Joyce G. Schwartz

Rapid Gastric Emptying of a Solid Pancake Meal in Type II Diabetic Patients

OBJECTIVE To estimate the rate of gastric emptying of a solid pancake carbohydrate meal in recently diagnosed asymptomatic type II diabetic patients compared with nondiabetic control subjects. RESEARCH DESIGN AND METHODS Gastric emptying studies using radiolabeled meals were performed on eight recently diagnosed asymptomatic diabetic patients and on eight sex-, BMI- and age-matched nondiabetic control subjects. Although a liquid protein drink was administered along with the pancake meal, the radioactivity was adherent to only the pancake portion of the meal. Plasma glucose and serum insulin levels were measured in fasting and postprandial blood samples collected at 15-min intervals up to 120 min after ingestion of the mixed nutrient meal. RESULTS The average gastric half-emptying time (time it takes for one-half of the meal to empty) was significantly more rapid for the diabetic patients (45.3 ± 4.8 min) when compared with the nondiabetic control subjects (60.4 ± 5.1 min; P = 0.05). The serum insulin concentrations were not statistically different between the two groups. Plasma glucose values were significantly higher in the diabetic patients compared with the nondiabetic control subjects. CONCLUSIONS Type II diabetic patients with no clinical evidence of neuronal dysfunction have a significantly more rapid rate of gastric emptying of a solid high-carbohydrate meal when compared with nondiabetic control subjects.

Treatment With an Oral Proteinase Inhibitor Slows Gastric Emptying and Acutely Reduces Glucose and Insulin Levels After a Liquid Meal in Type II Diabetic Patients

OBJECTIVE To determine whether an oral trypsin/chymotrypsin inhibitor, POT II, will delay the rate of gastric emptying in recently diagnosed type II diabetic patients and improve their postprandial metabolic parameters. RESEARCH DESIGN AND METHODS Two gastric emptying studies were performedon each of six type II diabetic patients. During one study, the patient ingested a glucose/protein solution, and during the other study, the patientingested the same glucose/protein solution with the addition of 1.5 g ofPOT II, a putative stimulant of cholecystokinin (CCK) release. Each patient served as their own control subject. Each of the two oral solutions were administered to the patients in a counterbalanced order separated by at least 1 week. RESULTS Serum insulin, plasma glucose, plasma gastric inhibitory polypeptide (GIP) values, and the rate of gastric emptying were all significantly (P <0.05) decreased over the 2-h testing period when POT II was added tothe oral glucose/protein meal. The area under the curve above baseline for glucose with POT II was 75% of the glucose value without POT II. The areaunder the curve above baseline for insulin with POT II was 68% of the value without POT II. Plasma CCK was significantly increased by POT II 15 min postprandially. CONCLUSIONS A trypsin/chymotrypsin inhibitor, POT II, can delay therate of gastric emptying, and decrease postprandial plasma glucose levels, GIP levels, and serum insulin levels in type II diabetic patients diagnosed recently. Delay of gastric emptying in diabetic patients may provide a uniqueor adjunctive approach to the treatment of type II diabetes.

Reduced postprandial blood glucose levels in recently diagnosed non-insulin-dependent diabetics secondary to pharmacologically induced delayed gastric emptying

In a previous study we demonstrated that patients with recently diagnosed non-insulin-dependent diabetes mellitus (NIDDM) had significantly increased gastric emptying rates of glucose solutions compared with those of nondiabetic sex- and age-matched controls. This finding of rapid gastric emptying contrasts with the delayed gastric emptying often exhibited as a late manifestation of diabetes mellitus that is attributed to autonomic neuropathy. The purpose of this study was to determine, in seven of the patients previously studied, whether (1) an intravenous infusion of cholecystokinin-8 (CCK-8) would delay the gastric emptying of a liquid glucose meal and, if so, (2) whether the delay in gastric emptying would result in reduced postprandial blood glucose concentrations due to prolongation of the absorption of the glucose in the liquid meal. Each patient underwent two separate gastric emptying studies, one during a saline infusion and one during a CCK-8 infusion. Blood samples were obtained at 15-min intervals for measurement of glucose, insulin, CCK-8, and gastric inhibitory polypeptide (GIP) concentrations. The average gastric half-emptying time was 41 min with the saline infusion and 94 min with the CCK-8 infusion (P=0.0042). The average glucose concentration over the 2-hr period following glucose ingestion was 17.1 mmol/liter with the saline infusion and 14.0 mmol/liter with the CCK-8 infusion (P=0.0073). The average glucose excursion value over the 2-hr period was reduced from 5.6 mmol/liter to 3.7 mmol/liter with the CCK-8 infusion (P=0.0550). Average CCK-8 (P=0.0247) and GIP (P=0.0032) excursion values were significantly different when patients received the CCK-8 infusion compared to concentrations after the saline infusion. Agents that delay gastric emptying may have therapeutic applications in patients with NIDDM.

Toxicity of a family from vacuumed mercury

A family of four developed toxic blood levels of mercury after the mother vacuumed a spilled jar of liquid mercury from a closet in their apartment. The youngest son developed severe thrombocytopenia which was initially diagnosed as idiopathic thrombocytopenic purpura secondary to viral illness. A possible association between acute mercury toxicity and idiopathic thrombocytopenic purpura has not been previously reported. Chelation therapy with penicillamine for the older child was administered soon after toxic blood mercury levels were known by the physician. Because thrombocytopenia has been reported to occur in up to 5% of patients receiving penicillamine therapy, the younger child was treated with dimercaptosuccinic acid. The mother was also treated with dimercaptosuccinic acid. The father received dimercaprol therapy. The toxic effects and rationale for now outdated therapeutic uses of mercury are discussed.

