Incidence and risk factors associated with preoperative deep venous thrombosis in the young and middle-aged patients after hip fracture

Objective This study aims to investigate the incidence, occurrence timing and locations of preoperative DVT and identify the associated factors in this group. Methods A retrospective analysis of collected data in young and middle-aged (18–59 years) patients who presented with hip fracture between October 2015 and December 2018 was conducted. Before operation, patients were routinely examined for DVT by Duplex ultrasonography (DUS). Electronic medical records were retrieved to collect the data, involving demographics, comorbidities, injury and laboratory biomarkers after admission. Multivariate logistic regression analysis was performed to identify factors that were independently associated with DVT. Results Eight hundred and fifty-seven patients were included, and 51 (6.0%) were diagnosed with preoperative DVT, with 2.5% for proximal DVT. The average age of patients with DVT is 48.7 ± 9.4 year, while that of patients without DVT is 45.0 ± 10.9 year. The mean time from injury to diagnosis of DVT was 6.8 ± 5.5 days, 43.1% cases occurring at day 2–4 after injury. Among 51 patients with DVT, 97 thrombi were found. Most patients had thrombi at injured extremity (72.5%), 19.6% at uninjured and 7.8% at bilateral extremities. There are significantly difference between patients with DVT and patients without DVT in term of prevalence of total protein (41.2% vs 24.4%, P = 0.008), albumin (54.9% vs 25.6%, P = 0.001), low lactate dehydrogenase (51.0% vs 30.3%, P = 0.002), lower serum sodium concentration (60.8% vs 29.9%, P = 0.001), lower RBC count (68.6% vs 37.0%, P = 0.001), lower HGB (51.0% vs 35.1%, P = 0.022), higher HCT (86.3% vs 35.1%, P = 0.022) and higher platelet count (37.3% vs 11.3%, P = 0.001). The multivariate analyses showed increasing age in year (OR 1.04, 95% CI; P = 0.020), delay to DUS (OR, 1.26; P = 0.001), abnormal LDH (OR, 1.45; P = 0.026), lower serum sodium concentration (OR, 2.56; P = 0.007), and higher HCT level (OR, 4.11; P = 0.003) were independently associated with DVT. Conclusion These findings could be beneficial in informed preventive of DVT and optimized management of hip fracture in specific group of young and mid-aged patients.

Edelman Revisited: Concepts, Achievements, and Challenges

The key message from the 1958 Edelman study states that combinations of external gains or losses of sodium, potassium and water leading to an increase of the fraction (total body sodium plus total body potassium) over total body water will raise the serum sodium concentration ([Na]S), while external gains or losses leading to a decrease in this fraction will lower [Na]S. A variety of studies have supported this concept and current quantitative methods for correcting dysnatremias, including formulas calculating the volume of saline needed for a change in [Na]S are based on it. Not accounting for external losses of sodium, potassium and water during treatment and faulty values for body water inserted in the formulas predicting the change in [Na]S affect the accuracy of these formulas. Newly described factors potentially affecting the change in [Na]S during treatment of dysnatremias include the following: (a) exchanges during development or correction of dysnatremias between osmotically inactive sodium stored in tissues and osmotically active sodium in solution in body fluids; (b) chemical binding of part of body water to macromolecules which would decrease the amount of body water available for osmotic exchanges; and (c) genetic influences on the determination of sodium concentration in body fluids. The effects of these newer developments on the methods of treatment of dysnatremias are not well-established and will need extensive studying. Currently, monitoring of serum sodium concentration remains a critical step during treatment of dysnatremias.

