The Impact of a Short-Term Ketogenic Low-Carbohydrate High-Fat Diet on Biomarkers of Intestinal Epithelial Integrity and Gastrointestinal Symptoms

Endurance exercise can disturb intestinal epithelial integrity, leading to increased systemic indicators of cell injury, hyperpermeability, and pathogenic translocation. However, the interaction between exercise, diet, and gastrointestinal disturbance still warrants exploration. This study examined whether a 6-day dietary intervention influenced perturbations to intestinal epithelial disruption in response to a 25-km race walk. Twenty-eight male race walkers adhered to a high carbohydrate (CHO)/energy diet (65% CHO, energy availability = 40 kcal·kg FFM-1·day-1) for 6 days prior to a Baseline 25-km race walk. Athletes were then split into three subgroups: high CHO/energy diet (n = 10); low-CHO, high-fat diet (LCHF: n = 8; <50 g/day CHO, energy availability = 40 kcal·kg FFM-1·day-1); and low energy availability (n = 10; 65% CHO, energy availability = 15 kcal·kg FFM-1·day-1) for a further 6-day dietary intervention period prior to a second 25-km race walk (Adaptation). During both trials, venous blood was collected pre-, post-, and 1 hr postexercise and analyzed for markers of intestinal epithelial disruption. Intestinal fatty acid-binding protein concentration was significantly higher (twofold increase) in response to exercise during Adaptation compared to Baseline in the LCHF group (p = .001). Similar findings were observed for soluble CD14 (p < .001) and lipopolysaccharide-binding protein (p = .003), where postexercise concentrations were higher (53% and 36%, respectively) during Adaptation than Baseline in LCHF. No differences in high CHO/energy diet or low energy availability were apparent for any blood markers assessed (p > .05). A short-term LCHF diet increased intestinal epithelial cell injury in response to a 25-km race walk. No effect of low energy availability on gastrointestinal injury or symptoms was observed.

Adherence to a Ketogenic Low-Carbohydrate, High-Fat Diet Is Associated With Diminished Training Quality in Elite Racewalkers

PURPOSE

To examine the effects of a high-carbohydrate diet (HCHO), periodized-carbohydrate (CHO) diet (PCHO), and ketogenic low-CHO high-fat diet (LCHF) on training capacity.

METHODS

Elite male racewalkers completed 3 weeks of periodic training while adhering to their dietary intervention. Twenty-nine data sets were collected from 21 athletes. Each week, 6 mandatory training sessions were completed, with additional sessions performed at the athlete's discretion. Mandatory sessions included an interval session (10 × 1-km efforts on a 6-min cycle), tempo session (14 km with a 450-m elevation gain), 2 long walks (25-40 km), and 2 easy walks (8-12 km) where "sleep-low" and "train-low" dietary strategies were employed for PCHO. Racewalking speed, heart rate, rating of perceived exhaustion, and blood metabolites were collected around key sessions.

RESULTS

LCHF covered less total distance than HCHO and PCHO (P < .001); however, no differences in training load between groups were evident (P = .285). During the interval sessions, walking speed was slower in LCHF (P = .001), equating to a 2.8% and 5.6% faster speed in HCHO and PCHO, respectively. LCHF was also 3.2% slower in completing the tempo session than HCHO and PCHO (P = .001). Heart rate was higher (P = .002) and lactate concentrations were lower (P < .001) in LCHF compared to other groups, despite slower walking speeds during the interval session. No between-groups differences in rating of perceived exhaustion were evident (P = .077).

CONCLUSION

Athletes adhering to an LCHF diet showed impaired training capacity relative to their high-CHO-supported counterparts, completing lower training volumes at slower speeds, with higher heart rates.

Predictors of mortality and nephrectomy in emphysematous pyelonephritis: a tertiary care centre study

INTRODUCTION

Emphysematous pyelonephritis (EPN) is a deadly disease due to its associated morbidity and mortality. Attempts have been made to identify predictors of severity, mortality and need for nephrectomy in EPN with little success.

METHODS

We conducted an ambispective study of EPN patients between March 2014 and September 2019. Retrospective data were collected which included age, sex, comorbidities, symptoms, signs, laboratory investigations including imaging, need for dialysis, management and any complications. All patients were then followed prospectively for renal dynamic scan, stone surgery or nephrectomy. Univariate analysis was performed to identify factors affecting mortality and need for elective nephrectomy.

RESULTS

In total, 112 patients were included. Mean patient age was 50.01 years, 55% were female and 5% had bilateral involvement. Fever and flank pain were the most common symptoms. Diabetes was seen in 75% of cases and 30% of cases required haemodialysis at initial presentation. About 60% of patients improved with pigtail drainage. Need for nephrectomy was greater in Huang-Tseng stage 3a (14.8%). Huang-Tseng stages 3b and 4 had higher mortality rates (25%) than the other stages (2.2%). Twelve of 99 patients had non functional kidney on follow-up and underwent elective nephrectomy. Low platelet counts, high body mass index, septic shock, dialysis and higher Huang-Tseng stage were found to be predictive of mortality and renal parenchymal thickness on computed tomography scan was predictive of follow-up nephrectomy.

CONCLUSIONS

Thrombocytopaenia, high body mass index, septic shock, haemodialysis and higher Huang-Tseng stage are predictors of mortality and renal parenchymal thickness <5mm is a predictor of poor salvage of affected kidney on follow-up.

Short-Term Very High Carbohydrate Diet and Gut-Training Have Minor Effects on Gastrointestinal Status and Performance in Highly Trained Endurance Athletes

We implemented a multi-pronged strategy (MAX) involving chronic (2 weeks high carbohydrate [CHO] diet + gut-training) and acute (CHO loading + 90 g·h−1 CHO during exercise) strategies to promote endogenous and exogenous CHO availability, compared with strategies reflecting lower ranges of current guidelines (CON) in two groups of athletes. Nineteen elite male race walkers (MAX: 9; CON:10) undertook a 26 km race-walking session before and after the respective interventions to investigate gastrointestinal function (absorption capacity), integrity (epithelial injury), and symptoms (GIS). We observed considerable individual variability in responses, resulting in a statistically significant (p < 0.001) yet likely clinically insignificant increase (Δ 736 pg·mL−1) in I-FABP after exercise across all trials, with no significant differences in breath H2 across exercise (p = 0.970). MAX was associated with increased GIS in the second half of the exercise, especially in upper GIS (p < 0.01). Eighteen highly trained male and female distance runners (MAX: 10; CON: 8) then completed a 35 km run (28 km steady-state + 7 km time-trial) supported by either a slightly modified MAX or CON strategy. Inter-individual variability was observed, without major differences in epithelial cell intestinal fatty acid binding protein (I-FABP) or GIS, due to exercise, trial, or group, despite the 3-fold increase in exercise CHO intake in MAX post-intervention. The tight-junction (claudin-3) response decreased in both groups from pre- to post-intervention. Groups achieved a similar performance improvement from pre- to post-intervention (CON = 39 s [95 CI 15−63 s]; MAX = 36 s [13−59 s]; p = 0.002). Although this suggests that further increases in CHO availability above current guidelines do not confer additional advantages, limitations in our study execution (e.g., confounding loss of BM in several individuals despite a live-in training camp environment and significant increases in aerobic capacity due to intensified training) may have masked small differences. Therefore, athletes should meet the minimum CHO guidelines for training and competition goals, noting that, with practice, increased CHO intake can be tolerated, and may contribute to performance outcomes.

