JS, a 12-year old girl with type 1 diabetes, has been experiencing episodes of fatigue, weakness, and weight loss. During a soccer game, she felt sick and her blood glucose level was found to be low. She was treated for heat exhaustion. The doctor thinks she may be experiencing diabetic ketoacidosis. Proper management of type 1 diabetes requires lifelong insulin administration, monitoring of blood glucose and ketone levels, and maintenance of a healthy diet and activity levels to prevent dangerous fluctuations.
Mrs. DM is a 35-year-old woman with type 1 diabetes who presents for her annual visit with poorly controlled hypertension and moderate albuminuria. She has been managing her diabetes for 20 years with insulin injections and glucose monitoring. Her medical history is otherwise normal, though she has a family history of cardiovascular disease. Her current medications include insulin, aspirin, and medications to treat her hypertension. Lab work shows her HA1c is elevated at 8.1%, indicating poorly controlled diabetes, and her urine albumin is very high. The patient's physician plans to adjust her insulin and add another antihypertensive medication to improve her diabetes and hypertension management.
1. The document describes the formulation and evaluation of prolonged release metformin hydrochloride tablets. Tablets were prepared by direct compression and wet granulation methods using polymers like Polyox-303 to sustain the release of the drug.
2. Tablets were evaluated for pre-compression and post-compression parameters. In-vitro dissolution and stability studies showed that the formulations had a controlled release of the drug over an extended period of time.
3. The optimized formulation was stable for 1 month under accelerated conditions as per ICH guidelines.
This document discusses the benefits of continuing metformin XR when insulin is added for treatment of type 2 diabetes. It notes that metformin is recommended as first-line therapy in treatment guidelines and can provide cardiovascular benefits when used long-term. When used in combination with insulin, metformin can help control blood glucose levels better while limiting weight gain and insulin requirements compared to insulin alone. The document recommends metformin XR over other formulations due to its once daily dosing and reduced gastrointestinal side effects.
A 50-year-old man with poorly controlled diabetes presented with fever, headache, and right-sided facial swelling. He was found to be septic and further examination revealed tender sinuses. Imaging and biopsy of sinus tissue showed fungal rhinosinusitis caused by zygomycetes. The patient underwent sinus surgery and was started on aggressive antifungal therapy including amphotericin B and iron chelation drugs. Repeat imaging showed the infection spreading in the brain despite initial treatment. His symptoms improved after switching to a higher dose of amphotericin B lipid complex therapy.
JS, a 12-year old girl with type 1 diabetes, has been experiencing episodes of fatigue, weakness, and weight loss. During a soccer game, she felt sick and her blood glucose level was found to be low. She was treated for heat exhaustion. The doctor thinks she may be experiencing diabetic ketoacidosis. Proper management of type 1 diabetes requires lifelong insulin administration, monitoring of blood glucose and ketone levels, and maintenance of a healthy diet and activity levels to prevent dangerous fluctuations.
Mrs. DM is a 35-year-old woman with type 1 diabetes who presents for her annual visit with poorly controlled hypertension and moderate albuminuria. She has been managing her diabetes for 20 years with insulin injections and glucose monitoring. Her medical history is otherwise normal, though she has a family history of cardiovascular disease. Her current medications include insulin, aspirin, and medications to treat her hypertension. Lab work shows her HA1c is elevated at 8.1%, indicating poorly controlled diabetes, and her urine albumin is very high. The patient's physician plans to adjust her insulin and add another antihypertensive medication to improve her diabetes and hypertension management.
1. The document describes the formulation and evaluation of prolonged release metformin hydrochloride tablets. Tablets were prepared by direct compression and wet granulation methods using polymers like Polyox-303 to sustain the release of the drug.
2. Tablets were evaluated for pre-compression and post-compression parameters. In-vitro dissolution and stability studies showed that the formulations had a controlled release of the drug over an extended period of time.
