Target comprehensive metabolic control and monitoring in diabetes

Diabetes mellitus (DM) is a common metabolic disorders where hyperglycemia is the predominant manifestation. It is a multi system disease because of the  associated metabolic dysregulation. In United states DM is the leading cause of end-stage renal disease (ESRD), adult blindness and non-traumatic lower extremity amputations.It also increases the risk  for cardiovascular disorders. Diabetes is a lifelong disease. Comprehensive diabetes care involves not only  plasma glucose control, but also detect and manage DM-specific complications and modify its risk factors .

Treatment of diabetes:

Old concept

Involves only glucose control

Which prevent only  microangiopathic complication.

Recent treatment

Comprehensive metabolic control, which control blood glucose and other metabolic disturbances

FPG - Fasting plasma glucose

PPG - Postprandial plasma glucose

HbA1C - hemoglobin A1C

LDL-C - Law density cholesterol

Tg - Tryglyceride

BP - Blood pressure

Following things needed to be monitored in diabetic patients

1. Urine glucose has no value.
2. Plasma glucose - Fasting or postprandial weekly.
3. Glycated Hb - 8 to 12 weeks (RBC life–12wks), marker for long term control.
4. HbA1C better co-relates with PPG than FPG.
5. Monitor all 3 parameters (FPG, PPG, HbA1C).
6. BP -  In all sittings, every 3 months.
7. Urine Albumin - Once in year.
8. Lipid profile - Once in 6 months.
9. Fundus/Foot exam - Once in a year.

                      Some blood glucose meters

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Sources of vitamin D

Vitamin D is a fat soluble essential  vitamin (sunshine vitamin). Activeform of vitamin D is vitamin D3. It is also called calcitriol, whose main function is promotion of calcium absorption. Liver and kidney plays important role in formation of D3.

What are the Sources of vitamin D

Sunlight and vitamin D

Skin exposure to sunlight is the main source of vitamin D. Active form of vitamin D  that is vitamin D3 is formed in the skin by the action of ultraviolet B exposure (UV-B wavelength 290–315 nm) on 7-dehydrocholesterol, which is a cholesterol metabolite present in skin. The intensity of UV light decreases as we move from equator, so at a latitude more than  50° (including northern Europe ), in winter seasons vitamin D is not synthesized, and there is seasonal variation even above 30° .These ultra violet B rays (wavelength) are present only if the ultra violet index is more than 3. Number of days with ultra violet index more than 3 decreases as we move from equator. 

Apart from that, during winter, people living at high altitude wear thick clothes, spend nearly all the day indoors and pollution of sky with smoke all decreases the ultra violet exposure. So the dietary intake is crucial during these season. They have to consume the body store  accumulated during summer. People living in tropics can get adequate amount of vitamin D, if they expose their unprotected skin to sunlight 15 minutes session twice a week. Though direct sunlight is a great source of vitamin D people should not overdo it . In United states vitamin D deficiency  is considered to be  an epidemic.

Factors that decrease synthesis of vitamin D by skin

• Living away from equator
• Cloud cover
• Smog
• Sunscreens
• Wearing clothes 
• Living indoor
• People with dark skin pigmentation
• Image of sun exposure

Food

If the body cannot synthesis adequate amount of vitamin D  due to insufficient sunlight you need dietary supplementation. Daily requirement is about 1000 units in the absence of sun exposure. Deficiency risk increased because of change in life style  such as mainly indoor jobs and change in dressing style.Many countries tried to overcome this by fortifying food with vitamin D, but even that is not enough to meet the complete demand of body. Except for  fish and fortified foods availability of vitamin D from other food is  limited.

Food sources of vitamin D are the following

• Fish liver oils.
• Fatty fish (sardines, herring, mackerel, tuna, salmon, pilchards).
• Margarine (fortified).
• Infant milk formulas (fortified).
• Eggs.
• Liver.
• Salmon (447 IUs per serving), tuna (154 IUs per serving) mackerel (388 IUs per serving), and  fish liver oils (one tablespoon -1,360 IUs)  are good source of vitamin D .

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Clinical manifestations of hypoglycemia in diabetic patients

Hypoglycemia is a major side effect of insulin treatment. It is a cause of anxiety in patient and the care givers. Hypoglycemia occur more during night and before meals. This  is due to imbalance between insulin administration and requirement.

