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James Richard Eshleman, Jr, M.D., Ph.D.

• Associate Director, Molecular Diagnostics Laboratory
• Professor of Pathology

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0011316/james-eshleman

Effect of metformin on glycaemic control in patients with type 1 diabetes: a meta-analysis of randomized controlled trials green tea causes erectile dysfunction buy cheap tadalafil 2.5 mg line. Efficacy and safety of canagliflozin impotence qigong cheap tadalafil 5 mg with amex, a sodium­ glucose cotransporter 2 inhibitor erectile dysfunction after age 50 tadalafil 20 mg order on-line, as add-on to insulin in patients with type 1 diabetes protein shake erectile dysfunction 5 mg tadalafil buy with visa. Diabetes medications as monotherapy or metformin-based combination therapy for type 2 diabetes: a systematic review and metaanalysis. Long-term treatment with metformin in type 2 diabetes and methylmalonic acid: post hoc analysis of a randomized controlled 4. Long-term metformin use and vitamin B12 deficiency in the Diabetes Prevention Program Outcomes Study. Comparative effectiveness and safety of medications for type 2 diabetes: an update including new drugs and 2-drug combinations. Glucagon-like peptide-1 receptor agonists compared with basal insulins for the treatment of type 2 diabetes mellitus: a systematic review and meta-analysis. Glucagon-like peptide-1 receptor agonists: a systematic review of comparative effectiveness research. Controversies in the management of patients with type 2 diabetes [Internet], December 2014. Pharmacokinetics and pharmacodynamics of insulin glargine given in the evening as compared with in the morning in type 2 diabetes. Efficacy and safety of insulin analogues for the management of diabetes mellitus: a metaanalysis. Patient-level meta-analysis of efficacy and hypoglycaemia in people with type 2 diabetes initiating insulin glargine 100 U/mL or neutral protamine Hagedorn insulin analysed according to concomitant oral antidiabetes therapy. Comparison of insulin degludec with insulin glargine in insulin-naive subjects with type 2 diabetes: a 2-year randomized, treat-to-target trial. Association of initiation of basal insulin analogs vs neutral protamine Hagedorn insulin with hypoglycemia-related emergency department visits or hospital admissions and with glycemic control in patients with type 2 diabetes. Meta-analysis of insulin aspart versus regular human insulin used in a basal-bolus regimen for the treatment of diabetes mellitus. Diabetes Obes Metab 2015;17:835­842 S102 Pharmacologic Approaches to Glycemic Treatment Diabetes Care Volume 42, Supplement 1, January 2019 81. Glucagon-like peptide 1 receptor agonist or bolus insulin with optimized basal insulin in type 2 diabetes. Glucagon-like peptide-1 receptor agonist and basal insulin combination treatment for the management of type 2 diabetes: a systematic review and meta-analysis. Insulin and glucagon-like peptide 1 receptor agonist combination therapy in type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials. Lancet Diabetes Endocrinol 2014;2:30­37 Diabetes Care Volume 42, Supplement 1, January 2019 S103 10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetesd2019 Diabetes Care 2019;42(Suppl. For prevention and management of diabetes complications in children and adolescents, please refer to Section 13 "Children and Adolescents. Furthermore, large benefits are seen when multiple cardiovascular risk factors are addressed simultaneously. Heart failure is another major cause of morbidity and mortality from cardiovascular disease. Recent studies have found that rates of incident heart failure hospitalization (adjusted for age and sex) were twofold higher in patients with diabetes compared with those without (5,6). These risk factors include obesity/overweight, hypertension, dyslipidemia, smoking, a this section has received endorsement from the American College of Cardiology. Cardiovascular disease and risk management: Standards of Medical Care in Diabetesd2019. S104 Cardiovascular Disease and Risk Management Diabetes Care Volume 42, Supplement 1, January 2019 family history of premature coronary disease, chronic kidney disease, and the presence of albuminuria.