3. The optimized formulation was stable for 1 month under accelerated conditions as per ICH guidelines.
This document discusses the benefits of continuing metformin XR when insulin is added for treatment of type 2 diabetes. It notes that metformin is recommended as first-line therapy in treatment guidelines and can provide cardiovascular benefits when used long-term. When used in combination with insulin, metformin can help control blood glucose levels better while limiting weight gain and insulin requirements compared to insulin alone. The document recommends metformin XR over other formulations due to its once daily dosing and reduced gastrointestinal side effects.
A 50-year-old man with poorly controlled diabetes presented with fever, headache, and right-sided facial swelling. He was found to be septic and further examination revealed tender sinuses. Imaging and biopsy of sinus tissue showed fungal rhinosinusitis caused by zygomycetes. The patient underwent sinus surgery and was started on aggressive antifungal therapy including amphotericin B and iron chelation drugs. Repeat imaging showed the infection spreading in the brain despite initial treatment. His symptoms improved after switching to a higher dose of amphotericin B lipid complex therapy.
Metformin is the first-line treatment for type 2 diabetes. It works by decreasing glucose production in the liver and increasing the body's sensitivity to insulin. Common side effects include gastrointestinal issues. Metformin is excreted through the kidneys, so renal impairment is a contraindication. Proper monitoring of HbA1c and kidney function is important when using metformin.
Metformin A Pharmacological PreespectiveDr. AsadUllah
This document discusses metformin, a first-line oral therapy for treating hyperglycemia. It is prescribed to over 120 million people worldwide. Metformin works by decreasing hepatic glucose production and intestinal glucose absorption. It also has anti-oxidative and anti-inflammatory properties. The document outlines metformin's mechanisms of action, pharmacological actions including its effects on weight, lipids, and insulin sensitivity, as well as its indications for treating conditions like diabetes and polycystic ovary syndrome. Potential side effects and contraindications are also presented. The document concludes by discussing metformin's potential role in cancer prevention and its novel therapeutic applications.
This document discusses the history and uses of the diabetes medication metformin. It traces metformin back to galega officinalis which was used in the Middle Ages to reduce diabetes symptoms. Metformin was first identified and studied in the 1950s and approved for use in the US in 1994. The document highlights that metformin is now recommended as a first-line treatment for type 2 diabetes and has been shown to reduce cardiovascular events and mortality in diabetes patients. Metformin is also effective in preventing or delaying the onset of diabetes in patients with prediabetes.
RECENT ADVANCES IN THE TREATMENT OF DIABETES MELLITUS AND ITS COMPLICATIONSSANJAY YADAV
This document summarizes recent advances in the treatment of diabetes mellitus and its complications. It discusses the classification and pathogenesis of diabetes as well as its major complications affecting the cardiovascular system, eyes, kidneys, nerves and increased risk of infections. The document also reviews recent oral and injectable medications used to treat diabetes, including newer drug classes such as GLP-1 analogues, DPP-4 inhibitors, SGLT2 inhibitors and amylin analogues. It provides details on specific drugs like exenatide, liraglutide and other GLP-1 receptor agonists that mimic the effects of endogenous GLP-1.
The document discusses various aspects of metformin, including:
- Metformin's mechanisms of action involve both direct and indirect activation of AMPK, leading to effects like decreased glucose, lipid, and protein synthesis.
- Studies have shown metformin may be associated with better cardiac outcomes compared to other glucose-lowering drugs and should not be withheld in patients with stable heart disease or heart failure.
- Infants exposed to metformin in utero had increased subscapular skinfolds but similar body fat compared to unexposed infants, potentially signaling healthier fat distribution.
- Metformin may lower B12 levels but does not necessarily cause deficiency if metabolic markers remain normal, as cellular B12 uptake may increase with metformin therapy
The document outlines a protocol for appropriately identifying and treating patients with potential food allergies in a correctional setting. It discusses differentiating true food allergies from food intolerance or aversion. Three case studies are presented and evaluated based on factors like age, food implicated, testing and management history. The goal is to accurately diagnose true food allergies while excluding claimed allergies that are not valid, in order to safely meet dietary needs while preventing manipulation.
