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Adigbli D, Li Y, Hammond N, Chatoor R, Devaux AG, Li Q, Billot L, Annane D, Arabi Y, Bilotta F, Bohé J, Brunkhorst FM, Cavalcanti AB, Cook D, Engel C, Green-LaRoche D, He W, Henderson W, Hoedemaekers C, Iapichino G, Kalfon P, de La Rosa G, Lahooti A, Mackenzie I, Mahendran S, Mélot C, Mitchell I, Oksanen T, Polli F, Preiser JC, Garcia Soriano F, Vlok R, Wang L, Xu Y, Delaney AP, Di Tanna GL, Finfer S. A Patient-Level Meta-Analysis of Intensive Glucose Control in Critically Ill Adults. NEJM EVIDENCE 2024:EVIDoa2400082. [PMID: 38864749 DOI: 10.1056/evidoa2400082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
BACKGROUND Whether intensive glucose control reduces mortality in critically ill patients remains uncertain. Patient-level meta-analyses can provide more precise estimates of treatment effects than are currently available. METHODS We pooled individual patient data from randomized trials investigating intensive glucose control in critically ill adults. The primary outcome was in-hospital mortality. Secondary outcomes included survival to 90 days and time to live cessation of treatment with vasopressors or inotropes, mechanical ventilation, and newly commenced renal replacement. Severe hypoglycemia was a safety outcome. RESULTS Of 38 eligible trials (n=29,537 participants), 20 (n=14,171 participants) provided individual patient data including in-hospital mortality status for 7059 and 7049 participants allocated to intensive and conventional glucose control, respectively. Of these 1930 (27.3%) and 1891 (26.8%) individuals assigned to intensive and conventional control, respectively, died (risk ratio, 1.02; 95% confidence interval [CI], 0.96 to 1.07; P=0.52; moderate certainty). There was no apparent heterogeneity of treatment effect on in-hospital mortality in any examined subgroups. Intensive glucose control increased the risk of severe hypoglycemia (risk ratio, 3.38; 95% CI, 2.99 to 3.83; P<0.0001). CONCLUSIONS Intensive glucose control was not associated with reduced mortality risk but increased the risk of severe hypoglycemia. We did not identify a subgroup of patients in whom intensive glucose control was beneficial. (Funded by the Australian National Health and Medical Research Council and others; PROSPERO number CRD42021278869.).
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Affiliation(s)
- Derick Adigbli
- Critical Care Division, The George Institute for Global Health, Sydney
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
- Medical School, Faculty of Medical Sciences, University College London, London
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Yang Li
- Critical Care Division, The George Institute for Global Health, Sydney
| | - Naomi Hammond
- Critical Care Division, The George Institute for Global Health, Sydney
- Royal North Shore Hospital, Malcolm Fisher Department of Intensive Care, St Leonards, NSW, Australia
| | - Richard Chatoor
- Royal North Shore Hospital, Malcolm Fisher Department of Intensive Care, St Leonards, NSW, Australia
| | - Anthony G Devaux
- The George Institute for Global Health, Biostatistics and Data Science Division, Barangaroo, NSW, Australia
| | - Qiang Li
- The George Institute for Global Health, Biostatistics and Data Science Division, Barangaroo, NSW, Australia
| | - Laurent Billot
- The George Institute for Global Health, Biostatistics and Data Science Division, Barangaroo, NSW, Australia
| | - Djillali Annane
- Department of Intensive Care, Hôpital Raymond-Poincare, Garches, France
- PROMETHEUS IHU, Université Paris-Saclay, Garches, France
- Laboratory of Infection & Inflammation, School of Medicine Simone Veil Santé, Université Paris-Saclay, Montigny Le Bretonneux, France
- FHU SEPSIS (Saclay and Paris Seine Nord Endeavour to PerSonalize Interventions for Sepsis), Garches, France
| | - Yaseen Arabi
- Intensive Care Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Federico Bilotta
- Department of Anesthesiology and Intensive Care Medicine, University of Rome La Sapienza, Rome
| | - Julien Bohé
- Service d'Anesthésie-Réanimation-Médecine Intensive, Hospices Civils de Lyon, Groupement Hospitalier Sud, Lyon, France
| | - Frank Martin Brunkhorst
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | | | - Deborah Cook
- Departments of Medicine, Clinical Epidemiology & Biostatistics (Division of Critical Care), McMaster University, Hamilton, ON, Canada
| | - Christoph Engel
- Institute for Medical Informatics, Statistics and Epidemiology, Leipzig University, Leipzig, Germany
| | | | - Wei He
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing
| | - William Henderson
- Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Cornelia Hoedemaekers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gaetano Iapichino
- Anestesiologia e Rianimazione, Università degli Studi di Milano, Milan
| | | | | | - Afsaneh Lahooti
- Critical Care Division, The George Institute for Global Health, Sydney
- School of Science, Western Sydney University, Campbelltown, NSW, Australia
| | | | - Sajeev Mahendran
- The George Institute for Global Health, Biostatistics and Data Science Division, Barangaroo, NSW, Australia
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, St Leonards, NSW, Australia
| | - Christian Mélot
- Faculté de Médecine, Université Libre de Bruxelles, Brussels
| | - Imogen Mitchell
- Office of Research and Education, Canberra Health Services Library, Canberra, ACT, Australia
- School of Medicine and Psychology, Australian National University, Canberra, ACT, Australia
| | - Tuomas Oksanen
- Division of Intensive Care Medicine, Department of Anesthesiology and Intensive Care, HUS Helsinki University Hospital, Helsinki
| | - Federico Polli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
| | | | - Francisco Garcia Soriano
- Departamento de Clínica Médica-Emergências Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo
| | - Ruan Vlok
- Critical Care Division, The George Institute for Global Health, Sydney
- CareFlight Australia, Wentworthville, NSW, Australia
| | - Lingcong Wang
- Department ICU, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yuan Xu
- Department of Critical Care Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing
| | - Anthony P Delaney
- Critical Care Division, The George Institute for Global Health, Sydney
- The George Institute for Global Health, Biostatistics and Data Science Division, Barangaroo, NSW, Australia
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, St Leonards, NSW, Australia
| | - Gian Luca Di Tanna
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
- Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of Southern Switzerland, Lugano, Switzerland
- Department of Clinical Care, University of Bern, Bern, Switzerland
| | - Simon Finfer
- Critical Care Division, The George Institute for Global Health, Sydney
- Faculty of Medicine and Health, University of New South Wales, Randwick, NSW, Australia
- School of Public Health, Imperial College London, London
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2
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Esdaile H. Is it all relative? Diabet Med 2024; 41:e15331. [PMID: 38613171 DOI: 10.1111/dme.15331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Affiliation(s)
- Harriet Esdaile
- Faculty of Medicine, Department of Metabolism, Digestion and Reproduction, Imperial Centre for Translational and Experimental Medicine, Imperial College London, London, UK
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3
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Teotia K, Jia Y, Link Woite N, Celi LA, Matos J, Struja T. Variation in monitoring: Glucose measurement in the ICU as a case study to preempt spurious correlations. J Biomed Inform 2024; 153:104643. [PMID: 38621640 PMCID: PMC11103268 DOI: 10.1016/j.jbi.2024.104643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 03/29/2024] [Accepted: 04/12/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVE Health inequities can be influenced by demographic factors such as race and ethnicity, proficiency in English, and biological sex. Disparities may manifest as differential likelihood of testing which correlates directly with the likelihood of an intervention to address an abnormal finding. Our retrospective observational study evaluated the presence of variation in glucose measurements in the Intensive Care Unit (ICU). METHODS Using the MIMIC-IV database (2008-2019), a single-center, academic referral hospital in Boston (USA), we identified adult patients meeting sepsis-3 criteria. Exclusion criteria were diabetic ketoacidosis, ICU length of stay under 1 day, and unknown race or ethnicity. We performed a logistic regression analysis to assess differential likelihoods of glucose measurements on day 1. A negative binomial regression was fitted to assess the frequency of subsequent glucose readings. Analyses were adjusted for relevant clinical confounders, and performed across three disparity proxy axes: race and ethnicity, sex, and English proficiency. RESULTS We studied 24,927 patients, of which 19.5% represented racial and ethnic minority groups, 42.4% were female, and 9.8% had limited English proficiency. No significant differences were found for glucose measurement on day 1 in the ICU. This pattern was consistent irrespective of the axis of analysis, i.e. race and ethnicity, sex, or English proficiency. Conversely, subsequent measurement frequency revealed potential disparities. Specifically, males (incidence rate ratio (IRR) 1.06, 95% confidence interval (CI) 1.01 - 1.21), patients who identify themselves as Hispanic (IRR 1.11, 95% CI 1.01 - 1.21), or Black (IRR 1.06, 95% CI 1.01 - 1.12), and patients being English proficient (IRR 1.08, 95% CI 1.01 - 1.15) had higher chances of subsequent glucose readings. CONCLUSION We found disparities in ICU glucose measurements among patients with sepsis, albeit the magnitude was small. Variation in disease monitoring is a source of data bias that may lead to spurious correlations when modeling health data.
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Affiliation(s)
- Khushboo Teotia
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA.
| | - Yueran Jia
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Naira Link Woite
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Leo Anthony Celi
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA; Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - João Matos
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA; Faculty of Engineering, University of Porto (FEUP), Porto, Portugal; Institute for Systems and Computer Engineering, Technology and Science (INESCTEC), Porto, Portugal.
| | - Tristan Struja
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA; Medical University Clinic, Kantonsspital Aarau, Aarau, Switzerland.
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Gholamalizadeh M, Salimi Z, Mobarakeh KA, Mahmoudi Z, Tajadod S, Mousavi Mele M, Alami F, Bahar B, Doaei S, Khoshdooz S, Rahvar M, Gholami S, Pourtaleb M. The association between enteral nutrition with survival of critical patients with COVID-19. Immun Inflamm Dis 2024; 12:e1261. [PMID: 38717056 PMCID: PMC11078021 DOI: 10.1002/iid3.1261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 02/16/2024] [Accepted: 04/12/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) results in several complications and mortality in intensive care unit (ICU) patients. Limited studies have investigated the effect of enteral nutrition (EN) on the survival of COVID-19 patients in the ICU. The aim of this study was to investigate the association of EN with biochemical and pathological indices associated with mortality in ICU patients with COVID-19. METHODS This case-control study was conducted on 240 patients with COVID-19 hospitalized in the ICU including 120 eventual nonsurvived as the cases and 120 survived patients as the controls. All of the patients received EN as a high protein high volume or standard formula. Data on general information, anthropometric measurements, and the results of lab tests were collected. RESULTS The recovered patients received significantly more high protein (60.8% vs. 39.6%, p = .004) and high volume (61.6% vs. 42.3%, p = .005) formula compared to the nonsurvived group. Mortality was inversely associated with high volume (odds ratio [OR]: 0.45 confidence interval [CI]95%, p = .008) and high protein (OR: 0.42 CI95%, p = .003) formula. The results remained significant after adjusting for age and sex. Further adjustment for underlying diseases, smoking, body mass index, and the acute physiology and chronic health evaluation II (APACHE II) score did not change the results. CONCLUSION The findings of the study showed that there was a significant inverse association between mortality and high volume and high protein formula in patients with COVID-19. Further investigation is warranted.
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Affiliation(s)
| | - Zahra Salimi
- Student Research Committee, Faculty of Nutrition and Food TechnologyShahid Beheshti University of Medical SciencesTehranIran
| | - Khadijeh Abbasi Mobarakeh
- Department of Community Nutrition, Nutrition and Food Security Research Center, School of Nutrition and Food ScienceIsfahan University of Medical SciencesIsfahanIran
| | - Zahra Mahmoudi
- Department of NutritionScience and Research Branch Islamic Azad UniversityTehranIran
| | - Shirin Tajadod
- Department of Nutrition, School of Public Health, International CampusIran University of Medical SciencesTehranIran
| | | | - Farkhondeh Alami
- Nutrition Sciences and Applied Food Safety Studies, Research Centre for Global Development, School of Sport and Health SciencesUniversity of Central LancashirePrestonUK
| | - Bojlul Bahar
- Department of Nutrition, Student Research Committee, Faculty of MedicineUrmia University of Medical SciencesUrmiaIran
| | - Saeid Doaei
- Cancer Research CenterShahid Beheshti University of Medical SciencesTehranIran
| | - Sara Khoshdooz
- Razi Clinical Research Development Unit, Razi HospitalGuilan University of Medical SciencesRashtIran
| | - Masoume Rahvar
- Intensive Care Unit (ICU), Razi HospitalGuilan University of Medical SciencesRashtIran
| | - Somayeh Gholami
- Intensive Care Unit (ICU), Razi HospitalGuilan University of Medical SciencesRashtIran
| | - Masoume Pourtaleb
- Intensive Care Unit (ICU), Razi HospitalGuilan University of Medical SciencesRashtIran
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Honarmand K, Sirimaturos M, Hirshberg EL, Bircher NG, Agus MSD, Carpenter DL, Downs CR, Farrington EA, Freire AX, Grow A, Irving SY, Krinsley JS, Lanspa MJ, Long MT, Nagpal D, Preiser JC, Srinivasan V, Umpierrez GE, Jacobi J. Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024: Executive Summary. Crit Care Med 2024; 52:649-655. [PMID: 38240482 DOI: 10.1097/ccm.0000000000006173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024]
Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- GUIDE Canada, McMaster University, Hamilton, ON, Canada
| | - Michael Sirimaturos
- System Critical Care Pharmacy Services Leader, Houston Methodist Hospital, Houston, TX
| | - Eliotte L Hirshberg
- Adult and Pediatric Critical Care Specialist, University of Utah School of Medicine, Salt Lake City, UT
| | - Nicholas G Bircher
- Department of Nurse Anesthesia, School of Nursing, University of Pittsburgh, Pittsburgh, PA
| | - Michael S D Agus
- Harvard Medical School and Division Chief, Medical Critical Care, Boston Children's Hospital, Boston, MA
| | | | | | | | - Amado X Freire
- Pulmonary Critical Care and Sleep Medicine at the University of Tennessee Health Science Center, Memphis, TN
| | | | - Sharon Y Irving
- Department of Nursing and Clinical Care Services-Critical Care, University of Pennsylvania School of Nursing, Children's Hospital of Philadelphia, Philadelphia, PA
| | - James S Krinsley
- Director of Critical Care, Emeritus, Vagelos Columbia University College of Physicians and Surgeons, Stamford Hospital, Stamford, CT
| | - Michael J Lanspa
- Division of Critical Care, Intermountain Medical Center, Salt Lake City, UT
| | - Micah T Long
- Department of Anesthesiology, Division of Critical Care, University of Wisconsin School of Medicine & Public Health, Madison, WI
| | - David Nagpal
- Division of Cardiac Surgery, Critical Care Western, London Health Sciences Centre, London, ON, Canada
| | - Jean-Charles Preiser
- Medical Director for Research and Teaching, Erasme Hospital, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Vijay Srinivasan
- Departments of Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
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6
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Honarmand K, Sirimaturos M, Hirshberg EL, Bircher NG, Agus MSD, Carpenter DL, Downs CR, Farrington EA, Freire AX, Grow A, Irving SY, Krinsley JS, Lanspa MJ, Long MT, Nagpal D, Preiser JC, Srinivasan V, Umpierrez GE, Jacobi J. Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024. Crit Care Med 2024; 52:e161-e181. [PMID: 38240484 DOI: 10.1097/ccm.0000000000006174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024]
Abstract
RATIONALE Maintaining glycemic control of critically ill patients may impact outcomes such as survival, infection, and neuromuscular recovery, but there is equipoise on the target blood levels, monitoring frequency, and methods. OBJECTIVES The purpose was to update the 2012 Society of Critical Care Medicine and American College of Critical Care Medicine (ACCM) guidelines with a new systematic review of the literature and provide actionable guidance for clinicians. PANEL DESIGN The total multiprofessional task force of 22, consisting of clinicians and patient/family advocates, and a methodologist applied the processes described in the ACCM guidelines standard operating procedure manual to develop evidence-based recommendations in alignment with the Grading of Recommendations Assessment, Development, and Evaluation Approach (GRADE) methodology. Conflict of interest policies were strictly followed in all phases of the guidelines, including panel selection and voting. METHODS We conducted a systematic review for each Population, Intervention, Comparator, and Outcomes question related to glycemic management in critically ill children (≥ 42 wk old adjusted gestational age to 18 yr old) and adults, including triggers for initiation of insulin therapy, route of administration, monitoring frequency, role of an explicit decision support tool for protocol maintenance, and methodology for glucose testing. We identified the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak or as a good practice statement. In addition, "In our practice" statements were included when the available evidence was insufficient to support a recommendation, but the panel felt that describing their practice patterns may be appropriate. Additional topics were identified for future research. RESULTS This guideline is an update of the guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. It is intended for adult and pediatric practitioners to reassess current practices and direct research into areas with inadequate literature. The panel issued seven statements related to glycemic control in unselected adults (two good practice statements, four conditional recommendations, one research statement) and seven statements for pediatric patients (two good practice statements, one strong recommendation, one conditional recommendation, two "In our practice" statements, and one research statement), with additional detail on specific subset populations where available. CONCLUSIONS The guidelines panel achieved consensus for adults and children regarding a preference for an insulin infusion for the acute management of hyperglycemia with titration guided by an explicit clinical decision support tool and frequent (≤ 1 hr) monitoring intervals during glycemic instability to minimize hypoglycemia and against targeting intensive glucose levels. These recommendations are intended for consideration within the framework of the patient's existing clinical status. Further research is required to evaluate the role of individualized glycemic targets, continuous glucose monitoring systems, explicit decision support tools, and standardized glycemic control metrics.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- GUIDE Canada, McMaster University, Hamilton, ON, Canada
| | - Michael Sirimaturos
- System Critical Care Pharmacy Services Leader, Houston Methodist Hospital, Houston, TX
| | - Eliotte L Hirshberg
- Adult and Pediatric Critical Care Specialist, University of Utah School of Medicine, Salt Lake City, UT
| | - Nicholas G Bircher
- Department of Nurse Anesthesia, School of Nursing, University of Pittsburgh, Pittsburgh, PA
| | - Michael S D Agus
- Harvard Medical School and Division Chief, Medical Critical Care, Boston Children's Hospital, Boston, MA
| | | | | | | | - Amado X Freire
- Pulmonary Critical Care and Sleep Medicine at the University of Tennessee Health Science Center, Memphis, TN
| | | | - Sharon Y Irving
- Department of Nursing and Clinical Care Services-Critical Care, University of Pennsylvania School of Nursing, Children's Hospital of Philadelphia, Philadelphia, PA
| | - James S Krinsley
- Director of Critical Care, Emeritus, Vagelos Columbia University College of Physicians and Surgeons, Stamford Hospital, Stamford, CT
| | - Michael J Lanspa
- Division of Critical Care, Intermountain Medical Center, Salt Lake City, UT
| | - Micah T Long
- Department of Anesthesiology, Division of Critical Care, University of Wisconsin School of Medicine & Public Health, Madison, WI
| | - David Nagpal
- Division of Cardiac Surgery, Critical Care Western, London Health Sciences Centre, London, ON, Canada
| | - Jean-Charles Preiser
- Medical Director for Research and Teaching, Erasme Hospital, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Vijay Srinivasan
- Departments of Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
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Ketaroonrut N, Kiertiburanakul S, Sriphrapradang C. Optimal initial insulin dosage for managing steroid-induced hyperglycemia in hospitalized COVID-19 patients: A retrospective single-center study. SAGE Open Med 2024; 12:20503121241238148. [PMID: 38516643 PMCID: PMC10956164 DOI: 10.1177/20503121241238148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 02/22/2024] [Indexed: 03/23/2024] Open
Abstract
Objectives To determine the optimal initial insulin dosage for controlling hyperglycemia in COVID-19 patients receiving steroids, an area with limited data. Methods We retrospectively analyzed 156 COVID-19 patients with steroid-induced hyperglycemia treated with insulin. Patients were categorized by their total daily dose of subcutaneous insulin therapy when starting dexamethasone ⩾6 mg/day or equivalent dose of glucocorticoid: Group A (⩽0.29 units/kg), Group B (0.3-0.49 units/kg), Group C (0.5-0.69 units/kg), and Group B (⩾0.7 units/kg). Treatment failure was defined as mean blood glucose level > 280 mg/dL for two consecutive days after initiating insulin or any blood glucose ⩾ 400 mg/dL. Results The mean age was 64 ± 14 years, with 50% male, and a mean body mass index of 26.9 ± 6.9 kg/m2. Most had preexisting type 2 diabetes (62%). Mean admission blood glucose and HbA1c were 233 ± 112 mg/dL and 7.8 ± 2.3%, respectively. Group A had the lowest HbA1c (6.7 ± 1.2%), while group D had the highest (9.8 ± 2.5%). Median daily dexamethasone dosage or equivalent was 36 (IQR 16.72) mg, with no significant differences in among groups. Group A had the lowest treatment failure rate. There were no significant differences in treatment failure rate between Groups B, C, and D. Additionally, there were no statistically significant differences in mean BG across the groups: Group A 232 ± 42 mg/dL, Group B 247 ± 57 mg/dL, Group C 247 ± 61 mg/dL, and Group D 227 ± 67 mg/dL (p = 0.2). Group D had a significantly higher rate of level 1 hypoglycemia (p = 0.008), while no differences in clinically significant hypoglycemia (level 2 or 3) were observed between groups. Conclusions Among patients requiring TDD ⩾ 0.3 units/kg/day, there was no significant difference in treatment failure rate between Groups B, C, and D. Group D had the highest rate of level 1 hypoglycemia. This initial insulin dosage for hospitalized COVID-19 patients on high-dose steroid therapy should be personalized.
