The festival season and diabetes

India is a land of festivals. The period between October and January is full of festivities. For people with certain health conditions, particularly those living with diabetes, this is a highly testing time. India is currently termed the diabetic capital of the world with more than 70 million people living with this condition. It is important for people living with diabetes to focus on their treatment and management goals during the festive season too.

Que: What are the hazards to the patient with diabetes during the festival season?

The festival season includes periods of fasting and feasting. Many patients with diabetes fast for varying periods during this period.

One of the serious consequences of fasting is hypoglycaemia (very low blood sugar which occurs if the sugar level is less than 70 mg/dl). This can be potentially fatal and can have long term consequences and should be avoided at all costs.

The symptoms of hypoglycaemia include sweating, shaking, hunger, dizziness, palpitations and in extreme cases confusion, drowsiness and unconsciousness.

If the patient is conscious then he/she should immediately consume 15 grams of glucose or sugar followed by some snacks like fruits, biscuits, sandwiches. Fingerpick glucose check 15 minutes after taking the sugar should ideally be done to see if the blood sugar has risen to at least 90mg/dL or more and if not, the sugar intake has to repeated. If the patient is unable to take by mouth because of drowsiness or unconsciousness then he must immediately be taken to the nearest hospital.

On most occasions high blood sugar does not have immediate symptoms. Typically, very high blood sugar symptoms include excessive thirst, frequent urination, blurry vision, fatigue, dry mouth.

Que: Should patients with diabetes fast during festivals?

Ideally patients with diabetes should not fast. None of the religions mandate fasting for people who have illness. However, should anyone have a strong desire to fast then he must discuss this with his diabetes doctor. Some anti diabetes medications carry a low risk of hypoglycaemia and hence in such cases the diabetes doctor may make temporary changes to the medications to include those with the lowest risk of hypoglycaemia. However, patients on insulin and sulphonylurea group of drugs remain at a higher risk of hypoglycaemia during fasting.

Que: Do we need to change the diabetes medications during the festival season?

Discussing the medications with the diabetes doctor before the festivities will always help in reducing the swings of blood sugar during festivals. If needed your doctor may make minor adjustments to your medications. Particularly those on insulin will definitely benefit from pre festival advice. On some occasions your doctor may advice extra rapid acting insulin on days where more than usual amount of food is consumed. It is of vital importance that medications must be taken on time and the food should be taken as close to the usual routine of the patient as possible.

Que: Should patients with diabetes have sweet products during festivals?

There has to be balance as far as food consumption is concerned. If occasionally a sweet is taken then for that particular meal the amount of carbohydrate (rice, roti) should be reduced so that there is less rise of blood sugar. “Cold drinks” cause significant elevations of blood sugar and hence should be replaced with low sugar drinks like diet coke/diet pepsi. Sugar free products in moderation may be taken and one of the sugar free agents called sucralose is also heat resistant and may be added to hot drinks.

Que: What food should a patient with diabetes choose during festivities?

Carbohydrates are the type of food which in higher quantities causes blood sugar to go up. High carbohydrate containing food includes sweets, chow mien, noodles, pizza, idli, and high amounts of rice, roti, paratha. So, the trick is to take less food with high carbohydrate content. Instead more amounts of vegetables (any vegetables, few pieces of potato are allowed), dal, fish can be taken. Taking more amounts of salad and boiled vegetables before a meal gives a feeling of fullness leading to less consumption of high carbohydrate and fried food. This may not be applicable for patients with kidney disease. It is a good idea to reduce the portion size and include a variety of food groups. Any two fruits a day is allowed for patients with diabetes and hence fruit based desserts rather than sugar based desserts should be encouraged. Walking after a meal also helps burn up the extra calories. The exertion during the festivities may cause dehydration and hence it is important to consume adequate water to prevent dehydration. Alcohol, if consumed, should only be taken in moderation (not more than two “standard pegs in 24 hours) and should not be taken in an empty stomach as it may lead to hypoglycaemia (very low blood sugar) after a few hours.

There is no reason that a person with diabetes cannot enjoy the festivities during the festival season. Actually, nowadays the term “Diabetes diet” has been replaced by the term “Healthy diet”. Hence the above advice is just as applicable to the common population without diabetes. It is important however to keep a regular check on the blood sugar levels for peole with diabetes. So, best wishes for all the upcoming festivals !!

