Overall Effects and Masking of Important Differences in Risk Factors—Reply

subgroup analysis for alcohol use disorder, the primary risk factor for ODS, and no dose-response effect was found (eFigure 14 in Supplement 1 1 ).A study by Seethapathy et al 2 demonstrated that slow correction of hyponatremia was associated with increased mortality in patients with liver disease, heart failure, and cancer.We recently confirmed this finding and expanded it to patients with severe hyponatremia (<110 mEq/L), which demonstrated increased mortality with slow correction. 3lthough some mild cases of ODS may have been missed in patients who did not have confirmatory results of imaging studies, it is known that mild cases of ODS have favorable long-term outcomes and that patients usually recover.We believe that any patient with permanent neurologic impairment attributable to ODS should have neuroimaging confirmation.Seethapathy et al point out that demyelination is a multifactorial condition, primarily associated with risk factors, such as alcohol use disorder and malnutrition, and that rigorous risk stratification should be done to identify highrisk patients.We agree with their assessment.However, we believe that the term ODS is a misnomer that should be abandoned in favor of the term cerebral demyelination, which describes both central pontine and extra pontine myelinolysis.The term ODS implies causality, that neurological injury in the setting of hyponatremia is related to rate of correction of hyponatremia.In their correspondence, Mohammed and Teelucksingh share the clinical observation that rapid correction of hyponatremia in hypoadrenalism is not associated with ODS.We agree with this observation.Cerebral demyelination is a rare condition that is primarily related to risk factors, such as alcohol use disorder, liver disease, hypokalemia, and malnutrition.It can occur in the absence of hyponatremia and with slow correction and is rare even when rapid correction of hyponatremia occurs. 4ODS is an extremely rare condition, with an incidence of less than 0.1% in patients with severe hyponatremia at low risk for ODS.Most physicians who treat hyponatremia have never encountered a case.For decades, the primary focus on the treatment of hyponatremia has been to limit the rate of correction to prevent the very rare complication of ODS, with insufficient attention to the minimum sodium correction to decrease mortality and produce the best outcome. 5The findings of our systematic review and meta-analysis 1 demonstrate that rapid correction of hyponatremia of 8 mEq/L or greater in the first 24 hours decreases mortality without a significant increase of ODS.