Prospective study of moderate alcohol consumption and risk of peripheral arterial disease in US male physicians

Sex differences in risk factors for incident peripheral artery disease hospitalisation or death: Cohort study of UK Biobank participants

BACKGROUND

Women with peripheral artery disease (PAD) often have atypical symptoms, late hospital presentations, and worse prognosis. Risk factor identification and management are important. We assessed sex differences in associations of risk factors with PAD.

METHODS

500,207 UK Biobank participants (54.5% women, mean age 56.5 years) without prior hospitalisation of PAD at baseline were included. Examined risk factors included blood pressure, smoking, diabetes, lipids, adiposity, history of stroke or myocardial infarction (MI), socioeconomic status, kidney function, C-reactive protein, and alcohol consumption. Poisson and Cox regressions were used to estimate sex-specific incidence of PAD hospitalisation or death, hazard ratios (HRs), and women-to-men ratios of HRs (RHR) with confidence intervals (CIs).

RESULTS

Over a median of 12.6 years, 2658 women and 5002 men had a documented PAD. Age-adjusted incidence rates were higher in men. Most risk factors were associated with a higher risk of PAD in both sexes. Compared with men, women who were smokers or had a history of stroke or MI had a greater excess risk of PAD (relative to those who never smoked or had no history of stroke or MI): RHR 1.18 (95%CI 1.04, 1.34), 1.26 (1.02, 1.55), and 1.50 (1.25, 1.81), respectively. Higher high-density lipoprotein cholesterol (HDL-C) was more strongly associated with a lower risk of PAD in women than men, RHR 0.81 (0.68, 0.96). Compared to HDL-C at 40 to 60 mg/dL, the lowest level of HDL-C (≤40 mg/dL) was related to greater excess risk in women, RHR 1.20 (1.02, 1.41), whereas the highest level of HDL-C (>80 mg/dL) was associated with lower risk of PAD in women, but higher risk in men, RHR 0.50 (0.38, 0.65).

CONCLUSIONS

While the incidence of PAD was higher in men, smoking and a history of stroke or MI were more strongly associated with a higher risk of PAD in women than men. HDL-C was more strongly associated with a lower risk of PAD in women than men.

Associations of habitual alcohol drinking with HDL cholesterol and D-dimer in patients with peripheral arterial disease

BACKGROUND

The risk of cardiovascular disease is lower in light-to-moderate alcohol drinkers than in nondrinkers in the general population. However, it remains to be clarified whether these beneficial effects of alcohol are shown in patients with peripheral arterial disease (PAD).

METHODS

The subjects were 153 male outpatients with PAD and they were divided by frequency of drinking into nondrinkers, occasional drinkers (1-4 day/wk) and regular drinkers (5-7 day/wk). Relationships of alcohol drinking with variables related to progression of atherosclerosis and cardiovascular risk were investigated.

RESULTS

The levels of HDL cholesterol and d-dimer were significantly higher and lower, respectively, in regular drinkers than in nondrinkers, while there were no significant differences in BMI, blood pressure, total cholesterol, LDL cholesterol, triglycerides, hemoglobin A_1c, platelet count, fibrinogen, ankle brachial index and intima-media thickness of the carotid artery in non-, occasional and regular drinkers. Odds ratios of regular drinkers vs. nondrinkers for low HDL cholesterol (0.24 [0.08∼0.70]) and high d-dimer (0.29 [0.14∼0.61]) were significantly lower than the reference level.

CONCLUSIONS

In patients with PAD, habitual alcohol drinking was associated with increase of HDL cholesterol and suppression of blood coagulability. However, progression of atherosclerosis was not different in nondrinkers and drinkers.

A Comprehensive Physiotherapy Rehabilitation for Lower Limb Amputation as a Consequence of Cannabis and Alcohol Dependency: A Case Report

Chronic marijuana and alcohol consumption leads to many forms of physical and physiological deterioration in the human body, mainly affecting the neurological system. A ​​​​65-year-old male patient suffered from stroke with the involvement of middle cerebral artery of the left side. Nine years later, patient presented with gangrene due to a traumatic unhealed wound on his left leg. The patient was under the influence of alcohol when he was injured. The infection spread, causing peripheral arterial disease, which eventually led to the development of gangrene till mid-calf of the left leg, for which he was amputated. Above-knee amputation with a fish-mouth incision was performed. Physiotherapy management focused on prehension and grip exercises for right upper limb, strengthening of all the limb musculature, stump management, transfer training, gait training with walker/crutches and prosthesis, and home exercise program, retraining activities of daily living. This case study embodies a rehabilitation program for this patient who suffered from stroke followed by amputation of the left leg. It focuses on bringing the patient back to his near-normal life. Regular physiotherapy helped the patient build up confidence, helped in resolving his addictions, and provided individual structure management. We present a rare case of above-knee amputation secondary to complications of alcohol abuse where an extensive post-op care and elaborate physiotherapy program resulted in a successful recovery.

Effects of walking impairment on mental health burden, health risk behavior and quality of life in patients with intermittent claudication: A cross-sectional path analysis

Introduction

Intermittent claudication is the leading symptom of peripheral artery disease (leg pain when walking). The present study investigates the extent to which walking impairment is associated with health-related quality of life, mental health and health risk behavior.

Methods

A theory-based, cross-sectional path model was empirically examined using pre-intervention baseline data from a multicenter, randomized-controlled trial of patients with intermittent claudication (PAD-TeGeCoach). Data were available from 1 696 patients who completed a battery of questionnaires between April 14, 2018 and March 12, 2019, including measures of walking impairment (Walking Impairment Questionnaire), health-related quality of life (SF-12), mental burden (GAD-7, PHQ-9), nicotine- and alcohol-related risk behavior (Fagerström-Test, AUDIT-C). Sociodemographic characteristics and comorbid conditions were included in the postulated model a priori to minimize confounding effects.

Results

Walking impairment was associated with an increase in depressive (β = -.36, p < .001) and anxiety symptoms (β = -.24, p < .001). The prevalence of depressive and anxiety symptoms was 48.3% and 35.5%, respectively, with female patients and those of younger age being at greater risk. Depressive symptoms were predictive of an increased tobacco use (β = .21; p < .001). Walking impairment had adverse effects on physical quality of life, both directly (β = .60, p < .001) and indirectly mediated through depressive symptoms (β = -.16, p < .001); and indirectly on mental quality of life mediated through depressive (β = -.43, p < .001) and anxiety symptoms (β = -.35, p < .001).

