The Journal of Emergency Medicine 121

that damage to vasculature, formation of clots, increase in bloodpressure, or utilization of antipsychotics as a result of the injurymay lead to stroke in the time period after injury. The study wasconducted in Taiwan via their National Health Insurance Pro-gram, which included 1,000,000 individuals randomly sampledfrom the registry of beneficiaries. Enrollment consisted of adultswith first-time TBI without current or history of strokes, totaling23,199 TBI patients. Cases were matched to three randomlychosen beneficiaries with similar characteristics of sex, age,and year of index. Total enrollments of 92,796 patients were fol-lowed for 5 years after index use of health care. Primary endpoint was use of ambulatory care, emergency medical services,or hospitalization for acute stroke. Mean age was 41.6 years;TBI patients were statistically more likely to have hypertension,diabetes, coronary artery disease, atrial fibrillation, or heart fail-ure than those in the comparison cohort. Patient risk of stroke inTBI vs. non-TBI was 2.9% vs. 0.30% at 3 months, 4.17 vs. 0.96at 1 year, and 8.20 vs. 3.89 at 5 years. After adjusting for con-founders, a diagnosis of TBI was associated with hazard ratios(HR) for stroke of 10.21, 4.61, and 2.32 at 3-month, 1-year,and 5-year follow-up. Stratification revealed that risk of strokewas higher in patients with skull fractures than those without,HR at 19.98, 8.39, and 3.54, respectively, for the same timeperiods. Risk of subarachnoid and intracerebral hemorrhage in-creased more in patients with TBI than without, with adjustedHR for subarachnoid of 4.89 and intracerebral HR at 6.33.This study had limitations in that it could evaluate only thosecases where patients sought treatment for TBI or stroke. Inaddition, this study did not have access to data on mechanismof TBI, and risk factors such as body mass index, diet, activitylevel, smoking, and alcohol consumption that may have alteredthe findings.

[Matt Taecker, MD

Denver Health Medical Center, Denver, CO]

Comments: Although limited by its design and of question-able generalizability, this study raises the specter of significantrisk of stroke for patients who have suffered TBI. Further pro-spective studies should be undertaken to validate these findingsand to attempt to delineate anymodifiable risk factors in patientswho have suffered TBI.

, COMPARATIVE EFFECTIVENESS OFANTIBIOTICTREATMENT STRATEGIES FOR PEDIATRIC SKINAND SOFT-TISSUE INFECTIONS. Williams DJ, CooperWO, Kaltenbach LA, et al. Pediatrics 2011;128:479–87.

This was a retrospective cohort study of 47,501 children aged0–17 years comparing the effectiveness of treatment withtrimethoprim-sulfamethoxazole (TMP-SMX) or a b-lactam vs.clindamycin in drained and undrained skin and soft-tissueinfections (SSTI). Children with an SSTI and prescriptionfor either clindamycin (reference treatment), trimethoprim-sulfamethoxazole, or a b-lactam (penicillin or cephalosporin)filled within 2 days of the SSTI were included in the studyand grouped based on drainage status. Exclusion criteria in-cluded: SSTI within the last 365 days, treatment with multi-ple agents, treatment with topical antibiotics, SSTI requiringhospital admission, burns, foreign bodies, or surgical-site

