The evaluation of desmopressin in treatment of adolescent nocturnal enuresis

This study was designed to determine the effectiveness of desmopressin in the treatment of adolescent nocturnal enuresis and factors that may predict responsiveness. Eighteen adolescents (14 boys, 4 girls) with monosymptomatic nocturnal enuresis were treated with oral desmopressin for three months, starting with 0.2 mg at night and controlling the symptoms every two weeks. After this period, desmopressin was used every other day and the dose was reduced gradually. The treatment was completed at the end of six months. As factors that may predict response before treatment, a range of variables (family history of enuresis, educational levels of parents, number of children, first child in family, birth weight) and urine osmolality was evaluated. Disappearance of bedwetting by using desmopressin has been observed in adolescents who have a high urine osmolality. We did not observe any relapse during reducing desmopressin dose gradually, but on complete cessation of the treatment, relapses were seen. Six months after the end of the therapy, we could not find any patient who recovered completely. Desmopressin seems to be effective in the treatment of primary nocturnal enuresis while on therapy but during the long-term follow-up, all cases relapsed.     

Clinical reasoning and decision making in practice: a 30-year-old man with unexplained coma

A 30-year-old man known to have a factor-IX deficiency was presented at the emergency department with unexplained coma. After immediate treatment with factor IX, a CT-scan of the brain revealed no intracerebral haemorrhage. However, blood tests showed severe hyponatraemia, low serum osmolarity and high urine-sodium excretion consistent with the Syndrome of Inappropriate Antiduretic Hormone Secretion (SIADH). Therapy with hypertonic saline was instituted resulting in a gradual rise in the serum-sodium concentration. The cause of the hyponatraemia however remained unclear. After repeat history taking the patient mentioned the use of desmopressin for nocturia. Hyponatraemia as a complication of desmopressin use occurs in 8% of adult patients treated for nocturia. Direct availability of a patient's drug history, by means of an electronic record for instance, could avoid unnecessary tests and delay in diagnosis.     

Further development of 'Enuresis nocturna' guidelines for children with persistent problems

To achieve dryness in children who suffer from persistent bedwetting, it is important to find out which factors play a role in their bedwetting and why previous treatment has failed. The use of a micturition diary is essential. The child's problems and needs have to be identified and treated individually. The enuresis alarm, with the proper guidance, is the preferred form of initial treatment. Desmopressin is particularly suitable in cases of nocturnal polyuria or if the use of the alarm is unfeasible. If the alarm does not have any effect within two weeks or if a rapid result is important, a combination of desmopressin and the alarm is advisable. Bedwetting combined with daytime micturition problems is often indicative of a small bladder capacity and/or detrusor instability. In these children bladder training and/or treatment with an anticholinergic drug (possibly combined with desmopressin) may be effective.     

Clinical reasoning and decision-making in practice. A patient with shortness of breath and hyponatraemia

A 61-year-old man with no significant medical history was referred by the general practitioner with progressive dyspnoea despite treatment with steroids and antibiotics. The patient had severe hyponatraemia. Eventually hypervolemic hyponatraemia due to ischemic cardiac failure was diagnosed. After recompensation by fluid restriction and lisdiuretics coronary bypass surgery was carried out. The patient was discharged free of symptoms. This case is a reminder that heart failure may not present itself in a classical manner but as hypervolemic hyponatraemia.     

Nocturnal enuresis and the use of desmopressin: is it helpful?

We assessed the outcome of the use of an enuretic alarm and desmopressin according to conventional guidelines and investigated the reasons for resistance to desmopressin. Children were given a 4 month course using an enuretic alarm if they had not previously used one; 12 out of 21 were dry (57%) after 4 months and one relapsed 1 month later. Those who had previously failed with an alarm or were considered poorly motivated to use it, were given a 4 month course of intranasal desmopressin. Of these 26 children, 10 (38%) were dry at the end of 4 months but only two (7%) remained dry after this was withdrawn. After the initial treatment with alarm or desmopressin, 27 children were still enuretic and attending the clinic. They were shown how to use the alarm and eight also used the dry bed training technique: 15 had become dry after a further 6 months. Of the 12 children who made no response to intranasal desmopressin, nine were given this medication under supervision in hospital; seven of these children still wet the bed despite producing small amounts of concentrated urine overnight. They also had small measured diurnal bladder capacities. We conclude that if a 4 month course with an enuretic alarm is unsuccessful, rather than using desmopressin, the alarm should be continued with relearning and consideration given to additional use of the dry bed training technique. The major factor causing nocturnal enuresis in children is likely to be a small nocturnal bladder capacity.     

