Hyperbaric oxygen therapy for diabetic neuropathy

Dom Van Loggerenberg shares how hyperbaric oxygen therapy (HBOT) not only healed his wound but helped with diabetic neuropathy.


People tend to think of diabetes as a silent, painless condition. Don’t tell that to the millions of folks with diabetes-induced tingling toes or painful feet. This problem, called diabetic neuropathy, can range from merely aggravating to disabling or even life-threatening. It’s something I have first-hand (or, more appropriately, first-foot)  knowledge about.

If you ask medical professionals what the biggest concerns around diabetes are, at the top of most of the list will be microvascular complications. Uncontrolled blood glucose damages nerves and capillaries (the smallest blood vessels). Starting with those furthest from the spinal cord, the toes and feet.

The start of neuropathy

I have been a Type 1 diabetic for the better part of the last 15 years. Being diagnosed as a young adult forced a lifestyle change on me that I was slow to adopt, and probably caused small medical complications that I will be dealing with for the rest of my life.

I am just over 1.9m tall and a rather large person and have had issues with peripheral circulation since I was a teenager. I have always had cold feet. This rapidly became a problem when I developed diabetes, turning into minor neuropathy that became increasingly severe. What started as a loss of sensation and occasional tingling became complete numbness.

This complication was manageable. Under doctor’s orders I needed to check my feet weekly (yay Sunday night foot rubs) and monthly pedicures. I’m serious, the doctor prescribed pedicures. It was a nice excuse for that end-of-the-month-treat-yourself-time. I also had to be extremely careful of hurting myself because I could very easily stub my toe or stand on a thorn and not even notice.

Small scratch, big problem

Now fast forward to 2020, life is changing for all of us. I don’t need to explain, the pandemic has affected everyone and we’ve all had to experience change as a result.

This is where the latest chapter of my diabetic journey took a turn for the worse. It’s early August and I’m having my first pedicure since lockdown started. It’s not the usual place I go to but a professional who was willing to visit my residence. While not being completely sure the chain of events they probably unfolded as follows: a small scratch on the side of my minimus (little toe). I don’t even react to this because it’s completely numb – so the pedicurist assumes no harm, no foul.

Wrong! Two days after this, I wake with my leg being a little stiff around the ankle. Due to me working from home I only walk maybe five minutes that day: kitchen, bathroom, desk (yes, not the most active). Next thing I know the sun is setting and I stand up from my desk. A sharp intense pain shoots up my leg and I panic. I haven’t felt pain in my foot for the better part of a decade. I start to examine my foot and it’s hot to the touch and very swollen. It’s infected and my toe is a deep purple. I swear it didn’t look like this when I woke up.

I contact my father, who is an emergency medicine specialist, and when I hear him say this is urgent I know I’m in trouble. He arranges a course of antibiotics to get to me that evening and examines my foot personally. I’m take four pills, three times of hospital grade antibiotics and my dad sends me into hospital first thing in the morning.

Diabetic foot

Arriving at the hospital, I have an emergency visit, the diagnosis is immediate: diabetic foot.

The truly scary thing about diabetic neuropathy is a 10-letter word we usually associate with horrific accidents or war veterans: amputation. When sensory nerves in the feet become damaged, a blister, cut, or sore can go unnoticed, allowing time for the wound to become infected. Infections that cause the tissue to die (gangrene) and that spread to the bone may be impossible to treat with cleansing and antibiotics.

Then I hear a sentence that shocks me to the core, one of the best doctors says, “I don’t think I can treat this, I am not comfortable in my ability as a doctor, the risks are too great.”

My mother, who is also a doctor, tells me will have a colleague look at me in the next hour. In the meantime, I have a Doppler ultrasound scan of my foot; it maps the blood flow, veins and arteries. Thankfully finding mine in my foot aren’t completely closed off. It has about 30% of a normal person circulation.

Hyperbaric oxygen therapy (HBOT)

Thankfully this medical horror story takes a turn for the better. About 45 minutes later, I have surgery on my foot and most of the dead and infected tissue is either drained or surgically removed. It’s now up to fate and my ability to heal.

I could completely recover with no permanent damage, and to promote this healing treatment it is suggested that I undergo Hyperbaric oxygen therapy (HBOT). Something that I had only heard of in movies (to treat divers from the bends).

