Evaluation of auditory evoked response among type-II diabetic individuals in central India.

ABSTRACT

Background: The Type II diabetes mellitus (DM) is characterized by
hyperglycemia, as a result of damaged beta cell function, along with
increase insulin resistance, either at receptor or at postreceptor
levels. Neuropathies complications are the most common in diabetes,
that’s may lead to delayed evoked potentials in the central
pathways. Aims and Objective: This study was undertaken to know the
hearing status of the Type II diabetic patients and to delay development
of its related complication like central neuropathy. Materials and
Methods: This study evaluates central neuropathy by brainstem evoked
response audiometry (BERA) in Type II DM patients. Results: We observed
significant differences in BERA latencies between diabetic patients and
healthy controls. There was significantly delayed Wave II, IV latency in
left ear (at 80 dB) and Wave II latency in left ear, as well as Wave IV
latency in right ear (at 90 dB) as compared to control. Diabetics
patients with and without peripheral neuropathy there were absolute
delayed latencies of Wave I, III, and V (80 dB). With relation to blood
glucose, a significant difference in absolute latencies of Wave II
(right ear at 90 dB), Wave IV (in right ear at 90 dB), Wave V (left ear
at 80 dB), and interpeak latencies I-V (in right ear at 90 band).
Conclusion: This study suggests that BERA is a simple, non-invasive
procedure to detect early impairment of acoustic nerve, and central
nervous system pathways, even in the absence of specific symptoms, if
BERA is carried out in diabetic patients, involvement of central
neuronal axis can be detected earlier.

KEY WORDS: Brainstem Evoked Response Audiometry; Type II Diabetes
Mellitus; Peripheral Neuropathy; Blood Glucose

INTRODUCTION

Diabetes mellitus (DM) is characterized by hyperglycemia resulting
from defects in insulin secretion, insulin action, or both. [1] Among
two (Types I and II), broad categories of DM, Type II diabetes is much
more common than Type I. [2] Type II diabetes, or non-insulin-dependent
diabetes or adult-onset diabetes, encompasses individuals who have
insulin resistance/insulin deficiency. [3] Although the pathogenesis of
morphologic disorder is not yet confirmed in Type II diabetes, but
directly related to hyperglycemia, and however there is diffused
thickening in the basilar membrane of the cochlea, [4] changes in
vascular endothelium along with vasoconstriction of smaller vessels in
the inner ear that leads to hypoxia and may leading to hearing loss.
[5-8]

Neuropathies complications are the most common in diabetes,
that’s may lead to delayed evoked potentials in the central
pathways. [9] Diabetic patients preserve a normal hearing function until
diabetic neuropathy developed; since then the nerve degeneration,
related to decrease in circulating nerve growth factor, leads to a
progressive impairment of the auditory pathway with consequent hearing
deficit. [10] A simple and non-invasive technique is brainstem evoked
response audiometry (BERA) to find out early impairment of acoustic
nerve and central nervous system (CNS) pathway, even in the absence of
specific symptoms. BERA is a recording of the synchronized response of a
large number of neurons in the lower portion of auditory pathway and can
evaluate electrophysiologically any lesions from acoustic nerve to the
brainstem to show subclinical variances and central neuropathy in
diabetics. [11] The involvement of cochlear and eighth nerve has been
observed for progressive sensorineural hearing loss in patients with DM.
[12]

The previous studies have been demonstrated sensorineural hearing
loss at the higher frequencies among DM individuals. [13-15] However,
the association between DM and hearing loss has been debated up to now.
[16] Hearing impairment related to diabetes has been described as
sensorineural in origin, implying that the lesion may be cochlear or of
the 8th cranial nerve, but evidence favoring a specific mechanism is
unsatisfactory. [17]

Hence, this study was planned to evaluate auditory functions
through evoked potentials in Type II DM and to evaluate the role of
potentially relevant factors such as blood glucose levels and the
presence of complications like peripheral neuropathy.

