A randomized, blinded trial of uncooked cornstarch to diminish nocturnal hypoglycemia at Diabetes Camp

Objective: To determine if uncooked cornstarch, as part of the evening snack, can avert nocturnal hypoglycemia in type 1 diabetes. Research Design and Methods: Fifty-one campers and counselors at the American Diabetes Association Camp in San Bernardino, CA were randomly assigned to receive 5 g of uncooked cornstarch as part of the 21:00 evening snack vs. a standard snack of equivalent carbohydrate content. Each snack was given for five nights and the participants and medical personnel were blinded as to assignment. Midnight and 07:00 finger stick blood glucose levels were compared with values <60 mg/dl defined as hypoglycemia and values >250 mg/dl defined as hyperglycemia. Results: There were 218 midnight and 222 07:00 values for comparison. There were six episodes of hypoglycemia at midnight and nine episodes of hypoglycemia at 07:00 for the cornstarch snack nights vs. 30 hypoglycemia episodes at midnight and 21 at 07:00 for the standard snack nights (P < 0.001 and < 0.05, respectively). There was no difference in the number of hyperglycemic events at midnight or 07:00 for the cornstarch vs. standard snack nights. At midnight, 12% of campers had hypoglycemia after the cornstarch snack vs. 46% after the standard snack (P < 0.001), and at 07:00, 16% had hypoglycemia after cornstarch vs. 26% after the standard snack (P = 0.327). Conclusions: These data suggest that uncooked cornstarch, as part of the evening snack, can diminish the nighttime and morning hypoglycemia associated with type 1 diabetes, without causing hyperglycemia.     

The effect of extend bar containing uncooked cornstarch on night-time glycemic excursion in subjects with type 2 diabetes

The objective of this study was to determine the effects of ingesting a snack bar containing uncooked cornstarch (Extend Bar, Clinical Products, Limited, Key Biscayne, FL) on nocturnal glycemic excursion in 28 adults (ages 22-78 years) with type 2 diabetes mellitus (mean HbAlc 8.21+/-1.28%). Thirteen subjects were treated with oral agents, eight with a combination of insulin and oral agents, and seven with insulin alone. Subjects ingested the study bar (Extend Bar, containing 30 g of total carbohydrate, including 5 g of uncooked cornstarch, 3 g protein, and 3 g fat) for three evenings followed by a placebo bar for 3 evenings (30 g of total carbohydrate, 3 g protein, and 3 g fat), or vice versa. Pre-snack before bedtime, midnight and before breakfast finger stick blood glucose levels were compared to determine the incidence of hypoglycemia (<60 mg/dl), hyperglycemia (>250 mg/dl), and to calculate any differences in the group's mean blood glucose levels when ingesting the study versus the placebo bar. There were no episodes of hypoglycemia or hyperglycemia. The mean blood glucose levels pre-snack at bedtime were nearly identical (Extend Bar value 117.5+/-45.6 mg/dl; placebo bar value 117.3+/-40.0 mg/dl; P=0.977), and lower at midnight and before breakfast on the Extend Bar nights compared to the placebo bar nights (Extend Bar, midnight value 127.9+/-31.0 mg/dl; placebo bar midnight value 148.2+/-32.1 mg/dl; P=0.0001; Extend Bar breakfast value 114.2+/-15.8 mg/dl; placebo bar breakfast value 158.49+/-30.3 mg/dl; P<0.0001). These data suggest that ingesting Extend Bar containing uncooked cornstarch as the nighttime snack may be an effective strategy to lesson the frequency of nocturnal and morning hyperglycemia in subjects with type 2 diabetes.     

Postprandial hypoglycemia after Nissen fundoplication for reflux esophagitis

The motility of the stomach is modulated by the complex interplay of muscular, humoral, and neuronal factors. Rapid gastric emptying has been described after gastrectomy, gastrojejunostomy, vagotomy with pyloroplasty, and with active peptic ulcer disease. Rapid emptying may result in "dumping" syndrome and in postprandial hypoglycemia. We report a patient who developed postprandial hypoglycemia after a Nissen fundoplication for reflux esophagitis. This is the first report of this complication after this surgical procedure. The hypoglycemia was secondary to a combination of rapid gastric emptying, rapid absorption of glucose causing hyperglycemia, and excessive insulin secretion. This syndrome should be considered in patients who develop hypoglycemic symptoms after fundoplication. Treatment with a low carbohydrate diet and anticholinergic agents may offer symptomatic relief.     

