Diabetes Homeopathic Treatments

Reverse Diabetes Now

Reverse Your Diabetes Today was developed by Matt Traverso, a medical researcher and diabetes expert. He performed a lengthy research to find ways to overcome diabetes. The findings of his research were quite amazing and allowed him to come up with a way to cure this disease effectively and quicker than other treatment methods. This diabetes healing program provides users with natural remedies for diabetes that are proven totally safe to apply. In fact, the author has research thousands of websites; read dozens of magazines, books, diet plans, and brochures out there to find out how to reverse diabetes for good. This treatment offers the tools that are proven effective by many people in many areas all over the world. Reverse Diabetes Today PDF is an extremely comprehensive treatment that encourages people to make positive changes in daily habits, more concretely, dieting, regularly exercising, and weight managing routines to reverse diabetics. Read more here...

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Diagnostic Criteria For Diabetes Prediabetes And Metabolic Syndrome

IGT or diabetes and or insulin resistance* PLUS diabetes BMI, body mass index HDL, high-density lipoprotein IDF, International Diabetes Federation IGT, impaired glucose tolerance NCEP ATP III, Adult Treatment Panel III of the National Cholesterol Education Program WHO, World Health Organization. Insulin resistance insulin sensitivity measured under hyperinsulinemic euglycemic conditions, glucose uptake below lowest quartile for background population under investigation. 'The 2001 American Diabetes Association (ADA) definition identified fasting plasma glucose of > 110 mg dL (6.1 mmol L) as elevated. This was modified in 2004 to be > 100 mg dL (5.6 mmol L), in accordance with the ADA's updated definition of impaired fasting glucose. Adapted from Alberti KG, Zimmet P, Shaw J Metabolic syndrome A new world-wide definition. A Consensus Statement from the International Diabetes Federation. Diabet Med 2006 23 469-480. BMI, body mass index HDL, high-density lipoprotein IDF, International...

Cardiovascular Disease In Diabetes

Heart disease and stroke account for more than two thirds of all deaths among diabetic patients.2 A recent population-based study documented that diabetes confers a CV risk equivalent to aging 15 years.25 In 2001, the Adult Treatment Panel III of the National Cholesterol Education Program (NCEP ATP III) recommended that diabetes be considered a CAD risk equivalent, thus mandating aggressive CV risk pre-vention.26 The notion of diabetes as a CAD risk equivalent came initially from a Finnish population-based study with 7-year follow-up involving 1059 diabetic patients and 1373 nondiabetic patients, which showed that diabetic patients without known CAD had the same likelihood of experiencing an MI as nondiabetic counterparts with a previous history of MI.27 A similar observation was made in a registry enrolling more than 8000 patients with ACS, which showed that diabetic patients with no previous CVD had the same long-term morbidity and mortality as nondiabetic patients with established...

Cardiovascular Diagnostic Modalities In Diabetes Patients

Summary of Studies Using Stress Testing in the Diagnosis of Suspected Coronary Artery Disease in Diabetic Patients From Albers AR, Krichavsky MZ, Balady GJ Stress testing in patients with diabetes mellitus Diagnostic and prognostic value. Circulation 2006 113 583-592. Table 2-4. Summary of Studies Using Stress Testing in the Diagnosis of Coronary Artery Disease in Asymptomatic Diabetic Patients From Albers AR, Krichavsky MZ, Balady GJ Stress testing in patients with diabetes mellitus Diagnostic and prognostic value. Circulation 2006 113 583-592. symptoms nor evidence of cardiac or peripheral vascular disease, the ADA guidelines recommend testing for those who have two or more CV risk factors (i.e., dyslipidemia, hypertension, active smoking, family history of premature CAD, or albuminuria). Although the short-term prognosis (i.e., up to 2 years) in diabetic patients after a negative stress imaging test is excellent, multiple studies have found that those patients may suffer...

Revascularization In Diabetic Patients With Stable Coronary Disease

Almost 1.5 million coronary revascularization procedures, either coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI), are performed each year in the United States, and approximately one quarter of them involve diabetic patients.41 The randomized data on diabetic patients are scarce and are mainly derived from subgroup analyses of revascularization trials of patients with multivessel disease initiated in the late 1980s and early 1990s. Overall, diabetic patients with multives-sel disease seem to have a better prognosis after CABG than after PCI. Although diabetic patients frequently have concurrent risk factors and comorbidities, diabetes has been identified as an independent predictor of CV events during and after revascularization, both percutaneous and surgical. Several pathophysiologic peculiarities of diabetic atherosclerosis previously discussed may negatively affect prognosis and response to coronary revascularization. Table 2-5. Indications for...

Antithrombotic Therapy In Diabetes

With respect to patients undergoing PCI, the Clopidogrel for the Reduction of Events During Observation (CREDO) study randomized patients either to a 300-mg loading dose followed by 12 months of clopidogrel therapy or to no loading dose and clopidogrel treatment for 1 month on top of aspirin. Among 560 diabetic patients, the benefit of pretreatment and prolonged clopidogrel therapy was modest (RRR 11.2 ) compared with the benefit of this regimen observed among 1556 patients without diabetes (RRR 32.8 ).112 In the setting of non-ST-elevation ACS, aspirin remains a cornerstone of therapy, although specific data for diabetic patients are lacking. The Clopido-grel in Unstable angina to prevent Recurrent Events (CURE) trial randomized patients with ACS primarily medically managed to aspirin or aspirin plus clopi-dogrel for 9 to 12 months. Diabetic patients (n 2840) derived only a modest, nonsignificant benefit from the combined treatment (death, MI, or stroke rate...

Special Considerations in Diabetic Patients

Compared with nondiabetic patients, patients with diabetes often have a more advanced coronary atherosclerosis with diffuse disease in small-lumen vessels. With any treatment modality for coronary revascularization, diabetic patients have an inferior outcome compared with nondiabetics. This was first shown for CABG. In patients with diabetes mellitus, CABG is associated with a more rapid progression of atherosclerosis of both grafted and nongrafted vessels, as well as an accelerated degeneration of venous bypass grafts, compared with nondiabetics. Nevertheless, CASS demonstrated that in older diabetics coronary revascularization confers a substantial benefit compared with lone medical therapy.52 Likewise, PCI in patients with diabetes is associated with a substantially increased risk of adverse short-term and long-term outcome compared with PCI in non-diabetics. In particular, it the risk of restenosis after any type of PCI is substantially increased in diabet-ics.53,54 Moreover,...

The Insulin Connection

Until recently, carbohydrates were ignored as a health issue. They are at least as important, and probably more so, than fats in determining weight and cardiovascular fitness. The key to carbohydrates' influence is insulin. Insulin is a hormone secreted by the pancreas in response to a carbohydrate-heavy meal. It is impossible to live without it, but it is possible to live much better without too much insulin. Insulin has many actions, but some of the most important affect body fat, cholesterol levels, and cardiovascular health. Insulin The bottom line is that insulin, certainly in excessive amounts, causes the body to produce and store fat as well as produce inordinate amounts of cholesterol. Insulin is now recognized as an important factor in the development of cardiovascular disease. It is known to act directly on the walls of arteries to produce atheroma atherosclerotic plaques that can narrow the blood vessels, limit blood flow and oxygen delivery, and result in strokes and heart...

Reduction in the Incidence of Diabetes

Captopril developed diabetes than those randomized of diabetes produced by the P-blocker comparator.6 the new incidence of diabetes in the ramipril arm.98 There has been a rather consistent reduction in diabetes as assessed as a secondary end point in some of CHARM heart failure program,43 have indicated that both pharmacologic inhibitors of the RAS reduced the risk of developing new-onset diabetes. A meta- analysis showed an approximately 20 reduction in the risk of developing diabetes in subjects receiving on the pancreatic fibrosis, improving insulin sensitivity in skeletal muscle, improving insulin signaling pathways, and other mechanisms whereby RAS inhibition could influence glucose homeostasis.132 However, all the consistent and important observations from clinical trials must be considered as nondefinitive because they were derived from secondary end points from studies that were designed to address other questions. As part of a two-by-two factorial design, the Diabetes...

Insulindependent diabetes mellitus

In healthy children, insulin levels decrease with exercise so that glucose can be liberated from stores in the liver and blood levels are maintained despite an increase in glucose uptake into the exercising muscle. Children suffering from insulin-dependent (type 1) diabetes mellitus have to inject insulin into the subcutaneous fat tissue. In consequence, insulin is liberated at a constant rate from the subcutaneous injection site, irrespective of glucose demand. Since insulin sensitivity increases during and following exercise, these children are at a high risk of experiencing severe hypoglycemia with exercise, resulting in a loss of consciousness or epileptic seizures. Low blood glucose levels have been described for up to 24 h following exercise in patients with insulin-dependent diabetes. In a survey of parents whose children had suffered from severe hypoglycemia, many parents blamed preceding exercise as trigger. Children should therefore be advised to measure blood glucose before...

Physical inactivity predicts type 2 diabetes

Data from several prospective epidemiologic studies have shown an inverse association between physical activity and the incidence of type 2 diabetes 1-3 . Recently, Wei et al. extended these findings, which were based on self-reporting of physical activity and type 2 diabetes, by examining the relationship of objectively measured cardiorespiratory fitness to the incidence of impaired fasting glucose and type 2 diabetes 4 . This analysis included 8633 mostly white men with non-insulin-treated type 2 diabetes, who were followed for 6 years after baseline assessment of cardiorespiratory fitness by a maximal exercise test on a treadmill. Men in the low fitness group (the least fit 20 of the cohort) had a 1.9-fold risk for impaired fasting glucose and a 3.7-fold risk for diabetes compared to those in the high fitness group (the most fit 40 of the cohort) after adjusting for age, smoking, alcohol consumption and parental diabetes. After additional adjustment for body mass index,...

