Abnormalities In Clinical Practice Research Articles

Multiparametric Ultrasound for Focal Testicular Pathology: A Ten-Year Retrospective Review.

Conventional ultrasonography (US), including greyscale imaging and colour Doppler US (CDUS), is pivotal for diagnosing scrotal pathologies, but it has limited specificity. Historically, solid focal testicular abnormalities often led to radical orchidectomy. This retrospective study evaluated the utilisation of contrast-enhanced ultrasound (CEUS) and strain elastography (SE) in investigating intratesticular focal abnormalities. A total of 124 cases were analysed. This study underscored the superior diagnostic capabilities of CEUS in detecting vascular enhancement in all malignant cases, even those with undetectable vascularity by CDUS. It also highlighted the potential of CEUS in identifying distinctive vascular patterns in benign vascular tumours. Definitive confirmation of benignity could be obtained when the absence of enhancement was demonstrated on CEUS. While SE alone offered no distinctive advantage in differentiating between benign and malignant pathologies, we demonstrated that incorporating a combination of CEUS and SE into the evaluation of focal testicular abnormalities could improve diagnostic performance metrics over conventional CDUS. Our findings underscore the role of advanced ultrasound techniques in enhancing the evaluation of focal testicular abnormalities in clinical practice and could aid a shift towards testis-sparing management strategies.

PROGNOSTIC IMPORTANCE OF HYPONATREMIA OCCURING AT VARIOUS TIME POINTS DURING HOSPITALISATION IN PATIENTS WITH ST ELEVATION MYOCARDIAL INFARCTION - AN OBSERVATIONAL STUDY AT A TERTIARY CARE HOSPITAL

ST-elevation myocardial infarction (STEMI) and heart failure (HF) are common, big-budget, debilitating andexpanding diseases. Cardiovascular diseases, especially STEMI and heart failure have been known to cause17.3 million deaths worldwide annually. Hyponatremia, delineated as a serum sodium (sNa) concentration<135mmol/l, is a frequently seen electrolyte disturbance in practice and the prevalence, clinical impact theprognostic factor of low SNa in STEMI/heart failure patients vary widely. The aim of this review is to assessits existence and comparing survival difference between hypo and normonatremic patients.Hyponatremia is the most frequently encountered electrolyte abnormality in clinical practice and has a poorprognosis in both STEMI and heart failure patients. It exacerbates both short and long term mortality,rehospitalization rates, as well as the average length of stay in the hospital. Although it is still a mysterywhether hyponatremia is just a marker of iller patients or the core of poor prognosis in patients with STEMIand HF, one thing is certain: timely recognition of patients at risk for developing hyponatremia could help tocommence early treatment.

Small airways dysfunction: The importance of utilising Z-scores to define MMEF abnormalities in clinical practice

BackgroundThe small airways comprise the largest cross-sectional area of the lungs, however, assessing and reporting abnormalities for this region of the bronchial tree has been practically and scientifically uncertain. MethodsUsing routinely collected spirometry data for patients with either asthma or COPD, the accuracy of % predicted values for defining small airways dysfunction was assessed. A z-score of ≤ −1.645 of the maximal-mid expiratory flow (MMEF) was used as the gold standard for defining abnormality in the small airways. ResultsRecords of 3396 patients were included in the analysis. The false positive (FP) rates were 24.6 %, 16.1 %, 11.5 %, or 7.9 % when the % predicted value of 80 %, 70 %, 65 %, or 60 % were used, respectively. Sex, age, and BMI were associated with FP rates. Males were more likely to be categorised as FP with odds ratio (OR) between 1.10 and 1.49 across % predicted groups. Age was associated with FP rates with an OR between 1.01 and 1.08. The BMI was also associated with FP rates with an OR of 1.03 across all % predicted groups. Assessing the association of age groups with FP rate showed that those above 60 years old were more likely to be categorised as FP with an OR between 1.23 and 73.2 compared to those less than 30 years old. ConclusionWhen assessing the small airways in clinical practice or for scientific purposes, the % predicted values overestimate the actual impairment leading to FP interpretation. Utilising z-score values are recommended to assess the small airways using the spirometric index, MMEF.

