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Pathophysiology Of Hyperlipidemia In Diabetes Mellitus.

Pathophysiology Of Hyperlipidemia In Diabetes Mellitus.

Abstract Many lipoprotein abnormalities are seen in the untreated, hyperglycemic diabetic patient. The non-insulin-dependent diabetic (NIDDM) patient with mild fasting hyperglycemia commonly has mild hypertriglyceridemia due to overproduction of TG-rich lipoproteins in the liver, associated with decreased high-density lipoprotein (HDL) cholesterol levels. The more hyperglycemic untreated NIDDM and insulin-dependent diabetic (IDDM) patient have mild to moderate hypertriglyceridemia due to decreased adipose tissue and muscle lipoprotein lipase, (LPL) activity. These patients also have decreased HDL cholesterol levels associated with defective LPL catabolism of TG-rich lipoproteins. Treatment of diabetes with oral sulfonylureas or insulin corrects most of the hypertriglyceridemia and some of the decrease in HDL cholesterol. The abnormality in adipose tissue LPL activity corrects slowly over several months of therapy. The treated IDDM patient often has normal lipoprotein levels. The treated NIDDM patient may continue to have mild hypertriglyceridemia, increased intermediate-density lipoprotein levels, small dense low-density lipoproteins (LDL) with increased apoprotein B, and decreased HDL cholesterol levels. The central, abdominal distribution of adipose tissue in IDDM is associated with insulin resistance, hypertension, and the above lipoprotein abnormalities. Improvement in glucose control, in the absence of weight gain, leads to lower triglyceride and higher HDL cholesterol levels. In addition, the diabetic patient is prone to develop other defects that, in themselves, lead to hyperlipidemia, such as proteinuria, hypothyroidism, and hypertension, treated with thiazide diuretics and beta-adrenergic-blocking agents. When a diabetic patient independently inherits a common Continue reading >>

Diabetic Gastroparesis

Diabetic Gastroparesis

Gastroparesisis defined by objective delaying of gastric emptying without any evidence ofmechanical obstruction. Diabetic gastroparesis is a potential complication that occurs in the setting of poorly controlled diabetes,resulting from dysfunctionin the coordination and function of the autonomic nervous system, neurons and specialized pacemaker cells (interstitial cells of Cajal, ICC) of the stomach and intestine, and the smooth muscle cells of the gastrointestinal tract. Hyperglycemia (blood glucose greater than 200 mg/dL), commonly seen in the setting of poorly controlled diabetes, has been associated with diabetic gastroparesis that occurs as a result of neuropathy in the setting of chronic hyperglycemia and does not resolve with improved glycemic control. Acute hyperglycemia, on the other hand, though it can also result in delayed gastric emptying, is often reversible with improved glycemic control. Gastric emptying requires coordination of fundal tone and antral phasic contraction with simultaneous inhibition of pyloric and duodenal contractions. This coordination also requires interactions between the enteric and autonomic nervous systems, smooth muscle cells, and the specialized pacemaker cells (ICC) of the stomach. The gastric motor dysfunction that is encountered in the setting of diabetes may occuras a result of autonomic neuropathy (both sympathetic and parasympathetic), enteric neuropathy (both excitatory and inhibitory neurons), ICC abnormalities (intrinsic neuropathy), acute blood glucose fluctuations, use of incretin-based medications, or psychosomatic factors. As a result, most diabetic patients tend tohave dysfunction at multiple points in the process of gastric emptying.This includes abnormal postprandial proximal gastric accommodation and contraction Continue reading >>

Diabetes Mellitus - Endocrine - Medbullets Step 2/3

Diabetes Mellitus - Endocrine - Medbullets Step 2/3

(M2.EC.4754) A 63-year-old male presents to the emergency department complaining of worsening nausea. He reports that the nausea began several months ago and is accompanied by occasional bloating and heartburn. He reports that he frequently feels full even after eating only a little at each meal, and occasionally he will vomit if he eats too much. The vomit is non-bloody and contains bits of undigested food. A review of systems is notable for occasional headaches, tingling in his distal extremities, and constipation. His medical history is significant for Parkinsons disease diagnosed 3 years ago, hypertension diagnosed 8 years ago, and type II diabetes mellitus diagnosed 10 years ago. The patient reports that he was given prescriptions for both his blood pressure and diabetes medications, but he has not taken either for months because one of them was causing erectile dysfunction. He reports he regularly takes his levodopa. An endoscopy is performed, which rules out cancer. In addition to restarting medications for his hypertension and diabetes, what of the following is most appropriate treatment for the patients symptoms? Review Topic Continue reading >>