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Affiliation(s)
- Nuttavadee Ketaroonrut
- Faculty of Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sasisopin Kiertiburanakul
- Faculty of Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chutintorn Sriphrapradang
- Faculty of Medicine, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Liu X, Zhang G, Li D, Ruan Z, Wu B. Effect of 24 h glucose fluctuations on 30-day and 1-year mortality in patients with acute myocardial infarction: an analysis from the MIMIC-III database. Front Cardiovasc Med 2024; 11:1371606. [PMID: 38572310 PMCID: PMC10987860 DOI: 10.3389/fcvm.2024.1371606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/11/2024] [Indexed: 04/05/2024] Open
Abstract
Background It is recognized that patients' blood glucose fluctuates over time during acute disease episodes, especially during the outbreak of cardiovascular events, regardless of the presence of an abnormal blood glucose profile prior to admission to the hospital. Glucose fluctuations in patients with acute myocardial infarction (AMI) in the intensive care unit (ICU) are currently not adequately monitored and studied. We focused on blood glucose fluctuation values within 24 h of admission to assess their association with 30-day and 1-year mortality. Methods Data of patients with AMI aged 18 years or older from the Critical Care Medical Information Marketplace database III V1.4 were available for analysis in this research. Glucose data were obtained by measurement. A total of 390 of them were treated with PCI. The principal consequence was 30-day and 1-year mortality in patients with AMI. The effect of different glucose fluctuations within 24 h of admission on mortality was predicted by constructing a multivariate Cox regression model with four model adjustments and Kaplan-Meier survival curves. Additionally, we performed curve-fitting analyses to show the correlation between blood glucose fluctuations and risk of death. Results We selected 1,699 AMI patients into our study through screening. The included population was categorized into three groups based on the tertiles of blood glucose fluctuation values within 24 h of admission to the ICU. The three groups were <25 mg/dl, 25-88 mg/dl and >88 mg/dl. By cox regression analysis, the group with the highest blood glucose fluctuation values (>88 mg/dl) had the most significant increase in 30-day and 1-year mortality after excluding confounding factors (30-day mortality adjusted HR = 2.11; 95% CI = 1.49-2.98 p < 0.001; 1-year mortality adjusted HR = 1.83; 95% CI = 1.40-2.39 p < 0.001). As demonstrated by the Kaplan-Meier survival curves, the group with the greatest fluctuations in blood glucose has the worst 30-day and 1-year prognosis. Conclusions The extent of glucose fluctuations in patients with AMI in the first 24 h after ICU admission is an essential predictor as to 30-day as well as 1-year mortality. When blood glucose fluctuates more than 88 mg/dl within 24 h, mortality increases significantly with the range of blood glucose fluctuations.
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Affiliation(s)
- Xiaohe Liu
- The First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Guihong Zhang
- The First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Dan Li
- The First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Zhishen Ruan
- The First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Bo Wu
- Department of Cardiovascular Medicine, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
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Taira T, Inoue A, Kuroda Y, Oosuki G, Suga M, Nishimura T, Ijuin S, Ishihara S. The association between blood glucose levels on arrival at the hospital and patient outcomes after out-of-hospital cardiac arrest: A multicenter cohort study. Am J Emerg Med 2024; 77:46-52. [PMID: 38101226 DOI: 10.1016/j.ajem.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/09/2023] [Accepted: 12/02/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND This study aimed to investigate the association between blood glucose levels on arrival at the hospital and 1-month survival and favorable neurological outcomes in patients with OHCA using a large Japanese dataset. METHODS This study was a secondary analysis of data from the JAAM-OHCA Registry. Adult (≥18 years) patients with witnessed OHCA transported to emergency departments and registered in the database from June 2014 to December 2019 were included in the study. The primary and secondary endpoints were 1-month survival and 1-month favorable neurological outcomes (Glasgow-Pittsburgh Cerebral Performance Category score 1 or 2), respectively. Patients were categorized into the following four groups based on blood glucose levels on arrival at the hospital: <80 mg/dL, 80-179 mg/dL, 180-299 mg/dL, and ≥300 mg/dL. RESULTS This study included 11,387 patients. Survival rates were 1.3%, 3.1%, 7.0%, and 5.7% in the <80 mg/dL, 80-179 mg/dL, 180-299 mg/dL, and ≥ 300 mg/dL blood glucose groups, respectively. The rates of favorable neurological outcomes in each group were 0.4%, 1.5%, 3.3%, and 2.5%, respectively. Multivariable analysis showed that 180-299 mg/dL glucose was significantly associated with 1-month survival and favorable neurological outcomes compared with 80-179 mg/dL glucose (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.34-2.31; p < 0.001 and OR, 1.52; 95 % Cl, 1.02-2.25; p = 0.035, respectively). In this study, blood glucose levels with the best outcomes likely ranged from 200 to 250 mg/dL based on the cubic spline regression model. CONCLUSIONS Blood glucose level of 180-299 mg/dL on arrival at the hospital was significantly associated with 1-month survival and favorable neurological outcomes compared to blood glucose level of 80-179 mg/dL in patients with OHCA.
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Affiliation(s)
- Takuya Taira
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan; Faculty of Medicine, Graduate School of Medicine, Kagawa University, Kagawa, Japan
| | - Akihiko Inoue
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan.
| | - Yasuhiro Kuroda
- Faculty of Medicine, Graduate School of Medicine, Kagawa University, Kagawa, Japan
| | - Gentoku Oosuki
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan
| | - Masafumi Suga
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan
| | - Takeshi Nishimura
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan
| | - Shinichi Ijuin
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan
| | - Satoshi Ishihara
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan
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10
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Feng M, Zhou J. Relationship between time-weighted average glucose and mortality in critically ill patients: a retrospective analysis of the MIMIC-IV database. Sci Rep 2024; 14:4721. [PMID: 38413682 PMCID: PMC10899565 DOI: 10.1038/s41598-024-55504-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 02/24/2024] [Indexed: 02/29/2024] Open
Abstract
Blood glucose management in intensive care units (ICU) remains a controversial topic. We assessed the association between time-weighted average glucose (TWAG) levels and ICU mortality in critically ill patients in a real-world study. This retrospective study included critically ill patients from the Medical Information Mart for Intensive Care IV database. Glycemic distance is the difference between TWAG in the ICU and preadmission usual glycemia assessed with glycated hemoglobin at ICU admission. The TWAG and glycemic distance were divided into 4 groups and 3 groups, and their associations with ICU mortality risk were evaluated using multivariate logistic regression. Restricted cubic splines were used to explore the non-linear relationship. A total of 4737 adult patients were included. After adjusting for covariates, compared with TWAG ≤ 110 mg/dL, the odds ratios (ORs) of the TWAG > 110 mg/dL groups were 1.62 (95% CI 0.97-2.84, p = 0.075), 3.41 (95% CI 1.97-6.15, p < 0.05), and 6.62 (95% CI 3.6-12.6, p < 0.05). Compared with glycemic distance at - 15.1-20.1 mg/dL, the ORs of lower or higher groups were 0.78 (95% CI 0.50-1.21, p = 0.3) and 2.84 (95% CI 2.12-3.82, p < 0.05). The effect of hyperglycemia on ICU mortality was more pronounced in non-diabetic and non-septic patients. TWAG showed a U-shaped relationship with ICU mortality risk, and the mortality risk was minimal at 111 mg/dL. Maintaining glycemic distance ≤ 20.1 mg/dL may be beneficial. In different subgroups, the impact of hyperglycemia varied.
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Affiliation(s)
- Mengwen Feng
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Jing Zhou
- Department of Geriatric Intensive Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
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11
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Nguyen DL, Schott LL, Lowen CC, Desai AM, Baumer DL, Miranowski MK, Cao Z, Torres KA. Characteristics and feeding intolerance in critically ill adult patients receiving peptide-based enteral nutrition: A retrospective cross-sectional study. Clin Nutr ESPEN 2024; 59:270-278. [PMID: 38220386 DOI: 10.1016/j.clnesp.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/17/2023] [Accepted: 12/05/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND & AIMS Patients who experience gastrointestinal (GI) intolerance and hyperglycemia (or glucose intolerance) may not achieve appropriate caloric requirements and experience poor outcomes. The aim was to examine patient characteristics, disease severity, and enteral nutrition (EN) formula use in relation to feeding intolerance and healthcare resource utilization. METHODS A retrospective, cross-sectional design using real-world data from PINC AI™ Healthcare Database, 2015-2019 was used. Critically ill hospitalized adults who required ≥3 days of 100% whey peptide-based EN, other peptide-based diets, or intact-protein standard and diabetic EN formulas were included. Primary outcomes were enteral feeding intolerance, including GI intolerance and hyperglycemia. Pairwise comparisons of other peptide-based and standard intact-protein groups with 100% whey-peptide were completed. Associations between EN group with GI intolerance and hyperglycemia, respectively, were evaluated via multivariable logistic regressions. RESULTS Across 67 US hospitals, 19,679 inpatients (3242,100% whey-peptide, 3121 other peptide-based, and 13,316 standard intact-protein) were included. The 100% whey-peptide group had higher severity of illness and frequencies of comorbidities compared with other peptide-based and standard intact-protein groups. Hospital length of stay, intensive care unit stay, and 30-day readmission were similar across peptide-based cohorts. After controlling for demographic, visit, and severity characteristics, odds of GI intolerance were 18% higher for the other peptide-based group and 15% higher for the standard intact-protein group compared with the 100% whey-peptide group (each P < 0.03). In secondary analysis, odds of hyperglycemia were 81% higher for the other peptide-based group compared with the subgroup of very high-protein/low carbohydrate 100% whey-peptide (P < 0.001). CONCLUSIONS Lower GI intolerance and greater glycemic control were associated with the use of 100% whey-peptide formulas relative to other formulas. Appropriate and optimal delivery of EN using specialized peptide-based formulas is a strategy to minimize feeding intolerance and benefit critically ill patients.
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Affiliation(s)
- Douglas L Nguyen
- Loma Linda University Medical Center, 11234 Anderson St., Loma Linda, CA, 92354, USA.
| | - Laura L Schott
- PINC AI™ Applied Sciences, Premier Inc., 13034 Ballantyne Corporate Pl, Charlotte, NC, 28277, USA.
| | - Cynthia C Lowen
- Nestlé Health Science, 1041 US Highway 202, Bridgewater, NJ, 08807, USA.
| | - Amarsinh M Desai
- Nestlé Health Science, 1041 US Highway 202, Bridgewater, NJ, 08807, USA.
| | - Dorothy L Baumer
- PINC AI™ Applied Sciences, Premier Inc., 13034 Ballantyne Corporate Pl, Charlotte, NC, 28277, USA.
| | - Mary K Miranowski
- Nestlé Health Science, 1041 US Highway 202, Bridgewater, NJ, 08807, USA.
| | - Zhun Cao
- PINC AI™ Applied Sciences, Premier Inc., 13034 Ballantyne Corporate Pl, Charlotte, NC, 28277, USA.
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12
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van Herpt TTW, van Rosmalen F, Hulsewé HPMG, van der Horst-Schrivers ANA, Driessen M, Jetten R, Zelis N, de Galan BE, van Kuijk SMJ, van der Horst ICC, van Bussel BCT. Hyperglycemia and glucose variability are associated with worse survival in mechanically ventilated COVID-19 patients: the prospective Maastricht Intensive Care Covid Cohort. Diabetol Metab Syndr 2023; 15:253. [PMID: 38057908 DOI: 10.1186/s13098-023-01228-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 11/22/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Data on hyperglycemia and glucose variability in relation to diabetes mellitus, either known or unknown in ICU-setting in COVID-19, are scarce. We prospectively studied daily glucose variables and mortality in strata of diabetes mellitus and glycosylated hemoglobin among mechanically ventilated COVID-19 patients. METHODS We used linear-mixed effect models in mechanically ventilated COVID-19 patients to investigate mean and maximum difference in glucose concentration per day over time. We compared ICU survivors and non-survivors and tested for effect-modification by pandemic wave 1 and 2, diabetes mellitus, and admission HbA1c. RESULTS Among 232 mechanically ventilated COVID-19 patients, 21.1% had known diabetes mellitus, whereas 16.9% in wave 2 had unknown diabetes mellitus. Non-survivors had higher mean glucose concentrations (ß 0.62 mmol/l; 95%CI 0.20-1.06; ß 11.2 mg/dl; 95% CI 3.6-19.1; P = 0.004) and higher maximum differences in glucose concentrations per day (ß 0.85 mmol/l; 95%CI 0.37-1.33; ß 15.3; 95%CI 6.7-23.9; P = 0.001). Effect modification by wave, history of diabetes mellitus and admission HbA1c in associations between glucose and survival was not present. Effect of higher mean glucose concentrations was modified by pandemic wave (wave 1 (ß 0.74; 95% CI 0.24-1.23 mmol/l) ; (ß 13.3; 95%CI 4.3-22.1 mg/dl)) vs. (wave 2 (ß 0.37 (95%CI 0.25-0.98) mmol/l) (ß 6.7 (95% ci 4.5-17.6) mg/dl)). CONCLUSIONS Hyperglycemia and glucose variability are associated with mortality in mechanically ventilated COVID-19 patients irrespective of the presence of diabetes mellitus.
