Stress hormone and blood glucose response following acute stroke in the elderly

Selective estrogen receptor activation prior to global cerebral ischemia in female rats impacts microglial activation and anxiety-like behaviors without effects on CA1 neuronal injury

Estrogen receptor (ER) activation by 17-ß estradiol (E2) can attenuate neuronal injury and behavioral impairments following global cerebral ischemia (GCI) in rodents. This study sought to further examine the discrete roles of ERs through characterization of the effects of selective ER activation on post-ischemic pro-inflammatory microglial activation, hippocampal neuronal injury, and anxiety-like behaviors. Forty-six ovariectomized (OVX) adult female Wistar rats received daily s.c injections (100 μg/kg/day) of propylpyrazole triol (PPT; ERα agonist), diarylpropionitrile (DPN; ERβ agonist), G-1 (G-protein coupled ER agonist; GPER), E2 (activating all receptors), or vehicle solution (VEH) for 21 days. After final injection, rats underwent GCI via 4-vessel occlusion (n=8 per group) or sham surgery (n=6, vehicle injections). The Open Field Test (OFT), Elevated Plus Maze (EPM), and Hole Board Test (HBT) assessed anxiety-like behaviors. Microglial activation (Iba1, CD68, CD86) in the basolateral amygdala (BLA), CA1 of the hippocampus, and paraventricular nucleus of the hypothalamus (PVN) was determined 8 days post-ischemia. Compared to sham rats, Iba1 activation and CA1 neuronal injury were increased in all ischemic groups except DPN-treated rats, with PPT-treated ischemic rats also showing increased PVN Iba1-ir expression. Behaviorally, VEH ischemic rats showed slightly elevated anxiety in the EPM compared to sham counterparts, with no significant effects of agonists. While no changes were observed in the OFT, emotion regulation via grooming in the HBT was increased in G-1 rats compared to E2 rats. Our findings support selective ER activation to regulate post-ischemic microglial activation and coping strategies in the HBT, despite minimal impact on hippocampal injury.

Review Article - Diabetes Technology in the Hospital: An Update

PURPOSE OF REVIEW

There have been many developments in diabetes technology in recent years, with continuous glucose monitoring (CGM), insulin pump therapy (CSII) and automated insulin delivery (AID) becoming progressively accepted in outpatient diabetes care. However, the use of such advanced diabetes technology in the inpatient setting is still limited for several reasons, including logistical challenges and staff training needs. On the other hand, hospital settings with altered diet and stress-induced hyperglycemia often pose challenges to tight glycemic control using conventional treatment tools. Integrating smarter glucose monitoring and insulin delivery devices into the increasingly technical hospital environment could reduce diabetes-related morbidity and mortality. This narrative review describes the most recent literature on the use of diabetes technology in the hospital and suggests avenues for further research.

RECENT FINDINGS

Advanced diabetes technology has the potential to improve glycemic control in hospitalized people with and without diabetes, and could add particular value in certain conditions, such as nutrition therapy or perioperative management. Taken together, CGM allows for more accurate and patient-friendly follow-up and ad hoc titration of therapy. AID may also provide benefits, including improved glycemic control and reduced nursing workload. Before advanced diabetes technology can be used on a large scale in the hospital, further research is needed on efficacy, accuracy and safety, while implementation factors such as cost and staff training must also be overcome.

Increased stress hyperglycemia ratio at hospital admission in stroke patients are associated with increased in-hospital mortality and length of stay

OBJECTIVE

Recently, the stress hyperglycemia ratio (SHR) has been introduced as a metric to signify relative hyperglycemia. This study aimed to investigate the relationship between SHR and in-hospital mortality and length of stay occurring during hospitalization in stroke patients.

METHODS

The retrospective cohort study comprised a total of 4,018 patients diagnosed with acute stroke. The SHR is expressed by the formula: SHR = ABG (mmol/L) / [1.59 × HbA1c (%) - 2.59]. Outcomes included in-hospital mortality and length of stay. Multivariable logistic and linear regression analyses were conducted. Receiver operating characteristic (ROC) analysis was performed to distinguish between the variables, and the area under the ROC curve (AUC) was compared.

RESULTS

In this analysis, a total of 4,018 individuals participated, including 2,814 male patients, accounting for 70.0%. Overall, in-hospital mortality and length of stay tended to rise as SHR increased. A higher prevalence of in-hospital mortality was observed with each standard deviation (SD) increase of the SHR (odds ratio [OR]: 1.26, 95% confidence interval [CI]: 1.05-1.52). Moreover, after considering the confounders, a significant positive association between SHR levels and length of stay was observed (β = 0.70, 95% CI: 0.40-1.00). ROC analysis showed that among stroke patients, SHR (AUC = 0.693) was more effective than admission blood glucose (ABG) (AUC = 0.646) and glycosylated hemoglobin (HbA1c) (AUC = 0.523), which were more predictive of in-hospital mortality.

CONCLUSIONS

Elevated SHR levels are associated with increased in-hospital mortality and prolonged length of stay in stroke patients.

Our Scientific Journey through the Ups and Downs of Blood Glucose Control in the ICU

This article tells the story of our long search for the answer to one question: Is stress hyperglycemia in critically ill patients adaptive or maladaptive? Our earlier work had suggested the lack of hepatic insulin effect and hyperglycemia as jointly predicting poor outcome. Therefore, we hypothesized that insulin infusion to reach normoglycemia, tight glucose control, improves outcome. In three randomized controlled trials (RCTs), we found morbidity and mortality benefit with tight glucose control. Moving from the bed to the bench, we attributed benefits to the prevention of glucose toxicity in cells taking up glucose in an insulin-independent, glucose concentration gradient-dependent manner, counteracted rather than synergized by insulin. Several subsequent RCTs did not confirm benefit, and the large Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation, or "NICE-SUGAR," trial found increased mortality with tight glucose control associated with severe hypoglycemia. Our subsequent clinical and mechanistic research revealed that early use of parenteral nutrition, the context of our initial RCTs, had been a confounder. Early parenteral nutrition (early-PN) aggravated hyperglycemia, suppressed vital cell damage removal, and hampered recovery. Therefore, in our next and largest "TGC-fast" RCT, we retested our hypothesis, without the use of early-PN and with a computer algorithm for tight glucose control that avoided severe hypoglycemia. In this trial, tight glucose control prevented kidney and liver damage, though with much smaller effect sizes than in our initial RCTs without affecting mortality. Our quest ends with the strong recommendation to omit early-PN for patients in the ICU, as this reduces need of blood glucose control and allows cellular housekeeping systems to play evolutionary selected roles in the recovery process. Once again, less is more in critical care.

Continuous glucose monitoring (CGM) in a non-Icu hospital setting: The patient's journey

AIMS

Although consistent data support the outpatient use of continuous glucose monitoring (CGM) to improve glycemic control and reduce hypoglycemic burden, and clinical outcomes, there are limited data regarding its use in the hospital setting, particularly in the non-intensive care unit (non-ICU) setting. The emerging use of CGM in the non-critical care setting may be useful in increasing the efficiency of hospital care and reducing the length of stay for patients with diabetes while improving glycemic control.

DATA SYNTHESIS

The purpose of this Expert Opinion paper was to evaluate the state of the art and provide a practical model of how CGM can be implemented in the hospital.

