SEVERE HYPERGLYCEMIA: KETOACIDOSIS IN PEOPLE WITH DIABETES
How do I know that I am getting ketoacidotic? For most people the first stage is a persistently high blood glucose level, usually associated with an infection or some other illness. You can test for ketones in the urine yourself. Buy the ketone testing sticks or get them from your doctor. If you cannot get your glucose level down within twenty-four to forty-eight hours by increasing your insulin and you have a lot of ketones in the urine, call your diabetic adviser.If this happens when your usual doctor is away, remember that another doctor may be less familiar with your diabetes than your own so you will need to do some explaining. If you know that things have really got out of hand and you have ketones in the urine or symptoms of ketosis, insist on going to the hospital.
Starvation ketosis Less frequently, people with diabetes develop starvation ketosis. Your blood glucose level may be low or high and you have lots of ketones because you have not been able to eat enough, for instance, during an illness when you vomited. Again, if you are not managing to eat very much and feeling ill, it is worth checking for ketones.
The risk of ketoacidosis is the reason why you must never stop your insulin.
Hospital treatment When you are in the hospital, ketoacidosis is treated by infusing plenty of saline (salty water) with potassium into a vein. Treatment also includes either continuous intravenous insulin infusion or hourly intramuscular insulin injections. Your blood acid levels, glucose and potassium will be checked frequently. The infection or other illness which caused the ketoacidosis will be treated. You may be admitted to the intensive care unit so that a close eye can be kept on you. You should feel much better within a couple of days.
Ketone testing It is useful to have a ketone testing kit in the house, but do not become obsessed with ketones. Virtually all insulin-treated diabetics show ketones occasionally. These usually settle with adjustments in diet or insulin. The time to worry is if you are showing a lot of ketones in every urine specimen.
*27/102/5*

TREATMENT OF RHEUMATOID ARTHRITIS: PRESENT APPROACHES TO THERAPYSeveral important pieces of information have come to light during the past decade. First, it has been acknowledged that irreversible damage can take place during the early years of RA, even before such damage is observable on physical examination or standard x-rays. Second, it has been shown that despite their effectiveness in decreasing inflammation, NSAIDs do not change the course of the RA because they do not appear to have an effect on the proliferating synovium. In addition, with long-term use, NSAIDs can cause significant side effects, mostly in the form of stomach problems. Finally, DMARDs, or remittive drugs, appear to be most effective in preventing damage if they are used early. Although these drugs have the potential to cause serious complications, severe and irreversible side effects from DMARDs rarely occur when their use is carefully monitored. Hence, the pyramid approach, which postpones the use of the most effective medications for treatment of RA until irreversible damage has already been done, makes little sense.Recent therapeutic recommendations within the rheumatology community reflect this opinion. Most rheumatologists now believe that if powerful medications are used early in the course of RA, the chances of preventing damage are greatly improved. This philosophy of starting potent therapy earlier in the course of RA is known as inverting the pyramid. Needless to say, there have been many suggestions about the optimal way to reconstruct the pyramid. At this time many physicians initiate use of the very strongest DMARDs within weeks of diagnosing RA.Other physicians propose that therapy begin with several DMARDs at once. This very aggressive – and effective – form of treatment is known as combination therapy. Proponents of this treatment strategy hope that early treatment with smaller doses of several DMARDs will provide rapid and sustained improvement. Once control is achieved, the dosage of the more toxic medications may slowly be decreased. The long-term goal is for the patient to discontinue use of these medications while continuing to use the safest medication that maintains control of arthritis.Many scientific trials testing combination therapy are currently under way throughout the United States. These studies will determine if this form of therapy has lasting benefits without intolerable side effects. We recommend that, if it is at all possible, you find a physician who keeps abreast of the research on this new and innovative form of treatment.*85/209/5*

FEVER IN RETURNED TRAVELERS: TRAVEL HISTORYQuestions regarding the travel history should focus on the following factors.
