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Orthostatic Sodium Retention

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81. Assistive Devices to Improve Independence (Diagnosis)

mobility, orthostatic hypotension (systolic blood pressure [SBP] < 20 mm Hg), balance disorders, and vasovagal syncope. Depression, confusion, dementia, and other cognitive deficits also contribute to falls. Cognitive impairment, depressive symptoms, and orthostatic hypotension most contribute to gait dysfunction. Slower performance on the Timed Up-and-Go Test (TUG), a mobility task, is independently associated with poorer performance on measures of global cognition, executive function, memory (...) , female sex, cognitive impairment, poor self-rated health, low BMD, osteoporosis, inactivity, sedative use, alcohol use, and orthostatic hypotension. Extrinsic risk factors include adverse effects of medications, polypharmacy, and environmental hazards. Psychotropics, neuroleptics, tricyclic antidepressants, benzodiazepines, analgesics, sedatives, skeletal muscle relaxants, cardiac drugs (diuretics, antiarrhythmics), vasodilators, and antihistamines may contribute to falls. Results of studies suggest

2014 eMedicine.com

82. Altitude-Related Disorders (Diagnosis)

to displace the CSF. Conversely, those with lesser CSF to brain volume ratio have limited space for compensation of brain swelling and are prone to AMS. The role of fluid retention in the pathogenesis of AMS remains uncertain. Secretion of antidiuretic hormone and atrial natriuretic factor is altered in AMS and may contribute to vasogenic edema. More recently, hypoxia-induced alterations in oxidative stress and free radical metabolism have been implicated in the pathophysiology of AMS. [ ] Treatment (...) of the pathogenesis of HAPE is shown below. This image shows the pathophysiology of high-altitude pulmonary edema (HAPE) following ascent to high altitude. Factors leading to a low partial pressure of oxygen (PO2), such as exercise, sleep, or a low ventilatory response to hypoxia, increase the likelihood of developing HAPE. Alterations in the sympathetic nervous system are also believed to contribute to the development of HAPE. Recent evidence suggests that a defect in sodium transport across the alveolar

2014 eMedicine.com

83. Cauda Equina and Conus Medullaris Syndromes (Treatment)

therapy. Methylprednisolone should be administered. It treatment must be started within 8 hours of injury. No evidence exists of any benefit if it is started more than 8 hours after injury; on the contrary, late treatment may have detrimental effects. Administration of ganglioside GM1 sodium salt beginning within 72 hours of injury may be beneficial; the dose is 100 mg IV qd for 18-32 days. Tirilazad mesylate (a nonglucocorticoid 21-aminosteroid) has been proven to be of benefit in animals (...) are to maximize the medical, physical, psychological, educational, vocational, and social function of the patient. To maximize medical function, ensure adequate prevention and treatment of possible medical complications already discussed, especially deep venous thrombosis, bladder and bowel problems, and decubitus ulcers Physical therapy Perform range of motion and strengthening exercises, sitting balance, transfer training, and tilt table as tolerated (because of tendency to orthostatic hypotension). Tilt

2014 eMedicine.com

84. Cardiovascular Concerns in Spinal Cord Injury (Treatment)

in the management of orthostatic hypotension Atropine: Drug of choice for bradycardia but rarely used in rehabilitation settings except during emergencies (phenylephrine and dopamine also can be considered) Alpha-adrenergic agonists: Improve the patient's hemodynamic status by increasing myocardial contractility and heart rate Corticosteroids: Cause sodium and fluid retention, resulting in improvements in symptomatic orthostatic hypotension Sympathomimetics: Augment coronary and cerebral blood flow (...) lead to increased blood pressure. Corticosteroids cause sodium and fluid retention to improve symptomatic orthostatic hypotension, and sympathomimetics augment coronary and cerebral blood flow. Anticholinergics are administered to improve conduction through the atrioventricular (AV) node; this is accomplished by a reduction of vagal tone by way of muscarinic receptor blockade. Previous References Partida E, Mironets E, Hou S, Tom VJ. Cardiovascular dysfunction following spinal cord injury. Neural

