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Diabetes Mellitus: Not So Sweet

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Diabetes Mellitus: Not So Sweet Prutha Dave, RN, BSN davep_at_alverno.edu MSN 621 Spring 2009 Alverno College * * * * * * * * * * * * * * * * * * * * * * * MINI ... – PowerPoint PPT presentation

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Title: Diabetes Mellitus: Not So Sweet


1
Diabetes Mellitus Not So Sweet
  • Prutha Dave, RN, BSN
  • davep_at_alverno.edu
  • MSN 621 Spring 2009
  • Alverno College

2
Lets Learn About Type II Diabetes Home Page
Click Below For Instructions On Navigating the
Tutorial
Tutorial Objectives
Navigation
Quick Facts
Patho Genetics
Mini Quiz
Click Below To Take The Pre-Test
Signs Symptoms
Mini Quiz
Pre - Test
Tests Diagnosis
Mini Quiz
Click Below To Start The Tutorial
Treatment Medications
Mini Quiz
Tutorial
Patient Education
Mini Quiz
Image retrieved with permission
fromhttp//www.fredscorner.nl/animations.html
3
Navigation
  • Click on to go to next slide.
  • Click on to go back to previous slide.
  • Click on to go to the home page.
  • Click on to return back to where you were.
  • Click on to learn more about the
    topic.
  • Role the mouse over or click underlined words to
    learn more about them.
  • Click on to take a quick quiz after
    each section.

Mini Quiz
Note An incorrect answer page will ONLY allow
you to return BACK to the QUESTION.
4
Objectives of this Tutorial
  • After completion of this tutorial the participant
    will gain a better understanding of Diabetes
    Mellitus, also known as Type II Diabetes.
  • Also the participant will be able to care for a
    patient with the disease more effectively.
  • Topics Covered include
  • Pathology Causes.
  • Symptoms Treatment.
  • Labs/Diagnosis Patient Education.

5
Quick Facts
  • In type 2 diabetes, either the body does not
    produce enough insulin or the cells ignore the
    insulin.
  • There are 23.6 million children and adults in the
    United States, or 7.8 of the population, who
    have diabetes.
  • Significant risk factor for coronary heart
    disease and stroke.
  • Leading cause of blindness and end stage renal
    disease.
  • Major contributor to lower extremity amputations.
  • Can be successfully managed with the right
    patient education.
  • Usually affects older adults but becoming common
    in obese adolescents.

Image retrieved with permission from
http//www.india-shopping.net/india-ayurveda-produ
cts/image/diabetes.gif
6
1. How is Diabetes diagnosed?
a. Two separate fasting glucose measurements of
126 mg/dL or higher
b. Using symptoms such as polydypsia, polyphagia,
and polyuria
c. A hemoglobin A1C level of 6.5
7
Correct! Yay! Great Job!
Two measurements are required to ensure
reproducibility and therefore decrease false
positives and increase specificity.
Image retrieved from Prutha DaveFamily Photos
8
Oops! Try Again!
Click On The Question To Return To It
Question 2
Question 3
Question 1
Question 4
Question 5
Image retrieved from Prutha DaveFamily Photos
9
2. A deficiency in which of the following results
in hyperglycemia?
a. Glucagon
b. Insulin
c. Ketones
d. Cortisol
10
Correct! Yay!
INSULIN helps to LOWER blood glucose
concentration by MOVING GLUCOSE into BODY
TISSUES for energy
Image retrieved with permission
fromhttp//www.fredscorner.nl/animations.html
11
3. What is the Metabolic Syndrome?
  • Seen in patients with very slow metabolism

