Risk factors of stroke in Western and Asian countries: a systematic review and meta-analysis of prospective cohort studies

Low-Dose Aspirin for Primary Prevention of Cardiovascular Events Comparing East Asians With Westerners: A Meta-Analysis

Background

East Asians have shown different risk profiles for both thrombophilia and bleeding than Western counterparts.

Objectives

The authors sought to evaluate the effect of low-dose aspirin for primary prevention between these populations.

Methods

We searched randomized clinical trials (RCTs) for intervention with low-dose aspirin (≤100 mg once daily) in participants without symptomatic cardiovascular disease until December 31, 2021. The number of events between the arms was extracted for analysis. Pooled risk ratios (RRs) and risk differences (RDs) were analyzed in each population. Outcomes included a major adverse cardiovascular event (MACE), cardiovascular death, myocardial infarction, stroke, and major bleeding (intracranial hemorrhage and major gastrointestinal bleeding).

Results

Two RCTs included 17,003 East Asians, and 9 RCTs had 117,467 Western participants. Aspirin treatment showed a similar effect in reducing the MACE rate (RR of East Asians: 0.87; 95% CI: 0.71-1.05; RR of Westerners: 0.90; 95% CI: 0.85-0.95) (Pinteraction = 0.721). In contrast, the risk of major bleeding during aspirin vs control was greater in the East Asian population (RR: 2.48; 95% CI: 1.86-3.30) compared with the Western population (RR: 1.45; 95% CI: 1.26-1.66) (Pinteraction = 0.001), which was driven by more frequent gastrointestinal bleeding (RR of East Asians: 3.29; 95% CI: 2.26-4.80 vs RR of Westerners: 1.56; 95% CI: 1.29-1.88) (Pinteraction < 0.001). The net RDs (RD of MACE plus RD of major bleeding) were 8.04 and 0.72 per 1,000 persons in East Asian and Western participants, indicating 124 and 1,389 of the net number needed to harm, respectively.

Conclusions

Low-dose aspirin for primary prevention in East Asians must be cautiously prescribed because of the increased risk of major bleeding relative to Western counterparts.

Evidence relating cigarettes, cigars and pipes to cardiovascular disease and stroke: Meta-analysis of recent data from three regions

BACKGROUND

More recent data are required relating to disease risk for use of various smoked products and of other products containing nicotine. Earlier we published meta-analyses of recent results for chronic obstructive pulmonary disease and lung cancer on the relative risk (RR) of current compared to never product use for cigarettes, cigars and pipes based on evidence from North America, Europe and Japan. We now report corresponding up-to-date evidence for acute myocardial infarction (AMI), ischaemic heart disease (IHD) and stroke.

AIM

To estimate, using recent data, AMI, IHD and stroke RRs by region for current smoking of cigarettes, cigars and pipes.

METHODS

Publications in English from 2015 to 2020 were considered that, based on epidemiological studies in the three regions, estimated the current smoking RR of AMI, IHD or stroke for one or more of the three products. The studies should involve at least 100 cases of stroke or cardiovascular disease (CVD), not be restricted to populations with specific medical conditions, and should be of cohort or nested case-control study design or randomized controlled trials. A literature search was conducted on MEDLINE, examining titles and abstracts initially, and then full texts. Additional papers were sought from reference lists of selected papers, reviews and meta-analyses. For each study identified, we entered the most recent available data on current smoking of each product, as well as the characteristics of the study and the RR estimates. Combined RR estimates were derived using random-effects meta-analysis for stroke and, in the case of CVD, separately for IHD and AMI. For cigarette smoking, where far more data were available, heterogeneity was studied by a wide range of factors. For cigar and pipe smoking, a more limited heterogeneity analysis was carried out. A more limited assessment of variation in risk by daily number of cigarettes smoked was also conducted. Results were compared with those from previous meta-analyses published since 2000.

RESULTS

Current cigarette smoking: Ten studies gave a random-effects RR for AMI of 2.72 [95% confidence interval (CI): 2.40-3.08], derived from 13 estimates between 1.47 and 4.72. Twenty-three studies gave an IHD RR of 2.01 (95%CI: 1.84-2.21), using 28 estimates between 0.81 and 4.30. Thirty-one studies gave a stroke RR of 1.62 (95%CI: 1.48-1.77), using 37 estimates from 0.66 to 2.91. Though heterogeneous, only two of the overall 78 RRs were below 1.0, 71 significantly (P < 0.05) exceeding 1.0. The heterogeneity was only partly explicable by the factors studied. Estimates were generally higher for females and for later-starting studies. They were significantly higher for North America than Europe for AMI, but not the other diseases. For stroke, the only endpoint with multiple Japanese studies, RRs were lower there than for Western studies. Adjustment for multiple factors tended to increase RRs. Our RR estimates and the variations by sex and region are consistent with earlier meta-analyses. RRs generally increased with amount smoked. Current cigar and pipe smoking: No AMI data were available. One North American study reported reduced IHD risk for non-exclusive cigar or pipe smoking, but considered few cases. Two North American studies found no increased stroke risk with exclusive cigar smoking, one reporting reduced risk for exclusive pipe smoking (RR 0.24, 95%CI: 0.06-0.91). The cigar results agree with an earlier review showing no clear risk increase for IHD or stroke.

CONCLUSION

Current cigarette smoking increases risk of AMI, IHD and stroke, RRs being 2.72, 2.01 and 1.62. The stroke risk is lower in Japan, no increase was seen for cigars/pipes.

Qualitative electroencephalogram and its predictors in the diagnosis of stroke

Introduction

Stroke is a typical medical emergency that carries significant disability and morbidity. The diagnosis of stroke relies predominantly on the use of neuroimaging. Accurate diagnosis is pertinent for management decisions of thrombolysis and/or thrombectomy. Early identification of stroke using electroencephalogram (EEG) in the clinical assessment of stroke has been underutilized. This study was conducted to determine the relevance of EEG and its predictors with the clinical and stroke features.

Methods

A cross-sectional study was carried out where routine EEG assessment was performed in 206 consecutive acute stroke patients without seizures. The demographic data and clinical stroke assessment were collated using the National Institutes of Health Stroke Scale (NIHSS) score with neuroimaging. Associations between EEG abnormalities and clinical features, stroke characteristics, and NIHSS scores were evaluated.

Results

The mean age of the study population was 64.32 ± 12 years old, with 57.28% consisting of men. The median NIHSS score on admission was 6 (IQR 3-13). EEG was abnormal in more than half of the patients (106, 51.5%), which consisted of focal slowing (58, 28.2%) followed by generalized slowing (39, 18.9%) and epileptiform changes (9, 4.4%). NIHSS score was significantly associated with focal slowing (13 vs. 5, p < 0.05). Type of stroke and imaging characteristics were significantly associated with EEG abnormalities (p < 0.05). For every increment in NIHSS score, there are 1.08 times likely for focal slowing (OR 1.089; 95% CI 1.033, 1.147, p = 0.002). Anterior circulation stroke has 3.6 times more likely to have abnormal EEG (OR 3.628; 95% CI 1.615, 8.150, p = 0.002) and 4.55 times higher to exhibit focal slowing (OR 4.554; 95% CI 1.922, 10.789, p = 0.01).

Conclusion

The type of stroke and imaging characteristics are associated with EEG abnormalities. Predictors of focal EEG slowing are NIHSS score and anterior circulation stroke. The study emphasized that EEG is a simple yet feasible investigational tool, and further plans for advancing stroke evaluation should consider the inclusion of this functional modality.

