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,

2015

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Theoretical top~csto be studied populated by the

department
1. Glucose estimation:
s. Normal blood glucose level
Jt

Regulation of blood glucose level

~ Abnormalities of blood glucose (Hypoglycemia & Glucosuria)


jt Insulin & Diabetes Mellitus

2. Total plasma proteins estimation:


!Z

General protein metabolism

Practical Exam

-7 Stations:

1. Pipetti ng of the reagent


2. Pipetting of the standard & test
3. Theoretical question (case)

--

4. Theoretical question (True or False)


5. Theoretical question (MCQ 9r essay question)

6. Reading of the absorbance of the test & standard &


7. Calculation of the concentration

of the test through the equation

Reading of test
C:mcer'U'z::tlc;l of test

X concentration

0'(

standard

R~acJing of standard

Concentration

of test =

X cone, of 5

+ Comment on the result (Normal,

increased or decreased)

~ Concentration of the standard for glucose is 100 mg/dl


.st Concentration of the standard for total plasma protein is 6..,gjdl
-----------------------------------------------------------------------------------------------------------------~

ctical 2nd year

2015

1. Glucose estimation

1-

Standard

Test (T)
Glucose reagent

1 ml

1 ml
10 u

Test solution
Standard solution

(S)

10 u

Regulation of blood glucose


Fasting blood glucose (8-12 h) : 70 - 100 mg /dl
2 h post prandial:

--

70 - 140 mg /dl

A. Regulation by tissues & organs:


1. GIT: prevents sudden t in blood glucose through
Slow rate of evacuation
Maximum rate of absorption is 1 g /kg / h
o Secretion of gastric inhibitory
peptide ~ 1 insulin (anttcipatorv
2. Liver:

effect)

Main glucose homoeostat

During hyperglycemia:

liver

blood glucose by :

-i Uptake

of glucose
=70xidation (major & minor)
-'I Utilization of glucose ,..~>Storage (glvcogenesis & lipogenesis)
During hypoglycemia (fasting) : Liver i blood glucose by :
~1 glycogenolysis & gluconeogenesis
3. Kidney:
e During hyperglycemia:
i Glycogenesis & excretion of glucose (if exceeds 180 mg/dl)
During fasting:

t gluconeogenesis

4. Skeletal Ms & adipose tissues:


e

During hyperglycemia:

During hypoglycemia:

i Uptake

by Glut 4 (insulin dependent)

Uptake &

i catabolism

& T storage

of Ms (S( lipolysis in adipose tissue

B. Hormonal regulation:

1. Insulin: The only hypoglycemic hormone by;


-i Uptake of glucose
!IT Oxidation
(major & minor)
i Utilization of glucose /~Storage
(glycogenesis & lipogenesis)
- 1glycogenolysis & gluconeogenesis
5

tical 2nd

year

i'

2015

. Anti-insulins : i Blood glucose


Glucagon: i Glycogenolysis & gluconeogenesis & t glycolysis I glycogenesis
Adrenaline: j Glycogenolysis I gluconeogenesis I lipolysis & ~ glycolysis} glycogenesis
Glucocorticoids & GH : j Gluconeogenesis} lipolysis & 1 uptake} glycolysis
Thyroxine: j Absorption, glycolysis} glycogenolysis gluconeogenesis & 1 storage
I

Hypoglycemia
Def. : J Blood glucose less than 4S mg /dl
Causes:
A. Fasting hypoglycemia:
1. t Insulin: Insulinoma or insulin overdose
2. 1Anti-insulins : Hypofunction of pituitary
hypothyroidism or Addison disease
3. Liver disease: 1 Glycogen & t gluconeogenesis
4. Renal failure : ~ gluconeogenesis
5. Genetic diseases: Von Gierk's disease, fructose 1)6 bis-Pase deficiency or abnormal carnitine shuttle
I

B. Post-prandial

hypoglycemia:

1. Alimentary hypoglycemis : In gastrectomy

~ rapid absorption of glucose


2.Reactive hvpoglvcernia : i glucose after CHO meal
3. Genetic diseases: Hereditary fructose intolerance & galactosemia

Glucosuria
Def. Presence of detectable amounts of glucose in urine
Causes:
A. Hyperglycemic glucosuria:
1. Diabetes mellitus: The commonest cause
2. Adrenaline glucosuria: Due to stress} pheochromocytoma & injection of adrenaline
3. Alimentary glucosuria; After gastrectomy or gastro-jejunostomy
C, Normoglycemic glucosuria:
1. Congenital renal glucosuria (diabetes innocens) : Isola Led defect in the kidneys
2. Renal fdilure
3. Pregnancy
4. Experimental glucosuria by phlorizin

