SEVERE HYPERGLYCEMIA: INSULIN-TREATED DIABETES
Theoretically, all blood glucose levels above the normal range represent hyperglycemia. The occasional value outside this range is no cause for concern. This section is about very high blood glucose levels, persistent values above 13 mmol/1 (234 mg/dl) or frequent readings of 22 mmol/1 (396 mg/dl) or more. There are many reasons for high blood glucose concentrations, a common one being infection, whether bacterial or viral. At the first signs of illness, start to measure your blood glucose frequently. It may rise even though you are unable to eat. Your insulin requirements may also increase as you become more resistant to the action of insulin while your body fights the infection. It is sensible to plan what you would do if this were to happen and discuss this with your doctor. Write the plan down. When you are feeling ill it is easier to consult the plan than try to remember all the details.
Insulin-treated diabetesIf your glucose level starts to rise, give yourself more insulin. But supposing I take more insulin and then I don’t feel like eating? I will make myself hypoglycemic! How much insulin should I take and when? There are many ways of solving this problem and there is no single correct solution. The only rules are:1.   Never stop your insulin injections2.   Ask for help sooner rather than later.The simplest and probably the safest way of coping is to continue your long-acting insulin, reducing the dose if necessary, and give extra short-acting insulin in doses of a few units, for example, two to four units, at frequent intervals, perhaps every four hours, according to your blood glucose measurements. Urine tests are not a very good guide at a time like this, when glucose levels may be changing rapidly.David, who is twenty and has been diabetic since he was four years old, takes Actrapid (short-acting) and Monotard (long-acting) insulin twice a day. He measures his blood glucose level four times daily and usually has values of 4 to 7 mmol/1 (72 to 126 mg/dl). He recently had an episode of abdominal cramps, diarrhea and nausea associated with poor glucose balance. The table shows how he coped with this at home. On Thursday he telephoned me because he still felt ill and his glucose levels were not returning to normal. I saw him that evening and admitted him to the hospital with suspected appendicitis. Fortunately, everything settled down, his glucose control improved and he went home. Throughout his illness his careful management ensured that his blood glucose level never rose above 17 mmol/1 (306 mg/dl). When he felt that things were not settling, he sensibly asked for help. I asked him to contact me earlier should this happen again.When changing your insulin dose or adding extra doses it is important to remember that your clear, fast-acting insulin is the one which will reduce a high glucose over the next few hours. Cloudy insulins have a longer and less predictable onset and duration of action. When adding extra doses of clear, fast-acting insulin, remember to consider whether any other insulin you have injected earlier will be starting to work at that time. Use this information to help calculate the right insulin dose. If you are unsure, contact your diabetic specialist nurse, or doctor for help, there and then.If your blood glucose is high try to work out why so that you can prevent it from happening again. Apart from the obvious reasons of too little insulin, too much food and too little exercise, consider infection, a reaction to injury, operation or stress, pregnancy, period times, and drugs or medicines. Steroid drugs (e.g. prednisolone) usually increase the blood glucose, thiazides, other diuretics (water pills) and tricyclic antidepressants may do so.
*25/102/5*

RHEUMATOID ARTHRITIS AND EXERCISES: GUIDELINES FOR SPECIFIC AEROBIC EXERCISESwimming or aquatic therapy Roxanne McNeal, president of the Aquatic Therapy Services in Abington, Maryland, has the following advice:•   Pool temperatures of 92° to 98° F are suitable for range-of-motion and stretching exercises but not for active aerobics.•   Pool temperatures of 82° to 86° F are best for aerobic exercise; aerobics in higher pool temperatures can cause the body temperature to increase and blood vessels to dilate, resulting in lightheadedness.•   Avoid pool therapy if you have an open wound, a fever, severe low or high blood pressure, or a history of uncontrolled seizures.•   Breathe regularly from the diaphragm throughout the exercise.
Bicycling• Adjust your seat high enough to have your legs almost fully straighten out.•   Do not ride a bike with the handlebars too far away from the seat. This increases stress on the lower back, shoulders, elbows, and wrists.•   If you can adjust the pedal tension, keep it at the lowest level to limit knee stress.•   Indoor cycles with arm motion attachments can decrease stress on the knees and still provide a good- aerobic workout.•   Try out various models of stationary bicycles (at a gym) or outdoor bicycles (at a bicycle shop) before purchasing one.•   Cooling down with light pedaling can be substituted for a range-of-motion cool down.
Walking• If you have severe arthritis of the knees or hips, walking may not be for you. Consider swimming or biking.•   Soak your feet in warm water, doing some gentle foot range-of-motion exercises before walking, to loosen up joints.•   Perform hip and knee range-of-motion exercises to stretch muscles in preparation for walking.•   Walk on a flat, level, relatively firm surface.•   Wear supportive walking shoes or athletic sneakers with good shock absorption capability.•   Swing your arms for balance while walking.•   Gradually increase your pace to reach your target heart rate.•   Visit a shopping mall or indoor track in inclement weather. Many malls have walking clubs you can join.•   If they are warm, soak your feet in cool water for ten minutes after walking.*83/209/5*

