Normal Serum Sodium Levels Research Articles

Exploration of predictors of benefit from nivolumab monotherapy for patients with pretreated advanced gastric and gastroesophageal junction cancer: post hoc subanalysis from the ATTRACTION-2 study

BackgroundThe phase 3 ATTRACTION-2 study demonstrated that nivolumab monotherapy was superior to placebo for patients with pretreated advanced gastric or gastroesophageal junction cancer, but early progression of tumors in some patients was of concern.MethodsThis post hoc analysis statistically explored the baseline characteristics of the ATTRACTION-2 patients and extracted a single-factor and double-factor combinations associated with early disease progression or early death. In the extracted patient subgroups, the 3-year restricted mean survival times of progression-free survival and overall survival were compared between the nivolumab and placebo arms.ResultsTwo single factors (age and peritoneal metastasis) were extracted as independent predictors of early progression, but none of them, as a single factor, stratified patients into two subgroups with significant differences in restricted mean survival time. In contrast, two double-factor combinations (serum sodium level and white blood cell count; serum sodium level and neutrophil–lymphocyte ratio) stratifying patients into two subgroups with significant differences in the restricted mean survival time were extracted. Additional exploratory analysis of a triple-factor combination showed that patients aged < 60 years with peritoneal metastasis and low serum sodium levels (approximately 7% of all patients) might receive less benefit from nivolumab, and patients aged ≥ 60 years with no peritoneal metastasis and normal serum sodium levels might receive higher benefit.ConclusionsA combination of age, peritoneal metastasis, and serum sodium level might predict benefit from nivolumab as salvage therapy in advanced gastric or gastroesophageal junction cancer patients, especially less benefit for patients having all three risk factors.

Changes in copeptin levels before and 3\xa0months after transsphenoidal surgery according to the presence of postoperative central diabetes insipidus

Copeptin levels reflect arginine vasopressin (AVP) release from the hypothalamus. Pituitary surgery often impairs AVP release and results in central diabetes insipidus (CDI). Here, we aimed to investigate how serum copeptin level changes 3 months after pituitary surgery and whether it has a diagnostic value for postoperative permanent CDI. Consecutive patients who underwent endoscopic transsphenoidal surgery at a single tertiary hospital were recruited. Serum copeptin levels were measured preoperatively and 3 months postoperatively. Among 88 patients, transient and permanent CDI occurred in 17 (19.3%) and 23 (26.1%), respectively. Three-month postoperative copeptin levels significantly declined from preoperative levels in permanent CDI group (P < 0.001, percentage difference = − 42.2%) and also in the transient CDI group (P = 0.002, − 27.2%). Three months postoperative copeptin level < 1.9 pmol/L under normal serum sodium levels was the optimal cutoff value for diagnosing permanent CDI with an accuracy of 81.8%, while 3-month postoperative copeptin level ≥ 3.5 pmol/L excluded the CDI with a negative predictive value of 100%. Conclusively, 3 months postoperative copeptin levels significantly decreased from preoperative levels in the transient CDI group as well as the permanent CDI group. Three-month postoperative copeptin levels ≥ 3.5 pmol/L under normal serum sodium levels may be diagnostic for excluding postoperative CDI.

An Unusual Case of Transient Diabetes Insipidus After Prolonged Vasopressin Infusion

Background: Vasopressin is a hormone produced in the hypothalamus and secreted by the posterior pituitary. Underproduction or resistance to vasopressin can lead to diabetes insipidus (DI) resulting in the imbalance of fluid status and serum sodium levels. Synthetic vasopressin is a common second line agent used in the critical care setting for its vasopressor effects with an added clinical benefit by increasing cerebral perfusion pressure. There have been reported cases of transient DI after discontinuation of vasopressin in neurosurgical patients, however only few cases have been reported in septic shock patients without neurological involvement. We present a case of transient DI during treatment for septic shock after attempts to wean off vasopressin infusion. Presentation: A 41-year-old female with history of type 2 diabetes mellitus, quadriplegia following a motor vehicle accident at age 11 was admitted to the surgical intensive care unit for urosepsis after placement of right ureteral stent. The patient was started on broad spectrum intravenous (IV) antibiotics and vasopressors norepinephrine and vasopressin. After 8 days of vasopressin treatment, with each effort to wean IV vasopressin, the patient was noted to have significant polyuria with urine output reaching as much as 800 mL/hr and increase in her serum sodium to a maximum of 148 mmol/L (n 145 mmol/L). During episodes of excessive diuresis, urine sodium reached 87 mmol/L, urine osmolality was 72 mOsm/kg (50-1400 mOsm/kg), and serum osmolality was 288 mOsm/kg (n 300 mOsm/kg). The patient received three doses of 1 microgram of desmopressin 24 hours apart while weaning off vasopressin. This helped slow excessive diuresis while also maintaining normal serum sodium levels. Urine output decreased to approximately 150 mL/hr after each administration of desmopressin. The serum sodium levels eventually stabilized between 135-140 mmol/L and urine output held steady around 200 cc/hr. The patient did not require additional desmopressin and was hemodynamically stable off all vasopressors. Discussion: The pathophysiology behind transient diabetes insipidus following vasopressin infusion is still unclear. It is known that in septic shock, there is depletion of vasopressin stores which suggests central DI. Yet, pharmacologic doses of vasopressin are speculated to downregulate V2 receptors in the renal distal convoluted tubules and collecting ducts which suggests nephrogenic DI. Our patient responded to desmopressin which indicates that she at least had a central component of DI. There is no consensus on the duration of vasopressin required to precipitate transient DI, but vasopressin infusion was administered for at least 24 hours in other cases prior to onset. We present a rare case of transient diabetes insipidus after prolonged vasopressin infusion that clinicians should be aware of in the critical care setting.

