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228 Abstracts

sthma, previous study enrollment, significant chest X-raytudy findings varying from COPD, a hypersensitivity to pred-isolone, or known medication non-compliance were excluded.atients received either 60 mg of i.v. or oral prednisolone for 5ays, followed by a taper. All patients received albuterol andpratroprium nebulized four times a day, antibiotics, spirome-ry, and health status measurements (St. George Respiratoryuestionnaire) on days 1 and 7, and daily quality of lifeeasurements for the first 7 days using the Clinical COPDuestionnaire. The primary outcome measure was treatment

ailure (defined as death from any cause, Intensive Care Unitdmission, readmission to the hospital for COPD, and in-ensified treatment). Treatment failure was divided into earlynd late (first 2 weeks vs. 2 weeks to 90 days). Secondaryutcomes included airflow measurements, health status,uality of life, and length of hospital stay. There were 210atients who met eligibility requirements and were random-zed to one of the treatment arms. Baseline patient charac-eristics were similar between the two groups. Althoughreatment failures, specifically late failures, were higher thanxpected (59%), no differences between the two groups wereound for any of the primary or secondary outcomes, leadinghe authors to conclude that oral prednisolone is not inferioro intravenous prednisolone for the treatment of acute COPDxacerbations.

[Maria G. Frank, MD,

Denver Health Medical Center, Denver, CO]

Comment: Although small and marred by a very high treat-ent failure rate, this study demonstrates once again that i.v.

nd oral steroids are equivalent in their efficacy.

ANTIBIOTICS FOR ADULTS WITH CLINICALLYIAGNOSED ACUTE RHINOSINUSITIS: A META-NALYSIS OF INDIVIDUAL PATIENT DATA. Young J,e Sutter A, Merenstein D, et al. Lancet 2008;371:908–14.

This meta-analysis pooled nine randomized trials identifiedrom the Cochrane, Medline and Embase databases to assesshe prognostic value of common signs and symptoms of rhi-osinusitis and the overall effect of antibiotic treatment ofatients with this condition. Trials were selected from all thosetudies randomly assigning placebo vs. antibiotics in adultatients with rhinosinusitis complaints. The suitable trials usedn the meta-analysis were selected by investigators based on thedentification of patients for treatment based on clinical symp-oms and physical findings of rhinosinusitis alone and not basedn any diagnostic studies. Despite differences in the methodsy which follow-up was obtained (e.g., patient diaries, tele-hone interview), the antibiotics used, and the clinical inclusionriteria, the selected trials maintained an intention-to-treat anal-sis and logical treatment of missing data. The intention-to-reat population from the nine trials consisted of 2640 patientshere the primary outcome was clinical cure from the illness asefined by the authors of the original publications. In theggregated data, the estimated odds ratio for overall treatmentffect of antibiotics was 1.35 with a number needed to treat of

5 before one additional patient benefited from treatment with b

ntibiotics. The treatment effect was almost independent ofnderlying risk, with an overall cure rate of 64% achieved at 14ays in patients without antibiotic treatment. Authors con-luded that the majority of signs and symptoms have littlerognostic value, with only purulent discharge in the pharynxnd fever (odds ratios of 1.6 and 1.28, respectively) being theost likely to benefit from treatment with antibiotics. Authors

lso looked at length of symptoms before enrollment and foundo difference in cure rates when patients presented 6 days orore from the onset of symptoms. Patients reporting a longer

uration of symptoms took longer to achieve cure but receivedo benefit from the addition of antibiotics to their treatmentegimen. The conclusions of this study were that antibioticsffer little benefit to patients with acute rhinosinusitis com-laints and that particular signs and symptoms do not helpistinguish patients whom are most likely to benefit from thoseho are not. Although many guidelines suggest such treatment

fter 7–10 days of symptoms, the authors suggest that antibi-tics are not justified in this situation unless signs of a moreerious complication are present.

[Todd Guth, MD,

Denver Health Medical Center, Denver, CO]

Comment: Although hampered by all of the limitationsnherent to a meta-analysis, this study once again providesvidence that antibiotics are unhelpful in treating patients withymptoms of rhinosinusitis no matter how long their symptomsave been present. Unfortunately, patients seeking care for thisroblem may yet need further convincing.

INITIATING A HOSPITAL-WIDE PEDIATRIC SE-ATION SERVICE PROVIDED BY EMERGENCY PHY-ICIANS. Yamamoto LG. Clin Pediatr (Phila) 2008;47:37–48.

This observational study from the University of Hawaiiescribes the use of a hospital sedation team managed bymergency physicians to provide deep sedation to 133 pediatricatients and the effects on patient care and hospital financialerformance. Over a 10-month period, a sedation team wasade available for all procedures requiring sedation outside themergency Department. The majority of patients were sedatedith propofol alone, some received ketamine, and 2 patients

eceived both drugs. The procedures and studies requiring seda-ion included magnetic resonance imaging scans, hematology-ncology procedures, computed tomography scans, nuclear med-cine studies, electroencephalograms, and surgical procedures.he sedation process was facilitated by having the physician setp pre-sedation clearance 7 days in advance, and having a nurseelephone service call the family to advise of what to expectnd to make sure the child had nothing by mouth before therocedure. Also, a sedation nurse was made available for allrocedures. During this 10-month period, there were eightocumented adverse events, including three cases of hyp-xia, three cases of apnea, three cases of noisy breathing,nd two cases of coughing. No endotracheal intubationsere required. After establishment of the sedation team, the

acklog of hematology-oncology procedures and radiologic

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The Journal of Emergency Medicine 229

tudies was eliminated. The authors concluded that havingn emergency-physician-based sedation service improvedatient care and was financially beneficial to their hospital.

