An intravenous insulin protocol for strict glycemic control in acute ischaemic stroke.

BACKGROUND AND PURPOSE: There is a J-shaped association between admission glycemia and outcome. We designed an intravenous insulin protocol aiming at rapid and strict glucose control in hyperglycemic ischaemic stroke patients. Here, we describe the initial experience, safety, and efficacy of this protocol to achieve and maintain euglycemia in the first 48h. METHODS: The protocol is based on parallel scales for adjustment of insulin infusion rate according to current glycemia and the rate of change of glycemia, which was recommended in our stroke unit in 4/2007 in acute ischaemic stroke patients with glycemia >6mM. Data were registered in the Acute Stroke Registry and Analysis of Lausanne (ASTRAL). Capillary blood glycemia was measured hourly with fingerprick test at onset of treatment and after each scale change. Target glycemia was 4.0-6.0mM pre-prandially (5.5-8.0mM post-prandially). Hypokalemia was defined as serum potassium <3.5mM and measured every 12h. Specific algorithms were employed during meals and for patients leaving temporarily the stroke unit for diagnostic or therapeutic workup. RESULTS: In the 90 protocol patients, the first normoglycemia was achieved within 8h of treatment in 91.1% of patients (median interval 4h (interquartile range (IQR): 3-6). During the median treatment duration of 25.5h (IQR: 19.7-37.7), median glucose reduction was 2.5mM (IQR: 1.3-4.3mM). The overall rate of hypoglycemias was 4.5% and hypokalemias 18.5%. There was a significant increase in the proportion of hypokalemias on the first on-treatment measurement compared to admission (24.4% vs. 8.9%, P=0.002). CONCLUSIONS: The proposed intravenous insulin protocol controls acute post-stroke hyperglycemia but frequently leads to hypokalemia. This issue needs to be addressed for the protocol to be suitable for use in larger, randomized controlled trial to explore its clinical effect.

Persistent hyperglycemia at 24-48 h in acute hyperglycemic stroke patients is not associated with a worse functional outcome.

BACKGROUND: Recently, it was shown that the relation between admission glucose and functional outcome after ischemic stroke is described by a J-shaped curve, with a glucose range of 3.7-7.3 mmol/l associated with a favorable outcome. We tested the hypothesis that persistence of hyperglycemia above this threshold at 24-48 h after stroke onset impairs 3-month functional outcome. METHODS: We analyzed all patients with glucose >7.3 mmol/l on admission from the Acute STroke Registry and Analysis of Lausanne (ASTRAL). Patients were divided into two groups according to their subacute glucose level at 24-48 h after last well-being time (group 1: ≤7.3 mmol/l, group 2: >7.3 mmol/l). A favorable functional outcome was defined as a modified Rankin Score (mRS) ≤2 at 3 months. A multiple logistic regression analysis of multiple demographic, clinical, laboratory and neuroimaging covariates was performed to assess predictors of an unfavorable outcome. RESULTS: A total of 1,984 patients with ischemic stroke were admitted between January 1, 2003 and October 20, 2009, within 24 h after last well-being time. In the 421 patients (21.2%) with admission glucose >7.3 mmol/l, the proportion of patients with a favorable outcome was not statistically significantly different between the two groups (59.2 vs. 48.7%, respectively). In multiple logistic regression analysis, unfavorable outcome was significantly associated with age (odds ratio, OR: 1.06, 95% confidence interval, 95% CI: 1.03-1.08 for every 10-year increase), National Institute of Health Stroke Score, NIHSS score, on admission (OR: 1.16, 95% CI: 1.11-1.21), prehospital mRS (OR: 12.63, 95% CI: 2.61-61.10 for patients with score >0), antidiabetic drug usage (OR: 0.36, 95% CI: 0.15-0.86) and glucose on admission (OR: 1.16, 95% CI: 1.02-1.31 for every 1 mmol/l increase). No association was found between persistent hyperglycemia at 24-28 h and outcome in either diabetics or nondiabetics. CONCLUSIONS: In ischemic stroke patients with acute hyperglycemia, persistent hyperglycemia (>7.3 mmol/l) at 24-48 h after stroke onset is not associated with a worse functional outcome at 3 months whether the patient was previously diabetic or not.

[Transition from acute inpatient to chronic outpatient diabetes care: an symbolic situation]. / Transition entre hospitalisation aiguë et suivi ambulatoire chronique du patient diabétique: situation emblématique.