SETTING

A patient's CGM journey from admission to the ward to the application of the sensor, from patient education on the device during hospitalization until discharge of the patient to maintain remote control.

CONCLUSIONS

This practical approach for the implementation and management of CGM in patients with diabetes admitted to non-ICUs could guide hospitals in their diabetes management initiatives using CGM, helping to identify patients most likely to benefit and suggesting how this technology can be implemented to maximize clinical benefits.

Pneumonia, Aspiration Pneumonia, or Frailty-Associated Pneumonia?

Pneumonia is a common reason for admission afflicting frail older adults. Those who are the frailest are more likely to be provided with a diagnosis of aspiration pneumonia. This diagnosis has no clear definition and no clinical consensus. It is therefore time to stop attempting to differentiate between pneumonia type and use the term frailty-associated pneumonia.

Circulating Biomarkers in Long-Term Stroke Prognosis: A Scoping Review Focusing on the South African Setting

Cerebrovascular disease, including both ischaemic and haemorrhagic strokes, remains one of the highest causes of global morbidity and mortality. Developing nations, such as South Africa (SA), are affected disproportionately. Early identification of stroke patients at risk of poor clinical prognosis may result in improved outcomes. In addition to conventional neuroimaging, the role of predictive biomarkers has been shown to be important. Little data exist on their applicability within SA. This scoping review aimed to evaluate the currently available data pertaining to blood biomarkers that aid in the long-term prognostication of patients following stroke and its potential application in the South African setting. This scoping review followed a 6-stage process to identify and critically review currently available literature pertaining to prognostic biomarkers in stroke. An initial 1191 articles were identified and, following rigorous review, 41 articles were included for the purposes of the scoping review. A number of potential biomarkers were identified and grouped according to the function or origin of the marker. Although most biomarkers showed great prognostic potential, the cost and availability will likely limit their application within SA. The burden of stroke is increasing worldwide and appears to be affecting developing countries disproportionately. Access to neuroradiological services is not readily available in all settings and the addition of biomarkers to assist in the long-term prognostication of patients following a stroke can be of great clinical value. The cost and availability of many of the reviewed biomarkers will likely hinder their use in the South African setting.

Diabetes and Ischemic Stroke: An Old and New Relationship an Overview of the Close Interaction between These Diseases

Diabetes mellitus is a comprehensive expression to identify a condition of chronic hyperglycemia whose causes derive from different metabolic disorders characterized by altered insulin secretion or faulty insulin effect on its targets or often both mechanisms. Diabetes and atherosclerosis are, from the point of view of cardio- and cerebrovascular risk, two complementary diseases. Beyond shared aspects such as inflammation and oxidative stress, there are multiple molecular mechanisms by which they feed off each other: chronic hyperglycemia and advanced glycosylation end-products (AGE) promote ‘accelerated atherosclerosis’ through the induction of endothelial damage and cellular dysfunction. These diseases impact the vascular system and, therefore, the risk of developing cardio- and cerebrovascular events is now evident, but the observation of this significant correlation has its roots in past decades. Cerebrovascular complications make diabetic patients 2–6 times more susceptible to a stroke event and this risk is magnified in younger individuals and in patients with hypertension and complications in other vascular beds. In addition, when patients with diabetes and hyperglycemia experience an acute ischemic stroke, they are more likely to die or be severely disabled and less likely to benefit from the one FDA-approved therapy, intravenous tissue plasminogen activator. Experimental stroke models have revealed that chronic hyperglycemia leads to deficits in cerebrovascular structure and function that may explain some of the clinical observations. Increased edema, neovascularization, and protease expression as well as altered vascular reactivity and tone may be involved and point to potential therapeutic targets. Further study is needed to fully understand this complex disease state and the breadth of its manifestation in the cerebrovasculature.

Uric Acid and Gluconic Acid as Predictors of Hyperglycemia and Cytotoxic Injury after Stroke

Hyperglycemia is a feature of worse brain injury after acute ischemic stroke, but the underlying metabolic changes and the link to cytotoxic brain injury are not fully understood. In this observational study, we applied regression and machine learning classification analyses to identify metabolites associated with hyperglycemia and a neuroimaging proxy for cytotoxic brain injury. Metabolomics and lipidomics were carried out using liquid chromatography-tandem mass spectrometry in admission plasma samples from 381 patients presenting with an acute stroke. Glucose was measured by a central clinical laboratory, and a subgroup of patients (n = 201) had apparent diffusion coefficient (ADC) imaging quantified on magnetic resonance imaging (MRI) to estimate cytotoxic injury. Uric acid was the leading metabolite in univariate analysis of both hyperglycemia (OR 19.6, 95% CI 8.6-44.7, P = 1.44 × 10-12) and ADC (OR 5.3, 95% CI 2.2-13.0, P = 2.42 × 10-4). To further prioritize model features and account for non-linear correlation structure, a random forest machine learning algorithm was applied to separately model hyperglycemia and ADC. The statistical techniques used have identified uric acid and gluconic acids as leading candidate markers common to all models (R2 = 68%, P = 2.2 × 10-10 for uric acid; R2 = 15%, P = 8.09 × 10-10 for gluconic acid). Both uric acid and gluconic acid were associated with hyperglycemia and cytotoxic brain injury. Both metabolites are linked to oxidative stress, which highlights two candidate targets for limiting brain injury after stroke.

Combined utility of blood glucose and white blood cell in predicting outcome after acute ischemic stroke: The ENCHANTED trial

BACKGROUND

As hyperglycemia and leukocytosis individually predict poor outcome in acute ischemic stroke (AIS), we aimed to determine the significance of their combination on functional outcome and symptomatic intracerebral hemorrhage (sICH) among participants of the Enhanced Control of Hypertension and Thrombolysis Stroke Study (ENCHANTED).

METHODS

Post-hoc analyzes of the full ENCHANTED cohort, an international, multicenter, quasi-factorial, randomized, open, blinded outcome-assessed trial of low- versus standard-dose intravenous alteplase and early intensive versus standard blood pressure (BaP) lowering treatment in 4557 thrombolysis-eligible and treated AIS patients. Patients were divided into four groups according to baseline blood glucose and white blood cells (WBC) levels: A (normal glucose + WBC), B (hyperglycemia + normal WBC), C (normal glucose + high WBC), and D (hyperglycemia + high WBC). Logistic regression models were used to determine associations of each group and poor functional outcome (modified Rankin scale scores 2-6) at 90 days and sICH within 48 h, adjusted for confounders. Quality of model fit was examined with Akaike information classification (AIC), Bayesian information classification (BIC), and likelihood ratio test.

RESULTS

Of 4181 AIS patients included in analyzes, and with group A as the reference, an increasing odds of poor functional outcome was evident across groups B (odds ratio [OR] 1.38, 95 % confidence interval [CI] 1.17-1.63), C (OR 1.26, 95 %CI 0.99-1.60), and D (OR 2.26, 95 %CI 1.79-2.85) (P trend <0.001). Group D patients also had a higher rate of sICH (P trend <0.05). The model fit with the combination of blood glucose and WBC was better than models of their individual components.

CONCLUSIONS

Using a combination of blood glucose and WBC provides strong prognostic significance than either alone in thrombolyzed AIS patients.

