Elevated+Glucose+and+Infection

**Why is elevated glucose level provides a nutrient medium for infection and at the same time compromised circulation limits its ability to cope with infection? Explain your answers further. ** **Mechanics for analysis **
 * __GROUP 6 __**

**1. Share the process on how you arrived to your answers **

**I. Process and Analysis **  The group considered some causative agent of infection particularly the opportunistic microorganisms like //Streptococcus mutans// on how they relate to increased glucose and associated diseases caused by infection relating to diabetes. The group collated answers from real-time experiences in a hospital and community setting of patients with Diabetes Mellitus Type 2. With these the group has come up these process. Here are the findings:

Glucose in the body is significant in the production of energy for the cells in terms of ATP formation, and for this, glucose also provides a means and contributing factor for invading pathogens for their attachment, cellular growth and pathogenicity as well. Almost all pathogens have some means of attaching themselves to host tissues at their portal of entry. This is called **adherence** or **adhesion** and is necessary step for pathogenicity. The attachment between pathogen and host is accomplished by means of surface molecules on the pathogens called **adhesins (ligands)** that binds specifically to surface receptors of host tissues. The receptors on the host cells are typically sugars such as mannose. Examples is //Streptococcus mutans//, a bacterium that plays a key role in tooth decay, attaches to the surface of teeth by **glycocalyx**. An enzyme produced by //S. mutans// called glucosyltransferase, converts glucose into a sticky polysaccharide called dextran which forms the glcocalyx.[1]
 * A. Why is elevated glucose levels provides a nutrient medium for infection: **

Infections are common concerns of people with diabetes. Certain types of infection occur with increased frequency in people with diabetes: soft tissue infections of the extremities, osteomyelitis, urinary tract infection, and pyelonephritis, candidal infection of the skin and mucous surfaces, dental carries and periodontal disease, and tuberculosis. Hyperglycemia and glycosuria may influence the growth of microorganisms and increase the severity of infection. Clients with diabetes are susceptible to infections of many types. Once infections occur, they are difficult to treat. There are three factors that may contribute to the development of an infection, they are impaired polymorphonuclear leukocyte function, diabetic neuropathies, and vascular insufficiency. Poor glycemic control augments the importance of there factors. Infected areas heal slowly because the damaged vascular system cannot carry sufficient oxygen, white blood cells, nutrients and antibodies to the injured site. Infections increase the need for insulin and enhance the possibility of ketoacidosis. Urinary tract infections are the most common type of infections affecting clients with diabetes, particularly women. One factor maybe the inhibition of polymorphonuclear leukocyte activity while glucosuria is present. Glucosuria is associated with hyperglycemia. The development of a neurogenic bladder, which results in incomplete emptying and urinary retention, may also contribute to the risk of a urinary tract infection. Diabetic foot infections are common. Their occurrence is directly related to the three factors mentioned earlier, plus hyperglycemia. Up to 40% of diabetic clients with foot infections may require amputation, and 5-10% will die despite amputation of the affected area. With proper education and early intervention, foot infections are usually eliminated in a timely manner**.**  **B. As compromised circulation limits its ability to cope with infection: ** Suboptimal response to infection in a person with diabetes is caused by the presence of chronic complications, such as vascular diseases and neuropathies, and by the presence of hyperglycemia and altered neutrophil function. Sensory deficits may cause the person with diabetes to ignore minor trauma and infection, and vascular disease may impair circulation and delivery of blood cells and other substances needed to produce and adequate inflammatory response and effect healing. <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">Diabetes and elevate blood glucose levels also impair host defenses such as the function of neutrophils and immune cells, Polymorphonuclear leukocytes function, particularly adherence, chemotaxis, and phagocytosis, are depressed in persons with diabetes, particularly those with poor hypoglycemic control. <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[2] <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">With poor circulation, related also to narrowing of the blood vessels particularly in the legs such in case of peripheral vascular disease, person may have cold feet. The hair on his feet or legs gradually falls off. His feet may become red whenever he is sitting with his feet hanging down and not touching the floor. As the condition worsens, ulcers may form on the toes or on the bony part of the foot. When diabetic does develop poor circulation, wound and infections do not heal as well or as quickly as they should. The medicines, oxygen, and nutrition are not able to reach the affected area to help in the germ killing healing, and thus, gangrene develops.