Insulin
Chemistry:
jl 51 aa. Arranged in 2 chains A (21aa) & B (30 aa) connected by 2 disulfide bonds
Synthesis:
" By ~ cells of islets of langerhans of pancreas
.ll Synthesized in the form preproinsulin (109 aa) by removal of signal peptide (23 aa) converted to
proinsulin (86 ad) A & B connected by C peptide (35 ad) w' is secreted in equimolar amounts e' insulin
" Circulating C peptide contains 31 aa and used to measure the endogenous insulin secretion
jl Stored in ~ cells in combination
e\ zinc

tical 2nd year

) 201 5

Secretion: in response to l' intracellular calcium


! l' : Glucose,aa. especially arginine & GIT hormones (oral glucose
insulin more than IV glucose)
! J :Anti-insulins
Catabolism: By GSH insulin transhvdrogsnase
& insulin protease
Mechanism of action:
! Through insulin receptors w' is formed of 4 subunits (2et & 2~)
~ Insulin binds e' a subunit leading to conformational change in the ~ subunit leading activation of
tyrosine kinase leads to autophosphorylation
of tyrosine activating IRS w' performs the action of insulin
~ 4 IRS are recognized having the same structure but different tissue distribution
Actions of insulin:
1. CHO metabolism:
~t uptake of glucose (activates Glut 4 & induces glcokinase of the liver)
,..
t utilization of glucose : ~ oxidation & "" storage (glycogenesis &Iipogenesis)
.t -l-glucose formation (glycogenesis & gluconeogenesis)

2. lipid metabolism:

l' lipogenesis & -l- lipolysis


.l ~ ketogenesis & l' ketolysis

.l

~ l'Cholesterol synthesis
~ l' activity of LPL -7 clearance of chylomicrons
3. Ptn metabolism:
~l' anabolism &~ Ptn catabolism
Insulin resistance:
Def. : A state at w' a given cone. Of insulin produce less than expected biological effect
Causes; Obesity: ~ No. of receptors - Post receptor failure to activate tyrosine kinase
Congenital: Mutation of insulin receptors, glucose transporters or signaling ptn - antibodies
Hereditary: -l- exercise - Diet 2' high CHO K F,!\ - Aging Mc:dications
Tissues affected: Muscle (~ glycogen) - Liver (~ glycogen & l'glu~ose formation) - adipose tissue
(1'Lipolysis)

Diabetes Mellitus
Def.: Disease characterized by hyperglycemia, glucosuria, polyuria, polydepsia, plyphagia & loss of wt.
Classifications: Type 10M, type 110M, gestational OM & other specific types
Gestational OM :
Oef. : Glucose intolerance w' is 1st recognized during pregnancy
Cause: Placental steroid hormones
Prognosis: Blood glucose returns normal after 2-4 weeks of labor but 10% may continue e' DM
Specific types of OM :

l1' anti

insulin hormones
" Hemochromatosis

~ Surgical excision of pancreas


.It Drug induced diabetes I.e. thiazide & salbutamol

2015

el & type" OM:

IACK OL T

incidence
Age

Type 1(100M)

Type 2 (NIDDM)

1Q..fQ...

9_Q.%

Under 20
.Autoimmune

Above ,iQ. yea rs

~ause

__

~~,"~

III

- Viral

destruction

- Defect in insulin secretion

II

of S-~~ils

- Insulin resistance

/'

'(-~.",,,,","

Ketosis

Common

Rare

Onset

Rapid

Slow

level of insulin

Absent or V&Ei low

Usually present

Ireatment

Insulin Injection

Oral hypoglycemic drugs

Metabolic changes In DM
Similar to those occurring during starvation

1. CHOmetabolism:

~ -l-'- -l-

uptake of glucose
utilization of glucose :

-'-1' glucose

-l-

oxidation &~ storage (glycogenesis &Iipogenesis)

