Adrenaline increases skeletal muscle glycogenolysis, pyruvate dehydrogenase activation and carbohydrate oxidation during moderate exercise in humans

Lactate kinetics at the lactate threshold in trained and untrained men

To understand the meaning of the lactate threshold (LT) and to test the hypothesis that endurance training augments lactate kinetics [i.e., rates of appearance and disposal (Ra and Rd, respectively, mg·kg−1·min−1) and metabolic clearance rate (MCR, ml·kg−1·min−1)], we studied six untrained (UT) and six trained (T) subjects during 60-min exercise bouts at power outputs (PO) eliciting the LT. Trained subjects performed two additional exercise bouts at a PO 10% lower (LT-10%), one of which involved a lactate clamp (LC) to match blood lactate concentration ([lactate]b) to that achieved during the LT trial. At LT, lactate Ra was higher in T (24.1 ± 2.7) than in UT (14.6 ± 2.4; P < 0.05) subjects, but Ra was not different between UT and T when relative exercise intensities were matched (UT-LT vs. T-LT-10%, 67% V̇o2max). At LT, MCR in T (62.5 ± 5.0) subjects was 34% higher than in UT (46.5 ± 7.0; P < 0.05), and a reduction in PO resulted in a significant increase in MCR by 46% (LT-10%, 91.5 ± 14.9, P < 0.05). At matched relative exercise intensities (67% V̇o2max), MCR in T subjects was 97% higher than in UT ( P < 0.05). During the LC trial, MCR in T subjects was 64% higher than in UT ( P < 0.05), in whom %V̇o2max and [lactate]b were similar. We conclude that 1) lactate MCR reaches an apex below the LT, 2) LT corresponds to a limitation in MCR, and 3) endurance training augments capacities for lactate production, disposal and clearance.

Changes in energy metabolism in pheochromocytoma

CONTEXT

Catecholamine overproduction in pheochromocytoma affects basal metabolism, resulting in weight loss despite normal food intake.

OBJECTIVE

The objective of the study was to evaluate changes in energy metabolism expressed as resting energy expenditure (REE) in patients with pheochromocytoma before and after adrenalectomy and the possible relationship with circulating inflammatory markers.

DESIGN

We measured REE in 17 patients (8 women) with pheochromocytoma by indirect calorimetry (Vmax-Encore 29N system) before and 1 year after adrenalectomy. Body fat percentage was measured with a Bodystat device. Inflammatory markers (leukocytes count and C-reactive protein) and cytokines (TNF-α, IL-6, and IL-8) were analyzed with a Luminex 200.

RESULTS

REE measured in the pheochromocytoma group was 10.4% higher than the predicted value (1731 ± 314 vs 1581 ± 271 kcal/d; P = .004). Adrenalectomy significantly increased body mass index (P =0.004) and the percentage of body fat (P = .01), with a proportional increase in fat distribution (waist circumference, P = .045; hip circumference, P = .001). REE significantly decreased after adrenalectomy (1731 ± 314 vs 1539 ± 215 kcal/d; P = .002), even after adjustments in body surface and body weight (P < .001). After adrenalectomy, we found a significant decrease in leukocyte counts (P = .014) and in the levels of TNF-α (P < .001), IL-6 (P = .048), and IL-8 (P = .007) but not C-reactive protein (P = .09). No significant correlations among calorimetry parameters, hormones, and proinflammatory markers were detected.

CONCLUSIONS

Chronic catecholamine overproduction in pheochromocytoma may lead to a proinflammatory and hypermetabolic state characterized by increased REE. Adrenalectomy leads to the normalization of energy metabolism followed by an increase in body mass index and body fat content and decreases in inflammatory markers and cytokines.

What do we need beyond hemoglobin A1c to get the complete picture of glycemia in people with diabetes?

Hemoglobin A1c (HbA1c) is currently the most commonly used marker for the determination of the glycemic status in people with diabetes and it is frequently used to guide therapy and especially medical treatment of people with diabetes. The measurement of HbA1c has reached a high level of analytical quality and, therefore, this biomarker is currently also suggested to be used for the diagnosis of diabetes. Nevertheless, it is crucial for people with diabetes and their treating physicians to be aware of possible interferences during its measurement as well as physiological or pathological factors that contribute to the HbA1c concentration without being related to glycemia, which are discussed in this review. We performed a comprehensive review of the literature based on PubMed searches on HbA1c in the treatment and diagnosis of diabetes including its most relevant limitations, glycemic variability and self-monitoring of blood glucose (SMBG). Although the high analytical quality of the HbA1c test is widely acknowledged, the clinical relevance of this marker regarding risk reduction of cardiovascular morbidity and mortality is still under debate. In this respect, we argue that glycemic variability as a further risk factor should deserve more attention in the treatment of diabetes.

Regulation of glucose and glycogen metabolism during and after exercise

Utilization of carbohydrate in the form of intramuscular glycogen stores and glucose delivered from plasma becomes an increasingly important energy substrate to the working muscle with increasing exercise intensity. This review gives an update on the molecular signals by which glucose transport is increased in the contracting muscle followed by a discussion of glycogen mobilization and synthesis by the action of glycogen phosphorylase and glycogen synthase, respectively. Finally, this review deals with the signalling relaying the well-described increased sensitivity of glucose transport to insulin in the post-exercise period which can result in an overshoot of intramuscular glycogen resynthesis post exercise (glycogen supercompensation).

Computational Model of Cellular Metabolic Dynamics in Skeletal Muscle Fibers during Moderate Intensity Exercise

Human skeletal muscles have different fiber types with distinct metabolic functions and physiological properties. The quantitative metabolic responses of muscle fibers to exercise provide essential information for understanding and modifying the regulatory mechanisms of skeletal muscle. Since in vivo data from skeletal muscle during exercise is limited, a computational, physiologically based model has been developed to quantify the dynamic metabolic responses of many key chemical species. This model distinguishes type I and II muscle fibers, which share the same blood supply. An underlying hypothesis is that the recruitment and metabolic activation of the two main types of muscle fibers differ depending on the pre-exercise state and exercise protocols. Here, activation measured by metabolic response (or enzymatic activation) in single fibers is considered linked but distinct from fiber recruitment characterized by the number (or mass) of each fiber type involved during a specific exercise. The model incorporates species transport processes between blood and muscle fibers and most of the important reactions/pathways in cytosol and mitochondria within each fiber type. Model simulations describe the dynamics of intracellular species concentrations and fluxes in muscle fibers during moderate intensity exercise according to various experimental protocols and conditions. This model is validated by comparing model simulations with experimental data in single muscle fibers and in whole muscle. Model simulations demonstrate that muscle-fiber recruitment and metabolic activation patterns in response to exercise produce significantly distinctive effects depending on the exercise conditions.

Effects of adrenaline on lactate, glucose, lipid and protein metabolism in the placebo controlled bilaterally perfused human leg

AIM

Adrenaline has widespread metabolic actions, including stimulation of lipolysis and induction of insulin resistance and hyperlactatemia. Systemic adrenaline administration, however, generates a very complex hormonal and metabolic scenario. No studies employing regional, placebo controlled and adrenaline infusion exist. Our study was designed to test the hypothesis that local placebo controlled leg perfusion with adrenaline directly increases local lactate release, stimulates lipolysis, induces insulin resistance and leaves protein metabolism unaffected.

METHODS

  We studied seven healthy volunteers with bilateral femoral vein and artery catheters during 3-h basal and 3-h hyperinsulinemic (0.6 mU kg(-1) min(-1) ) euglycemic clamp conditions. One femoral artery was perfused with saline and the other with adrenaline (0.4 μg min m(-2) ). Lipid metabolism was quantified with [9,10-(3) H] palmitate and amino acid metabolism with (15) N-phenylalanine and lactate and glucose by raw arterio-venous differences.

RESULTS

  Femoral vein plasma adrenaline increased ≈eightfold in the perfused leg with unaltered blood flows. Adrenaline perfusion significantly increased local leg lactate release from 0.01 to 0.25 mmol min(-1) per leg, palmitate release in the basal state 11.5-16.9 μmol min(-1) per leg and during the clamp 2.62-8.44 μmol min(-1) per leg. Glucose uptake decreased during the clamp from ≈180 to 30 μmol min(-1) per leg. Phenylalanine kinetics was not affected by adrenaline.

