Clinical Manifestation
In clinical practice one speaks of diabetic coma even if the patient has not lost conscious. About 10 of patients with coma diabeticum are really unconscious 6 . The causes of these conscious disturbances are cerebral dysfunction in association with severe hypertonic dehydration. The transition from hyperglycemic decompensation with severe ketoacidosis toward coma diabeticum is substantially dependent on the extent of the increase in serum osmolality. The consciousness correlates best with...
Cerebral Edema
A severe, but avoidable complication of therapy is cerebral edema 9 . Brain edema is observed mostly 3 to 13 hours after beginning of therapy. It must be considered especially in patients below 20 years. In one study in children and young adults a total of 55 death cases were investigated 35 . Thirty-six of these patients had a ketoacidosis. A further retrospective study in children investigated searched for risk factors for the development symptomatic brain edema 33 . The prevalence of...
Initial Bolus Of Insulin
The German diabetes association recommends in their latest guideline, to begin the insulin therapy with an intravenous initial bolus of 10 to 20 IE 11,20 . The insulin therapy should not be started without concomitant volume substitution, because a rapid decrease in blood glucose without fluid expansion can lead to intracellular edema 17 . In accordance with the concept outlined above, it is sensible to choose a lower dose of initial insulin, e.g., 2 to 15 IE 13 . The question of if and in...
Bicarbonate Therapy
The therapy with bicarbonate is one of the mostly discussed procedures of management in the treatment of diabetic ketoacidosis. In general, acidosis is decreased after adequate rehydration and implementation of insulin treatment. The main indication for bicarbonate is the emergency treatment of serious disturbances of heart rhythm with severe acidosis and hyperkalemia. In such cases a body weight-adjusted amount of sodium bicarbonate e.g., 50-100 mL is infused. Otherwise, bicarbonate therapy...
Pathophysiology Of Hyperglycemia
An enormous amount of research has been dedicated to unraveling the pathophysiology of type 2 diabetes mellitus over the last 30 years. While a large number of reviews have been devoted to its description, this chapter follows the line of our recent seminar 1 . Insulin is the key hormone for regulating blood glucose. In general, normoglycemia is maintained by the balanced interplay between insulin secretion and the efficacy of insulin actions. In the fasting state, the major part of glucose is...
Diabetes Mellitus Type Is A Multifactorial Disease With Strong Genetic
Diabetes mellitus type 2 is the most common endocrine-metabolic disorder and affects at least 5 of Western society. According to the persisting trends for increasing obesity, the amount of newly diagnosed patients will increase dramatically over the next decades. Unfortunately, lifestyle in combination with affluent alimentation does not spare the young, and increasing obesity in this group is already observed. Usually diabetes mellitus occurs at ages over 40 but we now observe a shift in the...
Screening Methods
The clinical exam and Rose questionnaire are useful though unfortunately fairly insensitive tools for the diagnosis of lower extremity vascular disease 163 . Ancillary modalities include the ABI, toe systolic blood pressure, ultrasound duplex scanning, tissue PO2 measurement, and arteriography. The ABI is a ratio of Doppler recorded systolic arterial blood pressures in the lower and upper extremities, 166 and is normally between 1.00 and 1.40 167 . PAD is defined as an ABI less than 0.9. Lower...
Longterm Implantable Cgm Enzymebased Blood Glucose Electrochemical Sensor
Medtronic Diabetes has developed an electrochemical sensor for long-term implantation in the superior vena cava called the Vascular Glucose Monitoring System http www. medtronicdiabetes.com . The distal tip of the flexible vascular catheter contains an oxygen FIGURE 5 Electrochemical ISF glucose sensor designed for long-term implantation within the subcutaneous tissue. ISF glucose data is transmitted wirelessly to the patient-worn display mg dL versus time www.DexCom.com . FIGURE 5...
