Nimodipine treatment in poor-grade aneurysm patients. Results of a multicenter double-blind placebo-controlled trial

A multicenter, randomized placebo-controlled double-blind trial of nimodipine in poor-grade aneurysm patients was carried out in 17 Canadian hospitals. Of 188 patients enrolled in the trial, 32 were excluded for protocol violations and two were excluded due to statistical considerations, leaving 154 patients for valid outcome analysis. Nimodipine treatment was associated with a significantly better outcome (p less than 0.001): 21 (29.2%) of 72 nimodipine-treated patients had a good outcome at 3 months after subarachnoid hemorrhage (SAH) compared to eight (9.8%) of 82 placebo-treated patients. Delayed ischemic deficits from vasospasm alone were significantly less frequent in the nimodipine group (p less than 0.05) with permanent deficits occurring in five nimodipine-treated patients (6.9%) and in 22 placebo-treated patients (26.8%). Improvement in the good outcome rate and reduction in delayed ischemic deficits from vasospasm alone occurred in both Grade 3 and 4 patients, with no difference between nimodipine- and placebo-treated patients being found in Grade 5 patients. Repeat angiography after Day 4 was carried out in 124 patients. There was no significant difference in the incidence of moderate or severe diffuse spasm, which was seen in 64.3% of nimodipine-treated patients and 66.2% of placebo-treated patients. The authors conclude that nimodipine treatment in poor-grade patients with SAH results in an increase in the number of good outcomes and a reduction in the incidence of delayed neurological deterioration due to vasospasm. This effect occurs by a mechanism other than prevention of large-vessel spasm as visualized on angiography.     

Sir David Cuthbertson Medal Lecture. The impact of dietary protein restriction on insulin secretion and action

The goal of this review is to develop the hypothesis, and review the evidence, that protein restriction, through synergistic effects on multiple organ systems predisposes to loss of normal regulation of fuel homeostasis that plays the central role in the development of type 2 (non-insulin-dependent) diabetes mellitus. The ability of insulin to regulate glucose production and disposal varies between individuals. These differences, together with the various compensatory mechanisms that are invoked to attempt to normalize fuel homeostasis, are of fundamental importance in the development and clinical course of type 2 diabetes mellitus. Protein deprivation impacts on both insulin secretion and insulin action. These effects may persist even when a diet containing adequate protein is presented subsequently. Data are presented that suggest that protein restriction results in an impaired ability of pancreatic beta-cells to compensate adequately for the defect in insulin action in insulin-resistant individuals. This persistent impairment of insulin secretion resulting from protein restriction predisposes to loss of glucoregulatory control and impaired insulin action after the subsequent imposition of a diabetogenic challenge. This inability to maintain the degree of compensatory hyperinsulinaemia necessary to prevent loss of glucose tolerance may have relevance to the increased incidence of diabetes on changing from a nutritionally-poor diet to a Western diet, and to the hypothesis that some cases of type 2 diabetes in adulthood may be related to poor early nutrition.     

Occupational Skin Allergies: Testing and Treatment (The Case of Occupational Allergic Contact Dermatitis)

Occupational contact dermatitis, including occupational allergic contact dermatitis, is one of the most common occupational diseases. Making a timely and accurate diagnosis is important to improving the outcome. Taking a work history and patch testing are essential elements in the diagnostic process. Management, based on an accurate diagnosis, must include both medical treatment to address the disease and workplace modifications as appropriate to reduce exposure the causative agents.     

Dexamethasone during late gestation exacerbates peripheral insulin resistance and selectively targets glucose-sensitive functions in beta cell and liver

We examined whether low-dose dexamethasone administration during late pregnancy modifies hepatic and/or peripheral insulin action or glucose-stimulated insulin secretion. Dexamethasone (100 microg/kg maternal body weight/d) was administered via an osmotic minipump from d 14--19 of gestation. Maternal glucose-insulin homeostasis was assessed on d 19 of pregnancy in the postabsorptive state. Insulin secretion and glucose tolerance was assessed after iv glucose, and insulin action examined during insulin infusion at euglycemia. Dexamethasone treatment during late pregnancy elicited fasting hyperinsulinaemia (by 88%; P < 0.001) and hyperglycaemia (by 20%; P < 0.05), and enhanced endogenous glucose production (by 29%; P < 0.001). Insulin secretion and rates of glucose disappearance after iv glucose were greatly impaired (by 44% and 39% respectively; P < 0.05). Suppression of endogenous glucose production by insulin was enhanced by dexamethasone treatment, but insulin's ability to promote glucose clearance was diminished. We demonstrate that excess maternal glucocorticoids during late pregnancy impairs glucose-stimulated insulin secretion and insulin-simulated glucose clearance but enhances insulin's ability to suppress endogenous glucose production. The data also indicate that elevated maternal glucocorticoids impair adaptations of the endocrine pancreas to pregnancy in vivo in that insulin hypersecretion in response to deteriorating peripheral insulin action is no longer apparent, leading to impaired glucose tolerance.     