Discussion

The findings underscore the need for a comprehensive treatment strategy in patients with intermittent claudication. Measures to improve walking impairment (e.g. exercise training) are key to enhance quality of life and should be the primary treatment. As a key mediator of mental quality of life, depressive and anxiety symptoms should be addressed by rigorously including mental health treatment. Risky health behaviors should be approached by promoting behavior change (e.g. smoking cessation) as a secondary prevention of peripheral artery disease.

Peripheral Arterial Disease in Persons with Diabetic Foot Ulceration: a Current Comprehensive Overview

In developed countries, the prevalence of persons with diabetes and peripheral arterial disease (PAD) is approximately 50%. The presence of PAD is associated with non-healing ulcers, major amputation, cardiovascular morbidity, and mortality. It is estimated that persons with diabetes, foot ulceration and PAD have 50% of 5-years mortality rate. Therefore, subjects with ischemic diabetic foot ulcers (DFUs) should be considered a special group of patients with specific clinical characteristics, general health status and prognosis. In persons with ischemic DFUs, an early diagnosis and treatment are mandatory to reduce the risk of worse outcomes such as major amputation. Revascularization of occluded lower extremity arteries is the main treatment to restore blood flow in the foot and promote wound healing. Nonetheless, there are several unmet needs in the management of diabetic subjects with PAD and foot ulceration as medical therapy, diagnostic criteria and indications for revascularization, revascularization strategy and technical approach as well as the management of no-option critical limb ischemia patients. It is a common opinion that there is an evolution of PAD features in diabetic persons, which seems to present a more aggressive pattern. This may be related to the frequent presence of concomitant comorbidities such as renal failure which could influence the characteristics of atherosclerotic plaques and their distribution. The aim of this review is to commence a complete overview and state of the art in the treatment of patients with diabetes, PAD, and foot ulceration and to describe the current challenges and future perspectives.

The effect of interaction between EtOH dosage and exposure time on gene expression in DPSC

Alcohol (EtOH) dosage and exposure time can affect gene expression. However, whether there exists synergistic effect is unknown. Here, we analyzed the hDPSC gene microarray dataset GSE57255 downloaded from Gene Expression Omnibus and found that the interaction between EtOH dosage and exposure time on gene expression are statistically significant for two probes: 201917_s_at near gene SLC25A36 and 217649_at near gene ZFAND5. GeneMania showed that SLC25A36 and ZFAND5 were related to 20 genes, three of which had alcohol-related functions. WebGestalt revealed that the 22 genes were enriched in 10 KEGG pathways, four of which are related to alcoholic diseases. We explored the possible nonlinear interaction effect and got 172 gene probes with significant p-values. However, no significantly enriched pathways based on the 172 probes were detected. Our analyses indicated a possible molecular mechanism that could help explain why alcohol consumption has both deleterious and beneficial effects on human health.

Increased risk of peripheral arterial disease in patients with alcohol intoxication: A population-based retrospective cohort study

Previous studies have reported that light-to-moderate drinkers have a lower risk of peripheral arterial disease (PAD) than abstainers, and that heavy drinking increases the risk of PAD. However, reports of the effects of severe alcohol drinking on PAD are lacking within a population-based cohort. Alcohol intoxication is typically considered a medical emergency at clinics in Taiwan and is commonly attributed to excessive alcohol use. The present study aimed to investigate the association between alcohol intoxication and PAD risk. We conducted a retrospective, population-based, health insurance cohort study consisting of 56,544 adult patients with alcohol intoxication between January 1, 2000 and December 31, 2009, using claims data from the National Health Insurance Research Database (NHIRD) of Taiwan. This database included a control cohort of 226,176 residents without alcohol intoxication. The patients were age- and gender-matched. The incidence rate of PAD, after data regarding alcohol intoxication were obtained, was 12.8 per 10,000 person-years, and the adjusted hazard ratio (aHR) of PAD was 3.80 (95% confidence interval [CI] = 3.35-4.32, p < 0.05). The log-rank test showed that patients with alcohol intoxication had a considerably higher PAD cumulative incidence rate than those without alcohol intoxication. Alcohol intoxication was significantly associated with an increased risk of PAD in men (hazard ratio [HR] = 3.77, 95% CI = 3.30-4.31) and women (HR = 4.26, 95% CI = 2.60-6.97). The aHRs of PAD risk were 7.64 (95% CI = 4.39-13.3), 4.51 (95% CI = 3.83-5.29), and 2.16 (95% CI = 1.69-2.77) for patients with alcohol intoxication compared to participants of the control group aged <35 years, 35-64 years, and ≥65 years, respectively. The individuals with alcohol intoxication and without any comorbidities had a 3.77-fold increased risk of PAD in comparison to that of the control cohorts (HR = 3.77, 95% CI = 3.30-4.30). The aHR of PAD in patients with alcohol intoxication was 4.53 (95% CI = 2.51-8.16) in comparison to the control cohort, which consisted of patients with at least one existing comorbidity. Alcohol intoxication, along with the severe complications of excessive alcohol use, should be considered as major risk factors of PAD in the setting of a medical emergency. Further research needs to be performed to evaluate the quantitative effect of alcohol use on PAD.

Antioxidant vitamin and mineral supplements for preventing age-related macular degeneration

BACKGROUND

There is inconclusive evidence from observational studies to suggest that people who eat a diet rich in antioxidant vitamins (carotenoids, vitamins C, and E) or minerals (selenium and zinc) may be less likely to develop age-related macular degeneration (AMD).

OBJECTIVES

To determine whether or not taking antioxidant vitamin or mineral supplements, or both, prevent the development of AMD.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Trials Register) (2017, Issue 2), MEDLINE Ovid (1946 to 29 March 2017), Embase Ovid (1947 to 29 March 2017), AMED (Allied and Complementary Medicine Database) (1985 to 29 March 2017), OpenGrey (System for Information on Grey Literature in Europe) (www.opengrey.eu/); searched 29 March 2017, the ISRCTN registry (www.isrctn.com/editAdvancedSearch); searched 29 March 2017, ClinicalTrials.gov (www.clinicaltrials.gov); searched 29 March 2017 and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en); searched 29 March 2017. We did not use any date or language restrictions in the electronic searches for trials.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing an antioxidant vitamin or mineral supplement (alone or in combination) to control.

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed risk of bias in the included studies and extracted data. One author entered data into RevMan 5; the other author checked the data entry. We pooled data using a fixed-effect model. We graded the certainty of the evidence using GRADE.

