 Hello all, in this video we are going to discuss about common viva questions for clinical social case of diabetes militias. Even though this presentation is going to be question-based, let me tell you about the contents of this presentation about diabetes militias. It consists of the definition of diabetes militias, problem statement, classification types which is the recent update in the classification of diabetes militias which is going to be dealt in detail, followed by diagnostic criteria, risk factors, complications and treatment aspect which is also again an extensive topic in case of diabetes militias followed by the commonly asked questions in diabetes militias. First is define diabetes militias. Diabetes militias is a group of metabolic disorders due to the disturbances of carbohydrate, fat and protein metabolism and remember it is not alone carbohydrate metabolism. It is due to the carbohydrate, fat and protein metabolism all are disturbed which is characterized by the presence of hyperglycemia when treatment is not provided and the root cause of this is due to either defects in the insulin secretion or the action of the insulin or this both can be present. So, the definition of diabetes militias is a group of metabolic disorder with disturbances in carbohydrate and fat metabolism and the common character is the hyperglycemia whenever there is treatment is not provided and this is due to either defective insulin secretion or defective insulin action or both. So, these four components has to be present when we are defining diabetes militias. Moving on to the problem statement of diabetes militias. There are more than half a billion population affected with diabetes militias. Robal prevalence reported as per 2019 data is 9.3 percentage but the Indian diabetes prevalence is 8.3 percentage which is just below the worldwide prevalence of diabetes militias. Then next we are moving to the classification of diabetes which is one of the recent update in our textbook and also in the classification of diabetes militias. As usual this type one and type two diabetes remains the same. Type one the root cause is the beta cell destruction which is mostly due to the immune mediation and there is absolute absence of insulin and usually the onset will be common in the childhood or in the early adulthood and the type two diabetes militias or insulin resistant diabetes militias is the most common type. There are varying degrees of beta cell dysfunction that causes insulin resistance commonly associated with overweight and obesity. The classification continues as hybrid forms of diabetes that is slow evolving immune mediated diabetes of adults. Previously this one was called as LADA that is latent autoimmune diabetes of the adults. It is similar to type one diabetes in adults but has more features of metabolic syndrome. There is one single auto antibody GEAD and there is a preservation of greater beta cell function. The second type under the hybrid form of diabetes is the ketosis prone type two diabetes which presents as ketosis and insulin deficiency but later it does not require insulin. There are common episodes of ketosis but this one is not immune related. The other sub types of diabetes militias include the monogenic diabetes which is due to the monogenic defects of the beta cell function or monogenic defects in the beta genetic action. These are caused by the specific gene mutations. The clinical manifestations require different treatment some occurring in the neonatal others may be in the early adulthood. Here in the insulin action it is associated without obesity and the diabetes develops when beta cells do not compensate for the insulin resistance. Then other specific sub types include diseases of the exogenic pancreas include fibrocalculus pancreatopathy, pancreatitis, pancreatectomy, trauma of pancreas, neoplasia, cystic fibrosis, hemopromatosis all are included under diseases of exocrine pancreas under diabetes militias classification. When it comes to endocrine disorders there are pushing syndrome, promigale, pheochromocytoma, glucogonoma, hyperthyroidism, somatostatinoma, all causes diabetes militias. These are all endocrine disorders causing diabetes militias. When it comes to drug or chemical induced chemicals interfering with the insulin secretion or action this may be due to glucocorticoids, thyroid hormone, thiocytes, alpha adrenergic agonist, beta adrenergic agonist, dilantin, pentamidin, nicotinic acid, pyrineuron, all-interferon alpha for infection-related diabetes, congenital droopala and cytomegalovirus are most common causes. There are some uncommon specific forms of immune-mediated diabetes militias under which you have insulin-automated immune syndrome, anti-insulin receptor antibodies, stiff man syndrome all comes under