Hyperbaric oxygen therapy is conducted within a pressurised chamber. It involves the type of treatment used to speed up healing of carbon monoxide poisoning, gangrene, stubborn wounds, and infections in which tissues are starved for oxygen.

If you undergo this therapy, you will enter a special chamber to breathe in pure oxygen in air pressure levels 1,5 to three times higher than average. The goal is to fill  the blood with enough oxygen to repair tissues and restore normal body function.

I was placed in a chamber for one hour for five days. This would help increase my healing and the wound would have a greater chance of successfully recovering back to normal.

Excellent results

And, yes, the wound healed well. But that’s not all, after my second treatment, getting out of the chamber and stepping off the bed, to my complete surprise I had tingling in my other foot, a sensation missing since I was first diagnosed. By the end of the week I could feel a touch on my foot and had a visible change in the tissue blood supply.

This was confirmed to still be the case six weeks later, when I went for my quarterly check-up at a diabetic centre. I hadn’t mentioned to my doctor that I went for HBOT yet she noticed the changes in my feet. My wounded one obviously had remnants of the procedure but my other foot had returned blood flow and sensation.

She recommended immediately to continue HBOT to see what changes further sessions could do. If 5 hours for one week could make a noticeable difference. Going for a maximum full six-week course of 30 sessions might do more. Normally five and 10 session sets are recommended. I am seeing what the maximum allowed would do.

Further benefits of hyperbaric oxygen therapy1

  • Many of patients mention that before they started HBOT, they had trouble sleeping. After the first session, their sleeping habits improved as did their attention to their diets.
  • HBOT is currently being tested in several antidepressants studies as the oxygenation of the brain seems to help.
  • It has long been known to help speed up wound healing and, in particular, wounds that have a poor recovery rate, like burns and skin flaps (it’s used post-surgery at the breast centre).

Reference:

  1. Milpark Hyperbaric Medicine Centre

MEET THE AUTHOR


Dom Van Loggerenberg (29) lives in Bryanston, Gauteng.


Insulin: overdosing and underdosing

Diabetes nurse educator, Tammy Jardine, explains the various reasons for overdosing and underdosing of insulin.


There are serious consequences of insulin-related medication errors. The first is overdosing which results in severe hypoglycaemia, causing seizures, coma and even death. The second is underdosing which results in hyperglycaemia and sometimes diabetic ketoacidosis and long-term diabetes complications.

Overdosing

Giving too much insulin will result in hypoglycaemia. A hypo is when your blood glucose level is too low, usually below 4mmol/L.

Low blood glucose can occur if the insulin, the food you eat, and the physical activity you do are not balanced correctly and it can happen very quickly.

Overdosing may happen for various reasons

  • You give too much insulin for the meal that you have eaten. This is common if you give a standard dose of rapid-acting insulin with meals. Often the amount of carbohydrate in the meals you eat is not the same, and giving a standard dose of rapid insulin with all meals when you do not need it will cause your blood glucose to drop. For example, if you give a standard dose of 8 units of rapid insulin with breakfast. It may be a suitable amount when you have oats for breakfast but too much if you have an omelette instead.Also, if you overestimate the amount of carbohydrates in a meal you may overestimate the amount of insulin needed and cause a hypo if you are carb-counting.
  • Giving insulin to correct high blood glucose can also cause a hypo if you give too much insulin. This can often happen when you correct a high blood glucose after exercise. Some types of exercise can increase your blood glucose straight after performing the exercise and then drop rapidly over the next few hours as the muscles absorb the glucose from the bloodstream. It is advised to not correct high blood glucose in the six hours after exercise.
  • It may happen if you give your rapid-acting insulin instead of your basal (long-acting insulin) by mistake. Since the basal insulin is usually a higher dose than the rapid-acting insulin, it could be that you give a large amount of rapid-acting insulin which will drop your blood glucose quickly.
  • You can also overdose on insulin on a pump if your basal and bolus pump settings are incorrect.

Notice the symptoms

Everyone has different symptoms of a hypo, but the most common signs are trembling and shaking, feeling disorientated, sweating, being anxious or irritable, going pale, palpitation and a fast pulse, lips tingling, blurred vision, feeling hungry, tiredness, losing concentration, headache, and a fogginess in your head.

