Gonadotropin releasing hormone (GnRH) agonists in male contraception

A potent gonadotropin releasing hormone (GnRH) agonist, D(Nal2)6 GnRH (Nafarelin) has been administered to two groups of normal men for 16 weeks by two routes in order to assess its effectiveness in suppressing spermatogenesis. In this report 400 micrograms of the GnRH agonist was given daily by constant subcutaneous infusion and the results compared to an earlier study in which 200 micrograms of the same agonist was given as a single daily subcutaneous injection. All subjects in both groups received an intramuscular injection of testosterone enanthate (200 mg) every two weeks to prevent symptoms of androgen deficiency. The higher dose infusion regimen was much more effective in suppressing spermatogenesis than the single daily injection. With infusion treatment, 3 of 7 subjects were azoospermic, a fourth subject had less than 1 million sperm per ml of semen and 5 of 7 subjects had sperm counts less than 5 million per ml. Because of the differences in GnRH dose it is unclear if the enhanced effect seen in the infusion group is the result of the route or dose of drug. Data from experimental animals and short term comparative studies with two routes and two doses suggest that both mechanisms may be operative. In either case, the results are the most promising to date and raise the possibility that constant delivery of a higher dosage of agonist could produce azoospermia in most or all subjects.     

Novel effects of PGF2 alpha on airway function in asthmatic subjects

The effects of inhaled prostaglandin F2 alpha (PGF2 alpha) have been examined in eight subjects with asthma. Incremental PGF2 alpha aerosol concentrations, ranging from 1 to 5,000 micrograms/ml, were administered at 15-min intervals. Plethysmographic specific airway conductance (sGaw), forced expiratory volume at 1 s (FEV1), and maximum expiratory flow at 50% vital capacity breathing air (Vmax50% air) and 80% He-20% O2 (Vmax50% He-O2) were measured after each dose and compared with saline control values. We observed unexpected triphasic dose-response characteristics, i.e., an initial decline in physiological variables at low concentrations (1-100 micrograms/ml), followed by improvement at intermediate concentrations (100-1,000 micrograms/ml) and a subsequent steep decline at high concentrations (1,000-5,000 micrograms/ml). Improvement in FEV1 and Vmax50% air between 100 and 1,000 micrograms/ml was associated with sGaw increases above control levels in six subjects and a significant fall in density-dependent index (Vmax50% He-O2/Vmax50% air) when compared with values before challenge and at low concentrations. Inhaled atropine (5 mg) improved prechallenge lung function but had no effect on PGF2 alpha dose-response characteristics. Intermediate PGF2 alpha concentrations given as a single dose consistently induced greater FEV1 reductions than the same concentration during graded dose challenges. Our findings are consistent with the demonstration of in vivo airway tachyphylaxis and indicate that airway effects of PGF2 alpha are far more complex than previously reported. Moreover, these novel effects suggest that, in addition to its well-known bronchoconstrictor effects, PGF2 alpha directly or indirectly causes airway relaxation, predominantly in large airways.     

Effects of misoprostol on human circulation

Prostaglandins (PGs) of the E-type are potent vasodilators in most species and in most vascular beds. However, vasoconstrictor effects of PGEs have also been noted at selected sites. This study examined the effects of misoprostol, a PGE₁ analog with antiulcer activity, on the human cardiovascular system. Twenty healthy subjetcs participated in this double-blind, placebo-controlled, parallel group study. Following a 12 hour fast, heart rate, arterial blood pressure, light reflex plethysmography of the finger, resting blood flow volume in the lower arm and leg and peripheral vascular resistance were measured at 10 min. intervals for 1 hour prior to drug administration, to permit calculating baseline values. Misoprostol (400 mcg) or its matching placebo were administered orally, and the measurements were repeated at 10 min. intervals over the next 2 hours. A decrease in leg blood flow volume and a corresponding increase in leg peripheral vascular resistance were noted in the misoprostol group. A statistically significant decrease in heart rate between the two treatment groups was also noted. These small changes were not considered to be of clinical importance. No adverse experiences were reported. In conclusion, a single dose of misoprostol (400 mcg) has no clinically significant vasoconstrictive or vasodilative properties in man.     

Stereospecific effects of a nonpeptidic NK1 selective antagonist, CP-96,345: antinociception in the absence of motor dysfunction.

