Mild Hyponatremia Research Articles

Impact of chronic hyponatremia on neurocognitive and neuromuscular function

Chronic hyponatremia is common and associated with increased morbidity and mortality. However, whether treatment improves outcome in patients without significant symptoms is unclear. We here assessed the therapeutic outcome on clinical symptoms, neurocognitive and neuromuscular function in patients with chronic non profound hyponatremia. Prospective case-control study in 19 patients from the University Hospital Würzburg with chronic non profound hyponatremia without clinically apparent symptoms. At baseline and after a 14-day treatment period of hyponatremia, patients were assessed by specific clinical symptoms questionnaire, neurocognitive and neuromuscular function was analysed by five attention tests and a gait test consisting of 3 steps "in tandem." The results were compared to a control group of healthy volunteers. Compared to healthy volunteers, patients with mild (n=10, mean serum sodium 132±1.2mmol/L) and moderate hyponatremia (n=9, mean 126±3.3mmol/L) performed significantly worse in the neurocognitive subtests alertness (P=0.018), divided attention (P=0.017) and go/no-go (P=0.026). Performance in the neuromuscular subtests was also lower in the patient group without reaching significance. The extent of hyponatremia had no impact on the specific test and questionnaire results. Fourteen-day treatment of hyponatremia improved clinical symptoms in all patients (P=0.003) and neurocognitive function in sodium-normalised patients (go/no-go test, P=0.029). Chronic hyponatremia is symptomatic and impairs neurocognitive and neuromuscular function. Short-time therapeutic intervention led to improved clinical symptoms and neurocognitive function, but had no effect on neuromuscular function. Larger trials with long-term treatment are needed to specify the therapeutic need in chronic hyponatremia.

Effect of different serum sodium levels on heart function and prognosis in very elderly patients with heart failure

Objective To investigate the effect of different serum sodium levels on heart function and prognosis in very elderly patients with heart failure. Methods Totally 152 elderly patients(aged ≥ 85 years)with hyponatremia were enrolled.Based on the serum sodium level, they were divided into mild(125 mmol/L≤ Na+ <135 mmol/L), moderate(125 mmol/L ≤Na+ < 135 mmol/L), and severe hyponatremia(Na+ < 115 mmol/L)groups, and 76 patients with normal blood sodium level(Na+ ≥ 135 mmol/L)were selected as control group.The general data, levels of serum creatinine and N-terminal pro-brain natriuretic peptide(NTproBNP)and prognosis were compared among the above groups. Results Compared with the control group, patients with severe hyponatremia were much older, with more diuretics administration, higher level of serum creatinine, lower level of eGFR and left ventricular ejection fractions[(38.1±3.9)% vs.(45.2±9.7)%]. There were higher incidences of coronary atherosclerotic heart disease[72.4%(n=21)vs. 56.6%(n=43)], diabetes[41.4%(n=12)vs. 23.7%(n=18)], chronic renal insufficiency[22.6%(n=8)vs. 11.8%(n=9)], stroke[20.6%(n=6)vs. 9.2%(n=7)]in patients with severe hyponatremia compared with other groups.The severe hyponatremia group showed significantly higher levels of NTproBNP[(4 823.9±588.1)ng/L vs.(1 124.4±349.1)ng/L, (1 836.2±369.3)ng/L, (2 894.1±687.3)ng/L]and higher rates of mortality[27.6%(n=8) vs.5.3%(n=4), 7.6%(n=6), 13.6%(n=6)]as compared to the control group, mild and moderate hyponatremia groups.Furthermore, length of stay in hospital were markedly longer in patients with severe hyponatremia than those with mild and moderate hyponatremia[(11.1±7.1)d vs.(19.6±5.7)d, (16.1±4.2)d]. Conclusions Hyponatremia is a common type of electrolyte disorder in very elderly patients with heart failure, and severe hyponatremia may predictand increased risk of death. Key words: Hyponatremia; Heart failure; Prognosis

Serum sodium level in dengue infected children: a retrospective study

Background: Dengue fever is one of the most common arbo virus mediated outbreaks, being reported from different parts of the world. Now as the outbreaks are hitting different geographic locations, different clinical manifestations are being reported recently. Aim of this study is to document the serum Sodium level in dengue infected children in a tertiary care centre.Methods: A total 128 cases of NS1 antigen, IgM positive or ELISA positive dengue patients were included in this observational study and analyzed.Results: The serum Sodium level in dengue varies according to the different groups. In group A (dengue with no warning signs) the serum Sodium level was normal, whereas in case of group B (dengue with warning signs), there was significant hyponatremia. In group C, severe dengue the serum Sodium was normalConclusions: Mild hyponatremia is a common electrolyte disturbance in patients with dengue with warning signs. Hence, the lower the serum Sodium levels the higher is the incidence of complications associated with dengue fever.

