Lower Incidence of Hypoglycemia With Angiotensin Receptor Blocker Versus ACE Inhibitor Therapy in People With or Without Diabetes

This article describes a study examining the association between treatment with ACE inhibitors or angiotensin receptor blockers (ARBs) and incident hypoglycemia in patients with or without diabetes who were admitted to the internal medicine departments of a tertiary hospital in the Tel Aviv district of Israel. The authors found that treatment with ARBs, but not ACE inhibitors, compared with treatment with neither, was associated with a reduced risk of hypoglycemia regardless of diabetes status.

The Effect of Percutaneous Endoscopic Gastrostomy on Prognosis of Patients at Risk of Malnutrition

BACKGROUND

Despite its wide use, evidence is inconclusive regarding the effect of percutaneous endoscopic gastrostomy (PEG) in patients with chronic diseases and dementia among hospitalized patients with malnutrition.

OBJECTIVES

To examine the effect of PEG insertion on prognosis after the procedure.

METHODS

This retrospective analysis of medical records included all adult patients who underwent PEG insertion between 1 January 2009 and 31 December 2013 during their hospitalization. For each PEG patient, two controls similar in age, sex, referring department, and underlying condition were randomly selected from the entire dataset of patients admitted. The effect of PEG on mortality and repeated admissions was examined.

RESULTS

The study comprised 154 patients, 49 referred for PEG insertion and 105 controls (mean age 74.8 ± 19.8 years; 72.7% females; 78.6% admitted to internal medicine units). Compared to controls, the PEG group had a higher 2-year mortality rate (59.2% vs. 17.1%, P < 0.001) but the 2-year readmission rate did not differ significantly (44.9% vs. 56.2% respectively, P = 0.191). Regression analysis showed PEG was associated with increased risk of the composite endpoint of death or readmission (hazard ratio 1.514, 95% confidence interval 1.016-2.255, P = 0.041). No specific characteristic of admission was associated with increased likelihood of death or readmission. Among readmitted patients, reasons for admission and baseline laboratory data, including albumin and cholesterol, did not differ between the PEG patients and controls.

CONCLUSIONS

In-hospital PEG insertion was associated with increased mortality at 2 years but had no effect on readmissions.

Tinea capitis caused by Trichophyton tonsurans among adults: Clinical characteristics and treatment response

BACKGROUND

Trichophyton tonsurans tinea capitis has become a growing epidemiological concern. Yet, its clinical manifestations and treatment response, specifically among adults, have only been described among small sample size studies.

OBJECTIVE

To assess clinical manifestations and treatment outcome of T. tonsurans tinea capitis among adults.

PATIENTS AND METHODS

A retrospective cohort study was carried out among 111 adults with T. tonsurans tinea capitis. Diagnosis was confirmed by fungal culture or polymerase chain reaction. Examinees' demographics, disease characteristics and treatment response were measured. The risk factors for the treatment failure were evaluated.

RESULTS

The mean age was 20.1 years (±3.1), with men (98.2%) outnumbering women. The follow-up lasted 12.2 months (±5.6). The majority of T. tonsurans tinea capitis was seen in the occipital area (87.6%). In 78.9% of the cases, the scalp manifestation was non-inflammatory (scaly plaques and papules:76.1% and seborrhoea-like: 2.8%). 21.1% of cases presented with inflammatory tinea capitis (21.1%; Kerion: 10.1% and pustular: 11%). Concomitant involvement of other than scalp areas was common: tinea corporis was seen in 38.7% of the cases; tinea faciei and barbae in 24.3%; nape and anterior neck in 76.6% and 2.7% of the cases, respectively. An adequate treatment course with oral terbinafine resulted in 83.2% clinical cure rate. Treatment failure was significantly associated with concomitant tinea corporis (odds ratio 3.9; 95% confidence interval 1.3-12.1, p-Value< .02).

CONCLUSION

The most common clinical presentation of T. tonsurans tinea capitis included occipital scaly plaques and papules with concomitant non-scalp lesions. Oral terbinafine was found to be highly effective. Concomitant tinea corporis increased the risk for treatment failure.

