Alcohol consumption at midlife and risk of stroke during 43 years of follow-up: cohort and twin analyses

Prevalence and risk factors of stroke in China: a national serial cross-sectional study from 2003 to 2018

Stroke imposes a substantial burden worldwide. With the rapid economic and lifestyle transition in China, trends of the prevalence of stroke across different geographic regions in China remain largely unknown. Capitalizing on the data in the National Health Services Surveys (NHSS), we assessed the prevalence and risk factors of stroke in China from 2003 to 2018. In this study, data from 2003, 2008, 2013, and 2018 NHSS were collected. Stroke cases were based on participants' self-report of a previous diagnosis by clinicians. We estimated the trends of stroke prevalence for the overall population and subgroups by age, sex, and socioeconomic factors, then compared across different geographic regions. We applied multivariable logistic regression to assess associations between stroke and risk factors. The number of participants aged 15 years or older were 154,077, 146,231, 230,067, and 212,318 in 2003, 2008, 2013, and 2018, respectively, among whom, 1435, 1996, 3781, and 6069 were stroke patients. The age and sex standardized prevalence per 100,000 individuals was 879 in 2003, 1100 in 2008, 1098 in 2013, and 1613 in 2018. Prevalence per 100,000 individuals in rural areas increased from 669 in 2003 to 1898 in 2018, while urban areas had a stable trend from 1261 in 2003 to 1365 in 2018. Across geographic regions, the central region consistently had the highest prevalence, but the western region has an alarmingly increasing trend from 623/100,000 in 2003 to 1898/100,000 in 2018 (P trend<0.001), surpassing the eastern region in 2013. Advanced age, male sex, rural area, central region, hypertension, diabetes, depression, low education and income level, retirement or unemployment, excessive physical activity, and unimproved sanitation facilities were significantly associated with stroke. In conclusion, the increasing prevalence of stroke in China was primarily driven by economically underdeveloped regions. It is important to develop targeted prevention programs in underdeveloped regions. Besides traditional risk factors, more attention should be paid to nontraditional risk factors to improve the prevention of stroke.

Elevated Blood Alcohol Concentration Is Associated with Improved Clinical Outcomes of Intravenous Thrombolysis Treatment in Acute Ischemic Stroke Patients—A Retrospective Study

Background: Intravenous thrombolysis (IVT) improves acute ischemic stroke (AIS) outcomes, but with limited success. In addition, ethanol potentiates the effect of r-tPA in ischemia models. Methods: The effect of acute alcohol consumption on IVT outcomes was investigated in a retrospective cohort study. AIS patients with detectable blood alcohol concentration (BAC) during IVT were included (alcohol group; n = 60). For each case, 3 control subjects who underwent IVT but denied alcohol consumption were matched in terms of age, sex, affected brain area, and stroke severity. Outcomes were determined using the NIHSS at 7 days and the modified Rankin scale (mRS) at 90 days. Results: Patients were younger and had a less severe stroke than in a standard stroke study. Favorable long-term outcomes (mRS 0–2) occurred significantly more frequently in the alcohol group compared to controls (90% vs. 63%, p < 0.001). However, the rates of hemorrhagic transformation were similar. Multiple logistic regression models identified elevated BAC as a significant protective factor against unfavorable short-term (OR: 0.091, 95% CI: 0.036–0.227, p < 0.001) and long-term outcomes (OR: 0.187, 95% CI: 0.066–0.535, p = 0.002). In patients with BAC > 0.2%, significantly lower NIHSS was observed at 3 and 7 days after IVT vs. in those with 0.01–0.2% ethanol levels. Conclusion: Elevated BAC is associated with improved outcomes in IVT-treated AIS without affecting safety.

Stroke Risk in Young Women with Primary Dysmenorrhea: A Propensity-Score-Matched Retrospective Cohort Study

BACKGROUND

Studies on strokes associated with dysmenorrhea are limited. We conducted a propensity-score-matched retrospective cohort study to assess the risk of stroke in women with primary dysmenorrhea (PD).

METHODS

From the claims data of one million people in Taiwan's insurance program, we identified 18,783 women aged 15-40 years, newly diagnosed with PD in 2000-2010, without a history of stroke. We randomly selected a comparison cohort without stroke history and dysmenorrhea, with the same sample size matched by age, index date, and propensity score. We began a follow-up with individuals one year after cohort entry to the end of 2013 to capture stroke events.

RESULTS

The two study cohorts were well-matched for age and comorbidities, with 54% of women aged 15-24. Stroke incidence was 1.5-fold higher in the PD cohort than in the comparison cohort (6.05 vs. 4.01 per 10,000 person-years, or 99 vs. 65 cases), with an adjusted hazard ratio (aHR) of 1.51 (95%CI 1.11-2.06) after adjustment for matched pairs. Nearly 70% of strokes were ischemic strokes, which occurred 1.6 times more frequently in the PD cohort than in the comparison cohort (4.40 vs. 2.71 per 10,000 person-years, or 72 vs. 44 cases), aHR = 1.61 (95% CI 1.11-2.33), after adjustment for matched pairs. The incidence of hemorrhagic stroke was also higher in the PD cohort than in the comparison cohort (1.65 vs. 1.29 per 10,000 person-years, or 27 versus 21 cases), but the difference was not significant.

