Self-perceived psychological stress and ischemic stroke: a case-control study

Protective effect of alpha-ketoglutarate against water-immersion restraint stress-induced gastric mucosal damage in mice

Gastric lesions have several aetiologies, among which stress is the most prominent. Therefore, identification of new therapies to prevent stress is of considerable importance. Alpha-ketoglutarate (α-kg) several beneficial effects and has shown promise in combating oxidative stress, inflammation, and premature aging. Thus, this study aimed to evaluate the protective effect of α-kg in a gastric damage model by water-immersion restraint stress (WIRS). Pretreatment with α-kg decreased stress-related histopathological scores of tissue oedema, cell loss, and inflammatory infiltration. The α-kg restored the percentage of type III collagen fibres. Mucin levels were preserved as well as the structure and area of the myenteric plexus ganglia were preserved after pretreatment with α-kg. Myeloperoxidase (MPO) levels and the expression of pro-inflammatory cytokines (TNF-α and IL-1β) were also reduced following α-kg pretreatment. Decreased levels of glutathione (GSH) in the stress group were restored by α-kg. The omeprazole group was used as standard drug e also demonstrated improve on some parameters after the exposition to WIRS as inflammatory indexes, GSH and mucin. Through this, was possible to observe that α-kg can protect the gastric mucosa exposed to WIRS, preserve tissue architecture, reduce direct damage to the mucosa and inflammatory factors, stimulate the production of type III collagen and mucin, preserve the myenteric plexus ganglia, and maintain antioxidant potential. Due to, we indicate that α-kg has protective activity of the gastric mucosa, demonstrating its ability to prevent damage associated with gastric lesions caused by stress.

Depression, anxiety, insomnia, stress, and the way of coping emotions as risk factors for ischemic stroke and their influence on stroke severity: A case-control study in Lebanon

BACKGROUND

Stroke is a leading cause of disability and death worldwide. There are numerous debates regarding the relationship between depression, anxiety, insomnia, perceived stress, and ischemic stroke. Moreover, no research on the efficacy of emotion regulation, which is critical for various components of healthy affective and social adaptability, is being conducted. To the best of our knowledge, this is the first study in the MENA region to shed light on the relationship between these conditions and stroke risk, aiming to determine whether depression, anxiety, insomnia, stress, and the way of coping with emotions may be risk factors for ischemic stroke occurrence and to further investigate the ability of two specific types of emotion regulation (cognitive reappraisal and expressive suppression) as possible moderators of the relationship between these psychological diseases and ischemic stroke risk. As a secondary objective, we sought to determine how these pre-existing conditions affect stroke severity levels.

METHODS

This is a case-control survey study involving 113 Lebanese inpatients with a clinical diagnosis of ischemic stroke admitted in hospitals and rehabilitation centers in Beirut and Mount Lebanon, and 451 gender-matched volunteers without clinical signs of stroke as controls recruited from the same hospitals as the cases or attending outpatient clinics for illnesses or treatments unconnected to stroke or transient ischemic attack, as well as visitors or relatives of inpatients (April 2020-April 2021). Data was collected by filling out an anonymous paper-based questionnaire.

RESULTS

According to the outcomes of the regression model, depression (aOR: 1.232, 95%CI: 1.008-1.506), perceived stress (aOR: 1.690, 95%CI: 1.413-2.022), a lower educational level (aOR: 0.335, 95%CI: 0.011-10.579), and being married (aOR: 3.862, 95%CI: 1.509-9.888) were associated with an increased risk of ischemic stroke. The moderation analysis revealed that expressive suppression had a significant moderating effect on the relationship between depression, anxiety, perceived stress, insomnia, and ischemic stroke risk, resulting in an increased risk of stroke incidence. In contrast, cognitive reappraisal significantly reduced the risk of ischemic stroke by moderating the association between ischemic stroke risk and the following independent variables: perceived stress and insomnia. On the other hand, our multinomial regression model revealed that the odds of moderate to severe/severe stroke were significantly higher in people with pre-stroke depression (aOR: 1.088, 95% CI: 0.747-1.586) and perceived stress (aOR: 2.564, 95% CI: 1.604-4.100) compared to people who had never had a stroke.

CONCLUSION

Despite several limitations, the findings of our study suggest that people who are depressed or stressed are more likely to have an ischemic stroke. Consequently, additional research into the causes and effects of depression and perceived stress may provide new directions for preventive strategies that can help reduce the risk of stroke. Since pre-stroke depression and perceived stress were also found to be strongly correlated with stroke severity, future studies should evaluate the association between pre-stroke depression, perceived stress, and stroke severity to gain a deeper understanding of the complex interaction between these variables. Lastly, the study shed new light on the role of emotion regulation in the relationship between depression, anxiety, perceived stress, insomnia, and ischemic stroke.

Cancer and stroke: What do we know and where do we go?

Cancer is an increasingly recognized cause for ischemic stroke, with recent acknowledgement of cancer-related stroke as an emerging stroke subtype with unique pathophysiologic mechanisms. In addition, cancer-related stroke may differ from stroke in the general population as cancer patients may not receive guideline-recommended stroke care, and the occurrence of stroke may also preclude patients from receiving optimal cancer treatments. Due to the high degree of morbidity and mortality associated with both conditions, understanding the relationship between stroke and cancer is crucial. In this narrative review, we discuss the association between cancer and stroke, the unique pathophysiologic mechanisms underlying this phenomenon, treatment options including acute reperfusion therapies and secondary prevention strategies, compare outcomes between cancer-related stroke and stroke in the general population, and review new and emerging evidence in this field.

Intervention for a Digital, Cognitive, Multi-Domain Alzheimer Risk Velocity Study: Protocol for a Randomized Controlled Trial

BACKGROUND

In the United States, more than 6 million adults live with Alzheimer disease (AD) that affects 1 out of every 3 older adults. Although there is no cure for AD currently, lifestyle-based interventions aimed at slowing the rate of cognitive decline or delaying the onset of AD have shown promising results. However, most studies primarily focus on older adults (>55 years) and use in-person interventions.

OBJECTIVE

The aim of this study is to determine the effects of a 2-year digital lifestyle intervention on AD risk among at-risk middle-aged and older adults (45-75 years) compared with a health education control.

METHODS

The lifestyle intervention consists of a digitally delivered, personalized health coaching program that directly targets the modifiable risk factors for AD. The primary outcome measure is AD risk as determined by the Australian National University-Alzheimer Disease Risk Index; secondary outcome measures are functional fitness, blood biomarkers (inflammation, glucose, cholesterol, and triglycerides), and cognitive function (Repeatable Battery for the Assessment of Neuropsychological Status and Neurotrack Cognitive Battery). Screening commenced in January 2021 and was completed in June 2021.

RESULTS

Baseline characteristics indicate no difference between the intervention and control groups for AD risk (mean -1.68, SD 7.31; P=.90).

CONCLUSIONS

The intervention in the Digital, Cognitive, Multi-domain Alzheimer Risk Velocity is uniquely designed to reduce the risk of AD through a web-based health coaching experience that addresses the modifiable lifestyle-based risk factors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04559789; https://clinicaltrials.gov/show/NCT04559789.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/31841.

Socioeconomic status and lifestyle in young ischaemic stroke patients: a possible relationship to stroke recovery and risk of recurrent event

OBJECTIVES

Socioeconomic status (SES) and lifestyle have impact on recovery after ischaemic stroke (IS) and on risk of recurrent ischaemic stroke (RIS) in elderly patients. With regard to currently available limited data on young people, we aimed to assess SES and parameters of lifestyle and evaluate their relationship to stroke recovery and risk of RIS in young patients.

METHODS

We analysed consecutive young IS patients < 50 years enrolled in the prospective HISTORY (Heart and Ischaemic STrOke Relationship studY) study registered on ClinicalTrials.gov (NCT01541163). Data were acquired from structured a self-evaluating multiple-choice questionnaire. Clinical outcome was assessed using the Modified Rankin Scale (MRS) after 3 months with score 0-1 for excellent outcome.

