Knockdown of cullin 4A inhibits growth and increases chemosensitivity in lung cancer cells.

Cullin 4A (Cul4A) has been observed to be overexpressed in various cancers. In this study, the role of Cul4A in the growth and chemosensitivity in lung cancer cells were studied. We showed that Cul4A is overexpressed in lung cancer cells and tissues. Knockdown of the Cul4A expression by shRNA in lung cancer cells resulted in decreased cellular proliferation and growth in lung cancer cells. Increased sensitivity to gemcitabine, a chemotherapy drug, was also noted in those Cul4A knockdown lung cancer cells. Moreover, increased expression of p21, transforming growth factor (TGF)-ß inducible early gene-1 (TIEG1) and TGF beta-induced (TGFBI) was observed in lung cancer cells after Cul4A knockdown, which may be partially related to increased chemosensitivity to gemcitabine. G0/G1 cell cycle arrest was also noted after Cul4A knockdown. Notably, decreased tumour growth and increased chemosensitivity to gemcitabine were also noted after Cul4A knockdown in lung cancer xenograft nude mice models. In summary, our study showed that targeting Cul4A with RNAi or other techniques may provide a possible insight to the development of lung cancer therapy in the future.

Red cell distribution width is an independent predictor of mortality in necrotizing fasciitis.

INTRODUCTION: Necrotizing fasciitis (NF) is a rapidly progressing and potentially lethal infectious disease of the soft tissue. An elevated red blood cell distribution width (RDW) is associated with increased risk of death in patients with heart disease and infectious disease. We retrospectively assessed the association of elevated RDW with in-hospital mortality due to NF. METHODS: All patients had diagnoses of NF and were admitted to the emergency department of a single institution in Taiwan over a 4-year period. Demographics, comorbidities, clinical presentations, and laboratory parameters were retrospectively reviewed. Red blood cell distribution width was categorized as elevated (>14.5%) or not elevated. Multivariate regression analysis was used to identify risk factors associated with mortality. RESULTS: A total of 98 patients were enrolled, and the mortality rate was 23%. Univariate analysis indicated that advanced age, initial hypotension, low hemoglobin level, and elevated RDW (69.6% vs 20%, OR = 9.14, P < .001) were significantly associated with mortality. Multivariate analysis indicated that RDW was a significant and independent predictor of mortality in enrolled patients. CONCLUSIONS: Elevated RDW is a significant and independent predictor of in-hospital mortality for patients with NF.

Association between the hepatitis B and C viruses and metabolic diseases in patients stratified by age.

BACKGROUND: Hepatitis B/C viruses cause liver disease and metabolic disturbances. AIMS: The purpose of this study was to evaluate the association between hepatitis B/C infection and metabolic syndrome (MS). METHODS: In total, 26,305 subjects were included in this multicentre, cross-sectional study. Systolic and diastolic blood pressures, body mass index and waist circumference were measured. Total cholesterol, high- and low-density lipoprotein cholesterol, triglyceride, fasting blood glucose and uric acid were determined, and hepatitis B serum antigen (HBsAg) and anti-HCV antibodies were assayed using commercial kits. RESULTS: MS was diagnosed in 2712 (23.0%) females, including 131 and 166 positive for HBsAg and anti-HCV respectively. In the men, 4594 (31.6%) were diagnosed with MS, including 326 positive for HBsAg and 131 positive for anti-HCV. No significant difference in the prevalence of MS was identified in any group, except men and women >45 years who were anti-HCV positive. Various metabolic alterations in both men and women >45 years were noted, including waist circumference, body mass index, fasting blood glucose and systolic and diastolic blood pressure. Notably, high- and low-density lipoproteins were significantly lower in positive subjects compared to those weakly positive and/or negative for anti-HCV. CONCLUSIONS: There were obvious metabolic derangements in patients coinflicted with MS and hepatitis C infections, particularly those >45 years of age. There is a pressing need to identify strategies to improve/resolve metabolic derangements to maximize sustained virological response rates in patients infected with HCV (and potentially HBV).

Waist-to-height ratio, waist circumference, and body mass index as indices of cardiometabolic risk among 36,642 Taiwanese adults.

