Iatrogenic hyperchloremia: An overview in hospitalized patients for pharmacists

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PURPOSE

The purpose of this therapeutic update is to provide pharmacists with a general overview of the pathophysiology of hyperchloremia and describe strategies to help prevent development of this electrolyte abnormality in hospitalized patients.

SUMMARY

Hyperchloremia is an electrolyte abnormality associated with an increased incidence of acute kidney injury and metabolic acidosis. Intravenous (IV) fluids utilized for volume resuscitation, medication diluents, and total parental nutrition all may contribute to the development of hyperchloremia. Current evidence suggests that administration of balanced crystalloids for either fluid resuscitation or maintenance fluids may impact serum chloride levels and patient outcomes. In multiple randomized controlled trials, administering balanced crystalloids for fluid resuscitation in critically ill patient populations did not decrease mortality. However, further analyses of subpopulations within these trials have demonstrated that patients with sepsis may benefit from receiving balanced crystalloids for initial fluid resuscitation. Results from several small studies suggest that altering the composition of these IV fluids may help prevent development of hyperchloremia.

CONCLUSION

Management of hyperchloremia is preventative in nature and can be mitigated through management of resuscitation fluids, medication diluents, and total parenteral nutrition. Inpatient pharmacists should be aware of the potential risk of fluid-associated hyperchloremia and assist with optimal fluid management to prevent and manage hyperchloremia.

Evidence for a single-spin azimuthal asymmetry in semi-inclusive pion electroproduction

Single-spin asymmetries for semi-inclusive pion production in deep-inelastic scattering have been measured for the first time. A significant target-spin asymmetry of the distribution in the azimuthal angle straight phi of the pion relative to the lepton scattering plane was formed for pi(+) electroproduction on a longitudinally polarized hydrogen target. The corresponding analyzing power in the sinstraight phi moment of the cross section is 0.022+/-0.005+/-0.003. This result can be interpreted as the effect of terms in the cross section involving chiral-odd spin distribution functions in combination with a chiral-odd fragmentation function that is sensitive to the transverse polarization of the fragmenting quark.

Measurement of the spin asymmetry in the photoproduction of pairs of high- p(T) hadrons at HERMES

We present a measurement of the longitudinal spin asymmetry A(||) in photoproduction of pairs of hadrons with high transverse momentum p(T). Data were accumulated by the HERMES experiment using a 27.5 GeV polarized positron beam and a polarized hydrogen target internal to the HERA storage ring. For h(+)h(-) pairs with p(h(1))(T)>1.5 GeV/c and p(h(2))(T)>1.0 GeV/c, the measured asymmetry is A(||) = -0. 28+/-0.12(stat)+/-0.02(syst). This negative value is in contrast to the positive asymmetries typically measured in deep inelastic scattering from protons, and is interpreted to arise from a positive gluon polarization.

Major life events, daily stressors, and perimenstrual symptoms

Major life events and daily stressors have been associated with women's experience of perimenstrual symptoms (PS). The purpose of this study was to determine the relationship of major life events and daily stressors to PS. Seventy-four women between 18 and 35 years of age kept daily recordings of stressors and symptoms for 2 months after which they completed the Schedule of Recent Events and the Moos Menstrual Distress Questionnaire (MDQ). Major life events were associated with PS reports on the MDQ but not with symptoms reported in the daily health diary. Daily stressors were more influential in perimenstrual symptoms than the cumulation of major life events. Moreover, a generally stressful life context was more influential in the experience of perimenstrual symptoms than episodes of stressful experiences during a particular menstrual cycle phase.

Prevalene of perimenstrual symptoms

The purpose of this study was to determine the prevalence of perimenstrual symptoms (PMS) in a free-living population of US women and to determine if prevalence estimates varied with parity, contraceptive status, characteristics of the menstrual cycle, and selected demographic variables. We identified all households from a census listing for five southeastern city neighborhoods that offered variation in racial composition and socioeconomic status. We ascertained all households in which there was one nonpregnant woman between the ages of 18 and 35 years per household. Of the 241 eligible women, 179 (74 per cent) participated in the study. Trained interviewers administered the Moos Menstrual Distress Questionnaire (MDQ) and other demographic measures to women between March and July 1979. Symptoms with a prevalence greater than 30 per cent included weight gain, headache, skin disorders, cramps, anxiety, backache, fatigue, painful breasts, irritability, mood swings, depression, or tension. Only 2 to 8 per cent of women found most of these severe or disabling. The exceptions were severe cramps reported by 17 per cent of women and severe premenstrual and menstrual irritability by 12 per cent. Cramps, backaches, fatigue, and tension were most prevalent during the menstruum; weight gain, skin disorders, painful breasts, swelling, irritability, mood swings, and depression were more prevalent in the premenstruum. Parity, oral contraceptive use, age, employment, education, and income were negatively associated with selected PMS. Use of an IUD, having long menstrual cycles, long menstrual flow, or heavy menstrual flow, and being able to predict the next period were positively associated with selected PMS. Race had both positive and negative effects on PMS.

