Week 5 Review Q's Flashcards
Anatomy of islets of L (1-36) obesity clinical overview (37-55) physiology obesity and diabetes (56-88) integration of fuel metabolism (89-112) Imunopathogenesis of T1DM (113-128) epidemiology of diabetes (129-159) KDA (160-179) clinical medicine (180-188) seminar haemoglobin A1c (189-220) lab investigation for obesity+diabetes (221-227) pancreatic hormones pharma (228-297)
Describe the location of the pancreas
a. intraperitoneal
b. retroperitoneal
b. retroperitoneal
Which of the following parts of the pancreas is relates to the spleen?
a. head
b. tail
b. tail
What two ducts join to secrete enzymes into the duodenum?
pancreatic duct
bile duct
Which part of the pancreas takes up more volume?
a. exocrine
b. endocrine
a. exocrine
Which of the following parts of the pancreas is relates to the duodenum loop?
a. head
b. tail
a. head
Where are the islets of Langerhans more numerous?
tail
Which appears darker in H&E?
a. pancreatic islets
b. pancreatic acini
b. pancreatic acini
Which forms the exocrine function of the pancreas?
a. pancreatic islets
b. pancreatic acini
b. pancreatic acini
Which of the following produces insulin?
a. α cells
b. β cells
c. D cells
b. β cells
Which of the following produces somatostatin?
a. α cells
b. β cells
c. D cells
c. D cells
Which of the following do you expect to become more active after a fatty meal?
a. α cells
b. β cells
c. D cells
a. α cells
because they secrete Cholecystokinin (CCK) and it secretes bile to help digest
What are three things somatostatin inhibits?
α cells
β cells
GH
Where are D cells mostly located?
at the periphery (of islets of langerhan)
Which cell secretes a hormone thats structurally equivalent to Growth hormone-releasing hormone (GHRH)?
a. α cells
b. β cells
c. D cells
c. D cells
somatostatin is structurally the same as GHRH
Which cell secretes ACTH?
a. α cells
b. β cells
c. D cells
a. α cells
Which hormone do you expect to raise in levels if theres a cancer of the center of the pancreatic islets?
insulin
Which cells stimulate the gastric chief cells?
a. D1 cell
b. EC cell
c. F cell
d. Epsilon cell
c. F cell (AKA PP cells)
Which do you expect to inhibit glycogen phosphorylase?
a. insulin
b. glucagon
a. insulin
to stop using glycogen and start making it instead
Which acts to stimulate appetite? What does it release?
a. D1 cell
b. EC cell
c. F cell
d. Epsilon cell
d. Epsilon cell
release ghrelin
Which of the following acts to self-regulate pancreatic secretion activities?
a. D1 cell
b. EC cell
c. F cell
d. Epsilon cell
c. F cell
self regulate by inhibiting bile secretion and pancreatic enzymes
Which secretes Substance P? (what does Substance P mean?)
a. D1 cell
b. EC cell
c. F cell
d. Epsilon cell
b. EC cell
has neurotransmitter properties
What does the EC cell stand for?
Enterochromaffin cell
Which secretes vasoactive intestinal peptide (VIP)?
a. D1 cell
b. EC cell
c. F cell
d. Epsilon cell
a. D1 cell
Which cell acts to stimulate HCO3? Through which enzyme did achieve this?
a. D1 cell
b. EC cell
c. F cell
d. Epsilon cell
b. EC cell
by secreting secretin
Which two are also available in exocrine acini and duct epithelium?
a. D1 cell
b. EC cell
c. F cell
d. Epsilon cell
a. D1 cell
&
b. EC cell
Which cell inhibits intestinal motility and which cell increases it?
a. D1 cell
b. EC cell
c. F cell
d. Epsilon cell
c. F cell (decreases)
d. Epsilon cell (increases)
Which cell is also found in the stomach and parts of the intestine?
a. D1 cell
b. EC cell
c. F cell
d. Epsilon cell
d. Epsilon cell
Where are G cells present? What do they produce?
present in the intestine
make gastrin
(D cells in the islets of Langerhans may also produce gastrin)
A cancer affected the islets of Langerhans and caused ulcerations. Can you explain the mechanism?
hyperactivity of the islets causes high gastrin secretion-> chief cells stimulated-> they produce HCl, which causes the ulcerations
Describe the “abdominal romance” What can go wrong?
the head of the pancreas incircled by the duodenum, this is abdominal romance. But an annular pancreas (which is a congenital anomaly) may occur, and that causes the pancreas to grow and surround the duodenum causing problems.
Reduced insulin and IGF production in the brain causes…
a. diabetes millitus
b. type 1 diabetes
c. type 2 diabetes
d. none of the above
d. none of the above
Reduced insulin and IGF production causes degeneration of brain cells, causing alzheimer’s
What (three things) regulate blood flow to the islets?
blood glucose level
autonomic nervous system
gastrointestinal peptides
What happens to insulin and glucagon levels during cholinergic stimulation?
both increase
What happens to insulin and glucagon levels during adrenergic stimulation?
increase glucagon and inhibit insulin
Which system stimulates glucagon release?
a. parasympathetic
b. sympathetic
c. both
d. neither
c. both
Which system stimulates insulin release?
a. parasympathetic
b. sympathetic
c. both
d. neither
a. parasympathetic
higher incomes are associated with a decreased risk of obesity in which of the following?
a. men
b. women
c. caucasians
d. all of the above
b. women
A person has BMI=25. what does he classify as?
