CMS200 midterm

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Questions and Answers

Which of the following blood pressure readings would meet the criteria for diagnosing metabolic syndrome?

Systolic BP of 120 mmHg and no history of hypertension

Systolic BP of 135 mmHg and Diastolic BP of 90 mmHg (correct)

Systolic BP of 125 mmHg and Diastolic BP of 85 mmHg

Systolic BP of 128 mmHg and Diastolic BP of 80 mmHg

What fasting glucose level indicates a potential for metabolic syndrome?

95 mg/dL (5.3 mmol/L)

90 mg/dL (5.0 mmol/L)

115 mg/dL (6.4 mmol/L) (correct)

105 mg/dL (5.8 mmol/L) (correct)

Which condition is considered a liver manifestation of metabolic syndrome?

Alcoholic liver disease

Hepatic steatosis

Hepatitis C

Non-alcoholic fatty liver disease (NAFLD) (correct)

What is the most common symptom experienced by patients with nonalcoholic fatty liver disease (NAFLD) in its early stages?

Mild abdominal discomfort Signup and view all the answers

Which factor is NOT considered a maternal protective factor against NAFLD?

Maternal obesity Signup and view all the answers

Which physical exam finding has the highest sensitivity for detecting hepatomegaly?

Midclavicular liver span ≥ 10 cm on percussion Signup and view all the answers

Which of the following dietary factors is a risk for developing NAFLD?

Excessive dietary fructose consumption Signup and view all the answers

Which symptom is typically associated with advanced stages of nonalcoholic fatty liver disease?

Gynecomastia Signup and view all the answers

What is a common presentation in 75% of patients with advanced nonalcoholic fatty liver disease?

Hepatomegaly Signup and view all the answers

Which of the following is NOT a sign of portal hypertension associated with advanced NAFLD?

Palmar erythema Signup and view all the answers

What is the specificity percentage of palmar erythema in diagnosing hepatocellular disease?

95 Signup and view all the answers

Which physical exam finding has the highest likelihood ratio positive (LR+) related to dilated abdominal veins in hepatocellular disease?

Dilated abdominal veins Signup and view all the answers

What is the sensitivity percentage of spider angiomas in diagnosing cirrhosis?

84 Signup and view all the answers

Which of the following findings has a specificity percentage of 98% when diagnosing cirrhosis?

Dilated abdominal wall veins Signup and view all the answers

Which physical exam finding has the lowest sensitivity for diagnosing hepatocellular disease?

Palpable gallbladder Signup and view all the answers

What is one of the serious comorbid conditions associated with obesity that has a prevalence rate of 8 - 15% in the obese population?

Sleep apnea Signup and view all the answers

Which measure classifies an individual as underweight according to BMI standards?

BMI < 18.5 Signup and view all the answers

What is the required weight loss progress after 6 months for patients undergoing postoperative follow-up for bariatric surgery?

Not lost ≥0.5kg/wk Signup and view all the answers

Which of the following obesity-related diseases has the highest attributable prevalence rate to obesity?

Type 2 diabetes Signup and view all the answers

What condition shows a relative risk of 1.75 for females with a BMI between 25 and 29.9 for developing hypertension?

Hypertension Signup and view all the answers

Which vitamin should be monitored yearly for all types of bariatric surgeries?

Vitamin B12 Signup and view all the answers

Which factor is most directly associated with increased appetite and caloric intake leading to obesity?

Insufficient sleep Signup and view all the answers

Which environmental factor is most likely to reduce physical activity and potentially contribute to obesity?

Obesogenic environment Signup and view all the answers

How often should lipid evaluations be conducted postoperatively for patients who had bariatric surgery?

Every 6-12 months Signup and view all the answers

Which category of obesity has a relative risk of extremely high for related diseases?

BMI ≥ 40 Signup and view all the answers

Which of the following factors primarily affects gastric function in patients with obesity?

Increased gastric capacity Signup and view all the answers

Which of the following factors is assessed during each visit after bariatric surgery?

Need for anti-hypertensives Signup and view all the answers

Which psychological factor is commonly associated with obesity in patients?

Increased anxiety Signup and view all the answers

What follow-up interval is recommended for patients who underwent laparoscopic sleeve gastrectomy (LSG) after stabilization?

Every 12 months Signup and view all the answers

What is the relationship between socioeconomic status and obesity prevalence?

Inverse relationship with weight gain Signup and view all the answers

Which of the following complications is NOT commonly associated with diabetes mellitus?

Asthma Signup and view all the answers

What is the estimated percentage of adults globally who are diagnosed with diabetes?

10.5% Signup and view all the answers

Which diagnostic test is commonly used to monitor diabetes, specifically linked to long-term glucose control?

HbA1c test Signup and view all the answers

What is a significant risk factor for developing diabetes that is often overlooked?

Sedentary lifestyle Signup and view all the answers

What is one major effect of diabetes on lifespan and mortality rates?

Reduces lifespan by 5-15 years Signup and view all the answers

What is the prevalence of gestational diabetes in pregnancies as of 2020?

7.8% Signup and view all the answers

Which screening method for gestational diabetes offers more sensitive results?

Non-fasting 50g glucose challenge test Signup and view all the answers

What is the recommended threshold for blood glucose in the two-step testing method to indicate a need for further testing?

130 mg/dL Signup and view all the answers

What percentage of women diagnosed with gestational diabetes experience increased psychological and emotional burden?

Greater than 25% Signup and view all the answers

What is the difference in diagnosis rates of gestational diabetes between one-step and two-step testing methods?

2% higher in one-step testing Signup and view all the answers

What factor is primarily associated with the increasing incidence of Type 1 diabetes globally?

