Classification & Screening of Diabetes Mellitus

Diabetes Mellitus

Classification and Screening of Diabetes Mellitus - Classification of Diabetes

Diabetes is a metabolic disorder characterized by resistance to the action of insulin, insufficient insulin secretion, or both. The clinical manifestation of these disorders is hyperglycemia. The vast majority of diabetic patients are classified into one of two broad categories: type 1 diabetes caused by an absolute deficiency of insulin, or type 2 diabetes defined by the presence of insulin resistance with an inadequate compensatory increase in insulin secretion. Women who develop diabetes because of the stress of pregnancy are classified as having gestational diabetes. Finally, uncommon types of diabetes caused by infections, drugs, endocrinopathies, pancreatic destruction, and known genetic defects are classified separately (Table).

Etiologic Classification of Diabetes Mellitus

Type 1 Diabetes

This form of diabetes results from autoimmune destruction of the β cells of the pancreas. Markers of immune destruction of the β cell are present at the time of diagnosis in 90% of individuals and include islet cell antibodies, antibodies to glutamic acid decarboxylase, and antibodies to insulin. Although this form of diabetes usually occurs in children and adolescents, it can occur at any age. Younger individuals typically have a rapid rate of β-cell destruction and present with ketoacidosis, whereas adults often maintain sufficient insulin secretion to prevent ketoacidosis for many years, which is often referred to as LADA.

Type 2 Diabetes

This form of diabetes is characterized by insulin resistance and a relative lack of insulin secretion, with progressively lower insulin secretion over time. Most individuals with type 2 diabetes exhibit abdominal obesity, which itself causes insulin resistance. In addition, hypertension, dyslipidemia (high triglyceride levels and low HDL-cholesterol levels), and elevated plasminogen activator inhibitor type 1 (PAI-1) levels are often present in these individuals. This clustering of abnormalities is referred to as the insulin resistance syndrome or the metabolic syndrome. Because of these abnormalities, patients with type 2 diabetes are at increased risk of developing macrovascular complications. Type 2 diabetes has a strong genetic predisposition and is more common in all ethnic groups other than those of European ancestry. At this point the genetic cause of most cases of type 2 diabetes is not well defined.

Gestational Diabetes Mellitus

GDM is defined as glucose intolerance that is first recognized during pregnancy. Gestational diabetes complicates approximately 7% of all pregnancies. Clinical detection is important, as therapy will reduce perinatal morbidity and mortality. 

Other Specific Types of Diabetes

Genetic Defects MODY is characterized by impaired insulin secretion with minimal or no insulin resistance. Patients typically exhibit mild hyperglycemia at an early age. The disease is inherited in an autosomal dominant pattern with at least six different loci identified to date. Genetic inability to convert proinsulin to insulin results in mild hyperglycemia and is inherited in an autosomal dominant pattern. Similarly, the production of mutant insulin molecules has been identified in a few families and results in mild glucose intolerance.

Several genetic mutations have been described in the insulin receptor and are associated with insulin resistance. Type A insulin resistance refers to the clinical syndrome of acanthosis nigricans, virilization in women, polycystic ovaries, and hyperinsulinemia. In contrast, type B insulin resistance is caused by autoantibodies to the insulin receptor. Leprechaunism is a pediatric syndrome with specific facial features and severe insulin resistance because of a defect in the insulin receptor gene. Lipoatrophic diabetes probably results from postreceptor defects in insulin signaling.

Screening

Type 1 Diabetes Mellitus

There is still a low prevalence of type 1 DM in the general population and because of the acuteness of symptoms, screening for type 1 DM is not recommended.

Type 2 Diabetes Mellitus

Based on expert opinion, and not uniformly accepted by all guidance organizations, the American Diabetes Association (ADA) recommends screening for type 2 DM every 3 years in all adults beginning at age 45 years. Testing should be considered at an earlier age and more frequently in individuals with risk factors. The recommended screening test is the fasting plasma glucose (FPG). An oral glucose tolerance test (OGTT) (more costly, less convenient, less reproducible) can be performed alternatively or in addition to FPG when a high index of suspicion for the disease is present.

Children and Adolescents

Despite a lack of clinical evidence to support widespread testing of children for type 2 DM, it is clear that more children and adolescents are developing type 2 DM. The ADA, by expert opinion, recommends that overweight (defined as BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% of ideal [50th percentile] for height) youths with at least two of the following risk factors: a family history of type 2 diabetes in first- and second-degree relatives; Native Americans, African Americans, Hispanic Americans, and Asians/South Pacific Islanders; and those with signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, or polycystic ovary syndrome) be screened. Testing should be done every 2 years starting at 10 years of age or at the onset of puberty if it occurs at a younger age.

