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Ilyas M, Holzwarth D, Ishaq R, Ali Y, Habiba U, Raja AM, Saeed S, Abdullah U, Khan SN, Ullah A, Raja GK, Baig SM, Fazeli W, Kunz WS, Shaiq PA. Whole-Exome sequencing identifies GYS2 biallelic variants in individuals with suspected epilepsy. Seizure 2024; 116:74-80. [PMID: 37574425 DOI: 10.1016/j.seizure.2023.07.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 07/04/2023] [Accepted: 07/25/2023] [Indexed: 08/15/2023] Open
Abstract
BACKGROUND Adequate glucose supply is essential for brain function, therefore hypoglycemic states may lead to seizures. Since blood glucose supply for brain is buffered by liver glycogen, an impairment of liver glycogen synthesis by mutations in the liver glycogen synthase gene (GYS2) might result in a substantial neurological involvement. Here, we describe the phenotypes of affected siblings of two families harboring biallelic mutations in GYS2. METHODS Two suspected families - a multiplex Pakistani family (family A) with three affected siblings and a family of Moroccan origin (family B) with a single affected child who presented with seizures and reduced fasting blood glucose levels were genetically characterized. Whole exome sequencing (WES) was performed on the index patients, followed by Sanger sequencing-based segregation analyses on all available members of both families. RESULTS The variant prioritization of WES and later Sanger sequencing confirmed three mutations in the GYS2 gene (12p12.1) consistent with an autosomal recessive pattern of inheritance. A homozygous splice acceptor site variant (NM_021957.3, c. 1646 -2A>G) segregated in family A. Two novel compound heterozygous variants (NM_021957.3: c.343G>A; p.Val115Met and NM_021957.3: c.875A>T; p.Glu292Val) were detected in family B, suggesting glycogen storage disorder. A special diet designed to avoid hypoglycemia, in addition to change of the anti-seizure medication led to reduction in seizure frequency. CONCLUSIONS This study suggests that the seizures in patients initially diagnosed with epilepsy might be directly caused, or influenced by hypoglycemia due to pathogenic variants in the GYS2 gene.
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Affiliation(s)
- Muhammad Ilyas
- University Institute of Biochemistry and Biotechnology, Pir Mehr Ali Arid Agriculture University Rawalpindi, Pakistan; Department of Medical laboratory technology, Riphah International University, Malakand Campus, Pakistan; Department of Epileptology, University of Bonn, Germany
| | - Dorothea Holzwarth
- Department of Neuropediatrics, Children's Hospital, University of Bonn, Germany
| | - Rafaqat Ishaq
- University Institute of Biochemistry and Biotechnology, Pir Mehr Ali Arid Agriculture University Rawalpindi, Pakistan
| | - Yasir Ali
- Institute of Chemistry, Slovak Academy of Sciences, 845 38 Bratislava, Slovakia
| | - Umme Habiba
- University Institute of Biochemistry and Biotechnology, Pir Mehr Ali Arid Agriculture University Rawalpindi, Pakistan
| | - Asad Mehmood Raja
- University Institute of Biochemistry and Biotechnology, Pir Mehr Ali Arid Agriculture University Rawalpindi, Pakistan
| | - Sadia Saeed
- University Institute of Biochemistry and Biotechnology, Pir Mehr Ali Arid Agriculture University Rawalpindi, Pakistan; Department of Clinical Molecular Biology, EpiGen, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Uzma Abdullah
- University Institute of Biochemistry and Biotechnology, Pir Mehr Ali Arid Agriculture University Rawalpindi, Pakistan
| | - Sadiq Noor Khan
- Department of Medical Laboratory Technology, University of Haripur, Khyber Pakhtunkhwa, Pakistan
| | - Ata Ullah
- Applied Genomics Centre and State Key Laboratory of Molecular Neuroscience, Hongkong University of Science and Technology, Division of Life Sciences, Hong Kong
| | - Ghazala Kaukab Raja
- University Institute of Biochemistry and Biotechnology, Pir Mehr Ali Arid Agriculture University Rawalpindi, Pakistan
| | | | - Walid Fazeli
- Department of Neuropediatrics, Children's Hospital, University of Bonn, Germany
| | | | - Pakeeza Arzoo Shaiq
- University Institute of Biochemistry and Biotechnology, Pir Mehr Ali Arid Agriculture University Rawalpindi, Pakistan.
