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Thabit H, Schofield J. Technology in the management of diabetes in hospitalised adults. Diabetologia 2024; 67:2114-2128. [PMID: 38953925 PMCID: PMC11447115 DOI: 10.1007/s00125-024-06206-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 05/14/2024] [Indexed: 07/04/2024]
Abstract
Suboptimal glycaemic management in hospitals has been associated with adverse clinical outcomes and increased financial costs to healthcare systems. Despite the availability of guidelines for inpatient glycaemic management, implementation remains challenging because of the increasing workload of clinical staff and rising prevalence of diabetes. The development of novel and innovative technologies that support the clinical workflow and address the unmet need for effective and safe inpatient diabetes care delivery is still needed. There is robust evidence that the use of diabetes technology such as continuous glucose monitoring and closed-loop insulin delivery can improve glycaemic management in outpatient settings; however, relatively little is known of its potential benefits and application in inpatient diabetes management. Emerging data from clinical studies show that diabetes technologies such as integrated clinical decision support systems can potentially mediate safer and more efficient inpatient diabetes care, while continuous glucose sensors and closed-loop systems show early promise in improving inpatient glycaemic management. This review aims to provide an overview of current evidence related to diabetes technology use in non-critical care adult inpatient settings. We highlight existing barriers that may hinder or delay implementation, as well as strategies and opportunities to facilitate the clinical readiness of inpatient diabetes technology in the future.
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Affiliation(s)
- Hood Thabit
- Diabetes, Endocrinology and Metabolism Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK.
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Jonathan Schofield
- Diabetes, Endocrinology and Metabolism Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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O'Connor MY, Flint KL, Sabean A, Ashley A, Zheng H, Yan J, Steiner BA, Anandakugan N, Calverley M, Bartholomew R, Greaux E, Larkin M, Russell SJ, Putman MS. Accuracy of continuous glucose monitoring in the hospital setting: an observational study. Diabetologia 2024:10.1007/s00125-024-06250-0. [PMID: 39126488 DOI: 10.1007/s00125-024-06250-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 06/26/2024] [Indexed: 08/12/2024]
Abstract
AIMS/HYPOTHESIS Continuous glucose monitoring (CGM) improves glycaemic outcomes in the outpatient setting; however, there are limited data regarding CGM accuracy in hospital. METHODS We conducted a prospective, observational study comparing CGM data from blinded Dexcom G6 Pro sensors with reference point of care and laboratory glucose measurements during participants' hospitalisations. Key accuracy metrics included the proportion of CGM values within ±20% of reference glucose values >5.6 mmol/l or within ±1.1 mmol/l of reference glucose values ≤5.6 mmol/l (%20/20), the mean and median absolute relative difference between CGM and reference value (MARD and median ARD, respectively) and Clarke error grid analysis (CEGA). A retrospective calibration scheme was used to determine whether calibration improved sensor accuracy. Multivariable regression models and subgroup analyses were used to determine the impact of clinical characteristics on accuracy assessments. RESULTS A total of 326 adults hospitalised on 19 medical or surgical non-intensive care hospital floors were enrolled, providing 6648 matched glucose pairs. The %20/20 was 59.5%, the MARD was 19.2% and the median ARD was 16.8%. CEGA showed that 98.2% of values were in zone A (clinically accurate) and zone B (benign). Subgroups with lower accuracy metrics included those with severe anaemia, renal dysfunction and oedema. Application of a once-daily morning calibration schedule improved accuracy (MARD 11.4%). CONCLUSIONS/INTERPRETATION The CGM accuracy when used in hospital may be lower than that reported in the outpatient setting, but this may be improved with appropriate patient selection and daily calibration. Further research is needed to understand the role of CGM in inpatient settings.
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Affiliation(s)
- Mollie Y O'Connor
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Kristen L Flint
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Amy Sabean
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Annabelle Ashley
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Hui Zheng
- Biostatics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Joyce Yan
- Biostatics Center, Massachusetts General Hospital, Boston, MA, USA
| | - Barbara A Steiner
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - Melissa Calverley
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Rachel Bartholomew
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Evelyn Greaux
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Mary Larkin
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Steven J Russell
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, USA
- Beta Bionics Inc, Concord, MA, USA
| | - Melissa S Putman
- Diabetes Research Center, Massachusetts General Hospital, Boston, MA, USA.
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Walt JR, Loughran J, Fourlanos S, Barmanray RD, Zhu J, Varadarajan S, Kyi M. Glycaemic outcomes in hospital with IDegAsp versus BIAsp30 premixed insulins. Intern Med J 2024; 54:1329-1336. [PMID: 38578058 DOI: 10.1111/imj.16391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 03/11/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND AND AIMS IDegAsp (Ryzodeg 70/30), a unique premixed formulation of long-acting insulin degludec and rapid-acting insulin aspart, is increasing in use. Management of IDegAsp during hospitalisation is challenging because of degludec's ultra-long duration of action. We investigated inpatient glycaemia in patients treated with IDegAsp compared to biphasic insulin aspart (BIAsp30; Novomix30). METHODS We performed a retrospective observational study at two hospitals assessing inpatients with type 2 diabetes treated with IDegAsp or BIAsp30 prior to and during hospital admission. Standard inpatient glycaemic outcomes were analysed based on capillary blood glucose (BG) measurements. RESULTS We assessed 88 individuals treated with IDegAsp and 88 HbA1c-matched individuals treated with BIAsp30. Patient characteristics, including insulin dose at admission, were well matched, but the IDegAsp group had less frequent twice-daily insulin dosing than the BIAsp30 group (49% vs 87%, P < 0.001). Patient-days with BG <4 mmol/L were not different (10.6% vs 9.9%, P = 0.7); however, the IDegAsp group had a higher patient-day mean BG (10.4 (SD 3.4) vs 10.0 (3.4) mmol/L, P < 0.001), and more patient-days with mean BG >10 mmol/L (48% vs 38%, P < 0.001) compared to the BIAsp30 group. Glucose was higher in the IDegAsp group in the evening (4 PM to midnight) (11.6 (SD 4.0) vs 10.9 (4.6) mmol/L, P = 0.004), but not different at other times during the day. CONCLUSIONS Inpatients treated with IDegAsp compared to BIAsp30 had similar hypoglycaemia incidence, but higher hyperglycaemia incidence, potentially related to less frequent twice-daily dosing. With the increasing use of IDegAsp in the community, development of hospital management guidelines for this insulin formulation is needed.
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Affiliation(s)
- Joshua R Walt
- Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Royal Melbourne Clinical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Julie Loughran
- Endocrinology Unit, Northern Hospital, Epping, Victoria, Australia
| | - Spiros Fourlanos
- Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine at Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Parkville, Victoria, Australia
| | - Rahul D Barmanray
- Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine at Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Parkville, Victoria, Australia
| | - Jasmine Zhu
- Endocrinology Unit, Northern Hospital, Epping, Victoria, Australia
| | | | - Mervyn Kyi
- Department of Diabetes and Endocrinology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Endocrinology Unit, Northern Hospital, Epping, Victoria, Australia
- Department of Medicine at Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
- Australian Centre for Accelerating Diabetes Innovations, The University of Melbourne, Parkville, Victoria, Australia
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Pikulin S, Yehezkel I, Moskovitch R. Enhanced blood glucose levels prediction with a smartwatch. PLoS One 2024; 19:e0307136. [PMID: 39024327 PMCID: PMC11257318 DOI: 10.1371/journal.pone.0307136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Accepted: 07/02/2024] [Indexed: 07/20/2024] Open
Abstract
Ensuring stable blood glucose (BG) levels within the norm is crucial for potential long-term health complications prevention when managing a chronic disease like Type 1 diabetes (T1D), as well as body weight. Therefore, accurately forecasting blood sugar levels holds significant importance for clinicians and specific users, such as type one diabetic patients. In recent years, Continuous Glucose Monitoring (CGM) devices have been developed and are now in use. However, the ability to forecast future blood glucose values is essential for better management. Previous studies proposed the use of food intake documentation in order to enhance the forecasting accuracy. Unfortunately, these methods require the participants to manually record their daily activities such as food intake, drink and exercise, which creates somewhat inaccurate data, and is hard to maintain along time. To reduce the burden on participants and improve the accuracy of BG level predictions, as well as optimize training and prediction times, this study proposes a framework that continuously tracks participants' movements using a smartwatch. The framework analyzes sensor data and allows users to document their activities. We developed a model incorporating BG data, smartwatch sensor data, and user-documented activities. This model was applied to a dataset we collected from a dozen participants. Our study's results indicate that documented activities did not enhance BG level predictions. However, using smartwatch sensors, such as heart rate and step detector data, in addition to blood glucose measurements from the last sixty minutes, significantly improved the predictions.
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Affiliation(s)
- Sean Pikulin
- Software and Information Systems Engineering, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Irad Yehezkel
- Software and Information Systems Engineering, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Robert Moskovitch
- Software and Information Systems Engineering, Ben Gurion University of the Negev, Beer Sheva, Israel
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González-Vidal T, Rivas-Otero D, Gutiérrez-Hurtado A, Alonso Felgueroso C, Martínez Tamés G, Lambert C, Delgado-Álvarez E, Menéndez Torre E. Hypoglycemia in patients with type 2 diabetes mellitus during hospitalization: associated factors and prognostic value. Diabetol Metab Syndr 2023; 15:249. [PMID: 38044455 PMCID: PMC10694969 DOI: 10.1186/s13098-023-01212-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/05/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND The risk factors for hypoglycemia during hospital admission and its consequences in patients with diabetes are not entirely known. The present study aimed to investigate the risk factors for hypoglycemia, as well as the potential implications of hypoglycemia in patients with type 2 diabetes mellitus admitted to the hospital. METHODS This retrospective cohort study included 324 patients (214 [66.0%] men; median age 70 years, range 34-95 years) with type 2 diabetes admitted to a university hospital who were consulted the Endocrinology Department for glycemic control during a 12-month period. We investigated the potential role of demographic factors, metabolic factors, therapy, and comorbidities on the development of in-hospital hypoglycemia. We explored the prognostic value of hypoglycemia on mortality (both in-hospital and in the long-term), hospital readmission in the following year, and metabolic control (HbA1c value) after discharge (median follow-up, 886 days; range 19-1255 days). RESULTS Hypoglycemia occurred in 154 (47.5%) patients during their hospitalization and was associated with advanced age, previous insulin therapy, higher Charlson Comorbidity Index, lower body mass index and lower baseline HbA1c values. Hypoglycemia was associated with greater in-hospital and long-term mortality, longer hospital stays, higher readmission rates, and poorer metabolic control after discharge. These negative consequences of hypoglycemia were more frequent in patients with severe (≤ 55 mg/dL) hypoglycemia and in patients who had hypoglycemia during a greater percentage of hospitalization days. CONCLUSIONS Hypoglycemia during hospital admission is a marker of a poor prognosis in patients with type 2 diabetes.
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Affiliation(s)
- Tomás González-Vidal
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias/University of Oviedo, Oviedo, Spain.
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain.
| | - Diego Rivas-Otero
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias/University of Oviedo, Oviedo, Spain
| | - Alba Gutiérrez-Hurtado
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias/University of Oviedo, Oviedo, Spain
| | - Carlos Alonso Felgueroso
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias/University of Oviedo, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Gema Martínez Tamés
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias/University of Oviedo, Oviedo, Spain
| | - Carmen Lambert
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
- University of Barcelona, Barcelona, Spain
| | - Elías Delgado-Álvarez
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias/University of Oviedo, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
- Department of Medicine, University of Oviedo, Oviedo, Spain
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
| | - Edelmiro Menéndez Torre
- Department of Endocrinology and Nutrition, Hospital Universitario Central de Asturias/University of Oviedo, Oviedo, Spain
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
- Department of Medicine, University of Oviedo, Oviedo, Spain
- Centre for Biomedical Network Research on Rare Diseases (CIBERER), Instituto de Salud Carlos III, Madrid, Spain
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Dei Cas A, Aldigeri R, Ridolfi V, Vazzana A, Ciardullo AV, Manicardi V, Sforza A, Tomasi F, Zavaroni D, Zavaroni I, Bonadonna RC. Efficacy of a training programme for the management of diabetes mellitus in the hospital: A randomized study (stage 2 of GOVEPAZ healthcare). Diabetes Metab Res Rev 2023; 39:e3708. [PMID: 37574863 DOI: 10.1002/dmrr.3708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 05/24/2023] [Accepted: 06/25/2023] [Indexed: 08/15/2023]
Abstract
AIMS To assess the efficacy of a structured educational intervention for health professionals on the appropriateness of inpatient diabetes care and on some clinical outcomes in hospitalised subjects. METHODS A multicentre (6 regional hospitals) cluster-randomized (2:1) two parallel-group pragmatic intervention trials, as a part of the GOVEPAZ study, was conducted in three clinical settings, that is, Internal Medicine, Surgery and Intensive Care. Intervention consisted of a 2-month structured education of clinical staff to inpatient diabetes care. Twelve wards - 2 for each hospital - and 6 wards - 1 for each hospital - were randomized to usual care and to the intervention arm, respectively. Consecutively hospitalised diabetic subjects (n = 524, age 74 ± 14 years, 57% males, median HbA1C 57 mmol/mol) were included. The clinical appropriateness of inpatient diabetes management was assessed by a previously validated multi-domain performance score (PS). Clinical outcomes included hypoglycemia, glucose control biomarkers, clinical conditions at discharge and inpatient mortality rate. RESULTS A numerically, but not statistically significant, higher PS (+0.94; 95% C.I.: -0.53 - +2.4) was achieved in the intervention than in the usual care wards. Hypoglycemias (p = 0.32), glucose control (p = 0.89) and survival rates (p = 0.71) were similar in the two experimental arms. Plasma glucose on admission (OR = 1.52 per 1 SD; C.I. 1.07-2.17; p = 0.021) and the number of hypoglycemic events per patient (OR = 1.55 per 1 SD; C.I.:1.11-2.16; p = 0.011) were independently associated with the inpatient mortality rate. CONCLUSIONS Structured education of the clinical staff failed to improve the inpatient appropriateness of diabetes care or clinical outcomes. In-hospital hypoglycemia was confirmed to be an independent indicator of death risk.
