HbA1c and its correlation with blood sugar level - An info for diabetes patients

HbA1c is used for assessment of long term glucose control.This lab test reveals average blood glucose level over the past 2 to 3 months.

Major use of HbA1c

1.Assessment of optimal glycemic control in a given patient.

2.Blood glucose control status in between checkups.

This is a quality control testing. Along with regular blood glucose testing it is also used to assess the success of present treatment and help to make necessary change in the treatment.

HbA1c results are expressed as a percentage. Normal value is 4% to 6%. 1% change in HbA1c represent 30 mg/dl change in mean blood glucose value.

HbA1c and blood glucose value correlation

HbA1c value(%)	Mean blood glucose
14	380
13	350
12	315
11	280
10	250
9	215
8	180
7	150
6	115
5	80
4	50

       

<7%	Excellent control. Those who are on drugs and insulin should be aware of hypoglycemia
7%-8%	Good control. Here the aim is to get a level <7% which indicate there should be attempt for further improvement.
>8%	Poor control, indicate that diabetes is not well controlled.

Frequency of measurement of HbA1c

1.Those people who meet the treatment target it has to be measured once in 6 months

2.Those are not adequately  controlled once in 3months.

3.Special care is required in preconception care of women with diabetes initially monitor in once a month and once glucose level is controlled once in 6 to 8 weeks.This is important for maximum fertility and optimum fetal growth.

Need for strict control of diabetes

Those who have adequate control of HbA1c has lesser complication of diabetes such as

1. Eye problems

2. Kidney problems

3. Nerve related complications

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Exercise in knee joint osteoarthritis

Osteoarthritis pain occur during activity in weight bearing joints such as hip and knee. This will lead to physical inactivity. As osteoarthritis is very common this will lead to significant public health concern. Physical inactivity lead to increased risk for heart disease and for obesity.Exercise capacity is poor in  those with osteoarthritis of knee joint.

There is weakness of muscles over the knee joint in osteoarthritis. Since adequate muscle power is needed for joint protection muscle weakness results in further damage to the joint and decreases the exercise capability. Degree of weakness correlate with severity of joint disease and degree of limitation of mobility of joint.

Causes of muscle weakness

1.Decrease strength with age

2.As pain occur during activity ,there is tendency for physical inactivity this will lead to disuse atrophy

3.Alteration in gait as a protective mechanism decreases the load on affected joint and further decreases the muscle power.

Exercise program in osteoarthritis

For knee and hip joint osteoarthritis exercise improves the power and reduces the pain.

Effective exercise program are

1.Aerobic exercise 

2.Resistance training

Resistance training is aimed at strengthening of muscle power. Exercise is maximum effective if the affected people are trained for their daily activities. Certain exercise increases the pain in joints they should be avoided. Strengthening of muscle by repeated bending of knee against resistance. It is done by flexing and extending the knee joint. Low impact exercise such as water aerobics and water resistance training is also found to be useful. This is better tolerated than loading exercise such as running. For getting maximum benefit from exercise patient should be referred to an exercise class or to a therapist to plan individual home based exercise regimen.

Major challenge in exercise program is lack of compliance. Trial showed 30 to 50 percentage of people stopped exercise after 6 months and less than 50 percentage continued after one year. Previous history of successful exercise is the strongest predictor for continued exercise in a given patient.

Role of physician

1.At each visit he should reinforce the exercise prescription.

2.Help the patient to identify obstacles in continuing exercise.

3.Identify convenient time for exercise daily.

It is also observed that calorie restriction along with exercise is very effective in decreasing pain. It is shown that early exercise and muscle strengthening help to improve the cartilage function on joint by MRI study.

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How will you identify that you have metabolic syndrome.

Identification of metabolic syndrome is important because it will help to predict the risk of future heart disease and diabetic risk. Worldwide more and more people are affected by this. This is due to change in lifestyle and food habits. Metabolic syndrome is highest among native Americans. It has got 5 components. Increased waist circumference is more in females where as fasting triglycerides and hypertension is more common in males.

Five components of metabolic syndrome are the following.

1.Central obesity(waist circumference)

2.Increased triglycerides

3.Low HDL cholesterol.

4.Diabetes mellitus

5.Hypertension

Risk factors of metabolic syndrome

1. Overweight and obesity

2. Aging

3. Heart disease

4. Diabetes mellitus

5. Sedentary lifestyle 

6. Lipodystrophy

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Lifestyle changes recommended for hypertension control

Healthy lifestyle will help to reduce the hypertension and pre-hypertension ,the effect is more on hypertensive than pre-hypertensive. Even if it wont completely eliminate the need of drugs this will reduce the number of drugs and their required dose.

Dietary modification that may  help to reduce the blood pressure are the following

1.Weight reduction

2.Decrease the salt intake.

3.Increased potassium intake.

4.Moderation of alcohol consumption.

5.Healthy diet.

