Elevated Anion Research Articles

Mass Poisoning From Ethylene Glycol at a U.S. Military Base.

Ethylene glycol (EG) toxicity is an important cause of toxic alcohol poisoning in the USA with over 5,000 exposures reported annually. While classically characterized by solitary accidental or intentional ingestions, mass toxic alcohol poisoning outbreaks and more rarely collective consumptions (typically of methanol) have been described. We describe an ethylene glycol poisoning from collective ingestion that involved soldiers presenting at William Beaumont Army Medical Center in El Paso, Texas. Eleven soldiers presented to the emergency department over a 12-h period after ingestion of an unknown substance. The first two patients exhibited severe neurologic symptoms, while the remainder were asymptomatic. As serum EG levels were not immediately available, treatment decisions were based on surrogate laboratory values. Two patients received immediate hemodialysis, and fomepizole (FOM) because of severe acidosis with elevated anion and osmolal gaps. These patients developed acute kidney injury with renal recovery within a 3-week period. Two patients with elevated lactate received bicarbonate-based intravenous (IV) fluids and FOM. Two patients received IV fluids only and required prolonged observation for worsening acidosis and/or acute kidney injury. Five patients with normal laboratory values were treated with IV fluids and observation. All patients received cofactors including thiamine and pyridoxine. All patients survived. The outbreak occurred in the setting of limited dialysis resources, limited FOM availability, and in a resource-limited community. Additional guidelines are needed to determine allocation of limited resources, optimal dialysis and FOM treatment course, and comorbid conditions, which may prolong recovery.

Investigation of Groundwater Quality from Selected Wells in Paiko, Northcentral Nigeria

Groundwater from hand dug wells and boreholes in Paiko, northcentral Nigeria were subjected to physico-chemical as well as microbiological analysis to determine their suitability for drinking purpose. The water from the hand dug wells are predominantly calcium magnesium chloride (Ca-Mg-Cl) water while those from boreholes are calcium magnesium bicarbonate water (Ca-Mg-HCO3) facies. The results showed elevated cations and anions concentration in the hand dug wells in addition to the water being slightly acidic. Also, the nitrate concentration in the hand dug wells is above the maximum permissible limit of 50mg/l postulated by World Health Organization (WHO) and Nigerian Standard for Drinking Water Quality (NSDQ). Microbiological analysis revealed Total Coliform Count of 100cfu and 360cfu in the hand dug wells and borehole respectively signifying faecal contamination. The study revealed that improper sewage systems as well as poor waste disposal is responsible for the poor water quality as well as elevated concentration of nitrate in hand dug wells, and as such the shallow aquifer groundwater in the area are not safe for drinking purpose with respect to all the parameters taken together.

P746Protective role of the longevity associated variant of BPIFB4 in chronic ischemia

