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The Journal of Emergency Medicine 459

ncluding revascularization procedures, which were not consid-red cardiac events for the purpose of the study.

DO PRESENTING SYMPTOMS EXPLAIN SEX DIF-ERENCES IN EMERGENCY DEPARTMENT DELAYSMONG PATIENTS WITH ACUTE STROKE? Gargano

W, Wehner S, Reeves MJ. Stroke 2009;40:1114–20.This cohort study reviewed 1922 acute stroke cases at 15

ifferent Michigan hospitals, comparing time to physician ex-mination (“door-to-doctor”) and time to computed tomogra-hy scan (“door-to-image”) for men and women. Data werebstracted from a statewide stroke registry, and individualymptoms were aggregated into five stroke warning signs:umbness/weakness, confusion/speech, vision, walking/dizzi-ess/balance, and headache. The authors’ intent was to testhether different presentations could account for sex differ-

nces in time intervals. Suspected strokes were identified bycreening for any mention of stroke or transient ischemic attackn the chief complaint field. Cases were limited to emergencyepartment (ED) presentations. Patients were further sub-rouped by time from symptom onset to arrival in the ED: �h, 2 to � 6 h, and � 6 h/unknown onset to arrival interval.he groups had similar baseline characteristics, although theomen were more likely to be older, to be nursing home

esidents, and to be non-ambulatory, but less likely to haveeart disease or to smoke. Men were more likely than womeno present with difficulty with walking/balance/dizziness13.7% to 9.5%, p � 0.01), as well as with any warning sign91.4% to 87.5%, p � 0.01). When assessing the relationshipetween warning sign and door-to-doctor or door-to-imageime, confusion/speech difficulty was associated with decreasedime ratios (0.87, 95% confidence interval [CI] 0.78–0.96oor-to-doctor and 0.88, 95% CI 0.82–0.96 door-to-image),hereas walking/dizziness/balance and vision problems were

ssociated with significantly increased time ratios for botheasures. However, when controlling for these variations,omen still had an 11% longer door-to-doctor time (time ratio.11, 95% CI 1.02–1.22) and 115% longer door-to-image timetime ratio 1.15, 95% CI 1.08–1.25).

[Marlow Macht, MD,

Denver Health Medical Center, Denver, CO]

Comment: This well-designed study demonstrates yet an-ther instance where a clear disparity exists in ED processingimes for men and women with the same chief complaint.lthough the study did not control for neurological examina-

ion or measure outcomes, the findings are concerning. Furtheresearch might focus on the reason for such delays, disparitiesn outcome related to such delays, or interventions designed toliminate such disparities.

CORTICOSTEROIDS IN THE TREATMENT OF SE-ERE SEPSIS AND SEPTIC SHOCK IN ADULTS: AYSTEMATIC REVIEW. Annane D, Bellissant E, BollaertE, et al. JAMA 2009;301:2362–75.

The authors of this systematic review evaluated the effects

f corticosteroids on 28-day all-cause mortality in patients with C

evere sepsis and septic shock, and as a secondary objectivehey investigated the effects of a lower total daily dose of 300g or less of hydrocortisone (or equivalent) and a treatment

uration of at least 5 days on patients’ outcomes. Additionalecondary outcomes included intensive care unit length of stay,hock reversal, and serious adverse events (e.g., gastrointestinalleeding, superinfection, hyperglycemia, hypernatremia, andeuromuscular weakness). Studies were identified from re-earch databases, referenced articles of qualifying studies, un-ublished data from trial authors, and proceedings of majoreetings. The authors included 17 randomized studies (n �

