Management of hyperkalaemia

Hyperkalaemia, an elevated extracellular fluid potassium concentration, is a common electrolyte disorder and is present in 1-10% of hospitalised patients. Elevated serum potassium concentrations are usually asymptomatic but may be associated with electrocardiogram (ECG) changes. Hyperkalaemia occasionally leads to life-threatening cardiac arrhythmias. Prompt recognition of this disorder, patient risk management and administration of appropriate treatment can prevent serious cardiac complications of hyperkalaemia. Further assessment of the underlying basis for hyperkalaemia usually reveals a problem with renal potassium excretion (rather than transcellular shift of potassium or excess potassium intake). Reduced potassium excretion is typically associated with decreased potassium secretion in the aldosterone-sensitive distal nephron of the kidney. Common causes for hyperkalaemia include kidney failure, limited delivery of sodium and water to the distal nephron and drugs that inhibit the renin-angiotensin-aldosterone system. Treatment of life-threatening hyperkalaemia (particularly those patients with ECG changes) involves administration of intravenous calcium salts to stabilise the resting cardiac membrane potential. The potassium concentration can be lowered by administration of intravenous insulin combined with an infusion of glucose to stimulate intracellular uptake of potassium. Nebulised β-2 adrenoceptor agonists can augment the effects of intravenous insulin and glucose pending more definitive management of the recurrent hyperkalaemia risk. Additional management steps include stopping further potassium intake and careful review of prescribed drugs that may be adversely affecting potassium homeostasis. Changes to prescribing systems and an agreed institutional protocol for management of hyperkalaemia can improve patient safety for this frequently encountered electrolyte disorder.

Evidence underlying the clinical management of diabetic macular oedema

Diabetic retinopathy (DR) is the leading cause of visual loss in the developed world in those of working age, and its prevalence is predicted to double by 2025. The management of diabetic retinopathy has traditionally relied on screening, on laser treatment delivered by ophthalmologists, and on optimising blood glucose and blood pressure. Recent evidence suggests that the role of systemic factors is more complex than originally thought, and that drugs such as ACE inhibitors, fibrates and glitazones may all influence the course of diabetic macular oedema. Antagonism of vascular endothelial growth factor offers a new therapeutic avenue that may transform the management of diabetic macular oedema. Several other therapeutic options are under investigation and development, including aminoguanidine, sorbinol, ruboxistaurin and autologous stem cell transfusion. © Royal College of Physicians, 2013.

Attitudes of physicians, patients, and village health workers toward glaucoma and diabetic retinopathy in rural China:A focus group study

Objective: To understand the knowledge and attitudes of rural Chinese physicians, patients, and village health workers (VHWs) toward diabetic eye disease and glaucoma. Methods: Focus groups for each of the 3 stakeholders were conducted in 3 counties (9 groups). The focus groups were recorded, transcribed, and coded using specialized software. Responses to questions about barriers to compliance and interventions to remove these barriers were also ranked and scored. Results: Among 22 physicians, 23 patients, and 25 VHWs, knowledge about diabetic eye disease was generally good, but physicians and patients understood glaucoma only as an acutely symptomatic disease of relatively low prevalence. Physicians did not favor routine pupillary dilation to detect asymptomatic disease, expressing concerns about workflow and danger and inconvenience to patients. Providers believed that cost was the main barrier to patient compliance, whereas patients ranked poorly trained physicians as more important. All 3 stakeholder groups ranked financial interventions to improve compliance (eg, direct payment, lotteries, and contracts) low and preferred patient education and telephone contact by nurses. All the groups somewhat doubted the ability of VHWs to screen for eye disease accurately, but patients were generally willing to pay for VHW screening. The VHWs were uncertain about the value of eye care training but might accept it if accompanied by equipment. They did not rank payment for screening services as important. Conclusions: Misconceptions about glaucoma's asymptomatic nature and an unwillingness to routinely examine asymptomatic patients must be addressed in training programs. Home contact by nurses and patient education may be the most appropriate interventions to improve compliance.

THE CITADEL THE MILITARY COLLEGE OF SOUTH CAROLINA ANNUAL REPORT 1985-1986

South Carolina laws require that each state agency submit an annual accountability report to the Governor and General Assembly that contains the agency's or department's mission, objectives to accomplish the mission, and performance measures that show the degree to which objectives are being met.

THE CITADEL THE MILITARY COLLEGE OF SOUTH CAROLINA ANNUAL REPORT 1986-1987

South Carolina laws require that each state agency submit an annual accountability report to the Governor and General Assembly that contains the agency's or department's mission, objectives to accomplish the mission, and performance measures that show the degree to which objectives are being met.

THE CITADEL THE MILITARY COLLEGE OF SOUTH CAROLINA ANNUAL REPORT 1991-1992

South Carolina laws require that each state agency submit an annual accountability report to the Governor and General Assembly that contains the agency's or department's mission, objectives to accomplish the mission, and performance measures that show the degree to which objectives are being met.

THE CITADEL THE MILITARY COLLEGE OF SOUTH CAROLINA ANNUAL REPORT 1987-1988

South Carolina laws require that each state agency submit an annual accountability report to the Governor and General Assembly that contains the agency's or department's mission, objectives to accomplish the mission, and performance measures that show the degree to which objectives are being met.

THE CITADEL THE MILITARY COLLEGE OF SOUTH CAROLINA ANNUAL REPORT 1988-1989

South Carolina laws require that each state agency submit an annual accountability report to the Governor and General Assembly that contains the agency's or department's mission, objectives to accomplish the mission, and performance measures that show the degree to which objectives are being met.

THE CITADEL THE MILITARY COLLEGE OF SOUTH CAROLINA ANNUAL REPORT 1989-1990

South Carolina laws require that each state agency submit an annual accountability report to the Governor and General Assembly that contains the agency's or department's mission, objectives to accomplish the mission, and performance measures that show the degree to which objectives are being met.

THE CITADEL THE MILTARY COLLEGE OF SOUTH CAROLINA ANNUAL REPORT 1990-1991

South Carolina laws require that each state agency submit an annual accountability report to the Governor and General Assembly that contains the agency's or department's mission, objectives to accomplish the mission, and performance measures that show the degree to which objectives are being met.

THE CITADEL THE MILITARY COLLEGE OF SOUTH CAROLINA ANNUAL REPORT 1992-1993

South Carolina laws require that each state agency submit an annual accountability report to the Governor and General Assembly that contains the agency's or department's mission, objectives to accomplish the mission, and performance measures that show the degree to which objectives are being met.

THE CITADEL THE MILITARY COLLEGE OF SOUTH CAROLINA ANNUAL REPORT 1993-1994

South Carolina laws require that each state agency submit an annual accountability report to the Governor and General Assembly that contains the agency's or department's mission, objectives to accomplish the mission, and performance measures that show the degree to which objectives are being met.