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What Is Starvation Ketosis?

Ketosis, The Weight-loss Key To The Atkins Diet, Does Work, But At A Price

Ketosis, The Weight-loss Key To The Atkins Diet, Does Work, But At A Price

Robert Atkins’ contentious death cast doubt on his already-controversial namesake diet. But he was onto something, apparently, because aspects of his high-fat regimen live on. Ketosis, a low-carb eating plan, promises to make people really thin, really quickly. Going keto is now a fad diet of its very own — look how good LeBron James looks! — despite concerns about its safety. In the world of crash diets, instant gratification is king, and ketosis appears to deliver rapid weight loss at full speed. That is, if you’re willing to take the risks. Phase one of the Atkins Diet had banked on ketosis, the body’s so-called “fat-burning” mode, which seemed to live up to the hype. Under normal conditions, the body fuels itself by burning up carbohydrates, fats, and protein, in that order. That’s because the simple sugars contained in pasta, rice, and sugar are easier molecules to break down. But if your body has no linguine to digest and is desperate for game fuel, it has no choice but to burn up the fat you’ve got on hand (or on love handles). And isn’t that the weight-loss dream? But ketosis is so-named because going low-carb causes the liver to break down fats into molecules called ketones, which can also be used a fuel source. The problem is, having too many ketones floating around can be dangerous. Diabetics unable to control their insulin levels can enter a state called ketoacidosis, when the buildup of ketones causes the blood to become dangerously acidic, which in turn messes with your organs. (At this point, ketones spill over into the urine, giving it a characteristic fruity smell. The term diabetes mellitus roughly means “pissing honey.”) Supporters of the Atkins Diet contend that the amount of ketones present in the blood during ketosis isn’t Continue reading >>

The Difference Between Ketosis And Ketoacidosis

The Difference Between Ketosis And Ketoacidosis

When you hear these two terms it’s easy to see how they can be confused. The confusion also stems from the fact that the two are both metabolic processes involving the breakdown of fats in the body (plus they look and sound like similar words). The truth is ketosis and ketoacidosis are two completely different things. Ketosis and the Ketogenic Diet Ketosis is a normal metabolic process in which the body has a high fat-burning rate. It is a healthy and natural state your body enters when your body is running on fat rather than glucose1. The state of ketosis occurs when ketone levels are raised in the blood due to the conversion of fats into fatty acids and ketones. This happens when the body runs out of carbohydrates – usually because a person hasn’t eaten in a while, for example during fasts, or they eat a very low-carbohydrate diet – leaving little sugar to convert into glycogen. Without glycogen, the body breaks down fat cells for energy. A low-carb, high fat diet, also known as a ketogenic diet, is necessary to enter and stay in ketosis long-term. When you eat a low-carbohydrate diet, your body enters the metabolic state of ketosis within 2 days but it can vary from person to person. There are many benefits2 to being in longer-term ketosis including: lowered triglycerides levels no spikes in blood glucose levels greater mental clarity lowered blood pressure and cholesterol reduced food and sugar cravings weight loss Ketoacidosis – The Body in a State of Toxicity Ketoacidosis is a metabolic state of toxicity. It occurs when the body fails to regulate ketone production resulting in severe accumulation of keto acids which cause the pH of the blood to decrease substantially making the blood more acidic. The most common causes for ketoacidosis are Type 1 Diabete Continue reading >>

Starvation Ketoacidosis: A Cause Of Severe Anion Gap Metabolic Acidosis In Pregnancy

Starvation Ketoacidosis: A Cause Of Severe Anion Gap Metabolic Acidosis In Pregnancy