A Preliminary Study on the Influence of Cannabis and Opioid Use on Weight Loss and Mental Health Biomarkers Post-weight Loss Surgery

PURPOSE

A subpopulation of weight loss surgery (WLS) patients endorse cannabis and/or opioid use; however, impact on post-WLS anxiety and depression is unclear. This study examined the influence of the independent and combined use of cannabis and opioids on (1) depression and anxiety, (2) duodenum serotonin and cortisol, and (3) total percent weight loss.

MATERIALS AND METHODS

A cross-sectional analysis was conducted among patients (N = 18) who had biomarkers of serotonin and cortisol collected from the duodenum during WLS. Cannabis and opioid use was determined by self-reported lifetime, past-year, and past 30-day use. The Beck Anxiety Inventory and Depression Inventory-II assessed depression and anxiety symptoms. Total percent weight loss was calculated from pre-WLS and post-WLS weight (kg). Chi-squared analyses and t tests were conducted.

RESULTS

Over a quarter (27.8%) were cannabis-only users and 16.7% used a combination of cannabis and opioids. None reported using only opioids in this sample. Combination users presented with greater depressive symptoms (22.7%, p = 0.01) and greater total percent weight loss (34.1%, p = 0.04) than cannabis users (7.8, 23.2%, respectively). Cannabis users had greater serotonin (p = 0.02) and cortisol (p = 0.01) levels than combination users and never users.

CONCLUSIONS

Cannabis users had greater cortisol levels than never users and combination users. Combination users had greater weight loss and depression symptoms than cannabis users. Future studies should consider a larger sample size, utilization of a cohort design to address causality, and examination of the type, dose, and route of cannabis and opioid administration to further understand the impact of the combined use of cannabis and opioids post-WLS.

The effects of diffusion and perfusion MRI mismatch on the admission blood glucose and blood pressure values measured in the first 12 hours of acute stroke

Patients with severe stroke and salvageable brain tissue at admission, who have higher glycaemic and blood pressure levels, may have a risk of iatrogenic hypoglycemia/iatrogenic hypotension. In this study, we examined the relationship between the presence of diffusion-weighted imaging (DWI)/perfusion-weighted imaging (PWI) mismatch, admission blood glucose level, and admission blood pressure level in patients who were admitted in the first 12 hours after onset. We studied 212 patients who were prospectively and consecutively registered to the stroke unit from 2006 to 2009. Correlations between mismatch and admission blood pressure level (ABPL) and admission blood glucose level (ABGL) were analyzed using multivariate logistic regression. Mismatch (P = .064, adjusted OR = 2.297, 95% CI, 0.953-5.536) was not associated with a high ABGL in the whole group. However, after excluding patients with diabetes mellitus (DM) (n = 67, 35%), mismatch (P = .033, adjusted OR = 3.801, 95% CI, 1.110-13.015), an impaired level of consciousness, use of anti-DM medication, glycated hemoglobin levels, and cardioembolic aetiology were independent predictors of a high ABGL. The presence of mismatch or proximal vessel occlusion was not associated with ABPL. Female sex (P = .048) and total anterior circulation stroke (P = .008) were independent predictors associated with a higher ABPL. We conclude that patients with hyperacute ischemic stroke with PWI/DWI mismatch are more likely to have hyperglycemia.

Combined utility of white blood cell count and blood glucose for predicting in-hospital outcomes in acute ischemic stroke

Background

High white blood cell (WBC) count and high blood glucose level are risk factors for mortality and pneumonia after acute ischemic stroke (AIS). We investigated the combined effect of high WBC count and high blood glucose level on hospital admission and in-hospital mortality and pneumonia in acute AIS patients.

Methods

A total of 3124 AIS patients enrolled from December 2013 to May 2014 across 22 hospitals in Suzhou city were included in the present study. We divided patients into four groups according to their level of WBC count and blood glucose: NWNG (normal WBC count and normal glucose), NWHG (normal WBC count and higher glucose), HWNG (higher WBC count and normal glucose), and HWHG (higher WBC count and higher glucose). Cox proportional hazard model and logistic regression model were used to estimate the combined effect of WBC count and blood glucose on all-cause in-hospital mortality and pneumonia in AIS patients.

Results

HWHG was associated with a 2.22-fold increase in the risk of in-hospital mortality in comparison to NWNG (adjusted hazard ratio [HR] 2.22; 95% confidence interval [CI], 1.21–4.07; P trend = 0.003). The risk of pneumonia was significantly higher in patients with HWHG compared to those with NWNG (adjusted odds ratio [OR] 2.61; 95% CI, 1.66–4.10; P trend < 0.001). The C-statistic for the combined WBC count and blood glucose was higher than WBC count or blood glucose alone for prediction of in-hospital mortality and pneumonia (all p < 0.01).

Conclusions

High WBC count combined with high blood glucose level at admission was independently associated with in-hospital mortality and pneumonia in AIS patients. Moreover, the combination of WBC count and blood glucose level appeared to be a better predictor than WBC count or blood glucose alone.

Electronic supplementary material

The online version of this article (10.1186/s12974-019-1422-7) contains supplementary material, which is available to authorized users.

Erythropoietin Pretreatment Effect on Blood Glucose and Its Relationship With Inflammatory Factors After Brain Ischemic-Reperfusion Injury in Rats

Introduction:

Brain Ichemic-Reperfusion Injury (IRI) activates different pathophysiological processes. It also changes physiological parameters such as Blood Glucose (BG) level. An increase in BG after stroke is associated with poor clinical outcomes. Erythropoietin has been shown to be effective on both reducing inflammation and BG level. Therefore, in this study the erythropoietin pretreatment effect on BG and its relationship with inflammatory markers after brain IRI was investigated.

Methods:

Thirty adult male Wistar rats were randomly divided into 5 groups: sham, control and 3 pretreatment groups: single dose, double dose, and triple dose that received 1000 U/kg of erythropoietin before stroke induction in different times intraperitoneally. A rat model of IRI was established by Middle Cerebral Artery Occlusion (MCAO) for 60 minutes. Infarct volume, neurological defects, Interleukin-1α (IL-1α) and IL-6 serum levels were evaluated 24 hours after reperfusion. Also BG was measured after 1, 6, and 24 hours.

Results:

Single dose of erythropoietin significantly decreased infarct volume and improved neurological defects which was associated with decreased serum level of IL-1α and IL-6 but higher doses of erythropoietin administration had adverse effects on histological, neurological, and inflammatory results. In addition, erythropoietin significantly increased BG in a dose-dependent manner.

Conclusion:

Erythropoietin could reduce brain IRI by reducing inflammation and BG stabilization. The results of the present study demonstrated a relationship between inflammatory factors and hyperglycemia after IRI and suggested that erythropoietin may be useful for preventing brain IRI, but its higher doses should be used with caution due to possible side effects.