Stage The Necrotic Foot Diagnosis
Necrosis has very grave implications, threatening the loss of the limb and is caused by infection or ischemia or by both together. It is classified as either wet or dry, each with its specific management. In the neuropathic foot, necrosis is invariably wet initially and is nearly always due to a septic arteritis secondary to soft tissue infection complicating a digital or metatarsal ulcer. The arterial lumen is often occluded by a septic thrombus. Both wet and dry necrosis can occur in the...
SUMMARY Nhi
GDM affects approximately 1 to 13 of all pregnancies and results from insulin resistance in the setting of limited P-cell reserve. Early universal screening and detection are important to optimize maternal and fetal outcomes. Screening should be performed at 24 to 28 weeks of gestation and earlier if there is a clinical concern of undiagnosed pregestational diabetes. The 50-g oGTT is used for screening. A 3-hour oral 100-g oGTT is used in women who screen positive, but a 75-g 2-h oral glucose...
INTRODUCTION Vdu
Gestational diabetes mellitus GDM is defined as glucose intolerance first recognized during pregnancy 1 . This definition applies regardless of treatment regimens and does not distinguish between those unrecognized cases of diabetes that may have preceded pregnancy. GDM occurs in 0.5 to 12.3 of pregnancies depending on the criteria used and the population being tested 2,3 . In the United States, prevalence rates are higher in African, Hispanic, Native American, and Asian women than in white...
Management
Non-Proliferative Diabetic Retinopathy Management of NPDR relies heavily on patient education, periodic screening and, when necessary, laser treatment. The American College of Physicians American Academy of Ophthalmology has recommended a schedule for ophthalmic evaluation for patients with diabetes Table 1 . Periodic eye examinations enable ophthalmologists to identify patients who would benefit from prophylactic treatment, before serious complications develop. The potential sight-threatening...
Insulin Perfusion
The normal insulin need is about 1 IE hr and should be adapted to the increased needs depending on the extent of ketoacidosis, sepsis, overweight, activation of counter regulatory hormone systems and eventually therapy with catecholamines or glucocorticoids leading to insulin resistance. The guidelines of the German diabetes association recommend the low-dose insulin therapy with a starting dose of 6 IE hr 0.1 IE kg bodyweight until ketoacidosis is controlled and blood glucose is lowered to 14...
Insulin Therapy in Type Diabetes
Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A. Type 2 diabetes mellitus is defined by hyperglycemia, which is the result of an inability of the pancreas to make enough insulin for an individual's insulin resistance. Once this relative deficiency in insulin develops, the ability to produce insulin is no longer balanced with the insulin resistance and hepatic glucose production, thus the sugar...
Contents
1. Epidemiology of Type 2 Diabetes 1 2. Pathogenesis of Type 2 Diabetes 13 Michael Stumvoll, Barry J. Goldstein, and Timon W. van Haeften 3. Rationale and Goals for Glucose Control in Diabetes Mellitus and Glucose Monitoring 27 4. The Role of the Diabetes Educator in the Education and Management of Diabetes Mellitus 45 5. Nutrition in the Etiology and Management of Type 2 Diabetes 59 Monika Toeller and Jim I. Mann 6. Diabetes and Exercise 73 Gerhard Schuler and Axel Linke 7. Psychosocial Issues...
Dietary Approaches
The gold standard in the dietary treatment of obese patients with type 2 diabetes is a balanced moderately energy-restricted diet. The energy deficit is between 500 and 800 kcal day. The most important single measure is the reduction in fat intake, particularly in saturated fatty acids. It is generally recommended to prefer a high-carbohydrate low-fat diet. As shown TABLE 5 Obesity Prevention and Treatment Flowchart 18.5-24.9 Normal weight BMI 18.5-24.9 plus risk factors s and or comorbidity...
Rhuna Shen Susan E Wiegers and Ruchira Glaser
Department of Medicine, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, U.S.A Cardiovascular disease is a leading cause of death in the diabetic population, accounting for close to 80 of the mortality in diabetic patients in North America 1,2 . Patients with diabetes mellitus have both a significantly higher risk for, and a higher mortality from, coronary artery disease CAD . The diabetic patient has a two-to four-fold increase in the...