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Affiliation(s)
- Thijs T W van Herpt
- Department of Intensive Care Medicine, Maastricht University Medical Centre +, Debyelaan 25, 6229 HX, Maastricht, the Netherlands.
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands.
| | - Frank van Rosmalen
- Department of Intensive Care Medicine, Maastricht University Medical Centre +, Debyelaan 25, 6229 HX, Maastricht, the Netherlands
| | - Hendrica P M G Hulsewé
- Department of Intensive Care Medicine, Maastricht University Medical Centre +, Debyelaan 25, 6229 HX, Maastricht, the Netherlands
| | - Anouk N A van der Horst-Schrivers
- Department of Emergency Medicine, Maastricht University Medical Centre +, Maastricht, The Netherlands
- Department of Endocrinology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Mariëlle Driessen
- Department of Intensive Care Medicine, Maastricht University Medical Centre +, Debyelaan 25, 6229 HX, Maastricht, the Netherlands
| | - Robin Jetten
- Department of Intensive Care Medicine, Maastricht University Medical Centre +, Debyelaan 25, 6229 HX, Maastricht, the Netherlands
| | - Noortje Zelis
- Department of Internal Medicine, Maastricht University Medical Centre +, Maastricht, The Netherlands
| | - Bastiaan E de Galan
- Department of Endocrinology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Centre +, Debyelaan 25, 6229 HX, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Bas C T van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Centre +, Debyelaan 25, 6229 HX, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
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13
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Harden Waibel B, Kamien AJ. Resuscitation and Preparation of the Emergency General Surgery Patient. Surg Clin North Am 2023; 103:1061-1084. [PMID: 37838456 DOI: 10.1016/j.suc.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Traditionally, the workflow surrounding a general surgery patient allows for a period of evaluation and optimization of underlying medical issues to allow for risk modification; however, in the emergency, this optimization period is largely condensed because of its time-dependent nature. Because the lack of optimization can lead to complications, the ability to rapidly resuscitate the patient, proceed to procedural intervention to control the situation, and manage common medical comorbidities is paramount. This article provides an overview on these subjects.
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Affiliation(s)
- Brett Harden Waibel
- Division of Acute Care Surgery, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA.
| | - Andrew James Kamien
- Division of Acute Care Surgery, Department of Surgery, University of Nebraska Medical Center, 983280 Nebraska Medical Center, Omaha, NE 68198-3280, USA
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14
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Teotia K, Jia Y, Woite NL, Celi LA, Matos J, Struja T. Variation in monitoring: Glucose measurement in the ICU as a case study to preempt spurious correlations. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.10.12.23296568. [PMID: 37873163 PMCID: PMC10593024 DOI: 10.1101/2023.10.12.23296568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Objective Health inequities can be influenced by demographic factors such as race and ethnicity, proficiency in English, and biological sex. Disparities may manifest as differential likelihood of testing which correlates directly with the likelihood of an intervention to address an abnormal finding. Our retrospective observational study evaluated the presence of variation in glucose measurements in the Intensive Care Unit (ICU). Methods Using the MIMIC-IV database (2008-2019), a single-center, academic referral hospital in Boston (USA), we identified adult patients meeting sepsis-3 criteria. Exclusion criteria were diabetic ketoacidosis, ICU length of stay under 1 day, and unknown race or ethnicity. We performed a logistic regression analysis to assess differential likelihoods of glucose measurements on day 1. A negative binomial regression was fitted to assess the frequency of subsequent glucose readings. Analyses were adjusted for relevant clinical confounders, and performed across three disparity proxy axes: race and ethnicity, sex, and English proficiency. Results We studied 24,927 patients, of which 19.5% represented racial and ethnic minority groups, 42.4% were female, and 9.8% had limited English proficiency. No significant differences were found for glucose measurement on day 1 in the ICU. This pattern was consistent irrespective of the axis of analysis, i.e. race and ethnicity, sex, or English proficiency. Conversely, subsequent measurement frequency revealed potential disparities. Specifically, males (incidence rate ratio (IRR) 1.06, 95% confidence interval (CI) 1.01 - 1.21), patients who identify themselves as Hispanic (IRR 1.11, 95% CI 1.01 - 1.21), or Black (IRR 1.06, 95% CI 1.01 - 1.12), and patients being English proficient (IRR 1.08, 95% CI 1.01 - 1.15) had higher chances of subsequent glucose readings. Conclusion We found disparities in ICU glucose measurements among patients with sepsis, albeit the magnitude was small. Variation in disease monitoring is a source of data bias that may lead to spurious correlations when modeling health data.
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15
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Kalamaras I, Dafoulas G, Bargiota A, Votis K. Real-world data analysis for the association of glucose control and mortality in critically ill patients. Health Informatics J 2023; 29:14604582231199554. [PMID: 37864314 DOI: 10.1177/14604582231199554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
Existing results regarding the usage of glycemic control in critically ill patients for reduced morbidity and mortality have been based on clinical studies but could not be reproduced in large prospective studies. Current guidelines for glycemic control suggest a target blood glucose of 140-180 mg/dL, with lower targets being appropriate for some patients. The current study aims to provide additional evidence to this area, through the usage of real-world retrospective data of everyday clinical practice. We have used the large, credentialed access database MIMIC-IV to assess the effect of glycemic control to patient mortality. Glycemic control has been characterized by the percentage of time that the glucose measurements fall within pre-specified glucose bands. Results from logistic regression and survival analysis are reported, along with visualizations based on methods from the machine learning literature, which all suggest that increased time in low and high glucose values is related to increased ICU mortality and decreased survival.
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Affiliation(s)
- Ilias Kalamaras
- Informatics and Telematics Institute, Centre for Research and Technology Hellas, Thermi Thessaloniki, Greece
| | - George Dafoulas
- Department of Endocrinology and Metabolic Diseases, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Alexandra Bargiota
- Department of Endocrinology and Metabolic Diseases, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Konstantinos Votis
- Informatics and Telematics Institute, Centre for Research and Technology Hellas, Thermi Thessaloniki, Greece
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16
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Gunst J, Debaveye Y, Güiza F, Dubois J, De Bruyn A, Dauwe D, De Troy E, Casaer MP, De Vlieger G, Haghedooren R, Jacobs B, Meyfroidt G, Ingels C, Muller J, Vlasselaers D, Desmet L, Mebis L, Wouters PJ, Stessel B, Geebelen L, Vandenbrande J, Brands M, Gruyters I, Geerts E, De Pauw I, Vermassen J, Peperstraete H, Hoste E, De Waele JJ, Herck I, Depuydt P, Wilmer A, Hermans G, Benoit DD, Van den Berghe G. Tight Blood-Glucose Control without Early Parenteral Nutrition in the ICU. N Engl J Med 2023; 389:1180-1190. [PMID: 37754283 DOI: 10.1056/nejmoa2304855] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND Randomized, controlled trials have shown both benefit and harm from tight blood-glucose control in patients in the intensive care unit (ICU). Variation in the use of early parenteral nutrition and in insulin-induced severe hypoglycemia might explain this inconsistency. METHODS We randomly assigned patients, on ICU admission, to liberal glucose control (insulin initiated only when the blood-glucose level was >215 mg per deciliter [>11.9 mmol per liter]) or to tight glucose control (blood-glucose level targeted with the use of the LOGIC-Insulin algorithm at 80 to 110 mg per deciliter [4.4 to 6.1 mmol per liter]); parenteral nutrition was withheld in both groups for 1 week. Protocol adherence was determined according to glucose metrics. The primary outcome was the length of time that ICU care was needed, calculated on the basis of time to discharge alive from the ICU, with death accounted for as a competing risk; 90-day mortality was the safety outcome. RESULTS Of 9230 patients who underwent randomization, 4622 were assigned to liberal glucose control and 4608 to tight glucose control. The median morning blood-glucose level was 140 mg per deciliter (interquartile range, 122 to 161) with liberal glucose control and 107 mg per deciliter (interquartile range, 98 to 117) with tight glucose control. Severe hypoglycemia occurred in 31 patients (0.7%) in the liberal-control group and 47 patients (1.0%) in the tight-control group. The length of time that ICU care was needed was similar in the two groups (hazard ratio for earlier discharge alive with tight glucose control, 1.00; 95% confidence interval, 0.96 to 1.04; P = 0.94). Mortality at 90 days was also similar (10.1% with liberal glucose control and 10.5% with tight glucose control, P = 0.51). Analyses of eight prespecified secondary outcomes suggested that the incidence of new infections, the duration of respiratory and hemodynamic support, the time to discharge alive from the hospital, and mortality in the ICU and hospital were similar in the two groups, whereas severe acute kidney injury and cholestatic liver dysfunction appeared less prevalent with tight glucose control. CONCLUSIONS In critically ill patients who were not receiving early parenteral nutrition, tight glucose control did not affect the length of time that ICU care was needed or mortality. (Funded by the Research Foundation-Flanders and others; TGC-Fast ClinicalTrials.gov number, NCT03665207.).
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Affiliation(s)
- Jan Gunst
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Yves Debaveye
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Fabian Güiza
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Jasperina Dubois
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Astrid De Bruyn
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Dieter Dauwe
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Erwin De Troy
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Michael P Casaer
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Greet De Vlieger
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Renata Haghedooren
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Bart Jacobs
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Geert Meyfroidt
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Catherine Ingels
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Jan Muller
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Dirk Vlasselaers
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Lars Desmet
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Liese Mebis
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Pieter J Wouters
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Björn Stessel
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Laurien Geebelen
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Jeroen Vandenbrande
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Michiel Brands
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Ine Gruyters
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Ester Geerts
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Ilse De Pauw
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Joris Vermassen
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Harlinde Peperstraete
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Eric Hoste
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Jan J De Waele
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Ingrid Herck
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Pieter Depuydt
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Alexander Wilmer
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Greet Hermans
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Dominique D Benoit
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
| | - Greet Van den Berghe
- From the Clinical Department of Intensive Care Medicine (J.G., Y.D., F.G., A.D.B., D.D., E.D.T., M.P.C., G.D.V., R.H., B.J., G.M., C.I., J.M., D.V., L.D., L.M., P.J.W., G.V.B.) and the Medical Intensive Care Unit (A.W., G.H.), University Hospitals of KU Leuven, Leuven, the Department of Anesthesiology and Intensive Care Medicine, Jessa Hospital, Hasselt (J.D., B.S., L.G., J. Vandenbrande, M.B., I.G., E.G., I.D.P.), and the Department of Intensive Care Medicine, Ghent University Hospital, Ghent (J. Vermassen, H.P., E.H., J.J.D.W., I.H., P.D., D.D.B.) - all in Belgium
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Yang S, Cao L, Zhou Y, Hu C. A Retrospective Cohort Study: Predicting 90-Day Mortality for ICU Trauma Patients with a Machine Learning Algorithm Using XGBoost Using MIMIC-III Database. J Multidiscip Healthc 2023; 16:2625-2640. [PMID: 37701177 PMCID: PMC10493110 DOI: 10.2147/jmdh.s416943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/29/2023] [Indexed: 09/14/2023] Open
Abstract
Objective The aim of this study was to develop and validate a machine learning-based predictive model that predicts 90-day mortality in ICU trauma patients. Methods Data of patients with severe trauma were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. The performances of mortality prediction models generated using nine machine learning extreme gradient boosting (XGBoost), logistic regression, random forest, AdaBoost, multilayer perceptron (MLP) neural networks, support vector machine (SVM), light gradient boosting machine (GBM), k nearest neighbors (KNN) and gaussian naive bayes (GNB). The performance of the model was evaluated in terms of discrimination, calibration and clinical application. Results We found that the accuracy, sensitivity, specificity, PPV, NPV and F1 score of our proposed XGBoost model were 82.8%, 79.7%, 77.6%, 51.2%, 91.5% and 0.624, respectively. Among the nine models, the XGBoost model performed best. Compared with traditional logistic regression, the calibration curves of the XGBoost model and decision curve analysis (DCA) performed well. Conclusion Our study shows that the XGBoost model outperforms other machine learning models in predicting 90-day mortality in trauma patients. It can be used to assist clinicians in the early identification of mortality risk factors and early intervention to reduce mortality.
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Affiliation(s)
- Shan Yang
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, People’s Republic of China
| | - Lirui Cao
- West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, People’s Republic of China
| | - Yongfang Zhou
- Department of Respiratory Care, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, People’s Republic of China
| | - Chenggong Hu
- Department of Critical Care Medicine, West China Hospital of Sichuan University, Chengdu, Sichuan, 610041, People’s Republic of China
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18
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Yu A, Zhong Y, Feng X, Wei Y. Quantile regression for nonignorable missing data with its application of analyzing electronic medical records. Biometrics 2023; 79:2036-2049. [PMID: 35861675 DOI: 10.1111/biom.13723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 07/15/2022] [Indexed: 11/27/2022]
Abstract
Over the past decade, there has been growing enthusiasm for using electronic medical records (EMRs) for biomedical research. Quantile regression estimates distributional associations, providing unique insights into the intricacies and heterogeneity of the EMR data. However, the widespread nonignorable missing observations in EMR often obscure the true associations and challenge its potential for robust biomedical discoveries. We propose a novel method to estimate the covariate effects in the presence of nonignorable missing responses under quantile regression. This method imposes no parametric specifications on response distributions, which subtly uses implicit distributions induced by the corresponding quantile regression models. We show that the proposed estimator is consistent and asymptotically normal. We also provide an efficient algorithm to obtain the proposed estimate and a randomly weighted bootstrap approach for statistical inferences. Numerical studies, including an empirical analysis of real-world EMR data, are used to assess the proposed method's finite-sample performance compared to existing literature.
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Affiliation(s)
- Aiai Yu
- School of Statistics and Management, Shanghai University of Finance and Economics, Shanghai, China
| | - Yujie Zhong
- School of Statistics and Management, Shanghai University of Finance and Economics, Shanghai, China
| | - Xingdong Feng
- School of Statistics and Management, Shanghai University of Finance and Economics, Shanghai, China
| | - Ying Wei
- Department of Biostatistics, Columbia University, New York, New York, USA
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19
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Ren J, Zhang C, Liu Y, Han H, Liang Y, Zhang Q, Li S, Benn BS, Nugent KM, Qu H, Liang G, Bai Y. Prognostic value of initial routine laboratory blood tests in patients with aneurysmal subarachnoid hemorrhage requiring mechanical ventilation: a retrospective cohort study. J Thorac Dis 2023; 15:4413-4425. [PMID: 37691687 PMCID: PMC10482645 DOI: 10.21037/jtd-23-854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/27/2023] [Indexed: 09/12/2023]
Abstract
Background Aneurysmal subarachnoid hemorrhage (aSAH) necessitating mechanical ventilation (MV) presents a serious challenge for intensivists. Laboratory blood tests reflect individual physiological and biochemical states, and provide a useful tool for identifying patients with critical condition and stratifying risk levels of death. This study aimed to determine the prognostic role of initial routine laboratory blood tests in these patients. Methods This retrospective cohort study included 190 aSAH patients requiring MV in the neurosurgical intensive care unit from December 2019 to March 2022. Follow-up evaluation was performed in May 2022 via routine outpatient appointment or telephone interview. The primary outcomes were death occurring within 7 days after discharge (short-term mortality) or reported at time of follow-up (long-term mortality). Clinico-demographic and radiological characteristics, initial routine laboratory blood tests (e.g., metabolic panels and arterial blood gas analysis), and treatment were analyzed and compared in relation to mortality. Multivariable logistic and Cox regression analyses, with adjustment of other clinical predictors, were performed to determine independent laboratory test predictors for short- and long-term mortality, respectively. Results The patients had a median age of 62 years, with a median World Federation of Neurosurgical Societies grade (WFNS) score of 5 and a median modified Fisher grade (mFisher) score of 4. The short- and long-term mortality of this cohort were 60.5% and 65.3%, respectively. Compared with survivors, non-survivors had more severe disease upon admission based on neurological status and imaging features and a shorter disease course, and were more likely to receive conservative treatment. Initial ionized calcium was found to be independently associate with both short-term [adjusted odds ratio (OR): 0.92; 95% confidence interval (CI): 0.86 to 0.99; P=0.020] and long-term mortality [adjusted hazard ratio (HR): 0.95; 95% CI: 0.92 to 0.99; P=0.010], after adjusting for potential confounders. Moreover, the admission glucose level was found to be associated only with short-term mortality (adjusted OR: 1.19; 95% CI: 1.06 to 1.34; P=0.004). Conclusions Laboratory screening may provide a useful tool for the management of aSAH patients requiring MV in stratifying risk levels for mortality and for better clinical decision-making. Further study is needed to validate the effects of calcium supplementation and glucose-lowering therapy on the outcomes in this disease.
