Ethanol Increases Surface-Localized Fibrinolytic Activity in Cultured Endothelial Cells

The impact of ETOH intoxication on the development of admission coagulopathy after traumatic brain injury: a prospective evaluation

INTRODUCTION

Coagulopathy after severe traumatic brain injury (sTBI) results in a ten-fold increased risk of death. Our aim was to investigate the effect of ETOH intoxication on admission coagulopathy after sTBI.

METHODS

Patients with sTBI [Glasgow Coma Scale <9 or evidence of intracranial pathology on computed tomography (CT)] from 1/2010 to 12/2011 were prospectively enrolled. Demographics, clinical characteristics, laboratory values, head CT scan findings, physical examination, injury severity indices, and interventions were recorded. ETOH blood levels were obtained. The incidence of admission coagulopathy was compared between patients who were ETOH-positive (ETOH+) and those who were ETOH-negative (ETOH-). Logistic regression was performed to identify independent risk factors.

RESULTS

A total of 216 patients were enrolled. 20.4 % were ETOH+. Admission coagulopathy was significantly lower for ETOH+ patients (15.9 vs. 39.0 %, adjusted p = 0.020). Prothrombin time (PT) and International Normalized Ratio (INR) on admission were significantly lower for ETOH+ patients (16.7 vs. 14.3, adjusted p = 0.016 and 1.35 vs. 1.13, adjusted p = 0.040, respectively). Injury Severity Score ≥25, hypotension, and loss of gray/white differential were identified as independent risk factors for the development of admission coagulopathy. ETOH intoxication was the only protective predictor [AOR (95 % CI): 0.32 (0.12, 0.84), adjusted p = 0.021].

CONCLUSIONS

ETOH intoxication is associated with a lower incidence of admission coagulopathy in patients with sTBI. Further research is warranted.

Brewing complications: the effect of acute ethanol exposure on wound healing

Ethanol consumption is linked to a higher incidence of traumatic wounds and increases the risk for morbidity and mortality following surgical or traumatic injury. One of the most profound effects of acute ethanol exposure on wound healing occurs during the inflammatory response, and altered cytokine production is a primary component. Acute ethanol exposure also impairs the proliferative response during healing, causing delays in epithelial coverage, collagen synthesis, and blood vessel regrowth. The accumulated data support the paradigm that acute ethanol intoxication prior to injury significantly diminishes a patient's ability to heal efficiently.

Acute ethanol exposure disrupts VEGF receptor cell signaling in endothelial cells

Physiological angiogenesis is regulated by various factors, including signaling through vascular endothelial growth factor (VEGF) receptors. We previously reported that a single dose of ethanol (1.4 g/kg), yielding a blood alcohol concentration of 100 mg/dl, significantly impairs angiogenesis in murine wounds, despite adequate levels of VEGF, suggesting direct effects of ethanol on endothelial cell signaling (40). To examine the mechanism by which ethanol influences angiogenesis in wounds, we employed two different in vitro angiogenesis assays to determine whether acute ethanol exposure (100 mg/dl) would have long-lasting effects on VEGF-induced capillary network formation. Ethanol exposure resulted in reduced VEGF-induced cord formation on collagen and reduced capillary network structure on Matrigel in vitro. In addition, ethanol exposure decreased expression of endothelial VEGF receptor-2, as well as VEGF receptor-2 phosphorylation in vitro. Inhibition of ethanol metabolism by 4-methylpyrazole partially abrogated the effect of ethanol on endothelial cell cord formation. However, mice treated with t-butanol, an alcohol not metabolized by alcohol dehydrogenase, exhibited no change in wound vascularity. These results suggest that products of ethanol metabolism are important factors in the development of ethanol-induced changes in endothelial cell responsiveness to VEGF. In vivo, ethanol exposure caused both decreased angiogenesis and increased hypoxia in wounds. Moreover, in vitro experiments demonstrated a direct effect of ethanol on the response to hypoxia in endothelial cells, as ethanol diminished nuclear hypoxia-inducible factor-1alpha protein levels. Together, the data establish that acute ethanol exposure significantly impairs angiogenesis and suggest that this effect is mediated by changes in endothelial cell responsiveness to both VEGF and hypoxia.

