Hyperglycemia: A Predictor of Death in Severe Head Injury Patients

Electronic Glycemic Management System Improved Glycemic Control and Reduced Complications in Patients With Diabetes Undergoing Coronary Artery Bypass Surgery: A Randomized Controlled Trial

BACKGROUND

In-hospital hyperglycemia poses significant risks for patients with diabetes mellitus undergoing coronary artery bypass graft (CABG) surgery. Electronic glycemic management systems (eGMSs) like InsulinAPP offer promise in standardizing and improving glycemic control (GC) in these settings. This study evaluated the efficacy of the InsulinAPP protocol in optimizing GC and reducing adverse outcomes post-CABG.

METHODS

This prospective, randomized, open-label study was conducted with 100 adult type 2 diabetes mellitus (T2DM) patients post-CABG surgery, who were randomized into two groups: conventional care (gCONV) and eGMS protocol (gAPP). The gAPP used InsulinAPP for insulin therapy management, whereas the gCONV received standard clinical care. The primary outcome was a composite of hospital-acquired infections, renal function deterioration, and symptomatic atrial arrhythmia. Secondary outcomes included GC, hypoglycemia incidence, hospital stay length, and costs.

RESULTS

The gAPP achieved lower mean glucose levels (167.2 ± 42.5 mg/dL vs 188.7 ± 54.4 mg/dL; P = .040) and fewer patients-day with BG above 180 mg/dL (51.3% vs 74.8%, P = .011). The gAPP received an insulin regimen that included more prandial bolus and correction insulin (either bolus-correction or basal-bolus regimens) than the gCONV (90.3% vs 16.7%). The primary composite outcome occurred in 16% of gAPP patients compared with 58% in gCONV (P < .010). Hypoglycemia incidence was lower in the gAPP (4% vs 16%, P = .046). The gAPP protocol also resulted in shorter hospital stays and reduced costs.

CONCLUSIONS

The InsulinAPP protocol effectively optimizes GC and reduces adverse outcomes in T2DM patients' post-CABG surgery, offering a cost-effective solution for inpatient diabetes management.

Traumatic Brain Injury as a Potential Risk Factor for Diabetes Mellitus in the Veteran Population

This review examines various aspects of traumatic brain injury (TBI) and its potential role as a causative agent for type 2 diabetes mellitus (T2DM) in the veteran population. The pituitary glands and the hypothalamus, both housed in the intracranial space, are the most important structures for the homeostatic regulation of almost every hormone in the human body. As such, TBI not only causes psychological and cognitive impairments but can also disrupt the endocrine system. It is well established that in addition to having a high prevalence of chronic traumatic encephalopathy (CTE), veterans have a very high risk of developing various chronic medical conditions. Unfortunately, there are no measures or prophylactic agents that can have a meaningful impact on this medically complex patient population. In this review, we explore several important factors pertaining to both acute and chronic TBI that can provide additional insight into why veterans tend to develop T2DM later in life. We focus on the unique combination of risk factors in this population not typically found in civilians or other individuals with a non-military background. These include post-traumatic stress disorder, CTE, and environmental factors relating to occupation and lifestyle.

The relationship between HbA1C levels and clinical outcome in patients with traumatic train injury: A prospective study

Introduction/Aim: Recently, hemoglobin A1c (HbA1c) has been suggested as a predictor of mortality and poor clinical outcome in patients with trauma. The aim of this study was to evaluate the relationship between HbA1c values and clinical outcome in patients with traumatic brain injury (TBI). Methods: In a cross-sectional study, a total of 133 TBI patients referred to the emergency department of Imam Khomeini Hospital in Sari, Mazandaran, Iran were evaluated. After transferring the patients to the neurosurgery ward, their HbA1c, fasting blood glucose (FBG) and postprandial glucose (PPG) were measured. Also, patients' Glasgow Coma Scale (GCS) score was recorded at the time of admission, 24 hours after admission and at the time of discharge from the hospital. Results: The mean of GCS score of patients at the time of admission, 24 hours after admission, and at the time of discharge were 9.02 (2.09), 10.07 (2.16), and 12.98 (1.82), respectively. The mean GCS score of patients with HbA1c < 5.7% was significantly lower than of patients with HbA1c = 5.7 - 6.5% at the time of admission (p < 0.05). At 24 hours after admission, the mean GCS score of patients with HbA1c < 5.7% was significantly lower than in other groups (p < 0.05). However, at the time of discharge, the mean GCS score of patients with HbA1c > 6.5% was significantly lower than in patients with HbA1c = 5.7 - 6.5% (p < 0.05). Over time, the mean of GCS scores in all patients significantly increased (p < 0.001). Conclusion: According to the results of this study it seems that HbA1c measurements cannot provide clear information about the clinical outcome of patients with TBI.

