Association of Stress-Induced Hyperglycemia and Diabetic Hyperglycemia with Mortality in Patients with Traumatic Brain Injury: Analysis of a Propensity Score-Matched Population

Insulin potential in preventing brain damage after traumatic brain injury: What we know

Traumatic brain injury (TBI) is a major global cause of disability and mortality. TBI results in a spectrum of primary and secondary injuries that impact neural function and overall survival. Insulin, beyond its well-known role in regulating blood glucose levels, plays critical roles in the central nervous system (CNS). These roles include the modulation of synaptic plasticity, neurotransmitter levels, neurogenesis, and neuroprotection. Central insulin resistance, a reduced sensitivity to insulin in the brain, has been observed in TBI patients. This insulin resistance impairs insulin function in the brain and increases the risk of neurodegenerative processes. This review will delve into the central role of insulin resistance in the pathological changes observed after TBI and explore the potential benefits of insulin therapy as a treatment approach for TBI.

Evaluating the prognostic value of the stress index in trauma patients

Background

The stress index (SI), defined as the serum glucose to potassium ratio, has emerged as a potential prognostic indicator in some patient populations. This study aims to evaluate the predictive value of SI on the trauma patients sustained by all trauma causes.

Methods

A retrospective analysis was conducted on 20,040 adult trauma patients admitted to a single trauma center from January 1, 2009, to December 31, 2022. The SI was calculated according to the serum levels of glucose (mg/dL) and potassium (mEq/L) upon patients' arrival to emergency room. The enrolled patients were stratified into two groups based on an optimal SI cutoff value determined by receiver operating characteristic (ROC) curve analysis. The association between SI and in-hospital mortality, as well as other clinical outcomes, was assessed using multivariate logistic regression, adjusting for potential confounders.

Results

The mortality patients had a significantly higher SI (59.7 ± 30.6 vs. 39.5 ± 17.5, p < 0.001) than those who survived. The SI was identified as a significant independent predictor of mortality (odds ratio [OR] 4.65, 95 % confidence interval [CI]: 2.61-8.27, p < 0.001) in the multivariate analysis. In addition, patients in the high SI group (≥42.7) demonstrated significantly worse outcomes, including higher in-hospital mortality (7.5 % vs. 1.4 %, p < 0.001), longer hospital stays compared to the low SI group (<42.7).

Conclusion

The SI serves as a simple and valuable prognostic tool in risk stratification of the trauma patients.

The significance of admission blood lactate and fibrinogen in pediatric traumatic brain injury: a single-center clinical study

BACKGROUND

Traumatic brain injury (TBI) is a significant cause of morbidity and mortality in pediatric patients, leading to long-term physical, cognitive, and psychological impairments. Blood lactate and fibrinogen levels have emerged as potential biomarkers associated with tissue hypoperfusion and coagulation dysfunction, respectively. However, limited research has specifically focused on the significance of these biomarkers in pediatric TBI. This study aimed to investigate the clinical significance of blood lactate and fibrinogen levels upon admission in pediatric patients with traumatic brain injury.

METHODS

The medical records of 80 children with a traumatic brain injury who were admitted from January 2017 to January 2021 were retrospectively analyzed. The two groups were compared according to whether the blood lactate in the admission arterial blood gas increased and the fibrinogen content in the coagulation function decreased. The clinical data of the children in the two groups were different, and then they were divided into a good prognosis group and a poor prognosis group according to the GOS prognostic score, and the differences in the clinical indicators of the two groups were compared.

RESULTS

Among the 80 patients, 33 had elevated blood lactate levels, 34 had decreased fibrinogen levels, and 29 had an unfavorable outcome (GOS < 4). Compared to the normal blood lactate group, there were no statistically significant differences in age, sex ratio, or platelet count in the elevated blood lactate group (P > 0.05). However, the elevated blood lactate group had lower Glasgow Coma Scale (GCS) scores upon admission, higher blood lactate levels, lower fibrinogen levels, longer hospital stay, lower GOS scores, and a higher proportion of GOS < 4 (P < 0.05). Compared to the normal fibrinogen group, there were no statistically significant differences in age, sex ratio, or platelet count in the decreased fibrinogen group (P > 0.05). However, the decreased fibrinogen group had lower GCS scores upon admission, higher blood lactate levels, lower fibrinogen levels, longer hospital stays, lower GOS scores, and a higher proportion of GOS < 4 (P < 0.05). Compared to the favorable outcome group, there were no statistically significant differences in age, sex ratio, or platelet count in the unfavorable outcome group (P > 0.05). However, the unfavorable outcome group had lower GCS scores upon admission, higher blood lactate levels, lower fibrinogen levels, longer hospital stays, a higher incidence of pulmonary infection, a higher incidence of stress ulcers, and lower GOS scores (P < 0.05).

