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Diabetes Insipidus

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Diabetes Insipidus
Diabetes Insipidus

Diabetes mellitus is a    clinical     syndrome characterized by hyperglycemia    caused    by absolute or relative deficiency of insulin. Hyperglycemia    has man causes but is    most commonly due to type1 or type2 diabetes. Lack of insulin affects the metabolism of carbohydrate, protein and fat, and can cause significant disturbance of water and electrolyte homeostasis; death may result from acute metabolic decompensation. Longstanding metabolic derangement is associated with functional and structural changes in many organs; particularly those of the vascular system, which lead to the clinical’ complications’ of diabetes. These characteristically affect the eye, the kidney and the nervous system.The distribution    of blood glucose concentration in populations    is unimodal, with no clear division between  Paople with normal and abnormal values. Hyperglycemia represents an independent risk factor for disease    of both small and large blood    vessels.
Diagnostic criteria for diabetes have been selected to identify those who have a degree of hyperglycemia which, if untreated, is associated with a significant risk of micro vascular disease, and in particular diabetic retinopathy. Less severe hyperglycemia is called’ impaired glucose  tolerance ’. This is not associated with increased risk of large vessel disease and with a greater  risk of developing diabetes in future. The implications of these  criteria are that there is no such thing as’  mild ’diabetes not requiring effective treatment.
•    Polyuria,polydipsia,and weight loss associated with random plasma glucose ≥ 200 mg/dl.
•    Plasma glucose of 126mg/dl or higher after an overnight fast, documented on more than one  occasion.
•    Ketonemia ,ketonuria, or both.
•    Islet auto antibodies are frequently present.
Type 2:
•    Most patients are over 40 years of age and obese.
•    Polyuria and polydipsia .ketonurioa and weight loss generally are uncommon at time of diagnosis .candidal  vaginitis in women may be an initial manifestation. many patients have few o no symptoms.
•    Plasma glucose of 126mg/dl or higher after an overnight fast on more than one occasion. After 75 g oral glucose, diagnostic values are 200 mg/dl or more 2 hrs after the oral glucose.
•    Hypertension, dyslipidemia, and atherosclerosis are often associated.
A.    Type 1 Diabetes Mellitus:
This form of diabetes is immune mediated in over 90% of cases and idiopathic in less than 10%.The rate of pancreatic B cell destruction is quite variable, being rapid in some individuals and slow in others. type 1 diabetes is usually associated with ketosis in its untreated state .it occurs at any age but most commonly arises in children and young adults with a peak incidence before school age and again at around puberty. It is a catabolic disorder in which circulating insulin is virtually absent, plasma glucagon is elevated, and the panacreatic B cells fail to respond to all insulinogenic stimuli.Exogenous insulin is therefore required to reverse the catabolic state ,prevent  ketosis, reduce the hyperglucagonemia ,and reduce blood glucose.

1.Immune Mediated:-
The highest incidence of immune-mediated type 1 diabetes mellitus is in Scandinavia and northern Europe, where the annual incidence is as high as37 per 100,000 children aged 14years or younger in finland 27 per 100,000in Sweden,22per 100,000 in Norway ,and 19 per 100,000 in the united kingdom. The annual incidence of type 1 diabetes decreases across the rest of Europe to 10 per 100,000 in GREECE AND 8 PER 100,000 in France.
Approximately o1one-third of the disease suspceptibillity is due to genes and two-thirds to environmental factors. Genes that are related to the HLAlocus contribute about 40% of the genetic risk. About 95% of patients with type 1 diabetes possess either HLA-DR3 or HLA-DR4,compared with 45-50% of white controls. HLA_DQ genes are even more specific markers of type 1 susceptibility, since a particular variety(HLA-DQB1*0302)is found in the DR$ patients with type1,while a “protective” gene is often present in the DR4 controls.
Less than 10% of subjects have no evidence of pancreatic B cell autoimmunity to explain their insulinopenia and ketoacidosis.this subgroup has been classified as “idiopathic type1 diabetes” and designated as “type 1B”. Although only minorities of patients with type 1 diabetes fall into this group, most of these are of Asian or African origin. it was recently reported that about 4% of the west Africans with ketosisprone diabetes are homozygous for a mutation in PAX-4 a gene that is essential for the development of pancreatic islets.
Types of Blood Tests Needed for Diabetes Insipidus:-
Diabetes insipidus (DI) is a rare condition that is not as well known as the diabetes that involves blood sugar. It can affect how the kidneys function and remove excess fluid from the body. If DI is left untreated, the kidneys could be permanently damaged.
1.    Defining Diabetes Insipidus:-
o    Diabetes insipidus is a rare condition causing frequent urination. You may feel like you need to drink a large amount of fluids, and your urine will be very diluted. If you don’t drink enough water you may become dehydrated. Diabetes insipidus develops when a delicate hormonal balance between your hypothalmus and your kidneys is disturbed. The hypothalmus makes a hormone called AHD (antidiuretic hormone). This hormone regulates the concentration of urine and instructs the kidneys to reabsorb previously-filtered water back into the bloodstream. This means, when everything works correctly, you make less urine
Diagnostic Testing
o    Your doctor will carry out several tests to arrive at the correct diagnosis. If she suspects D.I, she will conduct what is called a water deprivation test. This test does as it says. You will be deprived of water for the duration of this test. First, she will take a blood sample to measure the level of electrolytes in your system. She will also collect a urine sample. During the test, you will give a urine sample every hour and it will be tested to see how concentrated it is. After another blood test, you will be given the hormone vasopressin (ADH). One hour after receiving the vasopressin, you will provide one last urine sample. Your diagnosis will be made based on the changes which took place in your blood and urine during the test

