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Park S, Marinov A, Clarke H, Schiavo S, Greer E, Djaiani G, Tarshis J, Katznelson R. Safety of hyperbaric oxygen therapy in non-emergent patients with a history of seizures: A retrospective cohort study. PLoS One 2025; 20:e0317586. [PMID: 39808603 PMCID: PMC11731757 DOI: 10.1371/journal.pone.0317586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2024] [Accepted: 12/31/2024] [Indexed: 01/16/2025] Open
Abstract
BACKGROUND Hyperbaric oxygen therapy (HBOT) is well established as a treatment for various medical conditions. However, it poses a risk of oxygen toxicity, which can cause seizures particularly in individuals with pre-existing seizure disorders. Consequently, seizure disorders are considered a relative contraindication to HBOT. Despite this, the relative risk of HBOT-induced seizures in this patient population remains unclear. This retrospective cohort study aims to evaluate the safety of HBOT among patients with pre-existing seizure disorders. METHODS After obtaining approval from the Research Ethics Board, we retrospectively reviewed the patient charts of individuals with a history of seizures who were referred to the Rouge Valley Hyperbaric Medical Center and Toronto General Hyperbaric Medicine Unit for HBOT between January 2020 and December 2023. Relevant demographic information, past medical history, and HBOT session treatment protocols, such as the treatment pressure set in absolute atmospheric pressure (ATA) and number of air breaks, were recorded. The collected data was analyzed using descriptive statistics. RESULTS A total of 43 patients were referred to HBOT during the study period, and 21 patients did not proceed with the treatments. In total, 634 HBOT sessions were administered to 22 patients in monoplace chambers with five-minute air breaks, and one patient experienced a seizure event. Each patient completed an average of 29 (range 3-60) sessions lasting 90-120 minutes at 1.8 ATA (n = 3), 2.0 ATA (n = 18), or 2.4 ATA (n = 1). Fifteen patients were on oral antiseizure medications during the HBOT course. The overall incidence of seizures was one in 634 treatments. CONCLUSION While patients with a history of seizures may develop seizure activity during HBOT, the majority can safely undergo treatment when predetermined protocols are followed. With careful management and adherence to established protocols, HBOT can be a viable treatment option for those with seizure histories.
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Affiliation(s)
- Subin Park
- Temerty Faculty of Medicine, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Anton Marinov
- Hyperbaric Medicine Unit, Toronto General Hospital, Toronto, Ontario, Canada
- Rouge Valley Hyperbaric Medical Center, Scarborough, Ontario, Canada
| | - Hance Clarke
- Hyperbaric Medicine Unit, Toronto General Hospital, Toronto, Ontario, Canada
- Rouge Valley Hyperbaric Medical Center, Scarborough, Ontario, Canada
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Simone Schiavo
- Hyperbaric Medicine Unit, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Elise Greer
- Hyperbaric Medicine Unit, Toronto General Hospital, Toronto, Ontario, Canada
| | - George Djaiani
- Hyperbaric Medicine Unit, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jordan Tarshis
- Department of Anesthesia, Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Rita Katznelson
- Hyperbaric Medicine Unit, Toronto General Hospital, Toronto, Ontario, Canada
- Rouge Valley Hyperbaric Medical Center, Scarborough, Ontario, Canada
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, Ontario, Canada
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Lieberman OJ, Berkowitz AL. Diagnostic Approach to the Patient with Altered Mental Status. Semin Neurol 2024; 44:579-605. [PMID: 39353612 DOI: 10.1055/s-0044-1791245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2024]
Abstract
Acute encephalopathy is a common presenting symptom in the emergency room and complicates many hospital and intensive care unit admissions. The evaluation of patients with encephalopathy poses several challenges: limited history and examination due to the patient's mental status, broad differential diagnosis of systemic and neurologic etiologies, low yield of neurodiagnostic testing due to the high base rate of systemic causes, and the importance of identifying less common neurologic causes of encephalopathy that can be life-threatening if not identified and treated. This article discusses the differential diagnosis of acute encephalopathy, presents an approach to the history and examination in a patient with encephalopathy, reviews the literature on the yield of neurodiagnostic testing in this population, and provides a diagnostic framework for the evaluation of patients with altered mental status.
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Wahlster S, Johnson NJ. The Neurocritical Care Examination and Workup. Continuum (Minneap Minn) 2024; 30:556-587. [PMID: 38830063 DOI: 10.1212/con.0000000000001438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article provides an overview of the evaluation of patients in neurocritical care settings and a structured approach to recognizing and localizing acute neurologic emergencies, performing a focused examination, and pursuing workup to identify critical findings requiring urgent management. LATEST DEVELOPMENTS After identifying and stabilizing imminent threats to survival, including respiratory and hemodynamic compromise, the initial differential diagnosis for patients in neurocritical care is built on a focused history and clinical examination, always keeping in mind critical "must-not-miss" pathologies. A key priority is to identify processes warranting time-sensitive therapeutic interventions, including signs of elevated intracranial pressure and herniation, acute neurovascular emergencies, clinical or subclinical seizures, infections of the central nervous system, spinal cord compression, and acute neuromuscular respiratory failure. Prompt neuroimaging to identify structural abnormalities should be obtained, complemented by laboratory findings to assess for underlying systemic causes. The indication for EEG and lumbar puncture should be considered early based on clinical suspicion. ESSENTIAL POINTS In neurocritical care, the initial evaluation is often fast paced, requiring assessment and management to happen in parallel. History, clinical examination, and workup should be obtained while considering therapeutic implications and the need for lifesaving interventions.
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Urushidani S, Tanabe M, Baek K, Miyaguchi K, Ikegami T. Seizure occurrences among hypoglycemic patients in the emergency department. Acute Med Surg 2024; 11:e979. [PMID: 38966603 PMCID: PMC11223063 DOI: 10.1002/ams2.979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 05/30/2024] [Accepted: 06/25/2024] [Indexed: 07/06/2024] Open
Abstract
Aim Symptomatic hypoglycemia is a common problem in the emergency department (ED). However, without appropriate recognition and management, hypoglycemia remains a potentially fatal condition. The cause of sudden death associated with hypoglycemia might be attributed to cardiac arrhythmias and hypoxia with seizures. Despite advances in diabetes mellitus management and social background, the frequency and characteristics of patients with hypoglycemia-related seizures have remained unknown. Hence, our study aimed to investigate the frequency and characteristics of patients with hypoglycemia presenting with seizures in the ED. Methods This retrospective observational study was conducted in a single tertiary care center. Patient information was retrieved from the final diagnostic records in the ED. We reviewed all medical records and included patients with symptomatic hypoglycemia aged 16 years or older. The primary outcome was the frequency of seizures in patients with hypoglycemia. We also compared the initial blood sugar levels of the patients with and without seizures. Results We included a total of 380 patients (median age, 72 years, IQR 64-80 years; median initial blood sugar, 34 mg/dL, IQR 24-46; 62.9% male). Nineteen of 380 patients (5.0%) had seizures. Although 16 of the 19 patients had diabetes mellitus, none of the 19 patients had a history of epilepsy. The initial blood sugar levels of the patients with and without seizures were not significantly different (p = 0.97). Conclusion Approximately 5% of the patients with hypoglycemia presented with seizures. Blood glucose levels of hypoglycemic patients with and without seizures did not differ.
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Affiliation(s)
- Seigo Urushidani
- Emergency and Critical Care CenterKurashiki Central HospitalKurashikiOkayamaJapan
| | - Mao Tanabe
- Emergency and Critical Care CenterKurashiki Central HospitalKurashikiOkayamaJapan
| | - Kwangsoo Baek
- Emergency and Critical Care CenterKurashiki Central HospitalKurashikiOkayamaJapan
| | - Koki Miyaguchi
- Emergency and Critical Care CenterKurashiki Central HospitalKurashikiOkayamaJapan
| | - Tetsunori Ikegami
- Emergency and Critical Care CenterKurashiki Central HospitalKurashikiOkayamaJapan
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Ramos-Riera KP, Pérez-Severiano F, López-Meraz ML. Oxidative stress: a common imbalance in diabetes and epilepsy. Metab Brain Dis 2023; 38:767-782. [PMID: 36598703 DOI: 10.1007/s11011-022-01154-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 12/23/2022] [Indexed: 01/05/2023]
Abstract
The brain requires a large amount of energy. Its function can be altered when energy demand exceeds supply or during metabolic disturbances such as diabetes mellitus. Diabetes, a chronic disease with a high incidence worldwide, is characterized by high glucose levels (hyperglycemia); however, hypoglycemic states may also occur due to insulin treatment or poor control of the disease. These alterations in glucose levels affect the brain and could cause epileptic seizures and status epilepticus. In addition, it is known that oxidative stress states emerge as diabetes progresses, contributing to the development of diseases secondary to diabetes, including retinopathy, nephropathy, cardiovascular alterations, and alterations in the central nervous system, such as epileptic seizures. Seizures are a complex of transient signs and symptoms resulting from abnormal, simultaneous, and excessive activity of a population of neurons, and they can be both a cause and a consequence of oxidative stress. This review aims to outline studies linking diabetes mellitus and seizures to oxidative stress, a condition that may be relevant to the development of severe seizures in diabetes mellitus patients.
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Affiliation(s)
- Karen Paola Ramos-Riera
- Doctorado de Investigaciones Cerebrales, Instituto de Investigaciones Cerebrales, Universidad Veracruzana, Dr. Luis Castelazo Ayala s/n, Industrial Animas, 91190, Xalapa, Veracruz, México
| | - Francisca Pérez-Severiano
- Laboratorio de Neurofarmacología Molecular y Nanotecnología, Instituto Nacional de Neurología y Neurocirugía, "Manuel Velasco Suarez," Insurgentes Sur 3877, 14269, La Fama, CDMX, México
| | - María Leonor López-Meraz
- Instituto de Investigaciones Cerebrales, Universidad Veracruzana, Dr. Luis Castelazo Ayala s/n, Industrial Animas, 91190, Xalapa, Veracruz, México.
