scholarly journals 241 “From SIAD to Happy”: a Case of Effective Use of Tolvaptan for Hyponatremia in an Older Person

2019 ◽  
Vol 48 (Supplement_3) ◽  
pp. iii17-iii65
Author(s):  
Maria Costello ◽  
Christine Newman ◽  
Elaine Loughlin ◽  
Michelle Canavan ◽  
Marcia Bell ◽  
...  
Keyword(s):  
Scale Score ◽  
Clinical Symptoms ◽  
Urine Osmolality ◽  
Colonic Neoplasm ◽  
Fluid Restriction ◽  
Older Person ◽  
Clinical Frailty Scale ◽  
Significant Clinical Improvement ◽  
Ct Brain ◽  
Effective Use

Abstract Background Hyponatremia commonly affects the older person, leading to morbidity and mortality. Tolvaptan use is rare in this cohort, but may have benefit in select cases of syndrome of inappropriate antidiuresis (SIAD). Methods An 84-year-old gentleman presented with a history of increasing confusion, fatigue and lethargy attributed to symptomatic hyponatremia. He had background of a recent prolonged admission with small bowel obstruction, treated conservatively. That hospital course was complicated by hypovolaemic hyponatremia, sepsis and clostridium difficile colitis. On this admission, he had no clinical symptoms or signs of infection and his septic screen was negative. He had a Rockwood clinical frailty scale score of 7. His biochemical abnormality was a persistent hyponatremia of 129 mmol/L. Clinically, he was euvolaemic. Further biochemical work up revealed serum osmolality of 263 mmol/kg, serum urea of 6.3 umol/L, urine sodium 108 mmol/L and urine osmolality 541 mmol/kg. Thyroid function, cortisol, and HbA1c were normal. CT brain and chest x ray were unremarkable. A diagnosis of SIAD was made. Fluid restriction was ineffective and Tolvaptan (a selective non-peptide arginine vasopressin receptor antagonist) was commenced on consultation with Endocrinology. Results With initiation of Tolvaptan there was significant clinical improvement. Sodium normalised to 134 mmol/L. He became alert, less confused and more engaged with the multidisciplinary team. He was discharged home well, and on follow up four months later, his clinical frailty scale score was 4 with significant improvement in his mobility on continued Tolvaptan therapy. An underlying colonic neoplasm is the clinically suspected driver of his SIAD but he is declining further investigation at present. Conclusion This case reflects the positive benefits of careful selected use of Tolvaptan in the older population with refractory SIAD, resulting in improved functional status and quality of life.

A COMPARATIVE STUDY ON BIOASSAY AND RADIOIMMUNOASSAY OF VASOPRESSIN IN HUMAN URINE

1978 ◽  
Vol 87 (2) ◽  
pp. 283-291 ◽  
Author(s):  
Jens Dencker Christensen ◽  
Svend Erik Jensen
Keyword(s):  
Human Subjects ◽  
Extraction Procedure ◽  
Urine Osmolality ◽  
Exchange Chromatography ◽  
Biologically Active ◽  
Fluid Restriction ◽  
Healthy Human ◽  
Water Load ◽  
Second Peak ◽  
Total Fluid

ABSTRACT The excretion of vasopressin in urine from healthy human subjects under different stages of hydration was estimated in urine extracts by bioassay (rat antidiuresis) and radioimmunoassay. In normally hydrated subjects the excretion was 490 ± 164 μU/h and 430 ± 133 μU/h for bioassay and radioimmunoassay respectively (mean ± sem, n = 5). After total fluid restriction for 10 to 12 h the excretion increased to 1370 ± 329 μU/h for bioassay and 1163 ± 279 μU/h for radioimmunoassay (mean ± sem, n = 6). An oral water load (25 ml/kg) reduced the value to 169 μU/h (bioassay) and 118 μU/h (radioimmunoassay) (mean, n = 2). In general the biological estimations were 20 % higher than the immunological estimations (P < 0.01). The urinary vasopressin excretion was positively correlated to urine osmolality. Synthetic arginine vasopressin (AVP) and urine extracts were both heterogeneous in ion exchange chromatography. The immunoreactive material was always eluted in 2 peaks, situated at the same places in the elution diagram. The material in the second peak was biologically active. The first peak from the AVP standard was biologically inactive, whereas the same peak from urine extract was active. This peak was shown to be an artefact formed during the extraction procedure.