Blood Test:-
Your doctor will only conduct one blood test, to measure your electrolyte (potassium and salt) levels in your blood stream. If you have DI, your potassium and sodium levels in your blood stream will be high. (See Reference 2, paragraph 13)
DI can come on slowly or it can happen all at once. It can come on at any age. The symptoms include needing to urinate frequently, even at night, extreme thirst and drinking very large amounts of water, dehydration if you do not take in an amount of fluid sufficient for your individual needs and an imbalance of electrolytes in your system. These electrolytes provide electrical currents used by your body’s cells. Your body will be high in potassium, chloride, calcium, phosphate and sodium
1.    DIET:-
A well-balanced nutritious diet remains a fundamental element of therapy. The American Diabetes Association recommends about  45-65% of total daily calories in the form of carbohydrates:25-35% in the form of fat  (of which less than 7%are from of saturated fat), and 10-35% in the form of protein. In patient type 2 diabetes ,limiting the carbohydrate intake and substituting some of the calories with monounsaturated fats, such as olive oil, rapeseed (canola) oil, or the oils in nuts and avocados, can lower triglycerides and increase HDL cholesterol. Patients with type 1 diabetes or type 2 diabetes who take insulin should be taught “carbohydrate counting”, so they can administer their insulin bolus for each meal based on its carbohydrates content. In obese individuals with diabetes, an additional goal is weight reduction by caloric restriction.
The current recommendations for both types of diabetes continue to limit cholesterol to 300 mg daily ,and individuals with LDL cholesterol more than 100 mg/dl should limit dietary  cholesterol to 200 mg daily. High protein  intake may cause of progression of kidney disease in patients with diabetic nephropathy; for these individuals, a reduction in protein intake to 0.8 kg/day (or about 10%of total calories daily) is recommended.
(a): – Dietary fiber:-
Plant components such as cellulose ,gum, and pectin are indigestible by human and are termed dietary “fiber”. Insoluble fibers such as cellulose or hemicelluloses, as found in bran, tend to increase intestinal transit and may have  beneficial effects on colonic function. In contrast, soluble fibers such as gums and pectin’s, as found in beans, oatmeal, or apple skin, tend to retard nutrient absorption rates so that glucose absorption is slower and hyperglycemia may be slightly diminished. Although its recommendations do not include insoluble fiber supplements such as added bran, the ADA recommends food such as oatmeal, cereals, and beans with relatively high soluble fiber content as staple components of the diet in diabetics. High soluble fiber content in the diet may also have a favorable effect on blood cholesterol levels.
(b):-  Artificial and other sweeteners:-
Aspartame (nutrasweet) consists of two major amino acids,aspartic acid and phenylalanine,which combine to produce a sweetner 180 times as sweet as sucrose. A major limitation is that it is not  heat stable,so it cannot be used in cooking,saccharin(sweet’N Low),sucralose(splendA), AND Acesulfame potassium(sweet one) are other “artificial” sweetners that can be used in cooking and baking.
2:-Diabetes and Injections

