The heart pumps blood so that it can reach various parts of the body and supply these parts with oxygen and nutrients. The pressure generated by the heart forces the blood to go from the heart to various organs and return from there to be sent again. There is about 5 liters of blood in average adult and heart pumps about 70 ml in each heart beat. The force generated by heart results in pressure which can be measured.
Hypertension is said to occur when the recorded blood pressure is higher than expected for the particular age. Children have lower BP, it gradually rises to adult levels and continues to increase with age in most cases. BP is measured by sphygmomanometer which was earlier mercury based but are now aneroid or electronic. BP is measured as Systolic ( higher value of the two ) and diastolic (lower reading) and written as systolic/diastolic BP in mm of Hg. e.g. 120/80 mm Hg.
Blood pressure at birth is about 70 to 85 /30 to 45 , at 5 yrs 90-110/50-66 , at 10 yr 100-120/60-80. In adults blood pressure is diagnosed when it is usually more than 140/90 mm Hg.
Causes of high blood pressure.
In most cases, there is no apparent cause. Suspicion usually falls on genetic disease, high salt intake, higher weight etc. in younger patient sometimes a cause is detected. It is often due to kidney disease, hormonal disorders, blood vessel diseases or diseases disturbing immunity. It can at times be caused by drugs like steroids and analgesics.
Symptoms of high Blood pressure
Most patients have no symptoms due to high blood pressure. It is only the measurement of blood pressure which reveals the diagnosis. Some patients with high blood pressure may have headaches, dizziness, throbbing or at times shortness of breath. If blood pressure rises suddenly to very high levels it may cause emergencies. These may include vision loss, renal failure, alteration in consciousness ( drowsiness or unconsciousness), or heart failure (manifested as breathlessness worse on lying down or activity)
Clinically it is diagnosed by BP measurement, usually on more than one occasion while a person is sitting with back supported. 2 or 3 readings may be taken and the lower readings are usually more accurate. If in doubt multiple readings can be taken while the person is continuing his activities (ABPM or ambulatory BP monitoring). Eyes are checked as blood vessels can be seen in the retina, ECG and X Ray Chest may show heart enlargement.
Lab tests are done to find the cause of high blood pressure if any, its effects on various organ systems and complications. The usual tests done are Blood counts, urine routine examination, Blood Urea, S Creatinine, S electrolytes, Blood Sugar, Lipid profile in blood, ECG, X Ray of chest and Ultrasonography of abdomen. In special cases hormones may be measured or Doppler Ultrasound studies are done to check blood flow and vessels in different areas.
Complications of high blood pressure:-
Complications arise if the blood pressure is very high or it has been present for a long time. Not all persons with high BP get complications. Some of the complications are :
- Strokes (paralytic attacks due to bleeding in the brain or reduced blood supply to part of the brain)
- Increased likelyhood of heart attacks.
- Heart failure (not stoppage of heart beat or cardiac arrest ) but inability of heart to meet bodily demands. This is diagnosed by swelling of feet, breathlessness at night after sleeping for 2-3 hours, fatigue etc.
- Chronic renal disease resulting in renal failure if allowed to go unchecked for long periods.
- Decreased blood supply to other organs due to thickening of blood vessel walls and narrowing of their internal lumen (athersosclerosis of aorta, limb vessels, vessels supplying brain, kidneys, heart, eyes etc.)
Treatment of Hypertension
Why should hypertension be treated ?
The following are the benefits of treating hypertension:-
- 50 % reduction in risk of heart failure
- 30-40% reduction of risk of strokes of brain
- 20-30 % reduction in risk of heart attacks.
The benefit occurs in all age groups including elderly. If a cause has been found (as happens in very few cases) treatment of underlying cause is useful e.g. treating kidney disease, removing adrenal tumours, stopping steroids, analgesics, contraceptive pills, certain anti depressants etc.
In majority of cases no cause is found. In these we suggest non-pharmacologic ways as well as medicines to lower blood pressure.
Non pharmacological methods may reduce blood pressure by 5- 10 mm on their own. These include
Reduction of weight if overweight
Reduction of salt in diet (avoid pickles, salted foods, preserved foods). Do not take salt substitutes if there is associated kidney disease.
