The association between glucose levels and hospital outcomes in patients with acute exacerbations of chronic obstructive pulmonary disease

Pre-hospital glycemia as a biomarker for in-hospital all-cause mortality in diabetic patients - a pilot study

BACKGROUND

Type 2 Diabetes Mellitus (T2DM) presents a significant healthcare challenge, with considerable economic ramifications. While blood glucose management and long-term metabolic target setting for home care and outpatient treatment follow established procedures, the approach for short-term targets during hospitalization varies due to a lack of clinical consensus. Our study aims to elucidate the impact of pre-hospitalization and intra-hospitalization glycemic indexes on in-hospital survival rates in individuals with T2DM, addressing this notable gap in the current literature.

METHODS

In this pilot study involving 120 hospitalized diabetic patients, we used advanced machine learning and classical statistical methods to identify variables for predicting hospitalization outcomes. We first developed a 30-day mortality risk classifier leveraging AdaBoost-FAS, a state-of-the-art ensemble machine learning method for tabular data. We then analyzed the feature relevance to identify the key predictive variables among the glycemic and routine clinical variables the model bases its predictions on. Next, we conducted detailed statistical analyses to shed light on the relationship between such variables and mortality risk. Finally, based on such analyses, we introduced a novel index, the ratio of intra-hospital glycemic variability to pre-hospitalization glycemic mean, to better characterize and stratify the diabetic population.

RESULTS

Our findings underscore the importance of personalized approaches to glycemic management during hospitalization. The introduced index, alongside advanced predictive modeling, provides valuable insights for optimizing patient care. In particular, together with in-hospital glycemic variability, it is able to discriminate between patients with higher and lower mortality rates, highlighting the importance of tightly controlling not only pre-hospital but also in-hospital glycemic levels.

CONCLUSIONS

Despite the pilot nature and modest sample size, this study marks the beginning of exploration into personalized glycemic control for hospitalized patients with T2DM. Pre-hospital blood glucose levels and related variables derived from it can serve as biomarkers for all-cause mortality during hospitalization.

Predictors of Readmission, for Patients with Chronic Obstructive Pulmonary Disease (COPD) - A Systematic Review

Introduction

Chronic obstructive pulmonary disease (COPD) is the third-leading cause of death globally and is responsible for over 3 million deaths annually. One of the factors contributing to the significant healthcare burden for these patients is readmission. The aim of this review is to describe significant predictors and prediction scores for all-cause and COPD-related readmission among patients with COPD.

Methods

A search was conducted in Ovid MEDLINE, Ovid Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials, from database inception to June 7, 2022. Studies were included if they reported on patients at least 40 years old with COPD, readmission data within 1 year, and predictors of readmission. Study quality was assessed. Significant predictors of readmission and the degree of significance, as noted by the p-value, were extracted for each study. This review was registered on PROSPERO (CRD42022337035).

Results

In total, 242 articles reporting on 16,471,096 patients were included. There was a low risk of bias across the literature. Of these, 153 studies were observational, reporting on predictors; 57 studies were observational studies reporting on interventions; and 32 were randomized controlled trials of interventions. Sixty-four significant predictors for all-cause readmission and 23 for COPD-related readmission were reported across the literature. Significant predictors included 1) pre-admission patient characteristics, such as male sex, prior hospitalization, poor performance status, number and type of comorbidities, and use of long-term oxygen; 2) hospitalization details, such as length of stay, use of corticosteroids, and use of ventilatory support; 3) results of investigations, including anemia, lower FEV1, and higher eosinophil count; and 4) discharge characteristics, including use of home oxygen and discharge to long-term care or a skilled nursing facility.

Conclusion

The findings from this review may enable better predictive modeling and can be used by clinicians to better inform their clinical gestalt of readmission risk.

