Helen Eastman Martin

The fluid and electrolyte therapy of severe diabetic acidosis and ketosis; a study of twenty-nine episodes (twenty-six patients).

Abstract A detailed summary is given of the fluid and electrolyte therapy used in the early phases of treatment of twenty-nine episodes of severe diabetic ketoacidosis. There was little difference in the volume of fluid retained when repair solutions of varying tonicity were employed. Hyperosmolarity of the serum was present in 52 per cent of the patients on entry and in 46 per cent of the patients after twelve hours of therapy. When hypertonic fluids were used there was more hyperosmolarity of the serum after twelve hours of therapy than with hypotonic fluids, and hypernatremia and hyperchloremia were frequently noted. This indicates the need for use chiefly of hypotonic fluids. Factors influencing the correction of acidosis included the lactatechloride ratio of the intravenous fluids used (considered to be best at a ratio over 1.0), the entry serum chloride level, the use of hypertonic solutions, large loads of 0.9 per cent sodium chloride and the rate of fall of the blood ketone levels. Detailed balance studies in eight patients correlated well with previous estimates of 5 to 10 per cent body fluid loss and with balances of certain ions. From these studies we believe that the average range of intake in the early, more acute phases of treatment should be 70 to 120 ml. H 2 O/Kg.; 7 to 10 mEq. Na/Kg.; 5 mEq. Cl/Kg.; 2 to 3 mEq. K/Kg.; 0.2 mEq. Mg/Kg.; 1 mM P/ Kg.; and 4 to 5 mEq. HCŌ 3 /Kg.

Electrolyte changes and the electrocardiogram in diabetic acidosis

Abstract Correlation of electrolyte and pH changes with serial electrocardiographic changes was made in thirteen patients during therapy for severe diabetic acidosis. Sagging of the S-T segments was a prominent feature of the electrocardiogram on entry when acidosis was marked. This change usually disappeared within twenty-four hours. In nineteen instances of depressed S-T segment, the pH or carbon dioxide combining power was low in sixteen (84 per cent). However, in 31 per cent of the patients whose records showed isoelectric S-T segments, the pH or Carbon dioxide combining power was low. Experimentally, depression of the S-T segment occurs with moderate elevation of the serum potassium but there was no correlation in our series with changes in serum potassium levels. The etiology of this change requires further study. Thirty-seven records showed prolonged Q-T intervals, many of these occurring one to four days after intensive therapy had been instituted. Sixteen (43 per cent) of these were associated with low total or ionized serum calcium or potassium. Twenty-one (57 per cent) of the patients whose records showed prolonged Q-T intervals had normal levels of serum calcium and potassium. There were seven patients in whom the Q-T interval was markedly prolonged; in six of these the serum calcium or potassium levels were below normal. These findings suggest that in some cases other factors than serum calcium and potassium depletion may be responsible for the prolongation of the Q-T interval. There was a high degree of correlation between low T waves and low serum potassium levels. The T waves increased in amplitude with return of the potassium to normal or elevated levels. The relationship of low serum magnesium to the electrocardiographic changes needs additional study. The complex nature of the factors present in diabetic acidosis which may affect the myocardium is discussed. These factors include the relationship between extracellular and intracellular electrolytes, cardiac nutrition in acidosis and ketosis, and the effects of anoxia and azotemia.

The effect of ammonium chloride and sodium bicarbonate on the urinary excretion of magnesium, calcium, and phosphate

Abstract Six normal subjects showed mean or average increases, which were statistically significant, in urinary output of magnesium (+4.99 mEq.), calcium (+22.86 mEq.), and phosphate (+18.2 mM.) during 5 days of ingestion of ammonium chloride, as compared to a 5-day control period. This occurred despite differences in the intake of electrolytes, age, sex, or weight. The possible significance of the loss of magnesium during diuretic therapy was discussed. During ingestion of sodium bicarbonate there was a mean decrease over the control period which was statistically significant only for urinary output of calcium (−3.81 mEq.).