Syndromes

• Problems becoming pregnant, or infertility
• Growth hormone
• Slow heart rate
• Feeling of incomplete emptying of the bladder
• Sensory problem, such as blindness or deafness
• Fever or low body temperature (hypothermia)
• You are concerned about your personal alcohol use or that of a family member
• Nosebleeds or easy bruising
• Burning in the eye

It is estimated that essential hypertension accounts for about 10% of cases in people with diabetes erectile dysfunction on zoloft cheap 2.5 mg tadalafil free shipping. Finally erectile dysfunction protocol food lists tadalafil 10 mg lowest price, insulin may stimulate the proliferation of vascular smooth muscle cells erectile dysfunction heart disease diabetes 5 mg tadalafil order mastercard, which could lead to medial hypertrophy and increased peripheral resistance [22 impotence vasectomy purchase tadalafil 20 mg overnight delivery,25]. The association may be partly genetically determined: subjects with diabetes and microalbuminuria commonly have parents with hypertension and may also inherit overactivity of the cell-membrane Na+­H+ pump (indicated by increased Na+­Li+ counter-transport in red blood cells), 660 Cardiovascular Risk Factors Chapter 40 which would tend to raise intracellular Na+ concentrations and thus increase vascular smooth muscle tone [27]. The basic mechanisms of hypertension include decreased Na+ excretion with Na+ and water retention. Peripheral resistance is increased, to which raised intracellular Na+ will contribute. These discrepancies may be explained by differences in diet, treatment, metabolic control and the type and duration of diabetes. Patients with microalbuminuria who are insulin-resistant appear to be particularly susceptible to hypertension [30]. The deleterious effects of hypertension on left ventricular function are also accentuated by the presence of diabetes. Screening for hypertension in diabetes As the two conditions are so commonly associated, people with diabetes must be regularly screened for hypertension and vice versa. Hypertensive patients, especially if obese or receiving treatment with potentially diabetogenic drugs, should be screened for diabetes at diagnosis and during follow-up. Should hyperglycemia be detected, potentially diabetogenic antihypertensive drugs should be reduced or changed to others or used in combinations that do not impair glucose tolerance, and normoglycemia can then often be restored. This is especially important in those with other cardiovascular risk factors, such as nephropathy (which is associated with a substantial increase in the cardiovascular mortality rate), obesity, dyslipidemia, smoking or poor glycemic control. Impact of hypertension in diabetes A large proportion of hypertensive people with diabetes show signs of cardiovascular aging and target-organ damage [10]. Marked postural hypotension, which can coexist with supine hypertension, may indicate the need to change or reduce antihypertensive medication, especially if symptoms are provoked. Data from 342 815 people without diabetes and 5163 people with diabetes aged 35­57 years, free from myocardial infarction at entry. Vaccaro, paper presented at the 26th Annual Meeting of the European Diabetes Epidemiology Group, Lund, 1991. Various other expert bodies have suggested alternative, generally lower target levels (Figure 40. Investigation of hypertension in diabetes Initial investigation of the hypertensive patient with diabetes aims to exclude rare causes of secondary hypertension (Table 40. A standard 12-lead electrocardiogram may show obvious ischemia, arrhythmia or left ventricular hypertro662 phy; the latter is more accurately demonstrated by echocardiography, which will also reveal left ventricular dysfunction and decreased ejection fraction. Exercise testing (or stress-echo) testing and 24-hour Holter monitoring may also be appropriate. A fresh urine sample should be tested for microalbuminuria (see Chapter 37) and another examined microscopically for red and white blood cells, casts, and other signs of renal disease. Further specialist investigations that may be needed include an isotope renogram and other tests for renal artery stenosis (Figure 40. This complication of renal Cardiovascular Risk Factors Chapter 40 Other forms of secondary hypertension may be indicated by clinical findings of endocrine or renal disease, significant hypokalemia (plasma potassium <3. Investigations History Cardiovascular symptoms Previous urinary disease Smoking and alcohol use Medication Family history of hypertension or cardiovascular disease Examination Blood pressure erect and supine Left ventricular hypertrophy Cardiac failure Peripheral pulses (including renal bruits and radiofemoral delay) Ankle­brachial index Fundal changes of hypertension Evidence of underlying endocrine or renal disease Electrocardiography Left ventricular hypertrophy Ischemic changes Rhythm Chest radiography Cardiac shadow size Left ventricular failure Echocardiography Left ventricular hypertrophy Dyskinesia related to ischemia Blood tests Urea, creatinine, electrolytes Fasting lipids Urinary tests (Micro-)albuminuria Questions to be answered Is hypertension significant? This means weight reduction or weight stabilization in the obese, sodium restriction, diet modification and regular physical exercise (moderate intensity, 40­60 minutes, 2­3 times weekly). Dietary intake of saturated fat has been associated with impaired in insulin sensitivity and should therefore be reduced [37]. Alcohol should be restricted to 2­3 units/day in men and 2 units/day in women, but omitted altogether if hypertension proves difficult to control. Smoking causes an acute increase in blood pressure and greater variability overall [38]. Smoking cessation is especially important, as smoking not only accelerates the progression of atherosclerosis and vascular aging, but also impairs insulin sensitivity [39] and worsens albuminuria [40]. Treatment with nicotine supplementation for 4­6 weeks (chewing gum or patches), bupropion or varenicline may be useful. When adopted in full by the patient, lifestyle modification can be extremely effective. Accordingly, the clinician must be able to use a wide variety 663 Part 8 Macrovascular Complications in Diabetes of antihypertensive drugs and to choose combinations that exploit pharmacologic synergy.

