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Table V-2-2 Different preparations of insulin based on their duration of action: Preparation Onset of Peak action Clinical sue and rout of administration action and Duration of action Short acting 30-60 min P : 1-4 hrs Used in ketoacidosis for rapid control of high (crystalline /regular) D: 4-6 hrs sugar and acidosis purchase 80 mg telmisartan with amex blood pressure quiz questions. The other option for patient diagnosed before developing acute complications Start with 20- 25 units of Humulin insulin (equivalent to daily insulin production by islets) S proven 40 mg telmisartan blood pressure guidelines 2015. It helps to achieve near normal blood glucose level and thus delays the development of chronic complications cheap telmisartan 20mg otc blood pressure 39 year old male. Oral hypoglycemic agents These groups of drugs are widely used in type 2 patients whose hyperglycemia has failed to be controlled with conservative measures. The dose can be increased by 5 U every 3 to 7 days until adequate control is achieved. Follow up of patients:-Since this is a lifelong disease regular follow up of patient is crucial. Points to give emphasis during follow up Symptoms of hyper or hypoglycemia Wight Blood pressure Visual acuity Examine the oral cavity Examination of the feet Examine Injection site Laboratory tests: blood or urine sugar and urine albumin or protein. Hyperosmolar Comma 1) Hypoglycemia in the diabetic patient is caused by Overdose of insulin or hypoglycemic agents Missing of meal Strenuous exercise 446 Internal Medicine Clinical manifestations Early: one may feel the effects of sympathetic stimulation such as cold sweat, tremor, hunger or palpitations. This biochemical changes bring about: Increased production of glucose by the liver and increased glycogen degradation to glucose Decreased glucose uptake and utilization by muscles Lipolysis: enhanced break down of free fatty acids and subsequent ketogenesis. This increases blood levels of keton bodies such as acetoacetic acid, -hydroxybutyric acid, and acetone, resulting in metabolic acidosis. Signs and symptoms: Volume depletion : dehydration- dry tongue and bucal mucosa, poor skin turgor and hypotension Kussmaul respiration : deep and fast breathing resulting from metabolic acidosis Acetone ("fruity") odour of breath: due too acetone Nausea and vomiting and frequent complaint of abdominal pain. Supportive therapy: Airway maintenance, supplemental oxygen as needed, and treatment of shock. Fluid replacement: Fluid replacement corrects dehydration caused by glucose induced osmotic diuresis. Insulin: Insulin is administered to increase glucose use in the tissues, to inhibit ketogenesis, and to counter balance the effect of counter regulatory hormones. Then 5-10 /hr units or regular insulin is given per hour till the blood glucose level drops to 250-300mg/dl 449 Internal Medicine Blood glucose determination is done every hour. Close follow-up of patients Monitor serum glucose and potassium as well as urine output hourly. Oral intake may resume when mental status of the patient improves and nausea and vomiting are controlled. Initial diet should consist of fluids, and solid diet is may not be resumed until ketoacidosis is corrected. Symptoms: Such patients present with several weeks history of polyuria, weight loss, and diminished oral fluid intake that is followed by mental confusion, lethargy or comma. Physical examination: Patients have extreme dehydration, hypotension, tachycardia and altered state of consciousness or comma. The dehydration is caused by a hyperglycemia induced osmotic diuresis, when it is not matched by adequate fluid intake. Retinopathy : Is one of the commonest chronic complications and one of the leading causes of blindness in developed countries. Diabetic Foot Ulcer The following are underlying mechanism for diabetic foot ulcers Neuropathy o Loss of pain sensation exposes to injury o Loss of sweating results dry skin that is susceptible to injury Vascular: poor blood supply to the foot causes decreased healing of wound poor recovery from secondary infections. Since the foot is not in a normal anatomic position it is exposed to abnormal load and pressure sores develop. Thyroid disorder Learning objectives: at the end of this lesson the student will be able to: 1. Identify the clinical manifestation of diseases of the thyroid, with special emphasis on hyperthyroidism and hypothyroidism. Introduction: The thyroid gland normally weighs 20gm and is visible in thin women. The basic unit of thyroid structure is a follicle which is spherical in shape, filled with colloid, and encompassed by single epithelial cell layer. The hormones produced by the thyroid gland are referred to as tri- iodothyronine (T3) and thyroxin (T4). Thyroid disorders: Manifest with