Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Associations between Present-on-Admission Do-Not-Resuscitate Orders and Short-Term Outcomes in Patients with Pneumonia.

OBJECTIVES: Do-not-resuscitate (DNR) orders are used to express patient preferences for cardiopulmonary resuscitation. This study examined whether early DNR orders are associated with differences in treatments and outcomes among patients hospitalized with pneumonia. METHODS: This is a retrospective cohort study of 768,015 adult patients hospitalized with pneumonia from 2010 to 2015 in 646 US hospitals. The exposure was DNR orders present on admission. Secondary analyses stratified patients by predicted in-hospital mortality. Main outcomes included in-hospital mortality, length of stay, cost, intensive care admission, invasive mechanical ventilation, noninvasive ventilation, vasopressors, and dialysis initiation. RESULTS: Of 768,015 patients, 94,155 (12.3%) had an early DNR order. Compared with those without, patients with DNR orders were older (mean age 80.1 ± 10.6 years vs 67.8 ± 16.4 years), with higher comorbidity burden, intensive care use (31.6% vs 30.6%), and in-hospital mortality (28.2% vs 8.5%). After adjustment via propensity score weighting, these patients had higher mortality (odds ratio [OR] 2.39, 95% confidence interval [CI] 2.33-2.45) and lower use of intensive therapies such as vasopressors (OR 0.83, 95% CI 0.81-0.85) and invasive mechanical ventilation (OR 0.68, 95% CI 0.66-0.70). Although there was little relationship between predicted mortality and DNR orders, among those with highest predicted mortality, DNR orders were associated with lower intensive care use compared with those without (66.7% vs 80.8%). CONCLUSIONS: Patients with early DNR orders have higher in-hospital mortality rates than those without, but often receive intensive care. These orders have the most impact on the care of patients with the highest mortality risk.

Intravenous to Oral Antibiotic Switch Therapy Among Patients Hospitalized With Community-Acquired Pneumonia.

BACKGROUND: Community-acquired pneumonia (CAP) is a leading cause of hospital admissions and antimicrobial use. Clinical practice guidelines recommend switching from intravenous (IV) to oral antibiotics once patients are clinically stable. METHODS: We conducted a retrospective cohort study of adults admitted with CAP and initially treated with IV antibiotics at 642 US hospitals from 2010 through 2015. Switching was defined as discontinuation of IV and initiation of oral antibiotics without interrupting therapy. Patients switched by hospital day 3 were considered early switchers. We compared length of stay (LOS), in-hospital 14-day mortality, late deterioration (intensive care unit [ICU] transfer), and hospital costs between early switchers and others, controlling for hospital characteristics, patient demographics, comorbidities, initial treatments, and predicted mortality. RESULTS: Of 378 041 CAP patients, 21 784 (6%) were switched early, most frequently to fluoroquinolones. Patients switched early had fewer days on IV antibiotics, shorter duration of inpatient antibiotic treatment, shorter LOS, and lower hospitalization costs, but no significant excesses in 14-day in-hospital mortality or late ICU admission. Patients at a higher mortality risk were less likely to be switched. However, even in hospitals with relatively high switch rates, <15% of very low-risk patients were switched early. CONCLUSIONS: Although early switching was not associated with worse outcomes and was associated with shorter LOS and fewer days on antibiotics, it occurred infrequently. Even in hospitals with high switch rates, <15% of very low-risk patients were switched early. Our findings suggest that many more patients could be switched early without compromising outcomes.

Patient-reported Anxiety Scores Are Associated With Lower Physical Function in Patients Experiencing Orthopaedic Trauma.

