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The Journal of Emergency Medicine 557

etrospective, and by the fact that histological studies on brainutopsies were done only when macroscopic abnormalitiesere present.

INTRAVENOUS DRUG ADMINISTRATION DUR-NG OUT-OF-HOSPITAL CARDIAC ARREST: A RAN-OMIZED TRIAL. Olasveengen T, Sunde K, Brunborg C, et

l. JAMA 2009;302:2222–9.This prospective randomized trial from Norway had the

bjective of determining if removing intravenous (IV) drugdministration from advanced cardiac life support (ACLS)uidelines on adult non-traumatic cardiac arrests treated in there-hospital setting improves survival to hospital discharge. Alldult patients in Oslo, Norway, with non-traumatic out-of-ospital cardiac arrest over a 5-year period were randomized bymbulance personnel to either ACLS with access to IV drugdministration or ACLS without IV drug administration. Thereere 1183 patients with out-of-hospital non-traumatic cardiac

rrest resuscitated in this period; 946 patients were included inhe study. Of the 946 patients, 851 were successfully random-zed. In the IV group, 44 of 418 patients (10.5%) survived toospital discharge. In the no-IV group, 40 of 433 (9.2%)urvived to hospital discharge (odds ratio [OR] 1.16; 95%onfidence interval [CI] 0.74–1.82; p � 0.61). Short-termurvival was better in the IV group; 40% of the IV groupchieved return of spontaneous circulation (ROSC) vs. 25% inhe no-IV group (OR 1.99; 95% CI 1.48–2.67; p � 0.001). Inubgroup analysis, no difference in short- and long-term out-omes for patients with shockable rhythms was found. ROSCas threefold higher in the IV group (p � 0.001), but noifference in long-term outcomes were found because survivalates among those admitted to the Intensive Care Unit in theo-IV group were almost threefold higher than the IV groupp � 0.07). The quality of cardiopulmonary resuscitation (CPR),secondary outcome measured, was comparable between the

wo groups, indicating to the authors that administration of IVrugs did not interfere with the administration of CPR.

[Stacy Trent, MD, MPH

Denver Health Medical Center, Denver, CO]

Comments: This study raises important questions as to thetility of IV drugs during resuscitation in non-traumatic cardiacrrest, although it did not demonstrate harm, as another studyas. It also highlights the hazard of using ROSC as a primaryutcome in these kinds of trials. Further analysis of the patientsho survived to hospital discharge without significant cerebralisability would be a useful post hoc analysis that could helpdentify which patients may benefit from ACLS drugs duringesuscitation.

BELIEFS AND BARRIERS TO FOLLOW-UP AFTERN EMERGENCY DEPARTMENT ASTHMA VISIT: AANDOMIZED TRIAL. Zorc JJ, Chew A, Allen JL, et al.ediatrics 2009;124:1135–42.

Pediatric emergency departments (EDs) serve a sizable

sthmatic population nationwide, and in urban settings, ensur- t

ng follow-up with a primary care provider (PCP) is oftenuboptimal and thought to lead to more frequent return EDisits as well as decreased asthma-related quality of lifeAQoL). This study aimed to design and test a three-partntervention with two primary aims: to influence patient familyeliefs regarding the importance of preventive care and tomprove PCP follow-up. Secondary outcomes included evalu-tion of the need for return ED visits and AQoL during the 6onths after presentation. A total of 433 subjects presenting to

n urban pediatric ED with asthma symptoms that were suitableor discharge home were assigned to the control or interventionroup. Control patients received instructions to follow-up withPCP in 3–5 days. Intervention patients 1) received a letter to

ake to their PCP noting that they had screened positive forersistent asthma, 2) watched an educational video that ad-ressed the importance of regular asthma treatment and PCPollow-up, and 3) received a mailed reminder to schedule a PCPollow-up appointment. All participants were given a survey atime of ED discharge that measured perceived benefits andarriers to follow-up after an ED visit, and whereas bothontrol and intervention participants endorsed positive beliefsegarding the need for follow-up, intervention participants rec-gnized that asthmatic children with regular PCP follow-upave fewer ED visits, miss less school, and have fewer asthmaymptoms. However, when an identical survey was repeated 3onths after their ED visit, no statistically significant differ-

nces were noted in the responses given by the two groups. Allarticipants were contacted at 1, 3, and 6 months for a tele-hone survey to address patient symptoms since the ED visit,QoL, date(s) of PCP follow-up (confirmed by PCP), and

eturn ED visits. Symptoms, AQoL, likelihood of and time toCP follow-up, and repeat ED visits were similar betweentudy groups. Although this study concluded that their three-art ED-based intervention did not improve follow-up or othereasured outcomes, it was hypothesized that this may have

een because the effect of a single intervention was studied orhat a more interactive format might be more efficacious.

[Margaret Sande, MD, MS

Denver Health Medical Center, Denver, CO]

Comment: Although this study was interesting in that itttempted to influence patient family beliefs regarding themportance of long-term asthma control in hopes of directingare to more regular PCP visits and lessen the need for EDisits, it was unable to achieve its objective. Nonetheless, it isorth recognizing that visits to the ED can provide “teachableoments” that, over time and with reiteration, may prove

eneficial.

HIGH-FLOW OXYGEN FOR TREATMENT OF CLUS-ER HEADACHE: A RANDOMIZED TRIAL. Cohen AS,urns B, Goadsby PJ. JAMA 2009;22:2451–7.

