Muscle microvascular recruitment predicts insulin sensitivity in middle-aged patients with type 1 diabetes mellitus

AIMS/HYPOTHESIS

Insulin delivery to muscle is rate-limiting for insulin's metabolic action and is regulated by insulin's own action to increase skeletal muscle blood flow and to recruit microvasculature. Microvascular dysfunction has been observed in insulin resistant states. We investigated the relation between insulin's action to recruit microvasculature and its metabolic action in type 1 diabetes.

METHODS

Near euglycaemia was obtained by an overnight insulin infusion during 17 inpatient admissions of participants with type 1 diabetes. This was followed by a 2 h 1 mU kg⁻¹ min⁻¹ euglycaemic-hyperinsulinaemic clamp. Microvascular blood volume (MBV) was assessed using contrast-enhanced ultrasound 10 min before and 30 min after starting the clamp.

RESULTS

We observed that, after overnight modest hyperinsulinaemia (average ≈ 286 pmol/l), MBV was positively related to the steady-state insulin sensitivity measured during the subsequent clamp (r = 0.62, p = 0.008). The more marked hyperinsulinaemia during the clamp (average steady-state insulin ≈ 900 pmol/l) increased MBV in the more insulin resistant participants within 30 min but not in the insulin sensitive participants. The change in MBV during the clamp was negatively correlated to the insulin sensitivity (r = -0.55, p = 0.022). As a result, MBV after 30 min of marked hyperinsulinaemia was comparable between the insulin sensitive and resistant participants.

CONCLUSIONS/INTERPRETATION

We conclude that moderate overnight hyperinsulinaemia recruited microvasculature in the more sensitive participants, while higher levels of plasma insulin were needed for more insulin resistant participants. This suggests that microvascular responsiveness to insulin is one determinant of metabolic insulin sensitivity in type 1 diabetes.

Insulin entry into muscle involves a saturable process in the vascular endothelium

AIMS/HYPOTHESIS

Insulin's rate of entry into skeletal muscle appears to be the rate-limiting step for muscle insulin action and is slowed by insulin resistance. Despite its obvious importance, uncertainty remains as to whether the transport of insulin from plasma to muscle interstitium is a passive diffusional process or a saturable transport process regulated by the insulin receptor.

METHODS

To address this, here we directly measured the rate of (125)I-labelled insulin uptake by rat hindlimb muscle and examined how that is affected by adding unlabelled insulin at high concentrations. We used mono-iodinated [(125)I]Tyr(A14)-labelled insulin and short (5 min) exposure times, combined with trichloroacetic acid precipitation, to trace intact bioactive insulin.

RESULTS

Compared with saline, high concentrations of unlabelled insulin delivered either continuously (insulin clamp) or as a single bolus, significantly raised plasma (125)I-labelled insulin, slowed the movement of (125)I-labelled insulin from plasma into liver, spleen and heart (p < 0.05, for each) but increased kidney (125)I-labelled insulin uptake. High concentrations of unlabelled insulin delivered either continuously (insulin clamp), or as a single bolus, significantly decreased skeletal muscle (125)I-labelled insulin clearance (p < 0.01 for each). Increasing muscle perfusion by electrical stimulation did not prevent the inhibitory effect of unlabelled insulin on muscle (125)I-labelled insulin clearance.

CONCLUSIONS/INTERPRETATION

These results indicate that insulin's trans-endothelial movement within muscle is a saturable process, which is likely to involve the insulin receptor. Current findings, together with other recent reports, suggest that trans-endothelial insulin transport may be an important site at which muscle insulin action is modulated in clinical and pathological settings.

The vascular actions of insulin control its delivery to muscle and regulate the rate-limiting step in skeletal muscle insulin action

Evidence suggests that insulin delivery to skeletal muscle interstitium is the rate-limiting step in insulin-stimulated muscle glucose uptake and that this process is impaired by insulin resistance. In this review we examine the basis for the hypothesis that insulin acts on the vasculature at three discrete steps to enhance its own delivery to muscle: (1) relaxation of resistance vessels to increase total blood flow; (2) relaxation of pre-capillary arterioles to increase the microvascular exchange surface perfused within skeletal muscle (microvascular recruitment); and (3) the trans-endothelial transport (TET) of insulin. Insulin can relax resistance vessels and increase blood flow to skeletal muscle. However, there is controversy as to whether this occurs at physiological concentrations of, and exposure times to, insulin. The microvasculature is recruited more quickly and at lower insulin concentrations than are needed to increase total blood flow, a finding consistent with a physiological role for insulin in muscle insulin delivery. Microvascular recruitment is impaired by obesity, diabetes and nitric oxide synthase inhibitors. Insulin TET is a third potential site for regulating insulin delivery. This is underscored by the consistent finding that steady-state insulin concentrations in plasma are approximately twice those in muscle interstitium. Recent in vivo and in vitro findings suggest that insulin traverses the vascular endothelium via a trans-cellular, receptor-mediated pathway, and emerging data indicate that insulin acts on the endothelium to facilitate its own TET. Thus, muscle insulin delivery, which is rate-limiting for its metabolic action, is itself regulated by insulin at multiple steps. These findings highlight the need to further understand the role of the vascular actions of insulin in metabolic regulation.

Endothelial Na+-D-glucose cotransporter: no role in insulin-mediated glucose uptake

A recent report indicates that the Na+-D-glucose cotransporter SGLT1 is present in capillaries of skeletal muscle and is required for insulin-mediated glucose uptake in myocytes. This result is based on the complete inhibition of insulin-mediated muscle glucose uptake by phlorizin, an inhibitor of SGLT1. Using the pump-perfused rat hind limb, we measured glucose uptake, lactate efflux, and radioactive 2-deoxyglucose uptake into individual muscles with saline (control), phlorizin, insulin, and insulin plus phlorizin, as well as with saline and insulin using normal and low Na+ perfusion buffer. Insulin-mediated glucose uptake was not inhibited after correction for phlorizin interference in the glucose assay. Lactate efflux and 2-deoxyglucose uptake by individual muscles were unaffected by phlorizin. Low Na+ buffer did not affect insulin-mediated glucose uptake, lactate efflux, or 2-deoxyglucose uptake. We conclude that endothelial SGLT1 exerts no barrier for glucose delivery to myocytes.

Field trial of the efficacy of a combination of ivermectin and praziquantel in horses infected with roundworms and tapeworms

Two hundred and thirty-three horses were screened for the presence of roundworms by faecal egg counts (FECs) and for tapeworms by an ELISA specific for antibodies to the immunodominant 12 kDa and 13 kDa tapeworms antigen. The 62 horses were found to be infected with both parasites were treated with a combination of 0.2 mg/kg ivermectin and 1.5 mg/kg praziquantel. The treatment suppressed the median FEC of the horses to zero for 10 weeks and significantly reduced their anti-12/13 kDa antibody levels. The estimated risk of tapeworm-associated colic in these horses was halved by 12 weeks after the treatment.