It’s not uncommon to be scared of needles For many diabetics, injections are just a part of life. Yet a surprisingly high number of patients, and not just those who are newly diagnosed, find the injection process extremely upsetting.Needle phobia is common amongst diabetics. However, with practice and determination, diabetes injections can be made less painful through following our simple guide.Imagining the injection away
Diabetes-related injections can be annoying and painful, as most patients will agree. In particular, the first few weeks and months can be the most difficult. For some diabetics, this does not go away. However, relaxing through the injection can make it easier, and being confident is the key to making injections less painful.
Diabetic injection sitesChoosing the right injection site for your individual diabetic needs is very important, and your diabetic healthcare team should be able to help you with this. There are four key diabetic injection areas.
These are stomach, arms, thighs and bum. Within these sites, there are numerous smaller areas in which to inject. Although the idea of finding a place that you feel comfortable with may seem the best strategy, switching between injection sites is vital for the health of you your skin. Injecting in the same place time after time is quite dangerous, because small lumps can build up and make injected insulin less effective.
Which injection site is best?
Each of the four key injection sites are different, and the rate at which insulin is absorbed will differ depending on which one used.A general rule of thumb is that the stomach gets insulin to the blood most quickly, whilst the bum is the slowest route.
What else affects how fast insulin enters the blood?
For diabetics that inject insulin, injecting an area about to be used in physical activity (even if it is relatively minor, such as sustained typing) can mean the rate of absorption is much quicker.
Similarly a hot day can speed up the action of insulin. At any time, if you are unsure how quickly your insulin is being absorbed, check your blood glucose levels to make sure.
Living with Diabetes
Diabetes can’t stop us having a healthy, happy life! Diabetes doesn’t stop you living your life. Every person with diabetes has to live their life, and deal with whatever life throws at them. Diabetes and Life includes a number of information pages about the kind of things that you might need to know whilst living with diabetes.

Skin cancer is a cancer of the cells in the outermost layer of skin, called the epidermis. The epidermis itself has three layers: an upper and middle layer made up of squamous cells, and a bottom layer made up of melanocytes and basal cells. Different types of skin cancer affect each of these types of cells, including the following most common forms:
1:- Basal Cell Carcinoma
Basal cell carcinoma (BCC) is the most common form of skin cancer, accounting for 75% to 80% of cases. Upwards of one million people are diagnosed with basal cell carcinoma each year in the United States. It was once found mostly in middle-aged or older people but now it is also being seen at younger ages. Basal cell carcinoma usually begins on areas exposed to the sun such as the head and neck. It is a slow-growing cancer that rarely spreads to other parts of the body, but people with a history of BCC are at higher risk for getting a second BCC. If basal cell carcinoma is not treated it can damage the surrounding tissue, including bone.
2:-Squamous Cell Carcinoma
Squamous cell carcinoma (SCC) accounts for 16% to 20% of skin cancer cases and occurs twice as often in men than in women. Approximately 200,000 to 300,000 people are diagnosed with squamous cell carcinoma each year in the United States, and about 2,500 die from the disease. It usually appears on the face, ear, neck, lips, and backs of the hands. SCC can also begin within scars or skin ulcers on other places on the body. As with basal cell carcinoma, the available treatments.

Melanoma is the most aggressive type of skin cancer. Almost 68,720 people will be diagnosed with melanoma skin cancer, and 8,650 will die from it, in the United States in 2009. While melanoma accounts for roughly 4% of all skin cancers, it is responsible for more than 74% of skin cancer deaths. Melanoma is the most common form of cancer for young adults 25- to 29-years-old and the second most common cancer in adolescents and young adults 15- to 29-years-old. Unfortunately, it is increasing at a faster rate than any other cancer (with the exception of lung cancer in women). In the past 30 years, the incidence of malignant melanoma has increased by 270%.

