Anesthesia

One of the oldest forms of medical treatment is described in Genesis 2:18, 21-23, where the Creator Himself “caused a deep sleep” to come upon Adam while He took out the rib, closed up the incision, and made a “help meet for him.” Relief of pain is intimately associated with the rendering of needful medical care. This is one of the physician’s cardinal responsibilities.
For certain patients, some forms of severe pain may be life threatening. However, in the case of most effective pain relieving medications, addiction can occur, with distortion of mental imagery to the point of serious impairment. Thus, it is wise to look for the simplest methods of relieving pain when attempting to perform surgery.
Probably the oldest form of pain relief is refrigeration anesthesia. Extremities can be rendered pain free with ice packs. This is particularly valuable in the case of vascular disease where cardiac and circulatory impairment makes general anesthesia risky. During the World War II, army medics discovered that troops suffering from frostbite might save their limbs if the extremity remained frozen until medical care could be secured. This observation influenced all currently accepted first aid for frostbite used in our country.
In order to properly administer refrigeration anesthesia, the extremity needs to be cooled to the point of numbness, while keeping the remainder of the body warm to avoid a general drop in emperature, chilling, or agitation. Ice packs or snow can be used to progressively cool an xtremity, either a hand or foot. If the surgery is to be localized to the arm or leg, place the pack
just above the site of amputation. This reduces blood loss and allows for a careful, meticulous dissection of the tissue. Broken bones can be set with refrigeration. In the case of a simple fracture of the hand or wrist, immerse the extremity in ice water for one-half hour or more. This will allow manipulation and bone setting to be done quite painlessly.
Refrigeration can also be used topically in the removal of warts, moles, and other skin lesions. Dry ice or liquid nitrogen can be applied with a cotton applicator to freeze a small area and render it numb to pin prick.
A second method of anesthesia is the application of gradual pressure on a nerve. The ulnar nerve at the elbow (funny bone) is quite amenable to pressure. Quite often in certain positions a foot or a hand has been known to “go to sleep” due to stretching or pressure on an affected nerve. nowledge of neuroanatomy can utilize this principle favorably for surgery to an extremity.
Counterirritation can also be applied with electric stimulation near the point of incision. This can utilize DC current, but it is more effective with a pulsed generator, such as rehabilitation centers employ in treatment of chronic pain. Desensitization can be obtained with liniments and ointments, mustard packs or plasters. Even animal surgery has been performed using
counterirritation, e.g., the “twitch” on the nose of horses. Finally, it is helpful to understand some of the common injectable anesthetics that are used locally for the relief of pain. These are used both in dental and surgical care. But they have some side effects and potential allergic reactions. Injectable narcotics should always be avoided, as they leave behind serious effects on the brain. They are not only difficult to metabolize, but because of their tendency to produce euphoria can become rapidly addicting. On rare occasions for major procedures, general anesthesia may be necessary. The gaseous agent used in these cases should be that which is most rapidly metabolized and least toxic to the system. Nitrous oxide and oxygen are commonly employed together to relieve mild pain. Although ether is quite flammable, it still remains the safest form of general anesthesia, due to its rapid clearing from the blood by the way of the lungs and relatively low toxicity to the liver and other organs. Open drop techniques in a well ventilated area can be used, but for safety reasons general anesthesia ideally should be performed in a hospital. Newer anesthetic agents (Halothane, Ethrane, etc.), although more likely to cause toxicity, are less dangerous to the heart and usually nonflammable. Regional blocks, local nerve blocks, and spinal anesthesia have their places in hospital settings but it is beyond the scope of this book to detail their applications.

Suturing

Considerable practice is required to suture incisions and lacerations quickly and accurately. Yet these skills are not beyond the reach of the average layman gifted with manual dexterity or an interest in mastering the art. If possible, practice your suturing techniques on a piece of sponge rubber, upholstery, or even a pillow. Some surgeons become skilled in knot tying, practicing on door handles or in the automobile while traveling. The accompanying diagrams, located on pages 178 to 189, help demonstrate the principles of the three basic methods of surgical knot tying. The one described as an “instrument tie” utilizes a hemostat or needle holder, while the others require only skillful fingers for proper use. I would suggest that a novice begin with the two-handed tie and instrument tie, adding more complex forms as skill is gained.
Avoid tying the sutures so tightly that insufficient blood flow to the skin edges results. This would cause delayed and incomplete healing of the wound.
“Approximate, don’t strangulate” is the watch word for closure of lacerations with sutures. Human bites, animal bites, and lacerations opened longer than 12 hours, or those grossly contaminated are not sutured, but allowed to granulate and heal by secondary intention.
The placement of sutures and selection of suture material will be described in the following sections, as the various types of lacerations and their special care are considered. In a home-like setting it is possible to make the appropriate needles, like bending a sewing needle, sharpening the point in a chisel fashion to better penetrate the skin. Silk or cotton can be boiled along with the needle, thus sterilizing it for use in suturing. Prepared packages, that come already sterile, are available from suture manufacturing companies and can be obtained in various sizes and needle styles. Remember to consult the suture use manual for aid in selecting the appropriate sutures.

Wound Care

There are three basic methods by which a wound heals itself. Primary Intention is the usual type of healing when an incision or laceration is closed immediately to allow close adherence of the opposing skin edges and subcutaneous layers. This permits healing from side to side with the east amount of scarring and pain. The rate of healing of our skin depends on its blood supply and the presence or absence of pressure, tension, and infection. The facial skin, with its rich blood supply, can heal in 3-5 days, while a thickened area of skin with less nutritive potential, such as the back or feet, may require two weeks or more. If sutures are placed, it is important to know how long healing will require to avoid too early removal and wound separation.
Secondary healing of a wound occurs when the laceration is too large to be closed or is infected and must be left open. A general principle of laceration treatment is this. A wound that has been open more than 8-12 hours is never sutured, since infection may already have developed. In uch case, granulation occurs with the formation of a specialized tissue across the wound, and later coverage with new skin. Some deformity and scarring usually occurs. Nevertheless, with the exception of very large ulcers, the skin healing is usually complete. Understandably, this akes longer. Proper care of the wound to prevent or treat infection will serve to hasten the healing process.
The third method involves the initial formation of granulation tissue, then a secondary closure of the wound with sutures. This accelerates the healing in large open lesions and is usually used hen a surgical wound, for some reason, separates and must be closed again. Even more scarring takes place as a rule, but the healing is usually complete.
Some essential factors in wound healing are the presence of adequate protein, vitamins, oxygen, and the prevention of infection. It is generally recognized that the normal rate of healing in a perfectly healthy patient is the optimum rate that can be obtained. Wounds do not heal as well in anemic patients. With a normal complement of white blood cells the healing of a sterile wound is not impaired. However, when infection is present delayed healing does occur. Swelling (edema), whether local or general, appears to interfere with the healing process. Older individuals take onger to heal than the young. Endocrine factors, such as the possible deficiency of thyroid or growth hormone, or adrenal dysfunction, may retard or interfere with the healing process.
Local factors are important. According to Van’t Hoff’s law, reactions occur more rapidly when the temperature is increased. Conversely, hypothermia will delay wound healing in most areas, lthough cold is sometimes used for pain control. The areas of the skin which have the best blood supply, such as the face and neck, normally heal the fastest. Fat persons tend to heal more slowly, and their wounds tend to separate more often than in people of normal weight. Skin utures are usually left in longer. Cleanly incised wounds will heal more rapidly than irregular jagged lacerations. The presence of a blood clot or hematoma may interfere with proper wound healing by preventing close contact of the walls of the wound, and thus there forms a pocket, called “dead space.” Infected fluids, pus, and foreign bodies will all retard the healing of these wounds. It is critical to cleanse the wound of all foreign debris, irrigating it thoroughly before any suturing is attempted. Suture material is also important in the care of wounds. Although stainless steel is the least reactive, it is difficult to handle and remove. The absorption of foreign material, such as gut, silk, cotton, and nylon will occur slowly, in the order that they are here
mentioned. Newer sutures of nylon, Dacron, and Teflon last longer and cause less reaction, but are not suitable everywhere. A suture use manual may be consulted to aid in selecting ppropriate materials. The suture manufacturer’s suggestion of needle size, type, and techniques should also be consulted.

