Characteristics of patients treated for severe hypoglycaemia in emergency care settings - Analysis of routinely collected data.

OBJECTIVE: Severe hypoglycaemic events (SHE) commonly require emergency care. This study investigates the presentation of patients with SHE to a single Swiss emergency service, including pre-hospital care with emergency medical services (EMS) and emergency department (ED) presentations. METHOD: Retrospective analysis of routinely collected data by the EMS and ED during 2014. All adult patients with diabetes type 1 or type 2 with SHE were included in the analysis. RESULTS: 43 SHE were recorded in 38 patients with diabetes. Mean age of all patients was 65 years (SD ±â€¯17.51), 54% (n = 23) were men, 55.8% (n = 24) were living in a relationship, and 54.8% (n = 23) were diagnosed with type 2 diabetes. Of the 43 episodes, 65% (n = 28) of the presentations used EMS and were then taken to the ED, 28% (n = 12) involved contact with the EMS only, and 7% (n = 3) were seen by the ED but did not use EMS. Patients seen by the EMS only (n = 12) were younger compared to those admitted to ED (n = 28); Md 54 years vs Md 72 years; U = 98; p = .039. The same age difference was similar between patients in the ED setting discharged home (n = 11) and with in-patients (n = 20); Md 61 years vs. Md 79 years; U = 51; p = .013. CONCLUSIONS: People most likely to suffer a SHE were men, those living with a partner, over 65 years old, and living with type 2 diabetes. Younger patients treated by EMS at home tended to remain at home, in contrast to the older patients who were admitted to hospital. This was also true for the ED where older people in particular became in-patients after such an event. Elderly care specialist brief interventions conveyed by EMS and ED healthcare professionals might be of value to prevent further SHE. Validating these findings in multiple emergency settings is warranted to support the delivery of targeted interventions.

Treatment of Type 1 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes.

DESCRIPTION: The American Diabetes Association (ADA) annually updates Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes. METHODS: For the 2017 Standards of Care, the ADA Professional Practice Committee did MEDLINE searches from 1 January 2016 to November 2016 to add, clarify, or revise recommendations on the basis of new evidence. The committee rated the recommendations as A, B, or C, depending on the quality of evidence, or E for expert consensus or clinical experience. The Standards of Care were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions. RECOMMENDATION: This synopsis focuses on recommendations from the 2017 Standards of Care about monitoring and pharmacologic approaches to glycemic management for type 1 diabetes.

Neurodevelopmental Outcome of Asymptomatic Hypoglycemia Compared With Symptomatic Hypoglycemia and Euglycemia in High-Risk Neonates.

AIMS: We assessed the neurodevelopmental outcome at one year of age of children with asymptomatic neonatal hypoglycemia and compared their outcome with that of symptomatic hypoglycemic and euglycemic neonates. METHOD: Seventy two hypoglycemic (plasma glucose less than 50 mg/dL) neonates, both symptomatic (n = 27) and asymptomatic (n = 45), and 70 weight- and gestation-matched euglycemic neonates of gestational age greater than 32 weeks were enrolled during the first week of life then assessed for neurodevelopmental outcome at corrected age six and 12 months (n = 67 and 62 in hypoglycemia group and 63 and 54 in euglycemia group, with the rest lost to follow-up, and death = 1). RESULTS: At one year, 8% (five of 62, four in symptomatic and one in asymptomatic group) of hypoglycemic neonates developed cerebral palsy. Mean motor and mental development quotients were significantly lower at corrected ages six and 12 months in any hypoglycemia (P < 0.001) and if blood glucose was less than 40 mg/dL (P < 0.001) when compared with euglycemia. Symptomatic infants had lower motor development quotient (P = 0.004 and 0.003) and mental development quotient (P = 0.001 and 0.001) at corrected ages six and 12 months than asymptomatic infants, and asymptomatic infants had lower motor development quotient (P ≤ 0.001 and 0.004) and mental development quotient (P = 0.001 and 0.004) than the euglycemic group at corrected ages six and 12 months, respectively. Blood glucose of less than 40 mg/dL had high sensitivity (83% for motor development quotient and 81% for mental development quotient) for development quotient scores of less than 85. CONCLUSION: Hypoglycemia, both symptomatic and asymptomatic, leads to adverse neurodevelopmental outcome when compared with euglycemia, although it was worse in the symptomatic group and at blood glucose less than 40 mg/dL.