Physical inactivity and the burden of cardiovascular disease in type 2 diabetes

Patients with type 2 diabetes have a two- to four-fold increased mortality from cardiovascular disease 6 . The ultimate goal of all therapies in type 2 diabetes is to reduce this burden. In the Aerobic Center Longitudinal Study discussed above 7 , the association between low cardiorespiratory fitness and physical inactivity and total mortality in 1263 men with type 2 diabetes was also studied. After adjustment for age, preexisting and family history of cardiovascular disease, fasting glucose and cholesterol concentrations, overweight and hypertension, type 2 diabetic men in the low fitness group had a risk for all-cause mortality of 2. i. The majority of deaths were attributable to cardiovascular disease 7 .

Prevention of type 2 diabetes

The convincing epidemiologic evidence linking physical inactivity to the development of type 2 diabetes is supported by a few intervention studies. In the 6-year Malmo feasibility study, 181 subjects with impaired glucose tolerance (IGT) and 41 type 2 diabetic patients participated in an intervention program which consisted of supervised training and dietary advice organized either as group sessions or individually for 1 year 8 . The subjects were then encouraged to continue exercise without supervision from the investigators for 5 years. At 6 years, body weight was reduced 2.3-3.7 amongst participants as compared to 0.5-1.7 in non-intervened subjects. Maximal oxygen uptake was increased by 10-14 vs. decreased by 5-9 in participants vs. control subjects. Glucose tolerance was normalized in 52 of the subjects with IGT and in 23 in those with type 2 diabetes in the intervention groups, as compared to 36 in an IGT control group 8 . These encouraging data may not, however, be generally...

Treatment of type 2 diabetes

Data on effects of aerobic and resistance training on glycemic control in established type 2 diabetes are summarized in Tables 4.4.1 and 4.4.2. Many studies lacked an appropriate sedentary control group. This limitation is a concern as intensified patient-doctor interaction may itself improve glycemic control and other metabolic parameters. In many studies, the patients lost weight, which may or may not be a consequence of physical activity and confounds, as does small sample size, interpretation of effects of exercise as compared to weight loss per se on metabolic control. Overall effects of physical training on glycemic control have been modest and in roughly half of the studies non-significant. There are several potential explanations for the failure of exercise to be an effective antihyperglycemic therapy. First, physical training primarily improves insulin sensitivity in skeletal muscle (see below) rather than in the liver, which is the ultimate target of any antihyperglycemic...

Physical training in the treatment of type 1 diabetes

The role of physical activity has been emphasized in improving well-being and self-esteem in type 1 diabetic patients also. Although data specifically addressing type 1 diabetic patients are not available, exercise should have the same cardiovascular benefits in type 1 diabetic as in type 2 diabetic patients, provided the insulin treatment regimen and diet can be accurately adjusted to maintain normal glucose homeostasis during exercise. Effect of physical training on glucose control and insulin requirements Most studies have found no difference in glycemic control between type 1 diabetic patients who are physically active compared to those who are inactive 64,72,73 , and no improvement in glycemic control by physical training 74-77 . On the other hand, physical training does improve and even normalize insulin sensitivity in type 1 diabetic patients 77 (Fig. 4.4.5), and this is associated with slight (5 ) decreases in insulin requirements 75,77 . Effect of physical training on...

Drugs used to treat diabetes mellitus Commentary

Diabetes is common and the main clinical interest for anaesthetists lies in the maintenance of effective glucose homoeostasis. This is not, however, the focus of this question, which concentrates more on an understanding of intermediary metabolism. The range of drugs is expanding, but you will not be asked in any detail about newer agents such as the meglitinides and glitazones. You will, on the other hand, be expected to know about insulin and something about the well-established biguanides and sulphonylureas.

Complications of diabetes mellitus

Cardiovascular disorders (coronary artery, cerebrovascular and peripheral vascular) are common in diabetics, and there is an increased risk of perioperative myocardial infarction. Careful preoperative assessment of cardiovascular function, appropriate choice of anaesthetic technique and precise perioperative monitoring are essential. Infection. Diabetics are prone to infection and an increased risk of septicaemia and abscess formation. Infection is associated with increased insulin requirements, which return to normal on its eradication, e.g. after surgical drainage of an abscess.

Diagnosing Diabetes Is Easy

In fact, it's one of the simplest disorders to diagnose. A simple finger prick yields a couple of drops of blood that are analyzed for the presence of sugar. In nonpregnant adults, the criteria for diagnosis is as follows a blood-sugar level of greater than 200 mg dl, a fasting blood-sugar level of greater than 126 mg dl, or a two-hour blood-sugar level of greater than 200 mg dl during an oral glucose tolerance test. All pregnant women should be tested for GDM between 24 and 28 weeks of gestation. The testing, called an oral glucose tolerance test (OGTT), is painless and reliable. A blood-sugar level is obtained, and then the patient drinks a glass of sugary liquid. One hour later, a second blood-sugar reading is obtained. If a mom-to-be has a fasting blood sugar of greater than 126 mg dl, or a random blood sugar of greater than 200 mg dl, she meets the criteria for diabetes. It's very important to diagnose GDM because, when treated with proper diet and possibly insulin therapy,...

Can You Prevent Diabetes

So far, despite a number of research studies now underway, there are no definitive answers on how to prevent Type 1 diabetes. Type 2 diabetes is another story. You can reduce many of the risk factors that increase your chances for developing the condition. Poor lifestyle habits such as a bad diet and lack of exercise can increase your chances for getting diabetes. Other nonnutrition related risk factors for Type 2 diabetes include being over the age of 45, having a parent or sibling with the disease, being of Latino, Native American, African American, or Pacific Islander descent, and, in a woman, having polycystic ovarian syndrome. Furthermore, there's strong evidence that even modest weight loss and exercise can significantly reduce the onset of Type 2 diabetes in people with an impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). In one study, individuals who lost 5 to 7 percent of their body weight and walked for 150 minutes each week reduced their risk of developing...

Eating Smart When You Have Diabetes

If you're diagnosed with diabetes, you should definitely seek the nutritional advice of a registered dietitian, preferably one who is certified as a diabetes educator (credentials will read R.D., C.D.E.). The goal of nutrition therapy is to restore and maintain blood glucose levels to as near normal as possible. This means balancing your food with insulin and activity levels. What's more, you'll want to maintain appropriate cholesterol and trigylceride levels, consume the right number of calories for maintaining a reasonable weight, and improve your overall health by eating right.

Eating Disorders in Children With Diabetes

An additional and somewhat unique concern in children and adolescents with diabetes is the occurrence of disordered eating. Such disordered eating is believed to be the result of both the focus that the treatment of diabetes places on dietary intake and the fact that treatment modalities often result in weight gain. However, some controversy exists regarding the prevalence of disordered eating in individuals with type 1 diabetes. Some studies have found no significant increase in diagnoses of eating disorders, yet other studies have found a higher incidence of eating disorders and eating disorder-type behaviors in individuals who have type 1 diabetes. In addition, as in the general population, younger adolescent females with type 1 diabetes appear to be the most susceptible to the development of an eating disorder (Jones et al. 2000 Meltzer et al. 2001 Verrotti et al. 1999). The treatment for diabetes itself has also been used by some adolescents to manipulate their weight....

Cognitive Changes in Children With Type 1 Diabetes

Evidence suggests that children with type 1 diabetes may experience a wide range of cognitive difficulties associated with their disease. A number of studies document that these children are at risk for learning disabilities and may experience difficulties with attention, processing speed, long-term memory, and executive functioning (e.g., McCarthy et al. 2003 Rovet and Alvarez 1997 Schoenle et al. 2002). As a result, academic problems may emerge, particularly for those children who have earlier age at onset and who tend to have severe, recurring hypoglycemic episodes. Neurocognitive screening or a complete neuropsychological evaluation should therefore be considered for youth with type 1 diabetes, particularly for those who have experienced many negative glycemic events or who are struggling with school performance. Such an evaluation may well help the school develop an Individualized Education Plan that addresses needed academic and or physical accommodations.

Psychosocial Interventions for Children With Type 1 Diabetes and Their Parents

Over the past three decades, a variety of psychosocial and behavioral interventions have been utilized in the context of type 1 diabetes (for comprehensive reviews of such interventions, see Delamater 2007 Clearly, knowledge about diabetes and its treatment is an essential basis for diabetes management. Thus, systematic efforts have been made to impart such information through clinic-based interventions that occur immediately after diagnosis, as well as through other avenues such as summer camps (e.g., Harkavy et al. 1983 Karaguzel et al. 2005 San-tiprabhob et al. 2008). What is also clear, however, is that diabetes knowledge is insufficient for successful diabetes management. Indeed, knowledge is inconsistently associated with HbA1c levels (e.g., Johnson 1995). To further enhance diabetes management, researchers have used a variety of approaches that build on a knowledge base, such as group coping skills training (Grey et al. 2000) or behavioral contracting (e.g., Wysocki et al....

Child and Parental Adjustment to Type 2 Diabetes

Research on parent and child adjustment to type 2 diabetes is scant, especially considering the rising incidence of the disease (Naughton et al. 2008). One area of research has focused on health-related quality of life (HRQOL). Quality of life is thought to be an important factor in adjustment to the illness and has consequently been increasingly studied in patients with diabetes (e.g., de Wit et al. 2007). For instance, Pediatric Quality of Life Inventory scores were used to compare 91 children and adolescents with type 2 diabetes with approximately 300 healthy controls children with type 2 diabetes were found to have lower total health, psychosocial health, emotional functioning, social functioning, and school functioning scores (Varni et al. 2003). Another study comparing HRQOL in 257 individuals ages 8-22 years with type 2 diabetes and 2,188 same-age individuals with type 1 diabetes also revealed that participants with type 2 diabetes had lower HRQOL (Naughton et al. 2008)....

