Osmotic demyelination as locked in syndrome

Osmotic demyelination syndrome (ODS), also known as central pontine myelinolysis, is a disorder that affects the pons and extrapontine regions. This condition clinically presents with a multitude of neurological manifestations. The pathogenesis of ODS is not yet clearly understood. Most common cause of ODS is iatrogenic rapid correction of hyponatremia with a bolus of hypertonic saline. Very rarely it can be directly caused by alcohol intoxication and disrupted neuronal metabolism due to deficiency of essential substrates. A 34-year-old chronic alcoholic male presented with neurological symptoms and signs for 2 days. Clinical examination suggested multifactorial encephalopathy which was attributed to hyponatremia, Wernickes and hepatic encephalopathy substantiated by abnormal lab reports and unremarkable initial magnetic resonance imaging (MRI) findings. Although his sensorium improved over the next 3-4 days following slow correction of hyponatremia, parenteral thiamine and vitamin B12, B6 and B3, he suddenly went into a mute state followed by quadriparesis which aroused the suspicion of locked-in syndrome. Since his quadriparesis was accompanied by mutism and emotional incontinence, a lesion above cervical spine was suspected. So a repeat MRI brain was taken which showed development of demyelination of ventral pons, bilateral lentiform and caudate nucleus, posterior limb of internal capsule and both thalami which were conjunct with pontine and extrapontine ODS. Outcome of an established ODS cannot be predicted. Early diagnosis of ODS is a serious challenge as demyelination can be missed in initial MRI scan. So, a repeat MRI based on meticulous clinical assessment is crucial for early diagnosis and timely intervention.

Navigating the complexity of osmotic demyelination syndrome in the elderly: insight from three cases

Osmotic demyelination syndrome (ODS) results from rapid shifts in serum osmolality and can be triggered by various factors such as hyponatremia, hyperglycaemia, malnutrition, alcohol abuse, and liver disease. Although hyponatremia prevalence increases with age, ODS typically manifests between ages 30 to 50, indicating a complex age-susceptibility relationship. Its pathophysiology involves brain volume restoration adaptation, with rapid correction of osmolality leading to dehydration and subsequent demyelination. Hyperglycaemia-induced ODS results from rapid correction of hyperosmolar states, overwhelming neuronal compensatory mechanisms. Neuroimaging, usually MRI, is crucial for diagnosis, revealing hyperintense lesions. Clinical manifestations vary widely, from dysarthria and dysphagia to spastic quadriparesis, with poor outcomes, especially in older patients. Below, three cases of ODS in elderly patients are presented, each with distinct clinical presentations and outcomes. Case1 highlights the association between rapid correction of hyperglycaemia and ODS while Case 2 and 3 illustrates the consequences of overly rapid correction of hyponatremia. Diagnosing Osmotic Demyelination Syndrome (ODS) in the elderly poses challenges due to overlapping clinical features with conditions like encephalopathy, delirium, and postictal confusional states, which closely mimic ODS. Further research is needed to better understand the pathophysiology and optimize management approaches, especially in vulnerable populations like the elderly.

Hiponatremia y traumatismo craneoencefálico, una asociación importante. Reporte de caso / Hyponatremia and traumatic brain injury, an important association. Case report

Introducción: La hiponatremia se encuentra asociada aproximadamente con el 10% de los pacientes con traumatismo craneoencefálico, su baja frecuencia y la intuición clínica de esta relación la hace importante en el presente informe de caso. Objetivo: Describir la asociación de la hiponatremia con el traumatismo craneoen-cefálico con la finalidad de mejorar la comprensión de esta relación en el personal de salud y promover la implementación de estrategias de diagnóstico y manejo más efectivas basadas en predicciones bioquímicas y anatómicas actualizadas. Presentación del caso: Paciente masculino, adulto joven, con antecedentes de dos traumatismos craneoencefálicos, con hiponatremia sérica severa y síntomas persistentes de mareo y cefalea, tratado con diuréticos de asa y cloruro de sodio vía oral, con mejoría posterior al vigésimo día de hospitalización. Discusión: Ciertas alteraciones neurológicas con manifestación clínica evidente, se presentan por bajos niveles de sodio sérico, o por causas anatómicas y fisioló-gicas diferentes. Se ha demostrado una relación causal con mecanismo fisiopato-lógico no bien descrito sobre la hiponatremia y el traumatismo craneoencefálico. Conclusión: Es crucial tener una vigilancia meticulosa en pacientes con hipona-tremia severa, aunque presenten pocos síntomas clínicos (considerando antece-dentes como el traumatismo craneoencefálico en la anamnesis inicial y de segui-miento) como en este caso. Además, se destaca la necesidad de investigar las vías metabólicas que podrían verse afectadas por traumatismos craneoencefálicos, y que podrían tener un impacto directo en los niveles de sodio en sangre.