CONCLUSION

  Adrenaline directly increases lactate release and lipolysis and inhibits insulin-stimulated glucose uptake in the perfused human leg. Adrenaline has no direct effects on peripheral amino acid metabolism. Adrenaline-induced lactate release from striated muscle may be an important mechanism underlying hyperlactatemia in the critically ill.

Acute glucose dysmetabolism in the elderly with ST elevation myocardial infarction submitted to mechanical revascularization

Though age is a predictor of adverse events after acute coronary syndrome, including in-hospital and post-hospital mortality rates, elderly patients are under-represented in randomized trials evaluating strategies of early coronary revascularization in acute myocardial infarction. Several factors can account for the unfavorable outcome of the elderly, comprising increased glucose values. Diabetes is more common in the elderly patients with acute myocardial infarction in respect to younger patients and elevated glucose, though common, are rarely treated and associated with increased mortality, particularly in those without recognized diabetes. Age itself is thought to affect the acute glucose response to stress. Human aging is associated with impaired β-cell sensitivity to glucose and impaired β-cell compensation to insulin resistance and older people exhibit an impaired glucose response after injury characterized by a more marked increases in endogenous glucose production. In the early phase of ST elevation myocardial infarction (STEMI), the acute glucose response to stress comprises not only hyperglycemia but also insulin-resistance (assessed by the Homeostatic Model Assessment). Recently it has been documented in 346 STEMI patients submitted to mechanical revascularization that the acute glucose response to myocardial injury differs in respect to age, since older patients showed the highest glucose levels and the poorest glycemic control during ICCU stay in the lack of differences in insulin resistance incidence. Taking into account that aging impairs the acute glucose response to stress in elderly STEMI patients, further studies are needed to establish whether a different (more aggressive) therapeutic regime is needed in this subgroup of patients at higher risk.

Exercise-related hypoglycemia in diabetes mellitus

Current recommendations are that people with Type 1 and Type 2 diabetes mellitus exercise regularly. However, in cases in which insulin or insulin secretagogues are used to manage diabetes, patients have an increased risk of developing hypoglycemia, which is amplified during and after exercise. Repeated episodes of hypoglycemia blunt autonomic nervous system, neuroendocrine and metabolic defenses (counter-regulatory responses) against subsequent episodes of falling blood glucose levels during exercise. Likewise, antecedent exercise blunts counter-regulatory responses to subsequent hypoglycemia. This can lead to a vicious cycle, by which each episode of either exercise or hypoglycemia further blunts counter-regulatory responses. Although contemporary insulin therapies cannot fully mimic physiologic changes in insulin secretion, people with diabetes have several management options to avoid hypoglycemia during and after exercise, including regularly monitoring blood glucose, reducing basal and/or bolus insulin, and consuming supplemental carbohydrates.

Molecular mechanisms behind clinical benefits of intensive insulin therapy during critical illness: glucose versus insulin

High blood glucose levels have been associated with morbidity and poor outcome in critically ill patients, irrespective of underlying pathology. In a large, randomised, controlled study the use of insulin therapy to maintain normoglycaemia for at least a few days improved survival and reduced morbidity of patients who are in a surgical intensive care unit (ICU). Since the publication of this landmark study, several other investigators have provided support for, whereas others have questioned, the beneficial effects of intensive insulin therapy. In this review, we discuss the investigated potential molecular mechanisms behind the clinical benefits of intensive insulin therapy. We first describe the molecular origin of hyperglycaemia and the impact of the therapy on insulin sensitivity. Next, the molecular basis of glucose toxicity in critical illness and the impact of intensive insulin therapy hereon are described, as well as other non-glucose-toxicity-related metabolic effects of intensive insulin therapy.

Insulin therapy induces changes in the inflammatory response in a murine 2-hit model

Post-traumatic complications commonly seen on intensive care units include sepsis and associated disorders, which are accompanied by alterations in inflammatory cytokine expression patterns and in activation of neutrophils. Hyperglycaemia, often occurring after trauma and sepsis, is a further risk factor for morbidity and mortality among critically ill people. Clinical investigations have suggested that strict glycaemic control by insulin titration reduces overall mortality. This study aimed to further elucidate the pathophysiological and immunomodulative actions of insulin. Femoral fracture was induced in a murine model, followed by 1h of haemorrhage. Two days after the first hit, sepsis was induced by caecal ligation and puncture (CLP). In control animals, laparotomy only was performed. Insulin in two different concentrations (10IU or 20IU) or vehicle was administered daily. Insulin therapy was associated with improvement of clinical parameters, slightly improved survival rates and, in lungs and liver, fewer infiltrating neutrophils and reduced IL-6 and IL-10 mRNA expression. These results suggested that, in this animal model, insulin had a direct anti-inflammatory effect that was independent of modulation of blood glucose levels.

Prehospital endotracheal intubation in patients with severe traumatic brain injury: guidelines versus reality

The international Brain Trauma Foundation guidelines recommend prehospital endotracheal intubation in all patients with traumatic brain injury (TBI) and a Glasgow Coma Scale (GCS)< or =8. Close adherence to these guidelines is associated with improved outcome, but not all severely injured TBI patients receive adequate prehospital airway support. Here we hypothesized that guideline adherence varies when skills are involved that rely on training and expertise, such as endotracheal intubation. We retrospectively studied the medical records of CT-confirmed TBI patients with a GCS< or =8 who were referred to a level 1 trauma centre in Amsterdam (n=127). Records were analyzed for demographic parameters, prehospital treatment modalities, involvement of an emergency medical service (EMS) and respiratory and metabolic parameters upon arrival at the hospital. Patients were mostly male, aged 45+/-21 years with a median injury severity score (ISS) of 26. Of all patients for whom guidelines recommend endotracheal intubation, only 56% were intubated. In 21 out of 106 severe cases an EMS was not called for, suggesting low guideline adherence. Especially those TBI patients treated by paramedics tended to develop higher levels of stress markers like glucose and lactate. We observed a low degree of adherence to intubation guidelines in a Dutch urban area. Main reasons for low adherence were the unavailability of specialized care, scoop and run strategies and absence of a specialist physician in cases where intubation was recommended. The discrepancy between guidelines and reality warrants changing practice to improve guideline compliance and optimize outcome in TBI patients.

Glucose dysmetabolism and prognosis in critical illness

Acute hyperglycemia frequently present in stress conditions, has long been generally accepted as normal, and not thought to be a cause for concern since a moderate hyperglycemia in critically ill adult patients has been thought to be beneficial during the "fight or flight" response to ensure a supply of glucose as a source of energy to organs that do not require insulin for glucose uptake (i.e., the brain and the immune system). However, an increasing body of evidence associates the upon-admission degree and duration of hyperglycemia during critical illness with an adverse outcome. Hyperglycemia should be regarded as a part of the systemic and complex metabolic derangements observed in critical illness in response to stress and inflammation, which can lead, independent of initial disease, to multiorgan dysfunction and death. A tight glycemic control should be constantly pursued and achieved by insulin infusion bearing in mind that the therapeutic target is fighting the systemic inflammatory response and not merely the glucose plasma levels.

Glycemia management in neurocritical care patients: a review

Intensive research investigating the relation between the management of glycemia and outcome in patients receiving neurocritical care has underlined the possible benefits and adverse events related to glucose control. Here, we review experimental and clinical studies investigating the effects of hypoglycemia and hyperglycemia on the brain that advance current knowledge on managing glycemia in patients receiving neurocritical care.

