Antibiotic prophylaxis with urodynamic studies in spinal cord injury: Assessing practice patterns and outcomes to guide future practice in a single center

Despite urinary tract infections (UTIs) being a common problem in patients with spinal cord injuries (SCIs), and a well-known complication of invasive urologic procedures, little consensus exists regarding the standard of care for peri-procedural antibiotic use for SCI patients undergoing urodynamics studies (UDS). Our research seeks to evaluate local antibiotic prophylaxis pattern in SCI patients undergoing UDS, assess incidence of post-procedural UTI, describe local antibiotic resistance trends, and provide antibiotic stewardship considerations to guide future practice. Retrospective cohort study of SCI patients undergoing UDS from January 2010 to January 2020 at a Veterans Affairs SCI Center. Data on patient demographics, UTI risk factors, pre-procedural urinalysis and culture, and peri-procedural antibiotics was extracted. Incidence of post-procedural UTI was tabulated. Findings were summarized using descriptive statistics. 331 patients were studied. Pre-procedural urine culture was done in 73% of cases, with positive results in 49%. E. coli was the most commonly isolated organism (19%). Antibiotics were used in 86% of cases, 26% of which had a negative culture. A onetime dose of intramuscular gentamicin given immediately pre-procedure was the most common practice (53%; N = 152). No cases of post-procedural UTIs were identified during the study period. No post-UDS UTIs occurred under current local practice where most patients received a one-time dose of intramuscular gentamicin as prophylaxis. Though routine gentamicin prophylaxis may play a role in reducing UTI incidence, the low rate of post-UDS UTI in this population, including patients with positive cultures who received no antibiotics, suggests the possibility of refining practice patterns to improve antibiotic stewardship.</p

Image_1_Specialized intensive inpatient rehabilitation is crucial and time-sensitive for functional recovery from disorders of consciousness.TIF

BackgroundDisorders of consciousness (DoCs) after severe brain injury are considered to be conditions with dire prognosis. Despite the accumulating evidence, inpatient rehabilitation is often denied by payers referring to the Medicare/Medicaid criteria, under the assumption that such patients will not “actively” participate in therapy or make “measurable improvements.”ObjectiveThis study aimed to report on the effectiveness and efficiency of a specialized inpatient DoC rehabilitation program based on measurable clinical parameters.MethodsA retrospective cohort study was conducted. The cohort comprised 137 patients with DoC admitted to a specialized acute inpatient rehabilitation program between January 2014 and October 2018. Patients were categorized as having been admitted at the acute stage (365 days following a TBI or >90 days following a non-TBI). Outcomes included changes in level of consciousness (based on the Coma Recovery Scale–Revised (CRS-R), while also acknowledging scenarios beyond those captured by the CRS-R via Individualized Qualitative Behavioral Assessment and team consensus); Functional Independence Measure (FIM) levels; achievements in decannulation and initiation of oral diet; and time to those achievements.ResultsThe rates of emergence from a minimally conscious state were 90, 62, and 18% among patients admitted at the acute, subacute, and chronic stages, respectively. Among patients who emerged, 100, 85, and 67%, respectively, had measurable FIM scores. Approximately 60 and 20% of patients at the acute and subacute stages, respectively, required moderate assistance or less in transfer/communication/eating/grooming/upper body dressing by the time of discharge from Phase I admission. The decannulation rates were 94, 67, and 17%. The oral diet initiation rates were 70, 23, and 6%. The time to reach these achievements lengthened as chronicity increased. There was a weak positive correlation (rs = 0.308) in the case of decannulation and a strong positive correlation (rs = 0.606, both p ConclusionSpecialized intensive inpatient rehabilitation is crucial and time-sensitive for functional recovery from DoC caused by TBI and hypoxic–ischemic brain injury. Specific goals and different outcome measures need to be developed to appraise the benefits of acute inpatient rehabilitation for DoC.</p

Table_3_The Age-Related Perfusion Pattern Measured With Arterial Spin Labeling MRI in Healthy Subjects.DOCX

