Home Remedies for Hyperglycemia

Blood Sugar Miracle

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Blood Sugar Miracle Overview

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HyperglycemiaDRG CategoT 463

I I yperglycemia exists when the blood glucose level is greater than 110 mg dL. Normal blood glucose levels can be maintained between 70 and 110 mg dL when there is an adequate balance between insulin supply and demand. In acutely ill individuals, hyperglycemia is usually not diagnosed until a random test of serum glucose level shows an increase above the 150 to 200 mg dL range. Glucose is the most important carbohydrate in body metabolism. It is formed from the breakdown of polysaccharides, especially starch, and is absorbed from the intestines 440 Hyperglycemia Insulin is produced by the beta cells of the pancreas, which are stimulated to release it when the blood glucose level rises. Insulin transports glucose, amino acids, potassium, and phosphate across the cell membrane. Insufficient production or ineffective use of insulin causes an elevated blood glucose level (hyperglycemia), which promotes water movement into the bloodstream from the interstitial space and intracellular...

Hyperglycemia

Hyperglycemia has been shown to be the main cause of microvascular complications in the DCCT (11) and UKPDS study (12). For cardiovascular complications, the contribution of hyperglycemia is probably also significant. Several biochemical mechanisms appear to explain the adverse effects of hyperglycemia on vascular cells (Table 3). This is not surprising because the metabolism of glucose and its metabolites can affect multiple cellular pathways. Glucose is transported into the vascular cells mostly by GLUT-1 transporters, which can be regulated by extracellular glucose concentration and other physiological stimulators, such as hypoxia (40). Once glucose is transported, it is metabolized to alter signal transduction pathways, such as the activation of diacylglycerol (DAG) and protein kinase C (PKC), or to increase flux through the mitochondria to change the redox potential (41-44). Lastly, another metabolic pathway (such as that of aldose reductase), which is normally inactive, can be...

Electrolyte Abnormalities Sodium

Hypernatremia (> 150 mEq L) results from a total sodium excess or relative fluid loss. This can be from prolonged administration of excess sodium or excessive loss of free water. Hyperglycemia can also act as an osmotic diuretic increasing free water loss. Drugs such as amphoteracin B, methicillin and gentamicin can cause a nephro-genic diabetes and subsequent free water loss.

Understanding the Genetic Basis of Complex Traits Quantitative Trait Loci QTL Analysis

While most of the approaches discussed thus far are extremely useful in identifying and characterizing the role of genes in vivo, they are of limited use in determining the genetic basis of phenotypes that are determined by the interaction of a number of genes (epistasis). Quantitative trait loci (QTL) mapping is a technique used to identify chromosomal regions that contribute to such multigenic phenotypes. This approach takes advantage of naturally occurring genetic variations (e.g., in strains of mice). Once a phenotype of interest is selected, these mice are then crossed to map the association of the chosen trait(s) to chromosomal markers throughout the genome. For example, Plum and co-workers performed QTL mapping on an inbred obese mouse strain (New Zealand) with a high incidence of diabetes.152 They performed iterative matings with these mice and a lean inbred strain (SJL), and monitored levels of blood sugar in successive generations. Using statistical analysis, they were able...

Reduced Side Effect Liability

Current pharmacological approaches to the treatment of schizophrenia suffer from two major issues side effects and limited efficacy. The first major unmet medical need is improved side effect liability. Even the best of the modern atypical antipsychotics produce significant side effects with a low therapeutic index. Individuals with schizophrenia have an increased risk of death and, in general a 20 shorter life span84,85 that, in part, may be attributable to the use of current antipsychotic medications. As discussed above, atypical antipsychotics have a clear lower risk of inducing EPS and hyperprolactinemia (with the exception of risperidone) when compared to typical antipsychotics, but the risk still exists. Furthermore, several atypicals, particularly clozapine and olanzapine, increase the risk of sedation, obesity, high blood sugar and diabetes, and dyslipidemia. Very rare cases of neuroleptic malignant syndrome, a rare but potentially fatal reaction characterized by fever,...

Primary Nursing Diagnosis

The treatment prescribed is based on the acuity and severity of the symptoms. Some patients are treated pharmacologically with corticosteroids to relieve edema and analgesics to manage joint and GI discomfort. Allergy testing to identify the provocative allergen is usually performed. If the allergen is a food or medication, the patient needs to avoid ingesting the allergen for the rest of his or her life. Patients who are placed on corticosteroids or immunosuppressive therapy need an environment that protects them as much as possible from secondary infection. If the patient is on corticosteroids, monitor her or him for signs of Cushing's syndrome and the complications of corticosteroids, such as labile emotions, fluid retention, hyperglycemia, and osteoporosis.

Drug Interactions

Epinephrine l Effect of insulin due to epinephrine-induced hyper-glycemia Oxytetracycline T Effect of insulin Phenothiazines T Dosage of anti-diabetic due to phenothiazine-induced hyperglycemia Phenytoin Phenytoin-induced hy-perglycemia l diabetic control Salicylates T Effect of hypoglyce-mic effect of insulin Sulfinpyrazone T Hypoglycemic effect of insulin

Dehydroepiandrosterone DHEA

Polypeptide hormone synthesized in the A cells of the islets of Langerhans that inhibits the secretion of insulin and glucagons. It causes hyperglycemia, slows gastric emptying, decreases gastric acid secretion. Somatostatin inhibits CCK secretion leading to gallstones in patients with somatostatin secreting pancreatic tumors.

Advance Glycation End Products

Extended exposure of proteins to hyperglycemia can result in nonenzymatic reactions, in which the condensation of glucose with primary amines forms Schiff bases. These products can rearrange to form Amadori products and advanced glycation end-products (AGE). The glycation process occurs both intracellularly and extracellularly. It has been reported that the glycation modification target to intracellular signaling molecules and extracellular structure proteins alike, and furthermore, alter cellular functions. Multiple forms of proteins subjected to glycation have been identified with W -(carboxymethyl)lysine (CML), pentosidine, and pyralline being the major form of AGEs presented in diabetic states.

Activation of the Polyol Pathway

Increased activity of the polyol pathway has been documented in culture studies using vascular cells exposed to diabetic level of D-glucose and in animals with diabetes (58,59). In these studies, hyperglycemia has been shown to increase the activity of aldose reduc-tase and enhances the reduction of glucose to sorbitol, then further oxidized to fructose by sorbitol dehydrogenase. Abnormality in the polyol pathway has been suggested to cause vascular damage in the following ways (a) osmotic damage by the accumulation of sorbitol (58) (b) induction of oxidative stress by increasing nicotinamide adenine dinucleotide phosphate (NADP) NAD+ ratio and the activation of Na+ K+ adenosine triphosphate (ATP)ase (59) and (c) reduction of NO in the vasculature by decreasing cellular NADPH, a cofactor used by aldose reductase to reduce glucose to sorbitol (60). Multiple studies have shown that inhibition of aldose reductase, the key enzyme in the

Activation of the Dagpkc Pathway

DAG can be generated from multiple pathways. Agonist-induced formation of DAG depends mainly on hydrolysis of phosphatidylinositol by phospholipase C (84). However, this mechanism is most likely minimally involved in diabetes, because inositol phosphate products were not found to be increased by hyperglycemia in aortic cells and glomerular mesangial cells (85,86). When the fatty acids in DAG were analyzed (87), DAG induced by high-glucose condition has predominantly palpitate- and oleic- acid-enriched composition, whereas DAG generated from hydrolysis of phosphatidylinositol has the composition of 1-stearoly-2-arachidonyl-5N-glycerol (88). In labeling studies using 6-3H - or U-14C - glucose, we have shown that elevated glucose increase the incorporation of glucose into the glycerol backbone of DAG in aortic endothelial cells (87), aortic SMCs (89), and renal glomeruli (90). These facts indicate that the increased DAG levels in high-glucose condition are mainly derived from the de novo...

Vascular Contractility and Blood Flow

Abnormalities in hemodynamic have been documented to precede diabetic nephropa-thy. Elevated renal glomerular filtration rate and modest increases in renal blood flow are characteristic finding in IDDM patients and experimental diabetic animals with poor glycemic control (128-131). Diabetic glomerular filtration is likely to be the result of hyperglycemia-induced decreases in arteriolar resistance, especially at the level of afferent arteriole, resulting in an elevation of glomerular filtration pressure. This effect of hyperglycemia can be mimicked in vitro by incubating renal mesangial cells with elevated glucose levels that reduced cellular response to vasoconstriction. Several reports have suggested that the activation of PKC via the induction of prostaglandins may involve in this adverse effects of hyperglycemia (132,133).

