DIABETES

I/ Definition

+ It is a disease related to failure of biological mechanisms regulating blood sugar (glucose concentration in the blood) leading to hyperglycemia.

+ Venous Fasting glucose (FPG) ≥ 1.26 g / L (7 mmol / L) twice or plasma glucose
≥ 3 g / L (11mmol / L) regardless of the time.

II / Classiffication Etiology

+ Type 1 diabetes: insulin-dependent or malignant.
+ Diabetes type 2: non-insulin dependent or bold
+ Gestational Diabetes: Abnormal glucose tolerance starting during pregnancy

+ Secondary diabetes - pancreatic disease: chronic calcifying pancreatitis, 
                                      acute pancreatitis, pancreatic cancer, endocrine pancreas tumors,
                                       pancreatectomy, cystic fibrosis.

                                   - Endocrine disease: hyperthyroidism, acromegaly, hypercortisolism.
                                   - Iatrogenic: corticosteroids ++
                                   - infections
                                   - Liver: hemochromatosis, cirrhosis.

III / Acute Complications
       A / Acid-diabetic ketosis
       B / hyperosmolar syndrome
       C / lactic acidosis
       D / Hypoglycemia

IV / Complications Chronicles: CONFRI
       A / Cardiological (Macro angiopathy):
             -Infactus Infarction, angina, stroke
             - Coronary artery disease
             - Diffuse atheroma
             - PAD (peripheral arterial occlusive Lower Extremities)
       B / Ophthalmologic (Micro diabetic angiopathy):
             - Diabetic retinopathy
             - Cataracte, Chronic Glaucoma
       C / Neurological:
             - Peripheral Neuropathy: polyneuropathy, neuritis mono ...
              - Vegetative Neuropathy
       D / Feet
       E / Renal (micro angiopathy):
            - urinary tract infection
             - Diabetic nephropathy
       F / Infectious: - Cutaneous: + erysipelas
                                                  + Boil, furunculosis
                              - Urinary Infection: cystitis, pyelonephritis
                              - Dental Infection: Cellulitis

V / Education (MALEDUCAIS)

+ Drugs: no self-medication

+ A life treatment, never stop

+ List of cons-indicated drugs

+ Education

+ Diet: RHD

+ Emergency: learn to recognize the signs of hypo / hyperglycemia, and what to do in an emergency

+ Card, glucose monitoring diary

+ Adaptation doses: prospective, retrospective, compensatory, in case of sports

+ Insulin: learning injection techniques, prevention of lipodystrophy

+ Monitoring: BU, dextro

TYPE 1 DIABETES

A / Pathophysiology

      - Autoimmune disease

      - Destruction of pancreatic beta cells

      - Responsible absolutely insulinopenia (> 80% B ¢ destroyed)

B / Etiology

      - Genetic factors

      - Viral factors

      - Factors autoimmune:

         . Ac anti islets of Langerhans (70%)

          . Anti-insulin Ab (30%)

          . Ac anti-decarboxylase (anti-GAD) (90%)

C / Diagnosis

      1 / Clinical Signs

          + Children, young adults <35 years

          + Autoimmunity (ISAP)

          + Signs Cardinals: asthenia, polyuria-polydipsia syndrome, weight loss, polyphagia

          + Ketoacidosis (20% indicative of diabetes mellitus type 1)

          + Dehydration

          + Breath ketone

       2 / Signs Paraclinical

           + Glucose> 11 mmol / L regardless of the time

           + BU: Glycosuria massive> 20g / L ± ketonuria (sign of seriousness)

           + Signs of dehydration

           + Search + CVRF complications

           + Hyperlipidemia (triglycerides ± cholesterol)

           + TSH, acidosis (GDSA, bicar)

D / Differential Diagnosis

       + Moderate hyperglycemia,

       + Other diabetes

E / Treatment

1- etiological treatment: insulin subcutaneously

+ Insulin = treatment of type 1 diabetes +++

     - Ultra-fast insulin: in a few minutes is peaking at 30 minutes and 3 hours duration 
        action = 3h

     - Lente: acts 1h 30mn-3h and duration of action = 16h to 24h

     - Diagram to 4 injections 1 injection of slow and ultra fast 3 injections

+ Objectives

     - Fasting glucose = 0,8-1,2g / L

     - Postprandial blood glucose <1.8 g / L in the morning, <1.4 g / L for lunch and dinner