MAIN RESULTS

We included a total of five RCTs in this review with data available for 76,756 people. The trials were conducted in Australia, Finland, and the USA, and investigated vitamin C, vitamin E, beta-carotene, and multivitamin supplements. All trials were judged to be at low risk of bias.Four studies reported the comparison of vitamin E with placebo. Average treatment and follow-up duration ranged from 4 to 10 years. Data were available for a total of 55,614 participants. There was evidence that vitamin E supplements do not prevent the development of any AMD (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.90 to 1.06; high-certainty evidence), and may slightly increase the risk of late AMD (RR 1.22, 95% CI 0.89 to 1.67; moderate-certainty evidence) compared with placebo. Only one study (941 participants) reported data separately for neovascular AMD and geographic atrophy. There were 10 cases of neovascular AMD (RR 3.62, 95% CI 0.77 to 16.95; very low-certainty evidence), and four cases of geographic atrophy (RR 2.71, 95% CI 0.28 to 26.0; very low-certainty evidence). Two trials reported similar numbers of adverse events in the vitamin E and placebo groups. Another trial reported excess of haemorrhagic strokes in the vitamin E group (39 versus 23 events, hazard ratio 1.74, 95% CI 1.04 to 2.91, low-certainty evidence).Two studies reported the comparison of beta-carotene with placebo. These studies took place in Finland and the USA. Both trials enrolled men only. Average treatment and follow-up duration was 6 years and 12 years. Data were available for a total of 22,083 participants. There was evidence that beta-carotene supplements did not prevent any AMD (RR 1.00, 95% CI 0.88 to 1.14; high-certainty evidence) nor have an important effect on late AMD (RR 0.90, 95% CI 0.65 to 1.24; moderate-certainty evidence). Only one study (941 participants) reported data separately for neovascular AMD and geographic atrophy. There were 10 cases of neovascular AMD (RR 0.61, 95% CI 0.17 to 2.15; very low-certainty evidence) and 4 cases of geographic atrophy (RR 0.31 95% CI 0.03 to 2.93; very low-certainty evidence). Beta-carotene was associated with increased risk of lung cancer in people who smoked.One study reported the comparison of vitamin C with placebo, and multivitamin (Centrum Silver) versus placebo. This was a study in men in the USA with average treatment duration and follow-up of 8 years for vitamin C and 11 years for multivitamin. Data were available for a total of 14,236 participants. AMD was assessed by self-report followed by medical record review. There was evidence that vitamin C supplementation did not prevent any AMD (RR 0.96, 95% CI 0.79 to 1.18; high-certainty evidence) or late AMD (RR 0.94, 0.61 to 1.46; moderate-certainty evidence). There was a slight increased risk of any AMD (RR 1.21, 95% CI 1.02 to 1.43; moderate-certainty evidence) and late AMD (RR 1.22, 95% CI 0.88 to 1.69; moderate-certainty evidence) in the multivitamin group. Neovascular AMD and geographic atrophy were not reported separately. Adverse effects were not reported but there was possible increased risk of skin rashes in the multivitamin group.Adverse effects were not consistently reported in these eye studies, but there is evidence from other large studies that beta-carotene increases the risk of lung cancer in people who smoke or who have been exposed to asbestos.None of the studies reported quality of life or resource use and costs.

AUTHORS' CONCLUSIONS

Taking vitamin E or beta-carotene supplements will not prevent or delay the onset of AMD. The same probably applies to vitamin C and the multivitamin (Centrum Silver) investigated in the one trial reported to date. There is no evidence with respect to other antioxidant supplements, such as lutein and zeaxanthin. Although generally regarded as safe, vitamin supplements may have harmful effects, and clear evidence of benefit is needed before they can be recommended. People with AMD should see the related Cochrane Review on antioxidant vitamin and mineral supplements for slowing the progression of AMD, written by the same review team.

Tuberculosis increases the risk of peripheral arterial disease: A nationwide population-based study

BACKGROUND AND OBJECTIVE

According to several studies, tuberculosis (TB) may be involved in the pathogenesis of cardiovascular disease. However, the relationship between TB and peripheral arterial disease (PAD) has not been studied. The aim of this study was to investigate whether patients with TB exhibit an increased risk of developing PAD.

METHODS

The data assessed in this national population-based cohort study were obtained from the Taiwan National Health Insurance Database from 2000 to 2010. Patients with newly diagnosed TB were selected using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. The non-TB cohort was randomly frequency-matched to the TB cohort at a ratio of 2:1 according to age, sex and index year. Cox's proportional hazards regression models were used to analyse the risk of PAD.

RESULTS

We enrolled 14 350 patients with TB and 28 700 controls in this study. The risk of PAD was 3.93-fold higher in the patients with TB than in the non-TB controls after adjusting for age, sex, co-morbidities and socio-economic status. Based on the subgroup analysis, the TB cohort exhibited an increased risk of developing PAD compared with the non-TB cohort, regardless of age, sex, co-morbidities and socio-economic status. Patients with TB had a higher risk of developing PAD than healthy control subjects after 1 year of follow-up.

CONCLUSION

Patients with TB have a significantly higher risk of developing PAD than patients without TB. TB should be considered when evaluating a patient's risk of developing PAD.

Association between clinically recorded alcohol consumption and initial presentation of 12 cardiovascular diseases: population based cohort study using linked health records

Objectives To investigate the association between alcohol consumption and cardiovascular disease at higher resolution by examining the initial lifetime presentation of 12 cardiac, cerebrovascular, abdominal, or peripheral vascular diseases among five categories of consumption.Design Population based cohort study of linked electronic health records covering primary care, hospital admissions, and mortality in 1997-2010 (median follow-up six years).Setting CALIBER (ClinicAl research using LInked Bespoke studies and Electronic health Records).Participants 1 937 360 adults (51% women), aged ≥30 who were free from cardiovascular disease at baseline.Main outcome measures 12 common symptomatic manifestations of cardiovascular disease, including chronic stable angina, unstable angina, acute myocardial infarction, unheralded coronary heart disease death, heart failure, sudden coronary death/cardiac arrest, transient ischaemic attack, ischaemic stroke, intracerebral and subarachnoid haemorrhage, peripheral arterial disease, and abdominal aortic aneurysm.Results 114 859 individuals received an incident cardiovascular diagnosis during follow-up. Non-drinking was associated with an increased risk of unstable angina (hazard ratio 1.33, 95% confidence interval 1.21 to 1.45), myocardial infarction (1.32, 1.24 to1.41), unheralded coronary death (1.56, 1.38 to 1.76), heart failure (1.24, 1.11 to 1.38), ischaemic stroke (1.12, 1.01 to 1.24), peripheral arterial disease (1.22, 1.13 to 1.32), and abdominal aortic aneurysm (1.32, 1.17 to 1.49) compared with moderate drinking (consumption within contemporaneous UK weekly/daily guidelines of 21/3 and 14/2 units for men and women, respectively). Heavy drinking (exceeding guidelines) conferred an increased risk of presenting with unheralded coronary death (1.21, 1.08 to 1.35), heart failure (1.22, 1.08 to 1.37), cardiac arrest (1.50, 1.26 to 1.77), transient ischaemic attack (1.11, 1.02 to 1.37), ischaemic stroke (1.33, 1.09 to 1.63), intracerebral haemorrhage (1.37, 1.16 to 1.62), and peripheral arterial disease (1.35; 1.23 to 1.48), but a lower risk of myocardial infarction (0.88, 0.79 to 1.00) or stable angina (0.93, 0.86 to 1.00).Conclusions Heterogeneous associations exist between level of alcohol consumption and the initial presentation of cardiovascular diseases. This has implications for counselling patients, public health communication, and clinical research, suggesting a more nuanced approach to the role of alcohol in prevention of cardiovascular disease is necessary.Registration clinicaltrails.gov (NCT01864031).

