Complete Recovery From Prolonged Hypoglycemic Coma After Intentional Overdose With an Insulin Pump : The Endocrinologist

Journal Logo

You can read the full text of this article if you:

Access through Ovid
00019616-200409000-00005ReportThe EndocrinologistThe Endocrinologist© 2004 Lippincott Williams & Wilkins, Inc.14September 2004 p 257-260Complete Recovery From Prolonged Hypoglycemic Coma After Intentional Overdose With an Insulin PumpCase ReportSoni, Sonia MD*; Mentzelopoulos, Voula MD†; Hatipoglu, Betul MD‡From *Internal Medicine, Mercy Hospital and Medical Center, Chicago, Illinois; †Internal Medicine, Yale University, Bridgeport Hospital, Bridgeport, Connecticut; and the ‡Department of Medicine, University of Illinois at Chicago, Chicago, Illinois.Reprints: Betul Hatipoglu, MD, 1819 W. Polk M/C 640, Section of Diabetes and Metabolism, University Of Illinois, Chicago, IL 60612. E-mail: [email protected] resulting from insulin overdose can occur as documented by cases reported in the literature of malicious or factitious administration, in addition to self-inflicted insulin overdose by depressed individuals with intent of suicide. We describe a case of a patient with insulin-dependent diabetes mellitus who attempted suicide with the use of an insulin pump resulting in a severe prolonged hypoglycemic coma. She recovered after approximately 7 hours of hypoglycemia and 4 days of being in a decerebrate posture. The occurrence of unexplained hypoglycemia in a depressed diabetic patient should raise the suspicion of insulin overdose. Moreover, physicians should be aware of the potential of insulin pumps to be used as a suicidal weapon, and special caution and close monitoring of depressed patients using the pump is strongly advised.Systemic, neurologic, and psychiatric symptoms related to hypoglycemia have been documented as early as the 1920s1 Mental efficiency is disrupted significantly in diabetic adults at glucose levels between 43 and 49 mg/dL, with some investigators reporting transient declines in certain types of cognitive tasks at glucose levels as high as 55 mg/dL.2,3 A decrease in the blood glucose level or tissue utilization results in acute sequelae, including neurogenic symptoms, cognitive dysfunction, lethargy, obtundation, coma, convulsions, and, if prolonged and severe, death.4–6 Hypoglycemia resulting from insulin overdose can occur as documented by cases reported in the literature of malicious7,8 or factitious9,10 administration, in addition to self-inflicted insulin overdose by depressed individuals with intent of suicide.11–15 We describe a case of a patient with insulin-dependent diabetes mellitus who attempted suicide with the use of an insulin pump resulting in severe prolonged hypoglycemic coma followed by complete recoveryCASE REPORTA 35-year-old Asian woman with a 29-year history of insulin-dependent diabetes mellitus who was being treated with an insulin pump for the last 6 months was brought to the emergency department (ED) after being found unresponsive by her husband. On arrival at to the ED, 2.5 hours later (4.5 hours after initial overdose), the patient was unresponsive with blood glucose of 49 mg/dL. She had received 2 ampules of 50% dextrose by the rescue squad without clinical improvement. On examination, she was a thin young woman who was comatose with a blood pressure of 112/41 mm Hg and a pulse of 135 beats/min. Her pupils were 4 mm wide and sluggishly reactive to light. She was in a decerebrate posture and a positive Babinski sign was elicited bilaterally. The patient’s insulin pump was found in place and discontinued soon after the patient’s admission.Laboratory data were only remarkable for leukocytosis (WBC of 20,410/mm3) with a left shift. Repeat plasma glucose was 60 mg/dL after administration of 2 additional ampules of 50% dextrose. Other labs, including electrolytes, blood urea nitrogen, and creatinine, were normal. The toxicology screen was negative and the lumbar puncture results were normal. Blood, urine, and sputum samples were sent for culture.During the next few hours, the patient was placed on 10% dextrose solution to maintain glucose levels above 60 mg/dL. Two hours after her initial presentation, she became tachypneic (40 resp/min) and increasingly restless; dystonic movements of the mouth and protrusion of the tongue were noted. The blood glucose level at that time was 168 mg/dL. The patient was sedated and intubated in the intensive-care unit. A computed tomography (CT) scan of the head without contrast performed 2 hours after admission was unremarkable, but a repeat scan with contrast showed a mild degree of generalized brain swelling. A follow-up CT study 24 hours later confirmed the previous finding. An electroencephalogram (EEG) showed a nonreactive alpha coma. All cultures came back negative.On day 4 of admission, the patient recovered from her decerebrate posture and started responding to verbal stimuli. She was extubated the following day and her mental status slowly improved. She also started following simple commands.The patient’s