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Diabetic-ShockAlarmingly low level of blood sugar leads to Diabetic Shock or Insulin shock.
Diabetic-CareDiabetic Care involves- regular exercise, foot care, controlled diet, avoidance of alcohol and cigarette, and regular monitoring of blood glucose level.
HypoglycemiaHypoglycemia is the indication of decline in the blood sugar level below normal. Complications-of-diabetesComplications-of-diabetes include- Hypoglycemia, Hyperglycemia, Diabetic, Cardiomyopathy, Diabetic Nephropathy, Diabetic Neuropathy, Diabetic Retinopathy.
Diabetes MellitusAn imbalance in the blood glucose level may indicate low blood sugar or high blood sugar. Diabetes-and-DepressionDiabetes leads to Depression and sometimes even more complications.
Causes-of-DiabetesVarious Causes of Diabetes can be-genetic, obesity, abnormal functioning of pancreas and liver, unhealthy Food and lifestyle and certain infections. Diabetic-DietDiabetic-Diet should incorporate plenty of greens and vegetables, no-sugar,colocasia,rice or potato and chicken, mutton should be consumed sparingly. Tingling in hands and feet, Sudden weight loss, Always hungry, Always thirsty, Wounds take time to heal, Blurry Vision.
Prevent-DiabetesDiabetes can be successfully prevented by leading healthy lifestyle, less intake of sugar and avoiding alcohol consumption and cigarette smoking.
Risk-factors-for-diabetesModifiable Risk Factors Of Diabetes-Lifestyle, Eating Habits, Existing Health Problems. Is-Diabetes-HereditaryPeople with diabetes heredity have higher chances of getting this metabolic disorder.
Diabetes MellitusWhen the blood sugar is either below or above the normal level then it may lead to a disorder called diabetes mellitus. Nephrogenic-Diabetes-InsipidusNephrogenic Diabetes Insipidus is caused by insufficient amount of antidiuretic hormone in the body. A disorder that is caused by insufficient amount of antidiuretic hormone can lead to nephrogenic diabetes insipidus. A low level of vasopressin can affect the ability of the collecting renal tubules and distal in the kidney to concentrate the urine.
People who are diagnosed with nephrogenic diabetes insipidus may have several clinical manifestations, which are similar to those who have diabetes mellitus.
Some clinical experts believe that diabetes insipidus has no known cause (idiopathic in nature). The clinical manifestations of nephrogenic diabetes insipidus are quite similar to diabetes mellitus. The nephrogenic diabetes insipidus is usually treated with medications and intravenous fluid administration. People with nephrogenic diabetes insipidus are provided with special regimen as part of the treatment process. Possessing an appropriate dietary plan, which exclude food that produces a diuretic effect. It is important that people who have these clinical manifestations should consult their doctor. Anterior pituitary hormones are regulated by hypothalamic releasing and inhibitory hormones and by negative feedback of the target glandular hormones at the pituitary and hypothalamic levels (Table 1).
Pituitary adenomas arise from adenohypophyseal cells and are almost always benign (Table 2).
Pituitary adenomas are rarely associated with parathyroid and neuroendocrine hyperplasia or neoplasia as part of the multiple endocrine neoplasia type I (MEN I) syndrome. Pituitary tumors can manifest with signs and symptoms of pituitary hypofunction, hormone hypersecretion, or mass effect.
The goals for treatment of a pituitary tumor include reduction or complete removal of the tumor, elimination of mass effect, normalization of hormone hypersecretion, and restoration of normal pituitary function. Pituitary adenomas are the most common cause of hypopituitarism, but other causes include parasellar diseases, pituitary surgery, radiation therapy, inflammatory and granulomatous diseases, and head injury.
Random measurements of GH and gender- and age-adjusted insulin-like growth factor-1 (IGF-1) levels are not reliable to diagnose GH deficiency because GH secretion is pulsatile, and up to 65% of patients with GH deficiency have a normal IGF-1 level.