Mechanistic Insights of Polyphenolic Compounds from Rosemary Bound to Their Protein Targets Obtained by Molecular Dynamics Simulations and Free-Energy Calculations

Rosemary represents an important medicinal plant that has been attributed with various health-promoting properties, especially antioxidative, anti-inflammatory, and anticarcinogenic activities. Carnosic acid, carnosol, and rosmanol, as well as the phenolic acid ester rosmarinic acid, are the main compounds responsible for these actions. In our earlier research, we carried out an inverse molecular docking at the proteome scale to determine possible protein targets of the mentioned compounds. Here, we subjected the previously identified ligand-protein complexes with HIV-1 protease, K-RAS, and factor X to molecular dynamics simulations coupled with free-energy calculations. We observed that carnosic acid and rosmanol act as viable binders of the HIV-1 protease. In addition, carnosol represents a potential binder of the oncogene protein K-RAS. On the other hand, rosmarinic acid was characterized as a weak binder of factor X. We also emphasized the importance of water-mediated hydrogen-bond networks in stabilizing the binding conformation of the studied polyphenols, as well as in mechanistically explaining their promiscuous nature.

Psychometric properties of the Chinese version of Attitudes and Beliefs about Cardiovascular Disease Risk Perception Questionnaire

Cardiovascular disease (CVD) is the leading cause of global mortality and disease burden. The perceived risk of CVD, a central psychological construct, may affect health behavior change and maintenance, such as lifestyle modification and medication adherence. Risk perception varies based on the knowledge of risk in the context of cultural health-world views. Little is known about CVD-related knowledge and risk perception in China. The aim of this study is to cross-culturally translate, adapt, and evaluate the psychometric properties of the Attitudes and Beliefs about Cardiovascular Disease (ABCD) Risk Perception Questionnaire in Chinese. The translation and cross-cultural adaptation process followed established guidelines. A cross-sectional study of 318 adults between April and May 2022 was conducted in Zhejiang province. The study evaluated the item- and scale-level psychometric properties and validity indices of the ABCD risk perception questionnaire. The exploratory and confirmatory factor analyses of the risk scale supported a three-factor solution that accounts for 69.63% of the total variance, corresponding to risk perception (F1), perceived benefits and intention to change physical activity (F2), and perceived benefits and intention to change dietary habits (F3). Adequate content validity (I-CVI = 0.852-1.00, S-CVI = 946) was ensured by expert panel. The internal consistency of the dimensions showed good results ranging from 0.801 to 0.940 for Cronbach's α, and 0.853 to 0.952 for McDonald's ω. The item analysis of knowledge dimension indicated that the item difficulty index was 0.440 to 0.852, the item discrimination index was 0.572 to 0.707. This study confirmed that the Chinese version of the ABCD risk perception questionnaire has good psychometric properties in terms of measuring CVD-related knowledge and risk perception in the Chinese adult population, which can lead to the development of individually tailored CVD-risk reduction intervention programs or risk communication programs by health providers.

Association of the ApoB/ApoA-I ratio with stroke risk: Findings from the China Health and Nutrition Survey (CHNS)

BACKGROUND AND AIMS

Studies on associations of apolipoprotein B (ApoB), apolipoprotein A-I (ApoA-I) and the ApoB/ApoA-I ratio with stroke risk are scarce. We aimed to prospectively examine the associations of the ApoB/ApoA-I ratio and other lipid profiles with the risk of stroke using data from the China Health and Nutrition Survey (CHNS).

METHODS AND RESULTS

A total of 7318 participants without stroke at baseline in 2009 were included in the final analysis and followed for a median of 6.1 years. The serum lipid profiles including total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), ApoA-I, and ApoB were measured at baseline. Multivariable Cox proportional hazards models were used to evaluate the associations between these parameters and stroke risk. The ApoB/ApoA-I ratio was positively associated with incident stroke, yielding adjusted hazard ratio (HR) of 1.32 (95% CI: 1.09-1.59, P = 0.004). In comparison, ratio of ApoB and ApoA-I containing lipoproteins, the non-HDL-C/HDL-C ratio, possessed relatively weaker association with incident stroke (HR: 1.24, 95% CI: 1.01-1.52, P = 0.036). Furthermore, the risk associations for the ApoB/ApoA-I and non-HDL-C/HDL-C ratios were prominent among those participants aged >51, body mass index ≤23, or female. There were no significant associations of other lipids and their ratios with the stroke risk.

CONCLUSIONS

Higher ApoB/ApoA-I ratio was associated with an increased risk of stroke. Our findings suggest that the ApoB/ApoA-I ratio may serve as a better risk indicator of stroke than other lipid profiles and their ratios.

Mechanistic Insights into Biological Activities of Polyphenolic Compounds from Rosemary Obtained by Inverse Molecular Docking

Rosemary (Rosmarinus officinalis L.) represents a medicinal plant known for its various health-promoting properties. Its extracts and essential oils exhibit antioxidative, anti-inflammatory, anticarcinogenic, and antimicrobial activities. The main compounds responsible for these effects are the diterpenes carnosic acid, carnosol, and rosmanol, as well as the phenolic acid ester rosmarinic acid. However, surprisingly little is known about the molecular mechanisms responsible for the pharmacological activities of rosemary and its compounds. To discern these mechanisms, we performed a large-scale inverse molecular docking study to identify their potential protein targets. Listed compounds were separately docked into predicted binding sites of all non-redundant holo proteins from the Protein Data Bank and those with the top scores were further examined. We focused on proteins directly related to human health, including human and mammalian proteins as well as proteins from pathogenic bacteria, viruses, and parasites. The observed interactions of rosemary compounds indeed confirm the beforementioned activities, whereas we also identified their potential for anticoagulant and antiparasitic actions. The obtained results were carefully checked against the existing experimental findings from the scientific literature as well as further validated using both redocking procedures and retrospective metrics.

New Drug Targets to Prevent Death Due to Stroke: A Review Based on Results of Protein-Protein Interaction Network, Enrichment, and Annotation Analyses

This study used established biomarkers of death from ischemic stroke (IS) versus stroke survival to perform network, enrichment, and annotation analyses. Protein-protein interaction (PPI) network analysis revealed that the backbone of the highly connective network of IS death consisted of IL6, ALB, TNF, SERPINE1, VWF, VCAM1, TGFB1, and SELE. Cluster analysis revealed immune and hemostasis subnetworks, which were strongly interconnected through the major switches ALB and VWF. Enrichment analysis revealed that the PPI immune subnetwork of death due to IS was highly associated with TLR2/4, TNF, JAK-STAT, NOD, IL10, IL13, IL4, and TGF-β1/SMAD pathways. The top biological and molecular functions and pathways enriched in the hemostasis network of death due to IS were platelet degranulation and activation, the intrinsic pathway of fibrin clot formation, the urokinase-type plasminogen activator pathway, post-translational protein phosphorylation, integrin cell-surface interactions, and the proteoglycan-integrin extracellular matrix complex (ECM). Regulation Explorer analysis of transcriptional factors shows: (a) that NFKB1, RELA and SP1 were the major regulating actors of the PPI network; and (b) hsa-mir-26-5p and hsa-16-5p were the major regulating microRNA actors. In conclusion, prevention of death due to IS should consider that current IS treatments may be improved by targeting VWF, the proteoglycan-integrin-ECM complex, TGF-β1/SMAD, NF-κB/RELA and SP1.

Sex-specific association of BMI change with stroke in middle-aged and older adults with type 2 diabetes

BACKGROUND AND AIMS

We aimed to evaluate the association between BMI change and stroke in middle-aged and older adults with type 2 diabetes and identify sex differences.

METHODS AND RESULTS

The China Health and Retirement Longitudinal Study is an ongoing national population-based cohort study. Participants aged 45 or above with type 2 diabetes were enrolled and followed for stroke incidence. BMI change was defined as BMI at 2013-BMI at 2011. Of 1774 participants (mean [SD] age in 2011, 60.23 [8.88] years), 795 (44.8 %) were men. A total of 112 incident stroke cases were confirmed up to 2018. The incidence rate of stroke was similar between men and women (6.79 % vs 5.92 %, P = 0.516). BMI increase was independently associated with an increased stroke risk (adjusted odds ratio, 1.15; 95 % CI, 1.05-1.31) in men, while this positive association was not significant in women (adjusted odds ratio, 1.12; 95 % CI, 0.98-1.29). In addition, the positive dose-response relationship between BMI increase and stroke was observed only in men.