Intracavernosal Injection Therapy
Intracavernosal therapy requires some specialist knowledge and the ability to treat priapism should it occur. Many specialists used to regard this as the standard treatment and use it for both diagnostic and therapeutic reasons although its role as first-line therapy has been replaced by less invasive treatment modalities. Patients need to be taught how to perform self-injection and the dose needs to be chosen carefully to avoid prolonged erections or priapism. Some patients find it helpful to...
Diagnostic Procedures
The following basic diagnostic steps are needed usually during the first 24 hours clinical history, physical examination, clinical chemistry including TSH, parameters of sepsis, blood gases, urine status, blood and urine cultures in case of signs of infection, ECG, ultrasound of the abdomen, chest X-ray and eventually echocardiography. Especially in the beginning of the therapy of diabetic ketoacidosis, regular control of capillary blood glucose, potassium, and blood gases is needed. Initially,...
Physiology and Pathophysiology
Penile erection is a neurovascular event modulated by psychological factors and hormonal status depending on appropriate trabecular smooth muscle and arterial relaxation in the corpus cavernosum Fig. 1 . On sexual stimulation, nerve impulses cause the release of cholinergic and non-adrenergic non-cholinergic NANC neurotransmitters that mediate erectile function by relaxing the smooth muscle of the corpus cavernosum. A principal neural mediator of erection is NO which activates guanil cyclase to...
REFERENCES Hmj
1. American Diabetes Association. Type 2 diabetes in children and adolescents. Consensus statement. Diabetes Care 2000 23 381-9. 2. Seidell JC. Obesity, insulin resistance and diabetes a world wide epidemic. Br J Nutr 2000 83 Suppl. 1 5S-8S. 3. Dunstan DN, Zimmet PZ, Welborn TA, et al. The rising prevalence of diabetes and impaired glucose tolerance the Australian Diabetes, Obesity, and Lifestyle Study. Diabetes Care 2002 25 829-34. 4. Hadden DR, Blair ALT, Wilson EZ, et al. Natural history of...
Figure 1
features of diabetic retinopathy, including microaneurysms, cotton wool spots CWS , retinal edema, exudates, venous abnormalities and neovascularization, are all secondary to compromised capillary endothelium, which leads to increased capillary permeability and fragility. Widespread small vessel damage leads to areas of ischemia, which can promote intraocular angiogenesis. Numerous hypotheses explaining the microvascular complications of diabetes have been investigated, including the role of...
Mody Modyx
Diabetes, microvascular complications often reduced serum concentrations of triglycerides, Apolipoprotein AII ans CIII, and Lp a lipoprotein Impaired fasting glucose tolerance, diabetes, normal proinsulin-insulin ratio in serum Diabetes, microvascular complications often renal glucosuria, increased sensitivity to sulfonylurea drugs increased proinsulininsulin ratio in serum Diabetes Diabetes, renal cysts and other abnormalities of renal development progressive non-diabetic renal dysfunction,...
4. V. Emanuele N F. Swade T And Ann Emanuele M. Consequencies Of Alcohol Use In
1. American Diabetes Association. Diabetes Statistics. Alexandria, VA American Diabetes Association, 2006. 2. American Diabetes Association. Medical Management of Type 2 Diabetes. Alexandria, VA American Diabetes Association, 1998. 3. Diabetes Research Working Group. Congressional report on National Institutes of Health implementation of the recommendations of the Congressionally-directed Diabetes Research Working Group, 1998. 4. Mokdad AH, Ford ES. Diabetes trends in the U.S. 1990-1998....
REFERENCES Dti
1. Zimmet P, Alberti KG, Shaw J. Global and societal implications of the diabetes epidemic. Nature 2001 414 782-7. 2. King H, Aubert RE, Herman, W. Global burden of diabetes, 1995-2025 prevalence, numerical estimates, and projections. Diabetes Care 1998 21 1414-31. 3. Reaven G. The metabolic syndrome or the insulin resistance syndrome Different names, different concepts, and different goals. Endocrinol Metab Clin North Am 2004 33 2 283-303. 4. Expert Panel on Detection, Evaluation and Treatment...
