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By T. Ur-Gosh. Elms College.

These enable any interested biochemists at the local district hospital to tee up the facilities for the tests without requirement for any new equipment or expertise viagra super active 100mg. It was not until the early eighties that Stephen Davies became aware that there were people who were opposed to his medical practice 25mg viagra super active. In 1982 100mg viagra super active, he responded forcefully to an article by Dr Vincent Marks 25 mg viagra super active, a biochemist viagra super active 50mg, in Doctor? Some might think that such vested interests might preclude any doctor from passing medical opinions on sugar and illness 50 mg viagra super active. Although mere were general and consistent rumblings against nutritional medicine and the setting up of the British Society of Nutritional Medicine viagra super active 100 mg, it was not until 1988 that the first public shots were fired at Stephen Davies viagra super active 25mg. At the time this article was published viagra super active 50 mg, it did not occur to Davies or his colleagues that it represented the view of an organised opposition 100 mg viagra super active. Observer journalists sent an unsolicited sample of hair for analysis to Larkhall Laboratories, a firm which sub-contracts its hair-mineral analysisf to Biolab. The Observer took the results to Dr Stephen Davies, Medical Director of Biolab and a specialist in nutritional medicine, who practises in luxurious premises above his laboratories close to 5 Harley Street. Hair analysis is a valid measure for toxic elements such as lead and cadmium; in certain circumstances, it is considered the test. It is good for looking at the overall picture of mineral nutriture, whether or not diet is adequate or absorption is adequate or inadequate. It is exceptionally good for assessing levels of lead, mercury, arsenic, aluminium and cadmium. A whole half of the article deals with the apparent discrepancy between the two results. However, the article does not explain that there had been considerable dialogue between Stephen Davies and the Observer prior to publication. When Stephen Davies was asked for his opinion on the discrepancies in the hair-mineral analysis, he asked the journalists to explain how they had taken the sample. They admitted that they had taken the sample incorrectly, without concern for either the part of the hair, or the part of the head the sample came from. Biolab instructions for hair samples make it clear that hair has to be taken from the back of the head, cut as near to the scalp as possible, and preferably from a good quarter inch square. Annabel Ferriman and her colleague whose hair had been used arrived at Biolab at half eight one morning and sprung their story on me. We checked the internal quality control for the two days in question and it was impeccable. I asked them how they had taken the hair and they told me that they had taken it half way up the hair; there was a proximal sample for one and a distal sample for the other. There was a three month difference in the life of these two samples, three months of exposure to everything in the environment. This is why we insist upon the hair being taken from as close to the scalp as possible. Confident of the scientific accuracy of hair samples analysed at Biolab, Stephen Davies offered the journalists 10 free sample analyses from the same head and said that they could compare any two of those samples, and then write their story. When they refused the offer, Stephen Davies sought an injunction in the High Court, to postpone the publication of the article for a week. He also made the point that Stephen Davies would later have recourse to libel law. When I realised that we were being attacked I felt very protective of Biolab, its staff and all the patients who were benefiting from the kind of care that we are able to give. I felt how dare they distort the truth in an attack upon a form of medicine that can be so effective, and which attempts to help patients at the same time as reducing the risk of the patients falling foul of the side effects of potent and potentially toxic pharmaceutical drugs. The half of the article which did not deal with hair analysis argued against there being any conceivable value in taking vitamins and mineral supplements. There are extensive quotes taken from Professor John Garrow and Isobel Cole-Hamilton, both of whom are old school nutritionists, antagonistic to the use of vitamins and mineral supplements. Lurking behind this apparently investigative report on hair-mineral analysis is the much more serious covert content of the article, which attempts to expose nutritional medicine as quackery. John Garrow says: So far as minerals are concerned, I do not know of any evidence that there is any benefit to the 6 population of taking supplements. Isobel Cole-Hamilton, who is not even a doctor, is quoted as saying: If people were eating