Serum electrolytes and the electrocardiogram

Abstract 1. 1. Variations in potassium and calcium appear to be chiefly, if not entirely, responsible for electrolyte effects on the electrocardiogram. 2. 2. These effects are mainly on the form and duration of the repolarization wave. 3. 3. In the absence of gross changes due to heart disease, digitalis, or quinidine, a reasonably accurate prediction of marked deficits or excesses of either calcium or potassium can be made from the effects these ions produce on the electrocardiogram. 4. 4. In the interpretation of the electrocardiogram it should be appreciated that, at least in the case of potassium, it may be the intracellular, rather than the serum, level that influences the repolarization wave. 5. 5. Recognizable electrocardiographic abnormalities are usually present at levels of serum calcium below 3.5 meq. per liter and above 6.0 meq. per liter and at levels of serum potassium below 3.0 meq. per liter and above 6.0 meq. per liter.

Response of Diabetic Coma to Various Insulin Dosages

Over the years the treatment of diabetic acidosis and -coma has presented a vexing problem to the physician and has often meant an unfortunate outcome for the patient. Although coma is admittedly an unnecessary and preventable complication of diabetes mellitus, its frequency remains high; at the Los Angeles County Hospital it accounts for approximately 5 per cent of the admissions to the Diabetic Service. While the reports in the literature are in general agreement on the main principles of treatment, namely, the administration of adequate amounts of insulin and adequate hydration in conjunction with other supportive measures that may be required by the individual patient, there is still considerable disagreement as to what constitutes adequacy, and also as to the rate at which insulin and fluid should be given. Insulin dosages in the first twenty-four hours have varied from as little as 60 units, as reported by Crampton, Mellinger and Palmer, to as much as several thousand units, as noted by Harwood. The dosage schedule also varies widely, ranging from 20 to 50 units given hypodermically every 30 minutes to an amount equivalent to one-half of the blood sugar level or more. The mortality from diabetic coma likewise has a wide range. McCullagh has stated that a 10 per cent mortality of cases in actual coma is probably attained by few and that rates as high as 25 to 40 per cent still exist. Harwood in 1951 reported that the mortality figures in various parts of the country varied from 2.4 to 43.7 per cent.

Exchangeable Magnesium in Hypertension.

Summary Exchangeable magnesium, expressed per kg of body weight, was decreased in hypertensive men as compared to the controls. The serum magnesium level was also lower in hypertensive men. These changes were not found in hypertensive women. Results in hypertensive women were difficult to interpret accurately, probably because of the obesity of this group.

Bacterial endocarditis superimposed on syphilitic aortitis and valvulitis

Abstract Five cases of proved syphilitic endocarditis or aortitis, with superimposed bacterial vegetations, have been presented. In none of the cases were both diagnoses made clinically. In all five cases the blood Wassermann and Kahn reactions were positive. In four cases blood cultures were positive, and in the fifth case Streptococcus viridans was grown from the vegetation on the heart valve. Streptococcus viridans was recovered in four of the cases and Streptococcus hemolyticus in the remaining case. In three of the cases embolic phenomena were prominent, and in two the mesenteric vessels were involved. In one case there were multiple saccular mycotic aneurysms of the membranous septum and aortic cusps. In another case a fairly characteristic syphilitic aortic valvulitis and aortitis were associated with a typical rheumatic involvement of the mitral valve. The diagnosis of syphilitic aortitis and valvulitis does not exclude the possibility of superimposed bacterial involvement, as shown by the above cases, although the lesion undoubtedly is rare. This diagnosis should be considered clinically whenever there is a combination of sepsis of undetermined origin, a positive Wassermann reaction, and evidence of aortic insufficiency or aortitis, without evidence of previous rheumatic infection.Five cases of proved syphilitic endocarditis or aortitis, with superimposed bacterial vegetations, have been presented. In none of the cases were both diagnoses made clinically. In all five cases the blood Wassermann and Kahn reactions were positive. In four cases blood cultures were positive, and in the fifth case Streptococcus viridans was grown from the vegetation on the heart valve. Streptococcus viridans was recovered in four of the cases and Streptococcus hemolyticus in the remaining case. In three of the cases embolic phenomena were prominent, and in two the mesenteric vessels were involved. In one case there were multiple saccular mycotic aneurysms of the membranous septum and aortic cusps. In another case a fairly characteristic syphilitic aortic valvulitis and aortitis were associated with a typical rheumatic involvement of the mitral valve. The diagnosis of syphilitic aortitis and valvulitis does not exclude the possibility of superimposed bacterial involvement, as shown by the above cases, although the lesion undoubtedly is rare. This diagnosis should be considered clinically whenever there is a combination of sepsis of undetermined origin, a positive Wassermann reaction, and evidence of aortic insufficiency or aortitis, without evidence of previous rheumatic infection.