High rising flames: a sign of complex extraperitoneal bladder rupture

Extraperitoneal bladder rupture is the most common type of bladder injury following pelvic trauma and is seen in 80-90% of cases. Generally, the contrast extravasation seen on computed tomography (CT) cystography is confined to the perivesical space, giving a characteristic flame-shaped appearance. Occasionally contrast extravasation can extend to the scrotum, thigh or anterior abdominal wall, depending on the extent of injury. Here we report an unusual CT cystogram finding of complex extraperitoneal bladder rupture with associated pelvic fracture urethral distraction defect, showing large-volume contrast extravasation extending beyond the perivesical space to the left perinephric region resembling high rising flames.

Six Days of Low Carbohydrate, Not Energy Availability, Alters the Iron and Immune Response to Exercise in Elite Athletes

PURPOSE

To quantify the effects of a short-term (6-day) low carbohydrate (CHO) high fat (LCHF), and low energy availability (LEA) diet on immune, inflammatory, and iron-regulatory responses to exercise in endurance athletes.

METHODS

Twenty-eight elite male race walkers completed two 6-day diet/training phases. During phase 1 (Baseline), all athletes consumed a high CHO/energy availability (CON) diet (65% CHO and ~ 40 kcal·kg-1 fat free mass (FFM)·day-1). In phase 2 (Adaptation), athletes were allocated to either a CON (n = 10), LCHF (n = 8; <50 g·day-1 CHO and ~ 40 kcal·kg-1 FFM·day-1), or LEA diet (n = 10; 60% CHO and 15 kcal·kg-1 FFM·day-1). At the end of each phase, athletes completed a 25 km race walk protocol at ~75% VO2max. On each occasion, venous blood was collected before and after exercise for interleukin-6, hepcidin, cortisol and glucose concentrations, as well as white blood cell counts.

RESULTS

The LCHF athletes displayed a greater IL-6 (p = 0.019) and hepcidin (p = 0.011) response to exercise after Adaptation, compared to Baseline. Similarly, post-exercise increases in total white blood cell counts (p = 0.026) and cortisol levels (p < 0.001) were larger compared to Baseline following LCHF Adaptation. Decreases in blood glucose concentrations were evident post-exercise during Adaptation in LCHF (p = 0.049), whereas no change occurred in CON or LEA (p > 0.05). No differences between CON and LEA were evident for any of the measured biological markers (all p > 0.05).

CONCLUSION

Short-term adherence to a LCHF diet elicited small yet unfavorable iron, immune, and stress responses to exercise. In contrast, no substantial alterations to athlete health were observed when athletes restricted energy availability compared to athletes with adequate energy availability. Therefore, short-term restriction of CHO, rather than energy, may have greater negative impacts on athlete health.

Neither Beetroot Juice Supplementation nor Increased Carbohydrate Oxidation Enhance Economy of Prolonged Exercise in Elite Race Walkers

Given the importance of exercise economy to endurance performance, we implemented two strategies purported to reduce the oxygen cost of exercise within a 4 week training camp in 21 elite male race walkers. Fourteen athletes undertook a crossover investigation with beetroot juice (BRJ) or placebo (PLA) [2 d preload, 2 h pre-exercise + 35 min during exercise] during a 26 km race walking at speeds simulating competitive events. Separately, 19 athletes undertook a parallel group investigation of a multi-pronged strategy (MAX; n = 9) involving chronic (2 w high carbohydrate [CHO] diet + gut training) and acute (CHO loading + 90 g/h CHO during exercise) strategies to promote endogenous and exogenous CHO availability, compared with strategies reflecting lower ranges of current guidelines (CON; n = 10). There were no differences between BRJ and PLA trials for rates of CHO (p = 0.203) or fat (p = 0.818) oxidation or oxygen consumption (p = 0.090). Compared with CON, MAX was associated with higher rates of CHO oxidation during exercise, with increased exogenous CHO use (CON; peak = ~0.45 g/min; MAX: peak = ~1.45 g/min, p < 0.001). High rates of exogenous CHO use were achieved prior to gut training, without further improvement, suggesting that elite athletes already optimise intestinal CHO absorption via habitual practices. No differences in exercise economy were detected despite small differences in substrate use. Future studies should investigate the impact of these strategies on sub-elite athletes’ economy as well as the performance effects in elite groups.

A huge ureteric stone in a functionally, metabolically and anatomically normal kidney: an alliance of rarity

Urinary stones are a common health problem, necessitating frequent outpatient visits and hospital admissions. Ureteric stones demand special attention, given their propensity for upstream hydroureteronephrosis and loss of renal function. They are usually predisposed by diverse anatomical, functional or metabolic abnormalities of the urinary tract and have an early symptomatic presentation. We report an exceptional clinical presentation of a huge ureteric stone yet functional renal moiety with no obvious anatomical or metabolic predilection for urolithiasis, and its minimally invasive management in a young woman. We emphasise that swift salvaging of the renal function is of utmost importance in these cases. Open exploration can be avoided in favour of laparoscopic ureterolithotomy with better cosmesis and early recovery.

A Contemporary Variable-Power Cycling Protocol to Discriminate Race-Specific Performance Ability

PURPOSE

Traditional physiological testing and monitoring tools have restricted our ability to capture parameters that best relate to cycling performance under variable-intensity race demands. This study examined the validity of a 1-h variable cycling test (VCT) to discriminate between different-performance-level cyclists.

METHODS

Ten male national- and 13 club-level cyclists (body mass, 67 [9] and 79 [6] kg; peak power output, 359 [43] and 362 [21] W, respectively) completed a VO2max test and two 1-h VCT protocols on 3 separate occasions. The VCT consisted of 10 × 6-min segments containing prescribed (3.5 W·kg-1) and open-ended phases. The open-ended phases consisted of 4 × 30-40 s of "recovery," 3 × 10 s at "hard" intensity, and 3 × 6-s "sprint" with a final 10-s "all-out" effort.

RESULTS

Power output for the 6- and 10-s phases was moderately higher for the national- compared with club-level cyclists (mean [SD] 10.4 [2.0] vs 8.6 [1.6] W·kg-1, effect size; ±90% confidence limits = -0.87; ±0.65 and mean [SD] 7.5 [0.7] vs 6.2 [1.0] W·kg-1, effect size; ±90% confidence limits = -1.24; ±0.66, respectively). Power output for the final 10-s "all-out" sprint was 15.4 (1.5) for the national- versus 13.2 (1.9) W·kg-1 for club-level cyclists.

CONCLUSION

The 1-h VCT can successfully differentiate repeat high-intensity effort performance between higher-caliber cyclists and their lower-performing counterparts.