PURPOSE: We aimed to investigate the association of body mass index (BMI), waist circumference (WC), and waist-to-height ratio (WHtR) with cardiometabolic risk. METHODS: In this cross-sectional study, 21,038 men and 15,604 women who participated in a health check-up were included. RESULTS: In both men and women, the area under the curve (AUC) of WHtR was significantly greater than that of BMI or WC in the prediction of diabetes, hypertension, high total cholesterol, high triglycerides, and low HDL-cholesterol (P < 0.05 for all). The AUC for WHtR in the prediction of metabolic syndrome (MS) was also highest in the women (P < 0.05). After adjustment for potential confounders, the odds ratios and 95% confidence intervals for MS for each standard deviation increase in BMI, WHtR, and WC were 1.47 (1.46-1.49), 1.32 (1.31-1.33), and 1.19 (1.18-1.19), respectively. Finally, patients of either sex with a normal BMI or WC level, but with an elevated WHtR, had higher levels of various cardiometabolic risk factors in comparison with their normal BMI or WC, but low WHtR, counterparts (P < 0.05 for all). CONCLUSION: Among Taiwanese adults, a WHtR greater than 0.5 is a simple, yet effective indicator of centralized obesity and associated cardiometabolic risk, even among individuals deemed 'healthy' according to BMI and WC.

A prospective comparison of 3 scoring systems in upper gastrointestinal bleeding.

BACKGROUND: The clinical severities of upper gastrointestinal bleeding (UGIB) are of a wide variety, ranging from insignificant bleeds to fatal outcomes. Several scoring systems have been designed to identify UGIB high- and low-risk patients. The aim of our study was to compare the Glasgow-Blatchford score (GBS) with the preendoscopic Rockall score (PRS) and the complete Rockall score (CRS) in their utilities in predicting clinical outcomes in patients with UGIB. METHODS: We designed a prospective study to compare the performance of the GBS, PRS, and CRS in predicting primary and secondary outcomes in UGIB patients. The primary outcome included the need for blood transfusion, endoscopic therapy, or surgical intervention and was labeled as high risk. The secondary outcomes included rebleeding and 30-day mortality. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values for each system were analyzed. A total of 303 consecutive patients admitted with UGIB during a 1-year period were enrolled. RESULTS: For prediction of high-risk group, AUC was obtained for GBS (0.808), PRS (0.604), and CRS (0.767). For prediction of rebleeding, AUC was obtained for GBS (0.674), PRS (0.602), and CRS (0.621). For prediction of mortality, AUC was obtained for GBS (0.513), PRS (0.703), and CRS (0.620). CONCLUSIONS: In detecting high-risk patients with acute UGIB, GBS may be a useful risk stratification tool. However, none of the 3 score systems has good performance in predicting rebleeding and 30-day mortality because of low AUCs.

The influence of physician seniority on disparities of admit/discharge decision making for ED patients.

OBJECTIVES: Differences in disposition between emergency physicians (EPs) have been studied in select patient populations but not in general emergency department (ED) patients. After determining whether a difference existed in admit/discharge decision making of EPs for general ED patients, we focus our study in examining the influence of EP seniority on the decision to discharge ED patients. METHODS: In a 1-year retrospective study, we included a convenience sample of all 18 953 adult nontraumatic ED patients. We reviewed the admit/discharge dispositions at each shift made by 16 EPs. EPs were categorized by seniority to determine whether seniority influenced disposition. Three groups had 5, 4, and 7 EPs each, with >10 years, 5 to 9 years, and <5 years of working experience, respectively. RESULTS: Patient demographics, triage level, and number of patients per shift did not differ statistically between EPs and each group. The number of discharged patients per shift differed statistically between EPs (P < .001) and each group. The most senior EPs had the lowest discharge rates compared with EPs in intermediate and junior groups. They had lower discharge rates for patients at triage levels 1, 2, and 3 as well as for all patients. However, no difference in unscheduled ED revisit rates was found. CONCLUSIONS: EPs vary in their admit/discharge decision making for general ED patients. More importantly, the most senior EPs were found to have the lowest discharge rates compared with their junior colleagues.

Is direct transport to a trauma centre best for patients with severe traumatic brain injury? A study in south-central Taiwan.

