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Jia W, Zhang X, Sun R, Li P, Wang D, Gu X, Song C. Value of modified qSOFA, glucose and lactate in predicting prognosis in children with sepsis in the PICU. Ann Med 2024; 56:2337714. [PMID: 38590177 PMCID: PMC11005878 DOI: 10.1080/07853890.2024.2337714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/29/2024] [Indexed: 04/10/2024] Open
Abstract
The purpose was to investigate how well age-adjusted modified quick Sequential Organ Failure Assessment (qSOFA) scores paired with blood glucose and lactate levels predict the outcomes of septicemic children in the pediatric intensive care unit (PICU). One hundred children who were diagnosed with sepsis and septic shock in the PICU of Henan Children's Hospital were eligible, and other 20 patients in the same hospital at different times were selected as a validation set. Respiratory rate (RR), heart rate (HR), capillary refill time (CRT), and Alert, Voice, Pain, Unresponsive (AVPU) scale were included in the age-adjusted modified qSOFA scoring criteria for scoring. The primary outcome was 28-day all-cause mortality. The predictive values were evaluated by the ROC curve. In the sepsis group, 50 patients were male, and 50 patients were female. The 28-day all-cause mortality rate was 52%. Fifty-one patients with age-adjusted modified qSOFA scores >1. The serum lactate level was 2.4 mmol/L, and the blood glucose level was 9.3 mmol/L. The AUCs for the age-adjusted modified qSOFA score, serum lactate and blood glucose levels for the prediction of 28-day all-cause mortality in children with sepsis were 0.719, 0.719 and 0.737, respectively. The cut-off values were one point, 3.8 mmol/L and 10 mmol/L, respectively. The AUC of the age-adjusted modified qSOFA score for the validation set of was 0.925. When the three indices were combined, the AUC was 0.817, the Hosmer-Lemeshow goodness-of-fit test showed χ2 = 2.428 and p = .965. When children with sepsis are admitted to the ICU, we recommend performing rapid scoring and rapid bedside lactate and glucose testing to determine the early prognosis.
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Affiliation(s)
- Wanyu Jia
- Department of Emergency Medicine, Henan Province Engineering Research Center of Diagnosis and Treatment of Pediatric Infection and Critical Care, Children’s Hospital Affiliated to Zhengzhou University, Henan Children’s Hospital, Zhengzhou Children’s Hospital, Zhengzhou, China
| | - Xue Zhang
- Department of Emergency Medicine, Henan Province Engineering Research Center of Diagnosis and Treatment of Pediatric Infection and Critical Care, Children’s Hospital Affiliated to Zhengzhou University, Henan Children’s Hospital, Zhengzhou Children’s Hospital, Zhengzhou, China
| | - Ruiyang Sun
- Department of Emergency Medicine, Henan Province Engineering Research Center of Diagnosis and Treatment of Pediatric Infection and Critical Care, Children’s Hospital Affiliated to Zhengzhou University, Henan Children’s Hospital, Zhengzhou Children’s Hospital, Zhengzhou, China
| | - Peng Li
- Department of Emergency Medicine, Henan Province Engineering Research Center of Diagnosis and Treatment of Pediatric Infection and Critical Care, Children’s Hospital Affiliated to Zhengzhou University, Henan Children’s Hospital, Zhengzhou Children’s Hospital, Zhengzhou, China
| | - Daobin Wang
- Department of Pediatrics, Zhecheng County People’s Hospital, Shangqiu, China
| | - Xue Gu
- Department of Emergency Medicine, Henan Province Engineering Research Center of Diagnosis and Treatment of Pediatric Infection and Critical Care, Children’s Hospital Affiliated to Zhengzhou University, Henan Children’s Hospital, Zhengzhou Children’s Hospital, Zhengzhou, China
| | - Chunlan Song
- Department of Emergency Medicine, Henan Province Engineering Research Center of Diagnosis and Treatment of Pediatric Infection and Critical Care, Children’s Hospital Affiliated to Zhengzhou University, Henan Children’s Hospital, Zhengzhou Children’s Hospital, Zhengzhou, China
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Chandra J, Raby E, Wood FM, Fegan PG, Yeap BB. Associations of Diabetes and Hyperglycaemia with Extent and Outcomes of Acute Burn Injuries. Biomedicines 2024; 12:1127. [PMID: 38791089 PMCID: PMC11118006 DOI: 10.3390/biomedicines12051127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/10/2024] [Accepted: 05/15/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Severe burns may induce hyperglycaemia in the absence of diabetes, but how glucose trajectories relate to burns outcomes is unclear. AIM To assess incidence of hyperglycaemia following acute burn injury, and associations with diabetes history and length of stay (LOS). METHODS Retrospective cohort study of adults admitted with acute burns to tertiary centres. Blood glucose level (BGL), hyperglycaemic episodes (BGL ≥ 11.1 mmol/L) and hyperglycaemic days were recorded. Stress hyperglycaemia was defined as BGL ≥ 11.1 mmol/L without a diabetes history. RESULTS A total of 30 participants had a diabetes history and 260 did not. Participants with known diabetes had higher mean BGLs (9.7 vs. 9.0 mmol/L, p < 0.001), more hyperglycaemic episodes (28.0 vs. 17.2%, p < 0.001) and hyperglycaemic days (51 vs. 21%, p < 0.001), compared to those without diabetes, despite smaller burns (total body surface area 1.0 vs. 14.8%, p < 0.001). Fourteen participants with stress hyperglycaemia had similar BGLs (at admission 10.3 vs. 11.5 mmol/L; during inpatient stay 9.9 vs. 9.8 mmol/L), more severe burns (15.6% vs. 1.0% TBSA) and longer LOS (18 vs. 7 days, p < 0.001) compared to participants with known diabetes. Extent of burns, having NGT nutrition, age, having inpatient BGL monitoring in the setting of diabetes, or having inpatient BGL monitoring in the absence of diabetes were associated with longer LOS. CONCLUSIONS In participants with known diabetes, small burn injuries were associated with hyperglycaemia. Stress hyperglycaemia can be triggered by major burn injuries, with early and sustained elevation of BGLs. Further research is warranted to improve inpatient management of BGL in patients with acute burn injury.
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Affiliation(s)
- Jeffrey Chandra
- Medical School, University of Western Australia, Perth 6009, Australia
| | - Edward Raby
- State Adult Burns Unit, Fiona Stanley Hospital, Perth 6150, Australia
| | - Fiona M. Wood
- Medical School, University of Western Australia, Perth 6009, Australia
- State Adult Burns Unit, Fiona Stanley Hospital, Perth 6150, Australia
| | - P. Gerry Fegan
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth 6150, Australia
- Medical School, Curtin University, Perth 6102, Australia
| | - Bu B. Yeap
- Medical School, University of Western Australia, Perth 6009, Australia
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth 6150, Australia
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Olander A, Magnusson C, Sundler AJ, Bremer A, Andersson H, Herlitz J, Axelsson C, Andersson Hagiwara M. Prediction of the Risk of Sepsis by Using Analysis of Plasma Glucose and Serum Lactate in Ambulance Services: A Prospective Study. Prehosp Disaster Med 2023; 38:160-167. [PMID: 36752111 DOI: 10.1017/s1049023x23000110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
INTRODUCTION The early recognition of patients with sepsis is difficult and the initial assessment outside of hospitals is challenging for ambulance clinicians (ACs). Indicators that ACs can use to recognize sepsis early are beneficial for patient outcomes. Research suggests that elevated point-of-care (POC) plasma glucose and serum lactate levels may help to predict sepsis in the ambulance service (AS) setting. STUDY OBJECTIVE The aim of this study was to test the hypothesis that the elevation of POC plasma glucose and serum lactate levels may help to predict Sepsis-3 in the AS. METHODS A prospective observational study was performed in the AS setting of Gothenburg in Sweden from the beginning of March 2018 through the end of September 2019. The criteria for sampling POC plasma glucose and serum lactate levels in the AS setting were high or intermediate risk according to the Rapid Emergency Triage and Treatment System (RETTS), as red, orange, yellow, and green if the respiratory rate was >22 breaths/minutes. Sepsis-3 were identified retrospectively. A primary and secondary analyses were carried out. The primary analysis included patients cared for in the AS and emergency department (ED) and were hospitalized. In the secondary analysis, patients who were only cared for in the AS and ED without being hospitalized were also included. To evaluate the predictive ability of these biomarkers, the area under the curve (AUC), sensitivity, specificity, and predictive values were used. RESULTS A total of 1,057 patients were included in the primary analysis and 1,841 patients were included in the secondary analysis. In total, 253 patients met the Sepsis-3 criteria (in both analyses). The AUC for POC plasma glucose and serum lactate levels showed low accuracy in predicting Sepsis-3 in both the primary and secondary analyses. Among all hospitalized patients, regardless of Sepsis-3, more than two-thirds had elevated plasma glucose and nearly one-half had elevated serum lactate when measured in the AS. CONCLUSIONS As individual biomarkers, an elevated POC plasma glucose and serum lactate were not associated with an increased likelihood of Sepsis-3 when measured in the AS in this study. However, the high rate of elevation of these biomarkers before arrival in hospital highlights that their role in clinical decision making at this early stage needs further evaluation, including other endpoints than Sepsis-3.