Association of hyperglycemia, systolic and diastolic hypertension, and hyperthermia relative to baseline in the acute phase of stroke with poor outcome after intravenous thrombolysis

: In the acute phase of ischemic stroke, the trend of some physiological variables, such as blood glucose (BG), blood pressure, and body temperature (BT), might influence outcome. We aimed to assess the association of hyperglycemia, systolic and diastolic hypertension, and hyperthermia relative to baseline BG, systolic blood pressure, diastolic blood pressure and BT, respectively, in the first 12 h with poor outcome after intravenous thrombolysis (IVT). We conducted a retrospective analysis of data prospectively collected from 200 consecutive anterior ischemic stroke patients treated with IVT. Outcome measures were no neurological improvement at 24 h (National Institutes of Health Stroke Scale (NIHSS) score at 24 h ≥NIHSS score at baseline), and unfavorable functional outcome [modified Rankin Scale (mRS) score 3-6] at 3 months. No neurological improvement at 24 h was noted in 52 (26%) patients and mRS 3-6 at 3 months in 68 (34%) patients. The multivariate analyses showed that odds ratios (ORs) for no neurological improvement at 24 h were higher in patients with hyperglycemia relative to baseline [OR 3.50, 95% confidence interval (CI) 1.43-8.57, P = 0.006], and hyperthermia relative to baseline (OR 2.88, 95% CI 1.20-6.91, P = 0.018). OR for 3-month mRS score 3-6 was higher in patients with hyperthermia relative to baseline (OR 3.05, 95% CI 1.20-7.74, P = 0.019). Hyperglycemia and hyperthermia relative to baseline in the first 12 h after IVT are associated with no neurological improvement at 24 h. Hyperthermia relative to baseline is also associated with unfavorable functional outcome at 3 months.

High-throughput profiling of the circulating proteome suggests sexually dimorphic corticosteroid signaling following ischemic stroke

Increasing evidence suggests that there are innate differences between sexes with respect to stroke pathophysiology; however, the molecular mechanisms underlying these differences remain unclear. In this investigation, we employed a shotgun approach to broadly profile sex-associated differences in the plasma proteomes of a small group of male ( n = 6) and female ( n = 4) ischemic stroke patients. Peripheral blood was sampled during the acute phase of care, and liquid chromatography electrospray ionization mass spectrometry was used to quantify plasma proteins. We observed widespread differences in plasma composition, as 77 out of 294 detected proteins were significantly differentially expressed between sexes. Corticosteroid-binding globulin (CBG), a negative acute-phase reactant that inversely regulates levels of bioactive free cortisol, was the most dramatically differentially regulated, exhibiting 16-fold higher abundance in plasma from women relative to men. Furthermore, functional annotation analysis revealed that the remaining differentially expressed proteins were significantly enriched for those involved in response to corticosteroid signaling. Plasma CBG levels were further examined in an additional group of male ( n = 19) and female ( n = 28) ischemic stroke patients, as well as a group of male ( n = 13) and female ( n = 18) neurologically normal controls. CBG levels were significantly reduced in male stroke patients relative to male controls; however, no differences were observed between female stroke patients and female controls, suggesting that women may exhibit an attenuated cortisol response to stroke. Collectively, our findings reinforce the idea that there are sex-associated differences in stroke pathophysiology and suggest that cortisol signaling should be investigated further as a potential molecular mediator.

Impact of varying levels of hyperglycemia on clinicoradiographic outcomes after endovascular reperfusion treatment

We evaluated the effects of admission hyperglycemia with different cut-off levels on 3-month outcomes, infarct growth, and hemorrhagic transformation in acute stroke patients with large artery occlusion of anterior circulation who received endovascular treatment (EVT). Between January 2011 and May 2016, patients that underwent EVT with pre-procedural and post-procedural diffusion-weighted imaging were identified from a multicenter registry. Normoglycemia was defined as a glucose level ≤ 110 mg/dL, moderate hyperglycemia as >110 and ≤170 mg/dL, and overt hyperglycemia as >170 mg/dL. Its effects on poor outcomes (3-month modified Rankin Scale score 3-6), infarct growth, and parenchymal hematoma type 2 were analyzed. Of 720 patients encountered, 341 patients were eligible. There was a statistically significant difference in glycated hemoglobin levels between the normoglycemia/moderate hyperglycemia and overt hyperglycemia groups (p < 0.001). Moderate hyperglycemia (odds ratio 2.37 [95% confidence interval 1.26-4.45], p = 0.007) and overt hyperglycemia (2.84 [1.19-6.81], p = 0.019) were associated with poor outcomes. Post-procedural infarct volumes were significantly greater in hyperglycemic patients (p_adjusted = 0.003). Only overt hyperglycemia (9.28 [1.66-51.88], p = 0.011) was associated with parenchymal hematoma type 2. Overall hyperglycemia was associated with poor outcomes and infarct growth, whereas overt hyperglycemia was associated with parenchymal hematoma type 2.

Vitamin D deficiency in relation to the poor functional outcomes in nondiabetic patients with ischemic stroke

To assess the hypothesis that vitamin D, reflected by 25-hydroxyvitamin D (25(OH) D) would be associated with higher risk of poor functional outcomes amongst nondiabetic stroke patients. The present study was conducted in Nanchang, China. Serum concentration of 25(OH) D and National Institutes of Health Stroke Scale (NIHSS) were measured at the time of admission. Functional outcome was measured by modified Rankin scale (mRS) at 1 year after admission. Multivariate analyses were performed using logistic regression models. The cut point of 25(OH) D level for vitamin D deficiency was 20 ng/ml. In the present study, 266 nondiabetic subjects with stroke were included; 149 out of the 266 patients were defined as vitamin D deficiency (56%). The poor outcome distribution across the 25(OH) D quartiles ranged between 64% (first quartile) and 13% (fourth quartile). In those 149 patients with vitamin D deficiency, 75 patients were defined as poor functional outcomes, giving a prevalence rate of 50% (95% confidence interval (CI): 42–58%). In multivariate analysis models, for vitamin D deficiency, the adjusted risk of poor functional outcomes and mortality increased by 220% (odds ratio (OR): 3.2; 95% CI: 1.7–4.2, P<0.001) and 290% (OR: 3.9; 95% CI: 2.1–5.8, P<0.001), respectively. Vitamin D deficiency is associated with an increased risk of poor functional outcome events in Chinese nondiabetic stroke individuals.

Prognostic value of cortisol and thyroid function tests in poisoned patients admitted to toxicology ICU

BACKGROUND

Prognostic value of cortisol and thyroid function tests (TFTs) has previously been evaluated in medical ICUs. We aimed to evaluate prognostic efficacy of cortisol and TFTs in critically ill poisoned patients admitted to toxicology intensive care unit (ICU).

METHODS

In a prospective study of consecutively enrolled subjects admitted to the toxicology ICU, lab analyses included TFTs (total T3 and T4 as well as TSH) and cortisol levels drawn between 8 am-10 am during period of the first 24 hours post-ingestion/exposure. Simplified Acute Physiology Score II (SAPS II) and Acute Physiology and Chronic Health Evaluation II (APACHE II) were recorded. All scores were compared to detect the best prognostic factor. Type of poisoning was also included.

RESULTS

In 200 patients evaluated, 129 were male and mean age was 31 years. In general, SAPS II, T4, and cortisol could prognosticate death. After regression analysis, only cortisol had such efficacy (P=0.04; OR=1.06; 95%CI=1.05-1.08; cut-off=42 µg/dL; sensitivity=70%; specificity=82%). Between aluminium phosphide (ALP)- and non ALP-poisoned patients, level of consciousness, mean arterial pressure, and cortisol level could prognosticate death in ALP poisoning (all Ps<0.001 in both uni and multivariate analyses). Median (interquartile range; IQR) GCS was 7 (6, 10) and 15 (8, 15) in non-ALP and ALP-poisoned patients (P<0.003). SAPS II and APACHE II could not prognosticate death at all.

