Sudden Cardiac Arrest and Sudden Cardiac Death - Are They The Same?

What is Sudden Cardiac Death?

Sudden Cardiac Death refers to sudden, unexpected death caused by sudden cardiac arrest. It is estimated to be responsible for all deaths caused by heart disease.

Sudden Cardiac Arrest occurs when the electrical system of the heart malfunctions and becomes highly irregular. This in turn causes the heart to beat dangerously fast. Subsequently, ventricular fibrillation might occur with the end result being blood not being delivered to the body. Reduced blood flow to the brain will result in unconsciousness and emergency treatment is required.

Heart attacks, as the term is used in a traditional sense, refers to the situation where heart tissue fails to receive sufficient nutrients and blood flow due to blockages to one or more of the arteries supplying the heart, resulting in eventual cardiac tissue damage. With sufficient cardiac tissue damage, the electrical system of the heart will malfunction and that eventually leads to cardiac arrest.

Cardiopulmonary Resuscitation (CPR) and electrical defibrillation remain the mainstay of Emergency treatments for cardiac arrests.

CPR is a manual technique using repetitive chest compressions and manual assisted breathing to maintain sufficient oxygen and blood flow to the brain until a normal heart rhythm is restored. Defibrillation refers to the deliverance of an electrical current as an electric shock to the heart in an effort to reset the electrical rhythms therein and restore normal heart rhythm.

What Are the Symptoms of Sudden Cardiac Arrest?

Symptoms vary and can include:

• A racing heart beat
• Unexplained dizziness and giddiness
• Chest pain

Sometimes, cardiac arrest can occur without prior symptoms.

What Causes Sudden Cardiac Death?

Sudden Cardiac Death are caused by abnormal heart rhythms called arrhythmias, the most life threatening of which is ventricular fibrillation - an erratic and disorganized firing of impulses within the ventricles of the heart. If left untreated, ventricular fibrillation can cause brain death within minutes.

What Are the Risk Factors of Sudden Cardiac Arrest?

Risk factors include:

• History of previous cardiac events, especially if significant cardiac tissue damage has occurred.
• 6 months after an initial heart attack
• Coronary Artery disease
• Smoking
• Hypertension
• High cholesterol levels
• Family history of heart disease
• A cardiac Ejection fraction of <40%
• Congenital heart defects
• Recurrent syncope and fainting
• Heart Failure

• Hypertrophic cardiomyopathy - a condition where heart muscle is thickened without proper electrical connectivity
• Biochemical abnormalities, such as fluctuations in potassium and magnesium levels from use of other drugs (eg diuretics like Frusemide)
• Obesity
• Diabetes Type II
• Recreational drug use

Can Sudden Cardiac Death Be Prevented?

The following steps are recommended:

• Speak with your Doctor if you have any known risk factors and have a full medical assessment.
• Perform the necessary diagnostic tests such as a simple bedside electrocardiogram (ECG) or transthoracic echocardiogram.
• Determine your ejection fraction.

Ejection Fraction (EF): EF is a measurement of the percentage (fraction) of blood pumped (ejected) out of the heart with each beat.

It is usually measured during a transthoracic ultrasound echocardiogram and usually ranges from 55% - 75%.

An EF <40% predisposes a patient to sudden cardiac arrests.

• Lifestyle changes. These include quitting smoking, losing weight, exercising regularly, low fat diets etc.
• Control diabetes, hypertension and cholesterol levels.
• Medications as prescribed by your doctor.
• In certain situations where abnormal cardiac rhythms occur sporadically, and implantable cardioverter-defibrillator (ICD) can be inserted.

An ICD is a small machine similar to a pacemaker designed to correct arrhythmias once detected. It constantly monitors the heart rhythm and detects abnormal cardiac rhythms and records them. When it detects abnormal cardiac rhythms, it delivers a small electrical shock to cardiac tissue to reset the heart back to its normal rhythm. These events are then recorded and can be viewed by the attending doctors at a later date for further analysis and adjustment of the ICD.

ICDs are used for survivors of sudden cardiac arrests and for patients who require constant monitoring of their hearts due to existing conditions causing abnormal heart rhythms.

• Interventional Surgery such as angioplasty for patients with coronary artery disease or bypass surgery can be performed to reduce the risk of SCDs. For patients with congenital abnormalities or cardiomyopathies, surgical intervention will likely be needed to correct any underlying abnormal cardiac rhythms.
• Other non-invasive procedures like cardioversion electrically or catheter ablation techniques can also be used.
• Socially, speaking with family members who are at risk of SCD is the first step to preventing the occurrence of SCDs.

Can Sudden Cardiac Arrest Be Treated?