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Affiliation(s)
- Jiayi Ren
- School of Nursing, China Medical University, Shenyang, China
| | - Chong Zhang
- Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Yahua Liu
- Department of Emergency, Chinese PLA General Hospital (the Third Center), Beijing, China
| | - Hongguang Han
- Shuren International School, Shenyang Medical College, Shenyang, China
| | - Yong Liang
- Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Qiyan Zhang
- Department of Neurosurgery, First People’s Hospital of Benxi Manchu Autonomous County, Benxi, China
| | - Simeng Li
- Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Bryan S. Benn
- Pulmonary Department, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kenneth M. Nugent
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Hong Qu
- Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Guobiao Liang
- Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Yang Bai
- Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, China
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20
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Xia W, Li C, Kuang M, Wu Y, Xu L, Hu H. Predictive value of glycemic gap and stress glycemia ratio among critically ill patients with acute kidney injury: a retrospective analysis of the MIMIC-III database. BMC Nephrol 2023; 24:227. [PMID: 37528371 PMCID: PMC10394760 DOI: 10.1186/s12882-023-03278-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 07/21/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND AND AIMS Acute hyperglycemia has been identified as a risk factor for acute kidney injury occurrence and mortality in various diseases. The aim of the current study was to investigate the relationship between stress-induced hyperglycemia and adverse outcomes in critically ill patients with AKI. METHODS We extracted clinical data from Multiparameter Intelligent Monitoring in Intensive Care III version 1.4. Blood glucose and glycosylated hemoglobin during the first 24 h of ICU admission were used to calculate glycemic gap and stress hyperglycemia ratio (SHR). The outcomes included ICU mortality and need for renal replacement therapy. The association of the glycemic gap and SHR with outcomes were determined via logistic regression model and receiver-operating curves. The subgroup analysis of patients with and without diabetes was performed separately. RESULTS Higher glycemic gap and SHR were observed in patients who had increased need of RRT, higher mortality rates and longer ICU stay. Multivariate analysis demonstrated that higher glycemic gap (OR 1.01, 95%CI 1.00-1.02, P = 0.015), as well as SHR (OR 1.32; 95%CI 1.07-1.64, P = 0.009), were independently associated with ICU mortality after adjusting for potential covariates. In subgroup analysis, the association of glycemic gap and SHR were only significant in the non-diabetic population as for the outcome of ICU mortality (OR 2.25, 95%CI 1.64-3.08, P < 0.001 and OR 1.99; 95%CI 1.46-2.72, P < 0.001, respectively). CONCLUSIONS The glycemic gap and SHR might serve as a potential prognostic indicator of ICU mortality in critically ill patients with AKI, especially in the non-diabetic population.
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Affiliation(s)
- Wenkai Xia
- Department of Nephrology, Jiangyin People's Hospital Affiliated to Nantong University, 3 Yingrui Road, Jiangsu, 214400, Jiangyin, China
- Nephrologisches Zentrum, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Chenyu Li
- Nephrologisches Zentrum, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Meisi Kuang
- Nephrologisches Zentrum, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Yu Wu
- Department of Nephrology, Jiangyin People's Hospital Affiliated to Nantong University, 3 Yingrui Road, Jiangsu, 214400, Jiangyin, China
| | - Lingyu Xu
- Department of Nephrology, the Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Hong Hu
- Department of Nephrology, Jiangyin People's Hospital Affiliated to Nantong University, 3 Yingrui Road, Jiangsu, 214400, Jiangyin, China.
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21
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Meng C, Zhang J, Wang Y, Ye X, Zhuang S. Association between time in range 70-180 mg/dl in early stage and severity with in patients acute pancreatitis. BMC Endocr Disord 2023; 23:159. [PMID: 37496012 PMCID: PMC10369797 DOI: 10.1186/s12902-023-01414-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 07/12/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND It is not well understood whether glucose control in the early stage of acute pancreatitis(AP) is related to outcome. This study aimed to investigate the association between blood glucose time in range (TIR) of 70-180 mg/dL in the first 72 h(h) on admission and the progression of AP. METHODS Individuals admitted with AP to the Gastroenterology Department of the Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University between January 2017 and December 2021 were included and retrospectively evaluated. The percentage of TIR between 70 and 180 mg/dL in the first 72 h was calculated. According to the progress of AP at discharge, patients were divided into mild pancreatitis(MAP), and moderately severe acute pancreatitis (MSAP), or severe acute pancreatitis (SAP) groups. We examined the association between TIR or TIR ≥ 70% and AP severity using logistic regression models stratified by a glycosylated hemoglobin (HbA1c) level of 6.5%. Receiver operating characteristic (ROC) curves were generated to assess the ability of the TIR to predict MSAP or SAP. RESULTS A total of 298 individuals were included, of whom 35 developed MSAP or SAP. Logistic regression analyses indicated that TIR was independently associated with the incidence of more serious AP (odds ratio [OR] = 0.962, 95% CI = 0.941-0.983, p = 0.001). This association remained significant in individuals with HbA1c levels ≤ 6.5% (OR = 0.928, 95% CI = 0.888-0.969, p = 0.001). A TIR ≥ 70% was independently associated with reduced severity only in people with well-antecedent controls (OR = 0.238; 95% CI = 0.071-0.802; p = 0.020). TIR was not powerful enough to predict the severity of AP in both patients with poor antecedent glucose control (AUC = 0.641) or with HbA1c < 6.5% (AUC = 0.668). CONCLUSIONS TIR was independently associated with severity in patients with AP, particularly those with good antecedent glucose control.
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Affiliation(s)
- Chuchen Meng
- Department of Endocrinology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Jie Zhang
- Department of Endocrinology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Ying Wang
- Department of Endocrinology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Xinhua Ye
- Department of Endocrinology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Shaohua Zhuang
- Department of Gastroenterology, The Affiliated Changzhou No. 2 People's Hospital of Nanjing Medical University, 29 Xinglong Road Changzhou, Jiangsu, 213000, China.
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22
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Desgrouas M, Demiselle J, Stiel L, Brunot V, Marnai R, Sarfati S, Fiancette M, Lambiotte F, Thille AW, Leloup M, Clerc S, Beuret P, Bourion AA, Daum J, Malhomme R, Ravan R, Sauneuf B, Rigaud JP, Dequin PF, Boulain T. Insulin therapy and blood glucose management in critically ill patients: a 1-day cross-sectional observational study in 69 French intensive care units. Ann Intensive Care 2023; 13:53. [PMID: 37330419 DOI: 10.1186/s13613-023-01142-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/24/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND Hyperglycaemia is common in critically ill patients, but blood glucose and insulin management may differ widely among intensive care units (ICUs). We aimed to describe insulin use practices and the resulting glycaemic control in French ICUs. We conducted a multicentre 1-day observational study on November 23, 2021, in 69 French ICUs. Adult patients hospitalized for an acute organ failure, severe infection or post-operative care were included. Data were recorded from midnight to 11:59 p.m. the day of the study by 4-h periods. RESULTS Two ICUs declared to have no insulin protocol. There was a wide disparity in blood glucose targets between ICUs with 35 different target ranges recorded. In 893 included patients we collected 4823 blood glucose values whose distribution varied significantly across ICUs (P < 0.0001). We observed 1135 hyperglycaemias (> 1.8 g/L) in 402 (45.0%) patients, 35 hypoglycaemias (≤ 0.7 g/L) in 26 (2.9%) patients, and one instance of severe hypoglycaemia (≤ 0.4 g/L). Four hundred eight (45.7%) patients received either IV insulin (255 [62.5%]), subcutaneous (SC) insulin (126 [30.9%]), or both (27 [6.6%]). Among patients under protocolized intravenous (IV) insulin, 767/1681 (45.6%) of glycaemias were above the target range. Among patients receiving insulin, short- and long-acting SC insulin use were associated with higher counts of hyperglycaemias as assessed by multivariable negative binomial regression adjusted for the propensity to receive SC insulin: incidence rate ratio of 3.45 (95% confidence interval [CI] 2.97-4.00) (P < 0.0001) and 3.58 (95% CI 2.84-4.52) (P < 0.0001), respectively. CONCLUSIONS Practices regarding blood glucose management varied widely among French ICUs. Administration of short or long-acting SC insulin was not unusual and associated with more frequent hyperglycaemia. The protocolized insulin algorithms used failed to prevent hyperglycaemic events.
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Affiliation(s)
- Maxime Desgrouas
- Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, 45100, Orléans, France.
| | - Julien Demiselle
- Service de Médecine Intensive-Réanimation, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- UMR 1260 Nanomedicine Regenerative, INSERM, Université de Strasbourg, Strasbourg, France
| | - Laure Stiel
- Réanimation Médicale, Groupe Hospitalier de la Région Mulhouse Sud Alsace, Mulhouse, France
- UMR 1231, Inserm, LNC, Dijon, France
- LipSTIC, LabEx, Dijon, France
| | - Vincent Brunot
- Médecine Intensive Réanimation, Hôpital Universitaire Lapeyronie, Université de Montpellier, Montpellier, France
| | - Rémy Marnai
- Service de Réanimation Médico-Chirurgicale, Centre Hospitalier Le Mans, 72000, Le Mans, France
| | - Sacha Sarfati
- Medical Intensive Care Unit, Normandie Univ, UNIROUEN, UR 3830, CHU Rouen, 76000, Rouen, France
| | - Maud Fiancette
- Service de Médecine Intensive Réanimation, CHD Vendée la Roche Sur Yon, La Roche Sur Yon, France
| | - Fabien Lambiotte
- Service de Réanimation Polyvalente, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Arnaud W Thille
- CHU de Poitiers, Médecine Intensive Réanimation, Poitiers, France
| | - Maxime Leloup
- Service de Réanimation, Groupe Hospitalier La Rochelle Ré Aunis, La Rochelle, France
| | - Sébastien Clerc
- Service de Médecine Intensive Et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| | - Pascal Beuret
- Réanimation Et Soins Continus, Centre Hospitalier de Roanne, Roanne, France
| | | | - Johan Daum
- Médecine Intensive Réanimation, Centre Hospitalier Intercommunal Ballanger, Aulnay Sous Bois, France
| | - Rémi Malhomme
- Service de Réanimation, Centre Hospitalier Antibes Juan-Les-Pins, Antibes, France
| | - Ramin Ravan
- Réanimation Polyvalente et Surveillance Continue, Centre Hospitalier de Vichy, Vichy, France
| | - Bertrand Sauneuf
- Médecine Intensive Réanimation, Centre Hospitalier Public du Cotentin, 50100, Cherbourg en Cotentin, France
| | - Jean-Philippe Rigaud
- Médecine Intensive Réanimation, Centre Hospitalier de Dieppe, Avenue Pasteur, 76200, Dieppe, France
| | - Pierre-François Dequin
- Médecine Intensive - Réanimation, Hôpital Bretonneau, Tours, France
- Centre d'Étude Des Pathologies Respiratoires, UMR 1100, INSERM, Université de Tours, Tours, France
- INSERM CIC 1415, Tours, France
- CRICS-TriGGERSep Network, Paris, France
| | - Thierry Boulain
- Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, 45100, Orléans, France
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23
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Ceresoli M, Biloslavo A, Bisagni P, Ciuffa C, Fortuna L, La Greca A, Tartaglia D, Zago M, Ficari F, Foti G, Braga M. Implementing Enhanced Perioperative Care in Emergency General Surgery: A Prospective Multicenter Observational Study. World J Surg 2023; 47:1339-1347. [PMID: 37024758 PMCID: PMC10079158 DOI: 10.1007/s00268-023-06984-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2023] [Indexed: 04/08/2023]
Abstract
INTRODUCTION ERAS pathway has been proposed as the standard of care in elective abdominal surgery. Guidelines on ERAS in emergency surgery have been recently published; however, few evidences are still available in the literature. The aim of this study was to evaluate the feasibility of an enhanced recovery protocol in a large cohort of patients undergoing emergency surgery and to identify possible factors impacting postoperative protocol compliance. METHODS This is a prospective multicenter observational study including patients who underwent major emergency general surgery for either intra-abdominal infection or intestinal obstruction. The primary endpoint of the study is the adherence to ERAS postoperative protocol. Secondary endpoints are 30-day mortality and morbidity rates, and length of hospital stay. RESULTS A total of 589 patients were enrolled in the study, 256 (43.5%) of them underwent intestinal resection with anastomosis. Major complications occurred in 92 (15.6%) patients and 30-day mortality was 6.3%. Median adherence occurred on postoperative day (POD) 1 for naso-gastric tube removal, on POD 2 for mobilization and urinary catheter removal, and on POD 3 for oral intake and i.v. fluid suspension. Laparoscopy was significantly associated with adherence to postoperative protocol, whereas operative fluid infusion > 12 mL/Kg/h, preoperative hyperglycemia, presence of a drain, duration of surgery and major complications showed a negative association. CONCLUSIONS The present study supports that an enhanced recovery protocol in emergency surgery is feasible and safe. Laparoscopy was associated with an earlier recovery, whereas preoperative hyperglycemia, fluid overload, and abdominal drain were associated with a delayed recovery.
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Affiliation(s)
- Marco Ceresoli
- General and Emergency Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Via Pergolesi 33, 20900, Monza, Italy.
| | - Alan Biloslavo
- General Surgery Department, Cattinara Hospital, ASUGI, Strada Di Fiume, 447, 34149, Trieste, Italy
| | | | - Carlo Ciuffa
- General and Emergency Surgery, IRCCS Ospedale San Raffaele, Milan, Italy
| | | | - Antonio La Greca
- Emergency Surgery and Trauma, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma - Universita' Cattolica del Sacro Cuore, Rome RM, Italy
| | - Dario Tartaglia
- General, Emergency and Trauma Surgery Unit, University of Pisa, Pisa, Italy
| | - Mauro Zago
- Emergency and Robotic Surgery Department, Emergency and General Surgery Unit, A. Manzoni Hospital-ASST, Lecco, Italy
| | - Ferdinando Ficari
- General Surgery, Careggi Hospital, University of Firenze, Florence, Italy
| | - Giuseppe Foti
- Anesthesia and Intensive Care Department, School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Marco Braga
- General and Emergency Surgery Department, School of Medicine and Surgery, Milano-Bicocca University, Via Pergolesi 33, 20900, Monza, Italy
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24
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Adie SK, Ketcham SW, Marshall VD, Farina N, Sukul D. The association of glucose control on in-hospital mortality in the cardiac intensive care unit. J Diabetes Complications 2023; 37:108453. [PMID: 36907046 DOI: 10.1016/j.jdiacomp.2023.108453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 03/02/2023] [Accepted: 03/07/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Current guidelines recommend maintaining serum blood glucose (BG) levels between 150 and 180 mg/dL for patients admitted to the intensive care unit (ICU); however, these recommendations are based on randomized controlled trials among general ICU patients and observational studies among specific subgroups. Little is known about the impact of glucose control among patients cared for in the cardiac intensive care unit (CICU). METHODS This was a retrospective cohort analysis of patients >18 years of age admitted to the University of Michigan CICU from December 2016 through December 2020 with at least one BG measurement during CICU admission. The primary outcome was in-hospital mortality. The secondary outcome was CICU length of stay. RESULTS A total of 3217 patients were included. When analyzed based on quartiles of mean CICU BG, there were significant differences in in-hospital mortality across BG quartiles for those with diabetes mellitus (DM) and those without DM. In multivariable logistic regression, age, Elixhauser comorbidity score, use of mechanical ventilation, any hypoglycemic event, and any BG value >180 mg/dL were significant predictors for in-hospital mortality in both patients with and without DM, yet average BG was only predictive of in-hospital mortality in patients without DM. CONCLUSIONS This study highlights the importance of glucose control in critically ill adult patients admitted to the CICU. The trends in mortality based on quartiles and deciles of average BG suggest a difference in optimal blood glucose levels in those with and without DM. However, regardless of diabetes status, mortality increases with higher average BG.