Dash diet ( dietary approaches to stop hypertension diet ). Increase vegetables, whole grain cereals, low fat, low sugar and sweets, more fruits, fish and chicken if you are a non vegetarian
Increase physical activity, both physical aerobic activity and relaxation exercises may help
Stop or cut down on alcohol and smoking
Learn about Hypertension.
Pharmacological methods may reduce blood pressure
2 or more drugs are required if BP is >20/10 above the normal range. More medicines and higher doses are needed if blood pressure is due to kidney disease. These drugs may cause side effects and hence prescriptions are tailor made to suit particular requirements of the patient.
The Drugs include
Diuretics :- which increase salt and water excretion in the body. These work only if salt is cut down in diet.
ACE- inhibitors and ARB’s :-These are a class of medicines which protects against ill effects of high BP on kidneys, heart and brain. However treatment is complicated and always should be under the guidance of a competent physician. These drugs are known to cause fetal malformations. Inform your doctor if you are pregnant or are planning to have a child,
Calcium Channel blockers :- Very useful and often used class of drugs. Some times these may cause feet to swell otherwise these are well tolerated.
Betablockers:- These reduce heart rate and blood pressure. This is useful in reducing stress on the heart. However these may cause serious worsening in asthma and may aggravate prostate symptoms, and may cause impotence.
Centrally acting and alfa blockers:- These are also useful in controlling BP. Some of these may cause or worsen depression.
Diabetes is a condition where a person either does not produce required amounts of insulin or is unable to utilise insulin appropriately. It is a common (about 10% of population), complex disease. It can cause complications if not treated and controlled well.
Types of Diabetes:
There are 2 common types of diabetes Type I and Type II. There are other rare varieties due to pancreatic diseases, hormonal disorders, in pregnancy , after drugs and even rarer genetic disorders.
Type I is the cause in about 10 % of cases, onset is in childhood or young age and insulin is required for treatment.
Type II is the common variety, onset is usually around 50 yrs of age, often associated with overweight and the risk is high if one parent is diabetic (30 %) and if both parents are diabetic (50 %). sDuring initial stages diet modification and oral drugs may control sugars but later insulin may be required.
Classically symptoms in diabetes are polyuria (more urine), polydypsia (more thirst ) and polyphagia ( more eating). In children very high sugars may develop suddenly and patient may become unconscious at the onset (DKA etc). Infections both recurrent and difficult to treat may occur. However in a large no the disease remains without many symptoms and found out accidentally or when complecations arise.
Signs are seen only in advanced and long standing diseases. These are few and may include eye, heart, nerve changes, dehydration and very rapid breathing due to acid accumulation in the body.
Diagnosis of diabetes:
Diabetes is diagnosed by blood glucose testing or glycated hemoglobin levels.
Normal Plasma glucose level after 8 hrs of fasting is < 100 mg/dl. Normal 2 hrs after breakfast (called PP) or after 75 gms of glucose orally is <140 mg.
Diabetes is diagnosed if either fasting plasma glucose is >126 or PP or oral GTT (after 75 gms of glucose is >200 mg/dl.
If fasting value is 100 -125 it is called impaired fasting glucose and if PP or Oral GTT is between 140 and 199 mg/dl it is called impaired glucose tolerance( IGT).
In a person with symptoms of diabetes a random value of plasma sugar >200 mg /dl or fasing plasma sugar >126 mg/dl qualifies for diagnosis of diabetes.
Lab tests for diabetes :
For common types of diabetes the following tests may be required at the time of initial diagnosis.
Complete blood counts, Blood sugar, kidney and liver function tests, urine routine and urine for microalbumin, lipid profile, Chest X Ray, ECG. Ultrasonography of abdomen, fundus examination, foot examination and blood pressure is noted.
In Type I cases or where genetic, pancreatic or hormonal disorders are suspected, tests for these are carried out as appropriate.
This is a chronic disease and lifelong follow up and treatment are required.
Complications of Diabetes mellitus
Complications of diabetes are due to high sugars and damage to the small and big blood vessels mainly.
High sugars can cause frequent skin and deeper tissue infections. Infections are common, more severe, often require prolonged treatment and may turn serious if not treated fast and appropriately.