Environmental factors Signup and view all the answers

Which genetic factor significantly contributes to Type 1 diabetes susceptibility?

HLA-DR3 and HLA-DR4 loci Signup and view all the answers

What is the primary environmental factor that increases the risk of developing Type 2 diabetes?

Visceral obesity Signup and view all the answers

In the context of Type 2 diabetes, what is the observed risk for monzygotic twins when one twin develops the disease?

70% chance for the second twin to develop it Signup and view all the answers

What is a notable trend in all-cause mortality rates among diabetes patients?

They have decreased, indicating longer patient survival Signup and view all the answers

What condition is suggested if shoulder pain occurs only with active range of motion?

Subacromial bursitis Signup and view all the answers

Which type of shoulder pain is commonly associated with the elevation of the arm above the head?

Impingement syndrome Signup and view all the answers

What is the prevalence of impingement syndrome or rotator cuff tendinitis reported in the primary care setting?

48%-85% Signup and view all the answers

Which shoulder condition involves pain during both active and passive motions?

Frozen shoulder Signup and view all the answers

In the context of shoulder pain, which of the following is considered an intrinsic cause related to inflammatory conditions?

Rheumatoid arthritis Signup and view all the answers

What does weakness during the dropping sign test indicate?

Supraspinatus rotator cuff tear Signup and view all the answers

Which test is positive if a patient is unable to maintain external rotation?

External Rotation Lag Test Signup and view all the answers

What does inability to hold the hand in the internal rotation lag position test for?

Subscapularis disorder Signup and view all the answers

What is the specificity percentage for the External Rotation Lag Test?

94% Signup and view all the answers

Which of these tests assesses lesions specifically in the supraspinatus muscle and tendon?

Empty/Full Can Tests Signup and view all the answers

What does a positive Neer impingement test indicate?

Subacromial impingement/rotator cuff tendinitis Signup and view all the answers

Which clinical test is performed with the shoulder flexed at 90 degrees and the elbow flexed at 90 degrees?

Hawkins impingement test Signup and view all the answers

During the painful arc of abduction, pain is experienced at which degrees indicating a positive test?

60° to 120° Signup and view all the answers

What is the specificity of the passive abduction test?

10% Signup and view all the answers

Which test involves the patient flexing their elbow and elevating it while placing their hand on the contralateral shoulder?

Yocum test Signup and view all the answers

Which condition is associated with both atrophic gastritis and pernicious anemia?

Addison’s disease Signup and view all the answers

What factor is unlikely to cause aberrations in lab tests showing high TSH levels?

Strenuous exercise Signup and view all the answers

Which of the following is a drug that can lead to low levels of T4 and T3?

Phenobarbital Signup and view all the answers

What is the consequence of taking biotin before thyroid function tests?

Falsely high fT4 and fT3 levels Signup and view all the answers

Which condition is associated with high levels of anti-TSH receptor antibodies?

Graves’ disease Signup and view all the answers

What is the most common cause of primary hypothyroidism in North America?

Chronic autoimmune thyroiditis Signup and view all the answers

Which type of hypothyroidism is characterized by inadequate production of thyroid stimulating hormone (TSH)?

Secondary hypothyroidism Signup and view all the answers

Which symptom is likely to be experienced by a patient with hypothyroidism?

Constipation Signup and view all the answers

What could be a rare cause of primary hypothyroidism related to autoimmune conditions?

Hashimoto thyroiditis Signup and view all the answers

Which of the following medications is known to potentially cause iatrogenic hypothyroidism?

Amiodarone Signup and view all the answers

What is characterized by elevated TSH levels with normal fT4 levels?

Subclinical hypothyroidism Signup and view all the answers

Which age group has an increased risk of developing subclinical hypothyroidism?

Age > 65 years Signup and view all the answers

Which laboratory finding is primarily used to diagnose central hypothyroidism?

Low serum fT4 and relatively low serum TSH Signup and view all the answers

What is a significant management recommendation for patients with subclinical hypothyroidism?

Treatment if TSH > 10 mIU/L and symptomatic Signup and view all the answers

Which condition is associated with central hypothyroidism due to insufficient TSH stimulation?

Pituitary macroadenomas Signup and view all the answers

What is the typical duration for acute fatigue?

Less than 1 month Signup and view all the answers

Which factor is least likely to contribute to idiopathic fatigue?

Chronic lung disease Signup and view all the answers

What percentage of adults may experience significant fatigue lasting for two or more weeks?

25% Signup and view all the answers

How does fatigue in older adults influence their health outcomes?

Increases risk of negative health outcomes Signup and view all the answers

Which of the following conditions is NOT commonly included in the differential diagnosis for fatigue?

Acute appendicitis Signup and view all the answers

Which type of fatigue is characterized by lasting at least six months and is not relieved by rest?

Chronic fatigue Signup and view all the answers

What is a psychological symptom that may indicate a psychogenic illness?

Loss of interest in social activities Signup and view all the answers

What percentage of patients with chronic fatigue report complete long-term resolution of their symptoms?

2% Signup and view all the answers

Which medication class is likely to cause sedation that could contribute to feelings of fatigue?

Benzodiazepines Signup and view all the answers

Which demographic group is reported to have a higher prevalence of chronic fatigue?

Women and minority groups Signup and view all the answers

Which statement about the diagnosis of systemic exertion intolerance disease (SEID) is true?

At least 6 months of fatigue is necessary for diagnosis. Signup and view all the answers

What is the main characteristic of Systemic Exertion Intolerance Disease (SEID)?

Involves multiple organ systems affected by exertion Signup and view all the answers

What is the estimated global prevalence of Systemic Exertion Intolerance Disease (SEID)?

