This document defines type 1 diabetes, discusses its epidemiology, diagnosis, etiology, physiology, presentation, investigations, management, treatment, and complications. The key points are:
- Type 1 diabetes is an autoimmune disease resulting from insulin deficiency. It peaks in children aged 5-7 and during puberty.
- Diagnosis is based on symptoms plus random blood glucose ≥200 mg/dL or fasting blood glucose ≥126 mg/dL.
- Management requires a team approach including specialists, nurses, dietitians, and psychologists. Treatment involves insulin administration and nutrition management.
- Presentations include diabetic ketoacidosis and hyperglycemia. Investigations include blood glucose, HbA1c
Diabetes mellitus (DM) is a common, chronic, metabolic syndrome characterized by hyperglycemia as a cardinal biochemical feature. The major forms of diabetes are classified according to those caused by deficiency of insulin secretion due to pancreatic β-cell damage (type 1 DM, or T1DM) and those that are a consequence of insulin resistance occurring at the level of skeletal muscle, liver, and adipose tissue, with various degrees of β-cell impairment (type 2 DM, or T2DM). T1DM is the most common endocrine-metabolic disorder of childhood and adolescence, with important consequences for physical and emotional development. Individuals with T1DM confront serious lifestyle alterations that include an absolute daily requirement for exogenous insulin, the need to monitor their own glucose level, and the need to pay attention to dietary intake. Morbidity and mortality stem from acute metabolic derangements and from long-term complications (usually in adulthood) that affect small and large vessels resulting in retinopathy, nephropathy, neuropathy, ischemic heart disease, and arterial obstruction with gangrene of the extremities. The acute clinical manifestations are due to hypoinsulinemic hyperglycemic ketoacidosis. Autoimmune mechanisms are factors in the genesis of T1DM; the long-term complications are related to metabolic disturbances (hyperglycemia).
Type 1 Diabetes Mellitus
Formerly called insulin-dependent diabetes mellitus (IDDM) or juvenile diabetes, T1DM is characterized by low or absent levels of endogenously produced insulin and dependence on exogenous insulin to prevent development of ketoacidosis, an acute life-threatening complication of T1DM. The natural history includes 4 distinct stages: (1) preclinical β-cell autoimmunity with progressive defect of insulin secretion, (2) onset of clinical diabetes, (3) transient remission “honeymoon period,” and (4) established diabetes associated with acute and chronic complications and decreased life expectancy. The onset occurs predominantly in childhood, with median age of 7-15 yr, but it may present at any age. The incidence of T1DM has steadily increased in many parts of the world, including Europe and the USA. T1DM is characterized by autoimmune destruction of pancreatic islet β cells. Both genetic susceptibility and environmental factors contribute to the pathogenesis. Susceptibility to T1DM is genetically controlled by alleles of the major histocompatibility complex (MHC) class II genes expressing human leukocyte antigens (HLAs). It is also associated with autoantibodies to islet cell cytoplasm (ICA), insulin (IAA), antibodies to glutamic acid decarboxylase (GADA or GAD65), and ICA512 (IA2). T1DM is associated with other autoimmune diseases such as thyroiditis, celiac disease, multiple sclerosis, and Addison disease. There is some suggestion that high dietary intake of omega-3 polyunsaturated fatty acids and vitamin D supplementation in early childhood decreases the incidence of autoi
Diabetes mellitus (DM) is a common, chronic, metabolic syndrome characterized by hyperglycemia as a cardinal biochemical feature. The major forms of diabetes are classified according to those caused by deficiency of insulin secretion due to pancreatic β-cell damage (type 1 DM, or T1DM) and those that are a consequence of insulin resistance occurring at the level of skeletal muscle, liver, and adipose tissue, with various degrees of β-cell impairment (type 2 DM, or T2DM). T1DM is the most common endocrine-metabolic disorder of childhood and adolescence, with important consequences for physical and emotional development. Individuals with T1DM confront serious lifestyle alterations that include an absolute daily requirement for exogenous insulin, the need to monitor their own glucose level, and the need to pay attention to dietary intake. Morbidity and mortality stem from acute metabolic derangements and from long-term complications (usually in adulthood) that affect small and large vessels resulting in retinopathy, nephropathy, neuropathy, ischemic heart disease, and arterial obstruction with gangrene of the extremities. The acute clinical manifestations are due to hypoinsulinemic hyperglycemic ketoacidosis. Autoimmune mechanisms are factors in the genesis of T1DM; the long-term complications are related to metabolic disturbances (hyperglycemia).
