Presence Of Metabolic Acidosis Research Articles

Metformin-associated lactic acidosis and factors associated with 30-day mortality.

BackgroundMetformin-associated lactic acidosis (MALA) is a rare event but underrecognition may lead to unfavorable outcomes in type 2 diabetes patients. While many risk factors of MALA have been identified, how to reduce mortality from MALA is a matter of debate. This study aimed to explore the factors associated with 30-day mortality amongst MALA patients.MethodsAn observational study enrolled patients diagnosed with MALA between January 2014 and December 2017. MALA was defined by a history of metformin administration, metabolic acidosis (arterial blood gas pH <7.35 or HCO3 <15 mmol/L), and elevated plasma lactate level (>5 mmol/L). We examined risk factors including age, sex, underlying diseases, current medications, blood tests, disease severity, and dialysis data. Mortality status was identified from medical records or report on telephone.ResultsWe included 105 MALA patients. Most patients (95.2%) were diagnosed acute kidney injury stage 3 according to KDIGO 2012 definition. The 30-day mortality rate was 36.2% and dialysis rate was 85.7%. The survivors had higher proportions of underlying chronic kidney disease, presence of metabolic acidosis, receiving renal replacement therapy within 6 hours, and haemodialysis, whereas the non-survivors had higher percentage of hypertension and disease severity. Lower APACHE II score (HR = 0.95; 95%CI, 0.91–0.99; p = 0.038), time to dialysis < 6 hours (0.31; 0.14–0.69; 0.004), and haemodialysis (0.20;0.06–0.67; 0.010) were associated with lower 30-day mortality, using multivariate Cox-regression analysis.ConclusionsMortality rate amongst patients with MALA was high. Early dialysis treatment within 6 hours after admission and haemodialysis were independently associated with lower 30-day mortality. The large scale, well-designed studies need to confirm these encouraging results.

PH-Responsive Nanoparticles for Delivery of Paclitaxel to the Injury Site for Inhibiting Vascular Restenosis.

A high incidence of restenosis has been reported at the site of inflammation following angioplasty and stent implantation. The anti-proliferative drug paclitaxel (PTX) could help to reduce inflammation and restenosis; however, it has poor water solubility and serious adverse side effects at high doses. Given the presence of metabolic acidosis at the site of inflammation, we hypothesized that nanoparticles that are responsive to low pH could precisely release the loaded drug at the target site. We successfully constructed pH-responsive poly(D, L-lactic-co-glycolic acid) (PLGA) nanoparticles loaded with PTX and NaHCO3 as a pH-sensitive therapeutic agent (PTX-NaHCO3-PLGA NPs). The NPs exhibited remarkable pH sensitivity and a good safety profile both in vitro in rat vascular smooth muscle cells and in vivo in Sprague Dawley rats after tail vein injection. In the rat model, the PTX-NaHCO3-PLGA NPs treatment group showed suppressed intimal proliferation following balloon-induced carotid artery injury compared with that of the saline-treated control. Overall, these results demonstrate that our newly developed pH-responsive nanodrug delivery platform has the potential to effectively inhibit restenosis.

Rickets due to renal tubular acidosis: A case report and our perspective

Renal tubular acidosis (RTA) is a diverse group of tubular disorders characterized by failure of urinary acidification in the presence of metabolic acidosis with variable electrolyte abnormalities. RTA can present with a variety of manifestations to the nephrologist, orthopedist, pediatrician, and endocrinologist. Short stature, rickets, renal stones, and failure to thrive are the presentations that the endocrinologist can encounter. Here, we present one such case of rickets caused by distal RTA with secondary proximal tubular dysfunction.