Antisepsis

One of the outstanding advances that medical science has made in the past hundred years is the establishment of antiseptic principles in the practice of surgery. Milestone discoveries were the germ theory by Pasteur and Koch, the emphasis on hand washing by Semmelweis, and the principles of antisepsis by Lister. To understand the relationship between infective agents and disease has allowed the art and science of surgery to develop many new techniques, as well as life-saving procedures.
Fundamentally, the principles of antisepsis deal not only with the presence or absence of germs, but also with the resistance of the person (host) to their invasion. The acid mantle of the skin and our body’s resident normal flora constitute an important barrier to the growth of disease-producing germs. Enzymatic protection by lysozyme in the nasal secretions, tears, saliva, and other mucous membranes affords a defense of marvelous significance and complexity.
From simple wound care to most complicated surgery, every individual should know how to avoid contamination by harmful germs. During the 19th century in Austria, Doctor Semmelweis began to encourage hand washing, requiring this of his residents after each post-mortem examination and before contact with maternity patients. The death rate from infection dropped
precipitously. Although this brilliant physician was persecuted by his own profession for these “strange” doctrines, decades later he was acclaimed a medical trailblazer. Without doubt, the washing of hands is as important to safe surgery, as the use of water internally is to fighting fever.
It is especially important to know how to wash the hands and prepare them to handle diseased or injured tissues. Usually before surgery, a soft disinfected bristle brush is used to scrub the hands starting first around each finger, the ends and sides of the fingernails, the palm and backside of the hand, the wrist, and then the forearm. To prepare for a delicate operation, ten minutes of this type of scrubbing is required, typically with an antibacterial soap. Sterile rubber or latex gloves should then be worn. Disinfectants such as organic iodine (Betadine), hexachlorophene (Phisohex), or other antibacterial soaps are used to prepare the patient’s skin for the incision. Where this is not available, soap and water are employed, however the scrubbing must be prolonged. It is well to remember, moreover, that the mere washing of the hands with any substance does not guarantee a totally germ-free skin.
Sweating is especially common under rubber or latex gloves, with the natural bacteria present in hair follicles and around the nails. Thus the bacterial count is only transiently suppressed, while our real line of defense is our body’ sresistance. Several routines and techniques of skin preparation will be described in the accompanying table.
In the treatment of skin wounds, copious irrigation with water is essential, With some force, the stream of water is directed at the contaminated areas. The wound is thereby cleansed, allowing germs, foreign debris, and blood clots to be washed away, making the area clean for closure or suturing. Preparation of the skin with appropriate antiseptics is also helpful. Proper nutrition to the injured area includes abundant oxygen and vitamin C to aid wound healing. Elimination of refined sugar assists in fighting infection. These measures, together with the avoidance of tobacco and other harmful substances that impair oxygen supply, will enable healing to occur rapidly.

Hair Treatments

Hair treatments can consist of methods to curl, straighten, bleach, hair loss and dye the hair. These treatments may or may not cause damage to the hair cuticle and shaft. The variates for hair treatments include Absent/Not Apparent, Dyed, Bleached, Permed, Combination, and Other. The variate Absent/Not Apparent refers to hairs that appear to have had no treatment with regard to color and curl. The variate Dyed refers to hairs that show evidence of artificial coloring. The variate Bleached refers to hairs that have been treated to remove the natural hair color. The variate Permed refers to hairs that have been treated to alter the natural curl. The variate Combination refers to hairs that have been treated using more than one of the previously discussed hair loss treatment methods (e.g., some hairs may have been bleached and subsequently dyed during the same treatment process).
The variate Other refers to hairs that appear to be treated, but the observed treatment cannot be categorized as dyed, bleached, or permed.
The result of some treatments may be apparent using light microscopy, while others are not as easily detected. A hair that has been dyed may be apparent by the presence of a demarcation line, or a sharp boundary between the treated portion of the hair and the naturally pigmented newly grown portion. A dyed hair may also exhibit the dye color in the cuticle. A dyed hair also will be apparent by the uniformity of the color distribution. Some hair examiners may recognize a dyed hair based on their observation that the color of the subject hair is not typical of naturally colored hair.
The bleaching of hair may result from an artificial bleaching process, or it may result from natural exposure to the sun. A hair that has been bleached from exposure to sun is often referred to as a solar-bleached hair. A bleached hair may be recognized by the presence of a demarcation line between the treated portion and the naturally pigmented newly grown portion. The bleached portion may contain no pigment granules, or it may contain significantly fewer pigment granules than the natural portion. The demarcation line of solar-bleached hair typically is not as distinct as the demarcation line of artificially bleached hair. Repeated dyeing and bleaching of a hair may result in several lines of demarcation that might render a hair as being
unusual, resulting in a hair comparison that might have greater significance.
Hair Loss Product help the damage to the hair cuticle and shaft.The observation that a questioned hair and known hairs have received the same treatment may add to the strength of a hair comparison, but the widespread use of hair treatments may also limit the significance of the correspondence.
Permanent waved hairs sometimes may have buckles or bends in the hair shaft due to the use of perm curlers. These buckles may present themselves at roughly even intervals along the hair shaft due to the manner in which the hair is wrapped around the curler. Artificially straightened hairs sometimes may be recognized by the simple observation that a straight hair has
a cross-sectional shape (e.g., oval, flat) that is more consistent with curly hair.

