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Chee C, Roji AM, Lorde N, Divyateja H, Dow G, Shah J, Chokkalingam K. Excluding subarachnoid haemorrhage within 24 hours: to LP or not to LP? Br J Neurosurg 2020; 35:203-208. [PMID: 32650668 DOI: 10.1080/02688697.2020.1781055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND PURPOSE Subarachnoid haemorrhage (SAH) is a potentially life-threatening cause of acute headache. Current conventional practice in the United Kingdom (UK) is for head computed tomography (CT) followed by cerebrospinal fluid (CSF) xanthochromia analysis if the head CT is normal. However, with increasing radiological accuracy, head CT alone may be sufficient to exclude SAH without requiring CSF xanthochromia for confirmation. This study aims to determine whether CSF xanthochromia is still required to confirm exclusion of SAH after normal head CT within a tertiary referral centre. METHODS Data was obtained from Nottingham University Hospitals (NUH) NHS Trust databases on 999 patients presenting with symptoms suspicious of SAH from 2012 to 2015. All patients had CSF xanthochromia analysis when head CT was normal or inconclusive for suspected SAH. RESULTS A total of 179 patients were diagnosed with SAH (17.9%). 176 patients were diagnosed radiologically and 3 patients required further investigations. The 3 of the 802 patients who underwent lumbar puncture (LP) and were identified as having had SAH presented more than 24 hours after ictus. When stratified according to the time of presentation, a normal CT head was observed in those who presented within 24 hours from ictus (sensitivity of 100% [95% CI 92.5-100] and negative predictive value of 100% [97.2-100]). CONCLUSION Within a tertiary referral centre for SAH, a normal head CT has a very high negative predictive value to exclude SAH when carried out within 24 hours from ictus provided a 3rd generation CT scanner is utilised, and the scan is reported by a neuroradiologist. CSF xanthochromia analysis in this cohort may still be indicated in those presenting with a high clinical suspicion of SAH and in hospital settings where neuroradiologists or 3rd generation CT scanners are not easily accessible.
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Affiliation(s)
- Carolyn Chee
- Nottingham University Hospitals NHS Trust, QMC Campus, Nottingham, UK
| | | | - Nathan Lorde
- Nottingham University Hospitals NHS Trust, City Campus, Nottingham, UK
| | | | - Graham Dow
- Nottingham University Hospitals NHS Trust, QMC Campus, Nottingham, UK
| | - Jagrit Shah
- Nottingham University Hospitals NHS Trust, QMC Campus, Nottingham, UK
| | - K Chokkalingam
- Nottingham University Hospitals NHS Trust, City Campus, Nottingham, UK
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Stephens FB, Norton L, Jewell K, Chokkalingam K, Parr T, Tsintzas K. Basal and insulin-stimulated pyruvate dehydrogenase complex activation, glycogen synthesis and metabolic gene expression in human skeletal muscle the day after a single bout of exercise. Exp Physiol 2010; 95:808-18. [DOI: 10.1113/expphysiol.2009.051367] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Norton L, Parr T, Chokkalingam K, Bardsley RG, Ye H, Bell GI, Pelsers MMAL, van Loon LJC, Tsintzas K. Calpain-10 gene and protein expression in human skeletal muscle: effect of acute lipid-induced insulin resistance and type 2 diabetes. J Clin Endocrinol Metab 2008; 93:992-8. [PMID: 18089694 PMCID: PMC2729205 DOI: 10.1210/jc.2007-1981] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Our objective was to investigate the effect of lipid-induced insulin resistance and type 2 diabetes on skeletal muscle calpain-10 mRNA and protein levels. RESEARCH DESIGN AND METHODS In the first part of this study, 10 healthy subjects underwent hyperinsulinemic euglycemic (4.5 mmol/liter) clamps for 6 h with iv infusion of either saline or a 20% Intralipid emulsion (Fresenius Kabi AG, Bad Homburg, Germany). Skeletal muscle biopsies were taken before and after 3- and 6-h insulin infusion and analyzed for calpain-10 mRNA and protein expression. In the second part of the study, muscle samples obtained after an overnight fast in 10 long-standing, sedentary type 2 diabetes patients, 10 sedentary, weight-matched, normoglycemic controls, and 10 age-matched, endurance-trained cyclists were analyzed for calpain-10 mRNA and protein content. RESULTS Intralipid infusion in healthy subjects reduced whole body glucose disposal by approximately 50% (P<0.001). Calpain-10 mRNA (P=0.01) but not protein content was reduced after 6-h insulin infusion in both the saline and Intralipid emulsion trials. Skeletal muscle calpain-10 mRNA and protein content did not differ between the type 2 diabetes patients and normoglycemic controls, but there was a strong trend for total calpain-10 protein to be greater in the endurance-trained athletes (P=0.06). CONCLUSIONS These data indicate that skeletal muscle calpain-10 expression is not modified by insulin resistance per se and suggest that hyperinsulinemia and exercise training may modulate human skeletal muscle calpain-10 expression.