Aim: To analyze age-related cerebral blood flow (CBF) using arterial spin labeling (ASL) MRI in healthy subjects with multivariate principal component analysis (PCA).Methods: 50 healthy subjects (mean age 45.8 ± 18.5 years, range 21–85) had 3D structural MRI and pseudo-continuous ASL MRI at resting state. The relationship between CBF and age was examined with voxel-based univariate analysis using multiple regression and two-sample t-test (median age 41.8 years as a cut-off). An age-related CBF pattern was identified using multivariate PCA.Results: Age correlated negatively with CBF especially anteriorly and in the cerebellum. After adjusting by global value, CBF was relatively decreased with aging in certain regions and relatively increased in others. The age-related CBF pattern showed relative reductions in frontal and parietal areas and cerebellum, and covarying increases in temporal and occipital areas. Subject scores of this pattern correlated negatively with age (R2 = 0.588; P Conclusion: A distinct age-related CBF pattern can be identified with multivariate PCA using ASL MRI.</p

Image_3_The Age-Related Perfusion Pattern Measured With Arterial Spin Labeling MRI in Healthy Subjects.PDF

Aim: To analyze age-related cerebral blood flow (CBF) using arterial spin labeling (ASL) MRI in healthy subjects with multivariate principal component analysis (PCA).Methods: 50 healthy subjects (mean age 45.8 ± 18.5 years, range 21–85) had 3D structural MRI and pseudo-continuous ASL MRI at resting state. The relationship between CBF and age was examined with voxel-based univariate analysis using multiple regression and two-sample t-test (median age 41.8 years as a cut-off). An age-related CBF pattern was identified using multivariate PCA.Results: Age correlated negatively with CBF especially anteriorly and in the cerebellum. After adjusting by global value, CBF was relatively decreased with aging in certain regions and relatively increased in others. The age-related CBF pattern showed relative reductions in frontal and parietal areas and cerebellum, and covarying increases in temporal and occipital areas. Subject scores of this pattern correlated negatively with age (R2 = 0.588; P Conclusion: A distinct age-related CBF pattern can be identified with multivariate PCA using ASL MRI.</p

Table_1_The Age-Related Perfusion Pattern Measured With Arterial Spin Labeling MRI in Healthy Subjects.DOCX

<p>Aim: To analyze age-related cerebral blood flow (CBF) using arterial spin labeling (ASL) MRI in healthy subjects with multivariate principal component analysis (PCA).</p><p>Methods: 50 healthy subjects (mean age 45.8 ± 18.5 years, range 21–85) had 3D structural MRI and pseudo-continuous ASL MRI at resting state. The relationship between CBF and age was examined with voxel-based univariate analysis using multiple regression and two-sample t-test (median age 41.8 years as a cut-off). An age-related CBF pattern was identified using multivariate PCA.</p><p>Results: Age correlated negatively with CBF especially anteriorly and in the cerebellum. After adjusting by global value, CBF was relatively decreased with aging in certain regions and relatively increased in others. The age-related CBF pattern showed relative reductions in frontal and parietal areas and cerebellum, and covarying increases in temporal and occipital areas. Subject scores of this pattern correlated negatively with age (R² = 0.588; P < 0.001) and discriminated between the older and younger subgroups (P < 0.001).</p><p>Conclusion: A distinct age-related CBF pattern can be identified with multivariate PCA using ASL MRI.</p

Table_2_The Age-Related Perfusion Pattern Measured With Arterial Spin Labeling MRI in Healthy Subjects.DOCX

<p>Aim: To analyze age-related cerebral blood flow (CBF) using arterial spin labeling (ASL) MRI in healthy subjects with multivariate principal component analysis (PCA).</p><p>Methods: 50 healthy subjects (mean age 45.8 ± 18.5 years, range 21–85) had 3D structural MRI and pseudo-continuous ASL MRI at resting state. The relationship between CBF and age was examined with voxel-based univariate analysis using multiple regression and two-sample t-test (median age 41.8 years as a cut-off). An age-related CBF pattern was identified using multivariate PCA.</p><p>Results: Age correlated negatively with CBF especially anteriorly and in the cerebellum. After adjusting by global value, CBF was relatively decreased with aging in certain regions and relatively increased in others. The age-related CBF pattern showed relative reductions in frontal and parietal areas and cerebellum, and covarying increases in temporal and occipital areas. Subject scores of this pattern correlated negatively with age (R² = 0.588; P < 0.001) and discriminated between the older and younger subgroups (P < 0.001).</p><p>Conclusion: A distinct age-related CBF pattern can be identified with multivariate PCA using ASL MRI.</p

