1
|
[93/f-Sudden indisposition, confusion and cold sweat : Preparation for the medical specialist examination: part 119]. Internist (Berl) 2022; 63:95-98. [PMID: 35028700 DOI: 10.1007/s00108-021-01254-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2021] [Indexed: 10/19/2022]
|
2
|
Hwang JJ, Parikh L, Lacadie C, Seo D, Lam W, Hamza M, Schmidt C, Dai F, Sejling AS, Belfort-DeAguiar R, Constable RT, Sinha R, Sherwin R. Hypoglycemia unawareness in type 1 diabetes suppresses brain responses to hypoglycemia. J Clin Invest 2018; 128:1485-1495. [PMID: 29381484 DOI: 10.1172/jci97696] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 01/23/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Among nondiabetic individuals, mild glucose decrements alter brain activity in regions linked to reward, motivation, and executive control. Whether these effects differ in type 1 diabetes mellitus (T1DM) patients with and without hypoglycemia awareness remains unclear. METHODS Forty-two individuals (13 healthy control [HC] subjects, 16 T1DM individuals with hypoglycemia awareness [T1DM-Aware], and 13 T1DM individuals with hypoglycemia unawareness [T1DM-Unaware]) underwent blood oxygen level-dependent functional MRI brain imaging during a 2-step hyperinsulinemic euglycemic (90 mg/dl)-hypoglycemic (60 mg/dl) clamp for assessment of neural responses to mild hypoglycemia. RESULTS Mild hypoglycemia in HC subjects altered activity in the caudate, insula, prefrontal cortex, and angular gyrus, whereas T1DM-Aware subjects showed no caudate and insula changes, but showed altered activation patterns in the prefrontal cortex and angular gyrus. Most strikingly, in direct contrast to HC and T1DM-Aware subjects, T1DM-Unaware subjects failed to show any hypoglycemia-induced changes in brain activity. These findings were also associated with blunted hormonal counterregulatory responses and hypoglycemia symptom scores during mild hypoglycemia. CONCLUSION In T1DM, and in particular T1DM-Unaware patients, there is a progressive blunting of brain responses in cortico-striatal and fronto-parietal neurocircuits in response to mild-moderate hypoglycemia. These findings have implications for understanding why individuals with impaired hypoglycemia awareness fail to respond appropriately to falling blood glucose levels. FUNDING This study was supported in part by NIH grants R01DK020495, P30 DK045735, K23DK109284, K08AA023545. The Yale Center for Clinical Investigation is supported by an NIH Clinical Translational Science Award (UL1 RR024139).
Collapse
Affiliation(s)
| | | | | | - Dongju Seo
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Feng Dai
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Anne-Sophie Sejling
- Department of Cardiology, Nephrology and Endocrinology, Nordsjællands Hospital, Hillerød, Denmark
| | | | | | - Rajita Sinha
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
| | | |
Collapse
|
3
|
Trends in the management levels of metabolic risk factors in middle-aged and elderly patients with type 2 diabetes mellitus: The Korean National Health and Nutrition Examination Survey 1998-2014. PLoS One 2017; 12:e0189361. [PMID: 29228048 PMCID: PMC5724842 DOI: 10.1371/journal.pone.0189361] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 11/27/2017] [Indexed: 11/19/2022] Open
Abstract
The present study examined the temporal trends in the management of blood pressure, glucose, and lipid levels among middle-aged and elderly patients with type 2 diabetes using data from the Korean National Health and Nutrition Examination Survey (1998–2014). A total of 3,689 patients with diabetes were included and divided into middle-aged (30–64 years old) and elderly (≥65 years old) groups. Demographic and lifestyle data were obtained using a self-reported questionnaire, and trained medical staff obtained fasting blood samples and blood pressure data. Laboratory testing was performed to determine blood glucose, cholesterol, and triglyceride levels. In the multivariable adjusted models, significant decreasing trends in the prevalences of hyperglycemia and hypertension were observed in both age groups during 1998–2014, although no trends were observed for lipid levels. Based on the most recent survey, approximately 50% of patients with diabetes had hyperglycemia, and one-third of patients with diabetes and hypertension did not appropriately manage their blood pressure. In addition, 50% of the patients in both age groups did not manage their lipid profiles, and the management of lipid profiles did not improve in recent years. These results suggest that continuous follow-up is needed to effectively manage metabolic risk factors, especially lipid profiles, among patients with diabetes.