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Affiliation(s)
- Alessandra Dei Cas
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Division of Endocrinology and Metabolic Diseases, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | - Valentina Ridolfi
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Division of Endocrinology and Metabolic Diseases, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Angela Vazzana
- Division of Endocrinology and Metabolic Diseases, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | | | | | | | | | - Ivana Zavaroni
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Division of Endocrinology and Metabolic Diseases, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Riccardo C Bonadonna
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Division of Endocrinology and Metabolic Diseases, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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Wood M, Moses J, Andrade DC, De la Cova M, Parmar J, Middlebrook G, Beltran DC. Pharmacy stewardship to reduce recurrent hypoglycemia. J Am Pharm Assoc (2003) 2023; 63:1813-1820. [PMID: 37696492 DOI: 10.1016/j.japh.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/27/2023] [Accepted: 09/05/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Inpatient hypoglycemia is associated with increased morbidity and mortality. After a hypoglycemic event, the likelihood of additional episodes increases. The Joint Commission recommends evaluating all episodes of hypoglycemia for root-cause analysis. Studies have shown that pharmacists' involvement with glycemic control protocols can prevent hypoglycemia. OBJECTIVES This study aimed to assess whether the implementation of pharmacists' real-time assessment of hypoglycemic events using an electronic alert messaging system contributes to the reduction of the number of recurrent hypoglycemia during hospitalization. PRACTICE DESCRIPTION A community hospital that provides a wide range of health care services. The pharmacy department provides fully decentralized clinical services and team-based specialist services. PRACTICE INNOVATION The pharmacist-led hypoglycemia stewardship initiative included a comprehensive review of hypoglycemic alerts received via an automated message. The alerts generated in the electronic health record (EHR) every time a patient's blood glucose resulted in less than 70 mg/dL if there was a documented administration of a hypoglycemic agent 48 hours before the hypoglycemia event. Once the alert was received by the pharmacists via an EHR in-basket, a real-time review was conducted to identify the potential causes of the event and opportunities for therapy modification. EVALUATION METHODS A single-center retrospective observational study including a pre- and post-implementation phase from January 1 to June 3, 2020, and January 1 to June 30, 2021, respectively. Continuous data were analyzed using paired and equal variance t test. Noncontinuous data were analyzed using Fisher exact and chi-square test. Descriptive statistics were used to describe distribution and frequency of data. RESULTS There was a 5.1% absolute reduction in recurrent hypoglycemic events (P < 0.001) and a 0.6% reduction of severe hypoglycemic days (P = 0.269) in the postimplementation group. The average time to pharmacist intervention was 4 (± 3.5) hours with a 92% acceptance rate. CONCLUSION This study demonstrated the utility of pharmacist-led hypoglycemia reviews in the reduction of recurrent hypoglycemic events in the inpatient setting.
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Ayalon-Dangur I, Babich T, Samuel MH, Leibovici L, Grossman A. Safety and efficacy of non-insulin therapy in non-critically ill hospitalized patients with type 2 diabetes mellitus. Eur J Intern Med 2023; 116:106-118. [PMID: 37355348 DOI: 10.1016/j.ejim.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION Clinical guidelines recommend insulin as the mainstay of therapy for hospitalized patients with diabetes mellitus. The aim of the current study is to evaluate safety and efficacy of non-insulin anti-hyperglycemic therapy in hospitalized patients. MATERIALS AND METHODS Systematic review and meta-analysis of randomized controlled trials (RCTs) examining treatment of hospitalized patients with type 2 diabetes with insulin vs non-insulin therapy. We searched PubMed and the Cochrane Library for RCTs published from inception to November 30, 2022. Primary outcomes were 30-day mortality and hypoglycemic events during hospitalization. This meta-analysis includes two parts, the first is a comparison between insulin and non-insulin therapy and the second is a comparison between insulin only and a combination of insulin+non-insulin therapy. RESULTS A total of 14 randomized control studies and 1570 patients were included. There was a lower incidence of 30-day mortality in the insulin+non-insulin group compared with the insulin group without statistical significance, RR 0.64 (95%CI 0.30-1.35). Hypoglycemic events were significantly lower with the non-insulin therapies compared to insulin therapy, RR 0.23 (95%CI 0.09-0.55). Mean daily glucose levels were significantly lower in the insulin+non-insulin group compared to the insulin group by 10.83 mg/dL (95%CI -14.78-(-6.87)). CONCLUSIONS Non-insulin either with or without insulin, results in lower rates of hypoglycemia. Non-insulin+insulin is more effective than insulin alone in reducing blood glucose levels. Non-insulin-based therapy is safe and effective for control of hyperglycemia. Insulin combined with non-insulin drugs seems to be the preferred treatment option for the majority of hospitalized patients with type 2 DM in the non-critical care setting.
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Affiliation(s)
- Irit Ayalon-Dangur
- Institute of Endocrinology, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tanya Babich
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Research Authority, Rabin Medical Center, Petah-Tikva, Israel
| | | | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Research Authority, Rabin Medical Center, Petah-Tikva, Israel
| | - Alon Grossman
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Medicine B, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel.
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Luzuriaga MG, Lieberman M, Ma R, Casula S, Lagari-Libhaber V, Messinger S, Li H, Miranda B, Baidal DA, Mizrachi EB, Iacobellis G, Garg R, Vendrame F. Comparison of Glycemic Control Between In-Person and Virtual Diabetes Consults in Hospitalized Patients With Diabetes. J Diabetes Sci Technol 2023:19322968231199470. [PMID: 37727950 DOI: 10.1177/19322968231199470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
BACKGROUND There is limited evidence that the diabetes in-person consult in hospitalized patients can be replaced by a virtual consult. During COVID-19 pandemic, the diabetes in-person consult service at the University of Miami and Miami Veterans Affairs Healthcare System transitioned to a virtual model. The aim of this study was to assess the impact of telemedicine on glycemic control after this transition. METHODS We retrospectively analyzed glucose metrics from in-person consults (In-person) during January 16 to March 14, 2020 and virtual consults during March 15 to May 14, 2020. Data from virtual consults were analyzed by separating patients infected with COVID-19, who were seen only virtually (Virtual-COVID-19-Pos), and patients who were not infected (Virtual-COVID-19-Neg), or by combining the two groups (Virtual-All). RESULTS Patient-day-weighted blood glucose was not significantly different between In-person, Virtual-All, and Virtual-COVID-19-Neg, but Virtual-COVID-19-Pos had significantly higher mean ± SD blood glucose (mg/dL) compared with others (206.7 ± 49.6 In-person, 214.6 ± 56.2 Virtual-All, 206.5 ± 57.2 Virtual-COVID-19-Neg, 229.7 ± 51.6 Virtual-COVID-19-Pos; P = .015). A significantly less percentage of patients in this group also achieved a mean ± SD glucose target of 140 to 180 mg/dL (23.8 ± 22.5 In-person, 21.5 ± 20.5 Virtual-All, 25.3 ± 20.8 Virtual-COVID-19-Neg, and 14.4±18.1 Virtual-COVID-19-Pos, P = .024), but there was no significant difference between In-person, Virtual-All, and Virtual-COVID-19-Neg. The occurrence of hypoglycemia was not significantly different among groups. CONCLUSIONS In-person and virtual consults delivered by a diabetes team at an academic institution were not associated with significant differences in glycemic control. These real-world data suggest that telemedicine could be used for in-patient diabetes management, although additional studies are needed to better assess clinical outcomes and safety.
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Affiliation(s)
- Maria Gracia Luzuriaga
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
- Department of Endocrinology, Diabetes and Metabolism, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | | | - Ruixuan Ma
- Division of Biostatistics, Department of Epidemiology and Public Health Sciences, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Sabina Casula
- Endocrinology Section, Miami Veterans Affairs Healthcare System, Miami, FL, USA
| | - Violet Lagari-Libhaber
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
- Endocrinology Section, Miami Veterans Affairs Healthcare System, Miami, FL, USA
| | - Shari Messinger
- Department of Endocrinology, Diabetes and Metabolism, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Hua Li
- Department of Endocrinology, Diabetes and Metabolism, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Bresta Miranda
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - David A Baidal
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Ernesto Bernal Mizrachi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
- Endocrinology Section, Miami Veterans Affairs Healthcare System, Miami, FL, USA
| | - Gianluca Iacobellis
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Rajesh Garg
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
- Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Francesco Vendrame
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Miller School of Medicine, University of Miami, Miami, FL, USA
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Carreira A, Castro P, Mira F, Melo M, Ribeiro P, Santos L. Acute kidney injury: a strong risk factor for hypoglycaemia in hospitalized patients with type 2 diabetes. Acta Diabetol 2023; 60:1179-1185. [PMID: 37173530 PMCID: PMC10359379 DOI: 10.1007/s00592-023-02112-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 04/30/2023] [Indexed: 05/15/2023]
Abstract
AIMS Acute kidney injury (AKI) is highly prevalent during hospitalization of patients with type 2 diabetes (T2D). We aimed to assess the impact of AKI and its severity and duration on the risk of hypoglycaemia in hospitalized patients with T2D. METHODS Retrospective cohort analysis of patients with T2D, admitted at a University Hospital in 2018-2019. AKI was defined as an increase in serum creatinine by ≥ 0.3 mg/dl (48 h) or ≥ 1.5 times baseline (7 days), and hypoglycaemia as blood glucose concentration < 70 mg/dl. Patients with chronic kidney disease stage ≥ 4 were excluded. We registered 239 hospitalizations with AKI and randomly selected 239 without AKI (control). Multiple logistic regression was used to adjust for confounding factors and ROC curve analysis to determine a cutoff for AKI duration. RESULTS The risk of hypoglycaemia was higher in the AKI group (crude OR 3.6, 95%CI 1.8-9.6), even after adjusting for covariates (OR 4.2, 95%CI 1.8-9.6). Each day of AKI duration was associated with a 14% increase in the risk of hypoglycaemia (95%CI 1.1-1.2), and a cutoff of 5.5 days of AKI duration was obtained for increased risk of hypoglycaemia and mortality. AKI severity was also associated with mortality, but showed no significant association with hypoglycaemia. Patients with hypoglycaemia had 4.4 times greater risk of mortality (95%CI 2.4-8.2). CONCLUSIONS AKI increased the risk of hypoglycaemia during hospitalization of patients with T2D, and its duration was the main risk factor. These results highlight the need for specific protocols to avoid hypoglycaemia and its burden in patients with AKI.
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Affiliation(s)
- Ana Carreira
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar E Universitário de Coimbra, 3004-561 Coimbra, Portugal
| | - Pedro Castro
- Department of Nephrology, Centro Hospitalar E Universitário de Coimbra, 3004-561 Coimbra, Portugal
- Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Filipe Mira
- Department of Nephrology, Centro Hospitalar E Universitário de Coimbra, 3004-561 Coimbra, Portugal
- Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Miguel Melo
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar E Universitário de Coimbra, 3004-561 Coimbra, Portugal
- Faculty of Medicine, Coimbra University, Coimbra, Portugal
| | - Pedro Ribeiro
- Department of Internal Medicine, Centro Hospitalar E Universitário de Coimbra, 3004-561 Coimbra, Portugal
| | - Lèlita Santos
- Department of Internal Medicine, Centro Hospitalar E Universitário de Coimbra, 3004-561 Coimbra, Portugal
- Faculty of Medicine, Coimbra University, Coimbra, Portugal
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11
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Li G, Zhong S, Wang X, Zhuge F. Association of hypoglycaemia with the risks of arrhythmia and mortality in individuals with diabetes - a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2023; 14:1222409. [PMID: 37645418 PMCID: PMC10461564 DOI: 10.3389/fendo.2023.1222409] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 07/24/2023] [Indexed: 08/31/2023] Open
Abstract
Background Hypoglycaemia has been linked to an increased risk of cardiac arrhythmias by causing autonomic and metabolic alterations, which may be associated with detrimental outcomes in individuals with diabetes(IWD), such as cardiovascular diseases (CVDs) and mortality, especially in multimorbid or frail people. However, such relationships in this population have not been thoroughly investigated. For this reason, we conducted a systematic review and meta-analysis. Methods Relevant papers published on PubMed, Embase, Cochrane, Web of Knowledge, Scopus, and CINHAL complete from inception to December 22, 2022 were routinely searched without regard for language. All of the selected articles included odds ratio, hazard ratio, or relative risk statistics, as well as data for estimating the connection of hypoglycaemia with cardiac arrhythmia, CVD-induced death, or total death in IWD. Regardless of the heterogeneity assessed by the I2 statistic, pooled relative risks (RRs) and 95% confidence intervals (CI) were obtained using random-effects models. Results After deleting duplicates and closely evaluating all screened citations, we chose 60 studies with totally 5,960,224 participants for this analysis. Fourteen studies were included in the arrhythmia risk analysis, and 50 in the analysis of all-cause mortality. Hypoglycaemic patients had significantly higher risks of arrhythmia occurrence (RR 1.42, 95%CI 1.21-1.68), CVD-induced death (RR 1.59, 95% CI 1.24-2.04), and all-cause mortality (RR 1.68, 95% CI 1.49-1.90) compared to euglycaemic patients with significant heterogeneity. Conclusion Hypoglycaemic individuals are more susceptible to develop cardiac arrhythmias and die, but evidence of potential causal linkages beyond statistical associations must await proof by additional specifically well planned research that controls for all potential remaining confounding factors.
