The Cardiovascular Implications of Alcohol and Red Wine

Low-dose ethanol consumption inhibits neutrophil extracellular traps formation to alleviate rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease. Ethanol consumption has been reported to reduce morbidity in RA patients, but the mechanism behind it remains unclear. Our results showed that Muribaculaceae was predominant in the gut microbiota of mice after ethanol treatment, and the levels of microbiota metabolite acetate were increased. Acetate reduced arthritis severity in collagen-induced arthritis (CIA) mice, which was associated with a decrease in the articular neutrophils and the myeloperoxidase-deoxyribonucleic acid complex in serum. Meanwhile, in vitro experiments confirmed that acetate affected neutrophil activity by acting on G-protein-coupled receptor 43, which reduced endoplasmic reticulum stress in neutrophils and inhibited neutrophil extracellular traps formation. Furthermore, exogenous acetate reversed CIA mice with exacerbated gut microbial disruption, further confirming that the effect of gut microbial metabolite acetate on neutrophils in vivo is crucial for the immune regulation. Our findings illuminate the metabolic and cellular mechanisms of the gut-joint axis in the regulation of autoimmune arthritis, and may offer alternative avenues to replicate or induce the joint-protective benefits of ethanol without associated detrimental effects.

Red Wine and Sexual Function in Men: An Original Point of View

Red wine is a rich source of nutrients whose biological properties have inspired numerous scientific studies. Indeed, it has been widely reported that there is a correlation between the positive health effects of moderate consumption of red wine and its phenolic content, which, due to its antioxidant activity, has proved to be useful in the improvement of various diseases, such as cardiovascular diseases, metabolic syndrome, cognitive disorders, depression, and cancer. It is a common opinion that the antioxidant activity of red wine is to be ascribed to its entire content of polyphenols, which act synergistically and not as a single component. Furthermore, this health-promoting effect of red wine can also be linked to its ethanol content, which has shown a wide array of biological properties. Beyond this evidence, very little is known about a possible correlation between moderate consumption of red wine and male sexual function. This brief review aimed to evaluate the effects of moderate consumption of red wine on erectile function. To accomplish this, Pubmed and Google Scholar databases were searched to retrieve the most relevant studies on this topic. The evidence so far collected has shown that red wine, if consumed in moderation, can be potentially beneficial for patients with erectile dysfunction as well as can positively influence reproductive function through mechanisms that depend on the vasorelaxant properties of red wine and its antioxidant properties.

Therapeutic Potential of Flavonoids and Tannins in Management of Oral Infectious Diseases-A Review

Medicinal plants are rich sources of valuable molecules with various profitable biological effects, including antimicrobial activity. The advantages of herbal products are their effectiveness, relative safety based on research or extended traditional use, and accessibility without prescription. Extensive and irrational usage of antibiotics since their discovery in 1928 has led to the increasing expiration of their effectiveness due to antibacterial resistance. Now, medical research is facing a big and challenging mission to find effective and safe antimicrobial therapies to replace inactive drugs. Over the years, one of the research fields that remained the most available is the area of natural products: medicinal plants and their metabolites, which could serve as active substances to fight against microbes or be considered as models in drug design. This review presents selected flavonoids (such as apigenin, quercetin, kaempferol, kurarinone, and morin) and tannins (including oligomeric proanthocyanidins, gallotannins, ellagitannins, catechins, and epigallocatechin gallate), but also medicinal plants rich in these compounds as potential therapeutic agents in oral infectious diseases based on traditional usages such as Agrimonia eupatoria L., Hamamelis virginiana L., Matricaria chamomilla L., Vaccinium myrtillus L., Quercus robur L., Rosa gallica L., Rubus idaeus L., or Potentilla erecta (L.). Some of the presented compounds and extracts are already successfully used to maintain oral health, as the main or additive ingredient of toothpastes or mouthwashes. Others are promising for further research or future applications.

