The prognostic value of blood pH and lactate and metformin concentrations in severe metformin-associated lactic acidosis

AIMS: Analysis of the prognostic values of blood pH and lactate and plasma metformin concentrations in severe metformin-associated lactic acidosis may help to resolve the following paradox: metformin provides impressive, beneficial effects but is also associated with life-threatening adverse effects. RESEARCH DESIGN AND METHODS: On the basis of 869 pharmacovigilance reports on MALA with available data on arterial pH and lactate concentration, plasma metformin concentration and outcome, we selected cases with a pH < 7.0 and a lactate concentration >10 mmol/L. Outcomes were compared with those described for severe metformin-independent lactic acidosis. RESULTS: Fifty-six patients met the above-mentioned criteria. The mean arterial pH and lactate values were 6.75 ± 0.17 and 23.07 ± 6.94 mmol/L, respectively. The survival rate was 53%, even with pH values as low as 6.5 and lactate and metformin concentrations as high as 35.3 mmol/L and 160 mg/L (normal < 1 mg/L), respectively. Survivors and non-survivors did not differ significantly in terms of the mean arterial pH and lactate concentration. The mean metformin concentration was higher in patients who subsequently died but this difference was due to a very high value (188 mg/L) in one patient in this group, in whom several triggering factors were combined. Sepsis, multidrug overdoses and the presence of at least two triggering factors for lactic acidosis were observed significantly more frequently in non-survivors (p = 0.007, 0.04, and 0.005, respectively). This contrasts with a study of metformin-independent lactic acidosis in which there were no survivors, despite less severe acidosis on average (mean pH: 6.86). CONCLUSIONS: In 56 cases of severe metformin-associated lactic acidosis, blood pH and lactate did not have prognostic value. One can reasonably rule out the extent of metformin accumulation as a prognostic factor. Ultimately, the determinants of metformin-associated lactic acidosis appear to be the nature and number of triggering factors. Strikingly, most patients survived - despite a mean pH that is incompatible with a favorable outcome under other circumstances

Hipomineralização Molar-Incisivo: Uma revisão de literatura

TCC (graduação) - Universidade Federal de Santa Catarina. Centro de Ciências da Saúde. Odontologia.Indrodução: Hipomineralização Molar-Incisivo (HMI) é um termo que se refere a hipomineralização, que afeta um ou mais primeiros molares permanentes e é frequentemente associada com incisivos permanentes afetados. Objetivo: Uma revisão de literatura sobre Hipomineralização Molar-Incisivo com o intuito de verificar a prevalência, etiologia e o tratamento da doença. Metodologia: Foi realizado um levantamento bibliográfico, nas bases de dados Pubmed, Google Acadêmico, Scielo e MedLine em busca de artigos publicados entre os anos 2000 e 2015, com as palavras chave: “hypomineralization prevalence”, “molar-incisor”, “hipomineralização molar incisivo”. Resultados: Foram obtidos 27 artigos científicos, que abordavam a prevalência, etiologia e tratamento de HMI. Conclusão: A prevalência de Hipomineralização Molar Incisivo varia de 1,23% à 27,7% entre os países, sendo que as maiores são encontradas em países europeus. Infecções na mãe durante a gestação ou na criança após o nascimento, doenças na infância, problemas durante o parto, ou alterações genéticas sugerem hipóteses para a etiologia da HMI. Os tratamentos citados foram desde aplicação tópica de flúor à restaurações e exodontias. A decisão do tratamento depende do grau de acometimento do dente com HMI

Design of Field Rental System on Web-Based Garuda Mataram Badminton Club

Residents of West Nusa Tenggara, Mataram City, mostly like badminton. GOR Badminton Garuda is a sports building that provides sports field rental services specifically for badminton (badminton) in the city of Mataram. Rental management at the Garuda Badminton Building is still carried out conventionally, namely by manually recording the list of field tenants in the rental book, resulting in difficult data searches and frequent schedule recording errors. In addition, making reports takes a long time because they are still made from rental books. In terms of field reservation, it is also considered less effective because tenants have to come to the field. The solution provided is to create a web-based online field rental information system using the Waterfall method. The results of creating this information system can make it easier for admins to manage rentals and make it easier for the public to get information and field booking services online. Based on Usability testing using the ISO 9126 model, the Field Rental Information System at the Garuda Badminton Sports Hall is in good criteria with a percentage of 83%

Trajetórias de docentes negros/as universitários : desafios entre a presença e o reconhecimento a partir das relações raciais no Brasil

