l HSS舊名HONK強調non-ketoacidosis,並非正確。多發生在type2老年人。Glucose >600 mg/dL,amylase會上升,主要因唾腺分泌,Osm算一算>320
治療也是hydration,要住ICU,住一般病房要確實交班
l Effective osmolar gradient = 2xNa + glucose/8
l 學童type2是type1的6倍
l DKA可合併HSS,不影響治療
l Adrenal cortex:glucocorticoid(cortisol)、mineralocorticoid(aldosterol)、androgen(testosterol)
medulla:catecholamine
l Cushing’s syndrome比較specific的特徵:central obesity、buffalo hump、red-round face、high blood glucose(20%)、high BP(85%)、acne、thin skin and bruising、burple striae
以pituitary adenoma佔最多(70%),ectopic(ACTH dependent,15%),其中以bronchial carcinoid(25~49%)
l 可被overnight 1mg dexamethasone suppression test(11pm~8am decadron 1mg=2#)抑制cortisol<2 ug/dL→正常
>10 ug/dL→positive
high dose(2mg=4# qid for 2 days, check cortisol at day 4)是要去區分adrenal(沒抑制,<50% reduce) or pituitary tumor(抑制>50% reduce,Cushing’s dz),看抑制24hr urine 17-OHCS reduce > 50%
找bilateral inferior petrosal sinus and peripheral vein sampling for ACTH
標準值cortisol am 5~25, pm 2.5~10; ACTH 9~52 pg/mL; aldosterone supine 29.9~150, upright 50~300; PRA(plasma renin activity); 17-OHCS 4~16 mg/dL; 17-KS 2~8 mg/dL(高怕是adrenal carcinoma,>6cm也較可能是carcinoma)
NP-59 adrenal scan
l Renal echo較難看到adrenal tumor,肝下面、腎上面
adrenal tumor通常單側,雙側較可能是上游stimulate造成
不能做fine needle aspiration
和甲亢的K流失(進細胞)一樣也會近端肢體無力
iatrogenic cushing’s syndrome: ACTH要低
l Thyroid多在門診,Cushing多在轉診、會診,DM多在住院
l DM病人抱怨低血糖,若HbA1C 6左右,,可將SU換成DPP-4 inhibitor,HbA1C仍9,則不需換
l 看報告350元,拿一個月藥600元,拿三個月436元,不奇怪嗎?當然大家都想拿三個月,造成藥物囤積、濫用
l 血糖機和醫院量的結果大概誤差在30左右
l MODY:maturity-onset diabetes of the young,佔DM 1~2%
現較不用MODY,而用monogenic diabetes,年紀非criteria,autosomal dominant,常<25歲發病,最常見asymptomatic hypoglycemia
帶基因,環境又為易胖,病人常先表現hyperinsulinemia
l Macrosomia平均多790g
l glucose→GLUT-2→glucokinase作用(速率決定)→G6P→glycolysis→Krebs cycle→ATP→Ca channel(voltage dependent)出鉀進鈣(K channel ATP-sensitive)→胞內Ca↑
SU讓K channel關更緊
l maternally inheritted diabetes with deafness
l MELAS syndrome:Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like symptom
l Permanent neonatal DM:K channel關不緊
l GDM:24~28wk產前驗血糖,不須空腹下服用50g,1hr後血糖值<140正常,超過則須再接受100g三小時試驗,空腹<105、1hr <190、2hr <165、3hr <145為正常,兩個以上異常即可診斷GDM
l DM三大機制(舊)
n 增加週邊組織肌肉吸收利用glucose:TZD,PPAR增加glucose sensitivity to insulin(Rosiglitazone)
副作用:hepatic failure、骨折、pulmonary edema、CHF
n 抑制liver gluconeogenesis:biguanide(metformin),老藥,第一線,便宜,副作用少(lactic acidosis少),Cr>2不能開(女1.4, 男1.5),不會低血糖,反而會降BW
n 增加pancreas製造insulin:SU(glibenclamide)、meglitnide/g
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