Gut endocrine functions and the gut bacterial population (microbiota) are emerging key players in the regulation of intermediary metabolism erectile dysfunction dr. hornsby tadalafil 5 mg low price. Unfavorable microbiota may contribute to the onset of obesity and metabolic syndrome mainly by triggering proinflammatory responses protocol for erectile dysfunction discount tadalafil 2.5 mg otc, and by favoring efficient nutrient absorption [60 erectile dysfunction natural remedies diabetes generic tadalafil 10 mg mastercard,61] erectile dysfunction causes in early 20s buy 10 mg tadalafil fast delivery. On the other hand, beneficial bacterial strains may result in protection from metabolic disease, and interaction with non-digestible dietary carbohydrates contributes to this effect. In particular, dietary fibers interact with the gut microbiota and may reduce inflammation and unfavorable metabolic responses, thereby also reducing hepatic steatosis [41,62]. Gut microbiotadriven fermentation of non-digestible carbohydrates or prebiotics can decrease carbohydrate-induced blood glucose spikes that occur after a meal [63]. Obese individuals are reported to display metabolically unfavorable populations of gut microbes, and weight loss after gastric bypass surgery may shift this pattern towards one resembling normal weight individuals [64,65]. The possibility of harnessing microbiota to treat obesity and metabolic disease is under intensive investigation. Small-scale clinical studies of probiotic supplementation have found favorable changes to glucose and fat metabolism [61,66e68]. Research has identified metabolically beneficial bacterial strains in the gut microbiota, like Lactobacillus, and Bifidobacterium, or Akkermansia, though their role as modulators of the host metabolism is still debated [69,70]. Larger and longer-term human trials are still necessary before tailored probiotic use can be incorporated into official guidelines for the treatment of obesity and metabolic syndrome [61,71]. Fructose (as a monosaccharide or in the disaccharide sucrose) is also found in a variety of foods, but is processed differently by the body. Fructose has also been a focus of research, as it not only enters the diet through fruits but also is added to juices and other food products as a sweetener, and therefore is widely consumed. After absorption, fructose is metabolized by the liver and can be converted into glucose, lactate, and fatty acids. Fructose-induced hepatic lactate release is a unique feature and opposite to extrahepatic lactate flux to the liver for de novo glucose production. Highfructose diets have been reported to decrease insulin-mediated suppression of glucose production and to increase hepatic lipogenesis and plasma triglyceride concentrations [72], although recent meta-analyses have failed to confirm associations between fructose intake and several metabolic alterations potentially due to additional adaptive changes [73]. However, as these effects of fructose are still debated [73], additional trials to determine whether fructose in particular should be avoided in the diet are necessary. Diet and lifestyle Obesity and excess adiposity can lead to the development of glucose insensitivity, impaired insulin action, and inability to properly regulate glycemic variations. Insoluble fiber, especially cereal fiber, decreases the risk of T2D and cardiovascular disease [78]. High fiber intake is therefore recommended for people with diabetes or at risk of developing diabetes, including people with obesity and metabolic syndrome. Such nutritional recommendations (Tables 1 and 2) have been increasingly introduced by several health care organizations and are currently included in guidelines for patients with or at risk of developing T2D, and they are also appropriate for the management of plasma glucose concentration in type 1 diabetes (T1D) [79e81]. Disease-specific nutritional supplement formulas for diabetes Nutritional support can cause or exacerbate hyperglycemia, especially in obese and diabetic patients, and hyperglycemia is associated with higher morbidity and mortality [91,92]. In the clinical nutrition setting, a burgeoning field of research is dedicated to designing nutritional support products for people with diabetes. With the use of enteral nutrition, the risk of hyperglycemia can be decreased by modification of the total amount and of the quality of carbohydrates used. Standards of Medical Care in Diabetes-2016 [79] Target premeal capillary plasma glucose, 80e130 mg/dL (4. Type 1 diabetes in adults: diagnosis and Aim for a fasting plasma glucose level of 5e7 mmol/L on waking and a management 2015 [83] plasma glucose level of 4e7 mmol/L before meals at other times of day. Management of hyperglycaemia in type 2 diabetes: a patient- the usual HbA1c goal cut-off point is 7% (53. Type 2 diabetes in adults: manage-ment 2015 [86] Aim for HbA1c goal of 7%, but individualized target, as needed. Table 2 Nutrition support guidelines and expert opinions for glycemic management in patients with stress metabolism or metabolic syndrome/obesity. Additional randomized controlled studies are desirable to identify optimal formula composition for different clinical conditions.

