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Roberts G, Chang L, Park JM, Thynne T. The occurrence of Hospital-Acquired Pneumonia is independently associated with elevated Stress Hyperglycaemia Ratio at admission but not elevated blood glucose. Diabetes Res Clin Pract 2023; 205:110955. [PMID: 37839754 DOI: 10.1016/j.diabres.2023.110955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/02/2023] [Accepted: 10/13/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND The association between stress-induced hyperglycaemia (SIH) and increased infection rates in hospitalised subjects is well-known. It is less clear if SIH at admission independently drives new-onset infections. We assessed the relationship between early exposure at admission to both the Stress Hyperglycaemia Ratio (SHR) and Blood Glucose (BG) with Hospital-Acquired Pneumonia (HAP). METHODS This observational retrospective study included those with length-of-stay > 1 day, BG within 24 h of admission and recent haemoglobin A1c. SIH was defined as BG ≥ 10 mmol/L, or SHR ≥ 1.1, measured at both admission and as a 24-hour maximum. Multivariable analyses were adjusted for length-of-stay, age, mechanical ventilation, and chronic respiratory disease. RESULTS Of 5,339 eligible subjects, 110 (2.1%) experienced HAP. Admission SHR ≥ 1.1 was independently associated with HAP (OR 3.04, 95% CI 1.98-4.68, p < 0.0001) but not BG ≥ 10 mmol/L (OR 0.65, 95% CI 0.41-1.03, p = 0.0675). The association with SHR strengthened using maximum 24-hour values (OR 3.37, 95% CI 2.05-5.52, p < 0.0001) while BG ≥ 10 mmol/L remained insignificant (OR 0.96, 95% CI 0.63-1.46, p = 0.86). Of those experiencing HAP 40 (36.4%) occurred in subjects with no recorded BG ≥ 10 mmol/L but SHR ≥ 1.1. CONCLUSION SIH at admission defined as SHR ≥ 1.1, but not the conventional marker of BG ≥ 10 mmol/L, was independently associated with the subsequent onset of HAP, commonly at BG < 10 mmol/L.
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Affiliation(s)
- Gregory Roberts
- SA Pharmacy, Flinders Medical Centre, Bedford Park SA 5042, Australia; College of Medicine and Public Health, Flinders University, Bedford Park SA 5042, Australia.
| | - Leonard Chang
- College of Medicine and Public Health, Flinders University, Bedford Park SA 5042, Australia.
| | - Joong-Min Park
- College of Medicine and Public Health, Flinders University, Bedford Park SA 5042, Australia.
| | - Tilenka Thynne
- College of Medicine and Public Health, Flinders University, Bedford Park SA 5042, Australia; Department of Clinical Pharmacology, Flinders Medical Centre, Bedford Park SA 5042, Australia.
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2
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Olander A, Magnusson C, Sundler AJ, Bremer A, Andersson H, Herlitz J, Axelsson C, Andersson Hagiwara M. Prediction of the Risk of Sepsis by Using Analysis of Plasma Glucose and Serum Lactate in Ambulance Services: A Prospective Study. Prehosp Disaster Med 2023; 38:160-167. [PMID: 36752111 DOI: 10.1017/s1049023x23000110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The early recognition of patients with sepsis is difficult and the initial assessment outside of hospitals is challenging for ambulance clinicians (ACs). Indicators that ACs can use to recognize sepsis early are beneficial for patient outcomes. Research suggests that elevated point-of-care (POC) plasma glucose and serum lactate levels may help to predict sepsis in the ambulance service (AS) setting. STUDY OBJECTIVE The aim of this study was to test the hypothesis that the elevation of POC plasma glucose and serum lactate levels may help to predict Sepsis-3 in the AS. METHODS A prospective observational study was performed in the AS setting of Gothenburg in Sweden from the beginning of March 2018 through the end of September 2019. The criteria for sampling POC plasma glucose and serum lactate levels in the AS setting were high or intermediate risk according to the Rapid Emergency Triage and Treatment System (RETTS), as red, orange, yellow, and green if the respiratory rate was >22 breaths/minutes. Sepsis-3 were identified retrospectively. A primary and secondary analyses were carried out. The primary analysis included patients cared for in the AS and emergency department (ED) and were hospitalized. In the secondary analysis, patients who were only cared for in the AS and ED without being hospitalized were also included. To evaluate the predictive ability of these biomarkers, the area under the curve (AUC), sensitivity, specificity, and predictive values were used. RESULTS A total of 1,057 patients were included in the primary analysis and 1,841 patients were included in the secondary analysis. In total, 253 patients met the Sepsis-3 criteria (in both analyses). The AUC for POC plasma glucose and serum lactate levels showed low accuracy in predicting Sepsis-3 in both the primary and secondary analyses. Among all hospitalized patients, regardless of Sepsis-3, more than two-thirds had elevated plasma glucose and nearly one-half had elevated serum lactate when measured in the AS. CONCLUSIONS As individual biomarkers, an elevated POC plasma glucose and serum lactate were not associated with an increased likelihood of Sepsis-3 when measured in the AS in this study. However, the high rate of elevation of these biomarkers before arrival in hospital highlights that their role in clinical decision making at this early stage needs further evaluation, including other endpoints than Sepsis-3.
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Affiliation(s)
- Agnes Olander
- University of Borås, PreHospen - Centre for Prehospital Research, Borås, Sweden
- University of Borås, Faculty of Caring Science, Work Life and Social Welfare, Borås, Sweden
| | - Carl Magnusson
- University of Borås, PreHospen - Centre for Prehospital Research, Borås, Sweden
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Annelie J Sundler
- University of Borås, Faculty of Caring Science, Work Life and Social Welfare, Borås, Sweden
| | - Anders Bremer
- University of Borås, Faculty of Caring Science, Work Life and Social Welfare, Borås, Sweden
- Linnaeus University, Faculty of Health and Life Sciences, Växjö, Sweden
| | - Henrik Andersson
- University of Borås, PreHospen - Centre for Prehospital Research, Borås, Sweden
- University of Borås, Faculty of Caring Science, Work Life and Social Welfare, Borås, Sweden
- Linnaeus University, Faculty of Health and Life Sciences, Växjö, Sweden
| | - Johan Herlitz
- University of Borås, PreHospen - Centre for Prehospital Research, Borås, Sweden
- University of Borås, Faculty of Caring Science, Work Life and Social Welfare, Borås, Sweden
| | - Christer Axelsson
- University of Borås, PreHospen - Centre for Prehospital Research, Borås, Sweden
- University of Borås, Faculty of Caring Science, Work Life and Social Welfare, Borås, Sweden
| | - Magnus Andersson Hagiwara
- University of Borås, PreHospen - Centre for Prehospital Research, Borås, Sweden
- University of Borås, Faculty of Caring Science, Work Life and Social Welfare, Borås, Sweden
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3
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Pichardo-Lowden AR, Haidet P, Umpierrez GE, Lehman EB, Quigley FT, Wang L, Rafferty CM, DeFlitch CJ, Chinchilli VM. Clinical Decision Support for Glycemic Management Reduces Hospital Length of Stay. Diabetes Care 2022; 45:2526-2534. [PMID: 36084251 PMCID: PMC9679255 DOI: 10.2337/dc21-0829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 08/14/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Dysglycemia influences hospital outcomes and resource utilization. Clinical decision support (CDS) holds promise for optimizing care by overcoming management barriers. This study assessed the impact on hospital length of stay (LOS) of an alert-based CDS tool in the electronic medical record that detected dysglycemia or inappropriate insulin use, coined as gaps in care (GIC). RESEARCH DESIGN AND METHODS Using a 12-month interrupted time series among hospitalized persons aged ≥18 years, our CDS tool identified GIC and, when active, provided recommendations. We compared LOS during 6-month-long active and inactive periods using linear models for repeated measures, multiple comparison adjustment, and mediation analysis. RESULTS Among 4,788 admissions with GIC, average LOS was shorter during the tool's active periods. LOS reductions occurred for all admissions with GIC (-5.7 h, P = 0.057), diabetes and hyperglycemia (-6.4 h, P = 0.054), stress hyperglycemia (-31.0 h, P = 0.054), patients admitted to medical services (-8.4 h, P = 0.039), and recurrent hypoglycemia (-29.1 h, P = 0.074). Subgroup analysis showed significantly shorter LOS in recurrent hypoglycemia with three events (-82.3 h, P = 0.006) and nonsignificant in two (-5.2 h, P = 0.655) and four or more (-14.8 h, P = 0.746). Among 22,395 admissions with GIC (4,788, 21%) and without GIC (17,607, 79%), LOS reduction during the active period was 1.8 h (P = 0.053). When recommendations were provided, the active tool indirectly and significantly contributed to shortening LOS through its influence on GIC events during admissions with at least one GIC (P = 0.027), diabetes and hyperglycemia (P = 0.028), and medical services (P = 0.019). CONCLUSIONS Use of the alert-based CDS tool to address inpatient management of dysglycemia contributed to reducing LOS, which may reduce costs and improve patient well-being.
