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Original article
Analysis of the characteristics of patients with diabetes mellitus who attend a tertiary hospital emergency department for a hypoglycemic event
Análisis de las características de los pacientes con diabetes mellitus que consultan por hipoglucemia en el servicio de urgencias de un hospital terciario
Jordi Caballero-Corchueloa,b,
Corresponding author
, Fernando Guerrero-Péreza, Paula García-Sancho de la Jordanaa, Manuel Pérez-Maravera,b
a Servicio de Endocrinología y Nutrición, Hospital Universitari de Bellvitge-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
b CIBERDEM-CIBER de Diabetes y Enfermedades Metabólicas Asociadas, Instituto de Salud Carlos III, Madrid, Spain
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Hypoglycemia causes symptoms due to the activation of the autonomic nervous system &#40;tremor&#44; palpitations&#44; diaphoresis&#41; and manifestations derived from glucose deficiency in the central nervous system &#40;confusion&#44; behavioral changes&#44; diminished consciousness&#44; coma&#41;&#46; Severe hypoglycemia is defined as an episode of hypoglycemia in which the patient needs assistance for its treatment&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The immediate and subsequent consequences of hypoglycemia are multiple&#58; it affects patient quality of life&#44; work activity and common daily activities such as driving&#44; and in severe cases can lead to additional morbidity&#8211;mortality with neurological symptoms&#46; Hypoglycemia may cause patients to reduce their adherence to treatment with the purpose of reducing the risk of such episodes&#44; with the consequent worsening of metabolic control&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">4</span></a> Various studies have shown an association between severe hypoglycemia and cardiovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">5</span></a> There are several mechanisms by which hypoglycemia may promote adverse cardiovascular events&#46; Hypoglycemia can exert a proarrhythmic effect due to ST-segment and T-wave modifications&#44; QT prolongation or ectopic beats&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">6</span></a> Activation of the sympathetic nervous system by hypoglycemia causes an increase in heart rate and myocardial contractility&#44; and changes in vascular elasticity that can lead to cardiac overload&#44; particularly in patients with previous cardiovascular disease&#46; Catecholamines and other peptides released during hypoglycemia cause platelet activation and aggregation and endothelial dysfunction that in turn may favor atherosclerosis&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">7</span></a> Hypoglycemic episodes also result in increased direct and indirect economic costs associated with DM&#44; especially if hospital admission proves necessary&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Few studies in our setting have evaluated the characteristics of patients with hypoglycemia leading to emergency room visits&#44; and none have been carried out in recent years&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">9</span></a> This is particularly relevant in the current scenario&#44; characterized by the appearance of new drug classes and insulin analogs offering an improved safety profile in terms of hypoglycemia risk&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The objective of the present study was to analyze the characteristics&#44; treatment and course of patients with DM seen due to hypoglycemia in the Emergency Department of our hospital&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">A retrospective observational study was conducted at Hospital Universitari de Bellvitge &#40;Barcelona&#44; Spain&#41;&#46; We included patients seen in the emergency room of our center during 2012&#8211;2014 with a diagnosis of hypoglycemia&#46; Patients not diagnosed with DM were excluded&#44; as well as cases in which a capillary or plasma glucose level of &#60;70<span class="elsevierStyleHsp" style=""></span>mg&#47;dl was not confirmed&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We analyzed patient age&#44; the type of DM&#44; the time from the onset of the disease&#44; the degree of glycemic control&#44; the presence of vascular and renal complications&#44; as well as other relevant comorbidities &#40;including cognitive impairment and alcohol abuse&#41;&#44; recent hospitalization episodes&#44; background glucose-lowering therapy&#44; the treatment used to resolve the episode&#44; and the care outcome&#46; The data referring to each episode were compiled from the electronic emergency care reports&#46; Information regarding the disease history was obtained from the electronic primary care history &#40;<span class="elsevierStyleItalic">Estaci&#243; Cl&#237;nica d&#8217;Atenci&#243; Prim&#224;ria</span> &#91;ECAP&#93;&#41;&#46; The degree of glycemic control was assessed based on the glycosylated hemoglobin &#40;HbA<span class="elsevierStyleInf">1c</span>&#41; concentration in those cases where a measurement of this parameter