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Liu Y, Xu H, Li J, Yang Y, Zhang J, Liu X, Li J, Yu Y, Qin G. Separate and combined effect of visit-to-visit glycaemic variability and mean fasting blood glucose level on all-cause mortality in patients with type 2 diabetes: A population-based cohort study. Diabetes Obes Metab 2022; 24:2400-2410. [PMID: 35876225 DOI: 10.1111/dom.14826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/12/2022] [Accepted: 07/20/2022] [Indexed: 11/29/2022]
Abstract
AIMS To assess the independent and combined impacts of visit-to-visit fasting blood glucose variability (VVV-FBG) and mean fasting blood glucose level (M-FBG) on all-cause mortality. MATERIALS AND METHODS This prospective cohort study included 48 843 Chinese patients with type 2 diabetes. Cox proportional hazards regression models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) to evaluate the association of VVV-FBG and M-FBG with all-cause mortality. The potential nonlinear associations were examined using restricted cubic splines, and additive interaction was evaluated using relative excess risk due to interaction (RERI). Cox generalized additive models (CGAMs) and bivariate response surface models were further used to assess the combined effects of VVV-FBG and M-FBG. RESULTS A total of 4087 deaths were observed during a median follow-up of 6.99 years. Compared with patients with values at the 5th percentile of average real variability (ARV) and M-FBG, we observed a 23% and 38% increased risk of premature deaths among those with values at the 95th percentile of ARV (HR 1.23, 95% CI 1.10, 1.37) and M-FBG (HR 1.38, 95% CI 1.26, 1.51), respectively. The interaction between glycaemic variability (ARV) and M-FBG was significant on both the additive scale (RERI 0.80 [0.29, 1.32]) and the multiplicative scale (HR 1.90 [1.10, 3.28]). High VVV-FBG and high M-FBG conferred the highest risk of all-cause mortality (HR 1.89, 95% CI 1.64, 2.17), compared to low VVV-FBG and low M-FBG. The CGAMs showed significant synergistic effects between glycaemic variability and M-FBG (P < 0.05). Moreover, a bivariate surface plot showed that risk of death increased more rapidly in type 2 diabetes patients with lower M-FBG combined with lower VVV-FBG. CONCLUSIONS The coexistence of high glycaemic variability and high glucose level might exacerbate the independent risk of premature mortality in type 2 diabetes patients, highlighting the importance of achieving normal and stable glucose levels simultaneously in the management of glucose.
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Affiliation(s)
- Yahang Liu
- Department of Biostatistics, School of Public Health, and The Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Huilin Xu
- Shanghai Minhang Center for Disease Control and Prevention, Shanghai, China
| | - Jun Li
- Shanghai Minhang Center for Disease Control and Prevention, Shanghai, China
| | - Yating Yang
- Department of Biostatistics, School of Public Health, and The Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
| | - Jie Zhang
- Department of Public Health, Aarhus University, Aarhus, Denmark
- NCRR-National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
| | - Xiaoqin Liu
- NCRR-National Centre for Register-based Research, Aarhus University, Aarhus, Denmark
| | - Jiong Li
- Department of Clinical Medicine-Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Yongfu Yu
- Department of Biostatistics, School of Public Health, and The Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
- Shanghai Institute of Infectious Disease and Biosecurity, Shanghai, China
| | - Guoyou Qin
- Department of Biostatistics, School of Public Health, and The Key Laboratory of Public Health Safety of Ministry of Education, Fudan University, Shanghai, China
- Shanghai Institute of Infectious Disease and Biosecurity, Shanghai, China
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Kawahara T, Tsuji M, Tominaga N, Toyama N, Toda M. Frequency of adrenal insufficiency in patients with hypoglycemia in an emergency department: A cross-sectional study. J Endocr Soc 2022; 6:bvac119. [PMID: 36042975 PMCID: PMC9419498 DOI: 10.1210/jendso/bvac119] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Context
In most patients presenting with hypoglycemia in emergency departments, the etiology of hypoglycemia is identified. However, it cannot be determined in approximately 10% of cases.
Objective
We aimed to identify the causes of unknown hypoglycemia, especially adrenal insufficiency.
Methods
In this cross-sectional study, we evaluated the etiology of hypoglycemia among patients in our emergency department with hypoglycemia (plasma glucose level <70 mg/dL [3.9 mmol/L]) between April 1, 2016, and March 31, 2021, using a rapid adrenocorticotropic hormone (ACTH) test.
Results
There were 528 cases with hypoglycemia included (52.1% male; median age 62 years [range 19 to 92]). The majority (389 [73.7%]) of patients were using anti-diabetes drugs. Additionally, 33 (6.3%) consumed alcohol, 17 (3.2%) suffered from malnutrition, 13 (2.5%) liver dysfunction, 12 (2.3%) severe infectious disease, 11 (2.1%) malignancy, 9 (1.7%) heart failure, 4 (0.8%) insulin autoimmune syndrome, 3 (0.6%) insulinoma, 2 (0.4%) were using hypoglycemia-relevant drugs, and 1 (0.2%) suffered from non-islet cell tumor. Rapid ACTH tests revealed adrenal insufficiency in 32 (6.1%). In those patients, serum sodium levels were lower (132 vs. 139 mEq/L, P<0.01), eosinophil counts were higher (14 vs. 8%, P<0.01), and systolic blood pressure was lower (120 vs. 128 mmHg, P<0.05) at baseline than in patients with the other etiologies, respectively.
Conclusion
The frequency of adrenal insufficiency as a cause of hypoglycemia was much higher than what we anticipated. When protracted hypoglycemia of unknown etiology is recognized, we recommend that the patient is checked for adrenal function using a rapid ACTH test.
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Affiliation(s)
- Tetsuya Kawahara
- Department of Endocrinology and Diabetes, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
| | - Maiko Tsuji
- Department of Emergency Medicine, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
| | - Naoki Tominaga
- Department of Emergency Medicine, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
| | - Nagahiro Toyama
- Department of Emergency Medicine, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
| | - Mikio Toda
- Department of Internal Medicine, Shinkomonji Hospital , 8000057 Kitakyushu, Japan
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Hripcsak G, Albers DJ. Evaluating Prediction of Continuous Clinical Values: A Glucose Case Study. Methods Inf Med 2022; 61:e35-e44. [PMID: 35196735 PMCID: PMC9246512 DOI: 10.1055/s-0042-1743170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 12/28/2021] [Indexed: 10/26/2022]
Abstract
BACKGROUND It would be useful to be able to assess the utility of predictive models of continuous values before clinical trials are performed. OBJECTIVE The aim of the study is to compare metrics to assess the potential clinical utility of models that produce continuous value forecasts. METHODS We ran a set of data assimilation forecast algorithms on time series of glucose measurements from neurological intensive care unit patients. We evaluated the forecasts using four sets of metrics: glucose root mean square (RMS) error, a set of metrics on a transformed glucose value, the estimated effect on clinical care based on an insulin guideline, and a glucose measurement error grid (Parkes grid). We assessed correlation among the metrics and created a set of factor models. RESULTS The metrics generally correlated with each other, but those that estimated the effect on clinical care correlated with others the least and were generally associated with their own independent factors. The other metrics appeared to separate into those that emphasized errors in low glucose versus errors in high glucose. The Parkes grid was well correlated with the transformed glucose but not the estimation of clinical care. DISCUSSION Our results indicate that we need to be careful before we assume that commonly used metrics like RMS error in raw glucose or even metrics like the Parkes grid that are designed to measure importance of differences will correlate well with actual effect on clinical care processes. A combination of metrics appeared to explain the most variance between cases. As prediction algorithms move into practice, it will be important to measure actual effects.
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Affiliation(s)
- George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, New York, United States
- Medical Informatics Services, NewYork-Presbyterian Hospital, New York, New York, United States
| | - David J. Albers
- Department of Biomedical Informatics, Columbia University, New York, New York, United States
- Department of Pediatrics, University of Colorado Denver—Anschutz Medical Campus, Denver, Colorado, United States
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Bouyaknouden D, Peddada TN, Ravishankar N, Fatima S, Fong-Isariyawongse J, Gilmore EJ, Lee JW, Struck AF, Gaspard N. Neurological Prognostication After Hypoglycemic Coma: Role of Clinical and EEG Findings. Neurocrit Care 2022; 37:273-280. [PMID: 35437670 DOI: 10.1007/s12028-022-01495-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Hypoglycemic coma (HC) is an uncommon but severe clinical condition associated with poor neurological outcome. There is a dearth of robust neurological prognostic factors after HC. On the other hand, there is an increasing body of literature on reliable prognostic markers in the postanoxic coma, a similar-albeit not identical-situation. The objective of this study was thus to investigate the use and predictive value of these markers in HC. METHODS We conducted a retrospective, multicenter, cohort study within five centers of the Critical Care EEG Monitoring Research Consortium. We queried our electroencephalography (EEG) databases to identify all patients undergoing continuous EEG monitoring after admission to an intensive care unit with HC (defined as Glasgow Coma Scale < 8 on admission and a first blood glucose level < 50 mg/dL or not documented but in an obvious clinical context) between 01/01/2010 and 12/31/2020. We studied the association of findings at neurological examination (Glasgow Coma Scale motor subscale, pupillary light and corneal reflexes) and at continuous EEG monitoring(highly malignant patterns, reactivity, periodic discharges, seizures) with best neurological outcome within 3 months after hospital discharge, defined by the Cerebral Performance Category as favorable (1-3: recovery of consciousness) versus unfavorable (4-5: lack of recovery of consciousness). RESULTS We identified 60 patients (30 [50%] women; age 62 [51-72] years). Thirty-one and 29 patients had a favorable and unfavorable outcome, respectively. The presence of pupillary reflexes (24 [100%] vs. 17 [81%]; p value 0.04) and a motor subscore > 2 (22 [92%] vs. 12 [63%]; p value 0.03) at 48-72 h were associated with a favorable outcome. A highly malignant EEG pattern was observed in 7 of 29 (24%) patients with unfavorable outcome versus 0 of 31 (0%) with favorable outcome, whereas the presence of EEG reactivity was observed in 28 of 31 (90%) patients with favorable outcome versus 13 of 29 (45%) with unfavorable outcome (p < 0.001 for comparison of all background categories). CONCLUSIONS This preliminary study suggests that highly malignant EEG patterns might be reliable prognostic markers of unfavorable outcome after HC. Other EEG findings, including lack of EEG reactivity and seizures and clinical findings appear less accurate. These findings should be replicated in a larger multicenter prospective study.