a healthy diet with plenty of fruit, vegetables, lean meat, potatoes and bread, particularly wholemeal bread, they would be getting all the zinc, iron, vitamins and other minerals they need. The article ends with a quote from the Drug and Therapeutics Bulletin: Books distributed by health food stores suggest that many people lack zinc and that this may explain problems ranging from brittle nails, acne, and premenstrual tension to alopecia and impotence. It is hardly surprising that it takes the side of pharmaceutical companies and orthodox practitioners on the use of supplements. The anti-vitamin lobby in America has a tired joke about Americans having the most expensive urine in the world, because of the vitamins they consume but do not metabolise. Like all bad jokes about national identity, it can be quickly turned round to reflect on people of other nations. Since many of the minerals and vitamins that we consume but cannot use are excreted in our 9 urine, doctors believe that Britain could soon have the most expensive urine in the world. Someone should have told Annabel Ferriman one of the first principles of economics: that for something to be expensive, it must have an exchange value. Perhaps Annabel Ferriman knew someone in the market for used urine, or had the Observer taken it all? From the point of view of Stephen Davies, a hard working doctor seeing many patients with a variety of illnesses, the article was damaging to his practice because it upset patients and impugned the integrity of the scientists working at Biolab. It also caused Davies himself considerable upset because it questioned his professionalism. No one was to know at the time that the article was only a first shot fired by powerful covert vested interest. I was interviewed by a senior member of staff, I told him about the work of Dr Carl Pfeiffer and Dr Linus Pauling. He has been particularly influenced by the attitudes of Eastern religion to food and the body. He runs one of the only institutes in the private sector which give an education and training in nutrition. From about the age of 14, I got involved in different consciousness-raising groups. At the age of fifteen, my two heroes were Jung and Hesse and I read whatever I could. I finally decided to study psychology at York University, which turned out to be science-based experimental psychology, psychopharmacology and brain biochemistry! I had always been a member of the consciousness 2 movement, an extremely vocal one. It talked about the mind, body and spirit; it sold 10,000 copies in the first year. Within three years, the organisation was in deep financial trouble and went into liquidation. As well as carrying out research, it holds courses and meetings for the general public. It has been a difficult organisation to run, dependent on a continuous flow of students for its courses. Since 1984, the Institute has had around 80 students go through the process of training. We want to create a shift in the public consciousness away from the idea that as long as you eat a well-balanced diet, you get all the vitamins you need, and towards the idea that optimum nutrition is a dynamic process and many illnesses are the result of faulty nutrition. They said that if you change your diet and take vitamin and mineral supplements, it makes a lot of difference to your health and well-being. I lost a stone in weight very rapidly and never put it on again, my energy shot up, my number of hours sleeping went down, my skin cleared up and my headaches went. I was eating no wheat and virtually no meat, lots of fruit and vegetables, mainly raw, and a few vitamins and mineral supplements. Like many others in the field of nutrition, Holford was influenced by work on nutrition in America. Much of this work with nutritional programmes achieved better results in the treatment of various mental conditions than did drug treatments or psychotherapy. He was involved in studying the effect of chemicals and nutrients on the brain for something like fifty years. By his fifties he was treating mental dysfunction, mainly schizophrenia, with nutrients. Like many of those whose time has not yet arrived, Patrick Holford has become used to being isolated and marginalised and used to the continual rebuke that he is a crank. Having accepted that the prevalent social view is not his view, he has developed a certain insecurity that can look like diffidence. In a world which was utterly in conflict with his ideas, acceptance proved elusive. His first disappointment was an interview at Queen Elizabeth College, University of London, in 1982. It left him dispirited and pessimistic at his chances of finding a place where he could pursue nutrition without having to accommodate vested interests. In 1985 I made enquiries to do research into the clinical significance of hair mineral analysis. I applied to do this at Surrey University, in the Human Nutrition Department, which comes under the control of the Biochemistry Department. At