Gestational Diabetes

Risk assessment for GDM should occur at the first prenatal visit. Women at high risk (positive family history, history of GDM, marked obesity, or member of a high-risk ethnic group) should be screened as soon as feasible. If the initial screening is negative, they should undergo retesting at 24 to 28 weeks of gestation, as should all other pregnant women with the possible exception of low-risk primigravidas. Evaluation for GDM can be done in one of two ways. The one-step approach involves a 3-hour, 100 gram-OGTT and can be cost-effective in high-risk patient populations. The two-step approach uses a screening test to measure plasma or serum glucose concentration 1 hour after a 50 gram oral glucose load (glucose challenge test), followed by a diagnostic 3-hour OGTT on the subset of women exceeding a glucose threshold of either ≥140 mg/dL (80% sensitive) or ≥130 mg/dL (90% sensitive). The diagnosis of GDM is based on a 75-gram (not as well validated) or 100-gram OGTT. Criteria for diagnosis of GDM based on the OGTT are summarized in Table bellow

Diagnosis of Gestational Diabetes Mellitus with a
100-g or 75-g Glucose Load

Salam

by Umaee

Classification and Screening of Diabetes Mellitus

Source: Pharmacotherapy 7th

New Role For Public Health

New Role For Public Health - With the spiraling costs of medical care and the corresponding interest in cost containment and accountability, it is reasonable to avoid duplications. We need a closer link of clinical and public health disciplines and activities.

A recent example of the control of a new epidemic by the collaborative efforts of the World Health Organization (WHO), basic scientists and clinicians followed the outbreak of SARS—Severe Acute Respiratory Syndrome. WHO forcefully assumed international leadership, coordinated scientific investigations, and quickly reported all new advances from the laboratory and field epidemiological studies to clinicians. In medical schools it is propitious for these disciplines jointly to develop curricula and research projects.

In the health service arena, closer ties between clinicians and public health officials will be efficient and effective for the good of the population. A special role for public health officials could be to “translate” important epidemiological data for clinicians giving primary care. This could be particularly important and useful in enhancing prevention. Examples of useful data would be the risk ratios for becoming an alcohol abuser for persons with and without a family history of abuse; cigarette smoking for the smoker, those nearby, and the unborn fetus; and for fatal versus nonfatal injury in persons driving with and without a seat belt.

In the field of communicable diseases it is useful to know the risk of AIDS in those practicing intravenous drug abuse or unprotected sexual activities, the relative risk of Lyme disease in those using effective insect repellents versus those not using such agents, and the relative risk of hepatitis B in healthcare workers who have received the vaccine and those who have not. In 2006, a key role for a public health-clinicians partnership is the continual education of the public about the real risks of avian (H5N1) influenza and the progress toward its prevention and control.

An epidemiological approach to community-wide education about local health risks, perhaps with a well-designed periodical, would further link the clinician and public health official. The Centers for Disease Control and Prevention (CDC) has done this successfully with Morbidity and Mortality Weekly Report. A community-wide modification for consumption by local practitioners would be helpful. Such networking is feasible and desirable.

Networking with schools, businesses, health clubs, and senior citizen groups might increase compliance with behavior designed to enhance resistance to environmental hazards. Fundamentals of general and dental hygiene, nutrition, exercise, and stress control would be essential components. It would be reasonable to reinforce such basic principles as maintaining immunizations and proper use of antibiotics. In summary, we need a proactive and integrative role in education, one that involves networking with clinicians and the public directly. Improving environmental safety has been the focus and strength of public health. Essentially, the goal has been to reduce the microbial hazards to humans. For the most part, this is carried out by systematic measurement or a series of inspections of the environment. 

Good general sanitation and safe air, water, and food are hallmarks of public health. Environmental activist groups have heightened interest in environmental safety. This is an opportune time to build a coalition between informed public health officials and interested and energetic activists genuinely concerned with improving the environment. From infectious diseases point of view, an important goal would be to reduce the degree of exposure while preserving the vitality of the ecosystem. The government of Brazil was reported to have instituted a $200 million program to control malaria in the Amazon region by spraying dichlorodiphenyltrichloroethane (DDT) in thousands of rain forest huts. As McCoy pointed out, however, the chemical has been banned in over 40 countries because of its lethal effect on birds and fish.

