Hyponatremia is present on admission in almost 15% of hospitalized patients. Even mild hyponatremia carries a significantly increased risk of death in hospital. The risk of death associated with hyponatremia appears to be particularly strong in patients with cardiovascular disease, cancer, and those undergoing orthopedic procedures.
Abstract
Background
Hyponatremia is the most common electrolyte abnormality in hospitalized individuals.
Methods
To investigate the association between serum sodium concentration and mortality, we conducted a prospective cohort study of 98,411 adults hospitalized between 2000 and 2003 at 2 teaching hospitals in Boston, Massachusetts. The main outcome measures were in-hospital, 1-year, and 5-year mortality. Multivariable logistic regression and Cox proportional hazards models were used to compare outcomes in patients with varying degrees of hyponatremia against those with normal serum sodium concentration.
Results
Hyponatremia (serum sodium concentration <135 mEq/L) was observed in 14.5% of patients on initial measurement. Compared with patients with normonatremia (135-144 mEq/L), those with hyponatremia were older (67.0 vs 63.1 years, P<.001) and had more comorbid conditions (mean Deyo-Charlson Index 1.9 vs 1.4, P <.001). In multivariable-adjusted models, patients with hyponatremia had an increased risk of death in hospital (odds ratio 1.47, 95% confidence interval [CI], 1.33-1.62), at 1 year (hazard ratio 1.38, 95% CI, 1.32-1.46), and at 5 years (hazard ratio 1.25, 95% CI, 1.21-1.30). The increased risk of death was evident even in those with mild hyponatremia (130-134 mEq/L; odds ratio 1.37, 95% CI, 1.23-1.52). The relationship between hyponatremia and mortality was pronounced in patients admitted with cardiovascular disease, metastatic cancer, and those admitted for procedures related to the musculoskeletal system. Resolution of hyponatremia during hospitalization attenuated the increased mortality risk conferred by hyponatremia.
Conclusion
Hyponatremia, even when mild, is associated with increased mortality.
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-- Sushrut S. Waikar, MD, MPH, David B. Mount, MD, Gary C. Curhan, MD, ScD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
Kamis, 17 September 2009
Rabu, 16 September 2009
Seriously Stressed
Presentation
Substance abuse—or more likely, its abrupt cessation—was a likely trigger for an unusual cardiac syndrome. A 25-year-old woman was brought to the emergency department from home after a seizure episode. En route to the hospital, the patient lost consciousness, and the emergency medical team discovered that she was in torsades de pointes, which then progressed to ventricular fibrillation. The patient was defibrillated to sinus tachycardia with a monophasic waveform shock of 360 J. She was successfully resuscitated, regained consciousness, and denied any chest pain or shortness of breath. On further questioning, she denied any past history of arrhythmia or family history of sudden cardiac arrest or unexplained death.
Assessment
The patient admitted to daily heavy alcohol consumption, and 3 days before hospitalization, she had used cocaine. Her potassium and magnesium levels on admission were 3.2 mEq/L and 1.4 mg/dL, respectively. An electrocardiogram (ECG) performed 3 hours after resuscitation revealed a narrow complex sinus tachycardia with deep, inverted T waves in leads II, III, AVF, and V3-V6, and a remarkably prolonged QTc interval of more than 660 msec (Figure 1). She was not taking any medications known to prolong the QT interval.
Serial cardiac enzymes remained within the normal range. A chest X-ray and computed tomography of the head were normal. However, a transthoracic echocardiogram disclosed an anteroapical regional wall motion abnormality and a reduced left-ventricular ejection fraction of 35-40%. Coronary angiography was normal. Left ventriculography showed basal hyperkinesis with apical ballooning, a finding consistent with takotsubo cardiomyopathy. The condition also is known as stress cardiomyopathy, because it can be induced by short-term emotional or physiologic stress.