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Affiliation(s)
- Gangfeng Li
- Clinical Laboratory Center, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
| | - Shuping Zhong
- Department of Hospital Management, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
| | - Xingmu Wang
- Clinical Laboratory Center, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
| | - Fuyuan Zhuge
- Department of Endocrine and Metabolism, Shaoxing People’s Hospital, Shaoxing, Zhejiang, China
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12
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Khan SA, Shields S, Abusamaan MS, Mathioudakis N. Association between dysglycemia and the Charlson Comorbidity Index among hospitalized patients with diabetes. J Diabetes Complications 2022; 36:108305. [PMID: 36108545 DOI: 10.1016/j.jdiacomp.2022.108305] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/02/2022] [Accepted: 09/03/2022] [Indexed: 01/08/2023]
Abstract
AIM Inpatient dysglycemia has been linked to short-term mortality, but longer-term mortality data are lacking. Our aim was to evaluate the association between inpatient dysglycemia and one-year mortality risk. METHODS Retrospective chart review of adults with diabetes hospitalized between 2015 and 2019. The Charlson Comorbidity Index (CCI) was used to estimate 1-year mortality risk, stratified into low (CCI ≤ 5) and high risk (CCI ≥6). Simple and multivariable logistic regression was used to evaluate the association between dysglycemic measures and high mortality risk. RESULTS Among 22,639 unique admissions, BG ≥ 180, ≥300, ≤70, <54 and <40 mg/dL were associated with adjusted odds of 1.43 (95 % CI, 1.33, 1.54), 1.58 (95 % CI, 1.48, 1.68), 2.16 (95 % CI, 2.01, 2.32), 2.58 (95 % CI, 2.32, 2.86), and 2.56 (95 % CI, 2.19, 2.99) for high mortality risk, respectively. Older age and Black race were positively associated with hyperglycemia and hypoglycemia. Myocardial infarction, congestive heart failure (CHF), and moderate to severe liver disease were most strongly associated with hyperglycemia, while renal disease, CHF, peripheral vascular disease, and peptic ulcer disease were most strongly associated with hypoglycemia. CONCLUSIONS Inpatient hypoglycemia and hyperglycemia were both positively associated with higher one-year mortality risk, with stronger magnitude of association observed for hypoglycemia. The association appears to be mediated mainly by presence of diabetes-related complications.
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Affiliation(s)
- Sara Atiq Khan
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Stephen Shields
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Mohammed S Abusamaan
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America.
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Gokhale K, Mostafa SA, Wang J, Tahrani AA, Sainsbury CA, Toulis KA, Thomas GN, Hassan-Smith Z, Sapey E, Gallier S, Adderley NJ, Narendran P, Bellary S, Taverner T, Ghosh S, Nirantharakumar K, Hanif W. The clinical profile and associated mortality in people with and without diabetes with Coronavirus disease 2019 on admission to acute hospital services. Endocrinol Diabetes Metab 2022; 5:e00309. [PMID: 34859617 PMCID: PMC8754243 DOI: 10.1002/edm2.309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/23/2021] [Accepted: 10/02/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION To assess if in adults with COVID-19, whether those with diabetes and complications (DM+C) present with a more severe clinical profile and if that relates to increased mortality, compared to those with diabetes with no complications (DM-NC) and those without diabetes. METHODS Service-level data was used from 996 adults with laboratory confirmed COVID-19 who presented to the Queen Elizabeth Hospital Birmingham, UK, from March to June 2020. All individuals were categorized into DM+C, DM-NC, and non-diabetes groups. Physiological and laboratory measurements in the first 5 days after admission were collated and compared among groups. Cox proportional hazards regression models were used to evaluate associations between diabetes status and the risk of mortality. RESULTS Among the 996 individuals, 104 (10.4%) were DM+C, 295 (29.6%) DM-NC and 597 (59.9%) non-diabetes. There were 309 (31.0%) in-hospital deaths documented, 40 (4.0% of total cohort) were DM+C, 99 (9.9%) DM-NC and 170 (17.0%) non-diabetes. Individuals with DM+C were more likely to present with high anion gap/metabolic acidosis, features of renal impairment, and low albumin/lymphocyte count than those with DM-NC or those without diabetes. There was no significant difference in mortality rates among the groups: compared to individuals without diabetes, the adjusted HRs were 1.39 (95% CI 0.95-2.03, p = 0.093) and 1.18 (95% CI 0.90-1.54, p = 0.226) in DM+C and DM-C, respectively. CONCLUSIONS Those with COVID-19 and DM+C presented with a more severe clinical and biochemical profile, but this did not associate with increased mortality in this study.
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Affiliation(s)
- Krishna Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- School of Computer Science, University of Birmingham, Birmingham, UK
- Midlands Health Data Research UK, Birmingham, UK
| | - Samiul A Mostafa
- Department of Diabetes Medicine, University Hospitals of Birmingham, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Jingya Wang
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Abd A Tahrani
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS, Foundation Trust, Birmingham, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | | | | | - G Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Zaki Hassan-Smith
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Elizabeth Sapey
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Midlands Health Data Research UK, Birmingham, UK
| | - Suzy Gallier
- Midlands Health Data Research UK, Birmingham, UK
| | | | - Parth Narendran
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Srikanth Bellary
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS, Foundation Trust, Birmingham, UK
- School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Tom Taverner
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Sandip Ghosh
- Department of Diabetes Medicine, University Hospitals of Birmingham, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
- Midlands Health Data Research UK, Birmingham, UK
- Department of Diabetes and Endocrinology, University Hospitals Birmingham NHS, Foundation Trust, Birmingham, UK
| | - Wasim Hanif
- Department of Diabetes Medicine, University Hospitals of Birmingham, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
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14
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Preoperative optimization of diabetes. Int Anesthesiol Clin 2022; 60:8-15. [PMID: 34897217 DOI: 10.1097/aia.0000000000000351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
People with diabetes are more likely to require surgical intervention than those without and have an increased risk of developing postoperative complications. The Highs and lows review from the National Confidential Enquiry into Patient Outcome and Death reported on inadequate diabetes care in the perioperative period. As a result, the Centre for Perioperative Care has published guidance on perioperative management of diabetes recently. Early identification and glucose optimisation pre-operatively is key, and assists in formulating an individualised plan for diabetes care during admission, surgery and postoperatively. The plan will include dose adjustments of diabetes medication, and use of variable rate insulin infusion or continuous subcutaneous insulin infusion where applicable. The guideline also highlights the importance of improved communication between healthcare teams involved in the perioperative pathway in order to improve outcomes and care.
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Moussavi K, Garcia J, Tellez-Corrales E, Fitter S. Reduced alternative insulin dosing in hyperkalemia: A meta-analysis of effects on hypoglycemia and potassium reduction. Pharmacotherapy 2021; 41:598-607. [PMID: 33993515 DOI: 10.1002/phar.2596] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/01/2021] [Accepted: 04/18/2021] [Indexed: 11/08/2022]
Abstract
STUDY OBJECTIVE Recent studies have identified that reduced alternative intravenous insulin doses, such as 5 units or 0.1 units/kg, may reduce the risk of hypoglycemia compared to standard doses of 10 units in patients treated for hyperkalemia. However, some studies suggest that these alternative doses may reduce the ability to lower serum potassium. This study was performed to determine the impact of alternative insulin dosing on hypoglycemia and potassium reduction in patients with hyperkalemia. DESIGN Meta-analysis. DATA SOURCE PubMed/MEDLINE, CENTRAL, Ovid, and ClinicalTrials.gov were searched from inception through November 2020. PATIENTS Patients treated with standard (10 units) or alternative (<10 units) insulin dosing strategies for hyperkalemia. Only studies that evaluated hypoglycemia (serum glucose <70 mg/dl), severe hypoglycemia (serum glucose <50 mg/dl), and potassium reduction post-treatment were included in the meta-analysis. All articles were assessed for bias using the Cochrane Risk of Bias Assessment Tool and Newcastle-Ottawa scales for randomized prospective trials and retrospective trials, respectively. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Ten retrospective cohort studies (n = 3437) were included and had low- or moderate-risk of bias. Alternative insulin dosing strategies included 5 units, 0.1 units/kg, and <10 units. Alternative dosing had lower pooled odds of hypoglycemia (odds ratio [OR] 0.55, 95% confidence interval [CI] 0.43-0.69, I2 = 8%) and severe hypoglycemia (OR 0.41, 95% CI 0.27-0.64, I2 = 0%). No difference in potassium reduction was detected (mean difference -0.02 mmol/L, 95% CI -0.11-0.07, I2 = 53%). CONCLUSIONS Alternative insulin dosing strategies for hyperkalemia management resulted in less hypoglycemia and severe hypoglycemia without compromising potassium reduction compared to standard dose. Prospective studies are needed to confirm these findings.
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Affiliation(s)
- Kayvan Moussavi
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, California, USA
| | - Joshua Garcia
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, California, USA
| | - Eglis Tellez-Corrales
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, California, USA
| | - Scott Fitter
- Emergency Medicine, Loma Linda University Medical Center, Loma Linda, California, USA.,Loma Linda University School of Pharmacy, Loma Linda, California, USA
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Dhatariya K, Mustafa OG, Rayman G. Safe care for people with diabetes in hospital. Clin Med (Lond) 2021; 20:21-27. [PMID: 31941727 DOI: 10.7861/clinmed.2019-0255] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Diabetes is the most prevalent long-term condition, occurring in approximately 6.5% of the UK population. However, an average of 18% of all acute hospital beds are occupied by someone with diabetes. Having diabetes in hospital is associated with increased harm - however that may be defined. Over the last few years the groups such as the Joint British Diabetes Societies for Inpatient Care have produced guidelines to help medical and nursing staff manage inpatients with diabetes. These guidelines have been rapidly adopted across the UK. The National Diabetes Inpatient Audit has shown that over the last few years the care for people with diabetes has slowly improved, but there remain challenges in terms of providing appropriate staffing and education. Patient safety is paramount, and thus there remains a lot to do to ensure this vulnerable group of people are not at increased risk of harm.
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Affiliation(s)
- Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norwich, UK and Norwich Medical School, Norwich, UK
| | - Omar G Mustafa
- King's College Hospital NHS Foundation Trust, London, UK
| | - Gerry Rayman
- Norwich Medical School, Norwich, UK and Ipswich Hospital, Ipswich, UK
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18
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Hypoglycemic episodes predict length of stay in patients with acute burns. J Crit Care 2021; 64:68-73. [PMID: 33794469 DOI: 10.1016/j.jcrc.2021.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 03/10/2021] [Accepted: 03/12/2021] [Indexed: 11/23/2022]
Abstract
Hypoglycemic episodes are associated with worse hospital outcomes. All adult patients admitted to our burn center from 2015 to 2019 were retrospectively reviewed. Patient demographics and burn characteristics were recorded. The primary outcome was mortality, and secondary outcomes were total length-of-stay and intensive care unit length-of-stay. All patients experiencing at least one hypoglycemic episode were compared to patients who did not experience hypoglycemia. There were 914 patients with acute burns admitted during the study period, 33 of which (4%) experienced hypoglycemic episodes. Of these, 17 patients (52%) experienced a single hypoglycemic episode, while the remainder experienced multiple hypoglycemic episodes. Patients with one or more hypoglycemic events were matched to non-hypoglycemic controls using propensity matching. Patients that experienced hypoglycemia had significantly less TBSA involvement (5% vs. 13%,median, p < 0.0002), higher prevalence of diabetes (48% vs. 18%, p < 0.0001), higher mortality (18% vs. 7%, p = 0.01), longer total length-of-stay (22 vs. 8 days, median, p < 0.0001), and longer ICU length-of-stay (12 vs. 0 days, median, p < 0.0001). A single hypoglycemic episode was associated with prolonged total (IRR = 1.91, p < 0.0001) and ICU length-of-stay (IRR = 3.86, p < 0.0001). Hypoglycemia was not associated with higher mortality in the survival analysis (p = 0.46).
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Ruan Y, Moysova Z, Tan GD, Lumb A, Davies J, Rea R. Inpatient hypoglycaemia in older people is associated with a doubling in the increased length of stay compared with the younger population. Age Ageing 2021; 50:576-580. [PMID: 33068101 DOI: 10.1093/ageing/afaa212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Hypoglycaemia during hospital admission is associated with poor outcomes including increased length of stay. In this study, we compared the incidence of inpatient hypoglycaemia and length of stays among people of three age groups: ≤65 years, 65-80 years and >80 years old. METHODS The study was conducted using a 4-year electronic patient record dataset from Oxford University Hospitals NHS Foundation Trust. The dataset contains hospital admission data for people with diabetes. We analysed the blood glucose (BG) measurements and identified all level 1 (BG <4 mmol/l) and level 2 (BG <3 mmol/l) hypoglycaemic episodes. We compared the length of stays between different age groups and with different levels of hypoglycaemia. RESULTS We analysed data obtained from 17,658 inpatients with diabetes who underwent 32,758 hospital admissions. The length of stays for admissions with no hypoglycaemia were 3[1,6], 3[1,8] and 4[2,11] (median[interquartile range]) days for age groups ≤65 years, 65-80 years and >80 years, respectively. These were statistically significantly lower (P < 0.01 for all pairwise comparisons) than the length of stays for admissions with level 1 hypoglycaemia, which were 6[3,13], 10[5,20] and 12[6,22] days, and level 2 hypoglycaemia, which were 7[3,14], 11[5,24] and 13[6,24] days. CONCLUSIONS In all age groups, admissions with either level 1 or level 2 hypoglycaemia were associated with an increased length of stay. However, in both the older groups, the length of stay increments were much higher (double) than the younger counterparts. The clinical consequences of hypoglycaemia were more severe in older people compared with the younger population.