Acute hyponatremia after aneurysmal subarachnoid hemorrhage: Frequency, treatment, and outcome

We retrospectively examined the course of serum sodium levels in 180 patients with acute aneurysmal subarachnoid hemorrhage (SAH) who had been admitted to the anesthesiologic-neurosurgical intensive care unit of the University Medical Center Regensburg, Germany, between January 2014 and December 2018. Each patient file was analyzed regarding the frequency and intensity of hyponatremic episodes and the administered medication. At admission to the intensive care unit (ICU), 18patients had shown initial hyponatremia (<135 mmol/L) and 4 patients hypernatremia (greater than145 mmol/L). 88(48.9%) of the 158 patients with normal serum sodium levels developed at least one hyponatremic episode during ICU treatment. The number of hyponatremic episodes was similar between patients with higher-grade and lower-grade aneurysmal SAH (P = 0.848). At the end of ICU treatment, outcome did not differ between patients with and without hyponatremia (40/88, 45.5% vs. 38/70, 54.3%, P = 0.270). At 6 months after SAH, however, good outcome (Glasgow outcome scale, GOS 4–5) was more frequently observed in patients with hyponatremia (26/88, 29.5% vs. 32/70, 45.7%, P = 0.036). Medication with sodium chloride, fludrocortisone, or tolvaptan was initiated in 75.4% patients with mild hyponatremia (130–134 mmol/L) and in 92.9% with moderate hyponatremia (125–129 mmol/L). At 6 months after SAH, patients treated with tolvaptan had a lower rate of poor outcome than patients who had not received tolvaptan (1/14, 7.1% vs. 25/74, 33.8%, P = 0.045). In patients with acute aneurysmal SAH and hyponatremic episodes, consequent treatment of hyponatremia prevented impaired outcome. Because administration of tolvaptan rapidly normalized serum sodium levels, this therapy seems to be a promising treatment approach.

Comparison of isotonic versus hypotonic intravenous fluid for maintenance fluid therapy in neonates more than or equal to 34 weeks of gestational age – a randomized clinical trial

Background and objectives The use of hypotonic fluids as maintenance therapy in the neonatal population has been in practice for a long time, but there is a lack of evidence for the choice of this fluid in neonates. This study compared isotonic (sodium chloride, 0.9%, and dextrose, 5%) versus hypotonic (sodium chloride, 0.15%, and dextrose, 5%) intravenous fluid for maintenance fluid therapy in neonates more than or equal to 34 weeks of gestational age. Methods In this triple-blind randomized clinical trial, we recruited 60 neonates admitted to a neonatal intensive care unit of a tertiary care children's hospital from June 2017 through May 2018 with normal baseline serum sodium levels, anticipated to require intravenous maintenance fluids for 24 hours or longer (intention-to-treat analyses). Patients were randomized to receive isotonic or hypotonic intravenous fluid at maintenance rates for 72 hours. The primary outcome was the incidence of hyponatremia (defined as serum sodium <135mEq/L) at 24 hours in both groups. The secondary outcomes were incidence of hypernatremia at 24 hours (defined as serum sodium >145 mEq/L), the incidence of hypo and hypernatremia at 48 and 72 hours, mean serum sodium at 24, 48, and 72 hours, rate of change of serum sodium during the study period, mean serum osmolality at the end of the study period, the absolute difference in osmolality during the study period, the absolute difference in weight during the study period and edema during the study period. Results Of 60 enrolled neonates, 31 received isotonic fluids and 29 received hypotonic fluids. Three patients in the hypotonic group developed hyponatremia and none in isotonic group at 24 h (RR = 0.13; 95% CI = 0.007 − 2.485; p = .106). Fourteen neonates developed hypernatremia in the isotonic group and one in hypotonic group at 24 h (RR = 13.09; 95% CI = 1.83 − 93.4; p = .0001). Conclusions Our study results do not support the hypothesis that isotonic fluid is superior to hypotonic fluid in reducing the proportion of neonates developing hyponatremia after 24 hours of intravenous fluid therapy. The proportion of neonates developing hypernatremia is significantly higher after using isotonic fluid for maintenance therapy. TRIAL REGISTRATION CTRI/2017/05/008585

