Dairy cattle exposed to summer heat stress (HS) typically exhibit altered metabolic characteristics, including hyperinsulinemia concurrent with hypoglycemia. The reasons for this change in glycemic status and its consequences are currently unknown. This project aimed to examine the relationship between summer HS, blood glucose concentrations, and milk production in primiparous (n=26) and multiparous (n=27) Holstein cows. Glucose was measured in coccygeal vein blood twice weekly using a hand-held glucometer (Abbott Precision Xtra) from May through July. Rectal temperatures were also collected. The days surrounding sample collections were categorized as having no HS (0 h above 68 Thermal Humidity Index [THI]), moderate HS (>0 to 8 h above 68 THI) or severe HS (>8 h above 68 THI). A subset of cows with ≥5 blood glucose measurements spanning different THI categories were categorized as hypoglycemic (n=8 primiparous; n=9 multiparous) or non-hypoglycemic (n=6 primiparous; n=5 multiparous) based upon blood glucose concentrations on no-HS days and severe-HS days (hypoglycemic if sustained reduction on severe-HS days). When analyzed together, milk production did not differ between those categorized as hypoglycemic and non-hypoglycemic. When separated based upon parity, there was a tendency for primiparous hypoglycemic cows to produce more milk than their non- hypoglycemic counterparts (P<0.15). Variability in milk production measured as standard deviation across no-, moderate- and severe-HS days did not differ based upon glycemic status but was greater in multiparous than primiparous cows (P<0.01). Rectal temperatures were greater on severe-HS days than on no- or moderate-HS days (P<0.01) and were positively correlated with the number of h of HS in a day (r=0.45; P<0.01). Neither milk nor glucose differed based upon the category of HS severity. Interestingly, however, glucose was negatively correlated with milk production on the day of measurement (r=-0.24; P<0.01) and day after measurement (r=-0.23; P<0.01). These results are an initial indication that hypoglycemia during HS is related to milk production, particularly in primiparous cows. / Master of Science / Dairy producers lose production and profitability when their dairy cows experience heat stress. Heat stress in dairy cattle during the summer months causes declines in milk production and reproductive performance, which may be at least partially due to the unique metabolic changes observed in heat-stressed dairy cattle. One of these changes is a reduction in blood glucose that has been linked with productivity in previous studies. Measuring blood glucose concentrations may be a useful tool for measuring individual cow responses to heat stress, and ultimately lead to a better understanding of these changes. The work described here aims to explore the relationship between both summer heat stress and blood glucose concentrations in primiparous (calving =1) and multiparous (calving >1) Holstein cows. A total of 53 cows were used, 26 being primiparous and 27 being multiparous. Rectal temperatures, blood glucose measurements and milk production records were collected. A subset of cows were categorized as either hypoglycemic or non-hypoglycemic based on glucose concentrations on non-heat stress and heat stress days. When all cows were analyzed together, milk production did not differ based on glycemic category. When separated based upon parity, there was a tendency for cows that had calved once and were hypoglycemic to produce more milk than their non-hypoglycemic contemporaries. Rectal temperatures were greater on severe-heat stress days than on no- or moderate-heat stress days and were positively correlated with the number of hours of heat stress in a day. Neither the quantity of milk produced, nor blood glucose differed based upon the severity of heat stress. Interestingly, however, blood glucose was negatively correlated with the quantity of milk produced on the day of blood collection and day after blood collection. These Results indicate that measuring blood glucose concentrations could be a useful tool in predicting individual cow's responses to heat and their ability to sustain productivity in summer months.