Cardiac arrests require immediate action. If CPR and defibrillation is performed adequately during the initial few minutes of onset, survival is estimated to be as high as 90%.

What Should I Do if I Witness Sudden Cardiac Arrest?

• Call the emergency helpline and activate an ambulance immediately.
• Perform CPR if you are trained.
• Use a defibrillator if available and you are trained.
• Post CPR, have patient transferred to hospital at the earliest possible time.

Sudden Cardiac Death and Athletes

Do be aware that cardiac death can also occur in athletes. The usual scenario being that of runners participating in social marathons and collapsing in the process.

Hence, do not take the risk. See your doctor for the relevant investigations.

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.

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An Understanding of Hiatal Hernia

The term “Hernia” draws origin from the Greek latin word which means “tear” or “rupture”. Anatomically it refers to any abnormal protrusion of the abdominal contents.

A “Hiatal Hernia” therefore refers to the abnormal protrusion of the Gastrointestinal Tract through the opening (hiatus) within the diaphragm.

There are two main types of hiatal hernias: sliding hiatal hernias, and paraesophageal hiatal hernias.

Sliding hiatal hernias form when the stomach and the adjoining oesophagus slide up into the chest cavity through the diaphragm. It is more common.

Paraoesophgeal hernias are less common and it occurs when a portion of the stomach squeezes past the diaphragm and is lodged and strangulated in place beside the oesophagus. Such hernias can be asymptomatic but dangerous because the portion of stomach that is strangulated above the diaphragm will have a compromised blood supply.

In most cases, hiatal hernias are asymptomatic but sometimes patients might experience heartburn or reflux. While the two conditions appear to be linked, they do not independently cause the development of the other.

In some cases of heartburn, patients might experience chest pain instead and this can be confused with chest pain caused by cardiac issues.


Causes

Often, the cause remains unknown. However, any condition predisposing to an increased pressure within the abdomen such as pregnancy, obesity, coughing or straining during bowel movements, and/or congenital situations such as a larger hiatal opening will predispose a person to developing one.


Population at risk for developing Hiatal Hernias

There’s a predisposition for women, overweight individuals, and patients above fifty years of age to develop this condition.


Diagnosis

A hiatal hernia can be diagnosed with a specialized X-ray called a barium swallow that allows a doctor to see the esophagus or with endoscopy. The procedure involves the patient swallowing a radio-opaque liquid and having X-Rays of the chest and abdomen taken while in the erect posture. The radio-opaque liquid will outline the stomach lining and oesophagus, thereby demonstrating the presence/absence of the condition.


Treatment

If asymptomatic, no treatments are necessary. However, should the stomach become strangulated and there is a risk of vascular compromise to the stomach, surgery is usually needed to rectify the problem.

Other associated symptoms such as reflux disease, heartburn and chest discomfort should be treated accordingly.


When is Hiatal Hernia surgery necessary?

Surgery is indicated when the hernia becomes strangulated and the blood supply becomes compromised.

Surgical intervention for hiatal hernias is often performed laparoscopically (ie keyhole surgery) and is a day procedure. A camera and surgical tools are inserted via keyhole incisions into the abdomen and the surgeon will manipulate the surgical tools to reduce the hernia and possibly tighten the diaphragmatic hiatus. The procedure is usually done as a day procedure, involves smaller incisions, and has less pain and scarring compared to open surgery.

Most patients will be able to ambulate and walk around the next day. There are no dietary restrictions post surgery and patients resume regular activities after a week or so. Complete recovery will take up to a month and the patient should avoid hard labour and heavy lifting.


When Should I Call the Doctor About a Hiatal Hernia?

Speak with your doctor if you are symptomatic. It is difficult to diagnose and symptoms include chest pain, recurrent nausea and vomiting, poor bowel movements and non-specific symptoms like a funny sensation in the middle of the chest.

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.

What Is Dementia?

What is dementia?

Dementia is a condition that afflicts the brain. The mental abilities of dementia patients decline as the illness causes brain cells to die at a faster rate than normal. These patients experience memory loss, deteriorating mental abilities, and personality changes.

There are two main types of dementia: Alzheimer’s disease and multi-infarct dementia. Alzheimer patients experience a gradual decline in their mental abilities as the illness progresses. There is no known medical cure for the disease. On the other hand, multi-infarct dementia may result from a series of strokes in the brain.

Who is at risk?

Dementia is an illness that affects elderly people In Singapore, approximately 6.2% of elderly people aged 65 years and above have dementia.

What are the Symptoms?