In case of very high sugars (DKA or Hyperosmolar states) a person may become unconscious and this may be life threatening. Severe dehydration, salt and water imbalance, accumulation of acids, decreased kidney function may supervene. Treament in hospital is required for patients.
Long term complications are due to blood vessel and nerve tissue damage.
In feet painless wounds (trophic ulcers) may occur and not heal for months. If infected secondarily even amputations may result.
Damage to retina is called retinopathy. In most countries now, diabetes is the major cause of blindness. Regular check up by eye doctors and laser treatment of newly formed blood vessels may prevent blindness at a later stage.
Damage to nerves may cause numbness usually more in hands and feet. Involvement of nerves supplying muscles can cause weakness in moving limbs. Involvement of nerves supplying bladder and large intestines may result in disturbance in acts of passing urine and defecation. Constipation , diarrhea and retention of urine may occur.
Long term diabetes can damage kidney in multiple ways. The details can be seen later in the kidney care part.
Involvement of coronary arteries results in high risk of heart attacks and angina. Similarly strokes causing paralysis etc occur with a much higher frequency in diabetics.
Treatment of Diabetes in Type II Diabetes Mellitus
Treatment of diabetes starts with educating patient about his disease. He is also educated about symptoms related to low and high sugar levels so that he can recognise these. He is encouraged to carry a diabetes card with his medication, and name of his doctor written on it. He is also encouraged to carry with him sugar candies etc near him to treat hypoglycemia. Home blood glucose monitoring can be taught to nearly all patients.
The various risk factors are noted and the complications if any are studied. The goal of treatment is to reduce the sugar to near normal levels to ward of complications of diabetes and reduce risk to life, vital organs while permitting a good quality of life.
Non pharmacologic measures
To reduce risk of heart disease and stroke, weight should be reduced to normal levels. If a person is overweight (BMI ie Wt in kgs/ ht in meters squared) and BMI is between 25 to 29.9 wt can be reduced gradually to with in limits. If a person is obese BMI >30 then more urgent weight reduction is required.
A weight reduction of about 10 kgs will make a substantial difference in diabetic control
If overweight or obese calories are cut down. About 15% calories should come from proteins and < 30 % from fats. The rest of calories may be from complex carbohydrates. Simple sugars are not advisable. Sugar substitutes can be taken.
If weight does not reduce after 6 months of trial, weight reduction tablets (Orlistat) etc may be considered. In severe obesity cases bariatric surgery may be the only alternative if all else fails.
About 150 mins of exercise in a week is recommended. Aerobic exercises are preferred though in younger patients who do not have heart disease or advanced diabetic retinopathy weight lifting twice a week is encouraged.
The exercise should be done on most days of the week and be sufficiently vigorous to be of cardiac benefit.
Smoking is a huge risk factor for heart disease. Since diabetes itself is a high risk state for angina and myocardial infarction continued smoking increased the risk manifold. Smoking should be stopped totally to reduce this risk.
Drugs are required in nearly all cases for sugar control. More about drugs later.
Treatment of Diabetes Mellitus
The drug treatment of Diabetes mellitus consists of Insulin therapy and oral hypoglycemic (glucose lowering) drugs. In Type I diabetes insulin injections are almost always required and started at the time of diagnosis. In Type II Diabetes many drugs are available and are tailored to the patients’ needs.
There are some drugs which can result in weight gain (sulfonylureas) and Insulin while some facilitate weight reduction (GLP 1 agonists), Metformin etc. Some of these produce hypoglycemia more often then others (long acting sulfonylureas). While others may not cause hypoglycemia (DPP 4 inhibitors. Some of these are long acting, while others act only for a few hours.
Some of the newer drugs (GLP 1 agonists ) are also available as injections only.
The initial therapy in Type II cases is usually Metformin. The goal of treatment is to bring HbA1C to < 7.
Therapy is usually started when HbA1C is 7.5 to 8.5 or when symptomatic diabetes is present at onset or complications are evident.
All diabetic patients should be familiar with symptoms of hypoglycemia. Meals and exercise both should be regular.
Hypoglycemia should never be neglected and treated as early as possible while taking care that all symptoms in diabetics are not taken as due to hypoglycemia and treated with sugars.