a. underweight
b. normal
c. overweight
d. obese class I
e. obese class II
f. obese class III
c. overweight
A person has BMI=45. what does he classify as?
a. underweight
b. normal
c. overweight
d. obese class I
e. obese class II
f. obese class III
f. obese class III
A person has BMI=19. what does he classify as?
a. underweight
b. normal
c. overweight
d. obese class I
e. obese class II
f. obese class III
b. normal
A person has BMI=35. what does he classify as?
a. underweight
b. normal
c. overweight
d. obese class I
e. obese class II
f. obese class III
e. obese class II
A person has BMI=18.5. what does he classify as?
a. underweight
b. normal
c. overweight
d. obese class I
e. obese class II
f. obese class III
b. normal
less than this is underweight
Which gender is has more obese people?
women
Which gender is has more overweight people?
men
In which gender is age more strongly associated with higher BMI?
women
Which of the following men are more obese on average?
a. post-graduate education
b. primary education only
a. post-graduate
Which of the following are more overweight/obese on average?
a. single individuals
b. married individuals
b. married individuals
Which plays a bigger role in weight control?
a. diet
b. exercise
a. diet
The loss of function of which chromosome causes Prader–Willi syndrome (PWS)?
a. chromosome 21
b. chromosome 4
c. chromosome 19
d. chromosome 15
d. chromosome 15
monogenic cause of weight gain
Which causes weight gain?
a. melanocortin 1 receptor deficiency
b. melanocortin 2 receptor deficiency
c. melanocortin 3 receptor deficiency
d. melanocortin 4 receptor deficiency
d. melanocortin 4 receptor deficiency
satiety vs satiation
satiety= fullness in between meals satiation= instant (while eating etc.)
When are pharmaceutical agents used for weight management?
when BMI is over 30
or
when BMI is over 27 and the patient has a co-morbidity/ failed a previous intervention
When is bariatric surgery used for weight management?
when BMI is over 40
or
when BMI is over 35 and the patient has a co-morbidity
Which type of bariatric surgery is most common?
vertical sleeve gastrectomy
What two things are both causes and symptoms of obesity?
overeating and low physical activity
Whats the likely hood a male above the age of 50 has type 2 diabetes mellitus?
50%
POMC/CART activate which of the following?
a. hunger
b. satiety
b. satiety
What two cytokines are released from adipose tissue?
IL-6
TNF-alpha
What’s the primary function of brown adipose?
thermoregulation
what’s the main difference between brown and beige adipose tissue?
the location
NPY/AgRP activate which of the following?
a. hunger
b. satiety
a. hunger
What produces cytokines to counter-regulate white adipose cytokines?
brown adipose
What type (or types) of adipose tissue is in visceral fat?
white and beige
Who has a high leptin concentration? What are the two ways of lowering it?
high in obese people. they can lower it by fasting or losing body fat mass
Whats is Resistin? What does it do?
it’s a protein hormone that highers serum glucose (by impairing adipose cells from uptaking glucose) and decreases insulin sensitivity (so increasing resistance)
What acts as the feeding center of the body?
lateral nuclei
What acts as the satiety center of the body?
ventromedial nuclei
What occurs when the stomach is stretched and the stretch inhibitory signals are activated?
stretch inhibitory signals are released from the stomach and duodenum by vagi to stop the feeding center
What are the four orexigenic hormones?
NPY
AGRP
cortisol
ghrelin
Whats a Glucagon-like peptide-1 (GLP-1) agonists?
Saxenda
Liraglutide (GLP-1 receptor agonist)
How does GLP-1 (and its analogs) act to decrease obesity?
its usually released subsequent to food intake and stimulates the secretion of insulin, inhibits the release of glucagon, delays gastric emptying, and decreases food intake through increased satiety.
A known diabetic patient has high insulin levels, what can you conclude about the type of diabetes he has?
type 2 (high insulin but insulin resistant)
type 1 has low insulin
What secretes pancreatic polypeptide (PP)?
a. α cells
b. β cells
d. δ cells
e. ε cells
f. F cells
f. F cells
What secretes ghrelin?
a. α cells
b. β cells
d. δ cells
e. ε cells
f. F cells
e. ε cells
Which is found in the endoplasmic reticulum?
a. proinsulin
b. preproinsulin
c. insulin
d. C peptide
b. preproinsulin
Which is found in the golgi?
a. proinsulin
b. preproinsulin
c. insulin
d. C peptide
a. proinsulin
T/F: you can extract the insulin from animals and use it to treat humans
true
What’s the half-life of insulin?
5-8 minutes
along with insulin, what is available in the secretory vesicles of the beta cells?
C peptide (and insulin) are in the secretory granules
During exercise what happens to insulin levels? how about glucagon levels?
decrease insulin
increased glucagon
How do alpha 2-adrenergic agonists affect insulin?
inhibit its release (sympathetic nervous system stimulation)
How does insulin increase glucose uptake in the liver?
a. increase GLUT-1 availability
b. increase GLUT-2 availability
c. increase GLUT-3 availability
d. increase GLUT-4 availability
b. increase GLUT-2 availability
What helps transport/carry glucagon in the serum?
nothing, it’s unbound (tricked you)
How does insulin increase glucose uptake in the muscle/adipose tissue?
a. increase GLUT-1 availability
b. increase GLUT-2 availability
c. increase GLUT-3 availability
d. increase GLUT-4 availability
d. increase GLUT-4 availability
How do beta 2-adrenergic agonists affect glucagon?
stimulate its release (sympathetic nervous system stimulation)
how do ketone bodies affect insulin and glucagon?
stimulate insulin
inhibit glucagon
how many amino acids make up glucagon?