in the previous three months was available&#46; The time from the onset of DM was stratified by intervals &#40;less than or more than 10 years&#41;&#44; because in those patients diagnosed with DM before the introduction of the electronic case history system&#44; the stated date of diagnosis of DM was the date on which the diagnosis was recorded in the electronic case history&#46; Renal failure was defined as an estimated glomerular filtration rate &#40;eGFR&#41; of &#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> in more than one measurement over at least three months&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study was conducted in accordance with the recommendations of the Declaration of Helsinki &#40;Fortaleza&#44; 2013&#41;&#46; As this was a retrospective analysis&#44; patient informed consent was not considered necessary&#46; The patient data were anonymized according to the provisions of the Organic Act 15&#47;1999 on Personal Data Protection&#46; The present article was reviewed for publication by the Clinical Research Ethics Committee of Hospital Universitari de Bellvitge&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Quantitative variables were reported as the mean and standard deviation &#40;SD&#41;&#44; while qualitative variables were reported as number and percentage&#46; The comparative analysis of quantitative variables was performed using parametric tests &#40;Student <span class="elsevierStyleItalic">t</span>-test&#41; or nonparametric tests &#40;Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span>-test&#41; in the absence of a normal data distribution&#46; Qualitative variables were compared using the chi-squared test or nonparametric tests &#40;Fisher&#39;s exact test&#41; when the percentage of cells with an expected frequency of less than 5 was over 20&#37;&#46; Two-tailed tests were used for all variables&#44; with a significance level of 5&#37;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0045" class="elsevierStylePara elsevierViewall">During the study period&#44; 184 emergency room visits with a diagnosis of hypoglycemia were recorded in 181 patients&#46; Thirty-five of these cases were excluded because they involved patients with no diagnosis of DM&#44; or because the emergency care report failed to confirm a capillary or plasma glucose level below 70<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the epidemiological and clinical characteristics of the patients&#46; Of the 149 events included in the analysis&#44; 122 &#40;81&#46;9&#37;&#41; occurred in patients with type 2 DM&#44; 24 &#40;16&#46;1&#37;&#41; occurred in patients with type 1 DM&#44; and 3 &#40;2&#37;&#41; occurred in patients with other types of DM &#40;post-transplant DM&#44; diabetes secondary to pancreatic carcinoma&#44; and DM secondary to mitochondrial disease&#41;&#46; The mean patient age was 70&#46;5 years &#40;SD&#58; 15&#46;9&#41;&#46; A total of 69&#46;4&#37; of the patients had been diagnosed with DM more than 10 years previously &#40;the time from onset of the disease could not be established in two cases&#41;&#46; A measurement of HbA<span class="elsevierStyleInf">1c</span> obtained within the preceeding three months was available in 75 cases &#40;50&#46;3&#37;&#41;&#44; with a mean value of 7&#46;5&#37; &#40;SD&#58; 1&#46;8&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Patients with type 2 DM were older than those with type 1 DM &#40;75&#46;4 &#91;SD&#58; 10&#46;5&#93; vs&#46; 46&#46;5 &#91;SD&#58; 16&#46;7&#93; years&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; and had a lower HbA<span class="elsevierStyleInf">1c</span> concentration&#44; though the difference was not statistically significant &#40;7&#46;4&#37; &#91;SD&#58; 1&#46;8&#93; vs&#46; 8&#46;1&#37; &#91;SD&#58; 1&#46;8&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;08&#41;&#46; Patients with type 2 DM had a greater prevalence of other cardiovascular risk factors&#44; chronic complications and other comorbidities&#44; except active alcohol abuse&#44; though in some cases the differences were not statistically significant&#44; probably because of the small number of cases involved &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Of note among the patients with type 2 DM was the prevalence of renal failure &#40;38&#46;5&#37;&#41; and cognitive impairment &#40;19&#46;7&#37;&#41;&#44; while the patients with type 1 DM showed a prevalence of alcohol abuse of 8&#46;3&#37;&#46; A small percentage of patients &#40;4&#46;2&#37; of those with type 2 DM&#41; were diagnosed with liver cirrhosis&#46; Nine percent of the patients with type 2 DM were institutionalized&#46; A total of 12&#46;7&#37; of the patients had been admitted to hospital in the month before the emergency room visit &#40;12 emergency medical admissions&#44; 5 admissions for elective surgery&#44; and two for emergency surgery&#41;&#46; The difference in frequency of admission in the previous month between patients with type 2 and type 1 DM was not statistically significant &#40;13&#46;1&#37; vs&#46; 8&#46;3&#37;&#44; respectively&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;7&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">All