<span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">If large arteries of the legs become narrowed, blood clots form more easily. If a clot breaks loose, it may travel to where it can completely bocks a large blood vessel, a condition likely to result into a gangrene in whatever part of the leg below the blockage.<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[3]

2 **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 14.6667px;">. Please highlight the concepts tackled from modules 1-3 related to your answers. **
**<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Module 1. **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> Disease occurs when there is a failure in the homeostatic mechanism to adapt to the demands on the psychophysiologic system. **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Module 2. **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> There are cellular changes that occur during aging which affect body functions. The aging process is not the same for all individuals. The effect of aging on different tissues and organs varies, but in general, older people are more susceptible to fatigue and disease. **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Module 3. **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> The infected wound is one where pathogens have invaded and overcome the body’s first line of defense, producing clinical signs of infection. Two things are to be considered: the break in the skin and the presence of an infective agent. <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">(From page 52 of the Manual Unit 1 module 3)

<span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">3. **Circulation or blood supply to the area**. With decreased blood supply, nutrients to the injured tissues may be inadequate. The ability to remove exudative debris in the wound is likewise affected. <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">4. **Presence of chronic diseases like diabetes**. Person suffering from chronic illness like arthritis and diabetes over the years see their resistance to infection decreases. Diabetes results in altered vascular responses and circulation to an injured area is greatly compromised. Added to this are the effects of elevated blood sugar as a medium for multiplication of bacteria. <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">5. **Existing infection.** This is a confounder. It may contribute to local tissue destruction. Once the person becomes vulnerable to infection, the tendency for infection to spread to other tissues or body systems is likely to occur<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[4].

<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> 3. Present a textual explanation or paradigm for it

**<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Figure 1: A Flow Chart showing the Relationship of Elevated Blood Glucose level to Infection (Modified) **



__<span style="font-family: 'Arial','sans-serif';">OR __ <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;"> <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">The relationship of elevated glucose level would result to various complications including increased viscosity of the blood, peripheral vascular disease or narrowing of the blood vessels, ulcer formation, and other complications. Since the blood would result to slowed or sluggish circulation, ** (A) ** if there would be infection and inflammation, the blood would unable to deliver adequately blood supply that carries platelets, leukocytes, and RBC. Reduction in neutrophils occurs in severe prolonged infections when production of granulocytes cannot keep up with the demand. <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[1] This would result to compromised immune response and further delays wound healing and resistance to infection ** (B). ** Thus, infection may proliferate or spread to other tissues. **<span style="color: #ff0000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">(C) **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Vitamin C and Glucose have similar chemical structures. When they enter cells, they fight each other for survival. So when there is an increased in the level of blood glucose, Vitamin C decreases. This decrease in Vitamin C depresses immune system by weakening WBCs because WBC needs Vitamin C to phagocytize viruses and bacterias. The decrease in the function of WBC, increases the likelihood for infection to occur.<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[2]
 * <span style="color: #ff0000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">(D) **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Leukocyte move through the process of chemotaxis( movement in the intertices of inflamed tissues once they emigrate is apparently not random but is directionally oriented by a variety of chemical “signals” or (is the phenomenon in which somatic cells, bacteria, and other single-cell or multicellular organisms direct their movements according to certain chemicals in their environment. This is important for bacteria to find food (for example, glucose) by swimming towards the highest concentration of food molecules, or to flee from poisons (for example,phenol). <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[3]

<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Infectious agents, damaged tissues, and substances activated within the protein fraction of plasma leaking from the blood attacks leukocytes. Thus, hyperemia, changes in blood flow resulting in margination and pavementing, and chemotactic orientation of leukocyte motion results in the rapid accumulation of a significant leukocytic component in the exudates<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[4]. <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Since the blood would result to slowed or sluggish circulation, if there would be infection and inflammation, the blood would unable to deliver adequately blood supply that carries platelets, leukocytes, and RBC. Reduction in neutrophils occurs in severe prolonged infections when production of granulocytes cannot keep up with the demand.(From ray’s contribution).Thus, in elevated blood sugar, bacterial chemotaxis (bacteria can direct their motion to find favorable locations with high concentrations of attractants (usually food and that is glucose) and avoid repellents (usually poisons) will take place. <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[5]