29
how does somatostatin affect insulin and glucagon?
inhibit insulin and glucagon
How does glucose-6-phosphate affect glycogen?
it increases its levels by activating glycogen synthase (a key enzyme in glycogen synthesis) via allosteric stimulation
What enzymes transforms 2 ADP’s to an ATP and AMP?
adenylate kinase (aka myokinase)
AMPK promotes
a. anabolism
b. catabolism
b. catabolism
inhibits anabolic processes that consume ATP, while promoting catabolic processes that generate ATP
Explain how insulin and muscle contractions both enhance glucose uptake.
INSULIN- binds to receptors which cause increased expression of GLUT 4 in sarcolemma
MUSCLE CONTRACTION- causes an increase in AMP and decrease in creatinine phosphate, this activates AMPK, which will increase GLUT 4 expression on T-tubules
(Both insulin and muscle contraction trigger translocation of GLUT-4)
Which (one or multiple) of the following does the brain use for energy?
a. fatty acids
b. glucose
c. ketone bodies
d. amino acids
b. glucose
&
c. ketone bodies
Which (one or multiple) of the following do RBC’s use for energy?
a. fatty acids
b. glucose
c. ketone bodies
d. amino acids
b. glucose
Energy metabolism is controlled by three things. What are they?
insulin, glucagon, catecholamines
Describe how regulatory hormones (ex/insulin) effect:
energy storage
blood glucose
gluconeogenesis
increase energy storage
lower blood glucose
decrease gluconeogenesis
Which (one or multiple) of the following do muscle cells use for energy?
a. fatty acids
b. glucose
c. ketone bodies
d. amino acids
a. fatty acids
b. glucose
d. amino acids
What cell makes the major counter-regulatory hormone?
alpha cells (make glucagon)
Which (one or multiple) of the following does the liver use for energy?
a. fatty acids
b. glucose
c. ketone bodies
d. amino acids
a. fatty acid (oxidization)
What is the major regulatory hormone?
insulin
Whats the most important glucose-sensing cell in the body?
beta cells
After a meat-filled meal, describe insulin and glucagon levels. Why does this occur?
both increase (amino acids stimulate both). insulin increases immediately after high amino acid levels, and glucagon increases to stop hypoglycemia due to the insulin release.
Explain how beta cells trap glucose inside cells via phosphorylation?
they’re glucose-sensing cells that have GLUT-2 transporters and glucokinase activity. So they phosphorylate glucose based on the amounts they sense
What are incretins? What do they do?
they’re a group of metabolic hormones that stimulate a decrease in blood glucose levels by increasing insulin
How does insulin affect the following
liver gluconeogenesis
glycolysis
Suppresses liver gluconeogenesis
Stimulates glycolysis
How does high glucose decrease beta oxidization?
high glucose produces more Acetyl-CoA which becomes Malonyl-CoA. Malonyl-CoA inhibits carnitine palmitoyltransferase-1, which is needed to transport the free fatty acids to the mitochondria to start beta oxidization.
What does perilipin phosphorylation do?
help mobilize the triglycerol (free the fat and let HSL do its thing- which is hydrolyze the fat esters)
What occurs if the keto diet is applied?
a. high insulin/glucagon ration
b. low insulin/glucagon ration
b. low insulin/glucagon ration
What happens to glycogen and fat stores during an acute stress response?
epinephrine released causing glycogen breakdown and lipolysis
Which of the following has a thermogenic effects on brown adipose tissue?
a. Glucocorticoids
b. Growth hormone
c. Thyroid hormones
d. Cortisol
e. Epinephrine
c. Thyroid hormones
Thyroid hormones Sensitize which two organs to the effects of epinephrine.
liver and adipose tissue
Which of the following has anti-insulin activity while also stimulating insulin secretion?
a. Glucocorticoids
b. Growth hormone
c. Thyroid hormones
d. Cortisol
e. Epinephrine
b. Growth hormone
Which two mechanisms cause type 1 diabetes?
Delayed-type hypersensitivity
cytotoxic T cell
What initially causes autoimmune destruction in type 1 diabetes?
abnormal expression of HLA molecules (class 2 MHC) in beta cells
You biopsy the islets of Langerhans of a patient with type 1 diabetes, what do you see?
lymphocytic infiltration
A cell of an animal with type 1 diabetes was given to a healthy counterpart. The counterpart also got diabetes. What cell is capable of doing this and how?
Th1 cells, they activate other cell types leading to the formation of inflammation, damage, then disease
What causes the damage to beta cells in type 1 diabetes?
cytokines (IFN-gamma and TNF-alpha), enzymes, and cytotoxic T cells (mainly kills via apoptosis)
Whats the difference between necrosis and apoptosis?
apoptosis is mediated from the inside of the cell while necrosis is death from the outside
T/F: Necroptosis is like both necrosis and apoptosis, using caspases to occur
false, it’s caspase independent
Autoantigens against which of the following is a marker for type 1 diabetes?
a. GAD
b. Insulin
c. IA-2
d. all of them
e. none of them
e. none of them
a diagnostic marker needs to be available in close to 100% of the cases
Autoantigens against which of the following is the first to appear in T1DM (type 1 diabetes mellitus)?
a. GAD
b. Insulin
c. IA-2
d. all of them
e. none of them
b. Insulin
Autoantigens against which of the following is found in 70% of T1DM cases?
a. GAD
b. Insulin
c. IA-2
d. all of them
e. none of them
a. GAD
can you conclude that a patient has T1DM if autoantigens against GAD, Insulin, and IA-2 are present?
yes
What genetic component can most accurately predict T1DM?