patients with type 1 DM were treated with insulin&#44; and the great majority &#40;91&#46;7&#37;&#41; followed a basal-bolus insulin regimen&#46; In turn&#44; 83&#46;3&#37; were receiving insulin analogs&#46; <a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1&#8211;3</a> show the blood glucose-lowering therapies of the patients with type 2 DM&#46; A high percentage &#40;78&#46;7&#37;&#41; of them were treated with insulin with or without other associated glucose-lowering drugs&#46; Twenty-six patients with type 2 DM &#40;21&#46;3&#37;&#41; were treated with oral antidiabetic drugs alone&#46; Of these 26 cases&#44; 25 received sulfonylureas and one was treated with repaglinide&#46; In 19 of the mentioned 25 cases &#40;76&#37;&#41;&#44; the prescribed sulfonylurea was glibenclamide&#46; Seven of the 47 patients with type 2 DM and renal failure &#40;14&#46;9&#37;&#41; were treated with sulfonylureas &#40;glibenclamide in 5 cases and some other sulfonylurea in two patients&#41;&#46; One of these 7 patients had stage IV renal failure &#40;eGFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">In 73&#46;2&#37; of the cases the presenting symptoms of hypoglycemia corresponded to neuroglycopenia&#46; A hypoglycemia triggering factor was cited in 67 of the 149 cases analyzed &#40;45&#37;&#41;&#46; The most common factors were decreased food intake &#40;64&#46;2&#37;&#41; and the intensification of insulin therapy &#40;28&#46;3&#37;&#41;&#46; Less common triggering factors were increased insulin secretagogue dosage &#40;4&#46;5&#37;&#41;&#44; the start of insulin therapy &#40;4&#46;5&#37;&#41;&#44; errors in patient antidiabetic treatment administration &#40;3&#46;3&#37;&#41;&#44; physical activity &#40;2&#46;4&#37;&#41;&#44; and an abusive intake of toxic substances &#40;1&#46;5&#37;&#41;&#46; In 9 of the 67 cases there was more than one triggering factor&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Eighty-four patients &#40;56&#46;4&#37;&#41; required medical transport to reach the emergency room&#46; The treatment of the hypoglycemic episode was specified in 144 of the 149 cases&#46; In 42 cases &#40;29&#46;2&#37;&#41; treatment was limited to oral carbohydrates&#46; In the remaining 70&#46;8&#37; of the cases&#44; parenteral treatment was administered &#40;intravenous glucose and&#47;or glucagon&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The mean duration of stay in the emergency room was 7&#46;9<span class="elsevierStyleHsp" style=""></span>h &#40;SD&#58; 5&#46;4&#41;&#46; Most patients &#40;86&#46;6&#37;&#41; were discharged home from the emergency room&#46; Of the 20 patients requiring admission&#44; 95&#37; had type 2 DM&#46; Of these&#44; 42&#46;1&#37; were treated with oral antidiabetics alone&#44; without insulin&#44; and the majority &#40;87&#46;5&#37;&#41; received glibenclamide&#46; The mean duration of hospital admission was 1&#46;8 days &#40;SD&#58; 1&#46;2&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">Our study shows that most hypoglycemic episodes seen in the emergency room of our center occurred in elderly type 2 DM patients with&#44; a high prevalence of associated disease conditions&#44; such as renal failure or cognitive impairment&#46; In addition&#44; they were mainly receiving insulin or sulfonylureas&#44; particularly glibenclamide&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The individual risk of hypoglycemia is greater in patients with type 1 DM&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">10</span></a> However&#44; type 2 DM accounts for 90&#37; of all cases of diabetes&#59; as a result&#44; at the population level most hypoglycemic episodes occur in patients with type 2 DM&#46; In addition&#44; patients with type 1 DM are more accustomed to hypoglycemia&#44; and therefore probably consult less often for this reason&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In our study&#44; over 60&#37; of the patients had suffered DM for more than 10 years&#44; and the mean age of the patients with type 2 DM was 75&#46;4 years&#46; The prospective trial of the UK Hypoglycemia Study Group showed the frequency of hypoglycemia to be increased in patients with type 2 DM treated with insulin for more than 5 years&#44; and similar to that in patients with recently diagnosed type 1 DM&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">11</span></a> Other studies have shown the incidence of severe hypoglycemia in patients with type 2 DM to increase with age and the duration of DM&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">12</span></a> It has been reported that the counter-regulatory hormonal response to hypoglycemia is activated at lower blood glucose levels in individuals over 65 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">13</span></a> In addition&#44; type 2 DM is characterized by a gradual loss of pancreatic beta-cell function&#46; This loss of beta-cell function is associated with a deficient counter-regulatory response to hypoglycemia&#44; particularly as regards the glucagon secretion response of the