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Holly S. Divine, PharmD, BCACP, CGP, CDE, FAPhA

• Clinical Associate Professor
• Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky

http://pharmacy.uky.edu/faculty/hsdivi1/Holly-Divine

Good prognosis is associated with low rate of undesirable outcomes; poor prognosis is associated with a high rate of undesirable outcomes blood sugar 69 buy on line dapagliflozin. The publication of research can depend on the nature and direction of the study results diabetes type 1 vegetarian diet generic dapagliflozin 10mg with amex. Studies in which an intervention is not found to be effective are sometimes not published diabetes mellitus prevention order dapagliflozin 5 mg online. Because of this blood sugar 06 generic 5 mg dapagliflozin overnight delivery, systematic reviews that fail to include unpublished studies may overestimate the true effect of an intervention. P-value the probability that an observed difference could have occurred by chance, assuming that there is in fact no underlying difference between the means of the observations. Randomisation Allocation of participants in a research study to two or more alternative groups using a chance procedure, such as computer-generated random numbers. This approach is used in an attempt to ensure there is an even distribution of participants with different characteristics between groups and thus reduce sources of bias. Receiver operated A graphical method of assessing the accuracy of a diagnostic test. A perfect test will have a positive, vertical linear slope starting at the origin. Reference standard the test that is considered to be the best available method to establish the presence or absence of the outcome this may not be the one that is routinely used in practice. Retrospective study A retrospective study deals with the present/ past and does not involve studying future events. Review question In guideline development, this term refers to the questions about treatment and care that are formulated to guide the development of evidence-based recommendations. Secondary outcome An outcome used to evaluate additional effects of the intervention deemed a priori as being less important than the primary outcomes. Selection bias A systematic bias in selecting participants for study groups, so that the groups have differences in prognosis and/or therapeutic sensitivities at baseline. Sensitivity Sensitivity or recall rate is the proportion of true positives which are correctly identified as such. For example in diagnostic testing it is the proportion of true cases that the test detects. See the related term ?Specificity? Sensitivity analysis A means of representing uncertainty in the results of economic evaluations. Uncertainty may arise from missing data, imprecise estimates or methodological controversy. Sensitivity analysis also allows for exploring the generalisability of results to other settings. The analysis is repeated using different assumptions to examine the effect on the results. One-way simple sensitivity analysis (univariate analysis): each parameter is varied individually in order to isolate the consequences of each parameter on the results of the study. Multi-way simple sensitivity analysis (scenario analysis): two or more parameters are varied at the same time and the overall effect on the results is evaluated. Threshold sensitivity analysis: the critical value of parameters above or below which the conclusions of the study will change are identified. Probabilistic sensitivity analysis: probability distributions are assigned to the uncertain parameters and are incorporated into evaluation models based on decision analytical techniques (For example, Monte Carlo simulation). Significance (statistical) A result is deemed statistically significant if the probability of the result occurring by chance is less than 1 in 20 (p <0. For example in diagnostic testing the specificity is the proportion of non-cases Urinary incontinence in neurological disease 340 Urinary incontinence in neurological disease: management of lower urinary tract dysfunction in neurological disease Treatment to prevent urinary tract infection incorrectly diagnosed as cases. In terms of literature searching a highly specific search is generally narrow and aimed at picking up the key papers in a field and avoiding a wide range of papers. Stakeholders include manufacturers, sponsors, healthcare professionals, and patient and carer groups. Systematic review Research that summarises the evidence on a clearly formulated question according to a pre-defined protocol using systematic and explicit methods to identify, select and appraise relevant studies, and to extract, collate and report their findings. Time horizon the time span over which costs and health outcomes are considered in a decision analysis or economic evaluation. The utility scale assigns numerical values on a scale from 0 (death) to 1 (optimal or ?perfect? health). Urinary incontinence in neurological disease 341 Urinary incontinence in neurological disease: management of lower urinary tract dysfunction in neurological disease Treatment to prevent urinary tract infection 18 Glossary: clinical Alpha-blockers(Alpha (Also known as alpha adrenergic blocking agents or alpha