CONCLUSION

Women of reproductive age with PD are at increased risk for ischemic stroke.

Alcohol Use and Blood Pressure Among Older Couples: The Moderating Role of Negative Marital Quality

OBJECTIVES

Spouses often have concordant drinking behaviors and important influences on one another's cardiovascular health. However, little is known about the implications of dyadic drinking patterns for blood pressure, and the marital factors that confer risk or resilience. This article examined links between alcohol use and blood pressure within individuals and opposite-sex couples over time, and whether those links vary by negative marital quality among older adults.

METHODS

Participants were from the nationally representative longitudinal Health and Retirement Study that included 4,619 respondents in 2,682 opposite-sex couples who participated in at least 2 of the waves from 2006 to 2016. Participants reported the number of drinks they typically consume per week, negative marital quality, and had their blood pressure measured via a cuff.

RESULTS

Analyses revealed that greater drinking was associated with increased systolic blood pressure among both husbands and wives. Furthermore, husbands who drank more had higher blood pressure when wives drank more alcohol, whereas there was no association between husbands' drinking and blood pressure when wives drank less alcohol. Interactions with negative marital quality showed that drinking concordance may be associated with increased blood pressure over time in more negative marriages.

DISCUSSION

Findings indicated that spousal drinking concordance, although often associated with positive marital quality, may have negative long-term health effects.

Are there non-linear relationships between alcohol consumption and long-term health?: a systematic review of observational studies employing approaches to improve causal inference

Background

Research has long found ‘J-shaped’ relationships between alcohol consumption and certain health outcomes, indicating a protective effect of moderate consumption. However, methodological limitations in most studies hinder causal inference. This review aimed to identify all observational studies employing improved approaches to mitigate confounding in characterizing alcohol–long-term health relationships, and to qualitatively synthesize their findings.

Methods

Eligible studies met the above description, were longitudinal (with pre-defined exceptions), discretized alcohol consumption, and were conducted with human populations. MEDLINE, PsycINFO, Embase and SCOPUS were searched in May 2020, yielding 16 published manuscripts reporting on cancer, diabetes, dementia, mental health, cardiovascular health, mortality, HIV seroconversion, and musculoskeletal health. Risk of bias of cohort studies was evaluated using the Newcastle-Ottawa Scale, and a recently developed tool was used for Mendelian Randomization studies.

Results

A variety of functional forms were found, including reverse J/J-shaped relationships for prostate cancer and related mortality, dementia risk, mental health, and certain lipids. However, most outcomes were only evaluated by a single study, and few studies provided information on the role of alcohol consumption pattern.

Conclusions

More research employing enhanced causal inference methods is urgently required to accurately characterize alcohol–long-term health relationships. Those studies that have been conducted find a variety of linear and non-linear functional forms, with results tending to be discrepant even within specific health outcomes.

Trial registration

PROSPERO registration number CRD42020185861.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-021-01486-5.

Major epidemiological features of first-ever ischemic stroke in Tuzla Canton, Bosnia and Herzegovina

BACKGROUND AND AIMS

Opacity of data on stroke for Bosnia and Herzegovina (B&H) is mainly due to the lack of a unified national stroke registry. This article aims to present updated epidemiological data on the etiology and risk factors for first-ever ischemic stroke in Tuzla Canton, B&H.

METHODS

This retrospective hospital-based study included all first-ever ischemic stroke patients admitted between January 1, 2018 and December 31, 2018 at the Neurology Department, University Clinical Center Tuzla.

RESULTS

First-ever ischemic stroke was diagnosed in 739 patients. Leading risk factors were hypertension (94%), diabetes mellitus (40.7%), and dyslipidemia (38.8%). The most common stroke subtypes were atherothrombotic (36.8%), cardioembolic (21.9%), and stroke of undetermined etiologies (19.2%). Mean NIHSS score at discharge was 13 (IQR 2-16), and favorable patient outcome (mRs ≤2) was recorded in 26.4% patients. Men (aOR 0.39; 95% CI 0.24-0.64) and younger patients (aOR 0.96; 95% CI 0.93-0.98) had significantly higher probability of having a favorable outcome at discharge. Dyslipidemia could be considered as a predictive factor for patient outcome (aOR 0.66; 95% CI 0.43-1.00).

CONCLUSIONS

More than 92% of our patients had at least one modifiable risk factor, with hypertension and diabetes being at the forefront. One out of four patients had become functionally independent at discharge, while hospital mortality was lower than in other Eastern European countries. The overarching goal should be steered toward the development of a national stroke registry, which should be used as a reference for all further stroke management activities.

The association between psychological distress and risk of incident functional disability in elderly survivors after the Great East Japan Earthquake: The mediating effect of lifestyle and bodily pain

BACKGROUND

We previously reported that psychological distress was associated with an increased risk of functional disability. However, the mechanism of the association remains unclear. Our aim was to estimate the mediating effect of lifestyle and bodily pain on the association among elderly survivors after the Great East Japan Earthquake.