SEXUALLY TRANSMITTED INFECTIONSSexually transmitted infections (STIs) have been with us since our earliest recorded days on earth. In spite of our best efforts to eradicate them, prevent them, and control their spread, they continue to increase, affecting millions more Americans than previously thought, according to the first new STI estimate in a decade. Today, there are more than 20 known types of STIs. Once referred to as “venereal diseases” and then “sexually transmitted diseases,” the most current terminology is believed to be broader in scope and more reflective of the number and types of these communicable diseases. More virulant strains of the diseases and more antibiotic-resistant forms spell trouble for at-risk populations in the days ahead.A CDC report, issued in early December 2000, indicates that there were 16.2 million new occurrences of STIs in 1999, an increase of over 3.5 million since 1988. Although these numbers are reason for concern, the news may not be quite as bad as it appears. Experts say that the old estimates were probably too low, a product of age-old problems in reporting and failures of high-risk groups to access the health care system.In fact, rates for some diseases, such as syphilis and gonorrhea, are at all-time lows in many regions of the country, and HIV rates have shown a considerable decline among certain segments of the population. However, according to most experts, the overall numbers are still extremely high and indicate that STI research and treatment need considerably more national funding and priority status than they currently accrue. According to Felicia Stewart of the Kaiser Family Health Foundation, “there is no indication that STIs are coming rapidly under control. … In fact, people vastly underestimate risks and fail to take precautions. A . . . Kaiser survey found that just 14% of men and 8% of women felt at risk for STIs, even though at least one third will get one.”In many victims, early symptoms of an STI are mild and unrecognizable. Left untreated, some of these infections can have grave consequences, such as sterility, blindness, central nervous system destruction, disfigurement, and even death. Infants born to mothers carrying the organisms for these infections are at risk for a variety of health problems.As with many of the communicable diseases, much of the pain, suffering, and anguish associated with STIs can be eliminated through education, responsible action, simple preventive strategies, and prompt treatment. STIs can happen to anyone, but they won’t if you take appropriate precautions when you decide to engage in a sexual relationship.*26/277/5*

YOUR KNEE: SYMPTOMSAs a rule, orthopedists see two types of patients: first, patients who have recently suffered from an acute injury and are seeking immediate medical attention, and second, patients with chronic problems. These patients have often been in discomfort for some time and have learned to live with it. They seek help only when their symptoms take a turn for the worse.The acute patient should be able to give a fairly accurate account of how the injury happened. If possible, write down a brief description of the injury while it is still fresh in your mind. It can be very helpful to a physician to hear details such as “I was playing tennis, I reached for a backhand, and I twisted my foot. Then I heard a pop. Suddenly, I was in tremendous pain and I couldn’t continue playing.” Based on this description, a physician might suspect a ligament problem, which could be verified by further testing.It is also helpful if patients can help localize the pain. I often ask patients to—without stopping to think—quickly point to the exact spot where it hurts. By isolating the precise location of pain, it may further narrow down the possible diagnosis.The chronic patient may not be able to pinpoint the exact time when the problem began, but you, too, can provide invaluable information. Most importantly, you should be able to tell the doctor when and where your knee bothers you, and what activities seem to make it better or worse. Be as specific as possible; keep a diary if need be. Does your knee bother you when you walk or when you run? Does it hurt when you walk up stairs? Does it hurt when you get up from a chair? Does it hurt more at night than during the day? Is the knee swollen, or does it swell after certain activities? The answers to these questions may offer important clues as to what your problem is.It is also important for the chronic patient to tell the doctor about the degree to which you rely on pain medication such as aspirin, ibuprofen, or any other anti-inflammatory drug, either prescription or over the counter. If you can’t make it through the day without a hefty dose of painkillers, your doctor should know about it. It is also important to identify when you may need to take medication. For example, if you’re pain free except when you’re playing tennis, or dancing, it could provide some clues as to the cause of your problem.*8\185\2*