Nocturnal hypoglycemia in type 1 diabetes: an assessment of preventive bedtime treatments

OBJECTIVE: We assessed four putative bedtime treatments in the prevention of nocturnal hypoglycemia in type 1 diabetes. RESEARCH DESIGN AND METHODS: Plasma glucose concentrations were measured every 15 min from 2200 h through 0700 h in 21 patients with type 1 diabetes (mean +/- sd HbA(1C) = 7.1 +/- 1.0%) on five occasions with, in random sequence, bedtime (2200 h) administration of 1) no treatment, 2) a snack, 3) the snack plus the alpha-glucosidase inhibitor acarbose, 4) an uncooked cornstarch bar, or 5) the beta(2)-adrenergic agonist terbutaline. RESULTS: In the absence of a bedtime treatment, 27% of the measured nocturnal plasma glucose concentrations were less than 70 mg/dl (3.9 mmol/liter) in 12 patients; 16, 6, and 1% were less than 60, less than 50, and less than 40 mg/dl (3.3, 2.8, and 2.2 mmol/liter), respectively. Neither the snack (without or with acarbose) nor cornstarch raised the mean nadir nocturnal glucose concentration or reduced the number of low glucose levels or the number of patients with low levels. Terbutaline raised the mean nadir nocturnal glucose concentration (mean +/- se, 127 +/- 11 vs. 75 +/- 9 mg/dl; P < 0.001), eliminated glucose levels less than 50 mg/dl (P = 0.038), reduced levels less than 60 mg/dl (P = 0.005) to one, and reduced levels less than 70 mg/dl (P = 0.001) to five (four at 2215 h, one at 2230 h). However, it also raised glucose levels the following morning. CONCLUSIONS: Nocturnal hypoglycemia is common in aggressively treated type 1 diabetes. Bedtime administration of a conventional snack or of uncooked cornstarch does not prevent it. That of terbutaline prevents nocturnal hypoglycemia but causes hyperglycemia the following morning. The efficacy of a lower dose of terbutaline remains to be determined.     

Ultrasonographic comparison of gastric motility between diabetic gastroparesis patients with and without metabolic syndrome

Background and Aims:  Diabetic patients with poor glycemic control or long standing disease often have impaired gastric motility. Recently, metabolic factors such as blood glucose have been reported as influencing gastric motility independently of autonomic neuropathy. Many diabetic patients have metabolic syndrome, which is strongly associated with coronary and other diseases. We investigated whether metabolic syndrome influences diabetic gastroparesis patients.
Methods:  We observed gastric motility ultrasonographically in diabetic gastroparesis patients including nine with and nine without metabolic syndrome. Both groups complained of upper abdominal symptoms when hospitalized to improve blood sugar control. All patients underwent upper gastrointestinal endoscopy to rule out gastric and duodenal lesions. All had autonomic neuropathy. Gastric motility was evaluated within 3 days after admission by transabdominal ultrasonography after a test meal.
Results:  Gastric emptying was 45.0 ± 13.7% in patients with and 39.1 ± 11.9% in patients without metabolic syndrome, which was not statistically significant. Frequency of gastric contractions was 8.33 ± 2.78 per 3 min in patients with metabolic syndrome and 7.44 ± 2.13 per 3 min in the others, which was not statistically significant. The motility index, which involves antral contractility, was 3.21 ± 2.18 in patients with metabolic syndrome and 2.80 ± 1.87 in the others, which was not statistically significant.
Conclusions:  Metabolic syndrome did not appear to contribute to delayed gastric motility in diabetic gastroparesis.     

