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Sun J, Xie Z, Wu Y, Liu X, Ma J, Dong Y, Liu C, Ye M, Zhu W. Association of the Triglyceride-Glucose Index With Risk of Alzheimer's Disease: A Prospective Cohort Study. Am J Prev Med 2023; 65:1042-1049. [PMID: 37499890 DOI: 10.1016/j.amepre.2023.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 07/20/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023]
Abstract
INTRODUCTION Triglyceride-glucose index (TyG) is a reliable surrogate marker of insulin resistance, and insulin resistance has been implicated in Alzheimer's disease pathophysiology. However, the relationship between the TyG index and Alzheimer's disease remains unclear. This study aimed to evaluate the association of the TyG index with the risk of Alzheimer's disease. METHODS This prospective study included 2,170 participants free of Alzheimer's disease from the Framingham Heart Study Offspring Cohort Exam 7 (1998-2001), whose follow-up data were collected until 2018. The TyG index was calculated as Ln(fasting triglyceride [mg/dL] × fasting glucose [mg/dL]/2). The association of the TyG index with Alzheimer's disease was evaluated by competing risk regression model. Statistical analyses were performed in 2023. RESULTS During a median follow-up of 13.8 years, 163 (7.5%) participants developed Alzheimer's disease. When compared with the reference (TyG index ≤8.28), a significantly elevated risk of Alzheimer's disease was seen in the group with a triglyceride-glucose index of 8.68-9.09 (adjusted hazard ratio=1.69, 95% CI=1.02, 2.81). When the TyG index was considered as a continuous variable, each unit increment in the TyG index was not significantly associated with the risk of Alzheimer's disease (adjusted hazard ratio=1.32, 95% CI=0.98, 1.77). CONCLUSIONS This study showed that moderately elevated TyG index was independently associated with a higher incidence of Alzheimer's disease. TheTyG index might be used to define a high-risk population of Alzheimer's disease.
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Affiliation(s)
- Junyi Sun
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China; NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, People's Republic of China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Zengshuo Xie
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China; NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, People's Republic of China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Yuzhong Wu
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China; NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, People's Republic of China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Xiao Liu
- Department of Cardiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Jianyong Ma
- Department of Pharmacology & Systems Physiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Yugang Dong
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China; NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, People's Republic of China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Chen Liu
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China; NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, People's Republic of China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China
| | - Min Ye
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China; NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, People's Republic of China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China; Department of Medical Ultrasonics, Institute for Diagnostic and Interventional Ultrasound, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China.
| | - Wengen Zhu
- Department of Cardiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, People's Republic of China; NHC Key Laboratory of Assisted Circulation, Sun Yat-sen University, Guangzhou, People's Republic of China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, People's Republic of China.
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Keegan A, Strahley A, Taylor SP, Wilson TM, Shah MD, Williamson J, Palakshappa JA. Older Adults' Perspectives on Screening for Cognitive Impairment Following Critical Illness: Pre-Implementation Qualitative Study. Crit Care Explor 2023; 5:e0920. [PMID: 37197588 PMCID: PMC10184981 DOI: 10.1097/cce.0000000000000920] [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: 05/19/2023] Open
Abstract
Screening for cognitive impairment following ICU discharge is recommended but not part of routine care. We sought to understand older adults' perspectives on screening for cognitive impairment following an ICU admission to inform the design and delivery of a cognitive screening intervention. DESIGN Qualitative study using semi-structured interviews. SUBJECTS Adults 60 years and older within 3 months of discharge from an ICU in an academic health system. INTERVENTIONS Interviews were conducted via telephone, audio recorded and transcribed verbatim. All transcripts were coded in duplicate. Discrepancies were resolved by consensus. Codes were organized into themes and subthemes inductively. MEASUREMENTS AND MAIN RESULTS We completed 22 interviews. The mean age of participants was 71 ± 6 years, 14 (63.6%) were men, 16 (72.7%) were White, and 6 (27.3%) were Black. Thematic analysis was organized around four themes: 1) receptivity to screening, 2) communication preferences, 3) information needs, and 4) provider involvement. Most participants were receptive to cognitive screening; this was influenced by trust in their providers and prior experience with cognitive screening and impairment. Participants preferred simple, direct, compassionate communication. They wanted to understand the screening procedure, the rationale for screening, and expectations for recovery. Participants desired input from their primary care provider to have their cognitive screening results placed in the context of their overall health, because they had a trusted relationship, and for convenience. CONCLUSIONS Participants demonstrated limited understanding of and exposure to cognitive screening but see it as potentially beneficial following an ICU stay. Providers should use simple, straightforward language and place emphasis on expectations. Resources may be needed to assist primary care providers with capacity to provide cognitive screening and interpret results for ICU survivors. Implementation strategies can include educational materials for clinicians and patients on rationale for screening and recovery expectations.
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Affiliation(s)
- Alek Keegan
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Ashley Strahley
- Department of Social Sciences and Health Policy, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Stephanie P Taylor
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
- Carolinas Medical Center, Atrium Health, Charlotte, NC
| | - Taniya M Wilson
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Meehir D Shah
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Jeff Williamson
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Jessica A Palakshappa
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
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Kim M, Kwasny MJ, Bailey SC, Benavente JY, Zheng P, Bonham M, Luu HQ, Cecil P, Agyare P, O'Conor R, Curtis LM, Hur S, Yeh F, Lovett RM, Russell A, Luo Y, Zee PC, Wolf MS. MidCog study: a prospective, observational cohort study investigating health literacy, self-management skills and cognitive function in middle-aged adults. BMJ Open 2023; 13:e071899. [PMID: 36822802 PMCID: PMC9950895 DOI: 10.1136/bmjopen-2023-071899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 02/10/2023] [Indexed: 02/25/2023] Open
Abstract
INTRODUCTION The lack of definitive means to prevent or treat cognitive impairment or dementia is driving intense efforts to identify causal mechanisms. Recent evidence suggests clinically meaningful declines in cognition might present as early as middle age. Studying cognitive changes in middle adulthood could elucidate modifiable factors affecting later cognitive and health outcomes, yet few cognitive ageing studies include this age group. The purpose of the MidCog study is to begin investigations of less-studied and potentially modifiable midlife determinants of later life cognitive outcomes. METHODS AND ANALYSIS MidCog is a prospective cohort study of adults ages 35-64, with two in-person interviews 2.5 years apart. Data will be collected from interviews, electronic health records and pharmacy fill data. Measurements will include health literacy, self-management skills, cognitive function, lifestyle and health behaviours, healthcare use, health status and chronic disease outcomes. Associations of health literacy and self-management skills with health behaviours and cognitive/health outcomes will be examined in a series of regression models, and moderating effects of modifiable psychosocial factors.Finally, MidCog data will be linked to an ongoing, parallel cohort study of older adults recruited at ages 55-74 in 2008 ('LitCog'; ages 70-90 in 2023), to explore associations between age, health literacy, self-management skills, chronic diseases, health status and cognitive function among adults ages 35-90. ETHICS AND DISSEMINATION The Institutional Review Board at Northwestern University has approved the MidCog study protocol (STU00214736). Results will be published in peer-reviewed journals and summaries will be provided to the funders of the study as well as patients.
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Affiliation(s)
- Minjee Kim
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Center for Circadian and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mary J Kwasny
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stacy C Bailey
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Julia Y Benavente
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Pauline Zheng
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Morgan Bonham
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Han Q Luu
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Patrick Cecil
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Prophecy Agyare
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rachel O'Conor
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Laura M Curtis
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Scott Hur
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Fangyu Yeh
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rebecca M Lovett
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Andrea Russell
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Yuan Luo
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Phyllis C Zee
- Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Center for Circadian and Sleep Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michael S Wolf
- Center for Applied Health Research on Aging, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Division of General Internal Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Muacevic A, Adler JR. Can Alzheimer's Disease Be Secondary to Type-2 Diabetes Mellitus? Cureus 2022; 14:e31273. [PMID: 36505102 PMCID: PMC9732418 DOI: 10.7759/cureus.31273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/08/2022] [Indexed: 11/11/2022] Open
Abstract
Alzheimer's disease and insulin resistance are prevalent in older adults. Insulin's ability to effectively affect target tissues is diminished by IR. Hyperglycemia, higher blood pressure, elevated triglyceride levels, decreased HDL levels and central obesity are the outcomes of a condition, namely metabolic syndrome. Cognitive impairment and abnormalities of the brain have been linked to metabolic syndrome (MetS), a grouping of risk factors for type 2 diabetes mellitus. Type-2 diabetes mellitus and its relationship to other conditions have been investigated on the assorted extent in the pair of, human and animal subjects. First, it was shown that insulin receptors are present in the brain, namely the hippocampus. Most insulin is delivered to the brain by crossing the blood-brain barrier. Second, numerous research revealed that insulin impacts various neurotransmitters in a way that enhances memory and cognition. Thirdly, several pathological research has also shown that beta-amyloid plaques, hyperphosphorylated tau protein, and brain shrinkage, particularly in the hippocampus, are shared brain lesions between insulin and Alzheimer's disease. In light of this, type 2 diabetes mellitus may be viewed as a liability for dementia and Alzheimer's disease.
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Sharma K, Akre S, Chakole S, Wanjari MB. Stress-Induced Diabetes: A Review. Cureus 2022; 14:e29142. [PMID: 36258973 PMCID: PMC9561544 DOI: 10.7759/cureus.29142] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 09/13/2022] [Indexed: 12/04/2022] Open
Abstract
It has long been established that stress has a significant impact on metabolic function. Type 2 diabetes may be initiated by psychological and physical stress. The central and peripheral nervous systems are both involved in the neuroendocrine framework that underlies the underlying processes. The release of catecholamines and a rise in serum glucocorticoid concentrations caused by psychological stress enhance the requirement for insulin and insulin resistance. Experiencing persistent hyperglycemia in people with diabetes may be influenced by stress. Blood sugar levels may rise due to hormones being released in response to stress. Although this has adaptive significance in a healthy patient, in the long run, it can cause insulin resistance and lead to diabetes. Additionally, diabetes may cause abnormalities in the regulation of these stress hormones.