Sometimes you may already feel these symptoms when your blood glucose is falling quickly but are not yet below 4mmol/L. Testing your blood glucose regularly can help you to identify a hypo before you get any symptoms and prevent it from dropping too low.

If you are unable to tell when your blood glucose is low, you will only know by checking your level.

How to treat a hypo

You must act as soon as you notice symptoms of a hypo or if your blood glucose level is too low. If you don’t act quickly, it could get worse and you could start feeling confused and drowsy, and you could even become unconscious or have a fit. This is called a severe hypo.

To treat a hypo, immediately eat or drink something that has 15-20g of fast-acting carbohydrate. For example, three Super C sweets or five jelly babies or 200ml coke less sugar (new original taste) or 120ml litchi juice. Choose whatever you have on hand, or is preferable to your taste, or is easy to store.

If you are not sure how much carbohydrates are in a product, check the nutrition label on the product but be sure to look for the amount of carbs in the portion that you will be consuming. Wait 15 minutes and re-test your blood glucose. If they are not increasing at all then repeat the process.

Once you see your blood glucose rising, to prevent them from dropping again, eat 15-20g of slow-acting carbohydrate. For example, a slice of wholegrain bread with cheese or peanut butter, or a fruit and some nuts, or a glass of milk.

When help is needed

If you are feeling too confused or drowsy to eat or drink then ask someone to help you. It is important that your family, friends and colleagues know what to do if you have a severe hypo or become unconscious. If you are unconscious, they should put you on your side and call an ambulance.

Always keep hypo treatments by your bed in case you have a hypo at night. If a hypo doesn’t wake you up, you may realise that you had one if you feel very tired or have a headache the next morning.

Do a blood test before you go to sleep and during the night, If you think you may be having a hypo at night. If the one during the night is much lower, you may need to change your insulin dose. Speak to your healthcare provider about this.

Underdosing

Giving too little insulin will cause your blood glucose to rise above acceptable levels. This is called hyperglycaemia. A hyper is when your blood glucose levels are above 7mmol/L before a meal, or above 8,5mmol/L two hours after a meal.

If your blood glucose level is slightly higher than normal, you will not usually experience any symptoms but as they rise you may need to urinate more often especially at night, feel thirsty, have headaches, or feel lethargic and sleepy.

Underdosing may happen for various reasons

  • If you do not give enough insulin for the amount of food that you have eaten. Make sure you are aware of the amount of carbohydrate foods you are eating and how they affect your blood glucose after you eat them. Testing regularly will help you to identify foods that push your blood glucose up and need more insulin to prevent a hyper.
  • Not giving insulin or missing doses dose of insulin. Don’t skip insulin doses, specifically the long-acting bolus amount. You may occasionally fluctuate your rapid-acting insulin doses according to your blood glucose and what you are eating, but keep your long-acting insulin stable.
  • Your blood glucose levels could be higher than normal when you are unwell. You may need to drink more fluids, take more insulin and check your blood glucose more than you would usually. The amount of extra insulin needed will vary from person to person. Your diabetes team will help you to work out the correct dose for you.
  • Blood glucose levels may also spike because of a growth spurt or puberty, high stress period like exams, surgery or injury, and sometimes menstruation can increase blood glucose as well.

Diabetic ketoacidosis (DKA)

One of the risks of a rising blood glucose is DKA. If you blood glucose is more than 15mmol/L, you should check for ketones. If ketones are present, it is likely that you do not have enough insulin in your body.

DKA happens when there is severe lack of insulin in the body. Since glucose needs insulin to be able to make energy, this means the body can’t use glucose for energy and starts to use fat instead. When this happens, chemicals called ketones are released.

The difference between ketones when your blood glucose is high and you need more insulin, and the ketones that are produced on a (low carbohydrate diet) is the presence of excess blood glucose. Together with the ketones, the excess blood glucose will cause an acid build-up in your body, hence the name acidosis. If left unchecked, this can cause serious damage to your organs.

Warning signs

The warning signs for DKA are the same as for a hyper except that often there will be stomach pain, with or without vomiting. Sometimes there may also be a sweet smell on the breath that will smell like nail polish remover or boiled sweets.

Check your blood glucose straight away if you have any of the signs of a DKA. If your blood glucose is above 15mmol/L, check for ketones using urine sticks or a blood ketone meter. A blood test will show your ketone levels in real time but a urine test will show what they were a few hours ago.