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Affiliation(s)
- L Norton
- Centre for Integrated Systems Biology and Medicine, School of Biomedical Sciences, Nottingham University, Nottingham, NG7 2UH, United Kingdom
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Chokkalingam K, Tsintzas K, Snaar JEM, Norton L, Solanky B, Leverton E, Morris P, Mansell P, Macdonald IA. Hyperinsulinaemia during exercise does not suppress hepatic glycogen concentrations in patients with type 1 diabetes: a magnetic resonance spectroscopy study. Diabetologia 2007; 50:1921-1929. [PMID: 17639304 DOI: 10.1007/s00125-007-0747-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2007] [Accepted: 05/28/2007] [Indexed: 11/26/2022]
Abstract
AIMS/HYPOTHESIS We compared in vivo changes in liver glycogen concentration during exercise between patients with type 1 diabetes and healthy volunteers. METHODS We studied seven men with type 1 diabetes (mean +/- SEM diabetes duration 10 +/- 2 years, age 33 +/- 3 years, BMI 24 +/- 1 kg/m(2), HbA(1c) 8.1 +/- 0.2% and VO(2) peak 43 +/- 2 ml [kg lean body mass](-1) min(-1)) and five non-diabetic controls (mean +/- SEM age 30 +/- 3 years, BMI 22 +/- 1 kg/m(2), HbA(1c) 5.4 +/- 0.1% and VO(2) peak 52 +/- 4 ml [kg lean body mass](-1) min(-1), before and after a standardised breakfast and after three bouts (EX1, EX2, EX3) of 40 min of cycling at 60% VO(2) peak. (13)C Magnetic resonance spectroscopy of liver glycogen was acquired in a 3.0 T magnet using a surface coil. Whole-body substrate oxidation was determined using indirect calorimetry. RESULTS Blood glucose and serum insulin concentrations were significantly higher (p < 0.05) in the fasting state, during the postprandial period and during EX1 and EX2 in subjects with type 1 diabetes compared with controls. Serum insulin concentration was still different between groups during EX3 (p < 0.05), but blood glucose concentration was similar. There was no difference between groups in liver glycogen concentration before or after the three bouts of exercise, despite the relative hyperinsulinaemia in type 1 diabetes. There were also no differences in substrate oxidation rates between groups. CONCLUSIONS/INTERPRETATION In patients with type 1 diabetes, hyperinsulinaemic and hyperglycaemic conditions during moderate exercise did not suppress hepatic glycogen concentrations. These findings do not support the hypothesis that exercise-induced hypoglycaemia in patients with type 1 diabetes is due to suppression of hepatic glycogen mobilisation.