RESULTS

Data were obtained from 297 (163 males, mean age 39.6 ± 7.8 years) young patients. Patients with MRS 0-1 (237, 79.8%) did not differ in SES except university education (21.1 vs. 3.3%; p = 0.001), less smoked (16.5 vs. 58.3%; p < 0.001), more of them did regular sport activities (79.1 vs. 51.6%; p = 0.02) and passed regular preventive medical checks (45.6 vs. 24.2%; p = 0.01). Twelve (4%) patients suffered from RIS during a follow-up with median of 25 months. They did not differ in SES but had higher body mass index (31.6 vs. 26.7; p = 0.007), reported less regular sport activities (16.7 vs. 73.0%; p < 0.001) and less regular medical checks (8.3 vs. 40.0%; p = 0.001).

CONCLUSION

In young patients, SES had no relationship to clinical outcome after IS and to risk of RIS except education level. Some parameters of health lifestyle were presented more in patients with excellent outcome and without RIS during the follow-up.

Self-perceived acute psychological stress and risk of mortality, recurrence and disability after stroke: Mashhad Stroke Incidence Study

This longitudinal study was designed to evaluate the association between acute pre-stroke stress and the severity stroke and its outcomes including mortality, recurrence, disability and functional dependency. Patients with first-ever stroke (FES) were recruited from the Mashhad Stroke Incidence Study. Patients were asked about any acute severe pre-stroke stress in the 2 weeks prior to index stroke. Disability and functional disability were defined using modified the Rankin Scale and Barthel Index, respectively. We used logistic and ordinal regression tests to assess the association between acute pre-stroke stress and study outcomes. Among 624 patients with FES, 169 reported acute pre-stroke stress. Patients with acute pre-stroke stress were younger than those without stress (60.7 ± 14.4 vs. 66.2 ± 14.7; p < 0.001). The frequency of traditional vascular risk factors was not different in patients with and without acute pre-stroke stress. We did not find any association between acute pre-stroke stress and stroke outcomes. Although acute stress was common in our cohort, our results did not support an association between acute pre-stroke stress and the severity of stroke at admission and long-term stroke outcomes.

Knowledge, Prevention Practice and Associated Factors of Stroke Among Hypertensive and Diabetic Patients - A Systematic Review

INTRODUCTION

Because of the inadequate level of public awareness of the disease, the incidence of stroke has been sharply rising. Eventually, due to the prehospital delay, many stroke cases could not be eligible for thrombolysis thereby poor rehabilitative outcome has been tremendously increased. Thus, this study aimed to review the level of knowledge, prevention practice, and associated factors of stroke among hypertensive and diabetic patients.

METHODS

A systematic review of primarily published articles (2010-2020) related to knowledge and prevention practices of stroke was performed by searching online electronic databases like PubMed, Google Scholar, Refseek, Science direct, ResearchGate, and manual Google search by using the keywords and MeSH terms. Studies conducted on knowledge and prevention practices amongst hypertensive and/or diabetic patients were included.

RESULTS

Out of 531 searched studies, 42 articles were identified to be reviewed. The reported overall knowledge of stroke was ranging from 4.4% to 79%. Knowledge to the signs/symptoms of stroke was 23.6% to 87%. However, 15% to 77% of subjects were also reported that they did not know any sign of stroke. The range of risk factor knowledge was 10.5% to 86.6%. The reported level of stroke prevention practice was 2.4% to 72% but physical activity and weight reduction practice were relatively low. Inadequate level of knowledge and prevention practice of stroke was related to elderly, female gender, uneducated, unmarried, rural residents, economically low, comorbidity and unemployed individuals.

CONCLUSION

The current finding revealed that the level of knowledge and prevention practice of stroke was inadequate. Hence, the finding highlights health educational programs should be planned as an important avenue to enhance stroke awareness among the high-risk populations.

Employment Status Prior to Ischemic Stroke and Weekly Variation of Stroke Onset

OBJECTIVES

To investigate the differences in clinical backgrounds, especially weekly variations of stroke occurrence, between hyper-acute ischemic stroke patients with and without regular employment (RE), as well as the impact of RE on outcome.

MATERIALS AND METHODS

Symptomatic ischemic stroke patients with ≤4.5 h from onset to door were enrolled. First, we divided patients into the RE and non-RE group to analyze differences in clinical characteristics, especially relation between weekly variations of stroke occurrence and RE. Second, we divided the same patients into those with and without favorable outcomes (modified Rankin Scale score of 0 to 2 at 3 months from stroke onset) to analyze the impact of RE on outcomes.

RESULTS

We screened 1,249 consecutive symptomatic ischemic stroke patients and included 377 patients (284 [75%] males; median age, 67 years). Of these patients, 248 (66%) were included in RE group. First, RE was independently associated with occurrence of stroke on Monday in reference to Sunday or a public holiday (OR 2.562, 95% CI 1.004-6.535, p = 0.049). Second, RE (OR 2.888 95% CI 1.378-6.050, p = 0.005) was a factor independently associated with a favorable outcome.

CONCLUSIONS

Patients with RE were more likely to have a hyper-acute ischemic stroke on Monday in reference to Sunday or a public holiday. However, RE before stroke onset appears to have a positive impact on outcome.

Effects of Life Events and Social Isolation on Stroke and Coronary Heart Disease

The current coronavirus disease 2019 (COVID-19) pandemic represents a severe, life-changing event for people across the world. Life changes may involve job loss, income reduction due to furlough, death of a beloved one, or social stress due to life habit changes. Many people suffer from social isolation due to lockdown or physical distancing, especially those living alone and without family. This article reviews the association of life events and social isolation with cardiovascular disease, assembling the current state of knowledge for stroke and coronary heart disease. Possible mechanisms underlying the links between life events, social isolation, and cardiovascular disease are outlined. Furthermore, groups with increased vulnerability for cardiovascular disease following life events and social isolation are identified, and clinical implications of results are presented.

Self-rated stress, distress, mental health, and health as modifiers of the association between long-term exposure to ambient pollutants and mortality

BACKGROUND

Individual and neighbourhood-scale socioeconomic characteristics modify associations between exposure to air pollution and mortality. The role of stress, which may integrate effects of social and environmental exposures on health, is unknown. We examined whether an individual's perspective on their own well-being, as assessed using self-rated measures of stress and health, modifies the pollutant-mortality relationship.

METHODS

The Canadian Community Health Survey (CCHS)-mortality cohort includes respondents from surveys administered between 2001 and 2012 linked to vital statistics and postal codes from 1981 until 2016. Annual fine particulate matter (PM_2.5), nitrogen dioxide (NO₂), and ozone (O₃) exposure estimates were attached to a sample of cohort members aged 30-89 years (n = 398,300 respondents/3,848,400 person-years). We examined whether self-rated stress, distress, mental health, and general health modified associations between long-term exposure to each pollutant (three-year moving average with one-year lag) and non-accidental mortality using Cox survival models, adjusted for individual- (i.e. socioeconomic and behavioural) and neighbourhood-scale covariates.

RESULTS

In fully-adjusted models, the relationship between exposure to pollutants and mortality was stronger among those with poor self-rated mental health, including a significant difference for NO₂ (hazard ratio (HR) = 1.15, 95% CI 1.06-1.25 per IQR) compared to those with very good/excellent mental health (HR = 1.05, 95% CI 1.01-1.08; Cochran's Q = 4.01; p < 0.05). Poor self-rated health was similarly associated with higher pollutant-associated HRs, but only in unadjusted models. Stress and distress did not modify pollutant-mortality associations.

CONCLUSIONS

Poor self-rated mental and general health were associated with increased mortality attributed to exposure to ambient pollutants.

Acute Psychological Stress is a Trigger for Stroke: A Case-Crossover Study

BACKGROUND

Conventional risk factors for stroke that have been identified are mostly chronic diseases that explain much of the variation as to who develops stroke. However, these risk factors do not equip us with the means to predict when an event like stroke will occur. It has been observed that acute events like stroke and coronary heart disease are preceded by episodes of acute stress. The present study was undertaken to determine whether acute psychological stress is a potential triggering factor for the occurrence of stroke.

METHODS

In accordance with the case-crossover study design, patients or Legally Authorized Representative (LAR) were asked to report psychological stress during the two-hour hazard period before the event and during the control period, which was the same 2-hour time period the day before the event. Conditional logistic regression was used to compare each person's exposure during the hazard period to their exposure during the control period.

