Chris Isles

Renal impairment after high-dose flucloxacillin and single-dose gentamicin prophylaxis in patients undergoing elective hip and knee replacement

BACKGROUNDnFollowing advice from the Scottish Antimicrobial Prescribing Group, we switched our antibiotic prophylaxis for elective hip and knee replacement surgery from cefuroxime to flucloxacillin with single-dose gentamicin in order to reduce the incidence of Clostridium difficile associated diarrhoea (CDAD). A clinical impression that more patients subsequently developed acute kidney injury (AKI) led us to examine this possibility in more detail.nnnMETHODSnWe examined the incidence of AKI in 198 consecutive patients undergoing elective hip or knee surgery. These patients were given the following prophylactic antibiotics: cefuroxime (n = 48); then high-dose (HD) flucloxacillin (5-8 g) with single-dose gentamicin (n = 52); then low-dose (LD) flucloxacillin (3-4 g) with single-dose gentamicin (n = 46) and finally cefuroxime again (n = 52).nnnRESULTSnPatients receiving HD flucloxacillin required more vasopressors during surgery (P = 0.02); otherwise, there were no statistically significant differences in pre- and peri-operative characteristics between the four groups. The proportion of patients with any form of AKI by RIFLE criteria was first cefuroxime (8%), HD flucloxacillin with gentamicin (52%), LD flucloxacillin with gentamicin (22%) and second cefuroxime (14%; P < 0.0001). Odds ratios for AKI derived from a multivariate logistic regression model, adjusted also for sex and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, with the first cefuroxime group as a reference category were: HD flucloxacillin with gentamicin 14.53 (4.25-49.71); LD flucloxacillin with gentamicin 2.96 (0.81-10.81) and second cefuroxime 2.01 (0.52-7.73). Three patients required temporary haemodialysis. Biopsies in two of these showed acute tubulo-interstitial nephritis. All three patients belonged to the HD flucloxacillin with gentamicin group. None of the patients developed CDAD.nnnCONCLUSIONSnWe have shown an association between the prophylactic antibiotic regimen and subsequent development of AKI following primary hip and knee arthroplasty that appeared to be due to the use of HD flucloxacillin with single-dose gentamicin. We found no evidence to suggest that this association was confounded by any of the co-variates we measured.

Should hospitals provide all patients with single rooms

Hugh Pennington argues that having all private rooms would reduce hospital acquired infection and provide privacy, but Chris Isles says many patients seem more worried about being lonely in hospital and should be given the choice of shared rooms

Bilateral renovascular disease causing cardiorenal failure

Consider renovascular disease in patients with cardiorenal failure nnThe association between heart failure and bilateral renovascular disease was first recorded in 1988 and has since been the subject of numerous reports.1–12 Acute or “flash” pulmonary oedema is most commonly described, but chronic heart failure can also occur. Heart failure is thought to arise when the kidneys, “protected” by bilateral stenoses, fail to mount a pressure natriuresis to high arterial pressure. The syndrome is therefore characterised by fluid retention rather than ventricular failure. Clinical clues include the association of cardiac and renal failure with hypertension, widespread vascular disease, inequality of renal size (ue4211.5 cm difference) on ultrasonography, and a reversible increase in serum creatinine concentrations after taking an angiotensin converting enzyme inhibitor.13 A proportion of patients with this clinical syndrome may be cured by renal revascularisation. We report on such a case.nnA 75 year old woman with moderate left ventricular systolic dysfunction after an inferior myocardial infarction required temporary haemodialysis when she became moribund with cardiorenal failure while receiving an angiotensin converting enzyme inhibitor. Blood pressure was 102/58 mm Hg, and she had gross pulmonary and peripheral oedema. Her serum creatinine concentration was 731 µmol/l (reference range 70-120 µmol/l). She had had three less severe episodes of cardiorenal failure in the previous 15 months, each associated with an angiotensin converting enzyme inhibitor (fig 1). On ultrasonography the left kidney measured 7.0 cm and the right kidney 9.5 cm. Arteriography showed occlusion of the …