Exact Travel ItineraryThe risk of acquiring a travel-related infection depends on the precise geographic location and length of stay in each destination. Specific regions visited within each country should be determined, because some infections are focally transmitted, and risk is only present when traveling in endemic areas. The Centers for Disease Control and Prevention publishes an excellent reference, Health Information for the International Traveler, detailing specific infections that are found in different locations. Infections can be acquired en route, and layovers and intermediate stops should be identified. The type of transportation is also relevant, since outbreaks of many types of infections have been linked to airplanes, trains, and cruise ships.
Purpose of Travel Determining the reason for travel can further assist in assessing the risk for certain infections. Business travelers typically stay in modern accommodations in urban centers and have fewer disease exposures. Adventure travelers usually spend considerable periods of time in rural settings, where the possibility for disease exposure is greater.
AccommodationsTourists who stay in modern hotels in major urban centers generally have fewer exposures than backpackers or volunteer workers who spend significant time in rural settings with the local population. People who visit family and friends while abroad are also at increased risk for becoming ill during travel, since they often stay in local homes away from usual tourist routes. These individuals also are more likely to forgo recommended vaccines and chemoprophylactic regimens.*198/348/5*

INFLAMMATIONS OF BONES AND JOINTS: BURSITIS, ANKYLOSING SPONDYLITISBursitisBursitis is the painful inflammation of a bursa. Bursae are synovial-fluid-containing sacs that reduce local friction between bones, muscles, tendons, and ligaments. The most frequent cause of bursitis is a local injury. The bursae most commonly affected are located in the shoulders, hips, elbows, and knees.
Ankylosing spondylitis (AS) Ankylosing spondylitis is a disease of the joints in the spine, the sacroiliac joints in the lower back, and the tissues next to the vertebrae. AS affects eight males to every female and is a common cause of low back pain and stiffness in young men that usually begins insidiously between the ages of ten and thirty years. It affected one individual out of two thousand in a survey conducted in England.Approximately 25 percent of the patients develop a serious inflammation of some internal parts of the eyes, and the aorta (the large blood vessel that carries blood from the heart to supply the entire body with oxygen, food, etc.) may also become inflamed, leaving a damaged aortic heart valve where the aorta is connected to the heart. The tissue changes in the lower back may seriously affect the nerves of the end of the spinal cord in a few individuals and cause local pain or loss of sensation and loss of control of the bladder and rectum.A third to half of the patients with this condition, also known as Marie-Strumpell Spondylitis or rheumatoid spondylitis, has inflammation in other joints, especially the hips and shoulders. The outstanding feature of this disease is deposition of calcium, bone formation in the ligaments of the spine, and gradual development of a poker-back deformity of the spine. Treatment is directed toward prevention of spinal deformity as well as suppressing inflammation and relieving pain.*8/295/5*

RELAXATION TRAINING FOR WAYWARD NERVES: CREATIVE VISUALIZATION – RELAXATION SESSIONSome people are afraid to learn to relax because they use their tension as armour – it holds their fears and hurts (neuroses) inside, and keeps the frightening world out. Bui’ you cannot hold on to this tension and expect to be healthy. Neurosis is discussed in detail in my book Coping with Anxiety and Depression (see further reading).It is a good plan to stimulate the circulation before you lie down, not only because it helps you to relax, but also because some people feel cold as tension eases. Keep a rug near you. If you become aware of your heartbeat or feel lightheaded as you relax don’t be alarmed, just accept it; it is quite normal. Again, if you don’t like the suggested imagery, find your own. The fountain could be replaced by a waterfall, your shower, water being poured from a jug, and the garden could, for example, be replaced by the shore, a meadow or your favourite room.1 Do a few stretching movements and have a good shake.2 Lie on the floor or bed; to stretch the neck and to ensure the chin is not jutting forward, place a small firm pillow or a few paper-backed books under the head. Alternatively you can sit supported in a chair.3 Breathe slowly and gently and