Hospital related hyperglycemia as a predictor of mortality in non-diabetes patients: A systematic review

BACKGROUND AND AIMS

Hyperglycemia is a condition often found in hospitalized patients due to stress injury, parenteral nutrition or medications administered during hospitalization. According to previous studies, hyperglycemia could be an independent predictor of mortality. The objective of the study is to assess the risk of mortality in non-diabetic patients with hyperglycemia during hospitalization.

METHODS

In this systematic review, we conducted literature reviews on several databases. Twelve studies were retrieved and critically reviewed using NOS.

RESULTS

A majority of the studies reported that hospital related hyperglycemia increased the mortality rate.

CONCLUSIONS

Hospital related hyperglycemia is an independent predictor factor for both in-hospital and long-term mortality.

Effects on Outcomes of Hyperglycemia in the Hyperacute Stage after Acute Traumatic Spinal Cord Injury

Hyperglycemia has adverse effects on neuronal recovery after brain injury, but its effects after spinal cord injury (SCI) are understudied. This retrospective cohort study examined the potential effects on outcomes of hyperglycemia in the hyperacute stage after acute traumatic SCI. This study included all individuals enrolled in the National Acute Spinal Cord Injury Study 3 (NASCIS-3). Glycemic levels at 24 h, at 48 h, and at day 7 after acute SCI were examined as potential determinants of survival, neurological outcomes (using NASCIS motor, sensory, and pain scores), and functional outcome (using the Functional Independence Measure [FIM]) within the first year post-SCI. Hyperglycemia was defined using two thresholds (140 mg/dL and 180 mg/dL). Study subjects were 76 females and 423 males with an overall mean age of 36 years who sustained mostly cervical SCI due to motor vehicle accidents or falls. Hyperglycemia diagnosed at day 7 post-injury was associated with significantly greater mortality rates post-SCI. Among the survivors, hyperglycemia during the hyperacute stage was not significantly correlated with neurological recovery post-SCI. Hyperglycemia persistent until day 7 was significantly correlated with lower functional scores post-SCI. These results suggest that hyperglycemia at day 7 is correlated with greater mortality rates within the first year post-SCI. Although hyperglycemia during the hyperacute stage was not associated with neurological recovery, hyperglycemia at day 7 may adversely affect functional recovery within the first year post-SCI. Future investigations are needed to determine the optimal glycemic target in the management of patients with SCI.

Hyperglycemia in severe traumatic brain injury patients and its association with thirty-day mortality: a prospective observational cohort study in Uganda

Background

Traumatic brain injury (TBI) is a growing public health concern that can be complicated with an acute stress response. This response may be assessed by monitoring blood glucose levels but this is not routine in remote settings. There is a paucity of data on the prevalence of hyperglycemia and variables associated with mortality after severe TBI in Uganda.

Objective

We aimed to determine the prevalence of hyperglycemia in patients with severe TBI and variables associated with 30-day mortality at Mulago National Referral Hospital in Uganda.

Methods

We consecutively enrolled a cohort 99 patients patients with severe TBI. Serum glucose levels were measured at admission and after 24 h. Other study variables included: mechanism of injury, CT findings, location and size of hematoma, and socio-demographics. The main outcome was mortality after 30 days of management and this was compared in patients with hyperglycemia more than 11.1 mmol/L to those without.

Results

Most patients (92.9%) were male aged 18-30 years (47%). Road Traffic Collisions were the most common cause of severe TBI (64.7%) followed by assault (17.1%) and falls (8.1%). Nearly one in six patients were admitted with hyperglycemia more than 11.1 mmol/L. The mortality rate in severe TBI patients with hyperglycemia was 68.8% (OR 1.47; 95% CI [0.236-9.153]; P = 0.063) against 43.7% in those without hyperglycemia. The presence of hypothermia (OR 10.17; 95% CI [1.574-65.669]; P = 0.015) and convulsions (OR 5.64; 95% CI [1.541-19.554]; P = 0.009) were significant predictors of mortality.

Conclusion

Hypothermia and convulsions at admission were major predictors of mortality in severe TBI. Early hyperglycemia following severe TBI appears to occur with a tendency towards high mortality. These findings justify routine glucose monitoring and could form the basis for establishing a blood sugar control protocol for such patients in remote settings.

