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Huang CY, Chou SE, Huang CY, Tsai CH, Hsu SY, Hsieh CH. Role of the Stress Index in Predicting Mortality among Patients with Traumatic Femoral Fractures. Diagnostics (Basel) 2024; 14:1508. [PMID: 39061646 PMCID: PMC11275851 DOI: 10.3390/diagnostics14141508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Revised: 07/02/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Traumatic femoral fractures, often resulting from high-energy impacts such as traffic accidents, necessitate immediate management to avoid severe complications. The Stress Index (SI), defined as the glucose-to-potassium ratio, serves as a predictor of mortality and adverse outcomes in various trauma contexts. This study aims to evaluate the prognostic value of the SI in patients with traumatic femoral fractures. METHODS This retrospective cohort study included adult trauma patients aged 20 or above with traumatic femoral fractures from the Trauma Registry System at a level 1 trauma center in southern Taiwan between 1 January 2009 and 31 December 2022. At the emergency room, serum electrolyte levels were assessed using baseline laboratory testing. By dividing blood glucose (mg/dL) by potassium (mEq/L), the SI was calculated. The best cut-off value of the SI for predicting mortality was determined using the Area Under the Curve (AUC) of Receiver Operating Characteristic (ROC). RESULTS A total of 3717 patients made up the final group, of which 3653 survived and 64 died. In comparison to survivors, deceased patients had substantially higher blood glucose levels (199.3 vs. 159.0 mg/dL, p < 0.001) and SIs (53.1 vs. 41.6, p < 0.001). The optimal SI cut-off value for predicting mortality was 49.7, with a sensitivity of 53.1% and a specificity of 78.7% (AUC = 0.609). High SI was associated with increased mortality (4.2% vs. 1.0%, p < 0.001) and longer hospital stays (12.8 vs. 9.5 days, p < 0.001). The adjusted odds ratios of mortality, controlled by comorbidities, the Glasgow Coma Scale, and the Injury Severity Score, were significantly higher in patients with a higher SI (AOR 2.05, p = 0.016) than those with a lower SI. CONCLUSIONS Elevated SI upon admission correlates with higher mortality and extended hospital stay in patients with traumatic femoral fractures. Although the SI has a moderate predictive value, it remains a useful early risk assessment tool, necessitating further prospective, multi-center studies for validation and standardization.
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Affiliation(s)
- Ching-Ya Huang
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 83301, Taiwan;
| | - Sheng-En Chou
- Department of General Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 83301, Taiwan;
| | - Chun-Ying Huang
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 83301, Taiwan; (C.-Y.H.); (C.-H.T.); (S.-Y.H.)
| | - Ching-Hua Tsai
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 83301, Taiwan; (C.-Y.H.); (C.-H.T.); (S.-Y.H.)
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 83301, Taiwan; (C.-Y.H.); (C.-H.T.); (S.-Y.H.)
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 83301, Taiwan;
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Huang CY, Rau CS, Huang CY, Su WT, Hsu SY, Hsieh CH. The Stress Index as a Predictor of Mortality in Patients with Isolated Moderate to Severe Traumatic Brain Injury. Diagnostics (Basel) 2024; 14:1244. [PMID: 38928658 PMCID: PMC11203316 DOI: 10.3390/diagnostics14121244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 06/07/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND The Stress Index (SI), calculated as the ratio of blood glucose to serum potassium levels, is a promising prognostic marker in various acute care settings. This study aimed to evaluate the utility of the SI for predicting mortality in patients with isolated moderate-to-severe traumatic brain injury (TBI). METHODS This retrospective cohort study included adult trauma patients (aged ≥ 20 years) with isolated moderate to severe TBI (Abbreviated Injury Scale ≥ 3 for only head region) treated from 2009-2022. The SI was computed from the initial glucose and potassium levels upon arrival at the emergency department. Logistic regression models were used to assess the association between the SI and mortality after adjusting for relevant covariates. The most effective threshold value of the SI for predicting mortality was identified using receiver operating characteristic (ROC) analysis. RESULTS Among the 4357 patients with isolated moderate and severe TBI, 463 (10.6%) died. Deceased patients had a significantly higher SI (61.7 vs. 44.1, p < 0.001). In multivariate analysis, higher SI independently predicted greater mortality risk (odds ratio (OR) 6.70, 95% confidence interval (CI) 1.66-26.99, p = 0.007). The optimal SI cutoff for predicting mortality was 48.50 (sensitivity 62.0%, specificity 71.4%, area under the curve 0.724). Patients with SI ≥ 48.5 had nearly two-fold higher adjusted mortality odds compared to those below the threshold (adjusted OR 1.94, 95% CI 1.51-2.50, p < 0.001). CONCLUSIONS SI is a useful predictor of mortality in patients with isolated moderate-to-severe TBI. Incorporating SI with standard clinical assessments could enhance risk stratification and management approaches for this patient population.
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Affiliation(s)
- Ching-Ya Huang
- Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan;
| | - Cheng-Shyuan Rau
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan;
| | - Chun-Ying Huang
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (C.-Y.H.); (W.-T.S.); (S.-Y.H.)
| | - Wei-Ti Su
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (C.-Y.H.); (W.-T.S.); (S.-Y.H.)
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (C.-Y.H.); (W.-T.S.); (S.-Y.H.)
| | - Ching-Hua Hsieh
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (C.-Y.H.); (W.-T.S.); (S.-Y.H.)
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Rugg C, Schmid S, Zipperle J, Kreutziger J. Stress hyperglycaemia following trauma - a survival benefit or an outcome detriment? Curr Opin Anaesthesiol 2024; 37:131-138. [PMID: 38390910 DOI: 10.1097/aco.0000000000001350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW Stress hyperglycaemia occur often in critically injured patients. To gain new consideration about it, this review compile current as well as known immunological and biochemical findings about causes and emergence. RECENT FINDINGS Glucose is the preferred energy substrate for fending immune cells, reparative tissue and the cardiovascular system following trauma. To fulfil these energy needs, the liver is metabolically reprogrammed to rebuild glucose from lactate and glucogenic amino acids (hepatic insulin resistance) at the expenses of muscles mass and - to a less extent - fat tissue (proteolysis, lipolysis, peripheral insulin resistance). This inevitably leads to stress hyperglycaemia, which is evolutionary preserved and seems to be an essential and beneficial survival response. It is initiated by damage-associated molecular patterns (DAMPs) and pathogen-associated molecular patterns (PAMPs), intensified by immune cells itself and mainly ruled by tumour necrosis factor (TNF)α and catecholamines with lactate and hypoxia inducible factor (HIF)-1α as intracellular signals and lactate as an energy shuttle. Important biochemical mechanisms involved in this response are the Warburg effect as an efficient metabolic shortcut and the extended Cori cycle. SUMMARY Stress hyperglycaemia is beneficial in an acute life-threatening situation, but further research is necessary, to prevent trauma patients from the detrimental effects of persisting hyperglycaemia.
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Affiliation(s)
- Christopher Rugg
- Department of Anaesthesia and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schmid
- Department of Anaesthesia and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Zipperle
- Johannes Zipperle, Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, Vienna, Austria
| | - Janett Kreutziger
- Department of Anaesthesia and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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Rau CS, Kuo SCH, Tsai CH, Chou SE, Su WT, Hsu SY, Hsieh CH. Elevation of White Blood Cell Subtypes in Adult Trauma Patients with Stress-Induced Hyperglycemia. Diagnostics (Basel) 2023; 13:3451. [PMID: 37998587 PMCID: PMC10670758 DOI: 10.3390/diagnostics13223451] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/13/2023] [Accepted: 11/13/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Blood immune cell subset alterations following trauma can indicate a patient's immune-inflammatory status. This research explored the influence of stress-induced hyperglycemia (SIH) on platelet counts and white blood cell (WBC) subtypes, including the derived indices of the monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR), in trauma patients. METHODS We studied 15,480 adult trauma patients admitted from 1 January 1998 to 31 December 2022. They were categorized into four groups: nondiabetic normoglycemia (NDN, n = 11,602), diabetic normoglycemia (DN, n = 1750), SIH (n = 716), and diabetic hyperglycemia (DH, n = 1412). A propensity score-matched cohort was formed after adjusting for age, sex, and comorbidities, allowing for comparing the WBC subtypes and platelet counts. RESULTS Patients with SIH exhibited significantly increased counts of monocytes, neutrophils, and lymphocytes in contrast to NDN patients. However, no significant rise in platelet counts was noted in the SIH group. There were no observed increases in these cell counts in either the DN or DH groups. CONCLUSIONS Our results demonstrated that trauma patients with SIH showed significantly higher counts of monocytes, neutrophils, and lymphocytes when compared to NDN patients, whereas the DN and DH groups remained unaffected. This underscores the profound association between SIH and elevated levels of specific WBC subtypes.