CONCLUSION

Cortisol best prognosticated outcomes for subjects admitted to the toxicology ICU. Its level is higher in ALP-poisoned patients probably due to the higher stress while they remain conscious till the final stages of toxicity and are aware of deterioration of their clinical condition or may be due to their significantly lower blood pressures.

Range of glucose as a glycemic variability and 3-month outcome in diabetic patients with acute ischemic stroke

Glycemic variability (GV) is reportedly a predictor for poor outcome in various clinical conditions. We aimed to assess whether GV during hospital admission is associated with poor outcomes in patients with acute ischemic stroke (AIS) and diabetes. We prospectively enrolled consecutive patients with AIS from the registry of 6 tertiary hospitals between January 2013 and December 2014. For the GV index, we used a glucose level range that was divided into 4 quartiles. Multivariable binary and ordinal logistic regression analyses were performed to determine the association between GV and the modified Rankin Scale score (3–6) at 3 months. We enrolled 1,504 patients with AIS and diabetes (mean age, 68.1 years; male, 57.2%), of which 35.1% had poor outcomes at 3 months. An increasing glucose range quartile was positively associated with initial neurologic severity and development of hypoglycemia during hospital admission. Multivariable analysis showed that the glucose level range quartile was associated with poor outcomes, even after adjusting for the number of glucose measurement and hypoglycemia (odds ratio [OR] Q2 vs. Q1: 1.50, 95% confidence interval [CI]: 1.02–2.18; OR Q3 vs. Q1: 2.01, 95% CI: 1.34–3.01; OR Q4 vs. Q1: 1.98, 95% CI: 1.22–3.23). These associations remained significant after dichotomization according to glycated hemoglobin levels at admission. An increasing glucose level range as a GV index during hospital admission was associated with poor functional outcomes at 3 months in patients with AIS and diabetes.

Stress hyperglycemia and acute ischemic stroke in-hospital outcome

BACKGROUND AND AIMS

Stress hyperglycemia is frequent in patients with acute ischemic stroke. However, it is unclear whether stress hyperglycemia only reflects stroke severity or if it is directly associated with adverse outcome. We aimed to evaluate the prognostic significance of stress hyperglycemia in acute ischemic stroke.

METHODS

We prospectively studied 790 consecutive patients who were admitted with acute ischemic stroke (41.0% males, age 79.4±6.8years). The severity of stroke was assessed at admission with the National Institutes of Health Stroke Scale (NIHSS). Stress hyperglycemia was defined as fasting serum glucose levels at the second day after admission ≥126mg/dl in patients without type 2 diabetes mellitus (T2DM). The outcome was assessed with adverse outcome rates at discharge (modified Rankin scale between 2 and 6) and with in-hospital mortality.

RESULTS

In the total study population, 8.6% had stress hyperglycemia. Patients with stress hyperglycemia had more severe stroke. Independent predictors of adverse outcome at discharge were age, prior ischemic stroke and NIHSS at admission whereas treatment with statins prior to stroke was associated with favorable outcome. When the NIHSS was removed from the multivariate model, independent predictors of adverse outcome were age, heart rate at admission, prior ischemic stroke, log-triglyceride (TG) levels and stress hyperglycemia, whereas treatment with statins prior to stroke was associated with favorable outcome. Independent predictors of in-hospital mortality were atrial fibrillation (AF), diastolic blood pressure (DBP), serum log-TG levels and NIHSS at admission. When the NIHSS was removed from the multivariate model, independent predictors of in-hospital mortality were age, AF, DBP, log-TG levels and stress hyperglycemia.

CONCLUSION

Stress hyperglycemia does not appear to be directly associated with the outcome of acute ischemic stroke. However, given that patients with stress hyperglycemia had higher prevalence of cardiovascular risk factors than patients with normoglycemia and that glucose tolerance was not evaluated, more studies are needed to validate our findings.

Alterations in the corticotropin-releasing hormone (CRH) neurocircuitry: Insights into post stroke functional impairments

Although it is well accepted that changes in the regulation of the hypothalamic-pituitary adrenal (HPA) axis may increase susceptibility to affective disorders in the general population, this link has been less examined in stroke patients. Yet, the bidirectional association between depression and cardiovascular disease is strong, and stress increases vulnerability to stroke. Corticotropin-releasing hormone (CRH) is the central stress hormone of the HPA axis pathway and acts by binding to CRH receptors (CRHR) 1 and 2, which are located in several stress-related brain regions. Evidence from clinical and animal studies suggests a role for CRH in the neurobiological basis of depression and ischemic brain injury. Given its importance in the regulation of the neuroendocrine, autonomic, and behavioral correlates of adaptation and maladaptation to stress, CRH is likely associated in the pathophysiology of post stroke emotional impairments. The goals of this review article are to examine the clinical and experimental data describing (1) that CRH regulates the molecular signaling brain circuit underlying anxiety- and depression-like behaviors, (2) the influence of CRH and other stress markers in the pathophysiology of post stroke emotional and cognitive impairments, and (3) context and site specific interactions of CRH and BDNF as a basis for the development of novel therapeutic targets. This review addresses how the production and release of the neuropeptide CRH within the various regions of the mesocorticolimbic system influences emotional and cognitive behaviors with a look into its role in psychiatric disorders post stroke.

Rationale and design of Short-Term EXenatide therapy in Acute ischaemic Stroke (STEXAS): a randomised, open-label, parallel-group study

INTRODUCTION

Both hyperglycaemia and hypoglycaemia in acute ischaemic stroke (AIS) are associated with increased infarct size and worse functional outcomes. Thus, therapies that can maintain normoglycaemia during stroke are clinically important. Glucagon-like peptide 1 (GLP-1) analogues, including exenatide, are routinely used in the treatment of hyperglycaemia in type 2 diabetes, but data on the usefulness of this class of agents in the management of elevated glucose levels in AIS are limited. Owing to their glucose-dependent mechanism of action, GLP-1 analogues are associated with a low risk of hypoglycaemia, which may give them an advantage over intensive insulin therapy in the acute management of hyperglycaemia in this setting.

METHODS AND ANALYSIS

The Short-Term EXenatide therapy in Acute ischaemic Stroke study is a randomised, open-label, parallel-group pilot study designed to investigate the efficacy of exenatide at lowering blood glucose levels in patients with hyperglycaemia with AIS. A total of 30 patients presenting with AIS and blood glucose levels >10 mmol/L will be randomised to receive the standard therapy (intravenous insulin) or intravenous exenatide for up to 72 h. Outcomes including blood glucose levels within the target range (5-10 mmol/L), the incidence of hypoglycaemia and the feasibility of administering intravenous exenatide in this patient population will be assessed. A follow-up visit at 3 months will facilitate evaluation of neurological outcomes post-stroke.

ETHICS AND DISSEMINATION

This study has been approved by the local Institutional Review Board (Northern Sydney Local Health District Human Research Ethics Committee). The study results will be communicated via presentations at scientific conferences and through publication in peer-reviewed journals.

