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Oxygen versus Placebo for Procedural Pain in Children: A Randomized Trial
344 improved survival after cardiac arrest compared to men, but it has not been elucidated whether this was due to differences in age or sex-based biologic variation. To evaluate this, the authors developed a descriptive observational study based in Japan, which assembled a population of patients from a national outof-hospital cardiac arrest database between January 2005 and December 2007. A total of 276,590 patients were selected from a broader sample (women comprised 37.8%), with ages ranging from 20 to 89 years. The broad age range was selected to evaluate the role of estrogen on outcomes for women from reproductive age through menopause. Patients suffering out-ofhospital cardiac arrest were included without regard to the insult that may have resulted in such arrests (e.g., trauma, asphyxia, or stroke). Additionally, both witnessed and non-witnessed cases were included. Initial cardiac rhythm, 1-month survival rates, and favorable neurologic outcomes were assessed. The overall incidence of out-of-hospital cardiac arrest was 0.12% for men and 0.07% for women. Women were more likely to receive bystander cardiopulmonary resuscitation (38.3% vs. 32.8%), with the exception of witnessed events in women aged 20–29 years, with better survival rates noted between 20 and 49 years of age. Men were more prone to ventricular tachycardia/fibrillation than women (10.1% vs. 4.7%). Women aged 30–49 years were noted to have a higher incidence of favorable neurologic outcome than men, and women aged 30–79 years were additionally shown to have a higher 1-month survival rate. Overall, men more frequently succumbed to out-of-hospital cardiac arrest and were more likely to be witnessed during an acute event, were more likely to suffer ventricular tachycardia/fibrillation, and had a higher 1-month survival rate overall secondary to higher rates of ventricular dysrhythmias. It remains to be shown how estrogen may play a role in outcomes from out-of-hospital cardiac arrest. [Elena Ewert, MD Denver Health Medical Center, Denver, CO] Comments: This study adds to the growing body of evidence that suggests an important effect of gender on the survivability of cardiac arrest. Although it might be impossible to do, a larger study with more data points relating to associated medical conditions, family history, and other known risk factors might shed more light on why this discrepancy exists. For now though, the plausibility that this difference is secondary to hormonal influences is difficult to dispute. , IMPACT OF BUSINESS CYCLES ON US SUICIDE RATES, 1928–2007. Luo F, Florence CS, Quispe-Agnoli M, Ouyang L, Crosby AE. Am J Public Health 2011;101:1139–46. Despite prevention efforts, suicide was the 11th leading cause of death in the United States in 2007. A proposed association between suicide rates and unemployment, based on a number of sociological models, has been studied extensively but inconclusively. This study broadened the scope of the hypothesis to look at the relationship between suicide rates and business cycles, which include both economic expansions and recessions. The authors extracted data on suicide deaths from 1928–2007 from multiple sources. Business-cycle data were drawn from the National Bureau of Economic Research using
Abstracts 1-year time intervals. The overall suicide rate (per 100,000 people) peaked during the Great Depression at 22.1, and reached a nadir of 10.4 in 2000, during the longest period of economic expansion in the years studied. The suicide rate increased in 11 of the 13 recessions and decreased in 10 of the 13 expansions. Examining the data by age bracket showed statistically significant (p < 0.05) countercyclicality only among working-age groups (ages 25–34, 35–44, 45–54, and 55–64 years). At the extremes of age, there was no statistically significant association between suicide rates and business cycles. [Nir Harish, MD Denver Health Medical Center, Denver, CO] Comments: This study is inherently limited because many potential confounding variables for suicide rates (such as ‘‘social unrest’’) are difficult to quantify or even dichotomize. Nonetheless, the data strongly suggest that suicide rates are higher during times of economic decline, and that people of working age are especially vulnerable. In addition to the implications for public policy, this study is important in reminding emergency physicians to be particularly vigilant for suicide risk factors during times of economic uncertainty or decline. , EQUIMOLAR NITROUS OXIDE/OXYGEN VERSUS PLACEBO FOR PROCEDURAL PAIN IN CHILDREN: A RANDOMIZED TRIAL. Reinoso-Barbero F, Pascual-Pascual SI, de Lucal R, et al. Pediatrics 2011;127:e1464–70. This Spanish randomized, placebo-controlled, doubleblinded study evaluated the effectiveness of oxygen and nitrous oxide inhalation (EMONO) when used for short procedures including nevus excision, laceration repair, skin biopsy, venous cannulation, lumbar puncture, joint aspiration, or bone marrow aspiration. The study enrolled 100 children and randomized them to treatment with EMONO or placebo. For large cutaneous procedures, eutectic mixture of local anesthetic cream was applied. Two scales were used to evaluate the quality