17 to 24 million people Signup and view all the answers

Which emotional state is associated with increased worry and agitation in psychogenic illness?

Constant feeling of worry Signup and view all the answers

In patients with chronic fatigue, what is the predominant cause of fatigue when a medical or psychological explanation is identified?

Psychiatric disorders Signup and view all the answers

Study Notes

Metabolic Syndrome

Three or more of the following criteria constitute a diagnosis of metabolic syndrome:
- Systolic blood pressure ≥ 130 mmHg or Diastolic blood pressure ≥ 85 mmHg or Antihypertensive pharmacotherapy in a patient with a history of hypertension
- Fasting glucose level ≥ 100 mg/dL (5.6 mmol/L) or Pharmacotherapy for elevated glucose level.
- High-density lipoprotein (HDL) cholesterol level < 50 mg/dL (1.29 mmol/L) in women; < 40 mg/dL (1.04 mmol/L) in men or Pharmacotherapy for reduced high-density lipoprotein cholesterol level.
- Triglyceride level ≥ 150 mg/dL (1.7 mmol/L) or Pharmacotherapy for elevated triglyceride level.
- Waist circumference ≥ 35 inches (89 cm) in women; ≥ 40 inches (102 cm) in men.

NAFLD aka MAFLD

NAFLD is the liver manifestation of metabolic syndrome.
Due to a strong association, the new terminology for NAFLD is Metabolic-associated (or metabolic dysfunction-associated) fatty liver disease (MAFLD).

NAFLD: Risk Factors and Causes

Maternal risk factors:

Maternal obesity
High maternal early-pregnancy glucose concentrations.

Maternal protective factors:

Breastfeeding greater than 6 months (avoidance of early supplemental milk formula) reduces NAFLD risk in offspring and in mother.

Exposures:

Drugs (corticosteroids, amiodarone, diltiazem, methotrexate, tamoxifen, irinotecan, oxaliplatin, antiretroviral therapy).
Toxins (vinyl chloride, carbon tetrachloride, yellow phosphorus, inorganic arsenic exposure).

Dietary and nutritional factors:

Excessive dietary fructose consumption.
Malnutrition.
Starvation and refeeding syndrome.
Total parenteral nutrition.

Genetic factors:

Polymorphisms of the gene encoding apolipoprotein C3.
Polymorphisms of the patatin-like phospholipase domain-containing 3 (PNPLA3) gene.
Polymorphism of TM6SF2.
Polymorphism of HSD17B13.
Variants of MBOAT1 and GCKR.

Associated conditions:

Cushing syndrome
Hypopituitarism
Polycystic ovarian syndrome
Hypothyroidism
Hypobetalipoproteinemia (low apolipoprotein B and LDL cholesterol)
Obstructive sleep apnea
Gut dysbiosis
Altered bile acid metabolism
Cholecystectomy
Psoriasis

NAFLD: Protective Factors

Physical activity protects against the development of NAFLD.

NAFLD: Signs and Symptoms

Most are asymptomatic.

Possible presentations in early stages:

Fatigue
Malaise
Mild abdominal discomfort: right upper quadrant

Possible presentations in advanced stages:

Nausea
Vomiting
Jaundice
Pruritis
Memory impairment
Easy bleeding
Loss of appetite
Hepatomegaly (in 75% of patients)
Spider angiomas
Signs of portal hypertension (edema, ascites, caput medusae)
Palmar erythema
Gynecomastia
Dupuytren contracture
Petechiae

Detecting Hepatomegaly

Diagnostic accuracy of physical exam findings:
- Midclavicular liver span ≥ 10 cm on percussion: sensitivity 61-92%, specificity 30-43%
- Palpable liver edge: sensitivity 39-71%, specificity 56-85%

Diagnosing Hepatocellular Disease in patients with Jaundice

Diagnostic accuracy of physical exam findings:
- Spider angiomas: sensitivity 35-47%, specificity 88-97%
- Palmar erythema: sensitivity 49%, specificity 95%
- Dilated abdominal veins: sensitivity 42%, specificity 98%
- Ascites: sensitivity 44%, specificity 90%
- Palpable spleen: sensitivity 29-47%, specificity 83-90%
- Palpable gallbladder: sensitivity 0%, specificity 69%
- Palpable liver: sensitivity 71-83%, specificity 15-17%
- Liver tenderness: sensitivity 37-38%, specificity 70-78%

Diagnosing Cirrhosis in Patients with Chronic Liver Disease

Diagnostic accuracy of physical exam findings:
- Spider angiomas: sensitivity 33-84%, specificity 48-98%
- Palmar erythema: sensitivity 12-70%, specificity 49-98%
- Gynecomastia: sensitivity 18-58%, specificity 92-97%
- Reduction of body or pubic hair: sensitivity 24-51%, specificity 94-97%
- Jaundice: sensitivity 16-44%, specificity 83-99%
- Dilated abdominal wall veins: sensitivity 9-51%, specificity 79-100%

NAFLD: Differential Diagnosis

Viral hepatitis (hepatitis B, hepatitis C)
Alcoholic hepatitis
Autoimmune hepatitis
Hereditary hemochromatosis
Alpha-1 antitrypsin deficiency
Primary sclerosing cholangitis
Wilson disease
Primary biliary cholangitis
Cirrhosis

