Re: A test for Glass318

On Wed, 25 Jul 2007 23:18:45 -0700, glass318
<glass318@xxxxxxxxx> wrote:

On Jul 26, 12:52 am, Alan S <loralgtweightandca...@xxxxxxxxx> wrote:
On Wed, 25 Jul 2007 19:37:21 -0500, "krom"

<thekromremoverem...@xxxxxxxxxxx> wrote:
Perhaps have a nice glass of wine as you wait...altho i got the feeling you
could plant a vineyard and make your own wine before this guy comes through
sadly.

KROM

To be honest, I truly hope I'm wrong. Despite the
differences of opinion we could do with a sane qualified doc
on the group for a different point of view. I've always felt
that the best way to improve out knowledge is healthy
debate; unfortunately too many can't see the difference
between that and an argument or flame war.

However, the response so far has been underwhelming.

Cheers, Alan, T2, Australia.
d&e, metformin 1500mg, ezetrol 10mg

Everything in Moderation - Except Laughter.
--http://loraltraveloz.blogspot.com/
latest: Mossman Gorge in the Daintree Rainforesthttp://loraldiabetes.blogspot.com/
latest: Self-Testing and Type 2 Management

Interesting. Today has been unusually busy but such is life outside
the internet.

For the record, I am an Internist with an unusually high number of
Diabetic patients. Not a surgeon!

This is ridiculous but I will use it as mental exercise so here you
go:

Question 1. I am tempted not to answer your first question because
anyone can Google or use Web MD, cut and paste the info you requested.
I realized, however, that you said "lay readers". You may point out
inaccuracies - I'm no biochemist.

a) Your body needs energy to function (we call it ATP)
b) Energy is produced by 'burning' or using fuel
c) Your body's fuel: Glucose and Free fatty acids (your body processes
glucose in such a way that energy is released in the form of ATP,
which is used in almost every process that occurs in the body. E.g.
muscle contraction)
d) Most of the time, after you eat, your body uses glucose for energy
and stores fat. Excess glucose is stored or indirectly converted into
fat (for storage--that explains why carbs make you gain weight).
- Your gut breaks food down (carbohydrates, protein, fat) into
glucose, aminoacids and free fatty acids.
e) Insulin is a hormone (protein) that your body calls whenever your
blood glucose levels go up (after eating)
f) Insulin is produced by the Beta cells found in the pancreas
g) When Insulin is called on, it goes around telling your cells to
open their doors for the glucose to enter. It also tells the cells to
use glucose as the primary fuel; not the fatty acids (they are stored
for later use if necessary). It also specifically tells your liver to
store excess glucose for times of need (in form of glycogen--this
takes place primarily in the liver). Insulin also serves as a signal
to the liver so it does not release any of the stored sugar into the
bloodstream. It does many other things (like stimulate processes that
convert aminoacids into glucose).

h) If your body does not produce any insulin at all, when you eat and
your blood sugar increases, there is no one to let the cells know that
they are supposed to open up for the glucose to enter. The liver, due
to the lack of insulin, does not know the sugar situation and thinks
you are fasting, therefore it releases more sugar into the
bloodstream, worsening the problem (this explains why you might go to
bed with a blood sugar of 150 and wake up with a sugar of 250 without
ever making a trip to your kitchen).

- Now, what does your body do? The next logical pre-programmed thing
is to use the alternate fuel -- fatty acids. Through the 'burning' of
fatty acids, the body can produce energy in a real quest for survival.
This is a less efficient process. The bodybreaks the fatty acids into
Acetyl CoA. The liver then takes this end product and produces what we
call 'ketone bodies'. These ketone bodies are acids used as fuel by
the brain, heart and skeletal muscle in times when sugar is not
available. The problem is, the rate at which acid is produced, far
exceeds the rate at which these organs use them. Acid then builds up
in the blood and causes many problems like belly aches, vomiting,
headache, drowsiness, and through organ malfunction, even death.

- Type One Diabetics do not produce Insulin at all, so they are most
prone to the above scenario. If you want to get a bit more detailed,
Type 1A patients do not produce insulin because their bodies have
produced antibodies against their own pancreatic B cells. Type 1B
patients do not have these antibodies but have evidence of beta cell
destruction (we just do not know how they got destroyed).

Without Insulin treatment, Type 1s will invariably develop
Ketoacidosis and may die.

