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Gastric emptying in subclinical hyperthyroidism.

INTRODUCTION AND AIM: About 15% of hyperthyroid patients suffer from gastrointestinal symptoms such as diarrhea, constipation, nausea and early satiety the problem. Published reports on the topic of gastric emptying in hyperthyroidism are rare and discrepant in their results. PATIENTS AND METHODS: Thirteen patients (8 women, 5 male; aged 41.92+/-1.491 SE yr) with a recently established diagnosis of subclinical hyperthyroidism due to Graves-Basedow disease and as control group 10 age-matched healthy subject (7 women, 3 male; 39.6+/-2.918 SE yrs) participated in this study. Scintigraphic method (food labeled with 99mTc sulfur colloid) was used for measurement of gastric emptying. RESULTS: Gastric emptying time was similar in both subclinical hyperthyroid and control groups (p=0.413). DISCUSSION: There are few studies on the subject of gastric emptying in hyperthyroidism with either delayed emptying or with emptying time similar to controls. In the only one study in subclinical hyperthyroidism, gastric emptying was found to be delayed. We also found that gastric emptying was delayed in subclinical hyperthyroidism. On the basis of this and other studies, we may suggest that in subclinical hyperthyroidism, gastric emptying of solids were similar to that in age-matched healthy control subjects and gastrointestinal dysfunction is dependent on severity of the hyperthyroid state and might be a result of impaired neuro-hormonal regulation. Yet the data must be supported on larger groups.

Adult↗

[Pharyngo-esophageal motility disorders in Steinert's myotonic dystrophy. Description of a case presenting with dysphagia].

In Myotonic Dystrophy symptoms of gastrointestinal dysfunction may dominate the clinical picture or they may be manifested long before the musculoskeletal disturbances become apparent. A case of Myotonic Dystrophy in a 26-year-old woman with dysphagia as the symptom of clinical presentation is reported. Manometric investigations demonstrated motor dysfunctions in pharynx and in proximal, middle and distal portions of the esophageal body, indicating both striated and smooth muscle involvement. The pathophysiology of the esophageal motility disorders in Myotonic Dystrophy and the related therapeutic problems are briefly discussed.

Adult↗

Solid pseudopapillary pancreatic tumor in pregnancy. A case report.

BACKGROUND: Solid pseudopapillary tumor (SPT) of the pancreas is a rare neoplasm, occurring predominantly in young African American women. Tumor growth, which is typically slow, may be accelerated during pregnancy secondary to the influence of progesterone. CASE: We report a rare case of an 8-cm SPT in the head of the pancreas presenting as hyperemesis gravidarum during pregnancy. In contrast to previous case reports, surgical resection of the tumor at 16 weeks' gestation, although successful, did not ameliorate the patient's abdominal pain, nausea or vomiting. With intravenous nutritional support, she delivered a healthy infant near term. CONCLUSION: SPT may present as hyperemesis gravidarum. Patients with refractory hyperemesis gravidarum should be evaluated for thyroid disease, gastroesophageal reflux, cholestasis and pancreatitis. If these more common etiologies are excluded, then one may consider SPT in the differential diagnosis, particularly in African American patients. SPT may grow during pregnancy due to progesterone responsiveness. Surgical resection during pregnancy is possible without harmful fetal effects but may not correct gastrointestinal dysfunction during pregnancy.

Adult↗

Induction of cutaneous graft-versus-host disease by administration of cyclosporine to patients undergoing autologous bone marrow transplantation for acute myeloid leukemia.

