Tinnitus associated with vertigo extremo,window tint laws us,whats a sinus infection yahoo - Step 2

Author: admin, 27.06.2014. Category: Severe Tinnitus Symptoms

In daily clinical practice, it is seen that elderly patients complain most frequently of dizziness, tinnitus, and hearing loss. With an increase in the elderly population, the pattern of diseases changes, and the age factor has to be considered in diagnosis and treatment. In daily clinical practice, the elderly patients seen complain most frequently of dizziness, tinnitus, and hearing loss. In comparison to younger people, what is first noticeable about elderly people is that they have a good deal of body fat and a markedly low level of intracellular water. Listed in Table 2 are the diseases involving vertigo, which we often encounter in daily clinical practice, specifically among elderly patients.
The extension, flexion, or stenosis of a vertebral artery, cervical spondylosis, and cervical torsion due to the abnormality of cervical soft tissue induce rotary vertigo and sometimes a transient disturbance of consciousness.
For oral drug treatment, it is important to use such agents as clonazepam, imipramine hydrochloride, and thyrotropin-releasing hormone. INTRODUCTION: Sudden deafness is characterized by an abrupt onset, often idiopathic and tinnitus is present, and becomes the main complaint in up to 80% of patients.
OBJECTIVE: To review carefully all studies of the past 10 years on sudden deafness and tinnitus and analyze the effectiveness of oral and intratympanic steroids for tinnitus control in eight patients with sudden deafness and severe disabling tinnitus. METHOD: An analytical prospective in which 64 patients after sudden deafness with tinnitus were monitored and 08 of these suffering with severe disabling tinnitus underwent hearing evaluation and application of the Tinnitus Handicap Inventory and Visual Analogue Scale before, during and after sudden deafness treated with oral and intratympanic steroids.
Sudden sensorineural hearing loss (SSHL) was first described by De Kleyn in 1944 and defined as a hearing loss of at least 30 dB in three sequential frequencies in the standard pure-tone audiogram over 3 days or less1. Population studies of SSHL show a wide distribution, ranging from 5 to 30 cases per 100.000 per year, with an average of 50-60 years and no sex preference. Hypotheses are proposed to explain the pathogenesis of sudden hearing loss as the vascular, the viral, the autoimmune and the rupture of membranes one.
Patients with tinnitus and SSHL are very frustrated by residual tinnitus even after accomplishment of the treatment for SSHNL.
All patients received information about the risks and expectations of therapy and signed a free informed consent form. Next, salvage therapy with intratympanic methyl-prednisolone was offered to XX patients with a diagnosis of SHL, after systemic therapy failed and no improvements were demonstrated audiometrically. All patients underwent tonal and vocal audiometry and speech recognition rate analysis done by audiologists before and after treatment. Prior to any procedure, patients were oriented as to the risks and expectations about the procedure and signed a free informed consent form. After intratympanic application of the steroid, the patient remained in the supine position and cervical rotation at 45? for 30 minutes to maximize exposure of the round window membrane to the solution.
The criteria for defining successful recovery after therapy vary in the literature on intratympanic therapy. All patients underwent Questionnaire Tinnitus Handicap Inventory (THI)5 and the Visual Analogue Scale (VAS) to assess quantitatively and qualitatively the therapeutic response in relation to tinnitus.
The search strategy employed in the literature review was guided by the combination of two descriptors indexed in MeSH (Medical Subject Headings): sudden deafness and tinnitus. Most of the patients had vertigo associated with sudden deafness, being classified as mild in 75% of cases and severe in 12.5%. We performed a literature search with the following aliases: sudden hearing loss and tinnitus. Their ages ranged from 26-73 years with a mean of 39,5 years and the ear most affected was the left ear (n = 5). In this study, we chose to intratympanic corticosteroid associated with oral corticosteroids and showed that this association was particularly effective in relation to tinnitus, from the eight cases analyzed, seven of these showed a significant improvement verified by THI and EVA.
Several factors may affect the prognosis of the PANSS (eg, hearing loss severity, symptoms duration before treatment, vertigo, type of audiogram, and the patients ages). Regarding hearing improvement, only two patients had good responses to therapeutic intervention. Given the results, we note that in addition to the proposed intervention, especially those cases where there were no improvement or even where there were worsening of symptoms over time, there are other recommended therapies such as cognitive-behavioral and Tinnitus Retraining Therapy.
Some therapies for tinnitus tend to focus on the impact of noise on the quality of life and humor, and include antidepressants, anticonvulsants and benzodiazepines, or attempt to mask their own noise with white noise generators.
In 2005, a review of published randomized clinical trials addressing the correlation between sudden sensorineural hearing loss and tinnitus and treatment by hyperbaric oxygen therapy (HBOT). The sudden sensorineural hearing loss (SSHL) is a considerable diagnostic challenge because it can be caused by many different diseases and there is still no definitive treatment for PANSS universally accepted. In search of a therapeutic approach, the efficacy of enoxaparin sodium associated with venous hemofiltration was studied. In 2008, Ishida et al.15 investigated how the symptoms of ear fullness, tinnitus and otoacoustic emissions (OAE) varied over the course of recovery thresholds in pure tone audiometry in SSHL.
Kleinjung et al.16, in 2009, described the case of a man of 55 years who suffered from tinnitus in the right ear as a result of a SSHL. Hikita-Watanabe et al.17, in 2010, in an article entitled "Tinnitus as a prognostic factor of sudden deafness", rebound that in the group "buzzing rare" there was a worst prognosis to hear than in the group "buzz often".
In 2012, Fioretti et al.18 described the case of a 67 years-old women with severe and disabling tinnitus in the right ear, hyperacusis and mild headache. In 2012, a research was also conducted by Ramos et al.10, in which the authors assessed the effectiveness of cochlear implants in patients with SSHL and disabling tinnitus. The tinnitus severity was assessed using the Tinnitus Handicap Inventory (THI) and the Visual Analogue Scale (VAS) before and after deployment. Given the results, it can be concluded that the reduction of tinnitus after cochlear implantation may be due to several mechanisms such as habituation, acoustic masking, direct stimulation of the cochlear nerve and reorganization of cortical areas. Michiba et al.19, in 2013, highlighted the fact that many patients are frustrated with the SSHL residual buzz, even after complete SSHL treatment.
The hearing improvement rate was determined by comparing the thresholds before and 6 months after initiation of treatment. The improvement of hearing thresholds were significantly correlated with improvement in the score of tinnitus 6 months after initiation of treatment compared with before treatment.