Type 1 Diabetes Mellitus
Formerly called insulin-dependent diabetes mellitus (IDDM) or juvenile diabetes, T1DM is characterized by low or absent levels of endogenously produced insulin and dependence on exogenous insulin to prevent development of ketoacidosis, an acute life-threatening complication of T1DM. The natural history includes 4 distinct stages: (1) preclinical β-cell autoimmunity with progressive defect of insulin secretion, (2) onset of clinical diabetes, (3) transient remission “honeymoon period,” and (4) established diabetes associated with acute and chronic complications and decreased life expectancy. The onset occurs predominantly in childhood, with median age of 7-15 yr, but it may present at any age. The incidence of T1DM has steadily increased in many parts of the world, including Europe and the USA. T1DM is characterized by autoimmune destruction of pancreatic islet β cells. Both genetic susceptibility and environmental factors contribute to the pathogenesis. Susceptibility to T1DM is genetically controlled by alleles of the major histocompatibility complex (MHC) class II genes expressing human leukocyte antigens (HLAs). It is also associated with autoantibodies to islet cell cytoplasm (ICA), insulin (IAA), antibodies to glutamic acid decarboxylase (GADA or GAD65), and ICA512 (IA2). T1DM is associated with other autoimmune diseases such as thyroiditis, celiac disease, multiple sclerosis, and Addison disease. There is some suggestion that high dietary intake of omega-3 polyunsaturated fatty acids and vitamin D supplementation in early childhood decreases the incidence of autoi
MODY is the name given to a collection of different types of inherited forms of diabetes that usually develop in adolescence or early adulthood.
MODY stands for “Maturity-onset diabetes of the young” and was given that name in the past because it acted more like the adult type of diabetes (Type 2 Diabetes) but was found in young people.
MODY limits the body’s ability to produce insulin, but is different than the juvenile type of diabetes (Type 1 Diabetes).
When our bodies don’t produce enough insulin, it can increase blood glucose levels. High blood glucose levels lead to diabetes.
Diabetes mellitus (DM) is a significant public health problem associated with many debilitating health conditions
This presentation will briefly tackle management of Diabetes
Management Of Nephrotic Syndrome
Objectives
To briefly review the definition & etiology of nephroticsyndrome.
To understand the terminology pertaining to clinical course of nephroticsyndrome.
To understand the management of nephroticsyndrome:Specific management & Supportive care and management of complications
Management of congenital nephrotic syndrome
Diabetes mellitus (DM) is a syndrome of chronic hyperglycaemia is due to one of two mechanisms:
Inadequate production of insulin , or
Inadequate sensitivity of cells to the action of insulin.
It affects more than 220 million people worldwide, and it is estimated that it will affect 440 million by the year 2030
"Diabetes" comes from the Greek word for "siphon", and implies that a lot of urine is made.
The second term,"mellitus" comes from the Latin word, "mel" which means "honey", and was used because the urine was sweet.
• The onset of type 1 diabetes may also be associated with sudden weight loss or nausea, vomiting, or abdominal pains, if DKA has developed.
Nursing Management · Monitor blood sugar and use a sliding scale to treat high levels of glucose · Educate patient about diabetes · Examine feet .
Diagnosis involves measuring blood glucose levels. Ongoing specialized assessment and evaluation for complications are essential for diabetes management.
MODY is the name given to a collection of different types of inherited forms of diabetes that usually develop in adolescence or early adulthood.
MODY stands for “Maturity-onset diabetes of the young” and was given that name in the past because it acted more like the adult type of diabetes (Type 2 Diabetes) but was found in young people.
MODY limits the body’s ability to produce insulin, but is different than the juvenile type of diabetes (Type 1 Diabetes).
When our bodies don’t produce enough insulin, it can increase blood glucose levels. High blood glucose levels lead to diabetes.
Diabetes mellitus (DM) is a significant public health problem associated with many debilitating health conditions
This presentation will briefly tackle management of Diabetes
Management Of Nephrotic Syndrome
Objectives
To briefly review the definition & etiology of nephroticsyndrome.
To understand the terminology pertaining to clinical course of nephroticsyndrome.
To understand the management of nephroticsyndrome:Specific management & Supportive care and management of complications
Management of congenital nephrotic syndrome
Diabetes mellitus (DM) is a syndrome of chronic hyperglycaemia is due to one of two mechanisms:
Inadequate production of insulin , or
Inadequate sensitivity of cells to the action of insulin.
It affects more than 220 million people worldwide, and it is estimated that it will affect 440 million by the year 2030
"Diabetes" comes from the Greek word for "siphon", and implies that a lot of urine is made.
