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Bajwa SJS, Haldar R. Endocrinological disorders affecting neurosurgical patients: An intensivists perspective. Indian J Endocrinol Metab 2014; 18:778-783. [PMID: 25364671 PMCID: PMC4192981 DOI: 10.4103/2230-8210.140240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Management of critically ill neurosurgical patients is often complicated by the presence or development of endocrinological ailments which complicate the clinical scenario and adversely affect the prognosis of these patients. The anatomical proximity to the vital centers regulating the endocrinological physiology and alteration in the neurotransmitter release causes disturbances in the hormonal homeostasis. This paves the way for development of diverse disorders where single or multiple hormones may be involved which can have deleterious effect on the different organ system. Understanding and awareness of these disorders is important for the treating intensivist to recognize these changes early in their course, so that appropriate and timely therapeutic measures can be initiated along with the treatment of the primary malady.
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Affiliation(s)
- Sukhminder Jit Singh Bajwa
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India
| | - Rudrashish Haldar
- Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India
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Park JB, Park SH, Seo EH, Park HS, Jeong JK. Severe Hypernatremia with Craniopharyngioma - A Case Report -. Korean J Crit Care Med 2013. [DOI: 10.4266/kjccm.2013.28.1.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jun Bum Park
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Se Hun Park
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Eun Hui Seo
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Hyun Seok Park
- Department of Neurosurgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jin Kyu Jeong
- Department of Anesthesiology and Pain Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
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Poon WS. Great hospitals of Asia: neurosurgery at Prince of Wales Hospital. World Neurosurg 2011; 75:383-6. [PMID: 21600469 DOI: 10.1016/j.wneu.2011.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 02/08/2011] [Indexed: 10/18/2022]
Abstract
Prince of Wales Hospital, a 1400-bed regional referral center, was established in 1984 as the primary teaching hospital of the second medical school in Hong Kong at the Chinese University of Hong Kong. The Academic Division of Neurosurgery was given an autonomous status, the support of 40 acute beds, and a well-equipped and well-staffed intensive care unit (ICU), in developing neurosurgery as a distinct surgical specialty. Over this short 26-year history, we have gone through the difficult time of one-man-band neurosurgery, excelled in emergency neurosurgery, and evolved to an era of organized neurosurgical practice, where clinical services, teaching of undergraduate and postgraduate students, and clinical and translational research have been brought up to international standards.
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Affiliation(s)
- Wai S Poon
- Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong.
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Abla AA, Wait SD, Forbes JA, Pati S, Johnsonbaugh RE, Kerrigan JF, Ng YT. Syndrome of alternating hypernatremia and hyponatremia after hypothalamic hamartoma surgery. Neurosurg Focus 2011; 30:E6. [PMID: 21284452 DOI: 10.3171/2010.12.focus10235] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In this paper, the authors' goal was to describe the occurrence of alternating hypernatremia and hyponatremia in pediatric patients who underwent resection of hypothalamic hamartomas (HHs) for epilepsy. Hypernatremia in patients after pituitary or hypothalamic surgery can be caused by diabetes insipidus (DI), whereas hyponatremia can occur due to a syndrome of inappropriate antidiuretic hormone, cerebral salt wasting, or excessive administration of desmopressin (DDAVP). The triphasic response after surgery in the pituitary region can also explain variations in sodium parameters in such cases. METHODS One hundred fifty-three patients with HH who underwent surgery were enrolled in a prospective study to monitor outcomes. Of these, 4 patients (2.6%) were noted to experience dramatic alterations in serum sodium values. The medical records of these patients were identified and evaluated. RESULTS Patients' ages at surgery ranged from 1.2 to 6.0 years. All patients were girls. Two patients had Delalande Type IV lesions (of 16 total Type IV lesions surgically treated) and 2 had Type III lesions (of 39 total Type III lesions). All patients had a history of gelastic seizures refractory to medication. Seizure frequency ranged from 3 to 300 per day. After surgery, all patients experienced hypernatremia and hyponatremia. The largest fluctuation in serum sodium concentration during hospitalization in a single patient was 53 mEq/L (range 123-176 mEq/L). The mean absolute difference in maximum and minimum sodium values was 38.2 mEq/L. All patients exhibited an initial period of immediate DI (independent of treatment) after surgery followed by a period of hyponatremia (independent of treatment), with a minimum value occurring between postoperative Days 5 and 8. All patients then returned to a hypernatremic state of DI, and 3 patients still require DDAVP for DI management. A second occurrence of hyponatremia lasting several days without DDAVP administration occurred in 2 patients during their hospitalization between periods of hypernatremia. One patient stabilized in the normal range of sodium values prior to discharge from rehabilitation without the need for further intervention. At last follow-up, 3 patients are seizure-free. CONCLUSIONS Severe instability of sodium homeostasis with hypernatremia and hyponatremia is seen in up to 2.6% of children undergoing open resection of HH. This risk appears to be related to HH type, with a higher risk for Types III (2 [5.1%] of 39) and IV (2 [12.5%] of 16) lesions. Here, the authors describe alternating episodes of hypernatremia and hyponatremia in the postoperative period following HH surgery. Management of this entity requires careful serial assessment of volume status and urine concentration and will often require alternating salt replacement therapy with DDAVP administration.
