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A. ABNORMAL PAP SMEARS Clients with abnormal Pap smears may need additional evaluation treatment e.g., colposcopy and biopsy, loop excision or conization ; . See Tables 6-1 to 6-3 pages 44-45. ; B. OTHER REASONS FOR REFERRALS.

This object has been achieved by providing a transdermal therapeutic system tts ; for the transcutaneous administration of tolterodine which contains a self-adhesive matrix material in the form of a layer, which layer contains a meth ; acrylate copolymer comprising ammonium groups, at least one plasticiser, and up to 25% by weight tolterodine. Kentera is a transdermal patch formulation of oxybutynin, licensed for the symptomatic treatment of urge incontinence and or increased urinary frequency and urgency that can occur in patients with unstable bladder. In a randomised, double-blind study in 520 patients with an unstable bladder, transdermal oxybutynin, in a daily dose of 3.9mg, significantly reduced the weekly frequency of incontinence episodes compared with placebo median change -19 vs. -14.5; P 0.0165 ; . Micturition frequency was also reduced and average voided urine volume increased. Data from two other studies showed a similarly beneficial effect, comparable to that of immediate-release oral oxybutynin and of longacting oral tolterodine. However, transdermal oxybutynin was associated with a lower incidence of antimuscarinic effects, particularly dry mouth. Approximately one-fifth of patients using transdermal oxybutynin experienced application site reactions including pruritus and erythema. These were usually transient and self-limiting but were a cause of treatment withdrawal in about 8% of patients. The limited trial data indicate a second-line role for transdermal oxybutynin as an alternative to immediate-release oral oxybutynin, for patients in whom antimuscarinic effects compromise treatment compliance. Comparative studies with oral modified-release. 175. HILDEBRANDT, J. P., AND P. HILDEBRANDT. Lysophosphatidic acid depletes intracellular calcium stores different from those mediating capacitative calcium entry in C6 rat glioma cells. Glia 19: 6773, 1997. HO, C., J. HICKS, AND M. W. SALTER. A novel P2-purinoceptor expressed by a subpopulation of astrocytes from the dorsal spinal cord of the rat. Br. J. Pharmacol. 116: 29092918, 1995. HOFMANN, F., M. BIEL, AND V. FLOCKERZI. Molecular basis for Ca2 channel diversity. Annu. Rev. Neurosci. 17: 399418, 1994. HOLGADO, A., AND L. BEAUGE. The Na -Ca2 exchange system in rat glial cells in culture: activation by external monovalent cations. Glia 14: 7786, 1995. HOLLMANN, M., M. HARTLEY, AND S. HEINEMANN. Ca2 permeability of KA-AMPA-gated glutamate receptor channels depends on subunit composition. Science 252: 851853, 1991. HOLLMANN, M., AND S. HEINEMANN. Cloned glutamate receptors. Annu. Rev. Neurosci. 