What is Melanoma?
Different skin cancers start in different layers or cells of the skin. Cells located in the basal layer of the epidermis called melanocytes produce a brown-black skin pigment (melanin) that determines skin and hair color. Melanin also helps protect the skin against the damaging rays of the sun. As a person ages, melanocytes often increase in number, forming concentrated clusters that appear on the surface as small, dark, flat, or dome-shaped spots. When this cell proliferation occurs in a controlled manner, the resulting lesion is benign (non-cancerous) and is commonly referred to as a mole or nevus. Sometimes, however, pigment cells grow out of control and become a cancerous and life-threatening melanoma. At first, melanoma cells are found in the epidermis and top layers of the dermis. However, once they grow downward into the dermis, the cancer can come into contact with lymph and blood vessels. The thicker the melanoma, the greater the likelihood that it could spread to distant sites. Removal of the lesion before it reaches the deeper layers of the skin is important for achieving a cure.
Types of Melanoma
Superficial Spreading Melanoma.
Superficial spreading melanoma is the most common melanomas melanoma skin cancer and the most curable. It is flat, asymmetrical, unevenly colored, and usually grows outward across the surface of the skin.
Nodular Melanoma.
Nodular melanoma skin cancer appears as a fast-growing brown or black lump, and its characteristics do not always fit the definitions described above.
Lentigo Maligna.
Lentigo maligna (sometimes called Hutchinson’s freckle) usually occurs in elderly people and is marked by flat, mottled, tan-to-brown freckle-like spots with irregular borders. These lesions often appear on the face or other sun-exposed areas and can take 5-15 years before they become invasive, after which the condition is called “lentigo maligna melanoma.”
Acral Lentiginous Melanoma. Although rare, acral lentiginous melanoma skin cancer is the most common melanoma among African and Asian populations. It commonly appears as a dark patch on the palms, soles, fingers, toes, under fingernails or toenails, or in mucous membranes.
Amelanotic Melanoma. A rare melanoma that can be very hard to diagnose because it is pink or flesh-colored. It also breaks the general “ABCDE” rule for recognizing
Growth Pattern
If untreated, melanoma cells usually spread first through the lymph vessels or glands. Melanoma cells can also spread by way of blood vessels to various organs, spreading cancer to the liver, lungs, brain, or other sites. Melanoma skin cancer tends to grow in stages. At first, most melanomas tend to be flat initially and spread laterally across the skin surface as they grow. At this early stage, which can last 1 to 5 years or longer, removal of the growth has an excellent chance of curing the melanoma. Still, there is a chance that some of these melanomas are invasive, and they should be treated aggressively. Lesions that become raised or dome-shaped over at least part of their surface indicate that downward growth has occurred. In some cases, this growth is rapid, occurring over a period of weeks to months. Later-stage melanoma is difficult to treat, especially when it has metastasized to distant organs or lymph nodes.
Any suspicious lesion should be checked immediately (this photo gallery shows what they look like), particularly if it has grown quickly or is partially flat and partially raised.
Common sites of melanoma skin cancer in men include the head, middle of the body (trunk), and neck. In women, common sites are the arms and legs. However, any area of the skin may be affected. You may not notice melanomas if they appear on areas that are difficult to examine, such as the scalp or the back. Less common sites for melanoma include:
Soles of the feet
Under the fingernails or toenails
The presence of a dark lesion under the nail that runs into the adjoining skin and doesn’t heal may signal melanoma. Rarely, melanomas appear in the mouth, in the iris of the eye, or in the retina at the back of the eye, where they may be detected during dental or eye examinations.
Causes Skin Cancer:-
Besides lung cancer, skin cancer is one of the most preventable types of cancer. This is due to the fact that the major risk factor is ultraviolet (UV) radiation. The sun is, of course, the main source of UV radiation, but it can also come from tanning booths. The amount of UV exposure depends on the strength of the light, how long the skin was exposed, and whether the skin was covered with clothing or sunscreen. Many studies also show that being sunburned at a young age increases the likelihood of skin cancer even decades later.
The other major risk factor is fair skin. Skin cancer is much more common in Caucasians than in African-Americans, for example. This is because the pigment, called melanin, offers some protection from UV radiation and people with dark skin have more melanin. People with fair skin that freckles or burns easily are at especially high risk. However, remember that people of all races and skin colors can get skin cancer.
Other cause:
1.    radiation from other cancer treatments
2.    previous history of skin cancer
3.    family history of skin cancer
4.    scars from burns or previous skin infections
5.    certain treatments for psoriasis involving UV light
6.    certain rare skin diseases, such as xeroderma pigmentosum and basal cell nevus syndrome
7.    weakened immune
Heart cancer symptoms are extremely rare. The tumors which cause these signs are divided as either primary or secondary. In the former type, the tumor is localized and does not affect the surrounding organs. The latter is known to spread cancer to other organs is known to spread cancer to other organs of the body.
Unfortunately, the secondary type tumors are more common than the primary types in heart cancer cases. This article tries to gain further insight on the signs of this rare cancer.
Heart Cancer Symptoms:
•    Fever
•    Heart attack – A condition where the flow of oxygen-rich blood flow from the heart is blocked
•    Fainting
•    Angina – Technical name for chest pain involving squeezing or pressure in the chest. It is caused when a particular region of the muscles of the heart does not get enough oxygen-rich blood.
•    Clubbing of finger
•    Heart failure – A condition involving inability of the heart to carry out its basic function, supplying blood to the entire body.
•    Valve dysfunction – Valves are door like structures which maintain the proper flow of blood to and from heart. Abnormality or poor functioning of these organs can be one of the heart cancer symptoms.
•    Irregular heart beat
•    Heart murmurs – Irregular blood flow into the heart produces more sound than normal heart beat.
•    Valve obstruction
•    Arrhythmias – A heart disorder involving abnormal rhythms of heart. It is caused by disturbance in the natural electrical conduction system of the organ.
Reduction of atrial cavitis Dyspnea – Technical name for shortness of breath owing to heart disease .
Chest Pain: Differential Diagnosis
–Sharp, stabbing pain that is usually very well localized, often worsened by deep breath or cough
–Costochondritis: Tender parasternal pain at insertion of ribs into cartilage en route to sternum; increases with palpation or mild chest compression (possibly postviral)
–Injury to chest wall
–Very common cause, usually associated with respiratory symptoms: Shortness of breath, cough, exercise intolerance
–Asthma (most common), often only EIA; may have personal/family history of atopy (asthma, eczema, seasonal allergies); shortness of breath is usually primary complaint, with feeling of chest tightness/pain as a secondary symptom
–Pleuritic chest pain: Sharp, stabbing pain with deep breaths, indicates pleural space inflammation, probably postinfectious (especially viral)
–Pneumonia: Chest pain secondary to cough or pleural involvement
–Pneumothorax can occur spontaneously, especially in tall, thin athletes
•    Gastrointestinal
–GERD and PUD: Burning, substernal pain with eating, worse at night
–Rarely pancreatitis (with back pain too), cholecystitis, hiatal hernia, hepatitis
•    Cardiac: Rare in children
–Precordial catch syndrome: Sharp, brief (seconds) chest pain usually associated with rising from lying or sitting; unclear etiology, but of no significance
–Pericarditis: Inflammation of the pericardium; often postviral, may represent connective tissue/autoimmune, cancer, bacterial infection (very ill appearing with fever), or post-cardiac surgery; patients often lean forward to decrease the pain
–MI (rare): Congenital coronary anomaly, post-Kawasaki, cocaine use, hypertrophic cardiomyopathy
–Aortic dissection: Consider if features or history of Marfan syndrome is present