2014 eMedicine.com

85. Hypertension (Treatment)

using newer techniques. [ ] Consultations Consultations with a nutritionist and exercise specialist are often helpful in changing lifestyle and initiating weight loss. Consultation with a hypertension specialist is indicated for management of secondary hypertension attributable to a specific cause. Next: Nonpharmacologic Therapy Dietary changes A number of studies have documented an association between sodium chloride intake and BP. The effect of sodium chloride is particularly important (...) in individuals who are middle-aged to elderly with a family history of hypertension. A moderate reduction in sodium chloride intake can lead to a small reduction in blood pressure. The American Heart Association recommends that the average daily consumption of sodium chloride not exceed 6 g; this may lower BP by 2-8 mm Hg. [ , ] One randomized controlled trial published found that moderate dietary sodium reduction (about 2500 mg Na + or 6 g NaCl per day) added to angiotensin-converting enzyme (ACE

2014 eMedicine.com

87. Portal Hypertension (Treatment)

in patients with advanced cirrhosis is that vasodilators can reduce arterial blood pressure and promote the activation of endogenous vasoactive systems that may lead to sodium and water retention. Although ISMN has been demonstrated to reduce HVPG markedly in acute administration, it provides significantly less reduction after long-term administration (due to probable development of patient tolerance). Combination therapy Although many authorities recommended a combination therapy of pharmacologic (...) , devascularization procedures, and liver transplantation. Decompressive shunts and devascularization procedures are mainly rescue therapies. Management of patients with liver cirrhosis and ascites but without variceal hemorrhage includes a low-sodium diet and diuretics. Nasogastric tube In patients with hemodynamically significant upper gastrointestinal (GI) tract bleeding, a nasogastric tube should remain in place for 24 hours to assist in identifying any rebleeding. Gastric lavage may be performed frequently

2014 eMedicine.com

88. Proteinuria (Treatment)

syndrome. Treatment with a loop diuretic or a combination of diuretics such as a thiazide and loop diuretic produces diuresis in most patients. The addition of albumin may improve natriuresis in patients with refractory salt and water retention, but the potential benefits must be weighed against the cost and risks of albumin infusion, which include the possibility of exacerbating fluid overload. Anticoagulants Patients with proteinuria tend to be hypercoagulable due to urinary losses of coagulation (...) of an experimental ETA-selective antagonist, avosentan, in patients with diabetic nephropathy showed a decrease in albuminuria, but with adverse effects including fluid retention and heart failure exacerbation. Atrasentan, another experimental ETA antagonist with a better adverse effect profile than avosentan, has also been shown to reduce proteinuria. [ , ] Vitamin D and proteinuria In animal studies, vitamin D and vitamin D analogues decrease inflammatory mediators and may act as immunosuppressive agents

2014 eMedicine.com

89. Proteinuria (Overview)

function. Glomerular proteinuria can also be categorized according to whether pathological damage of the glomerulus is present. Types that do not result from pathological damage to the glomerulus include transient and orthostatic proteinuria. Transient proteinuria occurs in persons with normal renal function, bland urine sediment, and normal blood pressure. The quantitative protein excretion is less than 1 g/day. The proteinuria is not indicative of significant underlying renal disease; it may (...) be precipitated by high fever or heavy exercise, and it disappears upon repeat testing. Exercise-induced proteinuria usually resolved wihtin 24 hours. Orthostatic proteinuria is diagnosed if the patient has no proteinuria in early morning samples but has low-grade proteinuria at the end of the day. It usually occurs in tall, thin adolescents or adults younger than 30 years (and may be associated with severe lordosis). Patients have normal renal function and proteinuria is usually < 1 g/day, with no hematuria

2014 eMedicine.com

91. Gynecologic Pain (Overview)

improvement in patients with IC who were treated with amitriptyline. [ ] Corticosteroids are not widely used because of adverse effects such as fluid retention and osteoporosis. However, a study reported improved pain control and overall satisfaction with oral prednisone in a cohort of women with severe refractory IC. [ ] Pentosan polysulfate sodium (PPS) (Elmiron) is claimed to restore the depletion in the glycosaminoglycan (GAG) layer. A double-blind placebo-controlled trial revealed subjective (...) a reproductive age woman presents with pelivic pain and a positive pregnancy test. An unruptured ectopic pregnancy produces localized pain due to dilatation of the fallopian tube. Once the ectopic pregnancy is ruptured, the pain tends to be generalized due to peritoneal irritation. Symptoms of rectal urgency due to a mass in the pouch of Douglas may also be present. Syncope, dizziness, and orthostatic changes in blood pressure are sensitive signs of hypovolemia in these patients. Abdominal examination

