Bod: Endocrinology: Diabetes Complications

Front 1

What is the "extracellular effect" of hyperglycemia?

Back 1

Advanced glycosylation end products.

Front 2

What are the three "intracellular effects" of hyperglycemia?

Back 2

1. Protein Kinase C activation (activation of second messenger pathways)
2. Oxidative stress
3. Aldose reductase pathway (disruption of intracellular energy balance)

Front 3

What are the chronic microangiopathic complications of diabetes mellitus?

Back 3

1. Diabetic nephropathy.
2. Diabetic retinopathy.
3. Diabetic neuropathy.

Front 4

What are the chronic macroangiopathic complications of diabetes mellitus?

Back 4

1. Cardiovascular disease.
2. Peripheral vascular disease.

Front 5

Chronic hyperglycemia predisposes diabetics to what?

Back 5

To infection and poor wound healing.

Front 6

Diabetes: pregnancy

Back 6

Increases risk of complications

Front 7

What is known as the "diabetic triopathy?"

Back 7

1. Retinopathy
2. Neuropathy (autonomic, peripheral)
3. Nephropathy

Front 8

How does peripheral vascular disease first present in patients with diabetes?

Back 8

1. Claudication (pain in calves)
2. Hair loss.

Front 9

What are some infections that patients with diabetes are susceptible to?

Back 9

1. UTI --> pyelonephritis
2. Cellulitis --> ulcerations
3. Candidal vaginitis
4. Candidal intertrigo (infection between skin folds)

Front 10

What should you ask all women with diabetes?

Back 10

"Any vaginal discharge?" Looking for signs of vaginal candidiasis.

Front 11

What are AGEs? What role do they play in the pathogenesis of diabetes?

Back 11

Advanced Glycosylation End-products. They are a product of the binding of amino acids and glucose. AGEs can bind to receptors on various cell types and can induce:

- Release of cytokines
- Increased endothelial permeability
- Increased endothelial pro-coagulant activity
- Enhanced proliferation of extracellular matrix.

Front 12

What does a hemoglobin A1c test give you?

Back 12

The average blood glucose level over 3 months.

Front 13

Exactly how does the hemoglobin A1c test work?

Back 13

Glycosylation of the amino terminus on the beta chain of adult hemoglobin A converts it to Hb A1c. This can be measured as a "minor migrating band" upon ion exchange chromatography of Hb A.

Front 14

What are four cases in which the Hb A1c can be inaccurate?

Back 14

1. Presence of Hb variants (e.g. having persistant fetal Hb)

2. Production of Hb derivatives (carbamylated Hb in renal failure, acetylated Hb with acetylsalacylic acid)

3. Erythrocyte disease

4. Liver disease

Front 15

What affect does diabetes have on PKC? Consequences of this?

Back 15

Hyperglycemia --> DAG up --> PKC activated -->

- microvascular contractility, permeability, extracellular matrix, number of endothelial and smooth muscle cells: all UP.

Front 16

What is the normal function of the aldose reductase pathway?

Back 16

Glucose is converted to sorbitol by aldose reductase.

Front 17

What affect does hyperglycemia have on the aldose reductase pathway? Consequences of this?

Back 17

Glucose is normally converted to sorbitol by aldose reductase. Hypergylcemia causes sorbitol accumulation.

Accumulation of sorbitol in the lens may lead to increased intracellular osmotic pressure.

Front 18

Advanced PVD presents as what in patients with diabetes?

Back 18

Gangrene

Front 19

What are the three main manifestations of diabetic nephropathy?

Back 19

1. Glomerulosclerosis (most common)
2. Renal arteriosclerosis
3. Necrotizing papillitis and pyelonephritis.

Front 20

Pathological finding on kidney biopsy pathognomonic for diabetes.

Back 20

Kimmelstiel-Wilson nodules

Front 21

Where does pyelonephritis start and where does it travel to?

Back 21

Starts in the interstitium and travels to the tubules.

