Diabetic status and the relation of the three domains of glycemic control to mortality in critically ill patients: an international multicenter cohort study

Introduction

Hyperglycemia, hypoglycemia, and increased glycemic variability have each been independently associated with increased risk of mortality in critically ill patients. The role of diabetic status on modulating the relation of these three domains of glycemic control with mortality remains uncertain. The purpose of this investigation was to determine how diabetic status affects the relation of hyperglycemia, hypoglycemia, and increased glycemic variability with the risk of mortality in critically ill patients.

Methods

This is a retrospective analysis of prospectively collected data involving 44,964 patients admitted to 23 intensive care units (ICUs) from nine countries, between February 2001 and May 2012. We analyzed mean blood glucose concentration (BG), coefficient of variation (CV), and minimal BG and created multivariable models to analyze their independent association with mortality. Patients were stratified according to the diagnosis of diabetes.

Results

Among patients without diabetes, mean BG bands between 80 and 140 mg/dl were independently associated with decreased risk of mortality, and mean BG bands >140 mg/dl, with increased risk of mortality. Among patients with diabetes, mean BG from 80 to 110 mg/dl was associated with increased risk of mortality and mean BG from 110 to 180 mg/dl with decreased risk of mortality. An effect of center was noted on the relation between mean BG and mortality. Hypoglycemia, defined as minimum BG <70 mg/dl, was independently associated with increased risk of mortality among patients with and without diabetes and increased glycemic variability, defined as CV >20%, was independently associated with increased risk of mortality only among patients without diabetes. Derangements of more than one domain of glycemic control had a cumulative association with mortality, especially for patients without diabetes.

Conclusions

Although hyperglycemia, hypoglycemia, and increased glycemic variability is each independently associated with mortality in critically ill patients, diabetic status modulates these relations in clinically important ways. Our findings suggest that patients with diabetes may benefit from higher glucose target ranges than will those without diabetes. Additionally, hypoglycemia is independently associated with increased risk of mortality regardless of the patient''s diabetic status, and increased glycemic variability is independently associated with increased risk of mortality among patients without diabetes.See related commentary by Krinsley, http://ccforum.com/content/17/2/131See related commentary by Finfer and Billot, http://ccforum.com/content/17/2/134     

Schwangerschaftsveränderungen beim Neugeborenen

Ohne Zusammenfassung     

Zur Frage der Totenstarre des Herzens

Ohne ZusammenfassungHerrn Prof.Fritz Reuter in Wien und Herrn Prof.V. Müller-Hess in Berlin danke ich verbindlichst für die Erlaubnis, daß ich die am Material ihrer Institute angestellten Beobachtungen verwerten konnte. Aussprache zum Vortrag Schneider: HerrWalcher-Würzburg erinnert an die Feststellung von F. Strassmann aus dem Jahre 1888, der schon durch die Bewegung eingestochener Nadeln die langsame Ausbildung der Totenstarre des Herzens nachwies.HerrMeixner-Innsbruck berichtet über Untersuchungen von Herrn Fritz. Ausgehend von der Beobachtung einer ungewöhnlich starken Fragmentatio cordis bei plötzlichem Herztod durch Coronarembolie, wurden eine Zeit lang alle Herzen daraufhin näher untersucht. Irgendeine Gesetzmäßigkeit ließ sich aber nicht erkennen.HerrK. Reuter-Breslau macht auf die Beobachtungen an Herzen Hingerichteter aufmerksam, die keine Rückschlüsse auf die Bedeutung psychischer Erregungen für den Ablauf der Totenstarre gestatten.HerrSchneider (Schlußwort): Zu vorstehendem Hinweis wird geltend gemacht, daß es sich bei Enthauptungen nicht um eine direkte Beeinflussung des Herzmuskels oder unvermitteltes Stillstehen des Herzens handelt. Die Verhältnisse sind ganz anders gelagert, wenn das Herz aus voller Gesundheit heraus durch ein Trauma plötzlich in den Ruhezustand abgebremst wird; dabei kann eine vorausgegangene besondere Erregung vielleicht ein rascheres Auftreten der Starre begünstigen. Eine solche rasch auftretende und lange anhaltende Herzstarre ist am ehesten noch mit einer Erhöhung des Milchsäurespiegels im Herzmuskel zu erklären.     

Subgroups in the treatment of nasal polyposis with dupilumab: A retrospective study

Dupilumab has been shown to be safe and effective in treating chronic rhinosinusitis with polyposis (CRSwNP). There is to this date no published data whether subgroups like patients with aspirin exacerbated respiratory disease (AERD), increased histologic eosinophilia or elevated blood eosinophil or IgE-levels benefit greater from dupilumab therapy. Moreover, there is no data comparing the efficacy of functional endoscopic sinus surgery (FESS) with dupilumab therapy. We conducted a retrospective chart review of all patients that were treated at a tertiary referral center for CRswNP with dupilumab. We also contacted the patients with a questionnaire to evaluate the efficacy of previous surgeries and dupilumab therapy by visual analogue scale (VAS) and the glasgow benefit inventory (GBI) as well as report on side effects. Overall, 75 patients were included in the study at hand that reported back 138 times. While dupilumab treatment was efficient, we found no systematic evidence of greater efficacy of dupilumab in patients with AERD, histologic eosinophilia or increased blood eosinophil or IgE-levels. All patients showed a considerable decrease in subjective burden of disease, objective smell tests and endoscopic findings. From the patients point of view, dupilumab therapy showed greater efficacy both in the VAS and the GBI overall and all subcategories but “social support.” Dupilumab is efficient in treating CRSwNP; this effect is independent from disease characteristics like AERD, histologic eosinophilia, serum IgE-levels or eosinophil counts. There seems to be a group of patients that benefit greater from dupilumab therapy compared to FESS.