138) and three quasi-randomized trials (n � 246), pooled intometa-analysis. Overall, they found no significant effect of

orticosteroid treatment on 28-day mortality for treated vs.ontrol patients; 35.3% vs. 38.5% in randomized trials (RR.84; 95% confidence interval [CI] 0.71–1.00; p � 0.05), and3.1% vs. 19.2% in quasi-randomized trials (RR 1.05; 95% CI.69–1.58; p � 0.83). However, subgroup analysis of 12 ran-omized trials (n � 1228) examining prolonged low-doseorticosteroid treatment found that 28-day mortality improvedor treated vs. control patients (37.5% vs. 44.1%; relative riskRR] 0.84; 95% CI 0.72–0.97; p � 0.02), confirmed by meta-egression analysis. Finally, this review also demonstrated thatorticosteroid therapy was not associated with an increased riskf gastroduodenal bleeding (8.1% treated vs 7.3% controls, p �.5), superinfection (18.4% treated vs. 17.9% controls, p �.92), or acquired neuromuscular weakness (1% treated vs.7% controls, p � 0.58). The authors concluded that althoughhere is no evidence to support higher doses of steroids in theherapy of septic patients, there may be value to a prolongedourse of a lower dose.

[Margaret Sande, MD, MS,

Denver Health Medical Center, Denver, CO]

Comment: Although this review suggests that a prolongedourse of low-dose corticosteroids may have a measurableffect on overall mortality, there is inherent variability in thencluded studies with regard to the optimal corticosteroid treat-ent strategy, and the real answer remains elusive. It is en-

ouraging that the investigation did not show a higher rate oferious adverse events, allowing clinicians to feel more com-ortable initiating a corticosteroid trial. There is still a need fordditional studies to determine optimal corticosteroid dosing,ptimal time of treatment initiation, optimal duration of treat-ent, and optimal weaning strategy.

EVALUATION OF THE ACCURACY OF DIFFER-NT METHODS USED TO ESTIMATE WEIGHTS INHE PEDIATRIC POPULATION. So TY, Farrington E,basher RF. Pediatrics 2009;123:E1045–51.

This prospective observational study from North Carolinaought to compare the accuracy of three existing methods tostimate the weight of children. Additionally, it identified sev-ral predictive factors that were used to derive two new weight-stimation models. Subjects were selected from children under0 years old who were inpatients at the University of North

arolina’s Children’s Hospital. The Broselow tape, Leffler

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460 Abstracts

ormula, and Theron formula were used to estimate the weightf each subject, which was then compared to actual weightsing analysis of variance on the percentage difference of thealues. Several subgroups were examined to determine theccuracy of estimation between different weight ranges. Addi-ional comparisons were made with subgroups of underweight,ormal weight, and overweight subjects. The results showedhat the Broselow tape was more accurate for subjects � 40 kgp � 0.05) (although the Broselow tape was not statisticallyignificantly better than the Leffler formula for subjects from5.1–40 kg.) The Theron formula performed better for subjectseighing � 40 kg (p � 0.05). For normal-weight children, theroselow tape was statistically significantly more accurate than

he Leffler and Theron formulas. For underweight children, theroselow tape and Leffler formula were more accurate than theheron formula. For overweight children, the Leffler formulaerformed better than the Theron formula, although it wasoted that the Theron formula was better for children whoeighed � 40 kg. The authors also identified three predictors

or weight estimation, age, gender, and race, and used theseredictors to derive two new weight estimation models. Oneodel was a linear model using a separate coefficient for

nfants vs. children, whereas the second was a log-linear modelhat used one formula for all ages. In conclusion, the authorstated that the Broselow tape is the most accurate weight-stimation method among most patients aged � 10 years old,ut acknowledge that better methods are needed for overweighthildren, especially in light of increasing rates of childhoodbesity. They also concluded that new models, such as the twoeveloped during this study, could be more accurate, but re-uire additional validation.

[Colleen Foster, MD,

Denver Health Medical Center, Denver, CO]

Comments: Although this study is not immune to selectionias and the weight subgroups were not evenly divided, it doesemonstrate that each of the currently available weight-estimationethods are less accurate within certain pediatric subgroups, and

hat further work is needed to develop more accurate tools that areractical to use in a clinical setting.