The second term,"mellitus" comes from the Latin word, "mel" which means "honey", and was used because the urine was sweet.
• The onset of type 1 diabetes may also be associated with sudden weight loss or nausea, vomiting, or abdominal pains, if DKA has developed.
Nursing Management · Monitor blood sugar and use a sliding scale to treat high levels of glucose · Educate patient about diabetes · Examine feet .
Diagnosis involves measuring blood glucose levels. Ongoing specialized assessment and evaluation for complications are essential for diabetes management.
Diabetes mellitus refers to a group of diseases that affect how the body uses blood sugar (glucose). Glucose is an important source of energy for the cells that make up the muscles and tissues. It's also the brain's main source of fuel.
Exploiting Artificial Intelligence for Empowering Researchers and Faculty, In...Dr. Vinod Kumar Kanvaria
Exploiting Artificial Intelligence for Empowering Researchers and Faculty,
International FDP on Fundamentals of Research in Social Sciences
at Integral University, Lucknow, 06.06.2024
By Dr. Vinod Kumar Kanvaria
A Strategic Approach: GenAI in EducationPeter Windle
Artificial Intelligence (AI) technologies such as Generative AI, Image Generators and Large Language Models have had a dramatic impact on teaching, learning and assessment over the past 18 months. The most immediate threat AI posed was to Academic Integrity with Higher Education Institutes (HEIs) focusing their efforts on combating the use of GenAI in assessment. Guidelines were developed for staff and students, policies put in place too. Innovative educators have forged paths in the use of Generative AI for teaching, learning and assessments leading to pockets of transformation springing up across HEIs, often with little or no top-down guidance, support or direction.
This Gasta posits a strategic approach to integrating AI into HEIs to prepare staff, students and the curriculum for an evolving world and workplace. We will highlight the advantages of working with these technologies beyond the realm of teaching, learning and assessment by considering prompt engineering skills, industry impact, curriculum changes, and the need for staff upskilling. In contrast, not engaging strategically with Generative AI poses risks, including falling behind peers, missed opportunities and failing to ensure our graduates remain employable. The rapid evolution of AI technologies necessitates a proactive and strategic approach if we are to remain relevant.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
June 3, 2024 Anti-Semitism Letter Sent to MIT President Kornbluth and MIT Cor...Levi Shapiro
Letter from the Congress of the United States regarding Anti-Semitism sent June 3rd to MIT President Sally Kornbluth, MIT Corp Chair, Mark Gorenberg
Dear Dr. Kornbluth and Mr. Gorenberg,
The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
harassment and intimidation at the Massachusetts Institute of Technology (MIT). Failing to act decisively to ensure a safe learning environment for all students would be a grave dereliction of your responsibilities as President of MIT and Chair of the MIT Corporation.
This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
unwillingness to rectify this violation through action requires accountability.
Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
students that opportunity and have been hijacked to become venues for the promotion of terrorism, antisemitic harassment and intimidation, unlawful encampments, and in some cases, assaults and riots.
The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
• The Committee on Oversight and Accountability is investigating the sources of funding and other support flowing to groups espousing pro-Hamas propaganda and engaged in antisemitic harassment and intimidation of students. The Committee on Oversight and Accountability is the principal oversight committee of the US House of Representatives and has broad authority to investigate “any matter” at “any time” under House Rule X.
• The Committee on Ways and Means has been investigating several universities since November 15, 2023, when the Committee held a hearing entitled From Ivory Towers to Dark Corners: Investigating the Nexus Between Antisemitism, Tax-Exempt Universities, and Terror Financing. The Committee followed the hearing with letters to those institutions on January 10, 202
Diabetes Mellitus in children for medical students
1.
2. Definition
• It’s a chronic metabolic disorder characterized
by hyperglycemia as a cardinal biochemical
feature, caused by deficiency of insulin or its
action, manifested by abnormal metabolism
of carbohydrates, protein and fat
3. Epidemiology
• Peaks of presentation occur in 2 age groups: at
5-7 yr of age (infectious) and at the time of
puberty (gonadal steroids ).
• Girls and boys are almost equally affected
• There is no apparent correlation with
socioeconomic status.
5. Diagnosis of diabetes is made when:
• Symptoms +
• random BGL ≥ 11.1 mmol/L (≥200 mg/dl) (or)
• Fasting BGL ≥ 7mmol/L (≥ 126 mg/dl)
6. ETIOLOGIC CLASSIFICATIONS OF DIABETES MELLITUS
Type I diabetes: (β-cell destruction, usually leading to absolute insulin deficiency)
-Immune mediated.
-Idiopathic.