Interventions for Children With Type 2 Diabetes and Their Parents

Limited research has been conducted on interventions for children and adolescents with type 2 diabetes. Indeed, the majority of research has been conducted with adults. However, given the connection between obesity and type 2 diabetes, preventive interventions for children and adolescents are becoming more common. These interventions focus on increasing dietary knowledge and promoting physical activity to help reduce the likelihood of type 2 diabetes. For example, a 1-year school-based intervention for students in grades 3-5 in Canada produced gains in dietary knowledge, overall health knowledge, and dietary self-efficacy (Saksvig et al. 2005). Similar interventions are described elsewhere (S.M. Davis et al. 1999 Macaulay et al. 1997). Other interventions that target adults diagnosed with type 2 diabetes have focused on group education programs (Davies et al. 2008) and self-management approaches (Thoolen et al. 2007). Pharmacological interventions, such as using metformin, have also...

Adherence Issues in Diabetes Care

A comprehensive review of treatment adherence in diabetes is beyond the scope of this chapter however, the tremendous importance of compliance with the complex medical regimen warrants a brief discussion (for additional information on adherence issues, see Delamater 2000 and Chapter 13, Treat ment Adherence, in this volume). As mentioned previously, diabetes adherence is a multifaceted construct, and children with diabetes face multiple task demands in regard to a complex treatment of a chronic illness. Although low overall adherence levels have been demonstrated in many chronic illnesses (Adams et al. 1997 Epstein and Cluss 1982), adherence levels in diabetes have often been found to be particularly poor (e.g., Johnson et al. 1986 La Greca et al. 1990 Reinehr et al. 2008). A number of types of adherence difficulties have been delineated in the research literature. Poor levels of adherence with young children and adolescents have been shown in self-monitoring of blood glucose...

Maturity Onset Diabetes of Young

Genetic defects of beta-cell function involve genes coding for hepatic transcription factors and glucokinase. In the MODY variant, hyperglycemia is observed during childhood or adolescence and is caused by a diminution in beta-cell secretion without impairment in insulin action. The genetic disorders are autosomal dominant, and the glucokinase defect impairs the conversion of glucose to glucose-6-phosphate, which is involved in insulin secretion. This glucokinase dysfunction causes a loss of the beta-cell glucose sensor. The resulting diabetes is generally not prone to ketosis. Many patients with milder forms of diabetes treated as type 1 eventually are found to have similar genetic defects.

Genetic Disorders of Insulin Resistance

These genetic defects may cause diabetes varying from mild to severe. Marked hyperinsulinemia activates epidermal growth factor receptors in skin, resulting in acanthosis nigricans, a darkening of skin folds at the nape of the neck or in the axilla. Marked hyperinsulinemia stimulates ovarian steroidogenesis, which can result in enlarged ovaries and a virilizing syndrome. This condition provided insight into the connection of insulin resistance to polycystic ovarian syndrome, which is now routinely treated with metformin to attenuate hirsutism and stimulate ovulation. The genetic defects in patients with generalized lipoatrophy have not been fully defined, but these patients are extremely insulin resistant because energy substrates can be stored only in liver and muscle. Impairment in fatty acid storage compromises muscle uptake and glucose oxidation.

Overt Type 2 Diabetes

Remarkably, only 20 to 25 of individuals with hyperin-sulinemia and insulin resistance progress to overt type 2 diabetes. This progression begins when FSG becomes 100 mg dL or greater, the threshold for the diagnosis of prediabetes. Type 2 diabetes may be diagnosed at this phase if a casual postprandial glucose of 200 mg dL or higher is detected. Most patients diagnosed with type 2 diabetes may not note the typical hyperglycemic symptoms described for type 1 diabetes. The difference may be that type 2 diabetes evolves over years below the symptomatic threshold because sufficient insulin is present to prevent the marked lipolysis and ketonemia more typical of type 1 diabetes, with its obligatory water and electrolyte losses. Most patients with type 2 diabetes are discovered incidentally, such as during routine risk factor assessment for cardiovascular disease or other work-up for various symptoms, including peripheral senso-rimotor neuropathy, Bell's palsy, erectile dysfunction, visual...

Initiating Insulin for Type 2 Diabetes

The classic setting for the use of insulin is in a newly diagnosed type 1 diabetic patient. However, insulin is more frequently used in the treatment of type 2 diabetes to compensate for the secretory defect that often progresses to a profound loss of insulin secretory reserve. This is suggested when FSG or HbA1c continue to rise despite the patient's best behavioral efforts and multiple oral drugs. A patient with type 2 diabetes can also present late in its course with marked hyperglycemia and even ketosis. In these patients, insulin treatment protocols used in type 1 diabetes are appropriate until the type 2 pattern of glucose homeostasis is recognized. In most patients, convenience insulins such as human or synthetic 70 30 or 75 25 combinations can be used for several days until the effects of behavioral measures and oral agents kick in. Dosage is usually from 0.2 to 0.5 units (U) kg body weight day (in elderly patients, consider 0.1 U kg day). The initial dosage selected is a...

Supportive Care for Children and Adolescents Requiring Insulin

As subacute diabetes is stabilized, the patient and family require extensive formal diabetic education, support, and empathy to ease the anxieties associated with a new diagnosis of a long-term disorder. A maladjustment in the needed insulin therapy could adversely affect the patient's success in living with diabetes. Instruction in dietary principles includes carbohydrate counting and insulin coverage, correction and adjustment of the insulin dosages based on glucose variability and physical activities, and the standards of care to limit acute and long-term risks of diabetes, as detailed next. Following clinical stabilization, the family physician can further consider the etiology and alternative treatments according to ongoing diabetic manifestations.

Initial Treatment Insulin and Potassium

Management of DKA involves administration of insulin, water, and electrolytes safely to prevent marked fluid shifts into the brain and a precipitous drop in potassium, which would impair compensatory hyperventilation. Insulinization promptly blocks further liposis and shuts down ketogenesis. R insulin is given as an intravenous (IV) bolus of 0.1 U kg with the start of saline administration. Some suggest the initial bolus should be as much as 20 U. The bolus infusion is followed by a continuous infusion of 0.1 U kg hr, with hourly adjustments based on decline in serum glucose and reversal of acidosis. Low-dose insulin infusions are safe if the potassium value is monitored, and improving metabolic parameters should be apparent in 1 or 2 hours. Some patients may be remarkably resistant, and a significant bolus adjustment of up to 20 units may be necessary in 1 hour, with modification of the infusion concentration. The objective is not to decrease glucose precipitously but to turn off...

Gestational Diabetes Mellitus

In about 50 of women, GDM is reversible after pregnancy and does not inevitably evolve to type 2 diabetes. Asymptomatic type 1 or 2 diabetes or LADA existing before pregnancy may become clinical and irreversible. Women with no prior evidence of diabetes may demonstrate their type 2 diabetic gene during pregnancy and either remain diabetic postpartum or experience a long, normal latent period before the gene is expressed again. The expected conversion rate of women with GDM to type 2 diabetes after pregnancy can be reduced with therapeutic lifestyle changes.

Postpartum Gestational Diabetes

Some authorities recommend GTT at 3 months postpartum to detect evidence of persisting DM if fasting values have normalized. This nonpregnant GTT merely measures the 2-hour value after a 75-g glucose challenge. Values of 200 mg dL or greater confirm type 2 diabetes values of 160 to 200 mg dL and higher indicate impaired tolerance consistent with insulin resistance. Finding normal glucose values at 3 months does not preclude the onset of type 2 diabetes later, when further changes in body composition occur with aging. Thus a woman with a history of GDM should periodically self-monitor fasting and postprandial values to assess her inherent diabetic risk and demonstrate her motivation to suppress it indefinitely.

Hospital Care of Diabetic Patients

Achieving diabetic control under normal ambulatory conditions is difficult enough in most patients. When illness prevents a patient from utilizing diabetic survival skills, however, and the stress of illness overcomes the patient's available insulin, care of the patient becomes a professional challenge. In the past, lack of data often resulted in less-than-optimal diabetic care in favor of managing the primary illness. Recent observations, however, demonstrate the efficacy of glycemic control in critically ill surgical patients. As a result, intensive glucose management protocols with continuous insulin infusion are now being widely applied. Good glucose control in known diabetic patients and those with marked hyperglycemia and critical illness shortens intensive care unit (ICU) and respirator time and reduces associated polymyopathy while generally improving all outcome parameters. Many post-cardiothoracic surgery units have adopted these protocols to improve myocardial energetics,...

Diabetic Nephropathy Diabetic Glomerulopathy Renal Interstitial Syndromes

Before the DCCT, a patient with type 1 diabetes had a 30 to 40 likelihood of developing macroproteinuria (> 300 mg day), which would quickly progress to renal insufficiency and the need for renal dialysis. This process begins with pro-teinuria and increasing BP as early as 10-15 years after diagnosis of type 1 diabetes. In the early 1970s, when repeated studies showed that lowering of BP reduced cardiovascular events, diabetologists began to observe that good BP control, including use of diuretics, prolonged the interval from the onset of proteinuria to renal failure. The first studies of the angiotension-converting enzyme (ACE) inhibitor capto-pril suggested that treatment reduced macroproteinuria in patients with moderate renal insufficiency. Subsequent work in the 1990s indicated that reduced proteinuria impaired nephron loss and preserved renal function. The protein leak into the glomerular space may contribute to the mesangial proliferative reaction, starting a process that may...