(glycogenesis & gluconeogenesis)

formation

This leads to hyperglycemia


glucosuria
2. Changes in lipid metabolism:
I

-'- -!;it

polyuria & polydepsia

+ lipolvsls

lipogenesis &

-'t ketogenesis

& ~ ketolysis -7 ketosis

Hypertriacylglycerolemia

& hypercholesterclem!a

3. Changes in Ptn metabolism:


.l

Ptn catabolism &

-L

4. Water & electrolyte


.!t

(,y

anabolism

healing of wounds &

infection)

imbalance :

Glucosuria & polyuria ~ Dehydration

~ Acidosis ~ loss of buffer cations:


5. Complications

of Diabetes:

Na , K & j\JH4

in uncontrolled

diabetics + genetic susceptibility

A. Vascular complications:
Macrovascular complications:
Microvascular complications:

due to atherosclerosis
Retinopathy,

-7 CHD & stroke ~ mortality

nephropathy

& neuropathy

Mechanism (cause) of vascular complications:


1. Activation of aldose

reductase-s I'

sorbitol w' poorly passes through membranes-7osmotic

2; Glycation of Ptns : glycated Ptns produce complex aggregates


3. Reactive oxygen species (ROS)
B. Diabetic

cataract:

Due to activation

of aldose reductase so :

~l' sorbitol w'

poorly passes through cell membranes

-'--l-

NADPH+H

-l-

GSH

-7

microvascular complications

damage

.ical2nd year

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Diagnosis of OM
.Fasting & 2 " post-prandial
j

blood glucose
Norma!
I

-t
-t

Fasting (mg/dl)
2h PP (mg/dl)

100
140

Diabetic

IGT

l' 126
l' 200

100-126
140 - 200

Z. Oral Glucose Tolerance Test (OGTT) :

,.After fasting

for 8 - 12 h blood sample is withdrawn

is given 75 g glucose in 250 ml water


'- Blood & urine samples are taken at intervals of 30 min
I Pt.

'- Blood samples are tested for glucose & urine samples
are tested for glucose & acetone

Normal curve:
Blood:

fasting glucose below 100, rises after oral glucose then decrease below 140

Urine: A" urine samples are free of glucose & acetone

Diabetic curve:
Blood: fasting glucose more than 126

rises more after oral glucose then 2h PP more than 200

Urine: urine samples contain glucose & may be acetone

IGT: Blood glucose is higher than normal but less than DM


Flat curve: due to malabsorption - delayed evacuation - hypopituitarism
Lagging curve.' due to gastrectomy - hyperthyroidism

Renal glucosuria: glucose in urine while blood glucose doesn't exceed 180 mg/dl
Gestational DM :
Normal blood glucose in pregnancy:
To diagnose gestational

fasting:

around 75 mg /dl - 2h PP rarely exceeds 120 mgjdl

OM 2 or more values must exceed the following values:

I Glucose level
I

(mgjdl)

I Fasting

11

1130

95

2h

~~3-h-~

1155

1140

__

3. Measurement of glycatec Hb (rlbAlc) ;


.!. Used in diagnosis & follow up of diabetes
.It

Glucose binds to f\1-terminal valine

~ Not affected by the immediate

change in blood glucose

Jt

Give idea about blood glucose for the last 60 days (6-8 weeks)

Jt

Normal: 4 - 6.5 %

4. Measurement

DM :

l' 6.5 %

of plasma fructosamine

Un controlled

DM :

l' 8 %

~ Suitable when there's a problem in measurement


or pregnancy
.It

of HbAlc i.e. hemolytic anemias, recent treatment

Gives an idea about the blood glucose over a shorter period 2 - 3 weeks

I"

/
ical 2nd year

2015

Diabetic coma
Hyperosmolar

D ketoacidosis

coma

Hypoglycemic
coma

Type of OM

Cause

Any

III
Poor treatment

Poor treatment

Over
treatment

Cause of coma

Ketoacidosis

Hvpercsmolaritv

Hypoglycemia

Respiration
Skin

Hyp erve nti lation

Normal

Normal

Dry

Dry

Sweaty

Pulse

Rapid weak

Rapid weak

Rapid strong

Plasma glucose

High

High

Low

Present

Absent

Absent

Absent

Urine glucose

Present

Urine ketone

Present

IV glucose
IV insulin + glucose
IV insulin
-~+ .bicarbonate + K
Diabetic ketoacidosis is common in type I & can occur in type II & is associated e' k~s
& dehydration
Treatment

Diabetic ketoacidosis can be precipitated

by stress and infection

Diabetic ketoacidosis is treated by K to prevent hypokalemia as insulin produces intracellular shift of K


