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Tamer R Armanious,1 Ahmed A Khalifa,2 Hossam Abubeih,1 Mahmoud Badran,1 Faisal Fahmy Adam,1 Osama Farouk1 1Orthopaedic Department, Assiut University Trauma Hospital, Assiut, Egypt; 2Orthopaedic Department, Qena Faculty of Medicine and University Hospital at South Valley University, Qena, EgyptCorrespondence: Ahmed A Khalifa, Orthopaedic and Traumatology, Orthopaedic Department, Qena Faculty of Medicine and University Hospital, South Valley University, Qena, Egypt, Tel +201224466151, Email ahmedₐdel0391@med.svu.edu.egBackground: Abnormal admission blood glucose levels were proved to have a mortality predictive value in polytraumatized patients, as reported by studies in developed countries. Reports from developing countries are scarce.Objective: To evaluate the reliability of on-admission blood glucose levels in predicting mortality in polytraumatized patients presented to a North African (developing country) trauma center. The secondary objectives were to investigate other possible mortality predictors and if a cutoff value for each could be obtained.Methods: In this prospective longitudinal study, over one year, we included adult (≥ 18 years) patients who were polytraumatized (ISS ≥ 17) and presented to our trauma center within six hours of the trauma incident. Various clinical, laboratory, and trauma scores were collected. Blood glucose levels were assessed from blood samples obtained directly after admission. Patients were divided into five groups based on the admission blood glucose levels.Results: We included 202 patients, having a mean age of 44± 13.9 (20 to 70) years, and 52% were females. The mortality rate was 10.9% (including all patients presented with blood glucose levels≥ 15 mmol/L). The following were significant mortality predictors, admission blood glucose (OR=3.31, 95% CI=1.902– 5.763, p< 0.001), serum lactate levels (OR=4.017, 95% CI=1.627– 9.917, p=0.003), length of hospital stay (OR=1.18, 95% CI= 1.058– 1.305, p=0.003), RTS score (OR=1.43, 95% CI=1.023– 2.005, p=0.037), and TRISS score (OR=1.099, 95% CI=1.052– 1.148, p< 0.001). Admission blood glucose levels cutoff value of 15 mmol/L can significantly differentiate between survivors and non-survivors with sensitivity, specificity, PPV, and NPV of 86.4%, 100%, 100%, and 88%, respectively.Conclusion: Abnormal admission blood glucose with a cutoff value of 15mmol/L is a significant mortality predictor in polytraumatized patients from developing country trauma center, among other clinical, laboratory, and trauma scores parameters.Keywords: severely injured patients, polytrauma, admission blood glucose, hyperglycemia, mortality

Background Type 4a myocardial infarction (MI) is a relevant complication in non–ST-segment elevation myocardial infarction (NSTEMI) patients undergoing percutaneous coronary intervention (PCI). While glucometabolic status has been linked to type 4a MI in chronic coronary syndromes, data in the acute setting are lacking. This study aimed to assess the association of glucometabolic parameters—admission blood glucose (ABG), glycated hemoglobin (HbA1c) and stress hyperglycemia ratio (SHR)—with type 4a MI in NSTEMI patients undergoing PCI and evaluate their independent predictive role. Methods Consecutive NSTEMI patients undergoing PCI from the AMIPE multicenter prospective registry (NCT03883711) with stable or falling pre-procedural cardiac troponin levels were analyzed. The optimal glucometabolic predictor of type 4a MI among ABG, HbA1c and SHR was identified using receiver operating characteristic analysis. The best cut-off for each parameter was derived using Youden’s index. Regression analysis and Kaplan–Meier curves were performed to identify independent predictors of type 4a MI and their prognostic implications. Results The study population included 1005 patients (mean age 70.3 ± 12.5 years, 25.5% females), with 45.9% having diabetes mellitus. SHR showed a significantly higher accuracy (AUC 0.69, 95% CI 0.65–0.73) in predicting type 4a MI compared with ABG and HbA1c ( p  < 0.001), with an optimal cut-off of 1.14, consistent across diabetic and non-diabetic patients. SHR > 1.14 was independently associated with type 4a MI (aOR = 2.73; 95% CI 1.70–4.42; p  < 0.001), unlike ABG and HbA1c, and was also linked to an increased risk of long-term major adverse cardiovascular events ( p  < 0.001). Conclusions SHR emerged as a strong predictor of type 4a MI in NSTEMI patients undergoing PCI, outperforming other glucometabolic markers. Graphical Abstract