insulin pump was sent to the manufacturing company for a safety check. According to the data on the day of admission, she had been injecting herself with frequent boluses of insulin throughout the day. Six hours 45 minutes before presentation to the ED, she injected a bolus of 45 U, reaching a total of 109.2 U of insulin for that day (her average requirement was around 50 U/day). This was the last recording of a bolus dose, although the pump continued to infuse on a standard rate 0.8 U per hour.According to her husband and friends, the patient was extremely depressed for days previous to her admission and had not been eating well. A neuropsychologic assessment 2 days after her extubation demonstrated severe depression with a flat and blunted affect. The patient admitted to attempting suicide because of marital conflict but was suffering from memory loss regarding details of the events that led to her suicide attempt.On discharge from the psychiatric clinic, the patient showed marked improvement. She was started on antidepressants and had weekly counseling sessions. She was able to return to her office job less than 2 months after her coma.Six months after her recovery, she continues to take antidepressants and attend counseling sessions. A repeat EEG was performed, which was found to be completely normal.DISCUSSIONPlasma glucose levels are maintained within a narrow range (60–150 mg/dL) irrespective of oral intake and activity level because glucose is an obligate metabolic fuel for the central nervous system. This dependence is the reason for profound vulnerability of brain cells to changes in systemic glucose supply.16 A rapid decline from euglycemia to hypoglycemic blood sugar levels will cause marked deterioration of central nervous system (CNS) function despite small reserves of glucose within the CNS. As a result, there are physiological mechanisms in place to rapidly prevent and correct hypoglycemia. Sustained hypoglycemia will ultimately lead to irreversible damage of neurons and persistent disruption of cerebral functions leading to hypoglycemic encephalopathy and coma.17 Cerebral dysfunction during severe and prolonged hypoglycemia has been manifested with seizure activity,11,18–22 focal neurologic deficits such as hemiplegia,18,20 or features of decortication or decerebration.13,22–24Since the discovery of insulin in 1921, the lethal potential of an overdose has been recognized and has led to its use as a suicidal,25 homicidal,7,8 and even as a recreational agent.19 However, the reports of insulin overdose for suicidal purposes have been a rare occurrence with only 73 cases reported in the world literature since 1927. Articles on insulin overdose have generally focused on the pharmacokinetics and different aspects in medical management, but not enough data exist on the initial presentation of comatose patients, the severity of the hypoglycemic encephalopathy, and the long-term course of these patients.26The case reported here is noteworthy for several reasons: 1) delayed onset of treatment of more than 6 hours is compatible with reversible brain damage, 2) recovery from deep hypoglycemic coma of long duration (decerebrate posturing for more than 48 hours) is possible with no serious cognitive or neurologic deficits, 3) demonstration that hypoglycemic unawareness as seen in insulin-dependent patients with diabetes can rapidly lead to symptoms of neuroglycopenia and subsequent development of hypoglycemic coma, and 4) this is the first case reported of intentional insulin overdose in a diabetic patient treated with the insulin pump.Unfortunately, in most cases of intentional insulin overdose, the exact time of the suicidal injection is unknown.27,28 Therefore, the exact time that elapses between the beginning of hypoglycemic symptoms and irreversible CNS damage is not known with absolute certainty. There are reports suggesting that the time from injection of insulin to the point of irreversible brain damage is frequently approximately 7 hours.29 In the majority of cases in which the onset of treatment is delayed for more than 8 hours, patients never recovered consciousness11,21 or suffered permanent neurologic damage.12,30 In the latter case, there was no mention of the severity of the coma. The patient was a nondiabetic who was on antidepressants and attempted suicide by insulin overdose. In the case presented here, the time that elapsed between the last insulin injection and the initiation of treatment is 6 hours 45 minutes and posturing was sustained for more than 48 hours. Based on this record, we believe that the delay in treatment of severe symptomatic hypoglycemia for almost 7 hours is compatible with complete recovery.As demonstrated by the diabetes control and complications trial (DCCT), patients with insulin-dependent diabetes mellitus who are undergoing intensive therapy have a 3-fold increase in severe hypoglycemia, particularly those who have a history of previous hypoglycemic episodes and a higher baseline HbA1c that rapidly declines after the start of intensive insulin