Different types of gall stone are pure cholesterol (white), mixed, bile salt predominant (black) stones. 4.Vitamin C supplementation is also useful in Chediak-Higashi syndrome and osteogenesis imperfecta. Due to the pain and disability of osteoarthritis patients experience depression, anxiety, fibromyalgia. A1C chart on this page has A1C to BS conversion chart and calculator using the DCCT formula. The hemoglobin A1C result is an important value for long-term glucose monitoring; about three months mean value of glucose level. DCCT (The Diabetes Control and Complications Trial) Formula: Below is the a1c chart to show a relation between A1C and BS equivalent. 2008 Guidelines2008 Clinical Practice Guidelines - Full guidelines2008 clinical Practice Guidelines - Executive Summary2008 Clinical Practice Guidelines PowerPoint Presentations20132013 Clinical Practice Guidelines are coming!
Discuss various statistics regarding diabetes mellitus, including its prevalence in the United States. Differentiate between type 1 and type 2 diabetes, including pathogenesis and prevalence for each type. List and explain the various tests and methodologies used for the identification of diabetes.
Discuss various features of hemoglobin A1c and other glycated proteins, including fructosamine and glycoalbumin and their use in the detection of diabetes.
Explain long-term monitoring of diabetes mellitus, including the use of estimated average glucose. Although simply defined on the basis of hyperglycemia, diabetes mellitus today is known to be a highly heterogeneous disease.
In the past, the diagnosis of diabetes was based on either fasting plasma glucose or two-hour plasma glucose level in the oral glucose [75 g] tolerance test (OGTT). The glycation of hemoglobin occurs at several amino acid residues and, as a result, several adducts of hemoglobin A (HbA) and various sugars are formed by the nonenzymatic post-translational glycation process. Various methods for the measurement of HbA1c have been described and reviewed.6 These methods can be classified in two major categories. Because of their ability to process a large number of samples and their superior precision, automated HPLC and automated immunoassays are among the most widely used methods. Besides the standardization of various methods, one may also be aware of the clinical situations in which HbA1c may not provide an accurate estimation of glycemic control.
Several assays designed to measure glycated serum proteins (fructosamine and GA) have been described. Despite these limitations, measuring fructosamine or GA provides some advantages over measuring glycohemoglobin A1c as they are not affected by RBC life span, and the glycated protein levels respond more quickly to changes in glycemic control than glycohemoglobin A1c. The effective clinical management of diabetes requires accurate measurement and monitoring of blood glucose levels. Several studies have explored the relationship between HbA1c and chronic glycemia and have supported the association of HbA1c with average glucose levels over the preceding five to 12 weeks.17 These studies have relied on infrequent measures of capillary glucose levels, calling into question the validity of their assessment of chronic glycemia. Recently, HbA1c has been incorporated into diabetes diagnosis, and is recommended by the International Expert Committee based on advances in instrumentation and standardization that make it an accurate and precise marker. International expert committee report on the role of the A1c assay in the diagnosis of diabetes. Those who have preexisting liver disease and who are on other drugs producing liver damage are at risk for valproate induced liver disease.
Need of vitamin c is increased during trauma and surgery for  extra collagen synthesis. It is proposed that high dose of vitamin C intake will increase the anti oxidant property of body. Absorption of Vitamin C enhances the non-haem iron absorption that is taken at the same time. This A1C chart is based on the DCCT formula, a randomized clinical trial designed to compare intensive and conventional therapies and their relative effects on the development and progression of diabetic complications in patients with type 1. Recently, the International Expert Committee (2009) and the ADA Clinical Practice Guidelines (just published in 2013) recommended the use of glycated hemoglobin (HbA1c) to diagnose diabetes.2-3 This article will review the current state of the laboratory testing with special focus on the role of  HbA1c and other emerging glycated protein biomarkers, including fructosamine and glycated albumin (GA), in the diagnosis and long-term monitoring of diabetes.