imagine your body is sinking into the floor.Now begin your visualization. Imagine you are standing at a gate looking down on a lovely garden; inside the garden is wholeness, love and peace. You choose to open the gate and go inside. On the right there is a crystal clear fountain, the sun is shining through it and you can see all the colours of the spectrum. You feel the desire to be refreshed in the fountain and imagine as you stand underneath it that a beautiful flower about a foot above you opens and allows the water to wash through your head, taking with it any drug deposits, allergens or anything harmful to your brain, eyes, ears or sinuses. Then see it cleaning your throat and flowing down into your chest and abdomen, taking anything harmful to your body with it. Watch it as it goes down your legs and see a muddy stream leave the area under the arch of the foot. The muddy water goes deep into the ground. See your feet looking soft and clean.Now watch the flower open again, and this time allow the water to wash through your mind, and release you from anything that has ever hurt you since before you were born: feelings of rejection, low self worth, grief, loneliness, unhappiness about your appearance, hurtful things people have said and done, guilt about how you have hurt others, frustrations, depression, anxiety, physical pain. Imagine it is all washing through you and leaving through your feet in a muddy stream; it completely disappears into the ground, leaving your feet looking soft and clean.*110\326\8*

LIVING WITH EPILEPSYOne wet and windy afternoon Sue Usiskin was passing her local building society when she recognized the first signs of one of her usual seizures. Wasting no time she entered, beckoning for help as she crumpled to the floor.’The seizure gained momentum. I felt very conspicuous as, apart from myself, the place was empty. The staff stayed exactly where they were behind the counter. None of them came to my aid as I shook and groaned.’Eventually the seizure subsided and I lay wondering how I might get one of the staff to ring my husband at his office nearby. As soon as I was able, I crawled across the floor to the counter, clutching my epilepsy card. I indicated my husbands work number on it and fortunately he appeared in minutes. The manager, who was still behind the counter, explained that he thought I was the diversion for a robbery and had he come to my aid there would have been a chance for an accomplice to get behind the counter.’The problem with fits is that they are unpredictable. They can disrupt your daily routine, your education, your social life and your work. Often they provoke anxiety in others which can alter their relationship with you in subtle ways. And very occasionally, your seizures may have catastrophic consequences.People who have epilepsy have always suffered as much from other peoples’ attitudes towards them and their condition as from the disease itself. Someone who has epilepsy may no longer be considered mad or possessed by the devil, but they are still often regarded, at the very least, as different and liable to occasional bouts of strange behaviour which may embarrass or distress the onlooker who does not understand them and does not know how to cope with them. The epilepsy sufferer may have to contend with other people’s belief that they are somehow second-class citizens, unable to live a normal life. It is often assumed that epilepsy is some form of mental handicap or that it causes a deterioration of personality, or even that it can be caught, like flu.Sue Usiskin, herself an epilepsy counsellor whose experience is quoted above, says she always makes a point of going back to see people where she has had a seizure. If they have been helpful they usually appreciate seeing her well and having the chance to ask her questions about the condition. To those who have not been so helpful she offers some basic education about epilepsy in the form of a leaflet giving information about first aid for fits.Shaping other people’s attitudesThe person who has epilepsy is someone who happens to have an occasional fit; between seizures he or she is as normal and capable as the person who happens to have an occasional cold. Such people do not need or want sympathy or special treatment. There are endless examples of famous people throughout history whose epilepsy clearly proved to be no barrier to the achievement of fame and even fortune. Julius Caesar, Alexander the Great and Alfred the Great were all said to have had epilepsy. The writers Jane Austen and Dostoevsky had epilepsy and so did the poet Byron. Tony Greig had epilepsy and captained the English cricket team.In almost every case, other people’s attitudes towards your epilepsy will reflect your own. If you regard it as a minor nuisance — something you have to live with but that need not affect your capacity for life or make you different or in need of sympathy or special treatment — your friends, colleagues and the people you meet in your everyday life will adopt this view too.However, it is sensible to warn friends and work colleagues what they should do if you have a seizure. If you have generalized tonic clonic seizures the important point to make is that, however horrifying it looks to them, it is not painful or distressing for you, because you are not in any real sense ‘there’ while it is happening.*54\193\2*