the time when Holford applied to do his research, Professor Dickerson held the Chair in Nutrition at Surrey. He was able to work with a company that had an atomic absorption spectrophotometer, a complex and expensive piece of equipment which analyses and measures the mineral content of hair. His problems began when the laboratory he was working with was suddenly sold and its operations moved to Hull. He took a year off, postponing the research until he was better equipped to do it. At about that time, Professor Dickerson retired and Professor Vincent Marks took over as head of the Biochemistry Department. At the time Marks became head of the Biochemistry Department at Surrey, apart 7 from publicising sugar for the sugar industry he was involved in the development of melatonin, a pharmaceutical solution to jet lag. Almost as soon as Marks took over, he wrote me a letter, the long and the short of which was that I had a few weeks to come up with a thesis which included experimental data, following which would be a live examination. I wrote back and told Marks about the difficulties I had had, and that I was thin on experimental data because I had little access to analytical equipment. Holford found out later that Delves was opposed to alternative health therapies and such things as hair mineral analysis. Soon after this failure, Holford was offered a place in the Chemistry Department, working under Dr Neil Ward, a lecturer who was particularly interested in hair mineral analysis. By 1989 Holford had re-established the Institute for Optimum Nutrition, this time with stronger foundations. Even many of the most conservative old school nutritionists agree that there are certain categories of people who may need their diet supplemented with vitamins. Many doctors and therapists now believe that the health and nutritional status not only of the pregnant woman, but of both prospective parents for some time prior to conception, affect both the chances of conception and the health of any new-born child. The relatively recent understanding of the various ways in which the actions and nutritional status of the future parents affect the health of a child has led to a growth of practice in the field of pre-conceptual care. Allopathic medicine and orthodox doctors, though they may consider the more obvious agents of pre-conceptual damage, such as smoking and drinking, rarely consider the nutritional status of possible parents. For those doctors and practitioners who use nutritional status as a guide to health, pre-conceptual care is one of the most important areas of work. Dealing with the health of couples who wish to conceive is dealing with the very foundation of life. It is the circumstances of conception and the medical history of the two parents which will to a great extent lay the foundations for the life-long health complexes of the child. All the nutritional deficiencies and the chemical toxicities which affect the adult have an effect upon foetal development. Cigarette smoking, consumption of alcohol and chemical interventions such as the contraceptive pill have an effect on the nutritional status of the adult and therefore the baby. Work by Professor Michael Crawford of the Institute of Brain Chemistry and Human Nutrition, in London, has shown that poor nutritional status of the mother can result in low birth weight and small head circumference. Small head circumference can mean also that there are 2 disorders in brain development, ranging from brain damage to poor learning ability. Factors which are likely to affect congenital malformations of the foetus are deficiencies of protein, amino acid, essential fatty acid and an inadequate carbohydrate intake. Vitamin deficiencies, especially of B1 and B2, folic acid and vitamin A, can also tend to produce 4 congenital abnormalities, as can mineral deficiencies of, for example, zinc and manganese. It has, for example, been common until recently for doctors to automatically prescribe an iron supplement to pregnant women. Research now shows, however, that this supplement is likely to inhibit the absorption of zinc. As British and American women tend to have a poor zinc intake, the prescription of such supplements could be counterproductive. Because orthodox medical practices are drug-dependent, there are inevitable difficulties in trying to convince orthodox doctors that pre-conceptual care is an important issue. This, however, is the task that Belinda Barnes, the founder of Foresight (The Association for the Promotion of Pre-Conceptual Care) set herself some years ago. At least now she is able to say that orthodox medical science is catching up with her. She and the doctors who work with Foresight have been giving nutritional advice to pregnant women and providing medical help to couples who have difficulty in conceiving or have frequent miscarriages, for over a decade. She has extended her own education through extensive reading, correspondence and frequent meetings with experts.