Haploinsufficiencies of FOXF1, FOXC2 and FOXL1 genes originated from deleted 16q24.1q24.2 fragment related with alveolar capillary dysplasia with misalignment of pulmonary veins and lymphedema-distichiasis syndrome: relationship to phenotype

ObjectiveWe describe a fetus with a 2.12-Mb terminal deleted fragment in 16q associated with alveolar capillary dysplasia with misalignment of pulmonary veins (ACDMPV) and lymphedema-distichiasis syndrome (LDS) and intend to provide a comprehensive prenatal management strategy for the fetuses with ACDMPV and LDS through reviewing other similar published studies.MethodsThe fetus presented a series of diverse structural malformations including congenital cardiovascular, genitourinary and gastro-intestinal anomalies in ultrasound at 23 + 5 weeks of gestation (GA). Amniocentesis was conducted for karyotype analysis and copy number variation sequencing (CNV-seq) after informed consent.ResultsThe fetal karyotype was 46,XX, however the result of CNV-seq showed an approximately 2.12-Mb deletion in 16q24.1q24.2 (85220000-87340000) × 1 indicating pathogenicity.ConclusionGenomic testing should be recommend as a first line diagnostic tool for suspected ACDMPV and/or LDS or other genetic syndromes for the fetuses with structural abnormalities in clinical practice.

Amblyopia and fixation eye movements

Amblyopia is a neurodevelopmental disorder caused by abnormal visual experience in early life that affects 3–5% of the population. Amblyopia results in a host of monocular and binocular visual afferent function deficits including reduced visual acuity, contrast sensitivity, depth perception, interocular suppression, and efferent function abnormalities such as unstable and inaccurate fixation. Conventional treatments such as patching therapy and newer dichoptic treatments are not always successful as 30–40% of patients experience recurrence/regression of amblyopia. There are numerous review articles focused on visual afferent function deficits and treatment modalities and outcomes in amblyopia. Recently, the advent of high spatial and temporal resolution eye trackers has spurred studies on fixation eye movements (FEMs) in healthy controls and neurologic and ophthalmic disorders. In this focused review, we will summarize studies evaluating FEM abnormalities in amblyopia. We will first describe the common devices and techniques used to quantify fixation abnormalities, and then highlight the importance of systematically evaluating the eye movements under different viewing conditions and describe the parameters crucial in assessing FEM abnormalities in amblyopia. We will summarize the evidence suggesting that FEM abnormalities are not limited to the amblyopic eye only but also affects the fellow eye and that FEM abnormalities can serve as biomarkers to predict the impact of amblyopia on visual functions. Beyond diagnosis, we will discuss the treatment and prognostic implications of the evaluation of FEM abnormalities in clinical practice.

Factors affecting prognosis of the patients with severe hyponatremia

IntroductionHyponatremia is one of the most common electrolyte abnormalities in clinical practice. Data regarding factors that have impact on mortality of severe hyponatremia and outcomes of its therapeutic management is insufficient. The present study aimed to examine the factors associated with mortality and the outcomes of treatment in patients with severe hyponatremia. Materials and methodsPatients with serum Na≤115mequiv./L who were admitted to Ordu State Hospital and Ordu University Training and Research Hospital between 2014 and 2018 were included in the study. Demographic and laboratory features, severity of the symptoms, comorbid diseases, medications, and clinical outcome measures of the patients were obtained retrospectively from their medical records. Factors associated with in-hospital mortality, overcorrection and undercorrection were assessed. ResultsA total of 145 patients (median age 69 years and 58.6% female) met inclusion criteria. Diuretic use was the most common etiologic factor for severe hyponatremia that present in 50 (34.5%) patients. Sixty-seven (46.2%) patients had moderately severe while 8 patients (5.5%) had severe symptoms. The median increase in serum Na 24h after admission in the study population was 8.9mequiv./L (−6 to 19). Nonoptimal correction was seen in 92 (63.4%) patients. Hypertonic saline use was associated with overcorrection (OR, 3.07; 95% CI: 1.47–6.39; p=0.002). Avoidance of hypertonic saline (aOR, 2.52; 95% CI: 1.12–5.66; p=0.029) and having neuropsychiatric disorder (aOR, 2.60; 95% CI: 1.10–6.11; p=0.025) were associated with undercorrection. In-hospital mortality rate was 12.4% and having CKD and cancer, undercorrection of sodium and presence of severe symptoms were significantly associated with in-hospital mortality. ConclusionSevere hyponatremia in hospitalized patients is associated with substantial mortality. The incidence of non-optimal correction of serum Na is high; under-correction, presence of severe symptoms, chronic kidney disease and cancer were the factors that increase mortality rate.