1. Weight reduction.

This is important for reducing blood pressure and heart disease. Even moderate reduction in weight help to reduce blood pressure and increases the insulin sensitivity.With a reduction of 9.2 kg weight loss blood pressure decreases 6.3/3.1 mmHg. Blood pressure may be reduced by 30 minutes of moderately severe exercise such as brisk walking 6 to 7 days a week.

2. Decrease the salt intake.

Reduced  salt intake.Effect of reduction in salt intake show individual variation. If the salt intake is reduced to less than 6 gm a day it will decrease the blood pressure and long term risk of heart disease in pre-hypertensive people.

3. Increased potassium intake - Potassium and calcium supplements

Both have mild anti-hypertensive effect. Potassium supplements will  also help to reduce the death due to stroke.

4. Alcohol consumption and hypertension.

High alcohol consumption is associated with high blood pressure,reduction in alcohol consumption is associated with low blood pressure.

DASH diet (dietary approach to stop hypertension).

Diet given for 8 week period show promising results.

It will lower the blood pressure in people with high blood pressure.

5. Healthy diet 

Diet should be rich in

1.Fruits.

2.Vegetables.

3.Low fat dairy products.

• The effect of diet is augmented by salt restriction to less than 6 gms a day. 
• Fruits and vegetables are enriched with potassium ,magnesium and fiber
• Dairy product contain calcium.

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Heart failure classification, risk factors and precipitating events

Heart failure:Clinical syndrome that occurs in patients due to any STRUCTURAL OR FUNCTIONAL CARDIAC DISORDER, so that patient develop a constellation of symptoms (DYSPNOEA and FATIGUE) and signs (OEDEMA and RALES) which lead to frequent hospitalizations, poor quality of life and a shortened life expectancy. It is the end result of various disease of heart. In cardiac failure heart fails to maintain an adequate blood supply to meet the metabolic demand of body. In mild to moderate disease heart maintain adequate cardiac output at rest but cant meet the increased demand such as exercise. Prevalence of heart failure increases with age. It carries a poor prognosis. Sudden death can occur due to malignant ventricular arrythmias or heart attack. Coronary artery disease is the leading cause of heart failure in western world.

Nyha classification.

Class I : Patients with cardiac disease but no limitation of physical activity; there are no symptoms from ordinary activities.

Class II : Slight limitation of physical activity; the patient is comfortable at rest.

Class III : Marked limitation of physical activity; the patient is comfortable only at rest.

Class IV : Any physical activity brings on discomfort and symptoms occur even at rest.

Following are the risk factors of heart failure

1. Coronary artery disease.
2. Hypertension.
3. Diabetes Mellitus.
4. Dilated and Hypertrophic cardiomyopathy.
5. Valvular heart disease.
6. Cigarette smoking.
7. Alcohol intake.
8. High output failure - Anaemia, thyrotoxicosis, arteriovenous fistulae,Paget’s disease
9. Pericardial disease - Constrictive pericarditis,Pericardial effusion
10. Primary right heart failure- Pulmonary hypertension

Preecipitating or aggrevating factor are those increases the oxygen demand of body.

Preecipitating factors

1. Myocardial ischemia or heart attack.
2. Infection.
3. Arrythmia.
4. Increased salt intake.
5. Non compliance with anti CHF medications.
6. Acute myocardial infarction.
7. Aggravation of Hypertension.
8. Administration of drugs with negative ionotropic properties(beta blockers) or fluid retaining properties(NSAIDS, steroids).
9. Pulmonary embolism.
10. Conditions associated with increased metabolic demand - Pregnancy, thyrotoxicosis, anemia.
11. Intravenous fluid overload – post operative iv infusion.
12. Rheumatic, Viral, and Other Forms of Myocarditis.
13. Infective Endocarditis.
14. Physical, Environmental, and Emotional Excesses.

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Significance of testing Hemoglobin in the blood

Hemoglobin is a protein in blood that help to carry oxygen to various body parts. Hemoglobin contain iron. There are a variety of conditions that is associated with alteration in hemoglobin level.When the blood hemoglobin  level is below the normal, that will lead to anemia. If the hemoglobin level is above the normal the condition is called polycythemia.

Normal hemoglobin levels are given below.

Normal level of hemoglobin in male and female vary.

Whole blood (Hb)

Male : 13.6g/dL to 17.5g/dL

Female : 12.0g/dL to15.5 g/dL (age dependent)

Be panic if hemoglobin is less than 7 g/dL ( Both male and female )

Measurement of hemoglobin is by spectrophotometry.

