CDCES Exam (2023) with complete solution
DCCT
The Diabetes Control and Complications Trial (pub. 1993)
The Diabetes Control and Complications Trial (pub. 1993)
1) Showed 60% reduced development of microvascular complications in T1DM w/ INTENSE THERAPY
2) Over 6.5 years, the intense therapy g...
CDCES Exam (2023) with complete solution
DCCT
The Diabetes Control and Complications Trial (pub. 1993)
The Diabetes Control and Complications Trial (pub. 1993)
1) Showed 60% reduced development of microvascular complications in T1DM w/
INTENSE THERAPY
2) Over 6.5 years, the intense therapy group mean A1c was 7% compared to 9% in the
control group
3) Was conducted from 1983 to 1993
UKPDS
The United Kingdom Prospective Diabetes Study (pub. 1998)
The United Kingdom Prospective Diabetes Study (UKPDS, pub. 1998)
1) Followed ppl w/ NEW type 2 for 10 years
2) Intense therapy resulted in mean A1c of <7% which reduced development of micro-
AND macro-vascular complications
3) Also suggested that intensive therapy could reduce risk of stroke and MI in diabetes
ACCORD
Action to Control Cardiovascular Risk in Diabetes (pub. 2008)
Action to Control Cardiovascular Risk in Diabetes (ACCORD, pub. 2008)
1) Compared the effects of intensive BG control and cardiovascular outcomes for ppl w/
DM
2) One arm of this study was terminated early due to the findings that intensive glycemic
control (A1c of <6%) was actually associated with increased mortality of patients
3) Other arms of ACCORD which study lipids and BP are still being carried out today.
Possible causes for elevated post-prandial BG
1) too many carbs in the meal
2) inadequate pre-meal insulin
3) improper/inadequate dosing of oral agents (except metformin)
4) not enough activity in the preceding hours/days
Possible causes for elevated fasting BG
1) not enough basal insulin
2) inadequate oral meds in the evening or bedtime
3) infection (if BG is otherwise usually well-controlled)
Possible causes for BG being elevated allllll of the time
1) Insufficient med doses
2) Patient requires combination therapy
3) Medication hasn't been taken for a long enough time
4) Not enough exercise
5) Too much carb overall
6) Excessive stress
Possible causes for BG being erratic/inconsistent
1) Erratic timing of meals or amount of carbs in meals
2) Irregular insulin injection technique
3) Insulin has lost its potency
4) Excessive stress
,ADA criteria for diabetes diagnosis
A1c > or = 6.5%
OR
FBG of > or = 126 mg/dL (fasting = no kcal for 8 hrs)
OR
2-hr plasma glucose > or = 200 during an OGTT*
(*Per the WHO, an OGTT should be performed using a glucose load of 75 grams)
ADA criteria for the diagnosis of diabetes in CHILDREN
The child must be overweight AND and 2 of the following...
- fam hx of DM in 1st or 2nd degree relatives
- Native American, African American, Hispanic/Latino, Asian American, Pacific Islander
- signs of insulin resistance (i.e. acanthosis nigricans, HTN, dyslipidemia, or PCOS)
- maternal hx of GDM during the child's gestation
For children at risk for DM, what should be tested every 3 years?
Fasting BG should be tested in children at risk for DM every 3 years.
Times when ppl w/ T1DM should test for ketones
- when BG is consistently >300
- if on a weight-loss diet
- when ill (especially if febrile or during infection)
Times when ppl w/ DMII should test for ketones
- when ill
- during infection
- on hypocaloric weight-loss diets
Medicare eligibility requirements
- over 65 yo
- disabled (any age)
- end-stage renal disease (any age)
Medicare - Part A specifics/coverage
- hospitalizations
- skilled nursing
- home health
- hospice
(beneficiary pays deductible)
Medicare - Part B specifics/coverage
- physician office visits
- outpatient services
- laboratory costs
- equipment and supplies
(this is elective and the beneficiary pays premiums)
Medicare - Part C specifics/coverage
AKA "Medicare Advantage"
(pays everything not covered by part A or B)
- extended hospital stays/extra hospital days
*beneficiary pays a monthly premium
Medicare - Part D specifics/coverage
A prescription drug insurance
,- lowers the costs of medications
*beneficiaries have to...
1) pay a monthly premium and...