CONCLUSION

Among middle-aged and older adults with type 2 diabetes, there is a sex-specific association of BMI change with stroke. An increase in BMI could result in a higher risk of incident stroke in men.

Prevalence and correlates of carotid artery stenosis in a cohort of Sri Lankan ischaemic stroke patients

Background

Large artery atherosclerotic disease is an important cause of stroke, accounting for 15–46% of ischaemic strokes in population-based studies. Therefore, current guidelines from west recommend urgent carotid imaging in all ischaemic strokes or transient ischaemic attacks and referral for carotid endarterectomy. However, the clinical features and epidemiology of stroke in Asians are different from those in Caucasians and therefore the applicability of these recommendations to Asians is controversial. Data on the prevalence of carotid artery stenosis (CAS) among South Asian stroke patients is limited. Therefore, we sought to determine the prevalence and associated factors of significant CAS in a cohort of Sri Lankan patients with ischaemic stroke.

Methods

We prospectively studied all ischaemic stroke patients who underwent carotid doppler ultrasonography admitted to the stroke unit of a Sri Lankan tertiary care hospital over 5 years. We defined carotid stenosis as low (< 50%), moderate (50–69%) or severe (70–99%) or total-occlusion (100%) by North American Symptomatic Trial Collaborators (NASCET) criteria. We identified the factors associated with CAS ≥ 50% and ≥ 70% by stepwise multiple logistic regression analysis.

Results

A total of 550 ischaemic stroke patients (326 (59.3%) male, mean age was 58.9 ± 10.2 years) had carotid doppler ultrasonography. Of them, 528 (96.0%) had low-grade, 12 (2.2%) moderate and 7 (1.3%) severe stenosis and 3 (0.5%) had total occlusion. On multivariate logistic regression, age was associated with CAS ≥ 50% (OR 1.12, p = 0.001) and CAS ≥ 70% (OR 1.14, p = 0.016), but none of the other vascular risk factors studied (sex, hypertension, diabetes mellitus, smoking, past history of TIA, stroke or ischemic heart disease) showed significant associations.

Conclusions

Carotid stenosis is a minor cause of ischemic stroke in Sri Lankans compared to western populations with only 4.0% having CAS ≥ 50 and 3.5% eligible for carotid endarterectomy. Our findings have implications for the management of acute strokes in Sri Lanka.

Therapeutic effectiveness of a single exercise session combined with WalkAide functional electrical stimulation in post-stroke patients: a crossover design study

A growing body of evidence has suggested that the imbalance of epigenetic markers and oxidative stress appears to be involved in the pathophysiology and progression of stroke. Thus, strategies that modulate these biomarkers might be considered targets for neuroprotection and novel therapeutic opportunities for these patients. Physical exercise has been reported to induce changes in these epigenetic markers and improve clinical outcomes in different populations. However, little is reported on this in post-stroke patients. The purpose of this study was to investigate the effect of a single exercise session with WalkAide functional electrical stimulation (FES) on cognitive performance, clinical functional parameters, oxidative stress and epigenetic modulation in post-stroke individuals. In this crossover design study, 12 post-stroke individuals aged 54–72 years of either sexes were included and subjected to a single session of exercise (45 minutes) without WalkAide functional electrical stimulation (EXE alone group), followed by another single session of exercise (45 minutes) with WalkAide functional electrical stimulation (EXE + FES group). The clinical functional outcome measures, cognitive performance and blood collections for biomarker measurements were assessed pre- and post-intervention. After intervention, higher Berg Balance Scale scores were obtained in the EXE + FES group than in the EXE alone group. There was no significant difference in the Timed Up and Go test results post-intervention between EXE alone and EXE + FES groups. After intervention, a better cognitive performance was found in both groups compared with before the intervention. After intervention, the Timed Up and Go test scores were higher in the EXE + FES group than in the EXE alone group. In addition, the intervention induced lower levels of lipid peroxidation. After intervention, carbonyl level was lower, superoxide dismutase activity and superoxide dismutase/catalase activity ratio were higher in the EXE + FES group, compared with the EXE group alone. In each group, both histone deacetylase (HDAC2) and histone acetyltransferase activities were increased after intervention compared with before the intervention. These findings suggest that a single exercise session with WalkAide FES is more effective on balance ability and cognitive performance compared with conventional exercise alone in post-stroke patients. This is likely to be related to the regulation of oxidative stress markers. The present study was approved by the Research Ethics Committee of the Methodist University Center-IPA (approval No. 2.423.376) on December 7, 2017 and registered in the Brazilian Registry of Clinical Trials—ReBEC (RBR-9phj2q) on February 11, 2019.

Clinical pattern and predictors of stroke treatment outcome among hospitalised patients who had a stroke at Felege Hiwot comprehensive specialised hospital, northwest Ethiopia: a retrospective cross-sectional study

OBJECTIVES

This study aimed to assess the clinical pattern and predictors of stroke treatment outcomes among hospitalised patients in Felege Hiwot comprehensive specialised hospital (FHCSH) in northwest Ethiopia.

DESIGN

A retrospective cross-sectional study.

SETTING

The study was conducted medical ward of FHCSH.

PARTICIPANTS

The medical records of 597 adult patients who had a stroke were included in the study. All adult (≥18 years) patients who had a stroke had been admitted to the medical ward of FHSCH during 2015-2019 were included in the study. However, patients with incomplete medical records (ie, incomplete treatment regimen and the status of the patients after treatment) were excluded in the study.

RESULTS

In the present study, 317 (53.1%) were males, and the mean age of the study participants was 61.08±13.76 years. About two-thirds of patients (392, 65.7%) were diagnosed with ischaemic stroke. Regarding clinical pattern, about 203 (34.0%) of patients complained of right-side body weakness and the major comorbid condition identified was hypertension (216, 64.9%). Overall, 276 (46.2%) of them had poor treatment outcomes, and 101 (16.9%) of them died. Patients who cannot read and write (AOR=42.89, 95% CI 13.23 to 111.28, p<0.001), attend primary school (AOR=22.11, 95% CI 6.98 to 55.99, p<0.001) and secondary school (AOR=4.20, 95% CI 1.42 to 12.51, p<0.001), diagnosed with haemorrhagic stroke (AOR=2.68, 95% CI 1.62 to 4.43, p<0.001) and delayed hospital arrival more than 24 hours (AOR=2.92, 95% CI 1.83 to 4.66, p=0.001) were the independent predictors of poor treatment outcome.

CONCLUSIONS

Approximately half of the patients who had a stroke had poor treatment outcomes. Ischaemic stroke was the most predominantly diagnosed stroke type. Education status, types of stroke and the median time from onset of symptoms to hospitalisation were the predictors of treatment outcome. Health education should be given to patients regarding clinical symptoms of stroke. In addition, local healthcare providers need to consider the above risk factors while managing stroke.

Factors Associated With Length of Stay for Patients With Stroke in Malaysia

Introduction

Globally, stroke continues to become a significant public health issue contributing to one of the significant causes of morbidity and mortality. The study aimed to describe the characteristics of patients with stroke who were admitted to a teaching hospital in Malaysia and to determine the factors associated with length of stay (LOS).

Methods

This is a single-center, cross-sectional study using in-patient data maintained by the Case-Mix Unit of a teaching hospital in Malaysia from 2016 to 2017. The study included all patients with International Classification of Disease (ICD) code 164 (stroke, not specified as hemorrhage or infarct). The significance of association was determined using nonparametric tests in the form of the Mann-Whitney U test and the Kruskal-Wallis test.

