Metformin and Glucose Concentration as Limiting Factors in Retinal Pigment Epithelial Cell Viability and Proliferation.

Metformin is a well-established drug for the treatment of type 2 diabetes; however, the mechanism of action has not been well described and many aspects of how it truly acts are still unknown. Moreover, regarding in vitro experiments, the glycaemic status when metformin is used is generally not considered, which, added to the suprapharmacological drug concentrations that are commonly employed in research, has resulted in gaps of its mechanism of action. The aim of this study was to determine how glucose and metformin concentrations influence cell culture. Considering that diabetic retinopathy is one of the most common complications of diabetes, a retinal pigment epithelial cell line was selected, and cell viability and proliferation rates were measured at different glucose and metformin concentrations. As expected, glucose concentration by itself positively influenced cell proliferation rates. When the metformin was considered, results were conditioned, as well, by metformin concentration. This conditioning resulted in cell death when high concentrations of metformin were used under physiological concentrations of glucose, while this did not happen when clinically relevant concentrations of metformin were used independently of glucose status. Our study shows the importance of in vitro cell growth conditions when drug effects such as metformin's are being analysed.

Development of Losartan Orally Disintegrating Tablets by Direct Compression: a Cost-Effective Approach to Improve Paediatric Patient's Compliance.

The development of suitable dosage forms is essential for an effective pharmacological treatment in children. Orally disintegrating tablets (ODTs) are attractive dosage forms that avoid swallowing problems, ensure dosage accuracy and are easy to administer as they disintegrate in the oral cavity. This study aimed to develop ODTs containing losartan potassium (LP) for the treatment of arterial hypertension in children. The ODTs, produced by the cost-effective manufacturing process of direct compression, consisted of a mixture of diluent, superdisintegrant, glidant and lubricant. Five superdisintegrants (croscarmellose sodium, two grades of crospovidone, sodium starch glycolate and pregelatinized starch) were tested (at two concentrations), and combined with three diluents (mannitol, lactose and sorbitol). Thus, thirty formulations were evaluated based on disintegration time, hardness and friability. Two formulations, exhibiting the best results concerning disintegration time (< 30 s), hardness and friability (≤ 1.0%), were selected as the most promising ones for further evaluation. These ODTs presented favourable drug-excipient compatibility, tabletability and flow properties. The in vitro dissolution studies demonstrated 'very rapid' drug release. Preliminary stability studies highlighted the requirement of a protective packaging. All quality properties retained appropriate results after 12 months of storage in airtight containers. In conclusion, the ODTs were successfully developed and characterised, suggesting a potential means to accomplish a final prototype that enables an improvement in childhood arterial hypertension treatment.

Pulsed magnetic field increases the effect of ultraviolet C radiation and thermal shock in aged yeasts.

The study of the effects of the magnetic field (MF) on living matter continues to be a dilemma. Until now, the interaction mechanisms of MF with living matter that explain the observed phenomena are unknown. Despite the existing literature and the multiple effects described to date, there are few published articles that study the combined effect of MF with other physical agents during the cellular aging process. In this sense, the aim of this work is to study whether low frequency and intensity pulsed and sinusoidal MF exposure produce alterations in the cell killing effect of ultraviolet C (UVC) radiation and thermal shock during the chronological aging of S. cerevisiae. Yeast cells were exposed to 2.45 mT (50 Hz) sinusoidal MF and 1.5 mT (25 Hz) pulsed MF, during 40 days of aging, in combination with UVC radiation (50 J/m2) and/or thermal shock (52°C). Cell survival was evaluated by clonogenic assay. The exposure of yeast to pulsed MF produces an acceleration of aging, which is not observed in cells exposed to sinusoidal MF. The pulsed MF modifies the cellular response to damaging agents only in aged S. cerevisiae cells. In this sense, the pulsed MF applied increases the damage induced by UVC radiation and by thermal shock. In contrast, the sinusoidal MF used has no effect.

Nanoparticle-based chewable gels of praziquantel.