Dietary intake and peripheral arterial disease incidence in middle-aged adults: the Atherosclerosis Risk in Communities (ARIC) Study

Background: Peripheral arterial disease (PAD) is a costly source of morbidity and mortality among older persons in the United States. Dietary intake plays a role in the development of atherosclerotic cardiovascular disease; however, few studies have examined the relation of food intake or dietary patterns with PAD.Objective: We examined the relation between habitual dietary intake at midlife and incident PAD over ∼20 y of follow-up.Design: Among 14,082 participants enrolled in the ARIC (Atherosclerosis Risk in Communities) Study initially free of PAD, dietary intake was assessed at baseline in 1987-1989 by using a modified Harvard food-frequency questionnaire. Food groups were created, and principal components analysis was used to develop "healthy" and "Western" dietary patterns; both were categorized into quintiles or quartiles. Incident PAD was determined by an ankle-brachial index <0.9 assessed at 2 subsequent examinations and hospital discharge codes through 2012. Multivariate-adjusted Cox proportional hazards regression was used.Results: During a mean follow-up of 19.9 y, 1569 participants developed incident PAD. In models adjusted for demographic characteristics, behaviors, and food groups, the HRs (95% CIs) for incident PAD increased across quintiles of meat consumption [quintile 1: reference, quintile 2: 1.38 (1.16, 1.65), quintile 3: 1.38 (1.16, 1.65), quintile 4: 1.45 (1.20, 1.74), quintile 5: 1.66 (1.36, 2.03); P-trend <0.001]. Compared with those who drank no alcohol, those who had 1-6 drinks/wk had a lower risk of incident PAD [0.78 (0.68, 0.89)]. For coffee, ≥4 cups/d compared with none was inversely associated with incident PAD [quintile 5 compared with quintile 1: 0.84 (0.75, 1.00); P-trend = 0.014]. There was no association between other food groups or patterns and incident PAD.Conclusions: In this prospective cohort study, greater meat consumption was associated with a higher risk, and moderate alcohol consumption was associated with a lower risk of incident PAD. Whether these associations are causal remains to be seen. This trial was registered at clinicaltrials.gov as NCT00005131.

Epidemiology and Pathophysiology of Lower Extremity Peripheral Arterial Disease

Peripheral arterial disease (PAD), a major cause of disability, loss of work, and lifestyle changes in the United States, is defined as obstruction of blood flow into an arterial tree excluding the intracranial or coronary circulations. PAD is mostly silent in its early stages, but when lesion obstruction exceeds 50%, it may cause intermittent claudication with ambulation. Further disease progression typically leads to rest pain or frank tissue loss. However, some patients may remain asymptomatic with severe disease because of extensive collateralization in the lower extremity. Estimates of the prevalence of intermittent claudication vary by population, from 0.6% to nearly 10%; the rate increases dramatically with age. Approximately 20% to 25% of patients will require revascularization, while fewer than 5% will progress to critical limb ischemia. Limb loss, although rare, is associated with severe disability and an overall poor prognosis, with 30% to 40% mortality in the first 24 months after limb loss. As with coronary artery disease, the most common cause of symptomatic obstruction in the peripheral arterial tree is atherosclerosis, a systemic inflammatory process in which cholesterol-laden plaque builds up in the artery and eventually blocks the lumen. Typical risk factors include age, gender, diabetes, tobacco abuse, hypertension, and hyperlipidemia.

Alcohol and Acute Myocardial Infarction

A number of studies from different countries and several large-scale meta-analyses have reported reduced coronary heart disease rates among those regularly consuming mild to moderate amounts of alcohol compared with those abstaining from alcohol. In contrast, various studies have also reported that heavy alcohol consumption promotes the progression of atherosclerosis and that binge drinking might trigger embolic stroke and acute myocardial infarction. We discuss the association between alcohol consumption and acute myocardial infarction on the basis of evidence from literature published recently. Alcohol consumption has both favourable and unfavourable effects on metabolism, lipid profile, blood coagulation and fibrinolysis, blood pressure and vascular tone depending on the amount of alcohol consumed and the way that it is drunk (i.e. drinking habits). We conclude that it is extremely important to warn people of the risks associated with binge drinking and to encourage them to remain within the recommended safe limits for alcohol consumption.

Beyond Ischemic Heart Disease: Are There other Health Benefits from Drinking Alcohol?

Evidence is growing that alcohol consumption confers health benefits beyond protection from ischemic heart disease. We review this evidence with regard to cerebrovascular disease, peripheral vascular disease, diabetes, cholelithiasis (gallstones), cognitive functioning, and stress reduction and subjective psychosocial benefits. Other possible benefits are briefly considered. The weight of evidence suggests that low-level alcohol consumption offers some protection against ischemic stroke. The evidence that moderate alcohol consumption protects against diabetes and gallstones is also fairly strong. The possibility of other health benefits cannot be dismissed. For all the conditions considered, more research is indicated. The application of more appropriate statistical techniques, studies of patterns of drinking, and experimental approaches to delineating underlying mechanisms should enable firmer conclusions to be drawn. A better understanding of both the benefits and the risks of alcohol use for individuals and populations will facilitate the development of appropriate program and policy interventions to promote health.