Several drugs and hormones have an effect on body weight.

Some hormones cause weight gain and others cause weight loss. Hormones that cause weight gain are of particular interest, because if researchers can study and understand how they work, they may be able to develop drugs that can interact with these hormones in a way that makes it easier for people to lose weight. Insulin is a hormone that helps turn glucose (the sugar found in food) into energy the body can use. High levels of insulin lead to weight gain, although the reason why is not fully understood. Drugs used to treat diabetes, such as insulin and medications that make the body produce more insulin, cause weight gain. Obese people often have higher levels of naturally occurring insulin than their leaner counterparts.
Female hormones, like progesterone and estrogen, are associated with weight gain. Obese women most commonly begin to gain weight after puberty, when their bodies begin to produce these hormones. Birth control pills contain estrogen and progesterone, and are associated with weight gain. Today, birth control pills cause less weight gain than in previous years because they contain lower levels of estrogen. Some women may gain more weight than usual during pregnancy, up to 110 pounds (50 kg), which may be related to differences in their hormone levels during pregnancy, as compared to other pregnant women. Women who gain excessive weight during pregnancy may never fully lose this weight. Changes in hormone levels also occur during menopause. These hormone changes lead to a change in fat distribution, including increased central obesity (fat around the midsection or waist). This fat distribution is associated with increased health risks, especially heart disease.
Thyroid hormones increase metabolism and cause weight loss. People with the disease hypothyroidism (underactivity of the thyroid gland) have a smaller amount of thyroid hormone. People with hypothyroidism are predisposed to weight gain.When these individuals are treated with a drug that contains thyroid hormones, they lose weight. Thyroid hormones are dangerous in very high levels and must be monitored closely when taken. An excess of thyroid hormones in the blood can lead to several health problems, including high blood pressure, nervousness, insomnia (trouble sleeping), menstrual cycle changes, heart palpitations (the feeling that the heart is pounding), and fever. Several hormones that may play a role in weight gain have recently been discovered. One of these is leptin, a newly discovered hormone produced in fatty tissue. Increased leptin decreases food intake and increases metabolism in rats and, according to some early studies, in humans as well. Other hormones released by the stomach—including neuropeptide Y, cholecystokinin (CCK), enterostatin, and polypeptide Y 3-36— tell the body it has consumed enough food and should stop eating. Another hormone, ghrelin, is produced by the
stomach. Ghrelin signals hunger and increases appetite.
Ghrelin concentrations increase in response to weight loss. This may make ghrelin partly responsible for people gaining weight back after a successful diet. Table 2.2 lists some of the hormones that influence body weight. Clearly, many hormones affect body weight. Some of these hormones are known, and some have not yet been discovered. By studying these hormones researchers can better understand what causes people to gain and lose weight. Eventually, researchers may be able to develop drugs that can change levels of these hormones in the body, thus giving people who are overweight or obese another weapon in the weight loss battle. Intensive study is required to identify the possible negative effects of increasing or decreasing the level of hormones in the body.

HEALTH RISKS ASSOCIATED WITH OBESITY

Obesity is currently the second leading cause of preventable death in the United States.1 Being overweight and obese can contribute to death by causing or worsening many different diseases, including but not limited to:

• High blood pressure;
• High cholesterol (overweight individuals often have higher levels of “bad” cholesterol and lower levels of “good” cholesterol);
• Obstructive sleep apnea (a condition where a person may stop breathing for a period of time while sleeping);
• Rheumatoid arthritis and osteoarthritis;
• Certain types of cancer, including breast, esophageal, stomach, colorectal, endometrial, and kidney cancer;
• In women: menstrual disturbances, infertility problems, and an increased incidence of birth defects in children;
• Increased daytime sleepiness and heat intolerance;
• Obesity may also contribute to gallbladder disease, gout, breathing problems, increased incidence of infections, liver diseases, and increased pain, especially in the lower back and knees.
  

Two of the biggest health problems that overweight individuals face are a greatly elevated risk of heart disease and stroke. The American Heart Association (AHA) has found a direct link between these health conditions and being overweight. Heart disease is now the number-one killer of women in the United States, and the rise of overweight and obesity can be directly correlated to it.
A person’s risk of developing these health conditions increases as his or her BMI increases, so obese individuals are at higher risk than overweight individuals. Weight loss of even 10 to 15 pounds (4.5 to 6.8 kg) in adults and children can decrease the risk of developing health problems such as diabetes and hypertension. This weight loss can also help to control or lessen the severity of these conditions in patients already afflicted with these conditions. As previously noted, adults with central obesity are at higher risk of developing many of these conditions than are people with evenly distributed body fat.
Obese children also have an increased incidence of health problems.As the prevalence of obesity has increased in children, there has been a similar rise in diseases that were previously rare in children, including type II diabetes and hypertension (high blood pressure). There is a high incidence of obesity among children with asthma, which may indicate a link between the two conditions. There is also an increase in bone and joint complications in obese children. During childhood, bone and cartilage is still growing and developing, and is not strong enough to bear excess weight.

The Link between Weight and Health

Weight and health are strongly related to each other. Disease risk goes up slowly as weight gain pushes you out of the healthy weight range and into the overweight range.Your risk of disease and death increase significantly if extra weight puts you in the obese range. One study reported that obesity in middle age reduces life expectancy by seven years.
The list of weight-related diseases continues to grow. Increased weight raises blood lipids (cholesterol and triglycerides) and blood pressure, which are heart disease risk factors.Weight gain impairs the body’s ability to handle glucose (blood sugar) and contributes to a prediabetic condition called insulin resistance. Other medical conditions that are associated with increased weight include certain cancers, osteoarthritis of the knees and other weight-bearing joints, gastrointestinal tract disturbances, interrupted sleep and sleep apnea, and reduced fertility.To date, obesity has been linked with more than thirty medical conditions.
As weight goes out of the healthy range, risk increases for
• Heart disease
• High blood pressure
• Stroke
• Diabetes
• Several forms of cancer
• Metabolic syndrome (Syndrome X)
• Gallbladder disease
• Gout

It is not just big gains that carry ill health effects—the consequences of gradual or modest weight gain add up quickly. Even 10 or 20 extra pounds increases the risk of death among adults, as shown in a large study published in the New England Journal of Medicine.A recently published study found that just a 5% increase in the BMI over time had a negative impact on simple body functions like walking. Research on women, weight gain, and cancer found that women who gained 21 to 30 pounds since age 18 and were not on hormone replacement therapy were 40% more likely to get breast cancer than women who had gained no more than 5 pounds. The risk increased as the women’s weight increased. Similarly, another study found an 8% increase in the
risk of postmenopausal breast cancer for every 11 pounds gained.