Generally, subjective feelings for the ringing residual 6 months after initiation of SSHL treatment are almost the same as 24 months after treatment.
Patients that carriers sudden deafness and severe disabling tinnitus, and underwent intratympanic and oral corticosteroids showed, in this study, significant reduction or remission of tinnitus. Paper submitted to the ITJ-SGP (Publishing Management System) on September 4, 2013; and accepted on October 4, 2013.
The first major impact of hyperinsulinemia in the clinical arena was in the clinical discipline of neuro-otoiopy. Using a bioassay for insulin, Bornstein2 in 1951 demonstrated increased insulin in the noninsulin-dependent diabetic. In 1971, the Phadebus insulin radioimmuno-assay test (Pharmacia Diagnostic AB, Uppsala, Sweden) became the first RIA insulin test available in the United States. In our laboratories, this assay was applied to the standard 100 g oral glucose tolerance for procedural evaluation. The hyperinsulin patterns with diabetic glucose tolerances became repetitive and distinctive for noninsulin-dependent diabetes mellitus, NIDDM, Type II. The insulin patterns as initially described and defined in diabetic, impaired glucose tolerance (IGT) and euglycemic glucose tolerances were unchanged in our ongoing database. Hyperinsulinemia with hyperglycemia glucose tolerances definitively diagnosed diabetes mellitus, noninsulin-dependent diabetes mellitus (NIDDM), Type II. Hyperinsulinemia with IGT and euglycemia tolerances identified the non-insulindependent diabetic state of NIDDM.
Hyperinsulinemia diabetic insulin patterns with normal glucose tolerance values established the earliest identification of the NIDDM state. The pathophysiologic model of gestational hyperinsulinemia diabetic state progression is a microcosm of the identical hyperinsulin noninsulin-dependent diabetic state of NIDDM. Hyperinsulinemia has been statistically confirmed in our database as the early metabolic marker in carbohydrate metabolism preceding hyperglycemia. Updegraff,13-14 Mangabeira-Albemaz,15-16 Fukuda,17 and Proctor18 independently identified and concurred hyperinsulinemia as the major diagnostic factor in up to 84 to 92% of their cases of idiopathic dizziness and tinnitus. Updegraff had noted that certain of his patients with Meniere's, as well as his migraine patients, had Diabetes Mellitus (DM) upon glucose tolerance. Independently all the investigators achieved and reported dramatic relief and sustained therapeutic response to their medical nutritional therapy. Of the 54 patients, 49 (91%) achieved control of their vertigo after the initial 6 months of dietary treatment. In previous publications,8-11 we have called attention that blood serum for insulin radio-immunoassay (RIA) can be kept frozen (up to 2 year) until sufficient specimens from multiple patient examinations are obtained.
The glucose clamp technique (wherein a fixed-rate insulin infusion is combined with a variable-rate glucose infusion adjusted to maintain precise euglycemia) is used to derive an index of whole-body insulin sensitivity. The term identifies the essential therapeutic role of supervised nutrition in hyperinsulinemia. Koniz22 and Festa23 have identified the patient as the most important person in the management team of physician, patient, and nutritionist. In addition to the idiopathic neurootologic disorders of tinnitus, dizziness, classic Meniere's disease, and migraine, hyperinsulinemia with euglycemia glucose tolerance has been etiologically identified with primary ovarian follicle dysfunction,24,25 essential hypertension,26 atherosclerosis,27 and coronary artery disease.28 All of the above compose the clinical pathology of hyperinsulinemia (Table 11).
Shulman29 notes that cardiac arrhythmias and hypertension have a significant incidence among patients with SIT.
Identification of hyperinsulinemia with euglycemia glucose tolerance does not guarantee that hyperglycemia status is inevitable. Priority early exclusion of hyperinsulinemia as part of the initial examination of the patient with SIT is indicated. The National Diabetes Data Group (NDDDG) Classification and Diagnosis of Diabetes Mellitus and Other Categories of Glucose Intolerance7 remains in place as of this date.
Identifying hyperinsulinemia provides a basis for immediate and prospective management of the associated disorders of hyperinsulinemia. All of the high quality ingredients used in the TinnitusWars Remedy are prepared homeopathically making them completely safe. In a randomized, double-blind clinical study, we evaluated the efficacy and tolerability of the fixed combination of cinnarizine, 20 mg, and dimenhydrinate, 40 mg (Arlevert [ARL]) in comparison to betahistine dimesylate (12 mg) in 82 patients suffering from Meniere's disease for at least 3 months and showing the characteristic triad of symptoms (paroxysmal vertigo attacks, cochlear hearing loss, and tinnitus). Meniere's disease, described for the first time in 1861 by Prosper Meniere, is characterized by a triad of symptoms in a characteristic, classic pattern of episodic vertigo, tinnitus, and fluctuating sensory hearing loss [1-3].
Surgical treatment of Meniere's disease is indicated only in severe cases and after attempts of conservative therapy have failed. The antivertiginous drug Arlevert (ARL), a fixed combination of the calcium antagonist cinnarizine (20 mg per tablet) and the antihistamine dimenhydrinate (40 mg per tablet), has been successfully used for a long time in the treatment of vertigo of various origins and has been tried and tested in numerous randomized, double-blind clinical trials [6,10,11].
Cinnarizine primarily leads to a cerebral and cochlear increase of perfusion [13,14] and acts as a vestibular sedative through inhibition of the calcium influx into the vestibular sensory cells [15]. In our study, the efficacy and safety of the fixed combination of cinnarizine and dimenhydrinate was investigated in patients suffering from Meniere's disease. The patient population consisted of 82 male and female white outpatients (age > 30 years) suffering from Meniere's disease for at least 3 months.
Patients taking benzodiazepines, acetylsalicylic acid, or piracetam were eligible for enrollment. The study was carried out according to a randomized, double-blind, reference-controlled design with two parallel groups. The patients were asked to judge the intensity of vertigo and concomitant symptoms on a visual analog scale with possible ratings between 0 (no symptom) and 4 (very strong symptom). Concomitant symptoms of vertigo (assessed by visual analog scale), vestibulospinal tests (assessed by CCG), ENG tests, and audiometry and a global judgment by both patient and investigator were used as secondary criteria of efficacy. Vestibulospinal (Unterberger's and Romberg's) tests were registered by CCG [16, 17], as previously described [10,18].