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Yahia A, Szlávecz Á, Knopp JL, Norfiza Abdul Razak N, Abu Samah A, Shaw G, Chase JG, Benyo B. Estimating Enhanced Endogenous Glucose Production in Intensive Care Unit Patients with Severe Insulin Resistance. J Diabetes Sci Technol 2022; 16:1208-1219. [PMID: 34078114 PMCID: PMC9445352 DOI: 10.1177/19322968211018260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Critically ill ICU patients frequently experience acute insulin resistance and increased endogenous glucose production, manifesting as stress-induced hyperglycemia and hyperinsulinemia. STAR (Stochastic TARgeted) is a glycemic control protocol, which directly manages inter- and intra- patient variability using model-based insulin sensitivity (SI). The model behind STAR assumes a population constant for endogenous glucose production (EGP), which is not otherwise identifiable. OBJECTIVE This study analyses the effect of estimating EGP for ICU patients with very low SI (severe insulin resistance) and its impact on identified, model-based insulin sensitivity identification, modeling accuracy, and model-based glycemic clinical control. METHODS Using clinical data from 717 STAR patients in 3 independent cohorts (Hungary, New Zealand, and Malaysia), insulin sensitivity, time of insulin resistance, and EGP values are analyzed. A method is presented to estimate EGP in the presence of non-physiologically low SI. Performance is assessed via model accuracy. RESULTS Results show 22%-62% of patients experience 1+ episodes of severe insulin resistance, representing 0.87%-9.00% of hours. Episodes primarily occur in the first 24 h, matching clinical expectations. The Malaysian cohort is most affected. In this subset of hours, constant model-based EGP values can bias identified SI and increase blood glucose (BG) fitting error. Using the EGP estimation method presented in these constrained hours significantly reduced BG fitting errors. CONCLUSIONS Patients early in ICU stay may have significantly increased EGP. Increasing modeled EGP in model-based glycemic control can improve control accuracy in these hours. The results provide new insight into the frequency and level of significantly increased EGP in critical illness.
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Affiliation(s)
- Anane Yahia
- Department of Control Engineering and Information Technology, Budapest University of Technology and Economics, Budapest, Hungary
- Anane Yahia, Department of Control Engineering and Information Technology, Budapest University of Technology and Economics, 2. Magyar tudosok Blvd., Budapest, H-1117, Hungary.
| | - Ákos Szlávecz
- Department of Control Engineering and Information Technology, Budapest University of Technology and Economics, Budapest, Hungary
| | - Jennifer L. Knopp
- Mechanical Engineering, Centre of Bio-Engineering, University of Canterbury, Christchurch, NZ
| | | | - Asma Abu Samah
- Institute of Energy Infrastructure, Universiti Tenaga Nasional, Jalan Ikram-UNITEN, Kajang, Selangor, Malaysia
| | - Geoff Shaw
- Mechanical Engineering, Centre of Bio-Engineering, University of Canterbury, Christchurch, NZ
| | - J. Geoffrey Chase
- Mechanical Engineering, Centre of Bio-Engineering, University of Canterbury, Christchurch, NZ
| | - Balazs Benyo
- Department of Control Engineering and Information Technology, Budapest University of Technology and Economics, Budapest, Hungary
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Ramnarain D, Aupers E, den Oudsten B, Oldenbeuving A, de Vries J, Pouwels S. Post Intensive Care Syndrome (PICS): an overview of the definition, etiology, risk factors, and possible counseling and treatment strategies. Expert Rev Neurother 2021; 21:1159-1177. [PMID: 34519235 DOI: 10.1080/14737175.2021.1981289] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Post-intensive care syndrome (PICS) has only recently been recognized as a new clinical entity in patients surviving their intensive care unit (ICU) stay due to critical illness. With increasing survival rates of ICU patients worldwide, there is a rising interest regarding post-ICU recovery. AREAS COVERED First, based on the current literature a definition is provided of PICS, including the domains of impairments that comprise PICS along with the etiology and risk factors. Second, preventive measures and possible treatment strategies integrated in the follow-up care are described. Third, the authors will discuss the current SARS-Cov-2 pandemic and the increased risk of PICS in these post-ICU patients and their families. EXPERT OPINION PICS is a relatively new entity, which not only encompasses various physical, cognitive, and psychological impairments but also impacts global health due to long-lasting detrimental socioeconomic burdens. Importantly, PICS also relates to caregivers of post-ICU patients. Strategies to reduce this burden will not only be needed within the ICU setting but will also have to take place in an interdisciplinary, multifaceted approach in primary care settings. Additionally, the SARS-Cov-2 pandemic has a high burden on post-ICU patients and their relatives.
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Affiliation(s)
- Dharmanand Ramnarain
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of Medical and Clinical Psychology, Center of Research on Psychological and Somatic Disease (Corps), Tilburg University, Tilburg, The Netherlands.,Department of Intensive Care Medicine, Saxenburg Medisch Centrum Hardenberg, The Netherlands
| | - Emily Aupers
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Brenda den Oudsten
- Department of Medical and Clinical Psychology, Center of Research on Psychological and Somatic Disease (Corps), Tilburg University, Tilburg, The Netherlands
| | - Annemarie Oldenbeuving
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Jolanda de Vries
- Department of Medical and Clinical Psychology, Center of Research on Psychological and Somatic Disease (Corps), Tilburg University, Tilburg, The Netherlands.,Board, ADRZ (Admiraal De Ruyter Ziekenhuis), Goes, The Netherlands
| | - Sjaak Pouwels
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
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Jiang J, Li S, Zhao Y, Zhou Z, Zhang J, Sun R, Luo A. Intensive glucose control during the perioperative period for diabetic patients undergoing surgery: An updated systematic review and meta-analysis. J Clin Anesth 2021; 75:110504. [PMID: 34509960 DOI: 10.1016/j.jclinane.2021.110504] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 08/29/2021] [Accepted: 09/04/2021] [Indexed: 12/29/2022]
Abstract
STUDY OBJECTIVE To evaluate the impact of intensive glucose control on diabetic patients undergoing surgery. DESIGN A systematic review and meta-analysis of randomized controlled trials. PubMed, CENTRAL, EMBASE, ISI Web of Science, and CINAHL databases were searched from inception to 13 December 2020. SETTING Operating room, postoperative recovery area and ward, up to 30 days after surgery. PATIENTS Diabetic patients undergoing surgery. INTERVENTIONS We used Review Manager 5.4 to pool the data with a random-effects model. The quality of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation system. MEASUREMENTS The primary outcomes were infectious complications, postoperative mortality, and hypoglycaemia. The secondary outcomes included atrial fibrillation, myocardial infarction, stroke, delirium, renal failure, postoperative mechanical ventilation time, length of intensive care unit (ICU) stay, and hospital stay. MAIN RESULTS Thirteen studies involving 1582 participants were included. Compared with conventional glucose control, intensive glucose control was associated with a lower risk of infectious complications (risk ratio [RR], 0.35; 95% confidence interval [CI], 0.19-0.63; low-quality evidence), atrial fibrillation (RR, 0.55; 95% CI, 0.42-0.71; high-quality evidence), and renal failure (RR, 0.38; 95% CI, 0.15-0.95; moderate-quality evidence), as well as a shorter length of stay in the ICU (mean difference (MD), -0.55 day; 95% CI, -1.05 to -0.05 days; very-low-quality evidence) and hospital (MD, -1.61 days; 95% CI, -2.78 to -0.44 days; very-low-quality evidence). However, intensive glucose control was associated with a higher risk of hypoglycaemia (RR, 3.00; 95% CI, 1.97-4.55; high-quality evidence). There were no significant differences in postoperative mortality, myocardial infarction, stroke, delirium, or postoperative mechanical ventilation time. CONCLUSIONS Intensive glucose control in diabetic patients is associated with a reduction in some adverse postoperative outcomes including infectious complications, but also appears to increase the risk of hypoglycaemia. Further well-designed studies may be needed to determine appropriate regimens to reduce hypoglycaemia incidence. PROSPERO REGISTRATION NUMBER CRD42021226138.
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Affiliation(s)
- Jie Jiang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Shiyong Li
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Yilin Zhao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Zhiqiang Zhou
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Jie Zhang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Rao Sun
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
| | - Ailin Luo
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
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Li CY, Kuo CL, Chang YH, Lu CL, Martini S, Hou WH. Association between trajectory of severe hypoglycemia and dementia in patients with type 2 diabetes: A population-based study. J Epidemiol 2021; 32:423-430. [PMID: 33678721 PMCID: PMC9359896 DOI: 10.2188/jea.je20200518] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background We aimed to investigate associations between exposure to various trajectories of severe hypoglycemic events and risk of dementia in patients with type 2 diabetes. Methods In 2002–2003, 677,618 patients in Taiwan were newly diagnosed as having type 2 diabetes. Among them, 35,720 (5.3%) experienced severe hypoglycemic events during the 3-year baseline period following diagnosis. All patients were followed from the first day after baseline period to the date of dementia diagnosis, death, or the end of 2011. A group-based trajectory model was used to classify individuals with severe hypoglycemic events during the baseline period. Cox proportional hazard models with the competing risk method were used to relate dementia risk to various severe hypoglycemia trajectories. Results After a median follow-up 6.70 and 6.10 years for patients with and without severe hypoglycemia at baseline, respectively, 1,952 (5.5%) individuals with severe hypoglycemia and 23,492 (3.7%) without developed dementia during follow-up, for incidence rates of 109.80 and 61.88 per 10,000 person-years, respectively. Four groups of severe hypoglycemia trajectory were identified with a proportion of 18.06%, 33.19%, 43.25%, and 5.50%, respectively, for Groups 1 to 4. Groups 3 (early manifestation but with later decrease) and 4 (early and sustained manifestation) were associated with a significantly increased risk of dementia diagnosis, with a covariate-adjusted subdistribution hazard ratio of 1.22 (95% confidence interval, 1.14–1.31) and 1.25 (95% confidence interval, 1.02–1.54), respectively. Conclusion Our analysis highlighted that early manifestation of severe hypoglycemic events may contribute more than does late manifestation to the risk of dementia among individuals newly diagnosed as having type 2 diabetes.