MATERIALS AND METHODS

Ethnic Statement

The study was approved by the local research advisory committee of
L.N. Medical College and Research Centre (LNMC/Dean/2015/2146). The
study was performed in accordance with the Declaration of Helsinki.
Detailed written consent of all the participants was taken and the
purpose of the study was explained to the participants and assurance was
given to the participants that test is harmless.

Participants

Inclusion and exclusion criteria

This study was conducted in the Department of Physiology, LN
Medical College and Research Center and associated J.K. Hospital,
Bhopal, India. Diabetic Patients (n = 50) of both genders (age-30-65
years) attending medical OPD of J.K. Hospital attached to LNMC and RC,
and healthy individuals (n = 50) of comparable age were recruited for
the study. Participants meeting the following criteria were included;
individuals suffering from biochemically proved DM were included in the
study. Individuals were referred to the Department of ENT for complete
check-up to exclude any ear pathology and were excluded with history of
hearing loss before diagnosis of diabetes and had history of ear
discharge, associated endocrine disorder such as myxedema, head injury,
neurological deficit, cerebrovascular accident or noise exposure in the
past as well as acute complication of diabetes such as diabetic
ketoacidosis, nonketotic hyperosmolar coma, and hypoglycemia.
Individuals with a history of drug intake, known to cause central
neuropathy, for example, reserpine, alpha methyldopa, phenytoin and
nitrofurantoin and had a history of taking ototoxic drugs, for example,
gentamycin, streptomycin, kanamycin, amikacin, and quinine.

All selected participants were divided randomly into following
groups. Group I (n = 50) – control group and the study group were
diabetic individuals Group II (n = 50). Proper history and
anthropometric measurements, as well as complete clinical examinations,
including general systemic and audiometric examination, were done for
all the included subjects.

Protocol

Estimation of blood glucose

Biochemically random blood glucose was estimated by glucose oxidase
peroxidase method to confirm Type II diabetes. [18]

Recording of BERA

Recording of BERA was done on root-mean-square electromyographic
Octopus by Clarity Medical Pvt. Ltd. with 2 amplifiers with hardware
version 2.5 and software version 4.2 (Figure 1). Before the test,
participants were instructed: To wash their hair to be oil free and the
procedure was elucidated to the patient and asked to lie down
comfortably on bed in a relaxed state in a quiet and dimly lit room.
Skin of the forehead and mastoid process was cleaned with acetone soaked
swab. Cleaned electrodes (ground electrode: (Fz), reference electrode
(Cz): Vertex, and active electrode (Oz): Mastoid process) were properly
placed using 10-20 conductive paste applied in the recess of electrode
and then adhered to cleaned surface of their respective side. Standard
silver chloride electrodes of 1 cm diameter were placed according to
10-20 international system. [19] The stimulus was given using head
phone. The stimulus rate was set at 11 clicks/s, sweep speed was set at
1 ms/div., low filter was set at 100 Hz, and high filter at 3 KHz.
Recording was taken at 80 and 90 dB HL for 3KHz frequency with rare
click stimulus. The resistance was kept below 5 Ohm. Auditory stimuli
consisting of rarefaction clicks of 100 [micro]s were provided through
electrically shielded earphones at a rate of 11.1/s. Contralateral ear
was masked with pure white noise of 40 dB. A band pass of 150-3000 Hz
was used to filter out undesirable frequencies in the surroundings.
Averaging was done for 2000 epochs. Impedance was kept <5 k[OMEGA].
At least two recordings were taken to confirm the reproducibility of
waveform and the absolute latencies of Wave I, III, and V and interpeak
latencies I-III, III-V, and I-V were recorded (Figure 2).

Statistical Analysis

Quantitative data are expressed as the mean [+ or -] standard
deviation (SD) separately for right and left ear. Comparison among the
study groups was done with the help of unpaired t-test as per results of
normality test. SPSS version 20 was used for statistical analysis.
Qualitative data were presented with the help of frequency and
percentage table. Association among the study groups was assessed with
the help of Chi-square test. P < 0.05 was taken as significant.