The safety of the study medications was assessed by registration of adverse events on the occasion of each follow-up visit; in addition, systolic and diastolic blood pressure was measured at each visit.
Statistical analysis was performed on the basis of the per-protocol population, including all patients who completed the study without any protocol deviation (n = 80).
Comparability of demographic and anamnestic variables between treatment groups before the start of treatment was assessed at the 20% significance level using the Wilcoxon-Mann-Whitney test (U-test) in case of quantitative data and Fisher's exact test in case of categorical data, as appropriate. Eighty-two patients were randomly assigned to treatment and were valid for safety analysis. The patients in the two treatment groups were comparable with regard to demographic characteristics (Table 1).
Tinnitus, typically associated with Meniere's disease, showed a relatively high initial mean score of approximately 3.3 in both treatment groups (Fig. The score of the mean vegetative symptoms, including nausea, vomiting, sweating, and tachycardia, also markedly improved during the treatment, with statistical significance reached as early as at the end of the first week of therapy (see Fig.
Spontaneous nystagmus was displayed by three patients in the ARL group and two patients in the betahistine group before the start of treatment.
In pure-tone audiometry, patients with unilateral disease showed an initial mean hearing loss on the side of the affected ear of approximately 40 dB, which was significantly reduced in the course of the 12-week treatment in patients belonging to the ARL group (p =.042) but not in patients belonging to the betahistine group. Finally, the global assessments of efficacy by both the investigator (data not shown) and the patients were largely in line with the distinct improvements of the SM and associated symptoms in the course of therapy. After 1 week of therapy, more than 90% of the patients judged the tolerability of the study medication as very good. The results of our study demonstrate a high antivertiginous efficacy and good tolerability of the fixed combination of cinnarizine and dimenhydrinate in the treatment of patients with Meniere's disease.
All parameters of the vestibulospinal tests (recorded by CCO) distinctly improved during the course of therapy (see Table 3), with comparable results for both medications. Spontaneous or positional nystagmus was found in fewer than 10% of the patients, which parallels clinical experience.
In contrast to the patients' subjective assessment of hearing, pure-tone audiometry did not show a clear-cut recovery of cochlear function during the treatment (Table 5). The good antivertiginous efficacy of the combination preparation found in our study corresponds with the findings of previous clinical studies in patients suffering from vertigo of various origins [9,10], from which patients with Meniere's disease had been excluded. The high efficacy of the two medications may be explained by their pharmacodynamic properties. The tolerability of both medications was judged by the vast majority of the patients (97.5%) as very good, which is underlined by a very low rate of dropouts (two patients in the betahistine group) and an absence of adverse events in any of the 80 patients who completed the study.
In conclusion, the fixed combination of cinnarizine, 20 mg, and dimenhydrinate, 40 mg, proved to be safe and highly effective in the treatment of Meniere's disease.
In the ear, nose, and throat field also, we are required to consider changes in organs and diseases associated with age and corresponding treatment approaches.
In other words, elderly people are always at risk of dehydration and are liable to enter a shock state. Even if they have the same disorder as is seen in younger people, they are less likely to manifest typical symptoms. Hypotension produces rotary vertigo in patients, as it does paroxysmal positional vertigo (PPY). Hyperlipidemia, ischemic heart disease, and diabetes mellitus require special attention in the elderly, as does orthostatic hypotension. Cerebellar infarction, particularly in the bilateral or median portion, often produces vertigo (Fig. The rare onset of this disease after the retirement age of between 60 and 65 years has to do with the decline of internal ear function with aging. Recall the familiar scene in which Robert Kennedy lay in the hotel lobby waiting for an ambulance immediately after he had been shot [4]. Of course, treatment should be provided on a case-by-case basis, but what is essential is to improve blood circulation. Eight patients treated with intratympanic and oral corticosteroids were selected, just two patients showed improvement over the hearing but seven of them showed big improvement in their tinnitus, which was demonstrated by an improvement in the values of the degrees of severity of tinnitus. In most cases, there is a unilateral hearing loss, with bilateral involvement reported en less than 5%1.
However, the current trend is to consider the sudden deafness as a disease of multifactorial etiology2. In idiopathic cases, the oral corticosteroids are widely used, although the supporting evidence is weak. However, there are few theories trying to explain its mechanism, one of than associates this symptom with a maladaptive attempts of a cortical reorganization process due to peripheral deafferentation4. The majority ask doctors about the prognosis of residual tinnitus at the final day of medical treatment for SSNHL. From June 2011 to July 2013, 64 patients with a diagnosis of sudden sensorineural hearing loss were seen at the otorhinolaryngology outpatient and emergency unit of our Center, Eight was suffering from severe disabling tinnitus.
A detailed clinical history was taken, followed by an otoneurological examination, and an initial audiological assessment by tonal and vocal audiometry, impedance testing, speech recognition rate (SRR), laboratory tests, and an image exam (magnetic resonance imaging with contrast of the inner auditory canal).
Eight patients suffering from severe disabling tinnitus agreed to undergo rescue therapy and signed the free informed consent form to be included in this study.
All patients with fluctuating hearing loss or suspected Meniere's disease were also excluded from this study. A second injection was done if there was any possibility that the first injection was not adequate.
A 20 dB improvement at 0.5, 1 and 2KHz, or a 20% improvement in discrimination was enough to consider the intervention as successful. In the Visual Analogue Scale (VAS) score ranges from 1 to 10, where 10 represents the highest degree of tinnitus severity.


However, corticosteroids seem to have universal acceptance and are the ones with proven effectiveness. Such treatments aim to improve inner ear oxygenation and include vasodilators, plasma expanders, steroids and anticoagulants11. In the EVA, it is observed that 100% of patients had a score greater than or equal to 7 and a significant reduction in scores of patients 1, 2, 3, 4, 7 and 8, in order to reduce at least two points on score and the same was observed in the degree of severity in THI (Table 1).
Patient 2, despite their age, presents a clinical STD (sexually transmitted disease) that could prevent or reduce the effectiveness of the proposed treatment. The administration of hyperbaric oxygen is based on the argument that both the hearing loss and the tinnitus may result from a hypoxic event in the cochlea, and that hyperbaric oxygen therapy may be able to reverse the oxygen deficit.
Eight patients were followed with improvement in SSHL auditory thresholds (Group A) and eight patients with poor hearing improvement (Group B), to elucidate the behavior of these symptoms in your ongoing recovery.