therapy. These patients are predisposed to developing hypoglycemic unawareness that arises when neurogenic warning symptoms do not occur and are not recognized before neuroglycopenia develops.31 This results from the direct losses of the counterregulatory hormones that are physiologically intact in to prevent hypoglycemia.32 It has also been demonstrated that there is no significant change in the uptake of glucose in the brain among patients with insulin-dependent diabetes mellitus who are undergoing intensive therapy. Therefore, these patients have a mechanism to preserve cerebral metabolism during hypoglycemia.33 In this case, the patient had a high baseline HbA1c after which she was started on intensive therapy with the insulin pump 6 months before admission. Given her predisposition to develop hypoglycemic unawareness, she may not have had the chance to abort the insulin overdose with an appropriate behavioral response such as eating before development of neuroglycopenia.Insulin pumps achieved a wider acceptance and application in diabetes management during the last decade, because they are considered to provide equivalent or improved glycemic control with reduced risk of hypoglycemia.34–37 There have been reports of death in patients using the pumps caused by malfunction of the device, acute bacterial endocarditis that arose from an abscess at the catheter-insertion site and DKA.38,39 There have even been incidents of overdelivery of insulin in high altitudes by a specific brand of infusion pump that led to life-threatening hypoglycemia40,41; however, there is no evidence suggesting that insulin pumps have ever been used as a suicide weapon before. Rather, it has been used as part of treating a patient who attempted suicide by insulin overdose.42 Recently developed pumps are designed to protect against the hazards of device malfunction.CONCLUSIONIn summary, we describe a case of a patient with hypoglycemic coma resulting from a suicide attempt with an insulin pump. She recovered after approximately 7 hours of hypoglycemia and 4 days of being in a decerebrate posture. The occurrence of unexplained hypoglycemia in a depressed diabetic patient should raise the suspicion of insulin overdose. Moreover, physicians should be aware of the potential of insulin pumps to be used as a suicidal weapon, and special caution and close monitoring of depressed patients using the pump is strongly advised.REFERENCES1.Wolf A, Hare CC, Riggs HW. Neurological manifestations in two patients with spontaneous hypoglycemia. Bull Neurol Inst NY. 1993;3:232–251.[Context Link]2.Heller SR, Macdonald IA. The measurement of cognitive function during acute hypoglycemia. Experimental limitations and their effect on the study of hypoglycemia unawareness. Diabet Med. 1996;13:607–615.[Context Link][CrossRef][Medline Link]3.Lobmann R, et al. Impairment and recovery of cognitive function induced by hypoglycemia in type 1 diabetic patients and healthy controls. J Clin Endocrinol Metab. 2000;85:2758–2766.[Context Link][Full Text][CrossRef][Medline Link]4.Simpson IA, Appel NH, Hokari M, et al. Blood–brain barrier glucose transport: effects of hypo and hyperglycemia revisited. J Neurochem. 1999;72:238–247.[Context Link][Full Text][CrossRef][Medline Link]5.Chalmers J, Risk M, Kean DM, et al. Severe amnesia after hypoglycemia. Clinical, psychometric, and magnetic resonance imaging correlations. Diabetes Care. 1991;14:922–925.[Context Link][CrossRef][Medline Link]6.Holmes CS, Hayford JT, Gonzalez JL, et al. A survey of cognitive functioning at different glucose levels in diabetic persons. Diabetes Care. 1983;6:180–185.[Context Link][CrossRef][Medline Link]7.Birkinshaw VJ, Gurd MR, Randall SS. Investigations in a case of murder by insulin poisoning. BMJ. 1958;2:463–468.[Context Link][CrossRef][Medline Link]8.Levy WJ, Gardner D, Moseley J, et al. Unusual problems for the physicians in managing a hospital patient who received malicious insulin overdose. Neurosurgery. 1985;17:992–996.[Context Link]9.Scarlet JA, Mako ME, Rubenstein AH, et al. Factitious hypoglycemia, diagnosis by measurement of serum C-peptide immunoreactivity and insulin binding antibodies. N Engl J Med. 1977;297:1029–1032.[Context Link]10.Marks V. Hypoglycemia factitious and felonious. Endocrionol Metab Clin North Am. 1999;28:579–601.[Context Link]11.Sturner WQ, Putman RS. Suicidal insulin poisoning with nine-day survival: recovery in bile at autopsy by radioimmunoassay. J Forensic Sci. 1972;17:514–521.[Context Link][Medline Link]12.Martin FIK, Hansen N, Warne GL. Attempted suicide by insulin overdose in insulin requiring diabetics. Med J Aust. 1977;3:58–60.[Context Link][CrossRef][Medline Link]13.Arem R, Zoghibi W. Insulin overdose in eight patients. Insulin pharmacokinetics and review of the literature. Medicine. 1985;64:323–332.[Context Link][Full Text][CrossRef][Medline Link]14.Roberge RJ, Martin TG, Delbridge TR. Intentional massive insulin overdose: recognition and management. Ann Emerg Med. 1993;22 228–234.