Hyponatremia caused by thiazide diuretics: be aware of drug combinations which enhance this effect

In 3 patients, two women aged 88 and 82 and a man aged 76, the consciousness became disrupted due to a severe hyponatraemia, after a thiazide diuretic had been combined with another drug without laboratory control. After a change in medication, the laboratory values and the patients' conditions normalised. Severe hyponatraemia is a well known but rare complication of thiazide therapy. It has a significant mortality and morbidity rate. The risk is greater for elderly women. This effect on serum sodium can be enhanced by the use of other drugs like furosemide, carbamazepine, paroxetine and NSAIDs. That a patient uses a thiazide is sometimes overlooked when a combined preparation of other drugs is prescribed. Diuretic serum electrolytes should be monitored once treatment with thiazide has been started, especially in elderly patients taking other drugs.     

Perceptions of school toilets as a cause for irregular toilet habits among schoolchildren aged 6 to 16 years

Irregular bladder and bowel habits can contribute to urinary and bowel problems. Schoolchildren undergoing treatment for these problems often do not follow the recommendation of regular toilet visits at school, claiming negative perceptions of school toilets. This study examined 6- to 16-year-old schoolchildren's perceptions of school toilets and whether the perceptions affect bladder and bowel habits at school Some 385 Swedish schoolchildren aged 6 to 16 years were surveyed using a semistructured questionnaire. Children aged 13 to 16 years had the most negative perceptions. Twenty-five percent (overall 16%) of older children reported never using the school toilet to urinate, and 80% (overall 63%) never used it to defecate. Perceptions of sight and smell and emotional constraints hindered children from using the school toilets. Children generally based their perceptions of school toilets on physical appearance, offensive smell, and feelings of insecurity. Children's perceptions affected their toilet habits and would rather endure physical discomfort than the psychological and social discomfort of using the school toilet. Children already suffering from urinary tract or intestinal problems face particular difficulties without regular toilet visits during the day.     

Hyponatraenmia during a long-distance run: due to excessive fluid intake

Hyponatraemia during a long-distance run, such as a marathon, is usually mild and asymptomatic. However, in runners who present with symptoms at a healthcare station, the diagnosis of hyponatraemia can have significant consequences. The complaints are usually aspecific, but in more severe hyponatraemia, signs of cerebral dysfunction due to incipient to severe cerebral oedema predominate. The most important aetiological factor is an excessive electrolyte-free fluid intake. The most important risk factors for the development of hyponatraemia are: a long duration of the run, female gender, recent use of NSAIDs, lower body weight and environmental factors like high temperature and high humidity. In the presence of symptoms, rapid correction must be started by administration ofhypertonic saline, sometimes in combination with a loop diuretic in cases of eu- and hypervolaemia. Isotonic saline must be added in case of dehydration. Prevention consists primarily of advice to moderate the fluid intake.     

Three patients with tuberculous meningitis: treatment started at tentative diagnosis

A 30-year-old man and a 37-year-old woman with no history of tuberculosis developed symptoms of headache, vomiting and subsequent aggressive behaviour. After several lumbar punctures, the PCR test for tuberculosis in the cerebrospinal fluid was positive, and a definitive diagnosis of tuberculous meningitis was made. Treatment with antimycobacterial agents was not started until a few days after hospital admission. The man recovered, but was treated for brainstem tuberculoma 12 months later; the woman died on day 11 of hospitalisation. A third patient, a 31-year-old man, was admitted to the hospital for miliary tuberculosis. He had signs of progressive apathy and meningismus. Mycobacterium tuberculosis was found in his cerebrospinal fluid. Each of these patients underwent cerebrospinal fluid drainage due to communicating hydrocephalus and each had hyponatraemia. Tuberculous meningitis is a lethal complication of tuberculosis that is often diagnosed late due to the insidious nature of its symptoms. Early treatment with antituberculous drugs and dexamethasone--even before a definitive microbiological diagnosis is made--may prevent severe neurological damage and death.     