Several therapeutic efforts including intravenous steroids and graft in the round window showed no positive responses. All subjects had SSHL, although the group "short" had a better prognosis than the group "longer duration" when restricted to SSHL accompanied by tinnitus. Ten patients with sudden hearing loss and severe-profound unilateral tinnitus associates were implanted with a mean age of 42.7 years deployment. It was conducted a prospective study that analyzed gender, laterality and age of patients, along with changes in the level of hearing and tinnitus, after scoring early SSHL to determine the prognostic factors of residual tinnitus after the last day of treatment for SSHL. The tinnitus was assessed subjectively by a questionnaire before, 6 and 24 months after initiation of treatment.
The scores of tinnitus in all three items were significantly better 6 months after initiation of treatment comparing with the last treatment. Especially younger patients with hearing improvement achieve an improvement of tinnitus in the period between 6 and 24 months after initiation of treatment. Specialist in Otology and Neurotology by Harvard Medical School, Boston, MA, USA, PhD in Medical Sciences from the University of Brasilia, Professor at Health Sciences School - University of Brasilia - Brasilia - DF - Brazil. It results in vertigoPersistent feeling of tilting, swaying, whirling or spinning motion of oneself or of the surrounding world when nothing is moving.Learn More and hearing dysfunction.
Hyperinsulinemia: the common denominator of subjective idiopathic tinnitus and other idiopathic central and peripheral neurootologic disorders. This was the identification by Updegraff in 1977 of hyperinsulinemia with idiopathic Meniere's disease. The unique and specific hyperinsulin patterns were diagnostic per se of the noninsulin-dependent diabetic state. The classification of tolerances according to glucose values are the guidelines of the American Diabetes Association. Hyperglycemia glucose tolerance with hypoinsulinemia identified insulin-dependent diabetes mellitus, (IDDM) designated Type I potential.
Hypoinsulinemia and euinsulinemia with IGT and euglycemic glucose tolerance are designated normal.
This control had been maintained at the same 91% rate during the 10 years since this study was initiated in 1980.
Whenever antibodies to exogenous insulin of significant amounts occurred and required a markedly increased dosage, the term insulin resistance was originally applied. In absolute terms, this index is reduced by 35 to 40% in NIDDM and is thereby judged "insulin resistant". If the nutritional state is sufficient to maintain a euglycemia status and yet insufficient to reverse hyperinsulinemia, risk factors for the clinical pathology of hyperinsulinemia remain. Shulman emphasizes that flexibility in thinking is required to allow for the development of new modalities in the diagnosis and treatment of tinnitus. Hyperinsulinemia identification with SIT, secondary endolymphatic hydrops (SEH), and other idiopathic disorders will significantly narrow the idiopathic categorization.
From time to time, a fresh look at this classification with periodic reevaluation has been suggested. Hyperinsulinemia is the common denominator of SIT and other idiopathic central and peripheral neuro-otologic disorders. National Diabetes Data Group: Classification and diagnosis of diabetes mellitus and other categories of glucose intolerance. Kraft JR: Insulin assay diabetic state identification, a specific diagnostic tool of the noninsulin dependent diabetic state, a metabolic disorder. Claussen C-F, Kirtane MV, Schlitter K: Nausea, Tinnitus and Hypoacusia in Metabolic Disorders.
Fukuda Y, Juliana L, Mangabeira-Albernaz PL: The physiopathological influence of hyperinsulinemia on the origin of Meniere's disease. Proctor CA, Proctor TB, Proctor B: Etiology and treatment of fluid retention (hydrops) in Meniere's syndrome. Caovilla HH, Malavasi-Gananca M, Freitas-Gananca F, Serafini F: Nutritional diet in the treatment of tinnitus.
Perez-Pelaez M, Jeyendran RS, Kraft JR, Sie KT: Abnormal insulin patterns and its relationship to defective folliculogenesis in infertile patients.
Porte D, Kahn SE: Hyperproinsulinemia and amyloid in NIDDM: clues to etiology of islet Bcell dysfunction? It is the unique combination of these exceptional ingredients that makes TinnitusWars an extremely effective remedy for the treatment of Tinnitus.
Fixed Combination of Cinnarizine and Dimenhydrinate Versus Betahistine Dimesylate in the Treatment of Meniere's Disease: A Randomized, Double-Blind, Parallel Group Clinical Study. The treatment (one tablet three times daily) extended to 12 weeks, with control visits at 1,3,6, and 12 weeks after drug intake. Frequently associated symptoms are aural fullness and vegetative symptoms, such as nausea and vomiting.
Medical treatment is composed of a great variety of agents, including vasodilators and vestibular suppressants [5,6]. The combination preparation is highly effective in both central and peripheral vestibular disorders owing to its dual mechanism of action. Dimenhydrinate acts as an antihistamine with anticholinergic properties and exhibits ani vertiginous and antiemetic effects.
Betahistine was chosen as the reference drug, as it is a generally accepted standard treatment, especially in the prophylactic treatment of Meniere's disease. Antivertiginous and or cerebrovascularly active drugs had to be discontinued prior to the start of treatment (1-week washout phase). It was conducted in accordance with the Declaration of Helsinki and the guidelines for good clinical practice.
From the ratings for six vertigo symptoms (dystasia and walking unsteadiness, staggering, rotary sensation, tendency to fall, lift sensation, and blackout) and six vertigo trigger factors (change of position, bowing, getting up, driving by car or train, head movements, and eye movements), a mean vertigo score (SM) was calculated, with theoretical values between 0 (no symptom at all) and 4 (all 12 symptoms present with maximum intensity).
Concomitant vegetative symptoms (nausea, vomiting, sweating, and tachycardia) and further symptoms related to the disease (tinnitus, impaired hearing, aural fullness, headache, and impaired vision) were registered. The intent-to-treat analysis included data of only 1 additional patient (n = 81) and is therefore not considered further. Analysis of primary and secondary efficacy variables was based on changes from baseline, as evaluated at 1,3,6, and 12 weeks after the start of treatment, with special consideration of the SM as a global parameter for vertigo intensity.
Categorical (efficacy and safety) variables were descriptively compared by means of Fisher's exact test. One patient of the betahistine group did not return to any subsequent control visit (owing to an adverse event) and was not valid for the intent-to-treat analysis. The study population included 39 male and 43 female patients, with a mean age of approximately 50 years in both groups. Vertigo symptoms (mean score [SM]) in the course of a 12-week treatment with the fixed combination of cinnarizine, 20 mg, and dimenhydrinate, 40 mg (ARL) or betahistine dimesylate, 12 mg, in Meniere's disease.