A procedure was developed for the quantitative separation of major fermentation products of uniformly labeled glucose-C¹⁴ produced by bovine rumen microorganisms in vitro. After 45 min, the fermentation mixture was fractionated into (a) one control subsample, and duplicate fractions of (b) solid matter “precipitate“, (c) ether extract, (d) “amino acid“, (e) “sugar“, (f) CO₂, and (g) CH₄. Similar fractionation of an unfermented control sample was made. A portion of the fermentation ether extract was subjected to column chromatography to resolve (a) C₁, (b) C₂, (c) C₃, (d) C₄, and (e) C₅ fatty acids, (f) succinic, and (g) lactic acids. Each fraction was analyzed in triplicate for C¹⁴ by a direct plating technique. Corrections for geometry, self absorption, and efficiency were made by direct plating additional triplicate fraction subsamples, each containing a uniformly labeled glucose-C¹⁴ internal standard. The data were expressed as per cent recovery of added C1u. The results indicated that glucose was rapidly fermented with most of the C¹⁴ found in the ether extractable fraction as acetic acid. Significant levels of C¹⁴ were found in the “precipitate“ fractions. The data were compatible with evidence that CH₄ was derived from CO₂. The results of 6 trials indicated that there was no significant difference in the distribution of products resulting from the in vitro fermentation of uniformly labeled glucose-C¹⁴ between animals, between days within animals, or between times within days. / Ph. D.

The prevalence of obesity and diabetes is increasing in the United States and abroad and strategies are needed to prevent the progression from an at-risk state to the clinically diagnosed diseases. Flavanols in cocoa powder have been shown to reduce blood glucose concentrations, improve insulin sensitivity, and decrease gut permeability in animals and humans, but it is unknown if this occurs in adults with prediabetes. Therefore, we first hypothesized that an acute dose of cocoa would reduce postprandial glucose and enhance insulin and incretin hormone responses to a mixed meal challenge compared to a placebo. Second, we hypothesized that 15 g cocoa/day for 4-weeks would reduce gut permeability, attenuate endotoxin response to a high fat meal, improve insulin sensitivity, and improve measures of skeletal muscle substrate flexibility in a randomized, double blinded, placebo controlled parallel group design. To test the first hypothesis, 30 overweight or obese volunteers who were at-risk for diabetes completed two meal challenges using a randomized crossover design. Blood samples were collected hourly for 4 hours and were analyzed for glucose, insulin, C-peptide, glucagon-like peptide 1 (GLP-1), and gastric inhibitory peptide (GIP). Cocoa did not influence these measures. However, participants with the lowest fasting blood glucose concentrations were more likely to respond to the cocoa as hypothesized. To test our second hypothesis, 15 overweight or obese adults at risk for developing diabetes consumed either the cocoa or placebo treatments along with a controlled diet for one month. Overall, cocoa did not seem to influence insulin sensitivity, gut permeability, or endotoxin levels, although cocoa may influence skeletal muscle substrate metabolism. In conclusion, the data for both studies suggests that cocoa did not exert substantial effects on the evaluated outcomes. However, the experiments did provide valuable information about incretin hormone levels in adults with impaired glucose tolerance. More research is needed to understand how cocoa can affect glucose homeostasis for overweight or obese adults. / Ph. D. / The purpose of this research project was to determine if cocoa powder could influence how we digest food and improve our health. For many people in the United States and abroad, controlling blood sugar levels is important for their well-being; uncontrolled spikes in blood sugar levels can eventually lead to type 2 diabetes and heart disease. Our first hypothesis was that one serving of cocoa could help reduce large spikes in blood sugar after a meal. Secondly, we hypothesized that consuming cocoa powder for one month could improve blood sugar and other health outcomes related to diabetes. To test the first hypothesis, 30 overweight or obese volunteers who were at-risk for diabetes completed two blood tests. At the beginning of the tests, they consumed a meal replacement shake mixed with cocoa powder or a placebo powder. The participants had their blood drawn every hour for four hours. A week later, they repeated the same test with the alternative powder. Blood samples were analyzed for sugar levels and four hormones that are important for controlling sugar spikes. We found that the cocoa made no difference in blood sugar levels. However, we noticed that some of our participants had greater sugar spikes than others. Those who had large sugar spikes had deficient levels of certain hormones. Although our experiments showed that cocoa did not affect these hormones, other studies found that compounds similar to cocoa could increase these hormone levels. Future directions could include using a different meal or studying more adults deficient in these hormones. For the second hypothesis, 15 overweight or obese adults at risk for developing diabetes completed the study. They consumed cocoa powder or placebo powder beverages along with a controlled diet provided to them for one month (they did not know which treatment they received). We tested several outcomes related to digestion and metabolism including leakiness of the gut, ability to control blood sugar levels, and the ability of skeletal muscle to burn sugars and fats. Overall, cocoa did not seem to influence any of our outcomes. In conclusion, my experiments did not demonstrate any substantial effects of cocoa on blood sugar levels. However, the experiments did provide valuable information about hormone levels in overweight and obese adults. More research is needed to understand how cocoa can affect health outcomes for overweight or obese adults.