Adaptation to a low carbohydrate high fat diet is rapid but impairs endurance exercise metabolism and performance despite enhanced glycogen availability

KEY POINTS

Brief (5-6 days) adaptation to a low carbohydrate high fat diet in elite athletes increased exercise fat oxidation to rates previously observed with medium (3-4 weeks) or chronic (>12 months) adherence to this diet, with metabolic changes being washed out in a similar time frame. Increased fat utilisation during exercise was associated with a 5-8% increase in oxygen cost at speeds related to Olympic Programme races. Acute restoration of endogenous carbohydrate (CHO) availability (24 h high CHO diet, pre-race CHO) only partially restored substrate utilisation during a race warm-up. Fat oxidation continued to be elevated above baseline values although it was lower than achieved by 5-6 days' keto adaptation; CHO oxidation only reached 61% and 78% of values previously seen at exercise intensities related to race events. Acute restoration of CHO availability failed to overturn the impairment of high-intensity endurance performance previously associated with low carbohydrate high fat adaptation, potentially due to the blunted capacity for CHO oxidation.

ABSTRACT

We investigated substrate utilisation during exercise after brief (5-6 days) adaptation to a ketogenic low-carbohydrate (CHO), high-fat (LCHF) diet and similar washout period. Thirteen world-class male race walkers completed economy testing, 25 km training and a 10,000 m race (Baseline), with high CHO availability (HCHO), repeating this (Adaptation) after 5-6 days' LCHF (n = 7; CHO: <50 g day^-1 , protein: 2.2 g kg^-1 day^-1 ; 80% fat) or HCHO (n = 6; CHO: 9.7 g kg^-1 day^-1 ; protein: 2.2 g kg^-1 day^-1 ) diet. An Adaptation race was undertaken after 24 h HCHO and pre-race CHO (2 g kg^-1 ) diet, identical to the Baseline race. Substantial (>200%) increases in exercise fat oxidation occurred in the LCHF Adaptation economy and 25 km tests, reaching mean rates of ∼1.43 g min^-1 . However, relative V ̇ O 2 (ml min^-1  kg^-1 ) was higher (P < 0.0001), by ∼8% and 5% at speeds related to 50 km and 20 km events. During Adaptation race warm-up in the LCHF group, rates of fat and CHO oxidation at these speeds were decreased and increased, respectively (P < 0.001), compared with the previous day, but were not restored to Baseline values. Performance changes differed between groups (P = 0.009), with all HCHO athletes improving in the Adaptation race (5.7 (5.6)%), while 6/7 LCHF athletes were slower (2.2 (3.4)%). Substrate utilisation returned to Baseline values after 5-6 days of HCHO diet. In summary, robust changes in exercise substrate use occurred in 5-6 days of extreme changes in CHO intake. However, adaptation to a LCHF diet plus acute restoration of endogenous CHO availability failed to restore high-intensity endurance performance, with CHO oxidation rates remaining blunted.

Corrigendum to "P095 - Clinical outcomes of robot-assisted laparoscopic partial nephrectomy: Lessons learnt from 221 cases" [Eur Urol Suppl 2019;18(11);e3528]

[This corrects the article DOI: 10.1016/S1569-9056(19)34675-5.].

Crisis of confidence averted: Impairment of exercise economy and performance in elite race walkers by ketogenic low carbohydrate, high fat (LCHF) diet is reproducible

INTRODUCTION

We repeated our study of intensified training on a ketogenic low-carbohydrate (CHO), high-fat diet (LCHF) in world-class endurance athletes, with further investigation of a "carryover" effect on performance after restoring CHO availability in comparison to high or periodised CHO diets.

METHODS

After Baseline testing (10,000 m IAAF-sanctioned race, aerobic capacity and submaximal walking economy) elite male and female race walkers undertook 25 d supervised training and repeat testing (Adapt) on energy-matched diets: High CHO availability (8.6 g∙kg-1∙d-1 CHO, 2.1 g∙kg-1∙d-1 protein; 1.2 g∙kg-1∙d-1 fat) including CHO before/during/after workouts (HCHO, n = 8): similar macronutrient intake periodised within/between days to manipulate low and high CHO availability at various workouts (PCHO, n = 8); and LCHF (<50 g∙d-1 CHO; 78% energy as fat; 2.1 g∙kg-1∙d-1 protein; n = 10). After Adapt, all athletes resumed HCHO for 2.5 wk before a cohort (n = 19) completed a 20 km race.

RESULTS

All groups increased VO2peak (ml∙kg-1∙min-1) at Adapt (p = 0.02, 95%CI: [0.35-2.74]). LCHF markedly increased whole-body fat oxidation (from 0.6 g∙min-1 to 1.3 g∙min-1), but also the oxygen cost of walking at race-relevant velocities. Differences in 10,000 m performance were clear and meaningful: HCHO improved by 4.8% or 134 s (95% CI: [207 to 62 s]; p < 0.001), with a trend for a faster time (2.2%, 61 s [-18 to +144 s]; p = 0.09) in PCHO. LCHF were slower by 2.3%, -86 s ([-18 to -144 s]; p < 0.001), with no evidence of superior "rebound" performance over 20 km after 2.5 wk of HCHO restoration and taper.

CONCLUSION

Our previous findings of impaired exercise economy and performance of sustained high-intensity race walking following keto-adaptation in elite competitors were repeated. Furthermore, there was no detectable benefit from undertaking an LCHF intervention as a periodised strategy before a 2.5-wk race preparation/taper with high CHO availability.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry: ACTRN12619000794101.

Contemporary Periodization of Altitude Training for Elite Endurance Athletes: A Narrative Review

Since the 1960s there has been an escalation in the purposeful utilization of altitude to enhance endurance athletic performance. This has been mirrored by a parallel intensification in research pursuits to elucidate hypoxia-induced adaptive mechanisms and substantiate optimal altitude protocols (e.g., hypoxic dose, duration, timing, and confounding factors such as training load periodization, health status, individual response, and nutritional considerations). The majority of the research and the field-based rationale for altitude has focused on hematological outcomes, where hypoxia causes an increased erythropoietic response resulting in augmented hemoglobin mass. Hypoxia-induced non-hematological adaptations, such as mitochondrial gene expression and enhanced muscle buffering capacity may also impact athletic performance, but research in elite endurance athletes is limited. However, despite significant scientific progress in our understanding of hypobaric hypoxia (natural altitude) and normobaric hypoxia (simulated altitude), elite endurance athletes and coaches still tend to be trailblazers at the coal face of cutting-edge altitude application to optimize individual performance, and they already implement novel altitude training interventions and progressive periodization and monitoring approaches. Published and field-based data strongly suggest that altitude training in elite endurance athletes should follow a long- and short-term periodized approach, integrating exercise training and recovery manipulation, performance peaking, adaptation monitoring, nutritional approaches, and the use of normobaric hypoxia in conjunction with terrestrial altitude. Future research should focus on the long-term effects of accumulated altitude training through repeated exposures, the interactions between altitude and other components of a periodized approach to elite athletic preparation, and the time course of non-hematological hypoxic adaptation and de-adaptation, and the potential differences in exercise-induced altitude adaptations between different modes of exercise.