Environmental Factors,Causes of Obesity

Along with genetics, environmental factors have been found to contribute to obesity. In particular, increased food consumption and an inactive (sedentary) lifestyle are environmental factors that very closely correlate with an increased risk of obesity. Americans have an ever-increasing number of energydense foods, packaged in enormous portions, conveniently available at low cost. Energy-dense foods contain large numbers of calories in very small portions. These foods promote the overconsumption of calories. Americans also consume 40% of their calories from fats, which is well above the level recommended by the American Heart Association (AHA). Fats are an extremely energy-dense form of nutrition. The AHA recommends that adults obtain less than 30% of their daily calories from fat. In the United States and in other developed countries, modern technology allows people to be less active in their daily tasks, since many things today are automated and do not require manual labor. For example, years ago people walked to most places. Today, people have access to cars and public transportation to take them to these same places, thus limiting the need for physical activity.
Decreases in physical activity can lead to weight gain. Ultimately, all the calories you eat are not utilized, or burned off. Calories that are not utilized are stored as fat tissue, which can lead to weight gain. Sedentary behavior is on the rise now that technology and automation are so widely available. All of the modern conveniences we now have accessible to us have eliminated the need for individuals to perform much of the physical activity that was once required for daily tasks at work and home (Table 2.1). Computers, cable and satellite television, movies on demand, and high-tech toys like video game systems have led to a decrease in physical activity in people of all ages. Reduced physical education requirements in schools across the nation have also caused physical activity to decline among adolescents. The CDC estimates that 70% of adults in the United States fail to meet minimal recommendations for physical activity. It also estimates that
about one-third of people over the age of 18 get no leisuretime physical activity at all.
Other environmental factors that have been linked to obesity are lower economic class, lower education level, and cessation (quitting) of smoking. The link between economic level, educational background, and obesity is not clear. One theory is that a person who is illiterate may not be able to read labels on food and may not be aware he or she is consuming high-fat, high-calorie foods that can lead to obesity.High-fat, high-calorie foods, such as the food served at most fast-food restaurants, are formulated to be cheap and great tasting. This food is readily available and affordable for people with lower incomes and it is speculated that these people may consume more of this type of food, which can lead to obesity.
People who quit smoking are also likely to gain weight and potentially become obese. It is believed that the nicotine withdrawal a person experiences when he or she quits smoking causes an increase in appetite that leads to an increased intake of calories and, thus, weight gain. This trade-off is not an easy one to handle. The harmful effects of smoking are many and include lung cancer, bronchitis (an infection of the tube that brings air to the lungs), and emphysema (a condition that results in labored breathing and increased risk of infections). Many people who quit smoking trade one health risk (smoking) for another (obesity) because they gain weight.

Genetics,Causes of Obesity

Genetics clearly play a role in obesity. It has been noted that an
adopted child’s body weight is usually more similar to the body
weight of his or her biological parents than that of his or her
adopted parents. Identical twins usually have similar occurrences
of obesity. Studies have also shown that fraternal twins
do not show this same likelihood of obesity; when one twin is
overweight, the other is very often not. These examples help
demonstrate that genetics play a significant role in obesity.
Researchers participating in the Human Obesity Gene
Map project are in the early stages of determining which genes
contribute to obesity in people. Several alterations in normal
genes have been discovered in laboratory rodents and linked to
obesity in these animals. These genes include the ob or lep gene
and the Agouti gene. Researchers are working to find out if
these same genes contribute to obesity in humans.
Not all people who have obesity genes will be overweight.
Conversely, some people who are overweight will not have
these genes. This is because environmental factors also play
a major role in causing overweight and obesity.

HEAT AND DRUG STABILITY

The variety of different body matrices that can be analyzed to determine the presence or absence of different psychoactive substances is extensive, ranging from semen to cerumen. There are, however, practical limitations to the extent to which different biological samples can be used, and the mechanism of collection and supervision of samples are critical to the procedure. This focuses on those biological samples that are commonly used for testing within various drug treatment settings, namely, urine, saliva, blood, and hair. Urinalysis is routinely used in hospitalbased services, blood in forensic environments, hair analysis for medicolegal cases, and saliva tests have been used in the prison services and outreach units. Many would advocate that the assessment of psychoactive drug use could reliably be achieved using self-report from the drug user (client). However,the drug rehabilitation are issues around the method of inquiry the context, purpose, interviewer characteristics, etc. that may bias self-report. Circumstances where the drug user sees the self-report to the inquirer about drug use as influential on his own continued treatment or possible loss of privileges are particular examples.
With a focus on alcohol rehab, Allan has recommended that patients presenting with anxiety and alcohol dependence should first be detoxified and reassessed after 6 weeks when only an expected 10% will be found to have persistent symptoms amounting to an anxiety state. The persistent anxiety can then be treated using conventional pharmacological or behavioral methods. She points out that patients may resist such an approach, preferring to deal with their psychological distress before tackling their substance use. People who are dependent on alcohol or other drugs usually succumb to a number of financial, family, health, and relationship problems, and it is not surprising that many will complain of depression; again it is not surprising that 80% or more will recover within a few weeks of abstinence without recourse to antidepressant treatment.

The drug being tested for and the period of time that the clinician wishes to consider influence
the choice of body fluid. Blood and, to a lesser degree, saliva are likely to give the most accurate
measurement of drugs currently active in the system, whereas urine provides a somewhat broader time period, but with less quantitative accuracy. Hair provides a substantially longer time frame. The routine drug testing strategy most widely adopted is to send urine samples to a laboratory for an initial screen to detect psychoactive drugs of interest. Analysis is performed using a semiautomated commercially available immunoassay or thin layer chromatography (TOXILAB) test. Several types of the former test exist and include radioimmunoassay, RIA:Europ/DPC, enzymemediated immunoassay test, Syva:EMIT, and fluorescence polarization immunoassay, FPIA. Recently, several rapid detection devices (near patient test, NPT) for drugs of abuse screening have been marketed in the U.K. Such tests offer a more rapid turnaround of results to aid clinical decision making.
However, all initial drug screen tests are nonspecific and identify only in a nonquantitative fashion the class of drug present, e.g., opiates, amphetamines, or benzodiazepines, etc. Ideally, any positive test result should then be confirmed by a second test working on different physicochemical principles to the screening test. Gas and liquid chromatography with mass spectrometric detection are regarded as the “gold standard” and are favored where legally defensible results are required. It cannot be overemphasized that the confirmation of drug screening test results is essential. For amphetamine-specific immunoassays, the confirmation test provides the opportunity to differentiate legitimate medicines. For instance, pseudoephedrine and phentermine give a positive test result (cross-react) with tests for illicit drugs like amphetamine and methylenedioxymethamphetamine, MDMA. For opiate drugs, initial immunoassay tests for morphine crossreact with codeine, dihydrocodeine, pholcodeine, 6-monoactetylmorphine (6-MAM), morphine glucuronide, and morphine-6-glucuronide. Consequently, if more than one of these substances is present in a urine sample, the test result will relate to the concentration of the sum of all these opiates and their metabolites. In this way an inaccurate picture of the window-of-detection of opiate drugs in urine may be concluded. The clinical benefit of the confirmation test is that it is able to verify the specific substance(s) present. For example, a confirmation test can detect the presence of 6-MAM, the only specific indicator (metabolite) of heroin use .