Chewable gels present significant advantages over conventional dosage forms, despite their development is not comprehensively assessed. In this sense, six formulations, varying gelatine concentration, dose, and form of incorporation of praziquantel, were developed and characterized. The novelty of this approach focused not only on the development of the formulation itself but also on the incorporation of the drug in a nanoparticulated form. The obtained results for moisture content, water activity, pH, and drug content were within the expected values for this type of formulation. On the other hand, texture and disintegration parameters were influenced by the form of incorporation of praziquantel and the amount of gelatine added. Finally, in vitro dissolution of chewable gels showed significant differences with intermediate products, though the improved dissolution of the nanoparticulated drug was maintained. In conclusion, nanoparticulate drugs can be incorporated into these semisolid formulations and could be successfully applied to other low-aqueous solubility drugs.

PhenoExam: gene set analyses through integration of different phenotype databases.

BACKGROUND: Gene set enrichment analysis (detecting phenotypic terms that emerge as significant in a set of genes) plays an important role in bioinformatics focused on diseases of genetic basis. To facilitate phenotype-oriented gene set analysis, we developed PhenoExam, a freely available R package for tool developers and a web interface for users, which performs: (1) phenotype and disease enrichment analysis on a gene set; (2) measures statistically significant phenotype similarities between gene sets and (3) detects significant differential phenotypes or disease terms across different databases. RESULTS: PhenoExam generates sensitive and accurate phenotype enrichment analyses. It is also effective in segregating gene sets or Mendelian diseases with very similar phenotypes. We tested the tool with two similar diseases (Parkinson and dystonia), to show phenotype-level similarities but also potentially interesting differences. Moreover, we used PhenoExam to validate computationally predicted new genes potentially associated with epilepsy. CONCLUSIONS: We developed PhenoExam, a freely available R package and Web application, which performs phenotype enrichment and disease enrichment analysis on gene set G, measures statistically significant phenotype similarities between pairs of gene sets G and G' and detects statistically significant exclusive phenotypes or disease terms, across different databases. We proved with simulations and real cases that it is useful to distinguish between gene sets or diseases with very similar phenotypes. Github R package URL is https://github.com/alexcis95/PhenoExam . Shiny App URL is https://alejandrocisterna.shinyapps.io/phenoexamweb/ .

Growth alteration of Allium cepa L. roots exposed to 1.5 mT, 25 Hz pulsed magnetic field.

The response of plants to magnetic fields (MF) is not fully understood. This work studies the effects of pulsed MF on the germination and growth of Allium cepa roots. Onions were exposed to 25Hz, 1.5mT, 33h. Pulsed MF was generated by a Helmholtz-type equipment that generated rectangular voltage pulses. The results showed that fewer roots grew in the specimens exposed to pulsed MF (14±6 roots on day 1 to 21±8 on day 4) than in the control groups (32±17 to 48±23) (p<0.05 Friedman). Control specimens showed a root mean length of 7±4 mm (day 1) and 24±10 mm (day 4). The specimens treated with pulsed MF showed a length of 4±2 mm (day 1), reaching 18±9 mm on day 4 (p<0.001 ANOVA). In conclusion, the exposure of Allium cepa specimens to 25Hz, 1.5mT pulsed MF during 33h produces a decrease in the germination and growth of roots.

Exposure of S. cerevisiae to pulsed magnetic field during chronological aging could induce genomic DNA damage.

This study evaluates the DNA damage induced by pulsed magnetic field (MF) on S. cerevisiae cells exposed during chronological aging. Samples were exposed to 25 Hz pulsed MF (1.5mT, 8 h/day) while cells were aging chronologically. Clonogenic drop test was used to study cellular survival and the mutation frequency was evaluated by scoring the spontaneous revertant mutants. DNA damage analysis was performed after aging by electrophoresis and image analysis. Yeast cells aged during 40 days of exposure showing that pulsed MF exposure induced a premature aging. In addition, a gradual increase in spontaneous mutants was found in pulsed MF samples in relation to unexposed controls. An increase in DNA degradation, over the background level in relation to controls, was observed at the end of the exposure period. In conclusion, exposure of S. cerevisiae cells to pulsed MF during chronological aging could induce genomic DNA damage.

Anaphylaxis to Vespa velutina nigrithorax: Pattern of Sensitization for an Emerging Problem in Western Countries.