Sample Size Calculation

Considering a confidence level of 95% and confidence interval of 10
and the number of patients in our study should be 96 to achieve
statistical significance. This was calculated by survey system
(http://www.surveysystem.com/sscalc.htm#one). The mathematics of
probability proves the size of the population is irrelevant unless the
size of the sample exceeds a few percent of the total population we are
examining. The Survey System ignores the population size when it is
“large” or unknown. Population size is only likely to be a
factor when we work with a relatively small and known group of people
(e.g., the members of an association). Hence, a sample size of 96 was
considered adequate for our study (we have studied 100, i.e., 50
diabetic and 50 control subjects).

RESULT

Blood Glucose Level

Random blood glucose was found to be significantly higher in
diabetic patients groups as compared to control group.

Comparison of BERA parameters for 80 dB and 90 dB in absolute
latencies (Wave I, II, II, IV, and V) and interpeak latency (I-III: I-V
and III-V).

The data are summarized in (Table 1A and B) with mean [+ or -] SD.
We observed, for 80 dB, there was statistically significant delayed in
absolute latencies of Wave II, IV of left ear in diabetic group as
compared to control group. Conversely, interpeak latency in both left
and the right side was comparable among both diabetic and control
groups. Although for 90 dB, there was statistically significant delayed
in absolute latencies of Wave II of left ear and Wave IV of right ear in
diabetic group as compared to control group. Conversely, interpeak
latency in both left and the right side was comparable among both
diabetic and control groups.

Comparison of BERA parameters for 80 and 90 dB in absolute
latencies (Wave I, II, II, IV, and V) and interpeak latency (I-III: I-V
and III-V) among diabetic individuals relation with/without peripheral
neuropathy.

The data are summarized in (Table 2A and B) with mean [+ or -] SD.
Absolute latencies of Waves I and III and interpeak latency difference
I-V was more in left and right ear together for 80 dB, however, the
difference was statistically significant only in left ear in
diabetic’s individuals with peripheral neuropathy, as a comparison
with diabetic’s individuals without peripheral neuropathy. Whereas
for 90 dB, there was not any significant alteration in the entire wave
of absolute latencies as well as interpeak latency difference.

Comparison of BERA parameters for 80 and 90 dB in absolute
latencies (Wave I, II, II, IV, and V) and interpeak latency (I-III: I-V
and III-V) among diabetic with relation to blood glucose.

The data are summarized in Table 3A and B. Intended for 80 dB, the
difference in the absolute latencies of entire Wave I, II, II, IV, and V
and interpeak latency I-III: I-V and III-V was not statistically
significant in diabetics with glucose level less/more than 140 mg/dl,
respectively. Whereas 90 dB, among diabetics with glucose level
less/more than 140 mg/dl, the difference in the absolute latencies of
entire wave and interpeak latency was not statistically significant
excluding the difference in the absolute latencies of Wave II as well as
IV and inter latency difference I-V, which was statistically significant
only in the right ears.

DISCUSSION

The Type II DM is characterized by hyperglycemia, as a result of
damaged beta cell function, along with increase insulin resistance,
either at receptor or at postreceptor levels. [20] DM has been concerned
as an independent contributing factor of sensorineural hearing loss.
[16] The electrophysiological testing reflects the bioelectric responses
of the nervous system to sensory (somatosensory evoked potentials),
auditory (brainstem auditory evoked potentials), or visual stimuli
(visual evoked potentials). [21] A study on brainstem auditory evoked
potential (BAEP) in overweight and obese individuals indicating CNS
conduction delays with brainstem as well as cerebral cortical. [22] BERA
comprise five or more waveforms that are recorded within 10 ms of an
acoustic stimulus. Wave I originates from peripheral portion of cranial
nerve VIII (auditory nerve) near the cochlear nucleus. Wave II
originates from cochlear nucleus, Wave III from superior olivary
nucleus, Wave IV from lateral lemniscus, and Wave V from inferior
colliculi in the midbrain. [23]