Controlling Pharmacy Costs in Correctionsjeffk2996
The document provides tips for reducing pharmaceutical budgets in correctional facilities. It recommends calculating current pharmacy costs per inmate per day and understanding pricing structures like AWP, MAC, and acquisition cost plus. It suggests developing a formulary to choose lower-cost equivalent medications and establishing an OTC commissary. The document also provides examples of large cost differences between branded and generic psychiatric drugs and dosage recommendations from treatment guidelines.
Emergency Chemical Restraint of Violent and Agitated Inmates: Why? When? How?jeffk2996
The document discusses guidelines for the emergency chemical restraint of violent and agitated inmates, including definitions, appropriate situations for use, recommended medication options and dosages, importance of proper documentation, and steps for safely administering chemical restraint. The overall message is that emergency chemical restraint can be a safer alternative to physical restraint for reducing risk of injury when an inmate is an acute danger to themselves or others.
Sample Hypertension Protocol for Correctionsjeffk2996
This document provides guidelines for treating hypertension in jail patients. It defines normal and abnormal blood pressure readings and stages of hypertension. It recommends screening all inmates for hypertension and referring those found to have it for treatment and counseling on lifestyle changes. Treatment involves starting medications like thiazide diuretics and ACE inhibitors and adjusting or adding medications based on the patient's level of blood pressure control. It also provides guidance for treating complicated cases of resistant, urgent, or emergency hypertension.
This document discusses approaches to inmates who refuse food in prison. It defines a true hunger strike as intending suicide for political or religious reasons to generate publicity. Most fasting inmates are not true hunger strikers but have other motives like dieting or mental illness. The approach depends on the individual's intent and health status. A step-by-step process is outlined involving initial interviews, exams, care plans, and legal considerations. For true hunger strikers, involuntary feeding may be necessary weeks into the fast if their health deteriorates.
1) Chest pain is a common complaint in correctional facilities that requires careful risk assessment given the risks of missing acute coronary syndrome.
2) History, physical exam, EKG, and cardiac biomarkers like troponin can help stratify cardiac risk but have limitations and tests results must be interpreted cautiously.
3) For high-risk inmates, further cardiology evaluation is generally warranted even with negative initial tests, while low-risk inmates may not require testing. Proper protocols and documentation are important.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Kosmoderma Academy, a leading institution in the field of dermatology and aesthetics, offers comprehensive courses in cosmetology and trichology. Our specialized courses on PRP (Hair), DR+Growth Factor, GFC, and Qr678 are designed to equip practitioners with advanced skills and knowledge to excel in hair restoration and growth treatments.
DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfRahul Sen
Time-lapse embryo monitoring is an advanced imaging technique used in IVF to continuously observe embryo development. It captures high-resolution images at regular intervals, allowing embryologists to select the most viable embryos for transfer based on detailed growth patterns. This technology enhances embryo selection, potentially increasing pregnancy success rates.
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdfrightmanforbloodline
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
Metformin is the first-line treatment for type 2 diabetes. It works by decreasing glucose production in the liver and increasing the body's sensitivity to insulin. Common side effects include gastrointestinal issues. Metformin is excreted through the kidneys, so renal impairment is a contraindication. Proper monitoring of HbA1c and kidney function is important when using metformin.
Metformin A Pharmacological PreespectiveDr. AsadUllah
This document discusses metformin, a first-line oral therapy for treating hyperglycemia. It is prescribed to over 120 million people worldwide. Metformin works by decreasing hepatic glucose production and intestinal glucose absorption. It also has anti-oxidative and anti-inflammatory properties. The document outlines metformin's mechanisms of action, pharmacological actions including its effects on weight, lipids, and insulin sensitivity, as well as its indications for treating conditions like diabetes and polycystic ovary syndrome. Potential side effects and contraindications are also presented. The document concludes by discussing metformin's potential role in cancer prevention and its novel therapeutic applications.
This document discusses the history and uses of the diabetes medication metformin. It traces metformin back to galega officinalis which was used in the Middle Ages to reduce diabetes symptoms. Metformin was first identified and studied in the 1950s and approved for use in the US in 1994. The document highlights that metformin is now recommended as a first-line treatment for type 2 diabetes and has been shown to reduce cardiovascular events and mortality in diabetes patients. Metformin is also effective in preventing or delaying the onset of diabetes in patients with prediabetes.
