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

Expression of TNFR1, VEGFA, CD147 and MCT1 as early biomarkers of diabetes complications and the impact of aging on this profile

Hyperglycemia leads to microvascular lesions in various tissues. In diabetic nephropathy-DN, alterations in usual markers reflect an already installed disease. The study of new biomarkers for the early detection of diabetic complications can bring new prevention perspectives. Rats were divided into diabetic adult-DMA-or elderly-DME and control sham adult-CSA-or control sham elderly-CSE. Blood and urine samples were collected for biochemical analysis. Bulbar region, cardiac, hepatic and renal tissues were collected for target gene expression studies. As result, DMA showed decreased TNFR1, MCT1 and CD147 expression in the bulbar region, TNFR1 in the heart, VEGFA and CD147 in the kidney and TNFR1 in blood. Positive correlations were found between TNFR1 and MCT1 in the bulbar region and HbA1c and plasma creatinine, respectively. DME showed positive correlation in the bulbar region between TNFR1 and glycemia, in addition to negative correlations between CD147 in the heart versus glycemia and urea. We concluded that the initial hyperglycemic stimulus already promotes changes in the expression of genes involved in the inflammatory and metabolic pathways, and aging alters this profile. These changes prior to the onset of diseases such as DN, show that they have potential for early biomarkers studies.

A Machine-Generated View of the Role of Blood Glucose Levels in the Severity of COVID-19

SARS-CoV-2 started spreading toward the end of 2019 causing COVID-19, a disease that reached pandemic proportions among the human population within months. The reasons for the spectrum of differences in the severity of the disease across the population, and in particular why the disease affects more severely the aging population and those with specific preconditions are unclear. We developed machine learning models to mine 240,000 scientific articles openly accessible in the CORD-19 database, and constructed knowledge graphs to synthesize the extracted information and navigate the collective knowledge in an attempt to search for a potential common underlying reason for disease severity. The machine-driven framework we developed repeatedly pointed to elevated blood glucose as a key facilitator in the progression of COVID-19. Indeed, when we systematically retraced the steps of the SARS-CoV-2 infection, we found evidence linking elevated glucose to each major step of the life-cycle of the virus, progression of the disease, and presentation of symptoms. Specifically, elevations of glucose provide ideal conditions for the virus to evade and weaken the first level of the immune defense system in the lungs, gain access to deep alveolar cells, bind to the ACE2 receptor and enter the pulmonary cells, accelerate replication of the virus within cells increasing cell death and inducing an pulmonary inflammatory response, which overwhelms an already weakened innate immune system to trigger an avalanche of systemic infections, inflammation and cell damage, a cytokine storm and thrombotic events. We tested the feasibility of the hypothesis by manually reviewing the literature referenced by the machine-generated synthesis, reconstructing atomistically the virus at the surface of the pulmonary airways, and performing quantitative computational modeling of the effects of glucose levels on the infection process. We conclude that elevation in glucose levels can facilitate the progression of the disease through multiple mechanisms and can explain much of the differences in disease severity seen across the population. The study provides diagnostic considerations, new areas of research and potential treatments, and cautions on treatment strategies and critical care conditions that induce elevations in blood glucose levels.

Verapamil as an Adjunct Therapy to Reduce tPA Toxicity in Hyperglycemic Stroke: Implication of TXNIP/NLRP3 Inflammasome

