MANAGEMENT OF DIABETES

It is a chronic metablic disorder charactersied by hyperglycemia with or withour glucosuria resulting from an absolute or relative deficiency of insulin.


The major clinical features of diabetes are:-Non healing ulcers,unexplained weight loss,recurrent respiratory or urinary tract infections,onset of cataract before 50 years,loss of sensations in the periphery,impotence in young males,history of overweight babies and recurrent fetal loss in women,recurrent infections like moniliasis,balanoposthitis and vulvitis,premature onset of stroke,heart disease and valvular occlusions,any vague ill health.

Diabetic patient is adviced to keep a check on his/her lifestyle,take oral anti-diabetic agents and insulin if indicated.

DIET AND LIFESTYLE:-It is the starting point and mainstay treatment in 1 and 2 type diabetes mellitus.It is also helpful in reducing weight in obese patients,to improve glycemic control and to reduce chronic vascular diseases like hyperlipedimia and hypertension.

CALORIE REQUIREMENT:-It is the basic requirement of the body which is about 20-25kcal/kg of desirable body weight.Additional energy required for sedentary persons is 30kcal/kg,for moderate working persons about 40kcal/kg and for people with strenuous lifestyle about 50kcal/kg.We will get 45-60% of total calories from carbohydrates,<35%from fats and 10-15% from proteins.

CARBOHYDRATES:-The major strategies to be followed in carbohydrate uptake are

1.maintain a regular intake of carbohydrate in meals throughout the day.

2.Avoidiing refined carbohydrates

3.Restriction of total intake of carbohydrates.

5.Taking food with low glycemic index.eg:-whole grain food,legumes,fruits,nuts,barley,oats.They cause only a slow gradual rise in blood glucose.



FAT:-Take saturated fat < 10%,monounsaturated fat 10-20%.eg:-- oils made from olive , groundnut .They help to reduce total & LDL cholesterol without reduction in HDL.Polyunsaturated fat <10% helps to reduce total, LDL & HDL cholesterol.w3 fatty acids can be taken once or twice weakly.eg:-mackerals, sardines.



WEIGHT MANAGEMENT:-Reducing energy intake,increasing energy expenditure through physical activity and regular exercise in the form of walking,swimming,cycling for approximately 30 minutes daily improves insulin sensitivity,lipid profile and lowers B.P.Alchohol intake in moderate amounts along with a meal is advisable.Quitting smoking,salt restriction to 6gmm/d-3gm/d in hypertensives is advisable.The patients must intake low calorie,sugar free drinks and foods.Avoid biscuits,cake and take nuts and fruits instead.Eat regular meals avoiding fried and sugary food.Eating plenty of vegetables,whole fruits and limit consumption of animal products like red meat,eggs,liver,high fat diary products.Replace those foods with lean meat,fish,poultry(without skin),low fat diary products.Patients must not overeat in any occasions.

TREATMENT:-Tretement by terapy with insulin secretogogues like suphonylureas,meglitinides and Insulin sensitizers like metformin,thiazolidinediones.

Liver decreases glucose output.Drugs like metformin,thiazolidinediones also do the same action.Pancreas increases insulin secretion and suplhonylureas and meglitinides are used to aid pancreas in insulin secretion.Peripheral glucose uptake is increased by metformin.Alpha gucosidase inhibitors are used to delay glucose absorption.Thaizolidinediones help in increasing insulin sensitivity.

SULPHONYLUREAS:-They are used to treat non-obese patients when lifestyle modification alone doesn’t work.The major limitations are hypoglycemia and weight gain.

METFORMIN:-They are used to treat diabetes in diabetic patients.Their action is synergestic with sulphonylureas and insulin.The major limitations are impaired hepatic/renal function,alcoholic shock and hypoxia.

THAIZOLIDINEDIONES:-Used to treat patients with severe insulin resisitance(abdominal abesity).The major limitations are liver dysfunction,salt and water retention and these drugs are avoided in cardiac failure.

INCRETINS:-Oral glucose ingestion induces the release of GLP-1 which is a gut hormone.It amplify glucose induced insulin release.It suppresses glucagon secretion and improve PP hyperglycemia.It also delays gastric emptying.EXENATIDE is a GLP-1 receptor agonist.S.C.injection twice a day 60 mins before breakfast and dinner is iadvised for type 2 DM patients.Adding Sulphonylureas or metformin further reduces B.glucose.The effects of this drug are weight loss,nausea and hypoglycemia.

PRAMLINTIDE:-Synthetic analogue of islet amyloid polypeptide.It delays gastric emptying,suppress glucagon secretion and decrease appetite.Subcutaneous injection immediately befor meal is done for type 1 and insulin treated type type 2 Diabetes mellitus patients.The effects of this drug are initial weight loss,nausea and hypoglycemia.

INSULIN:-It is advised for patients with type1 Diabetes mellitus,pregnancy induced diabetes,OHA failure,A/C disease atate and surgery.

