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Feng M, Zhou J. Relationship between time-weighted average glucose and mortality in critically ill patients: a retrospective analysis of the MIMIC-IV database. Sci Rep 2024; 14:4721. [PMID: 38413682 PMCID: PMC10899565 DOI: 10.1038/s41598-024-55504-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 02/24/2024] [Indexed: 02/29/2024] Open
Abstract
Blood glucose management in intensive care units (ICU) remains a controversial topic. We assessed the association between time-weighted average glucose (TWAG) levels and ICU mortality in critically ill patients in a real-world study. This retrospective study included critically ill patients from the Medical Information Mart for Intensive Care IV database. Glycemic distance is the difference between TWAG in the ICU and preadmission usual glycemia assessed with glycated hemoglobin at ICU admission. The TWAG and glycemic distance were divided into 4 groups and 3 groups, and their associations with ICU mortality risk were evaluated using multivariate logistic regression. Restricted cubic splines were used to explore the non-linear relationship. A total of 4737 adult patients were included. After adjusting for covariates, compared with TWAG ≤ 110 mg/dL, the odds ratios (ORs) of the TWAG > 110 mg/dL groups were 1.62 (95% CI 0.97-2.84, p = 0.075), 3.41 (95% CI 1.97-6.15, p < 0.05), and 6.62 (95% CI 3.6-12.6, p < 0.05). Compared with glycemic distance at - 15.1-20.1 mg/dL, the ORs of lower or higher groups were 0.78 (95% CI 0.50-1.21, p = 0.3) and 2.84 (95% CI 2.12-3.82, p < 0.05). The effect of hyperglycemia on ICU mortality was more pronounced in non-diabetic and non-septic patients. TWAG showed a U-shaped relationship with ICU mortality risk, and the mortality risk was minimal at 111 mg/dL. Maintaining glycemic distance ≤ 20.1 mg/dL may be beneficial. In different subgroups, the impact of hyperglycemia varied.
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Affiliation(s)
- Mengwen Feng
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Jing Zhou
- Department of Geriatric Intensive Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
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Undernutrition Scored Using the CONUT Score with Hypoglycemic Status in ICU-Admitted Elderly Patients with Sepsis Shows Increased ICU Mortality. Diagnostics (Basel) 2023; 13:diagnostics13040762. [PMID: 36832250 PMCID: PMC9955230 DOI: 10.3390/diagnostics13040762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/07/2023] [Accepted: 02/15/2023] [Indexed: 02/19/2023] Open
Abstract
This study aimed to clarify whether the influence of undernutrition status and the degree of glycemic disorders affected the prognosis of patients with sepsis. A total of 307 adult patients with sepsis were retrospectively enrolled and analyzed. Characteristics, including nutrition status, calculated according to the Controlling Nutritional Status (CONUT) score of survivors and non-survivors, were examined. The independent prognostic factors of these patients with sepsis were extracted using multivariable logistic regression analysis. The CONUT scores in three glycemic categories were compared. Most patients with sepsis (94.8%) in the study had an undernutrition status according to their CONUT scores. High CONUT scores (odds ratio, 1.214; p = 0.002), indicating a poor nutritional status, were associated with high mortality. The CONUT scores in the hypoglycemic group were significantly higher than those in other groups with an undernutrition status (vs. hyperglycemic, p < 0.001; vs. intermediate glycemic, p = 0.006). The undernutrition statuses of patients with sepsis in the study scored using the CONUT were independent predictors of prognostic factors.
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Fang CH, Ravindra V, Akhter S, Adibuzzaman M, Griffin P, Subramaniam S, Grama A. Identifying and analyzing sepsis states: A retrospective study on patients with sepsis in ICUs. PLOS DIGITAL HEALTH 2022; 1:e0000130. [PMID: 36812596 PMCID: PMC9931346 DOI: 10.1371/journal.pdig.0000130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 09/20/2022] [Indexed: 11/12/2022]
Abstract
Sepsis accounts for more than 50% of hospital deaths, and the associated cost ranks the highest among hospital admissions in the US. Improved understanding of disease states, progression, severity, and clinical markers has the potential to significantly improve patient outcomes and reduce cost. We develop a computational framework that identifies disease states in sepsis and models disease progression using clinical variables and samples in the MIMIC-III database. We identify six distinct patient states in sepsis, each associated with different manifestations of organ dysfunction. We find that patients in different sepsis states are statistically significantly composed of distinct populations with disparate demographic and comorbidity profiles. Our progression model accurately characterizes the severity level of each pathological trajectory and identifies significant changes in clinical variables and treatment actions during sepsis state transitions. Collectively, our framework provides a holistic view of sepsis, and our findings provide the basis for future development of clinical trials, prevention, and therapeutic strategies for sepsis.
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Affiliation(s)
- Chih-Hao Fang
- Department of Computer Science, Purdue University, West Lafayette, IN, United States of America
- * E-mail: (C-HF); (AG)
| | - Vikram Ravindra
- Department of Computer Science, University of Cincinnati, Cincinnati, OH, United States of America
| | - Salma Akhter
- Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, IN, United States of America
| | - Mohammad Adibuzzaman
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon, United States of America
| | - Paul Griffin
- Department of Industrial Engineering, Penn State University, University Park, PA, United States of America
| | - Shankar Subramaniam
- Department of Bioengineering, University of California, San Diego, La Jolla, CA, United States of America
| | - Ananth Grama
- Department of Computer Science, Purdue University, West Lafayette, IN, United States of America
- * E-mail: (C-HF); (AG)
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Liu D, Fan Y, Zhuang Y, Peng H, Gao C, Chen Y. Association of Blood Glucose Variability with Sepsis-Related Disseminated Intravascular Coagulation Morbidity and Mortality. J Inflamm Res 2022; 15:6505-6516. [DOI: 10.2147/jir.s383053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 11/15/2022] [Indexed: 12/02/2022] Open
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Lu Z, Tao G, Sun X, Zhang Y, Jiang M, Liu Y, Ling M, Zhang J, Xiao W, Hua T, Zhu H, Yang M. Association of Blood Glucose Level and Glycemic Variability With Mortality in Sepsis Patients During ICU Hospitalization. Front Public Health 2022; 10:857368. [PMID: 35570924 PMCID: PMC9099235 DOI: 10.3389/fpubh.2022.857368] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 03/25/2022] [Indexed: 01/13/2023] Open
Abstract
Background There was considerable debate regarding the effect of mean blood glucose (MBG) and glycemic variability (GV) on the mortality of septic patients. This retrospective cohort study aimed to assess the association between MBG and GV with ICU mortality of sepsis patients and to explore the optimal MBG range. Methods Sepsis patients were enrolled from the Medical Information Mart for Intensive Care IV database (MIMIC-IV). MBG and glycemic coefficient of variation (GluCV) were, respectively, calculated to represent the overall glycemic status and GV during ICU stay. The associations between MBG, GluCV, and ICU mortality of the septic patients were assessed by using multivariate logistic regression in different subgroups and the severity of sepsis. Restricted cubic splines evaluated the optimal MBG target. Results A total of 7,104 adult sepsis patients were included. The multivariate logistic regression results showed that increased MBG and GluCV were significantly correlated with ICU mortality. The adjusted odds ratios were 1.14 (95% CI 1.09–1.20) and 1.05 (95% CI 1.00–1.12). However, there was no association between hyperglycemia and ICU mortality among diabetes, liver disease, immunosuppression, and hypoglycemia patients. And the impact of high GluCV on ICU mortality was not observed in those with diabetes, immunosuppression, liver disease, and non-septic shock. The ICU mortality risk of severe hyperglycemia (≧200 mg/dl) and high GluCV (>31.429%), respectively, elevated 2.30, 3.15, 3.06, and 2.37, 2.79, 3.14-folds in mild (SOFA ≦ 3), middle (SOFA 3–7), and severe group (SOFA ≧ 7). The MBG level was associated with the lowest risk of ICU mortality and hypoglycemia between 120 and 140 mg/dl in the subgroup without diabetes. For the diabetic subset, the incidence of hypoglycemia was significantly reduced when the MBG was 140–190 mg/dl, but a glycemic control target effectively reducing ICU mortality was not observed. Conclusion MBG and GluCV during the ICU stay were associated with all-cause ICU mortality in sepsis patients; however, their harms are not apparent in some particular subgroups. The impact of hyperglycemia and high GV on death increased with the severity of sepsis. The risk of ICU mortality and hypoglycemia in those with no pre-existing diabetes was lower when maintaining the MBG in the range of 120–140 mg/dl.
