Background Hyperglycemia and insulin resistance are common in critically ill patients, even if they have not previously had diabetes. Whether the normalization of blood glucose levels with insulin therapy improves the prognosis for such patients is not known. Methods We performed a prospective, randomized, controlled study involving adults admitted to our surgical intensive care unit who were receiving mechanical ventilation. On admission, patients were randomly assigned to receive intensive insulin therapy (maintenance of blood glucose at a level between 80 and 110 mg per deciliter) or conventional treatment (infusion of insulin only if the blood glucose level exceeded 215 mg per deciliter and maintenance of glucose at a level between 180 and 200 mg per deciliter). Results At 12 months, with a total of 1548 patients enrolled, intensive insulin therapy reduced mortality during intensive care from 8.0 percent with conventional treatment to 4.6 percent (P<0.04, with adjustment for sequential analyses). The ...

https://www.nejm.org/doi/pdf/10.1056/NEJMoa011300

Intensive Insulin Therapy in Critically Ill Patients

Admission hyperglycemia has been associated with increased hospital mortality in critically ill patients; however, it is not known whether hyperglycemia in patients admitted to general hospital wards is associated with poor outcome. The aim of this study was to determine the prevalence of in-hospital hyperglycemia and determine the survival and functional outcome of patients with hyperglycemia with and without a history of diabetes. We reviewed the medical records of 2030 consecutive adult patients admitted to Georgia Baptist Medical Center, a community teaching hospital in downtown Atlanta, GA, from July 1, 1998, to October 20, 1998. New hyperglycemia was defined as an admission or in-hospital fasting glucose level of 126 mg/dl (7 mmol/liter) or more or a random blood glucose level of 200 mg/dl (11.1 mmol/liter) or more on 2 or more determinations. Hyperglycemia was present in 38% of patients admitted to the hospital, of whom 26% had a known history of diabetes, and 12% had no history of diabetes before the admission. Newly discovered hyperglycemia was associated with higher in-hospital mortality rate (16%) compared with those patients with a prior history of diabetes (3%) and subjects with normoglycemia (1.7%; both P < 0.01). In addition, new hyperglycemic patients had a longer length of hospital stay, a higher admission rate to an intensive care unit, and were less likely to be discharged to home, frequently requiring transfer to a transitional care unit or nursing home facility. Our results indicate that in-hospital hyperglycemia is a common finding and represents an important marker of poor clinical outcome and mortality in patients with and without a history of diabetes. Patients with newly diagnosed hyperglycemia had a significantly higher mortality rate and a lower functional outcome than patients with a known history of diabetes or normoglycemia.

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Hyperglycemia: An Independent Marker of In-Hospital Mortality in Patients with Undiagnosed Diabetes

Hyperglycemia: An independent marker of in-hospital mortality in patients with undiagnosed diabetes. Authors' reply

Background and Purpose “Stress” hyperglycemia may be associated with increased mortality and poor recovery in diabetic and nondiabetic patients after stroke. A systematic review and meta-analysis of the literature relating acute poststroke glucose levels to the subsequent course were done to summarize and quantify this relationship. Methods A comprehensive literature search was done for cohort studies reporting mortality and/or functional recovery after stroke in relation to admission glucose level. Relative risks in hyperglycemic compared with normoglycemic patients with and without diabetes were calculated and meta-analyzed when possible. Results Thirty-two studies were identified; relative risks for prespecified outcomes were reported or could be calculated in 26 studies. After stroke of either subtype (ischemic or hemorrhagic), the unadjusted relative risk of in-hospital or 30-day mortality associated with admission glucose level >6 to 8 mmol/L (108 to 144 mg/dL) was 3.07 (95% CI, 2.50 to 3.79) in non...

Stress Hyperglycemia and Prognosis of Stroke in Nondiabetic and Diabetic Patients A Systematic Overview

Objective— To determine the incidence of dysphagia and associated pulmonary compromise in stroke patients through a systematic review of the published literature. Methods— Databases were searched (1966 through May 2005) using terms “cerebrovascular disorders,” “deglutition disorders,” and limited to “humans” for original articles addressing the frequency of dysphagia or pneumonia. Data sources included Medline, Embase, Pascal, relevant Internet addresses, and extensive hand searching of bibliographies of identified articles. Selected articles were reviewed for quality, diagnostic methods, and patient characteristics. Comparisons were made of reported dysphagia and pneumonia frequencies. The relative risks (RRs) of developing pneumonia were calculated in patients with dysphagia and confirmed aspiration. Results— Of the 277 sources identified, 104 were original, peer-reviewed articles that focused on adult stroke patients with dysphagia. Of these, 24 articles met inclusion criteria and were evaluated. The r...

Dysphagia After Stroke Incidence, Diagnosis, and Pulmonary Complications

Background and PurposeThe published data on the relationship between dysphagia and both outcome and complications after acute stroke have been inconclusive. We examined the relationship between these, using bedside assessment and videofluoroscopic examination. MethodsWe prospectively studied 121 consecutive patients admitted with acute stroke. A standardized bedside assessment was performed by a physician. We performed videofluoroscopy blinded to this assessment within 3 days of stroke onset and within a median time of 24 hours of the bedside evaluations. The presence of aspiration was recorded. Mortality, functional outcome, length of stay, place of discharge, occurrence of chest infection, nutritional status, and hydration were the main outcome measures. ResultsPatients with an abnormal swallow (dysphagia) on bedside assessment had a higher risk of chest infection (P=.05) and a poor nutritional state (P<.001). The presence of dysphagia was associated with an increased risk of death (P=.001), disability ...