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Affiliation(s)
- Yue Ruan
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Zuzana Moysova
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Garry D Tan
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, OUH, Oxford, UK
| | - Alistair Lumb
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, OUH, Oxford, UK
| | - Jim Davies
- Big Data Institute, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, OUH, Oxford, UK
| | - Rustam Rea
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, OUH, Oxford, UK
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20
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Tee SA, Devine K, Potts A, Javaid U, Razvi S, Quinton R, Roberts G, Leech NJ. Iatrogenic hypoglycaemia following glucose-insulin infusions for the treatment of hyperkalaemia. Clin Endocrinol (Oxf) 2021; 94:176-182. [PMID: 32979855 DOI: 10.1111/cen.14343] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/02/2020] [Accepted: 09/15/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To study the incidence of, and risk factors for, iatrogenic hypoglycaemia following GwI infusion in our institution. CONTEXT Hyperkalaemia is a life-threatening biochemical abnormality. Glucose-with-insulin (GwI) infusions form standard management, but risk iatrogenic hypoglycaemia (glucose ≤ 3.9 mmol/L). Recently updated UK guidelines include an additional glucose infusion in patients with pretreatment capillary blood glucose (CBG) < 7.0 mmol/L. DESIGN Retrospective analysis of outcomes for GwI infusions prescribed for hyperkalaemia from 1 January to 28 February 2019, extracted from the Newcastle upon Tyne Hospitals NHS Foundation Trust electronic platform (eRecord). PARTICIPANTS 132 patients received 228 GwI infusions for hyperkalaemia. MAIN OUTCOME MEASURES Incidence, severity and time to onset of hypoglycaemia. RESULTS Hypoglycaemia incidence was 11.8%. At least 1 hypoglycaemic episode occurred in 18.2% of patients with 6.8% having at least 1 episode of severe hypoglycaemia (< 3.0 mmol/L). Most episodes (77.8%) occurred within 3 h of treatment. Lower pretreatment CBG (5.9 mmol/L [4.1 mmol/L-11.2 mmol/L], versus 7.6 mmol/L [3.7 mmol/L-31.3 mmol/L], P = .000) was associated with hypoglycaemia risk. A diagnosis of type 2 diabetes and treatment for hyperkalaemia within the previous 24 h were negatively associated. CONCLUSIONS Within our inpatient population, around 1 in 8 GwI infusions delivered as treatment for hyperkalaemia resulted in iatrogenic hypoglycaemia. Higher pretreatment CBG and a diagnosis of type 2 diabetes were protective, irrespective of renal function. Our findings support the immediate change to current management, either with additional glucose infusions or by using glucose-only infusions in patients without diabetes. These approaches should be compared via a prospective randomized study.
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Affiliation(s)
- Su Ann Tee
- Department of Diabetes & Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Kerri Devine
- Department of Diabetes & Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle, UK
- Department of Diabetes & Endocrinology, Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust, Gateshead, UK
- Translational & Clinical Research Institute, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK
| | - Adam Potts
- Department of Diabetes & Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Usman Javaid
- Department of Diabetes & Endocrinology, Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust, Gateshead, UK
| | - Salman Razvi
- Department of Diabetes & Endocrinology, Queen Elizabeth Hospital, Gateshead Health NHS Foundation Trust, Gateshead, UK
- Translational & Clinical Research Institute, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK
| | - Richard Quinton
- Department of Diabetes & Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle, UK
- Translational & Clinical Research Institute, University of Newcastle-upon-Tyne, Newcastle-upon-Tyne, UK
| | - Graham Roberts
- Diabetes Research Group, Swansea University, Swansea, UK
- Clinical Research Facility - Cork, University College Cork, Cork, Ireland
| | - Nicola J Leech
- Department of Diabetes & Endocrinology, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, Newcastle, UK
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21
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Fitchett D, Inzucchi SE, Wanner C, Mattheus M, George JT, Vedin O, Zinman B, Johansen OE. Relationship between hypoglycaemia, cardiovascular outcomes, and empagliflozin treatment in the EMPA-REG OUTCOME® trial. Eur Heart J 2021; 41:209-217. [PMID: 31504427 PMCID: PMC6945517 DOI: 10.1093/eurheartj/ehz621] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/19/2019] [Accepted: 08/15/2019] [Indexed: 12/26/2022] Open
Abstract
Aims Hypoglycaemia, in patients with Type 2 diabetes (T2D) is associated with an increased risk for cardiovascular (CV) events. In EMPA-REG OUTCOME, the sodium-glucose co-transporter-2 inhibitor empagliflozin reduced the risk of CV death by 38% and heart failure hospitalization (HHF) by 35%, while decreasing glycated haemoglobin (HbA1c) without increasing hypoglycaemia. We investigated CV outcomes in patients with hypoglycaemia during the trial and the impact of hypoglycaemia on the treatment effect of empagliflozin. Methods and results About 7020 patients with T2D (HbA1c 7–10%) were treated with empagliflozin 10 or 25 mg, or placebo and followed for median 3.1 years. The relationship between on-trial hypoglycaemia and CV outcomes, and effects of empagliflozin on outcomes by incident hypoglycaemia [HYPO-broad: symptomatic hypoglycaemia with plasma glucose (PG) ≤70 mg/dL, any hypoglycaemia with PG <54 mg/dL, or severe hypoglycaemia, and HYPO-strict: hypoglycaemia with PG <54 mg/dL, or severe hypoglycaemia] was investigated using adjusted Cox regression models with time-varying covariates for hypoglycaemia and interaction with treatment. HYPO-broad occurred in 28% in each group and HYPO-strict in 19%. In the placebo group, hypoglycaemia was associated with an increased risk of HHF for both HYPO-broad [hazard ratio (HR, 95% confidence interval, CI) 1.91 (1.25–2.93)] and HYPO-strict [1.72 (1.06–2.78)]. HYPO-broad (but not HYPO-strict) was associated with an increased risk of myocardial infarction (MI) [HR 1.56 (1.06–2.29)]. Empagliflozin improved CV outcomes, regardless of occurrence of hypoglycaemia (P-for interactions >0.05). Conclusion In this post hoc exploratory analysis, hypoglycaemia was associated with an increased risk of HHF and MI. Hypoglycaemia risk was not increased with empagliflozin and incident hypoglycaemia did not attenuate its cardio-protective effects. ![]()
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Affiliation(s)
- David Fitchett
- Division of Cardiology, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale School of Medicine, 333 Cedar St, New Haven, CT 06520, USA
| | - Christoph Wanner
- Division of Nephrology, Department of Medicine, University Hospital Würzburg, Oberdürrbacherstr 6, 97080 Würzburg, Germany
| | - Michaela Mattheus
- Biostatistics and Data Sciences, Boehringer Ingelheim, Binger Str. 173, 55216 Ingelheim am Rhein, Germany
| | - Jyothis T George
- Therapeutic area cardiometabolism, Boehringer Ingelheim, Binger Str. 173, 55216 Ingelheim am Rhein, Germany
| | - Ola Vedin
- Therapeutic area cardiometabolism, Boehringer Ingelheim AB, Hammarby allé 29, 120 32 Stockholm, Sweden
| | - Bernard Zinman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, 60 Murray Street, Toronto, ON M5T 3L9, Canada
| | - Odd Erik Johansen
- Therapeutic area cardiometabolism, Boehringer Ingelheim KS, Hagaløkkveien 26, 1373 Asker, Norway
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Leighton ME, Thompson BM, Castro JC, Cook CB. Nurse adherence to post–hypoglycemic event monitoring for hospitalized patients with diabetes mellitus. Appl Nurs Res 2020; 56:151338. [DOI: 10.1016/j.apnr.2020.151338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 07/16/2020] [Indexed: 10/23/2022]
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23
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Kao SL, Chen Y, Ning Y, Tan M, Salloway M, Khoo EYH, Tai ES, Tan CS. Evaluating the effectiveness of a multi-faceted inpatient diabetes management program among hospitalised patients with diabetes mellitus. Clin Diabetes Endocrinol 2020; 6:21. [PMID: 33292816 PMCID: PMC7643419 DOI: 10.1186/s40842-020-00107-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 10/15/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Diabetes mellitus (DM) is one of the most common chronic diseases. Individuals with DM are more likely to be hospitalised and stay longer than those without DM. Inpatient hypoglycemia and hyperglycemia, which are associated with adverse outcomes, are common, but can be prevented through hospital quality improvement programs. METHODS We designed a multi-faceted intervention program with the aim of reducing inpatient hypoglycemia and hyperglycemia. This was implemented over seven phases between September 2013 to January 2016, and covered all the non-critical care wards in a tertiary hospital. The program represented a pragmatic approach that leveraged on existing resources and infrastructure within the hospital. We calculated glucometric outcomes in June to August 2016 and compared them with those in June to August 2013 to assess the overall effectiveness of the program. We used regression models with generalised estimating equations to adjust for potential confounders and account for correlations of repeated outcomes within patients and admissions. RESULTS We observed significant reductions in patient-days affected by hypoglycemia (any glucose reading < 4 mmol/L: OR = 0.71, 95% CI: 0.61 to 0.83, p < 0.001), and hyperglycemia (any glucose reading > 14 mmol/L: OR = 0.84, 95% CI: 0.71 to 0.99, p = 0.041). Similar findings were observed for admission-level hypoglycemia and hyperglycemia. Further analyses suggested that these reductions started to occur four to 6 months post-implementation. CONCLUSIONS Our program was associated with sustained improvements in clinically relevant outcomes. Our described intervention could be feasibly implemented by other secondary and tertiary care hospitals by leveraging on existing infrastructure and work force.
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Affiliation(s)
- Shih Ling Kao
- Department of Medicine, National University Hospital and National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
| | - Ying Chen
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Yilin Ning
- NUS Graduate School for Integrative Sciences and Engineering, National University of Singapore, Singapore, Singapore
- Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
| | - Maudrene Tan
- Department of Medicine, National University Hospital and National University Health System, Singapore, Singapore
| | - Mark Salloway
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore
| | - Eric Yin Hao Khoo
- Department of Medicine, National University Hospital and National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
| | - E Shyong Tai
- Department of Medicine, National University Hospital and National University Health System, Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore and National University Health System, Singapore, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore, Singapore.
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Dei Cas A, Aldigeri R, Ridolfi V, Vazzana A, Ciardullo AV, Manicardi V, Sforza A, Tomasi F, Zavaroni D, Zavaroni I, Bonadonna RC. A performance score of the quality of inpatient diabetes care is a marker of clinical outcomes and suggests a cause-effect relationship between hypoglycaemia and the risk of in-hospital mortality. Diabetes Metab Res Rev 2020; 36:e3347. [PMID: 32445284 DOI: 10.1002/dmrr.3347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/04/2020] [Accepted: 05/10/2020] [Indexed: 12/17/2022]
Abstract
AIMS To build a tool to assess the management of inpatients with diabetes mellitus and to investigate its relationship, if any, with clinical outcomes. MATERIALS AND METHODS A total of 678 patients from different settings, Internal Medicine (IMU, n = 255), General Surgery (GSU, n = 230) and Intensive Care (ICU, n = 193) Units, were enrolled. A work-flow of clinical care of diabetes was created according to guidelines. The workflow was divided into five different domains: (a) initial assessment; (b) glucose monitoring; (c) medical therapy; (d) consultancies; (e) discharge. Each domain was assessed by a performance score (PS), computed as the sum of the scores achieved in a set of indicators of clinical appropriateness, management and patient empowerment. Appropriate glucose goals were included as intermediate phenotypes. Clinical outcomes included: hypoglycaemia, survival rate and clinical conditions at discharge. RESULTS The total PS and those of initial assessment and glucose monitoring were significantly lower in GSU with respect to IMU and ICU (P < .0001). The glucose monitoring PS was associated with lower risk of hypoglycaemia (OR = 0.55; P < .0001), whereas both the PSs of glucose monitoring and medical therapy resulted associated with higher in-hospital survival only in the IMU ward (OR = 6.67 P = .001 and OR = 2.38 P = .03, respectively). Instrumental variable analysis with the aid of PS of glucose monitoring showed that hypoglycaemia may play a causal role in in-hospital mortality (P = .04). CONCLUSIONS The quality of in-hospital care of diabetes may affect patient outcomes, including glucose control and the risk of hypoglycaemia, and through the latter it may influence the risk of in-hospital mortality.
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Affiliation(s)
- Alessandra Dei Cas
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | - Valentina Ridolfi
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Angela Vazzana
- Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | | | | | | | | | | | - Ivana Zavaroni
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Riccardo C Bonadonna
- Department of Medicine and Surgery, Università di Parma, Parma, Italy
- Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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Mukherjee T, Robbins T, Lim Choi Keung SN, Sankar S, Randeva H, Arvanitis TN. A systematic review considering risk factors for mortality of patients discharged from hospital with a diagnosis of diabetes. J Diabetes Complications 2020; 34:107705. [PMID: 32861561 DOI: 10.1016/j.jdiacomp.2020.107705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/16/2020] [Accepted: 07/30/2020] [Indexed: 11/23/2022]
Abstract
AIM To identify known risk factors for mortality for adult patients, discharged from hospital with diabetes. METHOD The systematic review was based on the PRISMA protocol. Studies were identified through EMBASE & MEDLINE databases. The inclusion criteria were papers that were published over the last 6 years, in English language, and focused on risk factors of mortality in adult patients with diabetes, after they were discharged from hospitals. This was followed by data extraction "with quality assessment and semi-quantitative synthesis according to PRISMA guidelines". RESULTS There were 35 studies identified, considering risk factors relating to mortality for patients, discharged from hospital with diabetes. These studies are distributed internationally. 48 distinct statistically significant risk factors for mortality can be identified. Risk factors can be grouped into the following categories; demographic, socioeconomic, lifestyle, patient medical, inpatient stay, medication related, laboratory results, and gylcaemic status. These risk factors can be further divided into risk factors identified in generalized populations of patients with diabetes, compared to specific sub-populations of people with diabetes. CONCLUSION A relatively small number of studies have considered risk factors relating to mortality for patients, discharged from hospital with a diagnosis of diabetes. Mortality is an important outcome, when considering discharge from hospital with diabetes. However, there has only been limited consideration within the research literature.