[Context Link][CrossRef][Medline Link]15.Cooper AJ. Attempted suicide using insulin by a non-diabetic using insulin by a non-diabetic. A case study demonstrating the acute and chronic consequences of profound hypoglycemia. Can J Psychiatry. 1994;39:103–107.[Context Link][CrossRef][Medline Link]16.Fischer F, Lees J, Newman J. Hypoglycemia in hospitalized patients. N Engl J Med. 1986;315:1245–1249.[Context Link][CrossRef][Medline Link]17.Teluskin PK, Nozdrachev AD. Hypoglycemia and the brain: metabolism and the mechanism of neuronal damage. Usp Fiziol Nauk. 1999;30:14–27.[Context Link][Medline Link]18.Malouf R, Brust J. Hypoglycemia: causes, neurological manifestations and outcome. Ann Neurol. 1985;17:421–430.[Context Link][CrossRef][Medline Link]19.Retsas S.: Insulin abuse by a drug addict. BMJ. 1972;4:792–793.[Context Link][CrossRef][Medline Link]20.Mac Leod KM, Hepburn DA, Frier BM. Frequency and morbidity of severe hypoglycemia in insulin-treated diabetic patients. Diabet Med. 1993;10:238–245.[Context Link]21.Patrick AW, Campbell IW. Fatal hypoglycemia in insulin treated diabetes mellitus: Clinical features and neuropathic changes. Diabet Med. 1990;7:349–354.[Context Link][CrossRef][Medline Link]22.Seibert GD. Reversible decerebrate posturing secondary to hypoglycemia. Am J Med. 1985;78:1036–1037.[Context Link][CrossRef][Medline Link]23.Kirk M, Hoogwerf BJ, Stoller J K. Reversible decerebrate posturing after profound and prolonged hypoglycemia. Cleve Clin J Med. 1991;58:361–363.[Context Link][CrossRef][Medline Link]24.Haines SJ. Decerebrate posturing misinterpreted as seizure activity. Am J Emerg Med. 1988;6:173–177.[Context Link][CrossRef][Medline Link]25.Secher K. Attempt at suicide with insulin. Ugesk J Laegar. 1927;89:378.[Context Link]26.Ellenhorn MJ, Barceloux OG. Medical Toxicology: Diagnosis and Treatment of Human Poisoning. New York: Elsevier; 1988:454–461.[Context Link]27.Fujioka M, Okuchi K, et al. Specific changes in human brain after hypoglycemic injury. Stroke. 1997;38:584–587.[Context Link][Full Text][CrossRef][Medline Link]28.Finelli PF. Diffusion weighted MRI in hypoglycemia coma. Neurology. 2001;57:933.[Context Link][Full Text][CrossRef][Medline Link]29.Simon R. Management of prolonged coma and determination of brain death. Symposium on poisonings and toxicological emergencies. Paper presented at: San Francisco Bay Area Regional Poison Center; 1983:33–47.[Context Link]30.Braaak E, et al. Clinical characteristics of type 1 diabetic patients with and without severe hypoglycemia. Diabetes Care. 2000;23:1467–1471.[Context Link][Full Text][CrossRef][Medline Link]31.The DCCT Research Group, Bethesda, Maryland Epidemiology of Severe Hypoglycemia in the Diabetes Control and Complications Trial. Am J Med. 1991;90:450–459.[Context Link][CrossRef][Medline Link]32.Service FJ. Hypoglycemic disorders. N Engl J Med. 1995;332:1144–1151.[Context Link][Full Text][CrossRef][Medline Link]33.Boyle PJ, Kempers SF, O’Connor AM, et al. Brain glucose uptake and unawareness of hypoglycemia in patients with insulin-dependent diabetes mellitus. N Engl J Med. 1995;333:1726–1731.[Context Link][Full Text][CrossRef][Medline Link]34.Reynolds LR. Reemergence of insulin pump therapy in the 1990s. South Med J. 2000;93:1157–1161.[Context Link][Full Text][CrossRef][Medline Link]35.Kaufman FR, et al. Insulin pump therapy in type 1 patients: now and into the year 2000. Diabetes Metab Res Rev. 1999;15:338–352.[Context Link][CrossRef][Medline Link]36.Chisholm DJ, Kraegen EW, Hewett MJ. Hypoglycemia episodes during continuous subcutaneous insulin infusion; decreased frequency but increased susceptibility. Aust N Z J Med. 1984;14:255–259.[Context Link][CrossRef][Medline Link]37.Guinn TS, et al. Factors related to discontinuation of continuous subcutaneous insulin-infusion therapy. Diabetes Care. 1998;11:46–51.[Context Link][CrossRef][Medline Link]38.Teutsch SM, et al. Mortality among diabetic patients using continuous subcutaneous insulin infusion pumps. N Engl J Med. 1984;310:361–368.[Context Link][CrossRef][Medline Link]39.Teutsch SM, et al. Mortality among diabetic patients using continuous subcutaneous insulin infusion pumps. N Engl J Med. 1984;310:361–338.[Context Link][CrossRef][Medline Link]40.Midthjell K, et al. Severe or life threatening hypoglycemia in insulin pump treatment. Diabetes Care. 1994;17:1235–1236.[Context Link][CrossRef][Medline Link]41.Prendergast J. Over-delivery of insulin by insulin pumps. Diabetes Care. 1995;18:1201–1202.[Context Link][Full Text][CrossRef][Medline Link]42.Gin H, et al. Attempted suicide by insulin injection treated with artificial pancreas. BMJ. 1983;287:249–250.