Effect of hyperglycemia on all-cause mortality from pediatric brain injury: A systematic review and meta-analysis

BACKGROUND

This study aimed to assess the effect of hyperglycemia on all-cause mortality in pediatric patients with brain injury, based on currently available evidence.

METHODS

We systematically searched the PubMed, Embase, and Cochrane Library databases with the keywords "hyperglycemia", "brain injury", and "pediatrics". The retrieved records were screened by title, abstract, and full-text to include original articles assessing the effects of hyperglycemia on pediatric brain injury. The extracted data were assessed by a fixed-effects model. The risk of bias in the eligible studies was evaluated with the Newcastle-Ottawa Scale. Publication bias was visually examined with a funnel plot. Begg and Egger tests, respectively, were used to identify small-study effects. Sensitivity analysis was performed to evaluate the robustness of the original effect size.

RESULTS

Nine observational studies were identified from 1439 primary hits. A total of 970 pediatric patients, including 304 with hyperglycemia and brain injury, were included for meta-analysis. Hyperglycemia was strongly associated with a higher risk of all-cause mortality in pediatric patients (odds ratio = 11.60, 95% confidence interval [CI] 7.88-17.08; I = 0%). The overall quality of eligible studies was low, but the funnel plot indicated no publication bias.

CONCLUSIONS

Hyperglycemia is significantly associated with high all-cause mortality in pediatric patients with brain injury. However, the relationship should be confirmed by larger-scale observational studies and randomized controlled trials.

Risk factors and outcomes of new-onset atrial fibrillation in patients hospitalized in an internal medicine ward: a case-control study

Atrial fibrillation (AF) is a frequent pathology in Internal Medicine departments. The aim of our study was to identify the risk factors associated with the development of new-onset AF during hospitalization and to evaluate its outcome as in-hospital mortality. We conducted a retrospective case-control study on a cohort of 14,179 patients admitted to an internal medicine department. We included in the study the patients who did not have an anamnestic history of AF, who presented a sinus rhythm at the time of admission and who developed a new-onset AF during hospitalization. For each of these cases, two controls were enrolled who were not affected by AF. The patients included in the study were 588, including 196 cases and 392 controls. Patients who developed AF during hospitalization had significantly more comorbidity than controls. The most frequent causes for hospitalization were sepsis, significantly higher in the case group. From the results of the multivariate analysis, the factors related independently to the development of AF were the presence of a number of comorbidities ≥ 3 (OR = 1.52; p = 0.017), sepsis as a reason of hospitalization (OR = 2, 16; p = 0.001) and glycemic value at the admission ≥ 130 mg/dL (OR = 1.44; p = 0.047). Both the length of hospital stay and in-hospital mortality were higher in the group of patients who developed AF, with a statistically significant difference compared to controls (p < 0.001).

Effects of a high concentration of hydrogen on neurological function after traumatic brain injury in diabetic rats

Reactive oxygen species, inflammation, and apoptosis are major contributors to secondary injuries that follow traumatic brain injury (TBI) in diabetic patients. Hydrogen (H₂) can selectively neutralize reactive oxygen species and downregulate inflammatory and apoptotic factors. Therefore, we investigated the effects of inhaled high and low concentrations of hydrogen on neurological function after TBI in diabetic rats and the potential mechanism. We found that the inhalation of high concentrations of H₂ significantly improved outcomes following TBI in diabetic rats. The inhalation of 42% H₂ for one hour per day for 48 h significantly reduced brain edema, decreased the extravasation of sodium fluorescein, and reduced oxidative stress markers (p < 0.05). In addition, the inhalation of a high concentration of H₂ (42% for one hour per day for 7 days) improved neurological deficits (p < 0.05) and reduced the expression of apoptotic protein markers (p < 0.05). However, the inhalation of 3% H₂ did not yield significant effects. These results showed that the inhalation of 42% H₂ can alleviate nerve damage and improve neurological function after TBI in diabetic rats. Therefore, the inhalation of a high concentration of H₂ may be associated with the treatment of traumatic brain injuries.

Anesthetic considerations for extracranial injuries in patients with associated brain trauma

Patients with severe traumatic brain injury often presents with extracranial injuries, which may contribute to fatal outcome. Anesthetic management of such polytrauma patients is extremely challenging that includes prioritizing the organ system to be dealt first, reducing on-going injury, and preventing secondary injuries. Neuroprotective and neurorescue measures should be instituted simultaneously during extracranial surgeries. Selection of anesthetic drugs that minimally interferes with cerebral dynamics, maintenance of hemodynamics and cerebral perfusion pressure, optimal utilization of multimodal monitoring techniques, and aggressive rehabilitation approach are the key factors for improving overall patient outcome.