NAFLD: Further Testing

Labs to evaluate liver function:
- Alanine aminotransferase (ALT) and aspartate aminotransferase (AST):
 - May be mildly elevated; normal in up to 80% patients.
 - AST/ALT ratio < 0.8 (ALT/AST ratio > 1) in early NAFLD (in contrast to alcohol associated liver disease where AST/ALT ratio > 1.5); but AST may be > ALT (i.e., AST/ALT ratio increases) as advanced fibrosis and cirrhosis develop.
- Alkaline phosphatase (ALP) and gamma-glutamyl transferase (GGT) may also be elevated.
Labs to examine for metabolic risk factors:
- Lipid levels: cholesterol, triglycerides, high-density lipoprotein, low-density lipoprotein.
- Fasting glucose or HbA1C levels.
- Fasting glucose and fasting insulin levels can be used to calculate measures of insulin resistance:
 - Homeostasis Model Assessment (HOMA): Normal value < 3.99 (online calculator available)
 - Quantitative Insulin Sensitivity Check Index (QUICKI): Normal value > 0.35 (online calculator available)
Consider labs to exclude other causes of liver disease:
- Condition | Clinical Features | Laboratory Evaluation
- Alpha1-antitrypsin deficiency | Hepatomegaly and elevated liver enzyme levels | Alpha1-antitrypsin level, phenotyping, liver biopsy
- Autoimmune hepatitis | More common in women and individuals with a history of thyroid disease | Antinuclear antibody, smooth muscle antibody, liver/kidney microsomal antibody testing
- Hereditary hemochromatosis | Bronze diabetes (darkening of skin and hyperglycemia), arthritis, congestive heart failure, impotence, family history | Complete blood count, ferritin level, transferrin saturations, genetic testing (HFE gene), liver biopsy with staining for iron, MRI
- Wilson disease | Neurologic and psychological presentation with liver disease at young age (< 40 years), family history | 24-hour urinary copper measurement, ceruloplasmin level, liver biopsy, genetic testing
- Viral hepatitis (hepatitis B or C) | One of the main causes of chronic liver disease along with NAFLD and alcohol | Hepatitis B surface antigen (HBsAg), hepatitis C virus antibody (anti-HCV)
Imaging tests:
- Ultrasonography: increased hepatic echogenicity. Imaging test of choice. Least invasive; relatively inexpensive; no exposure to radiation.
- Computed tomography (CT) – unenhanced or contrast-enhanced.
- Magnetic resonance imaging (MRI)
Diagnostic accuracy of imaging tests for the evaluation of NAFLD:
- Imaging Test | Sensitivity (%) | Specificity (%) | PPV (%) | NPV (%) | LR+ | LR-
- Ultrasonography | 60-100 | 77-95 | 52-89 | 82-100 | 1.1-8.6 | ∞-0.2
- Unenhanced CT | 88-95 | 90-99 | 79-98 | 95-98 | 2.7-40.7 | 0.02-0.05
- Contrast-enhanced CT | 84-87 | 75-86 | 59-72 | 92-94 | 1.4-2.7 | 0.06-0.09
- MRI | 96 | 93 | 85 | 98 | 5.9 | 0.02
Grading and staging of NAFLD histological lesions:
- Grade | Findings | Stages | Findings
- Grade 1 (mild) | Steatosis up to 66%, occasional ballooning in zone 3, scattered polymorphs with or without lymphocytes, mild or no portal inflammation | Stage 0 | No fibrosis
- Grade 2 (moderate) | Any degree of steatosis, obvious ballooning predominantly in zone 3, intralobular inflammation with polymorphs and chronic inflammation, and mild to moderate portal inflammation | Stage 1 | Zone 3 perisinusoidal fibrosis only
- Grade 3 (severe) | Panacinar steatosis, ballooning and obvious disarray predominantly in zone 3, intralobular inflammation with scattered polymorphs with or without mild chronic and mild to moderate portal inflammation | Stage 2 | Zone 3 perisinusoidal and periportal fibrosis | Stage 3 | Bridging fibrosis | Stage 4 | Cirrhosis
NAFLD Activity Score (NAS):
- Used in NAFLD patients who have had a liver biopsy.
- Score based on histology results:
  - Steatosis grade.
  - Lobular inflammation.
  - Liver cell injury (ballooning).
- Score correlates with steatohepatitis diagnosis but should not be used to definitively diagnosis NASH.
- Online calculator available via MDCalc.

NAFLD: Further Testing

While liver biopsy is a helpful diagnostic tool, not all NAFLD patients need it!

Weight Gain Causes

Dietary factors associated with weight gain include processed and fast foods, binge and night eating disorders, heavy alcohol consumption, insufficient sleep and smoking cessation.
Environmental factors contribute to weight gain by promoting sedentary lifestyles, physical disability, obesogenic environments, and societal influences.
Social determinants of health impact obesity, with socioeconomic status playing a role.
Cultural factors influence weight perception and body image.
Environmental chemicals including endocrine-disrupting chemicals contribute to weight gain.

Brain-Gut Axis

The brain-gut axis controls food consumption through communication between the gastrointestinal system, adipose tissue, and the brain.
Obesity is frequently associated with abnormalities in satiety, gastric motility, and psychological factors.

Secondary Weight Gain

Secondary weight gain results from genetic syndromes and other medical conditions such as taking certain medications, particularly steroids and glucocorticoids.

Red Flags for Weight Gain

Rapid weight gain, breathing difficulties, increased thirst, sleep disturbances, vision changes, increased waist size, joint pain, skin discoloration, prolonged bleeding, reduced urination, nausea, vomiting, itching, and swelling are red flags indicating potential underlying medical conditions.

Diagnostic Algorithm

Weight gain should be investigated to differentiate between primary and secondary causes.
Referrals or co-management with specialists may be necessary.

Obesity Comorbidities

Obesity is associated with a wide range of health conditions including cardiovascular disease, metabolic disorders, musculoskeletal issues, mental health concerns, and other complications significantly impacting quality of life.