infections. Effectiveness of each antibiotic therapy was de-fined with respect to risk of treatment failure (SSTI within14 days) or risk of recurrence (SSTI within 15 and 365days of the initial SSTI). The study found 6407 childrenwho underwent drainage, of which there were 568 (8.9%)treatment failures and 994 (22.8%) recurrences. The adjustedodds ratios (OR) for treatment failure with TMP-SMX andb-lactams were 1.92 (95% confidence interval [CI] 1.49–2.47) and 2.23 (95% CI 1.71–2.90), respectively, showingthat the odds of treatment failure is nearly doubled with ei-ther antibiotic when compared to clindamycin. The risk ofrecurrence in the drainage group was also significantlyhigher with both TMP-SMX (adjusted hazard ratio [HR]1.26; 95% CI 1.06–1.49) and b-lactams (adjusted HR 1.42;95% CI 1.19–1.69) when compared to clindamycin. Of the41,094 children without a drainage procedure, there were2435 (5.9%) treatment failures and 5436 (18.2%) recur-rences. The adjusted odds ratios for treatment failure were1.67 (95% CI 1.44–1.95) for TMP-SMX and 1.22 (95% CI1.06–1.44) for b-lactams. With respect to recurrences, therisk of recurrence in the group without drainage was signif-icantly higher with TMP-SMX (adjusted HR 1.30; 95% CI1.18–1.44) but not with b-lactams (adjusted HR 1.08; 95%CI 0.99–1.18) when compared to clindamycin. Theresearchers concluded that the use of TMP-SMX andb-lactams is associated with higher risk of treatment failureand recurrence when compared to clindamycin, especiallyin SSTIs where a drainage procedure is required, as theseare commonly purulent SSTIs where community-acquiredmethicillin-resistant Staphylococcus aureus is likely thepredominant organism. b-lactams, however, may still beeffective in SSTIs not requiring drainage (non-purulent) asthese are more commonly colonized by Streptococcusspecies, for which b-lactams and clindamycin show equalefficacy.

[Lina Tran, MD

Denver Health Medical Center, Denver, CO]

Comment: This retrospective study is limited by its designand in its generalizability, as the bacteria and sensitivity of thosebacteria that were responsible for the SSTIs in this study areunknown and may not be similar to other geographic areas. Inaddition, the high treatment failure rates seen suggest somekind of confounding that may not have been taken into accountby the authors.

, PREDICTORS OF EARLY AND LATE CASE-FATALITY IN A NATIONWIDE DANISH STUDY OF26,818 PATIENTS WITH FIRST-EVER ISCHEMICSTROKE. Andersen KK, Andersen ZJ, Olsen TS. Stroke2011;42:2806–12.

This study used data from the Danish National Indicator Pro-ject to retrospectively identify predictors of early case-fatality(3-day, 7-day, and 30-day) as well as late case-fatality (90-dayand 1-year) in patients with first-ever ischemic stroke. Itincluded 26,818 patients, all of whom were hospitalizedfor a first-ever ischemic stroke in Denmark between 2000and 2007. Multiple logistic regression identified stroke severity

122 Abstracts

(as defined by the Scandinavian Stroke Scale) and age as signif-icant predictors of 3-day, 7-day, and 30-day case fatality. Inter-estingly, 3-day and 7-day case-fatality rates stabilized atages > 70 years, and the 3-day case fatality rates even declinedat ages > 85 years. The authors postulated that this may havebeen secondary to a ‘‘survival of the fittest’’ phenomenon whereold age is associated with superiority in surviving disease. Theonly other variable identified as a significant predictor of earlycase-fatality was atrial fibrillation, which predicted 30-daycase fatality with an odds ratio (OR) of 1.56. Predictors oflate case-fatality included age and stroke severity, as well asatrial fibrillation (OR 1.37 at 90 days and 1.57 at 1 year) anddiabetes (OR 1.35 at 90 days and 1.33 at 1 year). Additionally,previous myocardial infarction (OR 1.40), male gender (OR1.28), and smoking (OR 1.21) were significantly associatedwith 1-year case fatality. Variables that were not significantlyassociated with case-fatality rates included hypertension, alco-hol consumption, intermittent arterial claudication, and maritalstatus.

[Mike MillerDenver Health Medical Center, Denver, CO]

Comments:Although limited by its retrospective design, thislarge-scale study adds to a growing body of literature onsurvival after an ischemic stroke, and identifies age and strokeseverity as important predictors of both early- and late-casefatality. Cardiovascular risk factors were mainly associatedwith late-case fatality, with the exception of atrial fibrillationand its association with 30-day case-fatality. Like other large-scale stroke studies, this study identified sex as an importantpredictor of late case-fatality, a finding that is not observed inmost studies with < 20,000 individuals.

, OUTCOMES OF HOSPITALIZED PATIENTSWITH NON-ACUTE CORONARY SYNDROME ANDELEVATED CARDIAC TROPONIN LEVEL. McFalls EO,Larson G, Johnson GR, et al. Am J Med 2011;124:630–5.