The disease generally progresses through three stages. Specific symptoms are associated with each stage, namely:

• Stage 1: Mild Dementia
• Forgetfulness
• Repeating himself/herself
• Odd behaviour
• Social Withdrawal
• Agitation
• Lethargy
• Difficulty with organisation of daily activities

• Stage 2: Moderate Dementia
• Obvious memory lapse
• Odd behaviour (e.g. Neglecting personal hygiene, getting lost, forgetting names of familiar people and objects)

• Stage 3: Severe Dementia
• Difficulty with performing familiar tasks (e.g. Personal care)
• Impaired speech
• Inability to comprehend conversation
• Unable to recognise family members
• Disorientation of place and time
• Poor judgement 
• Difficulty with abstract thinking
• Personality change

What should I do?

Consult your doctor If you or your relative manifest memory loss.

It is important to recognise that caring for dementia patients is emotionally and physically challenging. Your doctor can assist you in establishing a supportive environment by putting you in touch with allied healthcare professionals who can help.

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.

What Is Alzheimer’s Disease

What is Alzheimer’s Disease?

Alzheimer’s is a progressive disease that destroys your mental functions. It causes the degeneration of brain cells, and leads to a steady decline in memory and mental function. Alzheimer’s disease is the most common cause of dementia.

What are the Symptoms?

The disease progresses at a different rate from one patient to another.

At the early onset of Alzheimer’s, patients notice increasing forgetfulness and mild confusion. You may find yourself having difficulty remembering things and/or organising your thoughts. You may not realise that something has changed even when there are noticeable changes in your family members, friends, and colleagues.

Advanced patients manifest increasing memory lost, including the loss of recent memory. They may undergo a change in personality and behaviour. These patients may also experience depression, delusions, and a loss of inhibitions. Important mental functions like the ability to read, dance, sing, enjoy music, and tell stories are usually lost at an advanced stage of the disease.

What Causes Alzheimer’s Disease?

The causes of Alzheimer’s disease are not yet understood. It may be caused by genetic changes. It may also be caused by a combination of factors, such as genetic makeup, lifestyle, and environmental factors.

Risk factors may include:

• Age, particularly after age 65
• Family History
• Down Syndrome
• Gender, with women at a higher risk
• Cognitive Impairment
• Head trauma
• Lifestyle choices, particularly obesity, smoking, high blood pressure, Type 2 diabetes, low fibre diet

When do I seek Medical Advice?

Based on the information you provide and test results, your doctor will make an informed judgement about whether you have Alzheimer’s disease. A definitive test for Alzheimer’s disease does not exist.

Doctors rely on various tests in the diagnosis of Alzheimer’s disease, including:

• Physical exam to check neurological health. He may test your reflexes, muscle tone, sense of hearing and sight, coordination, and balance.
• Blood tests
• Neuropsychological tests to assess memory and thinking skills
• Brain imaging

What are the Treatment Options?

Although Alzheimer’s disease is irreversible, there is a range of treatment options available that may help the patient adjust to living with the disease.

• Medication to help manage cognitive changes and behavioural symptoms
• Creating a supportive environment that strengthens routine habits
• Exercise
• Nutrition
• Supplements like the Omega-3 fatty acids, ginkgo, and Vitamin E

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.

Home Care for Bed Bound Patients

To witness a family member or loved one bed bound is an emotionally draining experience. To be unable to do much to help their suffering and to provide the best of care makes the feeling worse. This article strives to offer some solutions and understanding for the layperson caring for bed bound patients.

Bed bound patients face a variety of issues, from manpower support, mental illnesses like depression, basic cleanliness and hygiene, bed sores, to chronic diseases like hypertension. Of this list, manpower issues usually rank highest.

Most bed bound patients in Singapore stay at home and are looked after by family members. Over time, this can take an exhausting toll on family members and an understanding of home-based care will be of immense aid to family as well as patient.


Understand the Cause for becoming bed bound

A patient can become bed bound for a multitude of reasons. A fracture of the spine, paralysis and coma post trauma, surgery, head injury, end of life causes, old age and the commonly encountered cerebrovascular accident are all situations which can cause patients to become bed bound. Understanding the causes can help prevent the problem from happening in the first place, while adjusting the care for such patients will improve the quality of life for these patients.

Common problems

Nursing Issues

• Ulcers or bedsores: Pressure ulcers and bed sores, if left unchecked, can cause serious complications over time.
• Basic Hygiene and Cleanliness. Basic cleaning of patients, regular change of diapers, monitoring of bowel movements, are all important but physically very demanding.

