Foods you can eat if you have Diabetes

The Big Diabetes Lie

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Treatment Of Central Diabetes Insipidus

Treatment of central diabetes insipidus (DI). Central DI may be treated with hormone replacement or drugs. In acute settings when renal water losses are extensive, aqueous vasopressin (pitressin) is useful. It has a short duration of action that allows for careful monitoring and avoiding complications like water intoxication. This drug should be used with caution in patients with underlying coronary artery disease and peripheral vascular disease, as it can cause vascular spasm and prolonged vasoconstriction. For the patient with established central DI, desmopressin acetate (dDAVP) is the agent of choice. It has a long half-life and does not have significant vasoconstrictive effects like those of aqueous vasopressin. It can be conveniently administered intranasally every 12 to 24 hours. It is usually tolerated well. It is safe to use in pregnancy and resists degradation by circulating vasopressinase. In patients with partial DI, agents that potentiate release of antidiuretic hormone...

Autoantibodies in Diabetes 321

15.2.1 Insulin as an Autoantigen 324 15.3 Islet Autoantibodies and the Prediction of Type 1 Diabetes 332 15.3.3 Distribution of Antibodies in Diabetic Patients at Time of Disease Diagnosis 335 15.3.4 Islet Autoantibodies and Diabetes Prediction 337 15.4 Relationship of Islet Autoantibodies to T-cell Responses in Type 1 Diabetes 339

Insulin resistant diabetes

Some rare insulin resistant states exist in which hundreds or even thousands of units of insulin may be ineffective. They are often associated with lipodystrophy, hyperlipidaemia, and acanthosis nigricans. Type A insulin resistance is due to genetic defects in the insulin receptor or in the post-receptor pathway. Type B insulin resistance occurs as a result of IgG autoantibodies directed against the insulin receptor it is often associated with other autoimmune disorders such as systemic lupus erythematosis, and it is much commoner in women of African descent. Management of these conditions can be very difficult and specialist texts should be consulted. Relative risk of Type 2 diabetes according to body mass index in US women aged 30 to 55 years Relative risk of Type 2 diabetes according to body mass index in US women aged 30 to 55 years A family with dominantly inherited Type 2 diabetes. HNF-1a defect (chromosome 12), formerly MODY 3. Diabetic patients are shown in black

Prevention of Type 2 diabetes

Lifestyle changes in those prone to Type 2 diabetes can effectively delay the onset of this disease. Several studies in different countries have demonstrated the feasibility of achieving this by a programme of weight reduction, improved diet (less fat, less saturated fat, and more dietary fibre) and increased physical activity. Recent investigations show that the development of diabetes can be approximately halved if these lifestyle changes are maintained over four years.

Measurement Of Insulin Resistance And Clinical Assessment

Clinically, a number of techniques have been developed to detect the presence of insulin resistance and assessments vary in complexity and precision (Figure 2.2)2-6. However, from a clinical perspective, the most practical way of assessing insulin resistance is the measurement of plasma insulin levels. (Insulin is produced in pancreatic p-cells and is released into the bloodstream in response to stimulation that occurs after a meal ingestion (Figures 2.3 and 2.4)7. As type 2 diabetes is characterized by an antecedent phase of insulin resistance that requires a compensatory increase in insulin secretion to maintain euglycemia, an elevated insulin level in the fasting state is indicative of insulin resistance.) It is suggested that this be performed in the overnight fasting condition, since in the postprandial state glucose levels are changing rapidly, and variable levels of glucose confound the simultaneous measurement of insulin. The homeostasis model assessment (HOMA)4,5 of insulin...

Identifying patients in need of insulin

Patients in need of treatment with insulin must be identified early. This is done by judging the patient's clinical features blood glucose concentrations alone offer a relatively poor guide, although most patients with a blood glucose concentration greater than 25 mmol l are likely to need insulin. Features suggesting need for insulin are The following groups of patients are likely to need insulin diabetic patients whose tablet treatment has failed If there is any doubt give insulin. It can never be wrong to do so, and if the decision was mistaken it can easily be reversed. need of insulin

Diabetes Mellitus and Sensory Neuropathies

A Nobleman in the vigour of his Age, became very prone to an excess of Pissing in the space of twenty four hours, he voided near a Gallon and a half of clear water, and wonderfully sweet, as though Honey were mixt in it. And we need not wonder that the urine of those labouring with the Diabetes is not salt. But why that it is wonderfully sweet like Sugar or hony.4 Sadly, the remedy for diabetics, insulin, the internal secretion of the pancreas,was not isolated before 1922 by Banting and Best.42 Its association with gangrene was probably determined in the 19th century. Lyot wrote in 1896 We find a few sparse observations of diabetics with gangrene before 1845, at which time, apparently, Carmichael was the first to establish a relationship between glyco-suria and gangrene.43 Treves, noting the hazards of operating on diabetics in 1895, observed In any event, sugar diabetes is believed to be an ancient ailment and a source of gangrenous complications caused, in younger patients, by loss...

The aims of controlling diabetes

Once diabetes treatment has been established, there is a need to agree the level of control to be achieved in each individual patient. Once symptoms have been eliminated, targets for optimal control (shown in the table) should be discussed and agreed, but it is not always possible to reach ideal goals and pragmatic decisions have to be made.

Indications for insulin in Type 2 diabetes

Approximately 6 of non-obese and 2 of obese Type 2 diabetic patients need to start insulin each year. Predicting the need for insulin is difficult those of lean body mass, especially in the presence of islet cell antibodies, are at greatest risk. Whether to give insulin to Type 2 diabetic patients is one of the most important yet difficult decisions to be made in treating these patients. Failure to give insulin to some patients results in protracted and needless malaise if not actual danger. On the other hand, giving insulin inappropriately can cause needless problems, notably from hypoglycaemia and weight gain. Indications for giving insulin to Type 2 diabetic patients who are inadequately controlled despite adherence to their recommended diet and oral hypoglycaemic agents are as follows Continuing weight loss (even if this is insidious), and persistent symptoms, or both. Insulin treatment in these patients almost always results in a substantial improvement in health. An obese...

Surgery in Type 2 diabetes

Management of diabetic patients treated with diet or oral hypoglycaemic agents is more straightforward, so long as the diabetes is well controlled. 12 mmol l start soluble insulin. If the diabetes is poorly controlled (random blood glucose greater than 12 mmol l) the patient should be started on

Combination treatment with insulin and metformin

Metformin can be given together with insulin to overweight Type 2 diabetic patients this can to a small extent limit the inevitable weight gain following introduction of insulin. A combination of sulphonylureas with insulin gives little benefit and has the added disadvantage that patients must continue with both modes of treatment. Insulin regimens suitable for Type 2 diabetic patients are described in chapter 5. The figure showing the cross sectional and 10-year cohort data for Hb 1c in patients receiving intensive or conventional treatment is adapted from UKPDS Lancet 1998 352 837-53 with permission from Elsevier Science. The histogram showing increased patient compliance is adapted from Paes AH, Bakker AS, Soe Agnie CJ. Impact of dosage frequency upon patient compliance. Diabetes Care 1997 20 1512-17.

Blindness in diabetic patients

Vision-threatening retinopathy is usually due mainly to neovascularisation in Type 1 diabetes and maculopathy in Type 2 diabetes. In North America, 3-6 of patients with Type 1 diabetes and 1-6 of patients with Type 2 diabetes are legally blind. In England and Wales about 1000 diabetic patients are registered as blind or partially sighted each year, with diabetic retinopathy being the commonest cause of blindness in the working population. Maculopathy. Macular disease has three causes in diabetic patients exudative maculopathy, retinal oedema, and ischaemia. Deterioration of vision in these situations is often insidious, it can to some extent be prevented by appropriate laser treatment, but once vision has been lost it cannot be restored. Ischaemic maculopathy due to loss of perifoveal capillaries may cause severe visual loss and is very difficult to treat. Cataract. Lens opacities or cataract develop earlier in diabetic patients and often progress more rapidly. Primary open-angle...

Initiating factors and progression promoters in diabetic nephropathy

Both development and early progression of diabetic nephropathy are most likely to occur following years of poor Cumulative incidence of coronary heart disease in Type 1 diabetic patients with and without proteinuria Type 2 diabetes diabetic control tight control over a decade both delays onset of the disease and slows progression chiefly of its early phase, although there is some effect in established disease as well. There is also a familial propensity to nephropathy in both Type 1 and Type 2 diabetes, although the precise genetic factors responsible have not been identified.

Treatment of Type 2 diabetes mellitus

Type 2 diabetes is a complex disorder generally affecting older people who are often overweight and likely to suffer other medical problems as well. Its management presents considerable challenges to medical and nursing staff, whose care must be directed at the sum of the problems of the individual patient. Management now requires not only attention to blood glucose control, but also to the treatment of hypertension and hyperlipidaemia, as well as introducing the necessary measures for reducing cardiovascular risk factors. Optimal treatment of Type 2 diabetic patients, especially those who are symptom-free, overweight and have in addition several cardiovascular risk factors, exercises our clinical skills and judgments to the limit. There needs to be a sense of reality within the consultation, bearing in mind the potential dangers of unacceptable polypharmacy accompanied by low adherence to prescribed treatment as well as a sense of guilt experienced by those who fail to achieve ideal...