Inhibiting NOS blocks microvascular recruitment and blunts muscle glucose uptake in response to insulin

We examined the effects of inhibiting nitric oxide synthase with Nomega-nitro-l-arginine-methyl ester (l-NAME) on total hindlimb blood flow, muscle microvascular recruitment, and hindlimb glucose uptake during euglycemic hyperinsulinemia in vivo in the rat. We used two independent methods to measure microvascular perfusion. In one group of animals, microvascular recruitment was measured using the metabolism of exogenously infused 1-methylxanthine (1-MX), and in a second group contrast-enhanced ultrasound (CEU) was used. Limb glucose uptake was measured by arterial-venous concentration differences after 2 h of insulin infusion. Saline alone did not alter femoral artery flow, glucose uptake, or 1-MX metabolism. Insulin (10 mU.min-1.kg-1) significantly increased hindlimb total blood flow (0.69 +/- 0.02 to 1.22 +/- 0.11 ml/min, P < 0.05), glucose uptake (0.27 +/- 0.05 to 0.95 +/- 0.08 micromol/min, P < 0.05), 1-MX uptake (5.0 +/- 0.5 to 8.5 +/- 1.0 nmol/min, P < 0.05), and skeletal muscle microvascular volume measured by CEU (10.0 +/- 1.6 to 15.0 +/- 1.2 video intensity units, P < 0.05). Addition of l-NAME to insulin completely blocked the effect of insulin on both total limb flow and microvascular recruitment (measured using either 1-MX or CEU) and blunted glucose uptake by 40% (P < 0.05). We conclude that insulin specifically recruits flow to the microvasculture in skeletal muscle via a nitric oxide-dependent pathway and that this may be important to insulin's overall action to regulate glucose disposal.

Skeletal muscle microvascular recruitment by physiological hyperinsulinemia precedes increases in total blood flow

Supraphysiological doses of insulin enhance total limb blood flow and recruit capillaries in skeletal muscle. Whether these processes change in response to physiological hyperinsulinemia is uncertain. To examine this, we infused either saline (n = 6) or insulin (euglycemic clamp, 3.0 mU x min(-1) x kg(-1), n = 9) into anesthetized rats for 120 min. Femoral artery flow was monitored continuously using a Doppler flow probe, and muscle microvascular recruitment was assessed by metabolism of infused 1-methylxanthine (1-MX) and by contrast-enhanced ultrasound (CEU). Insulin infusion raised plasma insulin concentrations by approximately 10-fold. Compared with saline, physiological hyperinsulinemia increased femoral artery flow (1.02 +/- 0.10 vs. 0.68 +/- 0.09 ml/min; P < 0.05), microvascular recruitment (measured by 1-MX metabolism [6.6 +/- 0.5 vs. 4.5 +/- 0.48 nmol/min; P < 0.05] as well as by CEU [167.0 +/- 39.8 vs. 28.2 +/- 13.8%; P < 0.01]), and microvascular flow velocity (beta, 0.14 +/- 0.02 vs. 0.09 +/- 0.02 s(-1)). Subsequently, we studied the time dependency of insulin's vascular action in a second group (n = 5) of animals. Using CEU, microvascular volume was measured at 0, 30, and 90 min of insulin infusion. Insulin augmented microvascular perfusion within 30 min (52.8 +/- 14.8%), and this persisted at 90 min (64.6 +/- 9.9%). Microvascular recruitment occurred without changes to femoral artery flow or beta. We conclude that insulin increases tissue perfusion by recruiting microvascular beds, and at physiological concentrations this precedes increases in total muscle blood flow by 60-90 min.

Evolving structures in surgical oncology and the role of the Federation of European Cancer Societies in continuing medical education

This article describes the evolution of a European system of accreditation of educational events in oncology and the establishment by the Federation of European Cancer Societies of the Accreditation Council of Oncology in Europe. It draws attention to the need for a coordinated system which is acceptable in the different European countries so that an international system of "Eurocredits" can be devised. Through the official Union Europeénne des Médecins Specialistes (UEMS), reciprocity with the accrediting bodies in the United States and other countries is planned.

Branched chain amino acids activate messenger ribonucleic acid translation regulatory proteins in human skeletal muscle, and glucocorticoids blunt this action

Branched chain amino acids (BCAA) are particularly effective anabolic agents. Recent in vitro studies suggest that amino acids, particularly leucine, activate a signaling pathway that enhances messenger ribonucleic acid translation and protein synthesis. The physiological relevance of these findings to normal human physiology is uncertain. We examined the effects of BCAA on the phosphorylation of eukaryotic initiation factor 4E-binding protein 1 (eIF4E-BP1) and ribosomal protein S6 kinase (p70(S6K)) in skeletal muscle of seven healthy volunteers. We simultaneously examined whether BCAA affect urinary nitrogen excretion and forearm skeletal muscle protein turnover and whether the catabolic action of glucocorticoids could be mediated in part by inhibition of the action of BCAA on the protein synthetic apparatus. BCAA infusion decreased urinary nitrogen excretion (P < 0.02), whole body phenylalanine flux (P < 0.02), plasma phenylalanine concentration (P < 0.001), and improved forearm phenylalanine balance (P = 0.03). BCAA also increased the phosphorylation of both eIF4E-BP1 (P < 0.02) and p70(S6K) (P < 0.03), consistent with an action to activate the protein synthetic apparatus. Dexamethasone increased plasma phenylalanine concentration (P < 0.001), prevented the BCAA-induced anabolic shift in forearm protein balance, and inhibited their action on the phosphorylation of p70(S6K). We conclude that in human skeletal muscle BCAA act directly as nutrient signals to activate messenger ribonucleic acid translation and potentiate protein synthesis. Glucocorticoids interfere with this action, and that may be part of the mechanism by which they promote net protein catabolism in muscle.

Pre-replantation storage of avulsed teeth: fact and fiction

Recent laboratory and clinical studies have proven that there is a rapid decrease in the regenerative potential of normal periodontal ligament the longer an avulsed tooth is out of the socket. These findings make some guidelines for the management of avulsed teeth inaccurate. This paper will review the effects of pre-replantation storage on periodontal ligament healing. In addition, current management recommendations are reviewed and suggestions for change presented.