Chronic Adherence to a Ketogenic Diet Modifies Iron Metabolism in Elite Athletes

PURPOSE

The short-term restriction of carbohydrate (CHO) can potentially influence iron regulation via modification of postexercise interleukin-6 (IL-6) and hepcidin levels. This study examined the effect of a chronic ketogenic low-CHO high-fat (LCHF) diet on iron status and iron-regulatory markers in elite athletes.

METHODS

International-level race walkers (n = 50) were allocated to one of three dietary interventions: (i) a high-CHO diet (n = 16), (ii) a periodized CHO availability (n = 17), or (iii) an LCHF diet (n = 17) while completing a periodized training program for 3 wk. A 19- to 25-km race walking test protocol was completed at baseline and after adaptation, and changes in serum ferritin, IL-6, and hepcidin concentrations were measured. Results from high-CHO and periodized CHO were combined into one group (CHO; n = 33) for analysis.

RESULTS

The decrease in serum ferritin across the intervention period was substantially greater in the CHO group (37%) compared with the LCHF (23%) group (P = 0.021). After dietary intervention, the postexercise increase in IL-6 was greater in LCHF (13.6-fold increase; 95% confidence interval [CI] = 7.1-21.4) than athletes adhering to a CHO-rich diet (7.6-fold increase; 95% CI = 5.5-10.2; P = 0.033). Although no significant differences occurred between diets, CI values indicate that 3 h postexercise hepcidin concentrations were lower after dietary intervention compared with baseline in CHO (β = -4.3; 95% CI = -6.6 to -2.0), with no differences evident in LCHF.

CONCLUSION

Athletes who adhered to a CHO-rich diet experienced favorable changes to the postexercise IL-6 and hepcidin response, relative to the LCHF group. Lower serum ferritin after 3 wk of additional dietary CHO might reflect a larger more adaptive hematological response to training.

Acute carbohydrate ingestion does not influence the post-exercise iron-regulatory response in elite keto-adapted race walkers

OBJECTIVES

Adhering to a low carbohydrate (CHO) high fat (LCHF) diet can alter markers of iron metabolism in endurance athletes. This investigation examined the re-introduction of CHO prior to, and during exercise on the iron-regulatory response to exercise in a homogenous (in regard to serum ferritin concentration) group of athletes adapted to a LCHF diet.

DESIGN

Parallel groups design.

METHODS

Three weeks prior to the exercise trials, twenty-three elite race walkers adhered to either a CHO-rich (n=14) or LCHF diet (n=9). A standardised 19-25km race walk was performed while athletes were still adhering to their allocated dietary intervention (Adapt). A second test was performed three days later, where all athletes were placed on a high CHO diet (CHO Restoration). Venous blood samples were collected pre-, post- and 3h post-exercise and measured for interleukin-6 (IL-6) and hepcidin-25.

RESULTS

The post-exercise IL-6 increase was greater in LCHF (p<0.001) during both the Adapt (LCHF: 13.1-fold increase; 95% CI: 5.6-23.0, CHO: 8.0-fold increase; 5.1-11.1) and CHO Restoration trials (LCHF: 18.5-fold increase; 10.9-28.9, CHO: 6.3-fold increase; 3.9-9.5); outcomes were not different between trials (p=0.84). Hepcidin-25 concentrations increased 3h post-exercise (p<0.001), however, they did not differ between trials (p=0.46) or diets (p=0.84).

CONCLUSIONS

The elevated IL-6 response in athletes adapted to a LCHF diet was not attenuated by an acute increase in exogenous CHO availability. Despite diet-induced differences in IL-6 response to exercise, post-exercise hepcidin levels were similar between diets and trials, indicating CHO availability has minimal influence on post-exercise iron metabolism.

A Short-Term Ketogenic Diet Impairs Markers of Bone Health in Response to Exercise

Objectives: To investigate diet-exercise interactions related to bone markers in elite endurance athletes after a 3.5-week ketogenic low-carbohydrate, high-fat (LCHF) diet and subsequent restoration of carbohydrate (CHO) feeding. Methods: World-class race walkers (25 male, 5 female) completed 3.5-weeks of energy-matched (220 kJ·kg·d^-1) high CHO (HCHO; 8.6 g·kg·d^-1 CHO, 2.1 g·kg·d^-1 protein, 1.2 g·kg·d^-1 fat) or LCHF (0.5 g·kg·d^-1 CHO, 2.1 g·kg·d^-1 protein, 75-80% of energy from fat) diet followed by acute CHO restoration. Serum markers of bone breakdown (cross-linked C-terminal telopeptide of type I collagen, CTX), formation (procollagen 1 N-terminal propeptide, P1NP) and metabolism (osteocalcin, OC) were assessed at rest (fasting and 2 h post meal) and after exercise (0 and 3 h) at Baseline, after the 3.5-week intervention (Adaptation) and after acute CHO feeding (Restoration). Results: After Adaptation, LCHF increased fasting CTX concentrations above Baseline (p = 0.007, Cohen's d = 0.69), while P1NP (p < 0.001, d = 0.99) and OC (p < 0.001, d = 1.39) levels decreased. Post-exercise, LCHF increased CTX concentrations above Baseline (p = 0.001, d = 1.67) and above HCHO (p < 0.001, d = 0.62), while P1NP (p < 0.001, d = 0.85) and OC concentrations decreased (p < 0.001, d = 0.99) during exercise. Exercise-related area under curve (AUC) for CTX was increased by LCHF after Adaptation (p = 0.001, d = 1.52), with decreases in P1NP (p < 0.001, d = 1.27) and OC (p < 0.001, d = 2.0). CHO restoration recovered post-exercise CTX and CTX exercise-related AUC, while concentrations and exercise-related AUC for P1NP and OC remained suppressed for LCHF (p = 1.000 compared to Adaptation). Conclusion: Markers of bone modeling/remodeling were impaired after short-term LCHF diet, and only a marker of resorption recovered after acute CHO restoration. Long-term studies of the effects of LCHF on bone health are warranted.

