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Endovascular Repair of Traumatic Rupture of the Aortic Isthmus: Midterm Results
The Journal of Emergency Medicine patients before and after implementation of an integrated system linking emergency medical service (EMS) stroke recognition and triage to designated stroke centers in Brooklyn and Queens, New York. In May of 2003, 14 hospitals were designated as stroke centers after first meeting survey criteria and subsequent site visits to ensure compliance with Brain Attack Coalition (BAC) core criteria. During this same time period, the EMS system in Brooklyn and Queens implemented a new protocol resulting in triage of all possible acute stroke patients meeting predetermined criteria to the designated stroke centers. Comparison of stroke centers at baseline relative to re-measurement demonstrated a significant decrease in average time to computed tomography (25 vs. 10 min, respectively, p ⬍ 0.001) and an increase in stroke unit admissions (30% vs. 56%, respectively, p ⬍ 0.001). Relative to 18 non-designated centers, the 14 stroke centers significantly decreased median time to tissue plasminogen activator (t-PA) administration (115 vs. 95 min, respectively, p ⬍ 0.05), admitted more patients to stroke units (11% vs. 56%, respectively, p ⬍ 0.001), and trended towards treating more eligible patients with t-PA (23% vs. 44%, respectively, p ⫽ 0.08). The authors conclude that establishing BAC designated stoke centers and selective triage of acute stroke patients led to more timely assessment, diagnosis, and treatment of acute stroke patients without an increase in t-PA protocol violations. [Peter Vraniak, MD, Denver Health Medical Center, Denver, Colorado] Comments: In establishing stroke centers and implementing a specialized triage protocol, this study effectively improved upon several quality care measures for acute stroke patients in one urban community. As the authors note, this system may not be applicable in a rural setting where transfer time to a stroke center may be significantly longer. It should also be noted that after designation as stroke centers, the 14 hospitals underwent further continuing educational training to encourage adherence to BAC core criteria. Simply designating stroke centers by survey and site visit in conjunction with similar EMS triage protocols may not produce the same results without significant further investment in continuing education.
e ENDOVASCULAR REPAIR OF TRAUMATIC RUPTURE OF THE AORTIC ISTHMUS: MIDTERM RESULTS. Marcheix B, Dambrin C, Bolduc JP, et al. J Thorac Cardiovasc Surg 2006;132:1037– 41. This prospective, non-randomized study reported the midterm results of endovascular repair of traumatic aortic injury in 33 patients at one center in France. All patients underwent infrainguinal iliofemoral access, received prophylactic broad-spectrum antibiotic coverage during the procedure, and were treated postoperatively with aspirin 325 mg daily. Follow-up was assessed with transesophageal echocardiography, computed tomography (CT), or magnetic resonance (MR) at 3, 6, 12, and 18 months. The patients were then followed with CT or MR annually. The immediate primary success rate, defined by complete exclusion of the false aneurysm, was 91%. Three patients experienced primary
433 endoleaks and were effectively treated with thrombosis. At a mean follow up of 2.7 years, all stent grafts were patent. There were no deaths, secondary endoleaks, migrations, or infections. Two midterm complications included an asymptomatic thrombus at 2.9 years and a stent fracture at 7 years. The authors conclude that endovascular repair of blunt traumatic aortic injury is safe and effective with low midterm morbidity and mortality. [Peter Vraniak, MD, Denver Health Medical Center, Denver, Colorado] Comment: This study reports encouraging results for endovascular repair of traumatic aortic injury. It is difficult to generalize upon the results of a multidisciplinary team at one center, as was the case in this study. As the authors note, a controlled, randomized comparison is necessary to establish performance of endovascular treatment relative to conventional surgery.