CP-96,345 has been identified as being a highly selective, nonpeptidic agent with subnanomolar affinity for the NK1 receptor. In the present study, we observed that pre but not posttreatment with this agent will produce depression in the second, but not the first phase of the agitation behavior induced by the injection of formalin into a rat's hindpaw. This effect is monotonically dose dependent after intrathecal (10-200 micrograms/10 microliters) or systemic (1-15 mg/kg, ip) administration. Even at the highest dose examined (400 micrograms/10 microliters), there was only a transient motor weakness of the hindpaw. The stereoisomer CP-96,344 has no binding affinity, and has no effect on the formalin response, but shows the same dose profile for motor dysfunction at the highest dose. In contrast, Spantide, a peptidic sP ligand, had only a modest effect upon the formalin response at 1 microgram/10 microliters and produced a prominent, long-lasting motor dysfunction at 4 micrograms/10 microliters. These results provide the first suggestion of sP antagonists having prominent analgesic activity with a significant therapeutic index (analgesic to motor), and emphasizes the probable role of the NK1 class of receptors in the spinal cord in mediating at least one class of nociceptive afferent input.     

Effect of aminophylline on the pulmonary and systemic hemodynamic response to group B beta-hemolytic Streptococcus and leukotriene D4 in newborn lambs.

Aminophylline, a methyl xanthine, has been used for many years in the treatment of apnea of prematurity and bronchospasm. Aminophylline relaxes smooth muscle through several proposed mechanisms. We hypothesized that aminophylline might be effective in relaxing preconstricted pulmonary vascular smooth muscle and would be ideally suited for clinical trial in babies with pulmonary hypertension. To test this hypothesis, the haemodynamic response of chronically instrumented newborn lambs to injections of heat-killed Group B beta-hemolytic Streptococcus (GBS) and leukotriene (LT) D4, potent pulmonary vasoconstrictors was compared before and after pretreatment with a clinically therapeutic dose of intravenous aminophylline. GBS (10(9)cfu) significantly increased pulmonary arterial pressure 130%. LTD4 (1.0 microgram/kg) significantly increased pulmonary arterial pressure 142% and systemic arterial pressure 23% and decreased cardiac output 47%. Aminophylline did not significantly affect the baseline variables or alter the pulmonary or systemic haemodynamic response to either stimuli. Therefore, it is unlikely that aminophylline will be clinically useful in the treatment of babies with persistent pulmonary hypertension whose etiology is infectious or leukotriene-mediated.     

The value of pulmonary function tests in the management of acute asthma.

We examined the influence of the forced expiratory volume in 1 second (FEV1) on the decision to admit or discharge patients who present with acute bronchospasm due to asthma and the ability of the FEV1 to predict the need for admission or the likelihood of relapse after discharge. The FEV1 was recorded at presentation before treatment and immediately after a decision to admit or discharge had been made. Of the 96 patients 10.4% were admitted, 10.4% were discharged but suffered a relapse, and 79.2% were discharged and did not suffer a relapse. The FEV1 had a low positive predictive value (47%) for admission or relapse when it was 0.7 L/min or less at presentation and 2.1 L/min or less before discharge or admission. The FEV1 did not alter the decision to admit or discharge in 97% of the cases. We believe that the FEV1 fails to identify patients who should be admitted or those who will likely suffer a relapse; however, patients with a final FEV1 greater than 2.4 L/min may be discharged with confidence.     

Interaction and dose equivalence of salbutamol and salmeterol in patients with asthma.