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Affiliation(s)
- Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University.,Department of Epidemiology, Faculty of Public Health, Universitas Airlangga.,Department of Public Health, College of Public Health, China Medical University.,Department of Healthcare Administration, College of Medical and Health Science, Asia University
| | - Chia-Lun Kuo
- Department of Public Health, College of Medicine, National Cheng Kung University.,Department of Psychiatry, Tsaotun Psychiatric Center, Ministry of Health and Welfare
| | - Ya-Hui Chang
- Department of Public Health, College of Medicine, National Cheng Kung University
| | - Chin-Li Lu
- Graduate Institute of Food Safety, College of Agriculture and Natural Resources, National Chung Hsing University
| | - Santi Martini
- Department of Epidemiology, Faculty of Public Health, Universitas Airlangga
| | - Wen-Hsuan Hou
- School of Gerontology Health Management & Master Program in Long-Term Care, College of Nursing, Taipei Medical University.,Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital.,Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University.,Center of Evidence-Based Medicine, Department of Education, Taipei Medical University Hospital
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Nora GJ, Reddy CC. Acute Delirium and Post-Delirium Encephalopathy. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00297-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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11
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Fernández-Gonzalo S, Navarra-Ventura G, Bacardit N, Gomà Fernández G, de Haro C, Subirà C, López-Aguilar J, Magrans R, Sarlabous L, Aquino Esperanza J, Jodar M, Rué M, Ochagavía A, Palao DJ, Fernández R, Blanch L. Cognitive phenotypes 1 month after ICU discharge in mechanically ventilated patients: a prospective observational cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:618. [PMID: 33087171 PMCID: PMC7579874 DOI: 10.1186/s13054-020-03334-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 10/06/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND ICU patients undergoing invasive mechanical ventilation experience cognitive decline associated with their critical illness and its management. The early detection of different cognitive phenotypes might reveal the involvement of diverse pathophysiological mechanisms and help to clarify the role of the precipitating and predisposing factors. Our main objective is to identify cognitive phenotypes in critically ill survivors 1 month after ICU discharge using an unsupervised machine learning method, and to contrast them with the classical approach of cognitive impairment assessment. For descriptive purposes, precipitating and predisposing factors for cognitive impairment were explored. METHODS A total of 156 mechanically ventilated critically ill patients from two medical/surgical ICUs were prospectively studied. Patients with previous cognitive impairment, neurological or psychiatric diagnosis were excluded. Clinical variables were registered during ICU stay, and 100 patients were cognitively assessed 1 month after ICU discharge. The unsupervised machine learning K-means clustering algorithm was applied to detect cognitive phenotypes. Exploratory analyses were used to study precipitating and predisposing factors for cognitive impairment. RESULTS K-means testing identified three clusters (K) of patients with different cognitive phenotypes: K1 (n = 13), severe cognitive impairment in speed of processing (92%) and executive function (85%); K2 (n = 33), moderate-to-severe deficits in learning-memory (55%), memory retrieval (67%), speed of processing (36.4%) and executive function (33.3%); and K3 (n = 46), normal cognitive profile in 89% of patients. Using the classical approach, moderate-to-severe cognitive decline was recorded in 47% of patients, while the K-means method accurately classified 85.9%. The descriptive analysis showed significant differences in days (p = 0.016) and doses (p = 0.039) with opioid treatment in K1 vs. K2 and K3. In K2, there were more women, patients were older and had more comorbidities (p = 0.001) than in K1 or K3. Cognitive reserve was significantly (p = 0.001) higher in K3 than in K1 or K2. CONCLUSION One month after ICU discharge, three groups of patients with different cognitive phenotypes were identified through an unsupervised machine learning method. This novel approach improved the classical classification of cognitive impairment in ICU survivors. In the exploratory analysis, gender, age and the level of cognitive reserve emerged as relevant predisposing factors for cognitive impairment in ICU patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier:NCT02390024; March 17,2015.
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Affiliation(s)
- Sol Fernández-Gonzalo
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain. .,Centro de Investigación Biomédica En Red en Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain. .,Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain.
| | - Guillem Navarra-Ventura
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Neus Bacardit
- Mental Health Department, Fundació Althaia - Xarxa Assistencial I Universitaria, Manresa, Spain
| | - Gemma Gomà Fernández
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain
| | - Candelaria de Haro
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Carles Subirà
- Critical Care Center, Fundació Althai, Universitat Internacional de Catalunya, Manresa, Spain
| | - Josefina López-Aguilar
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | | | - Leonardo Sarlabous
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain
| | - Jose Aquino Esperanza
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Department of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Mercè Jodar
- Centro de Investigación Biomédica En Red en Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.,Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain.,Neurology Department, Parc Taulí Hospital Universitari, I3PT, UAB, Sabadell, Spain
| | - Montse Rué
- Departament of Basic Medical Sciences, Universitat de Lleida, Lleida, Spain.,Health Services Research Network in Chronic Diseases (REDISSEC), Barcelona, Spain
| | - Ana Ochagavía
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Diego J Palao
- Centro de Investigación Biomédica En Red en Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain.,Mental Health Department, Parc Taulí Hospital Universitari, I3PT, UAB, Sabadel, Spain.,Department of Psychiatry and Forensic Medicine, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Rafael Fernández
- Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Critical Care Center, Fundació Althai, Universitat Internacional de Catalunya, Manresa, Spain
| | - Lluís Blanch
- Critical Care Center, Parc Taulí Hospital Universitari, Fundació- I3PT, UAB, Sabadell, Spain.,Centro de Investigación Biomédica En Red en Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Department of Medicine, Universitat de Barcelona, Barcelona, Spain
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Abstract
Neonatal hypoglycemia (HG) can cause neurologic damage, epilepsy, mental retardation, behavioral and personality disorders and death. The longest the HG lasts and the greatest the glucose nadir the consequences are more pronounced. Comorbidities are rather important in development of neurological damage. Hypoxemia and ischemia can cause permanent brain damage. Small for gestational age (SGA), large for gestational age (LGA), intrauterine growth restriction, gestational age bellow the 37th week, low Apgar score, sepsis, children whose mothers have toxemia, diabetes or chorioamnionitis are all newborns with increased HG risk. Comparing 34 patients with NH and 34 children without NH with similar GA, BW, BL, the Apgar score, we found statistically significant differences in motor and mental development using the Griffith scale. Children with neonatal HG fared significantly worse than those without neonatal HG. Therefore, CBG measurements and early recognition of neonatal HG is of significant importance in preventing motor and mental damage in children. A larger and well-balanced cohort of patients followed for a longer period is also necessary to clarify and discern in detail the importance of neonatal HG and other perinatal factors in neurodevelopmental damage.
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13
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Kohler J, Borchers F, Endres M, Weiss B, Spies C, Emmrich JV. Cognitive Deficits Following Intensive Care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:627-634. [PMID: 31617485 DOI: 10.3238/arztebl.2019.0627] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 02/06/2019] [Accepted: 07/16/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Illnesses that necessitate intensive care can impair cognitive function severely over the long term, leaving patients less able to cope with the demands of everyday living and markedly lowering their quality of life. There has not yet been any comprehensive study of the cognitive sequelae of critical illness among non- surgical patients treated in intensive care. The purpose of this review is to present the available study findings on cognitive deficits in such patients, with particular at- tention to prevalence, types of deficit, clinical course, risk factors, prevention, and treatment. METHODS This review is based on pertinent publications retrieved by a selective search in MEDLINE. RESULTS The literature search yielded 3360 hits, among which there were 14 studies that met our inclusion criteria. 17-78% of patients had cognitive deficits after dis- charge from the intensive care unit; most had never had a cognitive deficit before. Cognitive impairment often persisted for up to several years after discharge (0.5 to 9 years) and tended to improve over time. The only definite risk factor is delirium. CONCLUSION Cognitive dysfunction is a common sequela of the treatment of non-surgical patients in intensive care units. It is a serious problem for the affected persons and an increasingly important socio-economic problem as well. The effective management of delirium is very important. General conclusions are hard to draw from the available data because of heterogeneous study designs, varying methods of measurement, and differences among patient cohorts. Further studies are needed so that study designs and clinical testing procedures can be standard- ized and effective measures for prevention and treatment can be identified.
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Affiliation(s)
- Joel Kohler
- Department of Neurology With Experimental Neurology, Charité-Universitätsmedizin Berlin; Department of Anesthesiology and Operative Intensive Care Medicine at Campus Benjamin Franklin Charité-Universitätsmedizin Berlin
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14
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Sinclair A, Abdelhafiz A. Cognitive Dysfunction in Older Adults with Type 2 Diabetes: Links, Risks, and Clinical Implications. Clin Geriatr Med 2020; 36:407-417. [PMID: 32586471 DOI: 10.1016/j.cger.2020.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The prevalence of comorbid diabetes and cognitive dysfunction increases as the population ages. Diabetes increases the risk of progression of cognitive dysfunction through a spectrum of cognitive decline to mild cognitive impairment then to dementia. Cognitive dysfunction, especially impairment in the executive domain, has a negative impact on patients' self-care tasks. With further progression of dementia and the development of behavioral problems, the challenge to carers and health care professionals looking after these patients is significant. Therefore, clinical trials are needed to explore the impact of novel hypoglycemic therapy on cognitive function as an important outcome in this population.
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Affiliation(s)
- Alan Sinclair
- Foundation for Diabetes Research in Older People, Diabetes Frail Ltd, Droitwich Spa WR9 0QH, UK; Kings College, London SE1 9NH, UK.
| | - Ahmed Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham S60 2UD, UK
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15
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Yao RQ, Ren C, Wu GS, Zhu YB, Xia ZF, Yao YM. Is intensive glucose control bad for critically ill patients? A systematic review and meta-analysis. Int J Biol Sci 2020; 16:1658-1675. [PMID: 32226310 PMCID: PMC7097913 DOI: 10.7150/ijbs.43447] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 02/27/2020] [Indexed: 02/07/2023] Open
Abstract
Background: The monitoring and management of blood glucose concentration are standard practices in critical settings as hyperglycaemia has been shown close association with poorer outcomes. Several meta-analyses have revealed that intensive glucose control has no benefit in decreasing short-term mortality among critically ill patients, while the studies these meta-analyses have incorporated have been largely divergent. We aim to perform a more comprehensive meta-analysis addressing this problem to provide stronger evidence. Methods: We conducted comprehensive searches for relevant randomized controlled studies in online databases, including the Cochrane Library, EMBASE, and PubMed databases, up to September 1, 2018. The clinical data, which included all-cause mortality, severe hypoglycemia, need for RRT, infection resulting in sepsis, ICU mortality, 90-day mortality, 180-day mortality, and hospital and ICU lengths of stay, were screened and analyzed after data extraction. We applied odds ratios (ORs) to analyze dichotomous outcomes and mean differences for continuous outcomes with a random effects model. Results: A total of 57 RCTs involving a total of 21840 patients were finally included. Patients admitted to the ICU who underwent intensive glucose control showed significantly reduced all-cause mortality (OR: 0.89; 95% CI: 0.80-1.00; P=0.04; I2=32%), reduced infection rate (OR: 0.65, 95% CI: 0.51-0.82, P=0.0002; I2=47%), a lower occurrence of acquired sepsis (OR: 0.80, 95% CI: 0.65-0.99, P=0.04; I2=0%) and shortened length of ICU stay (MD: -0.70, 95% CI: -1.21--0.19, P=0.007, I2=70%) when compared to the same parameters as those treated with the usual care strategy. However, patients in the intensive glucose control group presented with a significantly higher risk of severe hypoglycemia (OR: 5.63, 95% CI: 4.02-7.87, P<0.00001; I2=67%). Conclusions: Critically ill patients undergoing intensive glucose control showed significantly reduced all-cause mortality, length of ICU stay and incidence of acquired infection and sepsis compared to the same parameters in patients treated with the usual care strategy, while the intensive glucose control strategy was associated with higher occurrence of severe hypoglycemic events.