RECENT ADVANCES IN THE TREATMENT OF DIABETES MELLITUS AND ITS COMPLICATIONSSANJAY YADAV
This document summarizes recent advances in the treatment of diabetes mellitus and its complications. It discusses the classification and pathogenesis of diabetes as well as its major complications affecting the cardiovascular system, eyes, kidneys, nerves and increased risk of infections. The document also reviews recent oral and injectable medications used to treat diabetes, including newer drug classes such as GLP-1 analogues, DPP-4 inhibitors, SGLT2 inhibitors and amylin analogues. It provides details on specific drugs like exenatide, liraglutide and other GLP-1 receptor agonists that mimic the effects of endogenous GLP-1.
The document discusses various aspects of metformin, including:
- Metformin's mechanisms of action involve both direct and indirect activation of AMPK, leading to effects like decreased glucose, lipid, and protein synthesis.
- Studies have shown metformin may be associated with better cardiac outcomes compared to other glucose-lowering drugs and should not be withheld in patients with stable heart disease or heart failure.
- Infants exposed to metformin in utero had increased subscapular skinfolds but similar body fat compared to unexposed infants, potentially signaling healthier fat distribution.
- Metformin may lower B12 levels but does not necessarily cause deficiency if metabolic markers remain normal, as cellular B12 uptake may increase with metformin therapy
The document outlines a protocol for appropriately identifying and treating patients with potential food allergies in a correctional setting. It discusses differentiating true food allergies from food intolerance or aversion. Three case studies are presented and evaluated based on factors like age, food implicated, testing and management history. The goal is to accurately diagnose true food allergies while excluding claimed allergies that are not valid, in order to safely meet dietary needs while preventing manipulation.
Controlling Pharmacy Costs in Correctionsjeffk2996
The document provides tips for reducing pharmaceutical budgets in correctional facilities. It recommends calculating current pharmacy costs per inmate per day and understanding pricing structures like AWP, MAC, and acquisition cost plus. It suggests developing a formulary to choose lower-cost equivalent medications and establishing an OTC commissary. The document also provides examples of large cost differences between branded and generic psychiatric drugs and dosage recommendations from treatment guidelines.
Emergency Chemical Restraint of Violent and Agitated Inmates: Why? When? How?jeffk2996
The document discusses guidelines for the emergency chemical restraint of violent and agitated inmates, including definitions, appropriate situations for use, recommended medication options and dosages, importance of proper documentation, and steps for safely administering chemical restraint. The overall message is that emergency chemical restraint can be a safer alternative to physical restraint for reducing risk of injury when an inmate is an acute danger to themselves or others.
Sample Hypertension Protocol for Correctionsjeffk2996
This document provides guidelines for treating hypertension in jail patients. It defines normal and abnormal blood pressure readings and stages of hypertension. It recommends screening all inmates for hypertension and referring those found to have it for treatment and counseling on lifestyle changes. Treatment involves starting medications like thiazide diuretics and ACE inhibitors and adjusting or adding medications based on the patient's level of blood pressure control. It also provides guidance for treating complicated cases of resistant, urgent, or emergency hypertension.
This document discusses approaches to inmates who refuse food in prison. It defines a true hunger strike as intending suicide for political or religious reasons to generate publicity. Most fasting inmates are not true hunger strikers but have other motives like dieting or mental illness. The approach depends on the individual's intent and health status. A step-by-step process is outlined involving initial interviews, exams, care plans, and legal considerations. For true hunger strikers, involuntary feeding may be necessary weeks into the fast if their health deteriorates.
1) Chest pain is a common complaint in correctional facilities that requires careful risk assessment given the risks of missing acute coronary syndrome.
2) History, physical exam, EKG, and cardiac biomarkers like troponin can help stratify cardiac risk but have limitations and tests results must be interpreted cautiously.
