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Malkan R, Baillio M, Gao HT, Varney SM. Elevated Osmolal Gap in a Case of Multiple Myeloma. J Emerg Med 2024; 66:e341-e345. [PMID: 38403563 DOI: 10.1016/j.jemermed.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 07/08/2023] [Accepted: 07/15/2023] [Indexed: 02/27/2024]
Abstract
BACKGROUND The estimated serum osmolality is a measurement of solutes in the blood, including sodium, glucose, and urea, but also includes ethanol and toxic alcohols (e.g., methanol, ethylene glycol, diethylene glycol, isopropyl alcohol, propylene glycol) when present. These rarely measured toxic alcohols can elevate the serum osmolality, giving the true measured osmolality. The difference between that and a calculated osmolality is the osmolal gap, which can be elevated in many clinical scenarios such as renal failure, ingestion of toxic alcohols, diabetic ketoacidosis, shock, and others. CASE REPORT We report a patient with a history of alcohol use disorder who came to the Emergency Department with an abnormally elevated osmolal gap in the setting of altered mental status. The patient's increased osmolal gap was further investigated while he was promptly treated with fomepizole, thiamine, and urgent hemodialysis. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We discuss the differential diagnosis for substances that increase the osmolal gap with respective ranges of elevation. This case demonstrates that although osmolal gap elevation is often attributed to the presence of toxic alcohols, other common etiologies may account for the gap, including acute renal failure and multiple myeloma.
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Affiliation(s)
- Ratna Malkan
- Department of Emergency Medicine, University of Texas Health Science Center, San Antonio, Texas
| | - Michael Baillio
- Department of Emergency Medicine, University of Texas Health Science Center, San Antonio, Texas
| | - Han T Gao
- Department of Emergency Medicine, University of Texas Health Science Center, San Antonio, Texas
| | - Shawn M Varney
- Department of Emergency Medicine, University of Texas Health Science Center, San Antonio, Texas; South Texas Poison Center, University of Texas Health Science Center, San Antonio, Texas
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Liang H, Wang JM, Wei XQ, Su XQ, Zhang BX. Thyroid function, renal function, and depression: an association study. Front Psychiatry 2023; 14:1182657. [PMID: 38179254 PMCID: PMC10765600 DOI: 10.3389/fpsyt.2023.1182657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 11/15/2023] [Indexed: 01/06/2024] Open
Abstract
Objective To investigate the correlations between thyroid function, renal function, and depression. Methods Clinical data of 67 patients with Major depressive disorder (MDD) and 36 healthy control subjects between 2018 and 2021 were collected to compare thyroid and renal function. Thyroid and renal functions of depressed patients were then correlated with the Hamilton Depression Rating Scale (HAMD) and the Hamilton Anxiety Rating Scale (HAMA).Spearman correlation analysis was used to find the correlation between renal function, thyroid function, and depression. A logistic regression was performed to find significant predictors of depression. Results Triiodothyronine protamine (T3), thyroxine (T4), free triiodothyronine protamine (FT3), uric acid, sodium, and anion gap were lower in the MDD group than in the control group (p < 0.05). Correlation analysis of thyroid function, renal function, and factor terms of HAMD in the MDD group suggested that diurnal variation, hopelessness, and depression level were positively correlated with thyrotropin (TSH) (p < 0.05). Cognitive disturbance, retardation, and depression level were negatively correlated with creatinine (p < 0.05). Diurnal variation was negatively correlated with sodium ion (p < 0.01); hopelessness and depression level were positively correlated with chloride ion (p < 0.05); diurnal variation, retardation, and depression level were negatively correlated with anion gap (p < 0.05). Diurnal variation (p < 0.01) and retardation (p < 0.05) were negatively correlated with osmolality. Cognitive disturbance and depression level were positively correlated with estimated glomerular filtration rate (eGFR) (p < 0.05). In the MDD group, correlation analysis of thyroid function, renal function, and HAMA factor terms suggested that the total HAMA score and anxiety level were positively correlated with chloride ion (p < 0.05); psychic anxiety, total HAMA score, and anxiety level were negatively correlated with anion gap (p < 0.05). Furthermore, a low level of anion gap was an independent risk factor for depression and anxiety levels (p < 0.05). Conclusion Low thyroid function and reduced waste metabolized by the kidneys in patients with MDD suggest a low intake and low metabolism in depressed patients. In addition, subtle fluctuations in the anion gap in depressed patients were strongly correlated with the degree of depression and anxiety.
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Affiliation(s)
- Hai Liang
- Department of Neurology, The Second People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, China
- Department of Neurology, The Third Affiliated People’s Hospital of Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Jin-min Wang
- Department of Neurology, The Second People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Xiao-qian Wei
- Department of Integrative Medicine and Psychiatry, Xiamen Xianyue Hospital, Xiamen, China
| | - Xiao-qin Su
- Department of Neurology, The Second People’s Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Bi-xia Zhang
- Department of Neurology, Minhou Country Hospital, Fuzhou, China
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Zijlstra HW, Stegeman CA. The elevation of the anion gap in steady state chronic kidney disease may be less prominent than generally accepted. Clin Kidney J 2023; 16:1684-1690. [PMID: 37779853 PMCID: PMC10539198 DOI: 10.1093/ckj/sfad100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Indexed: 10/03/2023] Open
Abstract
Background A presumed cause of metabolic acidosis in chronic kidney disease (CKD) is accumulation of unmeasured anions, leading to a high anion gap (AG). In patients with CKD with a high AG, only minor increases are expected. The aim of this study is to evaluate the magnitude of the AG in documented steady state CKD to examine the effect of CKD on a high-AG metabolic acidosis (HAGMA). Methods In this cross-sectional study the AG, bicarbonate, and chloride were evaluated in 1045 blood and urine samples of 501 patients with steady state CKD in the outpatient clinic. The influence of phosphate, albumin and potassium on the AG were evaluated. Results The mean AG increased from 8.8 mEq/l (±1.57) in CKD stage 1 to 11.2 mEq/l (±2.22) in CKD stage 5 (P < 0.001). Correction for albumin or phosphate did not influence the magnitude of the AG. Correction for potassium did alter the prevalence of HAGMA, but not the severity. [HCO3-] decreased between CKD stages 1 and 5 by 5.1 mEq/l. The [Cl-] increased by 2.6 mEq/l between CKD stages 1 and 5. Conclusions The elevation of the AG in patients with steady state CKD is limited and less pronounced than the decrease in [HCO3-]. Normal AG metabolic acidosis seems to be more important in CKD than HAGMA. The CKD stage and the magnitude of the AG should be taken into account when evaluating a patient with HAGMA. This study suggests that an AG >15 mEq/l is rarely due to renal failure alone.
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Affiliation(s)
- Hendrik W Zijlstra
- Department of Intensive Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Coen A Stegeman
- Department of Nephrology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Aydın SŞ, Aksakal E. Relationship Between Albumin-Corrected Anion Gap and Mortality in Hospitalized Heart Failure Patients. Cureus 2023; 15:e45967. [PMID: 37900402 PMCID: PMC10600590 DOI: 10.7759/cureus.45967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2023] [Indexed: 10/31/2023] Open
Abstract
BACKGROUND Heart failure (HF) is a disease with high morbidity and mortality. Despite the efforts to reduce mortality rates through medical progress, it is necessary to develop markers to identify critically ill patients. In our study, we aimed to investigate the relationship between albumin-corrected anion gap (ACAG) and mortality in hospitalized patients with HF. METHODOLOGY We performed a retrospective study that included patients with HF hospitalized in the Erzurum City Hospital between 2015 and 2022. The basal clinical, hematological, and biochemical findings of the patients were obtained from the electronic medical records. ACAG was calculated. The date and causes of death of the patients were searched and recorded through the Republic of Türkiye Ministry of Health Death Notification System (ÖBYS) and Central Population Administration System (MERNIS). Thus, the relationship between ACAG and mortality in hospitalized patients with HF was evaluated. RESULTS A total of 205 patients hospitalized for HF were included in the study. The mean age of all people in this study was 71.8 ± 10.7 years. A total of 104 (50.7%) of the patients included in the study were women. The mean left ventricular ejection fraction was 47.2 ± 13.6%. The mean follow-up period of the entire population was 76.5 ± 18.9 months. The mortality rate was 11.7% (24 patients). Serum anion gap (SAG) and ACAG were significantly higher in the group with death outcomes (p = 0.043 and p = 0.012, respectively). Cox regression analysis showed that ACAG was an independent predictor of HF mortality (p = 0.003). ACAG area under the curve was 0.773 (95% CI 0.634 - 0.914), the cut-off was 13, sensitivity was 75%, and specificity was 75.9% (p = 0.002). CONCLUSION Statistical analysis showed a meaningful connection between an increase in ACAG and mortality in hospitalized patients with HF. Consequently, ACAG can be used as an independent predictor of mortality in patients with HF.
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Li P, Shi L, Yan X, Wang L, Wan D, Zhang Z, He M. Albumin Corrected Anion Gap and the Risk of in-Hospital Mortality in Patients with Acute Pancreatitis: A Retrospective Cohort Study. J Inflamm Res 2023; 16:2415-2422. [PMID: 37313307 PMCID: PMC10258038 DOI: 10.2147/jir.s412860] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/02/2023] [Indexed: 06/15/2023] Open
Abstract
Purpose To explore the prognostic value of albumin corrected anion gap (ACAG) within 24 hours of admission to the intensive care unit (ICU) for acute pancreatitis (AP). Patients and Methods This was a retrospective cohort study. Adult AP patients admitted to ICU from June 2016 to December 2019 were included in the study, who were divided into three groups according to initial serum ACAG within 24 hours upon ICU admission: ACAG ≤ 14.87 mmol/L, 14.87 < ACAG ≤ 19.03 mmol/L, and ACAG > 19.03 mmol/L. The primary study outcome indicator was in-hospital mortality. Age, sex, Glasgow Coma Scale score, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score were matched through propensity score matching (PSM) method to balance the baseline between the survivors and non-survivors. Multivariate Cox regression was used to determine the relationship between ACAG and in-hospital mortality. Results A total of 344 patients (of them 81 non-survivors) were analyzed in this study. Patients with higher ACAG intended to present significantly higher in-hospital mortality, APACHE II score, creatine, lower albumin, and bicarbonate. Multivariate Cox regression analysis after matching demonstrated that white blood cell count, platelet count, and higher ACAG were independently associated with higher in-hospital mortality (ACAG ≤ 14.87 as a reference, 14.87 < ACAG ≤ 19.03 mmol/L with HR of 2.34 and 95% CI of 1.15-4.76, ACAG >19.03 with HR of 3.46 and 95% CI of 1.75-6.84). Conclusion Higher ACAG was independently associated with higher in-hospital mortality in patients with AP after matching the baseline between the survivors and non-survivors.
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Affiliation(s)
- Ping Li
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Lvyuan Shi
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Xin Yan
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Lietao Wang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Dingyuan Wan
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Zhongwei Zhang
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
| | - Min He
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, People’s Republic of China
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Allata Y, Chouhani BA, El Bardai G, Kabbali N, Sqalli Houssaini T. The Role of Nephrologists in the Management of Methanol Poisoning. Cureus 2023; 15:e37471. [PMID: 37187623 PMCID: PMC10176525 DOI: 10.7759/cureus.37471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2023] [Indexed: 05/17/2023] Open
Abstract
Acute methanol poisoning is a rare but serious condition that can lead to significant morbidity and mortality. Toxic metabolites produced by methanol, primarily formaldehyde, can cause high anion gap metabolic acidosis, with the severity of clinical presentation ranging from mild symptoms to multi-organ failure. Nine people died and four patients needed treatment at our university hospital following a collective intoxication caused by the consumption of homemade alcoholic beverages in the central region of Morocco. The four patients presented to the emergency department with varying clinical symptoms, such as decreased visual acuity, severe agitation, and dyspnea. The laboratory tests confirmed high anion gap metabolic acidosis and a subsequent toxicology screen revealed that they had consumed methanol-tainted alcohol. The treatment regimen involved inhibiting the formation of toxic metabolites using an antidote (ethanol or fomepizole), correcting metabolic acidosis, enhancing the elimination of toxic metabolites through prolonged hemodialysis, and administering adjunctive therapies. While two patients had favorable outcomes, the other two died from multi-organ failure. These findings highlight the importance of prompt diagnosis and treatment in cases of methanol poisoning.
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Affiliation(s)
- Yassine Allata
- Nephrology, Hemodialysis and Transplantation, Hassan II University Hospital, Fez, MAR
| | - Basmat Amal Chouhani
- Nephrology, Hemodialysis and Transplantation, Hassan II University Hospital, Fez, MAR
- Epidemiology and Health Sciences Research Laboratory, Faculty of Medicine, Pharmacy and Dentistry, Sidi Mohamed Ben Abdellah University, Fez, MAR
| | - Ghita El Bardai
- Nephrology, Hemodialysis and Transplantation, Hassan II University Hospital, Fez, MAR
- Epidemiology and Health Sciences Research Laboratory, Faculty of Medicine, Pharmacy and Dentistry, Sidi Mohamed Ben Abdellah University, Fez, MAR
| | - Nadia Kabbali
- Nephrology, Hemodialysis and Transplantation, Hassan II University Hospital, Fez, MAR
- Epidemiology and Health Sciences Research Laboratory, Faculty of Medicine, Pharmacy and Dentistry, Sidi Mohamed Ben Abdellah University, Fez, MAR
| | - Tarik Sqalli Houssaini
- Nephrology, Hemodialysis and Transplantation, Hassan II University Hospital, Fez, MAR
- Epidemiology and Health Sciences Research Laboratory, Faculty of Medicine, Pharmacy and Dentistry, Sidi Mohamed Ben Abdellah University, Fez, MAR
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Al-Reshed F, Sindhu S, Al Madhoun A, Bahman F, AlSaeed H, Akhter N, Malik MZ, Alzaid F, Al-Mulla F, Ahmad R. Low carbohydrate intake correlates with trends of insulin resistance and metabolic acidosis in healthy lean individuals. Front Public Health 2023; 11:1115333. [PMID: 37006572 PMCID: PMC10061153 DOI: 10.3389/fpubh.2023.1115333] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 02/16/2023] [Indexed: 03/18/2023] Open
Abstract
Introduction Both obesity and a poor diet are considered major risk factors for triggering insulin resistance syndrome (IRS) and the development of type 2 diabetes mellitus (T2DM). Owing to the impact of low-carbohydrate diets, such as the keto diet and the Atkins diet, on weight loss in individuals with obesity, these diets have become an effective strategy for a healthy lifestyle. However, the impact of the ketogenic diet on IRS in healthy individuals of a normal weight has been less well researched. This study presents a cross-sectional observational study that aimed to investigate the effect of low carbohydrate intake in healthy individuals of a normal weight with regard to glucose homeostasis, inflammatory, and metabolic parameters. Methods The study included 120 participants who were healthy, had a normal weight (BMI 25 kg/m2), and had no history of a major medical condition. Self-reported dietary intake and objective physical activity measured by accelerometry were tracked for 7 days. The participants were divided into three groups according to their dietary intake of carbohydrates: the low-carbohydrate (LC) group (those consuming <45% of their daily energy intake from carbohydrates), the recommended range of carbohydrate (RC) group (those consuming 45-65% of their daily energy intake from carbohydrates), and the high-carbohydrate (HC) group (those consuming more than 65% of their daily energy intake from carbohydrates). Blood samples were collected for the analysis of metabolic markers. HOMA of insulin resistance (HOMA-IR) and HOMA of β-cell function (HOMA-β), as well as C-peptide levels, were used for the evaluation of glucose homeostasis. Results Low carbohydrate intake (<45% of total energy) was found to significantly correlate with dysregulated glucose homeostasis as measured by elevations in HOMA-IR, HOMA-β% assessment, and C-peptide levels. Low carbohydrate intake was also found to be coupled with lower serum bicarbonate and serum albumin levels, with an increased anion gap indicating metabolic acidosis. The elevation in C-peptide under low carbohydrate intake was found to be positively correlated with the secretion of IRS-related inflammatory markers, including FGF2, IP-10, IL-6, IL-17A, and MDC, but negatively correlated with IL-3. Discussion Overall, the findings of the study showed that, for the first time, low-carbohydrate intake in healthy individuals of a normal weight might lead to dysfunctional glucose homeostasis, increased metabolic acidosis, and the possibility of triggering inflammation by C-peptide elevation in plasma.
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Affiliation(s)
- Fatema Al-Reshed
- Immunology and Microbiology Department, Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Sardar Sindhu
- Animal and Imaging Core Facility, Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Ashraf Al Madhoun
- Animal and Imaging Core Facility, Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Fatemah Bahman
- Immunology and Microbiology Department, Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Halemah AlSaeed
- Immunology and Microbiology Department, Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Nadeem Akhter
- Immunology and Microbiology Department, Dasman Diabetes Institute, Kuwait City, Kuwait
| | - Md Zubbair Malik
- Genetics and Bioinformatics, Dasman Diabetes Institute, Dasman, Kuwait
| | - Fawaz Alzaid
- Institute Necker Enfants Malades (INEM), French Institute of Health and Medical Research (INSERM), Immunity and Metabolism of Diabetes (IMMEDIAB), Université de Paris Cité, Paris, France
| | - Fahd Al-Mulla
- Genetics and Bioinformatics, Dasman Diabetes Institute, Dasman, Kuwait
| | - Rasheed Ahmad
- Immunology and Microbiology Department, Dasman Diabetes Institute, Kuwait City, Kuwait
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Cao S, Cao S. Diabetic Ketoalkalosis: A Common Yet Easily Overlooked Alkalemic Variant of Diabetic Ketoacidosis Associated with Mixed Acid-Base Disorders. J Emerg Med 2023; 64:282-288. [PMID: 36849308 DOI: 10.1016/j.jemermed.2022.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/21/2022] [Accepted: 12/13/2022] [Indexed: 03/01/2023]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is commonly complicated by mixed acid-base disorders. Therefore, patients with DKA can present with pH > 7.3 or bicarbonate > 18 mmol/L, which falls outside the values defined by the current traditional DKA criteria (pH ≤ 7.3 or bicarbonate ≤ 18 mmol/L). OBJECTIVE We aimed to study the spectrum of acid-base clinical presentations of DKA and the prevalence of diabetic ketoalkalosis. METHODS This study included all adult patients at a single institution admitted in 2018-2020 with diabetes, positive beta-hydroxybutyric acid, and increased anion gap ≥ 16 mmol/L. Mixed acid-base disorders were analyzed to determine the spectrum of presentation of DKA. RESULTS There were 259 encounters identified under the inclusion criteria. Acid-base analysis was available in 227 cases. Traditional acidemic DKA (pH ≤ 7.3), DKA with mild acidemia (7.3 < pH ≤ 7.4), and diabetic ketoalkalosis (pH > 7.4) account for 48.9% (111/227), 27.8% (63/227), and 23.3% (53/227) of cases, respectively. Of the 53 cases with diabetic ketoalkalosis, increased anion gap metabolic acidosis was present in all, and concurrent metabolic alkalosis, respiratory alkalosis, and respiratory acidosis were present in 47.2% (25/53), 81.1% (43/53), and 11.3% (6/53) encounters, respectively. In addition, 34.0% (18/53) of those with diabetic ketoalkalosis were found to have severe ketoacidosis, defined by beta-hydroxybutyric acid ≥ 3 mmol/L. CONCLUSIONS DKA can present as traditional acidemic DKA, DKA with mild acidemia, and diabetic ketoalkalosis. Diabetic ketoalkalosis is a common yet easily overlooked alkalemic variant of DKA associated with mixed acid-base disorders, and a high proportion of these presentations have severe ketoacidosis and thus, require the same treatment as traditional DKA.
