Актуальная Медицина - Diabetes Mellitus

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Diabetes Mellitus

Essentials of Diagnosis:
• Glucose found in urine on routine testing
• Polynuria, polydipsia, polyphagia, weight loss, somnolence, pruritus, paresthesias.
• Retinal micro aneurysms and vitreous hemorrhages, skin infections, premature atherosclerosis with angina and claudicating, peripheral neuritis.
• Hyperglycemia, decreased glucose tolerance, hypercholesterolemia. 

 Diabetic glycosuria must be differentiated from other causes of reducing substances in the urine which give a false-positive urine glucose test, renal glycosuria, and alimentary and glycosuria.
Distinguish also from stress glycosuria and insulin resistant diabetes, seen in pituitary lesions and adrenal lesions and adrenal lesions, and glycosuria seen in thyrotoxicosis and pheochromocytoma. Any patient with a strong family history of diabetes must be suspected of having the disease.
General Considerations:
 Diabetes mellitus is probably the most important of all endocrine diseases. Over 4 % of females and 2 % of males in the United States are or will eventually become diabetic. Up to 20 million carriers of the trait are estimated. The disease affects all age groups, and the incidence in children under fifteen is 4/10000.
The exact cause of diabetes mellitus is not known, but the major metabolic defect may be corrected by the administration of insulin.
Most of the metabolic abnormalities in diabetes can be traced to the inability of the organism to metabolize glucose properly, which in turn places an undue stress on protein and fat catabolism for the availability of energy.
Insulin is concerned not only with the utilization of glucose, but also with its active transfer across cell membranes and its storage as glycogen in the liver. If insulin is lacking, the capacity of the organism to store glycogen is impaired.
There are two different types of diabetes:
1. True deficiency of pancreatic islets.
2. Imbalance of the other regulatory hormones or production of insulin antibodies, which tends to increase the blood glucose.
Prolonged hyperglycemia and hyperlipemia may lead to premature vascular degeneration, coronary and peripheral atherosclerosis.
A peculiar type of renal disease, inter capillary glomerulosclerosis (Kimmelstiel- Wilson disease), and retinal degeneration with micro aneurysms and eventual retinitis proliferans are typical of diabetes.
The abnormality of small blood vessels may precede the onset of clinical diabetes and may be a widespread genetic defect.
Early detection and treatment has in part forestalled some but not all of the serious and fatal complications of diabetes.
There is a well-known hereditary predisposition to diabetes and the greater incidence in the obese is evident.
The fetal mortality rate is much higher in diabetic women than in normal women. Trauma, infections, and emotional stress often precipitate the disease in susceptible persons. The onset of diabetes may be preceded by functional hyper insulinism.
  Clinical Findings:
A: Symptoms:
• Polyuria and excessive thirst 
• Nocturia and enuresis 
• Increased appetite and loss of weight (in children)
• Pruritus (of the vulvar and anal mucous membranes)
• Premature perialveolar resorption with loosening of the teeth may occur 
• Asthenia, somnolence, paresthesias, impotence may occur.
B. Signs:
1. Ocular manifestations - (refractive changes, premature cataracts, optic neuritis)
2. Skin manifestations - (mycotic infections (condidiasis, perleche), carotenemia, boils or carbuncles).
3. Cardiovascular-renal manifestations – (premature coronary atherosclerosis, non – healing ischemic leg ulcer with gangrene, edema, heart failure).
4. Neurologic manifestations – Peripheral neuritis, areflexia, loss of vibration sense, neurogenic bladder, nocturnal diarrhea.
C. Laboratory Findings:
The diagnosis rests on laboratory determinations because the clinical features of the disease are so variable.
The principal laboratory sings of diabetes are glycosuria, hyperglycemia, decreased glucose tolerance, and elevated serum cholesterol.
1) The standard glucose tolerance test:
The urine samples are taken so that the threshold for glucose can be correlated with the blood findings to fortify the diagnosis.
2) The insulin tolerance test is of great value in differentiating insulin-sensitive diabetes from «insulin-resistant» forms.
Normal sensitivity to insulin will cause the blood glucose level to fall to half its initial value, or below 50 mg./100 ml.in 20 – 30 minutes, with return to normal levels in 90-120 minutes.
3) The Orinase tolerance test to determine «insulin reserve» is of value in assessing insulin production when the diagnosis of diabetes is questionable, e.g. in the prediabetic state.
4) Cortisone test: Decreased glucose tolerance following a short course of cortisone therapy is considered by some authors to be evidence of the prediabetic state. 
Serum cholesterol is often increased in diabetes, especially if poorly controlled.
D: X- ray Findings:
A plain film of the abdomen may show evidence of calcification of the pelvic blood vessels. This is an especially unfavourable sign in a young patient.
  Complications:
A. Acute Complications:  
1. Diabetic ketosis, acidosis, and coma.
