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230 Abstracts

equired interviews and follow-up. Overall, patients wereategorized into two groups: 1) those consuming � 200g/day or 2) those consuming � 200 mg/day based on the

etails of interviews and self-reporting diaries. For every50 mL of a beverage consumed that study subjects re-orted, the authors estimated 100 mg of caffeine for coffee,9 mg for tea, 15 mg for soda, and 2 mg for hot chocolate.ompared with non-users of caffeine (12%), the rates ofiscarriage among women who consumed � 200 mg/day of

affeine (15%) and � 200 mg/day (25%) were significantlyncreased. The authors calculated an adjusted hazard ratioaHR) of 1.42 for caffeine users of � 200 mg/day and 2.23or caffeine users of � 200 mg/day compared to non-users.n initial analysis, caffeine intake was associated with aariety of additional risk factors: age � 35 years, prioriscarriage, smoking, alcohol consumption, and use of

acuzzis. The authors then performed a stratified analysis ofnumber of confounders that did not change the overall

ffect of caffeine increasing the miscarriage rates. Addition-lly, the specific symptoms of nausea and vomiting weressessed as potential confounders and shown not to changehe overall increase in miscarriage rates in patients consum-ng larger amounts of caffeine.

[Todd Guth, MD,

Denver Health Medical Center, Denver, CO]

Comment: Recognizing the difficulties in assessing caffeinese through self-reporting and personal diaries and the use ofstimates to quantify actual caffeine use as limitations in thistudy, the authors nicely detailed their data demonstrating theffect of excessive caffeine use increasing a woman’s risk ofiscarriage before the 20th week of pregnancy. Emergency

hysicians should warn patients presenting with early preg-ancy to decrease or abstain from caffeine intake.

CONTEMPORARY MANAGEMENT OF ACUTE EX-CERBATIONS OF COPD: A SYSTEMATIC REVIEWND META-ANALYSIS. Quon BS, Gan WQ, Sin DD. Chest008;133:758–66.

This review and meta-analysis identified randomizedontrolled trials published in English from January 1968 toovember 2006 that examined evidence for use of systemic

orticosteroids, antibiotics, and non-invasive positive pres-ure ventilation (NPPV) in patients with acute chronic ob-tructive pulmonary disease (COPD) exacerbations. Tentudies with a total of 959 patients were identified examininghe role of systemic corticosteroids in acute COPD exacer-ations, 11 studies with a total of 1020 patients examined theole of antibiotics, and 14 studies with a total of 979 patientsxamined the role of NPPV. Two independent authors ex-mined the studies and extracted the data. When possible,esults were pooled to produce summary effects. Relativeisks and confidence intervals were calculated when resultsere dichotomous. Systemic corticosteroids reduced treat-ent failure by 46% compared with placebo (relative risk

RR] 0.54; 95% CI 0.41– 0.71; p � 0.27) and reduced

ospital length of stay (LOS) by a mean of 1.42 days (95% h

I 0.65–2.18; p � 0.40). Hyperglycemia was the only re-orted adverse event. Antibiotic use decreased treatmentailures when given to hospitalized patients (RR 0.34; 95%I 0.20 – 0.56; p � 0.48) but not in the outpatient setting.

n-hospital mortality was reduced by 78% in three studiesith the use of antibiotics (RR 0.22; 95% CI 0.08 – 0.62; p �.92). NPPV reduced intubation rates by 65% (RR 0.35;5% CI 0.26 – 0.47; p � 0.82), in-hospital mortality by 55%RR 0.45; 95% CI 0.30 – 0.66; p � 0.99), and LOS by a meanf 1.94 days (95% CI 0.01–3.81). The authors concludedrom this study that corticosteroids in acute COPD exacer-ation were beneficial in both in- and outpatient settings,ntibiotics were beneficial only in hospitalized patients (al-hough data and studies were largely heterogeneous), andPPV was beneficial particularly in patients with respiratory

cidosis (pH � 7.35).[Jessica Brooks, MD,

Denver Health Medical Center, Denver, CO]

Comment: This study is limited by the heterogeneity that isnherent in meta-analyses. Its results are helpful, however, bothn identifying subjects for further prospective study and inelineating the effects of certain treatments on acute COPDxacerbations.

CLINICAL OUTCOME OF PATIENTS WITH UPPER-XTREMITY DEEP VEIN THROMBOSIS. Muñoz JF,ismetti P, Poggio R, et al. Chest 2008;133:143–8.This study used data from an international multi-center

egistry called RIETE that is prospectively collecting consec-tive patients presenting with symptomatic, acute deep veinhrombosis (DVT) or pulmonary embolism (PE) confirmed bybjective tests. The authors analyzed demographic characteris-ics, treatment, and 3-month clinical outcomes of patients withpper-extremity (UE) DVT and lower-extremity (LE) DVT.he study evaluated 11,564 patients in the registry, of whom12 (4.4%) had UE DVT. Patients with UE DVT presentedith PE less often (9.0% vs. 29%, respectively) compared to

hose with LE DVT. Of the 512 patients with UE DVT, 196atients (38%) had cancer and 228 patients (45%) had catheter-elated DVT. At 3-month follow-up, patients with cancer-elated UE DVT had increased incidence of major bleeding,ecurrent venous thromboembolism, and death when comparedo non-cancer-related UE DVT. The authors concluded thatlthough UE DVT may not present with PE as often as LEVT, there is significant morbidity and mortality associatedith UE DVT, particularly in patients with cancer-related UEVT.

[Elijah Edwards, MD,

Denver Health Medical Center, Denver, CO]

Comment: Although this study is observational with notandardized treatment regimen, it identifies a patient popula-ion that is high risk in patients with UE DVT. As emergencyhysicians, it is important to recognize that patients presentingith UE DVT may have significant underlying disease and

ave the potential for serious life-threatening illnesses.