Islet Autoantibodies and Diabetes Prediction

Subjects participating in prospective studies of islet autoimmunity early in life (e.g., BABYDIAB, DAISY, DIPP) have also been followed for subsequent development of diabetes, and these studies provide an indication of the value of auto-antibodies as markers for diabetes development. The vast majority of subjects who developed diabetes at an early age in these studies possessed multiple islet autoantibodies months or years before disease onset 121, 126 . The cumulative risk of developing diabetes within five years of developing one or more islet au-toantibodies was estimated to be between 40 and 50 for individuals with multiple antibodies, but only 3 for those positive for only a single antibody specificity (IAA, GADA, or IA-2A). In these prospective studies of autoimmunity in early childhood, follow-up to disease is necessarily restricted to a narrow time window in the first few years of life, but the vast majority of patients who develop diabetes will do so at an older age....

Contraception and diabetes

Good contraceptive advice for diabetic patients is vital to ensure that pregnancies are planned and conception takes place when diabetic control is optimal. All methods of contraception are available to diabetic women the combined oral contraceptive pill is suitable in the absence of macrovascular disease or microvascular disease especially proteinuria, while progestogen-only methods provide a range of options including highly reliable long term methods, such as Depoprovera and implantable methods such as Implanon. There is no evidence of any clinically significant effect on diabetic control from either combined oestrogen-progestogen pills or progestogen-only methods, nor is there any influence on the progression of diabetic complications. In the case of women with a history of gestational diabetes, the use of combined pills does not influence the subsequent development of Type 2 diabetes, but there is at present some doubt regarding the use of progestogen-only pills during lactation...

Amylin in Type 2 Diabetes Mellitus

Rodent models of type 2 diabetes typically exhibit elevations in plasma concentrations of both amylin and insulin (Gill and Yen, 1991 Tokuyama et al., 1993 Pieber et al., 1994). However, rodent type 2 models may differ from humans in the etiopathogenesis of diabetes. They are often characterized by extreme insulin resistance, while the human condition is characterized by a sequence of worsening insulin resistance followed by insulin secretory failure (Saad et al., 1989). This sequence in humans was apparent in cross-sectional studies (Reaven and Miller, 1968) and was also apparent in individuals whose progression into diabetes was followed longitudinally (Saad et al., 1989). Loss of glucose-mediated insulin secretion marked the transition from impaired glucose tolerance into diabetes (Swinburn et al., 1995), consistent with the idea that insulin secretion was no longer sufficient to compensate for insulin resistance. In accordance with descriptions of insulin secretion in human type 2...

Therapeutic Trials Of Insulinlike Growth Factor I In Humans

Summary of an abstract describing the trial of insulin-like growth factor (IGF-I) in the treatment of patients with established acute renal failure (ARF). Based on the accumulated animal and human data, a multicenter, double-blind, randomized, placebo-controlled trial was performed to examine the effects of IGF-I in patients with established ARF. Enrolled patients had ARF of a wide variety of causes, including surgery, trauma, hypertension, sepsis, and nephro-toxic injury. Approximately 75 patients were enrolled, treatment being initiated within 6 days of the renal insult. Renal function was evaluated by iodothalimate clearance. Unfortunately, at an interim analysis (the study was originally designed to enroll 150 patients) there was no difference in renal function or survival between the groups. The investigators recognized several potential problems with the trial, including the severity of many patients' illnesses, the variety of causes of the renal injury, and delay in initiating...

Mechanisms of Chronic Diarrhea in Diabetes Mellitus

Table 71-1 provides an overview of the pathophysiological mechanisms and conditions associated with diarrhea in diabetes. The mechanisms of chronic diarrhea in diabetes are incompletely understood. However, several commonly Table 71-1 Mechanisms, Concomitant Conditions, and Clinical Characteristics of Diarrhea in Diabetes Mellitus encountered mechanisms for diarrhea in patients with diabetes should be considered. Diarrhea may result from intake of medications or the excessive use of dietetic foods that contain sorbitol as a sweetener. Autonomic neuropathy (Vinik et al, 2003) or diseases associated with diabetes, such as celiac disease, may be the underlying causes of chronic diarrhea.

Causes Of Diabetes Insipidus

The causes of diabetes insipidus can be divided into central and nephrogenic. Most (about 50 ) of the central causes are idiopathic the rest are caused by central nervous system involvement with infection, tumors, granuloma, or trauma. The nephrogenic causes can be congenital or acquired 23 . Congenital central diabetes insipidus (DI), autosomal-dominant form. This condition has been described in many families in Europe and North America. It is an autosomal dominant inherited disease associated with marked loss of cells in the supraoptic nuclei. Molecular biology techniques have revealed multiple point mutations in the vasopressin-neurophysin II gene. This condition usually presents early in life 25 . A rare autosomal-recessive form of central DI has been described that is characterized by DI, diabetes mellitus (DM), optic atrophy (OA), and deafness (dIDMOAD or Wolfram's syndrome). This has been linked to a defect in chromosome-4 and involves...

Culture Of Insulinoma Cells On Pancreas Sections

Abstract Cell therapy using pancreatic islets is a promising lifelong treatment for type 1 diabetes mellitus. However, before cell therapy can be extensively used, there are some problems that need overcome. Of these, we focused on the need for improved cell function during in vitro culture. The sources of cells for cell therapy for diabetes are classified into two categories primary cells isolated from a donor pancreas and established cell lines. The function of isolated primary cells decreases rapidly during in vitro culture and the function of established cell lines is too low for transplantation. To maintain and or improve cell function during in vitro culture we designed TOSHI-substrata (substrata made of tissue organ sections for histopathology), and investigated its effect on pancreatic cell lines derived from insulinomas. Before investigation, we estimated the influence of optimum cutting temperature (OCT) compound, which is used in preparation of the TOSHI-substrata, to...

Diabetes Preventive Care

The diabetes preventive care state consists of three substates screening, preventive care, and initial diagnosis. The screening state contains two substates Regular, aimed at low-risk patients - as indicated by the guard Risk Low and Targeted Risk High , aimed at high-risk patients. The risk level is determined by the criteria described in the Sect. 2 dedicated to diabetes mellitus. Inside both states similar actions are performed. Both states converge at a dynamic choice pseudostate. If a patient has no symptoms and preventive care of some sort is recommended (transition with guard Symptoms F AND PrevCare T ), the patient will leave the current state and will enter the preventive care state. However, if the patient presents any symptoms consistent with diabetes ( Symptoms T ), she he will enter the initial diagnosis state, where she he will be diagnosed and will move into long-term management. Note that when exiting the screening state two actions are carried out the session is...

Starting insulin in patients with Type 1 diabetes

Some patients start treatment with twice-daily insulin injections using either a mixture containing premixed short and medium acting insulins twice daily or medium acting insulin alone 8 units twice daily, 15 to 30 minutes before meals is a suitable initial dose for most patients others will start with a three or four times daily regimen. Only those who are seriously weakened or ill need hospital admission and treatment either with intravenous insulin and fluids or multiple insulin injections. Many patients who present with acute diabetes enter partial remission soon after diagnosis, known as the honeymoon phase, when a small dose of almost any insulin is enough to maintain control. The practice of withdrawing insulin at this stage is not encouraged because after a few months the need for insulin is almost inevitable.

Management of insulin treated diabetes during day surgery

Patients with insulin treated diabetes requiring an anaesthetic for relatively minor operations or investigative procedures (for example, barium radiological examinations, cystoscopy, endoscopy, etc.) can be treated as day cases without hospital admission provided that the procedure is undertaken in the morning first on the list (if the procedure is performed first on an afternoon list, a light breakfast is taken after half the normal insulin dose, followed by regular blood glucose monitoring) the patient is able to self-monitor blood glucose and adjust insulin appropriately. significant problems with diabetes c ntr l pCTS then hospital The photograph of blood glucose and ketone meter is with permission from admission may be required after all. MediSense. Instructions for management of insulin treated diabetes Insulin is taken on the previous evening as usual Insulin and breakfast are omitted on the morning of the procedure Within one hour after completion of the procedure, the normal...

Glucose Insulin and Potential Mechanisms of Vascular Stiffening

Among patients with diabetes 15 or the metabolic syndrome, arterial stiffening is observed across all age groups. In children with severe obesity, arterial wall stiffness and endothelial dysfunction are accompanied by low plasma apolipoprotein A-I levels, insulin resistance, and android fat distribution, changes that may be the main risk factors for the early events leading to atheroma formation 16 . The positive correlation between insulin resistance and central arterial stiffness and the close relationship between the extent of metabolic changes and the degree of arterial stiffness suggest that insulin resistance is a primary underlying factor. In animal models of insulin-resistant diabetes, chronic hyperglycemia and hyperinsulinemia increase local angio-tensin II production and expression of vascular Ang II type I receptors via stimulation of TGF- 1, upregulate plasminogen activator inhibitor-1, and downregulate matrix metalloprotease activity, all of which play a critical role in...