Abstract Background A rare Longevity Associated Variant (LAV) of the gene BPIFB4, whose protein product can be secreted, is recessively associated with extreme longevity, positively impacting the cardiovascular system and promoting therapeutic angiogenesis in an hindlimb ischemia model. Aim Aim of this work is to verify if LAV-BPIFB4 may temper the phenotype of chronic ischemia in humans, thus suggesting its therapeutic potential. Methods and results 39 hearts explanted from patients affected by end-stage ischemic heart disease were studied. Of these, 7 were homozygous for BPIFB4-LAV. Homozygous and non-homozygous patients did not differ in sex, age and in the prevalence of comorbidities or risk factors. However, the time elapsed from myocardial infarction to transplantation was significantly longer for LAV homozygous with respect to LAV heterozygous patients (159±95 vs 58±27 months, p=0.045). Histologically, while BPIFB4 levels did not differ in accordance with the genotype, the fraction of Tunel+and 53BP1+apoptotic and senescent myocytes was significantly lower in homozygous patients (1.2±0.4% vs 23.8±21.7%, p=0.026 and 31.5±6.7% vs 44.4±6.1%, p=0.031, respectively). Significantly lower levels of lipoperoxides and higher levels of Parkin were observed in homozygous hearts too. Next, we directly tested the role of BPIFB4 on PDGFRb+ NG2+Tbx18+cardiac pericytes/mural cells (PM) cultured from normal atria (PMnorm, n=10) and from ischemic failing hearts (PMfail, n=7). BPIFB4 gene transcript was significantly more expressed in PMnorm than PMfail. Silencing BPIFB4 expression in PMnorm significantly increased the proportion of senescent gH2AX+Ki67-cells (3.6±2.9% vs 13.6±9.5%, p=0.049). Conversely, addition of recombinant LAV BPIFB4 protein to PMfail cultures significantly reduced the rate of senescent cells (21.1±9.4% vs 6.0±4.8%, p=0.03), an effect that was not observed with the administration of WT BPIFB4. PMfail cultures exposed to LAV BPIFB4 significantly reversed alterations observed with pathology, such as the accumulation of both lipofuscins and of very elongated and interconnected mitochondria in the cell cytoplasm, as well as elevated mitochondrial superoxide anion levels. Finally, a larger fraction of PMnorm cells showed, with respect to PMfail, the nuclear translocation of vitamin D receptor (74.6±6.1% vs 50.1±14.4, p=0.04), coupled with a significant upregulation of its, longevity associated, target gene Klotho. Importantly, LAV BPIFB4 significantly increased the fraction of PMfail with vitamin D receptor nuclear localization (55.8±17.6% vs 85.1±8.2%, p=0.005). Conclusion LAV BPIFB4 could attenuate the progression of ischemic heart disease to heart failure. Part of its protective effect may be due to its ability to reduce mitochondrial oxidative stress and to revert the senescent phenotype of cardiac derived cells. Acknowledgement/Funding CARIPLO foundation

Effects of dietary cation and anion difference on eating, ruminal function and plasma leptin in goats under tropical condition.

ObjectiveThis study was carried out to determine the effects of elevated dietary cation and anion difference (DCAD) on dry matter intake (DMI) and ruminal fermentation pattern in lactating dairy goats under tropical conditions.MethodsTen dairy goats were divided into two groups of five animals each. The groups received diets at different DCAD levels, either a control diet (22.81 mEq/100 g dry matter [DM], DCAD-23) or a DCAD-39 diet (39.08 mEq/100 g DM, DCAD-39). After parturition, DMI and water intake were recorded daily. Ruminal fluid and urine were collected, and nutrient digestibility measurements were carried out at 8th weeks postpartum (PP-8). Blood samples were collected at PP-4 and PP-8 to measure plasma leptin.ResultsDry matter intake/body weight (DMI/BW) at PP-8 of the animals fed the DCAD-39 diet was significantly higher than those fed with DCAD-23 diet (p<0.05). Animals fed with DCAD-39 consumed more water than those fed DCAD-23 over 24 h, particularly at night (p<0.05). Ruminal pH, acetate concentration, and urinary allantoin excretion increased with the DCAD-39 diet, whereas ruminal butyrate concentration was lower with the DCAD-39 diet. On the other hand, other ruminal parameters, such as total volatile fatty acid concentration, propionate molar proportion and acetate/propionate average ratio, were not affected by increased DCAD supplementation. Apparent digestibility was improved by increased DCAD supplementation. Plasma leptin concentration was higher with DCAD supplementation.ConclusionWhen feeding goats with DCAD-39 under tropical conditions, an increase in DMI was associated with improved apparent digestibility of nutrients, ruminal fermentation and microbial protein synthesis. An increase in plasma leptin concentration could not explain the effect of high DCAD on DMI.