Role of NADH/NAD+ transport activity and glycogen store on skeletal muscle energy metabolism during exercise: in silico studies

Skeletal muscle can maintain ATP concentration constant during the transition from rest to exercise, whereas metabolic reaction rates may increase substantially. Among the key regulatory factors of skeletal muscle energy metabolism during exercise, the dynamics of cytosolic and mitochondrial NADH and NAD+ have not been characterized. To quantify these regulatory factors, we have developed a physiologically based computational model of skeletal muscle energy metabolism. This model integrates transport and reaction fluxes in distinct capillary, cytosolic, and mitochondrial domains and investigates the roles of mitochondrial NADH/NAD+ transport (shuttling) activity and muscle glycogen concentration (stores) during moderate intensity exercise (60% maximal O2 consumption). The underlying hypothesis is that the cytosolic redox state (NADH/NAD+) is much more sensitive to a metabolic disturbance in contracting skeletal muscle than the mitochondrial redox state. This hypothesis was tested by simulating the dynamic metabolic responses of skeletal muscle to exercise while altering the transport rate of reducing equivalents (NADH and NAD+) between cytosol and mitochondria and muscle glycogen stores. Simulations with optimal parameter estimates showed good agreement with the available experimental data from muscle biopsies in human subjects. Compared with these simulations, a 20% increase (or approximately 20% decrease) in mitochondrial NADH/NAD+ shuttling activity led to an approximately 70% decrease (or approximately 3-fold increase) in cytosolic redox state and an approximately 35% decrease (or approximately 25% increase) in muscle lactate level. Doubling (or halving) muscle glycogen concentration resulted in an approximately 50% increase (or approximately 35% decrease) in cytosolic redox state and an approximately 30% increase (or approximately 25% decrease) in muscle lactate concentration. In both cases, changes in mitochondrial redox state were minimal. In conclusion, the model simulations of exercise response are consistent with the hypothesis that mitochondrial NADH/NAD+ shuttling activity and muscle glycogen stores affect primarily the cytosolic redox state. Furthermore, muscle lactate production is regulated primarily by the cytosolic redox state.

Glycaemic control and perioperative organ protection

The concept of stress hyperglycaemia as an adaptive, beneficial response in critical illness has recently been challenged. Two large prospective randomized controlled trials in the Leuven University Hospital surgical and medical ICUs demonstrated that maintenance of normoglycaemia with intensive insulin therapy substantially prevents morbidity and reduces mortality. Strict normoglycaemia is required to gain most clinical benefit. With this therapy the risk of hypoglycaemia increased, but without inducing obvious clinical sequellae. Other studies have been used to advocate against implementation of intensive insulin therapy by showing lack of benefit or questioning safety. However, these studies are inconclusive on this subject, due to problems of not reaching normal glucose levels clearly separated from the standard glycaemic group or lack of statistical power. Clearly, future studies should be adequately powered and comply with the study protocol in order to confirm the survival and other clinical benefits of intensive insulin therapy.

Are hormonal responses to exercise in young men with Down's syndrome related to reduced endurance performance?

The aim of the present study was to analyse whether hormonal responses could explain an exercise limitation in Down's syndrome (DS). Fourteen young men with DS (mean age 22.5 +/- 0.7 years) and 15 controls (CONT, mean age 22.5 +/- 0.3 years) participated in the study. During a treadmill submaximal incremental test, blood samples were collected for determination of hormonal and metabolic variables. Compared to CONT, DS individuals showed lower VO(2max) (P < 0.05), and lower duration of submaximal incremental exercise (P < 0.001). At rest, DS individuals showed greater catecholamines, insulin and leptin values (P < 0.05), but lower testosteronemia and cortisolemia (P < 0.05), compared to CONT. During submaximal incremental tests, catecholamines and cortisol were not increased, whereas the insulin concentration of DS individuals was significantly higher (P < 0.01) compared to CONT. Glycaemia increased significantly at the end of submaximal incremental test for CONT but not for DS individuals (P < 0.01). Maximal fat oxidation was lower (P < 0.01), whereas non-esterified fatty acids concentrations rose significantly during submaximal exercise in DS individuals. These results indicate an altered hormonal response to exercise in DS individuals. This endocrine profile at rest and during exercise may limit endurance performance in DS individuals.

Tricarboxylic acid cycle intermediate pool size: functional importance for oxidative metabolism in exercising human skeletal muscle

The tricarboxylic acid (TCA) cycle is the major final common pathway for oxidation of carbohydrates, lipids and some amino acids, which produces reducing equivalents in the form of nicotinamide adenine dinucleotide and flavin adenine dinucleotide that result in production of large amounts of adenosine triphosphate (ATP) via oxidative phosphorylation. Although regulated primarily by the products of ATP hydrolysis, in particular adenosine diphosphate, the rate of delivery of reducing equivalents to the electron transport chain is also a potential regulatory step of oxidative phosphorylation. The TCA cycle is responsible for the generation of approximately 67% of all reducing equivalents per molecule of glucose, hence factors that influence TCA cycle flux will be of critical importance for oxidative phosphorylation. TCA cycle flux is dependent upon the supply of acetyl units, activation of the three non-equilibrium reactions within the TCA cycle, and it has been suggested that an increase in the total concentration of the TCA cycle intermediates (TCAi) is also necessary to augment and maintain TCA cycle flux during exercise. This article reviews the evidence of the functional importance of the TCAi pool size for oxidative metabolism in exercising human skeletal muscle. In parallel with increased oxidative metabolism and TCA cycle flux during exercise, there is an exercise intensity-dependent 4- to 5-fold increase in the concentration of the TCAi. TCAi concentration reaches a peak after 10-15 minutes of exercise, and thereafter tends to decline. This seems to support the suggestion that the concentration of TCAi may be of functional importance for oxidative phosphorylation. However, researchers have been able to induce dissociations between TCAi pool size and oxidative energy provision using a variety of nutritional, pharmacological and exercise interventions. Brief periods of endurance training (5 days or 7 weeks) have been found to result in reduced TCAi pool expansion at the start of exercise (same absolute work intensity) in parallel with either equivalent or increased oxidative energy provision. Cycloserine inhibits alanine aminotransferase, which catalyses the predominant anaplerotic reaction in exercising human muscle. When infused into contracting rat hindlimb muscle, TCAi pool expansion was reduced by 25% with no significant change in oxidative energy provision or power output. Glutamine supplementation has been shown to enhance TCAi pool expansion at the start of exercise with no increase in oxidative energy provision. In summary, there is a consistent dissociation between the extent of TCAi pool expansion at the onset of exercise and oxidative energy provision. At the other end of the spectrum, the parallel loss of TCAi, glycogen and adenine nucleotides and accumulation of inosine monophosphate during prolonged exercise has led to the suggestion that there is a link between muscle glycogen depletion, reduced TCA cycle flux and the development of fatigue. However, analysis of serial biopsies during prolonged exercise demonstrated dissociation between muscle TCAi content and both muscle glycogen content and muscle oxygen uptake. In addition, the delay in fatigue development achieved through increased carbohydrate availability does not attenuate TCAi reduction during prolonged exercise. Therefore, TCAi concentration in whole muscle homogenate does not seem to be of functional importance. However, TCAi content can currently only be measured in whole muscle homogenate rather than the mitochondrial subfraction where TCA cycle reactions occur. In addition, anaplerotic flux rather than TCAi content per se is likely to be of greater importance in determining TCA cycle flux, since TCAi content is probably merely reflective of anaplerotic substrate concentration. Methodological advances are required to allow researchers to address the questions of whether oxidative phosphorylation is limited by mitochondrial TCAi content and/or anaplerotic flux.

Catecholamine regulation of local lactate production in vivo in skeletal muscle and adipose tissue: role of -adrenoreceptor subtypes

CONTEXT

The regulation of lactate production in skeletal muscle (SM) and adipose tissue (AT) is not fully elucidated.

OBJECTIVE

Our objective was to investigate the catecholamine-mediated regulation of lactate production and blood flow in SM and AT in healthy, normal-weight subjects by using microdialysis.

METHODS

First, lactate levels in SM and AT were measured during an iv norepinephrine infusion (n = 11). Local blood flow was determined with the 133Xe-clearance technique. Second, muscle lactate was measured during hypoglycemia and endogenous epinephrine stimulation (n = 12). Third, SM was perfused with selective beta(1-3)-adrenoreceptor agonists in situ (n = 8). Local blood flow was measured with the ethanol perfusion technique.

RESULTS

In response to iv norepinephrine, the fractional release of lactate (difference between tissue and arterial lactate) increased by 40% in SM (P = 0.001), whereas remaining unchanged in AT. Blood flow decreased by 40% in SM (P < 0.005) and increased by 50% in AT (P < 0.05). In response to hypoglycemia, epinephrine increased 10-fold, and the fractional release of lactate in SM doubled (P < 0.0001). The blood flow remained unchanged. The beta2-agonist, terbutaline, caused a marked concentration-dependent increase of muscle lactate and blood flow (P < 0.0001). The beta(1)-agonist, dobutamine, induced a discrete increase of muscle lactate (P < 0.0001), and the blood flow remained unchanged. The beta3-agonist, CPG 12177, did not affect muscle lactate or blood flow.