In reproductive-aged women, gonadotropin deficiency causes infertility and oligomenorrhea or amenorrhea. Patients with ACTH deficiency maintain their mineralocorticoid secretion because aldosterone is regulated primarily by the renin-angiotensin system and serum potassium concentration. An ACTH stimulation test and early morning (8 am) plasma cortisol level measurement are reasonable initial tests for evaluating the corticotropin axis. The symptoms of thyrotropin (TSH) deficiency are similar to those in patients with primary hypothyroidism, including malaise, fatigue, leg cramps, dry skin, and cold intolerance.
The diagnosis cannot be established only through measurement of TSH because these patients might have a normal TSH level.
Prolactinomas are pituitary adenomas that secret prolactin in varying degrees and account for about 30% of all pituitary adenomas. Clinical features of prolactinomas may be related to excess prolactin and associated secondary hypogonadism or mass effect. Dopamine agonists are the therapy of choice for most patients, and they are effective in decreasing adenoma size and restoring normal prolactin level in most patients. Acromegaly is a rare disease caused by a GH-secreting pituitary adenoma in more than 99% of patients.
Because of the pulsatile nature of GH secretion, random GH levels can overlap in acromegalic patients and normal persons. Surgery is the treatment of choice for most patients presenting with acromegaly even if a cure cannot be achieved. Cushing’s syndrome (CS) comprises symptoms and signs associated with prolonged exposure to inappropriately high levels of plasma free glucocorticoids (Box 3). Surgical removal of the ACTH-secreting pituitary tumor is the treatment of choice.10 Availability of an experienced neurosurgeon is crucial, and the long-term remission rate is about 60 to 80% following surgery. Thyrotropin (TSH)-secreting pituitary adenomas account for less than 1% of all pituitary tumors. Nonfunctional and glycoprotein-secreting pituitary tumors account for about 25% to 30% of all pituitary adenomas. Patients with small nonfunctional pituitary adenomas are usually observed; however, the standard treatment for those with mass effect is surgery, mainly through the trans-sphenoidal approach. Lymphocytic hypophysitis is a rare inflammatory lesion of the pituitary gland, commonly affecting young women during late pregnancy or in the postpartum period. The empty sella is defined as a sella that, regardless of its size, is completely or partly filled with cerebrospinal fluid. Pituitary apoplexy is a rare endocrine emergency resulting from hemorrhagic infarction of a preexisting pituitary tumor (Fig.
Diabetes insipidus by itself is usually well tolerated and results in few symptoms, including polydipsia and polyuria. Once diabetes mellitus and hypercalcemia have been excluded, patients should have their 24-hour urinary volume measured during ad libitum fluid intake.
The therapy of choice for central DI is the administration of the ADH analogue desmopressin (DDAVP). Casanueva FF, Molitch ME, Schlechte JA, et al: Guidelines of the pituitary society for the diagnosis and management of prolactinomas. Ezzat S, Serri O, Chik CL, et al: Canadian consensus guidelines for the diagnosis and management of acromegaly. Krikorian A, Aron D: Evaluation and management of pituitary incidentalomas-revisiting an acquaintance. Schade R, Andersohn F, Suissa S, et al: Dopamine agonists and the risk of cardiac-valve regurgitation. Nachtigall LB, Valassi E, MCarty D, et al: Cardiac valvular function in hyperprolactinemic patients receiving cabergoline. When ketones appear in the urine, they signify high levels of blood acids and ill-controlled diabetes.
Urine showing ketones can be an alarming sign for people having diabetes requiring quick medical intervention.  Diabetic ketoacidosis is a severe complication arising out of high levels of blood acids (ketones). This leads to intoxication of the bloodstream causing diabetic ketoacidosis.  Excessive ketones can lead to poisoning of the body. Diabetic ketoacidosis can also case loss of consciousness, interfering with body’s metabolism. Ketones build up can also lead to abruptly changing fluid levels causing the lungs to fill up. When ketones reach dangerous levels in people suffering from diabetes, diabetic coma or even death can occur.  It is very important to check for ketones through examinations and warning signals.