Types of intravenous insulin infusion No type of insulin infusion used during surgery has been shown to be superior in either safety or effectiveness in achieving glucose control wellbutrin xl impotence generic tadalafil 2.5 mg on-line. The fixed rate insulin infusion and the intermittent bolus regimens have failed to gain popularity and are little used in clinical practice and are therefore not discussed further erectile dysfunction treatment tablets cheap 2.5 mg tadalafil otc. Individual intra-operative diabetes care treatment plan Management of the individual patient is determined by the following: · Severity and nature of surgery (major or minor surgery) · Duration of perioperative fast · Timing of surgery · Pre-existing diabetes treatment Variable rate separate insulin and glucose intravenous infusions In this commonly used regimen impotence 16 year old buy tadalafil 10 mg low cost, intravenous dextrose is infused at a rate of 5­10 g/hour and a separate insulin infusion is given erectile dysfunction medication costs proven 2.5 mg tadalafil. Following coronary artery bypass graft operations, insulin requirements may increase 10-fold [38]. Glucose insulin potassium infusion the glucose, insulin and potassium infusion is a single solution infusion comprising 500 mL 5% dextrose, 10 mmol/L potassium chloride and 15 units of soluble insulin. Glucose is usually measured 2-hourly and the insulin content of the infusion can be changed if necessary. This method has the disadvantage of inflexibility and wastefulness as the entire infusion has to be discarded and replaced if insulin requirements change. Major surgery (prolonged fast >6 hours) All patients with diabetes undergoing major surgery should have a dextrose and insulin infusion. Postoperative care and discharge For those undergoing minor surgery characterized by a short fast, generally the preoperative diabetes treatment can be reinstated at an early stage once the patient is eating well. Conversion to normal therapy, whether insulin or oral hypoglycemic therapy, should occur when the patient is eating and drinking and free from nausea and emesis. For patients with prolonged periods of nil by mouth or who are severely unwell or malnourished, hyperalimentation may be introduced. Patients with type 1 diabetes have no endogenous insulin and will therefore require exogenous insulin to prevent the development of severe hyperglycemia and subsequent life-threatening complications such as diabetic ketoacidosis. Such patients will also need a continuous supply of glucose of 5­10 g/hour to prevent hypoglycemia. The lack of clear evidence on glycemic specific targets is reflected in the varying glucose targets recommended by national guidelines [24,27,28]. It would seem reasonable therefore to advise treatment regimens to aim for as near normal glycemia with avoidance of hypoglycemia (80 mg/dL, 4 mmol/L). Conclusions Patients with diabetes are twice as likely to be admitted to hospital and stay twice as long as those without diabetes. They have worse outcomes and a poorer patient experience than those without diabetes. Diabetes inpatient care and training has become the Cinderella area of diabetes care delivery despite the setting of clinical standards by several professional bodies. Although there is now a wealth of evidence that specialist inpatient diabetes teams reduce length of stay, reduce errors in prescribing, improve the patient experience and clinical outcomes, many hospitals across the world still lack inpatient specialist teams. Patients voices are being raised in anger against this imbalance in care delivery. Providers of care need to listen to patients and professionals and ensure the delivery of a high quality inpatient service to include appropriate medical and nursing staff training, an equitable access to specialist services across the board, and an active partnership with patients to deliver a comprehensive range of services. Systems need to be in place to enable patients to selfmanage where it is clinically appropriate. If standards are to be improved there needs to be agreed national targets and key performance indicators for diabetes inpatient care for which health care providers should be held accountable. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. Perioperative glycemic control and risk of infectious complications in a cohort of adult with diabetes. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. The relation between hyperglycemia and outcomes in 2,471 patients admitted to the hospital with community-acquired pneumonia. Stress hyperglycemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. Clinical effects of hyperglycaemia in the cardiac surgery population: the Portland Diabetic Project. American College of Endocrinology and American Diabetes Association Consensus statement on inpatient diabetes and glycemic control: a call to action. Canadian Diabetes Association 2003 clinical practice guidelines for the prevention and management of diabetes in Canada.

