may be benefit in initiating TGC even earlier, in the Emer-gency Department.

[Matthew Mendenhall, MD, MPH,

Denver Health Medical Center, Denver, CO]

Comments: This study suffers from the usual bias inherentin the interrupted time-series design: namely, that the standardof patient care and medical knowledge shift rapidly, producingsubtle improvements in patient outcome over time. The authorsstate that “no significant changes” occurred in ventilator man-agement, nutritional support, or transfusion protocols duringthe 48-month study period, although they do not substantiatethis with any data. Nonetheless, the body of evidence in supportof glucose control in various disease states continues to grow.

e PROSPECTIVE EXTERNAL VALIDATION OF THECLINICAL EFFECTIVENESS OF AN EMERGENCYDEPARTMENT-BASED EARLY GOAL-DIRECTEDTHERAPY PROTOCOL FOR SEVERE SEPSIS ANDSEPTIC SHOCK. Jones AE, Focht A, Horton JM, Kline JA.Chest 2007;132:425–32.

This study sought to determine whether implementation ofan early goal-directed therapy (EGDT) protocol in the Emer-gency Department (ED) would be effective in reducing mor-tality from severe sepsis and septic shock. Clinical data andmortality rates were recorded for 1 year before and after im-plementing an EGDT protocol in an urban ED. In the yearbefore the EGDT protocol, all treatment decisions were left tothe emergency physician. In the year after initiation of theprotocol, all patients who had suspected or confirmed infectionand met two or more of the systemic inflammatory responsesyndrome criteria and showed evidence of shock were treatedaccording to the EGDT algorithm while in the ED. This pro-tocol included central venous and mean arterial pressure mea-surement, central venous oxygen saturation monitoring, theearly use of antibiotics, aggressive fluid resuscitation, and use ofvasopressor agents, inotropic agents, and blood transfusions whenrequired to meet physiologic goals. The authors enrolled 79 and 77patients, respectively, in the pre- and post-implementation years.In-hospital mortality declined from 27% to 18% after implemen-tation of the protocol (95% confidence interval �5 to �21%). Thevolume of fluid resuscitation increased after implementing theprotocol (2.54 L to 4.66 L, p � 0.001) as did the frequency ofvasopressor use (34% to 69%, p � 0.001) and the time to antibi-otic administration decreased (142 min to 99 min, p � 0.02). Theauthors conclude that implementation of the EGDT protocol in theED was clinically effective, as demonstrated by a 9% absolute and33% relative reduction in in-hospital mortality from severe sepsisand septic shock.

[Nathan J. Cleveland, MD,

Denver Health Medical Center, Denver, CO]

Comment: This study shows that implementation of anEGDT protocol can lead to more aggressive treatment andearlier pharmacologic interventions that may improve out-comes in severe sepsis and septic shock. However, due to thesmall sample size, this study only demonstrated reductions in

in-hospital mortality were not statistically significant. Nonethe-less, this is one more article demonstrating the potential im-portance of EGDT in the ED.

e WOMEN SEEKING EMERGENCY CONTRACEP-TIVE PILLS BY USING THE INTERNET. Wu J, Gipson T,Chin N, et al. Obstet Gynecol 2007;110:44–52.

This study was a quantitative survey of 200 women seekingemergency contraceptive pills (ECPs) from The EmergencyContraceptive Website (http://ec.princeton.edu). The objectiveof the study was to determine the barriers and attitudes relatedto emergency contraceptive access among women who use theInternet. Telephone surveys of a convenience sample of 200women requesting ECPs were obtained. These women werepredominantly white, college-educated, urban residents of highsocioeconomic status. A 27-item survey collected the followinginformation: 1) reason(s) for needing ECPs, 2) recent contra-ceptive and ECP use, 3) barriers to getting ECPs, 4) attitudesabout advanced prescription of ECPs and non-prescriptionECPs, and 5) demographics. The women most commonly re-ported condom breakage, slippage, or incorrect use as thereason for needing ECPs. Structural barriers, such as inconve-nient office hours, were cited as the largest barrier to obtainingemergency contraception for those women who attempted toobtain ECPs from local providers. The majority of women inthe study, however, employed unconventional resources suchas the Internet for emergency contraception. Most womensupported advanced prescription of ECPs for future use, butless than half were in support of non-prescription ECPs. Themain concern about non-prescription emergency contraceptionwas that it may promote risky sexual behavior and poor con-traceptive practice. The authors conclude that this study givesnew insight into the issue of emergency contraception throughan integrated analysis of both qualitative and quantitative data.

[Cameron D. Klug, MD,

Denver Health Medical Center, Denver, CO]

Comment: This study gives an interesting look into theattitudes and circumstances of women using emergency con-traception. Among those women who have the resources to doso, many are using unconventional methods, such as the Inter-net, to obtain ECPs. The main limitation of this study is in thepredominantly white, wealthy, and college-educated populationsample, which makes the study difficult to generalize. How-ever, this study demonstrates that significant barriers exist forwomen seeking emergency contraception and that unconven-tional methods are often employed to obtain it.

e NONINVASIVE CENTRAL VENOUS PRESSUREMEASUREMENT BY CONTROLLED COMPRESSIONSONOGRAPHY AT THE FOREARM. Thalhammer C,Aschwanden M, Odermatt A, et al. J Am Coll Cardiol 2007;50:1584–9.

