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Ivert T, Berge A, Bratt S, Dalén M. Incidence and healing times of postoperative sternal wound infections: a retrospective observational single-centre study. SCAND CARDIOVASC J 2024; 58:2330349. [PMID: 38500294 DOI: 10.1080/14017431.2024.2330349] [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: 08/22/2023] [Accepted: 03/09/2024] [Indexed: 03/20/2024]
Abstract
Objectives: Analyses of incidence and time required to heal sternal wound infections after heart surgery performed via a median sternotomy between 2020 and 2022. Results: Superficial wound infections (SWI) were five times more common (2.7%) than mediastinitis (0.5%) among 2693 patients. The median time between the operation and diagnosis of SWI was 26 (interquartile range [IQR] 15-33) days vs. 16 (IQR 9-25) days for mediastinitis (p = .12). Gram-negative bacteria caused 44% of the 85 infections. Sternal wound infection correlated to higher body mass index, female sex, smoking, diabetes mellitus, previous myocardial infarction, coronary artery bypass grafting, use of internal mammary graft, and re-entry for postoperative bleeding. Eight of 59 patients (13.6%) with sternal wound infections had bilateral mammary grafts, compared to 102 of 1191 patients (8.6%) without wound infections (p = .28). Negative pressure wound therapy was always used to treat mediastinitis and applied in 63% of patients with SWI. Two of 13 patients with mediastinitis (15%) and none of 72 patients with SWI died within 90 days after the operation. The median time until the wound healed was 1.9 (IQR 1.3-3.7) months after SWI vs. 1.7 (IQR 1.3-5.3) months after mediastinitis (p = .63). Six patients (7%) required longer than one year to treat the infection. Conclusions: Postoperative sternal wound infections usually appeared several weeks after surgery and were associated with factors as high body mass index, diabetes mellitus and coronary artery bypass. SWI were more common than mediastinitis and often required negative pressure wound therapy and similar treatment time as mediastinitis.
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Affiliation(s)
- Torbjörn Ivert
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Andreas Berge
- Unit of Infectious Diseases, Department of Medicine, Solna, Karolinska Institute, Stockholm, Sweden
- Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Sorosh Bratt
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Magnus Dalén
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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Câmara de Souza AB, Toyoshima MTK, Cukier P, Lottenberg SA, Bolta PMP, Lima EG, Serrano Júnior CV, Nery M. Electronic Glycemic Management System Improved Glycemic Control and Reduced Complications in Patients With Diabetes Undergoing Coronary Artery Bypass Surgery: A Randomized Controlled Trial. J Diabetes Sci Technol 2024:19322968241268352. [PMID: 39096188 DOI: 10.1177/19322968241268352] [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] [Indexed: 08/05/2024]
Abstract
BACKGROUND In-hospital hyperglycemia poses significant risks for patients with diabetes mellitus undergoing coronary artery bypass graft (CABG) surgery. Electronic glycemic management systems (eGMSs) like InsulinAPP offer promise in standardizing and improving glycemic control (GC) in these settings. This study evaluated the efficacy of the InsulinAPP protocol in optimizing GC and reducing adverse outcomes post-CABG. METHODS This prospective, randomized, open-label study was conducted with 100 adult type 2 diabetes mellitus (T2DM) patients post-CABG surgery, who were randomized into two groups: conventional care (gCONV) and eGMS protocol (gAPP). The gAPP used InsulinAPP for insulin therapy management, whereas the gCONV received standard clinical care. The primary outcome was a composite of hospital-acquired infections, renal function deterioration, and symptomatic atrial arrhythmia. Secondary outcomes included GC, hypoglycemia incidence, hospital stay length, and costs. RESULTS The gAPP achieved lower mean glucose levels (167.2 ± 42.5 mg/dL vs 188.7 ± 54.4 mg/dL; P = .040) and fewer patients-day with BG above 180 mg/dL (51.3% vs 74.8%, P = .011). The gAPP received an insulin regimen that included more prandial bolus and correction insulin (either bolus-correction or basal-bolus regimens) than the gCONV (90.3% vs 16.7%). The primary composite outcome occurred in 16% of gAPP patients compared with 58% in gCONV (P < .010). Hypoglycemia incidence was lower in the gAPP (4% vs 16%, P = .046). The gAPP protocol also resulted in shorter hospital stays and reduced costs. CONCLUSIONS The InsulinAPP protocol effectively optimizes GC and reduces adverse outcomes in T2DM patients' post-CABG surgery, offering a cost-effective solution for inpatient diabetes management.
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Affiliation(s)
- Alexandre Barbosa Câmara de Souza
- Department of Endocrinology and Metabolism, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marcos Tadashi Kakitani Toyoshima
- Oncoendocrinology Service, Instituto do Câncer do Estado de São Paulo Octávio Frias de Oliveira, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Priscilla Cukier
- Department of Endocrinology and Metabolism, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Simão Augusto Lottenberg
- Department of Endocrinology and Metabolism, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Paula Mathias Paulino Bolta
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo Gomes Lima
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Carlos Vicente Serrano Júnior
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marcia Nery
- Department of Endocrinology and Metabolism, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Takahashi T, Inose H, Hirai T, Matsukura Y, Morishita S, Egawa S, Hashimoto J, Takahashi K, Yoshii T. Factors associated with the time required for CRP normalization in pyogenic spondylitis: A retrospective observational study. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 17:100301. [PMID: 38225932 PMCID: PMC10788255 DOI: 10.1016/j.xnsj.2023.100301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 11/06/2023] [Accepted: 11/29/2023] [Indexed: 01/17/2024]
Abstract
Background Treatment for pyogenic spondylitis tends to be prolonged; however, few studies have examined the factors associated with the time required for infection control. Therefore, we analyzed a consecutive cohort of patients to identify factors associated with the time required to control infection in pyogenic spondylitis. This study aimed to clarify the factors linked to the duration necessary for achieving infection control in cases of pyogenic spondylitis, using C-reactive protein (CRP) normalization as an indicator. Methods In this retrospective observational study, we investigated 108 patients diagnosed with pyogenic spondylitis. We evaluated the number of days from the first visit to CRP normalization; for cases wherein CRP did not normalize, the number of days to the date of final blood sampling was evaluated. In the present study, infection control in pyogenic spondylitis was defined as a CRP falling within the normal range (≤0.14 mg/dL). We performed univariate and multivariate Cox regression analyses to identify various factors associated with the time required for CRP normalization in pyogenic spondylitis. Results The mean time required for CRP normalization was 148 days. Univariate Cox regression analysis showed that the serum creatinine level, estimated glomerular filtration rate (eGFR), lymphocyte percentage, neutrophil percentage, CRP level, CRP-albumin ratio, and neutrophil-to-lymphocyte ratio were significantly associated with the time required to control infection. Multivariate Cox regression analysis showed that a higher neutrophil percentage, diabetes mellitus, and a lower eGFR were the independent factors associated with a longer infection control time. Conclusions We found that a higher neutrophil percentage, diabetes mellitus, and a lower eGFR were significantly associated with a longer time for CRP normalization in pyogenic spondylitis. These findings may help identify patients with pyogenic spondylitis who are at a high risk for an extended infection control period.
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Affiliation(s)
- Takuya Takahashi
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Hiroyuki Inose
- Department of Orthopedic and Trauma Research, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
- Department of Orthopaedic Surgery, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya-shi, Saitama 343-8555, Japan
| | - Takashi Hirai
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Yu Matsukura
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Shingo Morishita
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Satoru Egawa
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Jun Hashimoto
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Kunihiko Takahashi
- Department of Biostatistics, M&D Data Science Center, Tokyo Medical and Dental University, 2-3-10 Kanda Surugadai, Chiyoda-ku, Tokyo 101‑0062, Japan
| | - Toshitaka Yoshii
- Department of Orthopedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
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Zhou J, Zhang M, Ju X, Wang H, Xiao H, Zhai Z, Zhong X, Hong J. Increased monocytic myeloid-derived suppressor cells in type 2 diabetes correlate with hyperglycemic and was a risk factor of infection and tumor occurrence. Sci Rep 2024; 14:4384. [PMID: 38388535 PMCID: PMC10883972 DOI: 10.1038/s41598-024-54496-w] [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: 08/30/2023] [Accepted: 02/13/2024] [Indexed: 02/24/2024] Open
Abstract
To investigate the frequency of monocytic myeloid-derived suppressor cells (M-MDSCs) in type 2 diabetes mellitus (T2DM) patients and explore the potential associations between M-MDSCs, glycemic control, and the occurrence of infections and tumor. 102 healthy and 77 T2DM individuals were enrolled. We assessed the M-MDSCs frequency, levels of fasting plasma glucose (FPG), haemoglobin A1c (HbA1c), and other relevant indicators. Each patient underwent a follow-up of at least 6 months after M-MDSCs detection. The M-MDSCs frequency was significantly higher in patients with poor glycemic control (PGC) compared to the healthy population (P < 0.001), whereas there was no significant difference between patients with good glycemic control and the healthy (P > 0.05). There was a positive correlation between the M-MDSCs frequency and FPG, HbA1c (R = 0.517 and 0.315, P < 0.001, respectively). T2DM patients with abnormally increased M-MDSCs have a higher incidence of infection and tumor (48.57% and 11.43% respectively). Our results shed new light on the pathogenesis of T2DM, help to understand why T2DM patients are susceptible to infection and tumor and providing novel insights for future prevention and treatment of T2DM.
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Affiliation(s)
- Ji Zhou
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, 230032, Anhui, China
- School of Nursing, Anhui Medical University, Hefei, 230032, Anhui, China
| | - Mengjie Zhang
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, 230601, Anhui, China
- Department of Endocrinology, Fuyang People's Hospital, Fuyang, 236000, Anhui, China
| | - Xiaodi Ju
- School of Nursing, Anhui Medical University, Hefei, 230032, Anhui, China
| | - Huiping Wang
- Hematologic Department/Hematologic Disease Research Center, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, China
| | - Hao Xiao
- Hematologic Department/Hematologic Disease Research Center, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, China
| | - Zhimin Zhai
- Hematologic Department/Hematologic Disease Research Center, the Second Affiliated Hospital of Anhui Medical University, Hefei, 230601, Anhui, China
| | - Xing Zhong
- Department of Endocrinology, The Second Affiliated Hospital of Anhui Medical University, 678 Furong Road, Hefei, 230601, Anhui, China.
| | - Jingfang Hong
- School of Nursing, Anhui Medical University, Hefei, 230032, Anhui, China.
- Nursing International Collaboration Research Center of Anhui Province, Hefei, 230601, Anhui, China.
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Jenkins S, Komber M, Mattam K, Briffa N. Negative pressure wound therapy in patients with diabetes undergoing left internal thoracic artery harvest: A randomized control trial. J Thorac Cardiovasc Surg 2024; 167:256-268. [PMID: 35550716 DOI: 10.1016/j.jtcvs.2022.01.060] [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: 05/31/2021] [Revised: 11/28/2021] [Accepted: 01/11/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients with diabetes undergoing CABG are at risk of wound infection. Incisional negative pressure wound therapy has been shown to be effective in decreasing incidence of infection in high-risk wounds. Near infrared spectroscopy (NIRS) can be used to assess wound oxygenation and low values can predict infection. OBJECTIVES To evaluate utility of NIRS to assess wound oxygenation, to assess effect of sternotomy, left internal thoracic artery harvest, and wound dressing type on wound edge oxygenation. METHODS In this blinded randomized control trial, patients with diabetes undergoing isolated coronary artery bypass grafting with a left internal thoracic artery were randomized to receive either incisional negative pressure wound therapy dressing or a standard dressing. NIRS measurements were made on the left upper arm (control), and left and right parasternal regions on day -1 (preoperative), day 5, and week 6 after surgery. Results were analyzed using repeated measures parametric methods. RESULTS Eighty patients with diabetes were recruited, 40 to the incisional negative pressure wound therapy group and 40 to the standard dressing group. Adjusted NIRS readings dropped significantly in all patients by day 5 and partially recovered by week 6. In both groups, there was no difference between readings on the left and right. At all time points and on both sides, there was no difference in readings between patients in the 2 groups. CONCLUSIONS NIRS can be used to assess oxygenation adjacent to a sternotomy wound. Adjusted tissue oxygen levels change with time after sternotomy and left internal thoracic artery harvest in patients with diabetes. Wound dressing type does not influence day 5 wound edge oxygenation.
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Affiliation(s)
- Sam Jenkins
- Department of Infection, Immunity, and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom
| | - Mohamed Komber
- Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, United Kingdom
| | - Kavitha Mattam
- Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, United Kingdom
| | - Norman Briffa
- Department of Infection, Immunity, and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom; Department of Cardiothoracic Surgery, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, United Kingdom.