Abstract 1021: Superoxide anion (O2.-) mediated activation of mTORC2 by estrogen receptor in breast cancer cells: Role of acetylation dependent inhibition of MnSOD

Abstract Introduction: We recently reported a hitherto unknown nongenomic pathway unique to estrogen responsive breast-cancer cells wherein, following stimulation by estrogen (E2), Estrogen-receptor-alpha (ER-α) may redox regulate mTORC2 activity by affecting transient up-regulation of O2.- levels particularly within mitochondria. Our study established O2.- not only as an upstream regulator of mTORC2 but a critical mediator of ER signaling. Precise knowledge of the mechanisms underlying aforementioned O2.- potentiation may lead to development of novel and more efficacious measures to intervene the breast-cancer progression. The principle enzyme that regulates mitochondrial superoxide anion levels is MnSOD (SOD2), thus current study was planned to determine whether ER may affect transient superoxide anion O2.- upregulation in E2 stimulated breast-cancer cells by modulating MnSOD activity, if so, how? Methodology/Principle findings: Evaluation of MnSOD specific activity in accordance with Mishra and Fridovich (1971) revealed time dependent inhibition of MnSOD enzyme in MCF-7 breast-cancer cells following their stimulation with E2. Detailed analysis revealed that the transient inhibition of MnSOD was a receptor dependent phenomenon. Western-blotting analysis revealed potentiation of inhibitory Lysine-K68 acetylation of MnSOD in a characteristic ER dependent manner. Co-immunoprecipitation and reverse co-immunoprecipitation studies revealed physical-interaction between ER and MnSOD which in-turn was associated with impaired association of MnSOD with key deacetylase SIRT3. Furthermore, knocking down SIRT3 levels through SIRT3 directed siRNA resulted in elevated superoxide anion O2.- levels and potentiated mTORC2 signaling. In-vivo experiments employing 4T1-BALB/c mouse model of breast-cancer corroborated these findings Summary of the results: Collectively our results demonstrate for the first time direct physical-interaction between ER and MnSOD following E2 stimulation; physical-interaction of ER with MnSOD in-turn resulted in disengagement of SOD2 with SIRT3. Resultant compromised deacetylation of SOD2 at critical K68 may lead to its inhibition and thus cause a transient buildup of superoxide anion O2.- within mitochondria leading to activation of mTORC2 signaling. Conclusion Our findings unravel a new role of MnSOD as an important control-switch through which ER might affect its downstream non-genomic signaling cascades in a redox dependent manner particularly potentiation of mTORC2. We present data in support of MnSOD being responsible for previously reported ER dependent superoxide anion O2.- potentiation in breast-cancer cells following E2 exposure. We showed that MnSOD interacts with ER-alpha leading to its diminished SIRT3 dependent deacetylation, its inhibition and superoxide anion O2.- build up and consequent mTORC2 activation. Citation Format: Mehraj U. lone, Ranjana Km Kanchan, Khemraj Singh Baghel, Chakrapani Tripathi, Brij Nath Tewari, Smrati Bhadauria. Superoxide anion (O2.-) mediated activation of mTORC2 by estrogen receptor in breast cancer cells: Role of acetylation dependent inhibition of MnSOD. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 1021. doi:10.1158/1538-7445.AM2015-1021

Abstract 4334: Elevated lactic acid is a negative prognostic factor in metastatic lung cancer