Background The role of stress hyperglycemia ratio (SHR) on the prognosis of spontaneous intracerebral hemorrhage (ICH) in patients with different diabetic status has not been elucidated. This study aimed to evaluate the prognostic value of SHR and admission blood glucose (ABG) for the short- and long-term mortality in diabetic and nondiabetic populations with ICH. Method Participants with ICH were retrospectively retrieved from the Medical Information Mart for Intensive Care (MIMIC-IV). The primary outcome was all-cause 30-day and 1-year mortality. The association of SHR and ABG with the primary outcomes in diabetic and nondiabetic cohorts were assessed by Cox proportional hazard regression. Results Overall, 1029 patients with a median age of 71.09 (IQR: 60.05–81.97) were included. Among them, 548 (53%) individuals were male, and 95 (19%) as well as 323 (31%) ones experienced the 30-day and 1-year mortality, respectively. After adjusting for confounding variables, individuals in quintile 5 of SHR had significantly higher risk of the 30-day and 1-year mortality than those in quintile 1 in the whole cohort (30-day mortality: HR 3.33, 95%CI 2.01–5.51; 1-year mortality: HR 2.09, 95% CI 1.46-3.00) and in nondiabetic patients (30-day mortality: HR 4.55, 95%CI 2.33–8.88; 1-year mortality: HR 3.06, 95%CI 1.93–4.86), but no significant difference was observed in diabetic patients. Similar results were observed for ABG as a categorical variable. As continuous variable, SHR was independently correlated with the 30-day and 1-year mortality in both of the diabetic and nondiabetic cohorts (30-day mortality: HR 2.63, 95%CI 1.50–4.60. 1-year mortality: HR 2.12, 95%CI 1.33–3.39), but this correlation was only observed in nondiabetic cohort for ABG (HR 1.00, 95%CI 0.99–1.01 for both of the 30-day and 1-year mortality). Moreover, compared with ABG, SHR can better improve the C-statistics of the original models regarding the 30-day and 1-year outcomes, especially in patients with diabetes ( p  < 0.001 in all models). Conclusion SHR might be a more useful and reliable marker than ABG for prognostic prediction and risk stratification in critically ill patients with ICH, especially in those with diabetes.

Background Hyperglycemia upon admission is associated with poor prognosis of many cardiovascular diseases. However, the relationship of stress hyperglycemia ratio (SHR), admission blood glucose (ABG), and hemoglobin A1c (HbA1c) with pulmonary hypertension has not been reported. This study aimed to explore the association of hyperglycemia indices with disease severity and long-term adverse outcomes in patients with idiopathic pulmonary arterial hypertension (IPAH). Methods This multi-center cohort study included 625 consecutive patients diagnosed with or treated for IPAH between January 2015 and June 2023. SHR was calculated using the followings: ABG (mmol/L)/(1.59 × HbA1c [%] − 2.59). The primary endpoint was defined as clinical worsening events. Multivariable Cox regression and restricted cubic spline analyses were employed to evaluate the association of SHR, ABG, and HbA1c with endpoint events. The mediating effect of pulmonary hemodynamics was evaluated to investigate the potential mechanism between hyperglycemia and clinical outcomes. Results During a mean follow-up period of 3.8 years, 219 (35.0%) patients experienced all-cause death or clinical worsening events. Hyperglycemia indices correlated with well-validated variables that reflected the severity of IPAH, such as the World Health Organization functional class, 6-min walk distance, and N-terminal pro-brain natriuretic peptide levels. Multivariable Cox regression analyses indicated that SHR (hazard ratio [HR] 1.328, 95% confidence intervals [CI]: 1.185, 1.489 per 0.1-unit increment, P  < 0.001) and ABG (HR 1.317, 95% CI: 1.134, 1.529 per 1.0-unit increment, P  < 0.001) were independent predictors of primary endpoint events. Mediation analysis indicated that pulmonary vascular resistance mediated 5.65% and 14.62% of the associations between SHR and ABG and clinical worsening events, respectively. The addition of SHR significantly improved reclassification, discrimination ability, and model fit beyond the clinical risk prediction model. Conclusions SHR is positively associated with clinical worsening in patients with IPAH. The association appeared to be partially mediated through the pathway of pulmonary vascular remodeling, indicating that SHR may serve as a valuable indicator for providing additional risk information.