<span style="font-family: 'Times New Roman','serif'; font-size: 13.3333px;">[1] Huether, Sue et al, **Understanding Pathophysiology 4th ed. Mosby Pub, 2008** <span style="font-family: 'Times New Roman','serif'; font-size: 16px;">[2] http://www.healingdaily.com/detoxification-diet/sugar.htm <span style="font-family: 'Times New Roman','serif'; font-size: 13.3333px;">[3] @http://en.wikipedia.org/wiki/Chemotaxis. <span style="font-family: 'Times New Roman','serif'; font-size: 13.3333px;">[4] Price, Sylvia et, al **Pathophysiology: Clinical Concepts of Disease Process,** 4th ed. Mosby, 1992 <span style="font-family: 'Times New Roman','serif'; font-size: 13.3333px;">[5] @http://en.wikipedia.org/wiki/Chemotaxis



4. Present updates like research articles that would support our answers (at least 2 articles)

**<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Article 1: High glucose environment inhibits p38MAPK signaling and reduces human beta-defensin 3 expressions in keratinocytes. ** <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[|Lan CC] <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">, <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[|Wu CS] <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">, <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[|Huang SM] <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">, <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[|Kuo HY] <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">, <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[|Wu IH] <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">, <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[|Wen CH] <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">, <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[|Chai CY] <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">, <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[|Ai-Hui F] <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">, <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[|Chen GS] <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">.

Department of Dermatology, Kaohsiung Medical University Hospital, Department of Dermatology, College of Medicine, and Center of Excellence of Environmental Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan Department of Dermatology, Kaohsiung Municipal Ta-Tung Hospital, Taiwan.
 * <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Source **

**<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Abstract ** <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">Diabetes mellitus is characterized by elevated plasma glucose and increased rates of skin infections. Altered immune responses have been suggested to contribute to this prevalent complication involving microbial invasion. This study explored the effects of high glucose environment on keratinocytes' innate immunity by focusing on beta defensin-3 (BD3) using in vivo and in vitro models. Our results demonstrated that the perilesional skins of diabetic rats failed to show enhanced BD3 expression after wounding. In addition, high glucose treatment reduced human BD3 (hBD3) expression of cultured human keratinocytes. This pathogenic process involved inhibition of p38MAPK signaling, an event resulted from increased advanced glycation endproducts formation. On the other hand, toll-like receptor-2 (TLR-2) expression and function of cultured keratinocytes were not significantly affected by high glucose treatment. In summary, high glucose conditions inhibited the BD3 expression of epidermal keratinocytes, which in turn contributed to the frequent occurrences of infection associated with diabetic wound. PMID: <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">21442129 <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">[PubMed - as supplied by publisher] <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[1]

**<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Article 2: New insights in diabetic foot infection. ** <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[|Richard JL] <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">, <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[|Sotto A] <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">, <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[|Lavigne JP] <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">. Jean-Louis Richard, Department of Nutritional Diseases and Diabetology, Medical Centre, University Hospital of Nîmes, Le Grau du Roi 30240, France.
 * <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Source **

**<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Abstract ** <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">Foot ulcers are common in diabetic patients, have a cumulative lifetime incidence rate as high as 25% and frequently become infected. The spread of infection to soft tissue and bone is a major causal factor for lower-limb amputation. For this reason, early diagnosis and appropriate treatment are essential, including treatment which is both local (of the foot) and systemic (metabolic), and this requires coordination by a multidisciplinary team. Optimal treatment also often involves extensive surgical debridement and management of the wound base, effective antibiotic therapy, consideration for revascularization and correction of metabolic abnormalities such as hyperglycemia. This article focuses on diagnosis and management of diabetic foot infections in the light of recently published data in order to help clinicians in identification, assessment and antibiotic therapy of diabetic foot infections<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[2].

