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492 Abstracts

asal discharge with unilateral predominance, local pain withnilateral predominance, purulent nasal discharge bilaterally,r pus on inspection inside the nose. The patients were thenandomized to four different treatment arms: antibiotic (500 mgf amoxicillin three times per day for 7 days) and a nasalteroid (200 �g of budesonide in each nostril once per day for0 days); placebo antibiotic and nasal steroid; antibiotic andlacebo nasal steroid; placebo antibiotic and placebo nasalteroid. The outcome data were obtained from a self-reportedatient diary that included 11 symptom variables and a ques-ionnaire. Patients were then divided into those with symptomsasting � 10 days compared to those who were symptom free.he proportions of patients with symptoms lasting 10 days orore were 29 of 100 (29%) for amoxicillin, compared to 36 of

07 (33.6%) for no amoxicillin (odds ratio 0.99). The propor-ions of patients with symptoms lasting 10 or more days were2 of 102 (31.4%) for topical budesonide, compared to 33 of05 (31.4%) for no budesonide (odds ratio 0.93). The authorsonclude that among patients with typical features of acuteacterial sinusitis, neither an antibiotic nor a topical steroidlone or in combination is effective in altering the symptomeverity, duration, or natural history of acute sinusitis in therimary care setting.

[Brad Talley, MD,

Denver Health Medical Center, Denver, CO]

Comment: This is a well-designed study that provides usefulvidence against the use of antibiotics for sinusitis in an era ofncreasing bacterial resistance. However, one limitation of thetudy is the unvalidated inclusion criteria used to define thetudy population. It is therefore possible that a number of theatients included in the study may not have actually had acuteacterial sinusitis, which could theoretically have affected theesults.

MRI-BASED AND CT-BASED THROMBOLYTICHERAPY IN ACUTE STROKE WITHIN AND BE-OND ESTABLISHED TIME WINDOWS: AN ANALY-IS OF 1210 PATIENTS. Schellinger PD, Thomalla G,iehler J, et al. Stroke 2007;38:2640–5.

Thrombolytic therapy is the only approved treatment forcute ischemic stroke and is currently approved in the Unitedtates only for therapy guided by computed tomography (CT)

maging and treatment within 3 h of onset of symptoms. Thistudy evaluated the safety and efficacy of magnetic resonancemaging (MRI) and CT-based thrombolytic therapy in acuteschemic stroke in 1210 patients from five European strokeenters. Each patient was prospectively enrolled and placed inne of three groups: CT-based therapy under 3 h, MRI-basedherapy under 3 h, or MRI-based therapy over 3 h. CT or MRIelection for therapy was not randomized, but particular to eachenter’s protocol. Thrombolytic therapy was conducted withtandard-dose recombinant tissue plasminogen activator infu-ion. Timing was based on the interval from the onset of symp-oms to the time of treatment and was irrespective of imaging time.

ean time to treatment was 130 min for the CT � 3 h group, 135

in for the MRI � 3 h group (not significant), and 240 min for b

he MRI � 3 h group. Safety outcomes were defined bypontaneous intracranial hemorrhage and mortality rates,hereas efficacy outcomes were defined by a modified Rankincore of 0–1. Of note, the MRI � 3 h group had a significantlyigher National Institute of Health Stroke Scale score of 14ompared with 12 and 13 for CT � 3 h and MRI � 3 h groups,espectively. Mortality was not significantly different betweenroups, with a mean of 13.1%. Patients grouped in an all-MRI-ased treatment group showed a trend toward decreased spon-aneous intracranial hemorrhage when compared to the all-CT-ased treatment group, but this was not significant. There waso significant difference between groups when comparing theercentage of patients with modified Rankin Scores of 0–1.he authors conclude that MRI-based thrombolytic therapyeems to be safe and more efficacious than the current standardf CT-based thrombolytic therapy for acute ischemic stroke.

[Zachary D. Tebb, MD,

Denver Health Medical Center, Denver, CO]

Comment: This was a retrospective study that pooled datarom different centers. In the absence of the review methodol-gy, it is impossible to know how robust the results truly are.his study reported treatment benefits in all of its arms farigher than are usually seen with stroke care. Consequently, allf the results and conclusions must be considered potentiallyuspect. Still, the idea that MRI could afford patients thepportunity to receive treatment outside of the standard 3-hindow for consideration is one that should be evaluatedrospectively.

PREVALENCE OF HIV INFECTION AMONG INPA-IENTS AND OUTPATIENTS IN DEPARTMENT OFETERANS AFFAIRS HEALTH CARE SYSTEMS: IM-LICATIONS FOR SCREENING PROGRAMS FORIV. Owens DK, Sundaram V, Lazzeroni LC, et al. Am Jublic Health 2007;97:2173–8.

This study from six Veterans Affairs hospitals around thenited States determined both the inpatient and outpatientrevalence of human immunodeficiency virus (HIV) after col-ecting associated demographic data and information on comor-idities in patients aged 25 years and older. A total of 4500utpatient and 4205 inpatient specimens were tested, with aotal of 326 of those samples confirmed positive for HIV.utpatient prevalence was 4.3% and inpatient prevalence was.1%. Of the 326 patients testing positive for HIV, 273 had arevious positive HIV test result. Therefore, out of 8705 pa-ients tested, there were only 53 new cases identified. Theuthors concluded that, based on the prevalence of HIV in theelected population, voluntary screening would be indicated.his is consistent with the Centers for Disease Control andrevention guidelines recommending screening in health careettings where the prevalence of HIV is � 0.1%.