Abstract Introduction: Hyperlactatemia with or without type B lactic acidosis is a rare complication of malignancy, previously observed most often in hematological malignancies. Underlying pathophysiology involves reduced lactic acid metabolism from metastatic liver dysfunction as well as overproduction of lactic acid from aberrant glycolytic metabolism of tumors. Clinical data to evaluate the potential value of arterial or venous lactic acid (LA) level assessment as a predictor of overall survival (OS) or/and response to treatment are lacking. The aim of this study was to assess the prognostic value of LA in patients with metastatic lung cancer. Methods: Patients diagnosed with stage IV non-small cell lung cancer (NSCLC) or extensive stage small cell lung cancer (SCLC) from 2012 to present, were included in this single center, retrospective study. Patients with sepsis or acute exacerbation of heart failure were excluded from the study. Arterial and venous LA level, bicarbonate, anion gap, urine ketones, serum LDH were recorded for each patient and their associations with demographic and clinical data and OS were analyzed with the Chi-square test, Kaplan-Meier's actuarial method (log-tank test) and Cox proportional hazard model. Results: 85 patients (43 males, mean age 73.1, range 45-96 years) were studied. The maximal levels of arterial or venous LA were significantly associated with presence of ≥2 metastatic sites (p = 0.001), ICU admission or transfer (p = 0.016), intubation (p = 0.029), elevated serum anion gap (p&amp;lt;0.001) and LDH levels (p&amp;lt;0.001). No significant associations emerged between LA level and gender, age, smoking status, histology, tumor size or grade, previous lung resection, location of metastases, COPD, previous metformin use, ketonuria, and previous or ongoing palliative chemotherapy. Hyperlactatemia (p&amp;lt;0.001), histologic subtype (p = 0.019), ICU admission or transfer (p = 0.014), intubation (p = 0.026), number of metastatic sites (p = 0.01), AG (p&amp;lt;0.01) and LDH (p&amp;lt;0.001) were univariately associated with OS. LDH was the only independent prognostic factor [OR = 0.162 (95% CI: 0038-0.687), p = 0.014]. Conclusion: Our results suggest that elevated LA is a predictor of poor OS in metastatic lung cancer patients, irrespective of chemotherapy. Here lie implications for targeting tumor-derived LA production via manipulation of glycolytic enzymes or lactate transporters, with use of LA as a surrogate marker of response. Citation Format: Panagiotis J. Vlachostergios, Nirav Parikh, Katerina Oikonomou, Eugene Gibilaro, George Apergis. Elevated lactic acid is a negative prognostic factor in metastatic lung cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4334. doi:10.1158/1538-7445.AM2015-4334

Abstract B27: Superoxide anion O2.-mediated activation of mTORC2 by estrogen receptor in breast cancer cells: Role of acetylation dependent inhibition of MnSOD

Abstract Introduction: We recently reported a hitherto unknown nongenomic pathway unique to estrogen responsive breast cancer cells wherein, following stimulation by E2, ER may redox regulate mTORC2 activity by affecting transient upregulation of O2.- levels particularly with in mitochondria. Our study established O2.- not only as an upstream regulator of mTOR signaling complex 2 but a critical mediator of ER signaling. Precise knowledge of the mechanisms underlying aforementioned O2.- potentiation may lead to development of novel and more efficacious measures to intervene the breast cancer progression. The principle enzyme that regulates mitochondrial superoxide anion levels is Manganese superoxide dismutase MnSOD (SOD2) thus current study was planned to determine whether ER may affect transient superoxide anion O2.- upregulation in E2 stimulated breast cancer cells by modulating MnSOD activity, if so, how? Methodology/Principle findings: Evaluation of MnSOD specific activity in accordance with Mishra and Fridovich (1971) revealed time dependent inhibition of MnSOD enzyme in MCF-7 breast cancer cells following their stimulation with E2. Detailed analysis revealed that the transient inhibition of MnSOD was a receptor dependent phenomenon. Western blotting analysis revealed potentiation of inhibitory Lysine-K68 acetylation of MnSOD in a characteristic ER dependent manner. Co-immunoprecipitation and reverse co-immunoprecipitation studies revealed physical interaction between ER and MnSOD which in turn was associated with impaired association of MnSOD with key deacetylase SIRT3. Furthermore, knocking down SIRT3 levels through SIRT3 directed siRNA resulted in elevated superoxide anion O2.- levels and potentiated mTOR signaling complex 2. In-vivo experiments employing 4T1 BALB/c mouse model of breast cancer corroborated these findings Summary of the results: Collectively our results demonstrated for the first time direct physical interaction between ER and MnSOD following E2 stimulation. Our results indicate the physical interaction of ER with MnSOD in turn resulted in disengagement of SOD2 with SIRT3. Resultant compromised deacetylation of SOD2 at critical K68 may lead to its inhibition and thus cause a transient buildup of superoxide anion O2.- with in mitochondria leading to activation of mTORC2 signaling. Conclusion: Our finding unravel a new role of MnSOD as important control switch through which ER might affect its downstream non genomic signaling cascades in a redox dependent manner particularly potentiation of mTOR signaling complex 2. We present data in support of MnSOD being responsible for previously reported ER dependent superoxide anion O2.- potentiation in breast cancer cells following E2 exposure. We showed that MnSOD interacts with ER alpha which in turn is associated with its diminished SIRT 3 dependent deacetylation, leading to its inhibition and superoxide anion O2.- build up and consequent activation of mTORC2 Note: This abstract was not presented at the conference. Citation Format: Mehraj U din Lone, Ranjana Km Kanchan, Chakrapani Tripathi, Khemraj Singh Baghel, Brijnath Tiwari, Smrati Bhadauria. Superoxide anion O2.-mediated activation of mTORC2 by estrogen receptor in breast cancer cells: Role of acetylation dependent inhibition of MnSOD. [abstract]. In: Proceedings of the AACR Special Conference: Targeting the PI3K-mTOR Network in Cancer; Sep 14-17, 2014; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2015;14(7 Suppl):Abstract nr B27.