Medical Issues

• Muscle atropy. After prolonged periods of inactivity, muscles eventually lose their strength and muscle weakness sets in, making it a vicious cycle. The bed bound patient becomes more bound to the bed with the passing of each day.
• Frequent Infections: Due to the sitting / lying posture, the lungs cannot fully inflate with each breath and hence respiratory infections are common. Due to the long term use of diapers, the urinary tract becomes easily infected.
• Mental Illnesses. It is common for patients who are bed bound to become depressed. Love, care and attention, frequent companionship and empathy will go a long way in treatment of these patients.
• Insomnia. It is common for bed bound patients to have poor sleep. 

General Issues due to lack of activity:

• Bed bound patients usually report a loss of appetite, loss of interest in all things big and small, and a general decline amongst all functions. .

Challenges for the Caregivers

Caring for a bed bound patient is challenging. With the passage of time, the daily grind of caring for the bed bound patient will take its toll on the caregiver.

Enforcing personal hygiene, administering the correct medications, serving proper foods, ensuring regular exercise, and providing companionship for bed bound patients are but the basic fundamentals required.

To go beyond the above, turning the bed bound patient every 2-4 hours to prevent bed sores round the clock, suctioning and cleaning the airway, feeding through tubes, dressing open skin sores and wounds, care for urinary catheters are all farther challenges faced by caregivers faced with patient who have complicated medical problems.

It is hence normal for a caregiver to feel overwhelmed at some stage, resulting in high levels of caregiver stress. Thus, the provision of manpower, simply an extra pair of hands, will make a big difference when it comes to home care.


Risks faced by bed bound patients

Common risks include:

• Development of bed or pressure sores which worsen if left untreated.
• Formation of blood clots in the veins of the lower limbs. If these clots break off and get lodged in the heart, lungs or brain, it can cause farther complications. 
• Muscle Atropy
• Frequent infections and complications from the general lack of activity.

As an aside, do note that bed sores rank highest where nursing care is deficient. It usually begins with a mild redness to the skin but if left unchecked, the bedsores will infiltrate deeper into the skin layers and can erode the skin all the way down to bone if left unchecked.


Do's and Don'ts

• Perform daily skin inspection to check for reddening of the skin, especially in bony areas like knees, hips, shoulders, ears, tailbone, and buttocks.
• If a bed sore is identified, cushion it immediately and seek medical help if the skin is broken.
• Keep skin clean and dry. Clean the skin with mild soap and water; pat dry.
• Moist the skin: Use body lotion to keep the skin lubricated. Use powder to dry the folds of the skins, such as armpits and under the breast.
• Bedding and linen should be changed daily. In case of bed wetting, change the wet sheets immediately.
• Keep the patient hydrated.
• Have a balanced diet: A healthy and nutritious diet is very important to boost the patient’s immunity. Keep a diary to record all meals taken.
• Exercise the patient: To prevent muscle weakness, exercises should be done, keeping in perspective the patient’s condition. If the patient can walk a little, help him/her walk around as per convenience.
• Massage: Deep massages can help prevent blood circulation-related complications. Light massages are ideal for painful muscles and prevention of bedsores.
• Positioning: Reposition the patient every 2 hours. Never drag the patient; always lift.
• Keep limbs elevated: Both hands and legs should be kept a little elevated to prevent swelling and help blood circulation.

What to do in case of bedsores?

Unless experienced or trained, the first contact of bedsores should be handled by medical professionals as far as possible.

However, for first response, the best treatment of bed sores is to leave it open to air and to alleviate any pressure on the bed sore as much as possible.

With enough experience with the type of dressings to be used, the caregiver should learn from each episode and become familiar with the available treatments and methods used to clean bed sores.

The best method of treatment bed sores is prevention. So constant vigilance is the key.

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.

Alzheimer’s and Dementia - Are They The Same?

Alzheimer’s Disease and Dementia are two different diagnoses. They are not the same. While both have often been confused with one another, they are two distinct entities.

What is Dementia?

“Dementia” refers to a group of symptoms inclusive of impaired thinking, memory loss, and is often associated with cognitive decline with aging.

While Alzheimer’s Disease is one of the causes for Dementia, “Dementia” can also be caused by other problems like Parkinson’s, Huntington’s Disease of Creutzfeldt - Jakob Disease (CJD).

Depending on the cause, Dementia can be reversible.

What is Alzheimer’s Disease?

Alzheimer’s Disease is a common cause of dementia totalling up to 70% of cases. Symptoms of which include impaired thought, speech and confusion. While these symptoms are common to all dementia patients, Alzheimer’s Disease is a disease that results in brain tissue destruction. This can be confirmed by extensive and sequential brain imaging.

Alzheimer’s is irreversible. It is a form of disease that is degenerative and incurable.

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.

Adult Nocturnal Enuresis (Adult Night Urination)

Adult Nocturnal Enuresis, literally translated to involuntary voiding of urine at night by adults, is a subject that is not often discussed or brought up voluntarily by patients.

