Decrease In Serum Sodium Level Research Articles

Association between the Serum Sodium Levels and the Response to Tolvaptan in Liver Cirrhosis Patients with Ascites and Hyponatremia.

Objective Hyponatremia is closely associated with the pathophysiology of cirrhosis. However, the association between the serum sodium level and the response to tolvaptan is unclear. This study evaluated the factors related to the tolvaptan response and the prognosis in cirrhosis patients with ascites and hyponatremia. Methods We retrospectively reviewed the clinical records of cirrhosis patients hospitalized for treatment with tolvaptan. The associations of patient baseline characteristics with the tolvaptan response after one week and of the characteristics after one-month tolvaptan treatment with the prognosis were analyzed. Results We analyzed 83 cirrhosis patients with ascites, including 34 patients with hyponatremia. The response rates to tolvaptan in patients with serum sodium <130 mEq/L, 130-135 mEq/L, and >135 mEq/L were 20%, 66%, and 58%, respectively (p=0.22). The serum sodium level was associated with the response to tolvaptan [odds ratio=1.18; 95% confidence interval (CI)=1.02-1.37; p=0.029]. In patients with hyponatremia, the serum sodium level after 1-month tolvaptan treatment was increased compared to baseline (132 mEq/L vs. 136 mEq/L, p=0.006), and an increasing serum sodium level was associated with a lower risk of mortality (hazard ratio=0.85; 95% CI=0.75-0.97; p=0.016). The survival rate was higher in patients with an increase in the serum sodium level after 1 month than in patients with a decreased serum sodium level (p=0.023). Conclusion Tolvaptan treatment was effective in cirrhosis patients with ascites and hyponatremia, but a low serum sodium level was associated with non-responsiveness to tolvaptan. An increased serum sodium level after one-month tolvaptan treatment may positively influence the mortality risk in cirrhosis patients with hyponatremia.

Schwartz-Bartter Syndrome: A Subtle Complication of Small Cell Lung Carcinoma

Paraneoplastic syndromes are defined as a conglomerate of clinical disorders that are caused by neoplastic diseases, specifically lung cancer. The clinical symptomatology of paraneoplastic syndromes usually precedes the diagnosis of the associated neoplasm, however, according to our current literature; the extent of the symptoms is not associated with the size of the tumor. Syndrome of inappropriate anti-diuretic hormone release (SIADH), also known as Schwartz-Bartter syndrome, is commonly caused by small cell lung carcinoma (SCLC) and is characterized by euvolemic hypoosmolar hyponatremia, which will lead to a low serum osmolality as well as a significantly high urine osmolality in the absence of other medical conditions such as adrenal insufficiency, heart failure, cirrhosis, and diuretic syndrome among others. The clinical presentation related to SIADH varies based upon the severity of the hyponatremia as well as the acuteness of the decrease in serum sodium levels. Symptoms due to SIADH include anorexia, nausea, vomiting, and in more severe cases, cerebral edema due to rapid of onset hyponatremia thus causing confusion, restlessness, coma, seizures, and respiratory arrest.

Decreased serum sodium levels predict symptomatic vasospasm in patients with subarachnoid hemorrhage

Background: Symptomatic vasospasm is a major cause of morbidity and mortality in subarachnoid hemorrhage patients. Hyponatremia and dehydration due to natriuresis after subarachnoid hemorrhage are related to symptomatic vasospasm. Therefore, most institutions are currently targeting euvolemia and eunatremia in subarachnoid hemorrhage patients to avoid complications. We retrospectively investigated the predictors of symptomatic vasospasm with respect to water and sodium homeostasis, while maintaining euvolemia and eunatremia after subarachnoid hemorrhage. Methods: We monitored changes in serum sodium levels, serum osmolarity, daily sodium intake, daily urine volume, and daily water balance for 14days after subarachnoid hemorrhage. Outcomes were assessed using the modified Rankin scale at 1month after subarachnoid hemorrhage. Results: Among 97 patients, 27 (27.8%) had symptomatic vasospasm. Patients with symptomatic vasospasm were older than those without symptomatic vasospasm; the occurrence of symptomatic vasospasm affected outcomes. Serum sodium levels were sequentially significantly decreased, but within the normal range from 1day before the occurrence of symptomatic vasospasm. Serum osmolarity of the spasm group was lower than that of the non-spasm group. Conclusions: Symptomatic vasospasm occurs more often in older patients and affects outcomes. A decrease in serum sodium levels occurs a day before symptomatic vasospasm. This observation may help predict symptomatic vasospasm.

