Resistance to insulin-mediated glucose uptake has been implicated in the pathogenesis of Type II (non±insulin-dependent) diabetes mellitus, hypertension and coronary heart disease [1]. Insulin resistance is present in several non-European ethnic groups in which prevalence of' Type II diabetes is higher than in Europeans matched with them for weight, for instance in people of South Asian (Indian, Pakistani, Bangladeshi and Sri Lankan) descent [2]. Insulin resistance is strongly associated with obesity, especially central obesity, but the mechanism of this association is poorly understood. One possibility is that non-esterified fatty acids (NEFA) produced by lipolysis of triglyceride stores in muscle cells block glucose uptake either through substrate competition, as proposed over 30 years ago [3], or through direct inhibition of glucose transport [4].The relation of insulin sensitivity to intramyocellular lipid (IMCL) has been examined in muscle biopsy Diabetologia (1999)
AbstractAims/hypothesis. To compare the relation between intramyocellular lipid content, central obesity and insulin sensitivity in Europeans and South Asians. Methods. Cross-sectional study of 40 South Asian and European non-diabetic men matched for age and body mass index. We measured intramyocellular lipid by proton magnetic resonance spectroscopy of soleus muscle, insulin sensitivity by the short insulin tolerance test, per cent body fat by dual-energy x-ray absorptiometry and visceral fat by single-slice computed tomography of the abdomen. Results. South Asians compared with Europeans had a higher mean per cent body fat (26.8 % vs 22.5 %, p = 0.05) and lower insulin sensitivity (mean ± SEM 2.4 ± 0.2 vs 3.4 %/min ± 0.3, p = 0.013). Mean ( ± SEM) intramyocellular lipid content was higher in South Asians than in Europeans (72.1 ± 7.5 vs 53.6 ± 4.9 mmol/kg dry weight, p = 0.046). In Europeans intramyocellular lipid was correlated with per cent body fat (r = 0.50, p = 0.028), waist:hip ratio (r = 0.74, p < 0.001), visceral fat (r = 0.62, p = 0.004) and insulin sensitivity (r = ±0.53, p = 0.016). In South Asians intramyocellular lipid was not significantly related to insulin sensitivity or obesity, and the strongest associations of insulin sensitivity were with fasting plasma triglyceride and waist:hip ratio. Conclusion/interpretation. The association of intramyocellular lipid with insulin sensitivity and obesity in Europeans is consistent with the hypothesis that muscle triglyceride mediates the effect of obesity on insulin sensitivity. The absence of a similar relation of insulin sensitivity to intramyocellular lipid in South Asians suggests that other mechanisms underlie the high insulin resistance observed in this group. [Diabetologia (1999) 42: 932±935]
IMPORTANCE End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time.OBJECTIVE To determine the changes in end-of-life practices in European ICUs after 16 years. DESIGN, SETTING, AND PARTICIPANTS Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999)(2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision.
The Royal College of Radiologists (RCR) has published guidelines concerning indications for imaging investigations. These include plain radiography of the knee, the indications for which are locking or signs of restricted movement. This audit consisted of 1153 knee radiographs in a 9 month period, results of a questionnaire sent to general practitioners (GPs), analysis of radiological reports and returned questionnaires (55% of cases), and subsequent comments from the GPs on receiving these results. Only 50% of cases fall within RCR guidelines, 90% of radiographs were normal or showed degenerative change. In 42% of cases, knee radiographs were requested to confirm previously expected degenerative change, and in 30% patient pressure was a significant factor. Most knee radiographs (87%) result in no significant change in management apart from continuation of symptomatic measures. Application of current guidelines, however, would miss some important diagnoses manifest clinically by persistent pain or effusion, for example loose body or Brodie's abscess. In cases of locking, where a radiograph may miss significant soft tissue abnormality, there was concern that reassurance was often gained by a normal examination. This audit shows that many knee radiographs are unnecessary. The guidelines appear appropriate with the proviso that persistent pain and effusion should be included as indications for investigation. Many GPs report medico-legal considerations as important reasons for unnecessary referrals, although the application of guidelines should be protection against this. The referral rate for knee radiographs before and after the communication of these results has not altered.
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