Vulnerable Hours of the Day for Severe Iatrogenic Hypoglycaemia in Type 2 Diabetes: A Single-Centre Retrospective Study.

INTRODUCTION: Iatrogenic hypoglycaemia is an event that should be avoided in the treatment of diabetes, but the pathophysiology thereof has been poorly examined and reported. There is no established method for preventing iatrogenic hypoglycaemia and the current approach is a reactive response following onset of the disease. In this study, we aimed to explore the existence of 'hypoglycaemia-vulnerable hours of the day' in patients with type 2 diabetes, with the ultimate goal of preventing the onset of iatrogenic hypoglycaemia by clarifying the time when severe hypoglycaemia is likely to occur. METHODS: Of the 553,201 patients who visited the Critical Care and Emergency Center of Aizawa Hospital between 2008 and 2019, patients with proven hypoglycaemia (blood glucose level <3.0 mmol/L) and those using insulin or oral hypoglycaemic agents for the treatment of type 2 diabetes were included: 146 insulin users and 148 oral hypoglycaemic agent users. Cosinor analysis was employed to identify hypoglycaemia-vulnerable hours of the day. RESULTS: Patients with type 2 diabetes and severe hypoglycaemia had two peaks: at 8:00 and 18:00-19:00. Hypoglycaemia was observed as quadra-peaked in insulin users and double-peaked in oral hypoglycaemic agent users. Single-cosinor analysis revealed that the cycle was 5.83 hours (R=0.417) in insulin users, whereas it was 11.0 hours (R=0.717) in oral hypoglycaemic agent users. In insulin users, a significant periodicity of six hours (P=0.003) was observed in the cosinor detection analysis, and a significant correlation (P<0.05) was present in the cosinor percent rhythmicity analysis. In contrast, in oral hypoglycaemic agent users, a significant periodicity of 11 hours (P=0.03) was ascertained in the cosinor detection analysis, and there was a significant correlation (P<0.001) in the cosinor percent rhythmicity analysis. There were different hypoglycaemia-vulnerable hours of the day in the patients with type 2 diabetes, suggesting an interaction between disease pathophysiology and pharmacology. CONCLUSIONS: These results can help elucidate the trend of the development of iatrogenic hypoglycaemia and contribute to the prevention of the onset thereof.

Reduction of Severe Hypoglycemic Events Among Outpatients with Type 2 Diabetes Following Sodium-Glucose Cotransporter 2 Inhibitor Marketing in Japan.

Recently, oral hypoglycemic agents with newer glucose lowering mechanisms have been on release. This is mostly to meet the diabetic patient's need to avoid hypoglycemia, which is profoundly important for better long-term outcome of the treatment. In this study, we quantified the annual number of patients with type 2 diabetes who experienced hypoglycemia needing the third-party assistance who had random sample plasma glucose<59.4 mg/dl (3.3 mmol/l) on the one hand and analyzed the prescription trend of hypoglycemic agents all over Japan on the other. Analysis of the annual number of hypoglycemic patients visited ER was performed at Aizawa Hospital, a medical center located in the midst of a city. The study duration was over 10 years from 2008 to 2019. We found a clear-cut decreasing trend of hypoglycemia over the 10 years, ca. 61/year to 39/year. Immediately after the release of sodium-glucose co-transporter-2 inhibitors, since 2013 to 2017, the decrease was rather sharp as 81/year to 31/year, and the change of the national number of its prescription inversely correlated with the change of the number of the patients with hypoglycemia. This was not the case immediately after the introduction of dipeptidyl peptidase-4 inhibitors in the Japanese market since 2008 to 2012. There was no significant correlation between its prescription and the number of patients with hypoglycemia. The data strongly suggested that there was a causal relationship exclusively between the introduction of sodium-glucose cotransporter-2 inhibitor, and the reduction of hypoglycemic events among patients with type 2 diabetes.

Association between underlying disease and serious events on a world cruise ship: A prospective cohort study.