BACKGROUND: The outcomes of orthopaedic trauma are not solely determined by injury severity or surgical treatment. Studies of numerous orthopaedic outcomes have found that psychosocial factors are also important. Symptoms of anxiety have been linked to long-term pain and disability. Although the existence of a relationship between psychosocial factors and functional outcomes is accepted across multiple disciplines, quantification of this association in patients who have experienced orthopaedic trauma has remained limited. Measuring the anxiety experienced by these individuals and the association with long-term functional outcomes remain poorly understood. QUESTIONS/PURPOSES: (1) Is there an association between early postoperative anxiety symptoms and late recovery of self-reported physical function in patients with orthopaedic trauma? (2) What was the impact of other factors such as demographic variables and comorbidities on late recovery physical function scores, and how did the magnitude of these factors compare with the association with anxiety score? (3) Did patients who presented as trauma activations differ regarding their anxiety symptoms and late-recovery self-reported physical function? METHODS: A total of 1550 patients with lower extremity fractures and postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and physical function scores treated between January 1, 2014, and January 1, 2021, at an academic Level I trauma center in North America were assessed. We performed a bivariate regression between the initial PROMIS anxiety and physical function, as well as a multivariate regression including age, gender, BMI, and American Society of Anesthesiologists class to control for potential confounding variables. In a subgroup of 787 patients presenting as trauma activations, we performed a separate regression including Injury Severity Score. RESULTS: PROMIS anxiety was associated with decreased late-recovery physical function (ß = -2.64 [95% CI -3.006 to -2.205]; p < 0.001). The relationship between PROMIS anxiety and physical function remained after controlling for confounding variables in our overall cohort (ß = -2.54 [95% CI -2.93 to -2.15]; p < 0.001) and in the trauma activation cohort (ß = -2.71 [95% CI -3.19 to -2.23]; p < 0.001). Age and American Society of Anesthesiologists score were associated with worse PROMIS physical function scores, while being a man was associated with better PROMIS physical function scores (age: ß= -1.26 [95% CI -1.50 to -1.02]; American Society of Anesthesiologists class: ß=-2.99 [95% CI -3.52 to -2.46]; men: ß = 0.95 [95% CI 0.16 to 1.75]). There were no differences in initial anxiety symptoms or late-recovery physical function between patients who presented as trauma activations and those who did not. Injury Severity Scores were independently associated with worse function (ß = -1.45 [95% CI -2.11 to -0.79]. CONCLUSION: Initial patient self-reported anxiety is negatively associated with patient-reported physical function at the final follow-up interval in a broad cohort of patients with orthopaedic lower extremity injuries undergoing surgery. Identifying patients with high initial PROMIS anxiety scores may allow us to determine which patients will report lower functional scores at the final follow-up. Future investigations could focus on the effect of psychosocial interventions such as cognitive behavioral therapy and mindfulness on functional scores. LEVEL OF EVIDENCE: Level III, therapeutic study.

Benchmarking Inpatient Mortality Using Electronic Medical Record Data: A Retrospective, Multicenter Analytical Observational Study.

OBJECTIVES: To develop a model to benchmark mortality in hospitalized patients using accessible electronic medical record data. DESIGN: Univariate analysis and multivariable logistic regression were used to identify variables collected during the first 24 hours following admission to test for risk factors associated with the end point of hospital mortality. Models were built using specific diagnosis (International Classification of Diseases, 9th Edition or International Classification of Diseases, 10th Edition) captured at discharge, rather than admission diagnosis, which may be discordant. Variables were selected based, in part, on prior the Acute Physiology and Chronic Health Evaluation methodology and included primary diagnosis information plus three aggregated indices (physiology, comorbidity, and support). A Physiology Index was created using parsimonious nonlinear modeling of heart rate, mean arterial pressure, temperature, respiratory rate, hematocrit, platelet counts, and serum sodium. A Comorbidity Index incorporates new or ongoing diagnoses captured by the electronic medical record during the preceding year. A Support Index considered 10 interventions such as mechanical ventilation, selected IV drugs, and hemodialysis. Accuracy was determined using area under the receiver operating curve for discrimination, calibration curves, and modified Brier score for calibration. SETTING AND PATIENTS: We used deidentified electronic medical record data from 74,434 adult inpatients (ICU and ward) at 15 hospitals from 2010 to 2013 to develop the mortality model and validated using data for additional 49,752 patients from the same 15 hospitals. A second revalidation was accomplished using data on 83,684 patients receiving care at six hospitals between 2014 and 2016. The model was also validated on a subset of patients with an ICU stay on day 1. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: This model uses physiology, comorbidity, and support indices, primary diagnosis, age, lowest Glasgow Coma Score, and elapsed time since hospital admission to predict hospital mortality. In the initial validation cohort, observed mortality was 4.04% versus predicted mortality 4.12% (Student t test, p = 0.37). In the revalidation using a different set of hospitals, predicted and observed mortality were 2.66% and 2.99%, respectively. Area under the receiver operating curve were 0.902 (0.895-0.909) and 0.884 (0.877-0.891), respectively, and calibration curves show a close relationship of observed and predicted mortalities. In the evaluation of the subset of ICU patients on day1, the area under the receiver operating curve was 0.87, with an observed mortality of 8.78% versus predicted mortality of 8.93% (Student t test, p = 0.52) and a standardized mortality ratio of 0.98 (0.932-1.034). CONCLUSIONS: Variables considered by traditional ICU prognostic models accurately benchmark patient mortality for patients receiving care in multiple hospital locations, not only the ICU. Unlike Acute Physiology and Chronic Health Evaluation, this model relies on electronic medical record data alone and does not require personnel to collect the independent predictor variables. Assessing the model's utility for benchmarking hospital performance will require prospective testing in a larger representative sample of hospitals.

