Hypoglycemia in patients with type 2 diabetes mellitus.

BACKGROUND: Although hypoglycemia is the most common complication of intensive diabetes therapy, there is little information about risk factors for hypoglycemia in patients with type 2 diabetes mellitus. OBJECTIVE: To determine the prevalence and predisposing factors for hypoglycemia in patients with type 2 diabetes. METHODS: Retrospective, cross-sectional analysis set in an outpatient specialty diabetes clinic. We included those patients who had baseline and follow-up visits from April 1 through October 31, 1999. Hypoglycemia was defined as typical symptoms relieved by eating, and/or blood glucose level of less than 60 mg/dL (<3.3 mmol/L). Univariate and multivariate logistic regression were used to determine the contributions to hypoglycemia of age, sex, diabetes duration, body mass index (calculated as weight in kilograms divided by the square of height in meters), fasting plasma glucose level, glycosylated hemoglobin (HbA(1c)) level, type of therapy, and previous episodes at the follow-up visit. RESULTS: We studied 1055 patients. Prevalence of hypoglycemic symptoms was 12% (9/76) for patients treated with diet alone, 16% (56/346) for those using oral agents alone, and 30% (193/633) for those using any insulin (P<.001). Severe hypoglycemia occurred in only 5 patients (0.5%), all using insulin. Multiple logistic regression analysis demonstrated that insulin therapy, lower HbA(1c) level at follow-up, younger age, and report of hypoglycemia at the baseline visit were independently associated with increased prevalence of hypoglycemia. There were no significant predictors of severe hypoglycemia. CONCLUSIONS: Mild hypoglycemia is common in patients with type 2 diabetes undergoing aggressive diabetes management, but severe hypoglycemia is rare. Concerns about hypoglycemia should not deter efforts to achieve tight glycemic control in most patients with type 2 diabetes.     

Hypoglycemia as a predictor of mortality in hospitalized elderly patients

BACKGROUND: Hypoglycemia during hospitalization occurs in patients with and without diabetes. The aims of this study were to determine the incidence, associated risk factors, and short- and long-term outcome of hypoglycemia among hospitalized elderly patients. METHODS: This is a case-control study conducted at geriatric and medicine departments. All patients 70 years or older with documented hypoglycemia hospitalized within 1 year (n = 281) were compared with a nonhypoglycemic group of 281 elderly, randomly selected patients from the same hospitalized population. RESULTS: Among 5404 patients 70 years or older, 281 (5.2%) had documented hypoglycemia. Compared with the nonhypoglycemic group, we found the following characteristics to be true in the hypoglycemic group: there were more women than men (58% vs 44%, P =.001); sepsis was 10 times more common (P<.001); malignancy was 2.8 times more common (P =.04); the mean serum albumin level was lower (2.8 g/dL vs 3.4 g/dL, P<.001); and the mean serum creatinine and alkaline phosphatase levels were higher (P<.001 for both). Diabetes was known in 42% of the hypoglycemic group and in 31% of the nonhypoglycemic group (P =.03); 70 patients in the hypoglycemic group were taking sulfonylureas or insulin. Multivariate logistic analysis showed that sepsis, albumin level, malignancy, sulfonyurea and insulin treatment, alkaline phosphatase level, female sex, and creatinine level were all independent predictors of developing hypoglycemia. In-hospital mortality and 3-month mortality were about twice as high in the hypoglycemic group (P<.001). Multivariate analysis of mortality found that sepsis, low albumin level, and malignancy were independent predictors, while hypoglycmia was not. CONCLUSIONS: Hypoglycemia was common in elderly hospitalized patients and predicted increased in-hospital 3- and 6-month cumulative mortality. However, in a multivariate analysis, hypoglycemia was not an independent predictor for mortality, implying that it is only a marker.     

