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Dahl AR, Dhamija R, Nofal AA, Pittock ST, Schwenk WF, Kumar S. Transient Neonatal Diabetes due to a Mutation in KCNJ11 in a Child with Klinefelter Syndrome. J Clin Res Pediatr Endocrinol 2018; 10:79-82. [PMID: 28766502 PMCID: PMC5838377 DOI: 10.4274/jcrpe.4807] [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] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Klinefelter syndrome is the most frequent chromosomal aneuploidy in males occurring in about 1 in 660 males. Epidemiological studies have demonstrated increased risk of type 1 diabetes and type 2 diabetes in adults with Klinefelter syndrome. There is only one previous report of neonatal diabetes in a patient with Klinefelter syndrome. We report transient neonatal diabetes due to a pathogenic heterozygous variant in KCNJ11 in a male infant with Klinefelter syndrome. A 78-day old male infant was noted to have sustained hyperglycemia with serum glucose ranging between 148 mg/dL (8.2 mmol/L) and 381 mg/dL (21.2 mmol/L) three days after undergoing a complete repair of an atrioventricular defect. Hemoglobin A1c was 6.6%. The patient was born at term with a birth weight of 2.16 kg following a pregnancy complicated by gestational diabetes that was controlled with diet. The patient was initially started on a continuous intravenous insulin drip and subsequently placed on subcutaneous insulin (glargine, human isophane and regular insulin). Insulin was gradually decreased and eventually discontinued at seven months of age. Chromosomal microarray at 11 weeks of age showed XXY and a panel-based, molecular test for neonatal diabetes revealed a pathogenic heterozygous variant c.685G>A (p.Glu229Lys) in KCNJ11. The patient is now 34 months old and continues to have normal fasting and post-prandial glucose and HbA1C levels. The patient will need prospective follow up for assessment of his glycemic status. To our knowledge this is the second reported case of neonatal diabetes in an infant with Klinefelter syndrome and the first due to a mutation in the KCNJ11 in a patient with Klinefelter syndrome.
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Affiliation(s)
- Amanda R. Dahl
- Mayo Clinic, Department of Pediatric and Adolescent Medicine, Rochester, Minnesota, USA
| | - Radhika Dhamija
- Mayo Clinic, Department of Clinical Genomics, Phoenix, Arizona, USA
| | - Alaa Al Nofal
- University of South Dakota, Sanford Children Specialty Clinic, Division of Pediatric Endocrinology, Sioux Falls, South Dakota, USA
| | - Siobhan T. Pittock
- Mayo Clinic, Department of Pediatric and Adolescent Medicine, Division of Pediatric Endocrinology, Rochester, Minnesota, USA
| | - W. Frederick Schwenk
- Mayo Clinic, Department of Pediatric and Adolescent Medicine, Division of Pediatric Endocrinology, Rochester, Minnesota, USA
| | - Seema Kumar
- Mayo Clinic, Department of Pediatric and Adolescent Medicine, Division of Pediatric Endocrinology, Rochester, Minnesota, USA,* Address for Correspondence: Department of Pediatric and Adolescent Medicine, Division of Pediatric Endocrinology, Rochester, Minnesota, USA GSM: +507-284-3300 E-mail:
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Iqbal AM, Schwenk WF, Theall KP. A Rare Presentation of the Syndrome of Inappropriate Antidiuretic Hormone in a 12-Year-Old Girl as the Initial Presentation of an Immature Ovarian Teratoma. J Pediatr Adolesc Gynecol 2018; 31:62-63. [PMID: 28818586 DOI: 10.1016/j.jpag.2017.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 08/01/2017] [Accepted: 08/06/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Immature ovarian teratoma is very rare in childhood. We report on a 12-year-old girl with immature ovarian teratoma who presented initially with syndrome of inappropriate antidiuretic hormone. CASE A 12-year-old girl presented with acute abdomen and distention. Initial laboratory tests showed hyponatremia (sodium, 123 mmol/L), that did not respond to fluid management. Computed tomography imaging showed a 15 cm × 9 cm × 20 cm mass in the right ovary with multifocal internal fat, and dystrophic calcifications. She underwent exploratory laparotomy with a right salpingo-oophorectomy, omentectomy, and peritoneal stripping. The pathology revealed metastatic immature teratoma. Hyponatremia resolved soon after the surgery. SUMMARY AND CONCLUSION Although a rare diagnosis, immature ovarian teratoma must be considered in a girl who presents with abdominal mass and hyponatremia.
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Affiliation(s)
- Anoop Mohamed Iqbal
- Division of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota.
| | - W Frederick Schwenk
- Division of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Katherine P Theall
- Department of Global Community Health and Behavioral Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA.
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Abstract
Pediatricians have relied on methods for determining skeletal maturation for >75 years. Bone age continues to be a valuable tool in assessing children's health. New technology for bone age determination includes computer-automated readings and assessments obtained from alternative imaging modalities. In addition, new nonclinical bone age applications are evolving, particularly pertaining to immigration and children's rights to asylum. Given the significant implications when bone ages are used in high-stake decisions, it is necessary to recognize recently described limitations in predicting accurate age in various ethnicities and diseases. Current methods of assessing skeletal maturation are derived from primarily white populations. In modern studies, researchers have explored the accuracy of bone age across various ethnicities in the United States. Researchers suggest there is evidence that indicates the bone ages obtained from current methods are less generalizable to children of other ethnicities, particularly children with African and certain Asian backgrounds. Many of the contemporary methods of bone age determination may be calibrated to individual populations and hold promise to perform better in a wider range of ethnicities, but more data are needed.
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Affiliation(s)
- Ana L Creo
- Divisions of Pediatric Endocrinology and Metabolism and
| | - W Frederick Schwenk
- Divisions of Pediatric Endocrinology and Metabolism and .,Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
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Abstract
Cystic fibrosis (CF) is the most frequent, lethal genetic disorder among northern Europeans. The etiology of this autosomal recessive disease is known to be a defect in the cAMP activation of chloride (Cl-) channels in secretory cells in many organs of the body. Although this defect usually leads to severe lung disease, many of these patients also have nutritional deficiencies. Nutrition is one of the key components in the management of CF. Patients are at high risk for malnutrition, which may result in accelerated progression of the disease and increased morbidity. This review will discuss nutrition recommendations for calories, protein, vitamins and minerals, and enteral and parenteral nutrition support practices.
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Affiliation(s)
- Diane L Olson
- Mayo Clinic College of Medicine, Rochester, Minnesota, USA.
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Schwenk WF. Adaptive role of energy expenditure in modulating body fat and protein deposition during catch-up growth after early undernutrition A G DULLOO AND L GIRARDIER Centre Medical Universitaire, University of Geneva, Geneva. Nutr Clin Pract 2016. [DOI: 10.1177/088453369400900415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Schwenk WF. Selenium status of infants is influenced by supplementation of formula or maternal diets M K MCGUIRE, S L BURGERT, J A MILNER, ET AL University of Illinois at Urbana-Champaign; The Pennsylvania State University, University Park; and Christie Clinic, Champaign, IL. Nutr Clin Pract 2016. [DOI: 10.1177/088453369400900414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Schwenk WF. Increased respiratory drive as an inhibitor or oral feeding of preterm infants B J M TIMMS, J M DIFIORE, R J MARTIN, ET AL Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, Ohio. Nutr Clin Pract 2016. [DOI: 10.1177/088453369400900317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Schwenk WF. Cytokine elevations in critically ill infants with sepsis and necrotizing enterocolitis MC HARRIS, AT COSTARINO JR, JS SULLIVAN, ET AL Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia. Nutr Clin Pract 2016. [DOI: 10.1177/088453369501000308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Schwenk WF. Patterns of postnatal weight changes in infants with very low and extremely low birth weights SL SMITH, KT KIRCHOFF, GM CHAN, ET AL Primary Children's Medical Center, University of Utah Hospital, University of Utah College of Nursing and School of Medicine, Salt Lake City, Utah. Nutr Clin Pract 2016. [DOI: 10.1177/088453369501000517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Schwenk WF. Role of intestinal mucus in transepithelial passage of bacteria across the intact ileum in vitro CT ALBANESE, M CARDONNA, S SMITH, ET AL Children's Hospital of Pittsburgh, Pennsylvania. Nutr Clin Pract 2016. [DOI: 10.1177/088453369501000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Abstract
One of the most important aspects of a well-child examination is an assessment of a child's growth. Children who are failing to grow are often labeled "failure to thrive." However, close examination of the pattern of growth on standardized growth charts often allows the caregiver to characterize the growth failure as failure to grow, failure to gain weight, or failure to grow and gain weight. Such refinement of the pattern of growth failure allows for a more specific differential diagnosis and helps to focus laboratory and radiographic evaluation.