[Context Link][CrossRef][Medline Link]insulin pump; insulin overdose; hypoglycemic coma00019616-200409000-0000500004794_1972_17_514_sturner_radioimmunoassay_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e624_citationRF_FLOATING))|11065405||ovftdb|SL0000479419721751411065405citation_FROM_JRF_ID_d1548e624_citationRF_FLOATING[Medline Link]468075300019616-200409000-0000500005679_1977_1_58_martin_attempted_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e654_citationRF_FLOATING))|11065213||ovftdb|SL00005679197715811065213citation_FROM_JRF_ID_d1548e654_citationRF_FLOATING[CrossRef]10.5694%2Fj.1326-5377.1977.tb130503.x00019616-200409000-0000500005679_1977_1_58_martin_attempted_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e654_citationRF_FLOATING))|11065405||ovftdb|SL00005679197715811065405citation_FROM_JRF_ID_d1548e654_citationRF_FLOATING[Medline Link]84008900019616-200409000-0000500005792_1985_64_323_arem_pharmacokinetics_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e689_citationRF_FLOATING))|11065404||ovftdb|SL0000579219856432311065404citation_FROM_JRF_ID_d1548e689_citationRF_FLOATING[Full Text]00005792-198509000-0000400019616-200409000-0000500005792_1985_64_323_arem_pharmacokinetics_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e689_citationRF_FLOATING))|11065213||ovftdb|SL0000579219856432311065213citation_FROM_JRF_ID_d1548e689_citationRF_FLOATING[CrossRef]10.1097%2F00005792-198509000-0000400019616-200409000-0000500005792_1985_64_323_arem_pharmacokinetics_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e689_citationRF_FLOATING))|11065405||ovftdb|SL0000579219856432311065405citation_FROM_JRF_ID_d1548e689_citationRF_FLOATING[Medline Link]389776600019616-200409000-0000500000566_1993_22_228_roberge_intentional_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e719_citationRF_FLOATING))|11065213||ovftdb|SL0000056619932222811065213citation_FROM_JRF_ID_d1548e719_citationRF_FLOATING[CrossRef]10.1016%2FS0196-0644%2805%2980210-000019616-200409000-0000500000566_1993_22_228_roberge_intentional_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e719_citationRF_FLOATING))|11065405||ovftdb|SL0000056619932222811065405citation_FROM_JRF_ID_d1548e719_citationRF_FLOATING[Medline Link]842743700019616-200409000-0000500002805_1994_39_103_anonymous_demonstrating_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e754_citationRF_FLOATING))|11065213||ovftdb|SL0000280519943910311065213citation_FROM_JRF_ID_d1548e754_citationRF_FLOATING[CrossRef]10.1177%2F07067437940390020700019616-200409000-0000500002805_1994_39_103_anonymous_demonstrating_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e754_citationRF_FLOATING))|11065405||ovftdb|SL0000280519943910311065405citation_FROM_JRF_ID_d1548e754_citationRF_FLOATING[Medline Link]814931300019616-200409000-0000500006024_1986_315_1245_fischer_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e779_citationRF_FLOATING))|11065213||ovftdb|SL000060241986315124511065213citation_FROM_JRF_ID_d1548e779_citationRF_FLOATING[CrossRef]10.1056%2FNEJM19861113315200200019616-200409000-0000500006024_1986_315_1245_fischer_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e779_citationRF_FLOATING))|11065405||ovftdb|SL000060241986315124511065405citation_FROM_JRF_ID_d1548e779_citationRF_FLOATING[Medline Link]353456700019616-200409000-0000500008005_1999_30_14_telushkin_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e815_citationRF_FLOATING))|11065405||ovftdb|SL000080051999301411065405citation_FROM_JRF_ID_d1548e815_citationRF_FLOATING[Medline Link]1061218500019616-200409000-0000500000668_1985_17_421_malouf_manifestations_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e845_citationRF_FLOATING))|11065213||ovftdb|SL0000066819851742111065213citation_FROM_JRF_ID_d1548e845_citationRF_FLOATING[CrossRef]10.1002%2Fana.41017050200019616-200409000-0000500000668_1985_17_421_malouf_manifestations_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e845_citationRF_FLOATING))|11065405||ovftdb|SL0000066819851742111065405citation_FROM_JRF_ID_d1548e845_citationRF_FLOATING[Medline Link]400416600019616-200409000-0000500002591_1972_4_792_retsas_insulin_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e875_citationRF_FLOATING))|11065213||ovftdb|SL000025911972479211065213citation_FROM_JRF_ID_d1548e875_citationRF_FLOATING[CrossRef]10.1136%2Fbmj.4.5843.792-e00019616-200409000-0000500002591_1972_4_792_retsas_insulin_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e875_citationRF_FLOATING))|11065405||ovftdb|SL000025911972479211065405citation_FROM_JRF_ID_d1548e875_citationRF_FLOATING[Medline Link]464652600019616-200409000-0000500003135_1990_7_349_patrick_neuropathological_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e935_citationRF_FLOATING))|11065213||ovftdb|SL000031351990734911065213citation_FROM_JRF_ID_d1548e935_citationRF_FLOATING[CrossRef]10.1111%2Fj.1464-5491.1990.tb01403.x00019616-200409000-0000500003135_1990_7_349_patrick_neuropathological_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e935_citationRF_FLOATING))|11065405||ovftdb|SL000031351990734911065405citation_FROM_JRF_ID_d1548e935_citationRF_FLOATING[Medline Link]214008900019616-200409000-0000500000439_1985_78_1036_seibert_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e965_citationRF_FLOATING))|11065213||ovftdb|SL00000439198578103611065213citation_FROM_JRF_ID_d1548e965_citationRF_FLOATING[CrossRef]10.1016%2F0002-9343%2885%2990229-300019616-200409000-0000500000439_1985_78_1036_seibert_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e965_citationRF_FLOATING))|11065405||ovftdb|SL00000439198578103611065405citation_FROM_JRF_ID_d1548e965_citationRF_FLOATING[Medline