People having diabetes or at risk for diabetes should be aware of the warning signs of diabetic ketoacidosis.


During treatment, if blood sugar level is adjusted too quickly it can cause swelling in the brain.
Ketoacidosis, which generally develops slowly, can become a fatal condition within a matter of hours.  Attending it immediately is crucial for avoiding life-threatening conditions.
A Diagnosis and Management of Sodium Disorders: Hyponatremia and HypernatremiaA  This is a corrected version of the article that appeared in print. This condition primarily starts in the extremities (lower and upper) that is arms and legs. In this case pancreas is able to produce insulin, however, it is not sufficient enough to stabilize the glucose level in the blood. The test may reveal urine specific gravity of 1.005 with osmolality level of 50 to 200 mOsm per kilogram. Their only aim is to share their opinion on the concerned topic, and help the reader understand it better. Among pituitary hormones, only the secretion of prolactin is increased in the absence of hypothalamic influence, because it is mainly under tonic suppression by dopamine, the main inhibitory factor. Pituitary carcinomas are extremely rare, but metastases from other solid malignancies (mainly breast and lung) can occur. Impingement on the chiasma by a pituitary tumor results in visual field defects, most commonly bitemporal hemianopia (Fig. Once a pituitary adenoma is found, it is necessary to determine the type of adenoma (secretory vs. Some patients, especially those with large tumors, require several therapeutic modalities, including medical, surgical, and radiation therapies.
The sequential loss of pituitary hormones secondary to a mass effect is in the following order: growth hormone (GH), luteinizing hormone (LH), follicle-stimulating hormone (FSH), thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), and prolactin. Patients with GH deficiency have increased body fat and decreased lean body mass, and they might have decreased bone mineral density. Measurement of gonadotropin and estradiol levels in reproductive-aged women with irregular menstruation is usually not informative. Symptoms usually include chronic malaise, fatigue, anorexia, low-grade fever, and hypoglycemia. Patients should be instructed to carry a medical alert, double their replacement dosage for 2 to 3 days in case of an acute disease, and should be covered by stress doses of hydrocortisone if undergoing surgery. For this reason, if secondary hypothyroidism is clinically suspected, TSH and free thyroxine (T4) should be measured together. The levothyroxine replacement dose should be adjusted according to the patient’s clinical status and free T4 and free triiodothyronine (T3) levels, but not TSH. They are seen in all age groups but are more common in women, with a peak incidence during the childbearing years. Women of reproductive age mainly present with oligomenorrhea, amenorrhea, galactorrhea, or infertility. Dopamine agonists usually restore visual field defects to an extent similar to surgery.4 Therefore, visual field defects associated with prolactinomas are not a neurosurgical emergency.
IGF-1 has a longer plasma half-life than GH and is the best single test for the diagnosing acromegaly (Fig. Even a subtotal resection of the tumor will improve the efficacy of subsequent adjuvant therapy. Cyclic CS is characterized by periods of excess alternating with intervals of normal or decreased cortisol production, which occurs in some patients with CS.
Radiotherapy is indicated in those with residual pituitary tumor following surgical debulking or in those who are not surgical candidates. It is important to monitor patients with varying degrees of hypopituitarism, because some have partial or full recovery of their pituitary axes.
The true prevalence of DI is unknown, but it is usually underdiagnosed because the symptoms and signs are benign and many patients ignore them or are unaware of them. Nocturia of a large urine volume is often the primary reason for which patients seek medical attention. Surprisingly, some people may recognize their diabetes only due to diabetic ketoacidosis appearing as the first sign. This is owing to insufficient insulin availability and can be more commonly observed in people suffering from type 1 diabetes. Since there is not sufficient insulin production, the body starts to rely on the alternate source of fuel – fat.