Measurement of superior mesenteric artery flow by means of doppler ultrasound in early dumping syndrome

Objective: Dumping occurs in about 10% of patients after gastric surgery. It has been suggested that early dumping is associated with an abnormal increase in postprandial splanchnic flow, but data from controlled studies are lacking. Therefore we have studied basal and postprandial superior mesenteric artery (SMA) blood flow in patients with dumping and in two control groups.
Methods: Three groups were studied, one group of patients after gastric surgery with early dumping (  n = 6  ), one surgical control group with patients after gastric surgery without dumping symptoms (  n = 7  ), and a healthy control group without previous gastric surgery (  n = 10  ). Blood glucose and heart rate were measured after dumping provocation by oral ingestion of 50 g glucose. SMA blood flow was measured both basally and 20 min after glucose ingestion.
Results: Basal SMA flow was similar in the three groups. After glucose ingestion SMA flow was not significantly different between dumping patients and surgical controls. However, stimulated SMA flow in both groups after gastric surgery combined was significantly (   p < 0.05  ) higher than in healthy controls.
Conclusions: The systemic symptoms associated with early dumping do not result from increased SMA blood flow per se. After gastric surgery patients have an increased postprandial SMA flow irrespective of the presence of dumping.     

Bedtime uncooked cornstarch supplement prevents nocturnal hypoglycaemia in intensively treated type 1 diabetes subjects

Abstract . Axelsen M, Wesslau C, Lönnroth P, Arvidsson Lenner R, Smith U (Sahlgrenska University Hospital, Göteborg University, Sweden). Bedtime uncooked cornstarch supplement prevents nocturnal hypoglycaemia in intensively treated IDDM subjects. J Intern Med 1999; 245 : 229–36. Objectives. The present study tests two interrelated hypotheses: (1) that bedtime ingestion of uncooked cornstarch exerts a lower and delayed nocturnal blood glucose peak compared with a conventional snack; (2) that bedtime carbohydrate supplement, administered as uncooked cornstarch, prevents nocturnal hypoglycaemia without altering metabolic control in intensively treated type 1 diabetes (IDDM) patients. Design  and subjects. The above hypotheses were tested separately (1) by pooling and analysing data from two overnight studies of comparable groups of patients with non-insulin dependent diabetes mellitus (NIDDM) (14 and 10 patients, respectively), and (2) by a double-blind, randomized 4-week cross-over study in 12 intensively treated IDDM patients. Setting. Sahlgrenska University Hospital, Göteborg, Sweden. Interventions. (1) Ingestion of uncooked cornstarch and wholemeal bread (0.6 g of carbohydrates kg^?1 body weight) and carbohydrate-free placebo at 22.00 h. (2) Intake of uncooked cornstarch (0.3 g kg^?1 body weight) and carbohydrate-free placebo at 23.00 h. Main outcome measures. (1) Nocturnal glucose and insulin levels; (2) frequency of self-estimated hypoglycaemia (blood glucose [BG] levels < 3.0 mmol L^?1) at 03.00 h, HbA_1c and fasting lipids. Results. Bedtime uncooked cornstarch ingestion led to a lower (2.9 ± 0.5 vs. 5.2 ± 0.6 m m , P = 0.01) and delayed (4.3 ± 0.6 vs. 2.0 ± 0.0 h, P < 0.01) BG peak, compared with a conventional snack, in NIDDM patients. Four weeks of bedtime uncooked cornstarch supplement, as compared with placebo, led to a 70% reduction in the frequency of self-estimated hypoglycaemia at 03.00 h (P < 0.05), without affecting HbA1c or fasting lipids in IDDM patients. Conclusions. Uncooked cornstarch, ingested at bedtime, mimicked the nocturnal glucose utilization profile following insulin replacement, with a peak in blood glucose after 4 h. In IDDM patients, bedtime uncooked cornstarch supplement diminished the number of self-estimated hypoglycaemic episodes, without adversely affecting HbA1c and lipid levels. Hence, bedtime uncooked cornstarch ingestion may be feasible to prevent a mid-nocturnal glycaemic decline following insulin replacement in IDDM and, based on the nocturnal blood glucose profile, may also be preferable compared with conventional snacks.     

Nutrition therapy for diabetic gastroparesis

The management of diabetic gastroparesis often represents a significant clinical challenge in which the maintenance of nutrition is pivotal. Gastric emptying is delayed in 30% to 50% of patients with longstanding type 1 or type 2 diabetes and upper gastrointestinal symptoms also occur frequently. However, there is only a weak association between the presence of symptoms and delayed gastric emptying. Acute changes in blood glucose concentrations affect gastric motility in diabetes; hyperglycemia slows gastric emptying whereas hypoglycemia may accelerate it; blood glucose concentrations may also influence symptoms. It is now recognized that gastric emptying is a major determinant of postprandial glycemia and, therefore, there is considerable interest in the concept of modulating gastric emptying, by dietary or pharmacologic means, to optimize glycemic control in diabetes.     

