Masked diabetes insipidus in pituitary metastasis from breast cancer after thalamic biopsy: a case report

Background Symptomatic pituitary metastasis is rare; furthermore, it can result in diabetes insipidus and panhypopituitarism. Since diabetes insipidus is masked by concurrent panhypopituitarism, it can impede the diagnosis of pituitary dysfunction. Case presentation A 68-year-old Japanese female suffering from pituitary and thalamic metastases caused by untreated breast cancer, underwent a biopsy targeting the thalamus, not the pituitary. She lacked prebiopsy pituitary dysfunction symptoms; however, these symptoms unexpectedly occurred after biopsy. Diabetes insipidus was masked by corticosteroid insufficiency, and she showed normal urinary output and plasma sodium levels. Upon commencement of glucocorticoid replacement therapy, the symptoms of diabetes insipidus appeared. Conclusions In this case, thalamic biopsy, as opposed to pituitary biopsy, was performed to preserve pituitary function. However, pituitary dysfunction could not be avoided. Caution is necessary for asymptomatic patients with pituitary metastases as invasive interventions, such as surgery, may induce pituitary dysfunction. Moreover, with respect to masked diabetes insipidus, there is a need to carefully consider pituitary dysfunction to avoid misdiagnosis and delayed treatment.

Hyponatremia at the onset of necrotizing enterocolitis is associated with intestinal surgery and higher mortality

It has previously been shown that hyponatremia reflects the severity of inflammation in pediatric gastrointestinal diseases. Interpretation of electrolyte disorders is a common, but not well studied challenge in neonatology, especially in the context of early detection of necrotizing enterocolitis and bowel necrosis. The aim of this study was to assess if hyponatremia, or a decrease in plasma sodium level, at the onset of necrotizing enterocolitis (NEC) is associated with intestinal ischemia/necrosis requiring bowel resection and/or NEC-related deaths. This was a retrospective cohort study including patients with verified NEC (Bell’s stage ≥ 2) during the period 2009–2014. Data on plasma sodium 1–3 days before and at the onset of NEC were collected. The exposure was hyponatremia, defined as plasma sodium < 135 mmol/L and a decrease in plasma sodium. Primary outcome was severe NEC, defined as need for intestinal resection due to intestinal ischemia/necrosis and/or NEC-related death within 2 weeks of the onset of NEC. Generalized linear models were applied to analyze the primary outcome and presented as odds ratio. A total of 88 patients with verified NEC were included. Fifty-four (60%) of them had severe NEC. Hyponatremia and a decrease in plasma sodium at onset of NEC were associated with increased odds of severe NEC (OR crude 3.91, 95% CI (1.52–10.04) and 1.19, 95% CI (1.07–1.33), respectively). Also, a sub-analysis, excluding infants with pneumoperitoneum during the NEC episode, showed an increased odds ratio for severe NEC in infants with hyponatremia (OR 23.0, 95% CI (2.78–190.08)).Conclusions: The findings of hyponatremia and/or a sudden decrease in plasma sodium at the onset of NEC are associated with intestinal surgery or death within 2 weeks. What is Known:• Clinical deterioration, despite optimal medical treatment, is a relative indication for surgery in infants with necrotizing enterocolitis.• Hyponatremia is a common condition in preterm infants from the second week of life. What is New:• Hyponatremia and a decrease in plasma sodium level at the onset of necrotizing enterocolitis are positively associated with need of surgery or death within 2 weeks.• In infants with necrotizing enterocolitis, without pneumoperitoneum, where clinical deterioration despite optimal medical treatment is the only indication for surgery, hyponatremia, or a decrease in plasma sodium level can predict the severity of the disease.

COMPARATIVE STUDY ON PREVALENCE AND ASSESSMENT OF ALTERED SENSORIUM AMONG SODIUM ABNORMALITY PATIENTS AT A TERTIARY CARE TEACHING HOSPITAL

