Factors associated with ciprofloxacin-resistant Escherichia coli urinary tract infections in discharged ED patients.

BACKGROUND: We sought to identify factors associated with Escherichia coli resistance to ciprofloxacin among discharged emergency department (ED) patient visits treated for a urinary tract infection (UTI). We hypothesized that specific historical factors available upon ED presentation would be associated with increased odds of ciprofloxacin resistance in this population. METHODS: We conducted a retrospective, observational cohort study of consecutive discharged adult ED patient visits with a primary diagnosis of UTI caused by E coli to a single center from 2011 to 2014. Two investigators separately abstracted to a preconstructed data collection form the following independent variables on each included visit: patient age, sex, residence, active immunosuppressive condition or medication, chronic indwelling Foley catheter, hospitalization or antibiotic use within 90 days prior to presentation, and history of recurrent UTIs. We used multivariable logistic regression after taking into account colinearity to identify those independent variables associated with increased odds of ciprofloxacin resistance and report descriptive characteristics of the study cohort, odds ratios (ORs) with 95% confidence interval (CI) and model strength. RESULTS: Age at least 65 years (OR, 3.15; 95% CI, 1.44-6.87; P=.004), recurrent UTI (OR, 6.23; 95% CI, 2.38-16.30; P<.001), and recent hospitalization (OR, 3.99; 95% CI, 1.56-10.23; P=.004) were significantly associated with ciprofloxacin-resistant E coli UTIs in relevant visits. CONCLUSION: In this single-center study, age at least 65 years, recurrent UTI, and recent hospitalization were most clearly associated with increased odds of ciprofloxacin-resistant UTIs in discharged adult ED patient visits. If validated, these factors should suggest that alternative antimicrobial agents should be considered in the treatment of this condition among discharged adult ED patients.

Pharmacist addition to the post-ED visit review of discharge antimicrobial regimens.

OBJECTIVE: Our objective was to evaluate whether pharmacist addition to the postvisit review of discharged adult emergency department (ED) visits' prescriptions/cultures would reduce the prevalence of revised antimicrobial regimen inappropriateness. METHODS: We conducted a retrospective observational study of discharged adult ED visits to a single center with positive cultures requiring antimicrobial regimen revision (May 1 to October 31, 2012, nurse process; February 1 to July 31, 2013, nurse/pharmacist process). Investigators abstracted cohorts' medical records for demographic, ED diagnosis, original/revised antibiotic regimen, culture result, medical history, medications, and patient instruction data and determined whether the revised regimen was inappropriate based on Infectious Diseases Society of America/Centers for Disease Control and Prevention and clinical guidelines. We used the large sample z-test to compare the prevalence of revised antimicrobial regimen inappropriateness between the 2 cohorts. RESULTS: In the prepharmacist cohort, there were 411 positive ED discharge cultures. Seventy-three (17.8%; 95% confidence interval [CI], 14.1%-21.5%) required antimicrobial regimen revision; 34 of these met 1 or more level of inappropriateness (46.6%; 95% CI, 35.1%-58.0%). In the postpharmacist cohort, there were 459 positive ED discharge cultures. Seventy-five (16.3%; 95% CI, 13.0%-19.7%) required revision; 11 of these met 1 or more level of inappropriateness (14.7%; 95% CI, 6.7%-22.7%; z = 4.2; P < .0001 for comparison). CONCLUSION: In this single-center study, pharmacist addition to the postvisit review of discharged adult ED patients' prescriptions/cultures reduced the prevalence of revised antimicrobial regimen inappropriateness.

Biomechanical evaluation of the docking plus ulnar collateral ligament reconstruction technique compared with the docking technique.

BACKGROUND: Surgical techniques for ulnar collateral ligament (UCL) reconstruction have evolved since first described by Jobe. A modified reconstruction technique has been developed, called the docking plus technique, and the authors biomechanically compared it to the commonly performed docking technique. HYPOTHESIS: The docking plus technique for UCL reconstruction will demonstrate greater ligament stiffness than the docking technique. STUDY DESIGN: Controlled laboratory study. METHODS: Ten matched pairs of human cadaveric specimens (mean age ± SD, 52 ± 6 years) were loaded to failure at an elbow flexion angle of 30° at a compressive rate of 14 mm/s. The specimens underwent reconstruction with an autologous graft using the docking plus or docking technique. The reconstructed and native specimens were loaded to failure at the same parameters. RESULTS: The most common mode of failure in the native UCL was midsubstance rupture and avulsion from the ulnar ligament insertion, while the docking plus group failed by suture rupture and the docking group by suture pullout and midsubstance rupture. The mean ± SD stiffness of the native UCL was 21.0 ± 9.0 N/mm, docking plus technique was 11.2 ± 6.6 N/mm, and docking technique was 5.3 ± 1.5 N/mm. The mean stiffness of the docking plus reconstruction was statistically greater (P = .004) than that of the docking technique. The mean ± SD ultimate moment for the native UCL was 35.0 ± 14.0 N·m, docking plus technique was 20.6 ± 7.3 N·m, and docking technique was 8.6 ± 5.1 N·m. The moment across the elbow joint at failure of the docking plus reconstruction was statistically greater (P = .002) than that of the docking technique. CONCLUSION: The docking plus technique reproduces greater ligament stiffness and demonstrates a higher failure moment immediately after reconstruction than does the docking technique. CLINICAL RELEVANCE: The docking plus technique allows greater stiffness and a higher moment to failure immediately after reconstruction and describes a way to maintain constant graft tension during fixation, resulting in a biomechanically stronger UCL reconstruction.

Postnatal growth of the clavicle: birth to 18 years of age.

BACKGROUND: The purpose of our study was to perform a large cross-sectional study aimed at determining the postnatal growth pattern of the clavicle from birth to 18 years of age. METHODS: We analyzed the digital chest radiographs of a convenience sample of 961 individuals between birth and 18 years of age. Malrotated radiographs were excluded. Right and left clavicle lengths were measured in millimeters from the most lateral ossified border to the most medial ossified border of each clavicle. Study patients were divided into 19 subgroups with the first group being labeled as "birth to 11 months of age" followed by 1-year-olds, 2-year olds, etc. Patients were also grouped by sex. There was a minimum of 25 patients in each group. RESULTS: At 18 years of age the mean+/-SD clavicle length for females was 149+/-12 mm and for males it was 161+/-11 mm. Although a statistically significant difference (P=0.049) was noted between the length of right and left clavicles it was not clinically significant (0.036 mm). A steady growth rate was noted for both genders from birth to the age of 12 years (8.4 mm/y). Above the age of 12 years there were significant differences in the growth of the clavicles of girls (2.6 mm/y) versus boys (5.4 mm/y) (P<0.001). Our data suggest that females achieve 80% of their clavicle length by 9 years of age and boys by 12 years of age. CONCLUSION: This cross-sectional study establishes that relatively little clavicle growth (20%) remains for girls beyond age 9 years and for boys beyond 12 years. The length of one clavicle may be properly judged by comparing it with the contralateral clavicle. CLINICAL RELEVANCE: Remodeling of the clavicle shaft fractures is currently believed to be proportional to remaining growth. Our study questions the capacity of the clavicle to re-establish normal length beyond the age thresholds we have identified.