Association of Pulmonary Function Decline over Time with Longitudinal Change of Glycated Hemoglobin in Participants without Diabetes Mellitus

Pulmonary damage and function impairment were frequently noted in patients with diabetes mellitus (DM). However, the relationship between lung function and glycemic status in non-DM subjects was not well-known. Here, we evaluated the association of longitudinal changes of lung function parameters with longitudinal changes of glycated hemoglobin (HbA1c) in non-DM participants. The study enrolled participants without prior type 2 DM, hypertension, and chronic obstructive pulmonary disease (COPD) from the Taiwan Biobank database. Laboratory profiles and pulmonary function parameters, including forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1), were examined at baseline and follow-up. Finally, 7055 participants were selected in this study. During a mean 3.9-year follow-up, FVC and FEV1 were significantly decreased over time (both p < 0.001). In the multivariable analysis, the baseline (unstandardized coefficient β = −0.032, p < 0.001) and longitudinal change (unstandardized coefficient β = −0.025, p = 0.026) of FVC were negatively associated with the baseline and longitudinal change of HbA1c, respectively. Additionally, the longitudinal change of FVC was negatively associated with the risk of newly diagnosed type 2 DM (p = 0.018). During a mean 3.9-year follow-up, our present study, including participants without type 2 DM, hypertension, and COPD, demonstrated that the baseline and longitudinal change of FVC were negatively and respectively correlated with the baseline and longitudinal change of HbA1c. Furthermore, compared to those without new-onset DM, participants with new-onset DM had a more pronounced decline of FVC over time.

Witnessed sleep apneas together with elevated plasma glucose are predictors of COPD exacerbations

Objective

Sleep apnea and elevated plasma glucose associates with inflammation which associates with the risk of COPD exacerbations. We investigated the risk of exacerbations in individuals with COPD, witnessed sleep apneas, and elevated plasma glucose.

Methods

From the Copenhagen City Heart Study cohort, we identified 564 individuals with COPD (forced expiratory volume in 1 sec divided by forced vital capacity, FEV₁/FVC<0.70), no asthma, above 40 years of age, and more than 10 pack-years of smoking history, with information on witnessed apneas and levels of plasma glucose. We prospectively recorded hospital admissions with COPD exacerbations during maximum available follow-up (26.3 years; mean 10.7 years). Cox-regression analyses were used to analyze the risk of COPD exacerbations.

Results

We identified 74 (13%) individuals with sleep apnea without elevated plasma glucose, 70 (12%) had elevated plasma glucose (above 6.9 mM (>125 mg/dL)) without sleep apnea and 11 individuals had the presence of both conditions. In univariable analysis, witnessed apneas together with elevated plasma glucose had a high risk of exacerbations, hazard ratio (HR) = 5.81 (2.34–14.4, p = 0.0001) compared to those without sleep apnea and without elevated plasma glucose. Multivariable analysis, adjusting for several risk factors of exacerbations, showed a similar result, HR = 3.45 (1.13–10.5, p = 0.03). Both presence of sleep apnea without elevated plasma glucose and the presence of elevated plasma glucose without sleep apnea showed no associations with the risk of exacerbations.

Conclusions

Witnessed sleep apneas in COPD are associated with increased risk of exacerbations, but only among those with elevated plasma glucose.

The association between admission glucose levels and outcomes in adults admitted to a tertiary care hospital

Background: Hyperglycemia at the time of hospital admission has been associated with poor outcomes in several patient groups, but there is little information about this association in hospitalized patients with diverse diagnoses.

Methods: We identified all adult patients admitted between 10/1/2015 and 9/30/2016 who had glucose levels measured during the first 24 h after admission to the hospital. Clinical information included age, gender, glucose levels, diagnoses based on ICD 10 discharge coding, length of stay (LOS), and mortality. Patients were classified into quartiles based on glucose levels and into clinically relevant glucose categories.

Results: This study included 18,478 adult patients admitted to a tertiary care hospital. The median age was 53 years, the median LOS was 4 days, and the overall in-hospital mortality was 3.8%. The median admission glucose level was 117 mg/dL. Mortality increased in each glucose quartile; it was also highest in patients admitted with a glucose <55 mg/dL or with a glucose >200 mg/dL. The LOS was significantly shorter in patients in glucose quartiles 1 and 2.

Conclusions: Admission glucose levels were associated with in-hospital mortality and LOS in this cohort of hospitalized patients. Attention to glucose levels can help identify patients at risk for poor outcomes.