OBJECTIVE: This study attempted to identify any differences between the outcomes of patients with severe traumatic brain injury (TBI) who were directly transported to Chang Gung Memorial Hospital and those who were stabilised initially at other hospitals in south-central Taiwan. METHODS: A retrospective review of the records of 254 patients with isolated severe TBI who visited this hospital's emergency department from July 2003 to June 2008, of whom 167 were referred from other hospitals. Logistic regression was used to assess the effects of transfer and its components on mortality. RESULTS: Transfer from another hospital was not significantly correlated with mortality in this study (OR 0.513, 95% CI 0.240 to 1.097). Moreover, neither intubation (OR 1.356, 95% CI 0.445 to 4.133) nor transfer time over 4 h (OR 0.549, 95% CI 0.119 to 1.744) had a significant effect on mortality. CONCLUSION: No differences in outcome were found between patients with isolated severe TBI who were directly transported and those transferred to this hospital's emergency room.

Serum leptin is associated with cardiometabolic risk and predicts metabolic syndrome in Taiwanese adults.

BACKGROUND: Leptin is associated with cardiovascular disease (CVD); however, few studies have assessed its relationship with metabolic syndrome, especially in an Asian population. Therefore, the aim of the present study was to assess leptin levels and evaluate its association with CVD and metabolic syndrome. METHODS: In 2009, 957 subjects, who underwent a routine physical examination and choose leptin examination, were selected to participate. Participants (269 females and 688 males) were stratified according to leptin level quartiles. Metabolic syndrome was defined by NCEP ATP III using waist circumference cutoffs modified for Asian populations, and CVD risk was determined using the Framingham Heart Study profile. RESULTS: Leptin levels were correlated with CVD risk in men and women. With the exception of fasting plasma glucose, increased leptin levels were observed as factors associated with metabolic syndrome increased in both males and females. After adjusting for age, an association between leptin levels and metabolic syndrome was observed. After adjusting for age alone or with tobacco use, subjects in the highest leptin quartile had a higher risk of having metabolic syndrome than those in the lowest quartile (OR=6.14 and 2.94 for men and women, respectively). After further adjustment for BMI, metabolic syndrome risk remained significantly increased with increasing leptin quartiles in men. Finally, increased leptin levels were a predictor of metabolic syndrome in men and women. CONCLUSIONS: Serum leptin levels are correlated with CVD risk and metabolic syndrome. Analysis of leptin as part of routine physical examinations may prove beneficial for early diagnosis of metabolic syndrome.

The microbiological profile and presence of bloodstream infection influence mortality rates in necrotizing fasciitis.

INTRODUCTION: Necrotizing fasciitis (NF) is a life threatening infectious disease with a high mortality rate. We carried out a microbiological characterization of the causative pathogens. We investigated the correlation of mortality in NF with bloodstream infection and with the presence of co-morbidities. METHODS: In this retrospective study, we analyzed 323 patients who presented with necrotizing fasciitis at two different institutions. Bloodstream infection (BSI) was defined as a positive blood culture result. The patients were categorized as survivors and non-survivors. Eleven clinically important variables which were statistically significant by univariate analysis were selected for multivariate regression analysis and a stepwise logistic regression model was developed to determine the association between BSI and mortality. RESULTS: Univariate logistic regression analysis showed that patients with hypotension, heart disease, liver disease, presence of Vibrio spp. in wound cultures, presence of fungus in wound cultures, and presence of Streptococcus group A, Aeromonas spp. or Vibrio spp. in blood cultures, had a significantly higher risk of in-hospital mortality. Our multivariate logistic regression analysis showed a higher risk of mortality in patients with pre-existing conditions like hypotension, heart disease, and liver disease. Multivariate logistic regression analysis also showed that presence of Vibrio spp in wound cultures, and presence of Streptococcus Group A in blood cultures were associated with a high risk of mortality while debridement > = 3 was associated with improved survival. CONCLUSIONS: Mortality in patients with necrotizing fasciitis was significantly associated with the presence of Vibrio in wound cultures and Streptococcus group A in blood cultures.

The association between anemia and the mortality of severe traumatic brain injury in emergency department.