Cutaneous graft-versus-host disease (GVHD) has been reported after administration of cyclosporine (CSP) after autologous bone marrow transplantation (ABMT) with unpurged marrow in patients with lymphoma. To determine whether GVHD can be induced after ABMT with chemopurged marrow in acute myeloid leukemia (AML), we administered intravenous CSP for 28 days (beginning on the day of ABMT) to 19 patients with AML (12 in first remission [CR1], six in CR2, and one in CR3) who received busulfan (16 mg/kg) and cyclophosphamide (200 mg/kg) and ABMT with 4-hydroperoxycyclophosphamide (4HC)-treated marrow. In this dose-escalation trial, CSP daily doses were 1 mg/kg in seven patients, 2.5 mg/kg in eight patients, or 3.75 mg/kg in four patients. Skin biopsies were obtained weekly after ABMT or on appearance of rash and were graded for GVH changes. Overall, 15 of 19 patients (79%) had cutaneous histopathologic grade 2 GVHD at a median of 33 days (range, 14 to 49) after ABMT; in 10, cutaneous manifestations were present at time of positive biopsy. The frequency, time to onset, and duration of GVHD were similar among the three CSP dosage groups. No patients had hepatic or gastrointestinal dysfunction attributable to GVHD or required specific therapy for GVHD. Positive biopsies for GVHD were seen in seven of eight patients who received full-course, full-dose CSP and 8 of 11 patients who had CSP discontinued or dosage reduced because of renal insufficiency. Three patients (one with positive biopsy) died with ABMT-related complications. Seven patients (four CR1, three CR2) relapsed with AML at a median of 411 days (range, 178 to 549) after ABMT; six of seven had positive biopsies for cutaneous GVHD. Nine patients (seven CR1, one CR2, and one CR3) are alive without relapse at a median of 501+ days (range, 252+ to 811+) after ABMT; eight of nine had cutaneous GVHD. Short-course CSP can induce autologous GVHD in recipients of chemopurged marrow autografts for AML, but randomized prospective trials are needed to determine whether this immunologic reaction is associated with alterations in leukemic relapse rate and disease-free survival after ABMT in AML.

Adolescent↗

[Safety of new anti-arrhythmic drugs].

The majority of new antiarrhythmic drugs are still undergoing clinical trials and are not yet available on the French market. The studies of efficacy are mainly targeted on the treatment of atrial fibrillation. Intravenous ibutilide prolongs the duration of the action potential by stimulating sodium exchange during phase 2 of the action potential. Used for terminating episodes of atrial flutter and fibrillation, ibutilide has been shown to have a low proarrhythmic effect. Dofetilide is a pure I(Kr) current antagonist and is given orally. The molecule prolongs the duration of the atrial and ventricular action potentials. The amplitude of this effect is inversely related to the heart rate. No effect has been observed on the mortality rate in the post-infarct period. Adjusting the dosage with respect to renal function has reduced the occurrence of torsades de pointe from 4.8 to 2.9%. Azimilide is an I(Kr) and I(Ks) current blocker and its efficacy decreases at rapid heart rates. After oral administration, azimilide does not appear to have a deleterious effect in patients with a history of myocardial infarction and left ventricular dysfunction. The risk of torsades de pointe is less than 1%. Cases of neutropaenia have been reported. Dronedarone is an amiodarone analogue without iodine. The molecule prolongs atrial and ventricular action potentials and its efficacy is maintained at high heart rates. This drug had deleterious effects when given to patients with coronary artery disease and left ventricular dysfunction. Gastrointestinal side effects may be observed at high dosage. The great advantages of dronedarone are the absence of thyroid complications and of pro-arrhythmic effects.

Administration, Oral↗

Treatment of irritable bowel syndrome.

Irritable bowel syndrome affects 10 to 15 percent of the U.S. population to some degree. This condition is defined as abdominal pain and discomfort with altered bowel habits in the absence of any other mechanical, inflammatory, or biochemical explanation for these symptoms. Irritable bowel syndrome is more likely to affect women than men and is most common in patients 30 to 50 years of age. Symptoms are improved equally by diets supplemented with fiber or hydrolyzed guar gum, but more patients prefer hydrolyzed guar gum. Antispasmodic agents may be used as needed, but anticholinergic and other side effects limit their use in some patients. Loperamide is an option for treatment of moderately severe diarrhea. Antidepressants have been shown to relieve pain and may be effective in low doses. Trials using alosetron showed a clinically significant, although modest, gain over placebo, but it is indicated only for women with severe diarrhea-predominant symptoms or for those in whom conventional treatment has failed. Tegaserod has an advantage over placebo in constipation-predominant irritable bowel syndrome; it is indicated for up to 12 weeks of treatment in women. However, postmarketing reports of severe diarrhea and ischemic colitis further limit its use. Herbal therapies such as peppermint oil also may be effective in the treatment of irritable bowel syndrome. Therapies should focus on specific gastrointestinal dysfunctions (e.g., constipation, diarrhea, pain), and medications only should be used when nonprescription remedies do not work or when symptoms are severe.

Adult↗

Celiac disease in an elite female collegiate volleyball athlete: a case report.

