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1.
Ann Biol Clin (Paris) ; 78(4): 417-424, 2020 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-32753366

RESUMO

We present the case of a four-year-old girl, who was hospitalized in intensive care unit for a coma resulting from metabolic acidosis with increased anion gap. The patient was treated for short bowel syndrome, following necrotising enterocolitis, which occurred 51 days after birth. In our initial evaluation of the patient's metabolic acidosis, we were unable to identify the cause of the increased anion gap. Urinary organic acids chromatography identified a large peak of lactate (quantified at 15 mmol/mol of creatiniuria), as well as its metabolites. The discrepancy between normal blood lactate concentration assayed by enzymatic assay, and the large amount of lactate found by gas-chromatography/mass spectrometry (GC/MS) in urine highlights the limit of the stereospecificity of enzymatic assays. Indeed, most lactates assay use enzymatic assays that are specific for L-lactate, whereas organic acids chromatography, whose column is mostly achiral, can detect both stereoisomers, D- and L-lactate. Organic acids in urine analysis, in addition to the clinical context, suggested a diagnosis of D-lactic acidosis. Following a review of the physiopathology and treatment of short bowel syndrome, we will discuss the mechanism and diagnosis of the D-lactic acidosis in our patient. This case highlights the need to perform an organic acid profile in urine in the presence of any unexplained increased anion gap to determine its cause.


Assuntos
Equilíbrio Ácido-Base/fisiologia , Acidose Láctica/diagnóstico , Acidose/diagnóstico , Coma/diagnóstico , Síndrome do Intestino Curto/diagnóstico , Acidose/etiologia , Acidose/metabolismo , Acidose Láctica/etiologia , Acidose Láctica/metabolismo , Acidose Láctica/urina , Análise Química do Sangue/métodos , Pré-Escolar , Coma/sangue , Coma/etiologia , Coma/urina , Diagnóstico Diferencial , Feminino , Cromatografia Gasosa-Espectrometria de Massas , Humanos , Ácido Láctico/sangue , Ácido Láctico/urina , Síndrome do Intestino Curto/complicações , Síndrome do Intestino Curto/metabolismo , Urinálise
3.
J Ayub Med Coll Abbottabad ; 32(2): 189-193, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32583992

RESUMO

BACKGROUND: Blood gases can provide information about the perinatal, natal and postnatal condition of newborn. Severity of metabolic acidosis has deleterious effect on the outcome of babies. When the cord blood gases are not available the arterial blood gases are used for interpreting the status of newborn. The purpose of study was to determine the relationship between severity of metabolic acidosis at admission with the stage of hypoxic ischemic encephalopathy, and its outcome in asphyxiated neonates. METHODS: This was descriptive cross-sectional study of 384 neonates born at ≥35 weeks to <42 weeks from June to December 2018, admitted in Neonatology department of the Children's hospital & the Institute of Child Health, Lahore within first 6 hours of birth. The neonates with history of delayed cry at birth and arterial pH ≤7.30 and base deficit ≥10 were included in the study. The pH and base deficit of babies was analyzed in relation to the stage of HIE, duration of stay and death or discharge of the babies using SPSS-20. The p-value was calculated using chi-square test. RESULTS: Total of 470 neonates were eligible. Eighty-four neonates were excluded. Finally, 384 neonates were included and analyzed for the outcome variables. With severe metabolic acidosis pH <7.01, all the babies developed HIEII/III. Majority (82.1%) of the babies expired and 27.9% had prolonged hospital stay. CONCLUSIONS: Increasing severity of metabolic acidosis at admission increases the likelihood of adverse outcome in asphyxiated neonates.