Classification of Obesity

Body mass index (BMI) is used to classify obesity.
Waist circumference further categorizes obesity risk.
Higher BMI and waist circumference indicate greater risk for developing associated diseases.

Attribution of Disease Prevalence to Obesity

A significant portion of the prevalence of type 2 diabetes, uterine cancer, gallbladder disease, osteoarthritis, hypertension, coronary heart disease, breast cancer, and colon cancer is attributable to obesity.

Serious Comorbidities in Obese Individuals

Obese individuals have a higher prevalence of type 2 diabetes, hypertension, hyperlipidemia, coronary heart disease, sleep apnea, osteoarthritis, and non-alcoholic fatty liver disease.

Obesity and Cardiovascular Disease

Obesity is a major risk factor for developing cardiovascular disease.
Elevated heart output, metabolic rate, sympathetic tone, thyroid hormone, caloric intake, visceral fat storage, and sodium retention contribute to a cascade of physiological changes leading to hypertension, hypercholesterolemia, and coronary artery disease, ultimately increasing the risk of cardiovascular disease.

Relative Risk of Heart Disease in Obese Individuals

Individuals with obesity have significantly increased relative risks for developing hypertension, hypercholesterolemia, diabetes mellitus, and cardiovascular disease compared to those with normal weight.

Postoperative Follow-Up for Bariatric Surgery

Patients undergoing different types of bariatric surgery require distinct postoperative follow-up protocols, including assessments, monitoring of specific parameters, and ensuring adequate vitamin and mineral supplementation to address potential nutritional deficiencies.

5As Framework for Obesity Management

The 5As framework provides a systematic approach for managing obesity in adults.
Key steps include asking about weight concerns, assessing risk factors, advising on health risks and benefits of weight loss, agreeing on personalized goals, and assisting with resources and support.

Edmonton Obesity Staging System

The Edmonton Obesity Staging System (EOSS) categorizes obesity based on comorbidities and functional status.
Higher EOSS stages indicate increased mortality risk and potential complications.

Obesity significantly impacts public health, leading to premature death, chronic health conditions, and increased healthcare costs.
Social stigma contributes to challenges in accessing healthcare and employment opportunities for individuals with obesity.

Patient Education

Obesity is associated with increased mortality and comorbidity.
Modest weight loss can significantly improve risk factors for various health conditions.
Weight loss is challenging, but prevention should be emphasized.

Key Resources

Several resources provide comprehensive information and guidance on obesity management for healthcare professionals and patients.

Diabetes Mellitus

A metabolic disease involving abnormally elevated blood glucose levels.
One of the most common chronic diseases and leading causes of disability and mortality.
Shortens lifespan by 5-15 years and the all-cause mortality rate is twice as high for those without diabetes.
1 in 11 adults between ages 20-79 globally is diagnosed with diabetes.
Approximately 34.2 million (10.5%) individuals in the U.S. and 5.7 million (14%) in Canada have diabetes.
Age-standardized prevalence rate has increased by an average of 3.3% each year since 2000.
All-cause mortality rate among those with diabetes has decreased, indicating individuals are living longer with a diabetes diagnosis.
Both genetic and environmental factors contribute to the development of diabetes.
The two main subtypes are Type 1 and Type 2 diabetes.
Other subtypes include maturity-onset diabetes of the young, gestational diabetes, and secondary causes due to endocrinopathies/steroid use.

Type 1 Diabetes

Characterized by the destruction of pancreatic islet beta cells, typically due to an autoimmune reaction.
More prevalent in children and young adults, with peak incidence at ages 4-6 and 10-14.
Global incidence of Type 1 diabetes is increasing by approximately 3% each year.
One-third of disease susceptibility is attributed to genetic factors, while two-thirds is attributed to environmental factors.

Genetic Factors

The HLA locus (HLA-DR3, -DR4, -DQ) contributes to approximately 40% of the genetic risk for developing Type 1 diabetes.
Most patients have circulating antibodies to islet cells, glutamic acid decarboxylase 65, insulin, tyrosine phosphatase IA2, and zinc transporter 8.

Environmental Factors

Highest incidence observed in Scandinavia and northern Europe, with the lowest incidence in China and parts of South America.

Type 2 Diabetes

Genetic Factors

Epidemiologic studies on monozygotic twins over 40 years of age have shown that if one twin develops Type 2 diabetes, the other twin will develop it within a year in 70% of cases.
Genome studies have identified 143 risk variants and regulatory mechanisms for Type 2 diabetes, including loci coding for proteins involved in beta cell function/development, insulin secretion, fat mass and obesity risk, and insulin resistance.

Environmental Factors

Obesity, particularly visceral obesity, is the most significant environmental factor causing insulin resistance.

Metabolic Syndrome

No pathophysiologic basis for the syndrome (WHO, 2010).
Only a modest association exists between metabolic syndrome and cardiovascular disease.
Other measures, such as the Framingham risk score and fasting glucose, are more valuable than the "metabolic syndrome" label.

Additional Types of Diabetes

Gestational diabetes
Diabetes in children and adolescents
Diabetes in geriatric patients
Secondary causes of diabetes

Gestational Diabetes

Comprised 7.8% of all pregnancies in 2020, representing a 13% increase since 2019 and a 30% increase since 2016.
Prevalence increases with advancing age and a higher pre-pregnancy BMI.
Screening typically occurs between 24-28 weeks' gestation with a non-fasting 50g glucose challenge test.
If blood glucose exceeds 140 mg/dL (7.8 mmol/L), a 3-hour fasting 100g glucose challenge test is conducted for confirmation.
A threshold value of 130 mg/dL (7.2 mmol/L) is more sensitive but less specific than a cutoff of 140 mg/dL.
Two testing approaches are available: one-step and two-step screening.
Diagnosis of gestational diabetes is more common in one-step screening but no statistically significant differences in perinatal or maternal complications have been observed.
Diagnosis of gestational diabetes is associated with increased psychological and emotional burden.
Conclusion: Two-step testing produces equivalent benefits and fewer harms compared to one-step testing.