Hyperosmolar Hyperglycemic State (hhs)

Hyperosmolar Hyperglycemic State (hhs)

By Erika F. Brutsaert, MD, Assistant Professor, Albert Einstein College of Medicine; Attending Physician, Montefiore Medical Center Hyperosmolar hyperglycemic state is a metabolic complication of diabetes mellitus (DM) characterized by severe hyperglycemia, extreme dehydration, hyperosmolar plasma, and altered consciousness. It most often occurs in type 2 DM, often in the setting of physiologic stress. HHS is diagnosed by severe hyperglycemia and plasma hyperosmolality and absence of significant ketosis. Treatment is IV saline solution and insulin. Complications include coma, seizures, and death. Hyperosmolar hyperglycemic state (HHSpreviously referred to as hyperglycemic hyperosmolar nonketotic coma [HHNK] and nonketotic hyperosmolar syndrome) is a complication of type 2 diabetes mellitus and has an estimated mortality rate of up to20%, which is significantly higher than the mortality for diabetic ketoacidosis (currently < 1%). It usually develops after a period of symptomatic hyperglycemia in which fluid intake is inadequate to prevent extreme dehydration due to the hyperglycemia-induced osmotic diuresis. Acute infections and other medical conditions Drugs that impair glucose tolerance (glucocorticoids) or increase fluid loss (diuretics) Serum ketones are not present because the amounts of insulin present in most patients with type 2 DM are adequate to suppress ketogenesis. Because symptoms of acidosis are not present, most patients endure a significantly longer period of osmotic dehydration before presentation, and thus plasma glucose (> 600 mg/dL [> 33.3 mmol/L]) and osmolality (> 320 mOsm/L) are typically much higher than in diabetic ketoacidosis (DKA). The primary symptom of HHS is altered consciousness varying from confusion or disorientation to coma, usually as Continue reading >>

Diabetes Mellitus

Diabetes Mellitus

Diabetes mellitus (DM) describes a group a metabolic diseases that are characterized by chronic hyperglycemia (elevated blood glucose levels). The two most common forms are type 1 and type 2 diabetes mellitus. Type 1 is the result of an autoimmune response that triggers the destruction of insulin-producing β cells in the pancreas and results in an absolute insulin deficiency. Type 2, which is much more common, has a strong genetic component as well as a significant association with obesity and sedentary lifestyles. Type 2 diabetes is characterized by insulin resistance (insufficient response of peripheral cells to insulin) and pancreatic β cell dysfunction (impaired insulin secretion), resulting in relative insulin deficiency. This form of diabetes usually remains clinically inapparent for many years. However, abnormal metabolism (prediabetic state or impaired glucose intolerance), which is associated with chronic hyperglycemia, causes microvascular and macrovascular changes that eventually result in cardiovascular, renal, retinal, and neurological complications. In addition, type 2 diabetic patients often present with other conditions (e.g. hypertension, dyslipidemia, obesity) that increase the risk of cardiovascular disease (e.g., myocardial infarction). Renal insufficiency is primarily responsible for the reduced life expectancy of patients with DM. Due to the chronic, progressive nature of type 1 and type 2 diabetes mellitus, a comprehensive treatment approach is necessary. The primary treatment goals for type 2 diabetes are the normalization of glucose metabolism and the management of risk factors (e.g., arterial hypertension). In theory, weight normalization, physical activity, and a balanced diet should be sufficient to prevent the manifestation of diabetes in Continue reading >>