Abstract Pregnancy is a diabetogenic state characterized by relative insulin resistance, enhanced lipolysis, elevated free fatty acids and increased ketogenesis. In this setting, short period of starvation can precipitate ketoacidosis. This sequence of events is recognized as "accelerated starvation." Metabolic acidosis during pregnancy may have adverse impact on fetal neural development including impaired intelligence and fetal demise. Short periods of starvation during pregnancy may present as severe anion gap metabolic acidosis (AGMA). We present a 41-year-old female in her 32nd week of pregnancy, admitted with severe AGMA with pH 7.16, anion gap 31, and bicarbonate of 5 mg/dL with normal lactate levels. She was intubated and accepted to medical intensive care unit. Urine and serum acetone were positive. Evaluation for all causes of AGMA was negative. The diagnosis of starvation ketoacidosis was established in absence of other causes of AGMA. Intravenous fluids, dextrose, thiamine, and folic acid were administered with resolution of acidosis, early extubation, and subsequent normal delivery of a healthy baby at full term. Rapid reversal of acidosis and favorable outcome are achieved with early administration of dextrose containing fluids. Discover the world's research 14+ million members 100+ million publications 700k+ research projects Join for free Starvation Ketoacidosis: A Cause of Severe Anion Gap Metabolic Nupur Sinha, Sindhaghatta Venkatram, and Gilda Diaz-Fuentes Division of Pulmonary and Critical Care Medicine, Bronx Lebanon Hospital Center and Albert Einstein College of Medicine, Correspondence should be addressed to Nupur Sinha; [email protected] Received  February ; Revised  May ; Accepted  May ; Published Continue reading >>

The Difference Between Fasting And Starvation

The Difference Between Fasting And Starvation

The big misconception about fasting and starvation is that theyre the same thing. Although they might seem very similar, theyre actually distinctive metabolic states. Theres quite a significant difference between them. Theyre almost like day and night. The Difference Between Fasting and Starvation Fasting is the complete abstention from food in any shape or form. Usually, people still drink water and other non-caloric beverages . Its voluntary and controlled. Youve planned it and are doing it because youve decided to do so. Starvation, on the other hand, is described as the absence of essential nutrients that could support the life of an organism. Whenever the body cant get access to fuel or has run out of it, then it begins to slowly die and waste away. This is irrational and involuntary. Its forced upon and not something you choose. The difference between fasting and starvation is like the difference between suicide and dying of old age. One is deliberate and carefully orchestrated, whereas the other is something that simply happens to you without you being able to do anything about it. Of course, here fasting resembles suicide because its self-imposed, but its not going to end with death. The idea remains. Abstention from food is the art of manipulating our metabolic system and can be done for many reasons. Malpractice might look like the person is starving, but if done correctly its very healthy and good for you. Our body can only be in 2 metabolic states Fasted meaning that there are no exogenous calories consumed at all. Fed there is some food circulating the bloodstream. Even consuming small amounts of food will put you into a fed state. It doesnt matter whether you eat 200 calories or 1000, youll still inhibit autophagy and be shifted out of a fasted state. Tha Continue reading >>

Ketosis Vs. Ketoacidosis: Understanding The Differences

Ketosis Vs. Ketoacidosis: Understanding The Differences

Introduction to Ketosis vs Ketoacidosis Historically, ketosis has been one of the most vaguely defined and poorly understood concepts of the last century. There are different scenarios in which are body can be in a state of ketosis (including ketoacidosis). The most basic definition of ketosis is a general increase in blood levels of ketone bodies to 0.5 mmol or above. However, the reasons for the development of ketosis, the resultant levels of blood ketones, and the associated outcomes (health versus possible death) differ drastically between different situations of ketosis. Failure to understand the differences between various incidents of ketosis has led to the common misconceptions we have today that ultimately has made educating the masses on the ketogenic diet difficult. The single most important take home from this article should be that diabetic ketoacidosis is not the same as the ketosis experienced from a ketogenic diet. Diabetic Ketoacidosis Whenever I speak about ketogenic dieting, almost inevitably I am asked the question: “But shouldn’t you be worried about going into a state of ketoacidosis?” Ketoacidosis occurs when the formation ketone bodies are uncontrolled (15-25 mmol) and acidity in the blood increases (1). It is important to understand that our body regulates blood acid concentrations tightly. We typically measure blood acidity vs. alkalinity using the pH scale. If your blood’s pH is less than 7 it is acidic, and if greater it is basic, or alkaline. Our blood is usually slightly alkaline with a pH ranging from 7.35 to 7.45. Any deviation up or down from the norm by even the smallest amount can prove fatal! The most common form of ketoacidosis to occur is known as diabetic ketoacidosis. This usually occurs in type I diabetics but can also oc Continue reading >>

