{"id":17524,"date":"2019-08-06T05:49:13","date_gmt":"2019-08-05T21:49:13","guid":{"rendered":"http:\/\/csccm.org.cn\/?p=17524"},"modified":"2019-08-06T06:24:19","modified_gmt":"2019-08-05T22:24:19","slug":"jama%e5%8f%91%e8%a1%a8%e8%ae%ba%e6%96%87%ef%bc%9a%e9%ab%98%e8%a1%80%e7%b3%96%e5%bc%ba%e5%8c%96%e6%b2%bb%e7%96%97%e4%b8%8e%e6%a0%87%e5%87%86%e6%b2%bb%e7%96%97%e5%af%b9%e6%80%a5%e6%80%a7%e7%bc%ba","status":"publish","type":"post","link":"https:\/\/csccm.org.cn\/?p=17524","title":{"rendered":"[JAMA\u53d1\u8868\u8bba\u6587]\uff1a\u9ad8\u8840\u7cd6\u5f3a\u5316\u6cbb\u7597\u4e0e\u6807\u51c6\u6cbb\u7597\u5bf9\u6025\u6027\u7f3a\u8840\u6027\u8111\u5352\u4e2d\u60a3\u8005\u529f\u80fd\u9884\u540e\u7684\u5f71\u54cd"},"content":{"rendered":"\n

Original Investigation | July 23\/30, 2019<\/p>\n\n\n\n

Intensive vs Standard Treatment of Hyperglycemia and Functional Outcome in Patients With Acute Ischemic Stroke: The SHINE Randomized Clinical Trial<\/h1>\n\n\n\n

Karen C. Johnston, Askiel Bruno, Qi Pauls, et al<\/h3>\n\n\n\n

JAMA. <\/em>2019;322(4):326-335. doi:10.1001\/jama.2019.9346<\/h3>\n\n\n\n

Abstract<\/p>\n\n\n\n

Importance<\/strong> \u80cc\u666f<\/h3>\n\n\n\n

Hyperglycemia during acute ischemic stroke is common and is associated with worse outcomes. The efficacy of intensive treatment of hyperglycemia in this setting remains unknown.<\/p>\n\n\n\n

\u6025\u6027\u7f3a\u8840\u6027\u5352\u4e2d\u65f6\u9ad8\u8840\u7cd6\u975e\u5e38\u666e\u904d\uff0c\u4e14\u4e0e\u4e0d\u826f\u9884\u540e\u76f8\u5173\u3002\u5728\u8fd9\u79cd\u60c5\u51b5\u4e0b\u5bf9\u4e8e\u9ad8\u8840\u7cd6\u7684\u5f3a\u5316\u6cbb\u7597\u6548\u679c\u5c1a\u5c5e\u672a\u77e5\u3002<\/p>\n\n\n\n

Objectives<\/strong> \u76ee\u7684<\/h3>\n\n\n\n

To determine the efficacy of intensive treatment of hyperglycemia during acute ischemic stroke.<\/p>\n\n\n\n

\u786e\u5b9a\u6025\u6027\u7f3a\u8840\u6027\u5352\u4e2d\u65f6\u9ad8\u8840\u7cd6\u5f3a\u5316\u6cbb\u7597\u7684\u7597\u6548\u3002<\/p>\n\n\n\n

Design, Setting, and Participants<\/strong> \u8bbe\u8ba1\u3001\u573a\u666f\u53ca\u7814\u7a76\u5bf9\u8c61<\/h3>\n\n\n\n

The Stroke Hyperglycemia Insulin Network Effort (SHINE) randomized clinical trial included adult patients with hyperglycemia (glucose concentration of >110 mg\/dL if had diabetes or \u2265150 mg\/dL if did not have diabetes) and acute ischemic stroke who were enrolled within 12 hours from stroke onset at 63 US sites between April 2012 and August 2018; follow-up ended in November 2018. The trial included 1151 patients who met eligibility criteria.<\/p>\n\n\n\n