Changes in Serum Creatinine May Cause Hypoglycemia among Non-Critically Ill Patients Admitted to Internal Medicine Units

Background: The association between changes in serum creatinine levels and hypoglycemia during hospitalization was investigated. Methods: This was a retrospective analysis of medical charts. Patients were categorized as having significant change in creatinine (SCIC) when serum creatinine levels rose or dropped ≥ 0.3 mg/dL from admission values at any time during their hospitalization. Patients were considered hypoglycemic if they had at least one documented glucose level ≤ 70 mg/dL during the hospitalization. Multiple logistic, linear and Cox regression analyses were used to ascertain the association between incident SCIC, severity and timing with incident hypoglycemia. Results: Included were 25,400 (mean age 69.9 ± 18.0, 49.3% were males). The rate of SCIC was 22.2%, and 62.2% of them were diagnosed upon admission. Patients with SCIC had a higher incidence of hypoglycemia compared to patients without (13.1% vs. 4.1%, respectively, p < 0.001). Patients with SCIC had an increased risk of hypoglycemia (OR 1.853, 95% CI 1.586−2.166, p < 0.001). The magnitude of SCIC was associated with the incidence (OR 1.316, 95% CI 1.197−1.447, p < 0.001) and the number of events (HR 0.054, 95% CI 0.021−0.087, p = 0.001). More than 60% of patients with hypoglycemia had their first event documented during days 0−6 after SCIC occurrence. Of those, the majority of events occurred on day 0−1, and the rate showed a gradual decrease throughout the first 5 days from SCIC occurrence. The results were similar for patients with and without DM. Conclusions: Changes in creatinine during hospitalization may cause hypoglycemia among patients admitted to internal medicine departments, regardless of DM status.

Association between estimated GFR and incident hypoglycaemia during hospitalization

BACKGROUND

Kidney function is a significant factor associated with increased incidence of hypoglycaemia, especially among patients with diabetes mellitus (DM). We here quantified the association between elevated creatinine and incident hypoglycaemia among patients admitted to internal medicine departments, with and without DM.

METHODS

This is a retrospective cohort analysis study. Included were all patients discharged from internal medicine units between 2010 and 2013. Patients were excluded if creatinine levels rose or dropped more than 0.3 mg/dL during hospitalization. The CKD-EPI equation was used to calculate glomerular filtration rate (eGFR). Logistic regression analysis (backward LR method) was used to study the association between eGFR and hypoglycaemia incidence.

RESULTS

Included were 39 316 patients (mean age 68.0 ± 18.0 years, 49.3% males, 25.9% with DM, eGFR 69.5 ± 24.9 mL/min/1.73 m² ). Among study participants, 6.5% had at least one hypoglycaemic event. Logistic regression modelling showed that eGFR was inversely associated with incident hypoglycaemia (OR 0.988, 95% CI 0.986-0.990, p < .001). Results were similar for patients with and without DM. Estimated GFR was negatively correlated with admission CRP levels for patients with (r = -.143, p < .001) and without DM (r = -.166, p < .001). Estimated GFR was also positively correlated with admission serum albumin levels for both patients with (r = .304, p < .001) and without DM (r = .354, p < .001).

CONCLUSION

Among non-critically-ill patients hospitalized in internal medicine departments, reduced eGFR is associated with increased risk of hypoglycaemia. Glucose monitoring for all inpatients with CKD is suggested, regardless of DM status.

Sex difference in the association between malnutrition and hypoglycemia in hospitalized patients

BACKGROUND

The aim of this paper was to examine the difference between males and females regarding association between malnutrition risk and hypoglycemia through a sub-analysis of a cross-sectional study of newly admitted patients to internal medicine departments.

METHODS

Malnutrition risk, assessed with Nutritional Risk Screening 2002 (NRS2002), and serum albumin were measured upon admission. Logistic regression was applied to men and women separately, to test the effect of malnutrition and hypoalbuminemia on incidence of hypoglycemia.

