Hyperglycemia and stroke mortality: comparison between fasting and 2-h glucose criteria

Assessing blood sugar measures for predicting new-onset diabetes and cardiovascular disease in community-dwelling adults

PURPOSE

Diabetes mellitus (DM) is a global health concern linked to various complications, including cardiovascular disease (CVD). However, long-term follow-up studies on the risk of DM and CVD using different blood glucose assessment methods in the general Korean population are lacking. This study aimed to assess the predictive abilities of fasting plasma glucose (FPG), 2-h oral glucose tolerance test (OGTT), and glycosylated hemoglobin (HbA1c) for new-onset DM and high CVD risk in a middle-aged and older Korean population.

METHODS

This study used data from the Korean Genome and Epidemiology Study, a population-based prospective cohort. Blood sugar measures (FPG, OGTT, and HbA1c) were examined. The primary endpoint was the development of new-onset DM, and CVD risk was evaluated using the Framingham risk score. The predictive abilities for new-onset DM based on glycemic values were evaluated using Harrell's Concordance index and 95% confidence intervals.

RESULTS

Among the 10,030 participants, data of 6813 participants without DM at baseline were analyzed. The study revealed that OGTT outperformed FPG and HbA1c in predicting new-onset DM. The combination of FPG and HbA1c did not significantly enhance predictions for DM compared with OGTT alone. OGTT also outperformed FPG and HbA1c in predicting high CVD risk, and this difference remained significant even after adjusting for additional confounders.

CONCLUSION

OGTT has superior predictive capabilities in identifying new-onset DM and high CVD risk in the Korean population. This suggests that relying solely on individual blood sugar measures may be insufficient for assessing DM and CVD risks.

Effect of Single Oral Coingestion of GABA and Malic Acid on Postprandial GLP-1, Glucose, and Insulin Responses in Healthy Volunteers: A Randomized, Double-Blind, Placebo-Controlled, Crossover Study

SCOPE

This study examines whether coingestion of γ-aminobutyric acid (GABA) and malic acid (MA) before meals enhances glucagon-like peptide-1 (GLP-1) secretion, and which affects subsequent insulin and glycemic responses in humans.

METHODS AND RESULTS

Initially, a murine enteroendocrine STC-1 cell line is used to verify coadministration of GABA and MA synergistically induces GLP-1 secretion. Next, 22 healthy adults are given water (50 mL) containing 400 mg GABA and 400 mg MA (Test), or only 400 mg citric acid (CA) (Placebo) 20 min before meal tolerance test (MTT). Interval blood samples are taken postprandially over 180 min to determine GLP-1, insulin, and glucose responses. By comparison to preload of Placebo, preload of Test significantly increases plasma GLP-1 (total/active) levels (incremental area under the curve by 1.2- and 1.6-fold), respectively. However, there are no significant differences in postprandial blood glucose and insulin.

CONCLUSION

Coingestion of GABA and MA before meals enhances postprandial GLP-1 secretion. Future studies should explore optimal dosage regimens to find the efficacy of the mixture on insulin and glycemic response.

Synergistic enhancement of glucagon-like peptide-1 release by γ-aminobutyric acid and L-phenylalanine in enteroendocrine cells-searching active ingredients in a water extract of corn zein protein

This study investigated the glucagon-like peptide-1 (GLP-1)-releasing activity of an aqueous extract (ZeinS) from corn zein protein and aimed to identify the active compounds responsible for this activity. Glucagon-like peptide-1-releasing activity was evaluated using a murine enteroendocrine cell line (GLUTag). Liquid chromatography-tandem mass spectrometry (LC-MS/MS) was performed on purified fractions of ZeinS to identify active molecules. ZeinS stimulated more GLP-1 secretion from GLUTag cells compared to zein hydrolysate. Fractions displaying biological activity were determined by solid-phase extraction and high-performance liquid chromatography (HPLC) fractionation. Subsequent LC-MS/MS analysis identified several amino acids in the active fractions of ZeinS. In particular, γ-aminobutyric acid (GABA) exhibited significant GLP-1-releasing activity both alone and synergistically with L-phenylalanine (Phe). Moreover, ZeinS-induced GLP-1 secretion was attenuated by antagonists for the GABA receptor and calcium sensing receptor. These results demonstrate that GABA and Phe identified in ZeinS synergistically stimulate GLP-1 secretion in enteroendocrine cells.

Sex differences in prognostic role of fasting glucose, Oral glucose tolerance, and HbA1c in diabetic cardiovascular disease

Highlights: Fasting glucose‐defined prediabetes and undiagnosed diabetes based on the American Diabetes Association criteria were associated with a greater risk of coronary heart disease, stroke, and composite atherosclerotic cardiovascular disease in women. In contrast, oral glucose tolerance‐defined prediabetes and undiagnosed diabetes were associated with a greater risk of all cardiovascular outcomes in men. Intermediate A1c was associated with a more pronounced effect on the risk of coronary heart disease and stroke in women, whereas the above diagnostic level of A1c was associated with a higher magnitude of coronary heart risk in undiagnosed men but a higher magnitude of stroke risk in undiagnosed women.

Combined Oral Triglyceride and Glucose Tolerance Test After Acute Ischemic Stroke to Predict Recurrent Vascular Events: The Berlin “Cream&Sugar” Study

Background:

Elevated triglyceride and glucose levels are associated with an increased cardiovascular disease risk including ischemic stroke. It is not known whether the response to a combined oral triglyceride and glucose challenge after ischemic stroke improves identification of patients with increased risk for recurrent vascular events.

Methods:

The prospective, observational Berlin “Cream&Sugar” study was conducted at 3 different university hospital sites of the Charité–Universitätsmedizin Berlin, Germany, between January 24, 2009 and July 31, 2017. Patients with first-ever ischemic stroke were recruited 3 to 7 days after stroke. An oral triglyceride tolerance test (OTTT) and consecutive blood tests before (t 0 ) as well as 3 (t 1 ), 4 (t 2 ), and 5 hours (t 3 ) after OTTT were performed in fasting patients. An oral glucose tolerance test was performed in all nondiabetic patients 3 hours after the start of OTTT. Outcomes of the study were recurrent fatal or nonfatal stroke as well as a composite vascular end point including stroke, transient ischemic attack, myocardial infarction, coronary revascularization, and cardiovascular death assessed 1 year after stroke. Cox regression models were used to estimate hazard ratios and corresponding 95% CIs between patients with high versus low levels of triglyceride and glucose levels.