Desmopressin in hemophilia A and Von Willebrand's disease

The treatment with desmopressin prior to surgery of patients with mild haemophilia A (HA) and Von Willebrand's disease (VWD) was retrospectively evaluated in a general hospital, from 1978 until 1987. From a group of 87 treated patients, 40 patients are reported (21 VWD, 19 HA) of which plasma factor VIII (FVIII) and Von Willebrand factor (VWF) concentrations were determined before, and twice after desmopressin treatment. Desmopressin was administered intravenously at a dose of 0.4 micrograms/kg body weight. Tranexamic acid was used only when surgery in the mouth cavity was performed, at a dose of 1 gram three times a day. Side effects were seen only in 5 patients (3 VWD, 2 HA). No significant difference between both groups was seen in bleeding tendency, transfusion necessity and side effects (chi 2 test). In both groups, FVIII and VWF concentrations increased significantly after 20 and 60 minutes following DDAVP administration (paired t-test). After 360 minutes, the FVIII concentration increased significantly in both groups, however, only in the VWD patients did VWF increase significantly. In neither group did initial FVIII concentrations correlate with the increase in FVIII (linear regression analysis). One female patient reacted differently to DDAVP, with a decrease in FVIII and VWF values. Desmopressin is a safe and effective agent in the management and prophylaxis of bleeding tendency in patients with mild HA and mild VWD.     

Mechanisms of hyponatraemia in alcohol patients

Hyponatraemia is commonly reported in chronic alcoholic patients. However, the underlying pathogenetic mechanisms are not well delineated. In the current study, we analysed the possible pathophysiological mechanisms of hyponatraemia in a group of alcoholic patients (n = 127) admitted to our hospital for causes related to alcohol misuse. Hyponatraemia (serum sodium <134 mmol/l) was found in 22 patients (17.3%). The most common cause of hyponatraemia in our cohort was hypovolaemia (12 patients); pseudohyponatraemia was diagnosed in six patients with alcohol-induced severe hypertriglyceridaemia. It is of interest that two patients fulfilled the criteria of the so-called 'beer potomania' syndrome, while in two others, hyponatraemia was due to reset osmostat or to cerebral salt wasting syndrome, not previously described in alcoholic patients. It is concluded that hyponatraemia is a frequently observed electrolyte disorder in hospitalized alcoholic patients and is related to various pathophysiological mechanisms.     

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) during treatment with the antipsychotic agents haloperidol and quetiapine

A 45-year-old man with paranoid schizophrenia repeatedly developed hyponatraemia due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH), both after treatment with haloperidol and after taking quetiapine. This side effect did not occur subsequently during clozapine treatment. SIADH has been described in connection with almost all psychotropic drugs. Since the risk of developing SIADH is increased with increasing age, comorbid somatic disorders and polypharmacy, and the mean age of the psychiatric patient will further increase in the years to come, the physician should be alert to the risk factors and the clinical symptoms of disturbances in water balance; moreover, the proper differential diagnostic deliberations should be made. In case of increased risk, it is recommended to monitor the serum sodium during the first 2-4 weeks of pharmacotherapy.     

Hyponatraemia in hip fracture patients

We performed a retrospective review of hyponatraemia in patients with hip fractures, before and after surgery. All patients admitted with fractures of the neck of femur who had a surgical intervention to deal with the fracture were included. Results were determined using two definitions for hyponatraemia. The incidence of pre-operative and post-operative hyponatraemia were both 2.8% if hyponatraemia was defined as [Na] < 130 mmol/l. No cases of hyponatraemia were found pre-operatively when hyponatraemia was defined as [Na] < 125 mmol/l. Using this definition the post operative incidence of hyponatraemia was 0.93%. The incidence of hyponatraemia in this group of patients is small. However the potentially severe affects of hyponatraemia warrant close monitoring of these patients and the establishment of methods to prevent this problem from occurring.     

Irreversible coma following hypoglycemia in Sheehan syndrome with adrenocortical insufficiency

A 24-year-old woman of Somali origin delivered at term after an uncomplicated pregnancy. Post-partum haemorrhage resulted in hypovolaemic shock which was treated by hysterectomy. Five days later she became comatose due to unrecognised hypoglycaemia which caused severe irreversible brain damage and status epilepticus. Treatment in the intensive care unit with artificial respiration, prednisolone, desmopressin, inotropic support, barbiturates and an anaesthetic under EEG guidance was unsuccessful. The patient died 28 days post-partum. The hypoglycaemia was due to a combination of (a) inadequate glucose intake and (b) lack of counter-regulatory mechanisms due to a deficiency of steroids and growth hormone as a result of loss of pituitary function (Sheehan syndrome) together with adrenocortical insufficiency. The combination of Sheehan syndrome and primary adrenocortical insufficiency has not been described previously in the literature.     