Collapse
|
4
|
Development and Validation of a Questionnaire Evaluating Impaired Hypoglycemia Awareness among Adult Filipino Patients with Type 2 Diabetes Mellitus. J ASEAN Fed Endocr Soc 2017; 32:158-164. [PMID: 33442100 PMCID: PMC7784180 DOI: 10.15605/jafes.032.02.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 09/18/2016] [Indexed: 11/17/2022] Open
Abstract
Introduction Hazards of hypoglycemia include accidents, cardiovascular events, neurologic damage, and impaired hypoglycemia awareness (IHA) which presents as inability to perceive and respond to hypoglycemic warning symptoms. Objective This study aimed to develop the first questionnaire evaluating IHA adapted from Clarke Hypoglycemia Index (CHI) and validated among adult Filipino patients with Type 2 Diabetes Mellitus (T2DM). Methodology A questionnaire development study was conducted involving CHI linguistic translation, its modification through literature review and focus group discussions, panel synthesis, and content validity. A cross-sectional analytic study followed by administration of the questionnaire to 117 adult Filipinos with T2DM, advanced age, long-standing T2DM, insulin or sulfonylurea, polypharmacy, comorbidities and/or prior hypoglycemia. There were 9 participants in pilot testing, 69 in criterion validity against continuous glucose monitoring (CGM), and 108 in construct validity. Results IHA domains in the concept map included Elusive Euglycemia Model, Developmental Model, and Cognitive Model. The Filipino-CHI formulated had 8 questions with content validity scores ranging from 87.5-93.75%. Owing to brevity, its internal consistency Cronbach's alpha was 0.45. Criterion validity against CGM yielded 21 patients with biochemical hypoglycemic events, of which 2 had clinical hypoglycemic events and 19 were positive monitor-identified IHA. A questionnaire IHA cutoff score of ≥4 had sensitivity of 89.47%, and area under the curve of 0.55. Conclusion An 8-item questionnaire evaluating IHA among adult Filipino T2DM patients was developed and validated.
Collapse
|
5
|
Sam S, Vellanki P, Yalamanchi SK, Bergman RN, Dunaif A. Exaggerated glucagon responses to hypoglycemia in women with polycystic ovary syndrome. Metabolism 2017; 71:125-131. [PMID: 28521865 PMCID: PMC5468004 DOI: 10.1016/j.metabol.2017.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 03/13/2017] [Accepted: 03/15/2017] [Indexed: 12/25/2022]
Abstract
CONTEXT Premenopausal women have blunted counter-regulatory hormone responses (CRR) to hypoglycemia compared to men. Postmenopausal women have CRR similar to men; the premenopausal pattern can be restored by estrogen. However, glucagon and pancreatic polypeptide (PP) responses remain lower in postmenopausal women than in men. Since hyperandrogenemia contributes to the metabolic phenotype of polycystic ovary syndrome (PCOS), we hypothesize that CRR to hypoglycemia especially of glucagon and PP is exaggerated in premenopausal women with PCOS compared to premenopausal control women. STUDY SUBJECTS AND METHODS Ten obese women with PCOS and 9 control women of similar ethnicity, age and BMI underwent determination of CRR in response to hypoglycemia during 180-min 60mU/m2/min insulin dose hypoglycemic clamp with isotopic assessment of endogenous glucose production (EGP). To assess CRR to hypoglycemia, glucagon, cortisol, growth hormone (GH), epinephrine, norepinephrine, PP, lactate, free