Results:

Overall 755 patients were included; 523 patients completed OTTT and 1-year follow-up. Patients were largely minor strokes patients with a median National Institutes of Health Stroke Scale score of 1 (0–3). Comparing highest versus lowest quartiles of triglyceride levels, neither fasting (adjusted hazard ratio t0 , 1.24 [95% CI, 0.45–3.42]) nor postprandial triglyceride levels (adjusted hazard ratio t3 , 0.44 [95% CI, 0.16–1.25]) were associated with recurrent stroke. With regard to recurrent vascular events, results were similar for fasting triglycerides (adjusted hazard ratio t0 , 1.09 [95% CI, 0.49–2.43]), however, higher postprandial triglyceride levels were significantly associated with a lower risk for recurrent vascular events (adjusted hazard ratio t3 , 0.42 [95% CI, 0.18–0.95]). No associations were observed between fasting and post–oral glucose tolerance test blood glucose levels and recurrent vascular risk. All findings were irrespective of the diabetic status of patients.

CONCLUSIONS:

In this cohort of patients with first-ever‚ minor ischemic stroke, fasting triglyceride or glucose levels were not associated with recurrent stroke at one year after stroke. However, higher postprandial triglyceride levels were associated with a lower risk of recurrent vascular events which requires further validation in future studies. Overall, our results do not support the routine use of a combined OTTT/oral glucose tolerance test to improve risk prediction for recurrent stroke.

Postload Plasma Glucose but Not Fasting Plasma Glucose Had a Greater Predictive Value for Cardiovascular Disease in a Large Prospective Cohort Study in Southwest China

BACKGROUND

Uncertainty remains regarding the relevance of glycemia, though below the threshold for diabetes, for the risk of cardiovascular disease (CVD) among the Southwest Chinese. We aimed to examine the associations of the first-onset CVD with fasting plasma glucose (FPG) and 2-h postload glucose (2h-PG) in Southwest China.

METHODS

The current study examined data from the Guizhou Population Health Cohort Study (GPHCS) of 9,280 participants aged 18 to 95 years recruited from 12 areas since 2010 in Guizhou Province, Southwest China. Participants were followed-up until December, 2020. Primary outcomes were the first onset of a composite of or one of major CVD events, including ischaemic stroke, haemorrhagic stroke and myocardial infarction. FPG, 2h-PG, other metabolic factors and some demographic factors were collected at baseline. Cox proportional hazards models were used to estimate the risk of CVD associated with FPG and 2h-PG. Sensitive analysis and stratified analysis were conducted among participants across different modifiable risk factors and demographic features.

RESULTS

During a median of 6.58 years of follow-up, of 7,593 participants with available data for analysis, 174 experienced at least one CVD events, 158 developed stroke (including 126 ischemic stroke and 39 Ischemic stroke events), and 24 developed myocardial infarction. The risk of major CVD events was significantly increased with elevated 2h-PG but not FPG. Compared with participants in the lowest tertile of 2h-PG, those in the highest tertile had a 1.87-fold (95%CI: 1.26-2.77) increased risk for overall CVD, a 1.82-fold (95%CI: 1.20-2.75) increased risk for overall Stroke, and a 1.82-fold (95%CI: 1.20-2.75) increased risk for ischemic stroke, respectively, after adjustment for age, sex, smoking, ethnic group, education level, systolic blood pressure (SBP), triglycerides (TG), body mass index (BMI) and waist circumference (WC). However, there was no relation of glycemia of haemorrhagic stroke or myocardial infarction (P > 0.05). The effect sizes in the associations of CVD with 2h-PG become enhanced among those within normal range of glycemia, SBP, TG, BMI, as well as those without hypertension, dyslipidemia.and obesity.

CONCLUSIONS

2h-PG, in contrast to FPG, is a significant indicator in predication of CVD in Southwest Chinese. Elevated 2h-PG, though below the below the threshold for diabetes, remains independently increased the risk of CVD.

Fasting blood glucose and risk of Stroke: A Dose-Response meta-analysis

BACKGROUND & PURPOSE

A growing number of studies have shown that fasting blood glucose is related to the risk of stroke, however, the dose-response association between fasting blood glucose and the risk of stroke is still unclear. Accordingly, we conducted a dose-response meta-analysis to evaluate the relationship between fasting blood glucose and the risk of stroke by summarizing cohort studies.

METHODS

PubMed and Embase databases were searched for related studies (until October 2020). Cohort studies examining the influence of fasting blood glucose on stroke risk were summarized. A dose-response relationship was determined using a random-effect model.

RESULTS

Eighteen cohort studies involving 2,555,666 participants were included. The pooled relative risk for the high-versus-low categories was 1.79 (95% CI: 1.68-1.91) in all people, and 1.16 (95% CI: 1.11-1.21) in non-diabetic people. In addition, there was a non-linear relationship between fasting blood glucose and stroke risk. The incidence of stroke was reduced to its lowest point when fasting blood glucose level was 70-100 mg/dL.

CONCLUSION

Fasting blood glucose was positively related to stroke risk, with a non-linear dose-response relationship.

Effect of Glucose Tolerance Factor (GTF) on Lipid Profile, Blood Glucose Levels, and Food Intake in Streptozotocin-Induced Diabetes in Rats

Introduction: This study was aimed to evaluate the beneficial effects of containing glucose tolerance factor (GTF) from Brewer's yeast in improving glycaemic control in diabetic rats and lowering some of the risk factors for cardiovascular disorders. Methodology: The study used Wistar rats of both sexes weighing 150-200 g. Animals were randomly (n=6) divided into eight groups as normal control, normal control receiving Brewer's yeast, diabetic, Brewer's yeast receiving diabetic, Metformin-treated diabetic, and Glimepiride-treated diabetic, and two diabetic groups treated with Brewer's yeast and 50% of the Metformin and Glimepiride doses, respectively. To induce diabetes, Streptozotocin was administered intraperitoneally to all rats, except control group rats. Body weight (weekly), food intake (every day), blood glucose, and lipid profile (initially and at the end of the study) were assessed for four weeks in all groups. Results: Brewer's yeast administration significantly decreased blood glucose levels and prevented reduction in body weight, increased food intake and alterations in the lipid profile compared to untreated groups, and were comparable to the groups treated with standard drugs. Conclusion: Results of this study showed that oral administration of Brewer's yeast extract might be an excellent alternative antidiabetic agent which could be also useful in reducing the required dose of standard antidiabetic agents when combined.

