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A life-threatening complication
Diabetics are more prone to frozen shoulder
Some major medical advances in past decade
Health Notes
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A life-threatening complication High blood sugar level, commonly referred to as diabetes mellitus, is quite familiar. However, not many are aware of its acute life-threatening complications. Diabetic keto-acidosis is a condition characterised by the blood sugar level of more than 250 mg/dl with blood pH of less than 7.3, presence of ketones in urine and elevated serum ketones of above 5 meq/L. Modern management with the use of insulin in controlling high blood sugar has brought down the reported mortality of nearly 100 per cent in 1922 to near 5 per cent now of this dreaded
complication. Generally, in young diabetic patients treated with insulin (Type-I diabetes), this complication is precipitated by some infection such as pneumonia or urinary tract infection, acute emotional stress, by missing adequate doses of insulin or by steroids. Effective insulin therapy is required to be taken under the supervision of an expert in diabetes management without which sometimes insulin deficiency and resistance with elevation of certain anti-insulin hormones (such as Glucagon, Cortisol, etc.) may remain undetected, till the patient manifests in diabetic keto-acodisis. Without adequate and effective insulin available in the body, "sugar" cannot be delivered to vital organs for metabolism. Barring fat, liver and muscle, almost all the vital organs, including the brain, cannot survive without the availability of sugar (glucose). In the absence of glucose the brain starts utilising ketones derived from fatty acid oxidation for
energy. High blood sugar results from increased glucose synthesis in the liver, breakdown of glycogen and impaired utilisation of glucose in the periphery (muscle). Insulin helps the entry of glucose available in circulating blood into the cells of various organs such as brain, heart, etc. In the absence of insulin, the brain tries to maintain itself by utilising excessive ketones generated from beta-oxidation of fatty acids triggered by the decreased availability of vital enzyme malonyl coA (an inhibitor of ketone synthesis in the
body)
Diagnosis and Presentation High blood sugar (hyperglycemia) manifests by the presence of sugar in urine which leads to more urination than required and eventually causes dehydration, leading to increased thirst. Simultaneously, excess ketone bodies thus formed result in severe acidosis, impairing the blood pH and affecting the functions of all the vital organs, including the brain, which invariably leads to coma if not treated
promptly. In an acute emergency, ketoacidosis is diagnosed by a suggestive history and examination with the evidence of high blood sugar and by the presence of ketone bodies in urine. The arterial blood gases generally show a reduction on pH (less than 7.3) accompanied by low bicarbonate which sometimes requires to be corrected along with the correction of low phosphate, though
rarely. Diabetic ketoacidosis in any diabetic manifests with increased urination associated with nausea, vomiting and upper abdominal pain, simulating pancreatic pain. A clinical examination reveals signs of dehydration, low blood pressure and rapid/deep respiration (Kussmaul), with the dryness of the skin and mouth. Such patients exhibit distinct fruity odour in breath. Unless treated promptly, patients generally slip into coma very rapidly, which demands an early and correct diagnosis and treatment in a specialised
hospital.
Treatment Immediately on suspicion, crucial time should not be wasted on shifting the patient from one to another clinic. Instead, the patient should be brought straight to specialised medical centre with adequate facilities. The treatment goals in such a case are: to correct dehydration rapidly by infusing normal saline which also helps in quick wash-out of excess ketones in the blood, to correct high blood sugar with intravenous insulin infusion, to correct electrolyte imbalance with particularly stress on the supplementation of potassium early after rehydration. If not treated in time, hypokalemia is dangerous and can cause death by inducing cardiac arrhythmias. Ironically, while managing such patients, IV glucose infusion is also to be given when blood sugar, hourly monitored, shows a fall below 200
mg/dl. Early rehydration improves blood circulation and reduces the levels of anti-insulin hormones (catecholamines and glucagon). It is important to monitor the patient under close supervision while on treatment to avoid complications related to the overload of fluids such as cerebral and pulmonary
edema.
The writer is a senior consultant at Fortis Hospital, Mohali.
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Diabetics are more prone to frozen shoulder A frozen shoulder is a commonly encountered problem in our day-to-day practice, especially in diabetic patients. A frozen shoulder in such patients is a more troublesome condition than in the non-diabetic population. If a diabetic patient develops frozen shoulder then the time to full recovery is often prolonged. Other causes for the frozen shoulder are an injury (as in a fall and lifting a heavy weight), an attack of stroke,
etc. Shoulder injuries can cause a tear of the rotator cuff muscle/tendon, disruption of the acromioclavicular joint, dislocation of the shoulder joint, etc. Such patients are advised a sling to provide rest to the shoulder, analgesic, etc. As the shoulder joint is a ball and socket joint and, if not moved intermittently, it could restrict the person's movement. It is pertinent thus to initiate shoulder movement at the earliest in a pain-free
range. A shoulder injury leads to the inflammation of the synovial membrane, building up sticky fluid causing contraction of the shoulder capsule. The capsule sticks to the underlying bone, resulting in pain and a decrease in the range of motion. This restriction of motion causes discomfort while wearing clothes, combing hair,
etc. Today's lifestyle is also to be blamed for this condition. Earlier, people undertook various activities like spinning, drawing water from the well, weaving and cutting fodder—all involving rotational activities of the shoulder joint, cutting down the incidence of frozen shoulders tremendously.
