The long-acting insulin dose may be given later around 11 p. Treatment with an insulin pump may be considered in children. Somogyi effect Rare Definition : early-morning hyperglycemia because of a co unterregulatory secretion of hormones ; that is triggered by nocturnal hypoglycemia secondary to an evening insulin injection Treatment : reduction of the evening dose of the long-acting insulin For additional side effects, see insulin. Conditions that require insulin adjustments Physical activity : decreases insulin by 1—2 units per 20—30 minutes activity Illness, stress, and changes in diet Increase in insulin demand : : many illnesses are associated with elevated blood glucose levels due to an acute stress reaction ;.
The subsequent increase in insulin demand cannot be met by patients with insulin deficiency. A higher insulin dose is required. Decrease in insulin demand : vomiting and diarrhea lead to decreased glucose uptake, increasing the risk of hypoglycemia. Poor glycemic control Increased risk of hyperglycemic coma References:            .
Advances in the cellular immunological pathogenesis of type 1 diabetes
Acute Hyperglycemic crisis : undiagnosed or insufficiently treated diabetes mellitus may result in severe hyperglycemia , potentially culminating in a coma Hyperosmolar hyperglycemic state HHS Diabetic ketoacidosis DKA Life-threatening hypoglycemia : secondary to inappropriate insulin therapy Long-term Macrovascular disease More common in patients with type 2 diabetes Pathophysiology: The major determinants are metabolic risk factors, which include obesity , dyslipidemia , and arterial hypertension.
Hyperglycemia may be less related to the development of macrovascular disease. Other complications Necrobiosis lipoidica Definition : inflammatory granulomatous disorder of the skin ; characterized by collagen degeneration and lipid accumulation in the surface of the skin. Mucormycosis zygomycosis Definition : rare fungal infection, primarily affecting immunocompromised patients and patients with diabetes mellitus Etiology : fungi of the order Mucorales , most commonly Rhizopus oryzae ; ubiquitous fungi found in vegetation and soil Pathophysiology : Inhalation of the spores into the nose and maxillary sinus diabetic ketoacidosis stimulates fungal growth causes sinusitis , tissue necrosis , and contiguous spread to the orbit , brain , and palate.
Inhalation of the spores into the pulmonary system may lead to contiguous spread to the mediastinum and heart. Differential diagnoses: other causes of chronic kidney disease e. Epidemiology After 15 years with disease, approx. Additionally, findings of nonproliferative retinopathy are usually present. Visual loss may be due to vitreous hemorrhage , retinal detachment , or neovascular glaucoma. Macular edema Findings : clinically significant retinal thickening and edema involving the macula , hard exudates , macular ischemia May occur in all stages of NPDR and PDR Treatment Nonproliferative retinopathy Laser treatment: focal photocoagulation Intravitreal anti-vascular endothelial growth factor VEGF injection Proliferative retinopathy and severe nonproliferative retinopathy Laser treatment: panretinal photocoagulation over the course of numerous appointments Risks associated with laser treatment: night vision impairment, visual field loss, further fibrosis of the vitreous body with risk of retinal detachment Vitrectomy in case of traction retinal detachment and vitreal hemorrhage Macular edema VEGF inhibitors Focal photocoagulation References:      .
Distal symmetric polyneuropathy Pathophysiology : Chronic hyperglycemia causes glycation of axon proteins with subsequent development of progressive sensomotoric neuropathy ; typically affects multiple peripheral nerves Epidemiology : Diabetic polyneuropathy is the most common form of polyneuropathy in Western countries.
Clinical features Early: progressive symmetric loss of sensation in the distal lower extremities A "stocking-glove" sensory loss pattern with proximal progression is typical Dysesthesia burning feet may occur A similar sensory loss pattern may occur in the upper extremities. Other manifestations Sweat gland dysfunction associated with heat intolerance Pupillary dysfunction Risk of hypoglycemia due to absence of hormonal counterregulation secretion of cortisol , glucagon , and catecholamines References:        .
Major risk factors include peripheral sensory neuropathy, autonomic neuropathy , microvascular changes , as well as macrovascular disease. Secondary infection of foot ulcers may lead to cellulitis and acute or chronic osteomyelitis. Diabetes mellitus is one of the leading causes of death in the US; common complications that result in death are myocardial infarction and end stage renal failure.