**<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Article 3: ****<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Candida Problems ** <span style="color: #000000; display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">If you have diabetes, chances are good you will also have problems with bacteria known as candida. Why? Because human being has candida in his or her system. Usually the "friendly bacteria" keep the non-friendly candida at bay, but certain factors can allow the candida to flourish -- factors that are often brought on by diabetes. <span style="color: #000000; display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">For example, candida is a cause of vaginal yeast infections in women, and while yeast infections are very common, they are even more common among women with diabetes. This is because diabetes impairs the body's immune system and its ability to fight infections. Candida growths that would be taken care of naturally in non-diabetic people become problematic in people with diabetes. <span style="color: #000000; display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">In addition, a high blood sugar level makes the mucous membranes more sugary, which is a perfect environment for yeasts to grow in. <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Foods that can trigger candida include sugar, flour, alcohol, corn, potatoes, pasta, rice, bread and other processed foods that contain sugar or flour. By eliminating these foods, most people can get rid of their candida. Ironically, these are the same foods that diabetics need to avoid to better control their blood glucose levels. Focus on periodic detox and eating more yogurt and vegetables, especially those that inhibit the growth of candida, i.e. cabbage, raw garlic, onions, broccoli, turnip, kale. <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[]

**<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Article 4: ****<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Relationship between hyperglycemia and infection in critically ill patients. **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[|Butler SO] <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">, <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[|Btaiche IF] <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">, <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[|Alaniz C] <span style="color: #000000; display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">Department of Pharmacy Services, University of Michigan Hospitals and Health Centers, Ann Arbour, Michigan 48109, USA. **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Type: **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> Journal Article, Review **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Article 5: ****<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Increased Risk of Common Infections in Patients with Type 1 and Type 2 Diabetes Mellitus ** [|**+**]<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Author Affiliations
 * **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Hyperglycemia **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> is a common problem encountered in hospitalized patients, especially in critically ill patients and those with diabetes mellitus. Uncontrolled hyperglycemia may be associated with complications such as fluid and electrolyte disturbances and increased infection risk. Studies have demonstrated impairment of host defenses, including **decreased polymorphonuclear leukocyte mobilization**, **chemotaxis**, and phagocytic activity related to hyperglycemia. Until 2001, hyperglycemia (blood glucose concentrations up to 220 mg/dl) had been tolerated in critically ill patients not only because high blood glucose concentrations were believed to be a normal physiologic reaction in stressed patients and excess glucose is necessary to support the energy needs of glucose-dependent organs, but also because the true significance of short-term hyperglycemia was not known. Recent clinical data show that the use of intensive insulin therapy to maintain tight blood glucose concentrations between 80 and 110 mg/dl decreases morbidity and mortality in critically ill surgical patients. Intensive insulin therapy minimizes derangements in normal host defense mechanisms and modulates release of inflammatory mediators. The principal benefit of intensive insulin therapy is a decrease in infection-related complications and mortality. Further research will define which patient populations will benefit most from intensive insulin therapy and firmly establish the blood glucose concentration at which benefits will be realized. ||
 * **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Hyperglycemia **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> is a common problem encountered in hospitalized patients, especially in critically ill patients and those with diabetes mellitus. Uncontrolled hyperglycemia may be associated with complications such as fluid and electrolyte disturbances and increased infection risk. Studies have demonstrated impairment of host defenses, including **decreased polymorphonuclear leukocyte mobilization**, **chemotaxis**, and phagocytic activity related to hyperglycemia. Until 2001, hyperglycemia (blood glucose concentrations up to 220 mg/dl) had been tolerated in critically ill patients not only because high blood glucose concentrations were believed to be a normal physiologic reaction in stressed patients and excess glucose is necessary to support the energy needs of glucose-dependent organs, but also because the true significance of short-term hyperglycemia was not known. Recent clinical data show that the use of intensive insulin therapy to maintain tight blood glucose concentrations between 80 and 110 mg/dl decreases morbidity and mortality in critically ill surgical patients. Intensive insulin therapy minimizes derangements in normal host defense mechanisms and modulates release of inflammatory mediators. The principal benefit of intensive insulin therapy is a decrease in infection-related complications and mortality. Further research will define which patient populations will benefit most from intensive insulin therapy and firmly establish the blood glucose concentration at which benefits will be realized. ||
 * 1) <span style="color: #000000; display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">1Julius Center for Health Sciences and Primary Care and University Medical Center Utrecht, Utrecht, The Netherlands
 * 2) <span style="color: #000000; display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">2Department of Medicine, Division of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
 * 3) <span style="color: #000000; display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">3Netherlands Institute for Health Services Research NIVEL, Utrecht, The Netherlands
 * 4) <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Reprints or correspondence: Dr. L. Muller, University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, PO Box 85060, 3508 AB Utrecht, The Netherlands ( <span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">l.m.a.muller@umcutrecht.nl <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">).