Serum Sodium Concentration and Increased Risk for Primary Epiretinal Membrane

Aims: To examine the prevalence of primary epiretinal membranes (ERMs) and associated systemic factors.Methods: The cross-sectional, community-based Tongren Health Care Study enrolled participants who received regular health examinations in the Beijing Tongren Hospital from 2017 to 2019. Using fundus photographs, retinal specialists assessed the presence of ERMs and their systemic associations.Results: Primary ERMs were detected in 841/22820 individuals, with a prevalence of 3.7% [95% confidence intervals (CI): 3.4–3.9%] in the total study population (mean age: 44.5 ± 13.8 years) and 6.5% (95% CI: 6.1–7.0%) in individuals aged 40+ years. In multivariable analysis, a higher ERMs prevalence was associated with older age [odds ratio (OR): 1.10; P < 0.001], higher serum cholesterol concentration (OR: 1.14; P = 0.003) and higher serum sodium concentration (SSC) (OR: 1.12; P < 0.001). In women, a higher SSC, even within the normal range, was associated with an increased risk of ERMs (OR: 1.19; P < 0.001). Female participants with an SSC of 144–145mmol/L as compared with those with an SSC of 135–137 mmol/L had a 5-fold increased odds of having ERMs (All women: OR: 5.33; P < 0.001; Women aged 40+years: OR: 4.63; P < 0.001).Conclusion: Besides older age and higher serum cholesterol concentration, a higher SSC, even if within the normal range, was independently associated with a higher ERM prevalence in women.

Changes in Factors Regulating Serum Sodium Homeostasis During Two Ultra-Endurance Mountain Races of Different Distances: 69km vs. 121km

Overdrinking and non-osmotic arginine vasopressin release are the main risk factors for exercise-associated hyponatremia (EAH) in ultra-marathon events. However, particularly during ultra-marathon running in mountainous regions, eccentric exercise and hypoxia, which have been shown to modulate inflammation, hormones regulating fluid homeostasis (hypoxia), and oxidative stress, could contribute to serum sodium changes in a dose-dependent manner. To the best of our knowledge, the contribution of these factors, the extent of which depends on the duration and geographical location of the race, has not been well studied. Twelve male participants (11 finishers) of the short (69km, 4,260m elevation-gain) and 15 male participants (seven finishers) of the long (121km, 7,554m elevation-gain) single-stage Südtirol Ultra Sky-Race took part in this observational field study. Venous blood was drawn immediately before and after the race. Analyses included serum sodium concentration, copeptin (a stable marker for vasopressin), markers of inflammation, muscle damage and oxidative stress. Heart rate was measured during the race and race time was obtained from the race office. During the short and the long competition two and one finishers, respectively showed serum sodium concentrations >145mmol/L. During the long competition, one athlete showed serum sodium concentrations <135mmol/L. Only during the short competition percent changes in serum sodium concentrations of the finishers were related to percent changes in body mass (r=−0.812, p=0.002), total time (r=−0.608, p=0.047) and training impulse (TRIMP) (r=−0.653, p=0.030). Data show a curvilinear (quadratic) relationship between percent changes in serum sodium concentration and body mass with race time when including all runners (short, long, finishers and non-finishers). The observed prevalence of hypo- and hypernatremia is comparable to literature reports, as is the relationship between serum sodium changes and race time, race intensity and body mass changes of the finishers of the short race. The curvilinear relationship indicates that there might be a turning point of changes in serum sodium and body mass changes after a race time of approximately 20h. Since the turning point is represented mainly by non-finishers, regardless of race duration slight decrease in body mass and a slight increase in serum sodium concentration should be targeted to complete the race. Drinking to the dictate of thirst seems an adequate approach to achieve this goal.

Increased risk of heart failure is associated with chronic habitual hypohydration that elevates serum sodium above 142 mmol/l suggesting lifelong optimal hydration as preventive measure

