Optimal Dose of Intranasal Dexmedetomidine for Laceration Repair in Children: A Phase II Dose-Ranging Study.

STUDY OBJECTIVE: To determine the optimal sedative dose of intranasal dexmedetomidine for children undergoing laceration repair. METHODS: This dose-ranging study employing the Bayesian Continual Reassessment Method enrolled children aged 0 to 10 years with a single laceration (<5 cm), requiring single-layer closure, who received topical anesthetic. Children were administered 1, 2, 3, or 4 mcg/kg intranasal dexmedetomidine. The primary outcome was the proportion with adequate sedation (Pediatric Sedation State Scale score of 2 or 3 for ≥90% of the time from sterile preparation to tying of the last suture). Secondary outcomes included the Observational Scale of Behavior Distress-Revised (range: 0 [no distress] to 23.5 [maximal distress]), postprocedure length of stay, and adverse events. RESULTS: We enrolled 55 children (35/55 [64%] males; median [interquartile range {IQR}] age 4 [2, 6] years). At 1, 2, 3, and 4 mcg/kg intranasal dexmedetomidine, respectively, the proportion of participants "adequately" sedated was 1/3 (33%), 2/9 (22%), 13/21 (62%), and 12/21 (57%); the posterior mean (95% equitailed credible intervals) for the probability of adequate sedation was 0.38 (0.04, 0.82), 0.25 (0.05, 0.54), 0.61 (0.41, 0.80), and 0.57 (0.36, 0.76); the median (IQR) Observational Scale of Behavior Distress-Revised scores during suturing was 2.7 (0.3, 3), 0 (0, 3.8), 0.6 (0, 5), and 0 (0, 3.7); the median (IQR) postprocedure length of stay was 67 (60, 78), 76 (60, 100), 89 (76, 109), and 113 (76, 150) minutes. There was 1 adverse event, a decrease in oxygen saturation at 4 mcg/kg, which resolved with head repositioning. CONCLUSION: Despite limitations, such as our limited sample size and subjectivity in Pediatric Sedation State Scale scoring, sedation efficacy for 3 and 4 mcg/kg were similarly based on equitailed credible intervals suggesting either could be considered optimal.

Provision of immobilization or ice by paramedics in Southwestern Ontario.

OBJECTIVES: Pain is the most common reason for prehospital transport. As emergency wait times increase, timely pain management is essential. In children, there is abundant evidence that prehospital pharmacologic analgesia is suboptimal, but little is known about non-pharmacologic therapies. We sought to characterize documentation by paramedics of non-pharmacologic (immobilization and ice) and pharmacologic analgesia in children with musculoskeletal injuries. METHODS: We reviewed all ambulance call reports for children 0-17 years transported to Southwestern Ontario regional hospitals from January 1, 2017, to December 31, 2019, with a musculoskeletal injury (Ontario Ministry of Health and Long-Term Care problem codes 66 and 67). Primary and secondary outcomes were documented immobilization or ice and pharmacologic analgesia, respectively. In a multivariable analysis, we explored the relationship between immobilization or ice and the following a priori covariates: age, sex, visible deformity, crew type, pain severity, and analgesia. RESULTS: Of 40,692 ambulance call reports reviewed, 4445 met inclusion criteria. There were 2584/4441 (58.2%) males, with a median (IQR) age of 14 (10, 16) years. In ambulance call reports with documented pain scores, 2106/3048 (69.1%) ambulance call reports reported "moderate or severe" pain. Immobilization or ice were documented in 1605/4445 (36.1%) and 385/4445 (8.7%) of ambulance call reports. Pharmacologic analgesia was documented in 275/1983 (13.9%) and 125/991 (12.6%) of ambulance call reports for primary care paramedics and advanced care paramedics, respectively. An increased odds of documented immobilization or ice was associated with moderate or severe pain [OR: 2.4; 95% CI 1.84-3.17; p < 0.01] and visible deformity [OR: 2.5; 95% CI 1.97-3.12; p < 0.01]. CONCLUSIONS: Documented immobilization and ice and pharmacologic analgesia to children by paramedics is suboptimal. Our findings underscore an important need for enhanced education surrounding the benefits of non-pharmacologic options for children with musculoskeletal injuries.