De-escalation of Empiric Antibiotics Following Negative Cultures in Hospitalized Patients With Pneumonia: Rates and Outcomes.

BACKGROUND: For patients at risk for multidrug-resistant organisms, IDSA/ATS guidelines recommend empiric therapy against methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas. Following negative cultures, the guidelines recommend antimicrobial de-escalation. We assessed antibiotic de-escalation practices across hospitals and their associations with outcomes in hospitalized patients with pneumonia with negative cultures. METHODS: We included adults admitted with pneumonia in 2010-2015 to 164 US hospitals if they had negative blood and/or respiratory cultures and received both anti-MRSA and antipseudomonal agents other than quinolones. De-escalation was defined as stopping both empiric drugs on day 4 while continuing another antibiotic. Patients were propensity adjusted for de-escalation and compared on in-hospital 14-day mortality, late deterioration (ICU transfer), length-of-stay (LOS), and costs. We also compared adjusted outcomes across hospital de-escalation rate quartiles. RESULTS: Of 14 170 patients, 1924 (13%) had both initial empiric drugs stopped by hospital day 4. Hospital de-escalation rates ranged from 2-35% and hospital de-escalation rate quartile was not significantly associated with outcomes. At hospitals in the top quartile of de-escalation, even among patients at lowest risk for mortality, the de-escalation rates were <50%. In propensity-adjusted analysis, patients with de-escalation had lower odds of subsequent transfer to ICU (adjusted odds ratio, .38; 95% CI, .18-.79), LOS (adjusted ratio of means, .76; .75-.78), and costs (.74; .72-.76). CONCLUSIONS: A minority of eligible patients with pneumonia had antibiotics de-escalated by hospital day 4 following negative cultures and de-escalation rates varied widely between hospitals. To adhere to recent guidelines will require substantial changes in practice.

Coronavirus Disease 2019 ICU Patients Have Higher-Than-Expected Acute Physiology and Chronic Health Evaluation-Adjusted Mortality and Length of Stay Than Viral Pneumonia ICU Patients.