Choice of Insulin Sensitizing Agent in PCOS

Currently, the commercially available insulin-sensitizing agents include metformin and the thiazolidinediones (rosiglitazone and pioglitazone). Most of the clinical studies in women with PCOS have been conducted with metformin. In addition, for several decades metformin has been used worldwide to treat diabetes, and thus its side effect profile has been well described. Adverse effects of metformin include gastrointestinal distress, such as diarrhea and nausea. More serious toxicity includes a documented, but rare, risk of lactic acidosis. Nearly all reports of lactic acidosis occurred in patients with renal insufficiency (plasma creatinine > 1.4 in women), hepatic dysfunction, heart failure, or other pulmonary and circulatory dysfunctions that can by themselves lead to hypoxia and lactic aci-dosis (70,71). Careful attention to these contraindications will prevent most occurrences of lactic acidosis. As discussed in a previous section, metformin is classified by FDA as Pregnancy...

National Service Framework NSF for Diabetes standards

The NSF for diabetes was published in 2002 and full details can be found on the website < www.doh.gov.uk nsf diabetes> The standards have been divided into 12 sections relating to the following nine categories 1 Prevention of Type 2 diabetes 2 Identification of people with Type 2 diabetes 3 Empowering people with diabetes 4 Clinical care of adults with diabetes 5 Clinical care of children and young people with diabetes 7 Care of people with diabetes during admission to hospital 8 Diabetes and pregnancy

Mechanisms Mediating the Role of the PDH Complex in Regulating Glucose Oxidation with Special Reference to Inhibitory

However, comparative mitochondrial studies showed that additional mechanism(s) were involved in the effects of diabetes or starvation. In studies with Drs. Kerbey Sugden and Hutson, three phosphorylation sites were identified in porcine and rat PDH complexes, and amino acid sequences around the sites were determined in porcine complex 44,45 . Inactivation was shown to require phosphorylation of only one of three sites (site 1) 43,44 . Later studies with ATPyS showed that complexes thiophosphory-lated in sites 2 plus 3 only are also inactive i.e. inactivation is not site 1 specific 45 . The eventual conclusion was that phosphoryla-tion of sites 1 or 2, but not of site 3 are inactivating. Phosphoryla-tion of sites 2 and 3 which occurs largely over the range of 70-100 percent phosphorylation of site 1 was shown to inhibit reactivation by PDH phosphatase i.e. multisite phosphorylation provides a locking mechanism retarding reactivation 46,47 . This was shown to involve an increase in...

Distribution of Antibodies in Diabetic Patients at Time of Disease Diagnosis

By the time of disease onset, the majority (> 90 ) of patients with type 1 diabetes possess serum antibodies to at least one of the major islet-cell antigens in type 1 diabetes GAD65, IA-2, or insulin 128 . The precise specificity of antibodies present in the serum of individual patients is dependent on both the age of the patient and the HLA genes expressed by the individual (Fig. 15.3). The frequency of IAA and IA-2A at the time of diabetes onset is highest among individuals who develop the disease at an early age and is less frequent in older patients 128 . IAAs show a particularly strong negative association with age. Since prospective studies have shown that some islet autoantibodies, particularly IAAs, can decrease in titer to undetectable levels over time 126 , the absence of these at the time of disease onset does not necessarily imply a lack of an immune response to that antigen in the pre-diabetic period. In contrast to IAA and IA-2A, GADA are present at moderate to high...

Requirements for diabetes care

A complex range of services for comprehensive diabetes care is needed as follows for education of all medical and nursing staff involved in diabetes care. The facilities needed to achieve these goals are provided by diabetes centres, which offer a common base for an integrated specialist and primary care diabetes service, and by the general practitioner.

Epidemiology of Diabetes

Diabetes is a growing health problem throughout the world more than 170 million people are estimated to have diabetes worldwide, the majority of whom have type 2 diabetes (DM-2). Largely unknown early in the 20th century, DM-2 is now the fifth leading cause of death in the USA. Conservative estimates suggest that by 2025 the diabetic population will more than double to over 366 million 1 . From a global perspective, Asia is expected to be the region most heavily impacted by diabetes, with an anticipated 2- to 3-fold increase in prevalence. Factors contributing to the rise in diabetes prevalence are the declining mortality from communicable diseases and infant and maternal mortality in less developed countries, aging and urbanization of the population, and, most importantly, the striking increase in obesity. The parallel rise in the prevalence of obesity and DM-2 has been appropriately labeled 'diabe-sity' 2 . The complications of diabetes, which include limb amputations, blindness,...

ABC of arterial and venous disease Vascular complications of diabetes

Adults with diabetes have an annual mortality of about 5.4 (double the rate for non-diabetic adults), and their life expectancy is decreased on average by 5-10 years. Although the increased death rate is mainly due to cardiovascular disease, deaths from non-cardiovascular causes are also increased. A diagnosis of diabetes immediately increases the risk of developing various clinical complications that are largely irreversible and due to microvascular or macrovascular disease. Duration of diabetes is an important factor in the pathogenesis of complications, but other risk factors for example, hypertension, cigarette smoking, and hypercholesterolaemia interact with diabetes to affect the clinical course of microangiopathy and macroangiopathy. A continuous relation exists between glycaemic control and the incidence and progression of microvascular complications. Hypertension and smoking also have an adverse effect on microvascular outcomes. In the diabetes control and complications trial...

Self assessment of diabetic control in Type 2 diabetes

Home blood glucose monitoring is of value for many (though not necessarily all) patients with Type 2 diabetes, as it is for those with Type 1 diabetes. Those taking oral hypoglycaemic agents or on diet alone have the option to monitor their control by either self blood glucose measurement or regular urine testing. Measurement of the fasting blood glucose two or three times weekly in those on diet alone provides a valuable guide to control, while the addition of some postprandial readings in those taking oral hypoglycaemic agents also provides important information.

Gestational diabetes diabetes discovered during pregnancy

The detection of gestational diabetes is undertaken by screening procedures in antenatal clinics. Babies born to women with gestational diabetes are frequently macrosomic and although both the effects on mortality and the benefits of intensive treatment are still uncertain, best practice requires optimal diabetic care for these patients.

Diabetes specialist nurses and consultant nurses

The most important single innovation in diabetic care during the past three decades has been the increasing involvement of highly trained diabetes specialist nurses who can transform the standard of diabetic care, achieving liaison between hospital, general practitioner and patients at home, and offering a wide range of clinical and educational expertise. The Royal College of Nursing recommends that there should be one specialist nurse for a population of 50 000, and one for every 50 families with a diabetic child. The training of nurses for diabetic care is of central importance and undertaken on specifically designed diploma and degree courses as well as at the diabetes centres themselves.

State Based Model for Management of Type II Diabetes

The Decision Systems Group at the Brigham & Women's Hospital, Boston, USA and the Clinical Knowledge Management Group at Partners HealthCare Systems, Inc. have developed a computational model that encompasses strategies for prevention, early diagnosis, and treatment of type II diabetes and associated complications. This effort is part of an on-going, enterprise-wide strategy to improve the quality, safety, and efficiency of provided care, by maximizing the use of new clinical information technology in key issues such as complex clinical workflows, usability, controlled terminology, knowledge management, and clinical decision support carried out by Partners HealthCare System. The proposed model is a disease state management system for the continuum of diabetes care that synergistically integrates patient care and education protocols at all levels of disease management, and supports the integration of evidence-based personalized care. Our approach could be easily adapted to...

Glucose and insulin in labour

Glucose and insulin are given by intravenous infusion for all vaginal deliveries as follows Intravenous insulin soluble insulin diluted in physiological saline (1 unit insulin ml saline) and administered by infusion pump at about 1 unit h (usual range 0-5-2 units h). If very low infusion rates are used the insulin concentration can be halved. Blood glucose concentrations should be maintained in the range 4-0-7-0 mmol l. Insulin infusion is continued until the patient can restart her normal meals. The pre-pregnancy insulin dose is then restarted, otherwise severe hypoglycaemia will occur if the patient was not previously on insulin, the insulin dose is halved. *If the blood glucose concentration decreases to < 3-0mmol 1, insulin infusion can be stopped for up to 30 minutes.

Vascular Effects of Insulin

Insulin is a slow vasodilator of peripheral resistance arteries in skeletal muscle 13 . This action of insulin is slow and requires prolonged exposure to supraphysiological doses. In normal subjects, infusion of a high physiological dose of insulin (1 mU kg min) increases peripheral blood flow slowly on average by 20 (range 10-90 ) within approximately 2 h in normal subjects 13-15 . Factors which contribute to interindividual variation in blood flow responses to insulin include limb muscularity 14 , the number of capillaries surrounding muscle fibers 16 and possibly endothelial function 17 . Regarding the mechanism responsible for insulin-induced vasodilatation of resistance vessels in vivo, stimulation of endothelial NO synthesis by insulin seems to be involved. Both Scherrer et al. 18 and Steinberg et al. 19 demonstrated that the insulin-induced increase in blood flow can be abolished by inhibiting NO-dependent vasodilatation with L-NMMA, but not by other vasoconstrictors such as...

Backgroundsummary 21 Insulin Resistance and PCOS

The role of insulin resistance in the pathogenesis of PCOS has been extensively reviewed in Chapter 24. Briefly, insulin resistance is an intrinsic and virtually universal feature of PCOS. Insulin resistance exists in PCOS independent of obesity, as evidenced by the presence of insulin resistance even in lean women with PCOS (1). In addition, about 50-80 of women with PCOS are obese. Hence, in PCOS obesity further induces an added burden of insulin resistance and hyperinsulinemia in addition to the component of insulin resistance that is intrinsic to the disorder (2).