Atrial Fibrillation Detection Based on Deep Learning Models

Atrial fibrillation is the most common sustained heart rhythm abnormality in clinical practice that can lead to well-known medical complications associated with increased mortality. The diagnosis of atrial fibrillation can be detected by using a short electrocardiogram recording (ECG). However, because the heartbeat is irregular and does not constantly present on a simple electrocardiogram, a single diagram is not enough for a final and certain diagnosis. To monitorizing one single patient requires hours of monitoring, important costs, and low yield. Our aim is to develop a rapid, inexpensive way to identify patients with atrial fibrillation using neural networks. This study serves to help the clinician with an automatic approach to give a quick and safe diagnosis for each patient population. The experiments show that this approach offers a promising atrial fibrillation classification and outperforms recently published studies that either use extracted features or raw data separately.

Factors affecting prognosis of the patients with severe hyponatremia

IntroductionHyponatremia is one of the most common electrolyte abnormalities in clinical practice. Data regarding factors that have impact on mortality of severe hyponatremia and outcomes of its therapeutic management is insufficient. The present study aimed to examine the factors associated with mortality and the outcomes of treatment in patients with severe hyponatremia. Materials and methodsPatients with serum Na≤115mequiv./L who were admitted to Ordu State Hospital and Ordu University Training and Research Hospital between 2014 and 2018 were included in the study. Demographic and laboratory features, severity of the symptoms, comorbid diseases, medications, and clinical outcome measures of the patients were obtained retrospectively from their medical records. Factors associated with in-hospital mortality, overcorrection and undercorrection were assessed. ResultsA total of 145 patients (median age 69 years and 58.6% female) met inclusion criteria. Diuretic use was the most common etiologic factor for severe hyponatremia that present in 50 (34.5%) patients. Sixty-seven (46.2%) patients had moderately severe while 8 patients (5.5%) had severe symptoms. The median increase in serum Na 24h after admission in the study population was 8.9mequiv./L (−6 to 19). Nonoptimal correction was seen in 92 (63.4%) patients. Hypertonic saline use was associated with overcorrection (OR, 3.07; 95% CI: 1.47–6.39; p=0.002). Avoidance of hypertonic saline (aOR, 2.52; 95% CI: 1.12–5.66; p=0.029) and having neuropsychiatric disorder (aOR, 2.60; 95% CI: 1.10–6.11; p=0.025) were associated with undercorrection. In-hospital mortality rate was 12.4% and having CKD and cancer, undercorrection of sodium and presence of severe symptoms were significantly associated with in-hospital mortality. ConclusionSevere hyponatremia in hospitalized patients is associated with substantial mortality. The incidence of non-optimal correction of serum Na is high; under-correction, presence of severe symptoms, chronic kidney disease and cancer were the factors that increase mortality rate.

Test\u2013retest reliability of laser evoked pain perception and fMRI BOLD responses

Pain perception is a subjective experience and highly variable across time. Brain responses evoked by nociceptive stimuli are highly associated with pain perception and also showed considerable variability. To date, the test–retest reliability of laser-evoked pain perception and its associated brain responses across sessions remain unclear. Here, an experiment with a within-subject repeated-measures design was performed in 22 healthy volunteers. Radiant-heat laser stimuli were delivered on subjects’ left-hand dorsum in two sessions separated by 1–5 days. We observed that laser-evoked pain perception was significantly declined across sessions, coupled with decreased brain responses in the bilateral primary somatosensory cortex (S1), right primary motor cortex, supplementary motor area, and middle cingulate cortex. Intraclass correlation coefficients between the two sessions showed “fair” to “moderate” test–retest reliability for pain perception and brain responses. Additionally, we observed lower resting-state brain activity in the right S1 and lower resting-state functional connectivity between right S1 and dorsolateral prefrontal cortex in the second session than the first session. Altogether, being possibly influenced by changes of baseline mental state, laser-evoked pain perception and brain responses showed considerable across-session variability. This phenomenon should be considered when designing experiments for laboratory studies and evaluating pain abnormalities in clinical practice.

Hyponatremia in peritoneal dialysis : free water overload, hyperosmolarity or malnutrition ?