CONCLUSIONS

Catecholamines stimulate lactate production in SM, but not in AT. In SM, the beta2-adrenoreceptor is the most important beta-adrenergic receptor subtype in the regulation of lactate production.

Modeling the effect of blood glucose and physical exercise on plasma adrenaline in people with type 1 diabetes

BACKGROUND

Adrenaline is often studied in people with type 1 diabetes during hypoglycemic episodes. Adrenaline is difficult and costly to measure, and therefore a pharmacokinetic model of adrenaline can be a supportive tool that adds information and saves measurements resources.

METHODS

We have developed a compartment model of adrenaline secretion and elimination. It is based on input on physical exercise, blood glucose level, and optional infused adrenaline. The model parameters are identified using least square regression on published data of adrenaline kinetics measured in a number of different clinical studies.

RESULTS

Simulation of published adrenaline measurements shows agreement with data of adrenaline infusion (R(2) = 0.9), exercise (R(2) = 0.97), and hypoglycemic episodes (R(2) = 0.93-0.97). The identified function describing adrenaline secretion during hypoglycemia shows an exponential increase for a blood glucose decreasing below 3.5 mmol/L and an approaching maximum around 1 mmol/L. Exercise intensity increasing above 50% of maximal oxygen uptake maximum causes approximately exponential increase in adrenaline secretion.

CONCLUSION

The model is a simple tool that can be used to simulate and predict adrenaline concentrations in situations of hypoglycemia, physical exercise, and adrenaline infusion. In conclusion, the developed model, although simple, seems to be useful for simulating adrenaline dynamics in situations with hypoglycemic episodes, physical exercise, or infusion.

Glucose metabolism and catecholamines

Until now, catecholamines were the drugs of choice to treat hypotension during shock states. Catecholamines, however, also have marked metabolic effects, particularly on glucose metabolism, and the degree of this metabolic response is directly related to the beta2-adrenoceptor activity of the individual compound used. Under physiologic conditions, infusing catecholamine is associated with enhanced rates of aerobic glycolysis (resulting in adenosine triphosphate production), glucose release (both from glycogenolysis and gluconeogenesis), and inhibition of insulin-mediated glycogenesis. Consequently, hyperglycemia and hyperlactatemia are the hallmarks of this metabolic response. Under pathophysiologic conditions, the metabolic effects of catecholamines are less predictable because of changes in receptor affinity and density and in drug kinetics and the metabolic capacity of the major gluconeogenic organs, both resulting from the disease per se and the ongoing treatment. It is also well-established that shock states are characterized by a hypermetabolic condition with insulin resistance and increased oxygen demands, which coincide with both compromised tissue microcirculatory perfusion and mitochondrial dysfunction. This, in turn, causes impaired glucose utilization and may lead to inadequate glucose supply and, ultimately, metabolic failure. Based on the landmark studies on intensive insulin use, a crucial role is currently attributed to glucose homeostasis. This article reviews the effects of the various catecholamines on glucose utilization, both under physiologic conditions, as well as during shock states. Because, to date (to our knowledge), no patient data are available, results from relevant animal experiments are discussed. In addition, potential strategies are outlined to influence the catecholamine-induced effects on glucose homeostasis.

Intensive insulin therapy in the intensive care unit: update on clinical impact and mechanisms of action

OBJECTIVE

Hyperglycemia is a common feature of the critically ill and has been associated with increased mortality. In this review, we give an overview of studies associating critical illness-induced hyperglycemia with adverse outcome and describe how mortality and morbidity are affected when blood glucose levels are strictly controlled to normoglycemia with intensive insulin therapy.

RESULTS

Maintaining normoglycemia with intensive insulin therapy improves survival rates and reduces morbidity in prolonged critically ill patients in both surgical and medical intensive care units (ICUs), as shown by 2 large randomized controlled studies. Prevention of cellular glucose toxicity by strict glycemic control appears to play a predominant role, but other metabolic and nonmetabolic effects of insulin also seem to contribute to the clinical benefits of this therapy.

CONCLUSION

These data support the generalized implementation of a strict blood glucose control management with intensive insulin therapy in adult surgical as well as medical ICU patients.

Absolute quantification of phosphorus metabolite concentrations in human muscle in vivo by 31P MRS: a quantitative review

31P MRS offers a unique view of muscle metabolism in vivo, but correct quantification is important. Inter-study correlation of estimates of [Pi] and [phosphocreatine (PCr)] in a number of published studies suggest that the main technical problem in calibrated 31P MRS studies is the measurement of PCr and Pi signal intensities, rather than absolute quantification of [ATP]. For comparison, we discuss the few published biopsy studies of calf muscle and a selection of the many studies of quadriceps muscle. The ATP concentration is close to the value that we obtained in calf muscle in our own study, presented here, on four healthy subjects, by localised 31P MRS using a surface coil incorporating an internal reference and calibrated using an external phantom. However, the freeze-clamp biopsy PCr concentration is approximately 20% lower than the value obtained by 31P MRS, consistent with PCr breakdown by creatine kinase during freezing. Finally, we illustrate some consequences of uncertainty in resting [PCr] for analysis of mitochondrial function from PCr kinetics using a published 31P MRS study of exercise and recovery: the lower the assumed resting [PCr], the lower the absolute rate of oxidative ATP synthesis estimated from the PCr resynthesis rate; in addition, the lower the assumed resting [PCr], or the higher the assumed [total creatine], the higher the apparent resting [ADP], and therefore the more sigmoid the relationship between the rate of oxidative ATP synthesis and [ADP]. Correct quantification of resting metabolite concentrations is crucially important for this sort of analysis. Our own results ([PCr] = 33 +/- 2 mM, [Pi] = 4.5 +/- 0.2 mM, and [ATP] = 8.2 +/- 0.4 mM; mean +/- SEM) are close to the overall mean values of the 10 published studies on calf muscle by 'calibrated' 31P MRS (as in the present work), and of [PCr] and [Pi] in a representative selection of 'uncalibrated' 31P MRS studies (i.e. from measured PCr/ATP and Pi/ATP ratios, assuming a literature value for [ATP]).

Modulation of the glycemic response using insulin attenuates the pulmonary response in an animal trauma model

BACKGROUND

Hyperglycemia has been shown to be an independent prognostic indicator of poor outcome in the traumatized patient. The role of insulin and the prevention of hyperglycemia in the trauma patient have as yet not been fully explored. We hypothesized that the systemic inflammatory response to trauma could be modified by modulating the glycemic response to trauma using insulin.

METHODS

A rodent model of end- organ (lung) injury in trauma was chosen. Two groups underwent bilateral femur fracture and 15% blood loss. The third group was anesthetized only. The treatment group immediately received subcutaneous insulin according to a sliding scale. The control groups received normal saline subcutaneously. The animals were maintained under anesthesia for 4 hours from injury. Blood samples were then taken. Bronchoalveolar lavage was performed for neutrophil content and total protein estimation. The left lower lobe was harvested for wet:dry lung weight ratios as a measure of end-organ tissue edema.

RESULTS

Measures of end-organ injury, wet:dry lung weight ratios, and bronchoalveolar lavage neutrophil content were significantly reduced in the insulin-treated animals compared with in the controls (p < 0.05). Neutrophil respiratory burst activity was increased in insulin-treated animals compared with in controls (p < 0.05).

CONCLUSIONS

Insulin reduces leukocyte lung sequestration and end-organ (lung) edema, indicating an endothelial protective effect in this injured-animal model without attenuating neutrophil function. This work confirms that modifying the glycemic response to trauma using insulin may have a role in reducing adult respiratory distress syndrome rates in injured patients and thereby lead to improved outcomes.