Frequency of electrolyte imbalance associated with cisplatin in oral cancer patients; a tertiary care experience from Pakistan

Introduction: Electrolyte imbalance associated with cisplatin is quite prevalent, and increase morbidity in cancer patients. Objectives: To determine the frequency of electrolyte imbalance associated with cisplatin in oral cancer patients. Patients and Methods: Oral cancer patients of more than 16 years of age, who received cisplatin-based cancer chemotherapy, were monitored for electrolyte imbalance (Na, K, Ca and Mg). Patients who were as the known cases of kidney disease (acute or chronic) or those having electrolyte imbalance prior to start of chemotherapy were excluded. Primary outcome was to determine electrolyte imbalance. Results: Among 98 patients, 90 patients developed electrolyte imbalance to cisplatin chemotherapy. The observed electrolyte imbalance included hyponatremia, hypokalemia, hypomagnesemia and hypocalcaemia. Hypokalemia is found to be the most common electrolyte to be affected in the patients (91.8%), whereas hypocalcemia in 88.7%, hypomagnesemia in 67.34% is also observed. Mild hyponatremia is also observed less frequently in 67% of patients. Conclusion: Cisplatin-based chemotherapy has a high potential to cause electrolyte imbalance. Most of the abnormalities were of milder nature and not associated with symptoms. The common electrolyte abnormalities such as hypokalemia, hypocalcemia and hypomagnesemia were statistically significant, but hyponatremia was not statistically significant.

Effects of Allocating Livers for Transplantation Based on Model for End-Stage Liver Disease–Sodium Scores on Patient Outcomes

The Model for End-stage Liver Disease and Sodium (MELD-Na) score was introduced for liver allocation in January 2016. We evaluated the effects of liver allocation, based on MELD-Na score, on waitlist and post-transplantation outcomes. We examined 2 patient groups from the United Network for Organ Sharing registry; the MELD-period group was composed of patients who were registered as transplant candidates from June 18, 2013 through January 10, 2016 (n= 18,850) and the MELD-Na period group was composed of patients who were registered from January 11, 2016 through September 30, 2017 (n= 14,512). We compared waitlist and post-transplantation outcomes and association with serum sodium concentrations between groups. Mortality within 90 days on the liver waitlist decreased (hazard ratio [HR] 0.738, P < .001) and transplantation probability increased significantly (HR 1.217, P < .001) in the MELD-Na period. Although mild, moderate, and severe hyponatremia (130-134, 125-129, and <125 mmol/L) were independent risk factors for waitlist mortality in the MELD period (HR 1.354, 1.762, and 2.656; P< .001, P < .001, and P < .001, respectively) compared with the reference standard (135-145 mmol/L), these adverse outcomes were decreased in the MELD-Na period (HR 1.092, 1.271 and 1.374; P= .27, P= .018, and P= .037, respectively). The adjusted survival benefit of transplant recipients vs patients placed on the waitlist in thesame scorecategories was definitive for patients with MELD-Na scores of 21-23 in the MELD-Na era (HR 0.336, P<.001) compared with MELD scores of 15-17 in the MELD era (HR0.365, P < .001). Liver allocation basedon MELD-Na score successfully improved waitlist outcomes and provided significant benefit to hyponatremic patients. Given the discrepancy in transplantation survival benefit, the current rules for liver allocation might require revision.