Moreover, in India, although it had a remarkable short-term effect initially (75 million annual cases of malaria reduced in the 1950s to 50,000), the number of cases rose to 65 million by 1976, the result of resistance in mosquito vectors. Moreover, bottled milk sampled in India in April 1990 had 10 times the permissible limit of DDT. DDT is fat soluble and has been carried in food chains to countries all over the world. The lesson we have learned from the Russian nuclear accident at Chernobyl, the AIDS epidemic, and the DDT experience and the SARS epidemic is that radiation, viruses, and pollutants respect no national borders.

The response to such lessons needs to be an enhanced commitment by individuals, communities, and nations to solve the problems of others and to view the world as a global village. Limiting the survival of important infection agents, their animal reservoirs, or hosts requires careful examination of the implications of such approaches in collaboration with veterinarians, entomologists, and toxicologists.

Salam

by Umaee

New Role For Public Health

Source: public health & preventive medicine

Role in Management of Hyperlipidemia

Role in Management of Hyperlipidemia. Some forms of dietary fiber lower blood lipids, notably total cholesterol and low-density lipoprotein (LDL) cholesterol. The earliest observations on fiber preparations and blood lipids date from the mid 1930s when there was a fairly extensive investigation of the effects of pectin (polygalacturonic acid). The next period of investigation dates from 1974 when extracted and purified dietary fiber preparations such as guar gum – a glucomannan – were tested in normal subjects, diabetics, and hyperlipidemic subjects and were found to lower blood cholesterol when given in sufficient quantities. 

In very large doses these materials increase fecal excretion of fat and sterol compounds and would be expected to reduce the body bile salt pool. Subsequent work has shown that at lower doses preparations of soluble dietary fiber have a mild cholestyramine-like effect: they bind bile salts rendering them unavailable for reabsorption in the terminal ileum, thus interfering with the normal entero-hepatic cycle of bile salts and depleting the bile salt pool. Total and LDL cholesterol fall as cholesterol is diverted for the resynthesis of lost bile salts. There have been few direct clinical applications of the early experimental work on pectin and guar gum. No pectin compounds have been developed commercially, but there are a few pharmaceutical preparations of guar gum presented primarily as adjuncts to dietary therapy in diabetes rather than for lipid lowering. Dietetic food products containing guar gum have been developed, again for use in controlling diabetes.

Preparations of soluble dietary fiber have been shown to lower blood cholesterol whereas most preparations of predominantly insoluble fiber, such as wheat bran, have little or no effect. The major food sources of soluble fiber are oats, beans, lentils, rye, and barley, and these foods have naturally become the subject of investigations. The addition of oats to the diet in normolipidemic and hyperlipidemic subjects following either their normal diets or where pretreated with low-fat diets has been the subject of extensive research. In sufficient quantity oats, oat products, and oat Beta-glucan (providing at least 3 g oat beta glucan per day) lower blood total cholesterol and LDL cholesterol (usually by 5–10%) while leaving triglycerides and HDL cholesterol largely unchanged. 

A sufficiently large number of good-quality studies have now been done on oats that the Food and Drug Administration (FDA) has allowed the first ever food-specific health claim: ‘‘Soluble fiber from oatmeal, as part of a low saturated fat, low cholesterol diet, may reduce the risk of heart disease.’’ Products that are labeled with this claim must provide at least 0.75 g of soluble fiber (as Beta-glucan) per serving. When considering the above claim the FDA reviewed 37 studies and found that a sufficient number provided convincing evidence of efficacy. An earlier metaanalysis of some of those trials had shown that the efficacy of oats and oat products was influenced by the initial values of blood cholesterol in the subjects: patients with high starting values (over 6.7 mmol per liter total cholesterol) showed the greatest reductions when treated with oats, while healthy young subjects with low–normal starting values showed little response. There was a dose effect: food products providing more than 3 g soluble fiber per day had a greater blood cholesterol lowering effect than diets that provided less than 3 g per day.

Other soluble fiber-containing products have been shown to lower blood cholesterol. Recent extensive studies on psyllium (Plantago ovata) presented both as a pharmaceutical preparation and as a food product (a ready to eat breakfast cereal) have shown blood cholesterol-lowering properties where the dose–effect relationship is such that a useful additional therapeutically meaningful lipid-lowering effect can be achieved by prescribing a daily portion of psyllium-fortified breakfast cereal. Products of this type are now marketed in the US and Australia, and the US FDA has now allowed a food specific health claim for psyllium.