Type 2 Diabetes Mellitus

According to BRFSS, the prevalence of type 2 diabetes mel-litus (T2DM) increased from 4.9 in 1990 to 7.9 in 2000 (Mokdad et al., 2003). This change has been clearly linked to the increase in obesity. The risk of T2DM is lowest below a BMI of 22 to 23 kg m2. At a BMI of 31, the risk for women in the NHS was 40-fold greater than in women with a BMI less than 22 (Colditz et al., 1995). For men in the Health Professionals Follow-up Study, the risk of T2DM above a BMI of 35 kg m2 was increased 60-fold. Up to 80 of cases of T2DM can be attributed to overweight and obesity. There appears to be a time delay of about 10 years between the development of overweight and onset of the diabetes (Bray, 2003). As weight increases, insulin resistance and compensatory insulin secretion also increase. At some point, the body's ability to secrete insulin does not meet requirements, and blood glucose rises. Weight loss is recommended to lower elevated glucose levels in overweight and obese persons with...

Type 2 Diabetes Mellitus Prevention

Obesity and overweight are important risk factors for developing type 2 diabetes mellitus. Lifestyle modifications, including diet, have been shown to reduce the risk of developing type 2. Diets that result in long-term weight loss of 5 to 7 , along with exercise of moderate intensity for at least 150 minutes per week (30 minutes for 5 days per week), reduce the incidence of type 2 diabetes (Knowles et al., 2002). Obesity tends to increase insulin resistance, so weight loss is an important tool in the prevention and management of type 2 diabetes (see Chapter 36). Dietary recommendations for type 2 patients are similar to those for type 1 patients. It is important to emphasize the importance of other lifestyle changes, such as increasing activity by these patients. In patients with insulin resistance, reduced calorie intake and modest weight loss can improve insulin resistance and blood glucose levels in the short term. Structured programs for making lifestyle modifications (e.g.,...

The Gut and Insulin Secretion

It has long been known that oral ingestion of glucose results in high levels of plasma insulin, although the increase in plasma glucose is only marginal.100'101 This is due to the action of gut hormones, called incretins, that are released into the circulation during meal intake and stimulate insulin secretion. The most important incretins are glucose-dependent insulinotropic polypeptide (GIP also called gastric inhibitory polypeptide) and GLP-1.102 103 GLP-1 is a 30-amino acid peptide produced in the L cells in the distal part of the small intestine, and GIP is a 42-amino acid peptide produced in the K cells in the duodenum and proximal portion of the small intestine. They are both released into the circulation during the first 15 minutes after initiation of food intake, and they both stimulate insulin secretion. Their importance as incretin hormones is illustrated by findings that insulin secretion and glucose tolerance are impaired in mice with genetic deletion of the GIP...

Endocrine Pancreas and Type 2 Diabetes

From the previous discussions, it is clear that the endocrine pancreas is a complexly regulated organ that integrates incoming impulses of nutrient, hormonal, and neural nature. The endocrine pancreas converts these impulses to an optimal secretion of the islet hormones mainly for the regulation of carbohydrate homeostasis. An example of the consequences that follow derangement of the endocrine pancreas is type 2 diabetes. A primary event during the development of this disease is a reduced action of insulin on the activation of peripheral insulin receptors.156 This results in a compensatory increase in insulin secretion, which explains the hyperinsulinemia that accompanies states with peripheral insulin insensitivity, such as obesity. The relation between Insulin sensitivity FIGURE 78-3. Schematic illustration of the relation between insulin sensitivity and insulin secretion. During progression to insulin resistance (i.e., low insulin sensitivity), insulin secretion is increased in a...

Glucose and Insulin Levels

Currently, the diagnosis of insulinoma is confirmed by demonstrating a circulating insulin level that is inappropriately high for the serum glucose level, measured at the time of hypoglycemia (Fig. 79-3). When a patient presents with symptoms of hypoglycemia (i.e., coma, convulsions, or other neurologic symptoms), blood samples should be taken for the determination of both insulin and glucose levels. Samples should be drawn as early as possible to avoid complications of hypoglycemia and before treatment with glucose. Also, later, epinephrine secretion may cause mobilization of liver glycogen with a compensatory rise in serum glucose, possibly masking the hypoglycemia associated with an insulinoma. Although normal serum glucose levels are 60 to 95 mg dL, symptoms of hypoglycemia usually do not occur until levels are less than 50 mg dL. Normal serum insulin levels are typically below 30 pU mL.

Measurement of Proinsulin and C Peptide

Proinsulin is the precursor molecule for insulin and is found in the rough endoplasmic reticulum of the beta cells in the pancreatic islets. As shown in Figure 79-2, the proteolytic conversion of proinsulin results in the formation of equimo-lar amounts of insulin and its connecting peptide, C peptide. In the presence of an insulinoma, there is an elevation of both proinsulin and C peptide.1015 Furthermore, proinsulin levels, which are usually less than 20 of the total immunoreactive insulin in normal individuals, are elevated in the presence of an insulinoma. Levels higher than 50 are thought by some to be diagnostic of an islet cell carcinoma. Finally, should the diagnosis still be in doubt, measurement of circulating C peptide may be helpful. The normal C peptide level is less than 1.2 ng dL. There are two specific instances in which measurement of C peptide levels has been particularly helpful. The first is in patients with insulin-dependent diabetes mellitus. Such patients may...

Oxidative Stress in Diabetes Mellitus Associated ED

Diabetes mellitus is one of the major risk factors for ED. It has been estimated that 50-75 of diabetic men have ED 41 . Compelling data from molecular, cellular, and in vivo animal studies implicate a crucial role for oxidative stress in the development and progression of ED associated with diabetes. Both hyperglycemia and free fatty acids augment ROS The mechanisms for ROS production and the source of ROS in the diabetic penis are, however, only starting to be evaluated. In type 1 diabetic animals, increased protein expression of NADPH oxidase subunit p47phox implies the role of NADPH oxidase as a ROS-producing source 50, 62 . While the role of eNOS uncoupling in diabetic ED is not known, several studies in the diabetic penis 54, 63 , and our unpublished studies (Musicki and Burnett, unpublished) indicate the role of eNOS uncoupling as another ROS source. Future studies are needed to establish the mechanism of NADPH upregulation and eNOS uncoupling in diabetes-associated ED....

Diabetes Mellitus

Diabetes is a rapidly growing worldwide pandemic, and cigarette smoking is responsible for about 10 of the incidence of type 2 diabetes. A dose-response relationship exists, with the risk increasing in direct proportion to the number of cigarettes smoked. People who smoke more than one pack a day have about double the risk for diabetes as nonsmokers, and the risk is still 1.5 times greater for those who smoke only 1 to 14 cigarettes a day (Manson et al., 2000 Willi et al., 2007). Smoking increases the risk for development of the metabolic syndrome and its attendant cardiovascular consequences (Chiolero et al., 2008). Patients with diabetes who smoke are at increased risk for both micro- and macrovascular complications. Cigarette smoking increases the risk for diabetic nephropathy, retinopathy, and neuropathy. This association is strongest in patients requiring insulin for control. Smoking cessation is essential for preventing diabetic complications.

Appropriate Antidiabetic Protocols

The family physician must determine if it is appropriate to continue the outpatient treatment schedule in the hospitalized diabetic patient, depending mainly on the reason for hospitalization. If the patient can eat, the regular outpatient treatment (oral agents and or insulin) should be continued with appropriate adjustments. Supplementing this with basal bolus insulin may be appropriate if significant hyper-glycemia (> 200 mg dL) occurs associated with the stress of illness and hospitalization. The outpatient regimen should not be discontinued in favor of a fixed sliding-scale insulin schedule, which will take days to titrate to the patient's needs and may result in erratic hyper- and hypoglycemic intervals. If the patient cannot be fed and glucose values are drifting above the 150- to 180-mg dL range because of stress-mediated gluconeogenesis, treatment to prevent further hypergly-cemia is appropriate. Basal insulin can be given to fasting patients at starting dosages of 0.25 U...

Subacute Presentation of Type 1 Diabetes

The management of type 1 diabetes will depend on the patient's age and the acuity of the diabetes at presentation. Since there is usually no family history of diabetes, or diabetic experience at home, and given the fragility of the new-onset diabetic state, many children or adolescents presenting with type 1 diabetes require hospitalization to initiate and teach glucose monitoring techniques and to begin insulin treatment. The indication for hospitalizing a newly diagnosed child who is not drifting into ketosis depends on the availability of outpatient educational resources and the clinical judgment that the patient can be closely monitored and the family appropriately advised while developing the capabilities of diabetic self-management.

Child Adjustment to Type 1 Diabetes

A considerable amount of research has been conducted over the past three decades that examines youth adjustment to type 1 diabetes. Collectively, the extant research suggests that many of these children are well adjusted across multiple domains of emotional and behavioral functioning (e.g., Dela-mater 2007 Jacobson et al. 1997 Johnson 1980). At the same time, a consistent subset of youth with type 1 diabetes appears to be at risk for developing significant adjustment difficulties, particularly depression, anxiety, and eating disorders (e.g., Kovacs et al. 1997). However, the relative risk to these individuals for developing a significant mental disorder and the extent to which their disease directly or indirectly contributes to psychiatric symptomatology remain to be determined. Indeed, some of these youth may have experienced premorbid adjustment problems and family dysfunction prior to the diagnosis of type 1 diabetes. Although Kovacs et al. (1997) found relatively high rates of...