METHODS

The study population comprised 1037 residents aged ≥ 65 years. The baseline surveys (exposure and mediators) were conducted in 2011. We classified participants into three categories according to their Kessler 6 score (low: 0-9, moderate: 10-12, and high: 13-24) and defined functional disability as certification for long-term care insurance in Japan. The Cox proportional hazards model was used to calculate the hazard ratios (HRs) and 95% confidence intervals (CIs) for incident functional disability according to Kessler 6 categories and explored the mediating effects of lifestyle and bodily pain on the association.

RESULTS

During approximately 8 years of follow-up, we documented 271 incident cases of functional disability. Compared with those in the low distress group, the multivariate adjusted HR for incident functional disability was 1.95 (95% CI 1.21-3.13) for those in the high distress group. Time spent walking, going out, and bodily pain significantly mediated the association between psychological distress and incident functional disability by 10.2%, 10.5%, and 10.3% for the high distress group, respectively.

LIMITATIONS

We did not consider unmeasured confounders and use of appropriate medication.

CONCLUSIONS

The evaluation and treatment of bodily pain as well as promotion of active lifestyle would be important for preventing disability among disaster survivors.

ACTB Methylation in Blood as a Potential Marker for the Pre-clinical Detection of Stroke: A Prospective Nested Case-Control Study

Background

Stroke is the second leading cause of death worldwide. If risk of stroke could be evaluated early or even at a preclinical stage, the mortality rate could be reduced dramatically. However, the identified genetic factors only account for 5-10% of the risk of stroke. Studies on the risk factors of stroke are urgently needed. We investigated the correlation between blood-based β-actin (ACTB) methylation and the risk of stroke in a prospective nested case-control study.

Methods

The methylation level of ACTB was quantitatively determined by mass spectrometry in 139 stroke cases who developed stroke within 2 years after recruitment and 147 age- and sex-matched controls who remained stroke-free in a median follow-up of 2.71 years.

Results

We observed a highly significant correlation between hypomethylation of one CpG site of ACTB and increased risk of stroke in an onset-time-dependent manner (for onset time ≤ 1.5 years: odds ratio (OR) per + 10% methylation = 0.76, P = 0.001; for onset time ≤ 1.32 years: OR per + 10% methylation = 0.59, P = 7.82 × 10^-7; for onset time ≤ 1 year: OR per + 10% methylation = 0.43, P = 3.00 × 10^-6), and the increased cumulative incidence of stroke (log-rank P = 3.13 × 10^-7). Neighboring CpG sites showed an inverse correlation with age and drinking status in controls (P < 0.05) but not in stroke cases.

Conclusion

We firstly reported the blood-based ACTB methylation as a marker for the risk evaluation and preclinical detection of stroke, which can be further modified by age and drinking.

Filling the gaps on stroke research: Focus on inflammation and immunity

For the last two decades, researchers have placed hopes in a new era in which a combination of reperfusion and neuroprotection would revolutionize the treatment of stroke. Nevertheless, despite the thousands of papers available in the literature showing positive results in preclinical stroke models, randomized clinical trials have failed to show efficacy. It seems clear now that the existing data obtained in preclinical research have depicted an incomplete picture of stroke pathophysiology. In order to ameliorate bench-to-bed translation, in this review we first describe the main actors on stroke inflammatory and immune responses based on the available preclinical data, highlighting the fact that the link between leukocyte infiltration, lesion volume and neurological outcome remains unclear. We then describe what is known on neuroinflammation and immune responses in stroke patients, and summarize the results of the clinical trials on immunomodulatory drugs. In order to understand the gap between clinical trials and preclinical results on stroke, we discuss in detail the experimental results that served as the basis for the summarized clinical trials on immunomodulatory drugs, focusing on (i) experimental stroke models, (ii) the timing and selection of outcome measuring, (iii) alternative entry routes for leukocytes into the ischemic region, and (iv) factors affecting stroke outcome such as gender differences, ageing, comorbidities like hypertension and diabetes, obesity, tobacco, alcohol consumption and previous infections like Covid-19. We can do better for stroke treatment, especially when targeting inflammation following stroke. We need to re-think the design of stroke experimental setups, notably by (i) using clinically relevant models of stroke, (ii) including both radiological and neurological outcomes, (iii) performing long-term follow-up studies, (iv) conducting large-scale preclinical stroke trials, and (v) including stroke comorbidities in preclinical research.

The efficacy and safety of Hirudin plus Aspirin versus Warfarin in the secondary prevention of Cardioembolic Stroke due to Nonvalvular Atrial Fibrillation: A multicenter prospective cohort study