3) For high-risk inmates, further cardiology evaluation is generally warranted even with negative initial tests, while low-risk inmates may not require testing. Proper protocols and documentation are important.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
Kosmoderma Academy, a leading institution in the field of dermatology and aesthetics, offers comprehensive courses in cosmetology and trichology. Our specialized courses on PRP (Hair), DR+Growth Factor, GFC, and Qr678 are designed to equip practitioners with advanced skills and knowledge to excel in hair restoration and growth treatments.
DECLARATION OF HELSINKI - History and principlesanaghabharat01
This SlideShare presentation provides a comprehensive overview of the Declaration of Helsinki, a foundational document outlining ethical guidelines for conducting medical research involving human subjects.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
NAVIGATING THE HORIZONS OF TIME LAPSE EMBRYO MONITORING.pdfRahul Sen
Time-lapse embryo monitoring is an advanced imaging technique used in IVF to continuously observe embryo development. It captures high-resolution images at regular intervals, allowing embryologists to select the most viable embryos for transfer based on detailed growth patterns. This technology enhances embryo selection, potentially increasing pregnancy success rates.
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdfrightmanforbloodline
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
low birth weight presentation. Low birth weight (LBW) infant is defined as the one whose birth weight is less than 2500g irrespective of their gestational age. Premature birth and low birth weight(LBW) is still a serious problem in newborn. Causing high morbidity and mortality rate worldwide. The nursing care provide to low birth weight babies is crucial in promoting their overall health and development. Through careful assessment, diagnosis,, planning, and evaluation plays a vital role in ensuring these vulnerable infants receive the specialize care they need. In India every third of the infant weight less than 2500g.
Birth period, socioeconomical status, nutritional and intrauterine environment are the factors influencing low birth weight
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Know the difference between Endodontics and Orthodontics.Gokuldas Hospital
Your smile is beautiful.
Let’s be honest. Maintaining that beautiful smile is not an easy task. It is more than brushing and flossing. Sometimes, you might encounter dental issues that need special dental care. These issues can range anywhere from misalignment of the jaw to pain in the root of teeth.
Co-Chairs, Val J. Lowe, MD, and Cyrus A. Raji, MD, PhD, prepared useful Practice Aids pertaining to Alzheimer’s disease for this CME/AAPA activity titled “Alzheimer’s Disease Case Conference: Gearing Up for the Expanding Role of Neuroradiology in Diagnosis and Treatment.” For the full presentation, downloadable Practice Aids, and complete CME/AAPA information, and to apply for credit, please visit us at https://bit.ly/3PvVY25. CME/AAPA credit will be available until June 28, 2025.
Are you looking for a long-lasting solution to your missing tooth?
Dental implants are the most common type of method for replacing the missing tooth. Unlike dentures or bridges, implants are surgically placed in the jawbone. In layman’s terms, a dental implant is similar to the natural root of the tooth. It offers a stable foundation for the artificial tooth giving it the look, feel, and function similar to the natural tooth.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
2. Type 1 DM Case
• 25 year old male, Type 1 diabetic
• Heroin addict, shootin’ and dealin’
• No doctor, doesn’t check blood sugars
• Use regular insulin according to how he feels
• Weight 70 kg
4. Insulin Rule #1
• Basic unit of insulin dosing is Total Daily dose
(TDD)
• TDD for most patients is 0.5-1.0 units/Kg
• Patient one will start with TDD of 35units/day
5. Rule #2
• Half TDD should be Lantus, half Humalog
• Patient one will take 18 units Lantus/day and
18 units of Humalog
6. Rule #3
• Humalog covers what the patient eats, should
be split among the 3 meals
• Easiest if your diabetic diet consists of the
same number of cabs with each meal
• Patient 1: 6 units of humalog each meal
7. Diabetic snack?
• You have to cover it with Humalog if you do
• You have to divide the appropriate number of
daily calories into four parts instead of 3 if you
do
• Easiest to NOT have diabetic snacks.
8. Rule #4
• 500/TDD = carbs covered by each unit of
insulin
• Patient # 1 = 14 Carbs/unit
9. Rule # 5
• 1800/TDD = Blood sugar drop with each unit
of Humalog
• Patient 1: 1800/36 = 50
10. Problems with Sliding Scales
• Reactive, rather than Proactive
• Encourages big fluctuations
• If used, must be frequently assessed. Why is it
needed? Basal insulin dose wrong? Dietary
snacking?