uncommon specific forms of immune-mediated diabetes. Other generic some syndromes sometimes associated with diabetes are Down syndrome, Fredericks Ataxia, Huntington's Corea, Clenifiltus syndrome, Lawrence Moon-Biddles syndrome, Myotonic dystrophy, Porphyria, Prader-Willi syndrome, Turner syndrome. Towards the end we have unclassified diabetes and lastly the hyperglycemia first detected during pregnancy which is diabetes militias in pregnancy or gestational diabetes militias. In the first type, type 1 and type 2 diabetes first diagnosed during the pregnancy here hyperglycemia below the diagnostic thresholds for diabetes in the pregnancy. Now the next question is what are the criteria for diagnosis of diabetes militias? For diagnosing diabetes militias we have fasting blood sugar, 2-hour plasma glucose after OGTT or post-frontal blood sugar, random blood sugar, glycosylated hemoglobin. We can use any of these parameters to diagnose diabetes militias but the criteria for diagnosing diabetes you can remember in milligrams per deciliter fasting blood sugar equal to or more than 126, post-frontal or 2-hour plasma glucose after OGTT greater than or equal to 200 milligram per deciliter, random blood sugar greater than or equal to 200 milligram per deciliter or if the glycosylated hemoglobin is greater than 6.5 then you can call it as diabetes militias. On the other hand you have a pre-diabetes or impaired glucose tolerance level where the fasting blood sugar will be 110 to 125 milligrams per deciliter and the post-frontal will be 142-199 milligram per deciliter. This is based on the international diabetes federation and WHO recommendations. Now mention the risk factors for diabetes. We have two types of risk factors one is non-modifiable another one is modifiable. Non-modifiable risk factor for type 2 diabetes is the genetic predisposition and family history of disease which is most significant risk factor for development of diabetes. Then race or the ethnicity and the age greater than 45 years all contribute to non-modifiable risk factors of diabetes militias. When it comes to the modifiable risk factors sedentary lifestyle or lack of exercise is one of the most important risk factor for development of diabetes followed by obesity, unhealthy diets and habits, stress and depression, altered intra-hydrogen environment, environment and environmental pollutants, inadequate sleep along with stress can contribute to development of diabetes militias. Next what are the complications of diabetes militias? We can divide the complications into two types that is acute and chronic complications. Under acute complication the over-treatment can lead to hypoglycemia and lack of control of glucose level can lead to diabetic ketoacidosis. The symptoms of hypoglycemia and symptoms and management of diabetic ketoacidosis can be read by the students by themselves. Now under chronic complications we have microvascular complication and macrovascular complication. Macrovascular complication includes nephropathy, neuropathy and retinopathy. Macrovascular complications includes cardiovascular, cerebrovascular and peripheral vascular disease. So cardiovascular disease causing coronary heart disease or heart attacks. Cerebrovascular accidents causes causing stroke, peripheral vascular disease causing TAO and diseases. Now what is the treatment for diabetes militias? Treatment of diabetes can be classified into oral insulin and neuro drugs. Oral drugs can be further classified into insulin sensitizer and insulin secretogog. Insulin sensitizer increases the insulin sensitivity or decreases the insulin resistance. The drugs such as bicoenates, for example metformin falls under bicoenates category, isolidin deons such as bioglytisone all comes under insulin sensitizer. The commonly used insulin secretogog is sulfonylureas, glenides such as repaglinide, natiglinide, etc. DPP4 inhibitors and GLP1 agonist all comes under insulin secretogogs. Then we have insulin which can be further classified into ultra rapid, intermediate rapid acting, short acting, long acting. So these are all the insulin action profiles. So this is ultra short to longer acting insulin. Now again with the drugs GLP1 agonist all ends with Tide and DPP4 inhibitors all ends with Glyptins and SGLT2 inhibitors which ends with Lipfluosins. Whenever you are presenting a diabetic case you need to know the side effect of the oral hypoglycemic drug at least the patient is consuming. So insulin and analogs the common adverse effects will be hypoglycemia, weight gain, insulin allergy and lipid dystrophy at the injection sites. For sulfonylureas you have hypoglycemia, weight gain, cardiovascular risk, rash, polystatic jaundice, bone marrow damage, photosensitivity all comes under side effects of sulfonylureas. We have