If your blood glucose are high and you have ketones present in your blood or urine, you should get medical help straight away especially if you have abdominal pain or are vomiting. DKA is serious and must be treated in hospital quickly with insulin and fluids to prevent dehydration. Left untreated, it could lead to a life-threatening situation.

Avoiding DKA

You can avoid DKA by monitoring your blood glucose levels regularly and altering your insulin dose in response to your blood glucose levels and what you eat. Speak to your healthcare provider on how you can individualise this.

It is still a good idea to contact your GP or diabetes team if you feel fine but are getting higher than usual readings for blood glucose and ketones, or if you feel unwell but your blood glucose and ketones are only slightly higher than normal.

Besides the risk of DKA, having high blood glucose levels regularly can increase your long-term risk in developing complications, including problem with your eyes, feet, and kidneys, erectile dysfunction if you are male, and an increased risk of stroke and heart attack.

If you notice that your blood glucose levels are often high, you should contact your diabetes healthcare team. They will review your treatment and provide you with advice on how to get your blood glucose levels back within your target range.

MEET THE EXPERT


Tammy Jardine is a qualified diabetes educator and a registered dietitian. Living with diabetes for over 15 years means that she knows first-hand how difficult it can be to achieve and maintain optimal blood glucose control with good lifestyle habits. She believes that diabetes affects every person differently and takes the time to understand how it’s affecting the individual and to help them manage it effectively. With more than 20 years of experience working as a dietitian in the UK and SA, she has a passion for helping people live a better and happier life with good food. Tammy currently works from Wilgeheuwel hospital. Email: [email protected]


Header image by FreePik

Artificial pancreas – now a reality

Type 1 diabetes patient, Marc Peverett, tells us how technology has allowed him to build his own artificial pancreas.


I have been living with Type 1 diabetes for over 30 years. I must admit, in my opinion, changes and advances in treating diabetes effectively have been slow.

After years of counting carbs, glucose levels and insulin units, not to mention the countless finger pricks, I’ve been living in a never-ending maths puzzle. Get the answer wrong and you’re dead. If not immediately, then in the long-term.

Open-source Loop app

It was after discovering the concept of the open-source Loop app, in 2019, when I began to feel hopeful. This artificial pancreas revolutionised my diabetes control.

During all the years of strictly managing my condition, I could never obtain a consistent HbA1c reading. Now, over the past year, my readings are between 6,1 and 6,4 and I can go to sleep with the confidence that my blood glucose levels are controlled throughout the night.

My 90-day blood glucose readings from my continuous glucose monitor show that I’m 96% in range.

Building my artificial pancreas

With a little IT knowledge and from the comfort of my home, I built my artificial pancreas, affordably.

I already had most of the components needed: a compatible Medtronic insulin pump, a Mac computer, iPhone and Libre glucose sensor. I had to source the remainder of the required components: a Bluetooth data reader (MiaoMiao2 – imported from China) and a transmitter device (Rileylink – imported from the USA). These were necessary to send communications between my iPhone and Medtronic insulin pump.  All these components are available in South Africa.

The MiaoMiao2 data reader  fits on the FreeStyle Libre glucose sensor and is instrumental in establishing a continuous glucose monitor, sending readings automatically to my phone every five minutes, without needing to scan. This is a game-changer for people with Type 1 and 2 diabetes.

MiaoMiao2 sounds an alarm if you’re high or low during the day or night, and glucose readings can be shared continuously with other family members who are not nearby.

Tidepool Loop

Tidepool Loop is an amazing international community, driving innovation forward to make software management for diabetes free and affordable.

Tidepool offers amazing data management for all diabetic devices, allowing the counting of the diabetic maths puzzle to be located and integrated seamlessly.

Achieving an artificial pancreas can be done in stages, with increased benefits at every stage.

STAGE 1: Start using a CGM

MiaoMiao2 + FreeStyle Libre Sensor or Dexcom G6 are compatible devices. Implementing Stage 1 will already improve blood glucose levels.

STAGE 2: Using a second-hand medtronic pump

Applicable Medtronic insulin pumps 515, 715, 522, 722, 523 or 723 (firmware 2.4 or older), Veo 554 or 754 (firmware 2.6A or lower).

