March 27, 2015

Deafness – Part 1

This is a topic that has many opinions and they are almost evenly divided into the opposing sides. There are those that do not believe diabetes causes hearing loss and those that can offer convincing evidence that it does cause hearing loss. They do agree that there are different types of hearing loss and can have different effects on how sounds are heard and understood. The different types of hearing loss tend to have different causes, and it appears that having diabetes can contribute to the development of certain types of hearing loss. Damage can occur anyplace along the hearing pathway. The location of the damage is the determining factor that determines the type of hearing loss.

The different types of hearing loss are:
Conductive hearing loss (outer and middle ear). Trauma to the structures of the ear that physically transmit sound, such as the eardrum and the bones in the middle ear, can result in conductive hearing loss, which reduces the ear’s ability to physically conduct sound vibrations. The eardrum can be damaged by chronic infection, trauma resulting from pressure changes in the ear (such as those that occur in deep-sea diving), or blunt force to the ear or head. The tiny bones in the middle ear also can be damaged by blunt force. A condition called otosclerosis, which involves abnormal growth of bone in the middle ear, can reduce the strength of the sound vibrations that are transmitted into the cochlea, thereby reducing the volume at which sounds are heard.

Conductive hearing loss causes a reduction in the overall volume of sounds, but if speech can be made loud enough, by means of a hearing aid or the speaker talking louder, for instance, it can most often be understood. In many cases, areas of the ear involved in conductive hearing loss may be treated with medicines or repaired with surgery.

Sensorineural hearing loss and central processing disorders (inner ear and central hearing pathway). Damage to the inner ear or to structures along the nerve pathway is called sensorineural hearing loss because it involves either the delicate sensory hair cells in the cochlea or the hearing nerve, and sometimes both. When the nerve pathway from the ear to the brain is damaged, this is usually referred to as a central processing disorder. Unlike people with conductive hearing loss, those with sensorineural hearing loss or processing disorders may have difficulty understanding speech even when it is amplified. In fact, too high a volume can result in distortion of the speech, causing an unpleasant sound and making it even more difficult to understand.

A person whose sensorineural hearing loss is caused by damage to the hair cells in the cochlea typically has difficulty hearing sounds at particular frequencies, or pitches. This is because each group of hair cells is sensitive only to one frequency, and when any damage occurs, some hair cells may be affected more than others. The hair cells nearest the entrance from the middle ear, which detect high-frequency sounds, seem to be more susceptible to damage related to aging and noise. This can lead to hearing loss in the high-frequency range, making it difficult to understand speech, which contains a mix of low- and high-frequency sounds.

Sudden sensorineural hearing loss. Sensorineural hearing loss that appears suddenly can have a number of causes, including a blow to the side of the head or a sudden loud sound like an explosion. This type of hearing loss can involve a wide range of frequencies, depending on the nature of the injury. Sudden sensorineural hearing loss that has no known explanation occurs only rarely, and in a large percentage of these incidents, the people recover their hearing spontaneously. (Many physicians think these cases are the result of viral infections, but this explanation has not been confirmed.)

There have been reports of sudden sensorineural hearing loss associated with diabetes, but this is extremely rare. However, there is evidence that high blood pressure may increase damage to the small blood vessels in the cochlea of people with diabetes, which could result in sudden sensorineural hearing loss. A recent study found that people with diabetes and sudden sensorineural hearing loss were more likely to have higher blood pressure, higher cholesterol, and a higher HbA1c (an indicator of blood glucose control over the previous 2–3 months) than people with diabetes but no sudden hearing loss.

If you experience sudden hearing loss, you should report it to a physician, preferably an otolaryngologist (ear, nose, and throat (ENT) specialist). It is important to get medical attention as soon as possible, because specific medicines can often recover some or most of the hearing if they are administered early.

Concluded in next blog.

March 26, 2015


Gastroparesis is one of the problems of diabetes and one to be very concerned about as it can affect your health in many adverse ways. The three blogs I have on the topic are complete and I will not write more.

This article is for people that already have gastroparesis and should be followed under the supervision of their doctor.

Other articles may be found in links in my blogs or use your search engine and type in gastroparesis.

March 25, 2015

Hyperglycemic Hyperosmolar Nonketotic Syndrome – Part 2

Hyperosmolar Hyperglycemic Nonketotic Syndrome, or HHNS, may include any of the following symptoms:
  • Coma
  • Confusion
  • Convulsions
  • Dry mouth, dry tongue
  • Fever
  • Increased thirst
  • Increased urination (at the beginning of the syndrome)
  • Lethargy
  • Nausea
  • Weakness
  • Weight loss
Symptoms may get worse over days or even weeks.  Warning - this condition requires immediate medical attention!