<span style="color: #000000; display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">**Abstract** **//<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Background //**<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">. Clinical data on the association of diabetes mellitus with common infections are virtually lacking, not conclusive, and often biased. We intended to determine the relative risks of common infections in patients with type 1 and type 2 diabetes mellitus (DM1 and DM2, respectively). **//<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Methods //**<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">. In a 12-month prospective cohort study conducted as part of the Second Dutch National Survey of General Practice, we compared 705 adult patients who had DM1 and 6712 adult patients who had DM2 with 18,911 control patients who had hypertension without diabetes. Outcome measures were medically attended episodes of infection of the respiratory tract, urinary tract, and skin and mucous membranes. We applied multivariable and polytomous logistic regression analysis to determine independent risks of infections and their recurrences in patients with diabetes, compared with control patients. **//<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Results //**<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">. Upper respiratory infections were equally common among patients with diabetes and control patients. Patients with diabetes had a greater risk of lower respiratory tract infection (for patients with DM1: adjusted odds ratio [AOR], 1.42 [95% confidence interval {CI}, 0.96–2.08]; for patients with DM2: AOR, 1.32 [95% CI, 1.13–1.53]), urinary tract infection (for patients with DM1: AOR, 1.96 [95% CI, 1.49–2.58]; for patients with DM2: AOR, 1.24 [95% CI, 1.10–1.39]), bacterial skin and mucous membrane infection (for patients with DM1: AOR, 1.59 [95% CI, 1.12–2.24]; for patients with DM2: AOR, 1.33 [95% CI, 1.15–1.54]), and mycotic skin and mucous membrane infection (for patients with DM1: AOR, 1.34 [95% CI, 0.97–1.84]; for patients with DM2: AOR, 1.44 [95% CI, 1.27–1.63]). Risks increased with recurrences of common infections.

**//<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Conclusions //**<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">. Patients with DM1 and DM2 are at increased risk for lower respiratory tract infection, urinary tract infection, and skin and mucous membrane infection. Studies are warranted into management of such infections in patients with diabetes.

5. Please present a script or a scenario on how to explain this to the following context. :

Community or individual patient, Students **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Scenario A **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">: The setting is in a community where a nurse is assigned to the Rural Heath Unit.The nurse is handling patients with tuberculosis during a monthly health check-up. One of the patients, a 62 year-old mother who have been diagnosed with type-2 diabetes mellitus for eight years and has a non-healing wound with purulent discharge in her left toe due to a 'blade-stick incident.' The patient talked to the nurse regarding the possibility of cure of her wound. (Written its original context.//)//

**<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Patient: **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> //Maam, ilang linggo na itong aking sugat, marami na akong nainom na gamot, at hindi ko naman binabasa itong sugat na ito, bakit hindi pa rin humihilom ang aking sugat//? (Nurse,I have had this wound for several weeks now, I have took medications and kept this wound dry, but why doesn't it seem to heal?) **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Nurse **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">: //Nanay, alam nyo naman po na meron kayong sakit na dyabetes, dahil ang katawan nyo ay hindi na maayos ang pagdaloy ng asukal sa dugo ninyo, ito ay nagdudulot ng paglapot ng inyong dugo. At dahil dito, nahihirapan ang inyong dugo na makadaloy lalo na sa dulong bahagi ng inyong paa na kung saan may sugat, kaya mahirap ang pag galing ng inyong sugat//. (Maam, you know for a fact that your condition – diabetes, causes your blood to become viscous due to inability of the body to regulate glucose level, and with this, the blood would have the difficult task of reaching further the periphery, and this results to inability of the body to fight infection within your wound) **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Patient: **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> //Ah ganon ba, eh, ano naman ang dapat kung gawin dito?// (in that case, what do I need to do with this?) **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Nurse: **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> Kailangan magpatingin tayo sa doctor para malaman natin kung ano ang pweding gawin medikal para maiwasan ang pag kalat ng impeksyon nanay. Buti nalang po at andito kayo para matulungan kayo mai-refer sa ospital kung kinakailangan. At mula rin ngayun ay dapat na mag ingat na po kayo na hindi na masugatan ang inyong paa. (We need to seek further medical and diagnostic evaluation to determine appropriate medical intervention in order to stop further spread of infection. It’s a good thing that you sought medical/nursing advise so that we can make referrals and interventions if necessary. And starting now, you should be cautious of preventing anymore wound in your lower extremities) **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Patient **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">: //Maraming salamat//. (Thank you very much)