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Bellon F, Solà I, Gimenez-Perez G, Hernández M, Metzendorf MI, Rubinat E, Mauricio D. Perioperative glycaemic control for people with diabetes undergoing surgery. Cochrane Database Syst Rev 2023; 8:CD007315. [PMID: 37526194 PMCID: PMC10392034 DOI: 10.1002/14651858.cd007315.pub3] [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] [Indexed: 08/02/2023]
Abstract
BACKGROUND People with diabetes mellitus are at increased risk of postoperative complications. Data from randomised clinical trials and meta-analyses point to a potential benefit of intensive glycaemic control, targeting near-normal blood glucose, in people with hyperglycaemia (with and without diabetes mellitus) being submitted for surgical procedures. However, there is limited evidence concerning this question in people with diabetes mellitus undergoing surgery. OBJECTIVES To assess the effects of perioperative glycaemic control for people with diabetes undergoing surgery. SEARCH METHODS For this update, we searched the databases CENTRAL, MEDLINE, LILACS, WHO ICTRP and ClinicalTrials.gov. The date of last search for all databases was 25 July 2022. We applied no language restrictions. SELECTION CRITERIA We included randomised controlled clinical trials (RCTs) that prespecified different targets of perioperative glycaemic control for participants with diabetes (intensive versus conventional or standard care). DATA COLLECTION AND ANALYSIS Two authors independently extracted data and assessed the risk of bias. Our primary outcomes were all-cause mortality, hypoglycaemic events and infectious complications. Secondary outcomes were cardiovascular events, renal failure, length of hospital and intensive care unit (ICU) stay, health-related quality of life, socioeconomic effects, weight gain and mean blood glucose during the intervention. We summarised studies using meta-analysis with a random-effects model and calculated the risk ratio (RR) for dichotomous outcomes and the mean difference (MD) for continuous outcomes, using a 95% confidence interval (CI), or summarised outcomes with descriptive methods. We used the GRADE approach to evaluate the certainty of the evidence (CoE). MAIN RESULTS A total of eight additional studies were added to the 12 included studies in the previous review leading to 20 RCTs included in this update. A total of 2670 participants were randomised, of which 1320 were allocated to the intensive treatment group and 1350 to the comparison group. The duration of the intervention varied from during surgery to five days postoperative. No included trial had an overall low risk of bias. Intensive glycaemic control resulted in little or no difference in all-cause mortality compared to conventional glycaemic control (130/1263 (10.3%) and 117/1288 (9.1%) events, RR 1.08, 95% CI 0.88 to 1.33; I2 = 0%; 2551 participants, 18 studies; high CoE). Hypoglycaemic events, both severe and non-severe, were mainly experienced in the intensive glycaemic control group. Intensive glycaemic control may slightly increase hypoglycaemic events compared to conventional glycaemic control (141/1184 (11.9%) and 41/1226 (3.3%) events, RR 3.36, 95% CI 1.69 to 6.67; I2 = 64%; 2410 participants, 17 studies; low CoE), as well as those considered severe events (37/927 (4.0%) and 6/969 (0.6%), RR 4.73, 95% CI 2.12 to 10.55; I2 = 0%; 1896 participants, 11 studies; low CoE). Intensive glycaemic control, compared to conventional glycaemic control, may result in little to no difference in the rate of infectious complications (160/1228 (13.0%) versus 224/1225 (18.2%) events, RR 0.75, 95% CI 0.55 to 1.04; P = 0.09; I2 = 55%; 2453 participants, 18 studies; low CoE). Analysis of the predefined secondary outcomes revealed that intensive glycaemic control may result in a decrease in cardiovascular events compared to conventional glycaemic control (107/955 (11.2%) versus 125/978 (12.7%) events, RR 0.73, 95% CI 0.55 to 0.97; P = 0.03; I2 = 44%; 1454 participants, 12 studies; low CoE). Further, intensive glycaemic control resulted in little or no difference in renal failure events compared to conventional glycaemic control (137/1029 (13.3%) and 158/1057 (14.9%), RR 0.92, 95% CI 0.69 to 1.22; P = 0.56; I2 = 38%; 2086 participants, 14 studies; low CoE). We found little to no difference between intensive glycaemic control and conventional glycaemic control in length of ICU stay (MD -0.10 days, 95% CI -0.57 to 0.38; P = 0.69; I2 = 69%; 1687 participants, 11 studies; low CoE), and length of hospital stay (MD -0.79 days, 95% CI -1.79 to 0.21; P = 0.12; I2 = 77%; 1520 participants, 12 studies; very low CoE). Due to the differences within included studies, we did not pool data for the reduction of mean blood glucose. Intensive glycaemic control resulted in a mean lowering of blood glucose, ranging from 13.42 mg/dL to 91.30 mg/dL. One trial assessed health-related quality of life in 12/37 participants in the intensive glycaemic control group, and 13/44 participants in the conventional glycaemic control group; no important difference was shown in the measured physical health composite score of the short-form 12-item health survey (SF-12). One substudy reported a cost analysis of the population of an included study showing a higher total hospital cost in the conventional glycaemic control group, USD 42,052 (32,858 to 56,421) compared to the intensive glycaemic control group, USD 40,884 (31.216 to 49,992). It is important to point out that there is relevant heterogeneity between studies for several outcomes. We identified two ongoing trials. The results of these studies could add new information in future updates on this topic. AUTHORS' CONCLUSIONS High-certainty evidence indicates that perioperative intensive glycaemic control in people with diabetes undergoing surgery does not reduce all-cause mortality compared to conventional glycaemic control. There is low-certainty evidence that intensive glycaemic control may reduce the risk of cardiovascular events, but cause little to no difference to the risk of infectious complications after the intervention, while it may increase the risk of hypoglycaemia. There are no clear differences between the groups for the other outcomes. There are uncertainties among the intensive and conventional groups regarding the optimal glycaemic algorithm and target blood glucose concentrations. In addition, we found poor data on health-related quality of life, socio-economic effects and weight gain. It is also relevant to underline the heterogeneity among studies regarding clinical outcomes and methodological approaches. More studies are needed that consider these factors and provide a higher quality of evidence, especially for outcomes such as hypoglycaemia and infectious complications.
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Affiliation(s)
- Filip Bellon
- Healthcare Research Group (GRECS), Institute of Biomedical Research in Lleida (IRBLleida), Lleida, Spain
- GESEC group, Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
| | - Ivan Solà
- Iberoamerican Cochrane Centre, Biomedical Research Institute Sant Pau (IIB Sant Pau), CIBER Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Gabriel Gimenez-Perez
- Endocrinology Section, Department of Medicine, Hospital General de Granollers, Granollers, Spain
- Department of Medicine, Faculty of Medicine and Health Sciences, Universitat Internacional de Catalunya, Sant Cugat del Vallés, Spain
| | - Marta Hernández
- Department of Endocrinology and Nutrition, Hospital Universitari Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida (IRBLLEIDA), Lleida, Spain
| | - Maria-Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Esther Rubinat
- Healthcare Research Group (GRECS), Institute of Biomedical Research in Lleida (IRBLleida), Lleida, Spain
- GESEC group, Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
- CIBER of Diabetes and Associated Metabolic Disease, Barcelona, Spain
| | - Didac Mauricio
- CIBER of Diabetes and Associated Metabolic Disease, Barcelona, Spain
- Department of Endocrinology and Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
- Department of Medicine, Faculty of Medicine, University of Vic & Central University of Catalonia, Vic, Spain
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Crowley K, Scanaill PÓ, Hermanides J, Buggy DJ. Current practice in the perioperative management of patients with diabetes mellitus: a narrative review. Br J Anaesth 2023:S0007-0912(23)00128-9. [PMID: 37061429 PMCID: PMC10375498 DOI: 10.1016/j.bja.2023.02.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/08/2023] [Accepted: 02/23/2023] [Indexed: 04/17/2023] Open
Abstract
The prevalence of diabetes is increasing, and patients with diabetes mellitus have both an increased likelihood of requiring surgery and of developing postoperative complications when they do. We summarise available evidence underpinning current guidelines on preoperative assessment and optimisation, perioperative management of prescribed insulin and oral hypoglycaemic medication, intraoperative glycaemic control, and postoperative patient care.
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Affiliation(s)
- Kieran Crowley
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland.
| | - Pádraig Ó Scanaill
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland
| | | | - Donal J Buggy
- Department of Anaesthesiology & Perioperative Medicine, Mater University Hospital, School of Medicine, University College Dublin, Dublin, Ireland; Outcomes Research Cleveland Clinic, Cleveland, OH, USA.
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Aimar K, Orozov N, Spencer-Jones K, Burhan H, Butler N, Kassim S, Forsyth J. Perioperative variable rate intravenous insulin infusion: a quality improvement project on a vascular surgery ward. BMJ Open Qual 2023; 12:bmjoq-2022-002048. [PMID: 36813469 PMCID: PMC9950905 DOI: 10.1136/bmjoq-2022-002048] [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: 07/12/2022] [Accepted: 02/13/2023] [Indexed: 02/24/2023] Open
Abstract
AIMS Variable rate intravenous insulin infusion (VRIII) is used perioperatively to maintain normoglycaemia in patients with diabetes who are undergoing surgery. The aims of this project were as follows: (1) to audit the extent to which perioperative prescribing of VRIII for diabetic vascular surgery inpatients at our hospital meets established standards and (2) to use the results of the audit to guide improvement in the quality and safety of prescribing practices and reduce VRIII overuse. METHODS Vascular surgery inpatients who had perioperative VRIII were included in the audit. Baseline data were collected consecutively from September to November 2021. There were three main interventions: a VRIII Prescribing Checklist, education of junior doctors and ward staff, and electronic prescribing system updates. Postintervention and reaudit data were collected consecutively from March to June 2022. RESULTS The number of VRIII prescriptions totalled 27 in preintervention, 18 in postintervention and 26 in reaudit periods. Prescribers used the 'refer to paper chart' safety check more frequently postintervention (67%) and on reaudit (77%) compared with preintervention (33%) (p=0.046). Rescue medication was prescribed in 50% of postintervention and 65% of reaudit cases compared with 0% preintervention (p<0.001). Intermediate/long-acting insulin was appropriately amended more often in the postintervention versus preintervention period (75% vs 45%, p=0.041). Overall, VRIII was appropriate for the situation in 85% of cases. CONCLUSIONS The quality of perioperative VRIII prescribing practices improved following the proposed interventions, with prescribers more frequently using recommended safety measures such as 'refer to paper chart' and rescue medication. There was a marked sustained improvement in prescriber-initiated adjustment of oral diabetes medications and insulins. VRIII is occasionally administered unnecessarily in a subset of patients with type 2 diabetes and may be an area for further study.
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Lamanna DL, McDonnell ME, Chen AF, Gallagher JM. Perioperative Identification and Management of Hyperglycemia in Orthopaedic Surgery. J Bone Joint Surg Am 2022; 104:2117-2126. [PMID: 36005390 DOI: 10.2106/jbjs.22.00149] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ The consequences of undermanaged perioperative hyperglycemia are notable and can have a serious impact on adverse postoperative outcomes, especially surgical site infections and periprosthetic joint infections (PJIs). ➤ Preoperative screening of hemoglobin A1c with a goal threshold of <7.45% is ideal. ➤ There are a variety of risk factors that contribute to hyperglycemia that should be considered in the perioperative period, including glucocorticoid use, nutritional factors, patient-specific factors, anesthesia, and surgery. ➤ There are expected trends in the rise, peak, and fall of postoperative blood glucose levels, and identifying and treating hyperglycemia as swiftly as possible are the fundamental aims of treatment and improved glucose control. Performing frequent postoperative blood glucose monitoring (in the post-anesthesia care unit, on the day of surgery at 1700 and 2100 hours, and in the morning of postoperative day 1) should be considered to allow for the early detection of alterations in glucose metabolism. In addition, instituting a postoperative dietary restriction of carbohydrates should be considered. ➤ The use of insulin as a hypoglycemic agent in orthopaedic patients is relatively safe and is an effective means of controlling fluctuating blood glucose levels. Insulin therapy should be administered to treat hyperglycemia at ≥140 mg/dL when fasting and ≥180 mg/dL postprandially. Insulin therapy should be ceased at blood glucose levels of <110 mg/dL; however, monitoring for glycemic dysregulation should be continued. In all cases of complex diabetes, consultation with diabetes specialty services should be considered. ➤ The emerging use of technology, including continuous subcutaneous insulin pump therapy and continuous glucose monitoring, is an exciting area of further research and development as such technology can more immediately detect and correct aberrations in blood glucose levels.
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Affiliation(s)
- Daniel L Lamanna
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marie E McDonnell
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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10
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Toyoshima MTK, Cukier P, Souza ABCD, Pereira J, Hoff AO, Nery M. Effects of glucocorticoids on interstitial glucose concentrations in individuals with hematologic cancer and without known diagnosis of diabetes: a pilot study. EINSTEIN-SAO PAULO 2022; 20:eAO8031. [PMID: 35830152 PMCID: PMC9262279 DOI: 10.31744/einstein_journal/2022ao8031] [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: 09/15/2021] [Accepted: 12/02/2021] [Indexed: 01/08/2023] Open
Abstract
Objective To analyze interstitial glucose behavior during glucocorticoid use in non-diabetic patients receiving chemotherapy for hematologic malignancies. Methods Prospective pilot study carried out to assess interstitial glucose levels in 15 non-diabetic individuals with hematologic malignancies who received glucocorticoids in combination with chemotherapy. The FreeStyle Libre flash monitoring system (Abbott Diabetes Care) was used for up to 14 days to measure interstitial glucose. Results Median age and body mass index were 53 (42-61) years and 25 (23-28) kg/m2 respectively. Interstitial glucose levels >180mg/dL lasting at least one hour were detected in 60% of participants. Interstitial glucose profile parameters (median and peak interstitial glucose levels and percentage of time during which interstitial glucose levels were >180mg/dL) were significantly (p<0.01) higher during glucocorticoid use (115mg/dL, 218mg/dL and 10% respectively) than after glucocorticoid discontinuation (97mg/dL, 137mg/dL and 0% respectively). Mean interstitial glucose levels increased in the afternoon and at night during glucocorticoid use. Conclusion This pilot study was the first to evaluate interstitial glucose levels in non-diabetic individuals using glucocorticoids in treatment of hematologic cancer. Glucocorticoid use during chemotherapy significantly increases interstitial glucose levels in these patients.
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11
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Witte H, Nakas CT, Bally L, Leichtle AB. Machine-learning Prediction of Hypo- and Hyperglycemia from Electronic Health Records: Algorithm Development and Validation. JMIR Form Res 2022; 6:e36176. [PMID: 35526139 PMCID: PMC9345028 DOI: 10.2196/36176] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 04/25/2022] [Accepted: 05/08/2022] [Indexed: 01/16/2023] Open
Abstract
Background Acute blood glucose (BG) decompensations (hypoglycemia and hyperglycemia) represent a frequent and significant risk for inpatients and adversely affect patient outcomes and safety. The increasing need for BG management in inpatients poses a high demand on clinical staff and health care systems in addition. Objective This study aimed to generate a broadly applicable multiclass classification model for predicting BG decompensation events from patients’ electronic health records to indicate where adjustments in patient monitoring and therapeutic interventions are required. This should allow for taking proactive measures before BG levels are derailed. Methods A retrospective cohort study was conducted on patients who were hospitalized at a tertiary hospital in Bern, Switzerland. Using patient details and routine data from electronic health records, a multiclass prediction model for BG decompensation events (<3.9 mmol/L [hypoglycemia] or >10, >13.9, or >16.7 mmol/L [representing different degrees of hyperglycemia]) was generated based on a second-level ensemble of gradient-boosted binary trees. Results A total of 63,579 hospital admissions of 38,250 patients were included in this study. The multiclass prediction model reached specificities of 93.7%, 98.9%, and 93.9% and sensitivities of 67.1%, 59%, and 63.6% for the main categories of interest, which were nondecompensated cases, hypoglycemia, or hyperglycemia, respectively. The median prediction horizon was 7 hours and 4 hours for hypoglycemia and hyperglycemia, respectively. Conclusions Electronic health records have the potential to reliably predict all types of BG decompensation. Readily available patient details and routine laboratory data can support the decisions for proactive interventions and thus help to reduce the detrimental health effects of hypoglycemia and hyperglycemia.
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Affiliation(s)
- Harald Witte
- University Institute of Clinical Chemistry, Inselspital - Bern University Hospital and University of Bern, Freiburgstrasse 10, Bern, CH
| | - Christos Theodoros Nakas
- University Institute of Clinical Chemistry, Inselspital - Bern University Hospital and University of Bern, Freiburgstrasse 10, Bern, CH.,Laboratory of Biometry, University of Thessaly, Volos, GR
| | - Lia Bally
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital - Bern University Hospital and University of Bern, Bern, CH
| | - Alexander Benedikt Leichtle
- University Institute of Clinical Chemistry, Inselspital - Bern University Hospital and University of Bern, Freiburgstrasse 10, Bern, CH.,Center of Artificial Intelligence in Medicine (CAIM), University of Bern, Bern, CH
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12
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Mendes TB, Câmara-de-Souza AB, Halpern B. Hospital management of hyperglycemia in the context of COVID-19: evidence-based clinical considerations. Diabetol Metab Syndr 2022; 14:37. [PMID: 35246230 PMCID: PMC8895065 DOI: 10.1186/s13098-022-00808-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 02/18/2022] [Indexed: 01/08/2023] Open
Abstract
The COVID-19 pandemic led to an unprecedented crisis, and early on, it has been shown that diabetes is an important risk factor for complications and mortality in infected patients, as demonstrated by several studies. Moreover, hyperglycemia, regardless of whether patients have diabetes, is associated with poorer outcomes, which suggests that adequate monitoring and treatment of elevated glycemia in the hospital setting can improve patient outcomes. In patients with COVID-19, glycemic control may be impaired as a consequence of the infection itself (aggravating pre-existing diabetes and potentially precipitating new-onset diabetes), inflammation, or corticosteroid use-a well-established therapy to reduce COVID-19 complications, especially in the intensive care unit. This article reviews the link between diabetes and hyperglycemia, and COVID-19, with a brief review of potential mechanisms, along with emerging evidence on the effect of glycemic control on COVID-19 outcomes, especially in hospital settings.
