The assessment and treatment of water imbalance in patients with psychosis

Hyponatremia Is Associated with Mortality in Acute Pancreatitis Patients

BACKGROUND

Disorders of serum sodium are common among general patients and are associated with poor outcomes. The prognostic value of serum sodium disorders in patients with acute pancreatitis (AP) has not been studied. We conducted this retrospective study to explore the association between serum sodium levels and the outcomes of patients with AP.

MATERIALS AND METHODS

Patients with AP from the Medical Information Mart for Intensive Care III (MIMIC-III) were screened for this study. The laboratory variables, including serum sodium levels, were obtained by analyzing the first blood sample on the first day after admission. Univariate logistic regression was performed to discover potential factors for mortality of AP. The unadjusted and adjusted association between serum sodium level and mortality of AP was shown by the restricted cubic spline (RCS). The categorical cutoff for the detrimental effect of serum sodium level on the prognosis of AP was also confirmed by stepwise logistic regression after adjusting for con-founding effects of significant factors in the univariate logistic regression.

RESULTS

A total of 869 patients with AP in the MIMIC-III were included with a mortality of 13.1%. Unadjusted logistic regression showed that age (p < 0.001), simplified acute physiological score (SAPS) (p < 0.001), systolic blood pressure (p < 0.001), diastolic blood pressure (p < 0.001), hemoglobin (p = 0.040), serum creatinine (p = 0.046), and serum phosphorus (p < 0.001) were significantly associated with the mortality of AP. The RCS showed that the serum sodium level was negatively and linearly associated with mortality of AP after adjusting for confounding effects of significant factors in the univariate logistic regression. Serum sodium < 133 mmol/L, which indicated hyponatremia, was significantly correlated with a higher mortality risk than serum sodium ≥ 133 mmol/L (p = 0.013).

CONCLUSIONS

Hyponatremia is widely developed among patients with AP and correlates with a higher mortality risk of AP. Physicians should pay more attention to managing patients with AP with hyponatremia.

Development of diagnostic criteria and severity scale for polydipsia: A systematic literature review and well-experienced clinicians' consensus

Despite the clinical importance of polydipsia, no diagnostic criteria or severity scales that comprehensively assess this condition are available. Thus, we aimed to develop diagnostic criteria and a severity scale for polydipsia based on a systematic review and well-experienced clinicians' consensus. We performed a systematic review, identified 27 studies related to diagnostic criteria or severity classification for polydipsia, and extracted items used to assess polydipsia in these studies. Ten well-experienced clinicians-5 psychiatrists and 5 nurses-participated in the Delphi method. They evaluated 39 items extracted based on the results of the systematic review regarding (1) their necessity in diagnosing and assessing the severity of polydipsia, and (2) their relative importance rated on 7-point scale among the items included in the severity scale. The Polydipsia Diagnostic Criteria (PDC) included 4 essential items-excessive drinking, low serum sodium level or low serum osmolality, abnormal normalized diurnal weight gain, and low urine specific gravity-based on consensus reached using the Delphi method. The Polydipsia Severity Scale (PSS) included 13 items with a maximum score of 59. The first diagnostic criteria and symptom scale for polydipsia were developed based on the findings of a systematic review and well-experienced clinicians' consensus.

Psychiatric pharmacist's role in overcoming barriers to clozapine use and improving management

Clozapine is an antipsychotic that exhibits superior efficacy and effectiveness for those with schizophrenia and other serious mental illness. However, its side-effect profile and administrative burdens present challenges to its use. In the United States, the medication is grossly underused even though it may improve outcomes and reduce costs. Current barriers to use include lack of prescriber knowledge and confidence, negative prescriber attitudes, special monitoring requirements, administrative factors, lack of clozapine on formularies, lack of support and infrastructure to use the medication within many health systems, and inadequate understanding or acknowledgement of clozapine prescribing and risks by policy makers and payers. Approaches using interprofessional models of care, which include pharmacists specializing in psychiatric care, can help meet the needs of patients receiving clozapine. This article lays out the big picture of barriers to clozapine and how psychiatric pharmacists could play a role in improving access.