Introduction: Hyponatremia is found to be associated with approximately 10% of patients with traumatic brain injury. Despite its low frequency, the clinical intuition regarding this relationship underscores its significance in this case report. Objective: Describe the association between hyponatremia and traumatic brain in-jury, aiming to enhance healthcare professionals' understanding of this correlation and to advocate for the implementation of more effective diagnostic and manage-ment strategies based on updated biochemical and anatomical predictions. Case Presentation: A young adult male patient with a history of two traumatic brain injuries, severe serum hyponatremia, and persistent symptoms of dizziness and headache, treated with loop diuretics and oral sodium chloride, exhibited improvement after twenty days of hospitalization. Discussion: Certain neurological alterations with evident clinical manifestation are characterized by low levels of serum sodium, possibly stemming from distinct ana-tomical and physiological causes. A causal relationship with a poorly described pathophysiological mechanism between hyponatremia and traumatic brain injury has been suggested. Conclusion: Meticulous monitoring is imperative for patients with severe hypona-tremia, even when clinical symptoms are minimal, as observed in this case. Fur-thermore, emphasis is placed on the need to investigate metabolic pathways that may be affected by traumatic brain injuries, potentially exerting a direct impact on blood sodium levels.

Osmotic demyelination as a complication of hyponatremia correction: a systematic review / Desmielinização osmótica como complicação da correção de hiponatremia: uma revisão sistemática

ABSTRACT Background: Rapid correction of hyponatremia, especially when severe and chronic, can result in osmotic demyelination. The latest guideline for diagnosis and treatment of hyponatremia (2014) recommends a correction limit of 10 mEq/L/day. Our aim was to summarize published cases of osmotic demyelination to assess the adequacy of this recommendation. Method: Systematic review of case reports of osmotic demyelination. We included cases confirmed by imaging or pathology exam, in people over 18 years of age, published between 1997 and 2019, in English or Portuguese. Results: We evaluated 96 cases of osmotic demyelination, 58.3% female, with a mean age of 48.2 ± 12.9 years. Median admission serum sodium was 105 mEq/L and > 90% of patients had severe hyponatremia (<120 mEq/L). Reports of gastrointestinal tract disorders (38.5%), alcoholism (31.3%) and use of diuretics (27%) were common. Correction of hyponatremia was performed mainly with isotonic (46.9%) or hypertonic (33.7%) saline solution. Correction of associated hypokalemia occurred in 18.8%. In 66.6% of cases there was correction of natremia above 10 mEq/L on the first day of hospitalization; the rate was not reported in 22.9% and in only 10.4% was it less than 10 mEq/L/day. Conclusion: The development of osmotic demyelination was predominant in women under 50 years of age, with severe hyponatremia and rapid correction. In 10.4% of cases, there was demyelination even with correction <10 mEq/L/day. These data reinforce the need for conservative targets for high-risk patients, such as 4-6 mEq/L/day, not exceeding the limit of 8 mEq/L/day.

RESUMO Antecedentes: A correção rápida da hiponatremia, principalmente quando grave e crônica, pode resultar em desmielinização osmótica. A última diretriz para diagnóstico e tratamento da hiponatremia (2014) recomenda um limite de correção de 10 mEq/L/dia. Nosso objetivo foi sumarizar os casos publicados de desmielinização osmótica para avaliar a adequação dessa recomendação. Método: Revisão sistemática de relatos de caso de desmielinização osmótica. Incluímos casos confirmados por imagem ou anatomia patológica, em maiores de 18 anos, publicados entre 1997 e 2019, nas línguas inglesa ou portuguesa. Resultados: Avaliamos 96 casos de desmielinização osmótica, sendo 58,3% do sexo feminino e com média de idade de 48,2 ± 12,9 anos. A mediana de sódio sérico admissional foi 105 mEq/L e > 90% dos pacientes apresentavam hiponatremia grave (<120 mEq/L). Foram comuns os relatos de distúrbios do trato gastrointestinal (38,5%), etilismo (31,3%) e uso de diuréticos (27%). A correção da hiponatremia foi feita principalmente com solução salina isotônica (46,9%) ou hipertônica (33,7%). Correção de hipocalemia associada ocorreu em 18,8%. Em 66,6% dos casos houve correção da natremia acima de 10 mEq/L no primeiro dia de internamento; a velocidade não foi relatada em 22,9% e em apenas 10,4% foi menor que 10 mEq/L/dia. Conclusão: O desenvolvimento da desmielinização osmótica foi predominante em mulheres, abaixo de 50 anos, com hiponatremia grave e correção rápida. Em 10,4% dos casos, houve desmielinização mesmo com correção <10 mEq/L/dia. Esses dados reforçam a necessidade de alvos conservadores para pacientes de alto risco, como 4-6 mEq/L/dia, não ultrapassando o limite de 8 mEq/L/dia.

