Bottom line: Use of dietary supplements in hospitalized patients is common, and communication about their use between patients and physicians is limited.
Citation: Young LA, Faurot KR, Gaylord SA. Use of and communication about dietary supplements among hospitalized patients. J Gen Intern Med. 2009;24(3):366-369.
Early Hyperglycemia Associated with Poor Outcomes After Acute Ischemic Stroke
Clinical question: Is there a threshold of hyperglycemia after an acute ischemic stroke (IS) that predicts a poor outcome?
Background: A growing body of evidence shows that admission hyperglycemia in an acute IS predicts a poor outcome. Current triggers to initiate glucose control measures are based on consensus data. However, capillary glucose is a continuous variable and could have a linear relationship with stroke outcomes. A particular glucose level may herald poor outcomes.
Study design: Prospective observational cohort study.
Setting: Seven university hospitals with dedicated stroke units in Spain.
Synopsis: 476 patients with acute IS had admission and maximum glucose levels recorded during the first 48 hours of admission. Stroke scales and brain imaging assessed the patients’ stroke severity. The primary endpoint of a poor outcome at three months was defined by a modified Rankin score of >2.
The primary endpoint was noted in 156 (38%) patients. Receiver operating characteristic curves for both capillary glucose at admission and maximal values within 48 hours pointed to 155mg/dL as a cutoff for the primary outcome. However, subsequent regression analysis confirmed only the maximal value as an independent predictor of poor outcome (OR 2.73; 95% CI, 1.42 to 5.24). Additionally, in contrast to patient age and infarct volume, the maximal glucose value of ≥155 mg/dL was associated with stroke severity on admission and a higher three-month mortality (HR 3.80; 95% CI, 1.79 to 8.10; P=0.001).
The observational nature of the study opens it to speculation: Does lowering the level to less than 155 mg/dl improve patient outcomes? However, it does offer a potential target for future interventional studies.
Bottom line: Hyperglycemia within the first 48 hours of an ischemic stroke offers a more robust predictor of poor outcomes compared with admission glucose levels. A glucose level less than 155 mg/dL could be a potential treatment goal in the future.
Citation: Fuentes B, Castillo J, San José B, et al. The prognostic value of capillary glucose levels in acute stroke: The GLycemia In Acute Stroke (GLIAS) study. Stroke. 2009;40(2):562-568.
Communication Between Inpatient Medical Teams and PCPs Does Not Improve Outcomes
Clinical question: Does communication between patients’ physicians in the hospital and their primary-care physicians (PCPs) improve outcomes after discharge?
Background: The increased use of the hospitalist model has resulted in concerns about discontinuity of patient care after discharge. This might hamper the quality of clinical care and increase adverse outcomes, including readmission or death. Effective communication could have the potential to improve clinical outcomes.
Study design: Survey based in a quasi-randomized cohort of medical inpatients.
Setting: Six academic medical centers throughout the U.S.
Synopsis: Of the initial 2,526 patients, only 1,078 were available for final analysis based on failure of patient followup and a 68% PCP response rate. PCP surveys were faxed two weeks after patient discharge. PCPs were asked about hospitalization awareness and communication methods. Patients were contacted post-discharge, and National Death Index data were reviewed to determine the primary composite outcomes of ED visits, hospital readmissions, or death at 30 days.
Four out of five PCPs surveyed were aware of their patients’ hospitalizations—23% via direct communication and 42% by discharge summary. The primary outcome occurred in 184 (22%) of 834 patients. In contrast, of the 244 PCPs unaware of their patients’ hospitalizations, the primary outcome occurred in 49 (20%) patients. After logistic regression, PCP awareness of hospitalization, irrespective of communication method, was not associated with risk of outcomes (adjusted OR 1.08, 95% CI, 0.73 to 1.59). Having a hospitalist as the hospital physician (34%) did not affect outcomes. These results could reflect the inclusion of patients with fewer comorbidities. Additionally, effect on adverse drug events, patient satisfaction, and quality of life were not evaluated.