Hyperosmolar coma is common in type II diabetes old age exposed to stress

Treatment of DM ;
1. Diet control

-l- weight

in obese persons e' type II DM

2. Exercise : ~ Hyperglycemia & improves glucose tolerance


3. Oral antidiabetic drugs: in type" OM NOT in type!
a. l' insulin secretion: Sulfonylurea: Binds ATP sensitive K channels
b.

l' insulin

sensitivity:

Metformin:

.l.hcpatic glucolJ2ogenesis; /~insllljn sensitivity

c. ,1- acscrprior 'JI' [;-)0 ;l, ',<:a~: Acarbose 2, orlistat


d. Glucagon like peptide receptor agonist: ~'insuljn - ~ glucagon - -l- gastric emptying -1'~cell mass
4. Insulin.' SC or inhalation (under trials)

Case study
Type
Characters:
Questions:

Child,

i level

diabetes mellitus

of blood glucose, Polyuria -loss of weight - coma

1. What is your diagnosis?

2. What are the causes of this condition?

_Auto-immune

destruction

3. What are the complications

of ~ cell-

_w
_
viral infection

of this condition?

Hypercholesterolemia - atherosclerosis
4. Comment on the repeating coma

- cataract - retinopathy

Diabetic ketoacidosis due to :


7

- nephropathy-

tical 2nd year


~

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lipolysis

---7

i FFA

---7

i TCA cycle

->

i acetyl

.. ~~~

CoA ---7

~~;Jy."'~I:(""""'>""'

.w~-_~:~n~~JO*'-=~""'::;~

i ATP

Ilnsulin &

t Anti-insulin ~

1Glycolysis

---7

.J.,

pyruvate

---7

oxaloacetate

"i Acetyl

C:oA in mitochondria may be either utilized iFl--E1J


f~X.Q.,.~sis(cytosol) or oxidation
cycle (mitochondria) or in ketogenesis (mitochondria)

'II

As there is no oxaloacetate

& i ATP level-

As there is low insulin, level

-7

..i Ketogenesis

&.,Iketolysis ~

in TeA

acetyl CoA is utilized in K8J>~he$i$

1 ketolysis

ketosis

5. What are the lines of treatment of this kind rf! coma ?


2. IV glucose & insulin in OM
3. Bicarbonate to correct acidosis
'5
4. K in case of hypokalemia
5. IV fluids in cases of dehydration

6. Compare between different types of coma in this condition?


See before
7. What is the normal level of blood glucose?
Fasting: less than 100 rng /dl & 2h post-prandial:

--".

Characters;
Questions:

less than 140 mg/dl

Type II diabetes mellitus

Adult (more than 40 years old), Obese,

i level

of blood glucose, Polyuria r loss of weight

1. What is your diagnosis ?


2, What are the causes of thls condition?
Insulin resistance - defect in insulin secretion

3. What are the complications


Hypercholesterolemia

of this condition?

- atherosclerosis

- cataract - retinopathy - nephropathv

- neuropcith\j

4. Cornpare bstwesn types o'r this condition


,S~:; oefor,:
5. iNhat are the lines of treatment in this case

L-- ...

