Advice for diabetic drivers

Driving is a complex activity which requires adequate vision,motor skill and proper judgement.It is required in day to day life.Diabetes can adversely affect driving by producing low blood glucose,decreased vision and neurological problems.

Following are the advice for diabetic drivers

1. Diabetic drivers should inform the licensing authority and motor insurer about the diabetes and its treatment.

2. If there is sudden deterioration in vision they should not drive.

3. Before starting journey they are advised to check the blood glucose (even before short journey) and in between long journey.

4. They should avoid alcohol.

5. Diabetic drivers should take frequent rests with snacks or meals.

6. For emergency use they are advised to keep fast and long acting carbohydrates in the vehicle.

7. All diabetic drivers should carry personal identification indicating that they are diabetic.

8. If they develop hypoglycemia they should stop driving ,switch off the engine and leave the driver seat for treatment.

9. They should not restart driving for 1 hour after  the blood glucose returned to normal level.

Reason for diabetic drivers to stop driving

1. Newly detected diabetic patients who are started on treatment particularly if on insulin shouldn't drive  unless they achieved diabetic control and proper vision.

2. If a diabetic patient develop recurrent severe daytime hypoglycemia.

3.If the diabetic patient has disabling unawareness of hypoglycemia.

4.Reduced vision in both eyes less than 6/12

5.Severe nervous system complication such as loss of pain and touch in limbs.

6.Severe peripheral blood vessel complication.

7. Lower limb amputation.

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What is osteoporosis and what are the risk factors

Osteoporosis is a condition in which there is weakness of bone strength. Although it is more common among postmenopausal women it can occur in any males and females with risk factors. The most common clinical manifestations are fracture of spine ad hip area, although  fracture can occur at any site. More than 10 million people in USA are affected by this disease but only a small proportion are identified and treated. Osteoporosis is defined as "bone density falls 2.5 standard deviation below the mean for young healthy adults of the same sex that is T score of  - 2.5".

After the age of 70 yrs the chance of hip fracture doubles every 5 yrs. Hip fracture is associated with increased risk of mortality during the year after the surgery.

Spinal fractures are associated with pain in back, bending of vertebral column and loss of height.

Osteoporosis and related fractures are more common in females.

1. Low peak bone mass.

2. Postmenopausal bone loss in women.

One fracture increases the risk of second fracture. For example spinal fracture increases the risk for other spinal fracture and wrist and hip fracture. Wrist fracture increase the risk of spine and hip fracture. Osteoporotic bone is at risk for developing fracture even with minor trauma. Irrespective of circumstances any fracture in people over the age of 50 yrs need evaluation of osteoporosis.

Following are the risk factors for osteoporosis

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Clinical features of osteoarthritis

Most common manifestation of osteoarthritis is joint pain and it is activity related pain occur during activity or immediately after the use of joint and it decreases gradually.

Site of pain - example

1. Hip and knee pain going up and down stairs.
2. Pain in weight bearing joints  while walking.
3. Hand osteoarthritis - pain while cooking.

Nature of pain.

Early in the disease, pain is present only when the affected joint is overused, but later the pain become constant and present even at night. This is associated with stiffness of joint. If early morning stiffness is present, it is very brief usually less than 30 minutes.

Osteoarthritis of knee joint.

In osteoarthritis of knee joint, pain occur on bending the knee. Some people experience buckling, catching and locking of the knee joint. Osteoarthritis of knee joint is the most common cause of chronic knee pain in persons over 45 yrs. In hip osteoarthritis restriction of hip movements will occur.

Investigation in osteoarthritis.

No blood test is required for evaluation of patients with osteoarthritis.

Tests that may be done.

1. Synovial fluid analysis.
2. Xray of joint.
3. MRI test.

Synovial fluid analysis.
If the WBC count more than 1000 it indicate inflammatory arthritis or gout

Xray

Correlate poorly with disease activity and joint pain .It may be normal in the early disease.It is indicated if the joint pain does not respond to usual management.

White arrow indicates joint space reduction compared to opposite side

MRI

Not a routine part of osteoarthritis evaluation.

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Risk factors of stroke

Risk factors of stroke Stroke is a neurological emergency. Stroke occurs as an end result of diminished blood supply to brain. It produces significant morbidity and mortality in the society. About 20% of patients die within 1 month of stroke attack. It has both modifiable and non modifiable risk factors. Treatment of modifiable risk factors will help in reducing about 80% stroke in the community.

General risk factors for stroke

Non-Modifiable risk factors

• Age - Age more than 55
• Gender - Male 
• Race (ischemic stroke): blacks > whites > Asians 
• History of stroke or TIA.

15-30% of strokes are preceded by TIA.

35% of pts with TIA will have stroke within 5 years.

10% risk of recurrent stroke within first years of stroke.

(TIA – transient ischemic attack).

• Family history.
• Fibromuscular Dysplasia.
• Patent Foramen Ovale (PFO or hole in the heart).

Modifiable risk factors

Modifiable risk facrors are divided into medical disorders and lifestyle disorders.

Medical Risk Factors 

High Blood Pressure.

Atrial Fibrillation.

High Cholesterol. 

Diabetes.

Atherosclerosis.

Circulation Problems.

