Glucose Variability as Measured by Inter-measurement Percentage Change is Predictive of In-patient Mortality in Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Critically ill aneurysmal subarachnoid hemorrhage (aSAH) patients suffer from systemic complications at a high rate. Hyperglycemia is a common intensive care unit (ICU) complication and has become a focus after aggressive glucose management was associated with improved ICU outcomes. Subsequent research has suggested that glucose variability, not a specific blood glucose range, may be a more appropriate clinical target. Glucose variability is highly correlated to poor outcomes in a wide spectrum of critically ill patients. Here, we investigate the changes between subsequent glucose values termed "inter-measurement difference," as an indicator of glucose variability and its association with outcomes in patients with aSAH. METHODS: All SAH admissions to a single, tertiary referral center between 2002 and 2016 were screened. All aneurysmal cases who had more than 2 glucose measurements were included (n = 2451). We calculated several measures of variability, including simple variance, the average consecutive absolute change, average absolute change by time difference, within subject variance, median absolute deviation, and average or median consecutive absolute percentage change. Predictor variables also included admission Hunt and Hess grade, age, gender, cardiovascular risk factors, and surgical treatment. In-patient mortality was the main outcome measure. RESULTS: In a multiple regression analysis, nearly all forms of glucose variability calculations were found to be correlated with in-patient mortality. The consecutive absolute percentage change, however, was most predictive: OR 5.2 [1.4-19.8, CI 95%] for percentage change and 8.8 [1.8-43.6] for median change, when controlling for the defined predictors. Survival to ICU discharge was associated with lower glucose variability (consecutive absolute percentage change 17% ± 9%) compared with the group that did not survive to discharge (20% ± 15%, p < 0.01). Interestingly, this finding was not significant in patients with pre-admission poorly controlled diabetes as indicated by HbA1c (OR 0.45 [0.04-7.18], by percentage change). The effect is driven mostly by non-diabetic patients or those with well-controlled diabetes. CONCLUSIONS: Reduced glucose variability is highly correlated with in-patient survival and long-term mortality in aSAH patients. This finding was observed in the non-diabetic and well-controlled diabetic patients, suggesting a possible benefit for personalized glucose targets based on baseline HbA1c and minimizing variability. The inter-measure percentage change as an indicator of glucose variability is not only predictive of outcome, but is an easy-to-use tool that could be implemented in future clinical trials.

Associations of Patient Mood, Modulators of Quality of Life, and Pharmaceuticals with Amyotrophic Lateral Sclerosis Survival Duration.

Associations of modulators of quality of life (QoL) and survival duration are assessed in the fatal motor neuron disease, Amyotrophic Lateral Sclerosis. Major categories include clinical impression of mood (CIM); physical health; patient social support; and usage of interventions, pharmaceuticals, and supplements. Associations were assessed at p < 0.05 and p < 0.001 significance thresholds using applicable methods (Chi-square, t-test, ANOVA, logistical regression, random forests, Fisher's exact test) within a retrospective cohort of 1585 patients. Factors significantly correlated with positive (happy or normal) mood included family support and usage of bi-level positive airway pressure (Bi-PAP) and/or cough assist. Decline in physical factors like presence of dysphagia, drooling, general pain, and decrease in ALSFRS-R total score or forced vital capacity (FVC) significantly correlated with negative (depressed or anxious) mood (p < 0.05). Use of antidepressants or pain medications had no association with ALS patient mood (p > 0.05), but were significantly associated with increased survival (p < 0.05). Positive patient mood, Bi-PAP, cough assist, percutaneous endoscopic gastrostomy (PEG), and accompaniment to clinic visits associated with increased survival duration (p < 0.001). Of the 47 most prevalent pharmaceutical and supplement categories, 17 associated with significant survival duration increases ranging +4.5 to +16.5 months. Tricyclic antidepressants, non-opioids, muscle relaxants, and vitamin E had the highest associative increases in survival duration (p < 0.05). Random forests, which examined complex interactions, identified the following pharmaceuticals and supplements as most predictive to survival duration: Vitamin A, multivitamin, PEG supplements, alternative herbs, antihistamines, muscle relaxants, stimulant laxatives, and antispastics. Statins, metformin, and thiazide diuretics had insignificant associations with decreased survival.

Short-notice (48 hours) ACCREDITATION trial in Australia: stakeholder perception of assessment thoroughness, resource requirements and workforce engagement.

BACKGROUND: External, independent accreditation assessments of healthcare organisations are necessary to ensure the nationally legislated minimum standards of quality and safety (QS) are met. The predetermined scheduling of the assessments continues to be criticised due to the high level of organisational emphasis on preparing for accreditation. OBJECTIVES: To determine the stakeholder perception of assessment thoroughness, staff resource requirements and workforce engagement changes if only 48 hours' notice is given to an organisation prior to an accreditation assessment, compared with the standard-notice accreditation process. METHODS: Logan and Beaudesert Hospitals in Brisbane, Australia, trialled the 'Short-Notice Survey Accreditation Assessment Process' (SNAAP) between August 2017 and December 2018. The organisation was given just 48 hours' notice prior to an accreditation assessment. Staff perception of the standard-notice accreditation process and short-notice process was assessed using a 5-point Likert scale repeated measures questionnaire (pretrial, 6 and 12 months after SNAAP launch). RESULTS: There was a statistically significant stakeholder opinion that SNAAP more effectively identified the true strengths and achievements of the organisation's QS compared with 'standard-notice' survey (p=0.033). There was a significantly lower overall perceived proportion of staff resources required for SNAAP preparation in contrast to 'standard-notice' process (Baseline Av=21.38% vs Follow-up 1 and 2 Av=9.75%-6.25%, p=0.021). The questionnaire results reflected that SNAAP increased staff engagement in QS activities (Av=3.75 and 3.69, 95% CI=3.45-4.05 and 3.45-3.94). CONCLUSIONS: With sufficient cultural and operational preparation to move to SNAAP, hospitals can potentially use SNAAP as a truer validation of QS standards, require less staffing resources to prepare for accreditation assessments and improve staff engagement in QS assurance and improvement.