Association of prestroke glycemic status with stroke mortality

OBJECTIVE

The role of diabetes as a predictor of mortality after stroke remains uncertain, and there are very few data for pre-diabetes. This study investigated the association of pre-diabetes and diabetes with 30-day and 1-year mortality after ischemic stroke (IS) and primary intracerebral hemorrhage (ICH).

RESEARCH DESIGN AND METHODS

Between 2006 and 2013, 2076 patients with IS and 586 patients with ICH (median age 79) were admitted to hospital within 24 hours after stroke onset and were treated in a stroke unit, where they underwent measurement of glycated hemoglobin (HbA1c). Diabetes was retrospectively defined based on medical history, diagnosis during hospital stay or HbA1c ≥6.5% (48 mmol/mol). Pre-diabetes was defined as HbA1c of 5.7%-6.4% (39-47 mmol/mol). Stroke severity was measured using the National Institutes of Health Stroke Scale (NIHSS). HRs were used to test the association of pre-diabetes and diabetes with 30-day and 1-year mortality after stroke onset.

RESULTS

Among patients with IS, 830 had pre-diabetes and 632 had diabetes; 280 died within 30 days and the other 77 within 1 year. Among patients with ICH, 106 had pre-diabetes and 56 had diabetes; 150 died within 30 days and the other 92 within 1 year. In both stroke subtypes, pre-diabetes and diabetes were associated with higher 30-day mortality. In IS, however, the association was limited to patients with prestroke disability and very severe stroke. At NIHSS 25, HR was 1.58 (95% CI 1.07 to 2.35) for pre-diabetes and 1.67 (95% CI 1.14 to 2.46) for diabetes compared with normoglycemia. In ICH, the association was limited to women for pre-diabetes (HR 1.93, 95% CI 1.15 to 3.24) and to men for diabetes (HR 1.78, 95% CI 1.02 to 3.12). Prestroke glycemic status was unrelated to 1-year mortality.

CONCLUSIONS

Both pre-diabetes and diabetes predict short-term mortality after acute stroke, but the association varies depending on both prestroke and stroke-related characteristics. These findings may explain the heterogeneous results obtained by previous studies.

Hyperglycemia is associated with poor in-hospital outcome in elderly patients with acute ischemic stroke

Fasting hyperglycemia is associated with poor neurologic outcome in acute ischemic stroke (AIS), but its relationship with in-hospital outcome in elderly patients remains largely unknown. To assess the association of in-hospital outcome with fasting plasma glucose (FPG) levels at admission in individuals with AIS.This retrospective propensity score-matched case-control study included patients aged over 60 years suffering from AIS and who were admitted to the emergency department from November 2013 to October 2016. Subjects were grouped into the poor-outcome and good-outcome groups based on mortality and intensive care unit (ICU) admission.The poor- and good-outcome groups comprised 74 and 1927 cases, respectively, before propensity score matching (PSM), and 74 and 296 cases, respectively, after PSM. Univariable logistic regression analysis showed that initial FPG after admission was associated with poor in-hospital outcome. Multivariable logistic regression analysis showed that initial FPG after admission was an independent predictor of poor in-hospital outcome (odds ratio = 1.11, 95% confidence interval: 1.037-1.188, P = .003).This study used PSM and strongly suggests that FPG is an independent predictive factor of poor in-hospital outcome in elderly patients with AIS. High initial FPG levels after admission may predict poor in-hospital outcome. Prospective studies are needed to confirm these findings.

Prevalence of diabetes and its effects on stroke outcomes: A meta-analysis and literature review

AIMS/INTRODUCTION

Diabetes mellitus is an established risk factor for stroke and maybe associated with poorer outcomes after stroke. The aims of the present literature review were to determine: (i) the prevalence of diabetes in acute stroke patients through a meta-analysis; (ii) the association between diabetes and outcomes after ischemic and hemorrhagic stroke; and (iii) to review the value of glycated hemoglobin and admission glucose-based tests in predicting stroke outcomes.

MATERIALS AND METHODS

Ovid MEDLINE and EMBASE searches were carried out to find studies relating to diabetes and inpatient stroke populations published between January 2004 and April 2017. A meta-analysis of the prevalence of diabetes from included studies was undertaken. A narrative review on the associations of diabetes and different diagnostic methods on stroke outcomes was carried out.

RESULTS

A total of 66 eligible articles met inclusion criteria. A meta-analysis of 39 studies (n = 359,783) estimated the prevalence of diabetes to be 28% (95% confidence interval 26-31). The rate was higher in ischemic (33%, 95% confidence interval 28-38) compared with hemorrhagic stroke (26%, 95% confidence interval 19-33) inpatients. Most, but not all, studies found that acute hyperglycemia and diabetes were associated with poorer outcomes after ischemic or hemorrhagic strokes: including higher mortality, poorer neurological and functional outcomes, longer hospital stay, higher readmission rates, and stroke recurrence. Diagnostic methods for establishing diagnosis were heterogeneous between the reviewed studies.

CONCLUSIONS

Approximately one-third of all stroke patients have diabetes. Uniform methods to screen for diabetes after stroke are required to identify individuals with diabetes to design interventions aimed at reducing poor outcomes in this high-risk population.

Interactive effect of acute and chronic glycemic indexes for severity in acute ischemic stroke patients

Background

Diabetes mellitus is a well-established risk factor for ischemic stroke and is known to increase stroke risk by 2–6 fold. Numerous studies have reported the relationship between parameters for glycemic status and stroke-related outcomes; however, studies focusing on the interaction between acute and chronic glycemic status indexes with stroke phenotype are lacking.

Methods

Acute ischemic stroke patients who were admitted to a tertiary hospital stroke center from 2002 to 2015 were consecutively enrolled in this study. Fasting blood sugar (FBS) and serum glycated hemoglobin (HbA1c) levels were recorded as acute and chronic glycemic indexes, respectively. The associations between initial stroke severity and both glycemic indexes were evaluated with consideration of the interaction between the glycemic indexes. Moreover, the distinct effects of stroke subtypes were evaluated.