OBJECTIVE: To define the sensitization pattern of patients with anaphylaxis to Vespa velutina nigrithorax (VVN). METHODS: We studied 100 consecutive Spanish patients with anaphylaxis to Hymenoptera venom and systematically determined specific IgE (sIgE) to whole venoms (Vespula species, Polistes dominula, Apis mellifera, Vespa crabro, and Dolichovespula maculata) and their molecular components (rApi m 1, rApi m 5, rApi m 10, rVes v 1, rVes v 5, rPol d 5, and cross-reactive carbohydrates). Specific IgE to VVN venom and its antigen 5 (nVesp v 5) were measured in a subsample. RESULTS: Seventy-seven patients had anaphylaxis to VVN. Of these, only 16 (20.8%) reported previous VVN stings, but were stung by other Hymenoptera. Positive sIgE (>0.35 kUA/L) to each of the whole venoms was detected in >70% of patients (Vespula species in 100%). The components showing >50% positivity were rApi m 5 (51.4%), rPol d 5 (80.0%), and rVes v 5 (98.7%). This pattern was similar to that of Vespula species anaphylaxis (n=11) but different from that of A mellifera anaphylaxis (n=10). Specific IgE to nVesp v 5 was positive in all patients (n=15) with VVN anaphylaxis and was correlated with sIgE to both rVes v 5 (R=0.931) and rPol d 5 (R=0.887). CONCLUSIONS: VVN has become the commonest cause of Hymenoptera anaphylaxis in our area. Most cases report no previous VVN stings. Their sensitization pattern is similar to that of patients with anaphylaxis to other Vespidae. Specific IgE to antigen-5 from VVN, Vespula species, and P dominula are strongly correlated in patients with VVN anaphylaxis.

CIoTVID: Towards an Open IoT-Platform for Infective Pandemic Diseases such as COVID-19.

The factors affecting the penetration of certain diseases such as COVID-19 in society are still unknown. Internet of Things (IoT) technologies can play a crucial role during the time of crisis and they can provide a more holistic view of the reasons that govern the outbreak of a contagious disease. The understanding of COVID-19 will be enriched by the analysis of data related to the phenomena, and this data can be collected using IoT sensors. In this paper, we show an integrated solution based on IoT technologies that can serve as opportunistic health data acquisition agents for combating the pandemic of COVID-19, named CIoTVID. The platform is composed of four layers-data acquisition, data aggregation, machine intelligence and services, within the solution. To demonstrate its validity, the solution has been tested with a use case based on creating a classifier of medical conditions using real data of voice, performing successfully. The layer of data aggregation is particularly relevant in this kind of solution as the data coming from medical devices has a very different nature to that coming from electronic sensors. Due to the adaptability of the platform to heterogeneous data and volumes of data; individuals, policymakers, and clinics could benefit from it to fight the propagation of the pandemic.

IoTCrawler: Challenges and Solutions for Searching the Internet of Things.

Due to the rapid development of the Internet of Things (IoT) and consequently, the availability of more and more IoT data sources, mechanisms for searching and integrating IoT data sources become essential to leverage all relevant data for improving processes and services. This paper presents the IoT search framework IoTCrawler. The IoTCrawler framework is not only another IoT framework, it is a system of systems which connects existing solutions to offer interoperability and to overcome data fragmentation. In addition to its domain-independent design, IoTCrawler features a layered approach, offering solutions for crawling, indexing and searching IoT data sources, while ensuring privacy and security, adaptivity and reliability. The concept is proven by addressing a list of requirements defined for searching the IoT and an extensive evaluation. In addition, real world use cases showcase the applicability of the framework and provide examples of how it can be instantiated for new scenarios.

Orphan Formulations in Pediatric Schistosomiasis Treatment: Development and Characterization of Praziquantel Nanoparticle-Loaded Powders for Reconstitution.

Praziquantel is a broad spectrum antihelmintic agent and represents the drug of choice for the treatment of schistosomiasis. However, its low aqueous solubility and strong bitter taste highly affect the bioavailability and compliance in pediatric patients. Thus, the purpose of this study was to develop a dry nanosuspension, by a combination of high-pressure homogenization and spray drying, intended for redispersion in a pleasant taste vehicle for extemporaneous use. Three formulations, varying stabilizers to drug ratio, were developed and characterized in terms of particle size distribution, crystallinity, morphology, in vitro dissolution, and sedimentation-redispersibility behavior. A significant reduction in particle size was achieved after the high-pressure homogenization process, and the nanoparticles were further microencapsulated by spray drying technique. The redispersed dried powders exhibited a conserved particle size distribution (in the nanometric range) and certain crystallinity extent, with satisfactory redispersion ability. Besides, the enhancement of the dissolution performance obtained after comminution was conserved, even after drying and redispersion of the extemporaneous powdered formulation. In conclusion, the developed nanoparticle-loaded powders comprise an interesting tool for the administration of praziquantel to preschool-age children.