CONCLUSION

The levels of blood lactate and fibrinogen may represent the severity of children with traumatic brain injury and may be risk factors for poor prognosis of children with traumatic brain injury.

Stress hyperglycaemia following trauma - a survival benefit or an outcome detriment?

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.

Classification and Regression Tree Predictive Model for Acute Kidney Injury in Traumatic Brain Injury Patients

Background

Acute kidney injury (AKI) is prevalent in hospitalized patients with traumatic brain injury (TBI), and increases the risk of poor outcomes. We designed this study to develop a visual and convenient decision-tree-based model for predicting AKI in TBI patients.

Methods

A total of 376 patients admitted to the emergency department of the West China Hospital for TBI between January 2015 and June 2019 were included. Demographic information, vital signs on admission, laboratory test results, radiological signs, surgical options, and medications were recorded as variables. AKI was confirmed since the second day after admission, based on the Kidney Disease Improving Global Outcomes criteria. We constructed two predictive models for AKI using least absolute shrinkage and selection operator (LASSO) regression and classification and regression tree (CART), respectively. Receiver operating characteristic (ROC) curves of these two predictive models were drawn, and the area under the ROC curve (AUC) was calculated to compare their predictive accuracy.

Results

The incidence of AKI on the second day after admission was 10.4% among patients with TBI. Lasso regression identified five potent predictive factors for AKI: glucose, serum creatinine, cystatin C, serum uric acid, and fresh frozen plasma transfusions. The CART analysis showed that glucose, serum uric acid, and cystatin C ranked among the top three in terms of the feature importance of the decision tree model. The AUC value of the decision-tree predictive model was 0.892, which was higher than the 0.854 of the LASSO regression model, although the difference was not statistically significant.

Conclusion

The decision tree model is valuable for predicting AKI among patients with TBI. This tree-based flowchart is convenient for physicians to identify patients with TBI who are at high risk of AKI and prompts them to develop suitable therapeutic strategies.

Hyperglycemia disrupted the integrity of the blood-brain barrier following diffuse axonal injury through the sEH/NF-κB pathway

OBJECTIVES

We aimed to investigate the role of soluble epoxide hydrolase for hyperglycemia induced-disruption of blood-brain barrier (BBB) integrity after diffuse axonal injury (DAI).

METHODS

Rat DAI hyperglycemia model was established by a lateral head rotation device and intraperitoneal injection of 50% glucose. Glial fibrillary acidic protein, ionized calcium-binding adapter molecule-1, β-amyloid precursor protein, neurofilament light chain, and neurofilament heavy chain was detected by immunohistochemistry. Cell apoptosis was examined by terminal deoxynucleotidyl transferase nick-end labeling (TUNEL) assay. The permeability of blood-brain barrier (BBB) was assessed by expression of tight junction proteins, leakage of Evans blue and brain water content. The soluble epoxide hydrolase (sEH) pathway was inhibited by 1-trifluoromethoxyphenyl-3-(1-propionylpiperidin-4-yl) urea (TPPU) and the nuclear transcription factor kappa B (NF-κB) pathway was inhibited by pyrrolidine dithiocarbamate and activated by phorbol-12-myristate-13-acetate in vivo and/or vitro, respectively. The inflammatory factors were detected by enzyme-linked immunosorbent assay.

RESULTS

Hyperglycemia could exacerbate axonal injury, aggravate cell apoptosis and glial activation, worsen the loss of BBB integrity, increase the release of inflammatory factors, and upregulate the expression of sEH and NF-κB. Inhibition of sEH could reverse all these damages and protect BBB integrity by upregulating the expression of tight junction proteins and downregulating the levels of inflammatory factors in vivo and vitro, while the agonist of NF-κB pathway abrogated the protective effects of TPPU on BBB integrity in vitro.