Results

A total of 2595 patients were included in the final analysis. After adjustment for covariates, FBS was associated with initial stroke severity (P < 0.001), while HbA1c was not (P = 0.16). However, an interaction between FBS and HbA1c in association with initial stroke severity was observed (P < 0.001). The association between FBS and initial stroke severity was stronger, with a relatively normal HbA1c level. Among stroke subtypes, the interactions were significant for the large artery disease and cardioembolism subtypes (all, P < 0.001), but for the small vessel occlusion subtype (P = 0.63).

Conclusions

This study shows that HbA1c is an effect modifier for the association between FBS and initial stroke severity, and the interactive effect differs among stroke subtypes.

Electronic supplementary material

The online version of this article (10.1186/s12883-018-1109-1) contains supplementary material, which is available to authorized users.

Glitazones and alpha-glucosidase inhibitors as the second-line oral anti-diabetic agents added to metformin reduce cardiovascular risk in Type 2 diabetes patients: a nationwide cohort observational study

Objective

Metformin is the standard first-line drug for patients with Type 2 diabetes (T2DM). However, the optimal second-line oral anti-diabetic agent (ADA) remains unclear. We investigated the cardiovascular risk of various ADAs used as add-on medication to metformin in T2DM patients from a nationwide cohort.

Methods

T2DM patients using different add-on oral ADAs after an initial metformin therapy of > 90 days were identified from the Taiwan National Health Insurance Database. Five classes of ADAs, including sulphonylureas (SU), glinides, thiazolidinediones (TZD), alpha-glucosidase inhibitors (AGI), and dipeptidyl peptidase-4 inhibitors (DPP-4I) were selected for analysis. The reference group was the SU added to metformin. Patients were excluded if aged < 20 years, had a history of stroke or acute coronary syndrome (ACS), or were receiving insulin treatment. The primary outcomes included any major adverse cardiovascular event (MACE) including ACS, ischemic/hemorrhagic stroke, and death. A Cox regression model was used to estimate the hazard ratio (HR) for MACE.

Results

A total of 26,742 patients receiving their add-on drug to metformin of either SU (n = 24,277), glinides (n = 962), TZD (n = 581), AGI (n = 808), or DPP-4I (n = 114) were analyzed. After a mean follow-up duration of 6.6 ± 3.4 years, a total of 4775 MACEs occurred. Compared with the SU+metformin group (reference), the TZD+metformin (adjusted HR: 0.66; 95% CI 0.50–0.88, p = 0.004) and AGI+metformin (adjusted HR: 0.74; 95% CI 0.59–0.94, p = 0.01) groups showed a significantly lower risk of MACE.

Conclusion

Both TZD and AGI, when used as an add-on drug to metformin were associated with lower MACE risk when compared with SU added to metformin in this retrospective cohort study.

Trial registration CE13152B-3. Registered 7 Mar, 2013, retrospectively registered

Electronic supplementary material

The online version of this article (10.1186/s12933-018-0663-6) contains supplementary material, which is available to authorized users.

Diabetes based on 2-h plasma glucose among those classified as having prediabetes based on fasting plasma glucose or A1c

OBJECTIVE

Determine the prevalence of diabetes using 2-h plasma glucose among people who otherwise would be categorized as having prediabetes based on A1c and fasting glucose, and to determine whether those people were more likely to have cardiometabolic risk factors.

METHODS

Among 3644 adults with prediabetes based on A1c and fasting glucose in the 2005-2014 National Health and Nutrition Examination Survey, a cross-sectional survey of the US general population, we estimated the percentage who would be categorized as having diabetes based on having a 2-h plasma glucose ⩾200 mg/dL. We calculated odds ratios of cardiometabolic risk factors associated with having 2-h plasma glucose ⩾200 mg/dL.

RESULTS

A total of 6.9% would be categorized as having diabetes based on 2-h plasma glucose. The adjusted odds ratios (95% confidence interval) associated with having 2-h plasma glucose ⩾200 mg/dL were significant for total hypertension (2.06, 1.35-3.14), high triglycerides (1.64, 1.10-2.44), low high-density lipoprotein cholesterol (1.55, 1.01-2.39), albuminuria (2.05, 1.33-3.14) and elevated alanine aminotransferase (1.78, 1.09-2.91), but not for other cardiometabolic risk factors.

CONCLUSION

A total of 6.9% of people categorized as having prediabetes based on A1c and fasting glucose would be categorized as having diabetes based on 2-h plasma glucose. They were more likely to have hypertension, high triglycerides, low high-density lipoprotein cholesterol, albuminuria and elevated alanine aminotransferase.

Synthesis of substituted 2H-benzo[e]indazole-9-carboxylate as a potent antihyperglycemic agent that may act through IRS-1, Akt and GSK-3β pathways

Based on high throughput screening of our chemical library, we identified two 4,5-dihydro-2H-benzo[e]indazole derivatives (5d and 5g), which displayed a significant effect on glucose uptake in L6 skeletal muscle cells. Based on these lead molecules, a series of benzo[e]indazole derivatives were prepared. Among all the synthesized dihydro-2H-benzo[e]indazoles, 8-(methylthio)-2-phenyl-6-p-tolyl-4,5-dihydro-2H-benzo[e]indazole-9-carboxylate (5e) showed significant glucose uptake stimulation in L6 skeletal muscle cells, even better than lead compounds. Additionally, 5e decreased glucagon-induced glucose release in HepG2 hepatoma cells. The 2H-benzo[e]indazole 5e exerted an antihyperglycemic effect in normal, sucrose challenged streptozotocin-induced diabetic rats and type 2 diabetic db/db mice. Treatment with 5e at a dose of 30 mg kg-1 in db/db mice caused a significant decrease in triglyceride and total cholesterol levels and increased the HDL-C level in a significant manner. The mechanistic studies revealed that the 2H-benzo[e]indazole 5e significantly stimulated insulin-induced signaling at the level of IRS-1, Akt and GSK-3β in L6 skeletal muscle cells, possibly by inhibiting protein tyrosine phosphatase-1B. This new 2H-benzo[e]indazole derivative has potential for the treatment of diabetes with improved lipid profile.