P-EGS15 Gastric pneumatosis in an elderly patient with recurrence of gastric volvulus

Abstract Background Gastric pneumatosis (GP), defined as the presence of air in the gastric wall, is a rare CT finding. It is associated with a spectrum of conditions which can range from benign and self-limiting to severe with high mortality rate. A gastric volvulus occurs with a rotation of 180 degrees or more of the stomach around its longitudinal or transverse axis. It is a rare event, and can culminate in obstruction, strangulation, ischaemia and necrosis. We present a case of gastric pneumatosis in a patient suffering with hiatus hernia and a history of recurrent gastric volvuli. Methods An 83-year-old man presented with a history of vomiting and abdominal pain. His background included a known hiatus hernia with previous episodes of gastric volvulus. A computer tomography (CT) showed a gastric volvulus with air in the gastric wall, in the intrahepatic biliary tree and porta hepatis. Conservative management was pursued with IV PPI and antibiotics, keeping the patient nil by mouth. He improved clinically and a repeat CT scan showed regression of the gastric pneumatosis, with resorption of gas in the porta hepatis and regression of the pneumobilia. He was discharged home 12 days after his initial presentation. Results Gastric pneumatosis (GP) is described as a rare finding that can occur in conditions such as gastric emphysema (GE) and emphysematous gastritis (EG). GE is described as a more benign condition, usually self-limiting which can be managed conservatively in most cases and rarely requires surgical interventions. EG is a more severe condition with a high mortality rate, and more aggressive treatment is advocated. The diagnostic process can be challenging but literature shows lactate, the presence of metabolic acidosis and peritonitis can help differentiating between the two clinical entities and choosing the appropriate management plan. Conclusions This case described a patient presenting with a gastric volvulus with the presence of gastric pneumatosis, pneumobilia and portal venous gas. These findings were diagnosed as gastric ischaemia secondary to volvulus. In this case the patient made a good recovery after being managed conservatively. GP is a rare CT entity which can be found in the presence of GE or EG. Differentiating between the two can be a challenging process, aided by clinical examination as well as blood test results. Achieving the right diagnosis is key as radical surgical intervention is not always needed to guarantee a good outcome.

The very elderly followed at a nephrology center: metabolic acidosis as a predictor of progressive chronic kidney disease

Chronic kidney disease is an increasingly common diagnosis in the very elderly and identifying the patients who benefit from a nephrologist’s intervention and the ones who would not might avoid wasteful or harmful interventions. The aim of this study is to identify the risk factors for progressive versus non -progressive chronic kidney disease in a population aged over 80 years old. We performed a cohort single -center retrospective study including 101 patients over 80 years old with chronic kidney disease diagnosed for at least five years and followed regularly by a nephrologist. Progressive disease was defined as glomerular filtration rate declines greater than 5 mL/min/1.73 m2/year. Of the 101 patients, 33.7% had progressive chronic kidney disease. The median glomerular filtration progression rate was 3.0 [2.1 -6.0] mL/ min/1.73m2/year. Hypertension and diabetes mellitus prevalence was similar between groups. Nephrology follow -up time was longer in the progressive group (5.0 vs 2.0 years, p=0.01). Regarding chronic kidney disease complications, 37.6% had anemia and half of these needed erythropoiesis -stimulating agents. None of the patients had hyperphosphatemia. About 18.8% presented metabolic acidosis. In multivariable analysis, after adjusting for covariables such as age, hypertension, and diabetes mellitus only the presence of metabolic acidosis (OR 0.4, CI: 0.1 -0.8) was associated with the development of progressive chronic kidney disease. Progressive chronic kidney disease group presented higher mortality (log rank 4.5, p=0.03). Ischemic cardiomyopathy (OR: 0.5, CI: 0.2 -0.9) and progressive chronic kidney disease (OR: 0.6, CI:0.3 -0.8) were associated with all -cause mortality. Our results showed that most elderly patients have non -progressive chronic kidney disease. Patients with metabolic acidosis seem to be at an increased risk for developing progressive disease. Most elderly patients die before reaching end -stage kidney disease, so it is important to look at progressive kidney disease in those patients as an important marker of comorbidity and privilege cardioprotective measures.

