Hyperglycemia-induced thrombin formation in diabetes. The possible role of oxidative stress

Health relevance of lowering postprandial glycaemia in the paediatric population through diet': results from a multistakeholder workshop

To summarize current knowledge and gaps regarding the role of postprandial glycaemic response in the paediatric population, a workshop was organized in June 2021 by the European branch of the International Life Science Institute (ILSI). This virtual event comprised of talks given by experts followed by in-depth discussions in breakout sessions with workshop participants. The main pre-specified topics addressed by the workshop organizing committee to the invited speakers and the workshop participants were: (1) the role of glycaemic responses for paediatric health, based on mechanistic insights from animal and human data, and long-term evidence from observational and intervention studies in paediatric populations, and (2) changes in metabolism and changes in dietary needs from infancy to adolescence. Each talk as well as the discussions were summarised, including the main identified research gaps. The workshop led to the consensus on the crucial role on health of postprandial glycaemic response in paediatric population. However, a lack of scientific data has been identified regarding detailed glucose and insulin profiles in response to foods commonly consumed by paediatric populations, as well as a lack of long-term evidence including the need for suitable predictors during childhood and adolescence to anticipate health effects during adulthood.

Glycemic Control and Plasma Levels of Pro-Inflammatory and Pro-Thrombotic Biomarkers in Diabetic Patients Presenting with Acute Pulmonary Embolism

Type I and type II diabetes are closely associated with a pro-inflammatory state and to a pro-thrombotic state. The role of glycemic control in pulmonary embolism (PE) is poorly understood and requires additional investigation. The aim of this study is to investigate the relationship between glycemic control and thrombo-inflammatory biomarkers in a PE patient cohort compared to normal samples. Demographic and clinical information for 86 diabetic patients and 106 non-diabetic patients presenting with acute PE was collected via retrospective chart review. Plasma levels of pro-inflammatory (C-reactive protein [CRP], tumor necrosis factor-alpha [TNF-α], interleukin-6 [IL-6]) and pro-thrombotic (d-dimer, plasminogen activator inhibitor-1 [PAI-1], tissue plasminogen activator [tPA], thrombin activatable fibrinolysis inhibitor [TAFI], von-Willebrand factor [vWF], endogenous glycosaminoglycans [GAGs]) biomarkers were drawn within 24 hours of diagnosis of acute PE. Data was also obtained for a population of healthy adult controls. All the pro-inflammatory and pro-thrombotic biomarkers were elevated in diabetic PE patients in comparison to healthy controls. None of the biomarkers were elevated in diabetic PE patients when compared to non-diabetic PE patients. There was no difference in the levels of the pro-inflammatory biomarkers according to glycemic control. The plasma level of TAFI was elevated in diabetic patients with poor glycemic control. Diabetic patients were more likely to have a more severe PE. These studies demonstrate that thrombo-inflammatory biomarkers are elevated in diabetic PE patients with associated comorbidities in comparison to normal individuals. However, there is no difference between the PE cohort alone in comparison to PE with diabetes. The role of TAFI within the continuum of diabetic vascular disease warrants additional investigation.

Analysis of co-expression gene network associated with intracranial aneurysm and type 2 diabetes mellitus

To screen for common target genes in intracranial aneurysms (IA) and type 2 diabetes mellitus (T2DM), construct a common transcriptional regulatory network to predict clusters of candidate genes involved in the pathogenesis of T2DM and IA, and identify the common neurovascular markers and pathways in T2DM causing IA. Microarray datasets (GSE55650, GSE25462, GSE26969, GSE75436, and GSE13353) from the GEO database were analyzed in this research. Screening of the IA and the T2DM datasets yielded a total of 126 DEGs, among which 78 were upregulated and 138 were downregulated. Functional enrichment analysis revealed that these DEGs were enriched for a total of 68 GO pathways, including extracellular matrix composition, coagulation regulation, hemostasis regulation, and collagen fiber composition pathways. We also constructed transcriptional regulatory networks, and identified key transcription factors involved in both the conditions. Univariate logistic regression analysis showed that ARNTL2 and STAT1 were significantly associated with the development of T2DM and IA, acting as the common neurovascular markers for both the diseases. In cellular experiments, hyperglycemic microenvironments exhibited upregulated STAT1 expression. STAT1 may be involved in the pathogenesis of IA in T2DM patients. Being the common neurovascular markers, STAT1 may acts as novel therapeutic targets for the treatment of IA and T2DM.

Organ-specific metabolic pathways distinguish prediabetes, type 2 diabetes, and normal tissues

Environmental and genetic factors cause defects in pancreatic islets driving type 2 diabetes (T2D) together with the progression of multi-tissue insulin resistance. Mass spectrometry proteomics on samples from five key metabolic tissues of a cross-sectional cohort of 43 multi-organ donors provides deep coverage of their proteomes. Enrichment analysis of Gene Ontology terms provides a tissue-specific map of altered biological processes across healthy, prediabetes (PD), and T2D subjects. We find widespread alterations in several relevant biological pathways, including increase in hemostasis in pancreatic islets of PD, increase in the complement cascade in liver and pancreatic islets of PD, and elevation in cholesterol biosynthesis in liver of T2D. Our findings point to inflammatory, immune, and vascular alterations in pancreatic islets in PD that are hypotheses to be tested for potential contributions to hormonal perturbations such as impaired insulin and increased glucagon production. This multi-tissue proteomic map suggests tissue-specific metabolic dysregulations in T2D.

Impact of Stress Hyperglycemia on No-Reflow Phenomenon in Patients with ST Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Background:

Stress hyperglycemia is a common finding during acute myocardial infarction and associated with poor prognosis. To reduce the occurrence of no-reflow, prognostic factors must be identified before primary percutaneous coronary intervention (PPCI). Our objective was to investigate the impact of stress hyperglycemia in non-diabetic and diabetic patients on no-reflow phenomenon after PPCI.

Methods:

The study comprised 480 patients with ST elevation myocardial infarction (STEMI) who were managed by PPCI. Patients were classified into two groups according to thrombolysis in myocardial infarction (TIMI) flow grade: Group I (Patients with normal flow, TIMI 3 flow) and Group II (Patients with no-reflow, TIMI 0-2 flow). Patients were analyzed for clinical outcomes including mortality and major adverse cardiac events.

Results:

Incidence of stress hyperglycemia was 14.8% in non-diabetic patients and 22.2% in diabetic patients; the incidence of no-reflow phenomenon was 13.5% and no-reflow was significantly higher in patients with stress hyperglycemia. Multivariate regression analysis identified the independent predictors of no-reflow phenomenon: stress hyperglycemia OR 3.247 (CI95% 1.656–6.368, P = 0.001), Killip class >1 OR 1.893 (CI95% 1.004–3.570, P = 0.049) and cardiogenic shock OR 3.778 (CI95% 1.458–9.790, P = 0.006).

Conclusion:

Stress hyperglycemia was associated with higher incidence of no-reflow phenomenon. The independent predictors of no-reflow were stress hyperglycemia, Killip class >1 and cardiogenic shock.