Vascular Permeability and Neovascularization

Increased vascular permeability is another characteristic vascular abnormality in diabetic patients and animals, in which increased permeability can occur at as early as 4-6 weeks' duration of diabetes, suggesting endothelial cell dysfunctions (139). Because the vascular barrier is formed by tight junctions between endothelial cells, the increase in permeability as a result of the abnormalities in the endothelial cells. The activation PKC can directly increase the permeability of albumin and other macromolecules through barriers formed by endothelial cells, probably by phosphorylating the cytoskeletal proteins forming the intercellular junctions (140-142). Recently, PKC- 1 overexpression in human dermal microvascular endothelial cells has been reported to enhance phorbol ester-induced increase in permeability to albumin (143). Thus, the actions of phorbol ester and hyperglycemia in endothelial-barrier functions are mediated in part through activation of PKC- 1 isoform.

Basement Membrane Thickening and Extracellular Matrix Expansion

Histologically, increases in type IV and VI collagen, fibronectin and laminin and decreases in proteoglycans are observed in the mesangium of diabetic patients with nephropathy and probably in the vascular endothelium in general (152,153). These effects can be replicated in mesangial cells incubated in increasing glucose levels that were prevented general PKC inhibitors (154-156). Additionally, increased expression of transforming growth factor (TGF)- P has been implicated in the development of mesangial expansion and basement membrane thickening in diabetes. Because PKC activation can increase the production of ECM and TGF-P, it is not surprising that several reports have shown that PKC inhibitors can also prevent hyperglycemia- or diabetes-induced increases in ECM and TGF-P in mesangial cells or renal glomeruli (98).

Melpomeni Peppa md Jaime Uribarri md and Helen Vlassara md

Two landmark clinical studies, the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study, showed that intensive control of hyperglycemia could reduce the occurrence or progression of retinopathy, neuropathy and nephropathy in patients with type 1 and type 2 diabetes (2,3). Although these studies reinforce the important role of hyperglycemia in the pathogenesis of diabetic complica- tions, the identification of the mechanisms by which hyperglycemia exerts these effects remains limited (4). It is well known that long-term hyperglycemia leads to the formation of advanced glycation or glycoxidation end-products (AGEs), which mediate most of the deleterious effects of hyperglycemia and seem to play a significant role in the pathogenesis of diabetic complications (5,6). AGEs, together with the interrelated processes of oxidative stress and inflammation, may account for many of the complications of diabetes (5,6). Evidence for this emerges not only...

Advanced glycoxidation endproducts metabolism

Other intracellular protective systems also help to limit the accumulation of reactive AGE intermediates. Methylglyoxal is first converted by glyoxalase-I to S-D-lacto-ylglutathione in the presence of reduced glutathione as an essential cofactor, and then converted to D-lactate by glyoxalase-II. The significance of such systems is supported by studies in which overexpression of glyoxalase-I prevented hyperglycemia-induced AGE formation and increased macromolecular endocytosis (47). These systems, however, could still be overwhelmed by high AGE conditions such as diabetes, renal failure, or sustained excess dietary AGE intake.

The Assessment of Care Quiz

If you do have protein or glucose in your urine that was not previously recognized, you may need to consult your doctor. But note that the transient appearance of protein in the urine can also be caused by vigorous exercise, infection, fever, or very high blood sugar. You may want to check it again before you consult your doctor.

Role of the reninangiotensin system in cardiovascular disease in diabetes

As reviewed elsewhere in this book, multiple factors, including hyperglycemia, insulin resistance, dyslipidemia, hypercoagulability, and inflammation contribute to the pathogenesis of atherosclerosis in DM. Although there is considerable evidence for a role of the RAS in vascular remodeling, inflammation, thrombosis, and atherogeneis (81-83), the role of this system in atherosclerosis in the context of the other diabetes-associated cardiovascular risk factors is not fully understood. There is a growing body of evidence from both clinical studies and experiments in diabetic rodent models suggesting that the RAS contributes to CVD in both type 1 and type 2 diabetes.

Factors that influence the development of nephropathy

Whether nephropathy ever develops and how rapidly it progresses vary immensely from patient to patient. For some, the risk of kidney damage increases with the duration of diabetes, but the risk does fall when the diabetes is continuously well controlled. For others, however, hereditary factors are also important. Even among those who have high blood sugar levels for years, there are some people who never develop nephropathy. On the other hand, there are people with fairly good diabetes control who nevertheless develop kidney damage. We know that children from families with diabetes in which one member already has a renal problem have a much higher risk, from the onset, of developing nephropathy. Unfortunately, there is as yet no definite known marker in the blood or the urine that can predict the risk of developing nephropathy for an individual patient. This would naturally be a great help, as patients at higher risk could then be managed much more intensively.

Gender Ethnicracial And Life Span Considerations

When assessing vital signs, you may note hypertension, a common complication in diabetic patients. Palpate the peripheral pulses to determine their strength, regularity, and symmetry. During the neurological examination, use an ophthalmoscope to evaluate the patient for retinopathy or cataracts. Assess the patient for any signs and symptoms of hypoglycemia or hyperglycemia (Table 2).

Acute vs Chronic Amphetamine Toxicity

Labs Hyperglycemia, leukocytosis, elevated liver function tests (LFTs), elevated creatine phosphokinase (CPK) from rhabdomyolysis with myoglobinuria. False-positive urine drug screens may result from ephedrine, pseudoephedrine, or phenylpropanolamine (PPA), often found in over-the-counter (OTC) cold medications.

Postprandial Glucose Response

Consumption of foods with a high glycemic index and a low dietary fiber content has been listed among the causes of insulin resistance (29). Insulin resistance occurs when high blood concentrations of insulin do not decrease hyperglycemia efficiently. The extended hyperglycemic periods continue to stimulate insulin secretion. These conditions may lead to NIDDM or type II diabetes) (29).

How to test urine for microalbuminuria

For people with Type 2 diabetes, the tests are best begun at the time of diagnosis of the diabetes, because many of these patients have already had high blood sugar levels for years, without knowing about it (Table 3.3). 4.1 The benefits of good blood sugar control Although the risk of developing diabetic kidney disease is partially determined by your genetic make-up, the onset of the disease can be prevented or at least postponed for a long time by good blood sugar control. This was demonstrated for patients with both Type 1 and Type 2 diabetes by two major trials that were published in the 1990s. With good blood sugar control, microalbuminuria seldom arises With good blood sugar control, microalbuminuria seldom arises There were some patients in the intensive group in the trial who, despite all efforts, did not achieve good blood sugar control (the HbAlc value of 7 was an average taken over the nine years of observation). This explains why diabetic kidney disease did develop in this...

Mechanisms responsible for hyperreactivity of platelets in people with diabetes

We have found that the osmotic effect of increased concentrations of glucose increase directly platelet reactivity (59). Exposure of platelets in vitro to increased concentrations of glucose is associated with increased activation of platelets in the absence and presence of added agonist. Exposure of platelets to isotonic concentrations of glucose or mannitol increases platelet reactivity to a similar extent (59). Thus, the osmotic effect of hyperglycemia on platelet reactivity may contribute to the greater risk of death and reinfarction that has been associated with hyperglycemia in patients with diabetes and MI (60-62).

Antiplatelet therapy and diabetes

Considered together, data acquired in vitro and in vivo suggest that platelets from subjects with diabetes are hypersensitive to diverse agonists. Unfortunately, currently available antiplatelet therapy does not restore normal responsiveness to platelets from subjects with diabetes. In animal preparations simulating selected aspects of diabetes, platelets remain hypersensitive to thrombin despite administration of aspirin (67). This observation suggests that the hypersensitivity is not a reflection of generation of thromboxane A2, and that the treatment of subjects with diabetes with aspirin (as is being done often inferentially) is unlikely to decrease platelet reactivity to the level typical of that seen with platelets from nondiabetic subjects. Because hyperglycemia per se appears to increase platelet reactivity, improved glycemic control is a critical component of the anti-thrombotic regimen.