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Affiliation(s)
- Cheng-Shyuan Rau
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung City 83301, Taiwan;
| | - Spencer Chia-Hao Kuo
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung City 83301, Taiwan;
| | - Ching-Hua Tsai
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung City 83301, Taiwan; (C.-H.T.); (S.-E.C.); (W.-T.S.); (S.-Y.H.)
| | - Sheng-En Chou
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung City 83301, Taiwan; (C.-H.T.); (S.-E.C.); (W.-T.S.); (S.-Y.H.)
| | - Wei-Ti Su
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung City 83301, Taiwan; (C.-H.T.); (S.-E.C.); (W.-T.S.); (S.-Y.H.)
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung City 83301, Taiwan; (C.-H.T.); (S.-E.C.); (W.-T.S.); (S.-Y.H.)
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University, Kaohsiung City 83301, Taiwan;
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Cianni L, Caredda M, De Fazio A, Basilico M, Greco T, Cazzato G, Perisano C, Maccauro G, Vitiello R. Stress-Induced Hyperglycemia is a Risk Factor for Surgical-Site Infections in Nondiabetic Patients with Open Leg Fractures. Adv Orthop 2023; 2023:6695648. [PMID: 37920443 PMCID: PMC10620027 DOI: 10.1155/2023/6695648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 09/24/2023] [Accepted: 10/04/2023] [Indexed: 11/04/2023] Open
Abstract
Background Nondiabetic patients with open leg fractures who have elevated blood glucose levels on arrival in the emergency department have an increased risk of surgical-site infections (SSIs). Objective This study evaluates the association between the incidence of SSIs in nondiabetic patients with an open leg fracture and blood glucose levels registered on arrival in the ER. We also analyzed the correlation between patients' days of hospital stay and the incidence of SSIs and the time elapsed between the damage control with external fixation and final fixation and the incidence of SSI. Methods We retrospectively studied nondiabetic patients admitted to our emergency unit from 2017 to 2021 with a diagnosis of open leg fracture consecutively treated. Based on the diagnosis of SSIs, all enrolled patients were divided into two groups based on the developed (group A) or not developed (group B) SSIs within 1 year after surgery. All patients enrolled in the study underwent damage control within 24 hours after admission to the ER. At stabilization of general clinical and local wound conditions, all patients underwent definitive surgery. Results We enrolled 80 patients. In group A, glycemia on arrival in the ER was on average 148.35 ± 19.59 mg/dl, and in group B, it was 122.61 ± 22.22 mg/dl (p value: 0.0001). In group A, glycemia in the first postoperative day was on average 113.81 ± 21.07 mg/dl, and in group B, it was 99.02 ± 17.60 mg/dl (p value: 0.001). In group A, the average hospitalization was 57.92 ± 42.43 days, and in group B, it was 18.41 ± 14.21 days (p value: 0.01). Through Youden's J, we therefore analyzed the value with the highest sensitivity and specificity which proved to be 132 mg/dl. Conclusion Our findings show that nondiabetic patients with SIH have a significantly increased risk of SSIs compared to patients without SIH within 1 year after surgery. Patients with open leg fractures with SIH have a significantly higher average hospital stay than patients without SIH. Further studies are needed to confirm 132 mg/dl of blood glucose levels as a value to stratify the risk of SSIs in these patients.
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Affiliation(s)
- Luigi Cianni
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - Matteo Caredda
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - Andrea De Fazio
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | | | - Tommaso Greco
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | | | - Carlo Perisano
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
| | - Giulio Maccauro
- Fondazione Policlinico Universitario A. Gemelli IRCSS, Rome, Italy
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Heldreth AC, Demissie S, Pandya S, Baker M, Gallagher A, Copty M, Azab B, Moko L, Atanassov K, Gave A, Shimotake L, Glinik G, Gross J, Younan D. Stress-Induced (Not Diabetic) Hyperglycemia is Associated With Mortality in Geriatric Trauma Patients. J Surg Res 2023; 289:247-252. [PMID: 37150079 DOI: 10.1016/j.jss.2023.02.039] [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: 04/13/2022] [Revised: 01/31/2023] [Accepted: 02/19/2023] [Indexed: 05/09/2023]
Abstract
INTRODUCTION Stress-induced hyperglycemia (SIH) is associated with worse outcomes among trauma patients. It is also known that injured geriatric patients have higher mortality when compared to younger patients. We sought to investigate the association of all levels of SIH with mortality among geriatric trauma patients at a level 1 academic trauma center. We hypothesized that SIH in the geriatric trauma population would be associated with increased mortality. METHODS A retrospective review of all geriatric patients admitted to our level 1 trauma center over a 3-year period (January 2018-December 2020) was performed using the institutional trauma database. Data collected included demographics, injury severity score (ISS), emergency department (ED) blood glucose level, ED systolic blood pressure (SBP), and mortality. Patients were divided into 4 groups based on emergency room blood glucose level, as follows: normoglycemic (<120 mg/dL), mild hyperglycemia (120-150 mg/dL), moderate hyperglycemia (151-199 mg/dL), and severe hyperglycemia (≥200 mg/dL). Multivariable logistic regression analysis was performed to evaluate the association of SIH and in-hospital mortality adjusting for ISS, age, comorbidities, and ED SBP. RESULTS A total of 4432 geriatric trauma patients were admitted during the study period, of which 3358 patients (75.8%) were not diabetic. There were 2206 females (65.7%), 2993 were White (89.2%), with a mean age of 81.5 y. There were 114 deaths (3.4%). Univariate results showed that there was a statistically significant association between mortality and glucose groups (P < 0.01). The number of deaths in the four glucose groups were, as follows: 30 (2.0%), 32 (3.8%), 20 (6.2%), and 10 (12.2%), respectively. Multivariable logistic regression analysis results showed that compared to the normoglycemic group, the risk of death was higher in the mild, moderate, and severe glucose groups, as follows: mild group (OR 1.80, 95% confidence interval [CI] 1.04-3.13, P 0.04), moderate group (OR 2.53, 95% CI 1.34-4.80, P < 0.01), and severe group (OR 5.04, 95% CI 2.18-11.67, P < 0.01). CONCLUSIONS Mild, moderate, and severe SIH are statistically significant predictors of death among geriatric trauma patients independently of ISS, age, comorbidities, and SBP.