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Affiliation(s)
- Agnes Olander
- University of Borås, PreHospen - Centre for Prehospital Research, Borås, Sweden
- University of Borås, Faculty of Caring Science, Work Life and Social Welfare, Borås, Sweden
| | - Carl Magnusson
- University of Borås, PreHospen - Centre for Prehospital Research, Borås, Sweden
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Prehospital Emergency Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Annelie J Sundler
- University of Borås, Faculty of Caring Science, Work Life and Social Welfare, Borås, Sweden
| | - Anders Bremer
- University of Borås, Faculty of Caring Science, Work Life and Social Welfare, Borås, Sweden
- Linnaeus University, Faculty of Health and Life Sciences, Växjö, Sweden
| | - Henrik Andersson
- University of Borås, PreHospen - Centre for Prehospital Research, Borås, Sweden
- University of Borås, Faculty of Caring Science, Work Life and Social Welfare, Borås, Sweden
- Linnaeus University, Faculty of Health and Life Sciences, Växjö, Sweden
| | - Johan Herlitz
- University of Borås, PreHospen - Centre for Prehospital Research, Borås, Sweden
- University of Borås, Faculty of Caring Science, Work Life and Social Welfare, Borås, Sweden
| | - Christer Axelsson
- University of Borås, PreHospen - Centre for Prehospital Research, Borås, Sweden
- University of Borås, Faculty of Caring Science, Work Life and Social Welfare, Borås, Sweden
| | - Magnus Andersson Hagiwara
- University of Borås, PreHospen - Centre for Prehospital Research, Borås, Sweden
- University of Borås, Faculty of Caring Science, Work Life and Social Welfare, Borås, Sweden
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Chen HK, Su PJ, Wang YL, Chang KC, Su YL, Chang PH, Kuan FC, Hsieh CH, Kuo YC, Sheng TW, Chang CF, Yu SM, Huang WK, Lin YC, Tsan DL, Yu KJ, Lin PH, Chen HY, Chang YH, Pang ST, Chuang CK, Lai ECC. Long-term use and risk of major adverse cardiac events: Comparing enzalutamide and abiraterone in chemotherapy-naïve patients with metastatic castration-resistant prostate cancer. Int J Cancer 2023; 152:1191-1201. [PMID: 36346116 DOI: 10.1002/ijc.34348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 09/18/2022] [Accepted: 10/11/2022] [Indexed: 11/11/2022]
Abstract
This is a retrospective cohort study by analyzing a multi-institutional electronic medical records database in Taiwan to compare long-term effectiveness and risk of major adverse cardiac events (MACE) in chemotherapy-naïve metastatic castration-resistant prostate cancer (mCRPC) patients treated with enzalutamide (ENZ) or abiraterone (AA). Patients aged 20 years and older and newly receiving androgen receptor targeted therapies ENZ or AA from September 2016 to December 2019 were included. We followed patients from initiation of therapies to the occurrence of outcomes (prostate-specific antigen (PSA) response rate, PSA progression free survival (PFS), overall survival (OS), and MACE), death, the last clinical visit, or December 31, 2020. We performed multivariable Cox proportional hazard models to compare ENZ and AA groups for the measured outcomes. A total of 363 patients treated with either ENZ (n = 157) or AA (n = 206) were identified. The analysis found a significantly higher proportion of patients with a PSA response rate higher than 50% among those receiving ENZ than among those receiving AA (ENZ vs AA: 75.80% vs 63.59%, P = .01). However, there was no significant difference in PSA PFS (adjusted hazard ratio: 0.86; 95% CI 0.63-1.17) and OS (0.68: 0.41-1.14) between the use of ENZ and AA in chemotherapy-naïve mCRPC patients. Regarding the cardiovascular (CV) safety outcome, there was a significantly lower risk of MACE in patients receiving ENZ, compared to patients receiving AA (0.20: 0.07-0.55). The findings suggest that enzalutamide may be more efficacious for PSA response and suitable for chemotherapy-naïve mCRPC patients with high CV risk profile.
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Affiliation(s)
- Hung-Kai Chen
- Division of Hematology Oncology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Pharmacy, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Po-Jung Su
- Division of Hematology Oncology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yan-Lin Wang
- Department of Pharmacy, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kai-Cheng Chang
- Department of Pharmacy, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Li Su
- Division of Hematology Oncology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Clinical Trial Center, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Pei-Hung Chang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Hematology Oncology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Feng-Che Kuan
- Division of Hematology Oncology, Department of Internal Medicine, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Chia-Hsun Hsieh
- Division of Hematology Oncology, Department of Internal Medicine, New Taipei Municipal TuCheng Hospital, New Taipei, Taiwan
| | - Yung-Chia Kuo
- Division of Hematology Oncology, Department of Internal Medicine, New Taipei Municipal TuCheng Hospital, New Taipei, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ting-Wen Sheng
- Department of Medical Imaging and Intervention, New Taipei Municipal TuCheng Hospital, New Taipei, Taiwan
| | - Ching-Fu Chang
- Division of Hematology Oncology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Shao-Ming Yu
- Division of Hematology Oncology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Kuan Huang
- Division of Hematology Oncology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yung-Chang Lin
- Division of Hematology Oncology, Department of Internal Medicine, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Din-Li Tsan
- Department of Radiation Oncology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Radiation Oncology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Kai-Jie Yu
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Urology, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Chemical Engineering and Biotechnology and Graduate Institute of Biochemical and Biomedical Engineering, National Taipei University of Technology, Taipei, Taiwan
| | - Po-Hung Lin
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Urology, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hui-Yu Chen
- Department of Pharmacy, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ying-Hsu Chang
- Department of Urology, New Taipei Municipal TuCheng Hospital, New Taipei, Taiwan
| | - See-Tong Pang
- Division of Urology, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Keng Chuang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Urology, Department of Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Nielsen FE, Chafranska L, Sørensen R, Abdullah OB. Predictors of outcomes in emergency department patients with suspected infections and without fulfillment of the sepsis criteria. Am J Emerg Med 2023; 68:144-154. [PMID: 37018890 DOI: 10.1016/j.ajem.2023.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/17/2023] [Accepted: 03/15/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Data on patient characteristics and determinants of serious outcomes for acutely admitted patients with infections who do not fulfill the sepsis criteria are sparse. The study aimed to characterize acutely admitted emergency department (ED) patients with infections and a composite outcome of in-hospital mortality or transfer to the intensive care unit without fulfilling the criteria for sepsis and to examine predictors of the composite outcome. METHODS This was a secondary analysis of data from a prospective observational study of patients with suspected bacterial infection admitted to the ED between October 1, 2017 and March 31, 2018. A National Early Warning Score 2 (NEWS2) ≥ 5 within the first 4 h in the ED was assumed to represent a sepsis-like condition with a high risk for the composite endpoint. Patients who achieved the composite outcome were grouped according to fulfillment of the NEWS2 ≥ 5 criteria. We used logistic regression analysis to estimate the unadjusted and adjusted odds ratio (OR) for the composite endpoint among patients with either NEWS2 < 5 (NEWS2-) or NEWS2 ≥ 5 (NEWS2+). RESULTS A total of 2055 patients with a median age of 73 years were included. Of these, 198 (9.6%) achieved the composite endpoint, including 59 (29.8%) NEWS2- and 139 (70.2%) NEWS2+ patients, respectively. Diabetes (OR 2.23;1.23-4.0), a Sequential Organ Failure Assessment (SOFA) score ≥ 2 (OR 2.57;1.37-4.79), and a Do-not-attempt-cardiopulmonary-resuscitation order (DNACPR) on admission (OR 3.70;1.75-7.79) were independent predictive variables for the composite endpoint in NEWS2- patients (goodness-of-fit test P = 0.291; area under the receiver operating characteristic curve for the model (AUROC) = 0.72). The regression model for NEWS2+ patients revealed that a SOFA score ≥ 2 (OR 2.79; 1.59-4.91), hypothermia (OR 2.48;1.30-4.75), and DNACPR order on admission were predictive variables for the composite endpoint (goodness-of-fit test P = 0.62; AUROC for the model = 0.70). CONCLUSION Approximately one-third of the patients with infections and serious outcomes during hospitalization did not meet the NEWS2 threshold for likely sepsis. Our study identified factors with independent predictive values for the development of serious outcomes that should be tested in future prediction models.
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Kim SH, Kim JY, Kim ES, Park IR, Ha EY, Chung SM, Moon JS, Yoon JS, Won KC, Lee HW. Early glycaemic variability increases 28-day mortality and prolongs intensive care unit stay in critically ill patients with pneumonia. Ann Med 2022; 54:2736-2743. [PMID: 36205625 PMCID: PMC9553150 DOI: 10.1080/07853890.2022.2128399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the effect of early glycaemic variability (GV) on 28-day mortality in critically ill patients with pneumonia. PATIENTS AND METHODS This single-centre retrospective study included patients admitted to the intensive care unit (ICU) due to pneumonia between 2018 and 2019. A total of 282 patients (mean age, 68.6 years) with blood sugar test (BST) results measured more than three times within 48 h after hospitalization and haemoglobin A1c (HbA1c) levels recorded within 2 months were enrolled. Coefficient of variation (CV) was calculated using the BST values. The effects of GV on 28-day mortality and prolonged ICU stay (>14 days) were also assessed. RESULTS The mean age was 60.6 years (male to female ratio, 2.5:1). The 28-day mortality rate was 31.6% (n = 89) and was not different according to the presence of diabetes (DM vs. non-DM) or HbA1c levels (≥7.5 vs. <7.5%; both p > .05). However, the mortality rate was significantly higher in patients with high GV (CV ≥ 36%) than in those with low GV (CV < 36%; 37.5 vs. 25.4%, p = .028). The risk of mortality in patients with high GV was prominent in the subgroups with DM or low HbA1c levels. Among the surviving patients (n = 193), 44 remained in the ICU for more than 14 days. Compared to low GV, high GV was associated with a higher rate of prolonged ICU stay, although not statistically significant (27.8 vs. 18.5%, p = .171). After adjusting for the severity of illness and treatment strategy, CV was an independent risk factor for 28-day mortality (hazard ratio [HR], 1.01, p = .04) and prolonged ICU stay (odds ratio, 1.02; p = .04). CONCLUSIONS High GV within 48 h of ICU admission was associated with an increased 28-day mortality risk and prolonged ICU stay. Early phase GV should be carefully managed in critically ill patients with pneumonia.KEY MESSAGESThe presence of diabetes or HbA1c alone is insufficient to predict 28-day mortality and prolonged ICU stay in critically ill patients with pneumonia.High glycaemic variability (GV) within 48 h of ICU admission increases 28-day mortality and prolongs ICU stay, which is consistent after adjusting for severity of illness and treatment strategy.Patients with high GV, especially those with DM or low HbA1c levels (<7.5%) should be more carefully treated to reduce mortality.
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Affiliation(s)
- Seong Ho Kim
- College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Ji Young Kim
- College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Eun Song Kim
- College of Medicine, Yeungnam University, Daegu, Republic of Korea
| | - Il Rae Park
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Eun Yeong Ha
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Seung Min Chung
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Jun Sung Moon
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Ji Sung Yoon
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Kyu Chang Won
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Hyoung Woo Lee
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Yeungnam University College of Medicine, Daegu, Republic of Korea
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Discharge status validation of the Chang Gung Research database in Taiwan. Biomed J 2022; 45:907-913. [PMID: 34971827 PMCID: PMC9795345 DOI: 10.1016/j.bj.2021.12.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/07/2021] [Accepted: 12/21/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The Chang Gung Research Database (CGRD) is the largest multi-institutional electronic medical records database in Taiwan and has been widely used to establish evidence studies. However, the accuracy of CGRD has rarely been validated. This study aims to validate the discharge status, especially with a focus on mortality, of admission data under CGRD. METHODS We constructed an observational study using CGRD linked with TDR to validate the discharge status. The CGRD and TDR data were obtained from the Chang Gung Memorial Hospital system and the Health and Welfare Data Science Center, respectively. The accuracy, positive predictive value (PPV), and underestimated mortality rate (UEM) were employed as indicators for validation. Year, sex, age, and the primary cause for admission (PCA) were analyzed. RESULTS A total of 1,972,044 admission records under CGRD were analyzed. The overall accuracy for mortality coding on discharge status was higher than 97% within one week after discharge. The accuracy increased by year and was more than 98% after 2010. A similar result was observed in UEM; the UEM within one week was lower than 10% after 2010. These indicators varied by age group and PCA-elderly patients had relatively lower accuracy and higher UEM (approximately 11%). The presence of UEM within one week was better but varied by disease. CONCLUSIONS Considering the data accuracy and UEM discharge status, prioritizing the use of inpatient data after 2010 under CGRD for mortality outcome follow-up studies is recommended.