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Affiliation(s)
- Thiago Bosco Mendes
- Department of Internal Medicine, Hospital das Clínicas, São Paulo State University (UNESP), Botucatu, Brazil
| | | | - Bruno Halpern
- Department of Endocrinology, Hospital 9 de Julho, Rua Alves Guimarães, 462, cj. 72, Pinheiros, São Paulo, SP, 05410-000, Brazil.
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13
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Madhok B, Nanayakkara K, Mahawar K. Safety considerations in laparoscopic surgery: A narrative review. World J Gastrointest Endosc 2022; 14:1-16. [PMID: 35116095 PMCID: PMC8788169 DOI: 10.4253/wjge.v14.i1.1] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 08/11/2021] [Accepted: 12/10/2021] [Indexed: 02/06/2023] Open
Abstract
Laparoscopic surgery has many advantages over open surgery. At the same time, it is not without its risks. In this review, we discuss steps that could enhance the safety of laparoscopic surgery. Some of the important safety considerations are ruling out pregnancy in women of the childbearing age group; advanced discussion with the patient regarding unexpected intraoperative situations, and ensuring appropriate equipment is available. Important perioperative safety considerations include thromboprophylaxis; antibiotic prophylaxis; patient allergies; proper positioning of the patient, stack, and monitor(s); patient appropriate pneumoperitoneum; ergonomic port placement; use of lowest possible intra-abdominal pressure; use of additional five-millimetre (mm) ports as needed; safe use of energy devices and laparoscopic staplers; low threshold for a second opinion; backing out if unsafe to proceed; avoiding hand-over in the middle of the procedure; ensuring all planned procedures have been performed; inclusion of laparoscopic retrieval bags and specimens in the operating count; avoiding 10-15 mm ports for placement of drains; appropriate port closures; and use of long-acting local anaesthetic agents for analgesia. Important postoperative considerations include adequate analgesia; early ambulation; careful attention to early warning scores; and appropriate discharge advice.
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Affiliation(s)
- Brij Madhok
- Upper GI Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Derby DE22 3NE, United Kingdom
| | - Kushan Nanayakkara
- Upper GI Surgery, University Hospitals of Derby and Burton NHS Foundation Trust, Derby DE22 3NE, United Kingdom
| | - Kamal Mahawar
- Department of General Surgery, South Tyneside and Sunderland NHS Foundation Trust, Sunderland SR4 7TP, United Kingdom
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14
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Párraga Solórzano PK, Shupe AC, Kehl-Fie TE. The Sensor Histidine Kinase ArlS Is Necessary for Staphylococcus aureus To Activate ArlR in Response to Nutrient Availability. J Bacteriol 2021; 203:e0042221. [PMID: 34606376 PMCID: PMC8604075 DOI: 10.1128/jb.00422-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 09/25/2021] [Indexed: 12/12/2022] Open
Abstract
Staphylococcus aureus is a versatile opportunistic pathogen whose success is driven by its ability to adapt to diverse environments and host-imposed stresses. Two-component signal transduction systems, such as ArlRS, often mediate these adaptations. Loss of ArlRS or the response regulator ArlR alone impairs the ability of S. aureus to respond to host-imposed manganese starvation and glucose limitation. As sensor histidine kinases and response regulators frequently work as pairs, it has been assumed that ArlS senses and activates ArlR in response to these stimuli. However, recent work suggests that the sensor histidine kinase GraS can also activate ArlR, calling the contribution of ArlS in responding to manganese and glucose availability into question. The results of current studies reveal that ArlS is necessary to activate ArlR in response to manganese sequestration by the host immune effector calprotectin and glucose limitation. Although the loss of ArlS does not completely eliminate ArlR activity, this response regulator is no longer responsive to manganese or glucose availability in the absence of its cognate histidine kinase. Despite the residual activity of ArlR in the absence of ArlS, ArlR phosphorylation by ArlS is required for S. aureus to resist calprotectin-imposed metal starvation. Cumulatively, these findings contribute to the understanding of S. aureus signal transduction in response to nutritional immunity and support the previous observation indicating that ArlRS is activated by a common signal derived from host-imposed manganese and glucose limitation. IMPORTANCE The ability of pathogens, including Staphylococcus aureus, to sense and adapt to diverse environments partially relies on two-component systems, such as ArlRS. Recent work revealed that the response regulator ArlR can be cross-activated by the sensor histidine kinase GraS, rendering the role of its cognate partner, ArlS, in response to manganese and glucose limitation uncertain. The results of this study reveal that ArlS is necessary for the activation of ArlR in response to calprotectin and glucose limitation. Although a low level of ArlR activity remains in the absence of ArlS, ArlS phosphotransfer to ArlR is required for S. aureus to overcome calprotectin-induced nutritional stress. Collectively, this study provides fundamental information to understand how ArlRS mediates staphylococcal adaptation during infection.
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Affiliation(s)
| | - Angela C. Shupe
- Department of Microbiology, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
| | - Thomas E. Kehl-Fie
- Department of Microbiology, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
- Carl R. Woese Institute for Genomic Biology, University of Illinois Urbana-Champaign, Urbana, Illinois, USA
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15
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Patzek S, MacMaster HW, Rov-Ikpah E, San Luis C, Johnson C, Juttukonda V, Rushakoff RJ. Automated Self-Adjusting Subcutaneous Insulin Algorithm for Patients NPO or on TPN or Enteral Feedings. J Diabetes Sci Technol 2021; 15:1282-1289. [PMID: 32783464 PMCID: PMC8655274 DOI: 10.1177/1932296820948132] [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] [Indexed: 11/15/2022]
Abstract
BACKGROUND Perioperative diabetes patients are often treated with sliding-scale insulin, despite a lack of evidence to support therapeutic effectiveness. We introduced an automated subcutaneous insulin algorithm (SQIA) to improve glycemic control in these patients while maintaining the simplicity of a q4 hour adjustable sliding-scale insulin order set. METHODS In this pilot study, we implemented a fully programmed, self-adjusting SQIA as part of a structured order set in the electronic medical record for adult patients who are nil per os, or on continuous enteral tube feedings or total parenteral nutrition. The nurse only enters the current glucose in the Medication Administration Record, and then the calculated dose is shown. The new dose is based on previous dose, and current and previous glucoses. The SQIA titrates the glucose to 120-180 mg/dL. For this pilot, this order set was utilized for complex perioperative oncologic patients. RESULTS The median duration on the SQIA was 58 hours. Glucoses at titration initiation were highest at 206 ± 63 mg/dL, and came down to 156 ± 29 mg/dL by 72 hours. The majority of measured glucoses (66.8%, n = 647) were maintained between 80 and 180 mg/dL. There were no glucoses lower than 60 mg/dL, and only 0.3% (n = 3) were below 70 mg/dL. There was a low rate of errors (1%). CONCLUSIONS A simple automated SQIA can be used to titrate insulin to meet the changing metabolic requirements of individuals perioperatively and maintain glucose within the target range for these hospitalized patients.
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Affiliation(s)
- Sophie Patzek
- Division of Endocrinology and
Metabolism, University of California, San Francisco, CA, USA
| | | | - Esther Rov-Ikpah
- Institute for Nursing Excellence,
University of California, San Francisco, CA, USA
| | - Craig San Luis
- Department of Clinical Systems,
University of California, San Francisco, CA, USA
| | - Craig Johnson
- Department of Health Informatics,
University of California, San Francisco, CA, USA
| | - Venkateswarlu Juttukonda
- Department of Clinical Applications
& Analytics, University of California, San Francisco, CA, USA
| | - Robert J. Rushakoff
- Division of Endocrinology and
Metabolism, University of California, San Francisco, CA, USA
- Robert J. Rushakoff, MD, Division of
Endocrinology and Metabolism, University of California, San Francisco, 1600
Divisadero, Room A430, SF, CA 94115, USA.
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16
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Gondhale H, Jaichandran VV, Jambulingam M, Anand AR, Srinivasan S, Raman R, Sharma T. Distribution and risk factors of postoperative endophthalmitis in people with diabetes. Indian J Ophthalmol 2021; 69:3329-3334. [PMID: 34708798 PMCID: PMC8725099 DOI: 10.4103/ijo.ijo_1485_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Purpose To evaluate (i) the distribution of postoperative endophthalmitis (POE) in patients who underwent cataract surgery, (ii) risk factors in diabetic versus nondiabetic patients, and (iii) distribution of POE in those who had undergone rapid reduction of preoperative blood sugar levels versus those with normal blood sugar levels. Methods Medical records were reviewed from January 1995 to July 2021. In total, 391 eyes of 391 patients who developed POE after cataract surgery were studied. Patients with POE were divided into Group A, patients with diabetes (n = 128), and Group B, patients without diabetes (n = 263), and the associations of various clinical factors in the two groups were studied. Patients with diabetes with raised random blood sugars (RBS) preoperatively were subjected to a rapid reduction of blood sugar (RBS <200 mg%) to be considered eligible for surgery. Microbiological profile of patients was examined. Results The cumulative incidence of POE over 26 years was 0.09%. Those who underwent a rapid reduction in preoperative blood sugar levels had higher rates of POE (53.1%) compared with (46.9%) those with blood sugar levels under control (P = 0.486). Men with diabetes had 1.634 times higher odds of POE (P = 0.048), and those with diabetes and hypertension had 3.961 times greater odds of having POE (P < 0.001) when adjusted for age, alcohol, smoking, and socioeconomic strata and presence of posterior capsule rupture. Positive culture results were observed in 45/128 (35%) patients with diabetes and 71/263 (27%) patients without diabetes. Staphylococcus epidermidis was the most commonly identified organism and was detected in 10/45 (22%) in those with diabetes and 21/71 (29%) in those without diabetes of all the culture-positive cases. Conclusion In patients with POE, the odds are greater for men with diabetes, those with a history of hypertension, as well as those who undergo a rapid reduction of preoperative blood sugar.
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Affiliation(s)
| | - V V Jaichandran
- Department of Anesthesiology, Sankara Nethralaya, Tamil Nadu, India, India
| | | | | | | | - Rajiv Raman
- Shri Bhagwan Mahavir Vitreoretinal Services, Sankara Nethralaya, Chennai, Tamil Nadu, India
| | - Tarun Sharma
- Edward S. Harkness Eye Institute, Columbia University Medical Center, New York, USA
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17
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Wong JKL, Ke Y, Ong YJ, Li H, Wong TH, Abdullah HR. The impact of preoperative glycated hemoglobin (HbA1c) on postoperative complications after elective major abdominal surgery: a meta-analysis. Korean J Anesthesiol 2021; 75:47-60. [PMID: 34619855 PMCID: PMC8831432 DOI: 10.4097/kja.21295] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/05/2021] [Indexed: 11/24/2022] Open
Abstract
Background Diabetes is a risk factor for postoperative complications. Previous meta-analyses have shown that elevated glycated hemoglobin (HbA1c) levels are associated with postoperative complications in various surgical populations. However, this is the first meta-analysis to investigate the association between preoperative HbA1c levels and postoperative complications in patients undergoing elective major abdominal surgery. Methods PRISMA guidelines were adhered to for this study. Six databases were searched up to April 1, 2020. Primary studies investigating the effect of HbA1c levels on postoperative complications after elective major abdominal surgery were included. Risk of bias and quality of evidence assessments were performed. Data were pooled using a random effects model. Meta-regression was performed to evaluate different HbA1c cut-off values. Results Twelve observational studies (25,036 patients) were included. Most studies received a ‘good’ and ‘moderate quality’ score using the NOS and GRADE, respectively. Patients with a high HbA1c had a greater risk of anastomotic leaks (odds ratio [OR]: 2.80, 95% CI [1.63, 4.83], P < 0.001), wound infections (OR: 1.21, 95% CI [1.08, 1.36], P = 0.001), major complications defined as Clavien-Dindo [CD] 3–5 (OR: 2.16, 95% CI [1.54, 3.01], P < 0.001), and overall complications defined as CD 1–5 (OR: 2.12, 95% CI [1.48, 3.04], P < 0.001). Conclusions An HbA1c between 6% and 7% is associated with higher risks of anastomotic leaks, wound infections, major complications, and overall postoperative complications. Therefore, guidelines with an HbA1c threshold > 7% may be putting pre-optimized patients at risk. Future randomized controlled trials are needed to explore causation before policy changes are made.
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Affiliation(s)
- Joanna K L Wong
- Department of Anaesthetics, Queen's Hospital, Romford, London, United Kingdom
| | - Yuhe Ke
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Yi Jing Ong
- Department of Medicine, National University of Singapore, Singapore
| | - HuiHua Li
- Health Services Research Unit, Singapore General Hospital, Singapore
| | - Ting Hway Wong
- Health Services Research Unit, Singapore General Hospital, Singapore.,Department of General Surgery, Singapore General Hospital, Singapore
| | - Hairil R Abdullah
- Department of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore.,DukeNUS Medical School, Singapore
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18
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Sadhu AR, Patham B, Vadhariya A, Chikermane SG, Johnson ML. Outcomes of "Real-World" Insulin Strategies in the Management of Hospital Hyperglycemia. J Endocr Soc 2021; 5:bvab101. [PMID: 34235360 PMCID: PMC8252645 DOI: 10.1210/jendso/bvab101] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Indexed: 11/28/2022] Open
Abstract
Context Guidelines recommend scheduled long-acting basal and short-acting bolus insulin several times daily to manage inpatient hyperglycemia. In the “real world,” insulin therapy is complicated, with limited data on the comparative effectiveness of different insulin strategies. Objective This work aimed to evaluate the association of different insulin strategies with glucose control and hospital outcomes after adjustment for patient and physician factors that influence choice of therapy. Methods This retrospective, observational study took place at an academic hospital. Participants included noncritically ill hospitalized medical/surgical patients (n = 4558) receiving subcutaneous insulin for 75% or longer during admission. Insulin therapy was grouped into 3 strategies within the first 48 hours: basal bolus (BB: scheduled long and short/rapid n = 2358), sliding scale (SS: short/rapid acting n = 1855), or basal only (BO: long only: n = 345). Main outcome measures included glucose control: hypoglycemic days, hyperglycemic days, euglycemic days, mean glucose; and hospitalization: in-hospital mortality, length of stay (LOS), and readmissions. Results Initial therapy with BB was associated with more hypoglycemic (2.40; CI, 2.04 to 2.82) (P < .001) and fewer euglycemic days (0.90; CI, 0.85 to 0.97) (P = .003) than SS, whereas BO was associated with fewer hyperglycemic days (0.70; CI, 0.62 to 0.79) (P < .001), lower mean glucose (–18.03; CI, –22.46 to –12.61) (P < .001), and more euglycemic days (1.22; CI, 1.09 to 1.37) (P < .001) compared to SS. No difference in mortality, LOS, and readmissions was found. However, decreased LOS was observed in the BB subgroup with a medical diagnostic related group (0.93; CI, 0.89 to 0.97) (P < .001). Conclusion BO had a more favorable hyperglycemia profile than SS. BB, on the other hand, showed worse glycemic control as compared to SS. In the real-world hospital, BO may be a simpler and more effective insulin strategy.