Hyperglycemia and Thrombocytopenia - Combinatorially Increase the Risk of Mortality in Patients With Acute Myocardial Infarction Undergoing Veno-Arterial Extracorporeal Membrane Oxygenation

Background: Patients with cardiogenic shock due to acute myocardial infarction (AMI) can rapidly undergo veno-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy to recover cardiac output and decrease mortality. However, the clinical indicators predictive of mortality in these patients remain unknown.

Methods and Results: We conducted a single-center retrospective cohort study targeting AMI patients undergoing VA-ECMO. All 63 patients undergoing VA-ECMO for AMI at the Japanese Red Cross Kumamoto Hospital between January 1, 2010 and June 30, 2020 were enrolled. An exploratory analysis was conducted using a survival tree model and variables selected in a univariate Cox proportional hazard model. The median survival time from the start of VA-ECMO was 6.3 days, and 77.8% (n=49) of patients died. Survival analysis divided patients into 3 groups based on 2 parameters at the initial medical examination: Group 1, patients with neither hyperglycemia (blood glucose ≥213 mg/dL) nor thrombocytopenia (platelets ≤145,100/μL); Group 2, patients with hyperglycemia; and Group 3, patients with hyperglycemia plus thrombocytopenia. Relative to Group 1, the risk of in-hospital mortality was significantly increased in Group 2 (hazard ratio [HR] 2.25; 95% confidence interval [CI] 1.13–4.46), and that risk further increased in Group 3 (HR 7.60; 95% CI 3.21–17.95).

Conclusions: Hyperglycemia plus thrombocytopenia on initial medical examination combinatorially increase the risk of mortality in patients with cardiogenic shock due to AMI undergoing VA-ECMO.

Investigating the hemostatic effect of medicinal plant Arnebia euchroma (Royle) I.M.Johnst extract in a mouse model

ETHNOPHARMACOLOGICAL RELEVANCE

Arnebia euchroma (Royle) I.M.Johnst (AE) has been reported to be a potentially useful medicinal herb for the treatment of several circulatory diseases in traditional Chinese medicine. It shows effects such as "cooling of the blood," promotion of blood circulation, detoxification, and rash clearance.

AIM OF THE STUDY

To explore the hemostatic effect of the ethyl acetate extract of AE in mice.

MATERIALS AND METHODS

In this study, we explored the effects of AE on bleeding time, blood coagulation time, platelet count, and blood coagulation parameters in normal Kunming mice. Different doses of the AE extract (5, 10, and 20 g kg^-1·day^-1) were administered to mice for 14 days. Sodium carboxymethyl cellulose (CMC-Na at 0.5%) and Yunnan Baiyao (0.8 g kg^-1·day^-1) were administered as negative and positive control treatments, respectively. Bleeding time, blood coagulation time, platelet count, blood platelet aggregation, blood platelet adhesion to fibrinogen, platelet factor 4 (PF-4) secretions from blood platelets, and blood coagulation parameters including prothrombin time (PT), activated partial thromboplastin time (aPTT), thrombin time (TT), and fibrinogen (FIB) levels were measured on day 15 of administration.

RESULTS

Bleeding and blood coagulation time were significantly lower and TT was shorter in the AE extract-treated groups than in the control groups. Furthermore, FIB levels and platelet count were higher, whereas blood platelet aggregation, blood platelet adhesion to fibrinogen, and PF-4 secretion from blood platelets were more obvious in the AE extract-treated groups than in the control group. However, no significant differences were detected for PT and aPTT between the extract-treated and control groups.

CONCLUSIONS

The ethyl acetate extract of AE showed potential hemostasis effects in mice by shortening the bleeding and coagulation time. In addition, the extract increased platelet count and induced blood platelet aggregation, blood platelet adhesion to fibrinogen, PF-4 secretion from blood platelets, and FIB level, while it shortened TT.

Pharmacological management of COVID-19 in type 2 diabetes

Evidence suggests that diabetes is one the most relevant comorbidity in affecting the prognosis of COVID-19. Albeit there are no specific trials nor subgroup analysis showing the effect of COVID-19 therapies in patients with diabetes, selected features of this disease and the side effects associated with certain drugs require a proper knowledge to optimize the pharmacological therapy of patients with diabetes and COVID-19. While chronic anti-hypertensive and glucose-lowering therapies should not be discontinued nor preferred for preventive purposes, the low-grade pro-inflammatory, the thrombosis-prone status of diabetes, the role of acute hyperglycaemia in promoting adverse outcomes in patients admitted to ICU, and the observed increased mortality in patients with poor long-term glycaemic control delineate a delicate balance in case of severe forms of COVID-19. Here, we briefly summarized some of the key pharmacological issues linked to the management of patients with diabetes and COVID-19, in order to provide indications to minimize the deleterious effects of the concomitant presentation of these diseases and to use the existing pharmacological options in an appropriate manner.

A Systematic Review of the Efficacy and Safety of Direct Oral Anticoagulants in Atrial Fibrillation Patients with Diabetes Using a Risk Index

Diabetes mellitus (DM) represents an independent risk factor for chronic AF and is associated with unfavorable outcomes. We aimed to evaluate the efficacy and safety of direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF), with and without diabetes mellitus (DM), using a new risk index (RI) defined as: RI =Rate of EventsRate of Patients at Risk. In particular, an RI lower than 1 suggests a favorable treatment effect. We searched MEDLINE, MEDLINE In-Process, EMBASE, PubMed, and the Cochrane Central Register of Controlled Trials. The risk index (RI) was calculated in terms of efficacy (rate of stroke/systemic embolism (stroke SEE)/rate of patients with and without DM; rate of cardiovascular death/rate of patients with and without DM) and safety (rate of major bleeding/rate of patients with and without DM) outcomes. AF patients with DM (n = 22,057) and 49,596 without DM were considered from pivotal trials. DM doubles the risk index for stroke/SEE, major bleeding (MB), and cardiovascular (CV) death. The RI for stroke/SEE, MB, and CV death was comparable in patients treated with warfarin or DOACs. The lowest RI was in DM patients treated with Rivaroxaban (stroke/SEE, RI = 0.08; CV death, RI = 0.13). The RIs for bleeding were higher in DM patients treated with Dabigatran (RI110 = 0.32; RI150 = 0.40). Our study is the first to use RI to homogenize the efficacy and safety data reported in the DOACs pivotal studies against warfarin in patients with and without DM. Anticoagulation therapy is effective and safe in DM patients. DOACs appear to have a better efficacy and safety profile than warfarin. The use of DOACs is a reasonable alternative to vitamin-K antagonists in AF patients with DM. The RI can be a reasonable tool to help clinicians choose between DOACs or warfarin in the peculiar set of AF patients with DM.