Post-admission glucose levels are associated with healthcare-associated bloodstream infections and pneumonia in hospitalized patients with diabetes

ObjectiveWe conducted a case–control study to examine if short-term glucose control is related to healthcare-associated bloodstream infections (BSI), urinary tract infections (UTI), and pneumonia in hospitalized adults with diabetes.Setting and PatientsWe analyzed 205 BSI, 510 UTI, and 109 pneumonia cases and 989, 2463, and 543 controls matched by age, sex and hospital stay seen at a large healthcare system in Manhattan from 2006 to 2008.MethodsWe examined whether infection risk was associated with serum glucose measured at admission and within 2 days to infection, using conditional logistic regression. Co-morbidities, immunosuppressive medications, prior hospitalizations, and insertion of indwelling devices were considered as potential confounders.ResultsAdmission glucose level was not associated with infection. Glucose levels of ≥ 110 mg/dL measured within 2 days to infection were associated with BSI (Odds ratios from 2.04 to 2.67). Glucose level of ≥ 180 mg/dL was associated with pneumonia (Odds ratio = 2.30). Decrease in glucose levels from admission to the infection was greater for controls than for infected cases.ConclusionHealthcare-associated BSI and pneumonia were associated with glucose levels prior to infection diagnosis, but not with glucose levels at admission. Persistently high glucose level could be an indication of an underlying undiagnosed infection.     

Acute phase markers are associated with reduced plasma lipid levels in a population of hospitalized elderly patients

BACKGROUND: Several epidemiological studies have documented the presence of a 'J' or 'U' association between total cholesterol levels and total mortality. Not only the mechanism underlying the association between increased mortality and low total cholesterol values is not completely clear, but the relationship itself also appears to be complex in the elderly. OBJECTIVE: The aim of the study was to evaluate the possible association between some biohumoral markers of the acute phase, comorbidity, disability, and reduced levels of some lipoprotein parameters in a sample of hospitalized elderly subjects. METHODS: 341 patients over 65 years of age (185 males, 156 females; mean age 76.2 years), consecutively admitted to our department from 1994 to 1995, were studied. Acute phase was defined as the simultaneous presence of: (1) increased alpha2-plasma protein on electrophoresis (>12%); (2) high fibrinogen concentration (>450 mg/dl), and (3) increased blood sedimentation rate (>15 and >20 mm 1 h in males and females, respectively). RESULTS: The prevalence of signs of acute phase was higher in males and in the youngest patients, but did not change with the level of comorbidity. Patients with signs of acute phase were characterized by lower total, low-density lipoprotein (LDL)- and high-density lipoprotein (HDL)-cholesterol levels compared to subjects without signs of acute phase; this difference was significant even after adjustment for indicators of comorbidity, disability, and nutritional status. Multivariate logistic regression analysis evidenced that the simultaneous presence of these three markers of acute phase was independently associated with low levels of total cholesterol [odds ratio (OR) 2.1, 95% confidence interval (CI) 1.1 - 3.9], and HDL-cholesterol (OR 2.3, 95% CI 1.2 - 4.2), considered as the sex-specific first quintile. CONCLUSION: The findings of this study demonstrate an independent association between acute phase markers and low levels of total and HDL-cholesterol, suggesting that recognized or subclinical diseases in elderly patients may determine a reduction in these plasma lipids. Low level of total and HDL-cholesterol should be considered as possible clinical markers of an underlying state of acute phase rather than a sign of malnutrition. Given the high prevalence of chronic diseases in the elderly, epidemiological studies addressing the lipid profile in this age group should take into account the possible confounding effect of the presence of signs of acute phase.     

