BACKGROUND:Low health literacy is associated with worse glycemic control among patients with diabetes; the relationship between health literacy and blood glucose among patients without diagnosed diabetes, particularly in resource-limited settings, is not known. Because emergency department patients are at risk for both low health literacy and undiagnosed diabetes, we examined their relationships among emergency department patients at the Georgetown Public Hospital Corporation in Guyana.METHODS:We conducted a cross-sectional study across random time blocks from May to August 2012 among Guyanese emergency department patients without a diagnosis of diabetes. Health literacy was assessed by the Single Item Literacy Screener (SILS, range 1-5); low health literacy was defined as SILS ≥ 3. We examined the relationships among health literacy, random blood glucose (RBG), and point-of-care glycated hemoglobin (HbA1c).RESULTS:Of the 228 enrolled patients, 125 (54%) were female, median age was 43 years (interquartile range 38 to 53), mean body mass index (BMI) was 25.6 kg/m(2) (standard deviation 6.8 kg/m(2)), and 103 (45.2%) had low health literacy. The receiver operating characteristic area under the curve for RBG to detect elevated HbA1c (≥48mmol/mol) was 0.94 (95% CI: 0.91-0.97). After adjustment for age, sex, BMI, ethnicity, and education, the odds of having HbA1c ≥ 48 mmol/mol, consistent with undiagnosed diabetes, rose with decreasing health literacy (OR 2.2, 95% CI 1.2-3.8, p = 0.007, per point decrease in literacy).CONCLUSION:This pilot study of Guyanese emergency department patients without diagnosed diabetes found that low health literacy was common and was associated with higher HbA1c and random blood glucose.

BACKGROUND:Intimate partner violence (IPV) is prevalent throughout the world and is a devastating public health problem. Healthcare workers (HCWs) are tasked with treating victims of IPV but may be victims themselves. Guyana is a lower-middle income country in South America. This study sought to determine the knowledge and attitudes of Guyanese HCWs and their perceived barriers to providing care in addition to determining the prevalence of IPV victimization and perpetration among HCWs.METHODS:HCWs at the only tertiary care hospital in the Guyana completed an anonymous survey that comprised 30 questions relating to IPV.RESULTS:The survey was completed by 87.5% of eligible HCWs. Of the respondents, 81.8% were female, 49.9% had ever experienced abuse and 21% admitted to perpetrating violence. Multivariate analysis found that the age groups 31-40 years (OR 2.3, 95% CI 1.1-4.6) and 41-50 years (OR 2.3, 95% CI 1.2-4.7) had higher odds of accepting justification for physical violence, and so did nursing staff (OR 4.3, 95% CI 1.4-13.1). Overall, 29.9% of HCWs accepted justification for physical violence in at least one of the named scenarios.CONCLUSION:This study demonstrates a high prevalence of IPV among HCWs and identifies prevailing attitudes regarding IPV. This knowledge is essential in developing effective, appropriate training programs and identifies a need to address IPV among the healthcare workforce.

Approximately 41,000 central line-associated blood stream infections (CLABSI) occur in U.S. hospitals each year. These infections typically cause prolongation of hospital stay, increased cost, risk of mortality and are a National Patient Safety Imperative. CLABSI can be minimized by implementation of published quality improvement, infection control initiatives and has been driven as low as 1.17 infections per 1000 patient days in the 350 hospital On the CUSP: Stop BSI AHRQ funded project. Central venous catheters (CVCs) are commonly placed in the emergency department (ED) setting and represent a core procedure for the emergency physician. Reporting is not specifically required for CLABSI rates of lines placed in the ED's outpatient setting, however, examination of these lines represents an important and rarely reported area of possible patient morbidity and safety. Our study objective was to examine the CLABSI rates for lines inserted in the ED setting at three large urban EDs. This IRB approved, cohort study includes all patients with a CVC inserted in the EDs of three hospitals in Cincinnati, Ohio between January, 2007 and June, 2012. The hospitals include a large, urban, academic medical center, and two smaller, community hospitals representing 160,000 patient visits per year. Patients were identified through billing and ICD-9 data followed by chart review utilizing a priori definitions and standardized case report forms by a trained research RN. A representative sample was examined by the investigators to determine average number of line days. Blood stream infections were identified through standard, daily, hospital-based quality/infection control RN rounds. During the study period, 1932 lines were placed. Average total complication rate was 6.45%. Average line duration was 3 days and 3 BSIs were identified, for a CLABSI rate of 0.52/1000 patient days. Reporting of CLABSI rates in the outpatient setting of the ED is not yet required by government agencies or payers in general. However, this study shows that it is possible, with implementation of recommended infection control practices, to improve upon published rates of inpatient unit CLABSI, in the unique environment of the ED.