Incidence of pathologic postobstructive diuresis after resolution of ureteropelvic junction obstruction with a normal contralateral kidney

Postobstructive diuresis (POD) after unilateral pyeloplasty or percutaneous nephrostomy (PCN) tube insertion for ureteropelvic junction obstruction (UPJO) in patients with a normal contralateral kidney is not well described. The objective of this study was to determine the incidence and characteristics of POD after relief of unilateral UPJO in patients with a normal contralateral kidney. Children who underwent a unilateral pyeloplasty or PCN for UPJO from 2010 to 2017 with a normal contralateral kidney were retrospectively reviewed. Postobstructive diuresis was defined as urine output (UO) of >300% of expected UO. Patients with a solitary kidneyor those who underwent bilateral pyeloplasty or bilateral PCN tube placement were excluded. Out of 396 children meeting inclusion criteria, seven (1.8%) developed POD (4 after pyeloplasty and 3 after PCN tube placement). Median age at intervention was 1.7 years (range 11 days-18 years); median weight was 11.4kg (range 3.7-54.2kg). Postobstructive diuresis was more likely to occur in patients with grade 4 hydronephrosis (3.0%) and larger kidneys and if a PCN tube was placed before pyeloplasty. There was no significant difference in age, gender, kidney laterality, or function between those who developed POD and those who did not. Postobstructive diuresis was managed with additional intravenous fluids and electrolyte monitoring. Median initial postprocedure UOwas 5.9mg/kg/hr (range 3.2-10.0mg/kg/hr). In five children who underwent PCN in whom UOcould be differentiated between kidneys, median initial postprocedure UOwas 6.1mg/kg/hr (range 2.5-9.1mg/kg/hr) from the affected side and 0.8mg/kg/hr (range 0.4-0.9mg/kg/hr) from the unaffected side. The median length of time to resolution of POD was 3 days (range 2-4 days). One patient developed significant acidosis and lethargy that improved with intravenous fluid management. Mild hyponatremia developed in two, hypokalemia in one, hypophosphatemia in one, acidosis in one, and hypoglycemia in 1 patient. A low but clinically significant risk of POD occurring after relief of unilateral UPJO in children with a normal contralateral kidney is described. Limitations include retrospective analysis and small sample size due to the rarity of the condition. Postobstructive diuresis after decompression of UPJO in patients with a normal contralateral kidney is a rare event (1.8%). However, POD does occur, and patients should be carefully monitored after these procedures given the potential for significant dehydration and electrolyte disturbances.

Hyponatraemia in Acute Confusional States and Coma

Background: Though hyponatraemia is a common scenario in our daily clinical practice, the mortality and morbidity are very high without early detection and prompt treatment. Both under and over treatment of hyponatraemia may cause permanent brain damage. Proper and meticulous treatment may prevent development of permanent brain disorder. So, a study was carried out to see the prevalence of hyponatraemia in acute confusional states and coma. The effect of hyponatraemia on consciousness level was also observed.Materials &amp; Methods: A cross sectional study.Results: A total number of sixty (60) cases with acute confusional state and coma were recruited in our study. Among 60 patients with acute confusional states including coma, 85% (51) patients were presented with hyponatraemia. In the study, mild, moderate and severe hyponatraemia were 20%, 13.33% and 51.67% respectively. Of the total study population, 31.67%, 33.33% and 35% presented with coma, stupor and drowsiness respectively. Severe hyponatraemia was found in 68.42% in comatose, 50% in stuporous and 38.1% in drowsy patients. 47.06% of hyponatraemic patients were noticed in several intracranial disorders. Hepatic encephalopathy, gastrointestinal disorders, chronic renal failure and ischemic heart disease comprised 13.73%, 11.76%, 9.80% and 5.89% respectively. Diabetic ketoacidosis and hypoglycaemic shock comprised 3. 92% each and congestive heart failure and acute respiratory distress syndrome comprised 1.96% each of hyponatraemic patients.Conclusions: Hyponatraemia is a common clinical problem in our day to day clinical practice. If neglected this may result in permanent brain malfunction which may be prevented with earlier detection and correction under meticulous supervision.J MEDICINE JUL 2018; 19 (2) : 110-113

Clinical characteristics of acute encephalopathy with acute brain swelling: A peculiar type of acute encephalopathy