Hyponatremia is one of the most common electrolyte abnormalities in clinical practice and is associated with higher morbidity and mortality. On dialysis, hyponatremia is also quite common: 6 to 29% of hemodialysis patients and 11 to 26% of peritoneal dialysis (PD) patients have a serum ≤ 135mmol / L.Hyponatremia in PD has unique aspects that confer different clinical consequences and treatment needs compared to subjects with normal kidney function.The specificities of PD are mainly related to an ultrafiltrate quality, both in terms of sodium extraction and free water transfer, different according to the osmotic agent used in the dialysate (crystalloid or colloid osmotic agent) and according to the characteristics of the peritoneal membrane (functionality of aquaporins, preservation of osmotic conductance to glucose ...).In the short or medium term, loss of residual renal function is highly correlated with the appearance of hyponatremia.Finally, undernutrition, a frequent situation in dialysis and often associated with hypokalemia, can also be a cause of hyponatremia.The purpose of this article is to help understand the pathophysiology of hyponatremia in PD, which is of paramount importance to ensure appropriate treatment.

Prognostic Significance of Hyponatremia in ST-elevation Myocardial Infarction/Heart Failure Patients.

ST-elevation myocardial infarction (STEMI) and heart failure (HF) are common, big-budget, debilitating and expanding diseases. Cardiovascular diseases, especially STEMI and heart failure have been known to cause 17.3 million deaths worldwide annually. Hyponatremia, delineated as a serum sodium (sNa) concentration <135 mmol/l, is a frequently seen electrolyte disturbance in practice and the prevalence, clinical impact; the prognostic factor of low SNa in STEMI/heart failure patients vary widely. The aim of this review is to assess its existence and comparing survival difference between hypo and normonatremic patients.A comprehensive review of the published articles was conducted using database PubMed. We found a total of over 1400 articles. The inclusion criteria used for this review were age >65 years, published within the last 10 years, written in English, performed on human subjects and of studies such as reviews and randomized controlled trials (RCTs), especially for heart failure MeSH words. By applying this inclusion criterion, we found out 40 relevant articles which included 26 cohort studies, four clinical trials, four review articles, and six RCTs. In the analysis of 7,06,899 patients with STEMI/heart failure, hyponatremia was significantly linked to causing all-cause mortality, both short and long term (hazard ratio [HR] as continuous variable: 1.06; 95% confidence interval [CI]: 1.01-1.11; P = 0.026; HR as categorical variable: 1.71; 95% CI: 1.06-2.75; P = 0.028). The rates of rehospitalization were also higher (odds ratio, 1.68; 95% confidence interval, 1.32-2.14) along with prolonged hospital stays as well as a greater cost burden as compared to patients with normal serum sodium. It was existent not only in patients with reduced ejection fraction (HFrEF) but also in subjects with preserved ejection fraction (HFpEF) (HR 1.40, 95% CI 1.12 to 1.75, P = 0.004). Rise of first follow-up and discharge sodium does seem to have positive linkage on survival as well (hazard ratio [HR] 0.429, 95% CI 0.191-0.960, P = 0.04).Hyponatremia is the most frequently encountered electrolyte abnormality in clinical practice and has a poor prognosis in both STEMI and heart failure patients. It exacerbates both short and long term mortality, rehospitalization rates, as well as the average length of stay in the hospital. Although it is still a mystery whether hyponatremia is just a marker of iller patients or the core of poor prognosis in patients with STEMI and HF, one thing is certain: timely recognition of patients at risk for developing hyponatremia could help to commence early treatment.

CME: Evaluation of Hypokalemia

CME: Evaluation of Hypokalemia Abstract. Hypokalemia is a common electrolyte abnormality in clinical practice. While often asymptomatic, it can be associated with severe adverse outcomes. The etiology is often obvious or can be established based on clinical history. In other cases, a systematic approach and knowledge of the physiologic and pathophysiologic key players are necessary. Pathophysiologically, inadequate intake, extra- to intracellular shift and potassium loss (renal, gastrointestinal, sweat) or a combination thereof can contribute to hypokalemia. In this article we discuss the differential diagnosis and the diagnostic approach to this common electrolyte abnormality.

Premanifest Huntington's disease: Examination of oculomotor abnormalities in clinical practice.