Ketosis Explained – For Weight Loss, Health Or Performance

Ketosis Explained – For Weight Loss, Health Or Performance

Get Started Ketosis is a natural state for the body, when it is almost completely fueled by fat. This is normal during fasting, or when on a strict low-carb diet. Ketosis has many potential benefits, but there are also side effects. In type 1 diabetes and certain other rare situations excessive ketosis can even become dangerous. On this page you can learn all about how to harness the benefits of ketosis, while avoiding any problems. It all starts with understanding what ketosis is. Choose a section, or keep reading below for all of them. Ketosis ExplainedKetosis Explained BenefitsBenefits How to Get Into KetosisHow to Get Into Ketosis Ketosis ExplainedSymptoms & How to Know You’re In Ketosis Side Effects, Fears & Potential DangersSide Effects, Fears & Potential Dangers How to Reach Optimal KetosisHow to Reach Optimal Ketosis ketones Ketosis Explained The “keto” in the word ketosis comes from the fact that it makes the body produce small fuel molecules called “ketones”.1 This is an alternative fuel for the body, used when blood sugar (glucose) is in short supply. Ketones are produced if you eat very few carbs (that are broken down into blood sugar) and only moderate amounts of protein (excess protein can be converted to blood sugar). Ketones are produced in the liver, from fat. They are then consumed as fuel in the body, including by the brain. This is important as the brain is a hungry organ that consumes lots of energy every day,2 and it can’t run on fat directly. It can only run on glucose… or ketones. Maximizing fat burning On a ketogenic diet your entire body switches its fuel supply to run almost entirely on fat. Insulin levels become very low and fat burning increases dramatically. It becomes easy to access your fat stores to burn them off. This is o Continue reading >>

Ketosis In An Evolutionary Context

Ketosis In An Evolutionary Context

Humans are unique in their remarkable ability to enter ketosis. They’re also situated near the top of the food chain. Coincidence? During starvation, humans rapidly enter ketosis; they do this better than king penguins, and bears don’t do it at all. Starvation ketosis Humans maintain a high level of functionality during starvation. We can still hunt & plan; some would even argue it’s a more finely tuned state, cognitively. And that’s important, because if we became progressively weaker and slower, chances of acquiring food would rapidly decline. Perhaps this is why fasting bears just sleep most of the time: no ketones = no bueno..? Animals with a low brain/carcass weight ratio (ie, small brain) don’t need it. Babies and children have a higher brain/carcass weight ratio, so they develop ketosis more rapidly than adults. Is this a harmful process? No, more likely an evolutionary adaptation which supports the brain. The brain of newborn babies consumes a huge amount of total daily energy, and nearly half comes from ketones. A week or so later, even after the carbohydrate content of breast milk increases, they still don’t get “kicked out of ketosis” (Bourneres et al., 1986). If this were a harmful state, why would Nature have done this? …and all those anecdotes, like babies learn at incredibly rapid rates… coincidence? Maybe they’re myths. Maybe not. Ketosis in the animal kingdom Imagine a hibernating bear: huge adipose tissue but small brain fuel requirement relative to body size and total energy expenditure. No ketosis, because brain accounts for less than 5% of total metabolism. In adult humans, this is around 19-23%, and babies are much higher (eg, Cahill and Veech, 2003 & Hayes et al., 2012). For the rest of this article and more, head over to Pat Continue reading >>

A Rare Cause Of Metabolic Acidosis: Ketoacidosis In A Non-diabetic Lactating Woman

A Rare Cause Of Metabolic Acidosis: Ketoacidosis In A Non-diabetic Lactating Woman

Gordon Sloan1, Amjad Ali1 and Jonathan Webster1[1] Department of Diabetes and Endocrinology, Sheffield Teaching Hospital, Sheffield, UK Summary Ketoacidosis occurring during lactation has been described infrequently. The condition is incompletely understood, but it appears to be associated with a combination of increased metabolic demands during lactation, reduction in carbohydrate intake and acute illness. We present a case of a 27-year-old woman, 8 weeks post-partum, who was exclusively breastfeeding her child whilst following a low carbohydrate diet. She developed gastroenteritis and was unable to tolerate an oral diet for several days. She presented with severe metabolic acidosis on admission with a blood 3-hydroxybutyrate of 5.4 mmol/L. She was treated with intravenous dextrose and intravenous sodium bicarbonate, and given dietary advice to increase her carbohydrate intake. She made a rapid and full recovery. We provide a summary of the common causes of ketoacidosis and compare our case with other presentations of lactation ketoacidosis. Learning points: Ketoacidosis in the lactating woman is a rare cause of raised anion gap metabolic acidosis. Low carbohydrate intake, starvation, intercurrent illness or a combination of these factors could put breastfeeding women at risk of ketoacidosis. Ketoacidosis in the lactating woman has been shown to resolve rapidly with sufficient carbohydrate intake and intravenous dextrose. Early diagnosis and prompt treatment are essential because the condition is reported to be reversible with a low chance of recurrence with appropriate dietary advice. Background Ketoacidosis is a common cause of raised anion gap metabolic acidosis. It most frequently occurs in individuals with type 1 diabetes. Starvation commonly causes ketosis but ra Continue reading >>