Dexamethasone inhibits the stimulation of muscle protein synthesis and PHAS-I and p70 S6-kinase phosphorylation

Glucocorticoids inhibit protein synthesis in muscle. In contrast, insulin and amino acids exert anabolic actions that arise in part from their ability to phosphorylate ribosomal p70 S6-kinase (p70(S6k)) and eukaryotic initiation factor (eIF)4E binding protein (BP)1 (PHAS-I), proteins that regulate translation initiation. Whether glucocorticoids interfere with this action was examined by giving rats either dexamethasone (DEX, 300 microg. kg(-1). day(-1), n = 10) or saline (n = 10) for 5 days. We then measured the phosphorylation of PHAS-I and p70(S6k) in rectus muscle biopsies taken before and at the end of a 180-min infusion of either insulin (10 mU. min(-1). kg(-1) euglycemic insulin clamp, n = 5 for both DEX- and saline-treated groups) or a balanced amino acid mixture (n = 5 for each group also). Protein synthesis was also measured during the infusion period. The results were that DEX-treated rats had higher fasting insulin, slower glucose disposal, less lean body mass, and decreased protein synthetic rates during insulin or amino acid infusion (P < 0.05 each). DEX did not affect basal PHAS-I or p70(S6k) phosphorylation but blocked insulin-stimulated phosphorylation of PHAS-I- and amino acid-stimulated phosphorylation of both PHAS-I and p70(S6k) (P < 0.01, for each). DEX also increased muscle PHAS-I concentration. These effects can, in part, explain glucocorticoid-induced muscle wasting.

Heterogeneity of laser Doppler flowmetry in perfused muscle indicative of nutritive and nonnutritive flow

Laser Doppler flowmetry (LDF) signal responses have been compared with metabolic changes using both a surface macroprobe and randomly placed implantable microprobes in muscles of the constant-flow-perfused rat hindlimb. Changes in response to total flow and to vasoconstrictors that are known to increase (norepinephrine, NE) or decrease (serotonin, 5-HT) hindlimb oxygen uptake were assessed. The surface macroprobe (anterior end of biceps femoris) identified only one type of LDF response characterized by increased signal in response to NE and decreased signal in response to 5-HT. Implanted microprobes (tibialis, gastrocnemius, vastus, or bicep femoris) identified sites that gave three LDF responses of differing character. These responses were where the LDF signal increased with NE and decreased with 5-HT (56.7%), where the LDF signal decreased with NE and increased with 5-HT (16.5%), or where there was no net response to either vasoconstrictor (24.7%). The data are consistent with discrete regions of nutritive and nonnutritive flow in muscle where flow in each as controlled by vasoconstrictors relates directly to the metabolic behavior of the tissue.

Insulin stimulates laser Doppler signal by rat muscle in vivo, consistent with nutritive flow recruitment

Insulin-mediated increases in limb blood flow are thought to enhance glucose uptake by skeletal muscle. Using the perfused rat hindlimb, we report that macro laser Doppler flowmetry (LDF) probes positioned on the surface of muscle detect changes in muscle capillary (nutritive) flow. With this as background, we examined the effects of insulin and adrenaline (epinephrine), which are both known to increase total leg blood flow, on the LDF signals from scanning and stationary probes on the muscle surface in vivo. The aim is to assess the relationship between capillary recruitment, total limb blood flow and glucose metabolism. Glucose infusion rate, femoral arterial blood flow (FBF) and muscle LDF, using either scanning or a stationary probe positioned over the biceps femoris muscle, were measured. With scanning LDF, animals received insulin (10 m-units x min(-1) x kg(-1)), adrenaline (0.125 microg.min(-1) x kg(-1)) or saline. By 1 h, insulin had increased the glucose infusion rate from 0 to 128 micromol.min(-1) x kg(-1) and the scanning LDF had increased by 62+/-8% (P<0.05), but FBF was unaffected. Adrenaline increased FBF by 49% at 15 min, but LDF was unchanged. With saline at 1 h, neither FBF nor LDF had changed. With the stationary LDF surface probe, insulin at 1 h had increased FBF by 47% (P<0.05) and LDF by 47% (P<0.05) relative to saline controls. Adrenaline increased FBF (39%), but LDF was unaltered. The stimulation of LDF by insulin is consistent with capillary recruitment (nutritive flow) as part of the action of this hormone in vivo. The recruitment may be independent of changes in total flow, as adrenaline, which also increased FBF, did not increase LDF. The time of onset suggests that LDF closely parallels glucose uptake. Thus, depending on probe design, measurement of muscle haemodynamic effects mediated by insulin in normally responsive and insulin-resistant patients should be possible.

Physiological hyperinsulinemia stimulates p70(S6k) phosphorylation in human skeletal muscle

Using tracer methods, insulin stimulates muscle protein synthesis in vitro, an effect not seen in vivo with physiological insulin concentrations in adult animals or humans. To examine the action of physiological hyperinsulinemia on protein synthesis using a tracer-independent method in vivo and identify possible explanations for this discrepancy, we measured the phosphorylation of ribosomal protein S6 kinase (P70(S6k)) and eIF4E-binding protein (eIF4E-BP1), two key proteins that regulate messenger ribonucleic acid translation and protein synthesis. Postabsorptive healthy adults received either a 2-h insulin infusion (1 mU/min.kg; euglycemic insulin clamp; n = 6) or a 2-h saline infusion (n = 5). Vastus lateralis muscle was biopsied at baseline and at the end of the infusion period. Phosphorylation of P70(S6k) and eIF4E-BP1 was quantified on Western blots after SDS-PAGE. Physiological increments in plasma insulin (42 +/- 13 to 366 +/- 36 pmol/L; P: = 0.0002) significantly increased p70(S6k) (P: < 0.01), but did not affect eIF4E-BP1 phosphorylation in muscle. Plasma insulin declined slightly during saline infusion (P: = 0.04), and there was no change in the phosphorylation of either p70(S6k) or eIF4E-BP1. These findings indicate an important role of physiological hyperinsulinemia in the regulation of p70(S6k) in human muscle. This finding is consistent with a potential role for insulin in regulating the synthesis of that subset of proteins involved in ribosomal function. The failure to enhance the phosphorylation of eIF4E-BP1 may in part explain the lack of a stimulatory effect of physiological hyperinsulinemia on bulk protein synthesis in skeletal muscle in vivo.

