Catherine Wall

A COMPARATIVE ANALYSIS OF PERCUTANEOUS AND OPEN SURGICAL TECHNIQUES FOR PERITONEAL CATHETER PLACEMENT

♦ Background: Peritoneal dialysis (PD) is the preferred available option of renal replacement therapy for a significant number of end-stage kidney disease patients. A major limiting factor to the successful continuation of PD is the long-term viability of the PD catheter (PDC). Bedside percutaneous placement of the PDC is not commonly practiced despite published data encouraging use of this technique. Its advantages include faster recovery and avoidance of general anesthesia. ♦ Methods: We carried out a retrospective analysis of the outcomes of 313 PDC insertions at our center, comparing all percutaneous PDC insertions between July 1998 and April 2010 (group P, n = 151) with all surgical PDC insertions between January 2003 and April 2010 (group S, n = 162). ♦ Results: Compared with group P patients, significantly more group S patients had undergone previous abdominal surgery or PDC insertion (41.8% vs 9.3% and 33.3% vs 3.3% respectively, p = 0.00). More exit-site leaks occurred in group P than in group S (20.5% vs 6.8%, p = 0.002). The overall incidence of peritonitis was higher in group S than in group P (1 episode in 19 catheter-months vs 1 episode in 26 catheter-months, p = 0.017), but the groups showed no significant difference in the peritonitis rate within 1 month of catheter insertion (5% in group P vs 7.4% in group S, p = 0.4) or in poor initial drainage or secondary drainage failure (9.9% vs 11.7%, p = 0.1, and 7.9% vs 12.3%, p = 0.38, for groups P and S respectively).Technical survival at 3 months was significantly better for group P than for group S (86.6% vs 77%, p = 0.037); at 12 months, it was 77.7% and 68.7% respectively (p = 0.126). No life-threatening complications attributable to the insertion of the PDC occurred in either group. ♦ Conclusions: Our analysis demonstrates further encouraging outcomes of percutaneous PDC placement compared with open surgical placement. However, the members of the percutaneous insertion group were primarily a selected subset of patients without prior abdominal surgery or PDC insertion, therefore limiting the comparability of the groups. Studies addressing such confounding factors are required. Local expertise in catheter placement techniques may affect the generalizability of results.

Collaborative pharmaceutical care in an Irish hospital: uncontrolled before-after study

Background We investigated the benefits of the Collaborative Pharmaceutical Care in Tallaght Hospital (PACT) service versus standard ward-based clinical pharmacy in adult inpatients receiving acute medical care, particularly on prevalence of medication error and quality of prescribing. Methods Uncontrolled before-after study, undertaken in consecutive adult medical inpatients admitted and discharged alive, using at least three medications. Standard care involved clinical pharmacists being ward-based, contributing to medication history taking and prescription review, but not involved at discharge. The innovative PACT intervention involved clinical pharmacists being team-based, leading admission and discharge medication reconciliation and undertaking prescription review. Primary outcome measures were prevalence per patient of medication error and potentially severe error. Secondary measures included quality of prescribing using the Medication Appropriateness Index (MAI) in patients aged ≥65 years. Findings Some 233 patients (112 PACT, 121 standard) were included. PACT decreased the prevalence of any medication error at discharge (adjusted OR 0.07 (95% CI 0.03 to 0.15)); number needed to treat (NNT) 3 (95% CI 2 to 3) and no PACT patient experienced a potentially severe error (NNT 20, 95% CI 10 to 142). In patients aged ≥65 years (n=108), PACT improved the MAI score from preadmission to discharge (Mann–Whitney U p<0.05; PACT median −1, IQR −3.75 to 0; standard care median +1, IQR −1 to +6). Conclusions PACT, a collaborative model of pharmaceutical care involving medication reconciliation and review, delivered by clinical pharmacists and physicians, at admission, during inpatient care and at discharge was protective against potentially severe medication errors in acute medical patients and improved the quality of prescribing in older patients.

Colchicine toxicity in renal patients - Are we paying attention?