Complications and Outcome After Acute Stroke Does Dysphagia Matter

To assess the frequency and natural history of swallowing problems following an acute stroke, 121 consecutive patients admitted within 24 hours of the onset of their stroke were studied prospectively. The ability to swallow was assessed repeatedly by a physician, a speech and language therapist, and by videofluoroscopy. Clinically 51% (61/121) of patients were assessed as being at risk of aspiration on admission. Many swallowing problems resolved over the first 7 days, through 28/110 (27%) were still considered at risk by the physician. Over a 6-month period, most problems had resolved, but some patients had persistent difficulties (6, 8%), and a few (2, 3% at 6 months) had developed swallowing problems. Ninety-five patients underwent videofluoroscopic examination within a median time of 2 days; 21 (22%) were aspirating. At 1 month a repeat examination showed that 12 (15%) were aspirating. Only 4 of these were persistent; the remaining 8 had not been previously identified. This study has confirmed that swallowing problems following acute stroke are common, and it has been documented that the dysphagia may persist, recur in some patients, or develop in others later in the history of their stroke.

The natural history of dysphagia following a stroke.

We studied the relation of reactive hyperglycemia, stress hormone response, and outcome in 23 consecutive elderly patients (median age 80 [range 75-92] years) following an acute first stroke The median delay from the onset of the stroke to the first blood sample (day 0) was 9 (range 4-22) hours Subsequent blood samples were taken, after fasting, for the determination of blood glucose, cortisol, catecholamine, insulin, C-peptide, glucagon, and lactate concentrations on days 1, 2, 3, 7, 14, 30, and 90 For all 23 patients, a significant relation was found between the blood glucose concentration and survival (p = 003) and the blood glucose concentration decreased with time (p less than 0001) There was also a significant relation between blood glucose concentration and outcome (p = 002) For the 15 patients with complete data, the major determinants of the blood glucose concentration were the cortisol, insulin, and glucagon concentrations (all p less than 0001), which accounted for 42% of the variance When all the indexes were analyzed together by logistic regression, only the cortisol concentration was related to outcome (p = 002) Hyperglycemia following a stroke probably reflects the intensity of the stress hormone response We have confirmed that hyperglycemia is a predictor of outcome in persons with stroke

https://www.ahajournals.org/doi/pdf/10.1161/01.STR.22.7.842

Stress hormone and blood glucose response following acute stroke in the elderly.

Objective: to investigate the ability of a bedside swallowing assessment to reliably exclude aspiration following acute stroke. Subjects: consecutive patients admitted within 24 h of stroke onset to two hospitals. Methods: a prospective study. Where possible, all patients had their ability to swallow assessed on the day of admission by both a doctor and a speech and language therapist using a standardized proforma. A videofluoroscopy examination was conducted within 3 days of admission. Results: 94 patients underwent videofluoroscopy; 20 (21%) were seen to be aspirating, although this was not detected at the bedside in 10. In 18 (22%) of the patients the speech and language therapist considered the swallow to be unsafe. In the medical assessment, 39 patients (41%) had an unsafe swallow. Bedside assessment by a speech and language therapist gave a sensitivity of 47%, a specificity of 86%, positive predictive value (PPV) of 50% and a negative predictive value (NPV) of 85% for the presence of aspiration. Multiple logistic regression was used to identify the optimum elements of the bedside assessments for predicting the presence of aspiration. A weak voluntary cough and any alteration in conscious level gave a sensitivity of 75%, specificity of 72%, PPV of 41% and NPV of 91% for aspiration. Conclusion: bedside assessment of swallowing lacks the necessary sensitivity to be used as a screening instrument in acute stroke, but there are concerns about the use of videofluorosc opy as a gold standard. The relative importance of aspiration and bedside assessment in predicting complications and outcome needs to be studied.

Can bedside assessment reliably exclude aspiration following acute stroke

GH secretion declines by 14% decade of adult life, leading to the suggestion that people over the age of 60 yr are functionally GH deficient. If this is the case, one might not be able to detect a difference in GH secretion between the elderly with documented hypothalamic-pituitary disease and an age-matched control group. We studied GH secretion in 24 patients with hypothalamic-pituitary disease and 24 controls matched for body mass index and age using 24-h GH profiles, arginine stimulation tests, and serum insulin-like growth factor I (IGF-I) levels. The median (range) area under the curve of the GH profile [< 9.6 (< 9.6-20) vs. 18.5 (10.7-74.4) micrograms/L.24 h; P < 0.0001], the median stimulated peak GH response to arginine [< 0.4 (< 0.4-7.7) vs. 8.0 (1.6-37.0) micrograms/L; P < 0.0001], and the median serum IGF-I concentration [102 (< 14-162) vs. 147 (65-255) ng/mL; P = 0.0002] were significantly lower in the patients than in the controls. Fifteen patients showed no evidence of spontaneous or stimulated GH secretion, whereas all controls had evidence of both. The area under the GH curve in the 33 subjects with demonstrable GH secretion correlated significantly with the peak GH response to arginine (r = 0.71; P < 0.0001), but not with serum IGF-I concentration. This study suggests that organic GH deficiency in the elderly is distinct from the decline in GH secretion associated with the aging process. These patients may benefit from GH replacement therapy.

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Paul A O'Neill

Papers

Complications and Outcome After Acute Stroke Does Dysphagia Matter

The natural history of dysphagia following a stroke.

Stress hormone and blood glucose response following acute stroke in the elderly.

Can bedside assessment reliably exclude aspiration following acute stroke

Beyond the somatopause: growth hormone deficiency in adults over the age of 60 years.