There is also a small literature on the effects of beans on blood lipids and the findings of a blood cholesterol-lowering effect are as expected. Virtually all of the reports of the effects of soluble fiber products on blood lipids report lowering effects on total cholesterol and LDL cholesterol without any effect on HDL cholesterol or triglycerides – this contrasts with the effects of some drugs that may cause slight rises of triglycerides and falls of HDL cholesterol. The relationship between lowering of blood cholesterol and lowering of risk of heart disease is now generally accepted and a proven lipid-lowering effect is taken to mean a beneficial effect on risk of coronary heart disease. This means that in clinical practice it is perfectly reasonable to include advice on use of foods high in soluble dietary fiber in a lipid-lowering diet, and perfectly proper to emphasize the benefits of oats and oat products. 

Generally, a high-soluble-fiber diet is more acceptable when the soluble fiber is drawn from smaller quantities of a larger range of foods; thus the diet includes beans, lentils, rye breads, and barley as well as generous use of oats. A range of foods containing mycoprotein and fungal mycelial cell walls (chitin) may also help to lower blood cholesterol.

Salam

by Umaee

Role in Management of Hiperlipidemia

Source: Nutritional Supplements

Image: Shannonassosiate.com

Role in Nutritional Management of Diabetes

Diabetes mellitus is characterized by either an absolute or relative lack of insulin, which has short-term and long-term consequences. Diabetic people may develop both microvascular complications (mainly affecting the eyes, kidneys, and nerves) and macrovascular complications (essentially accelerated development of atherosclerosis presenting mainly as heart attack and peripheral vascular disease). Medical management aims to replace the insulin, or modulate its production or efficacy using oral (hypoglycemic) drugs, in a metabolic environment enhanced by good control of diet and body composition. Medical management also aims to achieve early detection of complications and other risk factors for cardiovascular disease by regular testing of blood and urine biochemical variables and blood pressure and by regular physical examination of the eyes, neurological, and cardiovascular systems.

Control of dietary energy intake (in relation to the varying demands for growth, maintenance, physical activity, etc.) remains the key feature of dietary control affecting metabolic fluxes, blood glucose levels, and body weight. Views on the appropriate proportional sources of energy from fat, carbohydrate, and protein have changed enormously over the last century from seriously energy-restricted high-fat diets (with percentage energy from fat as high as 70% raising some doubts about the level of compliance) through to very high-carbohydrate diets (sometimes 60–65% energy from carbohydrate) used in specialist centers in the US. Today, for most diabetic patients in most countries the target is to achieve 50–55% energy from carbohydrate sources. 

Prior to the 1970s, when the move towards high-carbohydrate diets began, the high fat content of the diet along with less tight blood glucose (and urine glucose) control than is customary today was partly responsible for the high relative mortality from cardiovascular disease seen among diabetic patients. At that time young male diabetics were up to nine times more likely to die from heart attack than matched nondiabetic individuals. Reduction of fat in the diet and achievement of an optimal distribution from saturated, monounsaturated, and polyunsaturated sources (<10%, 10–20%, and no more than 10%, respectively, for patients with diabetes in the UK) remain a major aspect of dietary management of diabetic people in order to reduce the risk of developing coronary heart disease.

Control of blood glucose is critical in order to achieve avoidance of prolonged periods of hyperglycemia, which is associated with glycation of proteins and the risk of development of microvascular complications, and avoidance of hypoglycemia with its attendant risks of coma. In day-to-day practice, the avoidance of hypoglycemia is very important to patients and any new method of achieving normalization of blood glucose profiles is an advance. Dietary fiber offered such an advance from the mid 1970s when some forms (notably isolated polysaccharides such as guar gum, a glucomannan, and pectin, polygalacturonic acid) were shown to reduce the area under the blood glucose and insulin curves after acute test meals. Subsequent long-term
(6-week) clinical trials showed that diets high in foods containing soluble dietary fiber, such as beans, oats, and barley, were more effective in reducing the area under the 24-h blood glucose profiles than diets containing more high-fiber foods based on wheat products.