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Affiliation(s)
| | | | - Aisha Vadhariya
- University of Houston, College of Pharmacy, Houston, Texas 77204, USA
| | | | - Michael L Johnson
- University of Houston, College of Pharmacy, Houston, Texas 77204, USA
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19
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Hill A, Francis SJ, Horswill MS, Christofidis MJ, Watson MO. A human factors approach to subcutaneous insulin chart design improves user-performance: An experimental study. APPLIED ERGONOMICS 2021; 94:103389. [PMID: 33647789 DOI: 10.1016/j.apergo.2021.103389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 02/09/2021] [Accepted: 02/10/2021] [Indexed: 06/12/2023]
Abstract
Insulin is a high-risk medicine that has been implicated in serious adverse events for hospital inpatients, including medication-error related deaths. Most insulin errors occur during administration, and "wrong dose" is the most common type. A paper-based subcutaneous insulin chart (the "NSIC") was developed for the Australian Commission on Safety and Quality in Health Care, using a range of human factors methods, with the aim of reducing the opportunity for errors. The present lab-based study empirically assessed whether the NSIC's human factors design translates into improved user-performance in the determination of insulin doses, compared with a pre-existing chart. Forty-one experienced nurses and 48 novice chart-users completed 60 experimental trials (30 per chart), in which they determined doses to administer to patients. Both groups determined insulin doses faster, and made fewer dose errors, when using the NSIC. These results support the utility of the usability heuristics employed in developing the chart.
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Affiliation(s)
- Andrew Hill
- Clinical Skills Development Service, Metro North Hospital and Health Service, Herston, Brisbane, Queensland, 4006, Australia; School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia; Minerals Industry Safety and Health Centre, Sustainable Minerals Institute, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia.
| | - Sophie J Francis
- School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia
| | - Mark S Horswill
- School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia
| | - Melany J Christofidis
- School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia; Mater Hospital, Mater Health, Raymond Terrace, South Brisbane, Queensland, 4101, Australia
| | - Marcus O Watson
- Clinical Skills Development Service, Metro North Hospital and Health Service, Herston, Brisbane, Queensland, 4006, Australia; School of Psychology, The University of Queensland, St Lucia, Brisbane, Queensland, 4072, Australia; School of Medicine, The University of Queensland, Herston, Brisbane, Queensland, 4006, Australia
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20
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Pasquel FJ, Urrutia MA, Cardona S, Coronado KWZ, Albury B, Perez-Guzman MC, Galindo RJ, Chaudhuri A, Iacobellis G, Palacios J, Farias JM, Gomez P, Anzola I, Vellanki P, Fayfman M, Davis GM, Migdal AL, Peng L, Umpierrez GE. Liraglutide hospital discharge trial: A randomized controlled trial comparing the safety and efficacy of liraglutide versus insulin glargine for the management of patients with type 2 diabetes after hospital discharge. Diabetes Obes Metab 2021; 23:1351-1360. [PMID: 33591621 PMCID: PMC8571803 DOI: 10.1111/dom.14347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/21/2021] [Accepted: 01/23/2021] [Indexed: 11/29/2022]
Abstract
AIM To compare a glucagon-like peptide-1 receptor agonist with basal insulin at hospital discharge in patients with uncontrolled type 2 diabetes in a randomized clinical trial. METHODS A total of 273 patients with glycated haemoglobin (HbA1c) 7%-10% (53-86 mol/mol) were randomized to liraglutide (n = 136) or insulin glargine (n = 137) at hospital discharge. The primary endpoint was difference in HbA1c at 12 and 26 weeks. Secondary endpoints included hypoglycaemia, changes in body weight, and achievement of HbA1c <7% (53 mmol/mol) without hypoglycaemia or weight gain. RESULTS The between-group difference in HbA1c at 12 weeks and 26 weeks was -0.28% (95% CI -0.64, 0.09), and at 26 weeks it was -0.55%, (95% CI -1.01, -0.09) in favour of liraglutide. Liraglutide treatment resulted in a lower frequency of hypoglycaemia <3.9 mmol/L (13% vs 23%; P = 0.04), but there was no difference in the rate of clinically significant hypoglycaemia <3.0 mmol/L. Compared to insulin glargine, liraglutide treatment was associated with greater weight loss at 26 weeks (-4.7 ± 7.7 kg vs -0.6 ± 11.5 kg; P < 0.001), and the proportion of patients with HbA1c <7% (53 mmol/mol) without hypoglycaemia was 48% versus 33% (P = 0.05) at 12 weeks and 45% versus 33% (P = 0.14) at 26 weeks in liraglutide versus insulin glargine. The proportion of patients with HbA1c <7% (53 mmol/mol) without hypoglycaemia and no weight gain was higher with liraglutide at 12 (41% vs 24%, P = 0.005) and 26 weeks (39% vs 22%; P = 0.014). The incidence of gastrointestinal adverse events was higher with liraglutide than with insulin glargine (P < 0.001). CONCLUSION Compared to insulin glargine, treatment with liraglutide at hospital discharge resulted in better glycaemic control and greater weight loss, but increased gastrointestinal adverse events.
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Affiliation(s)
- Francisco J. Pasquel
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Maria A. Urrutia
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Saumeth Cardona
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Karla W. Z. Coronado
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Bonnie Albury
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Mireya C. Perez-Guzman
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rodolfo J. Galindo
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ajay Chaudhuri
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Gianluca Iacobellis
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami, Miami, Florida
| | - Juan Palacios
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami, Miami, Florida
| | - Javier M. Farias
- Division of Endocrinology Sanatorio Guemes, Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Patricia Gomez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Isabel Anzola
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Priyathama Vellanki
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Maya Fayfman
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Georgia M. Davis
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Alexandra L. Migdal
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Limin Peng
- Deartment of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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21
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Deng L, Aibibula W, Talat Z, Filion KB, Eintracht S, Dasgupta K, Tagalakis V, Majdan A, Yu OHY. The association between glycaemic control during hospitalization and risk of adverse events: A retrospective cohort study. ENDOCRINOLOGY DIABETES & METABOLISM 2021; 4:e00268. [PMID: 34277991 PMCID: PMC8279636 DOI: 10.1002/edm2.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 05/03/2021] [Accepted: 05/11/2021] [Indexed: 11/07/2022]
Abstract
Introduction Hyperglycaemia is common during hospitalization; glycaemic targets in non‐critical care settings have not been well studied. We assessed associations between inpatient glycaemic control and adverse events. Methods We conducted a retrospective cohort study on non‐critically ill medical patients hospitalized in a tertiary care hospital between 2015 and 2018. Mean glycaemia during the first four days of hospitalization was categorized as 4.0–7.0 mmol/L, 7.1–10.0 mmol/L and >10.0 mmol/L. The primary outcome was a composite of adverse events including mortality, infections, acute kidney injury, thromboembolic and cardiovascular events. The secondary outcome was hypoglycaemia, defined as any glycaemia <4.0 mmol/L. Logistic regression was used to assess adverse events, and a Cox proportional hazards model was used to estimate hypoglycaemia risk. Results Our cohort included 1,368 patients, of whom 407 (29.8%) experienced an adverse event. We did not find associations between glycaemia of 4.0–7.0 mmol/L (adjusted odds ratio [OR]: 0.88, 95% confidence interval [CI]: 0.63–1.23) or glycaemia of >10.0 mmol/L (adjusted OR: 0.98, 95% CI: 0.75–1.28) and the occurrence of adverse events, compared to a glycaemia of 7.1–10.0 mmol/L. Glycaemia of >10.0 mmol/L was associated with an increased risk of hypoglycaemia (adjusted hazard ratio [HR]: 1.72, 95% CI: 1.21–2.45). Hypoglycaemia was associated with adverse events (adjusted OR 1.85, 95% CI 1.31–2.60). Conclusions Neither glycaemia of 4.0–7.0 mmol/L nor glycaemia of >10.0mmol/L during non‐critical care hospitalization was associated with increased adverse events. Glycaemia of >10.0 mmol/L was associated with increased hypoglycaemia, likely due to aggressive glucose lowering. These findings highlight the need for further studies to discern optimal inpatient glycaemic targets.
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Affiliation(s)
- Lan Deng
- Department of Medicine McGill University Montreal QC Canada
| | - Wusiman Aibibula
- Center for Clinical Epidemiology Lady Davis Institute Jewish General Hospital Montreal QC Canada
| | - Zahra Talat
- Department of Medicine McGill University Montreal QC Canada
| | - Kristian B Filion
- Department of Medicine McGill University Montreal QC Canada.,Center for Clinical Epidemiology Lady Davis Institute Jewish General Hospital Montreal QC Canada.,Department of Epidemiology, Biostatistics and Occupational Health McGill University Montreal QC Canada
| | - Shaun Eintracht
- Department of Internal Medicine Division of Medical Biochemistry Jewish General Hospital McGill University Montreal QC Canada
| | - Kaberi Dasgupta
- Divisions of Internal Medicine, Endocrinology and Metabolism, and Epidemiology Department of Medicine McGill University Health Centre Montréal QC Canada.,Centre for Events Research and Evaluation (CORE) Research Institute of the McGill University Health Centre Montréal QC Canada
| | - Vicky Tagalakis
- Department of Medicine McGill University Montreal QC Canada.,Department of Epidemiology, Biostatistics and Occupational Health McGill University Montreal QC Canada.,Department of Internal Medicine Jewish General Hospital McGill University Montreal QC Canada
| | - Agnieszka Majdan
- Division of Endocrinology Jewish General Hospital Montreal QC Canada
| | - Oriana Hoi Yun Yu
- Department of Epidemiology, Biostatistics and Occupational Health McGill University Montreal QC Canada.,Division of Endocrinology Jewish General Hospital Montreal QC Canada
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22
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Hypoglycemic episodes predict length of stay in patients with acute burns. J Crit Care 2021; 64:68-73. [PMID: 33794469 DOI: 10.1016/j.jcrc.2021.03.005] [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: 08/10/2020] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 11/23/2022]
Abstract
Hypoglycemic episodes are associated with worse hospital outcomes. All adult patients admitted to our burn center from 2015 to 2019 were retrospectively reviewed. Patient demographics and burn characteristics were recorded. The primary outcome was mortality, and secondary outcomes were total length-of-stay and intensive care unit length-of-stay. All patients experiencing at least one hypoglycemic episode were compared to patients who did not experience hypoglycemia. There were 914 patients with acute burns admitted during the study period, 33 of which (4%) experienced hypoglycemic episodes. Of these, 17 patients (52%) experienced a single hypoglycemic episode, while the remainder experienced multiple hypoglycemic episodes. Patients with one or more hypoglycemic events were matched to non-hypoglycemic controls using propensity matching. Patients that experienced hypoglycemia had significantly less TBSA involvement (5% vs. 13%,median, p < 0.0002), higher prevalence of diabetes (48% vs. 18%, p < 0.0001), higher mortality (18% vs. 7%, p = 0.01), longer total length-of-stay (22 vs. 8 days, median, p < 0.0001), and longer ICU length-of-stay (12 vs. 0 days, median, p < 0.0001). A single hypoglycemic episode was associated with prolonged total (IRR = 1.91, p < 0.0001) and ICU length-of-stay (IRR = 3.86, p < 0.0001). Hypoglycemia was not associated with higher mortality in the survival analysis (p = 0.46).
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23
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Wei Y, Zhang D, Liu J, Ou M, Liang P, Zuo Y, Zhou C. Effects of sevoflurane anesthesia and abdominal surgery on the systemic metabolome: a prospective observational study. BMC Anesthesiol 2021; 21:80. [PMID: 33731015 PMCID: PMC7968205 DOI: 10.1186/s12871-021-01301-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 03/08/2021] [Indexed: 02/08/2023] Open
Abstract
Background Metabolic status can be impacted by general anesthesia and surgery. However, the exact effects of general anesthesia and surgery on systemic metabolome remain unclear, which might contribute to postoperative outcomes. Methods Five hundred patients who underwent abdominal surgery were included. General anesthesia was mainly maintained with sevoflurane. The end-tidal sevoflurane concentration (ETsevo) was adjusted to maintain BIS (Bispectral index) value between 40 and 60. The mean ETsevo from 20 min after endotracheal intubation to 2 h after the beginning of surgery was calculated for each patient. The patients were further divided into low ETsevo group (mean − SD) and high ETsevo group (mean + SD) to investigate the possible metabolic changes relevant to the amount of sevoflurane exposure. Results The mean ETsevo of the 500 patients was 1.60% ± 0.34%. Patients with low ETsevo (n = 55) and high ETsevo (n = 59) were selected for metabolomic analysis (1.06% ± 0.13% vs. 2.17% ± 0.16%, P < 0.001). Sevoflurane and abdominal surgery disturbed the tricarboxylic acid cycle as identified by increased citrate and cis-aconitate levels and impacted glycometabolism as identified by increased sucrose and D-glucose levels in these 114 patients. Glutamate metabolism was also impacted by sevoflurane and abdominal surgery in all the patients. In the patients with high ETsevo, levels of L-glutamine, pyroglutamic acid, sphinganine and L-selenocysteine after sevoflurane anesthesia and abdominal surgery were significantly higher than those of the patients with low ETsevo, suggesting that these metabolic changes might be relevant to the amount of sevoflurane exposure. Conclusions Sevoflurane anesthesia and abdominal surgery can impact principal metabolic pathways in clinical patients including tricarboxylic acid cycle, glycometabolism and glutamate metabolism. This study may provide a resource data for future studies about metabolism relevant to general anaesthesia and surgeries. Trial registration www.chictr.org.cn. identifier: ChiCTR1800014327. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01301-0.