Hiponatremia in the practice of a psychiatrist. Part 2: psychogenic polydipsia

Objective. The study is the second part of the literature review on hyponatremia in patients with diagnosed mental disorders. This article focuses on psychogenic polydipsia as, along with the SIADH, one of the two most common causes of hyponatremia in the mentioned group of patients.

Method: The literature review was based on searching the Medline, the Google Scholar and the Ebsco databases in Polish and English by entering the following phrases: psychogenic polydipsia, the psychosis – intermittent hyponatremia – polydipsia syndrome, water intoxication.

Discussion: Psychogenic polydipsia occurs in up to 25% of patients treated for mental disorders. It most frequently concerns patients with schizophrenia. 30% of patients with psychogenic polydipsia suffer from hyponatremia with or without symptoms of water intoxication. In the etiology of psychogenic polydipsia, the influence of dopaminergic and noradrenergic neurotransmission has been considered, as well as angiotensin, which is claimed to have dipsogenic properties. In order to reduce the severity of the disorder, attempts have been made to administer the following groups of medications: β-blockers, opioid receptor antagonists, angiotensin convertase inhibitors and angiotensin receptor antagonists. Other methods include replacing classic antipsychotic drugs with clozapine. There are also reports of a reduced severity of polydipsia with hyponatremia after introducing risperidone and olanzapine. Preventing episodes of water intoxication in patients with psychogenic polydipsia requires the monitoring of their body weight and a suitable reduction of fluid intake by them.

Results: Mentally ill patients, especially those with chronic schizophrenia, should be monitored for psychogenic polydipsia and the concomitant hyponatremia.

Psychogenic polydipsia and hyponatremia – A side effect of psychosis: a review with a case report

ABSTRACT Primary polydipsia, or psychogenic polydipsia, is a condition that results in considerable morbidity and mortality. In psychiatric patients, psychogenic polydipsia and the syndrome of inappropriate antidiuretic hormone secretion may cause hyponatremia. In the 1970s, it was recognized that antipsychotics such as tiotixene and haloperidol could impair the excretion of a free water load. There are also several case reports of drug-induced hyponatremia in patients using atypical drugs suggesting that these probably can also impair water balance and induce hyponatremia. Case report and review of relevant literature are reported in this article. Psychogenic polydipsia is a common cause of hyponatremia among individuals with chronic mental illness. A case of severe hyponatremia caused by psychogenic polydipsia is described involving a female patient with an adult lifelong history of chronic mental illness diagnosed as schizoaffective disorder. After switching her antipsychotic medication to clozapine water ingestion was normalized as well as sodium levels and her psychotic symptoms improved. Primary polydipsia occurs commonly with schizophrenia and other mental diseases and can cause hyponatremia. PPD may present as an acute psychotic state or as inexplicable emergence of seizures. Appropriate, timely clinical assessment with special attention to thirst, fluid intake, and urine output is essential. Proper treatment may include drug withdrawal and fluid and saline restriction. Once corrected, some pharmacological agents can be tried. The article illustrates the importance of the diagnosis of psychogenic polydipsia given its electrolyte disturbances and life threatening situations.

Diffuse large B-cell lymphoma presenting with central pontine myelinolysis: a case report

Introduction

The most common cause of central pontine myelinolysis is an overly rapid correction of hyponatremia, although it can also occur in patients with any condition leading to nutritional or electrolyte stress. We report a case of diffuse large B-cell lymphoma with central pontine myelinolysis developing at the onset of disease. To the best of our knowledge, hematological malignancies presenting with central pontine myelinolysis have been rarely reported, especially in previously untreated patients, as in our case report.

Case presentation

A 78-year-old Japanese woman presented to a neighborhood clinic with persistent high fever, edema, and general weakness. Despite the absence of specific neurological findings, brain magnetic resonance imaging showed an abnormal lesion in the central pons area of her brain (hyperintense on T2-weighted and hypointense on T1-weighted sequences), compatible with central pontine myelinolysis. She was admitted to our emergency department in a state of shock one month later. The results of her blood tests showed greatly elevated C-reactive protein and lactate dehydrogenase levels. She had severe hypoalbuminemia and mild hyponatremia, and showed signs of disseminated intravascular coagulation. Mild bilateral pleural effusion, prominent subcutaneous edema, and splenomegaly were detected on her systemic computed tomography scan. Her body fluid cultures did not show signs of infection and her spinal aspiration did not show pleocytosis or abnormal cells. A diagnosis of diffuse large B-cell lymphoma was made based on the results of her bone marrow examination. As she was critically ill before the diagnosis was made, she was treated with methylprednisolone pulse therapy, followed by systemic chemotherapy (rituximab with modified THP-COP regimen, including cyclophosphamide, pirarubicin, vindesine, and prednisolone), which resulted in complete remission and recovery without any neurological defects, and resolution of her abnormal findings on magnetic resonance imaging.