Research in this area led David Jenkins to describe (in 1981) the concept of the ‘glycemic index’ (GI) which is a numerical expression of the ability of a food to raise blood glucose levels. In practice it is measured by comparing the blood glucose response to a 50-g carbohydrate portion of food with the response to 50 g glucose (in some papers the comparison is with a 50-g carbohydrate portion of bread). The dietary fiber (especially soluble fiber) content of a food slows down the rate of digestion and absorption of starch in foods giving flatter blood glucose responses and a lower GI; however, the structure of the starch (whether amylose or amylopectin) influences its rate of degradation and the extent to which the starch granules are hydrated by processing (including cooking) is also important.

The physical structure of the food (particularly the extent to which plant cells are intact), the presence of fat, which may slow gastric emptying, and the presence of some ‘antinutrient’ substances may all influence the GI. Low-GI diets have been shown in many clinical trials to improve important variables that are secondary indicators of blood glucose control, and to reduce blood lipids. Low-GI diets may be particularly helpful to patients who are frequently troubled by episodes of hypoglycemia though adequate proof of this is still awaited. 

Low-GI diets are not just relevant to treatment of diabetes but have been shown in two large-scale epidemiological surveys published in 1997 to result in a significant reduction in the risk of development of maturity onset (type 2) diabetes in middle-aged American men and women. Thus, there is good reason to believe that there should be greater emphasis on the GI of diabetic diets and the fiber content, as well as emphasis on GI for those at risk of developing diabetes, especially the older obese person. Expert committees in many developed countries of the world have set target values for dietary fiber intake for diabetic patients (e.., the American Diabetes Association (ADA) recommends 20–35 g day-1 total dietary fiber by the AOAC method) and many, especially the Australian Diabetes Association and with the notable exception of the ADA, have recommended an increase in low-GI foods.

In 2003 even Diabetes UK (the UK Diabetes Association) noted that there might be merit in taking account of GI in dietary management for those with diabetes. Some physicians believe that the GI of foods is too complex an issue for patients to grasp, but in essence simply requires a partial substitution of bread and potatoes with pasta products, an increased use of high-fiber breakfast cereals including oats, increased use of beans and lentils, and emphasis on the use of temperate fruits (e.g., apples and pears).

Obesity (body mass index (weight in kilograms divided by height in meters squared) in excess of 30 kgm-2) is becoming more prevalent in developing countries and attracts an increased risk of the development of diabetes mellitus; a high proportion of established type 2 diabetics are obese and overweight. In the popular diet book ‘The F-Plan Diet,’ published in 1982, Audrey Eyton claimed that dietary fiber would help people lose weight by a number of mechanisms including reducing the efficiency of dietary energy absorption and by making people feel full for longer after meals thus having an overall effect on reducing food intake. At the time of publication these ideas were hypothetical - subsequent investigation has shown that increasing fiber intake two- or threefold by a variety of dietary changes can increase fecal energy losses by 75–100 kcal day-1. 

Studies on the effects of dietary fiber on postprandial satiety where experimental meals are carefully designed to differ little except for fiber content have given variable results. However, there is a clear effect of fiber on chewing (the number of chews necessary to eat the same energy equivalent of food) where high- and low-fiber types of commonly consumed foods are eaten and this may have an important satiating effect. Clinical trials of highfiber weight loss regimens have given variable results. Double-blind placebo-controlled trials using pressed barley fiber and pectin tablets compared to a starch control have been undertaken in Scandinavia and have demonstrated statistically significantly greater weight losses in the fiber-treated groups up to 26 weeks of treatment. It seems reasonable to conclude that under some conditions the right kind of high-fiber diet can facilitate weight loss, but may not always do so.

Diabetic people are more likely to have dyslipidemia than nondiabetic people. When control of diabetes is lost, patients may demonstrate gross hypertriglyceridemia due to increased production of very-low-density lipoprotein (VLDL) particles in the liver as a consequence of the increased flux of free fatty acids from the peripheral tissues. At the same time total and LDL cholesterol may be raised. Improvement in diabetic control often achieves normalization of blood lipids, but where hyperlipidemia persists there may be a place for use of dietary fiber, especially soluble fiber, and especially oat Beta-glucan-containing foods as an adjunct to dietary and pharmacological therapy (see above).

Salam

by Umaee

Role in Nutritional Management of Diabetes

Source: Nutritional Supplement

Image: diabetes-ok.com

Clinical Problems of Headache

Assessment of the Patient with Headache

The interview and history are by far the most important parts of the assessment. It is very important to allow the patient to express feelings and fears and to ascertain his or her expectations of treatment and perception of the cause of the headache. The important data to be obtained from the history are length of headache  history, frequency of headaches, mode of onset, duration, site of headache, severity, description of pain, precipitating factors, warning symptoms, accompanying symptoms, relieving factors and coping strategies, history of trauma, current medications, and family history of headaches. If time is limited, anxiety to obtain all the data should not be allowed to reduce the opportunity for the patient to express himself or herself. If necessary, the full picture can be obtained over two or more visits.