Tinnitus (mean score) in the course of a 12-week treatment with a fixed combination of cinnarizine, 20 mg, and dimenhydrinate, 40 mg (ARL) or betahistine dimesylate, 12 mg, in Meniere's disease.
All six test parameters improved highly significantly in the course of the 12-week treatment, with mean reductions of approximately 40-60%. Only one patient (in the ARL group) still presented spontaneous nystagmus after the 12-week treatment period. Nystagmus frequencies and amplitudes were mostly within the normal range before, during, and after treatment. Hearing loss on the non affected side was initially approximately 13 dB in patients in both groups and remained largely unaffected by either treatment. After 1 week of treatment, more than one-half of the patients in each group stated an overall improvement in their health condition.
Only one patient (in the betahistine group) reported a nonserious adverse event (neurotic symptoms, judged by the investigator as not being related to the study medication), which was the reason for the retreat within the first week of the study (dropout). Of the remaining patients, three of the betahistine group and four of the ARL group rated the tolerability as good, and only one patient in each group gave the rating of moderate.
Because severe vertigo sensations are usually the most distressing complaint of patients suffering from Meniere's disease, a vertigo score, SM (mean score of vertigo symptoms and trigger factors), was chosen as the primary efficacy variable. Vegetative symptoms (mean score [VM]) in the course of a 12-week treatment with a fixed combination of cinnarizine, 20 mg, and dimenhydrinate, 40 mg (ARL) or betahistine dimesylate, 12 mg, in Meniere's disease. The majority of the Meniere's patients show spontaneous or provoked nystagmus during or immediately after the vertigo attacks but rarely during the period of remission [17].
Hearing loss in Meniere's disease is sensory, and it characteristically displays a fluctuating but progressively worsening course, with little or no correlation to vestibular dysfunction [23,24].
In patients with otogenic vertigo, acute vestibular disorders, and vertigo due to vertebrobasilar insufficiency, the fixed combination of cinnarizine and dimenhydrinate proved to be significantly more effective than was betahistine [10], whereas in Meniere's disease, our study demonstrates a very similar efficacy but no statistically significant difference between the two treatments. From a pathogenetic point of view, Meniere's disease is the classic form of endolymphatic hydrops [24].
This unusually low incidence of adverse events may reflect a generally positive attitude of the patients toward the study medication owing to the subjectively experienced success of the treatment, which may have prompted the patients to overlook minor inconveniences or adverse reactions. Owing to its pharmacological properties, the combination preparation may be used in both the management of acute episodes and in long-term therapy.
Against this background, we review vertigo in elderly patients briefly and consider the key points of its treatment.
Using this as backdrop, we review vertigo in elderly patients briefly and consider the key points of its treatment.
The dorsal root in the elderly is also degenerated, which ex-plains such diverse complaints as dizziness, tinnitus, ringing in the head, headache, neck and shoulder stiffness, and lumbago. Special effort should be made to differentiate between not only benign PPY but pseudobenign PPY and malignant PPY. Atrial fibrillation, among others, can be one of the major causes for cardiogenic embolism [3]. The leftward conjugated deviation of the eyes and right facial palsy were due to a pontine lesion.
The three keys are to facilitate blood circulation, prevent thrombosis, and improve blood rheology. In many cases, the etiology remains unknown and constitutes a major challenge, even after complete otologic evaluation, and these cases are classified as idiopathic sudden deafness3. Intratympanic dexamethasone has been trialled in patients with sudden sensorineural hearing loss, because it provides a high concentration of steroids in the labyrinth in animal models1, although its evidence are conflicting. This study was approved by the institutional review board of the Medical School and the University Hospital in which it was carried out. Below are the details of inclusion criteria, the audiometric assessment, application technique, analysis of The Tinnitus Handicap Inventory and Analogue Visual Scale for Tinnitus and outcome of recovery of Hearing Loss and Tinnitus. The speech recognition rate (SRR) was based on the percentage of correct answers for monosyllables.
EMLA cream was placed in the outer ear canal and the tympanic membrane and left for 30 to 45 minutes, after which it was removed. Failure of oral prednisolone therapy was absence of improvement, as just described, after 14 days of treatment. In relation to the mean-tone, obtained as a result of the following classifications: mild (25%), moderate (25%), severe (25%) and deep (25%).
Sudden hearing loss can occur mainly in the age group 43-53 years7, with equal gender distribution. Already Patient 4 also showed no change in auditory thresholds, showed a significant change in their tinnitus.
Significant increase of 25% was found in the hearing threshold of patients undergoing this type of therapy, but in relation to tinnitus, the study was not conclusive13. Seven patients (70%) treated with enoxaparin sodium and venous hemofiltration (group A) had reduced subjective tinnitus and four patients (40%) showed a complete hearing recovery after the first procedure. Given the failure of the rapies performed, it was suggested the cochlear implant that, according to the authors, is a routine procedure for patients with profound bilateral sensorineural hearing loss, and succeeded, some reports showed a suppression of tinnitus as a side effect after implantation.
This indicates that the tinnitus by itself cannot be a problem sign in the prognosis of hearing, but may be an essential sound for the early recovery of the damaged auditory system. Shortly after the standard fitting procedure, the patient reported a reduction of tinnitus, hyperacusis, and the headache disappeared completely in the follow-up of 3, 6 and 12 months. Seven patients experienced an improvement inTHI in different degrees and in only one patient there was no change. 44 patients with SSHL were followed, all treated with systemic steroids administration for 2 weeks and oral ingestion of vasoactive drugs and B12 vitamin for 6 months.
Among the comparison between 6 and 24 months after initiation of treatment, there was no significant change. Oral vs intratympanic corticosteroid therapy for idiopathic sudden sensorineural hearing loss: a randomized trial. Intratympanic dexamethasone injections as a treatment for severe, disabling tinnitus: does it work? Cochlear implant in patients with sudden unilateral sensorineural hearing loss and associated tinnitus.