Diabetic Retinopathy

Diabetic Retinopathy

- Did you know that diabetes is the most common cause of blindness in individuals from the ages of 25 to 65? And blindness can be caused by multiple different complications associated with diabetes including glaucoma and cataracts, however in this tutorial, let's discuss the most common cause of blindness due to diabetes which is a condition known as diabetic retinopathy. And if we break down the term, we can receive generally, an understanding of what this disease is, so you have retino here meaning the retina, and pathy meaning disease. So, diabetic retinopathy is a disease of the retina that's caused by diabetes. And to describe what the retina is, let's bring in a diagram of the eye and go through some of the structures as it will help us as we learn more about this condition. Over here on the left, we have a cross-section of the eye and there's a few important structures to note. So this is the front of the eye here, and this is the back of the eye, and this part right here is known as the cornea. And it is where light initially passes through as it goes through the eye, and then it hits this structure right here, which is known as the lens. And the lens focuses the light on this structure in the back of the eye, this kind of brownish structure, and this is the retina. And then exiting the back of the eye here, this is the optic nerve. Then, you can also see all of these blood vessels that are traveling through the retina and then exit the back of the eye in the middle of the optic nerve. So if you look over here on the right, this is a front view of the eye. So this is kind of what it looks like when a doctor looks in to your eye. So here, right here we have what's called the optic disc, and the optic disc is really just the convergence of the retina and where it Continue reading >>

Somogyi Effect Vs. Dawn Phenomenon: The Difference Explained

Somogyi Effect Vs. Dawn Phenomenon: The Difference Explained

For people who have diabetes , the Somogyi effect and the dawn phenomenon both cause higher blood sugar levels in the morning. The dawn phenomenon happens naturally, but the Somogyi effect usually happens because of problems with your diabetes management routine. Your body uses a form of sugar called glucose as its main source of energy. A hormone called insulin , which your pancreas makes, helps your body move glucose from your bloodstream to your cells. While you sleep , your body doesnt need as much energy. But when youre about to wake up, it gets ready to burn more fuel. It tells your liver to start releasing more glucose into your blood . That should trigger your body to release more insulin to handle more blood sugar . If you have diabetes, your body doesnt make enough insulin to do that. That leaves too much sugar in your blood, a problem called hyperglycemia . High blood sugar can cause serious health problems, so if you have diabetes, youll need help to bring those levels down. Diet and exercise help, and so can medications like insulin. If you have diabetes, your body doesnt release more insulin to match the early-morning rise in blood sugar. Its called the dawn phenomenon, since it usually happens between 3 a.m. and 8 a.m. The dawn phenomenon happens to nearly everyone with diabetes. But there are a few ways to prevent it, including: Dont eat carbohydrates before you go to bed. Take insulin before bedtime instead of earlier in the evening. Ask your doctor about adjusting your dose of insulin or other diabetes medicines. Continue reading >>

Diabetes Practice Questions

Diabetes Practice Questions

1. The risk factors for type 1 diabetes include all of the following except: a. Diet b. Genetic c. Autoimmune d. Environmental 2. Type 2 diabetes accounts for approximately what percentage of all cases of diabetes in adults? a. 55%-60% b. 35%-40% c. 90-95% d. 25-30% 3. Risk factors for type 2 diabetes include all of the following except: a. Advanced age b. Obesity c. Smoking d. Physical inactivity 4. What percentage of women with gestational diabetes is diagnosed with type 2 diabetes following pregnancy? a. 25%-30% b. 5%-10% c. <5% d. 20%-25% 5. Untreated diabetes may result in all of the following except: a. Blindness b. Cardiovascular disease c. Kidney disease d. Tinnitus 6. Prediabetes is associated with all of the following except: a. Increased risk of developing type 2 diabetes b. Impaired glucose tolerance c. Increased risk of heart disease and stroke d. Increased risk of developing type 1 diabetes 7. Diabetics are at increased risk of heart disease if they also: a. Smoke b. Have high HDL cholesterol levels c. Take aspirin d. Consume a high-fiber diet 8. Blood sugar is well controlled when Hemoglobin A1C is: a. Below 7% b. Between 12%-15% c. Less than 180 mg/dL d. Between 90 and 130 mg/dL 9. Excessive thirst and volume of very dilute urine may be symptoms of: a. Urinary tract infection b. Diabetes insipidus c. Viral gastroenteritis d. Hypoglycemia 10. Among female children and adolescents, the first sign of type 1 diabetes may be: a. Rapid weight gain b. Constipation c. Genital candidiasis d. Insomnia 11. Untreated hyperglycemia may lead to all of the following complications except: a. Hyperosmolar syndrome b Vitiligo c. Diabetic ketoacidosis d. Coma 12. Hyperinsulinemia may be caused by all of the following except: a. An insulinoma b. Nesidioblastosis c. Insulin Continue reading >>