Diagnosis and follow-up of 2 cases of pediatric nephrogenic syndrome of inappropriate antidiuresis resulting from activating mutation in AVPR2 and literature review

Objective: To analyze the clinical and genetic features, as well as the treatment outcomes of two boys with nephrogenic syndrome of inappropriate antidiuresis (NSIAD) caused by gain-of-function mutations in the V2 vasopressin receptor gene (AVPR2). Methods: The clinical manifestations, genetic testing, therapeutic interventions and the outcomes of two boys with NSIAD hospitalized in the Department of Endocrinology, Beijing Children's Hospital in April 2019 were reported. A literature search with "Nephrogenic syndrome of inappropriate antidiuresis" and "AVPR2 gene" as keywords was conducted at the China national knowledge infrastructure (CNKI), the Wanfang Data Knowledge Service Platform, PubMed and Springer Link up to May 2020. Relevant published articles were reviewed. Results: The two cases presented with chronic and severe hyponatremia with hypo-osmolality, inappropriately elevated urinary osmolality and urinary sodium levels. The onset age was 5.25-years and 2 months respectively. AVPR2 sequencing revealed a previously described hemizygous activating mutation (c.409C>T, p.R137C) in both of boys, each inherited the variant from their mother. Patient 1 limited fluid intake by himself in his daily life, intravenous and oral sodium supplementations showed no significant increase of serum sodium level. Oral furosemide increased the serum sodium level and maintained it within normal range. The serum sodium and potassium levels were in the normal range during the 1-year follow-up period with oral furosemide. The serum sodium level of Patient 2 increased with restricting fluid intake and with salt supplementation. However, after he experienced respiratory infection, the plasma sodium level decreased. Subsequently, oral anti-infection medicine and furosemide were applied. The serum sodium level increased two days later and remained at a normal range afterwards. The boy was 1 year old with normal growth. He stopped taking furosemide after 4 months while taking 1 gram of salt per day, the blood sodium level maintained at normal range. Literature search identified no reports in Chinese journals, whereas 50 publications were found in English journals. A total of 30 NSIAD probands were reported and 16 of those (53%) had childhood onset, most presented with seizures. The majority had a hotspot change at the nucleotide position of 409 in AVPR2. Nine cases had an amino acid change as R137C and five cases as R137L. Fluid restriction and oral urea intake were main treatment options, no report so far was found with oral furosemide treatment. Conclusions: NSIAD presented with hyponatremia without any other specific presentations. Genetic testing for variants in AVPR2 is helpful for early diagnosis and timely treatment. The first two cases of oral furosemide treatment were reported by the article which helped to maintain a normal serum sodium level after limiting fluid intake and supplementing sodium which showed limited effect.

Clinical Predictors of Encephalitis in UK Adults – A Multi-Centre Prospective Observational Cohort Study

Background: Encephalitis, brain inflammation and swelling, most often caused by an infection or the body’s immune defences, can have devastating consequences, especially if diagnosed late. We looked for clinical predictors of different types of encephalitis to help clinicians consider earlier treatment. Methods: We conducted a multicentre prospective observational cohort study (ENCEPH-UK) of adults (> 16 years) with suspected encephalitis at 31 UK hospitals. We evaluated clinical features and investigated for infectious and autoimmune causes. Findings: 341 patients were enrolled between December 2012 and December 2015 and followed up for 12 months. 233 had encephalitis, of whom 65 (28%) had herpes simplex virus (HSV), 38 (16%) had confirmed or probable autoimmune encephalitis, and 87 (37%) had no cause found. The median time from admission to 1st dose of aciclovir for those with HSV was 14 hours (IQR 5-50); time to 1st dose of immunosuppressant for the autoimmune group was 125 hours (IQR 45-250). Compared to non-HSV encephalitis, patients with HSV more often had fever, lower serum sodium and lacked a rash. Those with probable or confirmed autoimmune encephalitis were more likely to be female, have abnormal movements, normal serum sodium levels and a cerebrospinal fluid white cell count < 20 cells x106/L, but they were less likely to have a febrile illness. Interpretation: Initiation of treatment for autoimmune encephalitis is delayed considerably compared with HSV encephalitis. Clinical features can help identify patients with autoimmune disease and could be used to initiate earlier presumptive therapy. Clinical Trial Registration Details: Funding Information: National Institute for Health Research, UK. Declaration of Interests: None to declare. Ethics Approval Statement: The study protocols were approved by participating sites and the National Research Ethics Service (now part of the Health Research Authority) East Midlands Nottingham 1 committee (reference 11/EM/0442). Written consent for entry into the study was obtained from patients or an accompanying relative.