Ethanol: striking the cardiovascular system by harming the gut microbiota

Ethanol consumption represents a significant public health problem, and excessive ethanol intake is a risk factor for cardiovascular disease (CVD), one of the leading causes of death and disability worldwide. The mechanisms underlying the effects of ethanol on the cardiovascular system are complex and not fully comprehended. The gut microbiota and their metabolites are indispensable symbionts essential for health and homeostasis and therefore, have emerged as potential contributors to ethanol-induced cardiovascular system dysfunction. By mechanisms that are not completely understood, the gut microbiota modulates the immune system and activates several signaling pathways that stimulate inflammatory responses, which in turn, contribute to the development and progression of CVD. This review summarizes preclinical and clinical evidence on the effects of ethanol in the gut microbiota and discusses the mechanisms by which ethanol-induced gut dysbiosis leads to the activation of the immune system and cardiovascular dysfunction. The cross talk between ethanol consumption and the gut microbiota and its implications are detailed. In summary, an imbalance in the symbiotic relationship between the host and the commensal microbiota in a holobiont, as seen with ethanol consumption, may contribute to CVD. Therefore, manipulating the gut microbiota, by using antibiotics, probiotics, prebiotics, and fecal microbiota transplantation might prove a valuable opportunity to prevent/mitigate the deleterious effects of ethanol and improve cardiovascular health and risk prevention.

Resveratrol inhibits Ca2+ signals and aggregation of platelets

Background

Resveratrol has been shown to inhibit platelet aggregation. However, the mechanism for this action of resveratrol remains to be clarified. The purpose of this study was to elucidate the Ca²⁺-related mechanism for the inhibitory action of resveratrol on platelet aggregation.

Methods

Ca²⁺ entry and subsequent aggregation of human platelets induced by different stimulants including thrombin, thapsigargin, and 1-oleoyl-2-acetylglycerol (OAG) were measured by the fluorescence method and light transmittance method, respectively. Each stimulant was added to a nominally Ca²⁺-free medium containing platelets, and then CaCl₂ was added to the medium to induce Ca²⁺ influx into platelets.

Results

Thapsigargin-induced Ca²⁺ entry into platelets and subsequent platelet aggregation were significantly inhibited in the presence of resveratrol at 6.25 μM or higher concentrations, while OAG-induced Ca²⁺ entry and subsequent platelet aggregation were not affected by resveratrol at concentrations up to 50 μM. In the nominally Ca²⁺-free medium, thrombin induced a small transient increase in intracellular Ca²⁺ concentrations, which was attenuated in the presence of resveratrol at 12.5 μM or higher concentrations. Thrombin-induced Ca²⁺ entry into platelets and subsequent platelet aggregation were significantly inhibited in the presence of resveratrol at 12.5 μM or higher concentrations.

Conclusions

The results suggest that resveratrol inhibits thrombin-induced platelet aggregation through decreasing Ca²⁺ release from its stores and inhibiting store-operated Ca²⁺ influx into platelets.

Hormetic use of stress in gerontological interventions requires a cautious approach

Hormesis as a general principle is conceivable only for factors that are present in the natural environment. For such factors, existence of an optimal level can be assumed, which would correspond to the current environmental level or some average of historic levels. Theoretic basis of some hormetic mechanisms has been discussed within the scope of stress response pathways. Impacts of multiple stressing agents may produce combined effects larger than those expected from isolated impacts i.e. act synergistically. Adding the effect of a damaging stress to another damaging stress would possibly augment the damage; but if two mild stresses have positive hormetic effects, their combination can have additive positive effects. Potential adverse effects of excessive doses of hormetic agents should be pointed out particularly for senile age or a state close to decompensation when minor stimuli might be damaging. In conclusion, a hormetic use of stress in gerontological interventions requires a cautious approach.

The effects of smoking and drinking on all-cause mortality in patients with dilated cardiomyopathy: a single-center cohort study

SUBJECT

Recent studies have shown that smoking and drinking are associated with poorer outcomes in patients with cardiomyopathy. The purpose of this study was to determine all-cause mortality in dilated cardiomyopathy (DCM) associated with smoking and drinking.

METHODS

An observational cohort study was undertaken in DCM patients from November 2003 to September 2011. A total of 1118 patients were enrolled, with a mean follow-up of 3.5 ± 2.3 years. Standard demographics were obtained, and transthoracic echocardiography and routine blood testing were performed shortly after admission. Outcome assessment was based on the all-cause death after admission.