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Affiliation(s)
- Ariana R. Pichardo-Lowden
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
| | - Paul Haidet
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
- Department of Humanities and the Woodward Center for Excellence in Health Sciences Education, Penn State College of Medicine, Hershey, PA
| | | | - Erik B. Lehman
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Francis T. Quigley
- Department of Medicine, Penn State Health St. Joseph Medical Center, Reading, PA
| | - Li Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Colleen M. Rafferty
- Department of Medicine, Penn State Health, Penn State College of Medicine, Hershey Medical Center, Hershey, PA
| | - Christopher J. DeFlitch
- Department of Emergency Medicine, Office of the Chief Medical Information Officer, Penn State Health, Hershey, PA
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
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4
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Roberts GW, Larwood C, Krinsley JS. Quantification of stress-induced hyperglycaemia associated with key diagnostic categories using the stress hyperglycaemia ratio. Diabet Med 2022; 39:e14930. [PMID: 35945696 DOI: 10.1111/dme.14930] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/28/2022] [Indexed: 01/08/2023]
Abstract
AIM Stress-induced hyperglycaemia (SIH) is the acute increase from preadmission glycaemia and is associated with poor outcomes. Early recognition of SIH and subsequent blood glucose (BG) management improves outcomes, but the degree of SIH provoked by distinct diagnostic categories remains unknown. Quantification of SIH is now possible using the stress hyperglycaemia ratio (SHR), which measures the proportional change from preadmission glycaemia, based on haemoglobin A1c (HbA1c ). METHODS We identified eligible patients for eight medical (n = 892) and eight surgical (n = 347) categories. Maximum BG from the first 24 h of admission for medical, or postoperatively for surgical patients was used to calculate SHR. RESULTS Analysis of variance indicated differing SHR and BG within both the medical (p < 0.0001 for both) and surgical cohort (p < 0.0001 for both). Diagnostic categories were associated with signature levels of SHR that varied between groups. Medically, SHR was greatest for ST-elevation myocardial infarction (1.22 ± 0.33) and sepsis (1.37 ± 0.43). Surgically, SHR was greatest for colectomy (1.62 ± 0.48) and cardiac surgeries (coronary artery graft 1.56 ± 0.43, aortic valve replacement 1.71 ± 0.33, and mitral valve replacement 1.75 ± 0.34). SHR values remained independent of HbA1c , with no difference for those with HbA1c above or below 6.5% (p > 0.11 for each). BG however was highly dependent on HbA1c , invariably elevated in those with HbA1c ≥ 6.5% (p < 0.001 for each), and unreliably reflected SIH. CONCLUSION The acute stress response associated with various medical and surgical categories is associated with signature levels of SIH. Those with higher expected SHR are more likely to benefit from early SIH management, especially major surgery, which induced SIH typically 40% greater than medical cohorts. SHR equally recognised the acute change in BG from baseline across the full HbA1c spectrum while BG did not and poorly reflected SIH.
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Affiliation(s)
- Gregory W Roberts
- College of Medicine and Public Health, Flinders University, Flinders University Drive, Bedford Park, South Australia, Australia
- SA Pharmacy, Flinders Medical Centre, Flinders Drive, Bedford Park, South Australia, Australia
| | - Crystal Larwood
- College of Medicine and Public Health, Flinders University, Flinders University Drive, Bedford Park, South Australia, Australia
| | - James S Krinsley
- Division of Critical Care, Department of Medicine, Stamford Hospital, and the Columbia Vagelos College of Physicians and Surgeons 1 Hospital Plaza, Stamford, Connecticut, USA
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5
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Jiang L, Cheng M. Impact of diabetes mellitus on outcomes of patients with sepsis: an updated systematic review and meta-analysis. Diabetol Metab Syndr 2022; 14:39. [PMID: 35248158 PMCID: PMC8898404 DOI: 10.1186/s13098-022-00803-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/07/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The effect of concurrent diabetes on the outcome of sepsis is not conclusively known. A meta-analysis published in 2017 indicated that diabetes did not influence the mortality of patients with sepsis but increased the risk of acute renal injury. In view of publication of several new studies in recent years, there is a need for updated evidence. METHODS A systematic search was conducted using the PubMed, Scopus, Embase, and Google Scholar databases. Studies that were done in patients with sepsis, were observational in design- either cohort or case-control or analysed retrospective data were considered for inclusion. Statistical analysis was performed using STATA software. RESULTS A total of 21 studies were included. The risk of in-hospital mortality (RR 0.98, 95% CI 0.93, 1.04) and mortality at latest follow up i.e., within 90 days of discharge (RR 0.94, 95% CI 0.86, 1.04) among diabetic and non-diabetic subjects was statistically similar. There was an increased risk of in-hospital mortality among those with high blood glucose level at admission (RR 1.45, 95% CI 1.01, 2.09). Among those who were diabetic, the risk of acute renal failure (RR 1.54, 95% CI 1.34, 1.78) was higher than non-diabetics. The risk of respiratory failure, adverse cardiac events, need for additional hospitalization post-discharge and length of hospital stay was similar among diabetics and non-diabetics. CONCLUSIONS Diabetes is not associated with poor survival outcomes in patients with sepsis but is associated with increased risk of acute renal failure. High blood glucose levels, irrespective of the diabetes status, are associated with increased risk of in-hospital mortality. Findings underscore the need for better evaluation of renal function in diabetic patients with concurrent sepsis.
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Affiliation(s)
- Li Jiang
- Department of Infectious Diseases, The First People's Hospital of Wenling, Wenling, 317500, Zhejiang, China
| | - Mengdi Cheng
- Department of Emergency Medicine, The First People's Hospital of Wenling, Wenling, 317500, Zhejiang, China.
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6
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Akinosoglou K, Kapsokosta G, Mouktaroudi M, Rovina N, Kaldis V, Stefos A, Kontogiorgi M, Giamarellos-Bourboulis E, Gogos C. Diabetes on sepsis outcomes in non-ICU patients: A cohort study and review of the literature. J Diabetes Complications 2021; 35:107765. [PMID: 33187869 DOI: 10.1016/j.jdiacomp.2020.107765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 06/17/2020] [Accepted: 09/14/2020] [Indexed: 01/12/2023]
Abstract
AIMS We sought to determine whether primary outcomes differ between non-ICU septic patients with and without type 2 diabetes (T2D). METHODS This study utilized the Hellenic Sepsis Study Group Registry, collecting nationwide data for sepsis patients since 2006, and classified patients upon presence or absence of T2D. Patients were perfectly matched for a) Sepsis 3 definition criteria (including septic shock) b) gender, c) age, d) APACHE II score and e) Charlson's comorbidity index (CCI). Independent sample t-test and chi-square t-test was used to compare prognostic indices and primary outcomes. RESULTS Of 4320 initially included non-ICU sepsis patients, 812 were finally analysed, following match on criteria. Baseline characteristics were age 76 [±10.3] years, 46% male, APACHE II 15.5 [±6], CCI 5.1 [±1.8], 24% infection, 63.8% sepsis and 12.2% septic shock. No significant difference was noted between two groups in qSOFA, SOFA, or suPAR1 levels (p = 0.7, 0.1 & 0.3) respectively. Primary sepsis syndrome resolved in 70.9% of cases (p = 0.9), while mortality was 24% in 28-days time. Cause of death was similar between patients with and without T2D (sepsis 17.8% vs 15.8%, heart event 3.7% vs 3.2%, CNS event 0.5% vs 0.5%, malignancy 0.7% vs 2% respectively, p = 0.6). CONCLUSIONS DM does not appear to negatively affect outcomes in septic patients not requiring ICU.