Significance of Hypernatremia Due to SARS-CoV-2 Associated ARDS in Critically Ill Patients.

Background and ObjectivesSARS-CoV-2-induced ARDS is a new entity that should be characterized as it appears to be different from standard ARDS. Hypernatremia is a biological alteration that seems to occur very often in this population without any clear cause. The present study aims to clarify the possible causes of hypernatremia and evaluate its impact on patient outcome.Patients and MethodsWe conducted a retrospective one-day prevalence study in 2 intensive care units, which only treated COVID-19 patients with moderate to severe ARDS. We measured blood and urine electrolytes in all the patients. Patients with chronic renal failure or renal replacement therapy were excluded from the study. Hypernatremia was defined as plasma sodium levels above 145 mmol/L.ResultsInclusion criteria were met in 17 out of 24 patients. Hypernatremia was present in 52% patients. All had a natriuresis higher than 20 mmol/L and a urine osmolality above 600 mOsm/L. Hypernatremia was acquired in ICU as all the patients had a normal serum sodium level at admission.ConclusionThe incidence of hypernatremia was elevated and appears to be linked to significant insensible water losses. This should trigger us to optimize the maintenance fluid therapy in critically ill patients with SARS-CoV-2-induced ARDS.

Prognostic factors for survival in patients with gastric adenocarcinoma.

BackgroundGastric cancer ranks as a leading cause of cancer deaths worldwide. Information of prognostic factors related to gastric cancer are limited.AimThis study aimed to gather clinical data and prevalence of prognostic factors related to gastric adenocarcinoma in Thailand.Methods and resultsThis retrospective cohort study was conducted at Thammasat University Hospital, Thailand between January 2010 and July 2018. Gastric adenocarcinoma patients were enrolled and followed up for at least 5 years. Total of 210 gastric tumor patients were enrolled. One hundred patients were diagnosed with gastric adenocarcinomas (57 men and 43 women, mean age = 61.1 years). The leading presenting symptoms were weight loss (65%), followed by dyspepsia (54%) and UGI bleeding. Common clinical manifestations were thrombocytosis (26%), followed by syndrome of inappropriate antidiuretic hormone (SIADH; 15%). Eosinophilia was present in early cancer (25.0% vs 6.5%, P = .123), while SIADH and thrombocytosis were more common in advanced stages (16.3% vs 0%, P = .602, and 28.3% vs 0%, P = .108, respectively). SIADH was significantly related to reduced 1‐year survival rate compared to normal serum sodium levels (21.4% vs 71.4%, OR 0.109, 95% CI 0.024‐0.497, P = .004). Five‐year survival rates were worse in patients with SIADH, but better in patients with eosinophilia compared to patients without these conditions (0% vs 27.8%, P = .058 and 20.0% vs 7.8%, P = .375, respectively).ConclusionThrombocytosis and SIADH were common in gastric cancer. SIADH was significantly correlated with poor 1‐year survival. These clinical manifestations might be useful for predicting gastric cancer prognosis.

Prevalence of Hyponatremia in an Elderly Population: A Case Study

Hyponatremia is the most frequent electrolyte disorder both in hospitalized and outdoor patients. Elderly patients represent a high-risk group for the occurrence of hyponatremia because age is a strong independent risk factor for hyponatremia. Decreased serum sodium concentration is a rather frequent electrolyte disorder in the elderly population because of the presence of factors contributing to increased antidiuretic hormone, the frequent prescription of drugs associated with hyponatremia and also because of other mechanisms such as the “tea and toast” syndrome[1]. Hyponatremia in elderly subjects is mainly caused by drugs (more frequently thiazides and antidepressants), the syndrome of inappropriate antidiuretic hormone secretion (SIAD) or endocrinopathies; however, hyponatremia is multi-factorial in a significant proportion of patients. Special attention is needed in the elderly population to exclude endocrinopathies as a cause of hyponatremia before establishing the diagnosis of SIAD, which then requires a stepped diagnostic approach to reveal its underlying cause. Hyponatremia is an important and common electrolyte abnormality that can be seen in isolation or, as most often is the case, as a complication of other medical illnesses (eg, heart failure, liver failure, renal failure, pneumonia). The normal serum sodium level in the body is 135-145 mEq/L. Therefore, hyponatremia is defined as a serum sodium level of less than 135 mEq/L. This research is based on the prevalence of hyponatremia in an elderly population. This study indicates an increase in patients of hyponatremia above 60 years of age. This study also tells the increase in number of patients having hyponatremia as well as abnormal creatinine levels.

