Predictors of outcome in hypoglycemic encephalopathy

Prolonged Hypoglycemic Encephalopathy: A Case Report

Hypoglycemic encephalopathy is a rare yet life-threatening diabetes complication, where overlapping symptoms with neurological conditions can delay diagnosis. Early recognition and treatment are crucial to prevent irreversible brain damage. Clinicians should suspect hypoglycemia in diabetic patients with altered mental status, as timely intervention improves outcomes and reduces mortality.

Prognostic factors for hospitalization for severe hypoglycemia without diabetes mellitus: a retrospective study

Patients with non-diabetic hypoglycemia have a poorer prognosis than those with diabetic hypoglycemia. However, the factors associated with prognosis remain unclear. Therefore, this study aimed to identify the prognostic factors for non-diabetic hypoglycemia. This is a retrospective study of patients hospitalized for severe hypoglycemia with blood glucose ≤ 3.0 mmol/L (54 mg/dL) due to non-diabetic hypoglycemia between April 2008 and June 2023. Additionally, the underlying cause of hypoglycemia was identified, and the factors associated with mortality were examined. Of the 134 hospitalized patients, 126 were analyzed, excluding cases of multiple or scheduled hospitalizations. The most common causes of hypoglycemia were malnutrition (n = 79, 62.7%), alcohol intake (n = 27, 21.4%), and hypothermia (n = 27, 21.4%); 76 (60.3%) patients had multiple associated factors. Of the 126 patients, 52 died within 90 days. In the multivariate analysis, the estimated glomerular filtration rate (eGFR) (< 30 mL/min/1.73 m2) was independently associated with death [odds ratio (OR) 5.78, 95% confidence interval (CI) 1.69-19.8], whereas blood glucose (OR 0.95, 95% CI 0.92-0.99), serum albumin (OR 0.27, 95% CI 0.12-0.59), and alcohol intake (OR 0.03, 95% CI 0.004-0.34) were associated with survival. Moreover, age (OR 1.0, 95% CI 0.97-1.04) was not associated with death. Patients with non-diabetic hypoglycemia had a very high mortality. Low eGFR, blood glucose levels, and serum albumin levels at admission were associated with 90-day mortality, and alcohol intake was associated with survival.

Hypoglycemic encephalopathy with extensive brain injuries: A case report

Hypoglycemia is known as a sudden diminution in blood glucose level <50 mg/dL. Hypoglycemic encephalopathy is a metabolic encephalopathy that is usually observed in patients treated for diabetes or chronic alcoholism. Neurological manifestations may range from transient deficits to prolonged coma, depending on the duration and severity of hypoglycemia. Neuroradiological features of hypoglycemia are variable involving the cerebral white and gray matter regions. Acquired metabolic or toxic conditions can cause hypoglycemia-like damage to the cerebral white matter and basal ganglia. Widespread lesions in the brain parenchyma or basal ganglia have a poor prognosis. In this report, we present a patient with widespread brain damage secondary to profound and prolonged hypoglycemia.

Bilateral middle cerebellar peduncle compromise due to hypoglycemic encephalopathy: A case report and literature review

Hypoglycemic encephalopathy constitutes a critical presentation of severely diminished glucose levels. We present the case of a 53-year-old male patient with a history of diabetes mellitus with hypoglycemic encephalopathy and MRI findings of bilateral middle cerebellar peduncle lesions. Common findings of hypoglycemic encephalopathy described in the literature consist of bilateral compromise of the cerebral cortex, basal ganglia, hippocampus, and long tracts of white matter. The cerebellum and brainstem are usually not affected. This is the ninth report of cerebellar peduncle compromise with hypoglycemia. As increasing evidence regarding prognosis estimation of lesion distribution arises, we consider it important to report the different cases of rare patterns of compromise.

Description and Outcome of Severe Hypoglycemic Encephalopathy in the Intensive Care Unit

BACKGROUND

Disorders of consciousness due to severe hypoglycemia are rare but challenging to treat. The aim of this retrospective cohort study was to describe our multimodal neurological assessment of patients with hypoglycemic encephalopathy hospitalized in the intensive care unit and their neurological outcomes.