Assuntos
Acidose , Asfixia Neonatal , Acidose/epidemiologia , Acidose/etiologia , Acidose/mortalidade , Acidose/terapia , Asfixia Neonatal/complicações , Asfixia Neonatal/epidemiologia , Asfixia Neonatal/mortalidade , Asfixia Neonatal/terapia , Estudos Transversais , Humanos , Recém-Nascido , Admissão do Paciente , Resultado do Tratamento
4.
Ann Biol Clin (Paris) ; 78(3): 323-328, 2020 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-32540819

RESUMO

Ketosis is a metabolic situation involving an increase in blood and urine concentrations of ketones that, when prolonged, leads to acidosis. Moderate ketosis usually appears after a fast of a few hours, but its prolongation exposes to hyperketosis. Observation: A 25-year-old woman presented to the emergency department for cohercitive vomiting. She was fasting for a long time in a spiritual setting and had a restricted diet limited to water and vitamin supplements. Clinical and biological assessment was in favour of fasting ketoacidosis. Evolution was favorable with intravenous hydration, poly-ionic and micronutrient supplementation and a gradual resumption of oral feeding. Conclusion: We report the case of a patient with fasting ketoacidosis. Besides consequences of this ketoacidosis, the challenge was also in resuming oral feeding in order to avoid a potentially fatal inappropriate renutrition syndrome.


Assuntos
Jejum/efeitos adversos , Cetose/etiologia , Inanição/complicações , Acidose/sangue , Acidose/diagnóstico , Acidose/etiologia , Acidose/terapia , Adulto , Jejum/sangue , Feminino , Hidratação , Humanos , Cetose/sangue , Cetose/diagnóstico , Cetose/terapia , Nutrição Parenteral , Inanição/sangue , Inanição/terapia , Fatores de Tempo
6.
Medicine (Baltimore) ; 99(18): e19964, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32358368

RESUMO

RATIONALE: Holocarboxylase synthetase (HCLS) deficiency, especially the late-onset type, is a rare disease. Affected patients can present with irreversible metabolic acidosis and may be misdiagnosed with a glucose metabolic disorder. Prompt and correct diagnosis and treatment can reduce mortality to a great extent. PATIENT CONCERNS: We report 2 Chinese patients who were diagnosed with late-onset HCLS deficiency. The age of onset of the 2 patients was approximately 8 months. The 2 patients had skin lesions, severe profound metabolic acidosis, dyspnea, and hyperglycemia. DIAGNOSES: The results of urinary and blood organic acid analysis with gas chromatography/mass spectrometry revealed multiple carboxylase deficiency. Maple syrup urine disease and diabetic ketoacidosis could not be excluded. This finding is different from those of hypoglycemic complications reported in previous reports. Human genetic analysis eventually provided a definite diagnosis. INTERVENTIONS: Prompt oral treatment with biotin dramatically corrected the metabolic imbalances of the 2 patients, and continued oral biotin therapy was essential to the improvement of their prognoses. OUTCOMES: Their metabolic disorders were corrected within 48 hours. During long-term follow-up, the patients achieved developmental milestones. LESSONS: Late-onset HCLS deficiency may present with obvious hyperglycemia. Human genetic analysis eventually provided a definite diagnosis. Prompt treatment with biotin is vital to correct metabolic imbalances, and continued therapy is essential to the improving long-term prognoses. Their mutations were p.R508W and c.1088T > A, and these mutations might represent hot-spot genes in Chinese populations with HCLS deficiency. The variants c.1484T > G(p.L495*) and c.835G > T(p.E279x) are likely pathogenic, and more studies are needed to confirm these results.


Assuntos
Deficiência de Holocarboxilase Sintetase/diagnóstico , Deficiência de Holocarboxilase Sintetase/fisiopatologia , Acidose/etiologia , Biotina/uso terapêutico , China , Dispneia/etiologia , Feminino , Deficiência de Holocarboxilase Sintetase/complicações , Deficiência de Holocarboxilase Sintetase/tratamento farmacológico , Humanos , Hiperglicemia/etiologia , Lactente , Masculino
8.
Spine Deform ; 8(2): 345-348, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31925762

RESUMO

We report the case of a 12-year-old female, otherwise healthy patient, who underwent surgery for scoliosis correction in prone position under total intravenous general anesthesia, with CardioQ and sensory-motor-evoked potentials for hemodynamic and neurological monitoring. The patient showed severe intraoperative hypotension, lactic acidosis, and complete abolition of motor-evoked potentials during the positioning of posterior corrective bars. During the postoperative period, the increase in muscle and liver enzymes indicated an abdominal organ damage and confirmed hypoperfusion of the lower limbs. Both side effects were caused by the malposition of the patient on the operating table. The case resolved within the first postoperative week without sequelae.