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Affiliation(s)
- Alaa Al Nofal
- W. Frederick Schwenk, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA.
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Mehta NM, Corkins MR, Lyman B, Malone A, Goday PS, Carney LN, Monczka JL, Plogsted SW, Schwenk WF. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr 2013; 37:460-81. [PMID: 23528324 DOI: 10.1177/0148607113479972] [Citation(s) in RCA: 365] [Impact Index Per Article: 33.2] [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: 12/18/2022]
Abstract
Lack of a uniform definition is responsible for underrecognition of the prevalence of malnutrition and its impact on outcomes in children. A pediatric malnutrition definitions workgroup reviewed existing pediatric age group English-language literature from 1955 to 2011, for relevant references related to 5 domains of the definition of malnutrition that were a priori identified: anthropometric parameters, growth, chronicity of malnutrition, etiology and pathogenesis, and developmental/ functional outcomes. Based on available evidence and an iterative process to arrive at multidisciplinary consensus in the group, these domains were included in the overall construct of a new definition. Pediatric malnutrition (undernutrition) is defined as an imbalance between nutrient requirements and intake that results in cumulative deficits of energy, protein, or micronutrients that may negatively affect growth, development, and other relevant outcomes. A summary of the literature is presented and a new classification scheme is proposed that incorporates chronicity, etiology, mechanisms of nutrient imbalance, severity of malnutrition, and its impact on outcomes. Based on its etiology, malnutrition is either illness related (secondary to 1 or more diseases/injury) or non-illness related, (caused by environmental/behavioral factors), or both. Future research must focus on the relationship between inflammation and illness-related malnutrition. We anticipate that the definition of malnutrition will continue to evolve with improved understanding of the processes that lead to and complicate the treatment of this condition. A uniform definition should permit future research to focus on the impact of pediatric malnutrition on functional outcomes and help solidify the scientific basis for evidence-based nutrition practices.
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Affiliation(s)
- Nilesh M Mehta
- Department of Anesthesiology, Pain and Perioperative Medicine, Boston Children's Hospital, MSICU Office, Bader 634 Children’s Hospital, Boston, Massachusetts 2115, USA.
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Abstract
BACKGROUND Although minimally invasive surgery has been accepted for a variety of disorders, laparoscopic resection of colorectal cancer is performed by few. Concern about oncological radicality and long term outcome has limited the adoption of laparoscopic surgery for colorectal cancer. OBJECTIVES To determine long-term outcome after laparoscopically-assisted versus open surgery for non-metastasised colorectal cancer. SEARCH STRATEGY The Cochrane library, EMBASE, Pub med and Cancer Lit were searched for published and unpublished randomised controlled trials. SELECTION CRITERIA Randomised clinical trials comparing laparoscopically-assisted and open surgery for non-metastasised colorectal cancer were included. Studies that did not report any long-term outcomes were excluded. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the studies and extracted data. RevMan 4.2 was used for statistical analysis. MAIN RESULTS Thirty-three randomised clinical trials (RCT) comparing laparoscopically-assisted versus open surgery for colorectal cancer were identified. Twelve of these trials, involving 3346 patients, reported long-term outcome and were included in the current analysis. No significant differences in the occurrence of incisional hernia, reoperations for incisional hernia or reoperations for adhesions were found between laparoscopically assisted and open surgery (2 RCT, 474 pts, 7.9% vs 10.9%;P = 0.32 and 2 RCT, 474 pts, 4.0% vs 2.8%; P = 0.42 and 1 RCT, 391 pts, 1.1% vs 2.5%;P = 0.30, respectively). Rates of recurrence at the site of the primary tumor were similar (colon cancer: 4 RCT, 938 pts, 5.2% vs 5.6%; OR (fixed) 0.84 (95% CI 0.47 to 1.52)(P = 0.57); rectal cancer: 4 RCT, 714 pts, 7.2% vs 7.7%; OR (fixed) 0.81 (95% CI 0.45 to 1.43) (P = 0.46). No differences in the occurrence of port-site/wound recurrences were observed (P=0.16). Similar cancer-related mortality was found after laparoscopic surgery compared to open surgery ( colon cancer: 5 RCT, 1575 pts, 14.6% vs 16.4%; OR (fixed) 0.80 (95% CI 0.61 to 1.06) (P=0.15); rectal cancer: 3 RCT, 578 pts, 9.2% vs 10.0%; OR (fixed) 0.66 (95% CI 0.37 to 1.19) (P=0.16). Four studies were included in the meta-analyses on hazard ratios for tumour recurrence in laparoscopic colorectal cancer surgery. No significant difference in recurrence rate was observed between laparoscopic and open surgery (hazard ratio for tumour recurrence in the laparoscopic group 0.92; 95% CI 0.76-1.13). No significant difference in tumour recurrence between laparoscopic and open surgery for colon cancer was observed (hazard ratio for tumour recurrence in the laparoscopic group 0.86; 95% CI 0.70-1.08). AUTHORS' CONCLUSIONS Laparoscopic resection of carcinoma of the colon is associated with a long term outcome no different from that of open colectomy. Further studies are required to determine whether the incidence of incisional hernias and adhesions is affected by method of approach. Laparoscopic surgery for cancer of the upper rectum is feasible, but more randomised trials need to be conducted to assess long term outcome.
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Affiliation(s)
- E Kuhry
- Nord-Trøndelag Health Trust, Namsos Hospital, Department of General Surgery, Sykehusalleen 1, Namsos, Norway, 7800.
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Abstract
BACKGROUND Although minimally invasive surgery has been accepted for a variety of disorders, laparoscopic resection of colorectal cancer is performed by few. Concern about oncological radicality and long term outcome has limited the adoption of laparoscopic surgery for colorectal cancer. OBJECTIVES To determine long-term outcome after laparoscopically-assisted versus open surgery for non-metastasised colorectal cancer. SEARCH STRATEGY The Cochrane library, EMBASE, Pub med and Cancer Lit were searched for published and unpublished randomised controlled trials. SELECTION CRITERIA Randomised clinical trials comparing laparoscopically-assisted and open surgery for non-metastasised colorectal cancer were included. Studies that did not report any long-term outcomes were excluded. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the studies and extracted data. RevMan 4.2 was used for statistical analysis. MAIN RESULTS Thirty-three randomised clinical trials (RCT) comparing laparoscopically-assisted versus open surgery for colorectal cancer were identified. Twelve of these trials, involving 3346 patients, reported long-term outcome and were included in the current analysis. No significant differences in the occurrence of incisional hernia, reoperations for incisional hernia or reoperations for adhesions were found between laparoscopically assisted and open surgery (2 RCT, 474 pts, 7.9% vs 10.9%;P = 0.32 and 2 RCT, 474 pts, 4.0% vs 2.8%; P = 0.42 and 1 RCT, 391 pts, 1.1% vs 2.5%;P = 0.30, respectively). Rates of recurrence at the site of the primary tumor were similar (colon cancer: 4 RCT, 938 pts, 5.2% vs 5.6%; OR (fixed) 0.84 (95% CI 0.47 to 1.52)(P = 0.57); rectal cancer: 4 RCT, 714 pts, 7.2% vs 7.7%; OR (fixed) 0.81 (95% CI 0.45 to 1.43) (P = 0.46). No differences in the occurrence of port-site/wound recurrences were observed (P=0.16). Similar cancer-related mortality was found after laparoscopic surgery compared to open surgery ( colon cancer: 5 RCT, 1575 pts, 14.6% vs 16.4%; OR (fixed) 0.80 (95% CI 0.61 to 1.06) (P=0.15); rectal cancer: 3 RCT, 578 pts, 9.2% vs 10.0%; OR (fixed) 0.66 (95% CI 0.37 to 1.19) (P=0.16). Four studies were included in the meta-analyses on hazard ratios for tumour recurrence in laparoscopic colorectal cancer surgery. No significant difference in recurrence rate was observed between laparoscopic and open surgery (hazard ratio for tumour recurrence in the laparoscopic group 0.92; 95% CI 0.76-1.13). No significant difference in tumour recurrence between laparoscopic and open surgery for colon cancer was observed (hazard ratio for tumour recurrence in the laparoscopic group 0.86; 95% CI 0.70-1.08). AUTHORS' CONCLUSIONS Laparoscopic resection of carcinoma of the colon is associated with a long term outcome no different from that of open colectomy. Further studies are required to determine whether the incidence of incisional hernias and adhesions is affected by method of approach. Laparoscopic surgery for cancer of the upper rectum is feasible, but more randomised trials need to be conducted to assess long term outcome.