METHODS

Consecutive patients with disorders of consciousness related to hypoglycemia admitted for neuroprognostication from 2010 to 2020 were included. Multimodal neurological assessment included electroencephalography, somatosensory and cognitive event-related potentials, and morphological and quantitative magnetic resonance imaging (MRI) with quantification of fractional anisotropy. Neurological outcomes at 28 days, 3 months, 6 months, 1 year, and 2 years after hypoglycemia were retrieved.

RESULTS

Twenty patients were included. After 2 years, 75% of patients had died, 5% remained in a permanent vegetative state, 10% were in a minimally conscious state, and 10% were conscious but with severe disabilities (Glasgow Outcome Scale-Extended scores 3 and 4). All patients showed pathologic electroencephalography findings with heterogenous patterns. Morphological brain MRI revealed abnormalities in 95% of patients, with various localizations including cortical atrophy in 65% of patients. When performed, quantitative MRI showed decreased fractional anisotropy affecting widespread white matter tracts in all patients.

CONCLUSIONS

The overall prognosis of patients with severe hypoglycemic encephalopathy was poor, with only a small fraction of patients who slowly improved after intensive care unit discharge. Of note, patients who did not improve during the first 6 months did not recover consciousness. This study suggests that a multimodal approach capitalizing on advanced brain imaging and bedside electrophysiology techniques could improve diagnostic and prognostic performance in severe hypoglycemic encephalopathy.

Neurological Prognostication After Hypoglycemic Coma: Role of Clinical and EEG Findings

BACKGROUND

Hypoglycemic coma (HC) is an uncommon but severe clinical condition associated with poor neurological outcome. There is a dearth of robust neurological prognostic factors after HC. On the other hand, there is an increasing body of literature on reliable prognostic markers in the postanoxic coma, a similar-albeit not identical-situation. The objective of this study was thus to investigate the use and predictive value of these markers in HC.

METHODS

We conducted a retrospective, multicenter, cohort study within five centers of the Critical Care EEG Monitoring Research Consortium. We queried our electroencephalography (EEG) databases to identify all patients undergoing continuous EEG monitoring after admission to an intensive care unit with HC (defined as Glasgow Coma Scale < 8 on admission and a first blood glucose level < 50 mg/dL or not documented but in an obvious clinical context) between 01/01/2010 and 12/31/2020. We studied the association of findings at neurological examination (Glasgow Coma Scale motor subscale, pupillary light and corneal reflexes) and at continuous EEG monitoring(highly malignant patterns, reactivity, periodic discharges, seizures) with best neurological outcome within 3 months after hospital discharge, defined by the Cerebral Performance Category as favorable (1-3: recovery of consciousness) versus unfavorable (4-5: lack of recovery of consciousness).

RESULTS

We identified 60 patients (30 [50%] women; age 62 [51-72] years). Thirty-one and 29 patients had a favorable and unfavorable outcome, respectively. The presence of pupillary reflexes (24 [100%] vs. 17 [81%]; p value 0.04) and a motor subscore > 2 (22 [92%] vs. 12 [63%]; p value 0.03) at 48-72 h were associated with a favorable outcome. A highly malignant EEG pattern was observed in 7 of 29 (24%) patients with unfavorable outcome versus 0 of 31 (0%) with favorable outcome, whereas the presence of EEG reactivity was observed in 28 of 31 (90%) patients with favorable outcome versus 13 of 29 (45%) with unfavorable outcome (p < 0.001 for comparison of all background categories).

CONCLUSIONS

This preliminary study suggests that highly malignant EEG patterns might be reliable prognostic markers of unfavorable outcome after HC. Other EEG findings, including lack of EEG reactivity and seizures and clinical findings appear less accurate. These findings should be replicated in a larger multicenter prospective study.