Mechanisms responsible for a prothrombotic state associated with diabetes

Decreased activity of anti-thrombotic factors in blood can potentiate thrombosis. Of note, concentrations in blood of protein C and activity of anti-thrombin are decreased in diabetic subjects (88-91), although not universally (75). Unlike changes in concentrations of prothrombotic factors, altered concentrations and activity of anti-thrombotic factors appear to be reflections of the metabolic state typical of diabetes, either type 1 or type 2, especially hyperglycemia. Thus, decreased anti-thrombotic activity has been associated with nonenzymatic glycation of anti-thrombin. To recapitulate, functional activity of the prothrombinase complex and of thrombin itself are increased consistently in blood of people with diabetes. The increased activity is likely to be a reflection of increased procoagulant activity of platelets and monocytes in association with increased concentrations of fibrinogen, von Willebrand factor , and factor VII. Diminished activity in blood of anti-thrombotic...

Mechanisms responsible for the overexpression of pai1 in diabetes

A combination ofhyperinsulinemia, hypertriglyceridemia, and hyperglycemia increases the concentration of PAI-1 in blood in normal subjects (99). Although neither the infusion of insulin with euglycemia maintained by euglycemic clamping nor the infusion of triglycerides without induction of hyperinsulinemia in normal subjects increases the concentration of PAI-1 in blood, the induction of hyperglycemia, hypertriglyceridemia, and hyperinsulinemia by infusion of glucose plus emulsified triglycerides plus heparin (to elevate blood FFAs) does increase concentrations of PAI-1 in blood. Of note, the infusion of insulin under euglycemic clamp conditions results in a marked decrease in the concentration of blood triglycerides and FFAs. Thus, results of the infusion studies demonstrate that the combination of hyperinsulinemia, hyperglycemia, and hypertriglyceridemia is sufficient to increase expression of PAI-1 in healthy subjects. However, results in these studies do not answer the question of...

Therapeutic implications

Consideration of the derangements in platelet function, the coagulation system, and the fibrinolytic system and their contributions to exacerbation of macrovascular disease in type 2 diabetes gives rise to several therapeutic approaches. Empirical use of aspirin (160-325 mg per day in a single dose) seems appropriate in view of the high likelihood that covert CAD is present even in asymptomatic people with type 2 diabetes and the compelling evidence that prophylactic aspirin reduces the risk of heart attack when CAD is extant. Because many of the derangements contributing to a prothrombotic state in diabetes are caused by hyperglycemia, rigorous glycemic control is essential. Accordingly, the use of diet, exercise, oral hypoglycemic agents, insulin sensitizers, and if necessary insulin itself is appropriate to lower HbA1c to 7 . Because other derangements contributing to a prothrombotic state such as attenuation of fibrinolysis appear to be related to insulin resistance and...

Is there a threshold above which the risk noticeably increases

The answer is the lower the HbAlc concentration, the lower the risk of microalbuminuria Neither the DCCT nor the UKPDS could establish a threshold at which the risk either rose or fell significantly. This relationship was the same for both groups, whether treated intensively or conventionally. This means that someone who can achieve good blood sugar control by conventional treatment is equally well protected as someone who is treated intensively (see Figure 4.2).

Therapy and prophylaxis

Pentamidine is an alternative in patients who have adverse reactions or fail to respond to TMP-SMX. The dosage is 4 mg kg day IV for 14-21 days. Adverse effects include anemia (33 ), creatinine elevation (60 ), LFT elevation (63 ), and hyponatremia (56 ). Pancreatitis, hypo-glycemia, and hyperglycemia are common side effects.

Rosy periwinkle Catharanthus roseus Apocynaceae

In Madagascar the plant is widespread, reflecting its multiple uses in herbal treatments. The striking floral display of the plant has promoted its spread around the world and has led to variations in its medicinal applications. By the early 20th century it was being used as an oral hypoglycemic agent (to lower blood sugar levels) in South Africa, southern Europe, and the Philippines to treat diabetic ulcers in the West Indies and to control hemorrhages and scurvy in Brazil. The role

Benefits of Glycemic Control

Glycemic control is critical to the prevention of diabetic complications. The duration and severity of hyperglycemia correlates with both the development and rate of progression of diabetic retinopathy, nephropathy, and neuropathy. The DCCT and the UKPDS established the effectiveness of glycemic control in the prevention of diabetic complications in T1DM and T2DM, respectively, during the 1990s. The UKPDS, conducted from 1977 to 1997 in 23 centers throughout England, Northern Ireland, and Scotland, verified that optimal glycemic control has similar benefits in T2DM. This prospective, randomized intervention trial of 5102 newly diagnosed individuals with T2DM examined the effects of glucose control on cardiovascular and diabetic complications via diet therapy or pharmacologic intervention with sulfonylureas, metformin, or insulin therapy.54 After a 3-month dietary run-in period, subjects with persistent hyperglycemia were randomized to conventional therapy with diet alone (goal FPG <...

Combination therapy with insulin and oral agents

Insulin has been used in combination with every other type of pharmacological therapy for glycemic control in T2DM. Combination therapy with a sulfonylurea has been extensively studied, with overall improved glycemic control in individuals on a bedtime dose of intermediate or long-acting insulin.79,80 The concurrent use of insulin and metformin can modestly decrease HbA1C values and may also decrease the amount of weight gain associated with insulin alone. Thiazolidinediones maintain or slightly lower HbA1C levels when used with insulin, and further decrease the required insulin dose, but may result in additional weight gain. A clinical study investigating the use of acarbose with insulin therapy showed a 0.5 decrease in HbA1C values, which is likely due to an improvement in postprandial hyperglycemia.

Type 2 diabetes mellitus

Although the diagnosis of T2DM is straightforward, it is extremely difficult to monitor and to treat successfully long-term. Therapy and the monitoring of its effectiveness are complex, invasive, and expensive. Lack of patient education and resources compounds the problem and contributes to non-compliance and suboptimal glycemic control. The asymptomatic nature of chronic hyperglycemia does not allow the patient to truly understand the risk of diabetic complications until irreversible damage has developed. Therapies that have been added to available options in recent years have new and different mechanisms of action. However, when used as monotherapy, none of them (save insulin and its analogs) sustain optimal control for long intervals of time in the majority of patients.

Incretin Augmentation of Insulin Secretion

Dipeptidyl peptidase-IV (DPP-IV) is a membrane-associated peptidase that is widely distributed in tissues and also exists as a soluble circulating form. Several DPP-IV inhibitors have been characterized and shown to lower blood glucose via prolongation of circulating GLP-1 and GIP action.87 Animal studies with DPP-IV inhibitors show promising results. Progressive improvement in glycemic control, enhanced insulin secretory response, increased

Clinical manifestations

Hepatic encephalopathy is a diagnosis of exclusion. Therefore, if a patient with acute or chronic liver failure suddenly develops altered mental status, concomitant problems must be excluded, such as intracranial lesions (hemorrhage, infarct, tumor, abscess), infections (meningitis, encephalitis, sepsis), metabolic encephalopathies (hyperglycemia or hypoglycemia, uremia, electrolyte imbalance), alcohol intoxication or withdrawal, Wernicke's encephalopathy, drug toxicity (sedatives, psycho-active medications), or postictal encephalopathy.

The BB Rat as a Model of Human Insulin Dependent Diabetes Mellitus

Insulin-dependent diabetes mellitus (IDDM) in humans is a disorder characterized by severe hyperglycemia, weight loss, glycosuria, and ketoacidosis. These signs and symptoms are the result of severe insulin deficiency. IDDM results from selective destruction of the insulin-producing P cells in the pancreatic islets of Langerhans in the context of an inflammatory infiltrate. Its pathogenesis is believed to be autoimmune in origin. Affected individuals require chronic treatment with exogenous insulin for survival. Knowledge of IDDM advances steadily, but the disorder remains difficult to study in humans. The diseased organ is inaccessible, and ethical considerations limit procurement of biological samples and testing of treatment modalities. Use of the BioBreeding (BB) rat to model human IDDM offers numerous advantages. Characteristics of diabetes in the BB rat closely parallel those observed in human IDDM. Diabetic animals can be biopsied, autopsied, and bred to study the genetic basis...