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Affiliation(s)
- E Kuhry
- Nord-Trøndelag Health Trust, Namsos Hospital, Department of General Surgery, Sykehusalleen 1, Namsos, Norway, 7800.
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Sheikh-Ali M, Karon BS, Basu A, Kudva YC, Muller LA, Xu J, Schwenk WF, Miles JM. Can serum beta-hydroxybutyrate be used to diagnose diabetic ketoacidosis? Diabetes Care 2008; 31:643-7. [PMID: 18184896 DOI: 10.2337/dc07-1683] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Current criteria for the diagnosis of diabetic ketoacidosis (DKA) are limited by their nonspecificity (serum bicarbonate [HCO(3)] and pH) and qualitative nature (the presence of ketonemia/ketonuria). The present study was undertaken to determine whether quantitative measurement of a ketone body anion could be used to diagnose DKA. RESEARCH DESIGN AND METHODS A retrospective review of records from hospitalized diabetic patients was undertaken to determine the concentration of serum beta-hydroxybutyrate (betaOHB) that corresponds to a HCO(3) level of 18 mEq/l, the threshold value for diagnosis in recently published consensus criteria. Simultaneous admission betaOHB and HCO(3) values were recorded from 466 encounters, 129 in children and 337 in adults. RESULTS A HCO(3) level of 18 mEq/l corresponded with betaOHB levels of 3.0 and 3.8 mmol/l in children and adults, respectively. With the use of these threshold betaOHB values to define DKA, there was substantial discordance (approximately > or = 20%) between betaOHB and conventional diagnostic criteria using HCO(3), pH, and glucose. In patients with DKA, there was no correlation between HCO(3) and glucose levels on admission and a significant but weak correlation between betaOHB and glucose levels (P < 0.001). CONCLUSIONS Where available, serum betaOHB levels > or = 3.0 and > or = 3.8 mmol/l in children and adults, respectively, in the presence of uncontrolled diabetes can be used to diagnose DKA and may be superior to the serum HCO(3) level for that purpose. The marked variability in the relationship between betaOHB and HCO(3) is probably due to the presence of other acid-base disturbances, especially hyperchloremic, nonanion gap acidosis.
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Affiliation(s)
- Mae Sheikh-Ali
- Division of Endocrinology, Diabetes, Nutrition, and Metabolism, Mayo Clinic, Rochester, Minnesota 55905, USA
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Scolapio JS, DiBaise JK, Schwenk WF, Macke ME, Burdette R. Advances and Controversies in Clinical Nutrition: The Education Outcome of a Live Continuing Medical Education Course. Nutr Clin Pract 2008; 23:90-5. [DOI: 10.1177/011542650802300190] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- James S. Scolapio
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida; Mayo School of Continuing Medical Education, Jacksonville, Florida; Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona; Department of Pediatrics, Mayo Clinic, Rochester, Minnesota
| | - John K. DiBaise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida; Mayo School of Continuing Medical Education, Jacksonville, Florida; Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona; Department of Pediatrics, Mayo Clinic, Rochester, Minnesota
| | - W. Frederick Schwenk
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida; Mayo School of Continuing Medical Education, Jacksonville, Florida; Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona; Department of Pediatrics, Mayo Clinic, Rochester, Minnesota
| | - Mary E. Macke
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida; Mayo School of Continuing Medical Education, Jacksonville, Florida; Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona; Department of Pediatrics, Mayo Clinic, Rochester, Minnesota
| | - Rosann Burdette
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida; Mayo School of Continuing Medical Education, Jacksonville, Florida; Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona; Department of Pediatrics, Mayo Clinic, Rochester, Minnesota
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Abstract
The prevalence of obesity in children and adolescents has increased dramatically in the past 3 decades. Childhood and adolescent obesity are associated with serious comorbidities including type 2 diabetes mellitus, hyperlipidemia, and hypertension. Most obese children and adolescents have no defined underlying endocrine or genetic syndrome. Evaluation of an obese child or adolescent involves a detailed personal and family history, physical examination, and selected laboratory evaluation. Lifestyle interventions and behavioral modification aimed at decreasing caloric intake and increasing caloric expenditure are essential to management of childhood and adolescent obesity. Surgical approaches have a role in management of morbid obesity and serious obesity-related comorbidities in adolescents. Further research is needed to evaluate the role of various dietary approaches and pharmacotherapy in the treatment of obesity in childhood and adolescence.
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Affiliation(s)
- Vibha Singhal
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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Sherman J, Thompson GB, Lteif A, Schwenk WF, van Heerden J, Farley DR, Kumar S, Zimmerman D, Churchward M, Grant CS. Surgical management of Graves disease in childhood and adolescence: an institutional experience. Surgery 2006; 140:1056-61; discussion 1061-2. [PMID: 17188157 DOI: 10.1016/j.surg.2006.07.040] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2006] [Accepted: 07/04/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND Graves disease is the most common cause of hyperthyroidism in children. Medical therapy, radioiodine ablation, and thyroidectomy are all treatment options. To evaluate the safety and efficacy of operative therapy, we updated our operative experience with pediatric Graves disease at a single tertiary care center. METHODS The medical records of children <18 years old who underwent thyroidectomy for Graves disease between 1986-2003 were reviewed. RESULTS We identified 78 patients (median age, 13.8 years; 87% female). The most common presenting signs and symptoms included heat intolerance (61%), decreased academic performance (50%), tremor (49%), and ophthalmopathy (43%). All patients had clinical and laboratory evidence of autoimmune thyrotoxicosis. Sixty-nine percent chose operative therapy because of failure of medical therapy or adverse drug reactions. Near-total thyroidectomy was the most common surgical procedure performed (65%). Pathology demonstrated previously unrecognized thyroid malignancies in 4 (5%) patients. Operative morbidities were transient and included hypoparathyroidism (6%) and recurrent laryngeal nerve neuropraxia (1%). Three (4%) patients who underwent subtotal thyroidectomy developed recurrent hyperthyroidism; all were treated successfully with radioiodine ablation. Of patients presenting with ophthalmopathy, 85% noted improvement postoperatively, while 1 (3%) patient experienced worsening of symptoms. Only 5% developed new-onset Graves ophthalmopathy after operation. CONCLUSIONS Near-total thyroidectomy for Graves disease in children is safe and effective when performed by experienced thyroid surgeons. In addition to relief of systemic symptoms, the majority of patients presenting with Graves ophthalmopathy experienced improvement of their ocular disease after operation. In 5% of patients, surgical management allowed for detection and treatment of clinically occult thyroid malignancies.
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Affiliation(s)
- Jonathan Sherman
- Division of Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Abstract
UNLABELLED Since the first reported efficacious use of human growth hormone in 1958, numerous children have been treated with this hormone. This review discusses the five indications for use of human growth hormone in children that have been approved to date by the United States Food and Drug Administration. CONCLUSION Further, long-term studies will be needed to address the optimal use of this hormone in each of these conditions.
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Affiliation(s)
- W Frederick Schwenk
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Basu R, Basu A, Johnson CM, Schwenk WF, Rizza RA. Insulin dose-response curves for stimulation of splanchnic glucose uptake and suppression of endogenous glucose production differ in nondiabetic humans and are abnormal in people with type 2 diabetes. Diabetes 2004; 53:2042-50. [PMID: 15277384 DOI: 10.2337/diabetes.53.8.2042] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.8] [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: 11/13/2022]
Abstract
To determine whether the insulin dose-response curves for suppression of endogenous glucose production (EGP) and stimulation of splanchnic glucose uptake (SGU) differ in nondiabetic humans and are abnormal in type 2 diabetes, 14 nondiabetic and 12 diabetic subjects were studied. Glucose was clamped at approximately 9.5 mmol/l and endogenous hormone secretion inhibited by somatostatin, while glucagon and growth hormone were replaced by an exogenous infusion. Insulin was progressively increased from approximately 150 to approximately 350 and approximately 700 pmol/l by means of an exogenous insulin infusion, while EGP, SGU, and leg glucose uptake (LGU) were measured using the splanchnic and leg catheterization methods, combined with a [3-3H]glucose infusion. In nondiabetic subjects, an increase in insulin from approximately 150 to approximately 350 pmol/l resulted in maximal suppression of EGP, whereas SGU continued to increase (P < 0.001) when insulin was increased to approximately 700 pmol/l. In contrast, EGP progressively decreased (P < 0.001) and SGU progressively increased (P < 0.001) in the diabetic subjects as insulin increased from approximately 150 to approximately 700 pmol/l. Although EGP was higher (P < 0.01) in the diabetic than nondiabetic subjects only at the lowest insulin concentration, SGU was lower (P < 0.01) in the diabetic subjects at all insulin concentrations tested. On the other hand, in contrast to LGU and overall glucose disposal, the increment in SGU in response to both increments in insulin did not differ in the diabetic and nondiabetic subjects, implying a right shifted but parallel dose-response curve. These data indicate that the dose-response curves for suppression of glucose production and stimulation of glucose uptake differ in nondiabetic subjects and are abnormal in people with type 2 diabetes. Taken together, these data also suggest that agents that enhance SGU in diabetic patients (e.g. glucokinase activators) are likely to improve glucose tolerance.