Left Hemiplegia Possibly Due to Glucose Reperfusion Injury after Recovery of Severe Hypoglycemia in a Woman with Type 2 Diabetes Mellitus

A 79-year-old woman with type 2 diabetes receiving insulin was rushed to our hospital due to severe hypoglycemia. Glucose was administered, and the consciousness disturbance was promptly improved. A few hours later, conjugate deviation of the eyes to the right and left hemiplegia occurred at a normal glucose level. Cerebral magnetic resonance imaging (MRI) showed hyperintensities of the right posterior limb of the internal capsule and the medial thalamus on diffusion-weighted imaging sequences. However, the changes observed using MRI disappeared completely on the third day, and her symptoms subsequently improved. This may have been a case of glucose reperfusion injury.

Predictors of consciousness improvement in patients with hypoglycemic encephalopathy

AIMS

Hypoglycemic encephalopathy (HE) can cause long-lasting mental changes, disability, and even death. We aimed to investigate prognostic factors for HE and to determine when the treatment of HE becomes futile.

METHODS

We retrospectively evaluated the data of patients admitted for prolonged HE at Dongguk University Ilsan Hospital between December 2005 and July 2021. We assessed the Glasgow Outcome Scale (GOS) to assess functional outcome.

RESULTS

Forty-four patients were enrolled in the study. Thirty-two of these showed the improvement on GOS after treatment. Patients with improved consciousness had a shorter duration of hypoglycemia (1.6±1.4 vs. 7.8±15.0 hours, p = 0.04) and a lower incidence of brain lesions than those without improvements in consciousness (76.0% vs. 25.0%, p < 0.01). Patients whose lesions were detected in initial MRIs were 1.3 times less likely to recover consciousness after HE (odds ratios, 1.28; 95% CI, 1.09-1.52; p < 0.01). None of the patients recovered consciousness after 320 h. Maximum time spent to recover was 194 in patients without brain lesions and 319 in those with lesions.

CONCLUSIONS

Hypoglycemic brain injury detected in initial MRIs predicted poorer HE prognosis. Nevertheless, treatment should be provided for at least for 14 days after admission.

Acute Acquired Metabolic Encephalopathy Based on Diffusion MRI

Metabolic encephalopathy is a critical condition that can be challenging to diagnose. Imaging provides early clues to confirm clinical suspicions and plays an important role in the diagnosis, assessment of the response to therapy, and prognosis prediction. Diffusion-weighted imaging is a sensitive technique used to evaluate metabolic encephalopathy at an early stage. Metabolic encephalopathies often involve the deep regions of the gray matter because they have high energy requirements and are susceptible to metabolic disturbances. Understanding the imaging patterns of various metabolic encephalopathies can help narrow the differential diagnosis and improve the prognosis of patients by initiating proper treatment regimen early.

Sudden Death Associated with Severe Hypoglycemia in a Diabetic Patient During Sensor-Augmented Pump Therapy with the Predictive Low Glucose Management System

BACKGROUND Hypoglycemia is a frequent complication observed in diabetic patients under treatment. This metabolic complication is associated with an increased mortality rate in diabetic patients. The use of sensor-augmented pump therapy with predictive low glucose management systems has improved blood glucose level control and reduced the incidence of hypoglycemic attacks. However, this therapy may be associated with adverse events. CASE REPORT A 65-year-old Japanese woman with type 1 diabetes mellitus underwent hemodialysis with end-stage renal failure due to diabetic nephropathy. The patient received sensor-augmented pump therapy with the predictive low glucose management system to prevent recurrent severe hypoglycemia. Hypoglycemia was infrequent when the sensor-augmented pump therapy with a predictive low-glucose management system was properly working. However, the patient suddenly died 3 months after starting the treatment. A record of continuous glucose monitoring showed that hypoglycemia occurred before the sudden death of the patient. CONCLUSIONS The current case shows that sudden death associated with severe hypoglycemia may also occur during sensor-augmented pump therapy with a predictive low glucose management system. This case report underscores the need for close follow-up of diabetic patients receiving sensor-augmented pump therapy with the predictive low glucose management system and the critical importance of patient education on diabetes technology in high-risk patients.