Grouping a number of headache patients together in one category is an abstraction from a much larger picture. In each patient, the symptom of headache has to be considered in the larger context of the whole person. The family physician’s knowledge of the context may come from a number of sources but most probably from previous knowledge of the patient and the family and from the patient’s records. Any defi ciencies in this knowledge will need to be made up for during the initial visits. It is important to know about current problems in the patient’s life, previous illness patterns, and self-medication. A history of pain syndromes or a tendency to symptom formation is particularly important.

At the completion of the interview and history, the physician should already have ascertained, with a high probability of being correct, whether the headaches are primary or secondary and, if primary, whether they fall into the categories of migraine with aura or cluster headache. Texts on headache sometimes say that a full neurological examination should be done on every patient. For the primary physician this is poor advice. In most patients, a full neurological examination would be redundant and would only reduce the time available for listening to the patient. Apart from certain routines, the physical examination—its kind and extent—will be determined by the physician’s hypothesis after completing the interview and history. 

A hypothesis of sinusitis will direct the physician’s attention to the nose and sinuses; a headache of recent and sudden onset to the body temperature and a test for neck rigidity; a history of neurological symptoms to the appropriate neurological examination; and malaise accompanying the headaches to a search for infection. On the other hand, a patient with tight-band headache who breaks down and cries may have little or no physical examination at all. Besides a directed search, the physician should also have certain routines that are done for all patients or all patients in certain categories. 

These are not necessarily done on all patients; one or all may be omitted. The important thing is that the physician has to justify their omission to himself or herself. The routines headache patients may include pulse, blood pressure, fundi, selected cranial nerves, neck movements, palpation of neck and scalp, and, in patients over50 years, sedimentation rate. Hypertension seldom presents with headache; many patients, however, expect to have their blood pressure taken, and their visit provides an opportunity to detect hypertension unrelated to the headaches.

The Diagnosis of Headache

The family physician’s main tasks are to distinguish primary from secondary headache and, within these categories, to identify certain disorders with a specifi c etiology, specifi c therapy, or a threat to life.

Migraine with Aura

The distinguishing features of migraine with aura are recurrent headaches preceded or accompanied by focal neurological disturbances and also accompanied by nausea and/or vomiting. The headache is usually described as throbbing and severe and may be unilateral or bilateral. The frequency of the headaches varies greatly from one patient to another and in the same patient at different times. The most common neurological disturbances are visual. Typically, the patient fi rst notices a small area of scintillation and blurring in the fi eld of vision. This gradually enlarges into a ring of zig-zag lines, shaped like the fortifi cations of an ancient castle. Hence the term fortifi cation spectrum. 

The enlarging ring is followed by a crescent of blindness—the scotoma—which is followed in turn by restoration of vision. The whole sequence takes 15 to 20 minutes to pass over the visual fi eld. Typically, the headache begins as the aura wanes. Some patients may experience fl ashing lights, scotomata, or hemianopia. Others may have transient neurological disturbances of other kinds—paresthesia, vertigo, or aphasia, for example. The tongue, hands, and feet are areas of predilection for paresthesia.

These begin peripherally and spread centripetally. The rate of spread is very much slower than in the aura of epilepsy—an important distinguishing feature. In contrast to the crescendo of migraine—transient ischemic attacks (TIAs) are maximal at onset, after which they recede. The anatomical distribution of a TIA corresponds to the distribution of the artery involved. Attacks of migraine—with or without aura—may be preceded by premonitory or prodromal symptoms such as restlessness, insomnia, emotional arousal, mood changes, thirst, water retention, and gastrointestinal disturbances. After the attack, there may be a period of cognitive disturbance during which it is unwise for the patient to be doing work that involves judgment and decision making. 

