These are the complications of diabetes that don’t occur overnight. They are serious, and some of them are life-threatening.

They begin to show up five or more years after the initial diagnosis of diabetes. If and when they develop may be related to chance, to heredity and to whether or not a person has maintained good control of his or her diabetes.

Eye problems

People with diabetes are at risk for eye problems. In fact, in the United States diabetes is the leading cause of adult blindness.

In the past, most persons with diabetes who have had the disease for five to ten years showed some signs of eye damage. The most significant eye problems are diabetic cataracts and diabetic retinopathy.

Cataracts

Many older people suffer from cataracts. Even more older people with diabetes have them.

There seems to be a relationship between cataract development, aging and increased blood glucose levels.

Regular eye examinations by a qualified eye specialist (ophthalmologist) are a must for a person with diabetes. These examinations can detect the early signs of cataract development, as well as other diabetes-related eye problems.

Keeping blood glucose levels within the normal range seems to slow the development of premature cataracts in people with diabetes. If they develop, the eye specialist now has a variety of treatment options available.

One of these options is the surgical removal of the lens clouded by the cataract (with the wearing of eyeglasses or contacts following surgery). Another is the implantation of an artificial lens after removal of the diseased lens.

The early warning signs of cataracts are:

•   Blurred vision, particularly at night

•   Halos around bright lights

•   Loss of side vision

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When used as a specific diagnosis, this term refers to a rapid, regular heartbeat originating from a site in one of the ventricles. The rate can be anywhere from about 100 to 250 beats per minute.

Many episodes of ventricular tachycardia (called VT or V tach) do not stop spontaneously, unlike paroxysmal supraventricular tachycardia. What is worse, there is a predisposition for the VT to deteriorate further into ventricular fibrillation. Thus, VT is usually a medical emergency, even if the symptoms it is causing are rather minimal. Most VT is associated with other serious heart disease, such as coronary artery blockage, cardiomyopathy, or congenital or valvular heart disease.

Treatment is directed first to ending the bout of VT. If intravenously administered medications do not produce immediate results, a shock to the chest is usually required (see Defibrillation and Cardioversion, page 283). The next step is to prevent the VT from returning; options are medications, correction of an underlying problem such as myocardial ischemia, use of an internal cardioverter-defibrillator, or surgical or catheter techniques to eliminate the site in the ventricle that is causing the VT.

Ventricular  fibrillation.   The  absolutely worst heart rhythm you can have is ventricular fibrillation (VF). In this condition there is no effective heartbeat—only useless quivering of the ventricular muscle. As far as circulation of blood is concerned, the heart is stopped. Do not confuse VF with atrial fibrillation. VF is the rhythm that is almost always the cause of “cardiac arrest” or “sudden cardiac death.” Unless someone is nearby who can administer cardiopulmonary resuscitation when you go into VF, you will die. There are seldom second chances otherwise; this urgency underscores the importance of knowing CPR.

VF seldom occurs in the absence of other substantial problems with the heart, although rarely it may.

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Cancer of the pancreas is a disease in which cancer cells are found in the tissues of the pancreas. The pancreas is an oblong, pear-shaped organ, about six inches long, that lies within a loop of the small intestine behind the stomach. Pancreas produces juices that help break down food, and hormones such as insulin that regulate how the body stores and uses food.

The area of the pancreas that produces digestive juices is called the exocrine pancreas. About 95 per cent of pancreatic cancers begin in this area. The hormone-producing area of the pancreas is called the endocrine pancreas. Only about five per cent of pancreatic cancers start here.

Symptoms

The most common symptoms of pancreatic cancer are nausea, loss of appetite, unexplained loss of weight, pain in the upper or middle of the abdomen, or yellowing of the skin.

Causes

The precise cause of pancreatic cancer is not known. However, smoking has been strongly implicated as a factor because the occurrence among smokers is more than double than that of non smokers. A high meat diet too has been linked to an increased risk of pancreatic cancer. Working with dry cleaning agents, benzene and other chemicals are also believed to cause this cancer. A sudden onset of diabetes is also considered a cause for this cancer. Some studies suggest that diabetic women are at greater risk of developing this disease.

Diagnosis

Ultrasound test may be done to find tumours. A CT scan, a special type of x-ray that uses a computer to make a picture of the inside of the abdomen, may also be done. Another special scan called magnetic resonance imaging (MRI), which uses magnetic waves to make a picture of the inside of the abdomen, may be done as well. A test called an Endoscopic Retrograde Cholangio Pancreatography (ERCP) may also be done. During this test, a flexible tube is put down the throat, through the stomach, and into the small intestine. The doctor can see through the tube and inject dye into the drainage tube (duct) of the pancreas so that the area can be seen more clearly on a X-ray. During ERCP, the doctor may also put a fine needle into the pancreas to take out some cells for biopsy.

