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The usual signs and symptoms of hypoglycemia include tachycardia and profound diaphoresis. These will progress to include an altered mental status that can advance in severe cases to coma, seizures, and death. Occasionally, hypoglycemia may present with focal neurologic signs that can include hemiparesis or hemiplegia with preservation of mental status. In patients with the latter signs, the possibility of a cerebrovascular accident or other intracranial abnormality must be considered. The authors describe an elderly patient with hypoglycemic hemiplegia secondary to insulin administration. Their report includes observations on clinical presentation, the various mechanisms involved, and guidelines for the management of this syndrome.
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PMID:Hypoglycemic hemiplegia. 235 82

The Tecumseh project investigates the evolution of hypertension in a healthy population. Of 946 subjects aged 18 through 38 years, 124 had clinic blood pressure readings higher than 140/90 mm Hg (the mean for borderline hypertensive subjects was 130/94 mm Hg). Compared with normotensive subjects, borderline hypertensive subjects had higher home blood pressures (mean, 12/7 mm Hg higher). Their childhood and postpubertal blood pressures were elevated (6/4 mm Hg higher than normal at age 6 years and 12/7 mm Hg higher than normal at age 21 years), and hypertensive target organ changes were detected. Borderline hypertensive subjects also had elevated minimal forearm resistance (0.22 U higher than normal), decreased stroke index (1.8 mL/m2 lower than normal), and impaired ventricular diastolic relaxation (mitral Doppler peak early diastolic blood flow [E] to peak late diastolic blood flow [A] ratio 0.13 lower than normal). Borderline hypertensive subjects had significant abnormalities in other coronary risk factors (cholesterol levels were 0.39 mmol/L higher, triglyceride levels were 0.45 mmol/L higher, high-density lipoprotein levels were 0.08 mmol/L lower, insulin levels were 38 pmol/L higher, and 16.5% more of them were overweight). Borderline hypertension is neither transient nor innocuous. Its association with other predictors of atherosclerosis calls for clinical attention.
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PMID:The association of borderline hypertension with target organ changes and higher coronary risk. Tecumseh Blood Pressure study. 236 31

The effects of pharmacological doses of secretin were studied in closed-chest, pentobarbital anesthetized dogs. Infusion of secretin 16 clinical units (CU)/kg-h caused a rise in cardiac output (p less than 0.01), peak first derivative of the left ventricular pressure (p less than 0.01), and heart rate (p less than 0.01) and a fall in systemic arteriolar resistance (p less than 0.01) and left ventricular end-diastolic pressure (p less than 0.01). Stroke volume did not change significantly. Myocardial blood flow and oxygen consumption were unchanged. Secretin caused reductions in arterial lactate (p less than 0.01) and glucose (p less than 0.05) concentrations, and arterial concentrations of free fatty acids and insulin were unaltered. There was no change in myocardial uptake of lactate, glucose, or FFA. Secretin 64 CU/kg-h infused in two dogs caused further changes of the hemodynamic variables. Thus, secretin enhances left ventricular function in intact anesthetized dog by combined vasodilating, inotropic, and chronotropic effects, without changing myocardial oxygen or substrate uptake.
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PMID:Effects of secretin infusion on myocardial performance and metabolism in the dog. 241 8

Acute ischemic heart failure was induced in eight dogs by coronary embolization. Severe depression of the left ventricular (LV) performance was evidenced. At 15 min after the embolization procedure, dopamine was infused at a dosage sufficient to increase the maximum rate of LV pressure rise (LVdP/dtmax) by approximately 50%. The significant improvement in cardiac performance was obtained at unaltered myocardial oxygen consumption (MVo2). Dopamine infusion was concluded, and after a stabilization period 300 IU of insulin was injected. This was followed by the infusion of glucose and potassium to maintain levels. Insulin significantly improved the performance of the failing left ventricle at unaltered MVo2, but to a lesser extent than did dopamine. Additional dopamine infusion further significantly improved cardiac performance. The net effect of insulin and dopamine in combination as compared with dopamine alone was a significantly greater increase in stroke volume and cardiac output due to a more pronounced decrease in total peripheral resistance. Dopamine increased arterial concentrations and myocardial uptake of free fatty acids (FFA). The net metabolic effect of insulin and dopamine in combination as compared with dopamine alone was a shift in myocardial substrate uptake from FFA to carbohydrates.
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PMID:Hemodynamic and metabolic effects of dopamine and insulin during acute left ventricular failure in dogs. 242 68