Training Quantification and Periodization during Live High Train High at 2100 M in Elite Runners: An Observational Cohort Case Study

The questionable efficacy of Live High Train High altitude training (LHTH) is compounded by minimal training quantification in many studies. We sought to quantify the training load (TL) periodization in a cohort of elite runners completing LHTH immediately prior to competition. Eight elite runners (6 males, 2 females) with a V̇O_2peak of 70 ± 4 mL·kg^-1·min^-1 were monitored during 4 weeks of sea-level training, then 3-4 weeks LHTH in preparation for sea-level races following descent to sea-level. TL was calculated using the session rating of perceived exertion (sRPE) method, whereby duration of each training session was multiplied by its sRPE, then summated to give weekly TL. Performance was assessed in competition at sea-level before, and within 8 days of completing LHTH, with runners competing in 800 m (n = 1, 1500 m/mile (n = 6) and half-marathon (n = 1). Haemoglobin mass (Hb_mass) via CO rebreathing and running economy (RE) were assessed pre and post LHTH. Weekly TL during the first 2 weeks at altitude increased by 75% from preceding sea-level training (p = 0.0004, d = 1.65). During the final week at altitude, TL was reduced by 43% compared to the previous weeks (p = 0.002; d = 1.85). The ratio of weekly TL to weekly training volume increased by 17% at altitude (p = 0.009; d = 0.91) compared to prior sea-level training. Hb_mass increased by 5% from pre- to post-LHTH (p = 0.006, d = 0.20). Seven athletes achieved lifetime personal best performances within 8 days post-altitude (overall improvement 1.1 ± 0.7%, p = 0.2, d = 0.05). Specific periodization of training, including large increases in training load upon arrival to altitude (due to increased training volume and greater stress of training in hypoxia) and tapering, were observed during LHTH in elite runners prior to personal best performances. Periodization should be individualized and align with timing of competition post-altitude.

The impact of chronic carbohydrate manipulation on mucosal immunity in elite endurance athletes

Carbohydrate (CHO) availability could alter mucosal immune responses to exercise. This study compared the effect of three dietary approaches to CHO availability on resting and post-exercise s-IgA levels. Elite race walkers (n = 26) adhered to a high CHO diet (HCHO), periodised CHO availability (PCHO) or a low CHO/high fat diet (LCHF) for 3 weeks while completing an intensified training program. HCHO and PCHO groups consumed 8.0-8.5 g.kg^-1 CHO daily, with timing of ingestion manipulated to alter CHO availability around key training sessions. The LCHF diet comprised 80% fat and restricted CHO to < 50 g.day^-1. A race walk test protocol (19 km females, 25 km males) was completed at baseline, after adaptation, and following CHO restoration. On each occasion, saliva samples were obtained pre- and post-exercise to quantify s-IgA levels. Resting s-IgA secretion rate substantially increased ~ two-fold post-intervention in all groups (HCHO: 2.2 ± 2.2, PCHO: 2.8 ± 3.2, LCHF: 1.6 ± 1.6; fold-change± 95% confidence limits), however, no substantial differences between dietary treatments were evident. Post-exercise, substantial 20-130% increases in s-IgA concentration and 43-64% reductions in flow rate occurred in all dietary treatments, with trivial differences evident between groups. It appears that high volume training overrides any effect of manipulating CHO availability on mucosal immunity in elite athletes.

Chronic Ketogenic Low Carbohydrate High Fat Diet Has Minimal Effects on Acid-Base Status in Elite Athletes

Although short (up to 3 days) exposure to major shifts in macronutrient intake appears to alter acid-base status, the effects of sustained (>1 week) interventions in elite athletes has not been determined. Using a non-randomized, parallel design, we examined the effect of adaptations to 21 days of a ketogenic low carbohydrate high fat (LCHF) or periodized carbohydrate (PCHO) diet on pre- and post-exercise blood pH, and concentrations of bicarbonate (HCO₃-) and lactate (La-) in comparison to a high carbohydrate (HCHO) control. Twenty-four (17 male and 7 female) elite-level race walkers completed 21 days of either LCHF (n = 9), PCHO (n = 7), or HCHO (n = 8) under controlled diet and training conditions. At baseline and post-intervention, blood pH, blood [HCO₃-], and blood [La-] were measured before and after a graded exercise test. Net endogenous acid production (NEAP) over the previous 48-72 h was also calculated from monitored dietary intake. LCHF was not associated with significant differences in blood pH, [HCO₃-], or [La-], compared with the HCHO diet pre- or post-exercise, despite a significantly higher NEAP (mEq·day-1) (95% CI = [10.44; 36.04]). Our results indicate that chronic dietary interventions are unlikely to influence acid-base status in elite athletes, which may be due to pre-existing training adaptations, such as an enhanced buffering capacity, or the actions of respiratory and renal pathways, which have a greater influence on regulation of acid-base status than nutritional intake.

Temperate Performance Benefits after Heat, but Not Combined Heat and Hypoxic Training

PURPOSE

Independent heat and hypoxic exposure can enhance temperate endurance performance in trained athletes, although their combined effects remain unknown. This study examined whether the addition of heat interval training during "live high, train low" (LHTL) hypoxic exposure would result in enhanced performance and physiological adaptations as compared with heat or temperate training.

METHODS

Twenty-six well-trained runners completed 3 wk of interval training assigned to one of three conditions: 1) LHTL hypoxic exposure plus heat training (H + H; 3000 m for 13 h·d, train at 33°C, 60% relative humidity [RH]), 2) heat training with no hypoxic exposure (HOT, live at <600 m and train at 33°C, 60% RH), or 3) temperate training with no hypoxic exposure (CONT; live at <600 m and train at 14°C, 55% RH). Performance 3-km time-trials (3-km TT), running economy, hemoglobin mass, and plasma volume were assessed using magnitude-based inferences statistical approach before (Baseline), after (Post), and 3 wk (3wkP) after exposure.

RESULTS

Compared with Baseline, 3-km TT performance was likely increased in HOT at 3wkP (-3.3% ± 1.3%; mean ± 90% confidence interval), with no performance improvement in either H + H or CONT. Hemoglobin mass increased by 3.8% ± 1.8% at Post in H + H only. Plasma volume in HOT was possibly elevated above H + H and CONT at Post but not at 3wkP. Correlations between changes in 3-km TT performance and physiological adaptations were unclear.

CONCLUSION

Incorporating heat-based training into a 3-wk training block can improve temperate performance at 3 wk after exposure, with athlete psychology, physiology, and environmental dose all important considerations. Despite hematological adaptations, the addition of LHTL to heat interval training has no greater 3-km TT performance benefit than temperate training alone.

Factors influencing the post-exercise hepcidin-25 response in elite athletes

PURPOSE

The extent to which hepcidin regulation after acute bouts of exercise is influenced by baseline (resting) concentrations of key iron parameters remains uncertain. This investigation explored the influence of selected iron parameters and 25-km race walk time on 3-h post-exercise hepcidin-25 levels in international-level race walkers.

METHODS

Twenty-four male race walkers completed a graded exercise test and a 25-km race-walk trial. Throughout the 25-km race-walk, venous blood samples were collected pre-exercise, immediately post-exercise, and at 3-h post-exercise. Blood was analysed for serum ferritin, serum iron, Interleukin-6 (IL-6), and hepcidin-25 concentration.

RESULTS

IL-6 and hepcidin-25 increased (7.6- and 7.5-fold, respectively) in response to the 25-km race-walk trial (both p < 0.01). Significant individual relationships were evident between 3-h post-exercise hepcidin-25, baseline serum ferritin and serum iron (r > 0.62; p < 0.05). Multiple regression analysis showed that these two iron parameters, in addition to post-exercise IL-6 concentration and 25-km race-walk time, accounted for ~77% of the variance in 3-h post-exercise hepcidin-25 (p < 0.01). A median split by the cohort's baseline serum ferritin concentration (LOW: 58.0 vs. HIGH: 101.8 µg/L; p < 0.01) showed a significant between group difference in the 3-h post-exercise hepcidin-25 (LOW: 6.0 ± 3.6 vs. 11.3 ± 5.4 nM; p = 0.01), despite no differences in baseline serum iron, post-exercise IL-6, or 25-km race-walk time (all p > 0.05).