Rates of hypoglycaemia are lower in patients treated with insulin degludec/liraglutide (IDegLira) than with IDeg or insulin glargine, regardless of the hypoglycaemia definition used.

AIMS: To re-analyse, using a series of alternative hypoglycaemia definitions, the data from 2 trials, DUAL I and V, in which the once-daily, fixed ratio combination of insulin degludec/liraglutide (IDegLira) was compared with basal insulin therapy. MATERIAL AND METHODS: Post hoc analyses of the DUAL I (patients uncontrolled on oral antidiabetic drugs) and DUAL V (patients uncontrolled on insulin glargine (IGlar) U100) trials were carried out using different definitions of hypoglycaemia and according to whether treatments were administered in the morning or afternoon. Rates of hypoglycaemia for the definitions of confirmed and American Diabetes Association (ADA)-documented symptomatic hypoglycaemia were compared according to age, gender and body mass index (BMI). RESULTS: Although hypoglycaemia rates differed according to the alternative hypoglycaemia definitions, rates were consistently lower with IDegLira vs insulin degludec (IDeg) and IGlar U100. Despite glycated haemoglobin concentrations being lower with IDegLira at end of treatment, confirmed and nocturnal-confirmed hypoglycaemia rates were lower for IDegLira vs IDeg and IGlar U100, irrespective of dosing time. The definitions of confirmed and ADA-documented symptomatic hypoglycaemia did not have a significant effect on the treatment difference between IDegLira and IDeg, liraglutide or IGlar U100 when further assessed by baseline age, gender and BMI. CONCLUSIONS: Treatment with IDegLira, vs IDeg and IGlar U100, resulted in lower rates of hypoglycaemia regardless of dosing time and definition of hypoglycaemia used. The choice of hypoglycaemia definition did not influence the results of analyses when stratified by age, sex and BMI.

Validation of an International Statistical Classification of Diseases and Related Health Problems 10th Revision Coding Algorithm for Hospital Encounters with Hypoglycemia.

OBJECTIVES: To determine the positive predictive value and sensitivity of an International Statistical Classification of Diseases and Related Health Problems, 10th Revision, coding algorithm for hospital encounters concerning hypoglycemia. METHODS: We carried out 2 retrospective studies in Ontario, Canada. We examined medical records from 2002 through 2014, in which older adults (mean age, 76) were assigned at least 1 code for hypoglycemia (E15, E160, E161, E162, E1063, E1163, E1363, E1463). The positive predictive value of the algorithm was calculated using a gold-standard definition (blood glucose value <4 mmol/L or physician diagnosis of hypoglycemia). To determine the algorithm's sensitivity, we used linked healthcare databases to identify older adults (mean age, 77) with laboratory plasma glucose values <4 mmol/L during a hospital encounter that took place between 2003 and 2011. We assessed how frequently a code for hypoglycemia was present. We also examined the algorithm's performance in differing clinical settings (e.g. inpatient vs. emergency department, by hypoglycemia severity). RESULTS: The positive predictive value of the algorithm was 94.0% (95% confidence interval 89.3% to 97.0%), and its sensitivity was 12.7% (95% confidence interval 11.9% to 13.5%). It performed better in the emergency department and in cases of more severe hypoglycemia (plasma glucose values <3.5 mmol/L compared with ≥3.5 mmol/L). CONCLUSIONS: Our hypoglycemia algorithm has a high positive predictive value but is limited in sensitivity. Although we can be confident that older adults who are assigned 1 of these codes truly had a hypoglycemia event, many episodes will not be captured by studies using administrative databases.

Is all hypoglycaemia treated as equal? An observational study of how the type of diabetes and treatment prescribed prior to admission influences quality of treatment of inpatient hypoglycaemia.