This study examined the outcomes of patients with elevatedtroponin levels but with non-acute coronary syndrome with datafrom 2006 from the Veterans Affairs (VA) centralized database.All patients seen during this year who had an elevated troponinduring their index hospitalization were included and categorizedas acute coronary syndrome (ACS) or non-acute coronary syn-drome (non-ACS). Data for patients who died or who had a lowexpectation of survival based on discharges to hospice, skillednursing/community nursing, or an inpatient stay > 30 dayswere excluded, as they might not have been deemed eligiblefor cardiac imaging. Troponin results exceeding the 99th percen-tile of the upper reference limit for each hospitalization, medicalcenter, and each quarter of the fiscal year were utilized aspositive results. Researchers gathered hospital utilization datafor 1 year after the reference hospitalization, identified patientswho subsequently received cardiac imaging during hospitaliza-tion or within 90 days of reference hospitalization, then ana-lyzed re-hospitalizations or death within 1 year. In 2006,523,314 unique patients were admitted to the VA: 127,929had troponin measurements, 95,840 patients remained afterexclusion of deaths or low expectation of survival, 21,668

were troponin positive, 9268 were classified as ACS, and12,400 as non-ACS. Non-ACS mortality at 1 year was 22.8%,compared to 17.5% for ACS (odds ratio [OR] 1.38; 95% confi-dence interval [CI] 1.29–1.48). OR for death was 2.5 (95% CI2.13–2.92) for non-ACS patients that did not receive cardiac im-aging during hospitalization or within 90 days (OR 2.06; 95%CI 1.67–2.55). Among non-ACS patients, the most frequentdiagnosis involved the cardiovascular system. Within thatgroup, congestive heart failure and coronary artery diseasewere the most common clinical diagnoses. Specific therapiesadministered as a result of elevated markers and the rationalefor not obtaining cardiac imaging are also not known.

[Matt Taecker, MD

Denver Health Medical Center, Denver, CO]

Comments: Although limited by its retrospective nature, thisstudy highlights once again the important mortality risk amongpatients who present to the hospital with elevated troponinswithout the classic defining characteristics of ACS. A prospec-tive study would be helpful to determine whether any specificfeatures are unique to patients with the worst outcomes or ifchanges in management could alter mortality risk.

, ROLE OF CONSERVATIVE MANAGEMENT INTRAUMATIC AORTIC INJURY: COMPARISON OFLONG-TERM RESULTS OF CONSERVATIVE, SURGI-CAL, AND ENDOVASCULAR TREATMENT. MosqueraVX,Marini M, Lopez-Perez JM, et al. J Thorac Cardiovasc Surg2011;142:614–21.

Historically, the treatment of blunt traumatic aortic injuryhas been dichotomously defined by either open surgical repairand graft interposition or conservative medical management.However, the advent of endografting technologies over thepast 10 years has yielded another option for the managementof these rare but often devastating injuries. This study out ofSpain is one of a few large single-center retrospective studiescomparing the early and long-term outcomes of patients withacute traumatic aortic injury (ATAI) who were conservativelymanaged vs. those who underwent open surgical or endovascu-lar repair. The 30-year study identified 66 patients with bothminor ATAI (intramural hematoma without intimal tear or inti-mal tear < 10 mm) and major ATAI (transection or intimaltear > 10 mm or aneurysm/pseudoaneurysm) and divided theminto three groups depending on treatment intention at the timeof admission: conservative (n = 37), surgical (n = 22), and endo-vascular (n = 7). The primary outcomes were in hospital mortal-ity, late mortality (at 1, 5, and 10 years), and long-term survivalfree from aorta-related complications. The study found thatoverall in-hospital mortality was 18.2% and there was no statis-tically significant difference between the conservative group(21.6%), surgical group (22.7%), and the endovascular group(14.3%) (p = 0.57). One hundred percent of all in-hospitalaorta-related complications occurred in the conservative group(p < 0.001). Kaplan-Meier estimates of long-term survival inall groups were: 81.2% at 1 year, 75.1% at 5 years, and 72.7%at 10 years. In the conservative group, survival was 75.6%at 1 year, 72.3% at 5 years, and 66.7% at 10 years; whereasin the surgical group, survival remained at 77.2% at 1, 5, and