Parental Adjustment to Type 1 Diabetes

Although the majority of parents of children with type 1 diabetes adapt well, a subset of parents reports clinically significant psychological distress following initial diagnosis and throughout the course of their child's illness (e.g., Kovacs et al. 1990 Parker et al. 1994). Increased maternal psychological distress (e.g., symptoms of anxiety, somatiza-tion, anger, suspiciousness, depression, dysphoria) has been observed immediately following diagnosis. Parents of children with chronic illness have reported increased depressive symptoms (Mullins et al. 1995), greater negative affective states (Cadman et al. 1991), and higher global psychological distress (Chaney et al. 1997 Northam et al. 1996 Silver et al. 1998). Moreover, maternal distress after the ini tial diagnosis of child type 1 diabetes is highly predictive of subsequent maternal psychological symptomatology (Kovacs et al. 1990). The transactional association between maternal distress and child distress has also been well...

In Diabetes

Coronary artery disease is more prevalent, is more severe, and occurs at a younger age in patients with diabetes. Several metabolic abnormalities, including chronic hyperglycemia, dyslipidemia, and insulin Table 2-1. Diagnostic Criteria for Diabetes Mellitus, Impaired Glucose Tolerance, and Impaired Fasting Glucose According to the American Diabetes Association From Diagnosis and classification of diabetes mellitus. Diabetes Care 2006 29(Suppl 1) S43-S48. Copyright American Diabetes Association.

Insulin Resistance

Together with dyslipidemia, hypertension, and obesity, insulin resistance is a key feature of the metabolic syndrome. In addition, it is the first measurable metabolic disturbance among individuals who will subsequently develop type 2 diabetes. Insulin resistance describes a reduced sensitivity in body tissues to the action of insulin, which affects both glucose disposal in muscles and fat and insulin suppression of hepatic glucose output. As a consequence, higher concentrations of insulin are needed to stimulate peripheral glucose disposal and to suppress hepatic glucose production in patients with type 2 diabetes than those without diabetes. On a biologic level, insulin resistance has been associated with increased coagulation, pro-inflammation, and endothelial dysfunction, among other conditions.10 In insulin-resistant subjects, endothelium-dependent vasodilation is reduced, and the severity of the impairment correlates with the degree of insulin resistance. Abnormal...

Diabetes Prevention

The best way to prevent CV complications in diabetes is to prevent the disease itself. Several studies performed over the last decade have shown that, in subjects at high risk for development of diabetes, lifestyle modifications and pharmacologic interventions may effectively prevent or delay the onset of the disease. Regular physical activity, diet, and weight reduction in high-risk subjects with IGT were shown to reduce the risk of developing diabetes by 31 to 58 . Several drugs also were able to reduce the progression from IGT to diabetes. The risk of developing diabetes decreased with metformin by 31 over 2.8 years, with acarbose by 25 over 3.5 years, with tro-glitazone in women with a history of gestational diabetes by 56 over 5 years, and with orlistat in obese subjects with IGT by 45 over 4 years. Finally, the Diabetes REduction Assessment with ramipril and rosiglitazone Medication (DREAM) trial recently showed that rosiglitazone, administered for 3 years, reduced the incidence...

Diabetes

Diabetes is a risk factor for heart disease, but it can be controlled through medication. If diabetes is well controlled, the acceleration of atherosclerosis is not as rapid as it is in patients whose diabetes is poorly controlled. Diabetic patients should have regular checkups for signs of heart disease. Nutrition is often overlooked when discussion turns to the prevention or treatment of health problems today. Obesity, for instance, has become an underappreciated epidemic in the United States, especially among children and young adults. The incidence of diabetes has also increased threefold. According to ScentfcAmerican (August 1996), the U.S. nutritional industry has become a 33 billion business, and healthcare costs related to obesity exceed 45.8 billion annually. In addition, another 23 billion per year is lost in wages and other forms of compensation because people are absent from work for obesity-related problems. Simply stated, fat has become a 100 billion a year problem for...

Insulin and OPLL

Patients with OPLL and diffuse idiopathic skeletal hyperostosis (DISH) have been reported to be obese and have glucose intolerance as well 2-5 . The prevalence of OPLL is high in patients with non-insulin-dependent diabetes mellitus (NIDDM) 3,5 . Because patients with obesity and NIDDM often exhibit impaired action and increased secretion of insulin, there is a possibility that changes in the secretion or action of insulin may play a role in the progression of the disease. Our recent investigation examining the relation between glucose intolerance and the extent of ossification in OPLL patients revealed that the severity of glucose intolerance was not associated with the extent of ossification, but the insulin secretory response was 6 (Fig. 1). It is therefore speculated that the up- regulation of insulin production due to impaired insulin action may stimulate osteoprogenitor cells in the ligament to induce ossification. Insulin initiates cellular responses by binding to its...

Tropical Diabetes

A type of diabetes found primarily in many tropical areas of the world has characteristics of both type I and type II. The clinical profile involves the following (1) a different genetic pattern of diabetes than in temperate regions (2) a low prevalence rate of type I DM (3) a younger age of onset of type II (4) a sex ratio with male predominance in India and Africa, but female predominance in the West Indies (5) an association of low calorie and protein intake with underweight diabetic individuals in Old World areas but overweight individuals in the Western Hemisphere (6) the predominance of diabetes in urban areas, with the exception of rural populations in the West Indies and (7) intermittent need for insulin therapy. Information is relatively sparse on the genetics of diabetes in tropical countries. Recent studies have shown great population variability in increased susceptibility to diabetes. Genetic studies of Indian populations suggest a stronger familial factor among them...

Gestational Diabetes

A type of diabetes present only during pregnancy was noted in 1882. However, it was not until the 1940s that the term gestational diabetes appeared in medical literature. This form of the disease is difficult to distinguish from type II diabetes because a woman could have diabetes before pregnancy but not have it diagnosed until pregnancy. Babies born to diabetic mothers usually are large but may have immature organ systems, in which case they may not survive. In general, cities in the United States report a higher prevalence of gestational diabetes than do European cities. The highest reported rate of gestational diabetes occurs among the Pima Indians of Arizona, who also have the highest prevalence of type II diabetes of any known population.

Risk factor diabetes

The urine of diabetics is wonderfully sweet as if imbued with honey or sugar. Thomas Willis (1621-1675), physician to King Charles II, England Diabetes is a risk factor for coronary heart disease and stroke, and is the most common cause of amputation that is not the result of an accident. Insulin is a hormone produced by the pancreas and used by the body to regulate glucose (sugar). Diabetes occurs when the body does not produce enough insulin, or cannot use it properly, leading to too much sugar in the blood. Symptoms include thirst, excessive urination, tiredness, and unexplained weight loss. There are two main types of diabetes. Type 1 diabetes, in which the pancreas stops making insulin, accounts for 10 to 15 of cases. The majority of people with diabetes have type 2 disease, in which insulin is produced in smaller amounts than needed, or is not properly effective. This form is preventable, because it is related to physical inactivity, excess calorie intake and obesity. People...

Insulin

Insulin is one of a very few medications which is itself a whole protein, and can induce IgE sensitivity directly. This can result in anaphylaxis. Adverse reactions to insulin also include erythema, pruritis, and indurations, which are usually transient and may be injection site-related. For the sensitivity reactions, treatment options include dexa-methasone or desensitization. If the reaction is injection site-related, a change in delivery system (i.e., insulin pump or inhaled insulin) may be helpful.

Diabetes insipidus

This is caused by disease or damage affecting the hypothalamic-pos-terior pituitary axis. Common causes are pituitary tumours, craniopharyngiomas, basal skull fracture and infection, or it may occur as a sequel to pituitary surgery. In 10 of cases, diabetes insipidus is renal in origin.

Type 1 Diabetes

Typically diagnosed in childhood and with most cases occurring before the age of 30, this is the end result of an autoimmune attack. Special kind of cells in the pancreas called beta cells are destroyed, and this means the individual can no longer produce insulin and must rely on medication (insulin) to survive. While less common (just 10 percent of all diabetics in the United States have either Type 1, gestational diabetes, or secondary diabetes), Type 1 diabetes is also the most serious. Symptoms include weight loss, frequent urination, and thirst. If it's untreated, these same signs and symptoms can occur, along with nausea, dehydration, and vomiting. Once diagnosed, it is imperative that blood-sugar levels be well-controlled or a number of complications, including loss of vision and kidney disease, can occur. Those with Type 1 diabetes are also at an increased risk for hypertension, stroke, heart disease, and problems with the teeth and gums. So obviously, keeping a vigilant watch...

Type 2 Diabetes

Ninety percent of Americans with diabetes have this type, which is generally less serious than Type 1. Patients may not make enough insulin, or they may be resistant to the insulin that they do produce. In individuals with Type 2 diabetes, the insulin that should be produced after a meal can be decreased by as much as 50 percent. People with Type 2 usually don't have to take insulin right after diagnosis, and they may never Type 2 diabetes is often called the silent disease because out of the nearly 16 million people in this country who have it, nearly one third don't know it. In fact, Type 2 diabetes is present on average for about six and one half years before diagnosis. And even though at the time of diagnosis most Type 2 patients don't even have symptoms, they are still at significant risk for coronary heart disease, stroke, and peripheral vascular disease. The risk of developing Type 2 diabetes climbs with age, and is typically diagnosed after the age of 30. However, don't be so...

Basal Bolus Insulin

Synthetic insulin preparations designed to achieve either a prolonged steady effect or an acute action, mimicking physiologic insulin secretion, have allowed patients to develop personal and flexible injection schedules. This is known as the basal bolus regimen and is indicated in the treatment of type 1 diabetes. It provides rapidly acting or bolus insulin to cover carbohydrate ingestion in meals and snacks, and basal insulins are usually given at bedtime to achieve a steady state at breakfast, with an ideal FSG target of 120 mg dL or less. To a large extent, control of the important fasting blood (serum) glucose will depend on attaining an ideal bedtime value of 120 to 140 mg dL, which is based on rapidly active insulin given at dinner. The authors' experience indicates that basal insulin is most predictable in patients who demonstrate overnight glucose production and have controlled glucose values at bedtime. However, an occasional patient will experience hypoglycemia at 4 am, and...