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Affiliation(s)
- Siyuan Cao
- Department of Internal Medicine, New York University Grossman School of Medicine, New York, New York
| | - Shanjin Cao
- Division of Hospital Medicine, Department of Internal Medicine, St. Anne's Hospital, Fall River, Massachusetts; Prima CARE, P.C., Fall River, Massachusetts
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Muacevic A, Adler JR. 5-Oxoprolinemia in a Patient With Severe Hypothyroidism and Chronic Acetaminophen Use. Cureus 2023; 15:e34628. [PMID: 36751574 PMCID: PMC9900182 DOI: 10.7759/cureus.34628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2023] [Indexed: 02/05/2023] Open
Abstract
5-oxoprolinemia is caused by a defect in the gamma-glutamyl pathway which can present with severe anion gap metabolic acidosis not caused by ketoacidosis, lactic acidosis, methanol/ethylene glycol ingestion, renal failure, ethanol, iron/isoniazid or salicylate ingestion. This case will describe a 59-year-old female presenting with elevated anion gap metabolic acidosis with no discernible classical cause, chronic acetaminophen use, malnourishment, and severe hypothyroidism with 5-oxoprolinemia after extensive investigation of other causes. Treatment involved correcting the acidosis with bicarbonate, IV fluid administration, oral levothyroxine and avoiding further acetaminophen use. The patient's acidosis resolved soon after and she was counseled on the avoidance of acetaminophen in the future. This case highlights the importance of pharmacologic vigilance with everyday over-the-counter medicines such as acetaminophen and metabolic states such as hypothyroidism which can lead to tumultuous cases of metabolic acidosis. This is the first case in which we know that 5-oxoprolinemia has presented with concomitant severe hypothyroidism. Due to this patient's course, it may have been the preceding factor for the development of her oxoprolinemia alongside her acetaminophen consumption.
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Abstract
Acid-base disorders are common in the intensive care unit. By utilizing a systematic approach to their diagnosis, it is easy to identify both simple and mixed disturbances. These disorders are divided into four major categories: metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis. Metabolic acidosis is subdivided into anion gap and non-gap acidosis. Distinguishing between these is helpful in establishing the cause of the acidosis. Anion gap acidosis, caused by the accumulation of organic anions from sepsis, diabetes, alcohol use, and numerous drugs and toxins, is usually present on admission to the intensive care unit. Lactic acidosis from decreased delivery or utilization of oxygen is associated with increased mortality. This is likely secondary to the disease process, as opposed to the degree of acidemia. Treatment of an anion gap acidosis is aimed at the underlying disease or removal of the toxin. The use of therapy to normalize the pH is controversial. Non-gap acidoses result from disorders of renal tubular H + transport, decreased renal ammonia secretion, gastrointestinal and kidney losses of bicarbonate, dilution of serum bicarbonate from excessive intravenous fluid administration, or addition of hydrochloric acid. Metabolic alkalosis is the most common acid-base disorder found in patients who are critically ill, and most often occurs after admission to the intensive care unit. Its etiology is most often secondary to the aggressive therapeutic interventions used to treat shock, acidemia, volume overload, severe coagulopathy, respiratory failure, and AKI. Treatment consists of volume resuscitation and repletion of potassium deficits. Aggressive lowering of the pH is usually not necessary. Respiratory disorders are caused by either decreased or increased minute ventilation. The use of permissive hypercapnia to prevent barotrauma has become the standard of care. The use of bicarbonate to correct the acidemia is not recommended. In patients at the extreme, the use of extracorporeal therapies to remove CO 2 can be considered.
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Affiliation(s)
- Anand Achanti
- Internal Medicine/Nephrology, Medical University of South Carolina, Charleston, South Carolina
| | - Harold M. Szerlip
- Internal Medicine/Nephrology, Medical University of South Carolina, Charleston, South Carolina
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Zhao D, Li Y, Huang J, Zheng Z, Zhang X, Liu Y, Ma H, Ji F, Yun Y, Ji C, Xu Z, Yang X, Shen H, Chen S, Zhang S, Zhang H, Zou C, Ma X. Association of serum anion gap and risk of long-term mortality in patients following coronary artery bypass grafting: A propensity score matching study. J Card Surg 2022; 37:4906-4918. [PMID: 36378900 DOI: 10.1111/jocs.17167] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The present study aimed to explore the relationship between serum anion gap (AG) and long-term mortality in patients undergoing coronary artery bypass grafting (CABG). METHODS Clinical variables were extracted among patients undergoing CABG from Medical Information Mart for Intensive Care III (MIMIC III) database. The primary outcome was 4-year mortality following CABG. An optimal cut-off value of AG was determined by the receiver operating characteristic (ROC) curve. The Kaplan-Meier (K-M) analysis and multivariate Cox hazard analysis were performed to investigate the prognostic value of AG in long-term mortality after CABG. To eliminate the bias between different groups, propensity score matching (PSM) was conducted to validate the findings. RESULTS The optimal cut-off value of AG was 17.00 mmol/L. Then a total of 3162 eligible patients enrolled in this study were divided into a high AG group (≥17.00, n = 1022) and a low AG group (<17.00, n = 2,140). A lower survival rate was identified in the high AG group based on the K-M curve (p < .001). Compared with patients in the low AG group, patients in the high AG group had an increased risk of long-term mortality [1-year mortality: hazard ratio, HR: 2.309, 95% CI (1.672-3.187), p < .001; 2-year mortality: HR: 1.813, 95% CI (1.401-2.346), p < .001; 3- year mortality: HR: 1.667, 95% CI (1.341-2.097), p < .001; 4-year mortality: HR: 1.710, 95% CI (1.401-2.087), p < .001] according to multivariate Cox hazard analysis. And further validation of above results was consistent in the matched cohort after PSM. CONCLUSIONS The AG is an independent predictive factor for long-term all-cause mortality in patients following CABG, where a high AG value is associated with an increased mortality.
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Affiliation(s)
- Diming Zhao
- Department of Cardiovascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Yi Li
- Department of Cardiovascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - JunJie Huang
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Zheng Zheng
- Shandong Provincial Hospital, Jinan, Shandong, China
| | - XiangXi Zhang
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Yilin Liu
- Department of Ophthalmology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Huibo Ma
- Department of Vascular Surgery, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Feng Ji
- Dongying City PPL's Hospital, Dongying, Shandong, China
| | - Yan Yun
- Department of Radiology, Qilu Hospital of Shandong University, Jinan, China
| | - Congshan Ji
- Department of Radiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Zhenqiang Xu
- Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xiaomei Yang
- Department of Anesthesiology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Hechen Shen
- Department of Cardiovascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Shanghao Chen
- Department of Cardiovascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Shijie Zhang
- Department of Cardiovascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Haizhou Zhang
- Department of Cardiovascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Chengwei Zou
- Department of Cardiovascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Xiaochun Ma
- Department of Cardiovascular Surgery, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Cardiovascular Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
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12
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Lambert DC, Kane J, Slaton A, Abramowitz MK. Associations of Metabolic Syndrome and Abdominal Obesity with Anion Gap Metabolic Acidosis among US Adults. Kidney360 2022; 3:1842-1851. [PMID: 36514392 PMCID: PMC9717647 DOI: 10.34067/kid.0002402022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/12/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Obesity is a recently identified risk factor for metabolic acidosis and anion gap elevations in the absence of CKD. Metabolic acidosis is a treatable condition with substantial adverse effects on human health. Additional investigations are needed to characterize at-risk populations and explore potential mechanisms. We hypothesized metabolic syndrome (MetS) and waist circumference (WC) would be closely associated with this pathology. METHODS Adult participants from NHANES 1999-2018 meeting study criteria were compiled as main (n=31,163) and fasting (n=12,860) cohorts. Regression models adjusted for dietary acid, eGFR, and other factors examined associations of WC and MetS features with anion gap metabolic acidosis and its components (serum bicarbonate ≤23 mEq/L and anion gap >95th percentile). RESULTS Greater WC and MetS features were associated with progressively lower bicarbonate, higher anion gap, and greater odds ratios (OR) of metabolic acidosis (MA) and anion gap metabolic acidosis (AGMA). Compared with the reference, participants with the highest WC had ORs for MA and AGMA of 2.26; 95% CI, 1.96 to 2.62 and 2.89; 95% CI, 1.97 to 4.21; those with three and four versus zero MetS features had ORs for AGMA of 2.52; 95% CI, 1.95 to 2.94 and 3.05; 95% CI, 2.16 to 3.82. Associations of body mass index with outcomes were attenuated or absent after adjustment for WC or MetS. Findings were preserved after excluding eGFR <90 ml/min per 1.73 m2 and albuminuria. A lower MA cutoff (<22 mEq/L) raised the estimate of association between MetS and MA (OR for three and four vs zero features: 3.56; 95% CI, 2.53 to 5.02 and 5.44; 95% CI, 3.66 to 8.08). CONCLUSIONS Metabolic diseases are characterized by metabolic acidosis and anion gap elevations. Metabolic dysfunction may predispose patients without CKD to systemic acidosis from endogenous sources. Comprehensive acid-base analyses may be informative in patients with metabolic diseases.
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Affiliation(s)
- Douglas C Lambert
- Department of General Internal Medicine, Northwell Health, Great Neck, New York
- Department of Medicine, Section of Obesity Medicine, Northwell Health, New York
| | - Jamie Kane
- Department of General Internal Medicine, Northwell Health, Great Neck, New York
- Department of Medicine, Section of Obesity Medicine, Northwell Health, New York
| | - Anthony Slaton
- Department of General Internal Medicine, Northwell Health, Great Neck, New York
| | - Matthew K Abramowitz
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
- Department of Medicine, Institute for Aging Research, Albert Einstein College of Medicine, Bronx, New York
- Department of Medicine, Diabetes Research Center, Albert Einstein College of Medicine, Bronx, New York
- Department of Medicine, Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine, Bronx, New York
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13
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Tamargo C, Cervantes CE. Minding the Gap Beyond Kidney Disease: Utility of the Anion Gap in Metabolic Syndrome. Kidney360 2022; 3:1819-1822. [PMID: 36514414 PMCID: PMC9717632 DOI: 10.34067/kid.0005142022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/24/2022] [Indexed: 12/05/2022]
Affiliation(s)
- Christina Tamargo
- Department of Medicine, Osler Medical Residency, Johns Hopkins University, Baltimore, Maryland
| | - C. Elena Cervantes
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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14
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Rajasegaran VP, Tamilarasan P, Kalaimani T. Diabetic ketoacidosis masquerading behind alkalemia an undiagnosed or missed variant of diabetic ketoacidosis. J Pediatr Endocrinol Metab 2022; 35:1316-1318. [PMID: 35844096 DOI: 10.1515/jpem-2022-0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 06/20/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Diabetic ketoacidosis is a common emergency in type 1 diabetes mellitus patients. But rarely, they may present with alkalemia instead of acidosis. Diabetic ketoalkalosis which has been reported in adults can also be present in children with type 1 DM. The usual factors causing alkalemia were not found in our patients. This entity may manifest in both newly diagnosed and treated patients. CASE PRESENTATION The first patient, an 8 year male presented with features of DKA, was diagnosed for the first time as type 1 DM, but was found to have alkalemia. The second patient, a 7 year female was a known case of Type 1 DM on insulin, who presented with dehydration and alkalemia. Both were treated with hydration and insulin and made complete recovery. CONCLUSIONS A normal or alkalotic pH does not essentially eliminate DKA and needs to be evaluated further to identify the underlying acid-base disturbance.
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Affiliation(s)
| | - Preethi Tamilarasan
- Department of Pediatrics, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
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15
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Li J, Tian Y, Wang L, Chen J, Chen X, Huang H, Li Y. Postoperative anion gap associates with short- and long-term mortality after cardiac surgery: A large-scale cohort study. Front Cardiovasc Med 2022; 9:1024484. [PMID: 36312225 PMCID: PMC9596785 DOI: 10.3389/fcvm.2022.1024484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 09/20/2022] [Indexed: 11/20/2022] Open
Abstract
Objective To investigate whether postoperative anion gap (AG) is associated with short- and long-term mortality in patients following cardiac surgery. Materials and methods We conducted a retrospective cohort study of adults who underwent cardiac surgery from the Medical Information Mart for Intensive Care - III database. The generalized additive model (GAM), logistic regression, and Cox regression were performed to assess the correlations between AG levels and in-hospital, 90-day, and 4-year mortality. Linear regression was used to evaluate the associations between AG and length of stay (LOS). Results Totally, 6,410 subjects were enrolled in this study and classified into tertiles based on the initial AG levels. The GAM indicated a positive association between initial AG and in-hospital mortality after adjusting for potential confounders. Multivariate logistic analysis revealed that the risk of in-hospital mortality was higher among patients in tertile 2 (OR 2.05, 95% CI 1.11–3.76, P = 0.021) and tertile 3 (OR 4.51, 95% CI 2.57–7.91, P < 0.001) compared with those in tertile 1. For 90-day and 4-year mortality, multivariate Cox regression found similar associations between AG tertiles and mortality. The LOS in ICU and hospital also increased as AG tertiles increased. The E-value indicated robustness to unmeasured confounders. Conclusion This study found a positive association between postoperative AG levels and short- and long-term mortality among patients after cardiac surgery. This relationship warrants further research.
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Affiliation(s)
- Jiajing Li
- Department of Anesthesiology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Yu Tian
- Department of Emergency and Critical Care Medicine, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China
| | - Lingzhi Wang
- Department of Anesthesiology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Jiayue Chen
- Department of Anesthesiology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Xiaoshu Chen
- Department of Anesthesiology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Huansen Huang
- Department of Anesthesiology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China,Huansen Huang,
| | - Yihao Li
- Department of Anesthesiology, The Second Affiliated Hospital, Guangzhou Medical University, Guangzhou, China,*Correspondence: Yihao Li,
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16
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Sithole N, Lalla U, Davids MR, Chothia MY. The frequency of acid-base disorders on admission to the intensive care and its association with in-hospital outcome, Cape Town, South Africa: a retrospective cohort study. Pan Afr Med J 2022; 42:130. [PMID: 36060846 PMCID: PMC9430888 DOI: 10.11604/pamj.2022.42.130.32570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 05/02/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION acid-base disorders are very common in critically ill patients and contribute significantly to morbidity and mortality. The aim of this study was to identify the types of acid-base disorders at the time of admission to the intensive care unit (ICU) and its associated ICU and in-hospital mortality. METHODS we conducted a retrospective cohort study of all adult patients that were admitted to the ICU and had an arterial blood gas sample at the time of admission from 1st January 2019 to 31 December 2019. Using the traditional approach, acid-base disorders were categorised into six disorders. Variables predicting in-hospital death were identified using logistic regression. RESULTS a total of 375 patients were included. The median age for the entire cohort was 39 (IQR 30-52) years and 48.3% (n=181) were female. Mixed acid-base disorders were the most common at 48.8% (n=183), followed by no disorder at 24.8% (n=93), metabolic acidosis at 9.3% (n=35), metabolic alkalosis at 6.7% (n=25), respiratory acidosis 6.1% (n=23) and respiratory alkalosis at 4.3% (n=16). A total of 94 (25.0%) patients died. There were no differences in ICU (p = 0.35) or in-hospital death (p = 0.32) by acid-base disorder. Male sex (aOR: 5.8, 95% CI 1.55-21.42; p < 0.01), APACHE II score (aOR: 1.17, 95% CI 1.06-1.30; p < 0.01) and the corrected anion gap (aOR: 1.14, 95% CI 1.02-1.27; p = 0.02) were identified as predictors of in-hospital death using multivariable logistic regression. CONCLUSION there was no association between acid-base disorders at the time of ICU admission and ICU or in-hospital death. Therefore, in our setting, acid-base disorders at the time of ICU admission should not be used to predict the outcome of patients requiring intensive care.
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Affiliation(s)
- Nokwanda Sithole
- Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Usha Lalla
- Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Mogamat Razeen Davids
- Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Mogamat-Yazied Chothia
- Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa,,Corresponding author: Mogamat-Yazied Chothia, Division of Nephrology, Department of Medicine, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
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17
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Gifford JL, Seiden-Long I. Filling in the GAPS: validation of anion gap (AGAP) measurement uncertainty estimates for use in clinical decision making. Clin Chem Lab Med 2022; 60:851-858. [PMID: 35442590 DOI: 10.1515/cclm-2021-1279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/14/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES We compare measurement uncertainty (MU) calculations to real patient result variation observed by physicians using as our model anion gap (AGAP) sequentially measured on two different instrument types. An approach for discretely quantifying the pre-analytical contributions and validating AGAP MU estimates for interpretation of patient results is proposed. METHODS AGAP was calculated from sodium, chloride, and bicarbonate reported from chemistry or blood gas analyzers which employ different methodologies and specimen types. AGAP MU was calculated using a top-down approach both assuming no correlation between measurands and alternatively, including consideration of measurand correlation. MU-derived reference change values (RCV) were calculated between chemistry and blood gas analyzers results. Observational paired AGAP data (n=39,626 subjects) was obtained from retrospectively analyzed specimens from five urban tertiary care hospitals in Calgary, Alberta, Canada. RESULTS The MU derived AGAP RCV for paired specimen data by the two platforms was 5.2-6.1 mmol/L assuming no correlation and 2.6-3.1 mmol/L assuming correlation. From the paired chemistry and blood gas data, total observed variation on a reported AGAP has a 95% confidence interval of ±6.0 mmol/L. When the MU-derived RCV assuming correlation is directly compared against the observed distribution of patient results, we obtained a pre-analytical variation contribution of 2.9-3.5 mmol/L to the AGAP observed variation. In contrast, assuming no correlation leads to a negligible pre-analytical contribution (<1.0 mmol/L). CONCLUSIONS MU estimates assuming no correlation are more representative of the total variation seen in real patient data. We present a pragmatic approach for validating an MU calculation to inform clinical decisions and determine the pre-analytical contribution to MU in this system.
