722
path identification. The authors used a synthetic lower leg at-
tached to a tilt board, then had a trained marksman shoot the
leg with a Remington 0.30–06 rifle (similar to weapons used
in combat against US troops) at 6 clinometer-measured angles
from 50 yards away. The simulator leg was then put through
the CT scan, and three radiologists with varying levels of expe-
rience used a picture archiving and communication system
(PACS) angle tool to measure the trajectories. The radiologists
also used a coordinate system using Cartesian x, y, z coordinates
to separately measure the trajectory angles. Bland-Altman plots
were used to evaluate agreement between the radiologists’ cal-
culated angles and the actual clinometer-measured angles. All
three radiologists were able to identify the six separate wound
paths. Using the PACS angle tool, calculated angles were within
5 degrees of the shooting angles with 95% confidence. The cal-
culated Cartesian angles were within 6.5 degrees of the shooting
angles with 95% confidence and within 5 degrees of the PACS
angles with 95% confidence.
[Nicole Seleno, MD
Denver Health Medical Center, Denver, CO]
Comments: Although imperfect in many ways, this study
was both innovative and creative. The authors themselves admit
to various limitations, including not accounting for exterior bal-
listics, wound ballistics, weapon and ammunition properties,
weather conditions, tissue characteristics, and the assumption
of perfect linearity of the trajectories. Nonetheless, their results
suggest that CT may be useful as a means for identifying bullet
trajectory and subsequently, potential internal injury.
, CARDIOPULMONARY RESUSCITATION OUT-
COME OF OUT-OF-HOSPITAL CARDIAC ARREST IN
LOW-VOLUME VERSUS HIGH-VOLUME EMER-
GENCY DEPARTMENTS: AN OBSERVATION STUDY
AND PROPENSITY SCORE MATCHING ANALYSIS.
Shin SD, Suh GJ, Ahn KO, Song KJ. Resuscitation 2011;82:
32–9.
This retrospective cohort study investigated survival to dis-
charge for out-of-hospital cardiac arrest (OHCA) patients’ at
low-volume cardiopulmonary resuscitation (CPR) facilities
(< 68 CPR cases per year) vs. high-volume CPR facilities
(> 69 CPR cases per year). Data were collected from ambulance
run sheets during a 2-year period for all patients that had OHCA
in Korea. More than 20,000 patients with OHCA were included.
Patients were excluded if they were transferred to a facility other
than an emergency department, if the cause of OHCA was
trauma related, or if there was no CPR attempt by emergency
medical personal in the out-of-hospital setting. For patients
transported to a high-volume CPR facility, 16.9% survived to ad-
mission and 5.9% survived to discharge, whereas at low-volume
CPR facilities, 13.1% of OHCA patients survived to admission
and 3.6% survived to discharge (p-values < 0.01). No information
was available for functional neurologic outcomes.
[Anna Engeln, MD
Denver Health Medical Center, Denver, CO]
Comments: This study was flawed by its retrospective design.
In addition, no data were available on functional neurologic
Abstracts
outcomes of patients, arguably the most important outcome in
these kinds of studies. Another important limitation relates to
the lack of data related to potential confounders such as earlier
access to ventricular fibrillation, differences in intensive care
unit care post-resuscitation, and time to initial CPR, as well as
duration and effectiveness of CPR. Still, the study does provide
sufficient data to form a hypothesis that could be evaluated in
prospective trials.
, TREATMENT OF ACUTE OTITIS MEDIA IN CHIL-
DREN UNDER 2 YEARS OF AGE. Hoberman A, Paradise
JL, Rockette HE, et al. N Engl J Med 2011;364:105–15.
The goal of this prospective, randomized control trial was to
determine the affect of amoxicillin-clavulanate therapy on the
clinical course of acute otitis media among children 6–23
months of age. Children were eligible if they had at least two
doses of pneumococcal conjugate vaccine, and were diagnosed
with acute otitis media via three criteria: symptoms rated by par-
ents at least 3 on the Acute Otitis Media Severity of Symptoms
Scale (AOM-SOS) with an onset within the previous 48 h, the
presence of a middle-ear effusion and marked bulging of the
tympanic membrane or bulging accompanied by otalgia or
membrane erythema. Patients were excluded if they had an al-
lergy to amoxicillin, had other chronic illnesses, had a dose of
any antimicrobial within the previous 36 h, or otalgia for longer
than 48 h. There were 291 patients enrolled in the study. Chil-
dren were first randomized in a block fashion, to placebo or
amoxicillin-clavulanate at a dose of 90 mg/kg amoxicillin
with 6.4 mg/kg clavulanate, two doses per day for 10 days.
Symptomatic response within the first 7 days was recorded.
Time to resolution of symptoms was defined by two criteria:
time to first record of an AOM-SOS score of 0 or 1, and time
to the second of two successive recordings of that same score.
Clinical failure was defined as lack of significant improvement
in symptoms, worsening signs on otoscopic examination, or
failure to completely resolve clinical symptoms at 10–12-day
follow-up. All patients with failed treatment were given a
10-day course of amoxicillin, and cefixime. The authors found
that children randomized to the treatment group had no differ-
ence in recorded symptom resolution by day 2 in 35% of chil-
dren, day 4 in 61% of children, and day 7 in 80% of children,
in comparison with children who received placebo with symp-
tom resolution by day 2 in 28%, day 4 in 54%, day 7 in 74%
of children (p = 0.14 overall). Children who were treated with
amoxicillin-clavulanate were less likely than those treated with
placebo to have evidence of clinical failure at or before the
day 4–5 visit (4% vs. 23%; 95% confidence interval [CI]
12–27; p < 0.001), as well as at or before the day 10–12 visit
(16% vs. 51%; 95% CI 25–45; p < 0.001). In addition,
the mean AOM-SOS scores were lower in the amoxicillin-
clavulanate group than the placebo group. Mastoiditis developed
in one child treated with placebo therapy.
[Ann Arens, MD
Denver Health Medical Center, Denver, CO]
Comment: This study demonstrates once again the limited
benefit of the use of antibiotics in the treatment of acute otitis
media. Although there were differences in treatment failures