Screening Recommendations

To reduce maternal and fetal complications.
Screen women in their first trimester if risk factors are present, including obesity, advanced maternal age, history of gestational diabetes, family history of diabetes, and belonging to a high-risk ethnic group.
Screen asymptomatic patients at or after 24 weeks' gestation.

Complications

Adverse outcomes include gestational hypertension, preeclampsia, Cesarean delivery, shoulder dystocia, macrosomia, and birth defects.
Increased maternal risk of developing Type 2 diabetes later in life and increased risk of the child being overweight in childhood/adolescence.
In high-risk populations, diabetes develops in up to 50% of women with gestational diabetes.

Management

Short- and long-term follow-up is essential.
Screening at 6-12 weeks postpartum with a fasting glucose measurement or a 75g 2-hour glucose tolerance test.
Women with gestational diabetes history should be screened every 3 years for overt diabetes.

Diabetes in Children and Adolescents

Type 1 diabetes
Type 2 diabetes
Maturity-onset diabetes of the young (MODY)

Diabetes in Older Adults

Generally accepted as individuals over 65 years of age.
U.S.prevalence of diabetes in older adults increased by 62% from 1997-2010.
21.4% of adults aged ≥65 years in the U.S.have a known diabetes diagnosis, with 16% unaware of their condition.
Most commonly affected by Type 2 diabetes.
Older diabetic population exhibits heterogeneity in race/ethnicity, duration of diabetes, comorbidity, and functional status.
Diabetes increases the risk of mortality, cardiovascular and microvascular complications, as well as other geriatric conditions.

Screening Recommendations

No current recommendations for routine screening.
Screening is dependent on whether treatment would improve overall quality of life or life expectancy.
Decisions regarding treatment should be made based on age, life expectancy, functional status, and the presence of chronic co-morbid diseases.

Secondary Causes of Diabetes

Exocrine pancreas diseases, endocrinopathies, drug- or chemical-induced insulin resistance, and other genetic diseases.
Any disorder damaging the pancreas can result in diabetes.

Diagnostic Tests

Fasting plasma glucose levels (FPG)
Oral glucose tolerance test (OGTT)
Glycated hemoglobin (HbA1c)
Additional tests (urine, self-monitoring, continuous glucose monitoring, autoantibody, genetic)

Fasting Plasma Glucose (FPG)

100-125 mg/dL (5.6-6.9 mmol/L) = impaired fasting glucose tolerance, indicating an increased risk of diabetes ("pre-diabetes").
≥126 mg/dL (7.0 mmol/L) on more than one occasion, after at least 8-hour fasting = Diagnostic.
Diagnosis may be made with hyperglycemia signs and symptoms plus >200 mg/dL (11.1 mmol/L), and testing should be repeated for confirmation.
Pros: may identify more undiagnosed cases than A1c.
Cons: fasting is required.

Oral Glucose Tolerance Test (OGTT)

Perform if FPG is within the impaired fasting glucose range.
Requires a 2-hour fasting period followed by a 75g glucose drink.
Blood glucose is measured at 0, 1, and 2 hours.
≥200 mg/dL (11.1 mmol/L) at 2 hours = Diagnostic.
Pros: considered the gold standard.
Cons: Time-consuming and inconvenient.

Glycated Hemoglobin (HbA1c)

Reflects average blood glucose levels over the preceding 2-3 months.
A1c of 5.7-6.4% = Pre-diabetes.
A1c of ≥ 6.5% = Diagnostic.
Pros: convenient, does not require fasting, and reflects longer-term glucose control.
Cons: less sensitive than OGTT in detecting newly diagnosed diabetes.

Other Tests

Urine tests: Used to detect glucose and ketones in the urine, particularly useful in monitoring diabetic ketoacidosis.
Self-monitoring of blood glucose: Performed by individuals with diabetes using a home glucose meter, providing frequent blood glucose readings and assisting in adjusting medication dosages.
Continuous glucose monitoring (CGM): Offers continuous blood glucose readings throughout the day and night, providing a better understanding of glucose fluctuations and helping in optimizing medication.
Autoantibody tests: Useful in diagnosing Type 1 diabetes, as they identify antibodies against islet cells, insulin, and other proteins.
Genetic testing: May be helpful in identifying individuals with a higher risk of developing Type 2 diabetes and can guide preventive measures.

Extrinsic and Intrinsic Shoulder Pain

Extrinsic causes of shoulder pain can originate from the cervical or thoracic spine, or abdominal organs like the gallbladder.
Intrinsic shoulder pain originates from within the joint and surrounding structures.
Trauma should be considered as a potential cause of intrinsic shoulder pain.
Active range of motion should be assessed to determine if the pain is related to muscle, tendon, or ligament stress.
Passive range of motion should be assessed to evaluate the glenohumeral and AC joints.
Pain with elevation of the arm above the head suggests possible impingement syndrome.

Intrinsic Causes of Shoulder Pain

Impingement syndrome/rotator cuff tendinitis: High prevalence (48%-85%).
Calcific tendinitis: Prevalence of 6%.
Biceps tendinitis/long head: Common cause of shoulder pain.
Glenohumeral instability: Often occurs with trauma.
Acromioclavicular syndromes: Injuries to the AC joint.
Frozen shoulder/capsulitis: Prevalence of 16%-22%.
Glenoid labrum tear: Can lead to instability and pain.

