Severe hypoglycemia in patients with known diabetes requiring emergency department care: A report from an Italian multicenter study.
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ABSTRACT:
SUBMITTER: Mantovani A
PROVIDER: S-EPMC5644438 | biostudies-literature | 2016 Sep
REPOSITORIES: biostudies-literature
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Severe hypoglycemia in patients with known diabetes requiring emergency department care: A report from an Italian multicenter study.
Mantovani Alessandro A Grani Giorgio G Chioma Laura L Vancieri Giuseppe G Giordani Ilaria I Rendina Roberta R Rinaldi Maria Elena ME Andreadi Aikaterini A Coccaro Carmela C Boccardo Chiara C Fraenza Costanza C Bertazzoni Giuliano G Bellia Alfonso A Zoppini Giacomo G Targher Giovanni G Baroni Marco Giorgio MG Lauro Davide D D'Armiento Massimino M Bonora Enzo E
Journal of clinical & translational endocrinology 20160820
<h4>Aims</h4>To describe the characteristics and associated risk factors of patients with established diabetes who required Emergency Department (ED) care for severe hypoglycemia.<h4>Methods</h4>We performed an observational retrospective study to identify all cases of severe hypoglycemia among attendees at the EDs of three Italian University hospitals from January 2010 to December 2014.<h4>Results</h4>Overall, 520 patients with established diabetes were identified. Mean out-of-hospital blood gl ...[more]
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Project description:Hypoglycemia commonly occurs in patients who are being treated for diabetes. In some cases, these patients suffer from severe hypoglycemia that requires medical assistance and which can unfortunately result in long-term disabilities. Therefore, we investigated risk factors associated with severe hypoglycemia requiring medical assistance (HMA) and the resulting neurological sequelae in patients with diabetes. This investigation was a case-control study that assessed 129 patients with diabetes and documented hypoglycemia from a single tertiary hospital between February 2013 and May 2015. They were treated with oral hypoglycemic agents alone (54%) or with insulin with/without oral hypoglycemic agents (46%). If a patient with diabetes visited the emergency department due to hypoglycemia, this was defined as HMA. The control group was composed of patients with documented, nonsevere hypoglycemia who visited the outpatient clinic during the same period. The degree of neurological disability in the HMA patients was measured using the modified Rankin Scale. A multivariate analysis revealed that independent risk factors of HMA were associated with a lack of the self-monitoring of blood glucose (SMBG) and previous episodes of severe hypoglycemia. In the HMA group, 15 patients (22%) had neurological sequelae at the time of discharge. Patients with neurological sequelae were older than those without sequelae (74.3 years vs 65.8 years, P?=?0.006) and had increased psychological evidence of disorders such as insomnia, dementia, and depression (40% vs 11%, P?=?0.017). Patients with sequelae were also more likely to live in rural areas (47% vs 19%, P?=?0.04) and to have a longer time from last seen normal till glucose administration (5.2?hours vs 1.6?hours, P?=?0.027). In the present study, absence of SMBG and previous severe hypoglycemic episodes were independent risk factors of HMA and patients with an older age, a psychological disorder, a rural residence, and a prolonged duration of hypoglycemia had higher risks of neurological sequelae. Therefore, the present findings suggest that physicians should aim to prevent hypoglycemia in patients with a history of hypoglycemia and provide education for these patients regarding regular SMBG.