CONCLUSION

Despite exercise activating numerous hepcidin regulators, baseline iron status appears to play a dominant role in the regulation of hepcidin-25 in elite-level athletes subsequent to endurance exercise.

Low carbohydrate, high fat diet impairs exercise economy and negates the performance benefit from intensified training in elite race walkers

KEY POINTS

Three weeks of intensified training and mild energy deficit in elite race walkers increases peak aerobic capacity independent of dietary support. Adaptation to a ketogenic low carbohydrate, high fat (LCHF) diet markedly increases rates of whole-body fat oxidation during exercise in race walkers over a range of exercise intensities. The increased rates of fat oxidation result in reduced economy (increased oxygen demand for a given speed) at velocities that translate to real-life race performance in elite race walkers. In contrast to training with diets providing chronic or periodised high carbohydrate availability, adaptation to an LCHF diet impairs performance in elite endurance athletes despite a significant improvement in peak aerobic capacity.

ABSTRACT

We investigated the effects of adaptation to a ketogenic low carbohydrate (CHO), high fat diet (LCHF) during 3 weeks of intensified training on metabolism and performance of world-class endurance athletes. We controlled three isoenergetic diets in elite race walkers: high CHO availability (g kg^-1  day^-1 : 8.6 CHO, 2.1 protein, 1.2 fat) consumed before, during and after training (HCHO, n = 9); identical macronutrient intake, periodised within or between days to alternate between low and high CHO availability (PCHO, n = 10); LCHF (< 50 g day^-1 CHO; 78% energy as fat; 2.1 g kg^-1  day^-1 protein; LCHF, n = 10). Post-intervention, V̇O2 peak during race walking increased in all groups (P < 0.001, 90% CI: 2.55, 5.20%). LCHF was associated with markedly increased rates of whole-body fat oxidation, attaining peak rates of 1.57 ± 0.32 g min^-1 during 2 h of walking at ∼80% V̇O2 peak . However, LCHF also increased the oxygen (O₂ ) cost of race walking at velocities relevant to real-life race performance: O₂ uptake (expressed as a percentage of new V̇O2 peak ) at a speed approximating 20 km race pace was reduced in HCHO and PCHO (90% CI: -7.047, -2.55 and -5.18, -0.86, respectively), but was maintained at pre-intervention levels in LCHF. HCHO and PCHO groups improved times for 10 km race walk: 6.6% (90% CI: 4.1, 9.1%) and 5.3% (3.4, 7.2%), with no improvement (-1.6% (-8.5, 5.3%)) for the LCHF group. In contrast to training with diets providing chronic or periodised high-CHO availability, and despite a significant improvement in V̇O2 peak , adaptation to the topical LCHF diet negated performance benefits in elite endurance athletes, in part due to reduced exercise economy.

Population genetic structure of Indian shad, Tenualosa ilisha inferred from variation in mitochondrial DNA sequences

Indian shad, Tenualosa ilisha, is a commercially important anadromous fish representing major catch in Indo-pacific region. The present study evaluated partial Cytochrome b (Cyt b) gene sequence of mtDNA in T. ilisha for determining genetic variation from Bay of Bengal and Arabian Sea origins. The genomic DNA extracted from T. ilisha samples representing two distant rivers in the Indian subcontinent, the Bhagirathi (lower stretch of Ganges) and the Tapi was analyzed. Sequencing of 307 bp mtDNA Cytochrome b gene fragment revealed the presence of 5 haplotypes, with high haplotype diversity (Hd) of 0.9048 with variance 0.103 and low nucleotide diversity (π) of 0.14301. Three population specific haplotypes were observed in river Ganga and two haplotypes in river Tapi. Neighbour-joining tree based on Cytochrome b gene sequences of T. ilisha showed that population from Bay of Bengal and Arabian Sea origins belonged to two distinct clusters.

Probiotics in fish and shellfish culture: immunomodulatory and ecophysiological responses

Aquaculture is emerging as one of the most viable and promising enterprises for keeping pace with the surging need for animal protein, providing nutritional and food security to humans, particularly those residing in regions where livestock is relatively scarce. With every step toward intensification of aquaculture practices, there is an increase in the stress level in the animal as well as the environment. Hence, disease outbreak is being increasingly recognized as one of the most important constraints to aquaculture production in many countries, including India. Conventionally, the disease control in aquaculture has relied on the use of chemical compounds and antibiotics. The development of non-antibiotic and environmentally friendly agents is one of the key factors for health management in aquaculture. Consequently, with the emerging need for environmentally friendly aquaculture, the use of alternatives to antibiotic growth promoters in fish nutrition is now widely accepted. In recent years, probiotics have taken center stage and are being used as an unconventional approach that has numerous beneficial effects in fish and shellfish culture: improved activity of gastrointestinal microbiota and enhanced immune status, disease resistance, survival, feed utilization and growth performance. As natural products, probiotics have much potential to increase the efficiency and sustainability of aquaculture production. Therefore, comprehensive research to fully characterize the intestinal microbiota of prominent fish species, mechanisms of action of probiotics and their effects on the intestinal ecosystem, immunity, fish health and performance is reasonable. This review highlights the classifications and applications of probiotics in aquaculture. The review also summarizes the advancement and research highlights of the probiotic status and mode of action, which are of great significance from an ecofriendly, sustainable, intensive aquaculture point of view.

Parasagittal Ependymoma Mimicking Falcine Meningioma

Parasagittal Ependymoma Mimicking Falcine Meningioma

Langerhan's Cell Histiocystosis - a case report

Langerhan's Cell Histiocystosis - a case report Diagnostic challenge in a 21/2 years age girl: A cliniceo-radio-pathological correlation

Nature and Management of Penetrating Spinal Cord Missile Injuries at Shree Birendra Hospital, Chhauni from November 2001 to November 2004

Nature and Management of Penetrating Spinal Cord Missile Injuries at Shree Birendra Hospital, Chhauni from November 2001 to November 2004

Trauma Systems

Trauma systems

STUDY OF PHYSICAL COMPOSITION AND BACTERIOLOGICAL ANALYSIS OF SOLID WASTE OF KATHMANDU CITY

ABSTRACT

PREVALENCE OF GONOCOCCAL INFECTION AMONG THE PATIENTS VISITING AT DERMATOLOGY/VENEROLOGY AND GYNAECOLOGY DEPARTMENT OF TRIBHUVAN UNIVERSITY TEACHING HOSPITAL