pancreatic alpha-cells&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">14</span></a> These factors could contribute to an increased risk of hypoglycemia in older patients with more advanced DM&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">A total of 34&#46;9&#37; of the global patients in our study and 38&#46;5&#37; of the patients in the type 2 DM subgroup had renal failure&#46; Different studies have shown that chronic kidney disease increases the risk of severe hypoglycemia&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">15</span></a> The kidneys are involved in glucose homeostasis&#44; contributing to neoglycogenesis and reabsorbing filtered glucose&#46; In addition&#44; many hypoglycemic drugs and&#47;or their metabolites are excreted through the kidneys&#46; Renal failure can alter these mechanisms&#44; thereby favoring hypoglycemic events&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">16</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Dementia was diagnosed in 19&#46;7&#37; of our patients with type 2 DM&#46; There is evidence of an association between DM and dementia&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">17</span></a> A number of factors may contribute to an increased risk of dementia in patients with DM &#40;vascular complications&#44; the direct effect of hyperglycemia upon the central nervous system&#44; insulin resistance&#41;&#46; Hypoglycemia is one of the potential factors capable of influencing the relationship between DM and dementia&#46; Hypoglycemic episodes can cause neuronal damage&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">18</span></a> which may be particularly relevant in elderly patients with limited neuronal plasticity&#46; Hypoglycemia has also been associated with alterations in endothelial function and coagulation mechanisms that could promote brain ischemia&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">19</span></a> Prospective clinical studies have identified an epidemiological association between severe hypoglycemia and dementia&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">20</span></a> However&#44; the relationship between dementia and hypoglycemia may be bidirectional&#44; since patients with poorer cognitive function are more susceptible to hypoglycemia due to problems in recognizing the symptoms of hypoglycemia&#44; identifying situations predisposing to hypoglycemia&#44; and in adopting measures to correct the problem&#46; The causal relationship therefore remains controversial&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Alcohol reduces neoglycogenesis and favors hypoglycemia&#46; Furthermore&#44; some studies have shown that alcohol aggravates the alterations of cognitive functions induced by hypoglycemia&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">21</span></a> These factors may explain why alcohol abuse is a relatively common associated factor in patients with type 1 DM&#44; i&#46;e&#46;&#44; young patients with few associated disease conditions&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Some studies have shown hypoglycemia associated with drug treatment for DM to be one of the most common side effects in elderly patients after hospital discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">22</span></a> In our study&#44; 12&#46;7&#37; of the patients had been admitted in the month before the emergency room visit&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A total of 78&#46;7&#37; of the patients with type 2 DM were treated with insulin&#46; The remaining 21&#46;3&#37; were treated with sulfonylureas or meglitinides &#40;glibenclamide in the great majority of cases&#41;&#46; Within the sulfonylureas&#44; glibenclamide is associated with an increased risk of hypoglycemia&#46; The clinical guides therefore advise the use of other second-generation sulfonylureas &#40;glimepiride&#44; gliclazide and glipizide&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">23</span></a> especially in patients with renal failure&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">24</span></a> Five of the 20 patients treated with glibenclamide in our study had renal failure&#46; This situation is not exceptional in our setting&#46; A recent study analyzed the prevalence of chronic kidney disease and the associated characteristics in patients over 65 years of age with type 2 DM in Spain&#46; The study showed that although the use of sulfonylureas decreased as kidney function worsened&#44; 10&#46;5&#37; of the patients treated with sulfonylureas had a GFR<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#44; a situation in which sulfonylurea use is not recommended&#46; The same study found that 36&#46;4&#37; of the patients treated with glibenclamide had renal failure&#44; despite the formal contraindication of glibenclamide use in this situation&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">25</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Hypoglycemic events imply increased costs associated with DM&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">26</span></a> In this regard&#44; 56&#46;4&#37; of