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Affiliation(s)
- Karolina Akinosoglou
- Dept of Internal Medicine and Infectious Diseases, University Hospital of Patras, Greece.
| | | | - Maria Mouktaroudi
- 4th Dept of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Greece
| | - Nikoletta Rovina
- 1st Dept of Pulmonary Medicine and Intensive Care Unit, National and Kapodistrian University of Athens, Medical School, Greece
| | | | - Aggelos Stefos
- Dept of Internal Medicine, Larissa University General Hospital, University of Thessaly, Greece
| | - Marina Kontogiorgi
- 2nd Dept of Critical Care Medicine, National and Kapodistrian University of Athens, Medical School, Greece
| | | | - Charalambos Gogos
- Dept of Internal Medicine and Infectious Diseases, University Hospital of Patras, Greece
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7
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Kauppi W, Herlitz J, Magnusson C, Palmér L, Axelsson C. Characteristics and outcomes of patients with dyspnoea as the main symptom, assessed by prehospital emergency nurses- a retrospective observational study. BMC Emerg Med 2020; 20:67. [PMID: 32859155 PMCID: PMC7456019 DOI: 10.1186/s12873-020-00363-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 08/21/2020] [Indexed: 12/24/2022] Open
Abstract
Background Dyspnoea (breathing difficulty) is among the most commonly cited reasons for contacting emergency medical services (EMSs). Dyspnoea is caused by several serious underlying medical conditions and, based on patients individual needs and complex illnesses or injuries, ambulance staff are independently responsible for advanced care provision. Few large-scale prehospital studies have reviewed patients with dyspnoea. This study aimed to describe the characteristics and final outcomes of patients whose main symptom was classified as dyspnoea by the prehospital emergency nurse (PEN). Methods This retrospective observational study included patients aged > 16 years whose main symptom was dyspnoea. All the enrolled patients were assessed in the south-western part of Sweden by PENs during January and December, 2017. Of 7260 assignments (9% of all primary missions), 6354 fulfilled the inclusion criteria. Analysis was performed using descriptive statistics, and the tests used were odds ratios and Kaplan-Meier analysis. Results The patients mean age was 73 years, and approximately 56% were women. More than 400 different final diagnostic codes (International Statistical Classification of Diseases and Related Health Problems [ICD]-10th edition) were observed, and 11% of the ICD-10 codes denoted time-critical conditions. The three most commonly observed aetiologies were chronic obstructive pulmonary disease (20.4%), pulmonary infection (17.1%), and heart failure (15%). The comorbidity values were high, with 84.4% having previously experienced dyspnoea. The overall 30-day mortality was 11.1%. More than half called EMSs more than 50 h after symptom onset. Conclusions Among patients assessed by PENs due to dyspnoea as the main symptom there were more than 400 different final diagnoses, of which 11% were regarded as time-critical. These patients had a severe comorbidity and 11% died within the first 30 days.
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Affiliation(s)
- Wivica Kauppi
- PreHospen- Centre for Prehospital Research, Faculty of Caring, Work Life and Social Welfare, University of Borås, SE- 501 90, Borås, Sweden. .,Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden.
| | - Johan Herlitz
- PreHospen- Centre for Prehospital Research, Faculty of Caring, Work Life and Social Welfare, University of Borås, SE- 501 90, Borås, Sweden.,Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Carl Magnusson
- PreHospen- Centre for Prehospital Research, Faculty of Caring, Work Life and Social Welfare, University of Borås, SE- 501 90, Borås, Sweden.,Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lina Palmér
- Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Christer Axelsson
- PreHospen- Centre for Prehospital Research, Faculty of Caring, Work Life and Social Welfare, University of Borås, SE- 501 90, Borås, Sweden.,Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
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8
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Libert C, Ayala A, Bauer M, Cavaillon JM, Deutschman C, Frostell C, Knapp S, Kozlov AV, Wang P, Osuchowski MF, Remick DG. Part II: Minimum Quality Threshold in Preclinical Sepsis Studies (MQTiPSS) for Types of Infections and Organ Dysfunction Endpoints. Shock 2020; 51:23-32. [PMID: 30106873 DOI: 10.1097/shk.0000000000001242] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Although the clinical definitions of sepsis and recommended treatments are regularly updated, a systematic review has not been done for preclinical models. To address this deficit, a Wiggers-Bernard Conference on preclinical sepsis modeling reviewed the 260 most highly cited papers between 2003 and 2012 using sepsis models to create a series of recommendations. This Part II report provides recommendations for the types of infections and documentation of organ injury in preclinical sepsis models. Concerning the types of infections, the review showed that the cecal ligation and puncture model was used for 44% of the studies while 40% injected endotoxin. Recommendation #8 (numbered sequentially from Part I): endotoxin injection should not be considered as a model of sepsis; live bacteria or fungal strains derived from clinical isolates are more appropriate. Recommendation #9: microorganisms should replicate those typically found in human sepsis. Sepsis-3 states that sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection, but the review of the papers showed limited attempts to document organ dysfunction. Recommendation #10: organ dysfunction definitions should be used in preclinical models. Recommendation #11: not all activities in an organ/system need to be abnormal to verify organ dysfunction. Recommendation #12: organ dysfunction should be measured in an objective manner using reproducible scoring systems. Recommendation #13: not all experiments must measure all parameters of organ dysfunction, but investigators should attempt to fully capture as much information as possible. These recommendations are proposed as "best practices" for animal models of sepsis.
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Affiliation(s)
- Claude Libert
- Center for Inflammation Research, VIB, Ghent, Belgium.,Ghent University, Ghent, Belgium
| | - Alfred Ayala
- Rhode Island Hospital & Alpert School of Medicine at Brown University, Providence, Rhode Island
| | | | | | - Clifford Deutschman
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, New York
| | - Claes Frostell
- Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | | | - Andrey V Kozlov
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in the AUVA Research Center, Vienna, Austria
| | - Ping Wang
- Feinstein Institute for Medical Research, Manhasset, New York
| | - Marcin F Osuchowski
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in the AUVA Research Center, Vienna, Austria
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9
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Chen PC, Tsai SH, Wang JC, Tzeng YS, Wang YC, Chu CM, Chu SJ, Liao WI. An elevated glycemic gap predicts adverse outcomes in diabetic patients with necrotizing fasciitis. PLoS One 2019; 14:e0223126. [PMID: 31581199 PMCID: PMC6776331 DOI: 10.1371/journal.pone.0223126] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 09/13/2019] [Indexed: 01/08/2023] Open
Abstract
Background Diabetes is the most common comorbidity of necrotizing fasciitis (NF), but the effect of stress-induced hyperglycemia (SIH) on diabetic patients with NF has never been investigated. The aim of this study was to assess whether SIH, as determined by the glycemic gap between admission glucose levels and A1C-derived average glucose levels, predicts adverse outcomes in diabetic patients hospitalized with NF. Methods We retrospectively reviewed the glycemic gap and clinical outcomes in 252 diabetic patients hospitalized due to NF from 2011 to 2018 in a single medical center in Taiwan. A receiver operating characteristic (ROC) curve was used to analyze the optimal cutoff values for predicting adverse outcomes. Univariate and multivariate logistic regression analyses were employed to identify significant predictors of adverse outcomes. Results In total, 194 diabetic NF patients were enrolled. Compared with patients without adverse outcomes, patients with adverse outcomes had significantly higher glycemic gaps, Acute Physiology and Chronic Health Evaluation (APACHE) II scores and C-reactive protein (CRP) levels; lower albumin and hemoglobin levels; greater incidence of limb loss; and longer hospital and intensive care unit stays. The glycemic gap positively correlates with the laboratory risk indicator for NF scores, APACHE II scores and CRP levels. A glycemic gap of 146 mg/dL was the optimal cutoff value for predicting adverse outcomes using the ROC curve. Compared with patients with glycemic gaps ≤146 mg/dL, those with glycemic gaps >146 mg/dL had higher APACHE II scores and incidence rates of adverse outcomes, especially bacteremia and acute kidney injury. Multivariate analysis revealed that a glycemic gap >146 mg/dL and APACHE II score >15 were independent predictors of adverse outcomes, while the presence of hyperglycemia at admission was not. Conclusions An elevated glycemic gap was significantly independently associated with adverse outcomes in diabetic NF patients. Further prospective studies are warranted to validate the role of the glycemic gap in NF patients with diabetes.