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Affiliation(s)
- Teesta Mukherjee
- Institute of Digital Healthcare, WMG, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Tim Robbins
- Institute of Digital Healthcare, WMG, University of Warwick, Coventry CV4 7AL, United Kingdom; University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom
| | - Sarah N Lim Choi Keung
- Institute of Digital Healthcare, WMG, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Sailesh Sankar
- University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom; Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Harpal Randeva
- University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom; Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Theodoros N Arvanitis
- University Hospitals Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, United Kingdom.
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Kim SW. Letter: Differences in Clinical Outcomes between Patients with and without Hypoglycemia during Hospitalization: A Retrospective Study Using Real-World Evidence (Diabetes Metab J 2020;44:555-65). Diabetes Metab J 2020; 44:775-776. [PMID: 33115213 PMCID: PMC7643600 DOI: 10.4093/dmj.2020.0188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Sung-Woo Kim
- Department of Internal Medicine, Daegu Catholic University Hospital, Daegu Catholic University School of Medicine, Daegu, Korea
- Corresponding author: Sung-Woo Kim Department of Internal Medicine, Daegu Catholic University Hospital, Daegu Catholic University School of Medicine, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 42472, Korea E-mail:
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27
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Alfian G, Syafrudin M, Anshari M, Benes F, Atmaji FTD, Fahrurrozi I, Hidayatullah AF, Rhee J. Blood glucose prediction model for type 1 diabetes based on artificial neural network with time-domain features. Biocybern Biomed Eng 2020. [DOI: 10.1016/j.bbe.2020.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
People with diabetes occupy approximately 18% of all acute inpatient hospital beds in the UK, compared with 6.5% of the general population. For those undergoing surgery, having diabetes is known to be associated with increased harms, however harm is defined. For those undergoing elective surgery, there is a defined patient journey, starting with referral from primary care to surgical outpatients, then onto preoperative assessment clinic before being admitted for surgery, and then from recovery through to discharge home. Because of the multiple causes for possible harm, communication between members of the healthcare team at each stage of this journey and with the person with diabetes is essential.Recently, the National Confidential Enquiry into Patient Outcomes and Death has shown that the care of people with diabetes undergoing surgery needs to be improved, and they have made several recommendations that trusts should adopt to minimise the harms in this vulnerable population.
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Affiliation(s)
- Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norwich, UK and Norwich Medical School, Norwich, UK
| | - Nicholas Levy
- West Suffolk NHS Foundation Trust, Bury St Edmunds, UK
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29
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Electronic Measurement of a Clinical Quality Measure for Inpatient Hypoglycemic Events: A Multicenter Validation Study. Med Care 2020; 58:927-933. [PMID: 32833937 DOI: 10.1097/mlr.0000000000001398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hypoglycemia related to antidiabetic drugs (ADDs) is important iatrogenic harm in hospitalized patients. Electronic identification of ADD-related hypoglycemia may be an efficient, reliable method to inform quality improvement. OBJECTIVE Develop electronic queries of electronic health records for facility-wide and unit-specific inpatient hypoglycemia event rates and validate query findings with manual chart review. METHODS Electronic queries were created to associate blood glucose (BG) values with ADD administration and inpatient location in 3 tertiary care hospitals with Patient-Centered Outcomes Research Network (PCORnet) databases. Queries were based on National Quality Forum criteria with hypoglycemia thresholds <40 and <54 mg/dL, and validated using a stratified random sample of 321 BG events. Sensitivity and specificity were calculated with manual chart review as the reference standard. RESULTS The sensitivity and specificity of queries for hypoglycemia events were 97.3% [95% confidence interval (CI), 90.5%-99.7%] and 100.0% (95% CI, 92.6%-100.0%), respectively for BG <40 mg/dL, and 97.7% (95% CI, 93.3%-99.5%) and 100.0% (95% CI, 95.3%-100.0%), respectively for <54 mg/dL. The sensitivity and specificity of the query for identifying ADD days were 91.8% (95% CI, 89.2%-94.0%) and 99.0% (95% CI, 97.5%-99.7%). Of 48 events missed by the queries, 37 (77.1%) were due to incomplete identification of insulin administered by infusion. Facility-wide hypoglycemia rates were 0.4%-0.8% (BG <40 mg/dL) and 1.9%-3.0% (BG <54 mg/dL); rates varied by patient care unit. CONCLUSIONS Electronic queries can accurately identify inpatient hypoglycemia. Implementation in non-PCORnet-participating facilities should be assessed, with particular attention to patient location and insulin infusions.
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30
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Zhou D, Li Z, Shi G, Zhou J. Proportion of time spent in blood glucose range 70 to 140 mg/dL is associated with increased survival in patients admitted to ICU after cardiac arrest: A multicenter observational study. Medicine (Baltimore) 2020; 99:e21728. [PMID: 32872055 PMCID: PMC7437796 DOI: 10.1097/md.0000000000021728] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The benefit of any specific target range of blood glucose (BG) for post-cardiac arrest (PCA) care remains unknown.We conducted a multicenter retrospective study of prospectively collected data of all cardiac arrest patients admitted to the ICUs between 2014 and 2015. The main exposure was BG metrics during the first 24 hours, including time-weighted mean (TWM) BG, mean BG, admission BG and proportion of time spent in 4 BG ranges (<= 70 mg/dL, 70-140 mg/dL, 140-180 mg/dL and > 180 mg/dL). The primary outcome was hospital mortality. Multivariable logistic regression, Cox proportion hazard models and generalized estimating equation (GEE) models were built to evaluate the association between the different kinds of BG and hospital mortality.2,028 PCA patients from 144 ICUs were included. 14,118 BG measurements during the first 24 hours were extracted. According to TWM-BG, 9 (0%) were classified into the <= 70 mg/dL range, 693 (34%) into the 70 to 140 mg/dL range, 603 (30%) into the 140 to 180 mg/dL range, and 723 (36%) into the > 180 mg/dL range. Compared with BG 70 to 140 mg/dL range, BG 140 to 180 mg/dL range and > 180 mg/dL range were associated with higher hospital mortality probability. Proportion of time spent in the 70 to 140 mg/dL range was associated with good outcome (odds ratio 0.984, CI [0.970, 0.998], P = .022, for per 5% increase in time), and > 180 mg/dL range with poor outcome (odds ratio 1.019, CI [1.009, 1.028], P< .001, for per 5% increase in time). Results of the 3 kinds of statistical models were consistent.The proportion of time spent in BG range 70 to 140 mg/dL is strongly associated with increased hospital survival in PCA patients. Hyperglycemia (> 180 mg/dL) is common in PCA patients and is associated with increased hospital mortality.
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31
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Lee J, Kim TM, Kim H, Lee SH, Cho JH, Lee H, Yim HW, Yoon KH, Kim HS. Differences in Clinical Outcomes between Patients with and without Hypoglycemia during Hospitalization: A Retrospective Study Using Real-World Evidence. Diabetes Metab J 2020; 44:555-565. [PMID: 32431110 PMCID: PMC7453993 DOI: 10.4093/dmj.2019.0064] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 08/20/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Some patients admitted to hospitals for glycemic control experience hypoglycemia despite regular meals and despite adhering to standard blood glucose control protocols. Different factors can have a negative impact on blood glucose control and prognosis after discharge. This study investigated risk factors for hypoglycemia and its effects on glycemic control during the hospitalization of patients in the general ward. METHODS This retrospective study included patients who were admitted between 2009 and 2018. Patients were provided regular meals at fixed times according to ideal body weights during hospitalization. We categorized the patients into two groups: those with and those without hypoglycemia during hospitalization. RESULTS Of the 3,031 patients, 379 experienced at least one episode of hypoglycemia during hospitalization (HYPO group). Hypoglycemia occurred more frequently particularly in cases of premixed insulin therapy. Compared with the control group, the HYPO group was older (61.0±16.8 years vs. 59.1±16.5 years, P=0.035), with more females (60.4% vs. 49.6%, P<0.001), lower body mass index (BMI) (23.5±4.2 kg/m² vs. 25.1±4.4 kg/m², P<0.001), and higher prevalence of type 1 diabetes mellitus (6.1% vs. 2.6%, P<0.001), They had longer hospital stay (11.1±13.5 days vs. 7.6±4.6 days, P<0.001). After discharge the HYPO group had lower glycosylated hemoglobin reduction rate (-2.0%±0.2% vs. -2.5%±0.1%, P=0.003) and tended to have more frequent cases of cardiovascular disease. CONCLUSION Hypoglycemia occurred more frequently in older female patients with lower BMI and was associated with longer hospital stay and poorer glycemic control after discharge. Therefore, clinicians must carefully ensure that patients do not experience hypoglycemia during hospitalization.
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Affiliation(s)
- Jeongmin Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tong Min Kim
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyunah Kim
- College of Pharmacy, Sookmyung Women's University, Seoul, Korea
| | - Seung Hwan Lee
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Hyoung Cho
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyunyong Lee
- Clinical Research Coordinating Center, Catholic Medical Center, The Catholic University of Korea, Seoul, Korea
| | - Hyeon Woo Yim
- Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kun Ho Yoon
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hun Sung Kim
- Department of Medical Informatics, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
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Ruan Y, Moysova Z, Tan GD, Lumb A, Davies J, Rea RD. Inpatient hypoglycaemia: understanding who is at risk. Diabetologia 2020; 63:1299-1304. [PMID: 32300821 PMCID: PMC7286944 DOI: 10.1007/s00125-020-05139-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/04/2020] [Indexed: 02/07/2023]
Abstract
AIMS/HYPOTHESIS We analysed data obtained from the electronic patient records of inpatients with diabetes admitted to a large university hospital to understand the prevalence and distribution of inpatient hypoglycaemia. METHODS The study was conducted using electronic patient record data from Oxford University Hospitals NHS Foundation Trust. The dataset contains hospital admission data for patients coded for diabetes. We used the recently agreed definition for a level 1 hypoglycaemia episode as any blood glucose measurement <4 mmol/l and a level 2 hypoglycaemia episode as any blood glucose measurement <3 mmol/l. Any two or more consecutive low blood glucose measurements within a 2 h time window were considered as one single hypoglycaemic episode. RESULTS We analysed data obtained from 17,658 inpatients with diabetes (1696 with type 1 diabetes, 14,006 with type 2 diabetes, and 1956 with other forms of diabetes; 9277 men; mean ± SD age, 66 ± 18 years) who underwent 32,758 hospital admissions between July 2014 and August 2018. The incidence of level 1 hypoglycaemia was 21.5% and the incidence of level 2 hypoglycaemia was 9.6%. Recurrent level 1 and level 2 hypoglycaemia occurred, respectively, in 51% and 39% of hospital admissions in people with type 2 diabetes with at least one hypoglycaemic episode, and in 55% and 45% in those with type 1 diabetes. The incidence of level 2 hypoglycaemia in people with type 2 diabetes, when corrected for the number of people who remained in hospital, remained constant for the first 100 h at approximately 0.15 events per h per admission. With regards to the hypoglycaemia distribution during the day, after correcting for the number of blood glucose tests per h, there were two clear spikes in the rate of hypoglycaemia approximately 3 h after lunch and after dinner. The highest rate of hypoglycaemia per glucose test was seen between 01:00 hours and 05:00 hours. Medication had a significant impact on the incidence of level 2 hypoglycaemia, ranging from 1.5% in people with type 2 diabetes on metformin alone to 33% in people treated with a combination of rapid-acting insulin analogue, long-acting insulin analogue and i.v.-administered insulin. CONCLUSIONS/INTERPRETATION Retrospective analysis of data from electronic patient records enables clinicians to gain a greater understanding of the incidence and distribution of inpatient hypoglycaemia. This information should be used to drive evidence-based improvements in the glycaemic control of inpatients through targeted medication adjustment for specific populations at high risk of hypoglycaemia.
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Affiliation(s)
- Yue Ruan
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Headington, Oxford, OX3 7LE, UK
| | - Zuzana Moysova
- Big Data Institute, University of Oxford Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
| | - Garry D Tan
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Headington, Oxford, OX3 7LE, UK
- NIHR Oxford Biomedical Research Centre, OUH, Oxford, UK
| | - Alistair Lumb
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Headington, Oxford, OX3 7LE, UK
- NIHR Oxford Biomedical Research Centre, OUH, Oxford, UK
| | - Jim Davies
- Big Data Institute, University of Oxford Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, OUH, Oxford, UK
| | - Rustam D Rea
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals NHS Foundation Trust, Headington, Oxford, OX3 7LE, UK.
- NIHR Oxford Biomedical Research Centre, OUH, Oxford, UK.