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Affiliation(s)
- Zongqing Lu
- The Second Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Gan Tao
- The Second Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiaoyu Sun
- The Second Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yijun Zhang
- The Second Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Mengke Jiang
- The Second Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yu Liu
- Key Laboratory of Intelligent Computing and Signal Processing, Anhui University, Ministry of Education, Hefei, China
| | - Meng Ling
- The Second Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Jin Zhang
- The Second Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wenyan Xiao
- The Second Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Tianfeng Hua
- The Second Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Huaqing Zhu
- Laboratory of Molecular Biology and Department of Biochemistry, Anhui Medical University, Hefei, China
- Huaqing Zhu
| | - Min Yang
- The Second Department of Intensive Care Unit, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- The Laboratory of Cardiopulmonary Resuscitation and Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, China
- *Correspondence: Min Yang
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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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Wei X, Min Y, Yu J, Wang Q, Wang H, Li S, Su L. Admission Blood Glucose Is Associated With the 30-Days Mortality in Septic Patients: A Retrospective Cohort Study. Front Med (Lausanne) 2021; 8:757061. [PMID: 34778320 PMCID: PMC8581133 DOI: 10.3389/fmed.2021.757061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/27/2021] [Indexed: 12/05/2022] Open
Abstract
Background: Sepsis, as one of the severe diseases, is frequently observed in critically ill patients, especially concurrent with diabetes. Whether admission blood glucose is associated with the prognosis, and outcome of septic patients is still debatable. Methods: We retrospectively reviewed and analyzed the demographic characteristics of septic patients in the Medical Information Mart for Intensive Care III (MIMIC III, version 1.4) between June 2001 and October 2012. The Chi-square and Fisher's exact tests were used for the comparison of qualitative variables among septic patients with different glucose levels and the 30-day mortality in septic patients with diabetes or not. Univariate and stepwise multivariate Cox regression analyses were used to determine the risk factors for 30-day mortality. Kaplan-Meier analysis was conducted to reveal the different 30-day survival probabilities in each subgroup. Results: A total of 2,948 septic patients (910 cases with diabetes, 2,038 cases without diabetes) were ultimately included in the study. The 30-day mortality was 32.4% (956/2,948 cases) in the overall population without any difference among diabetic and non-diabetic septic patients (p = 1.000). Admission blood glucose levels <70 mg/dl were only observed to be significantly associated with the 30-day mortality of septic patients without diabetes (hazard ratio (HR) = 2.48, p < 0.001). After adjusting for confounders, age >65 years (HR = 1.53, p = 0.001), the Sequential Organ Failure Assessment (SOFA) score >5 (HR = 2.26, p < 0.001), lactic acid >2 mmol/L (Lac, HR = 1.35, p = 0.024), and platelet abnormality (<100 k/ul: HR = 1.49; >300 k/ul: HR = 1.36, p < 0.001) were the independent risk factors for 30-day mortality in septic patients with diabetes. In non-diabetes population, age >65 years (HR = 1.53, p < 0.001), non-White or non-Black patients (HR = 1.30, p = 0.004), SOFA score >5 (HR = 1.56, p < 0.001), blood glucose <70 mg/dl (HR = 1.91, p = 0.003), anion gap (AG) >2 mmol/L (HR = 1.60, p < 0.001), Lac (HR = 1.61, p < 0.001), urea nitrogen >21 mg/dl (HR = 1.45, p = 0.001), alanine aminotransferase (ALT, HR = 1.31, p = 0.009), total bilirubin >1.2 mg/dl (HR = 1.20, p = 0.033), and low hemoglobin (HR = 1.34, p = 0.001) were the independent risk factors for 30-day mortality. Conclusions: Our results indicate admission blood glucose, especially in terms of <70 mg/dl, is the key signaling in predicting the worse 30-day survival probability of septic patients without diabetes, which could help clinicians to make a more suitable and precise treatment modality in dealing with septic patients.
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Affiliation(s)
- Xiaoyuan Wei
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Yu Min
- Department of Breast and Thyroid Surgery, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Jiangchuan Yu
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Qianli Wang
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Han Wang
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Shuang Li
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
| | - Li Su
- Department of Cardiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
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Zohar Y, Zilberman Itskovich S, Koren S, Zaidenstein R, Marchaim D, Koren R. The association of diabetes and hyperglycemia with sepsis outcomes: a population-based cohort analysis. Intern Emerg Med 2021; 16:719-728. [PMID: 32964373 DOI: 10.1007/s11739-020-02507-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 09/12/2020] [Indexed: 01/10/2023]
Abstract
The independent association of diabetes and hyperglycemia on the outcomes of sepsis remains unclear. We conducted retrospective cohort analyses of outcomes among patients with community-onset sepsis admitted to Shamir Medical Center, Israel (08-12/2016). Statistical associations were queried by Cox and logistic regressions, controlled for by matched propensity score analyses. Among 1527 patients with community-onset sepsis, 469 (30.7%) were diabetic. Diabetic patients were significantly older, with advanced complexity of comorbidities, and were more often exposed to healthcare environments. Despite statistically significant univariable associations with in-hospital and 90-day mortality, the adjusted Hazard Ratios (aHR) were 1.21 95% CI 0.8-1.71, p = 0.29 and 1.13 95% CI 0.86-1.49, p = 0.37, respectively. However, hyperglycemia at admission (i.e., above 200 mg/dl (was independently associated with: increased in-hospital mortality, aHR 1.48 95% CI 1.02-2.16, p = 0.037, 30-day mortality, aHR 1.8 95% CI 1.12-2.58, p = 0.001), and 90-day mortality, aHR 1.68 95% CI 1.24-2.27, p = 0.001. This association was more robust among diabetic patients than those without diabetes. In this study, diabetes was not associated with worse clinical outcomes in community-onset sepsis. However, high glucose levels at sepsis onset are independently associated with a worse prognosis, particularly among diabetic patients. Future trials should explore whether glycemic control could impact the outcomes and should be part of the management of sepsis, among the general adult septic population.
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Affiliation(s)
- Yarden Zohar
- Department of Internal Medicine A, Shamir (Assaf Harofeh) Medical Center, 7030000, Zerifin, Israel
| | | | - Shlomit Koren
- Diabetes Unit, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ronit Zaidenstein
- Department of Internal Medicine A, Shamir (Assaf Harofeh) Medical Center, 7030000, Zerifin, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dror Marchaim
- Unit of Infection Control, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ronit Koren
- Department of Internal Medicine A, Shamir (Assaf Harofeh) Medical Center, 7030000, Zerifin, Israel.