It is, however, a very real medical problem and should be looked into.

Causes

Adult Nocturnal Enuresis can be caused by a variety of factors.

Family history appears to play a significant role with Adult Nocturnal Enuresis. Patients with one or both parents who suffer from the problem have a significant chance of developing the problems themselves.

A deficiency in Anti-Diuretic Hormone (ADH) production can also cause adult nocturnal enuresis. ADH is a hormone produced by a portion of the brain called the hypothalamus and acts to decrease the amount of urine produced, A deficiency in ADH will hence result in an increase in urine production and trigger urination.

Diabetes Mellitus can also cause an increase in urine production leading to nocturnal polyuria or urination in the night.

Patients with anatomically small bladders with smaller functional bladder capacities also suffer Adult Nocturnal Enuresis simply because the functional bladder capacity is smaller.

In other cases, overactive bladder muscles can trigger Adult Nocturnal Enuresis. This can be secondary to use of bladder irritants like alcohol and caffeine, or use of certain medications like hypnotics and psychotropic drugs like Selective Serotonin Reuptake Inhibitors.

Causes of Secondary Nocturnal Enuresis include any other medical issues that irritate the genitourinary system. Eg Urinary Tract Infections, Prostate enlargement / cancer etc


Seeing your Doctor

Prior to initiating treatment, your attending doctor will want to determine the cause of your nocturnal enuresis. Hence, it is important to document certain important issues:

• Timing of normal voiding during the day
• Timing of accidents
• Drinking patterns
• Nature of beverage consumed
• Nature of urinary stream (do you dribble?)
• Any existing medical problems
• Any accompanying symptoms (eg fevers etc)

Your attending doctor will then take a full clinical history and go through the list of medications you are on to identify any drugs that might cause nocturnal enuresis as a side effect. Following which, a full physical examination will be performed and your doctor might request for a urine sample for lab analysis. Thereafter, your doctor might order specific investigations like uroflowometry or post void residual urine measurements via ultrasound to evaluate bladder function.


Management

Many simple changes in the bedroom setting can help alleviate adult nocturnal enuresis. Use of waterproof mattress covers or sheet protectors makes nursing care easier. Wearing adult diapers or absorbent briefs help prevent leakage of urine. Skin care products like barrier creams help prevent skin irritation due to prolonged exposure to urine. Behavioural modifications like limiting fluid intake during late afternoon or in the evenings will reduce the amount of urine produced at night.

In situations where nocturnal enuresis are a symptom of an underlying condition, then treatment of the underlying condition remains paramount in managing nocturnal enuresis.


Surgical Treatment

Surgical treatment for adult nocturnal enuresis is limited and you should discuss this thoroughly with your healthcare provider before making a decision to undergo surgery for the condition.

Options include:

• Sacral Nerve Stimulation: This causes the bladder to become less active and hence result in fewer episodes of micturition. 
• Cystoplasty: This is a surgical procedure to increase bladder capacity and reduce bladder instability. 
• Detrusor Myectomy: This is also a surgical procedure which aims at strengthening bladder contractions while reducing the frequency of bladder activity. 

Pharmaceutical Treatment

Drugs like Desmopressin mimic ADH, causing the kidney to produce less urine. Anti-cholinergic medications have also demonstrated some success with treating adult nocturnal enuresis but anti-cholinergic drugs carry with them side effects that might affect patient compliance.

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.

What Is Urinary Tract Infection (UTI)

Overview

An infection of any part of the genitourinary system can be classified as an Urinary Tract Infection (UTI). Often, the lower urinary tract is involved ie Bladder and urethra, and women are at greater risk of developing UTIs compared to Men. If left untreated, UTIs can ascend and infect the kidneys and spread systemically via the bloodstream and affect the entire body. UTIs are usually treated with antibiotics and preventative measures can be taken.

Symptoms

• Burning sensation or pain while urinating
• Increased frequency of urination with small amounts voided each time. 
• Persistent and strong urges to urinate. 
• Cloudy urine, or urine stained brownish or light pink in colour. 
• Foul smelling urine
• If the UTI affects the kidneys, patients might experience pain over the loin regions where the kidneys are located. 

Classification

The terms used by your doctor to describe UTIs might be confusing. Listed below are explanations of some common terms used by doctors.

Acute Pyelonephritis:

• This refers to an acute situation where the kidneys have become infected. 
• “Pyelo-” refers to “fever”, “-nephritis” refers to inflammation of the kidneys. Hence Pyelonephritis literally means fever due to a kidney infection. 