Visual art in hospitals: case studies and review of the evidence

Summary In 2006 a Department of Health Working Group on Arts and Health reported that the arts have ‘a clear contribution to make and offer major opportunities in the delivery of better health, wellbeing and improved experience for patients, service users and staff alike’. In this review we examine the evidence underpinning this statement and evaluate the visual art of three of Scotlands newest hospitals: the Royal Infirmary of Edinburgh, the new Stobhill Hospital, and the new Victoria Infirmary in Glasgow. We conclude that art in hospitals is generally viewed positively by both patients and staff, but that the quality of the evidence is not uniformly high. Effects may be mediated by psychological responses to colour hue, brightness and saturation. Colours that elicit high levels of pleasure with low levels of arousal are most likely to induce a state of calm, while those causing displeasure and high levels of arousal may provoke anxiety. The fact that patients frequently express a preference for landscape and nature scenes is consistent with this observation and with evolutionary psychological theories which predict positive emotional responses to flourishing natural environments. Contrary to a view which may prevail among some contemporary artists, patients who are ill or stressed about their health may not always be comforted by abstract art, preferring the positive distraction and state of calm created by the blues and greens of landscape and nature scenes instead.

Patient Preferences for Single Rooms or Shared Accommodation in a District General Hospital

Objectives To determine whether patients who have used a Scottish district general hospital would prefer single or shared accommodation on a future admission. Methods We surveyed 80 in-patients in January 2008 in order to obtain 20 medical and 20 surgical patients in single rooms and the same number in shared accommodation. Each patient received a seven point questionnaire that had been validated in another centre. Results Forty four men and 36 women, median 64 years, who had been in hospital for a median of 4.5 days (range 1 to 53 days) participated in the survey. Seventy per cent of patients in shared and 40% of patients in single rooms said they would prefer shared accommodation during a future hospital admission. Those expressing a preference for shared accommodation were older (median age 68 versus 58 years) and had been in hospital for longer (median 5.5 versus 3.5 days) than those who said they would prefer a single room. Conclusions It is likely that the desire for company among older people who have to spend a week or more in hospital is driving the responses we obtained. Our findings do not support claims that the argument in favour of 100% single rooms is ‘overwhelming’.

Comparison of combined urea and creatinine clearance and prediction equations as measures of residual renal function when GFR is low

BACKGROUNDnUK, US and European guidelines recommend the decision to initiate dialysis should be based on a combination of measurements of kidney function, nutritional status and clinical symptoms. Such recommendations assume an accurate and reproducible measure of glomerular filtration rate (GFR).nnnMETHODSnProspective study of 97 patients with chronic kidney disease (CKD) and serum creatinine >200 micromol/l (2.26 mg/dl) who between them contributed 388 24 h urine collections. Our main outcome measure was the number of patients with low residual renal function identified by different tests, using widely accepted thresholds. We calculated sensitivity, specificity, positive and negative predictive values and receiver operating characteristic curves for each comparison using a combined urea and creatinine clearance of <15 ml/min to indicate the likely presence of end stage renal disease (CKD stage 5).nnnRESULTSnSeventy five patients had a combined urea and creatinine clearance <15 ml/min during the study. Using the highest measurement of serum creatinine for each patient, the best of the prediction equations was the 4-variable modification of diet in renal disease (MDRD) equation (area under ROC curve 0.93). This was followed by Kt/V (AUC 0.91) and Cockroft Gault with and without correction for ideal body weight (AUC 0.89). Further analyses showed that the 4-variable MDRD equation had higher NPV (64%) but lower PPV (89%) than the other tests (NPV 40-49%, PPV 92-100%), for identifying patients whose combined clearance was <15 ml/min.nnnCONCLUSIONnThe 4-variable MDRD formula is currently the best available prediction equation for GFR, but will nevertheless over estimate residual renal function when this is significantly impaired in up to 36% cases. Collection of 24 h urine samples may still have a role in the assessment of patients with stages 4 and 5 CKD.

Recovery of renal function after 90 d on dialysis: implications for transplantation in patients with potentially reversible causes of renal failure

Abstract:u2002 Background:u2002 Late recovery of renal function in patients requiring dialysis is a well recognized but uncommon phenomenon. Moves to increase the number of live donor transplants and the recognition that early transplantation is associated with better graft survival means it is possible that patients who are going to recover renal function may be transplanted unnecessarily.