| S-EPMC5134865 | biostudies-other
Project description:Hypoglycemia commonly occurs in patients who are being treated for diabetes. In some cases, these patients suffer from severe hypoglycemia that requires medical assistance and which can unfortunately result in long-term disabilities. Therefore, we investigated risk factors associated with severe hypoglycemia requiring medical assistance (HMA) and the resulting neurological sequelae in patients with diabetes. This investigation was a case-control study that assessed 129 patients with diabetes and documented hypoglycemia from a single tertiary hospital between February 2013 and May 2015. They were treated with oral hypoglycemic agents alone (54%) or with insulin with/without oral hypoglycemic agents (46%). If a patient with diabetes visited the emergency department due to hypoglycemia, this was defined as HMA. The control group was composed of patients with documented, nonsevere hypoglycemia who visited the outpatient clinic during the same period. The degree of neurological disability in the HMA patients was measured using the modified Rankin Scale. A multivariate analysis revealed that independent risk factors of HMA were associated with a lack of the self-monitoring of blood glucose (SMBG) and previous episodes of severe hypoglycemia. In the HMA group, 15 patients (22%) had neurological sequelae at the time of discharge. Patients with neurological sequelae were older than those without sequelae (74.3 years vs 65.8 years, P = 0.006) and had increased psychological evidence of disorders such as insomnia, dementia, and depression (40% vs 11%, P = 0.017). Patients with sequelae were also more likely to live in rural areas (47% vs 19%, P = 0.04) and to have a longer time from last seen normal till glucose administration (5.2 hours vs 1.6 hours, P = 0.027). In the present study, absence of SMBG and previous severe hypoglycemic episodes were independent risk factors of HMA and patients with an older age, a psychological disorder, a rural residence, and a prolonged duration of hypoglycemia had higher risks of neurological sequelae. Therefore, the present findings suggest that physicians should aim to prevent hypoglycemia in patients with a history of hypoglycemia and provide education for these patients regarding regular SMBG.
| S-EPMC5134865 | biostudies-literature
Project description:Despite concerns about hypoglycemia events from overly aggressive glycemic reduction, population trends in hypoglycemia and hyperglycemic crisis incidence are unclear. To address this gap, we examined changes in emergency department (ED) visit rates for hypoglycemia and hyperglycemic crisis 2006-2011.Using data from the Nationwide Emergency Department Sample, we estimated the number of ED visits for hypoglycemia and hyperglycemic crisis via ICD-9-CM among adults with diabetes. Using data from the National Health Interview Survey, we estimated the population of adults with diabetes and calculated ED visit rates.From 2006 to 2011, ED visit rates for hypoglycemia declined by 22% from 1.8 to 1.4 per 100 adults (p = 0.003). The rates decreased in all age groups (all P<0.05) except those aged 18 to 44 years (P = 0.31). Hypoglycemia rates displayed a J-shaped curve across age, with the highest rates among adults aged 75 years or older (P <0.001). ED visit rates for hyperglycemic crisis did not change overall but increased 17% for adults aged 65 to 74 years (P = 0.02) and 29% for women (P = 0.01). Hyperglycemic crisis rates were highest among adults aged 18 to 44 years (P <0.001).Hypoglycemia rates have declined for all adults but persons aged 18-44 years while rates for hyperglycemic crisis remained stable. Future preventive efforts should target on the susceptible population of adults aged 18 to 44 years and those aged 75 years or older.
| S-EPMC4529297 | biostudies-other
Project description:BackgroundSevere hypoglycemia is associated with adverse clinical outcomes. We evaluated the risk of severe hypoglycemia in older adults initiating newer glucose-lowering medications overall and across strata of known indicators of high hypoglycemia risk.MethodsWe conducted a comparative-effectiveness cohort study of older adults aged >65 years with type 2 diabetes initiating sodium-glucose cotransporter 2 inhibitors (SGLT2i) versus dipeptidyl peptidase-4 inhibitors (DPP-4i) or SGLT2i versus glucagon-like peptide-1 receptor agonists (GLP-1RA) using Medicare claims (3/2013-12/2018) and Medicare-linked-electronic health records. We identified severe hypoglycemia requiring emergency or inpatient visits using validated algorithms. After 1:1 propensity score matching, we estimated hazard ratios (HR) and rate differences (RD) per 1,000 person-years. Analyses were stratified by baseline insulin, sulfonylurea, cardiovascular disease (CVD), chronic kidney disease (CKD), and frailty.ResultsOver a median follow-up of 7 (interquartile range: 4-16) months, SGLT2i was associated with a reduced risk of hypoglycemia versus DPP-4i (HR 0.75 [0.68, 0.83]; RD -3.21 [-4.29, -2.12]), and versus GLP-1RA (HR 0.90 [0.82, 0.98]; RD -1.33 [-2.44, -0.23]). RD for SGLT2i versus DPP-4i was larger in patients using baseline insulin than in those not, although HRs were similar. In patients using baseline sulfonylurea, the risk of hypoglycemia was lower in SGLT2i versus DPP-4i (HR 0.57 [0.49, 0.65], RD -6.80 [-8.43, -5.16]), while the association was near-null in those without baseline sulfonylurea. Results stratified by baseline CVD, CKD and frailty were similar to the overall cohort findings. Findings for the GLP-1RA comparison were similar.ConclusionsSGLT2i was associated with a lower hypoglycemia risk versus incretin-based medications, with larger associations in patients using baseline insulin or sulfonylurea.