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Affiliation(s)
- Douaae Bouyaknouden
- Department of Neurology, Hôpital Erasme - Cliniques Universitaires de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Teja N Peddada
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Safoora Fatima
- Department of Neurology, University of Wisconsin, Madison, WI, USA
| | | | - Emily J Gilmore
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Aaron F Struck
- Department of Neurology, University of Wisconsin, Madison, WI, USA.,William S. Middleton Veterans Hospital, Madison, WI, USA
| | - Nicolas Gaspard
- Department of Neurology, Hôpital Erasme - Cliniques Universitaires de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium. .,Department of Neurology, Yale University, New Haven, CT, USA.
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Sharma M, Menon B, Manam G. Hypoglycemic hemiparesis as stroke mimic with transient splenial lesion and internal capsule involvement: A reversible clinico-radiological concurrence. J Postgrad Med 2022; 68:109-111. [PMID: 35466663 PMCID: PMC9196292 DOI: 10.4103/jpgm.jpgm_817_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Hypoglycemia presents with a spectrum of neurological manifestations ranging from lightheadedness to confusion and coma. We report here the case of a 61-year-old woman with right hemiparesis presenting within the window period for stroke thrombolysis. MRI brain showed diffusion restriction in posterior limb of left internal capsule and splenium. Patient had documented hypoglycemia of 38 mg/dL. Patient's hemiparesis resolved after glucose correction, and radiological findings completely resolved after 10 days. We present this case to highlight the rare radiological finding of simultaneous internal capsule and splenium involvement in hypoglycemic hemiparesis and the importance to rule out stroke mimics to avoid unwanted thrombolysis.
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11
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Thirumalai M, Zengul AG, Evans E. Challenges and Lessons Learned From a Telehealth Community Paramedicine Program for the Prevention of Hypoglycemia: Pre-Post Pilot Feasibility Study. JMIR Diabetes 2021; 6:e26941. [PMID: 34342593 PMCID: PMC8371490 DOI: 10.2196/26941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 03/26/2021] [Accepted: 06/17/2021] [Indexed: 12/03/2022] Open
Abstract
Background Prevention through Intervention is a community paramedicine program developed by Birmingham Fire and Rescue Services in Alabama. This program aims to reduce dependency on emergency medical services (EMS) for nonemergency-related events through education and to lower the frequency of emergency calls in underserved populations. A telehealth intervention with an emphasis on hypoglycemia was implemented to (1) tailor the intervention to meet the educational needs of participants and (2) facilitate follow-ups. A pre-post pilot feasibility evaluation of the telehealth intervention was conducted. Objective This paper describes the results of the feasibility evaluation, implementation challenges, and the lessons learned about the deployment of a hypoglycemia prevention program in an underserved area and its evaluation. Methods This single-arm pretest-posttest intervention included (1) an initial in-person visit (week 1), (2) 3 weekly telecoaching calls (weeks 2-4), (3) 1 biweekly call (week 6), and (4) a final in-person visit (week 8) for collecting posttest data from individuals who called EMS due to hypoglycemic events. In-person visits included educational sessions conducted by EMS personnel. Participants’ education included tailored content related to hypoglycemia. Weekly telecoaching calls focused on hypoglycemia symptom monitoring and education reinforcement via a telehealth dashboard. The primary measures focused on feasibility measures, and exploratory measures focused on the fear of hypoglycemia, self-efficacy, and a knowledge of diabetes. Results A total of 40 participants participated in the intervention. However, the study was marred with high attrition. The various factors behind the low retention rate were discussed. There was a decreasing trend in all three subdomains of the fear of hypoglycemia from pretest to posttest. There was also a significant increase in participants’ self-efficacy in hypoglycemia self-management (P=.03). Conclusions This study shows preliminary and promising results for a community-based intervention specifically for hypoglycemia. However, the socioeconomic setting in which the intervention was delivered may have resulted in high dropout rates and low attendance during the intervention, which are considerations for future telehealth studies. Trial Registration ClinicalTrials.gov NCT03665870; https://clinicaltrials.gov/ct2/show/NCT03665870
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Affiliation(s)
- Mohanraj Thirumalai
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ayse G Zengul
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Eric Evans
- Department of Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, United States
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12
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The diagnostic value of the neurological examination in coma of unknown etiology. J Neurol 2021; 268:3826-3834. [PMID: 33796895 PMCID: PMC8463407 DOI: 10.1007/s00415-021-10527-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 11/20/2022]
Abstract
Background Identifying the cause of non-traumatic coma in the emergency department is challenging. The clinical neurological examination is the most readily available tool to detect focal neurological deficits as indicators for cerebral causes of coma. Previously proposed clinical pathways have granted the interpretation of clinical findings a pivotal role in the diagnostic work-up. We aimed to identify the actual diagnostic reliability of the neurological examination with regard to identifying acute brain damage.
Methods Eight hundred and fifty-three patients with coma of unknown etiology (CUE) were examined neurologically in the emergency department following a predefined routine. Coma-explaining pathologies were identified retrospectively and grouped into primary brain pathology with proof of acute brain damage and other causes without proof of acute structural pathology. Sensitivity, specificity and percentage of correct predictions of different examination protocols were calculated using contingency tables and binary logistic regression models. Results The full neurological examination was 74% sensitive and 60% specific to detect acute structural brain damage underlying CUE. Sensitivity and specificity were higher in non-sedated patients (87/61%) compared to sedated patients (64%/59%). A shortened four-item examination protocol focusing on pupils, gaze and pyramidal tract signs was only slightly less sensitive (67%) and more specific (65%).
Conclusions Due to limited diagnostic reliability of the physical examination, the absence of focal neurological signs in acutely comatose patients should not defer from a complete work-up including brain imaging. In an emergency, a concise neurological examination should thus serve as one part of a multimodal diagnostic approach to CUE.
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Xu H, Zhang Y, Xu W, Chen L, Zhang M, Su H, Cheng Y, Zhao N, Xu D, Qin G. Associations of visit-to-visit fasting glucose with risk of mortality: A retrospective cohort study of 48,077 people with type 2 diabetes. DIABETES & METABOLISM 2021; 47:101161. [DOI: 10.1016/j.diabet.2020.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 04/02/2020] [Accepted: 05/06/2020] [Indexed: 12/12/2022]
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de Melo IS, Pacheco ALD, Dos Santos YMO, Figueiredo LM, Nicacio DCSP, Cardoso-Sousa L, Duzzioni M, Gitaí DLG, Tilelli CQ, Sabino-Silva R, de Castro OW. Modulation of Glucose Availability and Effects of Hypo- and Hyperglycemia on Status Epilepticus: What We Do Not Know Yet? Mol Neurobiol 2020; 58:505-519. [PMID: 32975651 DOI: 10.1007/s12035-020-02133-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/14/2020] [Indexed: 12/22/2022]
Abstract
Status epilepticus (SE) can lead to serious neuronal damage and act as an initial trigger for epileptogenic processes that may lead to temporal lobe epilepsy (TLE). Besides promoting neurodegeneration, neuroinflammation, and abnormal neurogenesis, SE can generate an extensive hypometabolism in several brain areas and, consequently, reduce intracellular energy supply, such as adenosine triphosphate (ATP) molecules. Although some antiepileptic drugs show efficiency to terminate or reduce epileptic seizures, approximately 30% of TLE patients are refractory to regular antiepileptic drugs (AEDs). Modulation of glucose availability may provide a novel and robust alternative for treating seizures and neuronal damage that occurs during epileptogenesis; however, more detailed information remains unknown, especially under hypo- and hyperglycemic conditions. Here, we review several pathways of glucose metabolism activated during and after SE, as well as the effects of hypo- and hyperglycemia in the generation of self-sustained limbic seizures. Furthermore, this study suggests the control of glucose availability as a potential therapeutic tool for SE.
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Affiliation(s)
- Igor Santana de Melo
- Department of Physiology, Institute of Biological Sciences and Health, Federal University of Alagoas (UFAL), Av. Lourival de Melo Mota, km 14, Campus A. C. Simões, Cidade Universitária, Maceió, AL, CEP 57072-970, Brazil
| | - Amanda Larissa Dias Pacheco
- Department of Physiology, Institute of Biological Sciences and Health, Federal University of Alagoas (UFAL), Av. Lourival de Melo Mota, km 14, Campus A. C. Simões, Cidade Universitária, Maceió, AL, CEP 57072-970, Brazil
| | - Yngrid Mickaelli Oliveira Dos Santos
- Department of Physiology, Institute of Biological Sciences and Health, Federal University of Alagoas (UFAL), Av. Lourival de Melo Mota, km 14, Campus A. C. Simões, Cidade Universitária, Maceió, AL, CEP 57072-970, Brazil
| | - Laura Mello Figueiredo
- Department of Physiology, Institute of Biological Sciences and Health, Federal University of Alagoas (UFAL), Av. Lourival de Melo Mota, km 14, Campus A. C. Simões, Cidade Universitária, Maceió, AL, CEP 57072-970, Brazil
| | - Dannyele Cynthia Santos Pimentel Nicacio
- Department of Physiology, Institute of Biological Sciences and Health, Federal University of Alagoas (UFAL), Av. Lourival de Melo Mota, km 14, Campus A. C. Simões, Cidade Universitária, Maceió, AL, CEP 57072-970, Brazil
| | - Leia Cardoso-Sousa
- Department of Physiology, Institute of Biomedical Sciences, Federal University of Uberlandia (UFU), ARFIS, Av. Pará, 1720, Campus Umuruama, Uberlandia, MG, CEP 38400-902, Brazil
| | - Marcelo Duzzioni
- Department of Physiology, Institute of Biological Sciences and Health, Federal University of Alagoas (UFAL), Av. Lourival de Melo Mota, km 14, Campus A. C. Simões, Cidade Universitária, Maceió, AL, CEP 57072-970, Brazil
| | - Daniel Leite Góes Gitaí
- Department of Physiology, Institute of Biological Sciences and Health, Federal University of Alagoas (UFAL), Av. Lourival de Melo Mota, km 14, Campus A. C. Simões, Cidade Universitária, Maceió, AL, CEP 57072-970, Brazil
| | - Cristiane Queixa Tilelli
- Physiology Laboratory, Federal University of Sao Joao del Rei (UFSJ), Central-West Campus, Divinopolis, MG, Brazil
| | - Robinson Sabino-Silva
- Department of Physiology, Institute of Biomedical Sciences, Federal University of Uberlandia (UFU), ARFIS, Av. Pará, 1720, Campus Umuruama, Uberlandia, MG, CEP 38400-902, Brazil.
| | - Olagide Wagner de Castro
- Department of Physiology, Institute of Biological Sciences and Health, Federal University of Alagoas (UFAL), Av. Lourival de Melo Mota, km 14, Campus A. C. Simões, Cidade Universitária, Maceió, AL, CEP 57072-970, Brazil.
