Letter to the Editor
Determination of glycosylated hemoglobin during hospitalization as an opportunity to assess and optimize glycemic control in our patients: An unresolved matter
La determinación de hemoglobina glucosilada durante la hospitalización como una oportunidad para valorar y optimizar el control glucémico en nuestros pacientes: una asignatura pendiente
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] "en" => array:14 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Determination of glycosylated hemoglobin during hospitalization as an opportunity to assess and optimize glycemic control in our patients: An unresolved matter" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "101" "paginaFinal" => "102" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Alberto de los Santos Moreno, Elvira Ruiz Blasco, Beatriz López Alonso, José Antonio Girón-González" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Alberto" "apellidos" => "de los Santos Moreno" "email" => array:1 [ 0 => "alberto.delossantosmoreno@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Elvira" "apellidos" => "Ruiz Blasco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Beatriz" "apellidos" => "López Alonso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "José Antonio" "apellidos" => "Girón-González" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Gestión Clínica, Hospital Universitario Puerta del Mar, Cádiz, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Medicina, Universidad de Cádiz, Cádiz, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La determinación de hemoglobina glucosilada durante la hospitalización como una oportunidad para valorar y optimizar el control glucémico en nuestros pacientes: una asignatura pendiente" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Diabetes mellitus is a highly prevalent disease in the general population, and this is particularly relevant for patients who require hospital admission for any reason because of its impact on morbidity and mortality.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1,2</span></a> Internal medicine departments assume a high proportion of admissions of elderly patients with diabetes and/or complex chronic diseases<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">3</span></a> who have great difficulty in accessing the healthcare system because of their functional and cognitive limitations. The hospitalization of these patients is a good opportunity for optimizing blood glucose control, thus improving their health outcomes.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Both the consensus document on the treatment of hyperglycemia during the hospital stay published in 2009 by Pérez et al. and the 2015 ADA standards recommend the measurement of glycosylated hemoglobin A1c (HbA1c) levels during or in the three months prior to hospitalization.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">4,5</span></a> In an interesting article recently published in this journal by Sáenz-Abad et al.,<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">6</span></a> the authors concluded that hospital protocols should consider HbA1c as one of the determinants of blood glucose control during the hospital stay, together with prior treatment, blood glucose levels at baseline and in the first 24<span class="elsevierStyleHsp" style=""></span>h of admission, fasting, and the use of corticosteroids.</p><p id="par0015" class="elsevierStylePara elsevierViewall">To analyze the adherence of our unit to international recommendations for measuring HbA1c levels during hospitalization, our group conducted a retrospective cohort study in a group of patients admitted for any reason to our internal medicine clinical management unit with a diagnosis of type 2 diabetes mellitus who were at least on metformin. The recruitment period was two and a half years (from November 2012 to April 2015), during which there were 330 episodes in 278 patients. The mean patient age was 76.