The Clinical Effect of Bipolar and Monopolar Transurethral Resection of the Prostate More Than 60 Milliliters

To compare the effect, safety, and complication rates of monopolar vs bipolar transurethral prostate resection (TURP) in patients with prostate gland larger than 60 mL. Patients with prostate gland larger than 60 mL who were scheduled for surgery because of benign prostatic hyperplasia were randomized into bipolar or monopolar TURP arms via software program with a 1:1 ratio. Preoperatively and postoperative sixth hour and first day, hemoglobin and serum sodium levels were measured. International Prostate Symptom Score (IPSS), IPSS-quality of life (IPSS-QoL), and International Index of Erectile Function scores were determined, and maximal flow rate and residual urine volume were calculated in the preoperative period and postoperative sixth month. Postoperative clot formation, blood transfusion rates, and other complications were recorded on a database. Of 81 patients included in the study, 45 (55.5%) underwent monopolar and 36 (44.5%) underwent bipolar TURP (M-TURP and B-TURP groups, respectively). The only statistically significant change between the preoperative and the postoperative variables was detected in sodium levels, which were -5.0 mmol/L and -1.2 mmol/L in the M-TURP and B-TURP groups, respectively (P = .001). Although 2 of the patients in the M-TURP group experienced transurethral resection syndrome, none of the patients in the B-TURP group experienced this complication (P = .584). Bipolar and monopolar TURP showed similar effect and safety in patients with prostate glands larger than 60 mL. The only significant difference between the 2 groups was the greater decrease in serum sodium levels in the M-TURP group.

Selective Serotonin Re-Uptake Inhibitors and Hyponatremia in Acutely Medically-Ill Inpatients.

Selective Serotonin Reuptake Inhibitors (SSRIs) have become the mainstay of treatment for depression, anxiety, and many other conditions. However, they have been associated with an increased risk of hyponatremia. Little is known about the risk of SSRI-associated hyponatremia in certain potentially at-risk populations, such as patients with acute medical illnesses. The main objective of this study was to examine the effect of SSRIs on serum sodium levels in medically-ill inpatients. We performed a retrospective cohort study of 239 medically-ill inpatients assessed by the psychiatric consultation-liaison team of a large Canadian academic hospital between 2008 and 2014. We grouped patients based on whether they were exposed to an SSRI, a non-SSRI antidepressant, or no antidepressant at all. Our primary outcome was the maximum decrease in serum sodium level observed within 30 days of antidepressant exposure in the inpatient setting. Our secondary outcome was the incidence of hyponatremia (serum sodium level <135 mEq/L) or severe hyponatremia (sodium level <130 mEq/L) within the same time frame. The maximum decrease in sodium serum level from baseline did not differ between the 3 groups studied (SSRIs - 3.31 mEq/L vs non-SSRI antidepressants -3.41 mEq/L vs no antidepressants -3.13 mEq/L, F (2) = 0.79, p= 0.92). The incidence of hyponatremia and severe hyponatremia did not differ between groups either. This remained the case after controlling for covariates. SSRIs do not appear to be associated with an increased risk of hyponatremia in medically-ill inpatients. Clinicians should not avoid prescribing SSRIs in this population based solely on the assumption of hyponatremia risk.

Acute effect of copper exposure on serum biochemical characteristics of common carp (Cyprinus carpio L.)