Yes / Telomerase reverse transcriptase (TERT) is a key component of the telomerase complex. By lengthening telomeres in DNA strands, TERT increases senescent cell lifespan. Mice that lack TERT age much faster and exhibit age-related conditions such as osteoporosis, diabetes and neurodegeneration. Accelerated telomere shortening in both human and animal models has been documented in conditions associated with insulin resistance, including T2DM. We investigated the role of TERT, in regulating cellular glucose utilisation by using the myoblastoma cell line C2C12, as well as primary mouse and human skeletal muscle cells. Inhibition of TERT expression or activity by using siRNA (100nM) or specific inhibitors (100nM) reduced basal 2-deoxyglucose uptake by ~50%, in all cell types, without altering insulin responsiveness. In contrast, TERT over-expression increased glucose uptake by 3.25-fold. In C2C12 cells TERT protein was mostly localised intracellularly and stimulation of cells with insulin induced translocation to the plasma membrane. Furthermore, co-immunoprecipitation experiments in C2C12 cells showed that TERT was constitutively associated with glucose transporters (GLUTs) 1, 4 and 12 via an insulin insensitive interaction that also did not require intact PI3-K and mTOR pathways. Collectively, these findings identified a novel extra-nuclear function of TERT that regulates an insulin-insensitive pathway involved in glucose uptake in human and mouse skeletal muscle cells.

The importance of understanding the stress response can not be underestimated in fisheries research or the aquaculture industry. Three studies were undertaken to quantify the secondary stress responses of striped bass and its hybrid. These were measured as fluctuations in glucose, glycogen, lactate, and osmolality. Fish were stressed by aerial emersion in a dipnet. The first study was conducted with fingerling inland and anadromous striped bass. The three goals were to: determine if fingerlings responded with the General Adaptation Syndrome, if the two had different responses to the stress, and if feeding state (fed up until the day of the stress vs. starved for three days prior) had an effect on the stress response. The second study was conducted with two-year-old pure and hybrid striped bass. The two goals were to: determine any differences in the stress response, and to see if the feeding state played a role in the response. The third study was conducted with hybrid fingerlings. This study looked at the ability of fed and three-day starved fish to moderate their secondary stress responses after handling stress, when placed in 0, 5, 10, or 15% saline recovery water. / Master of Science

The objective of this study is to determine if fat as an energy source, and fiber in a pasture supplement will be beneficial when compared to a concentrate high in sugar and starch. In the first experiment, 12 pregnant and lactating mares were used in three different glycemic response tests to determine the effect of feeds on pregnant mares. The mares were fed a pelleted concentrate (PC) three months before foaling; after foaling they were divided into two groups and fed a feed high in sugar and starch (SS), or a feed high in fat and fiber (FF). The second experiment, used the same 12 mares (R mares) and 10 barren mares (B mares) in three different tests to determine the effects of the feeds, season and reproductive stage. A series of blood samples was collected via a jugular catheter from 0 to 390 min after consuming a meal. Glucose and insulin baseline and peak values, increments and areas under curves (AUC) were compared by ANOVA. For the first experiment, responses to PC did not differ between the two groups. Peak plasma