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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Wu YF, Chen MY, Chen TH, Wang PC, Peng YS, Lin MS. The effect of pay-for-performance program on infection events and mortality rate in diabetic patients: a nationwide population-based cohort study. BMC Health Serv Res 2021; 21:78. [PMID: 33478477 PMCID: PMC7818736 DOI: 10.1186/s12913-021-06091-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 01/14/2021] [Indexed: 01/14/2023] Open
Abstract
Background Diabetes mellitus is a known risk factor for infection. Pay for Performance (P4P) program is designed to enhance the comprehensive patient care. The aim of this study is to evaluate the effect of the P4P program on infection incidence in type 2 diabetic patients. Methods This is a retrospective longitudinal cohort study using data from the National Health Insurance Research Database in Taiwan. Diabetic patients between 1 January 2002 and 31 December 2013 were included. Primary outcomes analyzed were patient emergency room (ER) infection events and deaths. Results After propensity score matching, there were 337,184 patients in both the P4P and non-P4P cohort. The results showed that patients’ completing one-year P4P program was associated with a decreased risk of any ER infection event (27.2% vs. 29%; subdistribution hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.86–0.88). While the number needed to treat was 58 for the non-P4P group, it dropped to 28 in the P4P group. The risk of infection-related death was significantly lower in the P4P group than in the non-P4P group (4.1% vs. 7.6%; HR 0.46, 95% CI 0.45–0.47). The effect of P4P on ER infection incidence and infection-related death was more apparent in the subgroups of patients who were female, had diabetes duration ≥5 years, chronic kidney disease, higher Charlson’s Comorbidity Index scores and infection-related hospitalization in the previous 3 years. Conclusions The P4P program might reduce risk of ER infection events and infection-related deaths in type 2 diabetic patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06091-2.
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Affiliation(s)
- Yi-Fang Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Mei-Yen Chen
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi, Taiwan.,Department of Nursing, Chang Gung University, Taoyuan, Taiwan
| | - Tien-Hsing Chen
- Department of Cardiology, Chang Gung Memorial Hospital, Keelung, Taiwan.,Biostatistical Consultation Center of Chang Gung Memorial Hospital, Keelung, Taiwan Community Medicine Research Center of Chang Gung Memorial Hospital, Keelung, Taiwan.,Chang Gung University, Taoyuan, Taiwan
| | - Po-Chang Wang
- Department of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yun-Shing Peng
- Department of Endocrinology and Metabolism, Department of internal medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Ming-Shyan Lin
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi, Taiwan. .,Department of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan. .,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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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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The Association of Premorbid Metformin Exposure With Mortality and Organ Dysfunction in Sepsis: A Systematic Review and Meta-Analysis. Crit Care Explor 2020; 1:e0009. [PMID: 32166255 PMCID: PMC7063877 DOI: 10.1097/cce.0000000000000009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Supplemental Digital Content is available in the text. To examine the association between premorbid metformin exposure and mortality, hyperlactatemia, and organ dysfunction in sepsis.
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Abe T, Suzuki T, Kushimoto S, Fujishima S, Sugiyama T, Iwagami M, Ogura H, Shiraishi A, Saitoh D, Mayumi T, Iriyama H, Komori A, Nakada TA, Shiino Y, Tarui T, Hifumi T, Otomo Y, Okamoto K, Umemura Y, Kotani J, Sakamoto Y, Sasaki J, Shiraishi SI, Tsuruta R, Hagiwara A, Yamakawa K, Takuma K, Masuno T, Takeyama N, Yamashita N, Ikeda H, Ueyama M, Gando S. History of diabetes may delay antibiotic administration in patients with severe sepsis presenting to emergency departments. Medicine (Baltimore) 2020; 99:e19446. [PMID: 32176076 PMCID: PMC7220469 DOI: 10.1097/md.0000000000019446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Clinical manifestations of sepsis differ between patients with and without diabetes mellitus (DM), and these differences could influence the clinical behaviors of medical staff. Therefore, we aimed to investigate whether pre-existing DM was associated with the time to antibiotics or sepsis care protocols.This was a retrospective cohort study.It conducted at 53 intensive care units (ICUs) in Japan.Consecutive adult patients with severe sepsis admitted directly to ICUs form emergency departments from January 2016 to March 2017 were included.The primary outcome was time to antibiotics.Of the 619 eligible patients, 142 had DM and 477 did not have DM. The median times (interquartile ranges) to antibiotics in patients with and without DM were 103 minutes (60-180 minutes) and 86 minutes (45-155 minutes), respectively (P = .05). There were no significant differences in the rates of compliance with sepsis protocols or with patient-centred outcomes such as in-hospital mortality. The mortality rates of patients with and without DM were 23.9% and 21.6%, respectively (P = .55). Comparing patients with and without DM, the gamma generalized linear model-adjusted relative difference indicated that patients with DM had a delay to starting antibiotics of 26.5% (95% confidence intervals (95%CI): 4.6-52.8, P = .02). The gamma generalized linear model-adjusted relative difference with multiple imputation for missing data of sequential organ failure assessment was 19.9% (95%CI: 1.0-42.3, P = .04). The linear regression model-adjusted beta coefficient indicated that patients with DM had a delay to starting antibiotics of 29.2 minutes (95%CI: 6.8-51.7, P = .01). Logistic regression modelling showed that pre-existing DM was not associated with in-hospital mortality (odds ratio, 1.26; 95%CI: 0.72-2.19, P = .42).Pre-existing DM was associated with delayed antibiotic administration among patients with severe sepsis or septic shock; however, patient-centred outcomes and compliance with sepsis care protocols were comparable.
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Affiliation(s)
- Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo
- Health Services Research and Development Center, University of Tsukuba, Tsukuba
| | - Tomoharu Suzuki
- Department of General Medicine, Urasoe General Hospital, Urasoe
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, Sendai
| | - Seitaro Fujishima
- Center for General Medicine Education, Keio University School of Medicine
| | - Takehiro Sugiyama
- Health Services Research and Development Center, University of Tsukuba, Tsukuba
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo
| | - Masao Iwagami
- Health Services Research and Development Center, University of Tsukuba, Tsukuba
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka
| | | | - Daizoh Saitoh
- Division of Traumatology, Research Institute, National Defense Medical College, Tokorozawa
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Kitakyushu
| | - Hiroki Iriyama
- Department of General Medicine, Juntendo University, Tokyo
| | - Akira Komori
- Department of General Medicine, Juntendo University, Tokyo
| | - Taka-aki Nakada
- Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba
| | - Yasukazu Shiino
- Department of Acute Medicine, Kawasaki Medical School, Kurashiki, Japan
| | - Takehiko Tarui
- Department of Trauma and Critical Care Medicine, Kyorin University School of Medicine
| | - Toru Hifumi
- Department of Emergency and Critical Care Medicine, St. Luke's International Hospital
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Center, Medical Hospital, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kohji Okamoto
- Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Kitakyushu
| | - Yutaka Umemura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Kobe
| | - Yuichiro Sakamoto
- Emergency and Critical Care Medicine, Saga University Hospital, Saga
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo
| | - Shin-ichiro Shiraishi
- Department of Emergency and Critical Care Medicine, Aizu Chuo Hospital, Aizuwakamatsu
| | - Ryosuke Tsuruta
- Advanced Medical Emergency & Critical Care Center, Yamaguchi University Hospital, Ube
| | | | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka
| | - Kiyotsugu Takuma
- Emergency & Critical Care Center, Kawasaki Municipal Kawasaki Hospital, Kawasaki
| | - Tomohiko Masuno
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo
| | - Naoshi Takeyama
- Advanced Critical Care Center, Aichi Medical University Hospital, Nagakute
| | - Norio Yamashita
- Advanced Emergency Medical Service Center, Kurume University Hospital, Kurume
| | - Hiroto Ikeda
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo
| | - Masashi Ueyama
- Department of Trauma, Critical Care Medicine, and Burn Center Community Healthcare Organization, Chukyo Hospital, Nagoya
| | - Satoshi Gando
- Division of Acute and Critical Care Medicine, Hokkaido University Graduate School of Medicine
- Department of Acute and Critical Care Medicine, Sapporo Higashi Tokushukai Hospital, Sapporo, Japan
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Wang W, Chen W, Liu Y, Li L, Li S, Tan J, Sun X. Blood Glucose Levels and Mortality in Patients With Sepsis: Dose-Response Analysis of Observational Studies. J Intensive Care Med 2019; 36:182-190. [PMID: 31746263 DOI: 10.1177/0885066619889322] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND We undertook a systematic review and meta-analysis to investigate the relationship between blood glucose levels and mortality in patients with sepsis. METHODS Medline and EMBASE were searched from inception to April 8, 2018. Cohort studies or case-control studies reported the association between blood glucose and mortality in patients with sepsis were selected. Study characteristics, baseline characteristics, definition of hyperglycemia, and outcomes of interest were extracted. We performed a dose-response meta-analysis to assess the effect of blood glucose level on mortality. We also conducted meta-analysis for patients with or without diabetes separately. RESULTS Ten cohort studies involving 26 429 patients were included, of which 5 were prospective studies and 5 retrospective studies. Dose-response analysis showed that the effect of blood glucose on mortality may differ in patients with versus without diabetes. There was a U-shaped relationship for patients with diabetes and a J-shaped relationship for patients without diabetes, with blood glucose at 145 to 155 mg/dL corresponding to lowest mortality both in patients with and without diabetes. CONCLUSIONS Current evidence suggested U-shaped relationship between blood glucose and mortality in all patients irrespective of their diabetes status. Diabetic patients with blood glucose below 145 mg/dL may have poorer prognosis compared to patients without established diabetes.
