Diabetes Part 2. PP slides 44-74 Flashcards Preview

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Flashcards in Diabetes Part 2. PP slides 44-74 Deck (35)
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3 Major metabolic problems in DM

  1. Decreased utilization of glucose (cellular uptake and storage)

  2. Increased fat metabolism and formation of ketone bodies

  3. Impaired protein utilization with increased amino acid metabolism and the formation of ketone bodies


Tissues affected to the greatest degree by DM (3)

 skeletal and cardiac muscle and adipose tissue


Tissues affected by DM but to a lesser degrees than skeletal,cardica, and adipose

  • nervous tissue (very sensitive to glucose changes b/c sensitive to osmotic changes- manifests as shakiness) 

  • erythrocytes

  • cells of liver

  • GI tract

  • kidneys (end stage renal disease)


Clinical manifestation is only Type I (3) 

  • Polyphagia- Deprivation of satiety centers of glucose stimulates appetite 
  • Weight loss-  Unavailability of glucose, fat and protein stores broken down for energy & dehydration 
  • Ketouria- Fatty acid and amino acid breakdown due to lack of glucose for metabolism producing ketone bodies


Clinical manifestations seen in Type I and II (4) 

  • Polyuria- H20 is not absorbed from renal tubules because of osmotic action of excess glucose in the tubular fluid 
  • Polydipsia- Polyuria causes dehydration with increased thirst 
  • Recurrent blurred vision- Chronic exposure of the lens and retina to hyperosmotic fluids causes distortion of lens or retinal surface  
  • Weakness, fatigue, dizziness- Dehydration producing weakness and postural hypotension; energy deficiency and protein catabolism leads to weakness and fatigue


Clinical Manifestations in only Type II (1)

Often asymptomatic- Adaptation to gradual changes in blood glucose levels


Progressive pathologies with diabetes

highlighted by Dr. T (7)

  1. Peripheral neuropathy

  2. Atherosclerosis

  3. Infection

  4. Retinopathy

  5. Nephropathy

  6. Musculoskeletal Problems

  7. Skin ulceration


Points about peripheral neuropathy and DM (4)

  • Diffuse polyneuropathy progressing from distal to proximal (stocking-glove pattern)

  • Accumulation of sorbitol in nerve cells as a result of improper glucose metabolism with osmotic shifts of fluid and electrolytes

  • Diminished peripheral vascular perfusion

  • Weakness, paresthesia, pain and numbness, balance and autonomic changes


Points about Atherosclerosis and DM (3)

  • Increased fat metabolism

  • Hypoglycemic damage to vessel walls

  • Poor healing of damage along blood vessels


Points about Infection and DM (4)

  • Impaired wound healing and increased risk of infection

  • Rapid multiplication of infectious organisms in glucose rich environment

  • Leukocyte mobilization impaired because of vascular insufficiencies

  • Impaired immune response


Points about Retinopathy and DM (4)

  • After 20 years, all type 1 and 60% type 2 have some degree of retinopathy (Klein, et al, 1984)
  • Blockage of microvascular perfusion  with retinal ischemia and necrosis
  • Increased risk with elevations of HbA1c (Massin M, et al, 2011)
  • Aggressive management of blood glucose levels (HbA1c < 6) delays onset and progression (Morita, et al, 2010) 


Points about Nephropathy and DM (3) 

  • Diabetes is most common cause of end-stage renal disease
  • Hardening and thickening of glomerular basement membrane decreased filtering capacity of nephrons
  • Can be delayed with intensive management of blood glucose levels, treatment of hypertension (ACE inhibitor or ACE inhibitor in combination with b-blocker), care with dietary protein and stopping smoking.