In the United States, physicians insert more than 5 million central venous catheters (CVCs) every year. CVC insertion is a core procedure for emergency physicians. Unfortunately, the use of CVCs is associated with adverse events that increase cost, and patient morbidity. Reported mechanical and thrombotic complication rates vary from 1.5 to 19% and 2 to 26%, respectively. The complication rates of CVC inserted in the ED by emergency physicians have not been reported and could be an under-recognized area of patient safety and morbidity. Our study objective is to estimate the mechanical and thrombotic complication rates for CVCs inserted by emergency physicians. This cohort study includes all patients with a CVC inserted in the EDs of three hospitals in Cincinnati, Ohio between January 2007 and June 2012. The hospitals include an urban, academic medical center, and 2 smaller, community hospitals. Combined volume is ∼160,000 visits per year. Patients with CVC placement were identified through billing and ICD-9 data, and evaluated by chart review using a priori definitions and standardized case report forms by a trained research nurse. During the study period, 1932 lines were placed. Complication rates are reported in the Table. Both mechanical and thrombotic complications are low in this large cohort of emergency medicine patients relative to reported rates in other settings. The majority of CVCs in this study were placed by PGY-2 emergency medicine residents and of the 121 events, only 20 (1.0%) required intervention. More study is required to further characterize this important area of EM patient safety in order to establish best practice parameters and to minimize future morbidity.TableCVC Insertion Complication RatesClassMechanicalThromboticTypeArterial PuncturePneumothoraxHemothoraxDysrythmiaAir EmbolismDVTHematomaTotalN8113162414121%4.20.670.050.310.100.210.726.3 Open table in a new tab

BACKGROUND:Left without being seen (LWBS) proportions are commonly used as quality control indicators, but little data is available on LWBS proportions in the developing world. This study sought to determine the proportion and characteristics of patients who LWBS from the emergency department (ED) of the main public hospital in Georgetown, Guyana.METHODS:This is a retrospective cross-sectional analysis of an ED quality assurance database. Registration personnel collected demographic information on patients presenting to the ED over a 2-week period in July 2010. Both univariate and multivariate analysis were conducted to determine patient characteristics associated with LWBS.RESULTS:The LWBS proportion was 5.7%. In univariate analysis, patients 18 or older (OR 1.48, 95%CI 1.03-2.12), presenting during the 4PM-12AM shift (OR 2.15, 95%CI 1.53-3.01), with non-urgent triage classification (OR 1.88, 95%CI 1.76-4.66), with non-traumatic chief complaints (OR 1.70, 95%CI 1.14-2.55), or who were not transferred (OR 2.13, 95%CI 1.00-4.55) had significantly higher odds of LWBS. On multivariate analysis, only patients 18 or older (OR 1.54, 95%CI 1.02-2.33), presenting during the 4PM-12AM shift (OR 2.29, 95%CI 1.54-3.40), and with non-traumatic chief complaints (OR 2.39, 95%CI 1.43-4.02) were found to be significantly associated with LWBS. Sex, residence in the capital city, time to triage, transfer status, use of EMS, and triage classification were not statistically associated with LWBS.CONCLUSIONS:LWBS proportions are used as quality control indicators and this study determined the LWBS proportion at a public hospital in a developing country and some of the patient characteristics associated with LWBS. This can be helpful to develop strategies to decrease LWBS proportions and to assess progress over time.

