原创： Alpha Jun 阿尔法医学英语 前天
医学的进步是先辈们筚路蓝缕，一点一滴开拓出来，从青霉素到HPV疫苗，从肿瘤化疗到CART细胞治疗。而现代医学的基石是一个个里程碑式的临床试验 （landmark trial）。我们的教科书的根本也是基于这些landmark trials。
让我们来一起阅读医学史上的经典。阅读，不仅仅是学习医学英语最好的方式，也能更好地理解现代医学的精髓。
Intensive VS Conventional Glucose Control in Critically Ill Patients
在ICU中，即使既往没有糖尿病史的患者也经常会出现血糖的升高，应激是其中一个很重要的原因。应激性高血糖是指在机体在应激状态下血糖的升高。导致重症患者血糖升高的因素包括应激性激素的释放（比如肾上腺素和皮质醇），外源性糖皮质激素及儿茶酚胺类药物的使用，严重感染或者外科创伤患者中介质的释放，这些因素都会抑制胰岛素的释放从而使得糖异生作用增强，糖原合成收到抑制，并使得组织的葡萄糖摄取能力下降。另外，在肠外营养及抗生素溶液中经常会使用静脉葡萄糖，这也是引起高血糖的一个原因。
那么ICU患者的血糖应该如何控制呢？是严格控制，还是温和控制？NICE-SUGAR (The Normoglycemia in Intensive Care Evaluation–Survival Using Glucose Algorithm Regulation) trial 给出了很好的答案。
主要结论
- Intensive glycemic control in critically ill patients significantly increases 90-day mortality when compared to conventional glycemic control.
- The incidence of severe hypoglycemia was significantly higher in patients receiving intensive glycemic control.
试验结果
The study involved 6,104 participants recruited from 42 hospitals from across Australia, New Zealand, and Canada. Patients were eligible if they stayed a minimum of 3 consecutive days in the ICU.
Participants were randomly assigned to either intensive glucose control (target blood glucose between 81-108 mg/dL, or 4.5-6.0 mmol/L) or conventional glucose control (target blood glucose ≤180 mg/dL, or ≤10 mmol/L). Glucose control was achieved through insulin infusion as needed. The intervention was stopped when the patient was eating or discharged from the ICU.
The primary outcome was death from any cause within 90 days after randomization. Secondary outcomes included survival time in the first 90 days, cause-specific death, and durations of mechanical ventilation/renal replacement therapy/ICU stay/hospital stay.
Patients were eligible if they stayed a minimum of 3 consecutive days in the ICU
Intensive glucose control significantly increased the risk of mortality at day 90 when compared to conventional control (OR 1.14; 95%CI 1.02-1.28; ARI 2.6%, NNH 38). The incidence of severe hypoglycemia was significantly higher in patients undergoing intensive glucose control (OR 14.7; 95%CI 9.0-25.9). There were no significant differences between the groups in mechanical ventilation (p=0.56) or renal replacement therapy requirements (p=0.39). Moreover, there were no differences between the groups in terms of duration of ICU (p=0.84) or hospital stay (p=0.86).
深度解析与批评
In the intensive care unit (ICU), hyperglycemia is a common problem that is associated with increased morbidity and mortality. Previously conducted trials, systematic reviews, and meta-analyses had reached conflicting conclusions on the effects of intensive glycemic control. Different groups, however, recommended intensive control for critically ill patients.
The Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation (NICE-SUGAR) trial sought to determine the impacts of intensive glycemic control on mortality in ICU patients.
In summary, the trial demonstrated that intensive glucose control to target 81-108 mg/dL (4.5-6.0 mmol/L) significantly increased 90-day mortality when compared to conventional glucose control to target ≤180 mg/dL (10.0 mmol/L). Moreover, the risk of severe hypoglycemia was significantly higher in the intensive control group. Based on the findings of this study, intensive glucose control was not recommended for patients in the ICU.
Intravenous insulin infusion in saline was used in achieving the blood glucose target in both control and interventional groups.
这是ICU严格的血糖控制的最大规模的研究，NICE-SUGAR试验共纳入了6104名患者和42个中心，大于其他所有研究的总和。与对照组相比，这项试验中强化治疗组死亡率的绝对值升高了2.6个百分点（P=0.02）, 低血糖的发生率也有所升高(6.8%vs0.5%)。强化治疗的血糖目标与其他研究中的类似，但是达到的血糖水平较高(118±25mg/dl)，对照组的目标值较低（＜180mg/dl)。
Key Word:
- Critically ill patient
- Critically ['krɪtɪklɪ]
- adj. 批判性地; 苛求地; 危急地; 严重地;
- Consecutive [kənˈsekjətɪv]
- adj. 连续的，连贯的
- SYNONYM successive
- Discharge from ICU
- Discharge [dɪsˈtʃɑ:dʒ]
- vt. 准许从（医院、监狱）离开；解雇
- ANTONYM admit to hosipital
- Normoglycemia
- ['nɔ:məglaɪ'si:mɪə]
- n. 血糖量正常
- SYNONYM euglycemia
- eu-+glyc-+emia
- Seek [si:k]
- (past and past participle sought [sɔ:t] )
- vt. 寻求；谋求；争取
回复SUGAR获得文献原文哦:D
阅读医学经典系列
慢性肝病之MELD评分
Child-Pugh Score的诞生之路
发了两次NEJM的地中海饮食研究PREDIMED
UKPDS—糖尿病治疗的基石研究
ADVANCE—糖尿病治疗的基石研究
CAST—终结心梗后抗心律失常药物的研究
AFFIRM——房颤的心率控制VS节律控制
点击“阅读原文”一览往期更多经典
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edited by zyr
Alpha Jun