2014 eMedicine.com

92. Geriatric Rehabilitation (Overview)

physiologic factors that can lead to falls include the following: decreased muscle mass (which decreases overall strength), postural changes of the hips with increasing valgus deformity, change in the center of gravity to behind the hips, increased postural sway, decreased righting reflexes, increased reaction time, visuoperceptual decline, decreased vibratory sensation and altered proprioception (poor lower-extremity sensory input), impaired mobility, orthostatic hypotension (systolic blood pressure [SBP (...) ] < 20 mm Hg), balance disorders, and vasovagal syncope. Depression, confusion, dementia, and other cognitive deficits also contribute to falls. Cognitive impairment, depressive symptoms, and orthostatic hypotension most contribute to gait dysfunction. Slower performance on the Timed Up-and-Go Test (TUG), a mobility task, is independently associated with poorer performance on measures of global cognition, executive function, memory, and processing speed, suggesting that a thorough cognitive

2014 eMedicine.com

93. Cardiovascular Concerns in Spinal Cord Injury (Overview)

in the management of orthostatic hypotension Atropine: Drug of choice for bradycardia but rarely used in rehabilitation settings except during emergencies (phenylephrine and dopamine also can be considered) Alpha-adrenergic agonists: Improve the patient's hemodynamic status by increasing myocardial contractility and heart rate Corticosteroids: Cause sodium and fluid retention, resulting in improvements in symptomatic orthostatic hypotension Sympathomimetics: Augment coronary and cerebral blood flow (...) lead to increased blood pressure. Corticosteroids cause sodium and fluid retention to improve symptomatic orthostatic hypotension, and sympathomimetics augment coronary and cerebral blood flow. Anticholinergics are administered to improve conduction through the atrioventricular (AV) node; this is accomplished by a reduction of vagal tone by way of muscarinic receptor blockade. Previous References Partida E, Mironets E, Hou S, Tom VJ. Cardiovascular dysfunction following spinal cord injury. Neural

2014 eMedicine.com

94. Toxic Neuropathy (Overview)

and symptoms Patients with neuropathy typically present with symptoms of pain, tingling, or numbness in their feet, consistent with dysfunction affecting the longest and largest fibers of the peripheral nervous system (PNS). Other manifestations of neurologic dysfunction that may be present include the following: Hypohidrosis or hyperhidrosis Diarrhea or constipation Urinary incontinence or retention Gastroparesis Sicca syndrome Blurry vision Facial flushes Orthostatic intolerance Sexual dysfunction (...) of neuropathy, such as sodium channel, neuromuscular transmission, or cranial neuropathies, also have toxic etiologies. In North America, sodium channel dysfunction may be the result of ciguatera toxin from reef fish or saxitoxin from shellfish. This often presents as an acute or subacute illness. Puffer fish may be intoxicated with tetrodotoxin in Japan. Neuromuscular transmission dysfunction is associated most commonly with organophosphate intoxication; however, envenomation from snake bites or botulism

2014 eMedicine.com

95. Altitude-Related Disorders (Overview)

to displace the CSF. Conversely, those with lesser CSF to brain volume ratio have limited space for compensation of brain swelling and are prone to AMS. The role of fluid retention in the pathogenesis of AMS remains uncertain. Secretion of antidiuretic hormone and atrial natriuretic factor is altered in AMS and may contribute to vasogenic edema. More recently, hypoxia-induced alterations in oxidative stress and free radical metabolism have been implicated in the pathophysiology of AMS. [ ] Treatment (...) of the pathogenesis of HAPE is shown below. This image shows the pathophysiology of high-altitude pulmonary edema (HAPE) following ascent to high altitude. Factors leading to a low partial pressure of oxygen (PO2), such as exercise, sleep, or a low ventilatory response to hypoxia, increase the likelihood of developing HAPE. Alterations in the sympathetic nervous system are also believed to contribute to the development of HAPE. Recent evidence suggests that a defect in sodium transport across the alveolar

2014 eMedicine.com

96. Multiple System Atrophy (Overview)

Orthostatic Hypotension in MSA Class Drug Description or Mechanism Corticosteroids Fludrocortisone (Florinef) Mineralocorticoid; sodium retention, primarily in extravascular compartment, causes tissue edema to venous capacitance bed in lower extremity. With this edema, venous bed accommodates decreased volume of blood in an upright posture (high doses, late effect); increases sensitivity to norepinephrine (even with small doses) Sympathomimetic amines Midodrine Alpha1-adrenoreceptor agonist acts directly (...) .) Table 5. Clinicopathologic Correlations Clinical Symptom Pathologic Findings and Location of Damage or Cell Loss Orthostatic hypotension Primary preganglionic damage of intermediolateral cell columns Urinary incontinence (not retention) Preganglionic cell loss in spinal cord (intermediolateral cell columns), related to detrusor hyperreflexia caused mainly by loss of inhibitory input to pontine micturition center (rather than to external urethral sphincter denervation alone) Urinary retention caused