IntroductionDifferent oculomotor abnormalities have been reported to occur in premanifest Huntington’s disease. The aim of this study is to investigate which oculomotor items of the Unified Huntington’s Disease Rating Scale (UHDRS) are affected in premanifest individuals compared to healthy controls, and if CAG repeat length and age are correlated with oculomotor abnormalities in premanifest Huntington’s disease gene carriers.MethodsWe compared baseline data of 70 premanifest individuals and 27 controls who participated in the Enroll-HD study at the Leiden University Medical Center, the Netherlands. Premanifest gene carriers were divided in individuals near to disease onset and individuals far from disease onset.ResultsUsing a logistic regression model, only horizontal ocular pursuit of the six oculomotor items of the UHDRS was significantly more frequently affected in premanifest individuals close to disease onset compared to controls (p = 0.044, OR 13.100). Age was significantly higher in premanifest individuals with affected horizontal ocular pursuit (p = 0.016, OR 1.115) and with affected vertical ocular pursuit (p = 0.030, OR 1.065) compared to premanifest individuals without ocular pursuit deficits.ConclusionsOur results suggest that horizontal ocular pursuit is the only affected oculomotor item of the UHDRS in premanifest individuals and could be used to assess early clinical signs of Huntington’s disease. Saccade initiation and saccade velocity do not seem useful for detecting differences between premanifest individuals and controls.

Responsibility of the doctor who prescribes serotonin and noradrenaline reuptake inhibitors for patients with chronic musculoskeletal pain

Duloxetine, a serotonin and noradrenaline reuptake inhibitor (SNRI), is indicated for the management of chronic musculoskeletal pain, as it helps inhibit pain signals by activating descending pain inhibitory pathways.1 Thus, duloxetine is increasingly being prescribed by many doctors who are not familiar with psychopharmacology. We conducted a questionnaire survey on Japanese physicians’ recognition of the severe side-effects of duloxetine. We surveyed 69 physicians who had prescribed duloxetine for chronic musculoskeletal pain and 52 (75.4%) responded. The main specialties of the responders were psychosomatic medicine (n = 26, 50.0%), orthopedics (n = 14, 26.9%), anesthesiology and pain (n = 6, 11.5%), and general internal medicine (n = 6, 11.5%). The average age of the 52 responders was 52.4 years. Seventeen responders reported side-effects in their patients due to duloxetine, as follows: falls (n = 12, 23.1%), hyponatremia (n = 2, 3.8%), and discontinuation syndrome (n = 3, 5.8%). Of the 52 responders, 24 (46.2%) considered falls and syncope as a side-effect, 13 (25.0%) recognized hyponatremia as a serious complication, and only 11 (21.2%) knew about discontinuation syndrome. These results suggest that many prescription doctors are unaware or ignore these side-effects of SNRI. Of the 52 responders, 26 (50.0%) considered duloxetine as an analgesic drug, and 26 (50.0%) recognized it as an SNRI. Duloxetine has some severe side-effects at the same level as other SNRI. Syncope and orthostatic hypotension can occur at any time during treatment, particularly after dose increases. SNRI, as well as selective serotonin reuptake inhibitors (SSRI), are well known to have side-effects, including the syndrome of inappropriate antidiuretic hormone secretion, which results in hyponatremia, the most commonly encountered electrolyte abnormality in clinical practice. Following the abrupt discontinuation of SNRI, discontinuation symptoms, such as dizziness, headache, irritability, insomnia, and fatigue, may occur. Moreover, the majority of patients with chronic musculoskeletal pain are elderly and tend to have a higher underlying risk for falls, such as use of multiple medications and medical comorbidities. In Japan, after the introduction of SSRI and SNRI for depression, pharmaceutical companies initiated educational campaigns. Due to these marketing practices, SSRI and SNRI sales have achieved a tremendous increase, resulting in an increase in severe side-effects.2 We can learn a great deal from this experience with the aggressive marketing of these drugs as a kind of disease mongering. Now, the same risk exists with duloxetine for chronic musculoskeletal pain. The doctor who prescribes SNRI must weigh the benefits against the side-effects. When prescribing an SNRI for chronic musculoskeletal pain, patients should be carefully monitored against side-effects. Discontinuation should be considered in patients who experience side-effects during SNRI therapy. Even then, a gradual reduction in the dose rather than abrupt cessation is recommended, whenever possible, to prevent discontinuation syndrome. The author declares no conflicts of interest.