Results

A total of 162 stroke patients from 2016 to 2017 from Case-Mix database were included in the study. The age ranged from 31 to 97 years old. The minimum and maximum LOS for patients with stroke ranged from 1 to 17 days. The severity of illness was found to be significantly associated with longer LOS (p < 0.001); however, age, sex, and presence of co-morbidities did not show any significant association.

Conclusion

Despite its limitations, this study is an essential first step to examine the characteristics of patients with stroke and to determine the factors associated with LOS.

Clinical significance of Platelet-to-White Blood Cell Ratio (PWR) and National Institute of Health Stroke Scale (NIHSS) in acute ischemic stroke

Introduction

Ischemic stroke can occur due to disruption of blood and oxygen supply to brain tissue. White blood cells and platelets play an important role in the pathogenesis of ischemic stroke. Several studies have concluded that the lower the platelet count and the higher the number of white blood cells in ischemic stroke patients will result in a more severe stroke and had worsen prognosis. Platelet and white blood cells counts can be converted into Platelet-to-White Blood Cell Ratio (PWR) which is a comparison between the number of platelets and white blood cells, so the higher PWR will provide better clinical outcomes. Here, we examined correlation between PWR and clinical outcome in acute ischemic stroke using NIHSS tools.

Method

This research method was a retrospective analytic from 503 medical records of ischemic stroke patients from January 2015 to December 2017. Ischemic stroke divided into 2 groups: cardioembolic stroke and atherothrombotic stroke based on medical records. We calculated PWR and National Institute of Health Stroke Scale (NIHSS) for assessing clinical outcome. Statistical significance calculated with Spearman rank test, ANOVA, and multiple logistic regression.

Results

A total of 391 research subjects consisting of 213 females (54.5%) and 178 males (45.5%). The mean age of 57.14 years, and 82% subjects had hypertension as risk factor. Mean PWR of atherothrombotic stroke subjects were higher than cardioembolic stroke (33.02 vs 26.73) but had lower mean of NIHSS (5.81 vs 10.31) and had strong negative significant correlation between PWR and NIHSS (r = -0.9603; p < 0.001). From logistic regression, we found that PWR and platelet was statistically significance correlate with NIHSS (p < 0.05). The coefficient if PWR is the highest (absolute value) among other independent variables.It shows that PWR has positive effect on clinical outcome using NIHSS tools in acute ischemic stroke patients.

Conclusion

Cardioembolic stroke had higher PWR compared with atherothrombotic stroke. PWR had a strong correlation with NIHSS. The higher PWR will provide higher NIHSS and PWR has positive effect on clinical outcome using NIHSS tools in acute ischemic stroke patients.

Stroke Factors Associated with Thrombolysis Use in Hospitals in Singapore and US: A Cross-Registry Comparative Study

BACKGROUND AND OBJECTIVES

This paper aims to describe and compare the characteristics of 2 stroke populations in Singapore and in St. Louis, USA, and to document thrombolysis rates and contrast factors associated with its uptake in both populations.

METHODS

The stroke populations described were from the Singapore Stroke Registry (SSR) in -Singapore and the Cognitive Rehabilitation Research Group Stroke Registry (CRRGSR) in St. Louis, MO, USA. The registries were compared in terms of demographics and stroke risk factor history. Logistic regression was used to determine factors associated with thrombolysis uptake.

RESULTS

A total of 39,323 and 8,106 episodes were recorded in SSR and CRRGSR, respectively, from 2005 to 2012. Compared to CRRGSR, patients in SSR were older, male, and from the ethnic majority. Thrombolysis rates in SSR and CRRGSR were 2.5 and 8.2%, respectively, for the study period. History of ischemic heart disease or atrial fibrillation was associated with increased uptake in both populations, while history of stroke was associated with lower uptake. For SSR, younger age and males were associated with increased uptake, while having a history of smoking or diabetes was associated with decreased uptake. For CRRGSR, ethnic minority status was associated with decreased uptake.

CONCLUSIONS

The comparison of stroke populations in Singapore and St Louis revealed distinct differences in clinicodemographics of the 2 groups. Thrombolysis uptake was driven by nonethnicity demographics in Singapore. Ethnicity was the only demographic driver of uptake in the CRRGSR population, highlighting the need to target ethnic minorities in increasing access to thrombolysis.

Estimating morbidity due to stroke in Nigeria: a systematic review and meta-analysis

BACKGROUND

The response to stroke in Nigeria is impaired by inadequate epidemiologic information. We sought to collate available evidence and estimate the incidence of stroke and prevalence of stroke survivors in Nigeria.

METHODS

Using random effects meta-analysis, we pooled nationwide and regional incidence and prevalence of stroke from the estimates reported in each study.

RESULTS

Eleven studies met our selection criteria. The pooled crude incidence of stroke in Nigeria was 26.0 (12.8-39.0) /100,000 person-years, with this higher among men at 34.1 (9.7-58.4) /100,000, compared to women at 21.2 (7.4-35.0) /100,000. The pooled crude prevalence of stroke survivors in Nigeria was 6.7 (5.8-7.7) /1000 population, with this also higher among men at 6.4 (5.1-7.6) /1000, compared to women at 4.4 (3.4-5.5) /1000. In the period 2000-2009, the incidence of stroke in Nigeria was 24.3 (95% CI: 11.9-36.8) per 100,000, with this increasing to 27.4 (95% CI: 2.2-52.7) per 100,000 from 2010 upwards. The prevalence of stroke survivors increased minimally from 6.0 (95% CI: 4.6-7.5) per 1000 to 7.5 (95% CI: 5.8-9.1) per 1000 over the same period. The prevalence of stroke survivors was highest in the South-south region at 13.4 (9.1-17.8) /100,000 and among rural dwellers at 10.8 (7.5-14.1) /100,000.

CONCLUSION

Although study period does not appear to contribute substantially to variations in stroke morbidity in Nigeria, an increasing number of new cases compared to survivors may be due in part to limited door-door surveys, or possibly reflects an increasing mortality from stroke in the country.

Associations for BCO2, PCSK9, and TR1B1 Polymorphism and Lifestyle Factors with Ischemic Stroke: A Nested Case-Control Study

PURPOSE

To investigate associations for polymorphisms in β-carotene 9',10'-oxygenase (BCO2, rs10431036 and rs11214109), proprotein convertase subtilisin kexin type 9 (PCSK9, rs11583680), and tribbles pseudokinase 1 (TRIB1, rs17321515 and rs2954029), as well as lifestyle factors, with ischemic stroke (IS).

MATERIALS AND METHODS

This nested case-control study included 161 patients with IS and 483 matched control individuals. We collected medical reports, lifestyle details, and blood samples from individuals and used the PCR-ligase detection reaction method to genotype single nucleotide polymorphisms (SNPs).

RESULTS

The GA+AA genotype of rs10431036 (p<0.001) and rs17321515 (p=0.003), the CT+TT genotype of rs11214109 (p=0.005), and the TA+AA genotype of rs2954029 (p=0.006) in dominant models increased the risk of IS. In additive models, the GG genotype of rs17321515 (p=0.005) and the TT genotype of rs2954029 (p=0.008) increased the risk of IS. Adequate intake of fruits/vegetables reduced the risk of IS (p=0.005). Although there was no interaction between genes and fruits/vegetables, people with inadequate intake of fruits/vegetables who carried a risk genotype had a higher risk of IS than those only having inadequate fruits/vegetables intake or those only carrying a risk genotype. Also, the haplotypes AC, AT, and GT (comprising rs10431036 and rs11214109) and GT (comprising rs2954029 and rs17321515) were found to be associated with an increased risk of IS (p<0.05).

CONCLUSION

Polymorphisms in BCO2 and TRIB1 and fruits/vegetables intake were associated with IS. These results provide the theoretical basis for gene screening to prevent chronic cerebrovascular diseases.