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Van Moorter N, Tackaert T, De Decker K, Van Vlem B, De Neve N. New potential for an old kid on the block: Impact of premorbid metformin use on lactate kinetics, kidney injury and mortality in sepsis and septic shock, an observational study. Endocrinol Diabetes Metab 2022; 6:e382. [PMID: 36444165 PMCID: PMC9836235 DOI: 10.1002/edm2.382] [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: 07/10/2022] [Revised: 09/27/2022] [Accepted: 09/30/2022] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Sepsis and septic shock cause significant mortality worldwide, with no targeted molecular therapies available. Metformin has pleomorphic effects that may be beneficial in sepsis, but at present, the impact of metformin exposure on sepsis remains controversial. Metformin might alter lactate metabolism, but little is known about its influence on lactate kinetics. We therefore investigated the impact of preadmission metformin use on lactate kinetics, acute kidney injury (AKI) and mortality in sepsis. MATERIALS AND METHODS We retrospectively analysed all ICU admissions with sepsis and septic shock between January 2013 and September 2020, identifying 77 users and 390 nonusers (subdivided in diabetics, n = 48 and nondiabetics, n = 342). RESULTS (Sub)groups did not differ in illness severity or sepsis aetiology. Admission lactate levels were similar, but evolution in lactate over the first 24 h showed a larger decrease in users vs nonusers (median - 53% vs. -36%, p = .010). No difference in AKI or renal replacement therapy was found. Mortality was lower in users vs nonusers in case of septic shock (21.9% (n = 7) vs. 42.7% (n = 61) for 90d mortality, p = .029, OR 0.38 [95% CI: 0.15-0.93]), but showed no significant differences in the combined sepsis and septic shock population. CONCLUSIONS In our data, preadmission metformin use is associated with a significantly larger decrease in lactate after admission with sepsis or septic shock and with reduced mortality in septic shock. This underscores the need for further studies investigating the interplay between metformin, lactate and sepsis, thereby exploring the potential use of metformin or its pathways in sepsis.
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Affiliation(s)
- Nina Van Moorter
- Department of Internal MedicineGhent University/Ghent University HospitalGhentBelgium
| | - Thomas Tackaert
- Department of Emergency MedicineGhent University/Ghent University HospitalGhentBelgium
| | - Koen De Decker
- Department of Anaesthesiology and Critical Care MedicineOLVZ AalstAalstBelgium
| | | | - Nikolaas De Neve
- Department of Anaesthesiology and Critical Care MedicineOLVZ AalstAalstBelgium
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Li X, Zhang D, Chen Y, Ye W, Wu S, Lou L, Zhu Y. Acute glycemic variability and risk of mortality in patients with sepsis: a meta-analysis. Diabetol Metab Syndr 2022; 14:59. [PMID: 35461267 PMCID: PMC9034073 DOI: 10.1186/s13098-022-00819-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute glycemic variability (GV) has been correlated with the severity of sepsis. The aim of the study was to evaluate the potential association between acute GV and mortality risk in patients with sepsis. METHODS Cohort studies comparing the risk of death within 3 months between septic patients with higher versus lower acute GV were retrieved by systematic search of Medline, Embase, Web of Science, Wanfang and CNKI databases. We used a random-effect model to pool the data by incorporating the between-study heterogeneity. Sensitivity analyses were performed to evaluate the stability of the findings. RESULTS Ten studies including 4296 patients were available for the meta-analysis. Pooled results showed that septic patients with higher acute GV had significantly increased mortality risk compared to those with lower acute GV, as evidenced by results using different parameters including standard deviation of blood glucose (SDBG, risk ratio [RR]: 1.74, 95% confidence interval [CI] 1.36-2.24, p < 0.001; I2 = 0%), coefficient of variation of blood glucose (RR: 1.91, 95% CI 1.57-2.31, p < 0.001; I2 = 0%), mean amplitude of glycemic excursion (RR: 1.81. 95% CI 1.36-2.40, p < 0.001; I2 = 0%), and glycemic lability index (RR: 2.52, 95% CI 1.72-3.68, p < 0.001; I2 = 0%). Sensitivity analyses by excluding one study at a time did not significantly affect the results (p all < 0.05). CONCLUSIONS Higher acute GV may be a predictor of mortality risk in patients with sepsis.
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Affiliation(s)
- Xiaofei Li
- Department of Infectious Diseases, Yiwu Central Hospital, No. 519 Nanmen Street, Yiwu, 322000, Zhejiang, China.
| | - Daofu Zhang
- Department of Intensive Care Unit, Liaocheng Daochangfu People's Hospital, Liaocheng, 252000, China
| | - Yongxin Chen
- Department of Infectious Diseases, Yiwu Central Hospital, No. 519 Nanmen Street, Yiwu, 322000, Zhejiang, China
| | - Weiwei Ye
- Department of Infectious Diseases, Yiwu Central Hospital, No. 519 Nanmen Street, Yiwu, 322000, Zhejiang, China
| | - Shuang Wu
- Department of Infectious Diseases, Yiwu Central Hospital, No. 519 Nanmen Street, Yiwu, 322000, Zhejiang, China
| | - Lianqing Lou
- Department of Infectious Diseases, Yiwu Central Hospital, No. 519 Nanmen Street, Yiwu, 322000, Zhejiang, China
| | - Yanshuang Zhu
- Department of Infectious Diseases, Yiwu Central Hospital, No. 519 Nanmen Street, Yiwu, 322000, Zhejiang, China
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10
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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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11
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Dong M, Liu W, Luo Y, Li J, Huang B, Zou Y, Liu F, Zhang G, Chen J, Jiang J, Duan L, Xiong D, Fu H, Yu K. Glycemic Variability Is Independently Associated With Poor Prognosis in Five Pediatric ICU Centers in Southwest China. Front Nutr 2022; 9:757982. [PMID: 35284444 PMCID: PMC8905539 DOI: 10.3389/fnut.2022.757982] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 01/17/2022] [Indexed: 12/15/2022] Open
Abstract
Background Glucose variability (GV) is a common complication of dysglycemia in critically ill patients. However, there are few studies on the role of GV in the prognosis of pediatric patients, and there is no consensus on the appropriate method for GV measurement. The objective of this study was to determine the “optimal” index of GV in non-diabetic critically ill children in a prospective multicenter cohort observational study. Also, we aimed to confirm the potential association between GV and unfavorable outcomes and whether this association persists after controlling for hypoglycemia or hyperglycemia. Materials and Methods Blood glucose values were recorded for the first 72 h and were used to calculate the GV for each participant. Four different metrics [SD, glycemic lability index (GLI), mean absolute glucose (MAG), and absolute change of percentage (ACACP)] were considered and compared to identify the “best” GV index associated with poor prognosis in non-diabetic critically ill children. Among the four metrics, the SD was most commonly used in previous studies, while GLI- and MAG-integrated temporal information, that is the rate and magnitude of change and the time interval between glucose measurements. The fourth metric, the average consecutive ACACP, was introduced in our study, which can be used in real-time clinical decisions. The primary outcome of this study was the 28-day mortality. The receiver operating characteristic (ROC) curve analysis was conducted to compare the predictive power of different metrics of GV for the primary outcome. The GV index with the largest area under ROC curve (AUC) was chosen for subsequent multivariate analyses. Multivariate Cox regression analysis was performed to identify the potential predictors of the outcome. To compare the contribution in 28-day mortality prognosis between glycemic variability and hyper- or hypoglycemia, performance metrics were calculated, which included AUC, net reclassification improvement (NRI), and integrated discrimination improvement (IDI). Results Among 780 participants, 12.4% (n = 97) died within 28 days after admission to the pediatric intensive care unit (PICU). Statistically significant differences were found between survivors and non-survivors in terms of four GV metrics (SD, GLI, MAG, and ACACP), in which MAG (AUC: 0.762, 95% CI: 0.705–0.819, p < 0.001) achieved the largest AUC and showed a strong independent association with ICU mortality. Subsequent addition of MAG to the multivariate Cox model for hyperglycemia resulted in further quantitative evolution of the model statistics (AUC = 0.651–0.681, p = 0.001; IDI: 0.017, p = 0.044; NRI: 0.224, p = 0.186). The impact of hyperglycemia (adjusted hazard ratio [aHR]: 1.419, 95% CI: 0.815–2.471, p = 0.216) on outcome was attenuated and no longer statistically relevant after adjustment for MAG (aHR: 2.455, 95% CI: 1.411–4.270, p = 0.001). Conclusions GV is strongly associated with poor prognosis independent of mean glucose level, demonstrating more predictive power compared with hypoglycemia and hyperglycemia after adjusting for confounding factors. GV metrics that contain information, such as time and rate of change, are the focus of future research; thus, the MAG may be a good choice. The findings of this study emphasize the crucial role of GVs in children in the PICU. Clinicians should pay more attention to GV for clinical glucose management.