Introduction: Academic departments of emergency medicine are becoming increasingly involved in assisting with the development of long-term emergency medicine training programs in low and middle-income countries. This article presents our 10-year experience working with local partners to improve emergency medical care education in Guyana. Methods: The Vanderbilt Department of Emergency Medicine has collaborated with the Georgetown Public Hospital Corporation on the development of Emergency Medicine skills followed by the implementation of an emergency medicine residency training program. Residency development included a needs assessment, proposed curriculum, internal and external partnerships, University of Guyana and Ministry of Health approval, and funding. Results: In our experience, we have found that our successful program initiation was due in large part to the pre-existing interest of several local partners and followed by long-term involvement within the country. As a newer specialty without significant local expertise, resident educational needs mandated a locally present full time EM trained attending to serve as the program director. Both external and internal funding was required to achieve this goal. Local educational efforts were best supplemented by robust distance learning. The program was developed to conform to local academic standards and to train the residents to the level of consultant physicians. Despite the best preparations, future challenges remain. Conclusion: While every program has unique challenges, it is likely many of the issues we have faced are generalizable to other settings and will be useful to other programs considering or currently conducting this type of collaborative project.

Background: Intimate partner violence (IPV) occurs throughout the world, and has both short-term and long-term negative health effects. Little is know about the prevalence of IPV in patients presenting to Emergency Departments (EDs) in the developing world. This information is needed to help delineate the scope of the problem and shape effective interventions to combat IPV. The purpose of this study was to determine the prevalence of intimate partner violence in adult patients with acute traumatic injuries presenting to an ED in Georgetown, Guyana.Methods: Retrospective descriptive analysis of a prospectively collected ED quality assurance database. Patients 18 years or older who presented with a traumatic injury and answered the question "Was the injury inflicted by a domestic partner?" were included in the analysis.Results: Overall, 38 of 475 (8%) patients admitted to having injuries inflicted by a domestic partner. Thirty-one (81.6%) patients disclosing IPV were female and 7 (18.4%) were male. The self-reported prevalence of IPV in females presenting with traumatic injuries was 16% compared to 2% for males (RR 6.4; 95% CI 2.9-14.3). IPV was the cause of 31 of the 67 (46.3%) women presenting with assaults.Conclusions: IPV is thought to be a serious problem in Guyana, and this study confirms a high prevalence (16%) of IPV in women presenting with traumatic injuries to the Georgetown Public Hospital Corporation ED. This is likely a significant underestimate of the true prevalence.

Background: Lumbar puncture is a common emergency department (ED) procedure with widely variable complication rates reported between 0.98-19% in various experimental protocol driven settings. In the current emergency medicine environment of ABEM required performance improvement, Flexner report recommendations for quality improvement and CMS non-pay for complications, it is vital that robust performance improvement data be reported that reflect actual practice experience, without the artificiality of experimentally controlled conditions. These performance improvement results must be disseminated for comparison, benchmarking and hypothesis generation. This study reports the results of an ongoing performance improvement initiative to reduce lumbar puncture complication rates and to improve patient outcomes. Study Objectives: We hypothesize that multiple, knowledge translation-driven interventions improve the rate of post-dural puncture headache. Methods: This is an institutional review board approved, retrospective analysis of 3 hospitals, including a large urban trauma center, and 2 community hospitals. The operators were emergency medicine residents and attending physicians. Complications were identified from equipment charge data, followed by chart review utilizing standardized definitions and a CRF by a trained quality RN who was blinded to the hypothesis. Data were analyzed with SPSS 18.0 for Windows (SPSS Inc., Chicago, IL). Results: (See Chart and Table) A total of 1,049 lumbar puncture's were performed over 4 years. 41 (3.8%) patients experienced post-dural puncture headaches, 17 (5.9%) in 2007 falling to 6 (2.4%)in 2010. The probability of complication fell from 0.06 to 0.02 (p=0.0602). No other complications were found. Five interventions relating to the performance of lumbar puncture were instituted during the study period.Tabled 1 Conclusion: While the results do not prove causation, and just missed arbitrary significance of 0.05, multiple, sequential, continuous performance improvement interventions trend toward improved post-dural puncture headache rates in our setting.