IMPROVED PATIENT SURVIVAL USING A MODI-IED RESUSCITATION PROTOCOL FOR OUT OFOSPITAL CARDIAC ARREST. Graza AG, Gratton MC,alomone JA, et al. Circulation 2009;119:2597–604.

The Emergency Medical System in Kansas City, MO im-lemented a revised cardiac arrest protocol in 2006 after theirardiac arrest survival rates showed no improvement over theast decade in spite of automatic external defibrillators. Theevised protocol aimed to improve coronary perfusion pressurehrough more effective chest compressions. The logic is basedn the three-phase time-dependent model for cardiac arrestesuscitation where quality chest compressions can increase theyocardium adenosine triphosphate, reversing the acidic envi-

onment created by ischemia that is not favorable to cardiover-ion. The study used the revised protocol to examine survival

ates for out-of hospital, witnessed, cardiac arrest patients with t

presumed cardiac origin who were in ventricular fibrillation.he survival rates of the study group were compared to aistorical control group. The survival of out-of-hospital arrestsmproved from 7.5% in the historical cohort to 13.9% in theevised protocol cohort (odds ratio [OR] 1.80; 95% confidencenterval [CI] 1.19–2.70). Increases in the return of spontaneousirculation improved from 37.8% to 59.6% (OR 2.44; 95% CI.24–4.80). Survival to hospital discharge also improved from2.4% to 43.9% (OR 2.71; 95% CI 1.34–1.59). The authorsonclude that the pre-hospital protocol for witnessed adultardiac arrest, which optimizes compressions and reduces dis-uptions from compressions, improves survival.

[Elisa Dannemiller, MD, MBA,

Denver Health Medical Center, Denver, CO]

Comment: Although the study attempted to capture theypical cardiac arrest patient with prolonged downtime andinimal resuscitation in the first few minutes, the revised

rotocol would not apply to patients who can be electricallyardioverted in the first several minutes after arrest where theyocardium is highly receptive to electric cardioversion. Aajor concern that raises questions as to the validity of the

tudy relates to the very high survival to discharge of 43.9%.his is far higher than most centers report and, given thebsence of neurologic capacity in this group, one is left toonder what survival truly means. Still, the study does rein-

orce the concept of early cardiopulmonary resuscitation inmproving outcomes in cardiac arrest.

ASPIRIN VS ANTICOAGULATION IN CAROTIDRTERY DISSECTION. Georgiadis D, Arnold M, vonuedingen HC, et al. Neurology 2009;72:1810–5.

This prospective, non-randomized cohort study enrolled98 consecutive patients from 1987 to 2005 with spontaneousnternal carotid artery dissection, and compared those treatedith systemic anticoagulants to those treated with aspirin alone.he authors assessed the incidences of ischemic events, symp-

omatic intracranial bleeding, and major extracranial bleedingt 3 months after the dissection. On enrollment, dissection wasonfirmed by magnetic resonance imaging or digital subtrac-ion angiography. Outcomes were assessed by neurologicalxamination at 3 months in 97% of patients, and by structuredelephone interview in 3%. Treatments were chosen by theeneral practitioner or neurologist caring for the patient, result-ng in 202 treated with heparin and warfarin, and 96 treatedith aspirin alone. The authors note that treatment allocation

hanged over time, with patients recruited later being moreikely to receive aspirin. The groups had similar baseline char-cteristics, except 26.2% in the anticoagulant group and 38.5%n the aspirin group were current smokers (p � 0.03). None ofhe endpoints had a statistically significant difference betweenhe two groups. Recurrent ischemic events occurred in 5.9% ofatients treated with anticoagulants and 2.1% of patients treatedith aspirin (odds ratio 3.0, 95% confidence interval 0.7–13.5).ymptomatic intracranial bleeding occurred in 2 patients

reated with anticoagulants and none treated with aspirin. Two