STAGE 3: Securing an iPhone

An iPhone 7 or higher.

STAGE 4: Sourcing a Rileylink

This is a component sourced in the USA and distributed locally here in South Africa.

STAGE 5: Building the Loop app

You will need an Apple Developer Account (which anyone can acquire). Tidepool has a vision of launching their product in the App Store. When this becomes a reality, building the app won’t be necessary.

Peace of mind

With the use of artificial intelligence comes some peace of mind. I’m no longer restricted by this condition. In some ways, I have my life back. I can look forward to a good night’s sleep without worrying about lows or highs. ‘Someone’ else is doing all the thinking and I can focus on the important things.

This feeling of finally being in control could be a reality for you too. Should you need any further information, please email me at [email protected].

 

Reference

  1. https://loopkit.github.io/loopdocs/

 


Marc Peverett (49) has been living with Type 1 diabetes since 1989. He is married and has two children. He is an industrial/organisational psychologist.


EDITED BY Kathleen Mukheibir


After obtaining her LLB degree and commencing with her articles of clerkship at a firm in Cape Town, Kathleen Mukheibir discovered her interests lay elsewhere. Following her passion, she took a leap and has pursued a new career path into the world of copywriting, proofreading, and editing.


Betadine Emtrix Fungal Nail Solution

We learn more about how Betadine Emtrix Fungal Nail Solution can help with fungal infection and nail psoriasis.


What is fungal infection and nail psoriasis?

Fungal infection and nail psoriasis are characterised by thickening, splitting, pitting and discolouration of the nail.2,3 These conditions may affect toenails or fingernails, but fungal toenail infections are notably more common, whereas psoriasis is more prominent in fingernails.3,4 

Fungal infections are often linked to wearing closed shoes, walking barefoot in bathrooms or showers where the fungi thrive. It’s also seen more often in people suffering from diabetes or compromised immunity, while others are prone to fungal infection genetically.5,6

Fungal nail infection affects the finger and toenails of 2-14% of the adult Western population. It can also affect children and up to 50% of people over 70 years of age.5,7 

The untreated fungal infection may cause great discomfort and even pain, preventing general activities and work-related tasks, such as prolonged standing, writing, or typing. It may even be the cause of falls in the elderly.4,5,7

The solution: Betadine Emtrix Fungal Nail Solution

Betadine Emtrix Fungal Nail Solution is clinically proven to effectively treat the nail fungus and nail psoriasis and improve the nail appearance even after one week of regular application.

Used to treat discoloured and deformed nails resulting from fungal infection or psoriasis, Betadine Emtrix Fungal Nail Solution applied to the infected nail once a day for eight weeks, improves nail thickening, discolouration, brittleness, and softness, with noticeable results after the first week of regular treatment.8

Betadine Emtrix Fungal Nail Solution is currently available at selected Clicks stores and leading pharmacies across South Africa.


References: 

  1. BETADINE™ EMTRIX™ Fungal Nail Solution Instructions for Use, December 2018.
  2. Akhtar N, Sharma H, Pathak K. Onychomycosis: Potential of Nail Lacquers in Transungual Delivery of Antifungals. Scientifica 2016; ArticleID:1387936, 12 pages.
  3. Dogra A, Arora AK. Nail Psoriasis: The Journey So Far. Indian J Dermatol.2014;59(4):319–33.
  4. Elewski BE. Onychomycosis: Pathogenesis, Diagnosis, and Management. Clinical Microbiology Reviews1998; 11(3):
    415–429.
  5. Rosen T. Concepts in Onychomycosis Treatment and Recurrence Prevention: An Update. Seminars in Cutaneous Medicine and Surgery, 2016; 35(3S):S56-S59.
  6. Muth CC. Fungal Nail Infection. JAMA2017; 317(5):546.
  7. Hultenby K, et al. The Effect of K101 Nail Solution on Trichophyton rubrum and Candida albicans growth and ultrastructure. Mycoses 2014; 57:630-638. 
  8. Piraccini BM, Starace M, Toft A. Early Visible Improvements during K101-03 Treatment: An Open-Label Multicenter Clinical Investigation in Patients with Onychomycosis and/or Nail Psoriasis. Dermatology 2017; 233:178-183. 

Header image by FreePik