ObjectivesAcute encephalopathy has been observed with acute brain swelling (ABS) that is characterized by rapid progression to whole-brain swelling. The objective of this study was to describe the clinical characteristics of ABS. MethodsWe encountered four patients with ABS and retrospectively investigated their clinical data with a medical chart review. ResultsThree patients had seizure clustering or status epilepticus in the clinical course. Signs of elevated intracranial pressure (ICP) appeared 3–9 h after the first convulsive attack in three patients. In all patients, signs of brainstem involvement appeared 1–8 h after signs of elevated ICP. Mild hyponatremia that progressed after signs of elevated ICP appeared was noted in three patients. Brain CT revealed mild brain swelling in the initial phase, which rapidly progressed to whole-brain swelling. No focal abnormalities were detected on brain MRI in one patient. Continuous electroencephalography was initially normal, but in two patients, high-amplitude slow waves appeared with rapid changes before signs of brainstem involvement. Although recovery was achieved without sequelae in two patients, outcome was fatal for the other two. ConclusionsThe pathogenesis of ABS has yet to be clarified, but clinical features in our patients are not consistent with any established subtypes of acute encephalopathy. Therefore, we believe that ABS should be recognized as a new type of acute encephalopathy.

Uremic encephalopathy in a rhesus macaque (Macaca mulatta): A case report and a brief review of the veterinary literature.

Uremic encephalopathy is uncommon yet is one of the most severe complications of renal failure. We present a case of acute renal failure and associated cerebral and vascular lesions consistent with uremic encephalopathy in a rhesus macaque (Macaca mulatta). A 14-year-old, female, specific-pathogen-free rhesus macaque presented in lateral recumbency, obtunded, severely dehydrated, and hypothermic, with severe azotemia, mild hyponatremia, hypokalemia, hypochloremia, increased anion gap, and hypercholesterolemia. Due to poor prognosis, the animal was euthanized and a complete necropsy was conducted. The animal had diffuse proximal renal tubular epithelial necrosis and loss; regeneration of tubular epithelium was not observed. There was bilateral necrosis and loss of neurons and glial cells in the hippocampus and deep cerebral cortex with edema and multifocal areas of hemorrhage. We present the first reported case of uremic encephalopathy in a rhesus macaque and describe the associated cerebral and vascular lesions.

Effectiveness of Alpha Chymotrypsin on the Treatment of Severe Paralysis due to Bungarus Multicinctus Snakebite

Background: In Vietnam, there are two main species of Bungarus: Bungarus multicinctus and Bungarus candidus. Trypsin is a serine protease digestive enzyme that has demonstrated efficacy in some of Elapidae envenomations. After their experiments with dogs and mice, Hsiung Yu-Liang et al. concluded the local injection of trypsin can be used in clinical practice as a new and effective therapy for snakebite. We report a case of successful application of alphachymotrypsin, a related enzyme, in the treatment of severe paralysis due to B. multicinctus snakebite. Case presentation: A 38-year-old man was bitten on his left hand by B. multicinctus. Two hours after the bite, the patient developed a sore throat, diffuse myalgia, and progressive paralysis. Since antivenom was not available, we decided to administer alphachymotrypsin after the risks and benefits were carefully discussed. A dose of 5000 IU alphachymotrypsin was administered by the IM route at 24 and 31 hours after bite. At the time of the first dose of alphachymotrypsin, muscle power was 0/5. The muscle power improved rapidly, from 0/5 (24 hours) to 2/5 (at 44 hours). After that, additional doses of 10.000 IU of alphachymotrypsin were administered at 45, 55, 69, 75, 94 and 100 hour after the bite; the muscle power increased gradually then to 3/5 (66 hours), 4/5 (75 hours), and 5/5 (97 hours). Discussion: The severity of the patient can be estimated through some factors as following: the heavier and longer the nake, the more severe the threat, time from bite to symptoms: the sooner the more severe, the level of paralysis, and the level of hyponatremia. According to these signs, the patient was classified under the severe group because the snake was long and heavy (1.5 m and 300 gr), symtoms appeared right after 2 hours after the bite, and level of paralysis was 0/5 17 hours after the bite. The mild hyponatremia could be related to either a minor B. multicinctus envenomation, which is unlikely given the severity of the other clinical findings, or the effectiveness of alphachymotrysin. This hypothesis requires further investigation, both mechanistically and clinically. Conclusion: The use of alphachymotrypsin was associated with a shortening of the need for mechanical ventilation, length of ICU stay, and a reduced extent of hyponatremia in a patient with severe B. multicinctus envenomation.