In this study, a comparison between the mean values of the various
wave latencies and interpeak latency was done separately for both ears,
in diabetics as well as control individuals. We observed that at 80 dB,
there was a significant delay in latency of Wave II, IV in left ear as
compared to control and at 90 dB, there was significantly delayed Wave
II latency in left ear and significantly delayed Wave IV latency in
right ear as compared to controls. These findings are similar to the
some of the previous studies. [24-28] The auditory brainstem response
recording revealed that there was delay in neural conductance along the
auditory pathway and absolute latencies of Wave I, III, and V were
significantly prolonged in the diabetic group when compared with the
control group. [23] Bilateral symmetrical hearing loss mainly with the
high frequencies (so-called sensory neural hearing loss) was observed in
152 out of 256 diabetes patients. [26] The previous report with BERA on
20 insulin dependent diabetic patients showed that the latency of Wave
III to be delayed by 0.30 ms and Wave V by 0.45 ms and interpeak latency
Wave III was delayed by 0.24 ms and IV delayed by 0.35 ms on 80, and 90
dB. [29] BERA study revealed that peripheral transmission time (Wave I)
and central transmission time (Wave IV) to be delayed in normoacoustic
insulin-dependent diabetic subjects. [27] The absolute latency of Wave
III representing superior olivary complex, at 80 dB had wave latency of
(3.99 [+ or -] 0.24) ms and at 90 dB (3.92 [+ or -] 0.28) ms. The
latency of Wave III was delayed by 0.42, and 0.42 ms at 80, and 90 dB,
respectively. However, the absolute latency of Wave V representing
inferior colliculus, and it was at 80 dB (5.98 [+ or -] 0.27) as well as
90 dB (6.02 [+ or -] 0.30) ms as compared with control. The latency of
Wave V was delayed by 0.47, and 0.50 ms at 80, and 90 dB, respectively.
[27]

At present study, when we compared diabetic patients with and
without peripheral neuropathy, we observed that at 80 dB, there was
significant delay in Waves I and V latencies in left ear and significant
delay in interpeak latencies I-V in left ear, whereas, for 90 dB, there
was not any significant alteration in the entire wave of absolute
latencies as well as interpeak latency difference. The previous study
[30] compared 25 diabetics with peripheral neuropathy and 15 diabetics
without peripheral neuropathy and observed delay in absolute latencies
of Waves III and V with prolonged interpeak latencies I-III and I-V in
diabetic with peripheral neuropathy as compared with diabetic without
neuropathy. Symmetrical sensorineural deafness was also observed in 55%
of Type II diabetes patients with neuropathy. [11] Abnormal brainstem
response with neuropathy was reported in 94% of cases of Type II
diabetes patients. When we compared BERA parameters with relation to
blood glucose levels <140 mg/dl and blood glucose levels more than
140 mg/dl in Type II DM patients, we observed significant difference in
absolute latencies of Wave IV (in right ear at 90 dB), Wave V (left ear
at 80 dB) and interpeak latencies I-V (in right ear at 90 dB and in
right ear at 70 dB). This differs from the study [31] in which there was
a non-significant positive correlation of BAEP latencies with fasting
blood glucose levels. The discrepancies between the results can be
explained by the fact that the studies used a different methodology, as
well as different inclusion and exclusion criteria. BERA abnormalities
in diabetes initially seem to appear due to central impairment of the
auditory pathway which gradually involves the peripheral parts in due
course of time. Therefore, BERA can be of clinical importance intended
for the diabetes, as it may reflect the degree of neural affection in
the auditory pathway and may alert the patients for adequate glycemic
control, which can resist the neuropathic progression any further. From
our study, we can say that presences of peripheral neuropathy are
definite risk factors for the development of central neuropathy.

CONCLUSION

Due to the high prevalence of DM in the community and its probable
adverse effects on the auditory system, this study investigated hearing
functions in well-characterized Type II diabetic patients and evaluated
the role of potentially relevant factors such as blood glucose levels
and presence of complications like peripheral neuropathy. In this study,
significant differences in BERA latencies were seen between diabetic
patients and healthy controls. These abnormalities were attributed to a
diabetic associated central auditory dysfunction. Evaluation of these
changes might help to determine early subclinical hearing impairment in
these patients. This study suggests that BERA is a simple, non-invasive
procedure to detect early impairment of acoustic nerve, and CNS
pathways, even in the absence of specific symptoms, if BERA is carried
out in diabetic patients, and involvement of central neuronal axis can
be detected earlier. Keeping in mind the consistent rise in the global
incidence of DM and the detrimental effects that it has on the hearing
ability of an individual, it is suggested that BERA testing may also be
included in the routine screening procedures that are of vital
importance in diabetic patients, wherever it is possible.