Hyponatremia: A clinical approach

Hyponatremia is the most common electrolyte metabolic abnormality in clinical practice. The unfavorable course of many diseases is associated with hyponatremia. Acute severe hyponatremia is life-threatening because cerebral edema may develop. Less obvious chronic hyponatremia increases the risk of balance problems, falls and fractures, especially in elderly patients. In any occasion, hyponatremia should not be now regarded only as a laboratory phenomenon in critically ill patients, but it necessitates a thorough clinical analysis of each individual case and appropriate therapy. The paper presents approaches to diagnosing and treating hyponatremia in various clinical situations.

Reproducibility and Normative Values of the Parameters of a New Hand-Held Digital Pupillometer

We evaluated the intra-examiner reproducibility and determined the standard values of pupil parameters using the PLR-3000 pupillometer (NeurOptics Inc). Generally good reproducibility was obtained, except for the T75 parameter. The standard values may be useful to distinguish various neurological abnormalities in clinical practice.

Measurement of carotid pulse wave velocity using ultrafast ultrasound imaging in hypertensive patients.

The study aimed to assess the utility of ultrafast ultrasound imaging for evaluation of carotid pulse wave velocity (PWV) in newly diagnosed hypertension patients. This prospective non-randomized study enrolled 90 hypertensive patients in our hospital from September to December 2013 as a hypertension group. An age- and sex-matched cohort of 50 healthy adults in our hospital from September to December 2013 was also included in the study as a control group. Carotid PWV at the beginning and at the end of systole (PWV-BS and PWV-ES, respectively) and intima-media thickness (IMT) were measured by ultrafast ultrasound imaging technology. The associations of PWV-BS, PWV-ES, and IMT with hypertension stage were evaluated by Spearman correlation analysis. PWV-BS and PWV-ES in the hypertension group were significantly elevated compared with those in control group. Different hypertension stages significantly differed in PWV-BS and PWV-ES. PWV-BS and PWV-ES appeared to increase with the hypertension stage. Moreover, IMT, PWV-BS, and PWV-ES were positively correlated with the hypertension stage in hypertensive patients. Ultrafast ultrasound imaging was a valid and convenient method for the measurement of carotid PWV in hypertensive patients. Ultrafast ultrasound imaging might be recommended as a promising alternative method for early detection of arterial abnormality in clinical practice.

Role of tolvaptan in the management of hyponatremia in patients with lung and other cancers: current data and future perspectives.

Hyponatremia is the most frequently observed electrolyte abnormality in clinical practice, and its frequency is almost double in hospitalized cancer patients. As a subset of cancer, hyponatremia is quite common in lung cancer patients, and it is often coupled with the diagnosis of syndrome of inappropriate antidiuretic hormone secretion. The presence of hyponatremia is consequential in that its presence adversely affects cancer patients’ prognosis and outcomes. Limited data suggest that correcting hyponatremia in lung cancer patients can increase response to anticancer treatment, may help reduce length of hospital stay and cost, and reduce morbidity and mortality. The type of treatment for hyponatremia depends on several factors; the key factors are the duration and severity of neurological symptoms of hyponatremia and the status of extracellular volume. When hyponatremia is caused by syndrome of inappropriate antidiuretic hormone, hypertonic saline is indicated for acute symptomatic cases, whereas fluid restriction is recommended in chronic asymptomatic hyponatremia. The latter allows a slower rate of correction, thus avoiding the dreaded complication of osmotic demyelination syndrome. Fluid restriction is, however, insufficient or impractical, and often the use of pharmacological therapy such as antidiuretic hormone receptor antagonists becomes necessary. Availability of these antagonists as an effective treatment in the management of hyponatremia has been a major breakthrough, and furthermore, its clinical or investigational use in cancer-related hyponatremia may offer a potential opportunity to gain further insights into the prognostic impact of hyponatremia correction on cancer patients’ outcomes. Tolvaptan is a prototype of ADH receptor antagonists that acts at renal tubular levels to increase free water excretion without inducing major systemic electrolyte abnormalities such as hypokalemia or alkalosis. The aim of this paper is to provide a brief review while focusing on cancer hyponatremia; (1) of the epidemiology of hyponatremia and its pathophysiology and diagnostic approaches and (2) of the pharmacokinetics of tolvaptan and its clinical efficacy, safety, and compliance.

Efficacy and Safety of Vasopressin Receptor Antagonists for Euvolemic or Hypervolemic Hyponatremia: A Meta-Analysis.