Effect on mortality of increasing the cutoff blood glucose concentration for initiating hypoglycaemia treatment in severely sick children aged 1 month to 5 years in Malawi (SugarFACT): a pragmatic, randomised controlled trial

BACKGROUND

Low blood glucose concentrations are common in sick children who present to hospital in low-resource settings and are associated with increased mortality. The cutoff blood glucose concentration for the diagnosis and treatment of hypoglycaemia currently recommended by WHO (2·5 mmol/L) is not evidence-based. We aimed to assess whether increasing the cutoff blood glucose concentration for hypoglycaemia treatment in severely ill children at presentation to hospital improves mortality outcomes.

METHODS

We did a pragmatic, randomised controlled trial at two referral hospitals in Malawi. Severely ill children aged 1 month to 5 years presenting to the emergency department with a capillary blood glucose concentration of between 2·5 mmol/L (3·0 mmol/L in severely malnourished children) and 5·0 mmol/L were randomly assigned (1:1) by a computer-generated randomisation sequence, stratified by study site and severe malnutrition, to receive either an immediate intravenous bolus of 10% dextrose at 5 mL/kg followed by a 24-h maintenance infusion of 10% dextrose at 100 mL/kg for the first 10 kg of bodyweight, 50 mL/kg for the next 10 kg, and 20 mL/kg for each subsequent kg of bodyweight (intervention group) or observation for a minimum of 60 min and standard care (control group). Participants and study personnel were not masked to treatment allocation. The primary outcome was all-cause in-hospital mortality, assessed on an intention-to-treat basis. Safety was also assessed in the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT02989675.

FINDINGS

Between Dec 5, 2016, and Jan 22, 2019, 10 947 children were screened, of whom 332 were randomly assigned, and 322 were included in the final analysis (n=162 in the control group and n=160 in the intervention group). The study was terminated after an interim analysis at 24% enrolment indicated futility. The median age of participants was 2·3 years (IQR 1·4-3·2), 65 (45%) were female, and the baseline characteristics of participants were similar between the two groups. The number of in-hospital deaths from any cause was 26 (16%) in the control group and 24 (15%) in the intervention group, with an absolute mortality difference of 1·0% (95% CI -6·9 to 9·0). Serious adverse events, including hypoglycaemia, hyperglycaemia, convulsions, reduced consciousness, and death, were reported in 47 (29%) children in the control group and 39 (24%) children in the intervention group.

INTERPRETATION

Increasing the cutoff blood glucose concentration for hypoglycaemia treatment in severely sick children in Malawi from 2·5 mmol/L to 5·0 mmol/L did not reduce all-cause in-hospital mortality. Our findings do not support changing the cutoff for dextrose administration, and further research on the optimal management of severely ill children who present to the emergency department with low blood glucose concentrations is warranted.

FUNDING

Swedish Research Council and Stockholm Country Council.

A multimodal approach using somatosensory evoked potentials for prognostication in hypoglycemic encephalopathy

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Hypoglycemic encephalopathy may be associated with poor neurological prognosis.

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Little data exists to guide prognostication in hypoglycemic encephalopathy.

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We describe a multimodal approach to prognostication in hypoglycemia.

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MRI, EEG, and SSEPs estimate severity of brain injury in hypoglycemic coma.

Objectives

We present a case of a patient with hypoglycemic encephalopathy with loss of median nerve N20 somatosensory evoked potentials (SSEPs) and describe our multimodal approach to prognostication in hypoglycemic encephalopathy.

Case

The patient was a 67-year-old woman with type 2 diabetes and stage 5 chronic kidney disease hospitalized for hypoglycemic encephalopathy. SSEPs showed bilateral absence of the median nerve N20 response. She ultimately suffered a poor outcome.

Discussion

There are no high-quality evidence-based clinical, neurophysiologic, or imaging studies available to aid in neurologic outcome prediction in hypoglycemic encephalopathy. In our practice we use a multimodal approach to neurologic prognostication, similar to that used in coma after cardiac arrest that includes SSEPs, EEG, and brain MRI, which enables an estimate of the severity of brain injury. As the literature is largely based on small studies or case reports, and is extrapolated from the cardiac arrest literature, we caution against early prognostication and disposition including the withdrawal of care, to avoid a self-fulfilling prophecy.