megalitinates and bicoenates where the hypoglycemia sensitivity reaction gastrointestinal effects, lactic acidosis will be the side effects. GLP1 agonist gastrointestinal effects, pancreatitis, risk for cancer and cardiovascular events are common. DPP4 inhibitors pancreatitis, risk for cancer, acute hepatitis and kidney impairment is common is the common adverse effects of DPP4 inhibitors. Thiazolidin diones, hepatitis, cardiovascular risk, bladder cancer, water retention and weight gain are the common adverse effects of thiazolidin diones. DLPAR agonist common side effects will be gastritis, asthenia, pyrexia, alfaglucosidus inhibitors, gastrointestinal effects and hepatitis are the adverse effects associated and amylin analogs SGLT inhibitors. The side effects are hypoglycemia, allergic glycosuria and cardiovascular concerns are there. So, you can freeze this slide, you can remember the most common side effects associated with the oral hypoglycemic drugs. Then the most commonly asked question is how will you prevent the diabetes militias? We have three levels of prevention. The question will be targeted at you at the specific level of prevention also where you have primordial, primary and secondary. Primordial prevention, you need to mention how it is applicable to diabetes militias. Primordial prevention is the prevention of emergence or development of the new risk factor in a locality where the risk factor is not present. You can do primordial prevention by incorporating exercise and dietary pattern changes for primordial prevention of diabetes militias. Primary prevention is defined as action taken prior to onset of the disease which removes the possibility of the disease to occur. So, correction of over nutrition and obesity all can be used as a primary prevention tools. Then the secondary prevention tools, the action which hauls the progress of the disease at the initial stage and prevents its complication is called a secondary prevention. The routine checking of blood sugar, visual acuity, urine for ketone and proteins, weight measurements all are included in the secondary prevention. Next important question is about glycated hemoglobin. Glycated hemoglobin or glycohemoglobin or glycosylated hemoglobin or HbA1c or simply A1c is a form of hemoglobin that is chemically linked to the sugar. Most monosaccharides including glucose, galactose, fructose spontaneously gets bonded with this hemoglobin when it is present in the bloodstream. Since the red blood cells live for about an average of nearly three months, this A1c test reflects the red blood cells that is present in the bloodstream at the time of the test. So, that is why A1c serves as an average blood sugar level for the for the recent 100 days. So, the normal glycosylated hemoglobin level or the A1c level is less than 5.7. 5.7 to 6.5 indicates the risk or you can call it as pre-diabetes or above 6.5 will be considered as diabetes militants. The inferences A1c reflects the recent control of diabetes militants in the past 100 days. We are moving to glycemic index. Glycemic index of the food is defined as the area under the curve of two-hour blood glucose response following the ingestion of the fixed third portion of the test carbohydrate usually 50 gram as proportion to that of the area under the curve of the standard glucose or white bread. This is the technical definition but you need to understand what is glycemic index is the ability of the food to raise the blood glucose level is called as glycemic index. So, how fast a food increases the blood glucose level is called as glycemic index. So, here you have high glycemic index food which are not recommended for diabetic patients and low glycemic index food which increases the blood glucose level on a steady level there is no spike. So, this low glycemic index foods are recommended in case of diabetic patients. What are these low glycemic foods? There is a slow release of sugar into the small intestine and absorption into the blood. So, there is a reduced peak and prolonged rate. The example for such low glycemic index foods are the most common fruits and vegetables have low glycemic index except for your potatoes, watermelons and sweet corn which has high glycemic index. The whole grains pasta foods beans and lentils all have low glycemic index. The medium glycemic index sucrose basmati rice and brown rice has medium glycemic index whereas high glycemic index is provided by corn flakes, baked potato, watermelon, some white rice varieties, white bread, candy bars and syrupy foods all produce high glycemic index apart from increased glycemic load. So, high glycemic fruits are readily digestible and have absorbable sugar which increases the blood sugar level very fast. Now, apart from diabetic smelly test, what are the disorders