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Affiliation(s)
- Sarah K Adie
- Department of Clinical Pharmacy, University of Michigan, Ann Arbor, MI, United States of America.
| | - Scott W Ketcham
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, MI, United States of America
| | - Vincent D Marshall
- University of Michigan College of Pharmacy, Ann Arbor, MI, United States of America
| | - Nicholas Farina
- Department of Clinical Pharmacy, University of Michigan, Ann Arbor, MI, United States of America
| | - Devraj Sukul
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, MI, United States of America
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25
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Chen AX, Radhakutty A, Zimmermann A, Stranks SN, Thompson CH, Burt MG. Clinical determinants of insulin requirements during treatment of prednisolone-induced hyperglycaemia. Diabetes Res Clin Pract 2023; 197:110557. [PMID: 36736733 DOI: 10.1016/j.diabres.2023.110557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 01/19/2023] [Accepted: 01/27/2023] [Indexed: 02/04/2023]
Abstract
AIMS The optimal treatment of prednisolone-associated hyperglycaemia is unclear, but guidelines recommend using a body weight-based daily insulin dose. This study evaluated how clinical variables were associated with insulin requirements in hospitalised patients with prednisolone-associated hyperglycaemia. METHODS In this prospective study, fifty adult inpatients who were taking prednisolone ≥20 mg/day and experienced hyperglycaemia were prescribed a 24-h intravenous insulin infusion. The daily insulin dose required to attain a mean glucose of 8 mmol/L was calculated. The associations between daily insulin dose and clinical variables were assessed. RESULTS The participants age was 69 ± 10 years, daily prednisolone dose was 34 ± 10 mg, HbA1c was 7.7 ± 2.0 % (61 ± 10 mmol/mol), 77 % had known type 2 diabetes and 30 % were female. In univariate analysis, weight was associated with daily insulin dose (r2 = 0.11, p = 0.024). A multivariate model comprising sex, HbA1c, a prior diagnosis of diabetes, diabetes treatment and weight explained nearly-two thirds of the variability in daily insulin dose (r2 = 0.65, p < 0.001). CONCLUSIONS In patients with prednisolone-associated hyperglycaemia, calculating insulin doses based on sex, HbA1c, diabetes status and regular diabetes treatment and weight may improve glycaemic control compared to weight-based dosing.
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Affiliation(s)
- Angela X Chen
- Department of Endocrinology, Flinders Medical Centre, Bedford Park, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, Australia.
| | - Anjana Radhakutty
- College of Medicine and Public Health, Flinders University, Bedford Park, Australia; Department of Medicine, Lyell McEwin Hospital, Elizabeth Vale, Australia.
| | - Anthony Zimmermann
- Department of Medicine, Lyell McEwin Hospital, Elizabeth Vale, Australia; Faculty of Medicine and Health Sciences, University of Adelaide, Adelaide, Australia.
| | - Stephen N Stranks
- Department of Endocrinology, Flinders Medical Centre, Bedford Park, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, Australia.
| | - Campbell H Thompson
- Faculty of Medicine and Health Sciences, University of Adelaide, Adelaide, Australia; Department of Medicine, Royal Adelaide Hospital, Adelaide, Australia.
| | - Morton G Burt
- Department of Endocrinology, Flinders Medical Centre, Bedford Park, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, Australia.
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26
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Suzuki M, Takeshita K, Kitamura Y, Kuribayashi M, Huang Z, Ichihara G, Oikawa S, Ichihara S. In Vitro Exposure to Glucose Alters the Expression of Phosphorylated Proteins in Platelets. Biomedicines 2023; 11:biomedicines11020543. [PMID: 36831080 PMCID: PMC9953272 DOI: 10.3390/biomedicines11020543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/30/2023] [Accepted: 02/07/2023] [Indexed: 02/16/2023] Open
Abstract
Diabetes mellitus (DM) is a pro-thrombotic state that can potentially cause serious cardiovascular complications. Platelet hyperactivation plays an important role in these pathological processes, however there is little or no information on the effect of hyperglycemia on platelet proteins. The aim of this study was to identify the molecular targets associated with platelet reactivity under hyperglycemia. Towards this goal, we examined the effects of the exposure of platelets to 1 and 2 h glucose (300 mg/dL) and control (vehicle and osmolality control using mannitol) on platelet proteins (n = 4 samples per group) using two-dimensional fluorescence difference gel electrophoresis (2D-DIGE) combined with MALDI-TOF/TOF tandem mass spectrometry. Two-hour exposure to glucose significantly up-regulated the expression of ATP synthase subunit beta, filamin-A, and L-lactate dehydrogenase A chain in platelets. Pro-Q Diamond staining confirmed the effect of 2 h glucose on vinculin, heat shock protein HSP 90-alpha, filamin-A, and fructose-bisphosphate aldolase A (platelet phosphorylated proteins). The identified proteins are involved in various cellular processes and functions and possibly in platelet reactivity under hyperglycemic conditions.
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Affiliation(s)
- Mizuho Suzuki
- Department of Environmental and Preventive Medicine, Jichi Medical University School of Medicine, Shimotsuke 329-0498, Japan
| | - Kyosuke Takeshita
- Department of Clinical Laboratory, Saitama Medical Center, Saitama University, Saitama 350-8550, Japan
| | - Yuki Kitamura
- Department of Environmental and Preventive Medicine, Jichi Medical University School of Medicine, Shimotsuke 329-0498, Japan
| | - Marie Kuribayashi
- Department of Human Functional Genomics, Life Science Research Center, Mie University, Tsu 514-8507, Japan
| | - Zhenlie Huang
- Department of Occupational and Environmental Health, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Gaku Ichihara
- Department of Occupational and Environmental Health, Nagoya University Graduate School of Medicine, Nagoya 466-8550, Japan
| | - Shinji Oikawa
- Department of Environmental and Molecular Medicine, Mie University Graduate School of Medicine, Tsu 514-8507, Japan
| | - Sahoko Ichihara
- Department of Environmental and Preventive Medicine, Jichi Medical University School of Medicine, Shimotsuke 329-0498, Japan
- Department of Human Functional Genomics, Life Science Research Center, Mie University, Tsu 514-8507, Japan
- Correspondence:
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27
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Qureshi N, Desousa J, Siddiqui AZ, Drees BM, Morrison DC, Qureshi AA. Dysregulation of Gene Expression of Key Signaling Mediators in PBMCs from People with Type 2 Diabetes Mellitus. Int J Mol Sci 2023; 24:2732. [PMID: 36769056 PMCID: PMC9916932 DOI: 10.3390/ijms24032732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 02/04/2023] Open
Abstract
Diabetes is currently the fifth leading cause of death by disease in the USA. The underlying mechanisms for type 2 Diabetes Mellitus (DM2) and the enhanced susceptibility of such patients to inflammatory disorders and infections remain to be fully defined. We have recently shown that peripheral blood mononuclear cells (PBMCs) from non-diabetic people upregulate expression of inflammatory genes in response to proteasome modulators, such as bacterial lipopolysaccharide (LPS) and soybean lectin (LEC); in contrast, resveratrol (RES) downregulates this response. We hypothesized that LPS and LEC will also elicit a similar upregulation of gene expression of key signaling mediators in (PBMCs) from people with type 2 diabetes (PwD2, with chronic inflammation) ex vivo. Unexpectedly, using next generation sequencing (NGS), we show for the first time, that PBMCs from PwD2 failed to elicit a robust LPS- and LEC-induced gene expression of proteasome subunit LMP7 (PSMB8) and mediators of T cell signaling that were observed in non-diabetic controls. These repressed genes included: PSMB8, PSMB9, interferon-γ, interferon-λ, signal-transducer-and-activator-of-transcription-1 (STAT1), human leukocyte antigen (HLA DQB1, HLA DQA1) molecules, interleukin 12A, tumor necrosis factor-α, transporter associated with antigen processing 1 (TAP1), and several others, which showed a markedly weak upregulation with toxins in PBMCs from PwD2, as compared to those from non-diabetics. Resveratrol (proteasome inhibitor) further downregulated the gene expression of these inflammatory mediators in PBMCs from PwD2. These results might explain why PwD2 may be susceptible to infectious disease. LPS and toxins may be leading to inflammation, insulin resistance, and thus, metabolic changes in the host cells.
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Affiliation(s)
- Nilofer Qureshi
- Department of Biomedical Sciences, Shock/Trauma Research Center, School of Medicine, University of Missouri-Kansas City, 2411 Holmes Street, Kansas City, MO 64108, USA
- Department of Pharmacology/Toxicology, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Julia Desousa
- Department of Biomedical Sciences, Shock/Trauma Research Center, School of Medicine, University of Missouri-Kansas City, 2411 Holmes Street, Kansas City, MO 64108, USA
- Department of Pharmacology/Toxicology, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Adeela Z. Siddiqui
- Department of Biomedical Sciences, Shock/Trauma Research Center, School of Medicine, University of Missouri-Kansas City, 2411 Holmes Street, Kansas City, MO 64108, USA
| | - Betty M. Drees
- Internal Medicine, School of Medicine, University of Missouri-Kansas City, 2411 Holmes Street, Kansas City, MO 64108, USA
| | - David C. Morrison
- Department of Biomedical Sciences, Shock/Trauma Research Center, School of Medicine, University of Missouri-Kansas City, 2411 Holmes Street, Kansas City, MO 64108, USA
| | - Asaf A. Qureshi
- Department of Biomedical Sciences, Shock/Trauma Research Center, School of Medicine, University of Missouri-Kansas City, 2411 Holmes Street, Kansas City, MO 64108, USA
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Mader JK, Brix JM, Aberer F, Vonbank A, Resl M, Hochfellner DA, Ress C, Pieber TR, Stechemesser L, Sourij H. [Hospital diabetes management (Update 2023)]. Wien Klin Wochenschr 2023; 135:242-255. [PMID: 37101046 PMCID: PMC10133359 DOI: 10.1007/s00508-023-02177-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 04/28/2023]
Abstract
This position statement presents the recommendations of the Austrian Diabetes Association for diabetes management of adult patients during inpatient stay. It is based on the current evidence with respect to blood glucose targets, insulin therapy and treatment with oral/injectable antidiabetic drugs during inpatient hospitalization. Additionally, special circumstances such as intravenous insulin therapy, concomitant therapy with glucocorticoids and use of diabetes technology during hospitalization are discussed.
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Affiliation(s)
- Julia K Mader
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich.
| | - Johanna M Brix
- Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
| | - Felix Aberer
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
| | - Alexander Vonbank
- Innere Medizin I mit Kardiologie, Angiologie, Endokrinologie, Diabetologie und Intensivmedizin, Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Michael Resl
- Abteilung für Innere Medizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich
| | - Daniel A Hochfellner
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
| | - Claudia Ress
- Innere Medizin, Department I, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Thomas R Pieber
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
| | - Lars Stechemesser
- Universitätsklinik für Innere Medizin I, Paracelsus Medizinische Privatuniversität - Landeskrankenhaus, Salzburg, Österreich
| | - Harald Sourij
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
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Chiu IM, Cheng CY, Chang PK, Li CJ, Cheng FJ, Lin CHR. Utilization of Personalized Machine-Learning to Screen for Dysglycemia from Ambulatory ECG, toward Noninvasive Blood Glucose Monitoring. BIOSENSORS 2022; 13:23. [PMID: 36671857 PMCID: PMC9855414 DOI: 10.3390/bios13010023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 06/17/2023]
Abstract
Blood glucose (BG) monitoring is important for critically ill patients, as poor sugar control has been associated with increased mortality in hospitalized patients. However, constant BG monitoring can be resource-intensive and pose a healthcare burden in clinical practice. In this study, we aimed to develop a personalized machine-learning model to predict dysglycemia from electrocardiogram (ECG) data. We used the Medical Information Mart for Intensive Care III database as our source of data and obtained more than 20 ECG records from each included patient during a single hospital admission. We focused on lead II recordings, along with corresponding blood sugar data. We processed the data and used ECG features from each heartbeat as inputs to develop a one-class support vector machine algorithm to predict dysglycemia. The model was able to predict dysglycemia using a single heartbeat with an AUC of 0.92 ± 0.09, a sensitivity of 0.92 ± 0.10, and specificity of 0.84 ± 0.04. After applying 10 s majority voting, the AUC of the model's dysglycemia prediction increased to 0.97 ± 0.06. This study showed that a personalized machine-learning algorithm can accurately detect dysglycemia from a single-lead ECG.
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Affiliation(s)
- I-Min Chiu
- Department of Computer Science and Engineering, National Sun Yat-Sen University, Kaohsiung 804, Taiwan
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Chi-Yung Cheng
- Department of Computer Science and Engineering, National Sun Yat-Sen University, Kaohsiung 804, Taiwan
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Po-Kai Chang
- Department of Computer Science and Engineering, National Sun Yat-Sen University, Kaohsiung 804, Taiwan
| | - Chao-Jui Li
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Fu-Jen Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan
| | - Chun-Hung Richard Lin
- Department of Computer Science and Engineering, National Sun Yat-Sen University, Kaohsiung 804, Taiwan
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Krinsley JS, Roberts G, Brownlee M, Schwartz M, Preiser JC, Rule P, Wang Y, Bahgat J, Umpierrez GE, Hirsch IB. Case-control Investigation of Previously Undiagnosed Diabetes in the Critically Ill. J Endocr Soc 2022; 7:bvac180. [PMID: 36532359 PMCID: PMC9753064 DOI: 10.1210/jendso/bvac180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Indexed: 11/27/2022] Open
Abstract
Context The outcome of patients requiring intensive care can be influenced by the presence of previously undiagnosed diabetes (undiagDM). Objective This work aimed to define the clinical characteristics, glucose control metrics, and outcomes of patients admitted to the intensive care unit (ICU) with undiagDM, and compare these to patients with known DM (DM). Methods This case-control investigation compared undiagDM (glycated hemoglobin A1c [HbA1c] ≥ 6.5%, no history of diabetes) to patients with DM. Glycemic ratio (GR) was calculated as the quotient of mean ICU blood glucose (BG) and estimated preadmission glycemia, based on HbA1c ([28.7 × HbA1c] - 46.7 mg/dL). GR was analyzed by bands: less than 0.7, 0.7 to less than or equal to 0.9, 0.9 to less than 1.1, and greater than or equal to 1.1. Risk-adjusted mortality was represented by the Observed:Expected mortality ratio (OEMR), calculated as the quotient of observed mortality and mortality predicted by the severity of illness (APACHE IV prediction of mortality). Results Of 5567 patients 294 (5.3%) were undiagDM. UndiagDM had lower ICU mean BG (P < .0001) and coefficient of variation (P < .0001) but similar rates of hypoglycemia (P = .08). Mortality and risk-adjusted mortality were similar in patients with GR less than 1.1 comparing undiagDM and DM. However, for patients with GR greater than or equal to 1.1, mortality (38.5% vs 10.3% [P = .0072]) and risk-adjusted mortality (OEMR 1.18 vs 0.52 [P < .0001]) were higher in undiagDM than in DM. Conclusion These data suggest that DM patients may develop tolerance to hyperglycemia that occurs during critical illness, a protective mechanism not observed in undiagDM, for whom hyperglycemia remains strongly associated with higher risk of mortality. These results may shed light on the natural history of diabetes.
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Affiliation(s)
- James S Krinsley
- Department of Medicine, Stamford Hospital and Columbia Vagelos Columbia College of Physicians and Surgeons, Stamford, CT 06902, USA
| | - Gregory Roberts
- Department of Pharmacology, Flinders Medical Centre, Bedford Park, SA 5042, Australia
| | - Michael Brownlee
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Michael Schwartz
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Brussels 1070, Belgium
| | - Peter Rule
- PRI Consultants, Los Altos Hills, CA 94024, USA
| | - Yu Wang
- Department of Medicine, Stamford Hospital and Columbia Vagelos Columbia College of Physicians and Surgeons, Stamford, CT 06902, USA
| | - Joseph Bahgat
- Department of Medicine, Stamford Hospital and Columbia Vagelos Columbia College of Physicians and Surgeons, Stamford, CT 06902, USA
| | | | - Irl B Hirsch
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA
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Li M, Deng CM, Su X, Zhang DF, Ding M, Ma JH, Wang DX. Hyperglycemia is associated with worse 3-year survival in older patients admitted to the intensive care unit after non-cardiac surgery: Post hoc analysis of a randomized trial. Front Med (Lausanne) 2022; 9:1003186. [PMID: 36579147 PMCID: PMC9790906 DOI: 10.3389/fmed.2022.1003186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 11/24/2022] [Indexed: 12/14/2022] Open
Abstract
Objective Hyperglycemia is common in critically ill patients after surgery and is associated with worse perioperative outcomes. Yet, the impact of postoperative hyperglycemia on long-term outcomes remains unclear. We therefore analyzed the association between early postoperative hyperglycemia and 3-year overall survival in older patients who were admitted to the intensive care unit after surgery. Methods This was a post hoc analysis of database obtained from a previous randomized trial and 3-year follow-up. The underlying trial enrolled 700 patients aged 65 years or older who were admitted to the intensive care unit after elective non-cardiac surgery. Early postoperative time-weighted average blood glucose was calculated and was divided into three levels, i.e., <8.0 mmol/L, from 8.0 to 10.0 mmol/L, and >10.0 mmol/L. The primary outcome was 3-year overall survival. The association between time-weighted average blood glucose level and 3-year overall survival was analyzed with Cox proportional hazard regression models. Subgroup analyses were also performed in patients with or without diabetes, and in patients following cancer or non-cancer surgery. Results A total of 677 patients (mean age 74 years, 60% male sex) were included in the final analysis. Within 3 years after surgery, deaths occurred in 22.1% (30/136) of patients with time-weighted average blood glucose <8.0 mmol/L, compared with 35.7% (81/227) of those from 8.0 to 10.0 mmol/L (unadjusted hazard ratio 1.75, 95% CI 1.15 to 2.67, P = 0.009), and 36.9% (116/314) of those >10.0 mmol/L (unadjusted hazard ratio 1.91, 95% CI 1.28 to 2.85, P = 0.002). After adjustment for confounding factors, the risk of 3-year mortality remained higher in patients with time-weighted average blood glucose from 8.0 to 10.0 mmol/L (adjusted hazard ratio 2.28, 95% CI 1.47 to 3.54, P < 0.001) and in those >10.0 mmol/L (adjusted hazard ratio 2.00, 95% CI 1.29 to 3.10, P = 0.002). Similar results were obtained in the subgroups of patients without diabetes and patients following cancer surgery. Conclusion For older patients admitted to the intensive care unit after elective non-cardiac surgery, high early blood glucose (time-weighted average blood glucose ≥ 8.0 mmol/L) was associated with poor 3-year overall survival. The impact of moderate glycemic control on long-term survival deserves further investigation.