Stress-Induced Hyperglycaemia in Non-Diabetic Patients with Acute Coronary Syndrome: From Molecular Mechanisms to New Therapeutic Perspectives

Stress-induced hyperglycaemia (SIH) at hospital admission for acute coronary syndrome is associated with poor outcome, especially in patients without known diabetes. Nevertheless, insulin treatment in these subjects was not correlated with the reduction of mortality. This is likely due to the fact that SIH in the context of an acute coronary syndrome, compared to that in known diabetes, represents an epiphenomenon of other pathological conditions, such as adrenergic and renin-angiotensin system over-activity, hyperglucagonaemia, increase of circulating free fatty acids and pancreatic beta-cell dysfunction, which are not completely reversed by insulin therapy and so worsen the prognosis. Thus, SIH may be considered not only as a biomarker of organ damage, but also as an indicator of a more complex therapeutic strategy in these subjects. The aim of this review is to analyse the molecular mechanisms by which SIH may favour a worse prognosis in non-diabetic patients with acute coronary syndrome and identify new therapeutic strategies, in addition to insulin therapy, for a more appropriate treatment and improved outcomes.

Comparative Phytochemical, Antioxidant, and Hemostatic Studies of Extract and Four Fractions from Paulownia Clone in Vitro 112 Leaves in Human Plasma

Background: The Paulownia Clone in Vitro 112, known as oxytree or oxygen tree, is a hybrid clone of the species Paulownia elongata and Paulownia fortunei (Paulowniaceae). The oxytree is a fast-growing hybrid cultivar that can adapt to wide variations in edaphic and climate conditions. In this work, Paulownia Clone in Vitro 112 leaves were separated into an extract and four fractions (A–D) differing in chemical content in order to investigate their chemical content using LC-MS analysis. The extract and fractions were also evaluated for their anticoagulant and antioxidant properties in a human plasma in vitro. Results: The Paulownia leaf extract contained mainly phenolic compounds (e.g., verbascoside), small amounts of iridoids (e.g., aucubin or 7-hydroxytometoside) and triterpenoids (e.g., maslinic acid) were also detected. Our results indicate that the extract and fractions have different effects on oxidative stress in human plasma treated with H₂O₂/Fe in vitro, which could be attributed to differences in their chemical content. For example, the extract and all the fractions, at the two highest concentrations of 10 and 50 µg/mL, significantly inhibited the plasma lipid peroxidation induced by H₂O₂/Fe. Fractions C and D, at all tested concentrations (1–50 µg/mL) were also found to protect plasma proteins against H₂O₂/Fe-induced carbonylation. The positive effects of fraction C and D were dependent on the dose. Conclusions: The extract and all four fractions, but particularly fractions C and D, which are rich in phenolic compounds, are novel sources of antioxidants, with an inhibitory effect on oxidative stress in human plasma in vitro. Additionally, the antioxidant potential of fraction D may be associated with triterpenoids.

Evaluation of the Effects of Acarbose on Weight and Metabolic, Inflammatory, and Cardiovascular Markers in Patients with Obesity and Overweight

Background:

Metabolic syndrome (MetS) refers to a cluster of risk factors for cardiovascular disease and type 2 diabetes. The aim of this study is to assess the effects of acarbose as an antihyperglycemic agent (drug) on late complications of MetS.

Methods:

This double-blind randomized clinical trial was done on patients with MetS admitted to Isfahan Endocrine and Metabolism Research Center. They were assigned randomly to two groups: A who received acarbose (n = 32) and group B who received a placebo (n = 42) for 6 months. Cardiovascular indexes including flow-mediated dilation (FMD), intima-media thickness (IMT), epicardial fat thickness (EFT), and C-reactive protein (CRP) were measured at baseline and 6 months after the treatment and compared between the two groups.

Results:

Post-intervention mean of weight (mean difference: −2.5 ± 0.89) and abdominal obesity (mean difference: −2.2 ± 0.64) in acarbose group were significantly decreased (P value < 0.001). High-density lipoprotein (HDL) level in acarbose group was significantly higher than control group (44.7 ± 7.6 vs 41.1 ± 6.4; P value = 0.043), while the other metabolic parameters were not significantly different between the two groups (P value > 0.05). In both groups, CRP and EFT decreased significantly after the intervention, and the levels of CRP, EFT, and IMT markers in the acarbose group were significantly lower than control group (P value < 0.05).

Conclusions:

The administration of acarbose in patients with MetS can decrease weight and abdominal obesity as well as the reduction of inflammatory and cardiovascular markers, including CRP, EFT, and IMT and also increases HDL.

Issues for the management of people with diabetes and COVID-19 in ICU

In the pandemic “Corona Virus Disease 2019” (COVID-19) people with diabetes have a high risk to require ICU admission. The management of diabetes in Intensive Care Unit is always challenging, however, when diabetes is present in COVID-19 the situation seems even more complicated. An optimal glycemic control, avoiding acute hyperglycemia, hypoglycemia and glycemic variability may significantly improve the outcome. In this case, intravenous insulin infusion with continuous glucose monitoring should be the choice. No evidence suggests stopping angiotensin-converting-enzyme inhibitors, angiotensin-renin-blockers or statins, even it has been suggested that they may increase the expression of Angiotensin-Converting-Enzyme-2 (ACE2) receptor, which is used by “Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to penetrate into the cells. A real issue is the usefulness of several biomarkers, which have been suggested to be measured during the COVID-19. N-Terminal-pro-Brain Natriuretic-Peptide, D-dimer and hs-Troponin are often increased in diabetes. Their meaning in the case of diabetes and COVID-19 should be therefore very carefully evaluated. Even though we understand that in such a critical situation some of these requests are not so easy to implement, we believe that the best possible action to prevent a worse outcome is essential in any medical act.

Thrombin inhibition by dabigatran attenuates endothelial dysfunction in diabetic mice

Diabetic patients have coagulation abnormalities, in which thrombin plays a key role. Whereas accumulating evidence suggests that it also contributes to the development of vascular dysfunction through the activation of protease-activated receptors (PARs). Here we investigated whether the blockade of thrombin attenuates endothelial dysfunction in diabetic mice. Induction of diabetes by streptozotocin (STZ) increased the expression of PAR1, PAR3, and PAR4 in the aorta. STZ-induced diabetic mice showed impairment of endothelial function, while the administration of dabigatran etexilate, a direct thrombin inhibitor, significantly attenuated endothelial dysfunction in diabetic mice with no alteration of metabolic parameters including blood glucose level. Dabigatran did not affect endothelium-independent vasodilation. Dabigatran decreased the expression of inflammatory molecules (e.g., MCP-1 and ICAM-1) in the aorta of diabetic mice. Thrombin increased the expression of these inflammatory molecules and the phosphorylation of IκBα, and decreased the phosphorylation of eNOS^Ser1177 in human umbilical endothelial cells (HUVEC). Thrombin significantly impaired the endothelium-dependent vascular response of aortic rings obtained from wild-type mice. Inhibition of NF-κB attenuated thrombin-induced inflammatory molecule expression in HUVEC and ameliorated thrombin-induced endothelial dysfunction in aortic rings. Dabigatran attenuated the development of diabetes-induced endothelial dysfunction. Thrombin signaling may serve as a potential therapeutic target in diabetic condition.

The importance of measurement of plasma fibrinogen level among patients with type- 2 diabetes mellitus

BACKGROUND & AIM

Fibrinogen has been implicated as a cause of atherosclerosis and its complications in patients with type 2 DM. We aimed to measure the plasma fibrinogen level in type 2 diabetics and to correlate it with the duration, type of treatment, HbA1c, smoking, lipid profile, diabetic retinopathy, hypertension and ischemic heart disease in comparison to control.