Afferent baroreflex failure with hyponatremia:A case report / 北京大学学报(医学版)

Afferent baroreflex failure(ABF)is a rare disease.It refers to the clinical syndrome caused by the impairment of the afferent limb of the baroreflex or its central connections at the level of the medul-la.The recognized causes include trauma,surgery in related areas(radical neck tumor surgery,carotid endarterectomy),neck radiotherapy,brain stem stroke,tumor growth paraganglioma and hereditary diseases,among which the most common cause is extensive neck surgery or radiotherapy for neck cancer.The main manifestations are fluctuating hypertension,orthostatic hypotension,paroxysmal tachycardia and bradycardia.This case is a young man,whose main feature is blood pressure fluctuation,accom-panied by neurogenic orthostatic hypotension(nOH).After examination,the common causes of hyper-tension and nOH were ruled out.Combined with the previous neck radiotherapy and neck lymph node dissection,it was considered that the blood pressure regulation was abnormal due to the damage of carotid sinus baroreceptor after radiotherapy for nasopharyngeal carcinoma and neck lymph node dissection,which was called ABF.At the same time,the patient was complicated with chronic hyponatremia.Com-bined with clinical and laboratory examination,the final consideration was caused by syndrome of in-appropriate antidiuretic hormone(SIADH).Baroreceptors controlled the secretion of heart rate,blood pres-sure and antidiuretic hormone through the mandatory"inhibition"signal.We speculate that the carotid sinus baroreceptor was damaged after neck radiotherapy and surgery,which leads to abnormal blood pres-sure regulation and nOH,while the function of inhibiting ADH secretion was weakened,resulting in higher ADH than normal level and mild hyponatremia.The goal of treating ABF patients was to reduce the frequency and amplitude of sudden changes in blood pressure and heart rate,and to alleviate the on-set of symptomatic hypotension.At present,drug treatment is still controversial,and non-drug treatment may alleviate some patients'symptoms,but long-term effective treatment still needs further study.The incidence of ABF is not high,but it may lead to serious cardiovascular and cerebrovascular events,and the mechanism involved is extremely complicated,and there are few related studies.The reports of rele-vant medical records warn that patients undergoing neck radiotherapy or surgery should minimize the da-mage to the baroreceptor in the carotid sinus in order to reduce the adverse prognosis caused by complica-tions.

Boswellia serrata intoxication manifesting with syndrome of inappropriate antidiuretic hormone secretion, hyponatremia, seizure, and rhabdomyolysis / Intoxicação por Boswellia serrata manifestando-se com síndrome da secreção inapropriada de hormônio antidiurético, hiponatremia, convulsão e rabdomiólise

ABSTRACT Boswellia serrata is an herbal extract from the Boswellia serrata tree that has anti-inflammatory and analgesic properties and alleviates pain caused by rheumatoid arthritis, gout, osteoarthritis, and sciatica. Syndrome of inappropriate antidiuretic hormone secretion accompanied by hyponatremia, seizures, and rhabdomyolysis as a manifestation of Boswellia serrata intoxication has not been reported previously. A 38-year-old female suffered clinically isolated syndrome and has since been regularly taking B. serrata capsules (200mg/d) to strengthen her immune system. She experienced hypersensitivity to light, ocular pain, nausea, dizziness, and lower limb weakness four days after receiving her first BNT162b2 vaccine dose, and she increased the dosage of B. serrata to five capsules (1000mg/d) one week after vaccination. After taking B. serrata at a dosage of 1000mg/d for 3 weeks, she was admitted to the intensive care unit because of a first, unprovoked generalized tonic-clonic seizure. The patient's workup revealed syndrome of inappropriate antidiuretic hormone secretion, which resolved completely upon treatment and discontinuation of B. serrata. In summary, B. serrata potentially causes syndrome of inappropriate antidiuretic hormone secretion when it is taken at high doses. Patients should not self-medicate.

