March 28, 2015

Deafness – Part 2

Continued from the previous blog.

Noise-induced hearing loss. Hearing damage from noise exposure typically occurs in a very restricted frequency range, creating a gap in the sequence of frequencies that can be heard. The gap is usually in the high-frequency range, which can affect a person’s ability to understand speech. However, noise damage can sometimes affect such a narrow frequency range that the person may not even be aware that he has hearing loss.

Protecting your ears from loud sounds can reduce the potential for hearing loss caused by noise exposure. Many comfortable forms of hearing protection are available, including earplugs, which fit into the ear canal, and earmuffs, which secure over the ears with a band. Some people are reluctant to wear hearing protection in noisy environments because they are concerned they won’t be able to hear others talking to them. This is not something to be concerned about, however, because most people talk louder in noisy situations, so it is possible to hear conversations even with ear protection.

I have some noise hearing loss from the military, but the tests were so poorly done, that I was not able to contest the results. Over the years, I have become more acutely aware of some sounds and often have to leave some gatherings when music is too loud.

Age-related hearing loss. As we age, hearing loss occurs gradually, beginning with the high frequencies. In general, vowels, which account for the loudness of speech, are in the low-frequency range, while consonants, which provide the clarity of speech, are in the high-frequency range. Therefore, high-frequency hearing loss may not affect how loudly sounds are heard, but it can make speech less clear and, as a result, more difficult to understand. This is especially the case when watching television or listening to the radio, where speech is often fast and where visual cues, such as lip movements and body language, are not as readily available, as well as in noisy situations.

As far as age-related changes in hearing are concerned, it’s important to remember that the ear alone is not responsible for hearing. Sound is converted into electrical signals that travel from the cochlea through a series of nerve pathways to the brain for interpretation. In addition to problems associated with physical deterioration of the hair cells in the cochlea, there are age-related changes in the processing ability of the hearing-related nerves (the central processing disorders mentioned earlier) as well as cognitive changes that may slow a person’s ability to understand speech. These changes can have a profound effect on a person’s verbal communication abilities, regardless of whether hearing loss is present. For example, a common complaint of some older people is that people talk too fast. This is because as we age, the mental processes that are needed to understand speech can overload when information is presented too rapidly. In a study, conducted at the Veterans Affairs National Center for Rehabilitative Auditory Research (NCRAR) in Portland, Oregon, it was found that older people who have poorer performance on certain cognitive tests (those related to thinking, learning, and remembering) also perform poorly on speech recognition tests (tests that use lists of sentences speeded up by a computer).

Age-related hearing loss may not be immediately evident to the person whose hearing is damaged, and as a result, his hearing may be significantly diminished before he seeks help. Indeed, older people may not think they have hearing loss at all. They can still hear a lot of sounds loudly, so they simply think that other people are mumbling. In fact, this type of hearing loss is often noticed first by friends and family who find communication becoming increasingly difficult.

Age-related hearing loss progresses at different rates in different people. Some people still have very little loss even in their 80s, although that isn’t common. It is not clear what makes some people more susceptible to hearing loss than others, but as with any other age-related condition, good nutrition, physical activity, and good prevention practices (hearing protection, in this case) can contribute to lessening the effects or delaying the onset of hearing loss.

Infection or earwax can block ear canals and reduce hearing. Earwax can be safely removed in most cases, but earwax that has hardened requires some treatment to be safely removed.

The link between diabetes and hearing loss has been debated since the 1960s or before, and the results show that a relationship exists even when researchers account for the major factors known to affect hearing, such as age, race, ethnicity, income level, noise exposure, and the use of certain medications.

Diabetes may lead to hearing loss by damaging the nerves and blood vessels of the inner ear, the researchers suggest. Autopsy studies of diabetes patients have shown evidence of such damage.

Diabetes is a group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. Afflicting nearly 21 million people in the United States, it is a major cause of heart disease and stroke and the most common cause of blindness, kidney failure, and lower limb amputations in adults. Prediabetes, which causes no symptoms, affects about 54 million adults in the United States, many of whom will develop type 2 diabetes in the next 10 years. Prediabetes raises the risk of a heart attack or stroke even if diabetes does not develop. People with prediabetes can often prevent or delay diabetes if they lose a modest amount of weight by cutting calories and increasing physical activity.

For other information about diabetes and deafness or hearing loss please read this, this, and this article.

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.