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Romley JA, Gong C, Jena AB, Goldman DP, Williams B, Peters A. Association between use of warfarin with common sulfonylureas and serious hypoglycemic events: retrospective cohort analysis. BMJ 2015; 351:h6223. [PMID: 26643108 PMCID: PMC4670968 DOI: 10.1136/bmj.h6223] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2015] [Indexed: 01/08/2023]
Abstract
STUDY QUESTION Is warfarin use associated with an increased risk of serious hypoglycemic events among older people treated with the sulfonylureas glipizide and glimepiride? METHODS This was a retrospective cohort analysis of pharmacy and medical claims from a 20% random sample of Medicare fee for service beneficiaries aged 65 years or older. It included 465,918 beneficiaries with diabetes who filled a prescription for glipizide or glimepiride between 2006 and 2011 (4,355,418 person quarters); 71,895 (15.4%) patients also filled a prescription for warfarin (416,479 person quarters with warfarin use). The main outcome measure was emergency department visit or hospital admission with a primary diagnosis of hypoglycemia in person quarters with concurrent fills of warfarin and glipizide/glimepiride compared with the rates in quarters with glipizide/glimepiride fills only, Multivariable logistic regression was used to adjust for individual characteristics. Secondary outcomes included fall related fracture and altered consciousness/mental status. SUMMARY ANSWER AND LIMITATIONS In quarters with glipizide/glimepiride use, hospital admissions or emergency department visits for hypoglycemia were more common in person quarters with concurrent warfarin use compared with quarters without warfarin use (294/416,479 v 1903/3,938,939; adjusted odds ratio 1.22, 95% confidence interval 1.05 to 1.42). The risk of hypoglycemia associated with concurrent use was higher among people using warfarin for the first time, as well as in those aged 65-74 years. Concurrent use of warfarin and glipizide/glimepiride was also associated with hospital admission or emergency department visit for fall related fractures (3919/416,479 v 20,759/3,938,939; adjusted odds ratio 1.47, 1.41 to 1.54) and altered consciousness/mental status (2490/416,479 v 14,414/3,938,939; adjusted odds ratio 1.22, 1.16 to 1.29). Unmeasured factors could be correlated with both warfarin use and serious hypoglycemic events, leading to confounding. The findings may not generalize beyond the elderly Medicare population. WHAT THIS STUDY ADDS A substantial positive association was seen between use of warfarin with glipizide/glimepiride and hospital admission/emergency department visits for hypoglycemia and related diagnoses, particularly in patients starting warfarin. The findings suggest the possibility of a significant drug interaction between these medications. FUNDING, COMPETING INTERESTS, DATA SHARING JAR and DPG receive support from the National Institute on Aging, the Commonwealth Fund, and the Leonard D. Schaeffer Center for Health Policy and Economics at the University of Southern California. ABJ receives support from the NIH Office of the Director. No additional data are available.
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Affiliation(s)
- John A Romley
- Leonard D. Schaeffer Center for Health Policy and Economics Price School of Public Policy, University of Southern California, 635 Downey Way, Los Angeles, CA 90089-3333, USA
| | - Cynthia Gong
- School of Pharmacy, University of Southern California, 635 Downey Way, Los Angeles, CA 90089-3333, USA
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115, USA
| | - Dana P Goldman
- Leonard D. Schaeffer Center for Health Policy and Economics Price School of Public Policy, School of Pharmacy, and Dornsife College of Letters, Arts and Sciences, University of Southern California, 635 Downey Way, Los Angeles, CA 90089-3333, USA Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115, USA
| | - Bradley Williams
- School of Pharmacy, University of Southern California, Health Sciences Campus, Los Angeles, CA 90089-9121, USA
| | - Anne Peters
- Keck School of Medicine, University of Southern California, 150 N. Robertson Blvd, Suite 210, Beverly Hills, CA 90211, USA
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Goldberg SA, Rojanasarntikul D, Jagoda A. The prehospital management of traumatic brain injury. HANDBOOK OF CLINICAL NEUROLOGY 2015; 127:367-78. [PMID: 25702228 DOI: 10.1016/b978-0-444-52892-6.00023-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Traumatic brain injury (TBI) is an important cause of death and disability, particularly in younger populations. The prehospital evaluation and management of TBI is a vital link between insult and definitive care and can have dramatic implications for subsequent morbidity. Following a TBI the brain is at high risk for further ischemic injury, with prehospital interventions targeted at reducing this secondary injury while optimizing cerebral physiology. In the following chapter we discuss the prehospital assessment and management of the brain-injured patient. The initial evaluation and physical examination are discussed with a focus on interpretation of specific physical examination findings and interpretation of vital signs. We evaluate patient management strategies including indications for advanced airway management, oxygenation, ventilation, and fluid resuscitation, as well as prehospital strategies for the management of suspected or impending cerebral herniation including hyperventilation and brain-directed hyperosmolar therapy. Transport decisions including the role of triage models and trauma centers are discussed. Finally, future directions in the prehospital management of traumatic brain injury are explored.
