Perioperative glycaemic control in diabetic patients undergoing cataract surgery under local anaesthesia: a survey of practices of Singapore ophthalmologists and anaesthesiologists

<p><b>INTRODUCTION</b>Perioperative glycaemic control is an important aspect of clinical management in diabetic patients undergoing cataract surgery under local anaesthesia. While poor long-term glycaemic control has significant implications for surgery, perioperative hypoglycaemia or hyperglycaemia may also compromise patient safety and surgical outcomes. We aimed to survey ophthalmologists and anaesthesiologists on their approach and to identify the prevalent practice patterns in Singapore.</p><p><b>METHODS</b>This was a cross-sectional questionnaire-based survey conducted in four public hospitals in Singapore with established ophthalmology and anaesthesia units. Respondents were approached individually, and the self-administered questionnaires comprised questions related to practice patterns, clinical scenarios and awareness of pre-existing guidelines.</p><p><b>RESULTS</b>A total of 129 doctors responded to the questionnaire survey. 76 (58.9%) were from ophthalmology departments and 53 (41.1%) were from anaesthesia departments. The majority chose to withhold oral hypoglycaemic agents (82.9%) and/or insulin (69.8%), and keep the patient fasted preoperatively. A blood glucose level ≥ 17 mmol/L prompted 86.0%-93.8% of respondents to adopt a treat-and-defer strategy, while a level ≥ 23 mmol/L prompted 86.0%-96.9% of respondents to cancel the cataract surgery. The respondents were consistently more concerned about perioperative hyperglycaemia (n = 99, 76.7%) than intraoperative hypoglycaemia (n = 83, 64.3%).</p><p><b>CONCLUSION</b>The current study presented the prevalent practice patterns of ophthalmologists and anaesthesiologists in the perioperative management of diabetic patients undergoing cataract surgery in four public hospitals in Singapore. Further research in this field is required, and may be useful for the future formulation of formal guidelines and protocols.</p>

Immediate access arteriovenous grafts versus tunnelled central venous catheters: study protocol for a randomised controlled trial.

BACKGROUND: Autologous arteriovenous fistulae (AVF) are the optimal form of vascular access for haemodialysis. AVFs typically require 6 to 8 weeks to "mature" from the time of surgery before they can be cannulated. Patients with end-stage renal disease needing urgent vascular access therefore traditionally require insertion of a tunnelled central venous catheter (TCVC). TCVCs are associated with high infection rates and central venous stenosis. Early cannulation synthetic arteriovenous grafts (ecAVG) provide a novel alternative to TCVCs, permitting rapid access to the bloodstream and immediate needling for haemodialysis. Published rates of infection in small series are low. The aim of this study is to compare whether TCVC ± AVF or ecAVG ± AVF provide a better strategy for managing patients requiring immediate vascular access for haemodialysis. METHODS/DESIGN: This is a prospective randomised controlled trial comparing the strategy of TCVC ± AVF to ecAVG ± AVF. Patients requiring urgent vascular access will receive a study information sheet and written consent will be obtained. Patients will be randomised to receive either: (i) TCVC (and native AVF if this is anatomically possible) or (ii) ecAVG (± AVF). 118 patients will be recruited. The primary outcome is systemic bacteraemia at 6 months. Secondary outcomes include culture-proven bacteraemia rates at 1 year and 2 years; primary and secondary patency rates at 3, 6, 12 and 24 months; stenoses; re-intervention rates; re-admission rate; mortality and quality of life. Additionally, treatment delays, impact on service provision and cost-effectiveness will be evaluated. DISCUSSION: This is the first randomised controlled trial comparing TCVC to ecAVG for patients requiring urgent vascular access for haemodialysis. The complications of TCVC are considered an unfortunate necessity in patients requiring urgent haemodialysis who do not have autologous vascular access. If this study demonstrates that ecAVGs provide a safe and practical alternative to TCVC, this could instigate a paradigm shift in nephrology thinking and access planning. TRIAL REGISTRATION: This study has been approved by the West of Scotland Research Ethics Committee 4 (reference no. 13/WS/0087, 28 August 2013) and is registered with the International Standard Randomised Controlled Trial Number Register (reference no. ISRCTN80588541 , 27 May 2014).