For decades the diagnosis of diabetes mellitus (type 1 and type 2) was made on the basis of an elevated fasting glucose level. Furthermore, in spite of standardization, many factors, including noncompliance for fasting and inability to tolerate the glucose load, among many other factors, influence the final test outcome. Glycemic biomarkers are important tools to monitor glycemic control.5 Measurement of glycated proteins, primarily HbA1c, has been widely used for routine long-term monitoring of glucose control and as a measure of risk for the development of diabetes complications. Hemoglobin A1c was first discovered in 1969 as an abnormal hemoglobin fraction in blood from diabetes patients.
This process involves the formation of a labile Schiff base intermediate followed by the Amadori rearrangement. One category is based on separation and detection of HbA1c on the basis of charge differences and includes ion-exchange chromatography, high performance liquid chromatography (HPLC), and agar gel electrophoresis. Glycation of HbA1c not only depends on average glycemia but also on the rate of production or destruction of RBCs. Like glycohemoglobin, glucose molecules are joined to protein molecules through a nonenzymatic glycation mechanism to form stable ketoamines termed fructosamine. However, these assays are currently used only to complement glycohemoglobin A1c assays to manage diabetic patients when the detection of short-term metabolic changes is required. Traditionally, plasma glucose has been the lab test used for monitoring the patient with diabetes.
More recently, an international multicenter study examined the relationship between average glucose, as assessed with a combination of continuous glucose monitoring and frequent finger-stick capillary glucose testing and HbA1c levels over time, and demonstrated a close relationship between the two. Currently HbA1c is widely used as a glycemic marker for long-term monitoring of diabetes, as it provides valuable information about the degree of glucose control during the previous eight to 12 weeks.
Repeatability of the oral glucose tolerance test for the diagnosis of impaired glucose tolerance and diabetes mellitus. Effects of hemoglobin variants and chemically modified derivatives on assays for glycohemoglobin. Defining the relationship between plasma glucose and HbA1c in the Diabetes Control and Complications Trial. Cholesterol stones are common in developed countries, whereas pigment stone occur in developing countries. It may be because vitamin C prevent the conversion of nitrites and secondary amines to carcinogenic nitrosamines.. Seven-point capillary blood-glucose profiles (pre-meal, post-meal, and bedtime) obtained in the DCCT were analyzed to define the relationship between HbA1c and BG.
Type 1 diabetes is characterized by absolute insulin deficiency due to autoimmunity leading to ?-cell destruction and can be identified by serological markers of autoimmunity (islet cell autoantibodies). The ADA proposes that fasting plasma glucose (FPG) should be measured in all asymptomatic people ?45 years of age and screening should be considered at a younger age in individuals at increased risk for diabetes.
Based on current recommendations from the National Diabetes Data Group, the OGTT must be done after three days on a diet containing a minimum of 150 g of carbohydrates per day. The test accurately assesses the mean blood glucose level during the preceding two to three months; therefore, it complements the more traditional measures of glucose control (blood or urine glucose testing). It was later shown that glucose binds to hemoglobin in red blood cells, and the term “glycohemoglobin” is applied to a number of chemically distinct hemoglobin components that are generated when glucose binds to hemoglobin. The reaction is slow, continuous, and irreversible, and the reaction rate depends on the ambient glucose concentration. There is no convincing data to show that one method is superior to the other, as practically all commercial methods are standardized to a common reference standard. Findings from the Diabetes Control and Complication Trial demonstrate that maintaining blood glucose close to normal reduces diabetes complications.17 This study compared the standard versus intensive blood glucose control on the complications of diabetes. It is also being used as a primary treatment target, as it has been shown to have close association with diabetes complications. However, it should be reiterated that there are some limitations, and HbA1c may not provide accurate information in certain clinical situations that affect RBC life span—for example, certain hemoglobulinopathies (hemoglobin S, C, or E), anemia, and renal dysfunction. Converting A1C to equivalent blood-glucose level (as shown by the glucometer) can be easier interpreting the result.