Home enteral tube feeding with a liquid diet in the long term management of inflammatory bowel disease and intestinal failure

A 35-year-old man, who had spent 10 1/2 out of 18 months in hospital, has required repeated courses of intravenous nutrition (IVN) because of nutritional failure due to severe inflammatory bowel disease. He has been maintained on a nocturnal pump-fed liquid diet supplementing his day-time oral diet for five months, four of which have been at home. The cost of such therapy is less than with an elemental diet and there are other advantages. This regime has been shown to be nutritionally adequate. The need to assess other cheaper liquid diets in patients with intestinal failure is recognised.     

Nocturnal enuresis in children. A four-year experience in outpatient clinics of pediatric urology

AIM: We present our experience in the treatment of enuresis at the Pediatric Urology Outpatient Office over a period of four years. We report pertinent epidemiological data, diagnostic workup, as well as routine treatment protocol. MATERIAL AND METHODS: Between April 1998 and May 2002, 142 healthy children, aged between 6.5 and 18 years (mean: 9 +/- 0.5 years), were referred to us for bedwetting. Ninety three of them were boys and 49--girls. Eight of them had also concurrent daytime enuresis. According to our protocol, the type of enuresis was identified (primary or secondary) and then we administered the respective treatment. Sixteen children underwent behavioural therapy only. Fifteen children with detrusor instability received oxybutinine or tolterodine. Twenty children with diurnal and nocturnal enuresis were given desmopressin and oxybutinine or desmopressin and tolterodine. The remaining 91 children received monotherapy with desmopressin (individualized dose). The initial follow up ranged from 3 to 6 months. RESULTS: Out of 111 children receiving desmopressin, 66 stopped wetting, but 28 relapsed in two weeks and treatment continued for 3 more months. Nine children became dry. In the other groups there was almost complete response to treatment. CONCLUSION: Enuresis continues to be a suppressed problem for both children and parents; however, effective treatment is possible.     

Pitfalls in the management of acute adrenocortical insufficiency: discussion paper.

In patients with acute adrenocortical insufficiency prompt recognition and treatment may be life-saving. Treatment should be initiated immediately before confirmation of the diagnosis. As shown by these case reports, junior staff on acute medical and surgical services, to whom these patients usually first present, may not appreciate that (a) hyponatraemia and hyperkalaemia, in the absence of renal failure, should immediately suggest the diagnosis of adrenal insufficiency and (b) treatment should precede confirmation of the diagnosis. Attempts to correct hyperkalaemia due to adrenocortical insufficiency with insulin and infusions of dextrose is inappropriate and potentially dangerous but seems to be a not unusual mistake.     

Clinical thinking and decision making in daily practice. An elderly man with hyponatremia

An 88-year-old man presented with nausea and vomiting. Recently a cutaneous B-cell lymphoma had been diagnosed on his right cheek. Laboratory investigation showed hyponatraemia. Fluid restriction was started, based on the diagnosis of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). However the hyponatraemia persisted and a diagnosis of 'reset osmostat' was made. CT of the abdomen revealed slight bilateral adrenal enlargement, which was interpreted as adrenal incidentaloma. No other localisation of the lymphoma, besides that on the right cheek, was seen. Although the symptoms initially disappeared, they recurred and were quickly followed by hypotension. The patient died. Post-mortem examination showed bilateral destruction of the adrenal glands due to lymphoma. The correct diagnosis was Addison's disease. This case shows that diseases do not always present with all the classical symptoms, and that it is important to consider test characteristics of diagnostic tests and to judge investigations in the context of the other clinical findings.     

Hyponatraemia and Moduretic-grand mal seizures: a review.

Three cases are presented which emphasize the importance of hyponatraemia as a cause of grand mal seizures. The combination of hydrochlorothiazide and amiloride appears to increase the risk of hyponatraemia. We discuss the aetiology and treatment of hyponatraemia and review the necessity for such combination therapy. We recommend caution in prescribing diuretics and preparations such as Moduretic should be used only in those few patients shown to need potassium supplementation.     

Effective demeclocycline therapy in a patient with over-secretion of antidiuretic hormone following head trauma

The syndrome of inappropriate secretion of antidiuretic hormone (SIADH) is a common cause of hyponatremia. In this study a case of SIADH caused by head trauma is reported, in which severe hyponatraemia, escorted by life-threatening neurological symptoms was observed that could only be managed by parenteral sodium chloride infusions. Severe hyponatraemia was accompanied by elevated urinary sodium excretion, a characteristic sign of SIADH. After introducing the therapy with demeclocycline, a tetracycline type antibiotic that inhibits the renal action of antidiuretic hormone, serum sodium levels began to rise gradually, and the urinary sodium excretion slowly decreased. These observations show the effectiveness of demeclocycline in the treatment of SIADH.