Hypercalcemia: A Review.

Importance: Hypercalcemia affects approximately 1% of the worldwide population. Mild hypercalcemia, defined as total calcium of less than 12 mg/dL (<3 mmol/L) or ionized calcium of 5.6 to 8.0 mg/dL (1.4-2 mmol/L), is usually asymptomatic but may be associated with constitutional symptoms such as fatigue and constipation in approximately 20% of people. Hypercalcemia that is severe, defined as total calcium of 14 mg/dL or greater (>3.5 mmol/L) or ionized calcium of 10 mg/dL or greater (≥2.5 mmol/L) or that develops rapidly over days to weeks, can cause nausea, vomiting, dehydration, confusion, somnolence, and coma. Observations: Approximately 90% of people with hypercalcemia have primary hyperparathyroidism (PHPT) or malignancy. Additional causes of hypercalcemia include granulomatous disease such as sarcoidosis, endocrinopathies such as thyroid disease, immobilization, genetic disorders, and medications such as thiazide diuretics and supplements such as calcium, vitamin D, or vitamin A. Hypercalcemia has been associated with sodium-glucose cotransporter 2 protein inhibitors, immune checkpoint inhibitors, denosumab discontinuation, SARS-CoV-2, ketogenic diets, and extreme exercise, but these account for less than 1% of causes. Serum intact parathyroid hormone (PTH), the most important initial test to evaluate hypercalcemia, distinguishes PTH-dependent from PTH-independent causes. In a patient with hypercalcemia, an elevated or normal PTH concentration is consistent with PHPT, while a suppressed PTH level (<20 pg/mL depending on assay) indicates another cause. Mild hypercalcemia usually does not need acute intervention. If due to PHPT, parathyroidectomy may be considered depending on age, serum calcium level, and kidney or skeletal involvement. In patients older than 50 years with serum calcium levels less than 1 mg above the upper normal limit and no evidence of skeletal or kidney disease, observation may be appropriate. Initial therapy of symptomatic or severe hypercalcemia consists of hydration and intravenous bisphosphonates, such as zoledronic acid or pamidronate. In patients with kidney failure, denosumab and dialysis may be indicated. Glucocorticoids may be used as primary treatment when hypercalcemia is due to excessive intestinal calcium absorption (vitamin D intoxication, granulomatous disorders, some lymphomas). Treatment reduces serum calcium and improves symptoms, at least transiently. The underlying cause of hypercalcemia should be identified and treated. The prognosis for asymptomatic PHPT is excellent with either medical or surgical management. Hypercalcemia of malignancy is associated with poor survival. Conclusions and Relevance: Mild hypercalcemia is typically asymptomatic, while severe hypercalcemia is associated with nausea, vomiting, dehydration, confusion, somnolence, and coma. Asymptomatic hypercalcemia due to primary hyperparathyroidism is managed with parathyroidectomy or observation with monitoring, while severe hypercalcemia is typically treated with hydration and intravenous bisphosphonates.

Tetralogy of Fallot Presenting as Severe Hypernatremic Dehydration: A Review of the Importance of Perinatal Care.

We present a case of a female American Indian neonate born via a provider unattended home delivery. Her mother received limited prenatal care and the infant was not examined by a healthcare provider until day of life 10 when she presented to the emergency department for evaluation of a skin rash. She was found to have severe hypernatremic dehydration. She was subsequently diagnosed with tetralogy of Fallot, and this was the likely cause of her breastfeeding failure dehydration. The infant underwent careful correction of her electrolyte abnormalities and surgical repair of her cardiac defect on day of life 27. This case highlights the importance of comprehensive care during the prenatal and postpartum/newborn periods, especially in rural locations where access to care can be difficult.

Pre-Competition Weight Loss Models in Taekwondo: Identification, Characteristics and Risk of Dehydration.