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Burman RJ, Raimondo JV, Jefferys JG, Sen A, Akerman CJ. The transition to status epilepticus: how the brain meets the demands of perpetual seizure activity. Seizure 2020; 75:137-144. [DOI: 10.1016/j.seizure.2019.09.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 09/23/2019] [Indexed: 02/08/2023] Open
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Uremic encephalopathy in patients undergoing assisted peritoneal dialysis: a case series and literature review. CEN Case Rep 2019; 8:271-279. [PMID: 31177383 DOI: 10.1007/s13730-019-00406-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 05/30/2019] [Indexed: 10/26/2022] Open
Abstract
We sometimes hesitate to switch renal replacement therapy from peritoneal dialysis (PD) particularly in elderly patients due to their physical tolerance levels and lifestyles. Here, we describe the cases of three patients treated with PD alone despite an anuric status who subsequently developed uremic encephalopathy, which was successfully treated with hemodialysis (HD). The first patient was a 75-year-old woman who developed uremic encephalopathy with an anuric status and inadequate PD after 7 months of treatment. HD immediately improved her condition; encephalopathy did not recur with combined therapy of PD and HD. The second patient was a 69-year-old woman who developed anuria and was treated with combined therapy. Her arteriovenous fistula was obstructed; therefore, she was treated with PD alone. Total weekly Kt/V was sufficiently high at 1.95; however, she developed uremic encephalopathy the following month, which was successfully treated with HD. The third patient was an 84-year-old woman who developed anuria, but was treated with PD alone with adequate total weekly Kt/V of 2.2. PD could not be performed for 2 days because of myocardial infarction intervention; subsequently, she developed uremic encephalopathy, which was successfully treated with HD. These cases are the first of their kinds, wherein patients undergoing PD, developed uremic encephalopathy without any obvious triggers, including drugs, and illustrate the necessity of initiating combined therapy for such patients considering the risk of developing severe uremia leading to uremic encephalopathy, in spite of it being less preferable for elderly patients due to their physical conditions and lifestyles.
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Jannin A, Espiard S, Benomar K, Do Cao C, Mycinski B, Porte H, D’Herbomez M, Penel N, Vantyghem MC. Non-islet-cell tumour hypoglycaemia (NICTH): About a series of 6 cases. ANNALES D'ENDOCRINOLOGIE 2019; 80:21-25. [DOI: 10.1016/j.ando.2018.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 11/21/2017] [Accepted: 01/04/2018] [Indexed: 12/30/2022]
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Hextrum S, Biller J. Clinical Distinction of Cerebral Ischemia and Triaging of Patients in the Emergency Department. Neuroimaging Clin N Am 2018; 28:537-549. [DOI: 10.1016/j.nic.2018.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Wareing W, Ho B, Ewins D, Chatterjee K. Reactive hypoglycaemia: a rarely considered ‘stroke mimic’ in non-diabetic individuals. BMJ Case Rep 2018; 2018:bcr-2017-223955. [DOI: 10.1136/bcr-2017-223955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Gosho M. Risk of Hypoglycemia After Concomitant Use of Antidiabetic, Antihypertensive, and Antihyperlipidemic Medications: A Database Study. J Clin Pharmacol 2018; 58:1324-1331. [DOI: 10.1002/jcph.1147] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 04/02/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Masahiko Gosho
- Department of Biostatistics; Faculty of Medicine; University of Tsukuba; Tsukuba Ibaraki Japan
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Okano Y, Ishimatsu K, Kato Y, Yamaga J, Kuwahara K, Okumoto K, Wada K. Clinical features of stroke mimics in the emergency department. Acute Med Surg 2018; 5:241-248. [PMID: 29988676 PMCID: PMC6028791 DOI: 10.1002/ams2.338] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/22/2018] [Indexed: 11/23/2022] Open
Abstract
Aim To clarify the features of stroke mimics. Methods We retrospectively investigated stroke mimic cases among the suspected stroke cases examined at our emergency department, over the past 9 years, during the tissue‐type plasminogen activator treatment time window. Results Of 1,557 suspected acute stroke cases examined at the emergency department, 137 (8.8%) were stroke mimics. The most common causes were symptomatic epilepsy (28 cases, 20.4%), neuropathy‐like symptoms (21 cases, 15.3%), and hypoglycemia (15 cases, 10.9%). Outcomes were survival to hospital discharge for 91.2% and death for 8.8% of the cases. Clinical results were significantly different between stroke mimics and the stroke group for low systolic blood pressure, low National Institutes of Health Stroke Scale score on initial treatment, history of diabetes, and no history of arrhythmia. On multivariate analysis, distinguishing factors for stroke mimics include systolic blood pressure ≤ 140 mmHg, National Institutes of Health Stroke Scale score ≤ 5 points, history of diabetes, and no history of arrhythmia. Conclusions Frequency of stroke mimics in cases of acute stroke suspected cases is 8.8%, and the most common cause is epilepsy. In order to distinguish stroke mimics, it is useful to understand common diseases presenting as stroke mimics and evaluate clinical features different from stroke by medical interview or nerve examination.
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Affiliation(s)
- Yuichi Okano
- Department of Emergency Medicine Kumamoto Red Cross Hospital Kumamoto Japan
| | - Kazuaki Ishimatsu
- Department of Emergency Medicine Kumamoto Red Cross Hospital Kumamoto Japan
| | - Yoichi Kato
- Department of Emergency Medicine Kumamoto Red Cross Hospital Kumamoto Japan
| | - Junichi Yamaga
- Department of Emergency Medicine Kumamoto Red Cross Hospital Kumamoto Japan
| | - Ken Kuwahara
- Department of Emergency Medicine Kumamoto Red Cross Hospital Kumamoto Japan
| | - Katsuki Okumoto
- Department of Emergency Medicine Kumamoto Red Cross Hospital Kumamoto Japan
| | - Kuniyasu Wada
- Department of Emergency Medicine Kumamoto Red Cross Hospital Kumamoto Japan
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Vilela P. Acute stroke differential diagnosis: Stroke mimics. Eur J Radiol 2017; 96:133-144. [DOI: 10.1016/j.ejrad.2017.05.008] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 05/04/2017] [Indexed: 01/09/2023]
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Sako A, Yasunaga H, Matsui H, Fushimi K, Hamasaki H, Katsuyama H, Tsujimoto T, Goto A, Yanai H. Hospitalization with hypoglycemia in patients without diabetes mellitus: A retrospective study using a national inpatient database in Japan, 2008-2012. Medicine (Baltimore) 2017; 96:e7271. [PMID: 28640135 PMCID: PMC5484243 DOI: 10.1097/md.0000000000007271] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
We aimed to examine prevalence, patient characteristics, etiology, and clinical outcomes of hospitalized patients who had hypoglycemia without a diagnosis of diabetes mellitus, using a Japanese nationwide database.This was a retrospective observational study using a national database of acute-care inpatients in Japan. Nondiabetic patients aged ≥15 years who were hospitalized for hypoglycemia were eligible. We estimated the annual numbers of hospitalized cases in Japan. We also investigated the patient characteristics, and risk factors of in-hospital mortality.We identified 8684 eligible patients out of 22.7 million discharge records between July 2008 and March 2013. The average age was 70.0 years and the average body mass index (BMI) was 19.9 kg/m. Most frequently recorded underlying diseases were malignancies, cerebrovascular diseases, pneumonia, renal failure, and heart failure. The estimated annual numbers of hospitalizations because of hypoglycemia in nondiabetic patients were 5000 to 7000. In-hospital mortality was 14.9%, and predictive factors for poor survival included older age, community hospital, low BMI, coma at admission, urgent admission, renal failure, heart failure, pneumonia, sepsis, chronic liver diseases, and malignancies.Patients without diabetes mellitus but with hypoglycemia had multiple comorbidities and high in-hospital mortality. Clinicians should carefully investigate the etiology of hypoglycemia in nondiabetic patients, and treat the underlying diseases.
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Affiliation(s)
- Akahito Sako
- Department of Internal Medicine, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo
| | - Kiyohide Fushimi
- Department of Health Informatics and Policy, Tokyo Medical and Dental University Graduate School of Medicine
| | - Hidetaka Hamasaki
- Department of Internal Medicine, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba
| | - Hisayuki Katsuyama
- Department of Internal Medicine, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba
| | - Tetsuro Tsujimoto
- Department of Diabetes, Endocrinology, and Metabolism, Center Hospital, National Center for Global Health and Medicine
| | - Atsushi Goto
- Metabolic Epidemiology Section, Epidemiology and Prevention Group, Center for Public Health Sciences, National Cancer Center, Tokyo, Japan
| | - Hidekatsu Yanai
- Department of Internal Medicine, Kohnodai Hospital, National Center for Global Health and Medicine, Chiba
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Zarnowska I, Luszczki JJ, Zarnowski T, Wlaz P, Czuczwar SJ, Gasior M. Proconvulsant effects of the ketogenic diet in electroshock-induced seizures in mice. Metab Brain Dis 2017; 32:351-358. [PMID: 27644408 PMCID: PMC5346421 DOI: 10.1007/s11011-016-9900-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 08/19/2016] [Indexed: 11/03/2022]
Abstract
Among non-pharmacological treatments, the ketogenic diet (KD) has the strongest demonstrated evidence of clinical success in drug resistant epilepsy. In an attempt to model the anticonvulsant effects of the KD pre-clinically, the present study assessed the effects of the KD against electroshock-induced convulsions in mice. After confirming that exposure to the KD for 2 weeks resulted in stable ketosis and hypoglycemia, mice were exposed to electroshocks of various intensities to establish general seizure susceptibility. When compared to mice fed the standard rodent chow diet (SRCD), we found that mice fed the KD were more sensitive to electroconvulsions as reflected by a significant decrease in seizure threshold (3.86 mA in mice on the KD vs 7.29 mA in mice on the SRCD; P < 0.05) in the maximal electroshock seizure threshold (MEST) test. To examine if this increased seizure sensitivity to electroconvulsions produced by the KD would affect anticonvulsant effects of antiepileptic drugs (AEDs), anticonvulsant potencies of carbamazepine (CBZ), phenobarbital (PB), phenytoin (PHT), and valproate (VPA) against maximal electroshock (MES)-induced convulsions were compared in mice fed the KD and SRCD. We found that potencies of all AEDs studied were decreased in mice fed the KD in comparison to those on the SRCD, with decreases in the anticonvulsant potencies ranging from 1.4 fold (PB) to 1.7 fold (PHT). Finally, the lack of differences in brain exposures of the AEDs studied in mice fed the KD and SRCD ruled out a pharmacokinetic nature of the observed findings. Taken together, exposure to the KD in the present study had an overall pro-convulsant effect. Since electroconvulsions require large metabolic reserves to support their rapid spread throughout the brain and consequent generalized tonic-clonic convulsions, this effect may be explained by a high energy state produced by the KD in regards to increased energy storage and utilization.