Coenzyme Q10 and oxidative stress, the association with peripheral sensory neuropathy and cardiovascular disease in type 2 diabetes mellitus

OBJECTIVE

Our study aimed to explore associations between metabolic control, oxidative stress and coenzyme Q10 (CoQ10) in relation to diabetes complications in a representative population of type 2 diabetes.

RESEARCH DESIGN AND METHODS

A geographic cohort of 156 subjects was recruited. Serum concentrations of CoQ10 and vitamin E were measured by HPLC. ROS was determined by free oxygen radicals testing (FORT). Glutaredoxin (Grx) activity, oxidized LDL cholesterol (oxLDLc), high sensitive CRP (hsCRP), HbA1c, urine albumin, serum creatinine, serum cystatin C, and plasma lipids were assayed with routine laboratory protocols.

RESULTS

Serum CoQ10 was higher than in nondiabetics. HbA1c, fP-glucose, hyperlipidemia, inflammation (hsCRP), and increased BMI were associated with signs of oxidative stress as increased levels of FORT, Grx activity and/or increased levels of oxLDLc Oxidative stress was found to be strongly correlated with prevalence of cardiovascular disease (CVD) and peripheral sensory neuropathy (PSN). In both gender groups there were positive correlations between CoQ10 and oxLDLc, and between BMI and the ratio CoQ10/chol. Grx activity was inversely correlated to oxLDLc and CoQ10. Women with CVD and PSN had higher waist index, oxLDLc, and FORT levels compared to men but lower CoQ10 levels. Men had worse kidney function and lower vitamin E. Multiple regression analysis showed increased levels of CoQ10 to be significantly correlated with increased levels of cholesterol, triglycerides, vitamin E, fB-glucose and BMI.

CONCLUSIONS

Hyperlipidemia, hyperglycemia and inflammation were associated with oxidative stress, which was correlated to the prevalence of diabetes complications. CoQ10 was increased in response to oxidative stress. There were gender differences in the risk factors associated with diabetes complications.

Fasting blood glucose levels affect hospitalization time and relapse and mortality rates of cerebral infarction patients

OBJECTIVE

This study determined the relationship between fasting glucose levels of cerebral infarction patients and the hospitalization time and relapse and mortality rates.

METHODS

A retrospective study was conducted between February 1996 and December 2006 involving 974 inpatients with cerebral infarctions. Fasting blood glucose and lipid levels and blood pressure were measured the morning after hospitalization. The length of hospital stay, and data obtained from telephone follow-up interviews regarding relapse and complications were recorded. The data were analyzed using multiple linear regressions, logistic regression, the chi-square test, and the Kruskal-Wallis analysis of variance of ranks test.

RESULTS

Our data show that the duration of hospitalization and relapse and mortality rates of patients with cerebral infarctions correlate with the admission fasting blood glucose levels. Cerebral infarction patients with fasting blood glucose levels > 11.1 mmol/L and LDL levels > 3.5 mmol/L have higher mortality rates (50.00%). Patients with fasting blood glucose levels > 11.1 mmol/L combined with a diastolic pressure < 80 mmHg or > 100 mmHg also have high mortality rates (33.33% and 30.00%, respectively).

CONCLUSIONS

Fasting glucose levels of inpatients with cerebral infarctions are closely related to the duration of hospitalization and relapse and mortality rates. Higher fasting blood glucose levels exacerbate damage to cerebral blood vessels caused by alterations in blood lipid levels and blood pressure. Therefore, blood glucose levels should be monitored during the early stage of cerebral infarction and intervention should be provided promptly to decrease the length of hospital stay and the risk of relapse and mortality.

A high-glycemic index, low-fiber breakfast affects the postprandial plasma glucose, insulin, and ghrelin responses of patients with type 2 diabetes in a randomized clinical trial

BACKGROUND

Meals with a low glycemic index (GI) and rich in fiber could be beneficial with regard to postprandial metabolic profile and satiety.

OBJECTIVE

The aim of this study was to investigate the effect of 4 breakfasts with a different GI and amount of fiber on postprandial plasma glucose, insulin, and appetite in patients with type 2 diabetes.

METHODS

This randomized 4-intervention crossover trial included 14 patients [7 men; ages 65.8 ± 5.2 y; glycated hemoglobin: 6.6 ± 0.9%; BMI (in kg/m(2)): 27.2 ± 3.1]. Dietary interventions were as follows: breakfasts with a high GI (60.4 ± 0.1%) and high fiber (6.0 ± 0.3 g) (HGI-HF), a high GI (60.9 ± 1.7%) and low fiber (2.5 ± 0.4 g) (HGI-LF), a low GI (37.7 ± 0.1%) and high fiber (6.2 ± 0.3 g) (LGI-HF), and a low GI (39.8 ± 1.3%) and low fiber (2.0 ± 0.1 g) (LGI-LF). Plasma glucose, insulin, and total ghrelin were evaluated postprandially (0-180 min). A visual analog scale was used to assess appetite. Data were analyzed by generalized estimating equations and post hoc least significant difference (LSD) tests. Data are reported as means ± SDs.

RESULTS

The area under the curve (AUC) [mean (95% CI); P for LSD tests] for plasma glucose (mmol/L × min) was higher after patients consumed the HGI-LF breakfast [9.62 (8.39, 10.84)] than after the LGI-HF breakfast [8.95 (7.71, 10.18)] (P ≤ 0.05). Insulin AUC (μIU/mL × min) after patients consumed the HGI-LF meal [65.72 (38.24, 93.19)] was higher than after the HGI-HF meal [57.24 (32.44, 82.04)] (P ≤ 0.05). The other observed difference was higher insulin AUC after the consumption of the LGI-LF breakfast [61.54 (36.61, 86.48)] compared with the AUC after the LGI-HF breakfast [54.16 (31.43, 76.88)] (P ≤ 0.05). Plasma ghrelin decreased in comparison with baseline only after patients consumed the LGI-HF and LGI-LF breakfasts (P ≤ 0.05). Subjective satiety did not differ between breakfasts.

CONCLUSIONS

Plasma glucose, insulin, and ghrelin responses were least favorable when patients with type 2 diabetes consumed a breakfast with a high GI and low fiber, which suggests that reducing the GI or increasing the fiber content or both of breakfasts may be a useful strategy to improve the postprandial metabolic profile of these patients. This trial was registered at clinicaltrials.gov as NCT01410292.