- Adult-Onset Type 1 Diabetes Mellitus - This is what you call Latent
Autoimmune Diabetes in Adults (LADA).
This is a relatively new description. I recall seeing it for the first
time when in 1993, some folks (I think from Down Under but I may be
wrong) published findings suggesting that some previously labelled
Type 2s actually had measurable levels of antibodies against their
pancreatic Islet cells. If you are having a hard time controlling your
sugars with diet, exercise and oral therapy, you might have to be
tested for antibodies (Islet cell antibody or ICA and Glutamic Acid
Decarboxylase or GAD). We still don't know how early such patients
should get insulin or whether any form of immune modulating treatment
can alter the course of the disease.

If you do not fit any of the above, you are most likely a Type 2
Diabetic unless you have:
1. A genetic defect of beta cell function (MODY - Type 1 through
6....and counting, mitochondrial mutations, genetic defect in insulin
action, Wolfram syndrome, etc)
2. Pregnant
3. Acquired beta cell destruction (viral infection, hemochromatosis,
pancreatitis, etc, etc)
4. Rarer than rare syndromes like Stiff-Person syndrome (Immune
mediated--anti-GAD-- with central neurologic signs) or anti-insulin
receptor antibody syndrome.


Question 2:

Give your patient TLC (Therapeutic lifestyle changes per ATP III) for
we need to work seriously on their insulin sensitivity and metabolic
syndrome. No HDL adviCe because you forgot to give this patient a
gender. All the other things would be patient-centered so I will not
speculate -- plus I have to go to bed).

Question 3

For Diabetes, Eyes only. Anything else and you'll have to back it up
with evidence.

Now, it would have been helpful to know the gender. Mammogram, Pap
Smear, Colonoscopy, PSA or no PSA, etc...take care of the whole
patient...not only a disease...

Question 4

Too tired to even read the question. Are you kidding? After the first
two acronyms, I gave up. Off to bed! If you insist, I actually will
but... adios!

Thank you for the response. I hope you slept well.

Before I say any more, a couple of clarifications. In
Australia, the room a GP sees his patients in is known as a
surgery, whether or not surgery is actually performed in the
room. Maybe it's one of those tomayto tomarto things as you
cross the Pacific.

And, "ridiculous"? Sorry, I don't agree, but the attitude
behind the comment is why some here have found it so
difficult to accept you. Think about it for a while. You
see, if you are a doctor and we are patients we see the
doctor-patient relationship a little differently from our
side. We see it in a similar light to a mechanic paid to fix
the car - we do not have the mechanic's knowledge and skill,
so we respect that, but we still consider the mechanic a
paid tradesman doing a job for us. Exacerbating that in me
is an Aussie trait of having extreme difficulty in accepting
pronouncements from "Revered Authority". I'm sorry if that
doesn't display the right deference for years of med-school
and internship. Well, no I'm not really sorry - I do respect
the training and knowledge, but I do not respect an attitude
of superiority and an unwillingness to learn from other's
experiences.

It wasn't a ridiculous request, because I felt it was a fair
way to at least give you a chance to convince some here that
you are genuine.

Finally, as a layman and patient, I cannot fault your
explanation and in fact I learnt a few new things from it.
Thank you. Yes, it could be a cut-and-paste, but a search
should be able to check that - but it was clear, lucid at my
level and informative. For the technical aspects I'll let
our more expert posters muse on that; but I'm satisfied.

I'm sure you are aware that we would have different
suggestions for your patient modifying "ATP III" (reading
that now at
http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm).
In fact, that's one reason I was suggesting you check out
that paper on the link.

I'm happy to learn from anyone who knows more than I. Are
you prepared to accept that there may be patients who know
more than you on specific aspects of self-treatment of
diabetes?

Later, I would seriously like an answer on that paper on
lipids.

PS Specialists I would recommend to any new Type 2 would be,
even if only for baseline setting:
Heart/cardio;
Ophthalmologist;
Podiatrist; and
despite my differences with them, a dietician.


Cheers, Alan, T2, Australia.
d&e, metformin 1500mg, ezetrol 10mg
Everything in Moderation - Except Laughter.
--
http://loraltraveloz.blogspot.com/
latest: Mossman Gorge in the Daintree Rainforest
http://loraldiabetes.blogspot.com/
latest: Self-Testing and Type 2 Management
.

Relevant Pages

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