Recently there is an increase in incidence as an attempt to achieve tight glycemic control. Hypoglycemic episodes are more in those patients whose blood glucose levels are reasonably well controlled. There is a person to person variation in the blood levels at which each patient  experience symptoms of hypoglycemia. Those patients whose glycemic control is poor experience symptoms at somewhat higher level of blood glucose. Thus patients should take extraprecaution during driving ,swimming etc .Patients on insulin are always advised to carry some form of sugar with them.Incidence of hypoglycemia is less in patients taking anti-diabetic drugs.

Hypoglycemia is  defined as plasma glucose level <45-50 mg/dl.Whipple’s triad forms an important frame work for diagnosis of hypoglycemia.

Whipple’s triad include the following 

Symptoms consistent with hypoglycemia

• Low plasma glucose concentration.
• Relief of symptoms after plasma glucose level is raised.
• clinical manifestations of hypoglycemia.

Clinical manifestation vary from mild tiredness to  unconsciousness .Most of the patients experience warning symptoms before severe manifestation occur .Sugar intake at this level can terminate further progression.  Warning symptom may be absent in patients on longstanding diabetes ,In such patients detachment from environment occur that can be easily detected by caregivers ..Most common warning symptoms are tremor and sweating. But periodical numbness is the most specific symptom. Manifestations of hypoglycemia can be neurogenic or neuroglycopenic. Symptoms of decreased glucose availability(neuroglycopenic symptoms) occur  only at later stages.

Symptoms of hypoglycemia

Early warning symptoms

• Adrenergic symptoms
• Palpitations(pounding heartbeat)
• Tremor
• Anxiety
• Cholinergic symptoms 
• Sweating
• Hunger
• Pins and needles in lips and tongue
• Headache (occasionally)

Neuroglycopenia symptoms 

Mild

• Double vision
• Slurring of speech
• Difficulty in concentrating

More advanced 

• Confusion
• Truculence
• Change of behaviour in the form of clumsiness ,irritability  or aggressiveness
• Naughtiness in children

Unconsciousness 

• Restlessness with sweating
• Hemiplegia, especially in older people (but rare)
• Convulsion

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Causes and medical conditions associated with fatigue

Fatigue is a common symptom that many of us experience in day to day life, but this may not be due to underlying disease. Certain factors associated with fatigue are 'normal' - and they are not due to medical problem which include fatigue due to 

• Physical exertion
• Emotional stress
• Boredome 
• Disturbed sleep

But certain people are more prone to fatigue

Predisposing factors

• Female sex
• Law socioeconomic status
• Physical and mental illness
• Personal habits and life style that increases fatigue
  (a) Staying up too late
  (b) Excessive caffeine intake
  (c) Excessive alcohol intake
  (d) Consumption of junk food

Precipitating factors

• Acute physical stresses - Infection with Epstein-Barr virus ( glandular fever).
• Psychological stresses - Bereavement, stress, anxiety and depression.
• Social stresses - Work problems.
• Physiological - Pregnancy, breastfeeding, inadequate rest or sleep, and excessive exercise.

Perpetuating factors

• Physical inactivity
• Emotional disorders
• Ongoing psychological or social stresses
• Disturbed sleep.

Diagnoses associated with fatigue

Only less than 10% of people presenting with fatigue has an underlying medical condition. There are variety of causes associated with fatigue, so detailed evaluation of individual circumstance by a doctor is important.

Medical conditions associated with fatigue

• General - Anemia, chronic infection, autoimmune disease, cancer
• Endocrine disease - Diabetes, hypothyroidism, hypoadrenalism
• Sleep disorders - Obstructive sleep apnoea and other sleep disorders
• Neurological - Myositis, multiple sclerosis
• Gastrointestinal - Liver disease
• Cardiovascular - Chronic heart disease
• Respiratory - Chronic lung disease
• Obesity

Lack of sleep may be associated with fibromyalgia which present with widespread body pain and fatigue.

Psychiatric diagnoses associated with fatigue.

• Depression
• Anxiety and panic disorder
• Eating disorders
• Substance misuse disorders
• Somatisation disorder

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What is fatigue or tiredness

Fatigue or tiredness is a common complaint in the general population. Approximately 15% of people present with fatigue in primary care center. Subjective symptom of malaise and decreased interest in activities and objectively impaired performance can been seen. It has physical and mental components. Patients consider it as important because tiredness is disabling, but usually doctors fails to give adequate care since it is nonspecific. Fatigue is twice more common in women than men. Association with age and occupation is not as strong as gender difference.