the patients used medical transport to reach the emergency room&#44; and the mean time spent in the emergency room was 7&#46;9<span class="elsevierStyleHsp" style=""></span>h&#46; In turn&#44; 13&#46;4&#37; of the patients required hospital admission&#44; with a mean duration of stay of 1&#46;8 days&#46; The patients with type 2 DM treated with oral antidiabetics alone represented 21&#46;3&#37; of the global study cohort&#46; However&#44; in the case of the patients admitted to hospital&#44; those treated with oral antidiabetics alone represented 42&#46;1&#37; of the cases&#44; and of these&#44; the great majority &#40;87&#46;5&#37;&#41; received glibenclamide&#46; This situation is probably secondary to the long-acting effects of some sulfonylureas and&#47;or their active metabolites&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">27</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Our study has a number of limitations&#46; In effect&#44; this was a retrospective study with a limited number of cases&#44; conducted at a single center&#44; and in which the clinical information was compiled from the emergency care reports and the electronic case history&#46; No recent HbA<span class="elsevierStyleInf">1c</span> measurement was available in all cases for the analysis of glycemic control&#46; Moreover&#44; we only considered cases of hypoglycemia seen in the emergency room&#44; i&#46;e&#46;&#44; not all episodes of hypoglycemia associated with DM treatment were represented&#44; only the most severe cases&#46; Furthermore&#44; we only included cases with a documented capillary or plasma glucose concentration of &#60;70<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; This means that some excluded cases may also have been hypoglycemic episodes in which blood glucose was not recorded&#44; or in which treatment was started in the presence of consistent symptoms despite the lack of prior confirmation of low blood glucose&#46; In any case&#44; our results are in agreement with those of prospective&#44; multicenter studies in other countries that have evaluated the characteristics of patients seen in emergency departments due to hypoglycemia&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">28</span></a> A study conducted in the United States has validated a tool that classifies the risk of suffering hypoglycemia requiring an emergency room visit or hospital admission in patients with type 2 DM &#40;low&#44; intermediate or high risk&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">29</span></a> This tool uses 6 clinical variables including age&#44; the use of insulin and&#47;or sulfonylureas&#44; and the degree of kidney function&#44; all of which were relevant variables in our study&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In conclusion&#44; most of the hypoglycemic episodes seen in the emergency room of our center occurred in elderly patients with type 2 DM and a high prevalence of other comorbidities&#44; particularly renal failure and cognitive impairment&#44; and who were treated with insulin and&#47;or sulfonylureas &#40;particularly glibenclamide&#41;&#46; The individualization of DM treatment should take into account risk factors for hypoglycemia such as patient age&#44; renal function and cognitive performance&#46; If sulfonylurea therapy is indicated&#44; glibenclamide should be avoided&#46; In recent years&#44; new glucose-lowering drugs &#40;DPP-IV inhibitors&#44; GLP-1 receptor agonists&#44; SGLT2 inhibitors&#41; and new insulin analogs &#40;degludec&#44; glargine U300&#41; have become available&#44; with benefits over other therapeutic options in relation to hypoglycemia risk&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">30&#8211;32</span></a> The limitations facing these new drugs are their greater cost and the fact that they have been introduced relatively recently&#46; Nevertheless&#44; they should be considered as a treatment alternative when avoiding hypoglycemia is an important issue&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflicts of interest</span><p id="par0135" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Hypoglycemia associated to insulin or other glucose-lowering agents is one of the most common causes of visits to the emergency department for adverse drug reactions&#46; The study objective was to analyze the characteristics of patients with diabetes mellitus &#40;DM&#41; who attend a tertiary hospital emergency department for a hypoglycemic event&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A 3-year retrospective analysis was conducted of patients with DM who attended the emergency department of Hospital Universitari de Bellvitge for a hypoglycemic event&#46; An analysis was made of epidemiological and diabetes-related characteristics&#44; prevalence of chronic diabetic complications and other comorbidities&#44; the glucose-lowering treatment and the result of the hypoglycemic episode&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Of the 149 hypoglycemic events analyzed&#44; 81&#46;9&#37; occurred in patients with type 2 DM&#46; Mean age of patients with type 2 