Drawing up insulin from the vials

1 Clean the top of the insulin bottle with industrial methylated spirit. 2 Draw air into the syringe to the number of units of insulin required and inject this into the insulin bottle. 3 Draw the required dose of insulin into the syringe, and before withdrawing the needle from the insulin bottle, expel the air bubble if one has formed. If clear and cloudy insulins are to be mixed 1 Inject the correct number of units of air first into the cloudy insulin bottle. 3 Inject the air into the clear bottle, and withdraw the insulin into the syringe. 4 Finally, insert the needle into the cloudy bottle and withdraw the insulin.

After recovery changing to subcutaneous insulin

Once the patient starts to eat and drink conversion back to subcutaneous insulin injections is undertaken as follows. Always change to subcutaneous insulin before breakfast and never in the evening so that adequate supervision can be assured. Stop the insulin pump 30 minutes after the first subcutaneous insulin injection. Insulin regimen and dose if the previous regimen is known then this should be given if the patient is still in bed or unwell the total dose may need to be 10 to 20 more than usual. If the patient was not previously taking insulin, predicting the requirement is not easy and the amount needs adjustment from day to day. Initially use insulin 30-40 units daily in divided doses given four times daily. Patients with hyperglycaemia often relapse after conversion back to subcutaneous insulin. When this happens there are three possible approaches. Give additional doses of soluble insulin at any of the four injection times (before meals or bedtime). Add an intravenous insulin...

Comparative Efficacy of Different Insulin Sensitizing Agents

Few studies have directly compared the utility of the various insulin-sensitizing drugs in women with PCOS. Ortega-Gonzalez et al. studied 52 obese (BMI > 28 kg m2), insulin-resistant women with PCOS who had not been previously treated and randomized them to either pioglitazone 30 mg day or metformin 850 mg three times daily for 6 months (35). Both metformin and pioglitazone significantly improved AUC-insulin and fasting glucose-to-insulin ratio despite a significant increase in weight (from BMI of 32.2 1.0 kg m2 at baseline to 34.0 1.2 kg m2 at 6 months) in the pioglitazone group. At 6 months, fasting AUC-insulin was significantly lower in the women treated with pioglitazone compared with those treated with metformin. However, women in the metformin group also had a higher AUC-insulin at baseline, and hence whether there was a true difference in the reduction of AUC-insulin between pioglitazone and metformin is unknown. Ovulation rates were not evaluated in this study. Baillargeon...

Glucoseinsulin infusion

(1) Give normal insulin on the night before the operation (2) Begin an infusion of 10 dextrose containing 20 mmol l potassium chloride and soluble insulin 15 units l. Run it at a rate appropriate to the patient's fluid requirements, usually 100ml h. Adjust insulin dose as follows Soluble insulin infusion insulin before the operation, using one of the regimens described on the previous page.

Insulin pens and syringes

The use of insulin pen devices which deliver metered doses of insulin from an insulin cartridge is now favoured by most Insulin regimens short acting insulin analogues can replace conventional soluble insulins Insulin regimens short acting insulin analogues can replace conventional soluble insulins Examples of insulin pens Examples of insulin pens patients. They are portable and simplify the procedure of measuring the insulin dose. The required dose can be dialled, and some pens feature audible and palpable dose graduations which are of value to those with impaired vision. Some versions of the pen are preloaded and disposable. Plastic insulin syringes with needle attached are still preferred by some patients, and they are still required by those who prefer to mix individual insulins in the syringe. They can be reused several times and between use can be stored in a refrigerator.

Effect of Hyperinsulinemia on Hyperandrogenism in PCOS

Several lines of evidence suggest that the compensatory hyperinsulinemia associated with insulin resistance is critical to the pathogenesis of hyperandrogenism in PCOS. In in vitro cultures of isolated human ovarian thecal cells, ovarian testosterone biosynthesis stimulated by insulin was fourfold greater in cells from women with PCOS than those of normal women, and in a dose-response study insulin stimulated thecal androgen production at physiological concentrations (3). This stimulation of testosterone production was almost fully prevented by antibody blockade of the insulin receptors. This suggests that insulin stimulates ovarian thecal testosterone biosynthesis via activation of its homologous receptor. Insulin also decreases circulating levels of sex hormone-binding globulin (SHBG), the primary circulating binding protein for testosterone (4). Because of testosterone's high-affinity binding to SHBG, lower SHBG levels translate to increased levels of free and bioavailable...

New recombinant insulin analogues

These have a very rapid onset and very short action, and have been developed by altering the structure and thus the property of the insulin. The preparations available in the United Kingdom Elizabeth Evans Hughes (1907-1981). Banting's prize patient, who found insulin unspeakably wonderful. The photograph is from Banting's scrapbook Elizabeth Evans Hughes (1907-1981). Banting's prize patient, who found insulin unspeakably wonderful. The photograph is from Banting's scrapbook

Management of insulin treated diabetes during surgery

The chief principle of diabetic management through any crisis in which patients cannot eat or drink for any reason is to continue insulin administration. The best method is to give the insulin by continuous intravenous infusion either by infusion pump or directly from the drip bag. For operations in which a patient is likely to be maintained on a drip for more than 12 hours a regimen is needed which can be continued for an indefinite period. Again there are two methods of administering the insulin a variable rate infusion using a pump, or if this is not available, a glucose insulin-infusion. Note

Insulin Sensitizing Drugs

In the past decade, several studies reported th+at insulin sensitization may be effective in improving several abnormalities of PCOS. In particular, metformin has been proposed as the first-line therapy for both reproductive and metabolic abnormalities in these women. Insulin sensitizers also lower serum testosterone, and a few controlled studies assessed the efficacy of these drugs on hirsutism. These studies, carried out with either metformin or troglitazone, showed limited effect of this approach on established hirsutism (26,27), suggesting that the treatment of hirsutism should not be a primary indication for using insulin sensitizers. However, it can be hypothesized that these drugs might be helpful in hirsute women with PCOS for the maintenance of the clinical improvement obtained with antiandrogen treatment.

Glucose And Insulin Levels

The ability to measure plasma insulin levels by radioimmunoassay has greatly aided the diagnosis of insulinoma. The diagnosis is made primarily by the recognition of a circulating insulin level that is inappropriately high for the existing level of blood glucose, especially at the time of hypoglycemia. Two types of measurements can be made fasting and following provocative testing. By far, fasting values are the most reliable and less dangerous, but an observed 72-hour fast is most helpful in some patients. Symptoms of hypoglycemia generally occur if the serum glucose levels are below 40 mg mL.

The story of Mrs BJ continued starting insulin

I was put in a Women's ward where I was given my first dose of insulin. I can remember vividly my parents' first visit and my mother's anxious face as she walked down the ward, with one enormous white chrysanthemum in her hand. She had expected to see me prone and white and half dead, not sitting up and a picture of health. I had a lesson on how insulin burnt up the sugar and produced energy, so that I could return to my former activities, and before long I was doing my own injections. I stayed in hospital for three weeks. The Sunday before I was discharged, my parents were asked to come to the diabetic kitchen to witness me doing my insulin and explaining what I was eating and how it had to be calculated. My mother did not see the injection, having passed out, and she told Sister Wheeler that she would never understand the diet. Sister replied Don't worry about it. She knows, so give her what she tells you. Such confidence was well founded, as my mother never got the hang of it, and...

Increase In The Insulin Secretion Of Hitt15 Cells

Abstract Gap junctional intracellular communications (GJIC) were found in almost all types of vertebrate cells. The p-cells of the endocrine pancreas are connected by gap junctions, and the membrane specializations are thought to provide channels for direct cell-to-cell and cell-to-matrix communications. Previous studies suggested that GJIC may participate in the control of insulin secretion. It has been suggested that hyaluronic acid (HA) increases the function of GJIC via the expression of Connexin43, a major protein component of gap junctions. However, the effects of HA on insulin secretion and gap-junctions between p-cells remains unclear. To determine whether insulin secretion is affected by gap-junctions after HA-treatment, we exposed HIT-T15, a clonal pancreatic p-cell line, in various concentrations of HA for 72 h, and detected their base- and glucose-stimulated insulin secretion, using an insulin assay kit by ELISA technique. The cellular functions of GJIC were assayed by dye...

Localization Of Insulinomas

Selective pancreatic angiography, using stereoscopic filming with magnification and subtraction techniques, identifies 50 of tumors with a minimum diameter of 5 mm.23 Arteriography was formerly the gold standard of insulinoma localization and, in our experience, successfully localized 47 of the tumors. Arteriography in our patients did not demonstrate improved sensitivity with increased tumor size, probably because the hypervascularity of the tumor was equally important for tumor localization. Arteriography is useful in selected patients,24 especially those with recurrent or persistent disease. Unfortunately, arteriography is invasive and expensive (Figure 13-9).25 We therefore do not recommend it for most patients. In our patients, transhepatic portal venous sampling (THPVS) detected 66 of the tumors < 1 cm in diameter, with an overall detection rate of 55 . In this procedure, the portal vein is catheterized using a percutaneous transhepatic needle, and the catheter is advanced by...