Cystitis:

• This refers to infection of the Bladder
• “Cyst-” refers to the bladder while “-itis” refers to inflammation. Hence Cystitis means inflammation of the bladder due to an infection, likely an ascending UTI. 

Urethritis:

• This refers to an infection of the urethra. Ie the UTI only involves the lower urinary tract. 

Causes

Urinary tract infections typically occur when bacteria enter the urinary tract through the urethra and begin to multiply in the bladder. Although the urinary system is designed to keep out such microscopic invaders, these defenses sometimes fail. When that happens, bacteria may take hold and grow into a full-blown infection in the urinary tract.

The most common UTIs occur mainly in women and affect the bladder and urethra.

• Infection of the bladder (cystitis). This type of UTI is usually caused by Escherichia coli (E. coli), a type of bacteria commonly found in the gastrointestinal (GI) tract. However, sometimes other bacteria are responsible. Sexual intercourse may lead to cystitis, but you don't have to be sexually active to develop it. All women are at risk of cystitis because of their anatomy — specifically, the short distance from the urethra to the anus and the urethral opening to the bladder.
• Infection of the urethra (urethritis). This type of UTI can occur when GI bacteria spread from the anus to the urethra. Also, because the female urethra is close to the vagina, sexually transmitted infections, such as herpes, gonorrhea, chlamydia and mycoplasma, can cause urethritis.

Risk Factors

• Females: Females are more likely than men to develop severe UTIs because the female urethra is much shorter than men. Ie the distance from the external environment to the bladder is much shorter. 
• Increased Sexual activity. While sexually active women tend to have more UTIs than do women who aren't sexually active, promiscuity, new sexual partners, or even having a sexual partner who is promiscuous increases the risks of UTIs. 
• Menopause. Women past menopause have reduced mucus production in their genital tissues due to the decline in circulating oestrogen. As a result, the genital regions are less lubricated and that in turn increases the chances of atypical bacterial colonisation and UTIs. 
• Structural abnormalities. Patients born with genetic defects affecting the urinary system with obstruction to urinary flow or patients afflicted with renal calculi (kidney stones) are more prone to developing UTIs due to the retention of urine. Patients who have recently undergone surgical procedures and trauma are also prone to developing UTIs, 
• Immunocompromised Patients. Immunocompromised patients are at an increased risk of develop all sorts of infections, UTIs being one of them. 
• Catheter use. The presence of a foreign body within the urinary tract, even that of an indwelling urinary catheter to assist urinary flow, increases the risk of UTIs. 

Complications

• Systemic spread of UTIs can be life threatening. If untreated and left unchecked, UTIs that overcome the body’s defences can ascend and infect the kidneys and become blood borne, thereby infecting all other organs and cause multi-organ failure. 
• Permanent organ damage, usually renal, are known sequelae of untreated UTIs. 
• Recurrent UTIs 

Diagnosis

• Urinalysis. Analysis of a urine sample is the most common way of diagnosing UTIs. A sample of urine is collected and can be tested with a dipstick on site, or sent off to an approved laboratory for further analysis.
• When collecting the urine sample, be sure to clean the genital area and collect midstream urine. Ie Pass urine normally but do not collect the initial sample. 
• Dipstick testing of urine reveals macro-abnormalities and is a convenient and quick way for clinicians to perform bedside testing. 
• Urine samples can also be sent off to a lab where the sample is incubated at optimal temperatures for bacterial growth. If bacteria is successfully cultured, they are then tested against a range of antibiotics to identify further options with regards to antibiotic therapy. 
• Imaging - Direct and Indirect
• Your doctor might recommend imaging for you if you experience recurrent UTIs. 
• Indirect Imaging involves either computerized tomography (CT) or magnetic resonance imaging (MRI). Your doctor will decide the modality to use. In most situations, contrast media is usually injected during the imaging process so if you are allergic to contrast media, definitely highlight your allergy. 
• Direct imaging involves a surgical procedure where your urologist will insert a scope up and through your urethra to view the bladder directly. This is a surgical procedure and is normally done under anaesthesia.

Treatment

Antibiotics remain the mainstay of treatment for UTIs. Choice of antibiotics to be used depend on the local epidemiology and will be made at your physician’s discretion.

Oral antibiotics are usually given as first line therapy though intravenous antibiotics are usually used for more serious infections, especially if the UTI has spread systemically.

For symptom control, your physician may also prescribe some analgesics to help control the pain and discomfort from the UTI.