Incidence of hyponatremia in acute bronchiolitis

Objective To assess the incidence and early detection of hyponatremia (below 135 mmol/l) associated with acute bronchoilitis in infants. Background Acute bronchiolitis is the most common disease of lower respiratory tract during the first year of life. It occurs as an annual epidemic in winter, and it often affects the child's ability to feed. Hyponatremia is a prognostic factor that might predict the disease course of children with severe bronchiolitis. Patients and methods This study was conducted on 300 patients having acute bronchiolitis from February 2015 to February 2016. They were divided into two groups: group I included 240 patients with normal serum sodium level (135–145 mmol/l), and group II consisted of 60 patients with low serum sodium level ( Results There was a highly significant statistical difference regarding length of stay in hospital (P = 0.001) and clinical scores on days 3 and 5 (P = 0.001 for both). There was a highly significant positive correlation between chest radiography and length of stay in hospital (r = 0.441, P = 0.001). There was a significant negative correlation between family history of allergy and length of stay in hospital in normonatremic patients (r = −0.238, P = 0.008), as well as a negative correlation between age and length of stay in hospital (r = −0.241, P = 0.007). Conclusion Hyponatremia on the day of hospitalization was associated with a higher severity of disease. It is a prognostic factor that might improve our ability to predict the disease course of children with severe bronchiolitis. Serum sodium should be measured in all patients with bronchiolitis within 48 h from admission. Further studies are needed to assess the incidence of hyponatremia in bronchiolitis on a broad scale and to follow-up the course of the disease.

Hyponatremia is a Predictor of Clinical Outcome for Resected Biliary Tract Cancers: A Retrospective Single-Center Study.

IntroductionBiliary tract cancers (BTC) include both gallbladder cancer and cholangiocarcinoma, both of which have a poor prognosis. The aim of our study was to evaluate the main clinical prognostic factors in this setting and to assess their impact on overall survival (OS).MethodsWe retrospectively analyzed data collected on 64 patients with BTC who underwent surgery with radical intent at our institution. OS was estimated using the Kaplan–Meier method. The Cox regression model was used to perform univariate and multivariate analyses.ResultsPreoperative hyponatremia was found to be an independent prognostic factor that correlated negatively with prognosis, with hyponatremic patients having a poor OS compared to the group of patients with normal serum sodium levels (9.44 vs. 15.47 months; p = 0.0215). In addition, high preoperative values for carbohydrate antigen 19-9 (Ca19.9), a tumor marker for some gastrointestinal cancers, and lactate dehydrogenase (LDH) were found to be prognostic factors for a significant reduction in OS (Ca19-9: 7.14 vs. 24.22 months, p = 0.0088; LDH: 1.70 vs. 15.47 months, p = 0.0384).ConclusionIdentification of these prognostic factors may support strategies to identify, in clinical practice, those subgroups of patients with a favorable or unfavorable prognosis before surgical treatment and, therefore, to guide therapeutic choices. In particular, to our knowledge, this is the first report of the prognostic role of serum sodium level in BTC. Early detection and careful monitoring of hyponatremia and supportive therapy can help to improve the treatment and prognosis of BTC.

Sodium to globulin ratio as a prognostic factor for patients with advanced gastric cancer

