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M. Murak, M.B. B.CH., M.B.B.Ch., Ph.D.

Professor, Keck School of Medicine of University of Southern California

In an anion gap plus hyperchloremic acidosis, the reduction in bicarbonate is offset by increases in both chloride and the anion gap. These concepts are also useful in evaluating the possibility of mixed acid-base disorders occurring in association with respiratory acidosis. The only practical treatment for acute respiratory acidosis involves treating the underlying disorder and ventilatory support. Under such severe circumstances, mechanically assisted ventilation should be considered. Administering alkalinizing salts has no place in the management of chronic respiratory acidosis. Chronic respiratory alkalosis may have the same causes in addition to being a commonly associated finding in pregnancy, hepatic encephalopathy, severe anemia, and chronic exposure to high altitudes. The acute hyperventilation syndrome is characterized by light-headedness, paresthesias, circumoral numbness, and tingling of the extremities. Both the acute respiratory alkalosis and the resultant reduction in ionized calcium and magnesium contribute to the increased neuromuscular excitability. When severe anxiety provokes the hyperventilation syndrome, air rebreathing with a paper bag generally terminates the acute attack. Shows that acid-base disturbances are easy to analyze if approached systematically. It is associated with a 35 to 65% mortality depending mainly on the presence of other diseases or complications. The urine is obtained first to avoid diagnostic problems caused by catheter-induced urethral or bladder trauma. Pre-renal azotemia from various causes (see Table 103-1) is characterized by decreased perfusion of the kidney leading to an accumulation of water and minerals. Chemical analysis of blood and urine: Serum bicarbonate, potassium, uric acid, calcium, phosphorus, urine osmolality, urine and serum urea, creatinine, sodium 5. Although autoregulation depends on relaxation of the pre-glomerular arterioles, the exact mechanism of this phenomenon is still debated. The pathophysiology of pre-renal azotemia, then, includes reduced perfusion of the kidney, with high plasma levels of renin, aldosterone, and antidiuretic hormone resulting in avid tubular reabsorption of water and ions. Because no histologic damage to the tubules is present, no erythrocytes, inflammatory cells, or granular casts should be present in the urine. In obstructive nephropathy, urine flow may decrease rapidly or cease, but this event is unusual for the following reasons: (1) if only one kidney is obstructed, the other kidney will compensate for the loss; and (2) even if a solitary kidney is obstructed (or both kidneys are obstructed simultaneously), filtration continues and tubular pressure rises to overcome the obstruction and increase urine flow. The different types of acute vasculitis and glomerulonephritis fall in this category, as do scleroderma, malignant hypertension, eclampsia, and microangiopathies. Whenever glomerular damage occurs, it will be reflected by abnormalities in clinical function and by urinalysis. Urinalysis reveals proteinuria, generally with hematuria; in classic cases, red cell casts are seen. Proteinuria and hematuria result from loss of the barrier function of the glomerular basement membrane. Normal subjects constantly excrete Tamm-Horsfall protein, but when pre-renal azotemia and a low urine flow coexist, Tamm-Horsfall proteins aggregate to form casts of the tubule lumen and are excreted as hyaline casts. Clinically, urine flow slows dramatically or ceases, and casts containing damaged tubular cells are formed. If casts remain in the kidney for only a short period, they appear as tubular cell casts, but more commonly the cells are partly degraded to form "coarsely granular casts". Ischemic injury to tubules occurs with hypotension during sepsis or surgery (especially in elderly patients) and produces loss of tubular cells (especially in the loop of Henle) or even irreversible necrosis of the kidney cortex. Cells in the loop of Henle appear to be especially prone to ischemic damage because blood flow to this region is low and the cells have a high adenosine triphosphate requirement. Pigmented coarsely and finely granular casts of different size plus erythrocytes and clumps of cells are seen.

Syndromes

• Place catheters (tubes) around your heart to drain fluids that build up.
• Confusion
• Computed tomography (CT) scan
• Avoid taking salt substitutes if you are asked to eat a low-salt diet
• Slowed or delayed start of the urinary stream
• Flank pain or pain in the side or back. Pain is usually on one side; it is rarely felt on both sides. Pain is often severe. It may get worse over days. You may also feel pain in the pelvis, groin, genitals, or between the upper abdomen and back.
• Walking aids and foot support devices
• Contrast can be given through a vein (IV) in your hand or forearm. If contrast is used, you may also be asked not to eat or drink anything for 4-6 hours before the test.
• Antinuclear antibodies (ANA) test
• Breathing test to see if lung muscles are affected