RESULTS

The patients were divided into three groups: non-smokers (n = 593), mild-to-moderate smokers (n = 159) and heavy smokers (n = 366). The all-cause mortality rates showed no differences between the three groups (23.8, 20.8 and 24 %, respectively; log-rank χ (2) = 1.281, P = 0.527). There was also no significant difference in mortality between non-drinkers (n = 747), mild drinkers (n = 142) and moderate drinkers (n = 229) (23.7, 23.2 and 22.3 %, respectively; log-rank χ (2) = 2.343, P = 0.310). In the Cox analysis, neither the smoking (HR 0.971, P = 0.663) nor the drinking status (HR 0.891, P = 0.140) was a significant independent predictor of all-cause mortality in patients with DCM.

CONCLUSION

In conclusion, there were no significant differences in mortality between the smoking- and drinking-related patient groups, indicating no effect of smoking and drinking on all-cause mortality in patients with DCM in the present large-scale study.

Hormesis and homeopathy: The artificial twins

Homeopathy claims a curative reaction from small doses of a substance, high doses of which cause symptoms similar to those the patient is suffering from. Hormesis is a concept of biphasic dose-response to different pharmacological and toxicological agents. According to this concept, a small dose of a noxious agent can exert a beneficial action. A hypothesis is defended here that hormesis as a general principle can be assumed only for the factors present in the natural environment thus having induced adaptation of living organisms. Generalizations of the hormesis phenomenon used in support of homeopathy are unfounded. Low-dose impacts may be associated with a higher risk in a state of organ sub-compensation or failure especially in the elderly patients. Practical recommendations should be based neither on the hormesis as a default approach nor on the postulates of homeopathy. All clinically relevant effects, hormetic or not, should be tested by the methods of evidence-based medicine.

Molecular studies on coronary artery disease-a review

Coronary artery disease (CAD) remains the major cause of mortality and morbidity in the entire world population. The conventional risk factors of CAD include hypertension, hyperlipidemia, diabetes mellitus, family history, smoking etc. These factors contribute only 50 % of the total risk of CAD. For providing a complete risk assessment in CAD, it is mandatory to have well-planned clinical, biochemical and genetic studies in patients with CAD and subjects who are at risk of developing CAD. In this review an attempt is made to critically evaluate the conventional and emerging risk factors which predispose the individual to CAD. Specifically, the molecular basis of CAD including high oxidative stress, low antioxidant status and increased DNA damage are covered. A comprehensive and multifactorial approach to the problem is the better way to reduce the morbidity and mortality of the disease.

Association between alcohol consumption and symptom severity and quality of life in patients with fibromyalgia

Introduction

Although alcohol consumption is a common lifestyle behavior with previous studies reporting positive effects of alcohol on chronic pain and rheumatoid arthritis, no studies to this date have examined alcohol consumption in patients with fibromyalgia. We examined the association between alcohol consumption and symptom severity and quality of life (QOL) in patients with fibromyalgia.

Methods

Data on self-reported alcohol consumption from 946 patients were analyzed. Subjects were grouped by level of alcohol consumption (number of drinks/week): none, low (≤3), moderate (>3 to 7), and heavy (>7).

Univariate analyses were used to find potential confounders, and analysis of covariance was used to adjust for these confounders. Tukey HSD pairwise comparisons were used to determine differences between alcohol groups.

Results

Five hundred and forty-six subjects (58%) did not consume alcohol. Low, moderate, and heavy levels of alcohol consumption were reported for 338 (36%), 31 (3%), and 31 patients (3%), respectively. Employment status (P <0.001), education level (P = 0.009), body mass index (P = 0.002) and opioid use (P = 0.002) differed significantly among groups with drinkers having higher education, a lower BMI, and a lower frequency of unemployment and opioid use than nondrinkers. After adjusting for these differences, the measures including the number of tender points (P = 0.01), FIQ total score (P = 0.01), physical function (P <0.001), work missed (P = 0.005), job ability (P = 0.03), and pain (P = 0.001) differed across groups, as did the SF-36 subscales of physical functioning (P <0.001), pain index (P = 0.002), general health perception (P = 0.02), social functioning (P = 0.02), and the physical component summary (P <0.001). Pairwise comparison among the 4 groups showed that the moderate and low alcohol drinkers had lower severity of fibromyalgia symptoms and better physical QOL than nondrinkers.

