A case report of Paracetamol related pyroglutamic acidosis: mind the gap in a malnourished patient.

BACKGROUND: Pyroglutamic acidosis is a rare cause of high anion gap metabolic acidosis. Most cases of paracetamol related pyroglutamic acidosis are described in malnourished women and patients with kidney/liver failure, alcohol use or severe sepsis. In this report, we describe how pyroglutamic acidosis could be related to the use of chronic therapeutic paracetamol with only malnutrition as an associated risk factor. CASE PRESENTATION: We report a case of a 67-year-old male patient developing a pyroglutamic acidosis. The patient was initially admitted to hospital for infectious osteoarthritis and developed a metabolic acidosis during his hospital stay. Analgesics included daily therapeutic doses of paracetamol. What makes our case unusual is that our malnourished male patient did not have renal or hepatic failure. The diagnosis of paracetamol related pyroglutamic acidosis was made after ruling out the main causes of metabolic acidosis. It was further confirmed by urine organic acids measurement showing a markedly elevated level of pyroglutamic aciduria. Paracetamol was discontinued allowing a prompt correction of the anion gap. CONCLUSION: This case is a representative of pyroglutamic acidosis related to chronic therapeutic paracetamol with only malnutrition as an associated risk factor. Physicians should be aware of such unusual cause of metabolic acidosis, which may be more common than expected in hospitalized patients. A high clinical suspicion is needed when urine organic acids analysis is not available.

Using Acidosis as a Surrogate for or Supplement to the Bedside Index of Severity in Acute Pancreatitis Scoring Prediction System Has a Nonsignificant Effect.

Currently, risk stratification calculators for acute pancreatitis (AP) can at best predict acute pancreatitis mortality at 12 hours from the presentation. Given the severe morbidity associated with AP, the identification of additional prognostic indicators, which may afford earlier prediction in length of stay (LOS) and mortality, is desired. Metabolic acidosis can be a prognostic marker for the severity of AP, and venous bicarbonate can reliably and accurately be substituted for arterial base deficit to detect metabolic acidosis. Since serum bicarbonate, anion gap (AG), and corrected AG (CAG) are routinely obtained upon presentation to the emergency department and often daily in the hospital, we conducted a retrospective analysis of 443 patients, evaluating if venous bicarbonate could predict the severity of pancreatitis as well as mortality, admission to the ICU, ICU LOS, and hospital LOS. The inclusion of venous bicarbonate, AG, and CAG in the first 12 hours only slightly improved the predictive capabilities of the Bedside Index for Severity in Acute Pancreatitis (BISAP) score for these secondary outcomes. None of our incorporations of acidemia improved severity predictions more than the BISAP alone. Adding CAG to BISAP scoring had the largest effect on predicting ICU admission and hospital LOS (area under the curve (AUC): 1.12 (confidence interval (CI) 95%: 1.06-1.19), p <.001 and AUC 1.02 (CI 95% 1.01-1.04), p <.001; respectively). ICU LOS was not impacted by the addition of AG, CAG, or venous bicarbonate. In-hospital death (n=12) was too small to be determined.

Association between the anion gap and mortality in critically ill patients with influenza: A cohort study.

Introduction: Influenza is an important global health concern, particularly in critically ill patients. The anion gap, a marker of metabolic acidosis, is associated with mortality in various critical illnesses. However, its association with mortality in critically ill patients with influenza remains unclear. This study investigated the association between the anion gap on admission and 28-day mortality in critically ill patients with influenza. Methods: A retrospective cohort study was conducted using data from MIMIC-IV database. Patients admitted to the intensive care unit (ICU) with influenza were included. The anion gap was measured within the first 24 h of ICU admission. The primary outcome was the 28-day mortality. The secondary outcomes were 60-day mortality and in-hospital mortality. Multivariable Cox regression was used to assess the association between the anion gap and mortality. Results: A total of 276 critically ill patients with influenza were included in the study. The mean age was 65 years, and 60 % were male. The overall 28-day mortality was 15.5 %. A greater anion gap on admission was associated with significantly increased 28-day mortality in the unadjusted analysis (hazard ratio [HR], 1.11; 95 % confidence interval [CI], 1.03-1.2; p < 0.001). The association remained significant after adjusting for age, sex, race, and illness severity (adjusted HR, 1.09; 95 % CI, 1.02-1.17; p = 0.017). Subgroup analysis showed consistent results across the different groups. Conclusion: A greater anion gap on admission was independently associated with increased 28-day mortality in critically ill patients with influenza. These findings suggest that the anion gap can be used as a prognostic marker in patients with influenza, aiding in risk stratification and guiding clinical management.