CONCLUSIONS

sEH was involved in mediating axonal injury induced by hyperglycemia after DAI by disrupting BBB integrity through inducing inflammation via the NF-κB pathway.

Elevation of White Blood Cell Subtypes in Adult Trauma Patients with Stress-Induced Hyperglycemia

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.

Plasma D-dimer levels are a biomarker for in-hospital complications and long-term mortality in patients with traumatic brain injury

Introduction

Traumatic brain injury (TBI) is a major health concern worldwide. D-dimer levels, commonly used in the diagnosis and treatment of neurological diseases, may be associated with adverse events in patients with TBI. However, the relationship between D-dimer levels, TBI-related in-hospital complications, and long-term mortality in patients with TBI has not been investigated. Here, examined whether elevated D-dimer levels facilitate the prediction of in-hospital complications and mortality in patients with TBI.

Methods

Overall, 1,338 patients with TBI admitted to our institute between January 2016 and June 2022 were retrospectively examined. D-dimer levels were assessed within 24 h of admission, and propensity score matching was used to adjust for baseline characteristics.

Results

Among the in-hospital complications, high D-dimer levels were associated with electrolyte metabolism disorders, pulmonary infections, and intensive care unit admission (p < 0.05). Compared with patients with low (0.00-1.54 mg/L) D-dimer levels, the odds of long-term mortality were significantly higher in all other patients, including those with D-dimer levels between 1.55 mg/L and 6.35 mg/L (adjusted hazard ratio [aHR] 1.655, 95% CI 0.9632.843), 6.36 mg/L and 19.99 mg/L (aHR 2.38, 95% CI 1.416-4.000), and >20 mg/L (aHR 3.635, 95% CI 2.195-6.018; p < 0.001). D-dimer levels were positively correlated with the risk of death when the D-dimer level reached 6.82 mg/L.

Conclusion

Overall, elevated D-dimer levels at admission were associated with adverse outcomes and may predict poor prognosis in patients with TBI. Our findings will aid in the acute diagnosis, classification, and management of TBI.

Stress-Induced (Not Diabetic) Hyperglycemia is Associated With Mortality in Geriatric Trauma Patients

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.

Development and validation of a prediction nomogram for a 6-month unfavorable prognosis in traumatic brain-injured patients undergoing primary decompressive craniectomy: An observational study

Objective

This study was designed to develop and validate a risk-prediction nomogram to predict a 6-month unfavorable prognosis in patients with traumatic brain-injured (TBI) undergoing primary decompressive craniectomy (DC).

Methods

The clinical data of 391 TBI patients with primary DC who were admitted from 2012 to 2020 were reviewed, from which 274 patients were enrolled in the training group, while 117 were enrolled in the internal validation group, randomly. The external data sets containing 80 patients were obtained from another hospital. Independent predictors of the 6-month unfavorable prognosis were analyzed using multivariate logistic regression. Furthermore, a nomogram prediction model was constructed using R software. After evaluation of the model, internal and external validations were performed to verify the efficiency of the model using the area under the receiver operating characteristic curves and the calibration plots.

Results

In multivariate analysis, age(p = 0.001), Glasgow Score Scale (GCS) (p < 0.001), operative blood loss of >750 ml (p = 0.045), completely effaced basal cisterns (p < 0.001), intraoperative hypotension(p = 0.001), and activated partial thromboplastin time (APTT) of >36 (p = 0.012) were the early independent predictors for 6-month unfavorable prognosis in patients with TBI after primary DC. The AUC for the training, internal, and external validation cohorts was 0.93 (95%CI, 0.89–0.96, p < 0.0001), 0.89 (95%CI, 0.82–0.94, p < 0.0001), and 0.90 (95%CI, 0.84–0.97, p < 0.0001), respectively, which indicated that the prediction model had an excellent capability of discrimination. Calibration of the model was exhibited by the calibration plots, which showed an optimal concordance between the predicted 6-month unfavorable prognosis probability and actual probability in both training and validation cohorts.

