Diabetes is a complex, chronic illness which requires continuous medical care with multifactorial risk-reduction strategies beyond glycemic control. Ongoing patient education on self- management and support are critical to preventing acute complications and reducing the risk of long-term complications.
Criteria for the diagnosis of Diabetes:
- Fasting Plasma Glucose ≥126 mg/dL. Fasting is defined as no caloric intake for at least 8 hours.* OR
- 2-h Plasma Glucose ≥200 mg/dL during Oral Glucose Tolerance Test. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75-g anhydrous glucose dissolved in water.*OR
- Glycosylated hemoglobin HbA1C ≥6.5%.* OR
- In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL
In the absence of unequivocal hyperglycemia, diagnosis requires two abnormal test results from the same sample or in two separate test samples.
Diabetes can be classified into the following general categories:
- Type 1 diabetes (due to autoimmune β-cell destruction, usually leading to absolute insulin deficiency)
- Type 2 diabetes (due to a progressive loss of β-cell insulin secretion frequently on the background of insulin resistance)
- Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation)
- Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (such as cystic fibrosis and pancreatitis), and drug- or chemical-induced diabetes (such as with steroid use)
If untreated or inadequately treated, it may lead to complications like cardiovascular diseases (heart attack), stroke (cerebrovascular accident), diabetic retinopathy and visual loss, foot ulcers, diabetic neuropathy, diabetic nephropathy with protein loss and chronic kidney disease.
Comprehensive care for a diabetic patient involves control of blood glucose, cholesterol levels, blood pressure, maintenance of ideal body weight and risk assessment for cardiovascular and peripheral vascular diseases. Regular eye check-up, foot care, self-monitoring of blood glucose, and ability to recognize hypoglycemic symptoms and take remedial measures is of paramount importance. Every person with diabetes need to know the correct technique to self- administer insulin, basics regarding anti-diabetic oral medications, and should be provided with an individualized diabetic diet plan.
With this comprehensive approach, a good control of diabetes can be achieved and the person can lead a productive life like any other individual.
Dr Udai Prakash is organising THE HYDERABAD OSTEOTOMY COURSE, on 2nd June at Taj Deccan to help knee surgeons share their wealth of experience in all aspects of knee osteotomy surgery, rehabilitation and dealing with complications.
Osteotomy means “cutting of bone in such a way so as to re-align it in its correct position”. There are many instances when a surgeon may offer an osteotomy as a course of treatment. For example:
- Bow legs or knock knees in children and young adults
- Straightening of man-united fractures
- Alleviate pain in arthritis of joint
- Correction of mal-tracking or recurrent dislocation of patella
- Correction of various congenital deformities etc
There has been a resurgence of interest in the use of osteotomy for alleviating pain in the knee due to arthritis. This procedure avoids or postpones knee replacement surgery or simply can be thought of as an alternative to knee replacement.
Many young adults also have deformities in their legs which could give them an awkward gait as well as prevent them from taking part in active sports. These deformities can also make them very socially conscious about the appearance of their legs. Many young girls with deformities are brought to us by parents anxious about their marriage.
The course has a mix of national, international and local faculty with a wealth of experience in this technique. There will be a live surgical demonstration and series of talks and discussions.
The course is targeted towards the young knee surgeon keen to develop an interest in this technique. Experienced surgeons will also gain from this course and will have a chance to network and learn the nuances of this surgery from experts.
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Ankylosing Spondylitis (AS) is a condition most commonly affects young males. It is known to cause stiffness in spine and hip joints. Importance of hip involvement in AS has been recognised as a commonly disabling problem, whereas involvement of other joints like shoulder is less frequent and less severe. In contrast to the classical changes of AS in the spine the changes in hip does not lead to formation of new bones, but it results in an erosive disease, which destroys the joint. These changes start occurring fairly early on in life, and total hip replacement is often the therapy of choice in this difficult clinical situation.
In the early stages, ankylosing spondylitis is likely to cause:
- pain in the lower back in the early morning which eases through the day or with exercise
- pain in the sacroiliac joints (the joints where the base of your spine meets your pelvis), in the buttocks or the backs of your thighs.
- Hip involvement usually comes on gradually, and although the pain often is felt in the groin area, it can sometimes be felt in other areas of the body, such as the knees or the front of the thigh
In advanced stages
- Lower back and neck stiffness resulting in bending and twisting of torso and neck
- Fusion of hips(Hip Ankylosis)
In the past, surgical fusion of the hip was performed to reduce the pain but at the cost of losing movement at the hip joint. Numerous studies now have however proven that total hip replacement in hip ankylosis is the most favourable line of treatment. It provides patient with pain relief , near normal movement of the hip joint and perfectly normal walking pattern.