A case report of elevated bromide levels from pyridostigmine bromide for treatment of myasthenia gravis.

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: Elevated serum bromide levels can cause dermatological, gastrointestinal, and neurological abnormalities. As bromide and chloride are both halogens, bromide may interfere with chloride assays, causing a falsely high serum chloride concentration and a low or negative anion gap. There is a paucity of data describing bromide toxicity from high doses of pyridostigmine bromide (PB). This case report describes a patient with an elevated bromide level with neurological symptoms from a therapeutic dose of PB. SUMMARY: A 37-year-old male with myasthenia gravis secondary to type B2 thymoma status following thymectomy presented in myasthenic crisis. He required mechanical ventilation and was managed with steroids, intravenous immune globulin, plasmapheresis, and PB. On day 9, the patient experienced acute agitation. He had an anion gap of 2 mEq/L and a chloride concentration of 109 mEq/L. The plasma creatinine concentration was 0.63 to 1.15 mg/dL and urine output was 0.76 to 1.79 mL/kg/h throughout his admission. All other laboratory values were normal. The daily dose of PB was 660 mg on day 9, but the patient received 76 mg of intravenous PB over the first few days of his admission with the largest dose in 24 hours equal to 48 mg. On day 10, the patient's bromide level was 37 µg/mL. His agitation was initially managed with quetiapine, followed by PB dose reduction. To our knowledge, there are 2 cases in the literature of bromide toxicity secondary to PB. These patients experienced neurological symptoms with bromide levels of 88 to 90 µg/mL. Bromide concentrations of more than 12 µg/mL are associated with a higher risk of neuronal dysfunction demonstrated as disturbances on an electroencephalogram, and levels greater than 50 µg/mL are considered toxic. While our patient's bromide level was not as high as those previously reported, no other causes for his agitation were identified. CONCLUSION: Elevated bromide levels from therapeutic PB can occur, and monitoring of these levels should be considered.

Association between Albumin-Corrected Anion Gap and Mortality in Patients with Cardiogenic Shock.

Background: Cardiogenic shock (CS) is a critical illness with a high mortality rate in clinical practice. Although some biomarkers have been found to be associated with mortality in patients suffering from CS in previous studies. The albumin-corrected anion gap (ACAG) has not been studied in depth. Our study aimed to explore the relationship between ACAG and mortality in patients with CS. Methods: All baseline data was extracted from Medical Information Mart for Intensive Care-IV version: 2.0 (MIMIC-IV). According to the prognosis at 30 days of follow-up, they were divided into survivors and non-survivors groups. The survival curves between the two groups were drawn using the Kaplan-Meier method and the log-rank test. Valid factors were selected using the least absolute shrinkage and selection operator (LASSO) logistic analysis model. Analysis was performed to investigate the relationship between mortality and all enrolled patients using restricted cubic spline (RCS) and Cox proportional hazards models. Receiver operating characteristic (ROC) curves were used to assess the predictive ability of ACAG. Evaluation of final result stability using sensitivity analysis. Results: 839 cases were selected to meet the inclusion criteria and categorized into survivors and non-survivors groups in the final analysis. The ACAG value measured for the first time at the time of admission was selected as the research object. Kaplan-Meier (K-M) survival curves showed that cumulative 30- and 90-day survival decreased progressively with elevated ACAG (p < 0.001), and multifactorial Cox regression analyses showed ACAG to be an independent risk factor for increased 30- and 90-day mortality in patients suffering from CS (p < 0.05). RCS curves revealed that all-cause mortality in this group of patients increased with increasing ACAG ( χ 2 = 5.830, p = 0.120). The ROC curve showed that the best cutoff value for ACAG for predicting 30-day mortality in patients with CS was 22.625, with a sensitivity of 44.0% and a specificity of 74.7%. The relationship between ACAG and CS short-term mortality remained stable in all sensitivity analyses (All p < 0.05). Conclusions: The ACAG is an independent risk factor for 30- and 90-day mortality in CS patients and predicts poor clinical outcomes in CS patients. According to our study, elevated ACAG at admission, especially when ACAG > 20 mmol/L, was an independent predictor of all-cause mortality in CS.