The prodromal symptoms can warn the patient to prepare for an attack. On the other hand, they may have a disturbing effect on the family. Migraine with aura usually begins in childhood or early adult life. Onset after the age of 50 is rare. The pattern of attacks varies greatly between patients and in the same patient at different periods of life. Some patients may have only occasional attacks throughout life. Some may have occasional attacks at one time of life, frequent attacks at another. Others may have the full syndrome at one
time of life and transient neurological symptoms without headaches at another. In childhood, the manifestation of migraine may be recurrent vomiting attacks (the periodic syndrome). In some patients, the pain may be felt in one side of the face—the so-called facial migraine. In certain rare variants of the migraine syndrome, the headaches are accompanied and followed by motor neurological defi cits such as hemiplegia or ophthalmoplegia. These motor phenomena require further pursuit.

Migraine without Aura

The attacks are distinguished from migraine with aura chiefl y by the absence of preceding neurological symptoms. The most common symptoms accompanying the headache are nausea, vomiting, photophobia, phonophobia, and general sensory excitability. Other symptoms include dizziness, drowsiness, abdominal pain, diarrhea, and nasal stuffi ness. If nausea is the only symptom accompanying the headache, differentiation from TTH may be diffi cult, especially if the headache is not typical of migraine. The
Headache Study Group found that only six patients out of 65 classifi ed as having common migraine were considered “defi nite” after 1 year of follow-up. Very frequent migraine (>15 days per month for at least 3 months) is called chronic migraine provided there is no medication overuse. Typically, chronic migraine evolves from migraine without aura.

Cluster Headache (Migrainous Neuralgia)

The salient features of cluster headache are its periodicity, its great severity, and its preponderance in males. The syndrome is periodic in two senses. Bouts of headaches, lasting from 2 to 12 weeks, alternate with pain-free intervals of several months to several years. Within each bout, headaches occur one or more times a day, often with great regularity. The headache is almost always unilateral and centered around the eye and is so severe that the sufferer cannot keep still. It is usually accompanied by lacrimation from the eye on the affected side. The conjunctiva is often injected in this eye, and there may be some drooping of the upper eyelid and miosis. If the patient is seen between headaches, these signs are of course absent. The male-to-female ratio in cluster headache is about 6 to 1. Most patients are between the ages of 20 and 40. 

Tension-type Headache and Recurrent Nonspecifi c Headache

The IHS (ICHD II) continues to include TTH, episodic and chronic, in its classifi cation system. The headache is defi ned by the features that distinguish it from migraine: moderate severity, bilateral distribution, longer duration, and absence of nausea and photophobia. The chronic form is distinguished from the episodic by the persistence of headaches for longer than 6 months. In addition, both episodic and chronic TTH are subdivided into those with and without pericranial tenderness elicited by manual palpation.
This classifi cation and nomenclature remains controversial. The physiological basis for these headaches has not been established, and in practice it is often diffi cult to make a clear distinction between common migraine and “tension-type” headaches. This diffi culty is refl ected in the discussions within the classifi cation
subcommittee of the International Headache Society( ICHD II, 2004, p. 32). The issue can be further complicated as TTH can occur in migraineurs making treatment decisions even more diffi cult.

After reviewing all the available clinical data in 265 new patients with headache, using the 1962 classifi cation, the Headache Study Group (1986) was unable to classify 50% of the patients with any degree of certainty. Thirty percent were classifi ed as having “possible muscle contraction headache” and 22% as “possible common migraine.” For these reasons, such patients were described in the fi rst edition of this book as having recurrent nonspecifi c headache (RNSH). Anxiety was associated with the headaches in about 60% of these patients and depression in about 25%. In many patients with RNSH, the headaches are related to transient situational anxiety and reactive depression. In some, the anxiety is focused on the cause of the headache. Of 1,331 patients attending primary care physicians with new headache, 1,131 (85%) did not return for a second visit within the 14-month study period (Becker et al., 1988). This suggests that in the great majority of patients with headache seen by family physicians, the condition is self-limiting or responds to measures such as reassurance and counseling. The following consultation is a good example of this type of headache.

Salam

by Umaee

Clinical Problems of Headache
Source: Familu Medicine

Image : nikadon.com

Food and Drug Administration Pregnancy Categories

Food and Drug Administration Pregnancy Categories

A. Controlled studies performed in pregnant women do not demonstrate a risk to the fetus during the first trimester of pregnancy with no evidence of risk in the second or third trimesters. The possibility of fetal harm appears highly unlikely.

B. Either studies in reproducing animals do not demonstrate a fetal risk but there are no controlled studies in pregnant women, or animal reproduction studies have shown adverse effects (other than a decrease in fertility) that were not confirmed in controlled studies in pregnant women in the first trimester and there is no evidence of a risk in later trimesters.

