Insulin Allergy & other side effects

Lipoatrophy(depression at the insulin injection site).

This complication is seen with old types of insulin and disappears when a patient is switched
to purified pork insulin.
Administration of purified insulin must be continued after resolution of the lipoatrophy,
however, because reexposure to the less pure
insulin, even though at a different injection site, can
cause a reappearance of the atrophy that is resistant to
subsequent treatment with the more purified forms.
Local allergy and lipo ( fat) atrophy are seen as a coincidence in some cases suggesting immune component of lipoatrophy.
Reduction of the atrophy is seen with local injection of steroids which suppress immunity.
Insulin hypertrophy (fat hypertrophy at injection
site). This complication may also have an immune
component. It does not always respond to therapy with purified insulins, however, with improvement occurring in only about 50% of the patients.
2 *

Allergic reactions to insulin.

Local allergic responses can occur within 15 minutes to 4 hours after the injection. Common allergies often occur one to four weeks after institution of insulin therapy or within a few days of reinstitution of insulin and are seen as a hard, red induration at the injection site.
The longer acting insulins are more likely to induce allergy. Protamine, is a significant antigen.

Systemic allergic responses

These occur as urticaria or angioedema, or both, which is mediated by IgE antibodies.
In urticaria, one gets rash on body or hives, is an allergic or non-allergic) condition. Chronic urticaria needs treatment - antihistamines, homeopathy and cortisone

Systemic allergic reactions to insulin can be dangerous and life threatening. Discontinue insulin if possible. If continuing insulin is necessary, patient should be desensitized using purified insulins and then maintenance doses of insulin must be administered to maintain the desensitization. These people might be allergic to penicillin.

Diabetologists, Ophthalmologists have to face this challenge of managing patients.

DIABETIC NEUROPATHY

Involvement of nerves caused by diabetes. Patient feels decreased sensations over affected areas. It also affects sex life

Undergoing A Surgery - Relax

Preoperative Instructions For Patients

Everybody likes to be healthy throughout life and nobody likes to visit a doctor. If one has to undergo a surgery that to for the first time in life – This may lead to a lot of stress and anxiety.

Preoperative Instructions For Patients

1. Avoid stress.

The risks involved in surgery have gone down in last few years due to availability of the latest technology in medical field.

2. Make friendship with doctor

If you have any doubts, discuss with the doctor, physician, surgeon, anaesthetist.

3. Surgical videos

Nowadays surgical videos are available. If patient requests, doctor can show him a few surgical videos which will help in relieving anxiety. Diagram and charts showing surgery details are also available.

4. Surgeon's experience

Surgery - Though it may be for the first time in the patient’s life, surgeons are doing it regularly. So for the surgeon, its a regular job. So relax. Everything will be fine.

5. Bad effects of stress

If patient is under stress, this may cause increase in blood pressure which can lead to postponement of surgery or more bleeding during surgery.

Read more at-

Good sleep essential

6.Good diet

Good diet is very essential before and after surgery. Protein and vitamin ( especially vitamin c) rich diet will help in wound healing. Discuss with the dietician. Specific diets are available for patients with kidney, heart, liver problems. Diabetic patients should be very particular about diet as alterations in sugar value can lead to postponement of surgery or can affect wound healing .

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Vitamins

7. Surgical complications

Though complications can occur during surgery, though keep on thinking that it will happen with you. If you think of rare complications, you will be rarely correct. Complications don’t occur during every surgery and even if they occur, most of them are manageable and only a few of them cause a real threat to life.

8. Blood group

Know your blood group. For some major surgeries, your surgeon and anaesthetist will ask you to keep blood ready. In such cases, one should be in touch with blood banks and inform blood banks in advance. Nowadays due to risk of HIV, its always better to accept blood from a close relative or a friend whom you know well. If such person is not available? Don’t worry. All the blood which a blood bank collects, gets screened for HIV, hepatitis B, C viruses by the most correct scientific methods.











Some foods that can cut cancer risk.
1. Grapes
2. Tomatoes contain lycopene which reduces cancer risk.
3. Green leafy vegetables- Spinach, fenugreek, etc.
4. Fruits like mangoes

Visual Hallucinations And Charles Bonnet syndrome

Many patients may present to an Ophthalmologist or physician with visual hallucinations.

What Is Meant By Visual hallucinations?

Visual hallucinations are defined as the perception of an external object when no such object is present.

Classification of Visual hallucinations

Visual hallucinations can be classified as
1. Simple or
2. Complex.

1. Simple visual hallucinations type includes photopsia, lines or patterns which can be seen in ocular diseases like posterior vitreous detachment, optic neuritis, migraine or occipital lobe seizures or tumours.