Link]401426300019616-200409000-0000500003024_1991_58_361_kirk_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e991_citationRF_FLOATING))|11065213||ovftdb|SL0000302419915836111065213citation_FROM_JRF_ID_d1548e991_citationRF_FLOATING[CrossRef]10.3949%2Fccjm.58.4.36100019616-200409000-0000500003024_1991_58_361_kirk_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e991_citationRF_FLOATING))|11065405||ovftdb|SL0000302419915836111065405citation_FROM_JRF_ID_d1548e991_citationRF_FLOATING[Medline Link]188911700019616-200409000-0000500001832_1988_6_173_haines_misinterpreted_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1026_citationRF_FLOATING))|11065213||ovftdb|SL000018321988617311065213citation_FROM_JRF_ID_d1548e1026_citationRF_FLOATING[CrossRef]10.1016%2F0735-6757%2888%2990057-500019616-200409000-0000500001832_1988_6_173_haines_misinterpreted_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1026_citationRF_FLOATING))|11065405||ovftdb|SL000018321988617311065405citation_FROM_JRF_ID_d1548e1026_citationRF_FLOATING[Medline Link]335562400019616-200409000-0000500007670_1997_28_584_fujioka_hypoglycemic_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1106_citationRF_FLOATING))|11065404||ovftdb|SL0000767019972858411065404citation_FROM_JRF_ID_d1548e1106_citationRF_FLOATING[Full Text]00007670-199703000-0001700019616-200409000-0000500007670_1997_28_584_fujioka_hypoglycemic_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1106_citationRF_FLOATING))|11065213||ovftdb|SL0000767019972858411065213citation_FROM_JRF_ID_d1548e1106_citationRF_FLOATING[CrossRef]10.1161%2F01.STR.28.3.58400019616-200409000-0000500007670_1997_28_584_fujioka_hypoglycemic_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1106_citationRF_FLOATING))|11065405||ovftdb|SL0000767019972858411065405citation_FROM_JRF_ID_d1548e1106_citationRF_FLOATING[Medline Link]905661500019616-200409000-0000500006114_2001_57_933_finelli_hypoglycemic_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1138_citationRF_FLOATING))|11065404||ovftdb|SL0000611420015793311065404citation_FROM_JRF_ID_d1548e1138_citationRF_FLOATING[Full Text]00006114-200109110-0004600019616-200409000-0000500006114_2001_57_933_finelli_hypoglycemic_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1138_citationRF_FLOATING))|11065213||ovftdb|SL0000611420015793311065213citation_FROM_JRF_ID_d1548e1138_citationRF_FLOATING[CrossRef]10.1212%2FWNL.57.5.933-a00019616-200409000-0000500006114_2001_57_933_finelli_hypoglycemic_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1138_citationRF_FLOATING))|11065405||ovftdb|SL0000611420015793311065405citation_FROM_JRF_ID_d1548e1138_citationRF_FLOATING[Medline Link]1155203900019616-200409000-0000500003135_1996_13_607_heller_hypoglycaemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e320_citationRF_FLOATING))|11065213||ovftdb|SL0000313519961360711065213citation_FROM_JRF_ID_d1548e320_citationRF_FLOATING[CrossRef]10.1002%2F%28SICI%291096-9136%28199607%2913%3A7%3C607%3A%3AAID-DIA159%3E3.0.CO%3B2-I00019616-200409000-0000500003135_1996_13_607_heller_hypoglycaemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e320_citationRF_FLOATING))|11065405||ovftdb|SL0000313519961360711065405citation_FROM_JRF_ID_d1548e320_citationRF_FLOATING[Medline Link]884009300019616-200409000-0000500003458_2000_23_1467_braak_characteristics_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1169_citationRF_FLOATING))|11065404||ovftdb|SL00003458200023146711065404citation_FROM_JRF_ID_d1548e1169_citationRF_FLOATING[Full Text]00003458-200010000-0000500019616-200409000-0000500003458_2000_23_1467_braak_characteristics_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1169_citationRF_FLOATING))|11065213||ovftdb|SL00003458200023146711065213citation_FROM_JRF_ID_d1548e1169_citationRF_FLOATING[CrossRef]10.2337%2Fdiacare.23.10.146700019616-200409000-0000500003458_2000_23_1467_braak_characteristics_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1169_citationRF_FLOATING))|11065405||ovftdb|SL00003458200023146711065405citation_FROM_JRF_ID_d1548e1169_citationRF_FLOATING[Medline Link]1102313800019616-200409000-0000500000439_1991_90_450_anonymous_complications_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1196_citationRF_FLOATING))|11065213||ovftdb|SL0000043919919045011065213citation_FROM_JRF_ID_d1548e1196_citationRF_FLOATING[CrossRef]10.1016%2F0002-9343%2891%2980085-Z00019616-200409000-0000500000439_1991_90_450_anonymous_complications_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1196_citationRF_FLOATING))|11065405||ovftdb|SL0000043919919045011065405citation_FROM_JRF_ID_d1548e1196_citationRF_FLOATING[Medline Link]201208500019616-200409000-0000500006024_1995_332_1144_service_hypoglycemic_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1218_citationRF_FLOATING))|11065404||ovftdb|SL000060241995332114411065404citation_FROM_JRF_ID_d1548e1218_citationRF_FLOATING[Full