AIMS: Inpatient hypoglycaemia is common and associated with adverse outcomes. There is often increased vigilance of hypoglycaemia in inpatients with type 1 diabetes (T1DM) compared to type 2 diabetes (T2DM). We aimed to investigate this apparent discrepancy, utilising the time to repeat (TTR) capillary blood glucose (CBG) measurement as a surrogate for engagement with guidelines stating that CBG should be rechecked following intervention within 15 min of an initial CBG of <4 mmol/L. METHODS: This is an observational study of inpatient CBG data from 8 hospitals over a 7-year period. A national diabetes registry allowed identification of individual's diagnosis and diabetes therapy. For each initial (index) CBG, the TTR for individuals with T2DM-on insulin or sulphonylurea-was compared with the TTR for individuals with T1DM, using a t test for significance performed on log(TTR). The median TTR was plotted for each group per index CBG. RESULTS: In total, 1480,335 CBG measurements were obtained. A total of 26,664 were <4 mmol/L. The TTR in T2DM individuals on sulphonylurea was significantly greater than in T1DM individuals where index CBG was ≥2.3 mmol/L (except index CBG 2.6 mmol/L). For T2DM patients receiving insulin significance exists for index CBGs of ≥3.2 mmol/L. CONCLUSIONS: This analysis suggests that quality of care of hypoglycaemia varies according to diagnosis and medication. The group with the highest TTR (T2DM sulphonylurea treated) are possibly the clinical group in whom hypoglycaemia is most concerning. These data therefore suggest a need for education and raising awareness within the inpatient nursing staff.

Neonatal Hypoglycemia: A Continuing Debate in Definition and Management.

Neonatal hypoglycemia (NH) is one of the most common abnormalities encountered in the newborn. Maintaining glucose homeostasis is one of the important physiological events during fetal-to-neonatal transition. Transient low blood glucose concentrations are frequently encountered in the majority of healthy newborns and are the reflections of normal metabolic adaptation processes. Nevertheless, there is a great concern that prolonged or recurrent low blood glucose levels may result in long-term neurological and developmental consequences. Strikingly, it was demonstrated that the incidence and timing of low glucose concentrations in the groups most at risk for asymptomatic neonatal hypoglycemia, did not find association between repetitive low glucose concentrations and poor neurodevelopmental outcomes. On the contrary, NH due to hyperinsulinism is strongly associated with brain injury. Fundamental issue of great professional controversy is concerning the best manner to manage asymptomatic newborns NH. Both, overtreating NH and undertreating NH are poles with significant potential disadvantages. Therefore, NH is one of the most important issues in the day-to-day practice. This article appraises the critical questions of definition (widely accepted blood glucose concentration: < 2.6 mmol/l or 47 mg/dl), follow-up ad management of NH.

[Diagnosis and assessment of hypoglycemia in patients with diabetes mellitus]. / La vignette diagnostique de l'etudiant. Diagnostic et evaluation d'une hypoglycémie chez le patient diabétique.

Hypoglycaemic episodes are rather common among diabetic patients, especially those treated with sulfonylureas or insulin (more in type 1 than in type 2 diabetes). The presentation of hypoglycaemia may considerably vary from patient-to-patient and from time-to-time in a given patient. With the illustration of a clinical case, we will describe the characteristics of the three main types of hypoglycaemia: severe hypoglycaemia (with or without coma), symptomatic hypoglycaemia (with or without confirmation) and asymptomatic hypoglycaemia ("hypoglycaemia unawareness") discovered as a low blood glucose measurement. We will also briefly analyse the reasons of such differences and the potential clinical consequences that these three main types of hypoglycaemia may exert in the real life of diabetic patients.

[Hypoglycemia]. / Hipoglucemia.

Hypoglycemia is the acute complications occur more often, people with diabetes mellitus, especially those treated with insulin and/or certain oral hypoglycemic agents. Studies such as The Diabetes Control and Complications Trial (DCCT) in type 1 diabetes mellitus or the United Kingdom Prospective Diabetes Study (UKPDS) in type 2 have shown that improvement in metabolic control, expressed in the reduction of HbA1c (glycated hemoglobin) decreases the risk of chronic complications associated with diabetes. However this reduction is associated with an increased incidence of hypoglycemia, especially in people with aggressive therapy Although in recent years the treatment of diabetes with new drugs (like insulin, new oral agents), it remains difficult to reproduce the endogenous insulin secretion and fear of patients have episodes of hypoglycemia is the strongest difficulty in optimizing the treatment of diabetes, and that adversely affects their quality of life.

Hipoglicemia infantil / Hypoglycemia of infancy

Hypoglycemia of infancy is a common metabolic disorder that can have serious neurological consequences. Therefore, its early diagnosis and treatment are crucial prognostic factors. Hypoglycemia has a variety of causes and a good clinical history, physical examination and laboratory determination will orient the correct diagnosis. Occasionally a molecular study will be required.

Describing hypoglycemia--definition or operational threshold?