Can Stereotactic Body Radiotherapy Effectively Treat Hepatocellular Carcinoma?

2016 ◽  
Vol 34 (5) ◽  
pp. 404-408 ◽  
Author(s):  
Aisling Barry ◽  
Jennifer J. Knox ◽  
Alice C. Wei ◽  
Laura A. Dawson
Keyword(s):  
Hepatocellular Carcinoma ◽  
Liver Function ◽  
Group Performance ◽  
Clinical Symptoms ◽  
Wedge Resection ◽  
Family Doctor ◽  
Eastern Cooperative Oncology Group ◽  
Local Therapy ◽  
Fluid Restriction ◽  
Liver Mass

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors’ suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 78-year-old woman with a past medical history of hepatitis C virus (HCV) presented on routine examination to her family doctor with abnormal liver function tests. She was referred for liver ultrasound, which detected a liver mass. Multiphasic magnetic resonance imaging (MRI) diagnosed liver cirrhosis and a segment 7/8 lesion measuring 4 cm, suspicious for a hepatocellular carcinoma (HCC), without evidence of portal hypertension. Child-Pugh (CP) score (ranging from 5 to 15) is a clinically relevant measure of synthetic liver function, based on international normalized ratio and albumin and bilirubin levels, as well as presence or absence of ascites and encephalopathy. A score of A5 or 6 is associated with better postoperative survival compared with CP B7 to 9 or CP C10 to 15, in which surgery is contraindicated. Her CP score was A6, based on a low albumin of 34 g/L. Platelets were slightly depressed at 121,000 μL, and alpha-fetoprotein level was 89 μg/L. She had not received treatment of her HCV because of her age and low viral load. She does not drink alcohol. Clinically the patient had an Eastern Cooperative Oncology Group performance status (PS) of 1, no stigmata of chronic liver disease, and no ascites or encephalopathy or other associated clinical symptoms. An HCC multidisciplinary cancer conference recommended surgical resection. The patient was taken to the operating room for a planned liver nonanatomic wedge resection. At the time of laparotomy, extensive cirrhosis was found and resection was abandoned because of the high risk of liver failure. A biopsy was not obtained, as the tumor had classic arterial enhancement and washout on venous and delayed-phase computed tomography (CT) imaging, which is diagnostic for HCC. After laparotomy, the patient developed liver insufficiency manifested by new ascites and peripheral edema, treated with diuretics, a low-salt diet, and fluid restriction. She was discharged home after a week and referred for a radiation oncology opinion. Three months after laparotomy, her liver function had recovered, with resolution of her ascites and PS of 2. It was decided to proceed with nonsurgical local therapy to the liver mass with curative intent.

scholarly journals Effects of sex and menstrual cycle on volume-regulatory responses to 24-h fluid restriction

2020 ◽  
Vol 319 (5) ◽  
pp. R560-R565
Author(s):  
Gabrielle E. W. Giersch ◽  
Abigail T. Colburn ◽  
Margaret C. Morrissey ◽  
Cody R. Butler ◽  
Michaela L. Pruchnicki ◽  
...  
Keyword(s):  
Menstrual Cycle ◽  
Specific Gravity ◽  
Body Mass ◽  
Urine Osmolality ◽  
Reproductive Hormones ◽  
Urine Specific Gravity ◽  
Fluid Restriction ◽  
Urine Color ◽  
Fluid Regulation ◽  
The Impact