At Udai Omni, total hip replacement for a fused or ankylosed hip has a long history of over ten years. To date, we have had a 100% success rate with no failures. This is a technically demanding procedure but if done well, the results are extremely gratifying as one can see in the example seen below:
A 33 year old software engineer came to us in 2009 with a fused right hip that resulted in a very awkward gait. He was obviously very conscious of his disability that affected his social life as well as his work. He had been to see many orthopaedic surgeons but could never get the confidence that he would walk normally again. During my annual visit to Udai Omni hospital from the UK, this young man consulted me and agreed to get his surgery done by me. Within six weeks, he could walk independently without a limp and eventually got back to his passion of swimming.
Video of patient swimming!
Update on Joint Replacement Surgery
Joint replacement surgery has come a long way over the last six decades. The most common joints that are being replaced across the world are the knee, hip, shoulder, elbow and ankle in that order. In the USA over 700,000 knee and around 400,000 hip replacements are done annually. These numbers are expected to rise exponentially to over 4 million procedures by 2030. The data in India is not very robust but estimates vary between 100,000 – 200,000 knee replacement procedures. Hip replacement numbers are substantially less. Indians seem genetically more predisposed to knee arthritis compared to their counterparts in the West. The most common indication for knee replacement is osteoarthritis. In contrast, Indians seem well protected against osteoarthritis of the hip which is very common in the West. The most common indication for a hip replacement in India is Avascular Necrosis because of injudicious and rampant use of steroids by medical practitioners.
Indications for a knee replacement include :
- Rheumatoid arthrits
- Post traumatic arthritis
When is a knee replacement advisable? I generally advise surgery in patients who have advanced arthritis when conservative measures have failed to control the pain and disability. Age should not be a criterion for advising a knee replacement.
There are two types of knee replacements : Total Knee Replacement and Partial Knee Replacement. Partial Knee replacements are done by surgeons who are trained in the procedure. Most surgeons perform a total knee as a standard procedure for osteoarthritis whether it involves a single compartment or not. At Udai Omni, we perform partial or unicompartmental knee replacement if the arthritis is limited to one compartment. About 40% of our knee replacement procedures are partial. The benefits of partial knee replacement include:
- early recovery
- fewer complications like MI and DVT
- ability to sit on the floor and climb stairs
- natural feel of the joint rather than a feeling of a lump of metal in the knee
- ability to take part in leisure sports and activities
The success rate or survivorship of knee replacements in general are very good. Overall we are seeing a 90% survivorship at 20 years.
Many different types of implants are available. A standard implant made of cobalt chrome alloy and a polyethylene spacer is sufficient for over 90% of the patients. A ceramic coated implant like the “bionic gold” or “oxinium” prosthesis is advisable for those with allergy to artificial jewellery. There is no evidence that these implants perform better than a standard implant.
The most common indication for a total hip replacement in India is Avascular necrosis of the femoral head. Other indications include rheumatoid arthritis, post traumatic arthritis, sequelae of childhood conditions like dysplasia, infections, Perthes’, SCFE etc.
Age is not a concern these days with advent of better materials and designs. Many patients in India tend to be young – in their 20s and 30s.
Floor activities: Traditionally, patients with hip replacements were told not to perform any activities on the floor. With better designs now available in India, a good competent surgeon should allow their patients to sit on the floor for various washroom activities and other activities like eating, praying etc. Many patients with a hip replacement get back to a normal lifestyle which can also include gentle sporting activities like badminton, table tennis, golf, trekking etc.
There are essentially two types of hip replacements – cemented and uncemented. Both perform equally well although the tendency is to do uncemented hips in the younger people. The bearing – ie the ball and the socket lining are the key for long term success. Ceramic heads and liners are generally recommended in the young and a metal head with polyethylene line may be suitable for the middle aged to elderly.
Survivorship and success of most standard hip replacements has improved significantly over the last few decades. Now, over 90% of our patients can expect their hip to survive 20 years. I would imagine this figure will get better as we follow our patients up in the future.
Enhanced Recovery after joint replacement:
Success of joint replacement, whether it is the hip or the knee depends on many factors. A well trained experienced surgeon is the key. However, other factors like patient engagement, physiotherapy and pain management are also extremely important.
At our hospital, we provide multi modal analgesia with the help of our expert anaesthetists to mobilise the patient within a day of surgery and discharge them home within 3 days on average. With advent of ambulatory selective nerve blocks and judicious use of oral and injectable analgesics, our patients mobile early and their VAS (visual analog score) for pain out of 10 is usually between 2-4. Knee and hip replacement need not be a painful experience any more.
Surgery and joint replacement for advanced arthritis is going be around for a long time to come. There is no procedure or medicine to reverse advanced arthritic changes and deformity, whether it is the hip or the knee. No stem cell procedure or cartilage regenerative procedure will help in this regard. Media and pharmaceutical industry have a long track record of influencing the patient who would obviously prefer conservative procedures over surgery.
Industry is working on improving the performance of the implant by improving the coating and bearing materials.
Preventing arthritis by keeping oneself active and lean may be the best solution to prevent future arthritis and this avoid surgery.
Biological replacement from either ones own tissue or animal tissue is still a distant dream but a lot of work is being done across the world.