Effects of ambient copper was investigated on serum stress markers, sodium and enzyme levels in Common carp ( Cyprinus carpio L.) over a 14-d exposure period. Fish were exposed to 0, 25 and 100 μg L -1 copper (as copper sulfate) and blood was sampled at 0, 3, 7 and 14 d after exposure. Serum profile was significantly affected by copper concentration, sampling time and their interaction. Increase in serum levels of cortisol, glucose, alanine aminotransferase and aspartate aminotransferase and decrease in serum sodium levels were observed in both copper-exposed groups, 3 d after copper exposure, which lasted until the end of the experiment. It is concluded that copper exposure causes stress response and sodium loss in common carp. Likewise alanine aminotransferase and aspartate aminotransferase increase after exposure which might be as results of either tissue damage or stress.

Tumor necrosis factor-alpha-induced reduction of glomerular filtration rate in rats with fulminant hepatic failure

The mechanism of renal failure during fulminant hepatic failure (FHF) or end-stage of liver disease is not fully understood. The present study aims to delineate the mechanisms of decreased glomerular filtration rate (GFR) in acute hepatic failure. A rat model of renal insufficiency in severe liver injury was established by lipopolysaccharide (LPS) plus D-galactosamine (GalN) exposure. GFR was evaluated by continuous infusion of fluorescein isothiocyanate–inulin with implanted micro-osmotic pumps. GalN/LPS intoxication resulted in severe hepatocyte toxicity as evidenced by liver histology and biochemical tests, whereas renal morphology remained normal. GFR was reduced by 33% of the controls 12 h after GalN/LPS exposure, accompanied with a decreased serum sodium levels, a marked increase in serum TNF-α and ET-1 levels as well as significantly upregulated renal type 1 inositol 1,4,5-trisphosphate receptor (IP3R1) expression. The upregulated IP3R1 expression was abrogated by the treatment of anti-TNF-α antibodies, but not by 2-aminoethoxydiphenylborate (2-APB), which blocks the inositol 1,4,5-trisphosphate signaling pathway. Treatments with either TNF-α antibodies or 2-APB also significantly improved the compromised GFR, elevated serum urea nitrogen and creatinine levels, and reversed the decrease in glomerular inulin space and the increase in glomerular calcium content in GalN/LPS-exposed rats. The extent of acute liver injury as reflected by serum ALT levels was much more attenuated by anti-TNF-α antibodies than by 2-APB. Liver histology further confirmed that anti-TNF-α antibodies conferred better protection than 2-APB in GalN/LPS-exposed rats. LPS-elicited TNF-α over-production is responsible for decreased GFR through IP3R1 overexpression, and the compromised GFR resulted in the development of acute renal failure in rats with FHF.

Safety and efficacy of desmopressin for the treatment of nocturia in elderly patients: a cohort study

Desmopressin is used widely to treat nocturnal polyuria (NP), but there is concern of hyponatremia especially in elderly patients. This study aimed to evaluate the safety and efficacy of long-term desmopressin treatment in elderly patients with NP. Patients who were ≥65 years old with NP were analyzed. All patients were started on 0.1 mg desmopressin, and the dose was escalated to 0.2 mg depending on patient symptoms. All patients were educated the mechanism of desmopressin. The voiding diary and serum sodium levels were evaluated at baseline, 3-7 days after starting treatment and every 3-6 months. Safety was evaluated by hyponatremia, hyponatremic symptoms and other adverse drug events. The mean changes in number of nocturia and nocturnal urine volume (NUV) were evaluated for efficacy. A total of 68 patients were included. The mean age was 72.6 (66-85) years. The mean night-time frequency was 3.0 ± 1.8 day, and the mean serum sodium level was 141.2 ± 2.1 mEq/L at baseline. The mean follow-up period was 27.9 months. The mean decrease in serum sodium level was 1.3 ± 3.4 mEq/L at the last follow-up (p = 0.003). Hyponatremia incidence was 4.4 %, and all patients recovered by stopping medication. Severe adverse events were not observed. The mean night-time frequency had decreased by 2.1, and the NUV had decreased by 374.2 ± 261.3 mL at the last follow-up (p < 0.001). Desmopressin at doses below 0.2 mg is safe and effective in elderly patients with NP if patients are well informed and are closely followed up.