Rationale For Insulinlike Growth Factor I Igfi In Acute Renal Failure

Reported therapeutic trials of insulin-like growth factor (IGF-I) in humans. Based on the compelling animal data and the fact that there are clearly identified disease states involving both Incidence of postoperative renal dysfunction treated with insulin (IGF-I) or placebo. IGF-I significantly reduced the incidence of postoperative renal dysfunction in these high-risk patients. Renal dysfunction occurred in 33 of those who received placebo but in only 22 of patients treated with IGF-I. The groups were well-matched with respect to age, sex, type of operation, ischemia time, and baseline renal function as defined by serum creatinine or glomerular filtration rate. The IGF-I was tolerated well no side effects were attributed to the drug. Secondary end-points such as discharge, serum creatinine, length of hospitalization, length of stay in the intensive care unit, or duration of intubation were not significantly different between the two groups. (Adapted from Franklin, et al. 3 with...

Insulin Like Growth FactorI

Insulin-like growth factor-I has recently been linked to prostate cancer risk in a series of studies. The initial observation was a relatively small case-control study noting increased IGF-I in men with prostate cancer but not benign prostate hyperplasia.30 A much larger nested case-control study using data derived from the Physicians' Health Study cohort has confirmed and extended this initial report.31 In the Chan et al.31 report, increasing plasma levels of IGF-I were directly linked to increasing prostate cancer risk. Importantly, this increased risk was detected in men with both normal and elevated PSA measurements, suggesting that these risk factors were independent of one another. When examining men with the highest quartile of IGF-I, the prospective risk of prostate cancer was increased 2.4-fold, relative to those with an IGF-I in the lowest quartile. In a multivariate

Exenatide Antidiabetic [3741

Exenatide is the first drug in a new class of anti-diabetics known as the incretin mimetics, and it is indicated as adjunctive therapy to improve glycemic control in patients with type 2 diabetes who are taking metformin, a sulfonylurea, or both, but have not achieved adequate glycemic control. Exenatide is a functional analog of the human incretin Glucagon-Like Peptide-1 (GLP-1). GLP-1 is naturally released from cells in the GI tract in response to food intake and acts on its receptor on p-cells to potentiate glucose-stimulated insulin secretion. Exenatide is a long-acting agonist at the GLP-1 receptor. It is a synthetic version of a 39-amino acid peptide found in the salivary secretions of the Gila monster lizard. It has 53 amino acid homology with GLP-1, but unlike GLP-1, exenatide is less susceptible to degradation by neutral endopeptidase, has a longer half-life, binds with greater affinity to GLP-1 receptor, and is a more potent insulinotrope. In addition to stimulating...

Scalling Dermatitis Diabetes

Macerated Skin Squamous Cell

A 50-year-old female with undiagnosed type 2 diabetes, applied Bazooker, a proprietary wart remedy, to a small brown tender papule over her right third metatarsal head. Within a few days she developed a cutaneous erosion which failed to heal for 9 months and became increasingly painful (Fig. 2.13a,b). Diabetes was diagnosed by her Practitioners treating diabetic patients may encounter dermatological conditions that first manifest themselves on the foot, including

Amylin in Insulin Resistance

In insulin-resistant animals, amylin expression and plasma amylin concentrations were elevated (Bretherton-Watt et al., 1989 Gill and Yen, 1991 Huang etal., 1991b, 1992 Koranyi etal, 1992 O'Brien etal., 1991 Pieber et al., 1994 Tokuyama et al., 1991,1993). This was especially true if insulin resistance was invoked with dexamethasone (Hiramatsu et al., 1994 Jamal et al., 1990, 1991 Koranyi et al., 1992 Mulder et al., 1995a O'Brien et al., 1991 Pieber etal., 1993). In insulin-resistant humans and those with impaired glucose tolerance, plasma amylin concentration was elevated (Enoki et al., 1992 Eriksson et al., 1992 Hanabusa et al., 1992 Koda et al., 1995, 1996 Ludvik et al., 1991,1996). In Pima Indians with impaired glucose tolerance (characterized by insulin resistance), fasting and peak stimulated plasma concentrations measured using a two-site assay were 6.0 pM and 43.5 pM, respectively (Koda et al., 1993). Values in obese Caucasians with impaired glucose tolerance ranged from 20 pM...

Effect of Hyperinsulinemia on Anovulation in PCOS

Numerous studies have demonstrated that hyperinsulinemia contributes to the chronic anovulation of PCOS. In the largest long-term study, 305 women with PCOS were randomized to the insulin sensitizer troglitazone (150, 300, or 600 mg daily) or placebo for 44 weeks (10). Women receiving troglitazone at doses of 300 and 600 mg daily had a significantly higher ovulation rate (0.42 and 0.58) than those receiving placebo (0.32 p < 0.05 and 0.0001, respectively). This increase in ovulation rate was dose dependent, suggesting that the improvement in ovulatory function was at least in part accounted for by the improvement in insulin sensitivity.

Malaria And Insulin Dependent Diabetes Mellitus An Ecological Study

There is scientific merit in studying the association between insulin dependent diabetes mellitus and malaria, since they are both associated with the human leukocyte antigen system. The human leukocyte antigen system is involved in controlling immunological responses, and the association between this system and insulin dependent diabetes mellitus has long been established.12 Malaria is the most important natural selective factor on human populations that has been discovered to date.13 In areas of high endemicity, malaria operates the genetic selection responsible for the influence on the susceptibility to autoimmune diseases.14 In Sardinia, malaria is known to have selected for some serious hereditary diseases such as 3-thalassaemia, Cool-ey's disease and favism the latter is caused by a deficiency of glucose-6-phospate dehydrogenase enzyme.10 Sardinia is therefore particularly suitable for investigating the association between insulin dependent diabetes mellitus and malaria. The...

Clinical presentation why is diabetes so often missed

Thirst, tiredness, pruritus vulvae or balanitis, polyuria, and weight loss are the familiar symptoms of diabetes. Why then is the diagnosis so often missed Of 15 new patients with diabetes presenting in our diabetic ward for the first time with ketoacidosis, 14 had had no tests for diabetes after a total of 41 visits to their doctors. Almost all these serious cases of ketoacidosis could have been prevented. Patients do not, of course, always describe their symptoms in the clearest possible terms, or else their complaints may occur only as an indirect consequence of the more common features. Many patients describe dry mouth rather than thirst, and patients have been investigated for dysphagia when dehydration was the cause. Polyuria is often treated blindly with antibiotics it may cause enuresis in young people and incontinence in elderly people and the true diagnosis is often overlooked. Complex urological investigations and even circumcision are sometimes performed before diabetes is...

Relationship of Islet Autoantibodies to Tcell Responses in Type 1 Diabetes

The analysis of islet autoantibodies provides a means by which individuals may be identified at early stages of pancreatic autoimmunity and gives an indication of the risk of development of type 1 diabetes. T cells are likely to be more directly related to diabetes development than are antibodies, but it is unclear to what extent autoantibody secretion reflects a pathogenic T-cell response. Measures of disease-related T-cell responses in diabetes and an understanding of the relationships of these to autoantibodies are essential for further advances in our understanding of the etiology of type 1 diabetes and to provide an accurate assessment of autoimmune status. Indicators of T-cell autoimmunity will become particularly valuable for monitoring signs of disease recurrence following immune intervention and islet transplantation. Analysis of T-cell reactivity in diabetes has proven to be an extremely complex task. Assessment of these responses requires that the lymphocyte population be...

Effect of Insulin Sensitizers on Hirsutism

Current data on the effect of insulin sensitizers on hirsutism are conflicting. In an open-label study of 39 women with PCOS, metformin 500 mg three times daily significantly decreased Ferriman-Gallwey hirsutism scores at the end of the 12-week study period (32). However, in a more rigorous randomized, placebo-controlled, 44-week trial, metformin at the same dose did not significantly reduce clinical hirsutism scores (17). In another randomized controlled 12-month study, metformin 500 mg three times daily was compared to Dianette (ethinyl estradiol 35 ig and cyproterone acetate 2 mg) in 52 women (33). Both groups demonstrated significant reductions in the Ferriman-Galwey scores, with a significantly greater reduction in the metformin arm (p < 0.01). In addition, in patient self-assessment, women taking metformin scored their hirsutism as having improved significantly more than the contraceptive group (p 0.01). In the long-term, placebo-controlled study using troglitazone, a...

Impaired Glucose Tolerance Impaired Fasting Glucose Insulin Resistance And Diabetes

Impaired glucose tolerance, impaired fasting glucose, insulin resistance, and diabetes mellitus represent a spectrum of disorders that is associated with an elevated risk of cardiovascular complications. Impaired glucose tolerance, impaired fasting glucose, and insulin resistance are also risk factors for the development of overt diabetes. Importantly, the NCEP ATP III considers diabetes to be a coronary heart disease risk equivalent, conferring the same risk for coronary events as would be observed in a patient with known coronary artery disease33. While diabetes has been a well-established cardiovascular risk factor, impaired glucose tolerance, impaired fasting glucose, and insulin resistance are emerging risk factors that are also associated with the metabolic syndrome as well as the development of overt diabetes. In general, impaired glucose tolerance is determined with an oral glucose tolerance test, impaired fasting glucose is detected by serum glucose after a fast, and insulin...

