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                                Patient-oriented evidence that matters                                                                  POEMs
      Severe hypoglycemic episodes                 ease, insulin use, and average A1C lev-                             Synopsis Evidence strongly supports
      increase risk of dementia                    els. The remaining attributable risk of                             the accuracy of the OAR in adults,
      Clinical question Do severe hypo-            dementia for patients with one or more                              but their accuracy in children is uncer-
      glycemic episodes increase the risk of       severe hypoglycemic episodes com-                                   tain. These investigators thoroughly
      dementia in adults with type 2 diabetes?     pared with those with no episodes was                               searched multiple databases, including
      Bottom line A history of severe hypo-        2.39% per year. Hazard ratios (HRs)                                 MEDLINE, the Cochrane Register of
      glycemia requiring hospitalization or        increased proportionally with the num-                              Controlled Trials, and EMBASE; meet-
      an emergency department visit is sig-        ber of episodes of hypoglycemia: at                                 ing abstracts; pertinent reference lists;
      nificantly associated with a diagnosis       least one episode, HR = 1.68; two epi-                              and validated citation search trackers.
      of dementia in adults with type 2 dia-       sodes, HR = 2.15; and three or more                                 No language restrictions applied. Ac-
      betes. Although the mean age of the          episodes, HR = 2.60. To determine                                   ceptable study designs included pro-
      patients in this study was 65 years,         whether preclinical dementia was re-                                spective or retrospective cohort studies,
      the authors report a significant associ-     sponsible for the increased likelihood                              cross-sectional studies, or case series
      ation between dementia diagnosis and         of hypoglycemic episodes, the authors                               with more than 10 patients using ra-
      prior hypoglycemic events occurring          performed a subanalysis examining                                   diograph of the ankle and/or foot or a
      at least 18 years earlier. Given recent      the risk in patients whose hypoglycemic                             proxy measure (eg, telephone follow-up
      evidence that tight glucose control (a       episodes occurred at least 2 years before                           at 14 days) for the diagnostic reference
      glycosylated hemoglobin [A1C] level          a dementia diagnosis and at least 18                                standard. Two reviewers independently
      less than 7.0) is not beneficial and in-     years before a diagnosis. Although there                            assessed the methodologic quality of
      creases the risk of hypoglycemia, clini-     were fewer hypoglycemic events, there                               included studies. Disagreements were
      cians and patients should re-evaluate        was still a significant increased risk for                          resolved by discussion. Publication bias
      their individual treatment goals. (Level     dementia with prior hypoglycemia (one                               was formally assessed using two stan-
      of evidence = 1b)                            or more episodes vs no episodes, HR =                               dard statistical tools. From the 12 stud-
      Synopsis These investigators hoped to        1.32 for 18-year lag time).                                         ies (N = 3,130 patients) meeting inclu-
      determine whether severe episodes of         Whitmer RA, Karter AJ, Yaffe K, et al. Hypoglycemic episodes        sion criteria, 671 fractures (21.4%) were
      hypoglycemia requiring hospitalization       and risk of dementia in older patients with type 2 diabetes mel-    identified. Of the 10 fractures that were
      or an emergency department visit in-         litus. JAMA. 2009;3
Description: The overall pooled sensitivity for detecting fractures was 98.5% (95% CI, 97.3%- 99.2%). Because of significant heterogeneity (7.9%-50%), the authors do not report a pooled specificity.
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