OBJECTIVES: To compare Acute Physiology and Chronic Health Evaluation-IV-adjusted mortality and length of stay outcomes of adult ICU patients who tested positive for coronavirus disease 2019 with patients admitted to ICU with other viral pneumonias including a subgroup with viral pneumonia and concurrent acute respiratory distress syndrome (viral pneumonia-acute respiratory distress syndrome). DESIGN: Retrospective review of Acute Physiology and Chronic Health Evaluation data collected from routine clinical care. SETTING: Forty-three hospitals contributing coronavirus disease 2019 patient data between March 14, and June 17, 2020, and 132 hospitals in the United States contributing data on viral pneumonia patients to the Acute Physiology and Chronic Health Evaluation database between January 1, 2014, and December 31, 2019. PATIENTS AND MEASUREMENTS: One thousand four hundred ninety-one patients with diagnosis of coronavirus disease 2019 infection and 4,200 patients with a primary (n = 2,544) or secondary (n = 1,656) admitting diagnosis of noncoronavirus disease viral pneumonia receiving ICU care. A subset of 202 viral pneumonia patients with concurrent acute respiratory distress syndrome was examined separately. INTERVENTIONS: None. MAIN RESULTS: Mean age was 63.4 for coronavirus disease (p = 0.064) versus 64.1 for viral pneumonia. Acute Physiology and Chronic Health Evaluation-IV scores were similar at 56.7 and 55.0, respectively (p = 0.060), but gender and ethnic distributions differed, as did Pao2 to Fio2 ratio and WBC count at admission. The hospital standardized mortality ratio (95% CI) was 1.52 (1.35-1.68) for coronavirus disease patients and 0.82 (0.75-0.90) for viral pneumonia patients. In the coronavirus disease group, ICU and hospital length of stay were 3.1 and 3.0 days longer than in viral pneumonia patients. Standardized ICU and hospital length of stay ratios were 1.13 and 1.46 in the coronavirus disease group versus 0.95 and 0.94 in viral pneumonia patients. Forty-seven percent of coronavirus disease patients received invasive or noninvasive ventilatory support on their first ICU day versus 65% with viral pneumonia. Ventilator days in survivors were longer in coronavirus disease (10.4 d) than in viral pneumonia (4.3 d) patients, except in the viral pneumonia-acute respiratory distress syndrome subgroup (10.2 d). CONCLUSIONS: Severity-adjusted mortality and length of stay are higher for coronavirus disease 2019 patients than for viral pneumonia patients admitted to ICU. Coronavirus disease patients also have longer time on ventilator and ICU length of stay, comparable with the subset of viral pneumonia patients with concurrent acute respiratory distress syndrome. Mortality and length of stay increase with age and higher scores in both populations, but observed to predicted mortality and length of stay are higher than expected with coronavirus disease patients across all severity of illness levels. These findings have implications for benchmarking ICU outcomes during the coronavirus disease 2019 pandemic.

Topical Oral and Intranasal Antiviral Agents for Coronavirus Disease 2019 (COVID-19).

With the largest viral loads in both symptomatic and asymptomatic patients with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) present in the oral and nasal cavities, agents that act on these two areas have the potential for large therapeutic and prophylactic benefit. A literature review was conducted to elucidate the possible agents useful in treatment of SARS-CoV-2. These agents were evaluated for their current applications, adverse reactions, their current state of study, and any future considerations in their management of coronavirus disease 2019 (COVID-2019). Our review has found that, while there are many promising agents with proven efficacy in their in-vitro efficacy against SARS-CoV-2, more clinical trials and in-vivo studies, as well as safety trials, must be conducted before these agents can be effectively implemented.

Comparative TMT Proteomic Analysis Unveils Unique Insights into Helicoverpa armigera (Hübner) Resistance in Cajanus scarabaeoides (L.) Thouars.

Pigeonpea [Cajanus cajan (L.) Millspaugh] is an economically important legume playing a crucial role in the semi-arid tropics. Pigeonpea is susceptible to Helicoverpa armigera (Hübner), which causes devastating yield losses. This pest is developing resistance to many commercially available insecticides. Therefore, crop wild relatives of pigeonpea, are being considered as potential sources of genes to expand the genetic base of cultivated pigeonpea to improve traits such as host plant resistance to pests and pathogens. Quantitative proteomic analysis was conducted using the tandem mass tag platform to identify differentially abundant proteins between IBS 3471 and ICPL 87 tolerant accession and susceptible variety to H. armigera, respectively. Leaf proteome were analysed at the vegetative and flowering/podding growth stages. H. armigera tolerance in IBS 3471 appeared to be related to enhanced defence responses, such as changes in secondary metabolite precursors, antioxidants, and the phenylpropanoid pathway. The development of larvae fed on an artificial diet with IBS 3471 lyophilised leaves showed similar inhibition with those fed on an artificial diet with quercetin concentrations with 32 mg/25 g of artificial diet. DAB staining (3,3'-diaminobenzidine) revealed a rapid accumulation of reactive oxygen species in IBS 3471. We conclude that IBS 3471 is an ideal candidate for improving the genetic base of cultivated pigeonpea, including traits for host plant resistance.