BACKGROUND: Anemia is a common medical problem for critically ill patients. Blood transfusion to augment oxygen delivery for these patients has been a traditional therapy. However, few studies have identified the impact of anemia on individuals suffering from severe traumatic brain injury (TBI). Hence, this study aims to evaluate the effects of initial anemia on patients with severe TBI admitted to the Emergency Unit. METHODS: We reviewed the medical records of patients with isolated severe TBI admitted to the Emergency Unit of a university hospital from July 2003 to June 2008. Patients were divided into two groups based on their initial anemia data taken while in the Emergency Unit. The anemia datum is defined as hemoglobin (Hb) <10 mg/dL. The t test was used to identify the differences between the two groups, while logistic regression was applied to determine any significant differences found in the statistical analysis. RESULTS: A total of 234 patients were signed up in our study. Based on their initial hemoglobin at emergency department, 23 patients (9.8%) comprised the anemia group, 17 patients (7.3%) comprised the nonanemia group, whereas 112 patients (47.9%) belonging to the nonanemia group were deceased. There is no significant difference between the two groups (p = 0.076; odds ratio, 0.97; confidence interval, 0.78-1.05). CONCLUSION: This study shows that initial anemia is not a mortality risk factor for patients with isolated severe blunt TBI.

The association between skull bone fractures and outcomes in patients with severe traumatic brain injury.

BACKGROUND: In traumatic brain injury (TBI), computed tomography (CT) provides a good assessment of anatomic pathologic findings and the prognostic value of CT characteristics has been well discussed. However, few studies have focused on skull bone fracture and its clinical prognostic importance. Hence, this study aims to evaluate the effects of skull bone fracture on patients with severe TBI admitted to the emergency unit. METHODS: We reviewed the medical records of patients with isolated severe TBI admitted to the emergency unit of a university hospital from July 2003 to June 2008. Patients were divided into two groups based on the presence of skull bone fracture identified by the CT scan while in the emergency unit. Mann-Whitney U test and a Student's t test were used to identify the differences between the two groups, whereas logistic regression was applied to determine any significant differences found in the statistical analysis. RESULTS: A total of 197 patients were signed up in our study. Based on the presence of skull bone fracture on CT scan at emergency department, 92 patients (46.7%) comprised the skull bone fracture group and 59 patients (64.1%) of these died. One hundred five patients (53.3%) comprised the nonskull bone fracture group, of which 33 patients (31.4%) died. There is significant difference between the two groups (p = 0.004). CONCLUSION: This study shows that skull bone fracture is a mortality risk factor for patients with isolated severe blunt TBI.

Corrigendum: The Association Between Emergency Department Revisit and Elderly Patients.

[This corrects the article on p. 20 in vol. 10.].

The Association Between Emergency Department Revisit and Elderly Patients.

BACKGROUND: Emergency department (ED) revisits may be associated with a higher percentage of adverse events and increased costs. Our hospital is a university affiliation hospital accepted regional referral patients, and located in the region in Taiwan with the highest percentage of elderly people. In this study, we attempted to identify whether old age was a risk factor of ED revisit. METHODS: Patients who visited the ED from July 2011 to June 2016 were included. Factors associated with revisit were collected from medical information database. A total of 239,405 patients were included in our study, with 13,272 having ED revisits within 72 hours. Chi square and independent t test were applied for univariable factors, and a logistic regression model was used for multivariable analysis. RESULTS: Old age (age ≥ 65 years) was found to be a risk factor for ED revisit (odds ratio [OR]: 1.14; 95% confidence interval [CI]: 1.09-1.19). Diagnosis, pulse rate, diastolic blood pressure, fever, pain management, paracentesis, triage level, registration category, male gender, discharge status, and major illness may have some effect on ED revisit. CONCLUSIONS: In our patients, old age is a risk factor for ED revisit; however, only a weak association was found.

The effect of prolonged ED stay on outcome in patients with necrotizing fasciitis.

OBJECTIVE: Overcrowding in hospitals, especially in EDs, is a serious problem in the United States, Europe, and Taiwan. However, the association between prolonged ED boarding stay and mortality in patients with necrotizing fasciitis remains underinvestigated. METHODS: This was a retrospective study. A total of 195 patients were enrolled and analyzed. The sample was divided into 2 groups: nonmortality and mortality. A stepwise logistic regression model was developed to investigate 3 factors of clinical relevance predicting patient mortality. RESULT: The results of the stepwise logistic regression analysis revealed that hypotension (odds ratio [OR], 32.9; 95% confidence interval [CI], 6.9-156.0) and prolonged ED boarding stay (OR, 3.4; 95% CI 1.3-8.6) were both associated with higher mortality. Early operation (OR: 0.16; 95% CI: 0.06-0.45) was associated with lower mortality. CONCLUSION: Prolonged ED boarding stay was associated with increased mortality in patients with necrotizing fasciitis. Early operation (within 24 hours of ED arrival) was associated with decreased mortality.