RESUMO Boswellia serrata é um extrato herbal da árvore Boswellia serrata que possui propriedades anti-inflamatórias e analgésicas e alivia a dor ciática e causada por artrite reumatoide, gota, osteoartrite. Não há relato na literatura de síndrome da secreção inapropriada do hormônio antidiurético, acompanhada por hiponatremia, convulsões e rabdomiólise, como manifestação de intoxicação por Boswellia serrata. Uma mulher de 38 anos diagnosticada com síndrome clinicamente isolada tomava regularmente cápsulas de B. serrata (200mg/dia) para fortalecer seu sistema imunológico. Ela desenvolveu hipersensibilidade à luz, dor ocular, náusea, tontura e fraqueza nos membros inferiores 4 dias após tomar a primeira dose da vacina BNT162b2 e aumentou a dose de B. serrata para 1.000mg/dia 1 semana após a vacinação. Após tomar B. serrata na dose de 1.000mg/dia por 3 semanas, ela foi internada na unidade de terapia intensiva devido à convulsão tônico-clônica generalizada não provocada. A investigação diagnóstica revelou síndrome da secreção inapropriada de hormônio antidiurético, que se resolveu completamente após tratamento e interrupção do uso de B. serrata. Em resumo, é possível que B. serrata cause síndrome da secreção inapropriada do hormônio antidiurético quando tomada em doses elevadas. Os pacientes não devem se automedicar.

Pontine myelinolysis with an uncommon manifestation of hallucination: a case report / Mielinólise pontina com manifestação incomum de alucinação: relato de caso

ABSTRACT This report aims to present an elderly woman with persistent delirium after hospitalization for lethargy secondary to hyponatremia. The diagnosis of pontine myelinolysis was made and there were no characteristic neurological manifestations such as pupillary changes or spastic tetraparesis. Hallucinations and personality changes were the clues to the diagnosis and should be considered an atypical manifestation of pontine myelinolysis.

RESUMO O objetivo deste relato é apresentar uma idosa que apresentou, após internação por letargia secundária à hiponatremia, delirium persistente depois da alta hospitalar. O diagnóstico de mielinólise pontina foi feito após a alta hospitalar e não houve manifestações neurológicas características, como alterações pupilares ou tetraparesia espástica. Alucinações e mudança de personalidade foram as pistas para o diagnóstico e devem ser consideradas como uma manifestação atípica de mielinólise pontina.

Urea como opción terapéutica en síndrome de antidiuresis inadecuada

El síndrome de antiduresis inadecuada (SADI) se produce por una alteración en el eje hipotálamo-neurohipófisis, por una falla en la respuesta regulatoria osmótica o por factores no osmóticos, con complicaciones en relación directa al grado de hiponatremia e impacto en la calidad de vida y mortalidad del paciente. El tratamiento consiste en la normalización de la natremia, y la búsqueda de la etiología. Presentamos el caso de un paciente adulto con el diagnóstico de SADI idiopático y trastorno neurocognitivo asociado, con respuesta favorable al tratamiento con urea.

Syndrome of Inappropriate Antidiuresis (SIAD), is produced by an alteration in the hypothalamus-neurohypophysis axis due to a failure in the osmotic regulatory response or non-osmotic factors, with complications directly related to the degree of hyponatremia and impact on quality of life and patient mortality. Management consists of normalization of natremia, and the search for the underlying etiology. We present the case of an adult patient diagnosed with idiopathic SIAD and associated neurocognitive disorder, with a favorable response to treatment with urea.

Reporte de caso: síndrome de absorción intravascular en histeroscopia, intoxicación por glicina / Case report: Intravascular absorption syndrome in hysteroscopy, glycine intoxication

El síndrome de absorción intravascular en histeroscopia se origina por la rápida absorción vascular de soluciones isotónicas e hipotónicas utilizadas en irrigación intrauterina, ocasionando hipervolemia y dilución de electrolitos, especialmente hiponatremia. Cuando este síndrome es debido a intoxicación por glicina al 1,5% causa acidosis severa y neurotoxicidad. La incidencia de este síndrome es baja pero puede aumentar por factores como: falta de control de altura de bolsas de irrigación, ausencia de equilibrio de fluidos de soluciones de irrigación, tejidos altamente vascularizados como miomas uterinos y uso de sistema de electrocirugía monopolar. Se reporta el caso de una paciente con miomas uterinos, programada para resección mediante histeroscopia que cursa con síndrome de absorción intravascular por glicina, el temprano diagnóstico y rápido tratamiento intraoperatorio y postoperatorio permitió una evolución favorable. El manejo se basó en el uso de diuréticos, restricción de fluidos y soluciones hipertónicas de sodio.