The treatment of end-stage renal diabetic nephropathy remains a challenge. A large experience allows us to clearly outline the advantages and the drawbacks of continuous ambulatory peritoneal dialysis (CAPD) and continuous cyclic peritoneal dialysis (CCPD). Eighty-one patients, mean age 51.3 years, were treated over the last 9 years by CAPD-CCPD. Extrarenal complications, mainly vascular lesions, were present in this high-risk group of patients. The technique was modified in order to inject intraperitoneally, 4 times per day, insulin to control blood glucose level in CAPD patients. Actuarial survival was 92% at 1 year, 50% at 4 years mainly influenced by age: 85% survival at 2 years in 35 patients aged less than 50 years old and 62% at 2 years in 46 patients aged more than 50 years old. The main causes of death were of cardiovascular origin: myocardial infarction, stroke, atherosclerotic vasculopathy. The main causes of transfer to hemodialysis were due to technical complications. Peritonitis rate was one episode every 14 patient-months. Control of blood pressure, blood glucose levels, main biological parameters, and visual status were the clear advantages of the method. Peripheral vascular disease is not influenced by the technique. CAPD-CCPD is the technique of first choice in young diabetics and the preferential technique for home dialysis.
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PMID:Clinical aspects of continuous ambulatory and continuous cyclic peritoneal dialysis in diabetic patients. 248 84

This study tests the hypothesis that metabolic support of remote "nonischemic" myocardium during acute infarction will reverse the trend toward cardiogenic shock. Thirty-seven dogs underwent ligation of the left anterior descending coronary artery and 50% stenosis of the circumflex coronary artery. Irreversible ventricular fibrillation developed in 11 of them. The 26 survivors were observed for up to 6 hours; global and regional left ventricular function (cardiac index, stroke work index, ultrasonic crystals) and regional blood flow (radioactive microspheres) were measured. After 2 hours, eight dogs received an intravenous infusion of glutamate/aspartate, glucose-insulin-potassium, coenzyme Q10, and 2-mercapto-propionyl-glycine for 4 hours. Five dogs received the mannitol infusion to raise serum osmolarity 30 mOsm. Four additional dogs received the intravenous substrate infusions over 4 hours without undergoing ischemia. The substrate infusion for 4 hours caused no change in regional or global cardiac function in the four control dogs. Three of nine untreated dogs died of cardiogenic shock, and progressive left ventricular power failure occurred in the six others (40% decrease in cardiac index, 50% decrease in stroke work index, p less than 0.05) because of persistent dyskinesia in the left anterior descending region (-40% of systolic shortening, p less than 0.05) and hypocontractility in the circumflex region (48% of control systolic shortening, p less than 0.05), despite normal transmural blood flow in the posterior left ventricular wall (76 ml/100 gm/min). In contrast, in treated dogs, hypercontractility recovered in the circumflex segment (138% of systolic shortening) and stroke work index rose to control levels (91%) without a change in regional blood flow. Mannitol infusion did not improve hemodynamics or avoid the development of progressive left ventricular power failure. We conclude that cardiogenic shock after myocardial infarction is due, in large part, to impaired ability of "nonischemic" myocardium to maintain hypercontractility. This limitation can be prevented by metabolic support of viable muscle, and the data imply that intravenous substrate infusions may be helpful before definitive treatment (i.e., coronary artery bypass grafting) is undertaken.
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PMID:Studies on prolonged acute regional ischemia. V. Metabolic support of remote myocardium during left ventricular power failure. 250 26

Most diabetic patients are elderly but their clinical characteristics remain poorly defined. A population survey identified 259 known diabetic patients aged 60 years or more giving a prevalence of 3% in this age group. A total of 193 patients (75%) were interviewed and examined, 155 (80%) of whom had been diagnosed at under 70 years of age. Forty-two patients (22%) were insulin-treated but clinical characteristics suggested that at least 95% of all elderly patients had Type 2 diabetes. Blood glucose control was poor with median HbA1 9.7% (range 4.9-17.1%, normal reference range 5.0-7.5%), and 55% were either overweight or obese. There was a high morbidity from diabetes and other conditions: the prevalence of hypertension (untreated blood pressure of 160/95 mmHg or more or antihypertensive medication) was 52%, of stroke 5%, of nephropathy (urinary albumin concentration greater than or equal to 300 mg l-1) 3%, of lower limb amputations 4%, and of foot ulcers 7%. The prevalence of symmetrically impaired distal vibration perception was 23%, and 54% of patients either needed or were receiving chiropody. The prevalence of a corrected distant visual acuity of 6/12 or worse was 32% and of retinopathy of any degree was 26%. There was extensive co-morbidity which was not confined to a single subgroup of patients.
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PMID:Diabetes in the elderly: the Oxford Community Diabetes Study. 252 2