ACKNOWLEDGMENTS

We gratefully acknowledge the L.N. Medical College Bhopal, India,
for providing the instrument facility in Department of Physiology and
Gandhi Medical College, Bhopal, India, for providing financial support.

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How to cite this article: Batham C, Choudhary AK, Yousuf PS.
Evaluation of auditory evoked response among type-II diabetic
individuals in central India. Natl J Physiol Pharm Pharmacol 2017;7(10):
1061-1069.

Source of Support: Nil, Conflict of Interest: None declared.

Chhaya Batham (1), Arbind Kumar Choudhary (2), Praveen S. Yousuf
(2)

(1) Department of Physiology, Gandhi Medical College, Bhopal,
Madhya Pradesh, India, (2) Department of Physiology, L. N. Medical
College and J. K. Hospital, Bhopal, Madhya Pradesh, India.

Correspondence to: Arbind Kumar Choudhary, E-mail:
arbindchoudhary111@mail.com

Received: April 25, 2017; Accepted: May 17, 2017


Table 1A: Comparison of BERA parameters for 80 dB between type II
diabetics and control

Side   Measurement                      Mean[+ or -]SD
                                  Control            Diabetic

Left   Absolute latencies (ms)
       I                          1.6[+ or -]0.19    1.54[+ or -]0.2
       II                         2.62[+ or -]0.3    2.47[+ or -]0.31
       III                        3.51[+ or -]0.2    3.4[+ or -]0.42
       IV                         4.58[+ or -]0.31   4.39[+ or -]0.41
       V                          5.42[+ or -]0.42   5.43[+ or -]0.3
       Interpeak latencies (ms)
       I-III                      1.92[+ or -]0.27   1.87[+ or -]0.51
       I-V                        3.8[+ or -]0.46    3.89[+ or -]0.4
       III-V                      1.9[+ or -]0.47    2[+ or -]0.39
Right  Absolute latencies (ms)
       I                          1.49[+ or -]0.24   1.53[+ or -]0.21
       II                         2.6[+ or -]0.27    2.6[+ or -]0.32
       III                        3.4[+ or -]0.26    3.4[+ or -]0.31
       IV                         4.47[+ or -]0.33   4.48[+ or -]0.46
       V                          5.45[+ or -]0.32   5.48[+ or -]0.31
       Interpeak latencies (ms)
       I-III                      1.98[+ or -]0.36   1.94[+ or -]0.47
       I-V                        3.9[+ or -]0.46    3.9[+ or -]0.45
       III-V                      1.98[+ or -]0.37   1.98[+ or -]0.48

Side   Measurement                Diabetic versus control   P value
                                  t value

Left   Absolute latencies (ms)
       I                          1.4                       0.138
       II                         2.5                       0.01 (*)
       III                        1.6                       0.105
       IV                         2.5                       0.01 (*)
       V                          0.135                     0.89
       Interpeak latencies (ms)
       I-III                      0.655                     0.514
       I-V                        0.874                     0.384
       III-V                      1.47                      0.143
Right  Absolute latencies (ms)
       I                          0.822                     0.413
       II                         1.32                      0.188
       III                        0.069                     0.945
       IV                         0.199                     0.843
       V                          0.432                     0.667
       Interpeak latencies (ms)
       I-III                      0.376                     0.708
       I-V                        0.239                     0.812
       III-V                      0.046                     0.963

(*) Significance change (P<0.05) compared with control, SD: Standard
deviation

Table 1B: Comparison of BERA parameters for 90 dB, between type II
diabetics and controls

Side   Measurement                      Mean[+ or -]SD
                                  Control            Diabetic