glucose and insulin concentrations were higher in SS group than in FF during both early and late lactation. Glucose and insulin AUCs were higher in SS than in FF during both early and late lactation. In the second experiment, peak glucose increments had differences for the main effects feed, pregnancy and season, and interactions feed by pregnancy and feed by season. The glucose AUC values showed similar differences for the main effects and the interaction feed by pregnancy. Peak insulin increments had a difference for feed and pregnancy, but not the interactions. Insulin AUCs also revealed a difference between feed and pregnancy, and also for season, and the interaction feed by pregnancy. These results indicate that metabolic fluctuations are moderated by the replacement of sugar and starch with fat and fiber. This replacement may reduce the risk of certain digestive and metabolic disorders. / Master of Science

Les récepteurs nucléaires LXRs sont associés aux métabolismes des lipides, du cholestérol et des hydrates de carbone. Ses agonistes naturels seraient des dérivés oxydés du cholestérol connus sous le nom d’oxystérols. Le cholestérol et les oxystérols sont associés au développement de l’athérosclérose une maladie cardiovasculaire qui a des graves conséquences sur les sociétés modernes. L’un des facteurs de risque majeurs de l’athérosclérose est le diabète de type II. Dans cette étude, qui essaye de faire un lien entre athérosclérose et diabètes, nous avons étudié les effets des LXRs sur le transport du glucose en conditions d’hyperglycémie et d’hyperglycémie/hyperinsulinémie qui sont des caractéristiques du diabète de type II. Nous avons mis en évidence que les transporteurs des hydrates de carbone Glut1, Glut3, Glut5 et Glut9 sont exprimés dans le macrophage humain THP1. Glut5 est connu comme étant un transporteur de fructose et Glut9 comme un transporteur d’urée. Nous avons démontré que Glut1 est impliqué dans le transport glucose des macrophages humain THP-1 et que ce transport est sensible à l’insuline. Tant l’activation spécifique que l’activation non spécifique de LXRs augmentent le transport de glucose dans les conditions étudiées, mais d’une manière différente. Cette étude nous a permis de démontrer qu’il pouvait y avoir un lien entre l’activation des récepteurs nucléaires LXRs sensibles aux oxystérols et une amélioration du transport du glucose dans les macrophages humains. / LXRs are nuclear receptors involved in lipids, cholesterol and carbohydrates metabolism. Their natural agonists are believed to be oxidized derivatives of cholesterol known as oxysterols. Cholesterol and oxysterols are associated with the development of atherosclerosis a cardiovascular disease having devastating consequences in modern societies. One of the major risk factors for atherosclerosis is type II diabetes. In this report, trying to make a link between atherosclerosis and diabetes, we attempt to demonstrate that LXRs may have an effect on glucose transport in conditions of hyperglycemia or hyperglycemia/hyperinsulinemia, two specific characteristics of type II diabetes. We found that in the THP1 human macrophage Glut1, Glut3, Glut5 and Glut9 are expressed. Glut5 is known as a fructose transporter and Glut9 as a urea transporter. We unveil that Glut1 was involved in glucose transport in human THP1 macrophages, and it was sensible to induction with insulin. Both specific and less specific activation of LXR increased glucose transport in hyperglycemic and hyperglycemic/hyperinsulinemic conditions but in a different way. This study demonstrated that activation of LXRs nuclear receptors that are sensible to oxysterols have benefic effects on glucose transport in human macrophages.