Risk Factors of Hypoglycemic Encephalopathy and Prolonged Hypoglycemia in Patients With Severe Hypoglycemia

Background

The aim of the study was to investigate risk factors of hypoglycemic encephalopathy (HE) in patients with severe hypoglycemia.

Methods

We retrospectively enrolled patients with severe hypoglycemia who were transported to the emergency department in an ambulance. We defined severe hypoglycemia as plasma glucose level < 60 mg/dL (or capillary levels < 50 mg/dL). HE was defined as severe hypoglycemia with altered level of consciousness (Glasgow coma scale < 12) and prolonged HE as coma or stupor lasting > 24 h after glucose administration. We compared several parameters between patients with and without HE and between prolonged and recovered patients.

Results

Included were 173 patients with severe hypoglycemia; of them, 94 were diagnosed with HE, with 12 of them prolonged HE. Glucose level in HE patients was lower than that in those without HE (P < 0.001). Moreover, we noted a significant difference in glucose levels between the prolonged and recovered groups. Furthermore, body temperature was higher in prolonged versus recovered patients (P = 0.0017).

Conclusion

Blood glucose level may be correlated with severity of altered level of consciousness. In addition, body temperature may be related to coma or prolonged stupor.

Glucose excursions and hypoglycemia in patients with type 2 diabetes treated with mitiglinide/voglibose versus glimepiride: A randomized cross-over trial

BACKGROUND

Glucose excursions and hypoglycemia are associated with cardiovascular complications. However, no studies have evaluated glucose excursions and the frequency of hypoglycemia in patients treated with mitiglinide/voglibose versus glimepiride as add-on to dipeptidyl peptidase-4 inhibitor therapy.

METHODS

This cross-over trial included 20 patients with type 2 diabetes. After initiating vildagliptin 100 mg, patients were randomly assigned to receive mitiglinide 10 mg/voglibose 0.2 mg three times daily for 3 days followed by glimepiride 1 mg once daily for the subsequent 3 days as add-on therapy, or vice versa. Glucose excursions and hypoglycemia frequency were measured using 24-h continuous glucose monitoring. Metabolic profile changes were evaluated using a meal tolerance test.

RESULTS

The mean glucose levels in the mitiglinide/voglibose and glimepiride phases were identical (8.01 vs 8.24 mmol/L, respectively). However, during the mitiglinide/voglibose phase compared with the glimepiride phase, the standard deviation of glucose (1.30 vs 2.10 mmol/L; P < 0.001), mean amplitude of glycemic excursions (3.47 vs 5.28 mmol/L; P < 0.001), M-value (24.6 vs 70.0; P < 0.001), continuous overlapping net glycemic action for a 1-h time interval (22.6 vs 31.0; P < 0.001), and area under the curve >10 mmol/L (0.18 vs 0.52 mmol/L per h; P < 0.001) were significantly lower. Hypoglycemia (glucose <3.8 mmol/L) was not observed during the mitiglinide/voglibose phase, but occurred 0.35 times/day in those taking glimepiride. Moreover, the mitiglinide/voglibose phase had higher premeal and lower post-meal glucose levels than the glimepiride phase.

CONCLUSIONS

Adding mitiglinide/voglibose to vildagliptin therapy results in more efficient postprandial glucose control and less hypoglycemia than adding glimepiride.

Continuous Glucose Monitoring in Resource-Constrained Settings for Hypoglycaemia Detection: Looking at the Problem from the Other Side of the Coin

The appearance, over a decade ago, of continuous glucose monitoring (CGM) devices has triggered a patient-centred revolution in the control and management of diabetes mellitus and other metabolic conditions, improving the patient’s glycaemic control and quality of life. Such devices, the use of which remains typically restricted to high-income countries on account of their elevated costs, at present show very limited implantation in resource-constrained settings, where many other urgent health priorities beyond diabetes prevention and management still need to be resolved. In this commentary, we argue that such devices could have an additional utility in low-income settings, whereby they could be selectively used among severely ill children admitted to hospital for closer monitoring of paediatric hypoglycaemia, a life-threatening condition often complicating severe cases of malaria, malnutrition, and other common paediatric conditions.