Cephalic arch stenosis: angioplasty to preserve a brachiocephalic fistula or new brachiobasilic fistula? A cost-effectiveness study.

BACKGROUND: Our aim was to evaluate the cost-effectiveness of repeat angioplasty versus new brachiobasilic fistula (BBF) in patients with symptomatic cephalic arch stenosis (CAS). METHODS: Patients presenting with symptomatic CAS (n = 22) underwent angioplasty. They were compared to patients undergoing BBF creation (n = 51). Primary outcomes were functional primary arteriovenous fistulae patency at 3, 6 and 12 months. Data were collected on number of interventions, alternative accesses and hospital days for access-related complications. Quality of life was assessed using Kidney Disease Quality of Life-36 scores. Decision tree, Monte Carlo simulation and sensitivity analysis permitted cost-utility analysis. Healthcare costs were derived from Department of Health figures and are presented as cost (£)/patient/year, cost/access preserved and cost/quality of life-adjusted year (QALY) for each of the treatment strategies. RESULTS: Functional primary patency rates at 3, 6, 12 months were 87.5%, 81% and 43% for repeated angioplasty and 78%, 63% and 41% for BBF. The angioplasty cohort required 1.64 ± 0.23 angioplasties/patient and 0.64 ± 0.34 lines/patient. BBF required 0.36 ± 0.12 angioplasties/patient and 1.2 ± 0.2 lines/patient. Patients in the BBF cohort spent an additional 0.9 days/year in hospital due to access-related complications. Mean cost/patient/year in the angioplasty group was £5247.72/patient/year versus £3807.55/patient/year in the BBF cohort. Mean cost per access saved was £11,544.98 (angioplasty) versus £4979.10 (BBF). Average cost per QALY was £13,809.79 (angioplasty) versus £10,878.72 per QALY (BBF). CONCLUSIONS: CAS poses a difficult management problem with poor outcomes from conventional angioplasty. Optimal management will depend on patient factors, local outcomes and expertise, but consideration should be given to creation of a new BBF as a cost-effective means to manage this difficult problem.

Factors affecting trial without catheter for first spontaneous acute urinary retention.

PURPOSE: To find the association of trial without catheter (TWOC) outcome for first spontaneous acute urinary retention (AUR) in benign prostatic obstruction with age, prior lower urinary tract symptoms (LUTS), retention volume at catheterization (RV), and size of prostate. METHODS: Our prospective observational analytical (interventional) study enrolled 77 cases of spontaneous AUR over 24 months. After clinical evaluation, digital rectal examination, and transabdominal ultrasonography, all patients were catheterized per urethra and their RV was recorded. TWOC was administered after 2 or 3 doses of 0.4 mg tamsulosin-oral absorption control system and after 48-72 hours had passed. A successful endpoint was defined as a maximum flow-rate, >5 mL/sec; voided volume, >100 mL; postvoid residue, <200 mL; and voiding within 6 hours of catheter removal. Data obtained from 58 patients were analyzed after excluding the cases lost to follow-up and secondary exclusion. Age, RV, duration of LUTS, and prostate volume on examination and ultrasonography (PUSG) were recorded and statistically analyzed. Prostate-specific antigen levels were obtained on follow-up and cases of cancer, as seen on transrectal ultrasound-guided biopsy, were secondarily excluded. RESULTS: The patients had a mean age of 65.89±8.67 years. Prior LUTS was seen in 35 patients (2.07±2.91 months). The mean PUSG and RV were 46.81±20.58 mL and 854.8±36.26 mL, respectively. Thirty patients underwent a successful TWOC; a mean age of 63.13±8.58 years (mean±standard deviation; unpaired t-test; P=0.0053) and a PUSG of ≤45 mL (Pearson chi-square test; P=0.0427) were significantly associated with a successful outcome. CONCLUSIONS: There is a significant association between TWOC outcome, age (P=0.0053), and PUSG (P=0.0427).