Conclusion

This prediction model for a 6-month unfavorable prognosis in patients with TBI undergoing primary DC can evaluate the prognosis accurately and enhance the early identification of high-risk patients.

Insulin resistance is associated with an unfavorable outcome among non-diabetic patients with isolated moderate-to-severe traumatic brain injury – A propensity score-matched study

Background

Hyperglycemia is an independent risk factor for the poor prognosis in patients with traumatic brain injury (TBI), and stress-induced impaired insulin function is the major factor of hyperglycemia in non-diabetic patients with TBI. Several types of research suggested that insulin resistance (IR) is related to the poor prognosis of neurocritical ill patients; here we focused on the role of IR in non-diabetic patients after TBI.

Methods

We performed a prospective observational study with the approval of the Ethics Committee of our institute. IR was accessed via the update Homeostasis Model Assessment (HOMA2) of IR, a computer-calculated index by glucose and insulin level. HOMA2 ≥ 1.4 was considered as the threshold of IR according to the previous studies. The glycemic variability (GV) indices were calculated by fingertip blood glucose concentration at an interval of 2 h within 24 h to explore the relationship between IR and GV. The outcome was the 6-month neurological outcome evaluated with the Glasgow outcome scale.

Results

A total of 85 patients with isolated moderate-to-severe TBI (admission GCS ≤ 12) were finally included in our study, 34 (40%) were diagnosed with IR with HOMA2 ≥ 1.4. After propensity score matching (PSM), 22 patients in IR group were matched to 34 patients in non-IR group. Patients with IR suffered increased systemic glycemic variation after isolated moderate-to-severe TBI. IR was a significant factor for the poor prognosis after TBI (OR = 3.25, 95% CI 1.03–10.31, p = 0.041).

Conclusions

The IR estimated by HOMA2 was associated with greater GV and an unfavorable outcome after isolated moderate-to-severe TBI. Ameliorating impaired insulin sensitivity may be a potential therapeutic strategy for the management of TBI patients.

XGBoost machine learning algorism performed better than regression models in predicting mortality of moderate to severe traumatic brain injury

BACKGROUND

Traumatic brain injury (TBI) brings severe mortality and morbidity risk to patients. Predicting outcome of these patients is necessary for physicians to make suitable treatments to improve prognosis. The aim of this study is to develop a mortality prediction approach using the XGBoost (extreme gradient boosting) in moderate to severe TBI.

METHODS

368 patients hospitalized in West China hospital for TBI with GCS below 13 were identified. To construct XGBoost prediction approach, patients were divided into training set and test set with ratio of 7:3. Logistic regression prediction model was also constructed and compared with XGBoost model. Area under the receiver operating characteristic curve (AUC), accuracy, sensitivity and specificity were calculated to compare the prognostic value between XGBoost and logistic regression.

RESULTS

205 patients suffered poor outcome with mortality of 55.7%. Non-survivors had lower Glasgow Coma Scale (GCS) (5 vs 7, p<0.001) and higher Injury Severit Score (ISS) than survivors (25 vs 16, p<0.001). Platelet (p<0.001), albumin (p<0.001), hemoglobin (p<0.001) were significantly lower in non-survivors while glucose (p<0.001) and prothrombin time (PT) (p<0.001)was significantly higher in non-survivors. Among the XGBoost approach, GCS, PT and glucose had the most significant feature importance. The AUC (0.955 vs 0.805) and accuracy (0.955 vs 0.70) of XGBoost were both higher than logistic regression.

CONCLUSION

Predicting mortality of moderate to severe TBI patients using XGBoost algorism is more effective and precise than logistic regression. The XGBoost prediction approach is beneficial for physicians to evaluate TBI patients at high risk of poor outcome.

HYPERGLYCEMIA IN NON-DIABETIC ADULT TRAUMA PATIENTS IS ASSOCIATED WITH WORSE OUTCOMES THAN DIABETIC PATIENTS: AN ANALYSIS OF 95,764 PATIENTS

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).

Optimal Glucose Target After Aneurysmal Subarachnoid Hemorrhage: A Matched Cohort Study

BACKGROUND

Hyperglycemia has been associated with poor outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, there remains debate as to what optimal glucose targets should be in this patient population.

OBJECTIVE

To assess whether we could identify an optimal glucose target for patients with aSAH.