Altered sensorium or altered level of consciousness is a common complaint among electrolyte abnormality patients and has several synonyms like altered behaviour, generalized weakness, lethargy, agitation, psychosis, disorientation, inappropriate behaviour, inattention, confusion, hallucination. The aim of the study was to evaluate the prevalence and to assess the level of consciousness dysnatremic patients at a tertiary care hospital. A prospective observational study, serum sodium level and other clinical profiles were recorded in a data collection form. GCS was used to analyses the level of consciousness among the enrolled patients. SPSS 22.0 statistical software was used for data analysis. During the study period, a total of 482 patients were enrolled in the study. Based on the serum sodium, they were categorized into Hyponatraemic (410) and Hyponatraemic (72) patients. Our study found a greater number of patients in the age group above 60 years and found that sodium imbalance increases generally in males with increasing age. Our study found that altered sensorium (60%) was predominant more in hyponatremia patients. Chi square test was performed to find statistically significant difference in level of consciousness between hypo and Hyponatraemic patients and was found to be significant p value (≤ 0.05). Abnormalities of plasma sodium are probably the most common electrolyte disorders and they are associated with serious morbidity including a poorer long-term neurologic outcome.

Changes in electrolyte concentrations and hydration status in endurance horses following transport and an overnight stay prior to competition

OBJECTIVE To evaluate changes in electrolyte concentrations and hydration status that take place in endurance horses prior to the start of a competition and determine whether these changes would be associated with elimination. ANIMALS 19 horses entered in the 2016 Tevis Cup 100-Miles (160 km) One-Day Western States Trail Ride. PROCEDURES Heparinized blood samples were collected at 5 time points: prior to transport to the ride (T0), during check-in the day before the ride (T1), 1 to 2 hours before the start of the ride (T2), at the 15-km mark (T3), and at the 55-km mark (T4). Packed cell volume and plasma sodium, potassium, chloride, urea nitrogen, glucose, bicarbonate, and total protein concentrations were determined and compared across time points and between finishers and nonfinishers. RESULTS Signif icant differences were detected among plasma sodium, potassium, and urea nitrogen concentrations measured prior to the start of the ride (ie, T0, T1, and T2). For all variables except chloride and bicarbonate concentrations, significant differences were detected between values obtained prior to the start of the ride and values obtained during the ride (ie, T3 and T4). Only bicarbonate concentration at the 15-km mark of the ride was significantly associated with finishing status. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that significant changes in plasma sodium, potassium, and urea nitrogen concentrations can occur in endurance horses during transport to a competition and when horses are stabled overnight before an event. Additionally, a lower bicarbonate concentration following a steep climb early during the ride was associated with subsequent elimination.

Cadence discovery: study protocol for a dose-finding and mechanism of action clinical trial of sodium benzoate in people with treatment-refractory schizophrenia

Background Schizophrenia is a persistent psychotic disorder often accompanied by severe disability and premature mortality. New pharmacological treatments are urgently needed. Sodium benzoate, a common food preservative holds potential to be an effective, accessible treatment for schizophrenia, though the optimal dosing and mechanism of action of the compound requires further investigation. Methods Individuals with persistent treatment-refractory schizophrenia (n=52) will be recruited. Patients will be randomised in a 1:1:1:1 ratio to receive treatment of one of three active doses (1000, 2000 or 4000 mg daily) of sodium benzoate or placebo for 6 weeks duration. The primary outcome measurement is change in the Positive and Negative Syndrome Scale (PANSS) total score. Secondary outcome measurements are PANSS subscales, Global Assessment of Function (GAF), Clinical Global Impression (CGI) and Patient Global Impression (PGI-I). Change in concentrations of peripheral amino acids (D-alanine, L-alanine, D-serine, L-serine, glycine and glutamate), plasma sodium benzoate, plasma catalase, 3-nitrotyrosine, malondialdehyde and high-sensitivity C-reactive protein (hs-CRP) will be determined as tertiary measures. Discussion This trial seeks to build upon previous research indicating potential efficacy of sodium benzoate for reduction of symptoms in individuals with treatment-refractory schizophrenia. The trial aims to improve the understanding of the mechanism of action of the compound. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621000327886. Registered on 23 March 2021.

A Personal and Practical Answer from A Clinical Perspective

Restoring sodium and fluid homeostasis in hemodialysis (HD) patients is a crucial aim to reduce cardiovascular burden and improve global outcome. This crucial target is achieved at maximum in one quarter of HD patients according to a recent study. Sodium and fluid balance relies on a multitarget approach involving dietary salt restriction, dialysis salt mass removal and eventually residual kidney function. Salt mass removal in hemodialysis relies on ultrafiltration (convective sodium), the dialysate–plasma sodium gradient (diffusive sodium) and total treatment time. Manual dialysate sodium prescription has three major aims: dialysate–plasma sodium gradient; sodium mass removal target; hemodialysis tolerance and patient risks. In the future, automated dialysate sodium adjustment by HD machine will facilitate this aim.