RESULTS

Included were 1186 patients (50.4% males, 39.2% with positive NRS2002). Rate of positive NRS2002 was similar across sexes (36.5% vs. 41.2% in males and females respectively, P=0.204). Among females, NRS2002 was associated with higher incidence of hypoglycemia (9.5% vs. 2.4% in NRS2002 negative females, P<0.001). Among males, no such difference was noted (9.2% compared to 7.1% in NRS2002 positive and negative males respectively, P=0.520). The weight loss/decreased food intake criterion of the NRS2002 was significantly higher in the hypoglycemic group within females (P=0.03). Logistic regression showed that serum albumin was inversely associated with hypoglycemia in both females (OR 0.477, 95% CI 0.282-0.806, P=0.006) and males (OR 0.532, 95% CI 0.355-0.795, P=0.002). However, increased malnutrition risk was associated with hypoglycemia only among females (OR 2.007, 95% CI 1.058-3.809, P=0.033). Diabetes status was associated with hypoglycemia (OR 1.907, 95% CI 1.056-3.445, P=0.032) only in males; this association did not occur in females.

CONCLUSIONS

Malnutrition risk, as measured by the NRS2002, is associated with significantly increased incidence of hypoglycemia in women alone. Females who lose weight prior to hospitalization have an increased risk to develop hypoglycemia.

Sex difference in the association between malnutrition and hypoglycemia in hospitalized patients

BACKGROUND

The aim of this paper was to examine the difference between males and females regarding association between malnutrition risk and hypoglycemia through a sub-analysis of a cross-sectional study of newly admitted patients to internal medicine departments.

METHODS

Malnutrition risk, assessed with Nutritional Risk Screening 2002 (NRS2002), and serum albumin were measured upon admission. Logistic regression was applied to men and women separately, to test the effect of malnutrition and hypoalbuminemia on incidence of hypoglycemia.

RESULTS

Included were 1186 patients (50.4% males, 39.2% with positive NRS2002). Rate of positive NRS2002 was similar across sexes (36.5% vs. 41.2% in males and females respectively, P=0.204). Among females, NRS2002 was associated with higher incidence of hypoglycemia (9.5% vs. 2.4% in NRS2002 negative females, P<0.001). Among males, no such difference was noted (9.2% compared to 7.1% in NRS2002 positive and negative males respectively, P=0.520). The weight loss/decreased food intake criterion of the NRS2002 was significantly higher in the hypoglycemic group within females (P=0.03). Logistic regression showed that serum albumin was inversely associated with hypoglycemia in both females (OR 0.477, 95% CI 0.282-0.806, P=0.006) and males (OR 0.532, 95% CI 0.355-0.795, P=0.002). However, increased malnutrition risk was associated with hypoglycemia only among females (OR 2.007, 95% CI 1.058-3.809, P=0.033). Diabetes status was associated with hypoglycemia (OR 1.907, 95% CI 1.056-3.445, P=0.032) only in males; this association did not occur in females.

CONCLUSIONS

Malnutrition risk, as measured by the NRS2002, is associated with significantly increased incidence of hypoglycemia in women alone. Females who lose weight prior to hospitalization have an increased risk to develop hypoglycemia.

Prediction of Hypoglycemia During Admission of Non-Critically Ill Patients: Results from the MENU Study

The objective of the work was to study admission parameters associated with an increased incidence of hypoglycemia during hospitalization of non-critically ill patients. Included in this cross-sectional study were patients admitted to internal medicine units. The Nutritional Risk Screening 2002 (NRS2002) was used for nutritional screening. Data recorded included admission serum albumin (ASA) and all glucose measurements obtained by the institutional blood glucose monitoring system. Neither of these are included in the NRS2002 metrics. Hypoalbuminemia was defined as ASA<3.5 g/dl. Patients were categorized as hypoglycemic if they had at least one documented glucose≤70 mg/dl during the hospitalization period. Included were 1342 patients [median age 75 years (IQR 61-84), 51.3% male, 52.5% with diabetes mellitus, (DM)], who were screened during three distinct periods of time from 2011-2018. The incidence of hypoglycemia was 10.8% with higher rates among DM patients (14.6 vs. 6.6%, p<0.001). Hypoglycemia incidence was negatively associated with ASA regardless of DM status. Multivariable regression showed that ASA (OR 0.550 per g/dl, 95% CI 0.387-0.781, p=0.001) and positive NRS2002 (OR 1.625, 95% CI 1.072-2.465, p=0.022) were significantly associated with hypoglycemia. The addition of hypoalbuminemia status to the NRS2002 tool improved the overall sensitivity from 0.55 to 0.71, but reduced specificity from 0.63 to 0.46. The negative predictive value was 0.93. Our data suggest that the combination of positive malnutrition screen and hypoalbuminemia upon admission are independently associated with the incidence of hypoglycemia among non-critically ill patients, regardless of diabetes mellitus status.