Lifestyle risk factors

Smoking.                                                                                                

Alcohol use.

Physical Inactivity.

Obesity. 

High risk factors for ischemic stroke

General population (0.6 %/yr)

Asymptomatic carotid bruit : 1.5 %/yr.

Prior myocardial infarction  : 1.5 %/yr.

Asymptomatic carotid stenosis : 2.0 %/yr.

Nonvalvular atrial fibrillation :  5.0 %/yr.

History of TIA : 6.0 %/yr.

Prior ischemic stroke : 10 %/yr.

Rare risk factors

Thrombocythaemia and  thrombophilia ( increased platelet count ) 

Polycythaemia ( Increased hemoglobin) 

Anticardiolipin and lupus anticoagulant antibodies (i.e. antiphospholipid syndrome). 

Endocarditis ( infection of heat valve) 

Low-dose oestrogen-containing oral contraceptives 

Migraine   

Vasculitis (SLE, polyarteritis nodosa, giant cell arteritis, granulomatous CNS angitis) 

Amyloidosis   

Hyperhomocysteinaemia 

CADASIL (cerebral dominant arteriopathy with subcortical infarcts and leucoencephalopathy)

Reduction of stroke risk following control of risk factors

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Risk factors for depression

Depression is the fourth leading cause of global burden of mental ill health. According to WHO it will be the second most common form of disability by 2020 after ischemic heart disease. Depression is a major cause of suicide. Nearly 1 million people die of suicide, annually. Incidence of major depressive disorder is 1 in 20 people during their entire life time. It is more common in women than men.

Depression affect compliance, immune functioning, quality of life and it will lead to unhealthy behaviours in patients. Due to depression patient experience a variety of somatic illness. Less than one half of depressed patients are identified and adequately treated by primary care physician. It is a common condition and is treatable. Hence identification of this syndrome is important.

Risk factors for depression are

1. Gender-common in females. 
2. Genetic/biological vulnerability. 
3. Stress/environmental/life events especially loss events such as bereavement. 
4. Physical illness especially chronic and painful illness.
5. Drugs.
6. Chronic and excessive alcohol intake.
7. Difficulties in interpersonal relationship.
8. Lack of social support with no confiding relationship. 

Pathways to depression

Broadly depression  can be classified as two major groups.

1. “Major” depression – Pharmacologically treated.
2. “Minor” depression – Treated mainly by psychological approaches.

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What is raynauds phenomenon ?

Raynauds phenomenon is due to episodic digital ischemia (decreased blood supply to digits). On exposure to cold there is color change to digits which change on rewarming. Emotional stress may precipitate Raynaud’s  phenomenon. Color changes are well demarcated and confined to fingers and toes.

Phases of raynauds phenomenon

Phase of  blanching/pallor - On exposure to cold there is spasm of arteries in the digits and cause diminished blood supply to digits, so that the the digit appears white. 

Phase of cyanosis - In this phase there is bluish discolouration of digits. There is dilatation of veins and small capillaries and lead to accumulation of de oxygenated blood in the vessels. In both these phases there is coldness and numbness of digits.

Phase of rubor/redness - It occur on rewarming the digit.This is due to dilatation of blood vessels, spasm resolves, so there is reactive hyperemia. In this phase patient experience pain and throbbing sensation. All the three phases need not be present in a given patient. Some patient experience only pallor and cyanosis where as others have only cyanosis.

Classification 

Primary or idiopathic condition is called Raynaud’s disease. Secondary is associated with underlying disease that is known to produce vasospasm.

Raynauds disease

It is more common in females and is usually seen between the age group 20 to 40. Fingers are more commonly affected than toes. Other areas affected may be ear lobes, tip of nose, penis. This is more common in those who suffer from migraine or variant angina. Those with raynauds disease have milder form of Raynaud’s phenomenon.  

Secondary causes of Raynaud’s phenomenon

a) Collagen vascular diseases:

1. Scleroderma (80-90%)
2. Dermatomyositis, Polymyositis(30%) 
3. Rheumatoid arthritis 
4. Systemic lupus erythematosus(20%)

b) Diseases  producing arterial occlusion: 

1. Atherosclerosis of the extremities-Common in men more than 50 yrs. 
2. Thromboangiitis obliterans (TAO) more common in young males who are smokers
3. Acute arterial occlusion 
4. Thoracic outlet syndrome

c) Pulmonary  artery hypertension

d) Nervous system disorders:

1. Intervertebral disk disease
2. Syringomyelia
3. Spinal cord tumors
4. Stroke 
5. Poliomyelitis
6. Carpal tunnel syndrome

e) Disease of Blood: 

1. Cold agglutinins
2. Cryoglobulinemia
3. Cryofibrinogenemia 
4. Myeloproliferative disorders
5. Waldenström’s macroglobulinemia

f) Trauma: 

1. Vibration injury
2. Hammer hand syndrome
3. Electric shock
4. Cold injury 
5. Typing
6. Piano playing

g) Drugs: 

1. Ergot derivatives
2. Methysergide
3. β-adrenergic receptor
4. Blockers
5. Bleomycin 
6. Vinblastine 
7. Cisplatin

Complication of Raynaud’s phenomenon 

Rarely progress to digital ischemia, gangrene, ulceration and auto amputation of digits.

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