| S-EPMC10692415 | biostudies-literature
Project description:BackgroundTigecycline, the first glycylcycline-class drug, is a broad-spectrum antibiotic with activity against multi-drug resistant (MDR) organisms. We describe a case of sustained and severe hypoglycemia in a patient treated with tigecycline for pneumonia due to MDR Klebsiella pneumoniae.Case presentationA 74-year-old man was admitted for treatment of pneumonia. At admission he had prediabetes. In the hospital he developed renal failure. On day 3, the patient experienced severe shortness of breath. He was intubated and transferred to the intensive care unit (ICU) for ventilator support. In the ICU the antibiotic regimen was cefoperazone and sulbactam (1?g every 12?h). Continuous Renal Replacement Therapy was started on that day. Test for anti-neutrophil cytoplasmic antibodies (ANCA) was positive, and so the nephrologist and rheumatologist agreed on a diagnosis of ANCA-associated vasculitis, with renal and pulmonary involvement and acute renal failure. Plasmapheresis, and high-dose methylprednisolone treatment were started on day 6, and there was obvious improvement in the patient's condition. The steroid regimen was gradually tapered to oral prednisone (35?mg every day) on day 19. Afterwards, the patient's pneumonia worsened. Sputum culture showed Klebsiella pneumoniae sensitive to only tigecycline. Tigecycline treatment (100?mg every 12?h) was administered on day 20. Hypoglycemia started about 37?h after the first dose of tigecycline. Infusion of 50% glucose through the femoral vein was required for over 20?h to maintain normal blood glucose concentrations. Tigecycline was stopped, but the hypoglycemia resolved only after a further 34?h. The insulin and C-peptide levels were found to be markedly elevated during the hypoglycemia. The Naranjo scale score of 7 indicated that the likelihood of tigecycline causing severe hypoglycemia was "probable."ConclusionThis is the first report of sustained severe hypoglycemia due to tigecycline. Oversecretion of insulin appears to have been the cause of the hypoglycemia in our patient. The mechanism needs to be investigated.
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Project description:We apply a previously described tool to forecast emergency department (ED) crowding at multiple institutions and assess its generalizability for predicting the near-future waiting count, occupancy level, and boarding count.The ForecastED tool was validated with historical data from 5 institutions external to the development site. A sliding-window design separated the data for parameter estimation and forecast validation. Observations were sampled at consecutive 10-minute intervals during 12 months (n=52,560) at 4 sites and 10 months (n=44,064) at the fifth. Three outcome measures-the waiting count, occupancy level, and boarding count-were forecast 2, 4, 6, and 8 hours beyond each observation, and forecasts were compared with observed data at corresponding times. The reliability and calibration were measured following previously described methods. After linear calibration, the forecasting accuracy was measured with the median absolute error.The tool was successfully used for 5 different sites. Its forecasts were more reliable, better calibrated, and more accurate at 2 hours than at 8 hours. The reliability and calibration of the tool were similar between the original development site and external sites; the boarding count was an exception, which was less reliable at 4 of 5 sites. Some variability in accuracy existed among institutions; when forecasting 4 hours into the future, the median absolute error of the waiting count ranged between 0.6 and 3.1 patients, the median absolute error of the occupancy level ranged between 9.0% and 14.5% of beds, and the median absolute error of the boarding count ranged between 0.9 and 2.8 patients.The ForecastED tool generated potentially useful forecasts of input and throughput measures of ED crowding at 5 external sites, without modifying the underlying assumptions. Noting the limitation that this was not a real-time validation, ongoing research will focus on integrating the tool with ED information systems.