Effect of pectin on gastric emptying and gut hormone release in the dumping syndrome

The effect of pectin on gastric emptying, gut hormone release, and symptoms was studied in four patients with dumping syndrome and in two healthy volunteers after ingestion of a hypertonic glucose meal with and without addition of pectin. The initial fraction emptied from the stomach was reduced in the patients, whose symptoms of dumping were abolished or alleviated by pectin. This change of the emptying seems to be caused by a prolonged stomach transit, probably due to the viscous nature of the pectin meal. Pectin had no effect on the gastric emptying of the volunteers. The motor activity of the stomach was not altered by pectin in either the patients or volunteers. In the patients insulin, enteroglucagon, neurotensin, and gastric inhibitory polypeptide rose to higher levels after the glucose meal than after the glucose-pectin meal. The individual differences in the hormone release were considered secondary to the altered gastric emptying produced by pectin.     

The neointimal response to endovascular injury is increased in obese Zucker rats

Background:  Restenosis after revascularization procedures is accelerated in persons with type 2 diabetes.
Aim:  The current study tested the hypothesis that the neointimal response to endovascular injury is enhanced in female obese Zucker (OZ) rats, a model of type 2 diabetes.
Methods:  Animals were randomized to receive either a standard diet (SD) or a diabetogenic diet (DD) for 6 weeks. Four weeks later, balloon injury of the right common carotid artery was induced. All rats were euthanized 2 weeks after injury. Lean Zucker (LZ) rats served as controls.
Results:  At the time of death, plasma glucose was elevated in OZ rats fed a SD (208 ± 13 mg/dl) and a DD (288 ± 21 mg/dl) compared to corresponding LZ rats (SD: 153 ± 8; DD: 132 ± 7 mg/dl). The ratio of high-density lipoprotein cholesterol (HDLc) to total cholesterol (Totc), an index of atherogenicity, was reduced in OZ rats on both diets (SD: 0.77 ± 0.06; DD: 0.80 ± 0.09) compared to LZ controls (SD: 1.11 ± 0.02; DD: 1.20 ± 0.05). Histomorphometric analysis of injured arteries showed that the intima to media (I : M) ratio was significantly increased in OZ (1.37 ± 0.07) compared to LZ (0.79 ± 0.08) rats. Elevations in plasma glucose and triglycerides (Tg) correlated positively and decreases in HDLc negatively with an increased I : M ratio. Administration of the DD did not further enhance the I : M ratio in LZ (0.87 ± 0.06) or OZ (1.29 ± 0.09) rats.
Conclusions:  These results suggest that neointima formation following endoluminal injury of the carotid artery is enhanced at an early stage in the development of diabetes mellitus.     

Seizures following Billroth II gastrectomy

HISTORY: A 64-year old somnolent man was admitted to the emergency department with a reported seizure half an hour earlier. Due to similar episodes the patient had been treated with antiepileptics in the past. The patient s past history revealed a partial gastrectomy (Billroth II) more than ten years ago. DIAGNOSTIC FINDINGS AND THERAPY: At the time of admission blood glucose was 31 mg/dl. Other routine laboratory analyses and the clinical examination were normal. In addition, a detailed neurological examination and a cranial CT-scan were normal. Due to the hypoglycemia a dumping syndrome was suspected. A three hour oral glucose tolerance test (OGTT) resulted in a late hypoglycemia, establishing the diagnosis of late dumping. After adaptation of the patient's diet no further hypoglycemic episodes occurred. CONCLUSION: Manifestation of a dumping syndrome may occur even years after gastrectomy. Therefore, in patients presenting with hypoglycemia and a history of gut surgery, a dumping syndrome should be suspected. Furthermore, seizures due to hypoglycemia may be the only manifestation of late dumping.     