Impact of visual art in patient waiting rooms: survey of patients attending a transplant clinic in Dumfries

Background The clinic waiting area in Dumfries received the highest score among nine units offering transplant follow-up (p < 0.001 for differences between units) in the recent Quality Improvement Scotland Renal Transplant Survey. Design The purpose of the present study was to determine which aspects of the Dumfries waiting area patients considered important to their outpatient experience. Methods We posted a questionnaire to all 44 renal transplant patients attending the Dumfries Renal Unit in October 2009 in which we asked patients to rate seven aspects of their clinic environment on a scale from 1 (not at all important) to 5 (very important). These were, in random order, comfy chairs, magazines and puzzle books, paintings on the wall, a 42-inch plasma screen TV, views from the windows, potted plants and computers with Internet access. Results Thirty-nine (89%) patients responded. The most highly rated feature of our clinic waiting room was the comfy chairs with an average score of 4.4. This was followed by the magazines and puzzle books (3.6), the plasma screen TV (3.6) and the paintings on the walls (3.4). The views from the windows (3.1), the computer (3.0) and the potted plants (2.9) were less highly rated. Respondents expressed a preference for landscapes/nature scenes (84%) and paintings of animals/birds (84%). Fewer wished to look at abstract paintings (27%) or portraits (24%). Conclusion The QIS transplant survey has shown large differences in the quality of the environment of the transplant follow-up clinics in Scotland. Our survey of renal transplant patients attending the Dumfries Renal Unit suggests that the paintings we chose to display in our clinic waiting room contributed positively to their outpatient experience.

Fulminating varicella despite prophylactic immune globulin and intravenous acyclovir in a renal transplant recipient: should renal patients be vaccinated against VZV before transplantation?

Abstract:u2002 We describe a case of fulminating varicella despite prophylactic immune globulin and intravenous acyclovir in a renal transplant recipient. This promoted a survey of all 383 adult patients awaiting a renal transplant in Scotland, which showed a low level of Varicella zoster virus (VZV) awareness but a willingness to consider vaccination if non immune. 359/363 serum samples tested were seropositive for VZV antibody giving a susceptibility to VZV of 1.2%. Although data on vaccination in adults with chronic kidney disease are limited, expert opinion is of the view that the benefits of vaccinating immunocompetent seronegative patients before transplantation are likely to outweigh the risks. We believe that adult patients awaiting a transplant in the UK should be tested for their susceptibility to VZV and that early vaccination should be offered to those who are both immunocompetent and seronegative.

Emergency medical admissions, deaths at weekends and the public holiday effect. Cohort study

Objectives To assess whether mortality of patients admitted on weekends and public holidays was higher in a district general hospital whose consultants are present more than 6u2005h per day on the acute medical unit with no other fixed clinical commitments. Design Cohort study. Setting Secondary care. Participants All emergency medical admissions to Dumfries and Galloway Royal Infirmary between 1 January 2008 and 31 December 2010. Methods We examined 7 and 30u2005day mortality for all weekend and for all public holiday admissions, using all weekday and non-public holiday admissions, respectively, as comparators. We adjusted mortality for age, gender, comorbidity, deprivation, diagnosis and year of admission. Results 771 (3.8%) of 20u2005072 emergency admissions died within 7u2005days of admission and 1780 (8.9%) within 30u2005days. Adjusted weekend mortality in the all weekend versus all other days analysis was not significantly higher at 7u2005days (OR 1.10, 95% CI 0.92 to 1.31; p=0.312) or at 30u2005days (OR 1.07, 95% CI 0.94 to 1.21; p=0.322). By contrast, adjusted public holiday mortality in the all public holidays versus all other days analysis was 48% higher at 7u2005days (OR 1.48, 95% CI 1.12 to 1.95; p=0.006) and 27% higher at 30u2005days (OR 1.27, 95% CI 1.02 to 1.57; p=0.031). Interactions between the weekend variable and the public holiday variable were not statistically significant for mortality at either 7 or 30u2005days. Conclusions Patients admitted as emergencies to medicine on public holidays had significantly higher mortality at 7 and 30u2005days compared with patients admitted on other days of the week.