b. Seen in patients who lack growth hormone,
insulin, and cortisol
c. Seen in patients with the following cluster of
abnormalities obesity, hyperlipidemia,
hypertension, and glucose intolerance
12
Correct! Yay!
Metabolic syndrome is a combination of
abnormalities including high triglycerides, low
HDLs, HTN, and inflammation.
Image retrieved from Prutha DaveFamily Photos
13
4. Which of the following class of oral
hypoglycemic medications can cause excessive
hypoglycemia?
a. Biguanides (Metformin)
b. ACE inhibitors (Lisinopril, Captopril)
c. Sulfonylureas (Glyburide, Glipizide)
d. Statins (Lipitor, Crestor)
14
Correct! Yay!
Sulfonylureas increase insulin levels and the
rate at which glucose is removed from the blood,
it is important to know that they can cause
hypoglycemic reactions.
Image retrieved from Prutha DaveFamily Photos
15
5. What are the most common signs of Type II
Diabetes?
a. Palpitations, restlessness, and diarrhea
b. Dehydration, hypotension, and fatigue
c. Excessive laughter, bad body odor, and hair
loss
d. Weight gain, blurred vision, and excessive
thirst
16
Correct! Yay!
Image retrieved from Prutha DaveFamily Photos
17
Pathophysiology
  • Can be due to absolute insulin deficiency or
    insulin resistance
  • A metabolic disorder which is characterized by
    disturbances in carbohydrate, lipid, and protein
    metabolism caused by an imbalance between insulin
    availability and insulin need
  • Results in an inability to transport glucose
    into the cells of the body,
  • thus causing a breakdown of fat and muscle
    protein

(Porth, 2005)
Image retrieved with permission
fromhttp//professional.diabetes.org/Multimedia_D
isplay.aspx?TYP8CID53310
18
Video What Happens in Type II Diabetes?
Click On Video To View
Video retrieved from with permission from
http//professional.diabetes.org/ResourcesForProfe
ssionals.aspx?typ17cid60425
19
Insulin
  • A polypeptide which has a direct effect in
    lowering blood glucose level
  • Three actions
  • Promotes glucose uptake by target cells and
    provides for storage as glycogen
  • Prevents fat and glycogen breakdown
  • Increases protein synthesis by inhibiting
    gluconeogenesis

20
Insulin Production
  • Made by the beta cells of the pancreas (islets of
    Langerhans)
  • Composed of two polypeptide chains A and B
  • Initially made as a larger molecule proinsulin
    and then cleaved to the active form of insulin
  • Other cleavage product is the inactive C-peptide

21
Insulin Release
  • Glucose enters cell
  • Glycolysis makes ATP
  • ATP production causes K channel to close and
    depolarize the cell
  • Depolarization opens voltage sensitive Ca2
    channels (Ca2 enters cell)
  • Ca2 influx causes insulin release by exocytosis

Image retrieved with permission from
http//professional.diabetes.org/Multimedia_Displa
y.aspx?TYP8CID53313
22
Insulin Action
  • Travels through the portal circulation to the
    liver
  • Binds to membrane receptor
  • Activates intracellular enzymes to increase
    protein, glycogen, and fat synthesis, as well as
    increasing glucose transporters

Image received with permission from
http//upload.wikimedia.org/wikipedia/commons/thum
b/8/8c/Insulin_glucose_metabolism.jpg/400px-Insuli
n_glucose_metabolism.jpg
23
Glucagon Another Polypeptide
  • Antagonist of Insulin
  • Released during periods of fasting to maintain
    blood glucose
  • Released by pancreatic alpha cells
  • Causes glycogen breakdown, gluconeogenesis,
    protein degradation, all resulting in elevation
    of blood glucose
  • In diabetes, can have a negative effect as
    glucagon production goes unchecked as cells are
    starved of glucose resulting in exacerbation of
    hyperglycemia

Image retrieved with permission from
http//www.endocrineweb.com/insulin.html
24
Pathogenesis
  • Genetic and Environmental factors can lead to
    insulin resistance decreased release.
  • This causes decreased glucose uptake and
    increased glucose output resulting in
    hyperglycemia and Type II Diabetes.

Image received with permission fromhttp//profess
ional.diabetes.org/Multimedia_Display.aspx?TYP8C
ID53319
25
Beta Cell Dysfuntion Another Sign
  • Initial decrease in beta cell mass.
  • Increased apoptosis of cell and decreased
    regeneration.
  • Long standing insulin resistance causing the
    beta cells to get TIRED.
  • Glucotoxicity, Lipotoxicity.
  • Amyloid disposition causing dysfuction.

(Porth, 2005)
Image retrieved with permission from
http//www.bodyclinicindonesia.com/library/beta_ce
ll.jpg
26
Genetics and Diabetes Mellitus
  • There is a strong inheritance pattern for Type II
    Diabetes and it is a heterogeneous condition.
  • Two major sets of factors play a role in the
    development of Diabetes Mellitus

Genetic Factors
Environmental Factors
27
Genetic Factors
  • Research shows that Diabetes Mellitus is
    polygenic ?
  • Meaning that it has different combinations of
    gene defects.
  • Multiple diabetogenic genes or polymorphisms,
    each insufficient in themselves, must be present
    in order to cause diabetes.