OBJECTIVE: To present the case of an elite female volleyball player who complained of diarrhea and fatigue after preseason training. BACKGROUND: The athlete lost 8.1 kg during the first 20 days of training, and we initially suspected an eating disorder. The sports medicine team interviewed the athlete and found she did not have psychological symptoms indicative of an eating disorder. The results of routine blood tests revealed critically high platelet counts; in conjunction with the physical findings, the athlete was referred to a gastroenterologist. DIFFERENTIAL DIAGNOSIS: Our initial suggestion was an eating disorder. Therefore, the differential diagnosis included anorexia athletica, anorexia nervosa, and bulimia nervosa. On referral, the differential diagnosis was anemia, gastrointestinal dysfunction, lymphoma, or bowel adenocarcinoma. Diarrhea, weight loss, and blood test results were suggestive of active celiac disease, and a duodenal biopsy specimen confirmed this diagnosis. TREATMENT: The athlete was treated with a gluten-free diet, which excludes wheat, barley, and rye. Dietary substitutions were incorporated to maintain adequate caloric intake. UNIQUENESS: The presence of active celiac disease may not be uncommon. However, elite athletes who face celiac disease present a new challenge for the athletic trainer. The athletic trainer can help guide the athlete in coping with the lifestyle changes associated with a gluten-free diet. CONCLUSIONS: One in every 200 to 400 individuals has celiac disease; many of these individuals are asymptomatic and, therefore, their conditions are undiagnosed. Undiagnosed, untreated celiac disease and patients who fail to follow the gluten-free diet increase the risk of further problems.

Journal Article↗

[Difficulties in diagnostics in recurrent abdominal pains in 71-years-old patient].

Neoplasm of B-cell origin is the most frequent malignant disease of the lymphatic tissue. It is usually presented as enlargement of lymph nodes, hepatosplenomegaly, skeletal pains and gastrointestinal dysfunction. Splenic lymphoma can cause the difficulties in diagnostic procedures (ultrasound and computed tomography). It may be nearly anechoic and mimic a cyst, abscess or parasitic mass. We describe a course of the disease and diagnostic troubles noted in 71-years-old patient, in whom splenic cysts enlarging rapidly were observed. Splenectomy due to presented difficulties in diagnosis such as clinical disquiet about subsequent course of the disease was performed. It let us to recognize malignant lymphoma and initiate a correct treatment strategy.

Abdominal Pain↗

[Psycho-autonomic aspects in patients with gastroesophageal reflux disease, and functional esophageal disorders].

The subjects of the study were 79 patients (35 with functional esophageal disorders (FED), 24 with nonerosive reflux disease (NERD), and 20 with erosive reflux disease (ERD), who were selected on the basis of clinical complaints, 24-hour ph-study, and esophagogastroduodenoscopy. All the subjects were evaluated by means of clinical questionnaires and psychological tests: Beck depression test, Spielberg State-Trait Anxiety inventory (STAI), and Toronto alexithymia test (TAS). In FED and NERD patients vs. ERD patients the following abnormalities were observed more frequently: autonomic and functional somatic symptoms (apart from gastrointestinal tract (GIT) complaints) (p < 0.01), sleep disturbances (p < 0.01), fatigue (p < 0.01), eating behavior disorders (DEBQ) (p < 0.05), maternal overprotection in childhood (p < 0.05), psychophysioligical GIT reaction in childhood (p < 0.05), higher levels of state and trait anxiety (p < 0.05), and hypochondria (p < 0.05). The clinical symptom index (CSI) (the sum of stomach and bowel complaints to the sum of esophageal complaints ratio) was calculated. CSI in FED and NERD patients was 1.8, while CSI in ERD patients--0.1 (p < 0). Thus, compared to ERD patients, patients with FED and NERD were characterized by more pronounced emotional, motivational, and autonomic disorders. Besides, CSI demonstrated that the character of gastrointestinal dysfunction was more diffuse in NERD and FED and more local--in ERD patients.

Adult↗

[Role of platelet activating factor in the injury of intestinal immuno-barrier function in young rats].