Discovery of biaryl-4-carbonitriles as antihyperglycemic agents that may act through AMPK-p38 MAPK pathway

A series of functionalized biaryl-4-carbonitriles was synthesized in three steps and evaluated for PTP-1B inhibitory activity. Among the synthesized compounds, four biaryls 6a-d showed inhibition (IC50 58-75 μM) against in vitro PTP-1B assay possibly due to interaction with amino acid residues Lys120, Tyr46 through hydrogen bonding and aromatic-aromatic interactions, respectively. Two biaryl-4-carbonitriles 6b and 6c showed improved glucose tolerance, fasting as well as postprandial blood glucose, serum total triglycerides, and increased high-density lipoprotein-cholesterol in SLM, STZ, STZ-S and C57BL/KsJ-db/db animal models. The bioanalysis of 4'-bromo-2,3-dimethyl-5-(piperidin-1-yl)biphenyl-4-carbonitrile (6b) revealed that like insulin, it increased 2-deoxyglucose uptake in skeletal muscle cells (L6 and C2C12 myotubes). The compound 6b significantly up-regulated the genes related to the insulin signaling pathways like AMPK, MAPK including glucose transporter-4 (GLUT-4) gene in muscle tissue of C57BL/KsJ-db/db mice. Furthermore, it was observed that the compound 6b up-regulated PPARα, UCP2 and HNF4α, which are key regulator of glucose, lipid, and fatty acid metabolism. Western blot analysis of the compound 6b showed that it significantly increased the phosphorylation of AMPK and p38 MAPK and ameliorated glucose uptake in C57BL/KsJ-db/db mice through the AMPK-p38 MAPK pathway.

[Prediction of cerebrovascular event risk following myocardial infarction]

INTRODUCTION

Patients with coronary artery disease (CAD) are at increased risk of stroke. The aim of this study was to analyze the prognostic accuracy of selected clinical and laboratory variables in stroke risk prediction following discharge after myocardial infarction (MI).

METHODS

We analyzed 404 consecutive patients (aged 68.1±13.7 years; 63.4% male; 37.4% with diabetes) without previous stroke who were discharged in sinus rhythm after being admitted for MI. The following data were collected: cardiovascular risk factors, admission blood glucose (BG), HbA1c, creatinine, peak troponin levels; glomerular filtration rate (GFR) by the MDRD formula; maximum Killip class; GRACE score for in-hospital and 6-month mortality; and extent of CAD. Patients were followed for two years and each variable was tested as a possible predictor of cerebrovascular events (stroke or transient ischemic attack [TIA]).

RESULTS

During follow-up, 27 patients were admitted for stroke or TIA. The presence of diabetes, hypertension, dyslipidemia and previously known CAD, type of MI (STEMI vs NSTEMI) and extent of CAD did not predict cerebrovascular risk. The following variables were associated with higher stroke risk: GFR <60ml/min/m(2) (p=0.029, OR 2.65, 95% CI 1.07-6.55); maximum Killip class >1 (p=0.025, OR 2.71, 95% CI 1.10-6.69); GRACE in-hospital mortality >180 (p=0.001, OR 4.09, 95% CI 1.64-10.22); admission BG >140 mg/dl (p=0.001, OR 5.74, 95% CI 1.87-17.58); GRACE 6-month mortality >150 (p=0.001, OR 4.50, 95% CI 1.80-6.27); and peak troponin >42ng/ml (p=0.032, OR 2.64, 95% CI 1.06-6.59). Logistic regression analysis produced a model with the predictors GRACE 6-month mortality >150 (OR 3.26; p=0.014) and admission BG >7.7mmol/l (OR 4.09; p=0.017) that fitted the data well (Hosmer-Lemeshow: p=0.916).

DISCUSSION/CONCLUSIONS

In patients with MI, variables known to be predictors of in-hospital mortality, including admission BG, renal function, acute heart failure and GRACE score, were found to be useful predictors of stroke during 2-year follow-up. While both GRACE score for 6-month mortality >150 and admission BG >7.7 mmol/l were independent predictors of stroke, CV risk factors, previously known CAD, and extent of CAD assessed by coronary angiography did not improve stroke risk prediction. This study highlights the need for even more aggressive secondary prevention in patients most at risk.

[Gender and stroke in Brazzaville]

BACKGROUND

The relationship between gender and cerebrovascular disease is controversial. The aim of our study was to evaluate the relationship between gender and vascular risk factors, biological variables and the severity of the neurological deficit in stroke.

METHODS

This cross-sectional study, conducted from March to August 2011 in the department of neurology of the university hospital of Brazzaville which included all patients hospitalized for confirmed stroke. The study variables were: age, sex, vascular risk factors, NIHSS scores and Glasgow, blood pressure, and the biological exams and complications. Statistical analysis was performed on SPSS12.

RESULTS

Eighty patients were included. The mean age was 62.7 ± 11.2 years, with 58.8% of men. Alcohol intake and smoking were more frequent in men than women respectively P=0.005 and P=0.032. Psychosocial stress was more often declared by women than men (P=0.042). However there was no significant difference in biological variables, the severity of stroke and the occurrence of complications

CONCLUSION

Our study suggests that in the Congolese context, gender does not influence significantly most parameters during stroke, but men consume more alcohol and women are exposed to psychosocial stress.

The effect of the ALAnerv nutritional supplement on some oxidative stress markers in postacute stroke patients undergoing rehabilitation

Stroke is a pathologic condition associated with redox imbalance. This pilot study was designed to evaluate the effect of the consumption of the nutritional supplement ALAnerv on some oxidative stress markers in postacute stroke patients undergoing rehabilitation. To achieve this goal, we assigned 28 patients to 2 study groups: (-)ALA and (+)ALA. Patients in both groups participated in the same rehabilitation program and received comparable standard medications; however, patients in the (+)ALA group received ALAnerv for 2 weeks (2 pills per day). We assessed total and nonproteic thiols, protein carbonyls, ceruloplasmin, oxidized low-density lipoprotein (LDL) particles, lipid hydroperoxide concentrations, gamma-glutamyl transpeptidase activity, and total antioxidant capacity. Regression analysis indicated that supplementation with ALAnerv was responsible for the significant decrease in glucose (p = 0.002) and oxidized LDL particles (p < 0.001) during the study period. For both parameters, the variation in the percent of concentration between the 2 groups during the study period reached statistical significance (p = 0.012 and p < 0.001, respectively). Moreover, Barthel Index values at discharge were significantly influenced by ALAnerv treatment. These preliminary results indicate that ALAnerv might be helpful because it rapidly corrects plasma fasting glucose and corrects serum oxidized LDL particle concentrations, suggesting the need for longer treatment with 2 pills or more per day.