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Affiliation(s)
- Wen Wang
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Wenwen Chen
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Yanmei Liu
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Ling Li
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Jing Tan
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Xin Sun
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
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Furukawa M, Kinoshita K, Yamaguchi J, Hori S, Sakurai A. Sepsis patients with complication of hypoglycemia and hypoalbuminemia are an early and easy identification of high mortality risk. Intern Emerg Med 2019; 14:539-548. [PMID: 30729384 PMCID: PMC6536472 DOI: 10.1007/s11739-019-02034-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 01/14/2019] [Indexed: 12/21/2022]
Abstract
Either hypoglycemia or hypoalbuminemia alone is an independent condition associated with increased risk of mortality in critical illness. This study evaluates whether the mortality risk increases in septic patients if these conditions are combined. Patients admitted to our hospital from 2008 to 2015 who satisfied the definition of sepsis were targeted (n = 336). We classified cases into three groups based on blood glucose (BG) level measured at admission: hypoglycemia (Hypo-G; BG < 80 mg/dl), intermediate glycemia (Inter-G; 80-199 mg/dl), and hyperglycemia (Hyper-G; ≥ 200 mg/dl) group, and then estimated mortality. We also compared the clinical data of these glycemic groups in combination with hypoalbuminemia (Hypo-A) or Inter-G with non-hypoalbuminemia (Inter-G + Nonhypo-A), as a secondary analysis. Diagnostic cut-off level of Hypo-A (< 2.8 mg/dl) was determined using the ROC curve between blood albumin and mortality. In Hypo-G group (n = 40), APACHE II/SOFA scores are significantly higher than in the Inter-G (n = 196) and Hyper-G groups (n = 100). Mortality is 52.5% in the Hypo-G and 60.0% in the Hypo-G with Hypo-A (Hypo-G + Hypo-A) groups. Significantly higher APACHE II or SOFA scores and mortality are observed in the Hypo-G + Hypo-A group compared to the Inter-G + Nonhypo-A group. A higher mortality risk is observed in cases with Hypo-G + Hypo-A (OR 5.065) than those with Hypo-G (OR 3.503), Inter-G (OR 1.175), Hyper-G (OR 1.756) or Hypo-A (OR 3.243), calculated by a single logistic-regression analysis. Hypo-G + Hypo-A in patients with sepsis is related to higher ICU mortality. Physicians should be keenly aware of these conditions to provide immediate intensive treatment after admission of septic patients.
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Affiliation(s)
- Makoto Furukawa
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610 Japan
| | - Kosaku Kinoshita
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610 Japan
| | - Junko Yamaguchi
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610 Japan
| | - Satoshi Hori
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610 Japan
| | - Atsushi Sakurai
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, 30-1, Oyaguchi Kami-cho, Itabashi-ku, Tokyo, 173-8610 Japan
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Siddiqi L, VanAarsen K, Iansavichene A, Yan J. Risk Factors for Adverse Outcomes in Adult and Pediatric Patients With Hyperglycemia Presenting to the Emergency Department: A Systematic Review. Can J Diabetes 2019; 43:361-369.e2. [PMID: 30846250 DOI: 10.1016/j.jcjd.2018.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 11/05/2018] [Accepted: 11/06/2018] [Indexed: 12/29/2022]
Abstract
Hyperglycemia is a significant cause of morbidity and mortality, often resulting in adverse outcomes. This review aimed to identify predictors of adverse outcomes, such as repeated hospital visits, hospitalization or death, in patients presenting to the emergency department (ED) with hyperglycemia. Electronic searches of Medline and EMBASE were conducted for studies in English of patients presenting to the ED with hyperglycemia. Both adult and pediatric populations were included, with and without diabetes. Two reviewers independently screened all titles and abstracts for relevance. If consensus was not reached, full-length manuscripts were reviewed. For discrepancies, a third reviewer was consulted. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Study- and patient-specific data were extracted and presented descriptively. Eight observational studies were reviewed; they included a total of 96,970 patients. Predictors of adverse outcomes included age, lowest income quintile, urban dwellers, presence of comorbidities, coexisting hyperlactatemia, having a family physician, elevated serum creatinine level, diabetes managed with insulin, sentinel visit for hyperglycemia in the past month, and high blood glucose level measured in the ED. Conflicting evidence was found for whether known history of diabetes was associated with risk. Factors associated with favourable outcomes included systolic blood pressure of 90 to 150 mmHg and tachycardia. This systematic review found 12 factors associated with adverse outcomes, and 2 factors associated with more favourable outcomes in patients presenting to the ED with hyperglycemia. These factors should be considered for easier identification of patients at higher risk for adverse outcomes to guide management and follow up.
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Affiliation(s)
- Lubna Siddiqi
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
| | - Kristine VanAarsen
- London Health Sciences Centre, Division of Emergency Medicine, London, Ontario, Canada
| | | | - Justin Yan
- Western University, London, Ontario, Canada; London Health Sciences Centre, London, Ontario, Canada; St. Joseph's Healthcare London, London, Ontario, Canada
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Hsieh MS, Hu SY, How CK, Seak CJ, Hsieh VCR, Lin JW, Chen PC. Hospital outcomes and cumulative burden from complications in type 2 diabetic sepsis patients: a cohort study using administrative and hospital-based databases. Ther Adv Endocrinol Metab 2019; 10:2042018819875406. [PMID: 31598211 PMCID: PMC6763626 DOI: 10.1177/2042018819875406] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 08/13/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The association between type 2 diabetes and hospital outcomes of sepsis remains controversial when severity of diabetes is not taken into consideration. We examined this association using nationwide and hospital-based databases. METHODS The first part of this study was mainly conducted using a nationwide database, which included 1.6 million type 2 diabetic patients. The diabetic complication burden was evaluated using the adapted Diabetes Complications Severity Index score (aDCSI score). In the second part, we used laboratory data from a distinct hospital-based database to make comparisons using regression analyses. RESULTS The nationwide study included 19,719 type 2 diabetic sepsis patients and an equal number of nondiabetic sepsis patients. The diabetic sepsis patients had an increased odds ratio (OR) of 1.14 (95% confidence interval 1.1-1.19) for hospital mortality. The OR for mortality increased as the complication burden increased [aDCSI scores of 0, 1, 2, 3, 4, and ⩾5 with ORs of 0.91, 0.87, 1.14, 1.25, 1.56, and 1.77 for mortality, respectively (all p < 0.001)].The hospital-based database included 1054 diabetic sepsis patients. Initial blood glucose levels did not differ significantly between the surviving and deceased diabetic sepsis patients: 273.9 ± 180.3 versus 266.1 ± 200.2 mg/dl (p = 0.095). Moreover, the surviving diabetic sepsis patients did not have lower glycated hemoglobin (HbA1c; %) values than the deceased patients: 8.4 ± 2.6 versus 8.0 ± 2.5 (p = 0.078). CONCLUSIONS For type 2 diabetic sepsis patients, the diabetes-related complication burden was the major determinant of hospital mortality rather than diabetes per se, HbA1c level, or initial blood glucose level.
