Alert Any patient with a wound that has lasted more than 8 weeks and who has tried standard wound care and revascularization without improvement should consider hyperbaric oxygen therapy. This treatment may speed healing by allowing more oxygen to get to the wound and may therefore result in fewer amputations.
Keeping glucose at near-normal levels for 5 years or more reduces both the onset and progression of retinopathy, nephropathy, and neuropathy. In type 2 diabetes, blood pressure control as well as smoking cessation reduces the onset and progression of complications, including cardiovascular disease.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Diabetic complications during pregnancy:
Treatment
(Professional Guide to Diseases (Eighth Edition))
Treatment of both the newly diagnosed and the established diabetic is designed to maintain blood glucose levels within acceptable limits through dietary management and insulin administration. Many females with overt diabetes mellitus require hospitalization at the beginning of pregnancy to assess physical status, check for cardiac and renal disease, and regulate diabetes.
For pregnant patients with diabetes, therapy includes:
❑ bimonthly visits to the obstetrician and the internist during the first 6 months of pregnancy; weekly visits may be necessary during the third trimester
❑ maintenance of fasting blood glucose levels at or below 100 mg/dl and 2-hour postprandial blood glucose levels at or below 120 mg/dl during the pregnancy
❑ frequent monitoring for glycosuria and ketonuria (ketosis presents a grave threat to the fetal central nervous system)
❑ weight control (gain not to exceed 3 to 3½ lb [1.4 to 1.6 kg] per month during the last 6 months of pregnancy)
❑ high-protein diet of 2 g/day/kg of body weight, or a minimum of 80 g/day during the second half of pregnancy; daily calorie intake of 30 to 40 calories/kg of body weight; daily carbohydrate intake of 200 g; and enough fat to provide 36% of total calories (however, vigorous calorie restriction can cause starvation ketosis)
❑ exogenous insulin if diet doesn’t control blood glucose levels. Be alert for changes in insulin requirements from one trimester to the next and immediately postpartum. Oral antidiabetic drugs are contraindicated during pregnancy because they may cause fetal hypoglycemia and congenital anomalies.
Generally, the optimal time for delivery is between 37 and 39 weeks’ gestation, although with reassuring antenatal testing and no evidence of macrosomia, 40 weeks or later is also feasible. The insulin-dependent diabetic may require hospitalization before delivery for frequent monitoring of blood glucose levels and prompt intervention if complications develop.
Depending on fetal status and maternal history, the obstetrician may induce labor or perform a cesarean delivery. During labor and delivery, the patient with diabetes should receive continuous I.V. infusion of dextrose with regular insulin in water. Maternal and fetal status must be monitored closely throughout labor. The patient may benefit from half her prepregnancy dosage of insulin before a cesarean delivery. Her insulin requirement will fall markedly after delivery.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Diabetic ketoacidosis:
Treatment (Tx)
(Professional Guide to Diseases (Eighth Edition))
Insulin, I.V. fluids, sodium bicarbonate
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Hereditary fructose intolerance:
Treatment
(Professional Guide to Diseases (Eighth Edition))
Treatment of hereditary fructose intolerance consists of exclusion of fructose and sucrose (cane sugar or table sugar) from the diet. Otherwise, treatment is supportive as the patient’s progress is monitored.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Protein-calorie malnutrition:
Treatment
(Professional Guide to Diseases (Eighth Edition))
The aim of treatment is to provide sufficient proteins, calories, and other nutrients for nutritional rehabilitation and maintenance. When treating severe PCM, restoring fluid and electrolyte balance parentally is the initial concern. A patient who shows normal absorption may receive enteral nutrition after anorexia has subsided. When possible, the preferred treatment is oral feeding. Foods are introduced slowly. Carbohydrates are given first to supply energy, and then high-quality protein foods, especially milk, and protein-calorie supplements, are given. A patient who’s unwilling or unable to eat may require supplementary feedings through a nasogastric tube or total parenteral nutrition (TPN), which is given through a central venous catheter because of its higher osmolality. Peripheral parenteral nutrition, which has a lower osmolality than TPN and can be given through a peripheral I.V. line, is an alternative to TPN, but it’s given less commonly. Accompanying infection must also be treated, preferably with antibiotics that don’t inhibit protein synthesis. Cautious realimentation is essential to prevent complications from overloading the compromised metabolic system.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Cholelithiasis and related disorders:
Treatment
(Professional Guide to Diseases (Eighth Edition))
Surgery, usually elective, is the treatment of choice for gallbladder and bile duct diseases and may include open or laparoscopic cholecystectomy, cholecystectomy with operative cholangiography, and possibly exploration of the common bile duct. Electrohydraulic shock wave lithotripsy can be used to fragment gallstones if they’re few in number; it may be used with ursodeoxycholic acid to improve dissolution. Other treatments include a low-fat diet to prevent attacks and vitamin K for itching, jaundice, and bleeding tendencies due to vitamin K deficiency. Treatment during an acute attack may include insertion of a nasogastric tube and an I.V. line and, possibly, antibiotic administration.