During an acute hospital stay, unpredictable glycemic changes related to the combined effects of multiple factors always ask for an increased attention to diabetes management. Initially an insulin treatment which has to be adjusted individually based on continuous glycemic follow-up is usually inevitable. This requires adequate coordination between the various health-care professionals who are simultaneously and successively involved in patient care. A proper discharge plan including reassessment of treatment, developed in consultation with the practicioners in charge of outpatient follow-up is a key component of this process. As in other complex conditions, deficiencies in this field are associated with increased errors and costs, which can be improved through interventions targeting inpatient to outpatient transition.

[Diabetes]. / Diabète.

In 2009 a novel screening strategy for diabetes based on the level of glycated hemoglobin has been proposed by the main international organizations, with a diagnostic threshold of 6.5%. The preventive efficacy of multiple risk factor control in type 2 diabetes reflected by the low rate of cardiac events in the DIAD 2 study calls for a revision of the current recommendations for coronary disease screening. In gestational diabetes, the linear correlation between degree of hyperglycemia and risk of associated complications in the HAPO study strenghtens the therapeutic targets for this frequent condition, which identifies women at high future risk of diabetes. No conclusive evidence for an increased risk of cancer associated with insulin glargin remains when taking into account all the data currently available on this topic.

[Treatments for cardiovascular risk factors and screening for coronary artery disease in type 2 diabetes mellitus]. / Traitements des facteurs de risque cardiovasculaire et dépistage de la maladie coronarienne dans le diabète de type 2.

The recent ACCORD and DIAD studies revealed results which could modify treatments and the screening of diabetes vascular complications. Indeed, ACCORD shows no benefit on the prevention of diabetes vascular complications by aggressive treatment of hypertension or the combined treatment of the dyslipidemia. The intensive treatment of the blood glucose, if associated with severe hypoglycemias, increases mortality. DIAD revealed 20% of silent myocardial ischaemia in diabetic patients but no beneficial effect on the cardiovascular mortality. A careful reading of these studies in the light of long term studies such as UKPDS and STENO reveals that these negative results are generated by a too short follow-up and too aggressive objectives. The long term studies reveal that more realistic objectives remain beneficial.

Induction of proliferation or hypertrophy of chondrocytes in serum-free culture: the role of insulin-like growth factor-I, insulin, or thyroxine.

In bone forming cartilage in vivo, cells undergo terminal differentiation, whereas most of the cells in normal articular cartilage do not. Chondrocyte hypertrophy can be induced also in vitro by diffusible signals. We have identified growth factors or hormones acting individually on 17-d chick embryo sternal chondrocytes cultured in agarose gels under strictly serum-free conditions. Insulin-like growth factor I or insulin triggered the first steps of chondrocyte maturation, i.e., cell proliferation and increased matrix deposition while the chondrocytic phenotype was maintained. However, cells did not progress to the hypertrophic stage. Proliferation and stimulated collagen production was preceded by a lag period, indicating that synthesis of other components was required before cells became responsive to insulin-like growth factor I or insulin. Very small amounts of FBS exerted effects similar to those of insulin-like growth factor I or insulin. However, FBS could act directly and elicited hypertrophy when constituting greater than 1% of the culture media. Basic FGF has been claimed to be the most potent chondrocyte mitogen, but had negligible effects under serum-free conditions. The same is true for PDGF, a major serum-mitogen. Under the direction of thyroxine, cells did not proliferate but became typical hypertrophic chondrocytes, extensively synthesizing collagen X and alkaline phosphatase.

[Trends in diabetes]. / Diabétologie.

A recent meta-analysis on the rosiglitazone in the treatment of type 2 diabetes revealed a significant increased risk of myocardial infarction and a trend to a higher cardiovascular mortality. In the following month after this publication, the methodology as its conclusions were criticized. This study shows the limits of the meta-analyses to which one lends a row obviously too high in the hierarchy of the levels of evidence. The study 4T evaluated 3 insulin strategies in the treatment of the type 2 diabetes. The results at one year show that only a minority of the patients achieve the goals. Post-Steno 2 was presented at the European congress diabetes. These new data confirm that the intensified treatment of all cardiovascular factors risk allows a major reduction of cardiovascular mortality after 13.3 years.

[The inefficacy of glycemic control in the hospitalized patient: origins and solutions]. / Inefficacité de la gestion de l'hyperglycémie du patient hospitalisé: origines et remèdes.

