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Orthostatic Sodium Retention

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142. Striatonigral Degeneration (Treatment)

-catheterization if urinary retention develops Referrals as needed Consultations Consultations in multiple system atrophy can include professionals in the following specialties: Neurology Sleep medicine Otolaryngology Physical and occupational therapy Speech-language pathology Psychiatry or counseling Diet Unless there are contraindications, patients with symptomatic postural hypotension may benefit from increased salt intake. Activity Patients with symptomatic postural hypotension should be advised to avoid (...) (eg, orthostatic hypotension). [ ] Surgical treatment Currently, no surgical treatment is appropriate for multiple system atrophy. Because it can be difficult to clinically distinguish multiple system atrophy from Parkinson disease, there are cases of multiple system atrophy patients undergoing placement of . The outcomes have generally been poor, even in patients who responded well to levodopa therapy. [ , ] Inpatient care Multiple system atrophy with predominantly parkinsonian features (MSA-P

2014 eMedicine.com

143. 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

144. 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

145. 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

147. Proteinuria (Follow-up)

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 (...) studies have reported statins to be renoprotective and decrease levels of proteinuria. [ , ] Dyslipidemia usually improves once the proteinuria resolves or immunosuppression is started. Previous Next: Diet Sodium restriction The glomerular capillary pressure can increase in the presense of high sodium intake. Vegter et al found that for nondiabetic patients with chronic kidney disease, high dietary salt (>14 g daily) appeared to blunt the antiproteinuric effect of ACE inhibitor therapy and increase

2014 eMedicine.com

148. Portal Hypertension (Follow-up)

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

149. Assistive Devices to Improve Independence (Overview)

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

150. 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

151. Multiple System Atrophy (Follow-up)

No data Table 9. Drugs Used to Manage 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 (...) compression, bending forward, and placing 1 foot on a chair, can be effective in preventing episodes of orthostatic hypotension. Wearing an external support garment that comes to the waist improves venous return and preload to the heart during standing but loses effectiveness if the patient also wears it while supine. Increased salt and fluid intake and tilted sleeping with the head elevated increase the circulatory plasma volume. Postprandial hypotension Small, frequent meals attenuate BP drop after

2014 eMedicine.com

152. Lower Gastrointestinal Bleeding (Follow-up)

, and urine output. Orthostatic hypotension (ie, a blood pressure fall of >10 mm Hg) is usually indicative of blood loss of more than 1000 mL. Next: Resuscitation and Initial Assessment The 2016 American Academy of Family Physicians (AAFP) guidelines recommend the following for the initial evaluation, risk stratifcation, and hemodynamic resuscitation [ ] : Obtain a focused history, physical examination, and laboratory studies at time of patient presentation (to determine bleeding severity and potential (...) postural changes with dyspnea, tachypnea, and tachycardia. An orthostatic drop in systolic blood pressure of more than 10 mm Hg or an increase in heart rate of more than 10 beats per minute is indicative of at least 15% of blood volume loss. Severe postural dizziness with a postural pulse increase of at least 30 beats per minute is a sensitive and specific indicator of acute blood loss of more than 630 mL. [ ] A hematocrit level of less than 18% or a decrease of about 6% is indicative of significant

2014 eMedicine.com

153. Migraine Headache: Pediatric Perspective (Follow-up)

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

154. Hypertension (Follow-up)

) inhibition was more effective than dual blockade (ACE inhibitor [ACEI] and angiotensin II receptor blocker [ARB]) in reducing both proteinuria and BP in nondiabetic patients with modest chronic kidney disease. Furthermore, a low-sodium diet added to dual therapy yielded additional reductions in both BP and proteinuria, emphasizing the beneficial effect of dietary salt reduction in the management of hypertensive patients with renal insufficiency. The DASH eating plan encompasses a diet rich in fruits (...) 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

2014 eMedicine.com

155. Rehabilitation of Persons With Spinal Cord Injuries (Diagnosis)

. Clinical problems result from inappropriately low or high sympathetic responses, the former during the acute phase and the latter in the subacute and chronic phases. Problems are most common in those with injuries to level T6 and above, as such levels isolate the sympathetic outflow to the splanchnic vascular bed. Resting blood pressure is low with higher cord injury, which is asymptomatic. Orthostatic blood pressure changes can cause weakness, light-headedness, and fainting. Management includes (...) gradual mobilization, liberal sodium intake, use of compression hose, and an abdominal binder. [ , ] Fludrocortisone acetate (0.1 mg PO qd) can expand intravascular volume and therefore is helpful. Midodrine (titrated upward daily from a dosage of 5 mg PO bid/tid) may be helpful. Midodrine can cause supine hypertension and presumably may exacerbate any tendency toward autonomic hyperreflexia (AH). Bradycardia is common soon after injury and usually resolves after several weeks. Tracheal suctioning can

2014 eMedicine Surgery

156. Striatonigral Degeneration (Follow-up)

-catheterization if urinary retention develops Referrals as needed Consultations Consultations in multiple system atrophy can include professionals in the following specialties: Neurology Sleep medicine Otolaryngology Physical and occupational therapy Speech-language pathology Psychiatry or counseling Diet Unless there are contraindications, patients with symptomatic postural hypotension may benefit from increased salt intake. Activity Patients with symptomatic postural hypotension should be advised to avoid (...) (eg, orthostatic hypotension). [ ] Surgical treatment Currently, no surgical treatment is appropriate for multiple system atrophy. Because it can be difficult to clinically distinguish multiple system atrophy from Parkinson disease, there are cases of multiple system atrophy patients undergoing placement of . The outcomes have generally been poor, even in patients who responded well to levodopa therapy. [ , ] Inpatient care Multiple system atrophy with predominantly parkinsonian features (MSA-P

2014 eMedicine.com

157. Cauda Equina and Conus Medullaris Syndromes (Follow-up)

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

158. Diabetes Mellitus, Type 2 (Follow-up)

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

159. Diabetic Neuropathy (Follow-up)

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 (...) such as vacuum devices or intracavernosal papaverine injections may be tried. Referral to a urologist is suggested. Orthostatic hypotension Symptomatic orthostatic hypotension can be troubling in patients with diabetic neuropathy. Increasing the dietary fluid and salt intake, along with use of compression stockings, may help. If these modalities do not improve symptoms, then medication may help. [ ] Gustatory sweating Glycopyrrolate is an antimuscarinic compound that can be used for the treatment

2014 eMedicine.com

160. Diabetic Neuropathy (Follow-up)

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 (...) such as vacuum devices or intracavernosal papaverine injections may be tried. Referral to a urologist is suggested. Orthostatic hypotension Symptomatic orthostatic hypotension can be troubling in patients with diabetic neuropathy. Increasing the dietary fluid and salt intake, along with use of compression stockings, may help. If these modalities do not improve symptoms, then medication may help. [ ] Gustatory sweating Glycopyrrolate is an antimuscarinic compound that can be used for the treatment

2014 eMedicine.com

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