Click to Learn about Specific Candidate Genes
Associated with DM
  • These genetic polymorphisms can affect the
  • utilization of blood glucose.

(Radha et al, 2003)
28
Polymorphic Genes Defects to Diabetes
Mutations in the following candidate genes are
seen in persons with Type II Diabetes and may
directly contribute to the onset of the
disease Click To Learn About Specific Genes
Genes Related to Insulin Secretion
Genes Related to Insulin Resistance
Genes Related to Obesity
29
Insulin Secretion Genes
Human Insulin Gene (INS) transcription of the
insulin gene is the restricting step for insulin
synthesis and secretion.
Beta Cell Genes (SUR/KIR 6.2) these genes
encode components of the B-Cell K ATP channel
which mediate glucose metabolism and membrane
depolaration to cause insulin realease.
Pancreatic Duodenal Homedomain Gene (PDX 1) a
transcription factor gene which regulates
pancreatic devleopment and islet cell function.
(Radha et al, 2003)
Images retrieved from Microsoft Word Clipart 2003
30
Insulin Resistance Genes
Glucose Transporter Gene (GLUT) acts as a
sensor to the B-cell and as a major signaling
molecule.
Peroxisome Proliferator Activated Receptor Gene
y (PPAR-y) a transcription factor gene
associated in the regulation of adipocyte gene
expression and glucose metabolism.
Insulin Receptor Substrate Gene (IRS) this
gene is shown to be associated with decreased
insulin sensitivity.
(Radha et al, 2003)
Images retrieved from Microsoft Word Clipart 2003
31
Obesity Related Genes
  • Research has shown that variations in obesity
    genes have resulted in insulin resistance
    followed with the onset of Diabetes Mellitus.
    (Radha et al, 2003)

Adiponectin Genes CLICK TO DISCOVER MORE
Single nucleotide polymorphisms within this gene
have been associated with a risk for Type II
Diabetes.
Leptin Receptor Genes CLICK TO DISCOVER MORE
Mutations of this gene have been associated
with hyperglycemia.
Uncoupling Protein 2 Genes CLICK TO DISCOVER MORE
Studies with these genes have shown to be
associated with obesity and DM. Mutations may
also cause interference with glucose homeostasis.
32
Environmental Factors
  • The complex interactions between genes and the
    environment make it difficult to identify a
    single factor that leads to Diabetes Mellitus.
    (Radha et all, 2003)
  • Environmental Factors Include
  • Central Obesity Lack of Activity
  • Uncontrolled Diet Viruses
  • Toxins (Smoking)

33
What is one function of insulin?
MINI QUIZ TEST YOUR KNOWLEDGE
a. Promote weight loss
b. Causes glycogen breakdown
c. Increases protein synthesis
d. Elevate blood glucose
34
Correct! Great Job!
INSULIN promotes glucose uptake, prevents fat and
glycogen breakdown, and Increases Protein
Synthesis! Good Reading!
35
Oops! Try Again!
Image retrieved from Prutha DaveFamily Photos
36
The release of Glucagon has a positive effect on
patients with Type II Diabetes True or False?
TRUE
FALSE
Image retrieved with permission
fromhttp//www.fredscorner.nl/animations.html
37
Correct! Great Job!
Glucagon production can have a NEGATIVE effect if
it goes unchecked as cells are starved of
glucose resulting in exacerbation of
hyperglycemia
Image retrieved from Prutha DaveFamily Photos
38
Sorry! Try Again!
Image retrieved from Prutha DaveFamily Photos
39
Signs Symptoms
  • Sneaky onset
  • Most common signs The Polys
  • Polyuria
  • Polydipsia
  • Blurred Vision
  • Fatigue
  • Skin Infections
  • Paresthesias
  • Weight loss at first

Image retrieved with permission from
http//en.wikipedia.org/wiki/Diabetes
40
Which symptom is the patient speaking of when she
says she is having an abnormal touch sensation?
MINI QUIZ TEST YOUR KNOWLEDGE
Polyuria
Gas
Presyncope
Paresthesias
41
Correct! Great Job!
Image retrieved from Prutha DaveFamily Photos
42
Uh-oh! Try Again!
Image retrieved from Prutha DaveFamily Photos
43
Tests and Diagnosis
  • TESTS TO KNOW
  • Fasting Plasma Glucose
  • A blood test that measure the blood glucose level
    after a person has been fasting for at least
    eight hours. This is the fastest, most
    reproducible, and cheapest method to make the
    diagnosis.
  • Oral Glucose Tolerance Test
  • A test in which a 75g dose of a sugary solution
    is given and then 2 hours later the blood glucose
    level is measured. This test is slightly more
    sensitive than the plasma glucose.
  • Glycosylated Hemoglobin (HbA1c)
  • Measures the percentage of red blood cells that
    have glucose bound to them and is useful in
    monitoring glycemic control. Not recommended for
    routine diagnosis.