Case of steroid-responsive encephalopathy from hypoglycaemia

Hypoglycaemic encephalopathy is a feared complication in the management of patients with diabetes mellitus. We report on a 73-year-old woman with type 1 diabetes managed with an insulin pump who presented unresponsive after an inappropriate insulin bolus. The patient had minimal improvement in her neurological status over 8 days. After administration of 1 g intravenous methylprednisolone, she had dramatic neurological improvement including successful extubation and discharge from the intensive care unit. Steroid responsive encephalopathy is increasingly recognised in practice and literature. However, to the best of our knowledge, this is the first case of hypoglycaemic encephalopathy that responded to high-dose steroids.

Functional outcome of patients with prolonged hypoglycemic encephalopathy

Background

Little is known about the causes, clinical course and long-term outcome of comatose patients with prolonged hypoglycemic encephalopathy.

Methods

In a multicenter retrospective study conducted in patients hospitalized from July 1, 2004, to July 1, 2014, we investigated functional long-term prognosis and identified prognosis factors of patients admitted in an intensive care unit (ICU) with prolonged neurological manifestations related to hypoglycemia. Eligible patients were adults admitted to the ICU with a Glasgow Coma Score <8 due to hypoglycemia and persistent consciousness disorders after normalizing blood glucose levels. Patients with possible other causes of consciousness disorders, previous cognitive disorders, hypothermia <35 °C or circulatory arrest within 24 h after ICU admission, were excluded. Follow-up phone call was used to determine patients’ functional outcome using modified Rankin Scale (mRS) at a minimum of 1-year follow-up with mRS 0–3 defining good and mRS 4–6 poor outcomes.

Results

Forty-nine patients were included. Causes of hypoglycemia were various, mainly including insulin or oral antidiabetic drugs abuse (65%) and neuroendocrine carcinoma (16%). Twenty (41%) patients died in the ICU, two (4%) patients further died and nine (18%) patients had a poor outcome at long-term follow-up. Five patients discharged from the ICU with mRS > 3 improved enough to be in the good outcome group 1 year later. Twenty-two (45%) patients underwent therapeutic limitation, mainly related to no expected hope for improvement. On multivariate analysis, only low mRS prior to ICU admission (OR 2.6; 95% CI 1.1–6.3; P = 0.03) and normal brain imaging (OR 7.1; 95% CI 1.1–44; P = 0.03) were significantly predictive of a good outcome. All patients (n = 15) who remained hypoglycemic >480 min had a poor outcome.

Conclusion

Poor outcome was observed in about 60% of this population of hypoglycemic encephalopathy. However, some patients can recover satisfactorily over time.

Risk factors of severe hypoglycemia requiring medical assistance and neurological sequelae in patients with diabetes: A case-control study

Hypoglycemia commonly occurs in patients who are being treated for diabetes. In some cases, these patients suffer from severe hypoglycemia that requires medical assistance and which can unfortunately result in long-term disabilities. Therefore, we investigated risk factors associated with severe hypoglycemia requiring medical assistance (HMA) and the resulting neurological sequelae in patients with diabetes. This investigation was a case-control study that assessed 129 patients with diabetes and documented hypoglycemia from a single tertiary hospital between February 2013 and May 2015. They were treated with oral hypoglycemic agents alone (54%) or with insulin with/without oral hypoglycemic agents (46%). If a patient with diabetes visited the emergency department due to hypoglycemia, this was defined as HMA. The control group was composed of patients with documented, nonsevere hypoglycemia who visited the outpatient clinic during the same period. The degree of neurological disability in the HMA patients was measured using the modified Rankin Scale. A multivariate analysis revealed that independent risk factors of HMA were associated with a lack of the self-monitoring of blood glucose (SMBG) and previous episodes of severe hypoglycemia. In the HMA group, 15 patients (22%) had neurological sequelae at the time of discharge. Patients with neurological sequelae were older than those without sequelae (74.3 years vs 65.8 years, P = 0.006) and had increased psychological evidence of disorders such as insomnia, dementia, and depression (40% vs 11%, P = 0.017). Patients with sequelae were also more likely to live in rural areas (47% vs 19%, P = 0.04) and to have a longer time from last seen normal till glucose administration (5.2 hours vs 1.6 hours, P = 0.027). In the present study, absence of SMBG and previous severe hypoglycemic episodes were independent risk factors of HMA and patients with an older age, a psychological disorder, a rural residence, and a prolonged duration of hypoglycemia had higher risks of neurological sequelae. Therefore, the present findings suggest that physicians should aim to prevent hypoglycemia in patients with a history of hypoglycemia and provide education for these patients regarding regular SMBG.