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Affiliation(s)
- Scott A Goldberg
- Department of Emergency Medicine, Brigham & Women's Hospital, Boston, MA, USA
| | - Dhanadol Rojanasarntikul
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, USA; Chulalongkorn University, Bangkok, Thailand
| | - Andrew Jagoda
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY, USA; Brain Trauma Foundation, New York, NY, USA.
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Abstract
Acute recognition and management of traumatic brain injury along the spectrum from mild to severe is essential in optimizing neurocognitive outcomes. Concussion is common following head trauma in children, and resulting symptoms can last for months if not diagnosed and managed properly. Emerging evidence and consensus demonstrate that a program of cognitive and physical activity with a graduated return to play, sport, and school may improve outcomes following concussion. "Return to Play" legislation for youth has been adopted by most states. Outcomes of patients with severe traumatic brain injury have improved.
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Affiliation(s)
- Shireen M Atabaki
- Division of Emergency Medicine, Department of Pediatrics and Emergency Medicine, Children's National Medical Center, 111 Michigan Avenue Northwest, Washington, DC 20010-1970, USA.
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Moppett IK. Traumatic brain injury: assessment, resuscitation and early management. Br J Anaesth 2007; 99:18-31. [PMID: 17545555 DOI: 10.1093/bja/aem128] [Citation(s) in RCA: 156] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
This review examines the evidence base for the early management of head-injured patients. Traumatic brain injury (TBI) is common, carries a high morbidity and mortality, and has no specific treatment. The pathology of head injury is increasingly well understood. Mechanical forces result in shearing and compression of neuronal and vascular tissue at the time of impact. A series of pathological events may then ensue leading to further brain injury. This secondary injury may be amenable to intervention and is worsened by secondary physiological insults. Various risk factors for poor outcome after TBI have been identified. Most of these are fixed at the time of injury such as age, gender, mechanism of injury, and presenting signs (Glasgow Coma Scale and pupillary signs), but some such as hypotension and hypoxia are potential areas for medical intervention. There is very little evidence positively in favour of any treatments or packages of early care; however, prompt, specialist neurocritical care is associated with improved outcome. Various drugs that target specific pathways in the pathophysiology of brain injury have been the subject of animal and human research, but, to date, none has been proved to be successful in improving outcome.
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Affiliation(s)
- I K Moppett
- Division of Anaesthesia and Intensive Care, University of Nottingham and Queen's Medical Centre Campus, Nottingham University Hospitals NHS Trust, Nottingham NG7 2UH, UK.
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Padder T, Jaghab K, Gorman JM. A 56-year-old male presenting with acute psychosis and acute change in mental status. J Psychiatr Pract 2006; 12:411-4. [PMID: 17122704 DOI: 10.1097/00131746-200611000-00011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Prehospital Evaluation and Management of Traumatic Brain Injury in Children. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2006. [DOI: 10.1016/j.cpem.2006.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Bazakis AM, Kunzler C. Altered mental status due to metabolic or endocrine disorders. Emerg Med Clin North Am 2005; 23:901-8, x-xi. [PMID: 15982551 DOI: 10.1016/j.emc.2005.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The differential diagnoses for mental status alteration is broad. Endocrine or metabolic causes for emergency department patients who present with lethargy, anxiety, psychosis, and seizures should be considered. Using the complaint-based approach, this article discusses some of the often less obvious etiologies for these presentations related to endocrine and metabolic disease states.