fatty acid (FFA), β-hydroxybutyrate, and glycerol levels were sampled at 15-min intervals throughout the clamp. MAIN FINDINGS Incremental glucagon levels were ~3-fold higher during hypoglycemia (P=0.03) in PCOS. Postabsorptive, steady-state and incremental GH, cortisol, epinephrine, norepinephrine, PP, FFA, glycerol and β-hydroxybutyrate did not differ. At target glucose levels of ~52mg/dL, insulin mediated glucose disposal (IMGD) was decreased by ~40% (P=0.02) in PCOS, compared to control women, despite ~20% higher steady-state insulin levels (P=0.03). Neither postabsorptive nor steady-state EGP differed. However, postabsorptive lactate levels were ~50% higher (P=0.02). PCOS status (P=0.04) and IMGD (P=0.02) predicted the differential glucagon response to hypoglycemia in separate regression models, however, neither parameter remained an independent predictor in a combined model. PRINCIPAL CONCLUSIONS Glucagon responses were increased in PCOS, whereas other CRR did not differ. Women with PCOS were insulin resistant under hypoglycemic conditions and higher postabsorptive lactate levels in PCOS were consistent with this finding. Insulin resistance may have contributed to exaggerated glucagon response to hypoglycemia in PCOS.
Collapse
Affiliation(s)
- Susan Sam
- Section of Adult and Pediatric Endocrinology, Diabetes, & Metabolism, University of Chicago, Chicago, IL, United States
| | - Priyathama Vellanki
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Sudha K Yalamanchi
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Richard N Bergman
- Diabetes and Obesity Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Andrea Dunaif
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States.
| |
Collapse
|
6
|
Kok VC, Lee PH. Management of Hypoglycemia in Nondiabetic Palliative Care Patients: A Prognosis-Based Approach. Palliat Care 2016; 10:1-5. [PMID: 27920549 PMCID: PMC5123827 DOI: 10.4137/pcrt.s38956] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 10/26/2016] [Accepted: 11/01/2016] [Indexed: 02/07/2023] Open
Abstract
Hypoglycemia due to underlying terminal illness in nondiabetic end-of-life patients receiving palliative care has not been fully studied. For example, we do not have adequate information on the frequency of spontaneous hypoglycemia in patients as occurs during the different stages of palliative care. Depending on the case-mix nature of the palliative care ward, at least 2% of palliative care patients may develop hypoglycemia near the end of life when the remaining life expectancy counts down in days. As many as 25%-60% of these patients will neither have autonomic response nor have neuroglycopenic symptoms during a hypoglycemic episode. Although it is not difficult to diagnose and confirm a true hypoglycemia when it is suspected clinically, an episode of hypoglycemic attack may go unnoticed in some patients in a hospice setting. Current trends in palliative care focus on providing treatments based on a prognosis-based framework, involving shared decision-making between the patient and caregivers, after considering the prognosis, professional recommendations, patient's autonomy, family expectations, and the current methods for treating the patient's physical symptoms and existential suffering. This paper provides professional care teams with both moral and literature support for providing care to nondiabetic patients presenting with hypoglycemia.
