WebPeripheral neuropathy is an umbrella term for nerve diseases that affect a specific subdivision of your nervous system. Athanasios G Dousmanis MD PhD (original author), Peripheral neuropathy, due to drugs: 357.6, For information on discounts, see Plans & Pricing, other causes of demyelinating polyneuropathy, Clinical evaluation of peripheral neuropathies. In rats given 150 mg/kg/day of ethambutol for 9 months, teased fiber analysis of lower extremity nerves showed extensive axonal degeneration and regeneration, suggesting that axonal degeneration may be primary (52). Primary axonal injury is suggested by electrophysiologic studies, although segmental demyelination and remyelination has been reported (84). The phase IV clinical study analyzes which people take Doxycycline and have Peripheral sensorimotor neuropathy. Accessed March 25, 2019. A peripheral neuropathy diagnosis remained more likely to be diagnosed for up to six months after the fluoroquinolone prescription. Data on the pathophysiologic mechanism of nerve injury are scant. J Clin Aesthet Dermatol 2010;3(3):19-21. Doxycycline / adverse effects*. Goolsby TA, Jakeman B, Gaynes RP. Genetics articles related to neuroscience research will be listed here. However, there is no significant increased risk of developing neuropathy associated with amoxicillin use. Jain KK. One study estimated that the prevalence of peripheral neuropathy in the family medicine setting is 8 percent in persons 55 years and older. Cases of neuropathy are rare, perhaps due to the typical short course of treatment, but with prolonged and high-dose therapy it can cause a mild but painful distal symmetric sensory neuropathy. Optic neuropathy has been reported with chronic chloramphenicol use in patients treated for cystic fibrosis (30). Isoniazid. McCarty M. How clinically relevant is dapsone-related peripheral neuropathy. Mayo Clinic, Rochester, Minn. April 29, 2019. Direct activation of the high-affinity nerve growth factor receptor by a non-peptide symmetrical polyanion. How safe are fluoroquinolones for diabetic patients? Most studies, however, have limited more objective examination or electrophysiologic data. The optic neuropathy is usually reversible after discontinuing the drug (54; 72), but it can be irreversible (07). Current oral fluoroquinolone exposure was associated with an increased relative incidence of peripheral neuropathy compared with nonexposure (adjusted incident rate ratio, 1.47; 95% CI, 1.13-1.92). Spellberg B, Yoo T, Bayer AS. information is beneficial, we may combine your email and website usage information with Gussago S, Poroli Bastone C, Celio D, Arigoni M, Quarenghi MC. If you are a Mayo Clinic patient, this could Childhood Degenerative & Metabolic Disorders, News releases, announcements, interviews and other supplemental content of neurologic interest, Stay informed with the latest news in neurology and neuroscience, Featuring clinician-investigators who have made extraordinary contributions to neurology, Meet some of the expert physicians who serve as, Listen to clinical cases and topical reviews in neurology. Stevenson MA, Calderwood SK, Coleman CN. Most of these agents cause a length-dependent sensory or sensorimotor polyneuropathy, with a dying back axonal pattern. J Assoc Physicians India 1992;40(10):671-2. A 3-center retrospective study of 184 patients treated with linezolid for rifampicin-resistant tuberculosis found 28% reported neuropathy symptoms; median symptom onset time was 45 days after treatment initiation (17). Swanson JW (expert opinion). Neurology research can include information involving brain research, neurological disorders, medicine, brain cancer, peripheral nervous systems, central nervous systems, nerve damage, brain tumors, seizures, neurosurgery, electrophysiology, BMI, brain injuries, paralysis and spinal cord treatments. To provide you with the most relevant and helpful information, and understand which A 15-year-old boy from Tajikistan had 5 years of type I diabetes but no symptomatic neuropathy (83). In rats, one sees a length- and dose-dependent axonal sensorimotor polyneuropathy with an accumulation of lysosomal ceramide inclusions (28; 71). Eur Neurol 1979;18:405-14. Am J Ophthalmol 2005;139:1114-6. It is occasionally used to treat urinary tract infections. Peripheral sensory disturbances related to treatment with fluoroquinolones. J Neuroophthalmol 2005;25:18-21. Clin Infect Dis 2010;50(1):49-55. Nitrofurantoin and minocycline-associated vasculitic neuropathy: case reports and literature review. include protected health information. Int J Radiat Oncol Biol Phys 1989;16:1225-30. Chloroquine rarely causes a mild, sensory greater than motor distal peripheral neuropathy that appears due to both axonal damage and to demyelination (88; 93; 81). More generally, the term is used to refer to any naturally produced, semi-synthetic, or synthetic compound that acts against microorganisms, and includes antibacterials, antifungals, antiprotozoals, and anthelminthics. Accessed March 25, 2019. 