The hospital inpatient prevalence of diabetes mellitus can be estimated between 20 and 30%. Even moderate hyperglycemia is associated with increased morbidity and mortality in the acute care setting, whereas efficient glycemic control has been shown to improve both of them significantly. Glycemic control however remains largely inefficient outside of the intensive care unit due to the persistance of an inadequate glycemic management practice. We are currently developing a clinical care project aimed at changing this practice. For an efficient glycemic control, a training programme for health care professionals based on the concept of covering the insulin needs of the patient is mandatory. This programme needs to be integrated in a systemic approach, which takes the professionals' context in account.

[What can be expected from the GLP-1 agonists and DPP-4 inhibitors in the treatment of type 2 diabetes?]. / Traitement du diabète de type 2: qu'attendre des analogues du GLP-1 et inhibiteurs de la DPP-4?

The GLP-1 agonists and DPP-4 inhibitors are two novel drug classes in the treatment of type 2 diabetes. They increase insulin secretion and inhibit glucagon secretion without risk of hypoglycaemia. A decrease of glycated haemoglobin of about 1% can be expected with their use as monotherapy and as add-on therapy to the usual oral antidiabetics. In addition, GLP-1 agonists induce weight reduction at the price of gastro-intestinal side-effects and the need for subcutaneous administration. DPP-4 inhibitors can be taken orally, are well-tolerated, but weight-neutral. In the absence of relevant clinical studies, their long-term efficacy is currently unknown, as well as the clinical impact of other promising effects like beta-cell preservation.

Detection of alkali metal ions in DNA crystals using state-of-the-art X-ray diffraction experiments.

The observation of light metal ions in nucleic acids crystals is generally a fortuitous event. Sodium ions in particular are notoriously difficult to detect because their X-ray scattering contributions are virtually identical to those of water and Na(+.)O distances are only slightly shorter than strong hydrogen bonds between well-ordered water molecules. We demonstrate here that replacement of Na(+) by K(+), Rb(+) or Cs(+) and precise measurements of anomalous differences in intensities provide a particularly sensitive method for detecting alkali metal ion-binding sites in nucleic acid crystals. Not only can alkali metal ions be readily located in such structures, but the presence of Rb(+) or Cs(+) also allows structure determination by the single wavelength anomalous diffraction technique. Besides allowing identification of high occupancy binding sites, the combination of high resolution and anomalous diffraction data established here can also pinpoint binding sites that feature only partial occupancy. Conversely, high resolution of the data alone does not necessarily allow differentiation between water and partially ordered metal ions, as demonstrated with the crystal structure of a DNA duplex determined to a resolution of 0.6 A.

[Oral antidiabetic agents: which role in 2006?]. / Les antidiabétiques oraux: quelle place en 2006?

This article offers a review of the five classes of oral antidiabetics which are currently available, and focuses on practical considerations about the daily use of these drugs. Based on data from recent studies, it addresses several frequently asked questions. Which treatment to choose for which patient? How to adapt the treatment facing the progression of type 2 diabetes, which most often necessitates an intensification of the therapeutic means over time? Usually there are several initial therapeutic options for a given patient. The glycemic control over the following months allows to verify the efficiency of the treatment chosen. In case of a persistant glycemic imbalance, early intensification of the treatment is recommended.

[The Polypill: between myths and reality in the treatment of type 2 diabetes mellitus]. / La polypill: entre mythes et réalité dans le traitement du diabète sucré.

The Polypill: between myths and reality in the treatment of type 2 diabetes mellitus The concept of "Polypill" was developed from modeling analyses and the data were extracted from randomized-control trials and epidemiological studies. This "Polypill" should be a combination of three antihypertensive drugs associated to aspirin, a statin and folic acid. This "Polypill" would allow to reduce of more than 80% the cardiovascular events. The original publication suggests that all subjects of more than 55 years could benefit from this magic pill. Numerous positive and negative reactions showed themselves further to this publication. Other approaches based on the change of lifestyle seem so effective. Nevertheless, to have a really effective approach the therapeutic educational dimension should be also included in the basic strategy.

Considerations in the Evaluation of Potential Efficacy of Medications for Alcohol and Drug Use Disorders: An Editorial.

The societal burden created by alcohol and drug use disorders is estimated to be on the order of hundreds of billions of dollars, creating a need for effective medications to reduce use and prevent relapse. While there are FDA-approved medications to facilitate abstinence and prevent relapse for some indications including, alcohol, tobacco, and opiate use disorders, there are no approved treatments for other abused substances, including cocaine, methamphetamine, and cannabis, leaving these critical medical needs unmet. The development of such medications has fallen largely to the government with efforts spearheaded by the National Institute on Drug Abuse and the National Institute on Alcoholism and Alcohol Abuse. Both agencies have medication development programs with preclinical components that include the standardized evaluation of compounds using animal models. This chapter describes the rationale and considerations involved in the use of such models, including reinstatement of drug self-administration.