Front 22

What are the most common bacteria associated with acute pyelonephritis?

Back 22

E. coli, Protus, Klebsiella, and Enterobacter.

Front 23

What is one of the major causes of blindness in persons under the age of 60 in the US?

Back 23

Diabetic neuropathy

Front 24

Risk of blindness: Type 1 vs. Type 2 diabetes?

Back 24

Risk higher in Type 1 diabetes.

Front 25

What are the two types of diabetic retinopathy?

Back 25

1. Non-proliferative (loss of pericytes --> microaneurysms, hemorrhages, exudates)

2. Proliferative (hypoxia, ischemia of retina --> new vessels (tend to bleed), fibrous tissue, contraction of fibrovascular proliferation leading to vitreous hemorrhage and retinal detachment).

Front 26

Diabetic neuropathy: characteristics of sensory deficits

Back 26

- Symmetrical
- More common in the lower extremities
- Pain, paresthesia, numbness

Front 27

Diabetic neuropathy: characteristics of autonomic deficits.

Back 27

- Loss of parasympathetic fibers (e.g. gastroparesis)
- Diarrhea
- Neurogenic bladder (difficulty urinating)
- Postural hypotension
- Erectile dysfunction

Front 28

What is the number one rule of managing foot care in the context of diabetes?

Back 28

Tell patient: never go barefoot! Never wear open-toed shoes! Make sure you have shoes with a large-enough toe box. Get a molded shoe for advanced cases.

Front 29

What is the major cause of death in patients with diabetes?

Back 29

MI secondary to coronary atherosclerosis.

Cardiovascular disease (CAD, ischemic stroke).

Front 30

Three factors that lead to the pathogenesis of macroangiopathy in diabetics. Also additional factors

Back 30

1. Qualitative changes in lipoproteins due to non-enzymatice glycosylation.

2. Low levels of HDL

3. Increased platelet adhesions to vessel walls.

Additional risk factors: Genetics, HTN, hyperlipidemia, obesity, inactivity, smoking

Front 31

What are the two most important studies concerning diabetes?

Back 31

1. DCCT (Diabetes Control and Complications Trial for Type 1 Diabetes)

2. UKPDS (United Kingdom Prospective Diabetes Study for Type 2 diabetes)

Front 32

What did the DCCT trial examine? What were the findings?

Back 32

The DCCT examined if tight glycemic control affected the progression of diabetic complications in Type 1 diabetes.

Showed that tight glycemic control of patients with type 1 diabetes slowed the onset and progression of diabetes complications.

- 76% reduction in risk of retinopathy
- 50% risk reduction for nephropathy
- 60% risk reduction for neuropathy

Front 33

What did the UKPDS study examine? What were the findings?

Back 33

The UKPDS examined if tight glycemic control affected the progression of diabetic complications in Type 2 diabetes.

Showed that for every percentage decrease in Hb A1c, there was a 35% risk in complications!

Front 34

What is a way to test neuropathy in patients with diabetes?

Back 34

Tuning fork on distal inter-phalangeal joint of the great toe. Also on the medial malleolus.

Front 35

What are the three most important aspects to treat in diabetes?

Back 35

1. Glucose control

2. Lipid control

3. Blood pressure control

Front 36

What is an early sign of diabetic nephropathy?

Back 36

Microalbuminemia

Front 37

When are diabetic neuropathies the worst?

Back 37

When there is nothing else going on in the sensorium (e.g. when sleeping)

Front 38

What is one way to test if a patient has diabetic autonomic neuropathy?

Back 38

Normal people have sinus arrhythmia when they inhale. Patients with diabetes lose this and so the R to R interval does not vary on an EKG.

Front 39

What are two strategies to help you approach the care of patients with diabetes?

Back 39

1. "I can make you feel better now" can decrease nocturia, can decrease fatigue

2. "The insurance policy" I can make sure that you are around to see your grandkids' wedding.