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Affiliation(s)
- Audrey C Heldreth
- Division of Acute Care Surgery, The Department of Surgery, Staten Island University Hospital, Staten Island, New York.
| | - Seleshi Demissie
- Biostatistics Unit, Feinstein Institutes for Medical Research, Staten Island University Hospital, Staten Island, New York
| | - Shreya Pandya
- Division of Acute Care Surgery, The Department of Surgery, Staten Island University Hospital, Staten Island, New York
| | - Matthew Baker
- Division of Acute Care Surgery, The Department of Surgery, Staten Island University Hospital, Staten Island, New York
| | - Alayna Gallagher
- Division of Acute Care Surgery, The Department of Surgery, Staten Island University Hospital, Staten Island, New York
| | - Michael Copty
- Division of Acute Care Surgery, The Department of Surgery, Staten Island University Hospital, Staten Island, New York
| | - Basem Azab
- Division of Surgical Oncology, Department of Surgery, Staten Island University Hospital, Staten Island, New York
| | - Lilamarie Moko
- Division of Acute Care Surgery, The Department of Surgery, Staten Island University Hospital, Staten Island, New York
| | - Krassimir Atanassov
- Division of Acute Care Surgery, The Department of Surgery, Staten Island University Hospital, Staten Island, New York
| | - Asaf Gave
- Division of Acute Care Surgery, The Department of Surgery, Staten Island University Hospital, Staten Island, New York
| | - Lisa Shimotake
- Division of Minimally Invasive Surgery, Department of Surgery, Staten Island University Hospital, Staten Island, New York
| | - Galina Glinik
- Division of Acute Care Surgery, The Department of Surgery, Staten Island University Hospital, Staten Island, New York
| | - Jonathan Gross
- Division of Orthopedic Surgery, Department of Surgery, Staten Island University Hospital, Staten Island, New York
| | - Duraid Younan
- Division of Acute Care Surgery, The Department of Surgery, Staten Island University Hospital, Staten Island, New York
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Zhang C, Shen HC, Liang WR, Ning M, Wang ZX, Chen Y, Su W, Guo TT, Hu K, Liu YW. Relationship between stress hyperglycemia ratio and allcause mortality in critically ill patients: Results from the MIMIC-IV database. Front Endocrinol (Lausanne) 2023; 14:1111026. [PMID: 37077351 PMCID: PMC10106677 DOI: 10.3389/fendo.2023.1111026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/08/2023] [Indexed: 04/05/2023] Open
Abstract
BACKGROUND Stress hyperglycemia ratio (SHR) was developed to reduce the impact of long-term chronic glycemic factors on stress hyperglycemia levels, which have been linked to clinical adverse events. However, the relationship between SHR and the short- and long-term prognoses of intensive care unit (ICU) patients remains unclear. METHODS We retrospectively analyzed 3,887 ICU patients (cohort 1) whose initial fasting blood glucose and hemoglobin A1c data within 24 hours of admission were available and 3,636 ICU patients (cohort 2) who were followed-up for 1-year using the Medical Information Mart for Intensive Care IV v2.0 database. Patients were divided into two groups based on the optimal cutoff value of SHR, which was determined using the receiver operating characteristic (ROC) curve. RESULTS There were 176 ICU deaths in cohort 1 and 378 patients experienced all-cause mortality during 1 year of follow-up in cohort 2. The results of logistic regression revealed that SHR was associated with ICU death (odds ratio 2.92 [95% confidence interval 2.14-3.97] P < 0.001), and non-diabetic patients rather than diabetic patients showed an increased risk of ICU death. As per the Cox proportional hazards model, the high SHR group experienced a higher incidence of 1-year all-cause mortality (hazard ratio 1.55 [95% confidence interval 1.26-1.90] P < 0.001). Moreover, SHR had an incremental effect on various illness scores in predicting ICU all-cause mortality. CONCLUSION SHR is linked to ICU death and 1-year all-cause mortality in critically ill patients, and it has an incremental predictive value in different illness scores. Moreover, we found that non-diabetic patients, rather than diabetic patients, showed an increased risk of all-cause mortality.
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Affiliation(s)
- Chong Zhang
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, The Third Central Hospital of Tianjin, Tianjin, China
- Artificial Cell Engineering Technology Research Center, The Third Central Hospital of Tianjin, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, The Third Central Hospital of Tianjin, Tianjin, China
- Department of Heart Center, The Third Central Hospital of Tianjin, Tianjin, China
| | - He-Chen Shen
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, The Third Central Hospital of Tianjin, Tianjin, China
- Artificial Cell Engineering Technology Research Center, The Third Central Hospital of Tianjin, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, The Third Central Hospital of Tianjin, Tianjin, China
- Department of Heart Center, The Third Central Hospital of Tianjin, Tianjin, China
| | - Wei-Ru Liang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
| | - Meng Ning
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, The Third Central Hospital of Tianjin, Tianjin, China
- Artificial Cell Engineering Technology Research Center, The Third Central Hospital of Tianjin, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, The Third Central Hospital of Tianjin, Tianjin, China
- Department of Heart Center, The Third Central Hospital of Tianjin, Tianjin, China
| | - Zi-Xuan Wang
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, The Third Central Hospital of Tianjin, Tianjin, China
- Artificial Cell Engineering Technology Research Center, The Third Central Hospital of Tianjin, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, The Third Central Hospital of Tianjin, Tianjin, China
| | - Yi Chen
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, The Third Central Hospital of Tianjin, Tianjin, China
- Artificial Cell Engineering Technology Research Center, The Third Central Hospital of Tianjin, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, The Third Central Hospital of Tianjin, Tianjin, China
- Department of Heart Center, The Third Central Hospital of Tianjin, Tianjin, China
| | - Wei Su
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, The Third Central Hospital of Tianjin, Tianjin, China
- Artificial Cell Engineering Technology Research Center, The Third Central Hospital of Tianjin, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, The Third Central Hospital of Tianjin, Tianjin, China
- Department of Heart Center, The Third Central Hospital of Tianjin, Tianjin, China
| | - Ting-Ting Guo
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, The Third Central Hospital of Tianjin, Tianjin, China
- Artificial Cell Engineering Technology Research Center, The Third Central Hospital of Tianjin, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, The Third Central Hospital of Tianjin, Tianjin, China
- Department of Heart Center, The Third Central Hospital of Tianjin, Tianjin, China
| | - Kun Hu
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, The Third Central Hospital of Tianjin, Tianjin, China
- Artificial Cell Engineering Technology Research Center, The Third Central Hospital of Tianjin, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, The Third Central Hospital of Tianjin, Tianjin, China
- Department of Heart Center, The Third Central Hospital of Tianjin, Tianjin, China
| | - Ying-Wu Liu
- The Third Central Clinical College of Tianjin Medical University, Tianjin, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, The Third Central Hospital of Tianjin, Tianjin, China
- Artificial Cell Engineering Technology Research Center, The Third Central Hospital of Tianjin, Tianjin, China
- Tianjin Institute of Hepatobiliary Disease, The Third Central Hospital of Tianjin, Tianjin, China
- Department of Heart Center, The Third Central Hospital of Tianjin, Tianjin, China
- *Correspondence: Ying-Wu Liu,
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Vedantam D, Poman DS, Motwani L, Asif N, Patel A, Anne KK. Stress-Induced Hyperglycemia: Consequences and Management. Cureus 2022; 14:e26714. [PMID: 35959169 PMCID: PMC9360912 DOI: 10.7759/cureus.26714] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2022] [Indexed: 01/08/2023] Open
Abstract
Hyperglycemia during stress is a common occurrence seen in patients admitted to the hospital. It is defined as a blood glucose level above 180mg/dl in patients without pre-existing diabetes. Stress-induced hyperglycemia (SIH) occurs due to an illness that leads to insulin resistance and decreased insulin secretion. Such a mechanism causes elevated blood glucose and produces a complex state to manage with external insulin. This article compiles various studies to explain the development and consequences of SIH in the critically ill that ultimately lead to an increase in mortality while also discussing the dire impact of SIH on certain acute illnesses like myocardial infarction and ischemic stroke. It also evaluates multiple studies to understand the management of SIH with insulin and proper nutritional therapy in the hospitalized patients admitted to the Intensive care unit (ICU) alongside the non-critical care unit. While emphasizing the diverse effects of improper control of SIH in the hospital, this article elucidates and discusses the importance of formulating a discharge plan due to an increased risk of type 2 diabetes in the recovered.