 Musculoskeletal Problems likely to be seen with DM (11)

  1. Syndrome of limited joint mobility 
  2. Stiff hand syndrome 
  3. Flexor tenosynovitis – inflammation and fibrotic changes of flexor tendons of the hand
  4. Dupuytren’s contracture 
  5. CTS 
  6. Adhesive capsulitis 
  7. Osteoporosis 
  8. Charcot’s arthropathy 
  9. Subluxation of tarsal and metatarsal joints
  10. Complex Regional Pain Syndrome (reflex sympathetic dystrophy)
  11. Diffuse Idiopathic Skeletal Hyperostosis (DISH)



What Dr. T highlights about: Syndrome of limited joint mobility

– flexion contractures of hand (and other joints eventually) leading to decreased ROM and strength


What Dr. T highlights about: Stiff hand syndrome

– paresthesias and pain and increased subcutaneous stiffness/hardness secondary to vascular insufficiency


What Dr. T highlights about: Dupuytren’s contracture 

– flexion contracture with thickening of the palmar fascia usually most involvement of 3rd & 4th digits in the diabetic population (compared to 4th and 5th digits from other causes)


What Dr. T highlights about: CTS (carpal tunnel) 

more neuropathic than entrapment in diabetic patient


What Dr. T highlights about: Complex Regional Pain Syndrome (reflex sympathetic dystrophy) 

– initiated by vascular disease and/or abnormalities in sensory and autonomic nerve conduction 


What Dr. T highlights about: Diffuse Idiopathic Skeletal Hyperostosis (DISH) 

– osteophytes grow and fuse from adjacent vertebrae, most common in thoracic spine but seen in other joints/areas


What Dr. T highlights about: Osteoporosis

– generalized osteoporosis within 5 years of Type 1 onset, less pronounced in Type 2, with microfractures and decreased bone repair


What Dr. T highlights very briefly about: Charcot’s arthropathy

loss of sensation with repeated trauma to joints


Points about skin ulcerations and DM 

  • Neuropathy decreases sensation and recognition of skin damage

  • Decreased vascular perfusion

  • Increased shear forces due to orthopedic changes, previous scarring, subcutaneous stiffness and loss of local fat pads

  • Lack of normal sweating, dry skin and inelastic

  • Decreased repair due to decreased vascularization


CDC stats on prevelance of DM in youth

(don't think we need to know this?) 

  • Reported at the 72nd American Diabetes Scientific Sessions, June 9, 2012

  • Prevalence of type 2 diabetes had increased 21% among American youth from 2001-2009

  • Prevalence of type 1 diabetes rose 23%

  • 189,000 Americans under the age of 20 with diabetes; 168,000 had type 1 & > 19,000 had type 2

  • Highest risk for type 2 diabetes was highest among American Indian and non-Hispanic black youth

  • Proportion of Hispanic and non-Hispanic white youth with type 2 diabetes was lower, but it increased over time


MB is daydreaming about being where right now? 



Complications of diabetes in youth (2)

  • More likely to have protein in the urine than youth with type 1, suggesting kidney pathology has already begun and they are at increase risk of kidney failure

  • Early indications of cardiovascular autonomic neuropathy with increased risk for future cardiovascular disease


Medication we are seeing more commonly with DM 

statin drugs


Info Dr. T highlight about statin drugs and DM 

  • Meta-analysis showed slight (12%) increased risk of Type 2 diabetes with high dose (80 mg) statin use 

  • Risk may be higher in middle aged women 

  • General agreement that benefits far out weight increased risk 
  • Dramatic decrease risk of cardiovascular disease in diabetes with statin use 

–25% decreased risk of all 1st time CV events

–31% decreased  risk fatal/non-fatal stroke

–30% decreased  risk of fatal/non-fatal MIs

–16% (but not significant) decrease all-cause mortality


How often should Type I diabetics check their BSLs (blood sugar levels)? 

  • If they have a closed loop system, meaning they have an insulin pump- not as frequently
  • New diabetics very often
  • Dr. T did not give a hard lined answer on this one, but in response to before and after meals she said certainly more often than not initially is good


How often should Type II and gestational diabetics check their BSLs?

–at least QD before a meal


Testing procudures for BSL

  •  Equipment: Lance,Test strips, Electronic monitor
  • Wash & dry hand well

  • Lance fingertip with spring lance

  • Insert test strip into monitor device to active monitor

  • Place drop of blood on test strip and wait for recording

  • Values displayed in mg/dl or mmol/L