Lorsque l’insuline se lie à son récepteur, elle induit une cascade de réactions indispensables à l’utilisation du glucose. La résistance à l’insuline et le diabète de type 2 qui affectent une fraction croissante de la population résultent d’un défaut de signalisation de l’insuline. La voie de signalisation PI3K qu’emprunte l’insuline pour promouvoir l’utilisation du glucose est d’abord décrite en introduction de cette thèse. Aussi, il existe plusieurs mécanismes de désensibilisation qui sont essentiels pour limiter l’ampleur du signal à la réponse métabolique requise. Cependant, ces mécanismes sont altérables et de faibles dérèglements peuvent devenir responsables d’une propagation défaillante du signal insulinique. Les souris viable motheaten (mev), déficientes en activité SHP-1, nous ont permis au premier chapitre de démontrer que SHP-1 constitue un de ces mécanismes de désensibilisation. Ces souris montrent une plus grande tolérance au glucose et une meilleure sensibilité à l’insuline que les souris non-déficientes en SHP-1, ainsi qu’une meilleure signalisation de l’insuline dans le foie et le muscle squelettique. De plus, nous avons pu démontrer que SHP-1 contrôle aussi la clairance hépatique de l’insuline, importante pour réguler la concentration et la sensibilité systémique de l’insuline. Cette première étude a donc permis d’établir un nouveau rôle pour SHP-1 dans la régulation de l’action de l’insuline. Par la suite, il devenait primordial de décrire les mécanismes impliqués dans la sensibilisation à l’insuline par la déficience en SHP-1 dans le muscle et le foie. À l’aide d’adénovirus codant pour un mutant catalytiquement inerte de SHP-1 (DNSHP-1), nous rapportons au deuxième chapitre, par l’expression de DNSHP-1 dans les hépatocytes Fao, que la diminution de la production hépatique de glucose observée chez les souris mev résulte d’une augmentation de la glycogénèse plutôt que d’une diminution de la gluconéogenèse. Enfin, au dernier chapitre, DNSHP-1 exprimé dans les myocytes L6 favorise la signalisation via Akt, et accroît l’expression de GLUT4, le principal transporteur de glucose sensible à l’insuline. Ensemble, nos résultats suggèrent clairement que SHP-1 est un nouveau modulateur de l’action de l’insuline dans le foie et le muscle squelettique. SHP-1 pourrait donc représenter une nouvelle cible thérapeutique pour traiter le diabète de type 2. / After binding to its receptor, insulin induces a reaction cascade that is essential for glucose utilization. Insulin resistance and type 2 diabetes are affecting an increasing portion of the population and result from insulin signaling impairment. Insulin signaling pathways promoting glucose utilization are reviewed in the introduction of the thesis, as well the desensitization mechanisms which are crucial to limit insulin signal duration and intensity. Viable motheaten (mev) mice, harboring a spontaneous mutation leading to SHP-1 activity deficiency, allowed us to demonstrate in chapter I that SHP-1 constitutes one of these desensitization mechanisms. Indeed, mev mice showed an increased glucose tolerance and insulin sensitivity as compared to wild type littermates, resulting from increased insulin signaling in liver and skeletal muscle. Moreover, we show that SHP-1 controls hepatic insulin clearance, which is important to control systemic insulin concentration and sensitivity. This first study thus establishes a novel role for SHP-1 in the regulation of insulin action and glucose homeostasis. Thereafter, it became primordial to describe cell autonomous mechanisms by which SHP-1 enhances insulin sensitivity in liver and muscle. In the second chapter, expression of DNSHP-1 using adenoviral gene transfer into Fao rat hepatoma cells indicates that decreased hepatic glucose production observed in mev mice is likely the result of enhanced glycogenesis rather than reduced gluconeogenesis. Finally, I show in the last chapter that DNSHP-1 expression in myocytes increased insulin signaling to Akt, and increased GLUT4 expression, the main insulin responsive glucose transporter. Together, our results clearly establish that SHP-1 is a new modulator of insulin action in liver and skeletal muscle. SHP-1 may represent a novel therapeutic target to combat type 2 diabetes.