These are injectable drugs. They can be injected by patients themselves.
Most are now available as Insulin Pens, where the dose of insulin can be dialled by patients and the pain of injections is negligible. Insulin injections site should be rotated. Always cleaned before injections and monitored for infections.
Various types of insulins are now available. Some are long acting while others may act for a few hours and a third variety may have an intermediate duration of action. Some of these are taken before and some immediately after the food.
Monitoring of diabetes
In children (Type I Diabetes ) sugars need to be monitored more often as high and low sugars are common. Daily sugar check is recommended in most.
In Type II Diabetes, sugar monitoring may be done less often. During checking days, do not alter the diet, exercise or drugs. A true state is required rather than one that pleases the doctor and patient.
Learn to do home glucose monitoring. HbA1C levels are checked once in 3 months or so. Eyes need to be checked every 6 months for changes of diabetic nephropathy.
Kidney check up, heart check up is done every year to detect early diabetic complications.
Feet are examined every day by the patient at home by seeing the sole in a mirror, to look for cuts, ulcers etc.
Dengue (pronounced as Dengii) fever is caused by a virus. Four types of viruses called DENV 1 to 4 are seen. These are spread while a mosquito (Aedes egypticus) is biting a human being. This mosquito bites during the day and breeds in stagnant water. It is widespread throughout India and South East Asia. About 400 million cases occur every year in the world.
Most of the infections do not produce symptoms. About ¼ may cause fever usually in children and young adults. Dengue infection can recur if a person is infected with the same type of virus as immunity decreases with time.
Common manifestations :
These begin 3-14 days after the bite. The symptoms are
- Fever with temp of > 38.5 o C
- Headache, pain behind the eyes
- Pain in the back (at times severe : break bone fever)
- Pain in the abdomen or chest
- Mild pain in the joints.
All symptoms need not occur simultaneously. The doctors or patient may notice a pink rash which fades temporarily on pressing the area. In severe cases vomiting , tiredness, abdominal pains may start.
Pin point like bright red spots or blotches of reddish areas may occur. Complicated cases are called Dengue Hemorrhagic Fever (DHF) or Dengue Shock Syndrome (DSS).
In DHF Bleeding may occur from nose, in stools or vomits or periods may be heavy in woman. Bleeding may be very heavy at times. Abdomen and Chest collect fluids (called ascites and pleural effusion).
In DSS life threatening situation occurs with fall in blood pressure and involvement of other vital organs. Blood pressure (systolic) is below 80 mm Hg in children under 5 yrs and < 90 mm in those older then 5 yrs.
Laboratory Tests :
In blood counts platelets and WBCs may be low. Hb may rise in DHF due to leakage of plasma under the skin or in lungs and abdomen.
Dengue is diagnosed by Direct tests showing Virus particle or its part (antigen or genome), or indirect tests (IgG and IgM antibodies in serum). Direct tests are more accurate but costlier.
Milder cases require only symptomatic treatment. In complicated cases hospitalisation and monitoring of platelets, bleeding, blood pressure, vital organ function is carried out.
Patients may require IV fluids, Blood and their components (platelets etc) After a critical phase of 24 to 48 hrs, patient may start recovering. Prevention of Dengue is by antimosquito measures and preventing mosquito bites esp in young children and adults.
Chikungunya fever is an acute febrile illness caused by a virus. Originally from Africa, now it is widespread in India and Asia. It is spread by a bite from a mosquito. Multiple species of Aedes can spread the virus. In some countries, the virus can also be transmitted to primates and other animals. Aedes egypti transmission is usually from a man to man or woman.
The virus multiplies in the mosquito and then goes to mosquito’s salivary gland. Multiplication is faster in summer months in mosquitoes. After a gap of 2-5 days (called incubation period) patient develops fever and pain in multiple joints.
Sometimes more than 5 or 6 joints, usually hands, ankles knees etc are involved. Joint swelling is common. Due to the pain patients often walk with a stoop or bending up (In Tanzania Chikungunya means bending up)
A rash over trunk which may be pinkish or bright may occur over limbs, chest or abdomen. This rash fades on pressure. Loose motions or vomitings may be seen. Pain and fever subsides in 3-5 days. In some cases joint pains may persist for 3-6 months.