OBJECTIVE--To examine the pharmacological interaction of salmeterol and salbutamol and to derive an estimate of dose equivalence of salmeterol for airway and systemic effects in patients with asthma. DESIGN--Randomised double blind crossover study. SUBJECTS--12 patients with mild asthma. INTERVENTION--Placebo or salmeterol 50, 100, 200 micrograms given on separate days followed two hours later by inhaled salbutamol in cumulative doses up to 3600 micrograms. MAIN OUTCOME MEASURES--Change in forced expiratory volume in one second (FEV1), heart rate, plasma potassium concentration, QTc interval, tremor amplitude, and creatine kinase myocardial isoenzyme concentration. RESULTS--Compared with placebo, the mean (95% confidence interval) changes in FEV1 and heart rate after salmeterol 200 micrograms were 0.61 (0.32 to 0.90) l and 7.0 (3.8 to 10.2) beats/min. Adding salbutamol caused a large increase in FEV1 after placebo (0.69 l) with progressively smaller changes after increasing doses of salmeterol (0.19 l after salmeterol 200 micrograms). Heart rate and QTc interval increased and plasma potassium concentration decreased roughly in parallel on the four study days with a suggestion of convergence at higher doses of salbutamol. Geometric mean dose equivalences for salmeterol 50 micrograms and 100 micrograms compared with salbutamol were 4.9 and 7.8 (mean 6.4) for FEV1 and ranged from 7.1 (2.9 to 17.0) to 12.6 (4.4 to 36.4) for heart rate, plasma potassium, and tremor (mean 9.5). CONCLUSIONS--The effect of adding salbutamol to salmeterol is largely additive. Weight for weight salmeterol may be up to 10 times more potent than salbutamol. Considering its longer duration of action salmeterol 50 micrograms twice daily could be equivalent to salbutamol in doses up to 500 micrograms four to six hourly.     

Toxicities associated with monoclonal antibody infusions in cancer patients

The toxicity during and following 291 infusions of 19 murine and three human monoclonal antibodies (MoAB) in 177 cancer patients with 10 different malignancies was assessed. Doses ranged from 0.5 to 500 mg administered over 0.25 to 24 hours. Various reactions in varying degrees were observed in 45 (28%) patients during their first MoAb infusion. Nine additional patients experienced toxicity following a subsequent antibody infusion. Antibodies that reacted with circulating cells were associated with toxicity in 20 of 28 (71%) of the first infusions, compared to 24 of 127 (19%) for patients receiving antibodies that did not react with circulating cells. Fevers, rigors, chills, and diaphoresis were observed in 10% to 12% of the patients and were associated with binding to circulating cells. Presumed hypersensitivity reactions, including urticaria, pruritus, bronchospasm, and anaphylaxis occurred in 20 patients (11%). There were five episodes of bronchospasm and a single episode of anaphylaxis. Liver transaminases were elevated in 14%. There was no correlation between dose or infusion rate and toxicity. Murine monoclonal antibodies that are not conjugated to cytotoxic agents can be given with an acceptable frequency of side effects and serious allergic reactions. There is a small risk of anaphylaxis, and one should avoid rapid infusion of high antibody doses in the presence of circulating target cells and/or circulating free antigen.     

The failure of aminophylline to modulate glucagon release in man

There are conflicting results regarding the impact of cyclic AMP on pancreatic glucagon release. The effect of aminophylline, a phosphodiesterase inhibitor, on glucagon secretion was studied in four non-obese, non-diabetic, healthy young male volunteers. The subjects received separate infusions of: 1) aminophylline; 2) aminophylline and propranolol; 3) arginine; 4) aminophylline and arginine; 5) insulin; 6) aminophylline and insulin; and 7) aminophylline and isoproterenol. Aminophylline not only failed to alter glucagon levels but also did not affect the glucagon responses observed after arginine and insulin-induced hypoglycemia. The concurrent infusion of isoproterenol and aminophylline also failed to cause a glucagon response. Although glucagon release has been evoked by cyclic AMP in some $\text{in vitro}$ systems, administration of aminophylline to human subjects does not enhance secretion. These results indirectly suggest that cyclic AMP is of little importance in the control of glucagon secretion in man, though the effects of aminophylline at the cellular level may be complex.     

Gonadotropin-releasing hormone infusion interval: importance in pharmacodynamics

Circulating gonadotropin-releasing hormone (GnRH) levels were measured during and after intravenous infusion intervals ranging from 0.08 minutes to 5 minutes and doses ranging from 1 to 25 micrograms per pulse. In all dose groups (1 vs. 5 vs. 25 micrograms), the peak levels of GnRH decreased from the 0.08 minute to the 5 minute infusion interval. Our results suggest that the infusion interval over which GnRH is administered has profound effects on the amount, duration, and pattern of GnRH measured in the peripheral circulation.     

Modification of bronchial reactivity by physiological concentrations of plasma epinephrine.