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Affiliation(s)
- Ren-qi Yao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100048, People's Republic of China
- Department of Burn Surgery, Changhai Hospital, the Second Military Medical University, Shanghai 200433, People's Republic of China
| | - Chao Ren
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100048, People's Republic of China
| | - Guo-sheng Wu
- Department of Burn Surgery, Changhai Hospital, the Second Military Medical University, Shanghai 200433, People's Republic of China
| | - Yi-bing Zhu
- Department of Critical Care Medicine, Fuxing Hospital, Capital Medical University, Beijing 100038, People's Republic of China
| | - Zhao-fan Xia
- Department of Burn Surgery, Changhai Hospital, the Second Military Medical University, Shanghai 200433, People's Republic of China
| | - Yong-ming Yao
- Trauma Research Center, Fourth Medical Center of the Chinese PLA General Hospital, Beijing 100048, People's Republic of China
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16
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Mostel Z, Perl A, Marck M, Mehdi SF, Lowell B, Bathija S, Santosh R, Pavlov VA, Chavan SS, Roth J. Post-sepsis syndrome - an evolving entity that afflicts survivors of sepsis. Mol Med 2019; 26:6. [PMID: 31892321 PMCID: PMC6938630 DOI: 10.1186/s10020-019-0132-z] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 12/20/2019] [Indexed: 12/11/2022] Open
Abstract
Background The sequelae of sepsis were once thought to be independent of sepsis itself and assumed to be either comorbid to sick patients or complications of critical illness. Recent studies have reported consistent patterns of functional disabilities in sepsis survivors that can last from months to years after symptoms of active sepsis had resolved. Body Post-sepsis syndrome is an emerging pathological entity that has garnered significant interest amongst clinicians and researchers over the last two decades. It is marked by a significantly increased risk of death and a poor health-related quality of life associated with a constellation of long-term effects that persist following the patient’s bout with sepsis. These include neurocognitive impairment, functional disability, psychological deficits, and worsening medical conditions. Conclusion This “post-sepsis syndrome” has been the subject of active preclinical and clinical research providing new mechanistic insights and approaches linked to survivor well-being. Here we review important aspects of these research efforts and goals of care for patients who survive sepsis.
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Affiliation(s)
- Zachary Mostel
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA. .,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Abraham Perl
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Matthew Marck
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Syed F Mehdi
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Barbara Lowell
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Sagar Bathija
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Ramchandani Santosh
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Valentin A Pavlov
- Center for Bioelectronic Medicine and Biomedical Science, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Sangeeta S Chavan
- Center for Bioelectronic Medicine and Biomedical Science, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Jesse Roth
- Laboratory of Diabetes and Diabetes-Related Research, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA.,Center for Bioelectronic Medicine and Biomedical Science, Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY, USA.,Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
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17
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Abstract
PURPOSE OF REVIEW Evaluating longer term mortality, morbidity, and quality of life in survivors of critical illness is a research priority. This review details the challenges of long-term follow-up studies of critically ill patients and highlights recently proposed methodological solutions. RECENT FINDINGS Barriers to long-term follow-up studies of critical care survivors include high rates of study attrition because of death or loss to follow-up, data missingness from experienced morbidity, and lack of standardized outcome as well as reporting of key covariates. A number of recent methods have been proposed to reduce study patients attrition, including minimum data set selection and visits to transitional care or home settings, yet these have significant downsides as well. Conducting long-term follow-up even in the absence of such models carries a high expense, as personnel are very costly, and patients/families require reimbursement for their time and inconvenience. SUMMARY There is a reason why many research groups do not conduct long-term outcomes in critical care: it is very difficult. Challenges of long-term follow-up require careful consideration by study investigators to ensure our collective success in data integration and a better understanding of underlying mechanisms of mortality and morbidity seen in critical care survivorship.
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Affiliation(s)
- M. Elizabeth Wilcox
- Department of Medicine (Critical Care Medicine), Division of Respirology, University Health Network, Toronto, Canada
- Interdepartment Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine and Center for Health Services Research, Department of Medicine, and the Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education and Clinical Center (GRECC) Service, Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
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18
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Risk Factors for Persistent Cognitive Impairment After Critical Illness, Nested Case-Control Study. Crit Care Med 2019; 46:1977-1984. [PMID: 30222636 DOI: 10.1097/ccm.0000000000003395] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Persistent cognitive impairment after critical illness is an important healthcare problem forecasted to worsen in the near future. However, the epidemiology is insufficiently explored. We aimed to determine potentially modifiable risk factors during ICU hospitalization that play a significant role in developing persistent cognitive impairment. DESIGN An observational case-control study. SETTINGS Mayo Clinic ICUs between July 1, 2004, and November 20, 2015. PATIENTS We conducted a study nested in a large cohort of 98,227 adult critically ill patients. Using previously validated computable phenotypes for dementia and cognitive impairment, we determined the onset of cognitive impairment relative to ICU hospitalization and associated risk factors. The primary endpoint of the study was new and persistent cognitive impairment documented between 3 and 24 months after ICU discharge. INTERVENTIONS Unadjusted and adjusted analyses were performed to identify potentially modifiable risk factors during ICU hospitalization. MEASUREMENTS AND MAIN RESULTS Among 21,923 unique patients identified as cognitively impaired (22% of the entire ICU cohort), 2,428 (2.5%) developed incident new and persistent cognitive dysfunction after the index ICU admission. Compared with age- and sex-matched ICU controls (2,401 pairs), cases had higher chronic illness burden (Charlson Comorbidity Index, 6.2 vs 5.1; p < 0.01), and were more likely to have multiple ICU stays (22% vs 14%; p < 0.01). After adjustment for baseline differences, new and persistent cognitive dysfunction was associated with higher frequency of acute brain failure in the ICU, a higher exposure to severe hypotension, hypoxemia, hyperthermia, fluctuations in serum glucose, and treatment with quinolones or vancomycin. Association with sepsis observed in univariate analysis did not persist after adjustment. CONCLUSIONS Cognitive dysfunction is highly prevalent in ICU patients. Incident new and persistent cognitive impairment is less common but important, potentially preventable problem after critical illness. Chronic comorbidities and number of ICU stays increase the risk of post-ICU cognitive dysfunction irrespective of age. Modifiable ICU exposures were identified as potential targets for future prevention trials.
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19
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Glycemic variability and mortality in patients hospitalized in general surgery wards. Surgery 2019; 166:184-192. [DOI: 10.1016/j.surg.2019.02.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 02/28/2019] [Accepted: 02/28/2019] [Indexed: 12/11/2022]
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20
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Abstract
Poorly controlled diabetes with comorbid manifestations negatively affects outcomes in lower extremity trauma, increasing the risk of short-term and long-term complications. Management strategies of patients with diabetes that experience lower extremity trauma should also include perioperative management of hyperglycemia to reduce adverse and serious adverse events.
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Affiliation(s)
- George T Liu
- Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390-8883, USA; Foot and Ankle Service, Orthopaedic Surgery, Parkland Memorial Hospital, Level 1 Trauma Center, 5200 Harry Hines Boulevard, Dallas, TX 75235, USA.
| | - Drew T Sanders
- Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390-8883, USA; Orthopaedic Trauma Service, Parkland Memorial Hospital, Level 1 Trauma Center, 5200 Harry Hines Boulevard, Dallas, TX 75235, USA
| | - Katherine M Raspovic
- Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390-8883, USA; Foot and Ankle Service, Orthopaedic Surgery, Parkland Memorial Hospital, Level 1 Trauma Center, 5200 Harry Hines Boulevard, Dallas, TX 75235, USA
| | - Dane K Wukich
- Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390-8883, USA; Foot and Ankle Service, Orthopaedic Surgery, Parkland Memorial Hospital, Level 1 Trauma Center, 5200 Harry Hines Boulevard, Dallas, TX 75235, USA
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21
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Agha MA, El-Habashy MM, Abdelshafy MS. Postintensive care syndrome in mechanically ventilated patients secondary to respiratory disorders. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2019. [DOI: 10.4103/ejb.ejb_58_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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22
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Abdelhafiz AH, Sinclair AJ. Cognitive Frailty in Older People with Type 2 Diabetes Mellitus: the Central Role of Hypoglycaemia and the Need for Prevention. Curr Diab Rep 2019; 19:15. [PMID: 30806826 DOI: 10.1007/s11892-019-1135-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW To highlight the central role of hypoglycaemia in the causation of cognitive frailty and explore ways of recognition and prevention of hypoglycaemia. RECENT FINDINGS Cognitive frailty is an emerging new concept defined as the concomitant presence of physical frailty and cognitive impairment. In older people with diabetes, cognitive frailty is associated with an increased risk of mortality greater than from either physical frailty or cognitive impairment alone. Hypoglycaemia is directly associated with increased risk of cognitive impairment and physical frailty which are the two components of cognitive frailty. The incidence of hypoglycaemia in older people with diabetes is rising and hypoglycaemia-related hospitalisation has overtaken that of hyperglycaemia. Recognition of hypoglycaemic episodes in old age remains challenging which leads to misdiagnoses and under-reporting. Therefore, hypoglycaemia prevention strategies are needed. Research is still required to investigate whether prevention of hypoglycaemia would lead to a reduction in the incidence of cognitive frailty.