Reproductive hormones have significant nonreproductive physiological effects, including altering fluid regulation. Our purpose was to explore the impact of sex and menstrual cycle (MC) phase on volume-regulatory responses to 24-h fluid restriction (24-h FR). Participants (men: n = 12, 20 ± 2 yr; women: n = 10, 20 ± 1 yr) were assigned two randomized and counterbalanced fluid prescriptions [Euhy: euhydrated, urine specific gravity (USG) < 1.020; Dehy: 24-h FR, USG > 1.020]. Men completed both (MEuhy, MDehy), while women completed both in the late-follicular ( days 10–13; FDehy, FEuhy) and midluteal ( days 18–22; LDehy, LEuhy) phases. We measured body mass, plasma and urine osmolality (Posm, Uosm), urine specific gravity (USG), urine color (Ucol), and serum copeptin; 24-h FR yielded mild dehydration without influence of sex or MC ( P > 0.05). Copeptin increased in men following Dehy (pre: 8.2 ± 5.2, post: 15.8 ± 12.6, P = 0.04) but not in women (FDehy pre: 4.3 ± 1.6, post: 10.5 ± 6.9, P = 0.06; LDehy pre: 5.6 ± 3.5, post: 10.4 ± 6.2, P = 0.16). In FDehy, Posm increased following FR (pre: 288 ± 2, post: 292 ± 1, P = 0.03) but not in men (pre: 292 ± 3, post: 293 ± 2, P = 0.46). No MC differences were observed between body mass loss, Posm, Uosm, USG, and copeptin ( P > 0.05). These results suggest that volume-regulatory responses to 24-h FR were present in men but not in women, without apparent effects of the menstrual cycle.

scholarly journals Thrombectomy for acute ischemic stroke with the new Sofia 6-French PLUS distal access reperfusion catheter: A single-center experience

2019 ◽  
Vol 33 (1) ◽  
pp. 17-23 ◽  
Author(s):  
Aaron P Wessell ◽  
Gregory Cannarsa ◽  
Helio Carvalho ◽  
Matthew J Kole ◽  
Pankaj Sharma ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Scale Score ◽  
Outcome Data ◽  
Vessel Occlusion ◽  
Safety And Efficacy ◽  
Single Center Experience ◽  
Comparative Safety ◽  
Effective Use

Introduction The Sofia 6-French PLUS catheter is a recently approved aspiration catheter for use in neuro-endovascular procedures. The description of Sofia 6-French PLUS use in acute ischemic stroke is limited. Objective The purpose of this article is to describe our initial experience with the new Sofia 6-French PLUS catheter for treatment of acute ischemic stroke and to report on its safety and efficacy. Methods We performed a retrospective study of 54 thrombectomy cases treated with the Sofia 6-French PLUS catheter. Mean patient age and admission National Institutes of Health Stroke Scale score were 65.30 (1.92) and 15.98 (0.89), respectively. The most common sites of vessel occlusion included the M1 segment (50%) and internal carotid artery (31%). Thrombectomy was performed using the direct aspiration first pass technique and/or aspiration in conjunction with a stent retriever. Results Successful navigation of the Sofia 6-French PLUS catheter to the site of thromboembolus was achieved in 94% of cases. Revascularization was achieved in a total of 47 cases (87%). Mean time from groin access to revascularization was 42.79 (3.23) min. There were no catheter-related complications. Final outcome data was available for 44 patients (81%). Of these patients, 41% achieved a good outcome (modified Rankin scale score of 0–2) at 60–90 day follow-up, 41% had a poor outcome (modified Rankin 3–5) and eight patients died (18%). Conclusions We demonstrate the safe and effective use of the Sofia 6-French PLUS catheter for treatment of acute ischemic stroke. Future studies in the form of a randomized clinical trial or multicenter registry are warranted to further evaluate its comparative safety and efficacy.