e WAIT-AND-SEE PRESCRIPTION FOR THE TREATMENT OF ACUTE OTITIS MEDIA: A RANDOMIZED CONTROLLED TRIAL. Spiro MD, Tay KY, Arnold DH, et al. JAMA 2006;296:1235– 41. This randomized, controlled trial at one pediatric emergency department in New Haven, Connecticut compared a Wait-andSee Prescription (WASP) approach to a Standard Prescription (SP) approach for antibiotic use in children ages 6 months to 12 years with acute otitis media (AOM). The primary outcome assessed the relative proportion of each group that filled the prescription for an antibiotic. Secondary outcomes evaluated clinical course, unscheduled medical visits, and parental comfort with the WASP approach. The primary and secondary outcomes were assessed using a telephone interview at 4 to 6, 11 to 14, and 30 to 40 days after enrollment. A significantly greater percentage of the WASP group did not fill a prescription compared to the SP group (62% vs. 13%, respectively, p ⬍ 0.001). The difference in the rates of otalgia and fever between the two groups were not statistically significant. However, of those parents who reported otalgia, the WASP group demonstrated a small, but statistically significant increase in duration relative to the SP group (2.4 vs. 2.0 days, respectively). Diarrhea was significantly more frequent in the SP compared to the WASP group (23% vs. 8%, respectively, p ⬍ 0.001). No adverse outcomes were reported in either group. The authors conclude that the WASP approach, when applied to an emergency department setting, is a safe alternative to routine treatment of AOM with antibiotics. [Peter Vraniak, MD, Denver Health Medical Center, Denver, Colorado] Comment: This study provides evidence that it is safe to use a WASP approach to treating otherwise healthy, well-appearing patients with AOM who present to the emergency department. However, as the authors point out, the study was insufficiently powered to detect differences in rare events such as mastoiditis. It is important to note that ibuprofen and topical otic analgesics were prescribed to all patients in this study, possibly accounting for the similar frequency of otalgia and fever between the two groups.
e ENDOVASCULAR REPAIR OF TRAUMATIC RUPTURE OF THE AORTIC ISTHMUS: MIDTERM RESULTS. Marcheix B, Dambrin C, Bolduc JP, et al. J Thorac Cardiovasc Surg 2006;132:1037– 41. This prospective, non-randomized study reported the midterm results of endovascular repair of traumatic aortic injury in 33 patients at one center in France. All patients underwent infrainguinal iliofemoral access, received prophylactic broad-spectrum antibiotic coverage during the procedure, and were treated postoperatively with aspirin 325 mg daily. Follow-up was assessed with transesophageal echocardiography, computed tomography (CT), or magnetic resonance (MR) at 3, 6, 12, and 18 months. The patients were then followed with CT or MR annually. The immediate primary success rate, defined by complete exclusion of the false aneurysm, was 91%. Three patients experienced primary
433 endoleaks and were effectively treated with thrombosis. At a mean follow up of 2.7 years, all stent grafts were patent. There were no deaths, secondary endoleaks, migrations, or infections. Two midterm complications included an asymptomatic thrombus at 2.9 years and a stent fracture at 7 years. The authors conclude that endovascular repair of blunt traumatic aortic injury is safe and effective with low midterm morbidity and mortality. [Peter Vraniak, MD, Denver Health Medical Center, Denver, Colorado] Comment: This study reports encouraging results for endovascular repair of traumatic aortic injury. It is difficult to generalize upon the results of a multidisciplinary team at one center, as was the case in this study. As the authors note, a controlled, randomized comparison is necessary to establish performance of endovascular treatment relative to conventional surgery.
e WAIT-AND-SEE PRESCRIPTION FOR THE TREATMENT OF ACUTE OTITIS MEDIA: A RANDOMIZED CONTROLLED TRIAL. Spiro MD, Tay KY, Arnold DH, et al. JAMA 2006;296:1235– 41. This randomized, controlled trial at one pediatric emergency department in New Haven, Connecticut compared a Wait-andSee Prescription (WASP) approach to a Standard Prescription (SP) approach for antibiotic use in children ages 6 months to 12 years with acute otitis media (AOM). The primary outcome assessed the relative proportion of each group that filled the prescription for an antibiotic. Secondary outcomes evaluated clinical course, unscheduled medical visits, and parental comfort with the WASP approach. The primary and secondary outcomes were assessed using a telephone interview at 4 to 6, 11 to 14, and 30 to 40 days after enrollment. A significantly greater percentage of the WASP group did not fill a prescription compared to the SP group (62% vs. 13%, respectively, p ⬍ 0.001). The difference in the rates of otalgia and fever between the two groups were not statistically significant. However, of those parents who reported otalgia, the WASP group demonstrated a small, but statistically significant increase in duration relative to the SP group (2.4 vs. 2.0 days, respectively). Diarrhea was significantly more frequent in the SP compared to the WASP group (23% vs. 8%, respectively, p ⬍ 0.001). No adverse outcomes were reported in either group. The authors conclude that the WASP approach, when applied to an emergency department setting, is a safe alternative to routine treatment of AOM with antibiotics. [Peter Vraniak, MD, Denver Health Medical Center, Denver, Colorado] Comment: This study provides evidence that it is safe to use a WASP approach to treating otherwise healthy, well-appearing patients with AOM who present to the emergency department. However, as the authors point out, the study was insufficiently powered to detect differences in rare events such as mastoiditis. It is important to note that ibuprofen and topical otic analgesics were prescribed to all patients in this study, possibly accounting for the similar frequency of otalgia and fever between the two groups.