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Affiliation(s)
- Po-Chuan Chen
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Hung Tsai
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Department of Physiology and Biophysics, Graduate Institute of Physiology, National Defense Medical Center, Taipei, Taiwan
| | - Jen-Chun Wang
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yuan-Sheng Tzeng
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yung-Chih Wang
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chi-Ming Chu
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Shi-Jye Chu
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wen-I Liao
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- * E-mail:
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10
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Donnelly JP, Nair S, Griffin R, Baddley JW, Safford MM, Wang HE, Shapiro NI. Association of Diabetes and Insulin Therapy With Risk of Hospitalization for Infection and 28-Day Mortality Risk. Clin Infect Dis 2017; 64:435-442. [PMID: 28174913 DOI: 10.1093/cid/ciw738] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 11/18/2016] [Indexed: 01/07/2023] Open
Abstract
Background Epidemiologic and experimental evidence suggests that individuals with diabetes are at increased risk of infection. We sought to examine the association of diabetes and insulin therapy with hospitalization for infection and 28-day mortality. Methods We performed a prospective cohort study using data from 30 239 community-dwelling participants aged ≥45 years enrolled in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. We defined diabetes as a fasting glucose level ≥126 mg/L (or ≥200 mg/L for those not fasting), the use of insulin or oral hypoglycemic agents, or self-reported history. We identified infection-related hospitalizations over the years 2003–2012. We fit Cox proportional hazards models to assess the association of diabetes with hazard rates of infection and logistic regression models for 28-day mortality. Results Among 29 683 patients from the REGARDS study with complete follow-up, 7375 had diabetes. Over a median follow-up period of 6.5 years, we identified 2593 first and 3411 total infection hospitalizations. In adjusted analyses, participants with diabetes had an increased hazard of infection (hazard ratio, 1.50; 95% confidence interval [CI], 1.37–1.64) compared with those without diabetes. Participants with diabetes hospitalized for infection did not have an increased odds of death within 28 days (odds ratio, 0.94; 95% CI, .67–1.32). Participants receiving insulin therapy had greater hazard of infection (hazard ratio, 2.18; 95% CI, 1.90–2.51) but no increased odds of mortality (odd ratio, 1.07; 95% CI, .67–1.71). Conclusions Diabetes is associated with increased risk of hospitalization for infection. However, we did not find an association with 28-day mortality. Insulin therapy conferred an even greater risk of hospitalization, without increased mortality.
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Affiliation(s)
- John P Donnelly
- Department of Emergency Medicine, University of Alabama School of Medicine, Birmingham, Alabama, United States of America,Division of Preventive Medicine, Department of Medicine, University of Alabama School of Medicine, Birmingham, Alabama, United States of America.,Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - Sunil Nair
- Department of Internal Medicine, University of Alabama School of Medicine, Birmingham, Alabama, United States of America
| | - Russell Griffin
- Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama, United States of America
| | - John W Baddley
- Division of Infectious Disease, Department of Medicine, University of Alabama School of Medicine, Birmingham, Alabama, United States of America
| | - Monika M Safford
- Department of Medicine, University of Alabama at Birmingham,Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Henry E Wang
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Nathan I Shapiro
- Center for Vascular Biology Research, Beth Israel Deaconess Medical Center,Department of Emergency Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Moreira J, Castro R, Lamas C, Ribeiro S, Grinsztejn B, Veloso VG. Hyperglycemia during tuberculosis treatment increases morbidity and mortality in a contemporary cohort of HIV-infected patients in Rio de Janeiro, Brazil. Int J Infect Dis 2017; 69:11-19. [PMID: 29253707 DOI: 10.1016/j.ijid.2017.12.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 11/12/2017] [Accepted: 12/07/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Hyperglycemia occurs in tuberculosis (TB), but the long-term impact is unknown. We estimated the prevalence of hyperglycemia and compared the TB treatment outcomes and 1-year mortality rate according to the glycemic status noted during TB treatment. METHODS We conducted a retrospective cohort analysis of adult patients who had TB and HIV coinfection and started receiving TB treatment at the Instituto Nacional de Infectologia Evandro Chagas, Brazil, between 2010-2015. Diabetes Mellitus (DM) and hyperglycemia were defined according to the American Diabetes Association. After excluding for known DM at baseline, the proportion of participants who developed new-onset DM after TB treatment was assessed. TB outcome was classified as successful or adverse (i.e., treatment failure, abandonment, and death). Kaplan-Meier survival curves were compared by the log-rank test based on the glycemic status of patients. Multivariate Cox regression models were used to assess the association between hyperglycemia and 1-year mortality. Two-sided p values <0.05 were considered statistically significant. RESULTS We identified 414 euglycemic patients (87.5%), 49 hyperglycemic patients (10.3%), and 10 patients with known DM (2.1%). Diabetic patients were older compared to the euglycemic and hyperglycemic patients (47.9 vs. 37 vs. 39.7 years, respectively, p=0.001). Diabetic patients frequently had cavitation on chest image compared to hyperglycemic and euglycemic patients (50% vs. 23.4% vs. 15.3%, p=0.007, respectively). Hyperglycemic patients had more new-onset DM at follow-up compared to euglycemic (22 vs. 1; p<0001). Hyperglycemia was associated with adverse outcomes (71.4% vs. 24.6%, p<0.0001) compared to euglycemia. Crude 1-year mortality was significantly higher in patients with hyperglycemia compared with euglycemia (48.9% vs. 7.9%; unadjusted HR: 5.79 (3.74-8.96)). In the adjusted Cox models, hyperglycemia remained a significant factor for increased 1-year mortality (adjusted HR: 3.72 (2.17-6.38)]. CONCLUSIONS Hyperglycemia frequently occurs in HIV-infected patients who commence TB treatment, and it increases the risks of adverse TB outcomes and 1-year mortality. Glucose testing during TB treatment detects patients at risk of adverse outcomes.
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Affiliation(s)
- José Moreira
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil; Instituto Nacional de Cardiologia, Rio de Janeiro, Brazil.
| | - Rodolfo Castro
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil; Instituto de Saúde Coletiva, Universidade Federal do Estado do Rio de Janeiro (UNIRIO), Rio de Janeiro, Brazil
| | - Cristiane Lamas
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil; Instituto Nacional de Cardiologia, Rio de Janeiro, Brazil; Universidade do Grande Rio (Unigranrio), Rio de Janeiro, Brazil
| | - Sayonara Ribeiro
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Valdiléa G Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
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Diabetes Is Not Associated With Increased 90-Day Mortality Risk in Critically Ill Patients With Sepsis. Crit Care Med 2017; 45:e1026-e1035. [PMID: 28737575 DOI: 10.1097/ccm.0000000000002590] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To determine the association of pre-existing diabetes, hyperglycemia, and hypoglycemia during the first 24 hours of ICU admissions with 90-day mortality in patients with sepsis admitted to the ICU. DESIGN We used mixed effects logistic regression to analyze the association of diabetes, hyperglycemia, and hypoglycemia with 90-day mortality (n = 128,222). SETTING All ICUs in the Netherlands between January 2009 and 2014 that participated in the Dutch National Intensive Care Evaluation registry. PATIENTS All unplanned ICU admissions in patients with sepsis. INTERVENTIONS The association between 90-day mortality and pre-existing diabetes, hyperglycemia, and hypoglycemia, corrected for other factors, was analyzed using a generalized linear mixed effect model. MEASUREMENTS AND MAIN RESULTS In a multivariable analysis, diabetes was not associated with increased 90-day mortality. In diabetes patients, only severe hypoglycemia in the absence of hyperglycemia was associated with increased 90-day mortality (odds ratio, 2.95; 95% CI, 1.19-7.32), whereas in patients without pre-existing diabetes, several combinations of abnormal glucose levels were associated with increased 90-day mortality. CONCLUSIONS In the current retrospective large database review, diabetes was not associated with adjusted 90-day mortality risk in critically ill patients admitted with sepsis.