1 Haffner Sm Et Al. Insulin Sensitivity In Subjects With Type 2 Diabetes.
1. Nathan DM, Singer DE, Godine JE, Perlmuter LC. Non-insulin-dependent diabetes in older patients. Complications and risk factors. Am J Med 1986 81 837-42. 2. United Kingdom Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes UKPDS 33 . Lancet 1998 352 837-53. 3. United Kingdom Prospective Diabetes Study Group. Effect of intensive blood-glucose control...
Historical Aspects And Introduction
The glucose-lowering potential of guanides was first described in medieval times when extracts of Galega officinalis goat's rue or French lilac were used as treatment of diabetes in Europe 1 . In 1957, metformin, a dimethylated biguanide, and phenformin, a phenetylated biguanide were introduced for the therapy of type 2 diabetes mellitus Fig. 1 . Because of the strong association with lactic acidosis, phenformin was withdrawn in the 1970s in most countries including the United States 2 . In...
Hyperglycemia
Acute hyperglycemia reversibly influences upper-gut motor and sensory function. In situations where postprandial insulin release is defective type 2 diabetes or absent type 1 diabetes , the rate of gastric emptying is a major determinant of postprandial blood glucose concentrations. Therefore, altered gastric emptying can contribute to GI symptoms as well as poor glycemic control 24 . Patients with type 2 diabetes mellitus and without neuropathic complications have been shown to exhibit...
Sexual Functioning
Impaired sexual functioning is a well-recognized complication of type 2 diabetes in men and women. The prevalence of erectile dysfunction ED in the overall population between the ages of 40 and 70 years is 52 , while the prevalence in men with diabetes is as high as 75 92-95 . Moreover, diabetic men develop ED at an earlier age than men without diabetes 2 . In women, type 2 diabetes has been shown to impact sexual desire, orgasmic capacity, lubrication, sexual satisfaction, sexual activity, and...
REFERENCES Ovy
1. American Diabetes Association. Standards of medical care in diabetes-2006. Diabetes Care 2006 29 S4-S34. 2. Downs JR, Clearfeld M, Weis S, et al. Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels. Results of the AFCAPS TexCAPs. J Am Med Assoc 1998 279 1615-22. 3. Sacks F, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996...
REFERENCES Bke
1. Centers for Disease Control and Prevention. National Diabetes Surveillance System. Atlanta, GA US Department of Health and Human Services. 2005 available at www.cdc.gov diabetes statistics index.htm, accessed 5 July 2006. 2. Cappuccino FP. Ethnicity and cardiovascular risk variations in people of African and South Asian origin. J Human Hypertens 1999 11 571-6. 3. Dagogo-Jack S, Gavin JR. Diabetes. In Multicultural Medicine and Health Disparities. McGraw-Hill Medical Publishing, 2005 181-96....
Dpp Inhibitors
Endogenous GLP-1 concentrations can be raised two- to threefold by inhibiting GLP-1 degradation via DPP-4. Support for this approach to therapy also comes from the observations that glucose tolerance is improved in animals in which the enzyme has been genetically deleted 75 and in animals treated with DPP-4 inhibitors 76 . Various substances with DPP-4 inhibition properties are currently being tested in preclinical and clinical trials. The two compounds have reached approval in several...
Koda Et Al Diabetes 1995
1. Drucker DJ. Biologic actions and therapeutic potential of the proglucagon-derived peptides. Nat Clin Pract Endocrinol Metab 2005 1 1 22-31. 2. Edelman SV, Weyer C. Unresolved challenges with insulin therapy in type 1 and type 2 diabetes potential benefit of replacing amylin, a second -cell hormone. Diabetes Technol Ther 2002 4 175-89. 3. Koda JE, Fineman M, Rink TJ, et al. Amylin concentrations and glucose control. Lancet 1992 339 1179-80. 4. Koda JE, Fineman MS, Kolterman OG, et al. 24 hour...