TYPES OF INSULIN are :-

1.Rapid acting(lispro,aspart)

2.short acting(soluble/regular)

3.Intermediate acting(Lente insulin)

4.Long acting(ultralente)

5.Long acting insulin analogues(glargine,detemir)

ROUTES OF INSULIN DELIVERY:-Insulin is deliverd by means of a syringe/pen.It is delivered subcutaneously to anterior abdominal wall,upper arms,upper thigh,buttocks.

The rate of absorption of insulin depends upon the site,depth,volume,warmth,local message and exercise.Other routes of drug delivery are intra muscular,Intra venous,peritoneal,intrapulmonary.it is also deliverd through continuous S.C or I.V infusion.SIDE EFFECTS of insulin are-hypoglycemia,weight gain,peripheral oedema,insulin antibodies,lipodystrophy,local allergy and phenomena like somogyi,DAWN phenomenon.

The major golas of therapy are maintain glucose level at a range of 90-130,peak post pandrial plasma glucose at <180 and HbA1C<7.

The patient can keep himself completely free from the complications and panic of diabetes by follwing the below mentioned steps.

1.Check HbA1C level 2-4 times/year.

2.Eye check up annually.

3.Foot examination 1-2 times/year by a physician,and daily by the patient.

4.B.P check up quarterly.

5.Lipid profile annually.

6.Educating the patient by giving proper guidance.

FIBROMYALGIA

It is a syndrome of widespread chronic muscular pain and tender joints without any definable musculoskeletal pathology.Patient may complain with a pain either axial pain with severe pain in the axial spine and in atleast two contralateral sides or a chronic pain for atleast 3 months duration with tender points(patient may have physical humps which are in the size of a grain upto the size of an apple) of more than 11 out of 18 total tender points.Associated symptoms are fatigue,disturbed sleep,depression,anxiety.There are other associations with this disease like irritable bowel syndrome and chronic fatigue.


The etiology of this disease is unknown.It is defined in psychiatry as an abnormal sensitivity to pain.Cognitive therapy and therapy with analgesics like diclofenac sodium are often advised.

There is no specific treatment for this condition.The treatment will not be beneficial for the patient.The patient need not find any improvement in his condition.The patient may be counseled instead,advising him to live with it and avoiding unnecessary further drug treatment and investigations.

ENTERIC FEVER

                                                    ENTERIC FEVER

EPIDEMIOLOGY:-


It is an endemic disease caused by salmonella enterica.Transmitted by ingestion of contaminated food water or milk.Natural reservoir of the microorganism is humans.It transmits over congenitally and by intrapartum means.

Convalescent carriers-excrete salmonella for 3 months after the illness.Period of communicability is as long as bacteria is present in the exctreta.The disease spreads rapidly in hot summer months,over crowding,breakdown in safe water supply and sewage disposal.

PATHOGENESIS:-

Risk increases with increase in inoculum size,stomatch acidity,possession of Vi antigen.The microorganism invade peyers patches,then get transported to intestinal lymph nodes,multiply inside monocytes and gets carries to mesenteric lymph nodes.Macrophages then engulf bacteria and gets carried away alng with it to blood stream through thoracic duct which eventually causes primary bacteremia.Results in onset of fever.The microorganism spread to liver,spleen and bone moarrow causing more complications.It multiplies in liver and spleen and release antigens causing secondary bacteremia.

CLINICAL MANIFESTATIONS:-

Incubation period is 7-14days.Its less common under 2 years.It has got a gradual onset.Fever is of step ladder pattern and it is continuous generally.Patient suffers rapid increase in fver,headache and vomiting.Constipation,diarrhea and abdominal pain may also occur.Tongue will get a white coat at the center and clear at margins.Patient may have bradycardia.Typhoid rash appears on 6th day.Appears in crops called as rose spots for a few hours and fade on pressure.On second and 3rd week abdomen gets distended with a tympanic resonance.Splenomegaly of about 1-2 cm.The patient will be in a typhoid state which is characterized by dull sensorum,apathy,stupor,muttering delirium,pick at clothes.For school aged children and adolescents,initial symptoms are fever,malaise,anorexia,myalgia,headache and abdominal pain develop over 2-3days.Dirrhoea have a pea soup consisitency.Constipation becomes a prominent symptom later.Cough and epistaxis are also symptomatic.

In 2nd week of illness major symptoms are-high fever,fatigue,cough,abdominal symptoms and severe lethargy.PHYSICAL FINDINGS-a relative bradycardia disproportionate to fever.In 50% subjects,macular or maculopapular rash measuring 1-5mm appears.Rose spots appear on 7th-10th day.The lesions are slightly raised and blanch on pressure.10-15 lesions appear on the lower chest and abdomen and lats for 2-3 days.They lave a brown discolouration.

IN INFANTS-this disease is not so common.Mild fever and malaise with diarrhoea accompaniying are the symptoms.

All fever more than 7 days,low heart rate,blood tinged fecal matter all points to this disease.

THERAPY DEPENDS UPON-age,health sattus,serotype,and complications.Mortality if untreated is 10%.The disease recurs in 10-20% subjects.Typhoid is treated by using antibilocs,analgesics.