Impact of weight loss on the metabolic syndrome

Aim: Individuals with the metabolic syndrome (MS), a clustering of risk factors [triglycerides, glucose, high-density lipoprotein cholesterol, blood pressure (BP), abdominal obesity] defined by the National Cholesterol Education Program (NCEP), are at high risk for coronary heart disease and type 2 diabetes mellitus, and may benefit from aggressive lifestyle modification.
Methods: We reviewed 1 year of consecutive patients' charts to determine the prevalence of the MS in obese individuals enrolled in a medically supervised rapid weight loss programme, the correlation of weight change with the components of the MS, and response to diet-induced weight loss.
Results: Out of 185 individuals, 125 (68%) met the NCEP definition of the MS. A moderate decrease in weight (6.5%) induced by a very low calorie diet (VLCD) resulted in substantial reductions of systolic (11.1 mmHg) and diastolic (5.8 mmHg) blood pressure (BP), glucose (17 mg/dl), triglycerides (94 mg/dl) and total cholesterol (37 mg/dl) at 4 weeks (all p < 0.001). These improvements were sustained at the end of active weight loss (average 16.7 weeks; total weight loss 15.1%), with further significant reductions in BP and triglycerides. Weight loss was related to the changes in each criterion of the metabolic syndrome.
Conclusions: The MS is prevalent in two-thirds of obese individuals enrolling in a structured weight loss programme. Moderate weight loss with a VLCD markedly improved all aspects of the MS.     

Gastric emptying in head-injured patients

Objective: Most patients with moderate to severe head injury (HI) initially do not tolerate enteral feedings. Intolerance to nasogastric feeding is also commonly observed after HI. Quantitative measurements of gastric emptying (GE), to determine a possible mechanism for intolerance to enteral feeding, are lacking.
Methods: We prospectively evaluated gastric emptying half-time (GET1/2) of liquid meals in 35 patients with moderate to severe HI.
Results: In comparison with 16 age-matched healthy control subjects (29.4 ± 3.7 min), GET1/2 was significantly prolonged (57.2 ± 20.8 min,   p < 0.05  ) and abnormal in 80% of the HI patients. A prolonged GET1/2 and higher incidence of abnormal GET1/2 were observed in female patients, older patients, and patients with low Glasgow coma scale (GCS) scores, when compared with male patients, younger patients, and patients with high GCS scores. However, the differences for the means of GET1/2 and the incidences of abnormal GET1/2 between the subgroup patients were not significant (   p >0.05  ). In addition, significantly prolonged GET1/2 and higher incidence of abnormal GET1/2 (   p < 0.05  ) were observed in patients with short injury duration, in comparison with patients with long injury duration.
Conclusion: Head injury can cause significant prolonged GE of liquid meals, especially in patients with short injury duration.     

Iodine deficiency in children 7–19 years old in Eastern Province of Cameroon

Objective  To determine the prevalence of iodine deficiency in children in Eastern Province, Cameroon.
Method  Urinary iodine (I) and thiocyanate (SCN) excretion levels were assessed in 158 children (62 boys and 96 girls) aged 7–19 years.
Results  Mean urinary iodine excretion was 4.49 μg/dl for girls and 4.71 μg/dl for boys, lower than the 5.0 μg/dl minimal value defined by WHO. Overall 64.42% of subjects had urinary iodine excretion below the minimum, more than three times the population percentage (20%) at which a zone is declared endemic. Mean urine SCN concentration and mean I/SCN ratios of the study population were 2.57 ± 1.43 mg/dl and 2.21 ± 1.35 μg/mg for boys and 2.91 ± 1.57 mg/dl and 1.91 ± 1.1μg/mg for girls.
Conclusion  Iodine deficiency remains a problem in Eastern Province of Cameroon.     