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Affiliation(s)
- Yiyong Wei
- Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, West China Hospital of Sichuan University, 37# Guoxue Xiang, Chengdu, 610041, Sichuan, China.,Department of Anesthesiology, West China Hospital of Sichuan University, 37# Guoxue Xiang, Chengdu, 610041, Sichuan, China
| | - Donghang Zhang
- Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, West China Hospital of Sichuan University, 37# Guoxue Xiang, Chengdu, 610041, Sichuan, China.,Department of Anesthesiology, West China Hospital of Sichuan University, 37# Guoxue Xiang, Chengdu, 610041, Sichuan, China
| | - Jin Liu
- Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, West China Hospital of Sichuan University, 37# Guoxue Xiang, Chengdu, 610041, Sichuan, China. .,Department of Anesthesiology, West China Hospital of Sichuan University, 37# Guoxue Xiang, Chengdu, 610041, Sichuan, China.
| | - Mengchan Ou
- Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, West China Hospital of Sichuan University, 37# Guoxue Xiang, Chengdu, 610041, Sichuan, China.,Department of Anesthesiology, West China Hospital of Sichuan University, 37# Guoxue Xiang, Chengdu, 610041, Sichuan, China
| | - Peng Liang
- Department of Anesthesiology, West China Hospital of Sichuan University, 37# Guoxue Xiang, Chengdu, 610041, Sichuan, China
| | - Yunxia Zuo
- Department of Anesthesiology, West China Hospital of Sichuan University, 37# Guoxue Xiang, Chengdu, 610041, Sichuan, China.
| | - Cheng Zhou
- Laboratory of Anesthesia & Critical Care Medicine, Translational Neuroscience Center, West China Hospital of Sichuan University, 37# Guoxue Xiang, Chengdu, 610041, Sichuan, China
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24
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Storey A, MacDonald B, Rahman MA. The association between preoperative length of hospital stay and deep sternal wound infection: A scoping review. Aust Crit Care 2021; 34:620-633. [PMID: 33750649 DOI: 10.1016/j.aucc.2020.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/10/2020] [Accepted: 12/13/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Deep sternal wound infection (DSWI) is a serious complication of cardiac surgery, associated with a significantly longer hospital stay, an increased mortality, and an almost doubling of treatment costs. The preoperative length of hospital stay has been suggested in a small number of studies as a modifiable risk factor yet is not included in surgical site infection prevention guidelines. The aim of this scoping review was to review the existing evidence on the association between preoperative length of hospital stay and DSWI, and to identify established risk factors for DSWI. METHODS A literature search of six electronic databases yielded 2297 results. Titles concerning risk factors for DSWI, sternal or surgical wound infection, or poststernotomy complications were included. Abstracts relating to preoperative length of stay as a risk factor for DSWI proceeded to full article review. Articles regarding paediatric surgery, DSWI management or unavailable in English were excluded. RESULTS The review identified 11 observational cohort studies. DSWI prevalence was between 0.9% and 6.8%. Preoperative length of stay ranged from 0-15.5 days and was found to be associated with DSWI in all studies. Preoperative length of stay and DSWI were inconsistently defined. Other risk factors for DSWI included diabetes, obesity, respiratory disease, heart failure, renal impairment, complex surgery, and reoperation (p < 0.05). CONCLUSION In this scoping review, an association between preoperative length of stay and the development of DSWI following cardiac surgery was identified. Thus, preoperative length of stay as a modifiable risk factor for DSWI should be considered for inclusion in cardiothoracic surgical infection prevention guidelines.
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Affiliation(s)
- Annmarie Storey
- Alfred Heart & Lung, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia; School of Nursing and Midwifery, La Trobe University, Plenty Rd & Kingsbury Dr, Bundoora, Melbourne, VIC 3086, Australia.
| | - Brendan MacDonald
- Alfred Heart & Lung, The Alfred Hospital, 55 Commercial Road, Melbourne, VIC 3004, Australia; Ward 2.2, Box Hill Hospital, Eastern Health, 8 Arnold St, Box Hill, Melbourne, Victoria, 3128, Australia
| | - Muhammad Aziz Rahman
- School of Health, Federation University Australia, Berwick, Melbourne, VIC 3806, Australia; Australian Institute of Primary Care and Ageing, La Trobe University, Melbourne, VIC 3086, Australia.
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25
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Carvalho RC, Nishi FA, Ribeiro TB, França GG, Aguiar PM. Association Between Intra-Hospital Uncontrolled Glycemia and Health Outcomes in Patients with Diabetes: A Systematic Review of Observational Studies. Curr Diabetes Rev 2021; 17:304-316. [PMID: 32000645 DOI: 10.2174/1573399816666200130093523] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/26/2019] [Accepted: 01/09/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Many people are still getting affected by uncontrolled glycemic events during hospital admission, which encompasses hypoglycemia, hyperglycemia, and high glycemic variability. INTRODUCTION Primary studies have shown an association of glycemic dysregulation with increased length of hospital stay and mortality among overall patients, however, there is no systematic review of current evidence on the association between uncontrolled in-hospital glycemia in patients with diabetes and health outcomes. This study aimed to systematically review the current evidence on the association between uncontrolled in-hospital glycemia in patients with diabetes and health outcomes. METHODS The association between glycemic dysregulation and health outcomes for inpatients with diabetes was systematically reviewed. PubMed, Embase, and LILACS databases were searched. Two independent reviewers were involved in each of the following steps: screening titles, abstracts, and fulltexts; assessing the methodological quality; and extracting data from included reviews. Descriptive analysis method was used. RESULTS Seven cohort studies were included, and only two had a prospective design, consisting of 7,174 hospitalized patients with diabetes. In-hospital occurrence of hypoglycemia, hyperglycemia, and glycemic variability were assessed, and outcomes were mortality, infections, renal complications, and adverse events. Among the exposure and outcomes, an association was observed between severe hypoglycemia and mortality, hyperglycemia and infection, and hyperglycemia and adverse events. CONCLUSION In-hospital uncontrolled glycemia in patients with diabetes is associated with poor health outcomes. More studies should be conducted for proper investigation because diabetes is a complex condition. Effects of glycemic dysregulation should be investigated on the basis of overall health of a patient instead from only organ-target perspective, which makes the investigation difficult.
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Affiliation(s)
- Renata Cunha Carvalho
- Division of Pharmacy of University Hospital, University of São Paulo, São Paulo, Brazil
| | - Fernanda Ayache Nishi
- Department of Nursing of University Hospital, University of São Paulo, São Paulo, Brazil
| | - Tatiane Bomfim Ribeiro
- Department of Preventive Medicine, Faculty of Medicine, University of São Paulo, São Paulo, Brazil
| | - Gustavo Galvão França
- Division of Pharmacy of University Hospital, University of São Paulo, São Paulo, Brazil
| | - Patricia Melo Aguiar
- Department of Pharmacy, Faculty of Pharmaceutical Sciences, University of São Paulo, São Paulo, Brazil
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26
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Jones JML, Feitosa ACR, Hita MC, Fonseca EM, Pato RB, Toyoshima MTK. Medical software applications for in-hospital insulin therapy: A systematic review. Digit Health 2020; 6:2055207620983120. [PMID: 34104463 PMCID: PMC8162202 DOI: 10.1177/2055207620983120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 12/02/2020] [Indexed: 01/08/2023] Open
Abstract
Background In-hospital hyperglycemia (HH) is frequent and related to higher morbidity and mortality. Despite the benefits of HH treatment, glycemic control is often poor and neglected. The use of health applications to support diagnosis and therapy is now incorporated into medical practice. Medical applications for inpatient glycemic management have potential to standardize this handling by the nonspecialist physician. However, related studies are scarce. We aim to evaluate the efficacy in inpatient glycemic control parameters of medical software applications in non-critical care settings. Methods This systematic review on in-hospital insulin applications was performed according to PRISMA guidelines. Data were extracted in triplicate and methodological quality was verified. Specific outcomes of interest were glycemic control efficacy, hypoglycemia risk, length of in-hospital stay, integration with the electronic medical record and healthcare staff acceptance. Results Among the 573 articles initially identified and subsequent revision of the references of each one, seven studies involving six applications were eligible for the review. A better glycemic control was reported with the use of most in-hospital insulin applications in the studies evaluated, but there was no mention of the time to reach the glycemic goal. The risk of hypoglycemia was low. Different reasons influenced the varied acceptance of the use of applications among health professionals. Conclusion The six applications of inpatient insulin therapy in a non-critical care environment proved to be useful and safe compared to the usual management. Medical apps are tools that can help improve the quality of patient care.
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Affiliation(s)
| | | | - Malena Costa Hita
- Faculdade de Medicina da Bahia, Universidade Federal da Bahia, Salvador, Brazil
| | | | | | - Marcos Tadashi Kakitani Toyoshima
- Oncoendocrinology service of Instituto do Cancer do Estado de Sao Paulo Octávio Frias de Oliveira, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Hospital Medicine service, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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27
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Page E, Allen R, Wensley F, Rayman G. Improving the peri-operative pathway of people with diabetes undergoing elective surgery: the IP3D project. Diabet Med 2020; 37:2019-2026. [PMID: 32297351 DOI: 10.1111/dme.14307] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2020] [Indexed: 11/27/2022]
Abstract
AIM To determine whether outcomes for people with diabetes undergoing elective surgery improve following the introduction of innovations in the peri-operative care pathway. METHODS Following a baseline audit of 185 people with diabetes listed for elective surgery (July to December 2017) with a length of stay > 24 hours, a number of changes in practice were implemented. These included dissemination of a 'diabetes peri-operative passport' to participants preoperatively, formation of a diabetes surgery working group, recruitment of surgical diabetes champions and the roll-out of surgical diabetes study days. Crucial was recruitment of a diabetes peri-operative nurse, whose role included engaging and educating others and supporting individuals throughout their peri-operative diabetes care. Records of 166 individuals listed for surgery during the implementation period (July to December 2018) were then audited using the same methodology. RESULTS The availability of a recent HbA1c measurement significantly increased (63% vs 92%; P ≤ 0.001). The mean HbA1c of those seen for optimizations by the diabetes peri-operative nurse significantly decreased [84 mmol/mol (9.8%) vs 62 mmol/mol (7.8%); P ≤ 0.001]. Recurrent hypoglycaemia significantly decreased (7.0% vs 0.6%; P = 0.002) and the mean number of hyperglycaemic events in people experiencing hyperglycaemia almost halved (3.0 vs 1.7; P=0.007). The mean length of hospital stay significantly decreased (4.8 vs 3.3 days; P=0.001) and, crucially, 30-day readmissions did not increase (12% vs 9%; P=0.307). Postoperative complications significantly decreased (28% vs 16%; P=0.008), including a composite of dysglycaemic complications, poor wound healing, wound infection and other infections (12% vs 5.4%; P=0.023). CONCLUSION The new pathway improved important peri-operative outcomes for people with diabetes undergoing elective surgery with the potential for cost savings. These findings could have important implications for peri-operative care on a wider scale.
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Affiliation(s)
- E Page
- East Suffolk and North Essex NHS Foundation Trust, Ipswich Hospital, Ipswich, UK
| | - R Allen
- East Suffolk and North Essex NHS Foundation Trust, Ipswich Hospital, Ipswich, UK
| | - F Wensley
- University Hospitals Southampton NHS Trust, Southampton, UK
| | - G Rayman
- East Suffolk and North Essex NHS Foundation Trust, Ipswich Hospital, Ipswich, UK
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28
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Himes CP, Ganesh R, Wight EC, Simha V, Liebow M. Perioperative Evaluation and Management of Endocrine Disorders. Mayo Clin Proc 2020; 95:2760-2774. [PMID: 33168157 DOI: 10.1016/j.mayocp.2020.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 05/02/2020] [Accepted: 05/12/2020] [Indexed: 12/25/2022]
Abstract
Evaluation of endocrine issues is a sometimes overlooked yet important component of the preoperative medical evaluation. Patients with diabetes, thyroid disease, and hypothalamic-pituitary-adrenal axis suppression are commonly encountered in the surgical setting and require unique consideration to optimize perioperative risk. For patients with diabetes, perioperative glycemic control has the strongest association with postsurgical outcomes. The preoperative evaluation should include recommendations for adjustment of insulin and noninsulin diabetic medications before surgery. Recommendations differ based on the type of diabetes, the type of insulin, and the patient's predisposition to hyperglycemia or hypoglycemia. Generally, patients with thyroid dysfunction can safely undergo operations unless they have untreated hyperthyroidism or severe hypothyroidism. Patients with known primary or secondary adrenal insufficiency require supplemental glucocorticoids to prevent adrenal crisis in the perioperative setting. Evidence supporting the use of high-dose supplemental corticosteroids for patients undergoing long-term glucocorticoid therapy is sparse. We discuss an approach to these patients based on the dose and duration of ongoing or recent corticosteroid therapy. As with other components of the preoperative medical evaluation, the primary objective is identification and assessment of the severity of endocrine issues before surgery so that the surgeons, anesthesiologists, and internal medicine professionals can optimize management accordingly.
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Affiliation(s)
- Carina P Himes
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN.
| | - Ravindra Ganesh
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
| | | | - Vinaya Simha
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN
| | - Mark Liebow
- Division of General Internal Medicine, Mayo Clinic, Rochester, MN
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29
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Ye Y, Pan B, Gu M, Xian G, Chen W, Zheng L, Zhang Z, Sheng P. Fluctuation of fasting blood glucose in patients who underwent primary or revision total joint arthroplasty: a retrospective review. J Orthop Surg Res 2020; 15:508. [PMID: 33153464 PMCID: PMC7643256 DOI: 10.1186/s13018-020-02029-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 10/20/2020] [Indexed: 12/18/2022] Open
Abstract
Background Perioperative hyperglycemia is a risk factor for postoperative complications after total joint arthroplasty (TJA). However, the variability of fasting blood glucose (FBG) after TJA remains unknown. We aimed to assess the fluctuation and extent of elevation of FBG following primary or revision TJA. Methods We retrospectively evaluated the medical records of 1788 patients who underwent primary or revision TJA between 2013 and 2018. We examined FBG values collected during 6 days of the perioperative period. The findings for each time point were evaluated with descriptive statistics. Postoperative glycemic variability was assessed by the coefficient of variation (CV). Results The final cohort included the medical records of 1480 patients (1417 primary and 63 revision). FBG was highest on postoperative day 1 in the primary and revision groups (P < 0.001), which had the highest number of hyperglycemic patients (FBG > 100 mg/dL), with 66.4% and 75.5% in the primary and revision groups, respectively. The CV of diabetics in the primary group, and diabetics and non-diabetics in the revision group, was higher than that of non-diabetics in the primary group. Conclusion Postoperative day 1 showed the highest FBG levels and proportion of patients with hyperglycemia in the perioperative period. Primary group diabetics, and revision group diabetics and non-diabetics, had higher postoperative fluctuation of FBG than primary group non-diabetics. Frequent FBG monitoring may therefore be warranted in diabetic patients undergoing TJA, and all patients undergoing revision TJA.
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Affiliation(s)
- Yongyu Ye
- Department of Orthopedic Surgery, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Baiqi Pan
- Department of Orthopedic Surgery, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Minghui Gu
- Department of Orthopedic Surgery, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Guoyan Xian
- Department of Orthopedic Surgery, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Weishen Chen
- Department of Orthopedic Surgery, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Linli Zheng
- Department of Orthopedic Surgery, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China
| | - Ziji Zhang
- Department of Orthopedic Surgery, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.
| | - Puyi Sheng
- Department of Orthopedic Surgery, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan 2nd Road, Guangzhou, 510080, China.