State Model for Management of Type II Diabetes

The proposed state model is a chronic disease state management system for the continuum of diabetes care. Developed by the Decision Systems Group at the Brigham & Women's Hospital, Boston, USA and the Clinical Knowledge Management Group at Partners HealthCare Systems, Inc., the state model aims to provide integrated care across the entire spectrum of the disease and its complications, and the prevention of comorbidities.

Problems associated with insulin injections

Insulin Injection Site Complications

Many patients develop some blurring of vision soon after starting insulin, which makes reading difficult. This is due to a change of lens refraction, and it corrects itself within two to three weeks. Patients should be advised that this may occur, both to avoid extreme anxiety which they may experience, and to stop the needless purchase of new glasses. Transient oedema of the feet is not uncommon during the first few weeks of insulin treatment. Loading insulin cartridge into pen Loading insulin cartridge into pen Fatty lumps at injection sites are common, and occasionally so large as to be unsightly. Their cause is not known but they sometimes develop if injections are repeatedly given over a very limited area of skin. For this reason it is best to vary the site from day to day. They are rarely troublesome, but once present they tend to persist the occasional very large fatty tumour may even require surgical removal. Furthermore if insulin is repeatedly injected into a fatty lump, the...

Adipocyte Dysfunction And Insulin Resistance

Adipose tissue plays a key role in directing whole-body glucose disposal, although it accounts for only about 10 of insulin-stimulated glucose disposal. There is now substantial evidence that factors that regulate adipocyte function can ultimately lead to insulin sensitization in muscle. Along these lines, the discovery of the peroxisome proliferator-activated receptors (PPARs) in the early 1990s has revolutionized Figure 4.6 CD68+ macrophages in human white adipose tissue. A hypertrophic adipocyte is surrounded by macrophages. Adipose tissue recruits macrophages for reasons that are not entirely clear. However, the local inflammatory milieu is thought to (a) increase adipocyte lipolysis as cytokines downregulate insulin signaling and (b) change the secretion of adipokines such as leptin and adiponectin. Photomicrograph courtesy of Barbara Kozak, PhD Figure 4.6 CD68+ macrophages in human white adipose tissue. A hypertrophic adipocyte is surrounded by macrophages. Adipose tissue...

Medical Treatment Of Insulinomas Diet

The most commonly used and effective drug for the management of hyperinsulinism with hypoglycemia is diazoxide. It is currently primarily used for its diabetogenic action in the treatment of hyperinsulinism. The dose of diazoxide ranges from 300 to 800 mg daily in patients with hyperinsulinism. Diazoxide inhibits insulin secretion by a direct action on beta cells and also by stimulating epinephrine release, which itself further inhibits insulin release. There are unpleasant effects of diazoxide, the most prominent being fluid retention, gastrointestinal irritation, hypertrichosis, and agranulocytosis. Fluid retention can usually be corrected by thiazide diuretics. Despite these associated conditions, dia-zoxide is usually tolerated by most patients and has been helpful both for preoperative management of these patients and for long-term therapy in patients with insulinoma who have unresectable tumors or who are unwilling to undergo surgery. In our medical center, a small number of...

Fasting Test and Insulinto Glucose Ratio

The most useful diagnostic test is the demonstration of fasting hypoglycemia in the face of inappropriately high levels of insulin in the serum. The patient is fasted, and blood samples are obtained every 6 hours or when symptoms develop for blood glucose and insulin measurements. The fast is continued until hypoglycemia or symptoms appear, or for a maximum of 72 hours. One-third of insulinoma patients become hypoglycemic within 12 hours of fasting, 80 within 24 hours, 90 within 48 hours, and 98 within 72 hours. Although insulin levels are not always elevated in patients with insulinoma (normal serum insulin levels are less than 30 mU mL), they will be inappropriately high relative to the blood glucose concentration. A ratio of plasma insulin to glucose greater than 0.3 is diagnostic, as mentioned above (Figure 13-4). Approximately 85 of patients with insulinomas have elevated plasma levels of proinsulin,6 which is particularly helpful when the fasting immunoreactive insulin (IRI) is...

Continuous subcutaneous insulin infusion CSSI

CSSI was introduced 25 years ago by workers at Guy's Hospital in London, and now the development of more reliable and more sophisticated pumps brings distinct advantages in specific indications to approximately 2 to 5 of those with Type 1 diabetes. A small improvement in overall diabetic control compared with optimised injection regimens can be achieved without necessarily aggravating or indeed actually reducing problems from hypoglycaemia. CSSI is not suitable for those with psychological or psychiatric problems.

Local diabetes service advisory groups LDSAGs

Coordination of services by LDSAGs is crucial to their success. Local committees can achieve this very effectively. They should comprise representatives of local purchasing authorities (for example health authorities or primary care trusts), providers (hospital consultants and general practitioners), diabetes specialist nurses, and consumers (diabetic patients). Effective discussions in this group can substantially enhance local services which might otherwise become seriously fragmented.

Pramlintide Antidiabetic [6568

Pramlintide is an injectable human amylin analog that has been launched for the treatment of both type 1 and type 2 diabetes, in conjunction with insulin. While it is also a 37-amino acid peptide, it differs from its parent predecessor by the substitution of Ala-25, Ser-28, and Ser-29 with prolines. Not only do these modifications improve the solubility of the peptide, they also eliminate the aggregation observed with amylin, resulting in a stable synthetic analog with retention of biological activity that is suitable for pharmaceutical use. As an indication of potency, pramlintide inhibits the binding of radioiodinated rat amylin to rat nucleus accumbens membranes with a K value of 23 pM. Its mechanism of action mimics amylin as a neurohormone that is co-secreted with insulin from the pancreatic p cells in response to meals, it is involved in glucose homeostasis. Both peptides lower postprandial glucose levels by inhibiting glucagon and by restraining the vagus-mediated rate of...

Insulin Sensitizers and Pregnancy Outcomes

Although ovulatory dysfunction is an important etiological feature of the infertility of PCOS, ovulation is only one aspect of fertility. In addition to ovulatory problems, women with PCOS suffer a high rate of early pregnancy loss (EPL) during the first trimester (30-50 in PCOS vs 10-15 in normal women) (38-42). It is possible that insulin resistance may contribute to EPL by adversely affecting the endometrial environment and or endometrial function. The effect of metformin on endometrial function has been studied using surrogate markers, such as circulating levels of glycodelin and insulin-like growth factor binding protein-1(IGFBP-1) (43). Glycodelin is secreted by endometrial glands (44,45) to lessen the endometrial immune response against the developing embryo (46,47). Decreased endometrial secretion of glycodelin has been associated with EPL (48,49). IGFBP-1 modulates adhesion processes at the feto maternal interface (50,51) and hence may be important in the peri-implantation...

Insulin dose during illness or infection

You MUST continue to take your normal insulin dose NEVER stop it. You may need an increased dose if your blood tests are bad. If you are vomiting, consult your doctor or the diabetic clinic at once. If you are unable to eat, take your carbohydrate portions in liquid form for example, milk, Lucozade, Ribena

Amylin in Insulin Deficiency

Insulin-deficient animals showed reduction or absence of amylin, whether insulin deficiency was invoked chemically with streptozotocin (Bretherton-Watt et al., 1989 Inman et al., 1990 Jamal et al., 1990 Mulder et al., 1995b, 1996c Ogawa et al., 1990) or by autoimmune b-cell destruction, as with BB rats (Bretherton-Watt et al., 1991 Huang et al., 1991a,b). That is, loss of insulin secretion was associated with loss of amylin secretion. This indicates that any source of amylin that is outside of b-cells (for example, pancreatic d-cells or the gastric antrum) must contribute comparatively little to overall circulating concentrations, or else the disappearance of amylin and insulin following b-cell destruction would be dissimilar. In human type 1 diabetes, pancreatic amylin content was low (Tasaka et al., 1995). Plasma amylin concentrations were described as low (e.g., 0.7 pM, Hartter et al., 1991 1.6 pM, Manley and Hales, 1997) or undetectable (van Hulst et al., 1994), and...

Diabetes associations for patients and health professionals

American Diabetes Association (Patient and Professional), Australian Diabetes Society (Professional), Diabetes UK (Patient and Professional), Tel 0044-20-7424-1000 < www.diabetes.org.uk> Canadian Diabetes Association (Patient and Professional), < www.diabetes.ca> Diabetes Australia (Patient), 1st Floor Churchill House, 218 Northbourne Avenue, Braddon ACT 2612, Australia. < www.diabetesaustralia.com.au> Diabetes New Zealand (Patient), PO Box 54, 1 Conquest Street, Oamaru, New Zealand. < www.diabetes.org.nz> e-mail < info diabetes.org.nz> European Association for Study of Diabetes (Professional), Diabetes Federation of Ireland (Patient), 76 Lower Gardiner Street, Dublin 1, Ireland. Juvenile Diabetes Research Foundation International, Juvenile Diabetes Research Foundation, 19, Angel Gate, London, ECIV 2PT, UK. National Diabetes International Clearing House, New Zealand Society for the Study of Diabetes (Professional), Society for Endocrinology, Metabolism and Diabetes...