Perioperative management of the diabetic patient

Diabetes mellitus is a significant global public health problem and is a major source of morbidity and mortality in the world today. Type 2 diabetes mellitus is the predominant form of diabetes worldwide and represents approximately 90% of all cases. There is an epidemic of type 2 diabetes mellitus in the world today in both developed and developing countries. Globally, it is expected that the number of people with diabetes will increase from the current 150 million to 220 million by the year 2010 and to 300 million by the year 2025. In addition, there has been an alarming increase in the incidence of type 2 diabetes in children and adolescents. It is therefore increasingly likely that diabetic patients will appear for dental and oral maxillofacial surgical treatment in both the office and ambulatory surgery clinic setting. Surgical stress often produces hyperglycemia in the perioperative period. Hyperglycemia has been shown to cause a significant increase in perioperative morbidity and mortality. It is the general consensus that strict glycemic control is beneficial and should be achieved for diabetic patients in the perioperative period. Preoperative, intraoperative, and postoperative management protocols for improved perioperative glycemic control of both type 1 and type 2 diabetics are presented.

Therapy insight: the effect of tight glycemic control in acute illness

Hyperglycemia commonly occurs in patients who are acutely ill, in a variety of clinical situations. Generally, moderate hyperglycemia in critically ill patients was thought to be beneficial; however, the degree of hyperglycemia on admission and the duration of hyperglycemia during critical illness are now recognized markers of adverse outcome. The use of insulin therapy to maintain normoglycemia for at least a few days improves survival and reduces morbidity in patients who are in a surgical intensive care unit (ICU), as shown by a large, randomized, controlled study. These results were recently confirmed by two studies--a randomized, controlled study of patients in a medical ICU, and a prospective, observational study of a heterogeneous patient population admitted to a mixed medical and surgical ICU. Results of multicenter trials that investigated tight blood-glucose control in critically ill patients are, however, still lacking. While we await those multicenter results, the current evidence favors the control of blood glucose levels in the ICU. Indeed, the studies showed that many lives are saved with this intervention, despite an increased incidence of hypoglycemia. Prevention of glucose toxicity by strict glycemic control (but also other metabolic and nonmetabolic effects of insulin) contribute to these clinical benefits.

Effect of intermittent high-intensity compared with continuous moderate exercise on glucose production and utilization in individuals with type 1 diabetes

Previously, the decline in glycemia in individuals with type 1 diabetes has been shown to be less with intermittent high-intensity exercise (IHE) compared with continuous moderate-intensity exercise (MOD) despite the performance of a greater amount of total work. The purpose of the present study was to determine whether this lesser decline in glycemia can be attributed to a greater increment in endogenous glucose production (Ra) or attenuated glucose utilization (Rd). Nine individuals with type 1 diabetes were tested on two separate occasions, during which either a 30-min MOD or IHE protocol was performed under conditions of a euglycemic clamp in combination with the infusion of [6,6-(2)H]glucose. MOD consisted of continuous cycling at 40% VO2 peak, whereas IHE involved a combination of continuous exercise at 40% VO2 peak interspersed with additional 4-s maximal sprint efforts performed every 2 min to simulate the activity patterns of intermittent sports. During IHE, glucose Ra increased earlier and to a greater extent compared with MOD. Similarly, glucose Rd increased sooner during IHE, but the increase by the end of exercise was comparable with that elicited by MOD. During early recovery from IHE, Rd rapidly declined, whereas it remained elevated after MOD, a finding consistent with a lower glucose infusion rate during early recovery from IHE compared with MOD (P<0.05). The results suggest that the lesser decline in glycemia with IHE may be attributed to a greater increment in Ra during exercise and attenuated Rd during exercise and early recovery.

Prognostic value of admission laboratory parameters in traumatic brain injury: results from the IMPACT study

Abnormalities in laboratory parameters are frequent following traumatic brain injury (TBI), but few studies have investigated their predictive value. We aimed to describe and quantify the relation between laboratory parameters that are routinely determined on admission and final outcome following TBI. Individual patient data were available in the IMPACT database from six Phase III randomized controlled trials and one observational study in TBI. We studied glucose (N = 4834), sodium ( N = 5270), pH ( N = 3398), hemoglobin (Hb, N = 3875), platelet count ( N = 1629), and prothrombin time (PT; N = 840) for their associations with outcome at 6 months (Glasgow Outcome Scale [GOS]). We used logistic regression models with linear, quadratic, and restricted cubic spline functions. The strength of the associations was expressed as an unadjusted odds ratio, calculated over the shift in outcome between the 25th and 75th percentiles. Proportional odds methodology was further applied to quantify the strength of the associations across the full range of the GOS. All parameters were consistently associated with outcome in a continuous relationship: glucose and prothrombin time showed a positive linear relation to outcome (i.e., increasing values associated with poorer outcome) and Hb, platelets, and pH an inverse linear relation (i.e., low values associated with poorer outcome). Sodium demonstrated a U-shaped relation to outcome, with low levels being more strongly related to poorer outcome. Effects were strongest for increasing levels of glucose (odds ratio 1.7; 95% CI 1.54-1.83) and decreasing levels of Hb (odds ratio 0.7; CI 0.60-0.78). Higher glucose values were associated with increasing age, but on adjusted analysis, the strength of the association with outcome remained. Whether treatment of abnormal values may improve outcome needs further rigorous study.

Dose-Response Effects of Ingested Carbohydrate on Exercise Metabolism in Women

PURPOSE

The effect of different quantities of carbohydrate (CHO) intake on CHO metabolism during prolonged exercise was examined in endurance-trained females.

METHOD

On four occasions, eight females performed 2 h of cycling at approximately 60% .VO2max with ingestion of beverages containing low (LOW, 0.5 g.min(-1)), moderate (MOD, 1.0 g.min(-1)), or high (HIGH, 1.5 g.min(-1)) amounts of CHO, or water only (WAT). Test solutions contained trace amounts of [U-13C] glucose. Indirect calorimetry combined with measurement of expired 13CO2 and plasma 13C enrichment enabled calculation of exogenous CHO, liver-derived glucose, and muscle glycogen oxidation during the last 30 min of exercise.

RESULTS

The highest rates of exogenous CHO oxidation were observed in MOD, with no further increases in HIGH (peak rates of 0.33 +/- 0.02, 0.50 +/- 0.03, and 0.48 +/- 0.05 g.min(-1) for LOW, MOD, and HIGH, respectively; P < 0.05 for LOW vs MOD and HIGH). Endogenous CHO oxidation was lowest in MOD (0.99 +/- 0.06, 0.82 +/- 0.08, 0.70 +/- 0.07, and 0.89 +/- 0.09 g.min(-1); P < 0.05 for MOD vs all other trials). Compared with WAT, CHO ingestion reduced liver glucose oxidation during exercise by approximately 30% (P < 0.05 for WAT vs all CHO). Differential rates of muscle glycogen oxidation were observed with different CHO doses (0.57 +/- 0.07, 0.53 +/- 0.08, 0.41 +/- 0.07, and 0.60 +/- 0.09 g.min(-1) for WAT, LOW, MOD, and HIGH respectively; P < 0.05 for MOD vs HIGH).

CONCLUSION

In endurance-trained women, the highest rates of exogenous CHO oxidation and greatest endogenous CHO sparing was observed when CHO was ingested at moderate rates (1.0 g.min(-1), 60 g.h(-1)) during exercise.

Diabetes of injury: novel insights

Critically ill patients usually develop hyperglycemia, a condition referred to as "diabetes of injury." More and more evidence argues against the concept that this is an adaptive beneficial response. Indeed, the development of hyperglycemia seems to be detrimental for the outcome of critically ill patients, because maintenance of normoglycemia with intensive insulin therapy prevents morbidity and reduces mortality of critically ill patients to a large extent. The mechanisms underlying these clinical benefits are being studied further.

Signalling mechanisms in skeletal muscle: role in substrate selection and muscle adaptation

Exercise produces a multitude of time- and intensity-dependent physiological, biochemical and molecular changes within skeletal muscle. With the onset of contractile activity, cytosolic and mitochondrial [Ca2+] levels are rapidly increased and, depending on the relative intensity of the exercise, metabolite concentrations change (i.e. increases in [ADP] and [AMP], decreases in muscle creatine phosphate and glycogen). These contraction-induced metabolic disturbances activate several key kinases and phosphatases involved in signal transduction. Important among these are the calcium dependent signalling pathways that respond to elevated Ca2+ concentrations (including Ca2+/calmodulin-dependent kinase, Ca2+-dependent protein kinase C and the Ca2+/calmodulin-dependent phosphatase calcineurin), the 5′-adenosine monophosphate-activated protein kinase, several of the mitogen-activated protein kinases and protein kinase B/Akt. The role of these signal transducers in the regulation of carbohydrate and fat metabolism in response to increased contractile activity has been the focus of intense research efforts during the past decade.