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Affiliation(s)
- K Chokkalingam
- Centre for Integrated Systems Biology and Medicine, School of Biomedical Sciences, University of Nottingham, Nottingham, UK
- Queen's Medical Centre, Nottingham, UK
| | - K Tsintzas
- Centre for Integrated Systems Biology and Medicine, School of Biomedical Sciences, University of Nottingham, Nottingham, UK
| | - J E M Snaar
- Sir Peter Mansfield Magnetic Resonance Centre, University of Nottingham, Nottingham, UK
| | - L Norton
- Centre for Integrated Systems Biology and Medicine, School of Biomedical Sciences, University of Nottingham, Nottingham, UK
| | - B Solanky
- Sir Peter Mansfield Magnetic Resonance Centre, University of Nottingham, Nottingham, UK
| | - E Leverton
- Sir Peter Mansfield Magnetic Resonance Centre, University of Nottingham, Nottingham, UK
| | - P Morris
- Sir Peter Mansfield Magnetic Resonance Centre, University of Nottingham, Nottingham, UK
| | - P Mansell
- Queen's Medical Centre, Nottingham, UK
| | - I A Macdonald
- Centre for Integrated Systems Biology and Medicine, School of Biomedical Sciences, University of Nottingham, Nottingham, UK.
- School of Biomedical Sciences, Queen's Medical Centre, University of Nottingham, Derby Road, Nottingham, NG7 2UH, UK.
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Chokkalingam K, Tsintzas K, Norton L, Jewell K, Macdonald IA, Mansell PI. Exercise under hyperinsulinaemic conditions increases whole-body glucose disposal without affecting muscle glycogen utilisation in type 1 diabetes. Diabetologia 2007; 50:414-21. [PMID: 17119916 DOI: 10.1007/s00125-006-0520-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2006] [Accepted: 09/19/2006] [Indexed: 10/23/2022]
Abstract
AIMS/HYPOTHESIS We examined whole-body and muscle metabolism in patients with type 1 diabetes during moderate exercise at differing circulating insulin concentrations. METHODS Eight men (mean +/- SEM age 36.4 +/- 1.5 years; diabetes duration 11.3 +/- 1.4 years; BMI 24.6 +/- 0.7 kg/m(2); HbA(1c) 7.9 +/- 0.2% and VO(2) peak 44.5 +/- 1.2 ml kg(-1) min(-1)) with type 1 diabetes were studied on two occasions at rest (2 h) and during 45 min of cycling at 60% maximum VO(2) with insulin infused at the rate of either 15 (LO study) or 50 (HI) mU m(-2) min(-1) and blood glucose clamped at 8 mmol/l. Indirect calorimetry, insulin-glucose clamps and thigh muscle biopsies were employed to measure whole-body energy and muscle metabolism. RESULTS Fat oxidation contributed 15 and 23% to total energy expenditure during exercise in the HI and LO studies, respectively. The respective carbohydrate (CHO) oxidation rates were 31.7 +/- 2.7 and 27.8 +/- 1.9 mg kg(-1) min(-1) (p < 0.05). Exogenous glucose utilisation rate during exercise was substantially greater (p < 0.001) in the HI study (18.4 +/- 2.1 mg kg(-1) min(-1)) than in the LO study (6.9 +/- 1.2 mg kg(-1) min(-1)). Muscle glycogen content fell by approximately 40% during exercise in both trials. Muscle glycogen utilisation, muscle intermediary metabolism, and phosphorylation of protein kinase B/Akt, glycogen synthase kinase 3alpha/beta and extracellular signal-regulated protein kinase 1 and 2 proteins were no different between interventions. CONCLUSIONS/INTERPRETATION In patients with type 1 diabetes, exercise under peak therapeutic insulin concentrations increases exogenous glucose utilisation but does not spare muscle glycogen utilisation. A disproportionate increase in exogenous glucose utilisation relative to the increase in CHO oxidation suggests an increase in glucose flux through non-oxidative pathways.