This condition, called adult respiratory distress syndrome, can create serious breathing problems. Diabetic ketoacidosis can be highest among people having type 1 diabetes,  those missing insulin too often and people younger than 19. When there is a sudden (quick) drop in blood sugar level due to insulin administration, there can be incidence of hypoglycemia.
The possibility of complications arising out of treating diabetic ketoacidosis are not common now, although they can prove to be concerning when they occur.
Gradual decreases in sodium usually result in minimal symptoms, whereas rapid decreases can result in severe symptoms. Urinary sodium levels are typically less than 20 mEq per L unless the kidney is the site of sodium loss. Euvolemia is diagnosed by findings from the history and physical examination, low serum uric acid levels, a normal blood urea nitrogen–to-creatinine ratio, and spot urinary sodium greater than 20 mEq per L. In volume overload states, the effective arterial blood volume is decreased compared with venous volume, resulting in excess ADH secretion. Antidiuretic hormone or also known as vasopressin works to regulate the excretion of water in the form of urine. Moreover, blood chemistry reflects high concentration of sodium, potassium, and osmolality.
Good or bad, Right or wrong is solely readers decision and should be taken under the guidance of a medical expert.
Cavernous sinuses are located laterally on each side of the sella, inclusive of the internal carotid artery and cranial nerves III, IV, V1, V2 and VI (Fig. Antidiuretic hormone (ADH, vasopressin) is produced by the supraoptic and paraventricular nuclei of the hypothalamus and travels in the axons through the pituitary stalk to the posterior pituitary gland.
Autopsy studies suggest that up to 20% of normal persons harbor pituitary microadenomas.1 Pituitary tumors discovered by computed tomography (CT) or magnetic resonance imaging (MRI) examination, in the absence of any symptoms or clinical findings, are referred to as pituitary incidentalomas. The most important factor in pituitary surgery is the availability of an experienced neurosurgeon. In men, hypogonadism is diagnosed less often, because decreased libido and impotence may be considered functions of aging. The presence of normal menstruation is the best indicator of the integrity of the gonadotropin axis in women of reproductive age. The serum prostate-specific antigen (PSA) level, hematocrit, and lipid profile should be monitored in men during testosterone replacement therapy. Patients might present with hyponatremia, which is secondary to inappropriate ADH secretion. In general, one should try to keep the free T4 level in the upper normal range while the free T3 level stays in the normal range. Men and postmenopausal women usually come to medical attention because of mass effect, such as headaches and visual field defects. Biochemical analysis to evaluate renal and hepatic function and the TSH determination should be carried out.
Cabergoline and bromocriptine are potent inhibitors of PRL secretion and often cause tumor shrinkage. Medical treatment of acromegaly has gained significance since the limitations of radiation and surgical therapy have become evident. Symptoms secondary to hyperthyroidism and goiter are the initial complaints in most patients, followed by pituitary mass effect if the disease remains undiagnosed.
Somatostatin analogues are effective in most patients for control of excess TSH production leading to improvement in hyperthyroidism and possibly to a decrease in tumor size.11 Beta blockers should be initiated in patients with uncontrolled hyperthyroidism, and antithyroid medications may be used only for a short period before surgery (if somatostatin analogues cannot be used) because long-term use can stimulate tumor growth.
The use of high-dose dopamine agonists has been associated with a decrease in tumor size in only about 10% of patients.
An empty sella is called secondary when it is seen after surgery, irradiation, or medical treatment for a pituitary pathology. The clinical manifestations are related to rapid expansion of the tumor secondary to hemorrhage, with compression of the pituitary gland and the perisellar structures leading to headache, hypopituitarism, visual field defect, and cranial nerve palsies.13 Headache is the most prominent symptom in most patients with clinically evident pituitary apoplexy. There are four major types of DI: central (neurogenic) DI, nephrogenic DI, primary polydipsia, and gestational DI.