Conclusions

Central pontine myelinolysis is a serious condition that may result in neuropathological sequelae and mortality, and clinicians should be aware of its potential presence in patients with malignancies.

Hyponatremia: A Review

Hyponatremia is the most frequently occurring electrolyte abnormality and can lead to life-threatening complications. This disorder may be present on admission to the intensive care setting or develop during hospitalization as a result of treatment or multiple comorbidities. Patients with acute hyponatremia or symptomatic chronic hyponatremia will likely require treatment in the intensive care unit (ICU). Immediate treatment with hypertonic saline is needed to reduce the risk of permanent neurologic injury. Chronic hyponatremia should be corrected at a rate sufficient to reduce symptoms but not at an excessive rate that would create a risk of osmotic injury. Determination of the etiology of chronic hyponatremia requires analysis of serum osmolality, volume status, and urine osmolality and sodium level. Correct diagnosis points to the appropriate treatment and helps identify risk factors for accelerated correction of the serum sodium level. Management in the ICU facilitates frequent laboratory draws and allows close monitoring of the patient's mentation as well as quantification of urine output. Overly aggressive correction of serum sodium levels can result in neurological injury caused by osmotic demyelination. Therapeutic measures to lower the serum sodium level should be undertaken if the rate increases too rapidly.

Applications of schedule-induced polydipsia in rodents for the study of an excessive ethanol intake phenotype

Schedule-induced polydipsia (SIP) is generated by subjecting a highly motivated animal to a sub-optimal rate of food reinforcement while also providing access to a fluid. SIP is one of several adjunctive (or displacement) behaviors that are expressed in an exaggerated form that is deemed 'excessive.' This feature makes SIP an attractive model for studying an excessive ethanol drinking phenotype in rodents. Multiple experimental variables are crucial for the full manifestation of adjunctive drinking, including the degree of food deprivation, the inter-pellet interval selected, and the size of the food reward offered. Although these variables were extensively studied and optimized for water polydipsia in rats, a similarly customized approach to ethanol SIP and application of the procedure in mice have largely been curtailed in favor of the default variable values historically used for water SIP in rats. Further, ethanol SIP also requires careful consideration of variables such as taste and ethanol concentration. Investigation of the stress axis and neurochemical systems such as dopamine and serotonin in mediating adjunctive drinking stemmed from two leading hypotheses regarding the underlying mechanisms of SIP generation: 1) SIP as a coping strategy to mitigate stress associated with the aversive environmental condition, and 2) SIP as a displacement of reward in a highly motivated animal. Ethanol SIP is a powerful model of excessive intake because it can generate an ethanol-dependent state and sustain frequent and intoxicating levels of blood ethanol with voluntary oral consumption. The required food deprivation and the loss of the excessive drinking phenotype following removal of the generator schedule are the two main limitations of the model. Future utility of ethanol SIP will be enhanced by more fully dissecting the underlying hormonal and neurochemical mechanisms and optimizing experimental variables for ethanol SIP on a per species and strain basis.

Regional brain responses associated with drinking water during thirst and after its satiation

The instinct of thirst was a cardinal element in the successful colonization by vertebrates of the dry land of the planet, which began in the Ordovician period about 400 million y ago. It is a commonplace experience in humans that drinking water in response to thirst following fluid loss is a pleasant experience. However, continuing to drink water once thirst has been satiated becomes unpleasant and, eventually, quite aversive. Functional MRI experiments reported here show pleasantness of drinking is associated with activation in the anterior cingulate cortex (Brodmann area 32) and the orbitofrontal cortex. The unpleasantness and aversion of overdrinking is associated with activation in the midcingulate cortex, insula, amygdala, and periaqueductal gray. Drinking activations in the putamen and cerebellum also correlated with the unpleasantness of water, and the motor cortex showed increased activation during overdrinking compared with drinking during thirst. These activations in motor regions may possibly reflect volitional effort to conduct compliant drinking in the face of regulatory mechanisms inhibiting intake. The results suggestive of a specific inhibitory system in the control of drinking are unique.