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Affiliation(s)
- Milan Dong
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- Department of Pediatrics, The People's Hospital of Yubei District of Chongqing City, Chongqing, China
| | - Wenjun Liu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
| | - Yetao Luo
- Department of Clinical Epidemiology and Biostatistics, Children's Institute of Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Li
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- *Correspondence: Jing Li
| | - Bo Huang
- Department of Pediatric Critical Care, The First People's Hospital of Zunyi, Zunyi, China
| | - Yingbo Zou
- Department of Pediatric Critical Care, The First People's Hospital of Zunyi, Zunyi, China
| | - Fuyan Liu
- Department of Pediatric Critical Care, The First People's Hospital of Zunyi, Zunyi, China
| | - Guoying Zhang
- Department of Pediatric Critical Care, Chengdu Women's and Children's Central Hospital, Chengdu, China
| | - Ju Chen
- Department of Pediatric Critical Care, Chengdu Women's and Children's Central Hospital, Chengdu, China
| | - Jianyu Jiang
- Department of Pediatrics, Chongqing Three Gorges Women and Children's Hospital, Chongqing, China
| | - Ling Duan
- Department of Pediatrics, Chongqing Three Gorges Women and Children's Hospital, Chongqing, China
| | - Daoxue Xiong
- Department of Pediatrics, Chongqing Three Gorges Women and Children's Hospital, Chongqing, China
| | - Hongmin Fu
- Department of Pediatric Critical Care, Kunming Children's Hospital, Kunming, China
| | - Kai Yu
- Department of Pediatric Critical Care, Kunming Children's Hospital, Kunming, China
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12
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Chen HK, Shao SC, Weng MY, Lin SJ, Hung MJ, Chan YY, Lai ECC. Risk of Heart Failure in Rheumatoid Arthritis Patients Treated with Tumor Necrosis Factor-α Inhibitors. Clin Pharmacol Ther 2021; 110:1595-1603. [PMID: 34496051 DOI: 10.1002/cpt.2415] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 08/22/2021] [Indexed: 11/12/2022]
Abstract
This is a retrospective cohort study by analyzing a multi-institutional electronic medical records database covering 1.3 million individuals (6% of Taiwan's population) to compare the risk of heart failure (HF) in patients with rheumatoid arthritis (RA) treated with tumor necrosis factor-α (TNF-α) inhibitors or conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs). We included patients with RA aged 20 years and older who had treatment failure with at least 2 different csDMARD regimens and newly switched to another csDMARD regimen or TNFis from 2009 to 2019. We followed patients from initiation of the new therapies to the occurrence of hospitalization for heart failure (hHF), death, to the last clinical visit or December 31, 2020. We performed multivariable Cox proportional hazard models to compare TNF-α inhibitors and csDMARD groups for the risk of hHF, with adjustment for patients' characteristics. A total of 1,278 TNF-α inhibitors and 1,932 csDMARDs treated patients were identified, with 78% being women and having an average age of 55 (SD 13.28) years. The incidence rates of hHF for the TNF-α inhibitors and csDMARD groups were 3.66 and 4.72 per 1,000 person-years, respectively (adjusted hazard ratio (aHR) 0.59; 95% confidence interval (CI) 0.35-0.97), and the results remained consistent in patients both with an HF history (aHR 0.66; 95% CI 0.03-14.46) and without (aHR 0.49; 95% CI, 0.27-0.89). The findings suggest that those who switched to TNF-α inhibitors had a reduced risk of hHF, compared with those who switched to another csDMARD regimen.
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Affiliation(s)
- Hung-Kai Chen
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shih-Chieh Shao
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Pharmacy, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Meng-Yu Weng
- Division of Allergy, Immunology, and Rheumatology, Department of Internal Medicine, College of Medicine, National Cheng Kung University Hospital, National Cheng Kung University, Tainan, Taiwan
| | - Swu-Jane Lin
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ming-Jui Hung
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Section of Cardiology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Yuk-Ying Chan
- Department of Pharmaceutical Materials Management, Chang Gung Medical Foundation, Taoyuan, Taiwan
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Wang J, Zhu CK, Yu JQ, Tan R, Yang PL. Hypoglycemia and mortality in sepsis patients: A systematic review and meta-analysis. Heart Lung 2021; 50:933-940. [PMID: 34433111 DOI: 10.1016/j.hrtlng.2021.07.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 07/09/2021] [Accepted: 07/28/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Hypoglycemia frequently occurs in patients with sepsis. The status of prognosis of sepsis patients varies with the cause of hypoglycemia. OBJECTIVE A meta-analysis was performed to obtain a reliable basis for assessing the severity of disease in sepsis patients. METHODS A search of electronic databases was performed. The random-effects model was employed to calculate the overall odds ratio (OR) and 95% CI. RESULTS Five cohort studies were included. Decreased blood glucose level was associated with an increased risk of death [OR:1.68; 95% CI (1.12-2.53)]. Incidents of mortality were analyzed based on the causative factor of hypoglycemia. Patients with spontaneous hypoglycemia showed a significantly higher mortality rate than the control subjects[OR 1.65; 95% CI (1.20-2.28); p = 0.002]. CONCLUSION In the early stages of sepsis, the occurrence of spontaneous hypoglycemia may be associated with the severity of the disease.
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Affiliation(s)
- Jing Wang
- Graduate school of Dalian Medical University, Dalian, Liaoning, China; Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | - Cheng-Kai Zhu
- Department of Gastroenterology, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | - Jiang-Quan Yu
- Clinical Medical College, Yangzhou University, Yangzhou, Jiangsu, China; Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China.
| | - Rui Tan
- Graduate school of Dalian Medical University, Dalian, Liaoning, China; Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
| | - Peng-Lei Yang
- Graduate school of Dalian Medical University, Dalian, Liaoning, China; Department of Critical Care Medicine, Northern Jiangsu People's Hospital, Yangzhou, Jiangsu, China
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14
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Incidence and Impact of Dysglycemia in Patients with Sepsis Under Moderate Glycemic Control. Shock 2021; 56:507-513. [PMID: 33978606 DOI: 10.1097/shk.0000000000001794] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Glycemic control strategies for sepsis have changed significantly over the last decade, but their impact on dysglycemia and its associated outcomes has been poorly understood. In addition, there is controversy regarding the detrimental effects of hyperglycemia in sepsis. To evaluate the incidence and risks of dysglycemia under current strategy, we conducted a preplanned subanalysis of the sepsis cohort in a prospective, multicenter FORECAST study. A total of 1,140 patients with severe sepsis, including 259 patients with pre-existing diabetes, were included. Median blood glucose levels were approximately 140 mg/dL at 0 h and 72 h indicating that blood glucose was moderately controlled. The rate of initial and late hyperglycemia was 27.3% and 21.7%, respectively. The rate of early hypoglycemic episodes during the initial 24 h was 13.2%. Glycemic control was accompanied by a higher percentage of initial and late hyperglycemia but not with early hypoglycemic episodes, suggesting that glycemic control was targeted at excess hyperglycemia. In nondiabetic patients, late hyperglycemia (hazard ratio, 95% confidence interval; p-value: 1.816, 1.116-2.955, 0.016) and early hypoglycemic episodes (1.936, 1.180-3.175, 0.009) were positively associated with in-hospital mortality. Further subgroup analysis suggested that late hyperglycemia and early hypoglycemic episodes independently, and probably synergistically, affect the outcomes. In diabetic patients, however, these correlations were not observed. In conclusion, a significantly high incidence of dysglycemia was observed in our sepsis cohort under moderate glycemic control. Late hyperglycemia in addition to early hypoglycemia was associated with poor outcomes at least in nondiabetic patients. More sophisticated approaches are necessary to reduce the incidence of these serious complications.
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15
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Laukkanen L, Lahtinen S, Raatiniemi L, Ehrola A, Kaakinen T, Liisanantti J. Emergency department admission and mortality of the non-transported emergency medical service patients: a cohort study from Northern Finland. Emerg Med J 2021; 39:443-450. [PMID: 33879493 DOI: 10.1136/emermed-2020-209914] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 03/26/2021] [Accepted: 03/31/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES A high number of emergency medical service (EMS) patients are not transported to hospital by ambulance. Various non-transport protocols and guidelines have been implemented by different EMS providers. The present study examines subsequent tertiary care ED and hospital admission and mortality of the patients assessed and not transported by EMS in Northern Finland and evaluates the factors predicting these outcomes. METHODS Data from EMS missions with a registered non-transportation code during 1 January 2018-31 December 2018 were screened retrospectively. EMS charts were retrieved from a local EMS database and data concerning hospital admission and mortality were collected from the medical records of Oulu University Hospital, Oulu, Finland. RESULTS A total of 12 530 EMS non-transport missions were included. Of those, a total of 344 (2.7%) patients were admitted to tertiary care ED in 48 hours after the EMS contact, and 229 (1.8%) of them were further admitted to the hospital. Patients with the dispatch code 'abdominal pain', clinical presentation with fever or hyperglycaemia, physician phone consultation and a decision not to transport during night hours were associated with a higher risk of ED admission within 48 hours after EMS contact. Overall 48-hour and 30-day mortalities of non-transported patients were 0.2% (n=25) and 1.0% (n=128), respectively. CONCLUSION In this cohort, the rate of subsequent tertiary care ED admission and mortality in the non-transported EMS patients was low. Dispatch code abdominal pain, clinical presentation with fever or hyperglycaemia, physician phone consultation and night-hours increased the risk of ED admission within 48 hours after EMS contact.
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Affiliation(s)
- Lauri Laukkanen
- Faculty of Medicine, Oulu University, Oulu, Finland .,Research Group of Surgery, Anaesthesiology and Intensive Care Medicine, Oulu University Hospital District, Oulu, Finland
| | - Sanna Lahtinen
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine, Oulu University Hospital District, Oulu, Finland.,Department of Anaesthesiology, Oulu University Hospital, Oulu, Finland
| | - Lasse Raatiniemi
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine, Oulu University Hospital District, Oulu, Finland.,Centre for Pre-Hospital Emergency Care, Oulu University Hospital District, Oulu, Finland
| | - Ari Ehrola
- Emergency Medical Services, Oulu-Koillismaa Rescue Department, Oulu University Hospital District, Oulu, Finland
| | - Timo Kaakinen
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine, Oulu University Hospital District, Oulu, Finland.,Department of Anaesthesiology, Oulu University Hospital, Oulu, Finland
| | - Janne Liisanantti
- Research Group of Surgery, Anaesthesiology and Intensive Care Medicine, Oulu University Hospital District, Oulu, Finland.,Department of Anaesthesiology, Oulu University Hospital, Oulu, Finland
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16
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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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17
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Farooq N, Chuan B, Mahmud H, El Khoudary SR, Nouraie SM, Evankovich J, Yang L, Dunlap D, Bain W, Kitsios G, Zhang Y, O’Donnell CP, McVerry BJ, Shah FA. Association of the systemic host immune response with acute hyperglycemia in mechanically ventilated septic patients. PLoS One 2021; 16:e0248853. [PMID: 33755703 PMCID: PMC7987165 DOI: 10.1371/journal.pone.0248853] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 03/07/2021] [Indexed: 12/13/2022] Open
Abstract
Hyperglycemia during sepsis is associated with increased organ dysfunction and higher mortality. The role of the host immune response in development of hyperglycemia during sepsis remains unclear. We performed a retrospective analysis of critically ill adult septic patients requiring mechanical ventilation (n = 153) to study the relationship between hyperglycemia and ten markers of the host injury and immune response measured on the first day of ICU admission (baseline). We determined associations between each biomarker and: (1) glucose, insulin, and c-peptide levels at the time of biomarker collection by Pearson correlation; (2) average glucose and glycemic variability in the first two days of ICU admission by linear regression; and (3) occurrence of hyperglycemia (blood glucose>180mg/dL) by logistic regression. Results were adjusted for age, pre-existing diabetes mellitus, severity of illness, and total insulin and glucocorticoid dose. Baseline plasma levels of ST2 and procalcitonin were positively correlated with average blood glucose and glycemic variability in the first two days of ICU admission in unadjusted and adjusted analyses. Additionally, higher baseline ST2, IL-1ra, procalcitonin, and pentraxin-3 levels were associated with increased risk of hyperglycemia. Our results suggest associations between the host immune response and hyperglycemia in critically ill septic patients particularly implicating the interleukin-1 axis (IL-1ra), the interleukin-33 axis (ST2), and the host response to bacterial infections (procalcitonin, pentraxin-3).