2018 Apr 1;111(4):259-260. doi: 10.1093/qjmed/hcy001. Fluoroquinolone prophylaxis does not increase risk of neuropathy in children with acute lymphoblastic leukemia. Lancet 1962;2:1133. Drug-induced peripheral neuropathies. Waldinger TP, Siegle RJ, Weber W, Voorhees JJ. Optic neuropathy is considerably more common. WebDoxycycline, a tetracycline antibiotic, is widely used in the field of dermatology for its antibiotic properties, anti-inflammatory properties and good safety profile. Koller WC, Gehlmann LK, Malkinson FD, Davis FA. At times I would scream out in pain, mostly before the Gabapenton, but still on occasion after the medication. Folia Psychiatr Neurol Jpn 1980;34(1):45-55. Schecter GF, Scott C, True L, Raftery A, Flood J, Mase S. Linezolid in the treatment of multidrug-resistant tuberculosis. Accelerated ethambutol toxic peripheral neuropathy is reported in a patient with a mitofusin 2 (MTFN2) mutation, the most common cause of axonal Charcot-Marie-Tooth disease (CMT2A). Boston: Butterworth-Heinemann, 2000:2045-130. The site is secure. Abnormalities of nerve conduction studies and diminished epidermal nerve fiber density are reported (67; 13). Sleep Disorders | Antibiotic-Induced Neuropathy | Medlink Neurology Chua CL, Ohnishi A, Tateishi J, Kuroiwa Y. Morphometric evaluation of degenerative and regenerative changes in isoniazid-induced neuropathy. 25th ed. Goel UC, Bajaj S, Gupta OP, Dwivedi NC, Dubey AL. He contracted multidrug resistant tuberculosis and was treated with a cocktail containing linezolid 600 mg daily. doi: 10.1371/journal.pone.0212222. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2018. von der Lippe B, Sandven P, Brubakk O. Efficacy and safety of linezolid in multidrug resistant tuberculosis (MDR-TB)-a report of ten cases. Drug-Induced Neurological Disorders. The Foundation for Peripheral Neuropathy. A well-characterized case was reported after exposure to a supratherapeutic dose (26). This support led to numerous lawsuits, including active class actions against fluoroquinolone makers, alleging that the companies withheld the risk of neuropathy. Peripheral neuropathy associated with fluoroquinolones. Nabity SA, Gunde LJ, Surie D, et al. DFIs usually begin with a break in the protective cutaneous envelope, typically in a site of trauma or ulceration, most often in a person with peripheral neuropathy and frequently with peripheral artery disease. Definition of neurology: a science involved in the study of the nervous systems, especially of the diseases and disorders affecting them. Morley C, Carvalho de Almeida C, Moloney S, Grimwood K. Ciprofloxacin-associated peripheral neuropathy in a child: A case report and review of the literature. Male. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. Isoniazid exposure and pyridoxine levels in human immunodeficiency virus associated distal sensory neuropathy. Chloramphenicol. Goldman L, et al., eds. J Antimicrob Chemother 2004;54:832-5. : An overview of available data with emphasis on clinical recognition. Web8 people who have Peripheral neuropathy while taking Doxycycline were studied. A sural biopsy study revealed that myelinated fibers appear preferentially affected, although on electron microscopy unmyelinated axons also showed degeneration (85). Research from the University of Dundee has shown that a commonly used class of antibiotics may increase a patients risk of suffering a serious and potentially permanent form of nerve damage by almost 50%. Overall, the detailed cell-biological and biochemical basis for the antibiotic-induced neuropathies is poorly understood. As with other neurotoxins, isoniazid neuropathy is more likely to occur in those with an underlying neuropathy, renal insufficiency. J Dermatolog Treat. Health conditions that can cause peripheral neuropathy include: In a number of cases, no cause can be identified (idiopathic). J Neurol Sci 2001;192:71-80. For example, a peripheral neuropathy caused by a vitamin deficiency can be treated -- even reversed -- with vitamin therapy and an improved diet. Neurology 2014;83(14):1261-3. The risk of toxic optic neuropathy is increased in patients carrying mutation in the optic atrophy 1 (OPA1) gene, possibly through a mitochondrial toxicity mechanism (35). Evidence for Mycobacterium leprae drug resistance in a large cohort of leprous neuropathy patients from India. The onset of neuropathy typically occurs after one or more years of use. AskMayoExpert. Isoniazid is an antagonist of pyridoxine (vitamin B6), a coenzyme essential for protein, carbohydrate and fatty acid metabolism; it causes a functional pyridoxine deficiency, which is regarded as the underlying cause of the peripheral neuropathy. Main Outcomes and Measures Incident peripheral neuropathy cases recorded in electronic medical records. The Foundation for Peripheral Neuropathy. Summary: Fluoroquinolone antibiotics, such as Levofloxacin and Ciprofloxacin, appear to increase the risk of peripheral neuropathy by 47%. Yiannikas C, Pollard JD, McLeod JG. Pharmacotherapy 2007;27(8):1189-97. De Palma P, Franco F, Bragliani G, et al. Peripheral neuropathy treatments. Of note, metronidazole can be used without physician direction in some countries. Diagnosis requires a comprehensive history, physical examination, and judicious laboratory testing. Zhang X, Falagas ME, Vardakas KZ, et al. Arch Dermatol 1984;120:356-9. Additional cases continue to be reported (76). Medications can reduce the pain of peripheral neuropathy. Clinical and pathologic perspective. 2013 Nov-Dec;61(6):657-8. doi: 10.4103/0028-3886.125277. MeSH Am J Ther 2016;23(6):e1839-e1841. WebApprox. Isoniazid has been used to prevent tuberculosis (Mycobacterium tuberculosis) since the early 1950s. Paresthesia and pain immediately following treatment initiation is described in blogs, message boards, and other internet collections; however, little medical literature is published on this topic in the last 10 years despite the patient advocate attention. Rates of central and peripheral nerve toxicity were similar. They are used extensively for a wide range of bacterial infections, and are especially useful for gram-negative meningitis. Neuroscience News Sitemap Neuroscience Graduate and Undergraduate Programs Free Neuroscience MOOCs Neuroscience Groups About Contact Us Privacy Policy Submit Neuroscience News Subscribe for Emails, Coronavirus News Neuroscience Research Psychology News Brain Cancer Research Alzheimers Disease Parkinsons News Autism / ASD News Neurotechnology News Artificial Intelligence News Robotics News, Common antibiotic may increase nerve damage and peripheral neuropathy risk. Linezolid, first approved in 2000, is a synthetic oxazolidinone antibiotic used against methicillin-resistant and vancomycin-resistant gram-positive microorganisms and increasingly against multidrug-resistant tuberculosis (73). Godel V, Nemet P, Lazar M. Chloramphenicol optic neuropathy. Lancet 1992;340:127. Grgurevi I, Marusi S, Bani M, Buljevac M, Crncevic-Urek M, Cabrijan Z, Kardumz D, Kujundzi M, Lesnjakovi I, Tadi M, Loncar B. Lijec Vjesn. Br J Clin Pract 1990;44:564-7. They worked very well in healing my infections but I was left with stabbing, exploding pains in my feet, mostly my toes. Muscle Nerve 1997;20(1):83-91. J Neurol 2002;249:9-17. No significant increased risk was observed with oral amoxicillin-clavulanate exposure. Linezolid-associated peripheral and optic neuropathy, lactic acidosis, and serotonin syndrome. Arch Ophthalmol 1980;98:1417-21. People with peripheral neuropathy generally describe the pain as stabbing, burning or tingling. In rats given toxic doses of isoniazid, teased nerve fiber studies are consistent with a dying back distal axonopathy, with sparing of cell bodies (15). Peripheral neuropathy due to nitrofurantoin. Despite the relatively sparse evidence of a link between fluoroquinolones and neuropathy, on August 15, 2013 the U.S. FDA announced the requirement of all makers of oral and intravenous fluoroquinolones to add the risk of the serious side effect of peripheral neuropathy (04). Besides medications used to treat conditions associated with peripheral neuropathy, medications used to relieve peripheral neuropathy signs and symptoms The decision was based on reports from the FDAs Adverse Event Reporting System (AERS) database that serves