Maintenance And Diagnosis Of Spontaneous Iddm In Diabetesprone Bb Rats

This protocol describes the procurement and husbandry of BB rats, diagnosis of insulin-dependent diabetes mellitus (IDDM), treatment and care of diabetic animals, and his-topathological evaluation of insulitis. The methods in this protocol are common to all the models of IDDM in this unit. Diabetes is diagnosed clinically by documenting a sustained increase in blood glucose concentration. Insulitis invariably precedes the development of diabetes, but does not always progress to diabetes. Insulitis is diagnosed morphologically by assessment of mononuclear cell infiltration of pancreatic islets (see Support Protocol 1). Overt hyperglycemia occurs only when > 90 of the P cell mass in the pancreas has been destroyed.

Diagnosis Of Insulitis

A normal pancreas has abundant islets and no cellular infiltrates. Early insulitis appears before the onset of hyperglycemia. As inflammation progresses, both the number of affected islets and the density of the infiltrate within the islets increase. As the central core of P cells within an islet is destroyed, the lymphoid cell infiltrate disappears and the residual islet a, 5, and pancreatic polypeptide-secreting cells form a shrunken, misshapen structure termed an end-stage islet (Nakhooda et al., 1977). Immunohistochemical and other methods have shown the cells comprising the insulitis lesion include CD4+ and CD8+ T lymphocytes, natural killer (NK) cells, macrophages, and, to a lesser extent, B lymphocytes. The earliest infiltrating cell type may be macrophages.

Oxidative and Nitrosative Stress in Diabetes Induced Vascular Dysfunction

Superoxide anion may quench NO, thereby reducing the efficacy of a potent endothe-lium-derived vasodilator system that participates in the homeostatic regulation of the vasculature, and evidence suggests that during hyperglycemia, reduced NO availability exists (64). Hyperglycemia-induced superoxide generation contributes to the increased expression of NAD(P)H oxidase, which in turn generate more superoxide anion. Hyperglycemia also favors, through the activation of NF-kB an increased expression of iNOS, which may increase the generation of NO (65,66). Superoxide anion interacts with NO, forming the strong oxidant peroxynitrite (ONOO-), which attacks various biomolecules, leading to among other processes the production of a modified amino acid, nitrotyrosine (67). Although nitrotyrosine was initially considered a specific marker of peroxynitrite generation, other pathways can also induce tyrosine nitration. Thus, nitrotyrosine is now generally considered a collective index of reactive...

Background Information

The BB rat strain was derived from a colony of outbred Wistar rats that developed spontaneous diabetes mellitus at the BioBreeding Laboratories, Ottawa, Canada, in the 1970s. Affected animals became the founders of the inbred diabetes-prone (DP)-BB Wor rat strain used in the majority of published studies. At the sixth generation of inbreeding, a subpopulation of nondiabetic DP-BB Wor rats was selected to start a control line. Now designated as diabetes-resistant (DR)-BB Wor rats, these coiso-genic descendants of DP-BB Wor forbearers do not develop spontaneous diabetes. Both BB Wor rat lines are now fully inbred. BB Wor and all other BB rat strains express the RT1u rat major histocompatibility complex (MHC) haplotype. As is the case with human insulin-dependent diabetes mellitus (IDDM), predisposition to the disease is strongly linked genetically to MHC genes. The onset of hypergly-cemia is preceded by mononuclear cell infiltration of the islets (insulitis) and the appearance of...

Induction of Autoimmune Disease by Depletion of Regulatory T Cells

Organ-specific autoimmune diseases can be induced in rodents that do not normally spontaneously develop autoimmunity by using procedures that render the animals partially T cell deficient. Using a protocol of adult thymectomy followed by four doses of sublethal y irradiation, insulin-dependent diabetes can be induced in normal PVG.RT1u rats, an inbred congenic strain that has the same major histocompatibility complex (MHC) allotype as the spontaneously diabetic BB rat. Onset of the disease ranges from 3 to 18 weeks after the final dose of irradiation, with 98 of male and 70 of female animals becoming diabetic. The animals develop an acute and rapidly fatal syndrome with severe weight loss and hyperglycemia. Using this protocol, 50 to 60 of PVG.RT1u animals may develop anti-thyroid antibodies but they have no adverse effect. Female rats of the strain PVG.RTIc will also develop diabetes if treated by this protocol, but with a much lower incidence (10 to 53 ).

Treatment of Insulin Dependent Diabetes Mellitus

Diabetic Lunch Meal

Therapeutic objectives are (1) prevention of life-threatening hypergly-cemic (diabetic) coma (2) prevention of diabetic sequelae (angiopathy with blindness, myocardial infarction, renal failure), with precise titration of the patient being essential to avoid even short-term spells of pathological hyperglycemia (3) prevention of insulin overdosage leading to life-threatening hypoglycemic shock (CNS disturbance due to lack of glucose). In the diabetic, insulin could be administered as it is normally secreted that is, injection of short-acting insulin before each main meal plus bedtime administration of a Lente preparation to avoid a nocturnal shortfall of insulin. This regimen requires a well-educated, cooperative, and competent patient. In other cases, a fixed-dosage schedule will be needed, e.g., morning and evening injections of a combination insulin in constant respective dosage (A). To avoid hypo- or hyperglycemias with this regimen, dietary carbohydrate (CH) intake must be...

Metformin hydrochloride

Uses Alone as an adjunct to diet to lower blood glucose in clients having non-insulin-dependent diabetes mellitus whose blood glucose cannot be managed satisfactorily via diet alone. Also, metformin may be used concomitantly with a sulfonylu-rea when diet and metformin or a sulfonylurea alone do not result in adequate control of blood glucose. Contraindications Renal disease or dysfunction (serum creatinine levels greater than 1.5 mg dL in males and greater than 1.4 mg dL in females) or abnormal CCR due to cardiovascular collapse, acute MI, or septicemia. In clients undergoing radio-logic studies using iodinated contrast media, because use of such products may cause alteration of renal function, leading to acute renal failure and lactic acidosis. Acute or chronic metabolic acidosis, including diabetic ketoacidosis, with or without coma. Lactation.

Discharge And Home Healthcare Guidelines

Reinforce the need for small, frequent meals. Warn against overeating at any one meal, which places too great a demand on the pancreas, and stress limiting caffeine and alcohol. Instruct the patient to inspect her or his stools daily and report to the physician any signs of steatorrhea. Teach the patient and family the care related to surgically induced diabetes symptoms and appropriate treatment for hypoglycemia and hyperglycemia, procedure for performing blood glucose monitoring, administration of insulin injections. Teach the patient or significant other to change the dressing over the abdominal incision and empty the drains daily (if present).

Glycemia and Quality of wellbeing in patients with diabetes

The study used the QWB-SA to explore the relationship between measures of glycemia and health-related quality of life. Glycemia was measured with self-reported frequency of symptomatic hypoglycemia and hyperglycemia, and HbA1c. HRQOL and health utility scores were assessed with the QWB-SA.

Physiologic effects of nitric oxide on the vascular system

Hyperglycemia and endothelium-derived vasocative substances. Hyperglycemia decreased the bioavailability of nitric oxide (NO) and prostacyclin (PGI2) and increased the synthesis of vasoconstrictor prostanoids and endothelin (ET-1) via multiple mechanisms (see text). PLC, phospholipase C DAG, diacylglycerol PKC, protein kinase C eNOS, endothelial nitric oxide synthase Thr, thrombin NAD(P)H Ox, nicotinamide adenine dinucleotide phosphate oxidase O2-, superoxide anion OONO-, peroxynitrite MCP, monocyte chemoattractant protein-1 NFkb, nuclear factor K b TNF, tumor necrosis factor Ils, interleukins COX-2, cyclooxygense-2. (Reproduced with permission from ref. 127.) Fig. 1. Hyperglycemia and endothelium-derived vasocative substances. Hyperglycemia decreased the bioavailability of nitric oxide (NO) and prostacyclin (PGI2) and increased the synthesis of vasoconstrictor prostanoids and endothelin (ET-1) via multiple mechanisms (see text). PLC, phospholipase C DAG, diacylglycerol PKC,...

Mechanisms of Renal Dysfunction

Endothelial dysfunction commonly occurs in obesity, type 2 diabetes, and hypertension. The endothelium acts to regulate vascular homeostasis by maintaining a balance between vasodilation and vasoconstriction, inhibition and stimulation of smooth muscle cell proliferation and migration, and inhibition of platelet activation, adhesion, and aggregation.24 Essential hypertension was first recognized to cause endothelial dysfunction early in the last decade where the increase in blood pressure has a direct influence on vascular function independent of other cardiovascular risk factors. Dysfunction of the endothelium could be due to decreased vasodilatory mediators and or increased vasoconstrictor mediators. Factors that lead to reduction of vasodilation and endothelial dysfunction include a reduction in nitric oxide (NO) production, increased oxidative stress, a decrease in NO bioavailability decreased prostacyclin levels, and a reduction of hyperpolarizing factors. Inflammatory responses...