DSME Coordinator Role
Diabetes educators often find themselves faced with the challenge of starting a diabetes education program service or they are hired to manage one. For many educators with varying levels of clinical competence, starting, coordinating or managing a diabetes self-management program poses many challenges, and the development of additional skills for diabetes educators has become as important as clinical skills. These skills include Strategic and business planning Continuous quality improvement CQI...
Hormonal Control
Numerous peptide hormones play a role in the regulation of intestinal motility and gastric emptying and also directly, or indirectly, in the control of satiety and caloric intake. Some of these peptides are also involved in glycemic control. These hormones may also influence the neural control of gut motility. Glucagon-like peptide-1 GLP-1 arises from the differential post-transcriptional processing of the proglucagon gene that occurs in the intestinal L cells and in the hypothalamus. It is an...
Info Tlj
adulthood 10-20 in Heterogenous Europe zipper superfamily and HNF-4a, a nuclear orphane receptor 18 . These transcription factors are expressed in the liver, pancreatic P-cells, kidney and reproductive organs and are central factors in the transcriptional network of these cells Fig. 1 . There is an integrative regulation of these factors in embryogenesis and also in adult tissues. Next to the insulin gene expression itself these transcription factors regulate genes that have key functions in...
Thiazolidindiones
Thiozolidindiones TZDs-Rosiglitazone and Piogitazone induce peripheral tissue sensitization to insulin by binding to nuclear peroxisome proliferators-activated receptor-y or PPAR-y, thus stimulating the transcription of genes that regulate carbohydrate and lipid metabolism. Studies have shown reduction of insulin resistance by up to 33 49 with the use of TZDs. Furthermore, recent data suggest that TZDs improve P-cell function by as much as 65 48 . Remarkable response to the metabolic effects of...
Perioperative Management Of The Type Diabetic Major Surgery
Type 2 diabetics unable to increase endogenous insulin secretion may behave metabolically in the perioperative period similar to the classic patient with type 1 diabetes 1,14,44 . Insulin therapy and frequent blood glucose monitoring are required to minimize the risk for ketoacidosis and hypoglycemia 16,17 . A variable-rate insulin infusion fixed-rate glucose infusion method provides the greatest flexibility, safety, and degree of glycemic control. Surgery should be scheduled as early in the...
Transition From Intravenous To Subcutaneous Insulin Therapy
The transition from i.v. insulin therapy to subcutaneous insulin and oral nutrition can be initiated in an awake patient when significant improvement and a pH-value of gt 7.2 have been reached. It is recommended to pursue a primary intensified therapy with pre-prandial applied doses of short acting insulin analogs combination with the prolonged acting insulin two or three times per day, or alternatively very long acting insulin analog once or twice a day. The first dose of long acting insulin...
Strategies For Management And Prevention Of Diabetes In Highrisk Ethnic
The ethnic disparity observed in the rates of diabetic nephropathy, neuropathy and retinopathy disappears when the ethnic groups are maintained at a comparable level of glycemic control. Response to lifestyle or pharmacological intervention was also similar among the ethnic groups in the DPP study 46 . These findings raise hope and confidence that the high morbidity of diabetes in the ethnic minority groups can be ameliorated provided the barriers to the delivery of optimal care are identified...
Approach To The Surgical Patient With Hyperglycemia
Diabetic and non-diabetic patients develop hyperglycemia during surgery and medical illness due to enhanced hepatic gluconeogenesis, relative insulin deficiency, and decreased sensitivity of the liver, skeletal muscle, and adipose tissue to the actions of insulin 1-3 . While clinical evidence suggests a direct association between hyperglycemia and adverse outcome in patients undergoing vascular and cardiac surgery, there is little prospective data available to indicate that glucose control...
REFERENCES Itb
1. Haffner SM, Miettinen H, Gaskill SP, Stern MP. Decreased insulin action and insulin secretion predict the development of impaired tolerance. Diabetologia 1996 39 1201-7. 2. Tripathy D, Carlsson M, Almgren P, et al. Insulin secretion and insulin sensitivity in relation to glucose tolerance. Lessons from the Bothnia study. Diabetes 2000 49 975-80. 3. Pratley RE, Weyer C. The role of impaired early insulin secretion in the pathogenesis of type II diabetes mellitus. Diabetologia 2001 44 929-45....