The influence of anemia on clinical presentation and outcome of patients with first-ever atherosclerosis-related ischemic stroke.

There is considerable debate regarding whether anemia qualifies as a prognostic factor for stroke. The purpose of this study was twofold: first, to assess the influence of anemia on vascular risk factors and clinical presentations in patients with first-ever atherosclerosis-related ischemic stroke and, second, to evaluate whether anemia may be of prognostic importance. A total of 774 consecutive patients with first-ever atherosclerosis-related ischemic stroke were prospectively investigated. Vascular risk factors, clinical presentations and outcomes were recorded and compared between those patients with and without anemia. Stroke recurrence and mortality were recorded at the 3-year follow-up. Of the study population, 168 (21.7%) were anemic. Multivariate analysis revealed that patients with anemia were more likely to be older than 70 years (p<0.001) and have chronic renal insufficiency (p<0.001). After a mean follow-up period of 958 days, 21 (12.5%) and 24 (4.0%) of the patients in the anemic and control groups, respectively, died. Within 3 years of initial onset, the mortality rate was significantly higher in patients with anemia (p=0.021). The Kaplan-Meier analysis for patients with and without anemia showed different survival curves (Log-rank test p<0.001). Within 3 years of the onset of first-ever atherosclerosis-related ischemic stroke, patients who had anemia at the time of the initial admission had an associated higher mortality rate. The stroke risk factors of being older than 70 years and having chronic renal insufficiency were more frequently observed in those patients with anemia.

Hemorrhagic bullae are not only skin deep.

BACKGROUND: Dermatologic complaints are common presentations in the ED. Hemorrhagic bullae are an example of dermatologic manifestation caused by variable etiologies. The life-threatening skin lesion usually is an external sign of a systemic or immune response stimulated by an infection, toxin, medication, or disease process. Although most patient with life-threatening skin lesion, such as hemorrhagic bullae, may appear ill, patients who present in the early course of illness may appear well but deteriorate rapidly. For greater comprehension of hemorrhagic bullae, we prospectively followed 42 patients who presented with hemorrhagic bullae at the ED and analyzed their clinical characteristics and their confirmative diagnoses. METHODS: This is a prospective, observational cohort study conducted at a university-affiliated community hospital. Data were collected from January 2002 to January 2007. Patients presenting to the ED with hemorrhagic bullae were enrolled prospectively. RESULTS: All of our patients with hemorrhagic bullae had evidence of a serious disease: necrotizing fasciitis (42 case, 100%). The most common comorbidity was diabetes mellitus (18 cases; 42.9%). Vibrio species was the most common organism from blood culture (8/16 cases) and wound culture (17/27 cases). Streptococcal species was found in only 1 patient via blood culture and 4 patients via wound culture. The yield of positive wound culture with Vibrio species was significantly greater than with streptococcal species (P < .05). Fourteen (33.3%) patients came to the ED for help 48 hours later after the onset of hemorrhagic bullae. None of these 14 patients died. In our total of 42 patients, 8 (19%) died. CONCLUSION: In our study, the most common causative disease of hemorrhagic bullae was necrotizing fasciitis. Hemorrhagic bullae are a more common clinical feature in Vibrio infection than in streptococcal infection. Hemorrhagic bullae may occur in the early stage of necrotizing fasciitis. Necrotizing fasciitis may be the first sign that emergency physicians come across in patients with hemorrhagic bullae that are not in the oral, genital, anal, ocular area, and high index of suspicion of Vibrio infection should be considered. More aggressive treatment may be needed as hemorrhagic bullae may occur in the early stage of a serious disease. Further multi-institution study may be required to support these findings.

Severe anemia associated with transient ischemic attacks involving vertebrobasilar circulation.

Transient ischemic attack is one of the most common causes of transient neurologic deficit. Anemic hypoxia results from reduced hemoglobin content with normal arterial oxygen tension and saturation. Anemic hypoxia caused by blood loss or hemolysis has not been considered as an independent factor leading to significant neurologic problems because cerebral homeostasis adjusted by the physiologic regulation in cerebral hemodynamics and oxygenation would meet the brain oxygen requirement in most circumstances even with profound anemia. We report a case of severe anemia associated with transient ischemic attack involving vertebrobasilar circulation.