Hyperglycemia-related central pontine demyelinization after a binge-eating attack in a patient with type-2 diabetes: a case report

BackgroundHere, we report a case of central pontine demyelinization in a type-2 diabetes patient with hyperglycemia after a binge-eating attack in the absence of a relevant hyponatremia.Case presentationA 55-year-old, male type-2 diabetic patient with liver cirrhosis stage Child-Pugh B was admitted due to dysmetria of his right arm, gait disturbance, dizziness, vertigo, and polyuria, polydipsia after a binge-eating attack of sweets (a whole fruit cake and 2 Liters of soft drinks). A recently initiated insulin therapy had been discontinued for 8 months. A serum glucose measurement obtained 5 days prior to hospitalisation was 38.5 mmol/l (694 mg/dl). The patient graved for sweets since stopping alcohol consumption 8 months earlier. On admission, venous-blood glucose was 29.1 mmol/l (523.8 mg/dl), glycated hemoglobin was 168.0 mmol/mol or 17.6%. No supplementation of sodium chloride was reported. Laboratory exams revealed an elevated serum ammonia level (127.1 μmol/l), rendering a hepatic encephalopathy very likely. After initiation of insulin therapy, capillary glucose normalized, and serum sodium rose from 133 on admission to 144 mmol/l during the hospital stay. In retrospect, the mild hyponatremia on admission was classified as pseudohyponatremia due to hyperglycemia. The patient had an insulin resistance (HOMA-IR 7.8 (normal range < 2.5)). A T2-weighted magnetic resonance imaging (MRI) of the head and a cranial computed tomography scan were obtained demonstrating a symmetric central pontine demyelinization. After 26 days in hospital, the patient was discharged with an inkretin-mimetic therapy (dulaglutide SC, 1.5 mg/week) and an intensified conventional insulin therapy (insulin aspart: 14 units/d in euglycemia, insulin glargin 20 units/d).ConclusionsCentral pontine and/or cerebellar myelinolysis can be caused by sudden, severe, and sustained hyperglycemia, especially when another risk factor (in this case, liver cirrhosis) is present. Functional neurological deficits in the context of hyperglycemia should prompt for the consideration of this differential diagnosis in all diabetes patients.

Serum Sodium and Cognition in Older Community-Dwelling Men.

Mild hyponatremia is a common finding in older adults; however, the association of lower serum sodium with cognition in older adults is currently unknown. We determined whether lower normal serum sodium is associated with cognitive impairment and risk of cognitive decline in community-dwelling older men. Five thousand four hundred thirty-five community-dwelling men aged ≥65 years who participated in Osteoporotic Fractures in Men, a cohort study with a median follow-up for cognitive function of 4.6 years, were included in this analysis. Multivariable logistic regression was used to examine the association between baseline fasting serum sodium levels and the odds of prevalent cognitive impairment (cross-sectional analysis; modified Mini-Mental Status [3MS] score <1.5 SD [<84] below or Trail Making Test Part B time >1.5 SD above the mean [>223 seconds]) and cognitive decline (prospective analysis [n=3611]; decrease in follow-up 3MS score or increase in Trails B time >1.5 SD of the mean score/time change [>9 or >67 seconds]). Participants were aged 74±6 years with a fasting mean serum sodium level of 141±3 mmol/L. Fifteen percent (n=274), 12% (n=225), and 13% (n=242) had prevalent cognitive impairment in tertiles 1, 2, and 3, respectively. After adjustment, lower serum sodium was associated with prevalent cognitive impairment (tertile 1 [126-140 mmol/L] versus tertile 2 [141-142 mmol/L], odds ratio [OR], 1.30; 95% confidence interval [95% CI], 1.06 to 1.61). Fourteen percent (n=159), 10% (n=125), and 13% (n=159) had cognitive decline in tertiles 1, 2, and 3, respectively. Lower serum sodium was also associated with cognitive decline (tertile 1 versus tertile 2, OR, 1.37; 95% CI, 1.06 to 1.77). Tertile 3 (143-153 mmol/L) was additionally associated with cognitive decline. Results were similar in sensitivity analyses according to clinical cut-offs and by quartiles. In community-dwelling older men, serum sodium between 126-140, and 126-140 or 143-153 mmol/L, are independently associated with prevalent cognitive impairment and cognitive decline, respectively.