Effects of short-term moderate alcohol administration on oxidative stress and nutritional status in healthy males

The effects of moderate amounts of different alcoholic beverages on oxidative stress and nutritional parameters were investigated in 40 healthy subjects. Ethanol 40 g/day was administered at the two main meals for 30 days by beer (group A), wine (group B) or spirit (group C); controls (group D) maintaned abstinence. Malondyaldeide (MDA), adenosine-triphosphate (ATP), reduced-glutathione (GSH), E-vitamin and nutritional status were evaluated at the start (T0) and the end (T1) of the study. At T1 controls did not present significant changes in the assessed parameters, while a significant increase of malondyaldeide (MDA) and a significant decrease of reduced-glutathione and E-vitamin in group A, B and C and of ATP in group C were observed. Fat mass (FM) increased slightly in group A and B and decreased in group C. Ethanol decreased antioxidant parameters and increased lipoperoxidation parameters. However some of these changes appeared attenuated when ethanol was consumed in beer or wine. Finally, short-term moderate ethanol intake appeared to influence the FM, although it was not able to significantly affect nutritional or body composition.

Mechanism by which Alcohol and Wine Polyphenols Affect Coronary Heart Disease Risk

The reduction in coronary heart disease (CHD) from moderate alcohol intake may be mediated, in part, by increased fibrinolysis; endothelial cell (EC)-mediated fibrinolysis should decrease acute atherothrombotic consequences (eg, plaque rupture) of myocardial infarction (MI). We have shown that alcohol and individual polyphenols modulate EC fibrinolytic protein (t-PA, u-PA, PAI-1, u-PAR and Annexin-II) expression at the cellular, molecular, and gene levels to sustain increased fibrinolytic activity. Herein we describe the sequence of molecular events by which EC t-PA expression is increased through common activation of p38 MAPK signaling. Up-regulation of t-PA gene transcription, through specific alcohol and polyphenol transcription factor binding sites in the t-PA promoter, results in increased in vitro fibrinolysis and in vivo clot lytic activity (using real-time fluorescence [Fl] imaging of Cy5.5-labeled fibrin clot lysis in a mouse model). Fl-labeled fibrin clots injected into untreated C56Bl/6 wild-type control mice are lysed in approximately 2 hours and clot lytic rates significantly increased in mice treated with either alcohol, catechins, or quercetin (4-6 weeks). Fl-labeled clot lysis in ApoE knock-out mice (atherosclerosis model) showed impaired in vivo clot lysis that was "normalized" to wild-type control levels by treatment with alcohol, catechin, or quercetin for 6 to 8 weeks.

Matrix proteolytic activity during wound healing: modulation by acute ethanol exposure

BACKGROUND

Clinical studies demonstrate that intoxicated patients exhibit an increased incidence of wound healing complications. Previous studies in a murine excisional wound model revealed that acute ethanol exposure impairs the wound healing response, causing decreased angiogenesis and a significant reduction in wound collagen content.

METHODS

Using the same murine model of excisional wounding, we examined the effect of a single dose of ethanol on the overall collagen content and collagen type I and type III mRNA expression, transforming growth factor-beta (TGF-beta) production, and levels of several components of the extracellular matrix proteolytic cascade.

RESULTS

Wounds from ethanol-treated mice exhibited a significant decrease in collagen and in the production of collagen type I mRNA compared with saline controls. Exposure to ethanol also caused significant increase in wound TGF-beta by day 2 after injury (1.69 +/- 0.29 vs 12.34 +/- 3.97 pg/microg protein, p<0.01). In addition, wounds from mice exposed to ethanol had significantly increased levels of active urokinase plasminogen activator at day 7, (205.10 +/- 48.79 vs 642.70 +/- 159.80 pg/microg protein, p<0.001). The level of matrix metalloproteinase-8, a collagen type I proteinase, was 2.2-fold higher in wounds of ethanol-treated mice compared with control at day 7 (p<0.05).