qualitative or quantitative alteration of thyroid hormone secretion, enlargement of thyroid, or both. The advantages of carrier proteins are: They are reservoirs to replenish free hormone level They buffer any fluctuation in gland secretion They protect against hepatic degradation and renal excretion of the hormone Standard lab tests measure protein bound hormone level so that results depend on the concentration of these proteins. Serum T3 and T4 level: measures the total bound (99 %) and free (1 %) hormone level in the circulation. This gives some clue about serum level of thyroid hormone, but has limitation since serum level of the hormone is influenced by conditions affecting the level of carrier proteins. It is a very sensitive test and, because it usually becomes elevated even before thyroid hormone (T3 and T4) level decline below normal. Thyroid stimulating antibodies, circulating antibody against T3 and T4 is an evidence for autoimmune disease of thyroid glands. Thyroid carcinoma Epidemiology of Thyroid Diseases is Ethiopia Simple nodular goiter is very common in areas where there is serious iodine deficiency. Of these 44% were thyrotoxic, 24% has solitary nodules, 29% simple toxic goiter, while thyroiditis and hypothyroidism were rare. Patients however remain asymptomatic probably due to decreased impact on peripheral tissue. Hyperthyroidism Definition: Hyperthyroidism is a hypermetabloic state, resulting from excessive thyroid hormone function. Etiology: Common causes of hyperthyroidism include: Gravesdiseases Toxic multinodular goiter Toxic adenomas 458 Internal Medicine Graves disease: Is the most common cause of hyperthyroidism in the third and fourth decades. Toxic multinodular goiter: It usually develops insidiously in a patient who has had a nontoxic nodular goiter for years.
Freud pro- posed that fetishism originates in the phallic phase of psychosexual development as a male child experiences anxiety about his mothers missing penis buy telmisartan 40 mg visa arrhythmia dysrhythmia, for which he nds a symbolic object buy 20 mg telmisartan with visa blood pressure medication quiz, thus resolving his fear and restoring an erotic attach- ment to his mother (70) buy 80 mg telmisartan mastercard arrhythmia from clonidine. The memory of sexual pleasure as a mechanism to cope with stress becomes xated and eventually transmutes into repetitive behavior. Psychoanalytic View of Transvestic Fetishism In the orthodox psychoanalytic view, cross-dressing is a defense against cas- tration anxiety. Some proposed that transvestism represents an unconscious wish for the fathers attention by identication with the mother (71,72). Stoller described transvestism as a hostile mastery of early trauma and humiliation by the mother (74). In contrast, Oversey and Person suggested anxiety as the central theme in transvestism, caused by awed maternal bonding and consequent incomplete sense of self (75). Psychoanalytic View of Exhibitionism To the psychoanalyst, exhibitionism is associated with childhood experiences with a dominant, seductive mother and a distant father (69,76). The assault on the male childs developing sense of masculinity and adequacy is resolved in the feelings of gratication and power when a female reacts to his genital displays. Kernberg suggested that masochists experience narcissistic gratication in the grandiose view of the self associated with high tolerance for pain (79). Waska described the masochist as alternating between compulsion toward servitude and rage at the internalized possessive, rejecting, or neglectful maternal object (80). The masochist suffers a core incapacity to self-soothe and, therefore, deep cravings to be soothed by others. The cravings, and accompanying rage, explain the masochists inherently ambivalent position, in which self-suffering disguises feelings of anger and yearning for maternal soothing. Ultimately, his compensatory style is one of the expecting to be hurt by those from whom he needs love, and one of the confusing pain and humiliation with longed-for love. He tolerates pain and suffering in order to remain attached to the needed but pain-causing mother, a stance that is preferable to no attachment at all. In Lebes formulation, the masochist is sensitive to others but cannot be to himself because as a child he was unable to differentiate between self and the punishing or rejecting mother (81). A more recent formulation proposed that sexual desire itself is a driving force in masochism, and that sadomasochistic aggression is, paradoxically, an attempt to nd safety under the primitive lure of sexual feelings and preoedipal yearnings (82). Psychoanalytic interpretations assist the clinician in formulating a sense of the early life experiences of individuals seeking treatment and in understanding their developmental vicissitudes. Most