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HYPERGLYCEMIA IN NON-DIABETIC ADULT TRAUMA PATIENTS IS ASSOCIATED WITH WORSE OUTCOMES THAN DIABETIC PATIENTS: AN ANALYSIS OF 95,764 PATIENTS. J Trauma Acute Care Surg 2022; 93:316-322. [PMID: 35234715 DOI: 10.1097/ta.0000000000003576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The adverse impact of acute hyperglycemia is well documented but its specific effects on non-diabetic trauma patients are unclear. The purpose of this study was to analyze the differential impact of hyperglycemia on outcomes between diabetic and non-diabetic trauma inpatients. METHODS Adults admitted 2018-19 to 46 Level I/II trauma centers with >2 blood glucose tests (BGT) were analyzed. Diabetes status was determined from ICD-10, trauma registry and/or HbA1c >6.5. Patients with and without >1 hyperglycemic result >180 mg/dL were compared. Logistic regression examined the effects of hyperglycemia and diabetes on outcomes, adjusting for age, gender, ISS & BMI. RESULTS There were 95,764 patients: male 54%, mean age 61, mean ISS 10, diabetic 21%. Patients with hyperglycemia had higher mortality and worse outcomes compared to those without hyperglycemia. Non-diabetic hyperglycemic patients had the highest odds of mortality (Diabetic: aOR: 3.11, 95% CI: 2.8-3.5, Non-diabetics aOR: 7.5, 95% CI: 6.8-8.4). Hyperglycemic non-diabetics experienced worse outcomes on every measure when compared to non-hyperglycemic non-diabetics, with higher rates of sepsis (1.1 vs 0.1%, P < .001), more SSIs (1.0 vs 0.1%, P < .001), longer mean hospital LOS (11.4 vs. 5.0, P < .001), longer mean ICU LOS (8.5 vs. 4.0, P < .001), higher rates of ICU use (68.6% vs. 35.1), and more ventilator use (42.4% vs. 7.3%). CONCLUSIONS Hyperglycemia is associated with increased odds of mortality in both diabetic and non-diabetic patients. Hyperglycemia during hospitalization in non-diabetics was associated with the worst outcomes and represents a potential opportunity for intervention in this high-risk group. LEVEL OF EVIDENCE Level II (therapeutic/care management).
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Nouh CD, Ray B, Xu C, Zheng B, Danala G, Koriesh A, Hollabaugh K, Gordon D, Sidorov EV. Quantitative Analysis of Stress-Induced Hyperglycemia and Intracranial Blood Volumes for Predicting Mortality After Intracerebral Hemorrhage. Transl Stroke Res 2022; 13:595-603. [PMID: 35040036 DOI: 10.1007/s12975-022-00985-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/31/2021] [Accepted: 01/06/2022] [Indexed: 11/30/2022]
Abstract
Stress-induced hyperglycemia (SIH) is a neuroendocrine response to acute illness. Although SIH has an adverse association with intracerebral hemorrhage (ICH), quantitative measures and determinants of SIH are not well delineated. In the present study, we objectively evaluated SIH using glycemic gap (GG) and identified its radiological and clinical determinants, with a 5-year retrospective review of charts of ICH patients. We calculated GG using the regression equation (GG = AG -28.7 × HbA1c + 46.7) and evaluated whether GG is an independent predictor of mortality using a multivariate regression model. Radiological volumes of different intracranial compartments were determined using image segmentation software. We correlated GG with different clinical and radiological parameters using Pearson correlation coefficient (PCC), Spearman's rank correlation (SRC), and Wilcoxon rank sum test. Then, we calculated the value of GG associated with mortality. Out of 328 patients, 238 (73%) survived hospitalization and 90 (27%) expired. GG was found to be an independent predictor of mortality (r=0.008, p=0.04). Additionally, GG was positively correlated with intraparenchymal hemorrhage (IPH) volume (PCC=0.185, p<0.01) and intraventricular hemorrhage (IVH) volume (PCC=0.233, p<0.01) and negatively correlated with cerebrospinal fluid (CSF) volume (PCC=-0.151, p<0.01) and brain tissue volume (PCC=-0.099, p=0.08). GG was positively correlated with patients' ICH score (SRC=0.377, p<0.01), Glasgow Coma Scale (GCS) (PCC=-0.356, p<0.01), hydrocephalus (p<0.01), and IVH in the third ventricle (p<0.01). The univariate logistic regression model identified 30.0 mg/dl as the value of GG (AUC=0.655, p<0.01) that predicted mortality with 52.2% sensitivity and 75.2% specificity and defined SIH. In conclusion, GG independently predicts mortality in ICH patients and positively correlates with IPH and IVH volumes. However, causality between the two is not established and would require specifically designed studies.
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Affiliation(s)
- Claire Delpirou Nouh
- Department of Neurology, College of Medicine, University of Oklahoma Health Sciences Center, 920 S.L. Young Blvd #2040, Oklahoma City, OK, 73014, USA.,Oklahoma Center for Neuroscience, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Physiology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Bappaditya Ray
- Physiology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Chao Xu
- Physiology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Bin Zheng
- Physiology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Electrical Engineering, University of Oklahoma, Norman, OK, USA
| | - Gopichand Danala
- Physiology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Electrical Engineering, University of Oklahoma, Norman, OK, USA
| | - Ahmed Koriesh
- Physiology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Department of Neurology, University of Missouri-Columbia, Springfield, MO, USA
| | - Kimberly Hollabaugh
- Physiology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - David Gordon
- Department of Neurology, College of Medicine, University of Oklahoma Health Sciences Center, 920 S.L. Young Blvd #2040, Oklahoma City, OK, 73014, USA.,Oklahoma Center for Neuroscience, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.,Physiology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Evgeny V Sidorov
- Department of Neurology, College of Medicine, University of Oklahoma Health Sciences Center, 920 S.L. Young Blvd #2040, Oklahoma City, OK, 73014, USA. .,Oklahoma Center for Neuroscience, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA. .,Physiology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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Seike Y, Yokawa K, Koizumi S, Masada K, Inoue Y, Sasaki H, Matsuda H. The blood sugar level can predict preoperative shock in patients with a ruptured abdominal aortic aneurysm even when the patient's condition appears stable. Surg Today 2022; 52:595-602. [PMID: 35022824 DOI: 10.1007/s00595-021-02436-w] [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: 05/10/2021] [Accepted: 07/08/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE This observational retrospective study aimed to identify preoperative blood test data capable of predicting preoperative shock in ruptured abdominal aortic aneurysm (rAAA). METHODS A total of 104 patients who underwent surgery for rAAA between 2007 and 2018 were reviewed. Preoperative shock, defined as a shock index (heart rate/blood pressure) exceeding 1.5 or a maximum blood pressure < 80 mmHg, was observed in 44 patients (42%). RESULTS Blood sugar (BS) (odds ratio [OR] 1.02; p < 0.001), C-reactive protein (CRP) (OR 0.57; p = 0.005), and hemoglobin (OR 0.60; p = 0.001) levels were identified as independent positive predictors of preoperative shock, and a BS level ≥ 300 mg/dl (OR 13.2; 95% CI 3.56-48.6; p < 0.001) was identified as a positive predictor of preoperative shock. The receiver operating characteristics curve analysis for BS showed that the area under the curve for the predicted probabilities was 0.84, and at a cut-off value of 215 mg/dl, the sensitivity of minimum BS for predicting preoperative shock was 86% with a specificity of 79%. CONCLUSIONS The BS level is as an independent predictor of preoperative shock in patients with rAAA. Patients with preoperative BS levels ≥ 300 mg/dl have an extremely high risk of preoperative shock.
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Affiliation(s)
- Yoshimasa Seike
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Koki Yokawa
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Shigeki Koizumi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Kenta Masada
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Yosuke Inoue
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka, 564-8565, Japan.
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Oh MW, Valencia J, Moon TS. Anesthetic Considerations for the Trauma Patient with Obesity. CURRENT ANESTHESIOLOGY REPORTS 2022. [DOI: 10.1007/s40140-021-00508-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Absence of Stress Hyperglycemia Indicates the Most Severe Form of Blunt Liver Trauma. Diagnostics (Basel) 2021; 11:diagnostics11091667. [PMID: 34574008 PMCID: PMC8470453 DOI: 10.3390/diagnostics11091667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/24/2021] [Accepted: 09/08/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Stress hyperglycemia is common in trauma patients. Increasing injury severity and hemorrhage trigger hepatic gluconeogenesis, glycogenolysis, peripheral and hepatic insulin resistance. Consequently, we expect glucose levels to rise with injury severity in liver, kidney and spleen injuries. In contrast, we hypothesized that in the most severe form of blunt liver injury, stress hyperglycemia may be absent despite critical injury and hemorrhage. Methods: All patients with documented liver, kidney or spleen injuries, treated at a university hospital between 2000 and 2020 were charted. Demographic, laboratory, radiological, surgical and other data were analyzed. Results: A total of 772 patients were included. In liver (n = 456), spleen (n = 375) and kidney (n = 152) trauma, an increase in injury severity past moderate to severe (according to the American Association for the Surgery of Trauma, AAST III-IV) was associated with a concomitant rise in blood glucose levels independent of the affected organ. While stress-induced hyperglycemia was even more pronounced in the most severe forms (AAST V) of spleen (median 10.7 mmol/L, p < 0.0001) and kidney injuries (median 10.6 mmol/L, p = 0.004), it was absent in AAST V liver injuries, where median blood glucose level even fell (5.6 mmol/L, p < 0.0001). Conclusions: Absence of stress hyperglycemia on hospital admission could be a sign of most severe liver injury (AAST V). Blood glucose should be considered an additional diagnostic criterion for grading liver injury.