Gastric emptying in Mexican Americans compared to non-Hispanic whites

Mexican Americans, a group at high risk for type II diabetes mellitus, have higher postprandial insulin and glucose levels when compared to non-Hispanic whites. A rapid rate of gastric emptying contributes to an increased rate of nutrient absorption and subsequent greater elevation of postprandial glucose and insulin levels. A more rapid rate of gastric emptying and hyperinsulinemia have been observed in patients with recently diagnosed type II diabetes mellitus. In this study, we examined whether Mexican Americans have a more rapid rate of gastric emptying than non-Hispanic whites. Gastric emptying studies were performed on 32 nondiabetic Mexican Americans and on 31 nondiabetic non-Hispanic whites. The rate of gastric emptying following a liquid glucose meal was measured. Serum insulin, plasma glucose, and GIP levels were measured in fasting and postprandial blood samples collected at 15-min intervals for 2 hr. Adjusting for age, body mass index, and gender, the gastric half-emptying time of a glucose meal was significantly (P<0.05) more rapid for the Mexican American subjects (56.5±3.4 min) compared to the non-Hispanic white subjects (66.4±3.5 min). Nondiabetic Mexican Americans empty a liquid glucose meal more rapidly from their stomachs than nondiabetic non-Hispanic whites. Rapid gastric emptying is associated with hyperinsulinemia as a normal physiologic response to increased nutrient availability. The rapid gastric emptying observed in nondiabetic Mexican Americans is associated with hyperinsulinemia and could be a contributing factor for the increased risk of obesity and type II diabetes in this population.

Accelerated gastric emptying of glucose in Zucker type 2 diabetic rats: role in postprandial hyperglycaemia

Summary Patients with early non-insulin-dependent diabetes mellitus (NIDDM) empty glucose solutions from their stomachs more rapidly than non-diabetic control subjects, and this exacerbates postprandial hyperglycaemia.To determine if accelerated gastric emptying occurred in a rat model of NIDDM and influenced postprandial hyperglycaemia, gastric emptying of glucose was measured, and the effect of slowing the gastric emptying rate on postprandial hyperglycaemia was observed. We tested eight male obese Zucker diabetic rats and eight age-matched lean Zucker controls at 10–13 weeks of age to measure gastric emptying of glucose (by gamma scintigraphy). Rats fasted overnight were gavaged with 30 % glucose at 1 ml/100 g body weight. Separately, six Zucker diabetic rats and six lean controls were tested for sensitivity to the inhibitory effects of cholecystokinin and secretin on gastric emptying. The diabetic rats emptied glucose significantly faster than controls (t1/2 = 37.3 ± 1.5 vs 58.8 ± 2.3 min in controls), and aging exaggerated this differential. Camostat, a stimulant of cholecystokinin and secretin release, added to the glucose meal significantly slowed gastric emptying (t1/2 = 123 ± 23 and 166 ± 19 min, diabetic vs lean, respectively), and significantly reduced postprandial hyperglycaemia in diabetic rats. Compared to Zucker lean controls, Zucker diabetic rats were as sensitive (cholecystokinin) or more sensitive (secretin) to gastrointestinal hormones that inhibit gastric emptying. The results demonstrate accelerated gastric emptying in a rat model of NIDDM, consistant with similar observations in humans with early NIDDM. These results also support the proposal that interventions to slow gastric emptying may improve glucose control in this disease. [Diabetologia (1997) 40: 136–142]

Granulocytic sarcoma of the mandible

The case is presented of a 54-year-old black man with a mass apparently involving only the soft tissue retromolar trigone on panoramic and mandibular series radiographs. A granulocytic sarcoma involving the mandible was diagnosed on biopsy with the aid of histochemical stains, immunologic cell surface markers, and electron microscopy. The autopsy also revealed involvement of the ribs and liver.

Nocardial osteomyelitis: A case report and review of the literature

The occurrence of human nocardiosis is increasing in both immunocompetent as well as immunosuppressed patients. A 63-yr-old male construction worker presented with complaints of left hip pain and rapidly enlarging masses on his left neck and chest. He had been treated for a pneumonia of unknown etiology 3 mo prior to admission. A debridement of the left femur was performed and the curetted material was positive for Nocardia asteroides. Osteomyelitis due to the hematogenous spread of Nocardia asteroides is rare, but will undoubtedly be seen with increasing frequency. The literature, as well as 11 reported cases of the hematogenous spread of this organism, are reviewed.

Gastric emptying of beer in Mexican-Americans compared with non-Hispanic whites

Gastric emptying studies were performed on 11 nondiabetic Mexican-Americans and 11 nondiabetic non-Hispanic whites following ingestion of 450 mL beer. Plasma glucose, serum insulin, and serum alcohol levels were measured in the fasting state and at 7, 15, 30, 45, and 60 minutes following ingestion of the beer. The area under the gastric emptying curve was significantly larger for non-Hispanic whites compared with Mexican-Americans (P = .0492), indicating that Mexican-Americans had faster stomach emptying. Partial correlation coefficients (adjusted for ethnicity, gender, age, and body mass index [BMI]) showed the gastric half-emptying time was inversely related to the incremental levels of glucose (r = -.709, P = .0010) and alcohol (r = -.650, P = .0035). The faster the rate of gastric emptying of beer, the higher the glucose and alcohol levels. There were no significant correlations between insulin and the rate of gastric emptying. The caloric emptying rate for the beer was much more rapid than previously reported for other liquid meals.

Filamentous Histoplasma capsulatum involving a ventriculoatrial shunt.

We describe the first case, to our knowledge, of filamentous Histoplasma capsulatum infection in a ventriculoatrial shunt. A review of the literature on the incidence, etiologies, and symptomatology of shunt-related infections is presented. The pathogenesis and treatment of the fungus-infected shunts are also discussed.