of glycemia? Impaired glucose tolerance that is the two-hour glucose levels ranges between 140 to 199 milligram per deciliter on 75 gram oral glucose tolerance test. Impaired fasting glucose, glucose levels between under to 125 milligram per deciliter in fasting gestational diabetes milliliters. It is any degree of glucose intolerance with onset or first recognition during the pregnancy. So, this is the basic pathogenesis of how gestational diabetes is developed. So, during pregnancy there will be increased placental hormones and pregnancy hormones which causes antagonistic action against the insulin producing the hyperglycemia. So, all these mechanisms leads to insulin resistance and hyperinsulinemia causes increased glucose level and gestational diabetes milliliters. Now, what is the criteria to diagnose gestational diabetes milliliters? We have different group providing different gestational diabetes criteria and different cut-offs also. This is given here. So, the most common given by ADA and WHO where you have glucose dose as 75 milligrams where the fasting blood sugar cut-off is 95 and 126 respectively for ADA and WHO. Same way OGTT, one-hour level, two-hour level will be there for ADA and directly two-hour level for WHO criteria and for diagnosis out of this two out of four in NDBG and two out of four in Carpenter and Causton, two out of three in ADA, one out of two in WHO and one out of two in AID, IPS criteria will diagnose gestational diabetes. Now, this is about syndrome X or metabolic syndrome which is commonly asked both in diabetes hypertension because it is a group of disorder or the syndrome which has insulin resistance, visceral adiposity, atherogenic dyslipidemia and endothelial dysfunction. The individual components of syndrome X consists of various circumference which is greater than or equal to 102 centimeter in men and greater than or equal to 88 centimeter in women and triglycerides greater than or equal to 150 milligrams per deciliter, HDL cholesterol with the following cut-offs, increased blood pressure with these cut-offs and the fasting glucose level with these cut-offs and the diagnosis of syndrome X can be made with any three of the above five features that is obesity, hypercholesterolemia, hypertension and hyperglycemia. So, we have two parameters for lipid profile, together it includes five features, any three out of these five features will diagnose syndrome X. Now, how to perform food examination in diabetic subjects? First of all, the diabetic patients need to inspect the food every day with the help of the mirror or prove a help of a person. Basically, they need to look for any ulcer, calluses, cracks, scars, edema and color changes present. So, they can look the soul like this and palpate for any temperature difference, any discharge is present or any tenderness is present. Then they need to palpate the dorsalis predis artery and the posterior tibial artery for the pedifural pulse. Check for the ankle reflexes, vibration sense using 128 hertz tuning fork. So, this is the food care recommended for diabetic patients. So, we need to educate the patient to do this food care every day in order to prevent serious damage later. Now, this is the last question that is what are all the investigations that needs to be done for diabetic patients? So, as we told earlier, they need to do food examination daily either by self or with the help of a helper and every month they need to do a fasting blood sugar and postfrontal blood sugar. It can be capillary and every month they need to do blood pressure measurements and weight measurements. Every three months they need to do A1C test that is HBA1C if the sugar is not under control. If the sugar is controlled, the HBNC needs to be done every six months and every one year they need to screen for retinopathy, nephropathy, neuropathy, peripheral vascular diseases and coronary artery diseases. So, the clinical examination includes detailed food examination with the palpation of dorsalis pedis, posterior tibial pulses, mono filament and vibration perception testing. Retinal checkups which includes fundal examination for retinopathy, blood urea creatinine LFT for nephropathy, urine protein urea albumin urea for nephropathy, ECG for any cardiac complications, lipid profile, hemogram, urine culture needs to be done every year. When indicated, X-ray chest needs to be taken, uric acid, TSH, the other liver enzymes such as SGOT and SGPT, vitamin B12 levels, electrolytes and ultrasound abdomen needs to be done if indicated. So, that is about the investigations to be done for diabetes militias. Thanks for watching this video. If you like this video, please click on the like button, share it to your friends. If you haven't subscribed to our channel, please subscribe. Thanks again.