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Affiliation(s)
- A H Abdelhafiz
- Department of Geriatric Medicine, Rotherham General Hospital, Moorgate Road, Rotherham, S60 2UD, UK.
| | - A J Sinclair
- Foundation for Diabetes Research in Older People, Diabetes Frail Ltd, Droitwich Spa, WR9 0QH, UK
- Kings College, London, SE1 9NH, UK
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23
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Fernandes A, Jaeger MS, Chudow M. Post–intensive care syndrome: A review of preventive strategies and follow-up care. Am J Health Syst Pharm 2019; 76:119-122. [DOI: 10.1093/ajhp/zxy009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | | | - Melissa Chudow
- University of South Florida College of Pharmacy, Tampa, FL
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24
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Ebadi SA, Darvish P, Fard AJ, Lima BS, Ahangar OG. Hypoglycemia and cognitive function in diabetic patients. Diabetes Metab Syndr 2018; 12:893-896. [PMID: 29887517 DOI: 10.1016/j.dsx.2018.05.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 05/14/2018] [Indexed: 01/02/2023]
Abstract
AIMS Hypoglycemia can be considered the most common complication of Diabetes Mellitus treatment. So far, controversial studies have been carried out to examine the impacts of hypoglycemia on the cognitive function. METHODS This study was conducted as case-control. The case group was 35 patients with Diabetes Mellitus Types I or II hospitalized in Imam Hussein Hospital, Tehran, Iran, who have experienced hypoglycemic attacks (glucose level below 70 mg/dl). The control group consisted of diabetic patients hospitalized in hospital, but they had no history of hypoglycemia. As the blood glucose level became in normal range and the patients' Mental status became stable, the brain cognitive function was examined using Mini-Mental State test. RESULTS The mean age of the subjects in the case and control groups was 56.77, 53.73 years old, respectively. The mean cognitive score in the control and hypoglycemic groups was 29.09 and 25.29, respectively. The mean MMSE cognitive score was significantly diminished in the hypoglycemic group (p < 0.001). CONCLUSIONS This study indicated that incidence of hypoglycemia in diabetic patients is associated with cognitive disorders. Further, there is a linear association between cognitive disorders and hypoglycemia, age and diabetes mellitus complication.
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Affiliation(s)
- Seyed Alireza Ebadi
- Department of Internal Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Parichehr Darvish
- Department of Internal Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Ali Jamshidi Fard
- Department of Internal Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Behnam Safarpour Lima
- Department of Neurology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Omid Gharoei Ahangar
- Department of Internal Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Calsavara AJ, Nobre V, Barichello T, Teixeira AL. Post-sepsis cognitive impairment and associated risk factors: A systematic review. Aust Crit Care 2018. [DOI: 10.1016/j.aucc.2017.06.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Marino BS, Tabbutt S, MacLaren G, Hazinski MF, Adatia I, Atkins DL, Checchia PA, DeCaen A, Fink EL, Hoffman GM, Jefferies JL, Kleinman M, Krawczeski CD, Licht DJ, Macrae D, Ravishankar C, Samson RA, Thiagarajan RR, Toms R, Tweddell J, Laussen PC. Cardiopulmonary Resuscitation in Infants and Children With Cardiac Disease: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e691-e782. [PMID: 29685887 DOI: 10.1161/cir.0000000000000524] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Cardiac arrest occurs at a higher rate in children with heart disease than in healthy children. Pediatric basic life support and advanced life support guidelines focus on delivering high-quality resuscitation in children with normal hearts. The complexity and variability in pediatric heart disease pose unique challenges during resuscitation. A writing group appointed by the American Heart Association reviewed the literature addressing resuscitation in children with heart disease. MEDLINE and Google Scholar databases were searched from 1966 to 2015, cross-referencing pediatric heart disease with pertinent resuscitation search terms. The American College of Cardiology/American Heart Association classification of recommendations and levels of evidence for practice guidelines were used. The recommendations in this statement concur with the critical components of the 2015 American Heart Association pediatric basic life support and pediatric advanced life support guidelines and are meant to serve as a resuscitation supplement. This statement is meant for caregivers of children with heart disease in the prehospital and in-hospital settings. Understanding the anatomy and physiology of the high-risk pediatric cardiac population will promote early recognition and treatment of decompensation to prevent cardiac arrest, increase survival from cardiac arrest by providing high-quality resuscitations, and improve outcomes with postresuscitation care.
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Hermanides J, Plummer MP, Finnis M, Deane AM, Coles JP, Menon DK. Glycaemic control targets after traumatic brain injury: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:11. [PMID: 29351760 PMCID: PMC5775599 DOI: 10.1186/s13054-017-1883-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Accepted: 10/31/2017] [Indexed: 01/04/2023]
Abstract
Background Optimal glycaemic targets in traumatic brain injury (TBI) remain unclear. We performed a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing intensive with conventional glycaemic control in TBI requiring admission to an intensive care unit (ICU). Methods We systematically searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials to November 2016. Outcomes of interest included ICU and in-hospital mortality, poor neurological outcome, the incidence of hypoglycaemia and infective complications. Data were analysed by pairwise random effects models with secondary analysis of differing levels of conventional glycaemic control. Results Ten RCTs, involving 1066 TBI patients were included. Three studies were conducted exclusively in a TBI population, whereas in seven trials, the TBI population was a sub-cohort of a mixed neurocritical or general ICU population. Glycaemic targets with intensive control ranged from 4.4 to 6.7 mmol/L, while conventional targets aimed to keep glucose levels below thresholds of 8.4–12 mmol/L. Conventional versus intensive control showed no association with ICU or hospital mortality (relative risk (RR) (95% CI) 0.93 (0.68–1.27), P = 0.64 and 1.07 (0.84–1.36), P = 0.62, respectively). The risk of a poor neurological outcome was higher with conventional control (RR (95% CI) = 1.10 (1.001–1.24), P = 0.047). However, severe hypoglycaemia occurred less frequently with conventional control (RR (95% CI) = 0.22 (0.09–0.52), P = 0.001). Conclusions This meta-analysis of intensive glycaemic control shows no association with reduced mortality in TBI. Intensive glucose control showed a borderline significant reduction in the risk of poor neurological outcome, but markedly increased the risk of hypoglycaemia. These contradictory findings should motivate further research. Electronic supplementary material The online version of this article (10.1186/s13054-017-1883-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jeroen Hermanides
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK. .,Department of Anesthesiology, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Mark P Plummer
- Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Mark Finnis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, 5000, Australia
| | - Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, 3050, Australia
| | - Jonathan P Coles
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
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Turon M, Fernández-Gonzalo S, de Haro C, Magrans R, López-Aguilar J, Blanch L. Mechanisms involved in brain dysfunction in mechanically ventilated critically ill patients: implications and therapeutics. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:30. [PMID: 29430447 DOI: 10.21037/atm.2017.12.10] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Critical illness may lead to significant long-term neurological morbidity and patients frequently develop neuropsychological disturbances including acute delirium or memory impairment after intensive care unit (ICU) discharge. Mechanical ventilation (MV) is a risk factor to the development of adverse neurocognitive outcomes. Patients undergoing MV for long periods present neurologic impairment with memory and cognitive alteration. Delirium is considered an acute form of brain dysfunction and its prevalence rises in mechanically ventilated patients. Delirium duration is an independent predictor of mortality, ventilation time, ICU length of stay and short- and long-term cognitive impairment in the ICU survivors. Although, neurocognitive sequelae tend to improve after hospital discharge, residual deficits persist even 6 years after ICU stay. ICU-related neurocognitive impairments occurred in many cognitive domains and are particularly pronounced with regard to memory, executive functions, attentional functions, and processing speed. These sequelae have an important impact on patients' lives and ICU survivors often require institutionalization and hospitalization. Experimental studies have served to explore the possible mechanisms or pathways involved in this lung to brain interaction. This communication can be mediated via a complex web of signaling events involving neural, inflammatory, immunologic and neuroendocrine pathways. MV can affect respiratory networks and the application of protective ventilation strategies is mandatory in order to prevent adverse effects. Therefore, strategies focused to minimize lung stretch may improve outcomes, avoiding failure of distal organ, including the brain. Long-term neurocognitive impairments experienced by critically ill survivors may be mitigated by early interventions, combining cognitive and physical therapies. Inpatient rehabilitation interventions in ICU promise to improve outcomes in critically ill patients. The cross-talk between lung and brain, involving specific pathways during critical illness deserves further efforts to evaluate, prevent and improve cognitive alterations after ICU admission, and highlights the crucial importance of tailoring MV to prevent adverse outcomes.
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Affiliation(s)
- Marc Turon
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Sol Fernández-Gonzalo
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain
| | - Candelaria de Haro
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Rudys Magrans
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Josefina López-Aguilar
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Lluís Blanch
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
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Sakusic A, O'Horo JC, Dziadzko M, Volha D, Ali R, Singh TD, Kashyap R, Farrell AM, Fryer JD, Petersen R, Gajic O, Rabinstein AA. Potentially Modifiable Risk Factors for Long-Term Cognitive Impairment After Critical Illness: A Systematic Review. Mayo Clin Proc 2018; 93:68-82. [PMID: 29304923 DOI: 10.1016/j.mayocp.2017.11.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 11/03/2017] [Accepted: 11/13/2017] [Indexed: 01/08/2023]
Abstract
Long-term cognitive impairment is common in survivors of critical illness. Little is known about the etiology of this serious complication. We sought to summarize current scientific knowledge about potentially modifiable risk factors during intensive care unit (ICU) treatment that may play a substantial role in the development of long-term cognitive impairment. All searches were run on October 1, 2017. The search strategy included Ovid MEDLINE, Ovid Embase, Ovid CDR, Cochrane Central Register of Controlled Trials and Database of Abstracts of Reviews of Effect, Scopus, and Web of Science, and included MeSH headings and keywords related to intensive care, critical care, and cognitive disorders. Searches were restricted to adult subjects. Inclusion required follow-up cognitive evaluation at least 2 months after ICU discharge. Studies assessing patients with cardiac arrest, traumatic brain injury, and cardiac surgery history were excluded. The search strategy resulted in 3180 studies. Of these, 28 studies (.88%) met our inclusion criteria and were analyzed. Delirium and duration of delirium were associated with long-term cognitive impairment after ICU admission in 6 of 9 studies in which this factor was analyzed. Weaker and more inconsistent associations have been reported with hypoglycemia, hyperglycemia, fluctuations in serum glucose levels, and in-hospital acute stress symptoms. Instead, most of the studies did not find significant associations between long-term cognitive impairment and mechanical ventilation; use of sedatives, vasopressors, or analgesic medications; enteral feeding; hypoxia; extracorporeal membrane oxygenation; systolic blood pressure; pulse rate; or length of ICU stay. Prolonged delirium may be a risk factor for long-term cognitive impairment after critical illness, though this association has not been entirely consistent across studies. Other potentially preventable factors have not been shown to have strong or consistent associations with long-term cognitive dysfunction in survivors of critical illness.