FASTING PLASMA GLUCOSE CLICK TO LEARN MORE
ORAL GLUCOSE TOLERANCE TEST CLICK TO LEARN MORE
HbA1c CLICK TO LEARN MORE
44
How The Diagnosis is Made
  • Normal Response
  • Fasting Plasma Glucose (FPG)
  • A fasting blood glucose level less than or equal
    to 110 mg/dl. This must be confirmed on a
    separate occasion.
  • Oral Glucose Tolerance Test (OGTT)
  • 2 hour postload glucose level of less than 140
    mg/dl.

45
Impaired Fasting Glucose Impaired Glucose
Tolerance
  • In essence, impaired fasting glucose and
    impaired glucose tolerance are the same thing,
    just measured differently.
  • Impaired Fasting Glucose
  • A fasting glucose gt 110 and lt 126 mg/dl. This is
    considered a risk factor diabetes, but by itself,
    does not make the diagnosis of diabetes. The
    patient will require close monitoring.
  • Impaired Glucose Tolerance
  • 2-hour glucose results from the OGTT that are gt
    140 and lt 200 mg/dl.  This is also considered a
    risk factor for future diabetes.

46
Diabetes
  • A DIAGNOSIS OF DIABETES IS MADE WHEN
  • 1. Fasting Plasma Glucose level greater than 126
    mg/dl on separate occasions.
  • 2. Random blood glucose gt 200 with classic
    symptoms.
  • 3. Oral glucose tolerance tests show that the
    blood glucose level at 2 hours is gt 200
    mg/dl.  This must be confirmed by a second
    test on another day.

47
Which of the following tests is not used for a
routine diagnosis of Type 2 Diabetes?
MINI QUIZ TEST YOUR KNOWLEDGE
Fasting Glucose
Oral Glucose
HbA1c
Finger Stick
48
Correct! Great Job!
Good Job. The HbA1C test is a measurement of
glycosylated hemoglobin and is a useful tool for
monitoring glycemic control but is not
recommended for diagnostic purposes.
Image retrieved from Prutha DaveFamily Photos
49
Almost! Try Again!
Image retrieved from Prutha DaveFamily Photos
50
True or False For a diagnosis for Diabetes to
be made a person must have a Fasting Plasma
Glucose level greater than 126 mg/dl on only one
occasion.
True
False
51
Correct! Yaayy!
Must have a Fasting Plasma Glucose of 126 mg/dl
or higher on TWO occasions. Great Job!
Image retrieved from Prutha DaveFamily Photos
52
Oops! Try Again!
Image retrieved from Prutha DaveFamily Photos
53
Treatments
  • Aim to control blood glucose levels
  • ?Oral medications which lower blood glucose by a
    variety of mechanisms
  • ?Injectable Insulin which directly lowers blood
    glucose
  • Prevention and reversal of diabetes can be
    achieved by a strict diet, exercise, and weight
    loss.

Images retrieved from Microsoft Word Clipart 2003
54
Oral Medications
  • Drugs that cause increased insulin release
  • Sulfonylureas (Glyburide, Glipizide)
  • Sitagliptin (Januvia) newer drug
  • Exanatide (Byetta) newer drug
  • Drugs that sensitize cells to insulin
  • Biguanides (Metformin)
  • Thiazolidinediones (Rosiglitazone, Pioglitazone)
  • Drugs that block carbohydrate absorption
  • Acarbose

CLICK TO REVEAL MEDICATIONS
CLICK TO REVEAL MEDICATIONS
CLICK TO REVEAL MEDICATIONS
55
Sulfonylureas
  • Drugs such as Glipizide and Glyburide
  • Mechanism Stimulate insulin secretion by closing
    the Beta cells K channel causing depolarization
    and calcium influx. See prior slide
  • Side Effects
  • Hypoglycemia
  • Rashes
  • GI upset
  • Hyponatremia