RESULTS

A total of 151 stroke patients were interviewed. Acute psychological stress was associated with transient increased odds of stroke in the subsequent 2 hours that was 3.4 times higher than the odds during periods with no exposure to these triggers (95% confidence interval 1.55-7.50).

CONCLUSIONS

Acute psychological stress is a potential independent triggering factor for the occurrence of stroke. Further confirmatory studies are required to help corroborate these findings and elucidate the mechanisms underlying this short-term increase in risk.

A review of psychosocial factors and stroke: A new public health problem

The role of psychosocial factors (PSF) in increased risk of stroke is a novel public health challenge, but unclear definitions for PSF and the multiple stroke subtypes have led to inconsistent reports. A review of this issue is therefore warranted.

METHODS

Several databases were used for this narrative systematic review (Medline, Embase and Cochrane Library). Two independent reviewers evaluated articles from between 2001 and 2018 on the themes of PSF and stroke/transient ischemic attack (TIA). PSF criteria were job strain, psychological interpersonal and behavioral stress, and social deprivation. Ischemic and hemorrhagic stroke and TIA subtypes were also identified.

RESULTS

Forty-five cohorts, five case-control studies and two meta-analyses were included. Despite mixed results, PSF were associated with an increased risk of ischemic and hemorrhagic stroke in populations of all ages, and more predominantly in women.

CONCLUSION

This broad review shows that the presence of PSF is associated with an increased risk stroke and TIA. As such, PSF must figure in both public health policy and stroke prevention programs, similar to other established metabolic and environmental factors.

Lifetime Trauma and Cardiometabolic Risk in Sexual Minority Women

Background: Sexual minority women (SMW; such as lesbian, bisexual, and mostly lesbian) exhibit excess cardiometabolic risk, yet factors that contribute to cardiometabolic risk in this population are poorly understood. Trauma exposure has been posited as a contributor to cardiometabolic risk in SMW. Materials and Methods: An analysis of data from Wave 3 of the Chicago Health and Life Experiences of Women Study was conducted. Multinomial logistic regression was used to examine correlates of trauma. Next, multiple logistic regression was used to examine the associations of different forms of trauma throughout the life course (childhood, adulthood, and lifetime), with psychosocial and behavioral risk factors and self-reported cardiometabolic risk (obesity, hypertension, and diabetes) in SMW adjusted for relevant covariates. Results: A total of 547 participants were included. Older age was associated with higher rates of childhood and adulthood trauma. SMW of color reported higher rates of childhood trauma than white participants. Higher education was associated with lower rates of adulthood trauma. All forms of trauma were associated with probable diagnosis of post-traumatic stress disorder and lower perceived social support. Adult trauma was associated with anxiety, whereas childhood and lifetime trauma were associated with higher odds of depression. No significant associations between forms of trauma and behavioral risk factors were noted, except that childhood trauma was associated with higher odds of past-3-month overeating. Logistic regression models examining the association of trauma and cardiometabolic risk revealed that childhood trauma was an independent risk factor for diabetes. Adulthood and lifetime trauma were significantly associated with obesity and hypertension. Conclusions: Trauma emerged as an independent risk factor for cardiometabolic risk in SMW. These findings suggest that clinicians should screen for trauma as a cardiovascular risk factor in SMW, with special attention to SMW most at risk.

Stress in Patients With (Un)ruptured Intracranial Aneurysms vs Population-Based Controls

BACKGROUND

Stress is associated with increased risk of stroke and might predispose to presence and rupture of intracranial aneurysms.

OBJECTIVE

To study the association of recent and lifelong stress with unruptured intracranial aneurysm (UIA) and aneurysmal subarachnoid hemorrhage (ASAH).

METHODS

In 227 UIA patients (mean age 61 ± 11 yr), 490 ASAH patients (59 ± 11 yr), and 775 controls (51 ± 15 yr) who were randomly retrieved from the general population, we assessed occurrence of major life events and perceived stress during the preceding 12 mo and the entire life. With multivariable logistic regression analysis, we calculated odds ratios (ORs) with 95% confidence intervals (95% CIs) for 4 categories of life events (financial-related, work-related, children-related, and death of family members) and for periods of perceived stress at home and at work (never vs sometimes, often, or always). We adjusted for sex, age, alcohol consumption, smoking, and hypertension.

RESULTS

The 4 categories of life events and perceived stress at work had ORs ranging from 0.4 to 1.7, of which financial stress for UIA was statistically significant (95% CI: 1.1-2.5). ORs for chronic perceived stress at home in the previous year were 4.3 (95% CI: 1.8-10.3) for UIA and 2.5 (1.2-5.5) for ASAH, and for lifelong exposure 5.7 (2.2-14.5) for UIA and 3.0 (1.3-7.0) for ASAH.

CONCLUSION

For some components of stress, there may be a relation with UIA and ASAH. The mechanisms underlying this relation should be unraveled; strategies to improve coping with stress may reduce the risk of rupture in patients with unruptured aneurysms.

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.

Genome-wide analysis of genetic determinants of circulating factor VII-activating protease (FSAP) activity

Essentials Knowledge of genetic regulators of plasma factor VII activating protease (FSAP) levels is limited. We performed a genome-wide analysis of variants influencing FSAP activity in Scandinavian cohorts. We replicated an association for Marburg-1 and identified an association for a HABP2 stop variant. We identified a novel locus near ADCY2 as a potential additional regulator of FSAP activity.

SUMMARY

Background Factor VII-activating protease (FSAP) has roles in both coagulation and fibrinolysis. Recent data indicate its involvement in several other processes, such as vascular remodeling and inflammation. Plasma FSAP activity is highly variable among healthy individuals and, apart from the low-frequency missense variant Marburg-I (rs7080536) in the FSAP-encoding gene HABP2, determinants of this variation are unclear. Objectives To identify novel genetic variants within and outside of the HABP2 locus that influence circulating FSAP activity. Patients/Methods We performed an exploratory genome-wide association study (GWAS) on plasma FSAP activity amongst 3230 Swedish subjects. Directly genotyped rare variants were also analyzed with gene-based tests. Using GWAS, we confirmed the strong association between the Marburg-I variant and FSAP activity. HABP2 was also significant in the gene-based analysis, and remained significant after exclusion of Marburg-I carriers. This was attributable to a rare HABP2 stop variant (rs41292628). Carriers of this stop variant showed a similar reduction in FSAP activity as Marburg-I carriers, and this finding was replicated. A secondary genome-wide significant locus was identified at a 5p15 locus (rs35510613), and this finding requires future replication. This common variant is located upstream of ADCY2, which encodes a protein catalyzing the formation of cAMP. Results and Conclusions This study verified the Marburg-I variant to be a strong regulator of FSAP activity, and identified an HABP2 stop variant with a similar impact on FSAP activity. A novel locus near ADCY2 was identified as a potential additional regulator of FSAP activity.

Sexual Orientation Differences in Modifiable Risk Factors for Cardiovascular Disease and Cardiovascular Disease Diagnoses in Men

PURPOSE

Despite higher rates of modifiable risk factors for cardiovascular disease (CVD) in gay and bisexual men, few studies have examined sexual orientation differences in CVD among men. The purpose of this study was to examine sexual orientation differences in modifiable risk factors for CVD and CVD diagnoses in men.

METHODS

A secondary analysis of the National Health and Nutrition Examination Survey (2001-2012) was conducted. Multiple imputation was performed for missing values. Differences across four distinct groups were analyzed: gay-identified men, bisexual-identified men, heterosexual-identified men who have sex with men (MSM), and heterosexual-identified men who denied same-sex behavior (categorized as exclusively heterosexual). Multiple logistic regression models were run with exclusively heterosexual men as the reference group.

RESULTS

The analytic sample consisted of 7731 men. No differences between heterosexual-identified MSM and exclusively heterosexual men were observed. Few differences in health behaviors were noted, except that, compared to exclusively heterosexual men, gay-identified men reported lower binge drinking (adjusted odds ratio [AOR] 0.58, 95% confidence interval [CI] = 0.37-0.85). Bisexual-identified men had higher rates of mental distress (AOR 2.39, 95% CI = 1.46-3.90), obesity (AOR 1.69, 95% CI = 1.02-2.72), elevated blood pressure (AOR 2.30, 95% CI = 1.43-3.70), and glycosylated hemoglobin (AOR 3.01, 95% CI = 1.38-6.59) relative to exclusively heterosexual men.