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Table 3: Total expenses and percent distribution for selected conditions by type of service: United States 100mg viagra super active, 2009 viagra super active 100mg. Interagency guideline on opioid dosing for chronic non-cancer pain: An educational aid to improve care and safety with opioid therapy: 2010 update 50 mg viagra super active. Are there genetic influences on addiction: Evidence from family 100 mg viagra super active, adoption and twin studies 50mg viagra super active. Clinical psychologists and smoking cessation: Treatment practices and perceptions 25 mg viagra super active. Detoxification from alcohol: A comparison of home detoxification and hospital-based day patient care viagra super active 25mg. Department of Health and Human Services viagra super active 25 mg, National Institutes of Health viagra super active 100 mg, National Institute on Alcohol Abuse and Alcoholism viagra super active 50mg. Development of an instrument to identify barriers to treatment for addicted women from their perspective. A prospective cohort study challenging the effectiveness of population-based medical intervention for smoking cessation. Efficacy of daily and alternate-day dosing regimens with the combination buprenorphine-naloxone tablet. Effectiveness of interventions on opiate withdrawal treatment: An overview of systematic reviews. An overview of systematic reviews of the effectiveness of opiate maintenance therapies: Available evidence to inform clinical practice and research. Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Rationale for screening and brief intervention for alcohol problems in primary care. American Academy of Pediatrics, Committee on Substance Abuse and Committee on Children With Disabilities. Standards for accreditation of baccalaureate and graduate degree nursing programs. The need for addiction medicine physicians and for addiction medicine residency training programs: A report of The American Board of Addiction Medicine Foundation. Content outline: Pediatric emergency medicine subspecialty in- training, certification, and maintenance of certification examinations. Content outline: Adolescent medicine subspecialty in-training, certification, and maintenance of certification examinations. Content outline: Child abuse pediatrics subspecialty in-training, certification, and maintenance of certification examinations. Content outline: Neonatal-perinatal medicine subspecialty in- training, certification, and maintenance of certification examinations. Content outline: Developmental-behavioral pediatrics subspecialty in-training, certification, and maintenance of certification examinations. Subspecialty certification examination in forensic psychiatry: 2009 content outline. Subspecialty certification examination in psychosomatic medicine: 2009 content outline. Subspecialty certification examination in geriatric psychiatry: 2010 content outline. Written certification examination in child and adolescent psychiatry (Part 1): 2010 content outline. Report to the Board of Trustees: Background on the organization "Physicians and Lawyers for National Policy": Resolution 425, A-06. Diagnostic and statistical manual of mental disorders, fourth edition: Primary care version. Practice guidelines for the treatment of patients with substance use disorders (2nd ed. Certificate of proficiency in the treatment of alcohol and other psychoactive substance use disorders. Public policy statement on how to identify a physician recognized for expertness in the diagnosis and treatment of addiction and substance-related health conditions. Desperately driven and no brakes: Developmental stress exposure and subsequent risk for substance abuse. The origins of the Minnesota model of addiction treatment: A first person account. Public beliefs about and attitudes towards people with mental illness: A review of population studies. Early intervention for substance abuse among youth and young adults with mental health conditions: An exploration of community mental health practices. Comparative epidemiology of dependence on tobacco, alcohol, controlled substances, and inhalants: Basic findings from the National Comorbidity Survey. Naltrexone combined with either cognitive behavioral or motivational enhancement therapy for alcohol dependence. Naltrexone and cognitive behavioral therapy for the treatment of outpatient alcoholics: Results of a placebo- controlled trial. Dietary approaches to prevent and treat hypertension: A scientific statement from the American Heart Association. Barriers to enrollment in drug abuse treatment and suggestions for reducing them: Opinions of drug injecting street outreach clients and other system stakeholders. Community studies on adolescent substance use, abuse, or dependence and psychiatric comorbidity. Acute cannabis consumption and motor vehicle collision risk: Systematic review of observational studies and meta-analysis. Association of Marital and Family Therapy Regulatory Boards, & Professional Examination Service. Varenicline versus transdermal nicotine patch for smoking cessation: Results from a randomised open-label trial. Adolescent smoking and depression: Evidence for self-medication and peer smoking mediation. Brief opportunistic smoking cessation interventions: A systematic review and meta-analysis to compare advice to quit and offer of assistance. Editorial: Standardizing terminology in addiction science: To achieve the impossible dream. Screening and interventions for alcohol and drug problems in medical settings: What works? Brief interventions for