Predictors of hypoglycemia in hospitalized patients with diabetes mellitus

Hypoglycemia is common among hospitalized patients with diabetes mellitus (DM), and is associated with increased morbidity and mortality. Identify pre-admission risk factors associated with in-hospital hypoglycemia. Historical prospectively collected data of adult DM patients hospitalized to medical wards between 2011 and 2013. Hypoglycemia and serious hypoglycemia were defined as at least one blood glucose measurement ≤ 70 and < 54 mg/dl, respectively, during hospitalization. The primary outcome was in-hospital hypoglycemia. The cohort included 5301 patients (mean age 73 ± 13 years, 51% male), including 792 patients (15%) with hypoglycemia, among them 392 patients (7%) with serious hypoglycemia. Patients with hypoglycemia or serious hypoglycemia during hospitalization were older, compared to patients without hypoglycemia and more likely to have chronic renal failure and cerebrovascular disease. Malignancy and female gender were risk factors for hypoglycemia, but not for serious hypoglycemia, while congestive heart failure was associated with increased risk only for serious hypoglycemia. Diabetes mellitus’ duration over 10 years was associated with an almost threefold increased risk for hypoglycemia, compared to DM duration less than a year. Insulin treatment and glycated hemoglobin > 9% were also more common in patients with hypoglycemia. Insulin treatment was associated with a fourfold increase in the risk for hypoglycemia among all glycated hemoglobin categories. Our results identified several risk factors for in-hospital hypoglycemia in patients with DM. These findings may lead to appropriate monitoring and early intervention to prevent hypoglycemia and to reduce morbidity and mortality associated with in-hospital hypoglycemia.     

Anxiety and depression symptoms in patients with diabetes

Aims To identify the prevalence and major determinants of anxiety and depression symptoms in patients with diabetes. Methods A cross‐sectional study of 2049 people with Types 1 and 2 diabetes, selected from patients experiencing three different models of care in Ireland: (i) traditional mixed care; (ii) hospital/general practitioner (GP) shared care; (iii) structured GP care. Anxiety and depression symptoms were assessed with the Hospital Anxiety and Depression Scale (HADS). Analyses were conducted primarily using logistic regression with adjustment for relevant confounders. Results The overall response rate was 71% (n = 1456). Based on the HADS, there was evidence of high levels of anxiety and depression symptoms in patients with diabetes; 32.0% (95% confidence interval = 29.5–34.6%) exceeded the HADS cut‐off score of ‘mild to severe’ anxiety and 22.4% (95% confidence interval = 20.2–24.7%) exceeded the HADS cut‐off score of ‘mild to severe’ depression. Diabetes complications, smoking, uncertainty about glycaemic control and being an ex‐drinker or a heavy drinker were risk factors for both higher anxiety and depression scores in multivariate analysis. Female gender and poor glycaemic control were risks factors associated only with higher anxiety scores. Higher socio‐economic status and older age were protective factors for lower anxiety and depression scores. Type of diabetes, insulin use, marital status and models of care were not significant predictors of anxiety and depression scores. Conclusions The prevalence of anxiety and depression symptoms in patients with diabetes is considerably higher than in general population samples. These data serve as a benchmark for the prevalence of anxiety and depression symptoms in patients with diabetes.     

Subclinical hypercortisolism in hospitalized patients with type 2 diabetes mellitus

Pre(sub)clinical Cushing's disease is a recently described entity defined by the autonomous secretion of ACTH and the absence of a cushingoid appearance. We screened 77 hospitalized patients with diabetes mellitus for subclinical hypercortisolism and detected pre(sub)clinical Cushing's disease in 2 (2.6%) of them. In both patients, transsphenoidal surgery was performed and a microadenoma was removed. Their metabolic clearance rate of glucose measured by a glucose clamp study, an index of insulin sensitivity, significantly improved after surgery. Our results indicate that screening for subclinical hypercortisolism in diabetic patients might be useful, as surgery improves glucose tolerance and insulin sensitivity.     

Retinal microvascular abnormalities are associated with early carotid atherosclerotic lesions in hospitalized Chinese patients with type 2 diabetes mellitus