2. Insulin reactions (actually a complication of therapy) usually occur when there is a sudden change in insulin requirements. The principal symptoms are:
• Weakness;
• Tremor;
• Hunger;
• coma or convulsions;
• irritability;
  (All of which are promptly relieved by giving glucose. If the diagnosis of insulin reaction is in doubt, a therapeutic trial of glucose is indicated. Diabetics should carry proper identification).
  3. Insulin allergy – (Hives or painful lumps at the site of injection).
B. Chronic Complications:
• notably infections (e.g., around the toenails)
• degenerative vascular diseases.
The disorders of longstanding diabetes:
• Premature arteriosclerosis with leg claudication, trophic ulcer, angina.
• Neuropathy (from paresthesias to actual muscular atrophy);
• Nocturnal diarrhea and bladder atony; orthostatic hypotension;
• Ocular disorders (from micro aneurysms and vitreous hemorrhage to retinitis proliferans and blindness)
• Intercapillary glomerulosclerosis with associated proteinuria and edema.
• Pyelonephritis 
• Chronic pyogenic infections of the skin.
• Xanthomas
• An unusual skin lesions, necrobiosis lipoidica diabeticorum, fat atrophy and hypertrophy at the sites of insulin injections.
• The incidence of tuberculosis in the diabetic is higher
• Insulin resistance (insulin may suddenly increase tremendously)
Treatment:
The treatment of diabetes mellitus requires a thorough understanding of the action of insulin and the various types of insulin and oral hypoglycemic agents available, dietary concepts, the complications of the disease and the complications which may arise as a result of its treatment.
a) Insulin is given to enhance carbohydrate utilization.
(The lowering of the blood glucose or the lessening or disappearance of glycosuria)
Three types of insulin:
• Short-acting (to control postprandial blood sugar elevations)
• Long-acting (to control the milder hyperglycemia between meals)
• Intermediate-acting
Long-acting insulin:
a) protamine zinc insulin (PZI)
b) ultra-lente insulin
Intermediate-acting insulin:
a) Isophane insulin (NPH)
b) Lente insulin, a mixture of 30 % semi-lente and 70 % ultra-lente 
(Its action is almost identical with that of NPH-insulin.
c) Globin zinc insulin is used, but it cannot be mixed with short-acting insulin.
d) Semi-lente insulin (has the shortest action of all the intermediate insulines)
Administration of Insulin:
Because the large number of insulin preparations available may cause confusion regarding dosage, it is recommended that the patient be placed on one type of insulin so that he can become familiar with it.
Prescribe insulin of such strength that the volume / injection is kept at 0.25-0.5 ml. About 80 % of patients are able to use U 40 insulin.
If syringes with two calibrations (U-20 –U- 40 or U- 40 – U- 80) are used, it is important that the patient should understand which scale he is using.
It is preferable, however, to use a syringe with one calibration only.  
Insulin is usually administrated subcutaneously.
The site of injection is generally the anterior thigh, but insulin may also be given in the lateral thigh, in the arms or anterior abdomen.
It is important that the sites be rotated so that the same site is not injected more often than once every 2 – 3 weeks.
Crystalline zinc insulin may be administered I.V. to patients who have been taking insulin without allergic reactions.
Note: Do not give PZI, NPH, or lente insulin I.V.
The following factors must be taken into consideration in estimating the diet:
1. Caloric needs (The diabetic patient should be kept of slightly subnormal weight levels) 
2. Protein (High-protein diets are desirable because the available glucose (58 %) from protein is released more slowly for utilization than ingested carbohydrate.
3. Carbohydrate should not be given in concentrated form.
(Preference should be given to 3 and 7 % vegetable and 10-15 % fruits; these take longer to digest and to absorb, and a less variable blood glucose level is obtained)
4. The «type» of fat to be administered should be considered in view of the high incidence of atherosclerosis in patients with diabetes and the fact that serum cholesterol levels are also often high.
5. Vitamins: Patients with diabetes tend to develop vitamin deficiencies, especially of B complex. Ideally, add vitamin B12 (1000 mcg. /ml.) to each bottle of insulin, to give 0.1- 0.2 ml./day, and give pyridoxine, 50 mg. orally/day.
6. Frequency of feeding (By frequent feedings, the use of high-protein intake, and less concentrated carbohydrate foods, one can maintain a lower and more even blood sugar level with less glycosuria.
C. Oral Hypoglycemic Agents:
These agents are of two types:
1. The sulfonylurea group of drugs (useful primarily in the older diabetic with a mild form of the disease).
2. The biquanide group of drugs (which are effective in reducing blood sugar almost all diabetics). 

D. Factors diabetes:
General factors:
Patients with diabetes should live as nearly normal hygienic lives as possible. They should be assured of adequate rest, should be able to eat at home if possible, should engage in an occupation requiring at least moderate exercise but must avoid strenuous occupations.
They should avoid obesity and have a good general knowledge of diabetes.

