Multicentre randomised controlled trial of nasal diamorphine for analgesia in children and teenagers with clinical fractures.

OBJECTIVE: To compare the effectiveness of nasal diamorphine spray with intramuscular morphine for analgesia in children and teenagers with acute pain due to a clinical fracture, and to describe the safety profile of the spray. DESIGN: Multicentre randomised controlled trial. SETTING: Emergency departments in eight UK hospitals. PARTICIPANTS: Patients aged between 3 and 16 years presenting with a clinical fracture of an upper or lower limb. MAIN OUTCOME MEASURES: Patients' reported pain using the Wong Baker face pain scale, ratings of reaction to treatment of the patients and acceptability of treatment by staff and parents, and adverse events. RESULTS: 404 eligible patients completed the trial (204 patients given nasal diamorphine spray and 200 given intramuscular morphine). Onset of pain relief was faster in the spray group than in the intramuscular group, with lower pain scores in the spray group at 5, 10, and 20 minutes after treatment but no difference between the groups after 30 minutes. 80% of patients given the spray showed no obvious discomfort compared with 9% given intramuscular morphine (difference 71%, 95% confidence interval 65% to 78%). Treatment administration was judged acceptable by staff and parents, respectively, for 98% (199 of 203) and 97% (186 of 192) of patients in the spray group compared with 32% (64 of 199) and 72% (142 of 197) in the intramuscular group. No serious adverse events occurred in the spray group, and the frequencies of all adverse events were similar in both groups (spray 24.1% v intramuscular morphine 18.5%; difference 5.6%, -2.3% to 13.6%). CONCLUSION: Nasal diamorphine spray should be the preferred method of pain relief in children and teenagers presenting to emergency departments in acute pain with clinical fractures. The diamorphine spray should be used in place of intramuscular morphine

Kinematics Comparison between Dominant and Non-Dominant Lower Limbs in Thai Boxing

Muay Thai, also known as Thai Boxing, is Thailand\u27s national sport, and it involves athletes using different stand-up striking and clinching techniques. There are a limited number of research studies that have examined Thai Boxing skills and specifically none have examined the kinematics of the dominant and non-dominant legs while in a double collar or double underhook clinching position. The purpose of the study was to investigate the kinematics of the dominant (right) and non-dominant leg (left) between the double collar and double underhook Thai Boxing clinching positions. Participants executed six continuous knee strikes with the dominant leg and non-dominant leg in each of the two clinching positions for twelve knee strikes. A standard two-dimensional video motion analysis was conducted. The results revealed statistical significant difference at the hip joint angle between both clinching positions (p = .013) but not at the knee and ankle joints. There were no statistical significant differences in the joint angular velocity and acceleration for the hip, knee, and ankle joint between both clinching positions. However, there was a statistical significant difference found in the joint angular velocity for the knee joint (p = 0.00) between the dominant and non-dominant leg. Lastly, there was a significant correlation of the joint angle (r = 0.65 and 0.63; double collar and double underhook) and the angular velocity (r = 0.76 and 0.67; double collar and double underhook) for the left and right knee between both clinching positions. In addition, there was a significant correlation of the joint angle between the left and right hip (r = 0.66) for the double collar position but not for the double underhook position. This study demonstrates the importance of hip joint flexibility and the angular velocity of the knee between the dominant and non-dominant leg. Future research studies investigating the impact of the knee at the point of contact in the Thai Boxing clinch positions among group of elite mixed martial arts athletes are warranted

Laparoscopic fundoplication compared with medical management for gastro-oesophageal reflux disease : cost effectiveness study

Peer reviewedPublisher PD

CRASH - Corticosteroid Randomisation after Significant Head Injury

A large simple placebo controlled trial, among adults with head injury and impaired consciousness, of the effects of a 48-hour infusion of corticosteroids on death and neurological disability. CRASH was a randomised, controlled, double-blind trial undertaken in 239 hospitals in 49 countries. A total of 10008 adults with head injury and a Glasgow Coma Score (GCS) of 14 or less within 8 hours of injury were randomly allocated 48 hour infusion of corticosteroids (methylprednisolone) or placebo. Primary outcomes were death within 2 weeks of injury or disability at 6 months. Prespecified subgroup analyses were based on injury severity (GCS) at randomisation and on time from injury to randomisation and analysis was by intention to treat. Access to this dataset is available via https://freebird.lshtm.ac.uk/

Comparative clinical effectiveness and cost effectiveness of endovascular strategy v open repair for ruptured abdominal aortic aneurysm: three year results of the IMPROVE randomised trial.