Metabolic acidosis is associated with increased risk of adverse kidney outcomes and mortality in patients with non-dialysis dependent chronic kidney disease: an observational cohort study

BackgroundManagement of chronic kidney disease (CKD) requires the management of risk factors, such as hypertension and albuminuria, that affect CKD progression. Identification of additional modifiable risk factors is necessary to develop new treatment strategies for CKD. We sought to quantify the association of metabolic acidosis with CKD progression and mortality in a large U.S. community-based cohort.MethodsIn this longitudinal, retrospective cohort study we identified non-dialysis-dependent patients with stage 3‒5 CKD from Optum’s de-identified integrated electronic health records. We selected cohorts of patients with confirmed metabolic acidosis or normal serum bicarbonate levels based on 2 consecutive serum bicarbonate values: 12 to < 22 mEq/L or 22-29 mEq/L, respectively, 28‒365 days apart. The primary composite outcome was ≥ 40 % decline in estimated glomerular filtration rate (eGFR), renal replacement therapy (chronic dialysis or kidney transplant), or all-cause mortality (DD40). Secondary outcomes included each component of the composite outcome. Cox proportional hazards models were used for the DD40 outcome and secondary outcomes, while logistic regression models were used for the DD40 outcome at 2 years.ResultsA total of 51,558 patients qualified for the study. The unadjusted 2-year incidence of adverse renal and fatal outcomes was significantly worse among patients in the metabolic acidosis group vs. those who had normal serum bicarbonate levels: 48 % vs. 17 % for DD40, 10 % vs. 4 % for ≥ 40 % decline in eGFR, 20 % vs. 6 % for renal replacement therapy, and 31 % vs. 10 % for all-cause mortality (all P < 0.001). Over a ≤ 10-year period, for each 1-mEq/L increase in serum bicarbonate, the adjusted hazard ratio for DD40 was 0.926 (95 % confidence interval [CI], 0.922–0.930; P < 0.001); over a ≤ 2-year period, the adjusted odds ratio for DD40 was 0.873 (95 % CI, 0.866–0.879; P < 0.001).ConclusionsIn this large community cohort of patients with stage 3‒5 CKD, the presence of metabolic acidosis was a significant, independent risk factor for the composite adverse outcome of CKD progression, renal replacement therapy, and all-cause mortality (DD40).

Total intravenous anaesthesia to facilitate bulbocavernous reflex in a 2-year-old child with tethered cord syndrome: A case report

Tethered cord syndrome is a neurological disorder caused by tissue attachments that limit the movement of the spinal cord within the spinal canal. Intraoperative neurophysiological monitoring like somatosensory evoked potentials and transcranial motor evoked potentials can preclude surgically induced lesions to the nervous system and has become standard of care for many neurosurgical procedures. Despite the potential advantages of total intravenous anaesthesia, it is not a widely used anaesthetic technique in children. Recently, a few case reports have been published regarding the presence of metabolic acidosis even with a short term infusion of propofol. We present a case report in which total intravenous anaesthesia was used to facilitate BCR in a 2-year-old child, to monitor the functional integrity of the sacral reflex, which enables bladder and bowel function.

Prevalence and clinical correlates of hyperkalemia in stable kidney transplant recipients.