adrenergic adrenergic antagonists) antagonists): drugs that inhibit the response to sympathetic impulses by blocking the alpha receptor sites of effector organs. Because they inhibit the contraction of non-vascular smooth muscle such as the trigone and sphincter muscles of the urinary bladderthat found at the bladder neck and within the prostate, aAlpha-blockers are sometimescommonly used to treat bladder outflow obstruction in men with normally innervated urinary tracts. Anticholinergic An anticholinergic agent is a substance that blocks the neurotransmitter acetylcholine in the central and the peripheral nervous system. Antimuscarinic drugs: An anticholinergic agent that specifically blocks the muscarinic form of the cholinergic receptor. Because they decrease the bladder tone and the amplification of contractions of the urinary bladder and counteract the relaxation of the trigone and external sphincter responsiveness of the bladder wall muscle to stimulating nerve impulses, Antimuscarinic drugs are used in the management of the overactive bladder. Appendicovesicostomy Surgical transference of the isolated appendix so that it can be used as a conduit for urinary diversion from the bladder to the skin in children with cloacal exstrophy or neurogenic bladder, making a route for insertion of a catheter. Asymptomatic bacteriuria Significant number of bacteria in the urine that occurs without usual symptoms of infection such as, burning during urination or frequent urination. Augmentation cystoplasty Surgical reconstruction of the bladder using an isolated intestinal segment to augment bladder capacity. Auto augmentation Surgical procedure in which the detrusor muscle of the bladder is removed, leaving the bladder epithelium otherwise intact. Autologous fascial sling A procedure to treat stress urinary incontinence, in which a harvested strip of surgery rectus fascia is used to provide support to the urethra. Autonomic dysreflexia Condition associated with damage to the spinal cord above the mid thoracic level characterized by a marked increase in the sympathetic response to minor stimuli such as bladder or rectal distention. It may be triggered by distension of the bladder or colon; catheterization of or irrigation of the bladder; cystoscopy; or during transurethral resection Manifestations include severe hypertension; bradycardia; flushing; and excessive sweating. This is a potentially life threatening condition which should be considered a medical emergency requiring immediate attention. Autonomic dysregulation Malfunctioning of the autonomic nervous system (the portion of the nervous system that conveys impulses between the blood vessels, heart, and all the organs in the chest, abdomen, and pelvis and the brain (mainly the medulla, pons and hypothalamus). Behavioural management Behavioural therapies are usually used to treat urge urinary incontinence and programmes mixed urinary incontinence. Such therapies include: Timed voiding where the person is asked to void at set time intervals, rather than in response to a sense of bladder filling. Bladder retraining where intervals between voids are progressively increased or the patient is asked to delay voiding for a specific time when they experience Urinary incontinence in neurological disease 342 Urinary incontinence in neurological disease: management of lower urinary tract dysfunction in neurological disease Treatment to prevent urinary tract infection the need to void. Biofeedback the process of becoming aware of various physiological functions using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will. Bladder stone Stone found in the urinary bladder formed by crystallization and concretion of salts from the urine usually in stagnate urine, and containing phosphate and oxalate salts of calcium or ammonium. Stones typically form in conjunction with bacterial colonization of the urine, for example when an indwelling catheter is present or bladder emptying is incomplete. This is the joining site of the ureters and the section of intestine used for the diversion for example in an ileal conduit. Cauda equina compression serious condition caused by compression of the nerves roots in the lower portion of the spinal canal that supplying the lower limbs and, crucially the bladder and urethral sphincter. Congenital sacral A congenital disorder in which there is abnormal foetal development of the dysgenesis sacrum. This can result in major malformation of the lower vertebrae and pelvis, affecting the spinal nerves in the region with resulting neurological impairment. Crede manoeuvre Use of manual pressure on a bladder, particularly an acontractile bladder, to express urine. Cutaneous diversion Surgical procedure that diverts urine to an abdominal wall stoma. For example a ureterostomy is formed by detaching one or both ureters from the bladder, and bringing them to the surface of the abdomen with the formation of an opening (stoma) to allow passage of urine. Detrusor Detrusor urinae muscle, also detrusor muscle, muscularis propria of the urinary bladder and (less precise) muscularis propria, contracts when urinating to squeeze out urine. Detrusor overactivity Frequently occurring condition characterized by frequency, urgency and urge (formerly detrusor incontinence.