Immune-inflammatory, oxidative stress and biochemical biomarkers predict short-term acute ischemic stroke death

The aim of the study was to define new immune-inflammatory, oxidative stress and biochemical biomarkers, which predict mortality within a period of 3 months after acute ischemic stroke (AIS). We recruited 176 healthy volunteers and 145 AIS patients, categorized as AIS survivors and non-survivors, and measured interleukin (IL)-6, high sensitivity C-reactive protein (hsCRP), ferritin, iron, total serum protein (TSP), erythrocyte sedimentation rate (ESR), white blood cells (WBC), 25 hydroxyvitamin D [25(OH)D], lipid hydroperoxides (CL-LOOH), insulin, glucose and high-density lipoprotein (HDL)-cholesterol. In patients, these biomarkers were measured within 24 h after AIS onset. We also computed two composite scores reflecting inflammatory indices, namely INFLAM index1 (sum of z scores of hsCRP+IL-6 + ferritin+ESR + WBC) and INFLAM index2 (z INFLAM index1 - z 25(OH)D - z iron + z TSP). Three months after AIS, non-survivors (n = 54) showed higher baseline levels of IL-6, hsCRP, ferritin and glucose and lower levels of HDL-cholesterol and 25(OH)D than survivors (n = 91). Non-survivors showed higher baseline ESR and lowered TSP than controls, while survivors occupied an intermediate position. Death after AIS was best predicted by increased IL-6, glucose, ferritin and CL-LOOH and lowered 25(OH)D levels. The area under the receiver operating curves computed on the INFLAM index1 and 2 scores were 0.851 and 0.870, respectively. In conclusion, activation of peripheral immune-inflammatory, oxidative and biochemical pathways is critically associated with mortality after AIS. Our results may contribute to identify new biomarker sets, which may predict post-stroke death, as well as suggest that IL-6 trans-signaling coupled with redox imbalances may be possible new targets in the prevention of short-term outcome AIS death.

Cost-utility analysis of the National Health Screening Program for chronic kidney disease in Korea

AIM

Although a National Health Screening Program (NHSP) for chronic kidney disease (CKD) has been implemented in Korea since 2002, its cost-effectiveness has never been determined. This study aimed to estimate the cost-utility of NHSP for CKD in Korea.

METHODS

A Markov decision analytic model was constructed to compare CKD screening strategies of the NHSP with no screening. We developed a model that simulated disease progression in a cohort aged 20-120 years or death from the societal perspective.

RESULTS

Biannual screening starting at age 40 for CKD by proteinuria (dipstick) and estimated glomerular filtration ratio had an ICUR of $66 874/QALY relative to no screening. The targeted screening strategy had an ICUR of $37 812/QALY and $40 787/QALY for persons with diabetes and hypertension, respectively. ICURs improved with lower cost strategies. The most influential parameter that might make screening more cost-effective was the effectiveness of treatment on CKD to decrease disease progression and mortality.

CONCLUSIONS

The Korean NHSP for CKD is more cost-effective for patients with diabetes or hypertension than the general population, consistent with prior studies. Although it is too early to conclude the cost-effectiveness of the Korean NHSP for CKD, this study provides evidence that is useful in evaluating the cost-effectiveness of CKD interventions.

Weight change and mortality and cardiovascular outcomes in patients with new-onset diabetes mellitus: a nationwide cohort study

BACKGROUND

Because weight control is a cornerstone of diabetes management, it is important to understand the relationship of weight change to risk of cardiovascular disease (CVD) among patients with type 2 diabetes mellitus (DM). We aimed to investigate whether changes in weight early after diagnosis influence the incidence of CVD and all-cause mortality in patients with type 2 DM.

METHODS

Using nationally representative data from the Korean National Health Insurance System, 173,246 subjects with new-onset DM who underwent health examinations during 2007-2012 were included. Weight was measured at the time of diabetes diagnosis and 2 years later. Weight change over 2 years was divided into five categories of 5% weight change, from weight loss ≥ - 10% to weight gain ≥ 10%.

RESULTS

There were 3113 deaths (1.8%), 2060 cases of stroke (1.2%), and 1767 myocardial infarctions (MIs) (1.0%) during a median follow-up of 5.5 years. Subjects with weight gain ≥ 10% had a significantly higher risk of stroke (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.23-1.84), compared with the group with stable weight. There was no significant association between weight change after diagnosis of DM and incident MI. All-cause mortality showed a U-shaped curve according to weight change. The group with weight loss ≥ - 10% had the highest HR for all-cause mortality (HR 1.86; 95% CI 1.61-2.14) and the HR for weight gain ≥ 10% was 1.61 (95% CI 1.37-1.89).

CONCLUSIONS

Weight changes of more than 10% after diabetes diagnosis were associated with higher mortality and over 10% weight gain was associated with increased risk of stroke.

Association of apolipoprotein A1 and A5 polymorphisms with stroke subtypes in Han Chinese people in Taiwan

BACKGROUND AND PURPOSES

Stroke is a leading cause of death and serious disability worldwide. Now, evidences indicate that dyslipidemia may play an important role in stroke. APOA1 and APOA5 involve in lipid metabolism. In this study, we investigated the association of APOA1 rs670 and APOA5 rs662799 with different stroke subtypes in the Han Chinese population of Taiwan.

METHODS

A total of 1751 participants, including 459 control subjects, 606 large artery atherosclerosis (LAA), 339 small vessel occlusion (SVO), and 347 hypertensive intracranial hemorrhage (HICH), were enrolled. The presence of rs670 and rs662799 was analyzed through polymerase chain react ion and matrix-assisted laser desorption/ionization-time-of-flight-mass spectrometry.

RESULTS

Notably, the frequency of the rs662799 C allele was significantly lower in the SVO patients than in the controls (24.36% vs. 29.74%, P = 0.024). The frequencies of heterozygote TC [odd ratio (OR) = 0.732, 95% confidence interval (CI) = 0.544-0.984, P = 0.038] and TC + CC (OR = 0.719, 95% CI = 0.542-0.953, P = 0.022) genotypes were significantly lower in the SVO patients than in the controls. In addition, triglyceride levels in individuals carrying the rs662799 TC + CC genotype were significantly higher than in those carrying the TT genotype, especially in older age, female, and body mass index (BMI) ≥ 25 groups. On the contrary, the low-density lipoprotein-cholesterol (LDL-C) was significantly lower in rs662799 TC + CC genotype than TT genotype. The BMI was significantly lower in subjects with rs662799 TC + CC genotype than those with TT genotype, especially in older age and female. High-density lipoprotein-cholesterol (HDL-C) levels were higher in individuals carrying the rs670 GG genotype than in those carrying the AG + AA genotype, especially in BMI < 25 group. Logistic regression analysis showed that the rs662799 C allele (TC + CC) was an independent protective factor for SVO after adjustment for conventional risk factors (OR = 0.709, 95% CI = 0.526-0.956; P = 0.024).

CONCLUSION

GG genotype of rs670 is correlated with high serum HDL-C levels, whereas TC + CC genotype of rs662799 is associated with high serum triglyceride and low LDL and BMI levels. In addition, the rs662799 C allele (TC + CC) is an independent protective factor for SVO in the Han Chinese population in Taiwan.

Determinants of Stroke in a General Male Population

Background and Purpose—

To further improve preventive strategies against stroke, there is a need for epidemiological long-term studies. The study aimed at a prospective investigation of stroke determinants in the general male population.

Methods—

During a period of 48 years, from 50 to 98 years of age, a population-based sample of 854 men was followed using repeated medical examinations, lifestyle questionnaires, data from hospital records and the National Cause of Death Register.