Collapse
Affiliation(s)
- Victor C. Kok
- Division of Palliative Medicine, Department of Internal Medicine, Kuang Tien General Hospital, Taichung, Taiwan
- Division of Medical Oncology, Cancer Center of Kuang Tien General Hospital, Taichung, Taiwan
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan
- CORRESPONDENCE:
| | - Ping-Hsueh Lee
- Division of Palliative Medicine, Department of Internal Medicine, Kuang Tien General Hospital, Taichung, Taiwan
- Division of Geriatric Medicine, Department of Family Medicine, Kuang Tien General Hospital, Taichung, Taiwan
| |
Collapse
|
7
|
Wehrwein EA, Limberg JK, Taylor JL, Dube S, Basu A, Basu R, Rizza RA, Curry TB, Joyner MJ. Effect of bilateral carotid body resection on the counterregulatory response to hypoglycaemia in humans. Exp Physiol 2014; 100:69-78. [DOI: 10.1113/expphysiol.2014.083154] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 11/04/2014] [Indexed: 11/08/2022]
Affiliation(s)
- Erica A. Wehrwein
- Department of Physiology; Michigan State University; East Lansing MI USA
| | | | | | - Simmi Dube
- Department of Endocrinology; Mayo Clinic; Rochester MN USA
| | - Ananda Basu
- Department of Endocrinology; Mayo Clinic; Rochester MN USA
| | - Rita Basu
- Department of Endocrinology; Mayo Clinic; Rochester MN USA
| | | | | | | |
Collapse
|
8
|
Du YF, Ou HY, Beverly EA, Chiu CJ. Achieving glycemic control in elderly patients with type 2 diabetes: a critical comparison of current options. Clin Interv Aging 2014; 9:1963-80. [PMID: 25429208 PMCID: PMC4241951 DOI: 10.2147/cia.s53482] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The prevalence of type 2 diabetes mellitus (T2DM) is increasing in the elderly. Because of the unique characteristics of elderly people with T2DM, therapeutic strategy and focus should be tailored to suit this population. This article reviews the guidelines and studies related to older people with T2DM worldwide. A few important themes are generalized: 1) the functional and cognitive status is critical for older people with T2DM considering their life expectancy compared to younger counterparts; 2) both severe hypoglycemia and persistent hyperglycemia are deleterious to older adults with T2DM, and both conditions should be avoided when determining therapeutic goals; 3) recently developed guidelines emphasize the avoidance of hypoglycemic episodes in older people, even in the absence of symptoms. In addition, we raise the concern of glycemic variability, and discuss the rationale for the selection of current options in managing this patient population.
Collapse
Affiliation(s)
- Ye-Fong Du
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Horng-Yih Ou
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Elizabeth A Beverly
- Department of Social Medicine, Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Ching-Ju Chiu
- Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| |
Collapse
|
9
|
Veldhuis JD, Sharma A, Roelfsema F. Age-dependent and gender-dependent regulation of hypothalamic-adrenocorticotropic-adrenal axis. Endocrinol Metab Clin North Am 2013; 42:201-25. [PMID: 23702398 PMCID: PMC3675779 DOI: 10.1016/j.ecl.2013.02.002] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Tightly regulated output of glucocorticoids is critical to maintaining immune competence, the structure of neurons, muscle, and bone, blood pressure, glucose homeostasis, work capacity, and vitality in the human and experimental animal. Age, sex steroids, gender, stress, body composition, and disease govern glucocorticoid availability through incompletely understood mechanisms. According to an ensemble concept of neuroendocrine regulation, successful stress adaptations require repeated incremental signaling adjustments among hypothalamic corticotropin-releasing hormone and arginine vasopressin, pituitary adrenocorticotropic hormone, and adrenal corticosteroids. Signals are transduced via (positive) feedforward and (negative) feedback effects. Age and gonadal steroids strongly modulate stress-adaptive glucocorticoid secretion by such interlinked pathways.
Collapse
Affiliation(s)
- Johannes D Veldhuis
- Endocrine Research Unit, Mayo School of Graduate Medical Education, Center for Translational Science Activities, Mayo Clinic, Rochester, MN 55905, USA.