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References

• Choi J, Goh G, Walradt T, et al. Genomic landscape of cutaneous T cell lymphoma. Nat Genet 2015;47(9):1011- 1019.
• Perry MO, Husmann DA. Urethral injuries in female subjects following pelvic fractures. J Urol. 1992;147(1):139-143.
• Rosenbaum F, Hecht H. The potential variations of the thorax and the esophagus in anomalous atrioventricular excitation (Wolff-Parkinson-White syndrome). Am Heart J. 1945 (29):281-326.
• Costello EK, Stagaman K, Dethlefsen L, et al. The application of ecological theory toward an understanding of the human microbiome. Science 2012;336(6086):1255-1262.
• Lamarche B, Tchernof A, Moorjani S, et al. Small, dense low-density lipoprotein as a predictor of the risk of ischemic heart disease in men. Prospective trial from the Quebec Cardiovascular Study. Circulation 1977;95:69.
• Yanagisawa M, Kurihara H, Kimura S, et al: A novel potent vasoconstrictor peptide produced by vascular endothelial cells, Nature 332:411-415, 1988.
• Hachulla E, Carpentier P, Gressin V, et al. Risk factors for death and the 3-year survival of patients with systemic sclerosis: the French ItinerAIR-Sclerodermie study. Rheumatology (Oxford). 2009;48:304-308.