What is blood pressure?
Blood pressure is simply the physical pressure of blood in the blood vessels. It is similar to the concept of air pressure in a car tyre.
What do the numbers mean?
A common blood pressure might be 120/80 (said as ‘120 over 80’). These values are quoted in units known as millimetres of mercury (mmHg). There are 2 numbers because the blood pressure varies with the heartbeat. The higher pressure (120) represents the pressure in the arteries when the heart beats, pumping blood into the arteries. This pressure is called systolic pressure. The lower pressure (80) represents the pressure in the arteries when the heart is relaxed between beats. This pressure is called diastolic pressure.
Does blood pressure change?
Blood pressure can be quite variable, even in the same person. Blood pressure goes up and down with different normal daily activities. For example, exercise, changes in posture and even talking changes blood pressure. Blood pressure tends to be higher during the day than at night and higher in the winter than in the summer. Blood pressure also rises when we grow older, particularly systolic blood pressure. Before adulthood, blood pressure rises in parallel with height. In adult years, weight and blood pressure are closely related. When weight goes up, blood pressure tends to go up and we can lower blood pressure by losing weight. Blood pressures differ between individuals. Some people have low, some average and some high blood pressure levels.
What is high blood pressure?
There are various definitions of high blood pressure, which is also known as hypertension, but most doctors consider blood pressures of 140/90 and greater to be high. The precise values that doctors might interpret as high blood pressure depend to an extent on individual circumstances. For example, in patients with diabetes, the definition of hypertension is considered by some to be pressures greater than 130/80. The definition of hypertension is used by doctors to help decide which patients would benefit from medical (lifestyle and drug) treatment to lower pressure. The definitions depend on the balance of risk of not lowering blood pressure (heart attack and stroke, etc) versus the risks of treatment (drug side effects, etc). This explains why hypertension is defined at lower blood pressure levels in diabetic subjects. For the same blood pressure, cardiovascular complications (that is damage to the heart, blood vessels and brain) are more likely in diabetics and blood pressure reduction offers benefit even when a diabetic’s blood pressure is not as high as regular definitions of hypertension.
How common is high blood pressure?
Approximately 4 in 10 adults over age 25 have hypertension and in many countries another 1 in 5 have prehypertension. An estimated 9/10 adults living to 80 years of age will develop hypertension. One half of blood pressure related disease occurs in people with higher levels of blood pressure even within the normal range.
Why is blood pressure important?
Blood pressure is important because it is the driving force for blood to travel around the body to deliver fresh blood with oxygen and nutrients to the organs of the body. However, high blood pressure is important because it leads to increased risk of serious cardiovascular disease, with complications such as heart attack, heart failure, stroke, kidney failure and blindness.
Who gets high blood pressure?
High blood pressure is more common is older age groups and in people with a family history of hypertension. It is also more frequent in those who are overweight. However, high blood pressure can affect young thin people with no family history, so no one should consider himself or herself immune from high blood pressure.
Does high blood pressure need to be treated?
It is the goal of good clinical practice to reduce high levels of pressure wherever possible in order to reduce the risk of complications such as heart attack and stroke. Changes to lifestyle such as weight loss, reduced salt intake, reduced alcohol consumption or exercise are often the first line of treatment. If these approaches don’t return blood pressure to acceptable levels then drug treatment is usually required.
How do I know if I have got high blood pressure?
The truth is you cannot know your blood pressure unless you have it measured and every adult should know his or her blood pressure. Although headaches and nose bleeds can be the result of very high blood pressure, there are many more innocent causes for these common ailments.
Can high blood pressure be cured?
Although not ‘cured’ as such, modern therapeutic approaches to blood pressure are very effective and generally very safe. However, if treatment is stopped the high blood pressure usually returns reasonably quickly.
A 45-year-old lady came to our hospital with a fracture of her right thigh bone following a simple twisting injury and severe pain in her spine and was not able to sit or even turn in bed. She was in agonising pain. She was fully evaluated with blood tests, PET CT and MRI scans. There was a strong suspicion of cancer in her spine as well as the thigh bone. She underwent surgery on her thigh bone and on her spine, which allowed us to take a tissue biopsy – as a sample from the site of cancer. The patient was mobilised with a walker after surgery, and the cancer was diagnosed as Multiple Myeloma – cancer that forms in a type of white blood cell called a plasma cell. Plasma cells help you fight infections by making antibodies that recognise and attack germs.
Following surgery, on her spine, she is almost pain-free and is now walking. She will undergo chemotherapy, which we hope will cure her cancer.
45-year-old non-diabetic female presented with complaints of:
- Rt. thigh pain and upper back pain since 4-5 months
An acute increase in Rt. thigh pain after mild twisting injury 1 day back
- Neurology: intact
x rays of the spine and fractured thigh bone
The circled area of spine shows cancer of spine
Fixed femur and sent for biopsy
Cancerous bone removed Spine stabilized with rods and screws