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Large decreases in the rates of sodium excretion, chloride excretion, and glomerular filtration were observed in patients with orthostatic hypotension when they assumed the upright posture following a period of recumbency. When they returned to the recumbent position, sodium excretion typically was not restored immediately in spite of immediate restoration of filtered sodium load. The decreased sodium excretion found to occur in patients with orthostatic hypotension when they are in the upright posture is considered to be due in part to the decreased filtered sodium load and in part to changes in tubular reabsorption that are independent of filtered sodium load.WV THEN the normal human subject changes from the recumbent to the erect position, arterial blood pressure is maintained,' and there is either no change or only a moderate decrease in renal sodium excretion.2-6 When the patient with orthostatic hypotension changes from the recumbent to the upright posture a marked fall in arterial blood pressure occurs7-"; therefore, it might be anticipated that the decreased arterial blood pressure in the upright posture would be reflected by a decreased intraglomerular pressure, decreased glomerular filtration rate, and decreased sodium excretion.The effect of posture upon the renal excretion of sodium in human subjects with orthostatic hypotension has not been reported previously. Studies

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Sir: Pathological crying after stroke is characterized by outbursts of weeping and tearfulness that are not related to an underlying emotional state, but that can be very distressing to the patient.1 Disturbed serotonergic transmission is believed to play a role.2 A number of treatments have been reported as successful, including sertraline, 3 amitriptyline, 9 and nortriptyline. 10 We report the first case of venlafaxine used to successfully treat poststroke pathological crying.Case report. Mr. A, a 67-year-old right-handed man, suffered a hypertensive stroke in 1999 manifested at first by slurred speech and collapse. Computed tomography scan of the head revealed hemorrhage in the left parietal lobe and basal ganglia, compressing the left lateral ventricle, with minimal edema and no midline shift. Also noted were old, small rightsided infarcts with no apparent clinical sequelae.Mr. A was transferred to the rehabilitation service approximately 2 weeks after his stroke. We were asked to evaluate him at that time for crying spells. He denied any past psychiatric history or past untreated mood symptoms. Since the stroke, he reported having between 5 and 20 crying spells daily that were not associated with any change in mood. He did report feeling distressed by these spells but did not endorse symptoms of depression. He denied episodes of pathological laughter. The Pathological Laughter and Crying Scale (PLACS) 10 was administered, on which the patient scored 14 points.After informed consent was obtained from the patient, venlafaxine was initiated at a dose of 37.5 mg twice daily. Within 24 hours, the patient reported complete resolution of his crying spells. Follow-up at 2 weeks revealed a score of 0 on the PLACS. We continued to see him at the rehabilitation service and during his stay in the nursing home care unit. Throughout that 6-month period, he remained symptom-free and did not require any increase in dose.Several tricyclic antidepressants and selective serotonin reuptake inhibitors, as well as other medications, have been reported to dramatically reduce the frequency and severity of pathological crying spells after stroke. Venlafaxine is a serotonin-norepinephrine reuptake inhibitor that may be particularly useful in older patients due to its relatively low protein binding, low anticholinergic effects, low sedation, low orthostatic hypotension, and relatively favorable cytochrome P450 profile. 11,12 While there is the possibility of hypertension with doses over 300 mg daily, 11 which would be a concern in a stroke patient, we found that a low dose of venlafaxine was effective in providing complete relief from this often distressing and embarrassing sequela of stroke.We considered the possibility that since the patient had a hemorrhagic stroke, he might have had seizures manifested by crying. It is known that seizures occur more commonly with hemorrhagic stroke than with ischemic stroke, particularly when the stroke is cortical in location.13 Additionally, we know that venlafaxine acts to increase catechol...

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