CONCLUSIONS

These studies demonstrate that a single dose of ethanol decreases collagen production, increases the production of TGF-beta and increases levels of matrix degrading enzymes. This alteration in protease balance may partially explain the impaired wound healing that follows acute alcohol intoxication.

Effects of ethanol on lipids and atherosclerosis

Moderate alcohol consumption is associated with an increase in plasma high density lipoprotein (HDL) cholesterol concentration and a decrease in low density lipoprotein (LDL) cholesterol concentration. Changes in the concentration and composition of lipoproteins are estimated to account for more than half of alcohol's protective effect for coronary heart disease. Alcohol intake also affects plasma proteins involved in lipoprotein metabolism: cholesteryl ester transfer protein, phospholipid transfer protein, lecithin:cholesterol acyltransferase, lipoprotein lipase, hepatic lipase, and phospholipases. In addition, alcohol intake may result in acetaldehyde modification of apolipoproteins. Furthermore, "abnormal" lipids, phosphatidylethanol and fatty acid ethyl esters are formed in the presence of ethanol and are associated with lipoproteins in plasma. Ethanol and ethanol-induced modifications of lipids may modulate the effects of lipoproteins on the cells in the arterial wall. The molecular mechanisms involved in these processes are complex, requiring further study to better understand the specific effects of ethanol in the pathogenesis of atherosclerosis. This review discusses the effects of ethanol on lipoproteins and lipoprotein metabolism, as well as the novel effects of lipoproteins on vascular wall cells.

IGF-I activity may be a key determinant of stroke risk--a cautionary lesson for vegans

IGF-I acts on vascular endothelium to activate nitric oxide synthase, thereby promoting vascular health; there is reason to believe that this protection is especially crucial to the cerebral vasculature, helping to ward off thrombotic strokes. IGF-I may also promote the structural integrity of cerebral arteries, thereby offering protection from hemorrhagic stroke. These considerations may help to explain why tallness is associated with low stroke risk, whereas growth hormone deficiency increases stroke risk--and why age-adjusted stroke mortality has been exceptionally high in rural Asians eating quasi-vegan diets, but has been declining steadily in Asia as diets have become progressively higher in animal products. There is good reason to suspect that low-fat vegan diets tend to down-regulate systemic IGF-I activity; this effect would be expected to increase stroke risk in vegans. Furthermore, epidemiology suggests that low serum cholesterol, and possibly also a low dietary intake of saturated fat--both characteristic of those adopting low-fat vegan diets--may also increase stroke risk. Vegans are thus well advised to adopt practical countermeasures to minimize stroke risk--the most definitive of which may be salt restriction. A high potassium intake, aerobic exercise training, whole grains, moderate alcohol consumption, low-dose aspirin, statin or policosanol therapy, green tea, and supplementation with fish oil, taurine, arginine, and B vitamins--as well as pharmacotherapy of hypertension if warranted--are other practical measures for lowering stroke risk. Although low-fat vegan diets may markedly reduce risk for coronary disease, diabetes, and many common types of cancer, an increased risk for stroke may represent an 'Achilles heel'. Nonetheless, vegans have the potential to achieve a truly exceptional 'healthspan' if they face this problem forthrightly by restricting salt intake and taking other practical measures that promote cerebrovascular health.