Effect of two different nutritional supplements on postprandial glucose response and energy- and protein intake in hospitalised patients with COPD: A randomised cross-over study

INTRODUCTION

Oral nutrition support is frequently used in treatment of malnutrition in patients with chronic obstructive pulmonary disease (COPD). Considering the use of corticoidsteroids in patients with COPD, little is known about the effect on postprandial glucose response and if they might interfere with glucose control. Our aims were to compare the effect of a liquid oral nutritional supplement (ONS) and semi solid inbetween meal snack (snack) on postprandial glucose and energy- and protein intake, and to compare the effect of timing of each intervention on postprandial glucose and energy- and protein intake.

METHODS

Patients with COPD (n = 17) admitted to the Department of Pulmonary Medicine, Iceland and defined as at low or medium nutritional risk (score 0-3) were recruited. In a randomised cross-over design, subjects consumed ONS or snack either in a fasting state (study 1) or following breakfast (study 2) and postprandial glucose responses were assessed at regular intervals for two hours (t = 15, t = 30, t = 45, t = 60, t = 90, t = 120 min). Energy- and protein intake was estimated using a validated plate diagram sheet. Wilcoxon Signed-Rank test was used to compare the two interventions.

RESULTS

In study 2, following breakfast, postprandial glucose was significantly higher after consuming ONS than the snack after 60 min (9.7 ± 2.4 mmol/L vs. 8.2 ± 3.2 mmol/L, p = 0.013 and 120 min 9.2 ± 3.2 mmol/L vs. 7.9 ± 2.4 mmol/L, p = 0.021, respectively). No difference was found in postprandial glucose concentrations between ONS and the snack when consumed after overnight fasting (study 1). No difference in energy or protein intake from hospital food was seen between supplement types neither in study 1 or 2.

CONCLUSION

Lower postprandial glucose concentrations were associated with the snack compared to ONS when taken after a meal compared to either type directly after overnight fasting. The clinical relevance of higher postprandial blood glucose after consuming a liquid ONS after breakfast compared with a semi solid snack needs to be studied further.

Bronchoalveolar pH and inflammatory biomarkers in patients with acute exacerbation of chronic obstructive pulmonary disease

Objectives

This study aimed to directly measure pH in the lungs, determine lactate dehydrogenase (LDH), C-reactive protein (CRP), and glucose levels in serum and bronchoalveolar aspirate, and identify bacterial pathogens from bronchoalveolar fluid during acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

Methods

We performed an observational, analytical case–control study from February 2015 to March 2017. We included 84 patients with AECOPD and 42 with stable chronic obstructive pulmonary disease (COPD). All participants underwent detailed medical anamnesis, a clinical examination, chest radiography, spirometry, an arterial blood gas test, bronchoscopy, bacterial culture, and serum/bronchiolar aspirate laboratory testing.

Results

The mean pH of bronchoalveolar fluid was significantly higher in patients with AECOPD than in patients with stable COPD. The mean lung pH value, bronchoalveolar and serum LDH levels, and serum CRP levels in patients with isolated bacteria were higher than those in patients without isolated bacteria in the AECOPD patient group. Lung pH values in patients with AECOPD were significantly correlated with bronchoalveolar LDH and glucose levels.

Conclusions

AECOPD is associated with local cell and tissue injury in the lungs, especially in the presence of bacterial pathogens, which is accompanied by a low systemic inflammatory response.