The ubiquitin-proteasome proteolytic pathway in heart vs skeletal muscle: effects of acute diabetes

The ubiquitin-proteasome system is thought to play a major role in normal muscle protein turnover and to contribute to diabetes-induced protein wasting in skeletal muscle. However, its importance in cardiac muscle is not clear. We measured heart muscle mRNA for ubiquitin and for the C2 and C8 proteasomal subunits, the amount of free ubiquitin and the proteasome chymotrypsin-like proteolytic activity in control and diabetic rats. Results were compared to those in skeletal muscle (rectus). Heart ubiquitin, C2 and C8 subunit mRNA and proteolytic activity were significantly greater than in skeletal muscle (P </= 0.05). This suggests that the ubiquitin proteasomal pathway may also be important for normal heart muscle turnover. Diabetes increased ubiquitin mRNA by approximately 50% in heart (P < 0.03) and by approximately 100% in skeletal muscle (P < 0.005). It remained high after 3 days of insulin treatment in both tissues. C2 and C8 subunit mRNA did not change with diabetes or insulin treatment. Diabetes did not change the amount of free ubiquitin or the proteasomal (lactacystin-inhibitable) chymotrypsin-like peptidase activity in heart or skeletal muscle. In conclusions, gene expression for several components of the ubiquitin-proteasome proteolytic pathway is significantly higher in cardiac than in skeletal muscle, as is the proteasome chymotrypsin-like peptidase activity. Diabetes increases the expression of ubiquitin but not C2 or C8 subunit mRNA, nor does it significantly alter the amount of free ubiquitin or the proteasome chymotrypsin-like peptidase activity. The rate-limiting step of enhanced protein degradation in diabetic rat heart and skeletal muscle may be located at ubiquitin conjugation and/or its binding to proteasome, not at the ubiquitin availability or the proteasome itself.

A national diabetes care and education programme: the Ghana model

An account is given of how a national diabetes care and education programme was developed in Ghana, a developing country, through international collaboration of medical schools, industry and government health care institutions. The approach is by way of trained diabetes teams consisting of physicians, dietitians and nurse educators at two tertiary institutional levels (teaching hospitals) who in turn trained teams consisting of physicians, dietitians or diettherapy nurses, nurse educators and pharmacists at regional and district/sub-regional levels to offer care and education to patients and the community. In three years all regional and about 63% of sub-regional/district health facilities had trained diabetes health care teams, run diabetes services and had diabetes registers at these institutions. Additionally a set of guidelines for diabetes care and education was produced. All programme objectives with the exception of one (deployment of diabetes kits) were met. Distances to be travelled by persons with diabetes to receive diabetes care had been reduced considerably. The success of the project has given an impetus to the collaborators to extend the programme to the primary health care level. The continuing prohibitive prices of diabetes medications and supplies however, could be addressed by removing taxes on such supplies. The Ghana diabetes care model, a 'top-down' approach, initially involving two diabetes centres is recommended to other developing countries, which intend to incorporate diabetes care and education into their health care system.

Amino acids regulate skeletal muscle PHAS-I and p70 S6-kinase phosphorylation independently of insulin

Refeeding reverses the muscle protein loss seen with fasting. The physiological regulators and cellular control sites responsible for this reversal are incompletely defined. Phosphorylation of phosphorylated heat-acid stabled protein (PHAS-I) frees eukaryotic initiation factor 4E (eIF4E) and stimulates protein synthesis by accelerating translation initiation. Phosphorylation of p70 S6-kinase (p70(S6k)) is thought to be involved in the regulation of the synthesis of some ribosomsal proteins and other selected proteins with polypyrimidine clusters near the transcription start site. We examined whether phosphorylation of PHAS-I and p70(S6k) was increased by feeding and determined the separate effects of insulin and amino acids on PHAS-I and p70(S6k) phosphorylation in rat skeletal muscle in vivo. Muscle was obtained from rats fed ad libitum or fasted overnight (n = 5 each). Other fasted rats were infused with insulin (3 microU x min(-1) x kg(-1), euglycemic clamp), amino acids, or the two combined. Gastrocnemius was freeze-clamped, and PHAS-I and p70(S6k) phosphorylation was measured by quantifying the several phosphorylated forms of these proteins seen on Western blots. We observed that feeding increased phosphorylation of both PHAS-I and p70(S6k) (P < 0.05). Infusion of amino acids alone reproduced the effect of feeding. Physiological hyperinsulinemia increased p70(S6K) (P < 0.05) but not PHAS-I phosphorylation (P = 0.98). Addition of insulin to amino acid infusion was no more effective than amino acids alone in promoting PHAS-I and p70(S6k) phosphorylation. We conclude that amino acid infusion alone enhances the activation of the protein synthetic pathways in vivo in rat skeletal muscle. This effect is not dependent on increases in plasma insulin and simulates the activation of protein synthesis that accompanies normal feeding.

Storage conditions of avulsed teeth affect the phenotype of cultured human periodontal ligament cells

After severe injury to the periodontal ligament (PL), the phenotypes of cells recolonizing root surfaces influence the extent and type of repair processes. In teeth that are replanted following avulsion injury, recolonization of the PL space by osteogenic cells instead of by PL fibroblasts may favor bone formation (i.e. ankylosis) instead of PL regeneration. We consider here that recolonization processes depend in part on the storage conditions of the teeth following avulsion. We used an in vitro cell culture model to assess the effect of storage conditions on immunohistochemical staining of several marker proteins that are expressed by osteogenic cells (osteopontin and alkaline phosphatase) and fibroblasts (alpha-smooth muscle actin, type III and XII collagens). Prior to cell culture, extracted human premolar teeth were stored in air ("dry") or in alpha-MEM ("wet") for either 30 or 120 min as surrogate conditions for the variations of extra-alveolar tooth storage that may occur following avulsion. Collagenase/trypsin-digested suspensions of PL cells were prepared from the tissue adherent to the extracted root surface. Passage #2 or #3 cultures were immunostained and examined by fluorescence microscopy. For type XII collagen, cells from wet samples displayed perinuclear staining while cells from 30-min dry samples showed only isolated foci. The staining for 120-min dry samples was weak and non-specific. alpha-Smooth muscle actin was not incorporated into stress fibers in wet samples, whereas dry samples demonstrated prominent stress fibers stained for alpha-smooth muscle actin. Detached cytoplasmic fragments resembling cell processes that stained for alpha-smooth muscle actin were abundant in dry samples, indicating the presence of highly contractile cells. The staining for osteopontin was mainly perinuclear but was more intense in dry samples. The focal adhesion pattern of osteopontin staining in 120-min dry samples resembled that of migrating osteogenic cells. The pattern of staining did not vary for type III collagen or alkaline phosphatase, although staining for alkaline phosphatase was more intense in samples stored under dry conditions. We conclude that prolonged extra-alveolar dry storage favors increased in vitro growth of contractile cells expressing osteogenic cell markers while storage in cell culture medium favors growth of cells with the classical phenotype of PL fibroblasts.