Background Recently, a novel parameter named admission blood glucose to albumin ratio (AAR) has been proposed and proved to be significantly associated with adverse prognosis of acute myocardial infarction. The prognostic utility of AAR for risk stratification in percutaneous coronary intervention (PCI) treated non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients has not been well established. Methods The present study recruited patients admitted for NSTE-ACS who successfully received PCI. The calculation of AAR involved the division of admission blood glucose by serum albumin concentration. The first occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) was defined as the primary endpoint. The predictive impact of AAR for MACCE was conducted in subgroups according to whether type 2 diabetes mellitus (T2DM) was combined or not. Results A total of 2107 patients (mean age 60.0 ± 9.0 years; 28.0% female) were included in this analysis. The study documented 293 MACCEs (13.9%), distributed as 128 events in the T2DM subgroup and 165 events in the non-T2DM subgroup. AAR exhibited to be a significant risk predictor for MACCE despite following comprehensive adjustment for confounding factors, either analyzed as a nominal or continuous variable (all P  < 0.05). AAR demonstrated superior discriminatory ability for MACCE, achieving the highest area under the receiver operating characteristic curve (AUC = 0.667) compared to its individual components. The addition of AAR to a baseline model yielded the greatest enhancement in MACCE risk stratification compared to its constituent measures, as confirmed by a marked improvement in the Harrell’s C-index (from 0.641 to 0.683, P  < 0.001), along with significant gains in both continuous net reclassification improvement (0.187, P  < 0.001) and integrated discrimination improvement (0.027, P  < 0.001). Subgroup analyses revealed that the predictive and stratified value of AAR for MACCE was more significant in patients without T2DM. Conclusion AAR serves as a significant independent predictor for risk stratification in PCI-treated NSTE-ACS patients. The predictive and stratified value of AAR for MACCE seems to be more significant in patients without T2DM.

Objective To investigate the association between admission blood glucose and atypical angina in patients with coronary artery disease (CAD), and to investigate the risk factors associated with atypical angina in coronary heart disease. Methods A total of 729 patients who underwent coronary angiography at Xuancheng People’s Hospital between December 2018 and December 2024 were enrolled. According to clinical presentation during CAD onset, patients were classified into a typical angina group and an atypical angina group. Clinical variables including admission blood glucose levels, and monocyte-to-lymphocyte ratio (MLR) were collected and compared between groups. Univariate and multivariate logistic regression analyses were performed to identify independent risk factors for atypical angina in patients with CAD. Receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive value of admission blood glucose and diabetes status for atypical angina. Mediation analysis was conducted to assess the mediating role of admission blood glucose in the association between diabetes and atypical angina. Restricted cubic spline analysis was applied to characterize the dose–response relationship between admission blood glucose and atypical angina. Results Both univariate and multivariate logistic regression analyses demonstrated that a history of diabetes, elevated admission blood glucose, and increased MLR were independent risk factors for atypical angina in patients with CAD (all P  < 0.05). ROC curve analysis indicated that history of diabetes and admission blood glucose exhibited modest predictive value for the occurrence of atypical angina in CAD patients ( P  < 0.05). Mediation analysis revealed that admission blood glucose significantly mediated the association between diabetes and atypical angina. Furthermore, restricted cubic spline analysis showed a significant linear relationship between admission blood glucose levels and the risk of atypical angina. Conclusions Admission blood glucose, a history of diabetes, and MLR are independently associated with the occurrence of atypical angina in patients with CAD. Admission blood glucose plays a significant mediating role in the relationship between diabetes and atypical angina. Both admission blood glucose and diabetes history demonstrate modest predictive value for atypical angina, suggesting their potential utility as early warning indicators in patients with CAD.