Systemic Treatment With Glucocorticoids Is Associated With Incident Hypoglycemia and Mortality: A Historical Prospective Analysis

PURPOSE

The purpose of this study was to examine whether the increased glycemic variability associated with systemic glucocorticoid treatment is also associated with increased incidence of hypoglycemia.

METHODS

All patients discharged from internal medicine units between 2010 and 2013 were included in this retrospective analysis. Patients were assigned to 3 groups: Group 1: no steroids were prescribed;. Group 2: topical or inhaled steroids were prescribed with no systemic treatment; and Group 3: systemic steroids were prescribed, with or without topical or inhaled treatment.

RESULTS

A total of 45,272 patients were included in the study. Patients in Group 3 had significantly higher rates of hypoglycemia (10.9%) compared to patients in Group 2 (7.4%), and patients in Group 1 (7.3%). Patients with diabetes mellitus had higher rates of hypoglycemia compared to patients without diabetes mellitus (14.3% vs 4.9%) but exhibited similar trends in response to steroid treatment. Multivariate analysis showed that systemic steroids were associated with increased risk for hypoglycemia (odds ratio [OR] 1.513, 95% confidence interval [CI] 1.311-1.746, P <0.001). Hypoglycemia associated with systemic steroid treatment was also associated with increased risk of death (hazard ratio [HR] 2.328, 95% CI 1.931-2.807, P <0.001). Patients who were treated with systemic steroids but did not have hypoglycemia did not have higher mortality rates (HR 1.068, 95% CI 0.972-1.175, P = 0.171).

CONCLUSION

Treatment with systemic steroids is associated with increased hypoglycemia incidence during hospitalization. Patients treated with steroids that had incident hypoglycemia had a higher 1-year mortality risk compared to patients without hypoglycemia treated with steroids.

Transient Pruritic Erythema as a Forme Fruste of Solar Urticaria

BACKGROUND

Solar urticaria (SU) is a rare and disabling photodermatosis. SU typically manifests as urticarial wheals and erythema appearing shortly after sun exposure. SU is often initially diagnosed clinically with subsequent confirmation through photoprovocation tests. Early diagnosis is important for correct management of patients.

OBJECTIVES

To present the clinical features of three cases of atypical presentation of SU and to discuss possible underlying mechanisms.

METHODS

We report a series of three patients who presented with transient pruritic erythema without wheals after sun exposure. All patients had photoprovocation tests conducted to confirm SU diagnosis and to determine their action spectra. Treatment outcomes were recorded.

RESULTS

All three patients developed classical manifestations of SU during photoprovocation tests within the UVA1 spectrum. Two patients required high-dose irradiation to provoke urticaria.

CONCLUSIONS

Erythema without urticaria can be the primary manifestation of SU, especially in countries with sunny climates where natural skin hardening is common. Such cases require a high index of suspicion for SU and highlight the importance of photoprovocation testing to confirm the diagnosis.

Hypoglycemia, Malnutrition and Body Composition

Hypoglycemia is one of the most significant factors to affect prognosis, and is detrimental to patients regardless of diabetes mellitus (DM) status. The classical paradigms dictate that hypoglycemia is a result of overtreatment with glucose lowering agents (iatrogenic hypoglycemia), or, as among patients without DM, this condition is attributed to disease severity. New information shows that hypoglycemia occurs among patients that have a tendency for it. Incident hypoglycemia is very prevalent in the hospital setting, occurring in 1:6 patients with DM and in 1:17 patients without DM (Leibovitz E, Khanimov I, Wainstein J, Boaz M; Diabetes Metab Syndr Clin Res Rev. 13:222-226, 2019).One of the major factors associated with incidence of hypoglycemia is the nutritional status on hospital admission and during the hospitalization. Assessment of nutritional status using questionnaires and biomarkers might be helpful in determining risk of hypoglycemia. Moreover, administration of oral nutritional supplements was shown to decrease this risk.It is also well known that a high burden of comorbidities is associated with an increased risk of hypoglycemia. For example, kidney disease, whether acute or chronic, was shown to increase the risk for hypoglycemia, as well as some endocrine disorders.In this review we elaborate on specific findings that are characteristic of patients at risk for developing hypoglycemia, as well as treatment aimed at preventing its occurrence.