17: 31108, 1994. HOLTZCLAW, L. A., V. GALLO, AND J. T. RUSSELL. AMPA receptors shape Ca2 responses in cortical oligodendrocyte progenitors and CG-4 cells. J. Neurosci. Res. 42: 124130, 1995. HOLZWARTH, J. A., S. J. GIBBONS, J. R. BRORSON, L. H. PHILIPSON, AND R. J. MILLER. Glutamate receptor agonists stimulate diverse calcium responses in different types of cultured rat cortical glial cells. J. Neurosci. 14: 18791891, 1994. HOLZWARTH, J. A., S. R. GLAUM, AND R. J. MILLER. Activation of endothelin receptors by sarafotoxin regulates Ca2 homeostasis in cerebellar astrocytes. Glia 5: 239250, 1992. HOSLI, E., AND L. HOSLI. Evidence for the existence of alphaand beta-adrenoceptors on neurones and glial cells of cultured rat central nervous system--an autoradiographic study. Neuroscience 7: 28732881, 1982. HOSLI, E., AND L. HOSLI. Autoradiographic localization of binding sites for muscarinic and nicotinic agonists and antagonists on cultured astrocytes. Exp. Brain Res. 71: 450454, 1988. HOSLI, E., AND L. HOSLI. Autoradiographic evidence for endothelin receptors on astrocytes of rat cerebellum, brainstem and spinal cord. Neurosci. Lett. 129: 5558, 1991. HOSLI, L., E. HOSLI, U. SCHNEIDER, AND W. WIGET. Evidence for the existence of histamine H1- and H2-receptors on astrocytes of cultured rat central nervous system. Neurosci. Lett. 48: 287 291, HOTH, M., AND R. PENNER. Calcium-release-activated calcium current in rat mast cells. J. Physiol. Lond. ; 465: 359386, 1993. HOYER, D., D. E. CLARKE, J. R. FOZARD, P. R. HARTIG, G. R. MARTIN, E. J. MYLECHARANE, P. R. SAXENA, AND P. P. HUMPHREY. International Union of Pharmacology classification of receptors for 5-hydroxytryptamine serotonin ; . Pharmacol. Rev. 46: 157203, 1994. HUGUENARD, J. R. Low threshold calcium currents in central nervous system. Annu. Rev. Physiol. 58: 329348, 1996. IINO, M., S. OZAWA, AND K. TSUZUKI. Permeation of calcium through excitatory amino acid receptor channels in cultured rat hippocampal neurones. J. Physiol. Lond. ; 424: 151165, 1990. IMOTO, K., H. TAKEMURA, M. KANEKO, AND H. OSHIKA. Lack of voltage operated calcium channel in rat glioma C6 cells. Res. Commun. Mol. Pathol. Pharmacol. 93: 249256, 1996. INAGAKI, N., H. FUKUI, S. ITO, AND H. WADA. Type-2 astrocytes show intracellular Ca2 elevation in response to various neuroactive substances. Neurosci. Lett. 128: 257260, 1991. INAGAKI, N., H. FUKUI, S. ITO, A. YAMATODANI, AND H. WADA. Single type-2 astrocytes show multiple independent sites of Ca2 signaling in response to histamine. Proc. Natl. Acad. Sci. USA 88: 42154219, 1991. INAGAKI, N., H. FUKUI, Y. TAGUCHI, N. P. WANG, A. YAMATODANI, AND H. WADA. Characterization of histamine H1-receptors on astrocytes in primary culture: [3H]mepyramine binding studies. Eur. J. Pharmacol. 173: 4351, 1989. INAGAKI, N., AND H. WADA. Histamine and prostanoid receptors on glial cells. Glia 11: 102109, 1994. INOUE, A., M. YANAGISAWA, S. KIMURA, Y. KASUYA, T. MIYAUCHI, K. GOTO, AND T. MASAKI. The human endothelin family: three structurally and pharmacologically distinct isopeptides predicted by three separate genes. Proc. Natl. Acad. Sci. USA 86: 28632867, 1989, for example, tolterodine l tart.