Objective To assess the three year clinical outcomes and cost effectiveness of a strategy of endovascular repair (if aortic morphology is suitable, open repair if not) versus open repair for patients with suspected ruptured abdominal aortic aneurysm.Design Randomised controlled trial.Setting 30 vascular centres (29 in UK, one in Canada), 2009-16.Participants 613 eligible patients (480 men) with a clinical diagnosis of ruptured aneurysm, of whom 502 underwent emergency repair for rupture.Interventions 316 patients were randomised to an endovascular strategy (275 with confirmed rupture) and 297 to open repair (261 with confirmed rupture).Main outcome measures Mortality, with reinterventions after aneurysm repair, quality of life, and hospital costs to three years as secondary measures.Results The maximum follow-up for mortality was 7.1 years, with two patients in each group lost to follow-up by three years. After similar mortality by 90 days, in the mid-term (three months to three years) there were fewer deaths in the endovascular than the open repair group (hazard ratio 0.57, 95% confidence interval 0.36 to 0.90), leading to lower mortality at three years (48% v 56%), but by seven years mortality was about 60% in each group (hazard ratio 0.92, 0.75 to 1.13). Results for the 502 patients with repaired ruptures were more pronounced: three year mortality was lower in the endovascular strategy group (42% v 54%; odds ratio 0.62, 0.43 to 0.88), but after seven years there was no clear difference between the groups (hazard ratio 0.86, 0.68 to 1.08). Reintervention rates up to three years were not significantly different between the randomised groups (hazard ratio 1.02, 0.79 to 1.32); the initial rapid rate of reinterventions was followed by a much slower mid-term reintervention rate in both groups. The early higher average quality of life in the endovascular strategy versus open repair group, coupled with the lower mortality at three years, led to a gain in average quality adjusted life years (QALYs) at three years of 0.17 (95% confidence interval 0.00 to 0.33). The endovascular strategy group spent fewer days in hospital and had lower average costs of -£2605 (95% confidence interval -£5966 to £702) (about €2813; $3439). The probability that the endovascular strategy is cost effective was >90% at all levels of willingness to pay for a QALY gain.Conclusions At three years, compared with open repair, an endovascular strategy for suspected ruptured abdominal aortic aneurysm was associated with a survival advantage, a gain in QALYs, similar levels of reintervention, and reduced costs, and this strategy was cost effective. These findings support the increasing use of an endovascular strategy, with wider availability of emergency endovascular repair.Trial registration Current Controlled Trials ISRCTN48334791; ClinicalTrials NCT00746122

Bayesian clinical trial designs : Another option for trauma trials?

The UK-REBOA Trial is funded by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme (project number 14/199/09). PP was supported by the MRC Network of Hubs for Trials Methodology Research (MR/L004933/1-R/N/P/B1).Peer reviewedPublisher PD

Spruce Budworm in Maine: The End of the Outbreak: Biological Conditions in 1986, 1987, and 1988, and a Look at the Future

Spruce Budworm in Maine: The End of the Outbreak: Biological Conditions in 1986, 1987, and 1988, and a Look at the Future by Henry Trial, Jr., Insect and Disease Management Division Technical Report No. 28 Maine Forest Service, Dept. of Conservation, Augusta, Maine, October 1989. Contents: Introduction / Biological Conditions in 1986, 1987, and 1988 / Control Activities / Forest Conditions-1986 to 1988 and a Look at the Future / Spray Operations and Forecast of Conditions in Quebec and New Brunswick, 1986-1988 / The Future of Budworm in the Region and in Maine / List of Figures / List of Tableshttps://digitalcommons.usm.maine.edu/me_collection/1130/thumbnail.jp