Background: To investigate the efficacy and safety of hirudin plus aspirin therapy compared with warfarin in the secondary prevention of cardioembolic stroke due to nonvalvular atrial fibrillation (NVAF). Methods: Patients with cardioembolic stroke due to NVAF were prospectively enrolled from 18 collaborating hospitals from Dec 2011 to June 2015. Fourteen days after stroke onset, eligible patients were assigned to the hirudin plus aspirin group (natural hirudin prescribed as the traditional Chinese medicine Maixuekang capsule, 0.75 g, three times daily, combined with aspirin 100 mg, once daily) or the warfarin group (dose-adjusted warfarin targeting international normalized ratio (INR) 2-3, with an initial daily dose of 1.25 mg). Patients were followed up at 1, 2, 3, 6, 9, and 12 months after stroke onset. Time in therapeutic range (TTR) was calculated according to Rosendaal methodology to evaluate the quality of INR management in the warfarin group. The primary efficacy endpoint was the recurrence of stroke within 12 months after stroke onset. Safety was assessed as the occurrence of the composite event "intracranial hemorrhage and other bleeding events, death, and other serious adverse events". The Cox proportional hazard model and Kaplan-Meier curve were used to analyze the efficacy and safety events. Results: A total of 221 patients entered final analysis with 112 patients in the hirudin plus aspirin group and 109 in the warfarin group. Over the whole duration of our study, TTR for patients taking warfarin was 66.5 % ± 21.5%. A significant difference was not observed in the recurrence of stroke between the two groups (3.57% vs. 2.75%; P = 0.728). The occurrence of safety events was significantly lower in the hirudin plus aspirin group (2.68% vs.10.09%; P = 0.024). The risk for efficacy event was similar between the two groups (hazard ratio (HR), 1.30; 95% confidence interval (CI), 0.29-5.80). The safety risk was significantly lower in the hirudin plus aspirin group (HR, 0.27; 95% CI, 0.07-0.95). Kaplan-Meier analysis revealed significant difference in the temporal distribution in safety events (P = 0.023) but not in stroke recurrence (P = 0.726). Conclusion: Significant difference in efficacy was not detected between warfarin group and hirudin plus aspirin group. Compared with warfarin, hirudin plus aspirin therapy had lower safety risk in the secondary prevention of cardioembolic stroke due to NVAF.

Left Atrial Mechanics Assessed Early during Hospitalization for Cryptogenic Stroke Are Associated with Occult Atrial Fibrillation: A Speckle-Tracking Strain Echocardiography Study

BACKGROUND

Occult atrial fibrillation (AF) is an important contributor to cryptogenic stroke, yet remains difficult to unmask at presentation. This study investigated the predictive value of left atrial (LA) mechanics by strain echocardiography during stroke hospitalization for the presence of AF as detected on early 30-day monitoring and routine clinical follow-up.

METHODS

Left atrial mechanics were studied by strain echocardiography in a retrospective cohort of 191 patients with cryptogenic stroke and 30-day mobile cardiac outpatient telemetry poststroke to diagnose AF. After this, AF was diagnosed via routine clinical follow-up. The independent and incremental value of measures of LA size and mechanics (i.e., strain and strain rate in the reservoir, conduit, and booster pump phase) to predict AF on top of clinical characteristics was assessed.

RESULTS

Of 191 patients, 15% (n = 28) developed AF, of which 10 were observed during 30-day mobile cardiac outpatient telemetry and 18 were observed at a median follow-up of 25 (interquartile range, 10-43) months. Median time from embolic stroke to strain echocardiography was 1 day (interquartile range, 1-2 days). Left atrial mechanics were significantly worse in AF (P < .05 for all), despite largely similar baseline cardiovascular risk profile. Booster pump strain rate was the strongest predictor for AF, independent of age, LA volume index, E/e', and reservoir strain (odds ratio = 2.88 per SD increase; 95% confidence interval, 1.29-6.41; P = .010). Adding LA strain reservoir strain and booster pump function significantly enhanced a multivariate model to predict AF. Freedom from AF was significantly lower in subjects with a booster pump strain rate (at stroke presentation) worse than -0.67 sec^-1, as derived from receiver operator curve analysis (P < .001).

CONCLUSIONS

Left atrial mechanics and particularly the LA booster pump function assessed early during hospitalization for cryptogenic stroke can identify patients at greater likelihood of future diagnosis of AF. These findings could in part relate to LA mechanical stunning after spontaneous cardioversion, which-when identified by early strain echocardiography-can inform further risk stratification and decision-making.

Association of alcohol consumption with prognosis of ischemic stroke by subtype in different follow-up periods: a hospital-based study in China

OBJECTIVES

Alcohol consumption is a risk factor for stroke. However, there are no available data on the effect of alcohol consumption on the long-term outcome of ischemic stroke in China. Therefore, this study aimed to explore the association of alcohol consumption with the prognosis of ischemic stroke by subtype in different follow-up periods after stroke.

METHODS

This 12-month follow-up study recruited 3830 acute ischemic stroke patients from Tianjin, China, between 2016 and 2018. Patients were categorized into two groups according to their consumption of alcohol. Differences in mortality, recurrence, and dependency rates at 3 and 12 months after stroke were compared between both groups.

RESULTS

The mortality, recurrence, and dependency rates at 12 months after stroke were significantly higher in patients who previously consumed alcohol than in those without previous alcohol consumption (all P < 0.005). A similar trend was observed for mortality rate at 3 months after stroke (P < 0.001). The risk of death at 3 months after an atherothrombotic stroke decreased by 63.4% (relative risk [RR], 0.366; 95% confidence interval [CI], 0.144-0.935) among patients who previously consumed alcohol compared with those who never consumed alcohol. Moreover, for patients with small artery disease classified according to the Trial of ORG 10,172 in Acute Stroke Treatment (TOAST), the recurrence and dependency rates at 12 months after stroke decreased by 49.2% (RR, 0.508; 95% CI, 0.259-0.996) and 49.5% (RR, 0.505; 95% CI, 0.258-0.990), respectively, among patients who consumed alcohol.