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Affiliation(s)
- Rita Basu
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota 55905, USA
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22
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Abstract
To determine whether regulation of fasting endogenous glucose production (EGP) and glucose disappearance (R(d)) are both abnormal in people with type 2 diabetes, EGP and R(d) were measured in 7 "severe" (SD), 9 "mild" (MD), and 12 nondiabetic (ND) subjects (12.7 +/- 0.6 vs. 8.1 +/- 0.4 vs. 5.1 +/- 0.4 mmol/l) after an overnight fast and during a hyperglycemic pancreatic clamp. Fasting insulin was higher in both the SD and MD than ND subjects, whereas fasting glucagon only was increased (P < 0.05) in SD. Fasting EGP, glycogenolysis, gluconeogenesis, and R(d) all were increased (P < 0.05) in SD but did not differ in MD or ND. On the other hand, when glucose ( approximately 11 mmol/l), insulin ( approximately 72 pmol/l), and glucagon ( approximately 140 pg/ml) concentrations were raised to values similar to those observed in the severe diabetic subjects, EGP was higher (P < 0.001) and R(d) lower (P < 0.01) in both SD and MD than in ND. The higher EGP in the SD and MD than ND during the clamp was the result of increased (P < 0.05) rates of glycogenolysis (4.2 +/- 1.7 vs. 3.5 +/- 1.0 vs. 0.0 +/- 0.8 micromol.kg(-1).min(-1)), since gluconeogenesis did not differ among groups. We conclude that neither glucose production nor disappearance is appropriate for the prevailing glucose and insulin concentrations in people with mild or severe diabetes. Both increased rates of gluconeogenesis (likely because of higher glucagon concentrations) and lack of suppression of glycogenolysis contribute to excessive glucose production in type 2 diabetics.
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Affiliation(s)
- Rita Basu
- Mayo Clinic, 200 1st St. SW, Rm 5-194 Joseph, Rochester, MN 55905, USA.
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Adkins A, Basu R, Persson M, Dicke B, Shah P, Vella A, Schwenk WF, Rizza R. Higher insulin concentrations are required to suppress gluconeogenesis than glycogenolysis in nondiabetic humans. Diabetes 2003; 52:2213-20. [PMID: 12941759 DOI: 10.2337/diabetes.52.9.2213] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.5] [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: 11/13/2022]
Abstract
To determine the mechanism(s) by which insulin inhibits endogenous glucose production (EGP) in nondiabetic humans, insulin was infused at rates of 0.25, 0.375, or 0.5 mU. kg(-1). min(-1) and glucose was clamped at approximately 5.5 mmol/l. EGP, gluconeogenesis, and uridine-diphosphoglucose (UDP)-glucose flux were measured using [3-(3)H]glucose, deuterated water, and the acetaminophen glucuronide methods, respectively. An increase in insulin from approximately 75 to approximately 100 to approximately 150 pmol/l ( approximately 12.5 to approximately 17 to approximately 25 microU/ml) resulted in progressive (ANOVA; P < 0.02) suppression of EGP (13.1 +/- 1.3 vs. 11.7 +/- 1.03 vs. 6.4 +/- 2.15 micromol x kg(-1) x min(-1)) that was entirely due to a progressive decrease (ANOVA; P < 0.05) in the contribution of glycogenolysis to EGP (4.7 +/- 1.7 vs. 3.4 +/- 1.2 vs. -2.1 +/- 1.3 micro mol x kg(-1) x min(-1)). In contrast, both the contribution of gluconeogenesis to EGP (8.4 +/- 1.0 vs. 8.3 +/- 1.1 vs. 8.5 +/- 1.3 micro mol x kg(-1) x min(-1)) and UDP-glucose flux (5.0 +/- 0.4 vs. 5.0 +/- 0.3 vs. 4.0 +/- 0.5 micro mol x kg(-1) x min(-1)) remained unchanged. The contribution of the direct (extracellular) pathway to UDP-glucose flux was minimal and constant during all insulin infusions. We conclude that higher insulin concentrations are required to suppress the contribution of gluconeogenesis of EGP than are required to suppress the contribution of glycogenolysis to EGP in healthy nondiabetic humans. Since suppression of glycogenolysis occurred without a decrease in UDP-glucose flux, this implies that insulin inhibits EGP, at least in part, by directing glucose-6-phosphate into glycogen rather than through the glucose-6-phosphatase pathway.
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Affiliation(s)
- Aron Adkins
- Endocrine Research Unit, Mayo Foundation, Rochester, Minnesota 55905, USA
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24
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Affiliation(s)
- Farid H Mahmud
- Division of Pediatric Endocrinology, Department of Pediatrics & Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
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25
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Abstract
Nutrition support may be more important in children than in adults. The first reports of the use of parenteral nutrition and of parentaneous endoscopic gastrostomies were in children. A number of unresolved questions in this area remain and will be answered by a coordinated effort of the nutrition community.
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Affiliation(s)
- W Frederick Schwenk
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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26
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Shah P, Vella A, Basu A, Basu R, Adkins A, Schwenk WF, Johnson CM, Nair KS, Jensen MD, Rizza RA. Elevated free fatty acids impair glucose metabolism in women: decreased stimulation of muscle glucose uptake and suppression of splanchnic glucose production during combined hyperinsulinemia and hyperglycemia. Diabetes 2003; 52:38-42. [PMID: 12502491 DOI: 10.2337/diabetes.52.1.38] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [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: 11/13/2022]
Abstract
The present study sought to determine whether elevated plasma free fatty acids (FFAs) alter the splanchnic and muscle glucose metabolism in women. To do so, FFAs were increased in seven women by an 8-h Intralipid/heparin (IL/hep) infusion, and the results were compared with those observed in nine women who were infused with glycerol alone. Glucose was clamped at approximately 8.3 mmol/l and insulin was increased to approximately 300 pmol/l to stimulate both muscle and hepatic glucose uptake. Insulin secretion was inhibited with somatostatin. Leg and splanchnic glucose metabolism were assessed using a combined catheter and tracer dilution approach. The glucose infusion rates required to maintain target plasma glucose concentrations were lower (P < 0.01) during IL/hep than glycerol infusion (30.8 +/- 2.6 vs. 65.0 +/- 7.9 micro mol. kg(-1). min(-1)). Whole-body glucose disappearance (37.0 +/- 2.2 vs. 70.9 +/- 8.7 micro mol. kg(-1). min(-1); P < 0.001) and leg glucose uptake (24.3 +/- 4.2 vs. 59.6 +/- 10.0 micro mol. kg fat-free mass of the leg(-1). min(-1); P < 0.02) were also lower, whereas splanchnic glucose production (8.2 +/- 0.8 vs. 4.3 +/- 0.7 micro mol. kg(-1). min(-1); P < 0.01) was higher during IL/hep than glycerol infusion. We conclude that in the presence of combined hyperinsulinemia and hyperglycemia, elevated FFAs impair glucose metabolism in women by inhibiting whole- body glucose disposal, muscle glucose uptake, and suppression of splanchnic glucose production.