CONCLUSIONS

Gay-identified and heterosexual-identified MSM demonstrated similar CVD risk to exclusively heterosexual men, whereas bisexual-identified men had elevations in several risk factors. Future directions for sexual minority health research in this area and the need for CVD and mental health screenings, particularly in bisexual-identified men, are highlighted.

Cardiovascular Disease Risk in Sexual Minority Women (18-59 Years Old): Findings from the National Health and Nutrition Examination Survey (2001-2012)

OBJECTIVE

Sexual minority women (lesbian and bisexual) experience significant stigma, which may increase their cardiovascular disease (CVD) risk. The purpose of this study was to examine the prevalence of modifiable risk factors for CVD (including mental distress, health behaviors, blood pressure, glycosylated hemoglobin, and total cholesterol) and CVD in sexual minority women compared with their heterosexual peers.

MATERIALS AND METHODS

A secondary analysis of the National Health and Nutrition Examination Survey (2001-2012) was conducted. Multiple imputation with chained equations was performed. Logistic regression models adjusted for relevant covariates were run. Self-report (medical history and medication use) and biomarkers for hypertension, diabetes, and high total cholesterol were examined.

RESULTS

The final analytic sample consisted of 7,503 that included 346 sexual minority women (4.6%). Sexual minority women were more likely to be younger, single, have a lower income, and lack health insurance. After covariate adjustment, sexual minority women exhibited excess CVD risk related to higher rates of frequent mental distress (adjusted odds ratio [AOR], 2.05; 95% confidence interval [CI], 1.45-2.88), current tobacco use (AOR, 2.11; 95% CI, 1.53-2.91), and binge drinking (AOR, 1.66; 95% CI, 1.17-2.34). Sexual minority women were more likely to be obese (AOR, 1.61; 95% CI, 1.23-2.33) and have glycosylated hemoglobin consistent with prediabetes (AOR, 1.56; 95% CI, 1.04-2.34). No differences were observed for other outcomes.

CONCLUSIONS

Sexual minority women demonstrated increased modifiable risk factors for CVD, but no difference in CVD diagnoses. Several emerging areas of research are highlighted, in particular, the need for CVD prevention efforts that target modifiable CVD risk in sexual minority women.

Association between self-perceived psychological stress and transitory ischaemic attack and minor stroke: A case-control study

INTRODUCTION

Stroke has a complex aetiopathogenesis influenced by numerous risk factors. There is growing interest in the study of the pathophysiological changes associated with stress and their potential relationship with cerebrovascular disease. The purpose of this paper is to assess the strength of association between exposure to stress and stroke.

METHODS

We conducted a case-control study (1:1) to compare exposure to stress in a group of patients with a history of a first transient ischaemic attack (TIA) or minor stroke and in a control group. Participants were asked a subjective question about their perception of stress in the previous months and completed the standardised Effort-Reward Imbalance (ERI) questionnaire. Logistic regression models were used for data analysis.

RESULTS

The study included data on 50 cases and 50 controls. There were no significant differences in demographic variables and economic, social, and employment status between cases and controls. Fifty percent of the cases reported moderate to severe stress, compared to 30% of controls (OR: 2.33; 95% CI: 1.02-5.30; P=.041). ERI questionnaire results found that greater effort at work (OR: 1.48; 95% CI: 1.19-1.83) and greater commitment is associated with stroke (OR: 1.34; 95% CI: 1.17-1.54), while higher reward constitutes a protective factor against the disease (OR: 0.71; 95% CI: 0.61-0.82).

CONCLUSIONS

There is a strong association between self-perceived psychological stress and TIA. The imbalance between effort and reward at work is also clearly related to TIA.

Effects of stressful life events on cerebral white matter hyperintensity progression

OBJECTIVE

Exposure to stressful events is associated with both occurrence of depression and also vascular disease. The objective of this study was to determine whether higher levels of stress exposure was related to measures of pathological brain aging, specifically white matter hyperintensity volumes, in older adults with and without depression.

METHODS

The sample included 130 depressed and 110 never-depressed older adults aged 60 years or older enrolled in a longitudinal study at an academic medical center. Participants completed clinical assessments, assessment of stressful event exposure and perceived stress, and magnetic resonance imaging at baseline and after 2 years. Analyses examined both cross-sectional and longitudinal relationships between stress measures and white matter hyperintensity volumes.

RESULTS

There were no statistically significant relationships observed between cross-sectional baseline stress measures and either baseline hyperintensity volume or 2-year change in hyperintensity volume. However, after controlling for demographic variables and baseline measures, change in stressor exposure was associated with change in hyperintensity volumes. In this analysis, increased stressor exposure was associated with greater increases in white matter hyperintensity volume, while reductions in stressor exposure were associated with less increase in hyperintensity volume. This relationship did not significantly differ based on the presence of either depression or medical comorbidities.

CONCLUSIONS

This work adds to a growing literature associating exposure to stressful events in later life with more rapid pathological brain aging. Work is needed to understand the physiological mechanisms by which stress exposure has this effect and examine whether stress reduction techniques may modify these observed outcomes. Copyright © 2016 John Wiley & Sons, Ltd.

Living alone predicts mortality in patients with ischemic stroke before 70 years of age: a long-term prospective follow-up study

Background

Living alone is associated with increased mortality after myocardial infarction but little data is available about whether this applies to prognosis after stroke. We aimed to examine the association between living situation and long-term mortality in patients with ischemic stroke and a control group, and to explore whether this association is modified by patient gender.

Methods

This is a prospective case-control study of 600 patients with ischemic stroke before 70 years of age and 600 age- and sex-matched controls who have been included in the Sahlgrenska Study on Ischemic Stroke. Mortality data were collected through national registers and medical records. We used Cox regression models for identifying predictors of mortality.

Results

In the entire sample, mean age was 57 years, proportion of males 64 %, proportion living alone 28 %, and median follow-up 8.6 years. Mortality rates were 36 % among patients living alone, 17 % among cohabitant patients, 15 % among controls living alone, and 9 % among cohabitant controls. Living alone was an independent predictor of all-cause mortality in cases after adjustment for stroke severity, stroke subtype, and vascular risk factors including physical activity, alcohol consumption, and socioeconomic status. A significant interaction was found between gender and living situation; the adjusted hazard ratio for mortality was 3.47 (95 % Confidence Interval 2.13–5.65) in male patients living alone, whereas no significant association was observed in women. Living alone was also a predictor of vascular mortality among cases and of all-cause mortality among controls.

Conclusions

Living alone is associated with increased long-term mortality after ischemic stroke in men. Further prospective studies are needed to confirm the observed gender difference and to identify modifiable factors underlying this increased risk.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-016-0599-y) contains supplementary material, which is available to authorized users.

Relationships Among Positive Emotions, Coping, Resilience and Mental Health

The broaden-and-build theory of positive emotions suggests that positive emotions can widen the range of potential coping strategies that come to mind and subsequently enhance one's resilience against stress. Studies have shown that high stress, especially chronic levels of stress, strongly contributes to the development of anxiety and depressive symptoms. However, researchers have also found that individuals who possess high levels of resilience are protected from stress and thus report lower levels of anxiety and depressive symptoms. Using a sample of 200 postdoctoral research fellows, the present study examined if (a) positive emotions were associated with greater resilience, (b) coping strategies mediated the link between positive emotions and resilience and (c) resilience moderated the influence of stress on trait anxiety and depressive symptoms. Results support the broaden-and-build theory in that positive emotions may enhance resilience directly as well as indirectly through the mediating role of coping strategies-particularly via adaptive coping. Resilience also moderated the association of stress with trait anxiety and depressive symptoms. Although stress is unavoidable and its influences on anxiety and depressive symptoms are undeniable, the likelihood of postdocs developing anxiety or depressive symptoms may be reduced by implementing programmes designed to increase positive emotions, adaptive coping strategies and resilience.

Protocol of the Stroke in Korean Young Adults Study: A Multicenter Case-Control Study and Prospective Cohort Study

BACKGROUND

The incidence of ischemic stroke in young adults has been rising over recent decades, but there is still limited information on its risk factors, etiologies, and outcomes. Because these patients generally participate in social life, risk factors associated with lifestyle may have a great impact and need to be identified.