Potential role of peroxisome proliferator-activated receptor-alpha in the modulation of glucose-stimulated insulin secretion

In this review, we discuss the influence of peroxisome proliferator-activated receptor (PPAR)-alpha on islet insulin secretion and develop the hypothesis that modulation of PPAR-alpha function may be important for the regulation of compensatory insulin secretion. We have attempted to analyze the role of PPAR-alpha-linked fatty acid metabolism in islet function in health and in insulin-resistant states linked to lifestyle factors, in particular pregnancy and a diet inappropriately high in saturated fat. We have emphasized the potential for both actions of PPAR-alpha on insulin sensitivity that may be relayed systemically to the islet, leading to modulation of the insulin response in accordance with changes in insulin sensitivity, and direct effects of PPAR-alpha action on the islet itself. Finally, we have developed the concept that compensatory insulin secretion may have a function not only in glucoregulation but also in liporegulation. Thus, augmented insulin secretion may reflect a requirement for lipid lowering as well as for increased glucose disposal and is perceived to aim to compensate for impaired suppression of islet lipid delivery by insulin. This introduces the possibility of a continuum between liporegulation with islet compensation and lipodysregulation leading to islet decompensation in the development of type 2 diabetes.     

Antecedent protein restriction and high-fat feeding interactively sensitise the leptin response to elevated insulin

Using a rat model of moderate (8 vs. 20% protein) isocaloric protein restriction initiated in early life (low protein, LP), we examined the possible basis for the association between impaired early growth and elevated leptin levels in later life in man by examining the acute leptin response to insulin and its relationship with glucose utilisation. We placed subsets of LP rats on a high-saturated-fat (HF) diet containing 20% protein for 4 weeks (LP-4HF) or 8 weeks (LP-8HF), making comparison with age-matched control (C) groups (C, C-4HF, C-8HF). At ambient insulin concentrations, LP was not associated with altered leptinaemia compared with C, despite a more active lipolytic programme as inferred from increased adipocyte sensitivity to norepinephrine. HF feeding led to insulin resistance with respect to whole-body glucose disposal (R(d)) (measured using [3-(3)H] glucose at steady state) in both LP and C in vivo and impaired suppression of agonist-stimulated lipolysis by insulin in LP but not C in vitro. Whereas insulin infusion for 2 h (while maintaining euglycaemia) only modestly increased plasma leptin levels in vivo in C, C-4HF, C-8HF and LP groups, the leptin response to insulin was greatly enhanced in the HF-fed LP groups. A close positive correlation (r = 0.96) existed between plasma leptin levels and R(d) in the C groups (viz. C, C-4HF, C-8HF) whereas a close inverse correlation (r = 0.95) existed between plasma leptin levels and insulin-stimulated R(d) in the LP groups (viz. LP, LP-4HF, LP-8HF). Glucose utilisation (estimated from 2-deoxy-D-[1-(3)H] glucose 6-phosphate accumulation) in vivo in two intra-abdominal and two superficial adipose-tissue depots was consistently higher in the LP group. After HF feeding, glucose utilisation by the superficial adipose-tissue depots was threefold higher in the LP than in the C group. We conclude that protein restriction from conception to adulthood followed by high-fat feeding sensitizes the acute leptin response to insulin, an adaptation associated with enhanced glucose utilisation by adipose tissue. This effect is observed despite impaired insulin sensitivity, both at the level of whole-body glucose disposal and adipocyte anti-lipolysis, and increased lipolytic activity (although the latter is not in itself sufficient to influence the leptin response). We propose that associations between a low birthweight and elevated leptin concentrations in later life may reflect long-term modulation of adipocyte glucose handling.     

Substrate interactions in the short- and long-term regulation of renal glucose oxidation.

The present study evaluated the substrate competition between fatty acids (FA) and glucose in the kidney in vivo in relation to the operation of the "glucose-FA" and "reverse glucose-FA" cycles. In fed rats, neither inhibition of adipocyte lipolysis by 5-methylpyrazole-3-carboxylic acid (MPCA) nor inhibition of mitochondrial long-chain FA oxidation by 2-tetradecylglycidate (TDG) influenced the renal ratio of free/acylated carnitine or the percentage of total renal pyruvate dehydrogenase complex (PDHC) in the active (dephosphorylated) form (PDHa). The additional provision of glucose, a precursor for the synthesis of malonyl-coenzyme A (coA), did not influence renal PDHa activity or the renal ratio of free to acylated carnitine, implying that FA oxidation is maximally suppressed in the fed state. A reverse glucose-FA cycle may therefore be important in suppressing renal FA oxidation in the fed state. After 48 hours of starvation, MPCA and TDG decreased short- and long-chain acylcarnitine concentrations (40% to 50%, P < .01) and elevated the renal ratio of free/acylated carnitine (2.5-fold, P < .001, and 3.3-fold, P < .001, respectively), indicating that FA oxidation is increased after starvation. Despite suppression of renal FA oxidation, renal PDHa activity in 48-hour starved rats was only partially restored by treatment with MPCA or TDG. The additional administration of glucose did not remedy this. The failure to reverse completely the effects of prolonged starvation in suppressing PDHC activity by acute inhibition of FA oxidation suggests additional regulatory mechanisms that dampen the PDHC response to acute changes in substrate supply. Estimations of PDH kinase (PDK) activity in renal mitochondria showed a significant 1.7-fold stable increase (P < .01) after 48 hours of starvation. Analysis of PDK pyruvate sensitivity in renal mitochondria incubated with respiratory substrate (5 mmol/L 2-oxoglutarate/0.5 mmol/L L-malate) showed that the pyruvate concentration required for 50% activation was substantially decreased by starvation. Enzyme-linked immunosorbent assay (ELISA) analysis over a range of PDHC activities demonstrated that increased PDK activity was concomitant with a significant (at least P < .01) 1.8-fold increase in the protein expression of the ubiquitously expressed PDK isoform, PDK2. We hypothesize that changes in protein expression and activity of individual PDK isoforms may dictate the renal response to incoming FA lesterification v oxidation) through modulation of the relationship between glycolytic flux and PDHC activity, and thus the provision of precursor for malonyl-coA production.