at-risk drinking: Patient outcomes and cost-effectiveness in managed care organizations. Brief intervention for heavy-drinking college students: 4-year follow-up and natural history. Brief cognitive behavioural interventions for regular amphetamine users: A step in the right direction. Site matters: Multisite randomized trial of motivational enhancement therapy in community drug abuse clinics. A 6-month controlled naltrexone study: Combined effect with cognitive behavioral therapy in outpatient treatment of alcohol dependence. The cost-effectiveness of a smoking cessation program for out-patients in treatment for depression. The cost-effectiveness of buprenorphine maintenance therapy for opiate addiction in the United States. Randomized controlled trial of motivational interviewing, cognitive behavior therapy, and family intervention for patients with comorbid schizophrenia and substance use disorders. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse. Increased attributable risk related to a functional mu-opioid receptor gene polymorphism in association with alcohol dependence in central Sweden. Drug abuse treatment entry and engagement: Report of a meeting on treatment readiness. Medicaid reforms in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act. Outpatient interventions for adolescent substance abuse: A quality of evidence review. A randomized clinical trial of a new behavioral treatment for drug abuse in people with severe and persistent mental illness. An exploratory study of recreational drug use and nutrition-related behaviors and attitudes among adolescents. Accountable care organizations in Medicare and the private sector: A status update: Timely analysis of immediate health policy issues. Is concern about post-cessation weight gain a barrier to smoking cessation among pregnant women? Screening and brief intervention to reduce marijuana use among youth and young adults in a pediatric emergency department. To treat or not to treat: Evidence on the prospects of expanding treatment to drug-involved offenders. Does attention-deficit hyperactivity disorder impact the developmental course of drug and alcohol abuse and dependence? Familial transmission of substance dependence: Alcohol, marijuana, cocaine, and habitual smoking: A report from the Collaborative Study on the Genetics of Alcoholism. Novel genes identified in a high-density genome wide association study for nicotine dependence. Substance abuse training and perceived knowledge: Predictors of perceived preparedness to work in substance abuse. Gender differences in trauma history and symptoms as predictors of relapse to alcohol and drug use. Effect of smoking cessation counseling on recovery from alcoholism: Findings from a randomized community intervention trial. Seeking safety treatment for male veterans with a substance use disorder and post-traumatic stress disorder symptomology. Improving primary care for patients with chronic illness: The chronic care model, Part 2. A model for the treatment of trauma-related syndromes among chemically dependent inpatient women. Research on rural residence and access to drug abuse services: Where are we and where do we go? Multisystemic treatment of serious juvenile offenders: Long-term prevention of criminality and violence. Guidelines for linking addiction treatment with primary healthcare developed for the Behavioral Health Recovery Management Project. Risk and reality: The implications of prenatal exposure to alcohol and other drugs. Department of Health and Human Services, Public Health Service, Alcohol, Drug Abuse, and Mental Health Administration, National Institute on Drug Abuse. Youth smoking cessation interventions: Treatments, barriers, and recommendations for Virginia. Happy ending: A randomized controlled trial of a digital multi-media smoking cessation intervention. Late-life drinking behavior: The influence of personal characteristics, life context, and treatment. Association between attention- deficit/hyperactivity disorder in adolescence and substance use disorders in adulthood. Child care in outpatient substance abuse treatment facilities for women: Findings from the 2008 National Survey of Substance Abuse Treatment Services. Wisconsin Initiative to Promote Healthy Lifestyles Retrieved June 14, 2012 from http://www. The prevalence and detection of substance use disorders among inpatients ages 18 to 49: An opportunity for prevention. Performance-based contracting within a state substance abuse treatment system: A preliminary exploration of differences in client access and client outcomes. Examining the effects of academic beliefs and behaviors on changes in substance use among urban adolescents. The looming expansion and transformation of public substance abuse treatment under the affordable care act. Naltrexone - Treatment for alcoholism and addiction: Blocks effects of opioids, reduces alcohol craving. A large randomized placebo controlled study of auricular acupuncture for alcohol dependence. The efficacy of motivational interviewing: A meta- analysis of controlled clinical trials. A comparison of self-report measures of nicotine dependence among male drug/alcohol-dependent cigarette smokers. Racial and ethnic differences in response to medicines: Towards individualized pharmaceutical treatment. Identifying substance abuse issues in high schools: A national survey of high school counselors. Black grandparents rearing children of drug-addicted parents: Stressors, outcomes, and social service needs. Monoclonal IgG affinity and treatment time alters antagonism of (+)-methamphetamine effects in rats.