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Affiliation(s)
- Mo Li
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Chun-Mei Deng
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China,*Correspondence: Chun-Mei Deng,
| | - Xian Su
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Dan-Feng Zhang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Mao Ding
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Jia-Hui Ma
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China
| | - Dong-Xin Wang
- Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital, Beijing, China,Outcomes Research Consortium, Cleveland, OH, United States,Dong-Xin Wang, ,
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Muacevic A, Adler JR, Narayanan N, Natarajaboopathi R, Reddy KS, Shanagonda D, Sakthivadivel V. Admission Blood Glucose Level as a Predictor of Outcome in Intensive Care Patients: A Cross-Sectional Study. Cureus 2022; 14:e32801. [PMID: 36578843 PMCID: PMC9788787 DOI: 10.7759/cureus.32801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION In the Intensive care unit (ICU), hyperglycemia is often observed; commonly associated with pre-existing diabetes or pre-diabetes or in nondiabetic patients. This study aimed to assess the role of admission blood sugar levels with outcomes in ICU patients. METHODS A total of 100 patients above 18 years of age were included in the study. A detailed history regarding the patient's age, sex, and any chronic illness were taken. Heart rate, systolic blood pressure, and Glasgow coma scale (GCS) scores were recorded. Admission blood glucose level, blood urea, total leucocyte count, and serum electrolytes were measured; and the outcome was noted. RESULTS The number of diabetics was significantly higher (65.5%) in the random blood sugar (RBS) ≥180 group. Hyponatremia was significantly associated with hyperglycemia. Patients with hyperglycemia had serum bicarbonate <18. A significantly greater number of patients with hyperglycemia had GCS scores of <8, and required mechanical ventilation. The duration of ICU stay and non-survivors were significantly higher in the hyperglycemia group. Random blood sugar at admission as a factor to assess outcome showed a sensitivity of 68.4 and specificity of 59.3 with a cut-off value of 197. CONCLUSION Admission of random blood sugar was significantly associated with poor outcomes. More stringent surveillance as well as routine blood glucose checks at the time of hospital admission should be emphasized.
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Pichardo-Lowden AR, Haidet P, Umpierrez GE, Lehman EB, Quigley FT, Wang L, Rafferty CM, DeFlitch CJ, Chinchilli VM. Clinical Decision Support for Glycemic Management Reduces Hospital Length of Stay. Diabetes Care 2022; 45:2526-2534. [PMID: 36084251 PMCID: PMC9679255 DOI: 10.2337/dc21-0829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/14/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Dysglycemia influences hospital outcomes and resource utilization. Clinical decision support (CDS) holds promise for optimizing care by overcoming management barriers. This study assessed the impact on hospital length of stay (LOS) of an alert-based CDS tool in the electronic medical record that detected dysglycemia or inappropriate insulin use, coined as gaps in care (GIC). RESEARCH DESIGN AND METHODS Using a 12-month interrupted time series among hospitalized persons aged ≥18 years, our CDS tool identified GIC and, when active, provided recommendations. We compared LOS during 6-month-long active and inactive periods using linear models for repeated measures, multiple comparison adjustment, and mediation analysis. RESULTS Among 4,788 admissions with GIC, average LOS was shorter during the tool's active periods. LOS reductions occurred for all admissions with GIC (-5.7 h, P = 0.057), diabetes and hyperglycemia (-6.4 h, P = 0.054), stress hyperglycemia (-31.0 h, P = 0.054), patients admitted to medical services (-8.4 h, P = 0.039), and recurrent hypoglycemia (-29.1 h, P = 0.074). Subgroup analysis showed significantly shorter LOS in recurrent hypoglycemia with three events (-82.3 h, P = 0.006) and nonsignificant in two (-5.2 h, P = 0.655) and four or more (-14.8 h, P = 0.746). Among 22,395 admissions with GIC (4,788, 21%) and without GIC (17,607, 79%), LOS reduction during the active period was 1.8 h (P = 0.053). When recommendations were provided, the active tool indirectly and significantly contributed to shortening LOS through its influence on GIC events during admissions with at least one GIC (P = 0.027), diabetes and hyperglycemia (P = 0.028), and medical services (P = 0.019). CONCLUSIONS Use of the alert-based CDS tool to address inpatient management of dysglycemia contributed to reducing LOS, which may reduce costs and improve patient well-being.
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Affiliation(s)
- Ariana R. Pichardo-Lowden
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
| | - Paul Haidet
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
- Department of Humanities and the Woodward Center for Excellence in Health Sciences Education, Penn State College of Medicine, Hershey, PA
| | | | - Erik B. Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Francis T. Quigley
- Department of Medicine, Penn State Health St. Joseph Medical Center, Reading, PA
| | - Li Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Colleen M. Rafferty
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
| | - Christopher J. DeFlitch
- Department of Emergency Medicine, Office of the Chief Medical Information Officer, Penn State Health, Hershey, PA
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
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Blonde L, Umpierrez GE, Reddy SS, McGill JB, Berga SL, Bush M, Chandrasekaran S, DeFronzo RA, Einhorn D, Galindo RJ, Gardner TW, Garg R, Garvey WT, Hirsch IB, Hurley DL, Izuora K, Kosiborod M, Olson D, Patel SB, Pop-Busui R, Sadhu AR, Samson SL, Stec C, Tamborlane WV, Tuttle KR, Twining C, Vella A, Vellanki P, Weber SL. American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. Endocr Pract 2022; 28:923-1049. [PMID: 35963508 PMCID: PMC10200071 DOI: 10.1016/j.eprac.2022.08.002] [Citation(s) in RCA: 136] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers. METHODS The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development. RESULTS This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes. CONCLUSIONS This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.
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Affiliation(s)
| | | | - S Sethu Reddy
- Central Michigan University, Mount Pleasant, Michigan
| | | | | | | | | | | | - Daniel Einhorn
- Scripps Whittier Diabetes Institute, La Jolla, California
| | | | | | - Rajesh Garg
- Lundquist Institute/Harbor-UCLA Medical Center, Torrance, California
| | | | | | | | | | | | - Darin Olson
- Colorado Mountain Medical, LLC, Avon, Colorado
| | | | | | - Archana R Sadhu
- Houston Methodist; Weill Cornell Medicine; Texas A&M College of Medicine; Houston, Texas
| | | | - Carla Stec
- American Association of Clinical Endocrinology, Jacksonville, Florida
| | | | - Katherine R Tuttle
- University of Washington and Providence Health Care, Seattle and Spokane, Washington
| | | | | | | | - Sandra L Weber
- University of South Carolina School of Medicine-Greenville, Prisma Health System, Greenville, South Carolina
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Roberts GW, Larwood C, Krinsley JS. Quantification of stress-induced hyperglycaemia associated with key diagnostic categories using the stress hyperglycaemia ratio. Diabet Med 2022; 39:e14930. [PMID: 35945696 DOI: 10.1111/dme.14930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/28/2022] [Indexed: 01/08/2023]
Abstract
AIM Stress-induced hyperglycaemia (SIH) is the acute increase from preadmission glycaemia and is associated with poor outcomes. Early recognition of SIH and subsequent blood glucose (BG) management improves outcomes, but the degree of SIH provoked by distinct diagnostic categories remains unknown. Quantification of SIH is now possible using the stress hyperglycaemia ratio (SHR), which measures the proportional change from preadmission glycaemia, based on haemoglobin A1c (HbA1c ). METHODS We identified eligible patients for eight medical (n = 892) and eight surgical (n = 347) categories. Maximum BG from the first 24 h of admission for medical, or postoperatively for surgical patients was used to calculate SHR. RESULTS Analysis of variance indicated differing SHR and BG within both the medical (p < 0.0001 for both) and surgical cohort (p < 0.0001 for both). Diagnostic categories were associated with signature levels of SHR that varied between groups. Medically, SHR was greatest for ST-elevation myocardial infarction (1.22 ± 0.33) and sepsis (1.37 ± 0.43). Surgically, SHR was greatest for colectomy (1.62 ± 0.48) and cardiac surgeries (coronary artery graft 1.56 ± 0.43, aortic valve replacement 1.71 ± 0.33, and mitral valve replacement 1.75 ± 0.34). SHR values remained independent of HbA1c , with no difference for those with HbA1c above or below 6.5% (p > 0.11 for each). BG however was highly dependent on HbA1c , invariably elevated in those with HbA1c ≥ 6.5% (p < 0.001 for each), and unreliably reflected SIH. CONCLUSION The acute stress response associated with various medical and surgical categories is associated with signature levels of SIH. Those with higher expected SHR are more likely to benefit from early SIH management, especially major surgery, which induced SIH typically 40% greater than medical cohorts. SHR equally recognised the acute change in BG from baseline across the full HbA1c spectrum while BG did not and poorly reflected SIH.
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Affiliation(s)
- Gregory W Roberts
- College of Medicine and Public Health, Flinders University, Flinders University Drive, Bedford Park, South Australia, Australia
- SA Pharmacy, Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia, Australia
| | - Crystal Larwood
- College of Medicine and Public Health, Flinders University, Flinders University Drive, Bedford Park, South Australia, Australia
| | - James S Krinsley
- Division of Critical Care, Department of Medicine, Stamford Hospital, and the Columbia Vagelos College of Physicians and Surgeons 1 Hospital Plaza, Stamford, Connecticut, USA
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Khan SA, Shields S, Abusamaan MS, Mathioudakis N. Association between dysglycemia and the Charlson Comorbidity Index among hospitalized patients with diabetes. J Diabetes Complications 2022; 36:108305. [PMID: 36108545 DOI: 10.1016/j.jdiacomp.2022.108305] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/02/2022] [Accepted: 09/03/2022] [Indexed: 01/08/2023]
Abstract
AIM Inpatient dysglycemia has been linked to short-term mortality, but longer-term mortality data are lacking. Our aim was to evaluate the association between inpatient dysglycemia and one-year mortality risk. METHODS Retrospective chart review of adults with diabetes hospitalized between 2015 and 2019. The Charlson Comorbidity Index (CCI) was used to estimate 1-year mortality risk, stratified into low (CCI ≤ 5) and high risk (CCI ≥6). Simple and multivariable logistic regression was used to evaluate the association between dysglycemic measures and high mortality risk. RESULTS Among 22,639 unique admissions, BG ≥ 180, ≥300, ≤70, <54 and <40 mg/dL were associated with adjusted odds of 1.43 (95 % CI, 1.33, 1.54), 1.58 (95 % CI, 1.48, 1.68), 2.16 (95 % CI, 2.01, 2.32), 2.58 (95 % CI, 2.32, 2.86), and 2.56 (95 % CI, 2.19, 2.99) for high mortality risk, respectively. Older age and Black race were positively associated with hyperglycemia and hypoglycemia. Myocardial infarction, congestive heart failure (CHF), and moderate to severe liver disease were most strongly associated with hyperglycemia, while renal disease, CHF, peripheral vascular disease, and peptic ulcer disease were most strongly associated with hypoglycemia. CONCLUSIONS Inpatient hypoglycemia and hyperglycemia were both positively associated with higher one-year mortality risk, with stronger magnitude of association observed for hypoglycemia. The association appears to be mediated mainly by presence of diabetes-related complications.
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Affiliation(s)
- Sara Atiq Khan
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Stephen Shields
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Mohammed S Abusamaan
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.
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Gunst J, Mebis L, Wouters PJ, Hermans G, Dubois J, Wilmer A, Hoste E, Benoit D, Van den Berghe G. Impact of tight blood glucose control within normal fasting ranges with insulin titration prescribed by the Leuven algorithm in adult critically ill patients: the TGC-fast randomized controlled trial. Trials 2022; 23:788. [PMID: 36123593 PMCID: PMC9483886 DOI: 10.1186/s13063-022-06709-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/01/2022] [Indexed: 11/16/2022] Open
Abstract
Background It remains controversial whether critical illness-related hyperglycemia should be treated or not, since randomized controlled trials (RCTs) have shown context-dependent outcome effects. Whereas pioneer RCTs found improved outcome by normalizing blood glucose in patients receiving early parenteral nutrition (PN), a multicenter RCT revealed increased mortality in patients not receiving early PN. Although withholding early PN has become the feeding standard, the multicenter RCT showing harm by tight glucose control in this context has been criticized for its potentially unreliable glucose control protocol. We hypothesize that tight glucose control is effective and safe using a validated protocol in adult critically ill patients not receiving early PN. Methods The TGC-fast study is an investigator-initiated, multicenter RCT. Patients unable to eat, with need for arterial and central venous line and without therapy restriction, are randomized upon ICU admission to tight (80–110 mg/dl) or liberal glucose control (only initiating insulin when hyperglycemia >215 mg/dl, and then targeting 180–215 mg/dl). Glucose measurements are performed on arterial blood by a blood gas analyzer, and if needed, insulin is only administered continuously through a central venous line. If the arterial line is no longer needed, glucose is measured on capillary blood. In the intervention group, tight control is guided by the validated LOGIC-Insulin software. In the control arm, a software alert is used to maximize protocol compliance. The intervention is continued until ICU discharge, until the patient is able to eat or no longer in need of a central venous line, whatever comes first. The study is powered to detect, with at least 80% power and a 5% alpha error rate, a 1-day difference in ICU dependency (primary endpoint), and a 1.5% increase in hospital mortality (safety endpoint), for which 9230 patients need to be included. Secondary endpoints include acute and long-term morbidity and mortality, and healthcare costs. Biological samples are collected to study potential mechanisms of organ protection. Discussion The ideal glucose target for critically ill patients remains debated. The trial will inform physicians on the optimal glucose control strategy in adult critically ill patients not receiving early PN. Trial registration ClinicalTrials.gov NCT03665207. Registered on 11 September 2018. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06709-8.
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Affiliation(s)
- Jan Gunst
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.,Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Liese Mebis
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.,Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Pieter J Wouters
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.,Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Greet Hermans
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium.,Medical Intensive Care unit, Clinical Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Jasperina Dubois
- Department of Anesthesiology and Intensive Care Medicine, Jessa Hospitals, Hasselt, Belgium
| | - Alexander Wilmer
- Medical Intensive Care unit, Clinical Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Eric Hoste
- Department of Intensive Care Medicine, University Hospitals Ghent, Ghent, Belgium
| | - Dominique Benoit
- Department of Intensive Care Medicine, University Hospitals Ghent, Ghent, Belgium
| | - Greet Van den Berghe
- Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium. .,Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium.
