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Pre-trial exchange of expert evidence to become normal practice in medical negligence actions.
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Treatment of hyponatraemia secondary to water overload.
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Treatment of hyponatraemia secondary to water overload.
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Confusion after visiting the radiology department.
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Opioid peptides and the control of human ingestive behaviour.
A variety of evidence suggests that endogenous opioid peptides play a role in the short-term control of eating. More recently, opioid receptor antagonists like naltrexone have been approved as a treatment for alcohol dependence. Here we review the evidence for a role of opioid peptides in both normal and abnormal eating and drinking behaviours and in particular try to identify the nature of the role of opioids in these behaviours. Particular attention is paid to the idea that opioid reward processes may be involved both in the short-term control of eating and hedonic aspects of alcohol consumption, and parallels are drawn between the effects of opiate antagonists on food pleasantness and the experience of drinking alcohol. The review also explores the extent to which data from studies using opiate antagonists and agonists provide evidence for a direct role of endogenous opioids in the control of ingestive behaviour, or alternatively whether these data may be better explained through non-specific effects such as the nausea commonly reported following administration of opiate antagonists. The review concludes that the present data suggests a single opioid mechanism is unlikely to explain all aspects of ingestive behaviour, but also concludes that opioid-mediated reward mechanisms play an important control in hedonic aspects of ingestion. The review also highlights the need for further empirical work in order to elucidate further the role of opioid peptides in human ingestive behaviour.
Reduction of hyponatremia in a schizophrenic with polydipsia-hyponatremia syndrome by surgical intervention.
In a chronic schizophrenic with polydipsia-hyponatremia syndrome, we observed physiological data consecutively before and after a successful LAPIDES vesicostomy for his bladder retention. Although his polydipsia was unchanged, frequency of hyponatremia was significantly reduced after the operation. We found that bladder retention might be one of the factors relevant to the prediction of hyponatremia from diurnal weight gain.
Brain water content, brain blood volume, blood chemistry, and pathology in a model of cerebral edema.
STUDY OBJECTIVES: The objective was to correlate regional changes during brain water content with alterations in blood chemistry and cerebral pathology during hypo-osmotic edema. PARTICIPANTS: Sprague-Dawley male adult rats were used in these studies. DESIGN: Animals were block-randomized to receive either an intraperitoneal distilled water injection equivalent to 5% or 15% of their body weight or no injection (controls). Rats were sacrificed 15 or 60 minutes after water injection or at an equivalent time for controls. INTERVENTIONS: No interventions were performed. MEASUREMENTS AND MAIN RESULTS: Water content of cerebral cortical gray and white matter was calculated from measurements of tissue specific gravity. Blood plasma osmolality and sodium and potassium concentrations were determined at various times after water injection. An index of blood-brain barrier permeability was obtained by measuring brain red blood cell and plasma volumes. A qualitative assessment of edema was made from light and electron micrographs of the cerebral cortex. We found that water injection produced a dose-dependent decrease in plasma osmolality and sodium concentration within 15 minutes. Cortical water content was unchanged after this period. An influx of water into cerebral gray, and, less readily, into cerebral white matter occurred during the next 15 minutes. Whole blood specific gravity and brain blood content were unchanged and thus did not confound the measurement of cerebral water content. Hematocrit was increased 60 minutes after a 15% water injection. The blood-brain barrier remained intact throughout this period. Microscopy revealed astrocytic swelling with slight extracellular fluid accumulation 60 minutes after the water injection. CONCLUSIONS: Homeostatic mechanisms in the cerebral cortex can maintain constant water content for at least 15 minutes during maintained intravascular hypo-osmolality. Fluid that subsequently moves into the tissue primarily enters an intracellular compartment. This model will be useful in investigating physiological mechanisms of brain water regulation and the pathogenesis of brain edema, a common clinical entity in emergency conditions.
Appropriate increased secretion of ADH.
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Hyponatremia as the cause of seizures in infants: a retrospective analysis of incidence, severity, and clinical predictors.
STUDY OBJECTIVES: (1) To determine the incidence of hyponatremic seizures in infants, (2) to compare the severity and outcome of seizures in hyponatremic and normonatremic patients, and (3) to evaluate the utility of clinical predictors of hyponatremia. DESIGN: Retrospective chart review of infants who presented to an urban pediatric emergency department from 1988 through 1993. PARTICIPANTS: Patients who experienced seizures while in the ED. These patients were divided into hyponatremic and normonatremic groups. RESULTS: Hyponatremia was the cause of seizures in 70% of 47 infants younger than 6 months who lacked other findings suggesting a cause. Median seizure duration was longer in hyponatremic patients (30 versus 17 minutes; P = .007), with a greater incidence of status epilepticus (73% versus 36%; P = .02) and fewer patients with seizures lasting less than 10 minutes (9% versus 36%; P = .04). Emergency intubation was performed more often in hyponatremic patients (12% versus 0%; P = .009). The median temperature was lower in hyponatremic infants than in normonatremic patients (35.5 degrees C versus 37.2 degrees C; P = .0001). Exact logistic-regression methods identified temperature of 36.5 degrees C or less as the best predictor of hyponatremic seizures, with an OR of 64 (95% CI, 8 to 1,026). CONCLUSION: Hyponatremia should be strongly suspected in an infant less than 6 months old with seizures and a temperature of 36.5 degrees C or less.
Plasma brain natriuretic peptide concentration on assessment of hydration status in hemodialysis patient.