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Affiliation(s)
- Jessica L Gifford
- Alberta Precision Laboratories and Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Canada
| | - Isolde Seiden-Long
- Alberta Precision Laboratories and Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Canada
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18
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Roberts DM, Hoffman RS, Brent J, Lavergne V, Hovda KE, Porter WH, McMartin KE, Ghannoum M. The serum glycolate concentration: its prognostic value and its correlation to surrogate markers in ethylene glycol exposures. Clin Toxicol (Phila) 2022; 60:798-807. [PMID: 35323087 DOI: 10.1080/15563650.2022.2049811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
CONTEXT Ethylene glycol poisoning manifests as metabolic acidemia, acute kidney injury and death. The diagnosis and treatment depend on history and biochemical tests. Glycolate is a key toxic metabolite that impacts prognosis, but assay results are not widely available in a clinically useful timeframe. We quantitated the impact of serum glycolate concentration for prognostication and evaluated whether more readily available biochemical tests are acceptable surrogates for the glycolate concentration. OBJECTIVES The objectives of this study are to 1) assess the prognostic value of the initial glycolate concentration on the occurrence of AKI or mortality in patients with ethylene glycol exposure (prognostic study); 2) identify surrogate markers that correlate best with glycolate concentrations (surrogate study). METHODS A systematic review of the literature was performed using Medline/PubMed, EMBASE, Cochrane library, conference proceedings and reference lists. Human studies reporting measured glycolate concentrations were eligible. Glycolate concentrations were related to categorical clinical outcomes (acute kidney injury, mortality), and correlated with continuous surrogate biochemical measurements (anion gap, base excess, bicarbonate concentration and pH). Receiver operating characteristic curves were constructed to calculate the positive predictive values and the negative predictive values of the threshold glycolate concentrations that predict acute kidney injury and mortality. Further, glycolate concentrations corresponding to 100% negative predictive value for mortality and 95% negative predictive value for acute kidney injury were determined. RESULTS Of 1,531 articles identified, 655 were potentially eligible and 32 were included, reflecting 137 cases from 133 patients for the prognostic study and 154 cases from 150 patients for the surrogate study. The median glycolate concentration was 11.2 mmol/L (85.1 mg/dL, range 0-38.0 mmol/L, 0-288.8 mg/dL), 93% of patients were treated with antidotes, 80% received extracorporeal treatments, 49% developed acute kidney injury and 13% died. The glycolate concentration best predicting acute kidney injury was 12.9 mmol/L (98.0 mg/dL, sensitivity 78.5%, specificity 88.1%, positive predictive value 86.4%, negative predictive value 80.9%). The glycolate concentration threshold for a 95% negative predictive value for acute kidney injury was 6.6 mmol/L (50.2 mg/dL, sensitivity 96.9%, specificity 62.7%). The glycolate concentration best predicting mortality was 19.6 mmol/L (149.0 mg/dL, sensitivity 61.1%, specificity 81.4%, positive predictive value 33.3%, negative predictive value 93.2%). The glycolate concentration threshold for a 100% negative predictive value for mortality was 8.3 mmol/L (63.1 mg/dL, sensitivity 100.0%, specificity 35.6%). The glycolate concentration correlated best with the anion gap (R2 = 0.73), followed by bicarbonate (R2 = 0.57), pH (R2 = 0.50) and then base excess (R2 = 0.25), while there was no correlation between the glycolate and ethylene glycol concentration (R2 = 0.00). These data can assist clinicians in planning treatments such as extracorporeal treatments and prognostication. Potentially, they may also provide some reassurance regarding when extracorporeal treatments can be delayed while awaiting the results of further testing in patients in whom ethylene glycol poisoning is suspected but not yet confirmed. CONCLUSIONS This systematic review demonstrates that the glycolate concentration predicts mortality (unlikely if <8 mmol/L [61 mg/dL]). The anion gap is a reasonable surrogate measurement for glycolate concentration in the context of ethylene glycol poisoning. The findings are mainly based on published retrospective data which have various limitations. Further prospective validation studies are of interest.
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Affiliation(s)
- Darren M Roberts
- Department of Clinical Pharmacology and Toxicology, St Vincent's Hospital, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia.,Drug Health Clinical Services, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, NY, USA
| | - Jeffrey Brent
- Departments of Medicine and Emergency Medicine, University of Colorado, School of Medicine and Colorado School of Public Health, Aurora, CO, USA
| | - Valéry Lavergne
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, QC, Canada
| | - Knut Erik Hovda
- The Norwegian CBRNE Centre of Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - William H Porter
- Department of Pathology and Laboratory Medicine, University of Kentucky Medical Center Lexington, KY, USA
| | | | - Marc Ghannoum
- Research Center, CIUSSS du Nord-de-l'île-de-Montréal, University of Montreal, Montreal, QC, Canada
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19
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Kuusela E, Järvisalo MJ, Hellman T, Uusalo P. Mortality and associated risk factors in patients with severe methanol or ethylene glycol poisoning treated with dialysis: a retrospective cohort study. J Int Med Res 2022; 50:3000605221081427. [PMID: 35209742 PMCID: PMC8891871 DOI: 10.1177/03000605221081427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To compare the initial clinical course and data on 90-day mortality in adults with methanol (MET) or ethylene glycol (EG) poisoning treated with dialysis. Methods Data on patient demographics and clinical parameters at intensive care unit (ICU) admission and for the first 24 hours after dialysis initiation were collected, and 90-day outcome data were collected for patients with MET (n = 15) or EG (n = 13) poisoning treated with dialysis in this retrospective cohort study. Results In univariate analysis, patients with EG poisoning were older and they had lower hourly urine output during the first 24 hours after the initiation of dialysis. Six (46%) patients with MET poisoning and three (20%) patients with EG poisoning died within 90 days of ICU admission. A larger anion gap and lower pH, bicarbonate levels, base excess, and Glasgow Coma Scale scores on admission, as well as the need for mechanical ventilation, were associated with 90-day mortality. Conclusions Metabolic acidosis, a large anion gap, and an altered mental status on admission appear to be associated with mortality in MET or EG poisoning, and EG poisoning may be linked to lower urine output.
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Affiliation(s)
- Emma Kuusela
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Turku, Finland
| | - Mikko J Järvisalo
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Turku, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Tapio Hellman
- Kidney Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Panu Uusalo
- Department of Anaesthesiology and Intensive Care, Turku University Hospital and University of Turku, Turku, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital and University of Turku, Turku, Finland
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20
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Jazdarehee A, Huget-Penner S, Pawlowska M. Pseudo-pheochromocytoma due to obstructive sleep apnea: a case report. Endocrinol Diabetes Metab Case Rep 2022; 2022:21-0100. [PMID: 35212265 PMCID: PMC8897593 DOI: 10.1530/edm-21-0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/02/2022] [Indexed: 11/11/2022] Open
Abstract
SUMMARY Obstructive sleep apnea (OSA) is a condition of intermittent nocturnal upper airway obstruction. OSA increases sympathetic drive which may result in clinical and biochemical features suggestive of pheochromocytoma. We present the case of a 65-year-old male with a 2.9-cm left adrenal incidentaloma on CT, hypertension, symptoms of headache, anxiety and diaphoresis, and persistently elevated 24-h urine norepinephrine (initially 818 nmol/day (89-470)) and normetanephrine (initially 11.2 µmol/day (0.6-2.7)). He was started on prazosin and underwent left adrenalectomy. Pathology revealed an adrenal corticoadenoma with no evidence of pheochromocytoma. Over the next 2 years, urine norepinephrine and normetanephrine remained significantly elevated with no MIBG avid disease. Years later, he was diagnosed with severe OSA and treated with continuous positive airway pressure. Urine testing done once OSA was well controlled revealed complete normalization of urine norepinephrine and normetanephrine with substantial symptom improvement. It was concluded that the patient never had a pheochromocytoma but rather an adrenal adenoma with biochemistry and symptoms suggestive of pheochromocytoma due to untreated severe OSA. Pseudo-pheochromocytoma is a rare presentation of OSA and should be considered on the differential of elevated urine catecholamines and metanephrines in the right clinical setting. LEARNING POINTS Obstructive sleep apnea (OSA) is a common condition among adults. OSA may rarely present as pseudo-pheochromocytoma with symptoms of pallor, palpitations, perspiration, headache, or anxiety. OSA should be considered on the differential of elevated urine catecholamines and metanephrines, especially in patients with negative metaiodobenzylguanidine (MIBG) scan results.
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Key Words
- adolescent/young adult
- adult
- geriatric
- neonatal
- paediatric
- pregnant adult
- female
- male
- american indian or alaska native
- asian - bangladeshi
- asian - chinese
- asian - filipino
- asian - indian
- asian - japanese
- asian - korean
- asian - pakistani
- asian - vietnamese
- asian - other
- black - african
- black - caribbean
- black - other
- hispanic or latino - central american or south american
- hispanic or latino - cuban
- hispanic or latino - dominican
- hispanic or latino - mexican, mexican american, chicano
- hispanic or latino - puerto rican
- hispanic or latino - other
- native hawaiian/other pacific islander
- white
- other
- afghanistan
- aland islands
- albania
- algeria
- american samoa
- andorra
- angola
- anguilla
- antarctica
- antigua and barbuda
- argentina
- armenia
- aruba
- australia
- austria
- azerbaijan
- bahamas
- bahrain
- bangladesh
- barbados
- belarus
- belgium
- belize
- benin
- bermuda
- bhutan
- bolivia
- bosnia and herzegovina
- botswana
- bouvet island
- brazil
- british indian ocean territory
- brunei darussalam
- bulgaria
- burkina faso
- burundi
- cambodia
- cameroon
- canada
- cape verde
- cayman islands
- central african republic
- chad
- chile
- china
- christmas island
- cocos (keeling) islands
- colombia
- comoros
- congo
- congo, the democratic republic of the
- cook islands
- costa rica
- côte d'ivoire
- croatia
- cuba
- cyprus
- czech republic
- denmark
- djibouti
- dominica
- dominican republic
- ecuador
- egypt
- el salvador
- equatorial guinea
- eritrea
- estonia
- ethiopia
- falkland islands (malvinas)
- faroe islands
- fiji
- finland
- france
- french guiana
- french polynesia
- french southern territories
- gabon
- gambia
- georgia
- germany
- ghana
- gibraltar
- greece
- greenland
- grenada
- guadeloupe
- guam
- guatemala
- guernsey
- guinea
- guinea-bissau
- guyana
- haiti
- heard island and mcdonald islands
- holy see (vatican city state)
- honduras
- hong kong
- hungary
- iceland
- india
- indonesia
- iran, islamic republic of
- iraq
- ireland
- isle of man
- israel
- italy
- jamaica
- japan
- jersey
- jordan
- kazakhstan
- kenya
- kiribati
- korea, democratic people's republic of
- korea, republic of
- kuwait
- kyrgyzstan
- lao people's democratic republic
- latvia
- lebanon
- lesotho
- liberia
- libyan arab jamahiriya
- liechtenstein
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- macedonia, the former yugoslav republic of
- madagascar
- malawi
- malaysia
- maldives
- mali
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- martinique
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- new caledonia
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- nicaragua
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- niue
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- norway
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- panama
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- poland
- portugal
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- samoa
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- saudi arabia
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- solomon islands
- somalia
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- south georgia and the south sandwich islands
- spain
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- swaziland
- sweden
- switzerland
- syrian arab republic
- taiwan, province of china
- tajikistan
- tanzania, united republic of
- thailand
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- togo
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- tonga
- trinidad and tobago
- tunisia
- turkey
- turkmenistan
- turks and caicos islands
- tuvalu
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- united kingdom
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- uruguay
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- venezuela
- viet nam
- virgin islands, british
- virgin islands, u.s.
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- western sahara
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- adipose tissue
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- duodenum
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- angiotensin
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- atrial natriuretic hormone
- avp
- beta-endorphin
- big igf2
- brain natriuretic peptide
- calcitonin
- calcitriol
- cck
- corticosterone
- corticotrophin
- cortisol
- cortisone
- crh
- dehydroepiandrostenedione
- deoxycorticosterone
- deoxycortisol
- dhea
- dihydrotestosterone
- dopamine
- endothelin
- enkephalin
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- epo
- fgf23
- fsh
- gastrin
- gh
- ghrelin
- ghrh
- gip
- glp1
- glp2
- glucagon
- glucocorticoids
- gnrh
- gonadotropins
- hcg
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- histamine
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- hydroxypregnenolone
- igf1
- igf2
- inhibin
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- mineralocorticoids
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- neuropeptide y
- noradrenaline
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- osteocalcin
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- pth
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- thymosin
- thymulin
- thyroxine (t4)
- trh
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- tsh
- vip
- 17-alpha hydroxylase/17,20 lyase deficiency
- 17-beta-hydroxysteroid dehydrogenase type 3 deficiency
- 3-m syndrome
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- abscess
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- adenocarcinoma
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- adrenal insufficiency
- adrenal salt-wasting crisis
- adrenarche
- adrenocortical adenoma
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- adrenoleukodystrophy
- aip gene variant
- amenorrhoea (primary)
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- amyloid goitre
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- anaemia
- aneuploidy
- androgen insensitivity syndrome
- anti-phospholipid antibody syndrome
- asthma
- autoimmune disorders
- autoimmune polyendocrine syndrome 1
- autoimmune polyendocrine syndrome 2
- autoimmune polyglandular syndrome
- autoimmune hypophysitis
- autosomal dominant hypophosphataemic rickets
- autosomal dominant osteopetrosis
- bardet-biedl syndrome
- bartter syndrome
- bilateral adrenal hyperplasia
- biliary calculi
- breast cancer
- brenner tumour
- brown tumour
- burkitt's lymphoma
- casr gene mutation
- catecholamine secreting carotid body paraganglionoma
- cancer-prone syndrome
- carcinoid syndrome
- carcinoid tumour
- carney complex
- carotid body paraganglioma
- c-cell hyperplasia
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- chronic fatigue syndrome
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- congenital adrenal hyperplasia
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- congenital hyperinsulinism
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- diabetes - lipoatrophic
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- diabetes insipidus - dipsogenic
- diabetes insipidus - gestational
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- diabetes insipidus - neurogenic/central
- diabetes mellitus type 1
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- diabetic foot syndrome
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- diverticular disease
- donohue syndrome
- down syndrome
- eating disorders
- ectopic acth syndrome
- ectopic cushing's syndrome
- ectopic parathyroid adenoma
- empty sella syndrome
- endometrial cancer
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- eosinophilic myositis
- euthyroid sick syndrome
- familial hypocalciuric hypercalcaemia
- familial dysalbuminaemic hyperthyroxinaemia
- familial euthyroid hyperthyroxinaemia
- fat necrosis
- female athlete triad syndrome
- fetal demise
- fetal macrosomia
- follicular thyroid cancer
- fractures
- frasier syndrome
- friedreich's ataxia
- functional parathyroid cyst
- galactorrhoea
- gastrinoma
- gastritis
- gastrointestinal perforation
- gastrointestinal stromal tumour
- gck mutation
- gender identity disorder
- gestational diabetes mellitus
- giant ovarian cysts
- gigantism
- gitelman syndrome
- glucagonoma
- glucocorticoid remediable aldosteronism
- glycogen storage disease
- goitre
- goitre (multinodular)
- gonadal dysgenesis
- gonadoblastoma
- gonadotrophic adenoma
- gorham's disease
- granuloma
- granulosa cell tumour
- graves' disease
- graves' ophthalmopathy
- growth hormone deficiency (adult)
- growth hormone deficiency (childhood onset)
- gynaecomastia
- hamman's syndrome
- haemorrhage
- hajdu-cheney syndrome
- hashimoto's disease
- hemihypertrophy
- hepatitis c
- hereditary multiple osteochondroma
- hirsutism
- histiocytosis
- huntington's disease
- hürthle cell adenoma
- hyperaldosteronism
- hyperandrogenism
- hypercalcaemia
- hypercalcaemic crisis
- hyperglucogonaemia
- hyperglycaemia
- hypergonadotropic hypogonadism
- hypergonadotropism
- hyperinsulinaemia
- hyperinsulinaemic hypoglycaemia
- hyperkalaemia
- hyperlipidaemia
- hypernatraemia
- hyperosmolar hyperglycaemic state
- hyperparathyroidism (primary)
- hyperparathyroidism (secondary)
- hyperparathyroidism (tertiary)
- hyperpituitarism
- hyperprolactinaemia
- hypersexuality
- hypertension
- hyperthyroidism
- hypoaldosteronism
- hypocalcaemia
- hypoestrogenism
- hypoglycaemia
- hypoglycaemic coma
- hypogonadism
- hypogonadotrophic hypogonadism
- hypoinsulinaemia
- hypokalaemia
- hyponatraemia
- hypoparathyroidism
- hypophosphataemia
- hypophosphatasia
- hypophysitis
- hypopituitarism
- hypothyroidism
- iatrogenic disorder
- idiopathic bilateral adrenal hyperplasia
- idiopathic pituitary hyperplasia
- igg4-related systemic disease
- inappropriate tsh secretion
- incidentaloma
- infertility
- insulin autoimmune syndrome
- insulin resistance
- insulinoma
- intracranial vasospasm
- intrauterine growth retardation
- iodine allergy
- ischaemic heart disease
- kallmann syndrome
- ketoacidosis
- klinefelter syndrome
- kwashiorkor
- kwashiorkor (marasmic)
- leg ulcer
- laron syndrome
- latent autoimmune diabetes of adults (lada)
- laurence-moon syndrome