DM was 75&#46;4 years&#46; DM duration was longer than 10 years in 69&#46;4&#37; of patients&#46; The prevalence rates of chronic kidney disease and cognitive decline were 38&#46;5&#37; and 19&#46;7&#37; respectively in patients with type 2 DM&#46; Insulin with or without other concomitant glucose-lowering agents was associated to 78&#46;7&#37; of episodes in type 2 DM patients&#46; The remaining 21&#46;3&#37; were associated to oral hypoglycemic agents&#44; mainly glibenclamide&#46; After the event&#44; 13&#46;4&#37; of patients required hospital admission&#44; and in 36&#46;8&#37; of these hypoglycemia was associated to use of glibenclamide&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A majority of hypoglycemic events occurred in elderly patients with type 2 DM&#44; with a high prevalence of associated comorbidities and treated with insulin and sulfonylureas&#44; particularly glibenclamide&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction and objective"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La hipoglucemia asociada a insulina u otros hipoglucemiantes es una de las principales causas de consulta a urgencias por efectos secundarios de medicamentos&#46; El objetivo del estudio es analizar las caracter&#237;sticas de los pacientes con diabetes mellitus &#40;DM&#41; que consultan a urgencias hospitalarias por un episodio de hipoglucemia&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se realiz&#243; un an&#225;lisis retrospectivo de los pacientes con DM que fueron atendidos en el Servicio de Urgencias del Hospital Universitari de Bellvitge con el diagn&#243;stico de hipoglucemia durante un periodo de 3 a&#241;os&#46; Se analizaron las caracter&#237;sticas epidemiol&#243;gicas&#44; las relacionadas con la DM&#44; sus complicaciones y otras comorbilidades&#44; el tratamiento hipoglucemiante de base y el resultado del episodio de hipoglucemia&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se analizaron 149 episodios de hipoglucemia&#46; El 81&#44;9&#37; de los casos eran pacientes con DM tipo 2&#46; La edad media de los pacientes con DM tipo 2 fue de 75&#44;4 a&#241;os&#46; La duraci&#243;n de la DM era superior a los 10 a&#241;os en el 69&#44;4&#37; de los casos&#46; La prevalencia de insuficiencia renal cr&#243;nica y deterioro cognitivo fue del 38&#44;5 y del 19&#44;7&#37;&#44; respectivamente&#44; en los pacientes con DM tipo 2&#46; El 78&#44;7&#37; de los pacientes con DM tipo 2 estaban tratados con insulina con o sin otros hipoglucemiantes asociados&#46; El 21&#44;3&#37; restante se trataban con agentes orales&#44; principalmente glibenclamida&#46; El 13&#44;4&#37; de los casos requirieron ingreso hospitalario y&#44; en el 36&#44;8&#37; de ellos&#44; la hipoglucemia estaba asociada al uso de glibenclamida&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La mayor&#237;a de episodios de hipoglucemia se produjeron en pacientes con DM tipo 2 de edad avanzada&#44; con elevada prevalencia de enfermedades asociadas y en tratamiento con insulina y sulfonilureas&#44; especialmente glibenclamida&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n y objetivos"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Pacientes y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Caballero-Corchuelo J&#44; Guerrero-P&#233;rez F&#44; Garc&#237;a-Sancho de la Jordana P&#44; P&#233;rez-Maraver M&#46; An&#225;lisis de las caracter&#237;sticas de los pacientes con diabetes mellitus que consultan por hipoglucemia en el servicio de urgencias de un hospital terciario&#46; Endocrinol Diabetes Nutr&#46; 2019&#59;66&#58;19&#8211;25&#46;</p>"
      ]
    ]
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        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Blood glucose-lowering treatment of patients with type 2 diabetes mellitus&#46;</p>"
        ]
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      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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            "imagen" => "gr2.jpeg"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Type of insulin regimen used in patients with type 2 diabetes mellitus&#46;</p>"
        ]
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      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Use of insulin analogs versus human insulin in patients with type 2 diabetes mellitus&#46;</p>"
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      3 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">SD&#58; standard deviation&#59; DM&#58; diabetes mellitus&#46;</p>"