[Andrew French, MD,

Denver Health Medical Center, Denver, CO]

Comment: Although this study is difficult to generalize

ased on selection bias, it adds support to the Centers for

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The Journal of Emergency Medicine 493

isease Control recommendations for HIV screening in healthare settings based on the prevalence of disease. The questionsf efficacy and cost remain to be addressed.

MOTORCYCLE SAFETY AND THE REPEAL OFNIVERSAL HELMET LAWS. Houston DJ, Richardson LE

r. Am J Public Health 2007;97:2063–9.This study used cross-sectional time series data from the 50

tates and the District of Columbia for the period 1975 through004 to examine the relationship between state helmet laws andotorcycle fatality rates. Trends in motorcyclist fatality rates in

he states in which recent repeals of universal coverage haveeen instituted were also addressed. Thirty observations wereade for each of the 51 cross-sections, each corresponding todifferent year, for a total of 1530 state-year observations.

atality counts were divided by the annual number of registeredotorcycles in each state, with the dependent variable as the

nnual number of motorcyclist fatalities per 10,000 registeredotorcycles. To control for variations across states, several

dditional variables were analyzed using regression models.hese included two binary variables representing whether atate law requires all or only some riders to wear a helmet;tates with no laws represented the omitted reference category.

inimum legal drinking age of 21 years, an illegal bloodlcohol concentration of 0.08, a maximum speed limit of 65iles per hour or higher, state climate, age, percentage of male

dults, alcohol consumption, per capital income, and popula-ion density were also included. Approximately one less fatalityer 10,000 registered motorcycles occurred in states with uni-ersal coverage than in states with partial or no laws (95%onfidence interval � �1.44 to �0.66), translating into an1.1% fatality rate reduction. In states in which recent repealsf universal coverage have been instituted, the motorcyclistatality rate increased by an average of 12.2% over what wouldave been expected had universal coverage been maintained.atality rates in states under partial coverage were not statisti-ally different from those with no helmet law. Minimum legalrinking age of 21 years was correlated with lower fatality ratesp � 0.01), whereas blood alcohol concentration law andaximum speed limits were not statistically significant. Per-

entage of young adults and percentage of the population aged0–69 years were positively correlated with fatality rates, asere alcohol consumption and income per capita. Fatality ratesere negatively correlated with population density. Climateariables had no statistically significant correlate with fatalityates. The authors conclude that motorcyclist safety has beenompromised in the states that have repealed universal cover-ge and is likely to be compromised in other states that abandonhese statutes.

[Susan Brion, MD,

Denver Health Medical Center, Denver, CO]

Comment: There are extensive data supporting the use ofelmets in the prevention of motorcycle fatalities. This study isnique in its efforts to control for state characteristics to prop-rly estimate the effects of helmet laws on motorcycle fatality

ates. Although it relies heavily on estimated multivariate mod- i

ls, this study provides an interesting and timely perspective onther factors correlated with motorcycle safety and changes inelmet laws.

IMPROVED NEUROLOGICAL OUTCOME WITHONTINUOUS CHEST COMPRESSIONS COMPAREDITH 30:2 COMPRESSIONS-TO-VENTILATIONS

ARDIOPULMONARY RESUSCITATION IN A REAL-STIC SWINE MODEL OF OUT-OF-HOSPITAL CAR-IAC ARREST. Ewy GA, Zuercher M, Hilwig RW, et al.irculation 2007;116:2525–30.

This study was designed to compare post-resuscitation neu-ological outcome of animals using the 2005 guideline-recom-ended single-bystander 30:2 cardiopulmonary resuscitation

CPR) compared to continuous chest compressions (CCC)ithout ventilations, in animals models with ventricular fibril-

ation (VF) arrest. Sixty-four animals (swine) underwent in-uced ventricular fibrillation. These animals were then ran-omly assigned to four experimental groups, each groupndergoing differing lengths of VF: 3, 4, 5, and 6 min, respec-ively, before the initiation of cardiopulmonary resuscitation.

ithin each group, the animals were randomly assigned toeceive either CCC without assisted ventilations or 30:2 CPR30 chest compressions with two assisted ventilations). After 12in of VF, all animals were given the first defibrillation at-

empt, followed by the advanced cardiac life support until thenimal was fully resuscitated. The neurological status of thenimals was then evaluated at 24 h, with normal neurologicalunction being the primary outcome measured. Secondary endoints included return of spontaneous circulation, the presencef a perfusing rhythm after the first defibrillation attempt, andhe overall 24-h survival of the animal. When all of the groupsere combined, the number of neurologically normal survivors4 h after resuscitation was 23 of 33 (70%) in the continuoushest compression group compared with 12 of 31 (42%) in the0:2 CPR group (p � 0.025). The overall 24-h survival andeturn of spontaneous circulation were not statistically signifi-ant between the two groups, p � 0.217 and p � 0.126,espectively. A perfusing rhythm after the first shock occurredn 21 of 33 (64%) in the CCC group compared to 9/31 (29%)n the 30:2 CPR group (p � 0.006). The authors concluded thatn out-of-hospital VF cardiac arrest, initial bystander adminis-ration of continuous chest compressions without assisted ven-ilations could result in better post-resuscitation neurologicalunction compared to initial bystander administration of 30:2PR, likely due to the consistent cerebral perfusion without

nterruptions to provide breaths during CPR.[Brad Talley, MD,

Denver Health Medical Center, Denver, CO]

Comment: Although this study is the first to look ateurological outcome in VF arrest using the new guideline-ecommended 30:2 CPR compared to continuous chest com-ressions, it is limited by the fact that this was done on swineodels. It is unclear if these results would be the same or

an be applied to a human model that may have differences

n chest wall compliance, baseline coronary artery disease,