Importance of Early Genetic Sequencing in Neonates Admitted to NICU with Recurrent Hypernatremia: Results of a Prospective Cohort Study

<b><i>Objectives:</i></b> The genetic characteristics in neonates admitted to the NICU with recurrent hypernatremia remained unknown. We aimed to implement early genetic sequencing to identify possible genetic etiologies, optimize the treatment, and improve the outcome. <b><i>Methods:</i></b> We prospectively performed exome sequencing or targeted panel sequencing on neonates diagnosed with recurrent hypernatremia (plasma sodium ≥150 mEq/L, ≥2 episodes) from January 1, 2016, to June 30, 2020. <b><i>Results:</i></b> Among 22,375 neonates admitted to the NICU, approximately 0.33% (73/22,375) developed hypernatremia. The incidence of hypernatremia &#x3e;14 days and ≤14 days was 0.03% and 0.3%, respectively. Among 38 neonates who had ≥2 hypernatremia episodes, parents of 28 patients consented for sequencing. Genetic diagnosis was achieved in 25% neonates (7/28). Precision medicine treatment was performed in 85.7% (6/7) of the patients, including hydrochlorothiazide and indomethacin for 57.1% (4/7) with arginine vasopressin receptor 2 (<i>AVPR2</i>) deficiency-associated congenital nephrogenic diabetes insipidus; a special diet of fructose formula for 1 patient with solute carrier family 5 member 1 deficiency-associated congenital glucose-galactose malabsorption (1/7, 14.3%); and kallikrein-inhibiting ointment for 1 patient with serine protease inhibitor of Kazal-type <i>5</i> deficiency-associated Netherton syndrome (1/7, 14.3%). Only hypernatremia onset age (adjusted odds ratio 1.32 [1.01–1.72], <i>p</i> = 0.040) independently predicted the underlying genetic etiology. The risk of a genetic etiology of hypernatremia was 9.0 times higher for neonates with a hypernatremia onset age ≥17.5 days (95% confidence interval, 1.1–73.2; <i>p</i> = 0.038). <b><i>Conclusions:</i></b> Single-gene disorders are common in neonates with recurrent hypernatremia, and &#x3e;50% of cases are caused by <i>AVPR2</i> deficiency-associated congenital nephrogenic diabetes insipidus. Early genetic testing can aid the diagnosis of unexplained recurrent neonatal hypernatremia and improve therapy and outcome.

Conflicting effects of haemolysis on plasma sodium and chloride are due to different haemolysis study protocols: A case for standardisation

Background Haemolysis has been reported as having a positive, negative or no effect on plasma sodium (PNa) and chloride (PCl). We investigated the haemoltytic effect of different haemolysis protocols on PNa and PCl using modelling and laboratory experiments. Methods In a modelling experiment, percentage change and recovery due to dilution in routinely ( in vitro) haemolysed samples were compared against shear stress haemolysis and samples spiked with haemolysate from whole blood freeze–thaw, packed cells freeze–thaw and osmotic shock protocols. The results were compared against a control base pool. Additionally, for the osmotic shock method, results were compared against saline- and deionised water (DIW)-spiked controls. In a laboratory experiment, percentage change and recovery were similarly compared using haemolysate from whole blood freeze–thaw and osmotic shock protocols. PNa, PCl and H-index were measured on the Abbott Architect and haemoglobin on the Sysmex XN-9000. Results In the modelling experiment, the percentage decrease in PNa and PCl was similar in in vitro haemolysis, shear stress haemolysis, whole blood freeze–thaw haemolysis and packed cells freeze–thaw haemolysis and this was lower compared to the osmotic shock method. In the laboratory experiment, the change in PNa compared to the base pool was less ( p < 0.001) per unit increase in H-index in the freeze–thaw method (−0.33 mmol, 95% CI −0.35 to −0.31) compared to the osmotic shock method (−0.65 mmol, 95% CI −0.66 to −0.64). PCl did not change with haemolysis in the freeze–thaw method and changed by −0.21 ± 0.01 mmol per unit increase in the H-index in the osmotic shock method. Recovery of PNa and PCl increased with increasing H-index in both methods. Conclusion The osmotic shock protocol is inappropriate for haemolysis studies because of dilution with DIW used for cell lysis. Recovery calculations may incorrectly compensate for genuine dilution caused by haemolysis.