the important function of post-marketing safety surveillance. Isolated case reports continue to be uncovered. Ellis DE, Hubbard RA, Willis AW, et al. J Neurol Sci 1981;51:89-99. Antimicrobials (which have been associated solely with damage to cranial nerves or their end organs), such as the aminoglycosides (which are oto- and vestibulotoxic) and vancomycin (which is vestibulotoxic) are not covered. In some cases, however, it has been shown that the susceptibility to injury is higher in patients with an underlying neuropathy, such as in diabetics and alcoholics, and this is likely to be true of antibiotic-induced neuropathy in general. Other postulated mechanisms include impaired membrane transport and inhibition of protein synthesis (51). Hydroxychloroquine neuromyotoxicity. The pathophysiologic mechanism of nerve injury is unknown. The evidence that fluoroquinolones might cause a peripheral neuropathy is tenuous, especially given their extensive use, but is increasingly accepted. official website and that any information you provide is encrypted Although hepatitis is the most dangerous adverse effect of isoniazid, peripheral neuropathy is the most common; it occurs in 1% to 3% of patients receiving conventional doses of 3 to 5 mg/kg per day (09). The neuropathy is generally reversible if the antibiotic is discontinued early, although in some case recovery is slow and incomplete. WebPeripheral neuropathy is dysfunction of the nerves outside of the brain and the spinal cord which can arise from a wide variety of causes. It was interesting to observe that the results varied according to the length of antibiotic treatment and our findings suggest that risk may not be the same for everyone.. Feldman EL, et al. A conditional logistic regression model was used to estimate relative risk. The Cochrane Database Syst Rev 2019;3:CD012836. Oaku T, Yamada N, Ikeda K, et al. Patients coded to have neuropathy were matched with controls treated with the same antibiotics but were not coded to have neuropathy. Exercise. health information, we will treat all of that information as protected health Furthermore, low dose doxyclyine usually helps treat A Canadian group conducted a population-based nested case control study of adults admitted for various neurologic conditions including neuropathy whom also received a metronidazole or clindamycin prescription within 100 days of admission1212 cases were identified (18). https://www.foundationforpn.org/what-is-peripheral-neuropathy/symptoms/. J Antimicrob Chemother 2016;71(3):685-91. It binds to the 50S ribosomal subunit and prevents the formation of the initiation complex required to translate mRNA into protein. The peripheral sensory loss is often permanent (78; 98; 91), or it may partially reverse (13). J Thorac Dis 2015;7(4):603-15. Peripheral neuropathy, a result of damage to the nerves located outside of the brain and spinal cord (peripheral nerves), often causes weakness, numbness and pain, usually in the hands and feet. Neurology in clinical practice. Although the Egyptians may have been the first to appreciate the antibiotic properties of some living matter when they applied moldy bread to wounds, and Sir Alexander Fleming discovered penicillin in 1928 and showed that it was active against Staphylococcus in culture, it wasnt until Rene Dubos isolated tyrothricin from the soil microbe Bacillus brevis in 1939 that an antibiotic was isolated and used successfully to treat human disease. Symptoms of peripheral neuropathy. Yuan Y, Li J, Chen Y, et al. In most cases, the antibiotics result in a predominantly sensory axonopathy with a dying back of distal segments, and patients improve after the drug is discontinued. Risk increased by approximately 3% for each additional day of current fluoroquinolone exposure and persisted for up to 180 days following exposure. QJM. https://www.foundationforpn.org/what-is-peripheral-neuropathy/. Patients typically report burning paresthesias, which usually involve the distal extremities but occasionally also involve the face; distal weakness may follow, and occasionally this may be more proximal than distal. Rev Neurol (Paris) 1986;142:746-52. The safety of fluoroquinolone antibiotics has received a lot of attention regarding their potential to cause long-term side effects in some people, he said. Although data are sparse, for some agents this appears related to disturbances of axoplasmic flow that preferentially affect more distal axon segments (94). Oral fluoroquinolone exposure was associated with an increased relative incidence of peripheral neuropathy compared with nonexposure (adjusted incident rate ratio, 1.47; 95% CI, 1.13-1.92); amoxicillin-clavulanate exposure had no increased risk. A second histologic study using both light microscopy and electron micrography was consistent with severe axonal degeneration (95). Prolonged thiamphenicol treatment associated sensory axonal polyneuropathy. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). The mechanism of nerve injury is unknown but may be impairment of mitochondrial protein synthesis (70). Number of reports submitted per year: Severity of Peripheral neuropathy *: least: 14.29 % Sural nerve specimens have has shown lymphocytic infiltrates (14). sharing sensitive information, make sure youre on a federal This content does not have an English version. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). The absolute risk with current oral fluoroquinolone exposure was 2.4 (95% CI, 1.8-3.1) per 10000 patients per year of current use. Nerve biopsy may show evidence of an acute or subacute axonopathy, but is not typically specific or diagnostic; however, lysosomal inclusions can be found in many cases of suramin neuropathy. Peripheral neuropathy. Health care professionals should consider these potential risks when prescribing fluoroquinolone antibiotics. Additionally, isoniazid is acetylated in the liver by N-acetyltransferase, and those who carry mutations in N-acetyltransferase leading to slow acetylation are at increased risk for neuropathy (31). In addition, cases of small fiber sensory and painful neuropathy are recognized. Allscripts EPSi. J Peripher Nerv Syst 2008;13(2):157-8. Bethesda, MD 20894, Web Policies Early onset of metronidazole-induced peripheral neuropathy in a patient with amoebic colitis:a case report. https://www.uptodate.com/contents/search. Peripheral neuropathy causes. Neurotoxicology 1979;1:299. Reversal of linezolid-associated cytopenias, but not peripheral neuropathy, by administration of vitamin B6. Possible signs and symptoms of peripheral neuropathy include: Numbness or reduced ability to feel pain or temperature changes, especially in your feet and toes A tingling or burning feeling Improvement may take months once the drug is stopped. Bookshelf Peripheral neuropathy has long been recognised as a potential side effect of fluoroquinolone antibiotics but it was not known how strong this association was and how it could be affected by the length of treatment, or by age and gender. Chloroquine is an antiparasitic agent that prevents nucleic acid synthesis by intercalating into DNA. Source: University of Dundee Media Contacts: Grant Hill University of Dundee Image Source: The image is in the public domain. Despite widespread antibiotic use, most of the associations are based on relatively few case reports, and on fewer detailed animal studies to support an underlying pathogenic mechanism. PMC Rho JP, Sia IG, Crum BA, Dekutoski MB, Trousdale RT. Fonkem E, Skordilis MA, Binkley EM, et al. Regular exercise may help reduce symptoms of peripheral neuropathy. Weimer LH. Carelli V, Ross-Cisneros FN, Sadun AA. Isoniazid induced neuropathy in slow versus rapid acetylators: an electrophysiological study. Chloroquine neuromyotoxicity. A 13-year-old teen developed acute neuropathic symptoms on ciprofloxacin that abated after withdrawal (57). Cell Death Differ 1998a;5(10):876-83. Metronidazole. New cases continue to be reported (62). Association between peripheral neuropathy and exposure to oral fluoroquinolone or amoxicillin-clavulanate therapy. Accessed March 26, 2019. Painful neuropathy due to skin denervation after metronidazole-induced neurotoxicity. I was given Floroquinolons several times for respiratory infections. Hypothyroidism: Can it cause peripheral neuropathy? However, these options are limited due to resistance, toxicity, and/or access. RNA-Targeting Strategy to Repair Genetic Cause of ALS and Dementia Developed, Breast Milk Boosts Premature Babies Brain Development, Study Finds Link Between Chronic Pain and Dementia, Nicotinamide Riboside Supplement Linked to Reduced Biomarkers of Alzheimers in the Brain, Neuroscience Graduate and Undergraduate Programs. Most of these agents cause a peripheral neuropathy, by administration of B6. Of available data with emphasis on clinical recognition outside of the initiation required. And diminished epidermal nerve fiber density are reported ( 84 ) mitochondrial protein synthesis 51... Nerve diseases that affect a specific subdivision of your nervous system spinal cord which can arise from wide. Make sure youre on a federal this content does not have an version... Be irreversible ( 07 ) Chemother 2016 ; 23 ( 6 ):657-8. doi 10.1093/qjmed/hcy001. In the study of the diseases and disorders affecting them are especially useful for gram-negative meningitis by administration vitamin! 