2- lifestyle and dietary rules:

+ Power supply: - with normal calorie, balanced, 3 + 1 meal snack

                       - 50-55% carbohydrates: limit high glycemic index, 
                                                                teach carbohydrate equivalents, no soda

                       - 30-35% fat: 10% Saturated fatty acids, 25% unsaturated, 
                                              lower cholesterol intake, promote vegetable fats

                       - 15-20% protein

                       - Moderate sodium intake <4g / day

                       - 5 fruits and vegetables not day

                       - 1.5L water per day

                       - No alcohol, no tobacco

+ Regular physical activity: 45min / day

+ Prevention of cardiovascular FdR

+ Hygiene foot

TYPE II DIABETES

1 / Pathophysiology

- 2 metabolic disorders:

         + Primitive Insulin resistance

         + Defect in insulin secretion

- No autoimmunity stigmata

- Can develop into insulin requérance but not insulin-dependent

- Less evolution to ketosis

2 / Etiology

+ Genetic factors +++ (family ATCD T2DM)

+ Environmental factor - physical inactivity

                                             - BMI (body mass index) ≥ 27 kg / m2

                                             - History of gestational / macrosomia diabetes

                                             - Hypertension (> 140/90 mmHg)

                                             - Hypertriglyceridemia (> 2 g / L) ± low HDL (<0.35 g / L)

                                             - Moderate hyperglycemia known to young (1.10 to 1.25 g / L)

                                             - History of steroid-induced diabetes

                                             - IUGR = hypotrophie

3 / Diagnosis

A- Clinical Signs:

+ Asymptomatic +++

+ Age> 40 years

+ Family ATCD: - Diabetes Type 2

                             - Gestational Diabetes

                             - Glucose intolerance

+ Personal ATCD: - Glucose intolerance

                                - Gestational Diabetes

                                - Macrosomia

                                - Poly cystic ovary syndrome (PCOS)

+ Obesity android

+ FdR associated CV

+ Metabolic syndrome: hypertension, dyslipidemia, ... ..

+ Insulin, on insulinopenia

B- Balance degenerative complication CONFRI + HbA1c

+ Cardiovascular: - Search for other cardiovascular risk factors

                    - Full clinical examination of the heart and vessels

                      (Carotid, aorta, lower limb)

                    - Resting ECG

                    - Arterial Doppler ultrasound of neck vessels, heart,

                      lower limbs

                    - (+/- Test effort and coronary angiographies (after stopping ADO) if indicated

+ Ophthalmologic : complete examination, fundus fluorescein angiography

+ Neurological : complete review including research autonomic neuropathy

+ Feet: Foot examination in search of a wound

+ Renal: urea / creat / clearance, BU, microalbuminuria

+ Infections: skin examination, examination stomatology, dental panoramic

+ + HbA1c

C- Signs Paraclinic

+ Biology: it raises blood sugar diagnosis

      - Young blood glucose> 1.26 g / L (7 mmol / L) in 2 samples at different times

      - Blood glucose> 2g / L (11mmol / L) at any time of day 2 collection

      - Blood glucose> 2g / l at any time in the presence of a complication

+ BU: systematically practiced

       - Important Glycosuria

       - +/- Ketonuria: + = Ketone young (physiological)

       - +++ = Research diabetic ketoacidosis

4/ Treatment

A- General measures

      + Individualized Home Project

      + PEC 100%

      + Psychological support, patient association

      + Vaccination against influenza and pneumococcal

 B- etiological treatment: Oral hypoglycaemic agents

      + That after failure of lifestyle and rules diatétiques 6 months

      + Never combine two molecules of the same class

 C- lifestyle and diatétiques Rules

 + Power supply: - low-calorie if overweight, balanced, 3 + 1 meal snack

                         - 50-55% carbohydrates: limit high glycemic index, 
                                                                 carbohydrate teach equivalences, no soda

                         - 30-35% fat: 10% Saturated fatty acids, lower cholesterol intake, 
                                                promote vegetable fats

                         - 15-20% protein

                         - Sodic moderate intakes <4g / day

                         - 5 fruits and vegetables not day

                         - 1.5L water per day

                         - No alcohol, no tobacco

+ Regular physical activity: 45 min x 3 / endurance week after cardiological assessment

+ Foot hygiene