Refractory Hyperlactatemia and Hypoglycemia in an Adult with Non-Hodgkin's Lymphoma: A Case Report and Review of the Warburg Effect

Lactate is a byproduct of anaerobic glycolysis, and hyperlactatemia is commonly seen in critically ill patients. We report a case of an elderly male presenting with undifferentiated constitutional symptoms, anemia, thrombocytopenia, severe lactic acidosis, refractory hypoglycemia, and a newly detected abdominal mass. A dedicated workup ruled out infectious etiologies and revealed metastatic non-Hodgkin's lymphoma. This study explores etiologies of type B lactic acidosis in oncology patients, with a focus on Warburg's effect, and its potential for prognostication.

Pregnancy and Neuromyelitis Optica Spectrum Disorder - Reciprocal Effects and Practical Recommendations: A Systematic Review

Introduction: Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory disorder of the central nervous system characterized by severe, antibody-mediated astrocyte loss with secondary demyelination and axonal damage, predominantly targeting optic nerves and the spinal cord. Recent publications have alluded to increased disease activity during pregnancy, and adverse maternal and fetal outcomes in patients with NMOSD. Our objective was to systematically review published literature to help counsel and manage women with NMOSD contemplating pregnancy. Methods: We searched five databases including MEDLINE and EMBASE, for English-language publications describing pregnancies in women with NMOSD. Article selection, data extraction, and risk-of-bias assessment using Joanna Briggs' critical appraisal tool for case reports and case series, were performed in duplicate. Pooled incidences were calculated where possible, and a narrative summary was provided. Results: Of 2,118 identified titles, 22 case reports and seven case series, representing 595 pregnancies in 389 women, were included. The mean maternal age was 28.12 ± 5.19 years. At least 20% of cases were first diagnosed during pregnancy. There were no maternal deaths. Pooled estimates for clinical outcomes could not be obtained due to inadequate reporting. NMOSD-related disability and relapses increased considerably during pregnancy and especially in the immediate postpartum period. Although a high proportion of early pregnancy losses were reported, an association with disease activity or therapeutic interventions could not be established. Apart from one publication which reported an increased risk of preeclampsia, there was no increase in adverse obstetric outcomes including preterm birth, fetal growth restriction or congenital malformations. Initial attacks and relapses were successfully managed with oral or intravenous corticosteroids and immunosuppressants, and refractory cases with immunoglobulin, plasma exchange and immunoadsorption. Conclusion: Increased NMOSD-related disability and relapses during pregnancy the postpartum period may respond to aggressive management with corticosteroids and immunosuppressants such as azathioprine, which are safely administered during pregnancy and lactation. Emerging safety data on monoclonal antibodies during pregnancy, make these attractive options, while intravenous immunoglobulin, plasma exchange and immunoadsorption can be safely used to treat severe relapses. The complex interplay between NMOSD and pregnancy outcomes would be best understood through prospective analysis of data collected through an international registry. Disclosure: Dalia Rotstein has served as a consultant or speaker for Alexion and Roche. She has received research support from Roche Canada. Rohan D'Souza has served as a consultant and speaker for Ferring Canada Inc and Ferring Global Inc, on topics unrelated to this manuscript. The other authors have no relevant relationships to disclose.

Devic syndrome and pregnancy: A case series

Background

Devic syndrome or neuromyelitis optica is an autoimmune neurological condition characterized by relapsing symptoms of optic neuritis and transverse myelitis. Women with neuromyelitis optica suffer from adverse pregnancy outcomes and high relapse rates during pregnancy and the postpartum period.

Methods

This case series describes 13 pregnancies in four women with neuromyelitis optica managed at a tertiary hospital in Toronto, Canada.

Results

In most cases, neurologic symptoms either worsened or developed for the first time during pregnancy or the postpartum period, and often responded to a combination of steroids, immunosuppressant medications, plasma exchange and intravenous immunoglobulin. The 13 pregnancies resulted in two miscarriages, three preterm and eight term births. One fetus whose mother was on gabapentin, prednisone and spironolactone, had congenital malformations (aplastic lung and fused fingers).

Conclusions

Despite high frequency of relapses in pregnancy and the postpartum period, with multidisciplinary team management, outcomes for women with neuromyelitis optica are encouraging.