This prospective, blinded study from Switzerland sought tovalidate controlled compression sonography (CCS) as an accu-rate non-invasive technique for indirect measurement of central

228 Abstracts

venous pressure (CVP). The efficacy of CCS was tested in 10healthy volunteers and 50 intensive care unit (ICU) patients bycomparison with invasively measured CVP. In healthy patients,CCS was used to measure non-invasive peripheral venouspressure (PVP) in the cephalic vein of the forearm, whereasinvasive PVP was measured through a 20-gauge catheter in-serted into the vein. A sphygmomanometer cuff on the upperarm of healthy subjects was used to induce changes in PVP toexamine the accuracy of the technique over a range of pres-sures. In ICU patients, non-invasive PVP was measured in themost visible vein in the forearm, and CVP was measuredthrough a central venous catheter in the subclavian or internaljugular vein. A significant positive correlation was found (p �0.001) between invasive and non-invasive techniques in bothhealthy individuals and ICU subjects, and CCS was found toremain accurate over a wide range of venous pressures (10 cmto 70 cm H2O). Authors conclude that CCS is a reliablenon-invasive tool for assessment of CVP that is as accurate, inthis limited study, as using a central venous catheter. Limitingfactors to the use of CCS include the need for experiencedultrasonographers trained in this specific technique with accessto high-end ultrasound equipment.

[Emily Johnston, MD,

Denver Health Medical Center, Denver, CO]

Comment: This study provides preliminary data on a novel,non-invasive technique for assessing CVP in Emergency De-partment patients. Although user training and equipment arenot yet widely available for this purpose, and the methods ofthe study make the results somewhat suspect, the concept is onethat may become pertinent.

e PROSPECTIVE EVALUATION OF UNSUSPECTEDPULMONARY EMBOLISM ON CONTRAST ENHANCEDMULTIDETECTOR CT (MDCT) SCANNING. Ritchie G,McGurk S, McCreath C, et al. Thorax 2007;62:536–40.

This prospective, observational study out of the UnitedKingdom attempted to quantify the incidence of pulmonaryembolism (PE) in hospital inpatients in whom PE was notsuspected. All patients who received contrast-enhanced multi-detector computed tomography (MDCT) scan of the thoraxover a 10-month period were identified, and those who hadsuspected PE or received the scan to rule out PE wereexcluded. The scans were reviewed by thoracic radiologistswho recorded the indication for MDCT scan, the presence orabsence of PE, the level of the most proximal PE, and patientdemographics. A total of 487 patients received scans. Twenty-eight patients were diagnosed with PE. Twenty of these patientswere over 70 years of age and 11 were over 80 years. There wasan association between age and rate of unsuspected PE (�2 �13.28, p � 0.001). There was no association between length ofhospital stay and rate of unsuspected PE. Malignancy was byfar the most common presumptive diagnosis for scan, followedby fluid collection, miscellaneous diagnoses, infection, trans-plant evaluation, and aneurysm. Eighteen of the 28 PE diag-noses were in patients with known or presumed malignancy.The majority of PEs (18/28) were segmental or sub-segmental

clots, and nine were missed on the initial reading. The authorsconclude that unsuspected PE is more common in older patientsand that PE should be sought on all contrast-enhanced MDCTscans of the thorax regardless of the indication for the scan.

[Nathan J. Cleveland, MD,

Denver Health Medical Center, Denver, CO]

Comment: This study reinforces the importance of suspect-ing pulmonary embolism, especially in patients who areknown to be at higher risk, such as hospital inpatients, theelderly, and those with malignancy. Although not specifi-cally addressed in this study, it is also a reminder of theimportance of deep vein thrombosis and pulmonary embo-lism prophylaxis in hospital inpatients.

e RISK OF THROMBOEMBOLISM IN WOMEN TAK-ING ETHINYLESTRADIOL/DROSPIRENONE ANDOTHER ORAL CONTRACEPTIVES. Seeger JD, LoughlinJ, Eng PM, et al. Obstet Gynecol 2007;110:587–93.

This study out of the Harvard School of Public Healthcompares the risk of thromboembolic events in women takingethinylestradiol/drospirenone relative to the risk in women tak-ing other oral contraceptives. The ethinylestradiol/drospirenone(Yasmin) combination is unique in that it is the only contra-ceptive currently using dropirenone as the progestin compo-nent. The study follows two cohorts of women selected from anational US insurer database. The first group includes 22,429women who initiated ethinylestradiol/drospirenone, and thesecond group follows 44,858 women (matched by health anddemographic factors to the first group) who initiated anothertype of oral contraceptive. The groups were followed for anaverage of 7.8 and 7.5 months, respectively, to observe forthromboembolic events. Eighteen women in the ethinylestra-diol/drospirenone group developed thromboembolism (inci-dence rate 1.3, 95% confidence interval 0.8–2.0). The rate wassimilar in the second group, with 39 women developing throm-boembolism (incidence rate 1.4, 95% confidence interval 1.0–1.9). The authors conclude there was no difference betweenethinylestradiol/drospirenone and other oral contraceptives inrisk of thromboembolism.

[Matthew Mendenhall, MD, MPH,

Denver Health Medical Center, Denver, CO]

Comment: This study draws upon a robust database toproduce a well-matched cohort study. Although the study sug-gests no significant difference in the relative risk betweenethinylestradiol/drospirenone and other oral contraceptive use,all oral contraceptive medications increase the absolute risk ofthromboembolism.

e A RED BLOOD CELL AGGLUTINATION D-DIMERTEST TO EXCLUDE DEEP VENOUS THROMBOSIS INPREGNANCY. Chan W-S, Chunilal S, Lee A, et al. AnnIntern Med 2007;147:165–70.

This prospective cohort study was designed to determine thesensitivity, specificity, negative predictive value, and false-

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