Conclusions

Our study demonstrates that low and moderate alcohol consumption was associated with lower fibromyalgia symptoms and better QOL compared to no alcohol consumption. The reasons for these results are unclear. Since recent studies have demonstrated that γ-Aminobutyric Acid (GABA) levels are low in fibromyalgia, and alcohol is known to be a GABA-agonist, future studies should examine whether alcohol could have a salutary effect on pain and other symptoms in fibromyalgia.

Effects of wine, alcohol and polyphenols on cardiovascular disease risk factors: evidences from human studies

AIMS

The aim of this review was to focus on the knowledge of the cardiovascular benefits of moderate alcohol consumption, as well as to analyze the effects of the different types of alcoholic beverages.

METHODS

Systematic revision of human clinical studies and meta-analyses related to moderate alcohol consumption and cardiovascular disease (CVD) from 2000 to 2012.

RESULTS

Heavy or binge alcohol consumption unquestionably leads to increased morbidity and mortality. Nevertheless, moderate alcohol consumption, especially alcoholic beverages rich in polyphenols, such as wine and beer, seems to confer cardiovascular protective effects in patients with documented CVD and even in healthy subjects.

CONCLUSIONS

In conclusion, wine and beer (but especially red wine) seem to confer greater cardiovascular protection than spirits because of their polyphenolic content. However, caution should be taken when making recommendations related to alcohol consumption.

Effects of red wine and vodka on collateral-dependent perfusion and cardiovascular function in hypercholesterolemic swine

BACKGROUND

Moderate consumption of alcohol, particularly red wine, has been shown to decrease cardiac risk. We used a hypercholesterolemic swine model of chronic ischemia to examine the effects of 2 alcoholic beverages on the heart.

METHODS AND RESULTS

Yorkshire swine fed a high-cholesterol diet underwent left circumflex ameroid constrictor placement to induce chronic ischemia at 8 weeks of age. One group (HCC, n=9) continued on the diet alone, the second (HCW, n=8) was supplemented with red wine (pinot noir, 12.5% alcohol, 375 mL daily), and the third (HCV, n=9) was supplemented with vodka (40% alcohol, 112 mL daily). After 7 weeks, cardiac function was measured, and ischemic myocardium was harvested for analysis of perfusion, myocardial fibrosis, vessel function, protein expression, oxidative stress, and capillary density. Platelet function was measured by aggregometry. Perfusion to the ischemic territory as measured by microsphere injection was significantly increased in both HCW and HCV compared with HCC at rest, but in only the HCW group under ventricular pacing. Microvessel relaxation response to adenosine 5'-diphosphate was improved in the HCW group alone as was regional contractility in the ischemic territory, although myocardial fibrosis was decreased in both HCW and HCV. Expression of proangiogenic proteins phospho-endothelial nitric oxide synthase and vascular endothelial growth factor was increased in both HCW and HCV, whereas phospho-mammalian target of rapamycin was increased only in the HCV group. Expression of Sirt-1 and downstream antioxidant phospho-FoxO1 was increased only in the HCW group. Protein oxidative stress was decreased in the HCW group alone, whereas capillary density was increased only in the HCV group. There was no significant difference in platelet function between groups.

CONCLUSION

Moderate consumption of red wine and vodka may reduce cardiovascular risk by improving collateral-dependent perfusion through different mechanisms. Red wine may offer increased cardioprotection related to its antioxidant properties.

Resveratrol

Resveratrol is a polyphenolic compound found in many products commonly consumed in the American diet. The reported benefits of resveratrol are broad and include antiaging effects, antioxidant effects, anticancer effects, neuroprotective effects, and an array of cardiovascular benefits such as improved cholesterol profiles, reduced atherosclerosis, improved glucose homeostasis, decreased blood pressure, and reduced ischemia– reperfusion injury. The current article discusses the literature relating the dosing, safety, and effectiveness of resveratrol for extended life span and improved cardiovascular health. Additionally, recommendations for use in clinical practice are discussed.