CONCLUSIONS

Previous alcohol consumption decreased the risk of death at 3 months after stroke among patients with atherothrombotic stroke according to the TOAST classification. Furthermore, for patients with small artery disease (according to TOAST classification), alcohol consumption significantly decreased the risk of recurrence and dependency at 12 months after stroke. This study highlights an urgent need to quantify the association of alcohol consumption with outcomes after stroke in China to improve stroke prognosis.

Executive Dysfunction Related to Binge Drinking in Ischemic Stroke

BACKGROUND

Recent evidence has shown that cognitive dysfunction is associated with a history of binge drinking in adolescents who do not have an alcohol use disorder. Most previous studies with adults, however, have failed to show a link between cognitive dysfunction and subdiagnostic binge drinking, nor have any studies investigated the additive cognitive effect of binge drinking to ischemic stroke.

OBJECTIVE

To examine whether a pattern of cognitive dysfunction, especially executive and memory dysfunction, in patients with a first-ever ischemic stroke is associated with a history of subdiagnostic binge drinking.

METHODS

We studied 206 first-ever ischemic stroke patients (18-65 years) and 50 healthy, demographically comparable adults-both groups with no alcohol use disorder. After exclusion by matching, 189 patients and 39 healthy participants were included in our study (228 participants). The binge-drinking group included 76 participants; the non-binge-drinking group included 152. A multivariate analysis of covariance was used to compare nine cognitive functions between the two groups, with age, education, and stroke severity used as covariates.

RESULTS

Binge drinking had a significant negative effect on executive functions (P<0.001). The non-binge-drinking group outperformed the binge-drinking group on the Stroop Test (P=0.001), Trail Making Test (P=0.002), and a phonemic fluency test (P=0.005). The Binge×Stroke Severity interaction (P=0.037) indicated that a history of binge drinking increased the negative effect of stroke on executive functions.

CONCLUSIONS

Subdiagnostic binge drinking may exacerbate the adverse effects of ischemic stroke on executive dysfunction.

Alcohol exposure-induced neurovascular inflammatory priming impacts ischemic stroke and is linked with brain perivascular macrophages

Alcohol abuse is a major public health problem worldwide, causing a wide range of preventable morbidity and mortality. In this translational study, we show that heavy drinking (HD) (≥6 standard drinks/day) is independently associated with a worse outcome for ischemic stroke patients. To study the underlying mechanisms of this deleterious effect of HD, we performed an extensive analysis of the brain inflammatory responses of mice chronically exposed or not to 10% alcohol before and after ischemic stroke. Inflammatory responses were analyzed at the parenchymal, perivascular, and vascular levels by using transcriptomic, immunohistochemical, in vivo 2-photon microscopy and molecular MRI analyses. Alcohol-exposed mice show, in the absence of any other insult, a neurovascular inflammatory priming (i.e., an abnormal inflammatory status including an increase in brain perivascular macrophages [PVM]) associated with exacerbated inflammatory responses after a secondary insult (ischemic stroke or LPS challenge). Similar to our clinical data, alcohol-exposed mice showed larger ischemic lesions. We show here that PVM are key players on this aggravating effect of alcohol, since their specific depletion blocks the alcohol-induced aggravation of ischemic lesions. This study opens potentially new therapeutic avenues aiming at blocking alcohol-induced exacerbation of the neurovascular inflammatory responses triggered after ischemic stroke.

Association Between Alcoholic Cirrhosis and Hemorrhagic Stroke: A Nationwide Population-based Study

AIMS

This study investigated whether patients with alcoholic cirrhosis have a high risk of hemorrhagic stroke.

METHODS

In this study, 17,094 patients diagnosed with cirrhosis between 2000 and 2010 were identified using the Taiwan National Health Insurance claims data. Identified patients were randomly selected and propensity score matched with individuals without cirrhosis according to age, sex, comorbidities and index year.

RESULTS

The overall incidence rate of stroke was 4.41 and 12.1 per 1000 person-years in the chronic liver disease and cirrhosis (CLDC) with hepatitis B virus (HBV) or hepatitis C virus (HCV) cohort and the alcoholic CLDC cohort, respectively. The alcoholic CLDC cohort exhibited a 4.53-fold higher risk of hemorrhagic stroke (adjusted subhazard ratio [aSHR] = 4.53, 95% confidence interval [CI] = 3.05-6.71) than did the non-CLDC cohort, and the CLDC with HBV or HCV cohort exhibited a 1.40-fold higher risk of hemorrhagic stroke (aSHR = 1.40, 95% CI = 1.10-1.78) than did the non-CLDC cohort. The alcoholic CLDC cohort and the CLDC with HBV or HCV cohort showed an aSHR of 1.80 (95% CI = 1.36-2.40) and 0.95 (95% CI = 0.83-1.07) for ischemic stroke, respectively, compared with the non-CLDC cohort.

CONCLUSION

Alcoholic patients with CLDC had a higher risk of hemorrhagic stroke compared with non-alcoholic patients with CLDC and patients without CLDC.