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type 1 DM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type 2 DM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-value<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">N</span> &#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">149&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 &#40;16&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">122 &#40;81&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&#46;5 &#40;SD&#58; 15&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">46&#46;5 &#40;SD&#58; 16&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">75&#46;4 &#40;SD&#58; 10&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gender &#40;&#37; males&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">84 &#40;57&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#40;50&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">72 &#40;59&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Time from DM onset &#62;10 years &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">102 &#40;69&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 &#40;79&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">83 &#40;69&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">HbA<span class="elsevierStyleInf">1c</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;5 &#40;SD&#58; 1&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#46;1 &#40;SD&#58; 1&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">7&#46;4 &#40;SD&#58; 1&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1950015.png"
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            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Comparative analysis between the two types of DM&#44; NS&#58; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#8805;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Epidemiological characteristics of the studied patients&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">DM&#58; diabetes mellitus&#59; GFR&#58; glomerular filtration rate&#59; AHT&#58; arterial hypertension&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type 1 DM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type 2 DM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span>-value<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AHT&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">107 &#40;73&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 &#40;41&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97 &#40;79&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dyslipidemia&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100 &#40;68&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;37&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91 &#40;74&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiovascular disease &#40;coronary&#44; cerebral and&#47;or peripheral&#41;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">62 &#40;42&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;20&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">57 &#40;46&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Coronary&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40 &#40;27&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;12&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">37 &#40;30&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cerebrovascular&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24 &#40;16&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;4&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;18&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Peripheral vascular disease&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25 &#40;17&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2 &#40;8&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">23 &#40;18&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;12&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;7&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;4&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
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                        0 => array:2 [
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                            0 => "E&#46; Chow"
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                          "etal" => true
                          "autores" => array:6 [
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                            1 => "S&#46; Alsifri"
                            2 => "R&#46; Aronson"
                            3 => "M&#46; Cigrovski"
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                      "Revista" => array:6 [
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                  "contribucion" => array:1 [
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                          "etal" => false
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                0 => array:2 [
                  "contribucion" => array:1 [
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                        0 => array:3 [
                          "colaboracion" => "Action to Control Cardiovascular Risk in Diabetes Study Group"
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46;C&#46; Gerstein"
                            1 => "M&#46;E&#46; Miller"
                            2 => "R&#46;P&#46; Byington"
                            3 => "D&#46;C&#46; Goff Jr&#46;"
                            4 => "J&#46;T&#46; Bigger"
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Article information
ISSN: 25300180
Original language: English
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