Severe glucose deficiency leads to cerebral energy failure, impaired cardiac performance, muscle weakness, glycogen depletion, and diminished glucose production. Thus, maintenance of glucose delivery to all organs is an essential physiological function. Normal term infants have sufficient alternate energy stores and capacity for glucose production from glycogenolysis and gluconeogenesis to ensure normal glucose metabolism during the transition to extrauterine life and early neonatal period. Milk feedings particularly enhance glucose homeostasis. Energy sources often are low in preterm and growth restricted infants, who are especially vulnerable to glucose deficiency. Plasma glucose concentration is the only practical measure of glucose sufficiency, but by itself is a very limited guide. Key to preventing complications from glucose deficiency is to identify infants at risk, promote early and frequent feedings, normalize glucose homeostasis, measure glucose concentrations early and frequently in infants at risk, and treat promptly when glucose deficiency is marked and symptomatic.

Evaluation and management of adult hypoglycemic disorders: an Endocrine Society Clinical Practice Guideline.

OBJECTIVE: The aim is to provide guidelines for the evaluation and management of adults with hypoglycemic disorders, including those with diabetes mellitus. EVIDENCE: Using the recommendations of the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system, the quality of evidence is graded very low (plus sign in circle ooo), low (plus sign in circle plus sign in circle oo), moderate (plus sign in circle plus sign in circle plus sign in circle o), or high (plus sign in circle plus sign in circle plus sign in circle plus sign in circle). CONCLUSIONS: We recommend evaluation and management of hypoglycemia only in patients in whom Whipple's triad--symptoms, signs, or both consistent with hypoglycemia, a low plasma glucose concentration, and resolution of those symptoms or signs after the plasma glucose concentration is raised--is documented. In patients with hypoglycemia without diabetes mellitus, we recommend the following strategy. First, pursue clinical clues to potential hypoglycemic etiologies--drugs, critical illnesses, hormone deficiencies, nonislet cell tumors. In the absence of these causes, the differential diagnosis narrows to accidental, surreptitious, or even malicious hypoglycemia or endogenous hyperinsulinism. In patients suspected of having endogenous hyperinsulinism, measure plasma glucose, insulin, C-peptide, proinsulin, beta-hydroxybutyrate, and circulating oral hypoglycemic agents during an episode of hypoglycemia and measure insulin antibodies. Insulin or insulin secretagogue treatment of diabetes mellitus is the most common cause of hypoglycemia. We recommend the practice of hypoglycemia risk factor reduction--addressing the issue of hypoglycemia, applying the principles of intensive glycemic therapy, and considering both the conventional risk factors and those indicative of compromised defenses against falling plasma glucose concentrations--in persons with diabetes.

Intensive insulin therapy and mortality in critically ill patients.

INTRODUCTION: Intensive insulin therapy (IIT) with tight glycemic control may reduce mortality and morbidity in critically ill patients and has been widely adopted in practice throughout the world. However, there is only one randomized controlled trial showing unequivocal benefit to this approach and that study population was dominated by post-cardiac surgery patients. We aimed to determine the association between IIT and mortality in a mixed population of critically ill patients. METHODS: We conducted a cohort study comparing three consecutive time periods before and after IIT protocol implementation in a Level 1 trauma center: period I (no protocol); period II, target glucose 80 to 130 mg/dL; and period III, target glucose 80 to 110 mg/dL. Subjects were 10,456 patients admitted to intensive care units (ICUs) between 1 March 2001 and 28 February 2005. The main study endpoints were ICU and hospital mortality, Sequential Organ Failure Assessment score, and occurrence of hypoglycemia. Multivariable regression analysis was used to evaluate mortality and organ dysfunction during periods II and III relative to period I. RESULTS: Insulin administration increased over time (9% period I, 25% period II, and 42% period III). Nonetheless, patients in period III had a tendency toward higher adjusted hospital mortality (odds ratio [OR] 1.15, 95% confidence interval [CI] 0.98, 1.35) than patients in period I. Excess hospital mortality in period III was present primarily in patients with an ICU length of stay of 3 days or less (OR 1.47, 95% CI 1.11, 1.93 There was an approximately fourfold increase in the incidence of hypoglycemia from periods I to III. CONCLUSION: A policy of IIT in a group of ICUs from a single institution was not associated with a decrease in hospital mortality. These results, combined with the findings from several recent randomized trials, suggest that further study is needed prior to widespread implementation of IIT in critically ill patients.