2014 eMedicine.com

97. Migraine Headache: Pediatric Perspective (Overview)

Postdrome Premonitory Migraine with aura (previously known as classic migraine) and migraine without aura (previously known as common migraine) each have a premonitory phase, or prodrome, which may precede the headache phase by up to 24 hours. During this phase, the following features may occur: Irritability Elation or sadness Talkativeness or social withdrawal Increased or decreased appetite Food craving or anorexia Water retention Sleep disturbances These premonitions are often more pronounced (...) , nystagmus, gait unsteadiness, limb incoordination, and dysarthria. Genetic abnormalities have been identified; CACNA1A gene mutations (coding for calcium channel) on chromosome 19 in FHM1; mutations in the ATP1A2 gene (coding for a K/Na-ATPase) on chromosome 1 in FHM2; and mutations in the SCN1A gene (coding for a sodium channel) on chromosome 2 in FHM3. [ ] Consider structural lesions, vasculitis, cerebral hemorrhage, brain tumor, mitochondrial myopathy, encephalopathy, and lactic acidosis

2014 eMedicine.com

98. Diabetes Mellitus, Type 2 (Treatment)

or insulin secretagogues. [ ] These effects may induce or worsen heart failure in patients with left ventricular compromise and occasionally in patients with normal left ventricular function. TZDs have not been tested in patients with New York Heart Association class III or IV heart failure. Fluid retention from TZDs has been considered resistant to treatment with loop diuretics, because of upregulation of renal epithelial sodium channels. However, a randomized, double-blind, placebo-controlled (...) in type 2 diabetes. Drug classes used for the treatment of type 2 diabetes include the following: Biguanides Sulfonylureas Meglitinide derivatives Alpha-glucosidase inhibitors Thiazolidinediones (TZDs) Glucagonlike peptide–1 (GLP-1) agonists Dipeptidyl peptidase IV (DPP-4) inhibitors Selective sodium-glucose transporter–2 (SGLT-2) inhibitors Insulins Amylinomimetics Bile acid sequestrants Dopamine agonists A literature review by Alfayez et al indicated that GLP-1 agonists, DPP-4 inhibitors, and SGLT-2

2014 eMedicine.com

99. Diabetic Neuropathy (Treatment)

if the drug is clinically appropriate for their patients on a case-by-case basis. Gabapentin and sodium valproate should also be considered for diabetic neuropathy pain management. According to a Cochrane review evaluating gabapentin for chronic neuropathic pain and fibromyalgia, gabapentin leads to significant pain relief in patients with chronic neuropathic pain when compared with a placebo. Although patients frequently experience adverse side effects, these are usually tolerable, and serious side (...) that adverse effects can be monitored if possible. Decrease or increase drug dose if indicated. For many of these medications, use for neuropathic pain is off-label; they were approved by the Food and Drug Administration for other indications. Many are in the news for questionable side effects (eg, increased blood pressure and edema from salt retention with fludrocortisones). Nevertheless, multiple clinical studies show benefit for the use of these medications in the treatment of neuropathic pain. Use

2014 eMedicine.com

100. Diabetic Neuropathy (Treatment)

if the drug is clinically appropriate for their patients on a case-by-case basis. Gabapentin and sodium valproate should also be considered for diabetic neuropathy pain management. According to a Cochrane review evaluating gabapentin for chronic neuropathic pain and fibromyalgia, gabapentin leads to significant pain relief in patients with chronic neuropathic pain when compared with a placebo. Although patients frequently experience adverse side effects, these are usually tolerable, and serious side (...) that adverse effects can be monitored if possible. Decrease or increase drug dose if indicated. For many of these medications, use for neuropathic pain is off-label; they were approved by the Food and Drug Administration for other indications. Many are in the news for questionable side effects (eg, increased blood pressure and edema from salt retention with fludrocortisones). Nevertheless, multiple clinical studies show benefit for the use of these medications in the treatment of neuropathic pain. Use

2014 eMedicine.com

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