**<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Nurse: **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> //Walang ano man nanay, tara at andito na si doc//. (you’re welcome, come, the doctor is in)

**<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Scenario B: **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Patient Y. M., a 67-year-old man, presented to the emergency room with a 5-day history of progressively worsening left-sided facial pain. The pain initially began in his ear. He also noted purulent drainage from the ear. The patient also complained of subjective fevers and chills. His hearing remained normal. He had no cough, sinus drainage, dysuria, nausea, vomiting, rashes, back pain, or cutaneous ulcers. **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Nurse **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">: Good morning Sir, ano po ang nangyari? **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Patient Y.M **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">. : Limang araw na sumasakit ang kaliwang bahagi ng mukha ko. Mas grabe nito nakaraang araw. Tapos may lumalabas na discharge ba ang tawag ninyo dun? Medyo mabaho. **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Nurse : **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> Tay ‘gaano po kasakit kung susukatin natin mula 1 ang katamtamang sakit hanggang 10 ang pinakamasakit? Nahihirapan po ba kayo makarinig? May pa po ba kayo iba sakit?Gaya ng Hypertension, diabetes? **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Patient Y.M **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">. : Naku, mas masakit ngayon. Mga 7. OK naman pandinig ko. Kaya lang nilagnat ako nitong nakaraang araw. Meron nga pla ako diabetes. May mga gamot ako iniinom. Eto ang listahan. **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Nurse **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">: Uminom po ba kayo ng gamot ninyo ngayun araw na ito? **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Patient **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">: Naku, hindi ako nakakainom ng araw araw. Masyado kasi mahal ang gamot kaya mga ikatlo o ikaapat na araw ako kung uminom. **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Nurse : **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> Dapat po makagawa tayo ng paraan para makainom kayo araw. Madali po kayo tamaan ng mga infection lalo at diabetic po kayo. <span style="color: #000000; display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">His **medical history** was significant for poorly controlled diabetes of 25 years’ duration. He did not follow a meal plan. His hemoglobin A1c concentration measured 2 months previously was 11.8%. He also had a history of no proliferative diabetic retinopathy and peripheral sensory neuropathy and a 10-year history of hypertension.

**<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Medications **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> at admission included glyburide, 5 mg twice a day, and benazepril, 10 mg daily. He had no allergies. He neither smoked cigarettes nor drank alcohol, and he had no history of substance abuse. His family history was significant for diabetes and hypertension in his father and grandfather.