Movement Behavior Patterns in People With First-Ever Stroke

Supplemental Digital Content is available in the text.

Movement behaviors, that is, both physical activity and sedentary behavior, are independently associated with health risks. Although both behaviors have been investigated separately in people after stroke, little is known about the combined movement behavior patterns, differences in these patterns between individuals, or the factors associated with these patterns. Therefore, the objectives of this study are (1) to identify movement behavior patterns in people with first-ever stroke discharged to the home setting and (2) to explore factors associated with the identified patterns.

Sibling Comparison Designs: Addressing Confounding Bias with Inclusion of Measured Confounders

Genetically informative research designs are becoming increasingly popular as a way to strengthen causal inference with their ability to control for genetic and shared environmental confounding. Co-twin control (CTC) models, a special case of these designs using twin samples, decompose the overall effect of exposure on outcome into a within- and between-twin-pair term. Ideally, the within-twin-pair term would serve as an estimate of the exposure effect controlling for genetic and shared environmental factors, but it is often confounded by factors not shared within a twin-pair. Previous simulation work has shown that if twins are less similar on an unmeasured confounder than they are on an exposure, the within-twin-pair estimate will be a biased estimate of the exposure effect, even more biased than the individual, unpaired estimate. The current study uses simulation and analytical derivations to show that while incorporating a covariate related to the nonshared confounder in CTC models always reduces bias in the within-pair estimate, it will be less biased than the individual estimate only in a narrow set of circumstances. The best case for bias reduction in the within-pair estimate occurs when the within-twin-pair correlation in exposure is less than the correlation in the confounder and the twin-pair correlation in the covariate is high. Additionally, the form of covariate inclusion is compared between adjustment for only one's own covariate value and adjustment for the deviation of one's own value from the covariate twin-pair mean. Results show that adjusting for the deviation from the twin-pair mean results in equal or reduced bias.

Cardiovascular effects of alcohol: A double-edged sword / how to remain at the nadir point of the J-Curve?

BACKGROUND

In addition to its established harmful effects on the liver and other organs, heavy alcohol use confers deleterious effects on the cardiovascular (CV) system, as well. However, data have emerged that light/moderate alcohol consumption (1 drink/day for women and 1-2 drinks/day for men) may be protective against CV disease.

OBJECTIVE/METHODS

English articles regarding the CV effects of alcohol/ethanol were reviewed by search in Medline, Scopus, and Google Scholar.

RESULTS

A J-shaped curve has been proposed to illustrate a differential effect of alcohol on the CV system with the lowest point on the curve (light/moderate drinking) corresponding to optimal exposure to alcohol, which may confer cardioprotection, the rather neutral effect of non-drinking, and the highest risk of heavy and/or binge drinking reflecting the consequence of harmful exposure. However, staying at the nadir of this J-shaped curve appears difficult. Furthermore, concern and distrust have also been raised about the quality of evidence for such "cardioprotection", emphasizing the need for further randomized controlled trials. Another concern relates to the risk of moderate drinking leading to problem drinking, since alcohol is the most common addictive substance.

CONCLUSION

Optimal exposure to alcohol (light/moderate use) means that one needs to stay at the nadir of the J-shaped curve for alcohol use to avail oneself of possible cardioprotection, and this may not be an easy thing to accomplish and/or adhere to, especially if one "likes" alcohol drinking. However, the evidence of "cardioprotection" conferred by alcohol has also been refuted, due to lack of randomized controlled trials.

Prevalence and correlates of stroke among older adults in Ghana: Evidence from the Study on Global AGEing and adult health (SAGE)

This study examines the prevalence and correlates of stroke among older adults in Ghana. This cross-sectional study retrieved data from Wave 1 of the World Health Organization (WHO) Survey on Global Ageing and Adult Health (SAGE) conducted between 2007 and 2008. The sample, comprising 4,279 respondents aged 50 years and above, was analysed using descriptive statistics, cross tabulations and Chi-Square tests, and a multivariable binary logistic regression. Respondents ranged in age from 50 to 114 years, with a median age of 62 years. Stroke prevalence was 2.6%, with the correlates being marital status, level of education, employment status, and living with hypertension or diabetes. The results showed that being separated/divorced, having primary and secondary education, being unemployed and living with hypertension and diabetes, significantly increased the odds of stroke prevalence in this population. The results suggest that interventions to reduce stroke prevalence and impact must be developed alongside interventions for hypertension, diabetes and sociodemographic/economic factors such as marital status, level of education, and employment status.

Alcohol Consumption and Incident Stroke Among Older Adults

Objectives

This study examines the relationship between alcohol consumption and incident stroke among older adults and tests whether alcohol consumption contributes to observed race and sex differences in stroke.

Method

Data are from a U.S. national cohort of black and white adults aged 45 and older, the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. Current and past drinking levels were reported at baseline (2003-2007). Participants who had never had a stroke were followed for adjudicated stroke events through September 2015 (n = 27,265). We calculated Cox proportional hazard models for stroke, adjusting for demographic, socioeconomic, behavioral, and health characteristics.