Intravascular absorption syndrome in hysteroscopy is caused by rapid vascular absorption of isotonic and hypotonic solutions used in intrauterine irrigation, causing hypervolemia and electrolyte dilution, especially hyponatremia. When this syndrome is due to 1.5% glycine toxicity, it causes severe acidosis and neurotoxicity. The incidence of this syndrome is low but may increase due to factors such as: lack of control of the height of irrigation bags, lack of fluid balance in irrigation solutions, highly vascularized tissues such as uterine myomas and use of a monopolar electrosurgery system. The case of a patient with uterine myomas, scheduled for resection by hysteroscopy, who presents with intravascular glycine absorption syndrome, is reported. Early diagnosis and rapid intraoperative and postoperative treatment allowed a favorable evolution. Management was based on the use of diuretics, fluid restriction, and hypertonic sodium solutions.

Clinical and biochemical profile of hyponatremia and the role of vaptans in comparison to other standard modalities of therapy

Background: This study, conducted from August 2014 to August 2015, investigated hyponatremia in 228 in-hospital patients, aiming to discern its clinical and biochemical features and compare the efficacy of vaptans against standard treatments. The null hypothesis assumed no significant disparity in outcomes, while the alternate hypothesis posited otherwise. Methods: Using an open-label, non-blinded, observational, prospective comparative design, we assessed 228 hyponatremia patients. We scrutinized their clinical and biochemical profiles and made comparisons between moderate and profound hyponatremia cases, along with different treatment approaches. Results: Our findings revealed that patients aged 61-80, primarily females, dominated the cohort. Moderate hyponatremia occurred in 56.6% of cases, with severe hyponatremia in 43.4%. Common symptoms included drowsiness, nausea, and vomiting. Euvolemic hyponatremia was predominantly due to SIADH, while heart failure led to most hypervolemic cases. Various treatments were employed, with fluid restriction and normal saline being common. Tolvaptan and 1.6% hypertonic saline significantly increased serum sodium levels at 24 and 48 hours. Hospital stay duration didn’t significantly differ, and no osmotic demyelination cases emerged. Mortality stood at 10.5%, notably higher in profound hyponatremia cases. Conclusions: This study provides insights into hyponatremia’s clinical and biochemical aspects and compares vaptans to standard treatments. Tolvaptan and hypertonic saline displayed promise in raising serum sodium levels. Nevertheless, further research is warranted to validate these findings and explore additional factors impacting hyponatremia treatment outcomes.

Hyponatremia and Hypokalemia Prevalence in Tuberculosis Patients in a Teaching Hospital.

Summary: Study is conducted on tuberculosis patients admitted to a teaching hospital and deals with serum electrolytes profile analysis. Study shows prevalence of hyponatremia (56.2%) and hypokalemia (28.4%) in tuberculosis patients receiving anti-tubercular therapy. Background: Tuberculosis is a contagious chronic disease caused by mycobacterium tuberculosis affecting millions of people worldwide. Although primarily known impact on respiratory system, tuberculosis can lead to systemic effects including serum electrolytes imbalances. Objective: Aim of the study is to analyze serum sodium and potassium concentrations of tuberculosis patients on anti-tubercular therapy in a teaching hospital to evaluate their imbalances. Patients and Procedures: The study is conducted on 169 patients of Pulmonary Tuberculosis (PTB) in the Department of Pulmonology, Khyber teaching hospital,Peshawar from January 2018 to June 2022. The patients were going through anti-tubercular therapy. Demographics and laboratory tests were collected from the patient’s hospital profile and analysis was done through GNU Project Statistical Programing Platform (GNU PSPP). Laboratory tests were performed during their stay at hospital. Results: The mean age was 46.29 ± 19.91 years and 51.5% of the patients were female. The mean serum sodium concentration was 133.31 ± 7.93 mmol/L and mean serum potassium concentration was 3.93 ± 0.87 mmol/L. Prevalence of hyponatremia and hypokalemia were recorded as 56.2% and 28.4% respectively. No statistically significant correlation found between variables with no statistically significant value of p. Conclusion: There is decrease in the level of serum sodium and potassium concentrations in tuberculosis patients.