Colchicine is an approved agent in the management and prophylaxis of gout and familial Mediterranean fever but its therapeutic value is limited by its narrow therapeutic index. Multisystem toxicity is uncommonly reported; and is often associated with renal impairment and/or specific drug interactions. We report two cases of colchicine toxicity marked by severe neuromyopathy in a diabetic with stage 4 chronic kidney disease (CKD) and a renal transplant recipient. Both patients presented with diarrhea, acute on chronic kidney injury and progressive muscle weakness while on colchicine for several weeks or longer. In addition to kidney disease, risk factors for colchicine toxicity included maintenance therapy with simvastatin in the first patient and cyclosporine in the second. Creatine phosphokinase (CPK) was elevated in both cases at presentation and neurophysiologic studies showed a pattern of severe myopathy with axonal sensorimotor neuropathy. The first patient recovered from neurological weakness in a few weeks, but the second patient suffered an extraordinarily protracted and severe neuromuscular disability for a year. The two cases reinforce the need for extra vigilance in prescribing and monitoring colchicine therapy in renal patients with specific attention to drug interactions known to increase the risk of toxicity, thus avoiding such combinations in patients with renal impairment.

Impact of the Collaborative Pharmaceutical Care at Tallaght Hospital (PACT) model on medication appropriateness of older patients

Objectives A high prevalence of potentially inappropriate prescribing (PIP) has been identified in older patients in Ireland. The impact of the Collaborative Pharmaceutical Care at Tallaght Hospital (PACT) model on the medication appropriateness of acute hospitalised older patients during admission and at discharge is reported. Methods Uncontrolled before-after study. The study population for this study was medical patients aged ≥65 years, using ≥3 regular medicines at admission, taken from a previous before-after study. Standard care involved clinical pharmacists being ward-based, contributing to medication history taking and prescription review, but not involved at discharge. The innovative PACT model involved clinical pharmacists being physician team-based, leading admission and discharge medication reconciliation and undertaking prescription review, with authority to change the prescription during admission or at discharge. The primary outcome was the Medication Appropriateness Index (MAI) score applied pre-admission, during admission and at discharge. Results Some 108 patients were included (48 PACT, 60 standard). PACT significantly improved the MAI score from pre-admission to admission (mean difference 2.4, 95% CI 1.0 to 3.9, p<0.005), and from pre-admission to discharge (mean difference 4.0, 95 CI 1.7 to 6.4, p<0.005). PACT resulted in significantly fewer drugs with one or more inappropriate rating at discharge (PACT 15.0%, standard 30.5%, p<0.001). The MAI criteria responsible for most inappropriate ratings were ‘correct directions’ (4.8% PACT, 17.3% standard), expense (5.3% PACT, 5.7% standard) and dosage (0.6% PACT, 4.0% standard). PACT suggestions to optimise medication use were accepted more frequently, and earlier in the hospital episode, than standard care (96.7% PACT, 69.3% standard, p<0.05). Conclusions Collaborative pharmaceutical care between physicians and pharmacists from admission to discharge, with authority for pharmacists to amend the prescription, improves medication appropriateness in older hospitalised Irish patients.

COMPARISON OF PERCUTANEOUS AND OPEN SURGICAL TECHNIQUES FOR FIRST-TIME PERITONEAL DIALYSIS CATHETER PLACEMENT IN THE UNBREACHED PERITONEUM

♦ Background: The percutaneous Seldinger method of peritoneal dialysis catheter (PDC) insertion has gained favor over recent years whereas traditionally it was reserved for patients considered not fit for general anesthesia. This blind technique is believed to be less safe, and is hence avoided in patients with previous laparotomy incisions. Reports on the success of this method may therefore be criticized for selection bias. In those with no prior abdominal surgery the optimal method of insertion has not been established. ♦ Methods: We retrospectively reviewed the outcomes of first-time PDC placements comparing the percutaneous (group P) and surgical (group S) insertion techniques in patients without a history of previous abdominal surgery in a single center between January 2003 and June 2010. We assessed catheter survival at 3 and 12 months post-insertion and compared complication rates between the two groups. ♦ Results: A total of 63 percutaneous and 64 surgical catheter insertions were analyzed. No significant difference was noted in catheter survival rates between group P and group S (86.2% vs 80% at 3 months, p = 0.37; and 78.3% vs 71.2% at 12 months, p = 0.42 respectively). Early and overall peritonitis rates were similar (5% vs 5.3%; p = 1, and 3.5 vs 4.9 episodes per 100 patient-months; p = 0.13 for group P and group S respectively). There were also no significant differences between the two groups in exit site leaks (15.9% in group P vs 6.3% in group S; p = 0.15), poor initial drainage (9.5% in group P vs 10.9% in group S, p = 0.34) or secondary drainage failure (7.9% in group P vs 18.8% in group S, p = 0.09). ♦ Conclusion: This study illustrates the success and safety of percutaneous PDC insertion compared with the open surgical technique in PD naive patients without a history of prior abdominal surgery. Catheter survival was favorable with percutaneous insertion in this low-risk patient population but larger prospective studies may help to determine whether either method is superior. The percutaneous technique can be recommended as a minimally invasive, cost-effective procedure that facilitates implementing an integrated care model in nephrology practice.