Minimally Invasive Coronary Artery Bypass Surgery

By: Dr. Ratan Kumar Das, MBBS, MS, MCh. Director Cardiac Surgery, BMBirla Heart Research centre, Kolkata 700027

We all know that bypass surgery is a big invasive surgery and  leaves behind a big scar . As an alternative  the same procedure can be done with a small cut which involves less trauma and discomfort.   Who will not like if he can has a bypass surgery with a smaller incision. We do not have a terminology like maximal invasive bypass surgery.  The normal  or traditional way of doing the bypass surgery involves a big cut  ( approximately 8 inch) in the middle of chest through the breast bone . However , Minimally invasive bypass surgery involves making a small incision ( 4 to 5 cm) in the left side of chest between the ribs.

Minimally Invasive bypass surgery is complex procedure and needs training and experience of the surgeon. Though it is not an option for everyone,  minimally  invasive procedure has  many benefits when compared with conventional bypass surgery   which includes

: Less blood loss

: Lower risk of infection as it does not involve cutting of bone

: As the trauma is less pain is lower and hospital stay is shorter

: Recovery is faster and patients can resume normal activities earlier

: There is smaller and less noticeable scar.

However there are some disadvantages we come across with this  procedure like, it requires special instruments, need trained and experienced surgeon, operative time is little longer than conventional bypass, occasionally you may need to abandon the procedure and  convert  the procedure to traditional method if we come across with problem while doing the surgery.

This procedure can be done for all three coronary arteries. Few years ago this procedure was limited only for left sided arteries. However,   more and more surgeons are bypassing the right sided vessel successfully nowadays.  Multi vessel coronary bypass can be performed with this technique in a large number of patients with an excellent procedural outcome.  We have been doing Minimally invasive multivessel  ( three vessel) bypass surgery in BMBirla Heart Research center regularly for years.

We often come across the term bypass with LIMA RIMA  in common parlance regarding its durability .  LIMA RIMA are arteries taken from inside the chest wall  and  used for bypassing the coronary arteries and usually done by conventional  technique.  In this way we can avoid making cut on legs. As this is a total arterial grafting, patient may not need a second surgery for more than 20 years.  Now the question is, can LIMA RIMA  bypass possible with minimally invasive procedure?  Yes with the invention of newer instrument it is nowadays possible to take out both the LIMA and RIMA  through the small cut in left side of the chest and surgeons are doing  LIMA RIMA bypass using minimally invasive technique  more often.

However there are some limitations of this procedure.  Not everyone is a candidate for minimally invasive bypass surgery.   Patients  who  have history of previous heart surgery,  history of chest trauma , too high risk patients, older age ,poor and big hearts should opt for the traditional bypass surgery which is still considered as gold standard procedure.

What is cardiac arrest?

Cardiac arrest is a medical condition where the heart stops functioning leading to a loss of breathing and consciousness. A cardiac arrest happens when the heart stops pumping blood leading to no flow of blood in the body, particularly the brain and resulting in death. 

Generally, the heart makes the blood in the upper chamber or atrium and then supplies the blood to the other organs in the body through a network of heart valves. However, in cardiac arrest, the upper chambers of the heart crash and stop functioning and thus, there is no supply of blood to the body. Alternatively, the bottom chambers, known as ventricles, stop beating and become identical to thick gooey masses that do no produce a heartbeat or supply oxygen and blood to the other organs of the body. 

This sudden crash of the system causes a complete loss o heartbeat, consciousness and can lead to an untimely death, if not resurrected timely. As per research, 95% of people who experience a cardiac arrest succumb to death. Also, each year in India, more than 10% of the total deaths occur because of cardiac arrest. It is also the most common cause of death in the entire world.

Symptoms of cardiac arrest

Mostly, a cardiac arrest is very sudden and hence, does not produce any significant signs and symptoms. However, some of the common symptoms of cardiac arrest include:

  • Abruptly racing heartbeat
  • Extreme anxiety
  • Dizziness
  • Dangerous heart rhythm
  • Fluttering ventricles
  • Frozen body temperature and numbness 
  • Sudden collapse
  • Painful and difficult breathing
  • Loss of pulse

That said, most of these signs appear very close to a cardiac arrest. However, some of the other symptoms that could indicate the upcoming dysfunctionality include:

  • Chest pain or discomfort
  • Shortness of breath
  • Fatigue 
  • Weakness
  • Palpitations

Apart from these, even if a person does not have these symptoms but experiences any irregularities in heart functioning, a doctor should be contacted immediately. Some of the irregularities include:

  • Chest pain or discomfort
  • Rapid or irregular heartbeats
  • Continuous unexplained wheezing
  • Shortness of breath
  • Extreme heart palpitations
  • Loss of consciousness
  • Dizziness and blurriness of sight

Mostly the symptoms of a cardiac arrest are very short-lived and hence, there is not much time to act before the heart stops functioning. Therefore, it is very important to get immediate medical treatment upon experiencing any of the above signs. Moreover, avoiding all cardiac arrest causes and staying clear of factors that can trigger a cardiac arrest, is the best way to prevent this problem.