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Affiliation(s)
- Nauman Farooq
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Byron Chuan
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Hussain Mahmud
- Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Samar R. El Khoudary
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Seyed Mehdi Nouraie
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - John Evankovich
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Libing Yang
- School of Medicine, Tsinghua University, Haidian District, Beijing, China
| | - Daniel Dunlap
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - William Bain
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States of America
| | - Georgios Kitsios
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Yingze Zhang
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Christopher P. O’Donnell
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Bryan J. McVerry
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- Center for Medicine and the Microbiome, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Faraaz Ali Shah
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States of America
- * E-mail:
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Chávez-Reyes J, Escárcega-González CE, Chavira-Suárez E, León-Buitimea A, Vázquez-León P, Morones-Ramírez JR, Villalón CM, Quintanar-Stephano A, Marichal-Cancino BA. Susceptibility for Some Infectious Diseases in Patients With Diabetes: The Key Role of Glycemia. Front Public Health 2021; 9:559595. [PMID: 33665182 PMCID: PMC7921169 DOI: 10.3389/fpubh.2021.559595] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 01/12/2021] [Indexed: 01/08/2023] Open
Abstract
Uncontrolled diabetes results in several metabolic alterations including hyperglycemia. Indeed, several preclinical and clinical studies have suggested that this condition may induce susceptibility and the development of more aggressive infectious diseases, especially those caused by some bacteria (including Chlamydophila pneumoniae, Haemophilus influenzae, and Streptococcus pneumoniae, among others) and viruses [such as coronavirus 2 (CoV2), Influenza A virus, Hepatitis B, etc.]. Although the precise mechanisms that link glycemia to the exacerbated infections remain elusive, hyperglycemia is known to induce a wide array of changes in the immune system activity, including alterations in: (i) the microenvironment of immune cells (e.g., pH, blood viscosity and other biochemical parameters); (ii) the supply of energy to infectious bacteria; (iii) the inflammatory response; and (iv) oxidative stress as a result of bacterial proliferative metabolism. Consistent with this evidence, some bacterial infections are typical (and/or have a worse prognosis) in patients with hypercaloric diets and a stressful lifestyle (conditions that promote hyperglycemic episodes). On this basis, the present review is particularly focused on: (i) the role of diabetes in the development of some bacterial and viral infections by analyzing preclinical and clinical findings; (ii) discussing the possible mechanisms by which hyperglycemia may increase the susceptibility for developing infections; and (iii) further understanding the impact of hyperglycemia on the immune system.
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Affiliation(s)
- Jesús Chávez-Reyes
- Departamento de Fisiología y Farmacología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Mexico
| | - Carlos E Escárcega-González
- Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, Nuevo León, Mexico.,Centro de Investigación en Biotecnología y Nanotecnología, Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Erika Chavira-Suárez
- Unidad de Vinculación Científica de la Facultad de Medicina, Universidad Nacional Autónoma de México en el Instituto Nacional de Medicina Genómica, Mexico City, Mexico
| | - Angel León-Buitimea
- Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, Nuevo León, Mexico.,Centro de Investigación en Biotecnología y Nanotecnología, Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Priscila Vázquez-León
- Departamento de Fisiología y Farmacología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Mexico
| | - José R Morones-Ramírez
- Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, Nuevo León, Mexico.,Centro de Investigación en Biotecnología y Nanotecnología, Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, Nuevo León, Mexico
| | - Carlos M Villalón
- Departamento de Farmacobiología, Cinvestav-Coapa, Mexico City, Mexico
| | - Andrés Quintanar-Stephano
- Departamento de Fisiología y Farmacología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Mexico
| | - Bruno A Marichal-Cancino
- Departamento de Fisiología y Farmacología, Centro de Ciencias Básicas, Universidad Autónoma de Aguascalientes, Aguascalientes, Mexico
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Abstract
Objectives: Poor glycemic control is associated with mortality in critical patients with diabetes. The aim of the study was to assess the predicting value of stress hyperglycemia in patients with diabetes following hospital admission for sepsis. Design: Retrospective observational study. Setting: Adult, emergency department, and critical care in a district hospital. Patients: In a 10-year retrospective analysis of sepsis-related hospitalizations in the emergency department, we carried out a secondary analysis of 915 patients with diabetes (males, 54.0%) in whom both fasting glucose at entry and glycosylated hemoglobin were available. Interventions: None. Measurements and Main Results: Patients’ mean age was 79.0 (sd 11.0), glucose at admission was 174.0 mg/dL (74.3 mg/dL), and glycosylated hemoglobin was 7.7% (1.7%). Stress hyperglycemia was defined by the stress hyperglycemia ratio, that is, fasting glucose concentration at admission divided by the estimated average glucose derived from glycosylated hemoglobin. A total of 305 patients died (33.3%) in hospital. Factors associated with in-hospital case fatality rate were tested by multivariable logistic model. Ten variables predicting outcomes in the general population were confirmed in the presence of diabetes (male sex, older age, number of organ dysfunction diagnoses, in particular cardiovascular dysfunction, infection/parasitic, circulatory, respiratory, digestive diseases diagnosis, and Charlson Comorbidity Index). In addition, also glycemic control (glycosylated hemoglobin: odds ratio, 1.17; 95% CI, 1.15–1.40) and stress hyperglycemia (stress hyperglycemia ratio: 5.25; 3.62–7.63) were significant case fatality rate predictors. High stress hyperglycemia ratio (≥ 1.14) significantly increased the discriminant capacity (area under the receiver operating characteristic curve, 0.864; se, 0.013; p < 0.001). Conclusions: Stress hyperglycemia, even in the presence of diabetes, is predictive of mortality following admission for sepsis. Stress hyperglycemia ratio may be used to refine prediction of an unfavorable outcome.
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20
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Gómez AM, Imitola Madero A, Henao Carrillo DC, Rondón M, Muñoz OM, Robledo MA, Rebolledo M, García Jaramillo M, León Vargas F, Umpierrez G. Hypoglycemia Incidence and Factors Associated in a Cohort of Patients With Type 2 Diabetes Hospitalized in General Ward Treated With Basal Bolus Insulin Regimen Assessed by Continuous Glucose Monitoring. J Diabetes Sci Technol 2020; 14:233-239. [PMID: 30678495 PMCID: PMC7196858 DOI: 10.1177/1932296818823720] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Continuous glucose monitoring (CGM) is a better tool to detect hyper and hypoglycemia than capillary point of care in insulin-treated patients during hospitalization. We evaluated the incidence of hypoglycemia in patients with type 2 diabetes (T2D) treated with basal bolus insulin regimen using CGM and factors associated with hypoglycemia. METHODS Post hoc analysis of a prospective cohort study. Hypoglycemia was documented in terms of incidence rate and percentage of time <54 mg/dL (3.0 mmol/L) and <70 mg/dL (3.9 mmol/L). Factors evaluated included glycemic variability analyzed during the first 6 days of basal bolus therapy. RESULTS A total of 34 hospitalized patients with T2D in general ward were included, with admission A1c of 9.26 ± 2.62% (76.8 ± 13 mmol/mol) and mean blood glucose of 254 ± 153 mg/dL. There were two events of hypoglycemia below 54 mg/dL (3.0 mmol/L) and 11 events below 70 mg/dL (3.9 mmol/L) with an incidence of hypoglycemic events of 0.059 and 0.323 per patient, respectively. From second to fifth day of treatment the percentage of time in range (140-180 mg/dL, 7.8-10.0 mmol/L) increased from 72.1% to 89.4%. Factors related to hypoglycemic events <70 mg/dL (3.9 mmol/L) were admission mean glucose (IRR 0.86, 95% CI 0.79, 0.95, P < .01), glycemic variability measured as CV (IRR 3.12, 95% CI 1.33, 7.61, P < .01) and SD, and duration of stay. CONCLUSIONS Basal bolus insulin regimen is effective and the overall incidence of hypoglycemia detected by CGM is low in hospitalized patients with T2D. Increased glycemic variability as well as the decrease in mean glucose were associated with events <70 mg/dL (3.9 mmol/L).
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Affiliation(s)
- Ana María Gómez
- Pontificia Universidad Javeriana,
Bogotá, Colombia
- Hospital Universitario San Ignacio,
Endocrinology Unit, Bogotá, Colombia
- Ana María Gómez, MD, Endocrinology Unit,
Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Carrera 7
No. 40-62, Bogotá, Colombia.
| | - Angélica Imitola Madero
- Pontificia Universidad Javeriana,
Bogotá, Colombia
- Hospital Universitario San Ignacio,
Endocrinology Unit, Bogotá, Colombia
| | - Diana Cristina Henao Carrillo
- Pontificia Universidad Javeriana,
Bogotá, Colombia
- Hospital Universitario San Ignacio,
Endocrinology Unit, Bogotá, Colombia
| | - Martín Rondón
- Department of Clinical Epidemiology and
Biostatistics, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Oscar Mauricio Muñoz
- Hospital Universitario San Ignacio,
Department of Internal Medicine, Bogotá, Colombia
| | | | | | | | | | - Guillermo Umpierrez
- Department of Medicine, Emory
University, Atlanta, GA, USA
- Division of Endocrinology, Metabolism
and Lipids, Emory University, Atlanta, GA, USA
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21
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Chao WC, Tseng CH, Wu CL, Shih SJ, Yi CY, Chan MC. Higher glycemic variability within the first day of ICU admission is associated with increased 30-day mortality in ICU patients with sepsis. Ann Intensive Care 2020; 10:17. [PMID: 32034567 PMCID: PMC7007493 DOI: 10.1186/s13613-020-0635-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 01/30/2020] [Indexed: 12/29/2022] Open
Abstract
Background High glycemic variability (GV) is common in critically ill patients; however, the prevalence and mortality association with early GV in patients with sepsis remains unclear. Methods This retrospective cohort study was conducted in a medical intensive care unit (ICU) in central Taiwan. Patients in the ICU with sepsis between January 2014 and December 2015 were included for analysis. All of these patients received protocol-based management, including blood sugar monitoring every 2 h for the first 24 h of ICU admission. Mean amplitude of glycemic excursions (MAGE) and coefficient of variation (CoV) were used to assess GV. Results A total of 452 patients (mean age 71.4 ± 14.7 years; 76.7% men) were enrolled for analysis. They were divided into high GV (43.4%, 196/452) and low GV (56.6%, 256/512) groups using MAGE 65 mg/dL as the cut-off point. Patients with high GV tended to have higher HbA1c (6.7 ± 1.8% vs. 5.9 ± 0.9%, p < 0.01) and were more likely to have diabetes mellitus (DM) (50.0% vs. 23.4%, p < 0.01) compared with those in the low GV group. Kaplan–Meier analysis showed that a high GV was associated with increased 30-day mortality (log-rank test, p = 0.018). The association remained strong in the non-DM (log-rank test, p = 0.035), but not in the DM (log-rank test, p = 0.254) group. Multivariate Cox proportional hazard regression analysis identified that high APACHE II score (adjusted hazard ratio (aHR) 1.045, 95% confidence interval (CI) 1.013–1.078), high serum lactate level at 0 h (aHR 1.009, 95% CI 1.003–1.014), having chronic airway disease (aHR 0.478, 95% CI 0.302–0.756), high mean day 1 glucose (aHR 1.008, 95% CI 1.000–1.016), and high MAGE (aHR 1.607, 95% CI 1.008–2.563) were independently associated with increased 30-day mortality. The association with 30-day mortality remained consistent when using CoV to assess GV. Conclusions We found that approximately 40% of the septic patients had a high early GV, defined as MAGE > 65 mg/dL. Higher GV within 24 h of ICU admission was independently associated with increased 30-day mortality. These findings highlight the need to monitor GV in septic patients early during an ICU admission.