Moderate ethanol ingestion and cardiovascular protection: from epidemiologic associations to cellular mechanisms

While ethanol intake at high levels (3-4 or more drinks), either in acute (occasional binge drinking) or chronic (daily) settings, increases the risk for myocardial infarction and stroke, an inverse relationship between regular consumption of alcoholic beverages at light to moderate levels (1-2 drinks per day) and cardiovascular risk has been consistently noted in a large number of epidemiologic studies. Although initially attributed to polyphenolic antioxidants in red wine, subsequent work has established that the ethanol component contributes to the beneficial effects associated with moderate intake of alcoholic beverages regardless of type (red versus white wine, beer, spirits). Concerns have been raised with regard to interpretation of epidemiologic evidence for this association including heterogeneity of the reference groups examined in many studies, different lifestyles of moderate drinkers versus abstainers, and favorable risk profiles in moderate drinkers. However, better controlled epidemiologic studies and especially work conducted in animal models and cell culture systems have substantiated this association and clearly established a cause and effect relationship between alcohol consumption and reductions in tissue injury induced by ischemia/reperfusion (I/R), respectively. The aims of this review are to summarize the epidemiologic evidence supporting the effectiveness of ethanol ingestion in reducing the likelihood of adverse cardiovascular events such as myocardial infarction and ischemic stroke, even in patients with co-existing risk factors, to discuss the ideal quantities, drinking patterns, and types of alcoholic beverages that confer protective effects in the cardiovascular system, and to review the findings of recent experimental studies directed at uncovering the mechanisms that underlie the cardiovascular protective effects of antecedent ethanol ingestion. Mechanistic interrogation of the signaling pathways invoked by antecedent ethanol ingestion may point the way towards development of new therapeutic approaches that mimic the powerful protective effects of socially relevant alcohol intake to limit I/R injury, but minimize the negative psychosocial impact and pathologic outcomes that also accompany consumption of ethanol.

Alcohol and the heart

Alcohol consumption and disease or mortality display a J-shaped curve, with moderate amounts of alcohol being more protective than abstention, binge drinking, or heavy drinking. Red wine appears to be particularly protective for cardiovascular disease and associated conditions such as type 2 diabetes. There are, however, controversies concerning the effect of red wine on hypertension, in which there may be significant gender and ethnic differences. Overall, it seems that both ethanol and the polyphenols in red wine may contribute to the protective effect.

The protective effect of the Mediterranean diet: focus on cancer and cardiovascular risk

The lower occurrence of cancer and cardiovascular disease in the population around the Mediterranean basin has been linked to the dietary habits of the region. Indeed, this so-called Mediterranean diet is essentially different from the diets consumed in Western and Northern European countries and is rich in nuts, fruits, vegetables, legumes, whole-wheat bread, fish, and olive oil, with moderate amounts of red wine, which is mainly consumed during meals. Although a variety of cultural and religious traditions exist among the peoples of the Mediterranean area, olive oil, fish, and red wine hold a traditional and central position in the culinary routines of the region. The components of the diet contain an ample source of molecules with antioxidant and anti-inflammatory actions, among which omega-3 fatty acids, oleic acid, and phenolic compounds hold a prominent place. This review will summarize the results of important epidemiological studies that have investigated the protective effect of fish and olive oil on the risk of breast, prostate, and colorectal cancer and of wine on the risk of cardiovascular disease. The present review also aims to elucidate the various mechanisms by which various dietary components exhibit their beneficial action. In this respect, emphasis will be placed on the properties of omega-3 fatty acids from fish, oleic acid from olive oil, and phenolic compounds from olive oil and red wine.

Substance use and women's health

Scientific findings show that substance abuse in women yields a higher risk of a variety of health problems than substance abuse in men. Research suggests that women experience addiction telescoping when they abuse alcohol, tobacco, specific stimulants, and possibly opioids. Medical side effects also develop more rapidly in women than men when they abuse many substances. Cancer and cardiac complications, specifically, pose a significant threat for women who abuse almost all types of substances. However, the physical consequences are not the only ones women suffer when they engage in substance abuse. Research on substance abuse in women ties opioids to mood and anxiety disorders, heroin to neurological deficiencies, cocaine to immune system suppression, and alcohol to intimate partner abuse. Additionally, female substance abusers, on average, have a lower level of education and lower rates of employment. In light of these gender-specific concerns, physicians should give particular consideration to detecting substance abuse in women.