One of the leading causes of blindness , nontraumatic lower limb amputation, end stage renal failure, and cardiovascular disease The prognosis primarily depends on glycemic control and treatment of comorbidities e. Gestational diabetes mellitus Pregestational diabetes mellitus Definition Impaired glucose tolerance diagnosed during pregnancy ; associated with an increased risk of maternal and fetal morbidity Diabetes mellitus type 1 or type 2 that is present prior to pregnancy , which is associated with a significantly increased risk for maternal complications during pregnancy and delivery, and congenital malformations!
In the first trimester, insulin sensitivity increases and there is a tendency towards hypoglycemia. In the second and third trimesters, hormonal changes trigger progressive insulin resistance that results in hyperglycemia , particularly after mealtimes. Prepare and succeed on your medical exams. Find hundreds of Learning Cards covering all clinical subjects Practice answering thousands of USMLE-formatted multiple choice questions in the Qbank Explore concepts in depth with interactive images, videos and charts Fill knowledge gaps with the help of supportive features and an analysis of your progress.
Benign acanthosis nigricans. Symptoms or signs of diabetes. Positive HLA association. Negative HLA association ; strong genetic predisposition. Absolute insulin deficiency. Insulin resistance. Insulin therapy. Oral antidiabetic drugs see below Insulin therapy see below Patients with prediabetes usually do not require medical treatment but do benefit from a healthy diet, weight loss, and exercise.
Regular monitoring of weight, abdominal circumference, blood pressure, blood lipids, renal retention parameters creatinine , electrolytes , injection site in patients receiving insulin therapy Yearly eye exam type 1 : after 5 years with diabetes mellitus or after the age of 11 years ; more frequently in patients with abnormal findings or diagnosed retinopathy Annual urine testing for microalbuminuria Foot exam for neuropathy and ulcers; advise patients to wear appropriate footwear and avoid injury Routine screening for psychosocial problems, including signs of depression and cognitive impairment Pneumococcal vaccines.
On average, the body requires 40 USP units of insulin daily. BMC Pediatr. Supporting self-management after attending a structured education programme: a qualitative longitudinal investigation of type 1 diabetes patients' experiences and views. BMC Public Health. Children as partners with adults in their medical care.
Arch Dis Child. Impact of genetic and non-genetic factors in type 1diabetes. Am J Med Genet. Westerberg DP.
Diabetic ketoacidosis: evaluation and treatment. Am Fam Physician. Diabetes Autoimmunity Study in the Young. J Clin Endocrinol Metab. A correlation between the relative predisposition of MHC class II alleles to type 1 diabetes and the structure of their proteins. Hum Mol Genet. Hum Immunol.
Genetics of Type 1 Diabetes Mellitus. Kuwait Medical Journal. Genetic Aspects of Diabetes mellitus. Elizabeth T. Genetics of type 1diabetes mellitus. Genes Immun. MHC class II proteins and disease: a structural perspective. Nat Rev Immunol. Epidemiol Rev.
Genetics of the HLA region in the prediction of type 1 diabetes. Curr Diab Rep. Progression to type 1 diabetes in islet cell antibody-positive relatives in the European Nicotinamide Diabetes Intervention Trial: the role of additional immune, genetic and metabolic markers of risk.
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Valdes AM, Thomson G. Diabetes Obes Metab. The CTLA-4 gene region of chromosome 2q33 is linked to, and associated with, type 1 diabetes. Belgian Diabetes Registry. A functional variant of lymphoid tyrosine phosphatase is associated with type I diabetes.http://blacksmithsurgical.com/t3-assets/textbook/awakened-one-night-by.php
Risk Factors and Primary Prevention Trials for Type 1 Diabetes
Nat Genet. Role of PTPN22 in type 1 diabetes and other autoimmune diseases. Hum Genet. Fine mapping of the diabetes-susceptibility locus, IDDM4, on chromosome 11q Am J Hum Genet. Diabetes Metab Res Rev. Hum Mutat. Evidence for linkage to and association with type 1 diabetes at the 3q21 region in the Finnish population. Susceptibility to insulin-dependent diabetes mellitus maps to a locus IDDM11 on human chromosome 14q Why is PTPN22 a good candidate susceptibility gene for autoimmune disease?
FEBS Lett. Evidence for a locus IDDM16 in the immunoglobulin heavy chain region on chromosome 14q A second-generation genome screen for linkage to type 1 diabetes in a Bedouin Arab family.