4/21/2014

New Diabetes Patients and Blood Pressure


Newly diagnosed diabetes and hypertension patients may have more time to learn how to control their high blood pressure without medications.
The consequences of delaying effective hypertension treatment for up to a year were small—only a two day reduction in quality-adjusted life expectancy—according to a study by University of Chicago researchers.
"Most patients would prefer to control their blood pressure through diet and exercise rather than with medications, and it can take months to learn how to change old habits and master new skills. Our results indicate that it's OK to spend from six months to a year, perhaps even longer, to make the difficult lifestyle changes that are necessary and will pay off in the long run." For newly diagnosed patients, this means we have time," study author Neda Laiteerapong, MD, instructor of medicine at the University of Chicago, was quoted as saying.
High blood pressure is particularly damaging for people with diabetes, increasing their risk of kidney failure, stroke, vision loss and amputations. The American Diabetes Association and the National Institute of Health both recommend a lower blood pressure goal for patients with diabetes then for the general public. They urge them to keep their blood pressures below 130/80 mmHg.

Unfortunately, two out of three adults with diabetes never accomplish that goal. Many patients are hindered by limited health care. While others are delayed by the hesitance of patients to implement lifestyle changes or reluctance by their doctors to push additional medications.
Until recently, the implications of these delays on patients' health had not been determined. Laiteerapong and colleagues determined the magnitude of harm caused by different delays in controlling blood pressure in patients from 50-59 years of age with newly diagnosed type 2 diabetes. With the use of computer models and published data, they found the damage caused by a one-year delay may be small but delays of ten years or more were comparable to smoking in patients with cardiovascular disease.
Many patients would prefer to control blood pressure through diet and exercise rather than with antihypertensive medications if given time to learn how to do so. Most guidelines, however, recommend at most a three-month trial of medication-free lifestyle therapy for patients with moderately elevated blood pressure.

Unfortunately that is often not enough time for patients to learn the methods, develop good habits, and demonstrate improvements.
"We ask patients with diabetes to do a billion things," Laiteerapong was quoted as saying, "to test their blood sugars, to count carbohydrates, to spend 30 minutes a day doing exercise. Most, if not all, of this is new to them. They need time to adapt. It's important to do this right, but our results say it's not that important to do it so fast."
This study argues that caregivers assist patients to help them develop the necessary skills gradually as opposed to rushing to medications, especially if their blood pressure is only mildly elevated. The authors suggest that patients and providers "have more time, at least up to one year, to focus on diabetes self-management and lifestyle modification."
Authors were quoted as saying "Health care providers may wish to focus on diabetes management alone in the first year after diagnosis, to help patients establish effective self-management and lifestyle modification. However, after the first year, it is clear that achieving and maintaining tight blood pressure control among US middle-aged adults with diabetes has the potential to generate substantial population-level health benefits."
SOURCE: Journal of General Internal Medicine, January 9, 2012
México a la vanguardia en el Síndrome de Post Polio

The Polio Crusade

THE POLIO CRUSADE IN AMERICAN EXPERIENCE A GOOD VIDEO THE STORY OF THE POLIO CRUSADE pays tribute to a time when Americans banded together to conquer a terrible disease. The medical breakthrough saved countless lives and had a pervasive impact on American philanthropy that ... Continue reading..http://www.pbs.org/wgbh/americanexperience/polio/

Erradicación de La poliomielitis

Polio Tricisilla Adaptada

March Of Dimes Polio History

Dr. Bruno

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A 41-year-old man developed an acute illness at the age of 9 months during which, following a viral illness with headache, he developed severe weakness and wasting of the limbs of the left side. After several months he began to recover, such that he was able to walk at the age of 2 years and later was able to run, although he was never very good at sports. He had stable function until the age of 18 when he began to notice greater than usual difficulty lifting heavy objects. By the age of 25 he was noticing progressive difficulty walking due to weakness of both legs, and he noticed that the right calf had become larger. The symptoms became more noticeable over the course of the next 10 years and ultimately both upper as well as both lower limbs had become noticeably weaker.

On examination there was wasting of the muscles of upper and lower limbs on the left, and massively hypertrophied gastrocnemius, soleus and tensor fascia late on the right. The calf circumference on the right exceeded that on the left by 10 cm (figure1). The right shoulder girdle, triceps, thenar eminence and small muscles of the hand were wasted and there was winging of both scapulae. The right quadriceps was also wasted. The wasted muscles were also weak but the hypertrophied right ankle plantar flexors had normal power. The tendon reflexes were absent in the lower limbs and present in the upper limbs, although the right triceps was reduced. The remainder of the examination was normal.

Figure 1

The patient's legs, showing massive enlargement of the right calf and wasting on the left

Questions

1
What is that nature of the acute illness in infancy?
2
What is the nature of the subsequent deterioration?
3
What investigations should be performed?
4
What is the differential diagnosis of the cause of the progressive calf hypertrophy?

Answers

QUESTION 1

An acute paralytic illness which follows symptoms of a viral infection with or without signs of meningitis is typical of poliomyelitis. Usually caused by one of the three polio viruses, it may also occur following vaccination and following infections with other enteroviruses.1 Other disorders which would cause a similar syndrome but with upper motor neurone signs would include acute vascular lesions, meningoencephalitis and acute disseminated encephalomyelitis.

QUESTION 2

A progressive functional deterioration many years after paralytic poliomyelitis is well known, although its pathogenesis is not fully understood.2 It is a diagnosis of exclusion; a careful search for alternative causes, for example, orthopaedic deformities such as osteoarthritis or worsening scoliosis, superimposed neurological disorders such as entrapment neuropathies or coincidental muscle disease or neuropathy, and general medical causes such as respiratory complications and endocrinopathies.3

QUESTION 3

Investigations revealed normal blood count and erythrocyte sedimentation rate and normal biochemistry apart from a raised creatine kinase at 330 IU/l (normal range 60–120 IU/l), which is commonly seen in cases of ongoing denervation. Electromyography showed evidence of denervation in the right APB and FDI with polyphasic motor units and complex repetitive discharges, no spontaneous activity in the left calf and large polyphasic units in the right calf consistent with chronic partial denervation. Motor and sensory conduction velocities were normal. A lumbar myelogram was normal. Magnetic resonance imaging (MRI) scan of the calves is shown in figure2.

Figure 2

Axial T1 weighted MRI scan (TR 588 ms, TE 15 ms) of the calves, showing gross muscle atrophy and replacement by adipose tissue on the left, and hypertrophy of the muscles on the right, with only minor adipose tissue deposition

QUESTION 4

The differential diagnosis of the progressive calf hypertrophy is given in the box.

Causes of calf muscle hypertrophy

Chronic partial denervation

  • radiculopathy

  • peripheral neuropathy

  • hereditary motor and sensory neuropathy

  • spinal muscular atrophy

  • following paralytic poliomyelitis

    Neuromyotonia and myokymia

  • Isaac's syndrome

  • generalised myokymia

  • neurotonia

  • continuous muscle fibre activity due to: chronic inflammatory demyelinating polyradiculopathy, Guillain Barre syndrome, myasthenia gravis, thymoma, thyrotoxicosis, thyroiditis

    Muscular dystrophies

    Myositis

    Infiltration

  • tumours

  • amyloidosis

  • cysticercosis

    Link here