Toward a construct of perimenstrual distress

Recent research findings contradict the notion that premenstrual and menstrual symptoms constitute two mutually exclusive categories of perimenstrual distress. The purposes of this study were to describe the prevalence of distress associated with menstruation in a community population and to determine whether perimenstrual distress could be regarded as a single construct. Nonpregnant women (N = 193) between 18 and 35 were selected from five neighborhoods in a southeastern city in a way that allowed for variability in race and income. The women were interviewed in their homes and 179 were asked to complete the Moos Menstrual Distress Questionnaire (MDQ). At least 30% of the women reported weight gain, skin disorders, backache, painful or tender breasts, irritability, depression, headache, cramps, fatigue, swelling, mood swings or tension in the perimenstruum. Cycle phase differences were not found for 31 MDQ symptoms, but were found for: weight gain, crying, lowered school or work performance, taking naps, headache, skin disorders, cramps, anxiety, backache, fatigue, painful or tender breasts, swelling, irritability, mood swings, depression, and tension. Although there were significant differences between the premenstrual and menstrual phases for certain symptoms, the magnitudes of the mean differences were small (less than .3) except for cramps, weight gain, and fatigue. Furthermore, premenstrual and menstrual reports of the same symptoms were highly correlated. Thus, it appears reasonable to study perimenstrual distress as a single construct.

Recollections of menarche, current menstrual attitudes, and perimenstrual symptoms

By menarche, girls are likely to have been influenced not only by cultural stereotypes about menstruation, but also by information acquired through significant others. Their own expectations about menstruation are likely to influence their reports of menarcheal experience. Moreover, some suggest that menarcheal experiences are likely to influence subsequent attitudes toward menstruation, and that these expectations may, in turn, influence perceptions of menstrual symptoms through psychophysiologic mechanisms. The purpose of this study was to explore the relationships between characteristics of women's menarche, their adult attitudes toward menstruation, and current experiences of perimenstrual symptoms. We selected 179 nonpregnant menstruating women between the ages of 18 and 35 from 5 lower to upper middle income neighborhoods. We found that negative recollections of their first menstruation had little effect on current menstrual attitudes. Moreover, positive recollections of menarche were associated with premenstrual and menstrual negative affect and impaired performance, and not in the expected direction. Current menstrual attitudes were more strongly associated with women's current menstrual symptoms. These results do not support the theory that menarcheal experiences have profound effects on subsequent menstrual attitudes and symptoms.

Stressful life events and perimenstrual symptoms

The purpose of this study was to determine whether the effects of stressful life events on perimenstrual symptoms were due to operational confounding of the instruments used to measure the independent and dependent variables. Women aged 18 to 35 (n = 179) completed the Schedule of Recent Events (SRE) and the Moos Menstrual Distress Questionnaire during a home interview. When variance in PMS scores attributable to age, parity, education, and contraceptive method was controlled using hierarchical multiple regression, total SRE scores were correlated with premenstrual and menstrual negative affect, menstrual water retention, and menstrual performance impairment. When health-related components of the SRE score were controlled in a similar manner, however, the residual SRE scores explain a diminished amount of the variance in premenstrual and menstrual negative affect and menstrual performance impairment. Future investigations are needed to clarify whether the effects of health-related life events on perimenstrual symptoms are simply a matter of operational confounding of measures of the independent and dependent variables, or whether women who recently have experienced personal illness or injury are at greater risk of developing perimenstrual symptoms.

Estimating perimenstrual distress: a comparison of two methods

The purpose of this study was to compare two methods of measuring menstrual distress. Seventy-three women, 18 to 35 years of age, selected from lower-middle to upper-middle income neighborhoods kept a daily diary for a two-month period. Following completion of the diary, the women responded to the Moos Menstrual Distress Questionnaire (MDQ) with reference to their last menstrual period. Estimates for all symptoms on the MDQ exceeded those in the diary. The greatest discrepancies between the two methods were found for water retention and negative affect symptoms. Concordance of perimenstrual symptom reporting across the two measures was statistically significant only for menstrual cramps, K = .248, p less than .021, and premenstrual backache, K = .203, p less than .036). Although these results suggest that estimates of dysmenorrhea symptoms are least affected by the data collection method, they are consistent with the hypothesized joint effects of menstrual stereotypes and recall bias on retrospective symptom reports; these sources of bias should be considered in future menstrual, distress research.