Endothelium Dependent Vasodilation in Animal Models

Similarly, in an animal model of type 2 diabetes, the Zucker rat, which is characterized by hyperglycemia because of insulin resistance, abnormal endothelium-dependent va-sodilation is also seen (46). The early vascular dysfunction that occurs in type 1 diabetic animal models can be prevented by insulin therapy (50,51). The abnormal endothelial cell function that develops appears to be as a result of hyperglycemia rather than any other metabolic disturbance. This has been demonstrated by in vitro incubation experiments in which isolated arteries exposed to elevated glucose concentrations have similar decreases in endothelium-dependent vasodilation (52,53). This effect does not seem to be as a result of the hyperosmolarity because similar concentrations of mannitol have no effect on endothelium-dependent relaxation (52). The decreased endothelium-dependent vasodi-lation that occurs may be as a result of decreased synthesis or release of NO, decreased Endothelial cell dysfunction in...

Classification Vitamin B complex

Side Effects GI N& V, diarrhea, peptic ulcer activation, abdominal pain. Dermatologic Flushing, warm feeling, skin rash, pruritus, dry skin, itching and tingling feeling, keratosis nigricans. Other Hypotension, headache, macular cystoid edema, amblyopia. NOTE Megadoses are accompanied by serious toxicity including the symptoms listed in the preceding as well as liver damage, hyperglycemia, hyperuricemia, arrhythmias, tachycardia, and dermatoses.

Possible mechanisms of impaired endotheliumdependent vasodilation

Although the data are conflicting, overwhelming evidence presently suggests that DM is associated with an impairment of endothelial vasodilation. The mechanism(s) for this impairment is even less well understood. The most likely initial insult is hyperglycemia. Tesfamarian and colleagues took normal rabbit aortic rings and exposed them to high concentrations of glucose (up to 800 mg dL for 3 hours), resulting in a decrease in endothelium-dependent relaxation, in response to acetylcholine and ADP (52,53). This effect appears to be both concentration and time dependent. As stated earlier, this effect does not appear to be a result of the hyperosmolar effects of glucose because mannitol did not cause any such endothelium-dependent vasodilation (53). Bohlen and Lash (73) demonstrated that hyperglycemia at 300 and 500 mg dL suppressed the vasodilatory response to acetylcholine but not to nitroprusside. Similarly, Williams and colleagues (68) found that acute hyperglycemia attenuated...

Increased Nitric Oxide Inactivation Decreased Bioavailability andor Breakdown of Nitric Oxide

Prolonged hyperglycemia results in an alternative metabolism of glucose through the polyol pathway in which glucose is oxidized to sorbitol. This reaction is coupled with the oxidation of NADPH to NADP+, generating free radicals. The second step is the oxidation of sorbitol to fructose, which is coupled with the reduction of NAD+ to NADH (109,110). The increased cytolosic NADH NAD+ results in an altered redox state, which may alter the availability of tetrahydrobiopterin, an essential cofactor for NOS. If tetrahydrobiopterin is depleted, NO production is decreased (111,112). Tetrahydrobiopterin supplementation has been shown to improve impaired endothelium-dependent vasodilation in diabetic animals (113).

Differential diagnosis of acidosiscausing conditions

Hyperglycemia caused by hyperosmolar nonketotic coma occurs in patients with type 2 diabetes with severe hyperglycemia. Patients are usually elderly and have a precipitating illness. Glucose level is markedly elevated (> 600 mg dL), osmolarity is increased, and ketosis is minimal.

Potential preventive and therapeutic options Oral Hypoglycemic Agents

The cornerstone of DM therapy is optimal glycemic control, because hyperglycemia is the basis of all the metabolic disturbances that occurs in the disease. As shown previously, both in vivo and in vitro elevated glucose levels have been shown to cause abnormal endothelium-dependent relaxation. Lower glucose levels also result in a decrease in insulin levels, which consequently may also improve endothelial function. Therefore, therapy should be directed toward lowering glucose levels and increasing insulin sensitivity.

Protein Kinase C Inhibitors

Hyperglycemia can activate PKC, which in turn increases oxidative stress. Inhibitors of PKC can restore vascular function and also increase mRNA expression of eNOS in aortic endothelial cells (143). Recently, an inhibitor of PKC, LY333531, has been developed it normalizes retinal blood flow and glomerular filtration rate in parallel with inhibition of PKC activity (169). LY333531 is discussed in detail in Chapter 2. Beckman and colleagues (170) found that this inhibitor of PKCP attenuated the impairment of endothelial-dependent vasodilation on healthy human subjects exposed to hyperglycemia.

Inhibitors of AGE Production

The production of AGE, as a result of prolonged exposure of proteins to chronic hyperglycemia, can result in direct quenching of NO and increasing the oxidative stress. Conversely, hyperglycemia, which increases oxidative stress, can convert even elevated levels of NO to peroxynitrite, which is deleterious to vascular function (179). A decrease in oxidative stress can restore vascular function rather than increase the NO supply. Prolonged hyperglycemia and hypercholesterolemia both cause a depletion of tetrahydrobiopterin (BH4), an essential cofactor for NOS, resulting in an uncoupling of eNOS and lowered production of NO (180). Studies using both diabetic animal models (113) and hypercholesterolemic patients (112) have demonstrated that tetrahydrobiopterin

HMG CoA Reductase Inhibitors

The normal endothelium plays an important role in the prevention of atherosclerosis and microvascular disease. DM is an important cause of both macro- and microvascular disease. Animal and clinical studies have demonstrated a decrease in endothelium-de-pendent vasodilation in both type 1 and type 2 DM. Possible mechanisms include abnormalities in signal transduction, reduced synthesis of NO, accelerated inactivation of NO, or production of vasoconstrictor prostanoids, probably through the relative increase of oxygen-derived free radicals (Table 1). The mediators of this abnormality include hyperinsulinemia, insulin resistance, or hyperglycemia. Improved glucose control, supplementation with either tetrahydrobiopterin, L-arginine, or vitamin C, or the addition of ACE inhibitors have been shown to improve endothelial function. Further research is required to determine whether restoring endothelial function in patients with either type 1 or type 2 diabetes will translate into an overall...

The Kallikrein Kinin Pathway

Abnormalities in the kallikrein kinin pathway have been found recently in the DCCT Echo Dobutamine International Cooperative cohort of type 1 diabetes (47) and increased expression of B2-kinin receptors has been described in the vessel wall of diabetic animals (48). Interestingly hyperglycemia, which is known to induce endothelial dysfunction as a result of its ability to promote endothelial cell toxicity, has also been shown to up-regulate the expression of kinin receptors in VSMC (49). Thus, in diabetes, the abnormalities in the kallikrein kinin system by modulating vascular fibrosis play an important role in the development of arteriosclerosis.

Additional Nursing Diagnoses Risk For Injury

Related to (Specify hyperglycemia or hypoglycemia.) Defining Characteristics (Specify hyperglycemia fatigue, irritability, headache, abdominal discomfort, weight loss, polyuria, polydipsia, polyphagia, dehydration, blurred vision hypoglycemia nervousness, sweating, hunger, palpitations, weakness, dizziness, pallor, behavior changes, uncoordinated gait.) Goal Client will not experience injury from hyperglycemia or hypoglycemia. Outcome Criteria hyperglycemia, blood glucose level, urinary glucose and ketones, pH and electrolyte levels. Provides information about complication caused by increased glucose levels resulting from improper diet, an illness, or omission of insulin administration glucose is unable to enter the cells, and protein is broken down and converted to glucose by the liver, causing the hyperglycemia fat and protein stores are depleted to provide energy for the body when carbohydrates are not able to be used for energy. Provides insulin replacement to maintain normal...

