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Alahmad B, Khraishah H, Kamineni M, Royé D, Papatheodorou SI, Maria Vicedo-Cabrera A, Guo Y, Lavigne E, Armstrong B, Sera F, Bernstein AS, Zanobetti A, Garshick E, Schwartz J, Bell ML, Al-Mulla F, Koutrakis P, Gasparrini A. Extreme Temperatures and Stroke Mortality: Evidence From a Multi-Country Analysis. Stroke 2024; 55:1847-1856. [PMID: 38776169 PMCID: PMC11196199 DOI: 10.1161/strokeaha.123.045751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 04/09/2024] [Indexed: 05/24/2024]
Abstract
BACKGROUND Extreme temperatures contribute significantly to global mortality. While previous studies on temperature and stroke-specific outcomes presented conflicting results, these studies were predominantly limited to single-city or single-country analyses. Their findings are difficult to synthesize due to variations in methodologies and exposure definitions. METHODS Within the Multi-Country Multi-City Network, we built a new mortality database for ischemic and hemorrhagic stroke. Applying a unified analysis protocol, we conducted a multinational case-crossover study on the relationship between extreme temperatures and stroke. In the first stage, we fitted a conditional quasi-Poisson regression for daily mortality counts with distributed lag nonlinear models for temperature exposure separately for each city. In the second stage, the cumulative risk from each city was pooled using mixed-effect meta-analyses, accounting for clustering of cities with similar features. We compared temperature-stroke associations across country-level gross domestic product per capita. We computed excess deaths in each city that are attributable to the 2.5% hottest and coldest of days based on each city's temperature distribution. RESULTS We collected data for a total of 3 443 969 ischemic strokes and 2 454 267 hemorrhagic stroke deaths from 522 cities in 25 countries. For every 1000 ischemic stroke deaths, we found that extreme cold and hot days contributed 9.1 (95% empirical CI, 8.6-9.4) and 2.2 (95% empirical CI, 1.9-2.4) excess deaths, respectively. For every 1000 hemorrhagic stroke deaths, extreme cold and hot days contributed 11.2 (95% empirical CI, 10.9-11.4) and 0.7 (95% empirical CI, 0.5-0.8) excess deaths, respectively. We found that countries with low gross domestic product per capita were at higher risk of heat-related hemorrhagic stroke mortality than countries with high gross domestic product per capita (P=0.02). CONCLUSIONS Both extreme cold and hot temperatures are associated with an increased risk of dying from ischemic and hemorrhagic strokes. As climate change continues to exacerbate these extreme temperatures, interventional strategies are needed to mitigate impacts on stroke mortality, particularly in low-income countries.
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Affiliation(s)
- Barrak Alahmad
- Environmental Health Department, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Haitham Khraishah
- Cardiology Division, University of Maryland Medical Center, University of Maryland, Baltimore, MD, USA
| | | | - Dominic Royé
- Climate Research Foundation, Madrid, Spain
- CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | | | - Ana Maria Vicedo-Cabrera
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Oeschger Center for Climate Change Research, University of Bern, Bern, Switzerland
| | - Yuming Guo
- Climate, Air Quality Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Eric Lavigne
- School of Epidemiology & Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Canada
- Environmental Health Science and Research Bureau, Health Canada, Ottawa, Canada
| | - Ben Armstrong
- Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Francesco Sera
- Department of Statistics, Computer Science and Applications G. Parenti, University of Florence, Florence, Italy
| | - Aaron S Bernstein
- Environmental Health Department, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Antonella Zanobetti
- Environmental Health Department, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Eric Garshick
- Pulmonary, Allergy, Sleep and Critical Care Medicine Section, Department of Medicine, Veterans Affairs Boston Healthcare System, West Roxbury, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Joel Schwartz
- Environmental Health Department, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Michelle L Bell
- School of the Environment, Yale University, New Haven, CT, USA
| | | | - Petros Koutrakis
- Environmental Health Department, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Antonio Gasparrini
- Environment & Health Modelling (EHM) Lab, Department of Public Health Environments and Society, London School of Hygiene & Tropical Medicine, London, UK
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Planas AM. Role of microglia in stroke. Glia 2024; 72:1016-1053. [PMID: 38173414 DOI: 10.1002/glia.24501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/07/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024]
Abstract
Microglia play key roles in the post-ischemic inflammatory response and damaged tissue removal reacting rapidly to the disturbances caused by ischemia and working to restore the lost homeostasis. However, the modified environment, encompassing ionic imbalances, disruption of crucial neuron-microglia interactions, spreading depolarization, and generation of danger signals from necrotic neurons, induce morphological and phenotypic shifts in microglia. This leads them to adopt a proinflammatory profile and heighten their phagocytic activity. From day three post-ischemia, macrophages infiltrate the necrotic core while microglia amass at the periphery. Further, inflammation prompts a metabolic shift favoring glycolysis, the pentose-phosphate shunt, and lipid synthesis. These shifts, combined with phagocytic lipid intake, drive lipid droplet biogenesis, fuel anabolism, and enable microglia proliferation. Proliferating microglia release trophic factors contributing to protection and repair. However, some microglia accumulate lipids persistently and transform into dysfunctional and potentially harmful foam cells. Studies also showed microglia that either display impaired apoptotic cell clearance, or eliminate synapses, viable neurons, or endothelial cells. Yet, it will be essential to elucidate the viability of engulfed cells, the features of the local environment, the extent of tissue damage, and the temporal sequence. Ischemia provides a rich variety of region- and injury-dependent stimuli for microglia, evolving with time and generating distinct microglia phenotypes including those exhibiting proinflammatory or dysfunctional traits and others showing pro-repair features. Accurate profiling of microglia phenotypes, alongside with a more precise understanding of the associated post-ischemic tissue conditions, is a necessary step to serve as the potential foundation for focused interventions in human stroke.