Alcohol and cardiovascular health: the dose makes the poison…or the remedy

Habitual light to moderate alcohol intake (up to 1 drink per day for women and 1 or 2 drinks per day for men) is associated with decreased risks for total mortality, coronary artery disease, diabetes mellitus, congestive heart failure, and stroke. However, higher levels of alcohol consumption are associated with increased cardiovascular risk. Indeed, behind only smoking and obesity, excessive alcohol consumption is the third leading cause of premature death in the United States. Heavy alcohol use (1) is one of the most common causes of reversible hypertension, (2) accounts for about one-third of all cases of nonischemic dilated cardiomyopathy, (3) is a frequent cause of atrial fibrillation, and (4) markedly increases risks of stroke-both ischemic and hemorrhagic. The risk-to-benefit ratio of drinking appears higher in younger individuals, who also have higher rates of excessive or binge drinking and more frequently have adverse consequences of acute intoxication (for example, accidents, violence, and social strife). In fact, among males aged 15 to 59 years, alcohol abuse is the leading risk factor for premature death. Of the various drinking patterns, daily low- to moderate-dose alcohol intake, ideally red wine before or during the evening meal, is associated with the strongest reduction in adverse cardiovascular outcomes. Health care professionals should not recommend alcohol to nondrinkers because of the paucity of randomized outcome data and the potential for problem drinking even among individuals at apparently low risk. The findings in this review were based on a literature search of PubMed for the 15-year period 1997 through 2012 using the search terms alcohol, ethanol, cardiovascular disease, coronary artery disease, heart failure, hypertension, stroke, and mortality. Studies were considered if they were deemed to be of high quality, objective, and methodologically sound.

Wine, Food and Health

Wine has historically been associated with religious rights, used as a salubrious beverage, employed as a medication as well as a medicinal solvent, and consumed as a food accompaniment. It is the latter that is most intimately associated in the minds of most modern consumers. Despite this, there is little flavor commonality on which pairing could be based. The first section of the chapter examines this feature, and wine’s primary role as a palate cleanser and food condiment. The synergistic role of food and wine in suppressing each other’s least pleasant attributes is also explained. The final section deals with the latest evidence relating to the many beneficial health effects of moderate wine consumption, shortfalls in the data, headache induction, dental erosion, and conditions under which wine intake is contraindicated.

Alcohol intake and triglycerides/high-density lipoprotein cholesterol ratio in men with hypertension

BACKGROUND

The triglycerides/high-density lipoprotein cholesterol (TG/HDL-C) ratio has been proposed to be a good predictor of cardiovascular disease. The relationship between alcohol consumption and TG/HDL-C ratio in patients with hypertension is unknown.

METHODS

Subjects were normotensive and hypertensive men aged 35-60 years who were divided by daily ethanol intake into non-, light (<22g/day), heavy (≥22 but <44g/day), and very heavy (≥44g/day) drinkers.

RESULTS

The TG/HDL-C ratio was significantly higher in the hypertensive group than in the normotensive group. Both in the normotensive and hypertensive groups, TG/HDL-C ratio was significantly lower in light, heavy, and very heavy drinkers than in nondrinkers and was lowest in light drinkers. In the hypertensive group, odds ratios (ORs) for high TG/HDL-C ratio (≥3.75) in light, heavy, and very heavy drinkers vs. nondrinkers were significantly lower (P < 0.01) than a reference level of 1.00 (light drinkers: OR = 0.49, 95% confidence interval (CI) = 0.40-0.59; heavy drinkers: OR = 0.59, 95% CI = 0.52-0.67; very heavy drinkers: OR = 0.70, 95% CI = 0.61-0.80) and were significantly lower than the corresponding ORs in the normotensive group. The ORs for hypertension in subjects with vs. subjects without high TG/HDL-C ratio were significantly higher than the reference level in all the alcohol groups and were significantly lower in light, heavy, and very heavy drinkers than in nondrinkers.

CONCLUSIONS

The results suggest that there is an inverted J-shaped relationship between alcohol and TG/HDL-C ratio in individuals with hypertension and that alcohol weakens the positive association between TG/HDL-C ratio and hypertension.

Moderate alcohol use and health: a consensus document

AIMS

The aim of this consensus paper is to review the available evidence on the association between moderate alcohol use, health and disease and to provide a working document to the scientific and health professional communities.

DATA SYNTHESIS

In healthy adults and in the elderly, spontaneous consumption of alcoholic beverages within 30 g ethanol/d for men and 15 g/d for women is to be considered acceptable and do not deserve intervention by the primary care physician or the health professional in charge. Patients with increased risk for specific diseases, for example, women with familiar history of breast cancer, or subjects with familiar history of early cardiovascular disease, or cardiovascular patients should discuss with their physician their drinking habits. No abstainer should be advised to drink for health reasons. Alcohol use must be discouraged in specific physiological or personal situations or in selected age classes (children and adolescents, pregnant and lactating women and recovering alcoholics). Moreover, the possible interactions between alcohol and acute or chronic drug use must be discussed with the primary care physician.

CONCLUSIONS

The choice to consume alcohol should be based on individual considerations, taking into account the influence on health and diet, the risk of alcoholism and abuse, the effect on behaviour and other factors that may vary with age and lifestyle. Moderation in drinking and development of an associated lifestyle culture should be fostered.

Antioxidant vitamin and mineral supplements for preventing age-related macular degeneration

BACKGROUND

There is inconclusive evidence from observational studies to suggest that people who eat a diet rich in antioxidant vitamins (carotenoids, vitamins C and E) or minerals (selenium and zinc) may be less likely to develop age-related macular degeneration (AMD).

OBJECTIVES

To examine the evidence as to whether or not taking antioxidant vitamin or mineral supplements prevents the development of AMD.

SEARCH METHODS

We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (The Cochrane Library 2011, Issue 12), MEDLINE (January 1950 to January 2012), EMBASE (January 1980 to January 2012), Open Grey (System for Information on Grey Literature in Europe) (www.opengrey.eu/), the metaRegister of Controlled Trials (mRCT) (www.controlled-trials.com), ClinicalTrials.gov (www.clinicaltrials.gov) and the WHO International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). There were no date or language restrictions in the electronic searches for trials. The electronic databases were last searched on 26 January 2012.

SELECTION CRITERIA

We included all randomised controlled trials (RCTs) comparing an antioxidant vitamin and/or mineral supplement (alone or in combination) to control.

DATA COLLECTION AND ANALYSIS

Both review authors independently assessed risk of bias in the included studies and extracted data. One author entered data into RevMan 5 and the other author checked the data entry. We pooled data using a fixed-effect model.

MAIN RESULTS

We included four RCTs in this review; 62,520 people were included in the analyses. The trials were conducted in Australia, Finland and the USA and investigated vitamin E and beta-carotene supplements. Overall the quality of the evidence was high. People who took these supplements were not at decreased (or increased) risk of developing AMD. The pooled risk ratio for any antioxidant supplement in the prevention of any AMD was 0.98 (95% confidence interval 0.89 to 1.08) and for advanced AMD was 1.05 (95% CI 0.80 to 1.39). Similar results were seen when the analyses were restricted to beta-carotene and alpha-tocopherol alone.