Clinical management of avulsed permanent incisors using Emdogain: initial report of an investigation

The enamel matrix derivative Emdogain was recently approved for clinical use in a number of countries, including Canada. It has been shown to stimulate regeneration of periodontal ligament following periodontal surgery in adults. This paper reviews pertinent clinical and laboratory studies of Emdogain and describes the protocol and methods used for a longitudinal outcome study of replantation of avulsed permanent incisors in children and adolescents. Application of these methods is described in an illustrative case report of Emdogain use. This paper is meant to inform clinicians and guide those who are instituting similar investigations.

The role of insulin and other hormones in the regulation of amino acid and protein metabolism in humans

While realizing the difficulties with the various methods used to study hormonal control of protein metabolism, there appear to be clear effects of both rapid-acting and slower-acting hormones. Moreover, some of these hormones affect protein metabolism in a dose dependent manner. Insulin and IGF-I appear to have differing effects at lower doses, with insulin primarily inhibiting protein degradation and IGF-I stimulating protein synthesis. At higher doses, infusions of insulin and IGF-I both seem to inhibit protein degradation and stimulate protein synthesis. Epinephrine primarily inhibits protein degradation whereas growth hormone primarily increases protein synthesis. Infusion of amino acids themselves can also increase protein synthesis. Thyroid hormone excess increases protein synthesis and protein degradation, with the latter effect predominating. Sex steroids appear to increase protein synthesis. To date, most interventions studying the metabolic effects of these hormones on protein metabolism have involved varying the concentration of one hormone at a time. In the complex milieu of many pathologic states (e.g. sepsis, renal failure or even the transition from fasting to feeding) multiple hormones change simultaneously. How interactions among these factors determine the overall response of body and muscle protein remains to be defined.

Hyponatremia: evaluating the correction factor for hyperglycemia

PURPOSE

There are no controlled experimental data that assess the accuracy of the commonly used correction factor of a 1.6 meq/L decrease in serum sodium concentration for every 100 mg/dL increase in plasma glucose concentration. The purpose of this study was to evaluate experimentally the hyponatremic response to acute hyperglycemia.

SUBJECTS AND METHODS

Somatostatin was infused to block endogenous insulin secretion in 6 healthy subjects. Plasma glucose concentrations were increased to >600 mg/dL within 1 hour by infusing 20% dextrose. The glucose infusion was then stopped and insulin given until the plasma glucose concentration decreased to 140 mg/dL. Plasma glucose and serum sodium concentrations were measured every 10 minutes.

RESULTS

Overall, the mean decrease in serum sodium concentration averaged 2.4 meq/L for every 100 mg/dL increase in glucose concentration. This value is significantly greater than the commonly used correction factor of 1.6 (P = 0.02). Moreover, the association between sodium and glucose concentrations was nonlinear. This was most apparent for glucose concentrations >400 mg/dL. Up to 400 mg/dL, the standard correction of 1.6 worked well, but if the glucose concentration was >400 mg/dL, a correction factor of 4.0 was better.

CONCLUSION

These data indicate that the physiologic decrease in sodium concentration is considerably greater than the standard correction factor of 1.6 (meq/L Na per 100 mg/dL glucose), especially when the glucose concentration is >400 mg/dL. Additionally, a correction factor of a 2.4 meq/L decrease in sodium concentration per 100 mg/dL increase in glucose concentration is a better overall estimate of this association than the usual correction factor of 1.6.

Acute vasoconstriction-induced insulin resistance in rat muscle in vivo

Insulin-mediated changes in blood flow are associated with altered blood flow distribution and increased capillary recruitment in skeletal muscle. Studies in perfused rat hindlimb have shown that muscle metabolism can be regulated by vasoactive agents that control blood flow distribution within the hindlimb. In the present study, the effects of a vasoconstrictive agent that has no direct effect on skeletal muscle metabolism but that alters perfusion distribution in rat hindlimb was investigated in vivo to determine its effects on insulin-mediated vascular action and glucose uptake. We measured the effects of alpha-methylserotonin (alpha-met5HT) on mean arterial blood pressure, heart rate, femoral blood flow, hindlimb vascular resistance, and glucose uptake in control and euglycemic insulin-clamped (10 mU x min(-1) x kg(-1)) anesthetized rats. Blood flow distribution within the hindlimb muscles was assessed by measuring the metabolism of 1-methylxanthine (1-MX), an exogenously added substrate for capillary xanthine oxidase. Alpha-met5HT (20 microg x min(-1) x kg(-1)) infusion alone increased mean arterial blood pressure by 25% and increased hindlimb vascular resistance but caused no change in femoral blood flow. These changes were associated with decreased hindlimb 1-MX metabolism indicating less capillary flow. Insulin infusion caused decreased hindlimb vascular resistance that was associated with increased femoral blood flow and 1-MX metabolism. Treatment with alpha-met5HT infusion commenced before insulin infusion prevented the increase in femoral blood flow and inhibited the stimulation of 1-MX metabolism. Alpha-met5HT infusion had no effect on hindlimb glucose uptake but markedly inhibited the insulin stimulation of glucose uptake (P < 0.05) and was associated with decreased glucose infusion rates to maintain euglycemia (P < 0.05). A significant correlation (P < 0.05) was observed between 1-MX metabolism and hindlimb glucose uptake but not between femoral blood flow and glucose uptake. The results indicate that in vivo, certain types of vasoconstriction in muscle such as elicited by 5HT2 agonists, which prevent normal insulin recruitment of capillary flow, cause impaired muscle glucose uptake. Moreover, if vasoconstriction of this kind results from stress-induced increase in sympathetic outflow, then this may provide a clue as to the link between hypertension and insulin resistance that is often observed in humans.

Tissue composition affects measures of postabsorptive human skeletal muscle metabolism: comparison across genders

Despite clear anthropomorphic differences, gender differences in human skeletal muscle protein and carbohydrate metabolism have not been carefully examined. We compared postabsorptive forearm glucose, oxygen, and lactate balances and forearm protein kinetics between 40 male and 36 female subjects. Forearm composition was measured in a subset of 17 subjects (8 males and 9 females) using multislice magnetic resonance imaging. Oxygen uptake, net phenylalanine release, and estimated rates of forearm protein synthesis and degradation were greater in male than in female subjects when expressed as the rate per 100 mL forearm volume (P < 0.05). In males, however, muscle accounted for 58% of forearm volume, compared with 46% in females (P < 0.001). When phenylalanine balance, protein degradation and synthesis, and glucose and oxygen uptake were expressed per 100 mL forearm muscle, there were no significant differences across gender. Likewise, the extraction fractions for oxygen, glucose, phenylalanine, and labeled phenylalanine were comparable in males and females. We conclude that cross-gender comparisons of metabolic variables must accommodate differences in tissue composition. These data indicate that in the postabsorptive state, skeletal muscle metabolism of glucose, protein, and oxygen do not differ by gender in healthy young humans.