Although hyperkalemia (HK) is often associated with adverse clinical outcomes in renal patients, few studies are available in the setting of kidney transplantation. Therefore, we evaluated prevalence and clinical correlates of HK in stable kidney transplant recipients (KTRs) on standard of care immunosuppressive therapy. We studied 160 stable KTRs (post-transplant vintage 46.6 ± 16.6months), most of whom (96.2%) on calcineurin inhibitor (CNI)-based immunosuppressive therapy. HK was defined as plasma potassium levels above 5mEq/L, confirmed in two consecutive samples. Office blood pressure was measured, and renal graft function was expressed by estimated glomerular filtration rate (eGFR), calculated according to the CKD-EPI formula. HK prevalence was 8.8%, and plasma K above 5.5mEq/L was found in 2.5% of all KTRs. In the univariate logistic regression analysis HK was significantly associated with serum urea concentration (OR 1.03, 95% CI 1.01-1.05 for each 1mg/dL increase), tCO2 (OR 0.77, 95% CI 0.66-0.90 for each 1mmol/L increase), the presence of arterial hypertension (OR 4.01, 95% CI 1.3-12.64), the use of RAAS inhibitors (OR 5.26, 95% CI 1.6-17.7), and eGFR less than 30ml/min/1.73m2 (OR 7.51, 95% CI 2.37-23.77). By multivariable backward stepwise regression analysis, the presence of metabolic acidosis (OR 0.83, 95% CI 0.69-0.99, P = 0.04), arterial hypertension (OR 4.65 95% CI 1.01-17.46 P = 0.03), and to be administered RAAS inhibitors (OR 6.11, 95% CI 1.03-25.96 P = 0.03) remained significantly associated with HK. We conclude that in stable KTRs the prevalence of HK is about 9%, slightly lower than previously reported. Moreover, it is not associated with eGFR, but with metabolic acidosis, arterial hypertension, and the use of RAAS inhibitors.

Metabolic acidosis as an important factor of pathogenesis of chronic pancreatitis

Article presents the results of the analysis of scientific literature on the role of metabolic acidosis in the pathogenesis of chronic pancreatitis. It is stated that metabolic acidosis is an important predictive factor in the formation and deepening of trophic insufficiency, which further reduces the quality of life of patients with chronic pancreatitis and worsens the prognosis. This motivates the need to take into account the presence of metabolic acidosis during the development of a complex treatment program for such patients.

Predictors of Mortality in Acute Kidney Injury Patients Admitted to Medicine Intensive Care Unit in a Rural Tertiary Care Hospital.

Background:Acute kidney injury (AKI) is a challenging problem faced by intensive care clinicians worldwide, and it is associated with high morbidity and mortality, especially in critically ill patients.Materials and Methods:A hospital-based prospective, observational study was conducted in patients of AKI admitted to the Intensive Care Unit (ICU) of the Department of Medicine in a rural tertiary care hospital located in central India. Data of all consecutive AKI inpatients related to demographic variables, clinical profile, and laboratory investigations were collected from patient's medical records.Results:Of the total 229 AKI patients enrolled in this study, 65 (28.4%) patients died during their hospital stay. The presence of metabolic acidosis, hypotension, Glasgow coma scale (GCS) and Acute Physiologic Assesment and Chronic Health Evaluation (APACHE 2) score, advanced AKI stage, higher serum creatinine and blood urea levels on diagnosis of AKI and the peak rise in their level within 48 h of diagnosis of AKI, the use of mechanical ventilator, leukocytosis, and hyperkalemia were significantly associated with in-hospital mortality in AKI patients (P < 0.05).Conclusion:The overall in-hospital mortality in patients of AKI admitted to medicine-ICU was 28.4%. Sepsis was the most common cause of AKI (24.5%). The presence of metabolic acidosis, hypotension, GCS and APACHE 2 score, advanced AKI stage, higher serum creatinine, and blood urea levels on diagnosis of AKI and the peak rise in their level within 48 h of diagnosis of AKI, use of mechanical ventilator, leukocytosis, and hyperkalemia were associated with in-hospital mortality in AKI patients.

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Metabolic acidosis is common and associates with disease progression in children with chronic kidney disease