Vocabulary

diabetes mellitus [daǐə`bi:tǐs`melǐtəs] – цукровий діабет; claudication [kl a υdǐ`keǐ∫n] – клавдікація;
Somnolence [`so:mn ə ə] – сонливість; to be differentiated [dǐfǐrǐn∫ǐ`eǐtǐd] – розрізнятися;
prosthesias [prəυs` θi:zǐəs] – парестезії; alimentary [əlǐ`mentərǐ] – харчовий;
retinal [`retǐnl] – що належить до сітківки; to distinguish [dǐs`tǐŋgwǐ∫] – відрізняти;
vitreous [`vǐtrǐəs] – скляний; to forestall [fo:`sto:l] – попередити;
premature [prǐmə`tј υə ]– передчасний,ранній; hereditary [hǐ`redǐtərǐ] – спадковий;
pheochromocytoma [fe əυ`krəυməsǐ`təυmə] – феохротоцитома; predisposition [pr ǐdǐspəzǐ∫n] – схильність до;
adrenal lesions [`ædrǐnl`li:зns] – надниркові ушкодження; eventually [ǐ`vent∫ υəlǐ] – рано чи пізно, з часом;
carriers [`kær ǐəz] – носіі; precipitate [prǐsǐpǐ`teǐt] – прискорювати, випадати в осад; 
trait [`treǐt] – спадкова риса obese [əυ`bi:z] – повний;
to affect [ə`fekt] – вражати; fetal [`fetl] – ембріональний, зародковий ; 
incidence [`ǐnsǐdǐns] – охоплення, сфера діі; precipitation [prǐsǐpǐ`teǐ∫n] – прискорення, осаджування;
administration [ədmǐnǐs`treǐ∫n] – управління, організація; susceptible [sə`septǐbl] – вразливий, який піддається;
abnormalities [əbnə`mælǐtǐz] – аномалія; excessive [ǐk`sesǐv] – надмірний;
inability [ǐnə`bǐlǐtǐ] – нездатність; vulvar [`vǎlvə] – вульварний;
undue [ǎn`dјu:] – надмірний; pruritus [`prυrǐtəs] – зуд;
availability [əveǐlə`bǐlǐtǐ] –наявність; refractive [rǐ`fræktǐv] – переломлюючий;
cell membranes [`sel mǐm`breǐnz] – клітинні оболонки; 
storage [`storədз] – зберігання; boils [`boǐlz] – нариви;
capacity [kə`pæsǐtǐ] – властивість, здатність; nocturnal [`nokt∫ənl] – нічний;
to be impaired [ǐm`peəd] – бути пошкодженим; to rest on [`rest on] – будуватися на;
pancreatic islets [pənkrǐ`ætǐk] – панкреатичні відокремлені тканини; threshold [`θreshold] – поріг, межа;
vascular degeneration [`væskјυlə dǐgrə`deǐ∫n] – судинне переродження; to fortify [`fo:tǐfa ǐ] – вітамінізувати,укріпляти;
Intercapillary [ǐntə`kǎpǐlərǐ] – міжкапілярний; assessing [əs`sesǐŋ] – оцінка, визначення;
proliferans [prə`lǐfǐrəns] – поширювачі; calcification [kǎlsǐfǐ`keǐ∫n] – виведення вапна;
onset [ən`set] – наступ; tremor [`tremə] – струс;
anterior [ən`ter ǐə] – передній; hives [`ha ǐvz] – кропивниця;
to be rotated [bi:rəυ`teǐtǐd] – змінюватися; lumps [l ǎmps] – шишки, пухлини;
strenuous [`strenјυəs] – напружений; familiar [fə`mǐl ǐə] – знайомий;


Exercises:
 Ex.1: Choose the correct variant:
1. Important in the diagnosis of diabetes is:
a) Extra weight c) polynuria
b) Hypertension d) premature vitamin deficiency
  2. Characteristics of diabetes mellitus include:
  a) metabolic defect c) tachycardia
  b) Abnormal trait d) vomiting 
  3. What does precipitate the disease in susceptible persons?
  a) Blood loss c) heart failure
  b) Infections d) ulcers
  4. All following clinical characteristics are symptoms of diabetes, Except for one;
  a) Enuresis c) asthenia
  b) pruritus d) inflammation
  5. One of the following laboratory techniques is used for the diabetics;
  a) Blood count test c) insulin examination/ test
  b) White cells tolerance test d) glucose tolerance test

2: Answer the following questions:
1. What are the main disorders of longstanding diabetes?
2. How can the diagnosis of diabetes be chronically complicated?
3. Does irritability tend to be the insulin reaction?
4. What types of allergy can be possible in case of diabetes?
5. Why should we inject insulin into the patient’s body?
6. When is the treatment of diabetes more effective?
7. Do any factors influence the procedure of treatment?
8. How should the patients administrate insulin?
9. What can be the diet for the diabetics?
10. What is so important in the procedure of insulin injections?

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