METHODS

The SKY (Stroke in Korean Young Adults) study is a multicenter case-control study and a prospective cohort study in 8 tertiary medical centers in the Republic of Korea. The case subjects are patients aged 18-44 years with first-ever ischemic stroke occurring within 1 month of stroke onset, and the control subjects are age- and gender-matched community controls. Our aim is to include 470 cases and 470 controls. The main objective of our study is to determine the risk factors and the causes of ischemic stroke in Korean young adults. Both well-documented risk factors and little-known lifestyle-related risk factors such as lifestyle habits and psychological distress including job strain will be evaluated by comparing cases and controls using a structured questionnaire. Secondary objectives are to determine the risks of mortality, recurrent vascular events, and poststroke epilepsy in these patients. Conditional logistic regression analysis will be used to estimate odds ratios and 95% confidence intervals.

CONCLUSIONS

The SKY study is designed to obtain more insights into relatively little-known risk factors in young Korean adults with ischemic stroke. The results may also help identify the frequencies of uncommon etiologies and outcomes in these patients.

Ischemic stroke in the young: Current perspectives on incidence, risk factors, and cardiovascular prognosis

About one-fourth of ischemic strokes occur in working-aged individuals in the high-income countries, with worldwide increasing incidence in this age group from 1980s to present. Recent evidence suggests that traditional vascular risk factors are more prevalent than previously suggested in young adult stroke patients and they accumulate with age particularly in men. Accordingly, relatively high rates of atherosclerotic changes have been detected in these patients. The strength of association of vascular risk factors has gone poorly studied, however. Many young patients with ischemic stroke have, in turn, no traditional risk factors, while they may harbor other conditions with weak or uncertain association with the stroke alone. These individual conditions often represent a risk factor that may be strictly young-age specific, more prevalent in younger than older stroke patients (e.g. patent foramen ovale), or more prevalent among the young in the population. Despite high rates of vascular risk factors and atherosclerotic changes, these findings do not translate to higher frequencies of identified classical stroke mechanisms. In fact, cryptogenic causes are markedly common and even more frequent among the very young patients. Limited randomized trial evidence exists to support secondary prevention decision-making in patients, yet they face an increased risk of death and future vascular events for years to come-dependent on risk factor profile and cause of the stroke. This review provides an overview of recent data on epidemiology, risk factors, and their strength of association in ischemic stroke in the young. Furthermore, the relationship between with the risk factors and cardiovascular outcomes and key features on the evidence related to secondary prevention will be discussed.

Effects of a Web-Based Intervention for Stress Reduction in Primary Care: A Cluster Randomized Controlled Trial

BACKGROUND

Preliminary findings suggest that Web-based interventions may be effective in achieving significant stress reduction. To date, there are no findings available for primary care patients. This is the first study that investigates a Web-based intervention for stress reduction in primary care.

OBJECTIVE

The aim was to examine the short-term effectiveness of a fully automated Web-based coaching program regarding stress reduction in a primary care setting.

METHODS

The study was an unblinded cluster randomized trial with an observation period of 12 weeks. Individuals recruited by general practitioners randomized to the intervention group participated in a Web-based coaching program based on education, motivation, exercise guidance, daily text message reminders, and weekly feedback through the Internet. All components of the program were fully automated. Participants in the control group received usual care and advice from their practitioner without the Web-based coaching program. The main outcome was change in the Perceived Stress Questionnaire (PSQ) over 12 weeks.

RESULTS

A total of 93 participants (40 in intervention group, 53 in control group) were recruited into the study. For 25 participants from the intervention group and 49 participants from the control group, PSQ scores at baseline and 12 weeks were available. In the intention-to-treat analysis, the PSQ score decreased by mean 8.2 (SD 12.7) in the intervention group and by mean 12.6 (SD 14.7) in the control group. There was no significant difference identified between the groups (mean difference -4.5, 95% CI -10.2 to 1.3, P=.13).

CONCLUSIONS

This trial could not show that the tested Web-based intervention was effective for reducing stress compared to usual care. The limited statistical power and the high dropout rate may have reduced the study's ability to detect significant differences between the groups. Further randomized controlled trials are needed with larger populations to investigate the long-term outcome as well as the contents of usual primary care.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00003067; http://drks-neu.uniklinik-freiburg.de/drks_web/navigate.do?=DRKS00003067 (Archived by WebCite at http://www.webcitation.org/6eXk0PXmO).

Evidence of perceived psychosocial stress as a risk factor for stroke in adults: a meta-analysis

BACKGROUND

Several studies suggest that perceived psychosocial stress is associated with increased risk of stroke; however results are inconsistent with regard to definitions and measurement of perceived stress, features of individual study design, study conduct and conclusions drawn and no meta-analysis has yet been published. We performed a systematic review and meta-analysis of studies assessing association between perceived psychosocial stress and risk of stroke in adults.The results of the meta-analysis are presented.

METHODS

Systematic searches of MEDLINE, EMBASE, CINAHL, PsycInfo, and Cochrane Database of Systematic Reviews were undertaken between 1980 and June 2014. Data extraction and quality appraisal was performed by two independent reviewers. Hazard ratios (HR) and odds ratios (OR) were pooled where appropriate.

RESULTS

14 studies were included in the meta-analysis, 10 prospective cohort, 4 case-control design. Overall pooled adjusted effect estimate for risk of total stroke in subjects exposed to general or work stress or to stressful life events was 1.33 (95 % confidence interval [CI], 1.17, 1.50; P < 0.00001). Sub-group analyses showed perceived psychosocial stress to be associated with increased risk of fatal stroke (HR 1.45 95 % CI, 1.19,1.78; P = 0.0002), total ischaemic stroke (HR 1.40 95 % CI, 1.00,1.97; P = 0.05) and total haemorrhagic stroke (HR 1.73 95 % CI, 1.33,2.25; P > 0.0001).A sex difference was noted with higher stroke risk identified for women (HR 1.90 95 % CI, 1.4, 2.56: P < 0.0001) compared to men (HR 1.24 95 % CI, 1.12, 1.36; P < 0.0001).

CONCLUSIONS

Current evidence indicates that perceived psychosocial stress is independently associated with increased risk of stroke.

Self-perceived stress is associated with adiposity and atherosclerosis. The GEA Study

Background

A growing body of evidence suggests that psychological stress is an independent cardiovascular risk factor. Obesity prevalence shows accelerating trends worldwide, and is known to be associated with a range of comorbidities and survival. The aim of this study was to assess the relationship between self-perceived psychological stress with parameters of adiposity, metabolic syndrome, and subclinical atherosclerosis in Mexican participants.

Methods

Metabolic Syndrome was defined using the Adult Treatment Panel III criteria, obesity was defined as BMI >30, subclinical atherosclerosis disease was determined by computed tomography, and carotid intima media thickness was determined by ultrasonography. Self-perceived psychological stress was assessed using a single-item questionnaire.

Results

A total of 1243 control subjects were included in the sample, mean age 54.2 ± 9 years old; the prevalence of chronic self-perceived psychological stress (>5 years) was 10.13 %, female gender (62.7 %), obesity prevalence (48.4 %), and self-reporting sedentary lifestyle (56.3 %). The chronic stressed cohort presented higher subcutaneous abdominal fat content (285 vs 319 cm²), and carotid intima media thickness (0.63 vs 0.66 mm; p < 0.01 for both). However, after adjustment for lifestyle/social covariates (Model 1) and biological mediators (Model 2), chronic self-perceived stress was independently associated with obesity in men (OR 2.85, 95 % CI 1.51 – 5.40) and carotid atherosclerosis in women (OR 2.262, 95 % CI 1.47 – 4.67; p < 0.01 for both).

Conclusion

Our study suggests that self-reported chronic stress is an independent risk factor for obesity in men. In addition, carotid atherosclerosis was also found to be an independent risk factor in women in a Mexican population sample.

Weekly variations of stroke occurrence: an observational cohort study based on the Kyoto Stroke Registry, Japan

OBJECTIVES

Understanding the temporal pattern of stroke onset and exploring the possible triggers are important strategies to reducing the incidence of stroke. If stroke occurs frequently on a specific day of the week, it is assumed that other factors, that is, 'triggering factors', induce stroke. The aim of the study is to investigate differences in the incidences of stroke among days of the week.