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Affiliation(s)
- Amra Sakusic
- Department of Physiology, Faculty of Medicine, University of Tuzla, Tuzla, Bosnia and Herzegovina; University Clinical Center Tuzla, Tuzla, Bosnia and Herzegovina; Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - John C O'Horo
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN; Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Mikhail Dziadzko
- Department of Anesthesiology, Mayo Clinic, Rochester, MN; Department of Anesthesiology, CHU Croix Rousse, Lyon, France
| | - Dziadzko Volha
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Rashid Ali
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Tarun D Singh
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN; Department of Neurology, Mayo Clinic, Rochester, MN
| | - Rahul Kashyap
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN; Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | | | - John D Fryer
- Department of Neuroscience, Mayo Clinic, Jacksonville, FL
| | | | - Ognjen Gajic
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Alejandro A Rabinstein
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC), Emergency and Perioperative Medicine, Mayo Clinic, Rochester, MN; Department of Neurology, Mayo Clinic, Rochester, MN.
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Ghosh S, Bajaj S, Pandit K, Agarwal S, Aravind SR, Chawla R, Gupta S, Jayaprakashsai J, Kalra S, Kumar CV, Maheshwari A, Makkar BM, Anand Moses CR, Panda J, Panikar V, Rao PV, Saboo B, Sahay R, Setty KRN, Viswanathan V. Diabetes and driving. Int J Diabetes Dev Ctries 2017. [DOI: 10.1007/s13410-017-0586-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Akirov A, Diker-Cohen T, Masri-Iraqi H, Shimon I. High Glucose Variability Increases Mortality Risk in Hospitalized Patients. J Clin Endocrinol Metab 2017; 102:2230-2241. [PMID: 28368484 DOI: 10.1210/jc.2017-00450] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 03/17/2017] [Indexed: 12/26/2022]
Abstract
CONTEXT Glucose variability (GV) is common among hospitalized patients, but the prognostic implications are not understood. OBJECTIVE Investigate the association between GV, hospital length of stay (LOS), and mortality. METHODS GV was assessed by coefficient of variance (CV) and standard deviation (SD) of glucose values during hospitalization. SETTING Historical prospectively collected data of patients hospitalized between January 2011 and December 2013. PATIENTS Patients ≥18 years old. MAIN OUTCOME LOS, and in-hospital and mortality at end of follow-up. RESULTS The cohort included 20,303 patients (mean age ± SD, 70 ± 17 years; 51% men; median follow-up, 1022 days), of whom 8565 patients (42%) had diabetes mellitus (DM). Mean LOS was longer with higher CV or SD tertiles in patients without and with DM. In-hospital mortality was 8.2%, associated with higher tertiles of CV (4%, 10%, 19%) and SD (4%, 11%, 21%) in patients without DM and with DM (3%, 5%, 10%; and 2%, 4%, 9%, respectively). Mortality at the end of follow-up was increased in patients without DM with higher CV (28%, 42%, 55%) and SD (28%, 44%, 57%) tertiles and in patients with DM (26%, 35%, 45%; and 25%, 34%, 44%, respectively). Multivariate analysis indicated increased risk for in-hospital and end of follow-up mortality, in both groups. Adjustment for glucocorticoid treatment or hypoglycemia did not affect the results. Glucose levels during hospitalization and GV were two independent factors affecting LOS and in-hospital mortality. In each CV tertile, mortality was higher with median glucose ≥180 mg/dL, compared with <180 mg/dL. CONCLUSIONS In hospitalized patients with and without DM, increased GV is associated with longer hospitalization and increased short- and long-term mortality.
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Affiliation(s)
- Amit Akirov
- Institute of Endocrinology, Beilinson Hospital, 4941492 Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, 6997801 Tel Aviv, Israel
| | - Talia Diker-Cohen
- Institute of Endocrinology, Beilinson Hospital, 4941492 Petach Tikva, Israel
- Internal Medicine A, Beilinson Hospital, 4941492 Petach Tikva, Israel
| | - Hiba Masri-Iraqi
- Institute of Endocrinology, Beilinson Hospital, 4941492 Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, 6997801 Tel Aviv, Israel
| | - Ilan Shimon
- Institute of Endocrinology, Beilinson Hospital, 4941492 Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, 6997801 Tel Aviv, Israel
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Stollings JL, Bloom SL, Huggins EL, Grayson SL, Jackson JC, Sevin CM. Medication Management to Ameliorate Post-Intensive Care Syndrome. AACN Adv Crit Care 2017; 27:133-40. [PMID: 27153300 DOI: 10.4037/aacnacc2016931] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Akirov A, Grossman A, Shochat T, Shimon I. Mortality Among Hospitalized Patients With Hypoglycemia: Insulin Related and Noninsulin Related. J Clin Endocrinol Metab 2017; 102:416-424. [PMID: 27854553 DOI: 10.1210/jc.2016-2653] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 10/10/2016] [Indexed: 01/15/2023]
Abstract
CONTEXT Hypoglycemia is common among hospitalized patients with and without diabetes mellitus. OBJECTIVE Investigate the association between spontaneous or insulin-related hypoglycemia and mortality in hospitalized patients. DESIGN Hypoglycemia was defined as blood glucose <70 mg/dl (3.9 mmol/l), including moderate (40 to 70 mg/dl, 2.2 to 3.9 mmol/l) and severe hypoglycemia (<40 mg/dl, 2.2 mmol/l). Use of insulin during hospitalization defined insulin-related hypoglycemia, thus patients were classified into 6 groups: non-insulin treated (NITC) and insulin-treated controls (ITC), insulin-related hypoglycemia (IH) or severe hypoglycemia (ISH), and non insulin-related hypoglycemia (NIH) and severe hypoglycemia (NISH). SETTING AND PATIENTS Historical prospectively data of patients ≥ 18 years of age, hospitalized in medical wards for any cause between January 2011 and December 2013. MAIN OUTCOME MEASURE All-cause mortality at the end of follow-up. RESULTS The cohort included 33,675 patients, including 2605 with moderate hypoglycemia (IH, 1011; NIH, 1594) and 342 with severe hypoglycemia (ISH, 201; NISH,141). Overall end-of-follow-up mortality was 31.9% (NITC, 28.0%; ITC, 42.9%; NIH, 50.7%; IH, 55.3%; NISH, 70.9%; ISH, 69.1%). Compared with NITC, unadjusted hazard ratios (95% confidence intervals) for mortality were as follows: ITC, 1.7 (1.6 to 1.8), NIH, 2.2 (2.0 to 2.4), IH, 2.5 (2.2 to 2.7), NISH, 4.2 (3.5 to 5.2), and ISH, 3.8 (3.2 to 4.5); with P < 0.001. Following multivariate analysis, respective hazard ratios were 1.8, 2.1, 2.4, 3.2, and 3.6 (P < 0.001). Cause of admission did not affect the association. CONCLUSIONS In hospitalized patients, hypoglycemia, either with insulin use or spontaneous, is associated with increased short- and long-term mortality.
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Affiliation(s)
- Amit Akirov
- Institute of Endocrinology
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Alon Grossman
- Department of Internal Medicine E, and
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Tzipora Shochat
- Statistical Consulting Unit, Rabin Medical Center-Beilinson Hospital, Petach Tikva 49100, Israel; and
| | - Ilan Shimon
- Institute of Endocrinology
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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Hern HG, Kiefer M, Louie D, Barger J, Alter HJ. D10 in the Treatment of Prehospital Hypoglycemia: A 24 Month Observational Cohort Study. PREHOSP EMERG CARE 2016; 21:63-67. [PMID: 27918858 DOI: 10.1080/10903127.2016.1189637] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Prehospital first responders historically have used an IV bolus of 50 mL of 50% dextrose solution (D50) for the treatment of hypoglycemia in the field. A local Emergency Medical Services (EMS) system recently approved a hypoglycemia treatment protocol of IV 10% dextrose solution (D10) due to occasional shortages and higher cost of D50. We use the experience of this EMS system to report the feasibility, safety, and efficacy of this approach. METHODS Over the course of 104 weeks, paramedics treated 1,323 hypoglycemic patients with D10 and recorded patient demographics and clinical outcomes. Of these, 1,157 (87.5%) patients were treated with 100 mL of D10 initially upon EMS arrival, and full data on response to treatment was available on 871 (75%) of these 1,157. We captured the 871 patients' capillary glucose response to initial infusion of 100 mL of D10 and fit a linear regression line between elapsed time and difference between initial and repeat glucose values. We also explored the need for repeat glucose infusions as well as feasibility, and safety. RESULTS The study cohort included 469 men and 402 women with a median age of 66. The median initial field blood glucose was 37 mg/dL, while the subsequent blood glucose had a median of 91 mg/dL. The median time to second glucose testing was eight minutes after beginning the 100mL D10 infusion. Of 871 patients, 200 (23.0%) required an additional dose of IV D10 solution due to persistent or recurrent hypoglycemia and seven (0.8%) patients required a third dose. There were no reported deaths or other adverse events related to D10 administration for hypoglycemia. Linear regression analysis of elapsed time and difference between initial and repeat glucose values showed near-zero correlation. CONCLUSIONS The results of one local EMS system over a 104-week period demonstrate the feasibility, safety, and efficacy of using 100 mL of D10 as an alternative to D50. D50 may also have theoretical risks including extravasation injury, direct toxic effects of hypertonic dextrose, and potential neurotoxic effects of hyperglycemia. Additionally, our data suggest that there may be little or no short-term decrease in blood glucose results after D10 administration.
