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Mystery Molecule This mystery molecule has to do with biological variation. It is a commonly measured hormone notorious for having significant diurnal variation. Can you guess what it is? VOL. 17, NO. 4 • December 2010 Regional Response. Personal Results. What Is Diabetes? Answer: Cortisol Cortisol has many metabolic effects but, overall, its production appears to represent an adaptation to stress. Mammals have developed an internal rhythm for cortisol production. Levels rise upon awakening, preparing the body for the stress of the new day. Levels fall as the day wanes, preparing the body for sleep. This rhythm is influenced by sunlight, which activates production of pro-opiomelanocortin, the precursor of adrenocorticotropin in the anterior pituitary, which regulates production and secretion of cortisol by the adrenal gland. Although it was once common to draw cortisol levels at 8 a.m. (assuming that the patient had a conventional diurnal rhythm), most experts recommend a 24-hour urine collection to determine whether or not cortisol is elevated. Also, salivary cortisol, obtained by the patient at bedtime, is an excellent marker of the loss of the normal pattern of cortisol secretion seen in Cushing’s syndrome. Diabetes mellitus, or diabetes, is a metabolic disorder characterized by high blood-sugar levels that result from defects in insulin secretion. Diabetes was first identified in the ancient world as a disease associated with “sweet urine” and excessive muscle loss. The elevated level of blood glucose leads to spillage of glucose into the urine hence “sweet urine.” Mystery Molecule reprinted with permission from www.AACC.org Avera Laboratory Network Lab Links is published quarterly to provide information of interest from labs of the Avera Laboratory Network. Questions may be directed to your Avera Laboratory Network representative. Diabetes is a disease that deals with the pancreas, insulin and glucose. The pancreas is a deep-seated organ in the abdomen, located behind the stomach. Inside the pancreas are the Islets of Langerhans which contain specialized cells (beta cells) that produce a hormone called insulin. Insulin helps glucose enter the cells and regulates the level of glucose in the blood. After food is eaten, the blood-glucose level rises. In response to the increase in glucose, the pancreas normally releases more insulin into the bloodstream to help glucose enter the cells and lower the blood-glucose levels after digestion. When the blood-glucose levels are lowered, the amount of insulin released from the pancreas decreases. It is important to note that even when food is not being consumed, there is a low steady release of insulin that fluctuates a bit to help maintain steady blood-sugar levels. Without insulin the cells are unable to absorb the glucose. The abundant, unutilized glucose is wastefully excreted in the urine. 3900 W Avera Drive Sioux Falls, SD 57108 Insufficient production of insulin or the inability of cells to use insulin properly and efficiently leads to diabetes. There are two main forms of diabetes, type 1 and type 2. Avera St. Luke’s Hospital, Aberdeen Avera Queen of Peace Health Services, Mitchell Avera McKennan Regional Lab, Sioux Falls Avera Sacred Heart Hospital, Yankton Type 1 diabetes also is called insulindependent diabetes, or juvenile-onset diabetes. This type of diabetes is often diagnosed in children and teens. Type 1 diabetes is actually SIOUX FALLS SD PERMIT #666 PAID PRESORTED STANDARD US POSTAGE www.AveraLabNet.com an autoimmune disease where the immune system mistakenly manufactures antibodies and inflammatory cells that are directed against the beta cells in the pancreas, causing damage and rendering it incapable of making insulin. Antibodies are proteins in the blood that are part of the body’s immune system. Abnormal antibodies have been found in the majority of patients with type 1 diabetes. Patients with type 1 diabetes must rely on insulin medication for survival. Type 2 diabetes also is referred to as noninsulin-dependent diabetes, or adult-onset diabetes. In type 2 diabetes, people can still produce insulin, but inadequately for their body’s needs, particularly because of insulin resistance. A major part of type 2 diabetes is a lack of sensitivity to insulin by the cells of the body or insulin resistance (particularly fat and muscle cells). In addition to that problem, the release of insulin by the pancreas also may be defective. In fact, there is a known steady decline in beta-cell production of insulin in those with type 2 diabetes that contributes to worsening glucose control as does the production of glucose in the liver. Although type 2 diabetes usually occurs mostly in individuals older than age 30 and risk increases with age, there are alarming numbers of patients with type 2 diabetes who are barely in their teen years. In fact, for the first time in history, type 2 diabetes is now more common than type 1 diabetes in childhood. Most of these cases are a direct result of poor eating habits, higher body weight and physical inactivity. It is estimated that the chance of developing type 2 diabetes doubles for every 20-percent increase over desirable body weight. Continued on page 3 Regional Service Center Spotlight Each quarter, one of our regional service centers is featured in “Regional Spotlight.” In this issue, we share information on the Avera Queen of Peace Laboratory. Through a unique vision, the Avera Queen of Peace Cancer Center and Occupational Health, in collaboration with the Laboratory, Business Office and Social Services staff members, developed a promotional campaign called ASK ME. The campaign promotes screenings made available by the South Dakota Department of Health and Avera Queen of Peace. The screening provides men with free screenings similar to those provided to women by All Women Count. The men’s screenings are paid for by the Avera Queen of Peace Foundation. By combining both the All Women Count services and the newly available free screenings for men under the ASK ME umbrella, Avera Queen of Peace is able to provide free screenings for breast and cervical cancer, colon cancer, heart disease, diabetes and prostate cancer to adults ages 30-64 who are uninsured or underinsured