Diagnosis
Our patient's diagnosis of takotsubo cardiomyopathy was based on the following criteria: transient hypokinesis, akinesis, or dyskinesis of the left ventricular apical and mid-ventricular segments; absence of obstructive coronary artery disease; ECG changes, either ST-segment elevation and/or T-wave inversion; and absence of head trauma, intracranial bleeding, pheochromocytoma, hypertrophic obstructive cardiomyopathy, or myocarditis.(1, 2)
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-- Nishant Kalra, MD, Prashant Khetpal, MD, MPH, Vincent L. Sorrell, MD
This article was originally published in the August 2009 issue of The American Journal of Medicine.
Substance abuse—or more likely, its abrupt cessation—was a likely trigger for an unusual cardiac syndrome. A 25-year-old woman was brought to the emergency department from home after a seizure episode. En route to the hospital, the patient lost consciousness, and the emergency medical team discovered that she was in torsades de pointes, which then progressed to ventricular fibrillation. The patient was defibrillated to sinus tachycardia with a monophasic waveform shock of 360 J. She was successfully resuscitated, regained consciousness, and denied any chest pain or shortness of breath. On further questioning, she denied any past history of arrhythmia or family history of sudden cardiac arrest or unexplained death.
Assessment
The patient admitted to daily heavy alcohol consumption, and 3 days before hospitalization, she had used cocaine. Her potassium and magnesium levels on admission were 3.2 mEq/L and 1.4 mg/dL, respectively. An electrocardiogram (ECG) performed 3 hours after resuscitation revealed a narrow complex sinus tachycardia with deep, inverted T waves in leads II, III, AVF, and V3-V6, and a remarkably prolonged QTc interval of more than 660 msec (Figure 1). She was not taking any medications known to prolong the QT interval.
Serial cardiac enzymes remained within the normal range. A chest X-ray and computed tomography of the head were normal. However, a transthoracic echocardiogram disclosed an anteroapical regional wall motion abnormality and a reduced left-ventricular ejection fraction of 35-40%. Coronary angiography was normal. Left ventriculography showed basal hyperkinesis with apical ballooning, a finding consistent with takotsubo cardiomyopathy. The condition also is known as stress cardiomyopathy, because it can be induced by short-term emotional or physiologic stress.
Diagnosis
Our patient's diagnosis of takotsubo cardiomyopathy was based on the following criteria: transient hypokinesis, akinesis, or dyskinesis of the left ventricular apical and mid-ventricular segments; absence of obstructive coronary artery disease; ECG changes, either ST-segment elevation and/or T-wave inversion; and absence of head trauma, intracranial bleeding, pheochromocytoma, hypertrophic obstructive cardiomyopathy, or myocarditis.(1, 2)
To read this article in its entirety, please visit our website.
-- Nishant Kalra, MD, Prashant Khetpal, MD, MPH, Vincent L. Sorrell, MD
This article was originally published in the August 2009 issue of The American Journal of Medicine.
Jumat, 04 September 2009
Mild Hyponatremia Carries a Poor Prognosis in Community Subjects
Abstract
Objective
Hyponatremia has been shown to predict adverse outcome in congestive heart failure and pneumonia among other common clinical entities, but its significance in the general population is elusive.
Methods
The population-based Copenhagen Holter Study included 671 men and women aged 55 to 75 years with no history of cardiovascular disease, stroke, or cancer. Baseline evaluation included 48-hour ambulatory electrocardiogram monitoring, blood tests, and a questionnaire. Hyponatremia was defined as s-Na ≤ 134 mEq/L or s-Na ≤ 137 mEq/L according to previously accepted definitions. An adverse outcome was defined as deaths or myocardial infarction. Median follow-up was 6.3 years.