OBJECTIVE: Gastrointestinal dysfunction is closely correlated with the destruction of intestinal barrier function induced by serious infection. Platelet activating factor (PAF) may induce intestinal injuries. This study aimed to investigate the effect of PAF on the injury of intestinal mucosal immuno-barrier function in young rats. METHODS: Eighteen-day-old Wistar rats were randomized to lipopolysaccharide (LPS) (5 mg/kg), LPS plus PAF receptor antagonist and normal saline injection (Control). PAF receptor antagonist BN52021 5 mg/kg was administered before or 30 minutes after LPS injection (pretreatment or treatment). The ileum specimens (n=8) were harvested at 1.5, 3, 6, 24, 48 and 72 hrs after LPS injection. Double antibody-PEG radioimmunoassay was used to determine the secretory IgA (sIgA) content in intestinal mucosa. Hematoxylin and erosin staining was used for histological evaluation. The ratio of wet and dry weight (W/D) of ileum tissues was calculated. RESULTS: Intestinal villi edema, capillary congestion, extension of the subepithelial lympho channel, and polymorphonuclear infiltration in enteric cavity were noted in the LPS group at 1.5, 3, 6 and 24 hrs after LPS injection. In the PAF receptor antagonist group only villi edema was found. The W/D ratio in the LPS group was significantly higher than that in the Control group at all time points, but it was slightly reduced by the PAF receptor antagonist pretreatment or treatment. The sIgA content was obviously decreased after 1.5, 3, 6, 24 and 48 hrs of LPS challenge compared with that in the Control group (P < 0.01). It reached to a nadir at 6 hrs (0.15 +/- 0.04 microg/mL). The level of sIgA in the PAF receptor antagonist group was higher than that in the LPS group at each time point. There was no statistical difference in the sIgA level between the PAF receptor pretreatment and treatment groups. CONCLUSIONS: PAF plays roles in the injury of intestinal immuno-barrier function. Preventive and remedial use of PAF receptor antagonist BN52021 may relieve intestinal injury.

Animals↗

Regulative effects of ovarian steroids on rat gastric motility and sensitivity.

Women often complain gut symptoms during pregnancy and the luteal phase of the menstrual cycle. To investigate the relationship between ovarian steroids and the abnormal gut motility and sensitivity, the expressions of cholecystokinin (CCK), calcitonin gene-related peptide (CGRP) and their receptors in stomach were studied in ovariectomized rats. Blood samples were collected for estradiol (E(2)), progesterone (P(4)), CCK and CGRP radioimmunoassay. Expression of CCK(A) receptor in fundus was assessed by Western blot and CGRP receptor was determined by (125)I-CGRP radioligand binding assay (RBA). The replacement therapy with estradiol benzoate (EB) could dose-dependently increase the plasma CCK level and the expression of gastric CCK(A) receptor (P<0.05 respectively). P(4) replacement therapy could stimulate the release of CGRP and increase the binding sites of CGRP receptors in stomach (P<0.05 respectively). The combined effect of EB and P(4) was to stimulate the release of CCK and CGRP, and to increase the expressions of gastric CCK(A) and CGRP receptors. These results indicate that EB could inhibit gastric emptying by increasing CCK secretion and CCK(A) receptor expression in ovariectomized rats. P(4) could increase gut sensitivity by up-regulating the release of CGRP and the activity of CGRP receptor. It could be deduced from these observations that CCK(A) and CGRP receptor antagonists could be used for female patients who suffer from gastrointestinal dysfunction closely related with the menstrual cycle, such as distension, satiety, bloating and abdominal pain.

Animals↗

Gastrointestinal serotonin: depletion due to tetrahydrobiopterin deficiency induced by 2,4-diamino-6-hydroxypyrimidine administration.

To study the role of serotonin in gastrointestinal function in mice, a peripheral deficiency was induced by administration of 2,4-diamino-6-hydroxypyrimidine, an inhibitor of tetrahydrobiopterin (6-[dihydroxypropyl-(L-erthro)-5,6,7,8,-tetrahydropterin) (BH4) biosynthesis. BH4 is an essential cofactor for tryptophan hydroxylase, the rate limiting enzyme in the biosynthesis of serotonin. When 2,4-diamino-6-hydroxypyrimidine (DAHP) was administered for 4 days at the dose of 3 g/kg/day, serotonin decreased in the duodenum and colon to approximately 46 and 40% of the control levels, respectively. These mice showed visual signs of gastrointestinal dysfunction in addition to a remarkable decrease in uptake of a p.o. glucose load. The decrease in serotonin was prevented and prevention of the apparent dysfunction of digestive tract was observed by simultaneous administration of (6R)BH4. Serotonin levels in the brain and blood were also decreased by treatment with p-chlorophenylalanine, an irreversible inhibitor of tryptophan hydroxylase. In contrast, DAHP had no effect on brain serotonin levels, presumably due to poor brain penetration. DAHP caused a rapid decrease (T1/2 of less than 12 hr) in the BH4 levels in all tissues examined, except in the brain. The BH4 level returned to within the normal range less than 24 hr after cessation of the administration of DAHP, a finding which suggests that the BH4 level is in a dynamic steady state maintained by rapid local biosynthesis. Thus, the local biosynthesis of BH4 supports normal digestive functions, presumably by controlling normal serotonin biosynthesis.