In most patients, DI is not associated with any abnormality on the physical examination or routine laboratory evaluation, except a low urine osmolality.
Patients with DI who are conscious usually have sufficient thirst to maintain a normal serum sodium level in spite of polyuria.


The spray or oral form of desmopressin is usually started at bedtime and is gradually titrated for the desired antidiuretic effect.
Almost 50% of the diabetes-related hospitalizations (type 1 diabetes) can be accounted to this condition. Plasma osmolality plays a critical role in the pathophysiology and treatment of sodium disorders. Effective osmolality is the osmotic gradient created by solutes that do not cross the cell membrane.
Polydipsia, muscle cramps, headaches, falls, confusion, altered mental status, obtundation, coma, and status epilepticus may indicate the need for acute intervention. Fractional excretion of sodium is often inaccurately elevated in patients receiving diuretics because of diuretic-induced natriuresis; fractional excretion of urea can be utilized in these patients instead.
Diuretic therapy can artificially elevate urinary sodium, whereas a low-salt diet can artificially lower urinary sodium, thus clouding the diagnosis of hypovolemia vs.
The most common causes of hypervolemic hyponatremia are heart failure, cirrhosis, and kidney injury. Severe symptomatic hyponatremia must be corrected promptly because it can lead to cerebral edema, irreversible neurologic damage, respiratory arrest, brainstem herniation, and death. Patients with sellar mass pressing on the optic chiasma should have a Humphrey visual field test. Hypogonadism is often diagnosed retrospectively in men and postmenopausal women when patients present with mass effect.
Estrogen replacement is necessary in hypogonadal women of reproductive age to prevent osteoporosis and to treat hot flushes, decreased libido, and vaginal dryness. It is important to evaluate the corticotropin axis before initiating levothyroxine replacement, because therapy in those with underlying undiagnosed ACTH deficiency can result in an adrenocortical crisis secondary to an increase in metabolic demand. All patients with macroprolactinomas and most patients with microprolactinomas require treatment. The drug history is an important part of the initial evaluation, because some medications are associated with hyperprolactinemia and their discontinuation for at least 3 days, if possible, will prevent any further and often expensive workup (Fig. Dopamine agonists should be initiated slowly, because side effects often occur at the beginning of treatment.
Clinical features of acromegaly may be related to excess GH or IGF-1 or to associated mass effect including hypopituitarism, because most patients present with pituitary macroadenomas (Box 2 and Fig. Somatostatin analogues inhibit GH secretion mainly by binding to somatostatin receptors and result in normalization of IGF-1 in up to 65% of patients.
In contrast to pale striae that occur postpartum or with weight gain, the striae in CS are usually red-purple, more than 1 cm wide, and located on the abdomen, upper thighs, breasts, and arms (Fig. The most important biochemical feature is elevation of serum thyroid hormone levels (T4 and T3), with an inappropriately normal or elevated TSH level. Most patients have no pituitary dysfunction, but partial or complete pituitary insufficiency has been reported. Central DI is secondary to inadequate ADH secretion that is insufficient to concentrate the urine.
Overt disturbances in fluid and electrolytes are uncommon unless other factors interfere with the normal compensatory mechanism of polydipsia, such as loss of consciousness.
Hyponatremia and hypernatremia are classified based on volume status (hypovolemia, euvolemia, and hypervolemia).
Effective osmolality determines the osmotic pressure and the flow of water.11 Plasma osmolality is maintained by strict regulation of the arginine vasopressin (also called antidiuretic hormone [ADH]) system and thirst. Treatment includes the use of hypertonic 3% saline infused at a rate of 0.5 to 2 mL per kg per hour until symptoms resolve. Regular diet that includes restrictions of food, which produces a diuretic effect, must be implemented. Lateral extension of the pituitary mass to the cavernous sinuses can result in diplopia, ptosis, or altered facial sensation. Diabetes insipidus is almost never seen in patients with pituitary adenomas at presentation. Osteopenia is a consequence of long-standing hypogonadism and responds to hormone replacement therapy.