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Chapple CR, Arano P, Bosch JL, De Ridder D, Kramer AE, Ridder AM. Solifenacin appears effective and well tolerated in patients with symptomatic idiopathic detrusor overactivity in a placebo- and tolterodine-controlled phase 2 dose-finding study. BJU Int 2004; 93 1 ; : 71-7. Chapple CR, Rechberger T, Al-Shukri S, Meffan P, Everaert K, Huang M, Ridder A. Randomized, double-blind placebo- and tolterodinecontrolled trial of the once-daily antimuscarinic agent solifenacin in patients with symptomatic overactive bladder. BJU Int 2004; 93 3 ; : 303-10. Haab F, Stewart L, Dwyer P. Darifenacin, an M3 selective receptor antagonist, is an effective and well-tolerated once-daily treatment for overactive bladder. Eur Urol 2004; 45 4 ; : 420-9. Anderson RU, Mobley D, Blank B, Saltzstein D, Susset J, Brown JS. Once daily controlled versus immediate release oxybutynin chloride for urge urinary incontinence. OROS Oxybutynin Study Group. J Urol 1999; 161 6 ; : 1809-12. Birns J, Lukkari E, Malone-Lee JG. A randomized controlled trial comparing the efficacy of controlled-release oxybutynin tablets 10 mg once daily ; with conventional oxybutynin tablets 5 mg twice daily ; in patients whose symptoms were stabilized on 5 mg twice daily of oxybutynin. BJU Int 2000; 85 7 ; : 793-8. Van Kerrebroeck P, Kreder K, Jonas U, Zinner N, Wein A. T0lterodine once-daily: superior efficacy and tolerability in the treatment of the overactive bladder. Urology 2001; 57 3 ; : 414-21. Dmochowski RR, Davila GW, Zinner NR, Gittelman MC, Saltzstein DR, Lyttle S, et al. Efficacy and safety of transdermal oxybutynin in patients with urge and mixed urinary incontinence. J Urol 2002; 168 2 ; : 580-6. Davila GW, Daugherty CA, Sanders SW. A short-term, multicenter, randomized double-blind dose titration study of the efficacy and anticholinergic side effects of transdermal compared to immediate release oral oxybutynin treatment of patients with urge urinary incontinence. J Urol 2001; 166 1 ; : 140-5. Milani R, Scalambrino S, Milia R, Sambruni I, Riva D, Pulici L, et al. Double-blind crossover comparison of flavoxate and oxybutynin in women affected by urinary urge syndrome. Int Urogynecol J 1993; 4 1 ; : 3-8. Chapple CR, Parkhouse H, Gardener C, Milroy EJ. Double-blind, placebo-controlled, cross-over study of flavoxate in the treatment of idiopathic detrusor instability. Br J Urol 1990; 66 5 ; : 491-4. Dahm TL, Ostri P, Kristensen JK, Walter S, Frimodt-Moller C, Rasmussen RB, et al. Flavoxate treatment of micturition disorders accompanying benign prostatic hypertrophy: a double-blind placebocontrolled multicenter investigation. Urol Int 1995; 55 4 ; : 205-8. Department of Health. Good practice in continence services. London: The Department; 2000. [cited 1 Oct 2004]. Available from url: : dh.gov assetRoot 04 05 75 Cottenden AM, Dean GE, Brooks RJ, Haines-Nutt RF, Rothwell JG, Penfold PH. Disposable bedpads for incontinence: predicting their clinical leakage properties using laboratory tests. Med Eng Phys 1998; 20 5 ; : 347-59. Fader M, Pettersson L, Dean G, Brooks R, Cottenden AM, MaloneLee J. Sheaths for urinary incontinence: a randomized crossover trial. BJU Int 2001; 88 4 ; : 367-72. Fader M, Pettersson L, Dean G, Brooks R, Cottenden A. The selection of female urinals: results of a multicentre evaluation. Br J Nurs 1999; 8 14 ; : 918-25. Fader M, Moore KN, Cottenden AM, Pettersson L, Brooks R, MaloneLee J. Coated catheters for intermittent catheterization: smooth or sticky? BJU Int 2001; 88 4 ; : 373-7. Bakke A. Clean intermittent catheterization-physical and psychological complications. Scand J Urol Nephrol Suppl 1993; 150: 1-69. Bull E, Chilton CP, Gould CA, Sutton TM. Single-blind, randomised, parallel group study of the Bard Biocath catheter and a silicone elastomer coated catheter. Br J Urol 1991; 68 4 ; : 394-9. NHS Quality Improvement Scotland. Urinary catheterisation and catheter care. Best practice statement. Edinburgh: NHS QIS; 2004. [cited 1 Oct 2004]. Available from url: : nhshealthquality nhsqis files Urinary Cath COMPLETE Getliffe K. Managing recurrent urinary catheter blockage: problems, promises, and practicalities. J Wound Ostomy Continence Nurs 2003; 30 3 ; : 146-51. Fader M, Pettersson L, Brooks R, Dean G, Wells M, Cottenden A, Malone-Lee J. A multicentre comparative evaluation of catheter valves. Br J Nurs 1997; 6 7 ; : 359-67. Wilson M, Coates D. Infection control and urine drainage bag design. Prof Nurse 1996; 11 4 ; : 245-52. Medical Devices Agency. Sterile 500ml leg bags for urine drainage. London: The Agency; 1996 and phenoxybenzamine.