Low serum sodium level during cardiopulmonary bypass predicts increased risk of postoperative stroke after coronary artery bypass graft surgery

Rapid decreases in serum sodium levels are associated with altered mental status, seizures, and coma. During cardiac surgery, serum sodium levels decrease rapidly when cardiopulmonary bypass is initiated because cardiopulmonary bypass causes hemodilution. However, whether this decrease influences neurologic outcome after cardiac surgery remains unclear. We investigated whether the average serum sodium level during cardiopulmonary bypass is independently predictive of postoperative stroke or 30-day all-cause mortality in patients who undergo primary coronary artery bypass grafting. In a single-institution, retrospective cohort of 2348 consecutive patients who underwent primary, isolated coronary artery bypass grafting, sequential multivariate logistic regression was performed to determine the threshold below which the average serum sodium level during cardiopulmonary bypass independently predicts postoperative stroke or early death. To further test the validity of this threshold and to control for selection bias, stepwise multivariate logistic regression was also performed on propensity score-matched patients (n=924). An average serum sodium level less than 130 mEq/L during cardiopulmonary bypass was independently predictive of stroke, both in the entire study cohort (1.44% vs 2.92%; odds ratio, 2.09; 95% confidence interval, 1.1-4.1; P=.03) and in the propensity-matched patients (0.9% vs 3.0%; odds ratio, 4.1; 95% confidence interval, 1.3-13.0; P=.02). The average serum sodium level during cardiopulmonary bypass was not independently associated with early death, regardless of what threshold value was used. An average serum sodium level of less than 130 mEq/L during cardiopulmonary bypass is independently associated with an increased risk of postoperative stroke in patients who undergo primary coronary artery bypass grafting.

Initial serum sodium concentration determines the decrease in sodium level after terlipressin administration in patients with liver cirrhosis

BackgroundTerlipressin, as a prodrug of vasopressin, has agonistic effects on the V1 receptor and partial agonistic effects on renal vasopressin V2 receptors. However, its effects on serum sodium concentration are controversial.MethodsThis study retrospectively investigated 127 patients with liver cirrhosis to examine the incidence and risk factors for the decrease in serum sodium level following terlipressin administration.ResultsTerlipressin was prescribed for bleeding control (99) and management of hepatorenal syndrome (28). Serum sodium level decreased from 134.0 ± 6.5 mmol/L to 130.4 ± 6.2 mmol/L during or after terlipressin treatment (P < 0.001) in all patients. In 45 patients (35.4%), the serum sodium concentration decreased by > 5 mmol/L, in 29 patients (22.8%); by 5–10 mmol/L; and in 16 patients (12.6%), by > 10 mmol/L. Five patients in the latter group showed neurological manifestations. In the univariate analysis, several factors including age, purpose of use, serum creatinine, and Model for End-Stage Liver Disease score, representing liver function, were significantly associated with the decrease in serum sodium after terlipressin administration. However, a multivariate analysis revealed that only initial sodium level was the most powerful predictor of terlipressin-induced reduction in serum sodium.ConclusionAn acute reduction in serum sodium concentration was not uncommon during terlipressin treatment, and the baseline serum sodium level was closely related to the reduction in serum sodium concentration.

Determinants of mortality in patients with heart failure and atrial fi brillation during long-term follow-up

Background Heart failure (HF) and atrial fi brillation (AF) often occur together. Both are independently associated with an increased mortality. Clinical parameters associated with mortality in patients with HF such as left ventricular ejection fraction (LV-EF) and New York Heart Association (NYHA) functional class are infl uenced by AF. If these parameters are still determinants of mortality when HF is complicated by AF, or if other parameters determine mortality in this case is unknown.Methods and resultsWe studied 173 consecutive HF patients (mean age 67 ± 12 years, 30% female) in New York Heart Association (NYHA) functional class 2.6 ± 0.8 with left ventricular systolic dysfunction (ejection fraction ≤ 45%) and AF. Mortality was 42% after a mean follow-up of 41 months. Age (OR 1.04, CI 1.01-1.07, P= 0.003), chronic obstructive pulmonary disease (OR 2.07, CI 1.15-3.73, P= 0.015), elevated serum creatinine at admission (OR 1.25, CI 1.01-1.54, P= 0.033), prolongation of QRS duration (OR 1.02, CI 1.01-1.54, P= 0.001), decreased serum sodium at admission (OR 0.94, CI 0.89- 0.99, P= 0.026) and oral anticoagulation (OR 0.59, CI 0.36-0.99, P= 0.046) were independently associated with mortality when assessed with multivariable Cox proportional hazard analysis. Importantly, mortality was not associated with NYHA functional class or left ventricular ejection fraction (LVEF).Conclusions Elevated creatinine levels, decreased serum sodium levels, prolongation of QRS duration and the presence of COPD are associated with long-term mortality after hospitalization in patients with HF and AF. Oral anticoagulation is associated with better survival. LVEF and NYHA functional class are no reliable mortality markers in this patient population.