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Affiliation(s)
- Pankaj Shah
- Endocrine Research Unit, Mayo Clinic, Rochester, Minnesota 55905, USA
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27
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Affiliation(s)
- Mary Jo Atten
- Department of Internal Medicine, Cook County Hospital, Chicago, Illinois, USA
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28
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Affiliation(s)
- Annette Boogerd
- Department of Surgery, University of Chicago Pritzker School of Medicine, Illinois, USA
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Affiliation(s)
- Seema Kumar
- Department of Pediatrics, Mayo Clinic and Foundation, Rochester, Minnesota, USA
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Vella A, Shah P, Basu R, Basu A, Camilleri M, Schwenk WF, Rizza RA. Effect of enteral vs. parenteral glucose delivery on initial splanchnic glucose uptake in nondiabetic humans. Am J Physiol Endocrinol Metab 2002; 283:E259-66. [PMID: 12110530 DOI: 10.1152/ajpendo.00178.2001] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [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: 11/22/2022]
Abstract
To determine if enteral delivery of glucose influences splanchnic glucose metabolism, 10 subjects were studied when glucose was either infused into the duodenum at a rate of 22 micromol x kg(-1) x min(-1) and supplemental glucose given intravenously or when all glucose was infused intravenously while saline was infused intraduodenally. Hormone secretion was inhibited with somatostatin, and glucose (approximately 8.5 mmol/l) and insulin (approximately 450 pmol/l) were maintained at constant but elevated levels. Intravenously infused [6,6-(2)H(2)]glucose was used to trace the systemic appearance of intraduodenally infused [3-(3)H]glucose, whereas UDP-glucose flux (an index of hepatic glycogen synthesis) was measured using the acetaminophen glucuronide method. Despite differences in the route of glucose delivery, glucose production (3.5 +/- 1.0 vs. 3.3 +/- 1.0 micromol x kg(-1) x min(-1)) and glucose disappearance (78.9 +/- 5.7 vs. 85.0 +/- 7.2 micromol x kg(-1) x min(-1)) were comparable on intraduodenal and intravenous study days. Initial splanchnic glucose extraction (17.5 +/- 4.4 vs. 14.5 +/- 2.9%) and hepatic UDP-glucose flux (9.0 +/- 2.0 vs. 10.3 +/- 1.5 micromol x kg(-1) x min(-1)) also did not differ on the intraduodenal and intravenous study days. These data argue against the existence of an "enteric" factor that directly (i.e., independently of circulating hormone concentrations) enhances splanchnic glucose uptake or hepatic glycogen synthesis in nondiabetic humans.
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Affiliation(s)
- Adrian Vella
- Division of Endocrinology, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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31
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Shah P, Vella A, Basu A, Basu R, Adkins A, Schwenk WF, Johnson CM, Nair KS, Jensen MD, Rizza RA. Effects of free fatty acids and glycerol on splanchnic glucose metabolism and insulin extraction in nondiabetic humans. Diabetes 2002; 51:301-10. [PMID: 11812736 DOI: 10.2337/diabetes.51.2.301] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.9] [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: 11/13/2022]
Abstract
The present study sought to determine whether elevated plasma free fatty acids (FFAs) alter the ability of insulin and glucose to regulate splanchnic as well as muscle glucose metabolism. To do so, FFAs were increased in 10 subjects to approximately 1 mmol/l by an 8-h Intralipid/heparin (IL/Hep) infusion, whereas they fell to levels near the detection limit of the assay (<0.05 mmol/l) in 13 other subjects who were infused with glycerol alone at rates sufficient to either match (n = 5, low glycerol) or double (n = 8, high glycerol) the plasma glycerol concentrations observed during the IL/Hep infusion. Glucose was clamped at approximately 8.3 mmol/l, and insulin was increased to approximately 300 pmol/l to stimulate both muscle and hepatic glucose uptake. Insulin secretion was inhibited with somatostatin. Leg and splanchnic glucose metabolism were assessed using a combined catheter and tracer dilution approach. Leg glucose uptake (21.7 +/- 3.5 vs. 48.3 +/- 9.3 and 57.8 +/- 11.7 micromol x kg(-1) leg x min(-1)) was lower (P < 0.001) during IL/Hep than the low- or high-glycerol infusions, confirming that elevated FFAs caused insulin resistance in muscle. IL/Hep did not alter splanchnic glucose uptake or the contribution of the extracellular direct pathway to UDP-glucose flux. On the other hand, total UDP-glucose flux (13.2 +/- 1.7 and 12.5 +/- 1.0 vs. 8.1 +/- 0.5 micromol x kg(-1) x min(-1)) and flux via the indirect intracellular pathway (8.4 +/- 1.2 and 8.1 +/- 0.6 vs. 4.8 +/- 0.05 micromol x kg(-1) x min(-1)) were greater (P < 0.05) during both the IL/Hep and high-glycerol infusions than the low-glycerol infusion. In contrast, only IL/Hep increased (P < 0.05) splanchnic glucose production, indicating that elevated FFAs impaired the ability of the liver to autoregulate. Splanchnic insulin extraction, directly measured using the arterial and hepatic vein catheters, did not differ (67 +/- 3 vs. 71 +/- 5 vs. 69 +/- 1%) during IL/Hep and high- and low-glycerol infusions. We conclude that elevated FFAs exert multiple effects on glucose metabolism. They inhibit insulin- and glucose-induced stimulation of muscle glucose uptake and suppression of splanchnic glucose production. They increase the contribution of the indirect pathway to glycogen synthesis and impair hepatic autoregulation. On the other hand, they do not alter either splanchnic glucose uptake or splanchnic insulin extraction in nondiabetic humans.
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Affiliation(s)
- Pankaj Shah
- Endocrine Research Unit, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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Rother KI, Matsumoto JM, Rasmussen NH, Schwenk WF. Subtotal pancreatectomy for hypoglycemia due to congenital hyperinsulinism: long-term follow-up of neurodevelopmental and pancreatic function. Pediatr Diabetes 2001; 2:115-22. [PMID: 15016194 DOI: 10.1034/j.1399-5448.2001.002003115.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE To evaluate neurodevelopmental status as well as endocrine and exocrine pancreatic function in children who have undergone subtotal pancreatectomy for hypoglycemia due to congenital hyperinsulinism. PATIENTS AND METHODS Out of 15 identified patients, eight children (mean age 12.7 +/- 0.8 yr) participated in detailed psychometric testing and studies assessing glucose homeostasis, secretion of proinsulin, insulin, glucagon and C-peptide during a test meal. Additionally, a 24-h fast, glucagon challenge test, 72-h stool collection, and ultrasonography of the pancreatic remnant were performed. RESULTS Five of the 15 initially identified children had seizure disorders, including two with mental retardation. Diabetes developed in two of 15 children. All eight children investigated in the present study had evidence for attentional control impairment and 50% had subnormal intellectual functioning. Two had symptomatic hypoglycemia during the 24-h fast, while one had an elevated fasting glucose concentration. Four children, including the latter patient, had proinsulin/insulin ratios resembling patients with type 2 diabetes. Exocrine pancreatic function was normal in all eight children. No correlation was found between pancreatic endocrine function and pancreatic remnant size, nor between multiple pre- and postoperative factors (i.e., age at diagnosis and surgery) and neurodevelopmental outcome. CONCLUSION While severe mental retardation or diabetes occurred infrequently in our patient population compared with previous reports, all of the studied children had subtle anomalies in their cognitive performance tests and the majority had endocrine test results indicative of abnormal insulin secretion and stressed pancreatic beta cells. Although partial pancreatectomy remains the treatment of choice after medical therapy fails, improved therapeutic means are necessary to achieve better clinical outcome.
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Affiliation(s)
- K I Rother
- Diabetes Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892, USA.
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Vella A, Shah P, Basu R, Basu A, Camilleri M, Schwenk WF, Rizza RA. Type I diabetes mellitus does not alter initial splanchnic glucose extraction or hepatic UDP-glucose flux during enteral glucose administration. Diabetologia 2001; 44:729-37. [PMID: 11440366 DOI: 10.1007/s001250051682] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [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: 11/30/2022]
Abstract
AIMS/HYPOTHESIS Our aim was to determine whether an alteration in splanchnic glucose metabolism could contribute to postprandial hyperglycaemia in people with Type I (insulin-dependent) diabetes mellitus. METHODS Splanchnic glucose extraction, hepatic glycogen synthesis and endogenous glucose production were compared in 8 Type I diabetic patients and in 11 control subjects. Endogenous hormone secretion was inhibited with somatostatin while insulin (approximately 550 pmol/l) and glucagon (approximately 130 ng/l) concentrations were matched with exogenous hormone infusions. Glucose containing [3-3H] glucose was infused into the duodenum at a rate of 20 micromol.kg(-1).min(-1). Plasma glucose concentrations were maintained at about 8.5 mmol/l in both groups by means of a separate variable intravenous glucose infusion. RESULTS Initial splanchnic glucose uptake, calculated by subtracting the systemic rate of appearance of [3-3H] glucose from the rate of infusion of [3-3H] glucose into the duodenum, did not differ in the diabetic and non-diabetic patients (4.1 +/- 0.8 vs 3.0 +/- 1.0 micromol/kg/min). In addition, hepatic glycogen synthesis, measured using the acetaminophen glucuronide method did not differ (10.7 +/- 2.4 vs 10.1 +/- 2.7 micromol.kg(-1).min(-1)). On the other hand, suppression of endogenous glucose production, measured by an intravenous infusion of [6,6-2H2] glucose, was greater (p < 0.05) in the diabetic than in the non-diabetic subjects (1.7 +/- 1.6 vs 5.8 +/- 1.9 micromol.kg(-1).min(-1)). CONCLUSION/INTERPRETATION When glucose, insulin and glucagon concentrations are matched in individuals with relatively good chronic glycaemic control, Type I diabetes does not alter initial splanchnic glucose uptake of enterally delivered glucose or hepatic glycogen synthesis. Alterations in splanchnic glucose metabolism are not likely to contribute to postprandial hyperglycaemia in people with well controlled Type I diabetes.