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Affiliation(s)
- Anna M Planas
- Cerebrovascular Research Laboratory, Department of Neuroscience and Experimental Therapeutics, Instituto de Investigaciones Biomédicas de Barcelona (IIBB), Consejo Superior de Investigaciones Científicas (CSIC), Barcelona, Spain
- Cerebrovascular Diseases, Area of Clinical and Experimental Neuroscience, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)-Hospital Clínic, Barcelona, Spain
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Sun J, Halfvarson J, Appelros P, Bergman D, Ebrahimi F, Roelstraete B, Olén O, Ludvigsson JF. Long-term Risk of Stroke in Patients With Inflammatory Bowel Disease: A Population-Based, Sibling-Controlled Cohort Study, 1969-2019. Neurology 2023; 101:e653-e664. [PMID: 37316347 PMCID: PMC10424828 DOI: 10.1212/wnl.0000000000207480] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 04/18/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with inflammatory bowel disease (IBD) are at an increased risk of thromboembolic events, but evidence on the long-term risk of stroke remains scarce. We aimed to explore whether patients with a biopsy-confirmed IBD had an increased long-term risk of stroke. METHODS This cohort included all patients with biopsy-confirmed IBD in Sweden between 1969 and 2019 and up to 5 matched reference individuals per patient who were randomly selected from the general population and IBD-free full siblings. The primary outcome was incident overall stroke; secondary outcomes were ischemic and hemorrhagic strokes. Stroke was identified from the Swedish National Patient Register by using both primary and secondary diagnoses. Adjusted hazard ratios (aHRs) for stroke were estimated by flexible parametric survival models. RESULTS A total of 85,006 patients with IBD (including Crohn disease [CD, n = 25,257], ulcerative colitis [UC, n = 47,354], and IBD-unclassified [IBD-U, n = 12,395]), 406,987 matched reference individuals, and 101,082 IBD-free full siblings were included in the analysis. We observed 3,720 incident strokes in patients with IBD (incidence rate [IR] 32.6 per 10,000 person-years) and 15,599 in reference individuals (IR 27.7; aHR 1.13, 95% CI 1.08-1.17). The elevated aHR remained increased even 25 years after diagnosis, corresponding to 1 additional stroke case per 93 patients with IBD until then. The excess aHR was mainly driven by ischemic stroke (aHR 1.14; 1.09-1.18) rather than hemorrhagic stroke (aHR 1.06; 0.97-1.15). The risk of ischemic stroke was significantly increased across IBD subtypes (CD [IR 23.3 vs 19.2; aHR 1.19; 1.10-1.29], UC [IR 25.7 vs 22.6; aHR 1.09; 1.04-1.16], and IBD-U [IR 30.5 vs 22.8; aHR 1.22; 1.08-1.37]). Similar results were found when patients with IBD were compared with their siblings. DISCUSSION Patients with IBD were at an increased risk of stroke, especially of ischemic events, irrespective of the IBD subtype. The excess risk persisted even 25 years after diagnosis. These findings highlight the need for clinical vigilance about the long-term excess risk of cerebrovascular events in patients with IBD.