Left   Absolute latencies (ms)
       I                          1.51[+ or -]0.2    1.51[+ or -]0.22
       II                         2.68[+ or -]0.26   2.5[+ or -]0.25
       III                        3.61[+ or -]0.35   3.5[+ or -]0.41
       IV                         4.4[+ or -]0.24    4.5[+ or -]0.38
       V                          5.47[+ or -]0.39   5.27[+ or -]0.73
       Interpeak latencies (ms)
       I-III                      2.09[+ or -]0.35   2[+ or -]0.54
       I-V                        3.9[+ or -]0.38    3.8[+ or -]0.41
       III-V                      1.85[+ or -]0.45   1.81[+ or -]0.45
Right  Absolute latencies (ms)
       I                          1.55[+ or -]0.21   1.5[+ or -]0.28
       II                         2.6[+ or -]0.28    2.6[+ or -]0.31
       III                        3.58[+ or -]0.27   3.6[+ or -]0.27
       IV                         4.57[+ or -]0.24   4.33[+ or -]0.37
       V                          5.37[+ or -]0.43   5.4[+ or -]0.38
       Interpeak latencies (ms)
       I-III                      2.05[+ or -]0.35   2.08[+ or -]0.37
       I-V                        3.82[+ or -]0.48   3.9[+ or -]0.42
       III-V                      1.8[+ or -]0.55    1.85[+ or -]0.48

Side   Measurement                Diabetic versus control   P value
                                  t value

Left   Absolute latencies (ms)
       I                          0.001                     1
       II                         2.7                       0.008 (*)
       III                        0.696                     0.488
       IV                         1.34                      0.18
       V                          1.71                      0.089
       Interpeak latencies (ms)
       I-III                      0.65                      0.517
       I-V                        0.976                     0.331
       III-V                      0.375                     0.708
Right  Absolute latencies (ms)
       I                          0.953                     0.343
       II                         0.295                     0.768
       III                        0.291                     0.772
       IV                         3.77                      0.0001 (*)
       V                          0.583                     0.561
       Interpeak latencies (ms)
       I-III                      0.433                     0.66
       I-V                        1.01                      0.314
       III-V                      0.497                     0.62

(*) Significance change (P<0.05), SD: Standard deviation

Table 2A: Comparison of BERA parameters for 80 dB among type II
diabetics with peripheral neuropathy and without neuropathy

Side    Measurement                           Mean[+ or -]SD
                                   Without peripheral   With peripheral
                                   neuropathy (16)      neuropathy (34)

Left    Absolute latencies (ms)
        I                          1.45[+ or -]0.19     1.58[+ or -]0.19
        II                         2.48[+ or -]0.3      2.46[+ or -]0.31
        III                        3.41[+ or -]0.33     3.4[+ or -]0.47
        IV                         4.34[+ or -]0.5      4.41[+ or -]0.37
        V                          5.56[+ or -]0.26     5.3[+ or -]0.31
        Interpeak latencies (ms)
        I-III                      1.96[+ or -]0.34     1.82[+ or -]0.57
        I-V                        4.1[+ or -]0.24      3.7[+ or -]0.41
        III-V                      2.1[+ or -]0.37      1.9[+ or -]0.38
Right   Absolute latencies (ms)
        I                          1.5[+ or -]0.21      1.55[+ or -]0.22
        II                         2.71[+ or -]0.21     2.57[+ or -]0.35
        III                        3.54[+ or -]0.25     3.45[+ or -]0.34
        IV                         4.5[+ or -]0.39      4.4[+ or -]0.49
        V                          5.4[+ or -]0.39      5.4[+ or -]0.27
        Interpeak latencies (ms)
        I-III                      2.04[+ or -]0.38     1.9[+ or -]0.51
        I-V                        3.9[+ or -]0.5       3.91[+ or -]0.43
        III-V                      1.91[+ or -]0.44     2[+ or -]0.49

Side    Measurement                     With versus without
                                        peripheral neuropathy
                                   t value                 P value