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Wang Z, Ren J, Wang G, Liu Q, Guo K, Li J. Association Between Diabetes Mellitus and Outcomes of Patients with Sepsis: A Meta-Analysis. Med Sci Monit 2017; 23:3546-3555. [PMID: 28727676 PMCID: PMC5533197 DOI: 10.12659/msm.903144] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background Diabetes mellitus (DM) is a critical medical problem that can make people more likely to develop infectious complications, even sepsis. However, the influence of DM on the outcomes of septic patients is still controversial. Thus, we conducted the present meta-analysis to investigate whether DM worsens outcomes of septic patients. Material/Methods We searched studies from PubMed, Embase, and Cochrane Library databases from 1966 to July 1, 2016. The primary outcome we chose was 28-day or 30-day mortality or in-hospital mortality. Results Our meta-analysis of 10 enrolled studies performed between 2000 and 2016 shows that the mortality rate of septic patients with DM was slightly lower than that of non-diabetic patients (risk ratio [RR]=0.97, 95% confidence interval [CI]: 0.96 to 0.98, P<0.00001). On the other hand, septic patients with DM had a shorter hospital stay (weighted mean difference (WMD)=−2.27, 95% CI: −4.11 to −0.44, P=0.01), a higher incidence rate of AKI (RR=1.56, 95% CI: 1.25 to 1.95, P<0.001), and a similar incidence of respiratory dysfunction (RR=0.86, 95% CI: 0.71 to 1.04, P=0.11) compared with those without DM. Conclusions The results from the meta-analysis suggest that DM does not impair the outcome of patients with sepsis, and the incidence of acute kidney injury increases dramatically in septic patients with DM. Due to the limitations of the analysis, more well-designed trials are still necessary.
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Affiliation(s)
- Zhiwei Wang
- Department of Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Jianan Ren
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China (mainland)
| | - Gefei Wang
- Department of Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Qinjie Liu
- Department of Surgery, Jinling Hospital, Nanjing Medical University, Nanjing, Jiangsu, China (mainland)
| | - Kun Guo
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China (mainland)
| | - Jieshou Li
- Department of Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China (mainland)
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Kutz A, Struja T, Hausfater P, Amin D, Amin A, Haubitz S, Bernard M, Huber A, Mueller B, Schuetz P. The association of admission hyperglycaemia and adverse clinical outcome in medical emergencies: the multinational, prospective, observational TRIAGE study. Diabet Med 2017; 34:973-982. [PMID: 28164367 DOI: 10.1111/dme.13325] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2017] [Indexed: 01/04/2023]
Abstract
AIMS The clinical relevance of hyperglycaemia in an emergency department population remains incompletely understood. We investigated the association between admission blood glucose levels and adverse clinical outcomes in a large emergency department cohort. METHODS We prospectively enrolled 7132 adult medical patients seeking emergency department care in three tertiary care hospitals in Switzerland, France and the USA. We used adjusted multivariable logistic regression models to examine the association between admission blood glucose levels and 30-day mortality, as well as adverse clinical course stratified by pre-existing diabetes and principal medical diagnoses. RESULTS In 6044 people without diabetes (84.7%), severe hyperglycaemia, defined as a glucose level of > 11.1 mmol/l (200 mg/dl), was associated with a doubling in the risk of 30-day mortality [adjusted odds ratio (OR) 1.9; 95% confidence interval (95% CI), 1.1 to 3.3; P = 0.018] and a three-fold increase in the risk of intensive care unit admission (adjusted OR 3.0; 95% CI, 1.9 to 4.9; P < 0.001). These associations were similar among different diagnoses. In the population with diabetes (n = 1088), no association with 30-day mortality was found (adjusted OR 1.0; 95% CI, 0.6 to 1.8; P for interaction = 0.001), whereas the association with intensive care unit admission was weaker (adjusted OR 2.4; 95% CI, 1.5 to 4.1; P for interaction = 0.011). Overall 30-day mortality was higher in those with diabetes than in those without (6.1 vs. 4.4%, P = 0.015). CONCLUSIONS In this large medical emergency department patient cohort, admission hyperglycaemia was strongly associated with adverse clinical course in people without diabetes. (Clinical Trial Registry No: NCT01768494).
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Affiliation(s)
- A Kutz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - T Struja
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - P Hausfater
- Emergency Department, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
- Sorbonne Universités UPMC-Univ Paris 06, UMRS INSERM 1166, IHUC ICAN, Paris, France
| | - D Amin
- Morton Plant Hospital, Clearwater, Florida, USA
| | - A Amin
- Morton Plant Hospital, Clearwater, Florida, USA
| | - S Haubitz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - M Bernard
- Biochemistry Department, Hôpital Pitié-Salpêtrière and Univ-Paris Descartes, Paris, France
| | - A Huber
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - B Mueller
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - P Schuetz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
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15
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Forsblom E, Ruotsalainen E, Järvinen A. Prognostic impact of hyperglycemia at onset of methicillin-sensitive Staphylococcus aureus bacteraemia. Eur J Clin Microbiol Infect Dis 2017; 36:1405-1413. [PMID: 28265815 DOI: 10.1007/s10096-017-2946-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 02/20/2017] [Indexed: 11/29/2022]
Abstract
Previous reports have associated hyperglycemia to poor outcome among aged and comorbid Staphylococcus aureus bacteraemia (SAB) patients. However, the prognostic impact of hyperglycemia in SAB irrespective of age and underlying conditions including a diagnosis of diabetes has received little attention. The objective here was to evaluate the prognostic relevance of hyperglycemia at onset of methicillin-sensitive SAB (MS-SAB). It was a retrospective study of MS-SAB patients. Blood glucose was measured within 24 h of positive blood cultures. The patient cohort was analyzed en bloc and by categorization according to age, underlying conditions and a diagnosis of diabetes. Altogether 161 patients were identified. High initial blood glucose levels were observed among diabetics (p < 0.001), patients with deep infections (p < 0.05) and poor outcome at 28- or 90-days (p < 0.05). Receiver operating characteristics presented the glucose cut-off level of 7.2 mmol/L as a significant predictor of mortality with an area under the curve of 0.63 (95% CI 0.52-0.75, p < 0.05). Blood glucose ≥7.2 mmol/L connected to higher 28- (9 vs. 20%, p < 0.05) and 90-day (14 vs. 29%, p < 0.01) mortality. In Cox proportional hazard regression the blood glucose cut-off value of 7.2 mmol/L significantly predicted 90-day mortality (HR, 2.12; 95% CI, 1.01-4.46; p < 0.05). Among young and healthy non-diabetics the negative prognostic impact of high glucose was further accentuated (HR 7.46, p < 0.05). High glucose levels had no prognostic impact among diabetics. Hyperglycemia at SAB onset may associate to poor outcome. The negative prognostic impact is accentuated among young and healthy non-diabetics.
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Affiliation(s)
- E Forsblom
- Division of Infectious Diseases, Inflammation Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland. .,Division of Infectious Diseases, Department of Medicine, Helsinki University Central Hospital, Aurora Hospital, Nordenskiöldinkatu 26, Building 3, P.O. Box 348, 00029, HUS, Helsinki, Finland.