METHODS

A case control single center study included 50 patients with type 2 DM between the ages of 35-85 y who were randomly selected from the medical units of Baghdad Teaching Hospital compared to 30 non-diabetics as a control. After taking verbal consents; plasma fibrinogen levels were estimated and correlated with aimed variables. Odds ratios with 95% CI were calculated and regression analysis was performed for correlations. P ≤ 0.05 was considered statistically significant.

RESULTS

There were statistically significant differences regarding total cholesterol, TG, and LDL between cases and control. Mean HbA1c of diabetics was 8.31 ± 1.75% (P < 0.001). Cases showed plasma fibrinogen of (4.01 ± 1.89 g/dL) compared to (2.79 ± 0.55 g/dL) of control (P < 0.001). ROC curve revealed that the AUC was (0.679 ± 0.06, 95%CI = 0.561-0.797, P < 0.008). The sensitivity and specificity of the test at cut off value of 3.05 g/dL were 0.62 and 0.567 respectively. There was a significant correlation between fibrinogen level and each of HbA1c (r = 0.497, P < 0.001) and TG (r = 0.359, P = 0.01).

CONCLUSIONS

HbA1c has a significant positive effect on plasma fibrinogen and it is important to measure plasma fibrinogen level in patients with type 2 DM.

Concerns about clinical efficacy and safety of warfarin in diabetic patients with atrial fibrillation

Atrial fibrillation (AF) is one of the most common arrhythmias in elderly people. The risk of thromboembolic stroke is increased in AF patients, especially those with diabetes. Anticoagulant therapy, such as warfarin and non-vitamin K oral anticoagulants (NOACs), is recommended for diabetic patients with AF. However, recent guidelines do not preferentially recommend NOACs over warfarin for diabetic patients. Variability of glycemic control in diabetic patients could affect the pharmacokinetics and anticoagulant activity of warfarin, therefore, the risk-benefit balance of warfarin is prone to be compromised in diabetic patients with AF. Furthermore, since warfarin inhibits the vitamin K-dependent gamma-glutamyl carboxylation of proteins, including osteocalcin and matrix Gla protein, use of warfarin may increase the risk of osteoporotic bone fracture and vascular calcification, both of which are the leading causes of morbidity that diminish the quality of life in diabetic patients. Even though the cost of NOACs is high, NOACs may be preferable to warfarin for the treatment of diabetic patients with AF.

Targeting One-Hour Postmeal Glucose: Is It Time for a Paradigm Switch in Diabetes Management?

In the management of diabetes, postprandial glycemia (PPG) is usually targeted 2 h after the start of meal. Recent evidences, however, suggest that the value of glycemia at 1 h during an oral glucose tolerance test (OGTT) is a stronger predictor for developing diabetes than the value at 2 h and that it is an independent risk factor for cardiovascular disease. Studies in cells, animals, and humans suggest that 1-h high glucose is a sufficient stimulus for increasing several cardiovascular risk factors, such as inflammation, thrombosis, and endothelial dysfunction, with oxidative stress generation as the possible pathogenetic factor. One-hour glucose might be more dangerous than that at 2 h simply because glycemia is higher at 1 h, during an OGTT and postmeal. The new drugs, able to target better 1 h glycemia and the new noninvasive technologies for glucose monitoring, nowadays may help to change the therapeutic paradigm of targeting PPG at 2 h.

Summation of blood glucose and TAG to characterise the ‘metabolic load index’

Research points to postprandial glucose and TAG measures as preferable assessments of cardiovascular risk as compared with fasting values. Although elevated postprandial glycaemic and lipaemic responses are thought to substantially increase chronic disease risk, postprandial glycaemia and lipaemia have historically only been considered separately. However, carbohydrates and fats can generally ‘compete’ for clearance from the stomach, small intestine, bloodstream and within the peripheral cell. Further, there are previous data demonstrating that the addition of carbohydrate to a high-fat meal blunts the postprandial lipaemic response, and the addition of fat to a high-carbohydrate meal blunts the postprandial glycaemic response. Thus, postprandial glycaemia and lipaemia are interrelated. The purpose of this brief review is 2-fold: first, to review the current evidence implicating postprandial glycaemia and lipaemia in chronic disease risk, and, second, to examine the possible utility of a single postprandial glycaemic and lipaemic summative value, which will be referred to as the metabolic load index. The potential benefits of the metabolic load index extend to the clinician, patient and researcher.

Acute Insulin Resistance in Myocardial Ischemia: Causes and Consequences

Diabetes mellitus is associated with increased risk for cardiovascular mortality because of multiple pathophysiologic mechanisms. Acute stress-induced hyper-glycemia during acute myocardial infarction has gained much attention, as blood glucose levels seem to be an independent risk factor for acute myocardial infarction–related death. Clinical studies that identify stress-induced hyperglycemia as a risk factor are reviewed and its causes are discussed. They can be summarized as the consequence of acute insulin resistance, which in its turn is caused by stress hormones and by proinflammatory cytokines. Hyperglycemia causes the release of proinflammatory cytokines, the induction of reactive radicals, alterations in cardiovascular substrate metabolism, and propagation of coagulation and apoptosis. These all have harmful effects during and after acute myocardial infarction. Recommendations are for strict glycemic control in hyperglycemic patients with acute myocar-dial infarction, although the target glucose level is still a subject of debate.

Options for Controlling Type 2 Diabetes during Ramadan

The Muslim population is about 1.5 billion worldwide. Based on a global diabetes prevalence of 4.6%, it is estimated that there are about 50 million Muslims with diabetes around the world who observe fasting during the month of Ramadan each year. Ramadan, one of the five pillars of Islam, and which takes place during the ninth month of the Islamic calendar, involves fasting from sunrise to sunset. During the fast, Muslims are required to refrain from eating food, drinking, using medications, and smoking from dawn until after sunset, with no restrictions on food or fluid intake between sunset and dawn. Islam exempts people from the duty of fasting if they are sick, or if fasting may affect their health, as fasting for patients with diabetes carries a risk of an assortment of complications, including hypoglycemia, postprandial hyperglycemia, and metabolic complications, associated with dehydration. Nevertheless, a large number of people with diabetes who still choose to fast during Ramadan despite the advice of their doctor, and the permission received from religious authorities thus create medical challenges for themselves and their health-care providers. It is thus important for patients with diabetes who wish to fast during Ramadan to make the necessary preparations to engage in fasting as safely as possible. This review presents a guide to the care of diabetic patients during Ramadan to help them fast safely if they wish to do so.