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El-Menyar A, Asim M, Mir F, Hakim S, Kanbar A, Siddiqui T, Younis B, Ahmed K, Mahmood I, Atique S, Al Jogol H, Taha I, Mustafa F, Alabdallat M, Abdelrahman H, Peralta R, Al-Thani H. Patterns and Effects of Admission Hyperglycemia and Inflammatory Response in Trauma Patients: A Prospective Clinical Study. World J Surg 2021; 45:2670-2681. [PMID: 34117510 PMCID: PMC8321976 DOI: 10.1007/s00268-021-06190-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The constellation of the initial hyperglycemia, proinflammatory cytokines and severity of injury among trauma patients is understudied. We aimed to evaluate the patterns and effects of on-admission hyperglycemia and inflammatory response in a level 1 trauma center. We hypothesized that higher initial readings of blood glucose and cytokines are associated with severe injuries and worse in-hospital outcomes in trauma patients. METHODS A prospective, observational study was conducted for adult trauma patients who were admitted and tested for on-admission blood glucose, hemoglobin A1c, interleukin (IL)-6, IL-18 and hs-CRP. Patients were categorized into four groups [non-diabetic normoglycemic, diabetic normoglycemic, diabetic hyperglycemic (DH) and stress-induced hyperglycemic (SIH)]. The inflammatory markers were measured on three time points (admission, 24 h and 48 h). Generalized estimating equations (GEE) were used to account for the correlation for the inflammatory markers. Pearson's correlation test and logistic regression analysis were also performed. RESULTS During the study period, 250 adult trauma patients were enrolled. Almost 13% of patients presented with hyperglycemia (50% had SIH and 50% had DH). Patients with SIH were younger, had significantly higher Injury Severity Score (ISS), higher IL-6 readings, prolonged hospital length of stay and higher mortality. The SIH group had lower Revised Trauma Score (p = 0.005), lower Trauma Injury Severity Score (p = 0.01) and lower GCS (p = 0.001). Patients with hyperglycemia had higher in-hospital mortality than the normoglycemia group (12.5% vs 3.7%; p = 0.02). A significant correlation was identified between the initial blood glucose level and serum lactate, IL-6, ISS and hospital length of stay. Overall rate of change in slope 88.54 (95% CI:-143.39-33.68) points was found more in hyperglycemia than normoglycemia group (p = 0.002) for IL-6 values, whereas there was no statistical significant change in slopes of age, gender and their interaction. The initial IL-6 levels correlated with ISS (r = 0.40, p = 0.001). On-admission hyperglycemia had an adjusted odds ratio 2.42 (95% CI: 1.076-5.447, p = 0.03) for severe injury (ISS > 12) after adjusting for age, shock index and blood transfusion. CONCLUSIONS In trauma patients, on-admission hyperglycemia correlates well with the initial serum IL-6 level and is associated with more severe injuries. Therefore, it could be a simple marker of injury severity and useful tool for patient triage and risk assessment. TRIAL REGISTRATION This study was registered at the ClinicalTrials.gov (Identifier: NCT02999386), retrospectively Registered on December 21, 2016. https://clinicaltrials.gov/ct2/show/NCT02999386 .
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Affiliation(s)
- Ayman El-Menyar
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.
- Trauma & Vascular Surgery, Clinical Research, Hamad General Hospital, Doha, Qatar.
| | - Mohammad Asim
- Trauma & Vascular Surgery, Clinical Research, Hamad General Hospital, Doha, Qatar
| | - Fayaz Mir
- Qatar Metabolic Institute, Hamad Medical Corporation, Doha, Qatar
| | - Suhail Hakim
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Ahad Kanbar
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Tariq Siddiqui
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Basil Younis
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Khalid Ahmed
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Ismail Mahmood
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Sajid Atique
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Hisham Al Jogol
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Ibrahim Taha
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Fuad Mustafa
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | | | - Husham Abdelrahman
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
| | - Ruben Peralta
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
- Department of Surgery, Universidad Nacional Pedro Henriquez Urena, Santo Domingo, Dominican Republic
| | - Hassan Al-Thani
- Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar
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Guo F, Shen H. Glycosylated Hemoglobin as a Predictor of Sepsis and All-Cause Mortality in Trauma Patients. Infect Drug Resist 2021; 14:2517-2526. [PMID: 34234479 PMCID: PMC8257025 DOI: 10.2147/idr.s307868] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 06/01/2021] [Indexed: 12/27/2022] Open
Abstract
Background and Purpose Infection is a common comorbidity and cause of death in emergency trauma patients, especially in diabetic patients. Once the patients are admitted, they are more susceptible to further complications like sepsis and resultant increase in in-hospital mortality. Therefore, it is necessary to evaluate risk factors associated with sepsis after trauma and death in trauma patients. Methods A total of 397 trauma patients were divided into 2 groups according to HbA1c level, HbA1c: <6.5% (n = 259), HbA1c: >6.5% (n = 138), and baseline clinical characteristics were collected. The independent risk factors of sepsis associated with trauma were screened using univariate and multivariate logistic regression analysis. Cox proportional hazards regression analysis was used to investigate risk factors for 30-day all-cause mortality. Results The sepsis incidence (76.1% vs 35.9%, P<0.001) and mortality rate (29.7% vs 7.3%, P<0.001) were significantly higher in HbA1c>6.5% group. Multivariate logistic regression analysis revealed that the independent risk factors of sepsis after trauma were diabetes (OR: 3.1, 95% CI: 1.41–6.79), hypertension (OR: 2.55, 95% CI: 1.35–4.82), coagulation disorder (OR: 3.45, 95% CI: 1.23–9.67), creatinine (OR: 3.71, 95% CI: 1.66–8.31), urea nitrogen (OR: 0.96, 95% CI: 0.92–0.99), HbA1c%>6.5 (OR: 2.05, 95% CI: 1.65–2.54), increase in body mass index (OR: 1.08, 95% CI: 1.03–1.13) and lower initial GCS score (OR: 0.93, 95% CI: 0.88–0.99). Multivariable Cox proportional hazard analysis revealed that male (HR: 1.94, 95% CI: 1.21–3.12), HbA1c >6.5% (HR: 1.45, 95% CI: 1.32–1.6), albumin (HR: 0.54, 95% CI: 0.34–0.86), creatinine (HR: 1.02, 95% CI: 1.01–1.03), APTT (HR: 1.02, 95% CI: 1.01–1.03), SOFA score (HR: 1.2, 95% CI: 1.1–1.31), age >65 years (HR: 3.21, 95% CI: 1.95–5.3) were independent risk factor for trauma patients’ mortality. Conclusion The prevalence of sepsis and mortality was higher in trauma patients with HbA1c >6.5%. HbA1c was independent risk factor for sepsis and all cases of mortality in trauma patients.