Prediabetes Is On The Rise And Thus Likely To Appear In Your Usmle, Abim, And Pance Questions

Prediabetes Is On The Rise And Thus Likely To Appear In Your Usmle, Abim, And Pance Questions

Prediabetes is on the rise and thus likely to appear in your USMLE, ABIM, and PANCE questions A new UCLA study released last week found that 46% of adults in California are pre-diabetic, leading many media outlets to report on this diagnosis. Combining the 9% who have diabetes, the researchers found that over 1/2 of Californians have either diabetes or pre-diabetes. National numbers are also alarming, with the Centers for Disease Control and Prevention estimating that 86 million adults are prediabetic, making it an important public health issue . Given the increasing emphasis on preventative medicine, prediabetes is a topic that is often tested on various medical board examinations. Heres what you need to know about prediabetes for the Medical Shelf, USMLE, In-Training Exam (ITE), ABIM and PANCE/PANRE. The Los Angeles Times described pre-diabetes to the lay public as blood glucose levels are higher than normal but not high enough to be considered diabetic. That is, of course, very much accurate. Additionally, though, for the purposes of our exams, we need to know the specific diagnostic criteria. What is the fasting blood sugar criteria for prediabetes? Prediabetes is defined as two or more fasting blood sugar values of 100-125mg/dL. What is the two hour post-glucose load criteria for prediabetes? Prediabetes is defined as blood sugar of 140-199mg/dL two hours after a 75g glucose load. What is the hemoglobin A1c criteria for prediabetes? Prediabetes is defined as hemoglobin A1c between 5.7% and 6.4%. What is the random blood sugar criteria for prediabetes? There is no random blood sugar criteria for prediabetes. Continue reading >>

Usmle Review Notes: Diabetic Neuropathy

Usmle Review Notes: Diabetic Neuropathy

USMLE review notes. Step 1, Step 2, Step 3. Residency match. NBME. Resources for MD. Diabetic neuropathy: Diabetic neuropathy is the result of nerve ischemia from microvascular disease, direct effects of hyperglycemia on neurons, and intracellular metabolic changes that impair nerve function. There are multiple types, including symmetric polyneuropathy (with small- and large-fiber variants) and autonomic neuropathy. Symmetric polyneuropathy is most common and affects the distal feet and hands (stocking-glove distribution); it manifests as paresthesias, dysesthesias, or a painless loss of sense of touch, vibration, proprioception, or temperature. In the lower extremities, these symptoms can lead to blunted perception of foot trauma from ill-fitting shoes and abnormal weight bearing, which can in turn lead to foot ulceration and infection or to fractures, subluxation, and dislocation or destruction of normal foot architecture (Charcot's joint). Small-fiber neuropathy is characterized by pain, numbness, and loss of temperature sensation with preserved vibration and position sense. Patients are prone to foot ulceration and neuropathic joint degeneration and have a high incidence of autonomic neuropathy. Predominant large-fiber neuropathy is characterized by muscle weakness, loss of vibration and position sense, and lack of deep tendon reflexes. Atrophy of intrinsic muscles of the feet and foot drop are common. Autonomic neuropathy can produce orthostatic hypotension, exercise intolerance, resting tachycardia, dysphagia, nausea and vomiting (due to gastroparesis), constipation and diarrhea (including dumping syndrome), fecal incontinence, urinary retention and incontinence, erectile dysfunction and retrograde ejaculation, and decreased vaginal lubrication. Other forms of di Continue reading >>