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By Carl Abbott There is more to hypertension than elevated blood pressure BP ; . That is why all hypertension guidelines recommend target-organ brain, eyes, heart, kidneys and peripheral vessels ; assessment in the initial overall evaluation of patients with suspected hypertension and as part of the management strategy. Some target-organ damage TOD ; or reversible dysfunction can be ascertained by history alone previous stroke, transient ischemic attack [TIA], angina or myocardial infarction [MI], intermittent claudication, etc. ; but physical examination is needed to identify retinal-vessel abnormalities and to confirm brain or cardiac dysfunction, weak pulses and differences between brachial and ankle BPs. Laboratory function tests and imaging are used to reveal abnormalities of kidney function. The 12-lead ECG and sometimes the echocardiogram ; completes the picture. Visual complaints cannot be relied upon to predict funduscopic changes in hypertension. As medical students, we are taught with varying exposure and intensity ; how to examine the optic fundus because it is an essential part of the examination for some patients depending on their problem. Unfortunately, facility in the art of funduscopy varies. For ongoing evaluation of patients with diabetes mellitus, funduscopy is an essential regular examination to monitor for diabetic and hypertensive changes. The year of graduation often determines which classification of hypertensive changes we use. In 1939, Keith, Wagener and Barker1 suggested a classification system that endured for many years. Their four "grades" were used for predicting patient prognosis at a time antihypertensive treatment was virtually non-existent. Some physicians simply described the changes for the medical record. Retinal exudates and hemorrhages were rarely missed even through undilated pupils, but the presence or absence of papilledema in a given patient was often cause for uncertainty and discussion on ward rounds. The hospital ophthalmologist was called, dilated the pupils and gave the last word. The retina is the sole area where arterioles and veins can be seen, so we were taught--and always assumed-- that examination of these retinal vessels was useful, perhaps predictive of duration and severity of hypertension, even reflecting the state of the vasculature elsewhere in contrast to diabetes mellitus, a poor association seems to exists with renal pathology ; . Finding no retinal abnormalities was considered a good sign in hypertension, and in recent times has been used to support a diagnosis of office-induced or white-coat ; hypertension. Finding only "early vessel changes" could be comforting to the doctor and patient. But was funduscopic examination really useful? Retinal photography with a fundal camera soon allowed ophthalmologists to see earlier hypertensive changes than had been possible with the ophthalmoscope. In 1995, Fuchs et al2 questioned the usefulness of optic fundus examination when used by internists and cardiologists working in a hypertension clinic in Brazil. Pupils were dilated and a simplified Keith-Wagener KW ; classification was used in 400 patients, most of whom were receiving antihypertensive therapy. None had diabetes mellitus. Fundus abnormalities of any kind ; were infrequently seen, being observed in only 12% of patients with "less severe hypertension" some of whom may have had white-coat hypertension ; . Even in those with "severe hypertension" defined as DBP 105 mmHg, SBP 180 mmHg, for a duration 3 years ; , the frequency of abnormality was only 41%. Grades I and II KW changes were poor predictors of severity of hypertension in this study. The authors considered arteriolar narrowing to be a manifestation of atherosclerosis, increasing with age. AV crossing changes were more suggestive of high systolic pressure. Not everyone would agree with these conclusions. Dodson et al3 offers a simpler grading system which appeals to me and includes only strictly hypertensive changes: Grade A "non-malignant" hypertension ; : generalized narrowing or focal vasoconstriction; AV nicking not included. These changes may be determined by the level of BP but age and other factors e.g., lipid profile ; are important. Grade B "malignant" or accelerated hypertension ; : Hemorrhages, hard exudates and cotton wool spots with without optic disc swelling. Recently, Ikram et al4 measured retinal vessel diameters using digitized retinal photography in 6, 436 people in Rotterdam, aged 55 years or older, followed for a mean of 6.6 years. Subjects were classified as: a ; having normal BP and valsartan.