| | - E Ruotsalainen
- Division of Infectious Diseases, Inflammation Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - A Järvinen
- Division of Infectious Diseases, Inflammation Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
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16
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Chao HY, Liu PH, Lin SC, Chen CK, Chen JC, Chan YL, Wu CC, Blaney GN, Liu ZY, Wu CJ, Chen KF. Association of In-Hospital Mortality and Dysglycemia in Septic Patients. PLoS One 2017; 12:e0170408. [PMID: 28107491 PMCID: PMC5249165 DOI: 10.1371/journal.pone.0170408] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 01/04/2017] [Indexed: 11/18/2022] Open
Abstract
Background The associations between dysglycemia and mortality in septic patients with and without diabetes are yet to be confirmed. Our aim was to analyze the association of diabetes and sepsis mortality, and to examine how dysglycemia (hyperglycemia, hypoglycemia and glucose variability) affects in-hospital mortality of patients with suspected sepsis in emergency department (ED) and intensive care units. Methods Clinically suspected septic patients admitted to ED were included, and stratified into subgroups according to in-hospital mortality and the presence of diabetes. We analyzed patients’ demographics, comorbidities, clinical and laboratory parameters, admission glucose levels and severity of sepsis. Odds ratio of mortality was assessed after adjusting for possible confounders. The correlations of admission glucose and CoV (blood glucose coefficients of variation) and mortality in diabetes and non-diabetes were also tested. Results Diabetes was present in 58.3% of the patients. Diabetic patients were older, more likely to have end-stage renal disease and undergoing hemodialysis, but had fewer malignancies, less sepsis severity (lower Mortality in Emergency Department Sepsis Score), less steroid usage in emergency department, and lower in-hospital mortality rate (aOR:0.83, 95% CI 0.65–0.99, p = 0.044). Hyperglycemia at admission (glucose≥200 mg/dL) was associated with higher risks of in-hospital mortality among the non-diabetes patients (OR:1.83 vs. diabetes, 95% CI 1.20–2.80, p = 0.005) with the same elevated glucose levels at admission. In addition, CoV>30% resulted in higher risk of death as well (aOR:1.88 vs. CoV between 10 and 30, 95%CI 1.24–2.86 p = 0.003). Conclusions This study indicates that while diabetes mellitus seems to be a protective factor in sepsis patients, hyper- or hypoglycemia status on admission, and increased blood glucose variation during hospital stays, were independently associated with increased odds ratio of mortality.
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Affiliation(s)
- Hsiao-Yun Chao
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Peng-Hui Liu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Shen-Che Lin
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chun-Kuei Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Jih-Chang Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yi-Lin Chan
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chin-Chieh Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Gerald N. Blaney
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Zhen-Ying Liu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Cho-Ju Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Kuan-Fu Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
- Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan, Taiwan
- Community Medicine Research Center, Chang Gung Memorial Hospital, Keelung, Taiwan
- * E-mail:
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Adefurin A, Vanderbilt C, Okafor C, Kawai V, Li C, Shah A, Wei WQ, Kurnik D, Stein CM. Alpha2A adrenergic receptor genetic variation contributes to hyperglycemia after myocardial infarction. Int J Cardiol 2016; 215:482-6. [PMID: 27131769 PMCID: PMC4879094 DOI: 10.1016/j.ijcard.2016.04.079] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 04/11/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND Acute myocardial infarction (AMI) is frequently associated with transient hyperglycemia even in patients without pre-existing diabetes. Acute stress can lead to increased blood glucose through the effect of catecholamines on alpha2A-adrenergic receptors (α2A-ARs) present in pancreatic islet β-cells. Variation in the gene (ADRA2A) that encodes the α2A-AR affects insulin release and glucose control and may play a particularly important role during times of stress. METHODS We performed a retrospective cohort study using de-identified electronic medical records linked to a DNA repository in 521 Caucasians and 55 African-American non-diabetic patients with AMI. We examined the association between admission blood glucose concentrations and ten selected ADRA2A SNPs in Caucasians. RESULTS Three ADRA2A SNPS were associated with stress-induced hyperglycemia in Caucasians. Individuals homozygous for the rs10885122 variant (n=9) had a 23% lower admission glucose (geometric mean [95% CI], 99 [83-118]mg/dl) compared with non-carriers (121 [118-125] mg/dl; n=401; P=0.001). Admission glucose was 14% higher in rs1800544 variant homozygotes (134 [119-150]mg/dl; n=36) compared to non-carriers (118 [115-121]mg/dl; n=290, P=0.046). Furthermore, homozygotes of the rs553668 variant (n=13) had a 13% higher glucose (133 [110-160]mg/dl) compared to non-carriers (118 [115-122]mg/dl; n=366; P=0.056). Haplotypes including these ADRA2A SNPs were associated with higher admission glucose levels. CONCLUSIONS Three ADRA2A genetic variants are associated with blood glucose and stress-induced hyperglycemia after AMI in Caucasians.
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Affiliation(s)
- Abiodun Adefurin
- Departments of Medicine and Pharmacology, Division of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Charles Vanderbilt
- Departments of Medicine and Pharmacology, Division of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Chimalum Okafor
- Departments of Medicine and Pharmacology, Division of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Vivian Kawai
- Departments of Medicine and Pharmacology, Division of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Chun Li
- Department of Epidemiology and Biostatistics, Institute for Computational Biology, Case Western Reserve University, Cleveland, OH, United States
| | - Anushi Shah
- Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, USA
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University, Nashville, TN, USA
| | - Daniel Kurnik
- Departments of Medicine and Pharmacology, Division of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, USA; Clinical Pharmacology Unit, Rambam Medical Center, Haifa, Israel; Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.
| | - C Michael Stein
- Departments of Medicine and Pharmacology, Division of Clinical Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, USA
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An Elevated Glycemic Gap is Associated with Adverse Outcomes in Diabetic Patients with Acute Myocardial Infarction. Sci Rep 2016; 6:27770. [PMID: 27291987 PMCID: PMC4904212 DOI: 10.1038/srep27770] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 05/24/2016] [Indexed: 02/07/2023] Open
Abstract
Acute hyperglycemia is a frequent finding in patients presenting to the emergency department (ED) with acute myocardial infarction (AMI). The prognostic role of hyperglycemia in diabetic patients with AMI remains controversial. We retrospectively reviewed patients' medical records to obtain demographic data, clinical presentation, major adverse cardiac events (MACEs), several clinical scores and laboratory data, including the plasma glucose level at initial presentation and HbA1c levels. The glycemic gap, which represents changes in serum glucose levels during the index event, was calculated from the glucose level upon ED admission minus the HbA1c-derived average glucose (ADAG). We enrolled 331 patients after the review of medical records. An elevated glycemic gap between admission serum glucose levels and ADAG were associated with an increased risk of mortality in patients. The glycemic gap showed superior discriminative power regarding the development of MACEs when compared with the admission glucose level. The calculation of the glycemic gap may increase the discriminative powers of established clinical scoring systems in diabetic patients presenting to the ED with AMI. In conclusion, the glycemic gap could be used as an adjunct parameter to assess the severity and prognosis of diabetic patients presenting with AMI. However, the usefulness of the glycemic gap should be further explored in prospective longitudinal studies.
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Patel TS, Cottreau JM, Hirsch EB, Tam VH. Impact of hyperglycemia on outcomes of patients with Pseudomonas aeruginosa bacteremia. Diagn Microbiol Infect Dis 2016; 84:155-8. [DOI: 10.1016/j.diagmicrobio.2015.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 10/22/2015] [Accepted: 10/26/2015] [Indexed: 11/16/2022]
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Roberts GW, Quinn SJ, Valentine N, Alhawassi T, O'Dea H, Stranks SN, Burt MG, Doogue MP. Relative Hyperglycemia, a Marker of Critical Illness: Introducing the Stress Hyperglycemia Ratio. J Clin Endocrinol Metab 2015; 100:4490-7. [PMID: 26485219 DOI: 10.1210/jc.2015-2660] [Citation(s) in RCA: 200] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
CONTEXT Hyperglycemia in hospitalized patients is associated with increased morbidity and mortality. OBJECTIVE We examined whether critical illness is more strongly associated with relative or absolute hyperglycemia. DESIGN The study was an observational cohort study. PATIENTS AND SETTING A total of 2290 patients acutely admitted to a tertiary hospital. MAIN OUTCOME MEASURE The relative hyperglycemia (stress hyperglycemia ratio [SHR]) was defined as admission glucose divided by estimated average glucose derived from glycosylated hemoglobin. The relationships between glucose and SHR with critical illness (in-hospital death or critical care) were examined. RESULTS In univariable analyses, SHR (odds ratio, 1.23 per 0.1 increment [95% confidence interval, 1.18-1.28]; P < .001) and glucose (odds ratio, 1.18 per mmol/L [1.13-1.23]; P < .001) were associated with critical illness. In multivariable analysis, the association was maintained for SHR (odds ratio, 1.20 per 0.1 increment [1.13-1.28]; P < .001), but not glucose (odds ratio, 1.03 per mmol/L [0.97-1.11]; P = .31). Background hyperglycemia affected the relationship between glucose (P = .002) and critical illness, but not SHR (P = .35) and critical illness. In patients with admission glucose ≤ 10 mmol/L, the odds ratio for critical illness was higher in the fourth (2.4 [1.4-4.2]; P = .001) and fifth (3.9 [2.3-6.8]; P < .001) SHR quintiles than in the lowest SHR quintile. CONCLUSIONS SHR controls for background glycemia and is a better biomarker of critical illness than absolute hyperglycemia. SHR identifies patients with relative hyperglycemia at risk of critical illness. Future studies should explore whether basing glucose-lowering therapy on relative, rather than absolute, hyperglycemia improves outcomes in hospitalized patients.