Anti-Diabetic Effects of Madecassic Acid and Rotundic Acid

Anti-diabetic effects of madecassic acid (MEA) and rotundic acid (RA) were examined. MEA or RA at 0.05% or 0.1% was supplied to diabetic mice for six weeks. The intake of MEA, not RA, dose-dependently lowered plasma glucose level and increased plasma insulin level. MEA, not RA, intake dose-dependently reduced plasminogen activator inhibitor-1 activity and fibrinogen level; as well as restored antithrombin-III and protein C activities in plasma of diabetic mice. MEA or RA intake decreased triglyceride and cholesterol levels in plasma and liver. Histological data agreed that MEA or RA intake lowered hepatic lipid droplets, determined by ORO stain. MEA intake dose-dependently declined reactive oxygen species (ROS) and oxidized glutathione levels, increased glutathione content and maintained the activity of glutathione reductase and catalase in the heart and kidneys of diabetic mice. MEA intake dose-dependently reduced interleukin (IL)-1β, IL-6, tumor necrosis factor-α and monocyte chemoattractant protein-1 levels in the heart and kidneys of diabetic mice. RA intake at 0.1% declined cardiac and renal levels of these inflammatory factors. These data indicated that MEA improved glycemic control and hemostatic imbalance, lowered lipid accumulation, and attenuated oxidative and inflammatory stress in diabetic mice. Thus, madecassic acid could be considered as an anti-diabetic agent.

Admission hyperglycemia is associated with failed reperfusion following fibrinolytic therapy in patients with STEMI: results of a retrospective study

BACKGROUND

Hyperglycemia on admission is associated with increased mortality rates in patients with ST-elevation myocardial infarction (STEMI) who are treated with either fibrinolytic therapy (FT) or primary percutaneous coronary intervention (PCI). However, data regarding the relationship between hyperglycemia and the success of FT are lacking. The aim of this study was to investigate the value of admission blood glucose for the prediction of failed reperfusion following FT.

METHODS AND RESULTS

This is a retrospective study of 304 STEMI patients who received FT and whose admission glucose levels were recorded. The main outcome measure was ST segment resolution≥50%. The median (interquartile range [IQR]) blood glucose level in the entire study group was 112 (95-153). In 92 (30.2%) patients, FT was unsuccessful and rescue PCI was performed. Admission glucose (126 [99-192] vs. 110 [94-144] mg/dL, p<0.001), time from symptom onset to FT (180 [120-270] vs. 150 [120-180] min, p=0.009), and maximum ST elevation amplitude (3 [2-7] vs. 3 [2-6] mm, p=0.05) were higher in the failed reperfusion group than in the reperfusion group. Admission hyperglycemia was an independent predictive factor for failed reperfusion (hazard ratio 4.79 [1.80-12.76], p=0.002), along with time from symptom onset to fibrinolysis and anterior wall myocardial infarction.

CONCLUSIONS

In patients with STEMI who undergo FT, admission hyperglycemia is an independent predictor of the failure of fibrinolysis.

Sphingosine-1-phosphate signalling as a therapeutic target for patients with abnormal glucose metabolism and ischaemic heart disease

Abnormalities of glucose metabolism in patients with ischaemic heart disease (IHD) are common and are associated with a poor outcome in patients with and without diabetes. Sphingosine-1-phosphate (S1P) is a bioactive lipid which has been shown to increase insulin sensitivity in rodents and to increase myocardial tolerance to ischaemia. In the present review, I explore the relevance of S1P signalling pathway to IHD and abnormalities in glucose tolerance, and its potential as a therapeutic target for patients with abnormal glucose metabolism and IHD.

Asiatic acid and maslinic acid protected heart via anti-glycative and anti-coagulatory activities in diabetic mice

The cardiac protective effects of asiatic acid (AA) and maslinic acid (MA) in diabetic mice were examined.

Overview of platelet physiology: its hemostatic and nonhemostatic role in disease pathogenesis

Platelets are small anucleate cell fragments that circulate in blood playing crucial role in managing vascular integrity and regulating hemostasis. Platelets are also involved in the fundamental biological process of chronic inflammation associated with disease pathology. Platelet indices like mean platelets volume (MPV), platelets distributed width (PDW), and platelet crit (PCT) are useful as cheap noninvasive biomarkers for assessing the diseased states. Dynamic platelets bear distinct morphology, where α and dense granule are actively involved in secretion of molecules like GPIIb , IIIa, fibrinogen, vWf, catecholamines, serotonin, calcium, ATP, ADP, and so forth, which are involved in aggregation. Differential expressions of surface receptors like CD36, CD41, CD61 and so forth have also been quantitated in several diseases. Platelet clinical research faces challenges due to the vulnerable nature of platelet structure functions and lack of accurate assay techniques. But recent advancement in flow cytometry inputs huge progress in the field of platelets study. Platelets activation and dysfunction have been implicated in diabetes, renal diseases, tumorigenesis, Alzheimer's, and CVD. In conclusion, this paper elucidates that platelets are not that innocent as they keep showing and thus numerous novel platelet biomarkers are upcoming very soon in the field of clinical research which can be important for predicting and diagnosing disease state.

Hyperglycemia following recovery from hypoglycemia worsens endothelial damage and thrombosis activation in type 1 diabetes and in healthy controls

BACKGROUND AND AIMS

Hypoglycemia produces thrombosis activation, but little attention has been paid to the effects of hyperglycemia following recovery from hypoglycemia on thrombosis activation.

METHODS AND RESULTS

In both twenty-two healthy subjects and twenty-one matched persons with type 1 diabetes, recovery from a 2-h induced hypoglycemia was obtained by reaching normo-glycemia or hyperglycemia for another 2 h. After this, normal glycemia was maintained for the following 6 h. Hyperglycemia after hypoglycemia was also repeated with the concomitant infusion of vitamin C. In both controls and people with diabetes, the recovery with normo-glycemia was accompanied by a significant improvement of Von Willebrand factor (vWF), prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin III-complexes (TAT), P-selectin, plasminogen activator inhibitor-1 (PAI-1), nitrotyrosine and 8-iso-prostaglandin F2α (8-iso-PGF2α) (p < 0.01 vs hypoglycemia for all the parameters), all directly affected by hypoglycemia itself (p < 0.01 vs baseline for all the parameters). On the contrary, the recovery with hyperglycemia after hypoglycemia worsens all these parameters (p < 0.01 vs normoglycemia for all the parameters), an effect persisting even after the additional 6 h of normo-glycemia. The effect of hyperglycemia following hypoglycemia was partially counterbalanced when vitamin C was infused (p < 0.01 vs hyperglycemia alone for all the parameters), suggesting that hyperglycemia following hypoglycemia may activate thrombosis through the oxidative stress production.

CONCLUSION

This study shows that, in type 1 diabetes as well as in controls, the way in which recovery from hypoglycemia takes place could play an important role in favoring the activation of thrombosis and oxidative stress, widely recognized cardiovascular risk factors.

Association of activated partial thromboplastin time and fibrinogen level in patients with type II diabetes mellitus

Background

Patients with diabetes mellitus have a high risk of atherothrombotic events. Diabetes contributes for initiation and progression of microvascular and macrovascular complications. Shortened activated partial thromboplastin time (aPTT) values may reflect hypercoaguable state, which is associated with increased thrombotic risk and adverse cardiovascular events. Increased level of fibrinogen is common in type II diabetes. The present study was conducted to study the aPTT and fibrinogen levels in diabetics in a tertiary care Teaching Hospital of Nepal.