Factors Affecting Trial Without Catheter for First Spontaneous Acute Urinary Retention / 대한배뇨장애요실금학회지

PURPOSE: To find the association of trial without catheter (TWOC) outcome for first spontaneous acute urinary retention (AUR) in benign prostatic obstruction with age, prior lower urinary tract symptoms (LUTS), retention volume at catheterization (RV), and size of prostate. METHODS: Our prospective observational analytical (interventional) study enrolled 77 cases of spontaneous AUR over 24 months. After clinical evaluation, digital rectal examination, and transabdominal ultrasonography, all patients were catheterized per urethra and their RV was recorded. TWOC was administered after 2 or 3 doses of 0.4 mg tamsulosin-oral absorption control system and after 48-72 hours had passed. A successful endpoint was defined as a maximum flow-rate, >5 mL/sec; voided volume, >100 mL; postvoid residue, <200 mL; and voiding within 6 hours of catheter removal. Data obtained from 58 patients were analyzed after excluding the cases lost to follow-up and secondary exclusion. Age, RV, duration of LUTS, and prostate volume on examination and ultrasonography (PUSG) were recorded and statistically analyzed. Prostate-specific antigen levels were obtained on follow-up and cases of cancer, as seen on transrectal ultrasound-guided biopsy, were secondarily excluded. RESULTS: The patients had a mean age of 65.89+/-8.67 years. Prior LUTS was seen in 35 patients (2.07+/-2.91 months). The mean PUSG and RV were 46.81+/-20.58 mL and 854.8+/-36.26 mL, respectively. Thirty patients underwent a successful TWOC; a mean age of 63.13+/-8.58 years (mean+/-standard deviation; unpaired t-test; P=0.0053) and a PUSG of < or =45 mL (Pearson chi-square test; P=0.0427) were significantly associated with a successful outcome. CONCLUSIONS: There is a significant association between TWOC outcome, age (P=0.0053), and PUSG (P=0.0427).

Posterior urethral valve: delayed presentation in adolescence.

Posterior urethral valves (PUV) are now commonly suspected on antenatal ultrasound, but can present with a broad spectrum of severity postnatally. Rarely, the diagnosis is missed until adolescence or adulthood when the patient usually presents with lower urinary tract symptoms. We describe an even rarer case of PUV in a late adolescent who first presented with preserved renal function and urinary incontinence. We review the literature on presentation, natural history and outcomes of both early and late presenting PUV cases.

Combined laparoscopic and percutaneous management of calcified renal hydatid cyst--a novel nephroscope- and lithotripter-assisted technique.

OBJECTIVE: To describe the novel technique of percutaneous nephroscope-assisted renal hydatid cyst evacuation and lithotripter-assisted division of the cyst wall for combined laparoscopic and percutaneous management. METHODS: A calcified hydatid cyst of the kidney is a rare entity and needs special techniques for total laparoscopic management. A 45-year-old woman was treated successfully for a calcified renal hydatid cyst using the transperitoneal laparoscopic technique. A chlorhexidine gluconate and cetrimide mixture was used as the scolicidal solution to sterilize the cyst. The endocyst and daughter cysts were removed completely under vision, after placement of a single 26F nephroscope through a 10-mm port in the cyst, with grasper and lithotripter suction, using chlorhexidine-cetrimide mixture irrigation. Laparoscopic suction did not work well for the viscous contents. The calcified cyst wall did not yield to electrocautery or piecemeal fragmentation, until weakened by division and fragmentation using the pneumatic lithotripter. Partial cyst wall exicision/marsupialisation was complemented with omentoplasty. RESULTS: No intraoperative or early postoperative complications occurred. The patient recovered well with little pain and was discharged early. This technique, in which the principles of percutaneous nephrolithotomy were applied for a special problem, is the first of its type. CONCLUSION: Calcified renal hydatid cyst evacuation using the novel nephroscope-assisted retrieval of contents and lithotripter-assisted division of the calcified wall is a safe and feasible technique for total minimally invasive management.

Posterior Urethral Valve: Delayed Presentation in Adolescence / 대한배뇨장애요실금학회지

Posterior urethral valves (PUV) are now commonly suspected on antenatal ultrasound, but can present with a broad spectrum of severity postnatally. Rarely, the diagnosis is missed until adolescence or adulthood when the patient usually presents with lower urinary tract symptoms. We describe an even rarer case of PUV in a late adolescent who first presented with preserved renal function and urinary incontinence. We review the literature on presentation, natural history and outcomes of both early and late presenting PUV cases.