Hyponatremia, defined as a nonartifactual serum sodium level <135 mmol/L, is the most common fluid and electrolyte abnormality in clinical practice. Traditional managements (fluid restriction, hypertonic saline and loop diuretics, etc.) are difficult to maintain or ineffective. Recently, vasopressin receptor antagonists (VRAs) have shown promise for the treatment of hyponatremia.We aimed to conduct a meta-analysis to evaluate the efficacy and safety of VRAs in patients with euvolemic or hypervolemic hyponatremia. We searched Pubmed, Cochrane Library, Web of Science and Springer, etc. (latest search on June 4, 2015) for English publications with randomized controlled trials. Two authors independently screened the citations and extracted data. We calculated pooled relative risk (RR), risk difference (RD), weighted mean difference (WMD) or standard mean difference (SMD), and 95% confidence intervals (CIs) by using random and fixed effect models.We collected data from 18 trials involving 1806 patients. Both random and fixed effect meta-analyses showed that VRAs significantly increased the net change of serum sodium concentration (WMDrandom = 4.89 mEq/L, 95%CIs = 4.35–5.43 and WMDfixed = 4.70 mEq/L, 95%CIs = 4.45–4.95), response rate (RRrandom = 2.77, 95%CIs = 2.29–3.36 and RRfixed = 2.95, 95%CIs = 2.56–3.41), and 24-hour urine output (SMDrandom = 0.82, 95%CIs = 0.65–1.00 and SMDfixed = 0.79, 95%CIs = 0.66–0.93) compared to placebo. Furthermore, VRAs significantly decreased body weight (WMDrandom = −0.87 kg, 95%CIs = −1.24 to −0.49 and WMDfixed = −0.91 kg, 95%CIs = −1.22 to −0.59). In terms of safety, rates of drug-related adverse events (AEs), rapid sodium level correction, constipation, dry mouth, thirst, and phlebitis in the VRA-treated group were greater than those in control group. However, there was no difference in the total number of AEs, discontinuations due to AEs, serious AEs, death, headache, hypotension, nausea, anemia, hypernatremia, urinary tract infection, renal failure, pyrexia, upper gastrointestinal bleeding, diarrhea, vomiting, peripheral edema, and dizziness between the 2 groups. Random effect meta-analyses showed that post treatment urine osmolality, supine systolic blood pressure, and diastolic blood pressure were lowered (WMDrandom = −233.07 mOsmol/kg, 95%CIs = −298.20–147.94; WMDrandom = −6.11 mmHg, 95%CIs = −9.810 to −2.41; WMDrandom = −2.59 mmHg, 95%CIs = −4.06 to −1.11, respectively), but serum osmolality was increased (WMDrandom = 9.29 mOsmol/kg, 95%CIs = 5.56–13.03). There was no significant change from baseline in serum potassium concentration between the 2 groups (WMDfixed = 0.00 mmHg, 95%CIs = −0.07–0.06).VRAs are relatively effective and safe for the treatment of hypervolemic and euvolemic hyponatremia.

ID 214 – Optical coherence tomography and multifocal visual evoked potentials usefulness to detect visual pathway abnormalities in clinical practice

Objective Full-field visual evoked potentials (ff-VEP) are fundamental in neurological practice to define the nature of visual disturbances. We explored whether, in case of normal ff-VEP and suspected organic visual pathway involvement, multifocal visual evoked potentials (mf-VEP) and optical coherence tomography (OCT) can be useful in the diagnostic workup. Methods Observational case reports. Results Three patients arrived at our department for visual disturbances. Two had relapsing optic neuritis (ON) and visual acuity (VA) loss, with normal or non-significant ff-VEP outside acute clinical episodes. In both cases OCT showed a retinal nerve fiber layer (RNFL) thickness reduction, allowing visual pathway damage identification. The third, with meningioma involving left optic nerve, complained of blurred vision in the nasal field of the left eye as confirmed by computerized perimetry (CP). While ff-VEP showed normal latency and non-significant amplitude reduction in the left eye, mf-VEP showed important amplitude reduction in the whole lower left eye field. OCT scan confirmed axonal damage showing left RNFL thinning. Conclusions Sometimes ff-VEP fails in identifying abnormalities in patients with processes involving the visual pathway, particularly in cases with axonal or sectoral optic nerve involvement. We suggest the importance of a multimodal evaluation, including OCT and mf-VEP.