Syndromes

• Abnormal changes (such as polyps) found on sigmoidoscopy or x-ray tests (CT scan or barium enema)
• Had a kidney or other transplant
• Mental changes
• Allergic conjunctivitis
• Inserting a long, thin tube with a balloon at the end to open up narrowing (endoscopic balloon dilation of strictures)
• Shortness of breath
• Diagnose heart attack
• Certain additives help change the acid-base balance of foods to get a certain flavor or color.
• Endoscopy shows narrowing of the esophagus

This is most important in children who are not toilet-trained in whom obvious urinary tract symptoms are rarely present blood sugar diary printable dapagliflozin 10mg discount. Instructions to families need to include clear detailed information about the practicalities of the method used and advice about appropriate skin cleansing diabetes medications mayo clinic generic 5mg dapagliflozin. A variety of methods are used in primary care metabolic disease seizures order dapagliflozin 10mg with amex, predominantly ?clean catch? diabetes juvenile order dapagliflozin 10mg visa, urine collection pads (Euron Uricol?) or urine collection bags. Collection by clean catch is diffcult, particularly in children, and is not always successful. Other methods sometimes used to collect urine, includ ing gauze, cotton wool balls, sanitary towels and panty-liners placed in the nappy, often lead to inaccurate results because of bactericidal agents incorporated in these materials, rendering them unsuitable. The costs associated with urine collection include not only the costs of materials used and per sonnel time collecting and processing the urine, but also the costs of misdiagnosis. Failure to accurately diagnose a urine infection may result in treatment delay and may increase the likeli hood of renal parenchymal defects. All urine collection methods have a risk of contamination by organisms not present in the bladder. This may lead to misdiagnosis and unnecessary treatment or investigation if current guidelines are followed. Children who are not toilet-trained are particularly prone to yield contaminated samples, as they are unable to pass urine to order or to cooperate with the process. In addition urine often fushes the vagina in infant girls and the prepuce in infant boys. Thus contamination of samples occurs after leaving the bladder but before it can be retrieved for diagnostic purposes. The clean catch method tends to provide fewer contaminated samples than bags or pads. Urine collection bags are unpleasant for the child, costly and not environmentally friendly. The material cost of a clean catch specimen is negligible but it may be time-consuming; nevertheless, some parents/carers have expressed a preference for this method. Contamination was found in 0?75% of samples from different units (mean contamination rate 34%). Half of the studies were in children aged 0?12 years and half were in children aged younger than 3 years with a mean age of around 4 months. There was no study that directly compared diagnostic accuracy of this urine sampling between different age groups. Sensitivity ranged from 75% (specifcity 96%) to 100% (specifcity 100%) and specifcity ranged from 57% (sensitivity 83%) to 100% (sensitivity 100%). Review fndings early compared with mid-stream samples No studies were found comparing early to mid or late stream samples for any urine collection method in children. Review fndings pad/nappy samples A systematic review found four studies that examined the accuracy of specimens collected from pads/nappies. Three studies compared pad/nappy samples with culture of bag specimens, although bag collection was not considered likely to be the best method of urine sample col lection, limiting the value of these studies. Sixty-eight children were randomised into two groups: a single urine collec tion pad that was left in the nappy until a sample had been obtained; or a urine collection pad that was replaced every 30 minutes until a sample was obtained. Baseline characteristics of the groups were similar with respect to age but there were signifcantly more boys in the single pad group (25/37 versus 13/31; P = 0. One study compared culture and microscopy results of bag specimens to catheter specimens in two age groups, in children younger than 5 years and in the whole sample (children aged 9 days to 11 years). Hollister U-bags were used in 18 boys and seven