Treatment

Medically, three types of treatment are used. These are surgery, radiation therapy and chemotherapy.

Natural Method

Pain and other symptoms of cancer and the after-effects of medical treatment can be relieved through certain natural methods. These methods may include frequent warm water enemas, daily dry friction, cold hip or sitz bath, neutral immersion bath, relaxation methods and meditation. The use of biological therapy (using the body’s immune system to fight cancer) is being tested in clinical trials for treating pancreatic cancer. It uses materials made by the body or made in a laboratory to boost, direct, or restore the body’s natural defenses against the disease.

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The refusal of competent patients to follow medical advice is understandable when, for example, they lack information, are ambivalent about a risky procedure, or wish the opinion of another physician. Refusals of this type may be more common when patients feel as if they are being carried along on a kind of therapeutic conveyor belt, without an opportunity to influence the speed or direction of events. In these cases, an evaluation for competence can help patients reverse their decisions, perhaps because the physician now offers more detailed explanations, speaks directly to the patient’s concerns, or apologizes for not having had a more satisfactory discussion before. Sometimes, however, nothing the physician can do will change the patient’s mind. This may occur when the latter’s personality is so rigid that accommodation is impossible, as the following case illustrates.

The Case of Mr. J.-Mr. J., a 22-year-old man with acute myelogenous leukemia, was referred to the psychiatric consultation service for evaluation of competence to leave the hospital against medical advice.

The patient’s father and several cousins abused alcohol, but family history was otherwise negative for psychiatric disorder. Mr. J.’s childhood had been healthy, though his upbringing was chaotic because of his father’s drinking. The patient quit school in the eleventh grade, but had later obtained a general equivalency diploma. He worked as a salesman in a department store and, after several years of steady employment, had established an independent existence. Mr. J. was unmarried, but had been in a romantic relationship for two years. He lived alone and had no contact with his family. The patient did not use alcohol or illicit drugs. He was without religious affiliation.

Mr. J. described himself as a cheerful person who was a “go-getter” and a “hard worker.” He was proud of having pulled himself up by his bootstraps. There was no past psychiatric history.

Mr. J. had never been seriously ill and so was puzzled three months before admission when he developed fever, progressive fatigue, and bleeding gums. After a course of antibiotics had failed to produce improvement, the patient went to an emergency room, where his white blood cell count was found to be 160,000. He was transferred to the Johns Hopkins Oncology Service and the diagnosis of acute myelogenous leukemia was made. After leukophoresis was done, induction chemotherapy was given. Mr. J. quickly revealed a fatalistic attitude about his illness and requested not to be intubated or resuscitated.

Throughout his hospital course the patient was worried about missing work, for without an income he could not pay for his apartment or new car. He refused to apply for Social Security benefits because he did not want to take charity. As his hospital stay lengthened from days to weeks, he talked of leaving against medical advice but never did so, despite the unpleasant sequelae of chemotherapy. Mr. J. was discharged after a month’s stay. Though his leukemia was in remission, he did not feel well enough to work.

Five weeks later, the patient was readmitted for consolidation chemotherapy. He again requested not to be intubated or resuscitated. This time, his treatment was followed by worrisome and persistent problems, the most distressing of which were nausea, vomiting, and severe, embarrassing diarrhea. Because of this last complaint, Mr. J. had to wear a diaper and stay in his room. He was again preoccupied with his debts, which now included bills from his previous admission. Under the circumstances, Mr. J. decided to apply for Social Security benefits.

As his hospitalization entered its third week, the patient’s mood became increasingly sad and irritable. He stopped talking to certain members of the staff and began refusing treatments (e.g., antiemetics) and diagnostic procedures (e.g., arterial blood gases). When psychiatric consultation was suggested he refused that, too. Mr. J. was given emotional support and encouraged to voice his concerns as soon as they arose. His mood improved when his girlfriend visited, but she seemed to be a passive person and never became involved in his care.

On the day before psychiatric consultation, Mr.J. threatened to leave the hospital against medical advice. His physicians persuaded him to stay, but the next day he renewed the threat, saying that his situation was intolerable: “I’ve always had a hard life and I just can’t take this

anymore.” He thought that if he could get out of the hospital, he might be able to recover more quickly. Mr. J. now agreed to psychiatric consultation, which his physicians requested despite their belief that he was competent to be discharged.