Background: Electrolyte disturbance and systemic inflammation contributes to poor prognosis of cancer patients. Levels of serum sodium and globulin can reflect electrolyte homeostasis and inflammatory state, respectively, therefore have potential as prognostic factors for cancer patients. In this study, we hypothesized that sodium to globulin ratio (SGR) could have superior accuracy in predicting cancer patient survival, than sodium and globulin alone. We therefore sought to investigate its efficacy in prognosis of patients with advanced gastric cancer (GC) receiving first-line chemotherapy.Methods: A total of 265 patients, with advanced GC, were recruited in this retrospective study from January 2014 to January 2019. We first determined SGR cut-off values using the receiver operating characteristic (ROC) analysis, then analyzed the relationship between pretreatment SGR and clinicopathological features and the effect of chemotherapy. Finally, we evaluated progression-free survival (PFS) and overall survival (OS) rates of the entire and subgroup populations using univariate and multivariate logistic regressions.Results: SGR recorded a cut-off value of 5.54, and had a significantly higher area under the curve (AUC) value (0.619, p = 0.001) than fibrinogen (0.575, p = 0.034) and albumin (0.610, p = 0.002) alone. Organ metastasis, and peritoneal invasion ratios, as well as neutrophil and CA72-4 levels varied significantly between the low-SGR (SGR≤ 5.54) and high SGR (SGR> 5.54) groups (all p < 0.05). Specifically, patients in the low-SGR group exhibited significantly lower disease control rates (83.4%) than those in the high-SGR group (97.2%) (p < 0.001). Results from multivariate analysis indicated that high-SGR was an independent risk factor for PFS (Hazard ratio [HR]: 0.539, p < 0.001) and OS (HR: 0.574, p < 0.001). Moreover, patients in the low-SGR group exhibited significantly worse PFS (134 vs. 221 days, p < 0.001) and OS (311 vs. 420 days, p < 0.001) than those in the high-SGR group. Furthermore, subgroup analysis revealed that SGR was still a powerful prognostic indicator in GC patients with good prognosis or normal biochemical indexes, including no peritoneal infiltration, normal neutrophil counts, and normal serum sodium and globulin levels (all p < 0.001).Conclusions: Overall, our findings indicate that SGR is a novel and promising prognostic factor for GC patients. It has superior accuracy, to sodium and globulin alone, hence it is a powerful tool for evaluating effects of treatment, PFS, and OS in patients with advanced GC, who receive first-line chemotherapy.

Serum Sodium Level on the Recurrence of Febrile Seizure within the Same Febrile Illness-Experience in a District Level Hospital

Introduction: Febrile convulsion is the most common seizure disorder in the pediatric age group. It occurs in 2-5% of children. A febrile seizure is a seizure accompanied by fever (temperature 100.4°F or 38°C by any method), without central nervous system infection, that occurs in infants and children 6 through 60 months of age.&#x0D; Aim: The study was conducted to see the effect of serum sodium level on the recurrence of febrile seizure during the same febrile illness. Materials and Method: A cross-sectional descriptive study which enrolled 65 children admitted with febrile seizures at 100 bed district hospital, Naogaon. They were divided in to two groups, those with a single seizure and the rest were children with more than one seizures. Serum sodium levels were estimated after stabilization of patients. The probability of recurrent febrile seizures and serum sodium level was analyzed.&#x0D; Results: Hyponatremia (serum sodium &lt;135 mmol/l) was seen in 12(18.5%) of 65 children and the remaining 81.5% children had normal serum sodium level (serum sodium 135-145 mmol/l). Among the hyponatremia group all children developed more than one seizure during the same febrile episode. The mean serum sodium level in patients with single and recurrent seizure was 138.48±2.17mmol/l and 135.27±3.11mmol/(P&lt;0.001). The relationship between the probability of a recurrent seizure and serum sodium level is statistically highly significant.&#x0D; Conclusion: Estimation of the seum sodium in children with febrile seizures help in deciding for admission in hospital as well as to predict seizure recurrence within the same febrile episode.&#x0D; TAJ 2019; 32(1): 39-45

Acute Management of Ischemic Stroke During Pregnancy.

Acute stroke in pregnancy can be devastating. Although neurologists will at some point be involved in the management, most of these patients are likely to first be evaluated by an obstetric care provider. It is, therefore, important for obstetric care providers to have an understanding of the presentation and management of stroke, particularly in the initial period when the window of opportunity for therapy is critical. Once suspected, a head computed tomography (CT) without contrast media should be performed without delay to rule out a hemorrhagic component. Patients presenting within 4.5 hours of symptom onset and with an initial normal head CT scan are candidates for alteplase (tissue plasminogen activator [tPA]). Blood pressure (BP) control is paramount when administering tPA. During pregnancy, we recommend maintaining a BP between 140-160/90-110 mm Hg during tPA treatment. Pregnancy should not be a contraindication for mechanical thrombectomy in carefully selected patients. The use of therapeutic anticoagulation during the acute management of ischemic stroke is not indicated owing to an increased risk of hemorrhagic transformation. Supportive therapy should include aggressive treatment of fever, avoidance of hypotonic maintenance fluids, and maintenance of normal serum sodium levels. Serum glucose levels should be kept between 140 and 180 mg/dL. Antiplatelet agents are indicated for secondary prevention. The management of cerebral venous sinus thrombosis, carotid and vertebral dissections, and reversible cerebral vasoconstrictive disease should overall follow same guidelines as for nonpregnant individuals.