Left    Absolute latencies (ms)
        I                          2.3                     0.02 (*)
        II                         0.24                    0.81
        III                        0.05                    0.96
        IV                         0.58                    0.56
        V                          2.01                    0.05
        Interpeak latencies (ms)
        I-III                      0.89                    0.375
        I-V                        2.9                     0.005 (*)
        III-V                      1.59                    0.12
Right   Absolute latencies (ms)
        I                          0.749                   0.45
        II                         1.43                    0.15
        III                        0.943                   0.35
        IV                         0.211                   0.834
        V                          0.418                   0.67
        Interpeak latencies (ms)
        I-III                      0.97                    0.33
        I-V                        0.279                   0.78
        III-V                      0.613                   0.54

(*) Significance change (P<0.05), SD: Standard deviation

Table 2B: Comparison of BERA parameters for 90 dB, among type II
diabetics with/without peripheral neuropathy

Side    Measurement                           Mean[+ or -]SD
                                   Without peripheral   With peripheral
                                   neuropathy (16)      neuropathy (34)

Left    Absolute latencies (ms)
        I                          1.48[+ or -]0.18     1.53[+ or -]0.24
        II                         2.54[+ or -]0.27     2.54[+ or -]0.25
        III                        3.66[+ or -]0.36     3.51[+ or -]0.43
        IV                         4.57[+ or -]0.21     4.47[+ or -]0.43
        V                          5.38[+ or -]0.21     5.22[+ or -]0.87
        Interpeak latencies (ms)
        I-III                      2.1[+ or -]0.45      1.96[+ or -]0.58
        I-V                        3.9[+ or -]0.34      3.8[+ or -]0.44
        III-V                      1.73[+ or -]0.34     1.85[+ or -]0.49
Right   Absolute latencies (ms)
        I                          1.52[+ or -]0.26     1.49[+ or -]0.29
        II                         2.65[+ or -]0.37     2.6[+ or -]0.29
        III                        3.65[+ or -]0.26     3.5[+ or -]0.27
        IV                         4.37[+ or -]0.34     4.31[+ or -]0.4
        V                          5.38[+ or -]0.38     5.44[+ or -]0.39
        Interpeak latencies (ms)
        I-III                      2.11[+ or -]0.32     2.07[+ or -]0.4
        I-V                        3.85[+ or -]0.42     3.94[+ or -]0.43
        III-V                      1.74[+ or -]0.46     1.9[+ or -]0.49

Side    Measurement                     With versus without
                                        peripheral neuropathy
                                   t value                 P value

Left    Absolute latencies (ms)
        I                          0.77                    0.44
        II                         0.005                   0.996
        III                        1.24                    0.22
        IV                         0.84                    0.401
        V                          0.693                   0.491
        Interpeak latencies (ms)
        I-III                      1.23                    0.22
        I-V                        0.497                   0.622
        III-V                      0.93                    0.35
Right   Absolute latencies (ms)
        I                          0.39                    0.69
        II                         0.21                    0.83
        III                        0.96                    0.34
        IV                         0.49                    0.62
        V                          0.52                    0.6
        Interpeak latencies (ms)
        I-III                      0.39                    0.68
        I-V                        0.67                    0.5
        III-V                      1.11                    0.269

SD: Standard deviation

Table 3A: Comparison of BERA parameters for 80 dB with relation to
blood glucose levels among diabetic

Side    Measurement                          Mean[+ or -]SD
                                   Blood glucose      Blood glucose
                                   RBS <140 mg/dl     RBS >=140 mg/dl
                                   (n=9)              (n=41)

Left    Absolute latencies (ms)
        I                          1.51[+ or -]0.27   1.55[+ or -]0.19
        II                         2.4[+ or -]0.42    2.48[+ or -]0.28
        III                        3.21[+ or -]0.64   3.45[+ or -]0.36
        IV                         4.32[+ or -]0.19   4.4[+ or -]0.44
        V                          5.18[+ or -]0.39   5.49[+ or -]0.26
        Interpeak latencies (ms)
        I-III                      1.7[+ or -]0.82    1.91[+ or -]0.41
        I-V                        3.67[+ or -]0.56   3.9[+ or -]0.34
        III-V                      1.98[+ or -]0.5    2.03[+ or -]0.37
Right   Absolute latencies (ms)
        I                          1.5[+ or -]0.21    1.54[+ or -]0.22
        II                         2.75[+ or -]0.19   2.58[+ or -]0.33
        III                        3.48[+ or -]0.27   3.48[+ or -]0.32
        IV                         4.36[+ or -]0.35   4.51[+ or -]0.48
        V                          5.4[+ or -]0.5     5.5[+ or -]0.26
        Interpeak latencies (ms)
        I-III                      1.98[+ or -]0.39   1.93[+ or -]0.49
        I-V                        3.9[+ or -]0.62    3.93[+ or -]0.41
        III-V                      1.91[+ or -]0.48   1.99[+ or -]0.48