BACKGROUND: This study aimed to clarify the effects of underlying diseases on clinical outcomes of patients aboard a world cruise ship. METHODS: This prospective cohort study included patients who sought physician consultations at an onboard clinic on a 105-day world cruise (September-December 201X) on a ship chartered by a Japanese travel agency. Multivariable logistic regression analysis was performed to ascertain whether any concurrent disease, such as hypertension, was associated with additional onboard treatment by the primary physician or serious events, including unexpected final disembarkation, temporary disembarkation for hospitalization ashore, shore-side referral, and onboard clinic admission. RESULTS: Of 313 patients, 182 (58%) had at least one underlying disease. Sixty-eight (22%) required additional treatment, and 24 (8%) experienced serious events. After adjusting for age, sex, and underlying diseases, the 60-69- and 70-74-year age groups had a lower risk of serious events than the ≤59-year age group (odds ratio [OR], 95% confidence interval [CI]: 0.24, 0.069-0.81; p = 0.022 and 0.045, 0.0051-0.47; p = 0.0055). Underlying disease was associated with serious events (OR, 95% CI: 3.2, 1.1-9.5; p = 0.036). CONCLUSIONS: Unexpected events can occur in patients on world cruises regardless of age. Preexisting diseases may confer higher risk of serious events.

A study of the usefulness of inspection of radiology reports in the emergency room.

AIM: The aim of this study was to better understand the usefulness of retrospective inspection of radiology reports of CT (computed tomography) or MRI (magnetic resonance imaging) by emergency doctors in the emergency room. METHODS: Between April 2018 and March 2019, patients who went home after CT or MRI who needed to change their treatment plans and subsequent corresponding procedures after inspection of radiology reports by emergency doctors were reviewed. RESULTS: Among 7,661 CT or MRIs performed on 5,917 patients, there were 131 patients (133 CT or MRI or 1.7% among 7,661 examinations) who required a change in their treatment plans after inspection of radiology reports. Of the 133 CT or MRI performed, there were 51 (38.3% among 133 CT or MRI, 0.7% among 7,661 examinations) CT or MRI performed, which indicated findings to suspect a tumor (11.8% in the head, 41.2% in the chest, 35.3% in the abdomen, and 11.8% in others). With the need to make important changes in treatment plans, making appointments for outpatient clinics was necessary for 52 CT or MRI findings, and requiring the patients to return to the clinic or be admitted was necessary for 9 (totally 61; 0.8% among 7,661 examinations). CONCLUSION: Data from this study suggest that inspection of radiology reports of CT or MRI by emergency doctors after patients went home is useful in finding characteristics suggestive of tumors in 0.7% of all radiology reports and is necessary to identify important changes that should be made in treatment plans in 0.8% of all radiology reports.

A 60-y-old chylomicronemia patient homozygous for missense mutation (G188E) in the lipoprotein lipase gene showed no accelerated atherosclerosis.

BACKGROUND: Familial lipoprotein lipase (LPL) deficiency is a rare autosomal recessive disorder caused by mutations in the LPL gene. Patients with LPL deficiency have chylomicronemia; however, whether they develop accelerated atherosclerosis remains unclear. METHODS: We investigated clinical and mutational characteristics of a 60-y-old Japanese patient with chylomicronemia. RESULTS: The patient's fasting plasma triglyceride levels were >9.0 mmol/l. In postheparin plasma, one fifth of the normal LPL protein mass was present; however, LPL activity was undetectable. Molecular analysis of the LPL gene showed the patient to be a homozygote of missense mutation replacing glycine with glutamine at codon 188 (G188E), which had been known to produce mutant LPL protein lacking lipolytic activity. Ultrasonographic examination of the patient's carotid and femoral arteries showed no accelerated atherosclerosis. Moreover, 64-slice mechanical multidetector-row computer tomography (MDCT) angiography did not detect any accelerated atherosclerotic lesions in the patient's coronary arteries. The patient had none of the risk factors such as smoking, hypertension, and diabetes. CONCLUSIONS: Our case suggests that accelerated atherosclerosis may not develop in patients with LPL deficiency, when they have no risk factors.