Physiological Effect of Cholecystokinin on Gastric Emptying of Liquid in Functional Dyspepsia

Objective: Early satiety and postprandial epigastric fullness are common symptoms in functional dyspepsia. Cholecystokinin (CCK), a mediator of satiety in humans, may be responsible for these symptoms through an increased effect on delaying gastric emptying.
Methods: In five normal subjects and in five patients, gastric emptying of inert liquid mixed with technetium (Tc^99m) was studied during i.v . perfusion of normal saline and of physiological concentrations of CCK octapeptide.
Results: Administration of CCK significantly delayed emptying of inert liquid in patients and in normal subjects, and the effect was of similar magnitude in the two groups: residual gastric volumes at 90 min increased from 9.9 ± 6.1 to 32.1 ± 6.2% ( p < 0.025) in controls and from 9.8 ± 4.4 to 32.2 ± 4.7% ( p < 0.005) in patients during saline infusion in comparison with CCK infusion; also, prolongation of half emptying time was not different between the two groups (19.4 ± 1.9 min to 39.4 ± 15.2 min in controls and 19.5 ± 3.0 min to 31.4 ± 7.9 min in patients).
Conclusions: We conclude that CCK at physiological concentrations acts similarly in normal subjects and in patients with functional dyspepsia; this suggests that, if this hormone is normally released after a meal, a peripheral action of CCK through delayed gastric emptying is not responsible for increased postprandial satiety in functional dyspepsia.     

Gastric myoelectrical activity, gastric emptying, and correlations with symptoms and fasting blood glucose levels in diabetic patients

BACKGROUND: The aims of this study were to determine the electrogastrogram (EGG) changes and gastric emptying rates in diabetic patients and to investigate the correlation between upper gastrointestinal symptoms, fasting blood glucose, and gastric myoelectrical abnormalities. METHODS: Fourteen patients with long-standing type 1 diabetes mellitus and dyspepsia symptoms participated in the study. EGG recordings were obtained 30 minutes before and during a 2-hour radionuclide gastric emptying test for a solid meal. Fasting blood glucose was determined immediately before the gastric emptying study. Symptoms of nausea, vomiting, early satiety, abdominal bloating, and pain were rated from 0 to 3. RESULTS: Nine patients (64%) had delayed gastric emptying with 84.6 +/- 4.5% retention at 2 hours. Seven patients (50%) had abnormal EGG findings. The postprandial power change in the EGG of the patients with delayed gastric emptying (-0.48 +/- 0.16 dB) was decreased compared with patients with normal gastric emptying (4.7 +/- 2.6 dB) (P = 0.079). In patients with abnormal EGGs, the mean symptom score was significantly higher than patients with normal EGGs (2.42 +/- 0.13 versus 2.0 +/- 0.16; P < 0.05). Compared with normal gastric emptying patients, patients with delayed gastric emptying had higher but not significantly different symptom scores (2.31 +/- 0.11 versus 2.08 +/- 0.30; P = 0.225). There was no significant difference in fasting glucose levels in delayed (252 +/- 61.2 mg/dl) versus normal (378 +/- 82 mg/dl) gastric emptying or abnormal (288 +/- 86.4 mg/dl) EGGs versus patients with normal (304 +/- 57.6 mg/dl) EGGs. CONCLUSIONS: Overall, 78% (11 of 14) of patients with diabetes had either gastric motility or myoelectrical abnormalities. Patients with abnormal EGGs had more severe symptom scores. In diabetic patients with symptoms of gastropathy, an EGG may provide an important screening test for diagnosing abnormal gastric motility.     

Association of blood glucose with angiographic and clinical outcomes among patients with ST-segment elevation myocardial infarction (from the CLARITY-TIMI-28 study)

Overt hyperglycemia has been associated with adverse clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The association of hypoglycemia and mild hyperglycemia with angiographic outcomes and the effect of clopidogrel on these outcomes have not been extensively evaluated. Patients with STEMI enrolled in the CLARITY-TIMI 28 trial (n=3,491) were divided into 6 groups based on admission blood glucose level (<81, 81 to 99, 100 to 125, 126 to 149, 150 to 199, and >199 mg/dl). Angiographic and clinical outcomes were analyzed. Thirty-day mortality was increased (p<0.001) in patients with hypoglycemia (glucose<81 mg/dl, 6.3%) and severe hyperglycemia (glucose>199 mg/dl, 10.4%) compared with the euglycemic group (glucose 81 to 99 mg/dl, 2.6%). Occlusion of the infarct-related artery (IRA; Thrombolysis In Myocardial Infarction flow grade 0/1) at scheduled angiography was more common with increased glucose (9.3% for glucose 81 to 99 mg/dl, 15.6% for glucose>199 mg/dl, p=0.004). Multivariable analysis demonstrated that hyperglycemia was associated with a twofold increase in the composite of an occluded IRA, death, or recurrent MI before angiography (glucose>199 mg/dl, odds ratio 1.93, 95% confidence interval 1.17 to 3.18, p=0.01; glucose 150 to 199 mg/dl, odds ratio 2.04, 95% confidence interval 1.30 to 3.22, p=0.002). There was no significant interaction between clopidogrel administration and the association of glucose and IRA patency (p interaction=NS). In conclusion, in patients with STEMI, hypoglycemia and severe hyperglycemia are associated with increased 30-day mortality. IRA patency after fibrinolytic administration is related to admission glucose independent of clopidogrel administration.     