Methods

Observational study was performed at out-patients visiting Pathology Department at Tribhuvan University Teaching Hospital from August 5 to September 7, 2012. Research protocol was approved by Institutional Review Board at Tribhuvan University Institute of Medicine. Altogether 90 people who came to the hospital during study period and who met inclusion criteria were selected, out of which 72 were diabetics and 18 were normal controls. Diabetic cases were identified via verbal interview with patients themselves and review of laboratory findings and diagnosis performed by their physicians. Diabetics with a diabetic history of more than one year and stabilized with antidiabetic medicines such as insulin, metformin, glibenclamide, and gliclazide and diabetics with controlled diabetes as revealed by HbA_1c in the range 6.2-7% were taken for the study purpose. Data were analyzed with chi square test and Fischer’s exact test (when each cell frequency was less than 5) using Statistical Package for Social Sciences 17.

Results

Maximum (53; 73.6%) diabetics and all non-diabetics had aPTT in the range 26–40 seconds. Maximum (51; 70.8%) patients had fibrinogen beyond 351 whereas all non-diabetics had fibrinogen in the range 151–350. Mean aPTT values of the diabetic patients and non-diabetic persons were 29.88 ± 4.89 seconds and 32.44 ± 2.25 seconds respectively. Mean fibrinogen values of the diabetic patients and non-diabetic persons were 388.57 ± 60.90 mg/dL and 320.89 ± 10.20 mg/dL respectively. Test data identified in results were statistically significant for aPTT (p value 0.000) and fibrinogen (p value 0.000) between the diabetics and non-diabetics.

Conclusions

Diabetics have an increased level of fibrinogen and relatively shortened aPTT as compared to the non-diabetic patients.

Glucose-induced metabolic memory in Schwann cells: prevention by PPAR agonists

A major barrier in reversing diabetic complications is that molecular and pathologic effects of elevated glucose persist despite normalization of glucose, a phenomenon referred to as metabolic memory. In the present studies we have investigated the effects of elevated glucose on Schwann cells, which are implicated in diabetic neuropathy. Using quantitative PCR arrays for glucose and fatty acid metabolism, we have found that chronic (>8 wk) 25 mM high glucose induces a persistent increase in genes that promote glycolysis, while inhibiting those that oppose glycolysis and alternate metabolic pathways such as fatty acid metabolism, the pentose phosphate pathway, and trichloroacetic acid cycle. These sustained effects were associated with decreased peroxisome proliferator-activated receptor (PPAR)γ binding and persistently increased reactive oxygen species, cellular NADH, and altered DNA methylation. Agonists of PPARγ and PPARα prevented select effects of glucose-induced gene expression. These observations suggest that Schwann cells exhibit features of metabolic memory that may be regulated at the transcriptional level. Furthermore, targeting PPAR may prevent metabolic memory and the development of diabetic complications.

Free fatty acids inhibit TM-EPCR expression through JNK pathway: an implication for the development of the prothrombotic state in metabolic syndrome

Metabolic syndrome is associated with significant hypercoagulable prothrombotic tendency; however, the mechanism for the prothrombotic state is not completely understood. We hypothesize that higher circulating plasma free fatty acids (FFAs) in metabolic syndrome inhibit the endothelial thrombomodulin (TM)-endothelial protein C receptor (EPCR) pathway, thereby promoting thrombus formation. Human umbilical vein endothelial cells were cultured in media supplemented with various doses of palmitic acid (PA), in the presence or absence of JNK inhibitor, and the expression of TM and EPCR was measured by western blot. The thrombotic state of high fat fed C57BL/6J mice was examined by tail bleeding time and deep venous thrombosis (DVT) model. As a result, PA inhibited the expression of TM and EPCR in endothelial cells, and this effect was blunted by inhibiting JNK signaling. High fat diet fed mice had higher level of circulating FFAs and exhibited prothrombotic state, evidenced by increased tail bleeding time and enlarged thrombotic size in DVT model, compared to the control diet fed mice. Hence, FFAs inhibit TM-EPCR-Protein C system in endothelial cells through activating JNK signaling, which may be a mechanism for the prothrombotic state in metabolic syndrome.

Cardiometabolic aspects of the polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder amongst women of reproductive age and is associated with various metabolic perturbations, in addition to chronic anovulation and factors related to androgen excess. In general, women live longer than men and develop cardiovascular disease at an older age. However, women with PCOS, as compared with age- and body mass index-matched women without the syndrome, appear to have a higher risk of insulin resistance, hyperinsulinemia, glucose intolerance, dyslipidemia, and an increased prothrombotic state, possibly resulting in a higher rate of type 2 diabetes mellitus, fatty liver disease, subclinical atherosclerosis, vascular dysfunction, and finally cardiovascular disease and mortality. Further alterations in PCOS include an increased prevalence of sleep apnea, as well as various changes in the secretion and/or function of adipokines, adipose tissue-derived proinflammatory factors and gut hormones, all of them with direct or indirect influences on the complex signaling network that regulates metabolism, insulin sensitivity, and energy homeostasis. Reviews on the cardiometabolic aspects of PCOS are rare, and our knowledge from recent studies is expanding rapidly. Therefore, it is the aim of the present review to discuss and to summarize the current knowledge, focusing on the alterations of cardiometabolic factors in women with PCOS. Further insight into this network of factors may facilitate finding therapeutic targets that should ameliorate not only ovarian dysfunction but also the various cardiometabolic alterations related to the syndrome.

Postprandial dysmetabolism and the heart

Epidemiologic evidence indicates that abnormal elevations in glycemia and lipidemia after a meal, termed postprandial dysmetabolism, are linked with increased risk of morbidity and mortality due to cardiovascular disease in individuals with or without type 2 diabetes. Both postprandial hyperglycemia and postprandial hyperlipidemia are independently associated with deteriorating endothelial function and vascular damage, which are likely mediated by increased oxidative stress and are more pronounced when both derangements coexist. Pharmacotherapies that target postprandial hyperglycemia and/or postprandial dyslipidemia are likely to improve endothelial function, which may have positive implications for cardiovascular outcomes.

Thrombin induces MCP-1 expression through Rho-kinase and subsequent p38MAPK/NF-κB signaling pathway activation in vascular endothelial cells

Thrombin has been shown to increase expression of chemokines such as monocyte chemoattractant protein 1 (MCP-1) in endothelial cells, leading to the development of atherosclerosis. However, the precise mechanism of this induction remains unknown. In the present study, we investigated whether the small G protein RhoA, and its effector, Rho-kinase are involved in MCP-1 induction by thrombin in endothelial cells. Y-27632, a specific Rho-kinase inhibitor, potently inhibited MCP-1 induction by thrombin. Y-27632 significantly decreased the chemotactic activity of thrombin-stimulated supernatants of endothelial cells on monocytes. Importantly, fasudil, a specific Rho-kinase inhibitor, attenuated MCP-1 gene expression in the aorta of db/db mice. Y-27632 attenuated thrombin-mediated phosphorylation of p38MAPK and p65, indicating that Rho-kinase mediates thrombin-induced MCP-1 expression through p38MAPK and NF-κB activation. Our findings demonstrate that the Rho/Rho-kinase signaling pathway plays a critical role in thrombin-mediated MCP-1 expression and function, and suggest that Rho/Rho-kinase may be an important target in the development of new therapeutic strategies for atherosclerosis.