Facilities and resources for diabetes care at regional health facilities in southern Ghana

In the fall of 1995, each of the five provincial hospitals in southern Ghana was visited and facilities and resources for diabetes care assessed. In addition, health facilities and standards of care questionnaires were completed. Only Korle Bu Teaching Hospital run a diabetes clinic and had diabetologists. Only two facilities had an eye specialist or trained dietician. None of the five facilities had a trained diabetes educator or chiropodist. Except for sphygmomanometers, basic equipment for clinical care were lacking. Basic biochemistry tests were available at all facilities. Creatinine clearance and 24-h urine protein, glycated haemoglobin, fasting triglyceride, total cholesterol and HDL cholesterol were available at only one centre. None of the facilities measured C-peptide, islet cell antibody and urine microalbumin. None of the facilities had chronic haemodialysis service. Insulin supply was erratic at two institutions. Three regions had active diabetes associations. The facilities and system of diabetes care in southern Ghana revealed in this study are far from satisfactory. Training of health care personnel in diabetes management and education may enhance diabetes care despite the existing constraints. Furthermore, the development of international and regional guidelines for facilities and resources may facilitate implementation of international resolutions and clinical practice guidelines.

Extreme hyperinsulinemia unmasks insulin's effect to stimulate protein synthesis in the human forearm

Insulin clearly stimulates skeletal muscle protein synthesis in vitro. Surprisingly, this effect has been difficult to reproduce in vivo. As in vitro studies have typically used much higher insulin concentrations than in vivo studies, we examined whether these concentration differences could explain the discrepancy between in vitro and in vivo observations. In 14 healthy volunteers, we raised forearm insulin concentrations 1,000-fold above basal levels while maintaining euglycemia for 4 h. Amino acids (AA) were given to either maintain basal arterial (n = 4) or venous plasma (n = 6) AA or increment arterial plasma AA by 100% (n = 4) in the forearm. We measured forearm muscle glucose, lactate, oxygen, phenylalanine balance, and [3H]phenylalanine kinetics at baseline and at 4 h of insulin infusion. Extreme hyperinsulinemia strongly reversed postabsorptive muscle's phenylalanine balance from a net release to an uptake (P < 0.001). This marked anabolic effect resulted from a dramatic stimulation of protein synthesis (P < 0.01) and a modest decline in protein degradation. Furthermore, this effect was seen even when basal arterial or venous aminoacidemia was maintained. With marked hyperinsulinemia, protein synthesis increased further when plasma AA concentrations were also increased (P < 0.05). Forearm blood flow rose at least twofold with the combined insulin and AA infusion (P < 0.01), and this was consistent in all groups. These results demonstrate an effect of high concentrations of insulin to markedly stimulate muscle protein synthesis in vivo in adults, even when AA concentrations are not increased. This is similar to prior in vitro reports but distinct from physiological hyperinsulinemia in vivo where stimulation of protein synthesis does not occur. Therefore, the current findings suggest that the differences in insulin concentrations used in prior studies may largely explain the previously reported discrepancy between insulin action on protein synthesis in adult muscle in vivo vs. in vitro.

Interim storage of avulsed permanent teeth

This literature review examines the effects of extra-alveolar duration and storage conditions on the healing of the periodontal ligament (PL) of avulsed teeth following replantation. A critical assessment of the so-called "reconstitution theory" for PL cells is also presented. The ideal treatment for an avulsed tooth is immediate replantation (i.e. less than five minutes). Unfortunately, immediate replantation is not the norm, and most avulsed teeth experience delayed replantation. The greatest risk to the vitality of the PL cells attached to the root of an avulsed tooth is desiccation. Not surprisingly, storage media affect PL healing. Storing avulsed teeth in an isotonic liquid is superior to dry storage. Numerous studies support the use of Modified Eagle's Medium, Hank's Balanced Salt Solution (HBSS), ViaSpan, saline, milk, and saliva as storage media. A recent study has suggested that chicken egg white may also prove to be a suitable storage medium for avulsed teeth. Of these media, only saliva is always present at the scene of an accident, however. Milk can usually be obtained on short notice, but even 10 minutes of desiccation can affect the outcome of replantation. From a practical standpoint, milk packed in ice seems to be the best alternative for the temporary storage of avulsed teeth, due to its wide availability and the minimal detrimental effects it has on PL cells. There is no evidence to support the suggestion that HBSS or any other media will "reconstitute" the PL cells when the extra-alveolar duration of avulsed teeth is greater than 30 minutes.

The influence of storage conditions on the clonogenic capacity of periodontal ligament cells: implications for tooth replantation

Viable periodontal ligament (PL) cells are required for PL healing of avulsed teeth following replantation. If immediate replantation cannot be accomplished, the ability of PL progenitor cells to reproduce (clonogenic capacity) and recolonize the wound may be extended by prevention of desiccation and storage in physiological media. This investigation examined the effects of storage in saliva, milk, Hank's balanced salt solution (HBSS) and Eagle's medium (alpha MEM) on the clonogenic capacity of human PL progenitor cells at 30 and 60 min extra-alveolar time. Twenty erupted human premolar teeth extracted as atraumatically as possible for orthodontic purposes were used in the present study. Fifteen premolars were placed immediately in freshly collected autologous saliva at room temperature, (+ 23 degrees C) for 15 min. These 15 premolars were next divided into three groups of five and stored in either saliva, milk or HBSS at + 4 degrees C in plastic cups surrounded by ice. The remaining five teeth served as positive controls and were immediately placed in alpha MEM at + 4 degrees C. PL tissue was scraped from one-half of the root surface with a scalpel at 30 and 60 min total extra-alveolar duration. Cells were released from the tissue sample with a 30 min enzymatic digestion procedure and the cells from the tissue samples analyzed for clonogenic capacity. There was a reduction in clonogenic capacity with time for all protocols. Periodontal ligament cells stored in alpha MEM showed the least reduction between 30 and 60 min and the greatest reduction was observed for PL cells stored in saliva. The difference in clonogenic capacity following transfer from saliva to milk or HBSS was not significant at 30 min. At 60 min, cells transferred from saliva to HBSS had a statistically higher percentage of clonogenic cells than those transferred to milk (5.9% vs. 3.5%; P < 0.05). We conclude that immediate storage of avulsed teeth in autologous saliva, followed by transfer to chilled milk, preserves the presence of sufficient progenitor cells in the PL to warrant replantation and the possibility of PL healing at 60 min extra-alveolar duration.