[Moderate alcohol consumption and cardiovascular diseases]

While excessive ethanol consumption can result in higher rate of morbidity and mortality resulting from several diseases including cancer and cirrhosis, epidemiological studies suggest that moderate alcohol ingestion reduces the risk of cardiovascular diseases. However, the precise mechanisms by which moderate alcohol consumption protects against coronary heart disease (CHD) is not fully understood. Epidemiological studies suggest that alcohol consumption influences several risk factors for CHD including blood pressure, plasma cholesterol levels, platelet function, and fibrinolytic parameters, preventing both vascular thrombosis and occlusion. Turning to molecular and cellular levels, ethanol has been shown to act on several signal transduction mechanisms involve in the inhibition of smooth muscle cells proliferation and migration and in the activation of the release of vasoactive factors from vascular cells such as nitric oxide (NO). The latter is of importance since NO has been shown to possess antioxidant, antiaggregant properties, to regulate vascular tone and to inhibit both proliferation of smooth muscle cells and adhesion of leukocytes. Altogether, the above mentioned beneficial properties of moderate concentration of ethanol might help to explain the cardio- and vascular protection induced by ethanol. This review compels several bibliographic data concerning the cardiovascular effect of moderate alcohol consumption.

Alcohol consumption and plasminogen activator inhibitor type 1: the National Heart, Lung, and Blood Institute Family Heart Study

BACKGROUND

Plasminogen activator inhibitor type 1 (PAI-1) plays a key role in fibrinolytic activity, which is important for thrombotic cardiovascular events. It has been suggested that moderate alcohol consumption may protect against coronary heart disease and ischemic stroke. However, little is known about the effects of moderate doses of alcohol on PAI-1.

METHODS AND RESULTS

We assessed the association between different levels of alcohol consumption and PAI-1 among 1862 participants of the National Heart, Lung, and Blood Institute Family Heart Study. We fitted a regression model, adjusting for anthropometric, metabolic, and lifestyle factors. Individuals in the highest alcohol intake category were leaner, had higher high-density lipoprotein cholesterol levels, smoked more cigarettes, and consumed less dietary fiber compared with never-drinkers. For drinking categories of never-drinkers, ex-drinkers, and current drinkers of 0.1 to 1.4, 1.5 to 4.9, 5.0 to 14.9, and > or =15 g/d of alcohol, multivariate adjusted geometric mean PAI-1 levels among women were 10.77, 9.41, 9.99, 11.21, 11.28, and 16.40 ng/mL, respectively. With similar categories except the top category divided into 15.0 to 29.9 and > or =30 g/d, PAI-1 levels among men were 18.43, 15.77, 15.19, 16.20, 17.27, 24.02, and 29.46 ng/mL, respectively.

CONCLUSIONS

These results show that alcohol consumption up to 14.9 g/d is not associated with increased PAI-1, whereas the findings suggest increased PAI-1 with greater alcohol intake.

Ethanol downregulates transcription of the PAI-1 gene in cultured human endothelial cells

Human endothelial cells are a major site of synthesis for plasminogen activator inhibitor type-1. Elevated plasminogen activator inhibitor type-1 levels in young survivors of myocardial infarction [1] suggest that plasminogen activator inhibitor type-1 may have an important pathologic role in the development of coronary artery disease. Epidemiological studies indicate that moderate alcohol consumption (1-2 drinks/day) reduces the risk for cardiovascular mortality. This cardioprotective benefit has been attributed in part to an increase in fibrinolysis, which decreases fibrin-based thrombosis. The studies described herein were performed to determine whether moderate levels of ethanol affect plasminogen activator inhibitor type-1 gene expression. Cultured human endothelial cells were exposed to 0.1% v/v ethanol for 1 hour. Following incubation in the absence of ethanol plasminogen activator inhibitor type-1, mRNA levels were decreased in a time- and dose-dependent manner, reaching a maximum decrease of 3- to 4-fold at 2 to 4 hours following ethanol challenge. This decline in mRNA occurs at the transcription level; therefore, nuclear transcription run-on assays were performed. A 2.5- to 5-fold decrease in the rate of plasminogen activator inhibitor type-1 gene transcription was measured at 2 and 4 hours following ethanol challenge. Next, a 3.4- and a 1.1-kb fragment from the plasminogen activator inhibitor type-1 promoter region were linked to a luciferase reporter gene, and these constructs were transfected into human endothelial cells. Treatment of these transiently transfected human endothelial cells with ethanol showed a 2- to 3.5-fold decrease in promoter activity, respectively. These results indicate that low doses of ethanol downregulate transcription of the plasminogen activator inhibitor type-1 gene in cultured human endothelial cells. However, the mechanism(s) for this transcriptional decrease is currently unknown.