Acute anterior compartment syndrome associated with psychogenic polydipsia

OBJECTIVE

The aim of this paper is to describe the association of psychogenic polydipsia with anterior compartment syndrome.

METHOD

Case report.

RESULTS

A 31-year-old man with glucose-6-phosphate-dehydrogenase (G6PD) deficiency had a history of paranoid schizophrenia from age 16 complicated by the use of drugs. Four years after the initial diagnosis of schizophrenia, he developed psychogenic polydipsia. This was complicated by episodic severe acute hyponatraemia with seizures and, on one occasion, by generalized rhabdomyolysis. One episode of severe acute hyponatraemia with delirium led to anterior compartment syndrome in both legs. Delayed diagnosis and treatment led to extensive myonecrosis and permanent bilateral foot drop. For 6 years his polydipsia remained partially controlled in a locked psychiatric ward with limited leave, until his sudden death related to severe water intoxication.

CONCLUSIONS

Anterior compartment syndrome is a rare event associated with psychogenic polydipsia. Psychiatrists, physicians and surgeons should be aware of the seriousness of anterior compartment syndrome and its potential to increase morbidity in patients with psychogenic polydipsia.

Vaptans: a potential new approach for treating chronic hyponatremia in psychotic patients

OBJECTIVE

Hyponatremia (serum sodium concentration [Na+] <136 mEq/L) is a potentially life-threatening condition often found chronically in patients with psychotic disorders. Vasopressin antagonists have recently been shown in short-term studies to correct hyponatremia in diverse patient populations, including individuals with both psychosis and idiopathic hyponatremia. However, the safety and efficacy of long-term administration of vaptans is only beginning to be investigated. The objective of this study was to assess whether one of the vaptans, specifically tolvaptan, maintained its safety and efficacy over a prolonged period in patients with psychosis and chronic idiopathic hyponatremia.

METHODS

SALTWATER was a multicenter, open-label extension of the Study of Ascending Levels of Tolvaptan in Hyponatremia. Of the 111 patients enrolled in SALTWATER, eight were patients with both psychosis and idiopathic hyponatremia. These eight subjects provided a total of 7,406 patient days of exposure to oral tolvaptan.

RESULTS

Mean serum [Na+] in the eight psychotic patients increased from 131.6 mEq/L at baseline to >135 mEq/L throughout the observation period (p<0.05 versus baseline at most points). No drug-related adverse events led to study discontinuation.

CONCLUSIONS

Chronic hyponatremia is known to have deleterious effects on the quality of life for many patient groups. These preliminary results suggest that oral tolvaptan provides rapid, effective, and safe treatment of chronic hyponatremia in patients with psychotic disorders and that the effect is safely sustained over long periods of time. These findings represent an important step forward in treating a significant unmet need in psychotic populations.

Vacuolar pathology in the median eminence of the hypothalamus after hyponatremia

The median eminence of the hypothalamus is an important conduit by which neurosecretory hormones from hypothalamic nuclei are delivered to the pars nervosa (neural lobe) of the pituitary en route to the bloodstream. Dilutional hyponatremia was produced in adult rats to determine the effect on the morphology of the median eminence of the hypothalamus. Hyponatremia was caused by reducing electrolyte and organic osmolyte reserves to block the excretion of water through delivery of the nephrotoxin mercuric chloride (HgCl2). Histological examination of the brain 1 day after a hyponatremic insult revealed vacuolation within the median eminence of the hypothalamus. No other lesions were found in other parts of the brain after hyponatremia. The hyponatremic lesion consisted of a band of closely packed vacuoles that crossed the floor of the third ventricle. Vacuoles associated with hyponatremia were predominantly in the subependymal, fiber, reticular, and palisade layers of the median eminence. Vacuolation was not observed in the tanycyte layer of the median eminence. This study indicates that the median eminence is a potentially vulnerable site in human hyponatremic conditions that should be evaluated further in relevant animal models.