Hiponatremia severa por meningitis tuberculosa: complicación frecuente pero olvidada

Se presenta el caso de un paciente varón de 55 años que ingresó por alteración del estado de conciencia por una hiponatremia severa secundaria a una meningitis tuberculosa. No hubo mejoría de la hiponatremia al tratamiento con solución salina hipertónica, por lo cual se planteó el diagnóstico de síndrome de secreción inapropiada de hormona antidiurética (SIADH) y se evidenció mejoría con la restricción hídrica. El interés del presente caso es reportar una complicación frecuente pero olvidada de la meningitis tuberculosa.

We present the case of a 55-year-old male patient who was admitted due to an altered state of consciousness due to severe hyponatremia secondary to tuberculous meningitis. There was no improvement in hyponatremia after treatment with hypertonic saline solution, therefore the diagnosis of syndrome of inappropriate secretion of antidiuretic hormone (SIADH) was proposed, and improvement was evidenced with fluid restriction. The interest of this case is to report a common but forgotten complication of tuberculous meningitis.

A case control study to evaluate the electrolyte abnormalities in asphyxiated neonates

Background: Neonatal asphyxia is a hypoxic condition in new-born and leads to encephalopathy as well as electrolyte disturbances and imposes significant morbidity and mortality. So, the current study was performed to assess the electrolyte abnormalities among asphyxiated neonates as compare to controls.Methods: 50 neonates have beendistributedas2 groups, with case group with 25 cases and 25 cases in neonates group depending on the variables namely Apgar score, fetal heart rates and meconium-stained liquor after baby delivery. Serum sodium, potassium and calcium ranges has been estimated; compared between the groups. In asphyxiated neonates based on the severity the electrolytes levels were also compared.Results: The prevalence of birth asphyxia seems to be higher among male new born (64%). The sodium and calcium ranges has been decreased among asphyxiated babies when associated with control group and it was significant 129.78±4.18 vs 140.76±9.76; 8.12±2.87 vs 10.42±3.12 mg/dl). The electrolyte disturbances were higher in HIE stage 3 of high severity as compared to HIE stage I and II.Conclusions: Electrolyte imbalances namely hyponatremia, hyperkalemia, hypocalcemia were found to be communal in asphyxiated neonates. Thus, proper monitoring is required to prevent the morbidity and mortality among the neonates.

An Observational Cohort Study on Prescription Patterns of Intravenous Albumin Use in Different Indications of Liver Disease

Introduction: Albumin is administered 20% as a part of treatment in various indications associated with decompensated liver disease. Methods: The study was conducted on patients over six months. Data were collected from 50 patients including males and females who are administered 20% albumin for liver cirrhosis. Disease severity before and after albumin infusion was calculated using prognostic tools like Child-Pugh and MELD-Na scoring system. Results: Among 50 patients, a major percent of patients were found to be HRS (28%) for albumin infusion and few extended indications were noticed; Decompensated liver cirrhosis without any other complications (18%), HE (18%), Hyponatremia (16%). After albumin infusion for six months, prognostic tools (CPT and MELD-Na scores) and laboratory parameters (serum creatinine, serum sodium, serum albumin) were significantly improved with P-value less than 0.05. Conclusion: Albumin usage has increased in some extended indications like decompensated liver cirrhosis without any other complications, hyponatremia, hepatic encephalopathy. Doses used in the present study were significantly less (when compared to standard doses as per the clinical guidelines) to minimize the adverse effects of albumin primarily pulmonary edema due to volume overload. Our study was consistent with the ANSWER trial where 20% albumin was used for the long term in decompensated liver cirrhosis.