Assuntos
Complicações Intraoperatórias/diagnóstico , Complicações Intraoperatórias/etiologia , Fígado/lesões , Músculo Esquelético/lesões , Posicionamento do Paciente/efeitos adversos , Decúbito Ventral , Escoliose/cirurgia , Fusão Vertebral/efeitos adversos , Acidose/diagnóstico , Acidose/etiologia , Criança , Potencial Evocado Motor , Feminino , Humanos , Hipotensão/diagnóstico , Hipotensão/etiologia , Doença Iatrogênica , Monitorização Neurofisiológica Intraoperatória , Ácido Láctico , Fusão Vertebral/métodos
10.
Animal ; 14(1): 66-77, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31317849

RESUMO

Feed withdrawal (FW) is a frequent issue in open outdoor feedlot systems, where unexpected circumstances can limit the animals' access to food. The relationship among fasting period, animal behaviour during feed reintroduction (FR) and acidosis occurrence has not been completely elucidated. Twenty steers fitted with rumen catheters were fed a high-concentrate diet (concentrate : forage ratio 85 : 15) and were challenged by a protocol of FW followed by FR. The animals were randomly assigned to one of the four treatments: FW for 12 h (T12), 24 h (T24), 36 h (T36) or no FW (control group) followed by FR. The steers' behaviour, ruminal chemistry, structure of the ruminal microbial community, blood enzymes and metabolites and ruminal acidosis status were assessed. Animal behaviour was affected by the FW-FR challenge ( P < 0.05). Steers from the T12, T24 and T36 treatments showed a higher ingestion rate and a lower frequency of rumination. Although all animals were suspected to have sub-acute ruminal acidosis (SARA) prior to treatment, a severe case of transient SARA arose after FR in the T12, T24 and T36 groups. The ruminal pH remained below the threshold adopted for SARA diagnosis ( pH value = 5.6) for more than three consecutive hours (24, 7 and 19 h in the T12, T24 and T36 treatments, respectively). The FW-FR challenge did not induce clinical acute ruminal acidosis even though steers from the T36 treatment presented ruminal pH values that were consistent with this metabolic disorder (pH threshold for acute acidosis = 5.2). Total mixed ration reintroduction after the withdrawal period reactivated ruminal fermentation as reflected by changes in the fermentation end-products. Ruminal lactic acid accumulation in steers from the T24 and T36 treatments probably led to the reduction of pH in these groups. Both the FW and the FR phases may have altered the structure of the ruminal microbiota community. Whereas fibrolytic bacterial groups decreased relative abundance in the restricted animals, both lactic acid producer and utiliser bacterial groups increased ( P < 0.05). The results demonstrated a synchronisation between Streptococcus (lactate producer) and Megasphaera (lactate utiliser), as the relative abundance of both groups increased, suggesting that bacterial resilience may be central for preventing the onset of metabolic disturbances such as ruminal acidosis. A long-FW period (36 h) produced rumen pH reductions well below and lactic acid concentration increased well above the accepted thresholds for acute acidosis without any perceptible clinical signs.


Assuntos
Acidose/veterinária , Criação de Animais Domésticos/métodos , Doenças dos Bovinos/fisiopatologia , Privação de Alimentos/fisiologia , Acidose/etiologia , Acidose/fisiopatologia , Ração Animal , Animais , Análise Química do Sangue/veterinária , Bovinos/sangue , Doenças dos Bovinos/etiologia , Dieta/veterinária , Masculino , Distribuição Aleatória , Fatores de Tempo
11.
BJOG ; 127(3): 405-413, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31762140