Clinical Tests for Shoulder Pain

Neer Impingement Sign: Pain with full passive shoulder flexion suggests subacromial impingement. Sensitivity: 79%; Specificity: 53%.
Painful Arc of Abduction: Shoulder pain from 60° to 120° suggests subacromial impingement. Sensitivity: 71%; Specificity: 81%.
Hawkins Impingement Sign: Pain with internal rotation of the shoulder suggests supraspinatus impingement. Sensitivity: 79%; Specificity: 59%.
Passive Abduction: Pain with passive abduction suggests supraspinatus impingement. Sensitivity: 74%; Specificity: 10%.
Yocum Test: Pain with elbow elevation without raising the shoulder suggests rotator cuff or subacromial impingement. Sensitivity: 79%; Specificity: 40%.

Clinical Tests for Rotator Cuff Disease: Strength Tests

Drop Arm Test: Immediate pain and inability to slowly lower the arm suggests supraspinatus tear or bicipital tendinitis. Sensitivity: 24%; Specificity: 93%.
Dropping Sign: Weakness or pain during resisted external rotation suggests infraspinatus involvement. Sensitivity: 73%; Specificity: 77%.
External Rotation Lag Test: Inability to maintain external rotation suggests supraspinatus and infraspinatus disorders. Sensitivity: 47%; Specificity: 94%.
Internal Rotation Lag Test: Inability to hold the hand in internal rotation suggests subscapularis disorder. Sensitivity: 97%; Specificity: 83%.
Gerber Lift Off Test: Inability to lift the hand away from the back suggests subscapularis disorder. Sensitivity: 34-68%; Specificity: 50-77%.

Clinical Tests for Rotator Cuff Disease: Composite Tests

External Rotation Resistance Test: Pain or weakness during resisted external rotation suggests infraspinatus disorder. Sensitivity: 63%; Specificity: 75%.
Empty Can Test: Pain or weakness during resisted abduction suggests supraspinatus involvement. Sensitivity: 71%; Specificity: 49%.
Full Can Test: Pain or weakness during resisted abduction suggests supraspinatus involvement. Sensitivity: 75%; Specificity: 68%.
Resisted Abduction: Pain or weakness during resisted abduction suggests impingement. Sensitivity: 58%; Specificity: 20%.
Patte Test: Pain or weakness during resisted external rotation suggests infraspinatus/teres minor involvement. Sensitivity: 58%; Specificity: 60%.

Clinical Tests for RCD: Accuracy of Combinations of Findings

A positive painful arc test is the most useful pain provocation test with a LR greater than 2.0.
Positive Hawkins and Neer tests have little diagnostic value in isolation.
A normal result for the painful arc test has the lowest negative LR (<0.50).
For strength tests, the external rotation lag and internal rotation lag tests are the most accurate for detecting a full rotator cuff tear.
Composite tests measuring pain or weakness are useful when positive. The external rotation resistance test is an example of an accurate composite test.

Biceps Tendon Rupture

Incidence of distal biceps tendon rupture is approximately 2.55 per 100,000 patient-years.
Majority of cases occur in males between 35-54 years old.
Distal biceps rupture commonly affects the dominant limb.
Proximal biceps rupture is more common in elderly patients and often coexists with other shoulder problems.

Biceps Tendon Rupture: Evaluation

Clinical diagnosis is often possible.
Imaging is helpful to confirm diagnosis and identify partial tears.
Key diagnostic criteria:
- History of acute, traumatic event with a popping sensation.
- Palpable and visible biceps muscle retraction (reverse Popeye deformity).
- Weakness in elbow flexion and forearm supination.

Biceps Tendon Rupture: Differential Diagnosis

Rotator cuff disease
Shoulder dislocation/instability
Impingement syndrome
Humeral/radial head fracture

Biceps Tendon Rupture: Prognosis

Proximal biceps rupture usually resolves with non-operative treatment and no long-term functional deficits.
Distal biceps rupture can cause persistent pain, forearm supination weakness, and potential for retraction.
Early diagnosis and timely treatment are crucial, especially in younger, active individuals.

Acromioclavicular Joint Injury

Common injury among athletes and young individuals.
Frequently associated with sporting events, falls, and car accidents.

Cultural Competency and the Therapeutic Relationship

Cultural competency in helping professionals is important to ensure effective communication and understanding
Mismatches between client and helper can occur when there are differences in culture, language, or background
To become culturally competent, it's crucial to understand and respect different cultural perspectives
Culture encompasses various elements including values, beliefs, customs, and traditions.
Acculturation refers to the process of adapting to a new culture, and individuals may have multiple cultural influences.

Addressing Cultural Differences in Counselling

Adopting a tutorial stance by actively listening to clients' experiences and perspectives is beneficial
Tapping into clients' existing cultural support systems can provide additional resources and assistance
Building credibility and trust is essential for effective therapeutic relationships
Tailoring the approach based on individual client needs and cultural background is crucial
Openly acknowledging differences and respectfully broaching sensitive cultural issues is essential

Gender Considerations in Counselling

Addressing gender in the assessment process is paramount to understand client experiences
Discussing gender-related issues that surface helps avoid misunderstandings and biases
Utilizing supervision provides guidance and support in navigating gender-related complexities
Awareness of how gender influences attitudes, family roles, and family violence is crucial
Self-awareness of personal gender stereotypes helps in providing unbiased and ethical care

Older Patients and Primary Hypothyroidism

Many older patients lack a comprehensive understanding of hypothyroidism and its symptoms
Symptoms often appear before diagnosis, causing confusion and potentially delays in receiving treatment
The relationship between symptoms and hypothyroidism may not be readily apparent to individuals
Medication management for hypothyroidism requires dose adjustments based on individual needs and responses