Circulating epinephrine concentrations are altered in certain pathophysiological states, but whether such changes in epinephrine concentrations can alter bronchial responsiveness in subjects with asthma has not been studied. We studied 10 subjects with asthma in a double-blind crossover study on 4 nonconsecutive days. After measurement of baseline forced expiratory volume in 1 s (FEV1) and plasma epinephrine concentration, subjects were given placebo or 4, 16, or 64 ng.kg-1.min-1 epinephrine by intravenous infusion for 45 min. Blood was taken for plasma epinephrine concentration before the infusion and at 30 min, when a histamine challenge test was performed. Mean plasma epinephrine concentrations ranged from 0.37 nmol/l on placebo to 3.76 nmol/l with the 64-ng/kg infusion. FEV1 increased progressively with increasing concentrations of infused epinephrine, the mean change ranging from -0.051 on placebo to 0.331 after the highest concentration of epinephrine. The provocative dose of histamine causing a 20% fall in FEV1 increased progressively with increasing concentrations of infused epinephrine, geometric mean values ranging from 0.61 mumol with placebo to 1.7 mumol after the highest dose of epinephrine. Thus epinephrine, at physiological plasma concentrations, can modify bronchial reactivity.     

Beneficial effect of chronic treatment with the selective bradykinin B1 receptor antagonists, R-715 and R-954, in attenuating streptozotocin-diabetic thermal hyperalgesia in mice

Kinins are important mediators of cardiovascular homeostasis, inflammation and nociception. Bradykinin (BK) B(1) receptors (BKB1-R) are over-expressed in pathological conditions including diabetes, and were reported to play a role in hyperglycemia, renal abnormalities, and altered vascular permeability associated with type 1 diabetes. Recent studies from our laboratory demonstrated that BKB1-R are implicated in streptozotocin (STZ)-diabetes-mediated hyperalgesia, since acute administration of the selective BKB1-R antagonists significantly and dose-dependently inhibited such hyperalgesic activity. In the present study, we examined the effect of chronic treatment of STZ-diabetic mice with the selective BKB1-R agonist desArg9bradykinin (DBK) and two specific antagonists R-715 and R-954, on diabetic hyperalgesia. Diabetes was induced in male CD-1 mice by injecting a single high dose of STZ (200mg/kg, i.p.) and nociception was assessed using the hot plate, plantar stimulation, tail immersion and tail flick tests. Drugs were injected i.p. twice daily for 7 days, starting 4 days after STZ. We showed that chronically administered R-715 (400 micrograms/kg) and R-954 (200 micrograms/kg), significantly attenuated the hyperalgesic effect developed in STZ-diabetic mice as measured by the four thermal nociceptive tests. Further, chronic treatment with DBK (400 micrograms/kg) produced a marked potentiation of the hyperalgesic activity, an effect that was reversed by both R-715 and R-954. The results from this chronic study confirm a pivotal role of the BKB1-R in the development of STZ-diabetic hyperalgesia and suggest a novel approach to the treatment of this short-term diabetic complication using BKB1-R antagonists.     

Effects of the synthetic PGE1 derivative misoprostol on basal, stimulated and nocturnal acid secretion in duodenal ulcer cases. Mechanism of action

We studied the antisecretory effect of the synthetic PGE1 derivative misoprostol. Basal, histamine-stimulated and nocturnal acid secretion were determined on separate days in 3 groups of endoscopically confirmed duodenal ulcer patients. Misoprostol or placebo were given in random order in doses of 200, 400 and 800 mcg. H+ concentration, acid output and pH of gastric content were determined. Additionally, the effect of misoprostol on purified and gastric mucosa carbonic anhydrase was determined according to Maren's micromethod. Misoprostol reduced dose-dependently basal acid secretion (by 54% after 200 mcg, by 82% after 400 mcg and, respectively, by 94% after 800 mcg) as well as stimulated secretion which was reduced after the same doses by 22% (p less than 0.05), 48% and 64% (p less than 0.001), respectively. Nocturnal secretion was significantly reduced for a period of 4 h, with a consecutive rise of gastric pH. In vitro, misoprostol inhibited dose-dependently purified and gastric mucosa carbonic anhydrase basal activity. In conclusion, misoprostol inhibits basal, nocturnal and histamine-stimulated secretion in duodenal ulcer patients, an effect which could be mediated by inhibition of carbonic anhydrase.     