The Usefulness of Reduced Anion Gap and the Possibility of Pupillary Findings in the Treatment of Acute Bromvalerylurea Intoxication.

Bromvalerylurea is found as an over-the-counter analgesic and hypnotic drug in Japan and can be purchased at drugstores or over the Internet. Therefore, both acute poisoning due to large doses taken in suicide attempts and chronic poisoning due to continuous use for chronic pain have been observed. We report a case of acute BVU poisoning due to the use of an over-the-counter hypnotic sedative for a suicide attempt. A 34-year-old woman was referred to our ICU with unexplained disturbance of consciousness, respiratory failure, and shock. During ICU management, when her pupil diameter was measured with an automatic pupillometer to confirm her conscious state, the right pupil diameter was larger than the left, but one hour later, the left pupil diameter was larger than the right. The difference between right and left fluctuated with the time of day. After awakening, it was found that the patient had taken 108 tablets of Utt, an over-the-counter hypnotic sedative, and the possibility of acute poisoning by its component, BVU, was raised. Because a blood gas analysis at the time of admission showed metabolic acidosis with anion gap ≤1, a diagnosis of acute BVU poisoning was made. The patient's general condition stabilized, and she was transferred to the psychiatric ward. Symptoms of acute BVU poisoning include impaired consciousness and respiratory and circulatory depression, which may make it impossible to obtain a medical interview. When treating a patient with suspected drug intoxication who is unable to communicate, the clinician needs to include BVU poisoning in the differential when a reduced anion gap is observed. The clinician should also know that BVU poisoning can cause ocular manifestations such as anisocoria. This may lead to early diagnosis and therapeutic intervention.

Diabetic Ketoacidosis Presenting as Abdominal Pain in a Two-Year-Old Female: A Case Report.

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes and can sometimes be the first indication of undiagnosed type 1 diabetes mellitus (T1DM). Our case presents a unique scenario in which a two-year-old female presented to her pediatrician with persistent abdominal pain, along with fatigue and tachypnea. On physical examination, she was mildly distressed, tachypneic, and utilized accessory muscles during respiration. Subsequent urinalysis indicated elevated glucose levels of 500 milligrams/deciliter (mg/dL). She was promptly referred to the emergency department to be treated for DKA. Upon arrival, the patient's glucose level was elevated at 533 mg/dL, with an anion gap of 25. She was stabilized and admitted to the pediatric intensive care unit (PICU) with a new diagnosis of T1DM with ketoacidosis. Given the emergent nature of DKA and the need for immediate treatment, physicians should consider DKA as a potential diagnosis for any pediatric patient presenting with abdominal pain.

A Case of Metformin-Associated Lactic Acidosis Complicated by Acute Liver Failure, Acute Renal Failure, and Shock.

Metformin is an oral antihyperglycemic agent used for type 2 diabetes mellitus (T2DM) management and is considered to be the first-line treatment for diabetic patients. It works by improving insulin sensitivity, reducing intestinal absorption, and decreasing glucose production in the liver, leading to decreased blood glucose levels. It is generally considered a safe drug; however, it is associated with an uncommon but serious side effect known as metformin-associated lactic acidosis (MALA), a potentially life-threatening condition. Patients with renal failure and liver disease are at high risk of developing MALA; therefore, the medication should be used cautiously in these patients. The diagnosis of MALA requires high suspicion from the physician of this specific entity; otherwise, it may be easily missed. Herein, we report a case of a 63-year-old female with alcoholic liver disease on metformin who was found to have MALA complicated by acute decompensated liver failure, renal failure, and shock.

The relationship between serum anion gap levels and short-, medium-, and long-term all-cause mortality in ICU patients with congestive heart failure: a retrospective cohort study.