| | | | | |
Collapse
|
10
|
Abdelhafiz AH, Bailey C, Eng Loo B, Sinclair A. Hypoglycaemic symptoms and hypoglycaemia threshold in older people with diabetes--a patient perspective. J Nutr Health Aging 2013; 17:899-902. [PMID: 24257574 DOI: 10.1007/s12603-013-0351-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate patients' views about their lowest tolerable blood glucose level and explore symptoms they may develop below that level. DESIGN A semi-structured patient interview. SETTING Outpatient clinic for older people (≥75 years) with diabetes. PARTICIPANTS Patients attending an outpatient clinic over a six months period who are monitoring their blood glucose at home and able to participate in interview. RESULTS Sixty one patients gave answers to the interview questions. Mean (SD) age was 82.3 (3.9) years and 33 (54%) were females. All patients indicated that they were usually aware when hypoglycaemia occurs but the symptoms reported were mostly non specific. The threshold for hypoglycaemia was 5 mmol/L in 13 (21%) patients, 6 mmol/L in 14 (23%) patients, 7 mmol/L in 13 (21%) patients, 8 mmol/L in 17 (28%) patients and 9 mmol/L in 4 (7%) patients. There was no significant difference between patients who were symptomatic at a higher blood glucose level (>6 mmo/L) and those who developed symptoms at a lower level (≤6 mmol/L). CONCLUSION Older people with diabetes who seem to be aware of hypoglycaemia report mostly non specific symptoms. The threshold of experiencing hypoglycaemic symptoms appears to be higher than the usually defined <4 mmol/L.
Collapse
Affiliation(s)
- A H Abdelhafiz
- Dr Ahmed H Abdelhafiz, Department Of Elderly Medicine, Rotherham General Hospital, Moorgate Road, Rotherham, S60 2UD, Tel: 01709 307576, Fax: 01709 304419, E Mail:
| | | | | | | |
Collapse
|
11
|
Zammitt NN, Frier BM. Hypoglycemia in type 2 diabetes: pathophysiology, frequency, and effects of different treatment modalities. Diabetes Care 2005; 28:2948-61. [PMID: 16306561 DOI: 10.2337/diacare.28.12.2948] [Citation(s) in RCA: 284] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Nicola N Zammitt
- Department of Diabetes, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, Scotland, U.K
| | | |
Collapse
|
12
|
Podolin DA, Wills BK, Wood IO, Lopez M, Mazzeo RS, Roth DA. Attenuation of age-related declines in glucagon-mediated signal transduction in rat liver by exercise training. Am J Physiol Endocrinol Metab 2001; 281:E516-23. [PMID: 11500307 DOI: 10.1152/ajpendo.2001.281.3.e516] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This study investigated alterations in glucagon receptor-mediated signal transduction in rat livers from 7- to 25-mo-old animals and examined the effects of exercise training on ameliorating these changes. Sixty-six young (4 mo), middle-aged (12 mo), and old (22 mo) male Fischer 344 rats were divided into sedentary and trained (treadmill running) groups. Isolated hepatic membranes were combined with [(125)I-Tyr(10)]monoiodoglucagon and nine concentrations of glucagon to determine maximal binding capacity (B(max)) and dissociation constant (K(d)). No alterations were found in B(max) among groups; however, middle-aged trained animals had significantly higher glucagon affinity (lower K(d); 21.1 +/- 1.8 nM) than did their untrained counterparts (50.2 +/- 7.1 nM). Second messenger studies were performed by measuring adenylyl cyclase (AC) specific activity under basal conditions and with four pharmacological stimulations to assess changes in receptor-dependent, G protein-dependent, and AC catalyst-dependent cAMP production. Age-related declines were observed in the old animals under all five conditions. Training resulted in increased cAMP production in the old animals when AC was directly stimulated by forskolin. Stimulatory G protein (G(s)) content was reduced with age in the sedentary group; however, training offset this decline. We conclude that age-related declines in glucagon signaling capacity and responsiveness may be attributed, in part, to declines in intrinsic AC activity and changes in G protein [inhibitory G protein (G(i))/G(s)] ratios. These age-related changes occur in the absence of alterations in glucagon receptor content and appear to involve both G protein- and AC-related changes. Endurance training was able to significantly offset these declines through restoration of the G(i)/G(s) ratio and AC activity.
Collapse
Affiliation(s)
- D A Podolin
- University of Colorado, Boulder, CO 80303, USA.
| | | | | | | | | | | |
Collapse
|