Thesis (MSc)--Stellenbosch University, 2005. / ENGLISH ABSTRACT: Introduction: Exercise increases skeletal muscle glucose uptake via AMP-activated protein kinase (AMPK) activation and GLUT4 translocation from cytosol to cell membrane. It also promotes glucose utilisation in type 2 diabetic patients via increased insulin sensitivity. Insulin stimulates GLUT4 translocation by activating P13- kinase and protein kinase B (PKB/Akt). We therefore postulated that a connection exists between these two pathways upstream of GLUT4 translocation. Understanding this connection is important in the development of treatment strategies for type 2 diabetes. This exercise-induced increase in AMP-activated protein kinase (AMPK) activation can be mimicked by a pharmacological agent, 5'-aminoimidazole-4- carboxamide ribonucleoside (AlGAR), which is converted intracellularly into 5'- aminoimidazole-4-carboxamide-ribonucleosidephosphate (ZMP), an AMP analogue. Aim: To investigate the effect of two pharmacological AMPK-activating compounds, ZMP and AlGAR, on the phosphorylation of AMPK, the phosphorylation of PKB/Akt as well as possible feedback on insulin-stimulated glucose uptake and GLUT4 translocation. Materials and Methods: Adult ventricular cardiomyocytes were isolated from male Wistar rats by collagenase perfusion and treated with 1 mM AlGAR or 1 mM ZMP in the presence or absence of 100 nM insulin or 100 nM wortmannin, an inhibitor of P13- kinase. Glucose uptake was measured via eH]-2-deoxyglucose (2DG) accumulation. PKB/Akt and AMPK phosphorylation and GLUT4 translocation was detected by Western blotting. Purinergic receptors were blocked with 8-cyclopentyl-1,3- dipropylxanthine (8CPT) and the effect on AMPK phosphorylation noted. Certain results were confinned or refuted by repeating experiments using the isolated rat heart model. Results: AICAR and ZMP promoted AMPK phosphorylation. Neither drug increased glucose uptake but in fact inhibited basal glucose uptake, although GLUT4 translocation from cytosol to membrane occurred. Both compounds also attenuated insulin stimulated glucose uptake. Wortmann in abolished glucose uptake and PKB/Akt phosphorylation elicited by insulin while, in the presence of wortmannin, AICAR and ZMP increased levels of PKB/Akt phosphorylation. Although AICAR and ZMP increased glucose uptake in skeletal muscle, this was not seen in cardiomyocytes. However both compounds increased GLUT4 translocation, clearly demonstrating that translocation and activation of GLUT4 are separate processes. 8CPT had no effect on the phosphorylation of AMPK by either AICAR or ZMP indicating that there was no involvement of the purinergic receptors. Conclusion: Although AICAR and ZMP increase glucose uptake in skeletal muscle, this was not seen in cardiomyocytes. Conversely, both compounds inhibited both basal and insulin stimulated glucose uptake despite increasing GLUT4 translocation. Inhibition of PI3-kinase in presence or absence of insulin unmasked hitherto unknown effects of AICAR and ZMP on PKB phosphorylation. / AFRIKAANSE OPSOMMING: Agtergrond: Oefening verhoog skeletspier glukose opname via AMP-geaktiveerde protein kinase (AMPK) aktivering en GLUT4 translokering vanaf die sitosol na die selmembraan. Dit verbeter ook glukose verbruik in tipe 2 diabetes pasiënte via verhoogde insulien sensitiwiteit. Insulien stimuleer GLUT4 translokering deur P13- kinase en protein kinase B (PKB/Akt) te aktiveer. Dit word dus gepostuleer dat daar 'n verbinding tussen hierdie twee paaie, wat beide betrokke is by GLUT4 translokering, bestaan. Dit is belangrik om hierdie verbinding te verstaan aangesien dit in behandelingstrategieë van tipe 2 diabetes geteiken kan word. Die oefening geïnduseerde verhoging in AMPK aktivering, kan deur 'n farmakologiese middel 5'- aminoimidasool-4-karboksamied ribonukleosied (AICAR), wat intrasellulêr omgesit word na 5'-aminoimidasool-4-karboksamied-ribonukleosiedfosfaat (ZMP), 'n AMP analoog, nageboots word. Doel: Om die effek van twee farmakologiese AMPK-aktiveringsmiddels, AICAR en ZMP, op die fosforilering van AMPK en PKB/Akt, sowel as moontlike effekte daarvan op insulien-gestimuleerde glukose opname en GLUT4 translokering, te ondersoek. Materiale en Metodes: Volwasse ventrikulêre kardiomiosiete is uit manlike Wistar rotharte geïsoleer d.m.v kollagenase perfusies en behandel met 1 mM AICAR of 1 mM ZMP in die teenwoordigheid of afwesigheid van 100 nM insulien of 100 nM wortmannin. Glukose opname is gemeet via