Dysfunction of hypothalamic-hypophysial axis after traumatic brain injury in adults

2010 ◽  
Vol 113 (3) ◽  
pp. 581-584 ◽  
Author(s):  
David Krahulik ◽  
Jirina Zapletalova ◽  
Zdenek Frysak ◽  
Miroslav Vaverka
Keyword(s):  
Traumatic Brain Injury ◽  
Brain Injury ◽  
Glasgow Coma Scale ◽  
Scale Score ◽  
Glasgow Coma Scale Score ◽  
Clinical Symptoms ◽  
Empty Sella ◽  
Pituitary Hormone ◽  
Endocrine Dysfunction ◽  
Coma Scale

Object Traumatic brain injury (TBI) is a major cause of serious morbidity and mortality. The incidence is 100–500/100,000 inhabitants/year. Chronic pituitary dysfunction is increasingly recognized after TBI. To define the incidence of endocrine dysfunction and risk factors, the authors describe a prospectively assessed group of patients in whom they documented hormonal functions, early diagnosis, and treatment of neuroendocrine dysfunction after TBI. Methods Patients aged 18–65 years were prospectively observed from the time of injury to 1 year postinjury; the Glasgow Coma Scale score ranged from 3 to 14. Patients underwent evaluation of hormonal function at the time of injury and at 3, 6, and 12 months postinjury. Magnetic resonance imaging was also conducted at 1 year postinjury. Results During the study period, 89 patients were observed. The mean age of the patients was 36 years, there were 23 women, and the median Glasgow Coma Scale score was 7. Nineteen patients (21%) had primary hormonal dysfunction. Major deficits included growth hormone dysfunction, hypogonadism, and diabetes insipidus. Patients in whom the deficiency was major had a worse Glasgow Outcome Scale score, and MR imaging demonstrated empty sella syndrome more often than in patients without a deficit. Conclusions To the authors' knowledge, this is the third largest study of its kind worldwide. The incidence of chronic hypopituitarism after TBI was higher than the authors expected. After TBI, patients are usually observed on the neurological and rehabilitative wards, and endocrine dysfunction can be overlooked. This dysfunction can be life threatening and other clinical symptoms can worsen the neurological deficit, extend the duration of physiotherapy, and lead to mental illness. The authors recommend routine pituitary hormone testing after moderate or severe TBI within 6 months and 1 year of injury.

scholarly journals Inter-Rater Reliability of the Retrospectively Assigned Clinical Frailty Scale Score in a Geriatric Outreach Population

2018 ◽  
Vol 21 (1) ◽  
pp. 1-5 ◽  
Author(s):  
Jasmine Davies ◽  
Jennifer Whitlock ◽  
Iris Gutmanis ◽  
Sheri-Lynn Kane
Keyword(s):  
Scale Score ◽  
Daily Living ◽  
Chart Review ◽  
Tertiary Care ◽  
Clinical Syndrome ◽  
Clinical Frailty Scale ◽  
Rater Reliability ◽  
Outreach Service ◽  
Increased Risk ◽  
Nurse Clinician

BackgroundFrailty, a common clinical syndrome in older adults associated with increased risk of poor health outcomes, has been retrospectively calculated in previous publications; however, the reliability of retrospectively assigned frailty scores has not been established. The aim of this study was to see if frailty scores, based on chart review data, agreed with clinician-determined scores based on a comprehensive geriatric assessment.MethodsPer standard practice, all patients seen by one nurse clinician (JW) from the Southwestern Ontario Regional Geriatric Program, a tertiary care-based outreach service, between August 15, 2013 and December 31, 2015 received a comprehensive geriatric assessment which included the assignment of an interview-based Clinical Frailty Scale score (CFS-I). Subsequently, a medical student researcher (JD), blinded to the CFS-I, assigned each consenting patient a frailty score based on chart review data (CFS-C). The inter-rater reliability of the CFS-I and CFS-C was then determined.ResultsOf the 41 consented patients, 39 had both a CFS-I and CFSC score. The median CFS score was 6, indicating patients were moderately frail and required assistance for some basic activities of daily living. Cohen’s kappa coefficient was 0.64, indicating substantial agreement.ConclusionCFS scores can be reliably assigned retrospectively, thereby strengthening the utility of this measure.