Other symptoms that may occur with this disease:
  • Loss of feeling or function of muscles
  • Problems with movement
  • Speech impairment
The doctor or nurse will examine you and ask about your symptoms and medical history. The exam may show that you have:
  • Extreme dehydration
  • Fever higher than 100.4° Fahrenheit
  • Increased heart rate
  • Low systolic blood pressure
Test that may be done include:
  • Blood osmolarity (concentration)
  • BUN and creatinine levels
  • Blood sodium level
  • Ketone test
  • Blood glucose
Evaluation for possible causes may include:
  • Blood cultures
  • Chest x-ray
  • Electrocardiogram (ECG)
  • Urinalysis
The goal of treatment is to correct the dehydration. This will improve the blood pressure, urine output, and circulation. Fluids and potassium will be given intravenously (IV). The high glucose level is treated with insulin also given through a vein and sometimes as part of the same IV port.

Patients who develop this syndrome are often already ill. The death rate with this condition is as high as 40%.

Possible complications include:
  • Acute circulatory collapse (shock)
  • Blood clot formation
  • Brain swelling (cerebral edema)
  • Increased blood acid levels (lactic acidosis)
This condition is a medical emergency. Go to the emergency room or call the local emergency number (such as 911) if you develop symptoms of diabetic hyperglycemic hyperosmolar syndrome.

Managing type 2 diabetes and recognizing the early signs of dehydration and infection can help prevent this condition. This task will sometimes fall to the caregiver for some elderly patients that are bedridden.

For more discussion, read this from the Mayo Clinic.

March 24, 2015

Hyperglycemic Hyperosmolar Nonketotic Syndrome – Part 1

Hyperosmolar Hyperglycemic Nonketotic Syndrome, or HHNS, is a serious condition most frequently seen in older persons. HHNS can happen to people with either type 1 or type 2 diabetes that is not being controlled properly; however, it occurs more often in people with type 2.

It may also occur in those who have not been diagnosed with diabetes. The condition may be brought on by:
  • Infection
  • Other illness, such as heart attack or stroke
  • Medicines that decrease the effect of insulin in the body
  • Medicines or conditions that increase fluid loss
In HHNS, blood sugar levels rise, and your body tries to get rid of the excess sugar by passing it into your urine. You will make lots of urine at first, and you will have to go to the bathroom more often. Later you may not have to go to the bathroom as often, and your urine becomes very dark. Also, you may become very thirsty. Remember, even if you are not thirsty, you need to drink plenty of liquids. If you don't drink enough liquids at this point, you will become dehydrated.

If HHNS continues, the severe dehydration will lead to seizures, coma, and eventually death. HHNS may take days or even weeks to develop. Learn the warning signs of HHNS.
  • Blood sugar level over 600 mg/dl (33.3 mmol/L) or higher
  • Dry, parched mouth
  • Extreme thirst (although this may gradually disappear)
  • Warm, dry skin that does not sweat
  • High fever (over 101 degrees Fahrenheit, for example)
  • Sleepiness or confusion
  • Loss of vision
  • Hallucinations (seeing or hearing things that are not there)
  • Weakness on one side of the body
If you have any of these symptoms, call or have someone call your doctor immediately. HHNS requires immediate medical attention..

Risk factors include:
  • A stressful event such as infection, heart attack, stroke, or recent surgery
  • Congestive heart failure
  • Impaired thirst
  • Limited access to water (especially in patients with dementia or who are bedbound)
  • Older age
  • Poor kidney function
  • Poor management of diabetes -- not following the treatment plan as directed
  • Stopping insulin or other medications that lower glucose levels
HHNS only occurs when diabetes is uncontrolled. The best way to avoid HHNS is to check your blood glucose regularly. Many people check their blood sugar several times a day, such as before or after meals. Talk with your health care team about when to check and what the numbers mean. Learn self-monitoring of blood glucose (SMBG) and what the blood glucose readings mean when matched to a food log and other logs. Learn to keep your blood glucose levels as near to normal as possible and do not let them exceed 140 mg/dl (6.3 mmol/L). When your blood glucose levels consistently exceed this, or you are having too many episodes of hypoglycemia (lows) you should talk to your doctor. When you are sick, you should check your blood glucose more often, and drink a glass of water every hour. Work with your doctor to develop your own sick day plan.