Results
Fourteen subjects (2.1%, group A) had s-Na ≤ 134 mEq/L, and 62 subjects (9.2%, group B) had s-Na ≤ 137 mEq/L. No subject had s-Na < 129 mEq/L. An adverse outcome occurred in 43% of group A, 27% of group B, and 14% of subjects with s-Na >137mEq/L (controls) (P <.002). Adjusted hazard ratio for adverse outcome was 3.56 (95% confidence interval [CI], 1.53-8.28, P <.005) in group A compared with controls and 2.21 (95% CI, 1.29-3.80, P <.005) in group B after controlling for age, gender, smoking, diabetes, low-density lipoprotein cholesterol, and blood pressure. The hazard ratios were robust for additional adjusting for variables showing univariate association to hyponatremia (ie, beta-blocker and diuretic use, heart rate variability, creatinine, C-reactive protein, and NT-pro brain natriuretic peptide). By excluding diuretic users (18% of subjects), the adjusted hazard ratio for adverse outcome was 8.00 (95% CI, 3.04-21.0, P <.0001) in group A and 3.17 (95% CI, 1.76-5.72, P = .0001) in group B compared with controls.
Conclusion
Hyponatremia is an independent predictor of deaths and myocardial infarction in middle-aged and elderly community subjects.
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-- Ahmad Sajadieh, MD, DMSc, Zeynep Binici, MD, Mette Rauhe Mouridsen, MD, Olav Wendelboe Nielsen, MD, PhD, DMSc, Jørgen Fischer Hansen, MD, DMSc, Steen B. Haugaard, MD, DMSc
This article was originally published in the July 2009 issue of The American Journal of Medicine.
Objective
Hyponatremia has been shown to predict adverse outcome in congestive heart failure and pneumonia among other common clinical entities, but its significance in the general population is elusive.
Methods
The population-based Copenhagen Holter Study included 671 men and women aged 55 to 75 years with no history of cardiovascular disease, stroke, or cancer. Baseline evaluation included 48-hour ambulatory electrocardiogram monitoring, blood tests, and a questionnaire. Hyponatremia was defined as s-Na ≤ 134 mEq/L or s-Na ≤ 137 mEq/L according to previously accepted definitions. An adverse outcome was defined as deaths or myocardial infarction. Median follow-up was 6.3 years.
Results
Fourteen subjects (2.1%, group A) had s-Na ≤ 134 mEq/L, and 62 subjects (9.2%, group B) had s-Na ≤ 137 mEq/L. No subject had s-Na < 129 mEq/L. An adverse outcome occurred in 43% of group A, 27% of group B, and 14% of subjects with s-Na >137mEq/L (controls) (P <.002). Adjusted hazard ratio for adverse outcome was 3.56 (95% confidence interval [CI], 1.53-8.28, P <.005) in group A compared with controls and 2.21 (95% CI, 1.29-3.80, P <.005) in group B after controlling for age, gender, smoking, diabetes, low-density lipoprotein cholesterol, and blood pressure. The hazard ratios were robust for additional adjusting for variables showing univariate association to hyponatremia (ie, beta-blocker and diuretic use, heart rate variability, creatinine, C-reactive protein, and NT-pro brain natriuretic peptide). By excluding diuretic users (18% of subjects), the adjusted hazard ratio for adverse outcome was 8.00 (95% CI, 3.04-21.0, P <.0001) in group A and 3.17 (95% CI, 1.76-5.72, P = .0001) in group B compared with controls.
Conclusion
Hyponatremia is an independent predictor of deaths and myocardial infarction in middle-aged and elderly community subjects.
To read this article in its entirety, please visit our website
-- Ahmad Sajadieh, MD, DMSc, Zeynep Binici, MD, Mette Rauhe Mouridsen, MD, Olav Wendelboe Nielsen, MD, PhD, DMSc, Jørgen Fischer Hansen, MD, DMSc, Steen B. Haugaard, MD, DMSc
This article was originally published in the July 2009 issue of The American Journal of Medicine.
Kamis, 03 September 2009
Psychiatric Comorbidity and Other Psychological Factors in Patients with “Chronic Lyme Disease”
This study found that misdiagnosis of Lyme disease was common, resulting in repeated and unnecessary antibiotic treatment. Psychiatric comorbidity and other psychological factors were associated with functional outcomes.
