8/30/17 Flashcards
Behavioral Risk Factors for Type II
Sedentary lifestyle
Overweight: also fat distribution
Smoking: increases with cigs per day and pack years
Sleep: increased if less than 5 hours or more than 9
Unhealthy Diet: red meat and sweets increase
Vitamin D deficiency
Diabetes Prevention Program
Three groups-
- Lifestyle Intervention: achieve and sustain weight loss, increase exercise, education, and dietary goals
- Metformin
- Placebo
Done to overweight patients with high risk for type II
Lifestyle had biggest decrease of incidence relative to placebo, Metformin had lower decrease
Metformin helped more relative to lifestyle changes when fatter
Weight loss was the most effective lifestyle change (better hand diet change and exercise), 1 kg weight loss resulted in 16% reduction in type II incidence
Finnish Diabetes Prevention Study
Overweight people with impaired glucose tolerance (IGT)
Control: diet instruction at start of study
Experimental Group: personal advice given routinely, >5% weight loss, reduce fat intake to less than 30%, increase fiber, exercise 30 mins a day
Experimental diet intervention had less than half of diabetes incidents
Look AHEAD
Action for health in diabetes
Adults with type II, look at incidence of cardiovascular and cerebrovascular events
Control group with usual medical care (diabetes support and education)
Experimental group had usual medical care with intensive lifestyle intervention
Intensive Lifestyle Intervention: lose 7-10% of initial weight, physical activity requirement, calorie and fat restriction
There is an additive beneficial effect to combining pharmacotherapy with lifestyle modification, acts on internal and external environment
Intervention group had better BP, A1C, and lipid levels, also lost more weight
Limitations: unblinded, weight loss from meds, mess were not u inform across groups and some people stopped taking meds
Orlistat: gastric lipase inhibitor reduces fat uptake
Outcome of studying reduction of diabetes medications with lifestyle changes
Patients can reduce the number of diabetes medications or undergo diabetes remission with lifestyle changes
4 Components of Lifestyle Changes
Dietary Consultation (Medical Nutrition Therapy)
Behavioral Modification
Increased Physical Activity Level
Weight Loss
Dietary Consultation (Medical Nutrition Therapy) for Lifestyle Changes of Type II
Optimize A1C, BP, and LDL Cholesterol (ABCs)
No universal meal plan, needs to be individualized
Components-
1. Calorie Intake: balance between calories in/out, calories out measured by total energy expenditure
- Weight Management: different amount of kcal to maintain weight due to differences in RMR, weight loss of 5-10% helps with Glu, HT, and dyslipidemia
- Consistency in Carb Intake: avoid erratic blood sugars and hypoglycemia on fixed insulin doses
- Nutritional Content: specific diet composition in glycemic reduction and CV risk reduction is uncertain, better to choose patient preference to have long term adherence
Macronutrients of Nutritional Content for Lifestyle Changes
High fiber has lower glycemic index
Little difference in A1C or CV risk with low/high carb diets independent of weight loss
Fat quality better than fat quantity, low fat diet had no effect on glycemic control, omega 3-FAs don’t improve glycemic control but help with lipid levels
Protein-
Without kidney problems: high protein diet has conflicting A1C reports, lower lipid levels
With kidney probs: reducing protein in diet doesn’t change glycemic control, CV risk, or decline in GFR
Little evidence that altering macronutrient composition has a significant effect on glycemic control independent of weight loss or effect on reducing CV risk (omega 3, high protein without kidney probs, and higher soy intake with kidney probs are possible exception)
Importance of Glucose Control on Management of Type II
Intensive blood glucose control with sulphonylureas or insulin resulted in better A1C levels, less microvascular problems but no effect on macrovascular problems
Diabetes Regimen
Varies depending on if need insulin
Involves taking meds (insulin or oral meds)
Monitor food intake and blood glucose levels
Checking for ketones
Physical activity
Planning/organizing to have supplies ready for different situations
Alerting others
Complications of no adherence to diabetes regimen
Short term:
High blood glucose, diabetic ketoacidosis, higher A1C, BP, and hospitalizations
Long term: retinopathy, neuropathy, renal disease, amputation, higher LDL, sterility, heetndisease, gastroparesis, peripheral artery disease, death
Compliance
Extent o which patient behavior matches medical advice
Factors related to nonadherence
Patient/family characteristics: adolescents, men, lower SES, minorities
Disease related characteristics: duration, course, severity(real or perceived)
Regimen related characteristics: costs outweigh benefits, side effects
Health care provider/system: need support from medical team, increased contact, and quality doctor-patient relationship
No adherence in youth
Teens more likely to be non-adherent than little kids cuz less parental influence, more peer influence, and seek independence while rebel
Parents see long term while teens are short term
Different levels of motivation and burnout to follow 💯 the whole time