clinicians who treat individuals with para- philias can provide testimony to the life stories that offer convincing anecdotal evidence for the relevance of psychoanalytic constructs to our efforts to explain unusual erotic interests. Paraphilias 309 Family Dysfunction Models of Etiology Other etiological theories, while not based specically in psychoanalytic thought, view paraphilias as developing out of adverse early life experience and dysfunc- tional family processes. Studies have found varying degrees of association between the childhood experiences such as emotional and sexual abuse, family dysfunction, behavior problems, and the paraphilias. In a recent study, childhood sexual abuse was determined to be a specic developmental risk factor for ped- ophilia, whereas emotional abuse and other adverse experiences were found to be general risk factors for the paraphilias (83). Berlin has observed that of the females diagnosed with pedophilia in his clinic over the past 15 years, all reported histories of childhood sexual abuse, leading him to conclude that childhood sexual abuse may play a particularly signicant role in the development of pedophilia in females (F. A recent study of the perceptions of sexual offenders found a signicant positive association between child sex offending and offender self-reports of childhood neglect and abuse, including sexual abuse and early exposure to sexually deviant behavior (94). As in many studies, the sample population was described in nonspecic categorical language such as child molesters, leaving ambiguity regarding how many of the offenders were pedophilic. Nevertheless, the results are consistent with the hypothesis that negative early interpersonal experiences may play a contributing role in the development of problematic adult sexuality, including pedophilia. The investigators hypothesized that choking had become paired with sexual arousal and that the pairing, along with the abusive early experiences, were etiologically relevant to the development of a paraphilia in four of the ve boys (95). Behavioral Models of Etiology Conditioning Theories of Paraphilia Theorists of classical conditioning have proposed that some forms of fetishism can be explained by early learned associations between sexual stimulation and common objects of infancy such as diapers, bottles, and paciers (22). However, etiological explanations based on responses to treatment have limited validity. Clinical work in the Internet era provides observational support for the role of conditioning in the paraphilias. Exposure to Internet-based sexually explicit material and accompanying high levels of sexual arousal appear to, in some indi- viduals, profoundly inuence the development of conditioned sexual fantasy and arousal responses. Therefore, caution must be exercised in drawing conclusions about any direct causative effects of exposureInternet or otherwiseon the development or latensication of psychosexual pathology. Fisher and Barak have presented eloquent reviews on the effects of exposure to pornography, concluding that it is difcult to distinguish between the effects of exposure and the effects of pre-existing underlying personality factors in individuals who seek such exposure (97). In contrast to classic conditioning is the theory of imprinting, which pro- poses that early childhood is a critical period in which animals instinctually grow attached to a primary object. Species such as precocial birds are thought to become imprinted, or physiologically programed to follow whatever crea- ture or object they see shortly after hatching (98). Binet hypothesized pathologi- cal imprinting in humans as a possible explanation for the development of fetishes (41). Owing to events in sensitive developmental periods, an association between arousal and a particular object or experience becomes imprinted. Overall, empirical attempts to validate conditioning theories in the etiology of paraphilias have produced mixed results. Junginger pointed out the possible relevance of the two-process learning theory, which has earned acceptance as an explanation of avoidance behavior in obsessive-compulsive disorder, to the development of fetishism (46).