Nurofen Plus toxicity—what should nephrologists be alert to? Rare complications of an increasingly misused medication

We report the staggered clinical course of a young Caucasian female who suffered rare deleterious effects of Nurofen Plus misuse with a near fatal outcome. Several life-threatening events intervened before the underlying problem of serious dependency was identified. Effects on renal tubular acidification and bone marrow function as well as the commoner complications of acute kidney injury and peptic ulceration are described. In addition, this is the first case report in which the syndrome of reversible posterior leucoencephalopathy is linked to analgesic misuse, occurring after recovery of renal function. Recommendations for restricting availability of codeine-based analgesics are made.

Renal patients at end of life: A 5-year retrospective review

Context: Patients with end-stage renal disease (ESRD) have a life-limiting illness associated with significant morbidity. The ‘tipping point’ where increased medical and supportive care is needed urgently can be missed. It cannot be assumed that specialist palliative care (SPC) services which evolved to care for patients with cancer will also be right for patients with different diagnoses. Objectives: To review retrospectively the end-of-life care of patients receiving renal replacement therapy (RRT) from our institution. Methods: We conducted a single-centre retrospective cohort study. We reviewed medical charts and electronic records to record patient characteristics, mode of dialysis, place of death and the time spent in hospital. Results: One hundred and sixty-one patients were included in our study. The mean age at death was 63 years and 68% were male. In their last year of life, patients spent a median of 53 days as inpatients with a median of three admissions. The haemodialysis cohort spent a median of 59 inpatient days in their last year of life, excluding day case attendances. One hundred and twenty-two (76%) patients died in hospital, 103 of those in our institution. Twenty-seven (17%) patients died at home while four (2%) died in an inpatient hospice unit. Preference for place of care was documented for 33 (20%) patients. Overall, 56 (35%) patients were referred to SPC. Conclusion: End-of-life planning should be a more regular goal in all patients on RRT. Given the frequency of hospital attendance, opportunities should be grasped to make advance plans to facilitate patients’ wishes.

Comment on: Pharmacy-led medication reconciliation programmes at hospital transitions: a systematic review and meta-analysis

To the editor: Medication reconciliation is a resource-intensive process, and it is important to discern the most effective and efficient interventions to optimize patient safety at care transitions. Dr. Mekonnen and colleagues recently undertook a systematic review investigating the impact of pharmacy-led medication reconciliation programmes at care transitions on the prevalence of medication discrepancy. They sought to categorize interventions by the transition(s) they focussed on, to learn whether pharmacist-led medication reconciliation interventions delivered at a single transition (admission or discharge) were more effective than those delivered across multiple (two or more) transitions. Our recent study published in BMJ Quality and Safety was included in the meta-analysis. The intervention was complex, involving collaborative pharmaceutical care between doctors and pharmacists throughout the inpatient hospital episode. The target of the intervention was multiple transitions: admission and discharge. Our primary outcome measured discharge medication error, although we also reported admission medication error to illustrate the intervention’s impact at iterative stages of care. We consider it a single complex intervention delivered across the full inpatient journey, rather than discrete interventions at admission and discharge. Patients were followed longitudinally from admission to discharge, and therefore, it is the same cohort of patients, and not independent groups of patients, included at both care transitions. As with many complex interventions, it is difficult to identify whether the observed effect is attributable to any single intervention component, as distinct from the composite. Our belief is that admission medication reconciliation could not but have impacted on the likelihood of medication being

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A 55-year-old man presented with a 2-month history of blisters affecting his hands. His history was significant for treated multiple myeloma with residual monoclonal gammopathy of undetermined significance, and end stage renal disease on automated peritoneal dialysis. Medications included aspirin, clopidogrel, warfarin, pregabalin, bronchodilators and hydrocortisone. Examination showed widespread scarring on the dorsum of the hands with multiple …

An atypical pleural effusion

A 51-year-old male presented with increasing dyspnoea, pleuritic chest pain and pain in the right shoulder tip. Clinical examination revealed stony dull percussion and absent breath sounds on the right mid and lower zones of the chest. He had no clinical evidence of heart failure or systemic volume overload, the main differential diagnoses in this case. His background …