Dissertação apresentada ao Programa de Pós-Graduação em Educação da Universidade do Extremo Sul Catarinense -UNESC, como requisito parcial para a obtenção do título de Mestre em Educação.Esta pesquisa aborda os processos de construção subjetiva dos professores negros e negras no decorrer das suas trajetórias como sujeitos e como docentes. Nesse sentido o cerne desta pesquisa foram as experiências dos sujeitos, suas memórias expressas durante as conversas no momento da entrevista por meio da técnica do grupo focal. Para atingir o objetivo geral desta pesquisa, de analisar as percepções de professores negros e negras das suas trajetórias como sujeitos e como docentes, foram necessárias as releituras a respeito da história dos negros/as do Brasil, desde as questões voltadas ao tráfico de pessoas africanas que foram escravizados até o processo de abolição. Também as questões relativas ao que definimos como preconceito, discriminação racial, negritude, identidade na contemporaneidade. Desta forma, delimitou-se o seguinte problema de pesquisa: Quais as percepções dos professores negros das suas trajetórias como sujeitos e docentes universitários no extremo sul catarinense? O trabalho configurou-se em três objetivos específicos: a) Identificar professores negros/as que atuam em diversas áreas do conhecimento em instituições do ensino superior no extremo sul catarinense; b) Analisar a trajetória de docentes negros e negras numa universidade e os indicativos do processo de consolidação profissional; c) Compreender os principais desafios da docência de professores negros e negras e as relações de poder, bem como estratégias de enfrentamento do racismo por parte desses docentes negros/as. Buscamos elaborar um percurso metodológico que pudesse nos ajudar a compreender as construções identitárias de professores dessa universidade, do ponto de vista das experiências do tornar-se negro, bem como aqueles ligadas ao preconceito na forma do racismo, vivenciadas por eles enquanto sujeitos e docentes. Os instrumentos utilizados para a realização da pesquisa envolveram: levantamento bibliográfico e entrevistas semiestruturadas utilizando a técnica de grupo focal. Nesta investigação tivemos como categorias de análise as categorias de memória, identidade, negritude. A base teórica para desenvolver a metodologia se inspirou no método biográfico, sobretudo nos estudos de Ferraroti, Bauer, Woodward, entre outros. Esta pesquisa apoia-se teoricamente, sobretudo nos estudos de Stuart Hall (2013), Silva (2000); Bernd (1988), Borges (2002), Nogueira (1985), Barbosa (1994), Kabengele Munanga (1988) e Woodward (2005) dentre outros

Metformin-induced lactic acidosis: a case series

<p>Abstract</p> <p>Introduction</p> <p>Unlike other agents used in the treatment of type 2 diabetes mellitus, metformin has been shown to reduce mortality in obese patients. It is therefore being increasingly used in higher doses. The major concern of many physicians is a possible risk of lactic acidosis. The reported frequency of metformin related lactic acidosis is 0.05 per 1000 patient-years; some authors advocate that this rate is equal in those patients not taking metformin.</p> <p>Case presentation</p> <p>We present two case reports of metformin-associated lactic acidosis. The first case is a 77 year old female with a past medical history of hypertension and type 2 diabetes mellitus who had recently been prescribed metformin (3 g/day), perindopril and acetylsalicylic acid. She was admitted to the emergency department two weeks later with abdominal pain and psychomotor agitation. Physical examination revealed only signs of poor perfusion. Laboratory evaluation revealed hyperkalemia, elevated creatinine and blood urea nitrogen and mild leukocytosis. Arterial blood gases showed severe lactic acidemia. She was admitted to the intensive care unit. Vasopressor and ventilatory support was initiated and continuous venovenous hemodiafiltration was instituted. Twenty-four hours later, full clinical recovery was observed, with return to a normal serum lactate level. The patient was discharged from the intensive care unit on the sixth day. The second patient is a 69 year old male with a past medical history of hypertension, type 2 diabetes mellitus and ischemic heart disease who was on metformin (4 g/day), glycazide, acetylsalicylic acid and isosorbide dinitrate. He was admitted to the emergency department in shock with extreme bradycardia. Initial evaluation revealed severe lactic acidosis and elevated creatinine and urea. The patient was admitted to the Intensive Care Unit and commenced on continuous venovenous hemodiafiltration in addition to other supportive measures. A progressive recovery was observed and he was discharged from the intensive care unit on the seventh day.</p> <p>Conclusion</p> <p>We present two case reports of severe lactic acidosis most probably associated with high doses of metformin in patients with no known contraindications for metformin prescription. In both patients no other condition was identified to cause such severe lactic acidosis. Although controversial, lactic acidosis should be considered in patients taking metformin.</p

Risk of acute kidney injury and survival in patients treated with Metformin:an observational cohort study

Background: Whether metformin precipitates lactic acidosis in patients with chronic kidney disease (CKD) remains under debate. We examined whether metformin use was associated with an increased risk of acute kidney injury (AKI) as a proxy for lactic acidosis and whether survival among those with AKI varied by metformin exposure. Methods: All individuals with type 2 diabetes and available prescribing data between 2004 and 2013 in Tayside, Scotland were included. The electronic health record for diabetes which includes issued prescriptions was linked to laboratory biochemistry, hospital admission, death register and Scottish Renal Registry data. AKI events were defined using the Kidney Disease Improving Global Outcomes criteria with a rise in serum creatinine of at least 26.5 μmol/l or a rise of greater than 150% from baseline for all hospital admissions. Cox Regression Analyses were used to examine whether person-time periods in which current metformin exposure occurred were associated with an increased rate of first AKI compared to unexposed periods. Cox regression was also used to compare 28 day survival rates following first AKI events in those exposed to metformin versus those not exposed. Results: Twenty-five thousand one-hundred fourty-eight patients were included with a total person-time of 126,904 person years. 4944 (19.7%) people had at least one episode of AKI during the study period. There were 32.4 cases of first AKI/1000pyrs in current metformin exposed person-time periods compared to 44.9 cases/1000pyrs in unexposed periods. After adjustment for age, sex, diabetes duration, calendar time, number of diabetes drugs and baseline renal function, current metformin use was not associated with AKI incidence, HR 0.94 (95% CI 0.87, 1.02, p = 0.15). Among those with incident AKI, being on metformin at admission was associated with a higher rate of survival at 28 days (HR 0.81, 95% CI 0.69, 0.94, p = 0.006) even after adjustment for age, sex, pre-admission eGFR, HbA1c and diabetes duration. Conclusions: Contrary to common perceptions, we found no evidence that metformin increases incidence of AKI and was associated with higher 28 day survival following incident AKI