girls, while Urinicol bags were used in 15 boys and ten girls. In the outpatient centre the bag was replaced after 30 minutes, while in the emergency department it was not. Catheter specimens were only collected in the emergency department after cleansing with iodinated soap and sterile water. Of the bag specimens, 2597 were collected at the emergency department and 2530 at the outpatient unit. In ward B soap and water was used, followed by cleansing with sterile water and drying with cotton wool balls and urine collection bags, either Hollister U-bags or Simcare bags, were applied. Forty-six urine samples (23 from each ward) were obtained; in ward A 44 attempts were made to obtain 23 urine samples, 18 of which were obtained in 1 hour or less. Of the 11 times a nurse was involved, total time taken was 3 hours and 25 minutes, but for 2 hours and 15 minutes nurses were also feeding the infants, therefore extra time taken overall was 1 hour and 10 minutes. The urine collection bags were in place for 15 minutes to 4 hours and 10 minutes, with an average time of 1 hour and 25 minutes. There were no differences with respect to procedure time (53 59 seconds versus 60 40 seconds; P = 0. Additionally, the volume of urine obtained was approximately 6 ml for both groups (P > 0. No other studies were found comparing early with late stream samples for any other urine col lection method in children. In the combined dipstick and microscopy urinalysis, sensitivity of both bag and catheter specimens increased, and specifcity decreased compared with dipstick alone. The dipstick sensitivity in both bag and catheter samples did not differ according to sex. However, specifcity was higher in boys than in girls for all ages and could not be explained by the fact that circumcision had been performed. Of the 1482 infants who had urinalysis and urine culture, 1384 had samples obtained by bag or catheter. Overall, leucocyte esterase had higher sensitivity, while nitrites had higher specifcity. The only signifcant difference between bag and catheter was the comparison of specifcity of leucocyte esterase. There were no signifcant differences when the cut-off values for a positive result were changed. Further analysis was carried out on 54 patients who had false positive results for leucocyte este rase on bag urinalysis. Of the children who were also tested for nitrites, 4/15 (8%) had positive results. Parents/carers preferred using the pad frst, the bag second and the clean catch method third. Seven samples from pads, eight from bags and one from clean catch had contamination. However, these were excluded by sterile samples collected on the same day in hospital. Parents/carers found pads and bags easy to use and preferred them to the clean catch method. The pad was considered comfortable, whereas the bag was distressing, particularly on removal often leaking and leaving red marks. Most parents/carers complained that the clean catch method was time-con suming and often messy and nine parents/carers gave up after prolonged attempts. When both samples were cultured the agreement between the methods was reasonable for diagnostic values. There is insuffcient data to draw conclusions about urine collection bags and urine collection pads. There is low-level evidence that showed that the accuracy of urine collection pads was greatly improved if the pads were not used for longer than 30 minutes. None of the routine methods for urine collection (clean catch, pad or bag) are costly in terms of equipment or clinician time. The evi dence for choosing urine collection bags or pads is insuffcient, so the least costly method should be preferred. It is well recognised that time delay in culturing urine allows contaminants to multiply and produce inaccurate results. The addition of preservatives, usually boric acid, to the urine samples can be an alternative to lowering the temperature. Currently, boric acid is used in various commercially available transportation tubes. When analysis of urine samples is requested, there is often inadequate explanation of the collec tion procedure. Clinical question How should a urine sample be transported to ensure its reliability? Cultures were performed upon arrival at the laboratory and then 24, 48 and 72 hours after primary sampling.

Discount 10 mg dapagliflozin with amex. How to insert the Medtronic MiniMed Silhouette infusion set - diabetes therapy.