Heart conditions that can cause a cardiac arrest

A few heart issues that could potentially cause a cardiac arrest include:

Coronary artery disease: This causes the coronary arteries of the heart to become narrowed or clogged due to build-up of cholesterol and fatty items called plaque. 

Heart attack: A heart attack in many cases occurs because of severe coronary artery disease and can cause ventricular fibrillation leading to a cardiac arrest. A heart attack can also cause scar tissue, which can cause abnormalities in the functioning of the heart.

Enlarged heart: An enlarged heart can also cause cardiac arrest. An enlarged heart is indicative of weak heart muscles, coronary heart disease, or a valve problem. 

Congenital heart disease: Congenital heart disorders, including Brugada syndrome (BrS) and long-QT Syndrome (LQTS), can potentially lead to abnormal heartbeats and rhythms. These birth defects can cause intense complications for adolescents and children. Also, people who have a history of congenital heart disease surgery are at high risk of cardiac arrest.

Valvular heart problem: A valvular heart problem occurs when there is a damage or defect in any of the four valves of the heart. A leakage or narrowing of the valve hampers the normal functioning of the heart, causing the heart muscles to stretch and thicken obstructing the blood flow. Further, this issue causes stress on the enlarged or weakened heart chambers, thereby, causing irregularity of heartbeat and rhythm.

Risk factors of cardiac arrest

A few factors that make a person more prone to experience a cardiac arrest include:

  • Age – Men above 45 and women beyond 55
  • Medical history of heart attacks
  • A family history of heart issues or cardiac arrest
  • High blood pressure
  • Smoking
  • Excessive consumption of alcohol
  • High blood cholesterol
  • Overweight and obesity
  • Diabetes
  • Physical inactivity 
  • Abuse of drugs
  • Deficiency potassium and magnesium
  • Fatal kidney diseases

Treating of cardiac arrest

Since cardiac arrests are sudden, only immediate medical help can ensure survival. It is important to take prompt action and have an immense presence of mind to adopt the right medical approach. The heart can be revived if the patient receives treatment within the first minutes of an arrest. But every minute that is lost, reduces the chances of survival by 10%.

Here are some treatment options for a cardiac arrest:

CPR: CPR – Cardio-Pulmonary Resuscitation, includes chest compressions and mouth-to-mouth rescue breathing support to restore blood circulation. A person should give CPR to the patient until medical help is received.

Defibrillation: Defibrillation involvesdelivering electrical shocks through the chest wall to the heart muscle to revive it. This process aims to temporary stop the heart and the irregular rhythm. Once the heart is revived, the heartbeat is regularised. The defibrillators are configured such that they only send out signals when it is appropriate.

Long-term treatment: Once the patient is stabilised, the doctor will discuss the long-term treatment options to secure the heart from future cardiac arrests. These will include:

  • Drugs 
  • Implantable cardioverter-defibrillator (ICD)
  • Coronary angioplasty
  • Coronary bypass surgery
  • Radiofrequency catheter ablation
  • Corrective heart surgery

However, there is no better way to avoid cardiac arrest than to maintain a healthy lifestyle. Irrespective of the age or gender, a healthy lifestyle is very useful to avoid a cardiac arrest. Some healthy lifestyle habits that can prevent cardiac arrest include:

  • Opting for healthy eating food choices and habits
  • Increasing physical activeness
  • Getting regular check-ups done
  • Avoiding smoking or even passive smoking
  • Reducing stress 
  • Maintaining a healthy weight
  • Limiting alcohol intake

It is important to make these healthy lifestyle modifications a part of life. A person should aim to be more active and always be alert to his/her overall health. Regular medical check-ups can go a long way in detecting several issues in advance to minimise complications.