HLA genes
DR3-DQ2 OR DR4-DQ8
T/F: gut microbiota plays a role in development of T1DM
true
Which of the following can reduce recurrence of disease?
a. Stem cell transplant
b. Azathioprine
c. Pancreatic transplantation
d. Islet cell transplantation
e. Anti-T cell antibodies
f. Cyclosporin
f. Cyclosporin
Which of the following is relatively non-invasive?
a. Stem cell transplant
b. Pancreatic transplantation
c. Islet cell transplantation
c. Islet cell transplantation
Which of the following can lower HbA1c?
a. Stem cell transplant
b. Azathioprine
c. Pancreatic transplantation
d. Islet cell transplantation
e. Anti-T cell antibodies
f. Cyclosporin
e. Anti-T cell antibodies
A study was done to see the prevalence of T2DM among Chinese people living in different countries. Whats FALSE about this study?
a. suggests that life style plays an important role in T2DM
b. it does not limit genetic makeup as a confounder
b. it does not limit genetic makeup as a confounder
(it does limit gentics as a confounder. That just means that it made sure the genetics are the same so the study finds the effect of environment on T2DM)
What are two risk factors of T2DM?
high fat diet
obesity
What can we assume from a cohort study relating higher HgbA1 to heart conditions?
a. the higher the HgbA1 the greater likelihood of heart conditions
b. they are correlated
c. one aspect causes the other
b. they are correlated
its a correlation study, it doesn’t indicate causation
What can we assume from a randomized control study relating higher HgbA1 to heart conditions?
a. the higher the HgbA1 the greater likelihood of heart conditions
b. they are correlated
a. the higher the HgbA1 the greater likelihood of heart conditions
(randomized control studies determine causation)
Whats the prevalence of T2DM in kuwaitis above the age of 60?
a. 19%
b. 7%
c. 36%
d. 63%
d. 63%
he brings questions with precentages
How can we reduce macro/microvascular outcomes of diabetes mellitus?
intensive glucose control
Does a tighter control of hypertension reduce risk of complications in T2DM? If yes, by how much?
yes, in total it reduces risk by 25%
Which THREE of the following has a statistically significant reduction after tighter control of hypertension?
a. myocardial infections
b. stroke
c. peripheral vascular disease
d. microvascular diseases
e. total mortality
f. diabetes death
b. stroke & d. microvascular diseases & f. diabetes death
Which of the following does adding ace-inhibitors to the hypertension regimen decrease?
a. microvascular diseases
b. macrovascular diseases
b. macrovascular diseases
Which drug was shown to reduce cholesterol by 24% in DM patients?
simvastatin
T/F: diabetes is growing 5 times faster than the population growth
10 times faster
What percent of T2DM cases are undiagnosed?
40%
Whats the ratio of DM in boys vs girls?
3.0 boys : 1.7 girls
Which HLA type does the majority of people with DM have?
DR3 or DR4
Why are there seasonal variations in new cases of DM?
due to viral infections (more common in winter, so more cases)
(why? infections and stressors cause an increase in counter-regulatory hormones, like cortisol and glucagon, and they counter regulate the insulin and so insulin demand is higher)
Explain the thrifty gene hypothesis?
a theory that says that people who have rapid food storage would survive more because they would have extra storage to get through famine or starvation.
Which age group has the highest susceptibility to diabetes?
65-74
Whats the metabolic syndrome?
a group of conditions that hangout together (obesity, T2DM, hyperlipidemia, high BP)
T/F: women who get gestational diabetes have a higher risk of getting diabetes later
true
How does DM increase the risk of death?
X2 risk of death
Which two of the following studies find macrovascular event reduction?
a. The UKPDS-33 Study
b. The DCCT Trial
c. The MICRO-HOPE Trial
d. UKPDS-38
e. Heart Protection Study
c. The MICRO-HOPE Trial
&
e. Heart Protection Study
Which of the following does the UKPDS-38 study find a reduction in?
a. microvascular diseases
b. macrovascular diseases
a. microvascular diseases
Which of the following test patients with T2DM?
a. The UKPDS-33 Study
b. The DCCT Trial
c. both
d. neither
a. The UKPDS-33 Study
Which of the following test the affects of intensive insulin treatment?
a. The UKPDS-33 Study
b. The DCCT Trial
c. both
d. neither
c. both
Does fetal life have an effect on chronic diseases?
yes, fetal life, childhood, and adolescence all determine the trajectory that results in higher or lower risk
When are chronic disease risk factors established?
before adulthood, they establish the risk factors and the trajectory is somewhat set. If they start at a higher risk in adulthood, they’re then likely to get the bad outcomes.