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Affiliation(s)
- A Vella
- Department of Internal Medicine, Mayo Clinic and Foundation, Rochester, Minnesota 55905, USA
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34
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Basu A, Basu R, Shah P, Vella A, Johnson CM, Jensen M, Nair KS, Schwenk WF, Rizza RA. Type 2 diabetes impairs splanchnic uptake of glucose but does not alter intestinal glucose absorption during enteral glucose feeding: additional evidence for a defect in hepatic glucokinase activity. Diabetes 2001; 50:1351-62. [PMID: 11375336 DOI: 10.2337/diabetes.50.6.1351] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.5] [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: 11/13/2022]
Abstract
We have previously reported that splanchnic glucose uptake, hepatic glycogen synthesis, and hepatic glucokinase activity are decreased in people with type 2 diabetes during intravenous glucose infusion. To determine whether these defects are also present during more physiological enteral glucose administration, we studied 11 diabetic and 14 nondiabetic volunteers using a combined organ catheterization-tracer infusion technique. Glucose was infused into the duodenum at a rate of 22 micromol. kg(-1). min(-1) while supplemental glucose was given intravenously to clamp glucose at approximately 10 mmol/l in both groups. Endogenous hormone secretion was inhibited with somatostatin, and insulin was infused to maintain plasma concentrations at approximately 300 pmol/l (i.e., twofold higher than our previous experiments). Total body glucose disappearance, splanchnic, and leg glucose extractions were markedly lower (P < 0.01) in the diabetic subjects than in the nondiabetic subjects. UDP-glucose flux, a measure of glycogen synthesis, was approximately 35% lower (P < 0.02) in the diabetic subjects than in the nondiabetic subjects. This was entirely accounted for by a decrease (P < 0.01) in the contribution of extracellular glucose because the contribution of the indirect pathway to hepatic glycogen synthesis was similar between groups. Neither endogenous and splanchnic glucose productions nor rates of appearance of the intraduodenally infused glucose in the portal vein differed between groups. In summary, both muscle and splanchnic glucose uptake are impaired in type 2 diabetes during enteral glucose administration. The defect in splanchnic glucose uptake appears to be due to decreased uptake of extracellular glucose, implying decreased glucokinase activity. Thus, abnormal hepatic and muscle (but not gut) glucose metabolism are likely to contribute to postprandial hyperglycemia in people with type 2 diabetes.
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Affiliation(s)
- A Basu
- Division of Endocrinology, Metabolism and Nutrition, Mayo Clinic and Foundation, 200 1st St, SW, Rochester, MN 55905, USA
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35
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Shah P, Vella A, Basu A, Basu R, Schwenk WF, Rizza RA. Lack of suppression of glucagon contributes to postprandial hyperglycemia in subjects with type 2 diabetes mellitus. J Clin Endocrinol Metab 2000; 85:4053-9. [PMID: 11095432 DOI: 10.1210/jcem.85.11.6993] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.8] [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: 11/19/2022]
Abstract
We tested the hypothesis that a lack of suppression of glucagon causes postprandial hyperglycemia in subjects with type 2 diabetes. Nine diabetic subjects ingested 50 g glucose on two occasions. On both occasions, somatostatin was infused at a rate of 4.3 nmol/kg x min, and insulin was infused in a diabetic insulin profile. On one occasion, glucagon was also infused at a rate of 1.25 ng/kg x min to maintain portal glucagon concentrations constant (nonsuppressed study day). On the other occasion, glucagon infusion was delayed by 2 h to create a transient decrease in glucagon (suppressed study day). Glucagon concentrations on the suppressed study day fell to about 70 ng/L during the first 2 h, rising thereafter to approximately 120 ng/L. In contrast, glucagon concentrations on the nonsuppressed study day remained constant at about 120 ng/L throughout. The decrease in glucagon resulted in substantially lower (P < 0.001) glucose concentrations on the suppressed compared with the nonsuppressed study days (9.2+/-0.7 vs. 10.9+/-0.8 mmol/L) and a lower (P < 0.001) rate of release of [14C]glucose from glycogen (labeled by infusing [1-14C]galactose). On the other hand, flux through the hepatic UDP-glucose pool (and, by implication, glycogen synthesis), measured using the acetaminophen glucuronide method, did not differ on the two occasions. We conclude that lack of suppression of glucagon contributes to postprandial hyperglycemia in subjects with type 2 diabetes at least in part by accelerating glycogenolysis. These data suggest that agents that antagonize glucagon action or secretion are likely to be of value in the treatment of patients with type 2 diabetes.
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Affiliation(s)
- P Shah
- Endocrine Research Unit, Mayo Clinic, Rochester, Minnesota 55905, USA
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36
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Basu A, Basu R, Shah P, Vella A, Johnson CM, Nair KS, Jensen MD, Schwenk WF, Rizza RA. Effects of type 2 diabetes on the ability of insulin and glucose to regulate splanchnic and muscle glucose metabolism: evidence for a defect in hepatic glucokinase activity. Diabetes 2000; 49:272-83. [PMID: 10868944 DOI: 10.2337/diabetes.49.2.272] [Citation(s) in RCA: 143] [Impact Index Per Article: 6.0] [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: 11/13/2022]
Abstract
Insulin-induced stimulation of muscle glucose uptake (MGU) is impaired in people with type 2 diabetes. To determine whether insulin-induced stimulation of splanchnic glucose uptake (SGU) is also impaired, we simultaneously measured leg glucose uptake (LGU) and SGU in 14 nondiabetic subjects and 16 subjects with type 2 diabetes using a combined organ catheterization-tracer infusion technique. Glucose was clamped at approximately 9.3 mmol/l, while insulin concentrations were maintained at approximately 72 pmol/l (low) and approximately 150 pmol/l (high) for 3 h each. Endogenous hormone secretion was inhibited with somatostatin. Total body glucose disappearance was lower (P < 0.01) and glucose production higher (P < 0.01) during both insulin infusions in the diabetic compared with the nondiabetic subjects, indicating insulin resistance. Splanchnic glucose production was higher (P < 0.05) in the diabetic subjects during the low but not the high insulin infusion. SGU was slightly lower in the diabetic than in the nondiabetic subjects during the low insulin infusion and 50-60% lower (P < 0.05) during the high insulin infusion. LGU (P < 0.001), but not SGU, was inversely correlated with the degree of visceral adiposity. The contribution of the indirect pathway to hepatic glycogen synthesis did not differ in the diabetic and nondiabetic subjects. In contrast, both flux through the UDP-glucose pool (P < 0.05) and the contribution of the direct pathway to glycogen synthesis (P < 0.01) were lower in the diabetic than in the nondiabetic subjects, indicating decreased uptake and/or phosphorylation of extracellular glucose. On the other hand, glycogenolysis was equally suppressed in both groups. In summary, type 2 diabetes impairs the ability of insulin to stimulate both MGU and SGU. The defect appears to reside at a proximal (e.g., glucokinase) metabolic step and is not related to the degree of visceral adiposity. These data suggest that impaired hepatic glucose uptake as well as MGU contribute to hyperglycemia in people with type 2 diabetes.
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Affiliation(s)
- A Basu
- Department of Endocrinology, Mayo Foundation, Rochester, Minnesota 55905, USA
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37
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Babovic-Vuksanovic D, Patterson MC, Schwenk WF, O'Brien JF, Vockley J, Freeze HH, Mehta DP, Michels VV. Severe hypoglycemia as a presenting symptom of carbohydrate-deficient glycoprotein syndrome. J Pediatr 1999; 135:775-81. [PMID: 10586187 DOI: 10.1016/s0022-3476(99)70103-4] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.4] [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: 11/17/2022]
Abstract
We describe clinical, biochemical, and molecular findings in a 2(1/2)-year-old girl with a phosphomannose isomerase deficiency who presented with severe and persistent hypoglycemia and subsequently developed protein-losing enteropathy, liver disease, and coagulopathy. Six months of therapy with mannose supplementation resulted in clinical improvement and partial correction of biochemical abnormalities.