Results

Participants, mean age 64.7 years, consumed on average 2.2 drinks/week and experienced 1,140 first-time stroke events over median 9.1 years follow-up. Nondrinkers had a 12% higher risk of stroke than current drinkers; the risk of stroke among nondrinkers largely reflected high risks among past drinkers; these differences were explained by socioeconomic characteristics. Among current drinkers, light drinkers had significantly lower stroke risks than moderate drinkers after accounting for demographic, socioeconomic, behavioral, and health characteristics. Implications of alcohol did not differ between blacks and whites but did differ by sex: Especially among women, nondrinkers, and specifically past drinkers, had higher risks; these differences were largely explained by health characteristics and behaviors. Alcohol did not explain race and sex differences in stroke incidence.

Discussion

Among older adults, those who used to, but no longer, drink had higher risks of stroke, especially among women; current light drinkers had the lowest risk of stroke.

National Alcohol Survey of households in Trinidad and Tobago (NASHTT): Alcohol use in households

BACKGROUND

To determine the patterns of alcohol use among households in Trinidad and Tobago (T&T) and to estimate the association between alcohol use and negative psychological, social, or physical events experienced by the household.

METHODS

A convenience sample of 1837 households across T&T. We identified bivariate correlates of alcohol use, and heavy episodic drinking using chi-square and t-test analyses and used multivariable logistic regression to estimate adjusted associations between household alcohol use and experiences within the past 12 months adjusted for sociodemographic covariates.

RESULTS

One thousand five hundred two households had complete data for all variables (82% response rate). Nearly two thirds (64%) of households included alcohol users; 57% of household that consumed alcohol also reported heavy episodic drinking. Households that reported alcohol consumption were significantly more likely to report illnesses within the households, relationship problems, and behavioral and antisocial problems with children. Among households where a member was employed, those who consumed alcohol were nearly twice as likely (OR = 1.98; 95% confidence interval (CI) 1.03, 3.82) to have a household member call in sick to work and 2.9 times as likely (OR = 2.9; CI 1.19, 7.04) to have a household member suffer work related problems compared with households who reported not consuming alcohol.

CONCLUSIONS

Approximately two thirds of households in T&T reported using alcohol. These households were more likely to report psychological, physical, and social problems. These findings would support efforts to enforce current policies, laws, and regulations as well as new strategies to reduce the impact of harmful alcohol consumption on households in T&T.

Risk Factors for Stroke in the Chinese Population: A Systematic Review and Meta-Analysis

BACKGROUND

Stroke is the leading cause of death in China. According to the Chinese Stroke Screening and Prevention Project, 8 main risk factors were assessed and individuals with 3 or more risk factors were identified as high-risk population of stroke. To explore the potential impropriety of counting the risk factors but ignoring the different strength of association of each risk factor, we performed this study.

METHODS

Relevant databases were searched for case-control and cohort studies focusing on the risk factors of stroke. We systematically identified studies conducted between 1990 and 2015 that included data on the frequency of risk factors in Chinese Han populations. Pooled relative risks and odds ratios, with their 95% confidence intervals, were calculated for the cohort and case-control studies, respectively.

RESULTS

Fifteen cohort studies and 178 case-control studies were identified. Hypertension was the strongest independent risk factor for stroke (pooled odds ratio, 3.50; pooled relative risk, 2.68). Diabetes mellitus, heart disease, family history of stroke, hyperlipidemia, overweight, and smoking were also mildly predictive (pooled odd ratios, 1.82-2.68; pooled relative risks, 1.27-2.47). By contrast, physical exercise was a protective factor against stroke (pooled odd ratio, .49).

CONCLUSIONS

There was a measurable difference in the strength of association of the 8 risk factors with stroke; hypertension and diabetes were associated with the highest risks, indicating a need to focus resources on patients with these conditions. Giving risk factors equal weighting may not be an appropriate screening methodology.

Differing association of alcohol consumption with different stroke types: a systematic review and meta-analysis

BACKGROUND

Whether light-to-moderate alcohol consumption is protective against stroke, and whether any association differs by stroke type, is controversial. We conducted a meta-analysis to summarize the evidence from prospective studies on alcohol drinking and stroke types.

METHODS

Studies were identified by searching PubMed to September 1, 2016, and reference lists of retrieved articles. Additional data from 73,587 Swedish adults in two prospective studies were included. Study-specific results were combined in a random-effects model.

RESULTS

The meta-analysis included 27 prospective studies with data on ischemic stroke (25 studies), intracerebral hemorrhage (11 studies), and/or subarachnoid hemorrhage (11 studies). Light and moderate alcohol consumption was associated with a lower risk of ischemic stroke, whereas high and heavy drinking was associated with an increased risk; the overall RRs were 0.90 (95 % CI, 0.85-0.95) for less than 1 drink/day, 0.92 (95 % CI, 0.87-0.97) for 1-2 drinks/day, 1.08 (95 % CI, 1.01-1.15) for more than 2-4 drinks/day, and 1.14 (95 % CI, 1.02-1.28) for more than 4 drinks/day. Light and moderate alcohol drinking was not associated with any hemorrhagic stroke subtype. High alcohol consumption (>2-4 drinks/day) was associated with a non-significant increased risk of both hemorrhagic stroke subtypes, and the relative risk for heavy drinking (>4 drinks/day) were 1.67 (95 % CI, 1.25-2.23) for intracerebral hemorrhage and 1.82 (95 % CI, 1.18-2.82) for subarachnoid hemorrhage.