Which uses ramipril? (what is ramipril and what does it do?)
a. The UKPDS-33 Study
b. The DCCT Trial
c. The MICRO-HOPE Trial
d. UKPDS-38
e. Heart Protection Study
c. The MICRO-HOPE Trial
ramipril is the ace inhibitor. if you add it to the regimen you decrease macrovascular events
Which uses simvastatin? (what is simvastatin and what does it do?)
a. The UKPDS-33 Study
b. The DCCT Trial
c. The MICRO-HOPE Trial
d. UKPDS-38
e. Heart Protection Study
e. Heart Protection Study
simvastatin is a lipid-lowering medication. using it reduces macrovascular events by 24%
Which of the following found a decrease in macrovascular complications?
a. The UKPDS-33 Study
b. The DCCT Trial
c. both
d. neither
d. neither
they both found decreased microvascular complications
Which of the following test patients with T1DM?
a. The UKPDS-33 Study
b. The DCCT Trial
c. both
d. neither
b. The DCCT Trial
Which tests tight vs less tight BP control?
a. The UKPDS-33 Study
b. The DCCT Trial
c. The MICRO-HOPE Trial
d. UKPDS-38
e. Heart Protection Study
d. UKPDS-38
Patients with which are more likely to get diabetic ketoacidosis (DKA)?
a. T1DM
b. T2DM
a. T1DM
What true about insulin action when having low insulin levels?
the insulin is not as effective when there are low levels of it (why? because when insulin is low, glucagon is activated and it activates downstream pathways that go against insulin)
Which of the following is a symptom of DKA?
a. dehydration
b. abdominal pain
c. kussmal’s respirations
d. hypothermia
b. abdominal pain
the rest were signs, not symptoms
What happens to the pH and bicarbonate levels as DKA becomes more severe?
pH is lowered (more acidic)
bicarbonate levels decrease (less of the basic bicarb.)
What do SGLT2 inhibitors do?
they inhibit resorption of glucose
When should you give dextrose to a patient with DKA? Why would they need more sugar?
you give it if blood glucose is less than 14. They have low sugar because you gave them a whole liter of normal saline and that diluted the sugar concentration in the blood.
Why do we give insulin to a patient with DKA?
a. to reduce sugar
b. to reduce ketones
b. to reduce ketones
How much normal saline do you give a patient with KDA?
one liter
Which must you do if a DKA patient has normal K?
a. don’t give K
b. add 40mmol/L to each normal saline liter
c. don’t give insulin until K is corrected
b. add 40mmol/L to each normal saline liter
Always give K because they have a TOTAL K deficiency
Which must you do if a DKA patient 1.5 mmol/L of K?
a. don’t give K
b. add 40mmol/L to each normal saline liter
c. don’t give insulin until K is corrected
c. don’t give insulin until K is corrected
(this concentration is too low, if you start insulin therapy the K will go inside the cell and thus K is further decreased leading to serious damage)
What three things can you adjust the insulin rate according to?
ketones
glucose
bicarbonate
Which must you do if a DKA patient 4.6 mmol/L of K?
a. don’t give K
b. add 40mmol/L to each normal saline liter
c. don’t give insulin until K is corrected
b. add 40mmol/L to each normal saline liter
In what case of KDA do you give bicarbonate replacement?
when pH less than 6.9
In what case of KDA do you give IV phosphate replacement? Why?
when phosphate is less than 0.32mmol/L, less than this amount is associated with cardiac and muscle dysfunction.
Which is taken once a day?
a. basal insulin
b. bolus insulin
a. basal insulin
A patient with diabetes weighs 88Kg. What is the subcutaneous starting total dose per day? What are the basal/bolus units?
44 total dose units
taken as 22 basal and 22 bolus
(subcutaneous starting dose is 0.5 units per Kg BUT when a patient has DKA and you start giving them insulin via IV its 0.5 units/Kg/hour)
You see your diabetic friend inject insulin after eating pasta, what type of insulin do you think it is?
a. basal insulin
b. bolus insulin
b. bolus insulin
correct temporary glucose elevation
What glucose level must the patient reach to be able to resolve DKA? What other tests must they pass to be considered resolved of DKA?
less than 11mmol/L
(they must also pass two of the following three: bicarb more than or equal to 15, Ph more than 7.3, anion gap less than or equal to 12)
Should you give IV phosphate replacement to DKA patients? Why?
no, it can precipitate hypocalcemia and it doesn’t benefit
only given if phosphate is less than 0.32mmol/L though
How do you switch from IV insulin to subcutaneous insulin?
As you switch, continue giving IV insulin 2 hours after the subcutaneous injection (this gives it time to absorb)
What three components cause diabetic foot disease?
neuropathy
ischemia
infection
What usually starts the ulcer formation of diabetic foot disease?
most common cause are plaques of callus skin (which becomes necrotic and breaks through the skin surface)
What can you assume about a diabetic foot that has a white residue?
fungal infection (usually starts between the toes) (look at the picture in the clinical skills lab)
The diabetic patient has a non-healing foot ulcer and he doesn’t consent to amputation. What can you do?
surgically remove the necrotic tissue from the ulcer (until you get to clean, wet-looking tissue) then the ulcer is more likely to heal
Why do diabetic patients have decreased vision?
optic nerve involvement
The pupil of the eye of a diabetic patient appears white. What is this?
cataract (occurs in young age)
What is the macula?
is the functional center of the retina. It gives us the ability to see “20/20” and provides the best color vision.
Why do diabetic patients get hemorrhage in the retina?
retinal blood vessels become more permeable
patients usually also have high BP and inflammatory cells that both also contribute
How can scatter laser treatment aka panretinal photocoagulation help prevent diabetic retinopathy?
they use the laser to burn off the abnormal blood vessels and prevent hemorrhage
What is the normal result of fasting blood sugar level test?
normal= less than 100 mg/dL (5.6 mmol/L) prediabetic= 100 to 125 mg/dL (5.6 to 6.9 mmol/L) diabetes= 126 mg/dL (7 mmol/L) or higher on two separate tests
What is the normal range for the hemoglobin A1c level?
normal= 4% - 5.6% prediabetic= 5.7% - 6.4% diabetic= 6.5% or higher
(the precentage is basically the number of Hb bound to sugar divided by total Hb)
What two tests can be used to measure blood glucose levels?
