A practical approach to perioperative management of cardiac implantable electronic devices

With the increased use of cardiac implantable electronic devices (CIEDs), it is increasingly important to recognise the unique challenges involved in the management of patients with CIEDs who are undergoing surgery. Practice advisories and consensus statements have been issued by the American Society of Anesthesiologists and the Heart Rhythm Society, advocating a multidisciplinary approach. This review discusses and presents a practical approach to perioperative CIED management in the Singapore context.     

Overactive bladder--a practical approach to evaluation and management

The overactive bladder (OAB) is a highly prevalent condition characterized by the combination of urgency and frequency with or without urge incontinence. The pathophysiology is multifactorial; the background is complicated and not yet fully understood. The basic diagnostic workup comprises symptoms assessment, targeted physical examination, urine analysis, post-void residual urine estimation which mostly allows to make a working diagnosis and to find out which patients can be treated also by the nonspecialist. The bladder diary is an optimal diagnostic instrument with a lot of information, whereas urodynamics are expensive and somewhat unverified in their value. The symptom-focused diagnosis is absolutely sufficient to start nonoperative therapy for OAB symptoms. The OAB presents a treatment challenge, as the management of OAB patients is not standardized. An algorithm should include an initial period of at least 6 weeks of conservative therapy consisting of antimuscarinic drugs in combination with behavioral therapy including pelvic floor exercises. If this combination is not successful, the primary diagnosis should be questioned and additional diagnostic tests may be required. If the therapy is successful after 8 weeks, a continuation should be considered in case the symptoms occur after stopping pharmacological therapy. Further therapy depends on the severity of the initial symptoms, the presence of side effects and the motivation of the patient. If pharmacotherapy is not successful or additional therapy desirable, electrical neuromodulation can be added for another period of 6 weeks for up to 3-6 months considering firstly non-invasive therapeutic modalities before recommending invasive sacral neuromodulation. Neuromodulation should be discussed before more invasive procedures, such as bladder augmentation, are considered. There are potentially promising new therapies on the horizon for the OAB. The use of intravesical agents, which decrease the afferent-sensory input, may herald a new therapeutic paradigm for the treatment of the OAB. Refinements in the techniques and the delivery vehicle for electrical stimulation may offer an even less invasive method of neuromodulation. Finally, ongoing research in biotechnology and tissue engineering may produce a functional, stable, compatible tissue substitute suitable for bladder augmentation. The objectives are (1) to define the overactive bladder, (2) to understand the prevalence of the overactive bladder and its impact on the quality of life, (3) to review the basic evaluation of the patient with symptoms suggestive of the overactive bladder and how to differentiate the overactive bladder from other types of urinary dysfunction, and (4) to understand the rationale for and the approach to therapy for the overactive bladder.     

Penicillin allergy: a practical approach to management.

Although penicillin is nontoxic, it is highly immunogenic and is the most common drug that causes allergic reactions. A previous reaction to penicillin has been shown to be unreliable in predicting sensitivity in 75% to 90% of patients. To more accurately test for penicillin allergy, diagnostic skin test reagents have been developed; these include the major determinant (benzylpenicilloyl-polylysine) and the minor determinant mixture (penicillin G potassium, benzylpenicilloate sodium and benzylpenicilloyl-N-propylamine). Penicillin skin testing has been shown to be safe and useful in predicting immediate IgE-mediated reactions (overall predictive value 99%). Reactions that occur when patients are challenged with penicillin are mild or accelerated urticarial reactions. We outline a practical and rational therapeutic approach based on the current understanding of penicillin allergy.     

A practical approach to the management of lower urinary tract symptoms among men

Lower urinary tract symptoms (LUTS) are common among Australian men over the age of 45 years; most men with LUTS will have benign prostatic hyperplasia (BPH), overactive bladder (OAB), or both. The cause of LUTS should be diagnosed by assessing symptom severity and excluding of medical or pharmaceutical causes. All men with LUTS should undergo digital rectal examination; other diagnostic tools include urine and blood testing, voiding charts and imaging. Depending on disease severity, impact on quality of life, patient preference, presence of complications and fitness for surgery, BPH is managed with watchful waiting, pharmacotherapy (α-blockers or 5-α-reductase inhibitors), minimally invasive surgical therapies or surgery. OAB is initially treated with behavioural therapy; if this is ineffective, pharmacotherapy (usually antimuscarinics) can be used. Patients with LUTS with a provisional diagnosis other than BPH or OAB, or with complications or poor response to pharmacotherapy, should be referred to a urologist.     

A practical approach to managing community dwellers with Alzheimer's disease

This article will review multiple strategies and treatment options that can be utilized by clinicians to address the ever-changing and varied needs of community dwelling elders with Alzheimer's disease and those of their families. Comprehensive assessment and the judicious use of medications, together with other nonpharmacological interventions, may lessen the burden of care on families and decrease the likelihood of institutionalization.     

循证医学信息的实用检索方法

临床医生查找信息的原因通常有两个:一是更新知识,保持与医学的发展同步;二是解决临床工作中与病人相关的问题.由于浩瀚的信息量使临床医生快速获得高质量的信息非常困难,所以,文章就此介绍了临床循证医学信息的有用性、新的信息源及检索和获取有用性信息的实用方法.     

病态肥胖症患者围手术期气道管理

病态肥胖患者头颈部和胸腹部脂肪组织异常堆积可导致上气道梗阻和呼吸功能受损,且患者往往存在阻塞性睡眠呼吸暂停、低通气综合征,慢性阻塞性肺疾病或哮喘等合并症,因此围手术期出现困难气道、术中通气不足、术后呼吸抑制等呼吸系统并发症的风险明显升高,给围手术期气道管理带来巨大挑战.麻醉医生深刻理解肥胖患者呼吸系统的病理生理特点,掌握合适的处理原则,对于提高重度肥胖患者围手术期麻醉管理的安全性和有效性,改善患者的临床预后至关重要.     

SARS患者护理管理与相关因素探讨

探讨门诊护理管理者在大型综合医院应对突发疫情时的管理方法。建立新科室新体制与实施新制度新流程；建立健全消毒、隔离和防护管理制度；严格执行各项制度及工作流程；建立对各类工作人员的全员全面岗前培训考核制度；护理人员的统一协调；明确人员属地管理原则。经过采取上述一系列协调管理措施，使在门诊隔离病房、发热门诊和SARS专用手术室工作的各类人员无一人发生感染。对防止SARS向院内传播起到了重要的作用。     

SARS患者的心脏表现

目的 :初步探讨严重急性呼吸综合征 (severeacuterespiratorysyndrome ,SARS)病毒对心脏的影响。 方法 :收集 86例SARS患者的临床和实验室资料 ,进行统计分析。结果 :在恢复期 ,6 4 % (5 5 / 86 )的SARS患者静息心率超过 90次·min-1,72 .1% (6 2 / 86 )的SARS患者轻微活动后心率超过 10 0次·min-1。结论 :主要造成肺部损害的SARS病毒可能也会累及心脏