RESUMO

OBJECTIVE: To determine variations in cord blood gas (CBG) parameters after 3-minute delayed cord clamping (DCC) in vaginal deliveries (VDs) and caesarean deliveries (CDs) at term without fetal distress. DESIGN: Prospective observational study. SETTING: University hospital. SAMPLE: CBG from 97 VDs and 124 CDs without fetal distress. METHODS: Comparison of paired arterial-venous CBG parameters drawn at birth from the unclamped cord and after 3-minutes DCC for VDs and CDs. MAIN OUTCOME MEASURES: Base excess, bicarbonate, haematocrit and haemoglobin from both arterial and venous cord blood, lactate, neonatal outcomes, partial pressure of oxygen (pO2 ), partial pressure of carbon dioxide (pCO2 ), pH, and postpartum haemorrhage. RESULTS: Arterial cord blood pH, bicarbonate ( HCO 3 - , mmol/l), and base excess (BE, mmol/l) decreased significantly after 3-minute DCC both in VDs (pH = 7.23 versus 7.27; P < 0.001; HCO 3 -  = 23.3 versus 24.3; P = 0.004; BE = -5.1 versus -2.9; P < 0.001) and CDs (pH = 7.28 versus 7.34; P < 0.001; HCO 3 -  = 26.2 versus 27.2; P < 0.001; BE = -1.5 versus 0.7; P < 0.001). After 3-minute DCC, pCO2 increased in CDs only (57 versus 51; P < 0.001), whereas lactate increased more in CDs compared with VDs (lactate, +1.1 [0.9, 1.45] versus +0.5 [-0.65, 2.35]; P = 0.01). Postpartum maternal haemorrhage, neonatal maximum bilirubin concentration, and need for phototherapy were similar between the two groups. Newborns born by CD more frequently required postnatal clinical monitoring or admission to a neonatal intensive care unit. CONCLUSIONS: After 3-minute DCC, the acid-base status shifted towards mixed acidosis in CDs and prevalent metabolic acidosis in VDs. CDs were associated with a more pronounced increase in arterial lactate, compared with VDs. TWEETABLE ABSTRACT: By 3-minute DCC, acid-base status shifts towards mixed and metabolic acidosis in caesarean and vaginal delivery, respectively.


Assuntos
Acidose , Cesárea , Parto Obstétrico , Sangue Fetal/metabolismo , Complicações do Trabalho de Parto , Cordão Umbilical/cirurgia , Acidose/sangue , Acidose/diagnóstico , Acidose/etiologia , Gasometria/métodos , Cesárea/efeitos adversos , Cesárea/métodos , Cesárea/estatística & dados numéricos , Constrição , Parto Obstétrico/efeitos adversos , Parto Obstétrico/métodos , Parto Obstétrico/estatística & dados numéricos , Feminino , Humanos , Recém-Nascido , Itália/epidemiologia , Masculino , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/epidemiologia , Complicações do Trabalho de Parto/etiologia , Gravidez , Resultado da Gravidez/epidemiologia , Tempo para o Tratamento
12.
J Dairy Sci ; 103(1): 750-767, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31704012

RESUMO

Adequate feeding of high-performance dairy cows is extremely important to avoid the digestive disorder subacute ruminal acidosis. Subacute ruminal acidosis is defined as a status with a below-average ruminal pH that does not cause direct clinical symptoms at the individual level but is relevant for animal welfare due to a higher risk of secondary health problems at the herd level. The main objective of this study was to apply meta-analytical methods in an exploratory approach to investigate the association between pH parameters of the ventral rumen with milk and diet parameters. Data from 32 studies using continuous pH measurement in the ventral rumen of lactating cows were included in the meta-analysis. Available information extracted from all studies was categorized into parameters associated with management, cow, diet, milk, and pH. The statistical analysis was divided into 4 sections. First, a multiple imputation procedure based on a principal component model was applied, since approximately 19% of the data set consisted of missing values due to heterogeneity in provided information between the studies included in the analysis. In a second step, all potential predictors for the pH parameters, including the daily mean pH, the time with a pH below 5.8, and the pH range, were examined for their prediction suitability using multi-level mixed effects meta-regression models. These analyses were performed on the raw and the imputed data. Because the results of both approaches were consistent, the imputing procedure was considered to be appropriate. Third, automated variable selection was applied to all 3 pH parameters separately for the predictor groups milk and diet using the imputed data set. Thereby, multi-model inference was used to estimate the relative importance of the selected variables. Finally, a functional relationship between the 3 pH parameters was established. The fat to protein ratio of milk, milk fat, and milk protein showed significant associations in meta-regression analysis for all 3 pH parameters when used as a single predictor. Out of the group of diet-specific variables, the acid detergent fiber, neutral detergent fiber, nonfiber carbohydrate, starch content, as well as the forage to concentrate ratio, showed the highest significance in the models. In particular, the multi-model inference showed that the protein, fat, and lactose content of the milk can best quantify the association to the daily mean pH and the time with a pH below 5.8 in a multiple regression model.