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Affiliation(s)
- Wen-Cheng Chao
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan.,Department of Critical Care Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan
| | - Chien-Hua Tseng
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan.,Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chieh-Liang Wu
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan.,Center of Quality Management, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan.,Department of Automatic Control Engineering, Feng Chia University, Taichung, Taiwan
| | - Sou-Jen Shih
- Department of Nursing, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan
| | - Chi-Yuan Yi
- Department of Nursing, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan
| | - Ming-Cheng Chan
- Division of Chest Medicine, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan. .,Division of Critical Care and Respiratory Therapy, Department of Internal Medicine, Taichung Veterans General Hospital, 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan. .,Central Taiwan University of Science and Technology, Taichung, Taiwan. .,The College of Science, Tunghai University, Taichung, 40704, Taiwan.
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22
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Association of multiple glycemic parameters at intensive care unit admission with mortality and clinical outcomes in critically ill patients. Sci Rep 2019; 9:18498. [PMID: 31811218 PMCID: PMC6897941 DOI: 10.1038/s41598-019-55080-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 11/15/2019] [Indexed: 12/14/2022] Open
Abstract
The aim of the present study was to investigate the association of multiple glycemic parameters at intensive care unit (ICU) admission with outcomes in critically ill patients. Critically ill adults admitted to ICU were included prospectively in the study and followed for 180 days until hospital discharge or death. Patients were assessed for glycemic gap, hypoglycemia, hyperglycemia, glycemic variability, and stress hyperglycemia ratio (SHR). A total of 542 patients were enrolled (30% with preexisting diabetes). Patients with glycemic gap >80 mg/dL had increased need for renal replacement therapy (RRT; 37.7% vs. 23.7%, p = 0.025) and shock incidence (54.7% vs. 37.4%, p = 0.014). Hypoglycemia was associated with increased mortality (54.8% vs. 35.8%, p = 0.004), need for RRT (45.1% vs. 22.3%, p < 0.001), mechanical ventilation (MV; 72.6% vs. 57.5%, p = 0.024), and shock incidence (62.9% vs. 35.8%, p < 0.001). Hyperglycemia increased mortality (44.3% vs. 34.9%, p = 0.031). Glycemic variability >40 mg/dL was associated with increased need for RRT (28.3% vs. 14.4%, p = 0.002) and shock incidence (41.4% vs.31.2%, p = 0.039). In this mixed sample of critically ill subjects, including patients with and without preexisting diabetes, glycemic gap, glycemic variability, and SHR were associated with worse outcomes, but not with mortality. Hypoglycemia and hyperglycemia were independently associated with increased mortality.
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Shao SC, Lin YH, Chang KC, Chan YY, Hung MJ, Kao Yang YH, Lai ECC. Sodium glucose co-transporter 2 inhibitors and cardiovascular event protections: how applicable are clinical trials and observational studies to real-world patients? BMJ Open Diabetes Res Care 2019; 7:7/1/e000742. [PMID: 32043472 PMCID: PMC6954814 DOI: 10.1136/bmjdrc-2019-000742] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 11/08/2019] [Accepted: 11/22/2019] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE This study evaluated the characteristics of new users of sodium glucose co-transporter 2 inhibitors (SGLT2i) in clinical practice to assess the applicability of the findings from clinical trials (Empagliflozin, Cardiovascular Outcomes and Mortality in Type 2 Diabetes (EMPA-REG OUTCOME) trial, Dapagliflozin Effect on Cardiovascular Events (DECLARE)-TIMI 58 trial, Canagliflozin Cardiovascular Assessment Study (CANVAS) program and the Evaluation of Ertugliflozin Efficacy and Safety Cardiovascular Outcomes (VERTIS-CV) trial) and multinational observational studies (CVD-REAL Nordic study and CVD-REAL 2 study). RESEARCH DESIGN AND METHODS We conducted a retrospective cohort study using the largest electronic medical records database from seven hospitals in Taiwan. We included adult patients with type 2 diabetes initiating canagliflozin, dapagliflozin and empagliflozin between 1 January 2018 and 31 August 2019. We compared the patient characteristics with SGLT2i to examine the data representativeness of clinical trials and to evaluate channeling uses between canagliflozin, dapagliflozin and empagliflozin. RESULTS We identified a cohort of 11 650 patients newly initiating SGLT2i, 49.9% of whom received empagliflozin. However, only 18.7%, 19.2%, 50.4% and 57.3% of real-world SGLT2i new users were included in the EMPA-REG OUTCOME trial, VERTIS-CV trial, DECLARE-TIMI 58 trial and CANVAS program, respectively. Reasons for exclusion were largely reduced cardiovascular disease risks in real-world patients, namely 72.8%, 73.6% and 34.2% for EMPA-REG OUTCOME trial, VERTIS-CV trial and DECLARE-TIMI 58 trial and CANVAS program, respectively. However, hemoglobin A1c out of range accounted for the most frequent reason (25.0%) for exclusion of real-world patients from the CANVAS program. We found channeling uses in different SGLT2i, for example, more patients receiving empagliflozin (15.3%) and canagliflozin (19.6%) had poorer renal functions (eg, estimated glomerular filtration rate <60 mL/min/1.73 m2), compared with dapagliflozin (9.3%). CONCLUSIONS The findings provide clear evidence that results from current studies may be less applicable to real-world patients. Further studies are required to support the concept of real-world cardiovascular event protection through SGLT2i.
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Affiliation(s)
- Shih-Chieh Shao
- Department of Pharmacy, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Han Lin
- Department of Pharmacy, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Kai-Cheng Chang
- Department of Pharmacy, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yuk-Ying Chan
- Department of Pharmaceutical Materials Management, Chang Gung Medical Foundation, Taoyuan, Taiwan
| | - Ming-Jui Hung
- Division of Cardiology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- Chang Gung University, College of Medicine, Taoyuan, Taiwan
| | - Yea-Huei Kao Yang
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Pharmacy, National Cheng Kung University Hospital, Tainan, Taiwan
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Iturbide-Casas MA, Cámara-Martos F, Molina-Luque R, Molina-Recio G. Survival Analysis of Enterally Fed Patients: Prognosis and Mortality Risk According to Baseline Characteristics. JPEN J Parenter Enteral Nutr 2019; 44:1057-1065. [PMID: 31736137 DOI: 10.1002/jpen.1745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 10/09/2019] [Accepted: 10/25/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Enteral nutrition is widely used. However, its benefits remain unclear in specific conditions like dementia. This study assesses the survival of enterally fed patients and the baseline characteristics associated with higher mortality. METHODS A retrospective analysis of biochemical and clinical data from 377 patients (age 77.5 ± 13.8) who received enteral tube feeding (ETF) at a tertiary hospital in Spain was performed. Kaplan-Meier and Cox regressions were used to analyze survival expectancy and mortality risk (MR). Risk was evaluated for 30/180 days and up to 5 years. RESULTS The most common individual diagnoses leading to ETF prescription were dementia (37.9%) and head/neck/upper-gastrointestinal-tract cancer (17.5%). Comorbidities (high blood pressure [HBP] and/or diabetes) were present in 72.4% of patients. The first 30 days after tube placement showed the highest mortality rate, corresponding to 85.4% of patients that did not continue being tube-fed. Multivariate Cox analysis (P < .05, 95% CI) showed HBP and glycemia to be predictive of overall (hazard ratio [HR] = 1.600; HR = 1.756) and long-term (HR = 3.092; HR = 4.539) death. In the short-term, only glycemia showed an increased MR (HR = 1.572). CONCLUSION This enterally fed population showed a noticeably high initial mortality rate. Despite official recommendations against it, ETF is very common in advanced dementia. Baseline characteristics are useful for identifying patients that would be less benefited by the intervention. Accordingly, families should be informed about realistic outcomes and risks derived from this procedure.
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Affiliation(s)
| | - Fernando Cámara-Martos
- Departamento de Bromatología y Tecnología de los Alimentos, Universidad de Córdoba, Córdoba, Spain
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Shao SC, Chang KC, Hung MJ, Yang NI, Chan YY, Chen HY, Kao Yang YH, Lai ECC. Comparative risk evaluation for cardiovascular events associated with dapagliflozin vs. empagliflozin in real-world type 2 diabetes patients: a multi-institutional cohort study. Cardiovasc Diabetol 2019; 18:120. [PMID: 31551068 PMCID: PMC6760106 DOI: 10.1186/s12933-019-0919-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 08/21/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND To compare the cardiovascular event risk in type 2 diabetes patients newly receiving dapagliflozin vs. empagliflozin. METHODS We conducted a retrospective cohort study by analyzing a multi-institutional electronic medical records database (Chang Gung Research Database) in Taiwan and included adult type 2 diabetes patients who were newly receiving sodium-glucose co-transporter 2 (SGLT2) inhibitors from 2016 to 2017. The primary outcome was a composite of cardiovascular death, myocardial infarction, ischemic stroke and heart failure. We followed up patients from initiation of SGLT2 inhibitors until the occurrence of cardiovascular events before December 31, 2018. We performed multivariable Cox proportional hazard modeling, adjusting for patients' age, sex, laboratory data, co-morbidities, and concomitant medications. RESULTS We identified 12,681 new SGLT2 inhibitor users with a mean age of 58.9 (SD 11.8) years, of whom 43.9% were female and 45.8% were new dapagliflozin users. A total of 10,442 person-years of dapagliflozin use and 12,096 person-years of empagliflozin use were included. Compared to empagliflozin users, new users of dapagliflozin were found to have similar risks for primary composite outcome (adjusted HR: 0.91; 95% CI 0.73-1.14), cardiovascular death (adjusted HR: 0.54; 95% CI 0.14-2.12), myocardial infarction (adjusted HR: 0.77, 95% CI 0.49-1.19) and ischemic stroke (adjusted HR: 1.15; 95% CI 0.80-1.65), but a lower risk of heart failure (adjusted HR: 0.68; 95% CI 0.49-0.95). CONCLUSION The risk of cardiovascular events was similar between dapagliflozin and empagliflozin new users, but dapagliflozin may have a better outcome in the reduction of heart failure in type 2 diabetes patients. Future prospective studies are required to confirm the findings.