Nocturia and polyuria in men referred with lower urinary tract symptoms, assessed using a 7-day frequency-volume chart. Combination therapy-permanent interstitial brachytherapy and external beam radiotherapy for patients with localized prostate cancer. Impact of urethral injury management on the treatment and outcome of concurrent pelvic fractures. Fiveyear results from a multicentre randomized controlled trial of endoscopic laser ablation against transurethral resection of the prostate. Transurethral electrovaporization of the prostate: is it any better than conventional transurethral resection of the prostate. Expression of soluble urokinase plasminogen activator receptor may be related to outcome in prostate cancer patients. Ectopic prostatic tissue in the uterine cervix and vagina: report of a series with a detailed immunohistochemical analysis. An economic evaluation of doxazosin, finasteride and combination therapy in the treatment of benign prostatic hyperplasia. Lower urinary tract symptoms suggestive of benign prostatic obstruction-Triumph: health-economical analysis. The appropriateness of treatment of benign prostatic hyperplasia: a comparison of Dutch and multinational criteria. Page 150 138240 120220 140520 107500 112220 121600 119700 100770 108780 108500 105860 118670 118070 107350 128180 September 2010 Appendix 3: Master Bibliography American Urological Association, Inc. Outcome of primary vesicoureteric reflux detected following fetal renal pelvic dilatation. Alfuzosin: a review of the therapeutic use of the prolonged-release formulation given once daily in the management of benign prostatic hyperplasia. Basal cell proliferations of the prostate other than usual basal cell hyperplasia: a clinicopathologic study of 23 cases, including four carcinomas, with a proposed classification. Incidence, etiology, and risk factors for fever following acute spinal cord injury. Antibiotic resistance patterns of uropathogens in pediatric emergency department patients. Bladder volume at onset of reflux on initial cystogram predicts spontaneous resolution. Does ingestion of cranberry juice reduce symptomatic urinary tract infections in older people in hospital? Managing patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Role of cytologic criteria in the histologic diagnosis of Gleason grade 1 prostatic adenocarcinoma. Prostate size influences the outcome after presenting with acute urinary retention. Sustained-release alfuzosin and trial without catheter after acute urinary retention: a prospective, placebo-controlled. Postvoid residual urine in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia: pooled analysis of eleven controlled studies with alfuzosin. Alfuzosin 10 mg once daily in the management of acute urinary retention: results of a double-blind placebo-controlled study. Lower urinary tract symptoms suggestive of benign prostatic obstruction: what are the current practice patterns. Benign prostatic hyperplasia treated with saw palmetto: a literature search and an experimental case study. Lower urinary tract symptoms and sexual dysfunction: epidemiology and pathophysiology. Sildenafil citrate improves erectile function: a randomised double-blind trial with open-label extension. The relationship between erectile dysfunction and lower urinary tract symptoms: epidemiological, clinical, and basic science evidence.

Pseudo-obstruction is the manifestation of profound loss of bowel muscle and bowel wall fibrosis causing regions of dysmotility. Asymptomatic large-mouthed diverticula, pathognomonic of scleroderma, also result from fibrosis and atrophy of the bowel wall. Volvulus, stricture, or perforation are uncommon complications of severe bowel involvement. It is associated with significant morbidity and is now the leading cause of mortality in this disease. However, interstitial lung disease is more characteristic of diffuse scleroderma, and isolated pulmonary hypertension is more closely associated with limited disease. Spontaneous pneumothorax, adult respiratory distress syndrome, and pulmonary hemorrhage have been reported rarely. Pulmonary function testing is the most sensitive method for detecting early lung dysfunction but may be normal during the early phase of active disease. The outcome of untreated alveolitis is pulmonary fibrosis, severe restrictive ventilatory defects, and ineffective gas exchange. Progressive restrictive disease occurs in 20 to 30% of patients and is more likely to occur in patients with diffuse scleroderma, those of black race, and those with antibodies to topoisomerase I (Scl-70 antibodies). Right-sided heart catheterization provides confirmation of the diagnosis and permits the measurement of pulmonary hemodynamics with and without a vasodilator challenge. The dose of calcium-channel blockers in such patients should be increased to the maximum dose tolerated. Although symptoms of the cardiac involvement are often appreciated in later stages of the disease, objective noninvasive testing can demonstrate heart involvement early in the disease course. Asymptomatic pericardial effusions or clinically silent arrhythmias may be demonstrated, particularly in diffuse scleroderma. Pericardial disease is symptomatic in approximately 10% of patients, whereas pericardial disease can be demonstrated by echocardiography or at postmortem in 40 to 60% of cases. The fibrosis is distributed in patches of contraction band necrosis on both sides of the heart. This suggests that myocardial fibrosis is associated with reversible vasospasm of the coronary circulation and repeated bouts of ischemia-reperfusion injury. Echocardiography demonstrates myocardial disease in approximately 50 to 70% of cases, but in most patients, cardiac dysfunction is clinically silent until late in the disease. Defects in conduction and cardiac rhythm occur as a consequence of myocardial fibrosis. In contrast, death or end-stage renal disease resulting from scleroderma renal crisis is now rare. Mild proteinuria or microscopic hematuria without loss of renal function or evidence of glomerular disease is the most common sign of renal disease. Approximately 10% of patients with diffuse scleroderma have a renal crisis that mimics malignant hypertension. Microangiopathic hemolytic anemia, thrombocytopenia, and rapidly progressive loss of renal function also accompany scleroderma renal crisis. Studies demonstrate high levels of renin associated with vasospasm and intrinsic renal vessel disease. However, new anemia or thrombocytopenia, with or without hypertension, should alert the physician to scleroderma kidney disease. Some patients continue to have progressive 1522 renal failure despite control of blood pressure. Musculoskeletal Involvement Musculoskeletal symptoms are almost always present in scleroderma and are often the initial symptom of the disease. A sense of weakness in the muscles of the hands, arms, and legs can be subtle or profound. These "tendon friction rubs" are secondary to fibrin deposition and fibrosis in the tissues. They occur exclusively in diffuse scleroderma and are predictive of a poor overall prognosis. Musculoskeletal symptoms in scleroderma often fail to respond to anti-inflammatory medications. It can also occur because of malnutrition resulting from scleroderma bowel disease.