DESIGN

Hospital-based registry stroke over an 11-year period.

SETTING

Kyoto Prefecture, Japan.

PARTICIPANTS

A total of 13,788 patients with stroke identified from January 1999 to December 2009 inclusive in the entire Kyoto Prefecture and registered in the Kyoto Stroke Registry (KSR).

MAIN OUTCOME MEASURES

Patients with stroke were classified into seven groups based on the day of the week on which stroke developed. We confirmed the differences in the incidence among days using the χ(2) test and then performed multinomial logistic analysis referring to the stroke incidence on Sunday to calculate the OR and 95% CI of the stroke occurrence on each day of the week.

RESULTS

The OR (95% CI) for stroke occurring on Monday, Tuesday, Wednesday, Thursday, Friday and Saturday was 1.157 (1.030 to 1.293), 1.101 (0.981 to 1.236), 1.059 (0.943 to 1.188), 1.091 (0.972 to 1.225), 1.053 (0.938 to 1.205) and 1.074 (0.956 to 1.205), respectively. After stratification by stroke subtypes, cerebral infarction occurred more frequently on Monday than on Sunday (OR and 95% CI were 1.189 and 1.034 to 1.366, p=0.014) independent of age and gender. There was no significant day of the week variation in cerebral haemorrhage or subarachnoid haemorrhage.

CONCLUSIONS

Some factors that arise periodically appear to affect the incidence of cerebral infarction, which gradually develops over years, and this suggests an aetiological mechanism different from the conventional cumulative effect of risk factors due to long-term exposure. We propose a hypothesis that there is a 'triggering factor' for the development of cerebral infarction.

Using and interpreting mental health measures in the National Social Life, Health, and Aging Project

INTRODUCTION

National Social Life, Health, and Aging Project (NSHAP) included five unique mental health measures in Waves 1 and 2 that researchers can use to measure the overall emotional health of participants: depressive symptoms, happiness-unhappiness, anxiety symptoms, perceived stress, and felt loneliness. For each, we detail the rationale for its development and explain how to score, analyze, and interpret results.

METHOD

NSHAP developed its measures by modifying traditional short-form scales to improve response efficiency and reduce respondent burden. Scoring protocols and interpretations were developed for each measure. U.S. population estimates for older adults born between 1920 and 1947 were generated using age-eligible samples from Waves 1 and 2.

RESULTS

NSHAP's protocols yielded U.S. prevalence rates similar to other nationally representative studies of older adults and comparable between waves. Higher estimates of anxiety symptoms and perceived stress in Wave 2 compared with Wave 1 were explained by age, administration mode, and time period. Analytic strategies for longitudinal analyses are provided. In Wave 2, mental health generally was worse at older ages, with women having more symptoms at younger ages than men. Women had fewer anxiety symptoms at the oldest ages.

DISCUSSION

NSHAP's mental health measures were successfully integrated into the project's survey and showed acceptable external reliability as well as moderately stable individual characteristics across the 5 years between Waves 1 and 2. Depressive symptoms and unhappiness may form a mental health cluster in the elderly, distinct from anxiety symptoms, perceived stress, and felt loneliness. Gender differences in age-specific patterns of mental health were evident using the exact age of participants rather than the traditional decade groupings. Administration mode and time period (between 2005-2006 and 2010-2011) were determined to be potential confounds that need to be accommodated in longitudinal analyses of aging, whereas sample composition was not an issue for interpreting mental health measures.

Accommodation in a refugee shelter as a risk factor for peptic ulcer bleeding after the Great East Japan Earthquake: a case-control study of 329 patients

BACKGROUND

We have reported that the total number of peptic ulcers (PUs) had increased 1.5-fold after the Great East Japan Earthquake compared with those of the previous year, and that hemorrhagic ulcers were more prominently increased by 2.2-fold. The aim of this study is to determine the risk factors for bleeding ulcers after the Great East Japan Earthquake.

METHODS

Clinical data of all peptic ulcer subjects endoscopically detected at the 7 major hospitals in the middle of the stricken area during the 3 months after the earthquake were retrospectively collected. Based on endoscopic and laboratory findings, peptic ulcer cases were divided into 227 bleeding ulcer cases and 102 non-bleeding controls. Other than ordinary risk factors for bleeding ulcers, the refugee shelter was included in the analysis as a unique confounder after the earthquake. Multiple logistic regression analyses were used to adjust for potential confounders.

RESULTS

Eighty-seven (27%) of 329 PUs emerged from refuge shelters, and the majority (76 of 87) of PUs occurring in such shelters was the bleeding type. Multivariate regression showed that residence in a shelter was a strong risk factor for ulcer bleeding with OR (95% CI): 4.4 (2.1-9.6, p < 0.0001), independent of the progressiveness of ulcer diseases.

CONCLUSIONS

Accommodation in a refugee shelter can be a strong risk factor for ulcer bleeding after a large-scale disaster. Since acid-suppressive drugs are supposed to decrease the risk for stress-induced ulcer bleeding, our results will encourage effective use of a limited medical resource in such catastrophic events.

Stress resilience in male adolescents and subsequent stroke risk: cohort study

OBJECTIVE

Exposure to psychosocial stress has been identified as a possible stroke risk, but the role of stress resilience which may be relevant to chronic exposure is uncertain. We investigated the association of stress resilience in adolescence with subsequent stroke risk.

METHODS

Register-based cohort study. Some 237 879 males born between 1952 and 1956 were followed from 1987 to 2010 using information from Swedish registers. Cox regression estimated the association of stress resilience with stroke, after adjustment for established stroke risk factors.

RESULTS

Some 3411 diagnoses of first stroke were identified. Lowest stress resilience (21.8%) compared with the highest (23.7%) was associated with increased stroke risk, producing unadjusted HR (with 95% CIs) of 1.54 (1.40 to 1.70). The association attenuated slightly to 1.48 (1.34 to 1.63) after adjustment for markers of socioeconomic circumstances in childhood; and after further adjustment for markers of development and disease in adolescence (blood pressure, cognitive function and pre-existing cardiovascular disease) to 1.30 (1.18 to 1.45). The greatest reduction followed further adjustment for markers of physical fitness (BMI and physical working capacity) in adolescence to 1.16 (1.04 to 1.29). The results were consistent when stroke was subdivided into fatal, ischaemic and haemorrhagic, with higher magnitude associations for fatal rather than non-fatal, and for haemorrhagic rather than ischaemic stroke.

CONCLUSIONS

Stress susceptibility and, therefore, psychosocial stress may be implicated in the aetiology of stroke. This association may be explained, in part, by poorer physical fitness. Effective prevention might focus on behaviour/lifestyle and psychosocial stress.

Migraine and stroke: "vascular" comorbidity

Several comorbidities are associated to migraine. Recent meta-analyses have consistently demonstrated a relationship between migraine and stroke, which is well-defined for ischemic stroke and migraine with aura (MA), even stronger in females on oral contraceptives or smokers. However, there seems to be no clear-cut association between stroke in migraineurs and the common vascular risk factors, at least in the young adult population. Migraineurs also run an increased risk of hemorrhagic stroke, while the association between migraine and cardiovascular disease remains poorly defined. Another aspect is the relationship between migraine and the presence of silent brain lesions. It has been demonstrated that there is an increased frequency of ischemic lesions in the white matter of migraineurs, especially silent infarcts in the posterior circulation territory in patients with at least 10 attacks per month. Although there is a higher prevalence of patent foramen ovale (PFO) in migraineurs, the relationship between migraine and PFO remains controversial and PFO closure is not a recommended procedure to prevent migraine. As an increased frequency of cervical artery dissections has been observed in migrainous patients, it has been hypothesized that migraine may represent a predisposing factor for cervical artery dissection. There still remains the question as to whether migraine should be considered a true “vascular disease” or if the comorbidity between migraine and cerebrovascular disease may have underlying shared risk factors or pathophysiological mechanisms. Although further studies are required to clarify this issue, current evidence supports a clinical management where MA patients should be screened for other concomitant vascular risk factors and treated accordingly.