Hyperbaric oxygen therapy for idiopathic sudden sensorineural hearing loss and tinnitus: a systematic review of randomized controlled trials. Sodium enoxaparin and venovenous hemofiltration in treating sudden sensorineural hearing loss and tinnitus. Otoacoustic emissions, ear fullness and tinnitus in the recovery course of sudden deafness. Curing tinnitus with a Cochlear Implant in a patient with unilateral sudden deafness: a case report. It was based on the radioimmunoassay of insulin in known diabetic patients following a 100 g glucose load. The first international reference preparation of human insulin for immunoassay (WHO)4 was established in 1974.
Our reports of 2,500+,5 3,500+,6 10,000+,8 14,000+,9 and our current 15,000+ examinations provide the cumulative database. Proctor19 cites results of nutritional management in 54 patients with Meniere's disease elevated insulin levels as remarkable. The patients with Meniere's disease reported hearing improved to normal levels and complete relief of tinnitus. RIA insulin assay examinations thereby become practical and cost-efficient with international availability and worldwide application.
It has now been extended to include patients in whom there is evidence of a reduced biologic response to insulin as demonstrated by different investigative techniques. This research technique has also identified an index of insulin resistance in the euglycemic state.
An appreciation of idiopathic neuro-otologic disorders and an understanding of hyperinsulinemia are as important as the counseling skills required in diabetes mellitus. Scheduled follow-ups provide the support and encouragement necessary for the development of self-responsibility necessary for the patient to gain and maintain management control of the metabolic disorder.
This demonstrates the common denominator of hyperinsulinemia with essential hypertension and SIT. The unequaled therapeutic respones of SIT and other idiopathic disorders to medical nutritional therapy compliance mandates the earliest possible identification of hyperinsulinemia. Future application of molecular biologic techniques will clarify the role of the insulin-receptor complex and its relationship to hyperinsulinemia production. In lieu of the reported unequaled therapeutic response of idiopathic neuro-otologic disorders with hyperinsulinemia to medical nutritional therapy compliance, the earliest possible identification of hyperinsulinemia becomes mandatory. Presented at the 21st Congress NES, March 17-20, 1994, Bad Kissingen, Germany, publication pending.
In Vertigo, Nausea, Tinnitus and Hypoacusia in Metabolic Disorders Claussen CF, Kirtane MV, Schlitter K, Eds. The study demonstrated for both the fixed-combination ARL and for betahistine a highly efficient reduction of vertigo symptoms in the course of the 12 weeks of treatment; however, no statistically significant difference between the two treatment groups could be established.
The vertigo attacks (predominantly rotational vertigo) occur suddenly without warning-albeit in a majority these are preceded by an "aura," as in epilepsy, with aural fullness, tinnitus, and nausea for 10-30 minutesand last for several minutes to hours; they recur after days, weeks, or months, followed by episodes with weak or no symptoms (remission). Owing to these pharmacological properties of the components, the fixed combination is expected to show a favorable effect in the treatment of Meniere's disease:cinnarizine, with a prophylactic effect by means of improvement of inner ear circulation, and dimenhydrinate, intended to alleviate acute vertigo attacks through its anti vertiginous, antiemetic, and sedati ve effects. Exclusion criteria were convulsive seizures, suspicion of compressive intracranial processes, narrow-angle glaucoma, prostate adenoma with residual urine, Parkinson's disease, asthma, gastrointestinal ulcer, acute poisoning, severe renal insufficiency, epilepsy, and alcohol abuse.
The study documents were reviewed and approved by an independent ethics committee and by competent health authorities. For randomization, a computer-generated block sequence was used, which ensured equal distribution of the patients into the two treatment groups.


The change of SM in the course of the 12 weeks of treatment was used as the primary efficacy criterion.
The change of SM in the course of the 12-week treatment phase was used as the primary criterion of efficacy.
Analysis of changes from baseline within a treatment group was done by the Wilcoxon signed rank test. One other patient of the betahistine group discontinued the study after the second intermediate examination (week 3) for unknown reasons. The mean decreases in SM in each therapy group were highly significant at all times of assessment (p p > .05 , Mann-Whitney U-test) . The mean reductions in the subjective scores in each therapy group were highly significant at all times of assessment (p p > .05, Mann-Whitney U-test).
In both groups, the vegetative symptoms had nearly completely subsided by the end of the 12-week treatment period. In particular, the parameter of lateral sway (Unterberger's test) in the ARL group decreased to a significantly greater extent during the 12-week treatment period as compared to the symptom in the betahistine group (p =.042).
Caloric weakness and directional preponderance did not change significantly under either treatment.
In patients with bilateral disease, the hearing loss was initially approximately 44 dB in either group and showed no significant changes in the course of therapy. After 12 weeks of therapy, all patients judged the tolerability of the two medications as very good, except for one patient in each group, who gave the rating of good. Both the fixed combination and betahistine led to a highly significant reduction of SM by more than 80% in the course of the 12-week therapy (see Fig.
Scores for the symptoms of nausea, vomiting, sweating, and tachycardia were averaged to a mean vegetative score per patient. The reduction of this parameter seems to reflect a normalization of a patient's condition, at least with respect to the balance system, and corresponds with the reduction of the SM, chosen as the primary criterion of efficacy.
Caloric responses are reduced in approximately 40-70% of the cases [2,17]; the excitability decreases more rapidly at the beginning of the disease and stabilizes in the following 10 years to one-half or one-third of the initial level [2,22]. The initial hearing loss of 40-45 dB at the affected ear is close to values found in the chronic phase of the disease [22,23,25] and compatible with the long mean duration of the disease (6 years) in the patient population of our study. Several vasodilators have been used for the treatment of Meniere's disease, on the basis of the hypothesis that ischemia of the stria vascularis plays an important role in the development of endolymphatic hydrops [4]. Efficacy and safety were found to be similar to the widely used standard therapy with betahistine. Efficacy and tolerability of a fixed combination of cinnarizine and dimenhydrinate in treatment of vertigo.
Effects of diphenhydramine and dimenhydrinate on vestibular neuronal activity of cat: A search for the locus of their anti motion sickness action.
In comparison to younger people, what is first noticeable about elderly people is that they have a lot of fat in the body and a markedly low level of intracellular water.
However, these complaints cannot be dismissed simply as an "unidentified syndrome." One or another organic disorder always is behind these complaints. Because they are more or less conscious of death in daily life, they have a strong sensation of fear and thus visit with a variety of complaints. This tendency is particularly conspicuous among women, and their typical complaints include headache, vertigo, shoulder stiffness, palpitation, tinnitus, and lumbago (Table 1). When this vertigo is induced and associated with PPY symptoms, it is important to differentiate between benign and malignant forms (Fig. As compensation declines with aging, one usually becomes slower with age to recover from the same degree of disorder. This therapy should be continued for 10 consecutive days, followed by cessation for a subsequent 10 days.