Early dysglycemia and mortality in traumatic brain injury and subarachnoid hemorrhage

BACKGROUND

Traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH) are the most common causes of severe acute brain injury in younger Intensive Care Unit (ICU) patients. Dysglycemia (abnormal peak glycemia, glycemic variability, mean glycemia, nadir glycemia) is common in these patients but its comparative outcome associations are unclear.

METHODS

In a retrospective, cross-sectional, study of adults admitted to Australian and New Zealand ICUs with TBI and SAH from 2005 to 2015, we studied the relationship between multiple aspects of early (first 24 hours) dysglycemia and mortality and compared TBI and SAH patients with the general ICU population and with each other.

RESULTS

Among 670,301 patients, 11,812 had TBI and 6,098 had SAH. After adjustment for illness severity, we found that the mortality rate increased with each quintile of glycemia for each aspect of early dysglycemia (peak glycemia, glycemic variability, mean glycemia, nadir glycemia; P<0.0001 for all). This increased risk of death was greater in TBI and SAH patients than in the general ICU population. Moreover, it was stronger for mean glycemia (increase in mortality from 9.2% in the lowest quintile to 15.1% in general ICU patients compared with an increase in mortality from 4.4% to 49.0% for TBI and SAH patients; P<0.0001). Finally, in TBI patients, this relationship was significantly stronger than in SAH patients (P<0.0001).

CONCLUSIONS

In TBI and SAH patients, greater dysglycemia is associated with greater mortality. This association is significantly stronger than in the general population and it is significantly stronger in patients with TBI compared with SAH.

The role of coagulopathy on clinical outcome following traumatic brain injury in children: analysis of 66 consecutive cases in a single center institution

INTRODUCTION

Head injury is a significant economic, social, and medical problem in developing countries and remains one of the leading causes of pediatric morbidity and mortality. The association of traumatic brain injury and coagulopathy in children is linked with an increase in mortality and poor functional outcomes. However, its impact on long-term outcome has not been discussed in the literature so far.

OBJECTIVES

The aim of this paper was to investigate the effect of coagulopathy diagnosed by routine laboratory tests on neurological outcome following traumatic brain injury in children.

METHODS

A retrospective review was carried out using medical records of children with a traumatic brain injury admitted at a level I trauma center, between January 2013 and December 2016, submitted to any neurosurgical procedures. Statistical analysis was performed accordingly to identify factors predicting unfavorable or favorable outcomes at 1- and 6-month follow-ups. Data regarding age, gender, trauma mechanism, Glasgow Coma Scale at admission and at discharge, highest and lowest stable intracranial pressure, serum glucose and coagulation assessment, radiological findings, and length of stay were analyzed.

RESULTS

We identified 66 children with surgical head trauma. Mean age was 10.9 years (ranges from 3 months to 17 years), with male predominance (77.3%). Common mechanisms were road traffic accidents (66.7%), falls (19.7%), and blunt trauma (10.6%). Brain edema was detected in 68.2% of the patients, surgical fractures or intracranial bleeding in 75.8%. ICP monitoring was performed in 24.2% of the patients, and of these, 18.7% underwent consecutive decompressive craniectomy. Mean length of in-patient treatment was 16.3 ± 28.2 days. At 1- and 6-month follow-ups, favorable outcome was detected in 71.2 and 78.7% of the patients, respectively. The mortality rate was 12.1%. Routine coagulation assessments such as prothrombin time, fibrinogen levels, and thrombocyte count upon admission were potential prognostic variables identified.

CONCLUSIONS

The present study concluded that a trauma-related coagulopathy is an important predictor of unfavorable neurological outcome following TBI in pediatric patients. Initial GCS score, age, and neuroradiological findings, such as severe brain edema and different types of intracranial bleeding, correlated with GOS in the first 6 months following TBI. Sustained intracranial hypertension also predicted unfavorable outcome and death in this series.

Mortality prediction in patients with isolated moderate and severe traumatic brain injury using machine learning models

BACKGROUND

The purpose of this study was to build a model of machine learning (ML) for the prediction of mortality in patients with isolated moderate and severe traumatic brain injury (TBI).

METHODS

Hospitalized adult patients registered in the Trauma Registry System between January 2009 and December 2015 were enrolled in this study. Only patients with an Abbreviated Injury Scale (AIS) score ≥ 3 points related to head injuries were included in this study. A total of 1734 (1564 survival and 170 non-survival) and 325 (293 survival and 32 non-survival) patients were included in the training and test sets, respectively.