BACKGROUND: There hasn't been research done on the connection between serum anion gap (AG) levels and long-, medium-, and short-term all-cause mortality in congestive heart failure (CHF) patients. This study aims to investigate the association between serum anion gap levels and all-cause mortality in CHF patients after adjusting for other covariates. METHODS: For each patient, we gather demographic information, comorbidities, laboratory results, vital signs, and scoring data using the ICU (Intensive Care Unit) Admission Scoring System from the MIMIC-III database. The connection between baseline AG and long-, medium-, and short-term all-cause mortality in critically ill congestive heart failure patients was investigated using Kaplan-Meier survival curves, subgroup analysis, restricted cubic spline, and Cox proportional risk analysis. RESULTS: 4840 patients with congestive heart failure in total were included in this study. With a mean age of 72.5 years, these patients had a gender split of 2567 males and 2273 females. After adjusting for other covariates, a multiple regression analysis revealed that, in critically ill patients with congestive heart failure, all-cause mortality increased significantly with rising AG levels. In the fully adjusted model, we discovered that AG levels were strongly correlated with 4-year, 365-day, 90-day, and 30-day all-cause mortality in congestive heart failure patients with HRs (95% CI) of 1.06 (1.04, 1.08); 1.08 (1.05, 1.10); and 1.08 (1.05, 1.11) (p-value < 0.05). Our subgroup analysis's findings demonstrated a high level of consistency and reliability. K-M survival curves demonstrate that high serum AG levels are associated with a lower survival probability. CONCLUSION: Our research showed the association between CHF patients' all-cause mortality and anion gap levels was non-linear. Elevated anion gap levels are associated with an increased risk of long-, medium-, and short-term all-cause death in patients with congestive heart failure. Continuous monitoring of changes in AG levels may have a clinical predictive role.

Mind the Anion Gap: 5-Oxoproline-Induced High Anion Gap Metabolic Acidosis in End-Stage Renal Disease.

A rare complication, 5-oxoproline-induced high anion gap metabolic acidosis (HAGMA) is associated with chronic acetaminophen use, predominantly reported in outpatient settings. However, its occurrence in hospitalized patients, particularly those with end-stage renal disease (ESRD), remains underreported. We present a case of a 74-year-old female with ESRD on hemodialysis who developed HAGMA highly suspicious for 5-oxoproline toxicity from acetaminophen usage following cardiac surgery. Despite a standard analgesic dose, the patient's renal impairment likely predisposed her to 5-oxoproline accumulation, resulting in severe metabolic acidosis. Discontinuation of acetaminophen led to the resolution of HAGMA, highlighting the importance of recognizing this rare but potentially life-threatening complication in the inpatient and critical care setting. This case suggests a potential interaction between acetaminophen metabolism and renal dysfunction in the pathogenesis of 5-oxoproline-induced HAGMA.

A prognostic model incorporating the albumin-corrected anion gap in patients with aneurysmal subarachnoid hemorrhage.

Background: Aneurysmal subarachnoid hemorrhage (aSAH) patients typically have poor prognoses. The anion gap (AG) has been proven to correlate with mortality in various critically ill patients. However, hypoalbuminemia can lead to underestimations of the true anion gap levels. This study was conducted to verify the prognostic value of single AG and albumin-corrected anion gap (ACAG) among aSAH patients. Methods: Significant factors in the univariate logistic regression analysis were included in the multivariate logistic regression analysis to explore the risk factors for mortality in aSAH patients and to confirm the independent relationship between ACAG and mortality. The restricted cubic spline (RCS) was used to visually show the relationship between ACAG level and mortality risk of aSAH patients. The predictive model for mortality was developed by incorporating significant factors into the multivariate logistic regression analysis. The prognostic value of ACAG and the developed model was evaluated by calculating the area under the receiver operating characteristics curve (AUC). Results: Among 710 aSAH patients, a 30-day mortality was observed in 20.3% of the cases. A positive relationship was demonstrated between the ACAG level and mortality in aSAH patients using the RCS curve. The multivariate logistic regression analysis helped discover that only six factors were finally and independently related to mortality of aSAH patients after adjusting for confounding effects, including the Hunt-Hess scale score (p = 0.006), surgical options (p < 0.001), white blood cell count (p < 0.001), serum chloride levels (p = 0.023), ACAG (p = 0.039), and delayed cerebral ischemia (p < 0.001). The AUC values for the AG, albumin, and ACAG in predicting mortality among aSAH patients were 0.606, 0.536, and 0.617, respectively. A logistic regression model, which includes the Hunt-Hess scale score, surgical options, white blood cell count, serum chloride levels, ACAG, and delayed cerebral ischemia, achieved an AUC of 0.911 for predicting mortality. Conclusion: The ACAG is an effective prognostic marker for aSAH patients. A prognostic model incorporating ACAG could help clinicians evaluate the risk of poor outcomes among aSAH patients, thereby facilitating the development of personalized therapeutic strategies.

