Periprocedural Bleeding and Thromboembolic Events with Dabigatran Compared with Warfarin: Results...

The Journal of Emergency Medicine e381

calculated at 2500. Recent use and past use did not seem to influ-ence retinal detachment,with anARRof 0.92 (95%CI 0.45–1.87)for recent use, and 1.03 (95% CI 0.89–1.19) for past use.

[Elaine Reno, MD

Denver Health Medical Center, Denver, CO]

Comment:Although this article demonstrates an increased riskof retinal detachment with fluoroquinolones, the absolute risk re-mains small. Primary disease pathology should continue to guideantibiotic selection despite risk. If a patient presents with visualsymptoms, a detailed history with special attention to current an-tibiotic use is prudent, especially for Emergency Physicians.

, PERIPROCEDURAL BLEEDING AND THROMBO-EMBOLIC EVENTS WITH DABIGATRAN COMPAREDWITH WARFARIN: RESULTS FROM THE RANDO-MIZED EVALUATION OF LONG-TERM ANTI-COAGULATION THERAPY RANDOMIZED TRIAL.Healey JS, Eikelboom J, Douketis J, et al. Circulation2012;126:343–8.

The oral anticoagulation efficacy of dabigatran has beenproven superior to that of warfarin in the prevention of strokeand systemic embolism, with similar risks of bleeding. How-ever, the lack of a specific antidote for dabigatran has led to per-sistent concerns of bleeding risk in patients undergoing invasiveprocedures. This multi-center, multi-national study retrospec-tively compared rates of bleeding and thrombotic complicationsin 4591 patients receiving either dabigatran or warfarin therapywho underwent surgery or other invasive procedures includingdental work, cardiac catheterization, and invasive diagnosticprocedures over a 2-year period. There was no significant in-crease in rates of periprocedural major bleeding for patientson dabigatran; risk ratios were 0.83 (95% confidence interval[CI] 0.59–1.17) for 110 mg dabigatran vs. warfarin, and 1.09(95% CI 0.80–1.49) for 150 mg dabigatran vs. warfarin. Fur-thermore, the authors investigated rates of major bleeding inthe setting of urgent surgery, necessitating surgery within 24 hof holding anticoagulation. In this subset, dabigatran had a sig-nificant decrease in major bleeding risk; risk ratios were 0.18(95% CI 0.07–0.50) for 110 mg dabigatran vs. warfarin, and0.35 (95% CI 0.21–0.92) for 150 mg dabigatran vs. warfarin.

The authors then contend that the shorter half-life ofdabigatran may decrease the risk of thromboembolic comp-lications. By the study’s protocol, warfarin was held 5 days be-fore the intervention, and dabigatran was held 1–5 days prior,depending on the patient’s creatinine clearance. Due to itsshorter half-life, nearly half of the patients on dabigatrantherapy had their interventionwithin 48 h of stopping the oral an-ticoagulation, a rate over four times higher than among patientson warfarin. However, the data revealed no statistical differencein perioperative thromboembolic complications; risk ratios were1.05 (95%CI 0.55–2.01) for 110 mg dabigatranvs. warfarin, and1.29 (95% CI 0.70–2.38) for 150 mg dabigatran vs. warfarin.Therefore, although dabigatran does lead to a shorter interrup-tion of oral anticoagulation, the study does not prove that thisshorter timeline has any morbidity or mortality benefit.

[Jordan Ryan, MD

Denver Health Medical Center, Denver, CO]

Comment: Dabigatran and warfarin have similar rates ofperioperative bleeding and thromboembolic complications inthe setting of elective surgery when they are held according toprotocol, but dabigatran may be safer when urgent surgery isrequired.

, TRENDS INANTIBIOTICUSE INMASSACHUSETTSCHILDREN, 2000–2009. Greene SK, Kleinma KP,Lakoma MD, et al. Pediatrics 2012;130:15–22.

This retrospective observational study examined insurancecompanies’ claims data for children 3–72 months old in multipleMassachusetts communities over a 10-year period, to analyzetrends in antibiotic-prescribing habits. Previous studies estab-lished decreasing antibiotic-dispensing rates since the mid1990s, when awareness of antibiotic rates increased and cam-paigns promoted judicious antibiotic use. Total antibiotic dispens-ing decreased per patient-year (p-y) until 2004–2005, and thenleveled out thereafter. The antibiotics with the biggest decline inuse were first-line penicillins (decreasing from 1.21 prescriptionsper patient per year [rx/p-y] to 0.90 rx/p-y from 2000 to 2009) andsecond-line penicillins such as Augmentin (0.39 rx/p-y to 0.29 rx/p-y). The diagnosis with the largest drop in dispensing rate wasacute otitis media (AOM), with a drop of 12–21% from 2000 to2009, varying by age group. Thismay be attributable to an overalldecrease inAOMdiagnosis rate, as that alone decreased from2.03diagnoses per patient per year (dx/p-y) in 2000 to 1.84 dx/p-y in2009 in the youngest age subset. Other diagnoses that sawa decrease in antibiotic-dispensing rates include viral syndromeand bronchitis.

The authors contend that although certainly some of the de-crease in dispensing rates is attributable to awareness of antibi-otic resistance and education about futility in treating viralprocesses with antibiotics, vaccines may also have had a largeeffect. They argue that the increase in influenza and pneumococ-cal vaccination rates over the study’s timeframe likely decreasethe incidence of AOM and make physicians more comfortablenot treating febrile infants with antibiotics, knowing the chancesof serious bacterial infection are lower.

[Jordan Ryan, MD

Denver Health Medical Center, Denver, CO]

Comment: The generalizability of this study is unclear, giventhe selection bias inherent to analyzing prescription rates onlyfor insured children with pediatricians. Knowing the familiescan purchase prescribed medications and obtain good follow-up may affect a physician’s prescribing habits.

, RELATIONSHIP BETWEEN ARTERIAL PARTIALOXYGEN PRESSURE AFTER RESUSCITATION FROMCARDIAC ARREST AND MORTALITY IN CHILDREN.Ferguson LP, Durward A, Tibby SM. Circulation2012;126:335–42.

Current pediatric resuscitation guidelines recommend avoid-ing hyperoxia after resuscitation from cardiac arrest, but this isbased on observational studies on adults and animal models.This retrospective cohort study aimed to establish a relationshipbetween arterial partial oxygen pressure and survival in thepediatric population. Blood gases taken within 1 h of Pediatric