Rapid gastric emptying in diabetes mellitus: Pathophysiology and clinical importance

Although slow gastric emptying (gastroparesis) is a well-known complication of chronic hyperglycemia in diabetes mellitus (DM), it recently has become clear that rapid gastric emptying also is a frequent and important diabetic complication. In contrast, acute hyperglycemia causes slow gastric emptying, and acute hypoglycemia causes rapid gastric emptying. Rapid gastric emptying is frequent in T2DM; however, it may also occur in T1DM, particularly in the early stages of the disease, but may persist even into late stages. Recent studies suggest that usually, the stomach restricts the emptying of nutrients to 1–4 kcals/min. This restriction is due to the action of the gastric ‘braking’ hormones such as GLP-1, leptin, and amylin acting via the gastric inhibitory vagal motor circuit (GIVMC). Disruption of this braking system leads to rapid gastric emptying. Acute hyperglycemia also slows gastric emptying by stimulating the GIVMC, while acute hypoglycemia causes rapid gastric emptying by stimulating the gastric excitatory vagal motor circuit (GEVMC). In contrast, chronic hyperglycemia causes rapid gastric emptying by inducing oxidative stress in the stomach wall that disrupts inhibitory neuromuscular transmission and increases the contractility of the smooth muscle, while chronic hyperglycemia may also cause slow gastric emptying via severe inflammatory stress caused by proinflammatory macrophages and reduce contractility of the smooth muscle. There is a bidirectional relationship between blood glucose and gastric emptying. Thus, rapid gastric emptying may lead to a sizeable postprandial spike, and slow gastric emptying may blunt it. Postprandial hyperglycemia is involved in the development, progression, and complications of DM. Correction of fast gastric emptying involves agents that activate GIVMC and the use of gastric ‘braking’ hormones or their analogs. Recognition and treatment of rapid gastric emptying may contribute to better management of postprandial hyperglycemia and prevention of some diabetic complications.     

Usefulness of Acarbose and Dietary Modifications to Limit Glycemic Variability Following Roux-en-Y Gastric Bypass as Assessed by Continuous Glucose Monitoring

Abstract Background: About 70% of the patients operated on for a gastric bypass (Roux-en-Y gastric bypass [RYGB]) suffer from dumping syndrome. In these patients, previous studies have demonstrated a high glycemic variability with hypoglycemia and with altered continuous glucose monitoring (CGM) profiles. The aim of this study was to evaluate the effect of treatment with dietary counseling plus acarbose administration on the symptoms and on the characteristics of the CGM profile. Subjects and Methods: Eight consecutive patients with dumping syndrome were given dietary counseling for 6 weeks and also treated with acarbose (50-100?mg three times a day). Their symptoms and the features of the CGM were compared before and after treatment. Results: The symptoms disappeared in seven patients. There was a significant increase in the time to the interstitial glucose (IG) peak and a reduction in the rate of the IG increase after a meal and in the rate of the IG decrease following the peak. The time below 60?mg/dL was significantly decreased, and the minimal IG value was significantly increased. The maximum and mean IG levels and the time above 140?mg/dL were decreased, but not significantly. Six patients spent more than 1% of the time with IG values below 60?mg/dL before treatment, but after treatment this was reduced to one patient. Before treatment only one patient had an IG level neither below 60 or above 140?mg/dL, and after treatment four patients were in this category. Conclusions: Dietary counseling and acarbose treatment eliminated the symptoms and improved the CGM profile of patients suffering from dumping syndrome after RYGB.