Osteomyelitis
Classically, the treatment of osteomyelitis is surgical removal of bone. But long-term suppressive antibiotic therapy is also used. As osteomyelitis is usually associated with an infected ulcer and cellulitis, wide spectrum antibiotics should be initially given. On review, antibiotic selection is guided by the results of cultures. Ideally percutaneous bone biopsy should be carried out but this is not always practical especially in ischemic feet. Bone fragments in the base of the wound should be...
Ebenezer A Nyenwe and Samuel DagogoJack
Division of Endocrinology, Diabetes, and Metabolism, University of Tennessee Health Science Center, Memphis, Tennessee, U.S.A. Diabetes mellitus is a chronic debilitating disease currently estimated to affect 7 over 20 million of the total population of the United States 1 . Type 2 diabetes accounts for 90 to 95 of all cases of diabetes. Studies show that the prevalence of diabetes is disproportionately higher among ethnic minority groups, including African Americans, Asian Americans, Pacific...
Info Jrb
159159 152150 143138 126132 121 127 116123 FIGURE 6 Proportions of patients requiring early addition of insulin. Proportions of patients allocated to sulfonylurea requiring early addition of insulin each year because FPG increased to gt 108mg dL 6.0mmol L despite maximal sulfonylurea doses. Those requiring but refusing additional insulin are indicated separately. The number below each column is the number of patients per year. There were no significant differences between the chlorpropamide and...
Minimally Invasive Cgm Dialysis Cathetertype Isf Glucose Sensor
Dialysis catheter-type glucose sensors consist of a flexible catheter that the patient inserts through the skin into the sc tissue. The small pore dialysis catheter is connected to a fluidics system that transports a salt solution dialysate into and out of the body. Glucose-free dialysate is infused into the dialysis catheter previously inserted into the sc tissue, and allowed to equilibrate with ISF glucose. Glucose containing dialysate is pumped out of the body to an external electrochemical...
Clinical Efficacy Of Metformin In Patients With Type Diabetes Mellitus
The glucose-lowering effect of metformin, monotherapy or in combination, has been extensively reviewed 70-72 . In a meta-analysis 73 all randomized, controlled clinical trials comparing metformin with placebo 29,62,74-80 and sulfonylurea 62,74,81-87 were evaluated. The weighted mean difference between metformin and placebo after treatment median treatment duration 4.5 months for fasting blood glucose was -2.0 mM and for HbA1c -0.9 . Body weight was not significantly changed after treatment....
Diagnostic Strategy
Islet cell autoantibody testing is not always reliable, and the results are not immediately available. Thus, the physician must depend on clinical judgment in classifying new-onset diabetes patients. The pathways in bold in the decision trees provided in Figure 1 indicate the most likely outcomes. Classification may only be possible after months or longer of follow-up. In African American children with new, acute-onset diabetes, islet autoantibody testing can identify many of the children who...
Info Pkk
FIGURE 6 Postprandial glucose fluctuations were reduced by pramlintide. Patients with type 2 diabetes self-monitored blood glucose before and after the three major meals of the day and at bedtime at baseline and after 6 months of pramlintide treatment. Pramlintide significantly reduced blood glucose following all three major meals in patients with type 2 diabetes n 166 . P lt 0.05. Source From Ref. 37. Given that pramlintide decreases postprandial glucose excursions, oxidative stress markers...
Implantable Insulin Pumps Continuous Peritoneal Insulin Infusion
The safety and efficacy of continuous peritoneal insulin infusion CPII therapy using a programmable implantable insulin pump have been demonstrated in patients with type 1 and type 2 diabetes. An external programmer is used to control the basal rate and timing amount of a regular insulin bolus infused prior to meals. Peritoneal insulin delivery significantly reduces the risk of hypoglycemia, an advantage that may be due to portal delivery of insulin and a more physiological ratio of portal to...