March 23, 2015

Diabetic Ketoacidosis – Part 3

As a patient, we need to be aware of the treatments we may encounter. Radiologic studies that may be helpful in patients with DKA include the following:
  • Chest radiography: To rule out pulmonary infection such as pneumonia
  • Head CT scanning: To detect early cerebral edema; use low threshold in children with DKA and altered mental status
  • Head MRI: To detect early cerebral edema (order only if altered consciousness is present)
Doctors are told not to delay administration of hypertonic saline or mannitol in those pediatric cases where cerebral edema is suspected, as many changes may be seen late on head imaging.

Treatment of ketoacidosis should aim for the following:
  • Fluid resuscitation
  • Reversal of the acidosis and ketosis
  • Reduction in the plasma glucose concentration to normal
  • Replenishment of electrolyte and volume losses
  • Identification the underlying cause
Regular and analog human insulins are used for correction of hyperglycemia, unless bovine or pork insulin is the only available insulin.
Medications used in the management of DKA include the following:
  • Rapid-acting insulins (e.g., insulin aspart, insulin glulisine, insulin lispro)
  • Short-acting insulins (e.g., regular insulin)
  • Electrolyte supplements (e.g., potassium chloride)
  • Alkalinizing agents (e.g., sodium bicarbonate)
The risk of diabetic ketoacidosis is highest if you:
  • Have type 1 diabetes
  • Are younger than age 19
  • Frequently miss insulin doses
However, diabetic ketoacidosis can also occur if you have type 2 diabetes, although this is uncommon. In some cases, diabetic ketoacidosis may be the first sign that a person has diabetes.

Diabetic ketoacidosis is treated with fluids, electrolytes — such as sodium, potassium and chloride — and insulin. Perhaps surprisingly, the most common complications of diabetic ketoacidosis are related to this lifesaving treatment.

Treatment complications include:
  • Low blood sugar (hypoglycemia). Insulin allows sugar to enter your cells. This causes your blood sugar level to drop. If your blood sugar level drops too quickly, you may develop low blood sugar.
  • Low potassium (hypokalemia). The fluids and insulin used to treat diabetic ketoacidosis may cause your potassium level to drop too low. A low potassium level can impair the activities of your heart, muscles, and nerves.
  • Swelling in the brain (cerebral edema). Adjusting your blood sugar level too quickly can produce swelling in your brain. This complication appears to be more common in children, especially those with newly diagnosed diabetes.
Left untreated, the risks are much greater. Diabetic ketoacidosis can lead to loss of consciousness. Eventually, diabetic ketoacidosis can be fatal.

Blood tests used in the diagnosis of diabetic ketoacidosis will measure:
  • Blood sugar level. If there isn't enough insulin in your body to allow sugar to enter your cells, your blood sugar level will rise (hyperglycemia). As your body breaks down fat and protein for energy, your blood sugar level will continue to rise.
  • Ketone level. When your body breaks down fat and protein for energy, toxic acids known as ketones enter your bloodstream.
  • Blood acidity. If you have excess ketones in your blood, your blood will become acidic (acidosis). This can alter the normal function of various organs throughout your body.
Your doctor may order tests to identify underlying health problems that may have contributed to diabetic ketoacidosis and check for complications. Tests may include:
  • Blood electrolyte tests
  • Urinalysis
  • Chest X-ray
  • A recording of the electrical activity of the heart (electrocardiogram)
There's much you can do to prevent diabetic ketoacidosis and other diabetes complications.
  • Make a commitment to managing your diabetes. Make healthy eating and physical activity part of your daily routine. Take oral diabetes medications or insulin as directed.
  • Monitor your blood sugar level. You may need to check and record your blood sugar level at least three to four times a day — or more if you're ill or under stress. Careful monitoring is the only way to make sure that your blood sugar level remains within your target range.
  • Adjust your insulin dosage as needed. Talk to your doctor or diabetes educator about how to adjust your insulin dosage depending on your blood sugar level, what you eat, how active you are, whether you're ill, and other factors. If your blood sugar level begins to rise, follow your diabetes treatment plan to return your blood sugar level to your target range.
  • Check your ketone level. When you're ill or under stress, test your urine for excess ketones with an over-the-counter urine ketones test kit. If your ketone level is moderate or high, contact your doctor right away or seek emergency care.
  • Be prepared to act quickly. If you suspect that you have diabetic ketoacidosis — your blood sugar level is high and you have excess ketones in your urine — seek emergency care.
Diabetes complications are scary. But don't let fear keep you from taking good care of yourself. Follow your diabetes treatment plan carefully, and ask your diabetes treatment team for help when you need it.