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.4 years, with a distribution by sex of 45.8% males and 54.2% females. HbA1c was only measured during hospital admission in 143 (43.3%) of the episodes analyzed. The mean HbA1c level was 7.13<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>1.48% (range, 4.6–14.1), which agrees with the above mentioned study.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">To establish what should be considered as adherence to guidelines in terms of HbA1c measurement, nonfatal episodes were analyzed separately, because it was thought that healthcare professionals who cared for patients with a fatal vital prognosis during hospitalization did not consider it appropriate to determine the prior degree of blood glucose control in these patients as this would provide no clinical benefit and would therefore represent an unnecessary expense. Thus, the proportion of patients for whom HbA1c measurement was requested at admission and who were finally discharged was 49.1%. It may thus be concluded that HbA1c levels were not available during hospitalization in half the patients admitted. When patients in whom HbA1c had been tested in the three months prior to hospital admission were added, we found that HbA1c measurements performed during or in the three months prior to admission were not available for 87 (26.37% of all patients recruited) clinical episodes that resulted in discharge, although measurements had been performed in the previous year.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In a recent report by the same group of Sáenz-Abad et al.,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> HbA1c levels were not significantly associated with hospital mortality, being instead determined by blood glucose levels at admission and glycemic variability during the hospital stay. Hence, recommendations to measure HbA1c make no sense in patients with a poor prognosis at admission because a sufficient survival period during which benefits may be achieved from blood glucose control assessment and, thus, from changes in baseline treatment is unlikely. Moreover, information from the episode in question as a marker of hospital mortality would not be provided by such measurements. By contrast, the measurement of HbA1c has been shown to be an effective measure for optimizing blood glucose control in patients with diabetes admitted for any reason,<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">8–10</span></a> and an opportunity to detect previously unknown cases of diabetes mellitus in multiple clinical settings.<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">11,12</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Based on the data provided, strategies are needed to emphasize the need to use hospitalization to optimize blood glucose control in our patients by measuring HbA1c as recommended by the guidelines and to detect elements of improvement, and even to consider HbA1c testing to make new diagnoses of diabetes. Evidence is still needed to define which patients benefit from routine HbA1c measurement during hospitalization. This is especially important in the population commonly seen, whose fragility means that actions aimed at achieving mid- or long-term benefit (other than the detection of hypoglycemia) may be of doubtful value.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: de los Santos Moreno A, Ruiz Blasco E, López Alonso B, Girón-González JA. La determinación de hemoglobina glucosilada durante la hospitalización como una oportunidad para valorar y optimizar el control glucémico en nuestros pacientes: una asignatura pendiente. Endocrinol Nutr. 2016;63:101–102.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence of diabetes mellitus and impaired glucose regulation in Spain: the Di@bet.es Study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Soriguer" 1 => "A. Goday" 2 => "A. Bosch-Comas" 3 => "E. Bordiú" 4 => "A. Calle-Pascual" 5 => "R. 