IBS AND THE NERVOUS SYSTEM: NERVOUS CONSTIPATION – THE RELAXATION RESPONSEThis has the same cause as nervous diarrhoea except that the train receives a different signal, so to speak. This time the instructions say ‘Tight muscles ahead, slow down activity’. You will remember that the initial instructions of the person preparing to run were, ‘I need more blood in my arms and legs so take the blood from my digestive system; I do not need it there at the moment.’ Tense people get stuck in this situation, tight muscles all over including the abdomen.The Relaxation ResponseHealthy people are able to use their minds and bodies to full capacity and then when they are ready to relax they just switch off-their relaxation response is in working order. The relaxation response in people who are tense and nervously exhausted fails because it has been overworked. Before it will function normally again it needs some help. Here is a less dramatic scene than the charging bull to help you to understand why the nervous system eventually stops trying to cope with the extra load.*63\326\8*

NON-EPILEPTIC SEIZURESIt was the day of the end of term Christmas concert, and Carol, aged 15, was waiting in the wings, just about to go on and play her piano solo. Her family, sitting in the front row, were excited because her young brother was just out of hospital after lengthy treatment for a childhood illness. Carol’s parents had had a difficult four years during their son’s illness, the low point of which came when Carol’s mother had a confrontation with the specialist over diagnosis. She had determinedly and single-mindedly sought a second opinion which led to successful treatment.As she made her way onto the platform, Marian tripped and fell heavily on her arm. She managed her performance but was clearly in pain. That evening at home she looked flushed and feverish. She stayed in bed for the next two days and when she got up she felt dizzy, and her injured arm was weak. Matters didn’t improve and by the end of the week she could hardly use her arm and her GP referred her to a specialist. The specialist (a neurologist) told her that there was nothing wrong with the arm except some minor bruising. But her mother was certain it was more than this and insisted that Carol should be admitted to hospital for investigation.The specialist finally agreed to take Carol into hospital. On the neurological ward were several patients with severe epilepsy, and during her first day there Carol saw several grand mal seizures. That evening she had her first ‘seizure’. This consisted of thrashing side-to-side movements of her head which went on for some twenty minutes. The houseman diagnosed epilepsy and treated her with intravenous diazepam and informed her parents of the diagnosis.Every evening she was in hospital Carol had a similar attack, but meanwhile all tests and investigations, even an EEG, had proved normal. Eventually Carol was told that she didn’t have epilepsy at all but that she was pretending’ to have these attacks. She was discharged and sent home.Back in the bosom of her family Carol, predictably, had another attack that evening which lasted for four hours. Her distraught father rang the hospital and was told she was playacting. This situation continued for the next two weeks, with Carol having attacks every night. The local neurologist was again persuaded to see her, said he had nothing to offer, and that Carol should see a psychiatrist. But Carol’s mother, sensitized by her son’s experience and clinging to the houseman’s original diagnosis of epilepsy, refused to accept a psychological cause and sought second (and third, and fourth) opinions elsewhere. She was finally referred to a specialist unit, with the diagnosis of ‘unusual epileptic seizures’.
For the first week on the unit Carol would have an attack every night, after which she became exhausted and fell asleep. Video monitoring of the attacks showed that they were quite uncharacteristic of any form of epileptic seizure. If she was spoken to during an attack she would sometimes reply. Her attacks were so clearly not epileptic in nature that it was not even necessary to have the additional evidence of a normal EEG during an attack to clinch the diagnosis.A small number of people who are at first diagnosed as having epilepsy are eventually found to have non-epileptic seizures. Their seizures can look very much like epileptic seizures, and indeed they are easily mistaken for epilepsy by the doctors who examine them, most of whom may not have had special training in epilepsy. But when they are given an electroencephalogram during an attack, it does not show the characteristic patterns of a true epileptic seizure.Non-epileptic seizures usually serve some purpose. They are often an expression of the person’s emotional needs, and play a role in helping them cope with difficulties in their emotional life. It has been found that people who have been sexually abused as children quite often develop non-epileptic seizures (though of course this does not mean that everyone who has non-epileptic seizures has been sexually abused, or that everyone who has been sexually abused has non-epileptic seizures).Carol herself was a teenager with a poor self-image and almost complete lack of self-confidence. She was finding the transition from childhood to adulthood hard and needed emotional support from her family, particularly her mother, which she was not getting. Eventually Carol was able to talk to her doctor about her deep unhappiness about her relationship with her parents, particularly with her mother. She had seen how her brother’s illness had occupied her mother’s complete attention over the last four years. Wanting her mother’s love and support, she felt, with some reason, that only ‘proper’ illnesses interested her mother. Was it surprising that she felt the only way she could get the same degree of attention was by developing a ‘proper’ illness herself?*51\193\2*