OraJ hypoglycemic
drugs then insulin
sc
- ~~~...
~
5. 'What is the ncrrnal leve) 0'[ blood gtucoss ?
...

Fasting; Less than 100 mg /dl & 2h post-prandial:

les$ than 140 mg/dl

7. Explain why cataract


may occur in. this case
,
Due to activation of aldo$~ rgQl 1,.ilSe so :

l' sorbitol w' poorly passes through


~ .J,. NADPH+H+ ~ .J,. GSH
Jt l' NDH+H+ -7 .J., Glycolysis
.l

cell membranes

Mea questions
L. Ketoacidosis is both a normal physiologic response to prolonged caloric restriction

(during fasting)

ind also an abnormal process associated with type 1 diabetes. which one of the following sets of
rvents best distinguishes the untreated metabolic process from the physiological one 'of fasting?
relative to the fasting state I in type 1 diabetes mellitus I there is
8

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.:"~~':i::;{.~,..o.':~r.:!'!;'''*''''/''7'joiiy~~~;rt,;m~n('

~.An increased glucagon-insulin

ratio, a higher liver cAMP level and an eQuivale1,hlood


glucose level
b. An equivalent insulin level, a higher liver cAMP and a higher blood glucose le}'lel
c. A lower insulin level, a higher blood glucose and high blood FA level
\
d. A lower insulin level, a higher blood glucose and equivalent blood FA level
\
2. How does insulin promote the growth and di-ffereurtiation of hepatocvtes?
i
a. It increases adenylate cyclase activity
/'
b. It binds a nuclear receptors
c. It activates protein kinase C
d. It activates tyrosine kinase
'
3. Which of the following statements
about insulin is I\JOTcorrect? Insulin a,ts to :
a. Increase the rate of synthesis of liver glucokinase
!
j
b. Enhance the rate of transport of amino acids into muscles
i
c. Increase the activity of intracellular tyrosine kinase
d. Increase the rate of transport of glucose into brain cells
!
4. All the following statements correctly describes insulin EXCEPT:
.
a. It is a small protein composed of 2 chains connected by disulfide bridges
b. It is antagonistic to the action of glucagon
c. It is converted from proinsulin to insulin primarily following secretion from ~eta cells
d. It is inactive when in the proinsulin form!,
~
5. Relative or absolute lack 0-( insulin in humans would result in which one of the following reactions
in the liver?
I
A. Increased glycogen synthesis.

B. Decreased gluconeogenesis from lactate.


\
glycogenolysis.
D. Increased formation of 3-hydroxybutyrate.
E. Decreased action of hormone-sensitive lipase
.
\
6. Which one of the following is most often found in untreated patients with Tvpe 1 and Type 2
diabetes?
A. Hyperglycemia.
B. Extremely low levels of insulin synthesis and secretion.
C. Synthesis of an insulin with an abnormal amino acid sequence.
D. A simple pattern of genetic inheritance.
E. Ketoacidosis.
,
7. An obese individual with Type 2 diabetes:
A. Usually shows a normal glucose tolerance test.
B. Usually has a lower plasma level of insulin than a normal individual.
\
c. Usually shows significant improvement in glucose tolerance if body weight is redu;ced to normal.
D. Usually benefits from receiving insulin about six hours after a meal.
E. Usually has lower plasma levels of glucagon than a normal individual

c. Decreased

I
9

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Ii 201 5

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~;:.F~~:;;;!:",~~~.~~~:l_>:;'.:))'~~;'~~
"':tr"

. An individual with insulin resistance:


~. Usually shows elevated fasting glucose levels,

B. Usually shows elevated fasting insulin levels.


C, Will eventually become diabetic.

O. 15 rarely obese.
E. Is treated by injection of insulin
9. Glutathione-insulin transhvdrogenase:
J

a. requires the presence of glutathione as a coenzyme

.f

b. degrades insulin by reduction of the disulphide bonds


c. insulin degradation occurs in the liver

d. all of the above

lO.Which of the following statements

about insulin is NOT correct?

a. increase the rate of synthesis of liver glucokinase

b. enhance the rate of transport of amino acids into muscles

c.

increase the activity of intracellular

tyrosine kinase

d. increase the rate of transport of glucose into brain cells


11. Obesity, genetic profile, and aging all contribute to the development

of Tvpe, II diabetes. O'r the


r
following, which is the most important additive factor for these three conditions I in the development

I,

of Type 1\ diabetes?

(A) elevated hepatic ketogenesis


(8) elevated pancreatic glucagon secretion

(C) impaired renal clearance of glucose


i

(D) increased adipose tissue activity leading to hyperlipidemia


(E) muscle resistance to insulin
12. Patients with poorly controlled

diabetes mellitus have elevated levels of blood glucose. Om'!

severe consequence of the hyperglYCEmia is ar lncraass in gluCOSE 8U8cnment

to serum proteins,

Which of the following proteins, when glvcosylated, is an 0xcelient measure of the length of time
someone has suffered from an episode of hyperglycemia?

(A) albumin
(8) cholesterol
(C) fatty acids
(0) hemoglobin
13. In Type I diabetes, the increased production

\
(E) transferrin
of ketone bodies is primarily

following?

A)

a result O"{ which of the


\

a substantially increased rate of fatty acid oxidation by hepatocytes

8) an increase in the rate of the citric acid cycle


C) decreased cyclic adenosine monophosphate(cAMP)

levels in adipocytes

D) elevated acetyl-CoA levels in skeletal muscle

(E) increased gluconeogenesis

Answers:
2.0
7. C
.1.

12.D

3.0
8. B
13. A

4.C
9. D

10

5.0
10.0