Diagnostic Challenge in a Patient with Severe Anion Gap Metabolic Acidosis.

The approach to the patient with acute renal failure and elevated anion and osmolal gap is difficult. Differential diagnoses include toxic alcohol ingestion, diabetic or starvation ketoacidosis, or 5-oxoproline acidosis. We present a 76-year-old female with type 2 diabetes mellitus, who was found at home in a confused state. Laboratory analysis revealed serum pH 6.84, bicarbonate 5.8 mmol/L, pCO2 29 mmHg, anion gap 22.2 mmol/L, osmolal gap 17.4 mOsm/kg, elevated beta-hydroxybutyrate (4.2 mmol/L), random blood sugar 213 mg/dL, creatinine 2.1 mg/dL, and potassium 7.5 mmol/L with no electrocardiogram (EKG) changes. Fomepizole and hemodialysis were initiated for presumed ethylene glycol or methanol ingestion. Drug screens returned negative for ethylene glycol, alcohols, and acetaminophen, but there were elevated urine levels of acetone (11 mg/dL). The acetaminophen level was negative, and 5-oxoproline was not analyzed. After 5 days in the intensive care unit (ICU), her mental status improved with supportive care. She was discharged to a nursing facility. Though a diagnosis was not established, our patient's presentation was likely due to starvation ketosis combined with chronic acetaminophen ingestion. Acetone ingestion is less likely. Overall, our case illustrates the importance of systematically approaching an elevated osmolal and anion gap metabolic acidosis.

Groundwater Quality Assessment of Arid Regions of Punjab, India with Special Reference to Fluoride

Fluoride (F - ) intake with drinking water is a severe problem in several places in India including arid region of Punjab, North-West, India. Moderate amounts lead to dental fluorosis, but long-term ingestion of large amounts can lead to potentially severe skeletal problems. Keeping in view this fact, a study was planned to know the status of F - content in ground water of south western districts of Punjab and its relationship with other quality parameters. For this purposes, ninety-two ground water samples were collected in October 2009 from shallow aquifers and analyzed for fluoride and various other quality parameters. Fluoride content varied from 0.28 to 14.04 mg L -1 with a mean value of 5.15 mg L -1 . The elevated pH, dissolved salts, alkali metals (Na + , K + ) and anions (Cl - , HCO3 - and SO4 2- ) were accompanied by higher mean, median, 75 th and 90 th percentile fluoride concentration in groundwater. The concentration of fluoride declined with increasing concentration of calcium. Considering the World health organization safe limit of fluoride (1.5 mg L -1 ), 60 % of the total water samples collected were unfit for drinking purposes. From irrigation point of view, our results indicated that 86 % of the water samples are having F - content less than 10 mg L -1 which is the safe limit for all types of crop plants. The exposure doses to fluoride from ground water were also estimated for infants, children and adults. The maximum exposure dose to fluoride for the adults in the study area was 35 times higher than the minimum risk level proposed by Agency for Toxic Substances and Disease Registry's (ATSDR's MRL), indicating need of further research in this area.