Thrombolytic therapy has remained quite challenging in hyperglycemic patients for its association with poor prognosis and increased hemorrhagic conversions. We recently showed that tissue plasminogen activator (tPA)-induced cerebrovascular damage is associated with thioredoxin-interacting protein (TXNIP) upregulation, which has an established role in the detrimental effects of hyperglycemia. In the present work, we investigated whether verapamil, an established TXNIP inhibitor, may provide protection against hyperglycemic stroke and tPA-induced blood-brain barrier (BBB) disruption. Acute hyperglycemia was induced by intraperitoneal administration of 20% glucose, 15 min prior to transient middle cerebral artery occlusion (tMCAO). Verapamil (0.15 mg/kg) or saline was intravenously infused with tPA at hyperglycemic reperfusion, 1 h post tMCAO. After 24 h of ischemia/reperfusion (I/R), mice were assessed for neurobehavioral deficits followed by sacrifice and evaluation of brain infarct volume, edema, and microbleeding. Alterations in TXNIP, inflammatory mediators, and BBB markers were further analyzed using immunoblotting or immunostaining techniques. As adjunctive therapy, verapamil significantly reduced tPA-induced BBB leakage, matrix metalloproteinase 9 (MMP-9) upregulation, and tight junction protein deregulation, which resulted in lesser hemorrhagic conversions. Importantly, verapamil strongly reversed tPA-induced TXNIP/NLRP3 (NOD-like receptor pyrin domain-containing-3) inflammasome activation and reduced infarct volume. This concurred with a remarkable decrease in high-mobility group box protein 1 (HMGB-1) and nuclear factor kappa B (NF-κB) stimulation, leading to less priming of NLRP3 inflammasome. This preclinical study supports verapamil as a safe adjuvant that may complement thrombolytic therapy by inhibiting TXNIP's detrimental role in hyperglycemic stroke.

Assessment of the relation between the neutrophil to lymphocyte ratio and severity of ischemic stroke in a large cohort

AIM OF STUDY

The NLR is a simple and inexpensive parameter that is useful as a marker of subclinical inflammation. The purpose of this study was to investigate the clinical characteristics of patients diagnosed with acute cerebral ischemia at the time of initial evaluation in the emergency department.

PATIENTS AND METHODS

The study was designed as a multicentre cross-sectional study of acute ischemic stroke patients. Neurological evaluations were assessed using the NIHSS and mRS. Evaluations included the results of patients' laboratory tests performed at the time of presentation to the emergency department.

RESULTS

Seven hundred and thirty-five ischemic stroke patients were included in the study. Stroke cases assessed by the mRS as mild or severe showed significant differences with respect to age, leukocyte counts, neutrophil counts, NLR, LDL cholesterol values, and serum glucose values (P = .001). When analysed using NIHSS, lymphocyte levels were significantly higher in very severe stroke cases compared with mild, moderate, and severe cases. NLR was also significantly higher in very severe stroke cases and severe stroke cases as compared with the mild and moderate stroke groups. Neurological evaluations assessed using the mRS showed a mild positive correlation with neutrophil and leukocyte count and a weak correlation with the NLR.

CONCLUSION

The NLR exhibited a significant correlation with the results of the mRS and NIHSS. The NLR measured in the very early period was also significantly associated with clinical condition. These results suggest that high NLR values may be a marker of stroke' severity.What's known Stroke is an important disease that has a significant impact on mortality and morbidity and is closely related to the aging world population. In recent years, highly innovative approaches have been developed in the treatment of stroke. Although a long distance has been covered in the early diagnosis of stroke, the ability to predict the severity of the disease with many parameters is still up to date. What's new At the time of admission, in the absence of infection, parameters such as leukocytelymphocyte count and NLR may be telling about stroke severity. Demonstrating the utility of these simple, practical, inexpensive and naninvasive parameters to predict stroke severity can contribute to the scoring to be established at the time of initial diagnosis.

Clinical risk factors associated with recurrence of ischemic stroke within two years: A cohort study

To identify the clinical risk factors and investigate the efficacy of a classification model based on the identified factors for predicting 2-year recurrence after ischemic stroke.From June 2017 to January 2019, 358 patients with first-ever ischemic stroke were enrolled and followed up in Shenzhen Traditional Chinese Medicine Hospital. Demographic and clinical characteristics were recorded by trained medical staff. The outcome was defined as recurrence within 2 years. A multivariate logistic regression model with risk factors and their interaction effects was established and evaluated.The mean (standard deviation) age of the participants was 61.6 (12.1) years, and 101 (28.2%) of the 358 patients were female. The common comorbidities included hypertension (286 patients, 79.9%), diabetes (148 patients, 41.3%), and hyperlipidemia (149 patients, 41.6%). The 2-year recurrence rate was 30.7%. Of the 23 potential risk factors, 10 were significantly different between recurrent and non-recurrent subjects in the univariate analysis. A multivariate logistic regression model was developed based on 10 risk factors. The significant variables include diabetes mellitus, smoking status, peripheral artery disease, hypercoagulable state, depression, 24 h minimum systolic blood pressure, 24 h maximum diastolic blood pressure, age, family history of stroke, NIHSS score status. The area under the receiver operating characteristic curve (ROC) was 0.78 (95% confidence interval: 0.726-0.829) with a sensitivity of 0.61 and a specificity of 0.81, indicating a potential predictive ability.Ten risk factors were identified, and an effective classification model was built. This may aid clinicians in identifying high-risk patients who would benefit most from intensive follow-up and aggressive risk factor reduction.The clinical trial registration number: ChiCTR1800019647.