intrasellulêre [3H]-2-deoksiglukose akkumulasie; PKB/Akt en AMPK fosforilering sowel as GLUT4 translokering is bepaal deur Western blot analises. Purinergiese reseptore is geblokkeer met 8-siklopentiel- 1,3-dipropielxanthien (8CPT) en die effek daarvan op AMPK fosforilering genoteer. Ten einde resultate wat in die geïsoleerde kardiomiosiet-model verkry is, te bevestig, is sekere eksperimente in die geïsoleerde rothart herhaal. Resultate: Beide AIGAR en ZMP stimuleer AMPK fosforilering. Die middels kan nie glukose opname verhoog nie, inteendeel, basale glukose opname is onderdruk alhoewel GLUT4 translokering vanaf die sitosol na die selmembraan wel plaasgevind het. Wortmannin kon insulien gemedieerde glukose opname en PKB/Akt fosforilering onderdruk. In die teenwoordigheid van wortmannin het beide AIGAR en ZMP PKB/Akt fosforilering verhoog. Alhoewel beide AIGAR en ZMP glukose opname in skeletspier verhoog, was dit nie die geval in kardiomiosiete nie. Beide middels het wel GLUT 4 translokering verhoog, wat duidelik demonstreer dat die translokering en aktivering van GLUT4, verskillende prosesse is. 8GPT het geen effek gehad op die fosforilering van AMPK deur AIGAR of ZMP nie, wat bewys dat daar geen betrokkenheid van die purinergiese reseptore was nie. Gevolgtrekking: Alhoewel AIGAR en ZMP glukose opname in skeletspier verhoog is dit nie die geval in kardiomiosiete nie. Beide middels inhibeer basale en insuliengestimuleerde glukose opname maar stimuleer GLUT4 translokeering. Inhibisie van PI3-kinase in die teenwoordigheid of afwesigheid van insulien, ontmasker voorheen onbekende effekte van AIGAR en ZMP op PKB/Akt fosforilering.

Critically ill patients often exhibit abnormal glycaemia that can lead to severe complications and potentially death. In critically ill adults, hyperglycaemia is a common problem that has been associated with increased morbidity and mortality. In contrast, critically ill infants often suffer from hypoglycaemia, which may cause seizures and permanent brain injury. Further complicating the matter, both of these conditions are diagnosed by blood glucose (BG) measurements, often taken several hours apart, and, as a result, these conditions can remain poorly managed or go completely undetected. Emerging ‘continuous’ glucose monitoring (CGM) devices with 1-5 minute measurement intervals have the potential to resolve many issues associated with conventional intermittent BG monitoring. The objective of this research was to investigate and develop methods and models to optimise the clinical use of CGM devices in critically ill patients. For critically ill adults, an in-silico study was conducted to quantify the potential benefits of introducing CGM devices into the intensive care unit (ICU). Mathematical models of CGM error characteristics were implemented with existing, clinically validated, models of the insulin-glucose regulatory system, to simulate the behaviour of CGM devices in critically ill patients. An alarm algorithm was also incorporated to provide a warning at the onset of predicted hypoglycaemia, allowing a virtual dextrose intervention to be administered as a preventative measure. The results of the in-silico study showed a potential reduction in nurse workload of approximately 75% and a significant reduction in hypoglycaemia, while also providing insight into the optimal rescue dose size and resulting dynamics of glucose recovery. During 2012, ten patients were recruited into a pilot clinical trial of CGM devices in critical care with a primary goal of assessing the reliability of CGM devices in this environment, with a specific interest in the effects of CGM device type and sensor site on sensor glucose (SG) data. Results showed the mean absolute relative difference of SG data across the cohort was between 12-24% and CGM devices were capable of monitoring some patients with a high degree of accuracy. However, certain illnesses, drugs and therapies can potentially affect sensor performance, and one particular set of results suggested severe oedema may have affected sensor performance. A novel and first of its kind metric, the Trend Compass was developed and used to assesses trend accuracy of SG in a mathematically precise fashion without approximation, and, importantly, does so independent of glucose level or sensor bias, unlike any other such metrics. In this analysis, the trend accuracy between CGM devices was typically good. A recent hypothesis suggesting that glucose complexity is associated with mortality