Results—

Determinants of ischemic stroke were atrial fibrillation (hazard ratio [HR], 6.61; 95% CI, 4.47–9.77); mother dead from cardiovascular disease (HR, 1.53; 1.09–2.17); high education (HR, 0.81; 0.69–0.96); and high physical activity level during leisure time (HR, 0.68; 0.50–0.93). For hemorrhagic stroke heart rate (HR, 1.04; 1.01–1.06) and mother dead from stroke (HR, 3.56; 1.43–8.87) constituted an increased risk. Statistically significant determinants for all stroke were atrial fibrillation (HR, 5.34; 3.68–7.75); high diastolic blood pressure (HR, 1.02; 1.01–1.03); high body weight (HR, 0.96; 0.94–0.99); high educational level (HR, 0.79; 0.68–0.92); wide waist circumference (HR, 1.04; 1.01–1.07); smoking (HR, 1.25; 1.06–1.48); mother dead from cerebrovascular disease (HR, 1.43; 1.05–1.94); and diabetes mellitus (HR, 1.65; 1.02–2.68). Of all men diagnosed with atrial fibrillation, 88% had a stroke during follow-up.

Conclusions—

Atrial fibrillation was by far the strongest determinant of stroke during 48 years of follow-up in a male population sample followed until the age of 98 years. The results warrant improved prophylaxis through intense treatment of modifiable determinants.

Obstructive sleep apnea and stroke

Obstructive Sleep Apnea (OSA) is a common co-morbid condition in stroke patients. It represents a very important risk factor for stroke in addition to the other established ones such as hypertension, cardiovascular disease (CVD), hyperlipidemia, atrial fibrillation (AF), type 2 diabetes mellitus (T2DM), stress, smoking, and heavy drinking. Although in the United States the prevalence of OSA has somewhat decreased from the previous years, globally its prevalence remains constant, or in some cases, is on the rise. In this review we present the epidemiology for OSA in stroke populations and discuss the risk factors for stroke as well as the underlying pathogenetic mechanisms linking OSA, stroke and CVD. We also emphasize the more thorough evaluation and control of OSA in order to prevent the disabling side effects of a stroke, which not only compromises the physical and mental health of a person and increases the burden on families, but also adds a severe burden to national health economics. OSA should always be considered when assessing a patient with transient ischemic attacks (TIA). Work up and treatment for OSA will not only help prevent stroke with its devastating consequences, but will also help prevent CVD, and ameliorate co-morbid conditions such as diabetes and hypertension in these vulnerable populations.

The Epidemiological Characteristics of Stroke in Hunan Province, China

Previous studies have shown that Hunan Province has a high incidence of stroke and a high proportion of intracerebral hemorrhage (ICH). Considering the changes over the past three decades, little is known about the current epidemiological characteristics of stroke in Hunan Province. In 2013, a cross-sectional study was conducted at seven national disease surveillance points (DSPs) in Hunan Province. A multistage cluster sampling method was used to select a representative sample. A total of 21,156 participants aged 20 years and older were examined. Among the 21,156 participants, the number of prevalent strokes, incident strokes and deaths was 307, 87, and 36, respectively. The 2010 China census-standardized prevalence, incidence and mortality were 1191.0 per 100,000 people [95% confidence interval (CI) 1044.8-1337.2], 333.6 per 100,000 person-years (95% CI 255.7-411.5) and 129.7 per 100,000 person-years (95% CI 81.1-178.3), respectively. Ischemic stroke (IS), ICH, subarachnoid hemorrhage (SAH), and stroke of undetermined type (UND) constituted 50.6, 41.4, 5.7, and 2.3% of all incident stroke cases, respectively. Tianxin, Liuyang, Wuling, and Hongjiang have high proportions of ICH (61.5, 58.3, 60, and 50%, respectively). Hypertension is the most common risk factor for prevalent stroke (71.34%), followed by smoking (30.62%) and alcohol use (25.73%). In conclusion, Hunan Province has an extremely heavy stroke burden. The high proportion of ICH is not limited to the Changsha community; it represents an important issue for all of Hunan Province.

The Natural Compound Dansameum Reduces foam Cell Formation by Downregulating CD36 and Peroxisome Proliferator-activated Receptor-gamma; Expression

Background:

Atherosclerosis-induced vascular disorders are major causes of death in most western countries. During the development of atherosclerotic lesions, foam cell formation is essential and formed through the expression of CD36 and the peroxisome proliferator-activated receptor gamma (PPAR-γ).

Objective:

To investigate whether dansameum extract (DSE) could show anti-atherosclerotic effect through down-regulating cellular redox state including CD36 and PARP-γ expression in oxidative low-density lipoprotein (oxLDL)-treated RAW264.7 cells and on differentiated foam cells in ApoE Knockout (ApoE-/-) mice.

Materials and Methods:

The Korean polyherbal medicine DSE was prepared from three plants in the following proportions: 40 g of Salvia miltiorrhiza root, 4 g of Amomumxanthioides fruit, and 4 g of Santalum album lignum. The immunohistochemistry and reverse transcription-polymerase chain reaction was used for analysis of protein and mRNA involved in foam cell formation.

Results:

We first showed that effects of DSE on foam cell formation in both oxLDL-induced RAW264.7 cells and in blood vessels from apolipoprotein E deficientApoE-/- mice with high fat diet-fed. DSE treatment significantly reduced the expression of CD36 and PPAR-γ in oxLDL-stimulated RAW264.7 cells and ApoE-/-mice, in the latter case by regulating heme oxygenase-1. Furthermore, DSE treatment also reduced cellular lipid content in vitro and in vivo experiments.

Conclusion:

Our data suggest that DSE may have anti-atherosclerotic properties through regulating foam cell formation.

SUMMARY

Dansameum extract (DSE) Regulates the expression of CD36 and peroxisome proliferator-activated receptor gamma in oxidative low-density lipoprotein-stimulated RAW264.7 Cells and ApoE Knockout (ApoE Knockout [ApoE-/-]) mice

DSE Regulates Cholesterol Levels in the Serum of ApoE-deficient (ApoE-/-) mice

DSE Reduced the Formation of Foam Cells by Regulating heme oxygenase-1 in ApoE-/- mice with high fat diet-fed.

Abbreviations used: DSE: Dansameum extract, PPAR-γ: Peroxisome proliferator-activated receptor γ, HO-1: Heme oxygenase-1, CVD: Cardiovascular diseases

Differences in risk factors for 3 types of stroke: UK prospective study and meta-analyses

OBJECTIVE

To compare associations of behavioral and related factors for incident subarachnoid hemorrhage and intracerebral hemorrhage and ischemic stroke.

METHODS

A total of 712,433 Million Women Study participants without prior stroke, heart disease, or cancer reported behavioral and related factors at baseline (1999-2007) and were followed up by record linkage to national hospital admission and death databases. Cox regression yielded adjusted relative risks (RRs) by type of stroke. Heterogeneity was assessed with χ2 tests. When appropriate, meta-analyses were done of published prospective studies.

RESULTS

After 12.9 (SD 2.6) years of follow-up, 8,128 women had an incident ischemic stroke, 2,032 had intracerebral hemorrhage, and 1,536 had subarachnoid hemorrhage. In women with diabetes mellitus, the risk of ischemic stroke was substantially increased (RR 2.01, 95% confidence interval [CI] 1.84-2.20), risk of intracerebral hemorrhage was increased slightly (RR 1.31, 95% CI 1.04-1.65), but risk of subarachnoid hemorrhage was reduced (RR 0.43, 95% CI 0.26-0.69) (heterogeneity by stroke type, p < 0.0001). Stroke incidence was greater in women who rated their health as poor/fair compared to those who rated their health as excellent/good (RR 1.36, 95% CI 1.30-1.42). Among 565,850 women who rated their heath as excellent/good, current smokers were at an increased risk of all 3 stroke types, (although greater for subarachnoid hemorrhage [≥15 cigarettes/d vs never smoker, RR 4.75, 95% CI 4.12-5.47] than for intracerebral hemorrhage [RR 2.30, 95% CI 1.94-2.72] or ischemic stroke [RR 2.50, 95% CI 2.29-2.72]; heterogeneity p < 0.0001). Obesity was associated with an increased risk of ischemic stroke and a decreased risk of hemorrhagic stroke (heterogeneity p < 0.0001). Meta-analyses confirmed the associations and the heterogeneity across the 3 types of stroke.