Effect of Kalzoral preparation on prevention of parturient paresis relapse, in dairy cows

This research describes 20 cases of cows with parturient paresis (controls), which were treated with intravenous administrations of calcium gluconate and dextrose, and intramuscular injection of vit. D3 . In 20 other cases (experimental group), a solution of 250g Kalzoral was administrated orally, after the treatment mentioned above. Thiw Klzoral is a preparation of Dr E. Graeub AG, Bern Switzerland, containing 22% Ca, 4% Ρ, 5% Mg, 200.000 IU/kg vit D3 , flavours and taste improvements. The administration of Kalzoral was repeated twice, in the same dose, 24 and 48 h after the first administration. The levels of Ca, Ρ, Mg Κ and Na in the blood serum of the cows were measured before starting the treatment and also 24 and 72 h after it. Both groups, during the disease presented hypocalcemia (serum Ca&lt;6,5 mg/dl), hypophosphatemia, mild hyponatremia, and normal concentrations of Mg and K. Six anomals (30%) of the controls group had a relapse within the first 24 h after the treatment. There was no relapse in the experimental group. The concentration of Ρ of the experimental cows came back to normal, the first day after the initial treatment while that of the controls, on the third. The concentration of Mg and Κ in the blood serum of all animals was found to be normal always. The initial hyponatremia of both groups remained at the same level, as it was indicated by the last two measurements and it appeared no connection to the parturient paresis. It was considered to be the result of insufficient addition of NaCl in the animals diet.

The study of incidence of post operative delirium in geriatric patients with hyponatremia undergoing coronary artery bypass grafting procedure in a tertiary care hospital

Delirium, defined as an acute disorder of attention and global cognitive function is a common, serious and potentially preventable source of morbidity and mortality in hospitalized elderly patients. Different studies have shown that existence of hyponatremia in perioperative period can contribute to delirium.To assess the incidence of post operative delirium in elderly patients with peri operative hyponatremia undergoing coronary artery bypass grafting (a major cardiac surgery).Prospective cohort study, Study Period: 1 ½ years. Using a prepared questionnaire after obtaining fully informed written consent. 3 visits for each patient: 1) before surgery, 2) in the ICU: 48 hours after surgery, 3) In ward after shifting out from ICU. Details from patients, care givers and nursing staff regarding features of delirium are obtained. Patients were classified into two groups, one group included patients with normal/mild hyponatremia (serum sodium&gt;/= 130 mEq/L) and other group with moderate to severe hyponatremia (serum sodium&lt;/=129.9) for convenience of analysis.Out of total 250 patients included in the study, 43 (17.2%) patients developed post operative delirium. Patients with moderate- severe hyponatremia had more chance for development of post operative delirium. Out of 146 patients with moderate- severe hyponatremia 37 (25.34%) patients developed post operative delirium compared to 6 (5.77%) patients with normal or mild hyponatremia (p:&lt;0.001). Hyponatremia in peri operative period is a risk factor contributing to post operative delirium and patient’s sodium levels should be closely monitored in peri operative period.

Enteric fever among children: 50 cases in a French tertiary care centre

Enteric fever in France is primarily travel-associated. Characteristics of paediatric cases are scarce and information from field studies in endemic countries might not be generalizable to non-endemic countries. In this retrospective study, we reviewed all cases of typhoid and paratyphoid fever treated in a French paediatric tertiary care centre from 1993 to 2015. Fifty cases of enteric fever due to Salmonella enterica serovar Typhi (n = 44) and Paratyphi (n = 6) were identified. Sixty-one percent of the children had travelled to Africa and 34% to the Indian subcontinent. Among travel-associated cases, 85% were visiting friends and relatives (VFR). Ninety-six percent had high fever associated with gastrointestinal symptoms. Anaemia (66%), elevated C-reactive protein (80%), transaminitis (87%) and mild hyponatremia (50%) were the main biological findings. Blood cultures were positive in 90% of cases. Twelve strains (24%) were resistant at least to one antibiotic, and all of them had been isolated since 2003, increasing the resistance rate during this last period to 43% (12/28). Ceftriaxone was administered to 71 patients for a median duration of 6 days (interquartile range (IQR): 4-8). The median time to apyrexia after the onset of treatment was 4 days (IQR: 2-5 days). Complications occurred in nine children with five (10%) presenting neurologic disorders. All 50 patients recovered. In France, paediatric enteric fever is mainly a travel-associated disease and occurs in patients returning from a prolonged stay in an endemic area. Children VFR are at high risk and should be a priority target group for pre-travel preventive measures. The increase in antibiotic resistance reflects the situation in endemic countries and is a major concern.