Background Coagulopathy is prevalent in multiple trauma patients and worsens bleeding complications, leading to higher morbidity and mortality rates. Hyperglycemia upon admission predicts hemorrhagic shock and mortality in severely injured patients. This study aimed to assess admission glucose levels as an independent prognostic factor for coagulopathy in multiply injured patients. Methods This retrospective cohort study observed multiple trauma patients treated at a level I trauma center between January 1, 2005, and December 31, 2020. Coagulopathy was defined as an international normalized ratio (INR) > 1.4 and/or activated thromboplastin time (APTT) > 40 s. Analysis of variance compared clinical and laboratory parameters of patients with and without coagulopathy. Receiver-operating-characteristic (ROC) and multivariate logistic regression analyses identified risk factors associated with coagulopathy. Results The study included 913 patients, of whom 188 (20%) had coagulopathy at admission. Coagulopathy patients had higher mortality than those without (26% vs. 5.0%, p  < 0.001). Mean glucose level in coagulopathy patients was 10.09 mmol/L, significantly higher than 7.97 mmol/L in non-coagulopathy patients ( p  < 0.001). Admission glucose showed an area under the curve (AUC) of 0.64 (95% CI [0.59–0.69], p  < 0.001) with an optimal cut-off point of 12.35 mmol/L. After adjusting for other factors, patients with high admission glucose had a 1.99-fold risk of developing coagulopathy (95% CI 1.07–3.60). Other laboratory parameters associated with coagulopathy included haemoglobin, bicarbonate (HCO3), and lactate levels. Conclusion This study emphasizes the significance of admission blood glucose as an independent predictor of coagulopathy. Monitoring hyperglycemia can aid in identifying high-risk patients.

Background Left ventricular systolic dysfunction (LVSD) occurs frequently after acute ST-segment elevation myocardial infarction (STEMI). The predisposing factors and underlying mechanism of post-infarct LVSD are not fully understood. The present study mainly investigated the correlation between glycaemic gap, a novel index of stress-induced hyperglycaemia (SIH), and post-infarct LVSD. Methods A total of 274 first STEMI patients were enrolled in this cross-sectional study. Transthoracic echocardiography was performed within 48 h after admission and at 6 months after discharge to obtain left ventricular ejection fraction (LVEF). The change in LVEF was calculated as LVEF at 6 months after discharge minus baseline LVEF. Additionally, post-infarct LVSD was defined as LVEF ≤ 50%. Most importantly, glycaemic gap was calculated as admission blood glucose (ABG) minus the estimated average glucose over the previous 3 months. Results In patients without diabetes mellitus (DM), multivariate linear regression analysis revealed that both glycaemic gap (Beta = − 1.214, 95% CI − 1.886 to − 0.541, p < 0.001) and ABG (Beta = − 1.124, 95% CI − 1.795 to − 0.453, p = 0.001) were associated with change in LVEF. In DM patients, only glycaemic gap was still associated with change in LVEF, although this association was not observed in univariate linear regression analysis. Regarding the association between SIH and post-infarct LVSD, multivariate logistic regression analysis revealed that both glycaemic gap (OR = 1.490, 95% CI 1.043 to 2.129, p = 0.028) and ABG (OR = 1.600, 95% CI 1.148 to 2.229, p = 0.005) were associated with an increased risk of having post-infarct LVSD in non-DM patients. However, after multivariate adjustment in DM patients, only glycaemic gap (OR = 1.399, 95% CI 1.021 to 1.919, p = 0.037) remained associated with an increased risk of having post-infarct LVSD. Furthermore, the predictive value of glycaemic gap for post-infarct LVSD was not inferior to ABG in non-DM patients (p = 0.499), and only glycaemic gap, instead of ABG, could significantly predict post-infarct LVSD in DM patients (AUC = 0.688, 95% CI 0.591 to 0.774, p = 0.002). Conclusions Glycaemic gap was strongly associated with a change in LVEF and an increased risk of having post-infarct LVSD in patients following STEMI. In STEMI patients with DM, glycaemic gap could provide more valuable information than ABG in identifying patients at high risk of developing post-infarct LVSD.