and meet income guidelines. Avera Quee n of Pe ace IMPORTANT ALERT: CMS to Require Physician Signature on Laboratory Paper Requisitions The Centers for Medicare and Medicaid Services (CMS) is finalizing its controversial laboratory rule. Starting Jan. 1, 2011, the signature of a physician or non-physician practitioner (NPP) is required on the paper test requisition for clinical diagnostic laboratory tests paid under the Medicare Part B laboratory fee schedule. This reverses the long-standing Medicare policy, established by the congressionally mandated lab-negotiated rulemaking, that laboratory paper test requisitions do not require a signature. Until this new rule, all that was needed was order documentation and a signature in a retrievable format such as in the beneficiary’s medical record within the originating facility. This new CMS final rule will require changes to current processes within all Avera Laboratory Network Service Centers related to utilizing paper test requisition to order testing from each service center. These changes will not affect testing requests billed to individual facilities (account bill) or if the test requests utilize one of the approved electronic order systems (Meditech direct order entry, Atlas/elaborders, Emdeon or other electronically interfaced ordering systems). Look for additional communications and instructions that will be coming very soon! SAVE THE DATES! ASCLS-SD Spring Symposium - April 15, 2011, Sioux Falls, S.D. Avera McKennan Hospital & University Health Center ASCLS Region V Fall Symposium - Oct. 13-14, 2011, Fargo, N.D. ASCLS-SD & CLMA Fall Collaborative Conference - Nov. 3-4, 2011, Mitchell, S.D. 2 What Is Diabetes? Continued from page 1 Diabetes can occur temporarily during pregnancy due to significant hormonal changes that can lead to blood-sugar elevation in genetically predisposed individuals. Elevated blood glucose during pregnancy is called gestational diabetes. Gestational diabetes usually resolves once the baby is born. However, 25-to-50 percent of women with gestational diabetes will eventually develop type 2 diabetes later in life. Women with gestational diabetes are usually asked to undergo an oral glucose tolerance test about six weeks after giving birth to determine if their diabetes has persisted beyond the pregnancy and if there is future risk for developing diabetes. Secondary diabetes refers to elevated blood-sugar levels caused by another medical condition. Secondary diabetes may develop when the pancreatic tissue responsible for the production of insulin is destroyed by disease, such as chronic pancreatitis, trauma or surgical removal of the pancreas. Diabetes can also result from other hormonal disturbances, such as excessive growth hormone production and Cushing’s syndrome. In addition, certain medications may worsen diabetes control or “unmask” latent diabetes. This is seen most commonly when steroid medications (such as prednisone) are taken and also with medication used in the treatment of HIV infection (AIDS). Symptoms of Diabetes Symptoms of diabetes include: • Increased urine output • Increased thirst and water consumption • Weight loss despite an increase in appetite • Fatigue, nausea and vomiting • Infections of the bladder, skin and vaginal areas • Blurred vision • Ultimately a coma Diabetes Diagnosis To determine if patients have diabetes a fasting blood glucose test is done. Patients fast overnight (at least eight hours) then have blood drawn and sent to the laboratory for analysis. Patients also may check their blood-glucose levels at home using a glucose meter. Normal fasting blood-glucose levels are less than 100 milligrams per deciliter (mg/dl). Fasting blood-glucose levels of more than 126 mg/dl on two or more tests on different days indicate diabetes. A random blood-glucose test also can be used to diagnose diabetes. A random blood-glucose level of 200 mg/dl or higher indicates diabetes. When fasting blood-glucose stays above 100mg/dl, but in the range of 100-126 mg/dl, this is known as impaired fasting glucose. People with impaired fasting glucose are then given oral glucose-tolerance tests. The following are possible results of an oral glucose-tolerance test: • Normal response: A person is said to have a normal response when the two-hour oral-glucose level is less than 140 mg/dl, and all glucose values between zero and two hours are less than 200 mg/dl. • Impaired glucose tolerance: A person is said to have impaired glucose tolerance when the fasting bloodglucose is less than 126 mg/dl and the two-hour oralglucose level is between 140 and 199 mg/dl. While patients with impaired fasting glucose do not have the diagnosis of diabetes, this condition carries its own risks and concerns. Each year, 1-to-5 percent of people with impaired glucose tolerance eventually develop diabetes. Weight loss and exercise may help return glucose levels to normal. Some medications can be taken to help prevent or delay the onset of overt diabetes. Treatment of Diabetes Diabetes treatment depends on the type and severity of the diabetes. Type 1 diabetes is treated with insulin, exercise and a recommended diet. Type 2 diabetes is treated with weight reduction, a recommended diet and exercise. If these measures are unable to control the elevated blood sugars, oral medications are used. If oral medications are still insufficient, insulin medications are considered. For more information about diabetes, visit Avera’s Health Information page at www.Avera.org. Diabetes at a Glance • Diabetes is a chronic condition associated with abnormally high levels of sugar (glucose) in the blood. • Insulin produced by the pancreas lowers blood glucose. • Absence or insufficient production of insulin causes diabetes. • The two forms of diabetes are referred to as type 1 (insulin-dependent) and type 2 (non-insulin-dependent). • Symptoms of diabetes include increased urine output, thirst, hunger and fatigue. • Diabetes is diagnosed by blood-glucose testing. • The major complications of diabetes are both acute and chronic: • Acutely: Dangerously elevated blood sugar or abnormally low blood sugar due to diabetes medications may occur. • Chronically: Disease of the blood vessels (both small and large) that can damage the eyes, kidneys, nerves and heart may occur. 3