- left ventricular hypertrophy
- leukocytoclastic vasculitis
- leydig cell tumour
- lipodystrophy
- lipomatosis
- liver failure
- lung metastases
- luteoma
- lymphadenopathy
- macronodular adrenal hyperplasia
- macronodular hyperplasia
- macroprolactinoma
- marasmus
- maturity onset diabetes of young (mody)
- mccune-albright syndrome
- mckittrick-wheelock syndrome
- medullary thyroid cancer
- meigs syndrome
- membranous nephropathy
- men1
- men2a
- men2b
- men4
- menarche
- meningitis
- menopause
- metabolic acidosis
- metabolic syndrome
- metastatic carcinoma
- metastatic chromaffin cell tumour
- metastatic gastrinoma
- metastatic melanoma
- metastatic tumour
- microadenoma
- microprolactinoma
- motor neurone disease
- myasthenia gravis
- myelolipoma
- myocardial infarction
- myositis
- myotonic dystrophy type 1
- myotonic dystrophy type 2
- myxoedema
- myxoedema coma
- nelson's syndrome
- neonatal diabetes
- nephrolithiasis
- neuroblastoma
- neuroendocrine tumour
- neurofibromatosis
- nodular hyperplasia
- non-functioning pituitary adenoma
- non-hodgkin lymphoma
- non-islet-cell tumour hypoglycaemia
- noonan syndrome
- oculocerebrorenal syndrome
- osteogenesis imperfecta
- osteomalacia
- osteomyelitis
- osteoporosis
- osteoporosis (pregnancy/lactation-associated)
- osteosclerosis
- ovarian cancer
- ovarian dysgenesis
- ovarian hyperstimulation syndrome
- ovarian tumour
- paget's disease
- paget's disease (juvenille)
- pancreatic neuroendocrine tumour
- pancreatitis
- panhypopituitarism
- papillary thyroid cancer
- paraganglioma
- paranasal sinus lesion
- paraneoplastic syndromes
- parasitic thyroid nodules
- parathyroid adenoma
- parathyroid adenoma (ectopic)
- parathyroid carcinoma
- parathyroid cyst
- parathroid hyperplasia
- pcos
- periodontal disease
- phaeochromocytoma
- phaeochromocytoma crisis
- pickardt syndrome
- pituitary abscess
- pituitary adenoma
- pituitary apoplexy
- pituitary carcinoma
- pituitary cyst
- pituitary haemorrhage
- pituitary hyperplasia
- pituitary hypoplasia
- pituitary tumour (malignant)
- plurihormonal pituitary adenoma
- poems syndrome
- polycythaemia
- porphyria
- pneumonia
- posterior reversible encephalopathy syndrome
- post-prandial hypoglycaemia
- prader-willi syndrome
- prediabetes
- pre-eclampsia
- pregnancy
- premature ovarian failure
- premenstrual dysphoric disorder
- premenstrual syndrome
- primary hypertrophic osteoarthropathy
- prolactinoma
- prostate cancer
- pseudohypoaldosteronism type 1
- pseudohypoaldosteronism type 2
- pseudohypoparathyroidism
- psychosocial short stature
- puberty (delayed or absent)
- puberty (precocious)
- pulmonary oedema
- quadrantanopia
- rabson-mendenhall syndrome
- rhabdomyolysis
- rheumatoid arthritis
- rickets
- schwannoma
- sellar reossification
- sertoli cell tumour
- sertoli-leydig cell tumour
- sexual development disorders
- sheehan's syndrome
- short stature
- siadh
- small-cell carcinoma
- small intestine neuroendocrine tumour
- solitary fibrous tumour
- solitary sellar plasmacytoma
- somatostatinoma
- somatotrophic adenoma
- squamous cell thyroid carcinoma
- stiff person syndrome
- struma ovarii
- subcutaneous insulin resistance
- systemic lupus erythematosus
- takotsubo cardiomyopathy
- tarts
- testicular cancer
- thecoma
- thyroid adenoma
- thyroid carcinoma
- thyroid cyst
- thyroid dysgenesis
- thyroid fibromatosis
- thyroid hormone resistance syndrome
- thyroid lymphoma
- thyroid nodule
- thyroid storm
- thyroiditis
- thyrotoxicosis
- thyrotrophic adenoma
- traumatic brain injury
- tuberculosis
- tuberous sclerosis complex
- tumour-induced osteomalacia
- turner syndrome
- unilateral adrenal hyperplasia
- ureterolithiasis
- urolithiasis
- von hippel-lindau disease
- wagr syndrome
- waterhouse-friderichsen syndrome
- williams syndrome
- wolcott-rallison syndrome
- wolfram syndrome
- xanthogranulomatous hypophysitis
- xlaad/ipex
- zollinger-ellison syndrome
- abdominal adiposity
- abdominal distension
- abdominal cramp
- abdominal discomfort
- abdominal guarding
- abdominal lump
- abdominal pain
- abdominal tenderness
- abnormal posture
- abdominal wall defects
- abrasion
- acalculia
- accelerated growth
- acne
- acrochorda
- acroosteolysis
- acute stress reaction
- adverse breast development
- aggression
- agitation
- agnosia
- akathisia
- akinesia
- albuminuria
- alcohol intolerance
- alexia
- alopecia
- altered level of consciousness
- amaurosis
- amaurosis fugax
- ambiguous genitalia
- amblyopia
- amenorrhoea
- ameurosis
- amnesia
- amusia
- anasarca
- angiomyxoma
- anhedonia
- anisocoria
- ankle swelling
- anorchia
- anorectal malformations
- anorexia
- anosmia
- anosognosia
- anovulation
- antepartum haemorrhage
- anuria
- anxiety
- apathy
- aphasia
- aphonia
- apnoea
- appendicitis
- appetite increase
- appetite reduction/loss
- apraxia
- aqueductal stenosis
- arteriosclerosis
- arthralgia
- articulation impairment
- ascites
- asperger syndrome
- asphyxia
- asthenia
- astigmatism
- asymptomatic
- ataxia
- atrial fibrillation
- atrial myxoma
- atrophy
- adhd
- autism
- autonomic neuropathy
- avulsion
- babinski's sign
- back pain
- bacteraemia
- behavioural problems
- belching
- bifid scrotum
- biliary colic
- bitemporal hemianopsia
- blindness
- blistering
- bloating
- bloody show
- boil(s)
- bone cyst
- bone fracture(s)
- bone lesions
- bone pain
- bony metastases
- borborygmus
- bowel movements - bleeding
- bowel movements - increased frequency
- bowel movements - pain
- bowel obstruction
- bowel perforation
- brachycephaly
- brachydactyly
- bradycardia
- bradykinesia
- bradyphrenia
- bradypnea
- breast contour change
- breast enlargement
- breast lump
- breast reduction
- breast tenderness
- breastfeeding difficulties
- breathing difficulties
- bronchospasms
- brushfield spots
- bruxism
- buffalo hump
- cachexia
- calcification
- cardiac fibrosis
- cardiac malformations
- cardiac tamponade
- cardiogenic shock
- cardiomegaly
- cardiomyopathy
- cardiopulmonary arrest
- carpal tunnel syndrome
- caruncle - inflammation
- cataplexy
- cataract(s)
- catathrenia
- central obesity
- cerebrospinal fluid rhinorrhoea
- cervical pain
- cheeks - full
- cheiloschisis
- chemosis
- chest pain
- chest pain (pleuritic)
- chest pain (precordial)
- cheyne-stokes respiration
- chills
- cholecystitis
- cholestasis
- chondrocalcinosis
- chordee
- chorea
- choroidal atrophy
- chronic pain
- circulatory collapse
- cirrhosis
- citraturia
- claudication
- clitoromegaly
- cloacal exstrophy
- clonus
- club foot
- clumsiness
- coagulopathy
- coarctation
- coeliac disease
- cognitive problems
- cold intolerance
- collapse
- colour blindness
- coma
- concentration difficulties
- confusion
- congenital heart defect
- conjunctivitis
- constipation
- convulsions
- coordination difficulties
- coughing
- crackles
- cramps
- craniofacial abnormalities
- craniotabes
- cutaneous ischaemia
- cutaneous myxoma
- cutaneous pigmentation
- cyanosis
- dalrymple's sign
- deafness
- deep vein thrombosis
- dehydration
- delayed puberty
- delirium
- dementia
- dental abscess(es)
- dental problems
- depression
- diabetes insipidus
- diabetic neuropathy
- diabetic foot infection
- diabetic foot neuropathy
- diabetic foot ulceration
- diarrhoea
- diplopia
- dizziness
- duodenal atresia
- duplex kidney(s)
- dysarthria
- dysdiadochokinesia
- dysgraphia
- dyslexia
- dyslipidaemia
- dysmenorrhoea
- dyspareunia
- dyspepsia
- dysphagia
- dysphonia
- dysphoria
- dyspnoea
- dystonia
- dysuria
- ear, nose and/or throat infection
- early menarche
- ears - low set
- ears - pinna abnormalities
- ears - small
- ecchymoses
- ectopic ureter
- emotional immaturity
- encopresis
- endometrial hyperplasia
- enlarged bladder
- enlarged prostate
- eosinophilia
- epicanthic fold
- epilepsy
- epistaxis
- erectile dysfunction
- erythema
- euphoria
- eyebrows - bushy
- eyelid retraction
- eyelid swelling
- eyelids - redness
- eyes - almond-shaped
- eyes - dry
- eyes - feeling of grittiness
- eyes - inflammation
- eyes - irritation
- eyes - itching
- eyes - pain (gazing down)
- eyes - pain (gazing up)
- eyes - redness
- eyes - watering
- face - change in appearance
- face - coarse features
- face - numbness
- facial fullness
- facial palsy
- facial plethora
- facial weakness
- facies - abnormal
- facies - hippocratic
- facies - moon
- faecal incontinence
- failure to thrive
- fallopian tube hyperplasia
- fasciculation
- fatigue
- fatigue (post-exertional)
- feet - cold
- feet - increased size
- feet - large
- feet - pain
- feet - small
- fingers - thick
- flaccid paralysis
- flatulence
- flushing
- fontanelles - enlarged
- frontal bossing
- fungating lesion
- fungating mass
- funny turns
- gait abnormality
- gait unsteadiness
- gallbladder calculi
- gallstones
- gangrene
- gastro-oesophageal reflux
- genital oedema
- genu valgum
- genu varum
- gestational diabetes
- glaucoma
- glucose intolerance
- glucosuria
- growth hormone deficiency
- growth retardation
- haematemesis
- haematochezia
- haematoma
- haematuria
- haemoglobinuria
- haemoptysis
- hair - coarse
- hair - dry
- hair - temporal balding
- hairline - low
- hallucination
- hands - enlargement
- hands - large
- hands - single palmar crease
- hands - small
- head - large
- headache
- hearing loss
- heart failure
- heart murmur
- heat intolerance
- height loss
- hemiballismus
- hemianopia
- hemiparesis
- hemispatial neglect
- hepatic cysts
- hepatic metastases
- hepatomegaly
- hidradenitis suppurativa
- high-arched palate
- hip dislocation
- hippocampal dysgenesis
- hirschsprung's disease
- hot flushes
- hydronephrosis
- hypolipidaemia
- hyperactivity
- hyperacusis
- hyperandrogenaemia
- hypercalciuria
- hypercapnea
- hypercholesterolaemia
- hypercortisolaemia
- hyperflexibility
- hyperglucagonaemia
- hyperhidrosis
- hyperhomocysteinaemia
- hypernasal speech
- hyperopia
- hyperoxaluria
- hyperpigmentation
- hyperplasia
- hyperpnoea
- hypersalivation
- hyperseborrhea
- hypersomnia
- hyperthermia
- hypertrichosis
- hypertrophy
- hyperuricaemia
- hyperventilation
- hypoadrenalism
- hypoalbuminaemia
- hypocalciuria
- hypocitraturia
- hypomagnesaemia
- hypopigmentation
- hypoplastic scrotum
- hypopotassaemia
- hypoprolactinaemia
- hyporeflexia
- hyposmia
- hypospadias
- hypotension
- hypothermia
- hypotonia
- hypoventilation
- hypovitaminosis d
- hypovolaemia
- hypovolaemic shock
- hypoxia
- immunodeficiency
- impulsivity
- inattention
- infections
- inflexibility
- insomnia
- instability
- intussusception
- irritability
- ischaemia
- ischuria
- itching
- jaundice
- keratoconus
- ketonuria
- ketotic odour
- kidney dysplasia
- kidney stones
- kyphoscoliosis
- kyphosis
- labioscrotal fold abnormalities
- laceration
- late dentition
- learning difficulties
- leg pain
- legs - increased length
- leukaemia
- leukocytosis
- libido increase
- libido reduction/loss
- lichen sclerosus
- lips - dry
- lips - thin
- little finger - in-curved
- little finger - short
- liver masses
- lordosis
- lordosis (loss of)
- lymphadenectomy
- lymphadenitis
- lymphocytosis
- lymphoedema
- macroglossia
- malaise
- malaise (post-exertional)
- malodorous perspiration
- mania
- marcus gunn pupil
- mastalgia
- meckel's diverticulum
- melena
- menorrhagia
- menstrual disorder
- mesenteric ischaemia
- metabolic alkalosis
- microalbuminuria
- microcephaly
- micrognathia
- micropenis
- milk-alkali syndrome
- miscarriage
- mood changes/swings
- mouth - down-turned
- mouth - small
- movement - limited range of
- mucosal pigmentation
- muscle atrophy
- muscle freezing
- muscle hypertrophy
- muscle rigidity
- myalgia
- myasthaenia
- mydriasis
- myelodysplasia
- myeloma
- myoclonus
- myodesopsia
- myokymia
- myopathy
- myopia
- myosis
- nail clubbing
- nail dystrophy
- nasal obstruction
- nausea
- neck - loose skin (nape)
- neck - short
- neck mass
- neck pain/discomfort
- necrolytic migratory erythema
- necrosis
- nephrocalcinosis
- nephropathy
- neurofibromas
- night terrors
- nipple change
- nipple discharge
- nipple inversion
- nipple retraction
- nipples widely spaced
- nocturia
- normochromic normocytic anaemia
- nose - depressed bridge
- nose - flat bridge
- nose - thickening
- nystagmus
- obsessive-compulsive disorder
- obstetrical haemorrhage
- obstructive sleep apnoea
- odynophagia
- oedema
- oesophageal atresia
- oesophagitis
- oligomenorrhoea
- oliguria
- onychauxis
- oophoritis
- ophthalmoplegia
- optic atrophy
- orbital fat prolapse
- orbital hypertelorism
- orthostatic hypotension
- osteoarthritis
- osteopenia
- otitis media
- ovarian cysts
- ovarian hyperplasia
- palatoschisis
- pallor
- palmar erythema
- palpebral fissure (downslanted)
- palpebral fissure (extended)
- palpebral fissure (reduced)
- palpebral fissure (upslanted)
- palpitations
- pancreatic fibrosis
- pancytopaenia
- panic attacks
- papilloedema
- paraesthesia
- paralysis
- paranoia
- patellar dislocation
- patellar subluxation
- pedal ulceration
- pellagra
- pelvic mass
- pelvic pain
- penile agenesis
- peptic ulcer
- pericardial effusion
- periodontitis
- periosteal bone reactions
- peripheral oedema
- personality change
- pes cavus
- petechiae
- peyronie's disease
- pharyngitis
- philtrum - long
- philtrum - short
- phosphaturia
- photophobia
- photosensitivity
- pleurisy
- poikiloderma
- polydactyly
- polydipsia
- polyphagia
- polyuria
- poor wound healing
- postmenopausal bleeding
- post-nasal drip
- postprandial fullness
- postural instability
- prehypertension
- premature birth
- premature labour
- prenatal growth retardation
- presbyopia
- pretibial myxoedema
- proctalgia fugax
- prognathism
- proptosis
- prosopagnosia
- proteinuria
- pruritus
- pruritus scroti
- pruritus vulvae
- pseudarthrosis
- psoriatic arthritis
- psychiatric problems
- psychomotor retardation
- psychosis
- pterygium colli
- ptosis
- puberty (delayed/absent)
- puberty (early/precocious)
- puffiness
- pulmonary embolism
- purpura
- pyelonephritis
- pyloric stenosis
- pyrexia
- pyrosis
- pyuria
- rash
- rectal pain
- rectorrhagia
- refractory anemia
- reluctance to weight-bear
- renal agenesis
- renal clubbing
- renal colic
- renal cyst
- renal failure
- renal insufficiency
- renal phosphate wasting (isolated)
- renal tubular acidosis
- respiratory failure
- reticulocytosis
- retinitis pigmentosa
- retinopathy
- retrobulbar pain
- retrograde ejaculation
- retroperitoneal fibrosis
- salivary gland swelling
- salpingitis
- salt craving
- salt wasting
- sarcoidosis
- schizophrenia
- scoliosis
- scotoma
- seborrhoeic dermatitis
- seizures
- sensory loss
- sepsis
- septic arthritis
- septic shock
- shivering
- singultus
- sinusitis
- sixth nerve palsy
- skeletal deformity
- skeletal dysplasia
- skin - texture change
- skin infections
- skin necrosis
- skin pigmentation - spotty
- skin thickening
- skin thinning
- sleep apnoea
- sleep difficulties
- sleep disturbance
- sleep hyperhidrosis
- slow growth
- slurred speech
- social difficulties
- soft tissue swelling
- somnambulism
- somniloquy
- somnolence
- sore throat
- spasms
- spastic paraplegia
- spasticity
- speech delay
- spider naevi
- splenomegaly
- sputum production
- steatorrhoea
- stomatitis
- strabismus
- strangury
- striae
- stridor
- stroke
- subfertility
- suicidal ideation
- supraclavicular fat pads
- supranuclear gaze palsy
- sweating
- syncope
- syndactyly
- tachycardia
- tachypnoea
- teeth gapping
- telangiectasias
- telecanthus
- tetraparesis
- t-reflex (absent)
- t-reflex (depressed)
- tetany
- thermodysregulation
- thrombocytopenia
- thrombocytosis
- thrombophilia
- thrush
- tics
- tinnitus
- toe clubbing
- toe deformities
- toes - thick
- toes - widely spaced
- tongue - protruding
- tracheo-oesophageal compression
- tracheo-oesophageal fistula
- tremulousness
- tricuspid insufficiency
- umbilical hernia
- uraemia
- ureter duplex
- uricaemia
- urinary frequency
- urinary incontinence
- urogenital sinus
- urticaria
- uterine hyperplasia
- uterus duplex
- vagina duplex
- vaginal bleeding
- vaginal discharge
- vaginal dryness
- vaginal pain/tenderness
- vaginism
- ventricular fibrillation
- ventricular hypertrophy
- vertigo
- viraemia
- virilisation (abnormal)
- vision - acuity reduction
- vision - blurred
- visual disturbance
- visual field defect
- visual impairment
- visual loss
- vitiligo
- vocal cord paresis
- vomiting
- von graefe's sign
- weight gain
- weight loss
- wheezing
- widened joint space(s)
- xeroderma
- xerostomia
- 3-methoxy 4-hydroxy mandelic acid
- 17-hydroxypregnenolone (urine)
- 17-ketosteroids
- 25-hydroxyvitamin-d3
- 5hiaa
- aberrant adrenal receptors
- acid-base balance
- acth stimulation
- activated partial thromboplastin time
- acyl-ghrelin
- adrenal antibodies
- adrenal function
- adrenal scintigraphy
- adrenal venous sampling
- afp tumour marker
- alanine aminotransferase
- albumin
- albumin to creatinine ratio
- aldosterone (24-hour urine)
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- aldosterone (plasma)
- aldosterone (serum)
- aldosterone to renin ratio
- alkaline phosphatase
- alkaline phosphatase (bone-specific)
- alpha-fetoprotein
- ammonia
- amniocentesis
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- angiography
- anion gap
- anti-acetylcholine antibodies
- anticardiolipin antibody
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- asvs
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- chemokines
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- down syndrome screening
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- ethanol ablation
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- fmri
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- gallium scan
- gastric biopsy
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- hysteroscopy
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- inferior petrosal sinus sampling
- inhibin b
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- intracranial pressure
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- lactate
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- laparoscopy
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- laparotomy
- ldl cholesterol
- leuprolide acetate stimulation
- leukocyte esterase (urine)
- levothyroxine absorption
- lipase (serum)
- lipid profile
- liquid-based cytology
- liquid chromatography-mass spectrometry
- liver biopsy
- liver function
- lumbar puncture
- lung function testing
- luteinising hormone releasing hormone test
- macroprolactin
- magnesium
- mag3 scan
- mammogram
- mantoux test
- metanephrines (plasma)
- metanephrines (urinary)
- methoxytyramine
- metoclopramide
- metyrapone cortisol day curve
- metyrapone suppression
- metyrapone test dose
- mibg scan
- microarray analysis
- molecular genetic analysis
- mri
- myocardial biopsy
- nerve conduction study
- neuroendocrine markers
- neuron-specific enolase
- norepinephrine
- ntx
- oct
- octreotide scan
- octreotide suppression test
- osmolality
- ovarian venous sampling
- p1np
- palpation
- pap test
- parathyroid scintigraphy
- pentagastrin
- perchlorate discharge
- percutaneous umbilical blood sampling
- peripheral blood film
- pet scan
- ph (blood)
- phosphate (serum)
- phosphate (urine)
- pituitary function
- plasma osmolality
- plasma viscosity
- platelet count
- pneumococcal antigen
- pneumococcal pcr
- polymerase chain reaction
- polysomnography
- porter-silber chromogens
- potassium
- pregnancy test
- proinsulin
- prostate-specific antigen
- protein electrophoresis
- protein fingerprinting
- protein folding analysis
- psychiatric assessment
- psychometric assessment
- pulse oximetry
- pyelography
- pyridinium crosslinks
- quicki
- plasma renin activity
- radioimmunoassay
- radionuclide imaging
- raiu test
- red blood cell count
- renal biopsy
- renin (24-hour urine)
- respiratory status
- renin (blood)
- renin plasma activity
- rheumatoid factor
- salt loading
- sdldl cholesterol
- secretin stimulation
- selective parathyroid venous sampling
- selective transhepatic portal venous sampling
- semen analysis
- serotonin
- serum osmolality
- serum free insulin
- sestamibi scan
- sex hormone binding globulin
- shbg
- skeletal muscle mass
- skin biopsy
- sleep diary
- sodium
- spect scan
- supervised 72-hour fast
- surgical biopsy
- sweat test
- synaptophysin
- systemic vascular resistance index
- tanner scale
- thoracocentesis