Evaluation of Corticosteroid Dose in Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Background: Several recent studies have shown that both lower doses and shorter durations of systemic corticosteroids have similar efficacy for treatment of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). However, each trial has limitations that constrain direct applicability to a US hospital population. Objective: The aim of this study was to determine whether, in a US community hospital, low doses of corticosteroids provide the lowest risk of adverse effects without increasing length of stay or readmission rate. Methods: A single-center retrospective cohort was performed using patients meeting criteria for AECOPD. Primary endpoints included length of hospitalization, proportion of patients with >30% increase in blood glucose from baseline, and rate of 30-day readmission; multivariable regression analysis was used for comparison. The 3 inpatient cumulative dose range groups were low: ≤250-mg prednisone equivalents, medium: 251 to 500 mg, and high: ≥501 mg. Results: A total of 665 records were evaluated, with 369 records included. As the corticosteroid dose ranges increased, there were more patients with increased blood glucose (33.3%, 54.4%, 59.9%). When holding all other factors constant, there was a statistically significant increase in patients with elevated blood glucose with the medium- and high-dose groups as compared with the low-dose group (P < .009, P < .001), the average length of stay was 21.3 hours higher in the high-dose group as compared with the low-dose group (P < .001), and there were no significant differences in readmission rates between the dose groups. Conclusions: The lowest dose range of corticosteroids was associated with the lowest rate of impaired blood glucose without a statistically significant increase in length of stay or readmission rate.

Prevalence and burden of comorbidities in Chronic Obstructive Pulmonary Disease

The classical definition of Chronic Obstructive Pulmonary Disease (COPD) as a lung condition characterized by irreversible airway obstruction is outdated. The systemic involvement in patients with COPD, as well as the interactions between COPD and its comorbidities, justify the description of chronic systemic inflammatory syndrome. The pathogenesis of COPD is closely linked with aging, as well as with cardiovascular, endocrine, musculoskeletal, renal, and gastrointestinal pathologies, decreasing the quality of life of patients with COPD and, furthermore, complicating the management of the disease. The most frequently described comorbidities include skeletal muscle wasting, cachexia (loss of fat-free mass), lung cancer (small cell or non-small cell), pulmonary hypertension, ischemic heart disease, hyperlipidemia, congestive heart failure, normocytic anemia, diabetes, metabolic syndrome, osteoporosis, obstructive sleep apnea, depression, and arthritis. These complex interactions are based on chronic low-grade systemic inflammation, chronic hypoxia, and multiple common predisposing factors, and are currently under intense research. This review article is an overview of the comorbidities of COPD, as well as their interaction and influence on mutual disease progression, prognosis, and quality of life.

An Elevated Glycemic Gap is Associated with Adverse Outcomes in Diabetic Patients with Acute Myocardial Infarction

Acute hyperglycemia is a frequent finding in patients presenting to the emergency department (ED) with acute myocardial infarction (AMI). The prognostic role of hyperglycemia in diabetic patients with AMI remains controversial. We retrospectively reviewed patients' medical records to obtain demographic data, clinical presentation, major adverse cardiac events (MACEs), several clinical scores and laboratory data, including the plasma glucose level at initial presentation and HbA1c levels. The glycemic gap, which represents changes in serum glucose levels during the index event, was calculated from the glucose level upon ED admission minus the HbA1c-derived average glucose (ADAG). We enrolled 331 patients after the review of medical records. An elevated glycemic gap between admission serum glucose levels and ADAG were associated with an increased risk of mortality in patients. The glycemic gap showed superior discriminative power regarding the development of MACEs when compared with the admission glucose level. The calculation of the glycemic gap may increase the discriminative powers of established clinical scoring systems in diabetic patients presenting to the ED with AMI. In conclusion, the glycemic gap could be used as an adjunct parameter to assess the severity and prognosis of diabetic patients presenting with AMI. However, the usefulness of the glycemic gap should be further explored in prospective longitudinal studies.

Management of chronic obstructive pulmonary disease beyond the lungs

Chronic obstructive pulmonary disease (COPD) is an umbrella term that covers many clinical subtypes with clearly different pulmonary and extra-pulmonary characteristics, but with persistent airflow limitation in common. This insight has led to the development of a more personalised approach in bronchodilator therapy, prevention of exacerbations, and advanced treatments (such as non-invasive ventilation and lung volume reduction techniques). However, systemic manifestations and comorbidities of COPD also contribute to different clinical phenotypes and warrant an individualised approach as part of integrated disease management. Alterations in bodyweight and composition, from cachexia to obesity, demand specific management. Psychological symptoms are highly prevalent, and thorough diagnosis and treatment are necessary. Moreover, prevention of exacerbations requires interventions beyond the lungs, including treatment of gastro-oesophageal reflux disease, reduction of cardiovascular risks, and management of dyspnoea and anxiety. In this Review, we discuss the management of COPD beyond the respiratory system and propose treatment strategies on the basis of the latest research and best practices.