A substantial proportion of women with gonococcal infection are asymptomatic butsymptomatic in male. Thus in developing countries, problem arises in active casedetection where laboratory facilities for testing are limited. During the study, thediagnostic validity of the hierarchial clinical algorithm as well as that of a non-hierarchial scoring system were assessed among 102 patient visiting at Dermatology/Venerology (DV) and Gynecology(Gynae) out patient department(OPD) of TribhuvanUniversity Teaching Hospital (TUTH), Kathmandu, Nepal. In the study period of 8months, May –December 1999, 9 (8.82%) were infected with N. gonorrhoea& 2(1.96%)with Gram Negative intracellular diplococci. Age group of 20-30 years were found tobe more infected followed by age groups 30-40 years & 40-50 years ( P< 0.10). Themale were found to be predominantly infected than female and married were foundto be more infected than unmarried. Among the infected people most of them hadsecondary level education and least of them had higher level education. Service holderswere found to be more infected than farmers, drivers & others. But male serviceholders & housewives were equally infected.Antimicrobial susceptibility of N. gonorrhoeashowed 100% susceptible to Ceftriaxone,followed by Ciprofloxacin (88.88%) whereas 22.22% resistant to Tetracycline, 55.55%to Cotrimoxazole and 55.55% to Penicillin. Among isolates, 33.33% were ß- lactamaseproducer. Co-micro organisms like Candida sppand Staphylococcus sppwere alsoobserved.Key Words: Gonococcal infection; Outpatient department, Antimicrobial susceptibility, Nepal.

SURVEILLANCE OF ANTI-TUBERCULAR DRUG RESISTANCE

Tuberculosis is the leading cause of death in Nepal. Failure in early detection anddrug resistance are two most important problems in treatment and cure of thetuberculosis. The objective of the study was to assess the drug resistance pattern inMycobacterium tuberculosis isolated in Tribhuvan University teaching Hospital. Morethan 85% of isolates were sensitive to all the four drugs and 5.5% of isolates weremultidrug resistant. The drug resistant isolates were obtained more frequently frompreviously treated patients. More extensive studies should be carried out by independentorganizations to collect more representative data on drug resistance tuberculosis.Key Words: Tuberculosis, drug resistance and surveillance.

Study on Air Bacterial Flora of Kathmandu Valley

Abstract

Nature and Management of Penetrating Craniocerebral Missile Injuries at Shree Birendra Hospital From November 2001 to November 2002

Nature and Management of Penetrating Craniocerebral Missile Injuries at Shree Birendra Hospital From November 2001 to November 2002

Prognostic factors for persistent distal renal tubular acidosis after surgery for posterior urethral valve

Risk factors, including age at presentation, age at surgery, time between presentation and surgery, urodynamic abnormalities, and vesicoureteric reflux, were prospectively studied for the development of distal renal tubular acidosis (DRTA) before surgery and persistent DRTA after surgery in 24 boys with posterior urethral valve (PUV) with normal serum creatinine levels. DRTA was persistent in 11 of 17 boys (65%) at the end of follow-up after intervention. For the development of DRTA before surgery, only a longer time between presentation and surgery (intervening period) turned out to be a significant risk factor on multivariate analysis (beta = -0.13; P = 0.04). Boys with persistent DRTA after surgery had older age at presentation (P = 0.03), older age at surgery (P = 0.001), a longer intervening period (P = 0.0007), and bilateral or severe unilateral reflux (P = 0.04) before surgery. On univariate logistic regression, age at surgery (beta = -0.07; P = 0.04) and intervening period (beta = -0.13; P = 0.02) were found to be significant risk factors for persistent DRTA, but on multivariate analysis, only intervening period was found to be significant (beta = -0.13; P = 0.02). A delay in intervention after noticing voiding symptoms can predict a high incidence of DRTA before intervention and persistent DRTA after surgery in boys with PUV.

Prognostic significance of distal renal tubular acidosis in posterior urethral valve

The prognostic significance of distal renal tubular acidosis (DRTA) in the development of overt nephropathy (ON) in children with posterior urethral valves (PUV) is not clear. This condition was studied prospectively in 22 children with posterior urethral valve (PUV), with normal renal function. Prior to surgery, the children with ON had a higher incidence of bilateral reflux (P=0.006), but the difference was not significant for age at surgery (P=0.31), duration of voiding symptoms prior to surgery (P=0.30), presence of DRTA (P=0.35) and bladder abnormalities (P=0.27), with none of these factors being significant on logistic regression analysis. At the end of the follow-up, after surgery, age at surgery (P < or = 0.0001), duration of voiding symptoms prior to surgery (P < or = 0.0003), persistent DRTA (P=0.0001) and persistent bladder dysfunction (P=0.02) after surgery were significantly higher in children with ON. On univariate logistic regression analysis, age at surgery (P=0.009), duration of voiding symptoms prior to surgery (P=0.01), persistent DRTA (P=0.002) and persistent bladder abnormalities (P=0.03) after surgery were significant for ON after surgery, but on stepwise multivariate logistic regression analysis only persistent DRTA (P=0.002) turned out to be significant. We conclude that persistent DRTA after surgery can predict overt nephropathy in children with PUV after surgery.

Cyclosporin A withdrawal in live related renal transplantation: long-term results

Cyclosporin A (CsA) withdrawal after 1 yr of stable graft function has been shown to be beneficial in cadaveric renal transplantation. This strategy could be even more suitable for 'immunologically advantaged' grafts as in live related renal transplantation. We report the long-term outcome of patients in a live related transplantation programme undergoing early (between 1989 and 1992) and late (1993 onwards) CsA withdrawal as compared with those on long-term low dose CsA (1993 onwards). Two-hundred and fifty-two patients were divided into three groups based on the following immunosuppressive protocol: group ECyW (n=99), early CsA withdrawal (9 months after transplantation); group LCyW (n=44), late CsA withdrawal (median 16 months, range 13--22 months after transplantation); and group LDCy (n=109), long-term low dose CsA. The median period of follow-up was 66 months after transplantation (range 43--84 months). There was no difference in the actuarial 6-yr patient or graft survival among the three groups. Acute rejection episodes were more frequent in ECyW (54.4%) than in LDCy (31.8%) and LCyW (23.8%) (p=0.001). The risk of developing late (> or =9 months) acute rejection was highest in ECyW 32/99 (32.3%) as compared with LCyW 8/44 (18.4%; p=0.08) and LDCy 8/109 (7.3%; p=0.0001). Of the 32 ECyW patients who developed acute rejection episodes after CsA withdrawal, 13 (40.6%) lost their grafts either due to uncontrolled acute rejection or to chronic rejection. Chronic rejection was higher in ECyW (24%) than in LCyW (11%; p=0.04) and LDCy (17%; p=0.17). Antihypertensive requirement was highest in patients maintained on low dose CsA. Graft function, as measured by serum creatinine levels, was significantly better in LCyW (1.24+/-0.4 mg%) as compared with ECyW (1.49+/-0.5 mg%) and LDCy (1.48+/-0.6 mg%). Early CsA withdrawal after live related renal transplantation is associated with a significant risk of acute rejection and subsequent chronic rejection. Slow withdrawal after 1 yr is safe and more economical than the long-term administration of low dose CsA.