March 22, 2015

Diabetic Ketoacidosis – Part 2

Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that mainly occurs in patients with type 1 diabetes, but it does happen in some patients with type 2 diabetes. I think people with type 1 diabetes should learn the symptoms because in five type 1 patients I know, only three of them could name most of them while the other two just shook his/her head.

The most common early symptoms of DKA are the insidious increase in polydipsia (excessive thirst) and polyuria (passing of an excessive quantity of urine). Now I will list the other signs and symptoms of DKA:
  • Malaise, generalized weakness, and fatigability
  • Nausea and vomiting; may be associated with diffuse abdominal pain, decreased appetite, and anorexia
  • Rapid weight loss in patients newly diagnosed with type 1 diabetes
  • History of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons or history of mechanical failure of insulin infusion pump
  • Decreased perspiration
  • Altered consciousness (e.g., mild disorientation, confusion); frank coma is uncommon but may occur when the condition is neglected or with severe dehydration/acidosis
Signs and symptoms of DKA associated with possible intercurrent (occurring while another disease or illness is in progress) infection is as follows:
  • Fever
  • Coughing
  • Chills
  • Chest pain
  • Dyspnea
  • Arthralgia
Patients may present with a history of failure to comply with insulin therapy or missed insulin injections due to vomiting or psychological reasons. Decreased perspiration is another possible symptom of DKA. Altered consciousness in the form of mild disorientation or confusion can occur. Although frank coma (clinically evident) is uncommon, it may occur when the condition is neglected or if dehydration or acidosis is severe.

On examination, general findings of DKA may include the following:
  • Ill appearance
  • Dry skin
  • Labored respiration
  • Dry mucous membranes
  • Decreased skin turgor (the state of being swollen or distended)
  • Decreased reflexes
  • Characteristic acetone (ketotic) breath odor
  • Tachycardia
  • Hypotension
  • Tachypnea
  • Hypothermia
In addition, patients displaying ketoacidosis should be evaluated for signs of possible intercurrent illnesses such as MI, UTI, pneumonia, and perinephric abscess. Search for signs of infection should be mandatory in all cases. Perinephric abscess is the capsule of connective tissue that envelops the kidney.

Initial and repeat laboratory studies for patients with DKA include the following:
  • Serum glucose levels
  • Serum electrolyte levels (e.g., potassium, sodium, chloride, magnesium, calcium, phosphorus)
  • Bicarbonate levels
  • Amylase and lipase levels
  • Urine dipstick
  • Ketone levels
  • Serum or capillary beta-hydroxybutyrate levels
  • ABG measurements
  • CBC count
  • BUN and creatinine levels
  • Urine and blood cultures if intercurrent infection is suspected
  • ECG (or telemetry in patients with comorbidities)
Note that high serum glucose levels may lead to dilutional hyponatremia; high triglyceride levels may lead to factitious low glucose levels; and high levels of ketone bodies may lead to factitious elevation of creatinine levels.

To be concluded in the next blog.

March 21, 2015

Diabetic Ketoacidosis – Part 1

Diabetic ketoacidosis (DKA) is generally a complication for people with type 1 diabetes, but some people with type 2 diabetes do develop DKA. If you have type 2, especially when you are older, you are more likely to have a condition with some similar symptoms called HHNS (hyperosmolar hyperglycemic nonketotic syndrome). I will cover this in some future blogs.

DKA starts with high ketone levels when you body doesn't have enough insulin. This means your cells can't use the glucose in your blood for energy, and your body starts using fat for fuel instead. The ketones start building in your blood and if not corrected soon, the excess can change the chemical balance of your blood and change how your body works.

People with type 1 diabetes are at risk for ketoacidosis, since their bodies don't make any insulin. Your ketones can also go up when -
  1. You miss a meal,
  2. You're sick or stressed,
  3. You have an insulin reaction.
When your blood glucose level is over 240 mg/dl (13.3 mmol/L) or you have symptoms of high blood glucose, such as:
  • Dry mouth
  • Feeling really thirsty
  • Peeing a lot
When you have the above symptoms, it is important to test your ketones. For this you can use your blood glucose meter that measure ketones or use a urine test strip. Try to bring your blood glucose level down and check you ketones again in 30 minutes. Call your doctor or go to the emergency room right away if that doesn't work. This is more important if your ketones aren't normal and if you have one or more of the following symptoms:
  • You have been vomiting for more than 2 hours
  • You feel queasy or your belly hurts
  • Your breath smells fruity
  • You are tired, confused, or woozy headed
  • You are having a difficult time breathing
You may have to go to the hospital. You'll probably need insulin through an IV to bring your ketones down and fluids to get you hydrated and balance your blood chemistry again. If you don't treat ketoacidosis, you could pass out, go into a coma, and possibly die. Your doctor may change your insulin dose or the kind you use to prevent it from happening again.