C. Either study in animals has demonstrated adverse effects on the fetus (teratogenic, embryocidal, or other effects) and there are no controlled studies in women, or studies in women and animals are not available. These drugs should be given only if the potential benefits of the drug justify the potential or unknown risk to the fetus.

D. There is positive evidence of human fetal risk, but the benefits from administration in pregnant women may be acceptable despite the risk. For example, if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective, administration may be indicated.

X. Animals or human studies have demonstrated fetal abnormalities or there is evidence of risk to the fetus based on human experience, or both. The risk of the use of the drug in pregnant women clearly outweighs any possible benefit. The drug is therefore contraindicated in women who are or may become pregnant.

Salam

by Umaee

source: clinical handbook's of prescriotion drugs (WZFWS95V82ZM)

image: pregnancyandbaby.com

Maternal and Child Health

 Health Indicatiors

The development and continuous monitoring of health status indicators reflects one of the key infrastructure services at the core of maternal and child health. Many indicators are now routinely collected by a variety of health, economic, and social services agencies, but are routinely made available by the Maternal and Child Health Bureau, through the Title V Information System (https://perfdata.hrsa.gov/mchb/mchreports/Search/search.asp).

Although maternal mortality rates have reached a very low level (recently, about 11.8 deaths per 100,000 live births), this indicator can still serve as an important sentinel of failures in the health system. More generally, maternal health is better reflected in the population rates for a range of reproductive health outcomes: fertility (intended and otherwise), therapeutic abortion, birth, miscarriage, stillbirth, and especially low birth weight. Similarly, many process measures reflect the quality of maternity care: timing and quantity of prenatal care, place of delivery, attendant at delivery, vaginal or caesarian delivery, and complications (including those from nontherapeutic abortions).

The infant mortality rate remains an important outcome measure for MCH. Linking infant birth and death records has added to the ability to assess factors associated with pregnancy outcome.4 The birth certificate form that was adopted in 1989 includes a wider array of information on both the mother and the child, offering opportunities for exploration of the relationships between sociodemographic factors, health and social services factors, and various pregnancy outcomes.

Childhood morbidity is less routinely measured. Birth defect registries, neonatal intensive care use, discharge diagnoses, and national health surveys provide some estimates of morbidity. Immunization rates, school-based health data, and the data from such programs as EPSDT and Children With Special Health Care Needs (prior to the mid-1980s referred to as Crippled Children’s Programs) are also helpful indicators of child health, although they are not collected at either the state or national level as systematically as are infant birth data.

Larger social and demographic changes are also important indicators of the status of mothers and children. Over the last 20 years there has been a dramatic increase in the percentage of mothers in the work force, creating challenges for families and service providers as the interests of mothers working outside the home have gained more prominence. The number of children in single parent families, either through divorce or the absence of marriage to begin with, continues to rise as do the numbers of homeless mothers and children. These social problems contribute directly or indirectly to most of the health problems of women and children 

Principles of Services Delivery

Several principles of service delivery stem from the unique focus of MCH on children and their families. Family-Centered Care. In a recently issued statement by the Maternal and Child Health Bureau, “Family-Centered Care assures the health and well-being of children and their families through a respectful family-professional partnership. It honors the strengths, cultures, traditions and expertise that everyone brings to this relationship.

Family-Centered Care is the standard of practice which results in high quality services.”5 The child is not merely the passive recipient of the influences of the family, but, rather, plays an increasingly interactive role in the family, shaping in part the environment in which he or she lives. Similarly, the family works in partnership with the professionals providing services to children, especially where chronic diseases or disabling conditions are present.

Developmental Perspective. The fetus and child are being continuously shaped by the normal developmental processes that result in a reasonably predictable series of changes from conception through adolescence. Progress over this course is a sensitive measure both of health and disease. Singular events or continuous disruption of normal development can have progressively magnifying adverse effects on the fetus or child. Because of the importance of development, prompt identification of problems and early and continuous intervention hold the greatest promise for achieving the best outcome.

Health Promotion and Disease Prevention. Childhood is both a means to adulthood and an end in itself. There is great potential, therefore, for health promotion and disease prevention to benefit both the current child and the future adult. However, careful attention must be paid to the immediate implications of  interventions that are aimed at preventing problems in the distant future, making sure that the desired long-term benefits are not counterbalanced by short-term hazards.

Salam

by Umaee

source: public health and preventive medicine

image:workingnurse.com