High Performance Liquid Chromatography (HPLC) (tests HbA1c)
Immunoassay
What gene mutation can interfere with High-Performance Liquid Chromatography (HPLC) results?
hemoglobin Wayne
What produces HbA1c?
a. glycation
b. glycosylation
a. glycation
glycation VERSUS glycosylation
glycation= non-enzymatic glycosylation, it occurs spontaneously so it may disrupt protein conformation and cause the loss of the biological function of the proteins glycosylation= a controlled process, so it actually helps the proteins do their thing (their function)
After discovering that a patient has a high glucose level, the doctor prescribed a higher dose of insulin. Then, a month later he had them take a HbA1c test, what do you expect the findings to be and why?
the HbA1c would be high because they reflect the last three months of glucose levels. A month of low glucose does help the HbA1c levels decrease, but they would still be high.
Formation of which of the following is a reversible reaction?
a. ketoamine
b. aldimine
b. aldimine
Making Schiff base is a(n)
a. reversible reaction
b. irreversible reaction
a. reversible reaction
You cook a steak to a well-done state, and it has a crispy brown exterior. What is this an example of?
Maillard reaction
Advanced glycation of free amino groups on proteins and amino acids
Formation of which of the following is formed via the Amadori rearrangement?
a. ketoamine
b. aldimine
a. ketoamine
Making an Amadori produce a(n)
a. reversible reaction
b. irreversible reaction
b. irreversible reaction
How can we reverse the Schiff base?
lowered glucose concentration will unhook the sugars from the amino groups to which they are attached
“Maillard reaction”, is influenced by what factors?
intracellular glucose concentrations, pH, and time. (she also said temperature)
Which are more efficient initiators of intracellular advanced glycation? WHY?
a. glucose
b. glucose metabolites
b. glucose metabolites
(glucose exists as glucopyranose, which is cyclic. So it can hide its -CHO ring from the reactions. However, glucose metabolites ex/short-chain intermediates cannot hide their reactive bits. so, BOOM, glycation occurs)
WHat two things increase AGEs?
hyperglycemia and oxidative stress (ROS)
Describe the relationship between AGE and ROS.
ROS causes AGE formation. and AGE formation causes ROS release. its a cycle!
Where are AGEs more rapidly generated?
within cells
How do alterations in the krebs cycle or the pentose phosphate pathway increase AGEs?
the alterations cause more glucose intermediate release ex/short-chain intermediates (leftover from the bad pathways) those intermediates stimulate AGEs and are much more easily glycosylated
What occurs in the liver and kidney when AGE binds with the receptor (RAGE)?
liver phagocytosis activates kidney clearance (receptors) activate
Where is RAGE highly expressed? What is its function?
in mucous membranes; its function is activating immune and inflammatory reactions
give two sources of extracellular AGEs
burned/crispy/brown meat
smoking
give me five AGE associated conditions
Atherosclerosis Stroke Diabetic Retinopathy Alzheimer’s Disease skin aging
What tests are used to measure renal function?
urea (released by kidneys)
creatinine (waste product produced by muscles and is released by kidneys)
albumin (if found in urine then problem)
What can prevent chronic diabetes complications?
maintaining a normal level of sugar in blood
What are HbA1c levels better indicators of?
a. pre-diabetic patients
b. risk of diabetic complications
b. risk of diabetic complications
HbA1c= realted to risk of retinopathy
Also it’s less specific indicator of pre-diabetes (than a normal impaired fasting glycemia test)
What can we use to reduce HbA1c levels?
IV iron and erythropoietin stimulating agents
they do this without altering glycemic control
T/F: anemia is more frequent in diabetic patients with kidney disease than nondiabetic patients with kidney disease
true
Which patients present false HbA1c values?
patients with anemia or renal disease (and ones with hemoglobin variants)
Why do some conditions present false HbA1c values?
Any condition that affects the blood may alter the levels. If they have anemia, for example, it may lower the life span of RBC’s and decrease HbA1c. If the disease increases the RBC life span (EX/ prenicous anemia) then the HbA1c levels will increase. Chronic Renal Failure also lowers the HbA1c readings (shorter RBC life) and may sometimes even higher the readings (no erythropoietin).
Describe the relationship between RBC lifespan and HbA1c levels?
shorter life span -> low HbA1c levels
higher life span -> high HbA1c levels
Which of the following do you expect to have low HbA1c levels? Explain.
a. liver disease
b. jaundice
a. liver disease (it’s associated with anemia and decreased RBC life, thus low HbA1c)
however jaundice increases bilirubin and that increases HbA1c
Which tests are used to diagnose diabetes?
fasting sugar blood test
HbA1c blood test
Oral glucose tolerance test (OGTT)
How does insulin and bicarbonate affect potassium levels?
decrease them by forcing K inside cells
microalbuminuria is a marker for which two diseases?
renal damage and cardiovascular disease
Which affects T2DM patients more?
a. Diabetic ketoacidosis
b. Nonketotic hyperglycinemia
b. Nonketotic hyperglycinemia
(also called Hyperosmolar Hyperglycemic Nonketotic Syndrome)
(DKA more in T1DM)
Describe the glucose levels in Diabetic ketoacidosis versus Nonketotic hyperglycinemia
Diabetic ketoacidosis (high but still) less than 35mmol/L Nonketotic hyperglycinemia more than 35mmol/L (very, very high)
What are two reasons a diabetic patient may collapse and die?