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Although H pylori is clearly linked to gastric and duodenal ulcers and probably to gastric carcinoma and lymphoma 100mg viagra super active, whether it is more common in patients with nonulcer dyspepsia and whether treatment in those patients reduces symptoms are unclear viagra super active 50 mg. This patient is hemodynamically unstable with hypotension and tachycardia as a consequence of the acute blood loss viagra super active 50mg. Volume resusci- tation 50 mg viagra super active, immediately with crystalloid or colloid solution 25 mg viagra super active, followed by blood transfusion viagra super active 100 mg, if necessary viagra super active 25 mg, is the initial step to prevent irreversible shock and death 100 mg viagra super active. Later 25mg viagra super active, after stabilization viagra super active 25mg, acid suppression and H pylori treatment might be useful to heal an ulcer, if one is present. Patient in answer A has “red flag” symptoms: he is older than 45 years and has new onset symptoms. Patient in answer B may benefit from the reassurance of a negative endoscopic examination. This patient could be sent for an endoscopic examination if she does not improve following the therapy. Antibody tests show evidence of infection but remain positive for life,even after suc- cessful treatment. Helicobacter pylori eradication: equivalence trials and the optimal duration of therapy. This page intentionally left blank Case 5 A 65-year-old white woman is brought to the emergency room by her family for increasing confusion and lethargy over the past week. Her blood pressure is 136/82 mm Hg, heart rate 84 bpm, and res- piratory rate 14 breaths per minute and unlabored. On examination, she is an elderly appearing woman who is difficult to arouse and reacts only to painful stimuli. She is able to move her extremities without apparent motor deficits, and her deep tendon reflexes are decreased symmetrically. The remainder of her examination is normal, with a normal jugular venous pressure and no extremity edema. You order some laboratory tests, which reveal the serum sodium level is 108 mmol/L, potassium 3. She is afebrile and normoten- sive, and she has no edema or jugular venous distention. She is lethargic but is able to move her extremities without apparent motor deficits, and her deep tendon reflexes are decreased symmetrically. Know how to treat hyponatremia, and some of the potential complications of therapy. Considerations This elderly woman with small cell lung cancer presents in a stuporous state with hypotonic hyponatremia. She appears euvolemic, as she does not have findings suggestive of either volume overload (jugular venous distention or peripheral edema) or volume depletion. The patient does not take medications; thus, with the situation of hypotonic hyponatremia in a euvolemic state and with inappropriately concentrated urine, the most likely etiology is inappropriate antidiuretic hormone produced by the lung cancer. Because this individual is stuporous and the sodium level is severely decreased, hypertonic saline is required with fairly rapid partial cor- rection. Also, the target is not correction of the sodium level to normal but rather to a level of safety, such as 120 to 125 mmol/L. Depending on the rapidity with which the hyponatremia develops, most patients do not have symptoms until the serum sodium level is in the low 120 mmol/L range. The clinical manifestations are related to osmotic water shifts leading to cerebral edema; thus, the symptoms are mainly neurological: lethargy, con- fusion, seizures, or coma. Serum sodium concentrations are important because they almost always reflect tonicity, the effect of extracellular fluid on cells that will cause the cells (eg, brain cells) to swell (hypotonicity) or to shrink (hypertonicity). For pur- poses of this discussion, we use serum osmolality as a valid indicator of tonicity, which is almost always true, so we use the terms interchangeably. Whereas hypernatremia always reflects hyperosmolality, hyponatremia may occur in the setting of hyperosmolality, normal osmolality, or hypoosmolality (Table 5–1). Hyponatremia associated with a hypoosmolar state is more common and more dangerous. Some hyponatremic conditions are associated with hyper- osmolarity or with normal osmolarity. These solutes draw water out from the intracellular space, leading to relative hyponatremia. Hyperglycemia occurs