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Affiliation(s)
- Ming-Shun Hsieh
- Institute of Occupational Medicine and
Industrial Hygiene, National University College of Public Health,
Taipei
- Department of Emergency Medicine, Taipei
Veterans General Hospital, Taoyuan Branch, Taoyuan
- Department of Emergency Medicine, Taipei
Veterans General Hospital, Taipei
- School of Medicine, National Yang-Ming
University, Taipei
| | - Sung-Yuan Hu
- Department of Emergency Medicine, Taichung
Veterans General Hospital, Taichung
| | - Chorng-Kuang How
- Department of Emergency Medicine, Taipei
Veterans General Hospital, Taipei
- School of Medicine, National Yang-Ming
University, Taipei
| | - Chen-June Seak
- Department of Emergency Medicine, Lin-Kou
Medical Center, Chang Gung Memorial Hospital, Taoyuan
| | | | - Jin-Wei Lin
- Department of Emergency Medicine, Taipei
Veterans General Hospital, Taoyuan Branch, Taoyuan
- Department of Emergency Medicine, Taipei
Veterans General Hospital, Taipei
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18
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Perl SH, Bloch O, Zelnic-Yuval D, Love I, Mendel-Cohen L, Flor H, Rapoport MJ. Sepsis-induced activation of endogenous GLP-1 system is enhanced in type 2 diabetes. Diabetes Metab Res Rev 2018; 34:e2982. [PMID: 29334697 DOI: 10.1002/dmrr.2982] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 12/03/2017] [Accepted: 12/27/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND High levels of circulating GLP-1 are associated with severity of sepsis in critically ill nondiabetic patients. Whether patients with type 2 diabetes (T2D) display different activation of the endogenous GLP-1 system during sepsis and whether it is affected by diabetes-related metabolic parameters are not known. METHODS Serum levels of GLP-1 (total and active forms) and its inhibitor enzyme sDPP-4 were determined by ELISA on admission and after 2 to 4 days in 37 sepsis patients with (n = 13) and without T2D (n = 24) and compared to normal healthy controls (n = 25). Correlations between GLP-1 system activation and clinical, inflammatory, and diabetes-related metabolic parameters were performed. RESULTS A 5-fold (P < .001) and 2-fold (P < .05) increase in active and total GLP-1 levels, respectively, were found on admission as compared to controls. At 2 to 4 days from admission, the level of active GLP-1 forms in surviving patients were decreased significantly (P < .005), and positively correlated with inflammatory marker CRP (r = 0.33, P = .05). T2D survivors displayed a similar but more enhanced pattern of GLP-1 response than nondiabetic survivors. Nonsurvivors demonstrate an early extreme increase of both total and active GLP-1 forms, 9.5-fold and 5-fold, respectively (P < .05). The initial and late levels of circulating GLP-1 inhibitory enzyme sDPP-4 were twice lower in all studied groups (P < .001), compared with healthy controls. CONCLUSIONS Taken together, these data indicate that endogenous GLP-1 system is activated during sepsis. Patients with T2D display an enhanced and prolonged activation as compared to nondiabetic patients. Extreme early increased GLP-1 levels during sepsis indicate poor prognosis.
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Affiliation(s)
- Sivan H Perl
- Department 'C' of Internal Medicine, Assaf Harofeh Medical Center Affiliated to Sackler Medical School Tel Aviv University, Zerifin, Israel
| | - Olga Bloch
- Diabetes Research Laboratory, Assaf Harofeh Medical Center Affiliated to Sackler Medical School Tel Aviv University, Zerifin, Israel
| | - Dana Zelnic-Yuval
- Department 'C' of Internal Medicine, Assaf Harofeh Medical Center Affiliated to Sackler Medical School Tel Aviv University, Zerifin, Israel
| | - Itamar Love
- Department 'C' of Internal Medicine, Assaf Harofeh Medical Center Affiliated to Sackler Medical School Tel Aviv University, Zerifin, Israel
| | - Lior Mendel-Cohen
- Department 'C' of Internal Medicine, Assaf Harofeh Medical Center Affiliated to Sackler Medical School Tel Aviv University, Zerifin, Israel
| | - Hadar Flor
- Department 'C' of Internal Medicine, Assaf Harofeh Medical Center Affiliated to Sackler Medical School Tel Aviv University, Zerifin, Israel
| | - Micha J Rapoport
- Department 'C' of Internal Medicine, Assaf Harofeh Medical Center Affiliated to Sackler Medical School Tel Aviv University, Zerifin, Israel
- Diabetes Research Laboratory, Assaf Harofeh Medical Center Affiliated to Sackler Medical School Tel Aviv University, Zerifin, Israel
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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: 33] [Impact Index Per Article: 4.7] [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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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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23
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van Vught LA, Scicluna BP, Hoogendijk AJ, Wiewel MA, Klein Klouwenberg PMC, Cremer OL, Horn J, Nürnberg P, Bonten MMJ, Schultz MJ, van der Poll T. Association of diabetes and diabetes treatment with the host response in critically ill sepsis patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:252. [PMID: 27495247 PMCID: PMC4975896 DOI: 10.1186/s13054-016-1429-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 07/20/2016] [Indexed: 01/04/2023]
Abstract
Background Diabetes is associated with chronic inflammation and activation of the vascular endothelium and the coagulation system, which in a more acute manner are also observed in sepsis. Insulin and metformin exert immune modulatory effects. In this study, we aimed to determine the association of diabetes and preadmission insulin and metformin use with sepsis outcome and host response. Methods We evaluated 1104 patients with sepsis, admitted to the intensive care unit and stratified according to the presence or absence of diabetes mellitus. The host response was examined by a targeted approach (by measuring 15 plasma biomarkers reflective of pathways implicated in sepsis pathogenesis) and an unbiased approach (by analyzing whole genome expression profiles in blood leukocytes). Results Diabetes mellitus was not associated with differences in sepsis presentation or mortality up to 90 days after admission. Plasma biomarker measurements revealed signs of systemic inflammation, and strong endothelial and coagulation activation in patients with sepsis, none of which were altered in those with diabetes. Patients with and without diabetes mellitus, who had sepsis demonstrated similar transcriptional alterations, comprising 74 % of the expressed gene content and involving over-expression of genes associated with pro-inflammatory, anti-inflammatory, Toll-like receptor and metabolic signaling pathways and under-expression of genes associated with T cell signaling pathways. Amongst patients with diabetes mellitus and sepsis, preadmission treatment with insulin or metformin was not associated with an altered sepsis outcome or host response. Conclusions Neither diabetes mellitus nor preadmission insulin or metformin use are associated with altered disease presentation, outcome or host response in patients with sepsis requiring intensive care. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1429-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lonneke A van Vught
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Room G2-130, 1105, AZ, Amsterdam, The Netherlands. .,the Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
| | - Brendon P Scicluna
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Room G2-130, 1105, AZ, Amsterdam, The Netherlands.,the Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Arie J Hoogendijk
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Room G2-130, 1105, AZ, Amsterdam, The Netherlands.,the Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Maryse A Wiewel
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Room G2-130, 1105, AZ, Amsterdam, The Netherlands.,the Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter M C Klein Klouwenberg
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olaf L Cremer
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter Nürnberg
- Cologne Center for Genomics (CCG), University of Cologne, Cologne, Germany.,Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), University of Cologne, Cologne, Germany.,Center for Molecular Medicine Cologne (CMMC), University of Cologne, Cologne, Germany
| | - Marc M J Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Tom van der Poll
- Center for Experimental and Molecular Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, Room G2-130, 1105, AZ, Amsterdam, The Netherlands.,the Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Jia Y, Zhao Y, Li C, Shao R. The Expression of Programmed Death-1 on CD4+ and CD8+ T Lymphocytes in Patients with Type 2 Diabetes and Severe Sepsis. PLoS One 2016; 11:e0159383. [PMID: 27459386 PMCID: PMC4961422 DOI: 10.1371/journal.pone.0159383] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 07/03/2016] [Indexed: 12/25/2022] Open
Abstract
Objective To investigate the expression of Programmed death-1 (PD-1) on T lymphocytes in patients with type 2 diabetes mellitus (T2DM) and severe sepsis, we determined PD-1 expression on CD4+ and CD8+ T lymphocytes of patients with T2DM, severe sepsis, and T2DM combined with severe sepsis. Research Design and Methods This prospective and observational study included 50 healthy controls, 80 cases of T2DM without infection (T2DM group), 88 cases of severe sepsis without T2DM (SS group), and 77 cases of severe sepsis combined with T2DM (SS+T2DM group). Expression of peripheral blood PD-1+ CD4+ T cells and PD-1+ CD8+ T cells were compared between these 4 groups. Then, 28-day survival of the SS and SS+T2DM patients was assessed, and the expression of PD-1 on T cells was also compared between survivors and non-survivors. Results Percentages of PD-1+ CD4+ T cells and PD-1+ CD8+ T cells were higher in the T2DM group than in the healthy control group, and were highest in the SS and SS+T2DM groups. However, the expression of PD-1 on T cells and the mortality showed no significant difference between the SS and SS+T2DM groups. The expression of PD-1 on T cells was higher in non-survivors than survivors, but within the survivor group or non-survivor group, no difference can be detected between those with T2DM and those without T2DM. Conclusion The expression of PD-1 on T cells was increased in both T2DM and severe septic patients, but combining T2DM did not cause a further increase on the PD-1 expression in patients with severe sepsis.