In 2007, the WHO recommended that healthcare providers in areas of a generalised HIV epidemic perform HIV testing on all adults and adolescents presenting for healthcare. Studies regarding patient acceptability of opt-out testing, however, have reported wide variation in acceptance rates. This study examines patient-reported acceptability of such testing at the emergency department (ED) of Georgetown Public Hospital Corporation, the largest public hospital in Guyana. In June 2010, a convenience sample of 343 non-critical adult patients who presented to the ED were interviewed regarding potential acceptance of opt-out HIV testing, with 75.5% (95% CI 70.5-80.0%) stating they would accept testing should it be implemented in the ED. Of 12 patient characteristics, 3 had significant differences in acceptance rates on multivariate analysis: age; gender; and previous HIV testing. In this study, potential reasons for declining testing were also examined. The highest percentage of patient agreement was with the statements 'I have had an HIV test recently enough' (84%, 95% CI 74.0-91.4%) and 'I am not at risk for HIV/AIDS' (83%, 95% CI 73.0-90.4%). The results of this study indicate that the majority of patients in this setting would accept opt-out HIV testing, although some still had concerns regarding testing. Opt-out testing in the ED has the potential to facilitate national goals for increased testing and diagnosis.

Study Objectives: Intimate partner violence (IPV) is a complex public health problem with many health consequences. There is a paucity of research on IPV in patients presenting to emergency departments (EDs) in the developing world. We therefore sought to determine the prevalence of acute, ongoing, and lifetime IPV in patients presenting to the ED of the primary teaching hospital in a developing country. We also assessed the lifetime prevalence of perpetration of physical violence against a partner.Methods: This is a prospective cross-sectional pilot study conducted at Georgetown Public Hospital Corporation (GPHC) in Georgetown, Guyana. Guyana is an English-speaking country located in South America that is culturally and economically Caribbean. GPHC is the primary public referral hospital for the country with an annual ED volume of 75,000 patients. This study was conducted in January 2012. Consecutive patients were recruited during pre-identified 3-hour time blocks. Patients 18 years or older were eligible to participate. Patients too ill to be interviewed, triaged to receive care outside of the ED, or who could not be interviewed in private were excluded. Subjects completed an anonymous survey. They were asked 2 questions to determine if their current visit was related to IPV: "Are you here today because of injuries from a current or past partner?" and "Are you here today because of illness or stress related to threats, violent behavior, or fear from your current or past partner?" The Ongoing Violence Assessment Tool (OVAT) was used to assess current IPV and the Abuse Assessment Screen (AAS) assessed the lifetime prevalence of IPV. To assess perpetration, patients were asked, "Have you ever hit, slapped, kicked or done anything else physically abusive to an intimate partner?" The Institutional Review Board and the Guyana Ministry of Health approved this study.Results: 554 patients presented to the ED during the study time period. 187 patients met inclusion criteria. 47 patients refused consent and 25 were taken for care before completing the survey, leaving 115 patients for analysis. 53.9% (62/115) were female. 22.5% (25/111) presented with injuries, illness, or stress related to threats, violent behavior, or fear from a current or past partner. 46.4% (51/110) had a positive OVAT and 74.3% (81/109) had a positive AAS. 19.3% (21/109) admitted to ever being physically abusive to a partner. Most patients (19/21) who admitted perpetrating violence also screened positive on the OVAT and/or AAS. Overall, 80.0% (88/110) of patients had personal experience with IPV defined as having an IPV-related ED visit, positive OVAT, positive AAS, and/or admitting to perpetrating violence.Conclusions: IPV is prevalent in patients presenting for care to the GPHC ED with 22.5% of patients having a current visit related to IPV, 46.4% experiencing ongoing IPV, and 74.3% ever experiencing IPV. Although this study had a small sample size, these numbers are striking and higher than almost any previous reports. There was a large overlap between those who had experienced IPV and those who perpetrated physical violence, underscoring the complexities of addressing this issue. Future studies should continue to define the scope of the problem with the hope of developing effective