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Wong JKL, Ke Y, Ong YJ, Li HH, Abdullah HR. Impact of preoperative HbA1c on postoperative complications after elective major abdominal surgery: a systematic review protocol. BMJ Open 2020; 10:e039422. [PMID: 32998928 PMCID: PMC7528368 DOI: 10.1136/bmjopen-2020-039422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Diabetes has an increasing worldwide prevalence. It is known to be a predisposing factor for postoperative complications. Preoperative glycaemic control strategies should be pursued as glycaemic control could serve as a modifiable risk factor. Glycated haemoglobin (HbA1c), a marker of 3-month average glycaemic control, has been shown in meta-analyses to predict postoperative complications in cardiothoracic, bariatric and orthopaedic surgery. However, there is no meta-analysis in the major abdominal surgery population, in whom morbidity may be higher due to the nature of the surgery. Understanding the association between HbA1c and postoperative complications could help in preoperative risk prognostication, counselling and glycaemic target selection. The aim of this systematic review and meta-analysis is to evaluate all evidence on the association between preoperative HbA1c and postoperative complications in elective major abdominal surgery, and to investigate the threshold HbA1c level before postoperative complication rates increase. METHODS AND ANALYSIS This review will be performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines. PubMed, Embase, Cochrane Central Register of Controlled Trials, Google Scholar and China National Knowledge Infrastructure will be searched for all original studies. Study selection, data extraction, risk of bias and quality assessment will be conducted by two independent reviewers. The primary outcome is the association between preoperative HbA1c and major postoperative complications (Clavien Dindo 3-5), and the secondary outcome is the association between HbA1c and overall postoperative complications. Data management and synthesis will be performed using Microsoft Excel and Stata to derive pool estimates. ETHICS AND DISSEMINATION No ethics approval is required as only secondary data will be used. Findings will be disseminated through peer-reviewed journals and conference presentations. PROSPERO REGISTRATION NUMBER CRD42020167347.
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Affiliation(s)
| | - Yuhe Ke
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Yi Jing Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Hui Hua Li
- Health Services Research Unit, Singapore General Hospital, Singapore
| | - Hairil Rizal Abdullah
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
- DukeNUS Medical School, Singapore
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Rabizadeh S, Tavakoli Ardakani MA, Mouodi M, Bitaraf M, Shab-Bidar S, Esteghamati A, Nakhjavani M. DPP4 Inhibitors in the Management of Hospitalized Patients With Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Adv Ther 2020; 37:3660-3675. [PMID: 32671686 DOI: 10.1007/s12325-020-01434-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION We studied the effects of dipeptidyl peptidase 4 (DPP4) inhibitors on glycemic control in non-critically ill patients admitted to hospital. METHODS We searched MEDLINE and EMBASE for published studies in English up to July 2019. We included randomized clinical trials (RCTs) that compared DPP4 inhibitors plus insulin supplementation versus basal-bolus insulin regimen in the management of hyperglycemia non-critically ill patients with type 2 diabetes admitted to hospital. Mean difference (MD), relative risk (RR), and 95% confidence intervals (CI) were generated to interpret the data. RESULTS Of 401 papers, four RCTs including 648 participants met inclusion criteria. There was no significant difference in mean daily blood glucose level between the two groups (MD 4.63; 95% CI = - 1.57, 10.83; p = 0.14) (I2 = 14%, p = 0.32). Total insulin dose per day was lower in patients receiving DPP4 inhibitors (MD - 14.27; CI = - 22.47, - 6.07; p = 0.001) (I2 = 92%, p = 0.001). Also, the number of insulin injection was significantly lower in patients receiving DPP4 inhibitors (MD - 0.79; CI = - 1.01, - 0.57; p = 0.001) (I2 = 0%, p = 0.68). The rate of hypoglycemia was not significantly different between the two groups (RR 0.60, CI = 0.34, 1.074; p = 0.08) (I2 = 37.3%, p = 0.18). Treatment failure was not significantly different between the two groups (RR 0.87, CI = 0.64, 4.8; p = 0.38) (I2 = 49%, p = 0.11). CONCLUSION The results indicate that using DPP4 inhibitors plus basal or supplemental insulin in hospitalized patients is non-inferior to a standard basal-bolus insulin regimen and leads to a lower amount of insulin use and a lower rate of insulin injection. Limitations of this study were heterogeneity of baseline characteristics of included patients, small sample size, short duration, and non-uniformly defined outcome assessment parameters in the included studies.
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Lorenzo-González C, Atienza-Sánchez E, Reyes-Umpierrez D, Vellanki P, Davis GM, Pasquel FJ, Cardona S, Fayfman M, Peng L, Umpierrez GE. Safety And Efficacy Of Dpp-4 Inhibitors For The Management Of Hospitalized General Medicine And Surgery Patients with Type 2 Diabetes. Endocr Pract 2020; 26:722-728. [PMID: 33471640 PMCID: PMC11305855 DOI: 10.4158/ep-2019-0481] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 02/09/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE DPP-4 inhibitors (DPP-4i) have been shown to be effective for the management of inpatient diabetes. We report pooled data from 3 prospective studies using DPP-4i in general medicine and surgery patients with type 2 diabetes (T2D). METHODS We combined data from 3 randomized studies comparing DPP-4i alone or in combination with basal insulin or a basal-bolus insulin regimen. Medicine (n = 266) and surgery (n = 319) patients admitted with a blood glucose (BG) between 140 and 400 mg/dL, treated with diet, oral agents, or low-dose insulin therapy were included. Patients received DPP-4i alone (n = 144), DPP-4i plus basal insulin (n = 158) or basal-bolus regimen (n = 283). All groups received correctional doses with rapid-acting insulin for BG >140 mg/dL. The primary endpoint was differences in mean daily BG between groups. Secondary endpoints included differences in hypoglycemia and hospital complications. RESULTS There were no differences in mean hospital daily BG among patients treated with DPP-4i alone (170 ± 37 mg/dL), DPP-4i plus basal (172 ± 42 mg/dL), or basalbolus (172 ± 43 mg/dL), P = .94; or in the percentage of BG readings within target of 70 to 180 mg/dL (63 ± 32%, 60 ± 31%, and 64 ± 28%, respectively; P = .42). There were no differences in length of stay or complications, but hypoglycemia was less common with DPP-4i alone (2%) compared to DPP-4i plus basal (9%) and basal-bolus (10%); P = .004. CONCLUSION Treatment with DPP-4i alone or in combination with basal insulin is effective and results in a lower incidence of hypoglycemia compared to a basal-bolus insulin regimen in general medicine and surgery patients with T2D. ABBREVIATIONS BG = blood glucose; BMI = body mass index; CI = confidence interval; DPP-4i = dipeptidyl peptidase-4 inhibitors; HbA1c = hemoglobin A1c; OR = odds ratio; T2D = type 2 diabetes.
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Affiliation(s)
- Cristina Lorenzo-González
- Department of Endocrinology and Nutrition, Hospital Universitario Nuestra Señora de La Candelaria, Tenerife, Spain
| | - Elena Atienza-Sánchez
- Department of Endocrinology and Nutrition, Hospital Universitario Príncipe de Asturias, Madrid, Spain
| | | | | | | | | | | | - Maya Fayfman
- Department of Medicine, Emory University School of Medicine
| | - Limin Peng
- School of Public Health, Emory University, Atlanta, Georgia
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Pasquel FJ, Lansang MC, Khowaja A, Urrutia MA, Cardona S, Albury B, Galindo RJ, Fayfman M, Davis G, Migdal A, Vellanki P, Peng L, Umpierrez GE. A Randomized Controlled Trial Comparing Glargine U300 and Glargine U100 for the Inpatient Management of Medicine and Surgery Patients With Type 2 Diabetes: Glargine U300 Hospital Trial. Diabetes Care 2020; 43:1242-1248. [PMID: 32273271 PMCID: PMC7411278 DOI: 10.2337/dc19-1940] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 03/20/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The role of U300 glargine insulin for the inpatient management of type 2 diabetes (T2D) has not been determined. We compared the safety and efficacy of glargine U300 versus glargine U100 in noncritically ill patients with T2D. RESEARCH DESIGN AND METHODS This prospective, open-label, randomized clinical trial included 176 patients with poorly controlled T2D (admission blood glucose [BG] 228 ± 82 mg/dL and HbA1c 9.5 ± 2.2%), treated with oral agents or insulin before admission. Patients were treated with a basal-bolus regimen with glargine U300 (n = 92) or glargine U100 (n = 84) and glulisine before meals. We adjusted insulin daily to a target BG of 70-180 mg/dL. The primary end point was noninferiority in the mean difference in daily BG between groups. The major safety outcome was the occurrence of hypoglycemia. RESULTS There were no differences between glargine U300 and U100 in mean daily BG (186 ± 40 vs. 184 ± 46 mg/dL, P = 0.62), percentage of readings within target BG of 70-180 mg/dL (50 ± 27% vs. 55 ± 29%, P = 0.3), length of stay (median [IQR] 6.0 [4.0, 8.0] vs. 4.0 [3.0, 7.0] days, P = 0.06), hospital complications (6.5% vs. 11%, P = 0.42), or insulin total daily dose (0.43 ± 0.21 vs. 0.42 ± 0.20 units/kg/day, P = 0.74). There were no differences in the proportion of patients with BG <70 mg/dL (8.7% vs. 9.5%, P > 0.99), but glargine U300 resulted in significantly lower rates of clinically significant hypoglycemia (<54 mg/dL) compared with glargine U100 (0% vs. 6.0%, P = 0.023). CONCLUSIONS Hospital treatment with glargine U300 resulted in similar glycemic control compared with glargine U100 and may be associated with a lower incidence of clinically significant hypoglycemia.
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Affiliation(s)
| | | | - Ameer Khowaja
- Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
| | | | | | | | | | - Maya Fayfman
- Emory University School of Medicine, Atlanta, GA
| | | | | | | | - Limin Peng
- Rollins School of Public Health, Emory University, Atlanta, GA
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Marbou WJT, Kuete V. Methicillin-resistant Staphylococcus aureus in Metabolic Syndrome Patients at the Mbouda Hospitals, West Region of Cameroon. Cureus 2020; 12:e7274. [PMID: 32300494 PMCID: PMC7158605 DOI: 10.7759/cureus.7274] [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] [Indexed: 11/08/2022] Open
Abstract
Background Studies have revealed an increased risk of contracting Staphylococcus aureus infections in patients suffering from metabolic diseases. Methicillin-resistant Staphylococcus aureus (MRSA) in metabolic syndrome subjects is less reported in the medical literature. This study aimed at isolating and establishing the distribution of antibiotic-resistant Staphylococcus aureus from faecal samples in metabolic syndrome subjects from Mbouda Hospitals, West Region of Cameroon. Methods A cross-sectional study was conducted from May 2016 to May 2018 in 114 participants in whom Staphylococcus aureus was detected. Thirty (30) participants were suffering from metabolic syndrome and 84 did not suffer from this pathology. Staphylococcus aureus isolation was based on culture and confirmed by polymerase chain reaction (PCR) of the nuc gene. The Kirby-Bauer disk diffusion method was used for drug susceptibility assay. Molecular detection of the mecA gene by PCR was performed to screen MRSA. Results From the 114 Staphylococcus aureus isolates, the prevalence of the mecA gene confirming MRSA was 79.82%, higher than that of methicillin-sensitive Staphylococcus aureus (MSSA) (20.17%). The frequency of MRSA was higher in participants with metabolic syndrome (80.00%) compared to non-metabolic syndrome (79.76%) participants without significant difference (p=0.977). The antimicrobial susceptibility test revealed that the amikacin susceptibility profile was significantly different in metabolic and non-metabolic syndrome participants (p=0.037, chi-square=6.59). Regarding metabolic syndrome status, 72.62% of isolates were multidrug-resistant in non-metabolic syndrome participants versus 63.33% in metabolic syndrome participants. Conclusion This study suggests that metabolic syndrome patients harbour MRSA strains in their intestines even as the difference was not statistically significant with non-metabolic syndrome participants. The need for appropriate antimicrobial use to halt or at least limit the spread of resistance is suggested in the care of metabolic syndrome patients and the entire population.
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Affiliation(s)
| | - Victor Kuete
- Biochemistry, University of Dschang, Dschang, CMR
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Akiboye F, Adderley NJ, Martin J, Gokhale K, Rudge GM, Marshall TP, Rajendran R, Nirantharakumar K, Rayman G. Impact of the Diabetes Inpatient Care and Education (DICE) project on length of stay and mortality. Diabet Med 2020; 37:277-285. [PMID: 31265148 DOI: 10.1111/dme.14062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2019] [Indexed: 01/09/2023]
Abstract
AIM To determine whether the Diabetes Inpatient Care and Education (DICE) programme, a whole-systems approach to managing inpatient diabetes, reduces length of stay, in-hospital mortality and readmissions. RESEARCH DESIGN AND METHODS Diabetes Inpatient Care and Education initiatives included identification of all diabetes admissions, a novel DICE care-pathway, an online system for prioritizing referrals, use of web-linked glucose meters, an enhanced diabetes team, and novel diabetes training for doctors. Patient administration system data were extracted for people admitted to Ipswich Hospital from January 2008 to June 2016. Logistic regression was used to compare binary outcomes (mortality, 30-day readmissions) 6 months before and after the intervention; generalized estimating equations were used to compare lengths of stay. Interrupted time series analysis was performed over the full 7.5-year period to account for secular trends. RESULTS Before-and-after analysis revealed a significant reduction in lengths of stay for people with and without diabetes: relative ratios 0.89 (95% CI 0.83, 0.97) and 0.93 (95% CI 0.90, 0.96), respectively; however, in interrupted time series analysis the change in long-term trend for length of stay following the intervention was significant only for people with diabetes (P=0.017 vs P=0.48). Odds ratios for mortality were 0.63 (0.48, 0.82) and 0.81 (0.70, 0.93) in people with and without diabetes, respectively; however, the change in trend was not significant in people with diabetes, while there was an apparent increase in those without diabetes. There was no significant change in 30-day readmissions, but interrupted time series analysis showed a rising trend in both groups. CONCLUSION The DICE programme was associated with a shorter length of stay in inpatients with diabetes beyond that observed in people without diabetes.
