Severe Hypo Research Articles

Diabetes Mellitus as a Model of Psychosomatic and Somatopsychic Interrelationships

The article reviews research on the problem of interrelationship between different physical and psychosocial factors in type 1 diabetes mellitus (DM1). The authors consider methodological principles of health-related quality of life (HRQoL) assessment in DM1 patients and stress the need for an integrated biopsychosocial approach to the management of the disease. DM1 is a chronic metabolic disease with an absolute requirement for insulin replacement therapy. The stress-inducing nature of DM1 is associated with its unexpected and dramatic manifestation in juvenile years, life-threatening nature of severe hypo-/hyperglycaemias and long-term complications, with the burden of diabetes self-management, threat of work disability, employment and career problems etc. These features of DM1 increase the likelihood of the development of anxiety and depressive disorders, which, in turn, may negatively influence the course of diabetes and in particular, diabetes self-care. This necessitates early diagnosis of emotional and behavioral disturbances in DM1 using self-report instruments as well as clinical assessment. Evidence suggests that active problem-focused coping behavior and adequate social support promote adherence to diabetes regimes and may act as a buffer against negative effects of the disease on HRQoL in DM1 patients. The core element in the HRQoL structure is personal disease picture (as opposed by objective clinical picture)--the cognitive-affective-behavioral complex reflecting the patient's personal perception of the disease. Examination of the personal disease picture and attitude towards the ailment in DM1 patients may help to improve understanding of the mechanisms of poor adjustment. Problems in disease adjustment can be detected also by diabetes-specific HRQoL assessment. The measures of HRQoL can be applied as screening instruments useful in increasing the effectiveness of patient-provider interactions and diabetes care.

Volume‐targeted ventilation and arterial carbon dioxide in neonates

To review the arterial carbon dioxide tensions (PaCO(2)) in newborn infants ventilated using synchronized intermittent mandatory ventilation (SIMV) in volume guarantee mode (using the Dräger Babylog 8000+) with a unit policy targeting tidal volumes of approximately 4 mL/kg. Data on ventilator settings and arterial PaCO(2) levels were collected on all arterial blood gases (ABG; n = 288) from 50 neonates (<33 weeks gestational age) ventilated using the Dräger Babylog 8000+ ventilator (Dräger Medizintechnik GmbH, Lübeck, Germany) in SIMV plus volume guarantee mode. Data were analysed for all blood gases done on the entire cohort in the first 48 h of life and a subanalysis was done on the first gas for each infant (n = 38) ventilated using volume guarantee from admission to the nursery. The number of ABG showing severe hypocapnoea (PaCO(2) < 25 mmHg) and/or severe hypercapnoea (PaCO(2) > 65 mmHg) were determined. The mean (SD) PaCO(2) during the first 48 h was 46.6 (9.0) mmHg. The mean (SD) PaCO(2) on the first blood gas of those infants commenced on volume guarantee from admission was 45.1 (12.5) mmHg. Severe hypo- or hypercapnoea occurred in 8% of infants at the time of their first blood gas measurement, and in <4% of blood gas measurements in the first 48 h. Infants ventilated with volume guarantee ventilation targeting approximately 4 mL/kg (range: 2.9-5.1) have acceptable PaCO(2) levels at the first blood gas measurement and during the first 48 h of life; and avoid severe hypo- or hypercapnoea over 90% of the time.

Quality assessment of blood glucose testing in general practitioners’ offices improves quality

Measurement of blood glucose is a frequent test in Danish physicians' offices. We describe here a new design of external quality assessment wherein fresh, unstabilized whole-blood samples were analyzed by the physicians' office methods and by a hospital laboratory comparison method (glucose dehydrogenase assay, calibrated against NIST 909a). This approach was used in the offices of 171 general practitioners in our county during a 5-year period. The first survey, in 1992, revealed unsatisfactory performance in terms of our criterion that no difference between the physician's office and the hospital laboratory's single result should exceed +/-20% of the laboratory result. After initiation of a program of consultation and assistance, the proficiency testing rounds of 1994 and 1996 showed considerable improvement. Thus, whereas in 1992 12% of the values were outside the acceptance limits, in 1994 and 1996 the respective values were 4% and 3%. We believe the effect was mainly related to improvements in choice of technology, procedures, and handling of specimens. We conclude that the use of bedside instruments should be restricted to diagnosis of only severe hypo- or hyperglycemia and to monitoring glucose >5 mmo/L in already diagnosed diabetics. Our program differs from previous approaches to quality assessment and could also be useful for large hospitals' in-house proficiency testing.