Older Patients' Experiences with Hypothyroidism and Medications

Older patients frequently believe that medication adjustments directly impact health benefits
There may be a perception that medication increases lead to positive outcomes like weight loss and improved well-being
Doubts about the diagnosis and treatment plan are common among some older patients

Ongoing Management of Hypothyroidism in Older Patients

Hypothyroidism requires consistent management including regular appointments, monitoring, and dose adjustments
Insufficient feedback from healthcare providers can lead to anxiety and frustration
Lack of information sharing can contribute to feelings of confusion and vulnerability
Despite feeling vulnerable, older patients may exhibit passive acceptance of the status quo and trust their physicians

Chronic Fatigue and Burnout

Chronic Fatigue Syndrome (CFS) is often described in somatic terms, focusing on physical manifestations
Burnout, conversely, is often described in psychological terms, emphasizing emotional and mental exhaustion
Lack of energy is a common symptom experienced by individuals with both CFS and burnout

Fatigue

A common symptom, often short-lived and linked to a specific cause
Impacts work, family, and social relationships
One in five family medicine patients present with fatigue
International surveys indicate fatigue is the main reason for 6.5% of patient visits and a secondary reason for 19%
One in three adolescents experience fatigue at least four days per week
Men commonly describe fatigue as "tired" while women describe it as "depressed" or "anxious"
Lifetime prevalence of significant fatigue (lasting at least two weeks) is approximately 25%
Common causes include: overexertion, deconditioning, viral illness, upper respiratory tract infection, anemia, lung disease, medications, cancer, depression, and surgery. Individuals may experience up to 6-12 weeks of fatigue even after minor surgery

Fatigue Epidemiology

Fatigue with unknown cause (idiopathic fatigue) or related to psychiatric illness is more common than fatigue due to physical illness, injury, alcohol, or medications
One-third of cases have no identifiable etiology
Up to 75% of patients with fatigue exhibit psychiatric symptoms
Sleep disorders, particularly Obstructive Sleep Apnea and insomnia syndromes, are frequently encountered in patients with fatigue
Fatigue in older adults increases the risk of negative health outcomes, including:
- Mortality (OR, 2.14)
- Disabilities in basic activities of daily living (OR, 3.22)
- Occurrence of physical decline (OR, 1.42)

Fatigue Classification

Time Frame
- Acute fatigue lasts less than one month and resolves with rest
- Subacute fatigue lasts between one and six months
- Chronic fatigue lasts at least six months and does not resolve with rest
Etiology
- Secondary fatigue is caused by an underlying medical condition, often lasting more than one month but typically less than six months
- Physiologic fatigue is attributed to lifestyle imbalances in sleep, exercise, diet, or other activities not stemming from a medical condition and is alleviated with rest

Chronic Fatigue

Fatigue lasting longer than six months
Prevalence of idiopathic chronic fatigue ranges from 5 to 40 per 100,000 people
Occurs in all age groups, including children
Women, minority groups, and those with socioeconomic disadvantages have a higher prevalence
Two-thirds of patients with chronic fatigue do not meet the criteria for "Chronic Fatigue Syndrome" but have similar symptoms and a slightly better prognosis
Over 64% of patients experience limited improvement
Only 2% of patients report complete long-term resolution of symptoms
A poor prognosis is associated with symptoms worsening for more than 24 hours after physical exertion

Causes of Chronic Fatigue

In approximately 70% of patients, a medical or psychological explanation can be identified
- Psychiatric disorders (depression or anxiety) are the predominant contributors
- About 25% of patients have an acute or chronic medical condition underlying their fatigue
Some studies suggest social or personal factors may be important causes
- Examples include: home and outside work demands, poor sleep, interpersonal problems, caregiving for ill family members, and financial concerns
Other studies indicate social, geographic, environmental, and genetic factors contribute to the development of fatigue and depression

Systemic Exertion Intolerance Disease (SEID)

Also known as Chronic Fatigue Syndrome (CFS) or Myalgic Encephalomyelitis (ME)
Studies have shown that the term "Chronic Fatigue Syndrome" can negatively impact patients' perceptions of their illness, diminishing its seriousness and promoting misunderstanding
"Myalgic Encephalomyelitis" is also misleading due to a lack of evidence for brain inflammation, and myalgia is not a core symptom of the disease
"Systemic Exertion Intolerance Disease" accurately captures the main characteristic—multiple organ systems are impacted by exertion, including physical, cognitive, and emotional exertion, associated with autonomic, neuroendocrine, and immune dysfunction
A complex syndrome of uncertain etiology, causing profound unexplained fatigue
No physical finding or lab test can confirm the diagnosis
Studies have reported varying prevalence rates due to differences in definition, population surveyed, and study design
Estimated to affect 17 to 24 million people globally, roughly 1% of the population
Approximately 836,000 to 2.5 million individuals in the United States are affected

Referral and Management

Identify and treat the underlying condition contributing to fatigue
Adjust medications (replace or discontinue) if causing fatigue
Schedule regular follow-up visits (rather than sporadic urgent appointments) to optimize long-term management
Referral for co-management as needed

Constructing a Differential Diagnosis

Diagnosis of SEID depends on ruling out chronic active organic illnesses that can cause chronic fatigue
- Lab results are typically normal
Although a diagnosis of SEID requires at least six months of fatigue, clinical evaluation should be performed during the interim to exclude other treatable causes of fatigue

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This quiz explores the criteria for diagnosing metabolic syndrome, which involves a combination of risk factors such as blood pressure, glucose levels, and cholesterol. It also discusses the liver manifestation of this syndrome, now referred to as MAFLD. Test your knowledge on these critical health concepts!