Is the Fibular Station on Lateral Ankle Radiographs Symmetric? A Retrospective Observational Radiographic Study.

BACKGROUND: Precise reduction of a syndesmosis after disruption is critical to improve patient physical function. Intraoperative lateral radiographs of the unaffected ankle are often used in clinical practice as a template for anatomic syndesmotic reduction because sagittal plane malreduction is common. However, there is little data to suggest fibular station, or the position of the fibula in the AP plane on the lateral radiograph, is symmetric side-to-side in patients. QUESTIONS/PURPOSES: (1) Is the position of the fibula in the AP plane (fibular station) on lateral ankle radiographs symmetric in an individual? (2) Do the measurements used to judge the position of the fibula on lateral radiographs have good inter- and intraobserver reliability? METHODS: Over the period from August 2016 to October 2018, we identified 478 patients who presented to an orthopaedic clinic with forefoot and midfoot complaints. Skeletally mature patients with acceptable bilateral lateral ankle radiographs, which are common radiographs obtained for new patients to clinic for any complaint, were included. Based on that, 52% (247 of 478 patients) were included with most (22%, 107 patients) excluded for poor lateral radiographs. The most common diagnosis in the patient cohort was midfoot OA (14%, 35 patients). The median (range) age of the included patients was 54 years (15 to 88), and 65% (159 of 247) of the patients were female. Fibular station, defined as the position of the fibula in the AP plane, and fibular length were measured using a digital ruler and goniometer on lateral radiographs. A paired t-test was used to determine if no difference in fibular station existed between the left and right ankles. With 247 paired-samples, with 80% power and an alpha level of 0.05, we could detect a difference between sides of 0.008 for the posterior ratio, 0.010 for the anterior ratio, and 0.012 for fibular length. Two readers, one fellowship-trained orthopaedic traumatologist and one PGY-4, measured 40 patients to determine the inter- and intraobserver reliability by intraclass correlation coefficient (ICC). RESULTS: The posterior fibular station (mean right 0.147 [σ = 0.056], left 0.145 [σ = 0.054], difference = 0.03 [95% CI 0 to 0.06]; p = 0.59), anterior fibular station (right 0.294 [σ = 0.062], left 0.299 [σ = 0.061], difference = 0.04 [95% CI 0 to 0.08]; p = 0.20), and fibular length (right 0.521 [σ = 0.080], left 0.522 [σ = 0.078], difference = 0.05 [95% CI 0.01 to 0.09]; p = 0.87) ratios did not differ with the numbers available between ankles. Inter- and intraobserver reliability were excellent for the posterior ratio (ICC = 0.928 and ICC = 0.985, respectively) and the anterior ratio (ICC = 0.922 and ICC = 0.929, respectively) and moderate-to-good for the fibular length ratio (ICC = 0.732 and ICC = 0.887, respectively). CONCLUSION: The use of lateral radiographs of the contralateral uninjured ankle appears to be a valid template for determining the position of the fibula in the sagittal plane. However, further prospective studies are required to determine the efficacy of this method in reducing the syndesmosis over other methods that exists. LEVEL OF EVIDENCE: Level III, diagnostic study.

Patient satisfaction survey experience among American otolaryngologists.

BACKGROUND: Patient Satisfaction (PS) is a commonly used metric in health care settings to assess the quality of care given by physicians. Monitoring physicians in this way may impact physician quality of life. Studies evaluating this impact are not available. This study sought to examine the physician experience of measuring PS among practicing otolaryngologists. METHODS: Using an online survey platform, a 34-item survey was given to practicing otolaryngologists through email distribution. The survey included questions about physician, practice and patient demographics, as well as inquiries regarding the way in which PS was measured and how it affected physician work and personal life. Data from these questions were reviewed and analyzed. RESULTS: 174 otolaryngologists responded to the survey. A majority of physicians' (55.3%) PS scores had been tracked with 89.9% reporting being tracked for a length of at least 1 year. PS scores for individual physicians were noted to be inconsistent and vary significantly between reports. Measuring patient satisfaction led to increased occupational stress, yet most physicians (63.8%) felt the monitoring did not lead to improvements in their practice. Some physicians (36.2%) reported that the collection of patient satisfaction scores had negatively influenced the way they practiced medicine, including the pressure to order superfluous tests or to prescribe unnecessary medications. CONCLUSION: Overall, physicians are negatively affected by the tracking of patient satisfaction scores. Occupational stress caused by the collection of patient satisfaction scores may contribute to physician burnout.