Dextrose drip and variable rate insulin infusion

(1) Give normal insulin on the night before the operation (3) Make up a solution of soluble insulin 1 unit ml saline in a syringe and infuse intravenously by a line piggybacked to the intravenous drip by using a syringe pump. The infusion rate should normally be as shown in regimen 1, but in resistant cases use regimen 2 or 3 Soluble insulin infusion rate Do not stop the insulin infusion since intravenous insulin lasts for only a few minutes Only if the patient becomes frankly hypoglycaemic (blood glucose < 2-0 mmol l) should insulin be stopped for up to 30 minutes

Insulin as an Autoantigen

It is well established that therapeutic injection of insulin into type 1 diabetic patients leads to the generation of insulin antibodies in rare cases, such an immune response can lead to immunological insulin resistance. Type 1 diabetes is also associated with the appearance of insulin antibodies before clinical diagnosis and prior to initiation of insulin treatment 46 . Levels of antibodies detected after initiation of insulin treatment do not correlate with those detected at disease onset, so the response to the exogenous insulin is independent of the autoimmune response 52 . Insulin has also been shown to be a target of circulating natural autoantibodies that are generally of low affinity, often polyreactive, and that may play a role in immune regulation. Insulin can therefore be a target of immunity in a range of circumstances, and not all antibody responses are diabetes-associated. Insulin autoantibodies (IAAs) are commonly detected in diabetic patients who are young at the time...

Chronic Therapy in PCOS with Insulin Sensitizers

Both metformin and the thiazolidinediones have been shown to reduce blood pressure and inflammatory markers. Obese women on metformin also tend to lose weight while on metformin in a dose-dependent manner (63). Although the insulin sensitizers' effects on cardiovascular risk factors are favorable, currently there are no prospective randomized outcome trials examining the use of insulin sensitizers in the prevention of diabetes or cardiovascular events in women with PCOS. 2.3.2.1. Insulin Sensitizers in Preventing Type 2 Diabetes Mellitus Although not specifically conducted in women with PCOS, there are several outcome studies indicating that interventions to improve insulin sensitivity may decrease the incidence of diabetes in individuals at high risk. The Diabetes Prevention Project was a prospective study sponsored by the National Institutes of Health (64). The study included 3234 patients at high risk of diabetes (history of gestational diabetes or presence of impaired glucose...

WHO criteria for the diagnosis of diabetes

1 Symptoms of diabetes plus casual venous plasma glucose & 11-1 mmol l. Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss Fasting plasma glucose & 7-0 mmol l provisional diagnosis of diabetes the diagnosis must be confirmed (see above) Adapted from Diabetes Care 1997 20 1183-1195 Gestational diabetes This term embraces the criteria for both diabetes and impaired glucose tolerance when discovered during pregnancy (see page 80).

Insulin Sensitizing Agents

Insulin resistance with compensatory hyperinsulinemia is a prominent feature of PCOS diagnosed in both lean and obese patients (see Chapter 24). The exact mechanisms for abnormalities of insulin action in the syndrome have yet to be elucidated (65). However, hyperinsulinemia has been show to increase ovarian androgen biosynthesis (66) and decrease hepatic synthesis of SHBG (67), leading to increased bioavailability of free androgens. The increase in local ovarian androgen production mediated by hyperinsulinemia can also result in premature follicular atresia and anovulation (68). The strong association between PCOS and insulin resistance and the role of hyperinsulinemia in hyperandrogenism and disrupted folliculogenesis provide the rationale for the use of insulin sensitizers in the treatment of the syndrome. It seems logical that the therapeutic interventions directed at increasing insulin sensitivity, thereby decreasing hyperinsulinemia, would ameliorate the hyperandrogenism and...

Insulin injection sites

Insulin for routine treatment is given subcutaneously by intermittent injections or by continuous infusion. Insulin can be injected subcutaneously almost anywhere if there is enough flesh. The best site is the front of the thigh. The lower abdominal wall, buttocks, and upper arms may also be used. Patients who want to wear sleeveless clothes should normally avoid using the arms in case unsightly marks or fat hypertrophy should appear some may then prefer to confine injections to the lower abdomen. It is important to vary the injection sites from day to day, using for example, each thigh alternately over as wide an area as possible. Absorption of insulin varies from one site to another, being most rapid from the abdominal site, and less rapid from the arms and least from the legs. If there are any difficulties with control it is advisable to use one area consistently for example, the thigh. In diabetic emergencies soluble insulin is given intravenously, or occasionally intramuscularly...

Amyloid and Association with Diabetes

The time course of the appearance of pancreatic amyloid mirrors the appearance of clinical diabetes (Ohsawa et al., 1992). A relatively restricted number of mammalian species exhibit a propensity to form amyloid in pancreatic islets these are the same species that are susceptible to type 2 diabetes. In addition to humans (Westermark, 1972) and macaque monkeys (Clark et al., 1991 de Koning et al., 1993 Howard, 1988), islet amyloid is found in domestic cats (Betsholtz et al., 1990 Westermark et al., 1987b) as well as in tigers, lions, lynx, raccoons (Jakob, 1970), and cougars (Johnson et al., 1991b). It is not found in islets of dogs or other members of the Canidae (wolf, jackal, fox) (Jakob, 1970). Except for Octodon degu, which is a special case (Hellman et al., 1990), amyloid is not found in the islets of rodents. However, human islets transplanted into mice form amyloid (Westermark etal., 1995), suggesting that it is a species-specific characteristic of the peptide itself that leads...

Inhibition of Insulin Secretion

Reports of the effects of amylin and amylin agonists on insulin secretion have varied widely. Some confusion can be attributed to the use of human amylin, which has been shown to readily fall out of solution resulting in low estimates of bioactivity. Some confusion can be resolved by assessing the probability that this had happened. The view taken here, supported by authors using reliable and well-characterized ligands (representing the preponderance of recent studies), is that exogenously administered amylin agonists inhibit insulin secretion, at least partly via activation of an amylin-like receptor linked to Gi-mediated inhibition of cAMP in islets. There may additionally be autonomic extrapancreatic effects of amylin on insulin secretion that derive from its action at the area postrema. Studies with amylin receptor antagonists, including human studies, indicate that endogenously secreted amylin may physiologically inhibit b-cell secretion (insulin and amylin) via feedback...

Types of diabetes

Type 1 diabetes (previously insulin dependent diabetes) is due to B-cell destruction, usually leading to absolute insulin deficiency). It can be immune mediated or idiopathic. Type 2 diabetes (previously non-insulin dependent diabetes) ranges from those with predominant insulin resistance associated with relative insulin deficiency, to those with a predominantly insulin secretory defect with insulin resistance. Type 1 and Type 2 diabetes are the commonest forms of primary diabetes mellitus. The division is important both clinically in assessing the need for treatment, and also in understanding the causes of diabetes which are entirely different in the two groups.

Type 1 diabetes

Type 1 diabetes is due to destruction of B-cells in the pancreatic islets of Langerhans with resulting loss of insulin production. A combination of environmental and genetic factors that trigger an autoimmune attack on the B-cells is responsible, occurring in genetically susceptible individuals. Thus, among monozygotic identical twins only about one-third of the pairs are concordant for diabetes in contrast to the situation in Type 2 diabetes where almost all pairs are concordant. The process of islet destruction probably begins very early in life and is known to start several years before the clinical onset of diabetes. The major histocompatibility complex antigens are adjuncts to several types of immunological activity. Ninety percent of Type 1 diabetic patients show either DR3 or DR4, or both together, while DR2 is protective against diabetes. Islet cell antibodies are present at diagnosis in most Type 1 diabetic patients and gradually decline and disappear during the following...

Type 2 diabetes

There are numerous causes of Type 2 diabetes, which is now known to include a wide range of disorders with differing progression and outlook. The underlying mechanism is due either to diminished insulin secretion that is, an islet defect, associated with increased peripheral resistance to the action of insulin resulting in decreased peripheral glucose uptake, or increased hepatic glucose output. Probably as many as 98 of Type 2 diabetic patients are idiopathic that is, no specific causative defect has been identified. Whether decreasing insulin secretion or increasing insulin resistance occurs first is still uncertain, but the sequence of events may vary in different individuals. Obesity is the commonest cause of insulin resistance. Other rare insulin resistant states are shown in the table. Some adults (especially those not overweight) over 25 years of age who appear to present with Type 2 diabetes may have latent autoimmune diabetes of adulthood (LADA) and become insulin dependent....

Insulin

Insulin should be given by continuous infusion. The initial dose is 0-1 units kg hour. Once the blood sugar falls to less than 10 mmol l, glucose must be added to the IV. Do not stop using insulin. This is the child's prime requirement. Administer the insulin by separate line. Add 25 units of soluble insulin to 50 ml saline. This solution is 0.5 unit ml 0-1 units kg hour is equal to 0-05 x weight in kg, as ml hour. Thus a 20-kg child would have 2 ml hour, a 35 kg child 3-5 ml hour. This often needs decreasing when blood sugar starts to fall. In a very young diabetic (under 5 years), start with the smaller dose.