Safety and Efficacy of Tolvaptan in Korean Patients with Hyponatremia Caused by the Syndrome of Inappropriate Antidiuretic Hormone.

BackgroundThe aim of this multicenter study was to evaluate the safety and efficacy of tolvaptan (TLV) in Korean patients with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH).MethodsOf 51 enrolled patients with SIADH, 39 patients (16 female patients, aged 70.8 ± 11.3 years) were included in an intention to treat analysis. All patients received 15 mg/day as the initial dose, and the dose was then increased up to 60 mg/day (as needed) until day 4.ResultsSerum sodium increased significantly from baseline during the first 24 hours (126.8 ± 4.3 vs. 133.7 ± 3.8 mmol/L, P < 0.001), rose gradually between days 1 and 4 (133.7 ± 3.8 vs. 135.6 ± 3.6 mmol/L, P < 0.05), and then plateaued until day 11 (136.7 ± 4.5 mmol/L). The correlation between the change in serum sodium for the first 24 hours and initial serum sodium concentration was significant (r = −0.602, P < 0.001). In severe hyponatremia (< 125 mmol/L), the change was significantly higher (11.1 ± 4.8 mmol/L) than in moderate (6.4 ± 2.5 mmol/L, P < 0.05) or mild hyponatremia (4.3 ± 3.3 mmol/L, P < 0.01). In addition, logistic regression analysis showed that body weight (odds ratio [OR], 0.858; 95% confidence interval [CI], 0.775–0.976; P = 0.020) and body mass index (BMI) (OR, 0.692; 95% CI, 0.500–0.956; P = 0.026) were associated with rapid correction. No serious adverse events were reported, but in 13% of patients hyponatremia was overcorrected.ConclusionTLV is effective in correcting hyponatremia and well-tolerated in Korean patients with SIADH. However, those with low body weight, low BMI or severe hyponatremia, could be vulnerable to overcorrection with the initial dose of 15 mg TLV.

Characteristics and outcome of acute medical admissions with hyponatremia: even mild hyponatremia is associated with higher mortality

Hyponatremia is a common finding in hospitalized patients. In this retrospective cohort study we assessed the characteristics and outcome of acute medical admissions with hyponatremia. Compared to the normal sodium group, those with hyponatremia were significantly older and the Charlson Comorbidity Index (CCI) was higher. The number of admissions to MCU/ICU between both groups was similar, but hyponatremic patients had a longer length of stay and both 28-day and one-year mortality were higher, even in patients with mild hyponatremia. Hyponatremia was independently associated with mortality after adjustment for age, CCI and polypharmacy, as was found in the subgroup with mild hyponatremia.

Syndrome of inappropriate anti-diuresis induces volume-dependent hypercalciuria.

Chronic mild hyponatremia has been associated with bone demineralization of unknown mechanisms. During chronic hyponatremia, arginine-vasopressin secretion can result from hypovolemia or from syndrome of inappropriate anti-diuresis (SIAD) that leads to a slightly volemic expansion. Since volemia determines renal calcium excretion and balance, we evaluated calcium homeostasis in patients with chronic hyponatremia, related to SIAD or to hypovolemia. We retrospectively included all patients referred to our Department between May 2006 and May 2014 for hyponatremia, resulting from SIAD or chronic hypovolemia. None had edema, cirrhosis, cardiac, or renal insufficiency. Exploration included estimation of volemia, extracellular fluid volume (ECFV) measurement with inulin, and calcium homeostasis. In total, the SIAD and hypovolemic groups included 22 and 7 patients, respectively. The SIAD group exhibited signs of increased volemia: higher glomerular filtration rate, higher fractional excretion of uric acid, and lower plasma renin. ECFV exceeded that of the hypovolemic group and was above usual values. There was no difference between the two groups regarding plasma calcium, PTH, and vitamin D. However, in the SIAD group, calciuria was higher than in the hypovolemic group, reaching levels of hypercalciuria. Furthermore, there was a positive correlation between calciuria and markers of volemia. Our results show that SIAD results in a volemic expansion tendency that is associated with a decrease in renal calcium reabsorption and thus hypercalciuria, whereas in the hypovolemic group, calciuria was not increased. Therefore, renal loss of calcium and bone demineralization in SIAD patients could be partly induced by volemic expansion.

