1. A lady with vomiting

2. A 23-year-old female student presents to her GP 5 days after returning from a ski holiday. She developed what she thought was a stomach upset while away, but this failed to settle and she now has increasing nausea and recurrent vomiting.

3. Initial management Fingerprick blood glucose in GP surgery simply reads "high" on meter.

4. How would you manage her?

6. Investigations She has arrived in the emergency assessment unit and you are the first doctor to see her. You confirm the history as above and a nurse checks a fingerprick blood glucose for you which simply reads “high” on the meter. She looks unwell and is slightly drowsy and breathing rapidly.

7. What tests would you arrange and what might you expect to find?

8. ABG UE Blood glucose CXR ECG

9. Initial treatment I Her tests confirm that she is acidotic (pH 7.03) and blood glucose is 46 mM.

10. How would you manage her now?

11. Fluids Insulin Potassium replacement as necessary Ng tube ?ITU

12. Initial treatment II After 12 hours of iv insulin and fluids, she looks and feels better. Her acidosis has resolved and her blood glucose has fallen to 8 mM.

13. What do you do now?

14. Next step After 48 hours of intravenous insulin, her urinary ketones have cleared completely and she is eating and drinking.

16. monitoring

17. Prescribing Sometimes when diabetic patients in hospital are unwell or are nil by mouth for medical procedures or operations, they are prescribed 'sliding scale' insulin.

19. Change over The medical team has decided that the patient is stable enough to be changed over to a sub-cutaneous insulin regime.

20. How long before stopping the insulin infusion should the first sub- cutaneous insulin dose be given?

21. She asks you about the long-term implications for her health of developing diabetes.

22. Long term complications

23. large blood vesselssmall blood vessels TIA stroke angina myocardial infarction heart failure peripheral vascular disease diabetic retinopathy diabetic nephropathy erectile dysfunction autonomic neuropathy peripheral neuropathy Systems affected by diabetes

24. retinopathy

27. ischaemic heart disease

28. Diabetic Nephropathy

29. An insidious clinical syndrome characterised by persistent albuminuria, elevated blood pressure and, if left untreated, a relentless decline in GFR What is diabetic nephropathy ?

30. 20401201006080 Kidney function age Kidney function and age 100% Diabetic kidney disease Detected and treated trouble

33. GOOD NEWS #1 onset and course of diabetic nephropathy can be ameliorated to a very significant degree by interventions #2 these interventions have their greatest impact if instituted early on in the course of the condition

34. - the condition is important - there is treatment - facilities for diagnosis/ treatment exist - there is a recognised early stage - there is a suitable test - the test is acceptable to the population - interveniton is cost effective #2 Screening

35. Lewis, E. J. et al. N Engl J Med 1993;329:1456-1462 ACE inhibitors and diabetic nephropathy Cumulative incidence in patients with DN

36. What is glycosylated haemoglobin

38. betaalpha haemoglobin

39. betaalpha haemoglobin

40. betaalpha haemoglobin HbA 1C

41. HbA

42. HbA1C (%) Average Blood Sugar (mmol/L) 54.5 66.7 78.3 810.0 911.6 1013.3 1115.0 1216.7

43. DCCT The Diabetes Control and Complications Trial 1993 Retinopathy in Patients with Type 1 DM Receiving Intensive or Conventional Therapy- 9.1% 7.2%