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1b ; Health in your community Mon. 10.30 12.30 1c ; Dealing with Danger Wed. & Thurs. 2.30 3.30 pm and videx. Several health problems and behaviors can increase urine production. First, in both men and women, ingested fluid is excreted later in the day and into the night as we age, and renal efficiency decreases.12 This phenomenon is exaggerated among older people with lower extremity edema due to venous insufficiency. In your body and in your thinking, and report them as soon as practical to your treating team. This includes collaborating with your doctor to find a medication that gives you the most benefit and use it as recommended. It is wise to develop a plan to monitor early signs of relapse. You may want to ask close friends or family whanau to help. Finally, it is important to nurture all the positive relationships you have in your life to ensure you have support throughout treatment and a positive outlook for the future and digoxin and tolterodine, because drug interactions. Bladder is serious problem long-term care OItveractiveainresident'samorale, facilities. affects mobility, and self-confidence. This condition often is misunderstood by families and long-term care staff, frustrates families and clinicians, and consumes an appreciable amount of nursing staff time. Many residents are admitted to long-term care facilities with overactive bladder; in fact, many are admitted because of this condition and the burden it creates for caregivers. Residents attempt to manage this condition on their own by using tactics such as drinking less fluid or avoiding activities that are far from a bathroom, and these attempts often cause other conditions such as dehydration, urinary tract infections, or loss of independence. Management of overactive bladder is a daunting task that involves educating residents, their families, or caregivers; putting misconceptions held by staff members to rest; implementing a behavioral plan; and possibly using medication. Clearly, all members of the interdisciplinary team are important in the management of overactive bladder. This supplement to The Consultant Pharmacist addresses the complex origins, management, and possible outcomes of overactive bladder. In the first article, "Overactive Bladder: Definition, Etiology, Prevalence and Cost, " Judy A. Dutcher and Susan W. Miller clarify the confusing terminology associated with overactive bladder. They explain what it is, and what it isn't, and highlight its impact. In the second article, "Overactive Bladder: Assessment and Nonpharmacologic Interventions, " Joseph G. Ouslander and Dutcher address the importance of actions that are needed before considering medications as a treatment modality, and in fact, necessary even when the decision to use medications is made. This article underscores the absolute necessity for teamwork while emphasizing that a complete "cure" is rarely a realistic goal. In the third article, "Drug Therapy in Overactive Bladder, " Ouslander and Miller review some of the very few studies of drug treatment of overactive bladder that have been conducted in older people and discuss the available forms of toolterodine and oxybutynin. Clinicians will face many decisions when selecting a drug. Is a short-acting drug best or is the long-acting form needed? Is compliance an issue? What comordid conditions are of concern? These concerns are addressed in detail. The authors don't make precise recommendations about either drug, because each individual resident's unique situation will have to be considered. Perhaps in the future, new agents will make selection less arduous. The goal of this supplement is to further consultant pharmacists' understanding of overactive bladder, update their vocabulary with the newest terminology, and make them aware of the many interventions that are available for long-term care residents. Above all, this supplement should increase awareness that overactive bladder requires a comprehensive care plan and serious commitment to the plan by all involved. AGM: East Examination School on Monday at 17: 00 BAP Members only ; Certificates of Attendance: Please see Lynne van Vliet at the BAP desk Cybercaf: Available in Room 7 at the Examination Schools for conference participants to check and send emails. Please consider others and do not use for longer than 15 minutes at a time. Room 8 at the Examination Schools on Tuesday at 12: 45 Pharmaceutical companies publishers technical equipment and services, North School and Marquee for the duration of the conference and dipyridamole. Although the bilayer technology is more costly than conventional tableting, the superior end product makes it worthwhile.

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