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Affiliation(s)
- Andrew M Bazakis
- Synergy Medical Education Alliance, 1000 Houghton Avenue, Saginaw, MI 48602, USA.
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Abstract
OBJECTIVES To determine the usefulness of bedside evaluation of pupils in determining the aetiology of coma by adopting a probabilistic approach. PATIENTS AND METHODS One hundred and fifteen consecutive patients presenting with coma were enrolled in this prospective cohort during the 12 month study period in the emergency room of a community teaching hospital. Patients underwent structured clinical examinations and laboratory and imaging tests. Assignment of aetiology of coma was based on strict adherence to predetermined criteria and achieved by consensus of the two physician investigators. One year follow up was obtained in all patients. RESULTS Aetiology of coma was determined in 98% of the patients. It was metabolic in 69 patients (60%) and structural in 46 patients (40%). Metabolic causes included drug overdose, acute alcohol intoxication, hypoglycaemia, sepsis, and pneumonia. Structural causes included intracerebral haemorrhage, subarachnoid haemorrhage, cerebral infarction, subdural haematoma, and epidural haematoma. Multivariate logistic regression analysis showed light reflex loss (likelihood ratio for positive test result 3.59) and anisocoria (likelihood ratio for positive test result 9.0) as independent predictors of structural origin. CONCLUSIONS In this prospective study of patients presenting to the emergency room of a community based teaching hospital with coma, in about 60% the coma is of metabolic origins and in about 40% of structural origins. Light reflex loss and anisocoria suggest a structural aetiology.
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Affiliation(s)
- Y Tokuda
- Division of General Internal Medicine, Department of Medicine, Okinawa Chubu Hospital, Okinawa, Japan.
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Gabriel EJ, Ghajar J, Jagoda A, Pons PT, Scalea T, Walters BC. Guidelines for prehospital management of traumatic brain injury. J Neurotrauma 2002; 19:111-74. [PMID: 11852974 DOI: 10.1089/089771502753460286] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Affiliation(s)
- Edward J Gabriel
- Bureau of Operations-EMS Command, Fire Department, The City of New York, USA
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Brady WJ, Duncan CW. Hypoglycemia masquerading as acute psychosis and acute cocaine intoxication. Am J Emerg Med 1999; 17:318-9. [PMID: 10337905 DOI: 10.1016/s0735-6757(99)90140-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
The typical presentation of hypoglycemia involves a diaphoretic patient with a history of diabetes mellitus who is found with an altered mental status. The hypoglycemic patient's presentation may lead the physician to believe that the altered mentation may have been caused by some other condition. Hypoglycemia occurs rarely in the traumatic setting, yet is easily and rapidly diagnosed with bedside testing. A retrospective review was conducted in a university hospital emergency department (ED) (level 1 trauma center) of adult trauma patients with a Glasgow Coma Scale (GCS) score of <15 who had presented from July 1995 through August 1996. Hypoglycemia was defined as a serum glucose level of <60 mg/dL. A total of 926 patients (49% of all trauma cases encountered in the period) met entry criteria. Four (0.4%) cases of hypoglycemia were encountered in 1 nondiabetic and 3 diabetic patients; no patient had medical alert warnings. Rapid bedside screening identified 2 cases within a mean of 7 minutes after arrival; 1 patient had an improvement in mental status after dextrose therapy. Two cases were identified by formal laboratory analysis a mean of 35 minutes after ED arrival; dextrose therapy improved the mental status in 1 patient. These results show that hypoglycemia, rare in trauma patients with abnormal GCS scores, may mimic significant traumatic injury with mental status alterations. Physicians should consider such a diagnosis in patients with an abnormal GCS score and known risk situations for hypoglycemia, including diabetes mellitus and chronic alcohol use; in such cases, appropriate bedside screening should be performed after initial stabilization.