Recent studies in adult chronic kidney disease (CKD) suggest that metabolic acidosis is associated with faster decline in estimated glomerular filtration rate (eGFR). Alkali therapies improve the course of kidney disease. Here we investigated the prevalence and determinants of abnormal serum bicarbonate values and whether metabolic acidosis may be deleterious to children with CKD. Associations between follow-up serum bicarbonate levels categorized as under 18, 18 to under 22, and 22 or more mmol/l and CKD outcomes in 704 children in the Cardiovascular Comorbidity in Children with CKD Study, a prospective cohort of pediatric patients with CKD stages 3-5, were studied. The eGFR and serum bicarbonate were measured every six months. At baseline, the median eGFR was 27ml/min/1.73m2 and median serum bicarbonate level 21mmol/l. During a median follow-up of 3.3 years, the prevalence of metabolic acidosis (serum bicarbonate under 22 mmol/l) was 43%, 60%, and 45% in CKDstages 3, 4, and5, respectively. In multivariable analysis, the presence of metabolic acidosis as a time-varying covariate was significantly associated with log serum parathyroid hormone through the entire follow-up, but no association with longitudinal growth was found. A total of 211 patients reached the composite endpoint (ESRD or 50% decline ineGFR). In a multivariable Cox model, children with time-varying serum bicarbonate under 18 mmol/l had a significantly higher risk of CKD progression compared to those with a serum bicarbonate of 22 or more mmol/l (adjusted hazard ratio 2.44; 95% confidence interval 1.43-4.15). Thus, metabolic acidosis is a common complication in pediatric patients with CKD and may be arisk factor for secondary hyperparathyroidism and kidney disease progression.

Plasma Urotensin II levels in children and adolescents with chronic kidney disease: a single-centre study

BackgroundIncreased plasma Urotensin II (UII) levels have been found in adults with renal diseases. Studies in children are scarce. The objective of the study is to estimate plasma UII levels in subjects with chronic kidney disease (CKD) stages 3 to 5 and renal transplant recipients (RTR). In addition, the correlation of UII with anthropometric features and biochemical parameters was assessed.MethodsFifty-four subjects, aged 3 to 20 years old, 23 with CKD, 13 with end-stage kidney disease (ESKD) undergoing hemodialysis (HD) and 18 RTR were enrolled. A detailed clinical evaluation was performed. Biochemical parameters of renal and liver function were measured. Plasma UII levels were measured in all patients and in 117 healthy controls, using a high sensitive enzyme immunoassay (EIA) kit. All data were analyzed using STATA™ (Version 10.1).ResultsMedian UII and mean log-transformed UII levels were significantly higher in CKD and RTR patients compared to healthy subjects (p < 0.001). HD patients had higher but not statistically significant UII and log-UII levels than controls. UII levels increased significantly at the end of the HD session and were higher than controls and in line to those of other patients. The geometric scores of UII in HD (before dialysis), CKD and RTR patients increased respectively by 42, 136 and 164% in comparison with controls. Metabolic acidosis was associated with statistical significant change in log-UII levels (p = 0.001). Patients with metabolic acidosis had an increase in UII concentration by 76% compared to those without acidosis.ConclusionsChildren and adolescents with CKD, particularly those who are not on HD and RTR, have significantly higher levels of UII than healthy subjects. UII levels increase significantly at the end of the HD session. The presence of metabolic acidosis affects significantly plasma UII levels.

The evaluation of the relationship between serum levels of Interleukin-6 and Interleukin-10 and metabolic acidosis in hemodialysis patients.

Chronic kidney disease is defined as progressive kidney dysfunction. The levels of various cytokines increase in hemodialysis (HD) patients. High levels of interleukins (ILs) and presence of metabolic acidosis are described as independent risk factors for morbidity and mortality in these patients. This study was designed to evaluate the relationship between IL-6 and IL-10 and serum bicarbonate and metabolic acidosis in HD patients. In this analytical crosssectional study, patients referred to the HD units of Loghman Hakim and Shahid Ashrafi Esfahani Hospitals were randomly selected. Demographic and laboratory data, such as albumin, creatinine, calcium, phosphorus, parathormone, C-reactive protein, complete blood count, ferritin, ILs-6 and -10, and arterial blood gas analysis, were recorded for each patient. The correlation between IL and serum bicarbonate and other variables were evaluated by SPSS software. The patients were compared for the presence of acidosis and positivity for IL. A total of 84 patients with a mean age of 60.98 years and mean body mass index of 24.86 kg/m[2] were evaluated (53% male and 57% female). The mean dialysis duration was 24.86 ± 3.98 months. Overall, 41.7% of the patients had diabetes mellitus and 36.9% of them had hypotension. The mean serum levels of IL-6 and IL-10 were 6.036 and 17.46 pg/ml, respectively. There was a significant correlation between IL-6 and IL-10 levels and serum bicarbonate and the incidence of metabolic acidosis (P <0.05). Based on the results, metabolic acidosis and bicarbonate could be considered prognostic factors to differentiate the increased levels of IL-6 and IL-10 and associated morbidity and mortality.