Diabetes Drugs - Endocrine - Medbullets Step 1

Diabetes Drugs - Endocrine - Medbullets Step 1

Metformin is absolutely contraindicated in patients with renal failure due to the risk of lactic acidosis. An elevated serum creatinine suggests a decrease in GFR and the presence of renal failure. Metformin is a drug in the biguanide class used to treat diabetes mellitus type II. Metformin treats hyperglycemia by inhibiting gluconeogenesis. Metformin carries no risk of hypoglycemia, but is known to occasionally cause lactic acidosis in patients with renal failure, liver dysfunction, CHF, alcoholism, and sepsis. Vecchio et al. reviews metformin-induced lactic acidosis. They report that metformin is overall a safe drug when correctly used but is associated with lactic acidosis in rare cases. The most common condition in which this condition occurs is with renal insufficiency. Recent evidence has called into question the significance of the risk of lactic acidosis while using metformin. According to an April 2012 Cochrane review by Salpeter et al., there is no evidence from comparative trials or from observational cohort studies that metformin is associated with an increased risk of lactic acidosis when compared to other anti-hyperglycemic treatments. Illustration A depicts the actions of metformin on the liver, adipose tissue, muscle and pancreas. Answers 1-4: Hyperkalemia, hypernatremia, metabolic alkalosis, and hyperglycemia do not affect the physiology of metformin and are not a contraindication to its use. Continue reading >>

Welcome To World's Of Medicine

Welcome To World's Of Medicine

Blurry vision (when was the last eye exam? is there any abnormality) bloating(r/o gastroparesis)(do u have any pain,dyspepsia,nausea) Hypoglycemic episodes (availability of juice &candy) PHYSICAL EXAMINATIONfor Diabetes Follow Up mnemonic NOTE: Make sure to wash your hands or wear gloves before you start physical examination. Make sure to ask for permission before you start each physical exam. Make sure to use proper draping (dont forget to tie back patients gown). Make sure to explain the physical examination in laymans term to your patient. Do NOTrepeat painful maneuvers. Abdominal exam: Auscultation, palpation, percussion Extremities: Inspect feet for infection or ulcers, Checkperipheral pulses Neurologic exam: Motor, Sensation, DTRs, BabinskiReflex DIFFERENTIAL DIANGOSIS DDx for Diabetes Follow Up mnemonic In this case the DDxdepends on the patients HPI and whetherhe/she has any other complainsother than therequest for refill prescription. For example if the patientis complaining ofChest pain then you must do DDxfor Chest pain, or if the patient is having problem with erection then you must do differential diagnosis for Erectile dysfunctionand DIAGNOSTIC WORK UP for Diabetes Follow Upmnemonic Genital Exam (If patient complains of Erectile dysfunction ) Urine Microalbumin(to check Kidney function) COUNSELING for Diabetes Follow Up mnemonic Diabetes Mellitus& HypertensionCounseling >MEDOWS Exercise (For obese/secondary life style) Diet modification (Less Salty & Fatty food) Ophthalmoscopic exam (EVERY Year annually) HELLO,MRMILLER,MY NAME IS DR.CHONG . IM UR PHYSICIAN IN THE OFFICE TODAY IM HERE TODO SOME PHYSICAL EXAMINATION N ASK U SOME QUESTION IS THAT OK? R UCOMFORTABLE IN THIS ROOMMAY I PUT THIS DRAPED ON UR LAPED DO U MINDIF I SIT DOWN N TWRITE WHILE WE TALK? M Continue reading >>