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Affiliation(s)
- Adib A Abla
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA.
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Murphy-Human T, Diringer MN. Sodium Disturbances Commonly Encountered in the Neurologic Intensive Care Unit. J Pharm Pract 2010; 23:470-82. [DOI: 10.1177/0897190010372323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Disorders of sodium and water balance are common in patients with central nervous system (CNS) disease. These disorders frequently complicate the treatment course by precipitating or worsening neurological symptoms. These patients are not only at risk for symptoms secondary to dysnatremia but also at risk from the consequences of treatment. If not treated properly, this electrolyte disturbance can vastly increase morbidity and can even lead to death. Appropriate diagnosis and intervention requires an understanding of the physiologic and pathophysiologic mechanisms involved in sodium and water homeostasis.
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Affiliation(s)
- Theresa Murphy-Human
- Department of Pharmacy, Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, MO, USA
| | - Michael N. Diringer
- Neurological Surgery and Anesthesiology, Neurology/Neurosurgery Intensive Care Unit, Washington University School of Medicine, St Louis, MO, USA
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Yee AH, Burns JD, Wijdicks EFM. Cerebral salt wasting: pathophysiology, diagnosis, and treatment. Neurosurg Clin N Am 2010; 21:339-52. [PMID: 20380974 DOI: 10.1016/j.nec.2009.10.011] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Cerebral salt wasting (CSW) is a syndrome of hypovolemic hyponatremia caused by natriuresis and diuresis. The mechanisms underlying CSW have not been precisely delineated, although existing evidence strongly implicates abnormal elevations in circulating natriuretic peptides. The key in diagnosis of CSW lies in distinguishing it from the more common syndrome of inappropriate secretion of antidiuretic hormone. Volume status, but not serum and urine electrolytes and osmolality, is crucial for making this distinction. Volume and sodium repletion are the goals of treatment of patients with CSW, and this can be performed using some combination of isotonic saline, hypertonic saline, and mineralocorticoids.
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Affiliation(s)
- Alan H Yee
- Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA.
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Yee AH, Rabinstein AA. Neurologic presentations of acid-base imbalance, electrolyte abnormalities, and endocrine emergencies. Neurol Clin 2010; 28:1-16. [PMID: 19932372 DOI: 10.1016/j.ncl.2009.09.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Accurate identification of nervous system dysfunction is vital in the assessment of any multisystem disorder. The neurologic manifestations of acid-base disturbances, abnormal electrolyte concentrations, and acute endocrinopathies are protean and typically determined by the acuity of the underlying derangement. Detailed history and physical examination may guide appropriate laboratory testing and lead to prompt and accurate diagnosis. Neurologic manifestations of primary and secondary systemic disorders are frequently encountered in all subspecialties of medicine. This article focuses on key neurologic presentations of respiratory and metabolic acid-base derangements and potentially life-threatening endocrinopathies.
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Affiliation(s)
- Alan H Yee
- Department of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Tisdall M, Crocker M, Watkiss J, Smith M. Disturbances of sodium in critically ill adult neurologic patients: a clinical review. J Neurosurg Anesthesiol 2006; 18:57-63. [PMID: 16369141 PMCID: PMC1513666 DOI: 10.1097/01.ana.0000191280.05170.0f] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Disorders of sodium and water balance are common in critically ill adult neurologic patients. Normal aspects of sodium and water regulation are reviewed. The etiology of possible causes of sodium disturbance is discussed in both the general inpatient and the neurologic populations. Areas of importance are highlighted with regard to the differential diagnosis of sodium disturbance in neurologic patients, and management strategies are discussed. Specific discussions of the etiology, diagnosis, and management of cerebral salt wasting syndrome, the syndrome of inappropriate antidiuretic hormone secretion, and central diabetes insipidus are presented, as well as the problems of overtreatment. The importance of diagnosis at an early stage of these diseases is stressed, with a recommendation for conservative management of milder cases.