Lesion Orientation of O4-Alkylthymidine Influences Replication by Human DNA Polymerase η.

DNA lesions that elude repair may undergo translesion synthesis catalyzed by Y-family DNA polymerases. O4-Alkylthymidines, persistent adducts that can result from carcinogenic agents, may be encountered by DNA polymerases. The influence of lesion orientation around the C4-O4 bond on processing by human DNA polymerase η (hPol η) was studied for oligonucleotides containing O4-methylthymidine, O4-ethylthymidine, and analogs restricting the O4-methylene group in an anti-orientation. Primer extension assays revealed that the O4-alkyl orientation influences hPol η bypass. Crystal structures of hPol η•DNA•dNTP ternary complexes with O4-methyl- or O4-ethylthymidine in the template strand showed the nucleobase of the former lodged near the ceiling of the active site, with the syn-O4-methyl group engaged in extensive hydrophobic interactions. This unique arrangement for O4-methylthymidine with hPol η, inaccessible for the other analogs due to steric/conformational restriction, is consistent with differences observed for nucleotide incorporation and supports the concept that lesion conformation influences extension across DNA damage. Together, these results provide mechanistic insights on the mutagenicity of O4MedT and O4EtdT when acted upon by hPol η.

Insulin resistance, hyperlipidemia, and hypertension in mice lacking endothelial nitric oxide synthase.

BACKGROUND: Insulin resistance and arterial hypertension are related, but the underlying mechanism is unknown. Endothelial nitric oxide synthase (eNOS) is expressed in skeletal muscle, where it may govern metabolic processes, and in the vascular endothelium, where it regulates arterial pressure. METHODS AND RESULTS: To study the role of eNOS in the control of the metabolic action of insulin, we assessed insulin sensitivity in conscious mice with disruption of the gene encoding for eNOS. eNOS(-/-) mice were hypertensive and had fasting hyperinsulinemia, hyperlipidemia, and a 40% lower insulin-stimulated glucose uptake than control mice. Insulin resistance in eNOS(-/-) mice was related specifically to impaired NO synthesis, because in equally hypertensive 1-kidney/1-clip mice (a model of renovascular hypertension), insulin-stimulated glucose uptake was normal. CONCLUSIONS: These results indicate that eNOS is important for the control not only of arterial pressure but also of glucose and lipid homeostasis. A single gene defect, eNOS deficiency, may represent the link between metabolic and cardiovascular disease.

Atomic-resolution crystal structures of B-DNA reveal specific influences of divalent metal ions on conformation and packing.

Crystal structures of B-form DNA have provided insights into the global and local conformational properties of the double helix, the solvent environment, drug binding and DNA packing. For example, structures of the duplex with sequence CGCGAATTCGCG, the Dickerson-Drew dodecamer (DDD), established a unique geometry of the central A-tract and a hydration spine in the minor groove. However, our knowledge of the various interaction modes between metal ions and DNA is very limited and almost no information exists concerning the origins of the different effects on DNA conformation and packing exerted by individual metal ions. Crystallization of the DDD duplex in the presence of Mg(2+)and Ca(2+)yields different crystal forms. The structures of the new Ca(2+)-form and isomorphous structures of oligonucleotides with sequences GGCGAATTCGCG and GCGAATTCGCG were determined at a maximum resolution of 1.3 A. These and the 1.1 A structure of the DDD Mg(2+)-form have revealed the most detailed picture yet of the ionic environment of B-DNA. In the Mg(2+)and Ca(2+)-forms, duplexes in the crystal lattice are surrounded by 13 magnesium and 11 calcium ions, respectively.Mg(2+)and Ca(2+)generate different DNA crystal lattices and stabilize different end-to-end overlaps and lateral contacts between duplexes, thus using different strategies for reducing the effective repeat length of the helix to ten base-pairs. Mg(2+)crystals allow the two outermost base-pairs at either end to interact laterally via minor groove H-bonds, turning the 12-mer into an effective 10-mer. Ca(2+)crystals, in contrast, unpair the outermost base-pair at each end, converting the helix into a 10-mer that can stack along its axis. This reduction of a 12-mer into a functional 10-mer is followed no matter what the detailed nature of the 5'-end of the chain: C-G-C-G-A-ellipsis, G-G-C-G-A-ellipsis, or a truncated G-C-G-A-ellipsis Rather than merely mediating close contacts between phosphate groups, ions are at the origin of many well-known features of the DDD duplex structure. A Mg(2+)coordinates in the major groove, contributing to kinking of the duplex at one end. While Ca(2+)resides in the minor groove, coordinating to bases via its hydration shell, two magnesium ions are located at the periphery of the minor groove, bridging phosphate groups from opposite strands and contracting the groove at one border of the A-tract.