CONCLUSION

Classic risk factors for stroke have considerably different effects on the 3 main pathologic types of stroke.

Risk of Stroke in Elderly Dialysis Patients

Despite the current knowledge about the risk of stroke and its related factors in general population, this issue in elderly patients receiving dialysis remains unresolved. Firstly, to compare the risk of stroke between hemodialysis (HD) and peritoneal dialysis (PD), data on 13,065 incident dialysis patients (aged ≥ 65 years; 10,675 in HD and 2,390 in PD) were retrieved from the Korean Health Insurance dataset. Secondly, to identify the risk factors of stroke amongst various clinical and laboratory parameters in HD, 980 elderly patients were retrospectively analyzed using an independent prospective cohort from 31 dialysis centers. For a mean duration of 1.8 years (maximum of 5 years), the risk of all cardiovascular diseases (ischemic heart disease and stroke) did not differ between HD and PD. However, when analyses were conducted separately by subtype, the risk of stroke, not ischemic heart disease, was significantly higher in HD patients than in PD patients. When the risk factors of stroke were probed after HD for a mean duration of 2.6 years (maximum of 7 years), the absolute dependence on social support, a previous history of cardiovascular disease, high levels of low-density lipoprotein cholesterol, and the use of a high number of anti-hypertensive drugs were identified as being significant. Based on the discrepancy of stroke risk between modalities and the HD-tailored risk factors of stroke, the monitoring and management of these factors may be a key strategy to reduce the risk of stroke in elderly patients receiving dialysis.

The relationship between different dimensions of alcohol use and the burden of disease-an update

BACKGROUND AND AIMS

Alcohol use is a major contributor to injuries, mortality and the burden of disease. This review updates knowledge on risk relations between dimensions of alcohol use and health outcomes to be used in global and national Comparative Risk Assessments (CRAs).

METHODS

Systematic review of reviews and meta-analyses on alcohol consumption and health outcomes attributable to alcohol use. For dimensions of exposure: volume of alcohol use, blood alcohol concentration and patterns of drinking, in particular heavy drinking occasions were studied. For liver cirrhosis, quality of alcohol was additionally considered. For all outcomes (mortality and/or morbidity): cause of death and disease/injury categories based on International Classification of Diseases (ICD) codes used in global CRAs; harm to others.

RESULTS

In total, 255 reviews and meta-analyses were identified. Alcohol use was found to be linked causally to many disease and injury categories, with more than 40 ICD-10 three-digit categories being fully attributable to alcohol. Most partially attributable disease categories showed monotonic relationships with volume of alcohol use: the more alcohol consumed, the higher the risk of disease or death. Exceptions were ischaemic diseases and diabetes, with curvilinear relationships, and with beneficial effects of light to moderate drinking in people without heavy irregular drinking occasions. Biological pathways suggest an impact of heavy drinking occasions on additional diseases; however, the lack of medical epidemiological studies measuring this dimension of alcohol use precluded an in-depth analysis. For injuries, except suicide, blood alcohol concentration was the most important dimension of alcohol use. Alcohol use caused marked harm to others, which has not yet been researched sufficiently.

CONCLUSIONS

Research since 2010 confirms the importance of alcohol use as a risk factor for disease and injuries; for some health outcomes, more than one dimension of use needs to be considered. Epidemiological studies should include measurement of heavy drinking occasions in line with biological knowledge.

The relationship between different dimensions of alcohol use and the burden of disease-an update

BACKGROUND AND AIMS

Alcohol use is a major contributor to injuries, mortality and the burden of disease. This review updates knowledge on risk relations between dimensions of alcohol use and health outcomes to be used in global and national Comparative Risk Assessments (CRAs).

METHODS

Systematic review of reviews and meta-analyses on alcohol consumption and health outcomes attributable to alcohol use. For dimensions of exposure: volume of alcohol use, blood alcohol concentration and patterns of drinking, in particular heavy drinking occasions were studied. For liver cirrhosis, quality of alcohol was additionally considered. For all outcomes (mortality and/or morbidity): cause of death and disease/injury categories based on International Classification of Diseases (ICD) codes used in global CRAs; harm to others.

RESULTS

In total, 255 reviews and meta-analyses were identified. Alcohol use was found to be linked causally to many disease and injury categories, with more than 40 ICD-10 three-digit categories being fully attributable to alcohol. Most partially attributable disease categories showed monotonic relationships with volume of alcohol use: the more alcohol consumed, the higher the risk of disease or death. Exceptions were ischaemic diseases and diabetes, with curvilinear relationships, and with beneficial effects of light to moderate drinking in people without heavy irregular drinking occasions. Biological pathways suggest an impact of heavy drinking occasions on additional diseases; however, the lack of medical epidemiological studies measuring this dimension of alcohol use precluded an in-depth analysis. For injuries, except suicide, blood alcohol concentration was the most important dimension of alcohol use. Alcohol use caused marked harm to others, which has not yet been researched sufficiently.

CONCLUSIONS

Research since 2010 confirms the importance of alcohol use as a risk factor for disease and injuries; for some health outcomes, more than one dimension of use needs to be considered. Epidemiological studies should include measurement of heavy drinking occasions in line with biological knowledge.

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.

Traditional Risk Factors for Stroke in East Asia

Stroke is one of the leading causes of death and morbidity worldwide. The occurrence of stroke is strongly dependent on well-known vascular risk factors. After rapid modernization, urbanization, and mechanization, East Asian countries have experienced growth in their aged populations, as well as changes in lifestyle and diet. This phenomenon has increased the prevalence of vascular risk factors among Asian populations, which are susceptible to developing cardiovascular risk factors. However, differing patterns of stroke risk factor profiles have been noted in East Asian countries over the past decades. Even though the prevalence of vascular risk factors has changed, hypertension is still prevalent and the burden of diabetes and hypercholesterolemia will continue to increase. Asia remains a high tobacco-consuming area. Although indicators of awareness and management of vascular risk factors have increased in many East Asian countries, their rates still remain low. Here we review the burdens of traditional risk factors, such as hypertension, diabetes, hypercholesterolemia, and smoking in East Asia. We will also discuss the different associations between these vascular risk factors and stroke in Asian and non-Asian populations.

Association of dementia with death after ischemic stroke: A two-year prospective study

The association between dementia and the risk of death after ischemic stroke was investigated. Neurological, neuropsychological and functional assessments were evaluated in 619 patients with acute ischemic stroke. Dementia was diagnosed at admission and at three months after stroke onset. The patients were scheduled for a two-year follow-up after the index stroke. The Kaplan-Meier survival and Cox proportional hazards regression analyses were used to estimate the cumulative proportion of survival, and the association between dementia and risk of death after stroke. In total, 146 patients (23.6%) were diagnosed with dementia after stroke. The cumulative proportion of surviving cases was 49.3% in patients with dementia after a median follow-up of 21.2±5.6 months, and 92.5% in patients without dementia. Multivariate analysis revealed that dementia (HR, 7.21; 95% CI, 3.85–13.49) was associated with death, independent of age, atrial fibrillation, previous stroke and NIH stroke scale. In conclusion, the mortality rate is increased in stroke patients with dementia. Dementia is an important risk factor for death after stroke, independent of age, atrial fibrillation, previous stroke, and the severity of the stroke.