Acetaminophen induced high anion gap metabolic acidosis: a potentially under-recognized consequence from a common medication.

While metabolic acidosis is one of the most common complications in patients with chronic kidney disease (CKD), there are several uncommon etiologies that are challenging to diagnose. Here, we describe a patient on peritoneal dialysis who developed high anion gap metabolic acidosis secondary to acquired 5-oxoprolinemia from acetaminophen use. While CKD is a known risk factor for developing this potentially serious complication, this case further highlights how 5-oxoproline accumulation can occur, even with therapeutic dosing of acetaminophen.

Diagnostic accuracy of the anion gap to identify toxic lithium concentrations: a single-center retrospective observational study.

INTRODUCTION: Lithium exhibits a narrow margin between therapeutic doses and toxic blood concentrations, which can pose a substantial risk of toxic effects. Reportedly, lithium toxicity may be associated with a reduced anion gap; however, the precise relationship remains unclear. This study examined several different anion gap calculation methods to detect toxic lithium concentrations without directly measuring blood lithium concentrations. METHODS: Our retrospective study analyzed blood samples collected for lithium concentration measurements. The anion gap was determined using three different methods, both with and without albumin and lactate concentration corrections. Samples were categorized into two groups based on lithium concentration (<1.5 or ≥1.5 mmol/L), and anion gap values were compared. Correlation and logistic regression analyses were used to assess the relationship between each anion gap indicator and lithium concentration. Receiver operating characteristic curves were used for diagnostic analysis. RESULTS: Overall, 24 measurements were collected, with 41.7% of samples falling within the toxic range. The high-lithium concentration group exhibited significantly smaller anion gaps. Correlation and logistic regression analyses revealed a significant association between anion gap values and lithium concentrations. Areas under the receiver operating characteristic curve were: conventional anion gap 0.77 (95% CI: 0.55-0.94); albumin-corrected anion gap 0.85 (95% CI: 0.66-1.00); and both albumin- and lactate-corrected anion gap 0.86 (95% CI: 0.66-1.00). DISCUSSION: The anion gap is calculated as the difference between measured cations and anions. Accumulation of lithium (a cation) may decrease measured cations and decrease the calculated anion gap. Abnormal albumin and lactate concentrations may also alter the anion gap and affect its usefulness as a diagnostic marker for elevated serum lithium concentrations. A negative likelihood ratio of 0.1 suggests that the anion gap might be valuable in excluding toxicity. CONCLUSIONS: The corrected anion gap, accounting for albumin and lactate concentrations, may be beneficial in suggesting the possibility of toxic lithium concentrations.

Albumin corrected anion gap for predicting in-hospital death among patients with acute myocardial infarction: A retrospective cohort study.

OBJECTIVE: To explore the relationship between Anion Gap (AG), Albumin Corrected AG (ACAG), and in-hospital mortality of Acute Myocardial Infarction (AMI) patients and develop a prediction model for predicting the mortality in AMI patients. METHODS: This was a retrospective cohort study based on the Medical Information Mart for Intensive Care (MIMIC)-Ⅲ, MIMIC-IV, and eICU Collaborative Study Database (eICU). A total of 9767 AMI patients who were admitted to the intensive care unit were included. The authors employed univariate and multivariable cox proportional hazards analyses to investigate the association between AG, ACAG, and in-hospital mortality; p < 0.05 was considered statistically significant. A nomogram incorporating ACAG and clinical indicators was developed and validated for predicting mortality among AMI patients. RESULTS: Both ACAG and AG exhibited a significant association with an elevated risk of in-hospital mortality in AMI patients. The C-index of ACAG (C-index = 0.606) was significantly higher than AG (C-index = 0.589). A nomogram (ACAG combined model) was developed to predict the in-hospital mortality for AMI patients. The nomogram demonstrated a good predictive performance by Area Under the Curve (AUC) of 0.763 in the training set, 0.744 and 0.681 in the external validation cohort. The C-index of the nomogram was 0.759 in the training set, 0.756 and 0.762 in the validation cohorts. Additionally, the C-index of the nomogram was obviously higher than the ACAG and age shock index in three databases. CONCLUSION: ACAG was related to in-hospital mortality among AMI patients. The authors developed a nomogram incorporating ACAG and clinical indicators, demonstrating good performance for predicting in-hospital mortality of AMI patients.