CONCLUSIONS

As GLP-1 analogues require elevated glucose levels to exert their insulin potentiating activity, the use of exenatide in the management of hyperglycaemia in AIS may reduce the incidence of hypoglycaemia, thereby conferring a benefit in morbidity and mortality for patients in the long term.

TRIAL REGISTRATION NUMBER

ACTRN12614001189617.

Catecholamines, steroids and immune alterations in ischemic stroke and other acute diseases

The outcome of stroke patients is not only determined by the extent and localization of the ischemic lesion, but also by stroke-associated infections. Stroke-induced immune alterations, which are related to stroke-associated infections, have been described over the last decade. Here we review the evidence that catecholamines and steroids induced by stroke result in stroke-induced immune alterations. In addition, we compare the immune alterations observed in other acute diseases such as myocardial infarction, brain trauma, and surgical trauma with the changes seen in stroke-induced immune alterations.

Activation of hepatic inflammatory pathways by catecholamines is associated with hepatic insulin resistance in male ischemic stroke rats

Patients who experience acute ischemic stroke may develop hyperglycemia, even in the absence of diabetes. In the current study we determined the effects of acute stroke on hepatic insulin signaling, TNF-α expression, endoplasmic reticulum (ER) stress, the activities of c-Jun N-terminal kinase (JNK), inhibitor κB kinase β (IKK-β), and nuclear factor-κB (NF-κB) pathways. Rats with cerebral ischemia developed higher blood glucose, and insulin levels, and insulin resistance index, as well as hepatic gluconeogenic enzyme expression compared with the sham-treated group. The hepatic TNF-α mRNA and protein levels were elevated in stroke rats in association with increased ER stress, phosphorylation of JNK1/2 and IKK-β proteins, IκB/NF-κB signaling, and phosphorylation of insulin receptor-1 (IRS-1) at serine residue. The basal and insulin-stimulated tyrosine phosphorylation of IRS-1 and AKT proteins was reduced. In addition, acute stroke increased circulating catecholamines in association with hepatic adrenergic signaling activation. After administration of a nonselective β-adrenergic receptor blocker (propranolol) before induction of cerebral ischemic injury, hepatic adrenergic transduction, TNF-α expression, ER stress, and the activation of the JNK1/2, IKK-β, and NF-κB pathways, and serine phosphorylation of IRS-1 were all attenuated. In contrast, the phosphorylated IRS-1 at tyrosine site and AKT levels were partially restored with improved poststroke hyperglycemia and insulin resistance index. These results suggest that acute ischemic stroke can activate proinflammatory pathways in the liver by the catecholamines and is associated with the development of hepatic insulin resistance.

Cortisol levels and the severity and outcomes of acute stroke: a systematic review

Studies in non-stroke patients have shown an association between dysregulation of the hypothalamic-pituitary-adrenal axis and morbidity and mortality. We conducted a systematic review to evaluate cortisol levels in acute stroke and their associations with outcome. We searched MEDLINE and EMBASE for articles up to April 2013 and PsychINFO for articles up to July 2013, using the keywords "cortisol" and "stroke" and associated terms or synonyms. We included studies published in peer-reviewed journals that recruited 10 or more participants and measured cortisol at least once in the first year following stroke. Data were extracted regarding cortisol levels, including changes over time and their relationship to stroke severity, and outcome. Of 11,240 abstracts, 101 full texts were obtained and 48 fulfilled our inclusion criteria. Cortisol levels were high in the first week after stroke in the majority of studies (26 studies, n = 1,340). Higher cortisol was associated with dependency (8/11 studies, n = 822), delirium (5/6 studies, n = 269) depression (3/5 studies n = 117) and mortality (8/10 studies, n = 856). Five studies adjusted for stroke severity; one found an association between higher cortisol and dependency, and three found an association between higher cortisol and mortality. Cortisol levels are high for at least 7 days after stroke. Elevated cortisol after stroke is associated with dependency, morbidity, and mortality; however, there is insufficient evidence to conclude that these relationships are independent of stroke severity.

Insulin for glycaemic control in acute ischaemic stroke

BACKGROUND

People with hyperglycaemia concomitant with an acute stroke have greater mortality, stroke severity, and functional impairment when compared with those with normoglycaemia at stroke presentation. This is an update of a Cochrane Review first published in 2011.

OBJECTIVES

To determine whether intensively monitoring insulin therapy aimed at maintaining serum glucose within a specific normal range (4 to 7.5 mmol/L) in the first 24 hours of acute ischaemic stroke influences outcome.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (September 2013), CENTRAL (The Cochrane Library 2013, Issue 8), MEDLINE (1950 to September 2013), EMBASE (1980 to September 2013), CINAHL (1982 to September 2013), Science Citation Index (1900 to September 2013), and Web of Science (ISI Web of Knowledge) (1993 to September 2013). We also searched ongoing trials registers and SCOPUS.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing intensively monitored insulin therapy versus usual care in adults with acute ischaemic stroke.

DATA COLLECTION AND ANALYSIS

We obtained a total of 1565 titles through the literature search. Two review authors independently selected the included articles and extracted the study characteristics, study quality, and data to estimate the odds ratio (OR) and 95% confidence interval (CI), mean difference (MD) and standardised mean difference (SMD) of outcome measures. We resolved disagreements by discussion.

MAIN RESULTS

We included 11 RCTs involving 1583 participants (791 participants in the intervention group and 792 in the control group). We found that there was no difference between the treatment and control groups in the outcomes of death or dependency (OR 0.99, 95% CI 0.79 to 1.23) or final neurological deficit (SMD -0.09, 95% CI -0.19 to 0.01). The rate of symptomatic hypoglycaemia was higher in the intervention group (OR 14.6, 95% CI 6.6 to 32.2). In the subgroup analyses of diabetes mellitus (DM) versus non-DM, we found no difference for the outcomes of death and disability or neurological deficit. The number needed to treat was not significant for the outcomes of death and final neurological deficit. The number needed to harm was nine for symptomatic hypoglycaemia.

AUTHORS' CONCLUSIONS

After updating the results of our previous review, we found that the administration of intravenous insulin with the objective of maintaining serum glucose within a specific range in the first hours of acute ischaemic stroke does not provide benefit in terms of functional outcome, death, or improvement in final neurological deficit and significantly increased the number of hypoglycaemic episodes. Specifically, those people whose glucose levels were maintained within a tighter range with intravenous insulin experienced a greater risk of symptomatic and asymptomatic hypoglycaemia than those people in the control group.

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.

Glucose as a risk predictor in acute medical emergency admissions

AIMS

The aims of this study were to examine the relationship between admission blood glucose and mortality in a large, unselected cohort of acutely ill medical patients and to assess the impact of diabetes on this relationship.

METHODS

We studied the broad pattern of acute medical admissions over an eight year period and the impact of admission serum glucose on in-hospital mortality. Significant predictors of outcome, including acute illness severity and co-morbidity, were entered into a multivariate regression model, adjusting the univariate estimates of the glycaemic status on mortality.