interventions. Study Objectives: Intimate partner violence (IPV) is a complex public health problem with many health consequences. There is a paucity of research on IPV in patients presenting to emergency departments (EDs) in the developing world. We therefore sought to determine the prevalence of acute, ongoing, and lifetime IPV in patients presenting to the ED of the primary teaching hospital in a developing country. We also assessed the lifetime prevalence of perpetration of physical violence against a partner. Methods: This is a prospective cross-sectional pilot study conducted at Georgetown Public Hospital Corporation (GPHC) in Georgetown, Guyana. Guyana is an English-speaking country located in South America that is culturally and economically Caribbean. GPHC is the primary public referral hospital for the country with an annual ED volume of 75,000 patients. This study was conducted in January 2012. Consecutive patients were recruited during pre-identified 3-hour time blocks. Patients 18 years or older were eligible to participate. Patients too ill to be interviewed, triaged to receive care outside of the ED, or who could not be interviewed in private were excluded. Subjects completed an anonymous survey. They were asked 2 questions to determine if their current visit was related to IPV: "Are you here today because of injuries from a current or past partner?" and "Are you here today because of illness or stress related to threats, violent behavior, or fear from your current or past partner?" The Ongoing Violence Assessment Tool (OVAT) was used to assess current IPV and the Abuse Assessment Screen (AAS) assessed the lifetime prevalence of IPV. To assess perpetration, patients were asked, "Have you ever hit, slapped, kicked or done anything else physically abusive to an intimate partner?" The Institutional Review Board and the Guyana Ministry of Health approved this study. Results: 554 patients presented to the ED during the study time period. 187 patients met inclusion criteria. 47 patients refused consent and 25 were taken for care before completing the survey, leaving 115 patients for analysis. 53.9% (62/115) were female. 22.5% (25/111) presented with injuries, illness, or stress related to threats, violent behavior, or fear from a current or past partner. 46.4% (51/110) had a positive OVAT and 74.3% (81/109) had a positive AAS. 19.3% (21/109) admitted to ever being physically abusive to a partner. Most patients (19/21) who admitted perpetrating violence also screened positive on the OVAT and/or AAS. Overall, 80.0% (88/110) of patients had personal experience with IPV defined as having an IPV-related ED visit, positive OVAT, positive AAS, and/or admitting to perpetrating violence. Conclusions: IPV is prevalent in patients presenting for care to the GPHC ED with 22.5% of patients having a current visit related to IPV, 46.4% experiencing ongoing IPV, and 74.3% ever experiencing IPV. Although this study had a small sample size, these numbers are striking and higher than almost any previous reports. There was a large overlap between those who had experienced IPV and those who perpetrated physical violence, underscoring the complexities of addressing this issue. Future studies should continue to define the scope of the problem with the hope of developing effective interventions.

BACKGROUND:Pertussis is increasing among adolescents and adults despite universal childhood vaccination. This investigation describes an outbreak of pertussis among undergraduate students and assesses the burden of cough illness on a college campus.METHODS:Students presenting with prolonged cough were evaluated with culture, polymerase chain reaction (PCR), and serology. An e-mail survey was performed to determine the burden of cough illness on campus.RESULTS:Thirty-seven undergraduates were evaluated. Their mean duration of cough was 28 days. No student had cultures positive for B. pertussis; one was PCR positive. Ten (27%) had serologic values consistent with acute pertussis infection. The e-mail survey was returned by 225/500 (45%) students. Of these, 66 (29%; 95% confidence interval [CI], 23%-36%) reported a cough of 2 weeks or longer duration during the fall semester. A conservative estimate showed that the campus-wide incidence of a cough illness meeting the Centers for Disease Control and Prevention case definition for pertussis was 13% (95% CI, 10%-16%) during the fall semester.CONCLUSIONS:Adolescents and young adults are susceptible to pertussis infection. This study demonstrates that there was a substantial rate of pertussis infection during an outbreak on a college campus. Our findings support the routine use of the acellular pertussis vaccine in adolescents and adults.