He recommends DCCT's formula to convert A1C to BS than the formula by ADAG recommended by ADA.


The three-to-five hour oral glucose tolerance test, once the gold standard for diagnosing diabetes, is currently not recommended either by the ADA or the International Expert Committee.2-3 However, both the ADA and International Expert Committee continue to recommend use of the two-hour oral glucose challenge test, especially in gestational diabetes mellitus (GDM).
The clinical utility of insulin measurement is limited, primarily because when fasting glucose is elevated, ?-cell responsiveness decreases, and when the fasting glucose level is normal, late hyperinsulinism may occur in type 2 diabetes or in the early phase of type 1 diabetes. In addition to hemoglobin, other proteins in blood can also be glycated, and glycated proteins such as fructosamine and glycoalbumin (GA) can also be measured and used as an estimation of glucose control.5 Today the use of HbA1c is also recommended by the ADA and other organizations for diabetes screening and diagnosis. Minor components of HbA were first recognized because of the differences in their electrical charges and were called “fast hemoglobin” as they migrated at a faster rate than an entire HbA molecule when placed in an electrical field. Albumin is the most abundant serum protein, and it contains multiple lysine residues, all of which can be glycated. There are clinical situations in which fructosamine or GA should not be used, such as for thyroid disease (as in thyrotoxic or hypothyroid patients in whom protein turnover is increased or decreased). Now HbA1c levels can be expressed and reported as eAG for most patients with type 1 or type 2 diabetes. Furthermore, its value can be translated into eAG values, providing valuable information to clinicians in monitoring patients with diabetes. If a discrepancy between blood glucose and HbA1c is observed, one must consider the measurement of extracellular glycated proteins (fructosamine or GA), as these are not affected by RBC life span or iron status. Goldstein, MD "Defining the Relationship Between Plasma Glucose and HbA1c, Analysis of glucose profiles and HbA1c in the Diabetes Control and Complications Trial," Diabetes Care 25:275-278, 2002. Today, diabetes-associated complications remain the leading cause of heart disease- or stroke-related deaths and are associated with long-term damage including the failure of organs such as eyes and kidneys. Type 2 diabetes is caused by insulin resistance and lack of compensatory insulin secretory response.
However, it has some limitations, indicating the need for the use of other glycated protein biomarkers. Also, HbA1c levels can be false high in situations that increase the production of RBCs, as in patients with chronic kidney disease who receive erythropoietin for anemia or in patients who receive a blood transfusion.11 In brief, HbA1c levels are shown to be positively associated with hemoglobin levels and are negatively associated with erythropoietin dose.
Levels are also influenced by low albumin levels, as seen in patients with protein-losing enteropathy, nephritic syndrome, or liver failure. Today, use of HbA1c is accepted as a long-term monitoring tool for the management of diabetic patients and is used in conjunction with plasma or finger-stick glucose testing. The calculated eAG level gives healthcare providers a more useful index of chronic glycemia. However, their relationship to average glucose and their prognostic value to diabetes complications are not clear, as in the case of HbA1c.
In contrast to type 1 diabetes, type 2 diabetes is highly prevalent and accounts for 90% to 95% of all diabetes cases. The most important HbA component in diabetes is HbA1c, which has glucose attached at the N-terminal-amino groups of both ? chains of hemoglobin. Just like glycohemoglobin, fructosamine and GA measurements serve as an index of the mean concentration of glucose in the blood during the preceding several weeks. Portable glucose meters are routinely used either in physician offices or by patients at home. However, because of rapid turnover of serum proteins compared to hemoglobin, the fructosamine and GA levels reflect glucose control over a shorter period of two to three weeks rather than six to 10 weeks for glycohemoglobin.
The current recommendation, therefore, is to normalize fructosamine results to a given serum albumin or total protein concentration. Day-to-day management as guided by self-monitoring of blood glucose by patients with the use of glucose meters is a common practice today. Also, with a colorimetric analysis, bilirubin, hemolysis, and lipemia will likely interfere in the measurement.



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