WHAT’S HOT IN DIABETES: EXCITING RESEARCH  OF TYPE 2 DIABETES Exciting research indicates that one of the  otentially treatable risks markers are present in diabetes. Atherosclerosis is now recognized as an inflammatory disease, and the plasma level c-reactive protein (CRP), as determined by a highly sensitive new assay, has proven to be a cardiovascular risk marker. Studies are underway to determine if drugs which lower CRP levels (e.g., aspirin or nonsteroidal anti-inflammatory drugs) will decrease cardiovascular events. Homocysteine metabolism is occasionally altered in diabetes, and prospective trials are underway to determine if lowering plasma levels with folic acid, B6, or B12 will prevent cardiovascular events.Thus, there is more than a hotplate full of topics in type 1 and type 2 diabetes. Rather, consider a gigantic oven, with multiple shelves, nooks, and crannies in which a plethora of hot items are being baked at variable rates. In some areas, microwave speed has been achieved. The net effect is a body of new information which must be transmitted and understood by health care professionals in order to improve the lives of people with diabetes mellitus.*6\357\8*

ARTHRITIS AND DRINKING WATER: TEN BEST SUGGESTIONS TO BE WATER-WISEThe wisdom of using proper water habits has been shown throughout this chapter. By now, arthritics should be ready to accept some helpful recommendations. Your recovery from arthritis might depend on how well you follow a correct water regime.For easy reference, and to summarise the leading requirements, here is a basic set of ten reminders:Drink your water at least 10 minutes before your meal.After meals, wait at least 3 hours before drinking water.No water with your meals.Water is good for you upon arising, but try to drink it warm, one hour before breakfast. Taken that early, the water is mildly laxative.Never drink lemonade, or water flavoured with fruit.Never add water to milk.Avoid using aerated water, flavoured carbonated water or seltzer types.Hard water, soft water, fluoridated water, chlorinated water, spring water, distilled water—it makes little difference to your arthritis. The TIME of intake is important.Never add water to soup. (For instance, to cool it off once it is cooked and served.)When you drink coffee (which is water) be sure it is at least 10 minutes before or 3 hours after your meal.Remember the above laws on drinking “oil-free” liquids, and you will have taken a major step toward relieving your arthritic pains. You will be protecting the oils in your body, rather than “washing them away.”What these pages have been trying to say is that many liquids have high surface tension on oils. TENSION is the key word. Tension caused by water prevents your foods from being digested properly. When you create high tension inside your body, it repels digestive enzymes and disrupts the flow of lubricating oils.Water has the highest surface tension of any food on earth. Therefore, it could be your greatest enemy. Depriving your arthritic joints of those very essential oils!*35\146\2*

IF YOUR CHILD WITH ADHD (ATTENTION DEFICIT HYPERACTIVITY DISORDER) IS BEGGING YOU FOR A PETQ: Our nine-year-old son is begging us for a dog, but my husband and I are concerned that his ADHD makes him a poor candidate to own a pet. Should we risk it or wait until he’s older? A: The answer to your question depends on your son’s maturity level and how his ADHD most commonly manifests itself. If he’s prone to forgetfulness and inattention, then you and your husband will probably end up taking care of his new pet because he’ll never get around to it. However, if your son is fairly mature and good about doing what he’s told, a dog might be an appropriate companion.If you do decide to get a dog for your son, sit down with him first and explain in detail exactly what will be expected of him regarding the animal’s care. Make sure he understands that the dog will be his responsibility and that he will have to feed and walk it every day (even when it’s raining) and bathe it when necessary. Many times, pet ownership is an effective way of instilling a sense of maturity in youngsters with ADHD.If you feel that your son isn’t quite ready for the responsibility of owning a dog, you might want to consider a pet that’s a little less trouble, such as a hamster or a guinea pig. These are gentle animals that enjoy playing with people, but don’t require a lot of day-to-day care. Once your son has proven himself responsible in this way, you can reconsider his request for something larger.In my experience, ADHD children who have significant self-esteem problems and difficulties with social relations often feel very comfortable with animals and develop devoted relationships to them. The pet can then help the child to deal with upsetting incidents; in other words, help the child learn to soothe himself. This ability is extremely important in over coming the tendency to impulsive action brought on by intense emotional states. Similarly, the unconditional love of the pet for its young owner can be very enhancing to the child’s self-esteem. And as the child learns to care for his pet, it helps him to develop skills of empathy for others. In fact, so much benefit can be obtained by the experience of having and caring for a pet that I think you might want to consider it, even if your child may need reminding and help in caring for the pet.*108\173\2*