Demystifying normal-anion-gap metabolic acidosis: pathophysiology, aetiology, evaluation and diagnosis.

Normal-anion-gap metabolic acidosis (NAGMA) is a common but often under-recognised and poorly understood condition, especially by less-experienced clinicians. In adults, NAGMA might be an initial clue to a more significant underlying pathology, such as autoimmune diseases, hypergammaglobulinemia or drug toxicities. However, identifying the aetiology can be challenging due to the diverse processes involved in the development of acidosis. A better understanding of the pathophysiology of NAGMA can help treating physicians suspect and evaluate the condition early and reach the correct diagnosis. This article provides an overview of renal acid-base regulation, discusses the pathophysiological processes involved in developing NAGMA and provides a framework for evaluation to reach an accurate diagnosis.

Association of anion gap and albumin corrected anion gap with acute kidney injury in patients with acute ischemic stroke.

BACKGROUND: Acute kidney injury (AKI) has become a common complication of acute ischemic stroke (AIS) and may have a significant impact on clinical outcomes. Anion gap (AG)/albumin corrected anion gap (ACAG) are used to assess acid-base balance status and help identify the severity of metabolic acidosis. OBJECTIVES: To explore the association of AG and ACAG with the risk of AKI in AIS patients admitted to the intensive care unit (ICU). MATERIAL AND METHODS: Data of AIS patients in this retrospective cohort study were extracted from the electronic ICU (eICU) databases (2014-2015). The outcome was the occurrence of AKI after ICU admission. The covariates included demographic data, vital signs, comorbidities, laboratory parameters, and medication use. The association of AG and ACAG levels with AKI risk in AIS patients was evaluated using univariate and multivariate logistic regression models with odds ratios (ORs) and 95% confidence intervals (95% CIs). The predictive performance of AG and ACAG for the risk of AKI in AIS patients was assessed with the area under the curve (AUC). To further explore the association of AG and ACAG levels with AKI risk, subgroup analyses were performed according to comorbidities. RESULTS: Of the 1,260 AIS patients, 546 (43%) developed AKI. Elevated AG (OR = 1.73, 95% CI: 1.32-2.29) and ACAG (OR = 1.57, 95% CI: 1.21-2.04) were associated with the risk of AKI in AIS patients. The AUC of ACAG was superior to AG for predicting the risk of AKI (0.581 vs 0.558; p = 0.024). Elevated ACAG levels were associated with the risk of AKI in AIS patients without ischemic heart disease (OR = 1.60, 95% CI: 1.19-2.15), diabetes (OR = 1.58, 95% CI: 1.19-2.10) and hypertension (OR = 1.69, 95% CI: 1.24-2.30). CONCLUSIONS: Albumin corrected anion gap was a better predictor than AG for AKI risk in AIS patients, which may help clinicians identify high-risk patients for AKI.

Association between anion gap and the 30-day mortality of patients with ventilator-associated pneumonia: a study of the MIMIC-III database.