Heterologous expression of an α-amylase inhibitor from common bean (Phaseolus vulgaris) in Kluyveromyces lactis and Saccharomyces cerevisiae.

BACKGROUND: Phaseolamin or α-amylase inhibitor 1 (αAI) is a glycoprotein from common beans (Phaseolus vulgaris L.) that inhibits some insect and mammalian α-amylases. Several clinical studies support the beneficial use of bean αAI for control of diabetes and obesity. Commercial extracts of P. vulgaris are available but their efficacy is still under question, mainly because some of these extracts contain antinutritional impurities naturally present in bean seeds and also exhibit a lower specific activity αAI. The production of recombinant αAI allows to overcome these disadvantages and provides a platform for the large-scale production of pure and functional αAI protein for biotechnological and pharmaceutical applications. RESULTS: A synthetic gene encoding αAI from the common bean (Phaseolus vulgaris cv. Pinto) was codon-optimised for expression in yeasts (αAI-OPT) and cloned into the protein expression vectors pKLAC2 and pYES2. The yeasts Kluyveromyces lactis GG799 (and protease deficient derivatives such as YCT390) and Saccharomyces cerevisiae YPH499 were transformed with the optimised genes and transformants were screened for expression by antibody dot blot. Recombinant colonies of K. lactis YCT390 that expressed and secreted functional αAI into the culture supernatants were selected for further analyses. Recombinant αAI from K. lactis YCT390 was purified using anion-exchange and affinity resins leading to the recovery of a functional inhibitor. The identity of the purified αAI was confirmed by mass spectrometry. Recombinant clones of S. cerevisiae YPH499 expressed functional αAI intracellularly, but did not secrete the protein. CONCLUSIONS: This is the first report describing the heterologous expression of the α-amylase inhibitor 1 (αAI) from P. vulgaris in yeasts. We demonstrated that recombinant strains of K. lactis and S. cerevisiae expressed and processed the αAI precursor into mature and active protein and also showed that K. lactis secretes functional αAI.

The dangers of extreme body mass index values in patients with Clostridium difficile.

PURPOSE: To examine the association between body mass index (BMI) and in-hospital mortality in patients presenting with Clostridium difficile infections in emergency department visits (ED) in the USA. Infected patients with extreme BMIs may have an elevated mortality risk, but prior studies examining this question have been too small to reach definitive conclusions. METHODS: Data were from the Nationwide Emergency Department Sample (NEDS), Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality during 2012. NEDS records emergency department (ED) visits across the USA and provides statistical sampling weights to approximate a nationally representative sample of US hospital-based EDs. Inclusion criteria were adults age 18 or older with an ICD-9 code for C. difficile infection (008.45) and a documented body mass index ICD-9 V code (V85.x). Logistic regression was used to predict mortality after adjusting for demographic variables and chronic comorbidities defined by Elixhauser. RESULTS: A weighted sample of 22,937 ED visits met all inclusion criteria. The cohort's mean age was 66. 64.6% were female. The unadjusted mortality rate was 6.5%. Patients with a BMI < 19 kg/m2 had an adjusted odds ratio of 2.73; 95% CI (1.80, 4.16), p < 0.001 compared to patients with a BMI of 19.0-4.9 kg/m2 (the referent category). In obese patients, only BMI values >40 kg/m2 were associated with significantly greater mortality risk. CONCLUSION: Being underweight (BMI < 19) or morbidly obese (BMI > 40) was associated with increased risk of in-hospital mortality in patients presenting with C. difficile infections.

Association Between Initial Route of Fluoroquinolone Administration and Outcomes in Patients Hospitalized for Community-acquired Pneumonia.