All-cause in-hospital mortality and comorbidity in diabetic and non-diabetic patients with stroke

INTRODUCTION

The aim of this study was to compare diabetic and non-diabetic patients with stroke with regard to their all-cause in-hospital mortality and possible differences regarding their comorbidities.

METHODS

All patients of the Munich Stroke Registry (2003-2004, n=537) were assessed. Hospital mortality in diabetic (n=160, 29.8%) and non-diabetic (n=377, 70.2%) patients was compared. Pre-existing comorbidities such as hypertension, coronary artery disease (CAD), peripheral arterial disease (PAD), albuminuria and impaired renal function (IRF) were noted.

RESULTS

Regarding all-cause in-hospital mortality, no significant differences were found between diabetic and non-diabetic patients. Overall 71 patients (13.2%) died of whom 27 (16.9%) where diabetic and 44 (11.7%) non-diabetic patients (n.s.). Hypertension, CAD, PAD, albuminuria and IRF were more frequent in diabetic patients (p<0.05).

CONCLUSION

Despite multiple comorbidities and risk factors no significant difference in all-cause in-hospital mortality was seen in diabetic patients as compared to non-diabetic patients. Improved treatment strategies and early intervention may compensate for their poorer prognosis.

Development of coronary heart disease and ischemic stroke in relation to fasting and 2-hour plasma glucose levels in the normal range

Background

Individuals who had normoglycemia but whose 2-hour plasma glucose (2hPG) concentrations did not return to the fasting plasma glucose (FPG) levels during an oral glucose tolerance test (OGTT) have been shown to have increased cardiovascular mortality. This is further investigated regarding to the first events of coronary heart disease (CHD) and ischemic stroke (IS).

Method

Data from 9 Finnish and Swedish cohorts comprising 3743 men and 3916 women aged 25 to 90 years who had FPG < 6.1 mmol/l and 2hPG < 7.8 mmol/l and free of CVD at enrolment were analyzed. Hazard ratios (HRs) for first CHD and IS events were estimated for the individuals with 2hPG > FPG (Group II) compared with those having 2hPG ≤ FPG (Group I).

Results

A total of 466 (115) CHD and 235 (106) IS events occurred in men (women) during a median follow-up of 16.4 years. Individuals in Group II were older and had greater body mass index, blood pressure, 2hPG and fasting insulin than those in Group I in both sexes. Multivariate adjusted HRs (95% confidence intervals) for incidence of CHD, IS, and composite CVD events (CHD + IS) in men were 1.13 (0.93-1.37), 1.40 (1.06-1.85) and 1.20 (1.01-1.42) in the Group II as compared with those in the Group I. The corresponding HRs in women were 1.33 (0.83-2.13), 0.94 (0.59-1.51) and 1.11 (0.79-1.54), respectively.

Conclusion

Within normoglycemic range individuals whose 2hPG did not return to their FPG levels during an OGTT had increased risk of CHD and IS.

A prospective study of fasting plasma glucose and risk of stroke in asymptomatic men

OBJECTIVE

To examine the association between levels of fasting plasma glucose (FPG) and incidence of stroke outcomes in a large cohort of asymptomatic men.

PATIENTS AND METHODS

Participants were 43,933 men (mean ± SD age, 44.3 ± 9.9 years) who were free of known cardiovascular disease at baseline and whose FPG levels were assessed during a preventive medical examination at the Cooper Clinic, Dallas, TX, between January 7, 1971, and March 11, 2002. Patients with diagnosed diabetes mellitus (DM) or low FPG (<80 mg/dL [to convert to mmol/L, multiply by 0.0555]) were excluded. Fatal stroke was identified through the National Death Index, and nonfatal stroke was ascertained from mail-back surveys.

RESULTS

A total of 595 stroke events (156 fatal and 456 nonfatal strokes; 17 men reported a nonfatal stroke before they died of stroke) occurred during 702,928 person-years of exposure. Age-adjusted fatal, nonfatal, and total stroke event rates per 10,000 person-years for normal FPG (80-109 mg/dL), impaired fasting glucose (110-125 mg/dL), and undiagnosed DM (≥ 126 mg/dL) were 2.1, 3.4, and 4.0 (P(trend)=.002); 10.3, 11.8, and 18.0 (P(trend)=.008); and 8.2, 9.6, and 12.4 (P(trend)=.008), respectively. After further adjusting for potential confounders, the direct association between FPG and fatal, nonfatal, or total stroke events remained significant (P(trend)=.02, .03, and .01, respectively). For FPG levels of 110 mg/dL or greater, each 10-unit increment of FPG was associated with a 6% higher risk of total stroke events (P=.05).

CONCLUSION

Hyperglycemia (FPG, ≥ 110 mg/dL), even below the DM threshold (such as with impaired fasting glucose), was associated with a higher risk of fatal, nonfatal, or total stroke events in asymptomatic men.

Assessment and treatment of cardiovascular risk in prediabetes: impaired glucose tolerance and impaired fasting glucose

Individuals with impaired glucose tolerance (IGT) and/or impaired fasting glucose (IFG) are at high risk, not only to develop diabetes mellitus, but also to experience an adverse cardiovascular (CV) event (myocardial infarction, stroke, CV death) later in life. The underlying pathophysiologic disturbances (insulin resistance and impaired β-cell function) responsible for the development of type 2 diabetes are maximally/near maximally expressed in subjects with IGT/IFG. These individuals with so-called prediabetes manifest all of the same CV risk factors (dysglycemia, dyslipidemia, hypertension, obesity, physical inactivity, insulin resistance, procoagulant state, endothelial dysfunction, inflammation) that place patients with type 2 diabetes at high risk for macrovascular complications. The treatment of these CV risk factors should follow the same guidelines established for patients with type 2 diabetes, and should be aggressively followed to reduce future CV events.

Neuropathy in prediabetes: does the clock start ticking early?