Risk Factors for Developing Metabolic Acidosis after Radical Cystectomy and Ileal Neobladder.

PurposeTo investigate the serial changes of metabolic acidosis and identify associated risk factors in patients who underwent radical cystectomy and ileal neobladder.Material and MethodsFrom January 2010 to August 2014, 123 patients who underwent radical cystectomy and ileal neobladder reconstruction for bladder cancer were included in this study. Metabolic acidosis was defined as a serum bicarbonate level less than 22 mEq/L and impaired renal function was defined as a GFR <50ml/min. The presence of metabolic acidosis was evaluated at 1 month, 1 year, and 2 years after surgery. Multivariate logistic regression analysis was conducted to identify risk factors associated with development of metabolic acidosis.ResultsMetabolic acidosis was observed in 52%, 19.5%, and 7.3% of patients at 1 month, 1 year, and 2 years after surgery, respectively. At 1 month after surgery, impaired renal function was the only independent risk factor associated with metabolic acidosis (OR 3.87, P = 0.046). At 1 year after surgery, diabetes was the only independent risk factor associated with metabolic acidosis (OR 5.68, P = 0.002). At 2 years post-surgery, both age and diabetes were significant risk factors associated with metabolic acidosis.ConclusionApproximately, half of patients experienced metabolic acidosis one month after ileal neobladder reconstruction. Preoperative impaired renal function was the most significant risk factor for developing metabolic acidosis in the early postoperative period. However, the incidence of metabolic acidosis decreased to less than 20% 1 year after surgery, and diabetes was an independent risk factor during this period.

A study of clinical profile and outcome of intra ventricular hemorrhage in neonates admitted to neonatal intensive care unit of a tertiary care hospital, Eluru, Andhra Pradesh, India

Background: The human hemostatic system is dynamic and is profoundly influenced by age. Although considered immature in the new-born, it is a physiological system which results in few problems for the healthy term neonate, but may contribute to morbidity in the sick and preterm infants when additional acquired abnormalities may be present. The objectives were, the study has been conducted to evaluate the clinical presentation, etiological risk factors of Intraventricular haemorrhage (IVH) and to correlate the birth weight, gestational age, sex, mode of delivery, perinatal factors with the incidence of IVH and to study the immediate outcome. Methods: This is a prospective study which included neonates admitted in the Neonatal intensive care unit (NICU) of Department of Paediatrics, Alluri Sita Rama Raju Medical College, Eluru, Andhra Pradesh, India during the period of March 2013 and September 2014. We enrolled 135 newborns in the study and blood investigations and transcranial USG was done in all. Results: Incidence of IVH in new-borns admitted in NICU at Alluri Sita Rama Raju Medical College was 13.3% (18 out of 135 babies), whereas incidence of IVH in preterm babies was 26.9% (17 out of 63 babies) and incidence of IVH in term babies was 1.3% (1 out of 72 babies). 94.4% of the new-borns with IVH had prolonged prothrombin time (p&lt;0.01). Thrombocytopenia was responsible in 83.4% as an associated risk factor in the development of IVH (p&lt;0.01). Conclusions: Intraventricular Hemorrhage constitutes an important cause of morbidity and mortality in neonate. Need for assisted ventilation irrespective of the co morbidities, presence of metabolic acidosis, have been associated with increased incidence of IVH. Deranged coagulation profile (Thrombocytopenia, prolonged prothrombin time (PT)) have been associated with increased risk for the incidence of IVH in new-borns.