BACKGROUND: Fluoroquinolones have equivalent oral and intravenous bioavailability, but hospitalized patients with community-acquired pneumonia (CAP) generally are treated intravenously. Our objectives were to compare outcomes of hospitalized CAP patients initially receiving intravenous vs oral respiratory fluoroquinolones. METHODS: This was a retrospective cohort study utilizing data from 340 hospitals involving CAP patients admitted to a non-intensive care unit (ICU) setting from 2007 to 2010, who received intravenous or oral levofloxacin or moxifloxacin. The primary outcome was in-hospital mortality. Secondary outcomes included clinical deterioration (transfer to ICU, initiation of vasopressors, or invasive mechanical ventilation [IMV] initiated after the second hospital day), antibiotic escalation, length of stay (LOS), and cost. RESULTS: Of 36 405 patients who met inclusion criteria, 34 200 (94%) initially received intravenous treatment and 2205 (6%) received oral treatment. Patients who received oral fluoroquinolones had lower unadjusted mortality (1.4% vs 2.5%; P = .002), and shorter mean LOS (5.0 vs 5.3; P < .001). Multivariable models using stabilized inverse propensity treatment weighting revealed lower rates of antibiotic escalation for oral vs intravenous therapy (odds ratio [OR], 0.84; 95% confidence interval [CI], .74-.96) but no differences in hospital mortality (OR, 0.82; 95% CI, .58-1.15), LOS (difference in days 0.03; 95% CI, -.09-.15), cost (difference in $-7.7; 95% CI, -197.4-182.0), late ICU admission (OR, 1.04; 95% CI, .80-1.36), late IMV (OR, 1.17; 95% CI, .87-1.56), or late vasopressor use (OR, 0.94; 95% CI, .68-1.30). CONCLUSIONS: Among hospitalized patients who received fluoroquinolones for CAP, there was no association between initial route of administration and outcomes. More patients may be treated orally without worsening outcomes.

Chronic kidney disease after heart transplantation: a single-centre retrospective study at Skåne University Hospital in Lund 1988-2010.

We aimed to study the incidence, predictors and outcome of chronic kidney disease (CKD) after heart transplantation (HT). All our HT patients 1988-2010 were considered for inclusion. Of these, 134 came for annual follow-ups including evaluation of glomerular filtration rate (GFR) using iohexol clearance measurements, and the CKD-EPI (adults) or Schwartz (children) formulae. Median GFR (Q1-Q3) (ml/min/1.73 m(2) ) declined from 67.0 (50.0-82.0) during transplant assessment (TA) to 56.0 (45.0-69.0) at year 1, 53.0 (41.0-68.0) at year 5 and 44.5 (25.0-57.3) at year 10. The cumulative incidence of CKD ≥ stage 4 was 25% at 5 years and 41% at 10 years after transplantation. Proteinuria the first year post-HT was the only predictor related (P < 0.05) to a higher rate of GFR decline (HR 5.15, 95% CI 1.23-21.55). GFR ≥60 as compared to <60 before HT, or a first-year GFR decline <30% as compared to >30%, was moreover associated (P < 0.05) with a lower risk of death (HR 0.30, 95% CI 0.12-0.76 and HR 0.35, 95% CI 0.13-0.90, respectively). Notably, the CKD-EPI and Schwartz formulae overestimated GFR by 28 ± 29% and 26 ± 33%, respectively. In conclusion, CKD in HT patients is common and associated with worse outcome. To avoid diagnostic delay, GFR estimating equations' validity in HT patients needs further study.

Does Early versus Delayed Spanning External Fixation Impact Complication Rates for High-energy Tibial Plateau and Plafond Fractures?