ObjectiveControversies concerning the association of retinal microvascular abnormalities (RMAs) with atherosclerosis in patients with diabetes exist. The objective of this study was to investigate the association between RMAs and carotid atherosclerotic lesions in Chinese inpatients with type 2 diabetes.MethodsThis cross-sectional study involved 2870 type 2 diabetic patients including 1602 men aged 15–90 years and 1268 women aged 17–88 years. Both retinal arteriosclerosis (RA) and diabetic retinopathy (DR) were determined by digital fundus photography using a standardized protocol. RMAs are defined as the presence of either RA or DR. Carotid atherosclerotic lesions including carotid intima-media thickness (CIMT), carotid atherosclerotic plaque and stenosis were assessed and compared between patients with and without RMAs based on Doppler ultrasound. The association of RMAs with carotid atherosclerotic lesions was analyzed by linear and binary logistic regression analyses.ResultsThe CIMT values in both male and female diabetics with RMAs were significantly greater than in those without RMAs after controlling for age (0.88 ± 0.21 vs. 0.77 ± 0.20 mm for men, p = 0.002; and 0.84 ± 0.19 vs. 0.76 ± 0.21 mm for women, p = 0.002). The prevalence of carotid plaque was also markedly higher in patients with RMAs than in those without RMAs after adjusting for age (54.3% vs. 23.9% for men, p < 0.001; 48.4% vs. 32.0% for women, p = 0.046). However, no significant difference was observed in the prevalence of carotid stenosis in either men or women with or without RMAs. After controlling for multiple confounding factors, RMAs were independently associated with increased CIMT in both men (β: 0.067,95% CI: 0.026–0.269, p = 0.018) and women (β: 0.087, 95% CI: 0.058–0.334, p = 0.005) with type 2 diabetes, and they were also closely associated with the presence of carotid plaque (OR: 2.17, 95% CI: 1.54–3.05, p < 0.001 for men; OR: 1.38, 95% CI: 0.91–2.08, p = 0.129 for women) in men with type 2 diabetes.ConclusionsRMAs were closely associated with early carotid atherosclerotic lesions in hospitalized Chinese patients with type 2 diabetes. Our results suggested that changes in retinal microvasculature may play a role in the pathogenesis of atherosclerosis and may be used as an indicator of early atherosclerosis in patients with type 2 diabetes.     

Hypoglycemia in children with insulin-dependent diabetes mellitus.

The promotion of normal growth and development and the avoidance of acute and long-term complications are overall goals in the management of a child with insulin-dependent diabetes mellitus. Recent studies provide new and pertinent information about the acute effects of hypoglycemia on such cognitive functioning as learning, memory, reading, and visuospatial skills. The effects of early onset diabetes on school performance are also discussed. This information should be incorporated by diabetes educators into the educational plan for children with IDDM, their families, and schools.     

Inpatient management of hospitalized patients with type 2 diabetes

Over the past 4 years, the scientific literature addressing issues relevant to inpatient hyperglycemia and its management has grown dramatically but remains incomplete. The growing interest in inpatient diabetes management is particularly pertinent given the epidemic rise in the prevalence of type 2 diabetes and the associated increase in the proportion of inpatients carrying this diagnosis. The benefits of aggressive glucose control are well-established in certain admission categories. These benefits likely apply to many other admission diagnoses, but remain unproven at this time. Similarly, the best methods of glucose control remain uncertain in the various inpatient settings. Intensive insulin infusion therapy is becoming the standard care in the intensive care unit setting. Its use is also growing in less acute inpatient settings but requires further study. Inpatient subcutaneous insulin recommendations are general based on experience gained in the outpatient setting but offer a practical, physiologic approach.     

Hypoglycemia awareness and burden among hospitalized patients at high risk for hypoglycemia

BackgroundHypoglycemia, a common complication of insulin therapy in patients with diabetes, is associated with increased hospital morbidity and mortality. Hypoglycemia may be underrecognized in hospitalized patients due to impaired counter regulation or reduced recognition. Beta blocker (BB) use may also affect hypoglycemia recognition.AimTo characterize hypoglycemia unawareness and patient perceived hypoglycemia burden in hospitalized patients.Materials and methodsOver a 2-month period, we prospectively identified non-critically ill cognitively intact hospitalized insulin-requiring patients who were undergoing bedside glucose monitoring. Participants were included if they reported any episode of hypoglycemia in the 30 days prior to admission and either had no BB use or were on stable BB for 90 days. Hypoglycemia unawareness was assessed using the Clarke score and burden of hypoglycemia was assessed with the (TRIM-HYPO) score.ResultsOf the 46 participants, 20 were not taking a BB and 26 were taking a BB. Predictors of hypoglycemia during admission included glucose coefficient of variation and hospital length of stay. Nine participants (20%) had hypoglycemia unawareness (Clarke score ≥4). Participants with a history of coronary artery disease were less likely to have impaired awareness. Burden of hypoglycemia was associated with more hypoglycemia and longer hospital length of stay. There were no differences in measures of hypoglycemia unawareness or burden according to BB use.ConclusionsBB use was not related to hypoglycemia unawareness, or burden in hospitalized high risk patients. Hypoglycemia burden may identify patients at higher risk of hypoglycemia during admission.     