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Ruan Y, Bellot A, Moysova Z, Tan GD, Lumb A, Davies J, van der Schaar M, Rea R. Predicting the Risk of Inpatient Hypoglycemia With Machine Learning Using Electronic Health Records. Diabetes Care 2020; 43:1504-1511. [PMID: 32350021 DOI: 10.2337/dc19-1743] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 04/04/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We analyzed data from inpatients with diabetes admitted to a large university hospital to predict the risk of hypoglycemia through the use of machine learning algorithms. RESEARCH DESIGN AND METHODS Four years of data were extracted from a hospital electronic health record system. This included laboratory and point-of-care blood glucose (BG) values to identify biochemical and clinically significant hypoglycemic episodes (BG ≤3.9 and ≤2.9 mmol/L, respectively). We used patient demographics, administered medications, vital signs, laboratory results, and procedures performed during the hospital stays to inform the model. Two iterations of the data set included the doses of insulin administered and the past history of inpatient hypoglycemia. Eighteen different prediction models were compared using the area under the receiver operating characteristic curve (AUROC) through a 10-fold cross validation. RESULTS We analyzed data obtained from 17,658 inpatients with diabetes who underwent 32,758 admissions between July 2014 and August 2018. The predictive factors from the logistic regression model included people undergoing procedures, weight, type of diabetes, oxygen saturation level, use of medications (insulin, sulfonylurea, and metformin), and albumin levels. The machine learning model with the best performance was the XGBoost model (AUROC 0.96). This outperformed the logistic regression model, which had an AUROC of 0.75 for the estimation of the risk of clinically significant hypoglycemia. CONCLUSIONS Advanced machine learning models are superior to logistic regression models in predicting the risk of hypoglycemia in inpatients with diabetes. Trials of such models should be conducted in real time to evaluate their utility to reduce inpatient hypoglycemia.
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Affiliation(s)
- Yue Ruan
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals National Health Service Foundation Trust, Oxford, U.K.,Oxford National Institute for Health Research Biomedical Research Centre, Oxford, U.K.,Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, U.K
| | - Alexis Bellot
- Department of Mathematics, University of Cambridge, Cambridge, U.K.,Alan Turing Institute, London, U.K
| | - Zuzana Moysova
- Big Data Institute, University of Oxford Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, U.K
| | - Garry D Tan
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals National Health Service Foundation Trust, Oxford, U.K.,Oxford National Institute for Health Research Biomedical Research Centre, Oxford, U.K
| | - Alistair Lumb
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals National Health Service Foundation Trust, Oxford, U.K.,Oxford National Institute for Health Research Biomedical Research Centre, Oxford, U.K
| | - Jim Davies
- Big Data Institute, University of Oxford Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Oxford, U.K
| | - Mihaela van der Schaar
- Department of Mathematics, University of Cambridge, Cambridge, U.K.,Alan Turing Institute, London, U.K
| | - Rustam Rea
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford University Hospitals National Health Service Foundation Trust, Oxford, U.K. .,Oxford National Institute for Health Research Biomedical Research Centre, Oxford, U.K
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Avanzini F, Marelli G, Amodeo R, Chiappa L, Colombo EL, Di Rocco E, Grioni M, Moro C, Roncaglioni MC, Saltafossi D, Vandoni P, Vannini T, Vilei V, Riva E. The 'brick diet' and postprandial insulin: a practical method to balance carbohydrates ingested and prandial insulin to prevent hypoglycaemia in hospitalized persons with diabetes. Diabet Med 2020; 37:1125-1133. [PMID: 32144811 DOI: 10.1111/dme.14293] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2020] [Indexed: 12/13/2022]
Abstract
AIM Insulin is the preferred treatment for the control of diabetes in hospital, but it raises the risk of hypoglycaemia, often because oral intake of carbohydrates in hospitalized persons is lower than planned. Our aim was to assess the effect on the incidence of hypoglycaemia of giving prandial insulin immediately after a meal depending on the amount of carbohydrate ingested. METHODS A prospective pre-post intervention study in hospitalized persons with diabetes eating meals with stable doses of carbohydrates present in a few fixed foods. Foods were easily identifiable on the tray and contained fixed doses of carbohydrates that were easily quantifiable by nurses as multiples of 10 g (a 'brick'). Prandial insulin was given immediately after meals in proportion to the amount of carbohydrates eaten. RESULTS In 83 of the first 100 people treated with the 'brick diet', the oral carbohydrate intake was lower than planned on at least one occasion (median: 3 times; Q1-Q3: 2-6 times) over a median of 5 days. Compared with the last 100 people treated with standard procedures, postprandial insulin given on the basis of ingested carbohydrate significantly reduced the incidence of hypoglycaemic events per day, from 0.11 ± 0.03 to 0.04 ± 0.02 (P < 0.001) with an adjusted incidence rate ratio of 0.70 (95% confidence interval 0.54-0.92; P = 0.011). CONCLUSIONS In hospitalized persons with diabetes treated with subcutaneous insulin, the 'brick diet' offers a practical method to count the amount of carbohydrates ingested, which is often less than planned. Prandial insulin given immediately after a meal, in doses balanced with actual carbohydrate intake reduces the risk of hypoglycaemia.
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Affiliation(s)
- F Avanzini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
- Division of Clinical Cardiology, Ospedale di Desio, Desio, Italy
| | - G Marelli
- Endocrine Metabolic and Nutrition Diseases Departmental Unit, ASST Vimercate, Vimercate, Italy
| | - R Amodeo
- Division of Clinical Cardiology, Ospedale di Desio, Desio, Italy
| | - L Chiappa
- Division of Clinical Cardiology, Ospedale di Desio, Desio, Italy
| | - E L Colombo
- Endocrinology and Diabetology Departmental Unit, Ospedale di Desio, Desio, Italy
| | - E Di Rocco
- Division of Clinical Cardiology, Ospedale di Desio, Desio, Italy
| | - M Grioni
- Division of Clinical Cardiology, Ospedale di Desio, Desio, Italy
| | - C Moro
- Division of Clinical Cardiology, Ospedale di Desio, Desio, Italy
| | - M C Roncaglioni
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - D Saltafossi
- Division of Clinical Cardiology, Ospedale di Desio, Desio, Italy
| | - P Vandoni
- Division of Clinical Cardiology, Ospedale di Desio, Desio, Italy
| | - T Vannini
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - V Vilei
- Endocrine Metabolic and Nutrition Diseases Departmental Unit, ASST Vimercate, Vimercate, Italy
| | - E Riva
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
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Pratiwi C, Mokoagow MI, Made Kshanti IA, Soewondo P. The risk factors of inpatient hypoglycemia: A systematic review. Heliyon 2020; 6:e03913. [PMID: 32420485 PMCID: PMC7218453 DOI: 10.1016/j.heliyon.2020.e03913] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 04/07/2020] [Accepted: 04/29/2020] [Indexed: 12/21/2022] Open
Abstract
Hypoglycemia is an important and harmful complication of Diabetes Mellitus (DM) that often occurs in inpatient or outpatient settings. Hypoglycemia can be divided into two types, i.e. primary hypoglycemia when hypoglycemia is the main diagnosis for admission, whereas secondary hypoglycemia if hypoglycemia occurs during hospitalization. Hypoglycemia during hospitalization or secondary hypoglycemia may arise from various risk factors, such as advanced age, comorbid diseases, type of diabetes, previous history of hypoglycemia, body mass index, hyperglycemia therapy given, as well as other risk factors such as inadequate glucose monitoring, unclear or unreadable physician instructions, limited health personnel, limited facilities, prolonged fasting and incompatibility of nutritional intake and therapy administered. Hypoglycemia can lead to medical and non-medical impacts, such as increased mortality, cardiovascular disorders, cerebrovascular disorders, and increased health care costs and length of stay. The incidence of inpatient hypoglycemia can actually be prevented by controlling modifiable risk factors and also giving education about hypoglycemia to patients and health workers. We performed a literature research in Pubmed, EBSCOhost, and Scopus to review the possible risk factors for inpatient hypoglycemia. Eleven studies were retrieved. We presented the result of these studies as well as a brief overview of the epidemiology, pathophysiology, impact and preventive strategy.
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Affiliation(s)
- Chici Pratiwi
- Internal Medicine Department, Cipto Mangunkusumo National Hospital-Faculty of Medicine Universitas Indonesia
| | - Muhammad Ikhsan Mokoagow
- Division of Endocrinology and Metabolism, Internal Medicine Department, Cipto Mangunkusumo National Hospital-Faculty of Medicine Universitas Indonesia.,Internal Medicine Department Fatmawati General Hospital Indonesia
| | | | - Pradana Soewondo
- Division of Endocrinology and Metabolism, Internal Medicine Department, Cipto Mangunkusumo National Hospital-Faculty of Medicine Universitas Indonesia
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36
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Abusamaan MS, Klonoff DC, Mathioudakis N. Predictors of Time-to-Repeat Point-of-Care Glucose Following Hypoglycemic Events in Hospitalized Patients. J Diabetes Sci Technol 2020; 14:526-534. [PMID: 31640421 PMCID: PMC7576943 DOI: 10.1177/1932296819883332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Previous studies have shown low adherence to the recommendation to repeat point-of-care glucose (POCG) within 15 minutes following the treatment of inpatient hypoglycemia. We sought to evaluate whether patient and clinical factors may predict time-to-repeat (TTR) POCG following hypoglycemic events in hospitalized adult patients. METHODS This was a retrospective cross-sectional analysis of 22 226 index hypoglycemic (≤70 mg/dL) readings (of 993 395 total POCG samples) from 6226 hospital admissions within the Johns Hopkins Health System over three years. Time-to-repeat was defined as the difference in time (minutes) between the index POCG and the next POCG sample. Multivariable logistic regression was used to evaluate the association of TTR with clinical, patient, and hospital factors. RESULTS The median (IQR) TTR was 49 (25-119) minutes, and 14.1% of index POCGs had a TTR ≤15. Severity of hypoglycemia, intensive care unit (ICU), intermediate care (IMC) and pediatrics admissions, and dextrose or glucagon administration were associated with higher adjusted odds of TTR ≤15 minutes. Admission to community hospitals, procedural units, surgery, and labor and delivery was associated with lower adjusted odds of TTR ≤15 minutes. Age, sex, insulin on board, secretagogue use, diabetes type, nutritional status, previous POCG value, and glycemic variability were not significantly associated. CONCLUSION There is low adherence to the recommendation to repeat a POCG within 15 minutes following the treatment of inpatient hypoglycemia, which may be mediated by both patient and hospital factors. Further studies are needed to understand the mediators and implications of this practice variability.
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Affiliation(s)
- Mohammed S. Abusamaan
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
| | - Nestoras Mathioudakis
- Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Nestoras Mathioudakis, MD, MHS, Division of Endocrinology, Diabetes, & Metabolism, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 333, Baltimore, MA 21287, USA.
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Moussavi K, Nguyen LT, Hua H, Fitter S. Comparison of IV Insulin Dosing Strategies for Hyperkalemia in the Emergency Department. Crit Care Explor 2020; 2:e0092. [PMID: 32426734 PMCID: PMC7188424 DOI: 10.1097/cce.0000000000000092] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The objectives of this study were to evaluate the safety and efficacy of insulin dosing of less than 10 units versus 10 units in patients receiving hyperkalemia treatment. DESIGN Retrospective single-center study. SETTING Emergency department at a large academic medical center in the United States. PATIENTS Seven hundred adults treated for hyperkalemia with IV regular insulin between April 1, 2013, and September 27, 2018. INTERVENTIONS Patients that received less than 10 units of insulin were compared to those that received 10 units of insulin. MEASUREMENTS AND MAIN RESULTS Patients treated with less than 10 units had significantly lower frequency of hypoglycemia (11.2% vs 17.6%; p = 0.008). Reduction in serum potassium was significantly more modest in size in patients treated with less than 10 units (mean reduction 0.94 ± 0.71 mMol/L) compared with patients treated with 10 units (mean reduction 1.11 ± 0.8 mMol/L; p = 0.008). There were no statistically significant differences between groups in time to hypoglycemia, nadir serum glucose, severe hypoglycemia (<40 mg/dL), dextrose requirements, use of concurrent agents for hyperkalemia, need for repeat insulin dosing, length of stay, or mortality. CONCLUSIONS Patients treated for hyperkalemia with insulin doses less than 10 units had reduced frequency of hypoglycemia; however, potassium reduction post treatment was more modest in these patients. These findings suggest providers choosing to administer 10 units IV insulin should ensure patients have adequate monitoring for hypoglycemia.
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Affiliation(s)
- Kayvan Moussavi
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, CA
| | - Lani T Nguyen
- Department of Pharmacy, Loma Linda University Medical Center, Loma Linda, CA
| | - Henry Hua
- Department of Pharmacy Practice, Marshall B. Ketchum University College of Pharmacy, Fullerton, CA
| | - Scott Fitter
- Emergency Department, Department of Pharmacy, Loma Linda University Medical Center, Loma Linda, CA
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, Loma Linda, CA
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Abstract
The prevalence of diabetes in the inpatient setting is increasing, and suboptimal glucose control in hospital is associated with increased morbidity and mortality. Attaining the recommended glucose levels is challenging with standard insulin therapy. Hypoglycaemia and hyperglycaemia are common and diabetes management in hospital can be a considerable workload burden for health-care professionals. Fully automated insulin delivery (closed-loop) has been shown to be safe, and achieves superior glucose control than standard insulin therapy in the hospital, including in those patients receiving haemodialysis and enteral or parenteral nutrition where glucose control can be particularly challenging. Evidence that the improved glucose control achieved using closed-loop systems can translate into improved clinical outcomes for patients is key to support widespread adoption of this technology. The closed-loop approach has the potential to provide a paradigm shift in the management of inpatient diabetes, particularly in the most challenging inpatient populations, and may reduce staff work burden and the health-care costs associated with inpatient diabetes.
