The practical assessment and management of bladder outflow obstruction

The initial management of bladder outflow obstruction typically related to benign prostatic hyperplasia (BPH) falls to a large extent within the remit of general practice. Referral onwards to secondary care typically arises following the failure to respond to conservative measures or when complications have supervened; the most significant of which is urinary retention. In the hospital setting, anaesthesia, constipation and immobility are the common precipitants. What follows is a practical guide to the management of these situations and provides an overview of the conservative, medical, minimally invasive and surgical treatments available.     

Changing attitudes and practices in foregoing life-sustaining treatments

Advances in medical technology and practices have been associated with improved patient outcomes. At times, the price of this progress has included great financial costs and human suffering. During the last two decades, there have been significant changes in medical practices in America. In the late 1960s and early 1970s, the removal of a respirator or hydration or nutrition from a patient who was not brain dead was considered a deviation from accepted medical practices. In 1976, the Quinlan case allowed the removal of a ventilator from a patient in a persistent vegetative state. Subsequent court decisions in the 1980s have equated hydration and artificial feeding with other forms of life-sustaining treatments and have allowed their withdrawal in patients who were not terminally ill. Prominent physicians have recently stated that it is not immoral for a physician to assist in the rational suicide of a terminally ill patient. Active euthanasia programs in the United States are likely in the near future.     

Cardiovascular collapse during anesthesia in a patient with preoperatively discontinued chronic MAO inhibitor therapy

We describe a patient in whom long-term monoamine oxidase (MAO) inhibitor therapy was discontinued 20 days before surgery with general anesthesia. This patient developed severe perioperative hypotension after administration of 10 mg of bupivacaine through an epidural catheter, which was corrected only after potent vasopressor therapy. We attribute this hemodynamic instability to attenuation of this patient's sympathetic tone based on several mechanisms: (1) residual effect of long-term administration of MAO inhibitor that caused a decrease in the number of β-adrenergic receptors (adrenergic subsensitivity due to receptor down-regulation), (2) recovered MAO activity causing effective degradation of sympathetic amines, and (3) combined attenuating effects of general and epidural anesthesia on sympathetic tone.     

Apparent focal motor seizure with a jacksonian march induced by fentanyl: a case report and review of the literature.

This report describes an unusual presentation of focal motor activity resembling Jacksonian march, which developed during fentanyl induction of general anesthesia. Simultaneous spectral-edge activity recording of electroencephalography (EEG) failed to show evidence of an epileptic focus. A negative history of previous seizures, as well as failure to show postoperative postictal symptoms or seizure activity by 16-lead EEG, suggested a myoclonic rather than epileptic nature of the observed muscle activity. Pertinent literature and current theories regarding opioid-induced seizures are discussed.     

Measuring maternal mortality: An overview of opportunities and options for developing countries

Background  

There is currently an unprecedented expressed need and demand for estimates of maternal mortality in developing countries. This has been stimulated in part by the creation of a Millennium Development Goal that will be judged partly on the basis of reductions in maternal mortality by 2015.