of sedation and pain control. Children 6 years of age and older used the faces pain scale-revised (rFPS). Those 6 years of age and younger used the Spanish version of an observational pain scale (LLANTO) based on five behavioral items (crying, psychological attitude, respiratory patter, posture, and facial expression). Both used a 0 to 10 scale to establish the level of pain or comfort. If at any time during the procedure the pain scale reached a level $ 8, rescue anesthesia of either intravenous propofol or inhaled sevoflurane was used. There was a significant difference between the EMONO and placebo group for both scales (LLANTO p = 0.01, rFPS p = 0.0003). Scores with the use of EMONO were approximately 50% lower than those with placebo. Rescue anesthesia was also used significantly less in the EMONO group (p = 0.0208). Failure was also noted to occur more often in patients younger than 3 years old (p < 0.0001). The authors postulate that this could be secondary to pharmacokinetic reasons given the increased alveolar concentration requirement in very young children. Two patients in the EMONO group experienced a sense of malaise, for which treatment was stopped and the procedure delayed. The authors concluded, based on these results, that EMONO is a well-tolerated means of providing good pain control and sedation for minor
The Journal of Emergency Medicine pediatric procedures. Of note, this study received financial support from Air Liquide (Paris, France), a manufacturer of EMONO. [Christopher Johnston, MD Denver Health Medical Center, Denver, CO] Comments: Although small and limited by its heterogeneous patient population, this study suggests a new tool for procedural sedation for painful procedures in children. Larger trials with more suitable comparisons to propofol or ketamine would be useful in truly establishing EMONO’s legitimacy. , TRAUMA IN THE NEIGHBORHOOD: A GEOSPATIAL ANALYSIS AND ASSESSMENT OF SOCIAL DETERMINANTS OF MAJOR INJURY IN NORTH AMERICA. Newgard CD, Schmicker RH, Sopko G, et al. Am J Public Health 2011;101:669–77. Traumatic injuries are a major cause of morbidity and mortality worldwide. Although it has been shown that disparities exist among various racial, ethnic, and socioeconomic groups, it is unclear whether trends exist among geographic areas and neighborhood communities. In an attempt to further define the sociocultural framework and determinants for bodily injury, this multi-center observational study analyzed data from nine study sites across the United States and Canada. Through participation of 163 emergency medical services (EMS) systems, a sample of 7326 major trauma patients was evaluated between December 1, 2005 and April 30, 2007. Both children and adults were included (1137 were younger than 18 years old). Inclusion criteria were broadly defined, and included individuals who had sustained burns, penetrating or blunt injury, with severity ranging from brief EMS evaluation without significant intervention to air transportation and cardiopulmonary resuscitation, as well as those pronounced dead in the field. The primary study outcome was the incidence of major trauma. Secondary outcomes were rates of death in the field, penetrating injuries (92%
345 firearm-related or stabbings), and intentional injuries. Data were analyzed via grouping populations into census tracts, with additional clustering for increases in incidence within a single census tract. A number of these clusters were found to have higher proportions of major trauma as well as more deaths in the field, penetrating injuries, and intentional injuries. Notable demographic characteristics of such clusters were younger residents, higher rates of non-white residents and unemployment, lower proportions of foreign-born residents and those with high school education, and lower household incomes. Notably, despite adjustment for income, education, employment, age, primary language spoken, and household size, non-white populations were found to have more pronounced rates of major trauma as well as deaths in the field, penetrating injury, and intentional injury. This suggests a strong correlation between traumatic injury, particularly intentional violence, and racial and socioeconomic marginalization (with respect to lower education and employment rates). Despite the difficulty in assessing the causal relationship of these factors, the implications of this study steer toward further targeted intervention in areas with noted high-risk populations via community outreach programs, increased policing, and the onerous and potentially impossible task of combating unemployment and improving access to public education on a broader scale. [Elena Ewert, MD Denver Health Medical Center, Denver, CO] Comment: Although it is important to remember that trauma can occur to people in a seemingly random fashion, like other diseases, it has risk factors and preventable causes. This study highlights how socioeconomic status, manifested by where someone lives, is, as in so many other diseases, a significant risk factor for traumatic injury. This kind of public health approach is helpful in reframing trauma as a disease instead of a random occurrence, and may be helpful in designing preventive strategies (potentially in the form of legislation) targeted at those most at risk.