- thyroid transcription factor-1
- thyroglobulin
- thyroid antibodies
- thyroid function
- thyroid scintigraphy
- thyroid ultrasonography
- total cholesterol
- total ghrelin
- total t3
- total t4
- trabecular thickness
- transaminase
- transvaginal ultrasound
- trap 5b
- trh stimulation
- triglycerides
- triiodothyronine (t3) suppression
- troponin
- tsh receptor antibodies
- type 3 precollagen
- type 4 collagen
- ultrasound-guided biopsy
- ultrasound scan
- urea and electrolytes
- uric acid (blood)
- uric acid (urine)
- urinalysis
- urinary free cortisol
- urine 24-hour volume
- urine osmolality
- vaginal examination
- vanillylmandelic acid (24-hour urine)
- visual field assessment
- vitamin b12
- vitamin e
- waist circumference
- water deprivation
- water load
- weight
- western blotting
- white blood cell count
- white blood cell differential count
- x-ray
- zinc
- abscess drainage
- acetic acid injection
- adhesiolysis
- adrenalectomy
- amputation
- analgesics
- angioplasty
- arthrodesis
- assisted reproduction techniques
- bariatric surgery
- bilateral salpingo-oophorectomy
- blood transfusion
- bone grafting
- caesarean section
- cardiac transplantation
- cardiac pacemaker
- cataract extraction
- chemoembolisation
- chemotherapy
- chemoradiotherapy
- clitoroplasty
- continuous renal replacement therapy
- contraception
- cordotomy
- counselling
- craniotomy
- cryopreservation
- cryosurgical ablation
- debridement
- dialysis
- diazoxide
- diet
- duodenotomy
- endonasal endoscopic surgery
- exercise
- external fixation
- extracorporeal shock wave lithotripsy
- extraocular muscle surgery
- eye surgery
- eyelid surgery
- fasciotomy
- fluid repletion
- fluid restriction
- gamma knife radiosurgery
- gastrectomy
- gastrostomy
- gender reassignment surgery
- gonadectomy
- heart transplantation
- hormone replacement
- hormone suppression
- hypophysectomy
- hysterectomy
- inguinal orchiectomy
- internal fixation
- intra-cardiac defibrillator
- islet transplantation
- ivf
- kidney transplantation
- laparoscopic adrenalectomy
- laryngoplasty
- laryngoscopy
- laser lithotripsy
- light treatment
- liver transplantation
- lumpectomy
- lymph node dissection
- mastectomy
- molecularly targeted therapy
- neuroendoscopic surgery
- oophorectomy
- orbital decompression
- orbital radiation
- orchidectomy
- orthopaedic surgery
- osteotomy
- ovarian cystectomy
- ovarian diathermy
- oxygen therapy
- pancreas transplantation
- pancreatectomy
- pancreaticoduodenectomy
- parathyroidectomy
- percutaneous adrenal ablation
- percutaneous nephrolithotomy
- pericardiocentesis
- pericardiotomy
- physiotherapy
- pituitary adenomectomy
- plasma exchange
- plasmapheresis
- psychotherapy
- radiofrequency ablation
- radionuclide therapy
- radiotherapy
- reconstruction of genitalia
- resection of tumour
- right-sided hemicolectomy
- salpingo-oophorectomy
- small bowel resection
- speech and language therapy
- spinal surgery
- splenectomy
- stereotactic radiosurgery
- termination of pregnancy
- thymic transplantation
- thyroidectomy
- tracheostomy
- transcranial surgery
- transsphenoidal surgery
- transtentorial surgery
- vaginoplasty
- vagotomy
- 5-alpha-reductase inhibitors
- 17?-estradiol
- abiraterone
- acarbose
- acetazolamide
- acetohexamide
- adalimumab
- albiglutide
- alendronate
- alogliptin
- alpha-blockers
- alphacalcidol
- alpha-glucosidase inhibitors
- amiloride
- amlodipine
- amoxicillin
- anastrozole
- angiotensin-converting enzyme inhibitors
- angiotensin receptor antagonists
- anthracyclines
- antiandrogens
- antibiotics
- antiemetics
- antiepileptics
- antipsychotics
- antithyroid drugs
- antiseptic
- antivirals
- aripiprazole
- aromatase inhibitors
- aspirin
- astragalus membranaceus
- ativan
- atenolol
- atorvastatin
- avp receptor antagonists
- axitinib
- azathioprine
- bendroflumethiazide
- benzodiazepines
- beta-blockers
- betamethasone
- bexlosteride
- bicalutamide
- bisphosphonates
- bleomycin
- botulinum toxin
- bromocriptine
- cabergoline
- cabozantinib
- calcimimetics
- calcitonin (salmon)
- calcium
- calcium carbonate
- calcium chloride
- calcium dobesilate
- calcium edta
- calcium gluconate
- calcium-l-aspartate
- calcium polystyrene sulphonate
- canagliflozin
- capecitabine
- captopril
- carbimazole
- carboplatin
- carbutamide
- carvedilol
- ceftriaxone
- chlorothiazide
- chlorpropamide
- cholecalciferol
- cholinesterase inhibitors
- ciclosporin
- cinacalcet
- cisplatin
- clodronate
- clomifene
- clomiphene citrate
- clopidogrel
- co-cyprindiol
- codeine
- colonic polyps
- combined oral contraceptive pill
- conivaptan
- cortisone acetate
- continuous subcutaneous hydrocortisone infusion
- continuous subcutaneous insulin infusion
- coumadin
- corticosteroids
- cortisol
- cyproterone acetate
- dacarbazine
- danazol
- dapagliflozin
- daunorubicin
- deferiprone
- demeclocycline
- denosumab
- desmopressin
- dexamethasone
- diazepam
- diethylstilbestrol
- digoxin
- diltiazem
- diphenhydramine
- diuretics
- docetaxel
- dopamine agonists
- dopamine antagonists
- dopamine receptor agonists
- doxazosin
- doxepin
- doxorubicin
- dpp4 inhibitors
- dutasteride
- dutogliptin
- eflornithine
- enoxaparin
- empagliflozin
- epinephrine
- epirubicin
- eplerenone
- epristeride
- equilenin
- equilin
- erlotinib
- ethinylestradiol
- etidronate
- etomidate
- etoposide
- everolimus
- exenatide
- fenofibrate
- finasteride
- fluconazole
- fluticasone
- fludrocortisone
- fluorouracil
- fluoxetine
- flutamide
- furosemide
- gaba receptor antagonists
- gefitinib
- gemcitabine
- gemigliptin
- ginkgo biloba
- glibenclamide
- glibornuride
- gliclazide
- glimepiride
- glipizide
- gliquidone
- glisoxepide
- glp1 agonists
- glucose
- glyclopyramide
- gnrh analogue
- gnrh antagonists
- heparin
- hrt (menopause)
- hydrochlorothiazide
- hydrocortisone
- ibandronate
- ibuprofen
- idarubicin
- idebenone
- imatinib
- immunoglobulin therapy
- implanon
- indapamide
- infliximab
- iron supplements
- isoniazid
- insulin aspart
- insulin glargine
- insulin glulisine
- insulin lispro
- interferon
- intrauterine system
- iopanoic acid
- ipilimumab
- ipragliflozin
- irbesartan
- izonsteride
- ketoconazole
- labetalol
- lactulose
- lanreotide
- leuprolide acetate
- levatinib
- levodopa
- levonorgestrel
- levothyroxine
- linagliptin
- liothyronine
- liraglutide
- lithium
- lisinopril
- lixivaptan
- loperamide
- loprazolam
- lormetazepam
- losartan
- low calcium formula
- magnesium glycerophosphate
- magnesium sulphate
- mecasermin
- medronate
- medroxyprogesterone acetate
- meglitinides
- menotropin
- metformin
- methadone
- methimazole
- methylprednisolone
- metoprolol
- metyrapone
- miglitol
- mitotane
- mitoxantrone
- mozavaptan
- mtor inhibitors
- multivitamins
- naproxen
- natalizumab
- nateglinide
- nelivaptan
- neridronate
- nifedipine
- nilutamide
- nitrazepam
- nivolumab
- nsaid
- octreotide
- oestradiol valerate
- olanzapine
- olpadronate
- omeprazole
- opioids
- oral contraceptives
- orlistat
- ornipressin
- otelixizumab
- oxandrolone
- oxidronate
- oxybutynin
- paclitaxel
- pamidronate
- pancreatic enzymes
- pantoprazole
- paracetamol
- paroxetine
- pasireotide
- pegvisomant
- perindopril
- phenobarbital
- phenoxybenzamine
- phosphate binders
- phosphate supplements
- phytohaemagglutinin induced interferon gamma
- pioglitazone
- plicamycin
- potassium chloride
- potassium iodide
- pramlintide
- prazosin
- prednisolone
- prednisone
- premarin
- promethazine
- propranolol
- propylthiouracil
- protease inhibitors
- proton pump inhibitors
- pyridostigmine
- quetiapine
- quinagolide
- quinestrol
- radioactive mibg
- radioactive octreotide
- radioiodine
- raloxifene
- ramipril
- relcovaptan
- remogliflozin etabonate
- repaglinide
- risperidone
- risedronate
- rituximab
- romidepsin
- rosiglitazone
- salbutamol
- saline
- salmeterol
- salt supplements
- satavaptan
- saxagliptin
- selective progesterone receptor modulators
- selenium
- sglt2 inhibitors
- sildenafil
- simvastatin
- sirolimus
- sitagliptin
- sodium bicarbonate
- sodium chloride
- sodium polystyrene sulfonate (kayexalate)
- somatostatin analogues
- sorafenib
- spironolactone
- ssris
- statins
- streptozotocin
- steroids
- strontium ranelate
- sucralfate
- sulphonylureas
- sunitinib
- tamoxifen
- taspoglutide
- temazepam
- temozolomide
- teplizumab
- terazosin
- teriparatide
- testolactone
- testosterone enanthate esters
- tetrabenazine
- thalidomide
- thiazolidinediones
- thyrotropin alpha
- tibolone
- tiludronate
- tiratricol (triac)
- tofogliflozin
- tolazamide
- tolbutamide
- tolvaptan
- tramadol
- trastuzumab
- trazodone
- triamcinolone
- triamterene
- trimipramine
- troglitazone
- tryptophan
- turosteride
- tyrosine-kinase inhibitors
- valproic acid
- valrubicin
- vandetanib
- vaptans
- vildagliptin
- vinorelbine
- voglibose
- vorinostat
- warfarin
- zaleplon
- z-drugs
- zoledronic acid
- zolpidem
- zopiclone
- cardiology
- dermatology
- gastroenterology
- general practice
- genetics
- geriatrics
- gynaecology
- nephrology
- neurology
- nursing
- obstetrics
- oncology
- otolaryngology
- paediatrics
- pathology
- podiatry
- psychology/psychiatry
- radiology/rheumatology
- rehabilitation
- surgery
- urology
- insight into disease pathogenesis or mechanism of therapy
- novel diagnostic procedure
- novel treatment
- unique/unexpected symptoms or presentations of a disease
- new disease or syndrome: presentations/diagnosis/management
- unusual effects of medical treatment
- error in diagnosis/pitfalls and caveats
- february
- 2022
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Affiliation(s)
- Aria Jazdarehee
- Department of Medicine and Faculty of Medicine, University of British Columbia, British Columbia, Canada
| | - Sawyer Huget-Penner
- Division of Endocrinology and Metabolism, Fraser Health Authority, British Columbia, Canada
| | - Monika Pawlowska
- Division of Endocrinology and Metabolism, University of British Columbia, British Columbia, Canada
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Xu C, Sun L, Dong M, Ullah H, Ullah H, Zhou J, Yuan Z. Serum Anion Gap is Associated with Risk of All-Cause Mortality in Critically Ill Patients with Acute Myocardial Infarction. Int J Gen Med 2022; 15:223-231. [PMID: 35023960 PMCID: PMC8747706 DOI: 10.2147/ijgm.s336701] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 12/10/2021] [Indexed: 12/30/2022] Open
Abstract
Purpose Anion gap (AG) is a valuable and easily obtained clinical tool for differentially diagnosis of acid-base disorders. Current understanding of the prognostic impact of AG on mortality after acute myocardial infarction (AMI) is limited. We aimed to investigate whether AG is a predictor of short-term and long-term all-cause mortality after AMI. Patients and Methods We examined 1806 patients diagnosed with AMI in intensive care unit from the Medical Information Mart for Intensive Care III (MIMIC-III) database. We analyzed the association of AG with 30-day, 180-day and 1-year all-cause mortality on a continuous scale and in categories, using multivariable Cox regression. We utilized restricted cubic splines to evaluate the linearity between hazard ratio (HR) and AG concentrations. Results AG was associated with a higher risk of 30-day, 180-day and 1-year all-cause mortality, with adjusted HRs of 1.083 (95% CI 1.051 to 1.117), 1.077 (95% CI 1.049 to 1.105), and 1.074 (95% CI 1.047 to 1.101), respectively. The results were consistent in subgroup analyses. The association between AG and all-cause mortality was linear for 180-day and 1-year mortality, and near linear for 30-day mortality, as higher concentrations were associated with high all-cause mortality. When stratified according to quartiles, AG was associated with 30-day mortality (HR[95% CI]: second quartile, 2.243[1.273, 3.955]; third quartile, 3.026[1.763, 5.194]; top quartile, 4.402[2.573, 7.531]), 180-day mortality (HR[95% CI]: second quartile, 1.719[1.118, 2.645]; third quartile, 2.362[1.575, 3.542]; top quartile, 3.116[2.077, 4.676]), and 1-year mortality (HR[95% CI]: second quartile, 1.700[1.143, 2.528]; third quartile, 2.239[1.536, 3.264]; top quartile, 2.876[1.969, 4.201]) using bottom quartile as reference. Conclusion We firstly demonstrated that higher AG was significantly associated with increased 30-day, 180-day and 1-year all-cause mortality in AMI patients. AG as an easily obtained marker is of strong and reliable predictive value for AMI mortality during follow-up.
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Affiliation(s)
- Chenbo Xu
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Lizhe Sun
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Mengya Dong
- Department of Cardiovascular Medicine, Shaanxi Provincial People's Hospital, Xi'an, Shaanxi, People's Republic of China
| | - Habib Ullah
- Department of Cardiology, Dow University of Health and Sciences, Karachi, Pakistan
| | - Hameed Ullah
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China
| | - Juan Zhou
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China.,Key Laboratory of Molecular Cardiology of Shaanxi Province, Xi'an, Shaanxi, People's Republic of China
| | - Zuyi Yuan
- Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, People's Republic of China.,Key Laboratory of Environment and Genes Related to Diseases, Xi'an Jiaotong University, Ministry of Education, Xi'an, Shaanxi, People's Republic of China
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Ukita K, Otomune K, Fujimoto R, Hasegawa K, Izumikawa K, Morimoto N, Sasaki K, Hirasaki A, Takaguchi K. Anion gap-opening metabolic acidosis and urinary findings in the early diagnosis of ethylene glycol poisoning: A case report. Clin Case Rep 2022; 10:e05215. [PMID: 35028142 PMCID: PMC8741873 DOI: 10.1002/ccr3.5215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/19/2021] [Accepted: 12/03/2021] [Indexed: 11/29/2022] Open
Abstract
Causative agent identification is important in the treatment of poisoning. We report the case of a patient who presented with an altered level of consciousness after drinking a fluorescent pink liquid. Upon measuring the anion gap and urinary calcium oxalate level, the patient was diagnosed with early ethylene glycol poisoning.
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Affiliation(s)
- Kentaro Ukita
- Postgraduate Clinical Training CenterKagawa Prefectural Central Hospital
| | - Kanako Otomune
- Department of Emergency MedicineKagawa Prefectural Central Hospital
| | - Ryo Fujimoto
- Postgraduate Clinical Training CenterKagawa Prefectural Central Hospital
| | - Kanako Hasegawa
- Postgraduate Clinical Training CenterKagawa Prefectural Central Hospital
| | - Koichi Izumikawa
- Department of General MedicineKagawa Prefectural Central Hospital
| | | | - Kazuhiro Sasaki
- Department of Emergency MedicineKagawa Prefectural Central Hospital
| | | | - Koichi Takaguchi
- Department of General MedicineKagawa Prefectural Central Hospital
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Dhanarisi J, Tzotzolaki TM, Vasileva AMD, Kjellberg MA, Hakulinen H, Vanninen P, Gawarammana I, Mohamed F, Hovda KE, Eddleston M. Osmolal and anion gaps after acute self-poisoning with agricultural formulations of the organophosphorus insecticides profenofos and diazinon: A pilot study. Basic Clin Pharmacol Toxicol 2021; 130:320-327. [PMID: 34796663 DOI: 10.1111/bcpt.13686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/30/2021] [Accepted: 11/10/2021] [Indexed: 11/28/2022]
Abstract
Self-poisoning with organophosphorus (OP) insecticides is an important means of global self-harm. The insecticides are formulated with solvents that may also contribute to toxicity. We set up a study to detect changes in osmolal and anion gaps following ingestion of OP insecticides. We recruited consecutive patients admitted to a Teaching Hospital, Sri Lanka, with a history of OP self-poisoning. The osmolal and anion gaps were calculated on admission and at 4, 24 and 72 h post-ingestion together with ethanol concentration. Forty-nine patients were recruited (28 profenofos, 10 diazinon, one coumaphos, one chlorpyrifos, one phenthoate and eight unknown OP). Only modest increases in osmolal and anion gaps were noted. Small rises in osmolal gap above the upper limit of normal were noted in 16/49 (32.7%) of all cases, 9/28 (32.1%) profenofos cases and 4/10 (40.0%) diazinon cases. The anion gap was raised in 24/49 (49.0%) of all cases, 15/28 (53.6%) profenofos cases and 5/10 (50.0%) diazinon cases. We observed a trend for a fall in osmolal gap during the first 24 h, followed by an increase up to 72 h. There was no correlation between the anion gap and serum lactate concentration, indicating that a lactic acidosis was not responsible for the anion gap. Formate, which could have explained the increased gap, was not detected in any of the samples; ketoacids (beta-hydroxybutyrate and acetoacetate) were not measured. This pilot study found that profenofos and diazinon poisoning caused only modest increases in the osmolal and anion gaps in a minority of cases.
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Affiliation(s)
- Jeevan Dhanarisi
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Tanita Maria Tzotzolaki
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.,Pharmacology, Toxicology, & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Ana-Mariya D Vasileva
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.,Pharmacology, Toxicology, & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Matti A Kjellberg
- VERIFIN, Finnish Institute for Verification of The Chemical Weapons Convention, Department of Chemistry, University of Helsinki, Helsinki, Finland
| | - Hanna Hakulinen
- VERIFIN, Finnish Institute for Verification of The Chemical Weapons Convention, Department of Chemistry, University of Helsinki, Helsinki, Finland
| | - Paula Vanninen
- VERIFIN, Finnish Institute for Verification of The Chemical Weapons Convention, Department of Chemistry, University of Helsinki, Helsinki, Finland
| | - Indika Gawarammana
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.,Department of Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka
| | - Fahim Mohamed
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.,Department of Pharmacy, Faculty of Allied Health Sciences, University of Peradeniya, Peradeniya, Sri Lanka
| | - Knut Erik Hovda
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.,The Norwegian CBRNe Centre of Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway
| | - Michael Eddleston
- South Asian Clinical Toxicology Research Collaboration, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka.,Pharmacology, Toxicology, & Therapeutics, University/BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
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Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE The anion gap is a calculated fundamental laboratory parameter used to identify and monitor acid-base disturbances. A recently popularized correction formula transforms the resulting integer to compensate for hypoalbuminemia and improve diagnostic yield. Clinical pharmacists should be aware of the underlying biochemistry, interpretation, and limitations of this formula to discern drug- and disease-related etiologies. SUMMARY The anion gap is utilized in most care settings, ranging from outpatient monitoring to inpatient intensive care units. Supported by decades of experience, the original anion gap derives its value from its simplicity. Applying the anion gap in metabolic acidosis can help narrow differential diagnosis and detect concomitant acid-base disorders. To account for hypoalbuminemia and potential missed diagnoses, a correction formula was developed to improve sensitivity. Yet, the law of electroneutrality ensures that hypoalbuminemia is already accounted for in the original anion gap, and the proposed correction formula was derived from samples unrepresentative of human physiology. Evidence from clinical trials shows no benefit from applying the correction formula. CONCLUSION There is no advantage to correcting the anion gap, and such correction may increase the risk of misinterpretation or error. Clinicians should understand these limitations when diagnosing or trending acid-base disturbances.