Background: Serum anion gap (AG) can potentially be applied to the diagnosis of various metabolic acidosis, and a recent study has reported the association of AG with the mortality of patients with coronavirus disease 2019 (COVID-19). However, the relationship of AG with the short-term mortality of patients with ventilator-associated pneumonia (VAP) is still unclear. Herein, we aimed to investigate the association between AG and the 30-day mortality of VAP patients, and construct and assess a multivariate predictive model for the 30-day mortality risk of VAP. Methods: This retrospective cohort study extracted data of 477 patients with VAP from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Data of patients were divided into a training set and a testing set with a ratio of 7:3. In the training set, variables significantly associated with the 30-day mortality of VAP patients were included in the multivariate predictive model through univariate Cox regression and stepwise regression analyses. Then, the predictive performance of the multivariate predictive model was assessed in both training set and testing set, and compared with the single AG and other scoring systems including the Sequential Organ Failure Assessment (SOFA) score, the confusion, urea, respiratory rate (RR), blood pressure, and age (≥65 years old) (CURB-65) score, and the blood urea nitrogen (BUN), altered mental status, pulse, and age (>65 years old) (BAP-65) score. In addition, the association of AG with the 30-day mortality of VAP patients was explored in subgroups of gender, age, and infection status. The evaluation indexes were hazard ratios (HRs), C-index, and 95% confidence intervals (CIs). Results: A total of 70 patients died within 30 days. The multivariate predictive model consisted of AG (HR =1.052, 95% CI: 1.008-1.098), age (HR =1.037, 95% CI: 1.019-1.055), duration of mechanical ventilation (HR =0.998, 95% CI: 0.996-0.999), and vasopressors use (HR =1.795, 95% CI: 1.066-3.023). In both training set (C-index =0.725, 95% CI: 0.670-0.780) and testing set (C-index =0.717, 95% CI: 0.637-0.797), the multivariate model had a relatively superior predictive performance to the single AG value. Moreover, the association of AG with the 30-day mortality was also found in patients who were male (HR =1.088, 95% CI: 1.029-1.150), and whatever the pathogens they infected (bacterial infection: HR =1.059, 95% CI: 1.011-1.109; fungal infection: HR =1.057, 95% CI: 1.002-1.115). Conclusions: The AG-related multivariate model had a potential predictive value for the 30-day mortality of patients with VAP. These findings may provide some references for further exploration on simple and robust predictors of the short-term mortality risk of VAP, which may further help clinicians to identify patients with high risk of mortality in an early stage in the intensive care units (ICUs).

Advancing necrotizing enterocolitis prediction through iterative monitoring.

Background: Necrotizing enterocolitis (NEC) is a severe inflammatory intestinal disease in preterm infants, marked by heightened morbidity and mortality. Timely prediction of NEC is significant in the management of critical neonates. However, it is difficult to predict NEC accurately because of the multi-factorial pathogenesis. This study aimed to develop a prediction model through repeated measurement data to further improve the accuracy of prediction in NEC. Methods: We retrospectively collected clinical data of premature infants admitted to the Neonatology Department of the First Affiliated Hospital of Anhui Medical University from January 2016 to December 2023. The infants were categorized into the NEC group (Bell's stage ≥ II) (n=150) and the non-NEC group (n=150). The clinical baseline data of the NEC and non-NEC groups were matched. Laboratory examination indicators were collected on the 1st day, the 7th day after birth, and the day of NEC onset. Univariate and multivariate logistic regression analyses were conducted to identify independent factors influencing NEC. A nomogram was constructed based on these factors to predict NEC. The concordance index and calibration plot were used to assess the efficiency of the nomogram in the training and validation cohorts. Results: This study demonstrated that antenatal steroids, antenatal antibiotics, probiotics treatment before NEC, anion gap (AG, day 7), and mean corpuscular volume (MCV, day 7) were independent risk factors which combined to accurately predict NEC. A nomogram of NEC was created utilizing these five predictors. With an area under the receiver operator characteristic (ROC) curve of 0.835 [95% confidence interval (CI): 0.785-0.884]. Concordance index for the training and validation groups were 0.835 and 0.848, respectively. As the calibration plots indicate, the predicted probability of NEC is highly consistent with the actual observation. Conclusions: The risk estimation nomogram for NEC offers clinical value by guiding early prediction, targeted prevention, and early intervention strategies for NEC.

[A case of chronic bromide intoxication due to continuous use of a commercially available analgesic in a patient diagnosed with pseudohyperchloremia].

An 87-year-old woman was admitted to our hospital with general fatigue, anorexia, nausea, and chest pain, and was diagnosed with Takotsubo cardiomyopathy and a stomal ulcer. Pseudohyperchloremia and a negative anion gap were detected in laboratory tests. She was continuously taking commercially available analgesics, including bromvalerylurea. On the 11th day of hospitalization, her bromide concentration was high (331.2 mg/L). She was readmitted with fatigue and anorexia one and a half years after her last hospitalization. On admission, her serum chloride and bromide levels were also high. Despite being instructed to stop taking analgesics after the first hospitalization, she was unable to stop taking the medication. It took more than two years for her blood bromide concentration to decrease and the withdrawal of the medication to be confirmed. Clinicians should consider bromide intoxication in patients with unclear neuropsychiatric symptoms and high chloride levels.

Hyperglycaemic crises in adults with diabetes: a consensus report.

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE) and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycaemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment and prevention of diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes healthcare professionals and individuals with diabetes.