SHINE\u968f\u673a\u4e34\u5e8a\u8bd5\u9a8c\u4e8e2012\u5e744\u6708\u81f32018\u5e748\u6708\u5728\u7f8e\u56fd63\u6240\u533b\u9662\u8fdb\u884c\uff0c\u7eb3\u5165\u6025\u6027\u7f3a\u8840\u6027\u5352\u4e2d\u4f34\u9ad8\u8840\u7cd6\uff08\u7cd6\u5c3f\u75c5\u60a3\u8005\u8840\u7cd6\u6c34\u5e73>110 mg\/dL\uff0c\u65e0\u7cd6\u5c3f\u75c5\u60a3\u8005\u2265150 mg\/dL\uff09\u7684\u6210\u5e74\u60a3\u8005\u3002\u968f\u8bbf\u4e8e2018\u5e7411\u6708\u7ed3\u675f\u3002\u8bd5\u9a8c\u7eb3\u51651151\u540d\u7b26\u5408\u5165\u9009\u6807\u51c6\u7684\u60a3\u8005\u3002<\/p>\n\n\n\n

Interventions<\/strong> \u5e72\u9884\u63aa\u65bd<\/h3>\n\n\n\n

Patients were randomized to receive continuous intravenous insulin using a computerized decision support tool (target blood glucose concentration of 80-130 mg\/dL [4.4-7.2 mmol\/L]; intensive treatment group: n\u2009=\u2009581) or insulin on a sliding scale that was administered subcutaneously (target blood glucose concentration of 80-179 mg\/dL [4.4-9.9 mmol\/L]; standard treatment group: n\u2009=\u2009570) for up to 72 hours.<\/p>\n\n\n\n

\u60a3\u8005\u88ab\u968f\u673a\u5206\u7ec4\uff0c\u5206\u522b\u6839\u636e\u8ba1\u7b97\u673a\u51b3\u7b56\u652f\u6301\u5de5\u5177\u8fdb\u884c\u6301\u7eed\u9759\u8109\u80f0\u5c9b\u7d20\u6cbb\u7597\uff08\u76ee\u6807\u8840\u7cd6\u6c34\u5e7380-130 mg\/dL [4.4-7.2 mmol\/L]\uff1b\u5f3a\u5316\u6cbb\u7597\u7ec4\uff1an = 581\uff09\u6216\u6839\u636e\u65b9\u6848\u76ae\u4e0b\u6ce8\u5c04\u80f0\u5c9b\u7d20\uff08\u76ee\u6807\u8840\u7cd6\u6c34\u5e7380-179 mg\/dL [4.4-9.9 mmol\/L]\uff1b\u6807\u51c6\u6cbb\u7597\u7ec4\uff1an\u2009=\u2009570\uff09\uff0c\u7597\u7a0b72\u5c0f\u65f6\u3002<\/p>\n\n\n\n

Main Outcomes and Measures<\/strong> \u4e3b\u8981\u9884\u540e\u6307\u6807<\/h3>\n\n\n\n

The primary efficacy outcome was the proportion of patients with a favorable outcome based on the 90-day modified Rankin Scale score (a global stroke disability scale ranging from 0 [no symptoms or completely recovered] to 6 [death]) that was adjusted for baseline stroke severity.<\/p>\n\n\n\n

\u4e3b\u8981\u9884\u540e\u6307\u6807\u4e3a\u826f\u597d\u9884\u540e\u60a3\u8005\u6bd4\u4f8b\uff0c\u9884\u540e\u6839\u636e90\u5929\u4fee\u8ba2Rankin\u91cf\u8868\u8bc4\u5206\u8bc4\u4f30\uff08\u5352\u4e2d\u6b8b\u75be\u91cf\u8868\uff0c\u5206\u503c\u4ece0\u5206[\u65e0\u4e34\u5e8a\u75c7\u72b6\u6216\u5b8c\u5168\u6062\u590d]\u52306\u5206[\u6b7b\u4ea1]\uff09\uff0c\u5e76\u9488\u5bf9\u57fa\u7ebf\u5352\u4e2d\u4e25\u91cd\u7a0b\u5ea6\u8fdb\u884c\u6821\u6b63\u3002<\/p>\n\n\n\n