Cost-effectiveness of amlodipine compared with valsartan in preventing stroke and myocardial infarction among hypertensive patients in Taiwan

Hypertension is a major risk factor for strokes and myocardial infarction (MI). Given its effectiveness and safety profile, the calcium channel blocker amlodipine is among the most frequently prescribed antihypertensive drugs. This analysis was conducted to determine the costs and quality-adjusted life years (QALYs) associated with the use of amlodipine and valsartan, an angiotensin II receptor blocker, in preventing stroke and MI in Taiwanese hypertensive patients. A state transition (Markov) model was developed to compare the 5-year costs and QALYs for amlodipine and valsartan. Effectiveness data were based on the NAGOYA HEART Study, local studies, and a published meta-analysis. Utility data and costs of MI and stroke were retrieved from the published literature. Medical costs were based on the literature and inflated to 2011 prices; drug costs were based on National Health Insurance prices in 2014. A 3% discount rate was used for costs and QALYs and a third-party payer perspective adopted. One-way sensitivity and scenario analyses were conducted. Compared with valsartan, amlodipine was associated with cost savings of New Taiwan Dollars (NTD) 2,251 per patient per year: costs were NTD 4,296 and NTD 6,547 per patient per year for amlodipine and valsartan users, respectively. Fewer cardiovascular events were reported in patients receiving amlodipine versus valsartan (342 vs 413 per 10,000 patients over 5 years, respectively). Amlodipine had a net gain of 58 QALYs versus valsartan per 10,000 patients over 5 years. Sensitivity analyses showed that the discount rate and cohort age had a larger effect on total cost and cost difference than on QALYs. However, amlodipine results were more favorable than valsartan irrespective of discount rate or cohort age. When administered to Taiwanese patients for hypertension control, amlodipine was associated with lower cost and more QALYs compared with valsartan due to a lower risk of stroke and MI events.

Alcoholic liver disease: Clinical and translational research

The present review spans a broad spectrum of topics dealing with alcoholic liver disease (ALD), including clinical research, translational research, pathogenesis and therapies. A special accent is placed on alcohol misuse, as alcohol is a legally commercialized and taxable product. Drinking alcohol, particularly from a young age, is a major health problem. Alcoholism is known to contribute to morbidity and mortality. A systematic literature search was performed in order to obtain updated data (2008-2015). The review is focused on genetic polymorphisms of alcohol metabolizing enzymes and the role of cytochrome p450 2E1 and iron in ALD. Alcohol-mediated hepatocarcinogenesis is also discussed in the presence or absence of co-morbidities such as viral hepatitis C as well as therapeutic the role of innate immunity in ALD-HCV. Moreover, emphasis was placed on alcohol and drug interactions, as well as liver transplantation for end-stage ALD. Finally, the time came to eradicate alcohol-induced liver and intestinal damage by using betaine.

The Indian consensus guidance on stroke prevention in atrial fibrillation: An emphasis on practical use of nonvitamin K oral anticoagulants

The last ten years have seen rapid strides in the evolution of nonvitamin K oral anticoagulants (NOACs) for stroke prevention in patients with atrial fibrillation (AF). For the preparation of this consensus, a comprehensive literature search was performed and data on available trials, subpopulation analyses, and case reports were analyzed. This Indian consensus document intends to provide guidance on selecting the right NOAC for the right patients by formulating expert opinions based on the available trials and Asian/Indian subpopulation analyses of these trials. A section has been dedicated to the current evidence of NOACs in the Asian population. Practical suggestions have been formulated in the following clinical situations: (i) Dose recommendations of the NOACs in different clinical scenarios; (ii) NOACs in patients with rheumatic heart disease (RHD); (iii) Monitoring anticoagulant effect of the NOACs; (iv) Overdose of NOACs; (v) Antidotes to NOACs; (vi) Treatment of hypertrophic cardiomyopathy (HCM) with AF using NOACs; (vii) NOACs dose in elderly, (viii) Switching between NOACs and vitamin K antagonists (VKA); (ix) Cardioversion or ablation in NOAC-treated patients; (x) Planned/emergency surgical interventions in patients currently on NOACs; (xi) Management of bleeding complications of NOACs; (xii) Management of acute coronary syndrome (ACS) in AF with NOACs; (xiii) Management of acute ischemic stroke while on NOACs.

Acute Stroke Registry Malaysia, 2010-2014: Results from the National Neurology Registry

BACKGROUND

Stroke remains a major health burden worldwide. The incidence and prevalence rates of stroke are decreasing in developed countries, an opposite trend is taking place in the Asia Pacific, where an increasing number of patients are being diagnosed with acute stroke. The results of the present study on acute stroke in multi-ethnic Malaysia will significantly contribute to the global stroke epidemiological data. We aimed to present epidemiological data of stroke including incidence and prevalence rates as well as associated risk factors from a prospective nationwide hospital-based registry from 2010 to 2014.

METHODS

Patients diagnosed with stroke upon admission at the hospital were prospectively enrolled into the registry from January 1, 2010, to December 31, 2014. Descriptive analyses were performed.

RESULTS

A total of 7668 patients were available for analysis. On average, patients were aged 62.7 years (standard deviation of 12.5). Ischemic stroke accounts for 79.4% of the cohort with a slightly higher proportion of male patients (55%). Ischemic stroke incidence is estimated to increase annually by 29.5% and hemorrhagic stroke by 18.7%. Hypertension is a major risk factor for both ischemic and hemorrhagic strokes regardless of stroke event with an excess of 8.4% hypertensive female compare to male patients (P ≤ .001). Majority of patients with ischemic and hemorrhagic strokes experienced mild and moderate stroke with 11.7% and 21.1%, respectively, documented as severe (P ≤ .001).

CONCLUSIONS

The incidence and prevalence of stroke in Malaysia increased dramatically in the 5-year study period. Therefore, implementation of risk factor control strategies is important to prevent further increase of stroke burden in the country.

Alcohol Dehydrogenase-1B (rs1229984) and Aldehyde Dehydrogenase-2 (rs671) Genotypes Are Strong Determinants of the Serum Triglyceride and Cholesterol Levels of Japanese Alcoholic Men

BACKGROUND

Elevated serum triglyceride (TG) and high-density-lipoprotein cholesterol (HDL-C) levels are common in drinkers. The fast-metabolizing alcohol dehydrogenase-1B encoded by the ADH1B*2 allele (vs. ADH1B*1/*1 genotype) and inactive aldehyde dehydrogenase-2 encoded by the ALDH2*2 allele (vs. ALDH2*1/*1 genotype) modify ethanol metabolism and are prevalent (≈90% and ≈40%, respectively) in East Asians. We attempted to evaluate the associations between the ADH1B and ALDH2 genotypes and lipid levels in alcoholics.

METHODS

The population consisted of 1806 Japanese alcoholic men (≥40 years) who had undergone ADH1B and ALDH2 genotyping and whose serum TG, total cholesterol, and HDL-C levels in the fasting state had been measured within 3 days after admission.

RESULTS

High serum levels of TG (≥150 mg/dl), HDL-C (>80 mg/dl), and low-density-lipoprotein cholesterol (LDL-C calculated by the Friedewald formula ≥140 mg/dl) were observed in 24.3%, 16.8%, and 15.6%, respectively, of the subjects. Diabetes, cirrhosis, smoking, and body mass index (BMI) affected the serum lipid levels. Multivariate analysis revealed that the presence of the ADH1B*2 allele and the active ALDH2*1/*1 genotype increased the odds ratio (OR; 95% confidence interval) for a high TG level (2.22 [1.67-2.94] and 1.39 [0.99-1.96], respectively), and decreased the OR for a high HDL-C level (0.37 [0.28-0.49] and 0.51 [0.37-0.69], respectively). The presence of the ADH1B*2 allele decreased the OR for a high LDL-C level (0.60 [0.45-0.80]). The ADH1B*2 plus ALDH2*1/*1 combination yielded the highest ORs for high TG levels and lowest OR for a high HDL-C level. The genotype effects were more prominent in relation to the higher levels of TG (≥220 mg/dl) and HDL-C (≥100 mg/dl).

CONCLUSIONS

The fast-metabolizing ADH1B and active ALDH2, and especially a combination of the two were strongly associated with higher serum TG levels and lower serum HDL-C levels of alcoholics. The fast-metabolizing ADH1B was associated with lower serum LDL-C levels.