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Affiliation(s)
- Iwona Zarnowska
- Department of Pathophysiology, Medical University, Jaczewskiego 8, 20-090, Lublin, Poland.
| | - Jarogniew J Luszczki
- Department of Pathophysiology, Medical University, Jaczewskiego 8, 20-090, Lublin, Poland
- Department of Physiopathology, Institute of Agricultural Medicine, Jaczewskiego 2, 20-950, Lublin, Poland
| | - Tomasz Zarnowski
- Chair of Ophthalmology, Medical University, Chmielna 1, 20-079, Lublin, Poland
| | - Piotr Wlaz
- Department of Animal Physiology, Institute of Biology and Biochemisry, Faculty of Biology and Biotechnology, Maria Curie-Skłodowska University, Akademicka 19, 20-033, Lublin, Poland
| | - Stanislaw J Czuczwar
- Department of Pathophysiology, Medical University, Jaczewskiego 8, 20-090, Lublin, Poland
- Department of Physiopathology, Institute of Agricultural Medicine, Jaczewskiego 2, 20-950, Lublin, Poland
| | - Maciej Gasior
- Department of Pharmacology and Physiology, Drexel University College of Medicine, Philadelphia, PA, USA.
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Jensen T, Sørensen MA, Nielsen EW. Alpine cross-country skier with energy depletion and reduced consciousness. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2017; 137:289-291. [PMID: 28225237 DOI: 10.4045/tidsskr.16.0267] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
| | | | - Erik Waage Nielsen
- Akuttmedisinsk avdeling Nordlandssykehuset Bodø og Institutt for klinisk medisin Universitetet i Tromsø og Profesjonshøgskolen Nord universitet, Bodø og Institutt for klinisk medisin Universitetet i Oslo
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Jeon JY, Kim SR, Kim HJ, Kim DJ, Lee KW, Lee JD, Han SJ. Risk factors of severe hypoglycemia requiring medical assistance and neurological sequelae in patients with diabetes: A case-control study. Medicine (Baltimore) 2016; 95:e5365. [PMID: 27893672 PMCID: PMC5134865 DOI: 10.1097/md.0000000000005365] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Hypoglycemia commonly occurs in patients who are being treated for diabetes. In some cases, these patients suffer from severe hypoglycemia that requires medical assistance and which can unfortunately result in long-term disabilities. Therefore, we investigated risk factors associated with severe hypoglycemia requiring medical assistance (HMA) and the resulting neurological sequelae in patients with diabetes. This investigation was a case-control study that assessed 129 patients with diabetes and documented hypoglycemia from a single tertiary hospital between February 2013 and May 2015. They were treated with oral hypoglycemic agents alone (54%) or with insulin with/without oral hypoglycemic agents (46%). If a patient with diabetes visited the emergency department due to hypoglycemia, this was defined as HMA. The control group was composed of patients with documented, nonsevere hypoglycemia who visited the outpatient clinic during the same period. The degree of neurological disability in the HMA patients was measured using the modified Rankin Scale. A multivariate analysis revealed that independent risk factors of HMA were associated with a lack of the self-monitoring of blood glucose (SMBG) and previous episodes of severe hypoglycemia. In the HMA group, 15 patients (22%) had neurological sequelae at the time of discharge. Patients with neurological sequelae were older than those without sequelae (74.3 years vs 65.8 years, P = 0.006) and had increased psychological evidence of disorders such as insomnia, dementia, and depression (40% vs 11%, P = 0.017). Patients with sequelae were also more likely to live in rural areas (47% vs 19%, P = 0.04) and to have a longer time from last seen normal till glucose administration (5.2 hours vs 1.6 hours, P = 0.027). In the present study, absence of SMBG and previous severe hypoglycemic episodes were independent risk factors of HMA and patients with an older age, a psychological disorder, a rural residence, and a prolonged duration of hypoglycemia had higher risks of neurological sequelae. Therefore, the present findings suggest that physicians should aim to prevent hypoglycemia in patients with a history of hypoglycemia and provide education for these patients regarding regular SMBG.
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Affiliation(s)
| | | | | | | | | | - Jung-Dong Lee
- Office of Biostatistics, Ajou University School of Medicine, Suwon, Republic of Korea
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Fisman EZ, Motro M, Tenenbaum A, Leor J, Boyko V, Mandelzweig L, Sherer Y, Adler Y, Behar S. Is hypoglycaemia a marker for increased long-term mortality risk in patients with coronary artery disease? An 8-year follow-up. ACTA ACUST UNITED AC 2016; 11:135-43. [PMID: 15187817 DOI: 10.1097/01.hjr.0000124326.85096.ec] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND No information is available regarding the association between low plasma glucose levels and cause-specific and all-cause mortality in patients with coronary artery disease (CAD). We aimed to investigate the relationship between hypoglycaemia and all-cause, cardiovascular and cancer mortality in a large population of patients with CAD. DESIGN Patients were recruited from the BIP (Bezafibrate Infarction Prevention) registry, a secondary prevention prospective multicentre randomized, placebo-controlled, double-blind trial aimed to assess the efficacy of bezafibrate in reduction of coronary events. METHODS The study included 14,670 CAD patients aged 45-74, divided into six groups: (1) hypoglycaemic (up to 69 mg/dl); (2) low normal (70-79 mg/dl); (3) euglycaemic (80-109 mg/dl); (4) impaired fasting glucose (IFG) (110-125 mg/dl); (5) borderline diabetics (126-139 mg/dl); (6) diabetics (> or 140 mg/dl). RESULTS Patients comprised 131 with hypoglycaemia (0.9%), 731 with low normal glucose (5%), 9308 euglycaemic (63.4%), 1577 with IFG (10.7%), 617 borderline diabetics (4.2%) and 2306 diabetics (15.7%). Over a mean 8-year follow-up, crude all-cause mortality was higher in both diabetic (31.8%) and hypoglycaemic groups (25.2%) as compared with euglycaemics (14.9%; P<0.0001); CAD mortality was higher in diabetic and borderline groups (17.8 and 13.3%, respectively, versus 7.9% in euglycaemics; P<0.0001). The highest prevalence of cancer mortality was documented in the hypoglycaemic group (6.1 versus 2.9% in euglycaemics; P<0.02). Actuarial survival curves showed the lowest mortality in euglycaemic and low normal groups; the highest was seen in diabetic and hypoglycaemic patients. Intermediate values were found in borderline and IFG patients. After adjustment for variables, a significantly higher mortality rate was seen in hypoglycaemics when compared with euglycaemics (P<0.0001). Hypoglycaemia was identified as a predictor of increased all-cause and cancer mortality with a hazard ratio (HR) of 1.84 [95% confidence interval (CI) 1.29-2.61] and 2.26 (95% CI 1.12-4.57), respectively, but not of increased CAD mortality, with HR 1.30 (95% CI 0.73-2.29). CONCLUSIONS Over a mean 8-year follow-up, hypoglycaemia emerges as a marker for substantially increased all-cause and cancer mortality among patients with CAD presenting with low fasting glucose levels.
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Affiliation(s)
- Enrique Z Fisman
- Cardiac Rehabilitation Institute, Chaim Medical Center, Tel-Hashomer, and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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Hao L, Sheng Z, Potian J, Deak A, Rohowsky-Kochan C, Routh VH. Lipopolysaccharide (LPS) and tumor necrosis factor alpha (TNFα) blunt the response of Neuropeptide Y/Agouti-related peptide (NPY/AgRP) glucose inhibited (GI) neurons to decreased glucose. Brain Res 2016; 1648:181-192. [PMID: 27473896 DOI: 10.1016/j.brainres.2016.07.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 07/18/2016] [Accepted: 07/19/2016] [Indexed: 02/07/2023]
Abstract
A population of Neuropeptide Y (NPY) neurons which co-express Agouti-related peptide (AgRP) in the arcuate nucleus of the hypothalamus (ARC) are inhibited at physiological levels of brain glucose and activated when glucose levels decline (e.g. glucose-inhibited or GI neurons). Fasting enhances the activation of NPY/AgRP-GI neurons by low glucose. In the present study we tested the hypothesis that lipopolysaccharide (LPS) inhibits the enhanced activation of NPY/AgRP-GI neurons by low glucose following a fast. Mice which express green fluorescent protein (GFP) on their NPY promoter were used to identify NPY/AgRP neurons. Fasting for 24h and LPS injection decreased blood glucose levels. As we have found previously, fasting increased c-fos expression in NPY/AgRP neurons and increased the activation of NPY/AgRP-GI neurons by decreased glucose. As we predicted, LPS blunted these effects of fasting at the 24h time point. Moreover, the inflammatory cytokine tumor necrosis factor alpha (TNFα) blocked the activation of NPY/AgRP-GI neurons by decreased glucose. These data suggest that LPS and TNFα may alter glucose and energy homeostasis, in part, due to changes in the glucose sensitivity of NPY/AgRP neurons. Interestingly, our findings also suggest that NPY/AgRP-GI neurons use a distinct mechanism to sense changes in extracellular glucose as compared to our previous studies of GI neurons in the adjacent ventromedial hypothalamic nucleus.