Flavonoids and age-related disease: risk, benefits and critical windows

Plant derived products are consumed by a large percentage of the population to prevent, delay and ameliorate disease burden; however, relatively little is known about the efficacy, safety and underlying mechanisms of these traditional health products, especially when taken in concert with pharmaceutical agents. The flavonoids are a group of plant metabolites that are common in the diet and appear to provide some health benefits. While flavonoids are primarily derived from soy, many are found in fruits, nuts and more exotic sources, e.g., kudzu. Perhaps the strongest evidence for the benefits of flavonoids in diseases of aging relates to their effect on components of the metabolic syndrome. Flavonoids from soy, grape seed, kudzu and other sources all lower arterial pressure in hypertensive animal models and in a limited number of tests in humans. They also decrease the plasma concentration of lipids and buffer plasma glucose. The underlying mechanisms appear to include antioxidant actions, central nervous system effects, gut transport alterations, fatty acid sequestration and processing, PPAR activation and increases in insulin sensitivity. In animal models of disease, dietary flavonoids also demonstrate a protective effect against cognitive decline, cancer and metabolic disease. However, research also indicates that the flavonoids can be detrimental in some settings and, therefore, are not universally safe. Thus, as the population ages, it is important to determine the impact of these agents on prevention/attenuation of disease, including optimal exposure (intake, timing/duration) and potential contraindications.

Characterization of a novel class of polyphenolic inhibitors of plasminogen activator inhibitor-1

Plasminogen activator inhibitor type 1, (PAI-1) the primary inhibitor of the tissue-type (tPA) and urokinase-type (uPA) plasminogen activators, has been implicated in a wide range of pathological processes, making it an attractive target for pharmacologic inhibition. Currently available small-molecule inhibitors of PAI-1 bind with relatively low affinity and do not inactivate PAI-1 in the presence of its cofactor, vitronectin. To search for novel PAI-1 inhibitors with improved potencies and new mechanisms of action, we screened a library selected to provide a range of biological activities and structural diversity. Five potential PAI-1 inhibitors were identified, and all were polyphenolic compounds including two related, naturally occurring plant polyphenols that were structurally similar to compounds previously shown to provide cardiovascular benefit in vivo. Unique second generation compounds were synthesized and characterized, and several showed IC(50) values for PAI-1 between 10 and 200 nm. This represents an enhanced potency of 10-1000-fold over previously reported PAI-1 inactivators. Inhibition of PAI-1 by these compounds was reversible, and their primary mechanism of action was to block the initial association of PAI-1 with a protease. Consistent with this mechanism and in contrast to previously described PAI-1 inactivators, these compounds inactivate PAI-1 in the presence of vitronectin. Two of the compounds showed efficacy in ex vivo plasma and one blocked PAI-1 activity in vivo in mice. These data describe a novel family of high affinity PAI-1-inactivating compounds with improved characteristics and in vivo efficacy, and suggest that the known cardiovascular benefits of dietary polyphenols may derive in part from their inactivation of PAI-1.

Alcohol consumption and cardiovascular risk: mechanisms of action and epidemiologic perspectives

An inverse association between moderate alcohol intake and cardiovascular risk, in particular coronary disease and ischemic stroke, has been demonstrated in many epidemiologic studies. In addition, several not primarily vascular diseases are also known to occur less frequently in moderate drinkers than in nondrinkers, whereas excess drinking is unquestionably harmful. As a consequence, strong concern exists on the possibility that at any dosage the benefit of alcohol could overcome its harmful effects. Alcohol affects several biochemical factors that have potential cardioprotective benefits, including lipids, platelet aggregation, fibrinogen, tissue-plasminogen activator, plasminogen-activator inhibitor and omega-3 fatty acids. Wine possibly acts through mechanisms that might provide additional cardiovascular benefits. Mechanisms supporting the protective effect of moderate alcohol intake against cardiovascular disease, and epidemiologic evidence concerning the relationship between alcohol dosing and vascular and all-cause mortality are discussed in this review.

Measuring gambling participation

There are many parallels between research on gambling and research on alcohol use, but a striking difference is the emphasis in the former area on problem gambling rather than the use of participation measures. We outline five topics that are underdeveloped as a consequence: (i) gambling participation and future problems; (ii) moderate gambling; (iii) separate measurement of exposures and harms; (iv) predictors of participation; and (v) natural history of participation. Challenges to the future development of gambling participation measures are discussed by reference to comparable difficulties in the field of alcohol use and some examples are given as to how progress could be made. Further development of measures will necessarily occur in the context of broader scientific aims. Some recent studies are highlighted that provide hope of gains in this area. We urge further progress to yield conceptually and operationally distinct indices of exposures and harms.