Severe hyponatraemia: investigation and management in a district general hospital.

AIMS: To study the incidence, investigation, and management of severe hyponatraemia (serum sodium < 120 mmol/litre) over a period of six months in a district general hospital. METHODS: The laboratory computer was used to identify all inpatients who had a serum sodium concentration of less than 120 mmol/litre over a six month period. The records of these patients were reviewed for the relevant demographic, clinical, and laboratory data, in addition to diagnosis, treatment, and outcome of hospitalisation. RESULTS: Forty two patients were studied, with a female to male ratio of 2 : 1. Nine patients had central nervous system symptoms, and four of these patients died in hospital. Only 14 patients had their urinary electrolytes and/or osmolality checked. A diagnosis of syndrome of inappropriate secretion of antidiuretic hormone (SIADH) was mentioned in eight patients, sometimes without checking their urinary electrolytes or osmolality. Twenty one patients died in hospital. The patients who died did not have lower serum sodium values or a higher rate of correction of hyponatraemia, but they all suffered from advanced medical conditions. CONCLUSIONS: The possible cause of hyponatraemia should always be sought and that will require an accurate drug history, clinical examination, and assessment of fluid volume, plus the measurement of urinary electrolytes and osmolality in a spot urine sample. The diagnosis of SIADH should not be confirmed without the essential criteria being satisfied. The current or recent use of diuretics is a possible pitfall in the diagnosis of SIADH. The rate of serum sodium correction of less than 10 mmol/day is probably the safest option in most cases.

Comparison of two direct methods for HDL cholesterol measurement with an indirect precipitation method in diabetic patients.

The conventional precipitation method for measuring HDL cholesterol involves a centrifugation step which prevents automation of the method. Several methods have been introduced for measuring HDL cholesterol without the need for a centrifugation step. These new methods are therefore automatable and can process a large number of samples in a short period of time. Measuring HDL cholesterol is an important aspect of management of diabetes mellitus. In this study, we compared 2 direct methods for measuring HDL cholesterol with a conventional precipitation technique in 63 patients with either Type 1 or Type 2 diabetes mellitus. Both direct methods showed acceptable precision but they both showed positive bias compared to the conventional precipitation method. The greatest degree of bias occurs at low HDL cholesterol levels, which are more important for Type 2 patients. Such differences may affect cardiovascular risk calculation in patients with diabetes. Further studies are required to investigate if a correction factor needs to be introduced when these direct assays are used to measure HDL cholesterol in patients with Type 2 diabetes mellitus.

Combined general and epidural anesthesia versus general anesthesia for major abdominal surgery: postanesthesia recovery characteristics.

BACKGROUND AND OBJECTIVES: Outcome studies comparing general anesthesia combined with epidural anesthesia (GEN-EPI) to general anesthesia (GEN) for major abdominal surgery have been equivocal. However, many believe that patients anesthetized with GEN-EPI fair better than GEN. This study tests the hypothesis that there are favorable recovery characteristics associated with GEN-EPI as compared with GEN following abdominal surgery. METHODS: A prospective randomized double-blind trial, consisting of 30 patients ages 18-74 undergoing abdominal surgery was undertaken. Patients received either GEN-EPI or GEN by standardized protocol. At the end of surgery the epidural catheter was removed and psychological testing was performed over 24 hours to determine recovery characteristics. These included the modified Slater test, the Self-Assessment Manikin, the Kendrick Digital Copying Test, the Hospital Anxiety and Depression Scale, as well as visual analog scales for pain and appearance. RESULTS: Patients receiving GEN-EPI emerged from anesthesia faster (P < .03) with less pain on awakening (P < .04 at rest; P < .01 on coughing), had better psychomotor function at 2 hours (P < .04), and were less drowsy at 4 hours (P < .04), than patients with GEN. There was no difference in pain intensity after the initial assessment, morphine usage, mood, anxiety, and depression at any other measurement period. CONCLUSION: Transient quantifiable differences in recovery characteristics exist between patients receiving GEN-EPI and GEN.

Transnasal endoscopic closure of anterior fossa cerebrospinal fluid fistula.

The anterior skull base can be approached intranasally, and the development of endoscopes and accompanying endoscopic instruments in recent years makes possible extremely precise and defined work along the ethmoid and sphenoid sinus roof. Since these areas are the most frequent locations of anterior skull base CSF rhinorrhea, it follows that the localization and subsequent closure of these defects theoretically can be accomplished in this manner. Our report and others show that closure of CSF leaks can be accomplished successfully using this procedure, with minimal morbidity and at a fraction of the cost of frontal craniotomy. In our opinion, this should become the initial procedure of choice for closure of anterior fossa CSF leaks in amenable cases.

Stapedectomy in residency--the UAB experience.

A retrospective study of the resident-performed stapedectomies at the University of Alabama-Birmingham over the last 10 years was done. "Satisfactory" results, depending on the audiologic criteria used, were obtained in 60-64 percent of cases, far below the 90-95% success rate of established otologic surgeons. The reason for the low success rate is extremely limited experience, an average of 0.78 cases per residency at this institution. Other training programs have reported slightly higher success rates, all in the 60-80 percent range, but each had a higher average number of stapedectomies per resident. Some comments and suggestions are offered on the continuing controversy of stapedectomy in residency.

Nasal obstruction in children.

Acute nasopharyngitis and adenoidal hypertrophy, common causes of nasal obstruction in children, are reviewed. The less common, but equally important, congenital and neoplastic lesions that result in blocked nasal airways in children are discussed in detail.

Melanotic neuroectodermal tumor of infancy.

We have presented the only melanotic neuroectodermal tumor of infancy treated at the Children's Hospital of Alabama in the last seven years. Early diagnosis, relatively aggressive surgical treatment, and a team approach to the patient's management and rehabilitation should provide an excellent cure rate and near normal development of the patient postoperatively.