Only 2 patients had improvement of hearing (from severe to normal, mild to normal), keeping unchanged all other results and no worsening (Table 2 and Figure 2).
Patient 8, 73 years, has hypertension and diabetes, as well as probable hearing loss due to presbycusis before the episode of sudden deafness. In group B, eight patients (80%) treated with conventional therapy showed a reduction of subjective tinnitus and hearing score also improved in eight patients (80%) - the hearing remained unchanged in two patients (20%). All patients in both groups had ear fullness and tinnitus in association with the onset of the SSHL. One year after the onset of symptoms on the right side, the cochlear implant was performed, and resulted in a complete suppression of tinnitus after activating the implant. It was concluded that, according to the survey of tinnitus, the time factor is the most reliable item for subjective tinnitus.
The international standard became, and continues to be, the primary standard for insulin assay credibility comparison. The definitions of euinsulinemia, hypoinsulinemia, and hyper-insulinemia are statistically affirmed. Hyperinsulinemia was identified as the common denominator in 80 of 93 (86%) cases, irrespective of the glycemia status following a 100 g glucose load. Caovilla, Malavasi Gananca, Freitas Gananca, and Serafini20 identified abnormal insulin levels in their 1128 outpatients who were suffering from tinnitus and other statoacoustic systems. This affirms our identification of hyperinsulinemia with euglycemia glucose tolerance as the earliest identification of the NIDDM state. Physical training also improves insulin sensitivity in subjects with hyperinsulinemia upon compliance with nutritional therapy. Medical nutritional therapy compliance is also a shared denominator becoming the cornerstone of conjoint therapy for essential hypertension and SIT. Adult-onset diabetes by hyperglycemia is diagnosed most frequently in the later decades of life.
In Vertigo, Nausea, Tinnitus and Hypoacusia in Metabolic Disorders Claussen C-F, Kirtane MV, Schlitter K, Eds.
Similar results were found for tinnitus (approximately 60% reduction) and for the associated vegetative symptoms (almost complete disappearance). The complete clinical picture usually develops only after several years, which makes it more difficult to establish the diagnosis in earlier stages.
Conversely, vestibular suppressants, such as dimenhydrinate, have proven to be very effective in the management of acute Meniere's attacks owing to their anti vertiginous, antiemetic, and sedative properties [5,6,9]. Further exclusion criteria included suspected acoustic neurinoma, apparent infection of the inner ear, caloric inexcitability (areflexia), vertigo due to unsolved organic primary disease, previous surgical treatment for Meniere's disease, and benign paroxysmal positional vertigo.
The entry examination took place on day 1 (before drug intake), followed by three intermediate examinations after 1, 3, and 6 weeks and a final examination after 12 weeks. The caloric test with ENG registration was performed according to standard procedures (irrigation of 20 ml water at 30° and 44°C for 30 seconds) [18]. All other patients (n = 80) completed the study with no protocol violations and were therefore valid for the per-protocol analysis.
On average, the enrolled patients suffered for 6-7 years (5 months-29 years) from Meniere's disease, the manifestation being approximately 65% unilateral and 35% bilateral, which is in accord with data found in the literature [20].
The statistical analysis showed highly significant changes within each group from the first week (p between the two treatment groups at any time. The other parameters showed no significant difference between the two treatments (Table 3).
In patients with unilateral disease, the affected ear showed a lower excitability than did the nonaffected ear.
No statistically significant difference between the two treatment groups could be observed in any case.
Blood pressure, measured at each examination visit, showed no changes of clinical relevance during the study. The mean decreases in VM in each therapy group were highly significant at all times of assessment (p p > .05, Mann-Whitney U-test).
Furthermore, the fixed combination was found to reduce the parameter of "lateral sway" in the Unterberger test, in a significantly stronger way than did betahistine, which may be attributed mainly to the centrally active component, dimenhydrinate, of the combination preparation. In accordance with literature data [4], in the unilateral cases, the mean frequency at the affected side was approximately 30% lower than that at the non affected side and close to the lower limit of the normal range. Audiometry showed a slight but statistically significant recovery only in unilateral cases after 12 weeks of therapy with the combination preparation. Betahistine is known to cause vasodilatation and improvement of cochlear blood flow [26] through a complex interaction with histamine receptors (stimulation of HI-receptors and inhibition of presynaptic H3-receptors) [27]. In other words, elderly people are always at risk of dehydration and liable to enter a shock state.
Therefore, when we examine elderly patients, we need to pay special attention to various factors [1].
Because of brain atrophy with aging, they are less likely to present, for example, symptoms of increased intracranial pressure even if they have a brain tumor. Indeed, the eyes are the windows of the mind, they are more eloquent than lips, and they are a window for diagnosis.
The procedure is well tolerated and relatively easy to perform as outpatient procedure performed under local anesthesia (topical), general anesthesia can be avoided, most patients understand the concept of intratympanic therapy and easily accepts the proposed therapy.
Regarding the THI scores, it ranged from 58 to 96, prior to initiation of therapy, 8-82 and 30 days after. Such comorbidities could not justify the improvement in hearing thresholds after the proposed therapy. None of the patients experienced side effects from this treatment, and the authors concluded that this option can be beneficial as adjuvant therapy for hearing improvement in patients with PANSS, but cost factors are the main obstacles to the use of this therapy14.
However, these symptoms improved only in Group A, showing a significant relationship between recovery of hearing thresholds and improvement of aural fullness. Clinical improvement was also reflected by a decrease in the scores of questionnaires THI and VAS. The hearing recovery was determined by comparing the hearing levels before and after treatment and tinnitus was subjectively evaluated by using a questionnaire. The hyperinsulinemia of the IGT and the DM patients with Meniere's was indistinguishable from hyperinsulinemia in 111 of 121 (92%) cases of Meniere's disease, irrespective of the glycemia status. In 1974, we were the first to define and identify diabetes mellitus in situ (occult diabetes) by glucose insulin tolerance.5,6 Insulin resistance has become an omnibus term21 and is defined in this paper as a concept of insulin sensitivity at the cellular level. Vestibulospinal reactions, recorded by means of craniocorpography, also improved distinctly, with a statistically significant superiority of ARL versus betahistine (p p =.042) was found for the combination preparation after 12 weeks of treatment.