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Yun JS, Ko SH. Risk Factors and Adverse Outcomes of Severe Hypoglycemia in Type 2 Diabetes Mellitus. Diabetes Metab J 2016; 40:423-432. [PMID: 27766794 PMCID: PMC5167706 DOI: 10.4093/dmj.2016.40.6.423] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 08/24/2016] [Indexed: 12/15/2022] Open
Abstract
Hypoglycemia has been considered as a major barrier to achieving the proper glycemic target in type 2 diabetes mellitus patients. In particular, severe hypoglycemia (SH), which is defined as a hypoglycemic episode requiring the assistance of another person to raise the patient's glucose level, is a serious complication of diabetes because of its possible fatal outcomes. Recently, the recommendations for diabetes care have emphasized a patient-centered approach, considering the individualized patient factors including hypoglycemia. Many studies have been performed which analyzed the risk factors and clinical outcomes for SH. From the studies, researchers recommend that targeting a less stringent glycosylated hemoglobin level and selecting a safer class of drugs for hypoglycemia are appropriate for patients with a high risk of SH. Also, careful clinical attention to prevent hypoglycemia, including intensive education, is necessary to minimize the risk of SH and SH-related fatal outcomes.
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Affiliation(s)
- Jae Seung Yun
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Seung Hyun Ko
- Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea.
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Associations between blood glucose level and outcomes of adult in-hospital cardiac arrest: a retrospective cohort study. Cardiovasc Diabetol 2016; 15:118. [PMID: 27557653 PMCID: PMC4997657 DOI: 10.1186/s12933-016-0445-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 08/19/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND We intended to analyse the associations between blood glucose (BG) level and clinical outcomes of in-hospital cardiac arrest (IHCA). METHODS We conducted a retrospective observational study in a single medical centre and evaluated patients who experienced IHCA between 2006 and 2014. We used multivariable logistic regression analysis to study associations between independent variables and outcomes. We calculated the mean BG level for each patient by averaging the maximum and minimum BG levels in the first 24 h after arrest, and we used mean BG level for our final analysis. RESULTS We included a total of 402 patients. Of these, 157 patients (39.1 %) had diabetes mellitus (DM). The average mean BG level was 209.9 mg/dL (11.7 mmol/L). For DM patients, a mean BG level between 183 and 307 mg/dL (10.2-17.1 mmol/L) was significantly associated with favourable neurological outcome (odds ratio [OR] 2.71, 95 % confidence interval [CI] 1.18-6.20; p value = 0.02); a mean BG level between 147 and 317 mg/dL (8.2-17.6 mmol/L) was significantly associated with survival to hospital discharge (OR 2.38, 95 % CI 1.26-4.53; p value = 0.008). For non-DM patients, a mean BG level between 143 and 268 mg/dL (7.9-14.9 mmol/L) was significantly associated with survival to hospital discharge (OR 2.93, 95 % CI 1.62-5.40; p value < 0.001). CONCLUSIONS Mean BG level in the first 24 h after cardiac arrest was associated with neurological outcome for IHCA patients with DM. For neurological and survival outcomes, the optimal BG range may be higher for patients with DM than for patients without DM.
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Kullmann S, Heni M, Hallschmid M, Fritsche A, Preissl H, Häring HU. Brain Insulin Resistance at the Crossroads of Metabolic and Cognitive Disorders in Humans. Physiol Rev 2016; 96:1169-209. [PMID: 27489306 DOI: 10.1152/physrev.00032.2015] [Citation(s) in RCA: 334] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Ever since the brain was identified as an insulin-sensitive organ, evidence has rapidly accumulated that insulin action in the brain produces multiple behavioral and metabolic effects, influencing eating behavior, peripheral metabolism, and cognition. Disturbances in brain insulin action can be observed in obesity and type 2 diabetes (T2D), as well as in aging and dementia. Decreases in insulin sensitivity of central nervous pathways, i.e., brain insulin resistance, may therefore constitute a joint pathological feature of metabolic and cognitive dysfunctions. Modern neuroimaging methods have provided new means of probing brain insulin action, revealing the influence of insulin on both global and regional brain function. In this review, we highlight recent findings on brain insulin action in humans and its impact on metabolism and cognition. Furthermore, we elaborate on the most prominent factors associated with brain insulin resistance, i.e., obesity, T2D, genes, maternal metabolism, normal aging, inflammation, and dementia, and on their roles regarding causes and consequences of brain insulin resistance. We also describe the beneficial effects of enhanced brain insulin signaling on human eating behavior and cognition and discuss potential applications in the treatment of metabolic and cognitive disorders.
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Affiliation(s)
- Stephanie Kullmann
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany; German Center for Diabetes Research (DZD e.V.), Tübingen, Germany; Department of Internal Medicine IV, University of Tübingen, Tübingen, Germany; Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany; and Department of Pharmacy and Biochemistry, Faculty of Science, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Martin Heni
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany; German Center for Diabetes Research (DZD e.V.), Tübingen, Germany; Department of Internal Medicine IV, University of Tübingen, Tübingen, Germany; Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany; and Department of Pharmacy and Biochemistry, Faculty of Science, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Manfred Hallschmid
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany; German Center for Diabetes Research (DZD e.V.), Tübingen, Germany; Department of Internal Medicine IV, University of Tübingen, Tübingen, Germany; Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany; and Department of Pharmacy and Biochemistry, Faculty of Science, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Andreas Fritsche
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany; German Center for Diabetes Research (DZD e.V.), Tübingen, Germany; Department of Internal Medicine IV, University of Tübingen, Tübingen, Germany; Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany; and Department of Pharmacy and Biochemistry, Faculty of Science, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Hubert Preissl
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany; German Center for Diabetes Research (DZD e.V.), Tübingen, Germany; Department of Internal Medicine IV, University of Tübingen, Tübingen, Germany; Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany; and Department of Pharmacy and Biochemistry, Faculty of Science, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Hans-Ulrich Häring
- Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Center Munich at the University of Tübingen, Tübingen, Germany; German Center for Diabetes Research (DZD e.V.), Tübingen, Germany; Department of Internal Medicine IV, University of Tübingen, Tübingen, Germany; Institute of Medical Psychology and Behavioral Neurobiology, University of Tübingen, Tübingen, Germany; and Department of Pharmacy and Biochemistry, Faculty of Science, Eberhard Karls Universität Tübingen, Tübingen, Germany
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Post-intensive care unit syndrome in gynecologic oncology patients. Support Care Cancer 2016; 24:4627-32. [DOI: 10.1007/s00520-016-3305-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 06/06/2016] [Indexed: 10/21/2022]
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Sheen YJ, Sheu WHH. Association between hypoglycemia and dementia in patients with type 2 diabetes. Diabetes Res Clin Pract 2016; 116:279-87. [PMID: 27321346 DOI: 10.1016/j.diabres.2016.04.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 03/17/2016] [Accepted: 04/14/2016] [Indexed: 12/27/2022]
Abstract
In addition to increased risks of macrovascular and microvascular complications, patients with type 2 diabetes mellitus (T2DM) usually also are at increased risk for cognitive impairment and dementia. Hypoglycemia, a common consequence of diabetes treatment, is considered an independent risk factor for dementia in patients with T2DM. Hypoglycemia and dementia are clinically underestimated and are related to poor outcomes; thus, they may compromise the life expectancy of patients with T2DM. Epidemiological evidence of hypoglycemia-associated cognitive decline and dementia is highly varied. Acute, severe hypoglycemic episodes induce chronic subclinical brain damage, cognitive decline, and subsequent dementia. However, the effects of recurrent moderate hypoglycemia on cognitive decline and dementia remain largely uninvestigated. Poor glycemic control (including fluctuation of hemoglobin A1C [HbA1c] and glucose values) and the viscous circle of bidirectional associations between dementia and hypoglycemia may be clinically relevant. The possible pathophysiological hypotheses include post-hypoglycemic neuronal damage, inflammatory processes, coagulation defects, endothelial abnormalities, and synaptic dysfunction of hippocampal neurons during hypoglycemia episodes. This article reviews previous findings, provides insight into the detection of groups at high risk of hypoglycemia-associated dementia, and proposes specific strategies to minimize the potential burdens associated with hypoglycemia-related neurocognitive disorders in patients with T2DM.
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Affiliation(s)
- Yi-Jing Sheen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Hospital, Ministry of Health and Welfare, No. 199 Section 1, Sanmin Road, Taichung 403, Taiwan
| | - Wayne H H Sheu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, No. 1650, Section 4, Taiwan Boulevard, Taichung 407, Taiwan; School of Medicine, National Defense Medical Center, Taipei, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Institute of Medical Technology, National Chung-Hsing University, Taichung, Taiwan.
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Gottschalk A, Welp HA, Leser L, Lanckohr C, Wempe C, Ellger B. Continuous Glucose Monitoring in Patients Undergoing Extracorporeal Ventricular Assist Therapy. PLoS One 2016; 11:e0148778. [PMID: 26963806 PMCID: PMC4786282 DOI: 10.1371/journal.pone.0148778] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 01/22/2016] [Indexed: 12/16/2022] Open
Abstract
Background Dysregulations of blood glucose (BG) are associated with adverse outcome in critical illness; controlling BG to target appears to improve outcome. Since BG-control is challenging in daily intensive care practice BG-control remains poor especially in patients with rapidly fluctuating BG. To improve BG-control and to avoid deleterious hypoglycemia, automated online-measurement tools are advocated. We thus evaluated the point-accuracy of the subcutaneous Sentrino® Continuous Glucose Monitoring System (CGM, Medtronic Diabetes, Northridge, California) in patients undergoing extracorporeal cardiac life support (ECLS) for cardiogenic shock. Methods Management of BG was performed according to institute’s standard aiming at BG-levels between 100–145 mg/dl. CGM-values were recorded without taking measures into therapeutic account. Point-accuracy in comparison to intermittent BG-measurement by the ABL-blood-gas analyzer was determined. Results CGM (n = 25 patients) correlated significantly with ABL-values (r = 0.733, p<0.001). Mean error from standard was 15.0 mg/dl (11.9%). 44.2% of the readings were outside a 15% range around ABL-values. In one of 635 paired data-points, ABL revealed hypoglycemia (BG 32 mg/dl) whereas CGM did not show hypoglycemic values (132mg/dl). Conclusions CGM reveals minimally invasive BG-values in critically ill adults with dynamically impaired tissue perfusion. Because of potential deviations from standard, CGM-readings must be interpreted with caution in specific ICU-populations.