Assuntos
Acidose/veterinária , Doenças dos Bovinos/etiologia , Bovinos/fisiologia , Modelos Biológicos , Modelos Estatísticos , Rúmen/química , Acidose/etiologia , Ração Animal/análise , Animais , Dieta/veterinária , Feminino , Concentração de Íons de Hidrogênio , Lactação , Leite , Análise de Regressão , Fatores de Risco , Rúmen/metabolismo
16.
Turk J Gastroenterol ; 30(10): 883-891, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31633484

RESUMO

BACKGROUND/AIMS: Metabolic acidosis is a common complication in patients with cirrhosis at the intensive care units (ICUs) and associated with increased mortality. The aim of our research was to explore the epidemiology and risk factors of metabolic acidosis in critically ill patients with cirrhosis. MATERIALS AND METHODS: A total of 975 patients with cirrhosis were selected into our study, and all participants were followed up for at least 28 days. Cox regression model and machine-learning algorithm were used to identify the importance of different risk factors, respectively. Finally, an improved prognostic model as Model for End-stage Liver Disease and metabolic acidosis (MELD-MA) was developed. RESULTS: Among the 975 patients with liver cirrhosis, 506 had metabolic acidosis, including 257 patients who had decompensated metabolic acidosis at ICU admission. The 28-day mortality was 41% (206/506) in patients with metabolic acidosis. Bilirubin (hazard ratio (HR): 1.023, 95% confidence interval (CI): 1.011-1.036), international normalized ratio (HR: 1.527, 95% CI: 1.332-1.750), pH (HR: 0.173, 95% CI: 0.047-0.640), BE-Lac (HR: 0.907, 95% CI: 0.868-0.948), and BE-Na (HR: 0.923, 95% CI: 0.859-0.991) were considered as independent prognostic parameters for 28-day mortality. MELD-NA had significantly higher discrimination (area under the receiver operating characteristic curve 0.79) than MELD and Child-Pugh score. CONCLUSION: Critically ill patients with cirrhosis have a high mortality rate and poor prognosis because of the high prevalence of metabolic acidosis. Lactic acidosis is the worst prognosis of all types of metabolic acidosis. MELD-MA performs well on the short-term mortality assessment in critically ill patients with cirrhosis and metabolic acidosis.


Assuntos
Acidose/mortalidade , Cirrose Hepática/mortalidade , Acidose/etiologia , Idoso , Estado Terminal/mortalidade , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Cirrose Hepática/complicações , Masculino , Pessoa de Meia-Idade , Prognóstico , Modelos de Riscos Proporcionais , Fatores de Risco , Índice de Gravidade de Doença
17.
Medicine (Baltimore) ; 98(41): e17434, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31593098

RESUMO

RATIONALE: Preoperative prolonged fasting may cause starvation ketoacidosis. Herein, we report of a case of starvation ketoacidosis due to long-term fasting before surgery. PATIENT CONCERNS: We report of a case of metabolic acidosis due to prolonged fasting in a previously healthy 44-year-old woman during a total laparoscopic hysterectomy. Hyperventilation was observed to occur when the surgery was completed. Metabolic acidosis and hypoglycemia were demonstrated by blood gas analysis of the radial artery. DIAGNOSIS: Metabolic acidosis. INTERVENTIONS: The patient received sodium bicarbonate and 5% glucose fluid at the end of the surgery. OUTCOMES: The tracheal tube was successfully removed when the tidal volume of the patient returned to normal after the therapy. However, the patient suffered pulmonary edema when she was transferred to the intensive care unit (ICU). With treatments with furosemide and sodium bicarbonate, acidosis and pulmonary edema were completely corrected at 8 hours after the surgery. On the second day after the surgery, the patient suffered nausea and vomiting. Nausea and vomiting were not completely relieved on the sixth day after the operation; therefore, the patient was transferred to the Department of Gastroenterology for further therapy. LESSONS: This case suggests that although the concept of enhanced recovery after surgery (ERAS) has been adopted by most physicians because of its positive outcomes, the issue of prolonged fasting still exists, and such patients may be exposed to the risk of starvation ketoacidosis.