Aspirin for primary prevention of cardiovascular control and vascular outcomes in patients with type 2 diabetes cheap telmisartan 20 mg without prescription xylazine arrhythmia. N Engl J Med events: Meta-analysis of randomized controlled trials and subgroup analysis by 2008 quality 40mg telmisartan 000 heart attack;358:256072 buy cheap telmisartan 40mg on-line paediatric blood pressure chart uk. A study comparing cardiovascular effects of ticagrelor versus placebo in patients glucose control in type 2 diabetes. The Heart Outcomes Prevention Evaluation Study Investigators, Yusuf S, Sleight 39. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on car- diabetes and the critical care setting. Saxagliptin and cardiovascular on cardiovascular and microvascular outcomes in people with diabetes melli- outcomes in patients with type 2 diabetes mellitus. Lixisenatide in patients with type 2 diabe- in patients at high risk for vascular events. Semaglutide and cardiovascular outcomes diovascular events among patients with stable coronary artery disease: in patients with type 2 diabetes. Should sulfonylureas remain an acceptable rst-line add-on to cation for use of renin angiotensin system blockers: Systematic review and meta- metformin therapy in patients with type 2 diabetes? Primary prevention of cardio- with trial sequential analysis of randomized clinical trials. Ecacy and safety of evolocumab urea and metformin monotherapy on cardiovascular events in type 2 diabetes in reducing lipids and cardiovascular events. Aspirin and clopidogrel: Ecacy and resistance in ing lipids and cardiovascular events. Cardiovascular safety and ecacy of clopidogrel after percutaneous coronary intervention. Lancet Diabetes Endocrinol vention of atherosclerotic events in patients with type 2 diabetes: A random- 2017 (in press). Preferred reporting items for systematic tion of cardiovascular events: A systematic evidence review for the U. Can J Diabetes 42 (2018) S170S177 Contents lists available at ScienceDirect Canadian Journal of Diabetes journal homepage: www. For any degree of perfusion abnormality, people with diabe- and at an earlier age. Hence, tes had a much greater risk of cardiac events and death compared it is desirable to identify people at high risk for cardiovascular events, espe- with people without diabetes (5). Similar ndings have been reported cially people with unknown established severe coronary artery disease. However, so far, there is no head- cal Outcomes Utilizing Revascularization and Aggressive Drug Evalu- to-head study showing which one is most cost-effective. Compared to people without diabetes, people people with diabetes without symptoms. There is evidence that early screening and puted tomography coronary angiography have an excellent prog- intervention in people with diabetes and silent ischemia is ben- nosis, with no cardiac events at 62-month follow up. It randomized 900 par- crepancy between clinical presentation and stress test results. Larger in improved outcomes in people with diabetes has not been dem- and adequately powered studies are necessary to support this onstrated. The strongest and most consistent prognostic marker iden- provocative observation before clinical practice is changed. Although exercise capacity is decreased in one-quarter of the 400 asymptomatic participants with type 2 individuals with diabetes (3234), it is still of prognostic impor- diabetes had silent myocardial ischemia, which was associated tance (13). Silent ischemia is most likely to occur in individuals with with a worse outcome (27). The yield of myocardial perfusion diabetes who are older (mean age 65 years) and have elevated total imaging can be improved by selecting a higher-risk group of cholesterol and proteinuria (23). The examina- diabetes and 11,195 without diabetes) undergoing a combination tion of peripheral pulses also is hampered by the presence of of exercise stress and pharmacologic stress testing (combined pro- medial arterial calcication, which is common in people with dia- tocol received intravenous dipyridamole [0. For the most Other studies reported that the sensitivity and specicity of unde- part, studies report an incidence of around 15% (65,72,73). Stroke is still an important outcome in type 1 diabetes; tality, heart failure and renal events, in people with type 2 diabe- the cumulative incidence of stroke was 3. This data should encourage the examination of peripheral African Americans (66), 5. Also, prevalence of silent limited access to specialized medical centres and technical resources. Late gadolinium hyper-enhancement as the criterion for the presence of peripheral atherosclerotic disease was demonstrated in 4. Of such, these risk increments are comparable to those observed in people with type 2 diabetes (65). In the same way, only 15% of the Oslo Study popu- parable to that of the general population. This publication (97) emphasizes the concept rates from ischemic heart disease were higher in women with type 1 that just because a test is rated appropriate or may be appro- diabetes than in men or women without diabetes. However, men priate, does not mean that it must always be performed, and clini- with type 1 diabetes had higher mortality rates than women with cal judgment of the health-care professional always has its place type 1 diabetes (90). This study found that among those with type 1 cardiac event, screening for silent myocardial ischemia targeted to diabetes, women had a 2.