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Affiliation(s)
- Lihong Hao
- Department of Pharmacology, Physiology & Neuroscience, New Jersey Medical School, Rutgers University, Newark, NJ, USA; Graduate School of the Biomedical Sciences, New Jersey Medical School, Rutgers University, Newark, NJ, USA
| | - Zhenyu Sheng
- Department of Pharmacology, Physiology & Neuroscience, New Jersey Medical School, Rutgers University, Newark, NJ, USA
| | - Joseph Potian
- Department of Pharmacology, Physiology & Neuroscience, New Jersey Medical School, Rutgers University, Newark, NJ, USA
| | - Adam Deak
- Department of Pharmacology, Physiology & Neuroscience, New Jersey Medical School, Rutgers University, Newark, NJ, USA
| | - Christine Rohowsky-Kochan
- Department of Pharmacology, Physiology & Neuroscience, New Jersey Medical School, Rutgers University, Newark, NJ, USA
| | - Vanessa H Routh
- Department of Pharmacology, Physiology & Neuroscience, New Jersey Medical School, Rutgers University, Newark, NJ, USA.
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Abstract
Hypoglycemia is diagnosed convincingly when typical symptoms are associated with a low plasma glucose concentration and are relieved by glucose administration. It requires urgent treatment (usually with intravenous glucose in the hospital setting), diagnostic explanation, and long-term prevention. The latter is based upon an understanding of the pathogenesis of hypoglycemia in the affected patient. Postabsorptive (fasting) hypoglycemia is often caused by drugs (especially insulin, a sulfonylurea, or alcohol); it can also result from endogenous hyperinsulinism (insulinoma, autoimmune hypoglycemia), a non-β-cell tumor, hormonal deficiencies, or a variety of clinical syndromes including sepsis, cardiac, renal, and hepatic failure, and even inanition per se. Hypoglycemia is a treatable cause of acute morbidity. It is sometimes a cause of chronic morbidity and even mortality that could have been prevented.
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Affiliation(s)
- Stephen B. Liggett
- Metabolism and Pulmonary Divisions of the Department of Medicine, and the General Clinical Research Center and Diabetes Research and Training Center, Washington University School of Medicine, St. Louis, MO
| | - Philip E. Cryer
- Metabolism and Pulmonary Divisions of the Department of Medicine, and the General Clinical Research Center and Diabetes Research and Training Center, Washington University School of Medicine, St. Louis, MO
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Zuccarelli BD, Hall AS. Utility of Obtaining a Serum Basic Metabolic Panel in the Setting of a First-Time Nonfebrile Seizure. Clin Pediatr (Phila) 2016; 55:650-3. [PMID: 26810624 DOI: 10.1177/0009922815627422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
New-onset nonfebrile seizures in an otherwise healthy child are common, affecting 25 000 to 40 000 U.S. children annually. We hypothesized seizure-provoking electrolyte disturbances such as hyponatremia, hypoglycemia, and hypocalcemia are uncommon in these children. From January 1, 2009 to May 31, 2009, 358 children aged 29 days to 18 years with a diagnosis code of 780.39 ("other convulsions" including "first time seizure," etc) were included for potential retrospective review. Children with known epilepsy and febrile seizures were excluded. Electrolytes were obtained in nearly all children with a history suggestive of an underlying abnormality (13 of 14, 93%) but also in half of children with a reassuring history (62 of 119, 52%). No child with an unremarkable history and exam was found to have electrolyte abnormalities falling below levels most likely to be associated with acute symptomatic seizures. Electrolytes are unlikely to be abnormal in an otherwise well-appearing child after a first-time nonfebrile seizure.
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Newman-Toker DE, Edlow JA. TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo. Neurol Clin 2016; 33:577-99, viii. [PMID: 26231273 DOI: 10.1016/j.ncl.2015.04.011] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Diagnosing dizziness can be challenging, and the consequences of missing dangerous causes, such as stroke, can be substantial. Most physicians use a diagnostic paradigm developed more than 40 years ago that focuses on the type of dizziness, but this approach is flawed. This article proposes a new paradigm based on symptom timing, triggers, and targeted bedside eye examinations (TiTrATE). Patients fall into 1 of 4 major syndrome categories, each with its own differential diagnosis and set of targeted examination techniques that help make a specific diagnosis. Following an evidence-based approach could help reduce the frequency of misdiagnosis of serious causes of dizziness. In the spirit of the flipped classroom, the editors of this Neurologic Clinics issue on emergency neuro-otology have assembled a collection of unknown cases to be accessed electronically in multimedia format. By design, cases are not linked with specific articles, to avoid untoward cueing effects for the learner. The cases are real and are meant to demonstrate and reinforce lessons provided in this and subsequent articles. In addition to pertinent elements of medical history, cases include videos of key examination findings.
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Affiliation(s)
- David E Newman-Toker
- Johns Hopkins Hospital, CRB-II, Room 2M-03 North, 1550 Orleans Street, Baltimore, MD 21231, USA.
| | - Jonathan A Edlow
- Department of Emergency Medicine Administrative Offices, Beth Israel Deaconess Medical Center, West CC-2, 1 Deaconess Place, Boston, MA 02215, USA
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Chandrakumar A, Dilip C, Suriyaprakash TNK, Thomas L, Surendran R. Incidence and risk factors of hypoglycemia among Type 2 diabetic patients in a South Indian hospital. Diabetes Metab Syndr 2016; 10:S22-S25. [PMID: 26806327 DOI: 10.1016/j.dsx.2016.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 01/09/2016] [Indexed: 02/03/2023]
Abstract
AIM The study was aimed at assessing the cumulative incidence of hypoglycemia and precipitating risk factors among type 2 diabetes mellitus in-patients of a tertiary care hospital in South India. METHODS The prospective cross sectional study spanning 14 months was conducted in a tertiary care hospital in Kerala. All T2DM patients who were administered any form of insulin during the length of hospital stay was monitored for assessing the hypoglycemic episodes. Any patient with a GRBS value less than 70mg/dL was defined to be hypoglycemic as per the ADA guidelines. The statistical analysis of collected data was performed using SPSS 18 for windows version. RESULTS Of the 1650 subjects enrolled in the study, 204 subjects developed hypoglycemia. The sample composed of 60.8% females and 39.2% males and the difference was significant with p=0.02. A significant positive correlation was observed between HbA1c values and GRBS value, with a 2 tailed Pearson correlation coefficient of 0.027. On stratifying as per the modality of insulin dose prescribed, 72.5% of the hypoglycemic patients were found to have been administered fixed dose insulin. CONCLUSION The cumulative incidence of institutional hypoglycemia among type 2 diabetic inpatients was gauged as 12.36%; among which, 26.96% had asymptomatic episodes.
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Affiliation(s)
- Abin Chandrakumar
- Department of Pharmacy Practice, Al Shifa College of Pharmacy, Poonthavanam, Kizhattur P.O, Perinthalmanna, Kerala, 679325.
| | - C Dilip
- Department of Pharmacy Practice, Al Shifa College of Pharmacy, Poonthavanam, Kizhattur P.O, Perinthalmanna, Kerala, 679325
| | - T N K Suriyaprakash
- Department of Pharmaceutics, Al Shifa College of Pharmacy, Poonthavanam, Kizhattur P.O, Perinthalmanna, Kerala, 679325
| | - Levin Thomas
- Department of Pharmacy Practice, Al Shifa College of Pharmacy, Poonthavanam, Kizhattur P.O, Perinthalmanna, Kerala, 679325
| | - Reshma Surendran
- Department of Pharmacy Practice, Al Shifa College of Pharmacy, Poonthavanam, Kizhattur P.O, Perinthalmanna, Kerala, 679325
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Glober NK, Sporer KA, Guluma KZ, Serra JP, Barger JA, Brown JF, Gilbert GH, Koenig KL, Rudnick EM, Salvucci AA. Acute Stroke: Current Evidence-based Recommendations for Prehospital Care. West J Emerg Med 2016; 17:104-28. [PMID: 26973735 PMCID: PMC4786229 DOI: 10.5811/westjem.2015.12.28995] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/07/2015] [Accepted: 12/08/2015] [Indexed: 12/20/2022] Open
Abstract
Introduction In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with a suspected stroke and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California. Methods We performed a literature review of the current evidence in the prehospital treatment of a patient with a suspected stroke and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the stroke protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were the use of a stroke scale, blood glucose evaluation, use of supplemental oxygen, patient positioning, 12-lead electrocardiogram (ECG) and cardiac monitoring, fluid assessment and intravenous access, and stroke regionalization. Results Protocols across EMS agencies in California varied widely. Most used some sort of stroke scale with the majority using the Cincinnati Prehospital Stroke Scale (CPSS). All recommended the evaluation of blood glucose with the level for action ranging from 60 to 80mg/dL. Cardiac monitoring was recommended in 58% and 33% recommended an ECG. More than half required the direct transport to a primary stroke center and 88% recommended hospital notification. Conclusion Protocols for a patient with a suspected stroke vary widely across the state of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.
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Affiliation(s)
- Nancy K Glober
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - Karl A Sporer
- EMS Medical Directors Association of California, California; University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Kama Z Guluma
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - John P Serra
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - Joe A Barger
- EMS Medical Directors Association of California, California
| | - John F Brown
- EMS Medical Directors Association of California, California; University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Gregory H Gilbert
- EMS Medical Directors Association of California, California; Stanford University, Department of Emergency Medicine, Stanford, California
| | - Kristi L Koenig
- EMS Medical Directors Association of California, California; University of California Irvine, Center for Disaster Medical Sciences, Orange, California
| | - Eric M Rudnick
- EMS Medical Directors Association of California, California
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Katoh M, Yoshino M, Aoki T, Abumiya T, Imamura H, Aida T. Localized reversible high signal intensities on diffusion-weighted MRI in hypoglycemia: A study of 70 cases. Asian J Neurosurg 2016; 11:412-415. [PMID: 27695547 PMCID: PMC4974968 DOI: 10.4103/1793-5482.144196] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION It is well-known that localized reversible high signal intensities in the splenium of the corpus callosum or the basal ganglia appear on diffusion-weighted MRI in the presence of hypoglycemia. The aim of this study was to clarify the incidence and significance of such high signal intensity lesions. RESULTS We analyzed 70 cases of hypoglycemia with consciousness disturbance referred to our outpatient office. Localized reversible high signal intensities on diffusion-weighted MRI were noted in 6 cases (8.6%). They were at the splenium of the corpus callosum in four cases (5.7%), and right frontal cortex and bilateral frontal white matter in one each. Convulsions were noted in five cases, and right hemiparesis was noted in three. None of the three cases of hemiparesis showed localized reversible high signal intensities on diffusion-weighted MRI. These lesions are reversible if the patients undergo treatment without delay. CONCLUSION The significance of these lesions is still unclear. However, when a high signal intensity lesion that is not reasonable for the symptom is detected on diffusion-weighted MRI, an immediate check of the blood sugar level is mandatory.