CONCLUSION

Light and moderate alcohol consumption was inversely associated only with ischemic stroke, whereas heavy drinking was associated with increased risk of all stroke types with a stronger association for hemorrhagic strokes.

Increased Risk of Mesenteric Ischemia in Patients With Alcohol Use Disorder: A Population-Based Retrospective Cohort Study

OBJECTIVE

To investigate the association between alcohol use disorder and the risk of mesenteric ischemia by conducting a population-based retrospective cohort study.

PATIENTS AND METHODS

The present study enrolled 62,115 patients hospitalized for alcoholic intoxication between January 1, 1999, and December 31, 2009, and matched each of them with 4 comparison patients with similar mean age and sex ratios. We determined the cumulative incidences and adjusted hazard ratios (aHRs) of mesenteric ischemia.

RESULTS

A significant association was observed between alcoholic intoxication and mesenteric ischemia (aHR, 5.21; 95% CI, 4.36-6.23; P<.0001) after adjustment for age, sex, and comorbidity history of hypertension, hyperlipidemia, diabetes, atrial fibrillation, stroke, heart failure, chronic renal disease, ischemic heart disease, chronic obstructive pulmonary disease, and cirrhosis. After less than 1 year of follow-up, the incidence rate of mesenteric ischemia in the alcoholic intoxication group was approximately 9.38-fold higher than that in the comparison patients (aHR, 9.38; 95% CI, 5.52-15.9; P<.0001).

CONCLUSION

Physicians should carefully consider the alcohol history of patients who complain of abdominal pain and respond poorly to treatment, because alcohol use disorder is a risk factor for mesenteric ischemia, a surgical emergency.

Job Loss, Unemployment and the Incidence of Hazardous Drinking during the Late 2000s Recession in Europe among Adults Aged 50-64 Years

BACKGROUND

To estimate the incidence of hazardous drinking in middle-aged people during an economic recession and ascertain whether individual job loss and contextual changes in unemployment influence the incidence rate in that period.

METHODS

Longitudinal study based on two waves of the SHARE project (Survey of Health, Ageing and Retirement in Europe). Individuals aged 50-64 years from 11 European countries, who were not hazardous drinkers at baseline (n = 7,615), were selected for this study. We estimated the cumulative incidence of hazardous drinking (≥40g and ≥20g of pure alcohol on average in men and women, respectively) between 2006 and 2012. Furthermore, in the statistical analysis, multilevel Poisson regression models with robust variance were fitted and obtained Risk Ratios (RR) and their 95% Confidence Intervals (95%CI).

RESULTS

Over a 6-year period, 505 subjects became hazardous drinkers, with cumulative incidence of 6.6 per 100 persons between 2006 and 2012 (95%CI:6.1-7.2). Age [RR = 1.02 (95%CI:1.00-1.04)] and becoming unemployed [RR = 1.55 (95%CI:1.08-2.23)] were independently associated with higher risk of becoming a hazardous drinker. Conversely, having poorer self-perceived health was associated with lower risk of becoming a hazardous drinker [RR = 0.75 (95%CI:0.60-0.95)]. At country-level, an increase in the unemployment rate during the study period [RR = 1.32 (95%CI:1.17-1.50)] and greater increases in the household disposable income [RR = 0.97 (95%CI:0.95-0.99)] were associated with risk of becoming a hazardous drinker.

CONCLUSIONS

Job loss among middle-aged individuals during the economic recession was positively associated with becoming a hazardous drinker. Changes in country-level variables were also related to this drinking pattern.

The impaired synthesis of insulin and its inability to inhibit platelet aggregation in cerebrovascular accident

Both ischemic stroke (IS) and hemorrhagic stroke (HS) are reported to occur due to thrombosis on the arteries of the brain. As diabetes mellitus is a risk factor for strokes and insulin is reported to prevent thrombosis, the role of insulin in IS and HS was investigated. Forty eight stroke victims (IS = 22, HS = 26) and equal number of aged and sex matched normal volunteers participated in the study. Nitric oxide was determined by methemoglobin method. Insulin and Dermcidin isoform-2 (DCN2) level was determined by ELISA by using insulin and dermcidin antibody. Insulin binding to the platelet membrane was analyzed by scat chard plot. Treatment of normal platelet rich plasma (10(8)platelets/ml) with 15μUnits insulin/ml produced 1.41 nmol NO. The PRP from the IS and HS victims produced 0.38 nmol NO and 0.08 nmol NO respectively. Pretreatment of PRP from IS or HS subjects with 15 μM aspirin followed by 15μUnits of insulin/ml resensitized the platelets to the inhibitory effect of insulin. Mice hepatocytes treated with 0.14 μM DCN2 abolished the glucose induced insulin synthesis by NO that can be reversed by using 15 μM aspirin. It can be concluded that presence of DCN2 in stroke causes a condition similar to type I diabetes and nullified the effect of insulin in the inhibition of platelet aggregation in both IS and HS. The effect was reversed by 15 μM aspirin.