CLICK TO LEARN THE MECHANISM
56
Biguanides
  • Major drug in this class is Metformin
  • Mechanism Makes liver more sensitive to insulin
  • Great at inducing weight loss
  • Side Effects
  • Diarrhea, abdominal pain
  • Lactic Acidosis- serious and potentially fatal
  • Thus avoid in patients with renal insufficiency,
    liver dysfunction or CHF

CLICK TO LEARN MECHANISM
57
Thiazolidinediones
  • Major drugs in this class are Rosiglitazone
    (Avandia) and Pioglitazone (Actos)
  • Mechanism Makes peripheral tissues such as fat
    and muscle more sensitive to insulin
  • Side Effects
  • Weight gain
  • Liver toxicity
  • Fluid retention and edema
  • Contradicted in CHF

CLICK TO LEARN MECHANISM
58
Acarbose
  • Mechanism Inhibits enteric enzymes that break
    down complex carbohydrates, resulting in partial
    malabsorption of carbohydrates.
  • Side Effects
  • Bloating
  • Abdominal discomfort
  • Diarrhea
  • Flatulence

CLICK TO LEARN THE MECHANISM
59
Insulin Formulations
  • Regular Insulin- (Clear solution) Short acting
    insulin and the only form given IV.
  • Lente and Ultralente- (Cloudy solutions)
    Intermediate and Long acting versions of insulin.
  • NPH- (Cloudy solution) Intermediate acting
    insulin. Usually given Subcutaneously (SubQ).

60
Synthetic Insulin
  • Modified to have either very short or long half
    lives.
  • Insulin Lispro (Humalog) and Insulin Aspart
    (Novolog) have a quicker onset and shorter
    duration than Regular Insulin.
  • Insulin Glargine (Lantus) is a very long acting
    form of insulin.
  • All are administered subcutaneously.

61
Characteristics of Insulin
(Andreoli, 2004)
62
Profile of Action
Image retrieved with permission from
http//www.endotext.org/Diabetes/diabetes20/figure
s/figure7.png
63
Dosing Regimens
  • Intermediate and long acting insulin's are given
    to mimic the bodys natural 24 hour basal insulin
    secretion.
  • Short acting insulin's are given pre-prandially
    to mimic nutrient stimulated insulin secretion.

64
Sample Regimens
Image retrieved with permission from
http//www.deo.ucsf.edu/images/graphs/graph_intens
e_type2.gif
65
Side Effects of Insulin
  • Hypoglycemia too much Insulin can cause an
    abnormal decrease in blood glucose resulting in
    hypoglycemia.
  • Lipohypertrophy at injection site
  • Edema
  • Weight Gain
  • Promotes atherosclerosis at high doses

Image retrieved with permission from Microsoft
Clipart 2003
66
Which of the following patients would you want to
avoid giving a Biguanide to?
MINI QUIZ TEST YOUR KNOWLEDGE
Patients with hypothyroidism
Patients with pneumonia
Patients with renal insufficiency and CHF
Patients with overactive bladders
67
Correct! Great Job!
Image retrieved with permission
fromhttp//www.fredscorner.nl/animations.html
68
Sorry! Try Again!
Image retrieved from Prutha DaveFamily Photos
69
Fill In The Blank________ insulin is the only
form of insulin given intravenously.
NPH
Regular
Lantus
Aspart
70
Correct! Yay!
Image retrieved with permission
fromhttp//www.fredscorner.nl/animations.html
71
Almost! Try Again!
Image retrieved from Prutha DaveFamily Photos
72
Patient Education
  • Patient education will be the single most
    important factor on helping a newly diagnosed
    patient manage their Diabetes.
  • CLICK ON THE STAR to learn about outcomes and
    guidelines for Registered Nurses who are
    initiating Diabetes Self management education

IMPORTANT !! Patient Education IMPORTANT !!
73
Patient Education
  • Describing the diabetes disease process and
    treatment options
  • Incorporating nutritional management into
    lifestyle
  • Incorporating physical activity into lifestyle
  • Using medication(s) safely and for maximum
    therapeutic effectiveness

Click Here To Learn More!!