With surgical fstula diabetes nerve damage signs 5mg dapagliflozin otc, 14 days of free drainage is recommended while with obstetric fstula diabetes mellitus medical management generic 5mg dapagliflozin fast delivery, 25 days is recommended diabetes type 1 diarrhea discount dapagliflozin uk. On removal of the catheter diabetes type 2 lose weight fast order dapagliflozin uk, patients are counselled that they should void more frequently initially and gradually increase the periods between voids aiming to be back to normal by 4 weeks postoperatively. It is important that any surgeon Generally, the endoscopic using endoscopic tools: approach allows the surgeon the. Prolapse Surgery However it is not for the beginner, since suturing in this area is Apical Prolapse diffcult laparoscopically. Laparoscopy to repair apical prolapse is well described and has Similarly, the use of mesh in the been practiced for many years. The laparoscopic management of procedure is identical to traditional anterior or posterior compartment sacrocolpopexy with the use of prolapse is well described, with mesh, and offers the patient acceptable long term outcomes, the advantages of endoscopy as mentioned above. However the operation is technically highly demanding and requires extensive experience in endoscopic surgery. Anterior Compartment Prolapse First described by Vancaille in the Long term results seem to be 199 equivalent to those of the traditional Burch, with equivalent cure and complication rates. Nowadays the laparoscopic Burch procedure is confned to surgery by laparoscopic experts when performing prolapse operations, when the patient has concomitant stress incontinence. Traditional Burch laparotomy procedures are similarly confned to cases where the patient undergoes a laparotomy for other reasons (for example, hysterectomy for large fbroids) and has concomitant stress incontinence. By the ffth the gynaecologist is presented day, fbroblasts are found in high with a bewildering array of sutures numbers and the formation of a and needles for pelvic surgery and microcirculation begins. The article aims second week, although collagen to narrow the choice to a few synthesis and angiogenesis are logical options that will meet most reduced, the pattern of repair is surgical requirements. Collagen Healing begins as soon as an synthesis and lysis are delicately incision is made, when platelets balanced. During the frst 12-14 are activated and release a days the rate at which wound series of growth factors. Within strength increases is the same, minutes, the wound displays irrespective of the type of tissue. Moreover, it takes three and until the proliferative phase months for an aponeurosis to of healing begins, wound strength recover 70% of its strength and is low. Macrophages peak at 24 it probably never regains its full hours and produce lactate. Postmenopausal length, direction and position of women having vaginal surgery the incision in such a way as to are therefore advised to use provide maximal exposure and pre-operative topical oestrogen. Maintenance of a sterile feld and With regard to infection, the aseptic technique. Laparoscopic or clean/contaminated when the surgery affords a favorable vagina is incised (2-5% rate of environment to prevent infection). Other surgical factors in contamination by extraneous infection include local trauma from debris and airborne infection. Avoid careless ripping of tissue planes and extensive cautery Foreign bodies burns. Atraumatic tissue handling Avoid strangulating tissue with is the hallmark of a good surgeon. These Pressure from retractors devitalizes represent a signifcant foreign structures, causes necrosis and body challenge and reduce tissue traumatizes tissue and this oxygen tension. Swabs are such as chromic gut, provoke more remarkably abrasive, and if used to infammatory reaction than others, pack off bowel, must be soaked in for example nylon. Haemostasis Wound closure Good haemostasis allows greater surgical accuracy of dissection, Choice of material prevents haematomas and the appropriate needle and suture promotes better healing. When combination allows atraumatic clamping, tying or cauterizing tension, free tissue approximation, vessels, prevent excessive tissue with minimal reaction, and damage. Avoid tissue dessication Elimination of dead space Long procedures may result in Separation of wound edges the tissue surface drying out, permits the collection of fuid with fbrinogen deposition and which promotes infection and ultimately adhesion formation. Stress on wounds Postoperative activity may Removal of surgical debris stress the wound during the Debride devitalised tissue, and healing phase. Coughing stresses remove blood clots, necrotic debris, abdominal fascia, and careful foreign material, and charred wound closure prevents disruption. The capillary the length of the suture for action of braided material promotes infec wound closure should be six times tion, as opposed to non-braided sutures length of the incision to prevent Resistant to shrinkage and contraction excessive suture tension. Complete absorption