A Practice Change to Eliminate Prophylactic Antibiotics for Elective Percutaneous Nephrostomy Tube Exchanges in Low-Risk Outpatients: A Retrospective Review on Risk for Infection

The purpose of this project was to determine if evidence-based practice change related to antibiotic administration criteria for outpatients receiving percutaneous nephrostomy tube exchanges implemented by a medical center's Vascular and Interventional Radiology department impacted hospital admission rates for infection in these patients. The 2017 practice change was based on 2010 guidelines from the Society of Interventional Radiology (SIR), stating that outpatients with a low risk of acquiring infection did not need to receive a perioperative antibiotic, as evidence has shown prophylactic therapy has no significant effect on infection rates for this population. Using a retrospective review design, 1 year of data before and after the practice change were collected and analyzed using the repeated measures generalized estimating equation (GEE) model with a binomial output by Liang & Zeger. Fisher's exact test was used to evaluate demographic variables by level of risk of infection. Data included 493 procedural events for 126 outpatients. The mean number of events per patient was 3.91 (SD: 4.15; median: 2; interquartile range: 3). Admission and infection criteria within thirty days of the event and infection risk factors were collected for each patient. Age, sex, and race were the variables that had a significant relationship with risk level of infection. Due to sample size, the GEE model could not be run using risk level (high/low) to predict admissions before or after the practice change. The relationship between the number of risk factors (0-5) and the odds of admission for infection was the same regardless of the practice change (before: odds ratio [OR] = 2.17, 95% confidence interval [CI] = 1.19-3.95; after: OR = 1.9, 95% CI = 1.12-3.22, p_interaction = .67). For every increase in a patient's number of risk factors, the odds of developing an infection would be expected to increase by almost 90% (OR = 1.9, 95% CI = 1.27-2.84). Although it was not possible to determine efficacy of the practice change, the predictive analysis indicated that risk level is a significant predictor of admission for infection regardless of antibiotic therapy. The results suggest that demographic indicators should be considered when determining appropriate therapies for this procedure; however, research studies should evaluate this relationship with larger samples to design specific recommendations. Our project results support the 2010 SIR antibiotic prophylaxis guidelines and their more recently updated antibiotic parameter guidelines from 2018.     

A comparison of the asthmatic response to methacholine and exercise

The airway responses to methacholine and to exercise challenges were compared in 45 young adults with asthma. The spirometric response to five minutes of treadmill exercise was first documented. On a separate day methacholine dose-response relationships were determined. All asthmatics had an abnormal response to methacholine, and 36 had an abnormal response to exercise. Methacholine sensitivity and exercise-induced asthma were significantly related (r = 0.69, p < 0.001), but the relationship was nonlinear; the increased response to exercise related to the logarithm of the methacholine response. Between asthmatics with generally unreactive airways, small variation in methacholine sensitivity was associated with large variations in the severity of exercise-induced asthma; between more responsive asthmatics, there was a smaller effect. It is suggested that exercise-induced asthma is dependent on two factors: a stimulus generated during exercise and a response from abnormal bronchi. The bronchial response may be a limiting factor in asthmatics with less responsive airways.     

Rupture of postcoarctation mycotic aneurysms of the aorta.

Sudden and usually fatal rupture is a common complication of postcoarctation mycotic aneurysms. Prompt operative treatment is always indicated, and can be performed using one of three techniques depending on the adequacy of the collateral circulation and the presence or absence of active bacterial infection. Renal dysfunction commonly is associated with bacterial endarteritis and is secondary to an immune-complex glomerulonephritis. The patient reported here was treated successfully by the placement of an emergency axillofemoral bypass graft, removal of the infected portion of the descending thoracic aorta, and delayed intrathoracic reconstruction.     

Pancreaticoduodenectomy in the treatment of congenital fibrosarcoma of the duodenum.

A 2-mo-old female with congenital fibrosarcoma causing duodenal obstruction had a pancreaticoduodenectomy. She is doing well with the aid of oral pancreatic enzyme supplements 14 mo after her pancreaticoduodenectomy with no evidence of tumor recurrence or pancreatic endocrine dysfunction.     

Global appropriateness of pain drawings: Blind ratings predict patterns of psychological distress and litigation status

Previous studies examining pain drawings of low back pain patients have shown conflicting results in predicting elevations of MMPI scores. A study of 82 patients whose drawings were rated only for overall, anatomical appropriateness was conducted using the SCL-90 rather than the MMPI as the psychological assessment instrument. Significant differences were found between appropriate and inappropriate drawings; however, these differences seem to reflect differences in cognitive style of coping with pain as opposed to psychopathology. The implications and limitations of the study are discussed.