Chronic stress, depressive symptoms, anger, hostility, and risk of stroke and transient ischemic attack in the multi-ethnic study of atherosclerosis

BACKGROUND AND PURPOSE

This study investigated chronic stress, depressive symptoms, anger, and hostility in relation to incident stroke and transient ischemic attacks in middle-aged and older adults.

METHODS

Data were from the Multi-Ethnic Study of Atherosclerosis (MESA), a population-based cohort study of 6749 adults, aged 45 to 84 years and free of clinical cardiovascular disease at baseline, conducted at 6 US sites. Chronic stress, depressive symptoms, trait anger, and hostility were assessed with standard questionnaires. The primary outcome was clinically adjudicated incident stroke or transient ischemic attacks during a median follow-up of 8.5 years.

RESULTS

One hundred ninety-five incident events (147 strokes; 48 transient ischemic attacks) occurred during follow-up. A gradient of increasing risk was observed for depressive symptoms, chronic stress, and hostility (all P for trend ≤0.02) but not for trait anger (P>0.10). Hazard ratios (HRs) and 95% confidence intervals indicated significantly elevated risk for the highest-scoring relative to the lowest-scoring group for depressive symptoms (HR, 1.86; 95% confidence interval, 1.16-2.96), chronic stress (HR, 1.59; 95% confidence interval, 1.11-2.27), and hostility (HR, 2.22; 95% confidence interval, 1.29-3.81) adjusting for age, demographics, and site. HRs were attenuated but remained significant in risk factor-adjusted models. Associations were similar in models limited to stroke and in secondary analyses using time-varying variables.

CONCLUSIONS

Higher levels of stress, hostility, and depressive symptoms are associated with significantly increased risk of incident stroke or transient ischemic attacks in middle-aged and older adults. Associations are not explained by known stroke risk factors.

Associations of stressful life events and social strain with incident cardiovascular disease in the Women's Health Initiative

Background

Epidemiologic studies have yielded mixed findings on the association of psychosocial stressors with cardiovascular disease (CVD) risk. In this study, we examined associations of stressful life events (SLE) and social strain with incident coronary heart disease (CHD) and stroke (overall, and for hemorrhagic and ischemic strokes) independent of sociodemographic characteristics, and we evaluated whether these relationships were explained by traditional behavioral and biological risk factors.

Methods and Results

Data from approximately 82 000 Women's Health Initiative Observational Study participants were used for the SLE and social strain analyses, respectively. Participants were followed for events for up to 18.0 years (median, 14.0). Separate Cox proportional hazards models were generated to estimate associations of each stress measure with incident CVD. After adjusting for sociodemographic characteristics and depressive symptoms, higher SLE and social strain were associated with higher incident CHD and stroke (each P trend <0.05). Hazard ratios and 95% confidence intervals were 1.12 (1.01, 1.25) for incident CHD and 1.14 (1.01, 1.28) for incident stroke among participants reporting high versus low SLE. Findings were similar for social strain. Associations were attenuated with further adjustment for mediating behavioral and biological risk factors. Findings were similar for associations of SLE with ischemic stroke and hemorrhagic stroke, but social strain was only associated with ischemic stroke.

Conclusions

Higher SLE and social strain were associated with higher incident CVD independent of sociodemographic factors and depressive symptoms, but not behavioral and biological risk factors.

A systematic review of the benefits of mindfulness-based interventions following transient ischemic attack and stroke

BACKGROUND

Recent epidemiological studies have demonstrated an association between perceived psychological stress and ischemic stroke. A feature of stroke is recurrence; 30-40% within five-years following first transient ischemic attack/stroke. Equipping patients with skills and coping strategies to help reduce or manage perceived psychological stress may represent an important secondary prevention intervention. Mindfulness-based interventions are structured, group-based self-management programmes with potential to help people with long-term conditions cope better with physical, psychological, or emotional distress. Review evidence suggests significant benefits across a range of physical and mental health problems. However, we could find no evidence synthesis relating specifically to the benefits of mindfulness-based interventions following transient ischemic attack/stroke.

AIM

The review aims to evaluate the benefits of mindfulness-based interventions following transient ischemic attack/stroke.

METHODS

Six major databases were searched using subject headings and key words. Papers were screened using review-specific criteria. Critical appraisal and data extraction were conducted independently by two reviewers. Statistical meta-analysis was not possible; therefore findings are presented in narrative form.

RESULTS

Four studies involving 160 participants were reviewed. Three papers reported mindfulness-based interventions delivered to groups; one paper reported a mindfulness-based intervention which was delivered one to one. The results demonstrate a positive trend in favor of the benefits of mindfulness-based interventions across a range of psychological, physiological, and psychosocial outcomes including anxiety, depression, mental fatigue, blood pressure, perceived health, and quality of life. No evidence of harm was found.

CONCLUSION

Following transient ischemic attack/stroke, people may derive a range of benefits from mindfulness-based interventions; however, further methodologically robust trials are required.

A longitudinal general population-based study of job strain and risk for coronary heart disease and stroke in Swedish men

OBJECTIVES

The aim was to investigate whether psychosocial stress based on the job-demand-control (JDC) model increased the risk for coronary heart disease (CHD) and stroke.

SETTING

Swedish men.

PARTICIPANTS

The Primary Prevention Study (PPS) comprises 6070 men born between 1915 and 1925 free from previous history of CHD and stroke at baseline (1974-1977). Psychosocial workplace exposure was assessed using a job-exposure matrix (JEM) for the JDC model based on occupation at baseline. The participants were followed from baseline examination, until death, until hospital discharge or until 75 years of age, whichever occurred first, using the Swedish national register on cause of death and the Swedish hospital discharge register for non-fatal and fatal stroke and CHD events. Cox regression models were used with stroke or CHD as the outcome, using JDC model and age as explanatory variables, as well as stratified models with regard to smoking, self-reported stress, socioeconomic status, obesity, hypertension and diabetes.

PRIMARY AND SECONDARY OUTCOME MEASURES

Risk for stroke and CHD.

RESULTS

There was an increased risk (HR) for CHD in relation to high strain (HR 1.31, 95% CI 1.01 to 1.70). The risk was further increased among ever-smokers and among blue-collar workers. There was a relation between low control and increased risk for CHD (HR 1.19, 95% CI 1.06 to 1.35). There was no increased risk for stroke in any of the JDC categories.

CONCLUSIONS

Exposure to occupational psychosocial stress defined as job strain or low control increased the risk for CHD, especially among smokers and blue-collar workers. There was no increased risk for stroke in any of the JDC categories.

Knowledge, attitude and practice of stroke in India versus other developed and developing countries

Rising stroke and higher mortality among Indian population needs focused attention for prevention and early management of stroke. In India, very few studies have been carried out to determine the causes of deficiencies in knowledge, attitude and practice (KAP) of stroke among Indians. Study on KAP is essential to improve the awareness about stroke, early diagnosis and institution of appropriate management. In this article, we have reviewed the existing literature on this issue and tried to compare it with those of developed countries and suggested the measures we need to adopt in India to improve awareness and knowledge base.

The role of neuroendocrine pathways in prognosis after stroke

A number of neuroendocrine changes have been described after stroke, which may serve adaptive or deleterious functions. The neuroendocrine changes include activation of the hypothalamo-pituitary-adrenal axis, sympathetic nervous system and alterations of several hormonal levels. Alterations of the HPA axis, increased catecholamines, natriuretic peptides and, decreased melatonin and IGF-1 levels are associated with poor post-stroke outcome, although there is no definitive proof of causality. Therefore, it remains to be established whether alteration of neuroendocrine responses could be used as a potential therapeutic target to improve stroke outcome. This article gives an overview of the major neuroendocrine pathways altered by stroke and highlights their potential for clinical use and further neurotherapeutic development by summarizing the evidence for their association with stroke outcome including functional outcome, post-stroke infection, delirium, depression and stroke-related myocardial injury.

The influence of perceived stress on the onset of arthritis in women: findings from the Australian Longitudinal Study on women's health

BACKGROUND

Psychosocial factors are considered as risk factors for some chronic diseases. A paucity of research exists surrounding the role of perceived stress in arthritis onset.

PURPOSE

Perceived stress as a risk factor for arthritis development was explored in an ageing cohort of Australian women.

METHODS

This study focused on 12,202 women from the 1946-1951 cohort who completed the Australian Longitudinal Study on Women's Health surveys in 2001, 2004 and 2007. Longitudinal associations were modelled, with and without a time lag.