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Affiliation(s)
- C K Boughton
- Clinical Research Fellow, University of Cambridge Metabolic Research Laboratories and NIHR Cambridge Biomedical Research Centre, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge CB2 0QQ
| | - R Hovorka
- Professor of Metabolic Technology, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge
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39
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Glucose point-of-care meter operators competency: An assessment checklist. Pract Lab Med 2020; 20:e00157. [PMID: 32215314 PMCID: PMC7090327 DOI: 10.1016/j.plabm.2020.e00157] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/11/2020] [Accepted: 02/24/2020] [Indexed: 11/23/2022] Open
Abstract
Background and objectives Glucose point-of-care testing meters are essential technology ubiquitous in hospitals. They are operated by non-specialized staff who are assessed through an auto-recertification process that is dependent on operators successfully producing expected outcomes. Alternatively, we suggest that operator practices be directly observed using a competency assessment checklist. Method We designed a checklist based on literature and manufacturers’ instructions and tested it by observing 30 operators at two sites (three hospitals) over two months in 2018. Results Despite all operators being auto-recertified, the checklist revealed that only 20% met the 80% threshold of compliance to standards. Moreover, the site with a POCT coordinator had a compliance rate of 82% versus 67% for the site that did not. Discussion The checklist is more reliable than auto-recertification in assessing operators’ competence. It also highlights areas for process improvement and provides an opportunity to give personalized feedback to operators. Develop and test the use of a standardized checklist for assessing operator’s competency with glucose point-of-care testing. All glucose meter operators observed were auto-recertified but only 20% of operators met the 80% compliance threshold. This approach helps identify individual training needs and areas for organizational process improvements. A dedicated POCT coordinator may foster operators’ competency by supporting communication.
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40
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Diabetes specialist nurse point‐of‐care review service: improving clinical outcomes for people with diabetes on emergency wards. PRACTICAL DIABETES 2020. [DOI: 10.1002/pdi.2263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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41
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Akiboye F, Adderley NJ, Martin J, Gokhale K, Rudge GM, Marshall TP, Rajendran R, Nirantharakumar K, Rayman G. Impact of the Diabetes Inpatient Care and Education (DICE) project on length of stay and mortality. Diabet Med 2020; 37:277-285. [PMID: 31265148 DOI: 10.1111/dme.14062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/01/2019] [Indexed: 01/09/2023]
Abstract
AIM To determine whether the Diabetes Inpatient Care and Education (DICE) programme, a whole-systems approach to managing inpatient diabetes, reduces length of stay, in-hospital mortality and readmissions. RESEARCH DESIGN AND METHODS Diabetes Inpatient Care and Education initiatives included identification of all diabetes admissions, a novel DICE care-pathway, an online system for prioritizing referrals, use of web-linked glucose meters, an enhanced diabetes team, and novel diabetes training for doctors. Patient administration system data were extracted for people admitted to Ipswich Hospital from January 2008 to June 2016. Logistic regression was used to compare binary outcomes (mortality, 30-day readmissions) 6 months before and after the intervention; generalized estimating equations were used to compare lengths of stay. Interrupted time series analysis was performed over the full 7.5-year period to account for secular trends. RESULTS Before-and-after analysis revealed a significant reduction in lengths of stay for people with and without diabetes: relative ratios 0.89 (95% CI 0.83, 0.97) and 0.93 (95% CI 0.90, 0.96), respectively; however, in interrupted time series analysis the change in long-term trend for length of stay following the intervention was significant only for people with diabetes (P=0.017 vs P=0.48). Odds ratios for mortality were 0.63 (0.48, 0.82) and 0.81 (0.70, 0.93) in people with and without diabetes, respectively; however, the change in trend was not significant in people with diabetes, while there was an apparent increase in those without diabetes. There was no significant change in 30-day readmissions, but interrupted time series analysis showed a rising trend in both groups. CONCLUSION The DICE programme was associated with a shorter length of stay in inpatients with diabetes beyond that observed in people without diabetes.
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Affiliation(s)
- F Akiboye
- Diabetes Research Unit, Ipswich Hospital NHS Trust, Ipswich, UK
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - N J Adderley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - J Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - K Gokhale
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - G M Rudge
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - T P Marshall
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - R Rajendran
- Diabetes Research Unit, Ipswich Hospital NHS Trust, Ipswich, UK
| | - K Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - G Rayman
- Diabetes Research Unit, Ipswich Hospital NHS Trust, Ipswich, UK
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Malabu UH, Adegboye O, Hayes OG, Ryan A, Vangaveti VN, Jhamb S, Robertson K, Sangla KS. Influence of Ethnicity on Outcomes of Diabetes Inpatient Hypoglycemia: an Australian Perspective. J Endocr Soc 2020; 4:bvaa009. [PMID: 32104749 PMCID: PMC7039405 DOI: 10.1210/jendso/bvaa009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 01/28/2020] [Indexed: 01/08/2023] Open
Abstract
Abstract
Aims
To evaluate outcomes of diabetic inpatient hypoglycemia among Aboriginal and Torres Strait Islander (ATSI) compared with Australian Caucasian patients.
Methods
A retrospective audit of diabetic patients aged > 18 years admitted at a regional hospital general ward between April 1, 2015, and March 31, 2016, was analyzed. The database contains clinical information at the time of admission and initial discharge and readmission within 4 weeks thereafter.
Results
A total of 1618 (of 6027) patients were admitted with diabetes representing 23.7% of the total ward admissions, of which 484 (29.9%) had inpatient hypoglycemia. Of the 91 patients with available data analyzed, ATSI origin with inpatient hypoglycemia was associated with longer length of stay (LOS) (hazard ratio [HR], 2.1, 95% confidence interval [CI], 1.2-3.5), whereas severe hypoglycemia (≤ 2.2 mmol/L) in both ATSI and non-ATSI was significantly associated with longer LOS (HR, 2.3; 95% CI, 1.2-4.2). No significant differences in LOS were found for gender, age, and Carlson comorbidity index (CCI). The adjusted model for likelihood of readmission, gender, indigenous status, and CCI were not significant risk factors for readmission to the hospital. Readmitted patients were older (50-59 years vs < 50 years, P = 0.001; 60-69 years vs < 50 years, P = 0.032; 70+ years vs < 50 years, P = 0.031).
Conclusion
We reported high rate of inpatient hypoglycemia in our study population. Indigenous Australian diabetic patients with inpatient hypoglycemia had significantly longer LOS compared with non-Indigenous Caucasian counterparts. Further prospective studies on a larger population are needed to confirm our findings.
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Affiliation(s)
- Usman H Malabu
- The Townsville Hospital, Douglas, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Australian Institute of Tropical Health and Medicine, James Cook University, Queensland, Australia
| | - Oyelola Adegboye
- Australian Institute of Tropical Health and Medicine, James Cook University, Queensland, Australia
| | | | | | - Venkat N Vangaveti
- College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
| | - Shaurya Jhamb
- College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
| | | | - Kunwarjit S Sangla
- The Townsville Hospital, Douglas, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
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Hu X, Xu W, Lin S, Zhang C, Ling C, Chen M. Development and Validation of a Hypoglycemia Risk Model for Intensive Insulin Therapy in Patients with Type 2 Diabetes. J Diabetes Res 2020; 2020:7292108. [PMID: 33015194 PMCID: PMC7525304 DOI: 10.1155/2020/7292108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 08/16/2020] [Accepted: 08/28/2020] [Indexed: 01/09/2023] Open
Abstract
AIMS To develop a simple hypoglycemic prediction model to evaluate the risk of hypoglycemia during hospitalization in patients with type 2 diabetes treated with intensive insulin therapy. METHODS We performed a cross-sectional chart review study utilizing the electronic database of the Third Affiliated Hospital of Sun Yat-sen University, and included 257 patients with type 2 diabetes undergoing intensive insulin therapy in the Department of Endocrinology and Metabolism. Logistic regression analysis was used to derive the clinical prediction rule with hypoglycemia (blood glucose ≤ 3.9 mmol/L) as the main result, and internal verification was performed. RESULTS In the derivation cohort, the incidence of hypoglycemia was 51%. The final model selected included three variables: fasting insulin, fasting blood glucose, and total treatment time. The area under the curve (AUC) of this model was 0.666 (95% CI: 0.594-0.738, P < 0.001). CONCLUSIONS The model's hypoglycemia prediction and the actual occurrence are in good agreement. The variable data was easy to obtain and the evaluation method was simple, which could provide a reference for the prevention and treatment of hypoglycemia and screen patients with a high risk of hypoglycemia.
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Affiliation(s)
- Xiling Hu
- Department of Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Weiran Xu
- School of Nursing, Sun Yat-sen University, Guangzhou 510085, China
| | - Shuo Lin
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Cang Zhang
- Department of Endocrinology and Metabolism, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Cong Ling
- Department of Neurosurgery, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Miaoxia Chen
- Nursing Department, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
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Lake A, Arthur A, Byrne C, Davenport K, Yamamoto JM, Murphy HR. The effect of hypoglycaemia during hospital admission on health-related outcomes for people with diabetes: a systematic review and meta-analysis. Diabet Med 2019; 36:1349-1359. [PMID: 31441089 PMCID: PMC7004204 DOI: 10.1111/dme.14115] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2019] [Indexed: 12/15/2022]
Abstract
AIM To assess the health-related outcomes of hypoglycaemia for people with diabetes admitted to hospital; specifically, hospital length of stay and mortality. METHODS We conducted a systematic review and meta-analysis of studies relating to hypoglycaemia (< 4 mmol/l) for hospitalized adults (≥ 16 years) with diabetes reporting the primary outcomes of interest, hospital length of stay or mortality. Final papers for inclusion were reviewed in duplicate and the adjusted results of each were pooled, using a random effects model then undergoing further prespecified subgroup analysis. RESULTS In total, 15 studies were included in the meta-analysis. The pooled mean difference in length of stay for ward-based inpatients exposed to hypoglycaemia was 4.1 days longer [95% confidence interval (CI) 2.36 to 5.79; I² = 99%] compared with those without hypoglycaemia. This association remained robust across the pre-specified subgroup analyses. The pooled relative risk (RR) of in-hospital mortality was greater for those exposed to hypoglycaemia (RR 2.09, 95% CI 1.64 to 2.67; I² = 94%, n = 7 studies) but not in intensive care unit mortality (RR 0.75, 95% CI 0.49 to 1.16; I² =0%, n = 2 studies). CONCLUSION There is an association between inpatient hypoglycaemia and longer length of stay and greater in-hospital mortality. Studies examining this association were heterogenous in terms of both clinical populations and effect size, but the overall direction of the association was consistent. Therefore, glucose concentration should be considered a potential tool to aid the identification of inpatients at risk of poor health-related outcomes.
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Affiliation(s)
- A. Lake
- Cambridge University Hospitals NHS Foundation TrustCambridgeUK
- University of East AngliaNorwich Research ParkNorwichUK
| | - A. Arthur
- University of East AngliaNorwich Research ParkNorwichUK
| | - C. Byrne
- Cambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - K. Davenport
- Cambridge University Hospitals NHS Foundation TrustCambridgeUK
| | - J. M. Yamamoto
- Departments of Medicine and Obstetrics and GynaecologyUniversity of CalgaryCalgaryAlbertaCanada
- Alberta Children's Hospital Research InstituteCalgaryAlbertaCanada
| | - H. R. Murphy
- Cambridge University Hospitals NHS Foundation TrustCambridgeUK
- University of East AngliaNorwich Research ParkNorwichUK
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Franco T, Aaronson B, Williams B, Blackmore C. Use of a real-time, algorithm-driven, publicly displayed, automated signal to improve insulin prescribing practices. Diabetes Res Clin Pract 2019; 157:107833. [PMID: 31476347 DOI: 10.1016/j.diabres.2019.107833] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 08/19/2019] [Accepted: 08/29/2019] [Indexed: 12/23/2022]
Abstract
AIM The clinical andon board (CAB) is a novel electronic surveillance and communication system, which alerts providers to and prompts treatment of dysglycemia. This investigation was designed to determine the CAB's effectiveness in supporting adherence to standardized evidence-based protocols, as well as improving glycemic control. METHODS This study was a retrospective pre/post analysis of insulin orders and blood glucose values. We used a Student's t-test for continuous variables and Chi2 for all other variables. This study included patients 18 years or older admitted to the hospital medical service as an inpatient with a length of stay greater than 24 h and less than 90 days. We used Pearson's correlation coefficient to evaluate the relationship between CAB and blood glucose. RESULTS The rate of compliance in prescribing basal insulin for patient with diabetes increased from 56% to 77% (p < 0.001). Similarly, compliance rates for prescribing correctional insulin in patients without diabetes increased from 15% to 37% (p < 0.001). Performance on the CAB was linearly related to blood glucose (p = 0.004), and there was a small statistically (not clinically) significant improvement in mean blood glucose values. CONCLUSION This approach is effective in alerting and engaging providers to prescribe insulin in a standardized manner with potential to improve glycemic control.
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Affiliation(s)
- Thérèse Franco
- Section of Hospital Medicine, Virginia Mason Medical Center, 925 Seneca, H8-25, Seattle, WA 98101, USA.
| | - Barry Aaronson
- Section of Hospital Medicine, Virginia Mason Medical Center, 925 Seneca, H8-25, Seattle, WA 98101, USA.
| | - Barbara Williams
- Center for Healthcare Improvement Science, Virginia Mason Medical Center, 1000 Seneca, Blackford Hall, Room 322-3, Seattle, WA 98101, USA.
| | - Craig Blackmore
- Center for Healthcare Improvement Science, Virginia Mason Medical Center, 1000 Seneca, Blackford Hall, Room 322-3, Seattle, WA 98101, USA.