Predictors of mortality in patients with necrotizing fasciitis.

BACKGROUND: Necrotizing fasciitis is an uncommon and life-threatening soft tissue infection with high mortality. Though early aggressive surgical intervention is important for improving survival, the impact of mortality from different microorganisms remains uncertain. Our study aims to identify the association of mortality and different microorganisms, and the positive and negative predictors of mortality in patients with necrotizing fasciitis. METHODS: This retrospective cohort study enrolled patients admitted via the emergency department (ED) with discharged diagnosis of necrotizing fasciitis (International Classification of Diseases, Ninth Revision, code 72886). Multivariate logistic regression analysis was used to identify microbiological, clinical, and biochemical variables independently associated with the mortality of necrotizing fasciitis. RESULTS: Multivariate logistic regression analysis showed that Vibrio infection, Aeromonas infection, hypotension, malignancy, and band form 10% or greater were significantly associated with increase of mortality (P < .05). They were considered as positive predictors of mortality. The presence of hemorrhagic bullae, however, was significantly associated with decrease of mortality (P < .05). It was considered as negative predictor of mortality. CONCLUSION: Aeromonas infection, Vibrio infection, cancer, hypotension, and band form white blood cell count greater than 10% are independent positive predictors of mortality in patients with necrotizing fasciitis. Streptococcal and staphylococcal infections, in contrast, are not predictors of mortality. The presence of hemorrhagic bullae is an independent negative predictor of mortality. Further study should focus on the accuracy of these factors.

Delayed diagnosis of active pulmonary tuberculosis in emergency department.

BACKGROUND AND PURPOSE: Tuberculosis (TB) is a worldwide health challenge. Emergency department (ED) is the major public access to the health care system. Delayed diagnosis of active pulmonary TB was believed to precipitate mortality and morbidity. The study was designed to investigate clinical characteristics and factors in patients with delayed diagnosis of active TB in ED. METHODS: We used a retrospective chart review. PATIENTS: A total of 103 patients were enrolled between December 2003 and March 2006. RESULTS: Typical chest radiographic findings were noted in 79.8% of nondelayed TB group and 31.6% of delayed TB group (P < .001). Diagnosis of pneumonia was made at ED in 22.6% of nondelayed TB group and 68.4% of delayed TB group (P < .001). Length of initiation of TB treatment intervention was 0 days (0-1 days) and 9 days (6-16 days), respectively (P < .001). In-hospital mortality rate was 15.5% and 47.4%, respectively (P < .01). Age (odds ratio, 1.07; 95% confidence interval, 1.01-1.1) and intensive care unit admission (odds ratio, 5.01; 95% confidence interval, 1.18-21.3) were associated with lower in-hospital survival. Delayed ED diagnosis of TB was associated with mortality in results of univariate analysis (P = .002), but no statistical significance was noted in the final result of stepwise logistic regression analysis. CONCLUSION: Intensive care unit admission and age are associated with mortality. Awareness of varying features of pulmonary TB by physicians is important.

Metformin-associated lactic acidosis in a pregnant patient.

Metformin-associated lactic acidosis is a rare but serious condition and potentially even more hazardous during pregnancy. We reported a case of lactic acidosis in a 28-year-old pregnant woman (gravida 3, para 0, abortion 2, ante-partum 22 weeks) after ingestion of 39.50 g (approximately 80 tablets) metformin in a suicide attempt. She had no pre-existing systemic illness. Analysis of arterial blood gases revealed a high anion gap (28.1 mEq/l) and a normal osmol gap (8 mEq/l) metabolic acidosis. Other etiologies of high anion gap and normal osmol gap metabolic acidosis were excluded by laboratory investigation. The patient was treated on an emergency basis and received aggressive fluid management, intravenous sodium bicarbonate (1 mEq/kg) and activated charcoal, orally. The fetal condition was monitored intensively. The fetus was delivered smoothly via vaginal delivery in a healthy state at the 38th gestational week. Clinical follow-up over the next 2 years confirmed no congenital abnormality. We present a case of successful management of metformin-associated lactic acidosis during pregnancy, treated simply, with intravenous sodium bicarbonate and intensive fetal monitoring. This relatively noninvasive method is an effective treatment option. However, hemodialysis still has a valuable role in the management of acidosis which proves refractory to conservative treatment, such as that described.