Differences Between Dawn Phenomenon Or Somogyi Effect

Differences Between Dawn Phenomenon Or Somogyi Effect

The dawn phenomenon and the Somogyi effect increase fasting (aka morning) blood glucose levels for people with diabetes, but for different reasons. Both occurrences have to do with hormones that tell the liver to release glucose into your blood stream while you sleep. The difference is why the hormones are released. Arandom elevated blood sugar could be a result of a variety of things: perhaps you ate too many carbohydrates the night before , you took less medicine than you're supposed to or you forgot to take it altogether . But,if you've noticed a pattern of elevated blood sugars in the morning, it could be a result of the dawn phenomenon or the Somogyi effect. Find out what causes this hormonal hyperglycemia and how you can prevent and can treat it. The dawn phenomenon is caused by a surge of hormones that the body puts out in the early morning hours. According to the American Diabetes Association, "everyone has the dawn phenomenon if they have diabetes or not. People with diabetes don't have normal insulin responses to adjust for it and that is why their blood sugars go up." This happens because: During the evening hours the body is making less insulin. Hormones trigger the liver to put out more glucose. Lack of insulin results in a blood sugar rise in the a.m. The Somogyi effect (or rebound hyperglycemia)results in morning high blood sugar ( hyperglycemia ) as a result very low bloodsugar (hypoglycemia) during the night. It's a very rare phenomenon and most often occurs in people with Type 1 diabetes. It occurs: More commonly in people who take night-time insulin , as a result of taking too much; Or if you are required to eat a snack before bed to keep your blood sugars stable and you skip it. The abundance of insulin in the blood and lack of glucose, causes the b Continue reading >>

Insulin Resistance

Insulin Resistance

The key feature of type 2 diabetes mellitus is insulin resistance. What this means is that the response to insulin is deficient. This is neatly illustrated by the test depicted in the graph. Two subjects are given a dose of insulin, and then the concentration of glucose in the blood (plasma glucose) is measured at different times following the insulin injection. The various actions of insulin promote a decrease in blood glucose. In a subject who is insulin resistant (red line), this decrease is less. In practice, such a test is not used to evaluate patients suspected of having type 2 diabetes mellitus. Instead, diabetes mellitus is diagnosed by tests that reveal evidence of hyperglycemia. One such test is the HbA1c test. Traditionally, this test has been used to monitor the effectiveness of diabetes treatments in controlling hyperglycemia (glycemic control). It has only recently been adopted for diagnosis following an effort to nationally standardize the test. This test measures the percentage of glycated hemoglobin in the blood, which will be higher if there have been more periods of hyperglycemia in the recent past. An HbA1c of 6.5% or greater is diagnostic for diabetes mellitus. The advantage of this test is that it doesn't require fasting, and can be done at any time of the day. Another way to reveal hyperglycemia is to look at the fasting plasma glucose. This test needs to be performed in the morning when the subject hasn't eaten for the previous 8 hours. A more sensitive test is the oral glucose tolerance test, as shown in the figure below. This test measures how the body responds to a glucose challenge, usually a drink containing 75 grams of glucose. At various times following consumption of the glucose drink, the blood glucose is measured. Blood glucose increase Continue reading >>

Diabetic Hypoglycemia

Diabetic Hypoglycemia

Diabetic hypoglycemia is a low blood glucose level occurring in a person with diabetes mellitus. It is one of the most common types of hypoglycemia seen in emergency departments and hospitals. According to the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP), and based on a sample examined between 2004 and 2005, an estimated 55,819 cases (8.0% of total admissions) involved insulin, and severe hypoglycemia is likely the single most common event.[1] In general, hypoglycemia occurs when a treatment to lower the elevated blood glucose of diabetes inaccurately matches the body's physiological need, and therefore causes the glucose to fall to a below-normal level. Definition[edit] A commonly used "number" to define the lower limit of normal glucose is 70 mg/dl (3.9 mmol/l), though in someone with diabetes, hypoglycemic symptoms can sometimes occur at higher glucose levels, or may fail to occur at lower. Some textbooks for nursing and pre-hospital care use the range 80 mg/dl to 120 mg/dl (4.4 mmol/l to 6.7 mmol/l). This variability is further compounded by the imprecision of glucose meter measurements at low levels, or the ability of glucose levels to change rapidly. Signs and symptoms[edit] Diabetic hypoglycemia can be mild, recognized easily by the patient, and reversed with a small amount of carbohydrates eaten or drunk, or it may be severe enough to cause unconsciousness requiring intravenous dextrose or an injection of glucagon. Severe hypoglycemic unconsciousness is one form of diabetic coma. A common medical definition of severe hypoglycemia is "hypoglycemia severe enough that the person needs assistance in dealing with it". A co-morbidity is the issue of hypoglycemia unawareness. Recent research using machine learning methods have proved to Continue reading >>

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