METHODS

We performed a post hoc analysis of the "clazosentan to overcome neurological ischemia and infarction occurring after subarachnoid hemorrhage" trial data set. Patients had laboratory results drawn daily for the entirety of their intensive care unit stay. Maximum blood glucose levels were assessed for a relationship with unfavorable outcomes using multiple logistic regression analysis. Maximum blood glucose levels were dichotomized based on the Youden index, which identified a maximum level of <9.2 mmol/L as the optimal cut point for prediction of unfavorable outcomes. Nearest neighbor matching was used to assess the relationship between maintaining glucose levels below the cut point and unfavorable functional outcomes (defined as a modified Rankin score of >2 at 3 mo post-aSAH). The matching was performed after calculation of a propensity score based on identified predictors of outcome and glucose levels.

RESULTS

Three hundred eighty-nine patients were included in the matched analysis. Propensity scores were balanced on both the covariates and outcomes of interest. There was a significant average treatment effect (-0.143: 95% confidence interval -0.267 to -0.019) for patients who maintained glucose levels <9.2 mmol/L.

CONCLUSION

Maintaining glucose levels below the identified cut point was associated with a decreased risk for unfavorable outcomes in this retrospective matched study.

Higher Stress Hyperglycemia Ratio Is Associated With a Higher Risk of Stroke-Associated Pneumonia

Objective

Stroke-associated pneumonia (SAP) is a frequent complication in stroke patients. This present study aimed to investigate the association between stress hyperglycemia and SAP.

Methods

Patients were screened between February 2013 and August 2020 from the First Affiliated Hospital of Wenzhou Medical University. We divided the blood glucose of the patients at admission by the glycated hemoglobin to calculate the stress hyperglycemia ratio (SHR). Binary logistic regression analysis was used to identify the association between SAP and SHR, with the confounders being controlled. Further, subgroup analyses were separately performed for stroke patients with and without diabetes.

Results

A total of 2,039 patients were finally recruited, of which 533 (26.14%) were diagnosed with SAP. SHR were divided into four quartiles in the logistic regression analysis, the highest SHR quartile (SHR ≥ 1.15) indicated a higher risk of SAP (OR = 1.57; 95% CI = 1.13–2.19, p = 0.01) in total patients. In patients without diabetes, the third quantile (SHR = 0.96–1.14) and the highest quantile (SHR ≥ 1.15) were both related to a higher risk of SAP (both p < 0.05). However, we did not find such an association in diabetic patients.

Conclusion

SHR was significantly associated with the risk of SAP in patients without diabetes. Adequate attention should be paid to the patients with high SHR levels at admission, especially those without diabetes.

Angelica dahurica and Rheum officinale Facilitated Diabetic Wound Healing by Elevating Vascular Endothelial Growth Factor

Traditional Chinese medicine (TCM) provides alternative treatment choices for diabetic wounds. The aim of this study was to evaluate the effects of Angelica dahurica and Rheum officinale (ARE) on diabetic wounds and its underlying action mechanism. A total of 36 healthy male Sprague-Dawley rats were randomly divided into three groups: diabetes mellitus (DM) rats treated with ARE (DM-ARE), DM rats treated with 0.9% saline (DM-NS), and non-DM rats treated with 0.9% saline (NDM-NS). DM was induced by intraperitoneal administration of 40 mg/kg of streptozotocin after a 2-week high-fat diet feeding. After excisional skin wounds and treatments, the remaining wound area (RWA) in each group was measured. The RWA in the DM-NS group (69.60% ± 2.35%) was greater than that in the DM-ARE (55.70% ± 1.85%) and NDM-NS groups (52.50% ± 2.77%) on day 6. Besides, the DM-ARE group showed higher vascular endothelial growth factor (VEGF), higher inducible nitric oxide synthase (iNOs), higher [Formula: see text]-smooth muscle actin ([Formula: see text]-SMA), and lower nuclear factor kappa-light-chain-enhancer of activated B cell (NF-[Formula: see text]B) expression in the wound skin tissue. These results showed that treatment with ARE shifted the recovery pattern of diabetic rats to the pattern of nondiabetic rats, indicating that ARE may improve wound healing in diabetic conditions.