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Affiliation(s)
- Gregory W Roberts
- Pharmacy Department (G.W.R.), Flinders Medical Centre, Bedford Park, South Australia 5042, Australia; School of Medicine (G.W.R., S.J.Q., S.N.S., M.G.B.), Flinders University, Bedford Park, South Australia 5041, Australia; Sturt Fleurieu General Practice Education and Training (N.V.), Adelaide, South Australia 5061, Australia; Discipline of Clinical Pharmacology (N.V., M.P.D.), Flinders University, Bedford Park South Australia 5041, Australia; College of Pharmacy (T.A.), Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia; School of Nursing (H.O.), Flinders University, Bedford Park, South Australia 5041 Australia; Southern Adelaide Diabetes and Endocrine Services (M.G.B., M.P.D.), Repatriation General Hospital, Daw Park, South Australia 5041, Australia; and Department of Medicine (M.P.D.), University of Otago, Christhcurch 8140, New Zealand
| | - Stephen J Quinn
- Pharmacy Department (G.W.R.), Flinders Medical Centre, Bedford Park, South Australia 5042, Australia; School of Medicine (G.W.R., S.J.Q., S.N.S., M.G.B.), Flinders University, Bedford Park, South Australia 5041, Australia; Sturt Fleurieu General Practice Education and Training (N.V.), Adelaide, South Australia 5061, Australia; Discipline of Clinical Pharmacology (N.V., M.P.D.), Flinders University, Bedford Park South Australia 5041, Australia; College of Pharmacy (T.A.), Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia; School of Nursing (H.O.), Flinders University, Bedford Park, South Australia 5041 Australia; Southern Adelaide Diabetes and Endocrine Services (M.G.B., M.P.D.), Repatriation General Hospital, Daw Park, South Australia 5041, Australia; and Department of Medicine (M.P.D.), University of Otago, Christhcurch 8140, New Zealand
| | - Nyoli Valentine
- Pharmacy Department (G.W.R.), Flinders Medical Centre, Bedford Park, South Australia 5042, Australia; School of Medicine (G.W.R., S.J.Q., S.N.S., M.G.B.), Flinders University, Bedford Park, South Australia 5041, Australia; Sturt Fleurieu General Practice Education and Training (N.V.), Adelaide, South Australia 5061, Australia; Discipline of Clinical Pharmacology (N.V., M.P.D.), Flinders University, Bedford Park South Australia 5041, Australia; College of Pharmacy (T.A.), Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia; School of Nursing (H.O.), Flinders University, Bedford Park, South Australia 5041 Australia; Southern Adelaide Diabetes and Endocrine Services (M.G.B., M.P.D.), Repatriation General Hospital, Daw Park, South Australia 5041, Australia; and Department of Medicine (M.P.D.), University of Otago, Christhcurch 8140, New Zealand
| | - Tariq Alhawassi
- Pharmacy Department (G.W.R.), Flinders Medical Centre, Bedford Park, South Australia 5042, Australia; School of Medicine (G.W.R., S.J.Q., S.N.S., M.G.B.), Flinders University, Bedford Park, South Australia 5041, Australia; Sturt Fleurieu General Practice Education and Training (N.V.), Adelaide, South Australia 5061, Australia; Discipline of Clinical Pharmacology (N.V., M.P.D.), Flinders University, Bedford Park South Australia 5041, Australia; College of Pharmacy (T.A.), Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia; School of Nursing (H.O.), Flinders University, Bedford Park, South Australia 5041 Australia; Southern Adelaide Diabetes and Endocrine Services (M.G.B., M.P.D.), Repatriation General Hospital, Daw Park, South Australia 5041, Australia; and Department of Medicine (M.P.D.), University of Otago, Christhcurch 8140, New Zealand
| | - Hazel O'Dea
- Pharmacy Department (G.W.R.), Flinders Medical Centre, Bedford Park, South Australia 5042, Australia; School of Medicine (G.W.R., S.J.Q., S.N.S., M.G.B.), Flinders University, Bedford Park, South Australia 5041, Australia; Sturt Fleurieu General Practice Education and Training (N.V.), Adelaide, South Australia 5061, Australia; Discipline of Clinical Pharmacology (N.V., M.P.D.), Flinders University, Bedford Park South Australia 5041, Australia; College of Pharmacy (T.A.), Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia; School of Nursing (H.O.), Flinders University, Bedford Park, South Australia 5041 Australia; Southern Adelaide Diabetes and Endocrine Services (M.G.B., M.P.D.), Repatriation General Hospital, Daw Park, South Australia 5041, Australia; and Department of Medicine (M.P.D.), University of Otago, Christhcurch 8140, New Zealand
| | - Stephen N Stranks
- Pharmacy Department (G.W.R.), Flinders Medical Centre, Bedford Park, South Australia 5042, Australia; School of Medicine (G.W.R., S.J.Q., S.N.S., M.G.B.), Flinders University, Bedford Park, South Australia 5041, Australia; Sturt Fleurieu General Practice Education and Training (N.V.), Adelaide, South Australia 5061, Australia; Discipline of Clinical Pharmacology (N.V., M.P.D.), Flinders University, Bedford Park South Australia 5041, Australia; College of Pharmacy (T.A.), Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia; School of Nursing (H.O.), Flinders University, Bedford Park, South Australia 5041 Australia; Southern Adelaide Diabetes and Endocrine Services (M.G.B., M.P.D.), Repatriation General Hospital, Daw Park, South Australia 5041, Australia; and Department of Medicine (M.P.D.), University of Otago, Christhcurch 8140, New Zealand
| | - Morton G Burt
- Pharmacy Department (G.W.R.), Flinders Medical Centre, Bedford Park, South Australia 5042, Australia; School of Medicine (G.W.R., S.J.Q., S.N.S., M.G.B.), Flinders University, Bedford Park, South Australia 5041, Australia; Sturt Fleurieu General Practice Education and Training (N.V.), Adelaide, South Australia 5061, Australia; Discipline of Clinical Pharmacology (N.V., M.P.D.), Flinders University, Bedford Park South Australia 5041, Australia; College of Pharmacy (T.A.), Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia; School of Nursing (H.O.), Flinders University, Bedford Park, South Australia 5041 Australia; Southern Adelaide Diabetes and Endocrine Services (M.G.B., M.P.D.), Repatriation General Hospital, Daw Park, South Australia 5041, Australia; and Department of Medicine (M.P.D.), University of Otago, Christhcurch 8140, New Zealand
| | - Matthew P Doogue
- Pharmacy Department (G.W.R.), Flinders Medical Centre, Bedford Park, South Australia 5042, Australia; School of Medicine (G.W.R., S.J.Q., S.N.S., M.G.B.), Flinders University, Bedford Park, South Australia 5041, Australia; Sturt Fleurieu General Practice Education and Training (N.V.), Adelaide, South Australia 5061, Australia; Discipline of Clinical Pharmacology (N.V., M.P.D.), Flinders University, Bedford Park South Australia 5041, Australia; College of Pharmacy (T.A.), Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia; School of Nursing (H.O.), Flinders University, Bedford Park, South Australia 5041 Australia; Southern Adelaide Diabetes and Endocrine Services (M.G.B., M.P.D.), Repatriation General Hospital, Daw Park, South Australia 5041, Australia; and Department of Medicine (M.P.D.), University of Otago, Christhcurch 8140, New Zealand
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Chen PC, Liao WI, Wang YC, Chang WC, Hsu CW, Chen YH, Tsai SH. An Elevated Glycemic Gap is Associated With Adverse Outcomes in Diabetic Patients With Community-Acquired Pneumonia. Medicine (Baltimore) 2015; 94:e1456. [PMID: 26313809 PMCID: PMC4602897 DOI: 10.1097/md.0000000000001456] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Several studies argue against the association between admission hyperglycemia and adverse outcomes in infected diabetic patients. When investigating the association, it is necessary to consider preexisting hyperglycemia. The objective of this study was to assess whether stress-induced hyperglycemia, determined by the glycemic gap between admission glucose levels and A1c-derived average glucose levels adversely affects outcomes in diabetic patients admitted to hospital with community-acquired pneumonia (CAP).We retrospectively analyzed the glycemic gap and adverse outcomes of diabetic patients hospitalized because of CAP from June 1, 2007 to August 31, 2012 in single medical center in Taiwan.A total of 203 patients admitted with principal diagnosis of CAP and available data of glycemic gap.Patients with glycemic gaps ≥40 mg/dL had greater AUROC values for the development of adverse outcomes compared with acute hyperglycemia and long-term glycemic controls. Patients with an elevated glycemic gap had an odds ratio of 3.84 for the incidence of combined adverse outcomes. Incorporation of the glycemic gap into pneumonia severity index, CURB-65 or SMART-COP scores, increased the discriminative performance of predicting the development of adverse outcomes.Glycemic gaps were associated with adverse outcomes of diabetic CAP patients. The discriminative performance of the calculated glycemic gaps was comparable with those of current clinical scoring systems and may further increase the AUROC of each system.