AUTHORS' CONCLUSIONS

There is accumulating evidence that taking vitamin E or beta-carotene supplements will not prevent or delay the onset of AMD. There is no evidence with respect to other antioxidant supplements, such as vitamin C, lutein and zeaxanthin, or any of the commonly marketed multivitamin combinations. Although generally regarded as safe, vitamin supplements may have harmful effects and clear evidence of benefit is needed before they can be recommended. People with AMD should see the related Cochrane review 'Antioxidant vitamin and mineral supplements for slowing the progression of age-related macular degeneration' written by the same review team.

Alcohol and the heart: to abstain or not to abstain?

Alcohol has been consumed by most societies over the last 7000 years. Abraham Lincoln said "It has long been recognized that the problems with alcohol relate not to the use of a bad thing, but to the abuse of a good thing." Light to moderate alcohol consumption reduces the incidence of coronary heart disease (CHD), ischemic stroke, peripheral arterial disease, CHD mortality, and all-cause mortality, especially in the western populations. However, heavy alcohol consumption is detrimental causing cardiomyopathy, cardiac arrhythmias, hepatic cirrhosis, pancreatitis, and hemorrhagic stroke. In this article, we review the effects of alcohol on CHD, individual cardiovascular risk factors, cardiomyopathy, and cardiac arrhythmias, including the most recent evidence of the effects of alcohol on CHD.

Obesity and fat distribution as predictors of aortoiliac peripheral arterial disease in middle-aged men

BACKGROUND

Peripheral arterial disease (PAD) in the aortoiliac segment is found in nearly a half of patients with PAD. The aim of this study was to estimate the influence of obesity and fat distribution on the occurrence of aortoiliac PAD in middle-aged men.

METHODS

This case-control study included 204 middle-aged men (mean 58±7 years; range 45-70 years): 102 patients with aortoiliac PAD and 102 healthy controls without PAD. Aortoiliac PAD was diagnosed by ankle-brachial index (ABI) and angiography. Body mass index (BMI) was categorized as: normal weight, overweight, and obese. Percents of body fat were grouped according to quartile distribution. The relationship between anthropometrics and aortoiliac PAD was estimated by multivariate logistic regression.

RESULTS

Patients with aortoiliac PAD had higher body mass index, waist circumference, waist-hip ratio and percent of body fat. A strong correlation between all anthropometric parameters and ABI index and mean angiographic score was shown among patients with PAD. Multivariate regression, adjusted for blood pressure and cholesterol level, identified being overweight, body fat over 26.5% and WHR over 1.02 as predictors for aortoiliac PAD. Body fat over 26.5% and WHR over 1.02 remained significant after further adjustment for blood pressure, cholesterol and body mass index.

CONCLUSION

This study has identified the quantity of fat tissue (body fat over 26.5%) and its visceral distribution (waist-hip ratio over 1.02) as predictors of aortoiliac PAD in middle-aged men. Body mass index, a crude indicator of obesity, should be combined with these parameters when assessing the risk for aortoiliac PAD.

Alcohol and acetaldehyde in public health: from marvel to menace

Alcohol abuse is a serious medical and social problem. Although light to moderate alcohol consumption is beneficial to cardiovascular health, heavy drinking often results in organ damage and social problems. In addition, genetic susceptibility to the effect of alcohol on cancer and coronary heart disease differs across the population. A number of mechanisms including direct the toxicity of ethanol, its metabolites [e.g., acetaldehyde and fatty acid ethyl esters (FAEEs)] and oxidative stress may mediate alcoholic complications. Acetaldehyde, the primary metabolic product of ethanol, is an important candidate toxin in developing alcoholic diseases. Meanwhile, free radicals produced during ethanol metabolism and FAEEs are also important triggers for alcoholic damages.

Associations between alcohol drinking and multiple risk factors for atherosclerosis in smokers and nonsmokers

This study investigated relationships between alcohol intake and multiple risk factors for atherosclerosis in smokers and nonsmokers. Men aged 35 to 54 years (n = 27 005) were divided into 6 groups by ethanol intake. The prevalence of multiple (>or=3 or >or=4) risk factors, including obesity, high blood pressure, high total cholesterol, triglyceride and fasting blood glucose, and low high-density lipoprotein (HDL) cholesterol, was compared among the groups in smokers and nonsmokers. Smokers and nonsmokers showed U- and J-shaped relationships, respectively, between alcohol intake and prevalence of multiple risk factors. Odds ratios of drinkers versus nondrinkers for multiple risk factors were significantly low in very light, light, moderate, and heavy drinkers in smokers and were significantly low in light and moderate drinkers but not in very low and heavy drinkers in nonsmokers. There is a U- or J-shaped relationship between alcohol consumption and multiple risk factors for atherosclerosis, and this relationship is modified by smoking.

Antioxidant vitamin and mineral supplements for preventing age-related macular degeneration

BACKGROUND

Some observational studies have suggested that people who eat a diet rich in antioxidant vitamins (carotenoids, vitamins C and E) or minerals (selenium and zinc) may be less likely to develop age-related macular degeneration (AMD).

OBJECTIVES

The aim of this review was to examine the evidence as to whether or not taking vitamin or mineral supplements prevents the development of AMD.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (which contains the Cochrane Eyes and Vision Group Trials Register) in The Cochrane Library (2007, Issue 3), MEDLINE (1966 to August 2007), SIGLE (1980 to 2005/03), EMBASE (1980 to August 2007), National Research Register (2007, Issue 3), AMED (1985 to January 2006) and PubMed (on 24 January 2006 covering last 60 days), reference lists of identified reports and the Science Citation Index. We contacted investigators and experts in the field for details of unpublished studies.

SELECTION CRITERIA

We included all randomised trials comparing an antioxidant vitamin and/or mineral supplement (alone or in combination) to control. We included only studies where supplementation had been given for at least one year.

DATA COLLECTION AND ANALYSIS

Both review authors independently extracted data and assessed trial quality. Data were pooled using a fixed-effect model.

MAIN RESULTS

Three randomised controlled trials were included in this review (23,099 people randomised). These trials investigated alpha-tocopherol and beta-carotene supplements. There was no evidence that antioxidant vitamin supplementation prevented or delayed the onset of AMD. The pooled risk ratio for any age-related maculopathy (ARM) was 1.04 (95% CI 0.92 to 1.18), for AMD (late ARM) was 1.03 (95% CI 0.74 to 1.43). Similar results were seen when the analyses were restricted to beta-carotene and alpha-tocopherol.