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Olson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2337/dc14-0479" "Revista" => array:6 [ "tituloSerie" => "Diabetes Care" "fecha" => "2014" "volumen" => "37" "paginaInicial" => "2934" "paginaFinal" => "2939" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25168125" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0115" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The reliability of in-hospital diagnoses of diabetes mellitus in the setting of an acute myocardial infarction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.V. Arnold" 1 => "K.J. Lipska" 2 => "S.E. Inzucchi" 3 => "Y. Li" 4 => "P.G. Jones" 5 => "D.K. McGuire" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bmjdrc-2014-000046" "Revista" => array:5 [ "tituloSerie" => "BMJ Open Diabetes Res Care" "fecha" => "2014" "volumen" => "2" "paginaInicial" => "e000046" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25452878" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0120" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Glucose and lipid assessment in patients with acute stroke" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.O. Ogbera" 1 => "O.O. Oshinaike" 2 => "O. Dada" 3 => "A. Brodie-Mends" 4 => "C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 2 | 4 |
| 2024 October | 19 | 3 | 22 |
| 2024 September | 20 | 14 | 34 |
| 2024 August | 19 | 18 | 37 |
| 2024 July | 15 | 8 | 23 |
| 2024 June | 15 | 8 | 23 |
| 2024 May | 13 | 16 | 29 |
| 2024 April | 11 | 6 | 17 |
| 2024 March | 51 | 11 | 62 |
| 2024 February | 29 | 7 | 36 |
| 2024 January | 10 | 9 | 19 |
| 2023 December | 27 | 14 | 41 |
| 2023 November | 32 | 13 | 45 |
| 2023 October | 43 | 12 | 55 |
| 2023 September | 13 | 5 | 18 |
| 2023 August | 15 | 4 | 19 |
| 2023 July | 16 | 7 | 23 |
| 2023 June | 23 | 5 | 28 |
| 2023 May | 53 | 11 | 64 |
| 2023 April | 27 | 3 | 30 |
| 2023 March | 36 | 8 | 44 |
| 2023 February | 29 | 3 | 32 |
| 2023 January | 28 | 7 | 35 |
| 2022 December | 21 | 7 | 28 |
| 2022 November | 21 | 10 | 31 |
| 2022 October | 21 | 6 | 27 |
| 2022 September | 55 | 10 | 65 |
| 2022 August | 24 | 7 | 31 |
| 2022 July | 16 | 9 | 25 |
| 2022 June | 23 | 4 | 27 |
| 2022 May | 57 | 5 | 62 |
| 2022 April | 32 | 12 | 44 |
| 2022 March | 22 | 7 | 29 |
| 2022 February | 32 | 9 | 41 |
| 2022 January | 48 | 9 | 57 |
| 2021 December | 9 | 17 | 26 |
| 2021 November | 16 | 19 | 35 |
| 2021 October | 23 | 24 | 47 |
| 2021 September | 14 | 11 | 25 |
| 2021 August | 21 | 11 | 32 |
| 2021 July | 14 | 14 | 28 |
| 2021 June | 25 | 16 | 41 |
| 2021 May | 33 | 10 | 43 |
| 2021 April | 49 | 15 | 64 |
| 2021 March | 24 | 16 | 40 |
| 2021 February | 8 | 6 | 14 |
| 2021 January | 10 | 12 | 22 |
| 2020 December | 18 | 13 | 31 |
| 2020 November | 14 | 3 | 17 |
| 2020 October | 9 | 8 | 17 |
| 2020 September | 13 | 23 | 36 |
| 2020 August | 13 | 9 | 22 |
| 2020 July | 11 | 16 | 27 |
| 2020 June | 13 | 7 | 20 |
| 2020 May | 15 | 7 | 22 |
| 2020 April | 3 | 2 | 5 |
| 2020 March | 13 | 7 | 20 |
| 2020 February | 6 | 2 | 8 |
| 2020 January | 9 | 5 | 14 |
| 2019 December | 13 | 7 | 20 |
| 2019 November | 15 | 4 | 19 |
| 2019 October | 8 | 0 | 8 |
| 2019 September | 7 | 5 | 12 |
| 2019 August | 10 | 9 | 19 |
| 2019 July | 11 | 19 | 30 |
| 2019 June | 28 | 6 | 34 |
| 2019 May | 120 | 18 | 138 |
| 2019 April | 8 | 5 | 13 |
| 2019 March | 6 | 5 | 11 |
| 2019 February | 13 | 2 | 15 |
| 2019 January | 7 | 5 | 12 |
| 2018 December | 2 | 4 | 6 |
| 2018 November | 15 | 3 | 18 |
| 2018 October | 13 | 5 | 18 |
| 2018 September | 14 | 3 | 17 |
| 2018 August | 9 | 0 | 9 |
| 2018 July | 2 | 4 | 6 |
| 2018 June | 9 | 0 | 9 |
| 2018 May | 7 | 1 | 8 |
| 2018 April | 7 | 1 | 8 |
| 2018 March | 12 | 0 | 12 |
| 2018 February | 9 | 0 | 9 |
| 2018 January | 6 | 1 | 7 |
| 2017 December | 12 | 2 | 14 |
| 2017 November | 10 | 1 | 11 |
| 2017 October | 11 | 12 | 23 |
| 2017 September | 6 | 4 | 10 |
| 2017 August | 20 | 0 | 20 |
| 2017 July | 7 | 0 | 7 |
| 2017 June | 12 | 9 | 21 |
| 2017 May | 24 | 1 | 25 |
| 2017 April | 12 | 20 | 32 |
| 2017 March | 31 | 17 | 48 |
| 2017 February | 40 | 5 | 45 |
| 2017 January | 10 | 4 | 14 |
| 2016 December | 16 | 4 | 20 |
| 2016 November | 20 | 2 | 22 |
| 2016 October | 24 | 4 | 28 |
| 2016 September | 20 | 2 | 22 |
| 2016 August | 18 | 1 | 19 |
| 2016 May | 0 | 1 | 1 |
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