Nuclear activation by thyroid hormone in liver of Singi fish: changes in different ion-specific adenosine triphosphatases activities

Various ion-dependent (Na+K+, Ca++ and Mg++) ATPases activities in liver cell nuclear membrane have been determined after a single injection of different doses (0.01, 0.025, 0.05, 0.1, 0.25, 0.5, 1, 2 and 4 micrograms/g) of L-triiodothyronine (T3) in Singi fish, Heteropneustes fossilis Bloch. Administration of T3 at a minimum effective dose of 0.05 micrograms upto 4 micrograms/g induced a rise (14 to 43% over control value) in the Na+K+-ATPase activity in a dose-dependent fashion maximum upto 1 microgram/g dose, whereas Ca++-ATPase showed a dose-dependent increase (20 to 43% over control) with 0.25-1 microgram/g of T3, although the increase in the respective enzyme activity was maintained upto 4 micrograms/g of T3 dose. Mg++-ATPase activity in liver cell nuclear membrane was found to be increased at 1 microgram-4 micrograms/g of T3 dose, showing a similar magnitude of increase (7% over the control value) with these doses of T3. Other doses of T3 (0.01 and 0.025 micrograms/g) were ineffective in altering the different ion-specific ATPase activity. Treatment of Singi fish with thiourea (1 mg/ml) for 30 days caused a significant fall in Na+K+, Ca++ and Mg++-ATPase activities upto 21%, 17% and 5%, respectively, below the euthyroid control level. A single injection of T3 at the dose of 1 microgram/g in the hypothyroid fish raised the Na+K+ and Ca++-ATPase activities to about 36% over the control value, and the Mg++-ATPase activity was restored to only the control level. Thus a dose-dependent nuclear effect of T3 is evident from the present investigation.     

Vasoactive intestinal peptide as a bronchodilator in asthmatic subjects

Vasoactive intestinal peptide (V.I.P.) caused bronchodilatation in 7 asthmatic volunteers when given intravenously at the rate of 6 pmol kg-1 min-1 for 15 minutes during a double blind study. Mean baseline FEV1 was 2.8 (+/- 0.3 S.E.) which was 81% of predicted and increased by 0.21 (range 0.1-0.45) l after 15 minutes infusion (p greater than 0.02). Tachycardia and cutaneous flushing were also observed during the infusion. Subsequent induced bronchoconstriction with a predetermined dose of histamine was ameliorated at 180 seconds following challenge when compared with placebo. Mean fall in FEV1 0.26 compared with 0.741 when pre-infusion FEV1 was taken on baseline. Mean fall in FEV1 0.49 l compared with 0.75 l when the FEV1 immediately preceding challenge was used on baseline (p greater than 0.02). The demonstration that V.I.P. is a bronchodilator in asthmatics and ameliorates histamine induced bronchoconstriction has important implications for the pharmacology of asthma.     

吸入M3受体拮抗剂对稳定期COPD肺功能的影响

目的：评价噻托溴铵干粉剂对中、重度稳定期慢性阻塞性肺疾病（COPD）患者肺功能的影响。方法：采用随机对照研究140例COPD患者,噻托溴铵组使用噻托溴铵干粉剂,对照组使用氨茶碱片,总观察时间12周,治疗前后测定肺功能。结果：治疗后噻托溴铵组深吸气量、第1秒用力肺活量和用力肺活量明显改善,分别增加了102mL,256mL和154mL,对照组改善不明显,仅分别增加了10mL,08mL,15mL。结论：噻托溴铵能改善中、重度稳定期COPD患者的肺功能,可提高患者的生活质量。     

Sparing effects of intrauterine treatment with prostaglandin E2 on luteal function in cycling gilts

Twelve crossbred gilts, 8 to 9 months of age, were used to study the effects of prostaglandin E2 (PGE2) on luteal function during the estrous cycle. Intrauterine and jugular vein catheters were surgically placed before day 7 of the treatment estrous cycle and gilts were randomly assigned to 1 of 3 treatment groups. Groups I and II received constant intrauterine infusion of vehicle (6.0 ml/24 hr) or PGE2 (2400 micrograms/day; 6.0 ml/24 hr) respectively; while group III was given intrauterine infusions of 400 micrograms PGE2 every 4 hr. All infusions were initiated on day 7 and continued until estrus or through day 23. Jugular blood samples were collected twice daily from days 7 to 30 for progesterone analysis. Intrauterine infusion of PGE2 at the dose and frequencies given in this study delayed the decline in jugular plasma progesterone and resulted in prolongation of the estrous cycle length. The results of this study have shown that PGE2 at the dosage and frequency of administration used was capable of extending corpus luteum function.     