Comparative studies of high resolution Z-DNA crystal structures. Part 1: Common hydration patterns of alternating dC-dG.

The water structure in three crystal forms of the left-handed Z-DNA hexamer [d(CGCGCG)]2 has been analyzed. Several common motifs have been found in the first hydration shells. On the convex surface, the major groove of the left-handed conformation, water molecules bridge the guanine O-6 keto groups at GpC steps. Cytosine N-4 nitrogens of opposite strands are hydrated by tandem water molecules. At the bottom of the minor groove, a string of water molecules connects the cytosine O-2 keto groups. Across the minor groove guanine N-2 nitrogens are bridged to phosphate oxygens of cytosine and guanine residues by one or two water molecules. In contrast to the very regular geometry of the water structure around the bases, the arrangement of water molecules between phosphate groups appears to be less ordered. However, there is a strong correlation between the interphosphate distances and the number of water molecules or ions which link the phosphate groups. In all three structures various ions, such as sodium and magnesium ions, as well as the protonated amino and imino groups of the polycation spermine displace and replace water molecules in the first hydration shell. Nevertheless, the analysis reveals that numerous first hydration shell water molecules in Z-DNA crystals can be regarded as part of the DNA structure. Their positions and thermal parameters are generally independent of changes in the local crystallographic environment.

Structure of 11-deoxydaunomycin bound to DNA containing a phosphorothioate.

The anthracyclines form an important family of cancer chemotherapeutic agents with a strong dependence of clinical properties on minor differences in chemical structure. We describe the X-ray crystallographic solution of the three-dimensional structure of the anthracycline 11-deoxydaunomycin plus d(CGTsACG). In this complex, two drug molecules bind to each hexamer duplex. Both the drug and the DNA are covalently modified in this complex in contrast with the three previously reported DNA-anthracycline complexes. In the 11-deoxydaunomycin complex the 11 hydroxyl group is absent and a phosphate oxygen at the TpA step has been replaced by a sulfur atom leading to a phosphorothioate with absolute stereochemistry R. Surprisingly, removal of a hydroxyl group from the 11 position does not alter the relative orientation of the intercalated chromophore. However, it appears that the phosphorothioate modification influenced the crystallization and caused the 11-deoxydaunomycin-d(CGTsACG) complex to crystallize into a different lattice (space group P2) with different lattice contacts and packing forces than the non-phosphorothioated DNA-anthracycline complexes (space group P4(1)2(1)2). In the minor groove of the DNA, the unexpected position of the amino-sugar of 11-deoxydaunomycin supports the hypothesis that in solution the position of the amino sugar is dynamic.

Characterization of Maize Acetyl-Coenzyme A Carboxylase.

Maize (Zea mays L.) leaf acetyl-CoA carboxylase (ACCase) was purified about 500-fold by ammonium sulfate fractionation and gel filtration and blue Sepharose affinity and anion-exchange chromatography. Most ACCase activity (85%) recovered from the anion-exchange column was found in a highly purified fraction (specific activity 5.5 [mu]mol acid-stable product min-1 mg-1) that consisted primarily of a single 227-kD biotinylated polypeptide. The fraction represented 29% of the original activity and was designated ACCase I. A second partially purified ACCase activity (ACCase II) eluted earlier during anion-exchange chromatography, contained a single biotinylated polypeptide of 219 kD, was poorly recognized by antiserum raised against the ACCase I polypeptide, and was less inhibited by the herbicides haloxyfop or sethoxydim than was ACCase I. ACCase I and II both utilized propionyl-CoA as substrate about 50% as effectively as acetyl-CoA, and neither utilized methylcrotonyl-CoA. Immunoprecipitation with antiserum and protein blotting of crude extracts of leaf, embryo, and endosperm tissue and suspension cells indicated that most ACCase activity in these tissues was immunologically similar and consisted of ACCase I. Only leaves contained significant amounts of the ACCase II polypeptide; however, no ACCase II polypeptide was found in isolated mesophyll chloroplasts. The ACCase I and II polypeptides appear to be subunits of distinct ACCase isoforms.