Discovery of a human liver glycogen phosphorylase inhibitor that lowers blood glucose in vivo

An inhibitor of human liver glycogen phosphorylase a (HLGPa) has been identified and characterized in vitro and in vivo. This substance, [R-(R*, S*)]-5-chloro-N-[3-(dimethylamino)-2-hydroxy-3-oxo-1-(phenylmethyl)pr opyl]-1H-indole-2-carboxamide (CP-91149), inhibited HLGPa with an IC50 of 0.13 microM in the presence of 7.5 mM glucose. CP-91149 resembles caffeine, a known allosteric phosphorylase inhibitor, in that it is 5- to 10-fold less potent in the absence of glucose. Further analysis, however, suggests that CP-91149 and caffeine are kinetically distinct. Functionally, CP-91149 inhibited glucagon-stimulated glycogenolysis in isolated rat hepatocytes (P < 0.05 at 10-100 microM) and in primary human hepatocytes (2.1 microM IC50). In vivo, oral administration of CP-91149 to diabetic ob/ob mice at 25-50 mg/kg resulted in rapid (3 h) glucose lowering by 100-120 mg/dl (P < 0.001) without producing hypoglycemia. Further, CP-91149 treatment did not lower glucose levels in normoglycemic, nondiabetic mice. In ob/ob mice pretreated with 14C-glucose to label liver glycogen, CP-91149 administration reduced 14C-glycogen breakdown, confirming that glucose lowering resulted from inhibition of glycogenolysis in vivo. These findings support the use of CP-91149 in investigating glycogenolytic versus gluconeogenic flux in hepatic glucose production, and they demonstrate that glycogenolysis inhibitors may be useful in the treatment of type 2 diabetes.

The effect of training and epinephrine infusion on ratings of perceived exertion (RPE)

Seven untrained males (mean age [+/-SD] = 25.6+/-3.9 yr, mean ht = 177.0+/-5.9 cm, mean wt = 65.8+/-7.4 kg) completed a 6-week exercise program (cycle ergometer). Prior to training, and at the end of each week of training, each subject performed a 20 min constant-power exercise test (absolute power was the same each week). At the end of the six week training program (within a few days), an additional 20 min constant-power test was performed, during which epinephrine was infused at a rate of 100 ng x kg(-1) x min(-1) over the final 10 min of exercise. Training significantly (P<0.05) reduced end-exercise ratings of perceived exertion (RPE), plasma epinephrine concentration [Epi], plasma norepinephrine concentration [NE], blood lactate concentration [La-], minute ventilation (V(E)), heart rate (HR), and blood glucose concentration [Glc]. Epinephrine infusion failed to increase RPE despite significant (p < 0.05) increases in [Epi], [La-], V(E) and [Glc]. Therefore, the present data indicate that RPE during exercise is not causally related to changes in plasma [Epi]. It also appears that modest changes in plasma [NE], blood [La-], V(E) and blood [Glc] during constant-power cycle ergometry (as observed during Epi infusion) do not impact RPE.

Survival of avulsed permanent maxillary incisors in children following delayed replantation

The purpose of this study was to identify the variables that significantly influenced the survival of incisors replanted after extended extra-alveolar duration at The Hospital for Sick Children, Toronto, Canada, between June 1988 and December 1993. Survival analysis was used to identify variables that significantly influence the retention of replanted incisor teeth. Survival was defined as the time that elapsed between the replantation of an avulsed incisor and the time it was finally lost. Information on 9 variables was collected for 38 patients (25 males; 13 females) and 52 replanted permanent maxillary incisors. The mean extra-alveolar duration for the sample was 123 min. The mean follow-up interval was 942 days (range: 364-2126 days). Incisors replanted with open apices had a significantly decreased survival compared with teeth with mature apices (P = 0.04; relative risk 4.2). There was also a significant association between increased survival and obturation of the root canal with gutta-percha and sealer (P = 0.006; relative risk 10.0). A trend towards improved survival of replanted incisors was found for children older than 11 years old at the time of replantation (P = 0.09; relative risk 2.8). These results are consistent with previous studies and may assist clinicians and parents in the decision-making process associated with the management of avulsed teeth in children.

Pain management for children

Dentists are often called upon to perform painful procedures on children. This may present a management problem for the practitioner who is unfamiliar with accepted behavioural management techniques or prescribing analgesics for paediatric patients. This article will review techniques that may be used to guide a child patient's behaviour through painful procedures as well as addressing the need for post-operative analgesics in the paediatric population.

Hemodynamic actions of insulin in rat skeletal muscle: evidence for capillary recruitment

Insulin-induced increases in blood flow are hypothesized to enhance overall glucose uptake by skeletal muscle. Whether the insulin-mediated changes in blood flow are associated with altered blood flow distribution and increased capillary recruitment in skeletal muscle is not known. In the present study, the effects of insulin on hemodynamic parameters in rat skeletal muscle in vivo were investigated. Mean arterial blood pressure, heart rate, femoral blood flow, hind leg vascular resistance, and glucose uptake were measured in control and euglycemic insulin-clamped (10 mU x min(-1) x kg[-1]) anesthetized rats. Blood flow distribution within the hind leg muscles was assessed by measuring the metabolism of 1-methylxanthine (1-MX), an exogenously added substrate for capillary xanthine oxidase. Insulin treatment had no effect on heart rate but significantly increased arterial blood pressure (12 mmHg) and femoral blood flow (80%) and decreased hind leg vascular resistance (31%). Changes were similar in magnitude and in time of onset to those reported in humans. Insulin treatment increased hind leg glucose uptake approximately fourfold and also increased hind leg 1-MX metabolism by 50%, suggesting increased exposure to endothelial xanthine oxidase. To ascertain whether the increased 1-MX metabolism was simply due to increased bulk femoral blood flow, epinephrine was infused at a dose (0.125 microg x min(-) x kg[-1]) chosen to match the insulin-induced increase in femoral blood flow. This dose of epinephrine had no significant effects on arterial blood pressure or heart rate but increased femoral blood flow and lowered hind leg vascular resistance to a similar extent as insulin. Epinephrine did not significantly alter 1-MX metabolism as compared with control animals. These results demonstrate that insulin increases total hind leg blood flow and metabolism of 1-MX, suggesting a recruitment of capillary blood flow in rat hind leg not mimicked by epinephrine.

Avulsed permanent teeth: a review of the literature and treatment guidelines

Dental trauma represents one of the few situations where dentists are called upon to make unscheduled diagnostic and treatment decisions in an area that is outside their routine experience. Since patients who sustain an avulsion present infrequently, except in child-oriented or emergency-based practices, clinicians often make diagnostic and management decisions based upon their previous rare treatment experiences. Clinicians also rely on published guidelines for this aspect of their practice and expect these standards to be up-to-date and based on current research information. None of the current protocols has been tested by a prospective longitudinal outcome study in humans. Nevertheless, current guidelines have become the standard for clinical practice around the world. An effort must be made to develop treatment protocols that are based upon the biological mechanisms that underlie periodontal wound healing.