Electrolyte abnormalities in patients with perinatal asphyxia

Background: Perinatal hypoxia is still a major cause of death and disability in developing countries. The infant mortality rate fell from 92 per 1000 live births in 1991 to 43 per 1000 live births in 2011. The aim of the study was to study the electrolyte abnormalities in perinatal asphyxia cases.Methods: This cross-sectional descriptive study was conducted at the Department of Obstetrics and Pediatrics, Rangpur Medical College and Hospital, Rangpur, Bangladesh. The study duration was 2 years, from January 2012 to December 2013. The study was conducted with a total of 120 neonates admitted in the neonatal ward of the study hospital, among which, 60 neonates who had perinatal asphyxia were selected for the case group, and the remaining 60 were age and gender-matched control group participants.Results: In 70% of cases, the mother was Primipara. Among the neonates, 61.67% were male, and 38.33% were female. Only 33% of the case neonates had received regular antenatal check-ups, while 55% had irregular check-ups, and 11.67% had no antenatal checkups. According to the grading of asphyxia, 51.67% of neonates had moderate asphyxia, 20% had mild asphyxia, and 28.33% had severe asphyxia. The comparison of mean values between the case, and control groups showed that both blood urea, and serum creatinine levels were significantly higher among the case group participants, compared to control group values. The mean serum sodium value in mild, moderate, and severe asphyxia were 135.33, 123.42, and 121.53 mmol/l respectively. Mean serum potassium values were 4.11, 4.86, and 5.51 mmol/l respectively. Mean serum creatinine 0.72, 1.00, and 1.83 mg/dl respectively. Mean blood urea levels were 36.17, 58.97, and 88.06 mg/dl respectively. A significant difference was observed between the mean values of serum electrolytes and patients’ asphyxia grade.Conclusions: The study findings can conclude that electrolyte abnormalities are common among perinatal asphyxia patients, and babies with perinatal asphyxia developed hyponatremia, and hyperkalemia at a higher frequency, and significant raises of serum creatinine, and blood urea was also observed, which was proportionate to the severity of asphyxia.

Hypopituitarism in elderly � A case series

Hypopituitarism is found to be one of the under investigated disease in elderly as it produces non specific symptoms which can be easily attributed to ageing and related co morbidities. Unless the hypopituitarism is identified and proper therapy is instituted, the clinical consequences of the untreated patients will be fatal. Here we report three cases of hypopituitarism in elderly patients whose clinical presentation and etiology was completely different. The first patient was fifty year old lady who is a known asthmatic for the past thirty years on steroids and had iatrogenic Cushing抯. On tapering the steroids she developed hypotension and giddiness. On eliciting the history she was suspected to have Sheehan抯 syndrome and was confirmed with investigations. She was advised to continue the steroids with calcium supplements. The second patient is an 80 years old female who came with complaints of increased tiredness daily more in the morning while getting up and improves slowly in the afternoon time and getting tired again in the night. When she was examined she had hypotension of 90/50 mm of hg. She was evaluated for Partial hypopituitarism and investigation confirmed hypopituitarism and she was started on Hydrocortisone tablets and she improved. The third patient was a 65 year old lady who was diagnosed to have diabetes mellitus and hypothyroidism and was on oral hypoglycemic drugs and eltroxine supplementation respectively. She had multiple hypoglycemic symptoms unresolved in spite of tapering the oral hypoglycemic drugs and on evaluation found to have partial hypopituitarism and started on T. Hydrocortisone and she improved well. We report these three cases as hypopitiutarism has multifaceted clinical presentation and needs high level of suspicion to diagnose it in elderly

Efficacy and safety of tolvaptan for hyponatremia：an overview of systematic reviews/meta-analysis / 中国药房

OBJECTIVE To reevaluate systematic reviews/meta-analysis of efficacy and safety of tolvaptan for hyponatremia. METHODS Retrieved from CNKI， Wanfang Data， VIP， CBM， PubMed， Embase and the Cochrane Library database， systematic reviews/meta-analysis about tolvaptan for the treatment of hyponatremia were included from the inception to June 15， 2022. After screening literature and extracting data， the PRISMA statement， AMSTAR 2 scale and GRADE method were used to evaluate the reporting quality， methodological quality and evidence quality of the included literature， respectively. RESULTS A total of 6 articles were included， of which 1 was systematic review and 5 were meta-analysis， including 56 outcome indicators. All of the 6 studies had PRISMA scores ranging from 15.0 to 20.5， and the quality of them was moderate. Results of the AMSTAR 2 scale showed that the methodological quality of 5 literatures were very low， and the quality of 1 literature was low. The quality of GRADE evidence showed that there were 6 moderate-quality indicators， 13 low-quality indicators， 35 very low-quality indicators， and 2 indicators that could not be assessed due to missing data. The main factors causing degradation were limitations， inconsistency， imprecision and publication bias. In terms of efficacy， tolvaptan could effectively increase the level of serum sodium， increase urine volume， reduce body weight， reduce abdominal circumference， relieve edema， and reduce alaninetransaminase level. In terms of safety， the incidence of total adverse drug reaction induced by tolvaptan was controversial； it may increase the risk of dry mouth， thirst， frequent urination or excessive correction of serum sodium. CONCLUSIONS Tolvaptan has great efficacy in the treatment of hyponatremia， but serum sodium overcorrection should be avoided in terms of safety. Relevant systematic reviews/meta-analysis have shortcomings of low reporting quality， methodological quality and evidence quality， which may reduce the reliability of the results， so the results should be treated with caution.