AUTHORS' CONCLUSIONS

There is no evidence to date that the general population should take antioxidant vitamin and mineral supplements to prevent or delay the onset of AMD. There are several large ongoing trials. People with AMD should see the related Cochrane review "Antioxidant vitamin and mineral supplements for slowing the progression of age-related macular degeneration" written by the same author.

Chronic ethanol ingestion increases aortic endothelial nitric oxide synthase expression and nitric oxide production in the rat

BACKGROUND

Chronic alcohol consumption perturbs cellular function in a variety of organ systems. Previous studies have suggested that moderate alcohol consumption reduces vascular disease, whereas heavier alcohol consumption may worsen it. The mechanisms for these vascular effects of chronic alcohol ingestion continue to be defined and constitute the focus of this study.

METHODS

Male Sprague Dawley rats were fed an isocaloric, Lieber-Decarli liquid diet containing either ethanol (36% calories) or Maltose-Dextrin (substituted for ethanol) for 6 weeks. Telemetric blood pressure measurements were taken before and after ethanol feeding. After the rats were killed, the aortas were analyzed for endothelial nitric oxide (NO) synthase expression and NO production.

RESULTS

Chronic ethanol ingestion decreased mean arterial pressure and increased aortic NO production as demonstrated by direct ex vivo measurements using iron diethyldithio-carbamic acid as well as analysis of nitrosyl-hemoglobin (NO-Hb) levels. Consistent with these assays of vascular NO production, endothelium-dependent relaxation responses to acetycholine (Ach) were enhanced in ethanol-fed animals. Aortic endothelial nitric oxide synthase expression was also increased by chronic ethanol ingestion.

CONCLUSIONS

These findings demonstrate that a regimen of chronic alcohol ingestion in the rat produced generally salutary effects in the systemic vasculature following a 6-week treatment regimen. These findings extend previous in vitro studies to demonstrate that alcohol has potent effects on vascular endothelial nitric oxide synthase expression, NO production, and vascular function. Consistent with previous reports, these findings confirm that alcohol-induced alterations in the production of reactive nitrogen species play an important role in the pathogenesis of alcohol-mediated tissue effects.

Prevalence and Risk Factors of Peripheral Arterial Disease in a Selected Thai Population

Peripheral arterial disease (PAD) is a condition with high mortality, but it is amenable to secondary prevention. Data on its prevalence in Thailand are scarce. To study the prevalence of PAD in a middle-class, urban Thai population, a cross-sectional study was conducted at the Electric Generating Authority of Thailand's head plant, Nonthaburi, in 2002 and 2003 on all surviving and contactable employees and former employees who had participated in the first cardiovascular risk factors survey in 1985. Participants completed a structured questionnaire detailing their medical history, and they underwent a physical examination. A diagnosis of PAD was made when the ankle-brachial index (ABI) was < 0.9. Ankle-brachial index data were available for 98% of participants in the survey; 75% were men, and participants' ages ranged from 52 to 73 years. The overall prevalence of PAD was 5.2%. The age-standardized prevalence of PAD was 4% in men and 9% in women. Multiple logistic regression analysis found hypertension (OR = 1.7), female gender (OR = 1.9), current smoking (OR = 3.0), current alcohol drinking (OR = 0.41), and overweight (body mass index [BMI] > 25 kg/m 2, OR = 0.54) to be significant (P < .05) predictors of PAD. The prevalence of PAD in urban, middle-class Thais was similar to that in the population in developed countries.

Independent vascular and cognitive risk factors for postoperative delirium

BACKGROUND

Delirium is a common, morbid, and costly syndrome that occurs frequently after surgery for atherosclerosis. We hypothesized that vascular risk factors and mildly impaired cognitive performance would independently predispose nondemented patients to develop delirium after noncardiac surgery.

METHODS

The International Study of Postoperative Cognitive Dysfunction recruited patients undergoing noncardiac surgery from 8 countries. Subjects provided detailed medical history and underwent preoperative testing of multiple cognitive domains with a neuropsychologic battery. Postoperatively, subjects (n=1161) were assessed daily for delirium.

RESULTS

Ninety-nine subjects (8%) developed delirium. In bivariable analysis, several vascular risk factors were significantly associated with the likelihood of delirium, including male sex, exposure to tobacco, previous myocardial infarction, and vascular surgery. After adjustment for age, tobacco exposure and vascular surgery were independent vascular risk factors for delirium (adjusted relative risk [RR] 3.2, 95% confidence interval [CI], 2.1-4.9). In addition, mildly impaired cognitive performance, defined as performance 1.5 standard deviation below the mean on either of 2 neuropsychologic tests, was independently associated with delirium (adjusted RR 2.2, 95% CI, 1.4-3.6). Subjects with both vascular risk factors and mildly impaired cognitive performance were at double the risk of delirium (RR 2.2, 95% CI, 1.2-4.2) compared with those with either of these risk factors alone.

CONCLUSIONS

Vascular risk and mildly impaired cognitive performance independently predispose patients to delirium after noncardiac surgery. These factors will help to identify high-risk patients for delirium and to design and target future intervention strategies.

Alcohol intake and noncoronary cardiovascular diseases

Moderate drinking has complex associations with cardiovascular diseases other than coronary heart disease. Recent cohort studies examining the relationship between alcohol use and ischemic stroke have shown a modest association, with risk ratios approximating 0.8 and the lowest risk among those who drink less than daily. In contrast, alcohol use is generally associated with an approximate dose-dependent risk for hemorrhagic stroke throughout the full range of intake. Several prospective studies of alcohol intake and congestive heart failure have found lower risk with moderate drinking. This risk is also dose dependent through the moderate range, but its underlying mechanism remains uncertain. Accounting for the lower risk of myocardial infarction associated with moderate intake does not eliminate the observed association. Cohort studies have found no association of long-term alcohol intake with risk of atrial fibrillation below levels of at least 3 standard drinks per day. Finally, two prospective studies have found lower risks of claudication or clinically more severe peripheral arterial disease among moderate drinkers, an association also supported by cross-sectional studies of alcohol intake and ankle-brachial index.