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Affiliation(s)
- Yumei Jia
- Department of Endocrinology, Beijing Chaoyang Hospital Affiliated to Capital Medical University, Beijing, China
| | - Yongzhen Zhao
- Department of Emergency Medicine, Beijing Chaoyang Hospital Affiliated to Capital Medical University, Beijing, China
| | - Chunsheng Li
- Department of Emergency Medicine, Beijing Chaoyang Hospital Affiliated to Capital Medical University, Beijing, China
- * E-mail:
| | - Rui Shao
- Department of Emergency Medicine, Beijing Chaoyang Hospital Affiliated to Capital Medical University, Beijing, China
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26
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Neuberger A, Shofty B, Bishop B, Naffaa M, Binawi T, Babich T, Rappaport Z, Zaaroor M, Sviri G, Yahav D, Paul M. Risk factors associated with death or neurological deterioration among patients with Gram-negative postneurosurgical meningitis. Clin Microbiol Infect 2016; 22:573.e1-4. [DOI: 10.1016/j.cmi.2016.03.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 03/21/2016] [Accepted: 03/22/2016] [Indexed: 10/22/2022]
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27
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Drumheller BC, Agarwal A, Mikkelsen ME, Sante SC, Weber AL, Goyal M, Gaieski DF. Risk factors for mortality despite early protocolized resuscitation for severe sepsis and septic shock in the emergency department. J Crit Care 2015; 31:13-20. [PMID: 26611382 DOI: 10.1016/j.jcrc.2015.10.015] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2015] [Revised: 10/03/2015] [Accepted: 10/17/2015] [Indexed: 01/28/2023]
Abstract
PURPOSE The purpose was to identify risk factors associated with in-hospital mortality among emergency department (ED) patients with severe sepsis and septic shock managed with early protocolized resuscitation. METHODS This was a retrospective, observational cohort study in an academic, tertiary care ED. We enrolled 411 adult patients with severe sepsis and lactate ≥4.0 mmol/L (n = 203) or septic shock (n = 208) who received protocolized resuscitation from 2005 to 2009. Emergency department variables, microbial cultures, and in-hospital outcomes were obtained from the medical record. Multivariable regression was used to identify factors independently associated with in-hospital mortality. RESULTS Mean age was 59.5 ± 16.3 years; 57% were male. Mean lactate was 4.8 mmol/L (3.5-6.7), 54% had positive cultures, and 27% received vasopressors in the ED. One hundred and five (26%) patients died in-hospital. Age, active cancer, do-not-resuscitate status on ED arrival, lack of fever, hypoglycemia, and intubation were independently associated with increased in-hospital mortality. Lactate clearance and diabetes were associated with a decreased risk of in-hospital death. CONCLUSIONS We identified a number of factors that were associated with in-hospital mortality among ED patients with severe sepsis or septic shock despite treatment with early protocolized resuscitation. These findings provide insights into aspects of early sepsis care that can be targets for future intervention.
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Affiliation(s)
- Byron C Drumheller
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia PA, 19104.
| | - Anish Agarwal
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia PA, 19104.
| | - Mark E Mikkelsen
- Department of Medicine, Division of Pulmonary, Allergy and Critical Care, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia PA, 19104; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia PA, 19104.
| | - S Cham Sante
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia PA, 19104.
| | - Anita L Weber
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce St, Philadelphia PA, 19104.
| | - Munish Goyal
- Department of Emergency Medicine, Washington Hospital Center, Georgetown University School of Medicine, 110 Irving St NW, Washington DC, 20010.
| | - David F Gaieski
- Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, 111 S 11th St, Philadelphia PA, 19107.
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Abstract
Glycemic control targets in intensive care units (ICUs) have three distinct domains. Firstly, excessive hyperglycemia needs to be avoided. The upper limit of this varies depending on the patient population studied and diabetic status of the patients. Surgical patients particularly cardiac surgery patients tend to benefit from a lower upper limit of glycemic control, which is not evident in medically ill patient. Patient with premorbid diabetic status tends to tolerate higher blood sugar level better than normoglycemics. Secondly, hypoglycemia is clearly detrimental in all groups of critically ill patient and all measures to avoid this catastrophe need to be a part of any glycemic control protocol. Thirdly, glycemic variability has increasingly been shown to be detrimental in this patient population. Glycemic control protocols need to take this into consideration and target to reduce any of the available metrics of glycemic variability. Newer technologies including continuous glucose monitoring techniques will help in titrating all these three domains within a desirable range.
