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The Journal of Emergency Medicine 131

earch of the Cochrane Central Database of Controlled Trials,ubMed, and EmBase that yielded a total of 11 studies that met

he search criteria, with 8164 study participants (4241 receivednhaled corticosteroids, 3923 placebo). Significant heterogene-ty of studies was noted. There were differences in studyedications, doses of medication used, presence or absence of

ystemic steroids, and even in the definition of COPD exacer-ations. The combined study population characteristics showedmean forced expiratory volume over 1 second (FEV1) value

f � 50% in 7 of 11 studies, and a predominance of male studyarticipants. Overall, an 18% relative risk (RR) reduction inccurrence of exacerbations was found with the use of inhaledteroids compared to the use of placebo (RR 0.82; 95% confi-ence interval [CI] 0.73–0.92). The authors performed sensi-ivity analysis to examine the degree of benefit associated withariation in baseline FEV1, finding that benefit occurred only inatients with FEV1 � 50% (RR 0.79; 95% CI 0.69–0.89). Inontrast, their meta-regression showed that the reduction of riskf COPD exacerbation was not related to baseline FEV1 (slope

0.0057, intercept � 20.4598, Q � 10.06, P � 0.36). Theuthors conclude that there is modest benefit only to the use ofnhaled corticosteroids to prevent COPD exacerbation, and thatlthough the subgroup analysis shows increased benefit inatients with FEV1 � 50%, their meta-regression did notupport this conclusion.

[Janetta Iwanicki, MD

Denver Health Medical Center, Denver, CO]

Comment: One major limitation to drawing conclusionsrom this study is the heterogeneity of the studies included. Aredominance of studies had a low average FEV1 of � 50%,aking it difficult to truly analyze the effects of the treatment

n patients with less severe COPD at baseline. Additionally, aredominance of male study participants makes the data lesseneralizable to much of the population in real practice. Furthertudies in these groups may help to demonstrate a more nu-nced understanding of which patients may receive the greatestenefit from inhaled corticosteroids.

RISK OF FATAL DYSRHYTHMIC EVENTS INONG QT SYNDROME PATIENTS AFTER SYNCOPE.

ons C, Moss A, Goldenberg I, et al. J Am Coll Cardiol010;55:783–8.

In this retrospective observational study of 1059 patientsrom the International Long QT Syndrome (LQTS) Registry,he authors analyzed risk factors for sudden cardiac deathSCD) and severe dysrhythmic events (SDE) in a database ofatients with LQTS. The study group included 1059 LQTSegistry patients from 764 families with corrected QT intervalQTc) of � 450 milliseconds (ms). In these patients, beta-locker therapy was initiated at the discretion of the patient’shysician. The primary endpoint was SDE or SCD. A total of10 SDEs were captured, of which 39% occurred during beta-locker therapy. The incidence of syncope in these patients waspproximately 5% per year, whereas the incidence of SCD was.9% per year. In patients with LQTS, a non-fatal event was the

trongest predictor of a fatal event, with those who have expe- t

ienced syncope having a 5% incidence of SCD (compared to.9% in those not experiencing syncope). The authors foundhat patients who experienced syncope after the initiation ofreatment with beta-blockers had a 3.59-fold higher risk of SDEp � 0.001, 95% confidence interval [CI] 2.25–5.74). Thoseatients who had multiple episodes of syncope before initiationf beta-blocker therapy had a hazard ratio of 1.96 for SDE (p

0.001, 95% CI 1.37–2.82). Female patients aged 14 to 40ears had a 1.86-fold higher risk (p � 0.001, 95% CI 1.40–.49), whereas those with QTc � 500 ms had a hazard ratio of.76 (p � 0.001, 95% CI 1.32–2.27).

[Charles M Reynolds, MD

Denver Health Medical Center, Denver, CO]

Comment: Patients with LQTS are at increased risk for SDEnd SCD. This study, although limited by its retrospectiveature, suggests that syncope or other non-fatal events confern increased risk of fatal events in these patients regardless ofhether or not they are receiving anti dysrhythmic treatment.

FAST FOOD AND NEIGHBORHOOD STROKEISK. Morgenstern LB, Escobar JD, Sanchez BN, et al. Anneurol 2009;66:165–70.

This observational cohort study evaluated the associationetween ischemic stroke and the density of fast food restaurantsn an area of Southern Texas. Study subjects were those witherebrovascular disease identified from the records from allocal hospitals, neurology offices, and the county coroner.eighborhoods were assessed for the number and location of

ast food restaurants. The distance from the homes of the strokeictims to fast food restaurants was calculated. A neighborhoodcore representing neighborhood disadvantage was calculatedsing median household income, median value of occupiedousing units, percent of households receiving interest, dividedr net rental income, percent of adults who completed highchool, percent of adults who completed college, and percent ofdults whose occupation was classified as managerial or pro-essional. Demographic information such as age, gender, race,nd neighborhood scores were examined with regard to strokeisk for the neighborhood, as was the number of fast foodestaurants. A total of 1246 stroke cases were identified. Thessociation between the number of fast food restaurants andtroke was found to be statistically significant, with the risk oftroke within a neighborhood increasing by 1% for every fastood restaurant in the neighborhood, even after adjusting foremographics and neighborhood score. The relative risk foreighborhoods in the 75th percentile for number of fast foodestaurants vs. those in the 25th percentile was 1.13 (95%onfidence interval 1.02–1.25). There was also an associationetween neighborhood score and fast food restaurants, althoughhis did not reach statistical significance.