[Effects of puberty on glucose-lipid balance during exercise in the obese child]

The aim of the present study was to investigate effect of puberty on substrate oxidation rates using a graded exercise test to exhaustion. Two groups of obese adolescent males (34 prepubertal: body mass index (BMI) = 25,94 +/- 2,63; Z-score = 4,43 +/- 1,83; and 26 postpubertal: BMI = 31,14 +/- 4,88; Z-score = 5,264 +/- 1,76) performed an exercise test on a cycle ergometer. The test consisted in a series of graded exercises on a cycle ergometer. Stage duration was 3 min 30 s. Fat and carbohydrate rates were calculated during the last 30 s of each stage using stoichiometric equations, and this permitted us to calculate substrate oxidation according to exercise intensity. Lipid oxidation rates are significantly higher in the postpubertal group. When the fat oxidation rates are reported relative to fat free mass, fat oxidation rates are higher in the prepubertal group. Puberty decreases significantly the capacity of fat free mass to oxidize fat for a same level of exercise.

Glucose kinetics differ between women and men, during and after exercise

As exercise can improve the regulation of glucose and carbohydrate metabolism, it is important to establish biological factors, such as sex, that may influence these outcomes. Glucose kinetics, therefore, were compared between women and men at rest, during exercise, and postexercise. It was hypothesized that glucose flux would be significantly lower in women than men during both the exercise and postexercise periods. Subjects included normal weight, healthy, eumenorrehic women and men, matched for habitual activity level and maximal oxygen uptake per kilogram lean body mass. Testing occurred following 3 days of diet control, with no exercise the day before. Subjects were tested in the overnight-fasted condition with women studied in the midluteal phase of the menstrual cycle. Resting (120 min), exercise (85% lactate threshold, 90 min), and postexercise (180 min) measurements of glucose flux and substrate metabolism were made. During exercise, women had a significantly lower rate of glucose appearance (Ra) (P<0.001) and disappearance (Rd) (P<0.002) compared with men. Maximal values were achieved at 90 min of exercise for both glucose Ra (mean+/-SE: 22.8+/-1.12 micromol.kg body wt-1.min-1 women and 33.6+/-1.79 micromol.kg body wt-1.min-1 men) and glucose Rd (23.2+/-1.26 and 34.1+/-1.71 micromol.kg body wt-1.min-1, respectively). Exercise epinephrine concentration was significantly lower in women compared with men (P<0.02), as was the increment in glucagon from rest to exercise (P<0.04). During the postexercise period, glucose Ra and Rd were also significantly lower in women vs. men (P<0.001), with differences diminishing over time. In conclusion, circulating blood glucose flux was significantly lower during 90 min of moderate exercise, and immediately postexercise, in women compared with men. Sex differences in the glucagon increase to exercise, and/or the epinephrine levels during exercise, may play a role in determining these sex differences in exercise glucose turnover.

Influence of caffeine on perception of effort, metabolism and exercise performance following a high-fat meal

This study examined the effects of caffeine, co-ingested with a high fat meal, on perceptual and metabolic responses during incremental (Experiment 1) and endurance (Experiment 2) exercise performance. Trained participants performed three constant-load cycling tests at approximately 73% of maximal oxygen uptake (VO2max) for 30 min at 20 degrees C (Experiment 1, n = 8) and to the limit of tolerance at 10 degrees C (Experiment 2, n = 10). The 30 min constant-load exercise in Experiment 1 was followed by incremental exercise (15 W . min-1) to fatigue. Four hours before the first test, the participants consumed a 90% carbohydrate meal (control trial); in the remaining two tests, the participants consumed a 90% fat meal with (fat + caffeine trial) and without (fat-only trial) caffeine. Caffeine and placebo were randomly assigned and ingested 1 h before exercise. In both experiments, ratings of perceived leg exertion were significantly lower during the fat + caffeine than fat-only trial (Experiment 1: P < 0.001; Experiment 2: P < 0.01). Ratings of perceived breathlessness were significantly lower in Experiment 1 (P < 0.01) and heart rate higher in Experiment 2 (P < 0.001) on the fat + caffeine than fat-only trial. In the two experiments, oxygen uptake, ventilation, blood [glucose], [lactate] and plasma [glycerol] were significantly higher on the fat + caffeine than fat-only trial. In Experiment 2, plasma [free fatty acids], blood [pyruvate] and the [lactate]:[pyruvate] ratio were significantly higher on the fat + caffeine than fat-only trial. Time to exhaustion during incremental exercise (Experiment 1: control: 4.9, s = 1.8 min; fat-only: 5.0, s = 2.2 min; fat + caffeine: 5.0, s = 2.2 min; P > 0.05) and constant-load exercise (Experiment 2: control: 116 (88 - 145) min; fat-only: 122 (96 - 144) min; fat + caffeine: 127 (107 - 176) min; P > 0.05) was not different between the fat-only and fat + caffeine trials. In conclusion, while a number of metabolic responses were increased during exercise after caffeine ingestion, perception of effort was reduced and this may be attributed to the direct stimulatory effect of caffeine on the central nervous system. However, this caffeine-induced reduction in effort perception did not improve exercise performance.

Adrenergic regulation of HSL serine phosphorylation and activity in human skeletal muscle during the onset of exercise

Skeletal muscle hormone-sensitive lipase (HSL) activity is increased by contractions and increases in blood epinephrine (EPI) concentrations and cyclic AMP activation of the adrenergic pathway during prolonged exercise. To determine the importance of hormonal stimulation of HSL activity during the onset of moderate- and high-intensity exercise, nine men [age 24.3 +/- 1.2 yr, 80.8 +/- 5.0 kg, peak oxygen consumption (VO2 peak) 43.9 +/- 3.6 ml x kg(-1) x min(-1)] cycled for 1 min at approximately 65% VO2 peak, rested for 60 min, and cycled at approximately 90% VO2 peak for 1 min. Skeletal muscle biopsies were taken pre- and postexercise, and arterial blood was sampled throughout exercise. Arterial EPI increased (P < 0.05) postexercise at 65% (0.45 +/- 0.10 to 0.78 +/- 0.27 nM) and 90% VO2 peak (0.57 +/- 0.34 to 1.09 +/- 0.50 nM). HSL activity increased (P < 0.05) following 1 min of exercise at 65% VO2 peak [1.05 +/- 0.39 to 1.78 +/- 0.54 mmol x min(-1) x kg dry muscle (dm)(-1)] and 90% VO2 peak (1.07 +/- 0.24 to 1.91 +/- 0.62 mmol x min(-1) x kg dm(-1)). Cyclic AMP content also increased (P < 0.05) at both exercise intensities (65%: 1.52 +/- 0.67 to 2.75 +/- 1.12, 90%: 1.85 +/- 0.65 to 2.64 +/- 0.93 micromol/kg dm). HSL Ser660 phosphorylation (approximately 55% increase) and ERK1/2 phosphorylation ( approximately 33% increase) were augmented following exercise at both intensities, whereas HSL Ser563 and Ser565 phosphorylation were not different from rest. The results indicate that increases in arterial EPI concentration during the onset of moderate- and high-intensity exercise increase cyclic AMP content, which results in the phosphorylation of HSL Ser660. This adrenergic stimulation contributes to the increase in HSL activity that occurs in human skeletal muscle in the first minute of exercise at 65% and 90% VO2 peak.