Original communicationBacterial endocarditis superimposed on syphilitic aortitis and valvulitis: A clinicopathological study with 5 case reports☆

Abstract Five cases of proved syphilitic endocarditis or aortitis, with superimposed bacterial vegetations, have been presented. In none of the cases were both diagnoses made clinically. In all five cases the blood Wassermann and Kahn reactions were positive. In four cases blood cultures were positive, and in the fifth case Streptococcus viridans was grown from the vegetation on the heart valve. Streptococcus viridans was recovered in four of the cases and Streptococcus hemolyticus in the remaining case. In three of the cases embolic phenomena were prominent, and in two the mesenteric vessels were involved. In one case there were multiple saccular mycotic aneurysms of the membranous septum and aortic cusps. In another case a fairly characteristic syphilitic aortic valvulitis and aortitis were associated with a typical rheumatic involvement of the mitral valve. The diagnosis of syphilitic aortitis and valvulitis does not exclude the possibility of superimposed bacterial involvement, as shown by the above cases, although the lesion undoubtedly is rare. This diagnosis should be considered clinically whenever there is a combination of sepsis of undetermined origin, a positive Wassermann reaction, and evidence of aortic insufficiency or aortitis, without evidence of previous rheumatic infection.Five cases of proved syphilitic endocarditis or aortitis, with superimposed bacterial vegetations, have been presented. In none of the cases were both diagnoses made clinically. In all five cases the blood Wassermann and Kahn reactions were positive. In four cases blood cultures were positive, and in the fifth case Streptococcus viridans was grown from the vegetation on the heart valve. Streptococcus viridans was recovered in four of the cases and Streptococcus hemolyticus in the remaining case. In three of the cases embolic phenomena were prominent, and in two the mesenteric vessels were involved. In one case there were multiple saccular mycotic aneurysms of the membranous septum and aortic cusps. In another case a fairly characteristic syphilitic aortic valvulitis and aortitis were associated with a typical rheumatic involvement of the mitral valve. The diagnosis of syphilitic aortitis and valvulitis does not exclude the possibility of superimposed bacterial involvement, as shown by the above cases, although the lesion undoubtedly is rare. This diagnosis should be considered clinically whenever there is a combination of sepsis of undetermined origin, a positive Wassermann reaction, and evidence of aortic insufficiency or aortitis, without evidence of previous rheumatic infection.

The effect of respiration on the arterial pulse in left ventricular failure

Abstract An anomalous effect of respiration on the arterial pulse has been found in several patients with severe left heart failure. In contrast to the behavior of the pulse in normals in which the pulse beat becomes stronger in expiration, in these cases the strong beats occurred in inspiration. In two of the cardiac patients the pattern reverted to normal with clinical improvement.

Staphylococcus aureus subacute bacterial endocarditis superimposed on a congenital heart lesion with recovery

Abstract A case of subacute bacterial endocarditis caused by the Staphylococcus aureus , with recovery and a four-year period of observation, is reported. The possible beneficial effect of staphylococcus antitoxin in the treatment in this case is discussed.