Pancreatic Ketoacidosis (kabadi Syndrome): Ketoacidosis Induced By High Circulating Lipase In Acute Pancreatitis

Pancreatic Ketoacidosis (kabadi Syndrome): Ketoacidosis Induced By High Circulating Lipase In Acute Pancreatitis

Broadlawns Medical Center, Des Moines University, Des Moines, Iowa and University of Iowa, Iowa City, Iowa, USA. *Corresponding Author: 17185, Berkshire Parkway Clive, Iowa, 50325, USA Phone +5152823041 E-mail [email protected] Visit for more related articles at JOP. Journal of the Pancreas Abstract Introduction Ketoacidosis is well established as a metabolic complication of both type 1 and type 2 diabetes Mellitus (Diabetic Ketoacidosis). It is often an initial presentation of type 1 diabetes in children and adolescents and occasionally in adults. Alternatively, it is induced of an onset of an acute disorder, e. g, sepsis, myocardial infarction, stroke, pregnancy etc. in subjects with type 1 and 2 diabetes. Ketoacidosis is also known to occur following an ethanol binge (Alcoholic Ketoacidosis). Finally, ketonemia with a rare progression to Ketoacidosis is documented to ensue following prolonged starvation. Methods The review of English literature for over 35 years from 01/1980 till 12/2015 for terms, 'ketonemia, ketonuria and ketoacidosis' 'pancreatic lipase' and 'acute pancreatitis'. Results 1) Description of individual patients presented as case reports, 2) Documentation of a series of consecutive subjects hospitalized for management of acute pancreatitis with special attention to establishing the prevalence of the disorder as well as examining the relationship between the severity of the disorder and occurrence of Ketoacidosis, 3) Studies demonstrating the relationship between progressively rising circulating pancreatic lipase concentrations with ketonuria, ketonemia and Ketoacidosis in subjects presenting with acute pancreatitis irrespective of the etiology and documenting resolution of ketonuria, ketonemia and ketoacidosis following the declining serum lipase leve Continue reading >>

Starvation Ketoacidosis As A Cause Of Unexplained Metabolic Acidosis In The Perioperative Period

Starvation Ketoacidosis As A Cause Of Unexplained Metabolic Acidosis In The Perioperative Period

Go to: Abstract Patient: Female, 24 Final Diagnosis: Starvation ketoacidosis Symptoms: None Medication: — Clinical Procedure: Lumbar laminectomy Specialty: Orthopedics and Traumatology Besides providing anesthesia for surgery, the anesthesiologist’s role is to optimize the patient for surgery and for post-surgical recovery. This involves timely identification and treatment of medical comorbidities and abnormal laboratory values that could complicate the patient’s perioperative course. There are several potential causes of anion and non-anion gap metabolic acidosis in surgical patients, most of which could profoundly affect a patient’s surgical outcome. Thus, the presence of an acute acid-base disturbance requires a thorough workup, the results of which will influence the patient’s anesthetic management. An otherwise-healthy 24-year-old female presented for elective spine surgery and was found to have metabolic acidosis, hypotension, and polyuria intraoperatively. Common causes of acute metabolic acidosis were investigated and systematically ruled out, including lactic acidosis, diabetic ketoacidosis, drug-induced ketoacidosis, ingestion of toxic alcohols (e.g., methanol, ethylene glycol), uremia, and acute renal failure. Laboratory workup was remarkable only for elevated serum and urinary ketone levels, believed to be secondary to starvation ketoacidosis. Due to the patient’s unexplained acid-base disturbance, she was kept intubated postoperatively to allow for further workup and management. Starvation ketoacidosis is not widely recognized as a perioperative entity, and it is not well described in the medical literature. Lack of anesthesiologist awareness about this disorder may complicate the differential diagnosis for acute intraoperative metabolic acidosi Continue reading >>