11. Rule #5 Sliding Scale
• Patient 1
– For blood sugars > 400, give 5 extra units of
Humalog
– If used, nurse creates task for provider to review
use the next day
12. Rule # 6 Part A
• Increase insulin by 5-10% every 2-3 days.
• Patient 1: TDD 36
– Increase 4 units, new TDD 40 units
– New Lantus dose 20units/day
– New Humalog dose: 7 units/meal
13. Rule #6 part B
• Add up all of the extra Sliding Scale Units used
to recalculate new TDD
• Patient 1:
– Used an average of 18 extra units/ day
– New TDD: 36 + 18 =54
– New Lantus dose: 27units/day
– New Humalog dose: 9 units/meal
14. Rule # 6
• Note that using sliding scale is a MUCH more
aggressive change in insulin.
• Be careful!
• Consider Rule #7!
15. Rule # 7
• If a diabetic patient’s blood sugars are
consistently high or erratic,
• Check Commissary purchases!
16. Rule # 8
• 20% of patients should have their Lantus
dosed BID
• Levemir does not tend to have this problem as
much
17. Other Considerations
• NPH/Regular insulin 2/3-1/3 Rule
• 2/3 Regular-1/3 NPH (Premixed)
• 2/3 of TDD given in the AM
– Regular covers Breakfast, NPH covers lunch
• 1/3 of TDD given in the PM
– Regular covers Dinner, NPH covers basal night
time.
• “Sloppy.” Inferior to Lantus/Humalog system.
18. Other Considerations
• “Compliance Trap”
• Patients will often need less insulin in jail
because they will be more compliant with
their diet.
19. Type 2 DM Case
• 48 year old patient with Type 2 diabetes.
• Weighs 390 pounds.
• Doesn’t take medication: “I control it with
diet.”
• Initial blood sugar 450
• HbA1C 13.8
• Blood Pressure 186/105
20. Essential Evidence
Type 2 DM Summary
• Intensive blood pressure control and lipid lowering, along with
smoking cessation, reduce complications and mortality in patients
with type 2 diabetes and should be the primary treatment goals. A
• Tight glucose control (hemoglobin A1c < 7.0) reduces microvascular
complications of questionable clinical significance, but does not
improve quality of life or reduce all-cause mortality. A
• Metformin lowers all-cause mortality independent of glycemic
control; similar mortality benefits have not yet been demonstrated
for insulin or the other hypoglycemic agents. A
• In type 2 diabetes, self glucose monitoring does not improve
hemoglobin A1c levels or reduce complications, but does result in
more symptomatic hypoglycemic events. A
21. • THE ACCORD TRIAL AND CONTROL OF BLOOD
GLUCOSE LEVEL IN TYPE 2 DIABETES
MELLITUS: TIME TO CHALLENGE
CONVENTIONAL WISDOM
• Havas, S., Arch Intern Med 169(2):150,
January 26, 2009
22. Summary
• Type 2 Diabetes is managed very differently
than Type 1 Diabetes.
• The only drug shown to reduce long term
Death/MI/stroke is Metformin
• Overly aggressive management causes more
harm than good
• It is more important to lower blood pressure
than to lower blood sugar
23. Summary
• Type 2 diabetes may have more in common
with Celiac Disease than with Type 1 diabetes.
• Disorder of carbohydrate metabolism.
• The key to controlling blood sugar in Type 2
DM is DIET.
• We can influence diet much more in
correctional setting than outside physicians.
25. Diet
• Nutritional considerations in type 2 diabetes mellitus
• Authors
Linda M Delahanty, MS, RD
David K McCulloch, MD
• Section Editors
Rury R Holman, FRCP
Timothy O Lipman, MD
• Deputy Editor
Jean E Mulder, MD
•
• Last literature review version 17.2: May 2009 | This topic last updated: February 5, 2009
• Diet is the most important behavioral aspect of diabetes treatment. Basic principles of nutritional
management, however, are often poorly understood, both by both clinicians and their patients.