2. Complex visual hallucinations are usually well formed images and relatively stereotyped and involve humans animals and figures in bright colours. The aetiologies vary and include delirium tremens, dementias, Parkinson’s disease, complex partial seizures, drug abuse etc.

The images may disturb the patient and the patient may lose mental balance.

Charles Bonnet syndrome

Charles Bonnet syndrome is a disorder in which affected individuals present with complex visual hallucinations and visual loss. It was first described by Charles Bonnet, a naturalist and philosopher in 1760.

First Case Of Charles Bonnet syndrome

Charles Bonnet described this condition in his grandfather who was otherwise cognitively unimpaired, had blindness due to cataract and suffered complex visual hallucinations.

In Which other Conditions Charles Bonnet syndrome has been described?

It has been described in several ophthalmic conditions associated with vision loss such as age related macular degeneration, diabetic retinopathy, glaucoma and cataract. The condition is attributed to a cortical release phenomenon due to lack of visual input much like the phantom limb phenomenon.

Prevalence Of Charles Bonnet syndrome

Its prevalence in patients with visual loss varies from 0.4% to 15%. Actual prevalence may be more because certain cases are not detected due to –
1. Some people do not report the symptoms for fear of being labeled as mentally unwell or demented.
2. Doctors are also unfamiliar with the syndrome as a possible diagnosis

Since visual hallucinations are associated with a wide variety of conditions affecting visual pathway as well as other brain structures, systemic diseases, organic brain pathology or psychiatric illnesses must be ruled out before a diagnosis of Charles Bonnet syndrome can be made.

Management Of Charles Bonnet syndrome

Mainstay of treatment of the syndrome involves recognition, reassurance and patient education. Pharmacotherapy has not universally proved to be useful although drugs like carbamazepine, haloperidol and cisapride have been used.

Ophthalmologists and physicians must be aware of this condition as it can occur in many patients with visual impairment. Elderly people with visual impairment should be asked whether they have complex hallucinations. Once other causes of hallucination have been eliminated a diagnosis of Charles Bonnet syndrome can be made. Firm reassurance that the syndrome is not related to mental illness is in itself a major relief to an elderly person.

Why common Man Should Know About Charles Bonnet syndrome?

Every house has old people. Any old person who is visually impaired can develop visual hallucinations. In such case, people may think whether person has developed a psychiatric problem and may neglect or hate him. if one knows that this is a case of Charles Bonnet syndrome, this attitude will change.

Diabetic nephropathy (kidney damage)

Diabetic nephropathy is a serious complication of diabetes. Many diabetics develop this complication after a duration 15-20 years.

How to suspect diabetic nephropathy

1. Appearance of albumin in urine which is detected by " Urine albumin test".

2. Rise in blood urea & serum creatinine levels.

Control of sugar is very important & a Nephrologist ( Kidney specialist) should be consulted. If neglected, it may lead to renal (kidney) failure & may need "dialysis". Dialysis may be needed on multiple occasions. This helps in maintaining electrolyte balance of body. Thus it prevents acidosis.

Diet & Anti-Diabetic Drugs

Diet

1. Diabetic patient should have small frequent meals throughout the day rather than eating more at a time. Always remember - Hypoglycemia is more dangerous than hyperglycemia.

2. Have whole grains and pulses food dishes

3. Avoid refined food items & junk food.

4. Add dietary fibers like fruits, leafy vegetables, millets in your daily diet. can Have a teaspoon of flaxseed powder, fenugreek powder which help in regulating blood sugar. Synchronize your meals with medications, physical activity and insulin dosage.

5. Bananas consist mainly of sugars (glucose, fructose and sucrose). So diabetics should avoid eating bananas in excess.

6. Dairy products – sweets made from milk, butter.

Oral hypoglycemic drugs

1) Sulfonyl urea

2) Biguanides- metformin

Phenformin –not used due to lactic acidosis
Newer drugs like glitazones –rosiglitazone,pioglitazone are used.

Diabetic Foot & Care

Diabetic Foot

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In diabetic patients, wound healing occurs slowly. Tight sugar control, wound dressing is needed. This can lead to infections. If neglected, it may lead to gangrene & amputation ( cutting of the part of foot ) may be required to save the patient from risk of septicemia.
Diabetic patients are advised to use special type of footwears which will not cause any injury to foot

Anti-VEGF Drugs

VEGF

VEGF is ne of the factors responsible for pathogenesis of diabetic retinopathy.

Which Drug Is Most Commonly Used ?.

Bevacizumab - It is available as- trade name " Avastin".

When this drug is given

1. In cases of nonresolving vitreous hemorrhage ( Blood in eye which is not clearing) where laser is not possible

2. Before vitrectomy surgery

Glucometer

All diabetics should have & know how to use a glucometer.Instrument is cheap, not very costly.Its a very simple user friendly instrument which can give your blood sugar levels in a minute. Anybody can use this with a little practice. This can be lifesaving. This is very true during emergencies as hypoglycemia can be fatal.