Opioid and benzodiazepine use in end-stage renal disease: a systematic review

BACKGROUND AND OBJECTIVES

Chronic pain and psychiatric disorders are common in dialysis patients, but the extent to which opioids and benzodiazepines are used is unclear. We conducted a systematic review to determine the: (1) prevalence of opioid and benzodiazepine use among dialysis patients; (2) reasons for use; (3) effectiveness of symptom control; and (4) incidence of adverse events.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Two authors reviewed all relevant citations in MEDLINE/EMBASE/CINAHL/BIOSIS Previews/Cochrane and hand-searched bibliographies. Studies after 1990 reporting prevalence estimates for opioid and/or benzodiazepine use in ≥50 dialysis patients were included.

RESULTS

We identified 15 studies from 12 countries over 1995 to 2006. Sample size ranged from 75 to 12,782. Prevalence of opioid and benzodiazepine use was variable, ranging from 5 to 36% (95% CI, 4.1 to 45.5%; n=10) and 8 to 26% (95% CI, 7.1 to 27.3%; n=9), respectively. Prevalence was positively correlated with years on dialysis. Five studies reported on the same cohorts but gave different prevalence estimates. One study verified medication use through patient interviews. Reasons for use were reported in one study. Effectiveness of pain control varied from 17 to 38%, and 72 to 84% of patients with significant pain had no analgesia (n=2). No study rigorously examined for adverse events.

CONCLUSIONS

The prevalence of opioid and benzodiazepine use in dialysis patients is highly variable between centers. Further information is needed regarding the appropriateness of these prescriptions, adequacy of symptom control, and incidence of adverse effects in this population.

Caries prevalence, oral hygiene and orthodontic status of Saudi Bedouin children

The objectives of the study were to determine caries prevalence, oral hygiene and orthodontic status of Bedouin children in a desert around Al-Qasseem Region of Saudi Arabia. One hundred and fifty three children were examined for caries, oral hygiene and orthodontic status with mirror and explorer utilizing natural light. These children were divided into two groups for analyses. The primary dentition group consisted of 77 children, 39 (50.6%) male and 38 (49.4%) female with a mean age of 4.0 (+/- 1.4) years. The mixed dentition group consisted of 76 children, 67 (88.2%) male and 9 (11.8%) female with a mean age of 9.7 (+/- 2.9) years. In Primary dentition group, 16 (20.8%) children were caries positive and mean DMFT was 0.91 (+/- 2.42). There was a highly significant relation (p < .001) between oral hygiene and caries. In the mixed dentition group, 15 (19.7%) children were caries positive. The mean DMFT and DMFT scores for these children were 0.72 (+/- 1.96) and 0.74 (+/- 1.48) respectively. There was a significant relation (P > .01) between oral hygiene and caries. One hundred and fifty one (98.6%) children had class I molar relation and 2 (1.4%) children had class II molar relation. Anterior open bite, anterior crossbite and posterior crossbite were found in one case (0.7%) each. The caries experience of these Bedouin children was low both in terms of prevalence and severity. There was a significant relation between oral hygiene and caries. The orthodontic problems were almost nonexistent in the study population.

The prevalence and pattern of nursing caries in Saudi preschool children

OBJECTIVES

To determine the prevalence and pattern of nursing caries in Saudi preschool children of Riyadh area.

DESIGN

Cross-sectional.

SUBJECTS AND METHODS

A list of kindergartens was derived through random selection of one kindergarten from every area of Riyadh. A sample of 1,016 children with primary dentition only was examined for dental caries. The criterion used for nursing caries was presence of caries on the labial or lingual surfaces of at least two maxillary incisors with absence of caries in mandibular incisors.

RESULTS

Two hundred and seventy-seven (27.3%) children were diagnosed as having nursing caries. The mean dmft of nursing caries children was 8.6 (+/- 3.4), with dt component of 7.6 (+/- 3.5), mt of 0 4 (+/- 0.9) and ft of 0.6 (+/- 1.7). The older children had significantly higher mean dmft as compared with younger children. The teeth most affected by caries were maxillary central incisors (93.9%), whereas the least affected were mandibular canines (9.6%). A great majority of children (95.7%) had caries in both anterior and posterior teeth. The probability of bilateral molar caries was very high in nursing caries children; highest (94.7%) in mandibular first molars.

CONCLUSIONS

The caries prevalence was high in the study population. The maxillary central incisors were most affected by caries. The probability of bilateral molar caries was very high.