Bilateral multiple pulmonary artery aneurysms associated with cavitary pulmonary tuberculosis: a case report

BackgroundPulmonary artery aneurysms constitute <1% of aneurysms occurring in the thoracic cavity. Congenital cardiac defects are responsible for the majority (>50%) of cases, however, pulmonary artery aneurysm is a rare sequelae of pulmonary tuberculosis reported in about 5% of patients with chronic cavitary tuberculosis on autopsy. The natural history of this potentially fatal condition remains poorly understood and guidelines for optimal management are controversial.Case presentationA 24-year-old man, a nursing student of African descent, was referred to us from an up-country regional hospital with a 4-week history of recurrent episodes of breathlessness, awareness of heartbeats and coughing blood 3 weeks after completing a 6-month course of anti-tuberculosis drugs. A physical examination revealed conjuctival and palmar pallor but there were no stigmata of connective tissue disorders, systemic vasculitides or congenital heart disease. An examination of the cardiovascular system revealed accentuated second heart sound (S2) with early diastolic (grade 1/6) and holosystolic (grade 2/6) murmurs at the pulmonic and tricuspid areas respectively. Blood tests showed iron deficiency anemia, prolonged bleeding time, and mild hyponatremia. A chest radiograph revealed bilateral ovoid-shaped perihilar opacities while a computed tomography scan showed bilateral multiple pulmonary artery pseudoaneurysms with surrounding hematoma together with adjacent cystic changes, consolidations, and tree-in-bud appearance. Our patient refused to undergo surgery and died of aneurismal rupture after 9 days of hospitalization.ConclusionsThe presence of intractable hemoptysis among patients with tuberculosis even after completion of anti-tuberculosis course should raise an index of suspicion for pulmonary artery aneurysm. Furthermore, despite of its rarity, early recognition and timely surgical intervention of pulmonary artery aneurysm is crucial to reducing morbidity and preventing the attributed mortality.

Sodium levels on admission are associated with mortality risk in hospitalized patients

AimsAbnormal sodium values are common among hospitalized patients. We aimed to investigate the association of admission sodium values and mortality. MethodsHistorical prospectively data of adult patients hospitalized to medical wards between January 2011 and December 2013. Admission sodium values were classified to five categories: severe hyponatremia (<125mEq/L), mild hyponatremia (125–135mEq/L), normal sodium values (135–145mEq/L), mild hypernatremia (145–150mEq/L) and severe hypernatremia (>150mEq/L). Main outcomes were length of hospitalization, in-hospital mortality and mortality at the end-of-follow-up. ResultsThe cohort included 27,889 patients (mean age 67±18years, 52% males). The total follow-up was 1065days. Most patients had normal sodium values (76%), 22% had hyponatremia, 3% had hypernatremia. Mean age increased with increase in severity of hyponatremia or hypernatremia. Median length of hospitalization was longer with mild and severe hypernatremia (7 and 5days, respectively) or with mild and severe hyponatremia (4 and 4days, respectively), compared to normal sodium levels (3days). Compared to in-hospital mortality with normal sodium levels (5%), mortality was higher with mild and severe hyponatremia (9% and 14%, respectively) and was highest with mild (28%), and severe hypernatremia (52%). Mortality rate at the end of follow-up was 28% with normal sodium levels, 44% and 48% with mild and severe hyponatremia, 66% and 90% with mild and severe hypernatremia, respectively. ConclusionsAbnormal sodium values on admission were associated with longer hospitalization and increased short- and long-term mortality. Mortality risk was higher with hypernatremia, compared to hyponatremia.