Methanol poisoning: acute MR and CT findings in nine patients

Methanol poisoning is an uncommon but potent central nervous system toxin. We describe here the CT and MR findings in nine patients following an outbreak of methanol poisoning. Five patients with a typical clinical presentation and elevated anion and osmolar gaps underwent conventional brain MRI with a 1.5-T Gyroscan Interna scanner. In addition nonenhanced CT was performed in another three patients with more severe toxicity. Bilateral hemorrhagic or nonhemorrhagic necrosis of the putamina, diffuse white matter necrosis, and subarachnoid hemorrhage were among the radiological findings. Various patterns of enhancement of basal ganglial lesions were found including no enhancement, strong enhancement and rim enhancement. A good knowledge of the radiological findings in methanol poisoning seems to be necessary for radiologists. The present study is unique in that it enables us to include in a single report most of the radiological findings that have been reported previously.

The importance of recognizing whewellite

An 81-year-old man was found lying on the ground outside his home. He was comatose and hypothermic. He had a severe metabolic acidosis with elevated anion and osmol gaps, and his plasma ethylene glycol level was 3180 mg/l. The urine sediment showed calcium oxalate monohydrate crystals (Figure 1). Due to prolonged exposure, the patient died despite treatment. Survival of ethylene glycol intoxication depends on the rapidity of diagnosis and treatment. If recognized, urinary calcium oxalate crystals may provide an important diagnostic clue. They exist in two forms. Best known are the envelope-shaped dihydrate crystals named weddellite after their first discovery in Antarctic Ocean sediment (Figure 2). The rod-shaped monohydrate crystals named after the British scientist William Whewell (1794–1866) are

Plasma Cl:Na ratio: a simple alternative to Stewart's Strong Ion equation for detection of elevated lactate or unmeasured anions in metabolic acidosis

Plasma Cl:Na ratio: a simple alternative to Stewart's Strong Ion equation for detection of elevated lactate or unmeasured anions in metabolic acidosis

Spurious rise in total carbon dioxide and chloride with negative anion gap after cystogram

We report a case of spurious hyperchloraemia, elevated total carbon dioxide and negative anion gap 9 days following a voiding cystourethrogram (VCU) in a patient with bladder exstrophy and obstructive uropathy. We believe that the spurious laboratory results were due to analytical interference of the absorbed iodine with the method of bicarbonate and chloride measurement. The absorbed iodine was retained in the circulation for an extended period because of associated renal impairment. Our patient was also on piperacillin which might have interfered with iodine clearance. Physicians and laboratory pathologists should be aware of this effect when interpreting laboratory results of patients who have undergone a VCU in association with obstructive uropathy and impaired renal function.

Massive ethylene glycol poisoning without evidence of crystalluria: A case for early intervention

A case of severe ethylene glycol poisoning is presented, characterized by protracted delirium, coma, and delayed adult respiratory distress syndrome. This patient never demonstrated evidence of calcium oxalate crystalluria or renal insufficiency. Ethylene glycol intoxication should be considered in the patient who presents with an altered mental status, unexplained metabolic acidosis, and elevated anion and osmolal gaps with or without crystalluria. Early empiric ethanol therapy and consideration of dialysis are recommended for those patients with such a presentation without evidence of abnormal levels of ketones, lactate, solicylate, or ethanol. It is proposed that early ethanol therapy may prevent the formation of ethylene glycol metabolites to the extent that calcium oxalate crystalluria is not seen.