Glucagon Is Secreted from Alpha-Cells, Β Cells Secrete Insulin

Sugar Momma

Quick Facts:

●Glucagon is secreted from alpha-cells, β cells secrete insulin

●The GLUT4 transporter is dependent on insulin

●74% of women with Type 2 Diabetes are obese in the UK.

●Ampicillin has weak oral bioavailability[1] (= the percentage of the drug that reaches the systemic circulation without undergoing[2] changes), amoxicillin has good oral bioavailability

●Biguanide medications decrease absorption of glucose from the G.I. tract and they also decrease hepatic gluconeogenesis and increase peripheral insulin sensitivity. Side effects include nausea, vomiting, diarrhoea, abdominal pain/bloating[3], metallic taste and lactic acidosis.

An example patient case:

A 54 year old obese lady presents to you, a GP (general practictioner) with frequency of micturition[4] and dysuria for the past 2/7. She has also noticed a dull pain [5]in her lower abdomen and feeling “a little under the weather”[6] for quite a while

On examination of the abdominal system you find suprapubic tenderness, a temperature of 38.0 degrees and no other abnormalities.

What are your differentials?

1.Lower Urinary Tract Infection/Cystitis

2.Pyelonephritis

3.Pelvic Inflammatory Disease

Investigations:

●Dipstick[7] urine shows Leu ++, Rbc[8] +, Nitrites ++

●Microscopy, Culture + Sensitivity of a mid stream[9] urine sample shows growth of E Coli

Diagnosis:

Urinary tract infection

Management:

●Antibiotics - Trimethoprim, Nitrofurantoin, (Amoxicillin) or (Ciprofloxacin)

●Investigation of glycosuria - fasting glucose blood test shows 9.6 mmol (conversion mmol to g/L = [X mmol * 0.18], 9.6 * 0.18 = 1.72 g/L) confirming diabetes, likely[10] type 2

Initial diabetes management:

Lifestyle advice: Diet (High fibre, Low glycaemic index sources of carbohydrates, Low fat dairy products, Oily fish, Saturated and trans fatty acids, Limit sucrose containing foods (particularly energy drinks)), Low alcohol, Weight loss if overweight (5-10%), increased physical activity, Smoking cessation ( Diabetes Guidance 2008)

However, the patient returns to see you 3/12 later with an HbA1C above 6.5%. In this case, what oral medication would you use for this obese lady?

●Biguanide (Metformin) An oral hypoglycaemic

Hypertension:

At this consultation you take her blood pressure, and notice that she has a reading of 146/98mmHg. The patient needs to return for 2 further readings before starting her on medication. Both are over 140/80mmHg.

You start this 54 year old caucasian women on an ACE inhibitor. Before starting the ACE inhibitor and for two weeks afterwards, you need to monitor her renal function (U&Es[11]) because there is risk of renal artery stenosis, hyperkalaemia and impaired renal function

Theory of medicine:

Theory of the consultation:

All consultations should follow:

●History

●Examination

●Investigation

●Management

Reasons why information is not disclosed by patients during a consultation:

●Time limitation

●Doctor not listening

●Doctor interrupting

●Depersonalisation

●Explaining away distress as normal

●Attending to physical aspects only

●Use of jargon

A study recorded over 5000 consultations by 74 primary care physicians. It found that in only 23% of the consultations were patients able to finish explanations. The average time to interruption was 18 seconds.

Poor doctor-patient communication leads to the patient being:

●Less likely to adhere to medical regimens

●Less likely to use health care services / seek professional medical help in the future

●Less likely to attend check-ups, screening[12] or other forms of preventive health care

●More likely to experience negative, but largely preventable, health outcomes[13]

Positive effects of good communication include:

●Increased patient satisfaction

●Greater recall of advice

●Greater adherence to treatment plans

●Improvements in disease control markers such as HbA1c and B.P.

●Increased doctor satisfaction and less burnout

Relevant[14] medical science:

●Women more prone to [15]lower UTIs then men because they have a shorter urethra.

●Stratified squamous epithelium lines[16] the urethra, while transitional epithelium lines the bladder[17].

●Common bacteria causing UTI’s include E.coli, Proteus, Klebsiella, Staph. Saprophyticus, Enterococcus

●The E.Coli bacterium is a gram negative rod[18]

●Criteria for diagnosing diabetes: Random venous plasma Glucose >11.1mmol/l (1.99 g/L), OR a Fasting plasma Glucose > 7.0mmol/l (1.26 g/L), OR a plasma glucose concentration >= 11.1 mmol/l 2 hours after an oral glucose tolerance test (NB diagnosis in a patient with no symptoms of diabetes cannot be made on the basis of a single reading. A further plamsa glucose reading with a value within the diabetic range is needed)

●Symptoms which can be found on first presentation with diabetes mellitus type 2 include polyuria, polydipsia, fatigue, blurred[19] vision, weight gain, complications of diabetes

●BMI = Weight (Kg)/ Height squared (M2)

●Diabetes patients are more susceptible to urinary tract infections because the glucosuria aids bacterial growth and they have impaired[20] immunity (glycosylation of antibodies)

●A brief pathophysiology of Type 2 Diabetes: Functionally normal pancreas but decreased peripheral sensitivity to insulin (obesity, receptor defect, decreased receptors) resulting in hyperinsulinemia and eventual diminished insulin secretion

●GLUT2 is on the surface of β cells and GLUT4 found in adipose/muscle tissue cells. GLUT4 uniquely is dependent on insulin for translocation

●Long term consequences of diabetes include:

●Blindness (diabetic retinopathy, glaucoma, cataracts)

●Kidney failure (diabetic nephropathy)

●Nerve damage (diabetic neuropathy)

●Atherosclerosis

●Stroke[21]

●Coronary Heart Disease

●HbA1C is glycosylated Hb and gives an idea of the average blood glucose level over the previous one to three months.

(based on a presentation written by Dr Emma Esquilant)

[1] biodisponibilité

[2] to undergo = subir

[3] bloating = ballonnement

[4] miction

[5] douleur diffuse (opposite of sharp pain)

[6] ne pas se sentir bien

[7] bandelette urinaire (to dip = plonger)

[8] Red Blood Cells

[9] débit

[10] probablement

[11] Urea and Electrolytes

[12] dépistage

[13] résultats

[14] pertinent

[15] être sujet à, enclin

[16] to line = tapisser

[17] vessie

[18] batonnet, bacille

[19] blur = flou

[20] affaibli, détérioré

[21] AVC