The symptoms generally encountered are inability to sleep on the affected side; difficulty/discomfort in lifting arms above the head; reaching behind the back as during the combing of hair and buttoning; feeling of pain midway between the elbow and the shoulder joint. This could radiate down the arm and towards the
fingers. Treatment is frustrating as recovery is slow. Most cases, however, recover completely. The priority is to reduce inflammation and enhance the range of motion of the shoulder joint. The following treatment provides relief and
recovery:
The following exercises can go a long way in relieving
pain:
The writer runs a pain management clinic in Chandigarh. E-mail:
chadha_r2003@yahoo.co.in
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Some major medical advances in past decade The first decade of the 21st century brought a number of discoveries and medical advances. In some cases, these advances changed deep-seated beliefs in medicine. In others, they opened up possibilities beyond what doctors thought was possible years
ago. Human genome: In 2000, scientists in California released a rough draft of the human genome for the public. For the first time the world could read the complete set of human genetic information and begin to discover what our roughly 23,000 genes do. By understanding the genetic causes and links to disease we can give more and more attention to preventing disease.
Beating heart surgery: Till 2000 we were operating on patients by putting them on a heart-lung machine, stopping the heart with a type of “poison”, putting it on ice and then doing the bypass surgery. This had a number of problems, including damage to the brain, liver, kidney and blood with resultant high mortality and need for blood. With the advent of beating heart surgery (this writer is a pioneer of this technique with the world’s first series of multi-vessel beating heart surgeries documented from Punjab in the medical literature and in the Limca Book of World Records), the situation has changed altogether. Now even high- risk patients (the elderly, those with poor lung and heart function, et al) can be operated upon easily. Incidentally, there is also a significant reduction in the cost of surgery.
Stem cell research: The clinical advances with embryonic or adult stem cells have been tantalising. For example, European researchers genetically manipulated bone marrow cells taken from two seven-year-old boys and then transplanted the altered cells back into the boys and apparently arrested the progress of a fatal brain disease called adrenoleukodystropy or ALD, which affected the child in the movie "Lorenzo's Oil."
Targeted therapies for cancer expand with new drugs Two blockbuster-targeted therapies burst on the cancer scene in the late 1990s, and changed forever the concept of cancer treatment, converting what was often a fatal disease into a chronic illness. The first, Herceptin, is a drug that targets a type of breast cancer that is characterised by a specific cancer gene — an oncogene — called HER-2.
The other drug, a cancer pill called Gleevec, targets genetic mutation called bcr-abl that causes cancer cells to grow and multiply in patients with a variety of cancers, including chronic myeloid leukemia or with a stomach cancer called
GIST. Combination drug cure for HIV: Since the introduction of highly active antiretroviral therapy, or HAART, as this combination therapy approach is called, HIV/AIDS has evolved into a controllable disease with survival stretching into decades. Moreover, this "cocktail" approach to treatment where drugs are combined in different ways or different sequences has become a model for treating other diseases ranging from lung cancer to heart
disease. Robotic surgery techniques: Tiny metal hands carefully manipulating sutures deep inside the heart seems like a scenario pulled from "Star Trek", but the reality is that robotic surgery is occurring daily in a growing number of centres across the country. The robot is manipulated by a surgeon working at a computer console and manipulating joy sticks to control the tiny "hands" while a camera attached to the robot's "third arm" sends an image back to computer monitor. Robotic surgeries give the benefit of tiny openings into the body rather than a large incision made by traditional surgery, and that means a shorter and less painful recovery
time. Peeping into mind: Mind-reading has moved from carnival attraction to the halls of medicine with what is known as a functional MRI. The process, often called fMRI, traces the working of neurons — brain cells — by tracking changes in the oxygen levels and blood flow to the brain. The more brain activity in one area, the more oxygen will be used and the more blood will flow to that area. The patient lies awake inside an MRI scanner. He or she is asked to perform a simple task like identifying a colour or solving a math problem. As the patient answers the question, the fMRI tracks the areas of the brain that are activated by tracing the speed at which the cells metabolise sugar or
glucose. Thus, the future is very bright as we stand on the threshold of the next
decade.
The writer is Head, Cardio-Vascular and Thoracic Surgery, CMC, Ludhiana. E mail:
drhsbedi@hotmail.com
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Health Notes London: Tucking in an apple with its skin on could help trim the risk of bowel cancer by more than a third, say researchers. Polish experts from Jagiellonian University in Krakow found that eating two could almost cut down the chances of getting the disease by almost
half. “Neither the consumption of vegetables nor other fruits have shown beneficial effects on the risk of bowel cancer. But a reduced risk of 35 per cent was observed with the consumption of at least one apple a day. With the intake of more than one apple a day, the risk was reduced by about 50 per cent,” the Daily Express quoted the team as saying. —
ANI
Plastic baby bottles ‘harmful’
Melbourne: The chemical bisphenol-A (BPA) used to make plastic baby bottles is harmful, according to experts. British scientists have announced that there is “compelling” evidence that the chemical is linked to breast cancer, sex hormone imbalances and has adverse health risks to
babies. The US has already banned these bottles while the health authorities in countries like Australia and Britain are under pressure to remove it from shelves. Also, the item is unavailable in France and Canada, reports the Daily Telegraph. Australia’s Federal Health Minister Nicola Roxon has put the responsibility to do away with the BPA bottle on the Therapeutic Goods Administration. —
ANI
Prostate: concerns over false test results
London: Researchers have raised concerns over false positive results of prostate cancer screening. They found that one in eight men screened for prostate cancer test positive when they do not have the disease and are compelled to undergo invasive tests such as biopsy as well as potentially unnecessary
treatment. The presence of prostate cancer may be indicated by symptoms, physical examination, prostate specific antigen (PSA) or
biopsy. Finnish researchers, who are a part of a large European trial, revealed that for every eight men screened, one ended up with a false positive result, even with a fairly high PSA threshold. —
ANI
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