in the setting of insulin-deficient states, such as uncontrolled diabetes mellitus. For glucose, each 100 mg/dL increase in serum glucose leads to an approximately 1. Transurethral resection of the prostate is a common cause of hyponatremia because of the large volume of mannitol-containing bladder irrigation fluid used intraopera- tively. For either of these states, correction of the glucose level (or excretion of the mannitol) corrects the hyponatremia. Pseudohyponatremia refers to an artifact of measurement in states where the serum sodium level and, thus, the tonicity are, in fact, normal. With current laboratory technology, the sodium level is directly measured, so pseudohyponatremia is not common. One can suspect pseudohyponatremia if the measured and calculated serum osmolarities are different. Hypotonic hyponatremia always occurs because there is water gain, that is, restriction or impairment of free water excretion. If one considers that the normal kidney capacity to excrete free water is approximately 18 to 20 L/d, it becomes apparent that it is very difficult to overwhelm this capacity solely through exces- sive water intake. Hyponatremia can also occur in cases of sodium loss, for example, as a consequence of diuretic use, or because of aldosterone deficiency. To determine the cause of the hypotonic hyponatremia, the physician must clinically assess the volume status of the patient by history and physical examina- tion. A history of vomiting, diarrhea, or other losses, such as profuse sweating, sug- gests hypovolemia, as do flat neck veins, dry oral mucous membranes, and diminished urine output. In hypovolemia, the kidney should be avidly retaining sodium, so the urine sodium level should be less than 20 mmol/L. If the patient is hypovolemic, yet the urine sodium level is more than 20 mmol/L, then kidneys do not have the ability to retain sodium normally. Either kidney function is impaired by the use of diuretics, or the kidney is lacking necessary hormonal stimulation, as in adrenal insufficiency, or there is a primary renal problem, such as tubular damage from acute tubular necrosis. When patients are hypovolemic, treatment of the hyponatremia requires correction of the volume status, usually replacement with isotonic (0. It commonly occurs as a result of congestive heart failure, cirrhosis of the liver, or the nephrotic syndrome. Renal failure itself can lead to hypotonic hyponatremia because of an inability to excrete dilute urine. In any of these cases, the usual initial treatment of hyponatremia is administration of diuretics to reduce excess salt and water. Thus, hypovolemic or hypervolemic hyponatremia is often apparent clinically and often does not present a diagnostic challenge. Euvolemic hyponatremia, however, is a frequent problem that is not so easily diagnosed. This measurement is taken to determine whether the kidney is actually capa- ble of excreting the free water normally (osmolality should be maximally dilute, <100 mOsm/kg in the face of hyposmolality or excess free water) or whether the free water excretion is impaired (urine not maximally concen- trated, >150-200 mOsm/kg). If the urine is maximally dilute, it is handling free water normally but its capacity for excretion has been overwhelmed, as in central polydipsia. More commonly, free water excretion is impaired and the urine is not maximally dilute as it should be. Two important diagnoses must be considered at this point: hypothyroidism and adrenal insufficiency. Thyroid hormone and cortisol both are permissive for free water excretion, so their deficiency causes water retention. In contrast, patients with Addison disease also lack aldos- terone, so they have impaired ability to retain sodium. Patients with adrenal insufficiency are usually hypovolemic and often present in shock. Because of retention of free water, patients actually have mild (although clinically inap- parent) volume expansion. Additionally, if they have a normal dietary sodium intake, the kidneys do not retain sodium avidly. Therefore, modest natriuresis occurs so that the urine sodium level is elevated to more than 20 mmol/L. Patients with severe neurologic symptoms, such as seizures or coma, require rapid partial correction of the sodium level. When there is concern that the saline infusion might cause volume overload, the infusion can be administered with a loop diuretic such as furosemide. The diuretic will cause the excretion of hypotonic urine that