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Project description:Priapism, a rare but well-known adverse reaction of first and second generation anti-psychotics, has been hypothesized to be associated with blockade of alpha 1 receptors. However, genetic abnormalities or heritability of affected cytochrome P450 alleles has not been ruled out as a causal mechanism. A case is presented with three episodes of priapism within 17 days while taking standard FDA (Food and Drug Administration) approved doses of quetiapine. Cytochrome P450 3A4 genotype testing was performed and resulted with normal enzymatic activity. This case further eliminates enzymatic metabolism as a possible cause of priapism, thus strengthening the alpha one receptor blockade hypothesis.
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Project description:Importance:Severe hypoglycemia is a serious and potentially preventable complication of diabetes, with some of the most severe episodes requiring emergency department (ED) care or hospitalization. A variety of health conditions increase the risk of hypoglycemia. People with diabetes often have multiple comorbidities, and the association of such multimorbidity with hypoglycemia risk in the context of other risk factors is uncertain. Objective:To examine the associations of age, cumulative multimorbidity, glycated hemoglobin (HbA1c) level, and use of glucose level-lowering medication with hypoglycemia-related ED visits and hospitalizations. Design, Setting, and Participants:Cohort study of claims and laboratory data from OptumLabs Data Warehouse, an administrative claims database of commercially insured and Medicare Advantage beneficiaries in the United States. Participants were adults (aged ?18 years) with diabetes who had an available HbA1c level result in 2015. Data from January 1, 2014, to December 31, 2016, were analyzed. Final analyses were conducted from December 2017 to September 2018. Main Outcomes and Measures:This study calculated rates of hypoglycemia-related ED visits and hospitalizations during the year after the index HbA1c level was obtained, stratified by patient demographic characteristics, diabetes type, comorbidities (from 16 guideline-specified high-risk conditions), index HbA1c level, and glucose level-lowering medication use. The association of each variable with hypoglycemia-related ED and hospital care was examined using multivariable Poisson regression analysis overall and by diabetes type. Results:The study cohort was composed of 201?705 adults with diabetes (mean [SD] age, 65.8 [12.1] years; 102?668 [50.9%] women; 118?804 [58.9%] white; mean [SD] index HbA1c level, 7.2% [1.5%]). Overall, there were 9.06 (95% CI, 8.64-9.47) hypoglycemia-related ED visits and hospitalizations per 1000 persons per year. The risk of hypoglycemia-related ED visits and hospitalizations was increased by age 75 years or older (incidence rate ratio [IRR], 1.56 [95% CI, 1.23-2.02] vs 18-44 years), black race/ethnicity (IRR, 1.30 [95% CI, 1.16-1.46] vs white race/ethnicity), lower annual household income (IRR, 0.63 [95% CI, 0.53-0.74] for ?$100?000 vs <$40?000), number of comorbidities (increasing from IRR of 1.66 [95% CI, 1.42-1.95] in the presence of 2 comorbidities to IRR of 4.12 [95% CI, 3.07-5.51] with ?8 comorbidities compared with ?1), prior hypoglycemia-related ED visit or hospitalization (IRR, 6.60 [95% CI, 5.77-7.56]), and glucose level-lowering treatment regimen (IRR, 6.73 [95% CI, 4.93-9.22] for sulfonylurea; 12.53 [95% CI, 8.90-17.64] for basal insulin; and 27.65 [95% CI, 20.32-37.63] for basal plus bolus insulin compared with other medications). Independent of these factors, having type 1 diabetes was associated with a 34% increase in the risk of hypoglycemia-related ED visits or hospitalizations (IRR, 1.34 [95% CI, 1.15-1.55]). The index HbA1c level was associated with hypoglycemia-related ED visits and hospitalizations when both low (IRR, 1.45 [95% CI, 1.12-1.87] for HbA1c level ?5.6% vs 6.5%-6.9%) and high (IRR, 1.24 [95% CI, 1.02-1.50] for HbA1c level ?10%). Conclusions and Relevance:In this cohort study of adults with diabetes, the risk of an ED visit or hospitalization for hypoglycemia appeared to be highest among patients with type 1 diabetes, multiple comorbidities, prior severe hypoglycemia, and sulfonylurea and/or insulin use. At-risk patients may benefit from individualized treatment regimens to decrease their risk of hypoglycemia.