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Affiliation(s)
- Subhash Todi
- Director, Critical Care and Emergency Medicine, AMRI Hospitals, P4 & 5, CIT Scheme - LXXII, Block- A, Gariahat Road, Kolkatta, West Bengal, India
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Optimizing triage and hospitalization in adult general medical emergency patients: the triage project. BMC Emerg Med 2013; 13:12. [PMID: 23822525 PMCID: PMC3723418 DOI: 10.1186/1471-227x-13-12] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 06/26/2013] [Indexed: 02/07/2023] Open
Abstract
Background Patients presenting to the emergency department (ED) currently face inacceptable delays in initial treatment, and long, costly hospital stays due to suboptimal initial triage and site-of-care decisions. Accurate ED triage should focus not only on initial treatment priority, but also on prediction of medical risk and nursing needs to improve site-of-care decisions and to simplify early discharge management. Different triage scores have been proposed, such as the Manchester triage system (MTS). Yet, these scores focus only on treatment priority, have suboptimal performance and lack validation in the Swiss health care system. Because the MTS will be introduced into clinical routine at the Kantonsspital Aarau, we propose a large prospective cohort study to optimize initial patient triage. Specifically, the aim of this trial is to derive a three-part triage algorithm to better predict (a) treatment priority; (b) medical risk and thus need for in-hospital treatment; (c) post-acute care needs of patients at the most proximal time point of ED admission. Methods/design Prospective, observational, multicenter, multi-national cohort study. We will include all consecutive medical patients seeking ED care into this observational registry. There will be no exclusions except for non-adult and non-medical patients. Vital signs will be recorded and left over blood samples will be stored for later batch analysis of blood markers. Upon ED admission, the post-acute care discharge score (PACD) will be recorded. Attending ED physicians will adjudicate triage priority based on all available results at the time of ED discharge to the medical ward. Patients will be reassessed daily during the hospital course for medical stability and readiness for discharge from the nurses and if involved social workers perspective. To assess outcomes, data from electronic medical records will be used and all patients will be contacted 30 days after hospital admission to assess vital and functional status, re-hospitalization, satisfaction with care and quality of life measures. We aim to include between 5000 and 7000 patients over one year of recruitment to derive the three-part triage algorithm. The respective main endpoints were defined as (a) initial triage priority (high vs. low priority) adjudicated by the attending ED physician at ED discharge, (b) adverse 30 day outcome (death or intensive care unit admission) within 30 days following ED admission to assess patients risk and thus need for in-hospital treatment and (c) post acute care needs after hospital discharge, defined as transfer of patients to a post-acute care institution, for early recognition and planning of post-acute care needs. Other outcomes are time to first physician contact, time to initiation of adequate medical therapy, time to social worker involvement, length of hospital stay, reasons for discharge delays, patient’s satisfaction with care, overall hospital costs and patients care needs after returning home. Discussion Using a reliable initial triage system for estimating initial treatment priority, need for in-hospital treatment and post-acute care needs is an innovative and persuasive approach for a more targeted and efficient management of medical patients in the ED. The proposed interdisciplinary , multi-national project has unprecedented potential to improve initial triage decisions and optimize resource allocation to the sickest patients from admission to discharge. The algorithms derived in this study will be compared in a later randomized controlled trial against a usual care control group in terms of resource use, length of hospital stay, overall costs and patient’s outcomes in terms of mortality, re-hospitalization, quality of life and satisfaction with care. Trial registration ClinicalTrials.gov Identifier,
NCT01768494
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30
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A syndrome of severe hypoglycemia and acidosis in young immunosuppressed diabetic monkeys and pigs-association with sepsis. Transplantation 2013; 94:1187-91. [PMID: 23128998 DOI: 10.1097/tp.0b013e318272210c] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Large animals treated with immunosuppressive drugs for preclinical experiments of transplantation have increased risks of infection, which can be compounded by the induction of diabetes if islet transplantation is planned. METHODS We report our experience with severe sepsis in two young cynomolgus monkeys and five pigs that were subjected to diabetes induction, immunosuppressive therapy, or islet allotransplantation. RESULTS In two monkeys and five pigs, infection was associated with a syndrome of profound hypoglycemia accompanied by severe acidosis, which was resistant to treatment. We do not believe that this syndrome has been reported previously by others. CONCLUSIONS Despite treatment, this syndrome complicated the interpretation of blood glucose readings as a measure of islet graft function and resulted in death or the need for euthanasia in all seven animals. We tentatively suggest that the syndrome may be related to the presence of microorganisms that metabolize glucose and produce lactate.
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Green JP, Berger T, Garg N, Horeczko T, Suarez A, Radeos MS, Hagar Y, Panacek EA. Hyperlactatemia affects the association of hyperglycemia with mortality in nondiabetic adults with sepsis. Acad Emerg Med 2012; 19:1268-75. [PMID: 23167858 DOI: 10.1111/acem.12015] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 07/05/2012] [Accepted: 07/06/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND Admission hyperglycemia has been reported as a mortality risk factor for septic nondiabetic patients; however, hyperglycemia's known association with hyperlactatemia was not addressed in these analyses. OBJECTIVES The objective was to determine whether the association of hyperglycemia with mortality remains significant when adjusted for concurrent hyperlactatemia. METHODS This was a post hoc, nested analysis of a retrospective cohort study performed at a single center. Providers had identified study subjects during their emergency department (ED) encounters; all data were collected from the electronic medical record (EMR). Nondiabetic adult ED patients hospitalized for suspected infection, two or more systemic inflammatory response syndrome (SIRS) criteria, and simultaneous lactate and glucose testing in the ED were enrolled. The setting was the ED of an urban teaching hospital from 2007 to 2009. To evaluate the association of hyperglycemia (glucose > 200 mg/dL) with hyperlactatemia (lactate ≥ 4.0 mmol/L), a logistic regression model was created. The outcome was a diagnosis of hyperlactatemia, and the primary variable of interest was hyperglycemia. A second model was created to determine if coexisting hyperlactatemia affects hyperglycemia's association with mortality; the main outcome was 28-day mortality, and the primary risk variable was hyperglycemia with an interaction term for simultaneous hyperlactatemia. Both models were adjusted for demographics; comorbidities; presenting infectious source; and objective evidence of renal, respiratory, hematologic, or cardiovascular dysfunction. RESULTS A total of 1,236 ED patients were included, and the median age was 77 years (interquartile range [IQR] = 60 to 87 years). A total of 115 (9.3%) subjects were hyperglycemic, 162 (13%) were hyperlactatemic, and 214 (17%) died within 28 days of their initial ED visits. After adjustment, hyperglycemia was significantly associated with simultaneous hyperlactatemia (odds ratio [OR] = 4.14, 95% confidence interval [CI] = 2.65 to 6.45). Hyperglycemia and concurrent hyperlactatemia were associated with increased mortality risk (OR = 3.96, 95% CI = 2.01 to 7.79), but hyperglycemia in the absence of simultaneous hyperlactatemia was not (OR = 0.78, 95% CI = 0.39 to 1.57). CONCLUSIONS In this cohort of septic adult nondiabetic patients, mortality risk did not increase with hyperglycemia unless associated with simultaneous hyperlactatemia. The previously reported association of hyperglycemia with mortality in nondiabetic sepsis may be due to the association of hyperglycemia with hyperlactatemia.