Management of Drug Abuse

The management of complications from drug abuse demands a variety of skills from airway management to control of seizures and shock. Several reviews have addressed the issues of general resuscitation and toxidromes.
The purpose of Drug rehab is to present a series of management strategies for the emergency physician or other clinical personnel caring for patients with acute complications from drug abuse. Immediate interventions (e.g., resuscitation and stabilization), secondary interventions (e.g., emergency care after the patient is stable), as well as diagnostic workup (e.g., laboratory data, imaging), and disposition of the patient are discussed. This is proposes a variety of treatment approaches based on a review of the pertinent literature and clinical experience. A general treatment approach based on symptom complex (i.e., seizures, coma, hyperthermia) is presented since initial management decisions frequently have to be made without the benefit of a reliable history. This is followed by a brief review of the each particular drug of abuse (i.e., psychostimulants, opiates, hallucinogens).
It should be emphasized that the adverse reaction to a drug may depend on the unique characteristics of an individual (i.e., presence of cardiovascular disease) as well as the type of drug abused. These protocols serve as guidelines only and an individualized approach to management should be made whenever possible. In the setting of drug overdose, coma usually reflects global depression of the brain’s cerebral cortex. This can be a direct effect of the drug on specific neurotransmitters or receptors or an indirect process such as trauma or asphyxia. Treatment deals largely with maintaining a functional airway, the administration of potential antidotes, and evaluation for underlying medical conditions. The following section describes the Drug rehab thats appropriate use of antidotes and the approach to the patient with a decreased level of consciousness from drug abuse.
Level vs. content of consciousness: It is often useful to distinguish between the level and the content of consciousness. Alertness and wakefulness refer to the level of consciousness; awareness is a reflection of the content of consciousness. In referring to coma, stupor, and lethargy here we address the level of consciousness as it applies to the drug-abusing patient along a clinical spectrum with deep coma on one end, stupor in the middle, and lethargy representing a mildly decreased level of consciousness. Agitation, delirium, and psychosis are addressed in a subsequent section with a greater focus on content of consciousness, i.e., presence or absence of hallucinations, paranoia, severe depression, etc. Attributes of a good antidote The ideal antidote should be safe, effective, rapidly acting, and easy to administer. It should also have low abuse potential, and act as long as the intoxicating drug.
The following standard antidotes are of potentially great benefit and little harm in all patients. Thiamine: Thiamine is an important cofactor for several metabolic enzymes that are vital for the metabolism of carbohydrates and for the proper function of the pentose–phosphate pathway.When thiamine is absent or deficient, Wernicke’s encephalopathy, classically described as a triad of oculomotor abnormalities, ataxia, and global confusion, may result. Although Wernicke’s is rare, empiric treatment for this disease is safe, inexpensive (wholesale price of 100 mg of thiamine is approximately $1), and cost-effective.

Nimodipine: Cocaine is known to decrease reuptake of serotonin, which is believed to play a
role in cocaine-induced headaches and may be associated with cocaine-induced vasoconstriction.
Rothrock et al. reported on three cases of amphetamine-related stroke: in one case a 35-year-old abuser had 20 episodes of transient right hemiparesis occurring within minutes of inhaling methamphetamine; later he developed permanent right hemiparesis. In animal studies,
intravenous methamphetamine administration has resulted in narrowing of the middle cerebral
artery branches within 19 min.While the pharmacologic approaches to cerebral vasospasm are varied, the calcium-channel blocker nimodipine has been used widely with proven efficacy in preventing vasospasm associated with hemorrhagic stroke.No studies looking at this issue in the setting of drug-induced hemorrhagic stroke exist. Although two animal studies found that nimodipine potentiated the toxicity of cocaine and amphetamines in rats, it is felt that in selected
patients the risk–benefit ratio may favor nimodipine administration. Such populations may include the drug-abusing patient who is experiencing transient ischemic attacks closely temporally related to substance abuse or who has had a documented subarachnoid hemorrhage associated with cerebral vasospasm. Recent reports suggest no benefit of nifedipine in ischemic strokes of any type.

OTHER HORMONAL DISORDERS

Finally, we turn to the common endocrine glands that occasionally produce a disease. Many people are concerned about the function of the thyroid gland. This endocrine organ, located at the base of the neck just below the “Adam’s apple” (larynx) is an important regulator of the metabolism of the body. Its overactivity results in characteristic symptoms, such as a rapid pulse, bulging of the eyes, nervousness, tremor, and diarrhea.
Tumors of the thyroid gland, as well as the overproduction of the brain hormone stimulating the gland to produce excessive amounts of thyroid hormone may cause these problems. Blood tests are available to determine the level of thyroxine, the major hormone, as well as others circulating in the system.
Although stress may be a precipitating factor in the development of hyperthyroidism, a failure to respond to the recommended change in lifestyle with increased rest and physical exercise, should lead a person to seek medical counsel, as surgery is occasionally indicated.
Many more people are concerned about underactivity of the thyroid gland. This is often blamed for obesity but in reality is seldom the cause. A tendency to fluid retention, sluggishness, drying of the skin, constipation, and fluid retention should lead one to seek the appropriate blood tests and accurate diagnosis. The typical patient with advanced hypothyroidism, called myxedema, becomes very complacent, with subdued emotional responses and dull mental processes. This so-called “bovine placidity” is much less distressing to its possessor than to the patient’s associates.
Neurologic syndromes are occasionally mimicked by hypothyroidism. They normally clear rapidly with replacement therapy. Many different forms of thyroid medications are available, but should not be used unless a definite deficiency is diagnosed. In such case full hormone replacement becomes necessary, usually for life.