RESULTS

Using demographics and injury characteristics, as well as patient laboratory data, predictive tools (e.g., logistic regression [LR], support vector machine [SVM], decision tree [DT], naive Bayes [NB], and artificial neural networks [ANN]) were used to determine the mortality of individual patients. The predictive performance was evaluated by accuracy, sensitivity, and specificity, as well as by area under the curve (AUC) measures of receiver operator characteristic curves. In the training set, all five ML models had a specificity of more than 90% and all ML models (except the NB) achieved an accuracy of more than 90%. Among them, the ANN had the highest sensitivity (80.59%) in mortality prediction. Regarding performance, the ANN had the highest AUC (0.968), followed by the LR (0.942), SVM (0.935), NB (0.908), and DT (0.872). In the test set, the ANN had the highest sensitivity (84.38%) in mortality prediction, followed by the SVM (65.63%), LR (59.38%), NB (59.38%), and DT (43.75%).

CONCLUSIONS

The ANN model provided the best prediction of mortality for patients with isolated moderate and severe TBI.

Retrospective characterization of coma and stupor in dogs and cats presenting to a multicenter out-of-hours service (2012-2015): 386 animals

OBJECTIVE

To describe the signalment, etiology, and short-term outcome of dogs and cats presenting in a coma or stupor.

DESIGN

Retrospective study conducted between May 2012 and February 2015.

SETTING

Multicenter out-of-hours emergency service provider.

ANIMALS

Three hundred eighty-six patients presenting in a coma or stupor to a multicenter out-of-hours emergency care provider.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Records were reviewed to determine the most likely etiology of coma or stupor. Short-term outcomes were defined as deceased (died or euthanized) or transferred (case handed over to a daytime clinic or discharged). There were 168 dogs (coma n = 112, stupor n = 56) and 218 cats (coma n = 148, stupor n = 70) identified. Coma and stupor were more prevalent in cats compared to dogs, and Chihuahuas were over represented. Blood glucose concentrations were frequently outside established reference intervals. Excluding undetermined causes, the most common causes in dogs included traumatic brain injury (TBI) 16.0% (n = 27, deceased n = 22), hypoglycemia 10.7% (n = 18, deceased n = 8), shock 10.1% (n = 17, deceased n = 16), seizure 9.5% (n = 16, deceased n = 13), and renal or hepatic dysfunction 5.3% (n = 9, deceased n = 7). For cats, the most common causes included TBI 21.6% (n = 47, deceased n = 38), renal or hepatic dysfunction 13.3% (n = 29, deceased n = 25), intoxication 10.1% (n = 22, deceased n = 18), hypoglycemia 6.0% (n = 13, deceased n = 4), and shock 5.0% (n = 11, deceased n = 8). When treatment was attempted, 46.0% of dogs (n = 44/96) and 41.2% of cats (n = 35/85) survived to be transferred. Compared to all other etiologies, death was less likely when coma or stupor was attributed to hypoglycemia.

CONCLUSION

In cases where a cause was determined, TBI was the predominant etiology of coma and stupor for both species. With the exception of coma and stupor attributed to hypoglycemia, the overall short-term prognosis was poor.

Artificial neural network approach to predict surgical site infection after free-flap reconstruction in patients receiving surgery for head and neck cancer

Background

The aim of this study was to develop an effective surgical site infection (SSI) prediction model in patients receiving free-flap reconstruction after surgery for head and neck cancer using artificial neural network (ANN), and to compare its predictive power with that of conventional logistic regression (LR).

Materials and methods

There were 1,836 patients with 1,854 free-flap reconstructions and 438 postoperative SSIs in the dataset for analysis. They were randomly assigned tin ratio of 7:3 into a training set and a test set. Based on comprehensive characteristics of patients and diseases in the absence or presence of operative data, prediction of SSI was performed at two time points (pre-operatively and post-operatively) with a feed-forward ANN and the LR models. In addition to the calculated accuracy, sensitivity, and specificity, the predictive performance of ANN and LR were assessed based on area under the curve (AUC) measures of receiver operator characteristic curves and Brier score.

Results

ANN had a significantly higher AUC (0.892) of post-operative prediction and AUC (0.808) of pre-operative prediction than LR (both P<0.0001). In addition, there was significant higher AUC of post-operative prediction than pre-operative prediction by ANN (p<0.0001). With the highest AUC and the lowest Brier score (0.090), the post-operative prediction by ANN had the highest overall predictive performance.

Conclusion

The post-operative prediction by ANN had the highest overall performance in predicting SSI after free-flap reconstruction in patients receiving surgery for head and neck cancer.