Results <\/strong>\u7ed3\u679c <\/h3>\n\n\n\n

Among 1151 patients who were randomized (mean age, 66 years [SD, 13.1 years]; 529 [46%] women, 920 [80%] with diabetes), 1118 (97%) completed the trial. Enrollment was stopped for futility based on prespecified interim analysis criteria. During treatment, the mean blood glucose level was 118 mg\/dL (6.6 mmol\/L) in the intensive treatment group and 179 mg\/dL (9.9 mmol\/L) in the standard treatment group. A favorable outcome occurred in 119 of 581 patients (20.5%) in the intensive treatment group and in 123 of 570 patients (21.6%) in the standard treatment group (adjusted relative risk, 0.97 [95% CI, 0.87 to 1.08], P<\/em>\u2009=\u2009.55; unadjusted risk difference, \u22120.83% [95% CI, \u22125.72% to 4.06%]). Treatment was stopped early for hypoglycemia or other adverse events in 65 of 581 patients (11.2%) in the intensive treatment group and in 18 of 570 patients (3.2%) in the standard treatment group. Severe hypoglycemia occurred only among patients in the intensive treatment group (15\/581 [2.6%]; risk difference, 2.58% [95% CI, 1.29% to 3.87%]).<\/p>\n\n\n\n

\u603b\u51711151\u540d\u60a3\u8005\u63a5\u53d7\u968f\u673a\u5206\u7ec4\uff08\u5e73\u5747\u5e74\u9f8466\u5c81[SD, 13.1 \u5c81]; 529\u540d [46%] \u5973\u6027\uff0c920\u540d [80%] \u7cd6\u5c3f\u75c5\u60a3\u8005\uff09\uff0c1118\u540d (97%) \u5b8c\u6210\u8bd5\u9a8c\u3002\u57fa\u4e8e\u9884\u5148\u786e\u5b9a\u7684\u4e2d\u671f\u5206\u6790\u6807\u51c6\uff0c\u56e0\u6cbb\u7597\u65e0\u6548\uff0c\u63d0\u524d\u7ec8\u6b62\u60a3\u8005\u5165\u9009\u3002\u5728\u6cbb\u7597\u8fc7\u7a0b\u4e2d\uff0c\u5f3a\u5316\u6cbb\u7597\u7ec4\u5e73\u5747\u8840\u7cd6\u6c34\u5e73\u4e3a118 mg\/dL (6.6 mmol\/L)\uff0c\u6807\u51c6\u6cbb\u7597\u7ec4179 mg\/dL (9.9 mmol\/L)\u3002\u5f3a\u5316\u6cbb\u7597\u7ec4581\u540d\u60a3\u8005\u4e2d119\u540d (20.5%) \u53ca\u6807\u51c6\u6cbb\u7597\u7ec4570\u540d\u60a3\u8005\u4e2d 123 \u540d (21.6%) \u7b26\u5408\u826f\u597d\u9884\u540e\u6807\u51c6\uff08\u6821\u6b63\u76f8\u5bf9\u5371\u9669\u5ea6\uff0c0.97 [95% CI, 0.87 to 1.08], P<\/em>\u2009=\u2009.55\uff1b\u672a\u6821\u6b63\u5371\u9669\u5dee\u5f02\uff0c\u22120.83% [95% CI, \u22125.72% to 4.06%]\uff09\u3002\u5f3a\u5316\u6cbb\u7597\u7ec4581\u540d\u60a3\u8005\u4e2d65\u540d (11.2%) \u4e0e\u6807\u51c6\u6cbb\u7597\u7ec4570\u540d\u60a3\u8005\u4e2d 18 \u540d (3.2%) \u56e0\u4f4e\u8840\u7cd6\u6216\u5176\u4ed6\u4e0d\u826f\u4e8b\u4ef6\u63d0\u524d\u505c\u6b62\u6cbb\u7597\u3002\u4ec5\u5f3a\u5316\u6cbb\u7597\u7ec4\u60a3\u8005\u53d1\u751f\u4e86\u4e25\u91cd\u4f4e\u8840\u7cd6(15\/581 [2.6%]; \u98ce\u9669\u5dee\u5f02, 2.58% [95% CI, 1.29% to 3.87%])\u3002<\/p>\n\n\n\n