Commissioning of the Controlled and Automatized Testing Facility for Human Behavior and Control (CASITA).

Human behavior is one of the most challenging aspects in the understanding of building physics. The need to evaluate it requires controlled environments and facilities in which researchers can test their methods. In this paper, we present the commissioning of the Controlled and Automatized Testing Facility for Human Behavior (CASITA). This is a controlled space emulation of an office or flat, with more than 20 environmental sensors, 5 electrical meters, and 10 actuators. Our contribution shown in this paper is the development of an infrastructure-Artificial Intelligence (AI) model pair that is perfectly integrated for the study of a variety of human energy use aspects. This facility will help to perform studies about human behavior in a controlled space. To verify this, we have tested this emulation for 60 days, in which equipment was turned on and off, the settings of the conditioning system were modified remotely, and lighting operation was similar to that in real behaviors. This period of commissioning generated 74.4 GB of raw data including high-frequency measurements. This work has shown that CASITA performs beyond expectations and that sensors and actuators could enable research on a variety of disciplines related to building physics and human behavior. Also, we have tested the PROPHET software, which was previously used in other disciplines and found that it could be an excellent complement to CASITA for experiments that require the prediction of several pertinent variables in a given study. Our contribution has also been to proof that this package is an ideal "soft" addition to the infrastructure. A case study forecasting energy consumption has been performed, concluding that the facility and the software PROPHET have a great potential for research and an outstanding accuracy.

Providing Personalized Energy Management and Awareness Services for Energy Efficiency in Smart Buildings.

Considering that the largest part of end-use energy consumption worldwide is associated with the buildings sector, there is an inherent need for the conceptualization, specification, implementation, and instantiation of novel solutions in smart buildings, able to achieve significant reductions in energy consumption through the adoption of energy efficient techniques and the active engagement of the occupants. Towards the design of such solutions, the identification of the main energy consuming factors, trends, and patterns, along with the appropriate modeling and understanding of the occupants' behavior and the potential for the adoption of environmentally-friendly lifestyle changes have to be realized. In the current article, an innovative energy-aware information technology (IT) ecosystem is presented, aiming to support the design and development of novel personalized energy management and awareness services that can lead to occupants' behavioral change towards actions that can have a positive impact on energy efficiency. Novel information and communication technologies (ICT) are exploited towards this direction, related mainly to the evolution of the Internet of Things (IoT), data modeling, management and fusion, big data analytics, and personalized recommendation mechanisms. The combination of such technologies has resulted in an open and extensible architectural approach able to exploit in a homogeneous, efficient and scalable way the vast amount of energy, environmental, and behavioral data collected in energy efficiency campaigns and lead to the design of energy management and awareness services targeted to the occupants' lifestyles. The overall layered architectural approach is detailed, including design and instantiation aspects based on the selection of set of available technologies and tools. Initial results from the usage of the proposed energy aware IT ecosystem in a pilot site at the University of Murcia are presented along with a set of identified open issues for future research.

Design and in vitro characterization of ivermectin nanocrystals liquid formulation based on a top-down approach.

The aim of this study was to develop ivermectin (IVM) nanosuspensions (NSs) to improve the dissolution rate of this poorly water-soluble drug. Different NSs combining different stabilizers, i.e. poloxamer 188 (P188), polysorbate 80 (T80), polyvinylpyrrolidone (PVP), and sodium lauryl sulfate (SLS), were prepared by high-pressure homogenization. The stabilizers were selected based on the saturation solubility and IVM stability within 72 h. The screening of formulations was performed by considering the drug content within the nanosize range. The best formulation (IVM:T80:PVP 1:0.5:0.5 wt%) was characterized in terms of the particle size distribution, morphology, crystallinity, drug content, and in vitro dissolution profile. This NS was also evaluated from a stability point of view, by conditioning samples at a constant temperature and relative humidity for six months. The fresh and conditioned best NSs Z-sizes were 174.6 and 215.7 nm, respectively; while both NSs showed low polydispersity indexes. The faster dissolution rate for the IVM NS was attributed to the presence of nanoparticles and changes to the crystal structure (i.e. amorphization) that further improved solubility. The best NS had a 4-fold faster initial dissolution rate than raw IVM, and is thus a promising formulation for the treatment of human and animal parasitic diseases.