Abnormalities in coagulation

Attention has been directed at fibrinogen levels and dynamics in diabetes for a variety of reasons. The most important one is the fact that the plasma level of fibrinogen has been shown to be an independent risk factor for thrombotic events in population-based studies (260-262). In diabetes, plasma fibrinogen levels are found to be elevated, particularly in patients with hyperglycemia (263-265). Insulin deficiency leads to an increase in fibrinogen synthesis in IDDM, and infusion of insulin will decrease the fibrinogen synthetic rate (266). Interestingly, fibrinogen survival is decreased in diabetes, and this abnormality can be reversed by administration of insulin or by administration of heparin, suggesting that intravascular fibrin formation may be taking place (262). Exercise may also affect plasma fibrinogen and it has been shown that exercise conditioning will lower plasma fibrinogen levels in NIDDM individuals (267). The above findings suggest that there may be increased fibrin...

Calciphylaxis Calcific Uremic Arteriolopathy

Calciphylaxis Pictures

Vascular calcification, the hallmark of calciphylaxis, is a complex process regulated by many factors. Medial arterial calcification is a feature characteristic of both diabetes mellitus and end-stage renal disease. This calcification involves a phenotype switch of the vascular myofibroblast to one of an osteoprogenitor, a process influenced by osteotropic hormones and inhibitors. In pathologic states, the end result is vascular calcification. Local para-crine control of the process involves bone morphogenetic protein-2, parathyroid hormone-related peptide, osteo-pontin, osteoprotegerin, Pit-1 (a sodium-dependent phosphate cotransporter), and matrix Gla protein, all of which respond to various metabolic and inflammatory stimuli (summarized in Figure 35.1) (9,10). Osteopontin production likely contributes to mineralization, and can be induced by hyperglycemia, uremia, and hyperphosphate-mia, all common features in patients with calciphylaxis (9). Matrix Gla protein (MGP) may be...

Diffusion Weighted Imaging in Epilepsy

Postictal cerebral lesion following partial seizure in a 64-year-old woman with generalized seizure secondary to hyperglycemia. a T2-weighted image 24 h after seizures shows hyperintense lesions in bilateral medial fronto-parietal cortex (arrows). b Coronal FLAIR image also shows cortical and subcortical hyperintense lesions (arrows). c Gadolinium-enhanced T1-weighted image shows no abnormal enhancement. d DW image shows these lesions as isointense with increased ADC (e) (arrows), representing vasogenic edema

Effects of the Renin Angiotensin System on Insulin Signaling

Gabriely I, Yang XM, Cases JA, Ma XH, Rossetti L, Barzilai N. Hyperglycemia modulates angiotensinogen gene expression. Am J Physiol Regul Integr Comp Physiol 2001 281 R795-R802. 71. Amiri F, Venema VJ, Wang X, Ju H, Venema RC, Marrero MB. Hyperglycemia enhances angiotensin II-induced janus-activated kinase STAT signaling in vascular smooth muscle cells. J Biol Chem 1999 274 32382-32386.

Effects of HRT on Endothelial Function in Postmenopausal Women With Diabetes

Endothelial dysfunction is the hallmark of diabetes and is regarded as an early manifestation of atherogenesis. In postmenopausal women with diabetes, multiple pathophysiological processes may contribute to endothelial dysfunction. These are diabetes- related, as a result of hyperglycemia and obesity insulin resistance and menopause-related as a result of loss of the protective effect of estrogen, as discussed earlier.

Expression of the Renin Angiotensin System in Diabetes

Acute hyperglycemia increases AGT expression in both liver and adipose tissue (63), suggesting that diabetes may increase AGT substrate availability. High glucose increases Ang II release from cardiomyocytes (64) and AT1 receptor expression in VSMC (65), suggesting that hyperglycemia may locally upregulate the RAS in vascular tissues.

Insulindependent Diabetes Mellitus Introduction

Insulin-dependent diabetes mellitus (IDDM) is a metabolic disorder caused by a deficiency of insulin. The deficiency is thought to occur in those individuals who are genetically predisposed to the disease and who have experienced a precipitating event, commonly a viral infection or environmental change, that causes an autoimmune condition affecting the beta cells of the pancreas. It is treated by injection of insulin and regulation of diet and activity that maintain body functions. Complications that occur from improper coordination of these include hypoglycemia and hyperglycemia which, if untreated, lead to insulin shock or ketoacidosis. Long-term effects of the disease include neuropathy, nephropathy, retinopathy, atherosclerosis, and microangiopathy.

Adenosine Ai Receptor Agonists

An example of how such tools have been used to develop novel, mechanism-based PK PD models is a project exploring the potential of a series of deoxribose and 8-alkylamino analogs of N6-cyclopentyladenosine (CPA), which were identified as adenosine A1 receptor agonists with reduced intrinsic efficacy54,55 as antilipolytic agents for the treatment of non insulin-dependent diabetes mellitus. Increased levels of non-esterified fatty acids (NEFAs) are a characteristic of non insulin-dependent diabetes and are believed to exacerbate insulin resistance and hyperglycemia. Therefore, selective A1 receptor agonists may provide a novel therapeutic strategy for the treatment of diabetes, since stimulation of adenosine A1 receptors in adipose tissue has been shown to decrease NEFA levels in rat and human.51 A key first step in this project was the development of an efficient and quality animal model and sensitive analytical assays for simultaneous and detailed characterization of the...

Diagnosis Of Insulindependent Diabetes Mellitus Iddm

Monitoring of glycemic status should begin when NOD mice reach 10 weeks of age. Generally, this is done at weekly intervals by using Diastix (Bayer Diagnostics appendix 5) or similar reagent strips to measure urine glucose. Picking a mouse up leads to immediate urination, allowing a drop to be collected on the test area (tip) of the reagent strip. High levels of glucose in the urine (glycosuria) appear when plasma glucose is > 300 mg dl. A nonfasting plasma glucose of > 300 mg dl for 2 consecutive weeks indicates IDDM. The nonfasting plasma glucose levels of young, prediabetic NOD mice ranges between 130 and 180 mg dl. Plasma glucose can be measured directly in small samples of venous blood using glucose oxidase methods (either commercially available glucose analyzers or small portable analyzers and glucose oxidase-coated test strips see unit 15.3 for details). Onset of IDDM can also be accelerated in young prediabetic NOD mice by intraperitoneal administration (unit 1.6) of...

Classification Oral antidiabetic

Action Kinetics Lowers blood glucose by stimulating release of insulin from pancreas. Action depends on functioning beta cells in pancreatic islets. Rapidly and completely absorbed from GI tract. Peak plasma levels 1 hr. Completely metabolized in liver with most excreted in feces. Uses Adjunct to diet and exercise in type 2 diabetes mellitus. In combination with metformin to lower blood glucose where hyperglycemia can not be controlled by exercise, diet, or either drug alone.

With nephropathy is there a point of no return

Another important question is whether there is any benefit of good blood sugar control once the signs of kidney failure, either micro- or even macroalbuminuria, have appeared. This was disputed for a long time. The opinion was that there was a point of no return, after which there could be no reversing the course of the disease - it would progress inexorably until dialysis was necessary, regardless of how well controlled the blood sugar level was. But the studies of recent years have shown clearly that good blood sugar control brings benefits, even at this stage. The progression of the nephropathy can be prevented, or at least delayed, by good management. This is true for both Type 1 and Type 2 diabetes.

NaKATPase

Na+-K+-ATPase, an integral component of the sodium pump, is involved in the maintenance of cellular integrity and functions such as contractility, growth and differentiation (147). It is well established that Na+ K+-ATPase activity is generally decreased in the vascular and neuronal tissues of diabetic patients and experimental animals (41,43,147149). However, the mechanism by which hyperglycemia inhibits Na+ K+-ATPase activity have provided some conflicting results regarding the role of PKC. Phorbol esters have shown to prevent the inhibitory effect of hyperglycemia on Na+ K+ATPase, which suggest that PKC activity might be decreased in the diabetic condition. However, we have reported that elevated glucose levels increased PKC and cytosolic phospholipase A2 (cPLA2) activities, resulting in increases of arachidonic acid release and prostaglandin E2 (PGE2) production and decrease in Na+-K+ ATPase activity (150). Inhibitors of PKC or PLA2 prevented hyperglycemia-induced reduction in...

Thrombosis

It is likely that insulin resistance and hyperglycemia are responsible, directly or indirectly, for the abnormality of vascular endothelial functions in diabetic patients. New studies on the adverse effects of hyperglycemia have suggested that alterations in the signal transduction pathways induced by glycation products, oxidants, and redox potentials are important mechanisms in endothelial and vascular cell functions, because it may affect both antiatherogenic and atherogenic actions. Selective impairment of insulin-signaling through the PI 3K Akt pathway causes the blunting of insulin's antiatherogenic actions. Hyperinsulinemia, when present concomitantly with insulin resistance, may enhance insulin's atherogenic actions. Agents that can improve insulin resistance in the endothelium and inhibit the adverse effects of hyperglycemia will ultimately prevent the microvascular and cardiovascular complications of diabetes.