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Affiliation(s)
- D Babovic-Vuksanovic
- Department of Medical Genetics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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38
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Abstract
Hypoglycemia is more common in the pediatric patient than in adults. This article discusses the many diagnoses that can be associated with hypoglycemia in infancy and childhood. A guide to help practitioners evaluate such patients and suggested treatments for many of these disorders are provided. As genetic diagnosis continues to develop, it is anticipated that the list of specific disorders associated with hypoglycemia in infancy and childhood will increase.
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Affiliation(s)
- A N Lteif
- Section of Pediatric Endocrinology, Mayo Medical School, Rochester, Minnesota, USA
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39
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Abstract
OBJECTIVE To assess the level of glycemic control and to determine whether more normal glycemic control, as measured by glycosylated hemoglobin, leads to frequent hypoglycemic episodes in young patients with type 1 diabetes mellitus. MATERIAL AND METHODS We undertook a retrospective review of the medical records of 59 children with type 1 diabetes diagnosed at age 9 years or younger, who underwent follow-up at our institution for at least 2 years. For each follow-up, insulin requirements, levels of glycosylated hemoglobin, and frequency of hypoglycemic reactions were analyzed for three age-groups--0 to 2 years, 2 to 5 years, and 5 to 9 years old. RESULTS The mean glycosylated hemoglobin for the first 2 years after diagnosis of type 1 diabetes was higher in children 0 to 2 years old in comparison with the other age-groups. This increased glycosylated hemoglobin occurred despite increased administration of insulin, expressed in units per kilogram daily, to these children (P < 0.05). Severe hypoglycemic reactions were more common in infants (55%) and children between 2 and 5 years old (45%) than in children from 5 to 9 years old (13%). In all age-groups, the mean glycosylated hemoglobin value closest to a hypoglycemic event and the mean glycosylated hemoglobin value for the 2-year study period were similar but were both less than 8% (the standard established by the Diabetes Control and Complications Trial). Most reactions had no clear cause in the youngest age-group, whereas a specific reason could usually be determined in children 2 to 5 years old. CONCLUSION Tight glycemic control is achievable in young patients with type 1 diabetes mellitus. Such tight control, however, may lead to an increase in the frequency of severe hypoglycemic reactions in this patient population. Our data support the guideline that children younger than 5 years should have a higher goal for premeal plasma glucose levels.
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Affiliation(s)
- A N Lteif
- Department of Pediatric and Adolescent Medicine, Mayo Clinic Rochester, Minnesota 55905, USA
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40
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Abstract
OBJECTIVE To compare the accuracy and precision of insulin syringes and pen devices used by children with type 1 diabetes and their parents. RESEARCH DESIGN AND METHODS There were 48 subjects (32 patients, a parent of an additional 16 patients) instructed to measure out morning insulin doses three times from vials and/or cartridges containing saline mixed with small amounts of [14C]glucose (solution used as regular insulin) and [3H]glucose (solution used as NPH insulin) and to dispense the contents into a scintillation vial. Statistical analysis was used to determine the accuracy and precision of both methods of insulin delivery. RESULTS The absolute error in measuring out doses of regular insulin < 5 U was greater with insulin syringes compared with pen injection devices (9.9 +/- 2.4 vs. 4.9 +/- 1.6%, respectively). Both were comparable for regular insulin doses > 5 U (3.2 +/- 0.6 vs. 2.2 +/- 0.4% for syringes and pens, respectively). The accuracy in drawing up NPH doses was similar for low and high insulin doses (mean percent error of 7.5 +/- 1.5 vs. 5.6 +/- 1.1%). CONCLUSIONS Pen devices are more accurate than insulin syringes in measuring out insulin at low insulin doses. The accuracy of insulin syringes improves when higher doses of regular insulin are measured out and becomes comparable to pen devices.
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Affiliation(s)
- A N Lteif
- Department of Pediatric Endocrinology, Mayo Clinic, Rochester, Minnesota 55905, USA
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41
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Abstract
Human milk has been shown to be the ideal source of nutrition for most growing infants. Its composition continues to be an active area of investigation. In several studies in preterm and term infants, long-chain polyunsaturated fatty acids were found to improve the maturation of visual evoked potentials. The clinical significance of this finding, however, remains unclear. Nucleotides present in breast milk or added to infant formula seem to enhance the humoral immune response to vaccination. Whether breastfeeding protects susceptible infants from the risk of the development of diabetes mellitus type 1 is still controversial. Breastfeeding by mothers infected with the human immunodeficiency virus is not recommended. Other viruses and pollutants have also been found in breast milk. The importance of these in the long-term health of children remains to be established.
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Affiliation(s)
- A N Lteif
- Endocrine Research Unit, Mayo Clinic Rochester, Minnesota 55905, USA
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42
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Nielsen MF, Wise S, Dinneen SF, Schwenk WF, Basu A, Rizza RA. Assessment of hepatic sensitivity to glucagon in NIDDM: use as a tool to estimate the contribution of the indirect pathway to nocturnal glycogen synthesis. Diabetes 1997; 46:2007-16. [PMID: 9392488 DOI: 10.2337/diab.46.12.2007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [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: 02/05/2023]
Abstract
NIDDM is associated with excessive rates of endogenous glucose production in both the postabsorptive and postprandial states. To determine whether this is due to an intrinsic increase in hepatic sensitivity to glucagon, 9 NIDDM and 10 nondiabetic subjects were studied on three occasions. On each occasion, glycogen was labeled the evening before the study with subjects ingesting meals containing [6-3H]galactose. Beginning at 6:00 A.M. on the following morning, somatostatin was infused to inhibit endogenous hormone secretion. Insulin concentrations were maintained constant at basal levels (defined as that necessary to keep glucose at approximately 5 mmol/l) in each individual. On one occasion, glucagon was infused at a rate of 0.65 ng x kg(-1) x min(-1) throughout the experiment, resulting in glucagon concentrations of approximately 130 pg/ml and a slow but comparable fall in endogenous glucose production with time in both groups. On the other two occasions, the glucagon infusion was increased at 10:00 A.M. to either 1.5 or 3.0 ng x kg(-1) x min(-1), resulting in an increase in glucagon concentrations to approximately 180 and 310 pg/ml, respectively. The increment in endogenous glucose production (i.e., area above basal) did not differ in diabetic and nondiabetic subjects during either the 1.5 ng x kg(-1) x min(-1) (0.75 +/- 0.055 vs. 0.78 +/- 0.048 mmol/kg) or 3.0 ng x kg(-1) x min(-1) (1.06 +/- 0.066 vs. 1.10 +/- 0.073 mmol/kg) glucagon infusions. In contrast, the amount of [6-3H]glucose released from glycogen was lower (P < 0.05) in the diabetic than nondiabetic subjects during both glucagon infusions. The specific activity of glycogen, calculated as the integrated release of [6-3H]glucose divided by the integrated release of unlabeled glucose, was lower (P < 0.05) in diabetic subjects than in nondiabetic subjects during both the 1.5 ng x kg(-1) x min(-1) (19.0 +/- 3.9 vs. 41.4 +/- 5.7 dpm/micromol) and 3.0 ng x kg(-1) x min(-1) (19.1 +/- 3.1 vs. 36.5 +/- 7.2 dpm/micromol) glucagon infusions, implying that a greater portion of the glucose released from glycogen was derived from the indirect pathway. We concluded that although NIDDM is not associated with an intrinsic alteration in hepatic sensitivity to glucagon, it does alter the relative contributions of the direct and indirect pathways to nocturnal glycogen synthesis.
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Affiliation(s)
- M F Nielsen
- Mayo Clinic and Foundation, Division of Endocrinology, Rochester, Minnesota 55905, USA
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43
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Abstract
To assess whether acetaminophen glucuronide accurately reflects uridyl diphosphate-glucose (UDP-glucose) derived from gluconeogenesis during fasting, three mongrel dogs received infusions of [U-14C]lactate, [1-13C]galactose, and [6-3H]glucose (after fasting overnight or for 2.5 days). After initiation of the isotopes (3 h), acetaminophen was given, and the urinary acetaminophen glucuronide was isolated. The mean plasma [14C]glucose specific activity (SA) was similar to the mean urinary acetaminophen glucuronide SA both after fasting overnight [299 +/- 19 vs. 296 +/- 14 disintegrations.min-1 (dpm).mumol-1, respectively] and after 2.5 days of fasting (511 +/- 8 vs. 562 +/- 32 dpm/mumol, respectively). Mean plasma glucose flux calculated using [6-3H]glucose decreased (P < 0.05) with two additional days of fasting (18.7 +/- 1.2 vs. 13.6 +/- 0.6 mumol.kg-1.min-1), as did intrahepatic (P < 0.05) UDP-glucose flux measured using [1-13C]galactose (8.6 +/- 0.7 vs. 5.5 +/- 0.3 mumol.kg-1.min-1). We conclude that, in fasted dogs, plasma glucose and UDP-glucose, as sampled by acetaminophen, equally reflect gluconeogenesis and appear to come from the same pool of glucose 6-phosphate. In addition, cycling of glucose moieties through UDP-glucose and glycogen decreases with an increased period of fasting.