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Affiliation(s)
- Masahito Katoh
- Department of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo, Japan
| | - Masami Yoshino
- Department of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo, Japan
| | - Takeshi Aoki
- Department of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo, Japan
| | - Takeo Abumiya
- Department of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo, Japan
| | - Hiroyuki Imamura
- Department of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo, Japan
| | - Toshimitsu Aida
- Department of Neurosurgery, Hokkaido Neurosurgical Memorial Hospital, Sapporo, Japan
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Naseem T, Zhao PS. Unexpected prolonged coma after general anesthesia in a patient with history of type II diabetes mellitus. J Anaesthesiol Clin Pharmacol 2015; 31:426-8. [PMID: 26330741 PMCID: PMC4541209 DOI: 10.4103/0970-9185.161738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Tariq Naseem
- Department of Anesthesiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA
| | - Pei-Shan Zhao
- Department of Anesthesiology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA
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Medical and Nonstroke Neurologic Causes of Acute, Continuous Vestibular Symptoms. Neurol Clin 2015; 33:699-716, xi. [DOI: 10.1016/j.ncl.2015.04.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Yorulmaz H, Kaptan E, Seker FB, Oztas B. Type 1 diabetes exacerbates blood-brain barrier alterations during experimental epileptic seizures in an animal model. Cell Biochem Funct 2015; 33:285-92. [PMID: 26011758 DOI: 10.1002/cbf.3113] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 04/08/2015] [Accepted: 04/09/2015] [Indexed: 11/08/2022]
Abstract
The aim of this study was to perform the effects of diabetes on the permeability of the blood-brain barrier (BBB) during pentylenetetrazole (PTZ)-induced epileptic attacks. For this propose, the animals were divided into four groups. These groups contained were intact, PTZ-treated, diabetic and PTZ-treated diabetic individuals, respectively. To evaluate the functioning of the BBB, Evans blue was used as a BBB permeability indicator, and the expressions of zonula occludens-1 and glial fibrillary acidic protein involving the functioning of the BBB were determined immunohistochemically. Also, the changes in the release of serum tumour necrosis factor-alpha and interleukin-10 and interleukin-12 were studied by using enzyme-linked immunosorbent assay method. BBB permeability in the seizures under diabetic conditions showed a considerable increase (p < 0·01) in all of the brain we studied. The immunoreactive staining intensity of zonula occludens-1 and glial fibrillary acidic protein was found reduced in the brain regions of diabetic rats (p < 0·01). However, the serum level of tumour necrosis factor-alpha increased in diabetes and diabetes + PTZ groups, and the serum level of interleukin-12 increased significantly in all experimental groups (p < 0·05). In conclusion, diabetes dramatically increases BBB damage during epileptic seizures, and it may be derived from an elevation of paracellular passage.
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Affiliation(s)
- Hatice Yorulmaz
- Department of Physiology, Faculty of Medicine, Halic University, Istanbul, Turkey
| | - Engin Kaptan
- Department of Biology, Faculty of Sciences, Istanbul University, Istanbul, Turkey
| | - F Burcu Seker
- Department of Physiology, Medical School, Yeditepe University, Istanbul, Turkey
| | - Baria Oztas
- Department of Physiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Ohshita T, Imamura E, Nomura E, Wakabayashi S, Kajikawa H, Matsumoto M. Hypoglycemia with focal neurological signs as stroke mimic: Clinical and neuroradiological characteristics. J Neurol Sci 2015; 353:98-101. [PMID: 25912175 DOI: 10.1016/j.jns.2015.04.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Revised: 03/28/2015] [Accepted: 04/10/2015] [Indexed: 10/23/2022]
Abstract
Our aim was to investigate the clinical and radiological features of patients with hypoglycemia with focal neurological signs (HFNS). Among 80 consecutive hypoglycemic patients (blood glucose levels less than 50mg/dL), who had been admitted between October 2008 and May 2012, we selected 11 patients (6 men and 5 women; mean age, 73.2 ± 12 years) with focal neurological signs. The mean initial blood glucose level was 27.9 mg/dL (range, 13-39 mg/dL). The most frequent symptom was unilateral motor weakness (n = 9), which was usually accompanied with mild or moderate alteration of consciousness. All patients had improved initial neurological signs within 1h of glucose injection. The initial DWI demonstrated a hyperintense lesion in the contralateral internal capsule with decreased values on the ADC (apparent diffusion coefficient) map in 2 of the patients (18%). The DWI performed one day later shows only faint lesion. The initial DWI in patients with HFNS may display a hyperintense lesion, which was difficult to distinguish from acute cerebral infarction. Hypoglycemia should be considered in cases with DWI showing a disproportionally small lesion in contrast to neurological signs.
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Affiliation(s)
- Tomohiko Ohshita
- Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan.
| | - Eiji Imamura
- Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan.
| | - Eiichi Nomura
- Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan.
| | | | - Hiroshi Kajikawa
- Department of Neurosurgery, Suiseikai Kajikawa Hospital, Hiroshima, Japan.
| | - Masayasu Matsumoto
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan.
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Yanai H, Adachi H, Katsuyama H, Moriyama S, Hamasaki H, Sako A. Causative anti-diabetic drugs and the underlying clinical factors for hypoglycemia in patients with diabetes. World J Diabetes 2015; 6:30-36. [PMID: 25685276 PMCID: PMC4317315 DOI: 10.4239/wjd.v6.i1.30] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Revised: 10/31/2014] [Accepted: 12/01/2014] [Indexed: 02/05/2023] Open
Abstract
Recent clinical trials indicated that the intensive glycemic control do not reduce cardiovascular disease mortality among diabetic patients, challenging a significance of the strict glycemic control in diabetes management. Furthermore, retrospective analysis of the Action to Control Cardiovascular Risk in Diabetes study demonstrated a significant association between hypoglycemia and mortality. Here, we systematically reviewed the drug-induced hypoglycemia, and also the underlying clinical factors for hypoglycemia in patients with diabetes. The sulfonylurea use is significantly associated with severe hypoglycemia in patients with type 2 diabetes. The use of biguanide (approximately 45%-76%) and thiazolidinediones (approximately 15%-34%) are also highly associated with the development of severe hypoglycemia. In patients treated with insulin, the intensified insulin therapy is more frequently associated with severe hypoglycemia than the conventional insulin therapy and continuous subcutaneous insulin infusion. Among the underlying clinical factors for development of severe hypoglycemia, low socioeconomic status, aging, longer duration of diabetes, high HbA1c and low body mass index, comorbidities are precipitating factors for severe hypoglycemia. Poor cognitive and mental functions are also associated with severe hypoglycemia.
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Jo H, Park HW, Baek S. Progress of Rehabilitation in Patients with Hypoglycemic Encephalopathy Accompanying Dysphagia and Voiding Difficulty: A Case Report. BRAIN & NEUROREHABILITATION 2015. [DOI: 10.12786/bn.2015.8.2.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Hannae Jo
- Department of Rehabilitation Medicine, Kangwon National University Hospital, Korea
| | - Hee-won Park
- Department of Rehabilitation Medicine, Kangwon National University Hospital, Korea
- Gangwon-do Rehabilitation Hospital, Korea
| | - Sora Baek
- Department of Rehabilitation Medicine, Kangwon National University Hospital, Korea
- Department of Rehabilitation Medicine, Kangwon National University School of Medicine, Korea
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Tsujimoto T, Yamamoto-Honda R, Kajio H, Kishimoto M, Noto H, Hachiya R, Kimura A, Kakei M, Noda M. Seasonal variations of severe hypoglycemia in patients with type 1 diabetes mellitus, type 2 diabetes mellitus, and non-diabetes mellitus: clinical analysis of 578 hypoglycemia cases. Medicine (Baltimore) 2014; 93:e148. [PMID: 25415670 PMCID: PMC4616344 DOI: 10.1097/md.0000000000000148] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Blood glucose control in patients with diabetes mellitus (DM) is reportedly influenced by the seasons, with hemoglobin A1c (HbA1c) levels decreasing in the summer or warm season and increasing in the winter or cold season. In addition, several studies have shown that sepsis is also associated with the seasons. Although both blood glucose control and sepsis can strongly affect the occurrence of severe hypoglycemia, few studies have examined the seasonal variation of severe hypoglycemia. The aim of the present study is to examine the association between severe hypoglycemia and the seasons in patients with type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM), and non-diabetes mellitus (non-DM). We retrospectively reviewed all the patients with severe hypoglycemia at a national center in Japan between April 1, 2006 and March 31, 2012. A total of 57,132 consecutive cases that had visited the emergency room by ambulance were screened, and 578 eligible cases of severe hypoglycemia were enrolled in this study. The primary outcome was to assess the seasonality of severe hypoglycemia. In the T1DM group (n = 88), severe hypoglycemia occurred significantly more often in the summer than in the winter (35.2% in summer vs 18.2% in winter, P = 0.01), and the HbA1c levels were highest in the winter and lowest in the summer (9.1% [7.6%-10.1%] in winter vs 7.7% [7.1%-8.3%] in summer, P = 0.13). In the non-DM group (n = 173), severe hypoglycemia occurred significantly more often in the winter than in the summer (30.6% in winter vs 19.6% in summer, P = 0.01), and sepsis as a complication occurred significantly more often in winter than in summer (24.5% in winter vs 5.9% in summer, P = 0.02). In the T2DM group (n = 317), the occurrence of severe hypoglycemia and the HbA1c levels did not differ significantly among the seasons. The occurrence of severe hypoglycemia might be seasonal and might fluctuate with temperature changes. Patients should be treated more carefully during the season in which severe hypoglycemia is more common.