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Affiliation(s)
- Andrew K Posen
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
| | - Frank P Paloucek
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
| | - Renee Petzel Gimbar
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA
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Jhou HJ, Chen PH, Yang LY, Chang SH, Lee CH. Plasma Anion Gap and Risk of In-Hospital Mortality in Patients with Acute Ischemic Stroke: Analysis from the MIMIC-IV Database. J Pers Med 2021; 11:1004. [PMID: 34683145 DOI: 10.3390/jpm11101004] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 09/30/2021] [Accepted: 10/02/2021] [Indexed: 02/06/2023] Open
Abstract
We aimed to investigate the association between the plasma anion gap (AG) and in-hospital mortality among patients with acute ischemic stroke (AIS). In total, 1236 AIS patients were enrolled using the Medical Information Mart for Intensive Care Database IV. Primary outcome was in-hospital mortality. The patients were divided into four groups according to AG category. The mean age and Charlson comorbidity index increased as the AG category increased. The fourth AG category was most related to the in-hospital mortality (hazards ratio (HR), 95% confidence interval (CI): 2.77, 1.60-4.71), even after adjusting for possible confounding variables (Model 1: HR, 95% CI: 3.37, 1.81-6.09; Model 2: HR, 95% CI: 3.57, 1.91-6.69). Moreover, intensive care unit mortality (p = 0.008) was higher in the highest AG category, but the intracranial hemorrhage (p = 0.071) did not associate with the plasma AG. The plasma AG had a satisfactory predictive ability for in-hospital mortality among AIS patients (areas under the receiver operating characteristic curve: 0.631). The plasma AG is an independent risk factor that can satisfactorily predict the in-hospital mortality among AIS patients.
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26
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Heldeweg MLA, Kluijver LG, Berend K. Intoxication by Hand-Sanitizers and other Toxic Alcohols in a Low-Resource Setting: Two Case Reports. Eur J Case Rep Intern Med 2021; 8:002751. [PMID: 34527620 DOI: 10.12890/2021_002751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/12/2021] [Indexed: 11/05/2022] Open
Abstract
Toxic alcohol poisoning can be lethal if not identified early and treated appropriately. Toxic alcohol assays are often unavailable in low-resource setting, so clinicians have to infer a diagnosis based on suspicion, repeated evaluation and biochemical course. We report a case of toxic alcohol poisoning concealed by auto-intoxication with in-hospital hand sanitizer. The eventual appearance of a concurrent high anion gap prompted dialysis. In another case, a comatose patient presented with a high osmolal gap and a high anion gap. Incorrect a priori opinions caused us to defer dialysis and the patient died shortly afterwards. Clinicians should be aware that toxic alcohol poisoning can produce a confusing diagnostic picture with an insidious course, and that doctor delay can prove fatal. LEARNING POINTS Toxic alcohol ingestion may be lethal and warrants early identification, but this is not always possible.Incorrect a priori opinions by clinicians, or the co-ingestion of other alcohols by a patient, may produce a confusing diagnostic picture.Physicians should not defer immediate treatment for patients suspected of toxic alcohol ingestion with a double gap or visual disturbances.
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Affiliation(s)
- Micah LA Heldeweg
- Department of Intensive Care, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Louisa G Kluijver
- Department of Internal Medicine, Alrijne Hospital, Leiden, the Netherlands
| | - Kenrick Berend
- Department of Internal Medicine, Curaçao Medical Center, Curaçao
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Lambert DC, Abramowitz MK. Obesity, Anion Accumulation, and Anion Gap Metabolic Acidosis: A Cohort Study. Kidney360 2021; 2:1706-1715. [PMID: 35372994 PMCID: PMC8785829 DOI: 10.34067/kid.0003562021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/07/2021] [Indexed: 02/04/2023]
Abstract
Background Obesity is associated with low serum bicarbonate, an indicator of metabolic acidosis and a CKD risk factor. To further characterize acid-base disturbance and subclinical metabolic acidosis in this population, we examined prospective associations of body mass index (BMI) with elevated anion gap and whether anion gap values in obesity associate with low bicarbonate. Methods Data from adult outpatients (n=94,448) in the Bronx, New York were collected from 2010 to 2018. Mixed effects models and Cox proportional hazards models were used to examine associations of BMI with elevated anion gap and anion gap metabolic acidosis and of baseline anion gap with incident low bicarbonate and anion gap metabolic acidosis. Anion gap was defined using traditional and albumin-corrected calculations. Results Greater BMI was associated with higher anion gap over time and with progressively greater risk of developing an elevated anion gap (hazard ratio [HR] for body mass index [BMI]≥40 kg/m2 versus 18 to <25 kg/m2, 1.32; 95% confidence interval [95% CI], 1.23 to 1.42 for traditional and HR for BMI≥40 kg/m2 versus 18 to <25 kg/m2, 1.74; 95% CI, 1.63 to 1.85 for corrected). Higher BMI was also associated with increased risk of developing anion gap metabolic acidosis (HR for BMI≥40 kg/m2, 1.53; 95% CI, 1.39 to 1.69). Among patients with obesity, higher anion gap was associated with increased risk of incident low bicarbonate (HR for fourth versus first quartile, 1.29; 95% CI, 1.23 to 1.44 for traditional and HR for fourth versus first quartile, 1.36; 95% CI, 1.26 to 1.48 for corrected) and higher risk of anion gap metabolic acidosis (HR for fourth versus first quartile, 1.78; 95% CI, 1.59 to 1.99). Conclusions Obesity is characterized by unmeasured anion accumulation and acid retention or overproduction. Modest elevations in anion gap among patients with obesity are associated with previously unrecognized anion gap metabolic acidosis.
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Affiliation(s)
- Douglas C. Lambert
- Department of General Internal Medicine, Northwell Health, Great Neck, New York,Section of Obesity Medicine, Northwell Health, Great Neck, New York
| | - Matthew K. Abramowitz
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York,Department of Medicine, Institute for Aging Research, Albert Einstein College of Medicine, Bronx, New York,Department of Medicine, Diabetes Research Center, Albert Einstein College of Medicine, Bronx, New York,Department of Medicine, Fleischer Institute for Diabetes and Metabolism, Albert Einstein College of Medicine, Bronx, New York
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28
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Zhang T, Wang J, Li X. Association Between Anion Gap and Mortality in Critically Ill Patients with Cardiogenic Shock. Int J Gen Med 2021; 14:4765-4773. [PMID: 34466021 PMCID: PMC8403005 DOI: 10.2147/ijgm.s329150] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 08/12/2021] [Indexed: 11/23/2022] Open
Abstract
Background No epidemiological study has determined the association between the anion gap (AG) and all-cause mortality in critically ill patients with cardiogenic shock (CS). This study was conducted to clarify the relationship between the AG and mortality in CS. Methods We extracted clinical data from the public database, MIMIC-III V1.4, by using a generalized additive model to identify the nonlinear relationship between the AG and the 30-day mortality in 1248 intensive care unit patients. Cox proportional hazard models were used to assess the association between the AG and the 30-day, 90-day, and 365-day mortality in CS. Results The AG and 30-day all-cause mortality showed a nonlinear relationship, indicated by a J-shaped curve. In the multivariate analysis, after adjusting for potential confounders, a high AG was associated with an increased risk of 30-day, 90-day, and 365-day all-cause mortality in patients with CS compared with patients who had low AG (hazard ratio [95% confidence interval] 1.62 [1.14-2.30]; 1.35 [1.04-1.84]; and 1.38 [1.03-1.84], respectively). Similar results were shown in Model I (adjusted for age, sex and ethnicity) and in Model II (fully adjusting for age, ethnicity, sex, acute kidney injury stage, CHF, renal disease, stroke, malignancy, respiratory failure, pneumonia, sodium, potassium, chloride, BUN, PT, WBC, pH, creatinine, albumin, glucose, bicarbonate, vasopressor use, diastolic blood pressure, respiration rate, temperature, the Elixhauser Comorbidity Index, SOFA score and SAPSII score). Conclusion The relationship between the AG and 30-day all-cause mortality followed a J-shaped curve. Higher AG was associated with an increased risk of 30-day, 90-day, and 365-day all-cause mortality in critically ill patients with CS.
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Affiliation(s)
- Tingting Zhang
- Department of Clinical Laboratory, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, People's Republic of China
| | - Jie Wang
- Department of Cardiology, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, 325000, Zhejiang, People's Republic of China
| | - Xiangyang Li
- Department of Clinical Laboratory, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, 325000, People's Republic of China
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29
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Hu B, Cao J, Hu Y, Qin Z, Wang J. The Association Between Serum Anion Gap and All-Cause Mortality in Disseminated Intravascular Coagulation Patients: A Retrospective Analysis. Int J Gen Med 2021; 14:4535-4544. [PMID: 34429638 PMCID: PMC8379146 DOI: 10.2147/ijgm.s318334] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 07/07/2021] [Indexed: 12/27/2022] Open
Abstract
Purpose Studies regarding death risk factors of disseminated intravascular coagulation (DIC) patients were limited. Therefore, we conducted this study to investigate whether the serum anion gap (AG) was independently related to all-cause mortality of DIC patients. Methods We used the data from Medical Information Mart for Intensive Care III version 1.4 (MIMIC-III v1.4). A total of 2,654 DIC patients were included. The main outcomes were in-hospital, 30-day, and 90-day all-cause mortality. The AG was measured upon ICU admission and its association with mortality was evaluated using the Cox proportional-hazards regression model. The generalized additive model and the smooth curve fitting were introduced to examine the non-linear association. Results After adjusting for potential covariates, the in-hospital, 30-day, and 90-day all-cause mortality were positively correlated with AG. The hazard ratio (HR), confidence intervals (CI), and P were 1.05 (1.04–1.07) <0.0001, 1.06 (1.04–1.07) <0.0001, and 1.05 (1.03–1.07) <0.0001, respectively. We did not find an obvious non-linear relationship between AG and in-hospital, 30-day, and 90-day mortality, which indicated that the association between AG and all-cause mortality of DIC patients was nearly linear. Conclusion Serum AG is positively related with all-cause mortality in DIC patients.
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Affiliation(s)
- Bin Hu
- Department of Hematology, First People's Hospital of Changde City, Changde, Hunan, People's Republic of China
| | - Jinxia Cao
- Department of Hematology, First People's Hospital of Changde City, Changde, Hunan, People's Republic of China
| | - Yangyang Hu
- Department of Rheumatology and Immunology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, People's Republic of China
| | - Zuoan Qin
- Department of Cardiovascular Medicine, First People's Hospital of Changde City, Changde, Hunan, People's Republic of China
| | - Jun Wang
- Department of Hematology, First People's Hospital of Changde City, Changde, Hunan, People's Republic of China
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Fenves AZ, Emmett M. Approach to Patients With High Anion Gap Metabolic Acidosis: Core Curriculum 2021. Am J Kidney Dis 2021; 78:590-600. [PMID: 34400023 DOI: 10.1053/j.ajkd.2021.02.341] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 02/24/2021] [Indexed: 11/11/2022]
Abstract
The anion gap (AG) is a mathematical construct that compares the blood sodium concentration with the sum of the chloride and bicarbonate concentrations. It is a helpful calculation that divides the metabolic acidoses into 2 categories: high AG metabolic acidosis (HAGMA) and hyperchloremic metabolic acidosis-and thereby delimits the potential etiologies of the disorder. When the [AG] is compared with changes in the bicarbonate concentration, other occult acid-base disorders can be identified. Furthermore, finding that the AG is very small or negative can suggest several occult clinical disorders or raise the possibility of electrolyte measurement artifacts. In this installment of AJKD's Core Curriculum in Nephrology, we discuss cases that represent several very common and several rare causes of HAGMA. These case scenarios highlight how the AG can provide vital clues that direct the clinician toward the correct diagnosis. We also show how to calculate and, if necessary, correct the AG for hypoalbuminemia and severe hyperglycemia. Plasma osmolality and osmolal gap calculations are described and when used together with the AG guide appropriate clinical decision making.
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Affiliation(s)
- Andrew Z Fenves
- Division of Nephrology, Department of Internal Medicine, Massachusetts General Hospital, and Medical School, Harvard University, Boston, MA
| | - Michael Emmett
- Internal Medicine, Baylor University Medical Center, Dallas, TX.
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Rymut HE, Rund LA, Bolt CR, Villamil MB, Southey BR, Johnson RW, Rodriguez-Zas SL. The Combined Effect of Weaning Stress and Immune Activation during Pig Gestation on Serum Cytokine and Analyte Concentrations. Animals (Basel) 2021; 11:2274. [PMID: 34438732 PMCID: PMC8388404 DOI: 10.3390/ani11082274] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/23/2021] [Accepted: 07/30/2021] [Indexed: 12/17/2022] Open
Abstract
Weaning stress can elicit changes in the metabolic, hormone and immune systems of pigs and interact with prolonged disruptions stemming from maternal immune activation (MIA) during gestation. The present study advances the characterization of the combined effects of weaning stress and MIA on blood chemistry, immune and hormone indicators that inform on the health of pigs. Three-week-old female and male offspring of control gilts or gilts infected with the porcine reproductive and respiratory syndrome virus were allocated to weaned or nursed groups. The anion gap and bilirubin profiles suggest that MIA enhances tolerance to the effects of weaning stress. Interleukin 1 beta and interleukin 2 were highest among weaned MIA females, and cortisol was higher among weaned relative to nursed pigs across sexes. Canonical discriminant analysis demonstrated that weaned and nursed pigs have distinct chemistry profiles, whereas MIA and control pigs have distinct cytokine profiles. The results from this study can guide management practices that recognize the effects of the interaction between MIA and weaning stress on the performance and health of pigs.
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Affiliation(s)
- Haley E. Rymut
- Department of Animal Sciences, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA; (H.E.R.); (L.A.R.); (C.R.B.); (B.R.S.); (R.W.J.)
| | - Laurie A. Rund
- Department of Animal Sciences, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA; (H.E.R.); (L.A.R.); (C.R.B.); (B.R.S.); (R.W.J.)
| | - Courtni R. Bolt
- Department of Animal Sciences, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA; (H.E.R.); (L.A.R.); (C.R.B.); (B.R.S.); (R.W.J.)
| | - Maria B. Villamil
- Department of Crop Sciences, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA;
| | - Bruce R. Southey
- Department of Animal Sciences, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA; (H.E.R.); (L.A.R.); (C.R.B.); (B.R.S.); (R.W.J.)
| | - Rodney W. Johnson
- Department of Animal Sciences, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA; (H.E.R.); (L.A.R.); (C.R.B.); (B.R.S.); (R.W.J.)
| | - Sandra L. Rodriguez-Zas
- Department of Animal Sciences, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA; (H.E.R.); (L.A.R.); (C.R.B.); (B.R.S.); (R.W.J.)
- Department of Crop Sciences, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA;
- Department of Statistics, University of Illinois at Urbana-Champaign, Urbana, IL 61820, USA
- Center for Digital Agriculture, University of Illinois at Urbana-Champaign, Urbana, IL 61801, USA
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Asahina Y, Sakaguchi Y, Kajimoto S, Hattori K, Doi Y, Oka T, Kaimori JY, Isaka Y. Association of Time-Updated Anion Gap With Risk of Kidney Failure in Advanced CKD: A Cohort Study. Am J Kidney Dis 2021; 79:374-382. [PMID: 34280508 DOI: 10.1053/j.ajkd.2021.05.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/29/2021] [Indexed: 11/11/2022]
Abstract
RATIONALE AND OBJECTIVE High anion gap acidosis frequently develops in patients with advanced chronic kidney disease (CKD) and might be involved in kidney injury. Its impact on kidney outcomes, however, has not been well studied. We sought to examine the association between time-updated anion gap and the risk of kidney failure with replacement therapy (KFRT) among patients with advanced CKD. STUDY DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS 1,168 patients with CKD stages G3b-G5 who had available data on anion gap. EXPOSURE High time-updated anion gap defined as values ≥9.2 (top 25th percentile). OUTCOMES KFRT and death. ANALYTICAL APPROACH Marginal structural models (MSM) were fit to characterize the association between anion gap and study outcomes while accounting for potential time-dependent confounding. RESULTS The mean baseline eGFR of the study participants was 28 mL/min/1.73m2. Over a median follow-up of 3.1 years, 317 patients progressed to KFRT (7.5/100 patient-years) and 146 died (3.5/100 patient-years). In the MSM, a high anion gap was associated with a higher rate of KFRT (hazard ratio [HR], 3.04; 95% confidence interval [CI], 1.94-4.75; P<0.001). This association was stronger in patients with baseline eGFR of <30 mL/min/1.73m2 (P for interaction=0.05). High anion gap was also associated with a higher mortality rate (HR, 5.56; 95% CI, 2.95-10.5; P<0.001). Sensitivity analyses with different definitions of high anion gap showed similar results. LIMITATIONS Observational study design; selection bias due clinical indications for measuring anion gap. CONCLUSION Among patients with advanced CKD, high anion gap was associated with an increased risk of progression to KFRT and death.
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Affiliation(s)
- Yuta Asahina
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yusuke Sakaguchi
- Department of Inter-Organ Communication Research in Kidney Diseases, Osaka University Graduate School of Medicine, Suita, Japan
| | - Sachio Kajimoto
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Kohki Hattori
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yohei Doi
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Tatsufumi Oka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Jun-Ya Kaimori
- Department of Inter-Organ Communication Research in Kidney Diseases, Osaka University Graduate School of Medicine, Suita, Japan.
| | - Yoshitaka Isaka
- Department of Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
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Dafal A, Kumar S, Agrawal S, Acharya S, Nirmal A. Admission Anion Gap Metabolic Acidosis and Its Impact on Patients in Medical Intensive Care Unit. J Lab Physicians 2021; 13:107-111. [PMID: 34483553 PMCID: PMC8409118 DOI: 10.1055/s-0041-1726568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction Anion gap (AG) metabolic acidosis is common in critically ill patients. The relationship between initial AG at the time of admission to the medical intensive care unit (MICU) and mortality or length of stay is unclear. This study was undertaken to evaluate this relationship. Materials and Method We prospectively examined the acid-base status of 500 consecutive patients at the time of MICU admission and outcome was measured in terms of mortality, length of ICU stay, need of ventilator, and laboratory parameters. The patients were divided into four stages based on the severity of AG. Outcome based on the severity of AG was measured, and comparisons that adjusted for baseline characteristics were performed. Results This study showed that increased AG was associated with the higher mortality. Patients with the highest AG also had the longest length of stay in the MICU, and patients with normal acid-base status had the shortest ICU length of stays ( p < 0.05). Conclusion A high AG at the time of admission to the MICU was associated with higher mortality and length of stays. Initial risk stratification based on AG and metabolic acidosis may help guide appropriate patient disposition (especially in patients without other definitive criteria for MICU admission) and assist with prognosis.