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Affiliation(s)
- W J Brady
- Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville 22906-0014, USA
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Luber S, Meldon S, Brady W. Hypoglycemia presenting as acute respiratory failure in an infant. Am J Emerg Med 1998; 16:281-4. [PMID: 9596434 DOI: 10.1016/s0735-6757(98)90103-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Hypoglycemia, a common metabolic abnormality seen in the pediatric population, is most often easily diagnosed and rapidly treated with satisfactory outcome. If not recognized and treated in prompt fashion, however, hypoglycemia may cause irreversible central nervous system injury or expose the patient to unnecessary procedures; it rarely results in death. The classic emergency department (ED) presentation of hypoglycemia, the diabetes mellitus patient using hypoglycemic therapy, is frequently encountered and adequately managed with excellent outcome. Alternatively, the patient may present to the ED in a fashion suggestive of a situation other than hypoglycemia. For example, the patient with an altered sensorium following a traumatic event, with a focal neurologic finding, or with bradycardia--all situations in which hypoglycemia is the causative issue--may not be immediately recognized as such a metabolic problem. This report presents a case of a 9-month-old boy who presented with acute respiratory failure and mental status change; the initial ED impression was one of pneumonia with sepsis. Further evaluation uncovered the actual reason for the mental status change and respiratory insufficiency: hypoglycemia was noted on laboratory analysis; no clinical evidence of pneumonia was found after thorough ED evaluation and a prolonged hospital stay. His mental status improved and his respiratory insufficiency resolved after glucose therapy. No other explanation for the respiratory failure was found during the hospital admission. It is imperative that the emergency physician consider hypoglycemia in all patients with any degree of mental status abnormality, even when the findings seem to be explained initially by other etiologies.
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Affiliation(s)
- S Luber
- Charlottesville-Albemarle Rescue Squad and the Department of Emergency Medicine, University of Virginia Health Sciences Center, Charlottesville, USA
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Petrikas R, Schumann L. Altered mental status: hypoglycemia. JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS 1998; 10:175-80; quiz 181-3. [PMID: 9801552 DOI: 10.1111/j.1745-7599.1998.tb01287.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Luber S, Brady WJ, Young JS, Woods WA. Psoas abscess with sepsis mimicking traumatic hemorrhagic shock after a fall. J Emerg Med 1997; 15:623-7. [PMID: 9348048 DOI: 10.1016/s0736-4679(97)00123-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Abscess of the psoas muscle is infrequently encountered. An infectious emergency of this type usually presents in a nonspecific manner and thus poses a significant diagnostic challenge to the emergency physician. Diagnosis and specific treatment are often delayed, which can lead to increased mortality. This case report presents a patient with altered mental status and hypotension after a fall, who was initially managed as a trauma victim. Emergency department evaluation initially focused on a traumatic etiology of the above abnormalities. Subsequent assessment determined that the patient's condition was due to an underlying psoas abscess with sepsis. Appropriate anatomy, clinical presentation, and management are discussed in hopes of increasing physician awareness of this uncommon infectious condition.
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Affiliation(s)
- S Luber
- Charlottesville-Albemarle Rescue Squad, and Department of Emergency Medicine, University of Virginia Health Sciences Center, USA
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Pollock G, Brady WJ, Hargarten S, DeSilvey D, Carner CT. Hypoglycemia manifested by sinus bradycardia: a report of three cases. Acad Emerg Med 1996; 3:700-7. [PMID: 8816187 DOI: 10.1111/j.1553-2712.1996.tb03495.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Three cases are reported of hypoglycemia manifested by profound sinus bradycardia and fatigue, which responded to i.v. dextrose with prompt normalization of the cardiac rhythm. The cases involved 3 different patients and disease processes: a young female who had anorexia nervosa and profound malnutrition; an elderly, nondiabetic male who subsequently experienced a transient ischemic attack: and a patient who had diabetes mellitus managed with chronic, subcutaneous insulin administration. It is vitally important that the emergency physician recognize unusual clinical manifestations of hypoglycemia and fully evaluate such scenarios when hypoglycemia may occur. Untreated, hypoglycemia may result in significant chronic morbidity, and rarely, in death. Bradyarrhythmias--particularly sinus bradycardia--should be added to the list of potential clinical manifestations of hypoglycemia.
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Affiliation(s)
- G Pollock
- Department of Emergency Medicine, University of Pittsburgh, PA, USA
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