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46
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Balmier A, Dib F, Serret-Larmande A, De Montmollin E, Pouyet V, Sztrymf B, Megarbane B, Thiagarajah A, Dreyfuss D, Ricard JD, Roux D. Initial management of diabetic ketoacidosis and prognosis according to diabetes type: a French multicentre observational retrospective study. Ann Intensive Care 2019; 9:91. [PMID: 31418117 PMCID: PMC6695456 DOI: 10.1186/s13613-019-0567-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 08/07/2019] [Indexed: 12/16/2022] Open
Abstract
Background Guidelines for the management of diabetic ketoacidosis (DKA) do not consider the type of underlying diabetes. We aimed to compare the occurrence of metabolic adverse events and the recovery time for DKA according to diabetes type. Methods Multicentre retrospective study conducted at five adult intermediate and intensive care units in Paris and its suburbs, France. All patients admitted for DKA between 2013 and 2014 were included. Patients were grouped and compared according to the underlying type of diabetes into three groups: type 1 diabetes, type 2 or secondary diabetes, and DKA as the first presentation of diabetes. Outcomes of interest were the rate of metabolic complications (hypoglycaemia or hypokalaemia) and the recovery time. Results Of 122 patients, 60 (49.2%) had type 1 diabetes, 28 (22.9%) had type 2 or secondary diabetes and 34 (27.9%) presented with DKA as the first presentation of diabetes (newly diagnosed diabetes). Despite having received lower insulin doses, hypoglycaemia was more frequent in patients with type 1 diabetes (76.9%) than in patients with type 2 or secondary diabetes (50.0%) and in patients with newly diagnosed diabetes (54.6%) (p = 0.026). In contrast, hypokalaemia was more frequent in the latter group (82.4%) than in patients with type 1 diabetes (57.6%) and type 2 or secondary diabetes (51.9%) (p = 0.022). The median recovery times were not significantly different between groups. Conclusions Rates of metabolic complications associated with DKA treatment differ significantly according to underlying type of diabetes. Decreasing insulin dose may limit those complications. DKA treatment recommendations should take into account the type of diabetes. Electronic supplementary material The online version of this article (10.1186/s13613-019-0567-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Adrien Balmier
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 rue des Renouillers, 92700, Colombes, France.,Department of Anesthesiology and Intensive Care, Bichat-Claude-Bernard Hospital, AP-HP, 75018, Paris, France
| | - Fadia Dib
- INSERM, CIC 1417, F-CRIN, I-REIVAC, Paris, France.,AP-HP, Hôpital Cochin, CIC Cochin Pasteur, Paris, France.,INSERM, Department of Social Epidemiology, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Sorbonne Université, 75012, Paris, France
| | - Arnaud Serret-Larmande
- Department of Epidemiology, Biostatistics and Clinical Research, Bichat-Claude-Bernard Hospital, Université de Paris, AP-HP, 75018, Paris, France
| | - Etienne De Montmollin
- Intensive Care Unit, Centre Hospitalier de Saint-Denis, Hopital Delafontaine, 93205, Saint Denis, France.,INSERM, IAME, UMR 1137, Université de Paris, 75018, Paris, France
| | - Victorine Pouyet
- Intensive Care Unit, Hôpital René-Dubos, 95300, Pontoise, France
| | - Benjamin Sztrymf
- Service de Réanimation polyvalente et surveillance continue, Université Paris Sud, Hôpital Antoine Béclère, AP-HP, 92400, Clamart, France.,INSERM U999, 92060, Le Plessis Robinson, France
| | - Bruno Megarbane
- Department of Medical and Toxicological Critical Care, Lariboisière Hospital, AP-HP, Université de Paris, 75010, Paris, France.,INSERM, UMRS-1144, Université de Paris, Paris, France
| | - Abirami Thiagarajah
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 rue des Renouillers, 92700, Colombes, France.,Intensive Care Unit, Hôpital René-Dubos, 95300, Pontoise, France
| | - Didier Dreyfuss
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 rue des Renouillers, 92700, Colombes, France.,INSERM, IAME, UMR 1137, Université de Paris, 75018, Paris, France
| | - Jean-Damien Ricard
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 rue des Renouillers, 92700, Colombes, France.,INSERM, IAME, UMR 1137, Université de Paris, 75018, Paris, France
| | - Damien Roux
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 rue des Renouillers, 92700, Colombes, France. .,INSERM, IAME, UMR 1137, Université de Paris, 75018, Paris, France.
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47
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Pasquel FJ, Fayfman M, Umpierrez GE. Debate on Insulin vs Non-insulin Use in the Hospital Setting-Is It Time to Revise the Guidelines for the Management of Inpatient Diabetes? Curr Diab Rep 2019; 19:65. [PMID: 31353426 DOI: 10.1007/s11892-019-1184-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Hyperglycemia contributes to a significant increase in morbidity, mortality, and healthcare costs in the hospital. Professional associations recommend insulin as the mainstay of diabetes therapy in the inpatient setting. The standard of care basal-bolus insulin regimen is a labor-intensive approach associated with a significant risk of iatrogenic hypoglycemia. This review summarizes recent evidence from observational studies and clinical trials suggesting that not all patients require treatment with complex insulin regimens. RECENT FINDINGS Evidence from clinical trials shows that incretin-based agents are effective in appropriately selected hospitalized patients and may be a safe alternative to complicated insulin regimens. Observational studies also show that older agents (i.e., metformin and sulfonylureas) are commonly used in the hospital, but there are few carefully designed studies addressing their efficacy. Therapy with dipeptidyl peptidase-4 (DPP-4) inhibitors, alone or in combination with basal insulin, may effectively control glucose levels in patients with mild to moderate hyperglycemia. Further studies with glucagon-like peptide-1 (GLP-1) receptor analogs and older oral agents are needed to confirm their safety in the hospital.
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Affiliation(s)
- Francisco J Pasquel
- Department of Medicine/Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA
| | - Maya Fayfman
- Department of Medicine/Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA
| | - Guillermo E Umpierrez
- Department of Medicine/Endocrinology, Emory University School of Medicine, 69 Jesse Hill Jr Dr, Atlanta, GA, 30303, USA.
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48
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Shah BR, Walji S, Kiss A, James JE, Lowe JM. Derivation and Validation of a Risk-Prediction Tool for Hypoglycemia in Hospitalized Adults With Diabetes: The Hypoglycemia During Hospitalization (HyDHo) Score. Can J Diabetes 2019; 43:278-282.e1. [DOI: 10.1016/j.jcjd.2018.08.061] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 08/01/2018] [Accepted: 08/02/2018] [Indexed: 12/21/2022]
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Boughton CK, Bally L, Martignoni F, Hartnell S, Herzig D, Vogt A, Wertli MM, Wilinska ME, Evans ML, Coll AP, Stettler C, Hovorka R. Fully closed-loop insulin delivery in inpatients receiving nutritional support: a two-centre, open-label, randomised controlled trial. Lancet Diabetes Endocrinol 2019; 7:368-377. [PMID: 30935872 PMCID: PMC6467839 DOI: 10.1016/s2213-8587(19)30061-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/07/2019] [Accepted: 02/12/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Glucose management is challenging in patients who require nutritional support in hospital. We aimed to assess whether fully closed-loop insulin delivery would improve glycaemic control compared with conventional subcutaneous insulin therapy in inpatients receiving enteral or parenteral nutrition or both. METHODS We did a two-centre (UK and Switzerland), open-label, randomised controlled trial in adult inpatients receiving enteral or parenteral nutrition (or both) who required subcutaneous insulin therapy. Patients recruited from non-critical care surgical and medical wards were randomly assigned (1:1) using a computer-generated minimisation schedule (stratified by type of nutritional support [parenteral nutrition on or off] and pre-study total daily insulin dose [<50 or ≥50 units]) to receive fully closed-loop insulin delivery with faster-acting insulin aspart (closed-loop group) or conventional subcutaneous insulin therapy (control group) given in accordance with local clinical practice. Continuous glucose monitoring in the control group was masked to patients, ward staff, and investigators. Patients were followed up for a maximum of 15 days or until hospital discharge. The primary endpoint was the proportion of time that sensor glucose concentration was in target range (5·6-10·0 mmol/L), assessed in the intention-to-treat population. This trial is registered with ClinicalTrials.gov, number NCT01774565. FINDINGS Between Feb 8, 2018, and Sept 21, 2018, 90 patients were assessed for eligibility, of whom 43 were enrolled and randomly assigned to the closed-loop group (n=21) or the control group (n=22). The proportion of time that sensor glucose was in the target range was 68·4% [SD 15·5] in the closed-loop group and 36·4% [26·6] in the control group (difference 32·0 percentage points [95% CI 18·5-45·5; p<0·0001]). One serious adverse event occurred in each group (one cardiac arrest in the control group and one episode of acute respiratory failure in the closed-loop group), both of which were unrelated to study interventions. There were no adverse events related to study interventions in either group. No episodes of severe hypoglycaemia or hyperglycaemia with ketonaemia occurred in either study group. INTERPRETATION Closed-loop insulin delivery is an effective treatment option to improve glycaemic control in patients receiving nutritional support in hospital. FUNDING Diabetes UK, Swiss National Science Foundation, National Institute for Health Research Cambridge Biomedical Research Centre, Wellcome Trust, and European Foundation for the Study of Diabetes.
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Affiliation(s)
- Charlotte K Boughton
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust Cambridge, Cambridge, UK
| | - Lia Bally
- Department of Diabetes, Endocrinology, Clinical Nutrition and Metabolism, Bern University Hospital, Bern, Switzerland
| | - Franco Martignoni
- Department of Diabetes, Endocrinology, Clinical Nutrition and Metabolism, Bern University Hospital, Bern, Switzerland
| | - Sara Hartnell
- Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust Cambridge, Cambridge, UK
| | - David Herzig
- Department of Diabetes, Endocrinology, Clinical Nutrition and Metabolism, Bern University Hospital, Bern, Switzerland
| | - Andreas Vogt
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Maria M Wertli
- Department of General Internal Medicine, Bern University Hospital, Bern, Switzerland
| | - Malgorzata E Wilinska
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Mark L Evans
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust Cambridge, Cambridge, UK
| | - Anthony P Coll
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust Cambridge, Cambridge, UK
| | - Christoph Stettler
- Department of Diabetes, Endocrinology, Clinical Nutrition and Metabolism, Bern University Hospital, Bern, Switzerland
| | - Roman Hovorka
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
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50
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Lim W, Goh SY, Bee YM, Chan TCE, Tan XHA, Wee Z, Xin X, Ang LC, Heng WM, Teh MM. High one-year mortality following hospitalization for severe hypoglycemia among patients with diabetes mellitus: findings of a retrospective cohort study at an acute tertiary care hospital in Singapore. Curr Med Res Opin 2019; 35:631-635. [PMID: 30244608 DOI: 10.1080/03007995.2018.1528213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Little is known about the 1-year short-term mortality rate following hospital admissions with severe hypoglycemia. This study aimed to determine the factors associated with increased 1-year mortality rate following hospitalization in diabetes patients admitted with severe hypoglycemia to the Singapore General Hospital. METHODS Clinical, biochemical, and 1-year mortality data from diabetes patients who were admitted with severe hypoglycemia in the year 2014 were extracted from institutional medical records. Patients who passed away during the episode of admissions with severe hypoglycemia were excluded from the analysis. The clinical and biochemical factors between patients who survived and those who did not survive within 1 year following admission were compared using logistic regression analysis. RESULTS Three hundred and four patients (181 female and 123 male) were admitted with severe hypoglycemia in 2014, and the mean capillary blood glucose on admission was 2.3 ± 0.7 mmol/L. Sixty-three (20.7%) patients died within 1-year post-discharge from the hospital. Compared with patients who survived 1-year post-discharge from the hospital, non-survivors were older (69.3 ± 11.0 vs 75.5 ± 11.2 years, p < .001), had longer lengths of stay (LOS) (5.0 ± 7.4 vs 9.0 ± 12.8 days, p = .02), and had a higher Charlson Comorbidity Index (CCI) (4.1 ± 1.9 vs 5.9 ± 2.4, p < .001). Factors associated with increased 1-year mortality risk were age (odds ratio [OR] = 1.06; 95% confidence interval [CI] = 1.03-1.09, p < .01), LOS in hospital (OR = 1.01; 95% CI = 1.01-1.08, p < .01), and CCI (OR = 1.51; 95% CI = 1.31-1.75, p < .01), respectively. CONCLUSIONS Older diabetes patients with more comorbidities and longer LOS were at increased risk of dying within a year of discharge after hospitalization with severe hypoglycemia. Admission with severe hypoglycemia has important prognostic implications. Healthcare professionals should address hypoglycemia and other health issues during the hospital admissions.
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Affiliation(s)
- Weiying Lim
- a Department of Endocrinology , Singapore General Hospital , Singapore
| | - Su-Yen Goh
- a Department of Endocrinology , Singapore General Hospital , Singapore
| | - Yong Mong Bee
- a Department of Endocrinology , Singapore General Hospital , Singapore
| | | | | | - Zongwen Wee
- a Department of Endocrinology , Singapore General Hospital , Singapore
| | - Xiaohui Xin
- a Department of Endocrinology , Singapore General Hospital , Singapore
| | - Li Chang Ang
- a Department of Endocrinology , Singapore General Hospital , Singapore
| | - Wee May Heng
- a Department of Endocrinology , Singapore General Hospital , Singapore
| | - Ming Ming Teh
- a Department of Endocrinology , Singapore General Hospital , Singapore
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