Athletes use different combinations of weight loss methods during competition preparation. The aim of this study was to identify and characterize pre-competition weight loss models, which describe these combinations. The second aim was to determine if any existing model pose a higher risk of severe dehydration and whether any of the models could be continued as a lower-risk option. The third aim was to explore whether athletes who used different weight management strategies could be differentiated based on age, sex, training experience or anthropometric parameters. Study participants were randomly selected from Olympic taekwondo competitors and 192 athletes were enrolled. Active (47% weight-reducing athletes), passive (31%) and extreme (22%) models have been described. In the extreme model, athletes combined the highest number of different weight loss methods (3.9 ± 0.9 methods vs. 2.4 ± 0.9 in active and 1.5 ± 0.6 in passive), reduced significantly more body mass than others (6.7 ± 3.5% body mass vs. 4.3 ± 1.9% and 4.5 ± 2.4%; p < 0.01) and all of them used methods with the highest risk of severe dehydration. The active and passive models could be continued as a lower-risk option, if athletes do not combine dehydrating methods and do not prolong the low energy availability phase. The extreme model carried the highest risk of severe dehydration. Every fifth weight-reducing taekwondo athlete may have been exposed to the adverse effects of acute weight loss. Taekwondo athletes, regardless of age, sex, training experience and anthropometric parameters, lose weight before the competition and those characteristics do not differentiate them between models.

Dehydration of a diver during a hyperbaric chamber exposure with oxygen decompression.

Objective: An analysis of factors that may indicate both the type and degree of dehydration of a diver's body following a dry chamber hyperbaric exposure. Methods: The study was participated by 63 men - professional divers, with extensive diving experience, aged 24-51 years (average age 32.6). The subjects underwent two hyperbaric exposures, one to a pressure of 0.3 MPa and one to a pressure of 0.6 MPa, with oxygen decompression. The exposures were carried out in a hyperbaric chamber pursuant to the decompression tables of the Polish Navy, with the observance of a 24-hour interval between exposures. Blood samples were collected from the participants in order to perform a blood morphology test. Body weight was measured with the bioelectrical impedance method using the Maltron BioScan 920 device.The results were subjected to statistical analysis. The following blood morphology parameters were analyzed: hematocrit (Ht), erythrocyte size (MCV), color index (MCHC) and body weight composition: total water (TBW), extracellular water (ECW), intracellular water (ICW). Results: The studies have shown that during a hyperbaric exposure in the chamber the diver's body becomes dehydrated, with observable loss of both intracellular water as evidenced by the reduction of hematocrit content and erythrocyte size, as well as extracellular water, with the accompanying increase in the color index. Conclusions: Hyperbaric conditions are conducive to the dehydration of the diver's body, however to a degree which does not lead to an occurrence of health hazards. Good care for one's health through proper nutrition and hydration are sufficient preventive and protective measures.

Case Study: Extreme Weight Making Causes Relative Energy Deficiency, Dehydration, and Acute Kidney Injury in a Male Mixed Martial Arts Athlete.

The aim of the present case study was to quantify the physiological and metabolic impact of extreme weight cutting by an elite male mixed martial arts athlete. Throughout an 8-week period, we obtained regular assessments of body composition, resting metabolic rate, peak oxygen uptake, and blood clinical chemistry to assess endocrine status, lipid profiles, hydration, and kidney function. The athlete adhered to a "phased" weight loss plan consisting of 7 weeks of reduced energy (ranging from 1,300 to 1,900 kcal/day) intake (Phase 1), 5 days of water loading with 8 L/day for 4 days followed by 250 ml on Day 5 (Phase 2), 20 hr of fasting and dehydration (Phase 3), and 32 hr of rehydration and refueling prior to competition (Phase 4). Body mass declined by 18.1% (80.2 to 65.7 kg) corresponding to changes of 4.4, 2.8, and 7.3 kg in Phases 1, 2, and 3, respectively. We observed clear indices of relative energy deficiency, as evidenced by reduced resting metabolic rate (-331 kcal), inability to complete performance tests, alterations to endocrine hormones (testosterone: <3 nmol/L), and hypercholesterolemia (>6 mmol/L). Moreover, severe dehydration (reducing body mass by 9.3%) in the final 24 hr prior to weigh-in-induced hypernatremia (plasma sodium: 148 mmol/L) and acute kidney injury (serum creatinine: 177 µmol/L). These data, therefore, support publicized reports of the harmful (and potentially fatal) effects of extreme weight cutting in mixed martial arts athletes and represent a call for action to governing bodies to safeguard the welfare of mixed martial arts athletes.