Neonatal systemic pseudohypoaldosteronism type I / 中国当代儿科杂志

An 18-day-old male infant was admitted to the hospital due to recurrent hyperkalemia for more than 10 days. The neonate had milk refusal and dyspnea. The blood gas analysis revealed recurrent hyperkalemia, hyponatremia and metabolic acidosis. Adrenocortical hormone replacement therapy was ineffective. Additional tests showed a significant increase in aldosterone levels. Family whole exome sequencing revealed that the infant had compound heterozygous in the SCNNIA gene, inherited from both parents. The infant was diagnosed with neonatal systemic pseudohypoaldosteronism type I. The infant's electrolyte levels were stabilized through treatment with sodium polystyrene sulfonate and sodium supplement. The infant was discharged upon clinical recovery. This study provides a focused description of differential diagnosis of salt-losing syndrome in infants and introduces the multidisciplinary management of neonatal systemic pseudohypoaldosteronism type I.

The association of hyponatremia with clinicopathological and prognostic characteristics of non-small cell lung cancer patients: A systematic review and meta-analysis / 中国胸心血管外科临床杂志

@#Objective    To explore the association of pretreatment hyponatremia with clinicopathological and prognostic characteristics of non-small cell lung cancer (NSCLC) patients. Methods    The PubMed, EMbase, Web of Science, VIP, CNKI and WanFang databases were searched from the inception to July 12, 2021 for relevant literatures. The quality of included studies was assessed by the Newcastle-Ottawa Scale (NOS) score. The relative risk (RR) and hazard ratio (HR) with 95% confidence interval (CI) were combined to assess the relationship between pretreatment hyponatremia and clinicopathological and prognostic characteristics. The prognostic indicators included the overall survival (OS) and progression-free survival (PFS). All statistical analysis was conducted by the STATA 15.0 software. Results    A total of 10 high-quality studies (NOS score≥6 points) involving 10 045 patients were enrolled and all participants were from Asian or European regions. The pooled results demonstrated that male [RR=1.18, 95%CI (1.02, 1.36), P=0.026], non-adenocarcinoma [RR=0.86, 95%CI (0.81, 0.91), P<0.001] and TNM Ⅲ-Ⅳ stage [RR=1.17, 95%CI (1.12, 1.21), P<0.001] patients were more likely to experience hyponatremia. Besides, pretreatment hyponatremia was significantly related to worse OS [HR=1.83, 95%CI (1.53, 2.19), P<0.001] and PFS [HR=1.54, 95%CI (1.02, 2.34), P=0.040]. Pretreatment hyponatremia was a risk factor for poor prognosis of NSCLC patients. Conclusion    Male, non-adenocarcinoma and advance stage NSCLC patients are more likely to experience hyponatremia. Meanwhile, the pretreatment sodium level can be applied as one of the prognostic evaluation indicators in NSCLC and patients with hyponatremia are more likely to have poor survival. However, more researches are still needed to verify above findings.

Clinical features of Guillain-Barré syndrome with positive anti sulfatide antibody in CSF and hyponatremia(report of one case) / 临床神经病学杂志

Objective To summarize the diagnosis and treatment experience of patients with Guillain-Barré syndrome(GBS)with positive anti sulfatide antibody in CSF.Methods The clinical data of a case of patient with GBS with positive anti sulfatide antibody in CSF in Department of Neurology,The Affiliated Brain Hospital of Nanjing Medical University in January,2023 were retrospectively analyzed,and the relevant literatures were reviewed.Results Two cases with GBS with positive anti sulfatide antibody in CSF from 2 literatures were retrieved,a total of 3 cases were retrieved.All cases were males.The onset duration was 4-6 d.Two patients with GBS with positive anti-sufatide antibody in CSF developed limb weakness,severe back and limb pain.Albuminocytologic dissociation in CSF and inefficacy of immunoglobin were found in the two cases.Severe hyponatremia secondary to intravenous immunoglobin was observed in our case.One patient presented with cranial nerve damage with mild elevation of CSF protein and improvement after immunoglobulin.Conclusion The plasmapheresis was recommended for the patients presenting with limb weakness with positive anti-sulfatide antibody in CSF in order to prevent inefficacy and severe hyponatremia secondary to intravenous immunoglobin.