Click Here To Learn More!!
Click here to Learn More!!
Click Here To Learn More!!
(Funnell et al, 2009)
74
Patient Education
  • Monitoring blood glucose and other parameters and
    interpreting and using the results for
    self-management decision making
  • Preventing, detecting, and treating acute and
    chronic complications
  • Developing personal strategies to address
    psychosocial issues and concerns
  • Developing personal strategies to promote health
    and behavior change

Click Here To Learn More!!
Click Here To Learn More!!
Click Here To Learn More!!
Click Here To Learn More!!
(Funnell et al, 2009)
75
How To Educate Self Management
Describing the Disease Process before
beginning education about the disease process,
perform a patient assessment to gain a better
understanding of the Patients background such
as cultural beliefs as well as readiness to
learn.
Teaching Nutritional Management first learn
about the patients current diet and any
cultural influences that may affect diet. Not
every patient will eat the same or like the
same food that is recommended.
Physical Activity always, always promote any
physical activity. Help the patients transition
into incorporating an exercise regimen which
is appropriate for them. Again, know that
each patient is exercise.
Safe Medication Use make sure the patient
understands the medication and why and how it
will help manage the disease. Speak clearly and
use simple terms. Also, recommending The use of a
medication box may be of great help for the
newly diagnosed Diabetic.
76
How To Educate Self Management
Blood Glucose Monitoring help the patient
understand the need for blood glucose
monitoring. Make sure they know how to use
their specific device and have them do a
repeat demonstration for you.
Preventing Complications teach patients to
watch out for any changes in health status,
and what specific symptoms to be aware of.
Examples are eye sight changes or numbness and
tingling.
Psychosocial Issues Promote discussing any
thoughts or feelings associated with the new
Diabetes diagnosis. Provide resources for
patients to use when dealing with difficult
psychosocial issues or concerns.
Promoting Health Always promote healthy
lifestyle behaviors such as quitting smoking,
eating healthy, exercising, and using a family
or personal support system to incorporate these
behaviors.
77
What is one of the most important nursing
practices before beginning patient education for
new onset Diabetes?
MINI QUIZ TEST YOUR KNOWLEDGE
Making sure that the patient has all their
medications in hand.
Making sure that they exercise everyday for 2
hours
Assessing the patients background and readiness
to learn.
78
Correct! Yay!
Image retrieved from Prutha DaveFamily Photos
79
Sorry! Try Again!
Image retrieved from Prutha DaveFamily Photos
80
Name a way that patients can remember to safely
take their medications?
Keep all their medication in one bottle.Slide 82
Just double up on medications the next day if
they forget.
Obtain a medication pill box with the days listed
and with separate compartments for each day.
81
Correct! Great Job!
Image retrieved from Prutha DaveFamily Photos
82
Oops! Try Again!
Image retrieved from Prutha DaveFamily Photos
83
The End Credits
Thank you to my dear husband who put up with me
through this crazy semester and for all his
medical and technical expertise. Thank you to my
mom who motivated me to pursue my knowledge in
Diabetes.
Image retrieved with permission
fromhttp//www.fredscorner.nl/animations.html
84
References
  • American Diabetes Association, www.diabetes.org.
  • Andreoli, T.E., Carpenter, C.J., Griggs,
    R.C., Loscalzo, J. (2004) Cecil Essentials of
    Medicine. Philadelphia Saunders.
  • Funnell, M. et al. (2009) National Standards for
    Diabetes Self-Management Education, American
    Diabetes Association Diabetes Care, 32, S87-S94
    DOI 10.2337/dc09-S087
  • Hansen, L. (2003). Candidate genes and late-onset
    type 2 diabetes mellitus. Susceptibility genes or
    common polymorphisms? Electronic Version. Dan
    Med Bull, 50(4), 320-46.
  • Jochen, A.L. (2005) Pharmacology of Insulin and
    Oral Sulfonylureas. Medical Pharmacology.
  • Porth, C.M. (2005) Pathophysiology Concepts of
    Altered Health States. Philadelphia Lippincott
    Williams Wilkins.
  • Radha, V., Vimaleswaran K.S., Deepa R.,
    Mohan, V. (2003). The genetics of diabetes
    mellitus. Indian J Med Res, 117, 225-238.
  • Rossini, A.A., Mordes, J.P., Handler, E.S.
    (1988). Perspectives in Diabetes Speculations on
    Etiology of Diabetes Mellitus Tumbler Hypothesis
    Electronic Version. Diabetes, 37, 257-61.
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