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Affiliation(s)
- Tetsuro Tsujimoto
- From the Department of Diabetes, Endocrinology, and Metabolism, National Center for Global Health and Medicine, Tokyo (TT, RY-H, HK, M Kishimoto, HN, RH); Division of General Medicine, Jichi Medical University Graduate School of Medicine, Tochigi (TT, M Kakei); Department of Diabetes Research, Diabetes Research Center (RY-H, M Kishimoto, HN, MN); Department of Emergency Medicine and Critical Care, Center Hospital, National Center for Global Health and Medicine, Tokyo (AK); and First Department of Comprehensive Medicine, Saitama Medical Center, Jichi Medical University School of Medicine, Saitama, Japan (M Kakei)
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Hypoglycemia and risk of seizures: a retrospective cross-sectional study. Seizure 2014; 25:147-9. [PMID: 25455725 DOI: 10.1016/j.seizure.2014.10.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 10/02/2014] [Accepted: 10/08/2014] [Indexed: 01/29/2023] Open
Abstract
PURPOSE Few studies have been dedicated to assess neurological symptoms in relations to hypoglycemia. In this study we investigated the association between different levels of hypoglycemia and the occurrence of epileptic seizures in patients without a prior diagnosis of epilepsy. METHOD A retrospective cross-sectional study. RESULTS We identified 388 individuals from a laboratory database in Swedish regional hospital who had been found to have a glucose value of ≤3.5 mM between January and December 2009. Medical records were reviewed. Hypoglycemia was defined at three different categories: 0-2 mM (40 patients), 2.1-3 mM (154 patients) and 3.1-3.5 mM (194 patients). 14 patients had disturbance of consciousness including 3 with seizures. The majority of cases had coma, a generalized tonic-clonic seizure was seen only when s-glucose dropped below 2.0 mM. Two cases with focal seizure were noted, one at s-glucose 2.0 mM, and one at s-glucose 3.3 mM. The absolute risks (95% confidence interval) for having major neurological symptoms at glucose levels of ≤2.0 mM were 0.25 (0.13-0.41), 0.02 (0-0.06) at 2.1-3.0 mM and 0.01 (0-0.03) at 3.1-3.5 mM. CONCLUSION Coma is the most common neurological symptom related to hypoglycemia. Epileptic seizures are rare and not as common as previously assumed.
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Reid CA, Mullen S, Kim TH, Petrou S. Epilepsy, energy deficiency and new therapeutic approaches including diet. Pharmacol Ther 2014; 144:192-201. [PMID: 24924701 DOI: 10.1016/j.pharmthera.2014.06.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Accepted: 05/28/2014] [Indexed: 02/08/2023]
Abstract
Metabolic dysfunction leading to epilepsy is well recognised. Dietary therapy, in particular the ketogenic diet, is now considered an effective option. Recent genetic studies have highlighted the central role that metabolism can play in setting seizure susceptibility. Here we discuss various metabolic disorders implicated in epilepsy focusing on energy deficiency due to genetic and environmental causes. We argue that low, uncompensated brain glucose levels can precipitate seizures. We will also explore mechanisms of disease and therapy in an attempt to identify common metabolic pathways involved in modulating seizure susceptibility. Finally, newer therapeutic approaches based on diet manipulation in the context of energy deficiency are discussed.
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Affiliation(s)
- Christopher A Reid
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia.
| | - Saul Mullen
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia
| | - Tae Hwan Kim
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia
| | - Steven Petrou
- Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Parkville, Australia; Centre for Neural Engineering, The University of Melbourne, Parkville, Melbourne, Australia; Department of Electrical Engineering, The University of Melbourne, Parkville, Melbourne, Australia
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Abstract
Hypoglycemia occurs in diabetic patients as a consequence of treatment with hypoglycemic agents, in insulinoma patients as a result of excessive insulin production, and in infants as a result of abnormal regulation of metabolism. Profound hypoglycemia can cause structural and functional disturbances in both the central (CNS) and the peripheral nervous system (PNS). The brain is damaged by a short and severe episode of hypoglycemia, whereas PNS pathology appears after a mild and prolonged episode. In the CNS, damaged mitochondria, elevated intracellular Ca2(+) level, released cytochrome c to the cytosol, extensive production of superoxide, increased caspase-3 activity, release of aspartate and glutamate from presynaptic terminals, and altered biosynthetic machinery can lead to neuronal cell death in the brain. Considering the PNS, chronic hypoglycemia is associated with delayed motor and sensory conduction velocities in peripheral nerves. With respect to pathology, hypoglycemic neuropathy in the PNS is characterized by Wallerian-like axonal degeneration that starts at the nerve terminal and progresses to a more proximal part of the axon, and motor axons to the muscles may be more severely damaged than sensory axons. Since excitatory neurotransmitters primarily involve the neuron in the CNS, this "dying back" pattern of axonal damage in the PNS may involve mechanisms other than excitotoxicity.
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Affiliation(s)
- Simin Mohseni
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Faculty of Health Sciences, Linköping University, Linköping, Sweden.
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Dynkevich Y, Rother KI, Whitford I, Qureshi S, Galiveeti S, Szulc AL, Danoff A, Breen TL, Kaviani N, Shanik MH, Leroith D, Vigneri R, Koch CA, Roth J. Tumors, IGF-2, and hypoglycemia: insights from the clinic, the laboratory, and the historical archive. Endocr Rev 2013; 34:798-826. [PMID: 23671155 DOI: 10.1210/er.2012-1033] [Citation(s) in RCA: 155] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Tumors of mesenchymal and epithelial origin produce IGF-2, which activates pathways in the tumors. In a minority of patients, the tumors (hepatomas, fibromas, and fibrosarcomas are the most common among many) release into the circulation enough IGF-2-related peptides to mimic the fasting hypoglycemia characteristic of patients with insulin-producing islet-cell tumors. Rarely, markedly elevated IGF-2 levels produce somatic changes suggestive of acromegaly. Typically, the elevated IGF-2 levels are associated with suppressed plasma levels of insulin, IGF-1, and GH. Complicating the pathophysiology are the IGF binding proteins (IGFBPs) that can bind IGF-2 and IGF-1, modifying hormone metabolism and action. IGFBP concentrations are often altered in the presence of these tumors. At the cellular level, the 3 hormone-related ligands, IGF-2, IGF-1, and insulin, all bind to 4 (or more) types of IGF-1 receptor (IGF-1R) and insulin receptor (IR). Each receptor has its own characteristic affinity for each ligand, a tyrosine kinase, and overlapping profiles of action in the target cells. The IGF-2R, in addition to binding mannose-6-phosphate-containing proteins, provides an IGF-2 degradation pathway. Recent evidence suggests IGF-2R involvement also in signal transduction. Surgery, the treatment of choice, can produce a cure. For patients not cured by surgery, multiple therapies exist, for the tumor and for hypoglycemia. Potential future therapeutic approaches are sketched. From 1910 to 1930, hypoglycemia, insulin, insulinomas, and non-islet-cell tumors were recognized. The latter third of the century witnessed the emergence of the immunoassay for insulin; the IGFs, their binding proteins, and assays to measure them; and receptors for the insulin-related peptides as well as the intracellular pathways beyond the receptor. In closing, we replace non-islet-cell tumor hypoglycemia, an outdated and misleading label, with IGF-2-oma, self-explanatory and consistent with names of other hormone-secreting tumors.
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Affiliation(s)
- Yevgeniya Dynkevich
- MD, FACP, Investigator, Feinstein Institute for Medical Research, Laboratory of Diabetes and Diabetes-Related Research, 350 Community Drive, Manhasset, NY 11030.
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Rapidly Raise Blood Sugar Will Aggravate Brain Damage After Severe Hypoglycemia in Rats. Cell Biochem Biophys 2013; 69:131-9. [DOI: 10.1007/s12013-013-9779-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kattah JC, Dhanani SS, Pula JH, Mantokoudis G, Tehrani ASS, Toker DEN. Vestibular signs of thiamine deficiency during the early phase of suspected Wernicke encephalopathy. Neurol Clin Pract 2013; 3:460-468. [PMID: 30107022 DOI: 10.1212/01.cpj.0000435749.32868.91] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Non-encephalopathic presentations of CNS thiamine deficiency may be difficult to diagnose. We describe neuro-otologic findings of Wernicke syndrome in 5 patients with vestibular manifestations. Diagnosis was confirmed by low serum levels, response to replacement, and brain MRI to exclude other causes. All had bilaterally abnormal horizontal head impulse vestibulo-ocular reflex (VOR) responses and pathologic gaze-evoked nystagmus, without encephalopathy. After thiamine replacement, 4 had total resolution of vestibular and oculomotor findings. Novel findings included 2 patients whose VOR function improved within minutes of IV repletion and 1 whose recovery was documented by serial quantitative recordings. Early diagnosis of Wernicke by examining vestibular reflexes and prompt IV treatment might prevent encephalopathy and other neurologic or systemic complications of thiamine depletion.
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Affiliation(s)
- Jorge C Kattah
- Department of Neurology (JCK, SSD, JHP), Illinois Neurologic Institute and the University of Illinois College of Medicine at Peoria; and Department of Neurology (GM, ASST, DENT), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sara S Dhanani
- Department of Neurology (JCK, SSD, JHP), Illinois Neurologic Institute and the University of Illinois College of Medicine at Peoria; and Department of Neurology (GM, ASST, DENT), Johns Hopkins University School of Medicine, Baltimore, MD
| | - John H Pula
- Department of Neurology (JCK, SSD, JHP), Illinois Neurologic Institute and the University of Illinois College of Medicine at Peoria; and Department of Neurology (GM, ASST, DENT), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Georgios Mantokoudis
- Department of Neurology (JCK, SSD, JHP), Illinois Neurologic Institute and the University of Illinois College of Medicine at Peoria; and Department of Neurology (GM, ASST, DENT), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ali S Saber Tehrani
- Department of Neurology (JCK, SSD, JHP), Illinois Neurologic Institute and the University of Illinois College of Medicine at Peoria; and Department of Neurology (GM, ASST, DENT), Johns Hopkins University School of Medicine, Baltimore, MD
| | - David E Newman Toker
- Department of Neurology (JCK, SSD, JHP), Illinois Neurologic Institute and the University of Illinois College of Medicine at Peoria; and Department of Neurology (GM, ASST, DENT), Johns Hopkins University School of Medicine, Baltimore, MD
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