Patient Interview

But this view was too optimistic, which soon became clear to the young man. When he finished school he trained as a dental technician. By his mid-20s, the consequences of the years of neglect of his illness began to show. He was reading the newspaper when he realized for the first time that he could no longer see as well. Then, on the way home from a skiing holiday, 'Suddenly, a cloud formed in front of my right eye - it was as though someone put a drop of ink in a glass of water and it slowly spread out.' At the eye clinic in Heidelberg, he was diagnosed as having advanced damage to the retina at the back of the eye, caused by chronic high blood sugar levels. The 'cloud' was due to a haemorrhage from one of the broken blood vessels in the eye.

Pancreas

Diabetes is a metabolic disorder characterized by hyperglycemia and a failure to a greater or lesser extent to secrete insulin. Approximately one third of all diabetics are juvenile onset diabetics. In this condition, the lack of insulin may be complete. This type of diabetes is differentiated from the mature onset diabetes by the tendency of the juvenile diabetic to develop ketoacidosis. Most individuals with juvenile onset diabetes present with the classical symptoms of diabetes previously mentioned. Approximately one third, however, initially present in acidosis or diabetic coma. In a number of instances, the onset of diabetes seems to be triggered by an infective illness. In diabetic ketoacidosis, blood glucose levels are seldom under 300 mg dL or over 1000 mg dL, with an average blood level reported as 736 mg dL. The biochemical derangement in diabetic ketoacidosis may be extremely severe with increased metabolism of fatty acids, resulting in the formation of ketone bodies and...

Diabetic Nephropathy

The prevalence of diabetic nephropathy has increased dramatically and is now the first cause of end-stage renal disease requiring renal replacement therapy worldwide (72). Although the genetic background is important in determining susceptibility to diabetic nephropathy, exposure to chronic hyperglycemia leading to the subsequent activation of multiple pathogenic pathways appears to be the main initiating factor (2,3,4-6,41).

Acarbose

Action Kinetics Acarbose delays the intestinal absorption of glucose resulting in a smaller increase in blood glucose following meals. Approximately 65 of an oral dose of acarbose remains in the GI tract, which is the site of action. Metabolized in the GI tract by both intestinal bacteria and intestinal enzymes. The acar-bose and metabolites that are absorbed are excreted in the urine. Uses Used alone, with diet control, to decrease blood glucose in type 2 diabetes mellitus. Also, used with a sulfonylurea when diet plus either acarbose or a sulfonylurea alone do not control blood glucose adequately. Contraindications Diabetic ketoa-cidosis, cirrhosis, inflammatory bowel disease, colonic ulceration, partial intestinal obstruction or predisposition to intestinal obstruction, chronic intestinal diseases associated with marked disorders of digestion or absorption, conditions that may deteriorate as a result of increased gas formation in the intestine. In significant renal dysfunction....

Diabetic Retinopathy

Diabetic retinopathy occurs in three-fourths of all persons with diabetes for more than 15 years (95) and is the most common cause of blindness in the industrialized world (96). It is primarily a disease of the intraretinal blood vessels, which become dysfunctional in response to hyperglycemia with progressive loss of retinal pericytes and eventually endothelial cells leading to capillary closure and widespread retinal ischemia (97).

Diabetic Neuropathy

About half of all people with diabetes experience some degree of diabetic neuropathy, which can present either as polyneuropathy or mononeuropathy (109). Diabetic neuropathy can also affect the central and the autonomic nervous systems. Level of hyperglycemia seems to determine the onset and progression of diabetic neuropathy (110,111).

Metabolic Factors

As hyperglycemia enhances AGE formation it is obvious that intensive treatment of hyperglycemia can modify the body AGE pool. Indeed, diabetic rats with good metabolic control exhibited lower levels of pentosidine, and lower intensity of collagen-linked fluorescence glycation and oxidation compared to rats with bad metabolic control (166). Skin collagen glycation, glycoxidation, and crosslinking were lower in a large group of type 1 diabetic patients under long-term intensive vs conventional treatment, as was shown in a cohort of patients studied in the DCCT (119).

Atenolol

Ness, drowsiness, fatigue, hallucinations, insomnia, lethargy, mental changes, memory loss, strange dreams. GI Diarrhea, ischemic colitis, nausea, mesenteric arterial thrombosis, vomiting. Hematologic Agranulocytosis, thrombocytopenia. Allergic Fever, sore throat, respiratory distress, rash, pharyngitis, laryngos-pasm, anaphylaxis. Skin Pruritus, rash, increased skin pigmentation, sweating, dry skin, alopecia, skin irritation, psoriasis. Ophthalmic Dry, burning eyes. GU Dysuria, impotence, nocturia. Other Hypoglycemia or hyperglycemia. Respiratory Bronchospasm, dyspnea, wheezing. Drug Interactions See also Drug Interactions for Beta-Adrenergic Blocking Agents and Antihypertensive Agents.

Animal Models

STZ-induced diabetes increases atherosclerotic plaque area by four- to fivefold in the aorta of apo-E deficient mice (72,84,85). Treatment of diabetic apo-E - - mice with the ACE inhibitor perindopril reduces lesion area, macrophage infiltration, and collagen content (85). A similar reduction in aortic plaque area was observed in STZ-induced diabetic apo-E-deficient mice treated with the AT1 receptor antagonist Irbesartan (72). Both ACE and AT1 receptor expression are increased in aortic lesions in the diabetic apo-E-deficient mice, suggesting that the Ang II AT1 pathway is upregulated within the atherosclerotic plaque and contributing to the accelerated lesion formation in this model. Multiple factors may contribute to the increased expression of ACE and the AT1 receptor in athersclerotic lesions in diabetes. As previously mentioned, hyperglycemia can increase both Ang II production and AT1 expression (64,65). Alternatively, the upregulation of AT1 receptor expression could be...

Diagnostic Tests

Labs Hyperglycemia, hypokalemia, increased CPK, and increased CPK-MB. Electrocardiogram (ECG) All tachydysrhyth-mias increased, ischemia, MI. Head CT All CVAs increased subarach-noid hemorrhage (SAH), intracranial (ICH), interventricular hemorrhage (IVH), ischemic cerebral infarcts, septic cerebral emboli, brain abscesses.

Summary

Subjects with DM have a high prevalence and rapid progression of coronary artery, peripheral vascular, and cerebral vascular disease secondary in part to (a) increased platelet reactivity (b) increased thrombotic activity reflecting increased concentrations and activity of coagulation factors and decreased activity of anti-thrombotic factors and (c) decreased fibrinolytic system capacity resulting from overexpression of PAI-1 by hepatic, arterial, and adipose tissue in response to hyperinsulinemia, hypertriglyceridemia, and hyperglycemia. Additionally, macrovascular disease appears to be accelerated by an insulin-dependent imbalance in proteo(fibrino)lytic system activity within walls of arteries predisposing to accumulation of ECM and paucity of migration of SMCs during the evolution of atheroma predisposing toward the development of plaques vulnerable to rupture. Therapy designed to reduce insulin resistance decreases concentrations in blood not only of insulin but also of PAI-1....

Macroalbuminuria

This was proved to be equally true for Type 1 diabetes as for Type 2 diabetes by two studies. People with Type 1 diabetes who had already developed microalbuminuria and who were treated intensively, as in the DCCT, showed a significant delay in the progress to macroalbuminuria. Kidney function deteriorated in only 8 of these, whereas it worsened in 31 of the conventionally treated group. The same result was obtained in the Kumamoto Trial, which enrolled people with Type 2 diabetes and microalbuminuria. Good blood sugar control reduced the risk of kidney damage progressing from 32 to 12 (Figure 4.4). The more advanced the kidney damage is, the smaller the effect that blood sugar control can exert on its progression. However, the

Clinical use

Sulfonylureas increase endogenous insulin secretion. Their efficacy, measured by the plasma glucose lowering effect, is greatest in individuals with newly diagnosed T2DM. Clinical studies have shown that sulfonylureas reduce mean FPG to 54-72 mgdL_ 1 and HbA1C levels by 1.5-2 . The benefit of sulfonylurea therapy depends on the initial degree of hyperglycemia, duration of diabetes (more effective in T2DM of shorter duration), and previous use of other oral hypoglycemic agents. Because many of the sulfonylurea metabolites are active, more conservative dosing is advised in any patient who may be at high risk for decreased hepatic metabolism or renal clearance of the active drug or metabolites.