scholarly journals FRAILTY AND MORTALITY RISK IN PATIENTS WITH SEVERE COVID-19: PROGNOSIS BEYOND THE AGE CRITERION

2021 ◽  
Author(s):  
Márlon Juliano Romero Aliberti ◽  
Claudia Szlejf ◽  
Claudia Kimie Suemoto ◽  
Murilo Bacchini Dias ◽  
Wilson Jacob-Filho ◽  
...  
Keyword(s):  
Disease Severity ◽  
Scale Score ◽  
Mortality Risk ◽  
Frailty Index ◽  
Hazard Ratio ◽  
Hospitalized Patients ◽  
Adjusted Hazard Ratio ◽  
Acute Disease ◽  
Clinical Frailty Scale ◽  
Risk Of Death

OBJECTIVE: To investigate the association between frailty and death in hospitalized patients with COVID-19. METHODOLOGY: Prospective cohort study with patients ≥ 50 years hospitalized with COVID-19. Frailty was assessed using the Clinical Frailty Scale and the frailty index. Patients with a Clinical Frailty Scale score ≥ 5 were considered frail. The primary endpoints were mortality at 30 and 100 days after hospital admission. We used Cox proportional hazard models to investigate the association between frailty and mortality. We also explored whether frailty predicted different mortality levels among patients within strata of similar age and acute disease severity (Sequential Organ Failure Assessment score). RESULTS: A total of 1,830 patients were included (mean age 66 years; 58% men; 27% frail according to Clinical Frailty Scale score). The mortality risk at 30 days (adjusted hazard ratio = 1.7; 95% CI 1.4 - 2.1; p <0.001) and 100 days (adjusted hazard ratio = 1.7; 95% CI 1.4 - 2.1; p <0.001) was almost double for frail patients. The Clinical Frailty Scale also predicted different mortality levels among patients within strata of similar age and acute disease severity. Frailty intensified the effect of acute disease severity on the risk of death (p for interaction = 0.01). Of note, the Clinical Frailty Scale achieved outstanding accuracy to identify frailty according to the frailty index (area under the ROC curve = 0.94; 95% CI 0.93 - 0.95). CONCLUSIONS: Our results encourage the use of the Clinical Frailty Scale in association with measures of acute disease severity to determine prognosis and promote adequate resource allocation in hospitalized patients with COVID-19.

scholarly journals Isolated Langerhans cell histiocytosis in the hypothalamic-pituitary region: a case report

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Weibin Zhou ◽  
Jia Rao ◽  
Chengjiang Li
Keyword(s):  
Langerhans Cell Histiocytosis ◽  
Clinical Symptoms ◽  
Elevated Serum ◽  
Urine Osmolality ◽  
Langerhans Cell ◽  
Lymphocytic Hypophysitis ◽  
Pituitary Stalk ◽  
High Signal ◽  
Cns Disorders ◽  
Hormonal Evaluation

Abstract Background Langerhans cell histiocytosis (LCH) is a rare disease that mainly affects children, but this disease is significantly rarer in patients who are older than 15 years. In this disease, any organ can be involved. The skeleton, skin and lung are commonly affected, and isolated hypothalamic-pituitary (HP) involvement is relatively rare. Here we report a 17-year-old adolescent with isolated HP-LCH of enlarged pituitary stalk presented with central diabetes insipidus (CDI). Case presentation A 17-year-old male adolescent with polydipsia and polyuria accompanied with elevated serum sodium level and low urine osmolality for 3 weeks was referred to our hospital. After admission, hormonal evaluation showed that his growth hormone (GH) was slightly elevated, and serum osmolality and glucose were normal. The fluid deprivation-vasopressin test demonstrated CDI. Imaging examination showed an obvious thickening of the pituitary stalk. Lymphocytic hypophysitis, sarcoidosis and granulation tissue lesions were suspected. After oral 1-deamino-8-Darginine vasopressin (DDAVP) and prednisone were administered for 2 months, symptoms were relieved, and he discontinued taking the drugs by himself. On reexamination, imaging revealed changes in the size and shape of the pituitary stalk, with thickened nodules. Then, a diagnostic biopsy of the pituitary stalk lesion was performed. Immunohistochemistry confirmed the definitive diagnosis of LCH. The clinical symptoms subsided with oral hormone replacements. Conclusion CDI is a rare symptom in children and adolescents. Most of the causes are idiopathic, while others are caused by central nervous system (CNS) disorders. Meanwhile, lymphocytic hypophysitis, germinoma, LCH and other CNS disorders can all present as thickening of the pituitary stalk, diffuse enlargement of the pituitary gland, and weakening of high signal intensity in the neurohypophysis on magnetic resonance imaging (MRI). The differential diagnosis among these diseases depends on immunohistochemistry evidence.