Type 2 diabetes: (may range from predominantly insulin resistance with relative insulin
deficiency to a predominantly secretory defect with insulin resistance).
Other specific types :
Genetic defects of β-cell function:Chromosome 7, glucokinase (MODY2)
Genetic defects in insulin action:Rabson-Mendenhall syndrome
Diseases of the exocrine pancreas: Pancreatitis
Endocrinopathies: Cushing disease
Drug- or chemical-induced : Glucocorticoids
Infections:Cytomegalovirus
Uncommon forms of immune-mediated diabetes :Stiff-man” syndrome
Other genetic syndromes sometimes associated with diabetes :Down syndrome
Gestational diabetes mellitus
Neonatal diabetes mellitus
7. Physiology
• The main function of insulin are:
• 1. Reduce glucose by:
• ↓ gluconeogenesis
• ↓ glycogenolysis
• ↑ uptake of glucose by cell
• 2. Inhibit fat breakdown (lipolysis)
• 3. Inhibit protein breakdown (proteolysis)
8. Insulin deficiency will lead to:
1. Hyperglycemia: increase glucose→ osmotic
diuresis → polyuria → dehydration →
compensatory polydepsia.
2. Proteolysis: → weight loss → Polyphagia.
3. Lipolysis: ↑ free fatty acids and
accumulation of acetyl Co-A → Liver → keton
bodies → ketonemia → ketonuria &
Metabolic acidosis.
9. Presentation:
1. Although most symptoms are nonspecific
2. polyuria , polydepsia, Polyphagia & weight
loss.
3. Recurrent infection: skin or UTI.
4. Diabetic Ketoacidosis
10. Investigations:
• Blood glucose : Fasting glucose > 126 mg/dl &
Random > 200 mg/dl.
• HbA1c: (glycated haemoglobin) average over
the last 2-3 months. Measures amount of
glucose that attaches to haemoglobin, The
target HbA1c < 7.5% (58 mmol/mol).
• Ketone testing: either urine strips, or blood.
• Urine: glucosuria & Ketonuria if DKA
suspected.
11. Management
• Need team & Special diabetic Clinic?
• Medical: specialist
• Specialist Nurses:
• Dietitian.
• Psychologist
• Equipments: insulin, glucometer, Ketones
meter and good maintenance.
• Good follow up.
14. Types of presentation
If newly diagnosed:
1. DKA: according to Guideline.
2. Only hyperglycemia.
Already diabetes on insulin therapy with:
1. DKA: according to Guideline.
2. Presence of ketonemia?
3. Only hyperglycemia? Not controlled?
15. 1. Diabetic Ketoacidosis (DKA):
• Occurs when there is profound insulin deficiency.
• It frequently occurs at diagnosis and also in
children and youth with diabetes if insulin is
omitted, or if insufficient insulin is given at times
of acute illness.
• The biochemical criteria for DKA are:
Hyperglycaemia (blood glucose >11mmol/l
(~200 mg/dl))
Venous pH <7.3 or bicarbonate <15 mmol/l
Ketonaemia and ketonuria
16. Management of DKA
• Management should be in centers with experience and
where vital signs, neurologic status, and biochemistry
can be monitored with sufficient frequency to prevent
complications .
• Fluid infusion should precede insulin administration by
1–2 hours;
• an initial bolus of 20 mL/kg 0.9% saline is followed by
0.45% saline calculated to supply maintenance and
replace 10% dehydration.
• Insulin administration (0.1 U/kg/h)
• Potassium (K) must be replaced early and sufficiently.
• Bicarbonate administration is contraindicated.
18. 2. New-Onset Diabetes without
Ketoacidosis
• Ideally, therapy can begin in the outpatient
setting, with diabetic team. (we prefer
admission).
• There are many Insulin regimens for
treatment with many advantages and
disadvantages
• We have to select one ??
19. Insulin regimens
A. Conventional Insulin therapy: Twice daily mixed Insulin.
B. Intensive Insulin therapy:
1. Basal – Bolus(3 Injections):
o 2 bolus of short acting before breakfast and lunch +
o Mixture of short acting and Intermediate acting at evening meal.
2. Basal – Bolus(3 +1 Injections):
o 3 bolus of short acting before breakfast + lunch + evening meal +
o Intermediate acting before bedtime.
3. Basal – Bolus(3 +1 Injections):
o 3 bolus of Rapid acting before breakfast + lunch + evening meal +
o Long acting before bedtime.