Rehabilitation of patients with acid-base and fluid balance disorders with short bowel syndrome after ileostomies

Patients with ileostomies regularly suffer from short bowel syndrome or high volume output associated with loss of absorptive surface and subsequent impairment of absorption for drugs and different nutrients resulting in electrolyte and fluid balance disorders as well as renal insufficiency. Adaptation of these fundamental functions of the gut with adequate fluid uptake, absorption of sufficient different nutrients and vitamins represents a major challenge to rehabilitate these patients shortly after surgery. Patients with ileostomy often develop metabolic acidosis with normal anion gap. In our retrospective study we would like to draw attention to these metabolic disorders in patients with ileostomy in comparison to patients with colostomy and patients undergoing gastrectomy for gastric cancer. In the period from 2005 to 2012 we examined 164 patients with ileostomy in our rehabilitation clinic, 109 patients with colostomy and 193 patients after surgery for gastric cancer of the possible presence of metabolic acidosis by using capillary blood gas analysis (metabolic acidosis was anticipated, if base excess was ≤- 3,0 mmol/l). Patients are treated as inpatients both in early stage and for follow-up rehabilitation. The length of time in our rehabilitation clinic lies in between 24-28 days. On the basis of random samples we tested blood samples in 19 patients with ileostomy in succession for ferritin, folic acid, zinc, selenium and vitamin B12. Statistical analysis comprised the classical intervals (mean and standard deviation, range and T-test for dependent and independent samples). In total we tested 164 inpatients with ileostomy in our rehabilitation clinic (median age 67.4 years, range 19-79 years). Surgery for ileostomy took place about 1.4 months on average ago (range ¼-56 months). 60 (36.5%) inpatients suffered from metabolic acidosis often combined with renal insufficiency. Supportive therapy intravenously administered in 10 patients and sodium bicarbonate given by mouth in 40 patients significantly improved metabolic acid (base excess improved on average from -7.2 to -3.2 mmol/l, p<0.00138) and renal function calculated on the basis of serum creatinine (serum creatinine decreased from 1.49 on average to 1.34 mg/dl, p<0.04039). Body weight remained constant over the whole period on average with 74 kg. Diuretics did not show any influence on the base excess. In 19 patients with ileostomy who did not take any kind of supplements, among the parameters tested were a high percentage of zinc (9 of 19 patients, 47%) and selenium deficiency (13 of 19 patients, 68%). 50 patients with ileostomy were younger than 65 years of age and thus in the working age population. In the group of patients after gastrectomy because of gastric cancer (n=193, median age 69.1 years, range 36-82 years), surgery for gastrectomy took place about 1.8 months on average ago and in this group only 14 patients (7%) showed metabolic acidosis. In the group of patients with colostomy (n=109, median age 69.5 years, range 39-82 years), surgery for colostomy took place about 2.1 months on average ago and in this group only 6 patients (5.5%) suffered from metabolic acidosis. Medical rehabilitation is indicated for patients with enterostoma. Acceptance of the enterostoma by the patient himself, psychological stabilization, achievement of self-sufficiency in stoma care, improvement of physical abilities and finally being fit for full or limited employment are the most important objectives in rehabilitation medicine. Metabolic acidosis was often found in patients with ileostomy and was an important clinical appearance. Blood gas analysis is recommended to verify metabolic acidosis and if confirmed sodium bicarbonate and in cases of high volume output salt-depleting ileostomy additionally intravenous fluid support should be offered controlling body weight in the follow-up. As could be shown by our analysis patients with ileostomy should also be tested for zinc and selenium deficiency.

The added predictive value of biphasic events in ST analysis of the fetal electrocardiogram for intrapartum fetal monitoring.