OBJECTIVE: The objective of this study was to assess attitudes of patrons and medical school faculty about physicians with nontraditional facial piercings. We also examined whether a piercing affected the perceived competency and trustworthiness of physicians.DESIGN: Survey.SETTING: Teaching hospital in the southeastern United States.PARTICIPANTS: Emergency department patrons and medical school faculty physicians.INTERVENTIONS: First, patrons were shown photographs of models with a nontraditional piercing and asked about the appropriateness for a physician or medical student. In the second phase, patrons blinded to the purpose of the study were shown identical photographs of physician models with or without piercings and asked about competency and trustworthiness. The third phase was an assessment of attitudes of faculty regarding piercings.MEASUREMENTS AND MAIN RESULTS: Nose and lip piercings were felt to be appropriate for a physician by 24% and 22% of patrons, respectively. Perceived competency and trustworthiness of models with these types of piercings were also negatively affected. An earring in a male was felt to be appropriate by 35% of patrons, but an earring on male models did not negatively affect perceived competency or trustworthiness. Nose and eyebrow piercings were felt to be appropriate by only 7% and 5% of faculty physicians and working with a physician or student with a nose or eyebrow piercing would bother 58% and 59% of faculty, respectively. An ear piercing in a male was felt to be appropriate by 20% of faculty, and 25% stated it would bother them to work with a male physician or student with an ear piercing.CONCLUSIONS: Many patrons and physicians feel that some types of nontraditional piercings are inappropriate attire for physicians, and some piercings negatively affect perceived competency and trustworthiness. Health care providers should understand that attire may affect a patient's opinion about their abilities and possibly erode confidence in them as a clinician.

OBJECTIVE:Neonates with fever generally undergo a full, invasive septic evaluation to exclude serious bacterial infection (SBI). The risk of SBI in febrile older infants and children with documented respiratory syncytial virus (RSV) infection has been found to be negligible. The purpose of this study was to investigate the prevalence of SBI in febrile infants who were younger than 8 weeks and had documented RSV infection and to compare the risk of SBI with control subjects who were febrile and RSV-negative.METHODS:This was a retrospective cohort study of infants who were age 8 weeks or less and presented with documented fever to the emergency department at an urban children's hospital in October through April during a 4-year period. RSV-positive cases were gender- and age-matched to febrile RSV-negative control subjects. Clinical characteristics and the rate of SBI were compared between the 2 groups.RESULTS:A total of 174 previously healthy infants with fever and a positive RSV antigen test were identified and matched with 174 previously healthy infants with fever and a negative RSV test. Infants with RSV infection were more likely to present with upper respiratory infection symptoms, increased work of breathing, and apnea. Overall, 2 patients in the RSV group had SBI (both with urinary tract infections), compared with 22 in the control group (relative risk: 0.009), 17 of which were urinary tract infections.CONCLUSIONS:The risk of SBI in febrile infants with RSV infection seems to be very low, particularly in comparison with a control group of RSV-negative infants. These data suggest that full septic evaluations are not necessary in nontoxic-appearing infants with a positive RSV test. It seems to be prudent to examine the urine in these infants, as there is a clinically relevant rate of urinary tract infection.