**<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Physical examination **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> revealed an elderly Filipino man in obvious discomfort. His temperature was 38.3 degrees Celcius. His pulse was 100, respiratory rate was 19, and blood pressure was 130/70 mmHg. Subjective Pain scale = 7/10. <span style="color: #000000; display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">His left external auditory canal was erythematous and edematous. It was exquisitely tender on examination. Granulation tissue was visible. The tympanic membrane was obscured by debris. The external ear was warm to touch, erythematous, and tender. A 2-cm ring of erythema surrounded the ear. The right external ear, external auditory canal, and tympanic membrane were normal. <span style="color: #000000; display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">The oropharynx had no masses or erythema. Nasal mucosa was normal. Sclerae were no icteric, conjunctivae were no injected, and ocular movements and reflexes were normal. <span style="color: #000000; display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">The patient’s neck was supple without lymphadenopathy or thyromegaly. His chest was clear. Cardiovascular and abdominal examinations were normal. Rectal examination revealed a diffusely enlarged prostate without nodules. Stool was brown and negative for occuly blood. **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Y.M. **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> was awake, alert, and communicative. Cranial nerve examination was normal. Decreased sensation to light touch and pinprick was noted in a stocking distribution in the lower extremities. Reflexes were absent in the ankles. <span style="color: #000000; display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">Laboratory studies revealed a leukocyte count of 9,000 with 30% band forms. Hematocrit was 42. Platelet count was 421. Serum chemistries revealed a sodium of 132 mEq/L, a potassium of 3.8 mEq/L, chloride of 106 mEq/L, bicarbonate of 26 mEq/L, BUN of 38 mg/dl, and a creatinine of 2.3 mg/dl. Serum glucose was 426 mg/dl. Hepatic functions were normal. Urinalysis revealed 1+ protein. Chest X-ray was normal. Electrocardiogram revealed a sinus tachycardia and was otherwise normal. **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Diagnosis ** **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Malignant otitis externa **<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> is a potentially severe infection caused almost exclusively by //Pseudomonas aeruginosa//, which invades the ear and adjacent structures. In the past, most cases were described among elderly patients with long-standing diabetes. Recently, however, cases have been described in patients without diabetes. <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[|23] //<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Pseudomonas aeruginosa //<span style="color: #000000; font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> is not a part of the normal flora of the ear. The presence of that organism is thought to be increased in the presence of hot, humid conditions or following irrigation of the ear with nonsterile water. <span style="color: #000000; display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">The organism is thought to penetrate the cartilage in the external auditory canal through the naturally occurring fissures of Santorini. A necrotizing cellulitis exacerbated by microvascular disease then occurs. Infection then involves mastoid air cells and the temporal bone. Subsequently, the base of the skull becomes involved. Complications of this infection include cranial nerve palsies, thromboses of lateral and sigmoid sinuses, extension to the contralateral base of the skull, and cavernous sinus thrombosis. <span style="color: #000000; display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">Symptoms include otalgia, which occurs in more than 75% of patients, and otorrhea, which occurs in more than 50% of patients.Hearing loss is another common symptom. Trismus and transmandibular joint (TMJ) pain may also occur. Swelling and erythema with a purulent drainage is usually noted on examination. Granulation tissue is often noted, and the tympanic membrane may be perforated. Erythema of the external ear and adjacent tissue may also be found. Ipsalateral cervical and auricular lymphadenopathy may be present. Parotid swelling may occasionally be noted. Cranial nerve palsies may occur with the facial nerve most commonly involved.2 The erythrocyte sedimentation rate is uniformly elevated. <span style="color: #000000; display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">Patient Y. M. had cultures from the external auditory canal that were positive for //Pseudomonas aeruginosa//. His other findings, including the otalga, otorrhea, and erythema of the canal, were also typical of malignant otitis externa. CT scan revealed temporal bone erosion. He was treated with debridement and a 6-week course of an anti-pseudomonal penicillin and an aminoglycoside to which the organism was sensitive. He recovered without further complication. **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Scenario C: ** **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Nurse **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">: Magandang araw po. Ako po si (name). Isa po akong nurse na nagtatrabaho sa (organization). Andito po ako upang magbigay kaalaman sa inyo tungkol sakit na Diabetes. Alam nyo po ba kung ano ang Diabetes? Meron po ba sa inyong may Diabetes? <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">Community (person 1): Ang alam ko po ang diabetes ay mataas ang asukal sa katawan. Ang akin pong nanay ay may sakit na Diabetes. **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Nurse: **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> tama po iyon. Ang diabetes po ay isang sakit na kung saan ang katawan ay may mataas na level o amount ng asukal sa dugo. Ito po ay dahil sa hindi kaya ng katawan na gumawa o mgproduce ng tamang level ng insulin. Ano naman po ang insulin? Ang insulin ay isa pong parang susi para maipasok ang asukal sa loob ng ating mga kasukasuhan, sa English po sa ating mga cells, tissues, at muscles, para magkameron po tayo ng lakas o energy s pang araw araw po nating gawain. Kung wala pong insulin o kulang ang produksyon ng insulin, mananatili po yong asukal sa dugo, kaya kadalasan po sa mga taong may diabetes ay parating pagod n pagod, ihi ng ihi, madalas mauhaw at magutom. <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">Community (person 1): A kaya naman pala si nanay ay parating parang pagod na pagod. <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">(person 2): Ang tatay ko din, may diabetes din sya. Dahil ba sa diabetes kaya din ba sya merong sugat sa paa na hindi gumagaling. Halos 2 buwan n po yon e. **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Nurse: **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> A opo, iyon po ay dahil sa diabetes. Isa po iyon sa kumplikasyon ng diabetes. Mataas po kasi talaga ang tendensiya sa mga taong may diabetes na kapitan ng impeksyon dahil na rin po sa taas ng asukal sa katawan. Sa pagtaas din po kasi ng asukal sa katawan, magiging mabagal po ang sirkulasyon ng ating dugo. At sa pagbagal po ng sirkulasyon ng ating dugo, mas lalong kakapitan ng impeksyon. <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">Community (person 3): napakakumplikado pala talaga ng diabetes ano? **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Nurse **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">: Opo, kaya kelangan po talaga na magpatingin po kayo sa doctor o kahit s health center lang po para matingnan po ang inyong kalusugan, lalo pa pos a mga taong nagkakaedad na. Wag po nating balewalain ang mga di magagandang sintomas na ating nararanasan. <span style="display: block; font-family: 'Arial','sans-serif'; font-size: 13.3333px; text-align: justify;">Community (person 4): Sya maraming salamat at nagkameron kami ng ideya. **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Nurse: **<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;"> Wala pong anuman, maraming salamat din po. At hangad kop o ang kalusugan ng inyong komunidad.