This randomized, control double-blind crossover study outf the United Kingdom (UK) evaluated the treatment of clustereadaches with high-flow oxygen vs. placebo. Subjects wereecruited from various clinics and support groups, primarily

hrough the Organisation for Understanding Cluster Headache

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558 Abstracts

UK). Seventy-six patients fully completed the study betweenhe years 2002 and 2007. Fifty-seven subjects with episodicluster headaches (bouts of attacks lasting 7 days with over aonth between attacks), as well as 19 with chronic headaches

defined as occurring for more than a year with less than aonth between attacks), were included in the study. Patients

elf-administered canisters of either 100% oxygen or air for 15in at the start of an attack. If there was no relief within 15in, patients were able to use any other rescue medication they

esired. This was repeated through four attacks. Canisters wereabeled treatment 1, treatment 2, treatment 3, and treatment 4.atients reported results in a diary at the 15-, 30-, 45-, and0-minute mark. The primary outcome measure was absence ofain or adequate relief from attack at 15 min. Secondaryutcomes included pain reduction at any further time marks,eed for rescue medications, and effect on associated symp-oms. Of the patients that participated, 78% receiving 100%xygen had symptom resolution or adequate pain control at 15in (95% confidence interval [CI] 71–85% over 150 attacks)

s. 20% receiving air (95% CI 14–26% over 148 attacks).here were not any significant adverse affects of the interven-

ion. These results demonstrate that 100% oxygen for 15 min isetter than high-flow room air to treat symptoms of clustereadache when applied at symptom onset.

[Whitney Barrett, MD

Denver Health Medical Center, Denver, CO]

Comment: Headache is one of the most common presentingomplaints in the emergency department. Although clustereadaches are only occasionally identified as the cause, thistudy would seem to indicate that when they are the etiology,hey should be treated with 100% oxygen. Although the studyas very small and subject to recall bias as well as the Haw-

horne effect, the results were very impressive and both statis-ically and clinically significant. One unanswered question isow oxygen works in this disease.

ASSOCIATION OF HOSPITAL PRIMARY ANGIO-LASTY VOLUME IN ST-SEGMENT ELEVATIONYOCARDIAL INFARCTION WITH QUALITY ANDUTCOMES. Kumbhani DJ, Cannon CP, Fonarow GC, et al.

AMA 2009;302:2207–13.This study applied recent data to study in-hospital mortality

mong patients presenting with ST-segment myocardial infarc-ion (STEMI) who underwent primary angioplasty at hospitalslassified as low, medium, or high volume hospitals based onhe number of primary angioplasties performed in a year. Givenhat several studies using data from 1994–1998 indicated thathere is an inverse relationship between hospital angioplastyolume and mortality in patients presenting with STEMI, thepplication of recent data to study this relationship incorporatedhanges in practice such as regular use of stents, dual antiplate-et therapy, and glycoprotein IIb/III a inhibitors, and standard-zation of care. The data included 29,513 patients with STEMIrom 166 angioplasty-capable hospitals from across the Unitedtates. Participating hospitals were divided into tertiles accord-

ng to volume of angioplasty: � 36 procedures per year, 36–70 m

rocedures per year, and � 70 procedures per year. Thirty-sixas chosen as the minimum threshold given that the latestuidelines recommend that angioplasty-capable hospitals per-orm a minimum of 36 angioplasties annually. The authorsoncluded that although higher volume angioplasty hospitalsere associated with shorter door-to-balloon time compared toedium and low volume hospitals (88 vs. 90 vs. 98 min,

espectively, p � 0.001) the length of stay was similar amongroups and there was no difference with in-hospital mortality3.2% vs. 3.2% vs. 3.9%, respectively). Additionally, all orone adherence with six key quality-of-care measures was lessikely in the low volume hospitals compared with the higholume hospitals (odds ratio 0.68; 95% confidence interval.49–.94; p � 0.02). Because less than a third of United StatesUS) hospitals do not achieve the recommended 36 angioplas-ies a year, the authors tested various additional volume thresh-lds and still did not find volume to be associated with in-ospital mortality. Consequently, this study argues against theationale that procedural volume is an adequate surrogate foruality of care.

[Elisa M. Dannemiller, MD, MBA

Denver Health Medical Center, Denver, CO]

Comment: Shorter door-to-balloon times and adherence touality-of-care guidelines have been associated with betterlinical outcomes. This study did not observe a difference withn-hospital mortality despite observed differences in door-to-alloon times and adherence to quality-of-care guidelines.mong several potential reasons for this discrepancy: 1) The

tudy did not evaluate mortality over a long enough time periodo capture accurate outcome data; 2) Selection bias existsmongst the participating hospitals given that the participatingospitals that have the ability to track and collect data are moreikely to adhere to guidelines and standardization of care;) Recent efforts to standardize care and create clinical careathways has greatly improved care within all facilities, allow-ng lower volume hospitals to offer a similar quality of careespite the fact that they do not adhere to guidelines as well asigher volume facilities.

D-DIMER TESTING IN PATIENTS WITH SUSPECTEDULMONARY EMBOLISM AND IMPAIRED RENALUNCTION. Karami-Djubani R, Frederikus K, Kooiman J,t al. Am J Med 2009;122:1050–3.

This study from the Netherlands aimed to determine thetility of D-dimer testing in patients with impaired renal func-ion. Because renal impairment is associated with elevated-dimer concentrations, the specificity of D-dimer testing inatients with suspected pulmonary embolism (PE) and im-aired renal function is reduced. Additionally, computed to-ography (CT) scanning in patients with impaired renal func-

ion is relatively contraindicated given the possibility oforsening renal function from contrast nephropathy. As a

esult, the diagnostic algorithms currently studied for diagnos-ng PE may be less efficacious in patients with renal impair-

ent than in patients with normal renal function. Utilizing this