TRACE MINERALS

Many trace minerals are known to be essential to physiologic processes. It is not known in all cases that supplementation of these can cure specific diseases, but a few of the common sources are listed below. Zinc is widely distributed in foods, particularly breads, cereals, lentils, beans, and rice. This nutrient is essential to growth, as well as in repair and healing processes. Copper is abundant in raisins, whole grain cereals, dried legumes, and nuts. It also plays a role in blood production, tissue metabolism, bone development, and nerve function.
Cobalt is a component of vitamin B12 and comes from a variety of sources. Called hydroxycobalamin, vitamin B12 is a vital ingredient in blood cell formation as well as healthy nerve function. Deficiency of B12 produces the disorder pernicious anemia. Vitamin B12 is found in many animal products, such as milk, eggs, and cheese. It is absorbed in the small intestine (ileum), and requires a protein intrinsic factor for complete absorption. Intrinsic factor is found in the stomach. It is often deficient in people who have chronic gastritis or those who have had the major part of the stomach removed by surgery. Total vegetarians should be sure that their diet includes some vitamin B 12. Many breakfast cereals, soy milks, and meat substitutes are fortified with 12. It is available in tablet form. One microgram is sufficient for daily protection.
On the other hand, many vegans have gone for years without evidence of vitamin B12 deficiency. There is a urine test that can determine any presence of B12 deficiency. It is called urinary homocysteine and methylmalonic acid.
Both of these substances are metabolites of vitamin B12. Together with serum B12 measurements, these analyses are effective in screening vegetarians for any trace of B12 deficiency before problems appear. The anemia of vitamin B12 deficiency is macrocytic, meaning that the red blood cells are unusually large. More serious are the nerve and spinal cord disorders that develop. Neurologic signs include loss of position and vibration sensation, combined with sensations of numbness and tingling. Later, serious impairment of gait and bladder (sphincter) control are seen. Some of these symptoms may persist long after vitamin 12 is again replenished. Moreover, this neurologic damage may occur before any evidence of anemia, making diagnosis very difficult in early stages. Prevention is the watchword for vitamin B12 disorders.
Selenium, like vitamin E, protects against cellular damage and lowers the risk of cancer. Cereal grains are good sources of this mineral also. Manganese and magnesium affect a host of enzyme systems. They likewise come from whole grain cereals, as well as many vegetables. Nickel, silicon, fluorine, and many other minerals are also important to the body. Whole grain cereals are a major source of Chromium. It is also found in Brewer’s yeast. This mineral helps to improve glucose tolerance and is an important preventive against the development of diabetes.

VITAMIN DEFICIENCIES 2

Vitamin B6 deficiency is seen occasionally in individuals who eat very few plant foods. Seizures occur in babies fed formulas deficient in B6. This has especially been a problem when a relatively high kidney excretion develops during pregnancy, while a mother was given high dose supplements. A number of drugs interfere with vitamin B6 utilization, such as isoniazid, used in the treatment of tuberculosis. Eating a natural varied diet, it is not difficult to get plenty of pyridoxine. It is the vegetable source of vitamin B6. Scurvy is another vitamin deficiency with worldwide prevalence as well as a colorful history. This condition is caused by a deficiency of ascorbic acid, also called vitamin C. It was a common cause of mortality in sailors during the fifteenth and sixteenth centuries. James Lind, a British naval surgeon, developed a simple cure in 1747 by giving the sailors two oranges and one lemon every day. Their swollen gums, weakness, and bleeding tendencies responded dramatically, giving rise to the nickname, “Limeys.” In more recent times scurvy appears more commonly in alcoholics, food faddists, and the impoverished elderly living on a grossly unbalanced diet.
The principal manifestations of scurvy are hemorrhages in the skin, swollen and bleeding gums, aching muscles, fatigue, and emotional changes. These symptoms appear after two months of depletion. Appearing occasionally in children, scurvy produces tenderness and swelling in the legs. Extreme pain may be present. Finally, after the teeth erupt, swollen gums and bleeding develops. Skeletal changes show signs of growth retardation. In some cases of a vitamin-D deficiency syndrome, rickets, may co-exist.
A carefully taken feeding history is helpful for the diagnosis of infantile scurvy. After 46 months of age any infant fed solely with the bottle, using only boiled cow’s milk or a milk substitute, may develop this disease. Fresh orange juice or another dietary source of vitamin C is rapidly curative. Extremely high supplements of ascorbic acid are seldom necessary. They may produce an abnormal dependency, based on the development of increased excretion originating in the kidneys to compensate for this superabundance.
Large doses of vitamin C can also inactivate vitamin B12. That, at times, unfavorably affects reproduction. Vitamin A is primarily manufactured by the conversion of dietary betacarotene into the active form, retinol. One of the first symptoms of vitamin A deficiency is inability to see in reduced light (night blindness). A later change in the eye is the presence of dryness, xerophthalmia. The conjunctiva becomes opaque, the secretion of tears decreases, then a sticky secretion appears over the cornea, called the Bitot spot. This mark has the appearance of a flake of meringue. Further destruction of the cornea may occur, leading eventually to blindness.
In treating the acute disease, a supplement of vitamin A is recommended. The prevention of deficiency using a balanced diet containing green and yellow vegetables, fresh fruit, and vitamin-supplemented milk is entirely adequate. Green and yellow foods such as carrots, cantaloupe, squash, and dark green leafy vegetables are considered excellent sources for this vitamin.
A high intake of carotene appears in adults using carrot juice or a similar food concentrate excessively. Carotenemia may color the skin, but should not be confused with jaundice. It is considered harmless and will subside when the carotene intake is reduced. Hypervitaminosis A, on the other hand, can produce an acute toxicity. In infants, it presents as drowsiness, vomiting,
and other signs of increased intracranial pressure. Adults commonly develop a headache within hours after any injection of a toxic dose. Blurred vision, nausea, vomiting, or drowsiness may also develop. The skin peels and hair loss occurs. With chronic ingestion of high doses, liver changes resembling cirrhosis are seen. Psychiatric side effects manifest themselves, but prognosis is good when vitamin A ingestion ceases.
Vitamin E is the common name of a group of related fat-soluble vitamin, called tocopherols. They vary in their potency, with the alpha form being thought most active. A number of animals develop a Vitamin E deficiency syndrome, with deterioration in the muscle fibers, impaired reproduction, or anemia. Clinically, these insufficiencies are rare in adults. When the diet contains enough polyunsaturated fatty acids, plenty of dietary vitamin B is usually available. Unfortunately, optimistic expectations of many researchers have been disappointed in spite of the literature proclaiming the miracleworking powers of this vitamin. We do not know for certain whether vitamin B supplementation can favorably affect physical endurance, cardiac status, sexual potency, or longevity in individuals with normal blood levels of Vitamin B (tocopherols).
A number of vitamins affect the production of blood or its proper coagulation. Vitamin K is present in most edible vegetables, particularly the green leafy ones. A similar vitamin is also produced by intestinal bacteria. The gradual accumulation of vitamin K levels in a newborn baby explains easily why ancient recommendation for an eight-day circumcision was made to the Jews. Hemorrhagic disease of the newborn as well as in adults is prevented by proper blood levels of this vitamin. Vitamin B12, folic acid, and iron are also closely related to blood production and have been discussed in Chapter 4, dealing with the circulatory system.