Hyponatremia associated with selective serotonin reuptake inhibitors, mirtazapine, and venlafaxine in Korean patients with major depressive disorder

Several reports of hyponatremia associated with the use of antidepressants such as selective serotonin reuptake inhibitors (SSRIs) have been published. This study compared the incidence of hyponatremia associated with SSRIs to that associated with mirtazapine and with venlafaxine in patients with major depressive disorder (MDD). This retrospective study examined MDD in patients treated with an antidepressant over at least 4 weeks. Using medical records of 93 patients treated with an SSRI (paroxetine, sertraline, escitalopram, and fluoxetine), 76 patients treated with mirtazapine, and 71 patients treated with venlafaxine, we analyzed demographic variables and changes in serum sodium levels (at baseline and Week 4). Eight SSRIs group patients (8.6%) and three venlafaxine group patients (4.2%) exhibited mild hyponatremia during the study period. The SSRIs group's serum sodium level decreased only slightly, but significantly during treatment; however serum sodium levels in the mirtazapine and venlafaxine groups did not change significantly. The risk of developing hyponatremia while on an SSRI was greater in elderly subjects (60 years and older). These results indicate that, among patients with MDD, SSRIs treatment may be associated with decreased serum sodium levels, and the elderly patients are at greater risk for hyponatremia. Further prospective studies would help clarify the relative risks of hyponatremia among various antidepressants.

Minimally Invasive Percutaneous Ablation of Parapelvic Renal Cysts and Caliceal Diverticula Using Bipolar Energy

The use of bipolar electrocautery has proven advantages over monopolar energy during transurethral surgery by limiting hyponatremia and its clinical sequelae. Percutaneous ablation of caliceal diverticula and parapelvic renal cysts has been shown to be an effective surgical approach for the management of these conditions when clinically indicated. We present single center results of percutaneous ablation of renal cysts and caliceal diverticula using a bipolar energy technique and compare the results with a cohort of patients undergoing the procedure using monopolar energy. Between July 2006 and June 2010, 30 patients with caliceal diverticula and renal cysts underwent percutaneous ablation using the bipolar resection system with saline irrigation (group 1). This group was compared with a cohort of 19 patients who underwent traditional ablation using a standard resectoscope, monopolar energy, and glycine irrigation (group 2). We evaluated operative times, change in hematocrit and serum sodium levels from preoperative levels, complication rates, as well as symptomatic and radiographic success rates. The mean operative times were 87 minutes and 63 minutes for groups 1 and 2, respectively (P = 0.07). The mean percent decrease in hematocrit was 3.27 ± 1.93 in group 1 and 3.82 ± 2.09 in group 2 (P = 0.16), and the mean decrease in serum sodium level was -0.21 ± 2.24 mEq/L in group 1 and 3.78 ± 2.18 mEq/L in group 2 (P < 0.001). There were no intraoperative complications. One patient needed ureteral stent placement for persistent urine leak. All patients with symptomatic renal cysts reported resolution of their discomfort, with radiographic success confirmed in 89% in group 1 and 79% in group 2 (P = 0.41). Percutaneous ablation of caliceal diverticula and renal cysts using a bipolar resection system is feasible and appears to have efficacy similar to that of the monopolar system. In addition, use of isotonic saline as the irrigation medium appears to reduce the risk of postoperative hyponatremia.