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Affiliation(s)
- Jiangwei Sun
- From the Department of Medical Epidemiology and Biostatistics (J.S., D.B., F.E., B.R., J.F.L.), Karolinska Institutet, Stockholm; Department of Gastroenterology (J.H.), and University Health Care Research Center (P.A.), Faculty of Medicine and Health, Örebro University, Sweden; Department of Gastroenterology and Hepatology (F.E.), Clarunis University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland; Clinical Epidemiology Division (O.O.), Department of Medicine Solna, Karolinska Institutet, Stockholm; Sachs' Children and Youth Hospital (O.O.), Stockholm South General Hospital; Department of Clinical Science and Education Södersjukhuset (O.O.), Karolinska Institutet, Stockholm; Department of Pediatrics (J.F.L.), Örebro University Hospital, Sweden; and Division of Digestive and Liver Disease (J.F.L.), Department of Medicine, Columbia University Medical Center, New York, NY.
| | - Jonas Halfvarson
- From the Department of Medical Epidemiology and Biostatistics (J.S., D.B., F.E., B.R., J.F.L.), Karolinska Institutet, Stockholm; Department of Gastroenterology (J.H.), and University Health Care Research Center (P.A.), Faculty of Medicine and Health, Örebro University, Sweden; Department of Gastroenterology and Hepatology (F.E.), Clarunis University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland; Clinical Epidemiology Division (O.O.), Department of Medicine Solna, Karolinska Institutet, Stockholm; Sachs' Children and Youth Hospital (O.O.), Stockholm South General Hospital; Department of Clinical Science and Education Södersjukhuset (O.O.), Karolinska Institutet, Stockholm; Department of Pediatrics (J.F.L.), Örebro University Hospital, Sweden; and Division of Digestive and Liver Disease (J.F.L.), Department of Medicine, Columbia University Medical Center, New York, NY
| | - Peter Appelros
- From the Department of Medical Epidemiology and Biostatistics (J.S., D.B., F.E., B.R., J.F.L.), Karolinska Institutet, Stockholm; Department of Gastroenterology (J.H.), and University Health Care Research Center (P.A.), Faculty of Medicine and Health, Örebro University, Sweden; Department of Gastroenterology and Hepatology (F.E.), Clarunis University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland; Clinical Epidemiology Division (O.O.), Department of Medicine Solna, Karolinska Institutet, Stockholm; Sachs' Children and Youth Hospital (O.O.), Stockholm South General Hospital; Department of Clinical Science and Education Södersjukhuset (O.O.), Karolinska Institutet, Stockholm; Department of Pediatrics (J.F.L.), Örebro University Hospital, Sweden; and Division of Digestive and Liver Disease (J.F.L.), Department of Medicine, Columbia University Medical Center, New York, NY
| | - David Bergman
- From the Department of Medical Epidemiology and Biostatistics (J.S., D.B., F.E., B.R., J.F.L.), Karolinska Institutet, Stockholm; Department of Gastroenterology (J.H.), and University Health Care Research Center (P.A.), Faculty of Medicine and Health, Örebro University, Sweden; Department of Gastroenterology and Hepatology (F.E.), Clarunis University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland; Clinical Epidemiology Division (O.O.), Department of Medicine Solna, Karolinska Institutet, Stockholm; Sachs' Children and Youth Hospital (O.O.), Stockholm South General Hospital; Department of Clinical Science and Education Södersjukhuset (O.O.), Karolinska Institutet, Stockholm; Department of Pediatrics (J.F.L.), Örebro University Hospital, Sweden; and Division of Digestive and Liver Disease (J.F.L.), Department of Medicine, Columbia University Medical Center, New York, NY
| | - Fahim Ebrahimi
- From the Department of Medical Epidemiology and Biostatistics (J.S., D.B., F.E., B.R., J.F.L.), Karolinska Institutet, Stockholm; Department of Gastroenterology (J.H.), and University Health Care Research Center (P.A.), Faculty of Medicine and Health, Örebro University, Sweden; Department of Gastroenterology and Hepatology (F.E.), Clarunis University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland; Clinical Epidemiology Division (O.O.), Department of Medicine Solna, Karolinska Institutet, Stockholm; Sachs' Children and Youth Hospital (O.O.), Stockholm South General Hospital; Department of Clinical Science and Education Södersjukhuset (O.O.), Karolinska Institutet, Stockholm; Department of Pediatrics (J.F.L.), Örebro University Hospital, Sweden; and Division of Digestive and Liver Disease (J.F.L.), Department of Medicine, Columbia University Medical Center, New York, NY
| | - Bjorn Roelstraete
- From the Department of Medical Epidemiology and Biostatistics (J.S., D.B., F.E., B.R., J.F.L.), Karolinska Institutet, Stockholm; Department of Gastroenterology (J.H.), and University Health Care Research Center (P.A.), Faculty of Medicine and Health, Örebro University, Sweden; Department of Gastroenterology and Hepatology (F.E.), Clarunis University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland; Clinical Epidemiology Division (O.O.), Department of Medicine Solna, Karolinska Institutet, Stockholm; Sachs' Children and Youth Hospital (O.O.), Stockholm South General Hospital; Department of Clinical Science and Education Södersjukhuset (O.O.), Karolinska Institutet, Stockholm; Department of Pediatrics (J.F.L.), Örebro University Hospital, Sweden; and Division of Digestive and Liver Disease (J.F.L.), Department of Medicine, Columbia University Medical Center, New York, NY