Cardiac sympathetic modulation increase after weight loss in combat sports athletes / Aumento da modulação cardíaca simpática depois de perda ponderal em atletas de combate / Aumento de la modulación cardíaca simpáticadespués de la pérdida ponderal en atletas de combate

INTRODUCTION: Although the rapid weight loss process is undertaken by combat sports athletes very often, the impact of this practice on cardiovascular health is not fully understood. OBJECTIVE: To verify the effects of the rapid weight loss process undertaken by combat sports athletes on hemodynamic parameters, cardiovascular autonomic modulation and mood state. METHODS: Eight male fighters (21.62±1.49 years, 71.25±3.54 kg, 1.74±0.03 cm) were assessed in the city of São Paulo. The subjects had 5.37±0.77 years of practice and were training 5.75±0.45 days per week, for 3.05±0.69 hours per day. The athletes were assessed on 2 occasions: 14 days before and 1 day before official weigh-in. Weight, height and bioimpedance were used for body composition analysis. Mood state was assessed using the Brums Mood Scale. Blood pressure was measured at rest with a digital meter. Cardiovascular autonomic modulation was obtained through an analysis of heart rate variability recorded for 25 minutes at rest. The Student's t-test for dependent samples was used for comparison between time points. Values of p<0.05 were considered significant. RESULTS: No differences in body composition were observed between the time points evaluated. After the weight loss strategy, increases in mood state parameters related to anger, vigor and fatigue categories were observed. Blood pressure did not change between the time points evaluated. However, an increase in heart rate associated with greater sympathetic modulation was observed after the weight loss strategy. There were no differences in autonomic modulation parameters representing parasympathetic activity. CONCLUSIONS: The study provided evidence of a higher cardiovascular risk in athletes as a result of this rapid weight loss practice, which is very concerning since combat sports athletes repeat this process several times during their lives. Level of Evidence IV; Study type: Case series

INTRODUÇÃO: Apesar de o processo de perda ponderal rápida ser realizado por atletas de esporte de combate com muita frequência, os impactos dessa prática sobre a saúde cardiovascular não estão totalmente esclarecidos. OBJETIVO: Verificar os efeitos do processo de perda ponderal rápida realizado pelos atletas de esportes de combate sobre parâmetros hemodinâmicos, modulação autonômica cardiovasculares estado de humor. MÉTODOS: Foram avaliados oito lutadores do sexo masculino (21,62 ± 1,49 anos, 71,25 ± 3,54 kg, 1,74±0,03 cm) na cidade de São Paulo. Os sujeitos tinham 5,37 ± 0,77 anos de prática, treinavam 5,75 ± 0,45 dias por semana, durante 3,05 ± 0,69 horas por dia. Os atletas foram avaliados em duas oportunidades: 14 dias e 1 dia antes da pesagem. Foram realizadas avaliações de massa corporal, altura e bioimpedância para análise da composição corporal. O estado de humor foi avaliado pela da escala de humor de Brums. A pressão arterial foi aferida em repouso com medidor digital. A modulação autonômica cardiovascular foi obtida pela análise de variabilidade da frequência cardíaca gravada durante 25 minutos em repouso. Para a comparação entre os momentos, foi utilizado teste t de Student para amostras dependentes. Os valores de p < 0,05 foram considerados significativos. RESULTADOS: Não foram observadas diferenças na composição corporal entre os momentos avaliados. Após a estratégia de perda ponderal, foram observados aumentos dos parâmetros de humor relacionados às categorias raiva, vigor e fadiga. A pressão arterial não se alterou entre os momentos avaliados. Entretanto, verificou-se aumento da frequência cardíaca associado à maior modulação simpática após a estratégia de perda ponderal. Os parâmetros de modulação autonômica representativos de atividade parassimpática não apresentaram diferenças. CONCLUSÕES: Houve maior risco cardiovascular nos atletas em decorrência dessa prática de perda ponderal rápida, o que é muito preocupante, tendo em vista que os atletas de esportes de combate repetem esse processo várias vezes durante a vida. Nível de Evidência IV; Tipo de estudo: Série de casos.