BACKGROUND: High-energy tibial plateau and tibial plafond fractures have a high complication rate and are frequently treated with a staged approach of spanning external fixation followed by definitive internal fixation after resolution of soft tissue swelling. A theoretical advantage to early spanning external fixation is that earlier fracture stabilization could prevent further soft tissue damage and potentially reduce the occurrence of subsequent infection. However, the relative urgency of applying the external fixator after injury is unknown, and whether delay in this intervention is correlated to subsequent treatment complications has not been examined. QUESTIONS/PURPOSES: Is delay of more than 12 hours to spanning external fixation of high-energy tibial plateau and plafond fractures associated with increased (1) infection risk; (2) compartment syndrome risk; and (3) time to definitive fixation, length of hospitalization, or risk of secondary surgeries? We further stratified our results based on injury site: plateau and plafond. In practical clinical terms, many of these high-energy C-type articular fractures will arrive at the regional trauma center in the evening and this investigation attempted to explore if these injuries need to be placed in temporizing fixators that evening or if they may be safely addressed in a dedicated trauma room the next morning. METHODS: We performed a retrospective review of all patients at a Level I university trauma center with high-energy tibial plateau and plafond fractures who underwent staged treatment with a spanning external fixation followed by subsequent definitive internal fixation between 2006 and 2012. Patients who received a fixator within 12 hours of recorded injury time were classified as early external fixation; those who received a fixator greater than 12 hours from injury were classified as delayed external fixation. There were 80 patients (42 plateaus and 38 plafonds) in the early external fixation cohort and 79 patients (45 plateaus and 34 plafonds) in the delayed external fixation cohort. Deep infection rate was 13% in plateau fractures and 18% in plafond fractures. Rates of infection, compartment syndrome, secondary surgeries, time to definitive fixation, and length of hospitalization were recorded. RESULTS: Controlling for differences in open fracture severity between groups, there was no difference in infection for plafond (early fixation: 12 of 38 [32%]; delayed fixation: seven of 34 [21%]; adjusted relative risk = 1.39 [95% confidence interval {CI}, 0.45-4.31], p = 0.573) and plateau (early fixation: eight of 42 [19%]; delayed fixation: nine of 45 [20%]; adjusted relative risk: 0.93 [95% CI, 0.31-2.78], p = 0.861) groups. For compartment syndrome risk, there was no difference between early and delayed groups for plateau fractures (early fixation: six of 42 [14%]; delayed fixation: three of 45 [7%]; relative risk = 0.47 [0.12-1.75], p = 0.304) and plafond fractures (early fixation: two of 38 [5%]; delayed fixation: three of 34 [9%]; relative risk = 1.67 [0.30-9.44], p = 0.662). There was no difference for length of hospitalization for early (9 ± 7 days) versus delayed fixation (9 ± 6 days) (mean difference = 0.24 [95% CI, -2.9 to 3.4], p = 0.878) for patients with plafond fracture. Similarly, there was no difference in length of hospitalization for early (10 ± 6 days) versus delayed fixation (8 ± 4 days) (mean difference = 1.6 [95% CI, -3.9 to 0.7], p = 0.170) for patients with plateau fracture. Time to definitive fixation for plateau fractures in the early external fixation group was 8 ± 6 days compared with 11 ± 7 days for the delayed external fixation group (mean difference = 2.9 [95% CI, 0.13-5.7], p = 0.040); there was no difference in time to definitive fixation for early (12 ± 7 days) versus delayed (12 ± 6 days) for patients with plafond fractures (mean difference = 0.39 [95% CI, -2.7 to 3.4], p = 0.801). There was no difference in risk of secondary surgeries between early external fixation (21 of 38 [55%]) and delayed external fixation (13 if 34 [38%]) for plafond fractures (adjusted relative risk = 0.69 [95% CI, 0.41-1.16], p = 0.165) and no difference between early fixation (24 of 42 [57%]) and delayed fixation (26 of 45 [58%]) for plateau fractures (adjusted relative risk = 1.0 [95% CI, 0.70-1.45], p = 1.00). CONCLUSIONS: We were unable to detect a difference in infection, compartment syndrome, secondary procedures, or length of hospitalization for patients who undergo early versus delayed external fixation for high-energy tibial plateau or plafond fractures. This may affect decisions for resource use at trauma centers such as whether high-energy periarticular lower extremity fractures need to be spanned on the evening of presentation or whether this procedure may wait until the morning trauma room. Given the high complication rate of these injuries and clinical relevance of this question, this may also need to be examined in a prospective manner. LEVEL OF EVIDENCE: Level IV, therapeutic study.