Acute renal failure associated with liver disease in India: etiology and outcome

Acute renal failure (ARF) associated with liver disease is a commonly encountered clinical problem of varied etiology and high mortality. We have prospectively analyzed patients with liver disease and ARF to determine the etiology, clinical spectrum, prognosis and factors affecting the outcome. Other than hepatorenal syndrome patients, out of 221 cases, 66 developed ARF secondary to various liver disease like cirrhosis (n = 29, mortality 8, risk factors-older age p < 0.01, grade III/IV encephalopathy p < 0.05), fulminant hepatic failure (n = 25, mortality 15, risk factor-prolonged prothrombin time p < 0.01), and obstructive jaundice (n = 12, mortality 7, risk factor-sepsis p < 0.01). In these three groups the factors leading to ARF were volume depletion (24), gastrointestinal bleed (28), sepsis (34), drugs (27) [aminoglycosides (9) and NSAID (18)] along with hyperbilirubinemia. Various types of ARF with contemporaneous liver injury were malaria (n = 37, mortality 15, risk factors-higher bilirubin p < 0.001, higher creatinine p < 0.05, anuria p < 0.05 and dialysis dependency p < 0.05), sepsis (n = 36, mortality 22, risk factors-age p < 0.001, higher bilirubin p < 0.01, oliguria p < 0.05), hypovolemia with ischemic hepatic injury (n = 14, mortality 5, risk factors-higher creatinine p < 0.05 and SGPT p < 0.01), acute pancreatitis (n = 12, mortality 4, risk factors-higher bilirubin p < 0.001, higher SGPT p < 0.01, dialysis dependency p < 0.05), rifampicin toxicity (n = 10, no mortality), paroxysmal nocturnal hemoglobinuria (n = 3, no mortality), CuSO4 poisoning (n = 3 mortality 2), post abortal (n = 11, mortality 6, risk factors higher creatinine p < 0.05 and SGPT p < 0.01), ARF following delivery including HELLP syndrome (n = 12, mortality 4, risk factors-higher bilirubin p < 0.01 and SGPT p < 0.01), and of uncertain etiology (n= 14 mortality 4). 133 patients (60.2%), required hemodialysis hemodialfiltration or peritoneal dialysis. ARF associated with liver disease is having high mortality (42.5%). Avoidance of dehydration, hypotension, nephrotoxic drugs and sepsis, with promote dialytic support are necessary to reduce mortality and morbidity.

Does serum albumin at start of continuous ambulatory peritoneal dialysis (CAPD) or its drop during CAPD determine patient outcome?

The impact of serum albumin at start of continuous ambulatory peritoneal dialysis (SA1), serum albumin before death (SA2), and change in serum albumin during continuous ambulatory peritoneal dialysis (delta SA) were prospectively studied in 41 continuous ambulatory peritoneal dialysis (CAPD) patients with a follow-up of 19 +/- 11.6 months. For analysis, patients were divided into two groups at each measurement point: SA1 or SA2 > 3.0 g/dL or delta SA < 1.0 g/dL (group I), and SA1 or SA2 < 3.0 g/dL or delta SA > 1.0 g/dL (group II). On log rank test, the mortality rate was significantly higher in group II patients in relation to SA1 (p < or = 0.0001), SA2 (p = 0.0002), and delta SA (p = 0.001). On univariate Cox proportional hazard regression analysis, SA1 (p = 0.0001), SA2 (p = 0.0001), delta SA (p = 0.002), and episodes of peritonitis (p = 0.0001) were significant. On multivariate analysis, SA2 (p = 0.003) was significantly related to patient mortality. SA2 (r = 0.8; p = 0.0001), but not delta SA, was related to SA1. We conclude that SA2 is the best predictor of patient mortality on CAPD. SA2 is strongly related to SA1. Thus protein restriction in the pre-dialysis stage should be advised cautiously to avoid consequent hypoalbuminemia.

Peritoneal equilibration test in Indian patients on continuous ambulatory peritoneal dialysis: does it affect patient outcome?

The variations in peritoneal equilibration test (PET) characteristics in various ethnic groups have been reported. Data are scarce regarding the pattern of membrane characteristics in Indian patients. The factors affecting PET and the PET, in turn, affecting patient outcome are controversial issues. We prospectively analyzed 41 patients to evaluate: (1) the pattern of PET characteristics in Indian patients; (2) the factors affecting the PET; (3) the effect of membrane characteristics on patient outcome. The mean period of follow up was 17.1 +/- 9.3 months. The PET results revealed 21 high transporters (51%), 13 high-average transporters (32%), 6 low-average transporters (15%), and 1 low transporter (2%). The distribution of the various PET categories in patients below the age of 60 years and those 60 years or above was not significant (p = 0.70). The sex distribution (p = 0.94) and prevalence of diabetes (p = 0.62) were not significantly different in various PET categories. On regression analysis, PET values were not affected by the age of patients (beta = 0.80, p = 0.61). Patient survival among high and high-average transporters was significantly less compared with low and low-average transporters (p = 0.01). We conclude that Indian patients on continuous ambulatory peritoneal dialysis (CAPD) have a higher proportion of high and high-average transporters. The pattern of membrane kinetics cannot be explained by differences in patient characteristics and diabetic status. Patients with high PET values have poorer patient survival on CAPD.

Varicose Veins: A 2-year study in Military Hospital, Chhauni

Varicose Veins: A 2-year study in Military Hospital, Chhauni

Etiology, prognosis, and outcome of post-operative acute renal failure

A Multivariate analysis was done in all patients who developed post operative ARF, during the period 1990-1995 to determine the etiological spectrum and to identify various variables affecting the outcome. Of 140 patients (110 operated at SGPGI and 30 operated outside) 116 underwent elective surgery. The different types of surgery leading to ARF were urosurgery (3.5%), open heart surgery (32.9%), gastrosurgery (16.4%), pancreatic surgery (9.3%), obstetrical surgery (3.6%) and others (2.8%). The incidence of ARF in SGPGI patients was highest in pancreatic surgery group (8.2%) followed by open heart surgery (3%). The different etiological factors responsible for ARF were perioperative hypotension (67.1%), sepsis (63.6%) and exposure to nephrotoxic drugs (29.3%). Sixty-four patients (45.7%) required dialysis. The overall mortality was 45%. The mortality was highest in patients who underwent open heart surgery (89.1%) followed by pancreatic surgery (84.6%). The factors associated with high mortality, other than the type of surgery, were preoperative hypotension (p < 0.05), oliguria (p < 0.01), need for dialysis (p < 0.05) and multiorgan failure (p < 0.001). AM following emergency surgery had poor outcome, though not statistically significant. Perioperative sepsis (p < 0.05) and preoperative use of aminoglycoside (p < 0.05) were significantly higher in patients operated outside SGPGI. This was associated with higher incidence of ARF. Thus we conclude that presence of multiorgan failure, oligoanuria, preoperative hypotension and need far dialysis are poor prognostic markers in ARF following surgery.