INTRODUCCIÓN: A pesar de que el proceso de pérdida ponderal rápida sea realizado por atletas de deporte de combate con mucha frecuencia, los impactos de esta práctica sobre la salud cardiovascular no están totalmente aclarados. OBJETIVO: Verificar los efectos del proceso de pérdida ponderal rápida realizado por los atletas de deportes de combate sobre parámetros hemodinámicos, modulación autonómica cardiovascular y el estado de humor. MÉTODOS: Se evaluaron 8 luchadores del sexo masculino (21,62±1,49 años, 71,25±3,54 kg, 1,74±0,03 cm) en la ciudad de São Paulo. Los sujetos tenían 5,37±0,77 años de práctica, entrenaban 5,75±0,45 días a la semana, durante 3,05±0,69 horas al día. Los atletas fueron evaluados en dos oportunidades: 14 días y 1 día antes del pesaje. Se realizaron evaluaciones de masa corporal, altura y bioimpedancia para análisis de la composición corporal. El estado de humor fue evaluado a través de la escala de humor de Brums. La presión arterial se midió en reposo con medidor digital. La modulación autonómica cardiovascular fue obtenida a través del análisis de variabilidad de la frecuencia cardíaca grabada durante 25 minutos en reposo. Para la comparación entre los momentos, se utilizó la prueba t de Student para muestras dependientes. Los valores de p <0,05 se consideraron significativos. RESULTADOS: No se observaron diferencias en la composición corporal entre los momentos evaluados. Después de la estrategia de pérdida ponderal, se observaron aumentos en los parámetros de humor relacionados con las categorías rabia, vigor y fatiga. La presión arterial no se alteró entre los momentos evaluados. Sin embargo, se observó un aumento en la frecuencia cardíaca asociado a la mayor modulación simpática después de la estrategia de pérdida ponderal. Los parámetros de modulación autonómica representativos de actividad parasimpática no presentaron diferencias. CONCLUSIONES: Hubo mayor riesgo cardiovascular en los atletas como consecuencia de esta práctica de pérdida ponderal rápida, lo que es muy preocupante, teniendo en cuenta que los atletas de deportes de combate repiten este proceso varias veces durante su vida. Nivel de Evidencia: IV. Tipo de estudio: Serie de casos.

Acquired pyloric stenosis resulting in hypokalaemic, hyperchloraemic normal anion gap metabolic acidosis. Persistent vomiting in an adult: cause and effect.

A 24-year-old woman presented with a history of persistent vomiting for at least 3 months. This resulted in severe dehydration with risk of acute kidney injury. In addition to volume depletion, loss of gastric fluid resulted in a specific metabolic derangement-hypokalaemic, hypochloraemic normal anion gap metabolic alkalosis with a reduced ionised calcium concentration and paradoxical aciduria. These metabolic changes were reflected in her ECG. Investigation demonstrated acquired gastric outflow tract obstruction secondary to a pyloric peptic ulcer. The patient was resuscitated with intravenous crystalloid and electrolyte supplements. The acquired pyloric stenosis was treated medically with a proton pump inhibitor and Helicobacter pylori eradication therapy with excellent recovery.

Efficacy of Glucose or Amino Acid-Based Commercial Beverages in Meeting Oral Rehydration Therapy Goals After Acute Hypertonic and Isotonic Dehydration.

BACKGROUND: The efficacy of different commercial beverage compositions for meeting oral rehydration therapy (ORT) goals in the treatment of acute dehydration in healthy humans has not been systematically tested. The objective of the study was to compare fluid retention, plasma volume (PV), and interstitial fluid (ISF) volume restoration when using 1 popular glucose-based and 1 novel amino acid-based (AA) commercial ORT beverage following experimental hypertonic or isotonic dehydration. METHODS: Twenty-six healthy adults (21 males, 5 females) underwent either a controlled bout of hypertonic (n = 13) or isotonic (n = 13) dehydration (3%-4% body mass) via eccrine or renal body water and electrolyte losses induced using exercise-heat stress (EHS) or Lasix administration (LAS), respectively. Rehydration was achieved over 90 minutes by matching fluid intake to water losses (1:1) using a sports drink (SP) or AA commercial ORT beverage. Fluid retention (water and electrolytes), PV, and ISF volume changes were tracked for 180 minutes. RESULTS: AA produced significantly (P <0.05) greater fluid retention (75% vs 57%), ISF volume restoration, and tended (P = 0.06) to produce greater PV restoration in trial EHS. In trial LAS, neither beverage exceeded 65% retention, but AA replaced electrolytes and preserved ISF volume better than SP (P <0.05). CONCLUSION: The results of this study demonstrate superior rehydration when using AA compared with SP for both hypertonic and isotonic dehydration.

The Use of a Triage-Based Protocol for Oral Rehydration in a Pediatric Emergency Department.