High-Intensity Statins Are Associated With Increased Incidence of Hypoglycemia During Hospitalization of Individuals Not Critically Ill

BACKGROUND

Serum cholesterol is inversely associated with incident hypoglycemia among patients admitted to internal medicine wards. We examined the association between statin use and incidence of hypoglycemia among patients who were not critically ill.

METHODS

In this retrospective study, we included all patients discharged between January 1, 2010, to December 31, 2013 from internal medicine units at the Wolfson Medical Center. Excluded were patients with hepatocellular or cholestatic liver disease upon admission. Patients were allocated to 4 groups, according to diabetes mellitus status (yes or no) and serum albumin <3.5 g/dL (yes or no) on admission. Regression analysis was used to examine the association of incident hypoglycemia during hospitalization and statin treatment (yes or no), and later, statin intensity.

RESULTS

Included in this analysis were 31,094 patients (mean age 68.9±17.5 years, 48.4% males, 21.7% with diabetes mellitus). Logistic regression models showed that among patients with low admission serum albumin, administration of high-intensity statins was associated with increased incidence of hypoglycemic events compared to patients not treated with statins (odds ratio [OR] 1.303, 95% confidence interval [CI] 1.016-1.671, P = 0.037), whereas treatment with low-intensity statins was associated with less hypoglycemic events (odds ratio 0.590, 95% confidence interval 0.396-0.879, P = 0.010). Among patients with normal serum albumin, no association was found between incident hypoglycemia and statin intensity. These findings were significant regardless of diabetes mellitus status.

CONCLUSION

Statin treatment in general is associated with reduced incidence of hypoglycemia. However, among patients with low serum albumin upon admission, use of high-intensity statins is associated with an increased risk of hypoglycemic events regardless of diabetes mellitus status.

Documented hypoglycemia is associated with poor short and long term prognosis among patients admitted to general internal medicine departments

AIM

To study the association of documented hypoglycemia with length of stay, 30-day mortality, and 1-year mortality, among patients with and without diabetes admitted to internal medicine units.

METHODS

The electronic medical records of all patients hospitalized in internal medicine departments at E. Wolfson Medical Center, Holon, Israel, between 1/1/2010 and 31/12/2013, were reviewed. Data extracted included all glucose measurements (performed using an institutional blood glucose monitoring system). Patients were considered hypoglycemic if at least one hypoglycemic event was recorded. Regression analysis was used to assess the association between documented hypoglycemia and length of stay, 30-day and one-year mortality. Age, sex, reason for admission, and the Charlson comorbidity index were entered as covariates, and the most conservative model was developed.

RESULTS

The study population included 45,272 patients (mean age 68.9 ± 17.8 years, 49.4% males, 21.0% had diabetes mellitus). The rate of hypoglycemia in the total study population was 7.5% (16.8% among DM patients, 6.0% among patients without diabetes, p < 0.001). Patients with documented hypoglycemia had a longer length of hospital stay (9.3 ± 18.7 vs. 3.1 ± 6.4 days, p < 0.001), as well as higher risk for both 30-day (23.7% vs. 7.0%, p < 0.001) and 1-year mortality (41.6% vs. 15.3%, p < 0.001). Cox regression analysis showed that hypoglycemia significantly increased risk death at one year (HR 2.436, 95% CI 2.298-2.582, p < 0.001) independent of age, sex, the Charlson comorbidity index, DM status and reason for admission.

CONCLUSION

Documented hypoglycemia is associated with prolonged length of hospital stay and increased risk for both 30-day and 1-year mortality, regardless of diabetes mellitus status.