Diabetes and Stroke: Part two—Treating diabetes and stress hyperglycemia in hospitalized stroke patients

Lower mortality among stroke patients with schizophrenia: a nationwide population-based study

OBJECTIVE

To examine 90-day mortality among schizophrenia patients who suffered a recent stroke, using population-based data and a retrospective cohort design. Increasing evidence demonstrates a higher cardiovascular risk for schizophrenia patients compared with the general population. There are no data on stroke outcomes among schizophrenia patients.

METHODS

Data were derived from the Taiwan National Health Insurance Research Database and Cause of Death Data File in Taiwan. During 2002 to 2004, 485 schizophrenia patients hospitalized for stroke were identified. We randomly selected 2,425 stroke patients without schizophrenia who were matched to the study group on sex, age, intensive care unit admission, length of stay, and stroke type. Stratified Cox proportional hazard regressions stratified by age, sex, intensive care unit admission, length of stay, and stroke type were performed to compute the 90-day survival rate, after adjusting for demographic variables and selected medical comorbidities.

RESULTS

Among the 2,910 sampled patients, 258 patients (8.9%) died within 90 days of their index hospitalization, 18 (3.7%) from the study group and 240 (9.9%) from the comparison group (p < .001). After adjusting for demographic and comorbidity factors, stratified Cox proportional hazard regressions confirmed likewise showed that 90-day mortality was less likely among stroke patients with schizophrenia relative to stroke patients without schizophrenia (hazard ratio, 0.35; 95% confidence interval, 0.21-0.57; p < .001).

CONCLUSION

A 90-day mortality among acute stroke patients with schizophrenia is significantly lower than that of stroke patients without schizophrenia.

Inpatient insulin therapy

PURPOSE OF REVIEW

In a 2001 report from a surgical intensive care unit in Leuven, Belgium, intravenous insulin infusion targeting blood glucose 80-110 mg/dl reduced patient mortality and morbidities. Subsequent research has failed to define glycemic targets necessary or sufficient for attainment of desired health outcomes in other inpatient settings, but a large body of evidence suggests hospital outcomes are related to hyperglycemia.

RECENT FINDINGS

Recent literature describes observational evidence for hypoglycemia as an independent predictor of mortality in a general medical intensive care unit; superiority of performance of computerized intravenous insulin algorithms in comparison to earlier manual algorithms; acceptability of early transition to scheduled basal prandial correction subcutaneous insulin analog therapy for maintenance of glycemic targets after induction of euglycemia by intravenous insulin infusion, among cardiothoracic surgery patients; inferiority of sliding scale insulin compared to basal prandial correction therapy; and feasibility of diabetes patient self-management in the hospital setting.

SUMMARY

With development of improved insulin administration strategies problems of hypoglycemia and variability of glycemic control are reduced. Investigators and care providers need to achieve glycemic targets to optimize patient outcomes.

Glucose neurotoxicity

Neurons have a constantly high glucose demand, and unlike muscle cells they cannot accommodate episodic glucose uptake under the influence of insulin. Neuronal glucose uptake depends on the extracellular concentration of glucose, and cellular damage can ensue after persistent episodes of hyperglycaemia--a phenomenon referred to as glucose neurotoxicity. This article reviews the pathophysiological manifestation of raised glucose in neurons and how this can explain the major components of diabetic neuropathy.

Practical aspects of intensive insulinization in the intensive care unit

PURPOSE OF REVIEW

Strategies used for intensive insulin therapy of critically ill patients and differences of approach according to medical condition are reviewed.

RECENT FINDINGS

Acceptance of proposed glycemic targets for critically ill patients has been tempered by uncertainties about benefit of strict glycemic control for specific target subpopulations, differences between treatment centers, optimal timing and duration of intervention, and safety. Present-day intravenous insulin infusion protocols may perform well only for restricted populations. Assessment of protocol performance requires knowledge of algorithm behavior on or near the narrow target range and, using the patient as unit of observation, examination of glycemic variability. Systems of the future will permit adjustment of algorithm parameters to meet individual- or population-specific targets and match carbohydrate exposure.

SUMMARY

Attainment and preservation of glycemic control among critically ill patients are best attempted with intravenous insulin infusion. Advances in the design of decision support and insulin delivery systems, and progress in the technology of continuous blood glucose monitoring, are likely to reduce the risk of hypoglycemia, without compromise of target range control, such that the patient outcomes enjoyed by experienced centers in the future will prove generalizable to others through the extension of new technologies.