BACKGROUND: Guidelines recommend oral rehydration therapy (ORT) and avoidance of laboratory tests and intravenous fluids for mild to moderate dehydration in children with gastroenteritis; oral ondansetron has been shown to be an effective adjunct. OBJECTIVES: The aim of this study was to determine if a triage-based, nurse-initiated protocol for early provision of ondansetron and ORT could safely improve the care of pediatric emergency department (ED) patients with symptoms of gastroenteritis. METHODS: This study evaluated a protocol prompting triage nurses to assess dehydration in gastroenteritis patients and initiate ondansetron and ORT if indicated. Otherwise well patients aged 6 months to 5 years with symptoms of gastroenteritis were eligible. Prospective postintervention data were compared with retrospective, preintervention control subjects. RESULTS: One hundred twenty-eight (81 postintervention and 47 preintervention) patients were analyzed; average age was 2.1 years. Ondansetron use increased from 36% to 75% (P < 0.001). Time to ondansetron decreased from 60 minutes to 30 minutes (P = 0.004). Documented ORT increased from 51% to 100% (P < 0.001). Blood testing decreased from 37% to 21% (P = 0.007); intravenous fluid decreased from 23% to 9% (P = 0.03). Fifty-two percent of postintervention patients were discharged with prescriptions for ondansetron. There were no significant changes in ED length of stay, admissions, or unscheduled return to care. CONCLUSIONS: A triage nurse-initiated protocol for early use of oral ondansetron and ORT in children with evidence of gastroenteritis is associated with increased and earlier use of ondansetron and ORT and decreased use of IV fluids and blood testing without lengthening ED stays or increasing rates of admission or unscheduled return to care.

Factors Associated with 60-Day Readmission Following Cytoreduction and Hyperthermic Intraperitoneal Chemotherapy.

INTRODUCTION: Readmission rates following surgery are subject to scrutiny in efforts to control health care costs. This study was designed to define the 60-day readmission rate following cytoreduction and HIPEC at a high-volume center and to identify factors associated with readmission. METHODS: Patients who underwent complete cytoreduction and HIPEC at a single institution from August 2007 through June 2014 were identified from a prospectively maintained database. Multiple preoperative and operative factors were analyzed for their ability to predict 60-day readmission following surgery. RESULTS: A total of 250 patients were identified. Forty patients (17%) experienced readmission within 60 days of surgery. The most common reasons for readmission were ileus/dehydration (12, 31%), deep space infection (8, 21%), and DVT/PE (6, 15%). Initial postoperative length of stay was longer for patients readmitted within 60 days (median 12 vs. 9 days, p = 0.013). Of categorical variables analyzed, including gender, histology, HIPEC agent, intraoperative transfusion, and individual procedures performed during cytoreduction, adjuvant systemic therapy, and postoperative morbidity, only Charlson comorbidity index CCI (odds ratio (OR) = 3.80 [1.68-8.60]) and stoma creation (OR = 6.04 [1.56-12.14]) were associated with 60-day readmission. CONCLUSIONS: Few measurable variables are associated with readmission following cytoreduction and HIPEC. Patients with high CCI and those with stomas created at the time of CRS/HIPEC may be at increased risk of readmission within 60 days. Earlier or more frequent follow-up for high-risk patients should be considered as a strategy to reduce readmissions.

[M'khinza-related intoxication: about two observations]. / Intoxication au M'khinza: à propos de deux observations.

Dysphania ambrosioides or anserine, known in Morocco as M'Khinza, is a plant belonging to family Chenopodiaceae. In Morocco, it is used for its therapeutic properties including, in particular, antipyretic properties. However, it can be toxic if it is incorrectly calibrated. We report two cases of poisoning whose data were collected in the Pediatric Emergency Department in Rabat. The study involved a 5-month old infant and a 10 year old girl with, respectively, toxic encephalopathy and severe dehydration associated with acute gastroenteritis after the ingestion of undetermined doses of infusion of this plant used as antipyretic. They both died in less than 12 hours. This study highlights the importance of considering M'Khinza-induced neurotoxicity and enterotoxicity in order to reach a correct diagnosis, the role of information and the need to fight against harmful consumption. Research on traditional pharmacopoeia should be encouraged in order to identify the therapeutic properties and to formalize, streamline and codify prescriptions.

Weight Loss Strategies in Combat Sports and Concerning Habits in Mixed Martial Arts.