Diabetic nephropathy

The development of proteinuria in any diabetic patient is ominous. It is associated with a risk of severe retinopathy and neuropathy, and above all carries a major increased risk in mortality from coronary artery disease, as well as progression to renal failure in some patients. Yet developments in this field to improve the prognosis have been substantial. The overall prevalence of proteinuria in Type 1 diabetes has decreased over half a century from more than 50 of patients down to between 10 and 20 , presumably as a result of better overall diabetic care. Furthermore, at the earliest sign of proteinuria, administration of medication and very tight blood pressure control ameliorate the course of the disease and substantially delay the development of renal failure. And for those who are less fortunate, transplantation and dialysis restore a good quality of life to the majority. Proteinuria occurs in both Type 1 diabetes and Type 2 diabetes. African-Caribbean and Asian Type 2 diabetic...

Diabetes Mellitus

Diabetes mellitus is a metabolic syndrome characterized by chronic hyperglycemia due to insulin deficiency, insulin resistance or both. Diabetes is a chronic illness that requires long-term continuing medical care and patient self-management education in order to reduce the risk of acute complications. Diabetic patients can have a reasonably normal lifestyle if they comply with the appropriate medical and educational guidelines aimed to maintain healthy blood glucose levels and reduce the likelihood and progression of adverse macrovascular complications, e.g., CAD, stroke, and peripheral vascular disease and microvascular complications, e.g., retinopathy, nephropathy, and neuropathy. Noninsulin-dependent diabetes mellitus or type II diabetes is relatively common in all populations, with higher prevalence rates in people of African, Caribbean, Native American, Latino, and South Asian ancestry. Type II diabetes and its concomitant complications require comprehensive models for...

Diabetes

Diabetes22 is any metabolic disorder exhibiting chronic polyuria. There are at least five forms of diabetes diabetes mellitus type I and type II, gestational diabetes, renal diabetes, and diabetes insipidus. In most cases, the polyuria results from a high concentration of glucose in the renal tubule. Glucose opposes the osmotic reabsorption of water, so more water is passed in the urine (osmotic diuresis) and a person may become severely dehydrated. In diabetes mellitus and gestational diabetes, the high glucose concentration in the tubule is a result of hyperglycemia, a high concentration of glucose in the blood. About 1 to 3 of pregnant women experience gestational diabetes, in which pregnancy reduces the mother's insulin sensitivity, resulting in hyperglycemia and glycosuria. In renal diabetes, blood glucose level is not elevated, but there is a hereditary deficiency of glucose transporters in the PCT, which causes glucose to remain in the tubular fluid. Diabetes insipidus results...

Iatrogenic Diabetes

Diabetes following surgical removal of the pancreas for organic diseases is one other possible indication for (3-cell replacement. Total pancreatectomy performed to relieve the pain associated with chronic pancreatitis invariably results in insulin-dependent diabetes. Approximately 50 of the patients develop diabetes within 5 to 10 years from onset of chronic pancreatitis, even in the absence of surgery. After surgery, one of the main reasons for hospital readmission is poor management of diabetes mellitus in these patients, suggesting the importance of preserving endocrine function by (-cell replacement. Additional causes of iatrogenic diabetes that could benefit of (-cell transplantation include total pancreatectomy following trauma or benign neoplasm. Diabetes can also be associated with metabolic disorders. A proportion of patients affected by cystic fibrosis (CF) may develop diabetes, and its development appears to have substantial impact on pulmonary function and significantly...

Insulin Resistance

IR is the underlying cause of type 2 diabetes. IR is an abnormal physiologic state that may exist for decades before diabetes becomes clinically evident because of increased glucose levels. Improving insulin sensitivity, ideally before the development of glucose intolerance, is a newer approach to the prevention and treatment of type 2 diabetes. One large trial in patients with diabetes comparing a pharmacological approach (metformin) with aggressive changes in lifestyle found that increasing physical activity may improve insulin sensitivity more than the drug would (Knowler et al, 2002). Because IR may be the most common predisposing factor for the development of NAFLD, these findings in the diabetic and prediabetic populations may be equally relevant to people with fatty liver.

Diabetes UK

The central resources of Diabetes UK provide direct advice for both patients and health professionals by printed literature, and access to scientific and epidemiological information. Diabetes UK also funds research, and provides scientific and educational meetings, children's camps, family weekends, and many other activities. Local branches of Diabetes UK, organised by people with diabetes, serve as self help and fundraising groups, as well as helping to maintain high quality local services. Diabetes UK is at 10 Parkway, London NW1 7AA telephone 020-7424-1000 < www.diabetes.org.uk>

Lipids and diabetes

Hyperlipidaemias also commonly exist in those with diabetes and increase still further the risk of ischaemic heart disease, especially in Type 2 diabetes. Detection and control of hyperlipidaemia can effectively reduce MI, coronary deaths and overall mortality. Indeed, even when low density lipoprotein (LDL) cholesterol is normal or even slightly raised in Type 2 diabetes (the major abnormalities being low HDL cholesterol and high triglyceride) the LDL particles may be qualitatively different and more atherogenic.

Diabetes Management

Motivated by the need of standards of care intended to provide clinicians and patients with the key components of diabetes care, the American Diabetes Association has published a series of recommendations focused on diagnostic and therapeutic actions believed to favorably affect the outcomes of patients with diabetes. Their recommendations include the criteria for diagnosis of type II diabetes in nonpregnant adults regular and targeted screening of asymptomatic adults, particularly those individuals at high risk criteria for a complete initial evaluation of newly diagnosed patients and customized long-term management. Long-term management includes a variety of strategies and techniques aimed at providing adequate glycaemic and lipid control prevention of complications support for lifestyle changes, e.g., physical activity, diet, smoking cessation routine follow-up, and immunization 8 .

Insulin mixtures

These are all mixtures of a short acting soluble insulin (or very short acting insulin analogue) with a medium acting isophane insulin (or insulin analogue). The number after the insulin name indicates the percentage of the short acting insulin, for example, 30 or M3 indicates 30 soluble insulin mixed with 70 isophane insulin.

Selection of insulin

The choice of insulin preparation is based on the duration of action. Although insulins can be broadly classified as having very short, short, medium or long duration of action, their effect varies considerably from one patient to another and can be discovered in the individual patient only by trial and error. There are several preparations of medium acting insulins, but those most often used are either one of the isophane preparations or less frequently Human Monotard zinc insulin preparation (see box on page 19). Most patients (85 ) now use insulin of human sequence, a few prefer porcine preparations, while use of some insulin Some insulins

Insulinoma

Less than 10 of patients with MEN type I have an insulinoma, and less than 10 of patients with insulinomas have MEN type I.20,21 The median age of onset is in the third decade. There is a 1 to 1 male-to-female ratio. In MEN type I, approximately 80 are associated with multifocal islet disease.22 Although the insulin-producing tumor may be one of several islet cell tumors in the patient, the tumor that is making the insulin is usually solitary and relatively large, on the order of 2 to 4 cm. Patients usually present with symptoms of neuroglycopenia during fasting hypoglycemia (< 40 mg dL). The diagnosis is made by documenting hypoglycemia in association with inappropriately increased plasma levels of insulin and C peptide during a prolonged fast. Other causes of hypoglycemia include medications (insulin, sul-fonylureas), liver dysfunction, renal failure, wasting, and growth hormone (GH) deficiency. Once a diagnosis is made, preparations for surgical approach by preoperative...

Insulin glargine

This is a new prolonged action, soluble insulin analogue (clear solution) forming a microprecipitate after subcutaneous injection. Its onset of action is after about 90 minutes, it has a prolonged plateau rather than a peak, and lasts 24 hours or more. Thus it mimics more closely the basal insulin secretion of healthy people. When taken at bedtime it reduces the incidence of nocturnal hypoglycaemia, and also reduces the prebreakfast hyperglycaemia. It does not appear to reduce symptomatic or severe hypoglycaemia during the day, and there is no significant beneficial effect on overall diabetic control. More extensive clinical experience in using this insulin is still needed.

Insulin treatment

An Ethiopian villager, after starting insulin. The astonishing power of insulin to restore health and well-being to rapidly deteriorating newly diagnosed Type 1 diabetic patients is as remarkable now as it was in 1922. After Banting gave insulin to Elizabeth Hughes in that year, she wrote to her mother that it is simply too wonderful for words this stuff. Insulin to this day always has this effect the challenge now is to optimise control in order to maintain health throughout life. Insulin is also needed to enhance well-being and control in many Type 2 diabetic patients when the natural progression of their disease has lead to loss of optimal control. The potential to reduce the development of long-term diabetic complications as demonstrated by the UKPDS (see page 42) has led to a recent explosion in conversions from tablets to insulin. The difficult decisions which surround the need for insulin in this situation, together with benefits, uses and misuses of insulin have been described...

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Supplements For Diabetics

Supplements For Diabetics

All you need is a proper diet of fresh fruits and vegetables and get plenty of exercise and you'll be fine. Ever heard those words from your doctor? If that's all heshe recommends then you're missing out an important ingredient for health that he's not telling you. Fact is that you can adhere to the strictest diet, watch everything you eat and get the exercise of amarathon runner and still come down with diabetic complications. Diet, exercise and standard drug treatments simply aren't enough to help keep your diabetes under control.

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