Correlation between mutational status and survival and second cancer risk assessment in patients with gastrointestinal stromal tumors: a population-based study.

BACKGROUND: Gastrointestinal stromal tumors are sarcomas of the digestive tract characterized by mutations mainly located in the c-KIT or in the platelet-derived growth factor receptor (PDGFR)-alpha genes. Mutations in the BRAF gene have also been described. Our purpose is to define the distribution of c-KIT, PDGFR and BRAF mutations in a population-based cohort of gastrointestinal stromal tumors (GIST) patients and correlate them with anatomical site, risk classification and survival. In addition, as most of the GIST patients have a long survival, second cancers are frequently diagnosed in them. We performed a second primary cancer risk assessment. METHODS: Our analysis was based on data from Tarragona and Girona Cancer Registries. We identified all GIST diagnosed from 1996 to 2006 and performed a mutational analysis of those in which paraffin-embedded tissue was obtained. Observed (OS) and relative survival (RS) were calculated according to risk classifications and mutational status. Multivariate analysis of variables for observed survival and was also done. RESULTS: A total of 132 GIST cases were found and we analyzed mutations in 108 cases. We obtained 53.7% of mutations in exon 11 and 7.4% in exon 9 of c-KIT gene; 12% in exon 18 and 1.9% in exon 12 of PDGFR gene and 25% of cases were wild type GIST. Patients with mutations in exon 11 of the c-KIT gene had a 5-year OS and RS of 59.6% and 66.3%, respectively. Patients with mutations in exon 18 of the PDGFR gene had a 5-year OS and RS of 84.6% and 89.7%. In multivariate analysis, only age and risk group achieved statistical significance for observed survival. GIST patients had an increased risk of second cancer with a hazard ratio of 2.47. CONCLUSIONS: This population-based study shows a spectrum of mutations in the c-KIT and PDGFR genes in GIST patients similar to that previously published. The OS and RS of GIST with the exon 18 PDGFR gene mutation could indicate that this subgroup of patients may be less aggressive and have a good prognosis, although less sensitive to treatment at recurrence. In our study, GIST patients have an increased risk of developing a second neoplasm.

Fractionated stereotactic radiotherapy plus bevacizumab after response to bevacizumab plus irinotecan as a rescue treatment for high-grade gliomas.

AIM: To evaluate the possibility of implementing a new scheme of rescue treatment after relapse or progression of high-grade glioma (HGG) treated at the first-line with bevacizumab and irinotecan (BVZ+CPT11), evaluating the response and toxicity of associating BVZ and fractionated stereotactic radiotherapy (BVZ+FSRT). MATERIALS AND METHODS: We retrospectively analysed data from 59 patients with relapse of HGG. Nine patients with HGG relapse after treatment using the Stupp protocol that were treated with BVZ+CPT11 for progression between July 2007 and August 2012, after which the response was assessed according to the Revised Assessment in Neuro-Oncology (RANO) criteria. BVZ was administered at a dose of 10 mg/kg and FSRT up to a prescribed dose of 30 Gy, 500 cGy per fraction, three days a week. The median follow-up was 38 months. RESULTS: The treatment was well-tolerated by all patients. The response after nuclear magnetic resonance imaging (MRI) at 3-6 months was progression in two patients, stable disease in four, and three patients had a partial response. The median overall survival (OS) from diagnosis until death or the last control was 36.8 months. The median progression-free survival (PFS) was 10.8 months. The results from tumour sub-group analysis indicated that the PFS was not statistically significant although it seemed that it was higher in grade-III. The OS was higher in grade-III gliomas. CONCLUSIONS: The combination of BVZ+FSRT as a second-line HGG relapse rescue treatment is well-tolerated and seems to offer promising results. We believe that multi-centre prospective studies are needed to determine the long-term efficacy and toxicity of this therapeutic approach.

Amiodarone chewable gels as a potential appproach for paediatric congenital cardiopathies treatment: Comparison between animal and vegetal gelling agents.