Abstract
Background
There is no evidence of current or previous Borrelia burgdorferi infection in most patients evaluated at university-based Lyme disease referral centers. Instead, psychological factors likely exacerbate the persistent diffuse symptoms or “Chronic Multisymptom Illness” (CMI) incorrectly ascribed to an ongoing chronic infection with B. burgdorferi. The objective of this study was to assess the medical and psychiatric status of such patients and compare these findings to those from patients without CMI.
Methods
There were 240 consecutive patients who underwent medical evaluation and were screened for clinical disorders (eg, depression and anxiety) with diagnoses confirmed by structured clinical interviews at an academic Lyme disease referral center in New Jersey. Personality disorders, catastrophizing, and negative and positive affect also were evaluated, and all factors were compared between groups and with functional outcomes.
Results
Of our sample, 60.4% had symptoms that could not be explained by current Lyme disease or another medical condition other than CMI. After adjusting for age and sex, clinical disorders were more common in CMI than in the comparison group (P <.001, odds ratio 3.54, 95% confidence interval, 1.97-6.55), but personality disorders were not significantly more common. CMI patients had higher negative affect, lower positive affect, and a greater tendency to catastrophize pain (P <.001) than did the comparison group. Except for personality disorders, all psychological factors were related to worse functioning. Our explanatory model based on these factors was confirmed.
Conclusions
Psychiatric comorbidity and other psychological factors are prominent in the presentation and outcome of some patients who inaccurately ascribe longstanding symptoms to “chronic Lyme disease.”
To read this article in its entirety, please visit our website.
-- Afton L. Hassett, PsyD, Diane C. Radvanski, MS, Steven Buyske, PhD, Shantal V. Savage, BA, Leonard H. Sigal, MD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
Abstract
Background
There is no evidence of current or previous Borrelia burgdorferi infection in most patients evaluated at university-based Lyme disease referral centers. Instead, psychological factors likely exacerbate the persistent diffuse symptoms or “Chronic Multisymptom Illness” (CMI) incorrectly ascribed to an ongoing chronic infection with B. burgdorferi. The objective of this study was to assess the medical and psychiatric status of such patients and compare these findings to those from patients without CMI.
Methods
There were 240 consecutive patients who underwent medical evaluation and were screened for clinical disorders (eg, depression and anxiety) with diagnoses confirmed by structured clinical interviews at an academic Lyme disease referral center in New Jersey. Personality disorders, catastrophizing, and negative and positive affect also were evaluated, and all factors were compared between groups and with functional outcomes.
Results
Of our sample, 60.4% had symptoms that could not be explained by current Lyme disease or another medical condition other than CMI. After adjusting for age and sex, clinical disorders were more common in CMI than in the comparison group (P <.001, odds ratio 3.54, 95% confidence interval, 1.97-6.55), but personality disorders were not significantly more common. CMI patients had higher negative affect, lower positive affect, and a greater tendency to catastrophize pain (P <.001) than did the comparison group. Except for personality disorders, all psychological factors were related to worse functioning. Our explanatory model based on these factors was confirmed.
Conclusions
Psychiatric comorbidity and other psychological factors are prominent in the presentation and outcome of some patients who inaccurately ascribe longstanding symptoms to “chronic Lyme disease.”
To read this article in its entirety, please visit our website.
-- Afton L. Hassett, PsyD, Diane C. Radvanski, MS, Steven Buyske, PhD, Shantal V. Savage, BA, Leonard H. Sigal, MD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
Rabu, 02 September 2009
“Common Sense Is Not So Common” (What We All Need to Remember) – Part Two
Common Sense Is Not So Common.
Voltaire (Francois Marie Arouet, 1694-1778)
Dictionnaire Philosophique, 1764
This essay is the second of 2 dealing with clinical aphorisms that I have derived during many years of clinical experience. The first part contained 8 items and was published in the August issue of The American Journal of Medicine.