Hypoglycemia and Risk Factors for Death in 13 Years of Pediatric Admissions in Mozambique

Hypoglycemia is a life-threatening complication of several diseases in childhood. We describe the prevalence and incidence of hypoglycemia among admitted Mozambican children, establishing its associated risk factors. We retrospectively reviewed clinical data of 13 years collected through an ongoing systematic morbidity surveillance in Manhiça District Hospital in rural Mozambique. Logistic regression was used to identify risk factors for hypoglycemia and death. Minimum community-based incidence rates (MCBIRs) for hypoglycemia were calculated using data from the demographic surveillance system. Of 49,089 children < 15 years hospitalized in Manhiça District Hospital, 45,573 (92.8%) had a glycemia assessment on admission. A total of 1,478 children (3.2%) presented hypoglycemia (< 3 mmol/L), of which about two-thirds (972) were with levels < 2.5 mmol/L. Independent risk factors for hypoglycemia on admission and death among hypoglycemic children included prostration, unconsciousness, edema, malnutrition, and bacteremia. Hypoglycemic children were significantly more likely to die (odds ratio [OR] = 7.11; P < 0.001), with an associated case fatality rate (CFR) of 19.3% (245/1,267). Overall MCBIR of hypoglycemia was 1.57 episodes/1,000 child years at risk (CYAR), significantly decreasing throughout the study period. Newborns showed the highest incidences (9.47 episodes/1,000 CYAR, P < 0.001). Hypoglycemia remains a hazardous condition for African children. Symptoms and signs associated to hypoglycemia should trigger the verification of glycemia and the implementation of life-saving corrective measures.

Effects of Alda-1, an Aldehyde Dehydrogenase-2 Agonist, on Hypoglycemic Neuronal Death

Hypoglycemic encephalopathy (HE) is caused by a lack of glucose availability to neuronal cells, and no neuroprotective drugs have been developed as yet. Studies on the pathogenesis of HE and the development of new neuroprotective drugs have been conducted using animal models such as the hypoglycemic coma model and non-coma hypoglycemia model. However, both models have inherent problems, and establishment of animal models that mimic clinical situations is desirable. In this study, we first developed a short-term hypoglycemic coma model in which rats could be maintained in an isoelectric electroencephalogram (EEG) state for 2 min and subsequent hyperglycemia without requiring anti-seizure drugs and an artificial ventilation. This condition caused the production of 4-hydroxy-2-nonenal (4-HNE), a cytotoxic aldehyde, in neurons of the hippocampus and cerebral cortex, and a marked increase in neuronal death as evaluated by Fluoro-Jade B (FJB) staining. We also investigated whether N-(1,3-benzodioxole-5-ylmethyl)-2,6-dichlorobenzamide (Alda-1), a small-molecule agonist of aldehyde dehydrogenase-2, could attenuate 4-HNE levels and reduce hypoglycemic neuronal death. After confirming that EEG recordings remained isoelectric for 2 min, Alda-1 (8.5 mg/kg) or vehicle (dimethyl sulfoxide; DMSO) was administered intravenously with glucose to maintain a blood glucose level of 250 to 270 mg/dL. Fewer 4-HNE and FJB-positive cells were observed in the cerebral cortex of Alda-1-treated rats than in DMSO-treated rats 24 h after glucose administration (P = 0.002 and P = 0.020). Thus, activation of the ALDH2 pathway could be a molecular target for HE treatment, and Alda-1 is a potentially neuroprotective agent that exerts a beneficial effect on neurons when intravenously administered simultaneously with glucose.