Diabetes does not alter mortality or hemostatic and inflammatory responses in patients with severe sepsis

OBJECTIVE

Diabetes patients have an increased risk of sepsis. Several inflammatory and coagulant pathways that are activated during sepsis are also up-regulated in diabetes patients. We tested our a priori hypothesis that the presence of diabetes adversely affects the outcome of sepsis.

DESIGN

Retrospective analysis of a previously published study.

SETTING

Intensive care units of 164 centers in 11 countries.

PATIENTS

Eight hundred thirty severe sepsis patients who were admitted to the intensive care unit and who received standard critical care treatment.

INTERVENTIONS

Patients were stratified into diabetic and nondiabetic patient groups. Mortality was assessed after 28 and 90 days, causative microorganisms were evaluated, and markers of coagulation, fibrinolysis, and inflammation were measured at several time points.

MEASUREMENTS AND MAIN RESULTS

Diabetes was present in 22.7% of all sepsis patients. Throughout the study, plasma glucose levels were higher in diabetic patients. Mortality was equal in diabetic and nondiabetic patients (31.4% vs. 30.5% after 28 days). Markers of coagulation, fibrinolysis, and inflammation were generally equal in diabetic and nondiabetic patients, although on admission diabetic patients had slightly higher levels of anticoagulation markers. Interestingly, nondiabetic patients with admission hyperglycemia (>11.1 mmol/L; 200 mg/dL) had a higher mortality rate compared to those without admission hyperglycemia (43.0% vs. 27.2%).

CONCLUSIONS

Although diabetes is a risk factor for sepsis, once established, the outcome of severe sepsis does not appear to be significantly influenced by the presence of diabetes. In nondiabetic patients, however, admission hyperglycemia is associated with an increased mortality.

An overview of glycemic control in the coronary care unit with recommendations for clinical management

The observation that elevated glucose occurs frequently in the setting of acute myocardial infarction was made decades ago. Since then numerous studies have documented that hyperglycemia is a powerful risk factor for increased mortality and in-hospital complications in patients with acute coronary syndromes. While some questions in this field have been answered in prior investigations, many critical gaps in knowledge continue to exist and remain subjects of intense debate. This review summarizes what is known about the relationship between hyperglycemia, glucose control, and outcomes in critically ill patients with acute coronary syndromes, addresses the gaps in knowledge and controversies, and offers general recommendations regarding glucose management in the coronary care unit.

Acute effects of dietary glycemic index on antioxidant capacity in a nutrient-controlled feeding study

Oxidative stress, caused by an imbalance between antioxidant capacity and reactive oxygen species, may be an early event in a metabolic cascade elicited by a high glycemic index (GI) diet, ultimately increasing the risk for cardiovascular disease and diabetes. We conducted a feeding study to evaluate the acute effects of low-GI compared with high-GI diets on oxidative stress and cardiovascular disease risk factors. The crossover study comprised two 10-day in-patient admissions to a clinical research center. For the admissions, 12 overweight or obese (BMI: 27-45 kg/m(2)) male subjects aged 18-35 years consumed low-GI or high-GI diets controlled for potentially confounding nutrients. On day 7, after an overnight fast and then during a 5-h postprandial period, we assessed total antioxidant capacity (total and perchloric acid (PCA) protein-precipitated plasma oxygen radical absorbance capacity (ORAC) assay) and oxidative stress status (urinary F(2alpha)-isoprostanes (F(2)IP)). On day 10, we measured cardiovascular disease risk factors. Under fasting conditions, total antioxidant capacity was significantly higher during the low-GI vs. high-GI diet based on total ORAC (11,736 +/- 668 vs. 10,381 +/- 612 micromol Trolox equivalents/l, P = 0.002) and PCA-ORAC (1,276 +/- 96 vs. 1,210 +/- 96 micromol Trolox equivalents/l, P = 0.02). Area under the postprandial response curve also differed significantly between the two diets for total ORAC and PCA-ORAC. No diet effects were observed for the other variables. Enhancement in plasma total antioxidant capacity occurs within 1 week on a low-GI diet, before changes in other risk factors, raising the possibility that this phenomenon may mediate, at least in part, the previously reported effects of GI on health.

Anticoagulatory, antiinflammatory, and antioxidative effects of protocatechuic acid in diabetic mice

Content of protocatechuic acid (PA) in eight locally available fresh fruits was analyzed, and the protective effects of this compound in diabetic mice were examined. PA at 1%, 2%, and 4% was supplied to diabetic mice for 8 weeks. PA treatments significantly lowered plasma glucose and increased insulin levels. PA treatments at 2% and 4% significantly lowered plasminogen activator inhibitor-1 activity and fibrinogen level; increased plasma activity of antithrombin-III and protein C; decreased triglyceride content in plasma, heart, and liver; elevated glutathione level and the retention of glutathione peroxidase and catalase activities in heart and kidney. PA treatments at 2% and 4% also significantly lowered plasma C-reactive protein and von Willebrand factor levels and reduced interleukin-6, tumor necrosis factor-alpha, and monocyte chemoattractant protein-1 levels in heart and kidney. These results support that protocatechuic acid could attenuate diabetic complications via its triglyceride-lowering, anticoagulatory, antioxidative, and antiinflammatory effects.

Intensive metabolic support: evolution and revolution

OBJECTIVE

To describe a new aspect of critical care termed intensive metabolic support.

METHODS

We performed a MEDLINE search of the English-language literature published between 1995 and 2008 for studies regarding the metabolic stages of critical illness, intensive insulin treatment, and intensive metabolic support in the intensive care unit, and we summarize the clinical data.

RESULTS

Intensive metabolic support is a 3-component model involving metabolic control and intensive insulin therapy, early nutrition support, and nutritional pharmacology aimed at preventing allostatic overload and the development of chronic critical illness. To improve clinical outcome and prevent mortality, intensive metabolic support should start on arrival to the intensive care unit and should end only when patients are in the recovery phase of their illness.

CONCLUSIONS

Intensive metabolic support should be an essential part of the daily treatment strategy in critical care medicine. This will involve a newfound and extensive collaboration between the endocrinologist and the intensivist. We call for well-designed future studies involving implementation of this protocol to decrease the burden of chronic critical illness.

Elevated admission glucose and mortality in elderly patients hospitalized with heart failure

BACKGROUND

Although some professional societies recommend target-driven glucose control for all hospitalized patients, the association between elevated glucose and adverse outcomes has not been well established in patients hospitalized with heart failure.