Assuntos
Acidose/etiologia , Jejum/efeitos adversos , Inanição/complicações , Adulto , Feminino , Humanos , Histerectomia , Período Pré-Operatório
18.
Kidney Blood Press Res ; 44(5): 1179-1188, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31536994

RESUMO

BACKGROUND: Metabolic acidosis (MA) is common in kidney transplant recipients (KTRs). Several studies have shown that MA is involved in the progression of chronic kidney disease. However, it is unclear if there is also a relationship between serum bicarbonate and graft function after kidney transplantation (KTx). We hypothesized that low serum bicarbonate is associated with a lower estimated glomerular filtration rate (eGFR) 1 year after KTx. METHODS: We performed a post hoc analysis of a single-center, open-label randomized trial in 90 KTRs and investigated the relationship of serum bicarbonate and graft function in the first year after KTx. RESULTS: Prevalence of MA was high after KTx (63%) and decreased to 28% after 1 year. Bicarbonate (20.6 ± 3.0 to 22.7 ± 2.7 mmol/L) increased in the first year after transplantation whereas eGFR (53.4 ± 15.8 to 56.9 ± 18.5 mL/min/1.73 m2) did not change significantly. Higher serum bicarbonate (p = 0.029) was associated with higher eGFR in the first year after KTx. CONCLUSION: Prevalence of MA is high in KTRs. In the first year after KTx, serum bicarbonate was positively correlated with eGFR, suggesting a potential role of MA in kidney graft function.


Assuntos
Acidose/etiologia , Bicarbonatos/sangue , Transplante de Rim/efeitos adversos , Progressão da Doença , Feminino , Humanos , Transplante de Rim/métodos , Masculino , Pessoa de Meia-Idade , Suíça , Transplantes , Resultado do Tratamento
19.
Nutrients ; 11(8)2019 Aug 15.
Artigo em Inglês | MEDLINE | ID: mdl-31443226

RESUMO

Metabolic acidosis can lead to inflammation, tissue damage, and cancer metastasis. Dietary acid load contributes to metabolic acidosis if endogenous acid-base balance is not properly regulated. Breast cancer survivors have reduced capacities to adjust their acid-base balance; yet, the associations between dietary acid load and inflammation and hyperglycemia have not been examined among them. We analyzed data collected from 3042 breast cancer survivors enrolled in the Women's Healthy Eating and Living (WHEL) Study who had provided detailed dietary intakes and measurements of plasma C-reactive protein (CRP) and hemoglobin A1c (HbA1c). Using a cross-sectional design, we found positive associations between dietary acid load and plasma CRP and HbA1c. In the multivariable-adjusted models, compared to women with the lowest quartile, the intakes of dietary acid load among women with the highest quartile showed 30-33% increases of CRP and 6-9% increases of HbA1c. Our study is the first to demonstrate positive associations between dietary acid load and CRP and HbA1c in breast cancer survivors. Our study identifies a novel dietary factor that may lead to inflammation and hyperglycemia, both of which are strong risk factors for breast cancer recurrence and comorbidities.


Assuntos
Acidose/etiologia , Glicemia/metabolismo , Neoplasias da Mama/terapia , Proteína C-Reativa/análise , Sobreviventes de Câncer , Dieta/efeitos adversos , Hiperglicemia/etiologia , Mediadores da Inflamação/sangue , Inflamação/etiologia , Acidose/sangue , Acidose/diagnóstico , Adolescente , Adulto , Idoso , Biomarcadores/sangue , Estudos Transversais , Feminino , Hemoglobina A Glicada/metabolismo , Humanos , Concentração de Íons de Hidrogênio , Hiperglicemia/sangue , Hiperglicemia/diagnóstico , Inflamação/sangue , Inflamação/diagnóstico , Pessoa de Meia-Idade , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Fatores de Tempo , Adulto Jovem
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