RESULTS

There were 45,068 consecutive acute medical emergency admissions between 2005 and 2012. The normoglycaemic (>4.0 ≤7.0 mmol/l) cohort (86%) had a 3.9% in-hospital mortality. Both hypoglycaemia (OR: 3.23: 95% CI: 2.59-4.04; p<0.001) and hyperglycaemia (OR: 2.1; 95% CI: 1.9-2.4; p<0.001) predicted an increased risk of an in-hospital death. Neither of these increased risks were fully adjusted nor explained by a highly predictive outcome model, using multiple acute illness parameters. Hyperglycaemia did not carry similar adverse prognostic implications for patients with diabetes.

CONCLUSION

In patients without diabetes, an abnormal serum glucose is independently predictive of an increased mortality among the broad cohort of acute emergency medical patients. Similar disturbances of glucose homeostasis for patients with diabetes do not confer equivalent adverse prognostic implications.

Cortisol as a prognostic marker of short-term outcome in chinese patients with acute ischemic stroke

Background

Early prediction of outcome is important for allocation of therapeutic strategies. Endocrine alterations of the hypothalamus–pituitary–axis are one of the first stress-induced alterations after cerebral ischemia. We therefore evaluated the prognostic value of serum cortisol in Chinese patients with an acute ischemic stroke.

Methods

In a prospective observational study, serum cortisol was measured using a solid-phase, competitive chemiluminescent enzyme immunoassay on admission in serum of 226 consecutive Chinese patients with an acute ischemic stroke. The prognostic value of serum cortisol to predict the functional outcome, mortality within 90 days, was compared with clinical variables (e.g., advanced age and the National Institutes of Health Stroke Scale [NHISS] score) and with other known predictors.

Results

Patients with a poor outcome and nonsurvivors had significantly increased serum cortisol levels on admission (P<0.0001, P<0.0001). There was a positive correlation between levels of cortisol and the NIHSS (r = 0.298, P<0.0001), glucose levels (r = 0.324, P<0.0001) and infarct volume (r = 0.328, P<0.0001). Cortisol was an independent prognostic marker of functional outcome and death [odds ratio 3.44 (2.58–6.23) and 4.21 (1.89–9.24), respectively, P<0.0001 for both, adjusted for age, the NIHSS and other predictors] in patients with ischemic stroke. In receiver operating characteristic curve analysis, cortisol could improve the NIHSS score in predicting short-term functional outcome (Area under the curve [AUC] of the combined model, 0.87; 95% CI, 0.82–0.92; P = 0.01) and mortality (AUC of the combined model, 0.90; 95% CI, 0.84–0.95; P = 0.01).

Conclusion

Cortisol can be seen as an independent short-term prognostic marker of functional outcome and death in Chinese patients with acute ischemic stroke even after correcting confounding factors. Combined model can add significant additional predictive information to the clinical score of the NIHSS.

Leptomeningeal collaterals are associated with modifiable metabolic risk factors

OBJECTIVE

We sought to identify potentially modifiable determinants associated with variability in leptomeningeal collateral status in patients with acute ischemic stroke.

METHODS

Data are from the Keimyung Stroke Registry. Consecutive patients with M1 segment middle cerebral artery ± intracranial internal carotid artery occlusions on baseline computed tomographic angiography (CTA) from May 2004 to July 2009 were included. Baseline and follow-up imaging was analyzed blinded to all clinical information. Two raters assessed leptomeningeal collaterals on baseline CTA by consensus, using a previously validated regional leptomeningeal score (rLMC).

RESULTS

Baseline characteristics (N = 206) were: mean age = 66.9 ± 11.6 years, median baseline National Institutes of Health Stroke Scale = 14 (interquartile range [IQR] = 11-20), and median time from stroke symptom onset to CTA = 166 minutes (IQR = 96-262). Poor collateral status at baseline (rLMC score = 0-10) was seen in 73 of 206 patients (35.4%). On univariate analyses, patients with poor collateral status at baseline were older; were hypertensive; had higher white blood cell count, blood glucose, D-dimer, and serum uric acid levels; and were more likely to have metabolic syndrome. Multivariate modeling identified metabolic syndrome (odds ratio [OR] = 3.22, 95% confidence interval [CI] = 1.69-6.15, p < 0.001), hyperuricemia (per 1mg/dl serum uric acid; OR = 1.35, 95% CI = 1.12-1.62, p < 0.01), and older age (per 10 years; OR = 1.34, 95% CI = 1.02-1.77, p = 0.03) as independent predictors of poor leptomeningeal collateral status at baseline.

INTERPRETATION

Metabolic syndrome, hyperuricemia, and age are associated with poor leptomeningeal collateral status in patients with acute ischemic stroke.

Trauma and aggressive homeostasis management

Homeostasis refers to the capacity of the human body to maintain a stable constant state by means of continuous dynamic equilibrium adjustments controlled by a medley of interconnected regulatory mechanisms. Patients who sustain tissue injury, such as trauma or surgery, undergo a well-understood reproducible metabolic and neuroendocrine stress response. This review discusses 3 issues that concern homeostasis in the acute care of trauma patients directly related to the stress response: hyperglycemia, lactic acidosis, and hypothermia. There is significant reason to question the "conventional wisdom" relating to current approaches to restoring homeostasis in critically ill and trauma patients.

Systematic review of descriptive cohort studies on the dynamics of glycaemia among adults admitted to hospital with acute stroke

AIM

This article presents the results of a systematic review of descriptive cohort studies on the dynamics of glycaemia among adults admitted to hospital with acute stroke.

BACKGROUND

Hyperglycaemia is common among adults admitted to hospital with stroke.

DESIGN

Systematic review.

DATA SOURCES

A search for descriptive cohort studies published between January 1996-June 2011, was conducted in MEDLINE, PubMed and Embase electronic databases. The search was performed using the terms 'stroke', 'hyperglycaemia' and/or 'glucose' combined and limited to adults and English language publications. Searching of citations from identified studies supplemented the electronic searches.

REVIEW METHODS

A systematic review was conducted of eight studies, meeting the criteria of: (1) descriptive cohort studies; (2) adults admitted to hospital with acute stroke; and (3) glycaemic status monitored over at least two consecutive days from admission to hospital. The review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis standards.

RESULTS

The dynamics of glycaemia after stroke has been investigated in seven prospective cohort studies and one retrospective study. The patterns that emerged were persisting normoglycaemia, transient hyperglycaemia, persisting hyperglycaemia and delayed hyperglycaemia. Surges in glycaemia are likely on days 2 and 3 and some adults will not exhibit hyperglycaemia till day 7.

CONCLUSION

Further large cohort studies are required to explore the dynamic of glycaemia after stroke for at least 1 week duration. The timing of formal screening for diabetes mellitus is important, as early screening may overestimate detection rates.

Insulin for glycaemic control in acute ischaemic stroke

BACKGROUND

Patients with hyperglycaemia concomitant with an acute stroke have greater stroke severity and greater functional impairment when compared to those with normoglycaemia at stroke presentation.

OBJECTIVES

To determine whether maintaining serum glucose within a specific normal range (4 to 7.5 mmol/L) in the first 24 hours of acute ischaemic stroke influences outcome.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (June 2010), CENTRAL (The Cochrane Library 2010, Issue 2), MEDLINE (1950 to June 2010), EMBASE (1980 to June 2010), CINAHL (1982 to June 2010), Science Citation Index (1900 to June 2010), and Web of Science (ISI Web of Knowledge) (1993 to June 2010). In an effort to identify further published, unpublished and ongoing trials we searched ongoing trials registers and SCOPUS.