On mental status examination Mr. J. was an alert, grudgingly cooperative young man who made good eye contact. He lay quietly in bed and appeared fatigued, but there were no psychomotor abnormalities. The patient spoke a moderate amount, both spontaneously and in reply to questions. Speech was prompt, brief, and without evidence of thought disorder. Mood was described as “calm” and assessed as slightly irritable. Affect was somewhat constricted, but appropriate to the content of speech. Mr. J.’s self-esteem was intact and he was hopeful about the future. He denied “passive death wishes,” suicidal thoughts, homicidal thoughts, hallucinations, delusions, obsessions, compulsions, and phobias. MMSE score was 27/30.

Mr. J. said that he had agreed to the consultation to satisfy his doctors that he was sane. He spoke feelingly about his sense that all he had worked for was coming undone, that his bills were growing while he was in the hospital, that he was frustrated at being confined to his room by

diarrhea, and that he could not decide anything for himself—not even what he ate. He understood that he needed treatment for the sequelae of chemotherapy but thought he would do better in a less restrictive setting.

My impression was that Mr. J. had been demoralized by his situation, a situation that was especially difficult for him because of his independent personality. Although his self-reliance had been helpful in other areas of his life, it was now undermining his treatment. I thought Mr. J. was unwise, but not incompetent, and that he might agree to stay in the hospital if he were given greater control over certain aspects of his care, such as his diet.

Mr. J.’s physicians and nurses agreed to do what they could to accommodate his wishes. For a time, he was in better spirits, was more cooperative with staff, and spoke less often about leaving the hospital. Several days later, however, when his nausea and vomiting had stopped, his

diarrhea had improved, and he was scheduled to begin a regular diet, Mr. J. demanded to leave and was discharged against medical advice.

Although he came regularly for outpatient visits as long as he needed transfusions, Mr. J. eventually began skipping appointments because he was worried about physicians’ fees and the cost of laboratory tests. A few months after discharge, when his leukemia was in remission and he had returned to work, the patient dropped out of follow-up entirely. Several months after that, the leukemia recurred and he was hospitalized again. This time Mr. J. was very cooperative with treatments and diagnostic procedures, but he died on the thirteenth day of admission.

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Erving Goffman, other researchers, and authors such as Lucy Grealy have vividly and movingly described the burden, emotional pain, and social isolation of people with visible physical deformities. Such disfigurements may result from birth defects, illnesses, accidents, or other causes. I’ve been struck by how similar the experiences of many of these people are to those of people with BDD. This makes sense. Because people with BDD think—and may be completely convinced—that their defect looks unattractive, even grotesque, it’s not surprising that their experience might be similar to that of people with actual disfigurement. Indeed, some people with BDD describe themselves this way: “I’m the third ugliest person in the world,” “I look like a burn victim,” “I look like the Elephant Man.”

Research suggests that people with facial disfigurements are very aware of their deformities and other people’s reaction to them. They feel stigmatized. They may assume that all of the behavior of others who interact with them is a reaction to their appearance. This awareness of being obviously deviant in a negative way profoundly shapes their self-concept and self-esteem, which may be quite low. The visibly damaged often feel a profound sense of shame and vulnerability to exposure, devaluation, and rejection. They may feel deeply defective and not quite human. These experiences are similar to those of many people with BDD.

Disfigured people generally need more energy to prepare for going out in public and must cope with emotional hurdles in social situations in which the defect will be visible. When they do go out into the world, they may hide the defect by disguising it. They often try to fade into the background rather than stand out “deviantly” in the crowd. They struggle to maintain self-esteem and be accepted by others. McGregor describes one reaction to facial disfigurement as “social death”—that is, badly disfigured individuals may cut off their relationships with the world and go into a closet existence. People with BDD— especially more severe BDD—experience strikingly similar feelings, fears, behaviors, and isolation.

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For a child whose hyposensitization continues even after the start of the aggravating season, injections are given throughout the year; but the interval between injections is increased gradually.

To begin with 1:5000 dilution of the allergens to which the child is sensitive, is given. Biweekly injections are given starting with 0.1 ml and then increasing by 0.1 ml each time till a 0.9 ml dose is reached.

If there is no reaction to this dose and concentration, then the next course is started and the concentration of the extracts increased ten times, i.e., 1:500 and weekly injections or them are given, starting with 0.1 ml and reaching 0.9 ml.