Abstracts 1-year time intervals. The overall suicide rate (per 100,000 people) peaked during the Great Depression at 22.1, and reached a nadir of 10.4 in 2000, during the longest period of economic expansion in the years studied. The suicide rate increased in 11 of the 13 recessions and decreased in 10 of the 13 expansions. Examining the data by age bracket showed statistically significant (p < 0.05) countercyclicality only among working-age groups (ages 25–34, 35–44, 45–54, and 55–64 years). At the extremes of age, there was no statistically significant association between suicide rates and business cycles. [Nir Harish, MD Denver Health Medical Center, Denver, CO] Comments: This study is inherently limited because many potential confounding variables for suicide rates (such as ‘‘social unrest’’) are difficult to quantify or even dichotomize. Nonetheless, the data strongly suggest that suicide rates are higher during times of economic decline, and that people of working age are especially vulnerable. In addition to the implications for public policy, this study is important in reminding emergency physicians to be particularly vigilant for suicide risk factors during times of economic uncertainty or decline. , EQUIMOLAR NITROUS OXIDE/OXYGEN VERSUS PLACEBO FOR PROCEDURAL PAIN IN CHILDREN: A RANDOMIZED TRIAL. Reinoso-Barbero F, Pascual-Pascual SI, de Lucal R, et al. Pediatrics 2011;127:e1464–70. This Spanish randomized, placebo-controlled, doubleblinded study evaluated the effectiveness of oxygen and nitrous oxide inhalation (EMONO) when used for short procedures including nevus excision, laceration repair, skin biopsy, venous cannulation, lumbar puncture, joint aspiration, or bone marrow aspiration. The study enrolled 100 children and randomized them to treatment with EMONO or placebo. For large cutaneous procedures, eutectic mixture of local anesthetic cream was applied. Two scales were used to evaluate the quality of sedation and pain control. Children 6 years of age and older used the faces pain scale-revised (rFPS). Those 6 years of age and younger used the Spanish version of an observational pain scale (LLANTO) based on five behavioral items (crying, psychological attitude, respiratory patter, posture, and facial expression). Both used a 0 to 10 scale to establish the level of pain or comfort. If at any time during the procedure the pain scale reached a level $ 8, rescue anesthesia of either intravenous propofol or inhaled sevoflurane was used. There was a significant difference between the EMONO and placebo group for both scales (LLANTO p = 0.01, rFPS p = 0.0003). Scores with the use of EMONO were approximately 50% lower than those with placebo. Rescue anesthesia was also used significantly less in the EMONO group (p = 0.0208). Failure was also noted to occur more often in patients younger than 3 years old (p < 0.0001). The authors postulate that this could be secondary to pharmacokinetic reasons given the increased alveolar concentration requirement in very young children. Two patients in the EMONO group experienced a sense of malaise, for which treatment was stopped and the procedure delayed. The authors concluded, based on these results, that EMONO is a well-tolerated means of providing good pain control and sedation for minor
The Journal of Emergency Medicine pediatric procedures. Of note, this study received financial support from Air Liquide (Paris, France), a manufacturer of EMONO. [Christopher Johnston, MD Denver Health Medical Center, Denver, CO] Comments: Although small and limited by its heterogeneous patient population, this study suggests a new tool for procedural sedation for painful procedures in children. Larger trials with more suitable comparisons to propofol or ketamine would be useful in truly establishing EMONO’s legitimacy. , TRAUMA IN THE NEIGHBORHOOD: A GEOSPATIAL ANALYSIS AND ASSESSMENT OF SOCIAL DETERMINANTS OF MAJOR INJURY IN NORTH AMERICA. Newgard CD, Schmicker RH, Sopko G, et al. Am J Public Health 2011;101:669–77. Traumatic injuries are a major cause of morbidity and mortality worldwide. Although it has been shown that disparities exist among various racial, ethnic, and socioeconomic groups, it is unclear whether trends exist among geographic areas and neighborhood communities. In an attempt to further define the sociocultural framework and determinants for bodily injury, this multi-center observational study analyzed data from nine study sites across the United States and Canada. Through participation of 163 emergency medical services (EMS) systems, a sample of 7326 major trauma patients was evaluated between December 1, 2005 and April 30, 2007. Both children and adults were included (1137 were younger than 18 years old). Inclusion criteria were broadly defined, and included individuals who had sustained burns, penetrating or blunt injury, with severity ranging from brief EMS evaluation without significant intervention to air transportation and cardiopulmonary resuscitation, as well as those pronounced dead in the field. The primary study outcome was the incidence of major trauma. Secondary outcomes were rates of death in the field, penetrating injuries (92%
345 firearm-related or stabbings), and intentional injuries. Data were analyzed via grouping populations into census tracts, with additional clustering for increases in incidence within a single census tract. A number of these clusters were found to have higher proportions of major trauma as well as more deaths in the field, penetrating injuries, and intentional injuries. Notable demographic characteristics of such clusters were younger residents, higher rates of non-white residents and unemployment, lower proportions of foreign-born residents and those with high school education, and lower household incomes. Notably, despite adjustment for income, education, employment, age, primary language spoken, and household size, non-white populations were found to have more pronounced rates of major trauma as well as deaths in the field, penetrating injury, and intentional injury. This suggests a strong correlation between traumatic injury, particularly intentional violence, and racial and socioeconomic marginalization (with respect to lower education and employment rates). Despite the difficulty in assessing the causal relationship of these factors, the implications of this study steer toward further targeted intervention in areas with noted high-risk populations via community outreach programs, increased policing, and the onerous and potentially impossible task of combating unemployment and improving access to public education on a broader scale. [Elena Ewert, MD Denver Health Medical Center, Denver, CO] Comment: Although it is important to remember that trauma can occur to people in a seemingly random fashion, like other diseases, it has risk factors and preventable causes. This study highlights how socioeconomic status, manifested by where someone lives, is, as in so many other diseases, a significant risk factor for traumatic injury. This kind of public health approach is helpful in reframing trauma as a disease instead of a random occurrence, and may be helpful in designing preventive strategies (potentially in the form of legislation) targeted at those most at risk.