It was earlier believed that complications and fatalitiesdo do not occur due to chikungunya. However, now both have been reported but are rare.
Involvement of heart, lungs, liver, kidneys and brain may occur. The disease is diagnosed by looking for antibodies in the blood against this virus.
Treatment is directed towards relief of fever and joint pains. The disease can be prevented by taking prevention against mosquito breeding and bites.
It is also known as H1N1 viral influenza A or simply as H1N1 Influenza.
The last big pandemic was in 2009. Nowadays it occurs off and on in India and other countries mainly during flu season.
Fever usually more than 100o F is common. It is accompanied by a sore throat, running nose, cough, headache and muscle pains. Shivering may occur as do vomiting and loose motions.
Individuals both very young and very old as well as pregnant women are at high risk of complications. Similarly, those with other debilitating conditions: malignancy, asthma, smokers, HIV +ve patients and those who have low immunity due to various drugs and disease may develop severe complications.
About 10 % persons may have no symptoms. Fever may not occur in some cases.
The complications may occur in about 20 % cases. These are in the form of failure of gas exchange by lungs, low BP, altered level or lack of consciousness, fits, liver and kidney failure etc.
The diagnosis is made by both nasopharynx and throat (combined) real time reverse transcriptase (rt RTPCR) which is nearly always positive. Chest X Rays can show pneumonia.
In some cases, superadded bacterial infections occur a few days later and complicate the illness.
Treatment and prevention
Treatment with antiviral drugs reduces complications. The drugs used are Oseltamivir and Zanamivir. The doses are different for children. These drugs are also used for prevention of infection after and before contact with swine flu patients.
The spread is by droplets (during coughing and sneezing ) and close contact. Patients should be diagnosed early to prevent the spread of the disease.
Obesity is evaluated by screening for confirmation and assessment of risk factors. Once the BMI confirms obesity severity is divided into
Grade I BMI >30 but < 35
Grade II BMI >35 but < 40
Grade III BMI > 40
Waist circumference is measured at the highest level of the hip bone by a tape placing it horizontally. In woman a waist circumference of > 88 cm or 35 inches and in Man >102 cm or 40 inches signifies central obesity.
Persons with central obesity are more at risk for heart disease, diabetes, Obstructive sleep apnoea and hyperlipidemia (excess lipids in blood).
Coexistence of coronary artery disease, atherosclerosis elsewhere, Sleep apnoea, high BP, h/o premature heart attacks in other close relatives, smoking and lack of exercise : all these act togather to increase mortality.
Japanese Encephalitis( JE)
It is caused by a virus called JE Virus or JEV. It is now endemic in Asia. Most cases occur in the beginning of rainy season.
The disease is spread by mosquitoes. The virus multiplies in pigs and aquatic birds. When a mosquito bites human beings after biting pigs the virus is transmitted to man. Pigs are the most important hosts due to very high levels of virus in their blood.
In man the virus multiplies but does not reach levels where a mosquito after biting one human being can transmit it to others. The name of mosquito spreading it most often is Culex Vishnui. However, it is found in other species of mosquitoes as well.
After a gap of 5 to 15 days (called incubation period), signs and symptoms of the disease appear.
Most of the cases where the bite transmits the virus are subclinical or mild. Only about 1% of the cases are severe and brain inflammation or encephalitis is seen.
In the beginning, there is fever and sometimes loose motions and body aches. Chills and rigors, headache and vomiting may occur. A few days later involvement of the brain is seen with the occurrence of fits, drowsiness, and patients may become unconscious.
Diagnosis is achieved by finding antibodies against this virus in the blood (ELISA Test) and rarely by finding viral particles (NAAT )
They may remain bedridden for weeks.
20 to 30 % of the patients who are hospitalised with JE die due to the illness. Of the survivors, 40 to 50 % may have permanent neurological damage.
Prevention is accomplished by preventing mosquito bites.
A vaccine grown in vera cell line given in doses of .5 ml on day 0 and 28 is available for adults. A live attenuated vaccine and other vaccines have also been manufactured. These vaccines may have side effects.
The efficacy of the vaccine is not yet clear.