Rule # 9: Physician, heal thyself. The physician should be a model of good health habits for 2 reasons. First, patients are unlikely to follow the advice of someone who they believe is hypocritical. A doctor who smokes cigarettes will hardly be believed when informing patients that they have to stop smoking. Secondly, physicians with poor health habits eventually become patients themselves; it is difficult to be an effective health care provider when one's own health is impaired.
Rule # 10: Respect your fellow health care workers; they are your most important clinical asset. Just as no man is an island, no physician works in isolation. The health care team consists of nurses, physician assistants, technicians, laboratory staff, administrators, and many other individuals who make the health care system run smoothly. It is essential that the physician, as the leader of the clinical team, establish smooth working relationships with the many individuals in that unit. Friction, irritation, and bad humor in the environment lead to poor performance and, in the end, harm the patient. When I was a medical student, Judah Folkman informed my classmates and me that if we had a negative relationship with the nurses in the hospital during our clinical rotations then we would be better off selecting a profession other than medicine (personal communication, Judah Folkman, 1967).
Rule # 11: Admission to an intensive care unit in a tertiary care hospital can be a harrowing experience for the patient. Proof of this aphorism can be obtained easily if one takes an objective and uninvolved look at patients in an intensive care unit setting. Many of these individuals are tied to the bed and connected to a variety of tubes that emerge from nearly every natural orifice as well as many iatrogenic orifices. Patients are often unable to communicate with caregivers because of tracheal intubation. Usually they are given periodic doses of mind-altering substances and often are left by themselves for periods of time even in the intensive care environment. Therefore, it is imperative that we periodically take a step back from the bedside and decide what our goals are for these patients. Is there a reasonable chance that all that is being done to them will result in meaningful survival? If the answer to this last question is “no” or “probably not,” then the time has come to start discussing plans with the patient's family for discontinuing life support.
An important corollary to this aphorism is that many patients in the United States undergo excessive testing in the name of defensive medicine. One example is the excessive numbers of brain computed tomography scans that are performed on patients with minimal head trauma or vague histories of headache. In a similar vein, many patients with atypical chest pain are admitted to coronary care units. Much of this excessive utilization of diagnostic services could be eliminated if physicians took the care to obtain a comprehensive history from the patient and spent a few minutes explaining to the patient why certain tests are being performed and why others are not indicated. Many malpractice lawsuits arise as a result of poor communication between the doctor and the patient and not because of medical errors. Establishing rapport with the patient by taking a careful history—the “careful listening” referred to by William Carlos Williams (1883-1963)—is the physician's best defense against liability risk.
Rule # 12: True, true, and unrelated. This phrase refers to a commonly used form of question on medical knowledge examinations. A series of possibly related entities are presented, and the examinee is asked to pair them and state whether they are related or not with respect to causation. Situations often arise in clinical medicine in which one event or one physical finding occurs in close proximity to a second event or finding. However, these 2 events may be related to each other, or they may have occurred spontaneously without any relationship.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
Voltaire (Francois Marie Arouet, 1694-1778)
Dictionnaire Philosophique, 1764
This essay is the second of 2 dealing with clinical aphorisms that I have derived during many years of clinical experience. The first part contained 8 items and was published in the August issue of The American Journal of Medicine.
Rule # 9: Physician, heal thyself. The physician should be a model of good health habits for 2 reasons. First, patients are unlikely to follow the advice of someone who they believe is hypocritical. A doctor who smokes cigarettes will hardly be believed when informing patients that they have to stop smoking. Secondly, physicians with poor health habits eventually become patients themselves; it is difficult to be an effective health care provider when one's own health is impaired.
Rule # 10: Respect your fellow health care workers; they are your most important clinical asset. Just as no man is an island, no physician works in isolation. The health care team consists of nurses, physician assistants, technicians, laboratory staff, administrators, and many other individuals who make the health care system run smoothly. It is essential that the physician, as the leader of the clinical team, establish smooth working relationships with the many individuals in that unit. Friction, irritation, and bad humor in the environment lead to poor performance and, in the end, harm the patient. When I was a medical student, Judah Folkman informed my classmates and me that if we had a negative relationship with the nurses in the hospital during our clinical rotations then we would be better off selecting a profession other than medicine (personal communication, Judah Folkman, 1967).