• Patients commonly fail to adhere to recommendations for diet and exercise, a source of ongoing
frustration for clinicians in caring for their patients with diabetes. One study, as an example, found
that fewer than 40 percent of patients with diabetes ate within 20 percent of their prescribed diet
[1]. Noncompliance rates among patients with diabetes in another study were 62 percent for diet
and 85 percent for exercise [2].
• Dietary compliance is a major factor in achieving glycemic control in type 2 diabetes.
26. Type 2 Diabetic Snacks
• Diabetic Snack adds calories and carbs
• Bad Idea!
27. When to use additional agents
• Oral Hypoglycemics
• Insulin: Lantus
• Insulin: Humalog
• Additional agents
28. ADA Consensus
• Stepwise Approach to Selecting Treatments for Type 2 Diabetes (American Diabetes Association Consensus Statement)
• Diagnosis of type 2 diabetes1,a
↓
Counsel patients regarding lifestyle modification (weight loss, exercise)
(expected decrease in A1C 1-2%) [well-validated*]
and
Initiate metformin [Glucophage, others] 500 mg once or twice daily,
titrate to 850 mg to 1000 mg twice daily (expected decrease in A1C 1-2%) [well-validated*]
↓
(A1C 7% or greater three months later)
Add sulfonylurea, not glyburide or chlorpropamide (expected decrease in A1C 1-2%)
[well validated*]
or
Add basal insulin (bedtime intermediate-acting insulin or bedtime or morning long-acting insulin)
(expected decrease in A1C 1.5%) [well-validated*]
or
Add pioglitazone [Actos], NOT rosiglitazone [Avandia] (expected decrease in A1C 0.5-1.4%)
[less well-validated]
or
Add exenatide [Byetta] (expected decrease in A1C 0.5-1%) [Insufficient clinical use to be confident regarding safety, less-well-validated]
↓
(A1C 7% or greater three months later)
In those receiving metformin and basal insulin or sulfonylurea, change to metformin plus intensive or basal insulin, respectively [well-validated*]
or
In those receiving metformin plus pioglitazone, add sulfonylurea or change to metformin plus basal insulin [less well-validated]
or
In those receiving metformin plus exenatide, change to metformin plus pioglitazone and sulfonylurea or metformin plus basal insulin [less well-
validated]
↓
(A1C 7% or greater three months later)
In patients not yet receiving metformin plus insulin, change to metformin plus basal insulin [well-validated*]
or
In those receiving metformin plus basal insulin, intensify insulin and continue to adjust [well-validated*]
29. Patient “DM”
(Diabetic Manipulation)
• 30 Y.O. Female, Type 1 DM
• Narcotic addiction
• Takes Lantus 21 units AM and 13 units PM
• Novolog 1 unit for 15 Carbs
30. Patient “DM” Further History
• Chronic abdominal pain syndrome
• Has seen many specialists, many work ups.
• No diagnosis
• Narcotic addiction. In jail for forging narcotic
prescriptions.
32. Patient “DM”
• “My Provider told me that when I am in pain,
my sugars get out of control.”
• C/O abdominal pain and vomiting. “Can’t
Eat.”
• Labs normal
• HSU. Narcotics. Sugars improve.
33. Patient “DM”
• Narcotics DC’d
• Sugars become high again
• “I’d get better if you would treat my pain.”
38. Patient “DM”
• Returns from ER with controlled BS
• Blood sugars uncontrolled next two days
• Vomiting, c/o pain
• “My sugars will improve if you give me
narcotics.”
40. Patient “DM”
• Blood sugars controlled
• Patient remains in reasonable diabetic control
for the remainder of her jail stay (2 months)
41. Other Diabetic Manipulation Tactics
• Get Humalog and then refuse to eat
• Eat, get Humalog, then force oneself to vomit.
• Dip finger tip in sugar to cause artificially high
reading
• Pay other inmates for their commissary items
• Eat other inmates leftovers
• Lie about doses to naïve staff