scholarly journals Retrospective frailty determination in critical illness from a review of the intensive care unit clinical record

2019 ◽  
Vol 47 (4) ◽  
pp. 343-348 ◽  
Author(s):  
Jai N Darvall ◽  
Tristan Boonstra ◽  
Jen Norman ◽  
Donal Murphy ◽  
Michael Bailey ◽  
...  
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Critical Illness ◽  
Scale Score ◽  
Clinical Record ◽  
Next Of Kin ◽  
Clinical Frailty Scale ◽  
Rater Reliability ◽  
Charlson Comorbidity Score ◽  
Future Work

Frailty is one of the major challenges for intensive care, affecting one-third of intensive care unit patients and being associated with a range of poor health outcomes. Determination of frailty in critical illness using the Clinical Frailty Scale has recently been adopted by the Australian and New Zealand Intensive Care Society, but it is not known whether this is able to be measured from the clinical record without interviewing patients or their relatives. The aims of this retrospective cohort study were to test whether a Clinical Frailty Scale score could be assigned in an intensive care unit population from the clinical record, and to assess the inter-rater reliability of frailty measured in this manner. A total of 144 patients were enrolled. Of these, 137 (95%) were able to have a Clinical Frailty Scale score assigned, and 22 (15%) were scored as frail (Clinical Frailty Scale ≥5). Cohen’s kappa coefficient for inter-rater reliability between assessors was 0.67, confirming substantial agreement. Consistent with other critically ill cohorts, frailty was associated on multivariate analysis with age, Charlson comorbidity score, dependence with activities of daily living, and limitation of medical treatment, indicating validity of this approach to frailty measurement. Our results imply that frailty measurement is possible and feasible from the intensive care unit clinical record, which is of importance as routine measurement and reporting of frailty in intensive care units in our region increases. Future work should seek to validate an assigned Clinical Frailty Scale score with that obtained directly from patients or their next of kin.

Osmotic demyelination syndrome following slow correction of hyponatraemia

2021 ◽  
Vol 14 (8) ◽  
pp. e241407
Author(s):  
Isabel Saunders ◽  
David M Williams ◽  
Aliya Mohd Ruslan ◽  
Thinzar Min
Keyword(s):  
Antidiuretic Hormone ◽  
Serum Sodium ◽  
Inflammatory Markers ◽  
Urine Osmolality ◽  
Fluid Restriction ◽  
Osmotic Demyelination Syndrome ◽  
Electrolyte Disturbance ◽  
Osmotic Demyelination ◽  
Sodium Correction ◽  
Hospital Inpatients

Hyponatraemia is the most common electrolyte disturbance observed in hospital inpatients. We report a 90-year-old woman admitted generally unwell following a fall with marked confusion. Examination revealed a tender suprapubic region, and investigations observed elevated inflammatory markers and bacteriuria. Admission investigations demonstrated a serum sodium of 110 mmol/L with associated serum osmolality 236 mmol/kg and urine osmolality 346 mmol/kg. She was treated for hyponatraemia secondary to syndrome of inappropriate antidiuretic hormone (SIADH) and urosepsis. However, her serum sodium failed to normalise despite fluid restriction, necessitating treatment with demeclocycline and hypertonic saline. Despite slow reversal of hyponatraemia over 1 month, the patient developed generalised seizures with pontine and thalamic changes on MRI consistent with osmotic demyelination syndrome (ODS). This case highlights the risk of ODS, a rare but devastating consequence of hyponatraemia treatment, despite cautious sodium correction.

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