A nonsurgical treatment for choledocholithiasis involves placement of a catheter through the percutaneous transhepatic cholangiographic route. Guided by fluoroscopy, the catheter is directed toward the stone. A basket is threaded through the catheter, opened, twirled to entrap the stone, closed, and withdrawn. This procedure can be performed endoscopically.
Chenodeoxycholic acid, which dissolves radiolucent stones, provides an alternative for patients who are poor surgical risks or who refuse surgery.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Diabetes insipidus:
Treatment
(Handbook of Diseases)
Until the cause of diabetes insipidus can be identified and eliminated, administration of various forms of vasopressin can control fluid balance and prevent dehydration.
Vasopressin injection
This aqueous preparation is administered S.C. or I.M. several times a day because it’s effective for only 2 to 6 hours. This form of the drug is used as a diagnostic agent and, rarely, in acute disease.
Desmopressin acetate
This drug can be given orally, by nasal spray that’s absorbed through the mucous membranes or by S.C. or I.V. injection. Desmopressin acetate is effective for 8 to 20 hours, depending on the dosage.
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Source: Handbook of Diseases, 2003
Diabetes mellitus:
Treatment
(Handbook of Diseases)
Effective treatment for both types of diabetes normalizes blood glucose and decreases complications.
Type 1 diabetes
Treatment includes insulin replacement, diet, and exercise. Current forms of insulin replacement include single-dose, mixed-dose, split-mixed dose, and multiple-dose regimens. The multiple-dose regimens may use an insulin pump.
Human insulin may be rapid-acting (Regular), intermediate-acting (NPH or Lente), long-acting (Ultralente, Lantus), or a combination of rapid-acting and intermediate-acting (70/30, 75/25, or 50/50 of NPH and Regular).
Clinical tip Insulin Lispro or Novalogue may be used in place of Regular insulin. It’s rapid in onset (15 minutes) and makes waiting to eat after injection unnecessary. It has a short duration of action (4 hours), which decreases between-meal and nocturnal hypoglycemia.
Islet cell or pancreas transplantation is available and requires chronic immunosuppression.
Type 2 diabetes
Patients may require oral antidiabetic drugs to stimulate endogenous insulin production, increase insulin sensitivity at the cellular level, suppress hepatic gluconeogenesis, and delay GI absorption of carbohydrates.
UNDER STUDY: Studies have shown that treatment with a lipase inhibitor (such as orlistat) combined with a low-calorie diet significantly decreases the weight of overweight patients with type 2 diabetes. Patients following this therapy also displayed improvements in glycemic control and cardiovascular risk profile; levels of glycosylated hemoglobin, fasting glucose, and postprandial glucose improved significantly.
Both types
Treatment of both types of diabetes requires a diet planned to meet nutritional needs, to control blood glucose levels, and to reach and maintain appropriate body weight.
For the obese patient with type 2 diabetes, weight reduction is a goal. In type 1, the calorie allotment may be high, depending on growth stage and activity level. For success, the diet must be followed consistently and meals eaten at regular times.
UNDER STUDY: Vitamin E is under investigation for its cellular effects that can possibly reduce the risk of macrovascular disease in patients with type 2 diabetes mellitus. The antioxidant effects of vitamin E were supported, and it was found that, in high doses, vitamin E acts as an anti-inflammatory. It’s postulated that heart disease and stroke risk can be decreased because vitamin E reduces plaque formation at the endothelial level. Vitamin E may also have an effect on the metabolic syndrome that causes diabetes mellitus and may prevent the disease from occurring.