Paediatric Cardiologists

A paediatric cardiologist is a doctor that specialises in the diagnosis and treatment of heart conditions in children under the age of 18 years, including infants. Heart issues in children can occur due to various reasons, including:

  • Genes
  • Birth defects
  • Unhealthy lifestyle
  • Improper growth in the mother’s womb
  • Smoking and consumption of alcohol by the mother during pregnancy
  • Lack of proper nutrition by the mother during pregnancy
  • Trauma, injury or stress faced by the mother during pregnancy

Most of the problems in children develop when they are in the uterus. However, some issues occur due to specific illnesses that occur during childhood. Cardiac issues in children need to medically treated by a paediatric cardiologist.

A paediatric cardiologist holistically treats heart problems in children of all ages. A paediatric cardiologist can provide care for patients through various stages including pregnancy, infancy, childhood, teenage, and later years. Paediatric cardiologists obtain specialised training since children require more effective and attentive care as compared to adults.

A paediatric cardiologist is also primarily trained in general cardiologist and then goes on to further get expertise in treating heart problems specifically in children. A paediatric cardiologist provides all-round care for the healthy growth and development of a child. Paediatric cardiology involves treating minor issues such as irregular heartbeat and rhythm, as well as complicated matters of the circulatory function issues. Moreover, paediatric cardiologists are trained specially to provide comprehensive care to the child in the best possible manner. Essentially, paediatric cardiology is a branch of general cardiology, which focuses on the diagnosis, prevention and treatment of heart problems and defects in children.

Symptoms of heart issues in children

Children are different from adults and hence, the symptoms in both differ. A child needs to be treated by a paediatric cardiologist if he/she displays any of the below symptoms:

  • Blue lips and skin
  • Difficulty in feeding (sweating, breathlessness, etc.)
  • Shortness of breath
  • Palpitations
  • Poor growth
  • Pale skin
  • Fatigue
  • Weak immunity
  • Heart murmur
  • Fainting
  • Lack of physical activeness
  • Chest pain

The above symptoms could indicate a potential heart issue in children and hence, should be given immediate medical attention. Paediatric cardiologists work closely with cardiothoracic surgeons, paediatricians focussed on other specialities, as well as specialised nurses and staff to provide superior, patient-centric and family-oriented care for children. 

Conditions treated by a paediatric cardiologist

A paediatric cardiologist can treat all conditions related to the heart of children. Some of the most common issues treated by paediatric cardiologists include:

  • Infancy cardiovascular collapse
  • Cardiac failure
  • Newborn cyanosis
  • Heart murmurs
  • Chest pain, palpitations
  • Fatigue and fainting
  • Congenital heart problem
  • Cardiovascular defects
  • Cardiac abnormalities
  • Heart transplant
  • Aortic valve stenosis
  • Arterial trunk
  • Atrial septal defect (ASD)

A paediatric cardiologist makes a general physical exam and then conducts various other medical tests including imaging tests (X-rays, ultrasound, MRI, CT scan, etc.), blood tests, and others. But the treatment of a particular issue depends on the type of problem, age of the child, medical history, family history, general health of the child and the severity of the condition. 

That said, in terms of treating a condition, the approach adopted by a paediatric cardiologist is similar to that of a general cardiologist. However, the former is more intensive and precise in handling the child. In general heart surgery, the paediatric cardiologist opens the chest cavity of the patient and divides the chest bone to access the heart. During this time, the heart of the patient is connected to a heart-lung bypass machine, which substitutes the functioning of the heart, allowing the cardiologist time to perform the surgery with utmost precision. Once the issue is treated, the cardiologist seals the chest incision with sternal wires. These wires are used to bind the separated chest wall and eventually dissolve on their own. The staples used are removed after 7-14 days and the glue wears off on its own. Overall, the recovery usually takes 6-8 weeks. This is an open-heart surgery, which is performed by a paediatric cardiologist to treat various conditions. However, the applicability of this procedure is only in extremely severe cases, when other non-invasive and minimally invasive forms of treatment fail to provide any result. 

The main difference between a general cardiologist and paediatric cardiologist are the types of problem, the intricacy of the surgery, and the approach or procedure of the surgery. That said, in many cases, minor heart issues in children tend to resolve on their own or with some minimum treatment administered by a qualified paediatric cardiologist. In case of slightly major issues, medications or minimally-invasive forms of treatment can be used by the paediatric cardiologist. However, for intense and critical cases, the paediatric cardiologist will perform invasive surgical procedures to treat the issue. But it is very important to take proper consultation and understand the issue of the child and the best treatment possible. It is very critical to select a qualified and attentive paediatric cardiologist that can provide superior care and treatment to the child.

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