5-Hydroxytryptophan↗

Acute renal failure prognostic indices in hospital inpatients referred for haemodialysis.

Forty-eight patients with acute renal failure (ARF) who were referred to the Department of Renal Medicine, Singapore General Hospital for acute dialysis between August 1985 and August 1989 were studied retrospectively to identify risk factors associated with ARF that serve as prognostic indicators. There was no difference in the mean age of survivors and non-survivors (49.5 +/- 17.5 years vs 53.5 +/- 18 years, p greater than 0.05). The overall mortality rate was 52%. ARF as a result of surgical complication had a higher mortality rate in comparison to ARF from medical complications (66% vs 50%, p greater than 0.05). Septicaemia was the most common cause of ARF requiring dialysis. Hepatobiliary sepsis was the most frequent cause of septicaemia. Pre-dialysis serum urea and creatinine levels, and the number of dialysis treatments did not affect the outcome. Poor prognostic indicators included oliguria or anuria, fluid overload and coma. Patients tended to have a worse outcome if they had more than three risk factors taken from the following list:-decreased renal perfusion, assisted ventilation, coma, gastrointestinal dysfunction, recent surgery, sepsis, congestive heart failure, hepatobiliary dysfunction, malignancy, diabetes mellitus, chronic renal insufficiency and poor nutritional status. Early referral of patients with septicaemia due in particular to hepatobiliary infection may improve the prognosis.

Acute Kidney Injury↗

Tardive dyskinesia.

Tardive dyskinesia is a potentially irreversible syndrome of involuntary hyperkinetic movements that occur in predisposed persons receiving extended neuroleptic (antipsychotic) drug therapy. It is usually characterized by choreoathetoid dyskinesias in the orofacial, limb, and truncal regions, but subtypes of this syndrome may include tardive dystonia and tardive akathisia. Although the mechanisms underlying the pathogenesis and pathophysiology of this disorder are unproven, altered dopaminergic functions will likely play a role in any explanation of it. Tardive dyskinesia develops in 20% of neuroleptic-treated patients, but high-risk groups such as the elderly have substantially higher rates. Risk factors include age, female sex, affective disorders, and probably those without psychotic diagnoses, including patients receiving drugs with antidopaminergic activity for nausea or gastrointestinal dysfunction for extended periods. Total drug exposure is positively correlated with tardive dyskinesia risk. Management strategies include a careful evaluation of both the psychiatric and neurologic states, a broad differential diagnosis, and adjustment of neuroleptic agents to the lowest effective dose that controls psychosis and minimizes motor side effects. No drug therapy is uniformly safe and effective for treating this disorder. A favorable long-term outcome of improvement or resolution correlates with younger age, early detection, lower drug exposure, and duration of follow-up.

Antipsychotic Agents↗

Modified smooth muscle responses of jejunum in streptozotocin-diabetic rats.

Complications of the gastrointestinal tract in patients with diabetes mellitus can cause marked discomfort and may modify the ability of the patient to maintain normal glucostasis. In an attempt to elucidate some of the factors causing gastrointestinal dysfunction in experimental diabetes we examined the responses of jejunal smooth muscle in streptozotocin-induced diabetes in rats to some of the neurotransmitters and autocoids found in the enteric nervous system. Jejunal tissues from 4- to 5-week diabetic rats were examined for their responses to neurokinin (NK) A, NKB, substance P (SP), bradykinin, neurotensin, bethanechol, isoproterenol and phenylephrine. The affinities for all these agonists, except for SP which increased slightly with diabetes, were the same in both control and diabetic tissues. NKA was the most potent neurokinin and elicited the largest contractile responses from jejunal tissues of both control and diabetic animals. The contractile response to NKA, but not that to NKB or SP, was increased in the jejunum from diabetic animals. Part of this increased responsiveness was antagonized by atropine. The contractile effects of the cholinergic agonist, bethanechol, were not altered by the diabetic state. Decreased relaxation responses in the jejunum from diabetic animals were observed for bradykinin, neurotensin and isoproterenol, but not for phenylephrine. These results suggest that the myogenic actions of several agonists are modified in experimental diabetes.