Starvation Ketoacidosis

Starvation Ketoacidosis

Eating disorders, prolonged fasting, severely calorie-restricted diets, restricted access to food (low socioeconomic and elderly patients) may be causes of starvation ketoacidosis. When insulin levels are low and glucagon levels are high (such as in a fasting state), long chain fatty acids and glycerol from triglycerides are released from peripheral fat stores and are transported to the liver. The fatty acids undergo beta-oxidation and generate acetyl-CoA. However, with excessive amounts of acetyl-CoA, the Krebs cycle may become oversaturated, and instead the acetyl-CoA enter the ketogenic pathway resulting in production of ketone bodies. Mild ketosis (1mmol/L) results after fasting for approximately 12 to 14 hours. However, the ketoacid concentration rises with continued fasting and will peak after 20 to 30 days (8-10mmol/L). Clinical Features Nausea and vomiting Abdominal pain Dehydration Altered mental status Fatigue Kussmaul breathing Differential Diagnosis Evaluation Serum chemistry (elevated anion gap) Glucose (usually euglycemic or hypoglycemic) Urinalysis (ketonuria) Serum beta-hydroxybutyrate Lactate Salicylate level (if overdose suspected) Serum osmolality (if toxic alcohol ingestion suspected) Management Dextrose and saline solutions Dextrose Will cause increase in insulin and decrease in glucagon secretion, which will reduce ketone production and increase ketone metabolism Beta-hydroxybutyrate and acetoacetate will regenerate bicarbonate, causing partial correction of metabolic acidosis Saline or lactated ringer Will provide volume resuscitation and will in turn reduce secretion of glucagon (which promotes ketogenesis) Considerations Rate of infusion dependent on volume status If hypokalemic, need to correct before administering glucose (as glucose stimulate Continue reading >>

Ketosis & Measuring Ketones

Ketosis & Measuring Ketones

Generally, ketone concentrations are lower in the morning and higher in the evening. Whatever time you pick to measure ketone levels, make sure to keep it consistent. Also, do not measure your ketone levels right after exercise. Ketone levels tend to be lower while your glucose levels higher so you won't get representative numbers. Keep in mind there are daily fluctuations caused by changes in hormone levels. Don't get discouraged! Another aspect that affects the level of ketones is the amount of fat in your diet. Some of you may show higher concentration of ketones after a high-fat meal. Coconut oil contains MCTs that will help you boost ketones. To easily increase your fat intake on a ketogenic diet, try fat bombs - snacks with at least 80% fat content. Ketone levels tend to be higher after extensive aerobic exercise as your body depletes glycogen stores. Exercise may help you get into ketosis faster. ketogenic "fruity" breath is not pleasant for most people. To avoid this, drink a lot of water, mint tea and make sure you eat foods rich in electrolytes. Avoid too many chewing gums and mints, as it may put you out of ketosis; there may be hidden carbs affecting your blood sugar. Increase your electrolyte intake, especially potassium. You are likely going to lose some sodium and potassium when switching to the keto diet. Finally, if you find it hard to lose weight on a ketogenic diet, there may be plenty other reasons than the level of ketone bodies: Not Losing Weight on Low-Carb Ketogenic Diet? Don’t Give Up and Read Further. Continue reading >>