Background With increasing prevalence of heart failure (HF) owing to the aging population, identification of preventive measures that delay onset of the disease and their implementation become increasingly important. Recent studies demonstrated that chronic subclinical hypohydration accelerates degenerative changes and increases prevalence of many age-dependent degenerative diseases including heart failure (1). Worldwide surveys find wide differences in habitual water intake between and within countries and substantial prevalence of hypohydration in general population (2). Hypohydration elevates extracellular sodium triggering activation of water conservation mechanisms when serum sodium exceeds a threshold around 142 mmol/l. These adaptive responses include secretion of antidiuretic hormone and activation of the renin angiotensin aldosterone system (3), important contributors to pathogenesis of HF. Purpose The purpose of this study was to evaluate whether serum sodium concentration at middle age of 44–66 years as a measure of hydration habits is a significant predictor for left ventricular hypertrophy (LVH) and HF events 25 years later at age of 70–90 years. Methods Data from Atherosclerosis Risk in Communities (ARIC) study were obtained from the BioLINCC data repository. In ARIC study, 15,792 44–66 year-old participants were evaluated over 5 visits spanning 25 years (Figure 1A). Two separate logistic regression models were used in the study, where the dependent variable is diagnosis of LVH and HF at visit 5 (age:70–90 years), and the predictors are serum sodium concentration measured at visits 1 and 2 (age: 44–66 years), age, gender, total cholesterol, glucose, eGFR, BMI, smoking and hypertension statuses. Results Midlife serum sodium is associated with LVH and HF diagnosis 25 years later at visit 5 both with adjustment for age only (LVH: OR=1.24, 95% CI 1.15–1.34, P<0.001; HF: OR=1.06, 95% CI 1.02–1.10, P=0.006) and in fully adjusted model (LVH: OR=1.20, 95% CI 1.11–1.30, P<0.001; HF: OR=1.11, 95% CI 1.01–1.22, P=0.031) (Figure 1B). Cornell voltage criteria used for LVH diagnosis is elevated in participants with higher serum sodium and demonstrates sharper increase with age indicating accelerated hypertrophic LV remodeling (Figure 1C). These associations are reflected in increased prevalence of HF and LVH in 70–90 year-old participants whose middle age serum sodium exceeded 142 mmol/l (Figure 1D). Conclusions Habitual life-long hypohydration increases risk to develop LVH and HF. Keeping serum sodium below 142 mmol/l by drinking appropriate amount of liquids may slow down decline in cardiac function and decrease prevalence of HF. FUNDunding Acknowledgement Type of funding sources: Other. Main funding source(s): NHLBI Intramural program

Approach to Hyponatremia

Hyponatremia is a common laboratory finding in numerous patients. It is defined as a serum sodium concentration <135 mmol/L and represents an excess of water in the extracellular compartment. The severity of this electrolyte abnormality ranges from asymptomatic to seizures, coma and death as a consequence of cerebral swelling. There are multiple medical conditions, medications and disease states that can cause hyponatremia. This article summarizes the important pathophysiological pathways involved in the development of hyponatremia, describes an approach to common causes and reviews the initial steps in management.

Thermal strain and fluid balance during a 72-km military route march in a field setting

Introduction: A physiological profiling study was done to evaluate thermal strain as well as fluid and electrolyte balances on heat-acclimatised men performing a 72-km route march in a field setting. Methods: 38 male soldiers (age range 18–23 years) participated in the study, as part of a cohort that marched for 72 km, with loads for about 26 hours. Core temperature and heart rate sensors were used for the duration of the march. Fluid and food intake and output were monitored for the duration of the march. Blood samples were taken one day before the march (pre-march), immediately after the march before they had any opportunity to recover (Post 1) and on the 15th day after the march to ascertain recovery (Post 2) to assess fluid and electrolyte profiles. Results: Mean core temperature was within safe limits, ranging from 37.1 to 38.1°C throughout the march. There was an average overall decrease in serum sodium levels, a decline in serum sodium concentration in 28 participants and three instances of hyponatraemia (serum sodium concentration < 135 mmol/L). Conclusion: Our study found low thermal strain among heat-acclimatised individuals during a 72-km route march. However, there was an average overall decrease in serum sodium levels, even when the participants were allowed to drink ad libitum. Challenges of exercise-associated hyponatraemia during prolonged activities remain to be addressed.

MO724IS INDIVIDUALIZED DIALYSATE SODIUM REASON FOR BETTER SURVIVAL IN HEMODIALYSIS PATIENTS?