Hyponatremia in systemic lupus erythematosus patients: Relation to disease activity and fatigue

Aim of the workTo investigate the relation of hyponatremia to disease activity and fatigue in systemic lupus erythematosus (SLE) patients. Patients and methodsThe present study included 30 SLE patients with hyponatremia and 70 with normal serum sodium (Na) level. SLE disease activity index and the Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue score were assessed. ResultsThe gender, age and disease duration of SLE patients with hyponatremia (26 females and 4 males; mean age 37.8 ± 9.3 years, 10.9 ± 5.1 years) were comparable with those without (60 females and 10 males; 36.9 ± 11.8 years, 11.1 ± 6.02; p = 0.71 and p = 0.9 respectively). SLE patients with hyponatremia showed significantly increased SLEDAI (14.2 ± 3.85 vs 3.86 ± 3.59; p < 0.001), ESR (55.2 ± 18.2 vs 14.70 ± 3.5 mm/1st h; p < 0.001) and CRP (30.97 ± 4.4 vs 5.17 ± 2.6 mg/dl; p < 0.001) and lower FACIT-Fatigue (21.99 ± 2.1 vs 35.87 ± 4.81; p < 0.001) compared to patients without. Serum Na levels significantly correlated with the FACIT-fatigue score (r = 0.99, p < 0.01), platelets (r = 0.22; p = 0.03), white blood cells count (r = 0.31, p < 0.001) and inversely with SLEDAI (r = −0.27, p = 0.01), ESR (r = −0.71; p < 0.001), CRP (r = −0.86, p < 0.001), anti-ds-DNA (r = 0.54, p < 0.001), C3 (r = −0.29, p = 0.01) and C4 (r = −0.2, p = 0.04). On regression, CRP (β = 0.3), SLEDAI (β = 0.28) and consumed C4 (β = −0.07) were significant independent risk factors for hyponatremia (p < 0.0001, p = 0.0005, p = 0.02 respectively). The optimal cut-off values to predict hyponatremia was a SLEDAI score ≥11 (90% sensitivity and 96% specificity), and ESR ≥ 17.5 mm/1st h (100% sensitivity and 80% specificity) and a CRP of ≥10.5 mg/dl (100% sensitivity and 97% specificity). ConclusionHyponatremia in SLE patients is associated with higher disease activity and more perceived fatigue. Hyponatremia could reflect severe inflammation and could be considered as one of the predisposing factors of fatigue.

Factors associated with acute kidney injury recovery in a tertiary hospital in Ghana: a prospective study.

IntroductionAcute kidney injury (AKI) is a challenging problem in developing countries due to late presentation of its victims to health care facilities. Data on the pattern of AKI, its outcome and factors associated with its recovery is scanty in developing countries therefore impeding AKI management. Aim: to study AKI recovery rate and its associated factors.MethodsAn observational study conducted from September 2013 to June 2014 at Korle-Bu Teaching Hospital (KBTH). Participants were adults, admitted with AKI at KBTH. Kidney Disease: Improving Global Outcomes (KDIGO) criteria was used to diagnose and stage AKI.ResultsMean age (SD) of the participants was 41.9 (± 19.2) years. About a third of the patients (34.6%) were less than 29 years with 30-39 years and 40-60 years constituting 23.0% and 23.6% respectively. Females were in the majority (56.0%). AKI stages I, II and III accounted for 11.0%, 6.8% and 70.7% respectively. Majority, 82.2% of the patients recovered their kidney function. Stage III AKI was significantly associated with decreasing odds of recovery [OR = 0.4, 95%CI = 0.4-2.6, p = 0.002]. In addition, normal blood sodium was associated with recovery from AKI [OR, 95%CI = 2.3, (1.1-5.3), p = 0.043]. Almost half (45.5%) presented with fever whereas 32.5% and 22.5% presented with peripheral oedema and pulmonary oedema respectively.ConclusionThe study demonstrated high kidney function recovery following AKI. Dominant clinical features were fever, peripheral and pulmonary oedema. Advanced stage was associated with poor recovery whereas normal serum sodium level improves kidney function recovery.

Association of optic nerve sheath diameter measurement with hyponatremia in emergency department

ObjectiveInvestigation of association of ONSD with hyponatremia in symptomatic patients. Methods89 patients who were diagnosed to have hyponatremia (Na + <135 mmol/L) were prospectively analyzed and compared with 72 patients who have normal serum sodium levels presented to ED at the same time interval. Subjects' demographic properties including age and sex were recorded, as were admission symptoms, serum Na + level, and pre-treatment and post-treatment optic nerve sheath diameter (ONSD). ResultsThe mean age of the study population was 62.3 ± 17.6 years, and the control group 55.1 ± 20.0 years (p < 0.05). There was a significant difference between the patient group's pre-treatment and post-treatment OSNDs compared to the controls (p < 0.05). There was a significant negative correlation between the admission sodium level and ONSD in the patient group (p < 0.05). In the pre-treatment period, patients with symptoms had a significantly greater mean ONSD than those without symptoms (0.546 ± 0.068 mm vs 0.448 ± 0.081 mm; p < 0.05). The area under the curve was 0.870; the cut-off level calculated for hyponatremia was 0.49 mm, which had a sensitivity of 81% and a specificity of 81.9%. ConclusionUltrasonic imaging of ONSD measurement in the emergency department appears to reflect changes consistent with ICP changes in hyponatremia and change in serum sodium.