Side    Measurement                    RBS <140 mg/dl versus
                                       RBS >=140 mg/dl
                                   t value                 P value

Left    Absolute latencies (ms)
        I                          0.525                   0.602
        II                         0.76                    0.44
        III                        1.54                    0.12
        IV                         0.57                    0.57
        V                          2.86                    0.006
        Interpeak latencies (ms)
        I-III                      1.12                    0.264
        I-V                        1.8                     0.06
        III-V                      0.344                   0.73
Right   Absolute latencies (ms)
        I                          0.51                    0.61
        II                         1.42                    0.16
        III                        0.07                    0.944
        IV                         0.85                    0.397
        V                          0.87                    0.38
        Interpeak latencies (ms)
        I-III                      0.281                   0.78
        I-V                        0.218                   0.82
        III-V                      0.47                    0.64

RBS: Random blood sugar, SD: Standard deviation

Table 3B: Comparison of BERA parameters for 90 dB with relation to
blood glucose levels among diabetic

Side    Measurement                          Mean[+ or -]SD
                                   Blood glucose       Blood glucose
                                   RBS <140 mg/dl      RBS >=140 mg/dl
                                   (9)                 (41)

Left    Absolute latencies (ms)
        I                          1.48[+ or -]0.23    1.52[+ or -]0.22
        II                         2.6[+ or -]0.21     2.5[+ or -]0.26
        III                        3.44[+ or -]0.45    3.58[+ or -]0.41
        IV                         4.48[+ or -]0.2     4.51[+ or -]0.41
        V                          5.33[+ or -]0.25    5.26[+ or -]0.8
        Interpeak latencies (ms)
        I-III                      1.95[+ or -]0.54    2[+ or -]0.55
        I-V                        3.85[+ or -]0.4     3.87[+ or -]0.41
        III-V                      1.88[+ or -]0.41    1.8[+ or -]0.46
Right   Absolute latencies (ms)
        I                          1.44[+ or -]0.25    1.51[+ or -]0.29
        II                         2.4[+ or -]0.42     2.68[+ or -]0.28
        III                        3.71[+ or -]0.26    3.57[+ or -]0.27
        IV                         4.6[+ or -]0.23     4.27[+ or -]0.38
        V                          5.6[+ or -]0.27     5.38[+ or -]0.4
        Interpeak latencies (ms)
        I-III                      2.26[+ or -]0.38    2.04[+ or -]0.36
        I-V                        4.16[+ or -]0.46    3.86[+ or -]0.4
        III-V                      1.9[+ or -]0.33     1.84[+ or -]0.51

Side    Measurement                     RBS <140 mg/dl versus
                                        RBS >=140 mg/dl
                                   t value                 P value

Left    Absolute latencies (ms)
        I                          0.41                    0.67
        II                         0.72                    0.47
        III                        0.92                    0.35
        IV                         0.16                    0.87
        V                          0.25                    0.79
        Interpeak latencies (ms)
        I-III                      0.446                   0.65
        I-V                        0.11                    0.9
        III-V                      0.51                    0.609
Right   Absolute latencies (ms)
        I                          0.67                    0.506
        II                         1.99                    0.05 (*)
        III                        1.33                    0.18
        IV                         2.41                    0.02 (*)
        V                          1.51                    0.136
        Interpeak latencies (ms)
        I-III                      1.58                    0.11
        I-V                        2.01                    0.05 (*)
        III-V                      0.29                    0.76

(*) Significance change (P<0.05), RBS: Random blood sugar, SD: Standard
deviation

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