Monitoring of sugar by diabetics

Glucometer

Uristicks- Strips for monitoring of sugar in urine

This is a simple method which all diabetics can use at home to monitor sugar in urine.
One has to dip these strips in urine & look for color changes & grade it accordingly as 0, 1+, 2+, 3+.

Newer Insulins

Nowadays we see a lot of “ Newer Insulins” in the market. All these have been introduced to make diabetic patients life easier. These injections are user friendly & easy to inject. Dose calculation is also very simple. One has to just adjust the marker line given on the insulin preloaded syringe. The needle is also very small & it reaches subcutaneous space only. It doesn't reach at a deeper level. So patients or relatives can give injection at home. This is very important as wrong dose can lead to –
1. Inadequate sugar control causing high sugars

2. Excess dose leading to hypoglycemia which is very risky for life & may lead to death if not treated immediately.

Certain brand names of “Newer Insulins”
Lilly is a pharma company which is manufacturing a lot of newer insulins. Insulin is available in prefilled syringes.

fundus fluorescein angiography tests & laser Rx

Before PRP in some cases FFA(fundus fluorescein angiography) is done.This is a simple test in which a dye is injected in vein which passes through eye circulation & serial retinal photographs are taken.PRP is done in 2-3 sittings.Its a OPD procedure which is done under topical anaesthesia-anaesthetic eye drops.Its not much painful.Patient can immediately go home & start his routine work.A gap of 5 - 7 days will be there between 2 sittings.Multiple burns stop vessels from growing and leaking. Hundreds of tiny spots of laser are placed in the retina to reduce the risk of vitreous hemorrhage and retinal detachment.During followup we have to look for regression of new vessels.During the subsequent visits, repeat photo-coagulation may be applied to cover up the ara left in earlier sittings.

Presence of Clinically Significant Macular Oedema (CSME) is defined in the ETDRS .This is the most important cause of vision loss.

Diabetics have to control body mass index, systolic and diastolic BP, fasting blood glucose, post-prandial blood glucose, glycated haemoglobin (HbA1c), total cholesterol, serum triglyceride, HDL cholesterol, serum creatinine, microproteinuria and macroproteinuria .Hypertension & nephropathy have been shown as a risk factors in the development & progression of retinopathy

                   Nephropathy has to be controlled after consulting a nephrologist.Control blood urea & serum creatinine.Dialysis may be needed in very severe cases

                     With recent improvements in vitrectomy techniques,surgical prognosis has improved if done at early stage

Management of diabetic eye disease

Once Retina specialist diagnoses PDR , he advises panretinal photocoagulation(PRP).

Recent advances in management consist of use of intravitreal Anti-VEGF agents

Diabetic retinopathy

Diabetic retinopathy has emerged as a major eye health problem.Number of diabetics is increasing day by day.After 5 - 10 years of diabetes almost everybody gets retinopathy in mild,moderate or severe form.Diabetic Retinopathy is a serious eye disorder .It is commonly seen in people who have DM for 5-10 yrs.

Type 2 diabetes mellitus is the most common constituting 90-95% of all diagnosed cases of diabetes. It occurs due to insulin resistance at receptor level.

Type 1 diabetes mellitus is the most prevalent type of diabetes among children and young adults. It occurs due to absence of insulin production or less  insulin production due to pancreatic disease

 Diabetes is a complex disorder that has many possible indicators. These include unexplained weight loss, excessive hunger (polyphagia), thirst (polydipsia), frequent urination (polyuria), dehydration, leg pain when walking (claudication), fatigue, dizziness and itching (pruritus).Awareness of these signs and symptoms can be an alert to potential onset of diabetes 

 Duration of diabetes is the most important factor for the development of Diabetic Retinopathy (DR); 98% of patients with Type 1 diabetes and about 60% of patients with Type 2 diabetes will develop DR after 20 years

 
Recent trends in diagnosis include single-field nonmydriatic digital fundus camera which can be placed in a Physician's/Ophthalmologist's office.The photographs can be used for screening.

Retinal hypoxia plays an important role in pathophysiology of the disease.
In severe cases called as proliferative DR,vitreous hemorrhage occurs.Vitreous hemorrhage may clear spontaneously slowly but sometimes it doesn't clear & one has to consider vitrectomy surgery with endolaser.
You can read more about diabetes , hypertension at
www.indiastudychannel.com/forum/17367-Diabetes-Hypertension-are-silent-Killers.aspx
www.indiastudychannel.com/resources/14574-Prevent-diabetes-problems-Keep-your-eyes-healthy.aspx

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Diabetes