Insulin Rebound

A diabetic complication that family physicians routinely manage is caused by nighttime or very-early-morning hypo-glycemia, which leads to fasting hyperglycemia and sometimes ketosis, especially in children (Somogyi effect). If the patient and physician are not careful, they can get caught in a spiral of ever-increasing insulin doses in response to rebounding glucose values. When confronting persisting morning hyperglycemia, the first step is for the patient to monitor 3 am glucose levels. If low, reduced dosage or timing change in evening insulin administration is necessary.

Insulin Pump Therapy

Motivated type 1 diabetic patients who are frequently monitoring and self-managing insulin dosages but have not attained their glycemic targets should be considered for an insulin pump protocol. Ideally in these patients, the target should be HbA1c less than 7 , with fluctuations in monitored FSG limited to 50 mg dL. A key requisite for pump therapy is the patient's willingness to monitor frequently (up to 6-8 times daily) to ensure a safe transition from the flexible insulin regimen and learn to adjust basal and bolus infusion rates. Use of the insulin pump in type 2 diabetic patients who fail to achieve therapeutic targets is less clear-cut. Often, insulin resistance accounts for failed outcomes rather than beta-cell insufficiency in these patients. If planning to use the pump, patients need to maintain high daily basal rates of 3 to 5 units per hour, which would mean frequent reloading of the insulin reservoir. On a physiologic basis, pump therapy may or may not overcome insulin...

Insulin Glucose Ratio

The insulin-glucose (I G) ratio provides a relationship between these two values that aids in the determination of the presence of an insulinoma. In a normal individual, the ratio is always less 0.4, but in patients with an insulinoma the ratio approaches 1.0 and may in some cases exceed 1.0. The I G ratio is important because as many as one third of patients with an insulinoma have insulin levels within normal limits when they have symptomatic hypoglycemia. FIGURE 79-3. Plasma insulin (in microunits per milliliter) and blood glucose (milligrams per deciliter). Relationships after overnight fasting in 33 normal persons and in 22 patients with solitary beta islet cell adenomas. Both plasma insulin and blood glucose show highly significant differences between the two groups. IRI immunoreactive insulin. (From Harrison TS. Hyperinsulinism and its surgical management. In Hardy JD ed , Rhoads' Textbook of Surgery Principles and Practice. Philadelphia, JB Lippincott, 1977.)

Insulinomas

Ninety percent of insulinomas are benign and are smaller than 2 cm in diameter. Ninety-nine percent are located in the pancreas. A variety of preoperative imaging modalities for the detection of insulinomas are currently available, such as US, CT, MRI, somatostatin receptor scintigraphy (SRS), and various invasive methods, including endosonography (ES), selective angiography (SA), selective portal venous Endosonography (ES) is the most sensitive preoperative procedure. It was introduced in the 1980s and provides direct visualization of the pancreas and is able to detect tumors down to 0.3 to 0.5 cm in diameter (Fig. 80-1). An early study by Rosch and colleagues in 19923 identified endocrine tumors by ES in the head of the pancreas in 95 of their patients and in the body and tail in 78 and 60 , respectively (Table 80-1). One year later, Palazzo and coworkers4 underlined its accuracy for localizing small endocrine pancreatic tumors. Thirteen insulinomas less than 15 mm in diameter were...

Diabetic Nephropathy

Renal failure is a major independent predictor of cardiovascular events. Diabetes is the leading cause of renal failure in Western countries. In 2002 in the United States, diabetic nephropathy accounted for more than 40 of the new cases of renal failure, and 44,000 diabetic patients began treatment for endstage renal disease.2 The condition underlying diabetic nephropathy is microvascular disease. Even in the absence of renal failure, albuminuria is a frequent finding in diabetes. Any degree of albuminuria has been found to be a risk factor for CV events, regardless of the presence or absence of diabetes.137 In addition, diabetic nephropathy with or without renal failure is a key determinant of risk after both PCI and CABG. A single-center analysis involving 1575 diabetic patients undergoing PCI showed that patients with renal failure had significantly more in-hospital complications than those with normal renal function, including mortality (2.6 versus 0.5 , respectively), neurologic...

Fastacting Insulins

Biostructure-based drug design is not limited to design of low-molecular weight compounds based on knowledge of the structure of their biological targets. In the following text we are presenting an example on biostructure-based design of macromolecular drug molecules, i.e., insulin analogs. This design was made possible only by a detailed insight into the structure of insulin and the intermolecular interactions between the insulin molecules in the crystalline phase. Insulin is a hormone produced in the pancreas and it is responsible for the regulation of glucose uptake and storage. Insulin is most often associated with diabetes mellitus, which is a disease causing hyperglycemia. Healthy people have a basal level of insulin in the bloodstream, but in response to intake of food or to cover glucose clearance from the blood, peaks of larger insulin concentrations appear throughout the 24 h of a day. Patients with diabetes may have difficulties in maintaining the proper insulin...

Pregnancy Associated Plasma Protein A

Pregnancy-associated plasma protein A (PAPP-A), a zinc-binding metalloproteinase that is secreted by activated macrophages, fibroblasts, vascular smooth muscle cells, osteoblasts, and placental syncytiotro-phoblasts, functions to activate insulin-like growth factor-1 (lGF-1) through actions on IGF-binding protein (IGF-BP). Although the role for PAPP-A as a biomarker for Down syndrome during pregnancy is well established, its potential role with respect to coronary atherosclerosis and ACS has only recently been recognized.

Patient Encounter Part

There may be similarities and differences in illnesses such as infections, asthma, allergic rhinitis, attention deficient hyperactivity disorder, diabetes, and seizure disorders between children and adults. These have been discussed throughout the textbook. The incidence of previously common childhood illness such as measles, mumps, and rubella has significantly decreased as a result of en masse vaccination of infants and children. The Advisory Committee on Immunization Practices (ACIP) within the CDC release and update child and adolescent immunization schedules every year. Patients' immunization records should be reviewed routinely for needed immunizations based on these schedules. , Most of the common illnesses in children leading to missed school and or need for clinician consultation are ambulatory in nature however, some complications may require hospitalization.

Genetic Basis For Inflammation

Arterial medial fracture, particularly deep into lipid-rich plaque, is associated with a higher degree of inflammatory infiltrate, increased neointimal thickness, and neoangiogenesis.41 Clinical factors associated with restenosis, particularly in diabetics, include longer stent length, active tobacco use, smaller arterial reference diameter, and inflammatory state as determined by CRP level.42

Genetics Inflammation And Restenosis

Presence of genetic polymorphisms may help define susceptibility and may affect the selection of therapy for certain patients undergoing PCI. The inflammatory response may, in part, be determined by underlying genetic predisposition. The value of such information, beyond traditional risk factors of restenosis (e.g., diabetes), will be determined in studies of large populations. The Genetic Determinants of Restenosis (GENDER) project is one of the studies that have set out to examine possible genetic risk factors.

Common Errors in Pediatric Drug Therapy

Decimal errors, including trailing zeroes (e.g., 1.0 mg misread as 10 mg) and missing leading zeroes (e.g., .5 mg misread as 5 mg) in drug dosing or body weight documentation are possible, resulting in several fold overdosing. Strength or concentration of drug should also be clearly communicated by the clinician in prescription orders. Similarly, labels that look alike may lead to drug therapy errors, e.g., mistaking a vial of heparin for insulin, when compounding parenteral solutions. Dosing errors of combination drug products can be prevented by using the right component for dose calculation (e.g., dose of sulfamethoxazole trimethoprim is calculated based on the trimethoprim component).

Physical training and patients with chronic diseases

Type-2 diabetes Type-1 diabetes (e.g.severe hypertension, ketoacidosis in diabetes) Acute episodes of joint swelling (e.g. rheumatoid arthritis) or severe muscle disease (e.g. myositis) (e.g. ischemic heart disease, type-2 diabetes), whereas other diseases are known to be relatively insensitive to exercise when it comes to primary disease manifestations (e.g. chronic lung disease, type-i diabetes). In the later group of diseases, it should, however, be noted that physical training can still have a beneficial effect on health-related parameters that can be achieved by individuals in general. This effect is achievable even in the absence of any worsening of the primary chronic disease. This emphasizes the importance of also encouraging individuals with chronic (and not necessarily fatal) diseases to train on a regular basis from a general health perspective. In addition, almost all diseased individuals can exercise in order to counteract the general loss in function that their...

Death by Brain Criteria

The ability to transplant organs successfully led to the need of criteria for brain death, and national and international definitions have been developed. Many now argue that current criteria are restrictive and should be expanded to include patients who have no reasonable chance of regaining consciousness. y If this change is to be made, a substantial shift in societal thinking about life and death may need to precede it. However, in North America, death by brain criteria is still considered to be irreversible loss of brain function, including that of the brain stem. The single exception to this rule appears to be in the area of osmolar control, and diabetes insipidus is not required for this diagnosis.