MICRONUTRIENTS FOR DIABETICSThe vitamin and mineral needs of patients with diabetes who are healthy appear to be adequately met by the RDAs. Furthermore, a patient’s response to vitamin and mineral supplement is largely determined by nutritional state, so only patients with micronutrient deficiencies respond favourably.People who are at greatest risk of micronutrient deficiency and who may require evaluation for vitamin/mineral supplements include those on extreme weight-reducing diets, strict vegetarians, the elderly, pregnant or lactating women, those taking medications known to alter macronutrient metabolism, patients in poor metabolic control (e.g., with glycosuria), patients with a malabsorption disorder or in a critical care environment, and patients with a congestive heart failure or myocardial infarction. There appears to be no justification for routine prescription of vitamin and mineral supplements for the majority of patients with diabetes.Chromium deficiency is associated with elevated blood glucose, cholesterol and triglyceride levels in animal models. However, it is unlikely that most individuals with diabetes are chromium deficient. Three double-blind crossover studies of chromium supplementation in people with diabetes did not show any improvement of blood glucose control. In people with impaired glucose tolerance (IGT) who consumed a diet deficient in chromium for 4 weeks, chromium supplementation improved glucose tolerance.Magnesium depletion has been associated with insulin sensitivity, which may improve with oral supplementation. Magnesium should be repleted only if hypomagnesaemia is demonstrated.*7/356/5*

ARTHRITIS: CAN VITAMINS SPEED RELIEF?The title of this chapter asks a question. Medical authorities have several answers on whether vitamins can help affect arthritis. Let’s see what they say. . . .A Disease of the ConstitutionMost arthritis, in the opinion of many outstanding rheumatologists, is a constitutional disease, which means, prior to the start of arthritis—or while it is in progress—other parts of the body can be simultaneously diseased. Vitamin deficiencies are present, too, but are not necessarily directly connected with the arthritis.Dr. R. H. Freyberg, in a report in the Journal of the American Medical Association (August 8, 1942), summed up the relationship between vitamins and arthritis. He said, in effect, that there was no relationship in the case of most vitamins to arthritis proper. But one vitamin—vitamin D—was allowed a supporting role.The point was established that vitamin A deficiencies were not uncommon among people who had arthritis and rheumatic diseases. However, when the vitamin deficiencies were corrected, the arthritis still remained. This also held true in the case of other vitamins, like vitamin B. (Arthritics are frequently deficient in vitamin B, as manifested by constipation.) Again, though, correcting the constipation by means of vitamin B does not correct the arthritis.As was stated earlier, leading doctors do believe that one vitamin can play a supporting role in the fight against arthritis: Vitamin D.So, let’s examine vitamin D. You, as an arthritic, should know whether you have a vitamin D deficiency. You should learn to recognise the symptoms … so you can take steps to correct the trouble. Here is a check list. Have you any of these signs? . . .Vitamin D Deficiency Symptoms includeRickets.Enlarged joints. Bow legs.Tendency to tooth decay.Soft brittle bones.Curved spine.Retarded growth.Jutting jaws—poor facial contour.Brittle, splitting nails.The next question, quite logically, is how to correct these conditions. What foods will give your body added amounts of vitamin D? Here is a helpful chart. . . .Foods which are a Good Source of Vitamin DBeefsteak, lean ButterCheddar cheese ClamsCod-liver oil Cream Egg yolk Halibut-liver oilHalibutHerringLiverMackerelSalmonSardinesShrimpVitamin D milkAbove, we have listed some foods which contain the right vitamin for arthritics. Now, what about obtaining vitamins the so-called “easy way”? Will vitamin pills or tablets do the trick?In one word the