Prison deprivation and protein nutritional status of inmates of a developing community prison

OBJECTIVE This study assesses the protein nutritional status of inmates of a small prison, in the light of a changing serum protein pattern in the environment. DESIGN Survey of prison inmates. SETTING A male prison and low social class hospital workers. SUBJECTS 81 inmates and 62 randomly selected controls, of which 42 of the former and 28 of the latter were further randomly selected. METHODS Nutritional and confinement history were obtained by a questionnaire, Weights and heights were measured and serum and urine samples collected for protein estimations. RESULTS The prisoners were confined for 229.1 (SD 210.1) days. 48.1% had BMI < 20 kg/m2 compared to 28.6% of controls (p = 0.04). Their diet was predominantly carbohydrate. Mean total serum protein was 81.5gm/L (6.1) (95% CI = 79.3-83.5) (prisoners); 88.7 gm/L (8.1) (95% CI = 85.7-91.7) (controls). Serum globulin was 44.9 gm/L (6.3) (95% CI = 42.9-46.9) (prisoners); 55.4 gm/L (8.2) (95% CI = 52.3-58.5) (controls) (p <0.001 respectively). More prisoners than controls had severe hypo- albuminaemia (p =0.001). All values were lower in those awaiting trial compared to convicted inmates. Total protein and albumin weakly correlated with duration of confinement (r = -0.23 and -0.15, respectively). CONCLUSION The study suggest that the prisoners might be undernourished with lower serum proteins than controls, within an average of seven months confinement. The picture appears worse in those awaiting trial and with prolonged duration of confinement.

Impairment of regional fatty acid uptake in relation to wall motion and thallium-201 uptake in ischaemic but viable myocardium: assessment with iodine-123-labelled beta-methyl-branched fatty acid.

In coronary artery disease, discrepancy in the uptake of thallium-201 and of methyl-branched fatty acid at rest has been described. The purpose of this study was to evaluate iodine-123 labelled beta-methyl-branched fatty acid (BMIPP) myocardial uptake and wall motion at rest in segments with stress-induced ischaemia identified by stress 201Tl tomography in patients with chronic coronary artery disease. 123I-BMIPP myocardial tomography was performed at rest and was compared with the findings of exercise-reinjection 201Tl tomography in 45 patients with chronic coronary artery disease. Regional wall motion was evaluated by contrast left ventriculography in 36 patients. Among 237 segments with reversible 201Tl defects, equally decreased uptake on both reinjection 201Tl and BMIPP images was observed in 93 (39%), more severely decreased uptake of BMIPP in 118 (50%) and more severely decreased uptake of reinjection 201Tl in 26 (11%). On the other hand, among 90 segments with non-reversible 201Tl defects, each pattern was observed in 71 (79%), 6 (7%) and 13 (14%) segments, respectively. When comparing the ischaemic segments with and without more severely reduced uptake of BMIPP than of reinjection 201Tl, wall motion was impaired to a greater extent in the segments with more severely reduced uptake of BMIPP than of reinjection 201Tl [severe hypo- or dyskinesis was present in 64 (70%) of 91 segments and in 24 (22%) of 110 segments, respectively, P<0.005]. In patients with chronic coronary artery disease, resting fatty acid uptake was frequently more reduced than reinjection 201Tl in the segments with stress-induced ischaemia, while in most of the fixed perfusion defects BMIPP and reinjection 201Tl uptake decreased concordantly. In ischaemic myocardium, wall motion was impaired to a greater extent in those segments which showed more severely reduced uptake of BMIPP than of reinjection 201Tl. In ischaemic but viable myocardium, discordant BMIPP uptake less than reinjection 201Tl uptake may indicate metabolic alterations and wall motion abnormality at rest independent of perfusion abnormalities. In conclusion, the combination of resting BMIPP and stress-reinjection 201Tl imaging may provide information on metabolic alterations and wall motion abnormality at rest independent of perfusion abnormalities.

Disorders of Water Metabolism: Hyponatremia and Hypernatremia

Patients with disorders of sodium and water metabolism are seen frequently in Emergency Departments, but in most cases these disorders do not require treatment. Severe hypo- and hypernatremia are relatively uncommon but can result in severe neurologic sequelae or death. Appropriate therapy, based on an understanding of the physiology involved, can reduce the morbidity and mortality associated with these disorders. A systematic approach to the assessment and management of patients with hypo- and hypernatremia is presented.

Effect of monosaccharide on dehydroascorbic acid uptake by placental membrane vesicles.