is essentially “half-normal saline,” so a greater portion of sodium than water will be retained, helping to correct the serum sodium level. When hyponatremia occurs for any reason, especially when it occurs slowly, the brain adapts to prevent cerebral edema. Solutes leave the intra- cellular compartment of the brain over hours to days, so patients may have few neurologic symptoms despite very low serum sodium levels. If the serum sodium level is corrected rapidly, the brain does not have time to readjust, and it may shrink rapidly as it loses fluid to the extracellular space. It is believed that this rapid shrinkage may trigger demyelination of the cerebellar and pontine neurons. Demyelination can occur even when fluid restric- tion is the treatment used to correct the serum sodium level. Therefore, sev- eral expert authors have published formulas and guidelines for the slow and judicious correction of hyponatremia, but the general rule is not to correct the serum sodium concentration faster than 0. His serum sodium level is initially 116 mEq/L and is corrected to 120 mEq/L over the next 3 hours with hypertonic saline. He has never had any health problems, but he has smoked a pack of cigarettes per day for about 35 years. His physical examination is notable for a low to normal blood pressure, skin hyperpigmentation, and digital clubbing. You tell him you are not sure of the problem as yet, but you will draw some blood tests and schedule him for follow-up in 1 week. The labo- ratory calls that night and informs you that the patient’s sodium level is 126 mEq/L, potassium level is 6. Which of the following is the likely cause of his hyponatremia given his presentation? Her medical history is remarkable only for hypertension, which is well controlled with hydrochlorothiazide. Her examination and laboratory tests show no signs of infection, but her serum sodium level is 119 mEq/L, and plasma osmolarity is 245 mOsm/kg. On the first postoperative day, he is noted to have significant hypona- tremia with a sodium level of 128 mEq/L. You suspect that the hypona- tremia is due to the intravenous infusion of hypotonic solution. In the postoperative state or in situations where the patient is in pain, the serum vasopressin level may rise, leading to inappropriate retention of free water, which leads to dilution of the serum. Hyponatremia in the setting of hyperkalemia and acidosis is sus- picious for adrenal insufficiency. This patient’s examination is also suggestive of the diagnosis, given his complaints of fatigue, weight loss, low blood pressure, and hyperpigmentation. The underlying cause of the adrenal gland destruction in this patient probably is either tuberculosis or malignancy. Because the patient is hypovolemic, probably as a result of the use of diuretics, volume replacement with isotonic saline is the best ini- tial therapy. Hyponatremia caused by thiazide diuretics can occur by several mechanisms, including volume depletion. In a patient with hyponatremia due to the infusion of excessive hypotonic solution, the serum osmolality should be low. The kidneys in responding normally should attempt to retain sodium and excrete water; hence, the urine sodium concentration should be low, and the urine osmolality should be low. When the infusion of hypotonic solution is used, the serum potassium level will also be low. This is in contrast to a situation of mineralocorticoid deficiency in which the sodium level will be decreased and potassium level may be elevated. Similarly, hyperaldosteronism can lead to hypertension and hypokalemia (Conn syndrome). Clinical Pearls ➤ Hyponatremia almost always occurs by impairment of free water excretion. Criteria include euvolemic patient, serum hypoosmolarity, urine that is not maximally dilute (osmolality >150-200 mmol/L), urine sodium more than 20 mmol/L, and normal adrenal and thyroid function. Patients with severe symptoms, such as coma or seizures, should be treated with hypertonic (3%) saline. This page intentionally left blank Case 6 A 42-year-old man is brought to the emergency room by ambulance after a sudden onset of severe retrosternal chest pain that began an hour ago while he was at home mowing the lawn. It was not relieved by three doses of sublingual nitroglycerin administered by the paramedics while en route to the hospital. He is a basketball coach at a local high school, and is usually physically very active.

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