Ischemic Myocardium

The reperfusate composition was modified to allow incorporation of the following principles 1) oxygenation with blood to provide substrate (O2) to generate energy for repair of cellular processes 3 2) cardioplegia (K+) to keep the heart from resuming electromechanical activity and raising O2 demand 3) replenishing of amino acid precursors of Krebs' cycle intermediates, i.e., glutamate aspartate and needed to ensure more effective oxidative metabolism to produce energy for cell repair and subsequent mechanical function65,95 because it has been shown that both hypoxia106 and ischemia14 reduce the tissue concentrations of precursors and some intermediates of the Krebs' cycle, 4) limitation of calcium influx by reperfusate hypo-calcemia (150 to 250 micromol L) with citrate-phosphate-dextrose to reduce calcium load and addition of a calcium channel-blocking drug, i.e., diltiazem, that could continue to retard calcium cell entry after normocalcemic reperfusion is started 2,38 5) reversal of...

Mechanisms

Diabetes-associated hyperglycemia and possibly other metabolic abnormalities may interfere with one or more of these mechanisms. Indeed, hyperglycemia decreases estra-diol-mediated NO production from cultured endothelial cells (116). Additionally, hyperglycemia may lead to increased formation of oxygen-derived free radicals that inactivate endothelium-derived NO and, thus, interfere with endothelium-dependent vasodilation. Further to this, a recent experimental study in cultured aortic smooth muscle cells from diabetic rats showed that iNOS response to inflammatory stimuli is less sensitive to estrogen inhibition probably on account of altered ERa ER ratio in the diabetic environment (117). It appears from this study that diabetes may also undermine the anti-inflammatory effects of estrogen on vascular wall, and this may provide another possible mechanism underlying the increased risk of macrovascular disease in diabetic premenopausal women. In summary therefore, diabetes-related...

Laboratory testing

An elevated WBC with a left shift and elevated hematocrit (indicating hemoconcentration) and hyperglycemia are common. Pre-renal azotemia may result from dehydration. Hypoalbuminemia, hyper-triglyceridemia, hypocalcemia, hyperbilirubinemia, and mild elevations of transaminases and alkaline phosphatase are common.

In Diabetes

As mentioned above there is circumstantial evidence that nitrosative stress and peroxynitrite formation importantly contribute to the pathogenesis of diabetic cardiomyopathy both in animals and humans. We have tested a novel metalloporphyrin peroxynitrite decomposition catalyst, FP15, in murine models of diabetic cardiovascular complications (92). We hypothesized that neutralization ofperoxynitrite with FP15 would ameliorate the development of cardiovascular dysfunction in a STZ-induced murine model of diabetes. To ensure that the animals received the FP15 treatment at a time when islet cell destruction was already complete and hyperglycemia has stabilized the treatment was initiated 6 weeks after the injection of STZ. Although FP15 did not affect blood glucose levels, it provided a marked protection against the loss of endothelium-depen-dent relaxant ability of the blood vessels (Fig. 1A) and improved the depression of both diastolic (Fig. 1B) and systolic function of the heart (92)....

Dysfunction

We have recently found that high glucose-induced oxidative and nitrosative stress leads to DNA single-strand breakage and PARP activation in murine and human endot-helial cells (49) (Fig. 2). The involvement of oxyradicals and NO-derived reactive species in PARP activation and the evidence for nitrated tyrosine residues both suggested that peroxynitrite may be one of the final mediators responsible for single-strand breakage, and subsequent PARP activation (49). The role of hyperglycemia-induced oxidative stress in producing DNA damage is supported by the recent findings that increased amounts of 8-hydroxyguanine and 8-hydroxydeoxy guanosine (markers of oxidative damage to DNA) can be found in both the plasma and tissues of streptozotocin diabetic rats (99). Importantly, various forms of oxidant-induced DNA damage (base modifications and DNA strand breaks) have also been demonstrated in diabetic patients (100-104). Pharmacological inhibition of PARP or genetic inactivation of PARP-1...

Bells Palsy

The use of corticosteroids to treat the patients with Bell's palsy has been widely accepted.6 Several studies show more favorable outcome with steroid therapy. It may reduce the risk of denervation if initiated early on. It may prevent synkinesis and progression of incomplete to complete paralysis it may also hasten recovery. Patients presenting within the first week of facial paralysis are administered corticosteroid therapy consisting of prednisone, 1 mg kg over three equal divided doses for the first week. Patients are then reevaluated during the second week after onset of facial paralysis. If their symptoms are resolving, the prednisone is tapered over the following week. The side effects of steroids are well documented, including hyperglycemia, emotional changes, fluid and electrolyte disturbances, gastrointestinal tract hemorrhage, and aseptic necrosis of the hip.

Diabetes

Diabetes is defined as failure of the b-cells of the pancreas to secrete sufficient insulin to satisfy body requirements and is one of the most common complications of obesity (see 6.19 Diabetes Syndrome X). Diabetes can be classified into two main types type 1 and 2. Type 1 generally shows a marked hyperglycemia with diabetic ketoacidosis. In contrast to type 1, type 2 diabetes shows less hyperglycemia and ketoacidosis. The incidence of diabetes has increased enormously in this decade. Diabetes can be diagnosed by determining blood glucose level where 8-h fasting blood glucose is X 126 mg dL _ 1 or 2-h postprandial blood glucose X 200 mg dL _ 1 following an oral glucose tolerance test. Additionally, symptoms of marked hyperglycemia include polyuria and polydipsia.12 There is a strong correlation between diabetes and the incidence of renal dysfunction. Diabetes mellitus is the most common cause of end-stage renal disease. Hyperglycemia itself can cause glomerular hyperfiltration,...

Insulin

Fifteen percent of women with gestational diabetes require insulin therapy because of elevated blood glucose concentrations despite dietary therapy. Insulin should be initiated when the fasting blood glucose is greater than 90 mg dL and the one-hour postprandial blood glucose is greater than 120 mg dL on two or more occasions within a two-week interval despite dietary therapy.

Postpartum concerns

After delivery, blood glucose should be measured to ensure that the mother no longer has hyperglycemia. Fasting blood glucose concentrations should be below 115 mg dL and one-hour postprandial concentrations should be below 140 mg dL. A woman with gestational diabetes should be able to resume a regular diet. However, she should continue to measure blood glucose at home for a few weeks after discharge.

Vitreous

Agonal hyperglycemia is extremely common, especially if there has been attempted resuscitation. It plays no part in contributing to the death, however. Agonal hyperglycemia is not reflected in the vitreous. Thus, Coe reported that, in all of 102 nondiabetics in whom postmortem peripheral blood glucose concentration exceeded 500 mg dL from a terminal rise in blood sugar, the vitreous glucose was below 100 mg dL.37 Even if intravenous glucose infusions are administered prior to death, the vitreous glucose levels in normal subjects are generally less than 200 mg dL. In individuals with elevated levels of glucose in the vitreous due to hyperglycemia, there is a gradual fall in vitreous levels postmortem. The fall is gradual enough to allow diagnosis of hyperglycemia for a considerable time after death. Unfortunately, because normal individuals start at significantly lower levels of vitreous glucose, the decline is sufficiently rapid that low levels of glucose are the rule. Because of...

Diuretics

The antihypertensive activity of diuretics was discovered in the clinic. Diuretics do not lower arterial pressure in acute experiments on normotensive animals. Only in chronic experiments on DSS or SH rats can the mild antihypertensive effect of diuretics be detected. The first diuretic found to lower arterial pressure in hypertensive patients was chlorothiazide, discovered by Beyer and his colleagues at Merck. Its discovery was soon followed by the introduction of hydrochlorothiazide, a closely related derivative with much higher relative potency that was discovered at Merck as well as at Ciba-Geigy. Many similar thiazides have been subsequently developed and marketed, but only a few are still available on the American market. The major side effect of thiazides is hypokalemia, due to the excessive excretion of K+ ions. Other side effects include hyperuricemia and hyperglycemia. The search for diuretics with longer duration of action and fewer side effects led to the discovery of...

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