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Affiliation(s)
| | | | | | - Martin Smith
- Corresponding author: Dr Martin Smith, Consultant in Neuroanaesthesia, The National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, , Tel: 44 (0)20 7829 8711, Fax: 44 (0)20 7829 8734
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Sata A, Hizuka N, Kawamata T, Hori T, Takano K. Hyponatremia after transsphenoidal surgery for hypothalamo-pituitary tumors. Neuroendocrinology 2006; 83:117-22. [PMID: 16864995 DOI: 10.1159/000094725] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2006] [Accepted: 07/04/2006] [Indexed: 12/21/2022]
Abstract
Transient diabetes insipidus is a well-known complication after transsphenoidal surgery (TSS). On the other hand, transient hyponatremia has been reported as being a delayed complication of TSS. Transient hyponatremia has been attributed to the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), but the details of hyponatremia have not been clarified. In the present study, we retrospectively reviewed 110 consecutive patients (39 males and 71 females, age 9-80 years) operated on transsphenoidally for pituitary and hypothalamic tumors. We investigated the frequency, time of onset, duration of hyponatremia after TSS, and analyzed possible factors associated with it. A postoperative sodium concentration <135 mEq/l was observed in 29 (26%) patients. Five patients were excluded from this study because their hyponatremia could be due to either overdose of desmopressin or SIADH for meningitis. Therefore, we investigated 24 (22%) patients with hyponatremia in this study. The sodium levels in the patients with hyponatremia ranged from 110 to 134, with a mean of 126.2 +/- 5.3 mEq/l. Hyponatremia was observed on average on postoperative day 9.5 +/- 2.4, the serum sodium levels normalized within 3.8 +/- 1.7 days. Hyponatremia occurred in patients with non-functioning pituitary adenoma (26%, 11/42), Rathke's cleft cyst (29%, 5/17), prolactinoma (31%, 4/13) and acromegaly (15%, 4/27). 18 patients (75%, 6/24) who developed hyponatremia had macrotumor (>10 mm), and 6 patients (25%, 6/24) had microtumor. The plasma arginine vasopressin (AVP) levels in the patients with hyponatremia ranged from 0.21 to 2.1, with a mean of 0.79 +/- 0.46 pg/ml, and the levels were inversely correlated with plasma osmolality (r = -0.80, p = 0.002). The urine to plasma osmolality ratios were >1. All the patients received appropriate hormonal replacement, including hydrocortisone. These data showed that postoperative hyponatremia after TSS was not rare, and the hyponatremia was mainly associated with SIADH. As the hyponatremia could be a life-threatening complication, all patients should be screened for serum electrolytes after TSS.
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Affiliation(s)
- Akira Sata
- Department of Medicine, Institute of Clinical Endocrinology, Tokyo Women's Medical University, Tokyo, Japan
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Wise-Faberowski L, Soriano SG, Ferrari L, McManus ML, Wolfsdorf JI, Majzoub J, Scott RM, Truog R, Rockoff MA. Perioperative management of diabetes insipidus in children. J Neurosurg Anesthesiol 2004; 16:220-5. [PMID: 15211159 DOI: 10.1097/00008506-200407000-00006] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Managing children with diabetes insipidus (DI) in the perioperative period is complicated and frequently associated with electrolyte imbalance compounded by over- or underhydration. In this study the authors developed and prospectively evaluated a multidisciplinary approach to the perioperative management of DI with a comparison to 19 historical control children. Eighteen children either with preoperative DI or undergoing neurosurgical operations associated with a high risk for developing postoperative DI were identified and managed using a standardized protocol. In all patients in whom DI occurred during or after surgery, a continuous intravenous infusion of aqueous vasopressin was initiated and titrated until antidiuresis was established. Intravenous fluids were given as normal saline and restricted to two thirds of the estimated maintenance rate plus amounts necessary to replace blood losses and maintain hemodynamic stability. In all children managed in this fashion, perioperative serum sodium concentrations were generally maintained between 130 and 150 mEq/L, and no adverse consequences of this therapy developed. In the 24-hour period evaluated, the mean change in serum sodium concentrations between the historical controls was 17.6 +/- 9.2 mEq/L versus 8.36 +/- 6.43 mEq/L in those children managed by the protocol. Hyponatremia occurred less frequently in the children managed with this protocol compared with historical controls.
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Affiliation(s)
- Lisa Wise-Faberowski
- Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts, USA.