Some indications for treatment of patients with microprolactinomas include bothersome galactorrhea, oligomenorrhea or amenorrhea, infertility, and sexual dysfunction. The most common side effects include nausea, headache, dizziness, nasal congestion, and constipation. The most common side effects are gastrointestinal, including diarrhea, abdominal pain, and nausea.
Medical therapy for Cushing’s syndrome has limited value because of the associated toxicity and gradual decrease in efficacy. The chronologic association with pregnancy or the postpartum period and isolated ACTH deficiency is a diagnostic clue.
The discovery of an empty sella needs to be followed by an endocrine evaluation to determine whether there is any associated pituitary dysfunction. Patients with mass effect benefit from tumor and blood clot debulking, which leads to resolution of visual field defects and improvement of cranial nerve palsies in most patients. A water deprivation test may need to be performed by an experienced endocrinologist to differentiate among types of partial DI. Sodium disorders are diagnosed by findings from the history, physical examination, laboratory studies, and evaluation of volume status. If plasma osmolality increases, ADH is secreted and water is retained by the kidneys, thus decreasing serum osmolality. At this time, vaptans have no role in the treatment of symptomatic hyponatremia because of the potential for overcorrection of sodium and variable sodium fluctuations.13 Loop diuretics may be needed in patients with concurrent symptomatic hyponatremia and volume overload.
There is no specific headache pattern associated with pituitary tumors and, in some patients, the headache is unrelated to pituitary adenoma. Bromocriptine is the drug of choice in women planning pregnancy because there is considerable worldwide experience with the drug. Excess growth hormone before the fusion of the epiphyseal growth plates results in gigantism. Gallbladder sludge and cholelithiasis have been reported in up to 25% of patients on long-term therapy with somatostatin analogues, but most patients were asymptomatic. Fluid restriction should be limited to 500 mL less than the daily urinary volume.13 Salt and protein intake should not be restricted. Cabergoline is more potent, may be taken only twice a week, and is better tolerated by most patients.
Acromegalic patients probably carry an increased risk of malignancy such as premalignant adenomatous colon polyps and colon cancer, although published data vary greatly in their findings. Dopamine agonists have variable efficacy in patients with acromegaly but may be an attractive first-line therapy, especially in those with cosecretion of prolactin and GH.
Supraclavicular and dorsocervical fat pads (buffalo hump) and moon face are nonspecific and are seen in many patients of obesity clinics. In general, hyponatremia is treated with fluid restriction (in the setting of euvolemia), isotonic saline (in hypovolemia), and diuresis (in hypervolemia).
Overcorrection is common and is typically caused by rapid diuresis secondary to decreasing ADH levels.
Pegvisomant has higher affinity to GH receptors than native GH but inhibits its dimerization, which is necessary for the action of GH.
Women complain of menstrual irregularity (84%) and hirsutism (especially vellous hypertrichosis of the face), and men and women exhibit loss of libido (≤100%).
Radiation therapy may be considered for patients who poorly tolerate dopamine agonists and cannot be cured by surgery. It is administered once daily and is usually reserved for patients not responding to other medical therapies.
Psychiatric abnormalities occur in 50% of patients, with agitated depression and lethargy being the most common manifestations. A high clinical suspicion, attention to suggestive clinical features (see Box 3), and an appropriate screening test are the keys to early diagnosis of CS (Fig. Medications such as vaptans may have a role in the treatment of euvolemic and hypervolemic hyponatremia. 7).9 Because of the challenging nature of diagnosing CS, it is important to follow a stepwise evaluation, know the limitations of each test, and avoid shortcuts. The treatment of hypernatremia involves correcting the underlying cause and correcting the free water deficit. Radiotherapy is reserved for patients who cannot be cured by surgery and do not respond to or tolerate medical therapy.



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