\"\"\/<\/figure>\n\n\n\n
\"\"\/<\/figure>\n\n\n\n
\"\"\/<\/figure>\n\n\n\n
\"\"\/<\/figure>\n\n\n\n
\"\"\/<\/figure>\n\n\n\n

Conclusions and Relevance<\/strong> \u7ed3\u8bba\u4e0e\u610f\u4e49<\/h3>\n\n\n\n

Among patients with acute ischemic stroke and hyperglycemia, treatment with intensive vs standard glucose control for up to 72 hours did not result in a significant difference in favorable functional outcome at 90 days. These findings do not support using intensive glucose control in this setting.<\/p>\n\n\n\n

\u5bf9\u4e8e\u4f34\u6709\u9ad8\u8840\u7cd6\u7684\u6025\u6027\u7f3a\u8840\u6027\u5352\u4e2d\u60a3\u8005\uff0c\u7597\u7a0b72\u5c0f\u65f6\u7684\u5f3a\u5316\u6cbb\u7597\u4e0e\u6807\u51c6\u8840\u7cd6\u63a7\u5236\u4e0d\u4f1a\u5bf990\u5929\u7684\u826f\u597d\u529f\u80fd\u9884\u540e\u9020\u6210\u663e\u8457\u5dee\u5f02\u3002\u8fd9\u4e9b\u53d1\u73b0\u4e0d\u652f\u6301\u5728\u6b64\u79cd\u60c5\u51b5\u4e0b\u91c7\u7528\u5f3a\u5316\u8840\u7cd6\u63a7\u5236\u3002<\/p>\n\n\n\n

Trial Registration<\/strong> \u8bd5\u9a8c\u6ce8\u518c<\/h3>\n\n\n\n

ClinicalTrials.gov Identifier:\u00a0NCT01369069<\/a><\/p>\n\n\n\n

\u8bc4\u8bba[\u4ec5\u4ee3\u8868\u4e2a\u4eba\u89c2\u70b9]<\/h3>\n\n\n\n
  • \u6211\u4eec\u662f\u5426\u6c38\u8fdc\u5728\u8bc1\u5b9e\u76f8\u5173\u5173\u7cfb\u5176\u5b9e\u4e3a\u56e0\u679c\u5173\u7cfb\u7684\u9053\u7406\u4e0a\u5931\u8d25\uff1f<\/li>
  • \u53ef\u80fd\u4ee5\u4e0b\u7684\u89c2\u70b9\u4ecd\u7136\u662f\u6b63\u786e\u7684\uff1a\u5bf9\u4e8e\u5371\u91cd\u75c5\u60a3\u8005\u800c\u8a00\uff0c\u4e00\u8fc7\u6027\u9ad8\u8840\u7cd6\u7684\u5371\u5bb3\u8fdc\u8f83\u4f4e\u8840\u7cd6\u5c0f<\/li><\/ul>\n","protected":false},"excerpt":{"rendered":"

    Original Investigation | July 23\/30, 201 […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":true,"template":"","format":"standard","meta":[],"categories":[32,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/17524"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=17524"}],"version-history":[{"count":3,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/17524\/revisions"}],"predecessor-version":[{"id":17537,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/17524\/revisions\/17537"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=17524"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=17524"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=17524"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}