Acetaminophen or Nonsteroidal Anti-Inflammatory Drugs in Acute Musculoskeletal Trauma: A Multicenter, Double-Blind, Randomized, Clinical Trial.

STUDY OBJECTIVE: We determine whether pain treatment with acetaminophen was not inferior to nonsteroidal anti-inflammatory drugs or the combination of both in minor musculoskeletal trauma. METHODS: The Paracetamol or NSAIDs in Acute Musculoskeletal Trauma Study was a double-blind, randomized, clinical trial conducted in 2 general practices and 2 emergency departments in the Netherlands. A total of 547 adults, aged 18 years and older, with acute blunt minor musculoskeletal extremity trauma were randomly assigned in a 1:1:1 ratio to acetaminophen 4,000 mg/day, diclofenac 150 mg/day, or acetaminophen 4,000 mg/day+diclofenac 150 mg/day during 3 consecutive days. Patients, health care staff, and outcome assessors were blinded for treatment allocation. Follow-up for each patient was 30 days. Primary outcome measures were between-group differences in mean numeric rating scale (NRS) pain scores in rest and with movement at 90 minutes after initial drug administration compared with baseline pain scores with a predefined noninferiority margin of 0.75 NRS points. Secondary outcomes included NRS pain scores during 3 consecutive days and need for additional analgesia. RESULTS: One hundred eighty-two patients were treated with acetaminophen, 183 with diclofenac, and 182 with combination treatment. Intention-to-treat analysis revealed mean NRS reduction in rest -1.23 (95% confidence interval [CI] -1.50 to -0.95) and -1.72 (95% CI -2.01 to -1.44) with movement, both for acetaminophen at 90 minutes compared with baseline. Pairwise comparison in rest with diclofenac showed a difference of -0.027 (97.5% CI -0.45 to 0.39) and -0.052 (97.5% CI -0.46 to 0.36) for combination treatment. With movement, these numbers were -0.20 (97.5% CI -0.64 to 0.23) and -0.39 (97.5% CI -0.80 to 0.018), respectively. All differences were well below the predefined noninferiority margin. CONCLUSION: Pain treatment with acetaminophen was not inferior to that with diclofenac or the combination of acetaminophen and diclofenac in acute minor musculoskeletal extremity trauma, both in rest and with movement.

Preoperative chest radiographs in hip fracture patients: is there any additional value?

PURPOSE: Preoperative screening in hip fracture patients is vital to minimize perioperative complications. Preoperative chest radiographs (POCR) are performed in many hip fracture patients. Earlier research showed that few POCR abnormalities influence perioperative policy. However, no studies in nonelective patient with a specific surgical conditions have been performed. With many hip fractures per year worldwide, a significant cost reduction could be made by performing selective POCR without compromising the quality of care. This study assessed the need for POCR in hip fracture patients. METHOD: Retrospective analysis of low-energy trauma patients was performed aged 18 years and older in the VU University Medical Center for a hip fracture in a 5-year period. All preoperative diagnostics were analyzed. All adjourned operations were evaluated. RESULTS: A total of 642 patients were included, 70% female, matching current epidemiologic figures. The POCR showed abnormalities in 22.6%. In 0.6% the POCR lead to an adjournment of the operation (2.8% of abnormal POCR's). These patients suffered from pneumonia. The POCR in these cases acted as a confirmation of the clinical diagnosis. CONCLUSION: Many factors involving the treatment of hip fracture patients are of importance in minimizing the risk of complications and mortality during and after admission. In 0.6% of all performed POCR's an abnormality leads to the adjournment of the operation. In all four cases the POCR matched the clinical findings. Because the additional value of the POCR in hip fracture patients was limited, we think that its selective use in clinical abnormalities is safe and will reduce unnecessary costs.

Prevalence and medical risks of body packing in the Amsterdam area.

AIM: Body packing is a way to deliver packets of drugs across international borders by ingestion. The aim of the study was to provide an estimate of the medical risks of body packing, describe predictors for hospital referral in detained body packers and provide an estimate for the prevalence of body packing in the Amsterdam area. METHODS: From May 2007 to December 2008, we studied medical records of body packers immediately detained after arrival at Amsterdam Schiphol airport, hospital records of both detained body packers and self-referrers at two emergency departments of hospitals in Amsterdam and records kept by forensic physicians in charge of post-mortem examinations of all unnatural deaths in the area (years 2005-2009). RESULTS: In airport detainees, the hospital referral rate was 4.2% (30 out of 707 detained body packers), the surgery rate was 1.3%. Significant predictors of hospital referral were delayed production of drug packets after arrest, cigarette smoking and country of departure. The surgery rate in self-referrers was comparable to the rate observed in those referred from the detention centre to hospital (30% vs. 31%). In addition, from 2005 to 2009, 20 proven cases of lethal body packing were identified. Based on our data, it is estimated that minimally 38% of all incoming body packers were missed by airport controls. CONCLUSION: The risk for lethal complications due to body packing is low on a population basis and comparable to other studies. This also applies for the hospital referral and surgery rates found in this study. Cigarette smoking has not yet been described in the literature as a potential predictor for hospital referral in detained body packers and therefore deserves attention in future research. A substantial fraction of body packers manages to remain undiscovered.