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Affiliation(s)
- F Akiboye
- Diabetes Research Unit, Ipswich Hospital NHS Trust, Ipswich, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - N J Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - J Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - K Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - G M Rudge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - T P Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - R Rajendran
- Diabetes Research Unit, Ipswich Hospital NHS Trust, Ipswich, UK
| | - K Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - G Rayman
- Diabetes Research Unit, Ipswich Hospital NHS Trust, Ipswich, UK
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Torkamani N, Churilov L, Robbins R, Jerums G, Beik V, Radcliffe N, Patterson S, Bellomo R, Burns J, Hart GK, Lam Q, Power DA, MacIsaac RJ, Johnson DF, Zajac J, Ekinci EI. Diabetes and higher HbA1c levels are independently associated with adverse renal outcomes in inpatients following multiple hospital admissions. J Diabetes Complications 2020; 34:107465. [PMID: 31735639 DOI: 10.1016/j.jdiacomp.2019.107465] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 09/02/2019] [Accepted: 09/25/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To assess the association between glycaemic status prior to the first hospital presentation with developing adverse renal outcomes overtime in patients with multiple hospital re-admissions. DESIGN A prospective observational cohort study. PARTICIPANTS All inpatients aged ≥54 years admitted between 2013 and 16 to a tertiary hospital. MAIN OUTCOMES We prospectively measured HbA1c levels in all inpatients aged ≥54 years admitted between 2013 and 16. Diabetes was defined as prior documented diagnosis of diabetes and/or HbA1c ≥6.5% (47·5 mmol/L). Included patients had ≥ two admissions (at least 90 days apart), baseline estimated glomerular filtration rate (eGFR) >30 ml/min/1·73m2 and no history of renal replacement therapy. We assessed several renal outcomes: (a) 50% decline in eGFR; (b) rapid decline in renal function (eGFR decline >5 mL/min/1·73m2/year) and (c) final eGFR<30 ml/min/1·73m2. RESULTS Of 4126 inpatients with a median follow-up of 465 days (254, 740), 26% had diabetes. The presence of diabetes was associated with higher odds of (a) 50% decline in eGFR (OR = 1·42;95% CI:1·18-1·70;p < 0·001); (b) rapid decline in renal function (OR = 1·40;95%CI:1·20-1·63;p < 0·001), and (c) reaching eGFR<30 ml/min/1.73m2 (OR = 1·25;95%CI:1·03-1·53;p < 0·05). Every 1% (11 mmol/L) increase in baseline HbA1c was associated with significantly greater odds of (a) >50% decline in eGFR (OR = 1·07;95% CI:1·01-1·4;p < 0·05) and (b) rapid decline in renal function (OR = 1·11;95% CI:1·05-1·18;p < 0·001). CONCLUSIONS In patients with ≥two admissions, the presence of diabetes and higher HbA1c levels were strongly and independently associated with adverse renal outcomes at follow up. Such patients are at high risk of relatively rapid deterioration in renal function and a logical target for structured preventive interventions.
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Affiliation(s)
- N Torkamani
- Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Victoria, Australia; Department of Endocrinology, Austin Health, Melbourne, Victoria, Australia
| | - L Churilov
- Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Victoria, Australia
| | - R Robbins
- Department of Administrative Informatics, Austin Health, Heidelberg, Victoria, Australia
| | - G Jerums
- Department of Endocrinology, Austin Health, Melbourne, Victoria, Australia
| | - V Beik
- School of Engineering, RMIT University, Melbourne, Victoria, Australia
| | - N Radcliffe
- Department of General Medicine, Austin Health, Melbourne, Victoria, Australia
| | - S Patterson
- Department of Endocrinology, Austin Health, Melbourne, Victoria, Australia
| | - R Bellomo
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia; Department of Medicine, The University of Melbourne, Parkville, Australia
| | - J Burns
- Clinical Informatics Unit, Austin Health, Heidelberg, Victoria, Australia
| | - G K Hart
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia; Centre for Digital Transformation of Health, University of Melbourne
| | - Q Lam
- Department of Pathology, Austin Health, Heidelberg, Victoria, Australia
| | - D A Power
- Department of Nephrology, Austin Health, Heidelberg, Victoria, Australia
| | - R J MacIsaac
- Department of Medicine, The University of Melbourne, Parkville, Australia; Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia
| | - D F Johnson
- Department of General Medicine, Austin Health, Melbourne, Victoria, Australia; Department of Medicine, The University of Melbourne, Parkville, Australia
| | - J Zajac
- Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Victoria, Australia; Department of Endocrinology, Austin Health, Melbourne, Victoria, Australia
| | - E I Ekinci
- Department of Medicine, University of Melbourne, Austin Health, Heidelberg, Victoria, Australia; Department of Endocrinology, Austin Health, Melbourne, Victoria, Australia.
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Enhanced Recovery in Patients With Diabetes: Is it Time for a Moratorium on Use of Preoperative Carbohydrate Beverages? Ann Surg 2019; 269:411-412. [PMID: 30048328 DOI: 10.1097/sla.0000000000002989] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The Effect of a Low Glycemic Index Pulse-Based Diet on Insulin Sensitivity, Insulin Resistance, Bone Resorption and Cardiovascular Risk Factors during Bed Rest. Nutrients 2019; 11:nu11092012. [PMID: 31461862 PMCID: PMC6770095 DOI: 10.3390/nu11092012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 08/19/2019] [Accepted: 08/20/2019] [Indexed: 12/16/2022] Open
Abstract
We determined the effects of a low glycemic-index pulse-based diet (i.e., containing lentils, chick peas, beans, and split peas) compared to a typical hospital diet on insulin sensitivity assessed by the Matsuda index from the insulin and glucose response to a two-hour oral glucose tolerance test, insulin resistance assessed by the homeostatic model assessment of insulin resistance (HOMA-IR), bone resorption assessed by 24 h excretion of urinary n-telopeptides(Ntx) and cardiovascular risk factors (blood lipids, blood pressure, arterial stiffness and heart rate variability) during bed rest. Using a randomized, counter-balanced cross-over design with one-month washout, six healthy individuals (30 ± 12 years) consumed the diets during four days of bed rest. The Matsuda index, HOMA-IR, urinary Ntx and cardiovascular risk factors were determined at baseline and after the last day of bed rest. Compared to the typical hospital diet, the pulse-based diet improved the Matsuda index (indicating increased insulin sensitivity; baseline to post-bed rest: 6.54 ± 1.94 to 6.39 ± 2.71 hospital diet vs. 7.14 ± 2.36 to 8.75 ± 3.13 pulse-based diet; p = 0.017), decreased HOMA-IR (1.38 ± 0.54 to 1.37 ± 0.50 hospital diet vs. 1.48 ± 0.54 to 0.88 ± 0.37 pulse-based diet; p = 0.022), and attenuated the increase in Ntx (+89 ± 75% hospital diet vs. +33 ± 20% pulse-based diet; p = 0.035). No differences for changes in cardiovascular risk factors were found between the two diet conditions, with the exception of decreased diastolic blood pressure during day three of bed rest in the pulse-based versus hospital diet (61 ± 9 vs. 66 ± 7 mmHg; p = 0.03). A pulse-based diet was superior to a hospital diet for maintaining insulin sensitivity, preventing insulin resistance, attenuating bone resorption and decreasing diastolic blood pressure during four days of bed rest.
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Haifa Elhadi A, Faiza H. Reasons for admission of individual with diabetes to the Tripoli Medical Center in 2015. Diabetes Metab Syndr 2019; 13:2571-2578. [PMID: 31405678 DOI: 10.1016/j.dsx.2019.07.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 07/08/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Diabetes mellitus is a complex, chronic, metabolic disease manifested in hyperglycemia and associated with various complications, Consequently, people with diabetes have higher rates of hospital admissions than the general population. There is little information about the burden of hospitalizations of diabetic patients in Libya. AIM The aim was to identify the causes of admission of individual with diabetes and to identify the risk factors for hospitalization. PATIENTS AND METHODS This is a retrospective case-series study conducted in Tripoli Medical Center, Tripoli. It covers 1037 individual with diabetes admitted between 1 January 2015 and 31 December 2015. All the data were collected from the patient files. RESULTS The mean age of the patients was 60.7 years ±15.1 standard deviation. The male-to-female ratio was 1:1. Type 2 diabetes accounted for 90.2% of the patients, 56.5% of whom had diabetes for >10 years, 40.5% had no prior chronic illness, 26.7% had hypertension, and 26.4% had multiple co-morbidities. The mean hospital stay was 6.1 days, and 60.8% of the patients were on insulin therapy. The main causes of admission were infection (23%), mainly in the chest, followed by lower extremity disease (22.4%), cardiovascular disease (19.3%), cerebrovascular disease (14.4%) and renal disease (11.8%). CONCLUSIONS The main causes of hospitalization as shown by this study were infections, and chronic complications of diabetes in the lower extremities and cardiovascular system. Most of the patients were >60 years old, had diabetes type 2 for >10 years, were on insulin treatment, and had no other comorbidity.
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Affiliation(s)
| | - Hander Faiza
- Consultant Endocrinologist, Tripoli Medical Center, Tripoli, Libya
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Sriphrapradang C, Mongkolrattanakul P, Tanasanitkul H, Reutrakul S. Improving inpatient glycemic control by diabetes education program in internal medicine residents. Diabetes Metab Syndr 2019; 13:2647-2652. [PMID: 31405689 DOI: 10.1016/j.dsx.2019.07.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 07/10/2019] [Indexed: 10/26/2022]
Abstract
AIMS The purpose of this study was to investigate the effectiveness of an inpatient diabetes care education during the first year of internal medicine residency training on inpatient glycemic control. METHODS The program was comprised of 1-hr small group teaching per 4-week rotation and twice-a-week morning insulin round by an endocrinologist. Inpatient insulin management guideline leaflet was provided to all internal medicine residents. We retrospectively collected the point-of-care testing for glucose (POCT-glu) data in patients admitted to the general medicine wards and compared the mean of blood glucose (BG) before and after the education program. A total of 134438 POCT-glu values from 7055 patients were analyzed. RESULTS After the initiation of the education program, mean BG levels significantly decreased during the first year and were lowest during the second year after education (Mean BG at baseline was 161.38 ± 64.10 mg/dL; 1st year, 159.48 ± 62.53 mg/dL and 2nd year, 155.60 ± 64.94 mg/dL, p-value < 0.0001). The reduction of BG levels was more pronounced in the patients with previously undiagnosed diabetes mellitus than patients with underlying diabetes mellitus. The rates of severe hypoglycemia (defined by BG < 40 mg/dL or 2.2 mmol/L) were not significantly different before and after education (baseline 0.12%, 1st year 0.14%, and 2nd year 0.14%, p-value = 0.632). CONCLUSIONS Lack of confidence and inadequate knowledge of insulin treatment in physicians were important barriers to glycemic management. Consistent education in internal medicine residents led to a significant improvement in inpatient glycemic control.
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Affiliation(s)
- Chutintorn Sriphrapradang
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand.
| | - Pannawat Mongkolrattanakul
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Hataiporn Tanasanitkul
- Department of Health Informatics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
| | - Sirimon Reutrakul
- Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand
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Franco T, Rupp S, Williams B, Blackmore C. Effectiveness of standardised preoperative assessment and patient instructions on admission blood glucose for patients with diabetes undergoing orthopaedic surgery at a tertiary referral hospital. BMJ Open Qual 2019; 8:e000455. [PMID: 31206054 PMCID: PMC6542547 DOI: 10.1136/bmjoq-2018-000455] [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: 06/19/2018] [Revised: 11/13/2018] [Accepted: 11/17/2018] [Indexed: 11/04/2022] Open
Abstract
Diabetes and hyperglycaemia affect a significant number of people and are associated with a variety of untoward effects, especially under physiological stress such as surgery. Due, in large part to limited evidence, clinical practice in monitoring blood glucose and treating hyperglycaemic conditions in the perioperative period is variable. We used Lean methodologies to implement a standardised approach to preoperative management of patients undergoing elective surgery in an effort to improve glycaemic control. Overall, we saw an appropriate increase in monitoring and a decrease in the rate of hyperglycaemia on presentation to the operating room. This approach may be useful in other care settings or patient populations, potentially contributing to improved glycaemic control and subsequent decrease in associated complications.
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Affiliation(s)
- Thérèse Franco
- Section of Hospital Medicine, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Stephen Rupp
- Department of Anesthesiology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Barbara Williams
- The Center for Healthcare Improvement Science, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Craig Blackmore
- The Center for Healthcare Improvement Science, Virginia Mason Medical Center, Seattle, Washington, USA
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Li S, Yi G, Peng H, Li Z, Chen S, Zhong H, Chen Y, Wang Z, Deng Q, Fu M. How Ocular Surface Microbiota Debuts in Type 2 Diabetes Mellitus. Front Cell Infect Microbiol 2019; 9:202. [PMID: 31263683 PMCID: PMC6590198 DOI: 10.3389/fcimb.2019.00202] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 05/23/2019] [Indexed: 12/20/2022] Open
Abstract
High glucose represents a good environment for bacterial growth on the skin, on the ocular surface (OS) and in the tears of type 2 diabetes mellitus (T2DM) patients, affecting the conjunctival bacterial community. This study aimed to investigate the OS bacterial flora of T2DM patients and healthy subjects using 16S rRNA sequencing-based bacterial identification. Among 23 healthy subjects (CON) and 31 T2DM patients, 54 eyes were examined to investigate the OS bacterial community. Factors potentially affecting the microbial growth were controlled. Results showed the OS microbiota presented higher diversity in the T2DM group than in the CON group. Bioinformatic analysis showed a lower abundance of Proteobacteria and a higher abundance of Bacteroidetes at the phyla level as well as a significantly increased abundance of Acinetobacter and Pseudomonas at the genus level in the T2DM group. The difference in OS microbiota at taxonomic level was associated with Ocular Surface Disease Index and course of T2DM. These findings indicate the OS flora in T2DM patients is significantly different from that in healthy subjects, which may be closely associated with OS discomfort and course of T2DM.
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Affiliation(s)
- Siqi Li
- Department of Ophthalmology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Guoguo Yi
- Department of Ophthalmology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Hui Peng
- School of Nursing, Hunan University of Medicine, Hunan, China
| | - Zhenhao Li
- Department of Ophthalmology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Shuze Chen
- Department of Ophthalmology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Huimin Zhong
- Department of Ophthalmology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Yifan Chen
- Department of Ophthalmology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Zhoucheng Wang
- Department of Ophthalmology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Qixin Deng
- Department of Ophthalmology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
| | - Min Fu
- Department of Ophthalmology, Zhujiang Hospital of Southern Medical University, Guangzhou, China
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Tatalovic M, Lehmann R, Cheetham M, Nowak A, Battegay E, Rampini SK. Management of hyperglycaemia in persons with non-insulin-dependent type 2 diabetes mellitus who are started on systemic glucocorticoid therapy: a systematic review. BMJ Open 2019; 9:e028914. [PMID: 31154314 PMCID: PMC6549610 DOI: 10.1136/bmjopen-2019-028914] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES What is the most effective pharmacological intervention for glycaemic control in known type 2 diabetes mellitus (DM) without prior insulin treatment and newly started on systemic glucocorticoid therapy? DESIGN We conducted a systematic literature review. DATA SOURCES We searched MEDLINE, Embase and Cochrane Library databases and Google for articles from 2002 to July 2018. ELIGIBILITY CRITERIA We combined search terms relating to DM (patients, >16 years of age), systemic glucocorticoids, glycaemic control, randomised controlled trials (RCTs) and observational studies. DATA EXTRACTION AND SYNTHESIS We screened and evaluated articles, extracted data and assessed risk of bias and quality of evidence according to Grading of Recommendations Assessment, Development and Evaluation guidelines. RESULTS Eight of 2365 articles met full eligibility criteria. Basal-bolus insulin (BBI) strategy for patients under systemic glucocorticoid therapy was comparatively effective but provided insufficient glucose control, depending on time of day. BBI strategy with long-acting insulin and neutral protamin Hagedorn as basal insulin provided similar overall glycaemic control. Addition of various insulin strategies to standard BBI delivered mixed results. Intermediate-acting insulin (IMI) as additional insulin conferred no clear benefits, and glycaemic control with sliding scale insulin was inferior to BBI or IMI. No studies addressed whether anticipatory or compensatory insulin adjustments are better for glycaemic control. CONCLUSION The lack of suitably designed RCTs and observational studies, heterogeneity of interventions, target glucose levels and glucose monitoring, poor control of DM subgroups and low to moderate quality of evidence render identification of optimal pharmacological interventions for glycaemic control and insulin management difficult. Even findings on the widely recommended BBI regimen as intensive insulin therapy for patients with DM on glucocorticoids are inconclusive. High-quality evidence from studies with well-defined DM phenotypes, settings and treatment approaches is needed to determine optimal pharmacological intervention for glycaemic control. PROSPERO REGISTRATION NUMBER CRD42015024739.