To study the predictive value of biphasic ST-events for interventions for suspected fetal distress and adverse neonatal outcome, when using ST-analysis of the fetal electrocardiogram (FECG) for intrapartum fetal monitoring. Prospective cohort study. Three academic hospitals in Sweden. Women in labor with a high-risk singleton fetus in cephalic position beyond 36weeks of gestation. In women in labor who were monitored with conventional cardiotocography, ST-waveform analysis was recorded and concealed. Traces with biphasic ST-events of the FECG (index) were compared with traces without biphasic events of the FECG. The ability of biphasic events to predict interventions for suspected fetal distress and adverse outcome was assessed using univariable and multivariable logistic regression analyses. Interventions for suspected fetal distress and adverse outcome (defined as presence of metabolic acidosis (i.e. umbilical cord pH <7.05 and base deficit in extracellular fluid >12mmol), umbilical cord pH <7.00, 5-min Apgar score <7, admittance to neonatal intensive care unit or perinatal death). Although the presence of biphasic events of the FECG was associated with more interventions for fetal distress and an increased risk of adverse outcome compared with cases with no biphasic events, the presence of significant (i.e. intervention advised according to cardiotocography interpretation) biphasic events showed no independent association with interventions for fetal distress [odds ratio (OR) 1.71, 95% confidence interval (CI) 0.65-4.50] or adverse outcome (OR 1.96, 95% CI 0.74-5.24). The presence of significant biphasic events did not discriminate in the prediction of interventions for fetal distress or adverse outcome. Therefore, biphasic events in relation to ST-analysis monitoring during birth should be omitted if future studies confirm our findings.

A case of a woman with late-pregnancy-onset DKA who had normal glucose tolerance in the first trimester

SummaryDiabetic ketoacidosis (DKA) during pregnancy is a serious complication in both mother and fetus. Most incidences occur during late pregnancy in women with type 1 diabetes mellitus. We report the rare case of a woman with type 1 diabetes mellitus who had normal glucose tolerance during the first trimester but developed DKA during late pregnancy. Although she had initially tested positive for screening of gestational diabetes mellitus during the first trimester, subsequent diagnostic 75-g oral glucose tolerance tests showed normal glucose tolerance. She developed DKA with severe general fatigue in late pregnancy. The patient's general condition improved after treatment for ketoacidosis, and she vaginally delivered a healthy infant at term. The presence of DKA caused by the onset of diabetes should be considered, even if the patient shows normal glucose tolerance during the first trimester.Learning points The presence of DKA caused by the onset of diabetes should be considered, even if the patient shows normal glucose tolerance during the first trimester.Symptoms including severe general fatigue, nausea, and weight loss are important signs to suspect DKA. Findings such as Kussmaul breathing with ketotic odor are also typical.Urinary test, atrial gas analysis, and anion gap are important. If pH shows normal value, calculation of anion gap is important. If the value of anion gap is more than 12, a practitioner should consider the presence of metabolic acidosis.

Clinico-biochemical correlation of ocular manifestations and visual prognosis in victims of hooch tragedy

Background: Hooch tragedies are very common in India, especially in the low socioeconomic group resulting in varying mortality and morbidity. Various biochemical changes occur following methanol poisoning. An attempt is made to follow up such patients to correlate these biochemical changes and clinical presentations to the final visual outcome. Aim: To study the visual problems in the victims of acute methanol poisoning and its correlation with biochemical changes. We also studied the visual prognosis and sequel of acute methanol poisoning in correlation with the initial presentation, biochemical changes and treatment modalities. Study Design: Observational study. Materials and Methods: Twenty-nine patients attended in ophthalmology casualty of a tertiary center with history of blurring of vision after consuming illicit liquor were included in the study. Four patients presented with no perception of light, 15 patients were having poor vision (<6/18). On follow up, the two patients remained with no perception of light. Even though four patients showed initial improvement, they later deteriorated. Patients who permanently lost vision were having severe metabolic acidosis at presentation. Statistical Analysis: Was done by chi square test using SPSS 16 version software for studying the significance. Results and Conclusion: Acute methanol poisoning can badly affect the visual functions. Blood pH and serum bicarbonate level has got direct correlation with visual deficit. The presence of metabolic acidosis, if not corrected early will result in permanent visual impairment. Early intervention with hemodialysis and systemic steroids can improve the visual outcome.