Diabulimia
Involves intentional nonadherence
Skip meals or eat only “free” foods to avoid administering insulin
30% of Type I women omit insulin to lose weight by piss glucose
Not diagnosable condition
Look for increased eating but weight loss, Hyperglycemia, low energy, and frequent urination
Interventions to improve adherence
Educational: help initially but need other interventions for chronic diseases
Organizational: improve doctor-patient relationship, increase access, simplify regimen
Behavioral: assess barriers and encourage incentives, use technology to monitor, changes in behavior
Low flow oxygen delivery
Low flow oxygen cannula: 2 pronged tube that fits in nose, flow rate is 1-6 LPM and generates FiO2 of 24-45%, need humidification if above 4 LPM
Oxygen Mask: flow rates above 5 LPM, for mouth breathers only, uncomfortable and hard to talk
Oxygen Catheter: deliver same rate as oxygen cannula, inserted through nose to above uvula, uncomfortable but would use if one nare is closed
High flow oxygen delivery
High flow oxygen cannula: oxygen flow up to 15 LPM, FiO2 from 57-81%, for severe hypoxemia
High Flow Venturi Mask: FiO2 of 24-50% and depended on the size of the entrapment port, mixes oxygen with room air, when concerned with CO2 retention
Hazards of Oxygen Therapy
- Oxygen toxicity: when given for long enough, free radicals accumulate and damage alveoli which will appear as patchy things in X-ray, damage to CNS and eyes also
- Atelectasis: nitrogen normally used to expand alveoli but gets washed out from high oxygen, alveoli collapse since reduced ability to expand
- O2 Induced Hypoventilation: patients normally rely on CO2 to tell when to breath, COPD people have reduced stimulus to breath since have high CO2 levels built up
- Combustible
Oxygen Tanks
Don’t roll or lean on wall since fire hazard
For transporting patients on oxygen
If PSI is below 300 then get new tank
Pulse Oximetry
Non-invasive monitor for estimate of arterial blood oxyhemoglobin saturation levels, SpO2 is oxygen saturation level
For vital signs, can be used on finger, toes, or earlobe
Uses 2 different wavelength of light
Accuracy check: compare SpO2 on pulse oximeter with patient’s arterial blood levels, check pulse rate with actual pulse
SpO2 of 90% is at least 60 PaO2, 70% SpO2 is close to 40 PaO2
Factors that affect Pulse Oximetry
Presence of HbCO, high levels of metHb, anemia, vascular dyes, dark skin pigmentation, ambient light, poor perfusion, motion artifacts, elevated bilirubin levels, nail polish
Fertilization
- Penetration of the corona radiata
- Penetration of the zona pellucida: sperm that penetrate this extracellular matrix make this layer impermeable to other sperm
- Fusion of the sperm and oocyte cell membranes: the pronuclei of each can fuse to form a zygote
Zygote Journey to Uterus
Start in Fallopian tube
30 hours after fertilization undergo cleavage to make blastomeres that are confined within the zona pellucida in a process called compaction
When enter uterus: 3 or 4 days after fertilization, zygote is a morula with 12-32 cells, blastomeres organize into inner cell mass for the embryo and outer cell mass for placenta
Blastocyst Formation
Morula absorbs fluid after 4 days and gets a blastocyst cavity, now called blastocyst
Inner cells form the stacked embryoblast cells (at the embryonic pole) and the outer cells form the single layered epithelium called the trophoblast (at the abembryonic pole)
Attachment and Differentiation of the Trophoblast
Blastocyst implants into the uterine lining
Syncytiotrophoblast: cells that are directly embedded in the endometrium
Cytotrophoblast: cells that line the wall of the blastocyst
Ectopic Pregnancy
Blastocyst implants in wrong spot
Threaten mom’s life cuz blood vessels rupture at site of embryo growth, often identified by vaginal bleeding or abdominal pain, need drugs or surgery to treat
Common locations-
Within uterine tubes: most common (tubular ampullar)
Within abdomen
Abnormal site within uterus like cervix
Development of Amniotic Cavity
Occurs at day 8
Embryoblast forms 2 layers: the epiblast and the hypoblast (primitive endoderm), now forms bilaminar embryonic disc
Amniotic cavity forms between epiblast and overlying trophoblast
Development of the Chorionic Cavity
Days 10-11
Chorionic Cavity forms by the extraembryonic mesoderm splitting into two layers
Development of the yolk sac
Days 12-13
Primary yolk sac is behind hypoblast
Hypoblast cells have division and split primary yolk in half to form definitive yolk sac and the remnants of the primary yolk sac away from the uterine wall
Use primary yolk sac for nutrient transfer , the extraembryonic mesoderm forming the outer layer of the yolk sac is for hematopoiesis
At 4 weeks the yolk sac is replaced by the embryonic disc
Gastrulation
Formative process by which the 3 embryonic germ layers are formed from the epiblast
Ectoderm, mesoderm, and endoderm
Occurs at day 15-16
First sign is the presence of the primitive streak, defines all major body axes
Major Germ Layers
All derived from epiblast
Ectoderm: nervous system, epidermis, mammary glands
Mesoderm: connective tissue, bones, muscle, heart, kidneys, gonads
Endoderm:epithelial linings, liver, pancreas
Most common cause of spontaneous abortions
Chromosomal abnormalities