Chest Pain:-
Attention to airway, breathing, and circulation
1.    All patients with suspected coronary artery disease should initially be treated with supplemental O2, aspirin, and nitroglycerin; morphine may be added if pain does not subside

If an acute myocardial infarction is suspected, β-blockers, ACE inhibitors, heparin (usually low molecular weight heparin, enoxaparin), thrombolytic therapy or primary angioplasty (PTCA), and/or glycoprotein IIb/IIIa inhibitors (e.g., eptifibatide, abciximab, or tirofiban) may be indicated
2.    Treat other etiologies as appropriate (e.g., antiarrhythmics and/or cardioversion for arrhythmias, pericardiocentesis for cardiac tamponade, H2 blockers or PPIs for GERD and peptic ulcer disease, antibiotics for pneumonia, bronchodilators and steroids for asthma)
3.    Emergent surgery for aortic dissections that involve the aortic arch proximal to left subclavian artery (type A); strict blood pressure control for type B dissections that only involve the aorta distal to left subclavian artery . Most patients/families with chest pain simply want reassurance that symptoms are not cardiac in origin
A careful history and physical exam are most important; however, a normal CXR and ECG provide therapeutic reassurance to the patient/family
Further cardiology consultation is rarely required but should be considered with patients experiencing chest pain with exercise, a history of Kawasaki disease, Marfan syndrome (this is an emergency), and for those patients with persistent chest pain
Costochondritis: Treated with NSAIDs until resolved
Pericarditis: Treated with aspirin or NSAIDs; requires cardiology follow-up until resolved, rarely requires pericardiocentesis
Appropriate therapy of identified pulmonary, gastrointestinal, or musculoskeletal problems .
Valvular heart disease: Treatment
Treatment depends on the nature and severity of associated symptoms. For example, heart failure requires digoxin, diuretics, a sodium-restricted diet and, in acute cases, oxygen. Other measures may include anticoagulant therapy or antiplatelet medications to prevent thrombus formation around diseased or replaced valves, prophylactic antibiotics before and after surgery or dental care, and valvuloplasty. An intra-aortic balloon pump may be used temporarily to reduce backflow by enhancing forward blood flow into the aorta.
If the patient has severe signs and symptoms that can’t be managed medically, open heart surgery using cardiopulmonary bypass for valve replacement is indicated.

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