[Colleen Foster, MD

Denver Health Medical Center, Denver, CO]

Comments: This study is limited by its observational designnd absence of controls. Furthermore, although the authors did

heir best to control for confounding, there are likely important

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132 Abstracts

onfounders that were not accounted for, making the associa-ion between fast food restaurants and stroke more question-ble. Nonetheless, this article raises an important question withegard to the health effects of too many fast food restaurants inoo many disadvantaged neighborhoods.

THE ROSE (RISK STRATIFICATION OF SYNCOPEN THE EMERGENCY DEPARTMENT) STUDY. ReedJ, Newby DE, Coull AJ, et al. J Am Coll Cardiol 2010;55:

13–21.This single-center prospective observational study was de-

igned to develop a clinical decision rule to predict seriousutcomes and all-cause mortality within 1 month of emergencyepartment (ED) presentation with a syncopal episode. Seriousutcomes were defined as acute myocardial infarction, life-hreatening cardiac dysrhythmia, need for pacemaker or im-lantable defibrillator placement, pulmonary embolism, acutetroke, acute intracranial hemorrhage, significant hemorrhageequiring blood transfusion, need for acute surgical interven-ion, or need for acute endoscopic procedure. A total of 550atients were included in the derivation cohort, with a subse-uent additional 550 patients included in the validation cohort.xamination of the data for the initial 550 patients using

ogistic regression analysis identified seven presenting featuresf patient history, examination, or laboratory values associatedith serious outcomes or death: B-type natriuretic peptide level

300 pg/mL, bradycardia � 50 in the ED or pre-hospital,ectal examination showing fecal occult blood, anemia withemoglobin � 90 g/L, chest pain associated with syncope,lectrocardiogram showing Q wave (not in lead III), and oxy-en saturation � 94% on room air. The rule recommends thatny patient with one or more of these criteria be admitted to theospital for observation. When applied to the validation cohort,he rule was found to have a sensitivity, specificity, positive andegative predictive values, and positive and negative likelihoodatios of 87.2%, 65.5%, 16.5% and 98.5%, and 2.5 and 0.2,espectively. The authors conclude that using this rule in thealidation cohort would have resulted in 80 fewer admissions,o additional deaths, and missing five serious outcomes (ele-ated troponin, ventricular tachycardia, subarachnoid hemor-hage, basal ganglia hemorrhage, and gastric ulcer). They sug-est that their rule is favorable compared to prior clinicalecision rules regarding syncope because the ROSE rule is ableo avoid admissions without compromising sensitivity. How-ver, no specific numeric comparisons are provided.

[Janetta Iwanicki, MD

Denver Health Medical Center, Denver, CO] c

Comment: This study provides yet another means of eval-ating patients with syncope for potentially life-threateningtiologies. Unfortunately, the sensitivity and negative likeli-ood ratios are poor, raising the question of whether or not thisule is as useful as the authors would have us believe. Althoughhe rule would have decreased admissions by 29%, five seriousutcomes were missed, representing more than 12% of allerious outcomes. Further study is needed to validate the safetyf this rule and to compare it to other prediction rules inxistence.

SUPERFICIAL VENOUS THROMBOSIS AND VE-OUS THROMBOEMBOLISM: A LARGE, PROSPEC-IVE EPIDEMIOLOGIC STUDY. Decouses H, Quere I,resles E, et al. Ann Intern Med 2010;152:218–24.

In this multicenter prospective, observational, cohort studyonducted in a French subspecialist referral setting, the authorsvaluated the incidence of concomitant deep venous thrombo-is (DVT) and pulmonary embolism (PE) in 844 consecutiveatients with symptomatic superficial venous thrombosisSVT) of the lower extremities measuring at least 5 cm onompression ultrasonography. Among this cohort of patientsresenting with SVT, 210 (24.9%) had either DVT (198 sub-ects, 23.5%) or PE (33 subjects, 15.7%) at the time of presen-ation with SVT. Patients with SVT were treated in a hetero-eneous fashion by vascular specialists: among the 600 patientsith DVT or PE, 62.9% received low-molecular-weight hepa-

ins (LMWH) at treatment doses and 36.7% received LMWH atrophylactic doses. Almost all (97.7%) received compressiontockings, whereas 47.2% received topical non-steroidal anti-nflammatory medications. Despite treatment for SVT, 18 sub-ects developed either DVT (15 subjects, 2.8%; 95% confi-ence interval [CI] 1.4–4.2), or PE (3 subjects, 0.5%; 95% CI–1.2). The authors also considered 28 subjects with eitherxtension or recurrence of SVT to be part of the thromboem-olic complications group.

[Charles M Reynolds, MD

Denver Health Medical Center, Denver, CO]

Comment: This study confirms that patients with SVT are atncreased risk for concomitant DVT/PE. In addition, patientsith SVT are at slightly increased risk for development of DVTr PE. It is unclear how emergency physicians should incor-orate this information into their daily practice besides simplyncreasing their level of suspicion for thromboembolic compli-

ations in patients with isolated SVT.