Prevention

• Increase water intake. Increasing water intake increases urine output, resulting in more flushing of the urinary tract. 
• Personal Hygiene. Keep the genital area clean. When cleaning the perineum, wipe from front to back. 
• Avoid beverages that change the pH of urine. Beverages like citrus juices can cause changes in the acidity of urine, resulting in more bacterial growth. 
• Void after sexual intercourse. Voiding the bladder and passing urine post sexual intercourse flushes the urinary tract and prevents bacteria from manifesting. 
• Avoid contraceptives if viable. Contraceptives like diaphragms, intra-uterine devices, and spermicides all alter the bacterial flora within the genital region and can contribute to higher rates of UTIs. 

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.

Tinnitus - The Ring In Your Ears

Tinnitus - An overview

Often referred to as “ringing in the ears” by patients, tinnitus is a common presenting complaint by patients and can affect to as many as 20% of the population.

Tinnitus is not a disease. It is not a pathological entity. It is a symptom of underlying conditions such as age-related hearing loss, ear injuries or other systemic diseases like hypertension.


Tinnitus - Symptoms

Symptoms include:

• Ringing in the ear
• Buzzing in the ear

These symptoms can vary in pitch and may be heard in one or both ears. In some instances, it can be so loud so as to cause patients to become distracted in entirety. The symptoms last for a varying period of time, may be cyclical or persistent.

Broadly speaking, tinnitus can be divided into:

• Tinnitus that is only heard by the patient. Ie Subjective tinnitus. Commonly, this kind of tinnitus is caused by problems with either the auditory nerves or nervous pathways involved with hearing.
• Tinnitus that is audible to the physical examiner. Ie the doctor. This type of tinnitus is extremely rare and can be caused by issues with the blood supply, middle ear issues or abnormal musculature.

Tinnitus - Time to see the Doctor?

Bottom line - if it bothers you, please seek a medical consult. Especially if:

• Tinnitus develops and is persistent after a recent upper respiratory infection such as the flu and does not resolve after a week or so.
• Tinnitus occurs out of the blue with no obvious reasons or cause that you can identify
• You experience hearing loss or dizziness and giddiness when experiencing tinnitus 

Tinnitus - Causes

While many conditions can cause tinnitus, sometimes the cause can remain elusive.

From first principles - Tinnitus is caused by abnormal nerve impulses being transmitted from the inner ear, an organ that is lined with microscopic and highly sensitive hairs that move in relation to sound waves. Abnormal nervous transmissions from these hairs causes the brain to interpret these signals as “sound”, thereby resulting in a “ringing” sensation.

Hence, any condition involving the ear or inbuilt physiology of hearing can and will cause tinnitus.


Tinnitus - Common causes

• Age-related hearing loss - Medically termed as “presbycusis”, tinnitus as a result of age-related hearing loss is common and often begins around age 60 or so. 

• Noise Pollution - Noise pollution secondary to industrial and or recreational activities can cause tinnitus. The banging of heavy equipment in factories, the whine of the chainsaw, the boom of the rifle, the roar of rock music played directly into the ear via headphones etc all cause loud noises that impact heavily on the eardrum. This in turn causes tinnitus. Short term exposure to noise pollution usually goes away after some time but chronic exposure can lead to permanent ear damage and hearing loss. 

• Ear Wax - Excessive amounts of ear wax can result in hearing loss and or irritation to the eardrum simply because of physical contact when accumulated in sufficient quantities. This in turn can cause tinnitus. 

•  Otosclerosis - Hardening of bones in the middle ear can affect hearing and cause tinnitus. There is a genetic link for patients suffering from this condition. 

Tinnitus - Less common causes

• Meniere's disease - This is an inner ear disorder caused by abnormal inner ear fluid pressure. It is harmless but can cause severe vertiginous giddiness in associated with tinnitus and can be psychologically traumatizing to patients experiencing their first attack. 

• Disorders with the Temporo-Mandibular Joint (TMJ) - Patients with abnormal TMJ joints can experience tinnitus as a side effect of their problem with the jaw. 

• Head and neck Trauma - Trauma involving this portion of the body can and will affect the inner ear, auditory nerves and brain function. Depending on the site of injury, tinnitus experienced by these patients is usually one sided in relation to their injury. 

• Acoustic Neuromas - This is a benign tumour of one of the cranial nerves that controls balance and hearing. Again, it generally causes tinnitus in only one ear. 

Tinnitus - Rare causes

These are usually related to the blood supply.

• Atherosclerosis. Loss of elasticity in the major blood vessels supplying the middle and inner ear with age due to the buildup of cholesterol causes blood flow within the vessels to be more forceful, causing each “flow” to be heard within the ears. 

• Cancers involving the Head and Neck Region. Any tumour causing compression on blood supply can cause tinnitus as one of the presenting symptoms. 

• Hypertension (“High Blood Pressure”) - Hypertension and any factors that trigger a sudden rise in blood pressure can cause tinnitus simply because of the increased pressure in blood flow to the ears. 