Complications
Treatment of long-term diabetic complications may include transplantation or dialysis for renal failure, photocoagulation for retinopathy, and vascular surgery for large-vessel disease. Meticulous blood glucose control is essential.
The Diabetes Control and Complications Trial has proved that intensive insulin therapy that focuses on keeping glucose at near-normal levels for 5 years or more reduces both the onset and progression of retinopathy (up to 63%), nephropathy (up to 54%), and neuropathy (up to 60%).
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Diabetic complications during pregnancy:
Treatment
(Handbook of Diseases)
Both the newly diagnosed and the established diabetic need dietary management and insulin administration to maintain blood glucose levels within acceptable limits. Most women with overt diabetes mellitus require hospitalization at the beginning of pregnancy to assess physical status, check for cardiac and renal disease, and regulate diabetes.
For pregnant patients with diabetes, therapy includes:
❑ frequent visits to the obstetrician and the internist during the first 6 months of pregnancy; weekly visits may be necessary during the third trimester, an internist may be consulted as necessary.
❑ maintenance of blood glucose levels at or below 95 mg/dl during the third trimester
❑ frequent monitoring for glycosuria and ketonuria (Ketosis presents a grave threat to the fetal central nervous system.)
❑ a high-protein diet of 2 g/day/kg of body weight (a minimum of 80 g/day during the second half of pregnancy), a daily calorie intake of 30 to 40 calories/kg of body weight, a daily carbohydrate intake of 200 g, and enough fat to provide 36% of total calories (However, vigorous calorie restriction can cause starvation ketosis.)
❑ exogenous insulin if diet doesn’t control blood glucose levels. Oral antidiabetic agents are generally contraindicated during pregnancy because they may cause fetal hypoglycemia and congenital anomalies.
Delivery
Generally, the optimal time for delivery is no different from a normal pregnancy, as long as blood sugars are controlled and no fetal compromise is present.
Depending on fetal status and maternal history, labor may be spontaneous induced or a cesarean section performed. During labor and delivery, the patient with diabetes should receive a continuous I.V. infusion of dextrose with regular insulin in water. Maternal and fetal status must be monitored closely throughout labor.
The patient may benefit from half her prepregnancy dosage of insulin before a cesarean delivery. Her insulin requirement will fall markedly after delivery.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Protein-calorie malnutrition:
Treatment
(Handbook of Diseases)
The aim of treatment is to provide sufficient proteins, calories, and other nutrients for nutritional rehabilitation and maintenance. When treating severe protein-calorie malnutrition, restoring fluid and electrolyte balance parenterally is the initial concern. A patient who shows normal absorption may receive enteral nutrition after anorexia has subsided. When possible, the preferred treatment is oral feeding of high-quality protein foods, especially milk, and protein-calorie supplements. A patient who’s unwilling or unable to eat may require supplementary feedings through a nasogastric tube or total parenteral nutrition (TPN) through a central venous catheter. Accompanying infection must also be treated, preferably with antibiotics that don’t inhibit protein synthesis. Cautious realimentation is essential to prevent complications from overloading the compromised metabolic system.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Cholelithiasis, cholecystitis, and related disorders:
Treatment
(Handbook of Diseases)
Surgery, usually elective, is the treatment of choice for gallbladder and bile duct diseases. Surgery may include open or laparoscopic cholecystectomy, cholecystectomy with operative cholangiography and, possibly, exploration of the common bile duct.
Other treatment includes a low-fat diet to prevent attacks and vitamin K for itching, jaundice, and bleeding tendencies resulting from vitamin K deficiency. Treatment during an acute attack may include insertion of a nasogastric tube and an I.V. line and, possibly, administration of an antibiotic.
A nonsurgical treatment for choledocholithiasis involves insertion of a flexible catheter, formed around a biliary tube (T tube), through a sinus tract into the common bile duct. Guided by fluoroscopy, the catheter is directed toward the stone. A Dormia basket is threaded through the catheter, opened, twirled to entrap the stone, closed, and withdrawn.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
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