Image_1_The Age-Related Perfusion Pattern Measured With Arterial Spin Labeling MRI in Healthy Subjects.PDF

<p>Aim: To analyze age-related cerebral blood flow (CBF) using arterial spin labeling (ASL) MRI in healthy subjects with multivariate principal component analysis (PCA).</p><p>Methods: 50 healthy subjects (mean age 45.8 ± 18.5 years, range 21–85) had 3D structural MRI and pseudo-continuous ASL MRI at resting state. The relationship between CBF and age was examined with voxel-based univariate analysis using multiple regression and two-sample t-test (median age 41.8 years as a cut-off). An age-related CBF pattern was identified using multivariate PCA.</p><p>Results: Age correlated negatively with CBF especially anteriorly and in the cerebellum. After adjusting by global value, CBF was relatively decreased with aging in certain regions and relatively increased in others. The age-related CBF pattern showed relative reductions in frontal and parietal areas and cerebellum, and covarying increases in temporal and occipital areas. Subject scores of this pattern correlated negatively with age (R² = 0.588; P < 0.001) and discriminated between the older and younger subgroups (P < 0.001).</p><p>Conclusion: A distinct age-related CBF pattern can be identified with multivariate PCA using ASL MRI.</p

Image_2_The Age-Related Perfusion Pattern Measured With Arterial Spin Labeling MRI in Healthy Subjects.PDF

<p>Aim: To analyze age-related cerebral blood flow (CBF) using arterial spin labeling (ASL) MRI in healthy subjects with multivariate principal component analysis (PCA).</p><p>Methods: 50 healthy subjects (mean age 45.8 ± 18.5 years, range 21–85) had 3D structural MRI and pseudo-continuous ASL MRI at resting state. The relationship between CBF and age was examined with voxel-based univariate analysis using multiple regression and two-sample t-test (median age 41.8 years as a cut-off). An age-related CBF pattern was identified using multivariate PCA.</p><p>Results: Age correlated negatively with CBF especially anteriorly and in the cerebellum. After adjusting by global value, CBF was relatively decreased with aging in certain regions and relatively increased in others. The age-related CBF pattern showed relative reductions in frontal and parietal areas and cerebellum, and covarying increases in temporal and occipital areas. Subject scores of this pattern correlated negatively with age (R² = 0.588; P < 0.001) and discriminated between the older and younger subgroups (P < 0.001).</p><p>Conclusion: A distinct age-related CBF pattern can be identified with multivariate PCA using ASL MRI.</p

Image_4_The Age-Related Perfusion Pattern Measured With Arterial Spin Labeling MRI in Healthy Subjects.PDF

<p>Aim: To analyze age-related cerebral blood flow (CBF) using arterial spin labeling (ASL) MRI in healthy subjects with multivariate principal component analysis (PCA).</p><p>Methods: 50 healthy subjects (mean age 45.8 ± 18.5 years, range 21–85) had 3D structural MRI and pseudo-continuous ASL MRI at resting state. The relationship between CBF and age was examined with voxel-based univariate analysis using multiple regression and two-sample t-test (median age 41.8 years as a cut-off). An age-related CBF pattern was identified using multivariate PCA.</p><p>Results: Age correlated negatively with CBF especially anteriorly and in the cerebellum. After adjusting by global value, CBF was relatively decreased with aging in certain regions and relatively increased in others. The age-related CBF pattern showed relative reductions in frontal and parietal areas and cerebellum, and covarying increases in temporal and occipital areas. Subject scores of this pattern correlated negatively with age (R² = 0.588; P < 0.001) and discriminated between the older and younger subgroups (P < 0.001).</p><p>Conclusion: A distinct age-related CBF pattern can be identified with multivariate PCA using ASL MRI.</p