Animals↗

Management and prevention of bacterial diarrhea.

The etiology, pathogenesis, transmission and communicability, diagnosis, and management of infectious diarrhea are reviewed. Infectious diarrhea is common in both industrialized and unindustrialized areas of the world. Better understanding of the etiology and pathogenesis and identification of "new" enteric pathogens has resulted in the use of a variety of drugs to relieve symptoms or to effect a clinical cure. Both host and microbial virulence factors are key in the acquisition of diarrheal illness. Host factors such as extreme age, a dysfunctional gastrointestinal tract, or underlying immunodeficiency enhance the risk of illness after ingestion of a pathogen or its toxins. Microbial virulence factors (the pathogen's ability to invade or produce enterotoxins, neurotoxins, or cytotoxins) characterize the type of illness manifested and the symptom complex (e.g., acute watery diarrhea versus chronic dysentery). Supportive care is indicated in the majority of cases of infectious enteritis, and rehydration is considered the mainstay of therapy in any diarrheal illness accompanied by dehydration. Antimicrobial therapy is beneficial in the treatment of severe diarrhea caused by Shigella, Campylobacter spp., Vibrio cholerae, Escherichia coli, and Clostridium difficile. Infectious diarrhea is common but is often self-limited and of short duration. Therapy frequently consists of symptomatic relief and fluid replacement.

Diarrhea↗

Experimental chloramphenicol intoxication in neonatal calves: intravenous administration.

Chloramphenicol was administered intravenously for eight to 17 days to five newborn calves at a daily dosage of 100 mg kg-1. Haemodynamic, haematological, blood chemistry, serum enzyme, urinalysis and clinical responses were evaluated. High levels of serum chloramphenicol were observed throughout the study although a marked increase in elimination rate was seen with increasing age. The most severe adverse effects were severe hypotension following rapid intravenous administration and severe gastrointestinal dysfunction with diarrhoea accompanying prolonged high dosage. There appeared to have been a haematological effect in one calf, but it was of minor significance compared with the other effects.

Animals↗

[Relation of hypoxia and edema of the intestinal wall and skin to colloid osmotic pressure].

Whereas the impact of colloids and crystalloids on hypoxia and edema has been extensively debated with respect to pulmonary function, their corresponding effects on the systemic circulation have been largely ignored. Manifest edema of the intestine and skin develops, however, when the serum colloid osmotic pressure (COP) is lowered to 15 mm Hg or less by crystalloid infusions. Hypoxia of wounds, which may be aggravated by crystalloids, impairs healing and antibacterial defense, and its has been speculated that edema and/or hypoxia of the intestine may be associated with postoperative gastrointestinal dysfunction. We therefore studies the relationship between lowering and restoration of the COP, the pO2 of the intestinal surface and skin, and tissue edema. We generated an acute hypoproteinemic fluid overload reducing the COP from around 20 to 10 mm Hg in 56 rabbits by means of a 50% plasma loss and excess replacement with Ringer's lactate. We measured the COP with a membrane having a cut-off level of 20,000 d, the cardiac output (with derivation of further hemodynamic data) with an electromagnetic flow probe around the ascending aorta, and the tissue pO2 (pO2t) in mm Hg with the Dortmund 8-channel surface electrode. After 30 min without infusion (Fig. 1), we assigned 14 animals each at random to 4 treatment groups: (1) no treatment (O); (2) 20% albumin 7.5 ml/kg (A); (3) furosemide 2 mg/kg i.v. given three times at 30-min intervals (F); and (4) the combination of both agents (AF). During the infusion-free interval, the cardiac output and pO2t fell by 20%-30% of baseline (Table 1).(ABSTRACT TRUNCATED AT 250 WORDS)

Acid-Base Equilibrium↗