Association between fasting blood glucose and outcomes and mortality in acute ischaemic stroke patients with diabetes mellitus: a retrospective observational study in Wuhan, China

OBJECTIVE

To evaluate the predictive value of fasting blood glucose (FBG) on unfavourable outcomes and mortality in diabetes mellitus (DM) patients after acute ischaemic stroke (AIS).

STUDY DESIGN

A hospital-based observational cohort study was conducted. Clinical data, including sex, age, body mass index, vascular risk factors and systolic/diastolic blood pressure, were routinely collected. National Institutes of Health Stroke Scale score was used to assess stroke severity on admission. FBG was determined on the first day after fasting for at least 8 hours. The modified Rankin Scale was used to assess functional outcome at 90 days: 3-6, unfavourable outcome and 6, death.

SETTING

Renmin Hospital of Wuhan University, Wuhan, China.

PARTICIPANTS

Patients who had AIS with DM, who were consecutively admitted within 24 hours of onset from January 2018 to June 2019.

RESULTS

For the 568 patients, the median age was 65 years (IQR, 55-74 years). There were 377 (66.4%) men. The median FBG values were 7.37 mmol/L (IQR, 5.99-10.10 mmol/L), and the median glycated haemoglobin (HbA1c) values were 6.6 (IQR, 5.8-8.3). Multivariable logistic and Cox regression analysis of confounding factors showed that FBG at the time of admission was an independent predictor of unfavourable outcome (OR, 1.25 (1.14-1.37); p<0.0001) and mortality (HR, 1.10 (1.03-1.15); p<0.05) at 90 days after onset. Time to death was analysed by Kaplan-Meier curves based on FBG quartiles. The risk of death in the two highest quartile groups (FBG, 7.38-10.10 mmol/L; FBG, ≥10.11 mmol/L) was significantly higher than that in the two lowest quartile groups (FBG, ≤6.00 mmol/L; FBG, 6.01-7.37 mmol/L; p<0.0001).

CONCLUSIONS

Higher FBG levels are associated with unfavourable outcomes and mortality in Chinese patients who had AIS with DM. Our data contribute to the knowledge regarding the relationship between FBG and prognosis in patients with DM who had AIS.

Effects of β-Adrenergic Blockade on Metabolic and Inflammatory Responses in a Rat Model of Ischemic Stroke

Ischemic stroke provokes an inflammatory response concurrent with both sympathetic nervous system activation and hyperglycemia. Currently, their crosstalk and consequences in stroke outcomes are of clinical attraction. We have provided experimental evidence showing the suppressive effects of the nonselective β-adrenoreceptor antagonist propranolol on hyperglycemia, inflammation, and brain injury in a rat model experiencing cerebral ischemia. Pretreatment with propranolol protected against postischemic brain infarction, edema, and apoptosis. The neuroprotection caused by propranolol was accompanied by a reduction in fasting glucose, fasting insulin, glucose tolerance impairment, plasma C-reactive protein, plasma free fatty acids, plasma corticosterone, brain oxidative stress, and brain inflammation. Pretreatment with insulin alleviated-while glucose augmented-postischemic brain injury and inflammation. Additionally, the impairment of insulin signaling in the gastrocnemius muscles was noted in rats with cerebral ischemia, with propranolol improving the impairment by reducing oxidative stress and tumor necrosis factor-α signaling. The anti-inflammatory effects of propranolol were further demonstrated in isoproterenol-stimulated BV2 and RAW264.7 cells through its ability to decrease cytokine production. Despite their potential benefits, stroke-associated hyperglycemia and inflammation are commonly linked with harmful consequences. Our findings provide new insight into the anti-inflammatory, neuroprotective, and hypoglycemic mechanisms of propranolol in combating neurodegenerative diseases, such as stroke.