CONTEXT: Combat sports are typically divided into weight classes, and body-mass manipulation to reach a weight class is commonplace. Previous research suggests that weight loss practices in mixed martial arts (MMA) may be more extreme than in other combat sports. PURPOSE: To investigate the magnitude of weight loss and the prevalence of weight loss strategies in different combat sports. METHODS: Competitors (N = 637) from Brazilian jiu-jitsu, boxing, judo, MMA, Muay Thai/kickboxing, taekwondo, and wrestling completed an online questionnaire seeking information regarding their weight loss practices. RESULTS: Body-mass manipulation was commonly undertaken by all combat-sport athletes, with a particularly high incidence of gradual dieting, increased exercise, and fluid restriction. Skipping meals was higher in taekwondo and wrestling (84%) compared with the other combat sports (∼58%), whereas training in heated rooms and forced oral fluid loss (spitting) was higher in wrestling (83% and 47%, respectively) compared with other combat sports (∼45% and ∼19%, respectively). MMA athletes reported the highest usage of sauna (76%) and water loading (67%) while also reporting the second-highest use of training in rubber/plastic suits (63%). CONCLUSIONS: Body-mass manipulation was present in all combat sports, with the prevalence and magnitude of acute weight loss greater in MMA. The incidence of and practices reported will help support staff be fully aware of the variety of methods these athletes and coaches may use to achieve weight loss. Additionally, the results could aid regulatory bodies in the further development of policies on weight cutting.

The role of nutrition and hydration in disease prevention and patient safety.

Omorogieva Ojo, Senior Lecturer in Primary Care at the University of Greenwich, O.Ojo@greenwich.ac.uk , looks at the importance of nutrition and hydration across healthcare settings.

Treatment of severe cholera: a review of strategies to reduce stool output and volumes of rehydration fluid.

Background: Severe cholera is a life-threatening illness of hypovolemic shock and metabolic acidosis due to rapid and profuse diarrheal fluid loss. Emergency life-saving therapy is i.v. saline, optionally supplemented with potassium and alkali to correct the fluid deficit, potassium losses and acidosis. After this initial rehydration, for the next 2 days ongoing stool losses are replaced with oral rehydration solution (ORS), which contains sodium chloride, potassium and alkali together with glucose or rice powder as a source of glucose to serve as a carrier for sodium. Results: In actual field trials, antibiotics are given to reduce fluid requirements, but large volumes averaging about 7 liters of i.v. fluid followed by about 14 liters of ORS have been given to adult patients. Disturbing trends during therapy have included overhydration, hyponatremia and polyuria. Conclusions: It is suggested that stool output and fluid requirements could be reduced, if borne out in future research, by avoiding overhydration by restricting ORS intake to match stool output and promoting intestinal reabsorption of luminal fluid by early introduction of glucose without salts into the intestine, more gradual correction of dehydration, giving mineralocorticoid and vasopressin, and infusing glucose or short-chain fatty acids into the proximal colon.

Electrolytes: Oral Electrolyte Solutions.

Oral electrolyte solutions are used widely for rehydration in diarrheal illness and to maintain hydration during vigorous exercise. In diarrheal illness, an oral rehydration solution (ORS) typically is preferred over intravenous fluids except for patients with severe dehydration. The preferred ORS is one similar to the glucose-containing reduced osmolarity World Health Organization ORS. There also are polymer-based solutions that use rice or wheat as the source of carbohydrates but these are not widely recommended. Use of other liquids, such as sport drinks, juice, soft drinks, and chicken broth is not recommended, though these can be considered for patients with no or mild dehydration. For maintaining hydration during exercise, particularly vigorous high-intensity exercise, recommendations are to consume fluids (ie, 5 to 7 mL/kg) and a sodium-containing snack at least 4 hours before. During exercise, individuals require 200 to 800 mL/hour of liquid that should contain 20 to 30 mEq/L of sodium. Carbohydrate intake is recommended during high-intensity exercise. Intake of excessive sodium-free fluids should be avoided to prevent exercise-induced hyponatremia. Additional fluids (ie, 1.5 L/kg of weight lost) can be consumed after exercise to restore hydration. Vitamin and mineral supplements are not recommended routinely for athletes unless known deficiencies exist.

Fluid, energy and nutrient recovery via ad libitum intake of different fluids and food.