The difficulty in swallowing is a frequent problem when oral solid dosage forms (conventional tablets or capsules) are administered to paediatric population or patients with dysphagia. An interesting alternative to overcome these problems are non-conventional formulations like chewable gels, commonly known as 'gummies'. Therefore, this work addresses the design, development and characterization of gummies using gelatine and pectin, for the vehiculization of the antiarrhythmic amiodarone (AMIO). Applying a Design of Experiments (DoE) approach, four gelatine (GG1-GG4) and eight pectin formulations (PG1-PG8) were developed. Considering the obtained results for responses during DoE evaluation (i.e., volume, syneresis, hardness, and gumminess), GG3 and PG8 were selected for complete characterization. Water activity, pH, drug content, texture parameters (adhesiveness, springiness, cohesiveness, and fracturability), disintegration time, in vitro dissolution, and microbiological features were evaluated. The obtained results were within the expected values for this type of formulation. The dissolution profiles showed a 94 % - 99 % of the AMIO content released for GG3 and PG8, respectively, so they could be considered suitable as immediate release dosage forms. In conclusion, the chewable gels were successfully developed and characterised, suggesting a potential means to accomplish a final prototype for the improvement of congenital cardiopathies treatment.

Continuous Glucose Monitoring Alarms in Adults with Type 1 Diabetes: User Characteristics and the Impact of Hypoglycemia and Hyperglycemia Alarm Thresholds on Glycemic Control.

Background: Few studies have evaluated the implications of the alarm thresholds of continuous glucose monitoring (CGM) systems for individuals with diabetes. The present study aimed to investigate the influence of hypoglycemia and hyperglycemia alarm thresholds on glycemic control in adults with type 1 diabetes (T1DM) and the characteristics of patients who use these alarms more frequently. Methods: This observational cross-sectional study included 873 users of the FreeStyle Libre 2 system (501 men, median age 48 years, range 18-90 years) with T1DM from a single center. We investigated the role of demographic and metabolic factors on the use of alarms and the impact of hypoglycemia and hyperglycemia alarms and their thresholds on glycemic control. Results: Alarm users were older than nonusers (median age 49 vs. 43 years, respectively; P < 0.001). The hypoglycemia alarms were set by 76.1% of women and by 69.1% of men (P = 0.022). The hypoglycemia alarms reduced hypoglycemia features and glucose variability, although at the expense of shorter time in range. The higher the hypoglycemia alarm threshold, the greater these effects. The hyperglycemia alarms were effective in reducing hyperglycemia and lowering the glucose management indicator, although at the expense of a greater tendency to hypoglycemia. The lower the hyperglycemia alarm threshold, the greater these effects. Conclusions: CGM alarms contribute to better glycemic control. However, hypoglycemia and hyperglycemia alarms have advantages and disadvantages. Adults with T1DM should explore, under medical supervision, which alarm thresholds will best help them achieve their individual glycemic goals.

Hypoglycemia during hyperosmolar hyperglycemic crises is associated with long-term mortality.

BACKGROUND: Previous research has indicated that hypoglycemia during hospitalization is a predictor of unfavorable outcomes in patients with diabetes. However, no studies have examined the long-term impact of hypoglycemia in adults admitted for hyperglycemic crises. The study was aimed to investigate the long-term implications of hypoglycemia during hyperosmolar hyperglycemic crises, particularly in terms of all-cause mortality. METHODS: This retrospective cohort study included 170 patients (82 men [48.2%], median age 72 years) admitted to a university hospital for hyperosmolar hyperglycemic crises, including pure hyperosmolar hyperglycemic states and hyperosmolar diabetic ketoacidoses. We separately investigated the prognostic significance of hypoglycemia on mortality during the initial intravenous insulin therapy phase and during the later subcutaneous insulin therapy phase, both during hospitalization and in the long term (median follow-up, 652 days; range 2-3460 days). RESULTS: Both hypoglycemia during the initial intravenous insulin therapy phase (observed in 26.5% of patients) and hypoglycemia during the later subcutaneous insulin therapy phase (observed in 52.7% of patients) were associated with long-term mortality. After adjusting for potential confounders, hypoglycemia during the initial intravenous insulin therapy phase remained associated with mortality (hazard ratio 2.10, 95% CI 1.27-3.46, p = 0.004). CONCLUSIONS: Hypoglycemia during hyperosmolar hyperglycemic crises is a marker of long-term mortality, especially when it occurs during the initial intravenous insulin therapy phase.