Between 25% and 62% of patients with idiopathic peripheral neuropathy are reported to have prediabetes, and among individuals with prediabetes 11-25% are thought to have peripheral neuropathy, and 13-21% have neuropathic pain. Population-based studies suggest a gradient for the prevalence of neuropathy, being highest in patients with manifest diabetes mellitus, followed by individuals with impaired glucose tolerance then impaired fasting glucose and least in those with normoglycemia. The most sensitive test to assess glucose metabolism status is the oral glucose tolerance test. Pathogenesis involves hyperglycemia, microvascular abnormalities, dyslipidemia and the metabolic syndrome. Individuals with prediabetes have less severe neuropathy than those with manifest diabetes mellitus. Sensory modalities are more frequently affected than motor modalities, but impairment of small nerve fibers could be the earliest detectable sign. Diagnosis should rely on careful clinical examination, with emphasis on the evaluation of small fibers. An oral glucose tolerance test should be performed in patients with idiopathic neuropathy. The only treatment with any efficacy is lifestyle modification to improve control of hyperglycemia and cardiovascular risk factors, but long-term efficacy of this approach has not been established. This Review summarizes the current evidence on the association between prediabetes and neuropathy.

The general use of glycated haemoglobin for the diagnosis of diabetes and other categories of glucose intolerance: still a long way to go

Glycated haemoglobin (HbA(1c)) is considered the 'gold standard' for monitoring metabolic control in diabetes. An International Expert Committee recently recommended HbA(1c) as a better method than measurement of glucose to use in the diagnosis of diabetes, based on its strong association with microvascular complications, a lower day-to-day variability and ease of use, not necessarily in the fasting state. These recommendations have been embraced by the American Diabetes Association (ADA), which stated in its Standards of Medical Care in Diabetes 2010 that "A(1c), fasting plasma glucose or the 2 h 75 g oral glucose tolerance test (OGTT) are appropriate for testing diabetes and assessing the risk of future diabetes," and that "a confirmed A(1c) ≥ 6.5% is diagnostic for diabetes." Measuring HbA(1c) has several advantages over glucose measurements, but its exclusive use should only be considered if the test is conducted under standardised conditions and its limitations are taken into due account. The impact of its use on the epidemiology of diabetes and other categories of glucose intolerance, as seen from recent reports, is also discussed.

Diabetes, hyperglycemia and the management of cerebrovascular disease

PURPOSE OF REVIEW

Hyperglycemia is frequent in patients with cerebrovascular disease. This review article aims to summarize the recent evidence from observational studies that examined the adverse cerebrovascular effects of dysglycemic states as well as interventional studies assessing intensive management strategies for hyperglycemia.

RECENT FINDINGS

In recent years, diabetes, prediabetic states and insulin resistance and their association with cerebrovascular disease were an important focus of research. The cerebrovascular consequences of these metabolic abnormalities were found to extend beyond ischemic stroke to covert brain infarcts, other structural brain changes and to cognitive impairment with and without dementia. Interventional studies did not reveal that more intensive management of chronic hyperglycemia and of hyperglycemia in the setting of acute stroke improves outcome. There is clear evidence, however, that the overall management of multiple risk factors and behavior modification in patients with dysglycemia may reduce the burden of cerebrovascular disease.

SUMMARY

Observational studies reveal the growing burden and adverse cerebrovascular effects of dysglycemic states. Currently available interventional studies assessing more intensive strategies for the management of hyperglycemia did not prove, however, to be effective. We discuss the current evidence, pathophysiological considerations and management implications.

Cardiovascular disease mortality in Europeans in relation to fasting and 2-h plasma glucose levels within a normoglycemic range

OBJECTIVE

To study mortality in relation to fasting plasma glucose (FPG) and 2-h plasma glucose levels within the normoglycemic range.

RESEARCH DESIGN AND METHODS

Data from 19 European cohorts comprising 12,566 men and 10,874 women who had FPG <6.1 mmol/l and 2-h plasma glucose <7.8 mmol/l at baseline examination were analyzed. Multivariate-adjusted hazard ratios (HRs) and 95% CIs for deaths from cardiovascular disease (CVD), non-CVD, and all causes were estimated for individuals whose 2-h plasma glucose > FPG (group II) compared with those whose 2-h plasma glucose ≤ FPG (group I).

RESULTS

A total of 827 (246) CVD and 611 (351) non-CVD and 1,438 (597) all-cause deaths occurred in men (women). Group II was older and had higher BMI, blood pressure, and fasting insulin than group I. The multivariate-adjusted HRs (95% CIs) for CVD, non-CVD, and all-cause mortality were 1.22 (1.05-1.41), 1.09 (0.92-1.29), and 1.16 (1.04-1.30) in men and 1.40 (1.03-1.89), 0.99 (0.79-1.25), and 1.13 (0.94-1.35) in women, respectively, for group II as compared with group I. HRs were 1.25 (1.05-1.50), 1.09 (0.89-1.34), and 1.18 (1.03-1.35) in men and 1.60 (1.03-2.48), 1.05 (0.78-1.42), and 1.18 (0.93-1.51) in women, respectively, after additional adjustment for fasting insulin in a subgroup of individuals.

CONCLUSIONS

In individuals with both FPG and 2-h plasma glucose within the normoglycemic range, high 2-h plasma glucose was associated with insulin resistance and increased CVD mortality.

The Berlin ‘Cream&Sugar’ Study: the Prognostic Impact of an Oral Triglyceride Tolerance Test in Patients after Acute Ischaemic Stroke

Rationale

Stratification according to risk factors is crucial for secondary prevention after acute ischaemic stroke. Nonfasting triglyceride levels seem to be associated with stroke in the general population. However, the exact role of triglyceride levels for the risk of recurrent stroke is unknown.

Hypothesis

We hypothesise that the results of a standardised oral triglyceride tolerance test in the subacute setting (3–7 days) after the first ischaemic stroke are associated with the risk of recurrent stroke within 12 months after the index event.

Design

Prospective observational study.

Study outcome(s)

The primary end-point of the study is recurrent fatal or nonfatal stroke within 12 months. The secondary outcomes are myocardial infarction, coronary revascularisation, cardiovascular death (death due to any cardiovascular or cerebrovascular event), or a transient ischaemic attack within 12 months after the qualifying event.

Discussion

The study has the potential to change clinical practice. It will show whether the oral triglyceride tolerance test in the subacute setting is a useful tool to predict the risk of recurrent stroke.