INTRODUCTION: This study compared the effects of ad libitum consumption of different beverages and foods on fluid retention and nutrient intake following exercise. METHODS: Ten endurance trained males (mean±SD; Age=25.3±4.9years, VO2max=63.0±7.2mL·kg·min-1) performed four trials employing a counterbalanced, crossover design. Following 60min of exercise (matched for energy expenditure and fluid loss) participants consumed either water (W1 and W2), a sports drink (Powerade® (P)) or a milk-based liquid meal supplement (Sustagen Sport® (SS)) over a four hour recovery period. Additionally, participants had access to snack foods on two occasions within the first 2h of recovery on all trials. All beverages and food were consumed ad libitum. Total nutrient intake, urine volume, USG, body weight as well as subjective measures of gastrointestinal tolerance and thirst were obtained hourly. Plasma osmolality was measured pre, post, 1 and 4h after exercise. RESULTS: Total fluid volume ingested from food and beverages in W1 (2.28±0.42L) and P (2.82±0.80L) trials were significantly greater than SS (1.94±0.54L). Total urine output was not different between trials (W1=644±202mL, W2=602±352mL, P=879±751mL, SS=466±129mL). No significant differences in net body weight change was observed between trials (W1=0.01±0.28kg, W2=0.08±0.30kg, P=-0.02±0.24kg, SS=-0.05±0.24kg). Total energy intake was higher on P (10,179±1484kJ) and SS (10,577±2210kJ) compared to both water trials (W1=7826±888kJ, W2=7578±1112kJ). CONCLUSION: With the co-ingestion of food, fluid restoration following exercise is tightly regulated and not influenced by the choice of either water, a carbohydrate-electrolyte (sports drink) or a milk-based beverage.

Extreme Rapid Weight Loss and Rapid Weight Gain Observed in UK Mixed Martial Arts Athletes Preparing for Competition.

There is a lack of research documenting the weight-making practices of mixed-martial-arts (MMA) competitors. The purpose of the investigation was to quantify the magnitude and identify the methods of rapid weight loss (RWL) and rapid weight gain (RWG) in MMA athletes preparing for competition. Seven athletes (mean ± SD, age 24.6 ± 3.5 yrs, body mass 69.9 ± 5.7 kg, competitive experience 3.1 ± 2.2 yrs) participated in a repeated-measures design. Measures of dietary intake, urinary hydration status, and body mass were recorded in the week preceding competition. Body mass decreased significantly (p < .0005) from baseline by 5.6 ± 1.4 kg (8 ± 1.8%). During the RWG period (32 ± 1 hr) body mass increased significantly (p < .001) by 7.4 ± 2.8 kg (11.7 ± 4.7%), exceeding RWL. Mean energy and carbohydrate intake were 3176 ± 482 kcal・day-1 and 471 ± 124 g・day-1, respectively. At the official weigh-in 57% of athletes were dehydrated (1033 ± 19 mOsmol・kg-1) and the remaining 43% were severely dehydrated (1267 ± 47 mOsmol・kg-1). Athletes reported using harmful dehydration-based RWL strategies, including sauna (43%) and training in plastic suits (43%). Results demonstrated RWG greater than RWL, this is a novel finding and may be attributable to the 32 hr duration from weigh-in till competition. The observed magnitude of RWL and strategies used are comparable to those which have previously resulted in fatalities. Rule changes which make RWL impractical should be implemented with immediate effect to ensure the health, safety and wellbeing of competitors.

Distinct clinical characteristics and therapeutic modalities for diabetic ketoacidosis in type 1 and type 2 diabetes mellitus.

AIMS: Patients with type 1 diabetes often develop diabetic ketoacidosis (DKA). Reportedly, DKA in type 2 diabetes has higher mortality despite its limited occurrence. The exact clinical characteristics and therapeutic modalities yielding successful outcomes in DKA type 2 diabetes remain unknown. METHODS: This retrospective study compared the clinical features and detailed treatment of consecutive type 1 and type 2 diabetes patients hospitalized with DKA between January 2001 and December 2014. RESULTS: We report on 127 patients with type 1 and 74 patients with type 2 diabetes whose DKA was successfully treated. The most frequent precipitating cause for DKA was infectious disease for patients with type 1 diabetes and consumption of sugar-containing beverages for those with type 2 diabetes. Type 2 diabetes patients showed higher mean plasma glucose levels than those with type 1 diabetes (48.4±21.6, vs. 37.1±16.4mmol/l, P<0.01) and higher serum creatinine, blood urea nitrogen, and hemoglobin levels, which normalized after DKA resolution. Compared with type 1 diabetes patients, those with type 2 diabetes required distinctly higher daily total insulin dosage (35.9±37.0U, vs. 20.2±23.3U, P<0.01), larger replacement fluid volumes (4.17±2.69L, vs. 2.29±1.57L, P<0.01) and greater potassium supplementation (23.9±36.5mEq, vs. 11.2±17.9mEq, P<0.01) to resolve DKA and reduce plasma glucose level to ≤16.7mmol/l. CONCLUSIONS: DKA patients with type 2 diabetes required management with a modified treatment protocol to resolve their profound hyperglycemia and dehydration compared with those with type 1 diabetes.