2) choose drug-coverage from participating private companies
Veterans Administration (VA) insurance specifics/coverage
Full coverage for*...
- veterans suffering from service-related medical conditions
- vets who served in specific wars
- or vets who meet low-income criteria
*vets who don't meet these requirements can also get care with co-payments
Indian Health Services (IHS) insurance specifics/coverage
medical care is provided free of charge to American Indians and Alaska Natives who
are members of federally recognized tribes
TRICARE insurance coverage/specifics
Offers health-care services to...
- active duty military
- retired military
- their relatives
- their survivors
Bureau of Primary Health Care
- provides medical services to vulnerable, underserved people having geographic,
financial, or cultural barriers to health care
- beneficiaries pay on a sliding scale basis at federally qualified centers, many of them
in rural areas
Type 1 DM pathophysiology
- destruction of the beta cells of the pancreas
- Islet cell antibodies appear early in T1 and begin their attack on the pancreas
- onset seems sudden (i.e. hyperglycemia, ketoacidosis, etc) but takes time to develop
- genetic pre-disposition exists BUT many ppl w/ the genetic risk don't develop the
disease
- environmental or viral triggers are thought to be required for T1 to express itself
-
_____-cell antibodies occur early in the course of T1DM and attack the ____ cells
of the pancreas.
Islet cell-antibodies/beta cells of pancreas
A high titer of _______-_______ ________ase is considered the best immunologic
predictor of the development of T1DM.
A high titer of glutamic-acid decarboxylase (GAD) is considered the best immunologic
predictor of the development of T1DM.
Type 2 DM Pathophysiology
- deficient insulin-production from the beta cells is inadequate to meet the body's needs
- at the time of diagnosis, most DM patients have a 50% reduction in beta cell function
- insulin resistance of the receptors on the muscle and liver tissue develops over
YEARS before hyperglycemia presents
- over-production of hepatic glucose (caused by inulin resistance of the hepatic insulin
receptors)
, I______ and a_____ are both ______-regulatory hormones secreted by the ____-
cells of the pancreas in response to a rise in ______.
Insulin and amylin are both gluco-regulatory hormones secreted by the beta-cells of
the pancreas in response to a rise in glucose.
Insulin prohibits glucose production in the l_____ and g_______-release from the
a____-cells of the pancreas.
Insulin prohibits glucose production in the liver and glucagon-release from the alpha-
cells of the pancreas.
Actions of amylin (a gluco-regulatory hormone)
- inhibits glucagon secretion from the alpha-cells of the pancreas
- slows gastric emptying
Glucose metabolism during the FASTING state
- BG is maintained by the liver
- liver makes BG (glyconeogenesis)
- converts stored glycogen into glucose (glycogenolysis)
Glucose metabolism during the FED (phase 1) state
When carbs are eaten, BG increases and...
- plasma insulin levels are high as BG is transported from the blood into tissues
- Concurrently, glucagon levels are low
Glucose metabolism during the POST-ABSORBTIVE (i.e. "fed phase 2") state
- occurs 4-16 hrs after food is eaten
- plasma insulin levels decrease
- plasma glucagon levels increase
ADA guidelines - BG control for hospitalized patients who are critically-ill
- BG range of 140-180 mg/dL
- insulin should be started at >180 mg/dL
ADA guidelines - BG control for hospitalized patients who are NOT critically-ill
- less than 140 mg/dL pre-meal
- random BG of <180 mg/dL
1 in ___ people w/ DM also suffer from depression, though it is often un______
1 in 5 people w/ DM also suffer from depression, though it is often undiagnosed
Ppl w/ DM have a ____-fold risk of developing dental problems
Ppl w/ DM have a three-fold risk of developing dental problems
An_______ is an autonomic neuropathic condition which leads to little or no
production of perspiration in the _______ and _______, resulting in dry and
cracked skin
Anhidrosis is an autonomic neuropathic condition which leads to little or no production
of perspiration in the feet and lower-legs, resulting in dry and cracked skin
A________ n_____ are velvety brown or black lesions found in the folds of the
skin which are associated with obesity and i_____ r______.
Acanthosis nigricans are velvety brown or black lesions found in the folds of the skin
which are associated with obesity and insulin resistance.
These three factors are associated with high risk for dermatitis/cellulitis
1) poor glycemic control
2) neuropathy
3) PVD
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