answer is “No!” My tests and research indicate that taking vitamins in concentrated form (capsules, etc.) does not gain the best results. At least not for victims of rheumatic diseases.If you disagree, then swallow vitamin capsules daily. But take them with MILK. They may not harm you, they just don’t contribute particularly to your war on arthritis.Meanwhile, however, food and diet can bring you greater amounts of vitamins. Drink milk at every meal. Take cod-liver oil (containing vitamin D) until you have normally lustrous skin, scalp and hair. Eat green leafy vegetables, whole grain bread, soups, and lean meats (like grilled or broiled steak, liver and roast beef). Then, you will not even require multiple vitamin tablets.The only reason to take special preparations of vitamins is if you really feel that your daily diet of foods is deficient. If you are unable to obtain or eat the correct foods, then you can supplement your diet with vitamins from bottles.Dr. T. Spies of the Hillman Nutrition Clinic in Birmingham, Alabama, feels that it would be safer for people to take multiple vitamins not knowing whether they need them, rather than trying to run their bodies on depleted foods. That’s the safe way.Dr. Spies is an internationally known and respected nutritionist, and we happen to agree with him.This chapter has covered vitamins and their affect on arthritis. Summed up, they are valuable to your general health. But only vitamin D will directly help arthritics. And it must be taken in oil form, not in concentrated capsules or tablets. Other chapters in this book will give you additional information on how to increase your vitamin D supply.*38\146\2*

HUMAN IMMUNODEFICIENCY VIRUS (HIV): IT CAUSES AIDSThe human immunodeficiency virus (HIV) causes acquired immunodeficiency syndrome (AIDS). If you test positive for HIV, you carry the virus and can infect others but may not have symptoms of the illness for some time. For adults, the average period from infection with the virus to development of AIDS is six to 10 years. After AIDS develops, death usually occurs within two or three years.Currently there are 34 million people estimated to have HIV/AIDS worldwide.Note your symptomsSome people experience symptoms of an acute viral infection within afew months after exposure. The symptoms typically last one to two weeks and resemble infectious mononucleosis: swollen glands, sore throat, fever, malaise, skin rash. Years may pass before early symptoms of AIDS appear, including:Prolonged, unexplained fatigueFever lasting more than 10 daysNight sweatsSwollen glands or rapid weight lossPersistent diarrhea, colds, unexplained dry cough or sore throatEasy bruising or unexplained bleedingTransmissionHIV is spread by unprotected sexual intercourse; sharing needles or syringes with someone who has HIV; receiving contaminated blood, blood products, organs for transplantation or semen for artificial insemination; and from mother to fetus during pregnancy or from mother to infant through breast-feeding.PreventionYou can prevent infection with HIV by eliminating risky behaviors:Limit your sex partners or abstain completely.Avoid unprotected sexual intercourse (oral, vaginal, anal). Always use latex condoms unless you are in a monogamous relationship and you and your partner have tested negative for HIV for six months or longer.Don’t use intravenous (IV) drugs, or share needles or syringes.NOTE: HIV does not appear to be transmitted through saliva, tears, sweat or feces. Nor can it be transmitted through mosquito bites, donating blood or contact with inanimate objects such as toilet seats. An infected person who is coughing, talking or eating poses no risk of spreading HIV to others.Testing for hivDo you suspect you have been exposed to HIV? If so, get tested immediately and repeat the test in six months. Continue testing every three to six months for as long as your high-risk behavior continues.Is your HIV test positive but you have no symptoms of AIDS? Schedule follow-up visits and tests with your doctor.Cooperate with your doctor and public health officials in identifying your sex partner(s) so they may be alerted to the possibility of exposure to HIV.What you can doThere is no vaccine for HIV infection and no drug that can cure HIV. Your best strategy for dealing with HIV is to prevent exposure by abstaining or practicing safe sex.Final notesDrug treatments for HIV and AIDS are aimed at prolonging life by preventing replication of the virus. In general, combinations of drugs appear to be most effective. People who test positive for HIV often experience depression and job-security issues, as well as major social and financial challenges. Always consult your doctor for diagnosis and treatment.*114\303\2*