Case Report: Lactation Ketoacidosis Can Complicate the Ketogenic Diet.

INTRODUCTION: Ketoacidosis is a metabolic condition caused by the buildup of ketone bodies. The most common causes are diabetes, alcoholism, and starvation. This is a case of a lactating mother on a ketogenic diet who developed a community-acquired pneumonia and then went into life-threatening ketoacidosis. CASE PRESENTATION: A 32-year-old, lactating, 8-week-postpartum woman presented to the hospital complaining of nausea, vomiting, rhinorrhea, and cough. She had no history of diabetes or of alcohol or drug use but reported following a ketogenic diet and was found to have a pneumonia. The pneumonia was treated with antibiotics, and the acidosis resolved with a dextrose solution. CONCLUSION: We report the case of a mother who, while lactating and losing weight on a ketogenic diet, developed a pneumonia and then went into ketoacidosis. Physicians should be aware that patients on the ketogenic diet are at risk for life-threatening acidosis, especially if they develop a second and/or third stressor or energy requirement on top of the low-carbohydrate diet. This case and those reviewed in the literature indicate that ketogenic diets may not be safe during lactation and could be associated with increased morbidity.

Tighter Blood Pressure Control Is Associated with Lower Incidence of Erectile Dysfunction in Hypertensive Men.

INTRODUCTION: Tighter blood pressure control is widely thought to be associated with better erectile function, although the preponderance of data is limited to dichotomous representations of hypertension without an attempt to look at degree of blood pressure control. AIM: To determine the association between optimal blood pressure control over time and the development of erectile dysfunction (ED) in a cohort of potent men. METHODS: We performed a retrospective cohort study of newly diagnosed hypertensive men without major medical comorbidities in an integrated healthcare system. Patients were stratified by exposure to hypertension, with varying levels of blood pressure control, as measured by ordinal categories of systolic blood pressure and deviation from the mean systolic pressure. MAIN OUTCOME MEASURES: Incidence of ED was defined by at least 2 primary care or urology diagnoses of ED in our electronic health records within 2 years, at least 2 filled prescriptions for ED medications within 2 years, or 1 diagnosis of ED and 2 filled prescriptions for ED medications. RESULTS: We identified 39,320 newly diagnosed hypertensive men. The overall incidence for ED was 13.9%, with a mean follow-up of 55.1 ± 28.7 months. Higher average systolic blood pressure was associated with a higher risk of ED in a dose-dependent manner (trend test, P < .001). Wide variation in blood pressure control was associated with a higher incidence of ED (OR [95% CI]; 1.359 [1.258-1.469]) and a shorter time to the development of ED (log rank, P < .0001). CLINICAL IMPLICATIONS: We believe these data may serve as a motivator for hypertensive men to better adhere to their hypertension treatment regimen. STRENGTH & LIMITATIONS: The retrospective nature of our study precludes us from drawing more than an association between tighter blood pressure control and ED. Strengths of our study include the large sample size, community cohort, and completeness of follow-up. CONCLUSION: Among adults diagnosed with hypertension, tighter blood pressure control, as measured by average systolic blood pressure and deviation from the average, is associated with a lower incidence and a longer time to the development of ED. Hsiao W, Bertsch RA, Hung Y-Y, et al. Tighter Blood Pressure Control Is Associated with Lower Incidence of Erectile Dysfunction in Hypertensive Men. J Sex Med 2019;16:410-417.

Study of the Use of Lipid Panels as a Marker of Insulin Resistance to Determine Cardiovascular Risk.

CONTEXT: When assessing the lipid panel, practical physicians tend to focus on the low-density lipoprotein cholesterol (LDL-c). However, an elevated triglyceride/high-density lipoprotein cholesterol (HDL-c) ratio, suggesting insulin resistance, also effectively predicts cardiovascular outcomes but requires different treatments than an elevated LDL-c. We tested whether high triglyceride/HDL-c ratios are associated with more risk than high LDL-c concentrations or other lipid markers of atherogenicity. METHODS: We followed 103,646 members aged 50 to 75 years without cardiovascular disease or diabetes in a community health plan. Subjects were categorized as insulin sensitive or insulin resistant on the basis of triglyceride and HDL-c in the index year. The primary outcome was ischemic heart disease. The percentage of subjects with a primary outcome after 8 years was stratified by insulin category, lipid measures, and blood pressure. Hazard ratios (HR) for insulin resistance, LDL-c, age, sex, and the presence of hypertension were determined in a multivariate analysis. RESULTS: Subjects with insulin resistance but lipid measures healthier than the median had worse outcomes than those who were insulin sensitive but had unhealthier lipid measures such as non-HDL-c and the ratios of total cholesterol/HDL-c and LDL-c/HDL-c. The HR for a 60 mg/dL increase in LDL-c was 1.14 (95% confidence interval [CI], 1.10-1.18); the HR for an LDL-c greater than 160 mg/dL was 1.19 (95% CI, 1.12-1.28). In contrast, the hazard ratio for having an insulin-resistant triglyceride/HDL-c ratio was 1.68 (95% CI, 1.57-1.80), compared with an insulin-sensitive ratio. There was no difference in outcomes between insulin-resistant but normotensive patients and insulin-sensitive but hypertensive patients. CONCLUSION: Insulin resistance, as manifested by a high triglyceride/HDL-c ratio, was associated with adverse cardiovascular outcomes more than other lipid metrics, including LDL-c, which had little concordance. Physicians and patients should not overlook the triglyceride/HDL-c ratio.