| S-EPMC6991264 | biostudies-literature
Project description:BackgroundCOVID-19 may lead to severe disease, requiring intensive care treatment and challenging the capacity of health care systems. The aim of this study was to compare the ability of commonly used scoring systems for sepsis and pneumonia to predict severe COVID-19 in the emergency department.MethodsProspective, observational, single centre study in a secondary/tertiary care hospital in Oslo, Norway. Patients were assessed upon hospital admission using the following scoring systems; quick Sequential Failure Assessment (qSOFA), Systemic Inflammatory Response Syndrome criteria (SIRS), National Early Warning Score 2 (NEWS2), CURB-65 and Pneumonia Severity index (PSI). The ratio of arterial oxygen tension to inspiratory oxygen fraction (P/F-ratio) was also calculated. The area under the receiver operating characteristics curve (AUROC) for each scoring system was calculated, along with sensitivity and specificity for the most commonly used cut-offs. Severe disease was defined as death or treatment in ICU within 14 days.Results38 of 175 study participants developed severe disease, 13 (7%) died and 29 (17%) had a stay at an intensive care unit (ICU). NEWS2 displayed an AUROC of 0.80 (95% confidence interval 0.72-0.88), CURB-65 0.75 (0.65-0.84), PSI 0.75 (0.65-0.84), SIRS 0.70 (0.61-0.80) and qSOFA 0.70 (0.61-0.79). NEWS2 was significantly better than SIRS and qSOFA in predicating severe disease, and with a cut-off of5 points, had a sensitivity and specificity of 82% and 60%, respectively.ConclusionNEWS2 predicted severe COVID-19 disease more accurately than SIRS and qSOFA, but not significantly better than CURB65 and PSI. NEWS2 may be a useful screening tool in evaluating COVID-19 patients during hospital admission.Trial registration: ClinicalTrials.gov Identifier: NCT04345536. (https://clinicaltrials.gov/ct2/show/NCT04345536).
| S-EPMC7577659 | biostudies-literature
Project description:BACKGROUND:Factitious disorder causing hypoglycemia is a psychiatric condition in which patients deliberately use blood sugar lowering medications to cause severe symptoms for the purposes of hospitalization or other primary gains. CASE PRESENTATION:We report a case of factitious hypoglycemia in a 19-year-old foster care adolescent female who presented to the Emergency Department with recurrent hypoglycemic episodes, to the degree that the patient required large amounts of dextrose and further management by intensive care unit hospitalization. Further inquiry revealed that the patient intentionally injected herself with large doses of insulin for the purposes of seeking hospital admission. CONCLUSION:Factitious disorder in the setting of recurrent hypoglycemia episodes may warrant a psychiatric referral and appropriate discharge follow-up to avoid multiple hospitalizations. Presentation in a non-diabetic patient from insulin use is a type of illness that is a challenge for emergency department physicians to appropriately diagnose and treat. Classic findings include a low blood sugar level, suppressed C-peptide level, and an inappropriately elevated insulin level. Recognizing these psychiatric presentations is crucial in order to stabilize patients and prevent unnecessary testing.
| S-EPMC6288932 | biostudies-other