Page 52 Complete Your CE Test Online - Click Here of Cushing’s syndrome. Adrenal medulla tumors cause headache tachycardia-related arrhythmias, and elevated blood pressure. If the parathyroid glands are affected, signs and symptoms are caused by the development of renal calculi[5] . Diagnosis Clinical manifestations will indicate the type of diagnostic tests needed. Signs and symptoms that suggest particular gland involvement indicate the type of testing to be done. For example, upper gastric pain and ulcers due to Zollinger-Ellison syndrome indicate the need for pancreatic evaluation. In fact, 50% of patients with Zollinger-Ellison syndrome are ultimately diagnosed with MEN[5] . CT scans, MRIs, and x-rays may be used to identify tumor location [5,32] . Examples of additional tests, based on the presenting clinical picture include[32] : ● ● Fasting blood sugar. ● ● Cortisol levels. ● ● Serum electrolyte levels. ● ● Serum levels of various hormones depending on specific signs and symptoms. ● ● Tumor biopsies. Since MEN is predominantly a hereditary disorder family members may undergo genetic testing[5,32] . Treatment Treatment focuses on tumor removal and therapy to control any residual symptoms[5] . Treatment of malignant tumors may include, in addition to surgical removal, radiation therapy and chemotherapy depending on the size of the tumor, the surgeon’s ability to remove all of the tumor, and if there is evidence of metastasis[5,32,33] . Side effects of particular tumors such as hypertension with adrenal medullary tumor or treatment of peptic ulceration with MEN I must be dealt with in conjunction with tumor removal. If significant amount of specific glandular tissue is removed, hormonal replacement therapy is necessary[5] . Diabetes mellitus Diabetes mellitus (DM) is a chronic disease of glucose intolerance. It is caused by a complete or relative deficiency of insulin or by a resistance to insulin characterized by disturbances in protein, fat, and carbohydrate metabolism[5,6] . In the United States, DM is[5,11] : ● ● The fifth leading cause of death. ● ● A contributing factor in approximately 50% of heart attacks. ● ● A contributing factor in about 75% of strokes. ● ● A contributing factor in renal failure. ● ● A contributing factor in peripheral vascular disease. ● ● The leading cause of new blindness. Types of diabetes, incidence, and etiology DM affects approximately 6.3% of the U.S. population or 18.2 million people. About 5.2 million people are not even aware that they have the disease, and incidence increases with age[11] . There are three types of DM. ● ● Type 1: Type 1 diabetes occurs when the beta cells in the pancreas are destroyed or suppressed. Formerly referred to as juvenile diabetes or insulin-dependent diabetes, type 1 diabetes is subdivided into idiopathic and immune-mediated types. In idiopathic diabetes there is permanent deficiency of insulin and no evidence of autoimmunity. In immune-mediated diabetes the body produces an autoimmune attack on pancreatic beta cells, and the pancreas becomes inflamed. By the time signs and symptoms appear, 80% of the beta cells are destroyed. Some experts, however, believe that beta cells are not destroyed but disabled and may later be reactivated[5,6,11] . ● ● Type 2: Type 2 diabetes, formerly referred to as adult-onset diabetes or non-insulin dependent diabetes, may be attributed to insulin resistance in target tissues, abnormal insulin secretion, or overproduction of glucose (inappropriate hepatic gluconeogenesis)[6,11] . Type 2 diabetes alert! Type 2 diabetes may also develop as a consequence of obesity. In fact, most patients with type 2 diabetes are obese[5] . ● ● Secondary diabetes: Secondary diabetes is so-called because this type occurs “secondarily” to another condition or event. The factors that trigger secondary diabetes include[11] : ○ ○ Physical or emotional stress that can cause prolonged elevation of cortisol, epinephrine, glucagon, and GH. Such elevations increase blood glucose levels and demands on the pancreas. ○ ○ Pregnancy, which causes weight gain, high levels of estrogen, and high levels of placental hormones[11] . This type of diabetes is referred to as gestational diabetes mellitus (GDM). Glucose levels usually return to normal after the women gives birth. However, women who have had GDM have a 40% to 60% chance of developing type 2 diabetes within 5 to 10 years[5] . ○ ○ Use of specific medications such as adrenal corticosteroids, hormonal contraceptives, and other drugs that oppose the desired effects of insulin[11] . Risk factors for type 2 diabetes Risk factors for type 2 diabetes include[5,6] : ● ● Black, Hispanic, Pacific Islander, Asian-American, or Native Americans. ● ● Family history of diabetes. ● ● High density lipoprotein cholesterol of less than 35 mg/dl or triglyceride of greater than 250 mg/dl. ● ● History of GDM. ● ● Hypertension. ● ● Obesity. ● ● Older than 45 years of age. ● ● Sedentary lifestyle. ● ● Significantly impaired glucose tolerance. Complications Patients with DM have a risk of numerous complications that can affect every system of the body. Possible complications include [5,6,11] : ● ● Cardiovascular disease. ● ● Gastroparesis (delayed gastric emptying and feelings of fullness after eating). ● ● Impaired ability to fight infection. ● ● Nephropathy. ● ● Nocturnal diarrhea. ● ● Orthostatic hypotension. ● ● Peripheral and autonomic neuropathy. ● ● Peripheral vascular disease. ● ● Retinopathy. ● ● Skin disease (diabetic dermopathy). ● ● Urinary tract infections (UTIs). ● ● Vaginitis. EBP alert! Research now shows that glucose readings do not need to be as elevated as once believed for complications to occur. This means that exact glucose control is more important than ever[11] .