METHODS AND RESULTS

We evaluated a nationally representative cohort of 50,532 elderly patients hospitalized with heart failure in the United States between April 1998 and June 2001. The association between admission glucose and all-cause mortality at 30 days and 1 year was analyzed with multivariable Cox regression models, both in the entire cohort and in patients with and without diabetes mellitus. After multivariable adjustment, no significant relationship was found between glucose and 30-day mortality (for glucose groups of >110 to 140, >140 to 170, >170 to 200, and >200 mg/dL; hazard ratios for 30-day mortality were 1.09 (95% confidence interval, 0.98 to 1.22), 1.27 (95% confidence interval, 1.11 to 1.45), 1.16 (95% confidence interval, 0.98 to 1.37), and 1.00 (95% confidence interval, 0.87 to 1.15), respectively, versus glucose < or =110 mg/dL; P for linear trend=0.53). Results were similar for 1-year mortality and did not differ between patients with and without known diabetes mellitus (for diabetesxglucose interaction, P=0.11 and 0.55 for 30-day and 1-year mortality, respectively).

CONCLUSIONS

We found no significant association between admission glucose levels and mortality in a large cohort of patients hospitalized with heart failure. Our findings suggest that the relationship between hyperglycemia and adverse outcomes seen in acute myocardial infarction cannot be automatically extended to patients hospitalized with other cardiovascular conditions.

High levels of plasma malondialdehyde, protein carbonyl, and fibrinogen have prognostic potential to predict poor outcomes in patients with diabetic foot wounds: a preliminary communication

Diabetic foot ulcer (DFU) is the leading cause of lower extremity amputation and is generally known to have poor prognosis. Oxidative stress is considered important in the pathogenesis of chronic wounds. Fibrinogen is a recognized marker in peripheral vascular disease; increasing levels predict an increased mortality and risk of amputation. The aim of this study was to evaluate if plasma malondialdehyde (MDA), protein carbonyl (PC) and fibrinogen levels can be used as prognostic markers in patients with DFU. The study design was prospective, nonrandomized, and controlled. A total of 41 DFU grade 1 and 20 DFU grade 2 patients were studied in this case-control study. Diabetic controls without foot ulcers and healthy controls were also studied. Plasma MDA, PC, and fibrinogen levels were significantly higher in patients with DFU compared with those without ulcers (P < .05) and nondiabetic controls (P < .001). These parameters increased in association with DFU grade (P < .01). Increased levels of plasma fibrinogen, MDA, and PC correlated with worsened outcomes. An augmented oxidative stress and plasma fibrinogen level >300.4 mg% (95% confidence interval, 100% sensitivity, 99.2% specificity) was correlated with a high risk of amputation in DFU.

Prevalence, incidence, and clinical resolution of insulin resistance in critically ill patients: an observational study

BACKGROUND

The primary objective of this study was to measure the prevalence, incidence, and resolution of insulin resistance (IR) in critically ill patients. A secondary objective was to explore the relationship between IR and inflammatory cytokines, coagulation abnormalities, and clinical outcomes.

DESIGN

Prospective observational study.

METHODS

The setting was the medical/surgical intensive care unit (ICU). We enrolled consecutive patients within 24 hours of admission to the ICU. Blood samples were collected daily until discharge, death, or a maximum of 10 days, then sent for measurement of markers of IR, inflammation, and coagulation. Charts were reviewed retrospectively to determine clinical outcomes. The homeostasis model assessment method (HOMA) was used to determine IR; a score of > or = 4 represents insulin resistance.

RESULTS

A total of 96 patients were enrolled. Upon admission, 64 (67%) patients had overt IR (glucose > 7 mmol/L or insulin use), 9 (9.4%) had non-overt IR (normal glucose but HOMA > 4), and 23 (24%) were insulin sensitive (IS; normal glucose and HOMA < 4). During the course of ICU stay, an additional 16 patients developed overt IR, while 10 (10%) remained IS. There were no significant differences in inflammatory markers, coagulation tests, and clinical outcomes between IR and IS patients. There was no significant correlation between HOMA and inflammatory markers and coagulation markers. In a multivariable regression model, only interleukin-6 levels were significantly associated with mortality.

CONCLUSIONS

A high proportion of critically ill patients have IR. There may not be any significant relationship between IR and measures of inflammation, coagulation, and clinical outcomes in a heterogeneous population of critically ill patients.

Effect of insulin therapy on coagulation and fibrinolysis in medical intensive care patients

OBJECTIVE

Most intensive care deaths beyond the first few days of critical illness are attributable to nonresolving organ failure, either due to or coinciding with sepsis. One of the mechanisms that is thought to contribute to the pathogenesis of organ failure is microvascular thrombosis. Recently, we reported significant improved survival and prevention of organ failure with the use of intensive insulin therapy to maintain normoglycemia for at least several days. We hypothesize that intensive insulin therapy also prevents severe coagulation abnormalities thereby contributing to less organ failure and better survival.

DESIGN

This was a preplanned subanalysis of a large randomized controlled study, conducted at a university hospital medical intensive care unit. The intervention was strict blood glucose control to normoglycemia with insulin.

RESULTS

Mortality of intensive insulin-treated patients was lower than that of conventionally treated patients for all classes of upon-admission disseminated intravascular coagulation (DIC) scores, except for those patients with overt DIC scores of 6 or higher (for DIC < 5, p = 0.003; for DIC > or = 5, p = 0.4). There was no effect of insulin therapy on any of the fibrinolytic, coagulation, or inflammatory parameters tested.

CONCLUSIONS

This negative observation does not support a key role for these systems in explaining the clinical benefit of intensive insulin therapy, although a short-lived effect within 5 days of treatment cannot be excluded.

Effects of glucose tolerance on the changes provoked by glucose ingestion in microvascular function

AIMS/HYPOTHESIS

Hyperglycaemia and hyperinsulinaemia have opposite effects on endothelium-dependent vasodilatation in microcirculation, but the net effect elicited by glucose ingestion and the separate influence of glucose tolerance are unknown.

METHODS

In participants with normal glucose tolerance (NGT), impaired glucose tolerance (IGT) or diabetic glucose tolerance, multiple plasma markers of both oxidative stress and endothelial activation, and forearm vascular responses (plethysmography) to intra-arterial acetylcholine (ACh) and sodium nitroprusside (SNP) infusions were measured before and after glucose ingestion. In another IGT group, we evaluated the time-course of the skin vascular responses (laser Doppler) to ACh and SNP (by iontophoresis) 1, 2 and 3 h into the OGTT; the plasma glucose profile was then reproduced by means of a variable intravenous glucose infusion and the vascular measurements repeated.

RESULTS

Following oral glucose, plasma antioxidants were reduced by 5% to 10% (p < 0.01) in all patient groups. The response to acetylcholine was not affected by glucose ingestion in any group, while the response to SNP was attenuated, particularly in the IGT group. The ACh:SNP ratio was slightly improved therefore in all groups, even in diabetic participants, in whom it was impaired basally. A time-dependent improvement in ACh:SNP ratio was also observed in skin microcirculation following oral glucose; this improvement was blunted when matched hyperglycaemia was coupled with lower hyperinsulinaemia (intravenous glucose).

CONCLUSIONS/INTERPRETATION

Regardless of glucose tolerance, oral glucose does not impair endothelium-dependent vasodilatation either in resistance arteries or in the microcirculation, despite causing increased oxidative stress; the endogenous insulin response is probably responsible for countering any inhibitory effect on vascular function.