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Affiliation(s)
- Po-Chuan Chen
- From the Department of Emergency Medicine (PCC, WIL, YHC, SHT); Department of Family Medicine (YCW); Department of Radiology, Tri-Service General Hospital, National Defense Medical Center (WCC); and Department of Emergency and Critical Care Medicine, Taipei Medical University-Wan Fang Hospital, Taipei, Taiwan (CWH)
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23
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Abstract
BACKGROUND The QT interval on an electrocardiogram represents ventricular repolarization time. Increased length of this interval, known as corrected QT (QTc) prolongation, can be a precursor to torsade de pointes, a potentially life-threatening ventricular dysrhythmia. An association exists between blood glucose and QTc interval in ambulatory populations. Because both hyperglycemia and QTc prolongation are common in critically ill patients, we sought to examine the relationship between blood glucose, QTc interval prolongation, and all-cause mortality in critically ill patients. METHODS We studied adult patients admitted to cardiac monitoring units. Blood glucose and other clinical variables were abstracted from the medical record. Corrected QT measurements were automatically derived from continuous bedside cardiac monitoring systems. RESULTS Twenty-five percent (233/940) of the patients had QTc prolongation, and 53% had elevated blood glucose (>140 mg/dL) during hospitalization. Adjusted odds for QTc prolongation were 2.1 (95% confidence interval, 1.5-3.1) for moderately elevated blood glucose (140-180 mg/dL) and 3.7 (95% confidence interval, 2.5-5.4) for severely elevated blood glucose (>180 mg/dL). Mortality rate was highest (16%) in patients experiencing both severely elevated blood glucose (>180 mg/dL) and QTc interval prolongation. CONCLUSIONS Hyperglycemia is linked with QTc prolongation, and both are associated with increased odds of mortality in critically ill patients. Further studies are needed to extrapolate the relationship between glucose and ventricular repolarization, as well as appropriate glucose control parameters and QTc interval monitoring in critical care units.
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Schuetz P, Friedli N, Grolimund E, Kutz A, Haubitz S, Christ-Crain M, Thomann R, Zimmerli W, Hoess C, Henzen C, Mueller B. Effect of hyperglycaemia on inflammatory and stress responses and clinical outcome of pneumonia in non-critical-care inpatients: results from an observational cohort study. Diabetologia 2014; 57:275-84. [PMID: 24270903 DOI: 10.1007/s00125-013-3112-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2013] [Accepted: 10/31/2013] [Indexed: 12/31/2022]
Abstract
AIMS/HYPOTHESIS Despite the condition's high prevalence, the influence of hyperglycaemia on clinical outcomes in non-critical-care inpatients with infections remains ill defined. In this study, we analysed associations of glucose levels at admission and during initial inpatient treatment with the inflammatory response and clinical outcome in community-acquired pneumonia (CAP) patients. METHODS This secondary observational analysis included 880 confirmed CAP patients. We used severity-adjusted multivariate regression models to investigate associations of initial and 96 h mean glucose levels with serially measured biomarker levels over 7 days (C-reactive protein [CRP], procalcitonin, white blood cell count [WBC], pro-adrenomedullin [ProADM]) and adverse clinical course (death and intensive-care unit admission). RESULTS In the 724 non-diabetic patients (82.3% of the study population), moderate or severe hyperglycaemia (glucose 6-11 mmol/l and >11 mmol/l, respectively) was associated with increased risk for adverse clinical course (adjusted OR [95% CI] 1.4 [0.8, 2.4] and 3.0 [1.1, 8.0], respectively) and with higher CRP, WBC and ProADM levels over 7 days (p < 0.05, ANOVA, all days). In diabetic patients (n = 156), no similar associations were found for initial hyperglycaemia, although mean 96 h glucose levels ≥ 9 mmol/l were associated with adverse clinical course (adjusted OR 5.4 [1.1, 25.8]; p = 0.03). No effect modification by insulin treatment was detected (interaction terms p > 0.2 for all analyses). CONCLUSIONS/INTERPRETATION Initial hyperglycaemia in non-diabetic CAP patients, and prolonged hyperglycaemia in diabetic or non-diabetic CAP patients, are associated with a more pronounced inflammatory response and CAP-related adverse clinical outcome. Optimal glucose targets for insulin treatment of hyperglycaemia in non-critical-care settings should be defined.
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Affiliation(s)
- Philipp Schuetz
- University Department of Internal Medicine, Kantonsspital Aarau, Tellstrasse, 5001, Aarau, Switzerland,
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25
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Liao WI, Sheu WHH, Chang WC, Hsu CW, Chen YL, Tsai SH. An elevated gap between admission and A1C-derived average glucose levels is associated with adverse outcomes in diabetic patients with pyogenic liver abscess. PLoS One 2013; 8:e64476. [PMID: 23724053 PMCID: PMC3665809 DOI: 10.1371/journal.pone.0064476] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2013] [Accepted: 04/14/2013] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES To assess whether chronic glycemic control and stress-induced hyperglycemia, determined by the gap between admission glucose levels and A1C-derived average glucose (ADAG) levels adversely affects outcomes in diabetic patients with pyogenic liver abscess (PLA). METHODS Clinical, laboratory, and multi-detector computed tomography (MDCT) findings of 329 PLA patients (2004-2010) were retrospectively reviewed. HbA1C levels were used to determine long-term glycemic control status, which were then converted to estimated average glucose values. For the gap between admission glucose levels and ADAG levels, we used receiver operating characteristic (ROC) curve to determine the optimal cut-off values predicting adverse outcomes. Univariate and multivariate logistic regressions were used to identify predictors of adverse outcomes. RESULTS Diabetic PLA patients with poorer glycemic control had significantly higher Klebsiella pneumoniae (KP) infection rates, lower albumin levels, and longer hospital stays than those with suboptimal and good glycemic control. The ROC curve showed that a glycemic gap of 72 mg/dL was the optimal cut-off value for predicting adverse outcomes and showed a 22.3% relative increase in adverse outcomes compared with a glycemic gap<72 mg/dL. Multivariate analysis revealed that an elevated glycemic gap≥72 mg/dL was important predictor of adverse outcomes. CONCLUSIONS A glycemic gap≥72 mg/dL, rather than admission hyperglycemia or chronic glycemic control, was significantly correlated with adverse outcomes in diabetic PLA patients. Poorer chronic glycemic control in diabetic PLA patients is associated with high incidence of KP infection, hypoalbuminemia and longer hospital stay.
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Affiliation(s)
- Wen-I Liao
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wayne Huey-Herng Sheu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wei-Chou Chang
- Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin-Wang Hsu
- Department of Emergency and Critical Care Medicine, Taipei Medical University-Wan Fang Hospital, Taipei, Taiwan
| | - Yu-Long Chen
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Hung Tsai
- Department of Emergency Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- * E-mail:
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