Gastrointestinal symptoms in patients hospitalized with COVID-19: Prevalence and outcomes

To characterize outcomes in patients hospitalized with coronavirus disease 2019 (COVID-19) who present with gastrointestinal (GI) symptoms.Clinical outcomes in patients with COVID-19 associated with GI symptoms have been inconsistent in the literature.The study design is a retrospective analysis of patients, age 18 years or older, admitted to the hospital after testing positive for COVID-19. Clinical outcomes included intensive care unit requirements, rates of discharges to home, rates of discharges to outside facilities, and mortality.Seven hundred fifty patients met the inclusion criteria. Three hundred seventy three (49.7%) patients presented with at least one GI symptom and 377 (50.3%) patients presented with solely non-GI symptoms. Patients who presented with at least one GI symptom had significantly lower ICU requirements (17.4% vs 20.2%), higher rates of discharges home (77.2% vs 67.4%), lower rates of discharges to other facilities (16.4% vs 22.8%), and decreased mortality (6.4% vs 9.8%) compared with patients with non-GI symptoms. However, patients who presented with solely GI symptoms had significantly higher ICU requirements (23.8% vs 17.0%), lower rates of discharges home (52.4% vs 78.7%), higher rates of discharges to facilities (28.6% vs 15.6%), and higher mortality (19.0% vs 5.7%) compared with those with mixed GI and non-GI symptoms.Although patients with COVID-19 requiring hospitalization with GI symptoms did better than those without GI symptoms, those with isolated GI symptoms without extra-GI symptoms had worse clinical outcomes. COVID-19 should be considered in patients who present with new onset or worsening diarrhea, nausea, vomiting, and abdominal pain even without pulmonary symptoms.     

糖尿病住院患者并发肺结核的临床特征分析

目的 了解糖尿病(包括1型、2型糖尿病患者)住院患者并发肺结核的发病率,以及对结核病活动状态的相关性进行分析。方法 回顾性分析2018年1月至2019年12月我院患糖尿病住院的2648例患者常规胸部影像学检查资料及临床资料,计算糖尿病患者并发肺结核的发病率,比较活动性与非活动性肺结核患者的基本情况,以及糖化血红蛋白(HbA1c)水平、糖尿病治疗情况。结果 2648例糖尿病患者中,2585例患者无肺结核证据,占97.62%(2585/2648);31例患者并发活动性肺结核,占1.17%(31/2648);32例患者并发非活动性肺结核,占1.21%(32/2648);活动性、非活动性肺结核均以男性为主,分别占90.32%(28/31)、84.38%(27/32);活动性肺结核患者的平均年龄为(51.16±13.06)岁,非活动性肺结核患者的平均年龄为(61.78±12.88)岁,二组比较差异有统计学意义(t=-3.236, P=0.002);活动性肺结核患者的HbA1c水平检测平均为(9.18±2.85)%,非活动性肺结核患者平均为(8.05±1.69)%,二组比较差异无统计学意义(t=1.884, P=0.070)。结论 糖尿病住院患者并发肺结核的比例高,以男性多见,应重视糖尿病住院患者的肺结核筛查和随访;血糖控制水平与糖尿病患者肺结核活动状态的相关性尚需进一步证实。     

Patient-provider communication in patients with diabetes and depressive symptoms

The association between depressive symptoms and patient-provider communication was examined in adult primary care patients with diabetes. Most communication was not patient-centered, but did not differ by level of patient's depressive symptoms.     

Neuro-otologic symptoms in patients with type 2 diabetes mellitus

To assess the prevalence of balance symptoms in type-2 diabetes mellitus (DM2), at the first level of health care. Compared to 101 controls, 101 patients showed a higher frequency of all the symptoms investigated through a standardized questionnaire (p < 0.01). In DM2 patients, balance symptoms should be intentionally investigated.