was also investigated using the clinical CGM data. The results showed that complexity results from detrended fluctuation analysis (DFA) were influenced far more by CGM device type than patient outcome. In addition, the location of CGM sensors had no significant effect on complexity results in this data set. Thus, while this emerging analytical method has shown positive results in the literature, this analysis indicates that those results may be misleading given the impact of technology outweighing that of physiology. This particular result helps to further delineate the range of potential applications and insight that CGM devices might offer in this clinical scenario. In critically ill infants, CGM devices were used to investigate hypoglycaemia during the first 48 hours after birth. More than 50 CGM data sets were obtained from several studies of CGM in infants at risk of hypoglycaemia at the Waikato hospital neonatal ICU (NICU). In light of concerns regarding CGM accuracy, particularly during the first few hours of monitoring and/or at low BG levels, an alternative, novel calibration scheme was developed to increase the reliability of SG data. The recalibration algorithm maximised the value of very accurate calibration BG measurements from a blood gas analyser (BGA), by forcing SG data to pass through these calibration BG measurements. Recalibration increased all metrics of hypoglycaemia (number, duration, severity and hypoglycaemic index) as the factory CGM calibration was found to be reporting higher values at low BG levels due to its least squares calibration approach based on the assumption of a less accurate calibration glucose meter. Thus, this research defined new calibration methods to directly optimise the use of CGM devices in this clinical environment, where accurate reference BG measurements are available. Furthermore, this work showed that metrics such as duration or area under curve were far more robust to error than the typically used counted-incidence metrics, indicating how clinical assessment may have to change when using these devices. The impact of errors in calibration measurements on metrics used to classify hypoglycaemia was also assessed. Across the cohort, measurement error, particularly measurement bias, had a larger effect on hypoglycaemia metrics than delays in entering calibration measurements. However, for patients with highly variable glycaemia, timing error can have a significantly larger impact on output SG data than measurement error. Unusual episodes of hypoglycaemia could be successfully identified using a stochastic model, based on kernel density estimation, providing another level of information to aid decision making when assessing hypoglycaemia. Using the developed algorithms/tools, with CGM data from 161 infants, the incidence of hypoglycaemia was assessed and compared to results determined using BG measurements alone. Results from BG measurements showed that ~17% of BG measurements identified hypoglycaemia and over 80% of episodes occurred in the first day after birth. However, with concurrent BG and SG data available, the SG data consistently identified hypoglycaemia at a higher rate suggesting the BG measurements were not capturing some episodes. Duration of hypoglycaemia in SG data varied from 0-10+%, but was typically in the range 4-6%. Hypoglycaemia occurred most frequently on the first day after birth and an optimal measurement protocol for at risk infants would likely involve CGM for the first week after birth with frequent intermittent BG measurements for the first day. Overall, CGM devices have the potential to increase the understanding of certain glycaemic abnormalities and aid in the diagnosis/treatment of other conditions in critically ill patients. This research has used a range of prospective and retrospective clinical studies to develop methods to further optimise the use of CGM devices within the critically ill clinical environment, as well as delineating where they are less useful or less robust. These latter results clearly define areas where clinical practice needs to adapt when using these devices, as well as areas where device makers could target technological improvements for best effect. Although further investigations are required before these devices are regularly implemented in day-to-day clinical practice, as an observational tool they are capable of providing useful information that is not currently available with conventional intermittent BG monitoring.