Local and systemic effects on blood lactate concentration during exercise with small and large muscle groups

To evaluate the relationship between lactate release and [lac](art) and to investigate the influence of the catecholamines on the lactate release, 14 healthy men [age 25+/-3 (SE) year] were studied by superimposing cycle on forearm exercise, both at 65% of their maximal power reached in respective incremental tests. Handgrip exercise was performed for 30 min at 65% of peak power. In addition, between the tenth and the 22nd minute, cycling with the same intensity was superimposed. The increase in venous lactate concentration ([lac](ven)) (rest: 1.3+/-0.4 mmol.l(-1); 3rd min: 3.9+/-0.8 mmol.l(-1)) begins with the forearm exercise, whereas arterial lactate concentration ([lac](art)) remains almost unchanged. Once cycling has been added to forearm exercise (COMB), [lac](art) increases with a concomitant increase in [lac](ven) (12th min: [lac](art), 3.2+/-1.3 mmol.l(-1); [lac](ven), 5.7+/-2.2 mmol.l(-1)). A correlation between oxygen tension (P(v)O(2)) and [lac](ven) cannot be detected. There is a significant correlation between [lac](art) and norepinephrine ([NE]) (y=0.25x+1.2; r=0.815; p<0.01) but no correlation between lactate release and epinephrine ([EPI]) at moderate intensity. Our main conclusion is that lactate release from exercising muscles at moderate intensities is neither dependent on P(v)O(2) nor on [EPI] in the blood.

Effect of exercise intensity and hypoxia on skeletal muscle AMPK signaling and substrate metabolism in humans

We compared in human skeletal muscle the effect of absolute vs. relative exercise intensity on AMP-activated protein kinase (AMPK) signaling and substrate metabolism under normoxic and hypoxic conditions. Eight untrained males cycled for 30 min under hypoxic conditions (11.5% O(2), 111 +/- 12 W, 72 +/- 3% hypoxia Vo(2 peak); 72% Hypoxia) or under normoxic conditions (20.9% O(2)) matched to the same absolute (111 +/- 12 W, 51 +/- 1% normoxia Vo(2 peak); 51% Normoxia) or relative (to Vo(2 peak)) intensity (171 +/- 18 W, 73 +/- 1% normoxia Vo(2 peak); 73% Normoxia). Increases (P < 0.05) in AMPK activity, AMPKalpha Thr(172) phosphorylation, ACCbeta Ser(221) phosphorylation, free AMP content, and glucose clearance were more influenced by the absolute than by the relative exercise intensity, being greatest in 73% Normoxia with no difference between 51% Normoxia and 72% Hypoxia. In contrast to this, increases in muscle glycogen use, muscle lactate content, and plasma catecholamine concentration were more influenced by the relative than by the absolute exercise intensity, being similar in 72% Hypoxia and 73% Normoxia, with both trials higher than in 51% Normoxia. In conclusion, increases in muscle AMPK signaling, free AMP content, and glucose disposal during exercise are largely determined by the absolute exercise intensity, whereas increases in plasma catecholamine levels, muscle glycogen use, and muscle lactate levels are more closely associated with the relative exercise intensity.

Glucose metabolism and insulin therapy

Hyperglycemia is a common feature of the critically ill patient and has been associated with increased mortality. Maintaining normoglycemia with insulin therapy improves survival and reduces morbidity in surgical ICU patients, as shown by a large randomized controlled study. Prevention of glucose toxicity by strict glycemic control but also other metabolic and non-metabolic effects of insulin contribute to these clinical benefits.

Hyperglycemia in the Critically Ill Patient

Hyperglycemia and insulin resistance are common among critically ill patients and occur in patients with or without a history of diabetes mellitus. All patients undergoing critical illness are at risk for stress-induced hyperglycemia. Some patients may be at greater risk for hyperglycemia than others when considering underlying disease states and iatrogenic factors. Many recent studies demonstrate that tight glucose control can decrease morbidity and mortality associated with critical illness. This article reviews the pathophysiology behind stress-induced hyperglycemia, the evidence to support tight glycemic control, and the importance of an intensive insulin therapy protocol to standardize treatment among critical care patients.

Effects of elevated plasma adrenaline levels on substrate metabolism, effort perception and muscle activation during low-to-moderate intensity exercise

The aim of this study was to differentiate the role of raised plasma adrenaline (Adr) concentrations from sympathoadrenal activation associated with moderate-intensity exercise, on muscle activation, cardiopulmonary responses, fuel metabolism, and ratings of perceived exertion (RPE) during low-intensity exercise. Two groups of subjects (MOD, n=6; LOW, n=7) cycled on two occasions for 90 min. MOD cycled at 68% VO(2max) with saline infusion, and at 34% VO(2max) with Adr infusion. LOW cycled twice at 34% VO(2max), with either Adr or saline infusion. Infusions (0.015 g Adr/kg/min) started at 15 min and increased plasma [Adr] somewhat higher than during exercise at 68% VO(2max) (approximately 1.9 vs. 1.4 nM, at 75 min). Mean plasma glucose and lactate concentrations during LOW were significantly higher with Adr than saline infusion (5.1+/-0.6 vs. 4.4+/-0.3 mmol/l, P<0.01 and 2.1+/-0.8 vs. 1.3+/-0.5 mmol/l, P<0.01, respectively). Elevated [Adr], without increased exercise intensity, did not alter glycogenolysis. There were also no effects of Adr infusion at 34% VO(2max) on heart rate, oxygen consumption, [FFA], respiratory exchange ratio, intramuscular triglyceride utilization, muscle activation or RPE. In conclusion, elevated [Adr] similar to those found during moderate-intensity exercise increased plasma glucose and lactate availability, but did not alter intramuscular fuel utilization, effort perception or muscle activation.

Glycemic and nonglycemic effects of insulin: how do they contribute to a better outcome of critical illness?

PURPOSE OF REVIEW

This review gives an overview of the clinical outcome benefits associated with intensive insulin therapy administered to critically ill patients and of the progress in the unraveling of the mechanisms underlying these positive effects.

RECENT FINDINGS

In a large, prospective, randomized, controlled study, strict blood glucose control with intensive insulin therapy strongly reduced mortality and morbidity of surgical intensive care patients. These results were recently confirmed in a more heterogeneous patient population admitted to a mixed medical-surgical intensive care unit. Most of the clinical benefits of intensive insulin therapy appear to be related to prevention of hyperglycemia, which has been demonstrated to adversely affect outcome. Part of the improvement is related to protection of the mitochondrial compartment and innate immunity from glucose toxicity. Also, direct insulin effects contribute to the improved outcome. The beneficial nonglycemic metabolic actions of insulin include a partial correction of the abnormal serum lipid profile and counteraction of the catabolic state evoked by critical illness. The prevention of excessive inflammation and myocardial protection illustrate other nonmetabolic direct anti-inflammatory and anti-apoptotic properties of insulin, although lowering of glucose levels may have played a role in these events as well.

SUMMARY

Substantial progress has been made in the understanding of the mechanisms underlying the improved survival and reduced morbidity with intensive insulin therapy in critical illness. More studies, however, are needed to further elucidate the exact pathways involved and the relative contribution of prevention of glucose toxicity and direct nonglycemic effects of insulin.

Caffeine increases exogenous carbohydrate oxidation during exercise

Both carbohydrate (CHO) and caffeine have been used as ergogenic aids during exercise. It has been suggested that caffeine increases intestinal glucose absorption, but there are also suggestions that it may decrease muscle glucose uptake. The purpose of the study was to investigate the effect of caffeine on exogenous CHO oxidation. In a randomized crossover design, eight male cyclists (age 27 +/- 2 yr, body mass 71.2 +/- 2.3 kg, maximal oxygen uptake 65.7 +/- 2.2 ml x kg(-1) x min(-1)) exercised at 64 +/- 3% of maximal oxygen uptake for 120 min on three occasions. During exercise subjects ingested either a 5.8% glucose solution (Glu; 48 g/h), glucose with caffeine (Glu+Caf, 48 g/h + 5 mg x kg(-1) x h(-1)), or plain water (Wat). The glucose solution contained trace amounts of [U-13C]glucose so that exogenous CHO oxidation could be calculated. CHO and fat oxidation were measured by indirect calorimetry, and 13C appearance in the expired gases was measured by continuous-flow IRMS. Average exogenous CHO oxidation over the 90- to 120-min period was 26% higher (P < 0.05) in Glu+Caf (0.72 +/- 0.04 g/min) compared with Glu (0.57 +/- 0.04 g/min). Total CHO oxidation rates were higher (P < 0.05) in the CHO ingestion trials compared with Wat, but they were highest when Glu+Caf was ingested (1.21 +/- 0.37, 1.84 +/- 0.14, and 2.47 +/- 0.23 g/min for Wat, Glu, and Glu+Caf, respectively; P < 0.05). There was also a trend (P = 0.082) toward an increased endogenous CHO oxidation with Glu+Caf (1.81 +/- 0.22 g/min vs. 1.27 +/- 0.13 g/min for Glu and 1.12 +/- 0.37 g/min for Wat). In conclusion, compared with glucose alone, 5 mg x kg(-1) x h(-1) of caffeine coingested with glucose increases exogenous CHO oxidation, possibly as a result of an enhanced intestinal absorption.

