Association Between Serum Calcium Level and Extent of Bleeding in Patients with Intracerebral Hemorrhage

392 Acute Otitis Media-Severity of Symptoms (AOM-SOS) scale. Patients were randomized to receive either a 10-day or 5-day course of amoxicillin-clavulanate, with the latter group subsequently receiving 5-days of placebo. The primary outcome was percentage of clinical failure. Symptom burden over time, recurrence rates and outcomes of recurrence treatment, nasopharyngeal colonization rates, days missed from work or childcare, and parental satisfaction were among secondary outcome measures. This was an intention-to-treat, noninferiority study, using logistic-regression for subgroup analyses. The study was halted due to early realization of the primary objective, with 515 subjects included in the final analyses. Criterion for noninferiority of the primary outcome were not met, as clinical failure after amoxicillin-clavulanate was observed in 34% of the 5-day group versus 16% in the 10-day group (17 percentage points; 95% CI, 9-25). Secondary analyses of symptomatic response using AOM-SOS showed no difference over days 6-14 (p=0.07). In contrast, from days 12-14 there was an observed difference in symptom severity in the 5-day (1.89) versus 10-day (1.20) groups (p=0.001). The 10-day group also showed a greater percentage of patients whose symptom scores decreased by >50% after treatment (91% in 10-day, 80% in 5-day, p=0.003). Recurrence rates did not differ between the two groups (p=0.22). Nasopharyngeal colonization rates did not differ between the two groups for Streptococcus pneumonia (p=0.31) and Haemophilus influenza (p=0.23). Authors concluded that for patients 6-23 months of age with AOM, short-term treatment failure was more common after 5 days versus the current standard of 10 days of amoxicillin-clavulanate. In addition, the shorter course did not improve antibiotic resistance nor adverse event rates. [Benjamin Li, MD Denver Health Medical Center, Denver, CO] Comments: While limited in generalizability, this study adds to the existing literature describing limitations of short-course therapy for AOM in pediatric patients, amidst the goal of balancing treatment efficacy while limiting antimicrobial resistance. , ASSOCIATION BETWEEN SERUM CALCIUM LEVEL AND EXTENT OF BLEEDING IN PATIENTS WITH INTRACEREBRAL HEMORRHAGE. Morotti A, Charidimou A, Phuah CL, et al. JAMA Neurol. 2016;73:1285-90 In spontaneous intracerebral hemorrhage (ICH), hematoma size and expansion are predictors of outcome. Calcium is an important cofactor in coagulation, and low levels are theorized

Abstracts to impair hemostasis. This study investigated whether hypocalcemia was associated with hematoma volume and risk for expansion in ICH. This was a retrospective analysis of spontaneous ICH patients at a single hospital from 1994-2015. Diagnosis of ICH was via non-contrast computed tomography (NCCT), and had to be within 72 hours of symptom onset. The investigators excluded traumatic ICH, intracranial tumor or vascular malformations, intraventricular hemorrhage, or ischemic to hemorrhagic stroke conversions. Total calcium and albumincorrected calcium were measured in all patients, while a subgroup used ionized calcium. Clinical variables included co-morbidities (eg. hypertension, diabetes) and medications (eg. antiplatelet drugs, oral anticoagulant therapy [OAT]). Multivariable linear regression was used to analyze calcium levels in association with baseline hematoma volume, while multivariable logistic regression was used to examine the association between calcium and hematoma expansion. A total of 2,103 patients were included (mean age, 72.7 years; 54.3% male) in the study, of which 229 (10.9%) were hypocalcemic on presentation. Hematoma volume was greater in hypocalcemic versus normocalcemic patients (37 mL [interquartile range [IQR] 15-72 mL] vs 16 mL [IQR, 6-44 mL]; p<0.001). Ionized calcium levels correlated with total calcium in conveying the same relationship with hematoma volume (p=0.004). When stratified by OAT, there was a stronger association between serum calcium and hematoma volume with nonOAT patients (p<0.001) than OAT users (p=0.04). Follow-up NCCT were available in 1,393 patients (66.2%). In this group, serum calcium levels were inversely related to risk of hematoma expansion (odds ratio, 0.72 [95% confidence interval, 0.540.97]; p=0.03). Authors concluded that while large, multicenter studies are needed, these data lend to the hypothesis describing the important role of calcium in the pathophysiology of ICH. Low levels were shown not only to be associated with greater ICH volume, but also with increased risk of hematoma expansion. [Benjamin Li, MD Denver Health Medical Center, Denver, CO] Comments: Given the associations described in the study, and with serum calcium being a modifiable factor, potential for future therapy in the head injured population is great. Before implementing widespread changes, these findings require more rigorous testing in generalizable populations, and further investigation into the pathophysiologic relationship between the calcium and ICH.