after predictable interval Choice Of Suture Available in desired diameters and lenghth Many surgeons have a personal Available with desired needle sizes preference for sutures both as a result of profciency in a particular technique and the suitable In general terms, the thinnest handling characteristics of a suture to support the healing suture and needle. This limits trauma of the physical characteristics of and, as a minimum of foreign suture material, the requirements material is used, reduces local of wound support, and the type tissue reaction and speeds re of tissue involved, is important absorption. The tensile strength of to ensure a suture used which the material need not exceed that will retain its strength until of the tissue. The properties and characteristics of the ?ideal? suture are listed in Because of its composition Table I monoflament material may have a ?memory? and care should be Table I: the Ideal Suture taken when handling and tying monoflament sutures perhaps Good handling and knotting characteristics a few extra throws on a proper High tensile strength surgical knot would prevent unravelling. Nylon sutures Multiflament sutures consist of have high tensile strength and very several flaments braided together, low tissue reactivity and degrade in affording greater tensile strength, vivo at 15% per year by hydrolysis. They 205 must be coated to reduce tissue Specifc Sutures And resistance and improve handling Applications characteristics. Because of their inherent capillarity they are Surgical gut more susceptible to harbouring Absorbable surgical gut may be organisms than monoflament plain or chromic, and spun from sutures. Ribbons of collagen are Absorbable sutures are prepared spun into polished strands, but from the collagen of animals or most protein-based absorbable from synthetic polymers. Surgical gut may be submucosa or bovine serosa and used in the presence of infection, may be treated with chromium but will then be more rapidly salts to prolong absorption time. Surfaces may be Enzymes degrade the suture, with irregular and so traumatise tissue an infammatory response. The loss of tensile strength and the rate of absorption are separate Plain surgical gut is absorbed phenomena. A suture can lose within 70 days, but tensile strength tensile strength rapidly and yet is maintained for only 7-10 days be absorbed slowly. Chromic gut is febrile or has a protein defciency, collagen fber tanned with chrome the suture absorption process may tanning solution before being accelerate, with a rapid loss of spun into strands. Chromic sutures produce processed from single or multiple less tissue reaction than plain gut flaments of synthetic or organic during the early stages of wound fbers rendered into a strand by healing, but are unsuitable for spinning, twisting or braiding. Recently, the use of sutures of 206 animal origin has been abandoned approximation where short-term in many countries because of the support is desired, for example for theoretical possibility of prion episiotomy repair. It has developed to counter the suture high tensile strength initially, antigenicity of surgical gut, with but all strength is lost after one its excess tissue reaction and month. Synthetic a lubricant to facilitate better absorbable monoflament sutures handling properties of the are useful for subcutaneous skin material. Absorption is minimal closure since they do not require until day 40, completed about 2 removal. This suture is suitable for months after suture placement, sheath closure at laparotomy. Non absorbable sutures Occasionally it is desirable to have Surgical silk consists of flaments a rapid-absorbing synthetic suture, spun by silkworms, braided into a such as Vicryl Rapide. The suture suture which is dyed then coated retains 50% of tensile strength with wax or silicone. It loses most at 5 days, and since the knot its strength after a year, and ?falls off? in 7 to 10 days, suture disappears after about 2 years. It is only Although it has superior handling suitable for superfcial soft tissue qualities, it elicits considerable 207 tissue reaction, so is seldom used in minimal tissue reactivity, and gynaecology nowadays. Prolene*, for example, has better Synthetic non absorbable suture handling properties sutures than nylon, and may be used in Nylon sutures consist of a contaminated or infected wounds polyamide monoflament with very to minimize sinus formation and low tissue reactivity. They do not degrades at 20% per year, and the adhere to tissue and are easily sutures are absorbed after several removed. Because of the ?memory? of nylon, more throws of the knot are Topical skin adhesions required to secure a monoflament Where skin edges appose under suture than braided sutures. Nylon low tension, it is possible to glue sutures in fne gauges are suitable edges together with glue, such for micro-surgery because of the as Dermabond.

Diseases

• Atelectasis
• Carbamoyl phosphate synthetase deficiency
• Eunuchoidism familial
• Beta-galactosidase-1 deficiency
• Matthew Wood syndrome
• Flavimonas oryzihabitans
• Ruzicka Goerz Anton syndrome