Safety and Efficacy of Fludrocortisone in the Treatment of Cerebral Salt Wasting in Patients With Tuberculous Meningitis

Tuberculous meningitis is associated with high frequency of cerebral salt wasting. There is a paucity of objective information regarding the best method of treatment of this condition. To evaluate the efficacy and safety of fludrocortisone in the treatment of cerebral salt wasting in patients with tuberculous meningitis. This is a single-center, open-label, randomized clinical trial conducted from October 2015 to April 2017 in India. Patients were randomized in a 1:1 ratio to arms receiving saline only or saline plus fludrocortisone, in addition to a standard treatment of 4 antitubercular drugs, prednisolone, and aspirin. The 2 arms were matched for demographic, clinical, and magnetic resonance imaging findings. The patients were followed up for at least 6 months. Patients were randomized to a 0.9% solution of intravenous saline with 5 to 12 g per day of oral salt supplementation, with or without the addition of 0.1 to 0.4 mg of fludrocortisone per day. The primary end point was the time needed to correct serum sodium levels; secondary end points were in-hospital deaths, disability at 3 months, disability at 6 months, occurence of stroke, and serious adverse reactions. Ninety-three patients with suspected tuberculous meningitis were recruited; 12 did not meet the inclusion criteria, including 4 with alternate diagnoses. A total of 37 patients with cerebral salt wasting were eligible for the study. One refused to participate, and therefore 36 patients were included, with 18 randomized to each group. The median (range) age was 30 (20-46) years, and 19 were male (52.8%). Those receiving fludrocortisone regained normal serum sodium levels after 4 days, significantly earlier than those receiving saline only (15 days; P = .004). In an intention-to-treat analysis, hospital mortality, disability at 3 months, and disability at 6 months did not differ significantly, but fewer infarcts occurred in the deep border zone in the group receiving fludrocortisone (1 of 18 [6%]) vs those in the control arm (6 of 18 [33%]; P = .04). Fludrocortisone was associated with severe hypokalemia and hypertension in 2 patients each, and pulmonary edema occurred in 1 patient. These adverse reactions necessitated discontinuation of fludrocortisone in 2 patients. Fludrocortisone results in earlier normalization of serum sodium levels, but did not affect outcomes at 6 months. Fludrocortisone had to be withdrawn in 2 patients because of severe adverse effects. This study provides class II evidence on the role of fludrocortisone in treatment of hyponatremia associated with cerebral salt wasting in patients with tuberculous meningitis. Clinical Trials Registry of India (ctri.nic.in) Identifier: CTRI/2017/10/010255.

The importance of early immunotherapy in patients with faciobrachial dystonic seizures.

Faciobrachial dystonic seizures and limbic encephalitis closely associate with antibodies to leucine-rich glioma-inactivated 1 (LGI1). Here, we describe 103 consecutive patients with faciobrachial dystonic seizures and LGI1 antibodies to understand clinical, therapeutic and serological differences between those with and without cognitive impairment, and to determine whether cessation of faciobrachial dystonic seizures can prevent cognitive impairment. The 22/103 patients without cognitive impairment typically had normal brain MRI, EEGs and serum sodium levels (P < 0.0001). Overall, cessation of faciobrachial dystonic seizures with antiepileptic drugs alone occurred in only 9/89 (10%) patients. By contrast, 51% showed cessation of faciobrachial dystonic seizures 30 days after addition of immunotherapy (P < 0.0001), with earlier cessation in cognitively normal patients (P = 0.038). Indeed, expedited immunotherapy (P = 0.031) and normal cognition (P = 0.0014) also predicted reduced disability at 24 months. Furthermore, of 80 patients with faciobrachial dystonic seizures as their initial feature, 56% developed cognitive impairment after 90 days of active faciobrachial dystonic seizures. Whereas only one patient developed cognitive impairment after cessation of faciobrachial dystonic seizures (P < 0.0001). All patients had IgG4-LGI1 antibodies, but those with cognitive impairment had higher proportions of complement-fixing IgG1 antibodies (P = 0.03). Both subclasses caused LGI1-ADAM22 complex internalization, a potential non-inflammatory epileptogenic mechanism. In summary, faciobrachial dystonic seizures show striking time-sensitive responses to immunotherapy, and their cessation can prevent the development of cognitive impairment.awx323media15681705685001.