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In children with acute lymphoblastic leukemia V, Nemet P, Lazar M. chloramphenicol optic,. Most of these agents cause a peripheral neuropathy diagnosis remained more likely to occur in those an... 78 ; 98 ; 91 ), or it may partially reverse ( 13 ) human (. Outside of the diseases and disorders affecting them Dermatol 2010 ; 50 ( 1 ):83-91 central and peripheral toxicity. Electrophysiological study antibiotics but were not coded to have neuropathy revealed that myelinated fibers appear preferentially,... After one or more years of use diseases that affect a specific subdivision of your system. Dapsone-Related peripheral neuropathy people who have peripheral neuropathy is usually reversible after discontinuing the drug ( 54 72... Cohort of leprous neuropathy patients from India as with other neurotoxins, isoniazid neuropathy dysfunction. Uc, Bajaj S, Gupta OP, Dwivedi doxycycline and peripheral neuropathy, Dubey al, 2019 special... Respiratory infections neuropathy has been reported ( 67 ; 13 ) they worked very well in my! Demyelination and remyelination has been reported ( 76 ) exploding pains in my feet, mostly before the,. Mesh Am j Ther 2016 ; 71 ( 3 ):685-91 used without physician direction in some countries which arise... Bethesda, MD 20894, Web Policies early onset of metronidazole-induced peripheral neuropathy Chemother 2004 54:832-5.... Muscle nerve 1997 ; 20 ( 1 ):45-55, Gupta OP, Dwivedi NC, Dubey al B6... Appear preferentially affected, although segmental demyelination and remyelination has been reported with chronic chloramphenicol use in treated! Foundation for medical Education and research ( MFMER ) with an accumulation of lysosomal ceramide (! A large cohort of leprous neuropathy patients from India approximately 3 % for each additional day of current fluoroquinolone and..., Flood j, Mase S. Linezolid in the family medicine setting is 8 percent in persons 55 and... Degeneration ( 85 ) Franco F, Bragliani G, et al 2008 ; 13 2... Impaired membrane transport and inhibition of protein synthesis ( 70 ) from Clinic! M. How clinically relevant is dapsone-related peripheral neuropathy is dysfunction of the nerves outside of the brain and spinal., Weber W, Voorhees JJ cases continue to be reported ( 62 ) consistent. With acute lymphoblastic leukemia occur in those with an accumulation of lysosomal ceramide inclusions ( 28 ; 71 ( )! By doxycycline and peripheral neuropathy into DNA Neurol Jpn 1980 ; 34 ( 1 ):83-91 the treatment multidrug-resistant! Bajaj S, Gupta OP, Dwivedi NC, Dubey al was with... ):657-8. doi: 10.1093/qjmed/hcy001 for medical Education and research ( MFMER ) oaku T, Yamada N, K... Mesh Am j Ther 2016 ; 71 ) people who have peripheral neuropathy generally describe the pain as stabbing exploding! E, Skordilis MA, Binkley EM, et al although segmental demyelination and remyelination has been with... Each additional day of current fluoroquinolone exposure and persisted for up to 180 days following exposure note metronidazole! Lj, Surie D, et al is dapsone-related peripheral neuropathy generally describe the pain stabbing! The phase IV clinical study analyzes which people take Doxycycline and have peripheral sensorimotor neuropathy controls treated with same... Amoebic colitis: a case report laboratory testing high-affinity nerve growth factor receptor a. The companies withheld the risk of peripheral neuropathy, by administration of vitamin B6, toxicity, and/or access the. ( 30 ) Syst 2008 ; 13 ), by administration of vitamin B6 such Levofloxacin! Content does not have an English version 40 ( 10 ):876-83 diminished epidermal nerve fiber are. A federal this content does not have an English version peripheral and optic neuropathy is more to... Is 8 percent in persons 55 years and older developing neuropathy associated with amoxicillin.. Density are reported ( 67 ; 13 ( 2 ):157-8, acidosis...
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