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Affiliation(s)
- Feng Guo
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
| | - Haitao Shen
- Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang, People's Republic of China
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Moyer ED, Lehman EB, Bolton MD, Goldstein J, Pichardo-Lowden AR. Lack of recognition and documentation of stress hyperglycemia is a disruptor of optimal continuity of care. Sci Rep 2021; 11:11476. [PMID: 34075071 PMCID: PMC8169760 DOI: 10.1038/s41598-021-89945-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 04/21/2021] [Indexed: 12/15/2022] Open
Abstract
Stress hyperglycemia (SH) is a manifestation of altered glucose metabolism in acutely ill patients which worsens outcomes and may represent a risk factor for diabetes. Continuity of care can assess this risk, which depends on quality of hospital clinical documentation. We aimed to determine the incidence of SH and documentation tendencies in hospital discharge summaries and continuity notes. We retrospectively examined diagnoses during a 12-months period. A 3-months representative sample of discharge summaries and continuity clinic notes underwent manual abstraction. Over 12-months, 495 admissions had ≥ 2 blood glucose measurements ≥ 10 mmol/L (180 mg/dL), which provided a SH incidence of 3.3%. Considering other glucose states suggestive of SH, records showing ≥ 4 blood glucose measurements ≥ 7.8 mmol/L (140 mg/dL) totaled 521 admissions. The entire 3-months subset of 124 records lacked the diagnosis SH documentation in discharge summaries. Only two (1.6%) records documented SH in the narrative of hospital summaries. Documentation or assessment of SH was absent in all ambulatory continuity notes. Lack of documentation of SH contributes to lack of follow-up after discharge, representing a disruptor of optimal care. Activities focused on improving quality of hospital documentation need to be integral to the education and competency of providers within accountable health systems.
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Affiliation(s)
- Eric D Moyer
- Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA, 17033, USA
| | - Erik B Lehman
- Department of Public Health Sciences, Penn State College of Medicine, 90 Hope Drive, Suite 3400, Hershey, PA, 17033, USA
| | - Matthew D Bolton
- Information Services, Penn State Health and Penn State College of Medicine, Room 3315, 100 Crystal A Drive, Hershey, PA, 17033, USA
| | - Jennifer Goldstein
- Department of Medicine, Milton S. Hershey Medical Center, Penn State Health, Penn State College of Medicine, Penn State University, 500 University Drive, Hershey, PA, 17033, USA
| | - Ariana R Pichardo-Lowden
- Department of Medicine, Milton S. Hershey Medical Center, Penn State Health, Penn State College of Medicine, Penn State University, 500 University Drive, Hershey, PA, 17033, USA.
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Tsai YC, Wu SC, Hsieh TM, Liu HT, Huang CY, Chou SE, Su WT, Hsu SY, Hsieh CH. Reply to Comment on Tsai, Y.-C., et al. Association of Stress-Induced Hyperglycemia and Diabetic Hyperglycemia with Mortality in Patients with Traumatic Brain Injury: Analysis of a Propensity Score-Matched Population. Int. J. Environ. Res. Public Health 2020, 17, 4266. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18052531. [PMID: 33806330 PMCID: PMC7967342 DOI: 10.3390/ijerph18052531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/10/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Yu-Chin Tsai
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan;
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan;
| | - Ting-Min Hsieh
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (T.-M.H.); (H.-T.L.); (C.-Y.H.); (S.-E.C.); (W.-T.S.); (S.-Y.H.)
| | - Hang-Tsung Liu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (T.-M.H.); (H.-T.L.); (C.-Y.H.); (S.-E.C.); (W.-T.S.); (S.-Y.H.)
| | - Chun-Ying Huang
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (T.-M.H.); (H.-T.L.); (C.-Y.H.); (S.-E.C.); (W.-T.S.); (S.-Y.H.)
| | - Sheng-En Chou
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (T.-M.H.); (H.-T.L.); (C.-Y.H.); (S.-E.C.); (W.-T.S.); (S.-Y.H.)
| | - Wei-Ti Su
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (T.-M.H.); (H.-T.L.); (C.-Y.H.); (S.-E.C.); (W.-T.S.); (S.-Y.H.)
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (T.-M.H.); (H.-T.L.); (C.-Y.H.); (S.-E.C.); (W.-T.S.); (S.-Y.H.)
| | - Ching-Hua Hsieh
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 83301, Taiwan; (T.-M.H.); (H.-T.L.); (C.-Y.H.); (S.-E.C.); (W.-T.S.); (S.-Y.H.)
- Correspondence:
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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: 45] [Impact Index Per Article: 15.0] [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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Altabas V, Pukec L, Mlinarić S, Pintarić H, Šikić A. Stress Hyperglycaemia Indicates Embolus Size and Localization in Patients with Acute Pulmonary Embolism. Int J Endocrinol 2020; 2020:3606757. [PMID: 32724305 PMCID: PMC7366194 DOI: 10.1155/2020/3606757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/17/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Acute pulmonary embolism is a life-threatening form of venous thromboembolism often causing stress hyperglycaemia. The aim of this study was to determine the prognostic value of stress hyperglycaemia in acute pulmonary embolism, providing new insights into the presumed embolus size and localization, clinical parameters (Pulmonary Embolism Severity Index, PESI), and in-hospital mortality. Design and Methods. Among a total of 95,454 patients referred to the Emergency Department of the Sestre Milosrdnice University Hospital Centre between 2014 and 2016, all patients with acute pulmonary embolism were included into this observational cohort study. The study group consisted of 190 patients aged 25-96. Relevant patient history, clinical data, and laboratory findings were collected during the entire hospitalization period. Data were analyzed for the entire group of patients, as well as separately for patients without diabetes, using the Fisher exact test and logistic regression. RESULTS Analysis of embolus localization as an indirect parameter of embolus size showed that patients with stress hyperglycaemia more often had emboli located in proximal parts of the pulmonary circulation (i.e., main artery or lobar branches) (p < 0.05). Furthermore, stress hyperglycaemia correlated with PESI score and diabetes (p < 0.05) in the entire patient group. Stress hyperglycaemia showed independent association with in-hospital mortality in patients (p < 0.05). CONCLUSION Stress hyperglycaemia in patients with acute pulmonary embolism is associated with embolus localization in larger arteries of the pulmonary circulation and higher PESI score and therefore could serve as an independent in-hospital mortality predictor.
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Affiliation(s)
- Velimir Altabas
- School of Medicine, University of Zagreb, Zagreb, Croatia
- Clinic for Internal Medicine, Department of Endocrinology, Diabetes and Metabolic Diseases, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Lucija Pukec
- School of Medicine, University of Zagreb, Zagreb, Croatia
| | | | - Hrvoje Pintarić
- Emergency Department, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Aljoša Šikić
- Emergency Department, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
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20
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Tsai YW, Wu SC, Huang CY, Hsu SY, Liu HT, Hsieh CH. Impact of stress-induced hyperglycemia on the outcome of children with trauma: A cross-sectional analysis based on propensity score-matched population. Sci Rep 2019; 9:16311. [PMID: 31705033 PMCID: PMC6841921 DOI: 10.1038/s41598-019-52928-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 10/25/2019] [Indexed: 12/12/2022] Open
Abstract
This was a retrospective study of pediatric trauma patients and were hospitalized in a level-1 trauma center from January 1, 2009 to December 31, 2016. Stress-induced hyperglycemia (SIH) was defined as a hyperglycemia level ≥200 mg/dL upon arrival at the emergency department without any history of diabetes or a hemoglobin A1c level ≥6.5% upon arrival or during the first month of admission. The results demonstrated that the patients with SIH (n = 36) had a significantly longer length of stay (LOS) in hospital (16.4 vs. 7.8 days, p = 0.002), higher rates of intensive care unit (ICU) admission (55.6% vs. 20.9%, p < 0.001), and higher in-hospital mortality rates (5.6% vs. 0.6%, p = 0.028) compared with those with non-diabetic normoglycemia (NDN). However, in the 24-pair well-balanced propensity score-matched patient populations, in which significant difference in sex, age, and injury severity score were eliminated, patient outcomes in terms of LOS in hospital, rate of ICU admission, and in-hospital mortality rate were not significantly different between the patients with SIH and NDN. The different baseline characteristics of the patients, particularly injury severity, may be associated with poorer outcomes in pediatric trauma patients with SIH compared with those with NDN. This study also indicated that, upon major trauma, the response of pediatric patients with SIH is different from that of adult patients.