MI or Stroke
What three things are required to diagnose Hyperglycaemic Hyperosmolar Nonketotic Coma (HONK)?
Plasma osmolarity > 320 mOsm/l
serum glucose > 35 mmol/L
Negative/low level ketone
generally speaking, the structure of insulin is
a. acidic
b. based
a. acidic
Describe the structure of insulin
two peptide chains referred to as the A chain and B chain. A and B chains are linked together by two disulfide bonds, and an additional disulfide is formed within the A chain
What is more common in the body, insulin or proinsulin?
insulin
Which is found in the rough ER?
a. preinsulin
b. proinsulin
a. preinsulin
What two things are found in beta granules?
C peptide and insulin
low C peptide means you have diabetes
What aids beta granule fusion to the plasma membrane?
myosin filaments
Which is found in the Golgi?
a. preinsulin
b. proinsulin
b. proinsulin
What the main stimulus for insulin secretion?
glucose
What traps glucose in the cell? Which enzyme used?
adding a phosphate traps it in, and hexokinase does that
What is needed for calcium to activate protein kinase in beta cells?
Ca needs to bind to calmodulin (two Ca can bind to it) to phosphorylate protein kinase
Which of the following releases Ca from the SR?
a. Inositol 1,4,5 Triphosphate
b. Diacylglycerol
a. Inositol 1,4,5 Triphosphate
Which is activated when epinephrine mediates insulin secretion?
a. phospholipase C
b. protein kinase
c. adenyl cyclase
c. adenyl cyclase
Which adrenoreceptor activates insulin secretion when stimulated?
a. alpha 2
b. beta 2
b. beta 2
alpha 2 inhibit insulin secretion
Which is activated when acetylcholine mediates insulin secretion?
a. phospholipase C
b. protein kinase
c. adenyl cyclase
a. phospholipase C
Which of the following phosphorylates (activates) protein kinase?
a. Inositol 1,4,5 Triphosphate
b. Diacylglycerol
b. Diacylglycerol
Which hormone activates both insulin and somatostatin?
glucagon
What percent of insulin released from the body doesn’t make it to circulation? Why? How does it get inactivated?
40-50% doesn’t make it through the first-pass metabolism. The disulfide bonds get hydrolyzed
Whats the half-life of insulin?
5-7 minutes (very short)
Which part of the insulin receptor does insulin bond to?
alpha subunit
What happens to the insulin receptor once insulin binds?
binding activates autophosphorylation of beta subunit, that activates tyrosine kinase which then activates PI3 kinase
The beta subunit of the insulin receptor is bound to which enzyme?
tyrosine kinase
Besides the amount of insulin, what three factors affect insulin action?
number of receptors
affinity of insulin to receptors
amount of intracellular mediators made after receptor activation
What two insulin types are used for patients in a diabetic coma? Why?
Lisopro Insulin
Crystalline Zinc Insulin (regular insulin)
we use them because they’re admitted via IV and they’re fast acting
How is Lisopro Insulin prepared?
proline B28→proline B29
lysine B29 → lysine B28
(basically proline of B28 is switched with lysine of 29)
Intermediately acting insulin has an onset of
1-2 hours
What two insulin types can be admitted via IV and can be mixed with other insulin types?
Lisopro Insulin
Crystalline Zinc Insulin (regular insulin)
long-acting insulin has an onset of
4-8 hours
Which is made by this process: basic insulin reacts with protamin and zinc, then dissolve with phosphate buffer.
a. Lente
b. Isophane (NPH)
c. Ultralente
d. Glargine
b. Isophane (NPH)
Which of the following has a duration of 36 hours?
a. Lente
b. Isophane (NPH)
c. Ultralente
d. Glargine
c. Ultralente
How is the Glargine (long-lasting insulin) made?
Asparagine→ Glycine (substitute in alpha chain)
then in beta chain the added two more Asparagines
How can we make insulin last longer without changing its formula?
delay the rate of absorption
Which of the following decreases insulin requirements?
a. pregnancy
b. surgery
c. thiazide diuretics
d. chronic exercise
d. chronic exercise
What should you give a hypoglycemia patient that is conscious?
sugar
Which of the following has no peak? What does this mean about the drug?
a. Lente
b. Isophane (NPH)
c. Ultralente
d. Glargine
d. Glargine
its not likely to produce hypoglycemia because its so stable
What should you give a hypoglycemia patient that is unconscious?
glucagon
Which increases insulin sensitivity?
a. Metformin
b. Tolbutamide
c. Rosiglitazone
d. Sitagliptin
e. Exenatide
c. Rosiglitazone
How does Acarbose work?
Reduce blood glucose by making the GI stop glucose uptake
Generally speaking, how do Sulfonylureas drugs work?
antidiabetic drugs that increase insulin release from the beta cells in the pancreas. (primarily works by increasing glucose-mediated insulin secretion)
Which Sulfonylurea has the highest duration of action?
Chlorpropamide (the first generation, works for 60 hours)
What occurs when Sulfonylureas drugs bind to sulfonylurea receptors?
they block ATP sensitive K channels, causing depolarization of cell and then release of insulin
Which K channel subunit do most Sulfonylureas drugs bind to?
a. 65Kd
b. 140Kd
b. 140Kd
Which sulfonylureas drug should be used for people with heart conditions? why?
glimepiride should be used because it binds to the 65Kd subunit of the K channels. The 65Kd subunit is found in beta cells and NOT in the cardiovascular system. So the heart would be unaffected by the medications.