| | - Ola Olén
- From the Department of Medical Epidemiology and Biostatistics (J.S., D.B., F.E., B.R., J.F.L.), Karolinska Institutet, Stockholm; Department of Gastroenterology (J.H.), and University Health Care Research Center (P.A.), Faculty of Medicine and Health, Örebro University, Sweden; Department of Gastroenterology and Hepatology (F.E.), Clarunis University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland; Clinical Epidemiology Division (O.O.), Department of Medicine Solna, Karolinska Institutet, Stockholm; Sachs' Children and Youth Hospital (O.O.), Stockholm South General Hospital; Department of Clinical Science and Education Södersjukhuset (O.O.), Karolinska Institutet, Stockholm; Department of Pediatrics (J.F.L.), Örebro University Hospital, Sweden; and Division of Digestive and Liver Disease (J.F.L.), Department of Medicine, Columbia University Medical Center, New York, NY
| | - Jonas F Ludvigsson
- From the Department of Medical Epidemiology and Biostatistics (J.S., D.B., F.E., B.R., J.F.L.), Karolinska Institutet, Stockholm; Department of Gastroenterology (J.H.), and University Health Care Research Center (P.A.), Faculty of Medicine and Health, Örebro University, Sweden; Department of Gastroenterology and Hepatology (F.E.), Clarunis University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland; Clinical Epidemiology Division (O.O.), Department of Medicine Solna, Karolinska Institutet, Stockholm; Sachs' Children and Youth Hospital (O.O.), Stockholm South General Hospital; Department of Clinical Science and Education Södersjukhuset (O.O.), Karolinska Institutet, Stockholm; Department of Pediatrics (J.F.L.), Örebro University Hospital, Sweden; and Division of Digestive and Liver Disease (J.F.L.), Department of Medicine, Columbia University Medical Center, New York, NY
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Xie J, Pang C, Yu H, Zhang W, Ren C, Deng B. Leukocyte indicators and variations predict worse outcomes after intravenous thrombolysis in patients with acute ischemic stroke. J Cereb Blood Flow Metab 2023; 43:393-403. [PMID: 36420778 PMCID: PMC9941866 DOI: 10.1177/0271678x221142694] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/14/2022] [Accepted: 10/14/2022] [Indexed: 11/26/2022]
Abstract
Leukocytes are systematic inflammation indicators related to stroke prognosis and can exhibit large dynamic waves before and after recombinant tissue plasminogen activator (r-tPA) therapy. However, additional evidence is needed to determine the prognostic significance of various leukocytes including both static and dynamic data among patients who underwent r-tPA therapy. A total of 251 patients treated with r-tPA were included; their leukocyte data were collected at two time points, and patients were followed up for three months. Analysis revealed the following findings. (i) Patients with hemorrhagic transformation (HT) and unfavorable outcomes had a higher level of leukocytes after r-tPA therapy (leukocyte count (adjusted OR (aOR) 1.191 for HT and 1.184 for unfavorable outcomes), neutrophil count (aOR 1.215 and 1.214), neutrophil-to-lymphocyte ratio (NLR; aOR 1.084 and 1.091)) and larger dynamic leukocyte changes. (ii)Among all leukocytes, the NLR after r-tPA administration demonstrated the strongest correlation with HT and unfavorable outcomes. (iii) Patients with an NLR ≥ 3.322 had a 3.492-fold increased risk for HT, and those with an NLR ≥ 5.511 had a 3.024-fold increased risk for functional outcomes. Overall, this study shows that leukocytes, especially leukocyte count, neutrophil count and the NLR, are independently associated with HT and functional outcomes in stroke patients.
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Affiliation(s)
- Jiali Xie
- Department of Neurology, First Affiliated Hospital of Wenzhou
Medical University, Wenzhou, PR China
- Department of Neurology, Shanghai East Hospital, Tongji
University, Shanghai, PR China
| | - Chunyang Pang
- Department of Neurology, First Affiliated Hospital of Wenzhou
Medical University, Wenzhou, PR China
- First Clinical College of Wenzhou Medical University, Wenzhou,
PR China
| | - Huan Yu
- Department of Pediatrics, Second Affiliated Hospital and Yuying
Children's Hospital of Wenzhou Medical University, Wenzhou, PR China
| | - Wanli Zhang
- Department of Neurology, First Affiliated Hospital of Wenzhou
Medical University, Wenzhou, PR China
| | - Chuancheng Ren
- Department of Neurology, Shanghai East Hospital, Tongji
University, Shanghai, PR China
| | - Binbin Deng
- Department of Neurology, First Affiliated Hospital of Wenzhou
Medical University, Wenzhou, PR China
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