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Affiliation(s)
- Akshay Dafal
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India
| | - Sunil Kumar
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India
| | - Sachin Agrawal
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India
| | - Sourya Acharya
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India
| | - Apoorva Nirmal
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, Maharashtra, India
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Gong F, Zhou Q, Gui C, Huang S, Qin Z. The Relationship Between the Serum Anion Gap and All-Cause Mortality in Acute Pancreatitis: An Analysis of the MIMIC-III Database. Int J Gen Med 2021; 14:531-538. [PMID: 33642873 PMCID: PMC7903165 DOI: 10.2147/ijgm.s293340] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 01/25/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose We aimed to investigate the relationship between the serum anion gap (AG) and all-cause mortality in patients with acute pancreatitis (AP) in intensive care units (ICUs). Patients and Methods In this retrospective cohort analysis, data of patients with AP were extracted from the Medical Information Mart for Intensive Care database (version III). We collected the maximum serum AG value within the first 24 hours of ICU admission. The main outcome was 90-day all-cause mortality. A multivariate Cox proportional hazard regression model was used to examine the association between the serum AG and mortality. The restricted cubic spline curve was used to confirm a non-linear relationship between serum AG values and mortality. Results Of the 279 patients included in the study, 87 (31.18%) died. The serum AG value was positively associated with 90-day all-cause mortality (hazard ratio [HR] 1.08, 95% confidence interval [CI] 1.02-1.14), after adjusting for age, sex, alcohol consumption, congestive heart failure, diabetes mellitus, hypertension, eGFR, albumin, and the SOFA score. There was a non-linear relationship between serum AG values and mortality after adjusting for potential confounders. We used a two-piecewise regression model to obtain a threshold inflection point value of 13.8 mmol/L. The HR and the 95% CI on the left inflection point were 0. 82 (0.61-1.09; p = 0.1719), and on the right inflection point were 1.15 (1.08-1.23; p < 0.0001). Conclusion The relationship between all-cause mortality in patients with acute pancreatitis and serum AG values was non-linear. All-cause mortality and serum AG values were positively correlated when the serum AG value was >13.8 mmol/L.
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Affiliation(s)
- Fang Gong
- Department of Intensive Care Unit, The First People's Hospital of Changde, Changde City, Hunan Province, 415000, People's Republic of China
| | - Quan Zhou
- Department of Science and Education Section, The First People's Hospital of Changde, Changde City, Hunan Province, 415000, People's Republic of China
| | - Chunmei Gui
- Department of Intensive Care Unit, The First People's Hospital of Changde, Changde City, Hunan Province, 415000, People's Republic of China
| | - Shaohua Huang
- Department of Intensive Care Unit, The First People's Hospital of Changde, Changde City, Hunan Province, 415000, People's Republic of China
| | - Zuoan Qin
- Cardiovascular Medicine Department, The First People's Hospital of Changde, Changde City, Hunan Province, 415000, People's Republic of China
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Patel R, Mistry AM, Mistry CM. Unintentional Ethylene Glycol Poisoning in an Adolescent. Cureus 2020; 12:e11521. [PMID: 33354465 PMCID: PMC7746011 DOI: 10.7759/cureus.11521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The differential diagnosis is broad when a patient presents with an altered mental status. Ethylene glycol poisoning, a life-threatening condition, can occur as an intentional self-harm attempt or unintentional consumption. It is metabolized in the liver by a series of enzymes, and the metabolites so formed are responsible for the majority of clinical effects. The diverse range of clinical effects includes central nervous system (CNS), gastrointestinal, cardiovascular system (CVS), pulmonary as well as renal effects. The evidence of metabolic acidosis, elevated anion gap, high osmolal gap, and calcium oxalate crystals in laboratory analysis strongly suggests ethylene glycol poisoning. The treatment traditionally consists of alcohol dehydrogenase inhibitors such as fomepizole or ethanol, and in some cases, hemodialysis is needed as well.
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Affiliation(s)
- Rutul Patel
- Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College (NHLMMC), Ahmedabad, IND
| | - Anuja Mahesh Mistry
- Internal Medicine, Smt. Nathiba Hargovandas Lakhmichand (NHL) Municipal Medical College (NHLMMC), Ahmedabad, IND
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Gulen M, Satar S, Avci A, Acehan S, Orhan U, Nazik H. Methanol poisoning in Turkey: Two outbreaks, a single center experience. Alcohol 2020; 88:83-90. [PMID: 32702502 DOI: 10.1016/j.alcohol.2020.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 07/07/2020] [Accepted: 07/14/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVES Methanol poisoning is still one of the major causes of mortality due to intoxication because of the challenging diagnosis and late hospital admissions. We aimed to evaluate epidemiological data, clinical characteristics, laboratory findings, treatment protocols, and prognosis of patients in a tertiary hospital in two different methanol outbreaks occurring in a three-year interval. METHODS The study was planned as a single-center and retrospective observational case series study. Patients ≥18 years of age who were admitted to the hospital between 1 September 2016 and 1 September 2019 and diagnosed with methanol poisoning were included in the study. RESULTS Sixty-seven patients whose data were sufficient and accessible were included in the study. Thirty-five (52.2%) patients were discharged without sequelae, 14 (20.9%) patients were discharged with sequelae (both central nervous system sequelae and visual sequelae in 3 patients, only visual sequelae in 11 patients) and 18 (26.9%) patients died. High anion gap (AG) metabolic acidosis (pH < 7.07, AG > 26.7), low Glasgow Coma Score, and increased lactate (lactate > 2.55 mmol/L) levels were found to be associated with poor outcome. Folate use in treatment did not have a statistically significant effect (p = 0.087) on the prevention of visual sequelae development, but it had a statistically significant effect on mortality (p = 0.041). CONCLUSIONS State of consciousness and the severity of metabolic acidosis were significant parameters associated with mortality. In addition to antidote and elimination therapies, given the benefit on mortality and low risk of adverse events, folate therapy should be considered for all patients with significant toxic methanol exposures.
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Affiliation(s)
- Muge Gulen
- Adana City Training and Research Hospital, Department of Emergency Medicine, Adana, Turkey.
| | - Salim Satar
- Adana City Training and Research Hospital, Department of Emergency Medicine, Adana, Turkey
| | - Akkan Avci
- Adana City Training and Research Hospital, Department of Emergency Medicine, Adana, Turkey
| | - Selen Acehan
- Adana City Training and Research Hospital, Department of Emergency Medicine, Adana, Turkey
| | - Ugur Orhan
- Bitlis State Hospital, Department of Emergency Medicine, Bitlis, Turkey
| | - Hakan Nazik
- Adana City Training and Research Hospital, Department of Gynecology and Obstetrics, Adana, Turkey
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Liu X, Feng Y, Zhu X, Shi Y, Lin M, Song X, Tu J, Yuan E. Serum anion gap at admission predicts all-cause mortality in critically ill patients with cerebral infarction: evidence from the MIMIC-III database. Biomarkers 2020; 25:725-732. [PMID: 33103496 DOI: 10.1080/1354750x.2020.1842497] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Recent studies reported that serum anion gap could be regarded as a prognostic biomarker for patients admitted to intensive care units. However, the association between AG and mortality in cerebral infarction patients remained largely unknown. METHODS Relevant clinical data were collected from Medical Information Mart for Intensive Care III. Patients were divided into three groups according to tertiles of AG. Kaplan-Meier curve and Cox proportional hazards models were used to evaluate the association between AG levels and all-cause mortality. Subgroup analyses were performed to verify the predictive role of AG on mortality. RESULTS Kaplan-Meier analysis showed that patients with higher AG had shorter survival time. Cox regression model indicated high AG as an independent risk factor of 30-day, 60-day and 180-day all-cause mortality (30-day: HR = 2.45, 95% CI = 1.21-4.97, 60-day: HR = 2.04, 95% CI = 1.07-3.89, and 180-day: HR = 1.85, 95% CI = 1.02-3.36). However, no significance was observed between AG and 365-day all-cause mortality (HR = 1.56, 95% CI = 0.87-2.78). CONCLUSIONS High AG was associated with increased risk of all-cause mortality, and AG could be an independent short-term prognostic factor for cerebral infarction.
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Affiliation(s)
- Xuefang Liu
- Department of Clinical Laboratory, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanlin Feng
- Program & Department of Clinical Laboratory Medicine, Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xinyu Zhu
- Program & Department of Clinical Laboratory Medicine, Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ying Shi
- Department of Clinical Laboratory, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Manting Lin
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xiaoyan Song
- Department of Clinical Laboratory, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiancheng Tu
- Program & Department of Clinical Laboratory Medicine, Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Enwu Yuan
- Department of Clinical Laboratory, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Trevor-Jones E, Hughes LT, Robson R, Bromley A, Stewart GW. Lessons of the month: Pyroglutamic acidosis: long-term paracetamol and a high anion gap. Clin Med (Lond) 2020; 20:522-523. [PMID: 32934051 DOI: 10.7861/clinmed.2020-0363] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
An 84-year-old woman presented in extremis with confusion and Kussmaul respiration. She had a history of urosepsis, renal impairment and osteoarthrosis. The venous blood gas showed a marked metabolic acidosis with a high anion gap. Lactate and ketones were normal. Her medications included regular paracetamol via a dosette box. Lactic acidosis and ketoacidosis being excluded, it emerged that the most likely cause of a high anion-gap acidosis in the presence of chronic paracetamol therapy is pyroglutamic acidosis, caused by the build-up of an acidic intermediate in the gamma-glutamyl cycle, the function of which is to synthesise glutathione. Paracetamol was stopped and fluids administered; she recovered over 7 days and was sent home. The biochemical diagnosis was confirmed by a central laboratory after discharge. This case emphasises the importance of the anion gap in diagnosis, and one important danger of chronic paracetamol administration.
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Affiliation(s)
| | - Lewis T Hughes
- speciality doctor in palliative and supportive care, Western Isles Hospital, Stornoway, UK
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Adrogué HJ, Madias NE. Veverimer: An Emerging Potential Treatment Option for Managing the Metabolic Acidosis of CKD. Am J Kidney Dis 2020; 76:861-867. [PMID: 32920151 DOI: 10.1053/j.ajkd.2020.07.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/05/2020] [Indexed: 11/11/2022]
Abstract
Sodium bicarbonate is the mainstay treatment of the metabolic acidosis of chronic kidney disease but associated concerns center on administering sodium to patients with hypertension and sodium-retentive states. Veverimer (formerly referred to as TRC101), a drug candidate for which Tricida, Inc is seeking approval from the US Food and Drug Administration, is a novel nonabsorbable polymer that binds hydrogen cations and chloride anions in the gastrointestinal tract and then is excreted fecally, thereby increasing serum bicarbonate concentration without administering sodium. We examine the published evidence on the investigational use of veverimer in patients with chronic kidney disease and metabolic acidosis. We highlight the achieved increase in serum bicarbonate concentration without coadministering sodium, effects on physical functioning, and the safety record of the drug. We also scrutinize certain unanticipated findings: a lack of dose dependency in the increase in serum bicarbonate concentration observed and that despite the presumed large hydrogen chloride losses in feces, veverimer induces an isochloremic increase in serum bicarbonate concentration that is accompanied by a decrease in serum anion gap. We propose likely explanations for these puzzling findings and raise questions about veverimer's mode of action and its potential interaction with colonic bacterial flora. Additional work is required to fill these knowledge gaps that could have important clinical implications.
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Affiliation(s)
- Horacio J Adrogué
- Department of Medicine, Baylor College of Medicine, Houston, TX; Division of Nephrology, Department of Medicine, Houston Methodist Hospital, Houston, TX
| | - Nicolaos E Madias
- Department of Medicine, Tufts University School of Medicine, Boston, MA; Division of Nephrology, Department of Medicine, St. Elizabeth's Medical Center, Boston, MA.
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Sławuta P, Sikorska-Kopyłowicz A, Sapikowski G. Diagnostic utility of different models used to assess the acid-base balance in cats with chronic kidney disease. Acta Vet Hung 2020; 68:169-176. [PMID: 32857709 DOI: 10.1556/004.2020.00032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 05/06/2020] [Indexed: 11/19/2022]
Abstract
Metabolic acidosis is diagnosed based on the concentration of bicarbonate ions and partial pressure of carbon dioxide in arterial blood, although acid-base balance (ABB) disorders may also be diagnosed based on the serum ion concentrations in order to determine the values of strong ion difference (SID), anion gap (AG), corrected anion gap (AGcorr) and chloride/sodium ratio (Cl-/Na+). The aim of this study was to assess and compare the classic model, the value of the AG, AGcorr, and Cl-/Na+ in the diagnosis of ABB disorders in cats with chronic kidney disease (CKD). The study group consisted of 80 cats with CKD, divided into four groups based on the guidelines of the International Renal Interest Society (IRIS). The control group (C) included 20 healthy cats. Metabolic acidosis - diagnosed based on the classic model (Hendersson-Hasselbalch equation) - was found in IRIS group IV. AG, AGcorr, SID calculated for IRIS groups II, III and IV were lower than in group C, while the value of AGdiff and Cl-/Na+ in those groups was higher than in group C. We can conclude that ABB analysis using the classic model enabled the detection of ABB disorders in cats in stage IV CKD. However, the analysis of the AG, AGcorr and Cl-/Na+ values enabled the diagnosis of acid-base balance disorders in cats with IRIS stage II, III and IV CKD.
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Affiliation(s)
- Piotr Sławuta
- Department of Internal Medicine and Clinic of Diseases of Horses, Dogs and Cats, The Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Science, Norwida 32, 50-375, Wrocław, Poland
| | - Agnieszka Sikorska-Kopyłowicz
- Department of Internal Medicine and Clinic of Diseases of Horses, Dogs and Cats, The Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Science, Norwida 32, 50-375, Wrocław, Poland
| | - Grzegorz Sapikowski
- Department of Internal Medicine and Clinic of Diseases of Horses, Dogs and Cats, The Faculty of Veterinary Medicine, Wrocław University of Environmental and Life Science, Norwida 32, 50-375, Wrocław, Poland
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Abstract
Paraquat (PQ) poisoning is associated with high mortality rate. Therefore, an accurate method for predicting the survival of patients with PQ poisoning is required. This study evaluated the value of serum anion gap (AG) at admission in predicting the survival of such patients.Cases of patients with PQ poisoning admitted to Cangzhou Central Hospital between May 2012 and March 2019 were retrospectively analyzed. The patients were classified into survival and nonsurvival groups on the basis of their 90-day prognosis. Correlation analysis, Cox regression analysis, and receiver operating characteristic and Kaplan-Meier curve analyses were performed to assess the value of AG in predicting the 90-day survival of patients with PQ poisoning.Only 44 of the 108 patients with PQ poisoning survived; thus, the 90-day survival was 40.74%. AG levels at admission were significantly higher in nonsurvivors (26.53 ± 4.93 mmol/L) than in survivors (20.88 ± 2.74 mmol/L) (P < .001) and negatively correlated with 90-day survival (r = -0.557; P < .001). Cox regression analysis revealed that AG at admission is an independent prognostic marker of the 90-day survival of patients with PQ poisoning. AG level at admission had an area under the receiver operating characteristic curve of 0.836 (95% confidence interval: 0.763-0.909) and an optimal cut-off value of 25.5 mmol/L (59.4% sensitivity and 95.5% specificity).AG level at admission may serve as a candidate marker for predicting the survival of patients with PQ poisoning.
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Downs IL, Shaia CI, Zeng X, Johnson JC, Hensley L, Saunders DL, Rossi F, Cashman KA, Esham HL, Gregory MK, Pratt WD, Trefry JC, Everson KA, Larcom CB, Okwesili AC, Cardile AP, Honko A. Natural History of Aerosol Induced Lassa Fever in Non‑Human Primates. Viruses 2020; 12:E593. [PMID: 32485952 PMCID: PMC7354473 DOI: 10.3390/v12060593] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/20/2020] [Accepted: 05/22/2020] [Indexed: 12/15/2022] Open
Abstract
Lassa virus (LASV), an arenavirus causing Lassa fever, is endemic to West Africa with up to 300,000 cases and between 5000 and 10,000 deaths per year. Rarely seen in the United States, Lassa virus is a CDC category A biological agent inasmuch deliberate aerosol exposure can have high mortality rates compared to naturally acquired infection. With the need for an animal model, specific countermeasures remain elusive as there is no FDA-approved vaccine. This natural history of aerosolized Lassa virus exposure in Macaca fascicularis was studied under continuous telemetric surveillance. The macaque response to challenge was largely analogous to severe human disease with fever, tachycardia, hypotension, and tachypnea. During initial observations, an increase trend of activated monocytes positive for viral glycoprotein was accompanied by lymphocytopenia. Disease uniformly progressed to high viremia followed by low anion gap, alkalosis, anemia, and thrombocytopenia. Hypoproteinemia occurred late in infection followed by increased levels of white blood cells, cytokines, chemokines, and biochemical markers of liver injury. Viral nucleic acids were detected in tissues of three non‑survivors at endpoint, but not in the lone survivor. This study provides useful details to benchmark a pivotal model of Lassa fever in support of medical countermeasure development for both endemic disease and traditional biodefense purposes.
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Affiliation(s)
- Isaac L. Downs
- US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA; (I.L.D.); (C.I.S.); (X.Z.); (J.C.J.); (L.H.); (D.L.S.); (F.R.); (K.A.C.); (H.L.E.); (M.K.G.); (W.D.P.); (J.C.T.); (K.A.E.); (A.C.O.); (A.H.)
| | - Carl I. Shaia
- US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA; (I.L.D.); (C.I.S.); (X.Z.); (J.C.J.); (L.H.); (D.L.S.); (F.R.); (K.A.C.); (H.L.E.); (M.K.G.); (W.D.P.); (J.C.T.); (K.A.E.); (A.C.O.); (A.H.)
| | - Xiankun Zeng
- US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA; (I.L.D.); (C.I.S.); (X.Z.); (J.C.J.); (L.H.); (D.L.S.); (F.R.); (K.A.C.); (H.L.E.); (M.K.G.); (W.D.P.); (J.C.T.); (K.A.E.); (A.C.O.); (A.H.)
| | - Joshua C. Johnson
- US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA; (I.L.D.); (C.I.S.); (X.Z.); (J.C.J.); (L.H.); (D.L.S.); (F.R.); (K.A.C.); (H.L.E.); (M.K.G.); (W.D.P.); (J.C.T.); (K.A.E.); (A.C.O.); (A.H.)
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Frederick, MD 21702, USA
| | - Lisa Hensley
- US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA; (I.L.D.); (C.I.S.); (X.Z.); (J.C.J.); (L.H.); (D.L.S.); (F.R.); (K.A.C.); (H.L.E.); (M.K.G.); (W.D.P.); (J.C.T.); (K.A.E.); (A.C.O.); (A.H.)
- Integrated Research Facility, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Frederick, MD 21702, USA
| | - David L. Saunders
- US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA; (I.L.D.); (C.I.S.); (X.Z.); (J.C.J.); (L.H.); (D.L.S.); (F.R.); (K.A.C.); (H.L.E.); (M.K.G.); (W.D.P.); (J.C.T.); (K.A.E.); (A.C.O.); (A.H.)
| | - Franco Rossi
- US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA; (I.L.D.); (C.I.S.); (X.Z.); (J.C.J.); (L.H.); (D.L.S.); (F.R.); (K.A.C.); (H.L.E.); (M.K.G.); (W.D.P.); (J.C.T.); (K.A.E.); (A.C.O.); (A.H.)
| | - Kathleen A. Cashman
- US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA; (I.L.D.); (C.I.S.); (X.Z.); (J.C.J.); (L.H.); (D.L.S.); (F.R.); (K.A.C.); (H.L.E.); (M.K.G.); (W.D.P.); (J.C.T.); (K.A.E.); (A.C.O.); (A.H.)
| | - Heather L. Esham
- US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA; (I.L.D.); (C.I.S.); (X.Z.); (J.C.J.); (L.H.); (D.L.S.); (F.R.); (K.A.C.); (H.L.E.); (M.K.G.); (W.D.P.); (J.C.T.); (K.A.E.); (A.C.O.); (A.H.)
| | - Melissa K. Gregory
- US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA; (I.L.D.); (C.I.S.); (X.Z.); (J.C.J.); (L.H.); (D.L.S.); (F.R.); (K.A.C.); (H.L.E.); (M.K.G.); (W.D.P.); (J.C.T.); (K.A.E.); (A.C.O.); (A.H.)
| | - William D. Pratt
- US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA; (I.L.D.); (C.I.S.); (X.Z.); (J.C.J.); (L.H.); (D.L.S.); (F.R.); (K.A.C.); (H.L.E.); (M.K.G.); (W.D.P.); (J.C.T.); (K.A.E.); (A.C.O.); (A.H.)
| | - John C. Trefry
- US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA; (I.L.D.); (C.I.S.); (X.Z.); (J.C.J.); (L.H.); (D.L.S.); (F.R.); (K.A.C.); (H.L.E.); (M.K.G.); (W.D.P.); (J.C.T.); (K.A.E.); (A.C.O.); (A.H.)