Epidemiology and pathophysiology of lower extremity peripheral arterial disease

Peripheral arterial disease (PAD), a major cause of disability, loss of work, and lifestyle changes in the United States, is defined as obstruction of blood flow into an arterial tree excluding the intracranial or coronary circulations. PAD is mostly silent in its early stages, but when lesion obstruction exceeds 50%, it may cause intermittent claudication with ambulation. Further disease progression typically leads to rest pain or frank tissue loss. However, some patients may remain asymptomatic with severe disease because of extensive collateralization in the lower extremity. Estimates of the prevalence of intermittent claudication vary by population, from 0.6% to nearly 10%; the rate increases dramatically with age. Approximately 20% to 25% of patients will require revascularization, while fewer than 5% will progress to critical limb ischemia. Limb loss, although rare, is associated with severe disability and an overall poor prognosis, with 30% to 40% mortality in the first 24 months after limb loss. As with coronary artery disease, the most common cause of symptomatic obstruction in the peripheral arterial tree is atherosclerosis, a systemic inflammatory process in which cholesterol-laden plaque builds up in the artery and eventually blocks the lumen. Typical risk factors include age, gender, diabetes, tobacco abuse, hypertension, and hyperlipidemia.

Does nutrition have a role in peripheral vascular disease?

Peripheral vascular disease (PVD) is a manifestation of systemic atherosclerosis in the lower limbs, and PVD patients have a 3- to 5-fold increased risk of cardiovascular mortality compared with age-matched controls. Nevertheless, recent reports show how PVD patients are undertreated with regard to CVD risk-factor reduction and the use of lipid-lowering or antiplatelet drugs. There is appreciable evidence that demonstrates the beneficial effects of certain nutrients and dietary habits in the prevention of CVD, but there has been little attention paid to the role of nutrients in PVD. The purpose of the present review is to provide an overview of our understanding of how foods could possibly benefit PVD. In the last few decades, several nutrients have arisen as potentially health-promoting in PVD. While nutritional interventions in PVD show positive clinical effects for fish oil, carnitine or vitamin E, others such as olive oil or vitamin C seem to interact only at a biochemical level by decreasing risk factors. Moreover, only epidemiological associations exist for the potential role of fibre, folates or vitamin B6 in this disease. In all cases, the limited data available provide no clear-cut evidence in favour of the clinical benefit of nutritional interventions aimed at reducing risk factors and ameliorating symptoms in PVD patients. No practical recommendations can be given at this stage, and further studies are clearly needed.

Diet, alcohol, and gout: how do we advise patients given recent developments?

The disease burden of gout remains substantial and may be increasing as a result of trends in demographics and lifestyles. Recent scientific data serve to illuminate the links between dietary and other factors and risk for gout. These lifestyle factors affect not only the risk for gout, but also are risk factors for other chronic diseases of public health importance. Accordingly, dietary and lifestyle recommendations related to gout should consider their effect on many diseases beyond gout. These recommendations should reinforce established recommendations where the influence on gout parallels the influence on other diseases, and consider modifying the recommendations where they are divergent.

Evidence of cardiovascular protection by moderate alcohol: role of nitric oxide

Epidemiological evidence indicates that moderate alcohol consumption reduces the incidence of heart disease. Endothelial nitric oxide synthase (eNOS) is a key regulator of vascular homeostasis and myocardial functions through the controlled production of nitric oxide (*NO). These studies were conducted to determine if the apparent alcohol-associated cardioprotection is mediated, in part, through modulation of the eNOS protein and activity in the cardiovascular system. Rats were fed alcohol and eNOS protein and *NO production were evaluated at the end of 8 weeks. Myocardial and vascular function was assessed ex vivo in a subset of animals. Moderate alcohol improved postischemic myocardial systolic and diastolic function and attenuated the postischemic reduction in coronary vascular resistance. Moderate alcohol also enhanced maximum vascular relaxation by 26 +/- 0.2% and increased plasma *NO production concomitant with a greater than 2.5-fold increase in eNOS protein. Higher levels of alcohol impaired maximum vascular relaxation by 22 +/- 0.1%. These results suggest that moderate alcohol improves postischemic myocardial functions and increases *NO production by vascular endothelium. An increase in *NO may explain, at least in part, the cardioprotective benefits of moderate alcohol consumption.

Hormesis and dose-response-mediated mechanisms in carcinogenesis: evidence for a threshold in carcinogenicity of non-genotoxic carcinogens

Recently the idea of hormesis, a biphasic dose-response relationship in which a chemical exerts opposite effects dependent on the dose, has attracted interest in the field of carcinogenesis. With non-genotoxic agents there is considerable experimental evidence in support of hormesis and the present review highlights current knowledge of dose-response effects. In particular, several in vivo studies have provided support for the idea that non-genotoxic carcinogens may inhibit hepatocarcinogenesis at low doses. Here, we survey the examples and discuss possible mechanisms of hormesis using phenobarbital, 1,1-bis(p-chlorophenyl)-2,2,2-trichloroethane (DDT), alpha-benzene hexachloride (alpha-BHC) and other non-genotoxins. Furthermore, the effects of low and high doses of non-genotoxic and genotoxic compounds on carcinogenesis are compared, with especial attention to differences in mechanisms of action in animals and possible application of the dose-response concept to cancer risk assessment in humans. Epigenetic processes differentially can be affected by agents that impinge on oxidative stress, DNA repair, cell proliferation, apoptosis, intracellular communication and cell signaling. Non-genotoxic carcinogens may target nuclear receptors, cause aberrant DNA methylation at the genomic level and induce post-translational modifications at the protein level, thereby impacting on the stability or activity of key regulatory proteins, including oncoproteins and tumor suppressor proteins. Genotoxic agents, in contrast, cause genetic change by directly attacking DNA and inducing mutations, in addition to temporarily modulating the gene activity. Carcinogens can elicit a variety of changes via multiple genetic and epigenetic lesions, contributing to cellular carcinogenesis.

Antiatherogenic potential of red wine: clinician update

Complications of atherosclerosis remain the leading cause of morbidity and mortality in industrialized countries. Epidemiological studies have repeatedly demonstrated that moderate alcohol intake has a beneficial effect on cardiovascular disease. The purpose of this review is to examine the epidemiological and biological evidence supporting the intake of red wine as a means of reducing atherosclerosis. On the basis of epidemiological studies, moderate intake of alcoholic beverages, including red wine, reduces the risk of cardiovascular, cerebrovascular, and peripheral vascular disease in populations. In addition to the favorable biological effects of alcohol on the lipid profile, on hemostatic factors, and in reducing insulin resistance, the phenolic compounds in red wine appear to interfere with the molecular processes underlying the initiation, progression, and rupture of atherosclerotic plaques. Whether red wine is more beneficial than other types of alcohol remains unclear. Definitive data from a large-scale, randomized clinical end-point trial of red wine intake would be required before physicians can advise patients to use wine as part of preventative or medical therapies.