Fatigue is associated with 

• Decreased energy level
• Loss of motivation
• Sleepiness
• Physical and mental exhaustion

Feeling of tiredness is different from sleepiness and psychological feeling of lack of motivation but both of this may accompany fatigue.We should take pain to differentiate lack of energy from loss of motivation or sleepiness because it may point towards certain diagnosis.

Effects of fatigue

• It can decrease the performance of work
• Affect the quality of life
• Worsen the interpersonal relationship

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Diagnosis of migraine

Migraine is a common familial disorder which is characterized by periodic,commonly unilateral and often throbbing headaches, it begin in childhood, adolescence, or early adult life and the frequency decreases during advancing years. The most characteristic features are throbbing nature and its occurrence in one side of head (Hemicranial ). In more than 80 percent of patients, the onset is before 30 years of age. 

There are two types migraine, classic Migraine( with aura ) and common migraine (without aura). Aura is commonly visual. Sensitivity to light and noise occur which is called as photophobia and phonophobia respectively. In women, the headaches tend to occur during the premenstrual period

Diagnostic criteria

Migraine without aura - Migraine without aura is a recurrent headache disorder that fulfills the following IHS criteria : 

• Headache attacks last 4 to 72 hours.
• Headache has at least two of the following characteristics.
  (a) Unilateral location.
   (b) Pulsating quality.
  (c) Moderate or severe intensity.
   (d) Aggravation by routine physical activity. 
• During headache at least one of the following occurs.
    (a) Nausea and /or vomiting.
    (b) Photophobia and phonophobia.
• At least five attacks occur fulfilling the above criteria. 
• History, physical examination, and neurological examination do not suggest any underlying organic disease.

Migraine with aura

• At least two attacks of aura with migraine headache.
• The migraine aura fulfills criteria for one of the sub forms of aura with migraine headache. 
• The symptoms are not attributed to another disorder.
• First, the aura has at least one of the following characteristics without motor weakness:
  (a) Fully reversible visual symptoms including positive features (example : flickering lights, spots, or lines) and/or negative features (ie, loss of vision)
  (b) Fully reversible sensory symptoms including positive features (ie, pins and needles) and/or negative features (ie, numbness)
  (c) Fully reversible dysphasic speech disturbance.
• Second, the aura has at least two of the following characteristics.
  (a) Homonymous visual symptoms or unilateral sensory symptoms.
  (b) At least one aura symptom develops gradually over greater than or equal to 5 minutes or different aura symptoms occur in succession over greater than or equal to 5 minutes. 
• Each symptom lasts greater than or equal to 5 minutes and less than or equal to 60 minutes.

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Significance of early diagnosis of heart attack

Chest pain is a Common complaint in  emergency department (ED). Approximately 5% of all ED visits or 5 million visits per year is due to chest pain .There is a wide range of etiologies Cardiac, Pulmonary, Gastrointestinal, Musculoskeletal. Distinguishing these causes matter because management vary  according to etiology.

When there is a block in coronary arteries that supply heart muscle it will produce heart attack .Most common manifestation is  cardiac pain which is called angina pectoris.

Key features of typical cardiac pain

From history 

Location : Pain can be central, left or right part of chest.

Timing : It can be gradual or sudden onset.

Provocation : By exertion.

Quality : Diffuse or constricting type of pain it can be an uncomfortable pressure, fullness, squeezing in the chest.

Radiation : Can radiate to back, neck and arm.

Severity : Severity vary from a scale of 1-10.

Associated symptoms : Breathlessness, sweating, nausea, fainting, feeling of impending doom, cold clammy skin may be present.

When the patient is asked to localize the sensation, he or she will typically press on the sternum, sometimes with a clenched fist, to indicate a squeezing, central, substernal discomfort (Levine's sign). 

                 Levine's sign 

Key Emergency Physical examination 

1. General appearance - Patients are usually anxious and restless.
2. Vital signs - Watch for hypotension or hypertension.
3. Heart - Examine the heart sounds is it muffled? regular? fast?
4. Neck dilated neck vein.
5. Abdominal distension.
6. Lowerlimb oedema and calf muscle tenderness.
7. All these features need not be present in every patients.

Whenever you have chest pain consider above mentioned points you should not ignore the chest pain if  at least one or two features are present  and attend the emergency department and do proper evaluation.Early diagnosis is important because if there is a delay in treatment  more than 6 hours, there will be irreversible damage to heart muscles.

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