- Defense Threat Reduction Agency, Fort Belvoir, VA 22060, USA
| | - Kyle A. Everson
- US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA; (I.L.D.); (C.I.S.); (X.Z.); (J.C.J.); (L.H.); (D.L.S.); (F.R.); (K.A.C.); (H.L.E.); (M.K.G.); (W.D.P.); (J.C.T.); (K.A.E.); (A.C.O.); (A.H.)
| | - Charles B. Larcom
- Madigan Army Medical Center, Joint Base Lewis-McChord, WA 98431, USA;
| | - Arthur C. Okwesili
- US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA; (I.L.D.); (C.I.S.); (X.Z.); (J.C.J.); (L.H.); (D.L.S.); (F.R.); (K.A.C.); (H.L.E.); (M.K.G.); (W.D.P.); (J.C.T.); (K.A.E.); (A.C.O.); (A.H.)
| | - Anthony P. Cardile
- US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA; (I.L.D.); (C.I.S.); (X.Z.); (J.C.J.); (L.H.); (D.L.S.); (F.R.); (K.A.C.); (H.L.E.); (M.K.G.); (W.D.P.); (J.C.T.); (K.A.E.); (A.C.O.); (A.H.)
| | - Anna Honko
- US Army Medical Research Institute of Infectious Diseases, Fort Detrick, Frederick, MD 21702, USA; (I.L.D.); (C.I.S.); (X.Z.); (J.C.J.); (L.H.); (D.L.S.); (F.R.); (K.A.C.); (H.L.E.); (M.K.G.); (W.D.P.); (J.C.T.); (K.A.E.); (A.C.O.); (A.H.)
- Investigator at National Emerging Infectious Diseases Laboratories, Boston University School of Medicine, Boston, MA 02118, USA
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Gardner J, Tuttle K, Raphael KL. Influence of Medications Containing Acid Salts on Serum Bicarbonate in CKD. Kidney360 2020; 1:330-336. [PMID: 35369374 PMCID: PMC8809288 DOI: 10.34067/kid.0000532019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/18/2020] [Indexed: 06/14/2023]
Abstract
BACKGROUND Many medications are formulated with acid salts. Their effect on acid-base balance in CKD is unclear. METHODS We calculated the acid load (meq/d) from medications prescribed to 74 United States veterans with diabetes and CKD to identify agents with high potential acid load. We also determined cross-sectional associations between the acid load from medications and acid-base parameters after adjusting for demographics, eGFR, protein intake, and other confounders. RESULTS Of the 125 medications prescribed, 31 (25%) contained an acid salt. Metformin hydrochloride (15.4 meq/d at 2550 mg/d) and gabapentin hydrochloride (13.0 meq/d at 2700 mg/d) were identified as agents with a high potential acid load. Mean daily acid load from medications was 6.6 meq/d in the overall cohort, 14.2 meq/d in the high medication acid load group (≥7.7 meq/d, n=29), and 1.6 meq/d in the low medication acid load group (<7.7 meq/d, n=45). After adjusting for potential confounders, those in the high acid load group had 1.7 meq/L lower total carbon dioxide (CO2) and 2.2 meq/L higher anion gap than those in the low acid load group. Use of gabapentin alone was not associated with differences in total CO2 or anion gap. Use of metformin alone was associated with 0.7 meq/L lower total CO2 and 1.0 meq/L higher anion gap. Use of metformin with gabapentin was associated with 1.8 meq/L lower total CO2 and 2.4 meq/L higher anion gap. The higher anion gap was not explained by higher serum lactate levels. The acid load from medications was not associated with differences in urinary ammonium, titratable acid, or pH. CONCLUSIONS Medications containing acid salts, particularly metformin hydrochloride and gabapentin hydrochloride, are sources of an exogenous acid load. These agents may influence serum total CO2 levels and serum anion gap in individuals with CKD. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Investigations of the Optimum Serum Bicarbonate Level in Renal Disease, NCT01574157.
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Affiliation(s)
- John Gardner
- Pharmacy Section, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, Utah
| | - Kunani Tuttle
- Department of Internal Medicine, University of Utah Health, Salt Lake City, Utah
| | - Kalani L. Raphael
- Department of Internal Medicine, University of Utah Health, Salt Lake City, Utah
- Medicine Section, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, Utah
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Erejuwa OO, Aja DOJ, Uwaezuoke NI, Nwadike KI, Ezeokpo BC, Akpan JL, Nwobodo NN, Araromi E, Asika E. Effects of honey supplementation on renal dysfunction and metabolic acidosis in rats with high-fat diet-induced chronic kidney disease. J Basic Clin Physiol Pharmacol 2020; 32:/j/jbcpp.ahead-of-print/jbcpp-2019-0151/jbcpp-2019-0151.xml. [PMID: 32396139 DOI: 10.1515/jbcpp-2019-0151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 03/03/2020] [Indexed: 12/27/2022]
Abstract
Background Metabolic diseases are associated with impaired renal function which accelerates chronic kidney disease (CKD) progression. The aim of this study was to investigate the effects of 16-week honey supplementation on renal function, metabolic acidosis and renal abnormalities in Wistar rats fed a high-fat diet (HFD). Methods Wistar rats were fed a HFD and sucrose (30%) solution and randomly grouped and treated. Group 1 was fed rat chow and treated with drinking water while groups 2, 3, 4 and 5 were fed a HFD and treated with drinking water, 1, 2 and 3 g/kg body weight (BW) of honey, respectively, once daily for 16 weeks. After the rats were sacrificed, the serum samples were obtained and used for the analysis of total cholesterol, urea, creatinine, sodium, potassium, calcium, bicarbonates and chloride ions. Histopathological examinations of the kidneys were performed. Results The serum creatinine and anion gap levels were significantly (p < 0.01) higher while the levels of serum total calcium and ionized fraction were significantly (p < 0.01) lower in HFD-fed control rats than in chow-fed rats. The kidney of HFD-fed control rats was characterized by tubular necrosis, glomerular atrophy, hemorrhage and severe focal aggregate inflammatory (FAIC) cells. Honey treatment (1, 2 or 3 g/kg BW) prevented elevations in serum creatinine while it restored serum levels of total calcium and ionized calcium towards those in rats fed chow only. All the three doses of honey also significantly (p < 0.01) reduced anion gap and ameliorated renal lesions. Honey treatment (2 g/kg BW) significantly (p < 0.05) increased bicarbonate and chloride ion in HFD-fed rats compared with HFD-fed control rats. Conclusions Sixteen-week honey supplementation ameliorates renal dysfunction, metabolic acidosis and renal morphological abnormalities in HFD-fed Wistar rats.
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Affiliation(s)
- Omotayo O Erejuwa
- Ebonyi State University Faculty of Clinical Medicine, Department of Pharmacology and Therapeutics, Abakaliki, Ebonyi, Nigeria
| | - Daniel Ogbonna John Aja
- Ebonyi State University, Department of Pharmacology and Therapeutics, Abakaliki, Ebonyi, Nigeria
| | - Nkemjika I Uwaezuoke
- University of Nigeria, Department of Pharmacology and Therapeutics, Enugu, Enugu State, Nigeria
| | - Kenneth I Nwadike
- University of Nigeria, Department of Pharmacology and Therapeutics, Enugu, Enugu State, Nigeria
| | | | - Joseph Linus Akpan
- Ebonyi State University, Department of Pharmacology and Therapeutics, Abakaliki, Ebonyi, Nigeria
| | - Nwobodo Ndubuisi Nwobodo
- Ebonyi State University, Department of Pharmacology and Therapeutics, Abakaliki, Ebonyi, Nigeria
| | - Ebisola Araromi
- Ekiti State University, Department of Pharmacology and Therapeutics, Ado Ekiti, Ekiti, Nigeria
| | - Ebere Asika
- Ebonyi State University, Department of Pharmacology and Therapeutics, Abakaliki, Ebonyi, Nigeria
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van den Bersselaar LR, van den Brule JMD, van der Hoeven JG. Acetaminophen Use Concomitant with Long-Lasting Flucloxacillin Therapy: A Dangerous Combination. Eur J Case Rep Intern Med 2020; 7:001569. [PMID: 32665925 PMCID: PMC7350975 DOI: 10.12890/2020_001569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 02/25/2020] [Indexed: 11/16/2022] Open
Abstract
Acetaminophen and flucloxacillin both interfere with the γ-glutamyl cycle. Long-lasting concomitant use of flucloxacillin and acetaminophen can lead to 5-oxoproline accumulation and severe high anion gap metabolic acidosis. Females and patients with sepsis, impaired kidney and/or liver function, malnutrition, advanced age, congenital 5-oxoprolinase deficiency and supratherapeutic acetaminophen and flucloxacillin dosage are associated with increased risk. Therefore, a critical attitude towards the prescription of acetaminophen concomitant with flucloxacillin in these patients is needed. We present the case of a 79-year-old woman with severe 5-oxoprolinaemia after long-lasting treatment with flucloxacillin and acetaminophen, explaining the toxicological mechanism and risk factors, and we make recommendations for acetaminophen use in patients with long-lasting flucloxacillin treatment.
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Venkataraman SS, Regone R, Ammar HM, Govindu RR. Pyroglutamic Acidemia: An Underrecognized and Underdiagnosed Cause of High Anion Gap Metabolic Acidosis - A Case Report and Review of Literature. Cureus 2019; 11:e5229. [PMID: 31565630 PMCID: PMC6758980 DOI: 10.7759/cureus.5229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Pyroglutamic acidemia (oxoprolinemia) is an underrecognized cause of high anion gap acidosis resulting from derangement in the gamma-glutamyl cycle. Pyroglutamic acidemia is most commonly diagnosed in the pediatric population in patients with inherited autosomal recessive enzyme deficiencies. However, acquired pyroglutamic acidemia can present in the adult population. Patients often present with confusion, nausea, and vomiting as well as an elevated anion gap metabolic acidosis. This article describes a case of acquired pyroglutamic acidemia and emphasizes the need to consider this entity.
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Affiliation(s)
- Sidish S Venkataraman
- Neurological Surgery, Wake Forest University Baptist Medical Center, Winston-Salem, USA
| | | | - Hussam M Ammar
- Internal Medicine, Medstar Washington Hospital Center, Washington, USA
| | - Rukma R Govindu
- Internal Medicine, The University of Texas Health Science Center at Houston, Houston, USA
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Banerjee T, Crews DC, Wesson DE, McCulloch CE, Johansen KL, Saydah S, Rios Burrows N, Saran R, Gillespie B, Bragg-Gresham J, Powe NR. Elevated serum anion gap in adults with moderate chronic kidney disease increases risk for progression to end-stage renal disease. Am J Physiol Renal Physiol 2019; 316:F1244-F1253. [PMID: 30908932 PMCID: PMC6620593 DOI: 10.1152/ajprenal.00496.2018] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 03/08/2019] [Accepted: 03/19/2019] [Indexed: 01/13/2023] Open
Abstract
Acid retention associated with reduced glomerular filtration rate (GFR) exacerbates nephropathy progression in partial nephrectomy models of chronic kidney disease (CKD) and might be reflected in patients with CKD with reduced estimated GFR (eGFR) by increased anion gap (AG). We explored the presence of AG and its association with CKD in 14,924 adults aged ≥20 yr with eGFR ≥ 15 ml·min-1·1.73 m-2 enrolled in the National Health and Nutrition Examination Survey III, 1988-1994, using multivariable regression analysis. The model was adjusted for sociodemographic characteristics, diabetes, and hypertension. We further examined the association between AG and incident end-stage renal disease (ESRD) using frailty models, adjusting for demographics, clinical factors, body mass index, serum albumin, bicarbonate, eGFR, and urinary albumin-to-creatinine ratio by following 558 adults with moderate CKD for 12 yr via the United States Renal Data System. Laboratory measures determined AG using the traditional, albumin-corrected, and full AG definitions. Individuals with moderate CKD (eGFR: 30-59 ml·min-1·1.73 m-2) had a greater AG than those with eGFR ≥ 60 ml·min-1·1.73 m-2 in multivariable regression analysis with adjustment for covariates. We found a graded relationship between the adjusted mean for all three definitions of AG and eGFR categories (P trend < 0.0001). During followup, 9.2% of adults with moderate CKD developed ESRD. Those with AG in the highest tertile had a higher risk of ESRD after adjusting for covariates in a frailty model [relative hazard (95% confidence interval) for traditional AG: 1.76 (1.16-2.32)] compared with those in the middle tertile. The data suggest that high AG, even after adjusting for serum bicarbonate, is a contributing acid-base mechanism to CKD progression in adults with moderate chronic kidney disease.
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Affiliation(s)
- Tanushree Banerjee
- Division of General Internal Medicine, Department of Medicine, University of California , San Francisco, California
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine , Baltimore, Maryland
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Donald E Wesson
- Baylor Scott & White Health and Wellness Center , Dallas, Texas
| | - Charles E McCulloch
- Department of Biostatistics, University of California , San Francisco, California
| | - Kirsten L Johansen
- Division of Nephrology, Department of Medicine, University of California , San Francisco, California
| | - Sharon Saydah
- Division of Diabetes Translation, Centers of Disease and Control and Prevention , Atlanta, Georgia
| | - Nilka Rios Burrows
- Division of Diabetes Translation, Centers of Disease and Control and Prevention , Atlanta, Georgia
| | - Rajiv Saran
- Kidney Epidemiology & Cost Center, University of Michigan , Ann Arbor, Michigan
- Division of Nephrology, Department of Medicine, University of Michigan , Ann Arbor, Michigan
| | - Brenda Gillespie
- Kidney Epidemiology & Cost Center, University of Michigan , Ann Arbor, Michigan
| | | | - Neil R Powe
- Division of General Internal Medicine, Department of Medicine, University of California , San Francisco, California
- Department of Medicine, Zuckerberg San Francisco General Hospital , San Francisco, California
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Basnet S, Tachamo N, Nazir S, Dhital R, Jehangir A, Donato A. Severe anion gap metabolic acidosis associated with initiation of a very low-carbohydrate diet. J Community Hosp Intern Med Perspect 2019; 9:165-167. [PMID: 31044050 PMCID: PMC6484640 DOI: 10.1080/20009666.2019.1583534] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 02/08/2019] [Indexed: 11/25/2022] Open
Abstract
Low carbohydrate diets have been popularized as an effective solution for weight loss. Although rare, life-threatening anion gap metabolic acidosis has been reported in patients on these diets. We present a case of a 31-year-old man with atypical symptoms of chest pain and shortness of breath found to have severe metabolic acidosis after starting low carbohydrate diet for a week.
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Affiliation(s)
- Sijan Basnet
- Department of Medicine, Reading Hospital, West Reading, PA, USA
| | | | - Salik Nazir
- Department of Medicine, Reading Hospital, West Reading, PA, USA
| | - Rashmi Dhital
- Department of Medicine, Reading Hospital, West Reading, PA, USA
| | - Asad Jehangir
- Department of Medicine, Reading Hospital, West Reading, PA, USA
| | - Anthony Donato
- Department of Medicine, Reading Hospital, West Reading, PA, USA
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Abstract
Acid-base homeostasis is fundamental for life. The body is exceptionally sensitive to changes in pH, and as a result, potent mechanisms exist to regulate the body's acid-base balance to maintain it in a very narrow range. Accurate and timely interpretation of an acid-base disorder can be lifesaving but establishing a correct diagnosis may be challenging. The underlying cause of the acid-base disorder is generally responsible for a patient's signs and symptoms, but laboratory results and their integration into the clinical picture is crucial. Important acid-base parameters are often available within minutes in the acute hospital care setting, and with basic knowledge it should be easy to establish the diagnosis with a stepwise approach. Unfortunately, many caveats exist, beginning in the pre-analytical phase. In the post-analytical phase, studies on the arterial reference pH are scarce and therefore many different reference values are used in the literature without any solid evidence. The prediction models that are currently used to assess the acid-base status are approximations that are mostly based on older studies with several limitations. The two most commonly used methods are the physiological method and the base excess method, both easy to use. The secondary response equations in the base excess method are the most convenient. Evaluation of acid-base disorders should always include the assessment of electrolytes and the anion gap. A major limitation of the current acid-base laboratory tests available is the lack of rapid point-of-care laboratory tests to diagnose intoxications with toxic alcohols. These intoxications can be fatal if not recognized and treated within minutes to hours. The surrogate use of the osmolal gap is often an inadequate substitute in this respect. This article reviews the role of the clinical laboratory to evaluate acid-base disorders.
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Affiliation(s)
- K Berend
- a St. Elisabeth Hospital , Willemstad , Curaçao
| | - A J Duits
- b Red Cross Blood Bank Foundation , Willemstad , Curaçao
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50
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Li Y, Matzka L, Flahive J, Weber D. Potential use of leukocytosis and anion gap elevation in differentiating psychogenic nonepileptic seizures from epileptic seizures. Epilepsia Open 2019; 4:210-215. [PMID: 30868134 PMCID: PMC6398111 DOI: 10.1002/epi4.12301] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 12/28/2018] [Indexed: 12/28/2022] Open
Abstract
Epileptic seizures (ES) and psychogenic nonepileptic seizures (PNES) can be difficult to differentiate from each other in the emergency department (ED) setting. We have previously shown that the anion gap (AG) can help differentiate between ES and PNES in the ED. In this study, we explored whether additionally considering leukocytosis can help better differentiate between ES and PNES. We screened a total of 1354 subjects seen in the ED of a tertiary care medical center; 27 PNES and 27 ES patients were identified based on clinical description and subsequent electroencephalography (EEG). Multivariable logistic regression analysis was used to model the association between ES, leukocytosis, and AG. Our results indicated that within 9 hours after the index event, serum AG (adjusted odds ratio [aOR] 2.07) and white blood cell (WBC) count (aOR 1.61) were both independently associated with ES. We derived an equation to help differentiate between ES and PNES: 1.5*AG+WBC. A score >24.8 indicated a >90% likelihood of ES. A score <15.5 indicated a <10% likelihood of ES (ie, the alternate diagnosis of PNES should be considered). This study for the first time provides evidence to help differentiate PNES and ES utilizing acidosis and leukocytosis.
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Affiliation(s)
- Yi Li
- Department of NeurologyUniversity of Massachusetts Medical SchoolWorcesterMassachusetts
- Department of NeurologyStanford UniversityStanfordCalifornia
| | - Liesl Matzka
- Department of NeurologyUniversity of Massachusetts Medical SchoolWorcesterMassachusetts
| | - Julie Flahive
- Quantitative Health SciencesUniversity of Massachusetts Medical SchoolWorcesterMassachusetts
| | - Daniel Weber
- Department of NeurologyUniversity of Massachusetts Medical SchoolWorcesterMassachusetts
- Department of NeurologySaint Louis University School of MedicineSt. LouisMissouri
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