Rule # 11: Admission to an intensive care unit in a tertiary care hospital can be a harrowing experience for the patient. Proof of this aphorism can be obtained easily if one takes an objective and uninvolved look at patients in an intensive care unit setting. Many of these individuals are tied to the bed and connected to a variety of tubes that emerge from nearly every natural orifice as well as many iatrogenic orifices. Patients are often unable to communicate with caregivers because of tracheal intubation. Usually they are given periodic doses of mind-altering substances and often are left by themselves for periods of time even in the intensive care environment. Therefore, it is imperative that we periodically take a step back from the bedside and decide what our goals are for these patients. Is there a reasonable chance that all that is being done to them will result in meaningful survival? If the answer to this last question is “no” or “probably not,” then the time has come to start discussing plans with the patient's family for discontinuing life support.
An important corollary to this aphorism is that many patients in the United States undergo excessive testing in the name of defensive medicine. One example is the excessive numbers of brain computed tomography scans that are performed on patients with minimal head trauma or vague histories of headache. In a similar vein, many patients with atypical chest pain are admitted to coronary care units. Much of this excessive utilization of diagnostic services could be eliminated if physicians took the care to obtain a comprehensive history from the patient and spent a few minutes explaining to the patient why certain tests are being performed and why others are not indicated. Many malpractice lawsuits arise as a result of poor communication between the doctor and the patient and not because of medical errors. Establishing rapport with the patient by taking a careful history—the “careful listening” referred to by William Carlos Williams (1883-1963)—is the physician's best defense against liability risk.
Rule # 12: True, true, and unrelated. This phrase refers to a commonly used form of question on medical knowledge examinations. A series of possibly related entities are presented, and the examinee is asked to pair them and state whether they are related or not with respect to causation. Situations often arise in clinical medicine in which one event or one physical finding occurs in close proximity to a second event or finding. However, these 2 events may be related to each other, or they may have occurred spontaneously without any relationship.
To read this article in its entirety, please visit our website.
-- Joseph S. Alpert, MD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
Vitamin D: Bone and Beyond, Rationale and Recommendations for Supplementation
Abstract
Adequate vitamin D status is necessary and beneficial for health, although deficiency plagues much of the world's population. In addition to reducing the risk for bone disease, vitamin D plays a role in reduction of falls, as well as decreases in pain, autoimmune diseases, cancer, heart disease, mortality, and cognitive function. On the basis of this emerging understanding, improving patients' vitamin D status has become an essential aspect of primary care. Although some have suggested increased sun exposure to increase serum vitamin D levels, this has the potential to induce photoaging and skin cancer, especially in patients at risk for these conditions. Vitamin D deficiency and insufficiency can be both corrected and prevented safely through supplementation.
To read this article in its entirety, please visit our website.
-- Sarah A. Stechschulte, BA, Robert S. Kirsner, MD, PhD, Daniel G. Federman, MD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
Adequate vitamin D status is necessary and beneficial for health, although deficiency plagues much of the world's population. In addition to reducing the risk for bone disease, vitamin D plays a role in reduction of falls, as well as decreases in pain, autoimmune diseases, cancer, heart disease, mortality, and cognitive function. On the basis of this emerging understanding, improving patients' vitamin D status has become an essential aspect of primary care. Although some have suggested increased sun exposure to increase serum vitamin D levels, this has the potential to induce photoaging and skin cancer, especially in patients at risk for these conditions. Vitamin D deficiency and insufficiency can be both corrected and prevented safely through supplementation.
To read this article in its entirety, please visit our website.
-- Sarah A. Stechschulte, BA, Robert S. Kirsner, MD, PhD, Daniel G. Federman, MD
This article was originally published in the September 2009 issue of The American Journal of Medicine.
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