Pilot safety study of low-dose vasopressin in non-septic critically ill children

To assess the safety of low-dose vasopressin infusion in critically ill children requiring prolonged mechanical ventilation (MV) at risk of developing sedation/analgesia-related hypotension. Randomized pilot safety study in children expected to require MV for at least 3 days. Children received either vasopressin (0.0005 U/kg/min) or sodium chloride (0.9%) infusion for a period of 48 h. Haemodynamic variables, urine output and serum electrolytes were closely monitored and analyzed. Twelve children in each group had similar baseline characteristics. Vasopressin infusion was associated with an 8 mmol/L fall in serum sodium concentration (p < 0.01) and with higher incidence of hyponatraemia (8 vs. 66%, p < 0.01). In normotensive children, low-dose vasopressin also induced a reversible decrease in urine output, and acutely increased blood pressure (p < 0.01). After stopping the vasopressin there was rebound hypotension (p < 0.01). Low-dose vasopressin infusion in haemodynamically stable, but critically ill, children is associated with reduction in urine output and decreased serum sodium level, yielding a high incidence of hyponatraemia. We conclude that these effects limit further study of prophylactic vasopressin for sedation-related hypotension in a randomized controlled trial.

Syndrome of Inappropriate Secretion of Antidiuretic Hormone Associated with Imatinib

To describe a patient with Bcr-abl(+) acute lymphoblastic leukemia who developed the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) while being treated with high-dose imatinib. A 29-year-old woman was diagnosed with Bcr-abl(+) acute lymphoblastic leukemia, and treatment was initiated with chemotherapy and imatinib 800 mg daily. Following imatinib initiation, a gradual decrease in serum sodium level was noticed. Prolonged aplasia and neutropenic fever prompted discontinuation of therapy for 4 weeks. Following the patient's recovery, complete remission was achieved and monotherapy with imatinib 800 mg daily was restarted; however, hyponatremia recurred a few days later. The clinical findings and laboratory workup were compatible with the diagnosis of SIADH, which was attributed to high-dose imatinib. Fluid restriction and imatinib dosage reduction (to 600 mg/day) restored sodium levels. According to the Naranjo probability scale, this adverse reaction was probably associated with imatinib. Imatinib emerged as the first tyrosine kinase inhibitor to enter everyday clinical practice for the treatment of Ph(+) leukemias. Due to its molecular specificity, imatinib lacks the broad cytotoxicity of conventional chemotherapy. Inhibition of kinases in normal tissues accounts for many of imatinib's adverse reactions. To our knowledge, this is the first reported case of imatinib-induced SIADH. We recommend monitoring for SIADH if a patient receiving high-dose imatinib develops hyponatremia.

Hyponatremia Impairs Early Posttransplantation Outcome in Patients With Cirrhosis Undergoing Liver Transplantation

Hyponatremia is associated with reduced survival in patients with cirrhosis awaiting liver transplantation. However, it is not known whether hyponatremia also represents a risk factor of poor outcome after transplantation. We aimed to assess the effects of hyponatremia at the time of transplantation on posttransplantation outcome in patients with cirrhosis. Two-hundred forty-one consecutive patients with cirrhosis submitted to liver transplantation during a 4-year period (January 2000-December 2003) were included in the study. The main end point was survival at 3 months after transplantation. Secondary end points were complications within the first month after transplantation. Patients with hyponatremia (serum sodium lower than 130 mEq/L) had a greater incidence of neurologic disorders, renal failure, and infectious complications than patients without hyponatremia (odds ratio; 4.6, 3.4 and 2.7, respectively) within the first month after transplantation. By contrast, hyponatremia was not associated with an increased incidence of severe intra-abdominal bleeding, acute rejection, or vascular and biliary complications. Hyponatremia was an independent predictive factor of early posttransplantation survival. Three-month survival of patients with hyponatremia was 84% compared with 95% of patients without hyponatremia (P < .05). Survival was similar after 3 months. In patients with cirrhosis, the presence of hyponatremia is associated with a high rate of neurologic disorders, infectious complications, and renal failure during the first month after transplantation and reduced 3-month survival. In cirrhosis, hyponatremia should be considered not only a risk factor of death before transplantation but also a risk factor of impaired early posttransplantation outcome.