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Affiliation(s)
- W F Schwenk
- Department of Pediatrics, Mayo Clinic, Rochester, Minnesota 55905, USA
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44
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Abstract
Children with glycogen storage disease type I (GSD I) lack the ability to convert glucose 6-phosphate to glucose and yet are able to produce glucose endogenously. To test the hypothesis that the source of this glucose is increased cycling of glucose moieties through hepatic glycogen, six children with GSD I were studied on two occasions during which they received enteral glucose for 6 h at 35 or 50 mumol.kg-1.min-1 along with [6,6-2H2]glucose to measure plasma glucose flux and [1-13C]galactose to label intrahepatic uridyl diphosphate (UDP)-glucose. After 3 h, acetaminophen was given to estimate UDP-glucose flux (reflecting the rate of glycogen synthesis). Mean steady-state plasma glucose concentrations (4.8 +/- 0.2 vs. 5.8 +/- 0.1 mM) and total flux (34.8 +/- 1.7 vs. 47.5 +/- 2.0 mumol.kg-1.min-1) were increased (P < 0.05 or better) on the high-infusion day. Endogenous glucose production was detectable only on the low-infusion day (2.0 +/- 0.5 mumol.kg-1.min-1). UDP-glucose flux was increased (P < 0.05) on the high-infusion day (25.8 +/- 1.6 vs. 34.7 +/- 4.1), ruling out cycling of glucose moieties through glycogen with release of glucose by debrancher enzyme as the source of glucose production.
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Affiliation(s)
- K I Rother
- Department of Pediatrics, Mayo Clinic, Rochester, Minnesota 55905, USA
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45
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Abstract
To validate a method to "biochemically biopsy" the immediate precursor of intrahepatic glycogen [uridyl diphosphate (UDP)-glucose] using acetaminophen and to assess how fasting affects the direct and indirect pathways of glycogen synthesis, dogs were fasted overnight (group 1, n = 5) or for 2.5 days (group 2, n = 5) and then given a 4-h duodenal infusion of unlabeled glucose, [3-3H]glucose, and [U-14C]lactate to label hepatic glycogen via the direct and indirect pathways, respectively, and [1-13C]galactose to measure intrahepatic UDP-glucose flux. After 3 h for equilibration, acetaminophen was given and urine was collected for acetaminophen glucuronide. Multiple liver biopsies were obtained. The mean 3H/14C ratios of glucose derived from glycogen (10.4 +/- 4.1 and 1.1 +/- 0.3 for groups 1 and 2, respectively) and glucose derived from acetaminophen glucuronide (11.5 +/- 4.0 and 1.0 +/- 0.1 for groups 1 and 2, respectively) were similar. Fasting significantly increased UDP-glucose flux, the rate of glycogen synthesis, and the contribution of the indirect pathway. We conclude that, in dogs, 1) no functional hepatic zonation exists with regard to acetaminophen glucuronidation and liver glycogen synthesis and 2) with appropriate choice of isotopic tracers and study design, UDP-glucose flux can accurately reflect rates of hepatic glycogen synthesis.
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Affiliation(s)
- K I Rother
- Department of Pediatrics, Mayo Clinic, Rochester, Minnesota 55905, USA
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46
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Schwenk WF. Metabolic consequences of increasing energy intake by adding lipid to parenteral nutrition in full-term infants JE VAN AERDE, PJ SAUER, PB PENCHARZ, ET AL University of Toronto and the Research Institute, The Hospital for Sick Children, Toronto; University of Rotterdam, The Netherlands; and University of Alberta, Edmonton, Canada. Nutr Clin Pract 1995. [DOI: 10.1177/088453369501000213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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47
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Abstract
The nonketotic hyperglycemic syndrome is rare during childhood and may occur as the initial manifestation of insulin-dependent diabetes mellitus or during an episode of gastroenteritis. In this article, we report an unusual case of this syndrome in a female infant who had atypically severe hyperglycemia in association with gastroenteritis. In addition, we provide a review of the literature and summarize the pathophysiologic mechanisms of the nonketotic hyperglycemic syndrome.
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Affiliation(s)
- K I Rother
- Section of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, MN 55905
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48
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Rother KI, Schwenk WF. Effect of rehydration fluid with 75 mmol/L of sodium on serum sodium concentration and serum osmolality in young patients with diabetic ketoacidosis. Mayo Clin Proc 1994; 69:1149-53. [PMID: 7967775 DOI: 10.1016/s0025-6196(12)65766-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [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: 01/28/2023]
Abstract
OBJECTIVE To evaluate whether rehydration of young patients with diabetic ketoacidosis (DKA) by use of a solution that contained 75 mmol/L of sodium would be associated with a decline in serum sodium concentrations. DESIGN We retrospectively studied 18 episodes of moderate to severe DKA (mean plasma bicarbonate concentration of 7.8 +/- 0.9 mmol/L) in 17 patients younger than 18 years of age who had been examined at the Mayo Clinic between 1986 and 1990. MATERIAL AND METHODS All patients had received an initial fluid bolus (about 20 mL/kg) of 0.9% saline or Ringer's lactate (or both), followed by rehydration with solutions that contained 75 mmol/L of sodium at rates of approximately 3,000 mL/m2 per day. Mean corrected and uncorrected serum sodium concentrations and effective serum osmolality (before and after administration of the fluid bolus and at 6 and 12 hours into treatment) were compared by use of the paired Student t test. RESULTS After 12 hours of therapy, we found a significant increase in the mean uncorrected serum sodium level from 135.1 +/- 0.9 mmol/L to 138.1 +/- 0.7 mmol/L (P < 0.05), whereas the mean corrected serum sodium value declined slightly from 143.1 +/- 1.1 mmol/L to 140.4 +/- 0.7 mmol/L (statistically not significant). Serum osmolality based on uncorrected serum sodium concentrations decreased at a rate of 2.6 mmol/kg per hour during the first 6 hours of treatment and remained stable thereafter. CONCLUSION In 18 episodes of DKA in young patients, rehydration with fluids that contained 75 mmol/L of sodium at rates of approximately 3,000 mL/m2 per day after administration of a fluid bolus of 0.9% saline or Ringer's lactate (or both) was not associated with a decline in the uncorrected serum sodium concentration.
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Affiliation(s)
- K I Rother
- Section of Pediatric Endocrinology and Metabolism, Mayo Clinic Rochester, MN 55905
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49
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Abstract
Insulin is a well-known anabolic hormone. The mechanism of insulin's protein anabolic effect remains controversial. Although insulin undoubtedly inhibits protein degradation, its effect on protein synthesis is incompletely defined. Recent studies reviewed in this article highlight the methodologic limitations in studying the effect of insulin on protein synthesis. These methodological issues are related to the hypoaminoacidemia that ensues after insulin administration and to the difficulty in measuring the obligatory precursor pool (aminoacyl tRNA) label. Differential responses to unweighing in different muscle proteins has been demonstrated. The protein loss during unweighing is due to the loss of myofibrillar proteins, although sarcoplasmic proteins are spared. A recent study has found that lipid emulsion has no effect on whole protein degradation but decreases forearm protein degradation and synthesis. Age-related muscle wasting in humans has been shown to be related to a decline in fractional myofibrillar protein synthesis rate. Although some progress has been made by recent studies, refined methodologies are needed to define the regulation of muscle protein turnover in humans.
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Affiliation(s)
- K S Nair
- Mayo Clinic, Rochester, Minnesota
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50
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Schwenk WF. Oxygen consumption and resting metabolic rate in sepsis, sepsis syndrome, and septic shock G KREYMAN, S GROSSER, P BUGGISCH, ET AL Medical Clinic University-Hospital, Eppendorf, Hamburg, Germany. Nutr Clin Pract 1994. [DOI: 10.1177/088453369400900308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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