• Turbulent Blood Flow. Any physical cause of narrowing or kinking in the arteries supplying the neck can cause tinnitus due to disruption of blood supply. This is usually seen with either damage or compression to the carotids.

• Congenital Arteriovenous Malformations (AVMs) -  AVMs are congenital and basically refer to direct but abnormal connections between arteries and veins without intervening capillaries. These malformations all for diversion of blood flow and pressure and can cause tinnitus. If present, tinnitus caused by this condition is often one sided.

Medications that can potentially cause tinnitus

• Antibiotics - eg Polymyxin B, erythromycin, vancomycin and neomycin
• Chemotherapy agents - eg mechlorethamine and vincristine
• Diuretics - eg frusemide
• Drugs used for Prophylaxis - eg Quinines 
• Antidepressants 
• Aspirin at high doses

Tinnitus - Risk Factors

• Noise Pollution, especially to loud noises - Extended periods of exposure to high amplitude sound waves damage the microscopic hair cells within the ear, thereby triggering tinnitus in turn. Patients working in noisy environments like industrial complexes, the army or even musicians are more prone to this effect. 
• Advance Age. Tinnitus can develop with advancement of age as the bony structures within the ear harden. 
• Gender - Men are more prone to developing tinnitus compared to women. 
• Smoking -  Likely the secondary effect of cigarette smoke advancing up the eustachian tube irritating the inner ear.
• Cardiovascular problems - As explained above, because changes in blood flow can trigger tinnitus, any condition affecting the cardiovascular system can potentially trigger tinnitus. 

Tinnitus - Complications

While tinnitus is most often simply irritating, in severe cases it can disturb rest and sleep and cause a host of other problems including:

• Memory loss
• Stress
• Fatigue
• Insomnia
• Depression
• Concentration loss
• Anxiety and irritability

Tinnitus - Diagnosis of Underlying Problems

Tinnitus is a symptom rather than a standing diagnosis by itself. To diagnose the underlying problems, the following tests may be used:

• Audiology - Sounds at specific pitch and frequency will be played to the patient in a soundproof room. The patient will be asked to indicate whenever they hear a sound. This test will differentiate between sounds that are played and heard, sounds that are played and not heard, and sounds that are heard but not played (tinnitus) 
• Bedside examination - Doctors might ask the patient to move in certain specified manners to help identify underlying disorders presenting as tinnitus. 
• Imaging - CT and MRI scans of the ear and brain can and will assist with the diagnosis for finding the underlying cause of tinnitus. 

Pitch and tone type of sounds experienced by patients can give a clue to the underlying cause for tinnitus. These include:

• Clicking - Often this is due to spasmic muscle contractions in and around the ear. 
• Rushing or Humming - This may be vascular in origin, especially if variations are noted with change of posture. 
• Rhythmic - Rhythmic pulsations and regular beats of tinnitus can be caused by abnormalities with the blood vessels or cardiovascular system. Eg aneurysms, tumours, or hypertension.
• Low-pitched ringing - eg Minere’s Disease, often associated with vertiginous giddiness and dizziness.
• High-pitched ringing - Often associated with prolonged exposure to noise pollution. Special care needs to be taken if the tinnitus is experienced only on one side. 
• Others - Foreign Bodies, ear wax or loose hair irritating the eardrum can all produce awkward and unpredictable sounds in the ear. 

Note: The underlying cause of tinnitus is often difficult to identify and in many cases, the cause may never be found. However, tinnitus can be managed well in many cases in collaboration with your primary physician.


Tinnitus - Management and Prevention

• Hearing Protectors - Use of hearing protectors reduces damage if exposed to loud sounds over prolonged periods of time. 
• Maintaining Good Cardiovascular Health - Preventing cardiovascular diseases reduces tinnitus. 
• Stop Smoking - Cessation of Smoking will reduce tinnitus. 

Remember - Management of Tinnitus involves treating the underlying cause if identifiable, or managing the symptoms thereof if not.

About The Author

Dr Lau Tzun Hon is a resident housecall doctor at CMY Medical. He received his MBBS (Hons) from Sydney University in 2001 and has served in the both private and government restructured hospitals prior to commencing his practice in Home Care.

While in the Government Restructured Hospitals, Dr Lau served primarily in the Department of Accident & Emergency Medicine and Anaesthesia. Upon entering the Private sector, Dr Lau worked in both public and private A&E departments before venturing into Home Care.

Over the years, he has developed a strong passion to maintain and  enhance the quality of life for patients under his care.  A strong believer that healthcare does not need to be financially straining, Dr Lau often delivers more value beyond expectations.