VITAMIN DEFICIENCIES 1

Although definite diseases can be associated with the excess intake of certain vitamins, these are seldom seen on a large scale. Much more common are the deficiencies described below. Pellagra is a disease caused by the deficiency of niacin, one of the B vitamins. The name is derived from the rough skin characteristically seen crusting around the hands and neck. Painful burning of the mouth, shaking of the body, and less commonly, mental disturbances can result. Pellagra was common in the United States in the early 1900’s. A healthful diet was discovered to be curative. One of the essential amino acids, tryptophan, is converted into nicotinic acid, a counterpart of niacin. Deficiency of other nutrients sometimes complicates the disease. Individuals subsisting on a diet primarily of corn are predisposed to pellagra, since corn protein is low in tryptophan and most of the milling removes the vitamin.
Classically pellagra is characterized by the “three D’s” — diarrhea, dermatitis, and dementia. Certain earlier symptoms may develop, however, including loss of appetite, indigestion, weakness, burning in the mouth, and insomnia. Pellagra most commonly appears in the spring or early summer, when the dietary deficiencies of winter combines with renewed exposure to the sun seems to precipitate the outbreak. The skin problems begin to look much like a sunburn. Burning may be intense. Sun-exposed areas, such as the neck, arms, and hands are affected most commonly. Later the skin becomes brownish in color, then rough and scaly. Soreness of the mouth is typical, with inflammation of the tongue. Diarrhea may or may not be present. Mental disturbances usually begin with episodes of nervousness and tremor. Later there occurs confusion, depression, or even delirium.
Early replacement of the B-complex vitamin with high doses of niacinamide is recommended. This related substance does not cause unpleasant vascular flushing like nicotinic acid does. Most people can take them orally. As symptoms subside, all vitamins should all be obtained from a wellbalanced, varied diet of natural foods.
Thiamine Deficiency, called Beriberi, has been known to western medical science since the seventeenth century. Recognized first in the Orient, beriberi has been associated with a deficiency of thiamine. It commonly appears when the diet exclusively consists of polished rice. Cases are occasionally encountered in the United States, particularly in infants and in alcoholics. Three main types of this disease are identified. A chronic form called “dry beriberi” causes tenderness in the calf muscles and weakness in the legs. The acute form, “wet beriberi”, is characterized by cardiovascular changes, with edema, congestion of the lungs, and heart failure. In alcoholics, the brain damage may be irreversible. Beriberi in infants continues to be a health problem in the Far East, where a child may lose his voice, develop heart failure, or gastrointestinal changes with vomiting and constipation.
Adequate nutrition for the breast-feeding mother is particularly important for its prevention. The therapeutic response to Thiamine in infants and adults with beriberi involving the heart is dramatic. A rapid transition, however, should be made from vitamin supplementation to a diet containing adequate wheat germ, rice polishings, or whole grain cereals. This disease is entirely preventable, and reflects one of many conditions following the wake of the industrial revolution.
Riboflavin deficiency is still common in many developing countries. In the Unites States there appears to be a correlation between low income and riboflavin intake. Milk and certain vegetables are good sources of riboflavin. However, when the milk is exposed to direct sunlight a considerable amount of this vitamin is destroyed. Riboflavin is reduced when the food is treated
with alkali, such as we find in certain preservatives and the use of soda. Lack of riboflavin usually results in sores, developing at the corners of the mouth, inflammation of the tongue, and sore throat. Late findings affect the nerves, as well as the blood, with the development of anemia. Replacement of the vitamin rapidly reduces these changes.

MALNUTRITION

Although over-nutrition so characteristic of obesity could be considered a type of malnutrition, such diagnosis is usually reserved for the deficiency syndromes. In all parts of the world various deficiencies of vitamins, minerals, protein, or calories can be seen. Deficiencies are naturally more prevalent in countries where food supply is limited and poverty abounds. Careful analysis
of food intake and any form of intemperance—such as manifested in alcohol consumption, bizarre food practices, food faddism, or the abuse of drugs— are productive to evaluate these conditions. Repeated closely spaced pregnancies and psychological disturbances manifested by a change in food intake should be assessed. Chronic infection, anorexia, or diarrhea likewise may profoundly affect the nutrient balance.
Measurement of height and weight should never be omitted. These are the most commonly used measurements of growth in children and adolescents. Other body measurements include skin fold thickness, head circumference, and biochemical tests measuring blood levels of various nutrients, such as proteins, vitamins and minerals. At times, therapeutic trials of replacement nutrients play a role in the diagnosis of deficiencies. In general, however, nutrient stores must be depleted before low blood levels of any nutrients are found. Changes in the body chemistry and functional neurologic defects occur late in the course of a deficiency. Take a careful history for invaluable help in the initial phase of treatment. Then combine this with a high index of suspicion for various nutrient-related disorders. In spite of modern technology and transportation, there are still large areas in our world where famine is epidemic. In fact, the risk of mass starvation in many countries is all too real, and often associated with other diseases. Body changes during the starvation reflect physiologic attempts to adapt to undernutrition. Fat stores are utilized first in order to spare structural protein. Thus, body fat diminishes more rapidly than does muscle. Extensive losses occur later in other organs, especially the liver and intestines. Fortunately, the central nervous system and circulation maintain themselves, whatever the cost to less essential parts of the organism. The person during starvation also conserves calories by reducing his output of energy. Voluntary physical activity decreases, as does the metabolic rate. A semi-starved patient complains of feeling tired, irritable, and depressed. He may also show lack of ambition, and narrowing of interests, then develops muscle soreness and cramps. The hair begins to fall out, andcuts and wounds heal slowly. Cold temperatures are poorly tolerated.
Ultimately, the individual looks haggard, pale, and emaciated. At times swelling (edema), particularly of the eyelids and cheeks appear, masking the degree of weight loss. The pulse weakens and the eyes become dull, looking like unglazed porcelain. Without relief and too often alone, the hapless victim of starvation then dies on the street of some large city.
The rehabilitation diet for patients recovering from starvation must begin with small quantities of the simplest food, taken at frequent intervals. A natural diet is preferable to the use of “predigested” end products. Vitamin and protein supplementation are ordinarily unnecessary. General dietary allowances should be approximately 100% of those recommended on the basis of the patient’s “desirable” weight. Recovery from starvation, however, advances at a very slow pace. Weakness, fatigability and muscle aches, as well as depression, may persist for weeks to months. Recovery of strength and working capacity is slow. Eventually, recovery is sure, and a life has been saved.
Protein Calorie Malnutrition is another type of disorder seen in early childhood. One such syndrome, called kwashiorkor, appears most commonly between the ages of one and three years. This tragic disorder occurs frequently in Africa in children displaced from their mother’s breast by subsequent pregnancies. Conditioning factors, such as diarrhea, parasites, and skin rash may be seen. Edema is the principal sign. It is associated with low serum proteins. The child’s face may appear round and moon-like. The hair changes with lightening of color, straightening of curly hair, and stripes of lightened color that attest to oscillating levels of good and poor nutrition in the past.
The other major type of malnutrition is called nutritional marasmus. This compares with severe semi-starvation in adults. It most commonly affects infants during the first year of life. The most conspicuous features in marasmus are wasting of muscle and fat, with growth retardation. Affected infants appear prematurely old, and often suffer from vitamin deficiency. Both types of malnutrition respond to a careful feeding regimen of simple foods, given first at frequent intervals, containing both adequate protein and calories.