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Affiliation(s)
- K Chokkalingam
- Department of Diabetes and Endocrinology, Queen's Medical Centre, Nottingham, UK
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Chokkalingam K, Jewell K, Norton L, Littlewood J, van Loon LJC, Mansell P, Macdonald IA, Tsintzas K. High-fat/low-carbohydrate diet reduces insulin-stimulated carbohydrate oxidation but stimulates nonoxidative glucose disposal in humans: An important role for skeletal muscle pyruvate dehydrogenase kinase 4. J Clin Endocrinol Metab 2007; 92:284-92. [PMID: 17062764 DOI: 10.1210/jc.2006-1592] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
AIM The aim of this report was to study the effect of high-fat (HF)/low-carbohydrate (CHO) diet on regulation of substrate metabolism in humans. METHODS Ten healthy men consumed either a HF (75% energy as fat) or control (35%) diet for 6 d in random order. On d 7, blood glucose disappearance rate (Rd) was determined before and during a hyperinsulinemic euglycemic clamp. Substrate oxidation was determined by indirect calorimetry. Muscle biopsies were obtained prediet, postdiet, and postclamps. RESULTS Rd was similar under basal conditions but slightly elevated (approximately 10%, P < 0.05) during the last 30 min of the clamp after the HF diet. HF diet reduced CHO oxidation under basal (by approximately 40%, P < 0.05) and clamp conditions (by approximately 20%, P < 0.05), increased insulin-mediated whole-body nonoxidative glucose disposal (by 30%, P < 0.05) and muscle glycogen storage (by approximately 25%, P < 0.05). Muscle pyruvate dehydrogenase complex activity was blunted under basal and clamp conditions after HF compared with control (P < 0.05) and was accompanied by an approximately 2-fold increase (P < 0.05) in pyruvate dehydrogenase kinase 4 (PDK4) mRNA and protein expression. CONCLUSION Short-term HF/low-CHO dietary intake did not induce whole-body insulin resistance, but caused a shift in im glucose metabolism from oxidation to glycogen storage. Insulin-stimulated CHO oxidation and muscle pyruvate dehydrogenase complex activity were blunted after the HF diet. Up-regulation of muscle PDK4 expression was an early molecular adaptation to these changes, and we showed for the first time in healthy humans, unlike insulin-resistant individuals, that insulin can suppress PDK4 but not PDK2 gene expression in skeletal muscle.
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Affiliation(s)
- K Chokkalingam
- Center for Integrated Systems Biology and Medicine, Institute of Clinical Research, School of Biomedical Sciences, University of Nottingham, Nottingham NG7 2UH, United Kingdom
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Abstract
Low-carbohydrate diets have been around for over 100 years. They have become very popular recently but the scientific basis for their use remains to be fully established. This article reviews the recent trials that have been published and also what is known about the effects of low-carbohydrate, high-protein diets on energy expenditure and body composition. Although many controversies remain, there is now mounting evidence that these diets can lead to effective weight loss and may thus be a useful intervention for patients who have, or are at risk of, diabetes. The practical aspects of using these diets as a short- to medium-term intervention are discussed.
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Affiliation(s)
- R L Kennedy
- Department of Diabetes and Endocrinology, Queen's Medical Centre, Nottingham, UK.
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Prasad PV, Paari T, Chokkalingam K, Vijaybushanam V. Malignant syphilis (leus maligna) in a HIV infected patient. Indian J Dermatol Venereol Leprol 2001; 67:192-4. [PMID: 17664738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
A 40-year-old promiscuous man presented with nodulo ulcerative lesions all over the body and a healing genital ulcer. Blood VDRL was reactive in 64 dilutions and HIV (Elisa) was positive. Patient was diagnosed to have malignant syphilis (leus maligna) and was given appropriate treatment. Lesions healed with hypopigmented macules suggestive of 'Icukoderma colli'.
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Affiliation(s)
- P V Prasad
- Department of Dermatology and STD, Rajah Muthiah Medical College & Hospital, Annamalai University, Annamalai Nagar-608 002, India
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