Text]00006024-199504270-0000700019616-200409000-0000500006024_1995_332_1144_service_hypoglycemic_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1218_citationRF_FLOATING))|11065213||ovftdb|SL000060241995332114411065213citation_FROM_JRF_ID_d1548e1218_citationRF_FLOATING[CrossRef]10.1056%2FNEJM19950427332170700019616-200409000-0000500006024_1995_332_1144_service_hypoglycemic_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1218_citationRF_FLOATING))|11065405||ovftdb|SL000060241995332114411065405citation_FROM_JRF_ID_d1548e1218_citationRF_FLOATING[Medline Link]770028900019616-200409000-0000500006024_1995_333_1726_boyle_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1243_citationRF_FLOATING))|11065404||ovftdb|SL000060241995333172611065404citation_FROM_JRF_ID_d1548e1243_citationRF_FLOATING[Full Text]00006024-199512280-0000200019616-200409000-0000500006024_1995_333_1726_boyle_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1243_citationRF_FLOATING))|11065213||ovftdb|SL000060241995333172611065213citation_FROM_JRF_ID_d1548e1243_citationRF_FLOATING[CrossRef]10.1056%2FNEJM19951228333260200019616-200409000-0000500006024_1995_333_1726_boyle_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1243_citationRF_FLOATING))|11065405||ovftdb|SL000060241995333172611065405citation_FROM_JRF_ID_d1548e1243_citationRF_FLOATING[Medline Link]749113500019616-200409000-0000500007611_2000_93_1157_reynolds_reemergence_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1280_citationRF_FLOATING))|11065404||ovftdb|SL00007611200093115711065404citation_FROM_JRF_ID_d1548e1280_citationRF_FLOATING[Full Text]00007611-200012000-0000300019616-200409000-0000500007611_2000_93_1157_reynolds_reemergence_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1280_citationRF_FLOATING))|11065213||ovftdb|SL00007611200093115711065213citation_FROM_JRF_ID_d1548e1280_citationRF_FLOATING[CrossRef]10.1097%2F00007611-200012000-0000300019616-200409000-0000500007611_2000_93_1157_reynolds_reemergence_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1280_citationRF_FLOATING))|11065405||ovftdb|SL00007611200093115711065405citation_FROM_JRF_ID_d1548e1280_citationRF_FLOATING[Medline Link]1114244800019616-200409000-0000500126072_1999_15_338_kaufman_pediatric_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1306_citationRF_FLOATING))|11065213||ovftdb|SL0012607219991533811065213citation_FROM_JRF_ID_d1548e1306_citationRF_FLOATING[CrossRef]10.1002%2F%28SICI%291520-7560%28199909%2F10%2915%3A5%3C338%3A%3AAID-DMRR57%3E3.0.CO%3B2-Y00019616-200409000-0000500126072_1999_15_338_kaufman_pediatric_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1306_citationRF_FLOATING))|11065405||ovftdb|SL0012607219991533811065405citation_FROM_JRF_ID_d1548e1306_citationRF_FLOATING[Medline Link]1058562000019616-200409000-0000500000926_1984_14_255_chisholm_susceptibility_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1333_citationRF_FLOATING))|11065213||ovftdb|SL0000092619841425511065213citation_FROM_JRF_ID_d1548e1333_citationRF_FLOATING[CrossRef]10.1111%2Fj.1445-5994.1984.tb03762.x00019616-200409000-0000500000926_1984_14_255_chisholm_susceptibility_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1333_citationRF_FLOATING))|11065405||ovftdb|SL0000092619841425511065405citation_FROM_JRF_ID_d1548e1333_citationRF_FLOATING[Medline Link]659411600019616-200409000-0000500003458_1988_11_46_guinn_discontinuation_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1368_citationRF_FLOATING))|11065213||ovftdb|SL000034581988114611065213citation_FROM_JRF_ID_d1548e1368_citationRF_FLOATING[CrossRef]10.2337%2Fdiacare.11.1.4600019616-200409000-0000500003458_1988_11_46_guinn_discontinuation_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1368_citationRF_FLOATING))|11065405||ovftdb|SL000034581988114611065405citation_FROM_JRF_ID_d1548e1368_citationRF_FLOATING[Medline Link]312318700019616-200409000-0000500006024_1984_310_361_teutsch_subcutaneous_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1395_citationRF_FLOATING))|11065213||ovftdb|SL00006024198431036111065213citation_FROM_JRF_ID_d1548e1395_citationRF_FLOATING[CrossRef]10.1056%2FNEJM19840209310060600019616-200409000-0000500006024_1984_310_361_teutsch_subcutaneous_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1395_citationRF_FLOATING))|11065405||ovftdb|SL00006024198431036111065405citation_FROM_JRF_ID_d1548e1395_citationRF_FLOATING[Medline Link]641911000019616-200409000-0000500006024_1984_310_361_teutsch_subcutaneous_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1422_citationRF_FLOATING))|11065213||ovftdb|SL00006024198431036111065213citation_FROM_JRF_ID_d1548e1422_citationRF_FLOATING[CrossRef]10.1056%2FNEJM19840209310060600019616-200409000-0000500006024_1984_310_361_teutsch_subcutaneous_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1422_citationRF_FLOATING))|11065405||ovftdb|SL00006024198431036111065405citation_FROM_JRF_ID_d1548e1422_citationRF_FLOATING[Medline Link]641911000019616-200409000-0000500004678_2000_85_2758_lobmann_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e350_citationRF_FLOATING))|11065404||ovftdb|SL00004678200085275811065404citation_FROM_JRF_ID_d1548e350_citationRF_FLOATING[Full