Background High admission blood glucose (ABG) level has been associated with a poor short-term outcome among non-diabetic patients with heart failure (HF). We aimed to investigate the association between ABG levels and long-term (10 years) mortality in patients with or without pre-existing diabetes mellitus (DM) admitted with HF. Methods We analyzed data on 1811 patients with DM and 2182 patients without pre-existing DM who were hospitalized with HF during a prospective national survey. The relationship between ABG and 10-year mortality was assessed using the Cox proportional hazard model adjusting for multiple variables. ABG was analyzed both as a categorical (<110, 110–140, 140–200, and >200 mg/dL) and as a continuous variable. Results At 10 years of follow-up the cumulative probability of mortality was 85 and 78% among patients with DM and patients with no pre-existing DM (p < 0.001), respectively. Among patients with no pre-existing DM, glucose levels of 110–140, 140–200 and ≥200 mg/dL were associated with 9% (p = 0.140), 16% (p = 0.031) and 53% (p < 0.001) increased mortality risk compared to ABG < 110 mg/dL. Each 18-mg/dL (1-mmol/L) increase in glucose level was associated with a 5% increased risk of mortality (p < 0.001) among patients with no-pre-existing DM. In contrast, among patients with DM, only those with glucose levels >200 mg/dL had an increased mortality risk (>200 mg/dL versus <110 mg/dL; HR = 1.20, p = 0.032). Conclusion Among hospitalized HF patients with no pre-existing DM there is a linear relationship between ABG level and long-term mortality, whereas among patients with DM only ABG level >200 mg/dL is associated with increased mortality risk.

Background: Blood glucose and serum albumin can be biomarkers at admission since they are easily accessible and demonstrate correlations with cardiovascular diseases. The predictive ability of the admission blood glucose to albumin ratio (AAR) for long-term prognosis in patients with acute coronary syndrome (ACS) and its potential to elevate the predictive value of the Global Registry of Acute Coronary Events (GRACE) risk score in ACS patients post-percutaneous coronary intervention (PCI) remains unknown. Hence, this study aimed to investigate the incremental prognostic value of the AAR in patients with ACS undergoing PCI. Methods: A rigorous development-validation approach was implemented to optimize the GRACE risk score, utilizing the AAR parameter in 1498 patients suffering from ACS after PCI at the Third People’s Hospital of Chengdu, Sichuan, China. Results: Over a median of 31.25 (27.53, 35.10) months, the incidence of major adverse cardiac events (MACEs), defined as a composite outcome encompassing all-cause death, cardiac death, nonfatal myocardial infarction, nonfatal stroke, and unplanned repeat revascularization, was higher in individuals with higher AARs. Thus, the AAR was an independent predictor of long-term prognosis in ACS patients undergoing PCI (HR, 1.145; 95% CI: 1.045–1.255; p = 0.004). The integration of the AAR score with the GRACE risk score increased the C statistic from 0.717 (95% CI: 0.694–0.740) to 0.733 (95% CI: 0.690–0.776) (p < 0.01). Conclusions: The AAR is an independent predictor of prognosis in ACS patients and significantly increased the predictive value of the GRACE risk score.