WATER RETENTION

Adults who suddenly increase their body weight may have an increase in fatty (adipose) tissue, accumulation of fluid (edema) or both disorders. Weight gain in excess of two pounds per day usually implies excess fluid retention. It is easy to confirm this by comparing the body weight in the morning and then again in the evening. Weight gains of less than two pounds during one day usually will subside by the following morning. Fluid retention may disclose increased salt and water intake or decreased sodium and water secretion.
Checking weight changes from morning to evening often provides early evidence of disease. Dietary indiscretion, the use of diuretics, excessive intake of licorice root, or a cortisol-type drug preparation may also be responsible. A special type of fluid retention called cyclic edema occurs predominantly in women. This is characterized by periodic episodes of fluid retention, frequently accompanied by distention of the abdomen, Patients may weigh several pounds more in the evening than in the morning. Although there is some relation to the menstrual cycle, evidence suggests also that psychological and hormonal factors may be related. The treatment of cyclic edema includes restriction in salt intake, rest in the feet elevated (supine) position for several hours during the day, and the use of elastic stockings.

Careful medical work-up is sometimes indicated to evaluate underlying causes.

HYPOGLYCEMIA

Low blood sugar, usually called hypoglycemia, has many causes. The most common one relates to our fast-paced lifestyle. Excessive sugar intake, frequent snacking, and caffeine or cola beverages contribute to this frequent malady. When the blood glucose level falls rapidly, emergency “fight-orflight” stress responses take over. The individual feels weak, very hungry, and frequently becomes irrational. Emotional reactions to hypoglycemic episodes vary from agitated to angry, depressed to suicidal. Personalities change rapidly, but return to normal function with some form of food.
Rather than frequent feedings such as the “six meal a day” diet, I recommend the following regimen: First, begin the day with a wholesome, hearty breakfast. Some whole grain cereal, bread, nut butter, or fruit makes a great way to start the day. Avoid coffee and frequent snacks. They both aggravate any tendency to low blood sugar. Mealtimes should be at regular intervals, usually five or six hours apart. Stress factors can affect hypoglycemia. Exercise is a great way to reduce or relieve stress. Try for an hour or two of extra sleep at night. Or find a weekend for a refreshing minivacation.
Careful testing of your blood, including the five-hour Glucose Tolerance Test (GTT), may help your medical advisor to “fine-tune” your dietary and lifestyle regimen. Most individuals can overcome this metabolic imbalance, particularly the so-called reactive hypoglycemia. This type comes several hours after a meal or sugar-rich snack. It responds very well to the remedies mentioned above. Rarely, tumors of the pancreas may produce abnormal secretions of insulin. In such case the symptoms of hypoglycemia occur during a fast, often early in the morning. Removal of the tumor is necessary to cure this uncommon condition. Finally, diabetes mellitus may be associated with hypoglycemia. It occurs in the context of early diabetes, erroneously termed borderline. Overdoses of insulin will produce hypoglycemia. They occur during vigorous exercise or at night. Adjusting the insulin dosage along with dietary modification will level the blood glucose fluctuations in all but the most “brittle” diabetics.

DIABETES MELLITUS 2

This is associated first of all by the achieving and maintaining of an ideal body weight. Our third goal is the prevention or delay of the specific complications associated with diseases of the eye, kidney, and nerves. Finally, we try to stem the accelerating atherosclerosis to which the diabetic is particularly liable. Success in these therapies depends on how well the patient has been instructed and his conscientiousness in following directions. The avoidance of cigarette smoking, with regular daily exercise, the monitoring of the urine and blood sugar, cholesterol and triglycerides, blood pressure and body weight are all imperative. Basically, however, the treatment of diabetes revolves around an appropriate diet.
The dietary treatment must meet the basic nutritional requirements. These are usually the same as those of a nondiabetic patient and, of course, to be acceptable, taste, variety, economy, and other nutritional factors should be considered. The prevention of high blood sugar occurring after a meal is important to avoid aggravating the symptoms. On the other hand, if a person is taking insulin it is important to provide enough calories of the right type to prevent hypoglycemic reactions. Ideal body weight should be achieved as soon as possible. In order to delay the atherosclerotic complications, the diet should be low enough in fat and animal products to normalize the serum cholesterol and triglyceride levels.
The basic caloric requirement is dictated by age, ideal weight, physical activity, climate, and the patient’ s occupation. An approximate calculation can be obtained by multiplying the ideal weight in pounds by ten. Individuals who are less active or past middle age should reduce their calories somewhat. Meals should be regular, usually spaced 5-6 hours apart. They are ideally limited to two or three meals a day, the latter especially for those taking insulin. I recommend taking the greater number of calories at breakfast, in order to provide energy during the active part of the day. Suppers should be light, eaten several hours before going to bed.
Careful regulation of the insulin level can usually avoid the necessity of a bedtime snack. The fat content of the diet should definitely be reduced from the 40% eaten by the average American. Protein should also be reduced slightly. The remaining calories should be obtained from complex
carbohydrates. This can lower the insulin requirement dramatically, and in many maturity onset diabetics, make a need for the needle entirely unnecessary. Some dietary suggestions for diabetics, as used in my institution, are presented in the accompanying tables. Insulin therapy is usually necessary for diabetes of juvenile onset. Several types are available, having fast, intermediate, and long duration of action.
Most of the insulin used in the United States today contains 100 units per milliliter. This has helped considerably to standardize the syringes and simplify the self-administration of this hormone. Regular or crystalline insulin is the shortest acting and is usually used for emergencies. Its duration of action is 6 to 8 hours. Intermediate acting insulins, such as NPH or Lente have a peak effect in 8-12 hours and usually last for 24. The longer-acting insulins are seldom used. At times, a second small dose of intermediate insulin before bedtime is preferable to increasing the daily dose.
It is preferable to have a small amount of sugar spill in the urine during the day than achieve such rigid glucose control as to render the patient hungry all the time or prone to hypoglycemic reactions. Be sure to rotate the sites of injections and use sterile techniques in the administration of all insulin hormones. Although many diabetic patients develop antibodies to the insulin used, only a few, about 0.1% will develop insulin resistance. A regular exercise program helps, in combination with the low fat diet, to lower daily insulin requirement. Using the more convenient but less physiologic oral diabetic pills should be discouraged, because of numerous side effects, particularly an increased acceleration of vascular complications. Hope is definitely on the way for patients with diabetes, who will eat properly, exercise regularly, and keep their weight under control.