Cerebral Salt Wasting Syndrome After Calvarial Remodeling in Craniosynostosis

Hyponatremia and increased urine output after calvarial remodeling have been noted in pediatric patients with craniosynostosis. If not treated properly, patients develop hypoosmotic conditions that can lead to cerebral edema, increased intracranial pressure, and collapsed circulation. Postoperative hyponatremia after central nervous system surgery is considered as the syndrome of inappropriate antidiuretic hormone (SIADH) secretion. Recently, however, cerebral salt wasting syndrome (CSWS) instead of SIADH has been reported frequently. CSWS is associated with a decreased serum sodium level, increased urinary sodium level, increased urine output, decreased ECF volume, increased atrial natriuretic peptide (ANP) level, and increased brain natriuretic peptide (BNP) level. We experienced nine patients with craniosynostosis who underwent calvarial remodeling. By postoperative day 1, the ANP and BNP levels increased by 3-6 folds compared with the preoperative levels. They returned to the normal levels by postoperative day 5. The ADH level was within the normal range even after operation. The urinary sodium level increased in all patients by postoperative day 1 and 3. But the serum sodium level, and serum and urine osmolarity were normal due to appropriate replacement of sodium and fluid. After calvarial remodeling, the potential development of CSWS should be considered and distinguished from SIADH. The patients with CSWS require normal saline resuscitation and should prophylactically receive normal saline.

Issues in the Treatment of Epilepsy

Issues in the Treatment of Epilepsy

La Crosse Encephalitis in Children

La Crosse encephalitis is a mosquito-borne disease that can be mistaken for herpes simplex encephalitis. It has been reported in 28 states but may be underrecognized. We investigated the manifestations and clinical course of La Crosse encephalitis in 127 patients hospitalized from 1987 through 1996. The diagnosis was established by serologic testing for IgM and IgG antibodies to La Crosse virus. Data were collected by chart review. Most of the patients were school-aged children (mean [+/-SD] age, 7.8+/-3.5 years; range, 0.5 to 15.0). Symptoms included headache, fever, and vomiting (each in 70 percent or more of the patients), seizures (in 46 percent), and disorientation (in 42 percent). Thirteen percent had aseptic meningitis. Hyponatremia developed in 21 percent, and there were signs of increased intracranial pressure in 13 percent. Six patients, including three with cerebral herniation, underwent intracranial-pressure monitoring. The 13 patients (11 percent) whose condition deteriorated in the hospital had decreases in serum sodium levels (P=0.007), and increases in body temperature (P=0.003) at the time of deterioration. At admission, these patients more often had a history of vomiting (P=0.047) and a score of 12 or lower on the Glasgow Coma Scale (P=0.02) than the others; a trend toward a greater prevalence of seizures at admission was also evident in this group (P=0.07). All the patients survived, but 15 of them (12 percent) had neurologic deficits at discharge. Follow-up assessments, performed in 28 children, suggested an increase in cognitive and behavioral deficits 10 to 18 months after the episode of encephalitis. La Crosse virus infection should be considered in children who present with aseptic meningitis or encephalitis. Hyponatremia and increasing body temperature may be related to clinical deterioration.

Experience with Isotonic 2.2% Glycine as Distension Medium for Hysteroscopic Endomyometrial Resection

The feasibility of performing hysteroscopic endomyometrial resection using isotonic 2.2% glycine as distension medium was studied in 181 consecutive operations. A standard continuous flow loop-resectoscope was used. Distension was achieved by means of a gravity-fed system and glycine flowed out under its own pressure. The mean (±SEM) glycine deficit was 160 ± 20 ml and in only 7 patients was it >1 liter (maximum 1,800 ml). Only in patients with >1 liter glycine absorption was there a significant decrease in serum sodium level (mean 9 mmol/l), while serum osmolality remained normal. Apart from 1 case of transient nausea, these patients had no sequelae. We experienced isotonic 2.2% glycine as a useful and safe distending medium for operative hysteroscopy.