The third course of injections begins with a 1:50 concentration of the allergens and the injections are given, starting with 0.1 ml and going upto 0.5 ml. This is followed with seven more weekly injections of 0.5 ml, keeping the concentrations of the extracts the same i.e., 1 in. 50, which is the maximum concentration. This schedule of injections and dosage is however not sacrosanct. Doctors modify the schedule according to their experience with the extracts of the allergen used.

A child may complain or experience an aggravation of illness for a day or two. If this becomes unbearable, the injection dose can be reduced. Sometimes, a swelling or urticarial patches appear at the site of injection. This also requires a reduction of dose. Since most reactions occur soon after the injection, it is better to keep the child under observation in the clinic for some time so that, required, proper remedial measures can be taken.

The perennial method of hyposensitization has a slightly higher incidence of reactions. However, most doctors believe that the effectiveness of perennial therapy is much greater than either seasonal or co-seasonal injections.

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Antihistamines. Antihistamines may be prescribed to dry up a post-nasal drip that can trigger an attack.

Newer antihistamines also appear to have a bronchodilating effect. Besides, they do not cause drowsiness associated with earlier generation of antihistamine compounds.

However, antihistamines dry up mucus thereby closing airways. If after taking antihistamines the attack becomes worse it should be brought to the notice of the physician.

Antibiotics. These are useful in bacterial infections that complicate an original viral infection, or when there is considerable mucus.

Antibiotics are also useful in treating sinus infection, such as sinusitis, if the secretions are dripping from the nose into the lung and precipitating an attack.

Finally, antibiotics can be used in the treatment of bacteria which grows from the sputum which cause pneumonitis or other lung infections.

Asthma Medicines: Some Important Information

People metabolize medications at different rates. To find out when your child’s medication will take effect, peak and then lose its effectiveness, ask the physician.

If your child does not like to take medications, try to find out the reasons and try to overcome them. The fwer the number of pills to be taken at a time and the easier they are to take (e.g., not having to divide a pill in half), better are the chances that the medication will be taken as prescribed.

Mixing a bad tasting medicine with something tasty such as a piece of bread, candy or juice, helps.

Certain medications, if taken before exercise or before encountering some allergen, can prevent an attack. Discuss this with your doctor.

If asthma attacks often occur in the middle of the night, changing the schedule of medication can help. Sleeping on two pillows also helps.

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Local applications to the unhealthy skin

As a general rule one should never rely too much on local treatment, no matter how circumscribed the skin ailment appears to be. But there are cases where local measures must be employed to help to increase the local circulation, to break up congested spots, to relieve irritation, and to give comfort in painful ailments. For these purposes we may make good use of the various compresses and hot fomentations which assist in elimination and are never harmful. If pain and discomfort can be relieved in this way it is so much better than using pain-killing drugs which invariably upset the digestive system.

The evaporating compress

When there is an overheated and painful area of the skin great relief may be obtained by the use of the simple evaporating compress.

The part is covered by a wet cloth, which still retains as much ordinary cold water as possible, and should not be covered by any other material. The heat of the skin will soon raise the temperature of the compress, and then it should either be quickly changed and another cold one applied, or cold water should be poured over the one already in use. The idea is that the skin must be kept moist all the time, and the evaporating process gives great comfort and relief.

The neutral compress

In some cases the neutral compress is a very useful application that will give more relief to some people than will the cold one.

The temperature of the compress should be about that of the normal skin, and used in this way it is soothing, especially to the great system of nerves under the skin. It should be employed in all cases where the skin troubles seem to set up nervous irritations, and in those cases where the pain is of a neuralgic character it is well worth trying. It excludes the air from contact with the skin and at the same time keeps up a uniform temperature in all the tissues. By keeping the skin moist it softens the parts and allows the skin to absorb a certain amount of water into the external parts. When the skin is affected by a complaint that is clearly associated with an irritated nervous system this compress should be freely employed for its soothing qualities.

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Treatment takes many forms and involves a number of different members of the treatment team as well as the social worker. Interventions must be individualised to address the particular needs of individual patients and their families.

Supportive counselling is the mainstay. It may be conducted on an individual basis for the patient or a family member, as a family meeting or as a discussion group involving other patients and families. Supportive counselling aims to facilitate coping and involves listening, allowing emotions to be expressed, answering and informing. Practical assistance such as the provision of aids for daily living, facilitating minor alterations in the home and accessing community resources and services will be beneficial. Every effort should be made to maximise the support, both professional and non-professional, available to families. Assistance with financial and legal matters is often necessary.

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