Evaluation of the Impact of Corticosteroid Dose on the Incidence of Hyperglycemia in Hospitalized Patients with an Acute Exacerbation of Chronic Obstructive Pulmonary Disease

PURPOSE

Guidelines recommend systemic corticosteroids for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) albeit in lower doses than studies that cemented corticosteroids' place in therapy. Corticosteroids potentiate hyperglycemia, however it is undetermined how corticosteroid dose impacts hyperglycemia incidence.

OBJECTIVES

To establish whether a greater incidence of steroid-induced hyperglycemia (SIHGLY) exists for high- versus low-dose corticosteroids.

METHODS

Patients with primary discharge diagnosis 491.21/491.22 in a community hospital were retrospectively reviewed and divided into tertiles based on corticosteroid dosage. Baseline characteristics and primary endpoint were statistically assessed between tertiles using logistic regression analysis. A Cox proportional hazards (CPH) model adjusted for potential covariates. Post hoc analysis for primary outcome and CPH model was run removing non-insulin dependent diabetics because of disproportionate event count. A secondary endpoint used a Kaplan-Meier curve to evaluate time to event between tertiles.

RESULTS

Tertile divisions were 125 and 187.5 mg methylprednisolone equivalents. The primary outcome for incidence of SIHGLY was insignificant; post hoc analysis removing non-insulin-dependent diabetics narrowly missed significance between tertiles 1 and 3 (P = .056). CPH analysis found significant differences in SIHGLY between tertiles 1 and 2 (hazard ratio [HR], 1.68; 95% CI, 1.02-2.76) and tertile 1 and 3 (HR, 1.79; 95% CI, 1.13-2.84), further post hoc analysis resulted in a loss of significance for the CPH analysis. Of 21 non-insulin-dependent diabetics, 20 met event status. The Kaplan-Meier analysis results were insignificant.

CONCLUSIONS

Study results suggest that a link between larger corticosteroid doses and hyperglycemia incidence may exist, but it requires further study. RESULTS in non-insulin-dependent diabetics provide evidence for increased glucose monitoring upon initiation of corticosteroid therapy.

Usefulness of Glycemic Gap to Predict ICU Mortality in Critically Ill Patients With Diabetes

Stress-induced hyperglycemia (SIH) has been independently associated with an increased risk of mortality in critically ill patients without diabetes. However, it is also necessary to consider preexisting hyperglycemia when investigating the relationship between SIH and mortality in patients with diabetes. We therefore assessed whether the gap between admission glucose and A1C-derived average glucose (ADAG) levels could be a predictor of mortality in critically ill patients with diabetes.We retrospectively reviewed the Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores and clinical outcomes of patients with diabetes admitted to our medical intensive care unit (ICU) between 2011 and 2014. The glycosylated hemoglobin (HbA1c) levels were converted to the ADAG by the equation, ADAG = [(28.7 × HbA1c) - 46.7]. We also used receiver operating characteristic (ROC) curves to determine the optimal cut-off value for the glycemic gap when predicting ICU mortality and used the net reclassification improvement (NRI) to measure the improvement in prediction performance gained by adding the glycemic gap to the APACHE-II score.We enrolled 518 patients, of which 87 (17.0%) died during their ICU stay. Nonsurvivors had significantly higher APACHE-II scores and glycemic gaps than survivors (P < 0.001). Critically ill patients with diabetes and a glycemic gap ≥80 mg/dL had significantly higher ICU mortality and adverse outcomes than those with a glycemic gap <80 mg/dL (P < 0.001). Incorporation of the glycemic gap into the APACHE-II score increased the discriminative performance for predicting ICU mortality by increasing the area under the ROC curve from 0.755 to 0.794 (NRI = 13.6%, P = 0.0013).The glycemic gap can be used to assess the severity and prognosis of critically ill patients with diabetes. The addition of the glycemic gap to the APACHE-II score significantly improved its ability to predict ICU mortality.