Dehydroascorbic acid (DHA), the oxidized form of vitamin C, is transported across the microvillous surface of the human placental syncytiotrophoblast by the D-glucose transporter. The existence of this mechanism suggests that maternal hyperglycemia may influence placental transfer of vitamin C. Therefore, we examined the effect of monosaccharides, equilibrated across the membrane, on the uptake of 0.5 mmol/L DHA by placental membrane vesicles. Relative to uptake in the absence of monosaccharide, the rate of DHA uptake was enhanced by up to 90% in the presence of 3-O-methyl-D-glucose equilibrated across the membrane. Comparable results were obtained with D-glucose and D-galactose. An inward-directed monosaccharide concentration gradient inhibited DHA uptake. However, with elevated equilibrium concentrations of monosaccharide, the magnitude of such uptake inhibition was reduced. Relative to DHA uptake at normal blood glucose concentrations (5 mmol/L), the results suggest that moderate maternal hyperglycemia does not alter, but that severe hypo- or hyperglycemia decreases, placental uptake of DHA from the maternal circulation.

Argyrophil cell hyperplasia of fundic mucosa in patients with chronic atrophic gastritis.

Eighteen cases of severe hyperplasia of fundic argyrophil cells observed during routine histologic examination of endoscopic gastric biopsy specimens from unselected patients with upper gastro-intestinal symptomatology were investigated. All patients, except one, were female with a mean age of 57 years. Atrophic gastritis of fundic mucosa with severe hypo- or achlorhydria was present in all cases. Hypergastrinaemia (of antral origin) was found in 15 subjects in which circulating gastrin levels were determined. Pernicious anaemia was seen in 1 patient. At light microscopy, the hyperplastic fundic cells were stained by the Grimelius and the Sevier-Munger silver methods and, in approximately 30% of cases, by lead-haematoxylin. In addition, these cells reacted with anti chromogranin antibodies. In 8 of 9 patients studied by electron-microscopy, enterochromaffin-like (ECL) cells were found to be the more frequent cell type. D1 cells prevailed in 1 case and were rare in the others. The frequency of P cells was intermediate between that of ECL cells and that of D1 cells. In conclusion, our observations indicate that: argyrophil cell hyperplasia of atrophic fundic mucosa is prevalently found in women with hypergastrinaemia, and the hyperplastic process involves mostly the ECL type of gastric endocrine cells. It is noteworthy that similar associations have been shown to be present in patients affected by fundic carcinoid tumours and atrophic gastritis.

Ion effects in measurement of ionized calcium with a calcium-selective electrode.

Abstract We examined the performance characteristics of an improved electrode for measurement of ionized calcium (Orion Research, Inc.) with respect to interferences by Na+, K+, Li+, Mg2+, and H+, as well as the effect of changes in ionic strength and osmolality. At physiologically observed concentrations, all ions except Na+ insignificantly affected ionized-calcium measurements. The decrease in ionized Ca2+ with increased Na+ concentration is caused by the increase in ionic strength and the associated decrease in Ca2+ activity. Sodium had no significant direct effect in concentrations below 250 mmol/L. A previously published (Clin. Chem. 23: 690, 1977) equation for the Na+ correction is invalid for this improved electrode. Changes in osmotic pressure negligibly affect electrode response. Significant changes in ionic strength, as would be observed in severe hypo- and hypernatremic sera, increase or decrease, respectively, values for ionized calcium by changing Ca2+ activity. With aqueous Ca2+ solutions, changes of less than or equal to 3% were observed for Na+ concentrations that deviate from 140 mmol/L by not more than 20 mmol/L. Because the calcium ion activity is considered to be the physiologically important variable, we suggest that no correlation be made for ionic strength effects.

Ion effects in measurement of ionized calcium with a calcium-selective electrode.

We examined the performance characteristics of an improved electrode for measurement of ionized calcium (Orion Research, Inc.) with respect to interferences by Na+, K+, Li+, Mg2+, and H+, as well as the effect of changes in ionic strength and osmolality. At physiologically observed concentrations, all ions except Na+ insignificantly affected ionized-calcium measurements. The decrease in ionized Ca2+ with increased Na+ concentration is caused by the increase in ionic strength and the associated decrease in Ca2+ activity. Sodium had no significant direct effect in concentrations below 250 mmol/L. A previously published (Clin. Chem. 23: 690, 1977) equation for the Na+ correction is invalid for this improved electrode. Changes in osmotic pressure negligibly affect electrode response. Significant changes in ionic strength, as would be observed in severe hypo- and hypernatremic sera, increase or decrease, respectively, values for ionized calcium by changing Ca2+ activity. With aqueous Ca2+ solutions, changes of less than or equal to 3% were observed for Na+ concentrations that deviate from 140 mmol/L by not more than 20 mmol/L. Because the calcium ion activity is considered to be the physiologically important variable, we suggest that no correlation be made for ionic strength effects.