BACKGROUND: Brain natriuretic peptide (BNP) is released into circulation in response to ventricular dilatation and pressure overload. Plasma BNP concentration correlates with left ventricular mass and dysfunction, which is prevalent in hemodialysis (HD) patients. METHODS: To evaluate the potential of BNP level for determination of hydration status, we measured inferior vena caval diameter (IVCD) and BNP levels and performed bioimpedance analysis in 49 HD patients. RESULTS: Pre-HD BNP levels remained unchanged after HD. Agreement between IVCD and pre-HD BNP level in overhydration was significant (kappa = 0.304). The area under the receiver operating characteristic (ROC) curve for overhydration was 0.819 for pre-HD BNP level. When extracellular fluid/total-body water (ECF/TBW) ratios of HD patients were compared with those of 723 controls, pre- and post-HD BNP levels were significantly greater in overhydrated patients. The area under the ROC curve for overhydration by ECF/TBW ratio was 0.781 for pre-HD BNP level. However, there was no significance for pre- or post-HD BNP levels on assessment of normohydration or underhydration. Pre-HD BNP level correlated significantly with post-HD BNP level, post-HD diastolic blood pressure, pulse pressure, and ECF/TBW ratio. IVCD correlated significantly with post-HD BNP level. CONCLUSION: BNP level seems to have a limited potential for assessment of overhydration in HD patients.
Effects of clonidine in schizophrenic patients with primary polydipsia: three single case studies.
A pilot study was conducted in schizophrenic patients with primary polydipsia to determine the tolerability of adding clonidine to an existing antipsychotic drug regimen and to seek evidence of an antidipsic effect. Three patients with chronic schizophrenia and primary polydipsia underwent open controlled prospective trials of treatment with clonidine in doses of up to 800 microg/day. The trials lasted from 2 to 5 months each, and analysis of variance was used to test for changes in dependent variables on a case-by-case basis. Blood pressure and pulse declined significantly in a dose-dependent manner, but fluid intake, as assessed by measurements of weight and 24-h urine volume, was not affected. Hypotension and bradycardia limited the extent to which the dose of clonidine could be increased. The lack of evident effect of clonidine on polydipsia in this small sample and the inconsistent results of two other recent studies of clonidine in patients with schizophrenia and primary polydipsia provide little overall support for the effectiveness of clonidine treatment in primary polydipsia associated with schizophrenia.
Central nervous system manifestations of disordered sodium metabolism.
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Temporal stability of polydipsia-hyponatremia.
We evaluated temporal stability and outcome predictors associated with polydipsia-hyponatremia (PH). Severity of PH was measured on two occasions separated by at least 1 year in 25 chronic psychiatric inpatients (24 with schizophrenia). Three-quarters of the sample had clinically evident PH on follow-up. Follow-up PH severity was significantly related to intake severity and hospitalization length. Our findings suggest that PH may be a persistent condition with specific outcome predictors.
Measuring and estimating daily urine volume in psychiatric patients: strengths and weaknesses.
We collected daily urine volumes (DUV) from 24 nonpolydipsic psychiatric patients and eight polydipsic schizophrenic patients. At 7 AM and 4 PM, we collected spot urine samples and measured urine creatinine concentration (UCr). Using morning weight and the UCr measurements, we compared actual DUV with estimated DUV using 3 methods to estimate DUV currently available in the literature. Each method of estimating DUV was superior among the polydipsic patients compared with the nonpolydipsic patients. We discuss the strengths and weaknesses of trying to estimate DUV in psychiatric patients. One method was simple but less accurate. The two remaining methods gave similar results but one method was substantially easier to use than the other.
[Behavior disorders in a child treated with desmopressin for enuresis].
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Transcervical electrosurgical resection of submucous leiomyomas for chronic menorrhagia.
STUDY OBJECTIVE: To evaluate the effectiveness and safety of transcervical electrosurgical resection (TSR) of submucous leiomyomas with or without concomitant transcervical endomyometrial resection (TEMR) for chronic menorrhagia. DESIGN: Prospective observational study, with 6-month follow-up of all 208 women and up to 6-year follow-up of 185 (88.9%). SETTING: Gynecology departments of teaching, community, and proprietary hospitals. PATIENTS: Two hundred eight women with submucous leiomyoma requiring surgical treatment of menorrhagia between March 1988 and March 1994. INTERVENTIONS: All 208 women (age range 32-63 yrs) underwent TSR with a continuous-flow gynecologic resectoscope. In 88 of these women who had no desire to preserve fertility, concomitant TEMR was performed. MEASUREMENTS AND MAIN RESULTS: Six months postoperatively 113 (94.2%) of the 120 women who underwent only TSR reported normal menses and 85 (96.6%) had satisfactory results; 62 (70.5%) who had both TSR and TEMR were amenorrheic. Eleven (73%) of the 15 women who had TSR and wanted to conceive subsequently became pregnant. One hundred eighty-five (88.9%) of the 208 patients have been followed for as long as 6 years. Ninety (84.1%) of the 107 women who had only the initial TSR and 69 (88.5%) of the 78 who had initial TSR and TEMR had satisfactory results. Only five women (2.7%) required major abdominal surgery. Among those undergoing TSR and TEMR, 49 (62.8%) were amenorrheic for as long as 6 years after TSR and one or two TEMRs. Eight (3.8%) of the 208 women had perioperative complications: 6 (2.9%) had fluid overload, 1 (0.5%) had dilutional hyponatremia, and 1 (0.5%) had excessive postoperative bleeding requiring tamponade. CONCLUSIONS: We believe that TSR with or without concomitant TEMR is an effective and safe treatment for women with submucous leiomyomas suffering from chronic menorrhagia.