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Affiliation(s)
- Antje Gottschalk
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Henryk A. Welp
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University Hospital Münster, Münster, Germany
- * E-mail:
| | - Laura Leser
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Christian Lanckohr
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Carola Wempe
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Björn Ellger
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
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Abstract
Sepsis predisposes to disordered metabolism and dysglycemia; the latter is a broad term that includes hyperglycemia, hypoglycemia, and glycemic variability. Dysglycemia is a marker of illness severity. Large randomized controlled trials have provided considerable insight into the optimal blood glucose targets for critically ill patients with sepsis. However, it may be that the pathophysiologic consequences of dysglycemia are dynamic throughout the course of a septic insult and also altered by premorbid glycemia. This review highlights the relevance of hyperglycemia, hypoglycemia, and glycemic variability in patients with sepsis with an emphasis on a rational approach to management.
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Affiliation(s)
- Mark P Plummer
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide 5000, Australia; Department of Critical Care Services, Royal Adelaide Hospital, North Terrace, Adelaide 5000, Australia.
| | - Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide 5000, Australia; Department of Critical Care Services, Royal Adelaide Hospital, North Terrace, Adelaide 5000, Australia
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Affiliation(s)
- Antje Gottschalk
- Department for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
| | - Björn Ellger
- Department for Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Münster, Münster, Germany
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Sonneville R, Vanhorebeek I, den Hertog HM, Chrétien F, Annane D, Sharshar T, Van den Berghe G. Critical illness-induced dysglycemia and the brain. Intensive Care Med 2014; 41:192-202. [PMID: 25465908 DOI: 10.1007/s00134-014-3577-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 11/19/2014] [Indexed: 01/04/2023]
Abstract
PURPOSE Dysglycemia is a characteristic feature of critical illness associated with adverse outcome. Whether dysglycemia contributes to brain dysfunction during critical illness and long-term neurological complications is unclear. We give an overview of glucose metabolism in the brain and review the literature on critical illness-induced dysglycemia and the brain. METHODS Medline database search using relevant search terms on dysglycemia, critical illness, acute brain injury/dysfunction, and randomized controlled trial. RESULTS Hyperglycemia has been associated with deleterious effects on the nervous system. Underlying mechanisms in critical illness remain largely speculative and are often extrapolated from knowledge in diabetes mellitus. Increased hyperglycemia-induced blood-brain barrier permeability, oxidative stress, and microglia activation may play a role and compromise neuronal and glial cell integrity. Hypoglycemia is feared as critically ill patients cannot recognize or communicate hypoglycemic symptoms, which furthermore are masked by sedation and analgesia. However, observational data on the impact of brief hypoglycemia on the brain in critical illness are controversial. Secondary analysis of two large randomized studies suggested neuroprotection by strict glycemic control with insulin during intensive care, with lowered intracranial pressure, reduction of seizures, and better long-term rehabilitation in patients with isolated brain injury, and reduced incidence of critical illness polyneuromyopathy in the general critically ill patient population. Several subsequent studies failed to reproduce neurological benefit, likely explained by methodological issues, which include divergent achieved glucose levels and inaccurate glucose monitoring tools. CONCLUSIONS Preventing hyperglycemia during critical illness holds promise as a neuroprotective strategy to preserve brain cell viability and prevent acute brain dysfunction and long-term cognitive impairment in survivors.
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Affiliation(s)
- Romain Sonneville
- Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
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Annane D, Sharshar T. Cognitive decline after sepsis. THE LANCET RESPIRATORY MEDICINE 2014; 3:61-9. [PMID: 25434614 DOI: 10.1016/s2213-2600(14)70246-2] [Citation(s) in RCA: 187] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The modern era of sepsis management is characterised by a growing number of patients who survive in the short term and are discharged from hospital. Increasing evidence suggests that these survivors exhibit long-term neurological sequelae, particularly substantial declines in cognitive function. The exact prevalence and outcomes of these neuropsychological sequelae are unclear. The mechanisms by which sepsis induces cognitive dysfunction probably include vascular injuries and neuroinflammation that are mediated by systemic metabolism disorders and overwhelming inflammation, a disrupted blood-brain barrier, oxidative stress, and severe microglial activation, particularly within the limbic system. Interventions targeting the blood-brain barrier, glial activation, and oxidative stress have shown promise in prevention of cognitive dysfunction in various experimental models of sepsis. The next step should be to translate these favourable effects into positive clinical results.
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Affiliation(s)
- Djillali Annane
- Department of Intensive Care Medicine, Raymond Poincaré Hospital, Assistance Publique-Hôpitaux de Paris, Garches, France; University of Versailles, Montigny le Bretonneux, France.
| | - Tarek Sharshar
- Department of Intensive Care Medicine, Raymond Poincaré Hospital, Assistance Publique-Hôpitaux de Paris, Garches, France; University of Versailles, Montigny le Bretonneux, France
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Mazeraud A, Polito A, Annane D. Experimental and clinical evidences for glucose control in intensive care: is infused glucose the key point for study interpretation? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:232. [PMID: 25177798 PMCID: PMC4220093 DOI: 10.1186/cc13998] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Stress-induced hyperglycemia has been considered an adaptive mechanism to stress up to the first intensive insulin therapy trial, which showed a 34% reduction in relative risk of in-hospital mortality when normalizing blood glucose levels. Further trials had conflicting results and, at present, stress-induced hyperglycemia management remains non-consensual. These findings could be explained by discrepancies in trials, notably regarding the approach to treat hyperglycemia: high versus restrictive caloric intake. Stress-induced hyperglycemia is a frequent complication during intensive care unit stay and is associated with a higher mortality. It results from an imbalance between insulin and counter-regulatory hormones, increased neoglucogenesis, and the cytokine-induced insulin-resistant state of tissues. In this review, we summarize detrimental effects of hyperglycemia on organs in the critically ill (peripheric and central nervous, liver, immune system, kidney, and cardiovascular system). Finally, we show clinical and experimental evidence of potential benefits from glucose and insulin administration, notably on metabolism, immunity, and the cardiovascular system.
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Abstract
INTRODUCTION Prehospital first responders historically have treated hypoglycemia in the field with an IV bolus of 50 mL of 50% dextrose solution (D50). The California Contra Costa County Emergency Medical Services (EMS) system recently adopted a protocol of IV 10% dextrose solution (D10), due to frequent shortages and relatively high cost of D50. The feasibility, safety, and efficacy of this approach are reported using the experience of this EMS system. METHODS Over the course of 18 weeks, paramedics treated 239 hypoglycemic patients with D10 and recorded patient demographics and clinical outcomes. Of these, 203 patients were treated with 100 mL of D10 initially upon EMS arrival, and full data on response to treatment was available on 164 of the 203 patients. The 164 patients' capillary glucose response to initial infusion of 100 mL of D10 was calculated and a linear regression line fit between elapsed time and difference between initial and repeat glucose values. Feasibility, safety, and the need for repeat glucose infusions were examined. RESULTS The study cohort included 102 men and 62 women with a median age of 68 years. The median initial field blood glucose was 38 mg/dL, with a subsequent blood glucose median of 98 mg/dL. The median time to second glucose testing was eight minutes after beginning the 100 mL D10 infusion. Of 164 patients, 29 (18%) required an additional dose of IV D10 solution due to persistent or recurrent hypoglycemia, and one patient required a third dose. There were no reported adverse events or deaths related to D10 administration. Linear regression analysis of elapsed time and difference between initial and repeat glucose values showed near-zero correlation. CONCLUSIONS In addition to practical reasons of cost and availability, theoretical risks of using 50 mL of D50 in the out-of-hospital setting include extravasation injury, direct toxic effects of hypertonic dextrose, and potential neurotoxic effects of hyperglycemia. The results of one local EMS system over an 18-week period demonstrate the feasibility, safety, and efficacy of using 100 mL of D10 as an alternative. Additionally, the linear regression line of repeat glucose measurements suggests that there may be little or no short-term decay in blood glucose values after D10 administration.
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Abstract
PURPOSE OF REVIEW Diabetes mellitus and its related comorbidities present a growing challenge in perioperative medicine. And also largely independent from a history of diabetes, dysregulations of glucose homeostasis occur as part of the body's stress response. Dysregulations of glucose homeostasis, acute or chronic, are closely correlated with impaired prognosis in perioperative medicine. Treatment strategies remain somewhat controversial, as both the affliction and its correction have a blind side. RECENT FINDINGS Anesthesia requires vigilant attention to diabetes-related comorbidities such as neuropathy, angiopathy, cardiopathy and immune dysfunction. Dysregulations of glycemia of any kind, in other words, hypoglycemia and hyperglycemia and fluctuations of blood glucose, should be avoided. Target glycemia remains a matter of discussion: moderate, achievable glycemic target below 180 or 150 mg/dl appears to be reasonable. Modern technical developments like continuous glucose measurement devices and computer-assisted control algorithms are under development, and will hopefully facilitate perioperative glycemic control in the future. SUMMARY Literature clearly shows that leaving glycemic control out of focus is dangerous for the patient; efforts to control glycemia to a moderate target improve the patient's outcome.
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Acute Hyperglycemia Associated with Short-Term Use of Atypical Antipsychotic Medications. Drugs 2014; 74:183-94. [DOI: 10.1007/s40265-013-0171-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Clinical practice guidelines for evidence-based management of sedoanalgesia in critically ill adult patients. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.medine.2013.04.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Celis-Rodríguez E, Birchenall C, de la Cal M, Castorena Arellano G, Hernández A, Ceraso D, Díaz Cortés J, Dueñas Castell C, Jimenez E, Meza J, Muñoz Martínez T, Sosa García J, Pacheco Tovar C, Pálizas F, Pardo Oviedo J, Pinilla DI, Raffán-Sanabria F, Raimondi N, Righy Shinotsuka C, Suárez M, Ugarte S, Rubiano S. Guía de práctica clínica basada en la evidencia para el manejo de la sedoanalgesia en el paciente adulto críticamente enfermo. Med Intensiva 2013; 37:519-74. [DOI: 10.1016/j.medin.2013.04.001] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Accepted: 04/16/2013] [Indexed: 01/18/2023]
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