Text]00004678-200008000-0002200019616-200409000-0000500004678_2000_85_2758_lobmann_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e350_citationRF_FLOATING))|11065213||ovftdb|SL00004678200085275811065213citation_FROM_JRF_ID_d1548e350_citationRF_FLOATING[CrossRef]10.1210%2Fjc.85.8.275800019616-200409000-0000500004678_2000_85_2758_lobmann_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e350_citationRF_FLOATING))|11065405||ovftdb|SL00004678200085275811065405citation_FROM_JRF_ID_d1548e350_citationRF_FLOATING[Medline Link]1094687800019616-200409000-0000500003458_1994_17_1235_midthjell_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1449_citationRF_FLOATING))|11065213||ovftdb|SL00003458199417123511065213citation_FROM_JRF_ID_d1548e1449_citationRF_FLOATING[CrossRef]10.2337%2Fdiacare.17.10.123500019616-200409000-0000500003458_1994_17_1235_midthjell_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1449_citationRF_FLOATING))|11065405||ovftdb|SL00003458199417123511065405citation_FROM_JRF_ID_d1548e1449_citationRF_FLOATING[Medline Link]782115900019616-200409000-0000500003458_1995_18_1201_prendergast_delivery_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1477_citationRF_FLOATING))|11065404||ovftdb|SL00003458199518120111065404citation_FROM_JRF_ID_d1548e1477_citationRF_FLOATING[Full Text]00003458-199508000-0002300019616-200409000-0000500003458_1995_18_1201_prendergast_delivery_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1477_citationRF_FLOATING))|11065213||ovftdb|SL00003458199518120111065213citation_FROM_JRF_ID_d1548e1477_citationRF_FLOATING[CrossRef]10.2337%2Fdiacare.18.8.1201a00019616-200409000-0000500003458_1995_18_1201_prendergast_delivery_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1477_citationRF_FLOATING))|11065405||ovftdb|SL00003458199518120111065405citation_FROM_JRF_ID_d1548e1477_citationRF_FLOATING[Medline Link]758786400019616-200409000-0000500002591_1983_287_249_gin_artificial_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1502_citationRF_FLOATING))|11065213||ovftdb|SL00002591198328724911065213citation_FROM_JRF_ID_d1548e1502_citationRF_FLOATING[CrossRef]10.1136%2Fbmj.287.6387.24900019616-200409000-0000500002591_1983_287_249_gin_artificial_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e1502_citationRF_FLOATING))|11065405||ovftdb|SL00002591198328724911065405citation_FROM_JRF_ID_d1548e1502_citationRF_FLOATING[Medline Link]640926900019616-200409000-0000500005064_1999_72_238_simpson_hyperglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e377_citationRF_FLOATING))|11065404||ovftdb|SL0000506419997223811065404citation_FROM_JRF_ID_d1548e377_citationRF_FLOATING[Full Text]00005064-199901000-0002800019616-200409000-0000500005064_1999_72_238_simpson_hyperglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e377_citationRF_FLOATING))|11065213||ovftdb|SL0000506419997223811065213citation_FROM_JRF_ID_d1548e377_citationRF_FLOATING[CrossRef]10.1046%2Fj.1471-4159.1999.0720238.x00019616-200409000-0000500005064_1999_72_238_simpson_hyperglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e377_citationRF_FLOATING))|11065405||ovftdb|SL0000506419997223811065405citation_FROM_JRF_ID_d1548e377_citationRF_FLOATING[Medline Link]988607500019616-200409000-0000500003458_1991_14_922_chalmers_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e415_citationRF_FLOATING))|11065213||ovftdb|SL0000345819911492211065213citation_FROM_JRF_ID_d1548e415_citationRF_FLOATING[CrossRef]10.2337%2Fdiacare.14.10.92200019616-200409000-0000500003458_1991_14_922_chalmers_hypoglycemia_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e415_citationRF_FLOATING))|11065405||ovftdb|SL0000345819911492211065405citation_FROM_JRF_ID_d1548e415_citationRF_FLOATING[Medline Link]177369400019616-200409000-0000500003458_1983_6_180_holmes_functioning_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e452_citationRF_FLOATING))|11065213||ovftdb|SL000034581983618011065213citation_FROM_JRF_ID_d1548e452_citationRF_FLOATING[CrossRef]10.2337%2Fdiacare.6.2.18000019616-200409000-0000500003458_1983_6_180_holmes_functioning_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e452_citationRF_FLOATING))|11065405||ovftdb|SL000034581983618011065405citation_FROM_JRF_ID_d1548e452_citationRF_FLOATING[Medline Link]634302300019616-200409000-0000500002591_1958_2_463_birkinshaw_investigations_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e489_citationRF_FLOATING))|11065213||ovftdb|SL000025911958246311065213citation_FROM_JRF_ID_d1548e489_citationRF_FLOATING[CrossRef]10.1136%2Fbmj.2.5094.46300019616-200409000-0000500002591_1958_2_463_birkinshaw_investigations_|00019616-200409000-00005#xpointer(id(citation_FROM_JRF_ID_d1548e489_citationRF_FLOATING))|11065405||ovftdb|SL000025911958246311065405citation_FROM_JRF_ID_d1548e489_citationRF_FLOATING[Medline Link]13560902Complete Recovery From Prolonged Hypoglycemic Coma After Intentional Overdose With an Insulin PumpSoni Sonia MD; Mentzelopoulos, Voula MD; Hatipoglu, Betul MDCase ReportCase Report514p 257-260