[Jessica Brooks, MD,

Denver Health Medical Center, Denver, CO]

Comment: This study is narrow in its scope given that itakes into account only one emergency medicine group’s ex-erience with initiating a sedation team. However, it doesndicate that using emergency physicians to staff a hospitaledation team may be beneficial both for patients and hospitalfficiency.

RISK FOR SYMPTOMATIC INTRACEREBRAL HEM-RRHAGE AFTER THROMBOLYSIS ASSESSED BYIFFUSION-WEIGHTED MAGNETIC RESONANCE IM-GING. Singer OC, Humpich MC, Fiehler J, et al. Ann Neurol008;63:52–60.

This study analyzed patients with acute ischemic stroke andvaluated the risk of developing symptomatic intracerebralemorrhage (sICH) after the administration of thrombolyticreatment. Patients were studied using data obtained retrospec-ively from a previous multi-center prospective trial. In total,45 patients with anterior circulation strokes were studied. Allatients received intravenous or intra-arterial thrombolysisithin 6 h of symptom onset. Patients were divided into threere-treatment groups based on magnetic resonance diffusion-eighted imaging (DWI) stroke lesion size: 1) small (� 10L), 2) moderate (10–100 mL), and 3) large (� 100 mL). Of

he 645 patients studied, 44 (6.8%) developed sICH afterhrombolysis. There was a significant difference of sICH in thehree pre-treatment groups, with rates of 2.8%, 7.8%, and6.1% in patients with small, moderate, and large DWItroke lesions, respectively (p � 0.05). In addition, pre-reatment DWI lesion size was an independent risk factor forotential sICH when evaluating multiple factors with logis-ic regression analysis. The authors concluded that DWIesion size is an important risk factor for the development ofICH after thrombolysis in acute stroke and that thrombo-ytics should be used judiciously in patients with large DWIesions.

[Elijah Edwards, MD,

Denver Health Medical Center, Denver, CO]

Comment: The use of thrombolytics in acute ischemictroke continues to be a controversial topic in emergencyedicine. This study demonstrates another tool that emergency

hysicians may use to guide treatment in ischemic stroke. IfWI magnetic resonance is available acutely, it may offer more

nformation to the treating physician and help to avoid poten-ially dangerous sICH after thrombolysis.

MEDICATION USE LEADING TO EMERGENCYEPARTMENT VISITS FOR ADVERSE DRUG EVENTS

N OLDER ADULTS. Budnitz DS, Shehab N, Kegler SR, et al.

nn Intern Med 2007;147:755–65. p

This study was an analysis of data compiled from theational Electronic Injury Surveillance System-Cooperativedverse Drug Event Surveillance (NEISS-CADES), Nationalmbulatory Medical Care Survey (NAMCS), and the Nationalospital Ambulatory Medical Care Survey (NHAMCS). It

ttempted to estimate the number of Emergency DepartmentED) visits for adverse drug events involving medications thaty consensus have been deemed potentially inappropriate forse in elderly patients (Beers criteria) compared with otheredications. By searching the NAMCS and NHAMCS data-

ases, the number of outpatient prescriptions written for Beersriteria as well as other more suitable medications was deter-ined. Data from patients aged 65 years or older seeking ED or

utpatient care in 58 non-pediatric hospitals participating inEISS-CADES from January 1, 2004 to December 31, 2005ere also obtained and were used to estimate ED visits for

dverse drug events that were defined as events that the phy-ician attributed to the use of a drug or to a specific drug effect.isits related to intentional overdose for self harm, therapyithdrawal, drug abuse, adverse events that occurred as a resultf treatment in the ED, and follow-up visits for previouslyiagnosed adverse events were excluded. In 10.5% of all out-atient visits, a prescription was written for a Beers criteriaedication. In an additional 9.4% of visits, a prescription wasritten for an appropriate anticoagulant, antiplatelet, or oralypoglycemic agent. On the basis of 4492 reported events, theuthors estimated that in 2004 and 2005 there were 177,504 EDisits annually for adverse drug events nationwide. Of those,.6% were related to medications listed in the Beers criteria,hereas 47.5% of events were related to oral anticoagulants,

ntiplatelet agents, oral hypoglycemics, and narrow therapeuticndex agents not listed in the Beers criteria. Thus, the numberf visits for adverse drug events was lower than expected foreers criteria medications, but significantly higher than ex-ected for certain agents not included in those criteria.

[Maria G Frank, MD,

Denver Health Medical Center, Denver, CO]

Comment: Although it is fraught with methodologic limita-ions, this article serves as a reminder of the peril associatedith the prescription of many common medications in the

lderly. Emergency physicians need to weigh the risks andenefits of such prescriptions carefully. An important questionot addressed in this article relates to interactions betweenedications and how often adverse events are related to those.

MATERNAL CAFFEINE CONSUMPTION DURINGREGNANCY AND THE RISK OF MISCARRIAGE: AROSPECTIVE COHORT STUDY. Weng X, Odouli R, Li. Am J Obstet Gynecol 2008;198:279.E1–8.

This population-based prospective cohort study was de-igned to address the issue of maternal caffeine consumptionuring pregnancy affecting the risk of miscarriage before the0th week of gestation. The study identified 2729 English-peaking, newly pregnant patients over a 2-year period from theaiser Permanente Medical Care Program, of which 1063

atients ultimately enrolled in the study and completed the