Preoperative alcoholism and postoperative morbidity

BACKGROUND

Preoperative risk assessment has become part of daily clinical practice, but preoperative alcohol abuse has not received much attention.

METHODS

A Medline search was carried out to identify original papers published from 1967 to 1998. Relevant articles on postoperative morbidity in alcohol abusers were used to evaluate the evidence.

RESULTS

Prospective and retrospective studies demonstrate a twofold to threefold increase in postoperative morbidity in alcohol abusers, the most frequent complications being infections, bleeding and cardiopulmonary insufficiency. Wound complications account for about half of the morbidity. The pathogenic mechanisms include preoperative immune incompetence, subclinical cardiac insufficiency and haemostatic imbalance. In addition, surgical trauma and/or postoperative abstinence result in an exaggerated stress response, which may further contribute to postoperative morbidity.

CONCLUSION

Alcohol consumption should be included in the preoperative assessment of likely postoperative outcome. Reduction of postoperative morbidity in alcohol abusers may include preoperative alcohol abstinence to improve organ function, or perioperative alcohol administration to avoid the abstinence response.

Endothelial cell fibrinolysis: transcriptional regulation of fibrinolytic protein gene expression (t-PA, u-PA, and PAI-1) by low alcohol

Epidemiological studies have associated moderate alcohol consumption with a reduced risk for coronary artery disease (CAD) and myocardial infarction (MI). This cardioprotection may be attributed to alcohol-induced changes in a variety of cellular functions, including increased fibrinolysis. Fibrinolysis is important in regulating normal hemostasis. Endothelial cells (ECs) synthesize fibrinolytic proteins, t-PA, u-PA, and PAs inhibitor, PAI-1. Systemic factors, i.e., alcohol, that affect one or more of these components, resulting in increased EC fibrinolysis, will reduce the risk for thrombosis, CAD, and MI and afford cardioprotection. These studies will identify/define the effects of low ethanol (< 0.1%, v/v) on the expression of PAs, PAI-1, and surface-localized fibrinolytic activity in cultured ECs. Low ethanol exerted a short-term time- and dose-dependent increase (approximately 5- to 8-fold) in activity at approximately 20 min and 0.05% ethanol, which was sustained for approximately 1 hr. On the other hand, a single brief exposure to low ethanol (< 0.1%, < 120 min), followed by 4-24 hr incubation in the absence of ethanol, showed a time- and dose-dependent increase (approximately 2- to 3-fold) in PAs antigen/mRNA and a concomitant approximately 2- to 3-fold sustained increase (approximately 24 hr) in fibrinolytic activity. Further nuclear transcription run-on assays and transient transfection experiments, using pPAs/luc and pPAI-1/luc promoter constructs, demonstrated that low ethanol transcriptionally upregulates t-PA and u-PA gene expression and downregulates PAI-1 gene expression. These combined studies have described a feasible molecular mechanism by which low ethanol can induce and sustain increased surface-localized EC fibrinolysis that may underlie and contribute, in part, to the cardioprotective benefit associated with moderate alcohol consumption.

Moderate drinking and cardiovascular health

Moderate alcohol consumption (1-2 drinks a day) can be beneficial in reducing the risk of coronary artery disease. This article focuses on cellular and molecular mechanisms underlying the beneficial effect of moderate drinking, including increased plasma high-density lipoprotein levels, changes in cellular signaling, reduction in platelet function, stimulation of fibrinolysis, and reduction in ischemia-reperfusion injury. While moderate drinking may be protective against coronary artery disease for some individuals, populations such as pregnant women and individuals who are about to operate motor vehicles or heavy machinery should not drink alcoholic beverages. People with family histories of alcoholism should exercise extreme caution in their decision to drink.