Background and Aims We are uncertain about whether dialysate sodium improves overall health and well-being for people on haemodialysis, since there are a mixture of probably good and bad effects. Dialysate sodium is one of the most easy changeable parameter which can influence hemodynamic stability, echocardiography and laboratory parameters. The aim of the study was to investigate whether dialysis patients will have some beneficial effects of dialysate sodium set up according to serum sodium. Method 77 nondiabetic subjects (41men; 36women) performed 12 months hemodialysis (HD) sessions with dialysate sodium concentration setup at 138 mmol/L, followed by additional 24 month ssessions wherein dialysate sodium was set up according to pre-HD serum sodium concentration. Interdialytic weight gain (IDWG), echocardiography, laboratory parameters and survival were analysed. Results Sodium individualization resulted in significantly lower IDWG by using individualized sodium according to pre HD serum sodium compared to standard dialysate sodium (2.17±0.79 vs 1.93±0.64 kg, p&lt;0,001). In all patients we confirmed positive sodium gradient and univariate regression analysis showed that by increasing the sodium gradient by 1 mmol/L, IDWG increased by an average of 0.189% and 7,1% changes in IDWG can be explain by changing of the sodium gradient. Echocardiography analysis showed an increase of 2.04 mm of left ventricular diastolic diameter (LVDD) by increasing the sodium gradient for 1mmol/L and significantly increased left ventricular mass (LVM) of 35.69 gr by 1kg increase of IDWG. Laboratory analysis showed statistical significant increase in Kt/V, URR (urea reduction rate), serum albumin and hemoglobin by using individualized dialysed sodium compared to standard dialysate sodium, respectively (1.50±0.24 vs 1.36±0.22; 70.80±5.24 vs 67.00±6.23%; 38.23±3.80 vs 34.46±2.53 g/L; 120.32±10.14 vs 114.62±10.34 g/L, p&lt;0.001). We confirmed significant decrease in serum potassium, with no change in other electrolities (5.62±0.60vs 5.15±0.94). During the study, 7 patients died and binary logistic regression univariate analysis showed that significant predictors of mortality in patients dialyzed with individualized sodium dialysis according to pre-HD plasma sodium concentrations were Kt/V, URR, and CRP (C reactive protein). Analysis showed that patients with Kt/V lower than 1,2 have 8.8 times higher risk for death compared to patients with Kt/V&gt;1,2, URR lower than 65% have 10,9 times higher risk compared to URR&gt;65% and CRP higher than 10 mg/L have 10.2 times higher risk for death compared to patients with CRP lower than 10 mg/L Conclusion Individualization of dialysate sodium according to pre HD serum sodium concentration result in better IDWG control, improvement of fluid overload and regression of left ventricular hypertrophy, better dialysis adequacy and higher survival compared to standard dialysate sodium.

Association between serum sodium level within normal range and handgrip strength in relation to hypertension status: a cross-sectional study

Serum sodium concentration within the normal range could act as an indicator of age-related changes such as decrease in muscle strength and impairment of capillary function. Since endothelial injury stimulates endothelial repair by enhancing CD34-positive cell production, the level of serum sodium may be inversely associated with that of circulating CD34-positive cells, thus indicating the degree of age-related endothelial injury. We conducted a cross-sectional study of 246 elderly Japanese men aged 60–69 years. Subjects were stratified by hypertension status because hypertension should act as a strong confounding factor for the analyses performed in this study. Serum sodium concentration was positively associated with handgrip strength in non-hypertensive subjects [standardized parameter estimate (β) = 0.29; p = 0.003], but not for hypertensive subjects (β = 0.01; p = 0.878), while it was inversely associated with circulating CD34-positive cell levels in non-hypertensive subjects [simple correlation coefficient (r) = − 0.28; p = 0.002] but not for hypertensive subjects (r = − 0.07; p = 0.454). For non-hypertensive elderly subjects, serum sodium concentration within the normal range is positively associated with handgrip strength and inversely associated with CD34-positive cells, thus partly indicating the degree of age-related endothelium injury. These associations could prove to be an efficient tool for clarifying the background mechanism governing the decrease in age-related muscle strength.