Conditions with increased hemoglobin  

1. Hemoconcentration (as in dehydration, burns, vomiting). 

2. Polycythemia

3. Extreme physical exercise.

Hemoglobin level low in: 

1. Iron deficiency

2. Thalassemia.

3. Vitamin B12 deficiency

4. Folate deficiency

5. Low thyroid hormone (hypothyroidism)

6. Anemia of chronic disease

7. Hemolytic anemia 

8. Acute hemorrhage

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Causes of lack of sleep (Insomnia)

Insomnia or lack of sleep is a very common complaint which many of us experience in day to day life. The pattern of insomnia vary from person to person. Some people experience difficulty in falling asleep or repeated awakening from sleep, very early morning awakening and unable to fall back to sleep. As a result of poor sleep at night person experience increased daytime sleepiness and fatigue. Following are the common causes of lack of sleep.

1. Stress - is associated with lack of sleep during that period.
2. Drugs - there are certain drugs which stimulate the brain such as caffeine, amphetamines, xanthines, nicotine, and phenylpropanolamine .They are well known to produce insomnia.
3. Medical disorders - Pain ,increased thyroid hormone,heart failure COPD, increased urinary frequency at night all can disturb.
4. Phase shift - Occur when the sleep wake cycle is reset,this is commonly seen  in alternating shift work or international travel.
5. Sleep apnea - Condition seen in obese and patient with thick neck. During sleep there will be heavy snoring interruption of breathing and disturbed sleep, this is followed by increased daytime sleepiness.
6. Conditioned insomnia - Person may become frustrated and anxious at bedtime  due to certain learned behavior  ,such people will get adequate sleep if they change their bed and bedroom.
7. Depression Insomnia - may be the chief complaint, manifesting as difficulty falling asleep or early awakening with inability to fall back to sleep. The manic phase of bipolar disorder will exhibit hyperactivity, racing thoughts, and speech with grandiosity.
8. Restless leg syndrome - in this syndrome patient experience a crawling sensation within the muscles,  this is relieved by by movement.
9. Nocturnal myoclonus - repetitive jerking of the legs. will awaken the patient from sleep.
10. Nightmares (dream anxiety attacks) - the patient will awaken from sleep with increased sweating.

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Treatment and prevention of Ebola fever.

Ebola fever is a dangerous viral fever associated with high death rate. Ebola is a viral disease caused by Ebola virus. Ebola affect multiple organs in the body, and may be associated with bleeding manifestation and low blood pressure which increase the death rate.

Prevention of Ebola fever

Prevention of Ebola fever is very important because no specific treatment is available for this disease.

Currently there is 

1. No vaccine 

2. No antiviral drug

3. Barrier nursing precautions in taken in African hospitals can significantly reduce the spread of Ebola virus from one person to other and can prevent epidemic.

4. An adenovirus - vectored Ebola glycoprotein gene is undergoing phase 1 trials in humans.

5. An experimental vaccine - vesicular stomatitis virus - based vaccine has protected macaques when it is given both before and after infection with the Zaire Ebola virus

Treatment of Ebola fever

For Ebola Virus Infections no virus specific treatment is available.

Usually what is given is supportive treatment, but sometime especially when the viral load is very high supportive treatment may not work well.

Animal studies shows improved survival in those treated with

1. Inhibitor of factor VIIa/tissue factor 

2. Activated protein C;. 

3. siRNA (small interfering RNA) interfere with viral multiplication is effective for prevention of disease after exposure to patient (post exposure prophylaxis)

Patients with low blood pressure vigorous treatment of shock is done with 

1. IV fluids.

2. Drugs to increase the blood pressure.

3. Those patients with significant blood loss require blood transfusion.

If the low blood pressure is not treated adequately the normal function of heart and lungs will be affected.

Ebola fever is treated with acetaminophen

Ensure adequate hydration is given to patients.

Useful Link : Clinical manifestations of Ebola fever.

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Clinical manifestations of Ebola fever.

Ebola fever is caused by  Ebola virus.The disease is associated with high death rate.High death rate is due to multiple organ involvement. Epidemics usually starts with single case who acquire the disease from unknown reservoir in the nature. Infection spread through close contact with the patient or their body fluid this can be acquired from home or hospital.

Initial manifestations include

1. Sudden onset of headache.

2. Musle pain.  

3. Fever .

4. Severe tiredness.

5. Vomiting and tendency to vomit.

6. Rash.

Continued fever is associated with 

1. Diarrhea (can be severe).

2. Chest pain (accompanied by cough).

3. Depressed mentation.

4. Bleeding manifestations in the skin or oral cavity,need not be present in all severe cases .It is seen in less than 50% of cases.

5. Low blood pressure.

Following are the additional findings 

1. Edema of the face, neck, and/or scrotum.

2. Enlargement of liver. 

3. Flushing.

4. Conjunctival injection.

5. Pharyngitis.

After 10 to 12 days after the onset of fever there may be improvement and patient recover from the disease. Some people may get the fever after sometime.

Some rare complications are 

1. Late liver involvement.

2. Infection of eye(Uveitis)

3. Infection of testes (Orchitis).

Useful links : Treatment and prevention of Ebola fever.

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