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38
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Yahia A, Szlávecz Á, Knopp JL, Norfiza Abdul Razak N, Abu Samah A, Shaw G, Chase JG, Benyo B. Estimating Enhanced Endogenous Glucose Production in Intensive Care Unit Patients with Severe Insulin Resistance. J Diabetes Sci Technol 2022; 16:1208-1219. [PMID: 34078114 PMCID: PMC9445352 DOI: 10.1177/19322968211018260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Critically ill ICU patients frequently experience acute insulin resistance and increased endogenous glucose production, manifesting as stress-induced hyperglycemia and hyperinsulinemia. STAR (Stochastic TARgeted) is a glycemic control protocol, which directly manages inter- and intra- patient variability using model-based insulin sensitivity (SI). The model behind STAR assumes a population constant for endogenous glucose production (EGP), which is not otherwise identifiable. OBJECTIVE This study analyses the effect of estimating EGP for ICU patients with very low SI (severe insulin resistance) and its impact on identified, model-based insulin sensitivity identification, modeling accuracy, and model-based glycemic clinical control. METHODS Using clinical data from 717 STAR patients in 3 independent cohorts (Hungary, New Zealand, and Malaysia), insulin sensitivity, time of insulin resistance, and EGP values are analyzed. A method is presented to estimate EGP in the presence of non-physiologically low SI. Performance is assessed via model accuracy. RESULTS Results show 22%-62% of patients experience 1+ episodes of severe insulin resistance, representing 0.87%-9.00% of hours. Episodes primarily occur in the first 24 h, matching clinical expectations. The Malaysian cohort is most affected. In this subset of hours, constant model-based EGP values can bias identified SI and increase blood glucose (BG) fitting error. Using the EGP estimation method presented in these constrained hours significantly reduced BG fitting errors. CONCLUSIONS Patients early in ICU stay may have significantly increased EGP. Increasing modeled EGP in model-based glycemic control can improve control accuracy in these hours. The results provide new insight into the frequency and level of significantly increased EGP in critical illness.
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Affiliation(s)
- Anane Yahia
- Department of Control Engineering and Information Technology, Budapest University of Technology and Economics, Budapest, Hungary
- Anane Yahia, Department of Control Engineering and Information Technology, Budapest University of Technology and Economics, 2. Magyar tudosok Blvd., Budapest, H-1117, Hungary.
| | - Ákos Szlávecz
- Department of Control Engineering and Information Technology, Budapest University of Technology and Economics, Budapest, Hungary
| | - Jennifer L. Knopp
- Mechanical Engineering, Centre of Bio-Engineering, University of Canterbury, Christchurch, NZ
| | | | - Asma Abu Samah
- Institute of Energy Infrastructure, Universiti Tenaga Nasional, Jalan Ikram-UNITEN, Kajang, Selangor, Malaysia
| | - Geoff Shaw
- Mechanical Engineering, Centre of Bio-Engineering, University of Canterbury, Christchurch, NZ
| | - J. Geoffrey Chase
- Mechanical Engineering, Centre of Bio-Engineering, University of Canterbury, Christchurch, NZ
| | - Balazs Benyo
- Department of Control Engineering and Information Technology, Budapest University of Technology and Economics, Budapest, Hungary
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Seisa MO, Saadi S, Nayfeh T, Muthusamy K, Shah SH, Firwana M, Hasan B, Jawaid T, Abd-Rabu R, Korytkowski MT, Muniyappa R, Antinori-Lent K, Donihi AC, Drincic AT, Luger A, Torres Roldan VD, Urtecho M, Wang Z, Murad MH. A Systematic Review Supporting the Endocrine Society Clinical Practice Guideline for the Management of Hyperglycemia in Adults Hospitalized for Noncritical Illness or Undergoing Elective Surgical Procedures. J Clin Endocrinol Metab 2022; 107:2139-2147. [PMID: 35690929 PMCID: PMC9653020 DOI: 10.1210/clinem/dgac277] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Indexed: 12/21/2022]
Abstract
CONTEXT Individuals with diabetes or newly recognized hyperglycemia account for over 30% of noncritically ill hospitalized patients. Management of hyperglycemia in these patients is challenging. OBJECTIVE To support development of the Endocrine Society Clinical Practice Guideline for management of hyperglycemia in adults hospitalized for noncritical illness or undergoing elective surgical procedures. METHODS We searched several databases for studies addressing 10 questions provided by a guideline panel from the Endocrine Society. Meta-analysis was conducted when feasible. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess certainty of evidence. RESULTS We included 94 studies reporting on 135 553 patients. Compared with capillary blood glucose, continuous glucose monitoring increased the number of patients identified with hypoglycemia and decreased mean daily blood glucose (BG) (very low certainty). Data on continuation of insulin pump therapy in hospitalized adults were sparse. In hospitalized patients receiving glucocorticoids, combination neutral protamine hagedorn (NPH) and basal-bolus insulin was associated with lower mean BG compared to basal-bolus insulin alone (very low certainty). Data on NPH insulin vs basal-bolus insulin in hospitalized adults receiving enteral nutrition were inconclusive. Inpatient diabetes education was associated with lower HbA1c at 3 and 6 months after discharge (moderate certainty) and reduced hospital readmissions (very low certainty). Preoperative HbA1c level < 7% was associated with shorter length of stay, lower postoperative BG and a lower number of neurological complications and infections, but a higher number of reoperations (very low certainty). Treatment with glucagon-like peptide-1 agonists or dipeptidyl peptidase-4 inhibitors in hospitalized patients with type 2 diabetes and mild hyperglycemia was associated with lower frequency of hypoglycemic events than insulin therapy (low certainty). Caloric oral fluids before surgery in adults with diabetes undergoing surgical procedures did not affect outcomes (very low certainty). Counting carbohydrates for prandial insulin dosing did not affect outcomes (very low certainty). Compared with scheduled insulin (basal-bolus or basal insulin + correctional insulin), correctional insulin was associated with higher mean daily BG and fewer hypoglycemic events (low certainty). CONCLUSION The certainty of evidence supporting many hyperglycemia management decisions is low, emphasizing importance of shared decision-making and consideration of other decisional factors.
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Affiliation(s)
- Mohamed O Seisa
- Correspondence: Mohamed Seisa, M.D., Mayo Clinic Rochester, Rochester, MN 55902, USA.
| | - Samer Saadi
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Tarek Nayfeh
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | | | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | | | - Bashar Hasan
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Tabinda Jawaid
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Rami Abd-Rabu
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | | | - Ranganath Muniyappa
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892, USA
| | | | - Amy C Donihi
- University of Pittsburgh School of Pharmacy,Pittsburgh, PA 15261, USA
| | | | - Anton Luger
- Medical University and General Hospital of Vienna, Austria
| | | | | | - Zhen Wang
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
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40
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Vedantam D, Poman DS, Motwani L, Asif N, Patel A, Anne KK. Stress-Induced Hyperglycemia: Consequences and Management. Cureus 2022; 14:e26714. [PMID: 35959169 PMCID: PMC9360912 DOI: 10.7759/cureus.26714] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2022] [Indexed: 01/08/2023] Open
Abstract
Hyperglycemia during stress is a common occurrence seen in patients admitted to the hospital. It is defined as a blood glucose level above 180mg/dl in patients without pre-existing diabetes. Stress-induced hyperglycemia (SIH) occurs due to an illness that leads to insulin resistance and decreased insulin secretion. Such a mechanism causes elevated blood glucose and produces a complex state to manage with external insulin. This article compiles various studies to explain the development and consequences of SIH in the critically ill that ultimately lead to an increase in mortality while also discussing the dire impact of SIH on certain acute illnesses like myocardial infarction and ischemic stroke. It also evaluates multiple studies to understand the management of SIH with insulin and proper nutritional therapy in the hospitalized patients admitted to the Intensive care unit (ICU) alongside the non-critical care unit. While emphasizing the diverse effects of improper control of SIH in the hospital, this article elucidates and discusses the importance of formulating a discharge plan due to an increased risk of type 2 diabetes in the recovered.
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41
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Association between stress hyperglycemia on admission and unfavorable neurological outcome in OHCA patients receiving ECPR. Clin Res Cardiol 2022; 112:529-538. [PMID: 35802161 DOI: 10.1007/s00392-022-02057-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/20/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Stress hyperglycemia is a normal response to stress and has been associated with outcomes in out-of-hospital cardiac arrest (OHCA) patients. However, this association remained unknown in OHCA patients receiving extracorporeal cardiopulmonary resuscitation (ECPR). This study aimed to examine the association between degree of stress hyperglycemia on admission and neurological outcomes at discharge in OHCA patients receiving ECPR. PATIENTS AND METHODS This was a retrospective cohort study of adult OHCA patients receiving ECPR between 2011 and 2021. Patients were classified into three groups: absence of stress hyperglycemia (blood glucose level on admission < 200 mg/dL), moderate stress hyperglycemia (200-299 mg/dL), and severe stress hyperglycemia (≥ 300 mg/dL). The primary outcome was unfavorable neurological outcome (Cerebral Performance Category: 3-5) at discharge. RESULTS This study included 160 patients; unfavorable neurological outcomes totaled 79.4% (n = 127). There were 23, 52, and 85 patients in the absence, moderate, and severe stress hyperglycemia groups, respectively. Of each group, unfavorable neurological outcomes constituted 91.3%, 71.2%, and 81.2%, respectively. Multivariable analysis showed that, compared with moderate stress hyperglycemia, absence of stress hyperglycemia on admission was significantly associated with unfavorable neurological outcome at discharge (odds ratio [OR], 4.70; 95% confidence interval [CI], 1.07-33.35; p = 0.039). CONCLUSION Compared with moderate stress hyperglycemia on admission, absence of stress hyperglycemia showed significant association with unfavorable neurological outcome at discharge in OHCA patients receiving ECPR.
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42
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Ram GK, Shekhar S, Singh RB, Anand R, De RR, Kumar N. Hyperglycemia Risk Evaluation of Hydrocortisone Intermittent Boluses versus Continuous Infusion in Septic Shock: A Prospective Randomized Trial. Anesth Essays Res 2022; 16:321-325. [PMID: 36620116 PMCID: PMC9813985 DOI: 10.4103/aer.aer_115_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/14/2022] [Accepted: 08/17/2022] [Indexed: 12/14/2022] Open
Abstract
Background Hydrocortisone showed an important role in reversal of shock when added to standard therapy in managing septic shock. Hyperglycemia is one of the most common side effects associated with corticosteroid treatment. Aims This study aimed to evaluate the risk of hyperglycemia of intermittent hydrocortisone boluses versus continuous infusion in septic shock patients. Settings and Design This was a prospective randomized controlled study conducted in a tertiary care teaching hospital. Materials and Methods One hundred and forty patients with septic shock and who received noradrenaline were enrolled in this randomized study. Group 1 was intermittent bolus hydrocortisone group (n = 70) and Group 2 was continuous infusion group (n = 70). All patients who were admitted with septic shock and who received noradrenaline and hydrocortisone were included in the study. Those patients who had exceeded 200 mg per day of hydrocortisone were excluded from the study. The primary outcome of the study was mean blood glucose. Statistical Analysis Used Qualitative variables were compared between the two groups with the Chi-square of the Fisher's exact test and continuous variables were compared using the Student's t-test or the Wilcoxon rank-sum test. Results Out of 112 patients, 54 patients received hydrocortisone as intermittent boluses (48.2%), and 58 patients (51.8%) received continuous infusion. For the primary outcome, no statistically or clinically significant difference was found in the blood glucose estimated marginal mean: 154.44 mg.dL-1 (95% confidence interval [CI]: 144.18-166.88) in the bolus group and 160.2 mg.dL-1 (95% CI: 143.82-176.76) in the infusion group with a mean difference of 05.76 mg.dL-1 (95% CI: -13.86-25.38). For the secondary outcomes of the study, no difference was found between the two groups in hyperglycemic or hypoglycemic events, mortality, length of stay in intensive care unit, and reversal of shock. Conclusions The risk of hyperglycemia is almost equal in both intermittent and continuous infusions of hydrocortisone in septic shock patients.
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Affiliation(s)
- Ganesh Kumar Ram
- Department of Trauma and Emergency (Anaesthesiology), Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Saurav Shekhar
- Department of Trauma and Emergency (Anaesthesiology), Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Raj Bahadur Singh
- Department of Trauma and Emergency (Anaesthesiology), Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Ravi Anand
- Department of Trauma and Emergency (Anaesthesiology), Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Ranjeet Rana De
- Department of Trauma and Emergency (Anaesthesiology), Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
| | - Nitin Kumar
- Department of Trauma and Emergency (Anaesthesiology), Indira Gandhi Institute of Medical Sciences, Patna, Bihar, India
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Mehta PB, Gosmanov AR. Inpatient glycemic control and community-acquired pneumonia outcomes in the pre-COVID-19 era: reviewing the evidence to pave the road for future studies. BMJ Open Diabetes Res Care 2022; 10:10/4/e003011. [PMID: 35790321 PMCID: PMC9257845 DOI: 10.1136/bmjdrc-2022-003011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Paras B Mehta
- Division of Endocrinology and Metabolism, University of California San Francisco, San Francisco, California, USA
| | - Aidar R Gosmanov
- Division of Endocrinology, Department of Medicine, Albany Medical College, Albany, New York, USA
- Endocrinology Section, Stratton VAMC, Albany, New York, USA
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Novel insights in endocrine and metabolic pathways in sepsis and gaps for future research. Clin Sci (Lond) 2022; 136:861-878. [PMID: 35642779 DOI: 10.1042/cs20211003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 11/17/2022]
Abstract
Sepsis is defined as any life-threatening organ dysfunction caused by a dysregulated host response to infection. It remains an important cause of critical illness and has considerable short- and long-term morbidity and mortality. In the last decades, preclinical and clinical research has revealed a biphasic pattern in the (neuro-)endocrine responses to sepsis as to other forms of critical illness, contributing to development of severe metabolic alterations. Immediately after the critical illness-inducing insult, fasting- and stress-induced neuroendocrine and cellular responses evoke a catabolic state in order to provide energy substrates for vital tissues, and to concomitantly activate cellular repair pathways while energy-consuming anabolism is postponed. Large randomized controlled trials have shown that providing early full feeding in this acute phase induced harm and reversed some of the neuro-endocrine alterations, which suggested that the acute fasting- and stress-induced responses to critical illness are likely interlinked and benefical. However, it remains unclear whether, in the context of accepting virtual fasting in the acute phase of illness, metabolic alterations such as hyperglycemia are harmful or beneficial. When patients enter a prolonged phase of critical illness, a central suppression of most neuroendocrine axes follows. Prolonged fasting and central neuroendocrine suppression may no longer be beneficial. Although pilot studies have suggested benefit of fasting-mimicking diets and interventions that reactivate the central neuroendocrine suppression selectively in the prolonged phase of illness, further study is needed to investigate patient-oriented outcomes in larger randomized trials.
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Xia W, Li C, Zhao D, Xu L, Kuang M, Yao X, Hu H. The Impact of Zinc Supplementation on Critically Ill Patients With Acute Kidney Injury: A Propensity Score Matching Analysis. Front Nutr 2022; 9:894572. [PMID: 35769374 PMCID: PMC9234667 DOI: 10.3389/fnut.2022.894572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/17/2022] [Indexed: 12/05/2022] Open
Abstract
Background Zinc is an essential trace element involved in multiple metabolic processes. Acute kidney injury (AKI) is associated with low plasma zinc, but outcomes with zinc supplementation in critically ill patients with AKI remain unknown. Our objective was to investigate the effectiveness of zinc supplementation in this patient population. Methods Critically ill patients with AKI were identified from the Medical Informative Mart for Intensive Care IV database. Prosperity score matching (PSM) was applied to match patients receiving zinc treatment to those without zinc treatment. The association between zinc sulfate use and in-hospital mortality and 30-day mortality, need for renal replacement therapy (RRT), and length of stay was determined by logistic regression and Cox proportional hazards modeling. Results A total of 9,811 AKI patients were included in the study. PSM yielded 222 pairs of patients who received zinc treatment and those who did not. Zinc supplementation was associated with reduced in-hospital mortality (HR = 0.48 (95% CI: 0.28, 0.83) P = 0.009) and 30-day mortality (HR = 0.51 (95% CI, 0.30, 0.86) P = 0.012). In the subgroup analysis, zinc use was associated with reduced in-hospital mortality in patients with stage 1 AKI and those with sepsis. Conclusions Zinc supplementation was associated with improved survival in critically ill patients with AKI. The supplementation was especially effective in those with stage 1 AKI and sepsis. These results need to be verified in randomized controlled trials.