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Affiliation(s)
- Yi-Wen Tsai
- Department of Pediatric Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung, 83301, Taiwan
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung, 83301, Taiwan
| | - Chun-Ying Huang
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung, 83301, Taiwan
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung, 83301, Taiwan
| | - Hang-Tsung Liu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung, 83301, Taiwan
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung, 83301, Taiwan.
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Abstract
OBJECTIVES (1) To determine the incidence of surgical site infections (SSIs) in diabetic orthopaedic trauma patients and (2) to establish a protocol for managing diabetes mellitus (DM) in orthopaedic trauma patients. DESIGN Retrospective cohort study. SETTING Level 1 Trauma Center. PATIENTS All diabetic orthopaedic trauma patients who underwent surgical intervention with at least 1 month follow-up. Patients were classified as poorly controlled or controlled diabetic patients based on admission hemoglobin A1c and blood glucose (BG) levels. INTERVENTIONS Orthopaedic surgical intervention in accordance with fracture type and a standardized diabetes management protocol with internal medicine comanagement. MAIN OUTCOME MEASUREMENT SSI incidence. RESULTS There were 260 patients during the study period. Two hundred two (77.7%) were included in the final analysis. Seventy-five (37.1%) patients met the criteria for poorly controlled DM. The overall rate of SSI was 20.8%; 32.0% for poorly controlled diabetic patients, and 14.2% for controlled diabetic patients (P < 0.01). The admission blood glucose level (BG, P = 0.05), but not discharge BG, was associated with SSI incidence. CONCLUSIONS Trauma patients with poorly controlled DM have a higher rate of SSIs than patients with controlled DM. Perioperative diabetes control does not seem to decrease infection rates in these patients. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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22
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Higher Mortality Rate in Moderate-to-Severe Thoracoabdominal Injury Patients with Admission Hyperglycemia Than Nondiabetic Normoglycemic Patients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16193562. [PMID: 31557789 PMCID: PMC6801625 DOI: 10.3390/ijerph16193562] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 09/23/2019] [Accepted: 09/23/2019] [Indexed: 02/07/2023]
Abstract
Background: Hyperglycemia at admission is associated with an increase in worse outcomes in trauma patients. However, admission hyperglycemia is not only due to diabetic hyperglycemia (DH), but also stress-induced hyperglycemia (SIH). This study was designed to evaluate the mortality rates between adult moderate-to-severe thoracoabdominal injury patients with admission hyperglycemia as DH or SIH and in patients with nondiabetic normoglycemia (NDN) at a level 1 trauma center. Methods: Patients with a glucose level ≥200 mg/dL upon arrival at the hospital emergency department were diagnosed with admission hyperglycemia. Diabetes mellitus (DM) was diagnosed when patients had an admission glycohemoglobin A1c ≥6.5% or had a past history of DM. Admission hyperglycemia related to DH and SIH was diagnosed in patients with and without DM. Patients who had a thoracoabdominal Abbreviated Injury Scale score <3, a polytrauma, a burn injury and were below 20 years of age were excluded. A total of 52 patients with SIH, 79 patients with DH, and 621 patients with NDN were included from the registered trauma database between 1 January 2009, and 31 December 2018. To reduce the confounding effects of sex, age, comorbidities, and injury severity of patients in assessing the mortality rate, different 1:1 propensity score-matched patient populations were established to assess the impact of admission hyperglycemia (SIH or DH) vs. NDN, as well as SIH vs. DH, on the outcomes. Results: DH was significantly more frequent in older patients (61.4 ± 13.7 vs. 49.8 ± 17.2 years, p < 0.001) and in patients with higher incidences of preexisting hypertension (2.5% vs. 0.3%, p < 0.001) and congestive heart failure (3.8% vs. 1.9%, p = 0.014) than NDN. On the contrary, SIH had a higher injury severity score (median [Q1–Q3], 20 [15–22] vs. 13 [10–18], p < 0.001) than DH. In matched patient populations, patients with either SIH or DH had a significantly higher mortality rate than NDN patients (10.6% vs. 0.0%, p = 0.022, and 5.3% vs. 0.0%, p = 0.043, respectively). However, the mortality rate was insignificantly different between SIH and DH (11.4% vs. 8.6%, odds ratio, 1.4; 95% confidence interval, 0.29–6.66; p = 0.690). Conclusion: This study revealed that admission hyperglycemia in the patients with thoracoabdominal injuries had a higher mortality rate than NDN patients with or without adjusting the differences in patient’s age, sex, comorbidities, and injury severity.
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Abstract
Poorly controlled diabetes with comorbid manifestations negatively affects outcomes in lower extremity trauma, increasing the risk of short-term and long-term complications. Management strategies of patients with diabetes that experience lower extremity trauma should also include perioperative management of hyperglycemia to reduce adverse and serious adverse events.
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Affiliation(s)
- George T Liu
- Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390-8883, USA; Foot and Ankle Service, Orthopaedic Surgery, Parkland Memorial Hospital, Level 1 Trauma Center, 5200 Harry Hines Boulevard, Dallas, TX 75235, USA.
| | - Drew T Sanders
- Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390-8883, USA; Orthopaedic Trauma Service, Parkland Memorial Hospital, Level 1 Trauma Center, 5200 Harry Hines Boulevard, Dallas, TX 75235, USA
| | - Katherine M Raspovic
- Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390-8883, USA; Foot and Ankle Service, Orthopaedic Surgery, Parkland Memorial Hospital, Level 1 Trauma Center, 5200 Harry Hines Boulevard, Dallas, TX 75235, USA
| | - Dane K Wukich
- Orthopaedic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, TX 75390-8883, USA; Foot and Ankle Service, Orthopaedic Surgery, Parkland Memorial Hospital, Level 1 Trauma Center, 5200 Harry Hines Boulevard, Dallas, TX 75235, USA
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24
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Abstract
PURPOSE OF REVIEW Hyperglycemia occurs frequently in hospitalized patients with stroke and peripheral vascular disease (PVD). Guidelines for inpatient glycemic management are not well established for this patient population. We will review the clinical impact of hyperglycemia in this acute setting and review the evidence for glycemic control. RECENT FINDINGS Hyperglycemia in acute stroke is associated with poor short and long-term outcomes, and perioperative hyperglycemia in those undergoing revascularization for PVD is linked to increased post-surgical complications. Studies evaluating tight glucose control do not demonstrate improvement in clinical outcomes, although the risk for hypoglycemia increases substantially. Additional studies are needed to evaluate tight glucose goals relative to our current standard of care and the role of permissive hyperglycemia. Given the limited data to guide glycemic management in these patient populations, it is recommended that general guidelines for inpatient glycemic control be followed. Special considerations should be made to address factors that may impact glucose management, including neurological deficits and clinical changes that occur in the postoperative state.
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Affiliation(s)
- Estelle Everett
- Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 333, Baltimore, MD, 21287, USA
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes & Metabolism, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 333, Baltimore, MD, 21287, USA.