Starvation Ketoacidosis In Pregnancy

Starvation Ketoacidosis In Pregnancy

Introduction: Starvation ketosis outside pregnancy is a rare phenomenon and is unlikely to cause a severe acidosis. Pregnancy is an insulin resistant state due to placental production of hormones including glucagon and human placental lactogen. Insulin resistance increases with advancing gestation and this confers a susceptibility to ketosis, particularly in the third trimester. Starvation ketoacidosis in pregnancy has been reported and is usually precipitated by a period of severe vomiting. Ketoacidosis has been associated with intrauterine death. Case report: A 22-year-old woman in her third pregnancy presented at 32 weeks gestation with a 24 h history of severe vomiting. She had been treated for an asthma exacerbation with prednisolone and erythromycin the day prior to presentation. She was unwell, hypertensive (145/70 mmHg) with a sinus tachycardia and Kussmaul breathing. Urinalysis showed ++++ ketones, + protein and pH 5. Fingerprick glucose was 4 mmol/l and ketones were 4.0 mmol/l. Arterial blood gas showed pH 7.27, PaCO2 1.1 kPa, base excess −23, bicarbonate 8.6 mmol/l and lactate 0.6 mmol/l. The anion gap was 20. Serum ethanol, salicylates and paracetamol levels were undetectable. She was fluid resuscitated but her biochemical parameters did not improve. She was intubated and underwent emergency caesarean section. A healthy boy was delivered and her acidosis resolved over the subsequent 8 h. Discussion: We believe this case is explained by starvation ketoacidosis. There was no evidence of diabetes mellitus or other causes of a metabolic acidosis. In view of the hypertension, proteinuria and raised urate the differential diagnosis was an atypical presentation of pre-eclampsia. This case illustrates the metabolic stress imposed by the feto-placental unit. It als Continue reading >>

Metabolism And Ketosis

Metabolism And Ketosis

Dr. Eades, If the body tends to resort to gluconeogenesis for glucose during a short-term carbohydrate deficit, are those who inconsistently reduce carb intake only messing things up by not effecting full blown ketosis? If the body will still prefer glucose as main energy source unless forced otherwise for at least a few days, is it absolutely necessary to completely transform metabolism for minimal muscle loss? Also, if alcohol is broken down into ketones and acetaldehyde, technically couldn’t you continue to drink during your diet or would the resulting gluconeogenesis inhibition from alcohol lead to blood glucose problems on top of the ketotic metabolism? Would your liver ever just be overwhelmed by all that action? I’m still in high school so hypothetical, of course haha… Sorry, lots of questions but I’m always so curious. Thank you so much for taking the time to inform the public. You’re my hero! P.S. Random question…what’s the difference between beta and gamma hydroxybutyric acids? It’s crazy how simple orientation can be the difference between a ketone and date rape drug…biochem is so cool! P.P.S. You should definitely post the details of that inner mitochondrial membrane transport. I’m curious how much energy expenditure we’re talkin there.. Keep doin your thing! Your Fan, Trey No, I don’t think people are messing up if they don’t get into full-blown ketosis. For short term low-carb dieting, the body turns to glycogen. Gluconeogenesis kicks in fairly quickly, though, and uses dietary protein – assuming there is plenty – before turning to muscle tissue for glucose substrate. And you have the Cori cycle kicking in and all sorts of things to spare muscle, so I wouldn’t worry about it. And you can continue to drink while low-carbing. Continue reading >>

Renal Fellow Network: Starvation Ketosis: A Rare Cause Of Metabolic Acidosis

Renal Fellow Network: Starvation Ketosis: A Rare Cause Of Metabolic Acidosis

Starvation Ketosis: A Rare Cause of Metabolic Acidosis Asa child growing up in India, I have seen several family members performingritual fasting. Fasting is aubiquitous religio-cultural practice that is found, in varying forms, acrossthe world. The month-long Ramadan and Buddhist Lent fasts are examples ofreligious observances practiced by followers of Islam, and Buddhism,respectively. These fasts are characterized by a documented impact on metabolic health , which can be minimized by well-known management strategies .The practice of fastingis a major part of Hinduism and can range from light restriction toextreme abstention. Mahatma Gandhi was a fervent supporter of fasting byreligious convictionand as a way of freeingoneself of theconstraints of the body. He used fasting as a means of exerting politicalpressure and engaged in several hungerstrikesto protest withnon-violence. Inthe western countries, starvation ketosis or ketoacidosis has been reported inindividuals with strict dieting (e.g. carb-restricted, ketogenic diets or Atkins diet), extreme exercise, andrarely with malnutrition. Few cases of starvation-induced ketoacidosis during pregnancy and lactation , and during the perioperative period have also been reported in literature. Isaw a young non-verbal woman with quadriplegia who was admitted from a nursinghome with a two-day history of worsening abdominal pain and leakage around herpercutaneous endoscopic gastrostomy(PEG) tube site. Her medical history was significant for severe developmentaldelay and chronic constipation. She was afebrile and the rest of the vitalswere stable. Her PEG tube feeds had been stopped one day prior to the hospitaladmission due to abdominal pain. Additionally, she received small doses of ivmorphine for pain control. Due to no oral Continue reading >>

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