Objectives The purpose of this study was to investigate patron attitudes toward a walk through a metal detector that was used for universal weapon screening in a pediatric emergency department. Additionally, we conducted a telephone survey to determine the nationwide prevalence of metal detectors in pediatric emergency departments. Methods A convenience sample of family and acquaintances of patients seen in the pediatric emergency department was selected, and members were interviewed using scripted questions. Members of the National Association of Children’s Hospitals and Related Institutions were interviewed for the nationwide survey. Results The vast majority of patrons responded favorably to the presence of the arch-style walk through a metal detector. The metal detector was felt to be appropriate in a pediatric emergency department by a large majority of patrons and was protective for both patrons and employees. Handbag searches were felt to be an invasion of privacy by 14%. Nationwide, the prevalence of arch-style metal detectors for security purposes in pediatric emergency departments was only 6%. Conclusions The public has a strong perception that a metal detector protects both patrons and employees in a pediatric emergency department. Fear that patrons will be disturbed or that the presence of a metal detector will reflect negatively upon the institution appear to be unfounded. Nationwide use of metal detectors in pediatric emergency departments remains uncommon but is apparently increasing.

OBJECTIVE: A large majority of urinary tract infections are caused by coliform organisms. Trimethoprim-sulfamethoxazole (TMP-SMX) resistance among uropathogens is increasing in many areas. The objective of this study was to determine risk factors for TMP-SMX-resistant coliforms in patients with urinary tract infections.DESIGN: Retrospective case-control study.SETTING: Emergency department of a tertiary care university hospital.PATIENTS: We studied 448 emergency department patients aged 14 years or older with a urinary tract infection caused by a coliform organism. Cases consisted of all patients with a culture-documented urinary tract infection caused by a TMP-SMX-resistant coliform, while control patients were those with a TMP-SMX-sensitive organism.MEASUREMENTS AND MAIN RESULTS: A univariate analysis of clinical variables associated with TMP-SMX resistance was performed. Multiple logistic regression was performed to determine independent predictors of TMP-SMX resistance. Resistance to TMP-SMX was seen in 15% of isolates. Numerous variables were associated with TMP-SMX resistance on the univariate screen. Independent predictors of resistance were diabetes (odds ratio [OR] 3.1; 95% confidence interval [CI] 1.2, 8.4), recent hospitalization (OR 2.5; 95% CI 1.1, 5.7), current use of antibiotics (OR 4.5; 95% CI 2.0, 10.2), and recent use of TMP-SMX (OR 5.1; 95% CI 2.2, 11.5). When those with recent hospitalization were excluded from analysis, independent predictors were current use of any antibiotic (OR 3.5; 95% CI 1.4, 8.4) and recent use of TMP-SMX (OR 5.9; 95% CI 2.4, 14.3).CONCLUSIONS: Coliforms resistant to TMP-SMX are common in our emergency department. Diabetes, recent hospitalization, and the use of antibiotics, particularly the use of TMP-SMX, are independent risk factors for TMP-SMX resistance, Clinicians should consider these findings when deciding on antimicrobial therapy for patients with urinary tract infections.

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Study objective: To determine whether history and clinical examination findings can identify young children who have sustained cervical injury after falling short distances. Methods: We conducted a retrospective review of the medical records of children younger than 6 years old with the diagnosis of cervical vertebral fracture or cervical spinal cord injury after a fall of less than 5 feet. Data from medical records over an average time span of 11 years at four large children's hospitals were compiled. Results: We identified eight children who sustained cervical spine injury after a fall of less than 5 feet. These children ranged in age from 9 to 68 months. Three had rotary subluxation of C1, and three had subluxation of C1–C2. One of the children in the latter group also had an odontoid fracture. Two children had a fracture of C2. All the children had limited range of motion of the neck or neck pain. Conclusion: All children in this study with the diagnosis of cervical spine injury had clinical evidence of that injury on history or physical examination. Clinicians treating asymptomatic young children who sustain short falls may not need to perform radiographic evaluation of the cervical spine. [Schwartz GR, Wright SW, Fein JA, Sugarman J, Pasternack J, Salhanick S: Pediatric cervical spine injury sustained in falls from low heights. Ann Emerg Med September 1997;30:249-252.]