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Affiliation(s)
- Milos Tatalovic
- Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Roger Lehmann
- Department of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Zurich, Zurich, Switzerland
| | - Marcus Cheetham
- Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
- Center of Competence Multimorbidity, University of Zurich, Zurich, Switzerland
| | - Albina Nowak
- Department of Endocrinology, Diabetes and Clinical Nutrition, University Hospital Zurich, Zurich, Switzerland
| | - Edouard Battegay
- Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
- Center of Competence Multimorbidity, University of Zurich, Zurich, Switzerland
| | - Silvana K Rampini
- Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland
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Vellanki P, Rasouli N, Baldwin D, Alexanian S, Anzola I, Urrutia M, Cardona S, Peng L, Pasquel FJ, Umpierrez GE. Glycaemic efficacy and safety of linagliptin compared to a basal-bolus insulin regimen in patients with type 2 diabetes undergoing non-cardiac surgery: A multicentre randomized clinical trial. Diabetes Obes Metab 2019; 21:837-843. [PMID: 30456796 PMCID: PMC7231260 DOI: 10.1111/dom.13587] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/05/2018] [Accepted: 11/15/2018] [Indexed: 12/19/2022]
Abstract
AIMS The use of incretin-based therapy, rather than or complementary to, insulin therapy is an active area of research in hospitalized patients with type 2 diabetes (T2D). We determined the glycaemic efficacy and safety of linagliptin compared to a basal-bolus insulin regimen in hospitalized surgical patients with T2D. MATERIALS AND METHODS This prospective open-label multicentre study randomized T2D patients undergoing non-cardiac surgery with admission blood glucose (BG) of 7.8 to 22.2 mmol/L who were under treatment with diet, oral agents or total insulin dose (TDD) ≤ 0.5 units/kg/day to either linagliptin (n = 128) daily or basal-bolus (n = 122) with glargine once daily and rapid-acting insulin before meals. Both groups received supplemental insulin for BG > 7.8 mmol/L. The primary endpoint was difference in mean daily BG between groups. RESULTS Mean daily BG was higher in the linagliptin group compared to the basal-bolus group (9.5 ± 2.6 vs 8.8 ± 2.3 mmol/L/dL, P = 0.03) with a mean daily BG difference of 0.6 mmol/L (95% confidence interval 0.04, 1.2). In patients with randomization BG < 11.1 mmol/L (63% of cohort), mean daily BG was similar in the linagliptin and basal-bolus groups (8.9 ± 2.3 vs 8.7 ± 2.3 mmol/L, P = 0.43); however, patients with BG ≥ 11.1 mmol/L who were treated with linagliptin had higher BG compared to the basal-bolus group (10.9 ± 2.6 vs 9.2 ± 2.2 mmol/L, P < 0.001). Linagliptin resulted in fewer hypoglycaemic events (1.6% vs 11%, P = 0.001; 86% relative risk reduction), with similar supplemental insulin and fewer daily insulin injections (2.0 ± 3.3 vs 3.1 ± 3.3, P < 0.001) compared to the basal-bolus group. CONCLUSIONS For patients with T2D undergoing non-cardiac surgery who presented with mild to moderate hyperglycaemia (BG < 11.1 mmol/L), daily linagliptin is a safe and effective alternative to multi-dose insulin therapy, resulting in similar glucose control with lower hypoglycaemia.
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Affiliation(s)
- Priyathama Vellanki
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta GA
| | - Neda Rasouli
- Division of Endocrinology, University of Colorado-Denver, Denver CO
| | - David Baldwin
- Division of Endocrinology, Rush University Medical Center, Chicago IL
| | | | - Isabel Anzola
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta GA
| | - Maria Urrutia
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta GA
| | - Saumeth Cardona
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta GA
| | - Limin Peng
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Francisco J. Pasquel
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta GA
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta GA
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Fayfman M, Galindo RJ, Rubin DJ, Mize DL, Anzola I, Urrutia MA, Ramos C, Pasquel FJ, Haw JS, Vellanki P, Wang H, Albury BS, Weaver R, Cardona S, Umpierrez GE. A Randomized Controlled Trial on the Safety and Efficacy of Exenatide Therapy for the Inpatient Management of General Medicine and Surgery Patients With Type 2 Diabetes. Diabetes Care 2019; 42:450-456. [PMID: 30679302 PMCID: PMC6905476 DOI: 10.2337/dc18-1760] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 11/21/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This multicenter, open-label, randomized trial examined the safety and efficacy of exenatide alone or in combination with basal insulin in non-critically ill patients with type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS A total of 150 patients with blood glucose (BG) between 140 and 400 mg/dL, treated at home with diet, oral agents, or insulin at a total daily dose <0.5 units/kg, were randomized to exenatide alone (5 μg twice daily), exenatide plus basal insulin, or a basal-bolus insulin regimen. The primary end point was difference in mean daily BG concentration among groups. RESULTS Mean daily BG was similar between patients treated with exenatide plus basal and a basal-bolus regimen (154 ± 39 vs. 166 ± 40 mg/dL, P = 0.31), and exenatide plus basal resulted in lower daily BG than did exenatide alone (177 ± 41 mg/dL, P = 0.02). Exenatide plus basal resulted in a higher proportion of BG levels in target range between 70 and 180 mg/dL compared with exenatide and basal-bolus (78% vs. 62% vs. 63%, respectively, P = 0.023). More patients in the exenatide and exenatide plus basal groups experienced nausea or vomiting than in the basal-bolus group (10% vs. 11% vs. 2%, P = 0.17), with three patients (6%) discontinued exenatide owing to adverse events. There were no differences in hypoglycemia <54 mg/dL (2% vs. 0% vs. 4%, P = 0.77) or length of stay (5 vs. 4 vs. 4 days, P = 0.23) among basal plus exenatide, exenatide, and basal-bolus groups. CONCLUSIONS The results of this pilot study indicate that exenatide alone or in combination with basal insulin is safe and effective for the management of hospitalized general medical and surgical patients with T2D.
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Affiliation(s)
- Maya Fayfman
- Department of Medicine, Emory University, Atlanta, GA
| | | | - Daniel J Rubin
- Department of Medicine, Temple University, Philadelphia, PA
| | - Dara L Mize
- School of Medicine, Vanderbilt University, Nashville, TN
| | - Isabel Anzola
- Department of Medicine, Emory University, Atlanta, GA
| | | | | | | | - J Sonya Haw
- Department of Medicine, Emory University, Atlanta, GA
| | | | - Heqiong Wang
- Rollins School of Public Health, Emory University, Atlanta, GA
| | | | - Rita Weaver
- School of Medicine, Vanderbilt University, Nashville, TN
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Seufert J, Borck A, Bramlage P. Addition of a single short-acting insulin bolus to basal insulin-supported oral therapy: a systematic review of data on the basal-plus regimen. BMJ Open Diabetes Res Care 2019; 7:e000679. [PMID: 31641521 PMCID: PMC6777409 DOI: 10.1136/bmjdrc-2019-000679] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/28/2019] [Accepted: 09/12/2019] [Indexed: 12/01/2022] Open
Abstract
We summarize here clinical and trial data on a once-daily administration of a single bolus to the meal with the largest expected postprandial glucose excursion (basal-plus), and comment on its clinical utility in the treatment of type 2 diabetes. A PubMed search of data published until September 2018 was taken into consideration and PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. Eighteen reports representing 15 studies were identified (age: 18-80 years; 50-890 patients; follow-up: 8 days to 60 weeks). Data suggest basal-plus is efficacious for improving glycemic control, with a low incidence of (severe) hypoglycemia and minor increases in bodyweight. The timing of short-acting insulin administration and use of different monitoring/titration approaches appear to have minimal impact. When compared with premixed insulin, basal-plus results in largely comparable outcomes. Compared with basal-bolus, it may result in non-inferior glycemic improvements with less weight gain, less hypoglycemia and fewer daily injections. A basal insulin/glucagon-like peptide-1 receptor agonist fixed ratio combination may offer several advantages over the basal-plus regimen, at the cost of gastrointestinal side effects. We conclude that the stepwise introduction of short-acting insulin via the basal-plus strategy represents a viable alternative to a full basal-bolus regimen and may help to overcome barriers associated with multiple injections and anticipated complexity of the insulin regimen.
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Affiliation(s)
- Jochen Seufert
- Division of Endocrinology and Diabetoligy, Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
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Enhanced Recovery After Surgery (ERAS) Outcomes in Patients with Prior Diagnosis of Diabetes. J ASEAN Fed Endocr Soc 2019; 34:73-79. [PMID: 33442139 PMCID: PMC7784095 DOI: 10.15605/jafes.034.01.11] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 09/17/2018] [Indexed: 12/20/2022] Open
Abstract
Objective To determine whether a prior diagnosis of diabetes mellitus (DM) is associated with longer postoperative length of stay (LOS) and higher complication rates among patients who underwent colorectal surgery under an Enhanced Recovery After Surgery (ERAS) protocol in a single hospital setting. METHODOLOGY In a cross-sectional study, we grouped 157 consecutive patients who underwent elective colorectal surgery under ERAS protocol according to preoperative DM status. Patient data was abstracted from the ERAS Interactive Audit Database from January 2016 to December 2017. We compared LOS between groups. Secondary outcomes were postoperative complications, reoperations, pneumonia and wound infection. Categorical and continuous variables were analyzed with Fisher’s exact test and student’s t-test, respectively, using Stata/SE version 13 with a significance level of p=0.05. Results One hundred thirteen subjects did not have diabetes (no T2DM) while 44 patients had type 2 diabetes mellitus (T2DM). Mean postoperative length of hospital stay was 6.4±5.1 days for the no T2DM group versus 5.8±3.8 in the T2DM group (p=0.476). Complications, reoperation rate, pneumonia and wound infection did not differ between groups. Among subjects in the T2DM group, LOS did not differ between patients with preoperative HbA1c ≤7.0% and those with HbA1c >7.0% (5.7±3.7 versus 6.1±4.2 days, p=0.748). Conclusion Among patients who underwent colorectal surgery under ERAS protocol, a prior diagnosis of diabetes was not associated with longer LOS or more complications. A preoperative HbA1c of <7% did not affect length of stay in ERAS among patients with T2DM.
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48
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Lim SF, Jong M, Chew DEK, Lee JYC. Impact of Timing Between Insulin Administration and Meal Consumption on Glycemic Fluctuation and Outcomes in Hospitalized Patients With Type 2 Diabetes. J Pharm Pract 2018; 33:449-456. [PMID: 30585104 DOI: 10.1177/0897190018818908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The effect of time interval from insulin injection to meal consumption ("insulin-meal") on glycemic fluctuation and outcomes is not well understood. OBJECTIVE This study aims to investigate the impact of coordinated versus mismatched insulin-meal administration on glycemic fluctuation and outcomes among hospitalized patients with type 2 diabetes (T2D). METHODS Hospitalized patients with T2D who received at least 1 dose of insulin as part of sliding scale regimen were included. Data such as capillary blood glucose values and insulin-meal time intervals were collected. RESULTS A total of 215 patients with 840 insulin-meal encounters were eligible for the study. Compared to the insulin-meal mismatch group (n = 206), the coordinated insulin-meal administration group (n = 9) had lower mean glycemic fluctuation (6.5 [2.6] mmol/L vs 5.6 [2.5] mmol/L or 117 [47] mg/dL vs 100 [45] mg/dL). Encounters with the insulin-meal time interval of 30 to 45 minutes (n = 172) were associated with the lowest percentage of severe hyperglycemia occurrences (13%) as compared to encounters with time interval of 0 to 29 minutes (n = 280, 15%) and more than 45 minutes (n = 246, 16%). CONCLUSION Coordinated insulin-meal administration was associated with lower glycemic fluctuation among hospitalized patients with T2D.
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Affiliation(s)
- Shu Fang Lim
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore
| | - Michelle Jong
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore.,Department of Metabolic Disease, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Daniel Ek Kwang Chew
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore, Singapore.,Department of Metabolic Disease, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Joyce Yu-Chia Lee
- Department of Pharmacy, Tan Tock Seng Hospital, Singapore, Singapore.,Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
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Meister KM, Hufford T, Tu C, Khorgami Z, Schauer PR, Brethauer SA, Aminian A. Clinical significance of perioperative hyperglycemia in bariatric surgery: evidence for better perioperative glucose management. Surg Obes Relat Dis 2018; 14:1725-1731. [DOI: 10.1016/j.soard.2018.07.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 06/05/2018] [Accepted: 07/22/2018] [Indexed: 01/04/2023]
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50
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Development of a Predictive Model for Hyperglycemia in Nondiabetic Recipients After Liver Transplantation. Transplant Direct 2018; 4:e393. [PMID: 30498770 PMCID: PMC6233666 DOI: 10.1097/txd.0000000000000830] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 07/03/2018] [Indexed: 12/20/2022] Open
Abstract
Background Posttransplant hyperglycemia has been associated with increased risks of transplant rejection, infections, length of stay, and mortality. Methods To establish a predictive model to identify nondiabetic recipients at risk for developing postliver transplant (LT) hyperglycemia, we performed this secondary, retrospective data analysis of a single-center, prospective, randomized, controlled trial of glycemic control among 107 adult LT recipients in the inpatient period. Hyperglycemia was defined as a posttransplant glucose level greater than 200 mg/dL after initial discharge up to 1 month following surgery. Candidate variables with P less than 0.10 in univariate analyses were used to build a multivariable logistic regression model using forward stepwise selection. The final model chosen was based on statistical significance and additive contribution to the model based on the Bayesian Information Criteria. Results Forty-three (40.2%) patients had at least 1 episode of hyperglycemia after transplant after the resolution of the initial postoperative hyperglycemia. Variables selected for inclusion in the model (using model optimization strategies) included length of hospital stay (odds ratio [OR], 0.83; P < 0.001), use of glucose-lowering medications at discharge (OR, 3.76; P = 0.03), donor female sex (OR, 3.18; P = 0.02) and donor white race (OR, 3.62; P = 0.01). The model had good calibration (Hosmer-Lemeshow goodness-of-fit test statistic = 9.74, P = 0.28) and discrimination (C-statistic = 0.78; 95% confidence interval, 0.65-0.81, bias-corrected C-statistic = 0.78). Conclusions Shorter hospital stay, use of glucose-lowering medications at discharge, donor female sex and donor white race are important determinants in predicting hyperglycemia in nondiabetic recipients after hospital discharge up to 1 month after liver transplantation.
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