Which of the following sulfonylureas drugs causes an adverse reaction to alcohol leading to nausea, vomiting, flushing, dizziness, & throbbing headache (disulfiram-like effect)?
a. Glipizide
b. Chlorpropamide
c. Glimepiride
d. Glyburide
b. Chlorpropamide
causes a disulfiram effect AKA disulfiram syndrome
Which K channel subunit does glimepiride bind to?
65Kd subunit
Which of the following is 50% excreted in the feces?
a. Glipizide
b. Chlorpropamide
c. Glimepiride
d. Glyburide
d. Glyburide
Which of the following has the highest potency?
a. Glipizide
b. Chlorpropamide
c. Glimepiride
d. Glyburide
c. Glimepiride
Which of the following has the lowest potency?
a. Glipizide
b. Chlorpropamide
c. Glimepiride
d. Glyburide
b. Chlorpropamide
its first generation, duh
Which of the following can be given to pregnant women?
a. Glipizide
b. Chlorpropamide
c. Glimepiride
d. Glyburide
d. Glyburide
least likely to cross the placenta
Which of the following most commonly causes dilutional hyponatremia? Why?
a. Glipizide
b. Chlorpropamide
c. Glimepiride
d. Glyburide
b. Chlorpropamide
due to the ADH-like effect
Explain disulfiram syndrome. What is it? What causes it? What’s the mechanism behind it? (symptoms, etc.)
it occurs when you take sulfonylureas drugs (especially Chlorpropamide) with alcohol. The drug inhibits the enzyme Aldehyde Dehydrogenase, which acts to metabolize the alcohol. The somewhat toxic acetaldehyde (which the substrate for the enzyme) builds up. Due to this, the patient experiences tachycardia and hyperventilation.
Which of the following acts to increase beta cell proliferation?
a. Acarbose
b. Repaglinide
c. Rosiglitazone
d. Metformin
e. Exenatide
f. Sitagliptin
e. Exenatide
Which of the following has a side effect of Stevens-Johnson syndrome?
a. Acarbose
b. Repaglinide
c. Rosiglitazone
d. Metformin
e. Exenatide
f. Sitagliptin
f. Sitagliptin
Which of the following mainly acts to inhibit hepatic glucose output?
a. Acarbose
b. Repaglinide
c. Rosiglitazone
d. Metformin
e. Exenatide
f. Sitagliptin
d. Metformin
Which of the following is minorly excreted in the urine?
a. Acarbose
b. Repaglinide
c. Rosiglitazone
d. Metformin
e. Exenatide
f. Sitagliptin
b. Repaglinide
Which of the following interferes with B12 absorption?
a. Acarbose
b. Repaglinide
c. Rosiglitazone
d. Metformin
e. Exenatide
f. Sitagliptin
d. Metformin
Which of the following has a similar structure to GLP (Glucagon-like peptide) and thus can activate its receptors?
a. Acarbose
b. Repaglinide
c. Rosiglitazone
d. Metformin
e. Exenatide
f. Sitagliptin
e. Exenatide
What is Stevens-Johnson syndrome?
rare, serious disorder of your skin and mucous membranes. It’s usually a reaction to a medication or an infection. Often, it begins with flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters.
(side effect of Sitagliptin)
T/F: Exenatide is taken orally
false, its subcutaneous
Which of the following inhibits GLP (Glucagon-like peptide) degradation?
a. Acarbose
b. Repaglinide
c. Rosiglitazone
d. Metformin
e. Exenatide
f. Sitagliptin
f. Sitagliptin
What does GLP (Glucagon-like peptide) do? How can we use it for diabetes control?
promote insulin secretion
so in diabetes, we want to increase it, activate its receptors, or limit its degradation
T/F: Repaglinide has a short duration
true
How does Metformin inhibit hepatic glucose output?
by decreasing gluconeogenesis
Which is a pancreatic alpha-amylase inhibitor?
a. Acarbose
b. Repaglinide
c. Rosiglitazone
d. Metformin
e. Exenatide
f. Sitagliptin
a. Acarbose
What are the side effects of Acarbose? explain them.
abdominal discomfort and diarrhea. this is due to the fact that the drug stays and act from within the GI system.
Which has nausea and vomiting as a side effect?
a. Acarbose
b. Repaglinide
c. Rosiglitazone
d. Metformin
e. Exenatide
f. Sitagliptin
d. Metformin
Which cannot be given to any patient susceptible to metabolic acidosis? why?
a. Acarbose
b. Repaglinide
c. Rosiglitazone
d. Metformin
e. Exenatide
f. Sitagliptin
d. Metformin
(a side effect of it is lactic acidosis- because it blocks acetate flow through gluconeogenesis- so we don’t want to add on to the acidic environment)
Acarbose is contraindicated in
Inflammatory bowel disease (IBD) and intestinal obstruction (remember, the drug works in the GI)
Explain how Rosiglitazone increases insulin sensitivity?
by activating the “Peroxisome proliferator-activated receptor-gamma” (PPARγ). That receptor increases the promoter genes for glucose utilization, so we need less glucose to do the same effect -> insulin sensitivity
Which causes fluid retention (and mild anemia)?
a. Acarbose
b. Repaglinide
c. Rosiglitazone
d. Metformin
e. Exenatide
f. Sitagliptin
c. Rosiglitazone