Effectiveness of interventions to directly support food and drink intake in people with dementia: systematic review and meta-analysis.

BACKGROUND: Eating and drinking difficulties are recognised sources of ill health in people with dementia. In the EDWINA (Eating and Drinking Well IN dementiA) systematic review we aimed to assess effectiveness of interventions to directly improve, maintain or facilitate oral food and drink intake, nutrition and hydration status, in people with cognitive impairment or dementia (across all settings, levels of care and support, types and degrees of dementia). Interventions included oral nutrition supplementation, food modification, dysphagia management, eating assistance and supporting the social element of eating and drinking. METHODS: We comprehensively searched 13 databases for relevant intervention studies. The review was conducted with service user input in accordance with Cochrane Collaboration's guidelines. We duplicated assessment of inclusion, data extraction, and validity assessment, tabulating data, carrying out random effects meta-analysis and narrative synthesis. RESULTS: Forty-three controlled interventions were included, disappointingly none were judged at low risk of bias. Oral nutritional supplementation studies suggested small positive short term but unclear long term effects on nutritional status. Food modification or dysphagia management studies were smaller and of low quality, providing little evidence of an improved nutritional status. Eating assistance studies provided inconsistent evidence, but studies with a strong social element around eating/drinking, although small and of low quality provided consistent suggestion of improvements in aspects of quality of life. There were few data to address stakeholders' questions. CONCLUSIONS: We found no definitive evidence on effectiveness, or lack of effectiveness, of specific interventions but studies were small and short term. People with cognitive impairment and their carers have to tackle eating problems despite this lack of evidence, so promising interventions are listed. The need remains for high quality trials tailored for people with cognitive impairment assessing robust outcomes. SYSTEMATIC REVIEW REGISTRATION: The systematic review protocol was registered (CRD42014007611) and is published, with the full MEDLINE search strategy, on Prospero.

Hydration Status and Sodium Balance of Endurance Runners Consuming Postexercise Supplements of Varying Nutrient Content.

Postexercise protein and sodium supplementation may aid recovery and rehydration. Preserved beef provides protein and contains high quantities of sodium that may alter performance related variables in runners. The purpose of this study was to determine the effects of consuming a commercial beef product postexercise on sodium and water balance. A secondary objective was to characterize effects of the supplementation protocols on hydration, blood pressure, body mass, and running economy. Eight trained males (age = 22 ± 3 y, VO2max = 66.4 ± 4.2 ml·kg-1·min-1) completed three identical weeks of run training (6 run·wk-1, 45 ± 6 min·run-1, 74 ± 5% HRR). After exercise, subjects consumed either, a beef nutritional supplement (beef jerky; [B]), a standard recovery drink (SRD), or SRD+B in a randomized counterbalanced design. Hydration status was assessed via urinary biomarkers and body mass. No main effects of treatment were observed for 24 hr urine volume (SRD, 1.7 ± 0.5; B, 1.8 ± 0.6; SRD+B, 1.4 ± 0.4 L·d-1), urine specific gravity (1.016 ± 0.005, 1.018 ± 0.006, 1.017 ± 0.006) or body mass (68.4 ± 8.2, 68.3 ± 7.7, 68.2 ± 8.1 kg). No main effect of treatment existed for sodium intake-loss (-713 ± 1486; -973 ± 1123; -980 ± 1220 mg·d-1). Mean arterial pressure (81.0 ± 4.6, 81.1 ± 7.3, 83.8 ± 5.4 mm Hg) and average exercise running economy (VO2: SRD, 47.9 ± 3.2; B, 47.2 ± 2.6; SRD+B, 46.2 ± 3.4 ml·kg-1·min-1) was not affected. Urinary sodium excretion accounted for the daily sodium intake due to the beef nutritional supplement. Findings suggest the commercial beef snack is a viable recovery supplement following endurance exercise without concern for hydration status, performance decrements, or cardiovascular consequences.