4. Basal – Bolus(3 +1 Injections):
o Long acting before bedtime.
o Rapid acting before meal according to Carbohydrate Counting
and Insulin Correction
20. 2. New-Onset Diabetes without Ketoacidosis
Insulin regimens
50% of the total daily dose Rapid -acting insulin
(NovoRapid Pen)
divided up between 3 pre-
meal boluses
50% of the total daily dose long-acting insulin
(Lantus® (insulin glargine
Pen)
single evening injection
Insulin requirements:
Start with 0.5 IU/kg/day
Pre-pubertal 0.7-1.0 IU/kg/day.
During puberty 1 and even up to 2 U/kg/day.
The correct dose of insulin is that which achieves the best glycaemic control
21. BLOOD GLUCOSE MONITORING
• Blood glucose monitoring should ideally be
carried out 4-6 times a day, however, this is
dependent on the availability of testing strips.
• Recommended target blood glucose levels:
Blood Glucose Targets for Most People with Diabetes
During the day 4.5-7mmol/l 80-125mg/dl
Overnight & pre breakfast 5.5 -8mmol/l 100-145 mg/dl
22. Exercise
• Regular exercise; improves glucoregulation by
increasing insulin receptor number.
• No form of exercise, including competitive sports,
should be forbidden to the diabetic child.
• In patients who are in poor metabolic control,
vigorous exercise may precipitate ketoacidosis
because of the exercise-induced increase in the
counter-regulatory hormones.
• A major complication of exercise in diabetic
patients is the presence of a hypoglycemic
reaction during or within hours after exercise.
23. • The major contributing factor to hypoglycemia
with exercise is an increased rate of absorption
of insulin from its injection site.
• In anticipation of vigorous exercise, additional
carbohydrate exchange may be taken before
exercise, and glucose should be available
during and after exercise.
• The total dose of insulin may be reduced by
about 10-15% on the day of the scheduled
exercise.
Exercise
24. Diet
• There are 3 main nutrients in foods—fats,
proteins, and carbohydrates.
• Fats: Fat typically doesn't break down into sugar ,
and in small amounts, it doesn't affect blood
glucose levels.
• Proteins: Protein doesn't affect blood glucose
unless the patient eat more than the body needs.
• Carbohydrates: Carbohydrates affect blood
glucose more than any other nutrient.
25. Diet
• The same total caloric intake as usual in
normal child is given with the same ratio
• 50% CHO
• 35% Fat
• 15% Proteins
• Number of meals is preferred to be three fixed
major with two snakes in between.
33. Screening for complications and associated
conditions
• height and weight & state of injection sites at
each clinic visit.
• Thyroid disease & coeliac disease at diagnosis
and annually.
• annual foot care reviews.
• Regular dental and eye examinations every 2
years.
• from the age of 12 years: blood pressure,
retinopathy, microalbuminuria & S.Creatinine.
34. Special consideration
• Partial Remission or Honeymoon Phase in
Type 1 Diabetes
• Somogi Phenomena
• Dawn Phenomena.
• Management of DM during Infection.
35. Partial Remission or Honeymoon
Phase in Type 1 Diabetes
• Insulin requirements can decrease transiently following
initiation of insulin treatment.
• This has been defined as insulin requirements of less
than 0.5 units per kg of body weight per day with an
HbA1c < 7%.
• Ketoacidosis at presentation and at a young age reduce
the likelihood of a remission phase.
• It is important to advise the family of the transient
nature of the honeymoon phase to avoid the false
hope that the diabetes is spontaneously disappearing.
• Treatment by reduce the dose of Insulin Accordingly.
36. • In children with High dose of Insulin at Night
(Long acting) develop late night(3-4 a.m)
Hypoglycemia Counter regulatory hormon
will increase Early morning Hyperglycemia.
• Treatment: Reduce the dose of Long acting
Insulin at Night .
Somogyi Phenomenon
37. • In children with Normal dose of Insulin at
Night & Normal midnight glucose
(Normoglycemia), Counter regulatory
hormone may normally increase Early
morning Hyperglycemia.
• Treatment: Increase the dose of Long acting
Insulin at Night .
Dawn Phenomenon
38. • Infection may precipitate hyperglycemia or
DKA.
• Mild infection should be treated + increase
the dose of Insulin by 10 – 15%.
• Sever infection necessitate hospitalization.
Management during Infection
39. Important information
• Do not shake the insulin as this damages the
insulin?
• After first usage, an insulin vial should be
discarded after 3 months if kept at 2-8 C or 4
weeks if kept at room temperature.
• Intermediate-acting and short-acting/rapid-
acting insulin, can be combined in one
Syringe.
• Use 4mm needle for injection of Insulin SC.