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Affiliation(s)
- Shih-Chieh Shao
- Department of Pharmacy, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, No. 1, University Road, Tainan, 701 Taiwan
| | - Kai-Cheng Chang
- Department of Pharmacy, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Jui Hung
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Ning-I Yang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Yuk-Ying Chan
- Department of Pharmaceutical Materials Management, Chang Gung Medical Foundation, Taoyuan, Taiwan
| | - Hui-Yu Chen
- Department of Pharmacy, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yea-Huei Kao Yang
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, No. 1, University Road, Tainan, 701 Taiwan
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, No. 1, University Road, Tainan, 701 Taiwan
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Ben Hamou A, Kipnis E, Elbaz A, Bignon A, Nseir S, Tamion F, Du Cheyron D, Jaillette E, Voisin B, Robriquet L, Vanbaelinghem C, Thellier D, Abi Rached H, Jannin A, Duhamel A, Behal H, Machuron F, Espiard S, Preiser JC, Preau S, Pattou F, Jourdain M. Association of transcription factor 7-like 2 gene (TCF7L2) polymorphisms with stress-related hyperglycaemia (SRH) in intensive care and resulting outcomes: The READIAB study. DIABETES & METABOLISM 2019; 46:243-247. [PMID: 31121319 DOI: 10.1016/j.diabet.2019.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 05/03/2019] [Accepted: 05/05/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The study aimed to evaluate the impact of the single nucleotide polymorphism (SNP) rs7903146 on the transcription factor 7-like 2 (TCF7L2) gene in stress-related hyperglycaemia (SRH), defined as blood glucose≥11mmol/L in at least two blood samples during the first 3 days in the intensive care unit (ICU), and on 28-day and 1-year mortality, and incidence of type 2 diabetes (T2D) at 6 months and 1 year in patients hospitalized in the ICU. METHODS This prospective observational (non-interventional) multicentre READIAB study, carried out during 2012-2016 in six French ICUs, involved adult patients admitted to ICUs for at least two organ failures; patients admitted for<48h were excluded. During the 3-day ICU observational period, genetic testing, blood glucose values and insulin treatment were recorded. MAIN RESULTS The association of rs7903146 with SRH was assessed using logistic regression models. Cox proportional hazards regression models assessed the associations between rs7903146 and mortality and between SRH and mortality, both at 28 days and 1 year. A total of 991 of the 1000 enrolled patients were included in the READIAB-G4 cohort, but 242 (24.4%) had preexisting diabetes and were excluded from the analyses. SRH occurred within the first 3 days in the ICU for one-third of the non-diabetes patients. The association between the rs7903146 polymorphism and SRH did not reach significance (P=0.078): OR(peroneTcopy): 1.24, 95% CI: 0.98-1.58. A significant association was found between rs7903146 and 28-day mortality after adjusting for severity scores (P=0.026), but was no longer significant at 1 year (P=0.61). At 28 days, mortality was increased in patients with SRH (HR: 2.09, 95% CI: 1.43-3.06; P<0.001), and remained significant at 1 year after adjusting for severity scores (HR: 1.73, 95% CI: 1.32-2.28; P<0.001). On admission, non-diabetes patients with SRH had a higher incidence of T2D at 6 months vs. those without SRH (16.0% vs. 7.6%, RR: 2.11, 95% CI: 1.07-4.20; P=0.030). At 1 year, these figures were 13.4% vs. 9.2%, RR: 1.45, 95% CI: 0.71-2.96; P=0.31). Moreover, the rs7903146 polymorphism was not significantly associated with T2D development at either 6 months (P=0.72) or 1 year (P=0.64). CONCLUSION This study failed to demonstrate any significant association between rs7903146 and SRH. Nevertheless, the issue remains an important challenge, as SRH may be associated with increased rates of both mortality and T2D development.
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Affiliation(s)
- A Ben Hamou
- Endocrinology, Diabetology and Metabolism, CHU de Lille, 59000 Lille, France
| | - E Kipnis
- Medical School, université de Lille, 59000 Lille, France; Department of Anesthesiology and Critical care, CHU de Lille, 59000 Lille, France; EA 7366-Host Pathogen Translational Research, université de Lille, 59000 Lille, France
| | - A Elbaz
- Intensive Care Unit, CHU de Lille, 59000 Lille, France
| | - A Bignon
- Department of Anesthesiology and Critical care, CHU de Lille, 59000 Lille, France
| | - S Nseir
- Intensive Care Unit, CHU de Lille, 59000 Lille, France; Medical School, université de Lille, 59000 Lille, France
| | - F Tamion
- Intensive Care Unit, CHU de Rouen, 76031, Rouen, France; UMR 1096 Inserm-Université de Rouen-Biologie, médecine, santé-Endothélium, Valvulopathies et Insuffisance Cardiaque, 76031 Rouen, France
| | - D Du Cheyron
- Intensive Care Unit, CHU de Caen, 14033 Caen, France
| | - E Jaillette
- Intensive Care Unit, CHU de Lille, 59000 Lille, France
| | - B Voisin
- Intensive Care Unit, CHU de Lille, 59000 Lille, France
| | - L Robriquet
- Intensive Care Unit, CHU de Lille, 59000 Lille, France
| | - C Vanbaelinghem
- Intensive Care Unit, Victor Provo Hospital Center, 59100 Roubaix, France
| | - D Thellier
- Intensive Care Unit, Guy Chatiliez Hospital Center, 59200 Tourcoing, France
| | - H Abi Rached
- Endocrinology, Diabetology and Metabolism, CHU de Lille, 59000 Lille, France
| | - A Jannin
- Endocrinology, Diabetology and Metabolism, CHU de Lille, 59000 Lille, France
| | - A Duhamel
- Medical School, université de Lille, 59000 Lille, France; EA 2694 - Public Health, Epidemiology and Quality of Care, université de Lille, 59000 Lille, France
| | - H Behal
- EA 2694 - Public Health, Epidemiology and Quality of Care, université de Lille, 59000 Lille, France
| | - F Machuron
- EA 2694 - Public Health, Epidemiology and Quality of Care, université de Lille, 59000 Lille, France
| | - S Espiard
- Endocrinology, Diabetology and Metabolism, CHU de Lille, 59000 Lille, France; Medical School, université de Lille, 59000 Lille, France
| | - J-C Preiser
- Department of Intensive Care, CUB-Erasme, université Libre de Bruxelles (ULB), Brussels, Belgium
| | - S Preau
- Intensive Care Unit, CHU de Lille, 59000 Lille, France
| | - F Pattou
- Endocrinology, Diabetology and Metabolism, CHU de Lille, 59000 Lille, France; UMR 1190 Inserm Translational research in diabetes, 59000 Lille, France; EGID European Genomics Institute for Diabetes, CHU de Lille, 59000 Lille, France
| | - M Jourdain
- Intensive Care Unit, CHU de Lille, 59000 Lille, France; Medical School, université de Lille, 59000 Lille, France; PRESAGE Simulation Center, université de Lille, 59000 Lille, France; UMR 1190 Inserm Translational research in diabetes, 59000 Lille, France; EGID European Genomics Institute for Diabetes, CHU de Lille, 59000 Lille, France.
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Ye J, Liang Q, Xi X. Some questions about preadmission metformin use and mortality in patients with sepsis and diabetes mellitus. Crit Care 2019; 23:96. [PMID: 30909925 PMCID: PMC6434853 DOI: 10.1186/s13054-019-2392-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/13/2019] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jiarong Ye
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine and Guangdong Provincial Hospital of Chinese Medicine, No. 111, Dade Road, Yuexiu District, Guangzhou, 510120, China
| | - Qianrong Liang
- Guangdong University of Foreign Studies, No. 2, Baiyun Avenue North, Baiyun District, Guangzhou, 510420, China
| | - Xiaotu Xi
- The Second Affiliated Hospital of Guangzhou University of Chinese Medicine and Guangdong Provincial Hospital of Chinese Medicine, No. 111, Dade Road, Yuexiu District, Guangzhou, 510120, China.
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28
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Chen KF, Tsai MY, Wu CC, Han ST. Effectiveness of Treatments and Diagnostic Tools and Declining Mortality in Patients With Severe Sepsis: A 12-Year Population-Based Cohort Study. J Intensive Care Med 2019; 35:1418-1425. [PMID: 30700200 DOI: 10.1177/0885066619827270] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Sepsis is a major cause of morbidity and mortality worldwide. With the advance of medical care, the mortality of sepsis has decreased in the past decades. Many treatments and diagnostic tools still lack supporting evidence. We conducted a retrospective population-based cohort study with propensity score matched subcohorts based on a prospectively collected national longitudinal health insurance database in Taiwan. Severe sepsis-associated hospital admissions from 2000 to 2011 based on International Classification of Diseases, Ninth Revision, Clinical Modification codes of infections and acute organ dysfunction were identified. To compare the effectiveness of treatment and diagnostic tool, propensity scores were generated to match the comparable control groups. During the 12-year period, 33 375 patients and 50 465 hospitalizations of severe sepsis were identified. The age-standardized 28-day in-hospital mortality decreased significantly from 21% in 2008 to 15% in 2011 with increasingly implemented treatment and diagnostic tool. After propensity score matching, procalcitonin (odds ratio [OR]: 0.70, 95% confidence interval [95% CI]: 0.61-0.81) and lactate testing (OR: 0.90, 95% CI: 0.84-0.97, respectively), transfusion of packed red blood cell (OR: 0.60, 95% CI: 0.52-0.69), albumin (OR: 0.72, 95% CI: 0.55-0.93), balanced crystalloid (OR: 0.29, 95% CI: 0.20-0.41), and use of dopamine (OR: 0.44, 95% CI: 0.39-0.49) were found to be significantly associated with lower mortality rate. However, inconsistent findings need to be further validated.