Pregnant women and nursing mothers and women of child-bearing potential who were not taking adequate contraceptive measures were not allowed to participate in the study. On the occasion of all visits, vertigo anamnesis tests (including concomitant symptoms), vestibulospinal tests (Unterberger's and Romberg's tests) registered by craniocorpography (CCG), registration of spontaneous positional nystagmus (Frenzel's glasses), and pure-tone audiometry were carried out. Nystagmus frequency-which served for calculation of caloric weakness and directional preponderance, according to Jongkees [19] -as well as amplitude and culmination area were determined. The vast majority of the patients (78 of 82) had been pretreated with antivertiginous drugs, some with betahistine (38 patients), cinnarizine (6 patients), and the combination preparation (4 patients).
The marked improvements in subjective judgment of hearing reported by both groups of patients during therapy might be attributed to a subjective increase in stimuli perception or processing within the context of general recovery. The therapeutic efficacy of the fixed combination results from the different effects of its two active substances, cinnarizine and dimenhydrinate.
The dorsal root in the elderly is also degenerated, and this explains such diverse complaints as dizziness, tinnitus, ringing in the head, headache, neck and shoulder stiffness, and lumbago. When such patients have cerebral infarction, in particular, they experience a dizziness that is unexpectedly transient; thus, it requires careful attention. Cerebellar or pontine hemorrhage causes severe rotary vertigo, nausea and vomiting, tinnitus, and headache. However, it should be emphasized again that in relation to complaints of tinnitus, it has undergone a significant change, in which catastrophic change of the degree to mild (Table 1). Given this, the authors suggested the use of cochlear implants as a possible therapy for tinnitus persisted after sudden deafness. Migraine headaches have also been linked to this condition.ManagementTreatment focuses on symptom management. The statistical database affirmed hyperinsulinemia with or without hyperglycemia as the sine qua non of the noninsulin-dependent diabetic state.
With dietary control, the associated vertigo and other kinds of dizziness improved or were eradicated in 72% of the cases.
The tolerability was judged by the vast majority of patients (97.5%) in both groups to be very good. Concomitant medications, such as aminoglycoside antibiotics, monoamine oxidase inhibitors, tricyclic antidepressants, parasympatholytics, glucocorticoids, and heparin were not permitted. In addition, that caloric nystagmus test (e1ectronystagmography [ENG]) was performed at day 1 and after 3 and 12 weeks oftreatrnent. Standard pure-tone threshold audiometry was performed at frequencies of 250, 500,1,000, and 2,000 Hz.
2), hearing loss, and aural fullness (see Table 2) and for the associated vegetative symptoms (Fig. The calcium antagonist cinnarizine leads to vasodilatation and improves circulation in compromised intra-and extracranial areas [14,28]. However, these complaints cannot be dismissed simply as "an unidentified syndrome." Behind these complaints is invariably one or another organic disorder. By contrast, cerebral hemorrhage causes nonrotary vertigo and is sel-dom associated with tinnitus. In many cases, it progresses slowly after repeat transient ischemic attack and improves between episodes. Kennedy, Robert Kennedy's fatal bullet penetrated through the right mastoid to the right cerebellar hemisphere. We obtained an average difference of 38.6 points among patients who reported an improvement in tinnitus before and after the course of oral steroids and intratympanic.
In group A, the OAE responses appeared simultaneously with the improvement in hearing levels in five patients (63%).
Hyperinsulinemia was further statistically affirmed as the early metabolic marker in carbohydrate metabolism, preceding hyperglycemia. Only one patient (betahistine group) reported a nonserious adverse event, and two betahistine patients did not complete the study. Both patients and investigator gave a global judgment of the efficacy and tolerability of the study medication after 1,3,6, and 12 weeks of treatment. Furthermore, cinnarizine shows labyrinth sedative properties [28] and has therefore proven efficacy in the management of vertigo episodes of various origins, including also the acute phase of Meniere's disease. Subarachnoid hemorrhage, which occurs from various causes, produces headache, vomiting, and dizziness. Referring to EVA, there was a change from 7 to 10 points before therapy and from 1 to 8 points after it, in relation to intensity.
It was concluded that patients with hearing improvement PANSS (Group A) tend to have OAE responses and sensations of fullness in the ear and tinnitus improved almost simultaneously with the hearing improvement. Diuretics are sometimes used to help regulate the excess volume of endolymph (fluid contained in the inner ear) that is associated with Meniere's disease.An ENT physician consultation is recommended as surgical procedures may help achieve relief. In conclusion, the combination preparation proved to be a highly efficient and safe treatment option for Meniere's disease and may be used both in the management of acute episodes and in long-term treatment. Compliance was controlled on the basis of the number of tablets returned by the patients at the end of treatment. Nearly one-third of the patients had concomitant diseases, most frequently hypertension, and antihypertensives were the most frequent concomitant medication.
The actions of cinnarizine are reinforced by those of dimenhydrinate, which acts predominantly centrally. In relation to the nuisance, there was a change from 7 to 10 points before and 0-08 points after therapy. Dimenhydrinate exerts a regulating effect on the vestibular nuclei and closely associated vegetative centers in the brainstem [29,30].
The authors concluded that patients with poor hearing improvement tend to have absent OAE and ear fullness and tinnitus persisted. Owing to its antivertiginous and antiemetic properties, dimenhydrinate is particularly effective in the treatment of vertigo and associated vegetative symptoms, and it is also recommended for the management of acute episodes in Meniere's disease [4,31]. If you are at risk of experiencing disabling symptoms such as vertigo, disorientation, nausea or vomiting, you should not dive; should these symptoms occur underwater, they may lead to panic, choking and even drowning. Independently the investigations reported dramatic relief and sustained therapeutic response to medical nutritional therapy compliance unequaled by other modalities. In addition, these symptoms may be confused with dive-related injuries such as inner-ear barotrauma or inner-ear decompression sickness.Further ReadingMore Questions? Hyperinsulinemia with or without hyperglycemia is the major metabolic marker with diagnostic and therapeutic relationship to SIT and other idiopathic neuro-otologic disorders.
The unequaled therapeutic responses of SIT and other hyperinsulinemia idiopathic neuro-otologic disorders to medical nutritional therapy compliance mandates the earliest possible identification of hyperinsulinemia.



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