Friday, December 21, 2012

The AAP Policy on Firearm Safety

Might not it be helpful if, coincidentally, the Council on Injury, Violence, and Poison Prevention for the American Academy of Pediatrics had just updated their policy statement regarding firearm-related injuries?  Indeed, just two months ago, the AAP published an update, featuring a mere 66 citations worth of evidence, rather than politicized talking points.

A couple interesting statistics from their summary:
 - The firearm-associated death rate among youth ages 15 to 19 has fallen from its peak of 27.8 deaths per 100 000 in 1994 to 11.4 per 100 000 in 2009.
 - However, of all injury deaths of individuals younger than 20 years, still 1 in 5 were firearm related.
 - For youth 15 to 24 years of age, firearm homicide rates were 35.7 times higher than in other high-income countries.
 - For children 5 to 14 years of age, firearm suicide rates were 8 times higher, and death rates from unintentional firearm injuries were 10 times higher in the United States than other high-income countries. 
 - The difference in rates is postulated to the ease of availability of guns in the United States compared with other high-income countries.

Their recommendations section seems quite straightforward:
 - The most effective measure to prevent suicide, homicide, and unintentional firearm-related injuries to children and adolescents is the absence of guns from homes and communities.
 - Health care professionals should counsel the parents of all adolescents to remove guns from the home or restrict access to them.
 - Trigger locks, lock boxes, gun safes, and safe storage legislation are encouraged by the AAP.
 - Other measures aimed at regulating access of guns should include legislative actions, such as mandatory waiting periods, closure of the gun show loophole, mental health restrictions for gun purchases, and background checks.
 - The AAP recommends restoration of the ban on the sale of assault weapons to the general public.

Any chance policymakers might listen to the society of physicians "Dedicated to the health and well-being of infants, children, adolescents and young adults"?

"Firearm-Related Injuries Affecting the Pediatric Population"
www.ncbi.nlm.nih.gov/pubmed/10742344

Wednesday, December 19, 2012

Pain Control on the Wrong Track

Codeine, the oral narcotic analgesia that is long past its prime.  Approximately 8% of the caucasian population cannot metabolize codeine into morphine – and then a small handful are rapid metabolizers that will overdose on an otherwise therapeutic dose.  But, this didn't stop these folks in Montreal from evaluating its efficacy for pediatric musculoskeletal limb pain.

Pediatric pain is a little odd.  Overall, the Emergency Department does a poor job of treating pain.  Studies in pediatric EDs show significant percentages of injured patients don't receive any pain control. But, then, we all have the anecdotal experience in which a child is sitting on a stretcher watching TV with a fractured arm denying he's in any pain at all – why are you bothering me again?  Spongebob is on.

Long story short, this study randomized children to receive either ibuprofen alone or ibuprofen plus codeine.  At each time point, the difference in pain scales was no different between groups.  Pain scores weren't that high to begin with, and had moderate improvement after either treatment.

For minor pain, acetaminophen and ibuprofen are adequate options.  For more severe pain, intravenous narcotics, intranasal narcotics, or even intramuscular ketamine are probably better options.

"Efficacy of an Ibuprofen/Codeine Combination for Pain Management in Children Presenting to the Emergency Department With a Limb Injury: A Pilot Study"
www.ncbi.nlm.nih.gov/pubmed/23232154

Monday, December 17, 2012

Pouring Money Into Prehospital Stroke Thrombolysis


Staying consistent with the "brain attack!" slogan folks developed for stroke, the innovations in treatment continue to progress in their attempts to mimic myocardial infarction.  In myocardial infarction, a great deal of focus has been placed on rapid diagnosis and either thrombolysis or interventional catheterization.  This extends to the prehospital arena, with experimentation with ECG transmission, pre-hospital lytics, and pre-hospital cath lab activations.

For stroke, they're still trying to replicate this pre-hospital diagnosis and treatment – made slightly more complex because the diagnostics involved requires CT scanning.  However, with enough funding from telehealth and imaging industry, "mobile stroke units" have been created for feasibility evaluations. 

And, these authors have certainly demonstrated that it is feasible, diagnosing 48 acute strokes in the prehospital setting and giving half of them thrombolysis.  One patient given rt-PA had sepsis rather than an acute stroke, which is of uncertain significance in an underpowered feasibility case series such as this.

However, there's a difference between can and should.  I'm uncertain whether we should even be exploring the can portion in this pilot, considering should means a grossly excessive allocation of resources for a therapy of uncertain benefit.  Given the small absolute benefits seen in the handful of trials that even showed a benefit, I can't possibly see how trials of pre-hospital lytics could favor anything but surrogate endpoints, rather than patient-oriented endpoints.  30 minutes faster to TPA?  At what cost, and did outcomes change?

I won't fault the authors for their interesting experiment – as long as they don't seriously propose it as The Future based on our current evidence.

"Prehospital thrombolysis in acute stroke : Results of the PHANTOM-S pilot study" 
www.ncbi.nlm.nih.gov/pubmed/23223534