RESULTS

Findings from the multivariate time lag modelling, excluding women with persistent joint pain, revealed that perceived stress predicted the onset of arthritis, with women experiencing minimal and moderate/high stress levels having a 1.7 and 2.4 times greater odds of developing arthritis 3 years later, respectively (p's < 0.001).

CONCLUSION

Chronically perceiving life as stressful is detrimental to future health. The findings provide support for perceived stress to be considered alongside other modifiable risk factors.

Perceived mental stress in women associated with psychosomatic symptoms, but not mortality: observations from the Population Study of Women in Gothenburg, Sweden

Purpose

To investigate possible association between mental stress and psychosomatic symptoms, socioeconomic status, lifestyle, as well as incident mortality in a middle-aged female population followed over 37 years.

Methods

A prospective observational study initiated in 1968–1969, including 1462 women aged 60, 54, 50, 46, and 38 years, with follow-ups in 1974–1975, 1980–1981, and 2000–2001, was performed. Measures included self-reported mental stress as well as psychosomatic symptoms and smoking, physical activity, total cholesterol, S-triglycerides, body mass index, waist–hip ratio, blood pressure, socioeconomic status and mortality.

Results

Smoking, not being single, and not working outside home were strongly associated with reported mental stress at baseline. Women who reported high mental stress in 1968–1969 were more likely to report presence of abdominal symptoms (odds ratio [OR] = 1.85, 95% confidence interval [CI]: 1.39–2.46), headache/migraine (OR = 2.04, 95% CI: 1.53–2.72), frequent infections (OR = 1.75, 95% CI: 1.14–2.70), and musculoskeletal symptoms (OR = 1.70, 95% CI: 1.30–2.23) than women who did not report mental stress. Women without these symptoms at baseline 1968–1969, but with perceived mental stress were more likely to subsequently report incident abdominal symptoms (OR = 2.15, 95% CI: 1.39–3.34), headache/migraine (OR = 2.27, 95% CI: 1.48–3.48) and frequent infections (OR = 2.21, 95% CI: 1.12–4.36) in 1974–1975 than women without mental stress in 1968–1969. There was no association between perceived mental stress at baseline and mortality over 37 years of follow-up.

Conclusion

Women reporting mental stress had a higher frequency of psychosomatic symptoms than women who did not report these symptoms. Not working outside home and smoking rather than low socioeconomic status per se was associated with higher stress levels. Perception of high mental stress was not associated with increased mortality.

Vessels of Stone: Lenin's "circulatory disturbance of the brain"

Many have wondered what might have become of the totalitarian state Lenin founded on merciless terror, had he not died so young. He was 52 and at the height of his power when he had his first stroke. Six months later he had another and then a third stroke three months after that. He died 3 months shy of his 54th birthday with cerebral arteries so calcified that when tapped with tweezers at the time of his autopsy, they sounded like stone. The reason for his premature atherosclerosis has yet to be explained. He had a family history of cardiovascular disease and, therefore, is suspected of having had an inherited lipid disorder. Stress too might have had a role in the progression of his atherosclerosis. However, neither would explain the extent of the calcification of his cerebral arteries identified at post mortem examination. A recently described variant of the NT5E mutation might explain such calcification, as well as Lenin's family history of cardiovascular disease, and his premature cerebrovascular attacks.

Socio-economic differences in self-reported insomnia and stress in Finland from 1979 to 2002: a population-based repeated cross-sectional survey

Background

Over the decades, global public health efforts have sought to reduce socio-economic health differences, including differences in mental health. Only a few studies have examined changes in socio-economic differences in psychological symptoms over time. The aim of this study was to assess trends in socio-economic differences in self-reported insomnia and stress over a 24-year time period in Finland.

Methods

The data source is a repeated cross-sectional survey “Health Behaviour and Health among the Finnish Adult Population” (AVTK), from the years 1979 to 2002, divided into five study periods. Indicators for socio-economic status included employment status from the survey, and educational level and household income from the Statistics Finland register data. We studied the age group of 25–64 years (N = 70115; average annual response rate 75%). Outcome measures were single questions of self-reported insomnia and stress.

Results

The overall prevalence of insomnia was 18-19% and that of stress 16-19%. Compared to the first study period, 1979–1982, the prevalence of stress increased until study period 1993–1997. The prevalence of insomnia increased during the last study period, 1998–2002. Respondents who were unemployed or had retired early reported more insomnia and stress over time among both men and women. Lower education was associated with more insomnia especially among men; and conversely, with less stress among both sexes. Compared to the highest household income level, those in the intermediate levels of income had less stress whereas those in the lowest income levels had more stress among both sexes. Income level differences in insomnia were less consistent. In general, socio-economic differences in self-reported insomnia and stress fluctuated some, but did not change substantially over the study period 1979–2002.

Conclusions

Self-reported insomnia and stress were more common during later study periods. The socio-economic differences in insomnia and stress have remained fairly stable over a 24-year time period. However, some of the associations in socio-economic differences were curvilinear and converse. Future studies are needed to explore the complex socio-economic gradients, especially in stress.

Epidemiology and prevention of stroke: a worldwide perspective

This paper reviews how epidemiological studies during the last 5 years have advanced our knowledge in addressing the global stroke epidemic. The specific objectives were to review the current evidence supporting management of ten major modifiable risk factors for prevention of stroke: hypertension, current smoking, diabetes, obesity, poor diet, physical inactivity, atrial fibrillation, excessive alcohol consumption, abnormal lipid profile and psychosocial stress/depression.

Increased risks of coronary heart disease and stroke among spousal caregivers of cancer patients

BACKGROUND

Spousal caregivers of cancer patients suffer psychological and physical burdens that may affect their risk of subsequently developing coronary heart disease and stroke.

METHODS AND RESULTS

Cancer patients were identified in the Swedish Cancer Registry, and information on their spouses was retrieved from the Swedish Multi-Generation Register. Follow-up of caregivers was performed from the date of the first diagnosis of cancer in their spouses through 2008. Standardized incidence ratios were calculated for spousal caregivers of cancer patients compared with those without an affected spouse. After the cancer diagnosis in wives, the risks of coronary heart disease, ischemic stroke, and hemorrhagic stroke in husbands were 1.13 (95% confidence interval [CI], 1.10-1.16), 1.24 (95% CI, 1.21-1.27), and 1.25 (95% CI, 1.18-1.32), respectively. The corresponding risks in wives with an affected husband were 1.13 (95% CI, 1.10-1.16), 1.29 (95% CI, 1.26-1.32), and 1.27 (95% CI, 1.19-1.34). The increases were consistent over time and were more pronounced if the spouse was affected by a cancer with a high mortality rate, such as pancreatic and lung cancers.

CONCLUSIONS

Spousal caregivers of cancer patients have increased risks of coronary heart disease and stroke that persist over time. Clinical attention should be paid to spousal caregivers, especially those caring for cancer patients with high mortality rates.

Knowledge of Stroke Risk Factors and Warning Signs in Ireland: Development and Application of the Stroke Awareness Questionnaire (SAQ)

Background

Inability to recognize stroke warning signs and delay in seeking medical attention for recognized symptoms contribute to treatment delay, thus limiting the potential for intervention and impacting negatively on potential stroke outcome.

Aim

To examine knowledge of stroke risk factors and warning signs in the adult population in Ireland.

Methods

In 2009, 1000 members of the general public were interviewed by telephone using quota-based population sampling of adults (≥18 years). Information was gathered using the Stroke Awareness Questionnaire (SAQ).

Results

71% of participants could correctly list two or more risk factors for stroke, typically generic lifestyle risk factors. Two-thirds could not identify two warning signs for stroke. While 31% could identify two or more stroke warning signs, there was no consistency in warning signs identified. Less than 50% stated they would call an ambulance if having a stroke. Overall, there were significant gaps in knowledge, with poorest levels evident in those aged ≥65 years.

Conclusions

Survey findings provide first evidence on levels of knowledge of stroke risk factors and warning signs in the Irish adult population. Awareness of stroke warning signs was poor, as was awareness of the need to call emergency services and the potential for acute stroke intervention. These factors contribute to delay in seeking medical attention following stroke, with resulting implications for stroke outcome.