Explosionproof or dust-ignitionproof equipment may not be suitable for use at temperatures lower than -25°C (-13°F) unless they are identified for lowtemperature service. However, at low ambient temperatures, flammable concentrations of vapors may not exist in a location classified as Class I, Division 1 at normal ambient temperature. Determining whether or not a particular piece of generalpurpose equipment is suitable to use in a Division 2 location requires evidence of suitability from a qualified source. Equipment installed in a Class I, Division 1 location shall be identified for the Class I, Division 1 location. Informational Note: Equipment used for flow measurement is an example of equipment having a single compression seal, diaphragm, or tube. In addition, Class I equipment shall not have any exposed surface that operates at a temperature in excess of the autoignition temperature of the specific gas or vapor. Informational Note: Luminaires and other heat-producing apparatus, switches, circuit breakers, and plugs and receptacles are potential sources of ignition and are investigated for suitability in classified locations. Such types of equipment, as well as cable terminations for entry into explosionproof enclosures, are available as listed for Class I, Division 2 locations. Fixed wiring, however, may utilize wiring methods that are not evaluated with respect to classified locations. Wiring products such as cable, raceways, boxes, and fittings, therefore, are not marked as being suitable for Class I, Division 2 locations. The above section recognizes that the inside of an electrical equipment enclosure that is connected to a flammable process through a single seal, is in fact a Division 2 area. Leakage or failure of the seal could produce a flammable atmosphere inside the equipment enclosure. Since the inside of the enclosure meets the definition of a Division 2 location, the electrical equipment must be identified as suitable for use in a Division 2 location, even if the location outside the enclosure is not classified. Measures that must be taken to ensure process gas or fluid does not enter the wiring raceway are addressed in Section 501. Informational Note: the characteristics of various atmospheric mixtures of gases, vapors, and dusts depend on the specific material involved. Autoignition temperature is not related to other gas properties and has to be considered independently. Intrinsically safe installations are a system, and must be installed as a system in order to meet their design requirements, even when installed in Division 2. Explosionproof enclosures usually contain arcing and sparking devices, and the seals are necessary to maintain the Dust layers can cause an insulating effect that can raise the operating temperature of heat producing electrical equipment in normal operation. This might create a situation where an equipment surface temperature exposed to the flammable atmosphere would be cool enough for a particular flammable gas when dust is not present, but would be over the temperature rating of the same flammable gas when dust is present. Equipment shall be marked to show the environment for which it has been evaluated. Unless otherwise specified or allowed in (C)(6), the marking shall include the information specified in (C)(1) through (C)(5). Electrical equipment designed for use in the ambient temperature range between ­25°C to +40°C shall require no ambient temperature marking. For equipment rated for a temperature range other than ­25°C to +40°C, the marking shall specify the special range of ambient temperatures in degrees Celsius. The marking shall specify the division if the equipment is suitable for Division 2 only. Equipment suitable for Division 1 shall be permitted to omit the division marking. Informational Note: Equipment not marked to indicate a division, or marked "Division 1" or "Div. The marking shall specify the applicable material classification group(s) or specific gas, vapor, dust, or fiber/flying in accordance with 500. In the absence of specifying the material classification groups, the equipment may be classified for use in the presence of a specific classified material. The marking shall specify the temperature class or operating temperature at a 40°C ambient temperature, or at the higher ambient temperature if the equipment is rated and marked for an ambient temperature of greater than 40°C. The temperature class, if provided, shall be indicated using the temperature class (T codes) shown in Table 500. Exception: Equipment of the non­heat-producing type, such as junction boxes, conduit, and fittings, and equipment of the heat-producing type having a maximum temperature not more than 100°C shall not be required to have a marked operating temperature or temperature class. Informational Note: More than one marked temperature class or operating temperature, for gases and vapors, dusts, and different ambient temperatures, may appear.