The Burden Of The Disease

Worldwide, the estimated prevalence of diabetes for all age groups was 2.8 in the year 2000 and will be 4.4 in the year 2030.1 As a consequence, the total number of people affected from this condition is expected to double during the same period, from 171 million to 366 million. Within the United States, according to the American Diabetes Association (ADA), diabetes affected 20.6 million people in 2005, corresponding to 9.6 of all individuals older than 20 years of age.2 In that same year, 1.5 million new cases of diabetes were diagnosed. Importantly, in approximately one third of affected individuals, the condition remains unrecognized.2 With respect to gender, half of those affected are women.3 In 2004, the U.S. Department of Health and Human Services (USDHHS) estimated that approximately 40 of U.S. adults aged 40 to 74 years, or 41 million people, had prediabetes, a glucose metabolic disturbance predisposing to overt diabetes, heart disease, and stroke.3 Diabetes was the sixth...

The Biopsychosocial Model

Changes in relation to a patient's emotional patterns, life goals, attitudes toward illness, and social environment. Engel proposed that the brain and peripheral organs were linked in complex, mutually adjusting relationships, affected by changes in social as well as physical stimuli. Within this model, environmental and psychological stress is seen as potentially pathogenic for the individual. Emotions may serve as the organism's bridge between the meaning (or significance) of stressful events and the changes in physiologic function (Zegans, 1983). Engel urged physicians to evaluate the patient on biologic, psychological, and social factors in order to understand and manage clinical problems effectively (Wise, 1997). For example, a workplace accident could be seen as resulting from poorly designed equipment (social) and inattentiveness (psychological) brought about by low blood sugar (biologic). Similarly, the accident could result in damage to internal organs (biologic), distress...

Endothelial Dysfunction

Diabetes vascular disease is characterized by endothelial dysfunction, a biologic abnormality that has been related to hyperglycemia, increased free fatty acid production, decreased bioavailability of endothelium-derived NO, formation of advanced glycation end products (AGE), altered lipoproteins, hypertension, and, as previously mentioned, insulin resistance.11 A decreased bioavailability of endothelium-derived NO, with subsequent impaired endo-thelium-dependent vasodilation, has been observed in diabetic individuals even before the development of detectable atherosclerosis. NO is a potent vasodilator and a key compound of the endothelium-medi-ated control mechanisms of vascular relaxation. In addition, it inhibits platelet activation, limits inflammation by reducing leukocyte adhesion to endothe-lium and migration into the vessel wall, and reduces vascular smooth muscle cell proliferation and migration. As a consequence, an intact NO metabolism in the vessel wall has a protective...

Assessment of baroreceptor responses

The loss of baroreceptor reflex control of arterial pressure affects normal activities of daily living, resulting, for example, in postural hypotension. During anaesthesia, the loss of these reflexes (e.g. in patients with an autonomic neuropathy secondary to diabetes mel-litus) results in impairment of the normal cardiovascular responses to events such as positive pressure ventilation of the lungs.

Plaque Instability and Impaired Vascular Repair

In addition to promoting atherogenesis, diabetes conveys plaque instability.21 It has been shown that atherosclerotic lesions in diabetic patients have fewer vascular smooth muscle cells compared with those of controls. As the source of collagen, vascular smooth muscle cells strengthen the atheroma, making it less likely to rupture and cause thrombosis. In addition, diabetic endothelial cells may produce an excess of cytokines that decrease the de novo synthesis of collagen by vascular smooth muscle cells. Finally, diabetes enhances the production of matrix metallo-proteinases that lead to breakdown of collagen, potentially decreasing the mechanical stability of the plaque's fibrous cap. Overall, diabetes alters vascular smooth muscle function in ways that promote atherosclerotic lesion formation, plaque instability, and clinical events.21 It has been demonstrated that diabetic patients have a larger amount of lipid-rich plaques, which may be more prone to rupture.15 Moreover, recent...

Evidence Based Practice

Much research demonstrates the efficacy of psychosocial interventions in diseases historically viewed as purely medical, including cancer (Anderson et al., 2007 Edwards et al., 2008 Rehse and Pukrop, 2003 Spiegel et al, 1989) and diabetes (Bogner et al., 2007), as well as behavioral interventions such as exercise for cardiovascular disease (Taylor et al., 2004). Online resources are available to search for study results (see Web Resources at end of chapter). Treating depression in older patients with diabetes reduces mortality (SOR A Bogner et al., 2007).

Anatomic Pattern of Coronary Artery Disease

Autopsy and angiographic studies have shown that patients with diabetes more frequently have left main coronary artery lesions, multivessel disease, and diffuse CAD. A recent angiographic study on 534 patients with angina demonstrated that the greater the impairment of glucose metabolism (i.e., normal, IGT, newly diagnosed diabetes, or known diabetes), the smaller the average vessel diameter and longer the coronary lesions.30 It is common belief that diabetic patients have an impaired ability to develop coronary collaterals compared with nondiabetic counterparts. However, a recent study measuring coronary collateral flow using intracoronary pressure Figure 2-3. Coronary artery disease (CAD) mortality over 18 years according to the status of diabetes (DM) and prior myocardial infarction (MI). (From Juutilainen A, Lehto S, Ronnemaa T, et al Type 2 diabetes as a coronary heart disease equivalent An 18-year prospective population-based study in Finnish subjects. Diabetes Care 2005 28...

Other Contributing Processes and Factors

Many other processes are proposed to contribute to the development of hypertension, including obesity, physical inactivity, insulin resistance, potassium and magnesium depletion, chronic moderate alcohol consumption, and transient effects of cigarette smoking and caffeine intake.9 The assessment of global cardiovascular risk in all hypertensive patients should be part of the management plan while also pursuing target BPs through nonpharmacologic and pharmacologic means. Regardless of the initiat

Heart Failure and Diabetic Cardiomyopathy

Epidemiologic and clinical evidence links diabetes dence of heart failure in diabetic men and women, respectively. Diabetes has been shown to promote both systolic and diastolic heart failure. Abnormal of diabetic patients after exclusion of left ventricular hypertrophy or ischemia.32 In the 1970s, the observation that diabetic patients may suffer from congestive heart failure in the absence of hypertension, CAD, or other evident source of cardiac disease led to the concept of diabetic cardiomyopathy, also called diabetic heart disease. Although the exact mechanisms underlying the condition are unknown, the accumulation of extracellular matrix proteins, and in particular of collagen, appears to be a key biologic dysfunction (Fig. 2-4).33 The deposition may be the result of excess production, reduced degradation, and or chemical modification of extracellular matrix proteins. These processes are believed to be induced directly or indirectly by hyperglycemia. Fibrosis may be the result...

Transient Monocular Vision Loss TMVL

His past medical history included hypertension, high cholesterol, diabetes type 2, and peripheral vascular disease. He had never had a similar visual disturbance. Medications included Norvasc 10mg daily, simvastatin 40mg qhs, and metformin 500mg bid. He was not taking an antiplatelet agent.

Peripheral Arterial and Cerebrovascular Disease

Epidemiologic evidence confirms an association between diabetes and PAD, with a twofold to fourfold increased incidence compared with nondiabetic individuals. In the Framingham cohort, the presence of diabetes increased the risk of claudication by fourfold in men and ninefold in women. A study addressing the prevalence of PAD among 631 patients according to the degree of associated metabolic disturbance found that the rate of abnormal ankle-brachial index ranged from 7 in individuals with normal glucose tolerance to 21 in those requiring multiple antidiabetic medications.37 Diabetes-associated PAD is characterized by extensive vascular calcification and a more frequent infrapopliteal involvement. The lower limb amputation rate among diabetic patients is up to 13 times higher than that of nondiabetic individuals. In 2002, more than 80,000 lower limb amputations were performed in the United States in patients with diabetes, corresponding to more than 60 of all nontraumatic lower limb...

Future Of The Preparticipation Examination

Diabetes mellitus Explanation All sports can be played with proper attention to diet, blood glucose concentration, hydration, and insulin therapy. Blood glucose concentration should be monitored every 30 minutes during continuous exercise and 15 minutes after completion of exercise.

Angiotensin Receptor Blockers

Like ACE inhibitors, the antihypertensive effectiveness of ARBs is greatly enhanced by combining them with diuretics. Furthermore, they have proven their value as well-tolerated alternatives to ACE inhibitors for patients with CKD, diabetes mellitus, and post-AMI (Table 5-5). As of late, the addition of ARBs to standard therapy for patients with heart failure (HF), including ACE inhibitors, have demon- tensive regimens in patients with type 2 diabetes and left ventricular hypertrophy have demonstrated their usefulness as effective antihypertensives in these special populations. Studies (the Irbesartan Diabetic Nephropathy Trial IDNT and Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan RENAAL NIDDM refers to noninsulin-dependent diabetes mellitus ) have demonstrated superiority of delaying progression toward renal dysfunction for ARBs relative to alternat- ive antihypertensives in type 2 diabetics. Although better tolerated than ACE inhibitors,...

Adjunctive Metabolic Intervention at the Time of Coronary Revascularization

Recent studies have underscored the importance of optimal glycemic control at the time of coronary revascularization, both in the setting of PCI and with CABG. A prospective single-center analysis correlated HbA1c and the 12-month TVR rate in 179 diabetic patients undergoing PCI and demonstrated that diabetic patients with optimal glycemic control (i.e., HbA1c < 7 ) had a TVR rate similar to that of nondia-betic patients (n 60) 15 versus 18 .65 Those with HbA1c greater than 7 had a significantly higher TVR rate (34 ). In a multiple logistic regression analysis, HbA1c greater than 7 was identified as significant independent predictor of TVR (OR 2.9). In addition, optimal glycemic control was associated with a significantly lower rate of cardiac rehospitalization and recurrent angina at 12 months. Opposing these results, a single-center retrospective analysis of prospectively acquired registry data addressing outcomes after PCI among 1373 diabetic patients stratified for baseline...