Good glucose management should help you avoid ketoacidosis. Take your medicines as directed, follow your meal plan closely, maintain your exercise regimen, and test your blood glucose regularly. When you have an episode of ketoacidosis, always run down a checklist:
  1. Make sure your insulin has not expired.
  2. Do not use it if it has clumps (insulin should be either clear or evenly cloudy with small flecks.
  3. If you are using an insulin pump, look closely for insulin leaks, and check your tube connections for air bubbles.
  4. Lastly, talk to your doctor if your blood sugar levels are often out of your target range


March 20, 2015

Hyperglycemia – Part 3

Yes, emergency complications of hyperglycemia happen all too frequently, especially among the elderly and occasionally the not so elderly that are in severe depression.  If blood sugar rises high enough for a prolonged period, it can lead to two serious conditions.
  • Diabetic ketoacidosis. Diabetic ketoacidosis develops when you have too little insulin in your body. Without enough insulin, glucose can't enter your cells for energy. Your blood sugar level rises and your body begins to break down fat for energy. This process produces toxic acids known as ketones. Excess ketones accumulate in the blood and eventually "spill over" into the urine. Left untreated, diabetic ketoacidosis can lead to diabetic coma and be life threatening.
  • Hyperglycemic Hyperosmolar Nonketotic Syndrome. This condition occurs when people produce insulin, but it doesn't work properly. Blood glucose levels may become very high, greater than 600 mg/dl (33.3 mmol/L). Because insulin is present but not working properly, the body can't use either glucose or fat for energy. Glucose is then dumped in the urine, causing increased urination. Left untreated, diabetic hyperosmolar syndrome can lead to coma and life-threatening dehydration. Prompt medical care is essential.
Illness or infections can cause your blood sugar to rise, so it's important to plan for these situations. Talk to your doctor about creating a sick-day plan. Questions to ask include:
  • How often should I monitor my blood sugar during an illness?
  • Does my insulin injection or oral diabetes pill dose change when I'm sick?
  • When do I test for ketones?
  • What if I'm unable to eat or drink?
  • When do I seek medical help?
Some people will tell you to let your doctor set your blood glucose target, but I say that they should not. They can make suggestions and help guide you, but they should never set your goals. Too often, doctors only use the ADA target blood glucose levels. For many people who have diabetes, target levels set by the American Diabetes Association (ADA) are:
  • Fasting at least eight hours (fasting blood sugar level) — between 90 and 130 mg/dl (5 and 7 mmol/L)
  • Before meals — between 70 and 130 mg/dl (4 and 7 mmol/L)
  • One to two hours after meals — lower than 180 mg/dl (10 mmol/L)
Your target blood glucose range should differ, especially if you're pregnant or you develop diabetes complications. Your target blood glucose range may change as you get older, too. Sometimes reaching your target blood glucose range is a challenge. But the closer you get, the better you'll feel.

If you have any signs or symptoms of severe hyperglycemia, even if they're subtle, check your blood sugar level. If your blood sugar level is 240 mg/dl (13.1 mmol/L) or above, use an over-the-counter urine ketones test kit. If the urine test is positive, your body may have started making the changes that can lead to diabetic ketoacidosis. You'll need your doctor's help to lower your blood sugar level safely.  During an appointment, your doctor should conduct an A1c test. This blood test indicates your average blood sugar level for the past two to three months. It works by measuring the percentage of blood glucose attached to hemoglobin, the oxygen-carrying protein in red blood cells.

An A1c level of 7 percent or less means that your treatment plan is working and that your blood sugar was consistently within the normal range. If your A1c level is higher than 7 percent, your blood glucose, on average, was above the normal range. In this case, your doctor may recommend a change in your diabetes treatment plan.

Keep in mind that the normal range for A1c results may vary somewhat among labs. If you consult a new doctor or use a different lab, it's important to consider this possible variation when interpreting your A1c test results.

How often you need the A1c test depends on the type of diabetes you have, The medications you are taking, and how well you're managing your blood sugar. Most people with type 2 diabetes, on no or oral medications are mostly tested twice per year. If you are type 1 or type 2 on insulin, you should be tested at least four times per year.