had the highest prevalence of strokes (2.49%). With decreasing urbanization level, there was a general decline in stroke prevalence. After adjusting for other factors, the multivariate logistic regression analyses showed that compared to participants living in the highest urbanization level, the respective odds ratios of suffering a stroke for those living in areas at the lowest levels of urbanization (levels 7 and 8), were 0.43 and 0.30. We conclude that after adjusting for other stroke risk factors, the level of urbanization is an important contributory factor to the overall prevalence of strokes in Taiwan.

Primary intracerebral hemorrhage mortality reduction after installation of a tap-water supply system in an arseniasis-endemic area in southwestern Taiwan

Mortality and morbidity of vascular diseases, including stroke, are known to be associated with chronic exposure to inorganic arsenic through drinking water. A tap-water supply system was implemented in the early 1960s in the blackfoot disease (BFD) endemic areas of Taiwan. The objective of this study was to examine whether mortality attributed to stroke decreased among residents living in the BFD-endemic areas after the curtailment of arsenic exposure. Further it was of interest to determine whether arsenic exposure was related to a specific type of stroke. Standardized mortality ratios (SMRs) for stroke were calculated for the BFD endemic area for the years 1971-2000. The study results show that mortality due to primary intracerebral hemorrhage (PIH) declined gradually after the improvement of drinking-water supply system by elimination of arsenic exposure through removal of artesian well water. Based on the reversibility and specificity criteria, the association between arsenic exposure and mortality due to PIH is likely to be causal.