Catecholamine response is attenuated during moderate-intensity exercise in response to the "lactate clamp"

Catecholamine release is known to be regulated by feedforward and feedback mechanisms. Norepinephrine (NE) and epinephrine (Epi) concentrations rise in response to stresses, such as exercise, that challenge blood glucose homeostasis. The purpose of this study was to assess the hypothesis that the lactate anion is involved in feedback control of catecholamine concentration. Six healthy active men (26 +/- 2 yr, 82 +/- 2 kg, 50.7 +/- 2.1 ml.kg(-1).min(-1)) were studied on five occasions after an overnight fast. Plasma concentrations of NE and Epi were determined during 90 min of rest and 90 min of exercise at 55% of peak O2 consumption (VO2 peak) two times with exogenous lactate infusion (lactate clamp, LC) and two times without LC (CON). The blood lactate profile ( approximately 4 mM) of a preliminary trial at 65% VO2 peak (65%) was matched during the subsequent LC trials. In resting men, plasma NE concentration was not different between trials, but during exercise all conditions were different with 65% > CON > LC (65%: 2,115 +/- 166 pg/ml, CON: 1,573 +/- 153 pg/ml, LC: 930 +/- 174 pg/ml, P < 0.05). Plasma Epi concentrations at rest were different between conditions, with LC less than 65% and CON (65%: 68 +/- 9 pg/ml, CON: 59 +/- 7 pg/ml, LC: 38 +/- 10 pg/ml, P < 0.05). During exercise, Epi concentration showed the same trend (65%: 262 +/- 37 pg/ml, CON: 190 +/- 34 pg/ml, LC: 113.2 +/- 23 pg/ml, P < 0.05). In conclusion, lactate attenuates the catecholamine response during moderate-intensity exercise, likely by feedback inhibition.

Interstitial muscle lactate, pyruvate and potassium dynamics in the trapezius muscle during repetitive low-force arm movements, measured with microdialysis

AIM

Local muscle metabolic responses to repetitive low-force contractions and to intense static contractions were studied by microdialysis in humans.

METHODS

Microdialysate and electromyography (EMG) were sampled from the trapezius muscle, mixed venous blood samples were taken and perceived exertion was rated (0-9) before and during 20 min of standardized repetitive arm movement (REP), 60 min recovery (R1), and 10 min 90 degrees sustained arm position (SUS) at 20% maximum voluntary contraction, followed by 60 min recovery (R2) in six healthy male participants (28-33 years).

RESULTS

Average muscle activity was 8 +/- 2% of EMGmax-RMS (mean +/-SEM) during REP and 22 +/- 5% of EMGmax-RMS during SUS. Perceived exertion increased from 0 to 3.2 +/- 0.5 during REP and from 0 to 8.5 +/- 0.3 during SUS. During REP interstitial muscle lactate increased from 2.1 +/- 0.2 to 2.9 +/- 0.2 mmol L(-1) (P < 0.001) and returned to the baseline level during R1, while dialysate [K+] increased from 3.8 +/- 0.2 to 4.7 +/- 0.2 mmol L(-1) (P < 0.002) and returned to 3.8 +/- 0.2 mmol L(-1) during R1. In contrast, plasma lactate and [K+] remained unchanged. During SUS interstitial muscle lactate increased from 2.3 +/- 0.2 to 3.3 +/- 0.3 mmol L(-1) (P < 0.003), increased further to 6.5 +/- 1.3 mmol L(-1) post-exercise (P < 0.001) and returned to baseline levels during R2. Dialysate [K+] increased from 3.9 +/- 0.2 to 4.6 +/- 0.2 mmol L(-1) (P < 0.05) and returned to baseline level during R2. Plasma lactate increased significantly during SUS whereas plasma [K+] was unchanged. During REP and SUS interstitial pyruvate was unchanged but increased in the post-exercise period proportional to the exercise intensity.

CONCLUSIONS

The microdialysis technique was effective in revealing muscle metabolic events that were not found systemically. Furthermore, the trapezius muscle showed an anaerobic metabolism during low-force contraction, which could indicate inhomogeneous muscle activation.

Effects of carbohydrate supplementation on performance and carbohydrate oxidation after intensified cycling training

To study the effects of carbohydrate (CHO) supplementation on performance changes and symptoms of overreaching, six male endurance cyclists completed 1 wk of normal (N), 8 days of intensified (ITP), and 2 wk of recovery training (R) on two occasions in a randomized crossover design. Subjects completed one trial with a 6% CHO solution provided before and during training and a 20% solution in the 1 h postexercise (H-CHO trial). On the other occasion, subjects consumed a 2% CHO solution at the same time points (L-CHO). A significant decline in time to fatigue at ∼63% maximal power output (H-CHO: 17 ± 3%; L-CHO: 26 ± 7%) and a significant increase in mood disturbance occurred in both trials after ITP. The decline in performance was significantly greater in the L-CHO trial. After ITP, a significant decrease in estimated muscle glycogen oxidation (H-CHO: N 49.3 ± 2.9 kcal/30 min, ITP 32.6 ± 3.4 kcal/30 min; L-CHO: N 49.1 ± 30 kcal/30 min, ITP 39.0 ± 5.6 kcal/30 min) and increase in fat oxidation (H-CHO: N 16.3 ± 2.4 kcal/30 min, ITP 27.8 ± 2.3 kcal/30 min; L-CHO: N 16.9 ± 2.6 kcal/30 min, ITP: 25.4 ± 3.5 kcal/30 min) occurred alongside significant increases in glycerol and free fatty acids and decreases in free triglycerides in both trials. An interaction effect was observed for submaximal plasma concentrations of cortisol and epinephrine, with significantly greater reductions in these stress hormones in L-CHO compared with H-CHO after ITP. These findings suggest that CHO supplementation can reduce the symptoms of overreaching but cannot prevent its development. Decreased endocrine responsiveness to exercise may be implicated in the decreased performance and increased mood disturbance characteristic of overreaching.

Distributed control of glucose uptake by working muscles of conscious mice: roles of transport and phosphorylation

Muscle glucose uptake (MGU) is determined by glucose delivery, transport, and phosphorylation. C57Bl/6J mice overexpressing GLUT4, hexokinase II (HK II), or both were used to determine the barriers to MGU. A carotid artery and jugular vein were catheterized for arterial blood sampling and venous infusions. Experiments were conducted in conscious mice approximately 7 days after surgery. 2-Deoxy-[3H]glucose was administered during rest or treadmill exercise to calculate glucose concentration-dependent (Rg) and -independent (Kg) indexes of MGU. Compared with wild-type controls, GLUT4-overexpressing mice had lowered fasting glycemia (165 +/- 6 vs. 115 +/- 6 mg/dl) and increased Rg by 230 and 166% in the gastrocnemius and superficial vastus lateralis (SVL) muscles under sedentary conditions. GLUT4 overexpression was not able to augment exercise-stimulated Rg or Kg. Whereas HK II overexpression had no effect on fasting glycemia (170 +/- 6 mg/dl) or sedentary Rg, it increased exercise-stimulated Rg by 82, 60, and 169% in soleus, gastrocnemius, and SVL muscles, respectively. Combined GLUT4 and HK II overexpression lowered fasting glycemia (106 +/- 6 mg/dl), increased nonesterified fatty acids, and increased sedentary Rg. Combined GLUT4 and HK II overexpression did not enhance exercise-stimulated Rg compared with HK II-overexpressing mice because of the reduced glucose concentration. GLUT4 combined with HK II overexpression resulted in a marked increase in exercise-stimulated Kg. In conclusion, control of MGU shifts from membrane transport at rest to phosphorylation during exercise. Glucose transport is not normally a significant barrier during exercise. However, when the phosphorylation barrier is lowered by HK II overexpression, glucose transport becomes a key site of control for regulating MGU during exercise.