Neurological Examination

A number of neuropathies are associated with sleep alterations, and hence the sensory examination, including both position and vibration testing for myelinated fiber function and pain and temperature testing for unmyelinated fiber function should be performed. RLS can be frequently exacerbated by neuropathy, and diabetes mellitus and spinocerebellar atrophies have characteristic neuropathic findings. Autonomic Nervous System. Central sleep apnea is the loss of respiratory airflow associated with a loss of respiratory muscle effort. It is thought to arise from alterations in the functioning of chemoreceptors monitoring hypoxic and hypercapnic influences on respiration. Patients should be examined for waking respiratory difficulties and cardiac functioning, in particular for congestive heart failure. Neuromuscular diseases likewise may predispose to episodes of sleep apnea, as can autonomic nervous system instability. Patients should be assessed for evidence of orthostatic...

Journals and Publications

In Germany, practice guidelines are coordinated by an association of 153 scientific medical associations from all fields of medicine (Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften 2008) that represents Germany in the Council for International Organizations of Medical Sciences. Included are guidelines on consultation in psychosomatic medicine. National guidelines on the management of asthma and diabetes include a section on children, but no specific recommendations are provided covering children's mental health issues.

Nonstelevation Acute Coronary Syndromes

The high prevalence of abnormal glucose metabolism in patients with CAD, and in particular among those with acute manifestations of the disease, was recently confirmed in large-scale surveys in both the United States and Europe. Within the U.S. CRUSADE (Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC AHA guidelines) registry, among 46,410 patients with non-ST-elevation ACS, the prevalence of diabetes was 33 .89 Within the National Registry of Myocardial Infarction (NRMI), the prevalence of diabetes among patients presenting with ST-elevation MI (STEMI) and non-ST-elevation MI (NSTEMI) was 27 and 34 , respectively.90 In the Euro Heart Survey, glucose metabolism was addressed among 2854 patients with stable CAD and 2107 patients with unstable CAD.91 The overall prevalence of diabetes was approximately 30 in both groups. Among unstable CAD patients without known diabetes, an OGTT detected IGT in 36 and diabetes in...

Early Invasive Versus Conservative Strategy

In diabetic patients with non-ST-segment elevation ACS, the positive impact of an early invasive strategy can be derived from subgroup analyses of large-scale randomized studies. The Fragmin and Fast Re-vascularisation during InStability in Coronary artery disease (FRISC II) study randomized 2457 patients to an invasive or conservative strategy and detected a significant survival benefit associated with the invasive strategy at 1 year.94 The reduction in 1-year death or MI associated with early coronary angiography followed by revascularization (if needed) was marked among diabetic patients (n 299), in terms of relative and particularly of absolute risk reduction (39 and Newly detected diabetes Figure 2-8. Prevalence of abnormal glucose regulation in patients without known diabetes mellitus in the Euro Heart Survey assessed by oral glucose tolerance test (OGTT) or fasting plasma glucose (FPG). (From Bartnik M, Ryden L, Ferrari R, et al The prevalence of abnormal glucose regulation in...

Coronary Artery Bypass Surgery

The only randomized trial that has compared CABG with PCI in patients with ACS was the AWESOME trial.97 This study compared the two revascularization strategies in patients who had medically refractory unstable angina and were at high risk for adverse outcomes with CABG. Among 2431 patients identified, 454 were considered acceptable for both PCI and CABG 1650 patients were not deemed to be candidate for both therapies and entered a physician-directed registry, and the 327 who were considered candidates for both treatment but refused randomization entered a patient-choice registry. Overall, diabetes prevalence was 31 . The respective CABG and PCI 3-year survival rates for diabetic patients were 72 and 81 for those randomized, 85 and 89 for those in the patient-choice registry, and 73 and 71 for those in the physician-directed registry.97 None of these differences was statistically significant. These results must be interpreted with caution because, from both a surgical perspective...

Stelevation Myocardial Infarction

Paralleling the observations for non-ST-elevation ACS, diabetes is also an independent predictor of morbidity and mortality in STEMI. A retrospective study evaluating admission glucose of 141,680 patients presenting with acute MI demonstrated a linear correlation between glucose level and mortality (Fig. 2-10).98 Compared with individuals with admission glucose levels of 110mg dL or less, the hazard ratios for mortality for those with glucose Figure 2-10. Relationship between admission plasma glucose values and 30-day and 1-year mortality rates among patients presenting with acute myocardial infarction. (From Kosiborod M, Rathore SS, Inzucchi SE, et al Admission glucose and mortality in elderly patients hospitalized with acute myocardial infarction Implications for patients with and without recognized diabetes. Circulation 2005 111 3078-3086.) The impact of diabetes on outcomes after the acute MI phase was addressed in a contemporary large-scale study, the VALsartan In Acute...

Aspirin and Clopidogrel

Data on the efficacy of antiplatelet therapy for primary prevention in patients with diabetes are limited. The only prospective randomized study has been the Early Treatment Diabetic Retinopathy Study (ETDRS), which enrolled 3711 diabetic patients in the 1980s and randomized them to aspirin 650 mg day or placebo.107 The administration of aspirin over 5 years was associated with a nonsignificant reduction in all-cause mortality and in fatal or nonfatal MI (RR 0.91 and 0.83, respectively). In the secondary prevention setting, the Antiplatelet Trialist Collaboration demonstrated that prolonged use of an anti-platelet agent (mainly aspirin) among 5126 diabetic patients was associated with only a modest, nonsignificant benefit over placebo (RRR 7 ).108 Information on which oral antiplatelet agent may be best suited for diabetic patients in the prevention setting can be derived from a subgroup analysis of the only large-scale head-to-head comparison, the Clopido-grel versus Aspirin in...

Epidemiology And Etiology Epidemiology

HF is a major public health concern affecting approximately 5 million people in the United States. An additional 550,000 new cases are diagnosed each year. HF manifests most commonly in adults over the age of 60. The growing prevalence of HF corresponds to (a) better treatment of patients with acute myocardial infarctions (MIs) who will survive to develop HF later in life, and (b) the increasing proportion of older adults due to the aging Baby Boomer population. The relative incidence of HF is lower in women compared to men, but there is a greater prevalence in women overall due to their longer life expectancy. AHF accounts for 12 to 15 million office visits per year and 6.5 million hospitalizations annually. According to national registries, patients presenting with AHF are older (mean age 75 years) and have numerous co-morbidities such as coronary artery disease (CAD), renal insufficiency, and diabetes.

What is a sports injury

For younger athletes trying to establish themselves in their sport, an injury can result in major family-related conflicts. Over-ambitious or over-protective parents and pressure from coaches and team-mates can put stresses on to a young athlete not able to participate in their sport. For recreational athletes, injuries may mean loss of regular physical and social activities and problems with general health, such as blood pressure, insulin control or secondary problems to the lower back from limping. A shoulder injury from squash may cause difficulties for a builder or plumber with their own business or raise concerns about the safety of a police officer or firefighter. Completely irrational charity bets - 'I must

Glycoprotein IIbIIIa Receptor Antagonists

The use of intravenous platelet GP IIb IIIa receptor inhibitors and stents has markedly reduced the early hazard in diabetic patients undergoing PCI. In the Evaluation of Platelet IIb IIIa Inhibitor for Stenting (EPISTENT) trial, abciximab halved the risk of death, MI, or urgent revascularization at 30 days among diabetic patients undergoing stenting compared with placebo (12.1 versus 5.6 , respectively). The observed event rate was comparable to that of abcix-imab-treated nondiabetic patients (5.2 ). A pooled analysis of three early abciximab trials demonstrated a significant 1-year mortality rate reduction among diabetic patients randomized to the drug compared with placebo (2.5 versus 4.5 ).117 The Intracoro-nary Stenting and Antithrombotic Regimen is abciximab a Superior Way to Eliminate Elevated Thrombotic risk in diabetics (ISAR-SWEET) study demonstrated that, among 701 low-risk diabetic patients, abcix-imab did not confer additional benefit on top of aspirin and a high...

Patient Encounter Part 1

BE is a 62-year-old female with a history of known CAD and type 2 diabetes mellitus who presents for a belated follow-up clinic visit (her last visit was 2 years ago). She states that she used to be able to walk over one-half mile (0.8 km) and two flights of stairs before experiencing chest pain and becoming short of breath. Since her last visit, she has had increasing symptoms and has now progressed to shortness of breath (SOB) with walking only half a block and doing chores around the house. She also notes her ankles are always swollen and her shoes no longer fit, therefore she only wears slippers. Additionally, her appetite is decreased, and she often feels bloated. She also feels full after eating only a few bites of each meal.

Common Prescribing Issues

Long half-life leads to increased risk of hypoglycemia newer insulin secretagogues are preferred. On the other end of the spectrum is failure to prescribe clinically appropriate medications. Common oversights include a failure to prescribe a beta blocker for a patient with congestive heart failure or with a history of a myocardial infarction, aspirin in a patient with known coronary heart disease, or ACE inhibitors for a patient with diabetes and proteinuria (Rosen et al., 2004 Sloane et al., 2004).

Control and Treatment of Contributing Disorders

All causes of HF must be investigated to determine the etiology of cardiac dysfunction in a given patient. Because the most common etiology of HF in the United States is ischemic heart disease, assessment for cardiac ischemia, which may include stress testing, echocardiography, and or coronary angiography is warranted in the majority of patients with a history suggestive of underlying CAD. Revascularization of those with significant CAD may help restore some cardiac function in patients with reversible ischemic defects. Aggressive control of hypertension, diabetes, and obesity is also essential because each of these conditions can cause further cardiac damage. Surgical repair of valvular disease or congenital malformations may be warranted if detected. Because clinical HF is partly dependent on metabolic processes, correction of imbalances such as thyroid disease, anemia, and nutritional deficiencies is required. Other more rare causes such as autoimmune disorders or acquired...

Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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