Insulin and insulin-like growth factor-I enhance human skeletal muscle protein anabolism during hyperaminoacidemia by different mechanisms

Insulin inhibits proteolysis in human muscle thereby increasing protein anabolism. In contrast, IGF-I promotes muscle protein anabolism principally by stimulating protein synthesis. As increases or decreases of plasma amino acids may affect protein turnover in muscle and also alter the muscle's response to insulin and/or IGF-I, this study was designed to examine the effects of insulin and IGF-I on human muscle protein turnover during hyperaminoacidemia. We measured phenylalanine balance and [3H]-phenylalanine kinetics in both forearms of 22 postabsorptive adults during a continuous [3H] phenylalanine infusion. Measurements were made basally and at 3 and 6 h after beginning a systemic infusion of a balanced amino acid mixture that raised arterial phenylalanine concentration about twofold. Throughout the 6 h, 10 subjects received insulin locally (0.035 mU/min per kg) into one brachial artery while 12 other subjects were given intraaterial IGF-I (100 ng/min per kg) to raise insulin or IGF-I concentrations, respectively, in the infused arm. The contralateral arm in each study served as a simultaneous control for the effects of amino acids (aa) alone. Glucose uptake and lactate release increased in the insulin- and IGF-I-infused forearms (P < 0.01) but did not change in the contralateral (aa alone) forearm in either study. In the aa alone arm in both studies, hyperaminoacidemia reversed the postabsorptive net phenylalanine release by muscle to a net uptake (P < 0.025, for each) due to a stimulation of muscle protein synthesis. In the hormone-infused arms, the addition of either insulin or IGF-I promoted greater positive shifts in phenylalanine balance than the aa alone arm (P < 0.01). With insulin, the enhanced anabolism was due to inhibition of protein degradation (P < 0.02), whereas IGF-I augmented anabolism by a further stimulation of protein synthesis above aa alone (P < 0.02). We conclude that: (a) hyperaminoacidemia specifically stimulates muscle protein synthesis; (b) insulin, even with hyperaminoacidemia, improves muscle protein balance solely by inhibiting proteolysis; and (c) hyperaminoacidemia combined with IGF-I enhances protein synthesis more than either alone.

Chloroquine does not exert insulin-like actions on human forearm muscle metabolism

Insulin's anabolic action on skeletal muscle and whole body protein is attributable to its action to slow tissue proteolysis. The antimalarial chloroquine inhibits lysosomal proteolysis and is reported to improve glycemia in poorly controlled diabetic patients. We infused chloroquine into the brachial artery of seven healthy postabsorptive volunteers over 3 h during a steady-state infusion of L-[ring-2,6-3H]phenylalanine (Phe) to study its effect on muscle glucose and protein turnover. Compared with basal, chloroquine increased forearm blood flow (P < 0.01) but did not change glucose uptake or lactate release. Neither Phe released from muscle by proteolysis (78 +/- 15 vs. 94 +/- 16 nmol Phe.min-1.100 ml-1) nor Phe balance (-37 +/- 7 vs. -50 +/- 6 nmol.min-1.100 ml-1) was reduced from basal. We conclude that in postabsorptive human skeletal muscle: 1) lysosomal proteolysis does not make a major contribution to proteolysis; and 2) chloroquine does not cause an acute increase in glucose uptake. These findings suggest that the inhibition of postabsorptive muscle protein degradation provoked by physiological increases in plasma insulin is likely mediated by a nonlysosomal proteolytic pathway.

Overnight branched-chain amino acid infusion causes sustained suppression of muscle proteolysis

Short-term (3 to 4 hours) infusion of branched-chain amino acids (BCAA) has been shown to suppress muscle protein breakdown. Whether these effects are sustained with chronic elevations of BCAA is not known. In the present study, we examined the effect of an overnight (16-hour) systemic BCAA infusion on whole-body and skeletal muscle amino acid metabolism, as assessed by simultaneously measured 3H-phenylalanine and 14C-leucine kinetics in eight normal volunteers; 10 overnight-fasted subjects studied during a 4-hour saline infusion served as controls. Overnight BCAA infusion increased plasma BCAA concentrations by fivefold to eightfold, and this was associated with a 20% to 60% decline in arterial concentrations of other amino acids. For Phe, this decline was mediated by a reduction in the systemic rate of appearance ([Ra] 0.38 +/- 0.03 v 0.60 +/- 0.01 mumol/kg/min for BCAA and saline, respectively, P < .001). Endogenous Leu Ra, calculated more indirectly as the difference between the total Leu Ra and the unlabeled Leu infusion rate, did not differ between groups. In the forearm, overnight BCAA infusion resulted in a diminished net release of Phe (-3 +/- 2 v -18 +/- 4 [saline] nmol/min/100 mL, P < .02), and BCAA balance became markedly positive (751 +/- 93 v -75 +/- 30, P < .001). The diminished net forearm Phe release was accounted for by a decrease in local Phe Ra (P < .02). As with the systemic endogenous Leu Ra, forearm Leu Ra was not reproducibly affected by infused BCAA.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of epinephrine on human muscle glucose and protein metabolism

Systemic epinephrine infusion causes hypoaminoacidemia and inhibits whole body leucine flux (proteolysis) in humans. Its specific action on muscle protein is not known and is difficult to assess during systemic epinephrine infusions, which affect plasma insulin, amino acid, and free fatty acid concentrations. During a steady-state infusion of L-[ring-2,6-3H]phenylalanine, we examined the effect of locally infused epinephrine on the metabolism of protein and glucose in forearm muscle of 10 healthy human volunteers. During local epinephrine infusion, systemic concentrations of glucose, phenylalanine, insulin, and epinephrine were unchanged and lactate declined (P < 0.02). Compared with baseline, epinephrine induced significant increases in forearm blood flow (P < 0.01) and net lactate release (P < 0.001) and a decrease in glucose uptake (P < 0.01) at both 2 and 4 h. At 2 and 4 h phenylalanine release from muscle proteolysis was suppressed (P < 0.01), and at 4 h the net phenylalanine balance was less negative than baseline (P < 0.02), indicating an anticatabolic effect on muscle protein. We conclude that in human forearm muscle epinephrine, at physiological concentrations, has a catabolic effect on muscle glycogen but an anticatabolic action on muscle protein. The mechanism of this latter effect is not known.