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Affiliation(s)
- Wenkai Xia
- Department of Nephrology, The Jiangyin People's Hospital Affiliated to Nantong University, Jiangyin, China
- Nephrologisches Zentrum, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Chenyu Li
- Nephrologisches Zentrum, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Danyang Zhao
- Nephrologisches Zentrum, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Lingyu Xu
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Meisi Kuang
- Nephrologisches Zentrum, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Xiajuan Yao
- Department of Nephrology, The Jiangyin People's Hospital Affiliated to Nantong University, Jiangyin, China
| | - Hong Hu
- Department of Nephrology, The Jiangyin People's Hospital Affiliated to Nantong University, Jiangyin, China
- *Correspondence: Hong Hu
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Lou R, Jiang L, Wang M, Zhu B, Jiang Q, Wang P. Association Between Glycemic Gap and Mortality in Critically Ill Patients with Diabetes. J Intensive Care Med 2022; 38:42-50. [PMID: 35611506 DOI: 10.1177/08850666221101856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Dysglycemia is associated with poor outcomes in critically ill patients,which is uncertain in patients with diabetes regarding to the situation of glucose control before hospitalization. This study was aimed to investigate the effect of the difference between the level of blood glucose during ICU stay and before admission to ICU upon the outcomes of critically ill patients with diabetes. METHOD Patients with diabetes expected to stay for more than 24hs were enrolled, HbA1c was converted to A1C-derived average glucose (ADAG) by the equation: ADAG = [ (HbA1c * 28.7) - 46.7 ] * 18-1, blood glucose were measured four times a day during the first 7 days after admission, the mean glucose level(MGL) and SOFA (within 3, 5, and 7days) were calculated for each person, GAPadm and GAPmean was calculated as admission blood glucose and MGL minus ADAG, the incidence of moderate hypoglycemia(MH), severe hypoglycemia (SH), total dosage of glucocorticoids and average daily dosage of insulin, duration of renal replacement therapy(RRT), ventilator-free hours, and non-ICU days were also collected. Patients were divided into survival group and nonsurvival group according to survival or not at 28-day, the relationship between GAP and mortality were analyzed. RESULTS 431 patients were divided into survival group and nonsurvival group. The two groups had a comparable level of HbA1c, the nonsurvivors had greater APACHE II, SOFA, GAPadm, GAPmean-3, GAPmean-5, GAPmean-7 and higher MH and SH incidences. Less duration of ventilator-free, non-ICU stay and longer duration of RRT were recorded in the nonsurvival group. GAPmean-5 had the greatest predictive power with an AUC of 0.807(95%CI: 0.762-0.851), the cut-off value was 3.6 mmol/L (sensitivity 77.7% and specificity 76.6%). The AUC was increased to 0.852(95%CI: 0.814-0.889) incorporated with SOFA5 (NRI = 11.34%). CONCLUSION Glycemic GAP between the MGL within 5 days and ADAG was independently associated with 28-day mortality of critically ill patients with diabetes. The predictive power was optimized with addition of SOFA5.
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Affiliation(s)
- Ran Lou
- Department of Crtical Care Medicine, 71044Xuanwu Hospital Capital Medical University, 45Changchun Street, Xicheng District, Beijing 100053, China
| | - Li Jiang
- Department of Crtical Care Medicine, 71044Xuanwu Hospital Capital Medical University, 45Changchun Street, Xicheng District, Beijing 100053, China
| | - Meiping Wang
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, 10 Xitoutiao, Youanmenwai, Fengtai District, Beijing 100069, China
| | - Bo Zhu
- Department of Critical Care Medicine, 71043Fu Xing Hospital, Capital Medical University, 20A Fuxingmenwai Street, Xicheng District, Beijing 100038, China
| | - Qi Jiang
- Department of Critical Care Medicine, 71043Fu Xing Hospital, Capital Medical University, 20A Fuxingmenwai Street, Xicheng District, Beijing 100038, China
| | - Peng Wang
- Department of Critical Care Medicine, 71043Fu Xing Hospital, Capital Medical University, 20A Fuxingmenwai Street, Xicheng District, Beijing 100038, China
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Pattipati M, Gudavalli G, Dhulipalla L. The Influence of Obesity Hypoventilation Syndrome on the Outcomes of Patients With Diabetic Ketoacidosis. Cureus 2022; 14:e25157. [PMID: 35733497 PMCID: PMC9205449 DOI: 10.7759/cureus.25157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose: The effect of comorbid obesity hypoventilation syndrome (OHS) on hospitalized patients with diabetic ketoacidosis (DKA) has not been studied so far. This study elucidates the outcomes of DKA patients with OHS compared to those without OHS. Methods: Patients above 18 years of age were included in the study. The National Inpatient Sample (NIS) database of 2017 and 2018 was used and data were extracted using the International Classification of Diseases, Tenth Revision (ICD-10) codes; OHS ICD-10 code being “E66.2” and DKA ICD-10 codes being “E08.1, E09.1, E10.1, E11.1, and E13.1.” The comorbid medical conditions were also identified using the ICD-10 codes. Logistic regression analysis was performed to examine the impact of OHS on in-hospital outcomes of DKA patients. Results: OHS was prevalent in 0.61% of the general population, as per the NIS database in the years 2017 and 2018. Primary outcomes of the study were in-hospital mortality, whereas secondary outcomes included acute kidney failure, the requirement for invasive mechanical ventilation, length of stay, and cost of hospitalization. OHS in DKA patients was associated with increased mortality (odds ratio (OR): 4.35 (2.63-7.20), p < 0.00001; adjusted OR (aOR): 1.79 (1.01-3.15), p < 0.044), acute kidney failure (OR: 2.44 (1.79-3.33), p < 0.00001; aOR: 1.43 (1.03-2.00), p < 0.031), invasive mechanical ventilation (OR: 4.17 (2.90-5.98), p < 0.00001; aOR: 1.62 (1.08-2.41), p < 0.017), increased length of stay (10.02 ± 12.42 vs. 4.70 ± 6.31, p < 0.00001), and cost of care (132314 ± 197111.8 vs. 54245.06 ± 98079.89, p < 0.00001). All-cause mortality of patients with DKA and OHS using the Cox proportional hazards ratio was 1.70 (1.02-2.84, p < 0.024) after adjusting for age, race, sex, smoking, obesity, and comorbidities such as heart failure, hypertension, chronic obstructive pulmonary disease, chronic ischemic heart disease, chronic kidney disease, liver disease, and cerebral infarction. Conclusion: OHS is an independent risk factor for mortality in DKA, irrespective of the degree of obesity. Further prospective studies are recommended to study the effects of different treatment modalities of OHS such as identification of the need for early non-invasive ventilation or for early invasive mechanical ventilation to improve outcomes in DKA patients.
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Chou A, Carloni R, Xue W, Seeram V, Ferreira JA. Evaluation of glycemic control in critically ill patients with bacteremia: a retrospective, single-center cohort study. J Investig Med 2022; 70:1387-1391. [PMID: 35580916 DOI: 10.1136/jim-2021-002229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 11/03/2022]
Abstract
Dysglycemia is a common complication in hospitalized patients and has been suggested to play a significant role in the pathology and virulence of patients with bacteremia. The literature evaluating this relationship in critically ill patients, however, is limited. This retrospective, single-center cohort study aimed to investigate the relationship of glycemic control with 28-day intensive care unit (ICU)-free days in critically ill patients with bacteremia. Glycemic control was evaluated and determined based on time in targeted blood glucose range (TIR) of 70-140 mg/dL. Using a threshold of 80%, patients were then categorized into 2 groups: TIR-lo (<80%) and TIR-hi (≥80%). Unadjusted data identified a significant difference in ICU-free days (TIR-lo 21.29 days vs TIR-hi 24.08 days, p=0.007). However, due to an excess of zero ICU-free days, a zero-inflated Poisson model was used for analysis and demonstrated that patients in the TIR-lo group were 2.57 times more likely to have zero ICU-free days (p=0.033), which was attributed to mortality. Of the survivors, no difference was seen with TIR status and the number of ICU-free days (p=0.780). These findings demonstrate that glycemic control may increase the likelihood of being liberated from the ICU within a 28-day period, which the authors attributed to increased survival. However, of the patients who left the ICU, glycemic control was not associated with a significant difference in the number of ICU-free days.
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Affiliation(s)
- Alaina Chou
- Department of Pharmacy, UF Health Jacksonville, Jacksonville, Florida, USA
| | - Rachael Carloni
- Department of Pharmacy, UF Health Jacksonville, Jacksonville, Florida, USA
| | - Wei Xue
- Department of Biostatistics, UF Health Shands Hospital, Gainesville, Florida, USA
| | - Vandana Seeram
- Department of Pulmonary and Critical Care Medicine, UF Health Jacksonville, Jacksonville, Florida, USA
| | - Jason A Ferreira
- Department of Pharmacy, UF Health Jacksonville, Jacksonville, Florida, USA
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49
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Thouy F, Bohé J, Souweine B, Abidi H, Quenot JP, Thiollière F, Dellamonica J, Preiser JC, Timsit JF, Brunot V, Klich A, Sedillot N, Tchenio X, Roudaut JB, Mottard N, Hyvernat H, Wallet F, Danin PE, Badie J, Jospe R, Morel J, Mofredj A, Fatah A, Drai J, Mialon A, Ait Hssain A, Lautrette A, Fontaine E, Vacheron CH, Maucort-Boulch D, Klouche K, Dupuis C. Impact of prolonged requirement for insulin on 90-day mortality in critically ill patients without previous diabetic treatments: a post hoc analysis of the CONTROLING randomized control trial. Crit Care 2022; 26:138. [PMID: 35578303 PMCID: PMC9109308 DOI: 10.1186/s13054-022-04004-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Stress hyperglycemia can persist during an intensive care unit (ICU) stay and result in prolonged requirement for insulin (PRI). The impact of PRI on ICU patient outcomes is not known. We evaluated the relationship between PRI and Day 90 mortality in ICU patients without previous diabetic treatments. METHODS This is a post hoc analysis of the CONTROLING trial, involving 12 French ICUs. Patients in the personalized glucose control arm with an ICU length of stay ≥ 5 days and who had never previously received diabetic treatments (oral drugs or insulin) were included. Personalized blood glucose targets were estimated on their preadmission usual glycemia as estimated by their glycated A1c hemoglobin (HbA1C). PRI was defined by insulin requirement. The relationship between PRI on Day 5 and 90-day mortality was assessed by Cox survival models with inverse probability of treatment weighting (IPTW). Glycemic control was defined as at least one blood glucose value below the blood glucose target value on Day 5. RESULTS A total of 476 patients were included, of whom 62.4% were male, with a median age of 66 (54-76) years. Median values for SAPS II and HbA1C were 50 (37.5-64) and 5.7 (5.4-6.1)%, respectively. PRI was observed in 364/476 (72.5%) patients on Day 5. 90-day mortality was 23.1% in the whole cohort, 25.3% in the PRI group and 16.1% in the non-PRI group (p < 0.01). IPTW analysis showed that PRI on Day 5 was not associated with Day 90 mortality (IPTWHR = 1.22; CI 95% 0.84-1.75; p = 0.29), whereas PRI without glycemic control was associated with an increased risk of death at Day 90 (IPTWHR = 3.34; CI 95% 1.26-8.83; p < 0.01). CONCLUSION In ICU patients without previous diabetic treatments, only PRI without glycemic control on Day 5 was associated with an increased risk of death. Additional studies are required to determine the factors contributing to these results.
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Affiliation(s)
- François Thouy
- Service de Médecine Intensive Réanimation, CHU Hôpital Gabriel-Montpied, 58 rue Montalembert, 63000, Clermont Ferrand, France
| | - Julien Bohé
- Service d'Anesthésie-Réanimation-Médecine Intensive, Groupement hospitalier sud, Hospices Civils de Lyon, Pierre Bénite, France
| | - Bertrand Souweine
- Service de Médecine Intensive Réanimation, CHU Hôpital Gabriel-Montpied, 58 rue Montalembert, 63000, Clermont Ferrand, France
| | - Hassane Abidi
- Service d'Anesthésie-Réanimation-Médecine Intensive, Groupement hospitalier sud, Hospices Civils de Lyon, Pierre Bénite, France
| | - Jean-Pierre Quenot
- Service de Médecine Intensive Réanimation, CHU Dijon Bourgogne, Dijon, France
| | - Fabrice Thiollière
- Service d'Anesthésie-Réanimation-Médecine Intensive, Groupement hospitalier sud, Hospices Civils de Lyon, Pierre Bénite, France
| | - Jean Dellamonica
- Service de Médecine Intensive Réanimation, CHU Hôpital de L'Archet, Nice, France.,UR2CA Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur, Nice, France
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-François Timsit
- Service de Réanimation Médicale et des Maladies Infectieuses, Université Paris Diderot/Hôpital Bichat, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Vincent Brunot
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire, Montpellier, France
| | - Amna Klich
- Service de Biostatistique - Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France.,UMR5558, Laboratoire de Biométrie Et Biologie Évolutive, Équipe Biostatistique-Santé, CNRS, Villeurbanne, France
| | | | - Xavier Tchenio
- Service de Réanimation, Hôpital Fleyriat, Bourg en Bresse, France
| | | | - Nicolas Mottard
- Service d'Anesthésie-Réanimation-Médecine Intensive, Groupement hospitalier sud, Hospices Civils de Lyon, Pierre Bénite, France
| | - Hervé Hyvernat
- Service de Médecine Intensive Réanimation, CHU Hôpital de L'Archet, Nice, France
| | - Florent Wallet
- Service d'Anesthésie-Réanimation-Médecine Intensive, Groupement hospitalier sud, Hospices Civils de Lyon, Pierre Bénite, France
| | - Pierre-Eric Danin
- Service de Réanimation Médico-Chirurgicale, CHU Hôpital de L'Archet, Nice, France
| | - Julio Badie
- Service de Réanimation Médico-Chirurgicale, CHU Hôpital de L'Archet, Nice, France
| | - Richard Jospe
- Département d'Anesthésie et Réanimation, CHU, Saint Etienne, France
| | - Jérôme Morel
- Département d'Anesthésie et Réanimation, CHU, Saint Etienne, France
| | - Ali Mofredj
- Service de Réanimation, Hôpital du pays Salonais, Salon de Provence, France
| | - Abdelhamid Fatah
- Service de Réanimation, Hôpital Pierre Oudot, Bourgoin Jallieu, France
| | - Jocelyne Drai
- Laboratoire de Biochimie, Groupement Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Anne Mialon
- Laboratoire de Biochimie, Groupement Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Ali Ait Hssain
- Service de Médecine Intensive Réanimation, CHU Hôpital Gabriel-Montpied, 58 rue Montalembert, 63000, Clermont Ferrand, France
| | - Alexandre Lautrette
- Département d'Anesthésie et Réanimation, Centre Jean Perrin, Clermont Ferrand, France
| | - Eric Fontaine
- INSERM U1055 - LBFA, University Grenoble Alpes, Grenoble, France
| | - Charles-Hervé Vacheron
- Service d'Anesthésie-Réanimation-Médecine Intensive, Groupement hospitalier sud, Hospices Civils de Lyon, Pierre Bénite, France
| | - Delphine Maucort-Boulch
- Service de Biostatistique - Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France
| | - Kada Klouche
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire, Montpellier, France
| | - Claire Dupuis
- Service de Médecine Intensive Réanimation, CHU Hôpital Gabriel-Montpied, 58 rue Montalembert, 63000, Clermont Ferrand, France.
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Pansini A, Lombardi A, Morgante M, Frullone S, Marro A, Rizzo M, Martinelli G, Boccalone E, De Luca A, Santulli G, Mone P. Hyperglycemia and Physical Impairment in Frail Hypertensive Older Adults. Front Endocrinol (Lausanne) 2022; 13:831556. [PMID: 35498439 PMCID: PMC9048203 DOI: 10.3389/fendo.2022.831556] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/23/2022] [Indexed: 01/08/2023] Open
Abstract
Background Frailty is a multidimensional condition typical of elders. Frail older adults have a high risk of functional decline, hospitalization, and mortality. Hypertension is one of the most common comorbidities in elders. Hyperglycemia (HG) is frequently observed in frail older adults, and represents an independent predictor of worst outcomes, with or without diabetes mellitus (DM). We aimed at investigating the impact of HG on physical impairment in frailty. Methods We studied consecutive older adults with frailty and hypertension at the ASL (local health unit of the Italian Ministry of Health) of Avellino, Italy, from March 2021 to September 2021. Exclusion criteria were: age <65 years, no frailty, no hypertension, left ventricular ejection fraction <25%, previous myocardial infarction, previous primary percutaneous coronary intervention and/or coronary artery bypass grafting. Blood glucose, Hb1Ac, and creatinine were measured in all patients. Physical frailty was assessed applying the Fried Criteria; we performed a 5-meter gait speed (5mGS) test in all patients. Results 149 frail hypertensive older adults were enrolled in the study, of which 82 had normoglycemia (NG), and 67 had HG. We observed a significantly slower 5mGS in the HG group compared to the NG group (0.52 ± 0.1 vs. 0.69 ± 0.06; p<0.001). Moreover, we found a strong and significant correlation between 5mGS and glycemia (r: 0.833; p<0.001). A multivariable linear regression analysis using 5mGS as a dependent variable revealed a significant independent association with glycemia (p<0.001) after adjusting for likely confounders. Conclusions HG drives physical impairment in frail hypertensive older adults independently of DM.
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Affiliation(s)
| | - Angela Lombardi
- Department of Medicine, Einstein Institute for Aging Research, Einstein-Sinai Diabetes Research Center, Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY, United States
| | | | | | | | - Mario Rizzo
- ASL Avellino, Avellino, Italy
- Campania University, Caserta, Italy
| | | | | | | | - Gaetano Santulli
- Department of Medicine, Einstein Institute for Aging Research, Einstein-Sinai Diabetes Research Center, Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY, United States
| | - Pasquale Mone
- ASL Avellino, Avellino, Italy
- Department of Medicine, Einstein Institute for Aging Research, Einstein-Sinai Diabetes Research Center, Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY, United States
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