**<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">References: **
 * <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[1] <span style="font-family: 'Arial','sans-serif';">Balabagno, Arceli, et al. **Pathophysiology** UP-OU, 2006
 * <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">[1] <span style="font-family: 'Arial','sans-serif';">Johnson, Marilyn, **Sickeningly Sweet: What You Really Know About Diabetes,** Philippine Pub. House, 1997
 * <span style="font-family: 'Arial','sans-serif';">Huether, Sue et al, **Understanding Pathophysiology 4th ed. Mosby Pub, 2008**
 * <span style="font-family: 'Arial','sans-serif';">Porth, Carol **Pathophysiology, Concept of Altered Health State,** 7th ed. LWW, 2005
 * <span style="font-family: 'Arial','sans-serif';">Price, Sylvia et, al **Pathophysiology: Clinical Concepts of Disease Process,** 4th ed. Mosby, 1992
 * <span style="font-family: 'Arial','sans-serif';">Tortora, zGerald et, al, **Microbiology, An Introduction** 9th ed. Pearson Educ. Inc, 2007

**<span style="font-family: 'Arial','sans-serif'; font-size: 14.6667px;">Web References: ** <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">http://www.ncbi.nlm.nih.gov/pubmed/21442129 <span style="font-family: 'Arial','sans-serif'; font-size: 16px;">[1] <span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">http://www.ncbi.nlm.nih.gov/pubmed/21537457

<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">[1] http://www.ncbi.nlm.nih.gov/pubmed/21442129

<span style="font-family: 'Times New Roman','serif'; font-size: 16px;">[2] http://www.ncbi.nlm.nih.gov/pubmed/21537457

**<span style="font-family: 'Arial','sans-serif'; font-size: 13.3333px;">Group 6 **


 * 1) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">JUSTOL, RAIZA NOVAL **
 * 2) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">KAMAD, BAIDIDO DIBAO **
 * 3) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">LADERA, RAY DOMINIC REAGO **
 * 4) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">LAGUNZAD, CHERRY ANNE DICHOSA **
 * 5) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">LAUS, BERNARDITA LAUGUICO **
 * 6) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">LAZATIN, AILEEN TEDOR **
 * 7) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">LEANO, CHRISTOPHER JOHN EDICA **
 * 8) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">LIM, ARBERN SOLIS **
 * 9) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">LIMOS, HANNA GRACE SENO **
 * 10) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">LLENAS, AMOR AURO **
 * 11) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">LOMUGDANG, VALENTIN III ANTONIO **
 * 12) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">LOYOLA, TWINKLE RAMIREZ **
 * 13) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">LUBIANO, MERCY JOY NASIBA **
 * 14) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">MACALDE, STEPHANIE ANNE SEGURA **
 * 15) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">MACHA, PRINCESS GAY MARIANO **
 * 16) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">MACO, FLORIZA DE SAGUN **
 * 17) **<span style="color: #000000; font-family: 'Calibri','sans-serif';">MAGALLANES, JACINTO LOS BAÑOS **