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SD throughout the study more prone to misrepresentation due tooutliers than use of median and interquartile ranges, especiallywithout a control group for outcome comparison. Further, radialshortening was not measured due to a quoted but poorly defined‘‘minimally noticeable clinical deformity,’’ despite final follow-up radiographs being available for determination of such objec-tive data. The lack of data regarding shortening is especiallyimportant given that the initial protocol involved gentle moldingto correct angulation without any attempt to correct shortening.Although the study is not robust enough to alter the standard ofcare for such fractures, it presents an alternative approach tooverriding distal radial fractures in children. A prospective, ran-domized controlled trial with well-defined and clinically rele-vant outcome measures would be helpful to determinewhether or not this should become standard of care.

, SEX DIFFERENCES IN MANAGEMENT AND MOR-TALITY OF PATIENTS WITH ST-ELEVATION MYO-CARDIAL INFARCTION (FROMTHEKOREANACUTEMYOCARDIAL INFARCTION NATIONAL REGISTRY).Kang S, Suh J, Yoon C, et al. Am J Cardiol 2012;109:787–93.

Gender differences in the prognosis of coronary artery dis-ease have been reported since the early 1990s. This study soughtto utilize large data registries with data on patients with myocar-dial infarction (MI) to identify whether female gender was an in-dependent risk factor for mortality after MI, or whether thepreviously reported differences were more likely due to con-founding factors. Two large Korean databases were analyzed,yielding a study population of 14,123 patients with a diagnosisof ST-segment elevation MI, of whom 73.6% were men. Thebaseline characteristics differed significantly between men andwomen. Women in the study were more likely to be older andhave comorbidities including hypertension, diabetes mellitus,dyslipidemia, and a family history of coronary artery disease.Women also had a longer pain-to-door time when compared tomen. The primary endpoint of the study was all-cause mortalityat 1 year. The authors found an overall higher mortality rate inwomen than in men, with a hazard ratio for women of 2.08(95% confidence interval [CI] 1.86–2.34, p < 0.001). However,the increase inmortality correlated stronglywith age, and adjust-ing for age significantly reduced the effect of gender on mortal-ity, with a hazard ratio for women of 1.28 (95% CI 1.13–1.44,p < 0.001). After adjusting for additional baseline risk factorsand hemodynamic status on arrival, the effect of gender on mor-tality was no longer statistically significant, with a hazard ratioof 1.02 (95% CI 0.89–1.17, p = 0.760).

[Nir Harish, MD

Denver Health Medical Center, Denver, CO]

Comments:Although limited by its retrospective design, thisstudy reaffirms the concerning disparity in mortality amongmen and women after MI, but suggests that female gender in it-self is not the cause of this mortality difference. Instead, the in-creased mortality seen in women is likely due to other variables,such as older age at presentation and higher prevalence of addi-tional risk factors at the time of presentation. It is important forEmergency Physicians to recognize that women may presentlater, and sicker, than men. Ultimately, continued efforts will

be needed to educate women on early signs of coronary arterydisease and to encourage earlier evaluation of symptoms.

, DOPAMINE VERSUS NOREPINEPHRINE IN THETREATMENTOFSEPTIC SHOCK:AMETA-ANALYSIS.De Backer D, Aldecoa C, Njimi H, Vincent JL. Crit Care Med2012;40:725–30.

This meta-analysis evaluated the effects of norepinephrineand dopamine on outcome and adverse events in patients withseptic shock. The authors separately reviewed five observational(1360 patients) and six randomized (1408 patients) trials, total-ing 2768 patients (1474 who received norepinephrine and 1294who received dopamine). Using the primary outcome of 28-daymortality or closest estimate, in the observational studies theyfound there was significant heterogeneity (p < 0.001), therewas no difference in mortality (relative risk [RR] 1.09; confi-dence interval [CI] RR 1.23; CI 1.05–1.43; p < 0.01). In ran-domized trials, dopamine was associated with an increasedrisk of death (RR 1.12; CI 1.01–1.20; p = 0.035) and no hetero-geneity or publication bias was detected (p = 0.77). There wereno differences in intensive care unit (RR �0.3; CI �1.5–1.0;p = 0.67) or in hospital (RR 0.0; CI �2.8–2.6; p = 0.95) lengthof stay between patients who received dopamine and thosewho received norepinephrine in two intervention trials thatreported it. Of the two trials that reported dysrhythmias, thesewere more frequent with dopamine than with norepinephrine(RR 2.34; CI 1.46–3.77; p = 0.001).

[Douglas Melzer, MD

Denver Health Medical Center, Denver, CO]

Comments: This study lends further evidence to the notionthat norepinephrine is preferred to dopamine for themanagementof hypotension in patients with septic shock. Although the obser-vational studies thatwere evaluated demonstrated little differencebetween the two, these studies were found to be very heteroge-neous and thusmake thepooling of thedata of questionablevalue.More convincing is the pooling of the data from randomized stud-ies that clearly demonstrate the superiority of norepinephrine.

, SYSTOLIC BLOOD PRESSURE BELOW 110 MMHGIS ASSOCIATED WITH INCREASED MORTALITY INPENETRATING MAJOR TRAUMA PATIENTS: MULTI-CENTRE COHORT STUDY. Hasler RM, Nuesh E, Juni P,et al. Resuscitation 2012;83:476–81.

This study was a review of prospectively collected data fromthe Trauma Audit and Research Network (TARN) database todetermine the association between different systolic blood pres-sure (SBP) cutoffs at Emergency Department admission andoverall mortality at 30 days after admission in patients with pen-etrating trauma. The TARN database is a European multi-centertrauma registry of patients who are admitted for 72 h or more,are transferred to a participating hospital for specialist care,require high dependency care or intensive care unit treatment,or who die as a result of their injuries within 93 days of admis-sion. TARN does not include patients who are dead on arrival atthe hospital; who have simple skin lacerations, contusion, orabrasions, minor penetrating injuries, or single uncomplicatedlimb injuries; or patients over 65 years old with isolated fractureof the femoral neck or pubic ramus. Exclusion criteria for the