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Affiliation(s)
- Jeffrey P. Green
- From the Department of Emergency Medicine; UC Davis Health System; UC Davis School of Medicine; Sacramento CA
| | - Tony Berger
- From the Department of Emergency Medicine; UC Davis Health System; UC Davis School of Medicine; Sacramento CA
| | - Nidhi Garg
- the Department of Emergency Medicine; New York Hospital Queens; Weill Cornell Medical College; Flushing NY
| | - Timothy Horeczko
- From the Department of Emergency Medicine; UC Davis Health System; UC Davis School of Medicine; Sacramento CA
| | - Alison Suarez
- the Department of Emergency Medicine; New York Hospital Queens; Weill Cornell Medical College; Flushing NY
| | - Michael S. Radeos
- the Department of Emergency Medicine; New York Hospital Queens; Weill Cornell Medical College; Flushing NY
| | - Yolanda Hagar
- the Department of Applied Mathematics; University of Colorado, Boulder; Boulder CO
| | - Edward A. Panacek
- From the Department of Emergency Medicine; UC Davis Health System; UC Davis School of Medicine; Sacramento CA
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Schuetz P, Kennedy M, Lucas JM, Howell MD, Aird WC, Yealy DM, Shapiro NI. Initial management of septic patients with hyperglycemia in the noncritical care inpatient setting. Am J Med 2012; 125:670-8. [PMID: 22608986 DOI: 10.1016/j.amjmed.2012.03.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Revised: 03/07/2012] [Accepted: 03/09/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous research on the management of hyperglycemia in patients with sepsis has focused primarily on those with established organ failure in the critical care setting. The impact of hyperglycemia and glycemic control in patients with infection before developing severe sepsis or shock remains undefined. METHODS This observational, prospective, cohort study investigated the relationship between initial 72-hour time-weighted mean glucose concentrations and in-hospital mortality, intensive care unit transfer, and hospital length of stay in a cohort of patients with an acute infection who were admitted from the emergency department to a non-intensive care unit hospital ward. We used multivariate regression models adjusted for age, diabetes, and disease severity. RESULTS A total of 1849 patients were included, of whom 29% had diabetes. In the 1310 nondiabetic patients, we observed hyperglycemia using time-weighted glucose concentrations: 121 to 150 mg/dL (n=204, 16%), 151 to 180 mg/dL (n=32, 2.4%), and greater than 180 mg/dL (n=21, 1.6%). Insulin treatment was infrequent in nondiabetic patients, with 9%, 13%, and 29% of nondiabetic patients in these ranges receiving insulin, respectively. As patient glucose values increased, in-hospital mortality increased in nondiabetic patients, with odds ratios (ORs) of 4.4 (95% confidence interval [CI], 1.8-11), 10.0 (95% CI, 2.5-40), and 9.3 (95% CI, 1.9-44.0). Conversely, hyperglycemia did not confer an increased risk of adverse outcomes in diabetic patients. Likewise, increased risk for unplanned intensive care unit admission from the floor demonstrated ORs of 2.2 (95% CI, 1.1-4.3), 2.0 (95% CI, 0.45-8.9), and 6.3 (95% CI, 1.9-20.6) in nondiabetic patients, whereas no increased risk was found in diabetic patients. CONCLUSIONS In this cohort of acutely infected patients without established severe sepsis or shock, higher glucose concentrations within the first 72 hours in the nondiabetic population were associated with worse hospital outcomes and were less likely to be treated with insulin compared with diabetic patients.
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Affiliation(s)
- Philipp Schuetz
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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Tayek CJ, Tayek JA. Diabetes patients and non-diabetic patients intensive care unit and hospital mortality risks associated with sepsis. World J Diabetes 2012; 3:29-34. [PMID: 22375163 PMCID: PMC3284518 DOI: 10.4239/wjd.v3.i2.29] [Citation(s) in RCA: 15] [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: 08/24/2011] [Revised: 01/06/2012] [Accepted: 02/08/2012] [Indexed: 02/05/2023] Open
Abstract
AIM: To compare mortality risks associated with known diabetic patients to hyperglycemic non-diabetic patients.
METHODS: PubMed data base was searched for patients with sepsis, bacteremia, mortality and diabetes. Articles that also identified new onset hyperglycemia (NOH) (fasting blood glucose > 125 mg/dL or random blood glucose > 199 mg/dL) were identified and reviewed. Nine studies were evaluated with regards to hyperglycemia and hospital mortality and five of the nine were summarized with regards to intensive care unit (ICU) mortality.
RESULTS: Historically hyperglycemia has been believed to be equally harmful in known diabetic patients and non-diabetics patients admitted to the hospital. Unexpectedly, having a history of diabetes when admitted to the hospital was associated with a reduced risk of hospital mortality. Approximately 17% of patients admitted to hospital have NOH and 24% have diabetes mellitus. Hospital mortality was significantly increased in all nine studies of patients with NOH as compared to known diabetic patients (26.7% ± 3.4% vs 12.5% ± 3.4%, P < 0.05; analysis of variance). Unadjusted ICU mortality was evaluated in five studies and was more than doubled for those patients with NOH as compared to known diabetic patients (25.3% ± 3.3% vs 12.8% ± 2.6%, P < 0.05) despite having similar blood glucose concentrations. Most importantly, having NOH was associated with an increased ICU and a 2.7-fold increase in hospital mortality when compared to hyperglycemic diabetic patients. The mortality benefit of being diabetic is unclear but may have to do with adaptation to hyperglycemia over time. Having a history of diabetes mellitus and prior episodes of hyperglycemia may provide time for the immune system to adapt to hyperglycemia and result in a reduced mortality risk. Understanding why diabetic patients have a lower than expected hospital mortality rate even with bacteremia or acute respiratory distress syndrome needs further study.
CONCLUSION: Having hyperglycemia without a history of previous diabetes mellitus is a major independent risk factor for ICU and hospital mortality.
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Affiliation(s)
- Chandler J Tayek
- Chandler J Tayek, Palos Verdes Pennisula High School, Rolling Hills Estates, CA 90274, United States
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Chang CW, Kok VC, Tseng TC, Horng JT, Liu CE. Diabetic patients with severe sepsis admitted to intensive care unit do not fare worse than non-diabetic patients: a nationwide population-based cohort study. PLoS One 2012; 7:e50729. [PMID: 23236389 PMCID: PMC3517561 DOI: 10.1371/journal.pone.0050729] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 10/24/2012] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND We sought to examine whether type 2 diabetes increases the risk of acute organ dysfunction and of hospital mortality following severe sepsis that requires admission to an intensive care unit (ICU). METHODS Nationwide population-based retrospective cohort study of 16,497 subjects with severe sepsis who had been admitted for the first time to an ICU during the period of 1998-2008. A diabetic cohort (n = 4573) and a non-diabetic cohort (n = 11924) were then created. Relative risk (RR) of organ dysfunctions, length of hospital stay (LOS), 90-days hospital mortality, ICU resource utilization and hazard ratio (HR) of mortality adjusted for age, gender, Charlson-Deyo comorbidity index score, surgical condition and number of acute organ dysfunction, were compared across patients with severe sepsis with or without diabetes. RESULTS Diabetic patients with sepsis had a higher risk of developing acute kidney injury (RR, 1.54; 95% confidence interval (CI), 1.44-1.63) and were more likely to be undergoing hemodialysis (15.55% vs. 7.24%) in the ICU. However, the diabetic cohort had a lower risk of developing acute respiratory dysfunction (RR = 0.96, 0.94-0.97), hematological dysfunction (RR = 0.70, 0.56-0.89), and hepatic dysfunction (RR = 0.77, 0.63-0.93). In terms of adjusted HR for 90-days hospital mortality, the diabetic patients with severe sepsis did not fare significantly worse when afflicted with cardiovascular, respiratory, hepatic, renal and/or neurologic organ dysfunction and by numbers of organ dysfunction. There was no statistically significant difference in LOS between the two cohorts (median 17 vs. 16 days, interquartile range (IQR) 8-30 days, p = 0.11). Multiple logistic regression analysis to predict the occurrence of mortality shows that being diabetic was not a predictive factor with an odds ratio of 0.972, 95% CI 0.890-1.061, p = 0.5203. INTERPRETATION This large nationwide population-based cohort study suggests that diabetic patients do not fare worse than non-diabetic patients when suffering from severe sepsis that requires ICU admission.
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Affiliation(s)
- Cheng-Wei Chang
- Department of Information Management, Hsing Wu University, New Taipei City, Taiwan
- Division of Medical Oncology, Department of Internal Medicine, Kuang Tien General Hospital, Taichung, Taiwan
| | - Victor C. Kok
- Public Health and Clinical Informatics Research Group, Department of Biomedical Informatics, Asia University Taiwan, Taichung, Taiwan
- Division of Medical Oncology, Department of Internal Medicine, Kuang Tien General Hospital, Taichung, Taiwan
- * E-mail:
| | - Ta-Chien Tseng
- Bioinformatics Center, National Cheng Kung University, Tainan, Taiwan
| | - Jorng-Tzong Horng
- Public Health and Clinical Informatics Research Group, Department of Biomedical Informatics, Asia University Taiwan, Taichung, Taiwan
- Department of Computer Science and Information Engineering, National Central University, Chungli, Taiwan
| | - Chun-Eng Liu
- Division of Infectious Diseases, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
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