RéSUMé: OBJECTIFS: La douleur est le motif le plus fréquent de transport préhospitalier. À mesure que les temps d'attente aux urgences augmentent, la gestion de la douleur en temps opportun est essentielle. Chez les enfants, il existe de nombreuses preuves que l'analgésie pharmacologique préhospitalière est sous-optimale, mais on sait peu de choses sur les thérapies non pharmacologiques. Nous avons cherché à caractériser la documentation par les ambulanciers paramédicaux de l'analgésie non pharmacologique (immobilisation et glace) et pharmacologique chez les enfants souffrant de lésions musculo-squelettiques. MéTHODES: Nous avons examiné tous les rapports d'appels d'ambulance pour les enfants de 0 à 17 ans transportés vers les hôpitaux régionaux du Sud-Ouest de l'Ontario du 1er janvier 2017 au 31 décembre 2019, avec une blessure musculo-squelettique (codes de problèmes 66 et 67 du ministère de la Santé et des Soins de longue durée de l'Ontario). Les résultats primaires et secondaires étaient l'immobilisation documentée ou la glace et l'analgésie pharmacologique, respectivement. Dans une analyse multivariable, nous avons exploré la relation entre l'immobilisation ou la glace et les covariables a priori suivantes: âge, sexe, déformation visible, type d'équipage, intensité de la douleur et analgésie. RéSULTATS: Sur les 40 692 rapports d'appels d'ambulance examinés, 4 445 répondaient aux critères d'inclusion. Il y avait 2584/4441 (58,2 %) hommes, avec un âge médian (IQR) de 14 (10,16) ans. Dans les rapports d'appel d'ambulance avec des scores de douleur documentés, 2106/3048 (69,1 %) rapports d'appel d'ambulance ont signalé une douleur "modérée ou sévère". L'immobilisation ou la glace ont été documentées dans 1605/4445 (36,1 %) et 385/4445 (8,7 %) des rapports d'appel d'ambulance. L'analgésie pharmacologique a été documentée dans 275/1983 (13,9 %) et 125/991 (12,6 %) des rapports d'appel d'ambulance pour les ambulanciers de soins primaires et les ambulanciers de soins avancés, respectivement. Une probabilité accrue d'immobilisation documentée ou de glace était associée à une douleur modérée ou intense [OR: 2,4; IC à 95 %: 1,84-3,17; p < 0,01] et déformation visible [OR: 2,5; IC à 95 %: 1,97-3,12; p < 0,01]. CONCLUSIONS: L'immobilisation documentée et l'administration de glace et d'analgésie pharmacologique aux enfants par les ambulanciers est sous-optimale. Nos résultats soulignent le besoin important de renforcer l'éducation concernant les avantages des options non pharmacologiques pour les enfants souffrant de blessures musculo-squelettiques.

Longitudinal white matter changes associated with cognitive training.

Improvements in behavior are known to be accompanied by both structural and functional changes in the brain. However, whether those changes lead to more general improvements, beyond the behavior being trained, remains a contentious issue. We investigated whether training on one of two cognitive tasks would lead to either near transfer (that is, improvements on a quantifiably similar task) or far transfer (that is, improvements on a quantifiably different task), and furthermore, if such changes did occur, what the underlying neural mechanisms might be. Healthy adults (n = 16, 15 females) trained on either a verbal inhibitory control task or a visuospatial working memory task for 4 weeks, over the course of which they received five diffusion tensor imaging scans. Two additional tasks served as measures of near and far transfer. Behaviorally, participants improved on the task that they trained on, but did not improve on cognitively similar tests (near transfer), nor cognitively dissimilar tests (far transfer). Extensive changes to white matter microstructure were observed, with verbal inhibitory control training leading to changes in a left-lateralized network of frontotemporal and occipitofrontal tracts, and visuospatial working memory training leading to changes in right-lateralized frontoparietal tracts. Very little overlap was observed in changes between the two training groups. On the basis of these results, we suggest that near and far transfer were not observed because the changes in white matter tracts associated with training on each task are almost entirely nonoverlapping with, and therefore afford no advantages for, the untrained tasks.