SELECTION CRITERIA

Eligible studies were randomised controlled trials comparing intensively monitored insulin therapy versus usual care in adult patients with acute ischaemic stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the study characteristics, study quality, and data to estimate the odds ratio (OR) and 95% confidence interval (CI), mean difference (MD) and standardised mean difference (SMD) of outcome measures.

MAIN RESULTS

We included seven trials involving 1296 participants (639 participants in the intervention group and 657 in the control group). We found that there was no difference between treatment and control groups in the outcome of death or disability and dependence (OR 1.00, 95% CI 0.78 to 1.28) or final neurological deficit (SMD -0.12, 95% CI -0.23 to 0.00). The rate of symptomatic hypoglycaemia was higher in the intervention group (OR 25.9, 95% CI 9.2 to 72.7). In the subgroup analyses of diabetes mellitus (DM) versus non-DM, we found no difference for the outcomes of death and dependency or neurological deficit.

AUTHORS' CONCLUSIONS

With the current evidence, we found that the administration of intravenous insulin with the objective of maintaining serum glucose within a specific range in the first hours of acute ischaemic stroke does not provide benefit in terms of functional outcome, death, or improvement in final neurological deficit and significantly increased the number of hypoglycaemic episodes. Specifically, those who were maintained within a more tight range of glycaemia with intravenous insulin experienced a greater risk of symptomatic and asymptomatic hypoglycaemia than those individuals in the control group.

Inflammatory and neuroendocrine biomarkers of prognosis after ischemic stroke

Stroke is the third leading cause of mortality in the USA and one of the leading causes of severe morbidity. It is important to provide stroke patients and physicians with the most accurate prognostic information to optimize care and allocation of healthcare resources. Reliable prognostic markers available during the initial phase after acute stroke may aid clinical decision-making. Several interesting candidate biomarkers have been studied to address prognostic questions; this article will focus on selected inflammatory and neuroendocrine markers. The utility of a biomarker is defined by its ability to improve clinical decision-making and add timely information beyond that readily available from clinical examination and routine imaging. This aim has not been completely achieved yet for any biomarkers, but promising data are available and further studies are ongoing.

Failure to achieve euglycemia despite aggressive insulin control signals abnormal physiologic response to trauma

PURPOSE

We hypothesize that a failure to normalize a patient's glucose on an automated euglycemia protocol signals an adverse response after trauma and that this response can identify patients with an increased mortality.

MATERIALS AND METHODS

There were 1246 ventilated, critically ill trauma patients who were placed on an automated euglycemia. All glucose values collected both by laboratory serum measurements and by bedside arterial samples were included in the analysis.

RESULTS

Forty six thousand two hundred eighteen data entries for glucose (mg/dL) were analyzed. Time to normalization, defined as the first value in the goal range of 80 to 110 mg/dL, was different between the 2 groups, survivors correcting significantly faster (396 vs 487 minutes; P = .003). Mortality in patients who normalized (80-110 mg/dL) in the first 6 hours of admission was 13.6% vs 18.3% in patients requiring greater than 6 hours (P = .02). Patients who never normalized also required significantly greater insulin doses despite there being no significant difference in demographic data between the 2 groups.

CONCLUSIONS

A posttraumatic patient's response to tight glycemic control revealed important prognostic information about the patients' physiologic status. Patients who failed to reach euglycemia in the first 6 hours of admission had an increased hospital mortality. The time to normalization is significantly longer in those patients who died. Patients who did not correct rapidly required significantly higher insulin doses, suggesting insulin resistance.

Adipose proinflammatory cytokine expression through sympathetic system is associated with hyperglycemia and insulin resistance in a rat ischemic stroke model

Patients who experience acute ischemic stroke may develop hyperglycemia, even in the absence of diabetes, but the exact mechanisms are still unclear. Adipose tissue secretes numerous proinflammatory cytokines and is involved in the regulation of glucose metabolism. This study aimed to determine the effects of acute stroke on adipose inflammatory cytokine expression. In addition, because sympathetic activity is activated after acute stroke and catecholamines can regulate the expression of several adipocytokines, this study also evaluated whether alterations in adipose proinflammatory cytokines following acute stroke, if any, were medicated by sympathetic system. Acute ischemic brain injury was induced by ligating the right middle cerebral artery and bilateral common carotid arteries in male adult Sprague-Dawley rats. Adipose tumor necrosis factor-α (TNF-α) and monocyte chemoattractant protein-1 (MCP-1) mRNA and protein levels were determined by RT-PCR and enzyme-linked immunoassay, respectively. The stroke rats developed glucose intolerance on days 1 and 2 after cerebral ischemic injury. The fasting blood insulin levels and insulin resistance index measured by homeostasis model assessment were higher in the stroke rats compared with the sham group. Epididymal adipose TNF-α and MCP-1 mRNA and protein levels were elevated one- to twofold, in association with increased macrophage infiltration into the adipose tissue. When the rats were treated with a nonselective β-adrenergic receptor blocker, propranolol, before induction of cerebral ischemic injury, the acute stroke-induced increase in TNF-α and MCP-1 was blocked, and fasting blood insulin concentration and homeostasis model assessment-insulin resistance were decreased. These results suggest a potential role of adipose proinflammatory cytokines induced by the sympathetic nervous system in the pathogenesis of glucose metabolic disorder in rats with acute ischemic stroke.

Abnormal glucose metabolism in non-diabetic patients presenting with an acute stroke: prospective study and systematic review

BACKGROUND

Non-diabetic patients presenting with an acute stroke often have hyperglycaemia. In most populations it is unknown whether the hyperglycaemia is transient and due to the acute stress response or whether it represents undiagnosed abnormal glucose metabolism.

AIM

To evaluate the prevalence and predictors of persistent hyperglycaemia in non-diabetic patients with an acute stroke.

DESIGN

Prospective observational study.

METHODS

Non-diabetic patients over 40 years old with an acute stroke were enrolled over a 2-year period. On admission patients were evaluated with an HbA(1c) and a 75 g oral glucose tolerance test (OGTT). The OGTT was repeated 3 months later. A meta-analysis was performed to interpret our results in the context of published data.

RESULTS

One hundred and seven patients were analysed. On admission 26 (24%) patients had diabetes, 39 (37%) had impaired glucose tolerance and 42 (39%) had normal glucose tolerance. Forty-four (68%) patients with hyperglycaemia on admission were re-investigated at least 3 months after discharge. Of these, 6 (14%) had diabetes, 12 (27%) had impaired glucose tolerance and 26 (59%) had normal glucose tolerance. A 2-h post-load glucose value >or=10 mmol/l predicted persistent hyperglycaemia with 72.2% sensitivity, 65.4% specificity and a positive predictive value and negative predictive value of 59.1 and 77.3%, respectively. A meta-analysis of prevalence data of impaired glucose metabolism in non-diabetic individuals 3 months after having had an acute stroke revealed a combined prevalence of 58% (95% confidence interval 25.4-90.5%).

CONCLUSION

In this study hyperglycaemia in the setting of an acute stroke was transient in the majority of patients.