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Affiliation(s)
- Kuan-Fu Chen
- Department of Emergency Medicine, 125573Chang Gung Memorial Hospital, Keelung.,Department of Emergency Medicine, 125573Chang Gung Memorial Hospital, Linkou.,Clinical Informatics and Medical Statistics Research Center, Chang Gung University, Taoyuan.,Community Medicine Research Center, 125573Chang Gung Memorial Hospital, Keelung
| | - Meng-Ying Tsai
- Department of Emergency Medicine, 125573Chang Gung Memorial Hospital, Linkou
| | - Chin-Chieh Wu
- Department of Emergency Medicine, 125573Chang Gung Memorial Hospital, Keelung
| | - Shih-Tsung Han
- Department of Emergency Medicine, 125573Chang Gung Memorial Hospital, Linkou
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29
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Shao SC, Chan YY, Kao Yang YH, Lin SJ, Hung MJ, Chien RN, Lai CC, Lai ECC. The Chang Gung Research Database-A multi-institutional electronic medical records database for real-world epidemiological studies in Taiwan. Pharmacoepidemiol Drug Saf 2019; 28:593-600. [PMID: 30648314 DOI: 10.1002/pds.4713] [Citation(s) in RCA: 186] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 09/11/2018] [Accepted: 11/08/2018] [Indexed: 01/12/2023]
Abstract
PURPOSE The Chang Gung Research Database (CGRD), the largest multi-institutional electronic medical records (EMR) collection in Taiwan, provides good access for researchers to efficiently use the standardized patient-level data. This study evaluates the capacity and representativeness of the CGRD to promote secondary use of EMR data for clinical research with more accurate estimates. METHODS The National Health Insurance Research Database (NHIRD) which covers over 99.9% of the Taiwanese population served as the comparator in this study. We compare the data components of the CGRD with the NHIRD, including records for health care facilities, patients, diagnoses, drugs, and procedures. Using the chi-square test, we compared the distributions of age categories and sex of patients, and the rates of their health conditions between NHIRD and CGRD based on the year 2015. RESULTS The CGRD contains more clinical information such as pathological and laboratory results than the NHIRD. The CGRD includes 6.1% of outpatients and 10.2% of hospitalized patients from the NHIRD. We found the CGRD includes more elderly outpatients (23.5% vs 12.5%) and pediatric inpatients (19.7% vs 14.4%) compared with the NHIRD. We found patients' sex distributions were similar between CGRD and NHIRD, but coverage rates of severe conditions, such as cancer, were higher than other health conditions in CGRD. CONCLUSIONS The CGRD could serve as the basis for accurate estimates in medical studies. However, researchers should pay special attention to selection biases since patients' characteristics from CGRD differ from those of the national database.
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Affiliation(s)
- Shih-Chieh Shao
- Department of Pharmacy, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan.,School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yuk-Ying Chan
- Department of Pharmacy, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yea-Huei Kao Yang
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Swu-Jane Lin
- Department of Pharmacy Systems, Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Ming-Jui Hung
- Section of Cardiology, Department of Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Rong-Nan Chien
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chi-Chun Lai
- Department of Ophthalmology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Department of Pharmacy, National Cheng Kung University Hospital, Tainan, Taiwan
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30
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Diebel LN, Liberati DM, Martin JV. Acute hyperglycemia increases sepsis related glycocalyx degradation and endothelial cellular injury: A microfluidic study. Am J Surg 2019; 217:1076-1082. [PMID: 30635208 DOI: 10.1016/j.amjsurg.2018.12.066] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 11/16/2018] [Accepted: 12/29/2018] [Indexed: 11/15/2022]
Abstract
BACKGROUND Hyperglycemia promotes vascular inflammation; however its effect on endothelial dysfunction in sepsis is unknown. Microfluidic devices (MFD) may closely mimic the in vivo endothelial cell microenvironment. We hypothesized that stress glucose concentrations would increase sepsis related endothelial injury/activation. METHODS Human umbilical vein endothelial cell (HUVEC) monolayers were established in microfluidic channels. TNF was added followed by glucose. Endothelial glycocalyx (EG) integrity was indexed by shedding of the EG components as well as thickness. Endothelial cell (EC) injury/activation was indexed by soluble biomarkers. Intracellular reactive oxygen species (ROS) was by fluorescence. RESULTS TNF increased glycocalyx degradation and was associated with biomarkers of EC injury. These vascular barrier derangements were further increased by hyperglycemia. This may be related to increase ROS species generated followed by the combined insults. CONCLUSION MFD technology may be a useful platform to study endothelial barrier function and stress conditions and allow preclinical assessment of potential therapies.
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Affiliation(s)
- Lawrence N Diebel
- Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, MI, USA.
| | - David M Liberati
- Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, MI, USA.
| | - Jonathan V Martin
- Michael and Marian Ilitch Department of Surgery, Wayne State University, Detroit, MI, USA.
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31
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Zhang Z. Prediction model for patients with acute respiratory distress syndrome: use of a genetic algorithm to develop a neural network model. PeerJ 2019; 7:e7719. [PMID: 31576250 PMCID: PMC6752189 DOI: 10.7717/peerj.7719] [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] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 08/21/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is associated with significantly increased risk of death, and early risk stratification may help to choose the appropriate treatment. The study aimed to develop a neural network model by using a genetic algorithm (GA) for the prediction of mortality in patients with ARDS. METHODS This was a secondary analysis of two multicenter randomized controlled trials conducted in forty-four hospitals that are members of the National Heart, Lung, and Blood Institute, founded to create an acute respiratory distress syndrome Clinical Trials Network. Model training and validation were performed using the SAILS and OMEGA studies, respectively. A GA was employed to screen variables in order to predict 90-day mortality, and a neural network model was trained for the prediction. This machine learning model was compared to the logistic regression model and APACHE III score in the validation cohort. RESULTS A total number of 1,071 ARDS patients were included for analysis. The GA search identified seven important variables, which were age, AIDS, leukemia, metastatic tumor, hepatic failure, lowest albumin, and FiO2. A representative neural network model was constructed using the forward selection procedure. The area under the curve (AUC) of the neural network model evaluated with the validation cohort was 0.821 (95% CI [0.753-0.888]), which was greater than the APACHE III score (0.665; 95% CI [0.590-0.739]; p = 0.002 by Delong's test) and logistic regression model, albeit not statistically significant (0.743; 95% CI [0.669-0.817], p = 0.130 by Delong's test). CONCLUSIONS The study developed a neural network model using a GA, which outperformed conventional scoring systems for the prediction of mortality in ARDS patients.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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32
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Akirov A, Diker-Cohen T, Masri-Iraqi H, Duskin-Bitan H, Shimon I, Gorshtein A. Outcomes of hyperglycemia in patients with and without diabetes hospitalized for infectious diseases. Diabetes Metab Res Rev 2018; 34:e3027. [PMID: 29774650 DOI: 10.1002/dmrr.3027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 04/28/2018] [Accepted: 05/03/2018] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To examine the prognostic implications of diabetes mellitus (DM) and the importance of glycemic control during hospitalization for infectious diseases. METHODS Historical prospectively collected data of patients hospitalized between 2011 and 2013. Infection-related hospitalizations were classified according to site of infection. Median follow-up was 4.5 years. Outcome measures included in-hospital and end-of-follow-up mortality. RESULTS The cohort included 8051 patients (50% female, mean age ± SD, 68 ± 20 years) with a primary diagnosis of an infectious disease. Of these, 2363 patients (29%) had type 2 DM. The most common infectious sites included respiratory tract (n = 3285), genitourinary tract (n = 1804), skin and soft tissue (n = 934) and gastrointestinal tract (n = 571). There was no difference in admission rates of patients with and without DM according to the site of infection, except for skin and soft tissue infection which were more common among patients with DM (16% vs 10%). In-hospital mortality risk was greater in patients with DM (aOR = 1.3, 95% CI = 1.1-1.7). In the entire cohort, adjusted mortality risk (aHR, 95% CI) at the end-of-follow-up was greater among patients with DM (1.2, 1.1-1.4), with increased mortality risk following hospitalization for respiratory (1.1, 1.0-1.4) and skin and soft tissue infections (1.7, 1.3-2.3). In-hospital and end-of-follow-up mortality risk were highest among patients with and without DM with median glucose >180 mg/dL during hospitalization. CONCLUSIONS In patients hospitalized for infectious diseases, DM is associated with increased long-term mortality risk, specifically following hospitalization for respiratory and skin and soft tissue infections. Poor glycemic control during hospitalization is associated with increased long-term mortality.
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Affiliation(s)
- Amit Akirov
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Talia Diker-Cohen
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Internal Medicine A, Beilinson Hospital, Petach Tikva, Israel
| | - Hiba Masri-Iraqi
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hadar Duskin-Bitan
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Shimon
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Gorshtein
- Institute of Endocrinology, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Zoppini G, Fedeli U, Schievano E, Dauriz M, Targher G, Bonora E, Corti MC. Mortality from infectious diseases in diabetes. Nutr Metab Cardiovasc Dis 2018; 28:444-450. [PMID: 29519560 DOI: 10.1016/j.numecd.2017.12.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 12/12/2017] [Accepted: 12/18/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS To investigate the risk of mortality from infections by comparing the underlying causes of death versus the multiple causes of death in known diabetic subjects living in the Veneto region of Northern Italy. METHODS AND RESULTS A total of 185,341 subjects with diabetes aged 30-89 years were identified in the year 2010, and causes of death were assessed from 2010 to 2015. Standardized Mortality Ratios (SMRs) with 95% confidence intervals (CIs) were computed with regional mortality rates as reference. The underlying causes of death and all the diseases reported in the death certificates were scrutinized. At the end of the follow-up, 36,382 subjects had deceased. We observed an increased risk of death from infection-related causes in subjects with diabetes with a SMR of 1.83 (95% CI, 1.71-1.94). The SMR for death from septicemia was 1.91 (95% CI, 1.76-2.06) and from pneumonia was 1.47 (95% CI, 1.36-1.59). The use of the multiple causes of death approach emphasized the association of infectious diseases with mortality. CONCLUSION The results of the present study demonstrate an excess mortality due to infection-related diseases in patients with diabetes; more interestingly, by routine mortality analyses, the results show a possible underestimation of the effect of these diseases on mortality.
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Affiliation(s)
- G Zoppini
- Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Hospital Trust of Verona, Verona, Italy.
| | - U Fedeli
- Regional Epidemiology Service, Veneto Region, Italy
| | - E Schievano
- Regional Epidemiology Service, Veneto Region, Italy
| | - M Dauriz
- Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Hospital Trust of Verona, Verona, Italy
| | - G Targher
- Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Hospital Trust of Verona, Verona, Italy
| | - E Bonora
- Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Hospital Trust of Verona, Verona, Italy
| | - M C Corti
- Regional Epidemiology Service, Veneto Region, Italy
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