Ionic fluxes induced by topical misoprostol in canine gastric mucosa

We studied the dose response of ionic fluxes in canine chambered gastric segment mucosa to increasing doses of topical misoprostol (0.1, 1, 10, 100, and 1000 micrograms). The fluxes were also correlated with the simultaneous changes in focal gastric mucosal blood flow measured by laser-Doppler flowmetry. After misoprostol administration, there was a dose-dependent increase in focal gastric mucosal blood flow (Emax = 8.23 +/- 3.25 V at 10 micrograms; ED50 = 1.05 micrograms), pH, and the outputs of ions (Na+, K+, Cl-, and HCO3-) and fluid (Emax for pH and fluxes greater than or equal to 1000 micrograms). ED50 values for these outputs ranged from 215.40 to 340 micrograms (mean +/- SE = 279.08 +/- 24.27 micrograms). H+ output showed a dose-dependent decrease to zero at the 10-micrograms dose, the dose at and after which net HCO3- secretion became obvious. The slopes of the dose-response curves for the fluxes of fluid, Na+, K+, Cl-, and HCO3- were significantly different (p less than 0.01) from the slope of the curve for mucosal blood flow changes. There were no correlations between the changes in these fluxes and blood flow changes. Na+ and Cl- were the predominant cation (98.84%) and anion (98.19%), respectively, in the misoprostol-induced secretion. Misoprostol stimulates a composite alkaline gastric nonparietal secretion, predominantly Na+ and Cl-, but also containing K+ and HCO3-. Our results suggest different mechanisms for the effects on nonparietal secretion and focal gastric mucosal blood flow.(ABSTRACT TRUNCATED AT 250 WORDS)     

Central nervous system control of airway tone in guinea pigs: the role of histamine

The central nervous system (CNS) plays an important role in the reflex control of bronchomotor tone, but the relevant neurotransmitters and neuromodulators have not been identified. In this study we have investigated the effect of histamine. Anesthetized male guinea pigs were prepared with a chronically implanted intracerebroventricular (icv) cannula and instrumented for the measurement of pulmonary resistance (RL), dynamic lung compliance (Cdyn), tidal volume (VT), respiratory rate (f), blood pressure (BP), and heart rate (HR). Administration of histamine (2-30 micrograms) icv caused a significant (P less than 0.05) reduction of Cdyn with no change in RL, VT, and f. At a dose of 100 micrograms icv, histamine caused an increase in RL (202 +/- 78%), a reduction of Cdyn (77 +/- 9%), an increase in f (181 +/- 64%), and a reduction of VT (53 +/- 18%). There were no changes in BP and HR after 100 micrograms of icv histamine. In contrast, intravenous administration of histamine (0.1-2 micrograms/kg) caused a dose-dependent decrease in Cdyn and increase in RL that was associated with tachypnea at each bronchoconstrictor dose. Intravenous histamine (2 micrograms/kg) produced a fall in BP and an increase in HR. The bronchoconstrictor responses to icv histamine were completely blocked by vagotomy and significantly reduced by atropine (0.1 mg/kg iv), whereas vagotomy and atropine did not block the bronchospasm due to intravenous histamine. Additional studies indicated that the pulmonary responses due to icv histamine (100 micrograms) were blocked by pretreatment with the H1-antagonist chlorpheniramine (1 and 10 micrograms, icv). These data indicate that histamine may serve a CNS neurotransmitter function in reflex bronchoconstriction in guinea pigs.     

Lack of effect of thyrotropin-releasing hormone (TRH) on the peripheral plasma levels of pancreatic glucagon in man

Based on the fact that human pancreas has thyrotropin-releasing hormone (TRH) immunoreactivity and bioactivity, we studied the effect of TRH on peripheral plasma levels of pancreatic glucagon (IRG) and insulin (IRI) in healthy subjects. During the infusion of 400 micrograms TRH for 120 min basal plasma IRI and IRG levels did not change significantly. In addition, intravenous infusion of 400 micrograms TRH did not affect the increments in the plasma IRG levels and the decrements in the blood glucose during insulin hypoglycemia.