Although adequate volume resuscitation has decreased mortality from hemorrhagic shock, recovery in many patients is complicated by sepsis. To determine whether a subject debilitated by hemorrhagic shock would exhibit greater cardiocirculatory dysfunction when challenged with sepsis, ten dogs (Group I) were hemorrhaged to a mean arterial blood pressure of 30 mm Hg. After 2 hours of hypotension, shed blood and lactated Ringer's solution (50 ml/kg) were given, and the dogs were observed for 3 to 6 days. Ten dogs were sham hemorrhage and served as controls (Group II). On the experimental day, all cardiovascular and hemodynamic parameters were measured in both groups of animals before endotoxin challenge. There was no significant difference in cardiac output, stroke volume, stroke work, +dP/dt max, myocardial blood flow, myocardial oxygen metabolism, or acid-base balance in the two groups. Compared to sham-hemorrhaged dogs, resuscitated shock dogs had a significantly lower mean arterial blood pressure (127 +/- 7 vs. 110 +/- 6 mm Hg; p less than 0.05), and heart rate was significantly higher (86 +/- 6 vs. 109 +/- 7 beats/minute; p less than 0.05). Furthermore, maximal rate of left ventricular pressure fall (-dP/dT max) was significantly lower in the animals previously hemorrhaged, suggesting a persistent defect in left ventricular relaxation. Blood glucose and insulin levels were significantly elevated in the resuscitated shocked dogs, likely due to increased circulating catecholamine concentrations and enhanced glycogenolysis. Endotoxin shock caused significant hypotension, acidosis, and impaired regional perfusion in all dogs. In addition, cardiac output, stroke volume, dP/dT, and left ventricular end-diastolic pressure fell and hyperglycemia and hyperinsulinemia occurred in all dogs after endotoxin injection.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:The cardiocirculatory and metabolic effects of endotoxin challenge after canine resuscitated hemorrhagic shock. 256 78

The results of echocardiographic investigation of 48 patients with type I diabetes mellitus (DM) were compared: 48 patients received routine therapy including diabetic management, insulin and vitamin therapy, 32 received this type of therapy plus a complex consisting of inosine, benphothiamine and pyridoxal phosphate. A considerable decrease in myocardial contractility and hemodynamic disorder were revealed against a background of DM decompensation in both groups of patients. Clinical improvement resulting from the use of the above complex showed good correlation with a positive course of echocardiographic values of myocardial contractility and pumping function. Elimination of myocardial insufficiency was accompanied by an increase in the stroke volume, ejection fraction, the rate of circulatory shortening of myocardial fibers, left ventricular mass, and a decrease in end diastolic and systolic volumes. The second type of therapy was well tolerated by the patients and made it possible to considerably lessen myocardial insufficiency and reduce a period of treatment in hospital as compared to routine therapy.
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PMID:[The myocardial contractile function and central hemodynamics of patients with insulin-dependent diabetes mellitus during treatment]. 260 45

A prospective study was made in the years 1973 through 1983 on mortality among 4591 patients (2095 men and 2469 women) with usually noninsulin dependent diabetes, of 1-10 years duration. The anamnestic data and examination parameters obtained during a cross-sectional investigation served as the prognostic changeables (risk factors) to assess the mortality due the most frequent circulatory diseases. The applied model of the logistic regression allowed an attempt of the assessment of their independent effect. Analysis regarding the sex and the methods of diabetes treatment was done in four groups of mortality causes classified according to the VIII Revision of the International Classification of Disease. Injuries and Causes of Death: 1. Cardiovascular system diseases. 2. Ischaemic heart diseases. 3. Other diseases of the cardiovascular system. 4. Vascular diseases of the brain. The quantitative and qualitative effect of the arbitrarily chosen factor of death risk was of varying importance and was related to the sex and the methods of the hypoglycemising treatments. The effect of ageing was an independent factor of death risk among all analysed causes of mortality in both sexes independent from the methods of the hypoglycemising treatment with the one exception of women treated with insulin who died of stroke. Generally however, the ageing factor showed a greater prognostic value in patients treated with insulin. Hypertension, especially if marked, showed to have the most prognostic value among the all analysed factors of death-risk especially in patients on oral antidiabetics. The risk in this group was due mainly to the cerebral stroke, to a lesser degree to the "other" diseases of the circulatory system, and to the all diseases of the circulatory system but to the least degree it was related to the ischaemic heart disease, in both sexes. Among insulin treated diabetics the hypertension was a death-risk of most importance in men usually due to the vascular brain disease and other diseases of the cardiovascular system but to a lesser degree to the circulatory diseases, as a whole. In women however the marked hypertension increased the death-risk in patients with coexisting circulatory disease, not a particular one, but as a whole. Albuminuria had a pronounced prognostic value, especially if massive, in both types of diabetes, mainly, however, among women who died of any cardiovascular causes.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:[Mortality risk factors in cardiovascular diseases in patients with diabetes mellitus in Warsaw--a 10-year prospective study]. 262 54


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