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Wise-Faberowski L, Soriano SG, Ferrari L, McManus ML, Wolfsdorf JI, Majzoub J, Scott RM, Truog R, Rockoff MA. Perioperative management of diabetes insipidus in children [corrected]. J Neurosurg Anesthesiol 2004; 16:14-9. [PMID: 14676564 DOI: 10.1097/00008506-200401000-00004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Managing children with diabetes insipidus (DI) in the perioperative period is complicated and frequently associated with electrolyte imbalance compounded by over- or underhydration. In this study the authors developed and prospectively evaluated a multidisciplinary approach to the perioperative management of DI with a comparison to 19 historical control children. Eighteen children either with preoperative DI or undergoing neurosurgical operations associated with a high risk for developing postoperative DI were identified and managed using a standardized protocol. In all patients in whom DI occurred during or after surgery, a continuous intravenous infusion of aqueous vasopressin was initiated and titrated until antidiuresis was established. Intravenous fluids were given as normal saline and restricted to two thirds of the estimated maintenance rate plus amounts necessary to replace blood losses and maintain hemodynamic stability. In all children managed in this fashion, perioperative serum sodium concentrations were generally maintained between 130 and 150 mEq/L, and no adverse consequences of this therapy developed. In the 24-hour period evaluated, the mean change in serum sodium concentrations between the historical controls was 17.6 +/- 9.2 mEq/L versus 8.36 +/- 6.43 mEq/L in those children managed by the protocol. Hyponatremia occurred less frequently in the children managed with this protocol compared with historical controls.
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Affiliation(s)
- Lisa Wise-Faberowski
- Children's Hospital Boston and Harvard Medical School, Boston, Massachusetts, USA.
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Abstract
BACKGROUND Hyponatremia is the most common and important electrolyte disorder encountered in the neurologic intensive care unit (NICU). Advances in our knowledge of the pathophysiological mechanisms at play in patients with acute neurologic disease have improved our understanding of this derangement. REVIEW SUMMARY Evaluation of hyponatremia requires a structured approach beginning with the measurement of serum and urine osmolalities. Most cases of hyponatremia in the NICU are associated with serum hypotonicity. Iatrogenic causes, most conspicuously inadequate tonicity of intravenous fluids, should be promptly identified and removed when possible. Two main mechanisms are responsible for most non-iatrogenic cases of hyponatremia in patients with neurologic or neurosurgical disease: inappropriate secretion of antidiuretic hormone (SIADH) and cerebral salt wasting syndrome (CSW). Distinction between these two syndromes may be difficult and must be based on an accurate assessment of the patient's volume status. SIADH is associated with normal or slightly expanded volume status and should be treated with fluid restriction. Patients with CSW are hypovolemic and require adequate fluid and sodium replacement. Correction of hyponatremia should not exceed 8 to 10 mmol/L over any 24-hour period to avoid the risk of osmotic demyelination. CONCLUSIONS Hyponatremia may complicate the clinical course of many acute neurologic and neurosurgical disorders. It is most often iatrogenic causes, CSW, or SIADH. Physicians working with critically ill neurologic patients should be familiar with management strategies addressing these underlying pathophysiological mechanisms.
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Affiliation(s)
- Alejandro A Rabinstein
- Neurological Neurosurgical Intensive Care Unit, Saint Mary's Hospital, Rochester, MN 55905, USA
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Coenraad MJ, Meinders AE, Vandenbroucke JP, Frölich M, Taal JC, Bolk JH. Causes of hyponatremia in the Departments of Internal Medicine and Neurosurgery. Eur J Intern Med 2003; 14:302-309. [PMID: 13678755 DOI: 10.1016/s0953-6205(03)00100-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND: Hyponatremia is a common electrolyte disorder in hospitalised patients. The distribution of the various causes of hyponatremia has been studied in hospitalised patients in general, but little is known about the distribution in specific departments. We performed a prevalence study on the aetiology of hyponatremia in two departments in our hospital, namely, the Department of Internal Medicine and the Department of Neurosurgery. METHODS: Consecutive adult patients with hyponatremia (serum sodium concentration</=130 mmol/l) who had been admitted to the Departments of Internal Medicine and Neurosurgery were included in the study. The cause of hyponatremia was determined on the basis of information obtained from medical records, estimation of extracellular fluid volume status, water balance and biochemical parameters in blood serum and urine. RESULTS: Out of 41 hyponatremic patients, 12 had hyponatremia due to normovolemic disorders, 10 due to hypervolemic disorders, 11 due to hypovolemic disorders with extrarenal sodium loss and eight due to hypovolemic disorders with renal sodium loss. The most frequent causes of hyponatremia were extrarenal sodium loss due to vomiting or diarrhoea, hepatic cirrhosis, drug-induced hyponatremia and the syndrome of inappropriate ADH secretion. CONCLUSIONS: In the Departments of Internal Medicine and Neurosurgery, certain causes of hyponatremia are more prevalent than others. The use of clinical data, in combination with a few simple laboratory tests, can lead to a correct diagnosis of the principal cause of hyponatremia.
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Affiliation(s)
- Minneke J. Coenraad
- Department of Internal Medicine, Leiden University Medical Centre, Albinusdreef 2, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
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