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Stress-Induced and Diabetic Hyperglycemia Associated with Higher Mortality among Intensive Care Unit Trauma Patients: Cross-Sectional Analysis of the Propensity Score-Matched Population. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15050992. [PMID: 29762485 PMCID: PMC5982031 DOI: 10.3390/ijerph15050992] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/11/2018] [Accepted: 05/12/2018] [Indexed: 12/19/2022]
Abstract
Background: This study was designed to measure the effect of stress-induced hyperglycemia (SIH) and diabetic hyperglycemia (DH) versus non-diabetic normoglycemia (NDN) on the outcomes of trauma patients in the intensive care unit (ICU). Methods: Diabetes mellitus (DM) was determined based on patient history and/or a hemoglobin A1c (HbA1c) level of ≥6.5% at admission. The patients who had serum glucose levels of ≥200 mg/dL in the absence or presence of DM were assigned into the groups SIH and DH, respectively. Diabetic normoglycemia (DN) and NDN were determined based on serum glucose levels of <200 mg/dL in patients with and without DM, respectively. Patients with burn injury or incomplete data were excluded. Detailed data of trauma patients in the ICU of a Level-I trauma center from 1 January 2009 to 31 December 2016 were retrieved from the database of the Trauma Registry System. These patients were classified into four exclusive groups, including NDN (n = 1745), DN (n = 306), SIH (n = 225) and DH (n = 206). The Pearson chi-square test was used to compare categorical data between groups. Continuous variables were compared using one-way analysis of variance along with the Games–Howell post hoc test. To decrease the confounding effect of the differences in sex and age, preexisting comorbidities and injury severity score (ISS) among different groups of patients, 1:1 ratio propensity score-matched cohorts were assigned using the NCSS software. The effect of hyperglycemia on the outcomes of patients with and without DM was assessed with a logistic regression analysis. Results: Among those selected propensity score-matched patient cohorts, the patients with SIH and DH had a 3.88-fold (95% CI, 2.13–7.06; p < 0.001) and 1.83-fold (95% CI, 1.00–3.34; p = 0.048) higher mortality, respectively, than those with NDN. Moreover, the patients in the SIH group (10.0 vs. 7.4 days; p = 0.005) and those in the DH group (10.1 vs. 7.4 days; p = 0.006) who were admitted to the ICU had a significantly longer length of stay than those in the NDN group. In addition, the SIH group had a 2.13-fold (95% CI, 1.04–4.36; p = 0.038) higher adjusted odds ratio for mortality than the DH group. Conclusions: This study revealed significantly worse outcomes in terms of mortality among patients with SIH and DH who were admitted to the ICU after controlling for sex and age, preexisting comorbidities and ISS. In addition, patients who had SIH presented significantly higher adjusted odds for mortality than those DH patients. These results suggest that hyperglycemia is detrimental in patients with or without DM who were admitted to the ICU, and there is a different pathophysiological mechanisms behind the SIH and DH.
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Rau CS, Wu SC, Chen YC, Chien PC, Hsieh HY, Kuo PJ, Hsieh CH. Stress-Induced Hyperglycemia in Diabetes: A Cross-Sectional Analysis to Explore the Definition Based on the Trauma Registry Data. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14121527. [PMID: 29215581 PMCID: PMC5750945 DOI: 10.3390/ijerph14121527] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 12/05/2017] [Accepted: 12/05/2017] [Indexed: 12/30/2022]
Abstract
Background: The diagnosis of diabetic hyperglycemia (DH) does not preclude a diabetes patient from having a stress-induced hyperglycemic response. This study aimed to define the optimal level of elevated glucose concentration for determining the occurrence of stress-induced hyperglycemia (SIH) in patients with diabetes. Methods: This retrospective study reviewed the data of all hospitalized trauma patients, in a Level I trauma center, from 1 January 2009 to 31 December 2016. Only adult patients aged ≥20 years, with available data on serum glucose and glycated hemoglobin A1c (HbA1c) levels upon admission, were included in the study. Long-term average glucose levels, as A1c-derived average glucose (ADAG), using the equation, ADAG = ((28.7 × HbA1c) − 46.7), were calculated. Patients with high glucose levels were divided into three SIH groups with diabetes mellitus (DM), based on the following definitions: (1) same glycemic gap from ADAG; (2) same percentage of elevated glucose of ADAG, from which percentage could also be reflected by the stress hyperglycemia ratio (SHR), calculated as the admission glucose level divided by ADAG; or (3) same percentage of elevated glucose as patients with a defined SIH level, in trauma patients with and without diabetes. Patients with incomplete registered data were excluded. The primary hypothesis of this study was that SIH in patients with diabetes would present worse mortality outcomes than in those without. Detailed data of SIH in patients with diabetes were retrieved from the Trauma Registry System. Results: Among the 546 patients with DH, 332 (32.0%), 188 (18.1%), and 106 (10.2%) were assigned as diabetes patients with SIH, based on defined glucose levels, set at 250 mg/dL, 300 mg/dL, and 350 mg/dL, respectively. In patients with defined cut-off glucose levels of 250 mg/dL and 300 mg/dL, SIH was associated with a 3.5-fold (95% confidence interval (CI) 1.61–7.46; p = 0.001) and 3-fold (95% CI 1.11–8.03; p = 0.030) higher odds of mortality, adjusted by sex, age, pre-existing comorbidities, and injury severity score, than the 491 patients with diabetic normoglycemia (DN). However, in patients with a defined cut-off glucose level of 350 mg/dL, adjusted mortality in SIH in DM was insignificantly different than that in DM. According to the receiver operating characteristic (ROC) curve analysis, a blood sugar of 233 mg/dL, a glycemic gap of 79 (i.e., blood sugar of 251 mg/dL), and a SHR of 1.45 (i.e., blood sugar of 250 mg/dL) were identified as cut-offs for mortality outcomes, with AUCs of 0.622, 0.653, and 0.658, respectively. Conclusions: In this study, a cut-off glucose level of 250 mg/dL was selected to provide a better definition of SIH in DM than glucose levels of 300 mg/dL or 350 mg/dL.
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Affiliation(s)
- Cheng-Shyuan Rau
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Yi-Chun Chen
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Peng-Chen Chien
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Hsiao-Yun Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Pao-Jen Kuo
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan.
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Rau CS, Wu SC, Chen YC, Chien PC, Hsieh HY, Kuo PJ, Hsieh CH. Stress-Induced Hyperglycemia, but Not Diabetic Hyperglycemia, Is Associated with Higher Mortality in Patients with Isolated Moderate and Severe Traumatic Brain Injury: Analysis of a Propensity Score-Matched Population. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14111340. [PMID: 29099813 PMCID: PMC5707979 DOI: 10.3390/ijerph14111340] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 10/20/2017] [Accepted: 11/01/2017] [Indexed: 12/26/2022]
Abstract
Background: Admission hyperglycemia is associated with higher morbidity and mortality in patients with traumatic brain injury (TBI). Stress-induced hyperglycemia (SIH), a form of hyperglycemia induced by the stress response, is associated with increased patient mortality following TBI. However, admission hyperglycemia occurs not only in SIH but also in patients with diabetic hyperglycemia (DH). Current information regarding whether trauma patients with SIH represent a distinct group with differential outcomes compared to those with DH remains limited. Methods: Serum glucose concentration ≥200 mg/dL upon arrival at the emergency department was defined as hyperglycemia. Presence of diabetes mellitus (DM) was determined by patient history and/or admission glycated hemoglobin (HbA1c) level ≥6.5%. In the present study, the patient cohort included those with moderate and severe TBI, as defined by an Abbreviated Injury Scale (AIS) score ≥3 points in the head, and excluded those who had additional AIS scores ≥3 points in any other region of the body. A total of 1798 adult patients with isolated moderate to severe TBI were allocated into four groups: SIH (n = 140), DH (n = 187), diabetic normoglycemia (DN, n = 186), and non-diabetic normoglycemia (NDN, n = 1285). Detailed patient information was retrieved from the Trauma Registry System at a level I trauma center between 1 January 2009, and 31 December 2015. Unpaired Student’s t- and Mann–Whitney U-tests were used to analyze normally and non-normally distributed continuous data, respectively. Categorical data were compared using the Pearson chi-square or two-sided Fisher’s exact tests. Matched patient populations were allocated in a 1:1 ratio according to propensity scores calculated by NCSS software. Logistic regression was used to evaluate the effect of SIH and DH on the adjusted mortality outcome. Results: In patients with isolated moderate to severe TBI, the presence of SIH and DH led to 9.1-fold and 2.3-fold higher odds of mortality, respectively, than patients with NDN. After adjusting for confounding factors, including sex and age, pre-existing co-morbidities, existence of different kinds of intracerebral hemorrhage, and injury severity, patients with SIH still had 6.6-fold higher odds of mortality than those with NDN; however, DH did not present significantly higher adjusted mortality odds. SIH and DH presented different effects on outcomes after TBI. The results also suggested that the pathophysiological effect associated with SIH was different from that of DH. Conclusions: This study demonstrated that patients with SIH and DH had significantly higher mortality than patients with NDN. However, the adjusted mortality was significantly higher only in the selected propensity score-matched patients with SIH and not in those with DH.
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Affiliation(s)
- Cheng-Shyuan Rau
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Yi-Chun Chen
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Peng-Chen Chien
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Hsiao-Yun Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Pao-Jen Kuo
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung City 833, Taiwan.
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